Arizona, Area 00, 2015 Medicare Part B Fee Schedule

Transcription

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CPT codes and modifiers begin with a numeric character and HCPCS codes and modifiers begin with an alpha character. All Current procedural Terminology (CPT) codes and descriptors are
copyrighted 2014 by the American Medical Association.
Arizona, Area 00, 2015 Medicare Part B Fee Schedule (Effective January 1, 2015)
# - These amounts apply when services is performed in a facility setting.
C - The payment for the technical component is capped at the OPPS amount.
** - Limiting charge reduced based on the EHR negative adjustment program.
*** - Limiting charge reduced based on the PQRS negative adjustment program.
**** - Limiting charge reduced for EPs that are subject to both EHR and PQRS negative adjustment programs.
Limiting charge applied to unassigned claims by non-participating providers.
Notes
#
#
#
#
#
#
#
Procedure
Code
G0101
G0101
G0102
G0102
G0104
G0104
G0105
G0105
G0105
G0105
G0106
G0106
G0106
G0108
G0109
G0117
G0118
G0120
G0120
G0120
G0121
G0121
G0121
G0121
G0124
G0127
1/2/2015
Modifier
53
53
TC
26
TC
26
53
53
Par Fee
$38.40
$28.03
$19.62
$8.89
$139.14
$64.77
$381.19
$207.06
$139.14
$64.77
$212.43
$161.92
$50.51
$53.10
$14.26
$54.62
$45.36
$212.43
$161.92
$50.51
$381.19
$207.06
$139.14
$64.77
$32.45
$23.20
Nonpar Fee
$36.48
$26.63
$18.64
$8.45
$132.18
$61.53
$362.13
$196.71
$132.18
$61.53
$201.81
$153.82
$47.98
$50.45
$13.55
$51.89
$43.09
$201.81
$153.82
$47.98
$362.13
$196.71
$132.18
$61.53
$30.83
$22.04
Limiting
Charge
$41.95
$30.62
$21.44
$9.72
$152.01
$70.76
$416.45
$226.22
$152.01
$70.76
$232.08
$176.89
$55.18
$58.02
$15.58
$59.67
$49.55
$232.08
$176.89
$55.18
$416.45
$226.22
$152.01
$70.76
$35.45
$25.35
EHR Limiting PQRS Limiting
Charge**
Charge***
$41.54
$41.32
$30.31
$30.16
$21.22
$21.11
$9.63
$9.57
$150.49
$149.73
$70.05
$69.70
$412.29
$410.21
$223.95
$222.82
$150.49
$149.73
$70.05
$69.70
$229.76
$228.60
$175.12
$174.24
$54.63
$54.35
$57.44
$57.14
$15.42
$15.35
$59.08
$58.78
$49.06
$48.81
$229.76
$228.60
$175.12
$174.24
$54.63
$54.35
$412.29
$410.21
$223.95
$222.82
$150.49
$149.73
$70.05
$69.70
$35.10
$34.93
$25.09
$24.97
Arizona
EHR/eRx
Limiting
Charge**
$41.11
$30.02
$21.01
$9.52
$148.97
$69.35
$408.12
$221.70
$148.97
$69.35
$227.44
$173.35
$54.07
$56.86
$15.27
$58.48
$48.56
$227.44
$173.35
$54.07
$408.12
$221.70
$148.97
$69.35
$34.74
$24.84
EHR + PQRS
EHR/eRx +
Limiting PQRS Limiting
Charge****
Charge****
$40.92
$40.49
$29.85
$29.57
$20.90
$20.70
$9.48
$9.38
$148.24
$146.74
$69.00
$68.31
$406.10
$402.01
$220.59
$218.37
$148.24
$146.74
$69.00
$68.31
$226.31
$224.02
$172.50
$170.75
$53.81
$53.26
$56.58
$56.01
$15.19
$15.04
$58.19
$57.60
$48.32
$47.84
$226.31
$224.02
$172.50
$170.75
$53.81
$53.26
$406.10
$402.01
$220.59
$218.37
$148.24
$146.74
$69.00
$68.31
$34.57
$34.22
$24.71
$24.47
Page 1 of 323
Notes
#
#
#
#
#
Procedure
Code
G0127
G0128
G0130
G0130
G0130
G0141
G0166
G0168
G0168
G0179
G0180
G0181
G0182
G0202
G0202
G0202
G0204
G0204
G0204
G0206
G0206
G0206
G0237
G0238
G0239
G0245
G0245
G0246
G0246
G0247
G0247
G0248
G0249
1/2/2015
Modifier
TC
26
TC
26
TC
26
TC
26
Par Fee
$7.82
$7.82
$34.59
$23.20
$11.40
$32.45
$138.19
$103.11
$28.03
$41.34
$53.77
$107.85
$108.93
$134.58
$99.35
$35.22
$163.85
$119.73
$44.12
$129.21
$93.99
$35.22
$10.32
$10.68
$13.19
$65.93
$43.04
$38.48
$21.68
$73.17
$23.47
$112.18
$111.87
Nonpar Fee
$7.43
$7.43
$32.86
$22.04
$10.83
$30.83
$131.28
$97.95
$26.63
$39.27
$51.08
$102.46
$103.48
$127.85
$94.38
$33.46
$155.66
$113.74
$41.91
$122.75
$89.29
$33.46
$9.80
$10.15
$12.53
$62.63
$40.89
$36.56
$20.60
$69.51
$22.30
$106.57
$106.28
Limiting
Charge
$8.54
$8.54
$37.79
$25.35
$12.45
$35.45
$150.97
$112.64
$30.62
$45.16
$58.74
$117.83
$119.00
$147.03
$108.54
$38.48
$179.01
$130.80
$48.20
$141.16
$102.68
$38.48
$11.27
$11.67
$14.41
$72.02
$47.02
$42.04
$23.69
$79.94
$25.65
$122.56
$122.22
Charge**
Charge***
$8.46
$8.42
$8.46
$8.42
$37.41
$37.23
$25.09
$24.97
$12.33
$12.27
$35.10
$34.93
$149.47
$148.71
$111.52
$110.95
$30.31
$30.16
$44.71
$44.48
$58.16
$57.86
$116.66
$116.06
$117.82
$117.22
$145.56
$144.82
$107.46
$106.90
$38.10
$37.90
$177.22
$176.33
$129.49
$128.83
$47.71
$47.47
$139.75
$139.05
$101.66
$101.14
$38.10
$37.90
$11.16
$11.10
$11.56
$11.50
$14.26
$14.19
$71.30
$70.94
$46.55
$46.32
$41.62
$41.41
$23.45
$23.33
$79.13
$78.74
$25.39
$25.27
$121.33
$120.72
$121.00
$120.39
Arizona
EHR/eRx
Limiting
Charge**
$8.37
$8.37
$37.03
$24.84
$12.20
$34.74
$147.95
$110.39
$30.02
$44.25
$57.57
$115.47
$116.62
$144.08
$106.36
$37.71
$175.43
$128.19
$47.23
$138.35
$100.63
$37.71
$11.04
$11.44
$14.12
$70.59
$46.08
$41.20
$23.22
$78.34
$25.13
$120.11
$119.77
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$8.34
$8.25
$8.34
$8.25
$36.85
$36.48
$24.71
$24.47
$12.14
$12.02
$34.57
$34.22
$147.22
$145.73
$109.85
$108.73
$29.85
$29.57
$44.05
$43.59
$57.28
$56.71
$114.91
$113.74
$116.05
$114.87
$143.37
$141.92
$105.85
$104.77
$37.52
$37.15
$174.56
$172.80
$127.55
$126.27
$47.00
$46.52
$137.66
$136.28
$100.13
$99.12
$37.52
$37.15
$10.98
$10.88
$11.39
$11.27
$14.04
$13.92
$70.23
$69.53
$45.85
$45.39
$41.00
$40.58
$23.09
$22.87
$77.95
$77.17
$25.01
$24.75
$119.51
$118.30
$119.19
$117.98
Page 2 of 323
Notes
#
#
#
#
#
#
Procedure
Code
G0250
G0268
G0268
G0270
G0270
G0271
G0271
G0276
G0277
G0278
G0279
G0279
G0279
G0281
G0283
G0288
G0289
G0329
G0341
G0341
G0342
G0343
G0364
G0364
G0365
G0365
G0365
G0372
G0389
G0389
G0389
G0396
G0396
1/2/2015
Modifier
TC
26
TC
26
TC
26
Par Fee
$9.25
$53.59
$34.29
$29.99
$27.49
$16.05
$15.33
$402.64
$47.11
$13.72
$56.27
$25.70
$30.57
$13.90
$13.90
$32.85
$89.14
$9.97
$2,370.26
$378.37
$687.89
$1,255.15
$12.47
$8.89
$200.36
$187.98
$12.38
$8.89
$116.07
$87.20
$28.87
$36.29
$34.15
Nonpar Fee
$8.79
$50.91
$32.58
$28.49
$26.12
$15.25
$14.56
$382.51
$44.75
$13.03
$53.46
$24.42
$29.04
$13.21
$13.21
$31.21
$84.68
$9.47
$2,251.75
$359.45
$653.50
$1,192.39
$11.85
$8.45
$190.34
$178.58
$11.76
$8.45
$110.27
$82.84
$27.43
$34.48
$32.44
Limiting
Charge
$10.11
$58.55
$37.47
$32.76
$30.04
$17.54
$16.74
$439.89
$51.46
$14.98
$61.48
$28.08
$33.40
$15.19
$15.19
$35.89
$97.38
$10.89
$2,589.51
$413.37
$751.53
$1,371.25
$13.63
$9.72
$218.89
$205.37
$13.52
$9.72
$126.81
$95.27
$31.54
$39.65
$37.31
Charge**
Charge***
$10.01
$9.96
$57.96
$57.67
$37.09
$36.90
$32.44
$32.27
$29.74
$29.59
$17.37
$17.27
$16.57
$16.49
$435.48
$433.29
$50.95
$50.69
$14.84
$14.75
$60.87
$60.56
$27.81
$27.66
$33.06
$32.89
$15.04
$14.96
$15.04
$14.96
$35.54
$35.35
$96.40
$95.92
$10.79
$10.73
$2,563.61
$2,550.67
$409.24
$407.17
$744.02
$740.26
$1,357.54
$1,350.68
$13.49
$13.42
$9.63
$9.57
$216.71
$215.60
$203.31
$202.29
$13.39
$13.32
$9.63
$9.57
$125.55
$124.91
$94.31
$93.84
$31.23
$31.07
$39.26
$39.05
$36.94
$36.74
Arizona
EHR/eRx
Limiting
Charge**
$9.90
$57.37
$36.72
$32.11
$29.44
$17.19
$16.41
$431.09
$50.44
$14.69
$60.25
$27.52
$32.73
$14.89
$14.89
$35.18
$95.44
$10.67
$2,537.73
$405.10
$736.49
$1,343.82
$13.35
$9.52
$214.51
$201.26
$13.25
$9.52
$124.27
$93.36
$30.91
$38.86
$36.56
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$9.86
$9.75
$57.09
$56.51
$36.54
$36.17
$31.96
$31.63
$29.29
$29.00
$17.10
$16.94
$16.32
$16.17
$428.95
$424.63
$50.19
$49.68
$14.62
$14.47
$59.96
$59.34
$27.39
$27.11
$32.57
$32.23
$14.81
$14.67
$14.81
$14.67
$35.01
$34.65
$94.96
$94.01
$10.63
$10.51
$2,525.16
$2,499.66
$403.10
$399.03
$732.86
$725.44
$1,337.17
$1,323.66
$13.28
$13.16
$9.48
$9.38
$213.45
$211.29
$200.26
$198.24
$13.19
$13.05
$9.48
$9.38
$123.66
$122.41
$92.90
$91.95
$30.76
$30.45
$38.67
$38.27
$36.39
$36.01
Page 3 of 323
Notes
#
#
#
#
#
#
Procedure
Code
G0397
G0397
G0402
G0402
G0403
G0404
G0405
G0406
G0407
G0408
G0409
G0412
G0413
G0414
G0415
G0416
G0416
G0416
G0420
G0421
G0422
G0423
G0424
G0424
G0425
G0426
G0427
G0429
G0429
G0436
G0436
G0437
G0437
1/2/2015
Modifier
TC
26
Par Fee
$69.77
$67.63
$167.34
$128.01
$17.07
$8.54
$8.54
$39.11
$72.54
$104.50
$11.04
$741.26
$1,087.75
$985.88
$1,397.33
$645.82
$464.05
$181.77
$108.17
$24.94
$102.98
$102.98
$30.30
$13.86
$101.78
$137.45
$203.56
$99.81
$72.28
$14.26
$12.11
$28.11
$25.97
Nonpar Fee
$66.28
$64.25
$158.97
$121.61
$16.22
$8.11
$8.11
$37.15
$68.91
$99.28
$10.49
$704.20
$1,033.36
$936.59
$1,327.46
$613.53
$440.85
$172.68
$102.76
$23.69
$97.83
$97.83
$28.79
$13.17
$96.69
$130.58
$193.38
$94.82
$68.67
$13.55
$11.50
$26.70
$24.67
Limiting
Charge
$76.22
$73.89
$182.82
$139.85
$18.65
$9.33
$9.33
$42.72
$79.25
$114.17
$12.06
$809.83
$1,188.36
$1,077.08
$1,526.58
$705.56
$506.98
$198.58
$118.17
$27.24
$112.50
$112.50
$33.11
$15.15
$111.19
$150.17
$222.39
$109.04
$78.97
$15.58
$13.23
$30.71
$28.37
Charge**
Charge***
$75.46
$75.08
$73.15
$72.78
$180.99
$180.08
$138.45
$137.76
$18.47
$18.38
$9.23
$9.19
$9.23
$9.19
$42.30
$42.08
$78.45
$78.06
$113.03
$112.46
$11.95
$11.88
$801.73
$797.69
$1,176.48
$1,170.54
$1,066.30
$1,060.92
$1,511.32
$1,503.68
$698.50
$694.98
$501.91
$499.38
$196.59
$195.60
$116.99
$116.40
$26.97
$26.83
$111.38
$110.81
$111.38
$110.81
$32.78
$32.61
$15.00
$14.92
$110.08
$109.53
$148.66
$147.91
$220.17
$219.05
$107.95
$107.41
$78.18
$77.79
$15.42
$15.35
$13.10
$13.03
$30.39
$30.25
$28.08
$27.95
Arizona
EHR/eRx
Limiting
Charge**
$74.69
$72.42
$179.16
$137.06
$18.29
$9.14
$9.14
$41.87
$77.66
$111.88
$11.82
$793.64
$1,164.59
$1,055.54
$1,496.05
$691.45
$496.83
$194.61
$115.81
$26.70
$110.25
$110.25
$32.44
$14.85
$108.97
$147.17
$217.94
$106.86
$77.40
$15.27
$12.96
$30.10
$27.81
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$74.34
$73.58
$72.06
$71.33
$178.27
$176.47
$136.37
$135.00
$18.19
$18.01
$9.10
$9.00
$9.10
$9.00
$41.66
$41.24
$77.28
$76.50
$111.34
$110.20
$11.76
$11.65
$789.71
$781.74
$1,158.83
$1,147.13
$1,050.31
$1,039.70
$1,488.65
$1,473.61
$688.02
$681.08
$494.37
$489.38
$193.65
$191.69
$115.23
$114.07
$26.57
$26.30
$109.71
$108.59
$109.71
$108.59
$32.28
$31.96
$14.77
$14.63
$108.42
$107.34
$146.43
$144.96
$216.87
$214.67
$106.33
$105.26
$77.00
$76.23
$15.19
$15.04
$12.90
$12.77
$29.93
$29.65
$27.66
$27.39
Page 4 of 323
Notes
#
#
#
#
#
#
#
#
Procedure
Code
G0438
G0439
G0442
G0442
G0443
G0443
G0444
G0444
G0445
G0445
G0446
G0446
G0447
G0447
G0451
G0452
G0453
G0454
G0455
G0455
G0459
G0473
G0473
G6001
G6001
G6001
G6002
G6002
G6002
G6003
G6004
G6005
G6006
1/2/2015
Modifier
26
TC
26
TC
26
Par Fee
$172.71
$116.84
$18.19
$9.61
$25.97
$23.82
$18.19
$9.61
$26.37
$23.15
$25.97
$23.82
$25.97
$23.82
$9.61
$18.86
$33.03
$9.25
$131.14
$75.72
$40.99
$12.47
$11.76
$51.35
$21.77
$29.59
$74.95
$54.66
$20.29
$161.57
$125.10
$139.76
$139.04
Nonpar Fee
$164.07
$111.00
$17.28
$9.13
$24.67
$22.63
$17.28
$9.13
$25.05
$21.99
$24.67
$22.63
$24.67
$22.63
$9.13
$17.92
$31.38
$8.79
$124.58
$71.93
$38.94
$11.85
$11.17
$48.78
$20.68
$28.11
$71.20
$51.93
$19.28
$153.49
$118.85
$132.77
$132.09
Limiting
Charge
$188.68
$127.65
$19.87
$10.50
$28.37
$26.02
$19.87
$10.50
$28.81
$25.29
$28.37
$26.02
$28.37
$26.02
$10.50
$20.61
$36.09
$10.11
$143.27
$82.72
$44.78
$13.63
$12.85
$56.10
$23.78
$32.33
$81.88
$59.72
$22.17
$176.51
$136.68
$152.69
$151.90
Charge**
Charge***
$186.79
$185.85
$126.37
$125.74
$19.68
$19.57
$10.40
$10.34
$28.08
$27.95
$25.76
$25.63
$19.68
$19.57
$10.40
$10.34
$28.52
$28.37
$25.04
$24.91
$28.08
$27.95
$25.76
$25.63
$28.08
$27.95
$25.76
$25.63
$10.40
$10.34
$20.40
$20.30
$35.73
$35.55
$10.01
$9.96
$141.83
$141.12
$81.89
$81.48
$44.33
$44.11
$13.49
$13.42
$12.72
$12.65
$55.53
$55.26
$23.54
$23.43
$32.00
$31.84
$81.06
$80.65
$59.12
$58.82
$21.95
$21.84
$174.75
$173.87
$135.31
$134.63
$151.16
$150.40
$150.39
$149.63
Arizona
EHR/eRx
Limiting
Charge**
$184.91
$125.10
$19.47
$10.29
$27.81
$25.51
$19.47
$10.29
$28.23
$24.78
$27.81
$25.51
$27.81
$25.51
$10.29
$20.19
$35.36
$9.90
$140.40
$81.06
$43.88
$13.35
$12.59
$54.97
$23.31
$31.68
$80.25
$58.52
$21.72
$172.98
$133.94
$149.63
$148.87
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$183.99
$182.14
$124.48
$123.22
$19.38
$19.18
$10.24
$10.14
$27.66
$27.39
$25.37
$25.13
$19.38
$19.18
$10.24
$10.14
$28.09
$27.81
$24.66
$24.41
$27.66
$27.39
$25.37
$25.13
$27.66
$27.39
$25.37
$25.13
$10.24
$10.14
$20.09
$19.90
$35.19
$34.83
$9.86
$9.75
$139.70
$138.30
$80.66
$79.84
$43.67
$43.23
$13.28
$13.16
$12.52
$12.41
$54.71
$54.14
$23.18
$22.97
$31.52
$31.21
$79.84
$79.04
$58.24
$57.65
$21.62
$21.40
$172.13
$170.38
$133.29
$131.93
$148.89
$147.38
$148.13
$146.64
Page 5 of 323
Notes
#
#
#
#
#
#
Procedure
Code
G6007
G6008
G6009
G6010
G6011
G6012
G6013
G6014
G6015
G6016
G6018
G6019
G6019
G6020
G6022
G6022
G6023
G6024
G6024
G6025
G9157
G9187
P3001
Q0035
Q0035
Q0035
Q0091
Q0091
Q0092
10021
10021
10022
10022
1/2/2015
Modifier
TC
26
Par Fee
$257.03
$173.01
$191.60
$191.60
$274.91
$227.71
$256.32
$256.32
$399.92
$398.98
$161.58
$507.76
$274.99
$265.99
$339.82
$182.50
$170.48
$560.23
$330.33
$338.14
$97.22
$49.57
$32.45
$21.01
$12.11
$8.89
$45.23
$19.85
$25.34
$150.45
$70.72
$143.07
$67.27
Nonpar Fee
$244.18
$164.36
$182.02
$182.02
$261.16
$216.32
$243.50
$243.50
$379.92
$379.03
$153.50
$482.37
$261.24
$252.69
$322.83
$173.38
$161.96
$532.22
$313.81
$321.23
$92.36
$47.09
$30.83
$19.96
$11.50
$8.45
$42.97
$18.86
$24.07
$142.93
$67.18
$135.92
$63.91
Limiting
Charge
$280.81
$189.01
$209.32
$209.32
$300.33
$248.77
$280.03
$280.03
$436.91
$435.88
$176.53
$554.73
$300.43
$290.59
$371.25
$199.39
$186.25
$612.05
$360.88
$369.41
$106.21
$54.15
$35.45
$22.95
$13.23
$9.72
$49.42
$21.69
$27.68
$164.37
$77.26
$156.31
$73.50
Charge**
Charge***
$278.00
$276.60
$187.13
$186.17
$207.23
$206.18
$207.23
$206.18
$297.33
$295.83
$246.28
$245.04
$277.23
$275.83
$277.23
$275.83
$432.54
$430.35
$431.53
$429.34
$174.77
$173.88
$549.18
$546.40
$297.42
$295.92
$287.68
$286.24
$367.54
$365.69
$197.40
$196.40
$184.39
$183.46
$605.94
$602.88
$357.27
$355.47
$365.72
$363.87
$105.16
$104.62
$53.61
$53.34
$35.10
$34.93
$22.72
$22.61
$13.10
$13.03
$9.63
$9.57
$48.92
$48.68
$21.47
$21.37
$27.40
$27.27
$162.73
$161.91
$76.49
$76.10
$154.74
$153.96
$72.76
$72.39
Arizona
EHR/eRx
Limiting
Charge**
$275.20
$185.23
$205.14
$205.14
$294.33
$243.79
$274.42
$274.42
$428.17
$427.17
$172.99
$543.63
$294.42
$284.79
$363.83
$195.40
$182.53
$599.82
$353.66
$362.03
$104.09
$53.07
$34.74
$22.49
$12.96
$9.52
$48.43
$21.25
$27.13
$161.08
$75.72
$153.18
$72.02
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$273.83
$271.07
$184.32
$182.45
$204.13
$202.06
$204.13
$202.06
$292.87
$289.92
$242.59
$240.13
$273.07
$270.31
$273.07
$270.31
$426.05
$421.75
$425.05
$420.76
$172.14
$170.40
$540.95
$535.47
$292.96
$290.01
$283.37
$280.52
$362.03
$358.36
$194.44
$192.46
$181.62
$179.79
$596.85
$590.82
$351.91
$348.36
$360.24
$356.60
$103.58
$102.52
$52.81
$52.28
$34.57
$34.22
$22.38
$22.16
$12.90
$12.77
$9.48
$9.38
$48.19
$47.70
$21.15
$20.93
$26.99
$26.73
$160.29
$158.67
$75.34
$74.58
$152.42
$150.88
$71.67
$70.94
Page 6 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
10030
10030
10040
10040
10060
10060
10061
10061
10080
10080
10081
10081
10120
10120
10121
10121
10140
10140
10160
10160
10180
10180
11000
11000
11001
11001
11004
11005
11006
11008
11010
11010
11011
1/2/2015
Modifier
Par Fee
$787.43
$158.50
$101.60
$88.73
$117.82
$98.16
$207.85
$182.10
$180.84
$104.68
$270.55
$172.23
$153.80
$105.17
$275.34
$188.10
$164.35
$120.02
$131.23
$97.26
$247.73
$181.22
$54.84
$29.10
$21.01
$14.21
$589.61
$794.83
$713.80
$279.64
$495.17
$284.21
$531.47
Nonpar Fee
$748.06
$150.58
$96.52
$84.29
$111.93
$93.25
$197.46
$173.00
$171.80
$99.45
$257.02
$163.62
$146.11
$99.91
$261.57
$178.70
$156.13
$114.02
$124.67
$92.40
$235.34
$172.16
$52.10
$27.65
$19.96
$13.50
$560.13
$755.09
$678.11
$265.66
$470.41
$270.00
$504.90
Limiting
Charge
$860.27
$173.17
$111.00
$96.93
$128.72
$107.24
$227.08
$198.95
$197.57
$114.37
$295.57
$188.16
$168.03
$114.90
$300.81
$205.51
$179.55
$131.12
$143.37
$106.26
$270.64
$197.98
$59.92
$31.80
$22.95
$15.53
$644.15
$868.35
$779.83
$305.51
$540.97
$310.50
$580.64
Charge**
Charge***
$851.67
$847.37
$171.43
$170.57
$109.88
$109.33
$95.97
$95.48
$127.43
$126.79
$106.17
$105.63
$224.81
$223.68
$196.96
$195.97
$195.59
$194.60
$113.23
$112.65
$292.62
$291.13
$186.28
$185.35
$166.35
$165.51
$113.75
$113.17
$297.79
$296.30
$203.45
$202.42
$177.76
$176.86
$129.81
$129.16
$141.93
$141.22
$105.20
$104.66
$267.94
$266.58
$196.01
$195.02
$59.32
$59.02
$31.48
$31.33
$22.72
$22.61
$15.38
$15.30
$637.71
$634.49
$859.67
$855.32
$772.03
$768.13
$302.45
$300.93
$535.57
$532.85
$307.40
$305.84
$574.83
$571.93
Arizona
EHR/eRx
Limiting
Charge**
$843.07
$169.71
$108.78
$94.99
$126.14
$105.10
$222.54
$194.97
$193.61
$112.08
$289.66
$184.40
$164.67
$112.60
$294.79
$201.40
$175.96
$128.50
$140.51
$104.13
$265.22
$194.03
$58.72
$31.17
$22.49
$15.21
$631.27
$850.99
$764.23
$299.40
$530.15
$304.29
$569.02
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$838.89
$830.42
$168.85
$167.16
$108.24
$107.15
$94.53
$93.56
$125.52
$124.25
$104.58
$103.52
$221.44
$219.20
$194.01
$192.05
$192.66
$190.70
$111.53
$110.40
$288.22
$285.32
$183.48
$181.63
$163.85
$162.20
$112.04
$110.91
$293.33
$290.36
$200.40
$198.38
$175.09
$173.32
$127.87
$126.57
$139.81
$138.40
$103.63
$102.57
$263.93
$261.25
$193.06
$191.12
$58.43
$57.83
$31.00
$30.69
$22.38
$22.16
$15.15
$14.98
$628.14
$621.81
$846.78
$838.22
$760.45
$752.77
$297.92
$294.91
$527.53
$522.20
$302.78
$299.72
$566.20
$560.49
Page 7 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
11011
11012
11012
11042
11042
11043
11043
11044
11044
11045
11045
11046
11046
11047
11047
11055
11055
11056
11056
11057
11057
11100
11100
11101
11101
11200
11200
11201
11201
11300
11300
11301
11301
1/2/2015
Modifier
Par Fee
$301.93
$714.52
$430.63
$117.82
$62.76
$229.93
$158.06
$317.42
$235.89
$41.53
$26.51
$73.26
$56.46
$124.72
$100.76
$48.18
$16.36
$58.86
$23.11
$65.97
$30.22
$103.96
$49.26
$32.67
$25.17
$88.59
$74.29
$18.82
$16.67
$97.66
$35.45
$120.37
$54.22
Nonpar Fee
$286.83
$678.79
$409.10
$111.93
$59.62
$218.43
$150.16
$301.55
$224.10
$39.45
$25.18
$69.60
$53.64
$118.48
$95.72
$45.77
$15.54
$55.92
$21.95
$62.67
$28.71
$98.76
$46.80
$31.04
$23.91
$84.16
$70.58
$17.88
$15.84
$92.78
$33.68
$114.35
$51.51
Limiting
Charge
$329.85
$780.61
$470.47
$128.72
$68.56
$251.19
$172.68
$346.78
$257.72
$45.37
$28.96
$80.04
$61.69
$136.25
$110.08
$52.64
$17.87
$64.31
$25.24
$72.07
$33.02
$113.57
$53.82
$35.70
$27.50
$96.78
$81.17
$20.56
$18.22
$106.70
$38.73
$131.50
$59.24
Charge**
Charge***
$326.55
$324.91
$772.80
$768.90
$465.76
$463.40
$127.43
$126.79
$67.87
$67.54
$248.69
$247.42
$170.96
$170.10
$343.31
$341.58
$255.14
$253.85
$44.92
$44.69
$28.67
$28.52
$79.24
$78.84
$61.07
$60.77
$134.90
$134.21
$108.97
$108.42
$52.11
$51.84
$17.69
$17.61
$63.66
$63.34
$24.99
$24.86
$71.35
$70.99
$32.68
$32.52
$112.44
$111.87
$53.28
$53.02
$35.34
$35.16
$27.22
$27.08
$95.82
$95.34
$80.35
$79.95
$20.36
$20.25
$18.03
$17.94
$105.63
$105.10
$38.34
$38.15
$130.19
$129.52
$58.64
$58.35
Arizona
EHR/eRx
Limiting
Charge**
$323.25
$764.99
$461.06
$126.14
$67.19
$246.17
$169.23
$339.85
$252.56
$44.46
$28.38
$78.44
$60.46
$133.53
$107.88
$51.58
$17.51
$63.02
$24.74
$70.63
$32.36
$111.30
$52.74
$34.98
$26.94
$94.85
$79.55
$20.15
$17.85
$104.56
$37.96
$128.87
$58.05
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$321.66
$318.40
$761.21
$753.51
$458.77
$454.15
$125.52
$124.25
$66.85
$66.18
$244.96
$242.48
$168.39
$166.69
$338.16
$334.75
$251.31
$248.78
$44.24
$43.79
$28.24
$27.96
$78.05
$77.27
$60.15
$59.55
$132.87
$131.53
$107.34
$106.26
$51.32
$50.81
$17.42
$17.25
$62.71
$62.08
$24.61
$24.37
$70.28
$69.58
$32.19
$31.88
$110.75
$109.63
$52.49
$51.95
$34.81
$34.45
$26.81
$26.54
$94.38
$93.43
$79.14
$78.35
$20.04
$19.85
$17.76
$17.58
$104.04
$102.99
$37.77
$37.39
$128.24
$126.94
$57.76
$57.18
Page 8 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
11302
11302
11303
11303
11305
11305
11306
11306
11307
11307
11308
11308
11310
11310
11311
11311
11312
11312
11313
11313
11400
11400
11401
11401
11402
11402
11403
11403
11404
11404
11406
11406
11420
1/2/2015
Modifier
Par Fee
$141.69
$63.74
$156.26
$75.10
$99.13
$39.42
$122.20
$52.48
$144.19
$67.32
$151.70
$74.83
$113.98
$47.83
$111.65
$66.60
$160.86
$78.99
$185.99
$101.60
$124.97
$81.35
$149.74
$105.04
$166.36
$115.59
$192.43
$149.52
$217.91
$164.27
$314.42
$249.71
$123.23
Nonpar Fee
$134.61
$60.55
$148.45
$71.35
$94.17
$37.45
$116.09
$49.86
$136.98
$63.95
$144.12
$71.09
$108.28
$45.44
$106.07
$63.27
$152.82
$75.04
$176.69
$96.52
$118.72
$77.28
$142.25
$99.79
$158.04
$109.81
$182.81
$142.04
$207.01
$156.06
$298.70
$237.22
$117.07
Limiting
Charge
$154.80
$69.63
$170.72
$82.05
$108.30
$43.07
$133.50
$57.34
$157.53
$73.54
$165.74
$81.75
$124.52
$52.26
$121.98
$72.76
$175.74
$86.30
$203.19
$111.00
$136.53
$88.87
$163.59
$114.76
$181.75
$126.28
$210.23
$163.35
$238.06
$179.47
$343.51
$272.80
$134.63
Charge**
Charge***
$153.25
$152.48
$68.93
$68.59
$169.02
$168.15
$81.24
$80.82
$107.21
$106.67
$42.64
$42.42
$132.17
$131.50
$56.76
$56.48
$155.95
$155.17
$72.81
$72.44
$164.08
$163.25
$80.94
$80.52
$123.28
$122.66
$51.74
$51.47
$120.76
$120.15
$72.04
$71.67
$173.98
$173.11
$85.43
$85.00
$201.16
$200.15
$109.88
$109.33
$135.16
$134.48
$87.99
$87.54
$161.95
$161.14
$113.61
$113.03
$179.93
$179.02
$125.02
$124.38
$208.13
$207.08
$161.71
$160.90
$235.68
$234.49
$177.68
$176.78
$340.07
$338.35
$270.08
$268.71
$133.29
$132.61
Arizona
EHR/eRx
Limiting
Charge**
$151.71
$68.24
$167.30
$80.41
$106.13
$42.21
$130.84
$56.19
$154.38
$72.07
$162.43
$80.12
$122.03
$51.21
$119.54
$71.30
$172.22
$84.57
$199.13
$108.78
$133.80
$87.09
$160.32
$112.46
$178.11
$123.75
$206.02
$160.08
$233.30
$175.88
$336.64
$267.35
$131.94
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$150.95
$149.43
$67.90
$67.22
$166.49
$164.80
$80.02
$79.20
$105.60
$104.55
$42.00
$41.57
$130.19
$128.87
$55.91
$55.35
$153.62
$152.06
$71.71
$70.99
$161.62
$159.99
$79.72
$78.91
$121.43
$120.20
$50.97
$50.44
$118.94
$117.75
$70.96
$70.23
$171.37
$169.64
$84.16
$83.31
$198.15
$196.14
$108.24
$107.15
$133.14
$131.79
$86.66
$85.78
$159.53
$157.92
$111.91
$110.77
$177.23
$175.44
$123.14
$121.90
$205.01
$202.93
$159.29
$157.68
$232.15
$229.80
$175.01
$173.25
$334.96
$331.59
$266.03
$263.34
$131.28
$129.96
Page 9 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
11420
11421
11421
11422
11422
11423
11423
11424
11424
11426
11426
11440
11440
11441
11441
11442
11442
11443
11443
11444
11444
11446
11446
11450
11450
11451
11451
11462
11462
11463
11463
11470
11470
1/2/2015
Modifier
Par Fee
$82.47
$157.92
$111.43
$176.29
$137.32
$203.11
$159.85
$234.54
$182.69
$334.63
$278.49
$135.34
$104.23
$169.22
$133.47
$188.67
$147.55
$224.74
$180.77
$282.41
$230.56
$392.78
$329.49
$385.53
$255.74
$486.82
$327.36
$373.32
$243.18
$496.52
$330.26
$413.20
$283.41
Nonpar Fee
$78.35
$150.02
$105.86
$167.48
$130.45
$192.95
$151.86
$222.81
$173.56
$317.90
$264.57
$128.57
$99.02
$160.76
$126.80
$179.24
$140.17
$213.50
$171.73
$268.29
$219.03
$373.14
$313.02
$366.25
$242.95
$462.48
$310.99
$354.65
$231.02
$471.69
$313.75
$392.54
$269.24
Limiting
Charge
$90.10
$172.52
$121.74
$192.60
$150.02
$221.89
$174.64
$256.23
$199.59
$365.59
$304.26
$147.86
$113.87
$184.87
$145.82
$206.13
$161.20
$245.53
$197.49
$308.53
$251.88
$429.11
$359.97
$421.19
$279.39
$531.85
$357.64
$407.85
$265.67
$542.44
$360.81
$451.42
$309.63
Charge**
Charge***
$89.21
$88.75
$170.80
$169.94
$120.52
$119.91
$190.68
$189.72
$148.52
$147.76
$219.67
$218.57
$172.89
$172.02
$253.67
$252.39
$197.59
$196.60
$361.93
$360.10
$301.21
$299.69
$146.37
$145.64
$112.73
$112.16
$183.02
$182.10
$144.36
$143.64
$204.07
$203.03
$159.59
$158.78
$243.08
$241.85
$195.51
$194.52
$305.45
$303.91
$249.37
$248.10
$424.82
$422.67
$356.37
$354.57
$416.98
$414.87
$276.60
$275.21
$526.54
$523.87
$354.06
$352.28
$403.77
$401.73
$263.02
$261.68
$537.02
$534.30
$357.20
$355.40
$446.90
$444.65
$306.53
$304.98
Arizona
EHR/eRx
Limiting
Charge**
$88.30
$169.07
$119.30
$188.75
$147.02
$217.45
$171.14
$251.10
$195.60
$358.27
$298.17
$144.90
$111.60
$181.17
$142.90
$202.01
$157.98
$240.61
$193.55
$302.36
$246.85
$420.53
$352.77
$412.77
$273.80
$521.21
$350.49
$399.69
$260.36
$531.60
$353.60
$442.39
$303.44
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$87.87
$86.97
$168.23
$166.53
$118.71
$117.51
$187.82
$185.92
$146.29
$144.81
$216.37
$214.19
$170.29
$168.58
$249.86
$247.33
$194.63
$192.67
$356.50
$352.90
$296.69
$293.70
$144.18
$142.73
$111.04
$109.92
$180.27
$178.46
$142.20
$140.76
$201.01
$198.98
$157.19
$155.61
$239.43
$237.00
$192.58
$190.65
$300.87
$297.83
$245.63
$243.14
$418.45
$414.22
$351.03
$347.48
$410.72
$406.58
$272.45
$269.70
$518.64
$513.39
$348.75
$345.23
$397.70
$393.70
$259.07
$256.45
$528.97
$523.63
$351.84
$348.30
$440.20
$435.76
$301.93
$298.89
Page 10 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
11471
11471
11600
11600
11601
11601
11602
11602
11603
11603
11604
11604
11606
11606
11620
11620
11621
11621
11622
11622
11623
11623
11624
11624
11626
11626
11640
11640
11641
11641
11642
11642
11643
1/2/2015
Modifier
Par Fee
$510.28
$349.74
$193.14
$121.27
$229.34
$151.04
$248.20
$165.61
$283.88
$198.42
$315.70
$218.45
$452.09
$323.73
$195.24
$122.66
$230.73
$152.43
$257.01
$174.06
$301.53
$215.37
$339.71
$243.53
$410.21
$299.37
$200.96
$126.95
$238.55
$158.46
$271.90
$186.80
$320.98
Nonpar Fee
$484.77
$332.25
$183.48
$115.21
$217.87
$143.49
$235.79
$157.33
$269.69
$188.50
$299.92
$207.53
$429.49
$307.54
$185.48
$116.53
$219.19
$144.81
$244.16
$165.36
$286.45
$204.60
$322.72
$231.35
$389.70
$284.40
$190.91
$120.60
$226.62
$150.54
$258.31
$177.46
$304.93
Limiting
Charge
$557.49
$382.09
$211.00
$132.49
$250.55
$165.01
$271.16
$180.93
$310.14
$216.78
$344.91
$238.66
$493.91
$353.67
$213.30
$134.01
$252.07
$166.53
$280.78
$190.16
$329.42
$235.29
$371.13
$266.05
$448.16
$327.06
$219.55
$138.69
$260.61
$173.12
$297.06
$204.08
$350.67
Charge**
Charge***
$551.91
$549.13
$378.27
$376.36
$208.90
$207.84
$131.17
$130.50
$248.04
$246.79
$163.37
$162.54
$268.44
$267.09
$179.12
$178.22
$307.04
$305.49
$214.61
$213.52
$341.46
$339.73
$236.27
$235.08
$488.98
$486.51
$350.13
$348.37
$211.17
$210.11
$132.66
$132.00
$249.55
$248.29
$164.86
$164.04
$277.98
$276.58
$188.27
$187.31
$326.13
$324.47
$232.93
$231.76
$367.41
$365.56
$263.40
$262.06
$443.67
$441.43
$323.79
$322.15
$217.35
$216.26
$137.30
$136.61
$258.00
$256.70
$171.38
$170.52
$294.09
$292.61
$202.04
$201.02
$347.16
$345.41
Arizona
EHR/eRx
Limiting
Charge**
$546.33
$374.45
$206.78
$129.85
$245.54
$161.71
$265.73
$177.31
$303.95
$212.44
$338.01
$233.89
$484.04
$346.60
$209.04
$131.33
$247.03
$163.20
$275.17
$186.36
$322.83
$230.59
$363.71
$260.73
$439.20
$320.52
$215.15
$135.92
$255.40
$169.66
$291.11
$200.00
$343.65
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$543.63
$538.13
$372.60
$368.84
$205.77
$203.68
$129.20
$127.90
$244.32
$241.86
$160.92
$159.29
$264.42
$261.74
$176.43
$174.65
$302.44
$299.39
$211.39
$209.25
$336.34
$332.94
$232.73
$230.38
$481.64
$476.78
$344.87
$341.40
$208.01
$205.90
$130.67
$129.36
$245.81
$243.33
$162.39
$160.75
$273.80
$271.04
$185.44
$183.56
$321.24
$317.99
$229.44
$227.13
$361.91
$358.26
$259.44
$256.82
$437.01
$432.61
$318.94
$315.71
$214.10
$211.92
$135.24
$133.88
$254.13
$251.57
$168.81
$167.12
$289.67
$286.74
$199.01
$197.00
$341.95
$338.50
Page 11 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
11643
11644
11644
11646
11646
11719
11719
11720
11720
11721
11721
11730
11730
11732
11732
11740
11740
11750
11750
11752
11752
11755
11755
11760
11760
11762
11762
11765
11765
11770
11770
11771
11771
1/2/2015
Modifier
Par Fee
$234.10
$396.39
$289.13
$518.61
$402.05
$13.90
$7.82
$32.45
$14.93
$44.92
$24.90
$99.45
$51.18
$35.98
$20.61
$49.92
$33.12
$224.78
$176.15
$327.37
$266.94
$134.36
$78.94
$230.37
$133.47
$284.76
$188.58
$168.72
$95.43
$277.90
$187.08
$576.55
$438.54
Nonpar Fee
$222.40
$376.57
$274.67
$492.68
$381.95
$13.21
$7.43
$30.83
$14.18
$42.67
$23.66
$94.48
$48.62
$34.18
$19.58
$47.42
$31.46
$213.54
$167.34
$311.00
$253.59
$127.64
$74.99
$218.85
$126.80
$270.52
$179.15
$160.28
$90.66
$264.01
$177.73
$547.72
$416.61
Limiting
Charge
$255.76
$433.06
$315.87
$566.58
$439.24
$15.19
$8.54
$35.45
$16.31
$49.07
$27.21
$108.65
$55.91
$39.31
$22.52
$54.53
$36.18
$245.57
$192.44
$357.65
$291.63
$146.79
$86.24
$251.68
$145.82
$311.10
$206.02
$184.32
$104.26
$303.61
$204.39
$629.88
$479.10
Charge**
Charge***
$253.21
$251.92
$428.72
$426.56
$312.71
$311.13
$560.91
$558.08
$434.85
$432.65
$15.04
$14.96
$8.46
$8.42
$35.10
$34.93
$16.15
$16.07
$48.58
$48.33
$26.93
$26.81
$107.57
$107.02
$55.35
$55.07
$38.92
$38.72
$22.29
$22.18
$53.99
$53.72
$35.82
$35.64
$243.11
$241.89
$190.52
$189.55
$354.07
$352.29
$288.71
$287.26
$145.31
$144.59
$85.38
$84.95
$249.16
$247.91
$144.36
$143.64
$307.98
$306.43
$203.96
$202.93
$182.48
$181.56
$103.21
$102.70
$300.58
$299.06
$202.34
$201.32
$623.58
$620.43
$474.31
$471.91
Arizona
EHR/eRx
Limiting
Charge**
$250.64
$424.40
$309.56
$555.25
$430.46
$14.89
$8.37
$34.74
$15.99
$48.09
$26.67
$106.48
$54.80
$38.53
$22.07
$53.44
$35.45
$240.66
$188.59
$350.50
$285.80
$143.85
$84.51
$246.64
$142.90
$304.88
$201.91
$180.63
$102.18
$297.54
$200.31
$617.29
$469.52
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$249.41
$246.88
$422.29
$418.03
$308.02
$304.91
$552.49
$546.93
$428.33
$424.01
$14.81
$14.67
$8.34
$8.25
$34.57
$34.22
$15.90
$15.74
$47.85
$47.37
$26.53
$26.27
$105.96
$104.88
$54.52
$53.98
$38.33
$37.95
$21.95
$21.74
$53.19
$52.64
$35.28
$34.93
$239.46
$237.05
$187.66
$185.76
$348.76
$345.24
$284.37
$281.51
$143.13
$141.69
$84.10
$83.25
$245.42
$242.94
$142.20
$140.76
$303.36
$300.30
$200.91
$198.88
$179.75
$177.92
$101.66
$100.65
$296.07
$293.08
$199.31
$197.31
$614.23
$608.03
$467.19
$462.48
Page 12 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
11772
11772
11900
11900
11901
11901
11920
11920
11921
11921
11922
11922
11950
11950
11951
11951
11952
11952
11954
11954
11960
11970
11971
11971
11976
11976
11980
11980
11981
11981
11982
11982
11983
1/2/2015
Modifier
Par Fee
$701.26
$583.99
$55.51
$31.56
$69.68
$48.59
$171.91
$115.77
$198.86
$136.29
$61.55
$30.08
$78.40
$54.09
$106.70
$75.95
$129.72
$97.18
$159.53
$116.98
$955.19
$616.19
$474.15
$322.55
$143.84
$95.57
$94.58
$57.04
$142.19
$84.27
$160.96
$101.97
$224.03
Nonpar Fee
$666.20
$554.79
$52.73
$29.98
$66.20
$46.16
$163.31
$109.98
$188.92
$129.48
$58.47
$28.58
$74.48
$51.39
$101.37
$72.15
$123.23
$92.32
$151.55
$111.13
$907.43
$585.38
$450.44
$306.42
$136.65
$90.79
$89.85
$54.19
$135.08
$80.06
$152.91
$96.87
$212.83
Limiting
Charge
$766.13
$638.01
$60.64
$34.48
$76.13
$53.08
$187.81
$126.48
$217.26
$148.90
$67.24
$32.87
$85.65
$59.10
$116.58
$82.97
$141.71
$106.17
$174.28
$127.80
$1,043.54
$673.19
$518.01
$352.38
$157.15
$104.41
$103.33
$62.32
$155.34
$92.07
$175.85
$111.40
$244.75
Charge**
Charge***
$758.47
$754.64
$631.63
$628.44
$60.03
$59.73
$34.13
$33.96
$75.37
$74.99
$52.56
$52.29
$185.93
$184.99
$125.21
$124.58
$215.08
$214.00
$147.42
$146.67
$66.57
$66.23
$32.53
$32.37
$84.80
$84.36
$58.51
$58.21
$115.41
$114.83
$82.14
$81.73
$140.30
$139.59
$105.11
$104.58
$172.53
$171.67
$126.52
$125.88
$1,033.11
$1,027.89
$666.46
$663.09
$512.83
$510.23
$348.86
$347.09
$155.57
$154.79
$103.36
$102.84
$102.29
$101.78
$61.70
$61.39
$153.79
$153.01
$91.15
$90.69
$174.09
$173.21
$110.29
$109.73
$242.31
$241.09
Arizona
EHR/eRx
Limiting
Charge**
$750.81
$625.24
$59.43
$33.79
$74.61
$52.03
$184.05
$123.95
$212.91
$145.92
$65.90
$32.21
$83.94
$57.91
$114.24
$81.32
$138.89
$104.04
$170.80
$125.25
$1,022.67
$659.72
$507.64
$345.33
$154.01
$102.32
$101.26
$61.08
$152.24
$90.23
$172.33
$109.17
$239.86
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$747.10
$739.55
$622.15
$615.86
$59.13
$58.54
$33.61
$33.28
$74.24
$73.50
$51.76
$51.24
$183.14
$181.29
$123.34
$122.08
$211.85
$209.71
$145.21
$143.74
$65.57
$64.91
$32.05
$31.73
$83.52
$82.69
$57.64
$57.04
$113.68
$112.53
$80.91
$80.10
$138.20
$136.80
$103.53
$102.48
$169.95
$168.23
$124.63
$123.37
$1,017.61
$1,007.33
$656.47
$649.82
$505.14
$500.03
$343.63
$340.16
$153.24
$151.70
$101.81
$100.79
$100.76
$99.74
$60.78
$60.16
$151.48
$149.95
$89.78
$88.87
$171.48
$169.74
$108.63
$107.54
$238.67
$236.26
Page 13 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
11983
12001
12001
12002
12002
12004
12004
12005
12005
12006
12006
12007
12007
12011
12011
12013
12013
12014
12014
12015
12015
12016
12016
12017
12018
12020
12020
12021
12021
12031
12031
12032
12032
1/2/2015
Modifier
Par Fee
$176.84
$89.98
$44.92
$109.78
$59.36
$129.22
$74.16
$167.49
$100.27
$200.12
$121.81
$232.48
$151.68
$110.18
$55.83
$120.82
$62.90
$142.72
$79.79
$172.49
$99.55
$214.20
$134.82
$155.70
$176.76
$282.45
$191.63
$164.90
$140.94
$237.57
$155.33
$303.81
$197.97
Nonpar Fee
$168.00
$85.48
$42.67
$104.29
$56.39
$122.76
$70.45
$159.12
$95.26
$190.11
$115.72
$220.86
$144.10
$104.67
$53.04
$114.78
$59.76
$135.58
$75.80
$163.87
$94.57
$203.49
$128.08
$147.92
$167.92
$268.33
$182.05
$156.66
$133.89
$225.69
$147.56
$288.62
$188.07
Limiting
Charge
$193.20
$98.30
$49.07
$119.93
$64.85
$141.17
$81.02
$182.99
$109.55
$218.63
$133.08
$253.99
$165.72
$120.37
$61.00
$132.00
$68.72
$155.92
$87.17
$188.45
$108.76
$234.01
$147.29
$170.11
$193.11
$308.58
$209.36
$180.16
$153.97
$259.54
$169.69
$331.91
$216.28
Charge**
Charge***
$191.27
$190.30
$97.32
$96.83
$48.58
$48.33
$118.74
$118.14
$64.20
$63.87
$139.76
$139.06
$80.21
$79.80
$181.16
$180.24
$108.46
$107.90
$216.44
$215.35
$131.74
$131.08
$251.45
$250.18
$164.06
$163.23
$119.16
$118.57
$60.39
$60.08
$130.67
$130.02
$68.03
$67.69
$154.35
$153.58
$86.30
$85.86
$186.56
$185.62
$107.66
$107.12
$231.68
$230.51
$145.82
$145.08
$168.41
$167.56
$191.18
$190.21
$305.50
$303.96
$207.26
$206.22
$178.35
$177.46
$152.43
$151.66
$256.94
$255.65
$167.99
$167.15
$328.59
$326.93
$214.12
$213.04
Arizona
EHR/eRx
Limiting
Charge**
$189.34
$96.34
$48.09
$117.53
$63.55
$138.35
$79.40
$179.33
$107.35
$214.26
$130.42
$248.91
$162.40
$117.97
$59.78
$129.35
$67.34
$152.80
$85.42
$184.68
$106.58
$229.33
$144.35
$166.70
$189.24
$302.40
$205.17
$176.56
$150.89
$254.36
$166.30
$325.28
$211.96
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$188.40
$186.50
$95.86
$94.89
$47.85
$47.37
$116.96
$115.77
$63.24
$62.59
$137.67
$136.28
$79.01
$78.20
$178.45
$176.64
$106.84
$105.74
$213.20
$211.05
$129.77
$128.47
$247.68
$245.17
$161.60
$159.97
$117.38
$116.20
$59.48
$58.88
$128.72
$127.41
$67.01
$66.33
$152.04
$150.51
$85.00
$84.15
$183.77
$181.91
$106.05
$104.98
$228.21
$225.89
$143.64
$142.19
$165.88
$164.21
$188.31
$186.40
$300.92
$297.87
$204.16
$202.09
$175.67
$173.91
$150.14
$148.63
$253.09
$250.54
$165.47
$163.81
$323.66
$320.40
$210.91
$208.78
Page 14 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
12034
12034
12035
12035
12036
12036
12037
12037
12041
12041
12042
12042
12044
12044
12045
12045
12046
12046
12047
12047
12051
12051
12052
12052
12053
12053
12054
12054
12055
12055
12056
12056
12057
1/2/2015
Modifier
Par Fee
$312.62
$210.00
$383.56
$244.11
$420.98
$282.61
$483.52
$333.70
$242.53
$159.22
$289.37
$203.20
$360.84
$218.90
$406.35
$276.56
$484.24
$315.47
$562.66
$382.46
$258.49
$174.10
$294.65
$207.05
$346.59
$221.09
$368.85
$231.19
$478.14
$306.51
$500.63
$354.03
$584.84
Nonpar Fee
$296.99
$199.50
$364.38
$231.90
$399.93
$268.48
$459.34
$317.02
$230.40
$151.26
$274.90
$193.04
$342.80
$207.96
$386.03
$262.73
$460.03
$299.70
$534.53
$363.34
$245.57
$165.40
$279.92
$196.70
$329.26
$210.04
$350.41
$219.63
$454.23
$291.18
$475.60
$336.33
$555.60
Limiting
Charge
$341.54
$229.43
$419.04
$266.69
$459.92
$308.75
$528.24
$364.57
$264.96
$173.95
$316.14
$222.00
$394.22
$239.15
$443.93
$302.14
$529.03
$344.66
$614.71
$417.84
$282.41
$190.21
$321.91
$226.21
$378.65
$241.55
$402.97
$252.57
$522.36
$334.86
$546.94
$386.78
$638.94
Charge**
Charge***
$338.12
$336.42
$227.14
$225.99
$414.85
$412.75
$264.02
$262.68
$455.32
$453.02
$305.67
$304.12
$522.96
$520.32
$360.93
$359.10
$262.32
$260.98
$172.21
$171.34
$312.97
$311.40
$219.78
$218.66
$390.28
$388.31
$236.76
$235.57
$439.50
$437.28
$299.12
$297.61
$523.74
$521.10
$341.21
$339.48
$608.56
$605.49
$413.67
$411.57
$279.58
$278.17
$188.31
$187.36
$318.69
$317.08
$223.94
$222.81
$374.87
$372.97
$239.13
$237.92
$398.95
$396.92
$250.04
$248.79
$517.14
$514.53
$331.51
$329.83
$541.47
$538.74
$382.92
$380.98
$632.55
$629.36
Arizona
EHR/eRx
Limiting
Charge**
$334.71
$224.84
$410.65
$261.35
$450.72
$302.58
$517.67
$357.28
$259.66
$170.46
$309.81
$217.56
$386.33
$234.37
$435.06
$296.10
$518.45
$337.77
$602.42
$409.48
$276.76
$186.40
$315.47
$221.69
$371.07
$236.72
$394.91
$247.53
$511.92
$328.16
$536.00
$379.04
$626.16
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$333.05
$329.68
$223.73
$221.47
$408.63
$404.49
$260.06
$257.43
$448.49
$443.96
$301.08
$298.03
$515.12
$509.91
$355.51
$351.92
$258.38
$255.76
$169.63
$167.91
$308.28
$305.16
$216.48
$214.29
$384.42
$380.54
$233.21
$230.85
$432.91
$428.54
$294.63
$291.66
$515.89
$510.68
$336.09
$332.70
$599.43
$593.38
$407.46
$403.34
$275.38
$272.61
$185.48
$183.61
$313.90
$310.74
$220.58
$218.36
$369.24
$365.50
$235.54
$233.16
$392.97
$388.99
$246.30
$243.81
$509.38
$504.24
$326.54
$323.24
$533.35
$527.97
$377.18
$373.36
$623.06
$616.77
Page 15 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
12057
13100
13100
13101
13101
13102
13102
13120
13120
13121
13121
13122
13122
13131
13131
13132
13132
13133
13133
13151
13151
13152
13152
13153
13153
13160
14000
14000
14001
14001
14020
14020
14021
1/2/2015
Modifier
Par Fee
$383.54
$335.63
$209.42
$396.87
$256.71
$122.43
$75.59
$350.88
$240.04
$427.75
$271.15
$134.14
$86.95
$386.37
$254.07
$478.00
$318.89
$179.51
$133.39
$423.83
$291.53
$508.40
$352.86
$195.07
$143.94
$818.99
$625.74
$509.18
$803.92
$663.04
$700.20
$576.49
$875.65
Nonpar Fee
$364.36
$318.85
$198.95
$377.03
$243.87
$116.31
$71.81
$333.34
$228.04
$406.36
$257.59
$127.43
$82.60
$367.05
$241.37
$454.10
$302.95
$170.53
$126.72
$402.64
$276.95
$482.98
$335.22
$185.32
$136.74
$778.04
$594.45
$483.72
$763.72
$629.89
$665.19
$547.67
$831.87
Limiting
Charge
$419.01
$366.68
$228.79
$433.58
$280.45
$133.76
$82.58
$383.34
$262.25
$467.31
$296.23
$146.54
$94.99
$422.11
$277.58
$522.22
$348.39
$196.11
$145.73
$463.04
$318.49
$555.43
$385.50
$213.12
$157.25
$894.75
$683.62
$556.28
$878.28
$724.37
$764.97
$629.82
$956.65
Charge**
Charge***
$414.83
$412.72
$363.01
$361.18
$226.50
$225.37
$429.25
$427.08
$277.64
$276.24
$132.42
$131.76
$81.75
$81.34
$379.51
$377.59
$259.62
$258.31
$462.65
$460.30
$293.26
$291.79
$145.08
$144.35
$94.04
$93.56
$417.89
$415.77
$274.80
$273.41
$516.99
$514.38
$344.91
$343.17
$194.14
$193.17
$144.27
$143.54
$458.40
$456.09
$315.31
$313.72
$549.87
$547.10
$381.65
$379.72
$210.99
$209.92
$155.68
$154.89
$885.80
$881.33
$676.79
$673.36
$550.71
$547.93
$869.49
$865.10
$717.13
$713.51
$757.32
$753.49
$623.52
$620.37
$947.08
$942.30
Arizona
EHR/eRx
Limiting
Charge**
$410.63
$359.34
$224.22
$424.91
$274.84
$131.08
$80.93
$375.67
$257.00
$457.96
$290.31
$143.61
$93.09
$413.67
$272.02
$511.77
$341.42
$192.19
$142.82
$453.78
$312.12
$544.32
$377.80
$208.85
$154.11
$876.85
$669.94
$545.16
$860.72
$709.88
$749.67
$617.23
$937.51
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$408.61
$404.47
$357.57
$353.95
$223.11
$220.86
$422.81
$418.54
$273.48
$270.72
$130.43
$129.11
$80.52
$79.71
$373.82
$370.04
$255.73
$253.15
$455.71
$451.10
$288.86
$285.95
$142.91
$141.46
$92.62
$91.70
$411.62
$407.46
$270.69
$267.94
$509.24
$504.09
$339.73
$336.31
$191.23
$189.30
$142.11
$140.68
$451.52
$446.97
$310.58
$307.44
$541.63
$536.15
$375.92
$372.13
$207.83
$205.72
$153.34
$151.80
$872.52
$863.70
$666.63
$659.89
$542.46
$536.98
$856.45
$847.80
$706.38
$699.23
$745.96
$738.43
$614.17
$607.97
$932.88
$923.45
Page 16 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
14021
14040
14040
14041
14041
14060
14060
14061
14061
14301
14301
14302
14350
15002
15002
15003
15003
15004
15004
15005
15005
15040
15040
15050
15050
15100
15100
15101
15101
15110
15110
15111
15111
1/2/2015
Modifier
Par Fee
$728.70
$765.86
$641.79
$947.61
$788.50
$780.93
$683.32
$1,019.79
$843.88
$1,084.31
$895.53
$225.30
$704.41
$349.41
$230.71
$76.57
$46.54
$405.55
$276.47
$125.70
$92.45
$256.12
$129.55
$573.34
$454.64
$865.58
$726.85
$187.60
$112.88
$823.47
$719.07
$116.81
$105.37
Nonpar Fee
$692.27
$727.57
$609.70
$900.23
$749.08
$741.88
$649.15
$968.80
$801.69
$1,030.09
$850.75
$214.04
$669.19
$331.94
$219.17
$72.74
$44.21
$385.27
$262.65
$119.42
$87.83
$243.31
$123.07
$544.67
$431.91
$822.30
$690.51
$178.22
$107.24
$782.30
$683.12
$110.97
$100.10
Limiting
Charge
$796.11
$836.71
$701.16
$1,035.26
$861.44
$853.16
$746.52
$1,114.12
$921.94
$1,184.60
$978.36
$246.15
$769.57
$381.73
$252.05
$83.65
$50.84
$443.06
$302.05
$137.33
$101.00
$279.81
$141.53
$626.37
$496.70
$945.65
$794.09
$204.95
$123.33
$899.65
$785.59
$127.62
$115.12
Charge**
Charge***
$788.15
$784.17
$828.33
$824.16
$694.14
$690.63
$1,024.91
$1,019.74
$852.83
$848.52
$844.63
$840.36
$739.06
$735.32
$1,102.98
$1,097.41
$912.72
$908.11
$1,172.76
$1,166.84
$968.58
$963.69
$243.69
$242.45
$761.88
$758.02
$377.91
$376.00
$249.53
$248.26
$82.81
$82.40
$50.34
$50.08
$438.63
$436.41
$299.02
$297.52
$135.96
$135.27
$99.99
$99.49
$277.01
$275.61
$140.12
$139.40
$620.10
$616.98
$491.73
$489.24
$936.19
$931.47
$786.14
$782.17
$202.91
$201.88
$122.10
$121.47
$890.65
$886.16
$777.73
$773.80
$126.34
$125.71
$113.97
$113.39
Arizona
EHR/eRx
Limiting
Charge**
$780.18
$819.97
$687.14
$1,014.56
$844.22
$836.10
$731.60
$1,091.83
$903.51
$1,160.91
$958.80
$241.22
$754.18
$374.10
$247.01
$81.98
$49.83
$434.19
$296.01
$134.58
$98.98
$274.21
$138.70
$613.85
$486.76
$926.73
$778.21
$200.86
$120.87
$881.65
$769.88
$125.06
$112.82
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$776.33
$768.48
$815.91
$807.67
$683.73
$676.83
$1,009.54
$999.35
$840.04
$831.55
$831.96
$823.55
$727.97
$720.62
$1,086.43
$1,075.46
$899.02
$889.96
$1,155.16
$1,143.50
$954.05
$944.41
$240.03
$237.60
$750.44
$742.87
$372.24
$368.48
$245.79
$243.31
$81.57
$80.75
$49.58
$49.08
$432.06
$427.69
$294.54
$291.57
$133.93
$132.56
$98.50
$97.50
$272.86
$270.09
$138.01
$136.62
$610.80
$604.64
$484.36
$479.46
$922.15
$912.82
$774.35
$766.53
$199.86
$197.85
$120.27
$119.05
$877.29
$868.42
$766.07
$758.33
$124.44
$123.19
$112.25
$111.12
Page 17 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
15115
15115
15116
15116
15120
15120
15121
15121
15130
15130
15131
15131
15135
15135
15136
15136
15150
15150
15151
15151
15152
15152
15155
15155
15156
15156
15157
15157
15200
15200
15201
15201
15220
1/2/2015
Modifier
Par Fee
$835.62
$730.86
$170.09
$155.07
$857.56
$708.82
$210.00
$135.27
$685.25
$577.63
$92.09
$84.23
$850.40
$747.43
$96.11
$89.67
$701.94
$642.23
$121.60
$112.30
$149.99
$140.69
$700.76
$646.77
$164.03
$155.09
$158.86
$147.77
$835.21
$681.46
$149.11
$80.11
$775.65
Nonpar Fee
$793.84
$694.32
$161.59
$147.32
$814.68
$673.38
$199.50
$128.51
$650.99
$548.75
$87.49
$80.02
$807.88
$710.06
$91.30
$85.19
$666.84
$610.12
$115.52
$106.69
$142.49
$133.66
$665.72
$614.43
$155.83
$147.34
$150.92
$140.38
$793.45
$647.39
$141.65
$76.10
$736.87
Limiting
Charge
$912.92
$798.47
$185.83
$169.42
$936.88
$774.39
$229.43
$147.79
$748.64
$631.06
$100.61
$92.02
$929.06
$816.57
$105.00
$97.97
$766.87
$701.64
$132.85
$122.69
$163.86
$153.71
$765.58
$706.59
$179.20
$169.44
$173.56
$161.44
$912.47
$744.50
$162.90
$87.52
$847.40
Charge**
Charge***
$903.79
$899.22
$790.49
$786.50
$183.97
$183.05
$167.73
$166.88
$927.51
$922.83
$766.65
$762.77
$227.14
$225.99
$146.30
$145.57
$741.15
$737.41
$624.75
$621.60
$99.61
$99.11
$91.10
$90.64
$919.77
$915.12
$808.40
$804.32
$103.95
$103.42
$96.99
$96.50
$759.20
$755.37
$694.62
$691.12
$131.51
$130.86
$121.46
$120.85
$162.23
$161.40
$152.17
$151.41
$757.92
$754.09
$699.53
$695.99
$177.41
$176.51
$167.75
$166.90
$171.82
$170.96
$159.83
$159.01
$903.35
$898.78
$737.06
$733.33
$161.26
$160.46
$86.64
$86.20
$838.93
$834.69
Arizona
EHR/eRx
Limiting
Charge**
$894.65
$782.49
$182.11
$166.03
$918.15
$758.90
$224.84
$144.83
$733.67
$618.45
$98.60
$90.18
$910.48
$800.24
$102.89
$96.01
$751.53
$687.61
$130.19
$120.24
$160.59
$150.64
$750.27
$692.46
$175.62
$166.05
$170.09
$158.21
$894.22
$729.61
$159.64
$85.77
$830.45
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$890.23
$881.23
$778.63
$770.75
$181.21
$179.38
$165.21
$163.53
$913.59
$904.37
$755.15
$747.51
$223.73
$221.47
$144.11
$142.66
$730.03
$722.66
$615.38
$609.17
$98.12
$97.12
$89.73
$88.83
$905.97
$896.82
$796.28
$788.23
$102.38
$101.35
$95.53
$94.58
$747.81
$740.26
$684.20
$677.29
$129.54
$128.24
$119.65
$118.44
$159.79
$158.18
$149.89
$148.38
$746.55
$739.01
$689.05
$682.08
$174.75
$172.98
$165.23
$163.55
$169.25
$167.53
$157.44
$155.84
$889.80
$880.81
$726.01
$718.66
$158.85
$157.25
$85.34
$84.48
$826.34
$818.00
Page 18 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
15220
15221
15221
15240
15240
15241
15241
15260
15260
15261
15261
15271
15271
15272
15272
15273
15273
15274
15274
15275
15275
15276
15276
15277
15277
15278
15278
15570
15570
15572
15572
15574
15574
1/2/2015
Modifier
Par Fee
$624.06
$138.16
$72.73
$939.48
$812.55
$186.75
$113.45
$1,018.50
$871.19
$216.29
$142.64
$142.05
$86.27
$27.31
$17.66
$299.36
$206.04
$71.52
$46.49
$150.76
$98.20
$34.46
$25.17
$326.00
$229.82
$85.69
$58.16
$919.20
$745.79
$893.32
$756.73
$921.16
$779.57
Nonpar Fee
$592.86
$131.25
$69.09
$892.51
$771.92
$177.41
$107.78
$967.58
$827.63
$205.48
$135.51
$134.95
$81.96
$25.94
$16.78
$284.39
$195.74
$67.94
$44.17
$143.22
$93.29
$32.74
$23.91
$309.70
$218.33
$81.41
$55.25
$873.24
$708.50
$848.65
$718.89
$875.10
$740.59
Limiting
Charge
$681.79
$150.94
$79.45
$1,026.39
$887.71
$204.02
$123.95
$1,112.72
$951.77
$236.30
$155.84
$155.19
$94.25
$29.83
$19.30
$327.05
$225.10
$78.13
$50.80
$164.70
$107.28
$37.65
$27.50
$356.16
$251.08
$93.62
$63.54
$1,004.23
$814.78
$975.95
$826.72
$1,006.37
$851.68
Charge**
Charge***
$674.97
$671.57
$149.43
$148.67
$78.66
$78.26
$1,016.12
$1,010.99
$878.83
$874.39
$201.99
$200.96
$122.71
$122.08
$1,101.59
$1,096.03
$942.25
$937.50
$233.94
$232.76
$154.27
$153.50
$153.64
$152.87
$93.31
$92.84
$29.53
$29.38
$19.10
$19.01
$323.78
$322.14
$222.85
$221.72
$77.35
$76.96
$50.29
$50.04
$163.06
$162.23
$106.21
$105.67
$37.27
$37.09
$27.22
$27.08
$352.59
$350.81
$248.57
$247.32
$92.69
$92.22
$62.91
$62.58
$994.19
$989.16
$806.63
$802.55
$966.18
$961.31
$818.46
$814.33
$996.30
$991.27
$843.16
$838.90
Arizona
EHR/eRx
Limiting
Charge**
$668.15
$147.92
$77.87
$1,005.86
$869.95
$199.94
$121.46
$1,090.46
$932.74
$231.58
$152.72
$152.09
$92.37
$29.23
$18.91
$320.51
$220.60
$76.57
$49.78
$161.41
$105.13
$36.90
$26.94
$349.04
$246.05
$91.75
$62.27
$984.15
$798.48
$956.43
$810.19
$986.24
$834.65
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$664.85
$658.13
$147.19
$145.71
$77.48
$76.69
$1,000.88
$990.77
$865.65
$856.90
$198.96
$196.94
$120.87
$119.65
$1,085.06
$1,074.11
$928.12
$918.75
$230.44
$228.10
$151.96
$150.43
$151.34
$149.81
$91.91
$90.99
$29.08
$28.80
$18.81
$18.62
$318.93
$315.70
$219.50
$217.29
$76.19
$75.42
$49.53
$49.04
$160.61
$158.99
$104.62
$103.56
$36.71
$36.35
$26.81
$26.54
$347.30
$343.80
$244.85
$242.36
$91.30
$90.37
$61.96
$61.34
$979.27
$969.38
$794.54
$786.51
$951.69
$942.08
$806.17
$798.03
$981.35
$971.45
$830.51
$822.12
Page 19 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
15576
15576
15600
15600
15610
15610
15620
15620
15630
15630
15650
15650
15731
15731
15732
15732
15734
15734
15736
15736
15738
15738
15740
15740
15750
15756
15757
15758
15760
15760
15770
15775
15775
1/2/2015
Modifier
Par Fee
$811.90
$681.04
$326.42
$210.22
$359.23
$245.53
$442.55
$330.64
$463.51
$351.96
$511.53
$389.60
$1,140.06
$1,025.65
$1,296.44
$1,135.19
$1,514.54
$1,338.62
$1,329.36
$1,155.95
$1,413.54
$1,250.50
$1,027.13
$866.95
$935.95
$2,364.49
$2,344.54
$2,338.91
$860.62
$720.47
$680.61
$295.18
$219.02
Nonpar Fee
$771.31
$646.99
$310.10
$199.71
$341.27
$233.25
$420.42
$314.11
$440.33
$334.36
$485.95
$370.12
$1,083.06
$974.37
$1,231.62
$1,078.43
$1,438.81
$1,271.69
$1,262.89
$1,098.15
$1,342.86
$1,187.98
$975.77
$823.60
$889.15
$2,246.27
$2,227.31
$2,221.96
$817.59
$684.45
$646.58
$280.42
$208.07
Limiting
Charge
$887.01
$744.04
$356.62
$229.67
$392.46
$268.24
$483.48
$361.23
$506.38
$384.51
$558.84
$425.64
$1,245.52
$1,120.53
$1,416.36
$1,240.19
$1,654.63
$1,462.44
$1,452.32
$1,262.87
$1,544.29
$1,366.18
$1,122.14
$947.14
$1,022.52
$2,583.21
$2,561.41
$2,555.25
$940.23
$787.12
$743.57
$322.48
$239.28
Charge**
Charge***
$878.14
$873.70
$736.60
$732.88
$353.05
$351.27
$227.37
$226.22
$388.54
$386.57
$265.56
$264.21
$478.65
$476.23
$357.62
$355.81
$501.32
$498.79
$380.67
$378.74
$553.25
$550.46
$421.38
$419.26
$1,233.06
$1,226.83
$1,109.32
$1,103.71
$1,402.20
$1,395.12
$1,227.80
$1,221.59
$1,638.08
$1,629.81
$1,447.82
$1,440.50
$1,437.80
$1,430.54
$1,250.25
$1,243.93
$1,528.84
$1,521.13
$1,352.52
$1,345.68
$1,110.91
$1,105.30
$937.66
$932.94
$1,012.30
$1,007.18
$2,557.38
$2,544.47
$2,535.80
$2,522.99
$2,529.70
$2,516.92
$930.82
$926.13
$779.25
$775.31
$736.13
$732.41
$319.26
$317.64
$236.89
$235.69
Arizona
EHR/eRx
Limiting
Charge**
$869.26
$729.16
$349.49
$225.08
$384.61
$262.88
$473.81
$354.00
$496.25
$376.82
$547.66
$417.13
$1,220.61
$1,098.11
$1,388.04
$1,215.39
$1,621.53
$1,433.20
$1,423.27
$1,237.62
$1,513.40
$1,338.85
$1,099.69
$928.20
$1,002.08
$2,531.54
$2,510.17
$2,504.15
$921.43
$771.37
$728.70
$316.03
$234.50
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$864.97
$856.22
$725.55
$718.22
$347.76
$344.24
$223.95
$221.70
$382.71
$378.83
$261.58
$258.93
$471.48
$466.70
$352.26
$348.69
$493.80
$488.81
$374.96
$371.16
$544.95
$539.45
$415.06
$410.87
$1,214.57
$1,202.30
$1,092.68
$1,081.64
$1,381.16
$1,367.22
$1,209.39
$1,197.16
$1,613.51
$1,597.21
$1,426.10
$1,411.71
$1,416.24
$1,401.93
$1,231.49
$1,219.06
$1,505.91
$1,490.70
$1,332.23
$1,318.77
$1,094.25
$1,083.20
$923.60
$914.27
$997.12
$987.05
$2,519.02
$2,493.57
$2,497.75
$2,472.52
$2,491.75
$2,466.59
$916.86
$907.60
$767.57
$759.81
$725.09
$717.77
$314.48
$311.29
$233.34
$230.98
Page 20 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
15776
15776
15777
15780
15780
15781
15781
15782
15782
15783
15783
15786
15786
15787
15787
15788
15788
15789
15789
15792
15792
15793
15793
15819
15820
15820
15821
15821
15822
15822
15823
15823
15830
1/2/2015
Modifier
Par Fee
$480.74
$349.52
$217.26
$857.13
$649.03
$557.12
$438.05
$646.05
$456.55
$487.60
$378.91
$244.31
$136.69
$49.25
$17.43
$464.29
$249.77
$560.55
$430.04
$436.85
$259.51
$495.73
$370.95
$801.97
$576.85
$516.78
$610.29
$548.43
$449.07
$394.01
$611.49
$548.56
$1,189.07
Nonpar Fee
$456.70
$332.04
$206.40
$814.27
$616.58
$529.26
$416.15
$613.75
$433.72
$463.22
$359.96
$232.09
$129.86
$46.79
$16.56
$441.08
$237.28
$532.52
$408.54
$415.01
$246.53
$470.94
$352.40
$761.87
$548.01
$490.94
$579.78
$521.01
$426.62
$374.31
$580.92
$521.13
$1,129.62
Limiting
Charge
$525.21
$381.85
$237.36
$936.41
$709.07
$608.65
$478.57
$705.81
$498.78
$532.70
$413.95
$266.90
$149.34
$53.81
$19.04
$507.24
$272.87
$612.40
$469.82
$477.26
$283.51
$541.58
$405.26
$876.15
$630.21
$564.58
$666.75
$599.16
$490.61
$430.46
$668.06
$599.30
$1,299.06
Charge**
Charge***
$519.95
$517.33
$378.03
$376.12
$234.99
$233.80
$927.05
$922.37
$701.97
$698.43
$602.57
$599.52
$473.79
$471.40
$698.75
$695.22
$493.79
$491.29
$527.38
$524.71
$409.81
$407.74
$264.24
$262.90
$147.84
$147.10
$53.27
$53.00
$18.85
$18.76
$502.17
$499.63
$270.15
$268.78
$606.27
$603.21
$465.12
$462.77
$472.49
$470.10
$280.67
$279.25
$536.16
$533.46
$401.21
$399.18
$867.39
$863.01
$623.91
$620.76
$558.93
$556.12
$660.08
$656.74
$593.17
$590.17
$485.70
$483.25
$426.16
$424.01
$661.38
$658.04
$593.31
$590.31
$1,286.07
$1,279.58
Arizona
EHR/eRx
Limiting
Charge**
$514.71
$374.21
$232.61
$917.68
$694.89
$596.47
$469.00
$691.70
$488.81
$522.05
$405.67
$261.57
$146.35
$52.73
$18.66
$497.10
$267.41
$600.15
$460.43
$467.72
$277.84
$530.75
$397.15
$858.62
$617.61
$553.29
$653.41
$587.18
$480.80
$421.84
$654.70
$587.32
$1,273.08
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$512.15
$506.99
$372.36
$368.60
$231.46
$229.13
$913.15
$903.91
$691.44
$684.47
$593.53
$587.52
$466.68
$461.97
$688.28
$681.33
$486.38
$481.47
$519.47
$514.22
$403.66
$399.59
$260.27
$257.65
$145.62
$144.15
$52.47
$51.93
$18.56
$18.39
$494.64
$489.65
$266.10
$263.40
$597.17
$591.15
$458.14
$453.51
$465.41
$460.70
$276.46
$273.68
$528.13
$522.79
$395.20
$391.20
$854.38
$845.74
$614.55
$608.34
$550.55
$544.99
$650.18
$643.61
$584.27
$578.37
$478.41
$473.59
$419.76
$415.52
$651.45
$644.87
$584.41
$578.51
$1,266.78
$1,253.98
Page 21 of 323
Notes
#
#
#
Procedure
Code
15832
15833
15834
15835
15836
15837
15837
15838
15839
15839
15840
15841
15842
15845
15851
15851
15852
15860
15920
15922
15931
15933
15934
15935
15936
15937
15940
15941
15944
15945
15946
15950
15951
1/2/2015
Modifier
Par Fee
$926.11
$882.93
$899.20
$949.04
$799.16
$893.76
$751.82
$579.27
$889.57
$746.91
$1,020.15
$1,628.27
$2,486.37
$1,017.76
$99.72
$46.44
$47.97
$112.88
$607.64
$791.06
$694.56
$858.55
$942.61
$1,113.27
$898.12
$1,039.73
$707.38
$912.85
$908.02
$989.14
$1,655.27
$597.14
$889.90
Nonpar Fee
$879.80
$838.78
$854.24
$901.59
$759.20
$849.07
$714.23
$550.31
$845.09
$709.56
$969.14
$1,546.86
$2,362.05
$966.87
$94.73
$44.12
$45.57
$107.24
$577.26
$751.51
$659.83
$815.62
$895.48
$1,057.61
$853.21
$987.74
$672.01
$867.21
$862.62
$939.68
$1,572.51
$567.28
$845.41
Limiting
Charge
$1,011.77
$964.60
$982.38
$1,036.83
$873.08
$976.43
$821.36
$632.86
$971.85
$815.99
$1,114.51
$1,778.89
$2,716.36
$1,111.90
$108.94
$50.74
$52.41
$123.33
$663.85
$864.24
$758.80
$937.96
$1,029.80
$1,216.25
$981.19
$1,135.90
$772.81
$997.29
$992.01
$1,080.63
$1,808.39
$652.37
$972.22
Charge**
Charge***
$1,001.65
$996.59
$954.95
$950.13
$972.56
$967.64
$1,026.46
$1,021.28
$864.35
$859.98
$966.67
$961.78
$813.15
$809.05
$626.53
$623.37
$962.14
$957.27
$807.83
$803.76
$1,103.37
$1,097.79
$1,761.10
$1,752.21
$2,689.19
$2,675.61
$1,100.78
$1,095.23
$107.85
$107.31
$50.23
$49.98
$51.88
$51.62
$122.10
$121.47
$657.21
$653.89
$855.59
$851.28
$751.21
$747.42
$928.58
$923.90
$1,019.51
$1,014.36
$1,204.08
$1,198.01
$971.38
$966.47
$1,124.54
$1,118.86
$765.08
$761.22
$987.32
$982.33
$982.09
$977.13
$1,069.82
$1,064.42
$1,790.30
$1,781.26
$645.85
$642.59
$962.50
$957.64
Arizona
EHR/eRx
Limiting
Charge**
$991.53
$945.30
$962.73
$1,016.09
$855.62
$956.90
$804.94
$620.20
$952.42
$799.68
$1,092.22
$1,743.31
$2,662.03
$1,089.66
$106.77
$49.73
$51.36
$120.87
$650.57
$846.95
$743.62
$919.21
$1,009.21
$1,191.93
$961.57
$1,113.19
$757.36
$977.35
$972.18
$1,059.02
$1,772.22
$639.32
$952.78
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$986.63
$976.66
$940.62
$931.12
$957.96
$948.29
$1,011.06
$1,000.86
$851.39
$842.79
$952.17
$942.55
$800.95
$792.87
$617.14
$610.89
$947.70
$938.14
$795.71
$787.68
$1,086.82
$1,075.84
$1,734.68
$1,717.16
$2,648.85
$2,622.10
$1,084.27
$1,073.32
$106.23
$105.17
$49.47
$48.98
$51.09
$50.59
$120.27
$119.05
$647.36
$640.80
$842.75
$834.24
$739.94
$732.47
$914.65
$905.42
$1,004.21
$994.07
$1,186.02
$1,174.05
$956.81
$947.15
$1,107.67
$1,096.49
$753.61
$745.99
$972.51
$962.69
$967.36
$957.59
$1,053.78
$1,043.14
$1,763.44
$1,745.63
$636.17
$629.73
$948.07
$938.48
Page 22 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
15952
15953
15956
15958
16000
16000
16020
16020
16025
16025
16030
16030
16035
16036
17000
17000
17003
17003
17004
17004
17106
17106
17107
17107
17108
17108
17110
17110
17111
17111
17250
17250
17260
1/2/2015
Modifier
Par Fee
$914.48
$1,007.51
$1,164.26
$1,190.85
$69.24
$46.71
$82.56
$55.02
$149.34
$113.59
$184.07
$134.02
$197.54
$82.48
$66.55
$53.32
$5.68
$2.46
$150.49
$100.44
$343.64
$278.92
$433.39
$348.65
$644.87
$533.31
$111.25
$70.13
$131.81
$86.40
$79.83
$37.28
$94.94
Nonpar Fee
$868.76
$957.13
$1,106.05
$1,131.31
$65.78
$44.37
$78.43
$52.27
$141.87
$107.91
$174.87
$127.32
$187.66
$78.36
$63.22
$50.65
$5.40
$2.34
$142.97
$95.42
$326.46
$264.97
$411.72
$331.22
$612.63
$506.64
$105.69
$66.62
$125.22
$82.08
$75.84
$35.42
$90.19
Limiting
Charge
$999.07
$1,100.70
$1,271.96
$1,301.01
$75.65
$51.03
$90.19
$60.11
$163.15
$124.10
$201.10
$146.42
$215.81
$90.11
$72.70
$58.25
$6.21
$2.69
$164.42
$109.73
$375.43
$304.72
$473.48
$380.90
$704.52
$582.64
$121.54
$76.61
$144.00
$94.39
$87.22
$40.73
$103.72
Charge**
Charge***
$989.08
$984.09
$1,089.69
$1,084.19
$1,259.24
$1,252.88
$1,288.00
$1,281.49
$74.89
$74.51
$50.52
$50.26
$89.30
$88.84
$59.51
$59.21
$161.52
$160.70
$122.85
$122.23
$199.09
$198.09
$144.96
$144.22
$213.65
$212.58
$89.22
$88.76
$71.98
$71.61
$57.66
$57.37
$6.15
$6.12
$2.67
$2.65
$162.77
$161.95
$108.64
$108.09
$371.68
$369.79
$301.67
$300.15
$468.74
$466.37
$377.10
$375.19
$697.48
$693.96
$576.81
$573.90
$120.32
$119.72
$75.84
$75.46
$142.57
$141.84
$93.45
$92.98
$86.34
$85.91
$40.33
$40.12
$102.68
$102.17
Arizona
EHR/eRx
Limiting
Charge**
$979.09
$1,078.69
$1,246.52
$1,274.98
$74.13
$50.00
$88.39
$58.90
$159.88
$121.61
$197.08
$143.49
$211.50
$88.31
$71.25
$57.09
$6.08
$2.63
$161.13
$107.54
$367.92
$298.62
$464.01
$373.29
$690.44
$570.99
$119.12
$75.08
$141.13
$92.51
$85.47
$39.92
$101.65
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$974.25
$964.40
$1,073.35
$1,062.51
$1,240.36
$1,227.82
$1,268.68
$1,255.86
$73.76
$73.01
$49.76
$49.25
$87.96
$87.07
$58.62
$58.02
$159.09
$157.48
$121.01
$119.78
$196.10
$194.12
$142.78
$141.34
$210.44
$208.32
$87.88
$86.99
$70.90
$70.18
$56.80
$56.24
$6.06
$5.99
$2.63
$2.60
$160.33
$158.71
$107.01
$105.93
$366.10
$362.40
$297.15
$294.14
$461.71
$457.06
$371.44
$367.69
$687.01
$680.08
$568.16
$562.42
$118.52
$117.33
$74.70
$73.96
$140.43
$139.01
$92.05
$91.11
$85.04
$84.19
$39.72
$39.32
$101.14
$100.12
Page 23 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
17260
17261
17261
17262
17262
17263
17263
17264
17264
17266
17266
17270
17270
17271
17271
17272
17272
17273
17273
17274
17274
17276
17276
17280
17280
17281
17281
17282
17282
17283
17283
17284
17284
1/2/2015
Modifier
Par Fee
$70.62
$144.10
$92.62
$175.35
$117.78
$191.30
$130.52
$205.83
$139.69
$232.83
$163.82
$151.17
$101.11
$163.91
$112.42
$186.30
$129.45
$208.29
$146.44
$245.21
$178.35
$283.52
$213.80
$141.24
$91.90
$178.12
$126.28
$204.72
$146.08
$244.45
$181.88
$279.86
$212.99
Nonpar Fee
$67.09
$136.90
$87.99
$166.58
$111.89
$181.74
$123.99
$195.54
$132.71
$221.19
$155.63
$143.61
$96.05
$155.71
$106.80
$176.99
$122.98
$197.88
$139.12
$232.95
$169.43
$269.34
$203.11
$134.18
$87.31
$169.21
$119.97
$194.48
$138.78
$232.23
$172.79
$265.87
$202.34
Limiting
Charge
$77.15
$157.44
$101.19
$191.57
$128.67
$209.00
$142.59
$224.87
$152.62
$254.37
$178.97
$165.15
$110.46
$179.07
$122.82
$203.54
$141.43
$227.56
$159.99
$267.89
$194.84
$309.74
$233.58
$154.31
$100.41
$194.59
$137.97
$223.65
$159.60
$267.06
$198.71
$305.75
$232.69
Charge**
Charge***
$76.38
$75.99
$155.86
$155.08
$100.18
$99.67
$189.65
$188.69
$127.39
$126.74
$206.91
$205.86
$141.16
$140.45
$222.62
$221.50
$151.09
$150.33
$251.83
$250.55
$177.18
$176.30
$163.50
$162.68
$109.35
$108.80
$177.27
$176.38
$121.59
$120.98
$201.50
$200.49
$140.01
$139.31
$225.29
$224.15
$158.39
$157.58
$265.21
$263.88
$192.90
$191.92
$306.65
$305.10
$231.24
$230.07
$152.77
$152.00
$99.41
$98.90
$192.65
$191.67
$136.59
$135.90
$221.42
$220.29
$158.00
$157.21
$264.40
$263.06
$196.72
$195.73
$302.69
$301.16
$230.37
$229.20
Arizona
EHR/eRx
Limiting
Charge**
$75.61
$154.28
$99.16
$187.74
$126.10
$204.83
$139.74
$220.37
$149.57
$249.29
$175.40
$161.85
$108.25
$175.49
$120.36
$199.47
$138.60
$223.01
$156.79
$262.53
$190.95
$303.54
$228.91
$151.23
$98.39
$190.70
$135.21
$219.18
$156.40
$261.73
$194.73
$299.63
$228.03
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$75.23
$74.47
$153.53
$151.97
$98.67
$97.68
$186.81
$184.92
$125.48
$124.21
$203.80
$201.76
$139.05
$137.64
$219.28
$217.07
$148.82
$147.33
$248.06
$245.55
$174.52
$172.76
$161.05
$159.42
$107.71
$106.63
$174.62
$172.86
$119.76
$118.55
$198.48
$196.48
$137.91
$136.52
$221.90
$219.66
$156.01
$154.43
$261.23
$258.60
$190.00
$188.08
$302.05
$298.99
$227.77
$225.47
$150.48
$148.96
$97.91
$96.92
$189.76
$187.84
$134.54
$133.18
$218.10
$215.89
$155.63
$154.05
$260.43
$257.81
$193.76
$191.81
$298.15
$295.14
$226.92
$224.62
Page 24 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
17286
17286
17311
17311
17312
17312
17313
17313
17314
17314
17315
17315
17340
17340
17360
17360
19000
19000
19001
19001
19020
19020
19030
19030
19081
19081
19082
19082
19083
19083
19084
19084
19085
1/2/2015
Modifier
Par Fee
$360.14
$286.84
$662.42
$382.10
$389.53
$203.97
$619.86
$343.12
$373.62
$188.77
$79.96
$53.51
$52.16
$49.66
$128.95
$99.28
$114.29
$44.57
$27.31
$22.31
$475.78
$308.09
$167.70
$80.10
$672.88
$171.60
$552.06
$85.82
$656.67
$168.26
$531.37
$80.86
$1,037.61
Nonpar Fee
$342.13
$272.50
$629.30
$363.00
$370.05
$193.77
$588.87
$325.96
$354.94
$179.33
$75.96
$50.83
$49.55
$47.18
$122.50
$94.32
$108.58
$42.34
$25.94
$21.19
$451.99
$292.69
$159.32
$76.10
$639.24
$163.02
$524.46
$81.53
$623.84
$159.85
$504.80
$76.82
$985.73
Limiting
Charge
$393.45
$313.38
$723.70
$417.45
$425.56
$222.84
$677.20
$374.85
$408.18
$206.23
$87.35
$58.45
$56.98
$54.26
$140.88
$108.47
$124.87
$48.69
$29.83
$24.37
$519.79
$336.59
$183.22
$87.52
$735.13
$187.47
$603.13
$93.76
$717.42
$183.83
$580.52
$88.34
$1,133.59
Charge**
Charge***
$389.52
$387.55
$310.25
$308.67
$716.46
$712.84
$413.28
$411.19
$421.30
$419.18
$220.60
$219.49
$670.43
$667.05
$371.11
$369.23
$404.10
$402.06
$204.17
$203.14
$86.48
$86.04
$57.87
$57.58
$56.41
$56.13
$53.72
$53.44
$139.47
$138.76
$107.39
$106.85
$123.61
$122.99
$48.21
$47.96
$29.53
$29.38
$24.13
$24.00
$514.59
$511.99
$333.22
$331.55
$181.39
$180.47
$86.64
$86.20
$727.78
$724.10
$185.60
$184.66
$597.10
$594.08
$92.82
$92.36
$710.24
$706.65
$181.99
$181.07
$574.71
$571.81
$87.46
$87.02
$1,122.25
$1,116.58
Arizona
EHR/eRx
Limiting
Charge**
$385.58
$307.11
$709.22
$409.10
$417.05
$218.37
$663.65
$367.36
$400.02
$202.10
$85.61
$57.28
$55.84
$53.18
$138.06
$106.29
$122.37
$47.71
$29.23
$23.89
$509.39
$329.87
$179.55
$85.77
$720.43
$183.72
$591.07
$91.89
$703.06
$180.15
$568.91
$86.57
$1,110.92
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$383.67
$379.80
$305.59
$302.50
$705.71
$698.58
$407.08
$402.96
$414.98
$410.79
$217.29
$215.10
$660.38
$653.69
$365.54
$361.85
$398.04
$394.01
$201.11
$199.07
$85.18
$84.32
$57.01
$56.42
$55.56
$55.00
$52.91
$52.38
$137.38
$135.99
$105.78
$104.70
$121.76
$120.53
$47.48
$47.00
$29.08
$28.80
$23.77
$23.53
$506.87
$501.76
$328.22
$324.92
$178.66
$176.86
$85.34
$84.48
$716.86
$709.62
$182.82
$180.96
$588.14
$582.20
$91.43
$90.51
$699.59
$692.52
$179.26
$177.45
$566.09
$560.37
$86.15
$85.27
$1,105.41
$1,094.26
Page 25 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
19085
19086
19086
19100
19100
19101
19101
19105
19105
19110
19110
19112
19112
19120
19120
19125
19125
19126
19260
19271
19272
19281
19281
19282
19282
19283
19283
19284
19284
19285
19285
19286
19286
1/2/2015
Modifier
Par Fee
$203.82
$830.64
$96.60
$152.78
$71.26
$343.61
$224.55
$2,530.31
$208.04
$488.48
$345.11
$465.77
$316.32
$496.69
$417.31
$551.85
$463.90
$164.25
$1,220.11
$1,652.86
$1,813.80
$242.30
$104.28
$169.66
$52.75
$276.26
$104.64
$204.35
$53.10
$451.24
$89.04
$383.57
$44.97
Nonpar Fee
$193.63
$789.11
$91.77
$145.14
$67.70
$326.43
$213.32
$2,403.79
$197.64
$464.06
$327.85
$442.48
$300.50
$471.86
$396.44
$524.26
$440.71
$156.04
$1,159.10
$1,570.22
$1,723.11
$230.19
$99.07
$161.18
$50.11
$262.45
$99.41
$194.13
$50.45
$428.68
$84.59
$364.39
$42.72
Limiting
Charge
$222.67
$907.48
$105.54
$166.91
$77.86
$375.39
$245.32
$2,764.36
$227.29
$533.67
$377.03
$508.85
$345.58
$542.64
$455.91
$602.90
$506.82
$179.45
$1,332.97
$1,805.75
$1,981.58
$264.72
$113.93
$185.36
$57.63
$301.82
$114.32
$223.25
$58.02
$492.98
$97.28
$419.05
$49.13
Charge**
Charge***
$220.44
$219.34
$898.40
$893.86
$104.48
$103.95
$165.24
$164.40
$77.07
$76.68
$371.65
$369.76
$242.87
$241.64
$2,736.71
$2,722.89
$225.01
$223.88
$528.33
$525.67
$373.26
$371.37
$503.77
$501.22
$342.13
$340.39
$537.21
$534.50
$451.35
$449.06
$596.87
$593.86
$501.75
$499.22
$177.65
$176.76
$1,319.64
$1,312.97
$1,787.70
$1,778.67
$1,961.76
$1,951.85
$262.07
$260.75
$112.79
$112.22
$183.51
$182.57
$57.05
$56.76
$298.80
$297.29
$113.18
$112.61
$221.02
$219.90
$57.44
$57.14
$488.05
$485.59
$96.30
$95.82
$414.86
$412.76
$48.63
$48.39
Arizona
EHR/eRx
Limiting
Charge**
$218.22
$889.33
$103.42
$163.58
$76.30
$367.89
$240.41
$2,709.07
$222.74
$523.00
$369.48
$498.67
$338.66
$531.78
$446.79
$590.84
$496.69
$175.86
$1,306.31
$1,769.64
$1,941.95
$259.43
$111.65
$181.65
$56.48
$295.78
$112.03
$218.79
$56.86
$483.13
$95.34
$410.67
$48.15
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$217.13
$214.95
$884.93
$875.99
$102.91
$101.87
$162.76
$161.13
$75.91
$75.15
$366.07
$362.37
$239.22
$236.80
$2,695.66
$2,668.43
$221.64
$219.40
$520.41
$515.15
$367.66
$363.94
$496.21
$491.20
$337.00
$333.58
$529.15
$523.80
$444.58
$440.08
$587.91
$581.97
$494.22
$489.23
$174.98
$173.22
$1,299.85
$1,286.71
$1,760.88
$1,743.10
$1,932.33
$1,912.82
$258.14
$255.54
$111.10
$109.97
$180.76
$178.93
$56.20
$55.63
$294.32
$291.34
$111.48
$110.35
$217.71
$215.51
$56.58
$56.01
$480.72
$475.88
$94.85
$93.91
$408.64
$404.50
$47.91
$47.43
Page 26 of 323
Notes
#
#
#
#
#
#
#
Procedure
Code
19287
19287
19288
19288
19296
19296
19297
19298
19298
19300
19300
19301
19302
19303
19304
19305
19306
19307
19316
19318
19324
19325
19328
19330
19340
19342
19350
19350
19355
19355
19357
19361
19364
1/2/2015
Modifier
Par Fee
$881.21
$139.65
$708.67
$68.30
$3,962.98
$213.74
$96.21
$1,057.06
$331.95
$528.58
$417.74
$659.66
$910.15
$1,021.64
$581.19
$1,139.93
$1,211.90
$1,210.69
$780.71
$1,117.66
$495.90
$651.20
$501.63
$642.35
$1,017.21
$935.49
$831.63
$682.53
$708.27
$577.76
$1,526.95
$1,597.35
$2,798.32
Nonpar Fee
$837.15
$132.67
$673.24
$64.89
$3,764.83
$203.05
$91.40
$1,004.21
$315.35
$502.15
$396.85
$626.68
$864.64
$970.56
$552.13
$1,082.93
$1,151.31
$1,150.16
$741.67
$1,061.78
$471.11
$618.64
$476.55
$610.23
$966.35
$888.72
$790.05
$648.40
$672.86
$548.87
$1,450.60
$1,517.48
$2,658.40
Limiting
Charge
$962.72
$152.57
$774.23
$74.62
$4,329.55
$233.51
$105.11
$1,154.84
$362.65
$577.47
$456.38
$720.68
$994.34
$1,116.14
$634.95
$1,245.37
$1,324.01
$1,322.68
$852.92
$1,221.05
$541.78
$711.44
$548.03
$701.76
$1,111.30
$1,022.03
$908.56
$745.66
$773.79
$631.20
$1,668.19
$1,745.10
$3,057.16
Charge**
Charge***
$953.10
$948.28
$151.04
$150.28
$766.49
$762.61
$73.88
$73.51
$4,286.26
$4,264.61
$231.17
$230.00
$104.06
$103.53
$1,143.30
$1,137.52
$359.03
$357.21
$571.70
$568.81
$451.81
$449.54
$713.47
$709.87
$984.39
$979.42
$1,104.98
$1,099.40
$628.60
$625.43
$1,232.92
$1,226.69
$1,310.77
$1,304.15
$1,309.46
$1,302.85
$844.39
$840.12
$1,208.83
$1,202.73
$536.36
$533.65
$704.32
$700.76
$542.55
$539.81
$694.75
$691.24
$1,100.19
$1,094.63
$1,011.80
$1,006.70
$899.47
$894.93
$738.21
$734.47
$766.05
$762.19
$624.89
$621.74
$1,651.50
$1,643.17
$1,727.66
$1,718.93
$3,026.59
$3,011.30
Arizona
EHR/eRx
Limiting
Charge**
$943.47
$149.52
$758.75
$73.13
$4,242.96
$228.84
$103.01
$1,131.75
$355.40
$565.93
$447.25
$706.27
$974.45
$1,093.82
$622.25
$1,220.46
$1,297.52
$1,296.23
$835.87
$1,196.62
$530.94
$697.21
$537.07
$687.73
$1,089.07
$1,001.59
$890.39
$730.74
$758.31
$618.57
$1,634.83
$1,710.20
$2,996.01
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$938.80
$929.32
$148.78
$147.28
$754.99
$747.36
$72.77
$72.04
$4,221.96
$4,179.32
$227.70
$225.41
$102.50
$101.46
$1,126.15
$1,114.78
$353.65
$350.06
$563.12
$557.44
$445.04
$440.54
$702.77
$695.68
$969.62
$959.84
$1,088.41
$1,077.41
$619.17
$612.92
$1,214.42
$1,202.15
$1,291.11
$1,278.06
$1,289.82
$1,276.79
$831.73
$823.33
$1,190.70
$1,178.67
$528.31
$522.97
$693.75
$686.76
$534.41
$529.01
$684.33
$677.42
$1,083.69
$1,072.73
$996.62
$986.57
$885.98
$877.04
$727.13
$719.79
$754.56
$746.94
$615.51
$609.29
$1,626.73
$1,610.31
$1,701.75
$1,684.54
$2,981.19
$2,951.07
Page 27 of 323
Notes
#
#
#
#
#
#
#
#
#
#
Procedure
Code
19366
19367
19368
19369
19370
19371
19380
19396
19396
20005
20005
20100
20101
20101
20102
20102
20103
20103
20150
20200
20200
20205
20205
20206
20206
20220
20220
20225
20225
20240
20245
20250
20251
1/2/2015
Modifier
Par Fee
$1,427.17
$1,818.22
$2,235.39
$2,074.60
$695.00
$795.05
$783.47
$294.82
$148.23
$310.79
$236.78
$618.44
$456.73
$212.53
$495.58
$259.24
$588.37
$352.74
$927.78
$209.68
$97.06
$291.80
$158.44
$239.47
$60.70
$170.74
$74.56
$533.25
$112.06
$220.60
$626.09
$399.44
$427.29
Nonpar Fee
$1,355.81
$1,727.31
$2,123.62
$1,970.87
$660.25
$755.30
$744.30
$280.08
$140.82
$295.25
$224.94
$587.52
$433.89
$201.90
$470.80
$246.28
$558.95
$335.10
$881.39
$199.20
$92.21
$277.21
$150.52
$227.50
$57.67
$162.20
$70.83
$506.59
$106.46
$209.57
$594.79
$379.47
$405.93
Limiting
Charge
$1,559.18
$1,986.41
$2,442.16
$2,266.50
$759.29
$868.60
$855.95
$322.09
$161.94
$339.54
$258.68
$675.65
$498.97
$232.19
$541.42
$283.22
$642.79
$385.37
$1,013.60
$229.08
$106.04
$318.79
$173.10
$261.63
$66.32
$186.53
$81.45
$582.58
$122.43
$241.01
$684.01
$436.39
$466.82
Charge**
Charge***
$1,543.59
$1,535.79
$1,966.55
$1,956.61
$2,417.74
$2,405.54
$2,243.83
$2,232.51
$751.70
$747.90
$859.91
$855.57
$847.39
$843.11
$318.87
$317.26
$160.32
$159.52
$336.15
$334.44
$256.09
$254.81
$668.89
$665.52
$493.98
$491.49
$229.86
$228.70
$536.00
$533.30
$280.39
$278.98
$636.36
$633.16
$381.51
$379.58
$1,003.47
$998.40
$226.79
$225.64
$104.98
$104.45
$315.61
$314.01
$171.36
$170.50
$259.01
$257.70
$65.65
$65.32
$184.67
$183.74
$80.64
$80.24
$576.75
$573.84
$121.21
$120.59
$238.59
$237.39
$677.17
$673.75
$432.03
$429.85
$462.15
$459.82
Arizona
EHR/eRx
Limiting
Charge**
$1,527.99
$1,946.67
$2,393.32
$2,221.17
$744.11
$851.22
$838.82
$315.65
$158.70
$332.75
$253.51
$662.14
$488.99
$227.54
$530.59
$277.55
$629.94
$377.66
$993.32
$224.50
$103.93
$312.42
$169.64
$256.39
$65.00
$182.80
$79.82
$570.93
$119.98
$236.19
$670.32
$427.66
$457.48
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$1,520.44
$1,505.07
$1,937.05
$1,917.48
$2,381.47
$2,357.42
$2,210.17
$2,187.85
$740.43
$732.94
$847.01
$838.45
$834.68
$826.24
$314.09
$310.91
$157.92
$156.32
$331.11
$327.76
$252.25
$249.70
$658.86
$652.20
$486.58
$481.65
$226.41
$224.12
$527.97
$522.63
$276.18
$273.39
$626.82
$620.48
$375.79
$371.99
$988.41
$978.42
$223.39
$221.13
$103.41
$102.36
$310.87
$307.73
$168.79
$167.10
$255.13
$252.55
$64.66
$64.02
$181.90
$180.07
$79.43
$78.63
$568.10
$562.36
$119.39
$118.19
$235.01
$232.65
$667.01
$660.27
$425.55
$421.25
$455.22
$450.62
Page 28 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
20500
20500
20501
20501
20520
20520
20525
20525
20526
20526
20527
20527
20550
20550
20551
20551
20552
20552
20553
20553
20555
20600
20600
20604
20604
20605
20605
20606
20606
20610
20610
20611
20611
1/2/2015
Modifier
Par Fee
$105.93
$86.63
$119.83
$39.02
$205.79
$149.30
$486.94
$253.82
$77.96
$58.65
$85.02
$67.50
$59.67
$42.51
$61.10
$43.58
$55.51
$38.35
$64.41
$43.67
$338.47
$47.96
$36.16
$72.86
$46.76
$50.11
$37.59
$80.64
$53.46
$60.66
$46.71
$92.93
$62.90
Nonpar Fee
$100.63
$82.30
$113.84
$37.07
$195.50
$141.84
$462.59
$241.13
$74.06
$55.72
$80.77
$64.13
$56.69
$40.38
$58.05
$41.40
$52.73
$36.43
$61.19
$41.49
$321.55
$45.56
$34.35
$69.22
$44.42
$47.60
$35.71
$76.61
$50.79
$57.63
$44.37
$88.28
$59.76
Limiting
Charge
$115.72
$94.65
$130.92
$42.63
$224.83
$163.12
$531.98
$277.30
$85.17
$64.08
$92.89
$73.75
$65.19
$46.44
$66.76
$47.61
$60.64
$41.89
$70.37
$47.71
$369.78
$52.39
$39.50
$79.60
$51.08
$54.74
$41.07
$88.10
$58.41
$66.27
$51.03
$101.52
$68.72
Charge**
Charge***
$114.56
$113.99
$93.70
$93.23
$129.61
$128.95
$42.21
$41.99
$222.58
$221.46
$161.48
$160.67
$526.65
$524.00
$274.53
$273.14
$84.32
$83.89
$63.43
$63.11
$91.95
$91.49
$73.01
$72.65
$64.54
$64.22
$45.98
$45.74
$66.09
$65.76
$47.14
$46.90
$60.03
$59.73
$41.48
$41.26
$69.67
$69.31
$47.24
$47.00
$366.08
$364.24
$51.87
$51.61
$39.11
$38.90
$78.81
$78.41
$50.58
$50.31
$54.19
$53.92
$40.65
$40.45
$87.22
$86.78
$57.82
$57.53
$65.61
$65.29
$50.52
$50.26
$100.51
$100.00
$68.03
$67.69
Arizona
EHR/eRx
Limiting
Charge**
$113.41
$92.75
$128.29
$41.78
$220.33
$159.85
$521.34
$271.76
$83.47
$62.80
$91.02
$72.28
$63.89
$45.51
$65.42
$46.66
$59.43
$41.06
$68.97
$46.76
$362.39
$51.35
$38.71
$78.02
$50.06
$53.65
$40.25
$86.34
$57.24
$64.95
$50.00
$99.49
$67.34
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$112.85
$111.71
$92.30
$91.36
$127.66
$126.37
$41.57
$41.16
$219.25
$217.03
$159.06
$157.46
$518.75
$513.52
$270.41
$267.69
$83.05
$82.21
$62.48
$61.86
$90.57
$89.65
$71.92
$71.20
$63.57
$62.94
$45.29
$44.83
$65.10
$64.45
$46.44
$45.95
$59.13
$58.54
$40.86
$40.43
$68.62
$67.93
$46.53
$46.06
$360.59
$356.95
$51.08
$50.58
$38.53
$38.13
$77.63
$76.84
$49.82
$49.31
$53.37
$52.84
$40.04
$39.65
$85.91
$85.04
$56.96
$56.37
$64.62
$63.97
$49.76
$49.25
$99.00
$97.99
$67.01
$66.33
Page 29 of 323
Notes
#
#
#
#
#
#
#
Procedure
Code
20612
20612
20615
20615
20650
20650
20660
20661
20662
20663
20664
20665
20665
20670
20670
20680
20680
20690
20692
20693
20694
20694
20696
20697
20802
20805
20808
20816
20822
20824
20827
20838
20900
1/2/2015
Modifier
Par Fee
$61.46
$42.51
$249.95
$168.07
$208.52
$158.82
$251.23
$515.05
$471.12
$400.55
$894.53
$106.07
$91.41
$385.59
$150.32
$626.94
$430.65
$605.23
$1,138.28
$455.55
$430.90
$343.30
$1,231.02
$2,144.52
$2,813.91
$3,347.34
$4,052.06
$2,139.54
$1,829.53
$2,071.25
$1,880.40
$2,216.95
$425.92
Nonpar Fee
$58.39
$40.38
$237.45
$159.67
$198.09
$150.88
$238.67
$489.30
$447.56
$380.52
$849.80
$100.77
$86.84
$366.31
$142.80
$595.59
$409.12
$574.97
$1,081.37
$432.77
$409.36
$326.14
$1,169.47
$2,037.29
$2,673.21
$3,179.97
$3,849.46
$2,032.56
$1,738.05
$1,967.69
$1,786.38
$2,106.10
$404.62
Limiting
Charge
$67.15
$46.44
$273.07
$183.62
$227.80
$173.51
$274.47
$562.70
$514.69
$437.60
$977.27
$115.89
$99.87
$421.26
$164.22
$684.93
$470.49
$661.22
$1,243.58
$497.69
$470.76
$375.06
$1,344.89
$2,342.88
$3,074.19
$3,656.97
$4,426.88
$2,337.44
$1,998.76
$2,262.84
$2,054.34
$2,422.02
$465.31
Charge**
Charge***
$66.48
$66.14
$45.98
$45.74
$270.34
$268.97
$181.78
$180.86
$225.53
$224.39
$171.78
$170.91
$271.72
$270.35
$557.07
$554.25
$509.54
$506.98
$433.22
$431.03
$967.50
$962.61
$114.72
$114.15
$98.87
$98.37
$417.05
$414.94
$162.58
$161.76
$678.07
$674.66
$465.78
$463.43
$654.60
$651.30
$1,231.14
$1,224.92
$492.71
$490.22
$466.06
$463.70
$371.31
$369.44
$1,331.45
$1,324.72
$2,319.46
$2,307.74
$3,043.45
$3,028.08
$3,620.40
$3,602.11
$4,382.62
$4,360.48
$2,314.06
$2,302.38
$1,978.77
$1,968.78
$2,240.21
$2,228.90
$2,033.80
$2,023.52
$2,397.80
$2,385.69
$460.66
$458.33
Arizona
EHR/eRx
Limiting
Charge**
$65.80
$45.51
$267.61
$179.95
$223.25
$170.04
$268.99
$551.44
$504.40
$428.85
$957.72
$113.56
$97.87
$412.83
$160.93
$671.23
$461.08
$647.99
$1,218.70
$487.73
$461.35
$367.56
$1,317.99
$2,296.02
$3,012.71
$3,583.83
$4,338.34
$2,290.70
$1,958.78
$2,217.59
$2,013.25
$2,373.58
$456.01
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$65.48
$64.81
$45.29
$44.83
$266.28
$263.59
$179.06
$177.25
$222.15
$219.90
$169.20
$167.49
$267.65
$264.95
$548.71
$543.17
$501.89
$496.83
$426.72
$422.42
$952.98
$943.36
$113.00
$111.86
$97.38
$96.39
$410.79
$406.64
$160.14
$158.52
$667.91
$661.16
$458.79
$454.17
$644.78
$638.27
$1,212.68
$1,200.42
$485.31
$480.41
$459.07
$454.42
$365.75
$362.05
$1,311.47
$1,298.22
$2,284.67
$2,261.58
$2,997.80
$2,967.52
$3,566.09
$3,530.06
$4,316.88
$4,273.26
$2,279.36
$2,256.33
$1,949.09
$1,929.40
$2,206.61
$2,184.32
$2,003.29
$1,983.05
$2,361.82
$2,337.97
$453.74
$449.17
Page 30 of 323
Notes
#
#
#
#
#
#
#
Procedure
Code
20900
20902
20910
20912
20920
20922
20922
20924
20926
20931
20937
20938
20950
20950
20955
20956
20957
20962
20969
20970
20972
20973
20974
20974
20975
20979
20979
20982
20982
20983
20983
20985
21010
1/2/2015
Modifier
Par Fee
$193.87
$292.18
$464.65
$487.27
$400.82
$611.79
$505.60
$516.43
$436.86
$115.58
$172.30
$190.28
$249.99
$92.31
$2,570.70
$2,705.86
$2,156.23
$2,074.78
$2,811.76
$2,927.19
$2,349.41
$2,592.09
$77.69
$51.23
$182.58
$52.25
$32.59
$3,792.38
$389.97
$7,012.14
$403.95
$150.43
$775.92
Nonpar Fee
$184.18
$277.57
$441.42
$462.91
$380.78
$581.20
$480.32
$490.61
$415.02
$109.80
$163.69
$180.77
$237.49
$87.69
$2,442.17
$2,570.57
$2,048.42
$1,971.04
$2,671.17
$2,780.83
$2,231.94
$2,462.49
$73.81
$48.67
$173.45
$49.64
$30.96
$3,602.76
$370.47
$6,661.53
$383.75
$142.91
$737.12
Limiting
Charge
$211.81
$319.21
$507.63
$532.35
$437.90
$668.38
$552.37
$564.20
$477.27
$126.27
$188.24
$207.89
$273.11
$100.84
$2,808.50
$2,956.16
$2,355.68
$2,266.70
$3,071.85
$3,197.95
$2,566.73
$2,831.86
$84.88
$55.97
$199.47
$57.09
$35.60
$4,143.17
$426.04
$7,660.76
$441.31
$164.35
$847.69
Charge**
Charge***
$209.69
$208.63
$316.01
$314.42
$502.56
$500.02
$527.02
$524.37
$433.52
$431.33
$661.70
$658.35
$546.85
$544.09
$558.56
$555.74
$472.50
$470.11
$125.01
$124.37
$186.36
$185.41
$205.80
$204.77
$270.39
$269.02
$99.83
$99.33
$2,780.41
$2,766.37
$2,926.59
$2,911.81
$2,332.13
$2,320.34
$2,244.03
$2,232.69
$3,041.13
$3,025.77
$3,165.97
$3,149.99
$2,541.06
$2,528.23
$2,803.55
$2,789.38
$84.03
$83.61
$55.41
$55.13
$197.48
$196.48
$56.51
$56.24
$35.25
$35.08
$4,101.74
$4,081.03
$421.79
$419.65
$7,584.15
$7,545.85
$436.90
$434.69
$162.70
$161.89
$839.21
$834.97
Arizona
EHR/eRx
Limiting
Charge**
$207.58
$312.82
$497.48
$521.70
$429.13
$655.02
$541.32
$552.92
$467.73
$123.74
$184.48
$203.72
$267.65
$98.83
$2,752.33
$2,897.03
$2,308.57
$2,221.36
$3,010.41
$3,133.99
$2,515.40
$2,775.23
$83.18
$54.86
$195.48
$55.95
$34.89
$4,060.31
$417.52
$7,507.55
$432.49
$161.06
$830.74
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$206.54
$204.46
$311.27
$308.13
$495.02
$490.02
$519.12
$513.88
$427.02
$422.69
$651.77
$645.20
$538.65
$533.20
$550.17
$544.63
$465.42
$460.71
$123.13
$121.89
$183.56
$181.71
$202.72
$200.66
$266.33
$263.64
$98.34
$97.35
$2,738.70
$2,711.04
$2,882.69
$2,853.58
$2,297.15
$2,273.94
$2,210.37
$2,188.05
$2,995.51
$2,965.25
$3,118.48
$3,086.98
$2,502.95
$2,477.66
$2,761.50
$2,733.60
$82.77
$81.94
$54.58
$54.03
$194.51
$192.54
$55.66
$55.11
$34.72
$34.36
$4,040.21
$3,999.40
$415.46
$411.25
$7,470.39
$7,394.94
$430.34
$426.01
$160.26
$158.64
$826.62
$818.27
Page 31 of 323
Notes
#
#
#
#
#
#
#
#
#
#
Procedure
Code
21011
21011
21012
21013
21013
21014
21015
21016
21025
21025
21026
21026
21029
21029
21030
21030
21031
21031
21032
21032
21034
21034
21040
21040
21044
21045
21046
21047
21048
21049
21050
21060
21070
1/2/2015
Modifier
Par Fee
$352.71
$262.97
$342.95
$525.44
$407.45
$528.37
$717.99
$1,038.74
$913.78
$772.20
$633.42
$512.57
$779.41
$649.98
$531.69
$428.71
$405.23
$303.33
$410.91
$300.07
$1,349.80
$1,189.26
$536.65
$430.46
$899.73
$1,253.45
$1,149.46
$1,353.64
$1,180.26
$1,238.92
$859.77
$830.27
$630.37
Nonpar Fee
$335.07
$249.82
$325.80
$499.17
$387.08
$501.95
$682.09
$986.80
$868.09
$733.59
$601.75
$486.94
$740.44
$617.48
$505.11
$407.27
$384.97
$288.16
$390.36
$285.07
$1,282.31
$1,129.80
$509.82
$408.94
$854.74
$1,190.78
$1,091.99
$1,285.96
$1,121.25
$1,176.97
$816.78
$788.76
$598.85
Limiting
Charge
$385.33
$287.29
$374.67
$574.05
$445.14
$577.24
$784.40
$1,134.82
$998.30
$843.63
$692.01
$559.98
$851.51
$710.10
$580.88
$468.36
$442.72
$331.38
$448.91
$327.83
$1,474.66
$1,299.27
$586.29
$470.28
$982.95
$1,369.40
$1,255.79
$1,478.85
$1,289.44
$1,353.52
$939.30
$907.07
$688.68
Charge**
Charge***
$381.48
$379.55
$284.42
$282.98
$370.92
$369.05
$568.31
$565.43
$440.69
$438.46
$571.47
$568.58
$776.56
$772.64
$1,123.47
$1,117.80
$988.32
$983.33
$835.19
$830.98
$685.09
$681.63
$554.38
$551.59
$843.00
$838.73
$703.01
$699.45
$575.07
$572.16
$463.68
$461.33
$438.29
$436.08
$328.07
$326.42
$444.43
$442.18
$324.55
$322.91
$1,459.91
$1,452.54
$1,286.28
$1,279.78
$580.43
$577.50
$465.58
$463.23
$973.12
$968.21
$1,355.70
$1,348.86
$1,243.23
$1,236.95
$1,464.07
$1,456.67
$1,276.55
$1,270.09
$1,339.98
$1,333.22
$929.90
$925.21
$898.00
$893.47
$681.79
$678.35
Arizona
EHR/eRx
Limiting
Charge**
$377.63
$281.54
$367.17
$562.57
$436.24
$565.70
$768.72
$1,112.12
$978.34
$826.76
$678.18
$548.78
$834.47
$695.90
$569.26
$458.99
$433.86
$324.76
$439.93
$321.28
$1,445.16
$1,273.28
$574.56
$460.87
$963.30
$1,342.00
$1,230.67
$1,449.28
$1,263.65
$1,326.44
$920.51
$888.93
$674.90
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$375.75
$371.96
$280.15
$277.32
$365.36
$361.66
$559.79
$554.13
$434.08
$429.70
$562.90
$557.21
$764.91
$757.18
$1,106.62
$1,095.43
$973.50
$963.67
$822.66
$814.36
$674.81
$668.00
$546.07
$540.55
$830.35
$821.96
$692.46
$685.46
$566.44
$560.72
$456.72
$452.10
$431.71
$427.35
$323.15
$319.88
$437.76
$433.33
$319.69
$316.46
$1,438.02
$1,423.48
$1,266.98
$1,254.18
$571.72
$565.95
$458.60
$453.96
$958.53
$948.85
$1,335.37
$1,321.88
$1,224.58
$1,212.22
$1,442.10
$1,427.54
$1,257.40
$1,244.70
$1,319.88
$1,306.55
$915.95
$906.69
$884.53
$875.60
$671.57
$664.78
Page 32 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
21073
21073
21076
21076
21077
21077
21079
21079
21080
21080
21081
21081
21082
21082
21083
21083
21084
21084
21085
21085
21086
21086
21087
21087
21100
21100
21110
21110
21116
21116
21120
21120
21121
1/2/2015
Modifier
Par Fee
$404.34
$260.25
$1,030.17
$863.55
$2,586.27
$2,179.03
$1,739.47
$1,442.70
$1,947.40
$1,600.94
$1,802.04
$1,477.75
$1,708.34
$1,390.84
$1,627.96
$1,291.51
$1,862.29
$1,494.01
$782.78
$585.77
$1,922.07
$1,606.71
$1,922.07
$1,606.71
$1,181.27
$534.47
$830.47
$694.61
$150.76
$45.28
$612.67
$489.68
$819.10
Nonpar Fee
$384.12
$247.24
$978.66
$820.37
$2,456.96
$2,070.08
$1,652.50
$1,370.57
$1,850.03
$1,520.89
$1,711.94
$1,403.86
$1,622.92
$1,321.30
$1,546.56
$1,226.93
$1,769.18
$1,419.31
$743.64
$556.48
$1,825.97
$1,526.37
$1,825.97
$1,526.37
$1,122.21
$507.75
$788.95
$659.88
$143.22
$43.02
$582.04
$465.20
$778.15
Limiting
Charge
$441.74
$284.33
$1,125.46
$943.43
$2,825.50
$2,380.59
$1,900.38
$1,576.16
$2,127.53
$1,749.02
$1,968.73
$1,614.44
$1,866.36
$1,519.50
$1,778.54
$1,410.97
$2,034.56
$1,632.21
$855.19
$639.95
$2,099.87
$1,755.33
$2,099.87
$1,755.33
$1,290.54
$583.91
$907.29
$758.86
$164.70
$49.47
$669.35
$534.98
$894.87
Charge**
Charge***
$437.32
$435.11
$281.49
$280.06
$1,114.20
$1,108.58
$934.00
$929.27
$2,797.25
$2,783.13
$2,356.79
$2,344.88
$1,881.38
$1,871.87
$1,560.39
$1,552.51
$2,106.26
$2,095.62
$1,731.53
$1,722.79
$1,949.04
$1,939.20
$1,598.29
$1,590.22
$1,847.69
$1,838.37
$1,504.30
$1,496.70
$1,760.75
$1,751.86
$1,396.86
$1,389.81
$2,014.21
$2,004.04
$1,615.89
$1,607.72
$846.63
$842.36
$633.56
$630.35
$2,078.87
$2,068.37
$1,737.78
$1,728.99
$2,078.87
$2,068.37
$1,737.78
$1,728.99
$1,277.64
$1,271.19
$578.07
$575.15
$898.22
$893.69
$751.27
$747.48
$163.06
$162.23
$48.98
$48.73
$662.65
$659.31
$529.63
$526.95
$885.93
$881.45
Arizona
EHR/eRx
Limiting
Charge**
$432.91
$278.65
$1,102.95
$924.55
$2,768.99
$2,332.98
$1,862.37
$1,544.63
$2,084.98
$1,714.04
$1,929.36
$1,582.15
$1,829.03
$1,489.10
$1,742.97
$1,382.75
$1,993.87
$1,599.56
$838.09
$627.15
$2,057.87
$1,720.22
$2,057.87
$1,720.22
$1,264.74
$572.24
$889.15
$743.68
$161.41
$48.48
$655.96
$524.29
$876.98
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$430.77
$426.41
$277.27
$274.47
$1,097.49
$1,086.41
$919.99
$910.69
$2,755.29
$2,727.46
$2,321.44
$2,297.99
$1,853.16
$1,834.43
$1,536.99
$1,521.46
$2,074.67
$2,053.70
$1,705.55
$1,688.33
$1,919.81
$1,900.41
$1,574.32
$1,558.41
$1,819.98
$1,801.59
$1,481.74
$1,466.77
$1,734.34
$1,716.84
$1,375.91
$1,362.00
$1,984.00
$1,963.96
$1,591.65
$1,575.57
$833.93
$825.52
$624.06
$617.75
$2,047.68
$2,027.00
$1,711.71
$1,694.41
$2,047.68
$2,027.00
$1,711.71
$1,694.41
$1,258.48
$1,245.76
$569.40
$563.66
$884.74
$875.81
$740.00
$732.53
$160.61
$158.99
$48.24
$47.76
$652.72
$646.12
$521.69
$516.42
$872.63
$863.82
Page 33 of 323
Notes
#
#
#
Procedure
Code
21121
21122
21123
21125
21125
21127
21127
21137
21138
21139
21141
21142
21143
21145
21146
21147
21150
21151
21154
21155
21159
21160
21172
21175
21179
21180
21181
21182
21183
21184
21188
21193
21194
1/2/2015
Modifier
Par Fee
$682.52
$655.92
$791.00
$3,208.49
$748.57
$4,441.20
$905.41
$702.17
$900.46
$1,145.58
$1,379.25
$1,475.62
$1,488.27
$1,671.37
$1,740.79
$1,839.67
$1,716.63
$2,098.48
$2,257.30
$2,413.67
$2,467.20
$2,676.83
$1,810.90
$2,325.53
$1,339.67
$1,560.29
$752.22
$1,952.24
$2,281.56
$2,451.40
$1,597.23
$1,212.73
$1,529.94
Nonpar Fee
$648.39
$623.12
$751.45
$3,048.07
$711.14
$4,219.14
$860.14
$667.06
$855.44
$1,088.30
$1,310.29
$1,401.84
$1,413.86
$1,587.80
$1,653.75
$1,747.69
$1,630.80
$1,993.56
$2,144.44
$2,292.99
$2,343.84
$2,542.99
$1,720.36
$2,209.25
$1,272.69
$1,482.28
$714.61
$1,854.63
$2,167.48
$2,328.83
$1,517.37
$1,152.09
$1,453.44
Limiting
Charge
$745.65
$716.59
$864.17
$3,505.28
$817.81
$4,852.01
$989.16
$767.12
$983.76
$1,251.55
$1,506.83
$1,612.12
$1,625.94
$1,825.97
$1,901.81
$2,009.84
$1,875.42
$2,292.59
$2,466.11
$2,636.94
$2,695.42
$2,924.44
$1,978.41
$2,540.64
$1,463.59
$1,704.62
$821.80
$2,132.82
$2,492.60
$2,678.15
$1,744.98
$1,324.90
$1,671.46
Charge**
Charge***
$738.20
$734.46
$709.42
$705.84
$855.53
$851.21
$3,470.23
$3,452.70
$809.63
$805.54
$4,803.49
$4,779.23
$979.27
$974.33
$759.45
$755.61
$973.92
$969.00
$1,239.03
$1,232.78
$1,491.77
$1,484.24
$1,595.99
$1,587.93
$1,609.68
$1,601.55
$1,807.71
$1,798.58
$1,882.79
$1,873.28
$1,989.74
$1,979.69
$1,856.66
$1,847.29
$2,269.66
$2,258.21
$2,441.45
$2,429.11
$2,610.57
$2,597.39
$2,668.46
$2,654.98
$2,895.19
$2,880.58
$1,958.63
$1,948.73
$2,515.23
$2,502.53
$1,448.95
$1,441.64
$1,687.58
$1,679.06
$813.58
$809.47
$2,111.49
$2,100.83
$2,467.68
$2,455.22
$2,651.37
$2,637.99
$1,727.53
$1,718.80
$1,311.66
$1,305.03
$1,654.75
$1,646.39
Arizona
EHR/eRx
Limiting
Charge**
$730.73
$702.26
$846.88
$3,435.18
$801.46
$4,754.97
$969.38
$751.78
$964.08
$1,226.51
$1,476.69
$1,579.87
$1,593.42
$1,789.45
$1,863.78
$1,969.65
$1,837.91
$2,246.74
$2,416.78
$2,584.20
$2,641.50
$2,865.95
$1,938.84
$2,489.83
$1,434.33
$1,670.52
$805.37
$2,090.17
$2,442.75
$2,624.59
$1,710.07
$1,298.41
$1,638.03
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$727.12
$719.77
$698.79
$691.73
$842.70
$834.18
$3,418.18
$3,383.65
$797.49
$789.44
$4,731.45
$4,683.65
$964.59
$954.85
$748.05
$740.50
$959.32
$949.62
$1,220.45
$1,208.11
$1,469.39
$1,454.54
$1,572.05
$1,556.17
$1,585.53
$1,569.52
$1,780.59
$1,762.61
$1,854.55
$1,835.83
$1,959.90
$1,940.11
$1,828.81
$1,810.34
$2,235.62
$2,213.04
$2,404.83
$2,380.53
$2,571.41
$2,545.43
$2,628.43
$2,601.89
$2,851.77
$2,822.96
$1,929.25
$1,909.76
$2,477.50
$2,452.48
$1,427.22
$1,412.81
$1,662.27
$1,645.47
$801.38
$793.29
$2,079.82
$2,058.82
$2,430.66
$2,406.11
$2,611.60
$2,585.22
$1,701.62
$1,684.42
$1,291.98
$1,278.93
$1,629.93
$1,613.45
Page 34 of 323
Notes
#
#
#
#
#
#
#
#
Procedure
Code
21195
21196
21198
21199
21206
21208
21208
21209
21209
21210
21210
21215
21215
21230
21235
21235
21240
21242
21243
21244
21245
21245
21246
21247
21248
21248
21249
21249
21255
21256
21260
21261
21263
1/2/2015
Modifier
Par Fee
$1,369.59
$1,511.84
$1,190.67
$1,025.04
$1,265.95
$1,953.42
$863.97
$825.88
$629.95
$2,354.77
$892.40
$4,211.11
$925.97
$775.83
$738.50
$577.96
$1,148.05
$1,051.86
$1,743.16
$1,091.79
$1,127.44
$901.83
$917.98
$1,556.35
$1,140.91
$932.10
$1,565.43
$1,328.02
$1,345.33
$1,221.47
$1,172.62
$2,080.20
$1,922.77
Nonpar Fee
$1,301.11
$1,436.25
$1,131.14
$973.79
$1,202.65
$1,855.75
$820.77
$784.59
$598.45
$2,237.03
$847.78
$4,000.55
$879.67
$737.04
$701.58
$549.06
$1,090.65
$999.27
$1,656.00
$1,037.20
$1,071.07
$856.74
$872.08
$1,478.53
$1,083.86
$885.50
$1,487.16
$1,261.62
$1,278.06
$1,160.40
$1,113.99
$1,976.19
$1,826.63
Limiting
Charge
$1,496.28
$1,651.69
$1,300.81
$1,119.86
$1,383.05
$2,134.11
$943.89
$902.28
$688.22
$2,572.58
$974.95
$4,600.63
$1,011.62
$847.60
$806.82
$631.42
$1,254.25
$1,149.16
$1,904.40
$1,192.78
$1,231.73
$985.25
$1,002.89
$1,700.31
$1,246.44
$1,018.33
$1,710.23
$1,450.86
$1,469.77
$1,334.46
$1,281.09
$2,272.62
$2,100.62
Charge**
Charge***
$1,481.32
$1,473.83
$1,635.17
$1,626.92
$1,287.80
$1,281.30
$1,108.66
$1,103.06
$1,369.21
$1,362.30
$2,112.77
$2,102.10
$934.44
$929.73
$893.25
$888.74
$681.34
$677.89
$2,546.86
$2,533.99
$965.20
$960.32
$4,554.62
$4,531.62
$1,001.50
$996.44
$839.12
$834.88
$798.74
$794.72
$625.11
$621.94
$1,241.70
$1,235.43
$1,137.67
$1,131.92
$1,885.36
$1,875.83
$1,180.85
$1,174.89
$1,219.41
$1,213.25
$975.40
$970.47
$992.86
$987.85
$1,683.30
$1,674.80
$1,233.97
$1,227.74
$1,008.15
$1,003.05
$1,693.13
$1,684.58
$1,436.35
$1,429.11
$1,455.07
$1,447.72
$1,321.12
$1,314.44
$1,268.28
$1,261.87
$2,249.89
$2,238.53
$2,079.61
$2,069.11
Arizona
EHR/eRx
Limiting
Charge**
$1,466.35
$1,618.66
$1,274.80
$1,097.46
$1,355.39
$2,091.44
$925.00
$884.24
$674.45
$2,521.13
$955.44
$4,508.62
$991.39
$830.65
$790.68
$618.79
$1,229.17
$1,126.17
$1,866.31
$1,168.93
$1,207.10
$965.55
$982.84
$1,666.30
$1,221.51
$997.96
$1,676.03
$1,421.85
$1,440.38
$1,307.77
$1,255.47
$2,227.17
$2,058.62
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$1,459.10
$1,444.35
$1,610.64
$1,594.38
$1,268.48
$1,255.67
$1,092.03
$1,081.00
$1,348.67
$1,335.06
$2,081.07
$2,060.06
$920.43
$911.12
$879.85
$870.98
$671.12
$664.33
$2,508.66
$2,483.32
$950.72
$941.11
$4,486.30
$4,440.99
$986.48
$976.52
$826.53
$818.19
$786.76
$778.83
$615.73
$609.51
$1,223.07
$1,210.73
$1,120.61
$1,109.28
$1,857.08
$1,838.32
$1,163.14
$1,151.39
$1,201.12
$1,189.00
$960.77
$951.07
$977.97
$968.09
$1,658.05
$1,641.31
$1,215.46
$1,203.19
$993.03
$982.99
$1,667.74
$1,650.89
$1,414.81
$1,400.52
$1,433.25
$1,418.77
$1,301.31
$1,288.15
$1,249.26
$1,236.63
$2,216.14
$2,193.76
$2,048.41
$2,027.74
Page 35 of 323
Notes
#
#
#
#
#
#
#
Procedure
Code
21267
21268
21270
21270
21275
21280
21282
21295
21296
21310
21310
21315
21315
21320
21320
21325
21330
21335
21336
21337
21337
21338
21339
21340
21343
21344
21345
21345
21346
21347
21348
21355
21355
1/2/2015
Modifier
Par Fee
$1,610.54
$1,882.50
$983.76
$739.19
$850.84
$577.71
$385.38
$192.20
$428.08
$133.77
$27.22
$283.69
$155.69
$261.16
$138.17
$486.89
$584.26
$739.59
$657.29
$413.54
$301.63
$767.24
$868.94
$816.92
$1,238.67
$1,418.39
$795.06
$640.24
$922.28
$1,159.87
$1,228.83
$492.58
$365.29
Nonpar Fee
$1,530.01
$1,788.38
$934.57
$702.23
$808.30
$548.82
$366.11
$182.59
$406.68
$127.08
$25.86
$269.51
$147.91
$248.10
$131.26
$462.55
$555.05
$702.61
$624.43
$392.86
$286.55
$728.88
$825.49
$776.07
$1,176.74
$1,347.47
$755.31
$608.23
$876.17
$1,101.88
$1,167.39
$467.95
$347.03
Limiting
Charge
$1,759.51
$2,056.64
$1,074.76
$807.56
$929.55
$631.14
$421.03
$209.98
$467.68
$146.14
$29.74
$309.94
$170.10
$285.32
$150.95
$531.93
$638.31
$808.00
$718.09
$451.79
$329.53
$838.21
$949.31
$892.48
$1,353.25
$1,549.59
$868.61
$699.46
$1,007.60
$1,267.16
$1,342.50
$538.14
$399.08
Charge**
Charge***
$1,741.92
$1,733.12
$2,036.08
$2,025.78
$1,064.00
$1,058.63
$799.49
$795.46
$920.25
$915.61
$624.83
$621.68
$416.82
$414.71
$207.87
$206.83
$463.00
$460.67
$144.68
$143.95
$29.44
$29.29
$306.83
$305.29
$168.39
$167.54
$282.46
$281.04
$149.44
$148.68
$526.61
$523.95
$631.93
$628.73
$799.92
$795.88
$710.92
$707.32
$447.27
$445.02
$326.23
$324.59
$829.83
$825.64
$939.83
$935.08
$883.56
$879.09
$1,339.72
$1,332.95
$1,534.10
$1,526.35
$859.92
$855.58
$692.47
$688.98
$997.52
$992.48
$1,254.49
$1,248.15
$1,329.08
$1,322.36
$532.76
$530.07
$395.09
$393.09
Arizona
EHR/eRx
Limiting
Charge**
$1,724.32
$2,015.50
$1,053.26
$791.42
$910.95
$618.52
$412.61
$205.78
$458.33
$143.22
$29.14
$303.74
$166.69
$279.61
$147.92
$521.30
$625.54
$791.84
$703.73
$442.75
$322.94
$821.45
$930.33
$874.63
$1,326.19
$1,518.60
$851.23
$685.48
$987.45
$1,241.82
$1,315.65
$527.38
$391.10
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$1,715.79
$1,698.46
$2,005.53
$1,985.27
$1,048.04
$1,037.46
$787.50
$779.55
$906.45
$897.29
$615.46
$609.24
$410.56
$406.42
$204.76
$202.70
$456.06
$451.46
$142.51
$141.07
$29.00
$28.70
$302.23
$299.18
$165.86
$164.20
$278.23
$275.41
$147.20
$145.71
$518.71
$513.48
$622.45
$616.16
$787.92
$779.96
$700.26
$693.17
$440.57
$436.11
$321.33
$318.10
$817.39
$809.13
$925.73
$916.38
$870.31
$861.51
$1,319.63
$1,306.30
$1,511.09
$1,495.82
$847.02
$838.47
$682.09
$675.20
$982.56
$972.64
$1,235.68
$1,223.19
$1,309.14
$1,295.91
$524.77
$519.47
$389.17
$385.24
Page 36 of 323
Notes
#
#
#
#
#
#
#
Procedure
Code
21356
21356
21360
21365
21366
21385
21386
21387
21390
21395
21400
21400
21401
21401
21406
21407
21408
21421
21421
21422
21423
21431
21432
21433
21435
21436
21440
21440
21445
21445
21450
21450
21451
1/2/2015
Modifier
Par Fee
$511.84
$385.98
$548.46
$1,133.21
$1,180.08
$695.04
$708.01
$725.35
$807.63
$1,025.26
$197.38
$160.56
$501.77
$312.63
$582.31
$656.54
$914.49
$861.49
$712.40
$688.96
$806.80
$805.11
$653.96
$1,770.44
$1,286.26
$2,078.16
$593.21
$480.94
$794.14
$645.76
$641.89
$512.45
$844.64
Nonpar Fee
$486.25
$366.68
$521.04
$1,076.55
$1,121.08
$660.29
$672.61
$689.08
$767.25
$974.00
$187.51
$152.53
$476.68
$297.00
$553.19
$623.71
$868.77
$818.42
$676.78
$654.51
$766.46
$764.85
$621.26
$1,681.92
$1,221.95
$1,974.25
$563.55
$456.89
$754.43
$613.47
$609.80
$486.83
$802.41
Limiting
Charge
$559.19
$421.68
$599.20
$1,238.03
$1,289.24
$759.33
$773.50
$792.44
$882.34
$1,120.10
$215.64
$175.41
$548.18
$341.55
$636.17
$717.27
$999.09
$941.18
$778.30
$752.69
$881.43
$879.58
$714.45
$1,934.21
$1,405.24
$2,270.39
$648.08
$525.42
$867.59
$705.49
$701.27
$559.85
$922.77
Charge**
Charge***
$553.60
$550.80
$417.46
$415.36
$593.20
$590.20
$1,225.65
$1,219.46
$1,276.35
$1,269.90
$751.74
$747.95
$765.76
$761.90
$784.52
$780.55
$873.52
$869.10
$1,108.90
$1,103.30
$213.47
$212.41
$173.65
$172.78
$542.70
$539.96
$338.13
$336.43
$629.81
$626.62
$710.09
$706.50
$989.09
$984.10
$931.78
$927.06
$770.51
$766.62
$745.15
$741.39
$872.62
$868.20
$870.78
$866.39
$707.31
$703.73
$1,914.87
$1,905.19
$1,391.19
$1,384.16
$2,247.69
$2,236.34
$641.60
$638.37
$520.17
$517.55
$858.92
$854.58
$698.44
$694.91
$694.26
$690.75
$554.25
$551.46
$913.55
$908.93
Arizona
EHR/eRx
Limiting
Charge**
$548.01
$413.25
$587.21
$1,213.27
$1,263.46
$744.14
$758.03
$776.60
$864.70
$1,097.70
$211.32
$171.90
$537.22
$334.72
$623.45
$702.93
$979.10
$922.36
$762.73
$737.63
$863.80
$861.98
$700.15
$1,895.52
$1,377.14
$2,224.99
$635.12
$514.91
$850.24
$691.38
$687.24
$548.65
$904.31
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$545.30
$539.79
$411.19
$407.05
$584.30
$578.40
$1,207.26
$1,195.07
$1,257.20
$1,244.51
$740.46
$732.98
$754.27
$746.66
$772.75
$764.95
$860.42
$851.72
$1,092.27
$1,081.23
$210.28
$208.15
$171.05
$169.33
$534.55
$529.16
$333.06
$329.69
$620.37
$614.10
$699.44
$692.38
$974.26
$964.41
$917.80
$908.52
$758.95
$751.28
$733.98
$726.57
$859.53
$850.84
$857.72
$849.06
$696.69
$689.66
$1,886.14
$1,867.09
$1,370.32
$1,356.48
$2,213.97
$2,191.61
$631.97
$625.60
$512.37
$507.18
$846.04
$837.49
$687.96
$681.01
$683.84
$676.94
$545.94
$540.42
$899.84
$890.74
Page 37 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
21451
21452
21452
21453
21453
21454
21461
21461
21462
21462
21465
21470
21480
21480
21485
21485
21490
21495
21497
21497
21501
21501
21502
21510
21550
21550
21552
21554
21555
21555
21556
21557
21558
1/2/2015
Modifier
Par Fee
$695.18
$590.70
$348.64
$941.23
$806.08
$587.40
$2,191.60
$963.79
$2,330.13
$1,073.35
$954.32
$1,235.22
$100.43
$32.50
$724.45
$605.03
$941.89
$654.75
$757.07
$628.00
$459.55
$325.83
$515.80
$447.22
$266.40
$160.92
$453.07
$743.51
$421.25
$310.77
$538.75
$974.79
$1,367.04
Nonpar Fee
$660.42
$561.17
$331.21
$894.17
$765.78
$558.03
$2,082.02
$915.60
$2,213.62
$1,019.68
$906.60
$1,173.46
$95.41
$30.88
$688.23
$574.78
$894.80
$622.01
$719.22
$596.60
$436.57
$309.54
$490.01
$424.86
$253.08
$152.87
$430.42
$706.33
$400.19
$295.23
$511.81
$926.05
$1,298.69
Limiting
Charge
$759.48
$645.35
$380.89
$1,028.30
$880.65
$641.73
$2,394.32
$1,052.94
$2,545.66
$1,172.63
$1,042.59
$1,349.48
$109.72
$35.51
$791.46
$661.00
$1,029.02
$715.31
$827.10
$686.09
$502.06
$355.97
$563.51
$488.59
$291.04
$175.80
$494.98
$812.28
$460.22
$339.51
$588.58
$1,064.96
$1,493.49
Charge**
Charge***
$751.89
$748.09
$638.89
$635.66
$377.09
$375.18
$1,018.01
$1,012.87
$871.84
$867.43
$635.32
$632.11
$2,370.38
$2,358.41
$1,042.41
$1,037.15
$2,520.20
$2,507.48
$1,160.90
$1,155.04
$1,032.16
$1,026.95
$1,335.99
$1,329.24
$108.63
$108.08
$35.16
$34.98
$783.55
$779.60
$654.38
$651.08
$1,018.73
$1,013.59
$708.16
$704.58
$818.83
$814.69
$679.22
$675.80
$497.03
$494.52
$352.41
$350.64
$557.88
$555.06
$483.70
$481.26
$288.13
$286.67
$174.04
$173.17
$490.04
$487.55
$804.16
$800.10
$455.62
$453.32
$336.12
$334.42
$582.69
$579.75
$1,054.31
$1,048.98
$1,478.56
$1,471.09
Arizona
EHR/eRx
Limiting
Charge**
$744.29
$632.44
$373.28
$1,007.73
$863.03
$628.90
$2,346.44
$1,031.88
$2,494.75
$1,149.18
$1,021.74
$1,322.49
$107.53
$34.80
$775.64
$647.77
$1,008.44
$701.01
$810.57
$672.37
$492.02
$348.85
$552.24
$478.81
$285.22
$172.28
$485.08
$796.03
$451.02
$332.73
$576.81
$1,043.66
$1,463.63
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$740.61
$733.13
$629.31
$622.96
$371.43
$367.68
$1,002.74
$992.62
$858.76
$850.08
$625.78
$619.47
$2,334.82
$2,311.24
$1,026.77
$1,016.40
$2,482.40
$2,457.33
$1,143.49
$1,131.95
$1,016.68
$1,006.41
$1,315.95
$1,302.65
$107.00
$105.92
$34.63
$34.28
$771.80
$764.00
$644.56
$638.05
$1,003.44
$993.31
$697.53
$690.49
$806.55
$798.41
$669.04
$662.29
$489.58
$484.63
$347.12
$343.62
$549.50
$543.96
$476.45
$471.63
$283.81
$280.95
$171.43
$169.69
$482.69
$477.80
$792.10
$784.09
$448.79
$444.26
$331.09
$327.74
$573.95
$568.16
$1,038.50
$1,028.01
$1,456.37
$1,441.67
Page 38 of 323
Notes
#
#
#
#
Procedure
Code
21600
21610
21615
21616
21620
21627
21630
21632
21685
21700
21705
21720
21725
21740
21750
21805
21811
21812
21813
21820
21820
21825
21920
21920
21925
21925
21930
21930
21931
21932
21933
21935
21936
1/2/2015
Modifier
Par Fee
$567.45
$1,238.27
$635.31
$742.66
$513.15
$552.25
$1,225.14
$1,223.68
$1,014.43
$373.48
$556.42
$490.22
$550.06
$1,048.94
$696.15
$276.47
$615.10
$737.42
$1,003.73
$144.38
$147.95
$550.03
$259.60
$162.71
$453.04
$360.79
$478.11
$369.42
$476.59
$671.09
$750.27
$1,041.37
$1,434.43
Nonpar Fee
$539.08
$1,176.36
$603.54
$705.53
$487.49
$524.64
$1,163.88
$1,162.50
$963.71
$354.81
$528.60
$465.71
$522.56
$996.49
$661.34
$262.65
$584.35
$700.55
$953.54
$137.16
$140.55
$522.53
$246.62
$154.57
$430.39
$342.75
$454.20
$350.95
$452.76
$637.54
$712.76
$989.30
$1,362.71
Limiting
Charge
$619.94
$1,352.81
$694.07
$811.36
$560.61
$603.34
$1,338.46
$1,336.88
$1,108.27
$408.03
$607.89
$535.57
$600.94
$1,145.96
$760.54
$302.05
$672.00
$805.63
$1,096.57
$157.73
$161.63
$600.91
$283.61
$177.76
$494.95
$394.16
$522.33
$403.59
$520.67
$733.17
$819.67
$1,137.70
$1,567.12
Charge**
Charge***
$613.74
$610.64
$1,339.29
$1,332.52
$687.13
$683.66
$803.24
$799.19
$555.01
$552.21
$597.30
$594.29
$1,325.08
$1,318.38
$1,323.51
$1,316.82
$1,097.18
$1,091.64
$403.95
$401.91
$601.81
$598.77
$530.21
$527.53
$594.93
$591.93
$1,134.51
$1,128.77
$752.94
$749.13
$299.02
$297.52
$665.29
$661.92
$797.57
$793.55
$1,085.60
$1,080.13
$156.16
$155.37
$160.01
$159.21
$594.90
$591.89
$280.77
$279.36
$175.97
$175.09
$490.00
$487.52
$390.22
$388.25
$517.11
$514.50
$399.56
$397.54
$515.46
$512.87
$725.83
$722.18
$811.47
$807.38
$1,126.32
$1,120.63
$1,551.44
$1,543.61
Arizona
EHR/eRx
Limiting
Charge**
$607.55
$1,325.75
$680.19
$795.13
$549.40
$591.27
$1,311.69
$1,310.14
$1,086.11
$399.87
$595.73
$524.86
$588.93
$1,123.04
$745.33
$296.01
$658.56
$789.52
$1,074.64
$154.58
$158.40
$588.89
$277.94
$174.20
$485.05
$386.29
$511.89
$395.52
$510.26
$718.51
$803.28
$1,114.94
$1,535.78
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$604.53
$598.44
$1,319.20
$1,305.87
$676.82
$669.99
$791.19
$783.21
$546.69
$541.16
$588.34
$582.41
$1,305.20
$1,292.01
$1,303.66
$1,290.48
$1,080.72
$1,069.81
$397.89
$393.86
$592.78
$586.80
$522.25
$516.98
$586.01
$580.09
$1,117.49
$1,106.20
$741.65
$734.15
$294.54
$291.57
$655.30
$648.68
$785.61
$777.68
$1,069.32
$1,058.52
$153.81
$152.26
$157.61
$156.02
$585.97
$580.06
$276.56
$273.77
$173.33
$171.59
$482.66
$477.77
$384.36
$380.49
$509.36
$504.21
$393.56
$389.59
$507.74
$502.60
$714.94
$707.73
$799.31
$791.22
$1,109.43
$1,098.22
$1,528.17
$1,512.74
Page 39 of 323
Notes
#
#
#
Procedure
Code
22010
22015
22100
22101
22102
22103
22110
22112
22114
22116
22206
22207
22208
22210
22212
22214
22216
22220
22222
22224
22226
22305
22305
22310
22310
22315
22315
22318
22319
22325
22326
22327
22328
1/2/2015
Modifier
Par Fee
$970.42
$922.44
$951.81
$840.36
$812.88
$143.82
$1,068.44
$1,154.15
$1,014.97
$144.95
$2,501.81
$2,450.85
$588.60
$1,830.32
$1,519.40
$1,518.01
$373.53
$1,631.72
$1,596.93
$1,615.76
$371.56
$193.82
$175.58
$311.75
$287.08
$902.24
$788.18
$1,680.21
$1,887.64
$1,464.81
$1,532.07
$1,539.23
$291.20
Nonpar Fee
$921.90
$876.32
$904.22
$798.34
$772.24
$136.63
$1,015.02
$1,096.44
$964.22
$137.70
$2,376.72
$2,328.31
$559.17
$1,738.80
$1,443.43
$1,442.11
$354.85
$1,550.13
$1,517.08
$1,534.97
$352.98
$184.13
$166.80
$296.16
$272.73
$857.13
$748.77
$1,596.20
$1,793.26
$1,391.57
$1,455.47
$1,462.27
$276.64
Limiting
Charge
$1,060.19
$1,007.77
$1,039.85
$918.09
$888.08
$157.12
$1,167.27
$1,260.91
$1,108.85
$158.36
$2,733.23
$2,677.56
$643.05
$1,999.62
$1,659.94
$1,658.43
$408.08
$1,782.65
$1,744.64
$1,765.22
$405.93
$211.75
$191.82
$340.58
$313.64
$985.70
$861.09
$1,835.63
$2,062.25
$1,600.31
$1,673.79
$1,681.61
$318.14
Charge**
Charge***
$1,049.58
$1,044.28
$997.69
$992.66
$1,029.46
$1,024.26
$908.91
$904.31
$879.20
$874.76
$155.55
$154.77
$1,155.60
$1,149.76
$1,248.30
$1,241.99
$1,097.77
$1,092.22
$156.77
$155.97
$2,705.89
$2,692.23
$2,650.78
$2,637.40
$636.62
$633.40
$1,979.62
$1,969.63
$1,643.35
$1,635.05
$1,641.84
$1,633.55
$404.00
$401.96
$1,764.82
$1,755.91
$1,727.20
$1,718.47
$1,747.56
$1,738.74
$401.87
$399.84
$209.63
$208.58
$189.90
$188.95
$337.18
$335.48
$310.50
$308.94
$975.84
$970.91
$852.47
$848.17
$1,817.28
$1,808.10
$2,041.63
$2,031.31
$1,584.30
$1,576.31
$1,657.06
$1,648.69
$1,664.80
$1,656.39
$314.95
$313.36
Arizona
EHR/eRx
Limiting
Charge**
$1,038.98
$987.61
$1,019.06
$899.73
$870.32
$153.99
$1,143.93
$1,235.69
$1,086.68
$155.19
$2,678.57
$2,624.00
$630.19
$1,959.62
$1,626.74
$1,625.26
$399.91
$1,747.00
$1,709.75
$1,729.91
$397.81
$207.52
$187.98
$333.78
$307.37
$965.99
$843.86
$1,798.92
$2,021.00
$1,568.30
$1,640.31
$1,647.97
$311.78
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$1,033.84
$1,023.40
$982.73
$972.80
$1,014.01
$1,003.78
$895.28
$886.22
$866.01
$857.27
$153.21
$151.67
$1,138.27
$1,126.77
$1,229.58
$1,217.15
$1,081.30
$1,070.39
$154.42
$152.87
$2,665.31
$2,638.39
$2,611.02
$2,584.64
$627.07
$620.74
$1,949.93
$1,930.23
$1,618.71
$1,602.34
$1,617.21
$1,600.88
$397.93
$393.91
$1,738.35
$1,720.79
$1,701.29
$1,684.11
$1,721.35
$1,703.97
$395.84
$391.84
$206.49
$204.40
$187.05
$185.16
$332.12
$328.77
$305.84
$302.76
$961.20
$951.50
$839.68
$831.20
$1,790.02
$1,771.94
$2,011.01
$1,990.68
$1,560.54
$1,544.77
$1,632.21
$1,615.70
$1,639.83
$1,623.25
$310.22
$307.10
Page 40 of 323
Notes
#
#
#
#
#
#
Procedure
Code
22505
22510
22510
22511
22511
22512
22512
22513
22513
22514
22514
22515
22515
22532
22533
22534
22548
22551
22552
22554
22556
22558
22585
22586
22590
22595
22600
22610
22612
22614
22630
22632
22633
1/2/2015
Modifier
Par Fee
$135.27
$1,787.05
$464.48
$1,770.82
$436.10
$993.76
$216.09
$7,450.92
$552.40
$7,412.20
$514.76
$4,497.73
$232.56
$1,820.12
$1,687.69
$369.96
$2,028.48
$1,758.70
$411.38
$1,288.06
$1,713.90
$1,576.82
$338.80
$2,060.11
$1,619.09
$1,548.31
$1,322.86
$1,294.67
$1,626.50
$403.86
$1,608.07
$330.68
$1,900.74
Nonpar Fee
$128.51
$1,697.70
$441.26
$1,682.28
$414.30
$944.07
$205.29
$7,078.37
$524.78
$7,041.59
$489.02
$4,272.84
$220.93
$1,729.11
$1,603.31
$351.46
$1,927.06
$1,670.77
$390.81
$1,223.66
$1,628.21
$1,497.98
$321.86
$1,957.10
$1,538.14
$1,470.89
$1,256.72
$1,229.94
$1,545.18
$383.67
$1,527.67
$314.15
$1,805.70
Limiting
Charge
$147.79
$1,952.36
$507.45
$1,934.62
$476.45
$1,085.68
$236.08
$8,140.13
$603.50
$8,097.83
$562.37
$4,913.77
$254.07
$1,988.48
$1,843.81
$404.18
$2,216.12
$1,921.39
$449.43
$1,407.21
$1,872.44
$1,722.68
$370.14
$2,250.67
$1,768.86
$1,691.52
$1,445.23
$1,414.43
$1,776.96
$441.22
$1,756.82
$361.27
$2,076.56
Charge**
Charge***
$146.30
$145.57
$1,932.83
$1,923.06
$502.38
$499.84
$1,915.28
$1,905.61
$471.68
$469.30
$1,074.82
$1,069.40
$233.73
$232.54
$8,058.73
$8,018.02
$597.46
$594.45
$8,016.85
$7,976.37
$556.75
$553.93
$4,864.63
$4,840.06
$251.53
$250.26
$1,968.59
$1,958.65
$1,825.37
$1,816.15
$400.14
$398.12
$2,193.96
$2,182.87
$1,902.17
$1,892.57
$444.94
$442.69
$1,393.13
$1,386.11
$1,853.72
$1,844.36
$1,705.45
$1,696.84
$366.44
$364.58
$2,228.16
$2,216.90
$1,751.17
$1,742.33
$1,674.61
$1,666.15
$1,430.77
$1,423.55
$1,400.29
$1,393.21
$1,759.19
$1,750.30
$436.80
$434.60
$1,739.25
$1,730.46
$357.66
$355.86
$2,055.79
$2,045.40
Arizona
EHR/eRx
Limiting
Charge**
$144.83
$1,913.31
$497.29
$1,895.92
$466.91
$1,063.97
$231.36
$7,977.32
$591.42
$7,935.87
$551.13
$4,815.49
$248.99
$1,948.71
$1,806.93
$396.09
$2,171.80
$1,882.95
$440.44
$1,379.07
$1,835.00
$1,688.22
$362.73
$2,205.65
$1,733.49
$1,657.69
$1,416.33
$1,386.14
$1,741.42
$432.40
$1,721.69
$354.05
$2,035.03
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$144.11
$142.66
$1,903.84
$1,884.61
$494.85
$489.83
$1,886.55
$1,867.49
$464.61
$459.91
$1,058.70
$1,048.01
$230.22
$227.88
$7,937.85
$7,857.66
$588.50
$582.56
$7,896.59
$7,816.84
$548.40
$542.86
$4,791.66
$4,743.26
$247.76
$245.25
$1,939.06
$1,919.48
$1,797.99
$1,779.82
$394.14
$390.15
$2,161.05
$2,139.22
$1,873.64
$1,854.71
$438.27
$433.84
$1,372.24
$1,358.38
$1,825.91
$1,807.48
$1,679.87
$1,662.90
$360.94
$357.29
$2,194.74
$2,172.57
$1,724.91
$1,707.49
$1,649.49
$1,632.83
$1,409.31
$1,395.09
$1,379.29
$1,365.35
$1,732.80
$1,715.31
$430.25
$425.91
$1,713.16
$1,695.86
$352.29
$348.74
$2,024.95
$2,004.51
Page 41 of 323
Notes
Procedure
Code
22634
22800
22802
22804
22808
22810
22812
22818
22819
22830
22840
22842
22843
22844
22845
22846
22847
22848
22849
22850
22851
22852
22855
22856
22857
22858
22861
22862
22864
22865
22900
22901
22902
1/2/2015
Modifier
Par Fee
$510.98
$1,384.17
$2,148.95
$2,489.01
$1,890.67
$2,068.62
$2,263.47
$2,223.38
$2,840.49
$831.70
$783.16
$785.31
$840.35
$1,015.13
$753.68
$782.42
$822.56
$370.49
$1,333.65
$740.77
$419.28
$710.10
$1,135.25
$1,629.67
$1,818.13
$508.16
$1,969.02
$1,803.14
$2,147.12
$2,097.71
$572.03
$674.54
$444.01
Nonpar Fee
$485.43
$1,314.96
$2,041.50
$2,364.56
$1,796.14
$1,965.19
$2,150.30
$2,112.21
$2,698.47
$790.12
$744.00
$746.04
$798.33
$964.37
$716.00
$743.30
$781.43
$351.97
$1,266.97
$703.73
$398.32
$674.60
$1,078.49
$1,548.19
$1,727.22
$482.75
$1,870.57
$1,712.98
$2,039.76
$1,992.82
$543.43
$640.81
$421.81
Limiting
Charge
$558.24
$1,512.20
$2,347.73
$2,719.24
$2,065.56
$2,259.97
$2,472.85
$2,429.04
$3,103.24
$908.64
$855.60
$857.95
$918.08
$1,109.03
$823.40
$854.80
$898.64
$404.77
$1,457.02
$809.29
$458.07
$775.79
$1,240.26
$1,780.42
$1,986.30
$555.16
$2,151.16
$1,969.93
$2,345.72
$2,291.74
$624.94
$736.93
$485.08
Charge**
Charge***
$552.67
$549.87
$1,497.08
$1,489.53
$2,324.25
$2,312.51
$2,692.05
$2,678.45
$2,044.91
$2,034.58
$2,237.37
$2,226.07
$2,448.12
$2,435.76
$2,404.75
$2,392.61
$3,072.21
$3,056.69
$899.55
$895.01
$847.04
$842.77
$849.37
$845.08
$908.90
$904.31
$1,097.94
$1,092.39
$815.17
$811.05
$846.25
$841.97
$889.66
$885.17
$400.72
$398.69
$1,442.45
$1,435.17
$801.19
$797.15
$453.49
$451.20
$768.03
$764.15
$1,227.87
$1,221.66
$1,762.62
$1,753.72
$1,966.44
$1,956.51
$549.61
$546.84
$2,129.64
$2,118.89
$1,950.23
$1,940.38
$2,322.26
$2,310.53
$2,268.82
$2,257.37
$618.70
$615.57
$729.56
$725.88
$480.23
$477.80
Arizona
EHR/eRx
Limiting
Charge**
$547.08
$1,481.96
$2,300.77
$2,664.86
$2,024.25
$2,214.77
$2,423.38
$2,380.47
$3,041.18
$890.47
$838.49
$840.79
$899.71
$1,086.84
$806.93
$837.69
$880.67
$396.67
$1,427.87
$793.11
$448.90
$760.28
$1,215.46
$1,744.81
$1,946.58
$544.07
$2,108.13
$1,930.53
$2,298.80
$2,245.90
$612.44
$722.19
$475.38
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$544.38
$538.87
$1,474.62
$1,459.73
$2,289.39
$2,266.26
$2,651.67
$2,624.89
$2,014.24
$1,993.89
$2,203.81
$2,181.55
$2,411.40
$2,387.03
$2,368.68
$2,344.76
$3,026.13
$2,995.55
$886.06
$877.12
$834.34
$825.91
$836.63
$828.17
$895.26
$886.21
$1,081.47
$1,070.54
$802.94
$794.82
$833.55
$825.13
$876.32
$867.46
$394.70
$390.72
$1,420.81
$1,406.46
$789.18
$781.22
$446.68
$442.16
$756.50
$748.87
$1,209.44
$1,197.23
$1,736.18
$1,718.64
$1,936.95
$1,917.38
$541.36
$535.90
$2,097.69
$2,076.51
$1,920.97
$1,901.57
$2,287.43
$2,264.33
$2,234.80
$2,212.22
$609.42
$603.26
$718.61
$711.36
$473.03
$468.25
Page 42 of 323
Notes
#
#
#
#
#
#
#
Procedure
Code
22902
22903
22904
22905
23000
23000
23020
23030
23030
23031
23031
23035
23040
23044
23065
23065
23066
23066
23071
23073
23075
23075
23076
23077
23078
23100
23101
23105
23106
23107
23120
23125
23130
1/2/2015
Modifier
Par Fee
$335.32
$445.47
$1,068.48
$1,348.83
$596.55
$378.80
$700.79
$448.06
$259.99
$434.19
$223.95
$692.21
$731.41
$581.49
$218.67
$169.68
$564.81
$362.44
$425.04
$704.03
$474.35
$330.98
$547.07
$1,157.87
$1,452.79
$508.79
$456.32
$647.55
$504.90
$670.48
$594.17
$721.94
$620.37
Nonpar Fee
$318.55
$423.20
$1,015.06
$1,281.39
$566.72
$359.86
$665.75
$425.66
$246.99
$412.48
$212.75
$657.60
$694.84
$552.42
$207.74
$161.20
$536.57
$344.32
$403.79
$668.83
$450.63
$314.43
$519.72
$1,099.98
$1,380.15
$483.35
$433.50
$615.17
$479.66
$636.96
$564.46
$685.84
$589.35
Limiting
Charge
$366.33
$486.68
$1,167.32
$1,473.60
$651.73
$413.84
$765.61
$489.51
$284.04
$474.35
$244.66
$756.24
$799.07
$635.28
$238.90
$185.38
$617.06
$395.97
$464.36
$769.15
$518.22
$361.59
$597.68
$1,264.98
$1,587.17
$555.85
$498.53
$707.45
$551.61
$732.50
$649.13
$788.72
$677.75
Charge**
Charge***
$362.66
$360.84
$481.82
$479.38
$1,155.65
$1,149.80
$1,458.87
$1,451.50
$645.21
$641.95
$409.70
$407.63
$757.95
$754.12
$484.61
$482.17
$281.20
$279.78
$469.61
$467.23
$242.21
$240.99
$748.67
$744.90
$791.07
$787.08
$628.94
$625.75
$236.51
$235.31
$183.53
$182.60
$610.88
$607.80
$392.01
$390.03
$459.71
$457.39
$761.46
$757.62
$513.04
$510.45
$357.98
$356.17
$591.70
$588.71
$1,252.33
$1,246.00
$1,571.30
$1,563.37
$550.30
$547.52
$493.55
$491.05
$700.37
$696.83
$546.09
$543.34
$725.18
$721.52
$642.64
$639.39
$780.83
$776.88
$670.98
$667.59
Arizona
EHR/eRx
Limiting
Charge**
$359.01
$476.95
$1,143.97
$1,444.12
$638.70
$405.56
$750.31
$479.72
$278.36
$464.86
$239.78
$741.12
$783.08
$622.58
$234.13
$181.68
$604.72
$388.04
$455.07
$753.77
$507.86
$354.36
$585.73
$1,239.68
$1,555.43
$544.73
$488.55
$693.30
$540.58
$717.85
$636.15
$772.94
$664.19
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$357.22
$353.63
$474.59
$469.80
$1,138.32
$1,126.82
$1,436.98
$1,422.46
$635.52
$629.12
$403.56
$399.48
$746.58
$739.05
$477.34
$472.52
$276.98
$274.18
$462.56
$457.90
$238.58
$236.18
$737.44
$730.00
$779.21
$771.34
$619.51
$613.24
$232.97
$230.62
$180.78
$178.95
$601.71
$595.64
$386.14
$382.23
$452.81
$448.24
$750.04
$742.46
$505.34
$500.25
$352.61
$349.05
$582.82
$576.94
$1,233.55
$1,221.08
$1,547.73
$1,532.10
$542.04
$536.56
$486.14
$481.23
$689.86
$682.90
$537.90
$532.47
$714.30
$707.09
$633.01
$626.60
$769.12
$761.35
$660.92
$654.24
Page 43 of 323
Notes
#
#
Procedure
Code
23140
23145
23146
23150
23155
23156
23170
23172
23174
23180
23182
23184
23190
23195
23200
23210
23220
23330
23330
23333
23334
23335
23350
23350
23395
23397
23400
23405
23406
23410
23412
23415
23420
1/2/2015
Modifier
Par Fee
$536.16
$707.82
$632.18
$673.62
$807.64
$690.20
$570.04
$575.72
$771.60
$678.81
$670.35
$747.69
$581.30
$769.24
$1,547.58
$1,818.80
$1,993.37
$244.23
$155.56
$462.57
$1,090.82
$1,298.79
$132.93
$52.48
$1,307.09
$1,163.71
$988.69
$635.21
$783.58
$836.20
$866.64
$709.82
$985.28
Nonpar Fee
$509.35
$672.43
$600.57
$639.94
$767.26
$655.69
$541.54
$546.93
$733.02
$644.87
$636.83
$710.31
$552.24
$730.78
$1,470.20
$1,727.86
$1,893.70
$232.02
$147.78
$439.44
$1,036.28
$1,233.85
$126.28
$49.86
$1,241.74
$1,105.52
$939.26
$603.45
$744.40
$794.39
$823.31
$674.33
$936.02
Limiting
Charge
$585.75
$773.29
$690.66
$735.93
$882.35
$754.04
$622.77
$628.97
$842.97
$741.60
$732.35
$816.86
$635.08
$840.40
$1,690.73
$1,987.04
$2,177.76
$266.82
$169.95
$505.36
$1,191.72
$1,418.93
$145.22
$57.34
$1,428.00
$1,271.35
$1,080.15
$693.97
$856.06
$913.55
$946.81
$775.48
$1,076.42
Charge**
Charge***
$579.90
$576.97
$765.57
$761.69
$683.74
$680.29
$728.57
$724.89
$873.53
$869.11
$746.50
$742.73
$616.54
$613.43
$622.68
$619.54
$834.54
$830.32
$734.18
$730.48
$725.03
$721.37
$808.69
$804.61
$628.73
$625.55
$831.99
$827.79
$1,673.83
$1,665.37
$1,967.17
$1,957.23
$2,155.97
$2,145.08
$264.16
$262.82
$168.25
$167.39
$500.31
$497.78
$1,179.81
$1,173.85
$1,404.74
$1,397.64
$143.77
$143.05
$56.76
$56.48
$1,413.72
$1,406.58
$1,258.63
$1,252.28
$1,069.35
$1,063.95
$687.03
$683.56
$847.50
$843.21
$904.42
$899.84
$937.34
$932.60
$767.73
$763.85
$1,065.66
$1,060.28
Arizona
EHR/eRx
Limiting
Charge**
$574.03
$757.83
$676.84
$721.21
$864.70
$738.97
$610.32
$616.39
$826.11
$726.77
$717.70
$800.52
$622.38
$823.58
$1,656.92
$1,947.30
$2,134.20
$261.49
$166.54
$495.25
$1,167.88
$1,390.55
$142.31
$56.19
$1,399.45
$1,245.92
$1,058.54
$680.09
$838.94
$895.28
$927.87
$759.97
$1,054.90
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$571.21
$565.42
$754.08
$746.47
$673.49
$666.69
$717.65
$710.39
$860.43
$851.72
$735.30
$727.88
$607.29
$601.16
$613.34
$607.14
$822.02
$813.72
$723.17
$715.86
$714.15
$706.94
$796.56
$788.51
$619.30
$613.04
$819.51
$811.23
$1,648.72
$1,632.07
$1,937.66
$1,918.09
$2,123.64
$2,102.19
$260.19
$257.57
$165.73
$164.05
$492.80
$487.82
$1,162.11
$1,150.37
$1,383.67
$1,369.68
$141.61
$140.17
$55.91
$55.35
$1,392.51
$1,378.46
$1,239.75
$1,227.23
$1,053.31
$1,042.66
$676.73
$669.89
$834.80
$826.36
$890.85
$881.84
$923.28
$913.95
$756.22
$748.57
$1,049.67
$1,039.07
Page 44 of 323
Notes
#
#
#
#
#
#
Procedure
Code
23430
23440
23450
23455
23460
23462
23465
23466
23470
23472
23473
23474
23480
23485
23490
23491
23500
23500
23505
23505
23515
23520
23520
23525
23525
23530
23532
23540
23540
23545
23545
23550
23552
1/2/2015
Modifier
Par Fee
$759.57
$768.74
$966.34
$1,019.04
$1,110.60
$1,084.59
$1,141.94
$1,143.49
$1,225.12
$1,484.49
$1,657.80
$1,792.81
$836.03
$970.54
$878.00
$1,030.98
$220.01
$223.58
$356.80
$336.42
$731.99
$234.23
$237.45
$390.14
$360.82
$582.65
$634.95
$227.38
$230.96
$344.27
$312.45
$576.02
$663.28
Nonpar Fee
$721.59
$730.30
$918.02
$968.09
$1,055.07
$1,030.36
$1,084.84
$1,086.32
$1,163.86
$1,410.27
$1,574.91
$1,703.17
$794.23
$922.01
$834.10
$979.43
$209.01
$212.40
$338.96
$319.60
$695.39
$222.52
$225.58
$370.63
$342.78
$553.52
$603.20
$216.01
$219.41
$327.06
$296.83
$547.22
$630.12
Limiting
Charge
$829.83
$839.85
$1,055.72
$1,113.30
$1,213.33
$1,184.91
$1,247.57
$1,249.27
$1,338.44
$1,621.81
$1,811.15
$1,958.65
$913.36
$1,060.31
$959.22
$1,126.34
$240.36
$244.26
$389.80
$367.54
$799.70
$255.90
$259.42
$426.22
$394.20
$636.55
$693.68
$248.41
$252.32
$376.12
$341.35
$629.30
$724.64
Charge**
Charge***
$821.53
$817.39
$831.45
$827.25
$1,045.17
$1,039.89
$1,102.17
$1,096.61
$1,201.20
$1,195.13
$1,173.07
$1,167.14
$1,235.09
$1,228.86
$1,236.78
$1,230.53
$1,325.05
$1,318.36
$1,605.60
$1,597.49
$1,793.03
$1,783.98
$1,939.06
$1,929.26
$904.23
$899.67
$1,049.71
$1,044.41
$949.62
$944.83
$1,115.09
$1,109.45
$237.96
$236.75
$241.82
$240.59
$385.91
$383.96
$363.86
$362.03
$791.71
$787.70
$253.33
$252.06
$256.82
$255.53
$421.96
$419.83
$390.25
$388.29
$630.18
$627.00
$686.75
$683.27
$245.93
$244.69
$249.80
$248.54
$372.36
$370.47
$337.94
$336.24
$623.01
$619.86
$717.39
$713.77
Arizona
EHR/eRx
Limiting
Charge**
$813.23
$823.04
$1,034.61
$1,091.04
$1,189.07
$1,161.21
$1,222.61
$1,224.28
$1,311.67
$1,589.37
$1,774.92
$1,919.48
$895.10
$1,039.11
$940.03
$1,103.82
$235.55
$239.37
$382.01
$360.19
$783.70
$250.78
$254.23
$417.70
$386.31
$623.82
$679.81
$243.44
$247.27
$368.60
$334.52
$616.72
$710.15
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$809.20
$801.03
$818.98
$810.69
$1,029.49
$1,019.10
$1,085.63
$1,074.68
$1,183.18
$1,171.23
$1,155.47
$1,143.79
$1,216.56
$1,204.27
$1,218.23
$1,205.91
$1,305.18
$1,291.99
$1,581.51
$1,565.53
$1,766.14
$1,748.30
$1,909.98
$1,890.68
$890.68
$881.67
$1,033.97
$1,023.52
$935.38
$925.93
$1,098.37
$1,087.26
$234.39
$232.02
$238.20
$235.78
$380.12
$376.28
$358.40
$354.79
$779.83
$771.95
$249.54
$247.02
$252.97
$250.41
$415.63
$411.44
$384.40
$380.51
$620.72
$614.46
$676.44
$669.61
$242.24
$239.79
$246.05
$243.56
$366.77
$363.07
$332.87
$329.51
$613.66
$607.48
$706.63
$699.50
Page 45 of 323
Notes
#
#
#
#
#
#
#
#
#
Procedure
Code
23570
23570
23575
23575
23585
23600
23600
23605
23605
23615
23616
23620
23620
23625
23625
23630
23650
23650
23655
23660
23665
23665
23670
23675
23675
23680
23700
23800
23802
23900
23920
23921
23930
1/2/2015
Modifier
Par Fee
$234.36
$241.51
$406.24
$380.49
$997.00
$329.38
$310.08
$469.44
$429.75
$899.54
$1,264.28
$272.80
$259.57
$384.73
$358.28
$794.53
$316.51
$290.05
$406.69
$589.03
$429.43
$399.76
$892.97
$560.14
$509.73
$945.77
$200.08
$1,045.06
$1,309.84
$1,416.42
$1,149.22
$467.38
$355.49
Nonpar Fee
$222.64
$229.43
$385.93
$361.47
$947.15
$312.91
$294.58
$445.97
$408.26
$854.56
$1,201.07
$259.16
$246.59
$365.49
$340.37
$754.80
$300.68
$275.55
$386.36
$559.58
$407.96
$379.77
$848.32
$532.13
$484.24
$898.48
$190.08
$992.81
$1,244.35
$1,345.60
$1,091.76
$444.01
$337.72
Limiting
Charge
$256.04
$263.84
$443.82
$415.69
$1,089.22
$359.85
$338.77
$512.87
$469.50
$982.74
$1,381.23
$298.03
$283.58
$420.31
$391.43
$868.02
$345.78
$316.88
$444.31
$643.52
$469.15
$436.74
$975.57
$611.95
$556.88
$1,033.25
$218.59
$1,141.73
$1,431.00
$1,547.44
$1,255.52
$510.61
$388.38
Charge**
Charge***
$253.47
$252.20
$261.21
$259.89
$439.38
$437.16
$411.54
$409.46
$1,078.33
$1,072.88
$356.25
$354.45
$335.37
$333.68
$507.74
$505.17
$464.81
$462.46
$972.91
$968.00
$1,367.42
$1,360.51
$295.06
$293.56
$280.74
$279.32
$416.12
$414.01
$387.52
$385.55
$859.34
$855.00
$342.32
$340.60
$313.71
$312.13
$439.88
$437.64
$637.08
$633.87
$464.46
$462.12
$432.37
$430.18
$965.82
$960.94
$605.83
$602.77
$551.31
$548.53
$1,022.93
$1,017.75
$216.41
$215.31
$1,130.31
$1,124.61
$1,416.70
$1,409.53
$1,531.96
$1,524.23
$1,242.97
$1,236.69
$505.51
$502.95
$384.49
$382.55
Arizona
EHR/eRx
Limiting
Charge**
$250.92
$258.57
$434.94
$407.38
$1,067.44
$352.65
$331.99
$502.61
$460.10
$963.09
$1,353.61
$292.08
$277.91
$411.91
$383.59
$850.66
$338.87
$310.55
$435.42
$630.65
$459.77
$428.00
$956.05
$599.71
$545.74
$1,012.59
$214.22
$1,118.89
$1,402.38
$1,516.49
$1,230.41
$500.40
$380.62
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$249.67
$247.16
$257.29
$254.69
$432.79
$428.42
$405.36
$401.27
$1,062.15
$1,051.43
$350.90
$347.36
$330.35
$327.01
$500.12
$495.06
$457.84
$453.20
$958.32
$948.65
$1,346.90
$1,333.30
$290.63
$287.70
$276.53
$273.75
$409.87
$405.73
$381.71
$377.84
$846.45
$837.89
$337.18
$333.79
$309.01
$305.89
$433.27
$428.89
$627.52
$621.18
$457.49
$452.87
$425.88
$421.58
$951.33
$941.71
$596.75
$590.72
$543.04
$537.56
$1,007.58
$997.40
$213.16
$211.01
$1,113.36
$1,102.11
$1,395.44
$1,381.35
$1,508.98
$1,493.75
$1,224.32
$1,211.95
$497.93
$492.89
$378.72
$374.91
Page 46 of 323
Notes
#
#
#
#
#
Procedure
Code
23930
23931
23931
23935
24000
24006
24065
24065
24066
24066
24071
24073
24075
24075
24076
24077
24079
24100
24101
24102
24105
24110
24115
24116
24120
24125
24126
24130
24134
24136
24138
24140
24145
1/2/2015
Modifier
Par Fee
$218.55
$290.62
$162.62
$513.62
$484.92
$723.14
$258.84
$170.53
$633.66
$421.99
$411.00
$705.37
$496.29
$333.61
$549.48
$1,049.20
$1,347.01
$424.39
$507.67
$624.44
$355.55
$597.62
$750.82
$877.92
$535.25
$631.42
$659.98
$514.65
$761.10
$586.48
$686.89
$715.23
$602.05
Nonpar Fee
$207.62
$276.09
$154.49
$487.94
$460.67
$686.98
$245.90
$162.00
$601.98
$400.89
$390.45
$670.10
$471.48
$316.93
$522.01
$996.74
$1,279.66
$403.17
$482.29
$593.22
$337.77
$567.74
$713.28
$834.02
$508.49
$599.85
$626.98
$488.92
$723.05
$557.16
$652.55
$679.47
$571.95
Limiting
Charge
$238.76
$317.50
$177.66
$561.13
$529.77
$790.03
$282.79
$186.30
$692.28
$461.02
$449.02
$770.62
$542.20
$364.47
$600.31
$1,146.25
$1,471.61
$463.65
$554.63
$682.20
$388.44
$652.90
$820.27
$959.12
$584.76
$689.83
$721.03
$562.26
$831.51
$640.73
$750.43
$781.39
$657.74
Charge**
Charge***
$236.37
$235.19
$314.33
$312.74
$175.89
$175.00
$555.52
$552.71
$524.47
$521.82
$782.13
$778.18
$279.96
$278.54
$184.44
$183.51
$685.35
$681.89
$456.41
$454.11
$444.53
$442.28
$762.91
$759.06
$536.79
$534.07
$360.82
$359.01
$594.31
$591.31
$1,134.79
$1,129.06
$1,456.89
$1,449.54
$459.01
$456.69
$549.09
$546.32
$675.38
$671.97
$384.55
$382.61
$646.37
$643.10
$812.07
$807.97
$949.53
$944.74
$578.92
$575.99
$682.93
$679.48
$713.82
$710.22
$556.63
$553.83
$823.19
$819.03
$634.33
$631.12
$742.92
$739.17
$773.58
$769.67
$651.16
$647.88
Arizona
EHR/eRx
Limiting
Charge**
$233.99
$311.16
$174.11
$549.91
$519.18
$774.23
$277.13
$182.57
$678.43
$451.80
$440.04
$755.21
$531.36
$357.18
$588.31
$1,123.33
$1,442.18
$454.38
$543.54
$668.56
$380.66
$639.85
$803.86
$939.94
$573.07
$676.03
$706.61
$551.01
$814.88
$627.92
$735.43
$765.76
$644.59
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$232.83
$230.48
$309.61
$306.49
$173.26
$171.50
$547.18
$541.66
$516.60
$511.39
$770.40
$762.61
$275.76
$272.98
$181.67
$179.84
$675.07
$668.25
$449.57
$445.03
$437.86
$433.44
$751.47
$743.88
$528.74
$523.39
$355.41
$351.82
$585.40
$579.49
$1,117.77
$1,106.48
$1,435.04
$1,420.55
$452.12
$447.56
$540.86
$535.38
$665.25
$658.54
$378.78
$374.95
$636.67
$630.25
$799.89
$791.80
$935.28
$925.84
$570.24
$564.48
$672.68
$665.88
$703.11
$696.00
$548.29
$542.74
$810.84
$802.65
$624.82
$618.50
$731.78
$724.40
$761.98
$754.27
$641.40
$634.92
Page 47 of 323
Notes
#
#
#
Procedure
Code
24147
24149
24150
24152
24155
24160
24164
24200
24200
24201
24201
24220
24220
24300
24301
24305
24310
24320
24330
24331
24332
24340
24341
24342
24343
24344
24345
24346
24357
24358
24359
24360
24361
1/2/2015
Modifier
Par Fee
$633.37
$1,192.99
$1,588.75
$1,379.58
$868.80
$1,282.55
$740.04
$209.95
$142.73
$565.93
$372.14
$162.78
$70.54
$423.93
$757.60
$583.70
$479.64
$795.12
$730.75
$800.44
$623.10
$621.58
$758.00
$788.45
$717.32
$1,119.04
$720.59
$1,119.04
$438.55
$530.42
$668.42
$916.14
$1,024.68
Nonpar Fee
$601.70
$1,133.34
$1,509.31
$1,310.60
$825.36
$1,218.42
$703.04
$199.45
$135.59
$537.63
$353.53
$154.64
$67.01
$402.73
$719.72
$554.52
$455.66
$755.36
$694.21
$760.42
$591.95
$590.50
$720.10
$749.03
$681.45
$1,063.09
$684.56
$1,063.09
$416.62
$503.90
$635.00
$870.33
$973.45
Limiting
Charge
$691.96
$1,303.34
$1,735.71
$1,507.19
$949.16
$1,401.18
$808.50
$229.37
$155.93
$618.27
$406.56
$177.84
$77.06
$463.14
$827.68
$637.70
$524.01
$868.66
$798.34
$874.48
$680.74
$679.08
$828.12
$861.38
$783.67
$1,222.55
$787.24
$1,222.55
$479.11
$579.49
$730.25
$1,000.88
$1,119.47
Charge**
Charge***
$685.03
$681.57
$1,290.31
$1,283.79
$1,718.35
$1,709.67
$1,492.11
$1,484.58
$939.68
$934.93
$1,387.18
$1,380.16
$800.41
$796.36
$227.08
$225.93
$154.36
$153.59
$612.09
$609.01
$402.49
$400.46
$176.05
$175.17
$76.29
$75.90
$458.51
$456.19
$819.40
$815.26
$631.32
$628.13
$518.77
$516.15
$859.98
$855.63
$790.36
$786.37
$865.74
$861.36
$673.93
$670.53
$672.29
$668.89
$819.84
$815.70
$852.77
$848.46
$775.84
$771.91
$1,210.33
$1,204.21
$779.37
$775.43
$1,210.33
$1,204.21
$474.32
$471.93
$573.69
$570.79
$722.95
$719.30
$990.87
$985.87
$1,108.28
$1,102.68
Arizona
EHR/eRx
Limiting
Charge**
$678.12
$1,277.27
$1,700.99
$1,477.05
$930.18
$1,373.16
$792.33
$224.78
$152.81
$605.91
$398.43
$174.28
$75.52
$453.88
$811.13
$624.94
$513.53
$851.29
$782.38
$856.99
$667.13
$665.49
$811.56
$844.16
$767.99
$1,198.10
$771.50
$1,198.10
$469.53
$567.89
$715.65
$980.86
$1,097.08
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$674.75
$667.94
$1,270.96
$1,258.11
$1,692.58
$1,675.47
$1,469.73
$1,454.89
$925.58
$916.23
$1,366.37
$1,352.56
$788.41
$780.45
$223.68
$221.41
$152.05
$150.52
$602.91
$596.83
$396.45
$392.45
$173.41
$171.67
$75.14
$74.38
$451.63
$447.07
$807.10
$798.96
$621.85
$615.57
$510.98
$505.83
$847.08
$838.52
$778.50
$770.65
$852.76
$844.13
$663.83
$657.12
$662.20
$655.51
$807.54
$799.38
$839.98
$831.50
$764.20
$756.47
$1,192.17
$1,180.13
$767.67
$759.93
$1,192.17
$1,180.13
$467.20
$462.50
$565.09
$559.37
$712.10
$704.92
$976.02
$966.15
$1,091.65
$1,080.62
Page 48 of 323
Notes
#
#
#
#
#
#
Procedure
Code
24362
24363
24365
24366
24370
24371
24400
24410
24420
24430
24435
24470
24495
24498
24500
24500
24505
24505
24515
24516
24530
24530
24535
24535
24538
24545
24546
24560
24560
24565
24565
24566
24575
1/2/2015
Modifier
Par Fee
$1,079.62
$1,482.51
$650.33
$691.72
$1,581.17
$1,829.94
$832.00
$1,076.93
$1,011.04
$1,075.49
$1,096.49
$682.91
$543.66
$883.59
$362.60
$329.70
$505.56
$457.29
$890.73
$874.83
$384.14
$347.68
$621.02
$573.11
$756.49
$945.59
$1,056.81
$323.48
$289.16
$540.65
$495.96
$729.58
$746.16
Nonpar Fee
$1,025.64
$1,408.38
$617.81
$657.13
$1,502.11
$1,738.44
$790.40
$1,023.08
$960.49
$1,021.72
$1,041.67
$648.76
$516.48
$839.41
$344.47
$313.22
$480.28
$434.43
$846.19
$831.09
$364.93
$330.30
$589.97
$544.45
$718.67
$898.31
$1,003.97
$307.31
$274.70
$513.62
$471.16
$693.10
$708.85
Limiting
Charge
$1,179.49
$1,619.64
$710.48
$755.70
$1,727.43
$1,999.21
$908.96
$1,176.54
$1,104.56
$1,174.98
$1,197.92
$746.07
$593.95
$965.32
$396.14
$360.20
$552.32
$499.59
$973.12
$955.75
$419.67
$379.85
$678.47
$626.12
$826.47
$1,033.06
$1,154.57
$353.41
$315.91
$590.66
$541.83
$797.07
$815.18
Charge**
Charge***
$1,167.69
$1,161.80
$1,603.45
$1,595.34
$703.37
$699.82
$748.14
$744.36
$1,710.15
$1,701.52
$1,979.22
$1,969.21
$899.88
$895.32
$1,164.78
$1,158.89
$1,093.52
$1,087.99
$1,163.23
$1,157.35
$1,185.94
$1,179.95
$738.61
$734.88
$588.02
$585.04
$955.67
$950.84
$392.18
$390.20
$356.60
$354.80
$546.80
$544.04
$494.60
$492.10
$963.39
$958.53
$946.20
$941.41
$415.47
$413.38
$376.05
$374.15
$671.68
$668.29
$619.86
$616.72
$818.20
$814.07
$1,022.73
$1,017.57
$1,143.02
$1,137.25
$349.88
$348.11
$312.74
$311.17
$584.75
$581.81
$536.42
$533.70
$789.10
$785.11
$807.02
$802.95
Arizona
EHR/eRx
Limiting
Charge**
$1,155.90
$1,587.24
$696.27
$740.59
$1,692.88
$1,959.22
$890.78
$1,153.01
$1,082.47
$1,151.48
$1,173.97
$731.15
$582.07
$946.01
$388.22
$353.00
$541.27
$489.60
$953.66
$936.64
$411.27
$372.24
$664.90
$613.59
$809.95
$1,012.39
$1,131.47
$346.33
$309.59
$578.85
$531.00
$781.13
$798.87
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$1,150.17
$1,138.56
$1,579.40
$1,563.44
$692.83
$685.83
$736.92
$729.48
$1,684.50
$1,667.49
$1,949.53
$1,929.83
$886.37
$877.42
$1,147.31
$1,135.72
$1,077.12
$1,066.23
$1,145.78
$1,134.21
$1,168.15
$1,156.36
$727.54
$720.18
$579.20
$573.34
$941.33
$931.82
$386.30
$382.40
$351.26
$347.71
$538.60
$533.15
$487.19
$482.25
$948.93
$939.35
$932.01
$922.59
$409.24
$405.11
$370.42
$366.65
$661.61
$654.93
$610.56
$604.39
$805.93
$797.80
$1,007.39
$997.20
$1,125.87
$1,114.50
$344.63
$341.14
$308.05
$304.95
$575.98
$570.17
$528.37
$523.03
$777.26
$769.41
$794.91
$786.89
Page 49 of 323
Notes
#
#
#
#
#
#
#
#
Procedure
Code
24576
24576
24577
24577
24579
24582
24586
24587
24600
24600
24605
24615
24620
24635
24640
24640
24650
24650
24655
24655
24665
24666
24670
24670
24675
24675
24685
24800
24802
24900
24920
24925
24930
1/2/2015
Modifier
Par Fee
$344.40
$309.00
$557.19
$510.36
$849.25
$821.97
$1,102.63
$1,108.50
$367.61
$336.15
$476.96
$721.35
$552.64
$683.53
$141.34
$95.57
$263.85
$242.04
$439.35
$399.66
$662.12
$745.22
$294.25
$264.93
$461.03
$420.63
$664.53
$844.03
$1,019.76
$735.49
$745.82
$517.79
$788.73
Nonpar Fee
$327.18
$293.55
$529.33
$484.84
$806.79
$780.87
$1,047.50
$1,053.08
$349.23
$319.34
$453.11
$685.28
$525.01
$649.35
$134.27
$90.79
$250.66
$229.94
$417.38
$379.68
$629.01
$707.96
$279.54
$251.68
$437.98
$399.60
$631.30
$801.83
$968.77
$698.72
$708.53
$491.90
$749.29
Limiting
Charge
$376.26
$337.58
$608.73
$557.57
$927.81
$898.00
$1,204.63
$1,211.04
$401.61
$367.24
$521.08
$788.07
$603.76
$746.75
$154.41
$104.41
$288.26
$264.43
$479.99
$436.63
$723.36
$814.15
$321.47
$289.43
$503.68
$459.54
$726.00
$922.10
$1,114.09
$803.53
$814.81
$565.69
$861.68
Charge**
Charge***
$372.50
$370.61
$334.20
$332.52
$602.65
$599.60
$551.99
$549.21
$918.53
$913.89
$889.02
$884.53
$1,192.58
$1,186.56
$1,198.93
$1,192.87
$397.60
$395.59
$363.57
$361.73
$515.87
$513.26
$780.19
$776.25
$597.72
$594.70
$739.29
$735.55
$152.87
$152.10
$103.36
$102.84
$285.37
$283.94
$261.79
$260.46
$475.19
$472.79
$432.26
$430.08
$716.13
$712.51
$806.01
$801.94
$318.25
$316.65
$286.53
$285.09
$498.64
$496.12
$454.94
$452.65
$718.74
$715.10
$912.88
$908.27
$1,102.94
$1,097.38
$795.49
$791.48
$806.66
$802.59
$560.03
$557.20
$853.07
$848.76
Arizona
EHR/eRx
Limiting
Charge**
$368.74
$330.83
$596.55
$546.41
$909.25
$880.04
$1,180.53
$1,186.82
$393.59
$359.89
$510.66
$772.31
$591.69
$731.81
$151.32
$102.32
$282.50
$259.14
$470.38
$427.90
$708.89
$797.87
$315.04
$283.65
$493.60
$450.35
$711.47
$903.66
$1,091.80
$787.46
$798.51
$554.37
$844.45
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$366.91
$363.20
$329.19
$325.86
$593.61
$587.60
$543.71
$538.21
$904.75
$895.61
$875.68
$866.84
$1,174.69
$1,162.82
$1,180.95
$1,169.02
$391.63
$387.69
$358.12
$354.50
$508.13
$503.00
$768.49
$760.73
$588.75
$582.81
$728.20
$720.83
$150.58
$149.05
$101.81
$100.79
$281.09
$278.27
$257.86
$255.25
$468.06
$463.32
$425.78
$421.49
$705.39
$698.26
$793.93
$785.90
$313.48
$310.32
$282.23
$279.39
$491.17
$486.20
$448.12
$443.60
$707.96
$700.80
$899.19
$890.10
$1,086.39
$1,075.42
$783.55
$775.65
$794.56
$786.53
$551.63
$546.05
$840.27
$831.78
Page 50 of 323
Notes
#
#
Procedure
Code
24931
24935
25000
25001
25020
25023
25024
25025
25028
25031
25035
25040
25065
25065
25066
25071
25073
25075
25075
25076
25077
25078
25085
25100
25101
25105
25107
25109
25110
25111
25112
25115
25116
1/2/2015
Modifier
Par Fee
$786.76
$914.97
$340.61
$348.39
$581.32
$1,117.12
$789.71
$1,250.25
$530.77
$369.77
$590.68
$570.30
$257.50
$166.68
$364.58
$431.07
$540.09
$483.10
$319.70
$523.36
$898.80
$1,182.31
$457.79
$350.99
$408.92
$487.28
$625.81
$544.54
$345.13
$324.12
$389.79
$768.50
$606.90
Nonpar Fee
$747.42
$869.22
$323.58
$330.97
$552.25
$1,061.26
$750.22
$1,187.74
$504.23
$351.28
$561.15
$541.79
$244.63
$158.35
$346.35
$409.52
$513.09
$458.95
$303.72
$497.19
$853.86
$1,123.19
$434.90
$333.44
$388.47
$462.92
$594.52
$517.31
$327.87
$307.91
$370.30
$730.08
$576.56
Limiting
Charge
$859.53
$999.60
$372.12
$380.62
$635.09
$1,220.45
$862.75
$1,365.90
$579.86
$403.97
$645.32
$623.06
$281.32
$182.10
$398.30
$470.95
$590.05
$527.79
$349.28
$571.77
$981.94
$1,291.67
$500.14
$383.46
$446.74
$532.36
$683.70
$594.91
$377.05
$354.10
$425.85
$839.59
$663.04
Charge**
Charge***
$850.94
$846.64
$989.61
$984.61
$368.39
$366.54
$376.81
$374.91
$628.74
$625.57
$1,208.25
$1,202.14
$854.13
$849.82
$1,352.24
$1,345.41
$574.07
$571.17
$399.94
$397.91
$638.87
$635.64
$616.83
$613.71
$278.51
$277.10
$180.29
$179.37
$394.32
$392.32
$466.23
$463.89
$584.15
$581.20
$522.51
$519.88
$345.78
$344.03
$566.05
$563.19
$972.12
$967.21
$1,278.75
$1,272.29
$495.13
$492.64
$379.63
$377.71
$442.28
$440.04
$527.03
$524.38
$676.86
$673.44
$588.96
$585.98
$373.28
$371.39
$350.55
$348.78
$421.59
$419.46
$831.20
$827.00
$656.41
$653.10
Arizona
EHR/eRx
Limiting
Charge**
$842.34
$979.62
$364.68
$373.00
$622.39
$1,196.03
$845.50
$1,338.59
$568.27
$395.89
$632.42
$610.59
$275.70
$178.46
$390.33
$461.53
$578.25
$517.24
$342.30
$560.34
$962.30
$1,265.84
$490.13
$375.79
$437.81
$521.71
$670.02
$583.00
$369.51
$347.01
$417.32
$822.80
$649.78
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$838.18
$829.70
$974.76
$964.92
$362.86
$359.20
$371.16
$367.40
$619.31
$613.05
$1,190.12
$1,178.09
$841.32
$832.82
$1,331.95
$1,318.51
$565.46
$559.75
$393.93
$389.95
$629.29
$622.93
$607.57
$601.44
$274.33
$271.56
$177.58
$175.78
$388.41
$384.48
$459.24
$454.61
$575.39
$569.58
$514.67
$509.47
$340.60
$337.17
$557.57
$551.93
$957.54
$947.86
$1,259.57
$1,246.85
$487.70
$482.78
$373.93
$370.15
$435.64
$431.24
$519.13
$513.89
$666.70
$659.97
$580.13
$574.26
$367.68
$363.96
$345.30
$341.80
$415.27
$411.07
$818.73
$810.46
$646.56
$640.03
Page 51 of 323
Notes
#
Procedure
Code
25118
25119
25120
25125
25126
25130
25135
25136
25145
25150
25151
25170
25210
25215
25230
25240
25246
25246
25248
25250
25251
25259
25260
25263
25265
25270
25272
25274
25275
25280
25290
25295
25300
1/2/2015
Modifier
Par Fee
$385.36
$505.58
$503.56
$608.26
$607.14
$451.25
$567.31
$500.97
$524.98
$576.34
$596.46
$1,509.09
$493.00
$625.99
$438.25
$432.52
$164.53
$77.29
$419.53
$538.66
$719.28
$422.23
$638.82
$637.27
$761.91
$495.73
$563.25
$682.20
$679.72
$569.66
$441.51
$529.12
$696.41
Nonpar Fee
$366.09
$480.30
$478.38
$577.85
$576.78
$428.69
$538.94
$475.92
$498.73
$547.52
$566.64
$1,433.64
$468.35
$594.69
$416.34
$410.89
$156.30
$73.43
$398.55
$511.73
$683.32
$401.12
$606.88
$605.41
$723.81
$470.94
$535.09
$648.09
$645.73
$541.18
$419.43
$502.66
$661.59
Limiting
Charge
$421.00
$552.35
$550.14
$664.53
$663.30
$492.99
$619.78
$547.31
$573.54
$629.65
$651.64
$1,648.69
$538.60
$683.89
$478.79
$472.52
$179.75
$84.44
$458.33
$588.49
$785.82
$461.29
$697.91
$696.22
$832.38
$541.58
$615.35
$745.30
$742.59
$622.36
$482.34
$578.06
$760.83
Charge**
Charge***
$416.79
$414.69
$546.83
$544.07
$544.64
$541.88
$657.88
$654.56
$656.66
$653.35
$488.06
$485.60
$613.58
$610.49
$541.83
$539.10
$567.80
$564.94
$623.35
$620.21
$645.12
$641.86
$1,632.20
$1,623.96
$533.22
$530.52
$677.05
$673.64
$474.01
$471.60
$467.80
$465.44
$177.95
$177.05
$83.61
$83.18
$453.74
$451.46
$582.60
$579.66
$777.96
$774.03
$456.68
$454.37
$690.93
$687.45
$689.26
$685.78
$824.06
$819.89
$536.16
$533.46
$609.20
$606.12
$737.85
$734.13
$735.16
$731.45
$616.14
$613.02
$477.53
$475.11
$572.27
$569.39
$753.22
$749.42
Arizona
EHR/eRx
Limiting
Charge**
$412.59
$541.29
$539.13
$651.23
$650.03
$483.14
$607.38
$536.36
$562.07
$617.06
$638.61
$1,615.72
$527.83
$670.22
$469.21
$463.07
$176.15
$82.75
$449.17
$576.73
$770.10
$452.07
$683.95
$682.30
$815.73
$530.75
$603.05
$730.40
$727.74
$609.91
$472.70
$566.50
$745.61
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$410.54
$406.40
$538.63
$533.17
$536.48
$531.05
$648.01
$641.47
$646.81
$640.27
$480.73
$475.89
$604.38
$598.28
$533.70
$528.31
$559.28
$553.64
$614.00
$607.80
$635.44
$629.03
$1,607.71
$1,591.49
$525.22
$519.92
$666.90
$660.17
$466.90
$462.17
$460.78
$456.12
$175.28
$173.50
$82.35
$81.51
$446.94
$442.43
$573.86
$568.08
$766.29
$758.55
$449.82
$445.28
$680.57
$673.69
$678.93
$672.06
$811.69
$803.49
$528.13
$522.79
$600.06
$594.00
$726.79
$719.44
$724.13
$716.83
$606.89
$600.76
$470.36
$465.60
$563.70
$558.00
$741.92
$734.42
Page 52 of 323
Notes
Procedure
Code
25301
25310
25312
25315
25316
25320
25332
25335
25337
25350
25355
25360
25365
25370
25375
25390
25391
25392
25393
25394
25400
25405
25415
25420
25425
25426
25430
25431
25440
25441
25442
25443
25444
1/2/2015
Modifier
Par Fee
$651.61
$627.51
$728.19
$784.93
$929.55
$1,000.45
$851.74
$959.45
$900.59
$683.52
$779.79
$663.73
$930.62
$1,023.91
$969.33
$780.22
$1,013.68
$1,025.12
$1,145.00
$808.76
$814.82
$1,050.54
$984.80
$1,189.90
$979.57
$1,144.71
$744.38
$794.95
$779.14
$945.63
$808.72
$794.94
$840.09
Nonpar Fee
$619.03
$596.13
$691.78
$745.68
$883.07
$950.43
$809.15
$911.48
$855.56
$649.34
$740.80
$630.54
$884.09
$972.71
$920.86
$741.21
$963.00
$973.86
$1,087.75
$768.32
$774.08
$998.01
$935.56
$1,130.41
$930.59
$1,087.47
$707.16
$755.20
$740.18
$898.35
$768.28
$755.19
$798.09
Limiting
Charge
$711.88
$685.55
$795.55
$857.53
$1,015.53
$1,092.99
$930.52
$1,048.20
$983.89
$746.74
$851.92
$725.12
$1,016.70
$1,118.62
$1,058.99
$852.39
$1,107.45
$1,119.94
$1,250.91
$883.57
$890.19
$1,147.71
$1,075.89
$1,299.97
$1,070.18
$1,250.59
$813.23
$868.48
$851.21
$1,033.10
$883.52
$868.47
$917.80
Charge**
Charge***
$704.77
$701.20
$678.70
$675.27
$787.59
$783.61
$848.95
$844.66
$1,005.38
$1,000.29
$1,082.07
$1,076.60
$921.22
$916.56
$1,037.73
$1,032.48
$974.05
$969.14
$739.28
$735.54
$843.40
$839.14
$717.86
$714.24
$1,006.54
$1,001.45
$1,107.43
$1,101.84
$1,048.40
$1,043.11
$843.87
$839.60
$1,096.38
$1,090.84
$1,108.74
$1,103.14
$1,238.40
$1,232.14
$874.74
$870.32
$881.29
$876.84
$1,136.23
$1,130.50
$1,065.13
$1,059.76
$1,286.98
$1,280.47
$1,059.47
$1,054.12
$1,238.09
$1,231.83
$805.10
$801.03
$859.80
$855.45
$842.70
$838.44
$1,022.78
$1,017.60
$874.69
$870.27
$859.79
$855.44
$908.63
$904.04
Arizona
EHR/eRx
Limiting
Charge**
$697.65
$671.84
$779.63
$840.39
$995.22
$1,071.13
$911.92
$1,027.24
$964.22
$731.80
$834.88
$710.62
$996.37
$1,096.25
$1,037.81
$835.35
$1,085.30
$1,097.54
$1,225.90
$865.89
$872.39
$1,124.76
$1,054.38
$1,273.97
$1,048.78
$1,225.58
$796.97
$851.12
$834.19
$1,012.44
$865.85
$851.10
$899.45
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$694.20
$687.18
$668.52
$661.77
$775.78
$767.94
$836.22
$827.78
$990.30
$980.29
$1,065.84
$1,055.07
$907.40
$898.24
$1,022.15
$1,011.83
$959.45
$949.75
$728.19
$720.82
$830.75
$822.35
$707.10
$699.96
$991.44
$981.42
$1,090.82
$1,079.80
$1,032.68
$1,022.24
$831.21
$822.81
$1,079.93
$1,069.02
$1,092.11
$1,081.07
$1,219.83
$1,207.51
$861.61
$852.91
$868.07
$859.30
$1,119.19
$1,107.89
$1,049.16
$1,038.57
$1,267.67
$1,254.86
$1,043.58
$1,033.05
$1,219.52
$1,207.19
$793.03
$785.01
$846.91
$838.35
$830.06
$821.68
$1,007.43
$997.25
$861.57
$852.86
$846.89
$838.34
$895.00
$885.96
Page 53 of 323
Notes
#
#
#
#
#
#
#
#
#
Procedure
Code
25445
25446
25447
25449
25450
25455
25490
25491
25492
25500
25500
25505
25505
25515
25520
25520
25525
25526
25530
25530
25535
25535
25545
25560
25560
25565
25565
25574
25575
25600
25600
25605
25605
1/2/2015
Modifier
Par Fee
$731.81
$1,187.72
$838.86
$1,045.43
$508.52
$602.34
$673.59
$752.92
$919.71
$275.12
$252.24
$507.70
$465.15
$680.58
$575.75
$546.07
$797.48
$973.22
$264.93
$239.18
$495.63
$458.45
$632.83
$280.17
$253.00
$525.45
$475.75
$684.83
$914.56
$331.39
$313.16
$552.00
$518.75
Nonpar Fee
$695.22
$1,128.33
$796.92
$993.16
$483.09
$572.22
$639.91
$715.27
$873.72
$261.36
$239.63
$482.32
$441.89
$646.55
$546.96
$518.77
$757.61
$924.56
$251.68
$227.22
$470.85
$435.53
$601.19
$266.16
$240.35
$499.18
$451.96
$650.59
$868.83
$314.82
$297.50
$524.40
$492.81
Limiting
Charge
$799.50
$1,297.58
$916.46
$1,142.13
$555.55
$658.05
$735.90
$822.56
$1,004.78
$300.56
$275.57
$554.67
$508.17
$743.53
$629.00
$596.59
$871.25
$1,063.24
$289.43
$261.30
$541.48
$500.86
$691.37
$306.08
$276.40
$574.06
$519.75
$748.18
$999.15
$362.04
$342.13
$603.06
$566.73
Charge**
Charge***
$791.51
$787.51
$1,284.61
$1,278.12
$907.29
$902.72
$1,130.71
$1,125.00
$550.00
$547.22
$651.48
$648.19
$728.54
$724.86
$814.34
$810.22
$994.73
$989.70
$297.56
$296.06
$272.81
$271.45
$549.13
$546.35
$503.09
$500.55
$736.09
$732.38
$622.71
$619.57
$590.62
$587.64
$862.53
$858.19
$1,052.61
$1,047.29
$286.53
$285.09
$258.69
$257.38
$536.06
$533.36
$495.85
$493.35
$684.46
$681.00
$303.03
$301.50
$273.64
$272.25
$568.32
$565.44
$514.56
$511.96
$740.69
$736.95
$989.16
$984.17
$358.42
$356.62
$338.71
$337.00
$597.03
$594.01
$561.06
$558.23
Arizona
EHR/eRx
Limiting
Charge**
$783.52
$1,271.62
$898.13
$1,119.30
$544.44
$644.90
$721.18
$806.10
$984.69
$294.55
$270.07
$543.57
$498.01
$728.66
$616.42
$584.65
$853.83
$1,041.98
$283.65
$256.08
$530.64
$490.84
$677.55
$299.97
$270.87
$562.58
$509.36
$733.22
$979.17
$354.80
$335.28
$591.00
$555.39
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$779.64
$771.77
$1,265.33
$1,252.55
$893.69
$884.66
$1,113.75
$1,102.51
$541.75
$536.28
$641.70
$635.23
$717.61
$710.36
$802.13
$794.02
$979.81
$969.92
$293.10
$290.13
$268.72
$266.02
$540.89
$535.42
$495.55
$490.53
$725.05
$717.74
$613.38
$607.18
$581.76
$575.87
$849.60
$841.02
$1,036.82
$1,026.35
$282.23
$279.39
$254.82
$252.24
$528.02
$522.69
$488.41
$483.48
$674.19
$667.38
$298.48
$295.47
$269.54
$266.81
$559.80
$554.14
$506.84
$501.72
$729.58
$722.22
$974.33
$964.48
$353.04
$349.47
$333.63
$330.26
$588.08
$582.13
$552.64
$547.07
Page 54 of 323
Notes
#
#
#
#
#
#
Procedure
Code
25606
25607
25608
25609
25622
25622
25624
25624
25628
25630
25630
25635
25635
25645
25650
25650
25651
25652
25660
25670
25671
25675
25675
25676
25680
25685
25690
25695
25800
25805
25810
25820
25825
1/2/2015
Modifier
Par Fee
$673.61
$745.53
$836.50
$1,063.01
$306.45
$278.92
$485.08
$441.46
$730.78
$308.02
$282.63
$451.25
$401.55
$579.20
$322.28
$302.26
$490.58
$632.97
$414.28
$613.35
$538.25
$441.58
$402.25
$638.84
$473.64
$749.03
$488.14
$643.98
$742.04
$859.45
$879.41
$623.21
$766.84
Nonpar Fee
$639.93
$708.25
$794.68
$1,009.86
$291.13
$264.97
$460.83
$419.39
$694.24
$292.62
$268.50
$428.69
$381.47
$550.24
$306.17
$287.15
$466.05
$601.32
$393.57
$582.68
$511.34
$419.50
$382.14
$606.90
$449.96
$711.58
$463.73
$611.78
$704.94
$816.48
$835.44
$592.05
$728.50
Limiting
Charge
$735.92
$814.49
$913.88
$1,161.34
$334.80
$304.72
$529.95
$482.30
$798.38
$336.51
$308.78
$492.99
$438.69
$632.78
$352.10
$330.22
$535.96
$691.52
$452.61
$670.08
$588.04
$482.43
$439.46
$697.94
$517.45
$818.32
$533.29
$703.55
$810.68
$938.95
$960.76
$680.86
$837.78
Charge**
Charge***
$728.56
$724.88
$806.35
$802.27
$904.74
$900.17
$1,149.72
$1,143.92
$331.45
$329.77
$301.67
$300.15
$524.65
$522.01
$477.48
$475.07
$790.40
$786.40
$333.14
$331.46
$305.69
$304.14
$488.06
$485.60
$434.31
$432.11
$626.45
$623.29
$348.58
$346.82
$326.92
$325.27
$530.60
$527.92
$684.61
$681.15
$448.07
$445.82
$663.38
$660.03
$582.16
$579.22
$477.61
$475.19
$435.07
$432.87
$690.95
$687.47
$512.28
$509.69
$810.13
$806.05
$527.95
$525.29
$696.51
$692.99
$802.57
$798.53
$929.57
$924.86
$951.15
$946.35
$674.05
$670.65
$829.40
$825.21
Arizona
EHR/eRx
Limiting
Charge**
$721.20
$798.20
$895.61
$1,138.11
$328.11
$298.62
$519.35
$472.65
$782.41
$329.79
$302.60
$483.14
$429.92
$620.13
$345.06
$323.62
$525.24
$677.68
$443.56
$656.68
$576.28
$472.78
$430.68
$683.97
$507.10
$801.95
$522.63
$689.47
$794.47
$920.17
$941.54
$667.24
$821.02
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$717.63
$710.38
$794.25
$786.23
$891.17
$882.18
$1,132.47
$1,121.04
$326.49
$323.18
$297.15
$294.14
$516.79
$511.57
$470.32
$465.57
$778.54
$770.67
$328.14
$324.84
$301.10
$298.06
$480.73
$475.89
$427.80
$423.46
$617.06
$610.82
$343.34
$339.88
$322.02
$318.77
$522.64
$517.36
$674.34
$667.52
$441.36
$436.90
$653.43
$646.83
$573.44
$567.63
$470.44
$465.68
$428.55
$424.21
$680.59
$673.72
$504.60
$499.50
$797.97
$789.92
$520.03
$514.79
$686.07
$679.13
$790.53
$782.55
$915.63
$906.37
$936.88
$927.42
$663.94
$657.24
$816.96
$808.70
Page 55 of 323
Notes
#
#
#
Procedure
Code
25830
25900
25905
25907
25909
25915
25920
25922
25924
25927
25929
25931
26010
26010
26011
26011
26020
26025
26030
26034
26035
26037
26040
26045
26055
26055
26060
26070
26075
26080
26100
26105
26110
1/2/2015
Modifier
Par Fee
$967.82
$715.76
$713.76
$623.24
$697.18
$995.10
$708.57
$621.49
$691.58
$823.97
$553.48
$756.33
$266.75
$139.46
$394.05
$187.74
$439.14
$428.14
$498.14
$545.75
$871.96
$572.08
$314.78
$474.10
$564.47
$313.83
$265.52
$319.96
$337.62
$394.34
$340.08
$342.23
$324.92
Nonpar Fee
$919.43
$679.97
$678.07
$592.08
$662.32
$945.35
$673.14
$590.42
$657.00
$782.77
$525.81
$718.51
$253.41
$132.49
$374.35
$178.35
$417.18
$406.73
$473.23
$518.46
$828.36
$543.48
$299.04
$450.40
$536.25
$298.14
$252.24
$303.96
$320.74
$374.62
$323.08
$325.12
$308.67
Limiting
Charge
$1,057.34
$781.97
$779.78
$680.89
$761.67
$1,087.15
$774.11
$678.98
$755.55
$900.19
$604.68
$826.29
$291.42
$152.36
$430.50
$205.10
$479.76
$467.74
$544.21
$596.23
$952.61
$625.00
$343.90
$517.96
$616.69
$342.86
$290.08
$349.55
$368.85
$430.81
$371.54
$373.89
$354.97
Charge**
Charge***
$1,046.78
$1,041.49
$774.15
$770.24
$771.98
$768.09
$674.08
$670.68
$754.06
$750.25
$1,076.29
$1,070.85
$766.37
$762.50
$672.20
$668.79
$747.99
$744.22
$891.18
$886.68
$598.63
$595.61
$818.02
$813.89
$288.51
$287.05
$150.85
$150.08
$426.20
$424.04
$203.06
$202.02
$474.96
$472.56
$463.06
$460.72
$538.78
$536.05
$590.27
$587.28
$943.09
$938.32
$618.76
$615.63
$340.46
$338.73
$512.79
$510.19
$610.52
$607.44
$339.43
$337.72
$287.18
$285.73
$346.06
$344.31
$365.16
$363.32
$426.50
$424.35
$367.83
$365.96
$370.15
$368.28
$351.42
$349.65
Arizona
EHR/eRx
Limiting
Charge**
$1,036.20
$766.33
$764.19
$667.28
$746.43
$1,065.41
$758.63
$665.40
$740.44
$882.18
$592.58
$809.76
$285.59
$149.32
$421.89
$201.00
$470.17
$458.39
$533.34
$584.30
$933.56
$612.50
$337.02
$507.60
$604.36
$336.01
$284.28
$342.56
$361.48
$422.20
$364.11
$366.41
$347.88
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$1,031.08
$1,020.65
$762.53
$754.83
$760.40
$752.72
$663.98
$657.27
$742.74
$735.23
$1,060.14
$1,049.42
$754.87
$747.25
$662.11
$655.42
$736.77
$729.33
$877.82
$868.94
$589.65
$583.69
$805.75
$797.62
$284.19
$281.30
$148.58
$147.07
$419.81
$415.56
$200.01
$197.98
$467.83
$463.12
$456.11
$451.51
$530.69
$525.33
$581.42
$575.54
$928.95
$919.55
$609.48
$603.31
$335.35
$331.96
$505.09
$499.99
$601.37
$595.30
$334.34
$330.97
$282.87
$280.01
$340.87
$337.42
$359.69
$356.06
$420.11
$415.86
$362.31
$358.65
$364.60
$360.92
$346.15
$342.65
Page 56 of 323
Notes
#
#
#
Procedure
Code
26111
26113
26115
26115
26116
26117
26118
26121
26123
26125
26130
26135
26140
26145
26160
26160
26170
26180
26185
26200
26205
26210
26215
26230
26235
26236
26250
26260
26262
26320
26340
26341
26341
1/2/2015
Modifier
Par Fee
$423.86
$554.92
$509.83
$336.77
$533.68
$755.81
$1,072.97
$605.03
$844.27
$279.13
$469.63
$555.49
$509.81
$518.44
$580.21
$337.44
$410.97
$448.61
$549.44
$453.85
$611.97
$446.96
$572.14
$505.29
$499.13
$445.40
$1,093.25
$818.15
$644.92
$350.36
$337.07
$100.08
$76.12
Nonpar Fee
$402.67
$527.17
$484.34
$319.93
$507.00
$718.02
$1,019.32
$574.78
$802.06
$265.17
$446.15
$527.72
$484.32
$492.52
$551.20
$320.57
$390.42
$426.18
$521.97
$431.16
$581.37
$424.61
$543.53
$480.03
$474.17
$423.13
$1,038.59
$777.24
$612.67
$332.84
$320.22
$95.08
$72.31
Limiting
Charge
$463.07
$606.25
$556.99
$367.92
$583.05
$825.72
$1,172.22
$661.00
$922.37
$304.95
$513.07
$606.88
$556.97
$566.40
$633.88
$368.66
$448.98
$490.11
$600.27
$495.83
$668.58
$488.30
$625.06
$552.03
$545.30
$486.60
$1,194.38
$893.83
$704.57
$382.77
$368.25
$109.34
$83.16
Charge**
Charge***
$458.44
$456.12
$600.19
$597.15
$551.43
$548.63
$364.24
$362.40
$577.22
$574.31
$817.47
$813.34
$1,160.50
$1,154.63
$654.38
$651.08
$913.15
$908.53
$301.90
$300.37
$507.94
$505.38
$600.81
$597.77
$551.40
$548.62
$560.73
$557.90
$627.54
$624.37
$364.96
$363.12
$444.50
$442.24
$485.21
$482.76
$594.26
$591.26
$490.88
$488.39
$661.89
$658.55
$483.41
$480.98
$618.80
$615.69
$546.51
$543.75
$539.84
$537.12
$481.74
$479.30
$1,182.43
$1,176.46
$884.89
$880.42
$697.52
$694.00
$378.94
$377.03
$364.57
$362.73
$108.25
$107.70
$82.33
$81.91
Arizona
EHR/eRx
Limiting
Charge**
$453.81
$594.12
$545.85
$360.56
$571.39
$809.21
$1,148.77
$647.77
$903.92
$298.85
$502.81
$594.75
$545.82
$555.07
$621.21
$361.28
$440.00
$480.31
$588.26
$485.92
$655.20
$478.54
$612.56
$540.99
$534.39
$476.87
$1,170.49
$875.96
$690.48
$375.11
$360.89
$107.16
$81.49
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$451.56
$447.01
$591.18
$585.21
$543.16
$537.66
$358.78
$355.15
$568.56
$562.82
$805.21
$797.08
$1,143.09
$1,131.54
$644.56
$638.05
$899.45
$890.36
$297.37
$294.37
$500.32
$495.27
$591.79
$585.82
$543.13
$537.64
$552.32
$546.74
$618.13
$611.89
$359.49
$355.87
$437.83
$433.40
$477.93
$473.11
$585.35
$579.44
$483.52
$478.63
$651.97
$645.37
$476.16
$471.36
$609.52
$603.37
$538.32
$532.88
$531.75
$526.38
$474.51
$469.72
$1,164.70
$1,152.93
$871.62
$862.81
$687.06
$680.12
$373.26
$369.48
$359.10
$355.48
$106.63
$105.55
$81.10
$80.27
Page 57 of 323
Notes
Procedure
Code
26350
26352
26356
26357
26358
26370
26372
26373
26390
26392
26410
26412
26415
26416
26418
26420
26426
26428
26432
26433
26434
26437
26440
26442
26445
26449
26450
26455
26460
26471
26474
26476
26477
1/2/2015
Modifier
Par Fee
$710.80
$811.17
$1,095.84
$874.69
$899.96
$758.32
$889.13
$830.59
$840.47
$978.99
$563.16
$694.14
$685.73
$890.39
$576.29
$706.38
$506.82
$739.04
$499.28
$530.04
$648.91
$621.90
$617.68
$964.34
$573.88
$704.07
$406.09
$403.63
$391.56
$611.93
$602.77
$585.38
$575.26
Nonpar Fee
$675.26
$770.61
$1,041.05
$830.96
$854.96
$720.40
$844.67
$789.06
$798.45
$930.04
$535.00
$659.43
$651.44
$845.87
$547.48
$671.06
$481.48
$702.09
$474.32
$503.54
$616.46
$590.81
$586.80
$916.12
$545.19
$668.87
$385.79
$383.45
$371.98
$581.33
$572.63
$556.11
$546.50
Limiting
Charge
$776.55
$886.20
$1,197.21
$955.60
$983.20
$828.46
$971.37
$907.42
$918.22
$1,069.55
$615.25
$758.34
$749.16
$972.75
$629.60
$771.72
$553.70
$807.40
$545.47
$579.07
$708.93
$679.43
$674.82
$1,053.54
$626.97
$769.20
$443.66
$440.97
$427.78
$668.53
$658.52
$639.53
$628.48
Charge**
Charge***
$768.79
$764.90
$877.34
$872.91
$1,185.24
$1,179.24
$946.05
$941.28
$973.37
$968.46
$820.18
$816.03
$961.65
$956.80
$898.35
$893.80
$909.04
$904.44
$1,058.85
$1,053.50
$609.10
$606.03
$750.77
$746.97
$741.67
$737.92
$963.02
$958.16
$623.31
$620.16
$764.00
$760.14
$548.17
$545.40
$799.33
$795.29
$540.02
$537.29
$573.28
$570.39
$701.85
$698.29
$672.64
$669.24
$668.07
$664.70
$1,043.00
$1,037.74
$620.70
$617.56
$761.51
$757.67
$439.22
$437.00
$436.56
$434.36
$423.50
$421.36
$661.85
$658.50
$651.94
$648.65
$633.13
$629.94
$622.20
$619.05
Arizona
EHR/eRx
Limiting
Charge**
$761.01
$868.48
$1,173.26
$936.49
$963.54
$811.89
$951.95
$889.27
$899.85
$1,048.16
$602.95
$743.18
$734.17
$953.29
$617.01
$756.29
$542.63
$791.26
$534.55
$567.49
$694.75
$665.84
$661.32
$1,032.47
$614.43
$753.81
$434.78
$432.15
$419.22
$655.16
$645.36
$626.74
$615.91
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$757.25
$749.59
$864.18
$855.45
$1,167.46
$1,155.67
$931.86
$922.44
$958.77
$949.08
$807.88
$799.71
$947.23
$937.66
$884.87
$875.93
$895.40
$886.35
$1,042.97
$1,032.44
$599.97
$593.91
$739.51
$732.03
$730.55
$723.15
$948.58
$939.00
$613.96
$607.75
$752.54
$744.95
$539.95
$534.49
$787.34
$779.39
$531.92
$526.54
$564.67
$558.98
$691.32
$684.33
$662.55
$655.86
$658.05
$651.39
$1,027.36
$1,016.98
$611.39
$605.22
$750.09
$742.51
$432.63
$428.26
$430.02
$425.66
$417.15
$412.93
$651.92
$645.32
$642.16
$635.67
$623.63
$617.34
$612.86
$606.67
Page 58 of 323
Notes
Procedure
Code
26478
26479
26480
26483
26485
26489
26490
26492
26494
26496
26497
26498
26499
26500
26502
26508
26510
26516
26517
26518
26520
26525
26530
26531
26535
26536
26540
26541
26542
26545
26546
26548
26550
1/2/2015
Modifier
Par Fee
$616.13
$610.58
$749.41
$840.61
$805.56
$940.23
$799.43
$886.60
$779.78
$853.57
$869.52
$1,157.90
$816.47
$621.58
$712.30
$630.00
$592.70
$697.57
$828.98
$823.13
$649.20
$649.56
$544.01
$631.40
$426.26
$709.81
$654.84
$800.30
$677.86
$709.93
$996.09
$758.10
$1,660.77
Nonpar Fee
$585.32
$580.05
$711.94
$798.58
$765.28
$893.22
$759.46
$842.27
$740.79
$810.89
$826.04
$1,100.01
$775.65
$590.50
$676.69
$598.50
$563.07
$662.69
$787.53
$781.97
$616.74
$617.08
$516.81
$599.83
$404.95
$674.32
$622.10
$760.29
$643.97
$674.43
$946.29
$720.20
$1,577.73
Limiting
Charge
$673.12
$667.06
$818.73
$918.37
$880.07
$1,027.20
$873.38
$968.61
$851.91
$932.52
$949.95
$1,265.01
$892.00
$679.08
$778.19
$688.28
$647.53
$762.09
$905.66
$899.27
$709.25
$709.64
$594.33
$689.80
$465.69
$775.47
$715.42
$874.33
$740.57
$775.59
$1,088.23
$828.23
$1,814.39
Charge**
Charge***
$666.39
$663.02
$660.39
$657.05
$810.54
$806.45
$909.18
$904.59
$871.27
$866.87
$1,016.93
$1,011.79
$864.65
$860.28
$958.93
$954.09
$843.39
$839.13
$923.20
$918.54
$940.45
$935.70
$1,252.36
$1,246.04
$883.07
$878.62
$672.29
$668.89
$770.41
$766.52
$681.40
$677.95
$641.06
$637.81
$754.47
$750.66
$896.60
$892.08
$890.27
$885.78
$702.16
$698.61
$702.55
$698.99
$588.39
$585.42
$682.90
$679.45
$461.04
$458.71
$767.72
$763.84
$708.26
$704.69
$865.59
$861.22
$733.16
$729.46
$767.84
$763.96
$1,077.35
$1,071.92
$819.95
$815.81
$1,796.24
$1,787.17
Arizona
EHR/eRx
Limiting
Charge**
$659.65
$653.72
$802.36
$900.00
$862.47
$1,006.66
$855.91
$949.23
$834.87
$913.87
$930.95
$1,239.71
$874.16
$665.49
$762.63
$674.51
$634.58
$746.86
$887.55
$881.28
$695.07
$695.45
$582.44
$676.00
$456.38
$759.95
$701.11
$856.84
$725.75
$760.08
$1,066.46
$811.67
$1,778.11
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$656.40
$649.76
$650.49
$643.91
$798.39
$790.31
$895.54
$886.50
$858.21
$849.53
$1,001.68
$991.56
$851.68
$843.08
$944.54
$935.00
$830.74
$822.34
$909.35
$900.16
$926.34
$916.99
$1,233.57
$1,221.12
$869.83
$861.05
$662.20
$655.51
$758.85
$751.19
$671.17
$664.39
$631.44
$625.06
$743.15
$735.66
$883.15
$874.23
$876.92
$868.07
$691.62
$684.64
$692.01
$685.02
$579.57
$573.70
$672.66
$665.86
$454.12
$449.54
$756.21
$748.56
$697.64
$690.60
$852.61
$843.99
$722.17
$714.86
$756.32
$748.68
$1,061.20
$1,050.47
$807.66
$799.49
$1,769.30
$1,751.44
Page 59 of 323
Notes
#
#
#
#
#
Procedure
Code
26551
26553
26554
26555
26556
26560
26561
26562
26565
26567
26568
26580
26587
26590
26591
26593
26596
26600
26600
26605
26605
26607
26608
26615
26641
26641
26645
26645
26650
26665
26670
26670
26675
1/2/2015
Modifier
Par Fee
$3,346.65
$2,762.38
$3,232.02
$1,382.58
$2,855.22
$592.05
$930.74
$1,334.16
$680.07
$677.51
$904.64
$1,526.04
$968.66
$1,420.46
$432.94
$598.56
$754.62
$296.57
$279.05
$325.09
$295.78
$463.69
$481.69
$584.06
$380.93
$346.60
$433.42
$397.66
$484.86
$637.93
$339.85
$308.74
$460.68
Nonpar Fee
$3,179.32
$2,624.26
$3,070.42
$1,313.45
$2,712.46
$562.45
$884.20
$1,267.45
$646.07
$643.63
$859.41
$1,449.74
$920.23
$1,349.44
$411.29
$568.63
$716.89
$281.74
$265.10
$308.84
$280.99
$440.51
$457.61
$554.86
$361.88
$329.27
$411.75
$377.78
$460.62
$606.03
$322.86
$293.30
$437.65
Limiting
Charge
$3,656.22
$3,017.90
$3,530.98
$1,510.47
$3,119.33
$646.82
$1,016.83
$1,457.57
$742.98
$740.17
$988.32
$1,667.20
$1,058.26
$1,551.86
$472.98
$653.92
$824.42
$324.00
$304.87
$355.17
$323.14
$506.59
$526.25
$638.09
$416.16
$378.66
$473.51
$434.45
$529.71
$696.93
$371.29
$337.30
$503.30
Charge**
Charge***
$3,619.66
$3,601.37
$2,987.72
$2,972.64
$3,495.68
$3,478.01
$1,495.37
$1,487.81
$3,088.14
$3,072.54
$640.35
$637.11
$1,006.66
$1,001.58
$1,443.00
$1,435.71
$735.55
$731.84
$732.77
$729.08
$978.44
$973.50
$1,650.53
$1,642.19
$1,047.68
$1,042.39
$1,536.34
$1,528.58
$468.26
$465.89
$647.38
$644.12
$816.18
$812.06
$320.76
$319.14
$301.82
$300.29
$351.61
$349.84
$319.91
$318.30
$501.52
$498.99
$520.98
$518.36
$631.71
$628.52
$412.00
$409.92
$374.88
$372.98
$468.77
$466.41
$430.10
$427.93
$524.41
$521.77
$689.97
$686.48
$367.57
$365.72
$333.93
$332.24
$498.26
$495.75
Arizona
EHR/eRx
Limiting
Charge**
$3,583.09
$2,957.54
$3,460.36
$1,480.26
$3,056.94
$633.88
$996.50
$1,428.42
$728.12
$725.37
$968.55
$1,633.86
$1,037.10
$1,520.82
$463.52
$640.85
$807.93
$317.53
$298.77
$348.06
$316.68
$496.46
$515.73
$625.32
$407.84
$371.08
$464.05
$425.75
$519.12
$683.00
$363.86
$330.54
$493.24
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$3,565.37
$3,529.34
$2,942.91
$2,913.17
$3,443.24
$3,408.45
$1,472.94
$1,458.05
$3,041.82
$3,011.09
$630.75
$624.37
$991.56
$981.55
$1,421.35
$1,406.99
$724.52
$717.20
$721.77
$714.50
$963.77
$954.03
$1,625.77
$1,609.36
$1,031.96
$1,021.55
$1,513.30
$1,498.00
$461.23
$456.56
$637.68
$631.24
$803.93
$795.81
$315.95
$312.77
$297.29
$294.29
$346.33
$342.84
$315.11
$311.93
$493.99
$489.00
$513.16
$507.99
$622.23
$615.94
$405.82
$401.72
$369.25
$365.52
$461.75
$457.09
$423.65
$419.37
$516.55
$511.34
$679.62
$672.75
$362.07
$358.40
$328.91
$325.59
$490.79
$485.84
Page 60 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
26675
26676
26685
26686
26700
26700
26705
26705
26706
26715
26720
26720
26725
26725
26727
26735
26740
26740
26742
26742
26746
26750
26750
26755
26755
26756
26765
26770
26770
26775
26775
26776
26785
1/2/2015
Modifier
Par Fee
$423.50
$506.50
$584.42
$633.92
$324.20
$303.82
$421.03
$385.64
$441.18
$579.32
$199.67
$185.72
$339.80
$306.19
$474.58
$604.58
$231.18
$216.88
$369.44
$334.76
$751.16
$185.41
$185.77
$316.60
$274.77
$421.43
$507.21
$277.22
$256.48
$386.74
$349.91
$447.72
$553.44
Nonpar Fee
$402.33
$481.18
$555.20
$602.22
$307.99
$288.63
$399.98
$366.36
$419.12
$550.35
$189.69
$176.43
$322.81
$290.88
$450.85
$574.35
$219.62
$206.04
$350.97
$318.02
$713.60
$176.14
$176.48
$300.77
$261.03
$400.36
$481.85
$263.36
$243.66
$367.40
$332.41
$425.33
$525.77
Limiting
Charge
$462.68
$553.36
$638.48
$692.55
$354.19
$331.92
$459.98
$421.31
$481.99
$632.90
$218.14
$202.89
$371.23
$334.51
$518.48
$660.50
$252.56
$236.95
$403.62
$365.72
$820.64
$202.56
$202.95
$345.89
$300.18
$460.41
$554.13
$302.86
$280.21
$422.51
$382.27
$489.13
$604.64
Charge**
Charge***
$458.06
$455.75
$547.83
$545.05
$632.10
$628.90
$685.63
$682.17
$350.65
$348.88
$328.60
$326.95
$455.38
$453.08
$417.11
$414.99
$477.17
$474.75
$626.58
$623.40
$215.96
$214.87
$200.87
$199.85
$367.52
$365.67
$331.17
$329.50
$513.29
$510.70
$653.90
$650.59
$250.03
$248.78
$234.58
$233.39
$399.58
$397.57
$362.07
$360.24
$812.43
$808.34
$200.54
$199.53
$200.93
$199.90
$342.42
$340.70
$297.18
$295.68
$455.81
$453.50
$548.58
$545.81
$299.84
$298.32
$277.40
$276.01
$418.29
$416.17
$378.45
$376.53
$484.24
$481.79
$598.59
$595.56
Arizona
EHR/eRx
Limiting
Charge**
$453.42
$542.29
$625.72
$678.71
$347.10
$325.29
$450.78
$412.88
$472.35
$620.24
$213.79
$198.84
$363.80
$327.82
$508.10
$647.29
$247.51
$232.21
$395.54
$358.41
$804.23
$198.51
$198.89
$338.96
$294.18
$451.20
$543.04
$296.80
$274.61
$414.06
$374.62
$479.34
$592.54
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$451.19
$446.63
$539.60
$534.16
$622.62
$616.33
$675.35
$668.53
$345.39
$341.90
$323.67
$320.41
$448.55
$444.02
$410.85
$406.69
$470.02
$465.27
$617.18
$610.94
$212.72
$210.58
$197.86
$195.86
$362.01
$358.34
$326.20
$322.90
$505.59
$500.48
$644.09
$637.58
$246.28
$243.80
$231.06
$228.72
$393.59
$389.61
$356.64
$353.04
$800.24
$792.17
$197.52
$195.53
$197.92
$195.91
$337.28
$333.88
$292.72
$289.77
$448.97
$444.43
$540.35
$534.90
$295.34
$292.35
$273.24
$270.49
$412.01
$407.85
$372.77
$369.00
$476.97
$472.16
$589.61
$583.65
Page 61 of 323
Notes
#
#
Procedure
Code
26820
26841
26842
26843
26844
26850
26852
26860
26861
26862
26863
26910
26951
26952
26990
26991
26991
26992
27000
27001
27003
27005
27006
27025
27027
27030
27033
27035
27036
27040
27040
27041
27043
1/2/2015
Modifier
Par Fee
$790.62
$724.98
$784.17
$740.82
$806.99
$689.57
$793.37
$563.16
$105.50
$724.22
$233.66
$715.65
$652.07
$643.40
$635.88
$712.29
$528.51
$972.71
$422.51
$548.54
$606.34
$737.40
$748.13
$926.40
$902.85
$953.95
$988.60
$1,096.29
$1,029.58
$349.36
$203.48
$698.07
$476.19
Nonpar Fee
$751.09
$688.73
$744.96
$703.78
$766.64
$655.09
$753.70
$535.00
$100.23
$688.01
$221.98
$679.87
$619.47
$611.23
$604.09
$676.68
$502.08
$924.07
$401.38
$521.11
$576.02
$700.53
$710.72
$880.08
$857.71
$906.25
$939.17
$1,041.48
$978.10
$331.89
$193.31
$663.17
$452.38
Limiting
Charge
$863.75
$792.04
$856.70
$809.35
$881.64
$753.35
$866.76
$615.25
$115.26
$791.21
$255.28
$781.85
$712.39
$702.91
$694.70
$778.18
$577.39
$1,062.68
$461.59
$599.28
$662.42
$805.61
$817.33
$1,012.09
$986.37
$1,042.19
$1,080.05
$1,197.70
$1,124.82
$381.67
$222.31
$762.65
$520.24
Charge**
Charge***
$855.12
$850.79
$784.12
$780.16
$848.14
$843.86
$801.25
$797.20
$872.82
$868.41
$745.82
$742.05
$858.08
$853.75
$609.10
$606.03
$114.11
$113.54
$783.30
$779.34
$252.72
$251.45
$774.03
$770.12
$705.27
$701.71
$695.89
$692.37
$687.76
$684.28
$770.40
$766.51
$571.62
$568.73
$1,052.05
$1,046.74
$456.98
$454.66
$593.29
$590.28
$655.80
$652.49
$797.55
$793.52
$809.15
$805.07
$1,001.97
$996.91
$976.50
$971.57
$1,031.77
$1,026.56
$1,069.25
$1,063.84
$1,185.73
$1,179.74
$1,113.57
$1,107.94
$377.86
$375.95
$220.09
$218.97
$755.02
$751.20
$515.04
$512.43
Arizona
EHR/eRx
Limiting
Charge**
$846.48
$776.20
$839.57
$793.16
$864.01
$738.29
$849.42
$602.95
$112.96
$775.39
$250.17
$766.21
$698.14
$688.86
$680.81
$762.62
$565.85
$1,041.43
$452.35
$587.29
$649.18
$789.50
$800.99
$991.85
$966.64
$1,021.35
$1,058.45
$1,173.75
$1,102.32
$374.04
$217.86
$747.40
$509.83
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$842.29
$833.78
$772.35
$764.57
$835.42
$826.98
$789.23
$781.25
$859.73
$851.05
$734.63
$727.21
$845.22
$836.68
$599.97
$593.91
$112.40
$111.27
$771.55
$763.76
$248.93
$246.42
$762.42
$754.72
$694.69
$687.67
$685.45
$678.52
$677.44
$670.60
$758.84
$751.18
$563.04
$557.36
$1,036.28
$1,025.81
$450.12
$445.57
$584.38
$578.48
$645.97
$639.43
$785.59
$777.65
$797.02
$788.97
$986.94
$976.97
$961.85
$952.14
$1,016.29
$1,006.03
$1,053.20
$1,042.57
$1,167.94
$1,156.14
$1,096.87
$1,085.78
$372.19
$368.43
$216.79
$214.59
$743.69
$736.18
$507.31
$502.18
Page 62 of 323
Notes
#
#
#
#
#
Procedure
Code
27045
27047
27047
27048
27049
27050
27052
27054
27057
27059
27060
27062
27065
27066
27067
27070
27071
27075
27076
27077
27078
27080
27086
27086
27087
27090
27091
27093
27093
27095
27095
27096
27096
1/2/2015
Modifier
Par Fee
$761.21
$475.84
$368.93
$618.65
$1,359.89
$408.26
$589.57
$695.60
$1,033.49
$1,852.75
$472.63
$464.18
$526.67
$827.03
$1,054.00
$862.57
$929.58
$2,146.98
$2,599.48
$2,901.64
$2,117.34
$521.68
$299.65
$171.29
$635.13
$840.76
$1,628.30
$189.91
$71.92
$244.80
$84.62
$162.51
$86.00
Nonpar Fee
$723.15
$452.05
$350.48
$587.72
$1,291.90
$387.85
$560.09
$660.82
$981.82
$1,760.11
$449.00
$440.97
$500.34
$785.68
$1,001.30
$819.44
$883.10
$2,039.63
$2,469.51
$2,756.56
$2,011.47
$495.60
$284.67
$162.73
$603.37
$798.72
$1,546.89
$180.41
$68.32
$232.56
$80.39
$154.38
$81.70
Limiting
Charge
$831.62
$519.86
$403.05
$675.88
$1,485.69
$446.03
$644.10
$759.94
$1,129.09
$2,024.13
$516.35
$507.12
$575.39
$903.53
$1,151.50
$942.36
$1,015.57
$2,345.57
$2,839.94
$3,170.04
$2,313.19
$569.94
$327.37
$187.14
$693.88
$918.53
$1,778.92
$207.47
$78.57
$267.44
$92.45
$177.54
$93.96
Charge**
Charge***
$823.31
$819.15
$514.66
$512.06
$399.03
$397.00
$669.12
$665.74
$1,470.83
$1,463.40
$441.57
$439.33
$637.66
$634.44
$752.34
$748.55
$1,117.80
$1,112.15
$2,003.89
$1,993.77
$511.19
$508.61
$502.04
$499.51
$569.64
$566.75
$894.49
$889.97
$1,139.98
$1,134.22
$932.94
$928.22
$1,005.41
$1,000.33
$2,322.11
$2,310.40
$2,811.53
$2,797.34
$3,138.34
$3,122.49
$2,290.06
$2,278.50
$564.24
$561.40
$324.09
$322.46
$185.27
$184.33
$686.94
$683.47
$909.34
$904.75
$1,761.13
$1,752.24
$205.40
$204.36
$77.79
$77.40
$264.76
$263.43
$91.53
$91.06
$175.77
$174.87
$93.01
$92.54
Arizona
EHR/eRx
Limiting
Charge**
$814.99
$509.46
$394.99
$662.37
$1,455.97
$437.10
$631.22
$744.74
$1,106.51
$1,983.65
$506.02
$496.97
$563.88
$885.47
$1,128.46
$923.51
$995.26
$2,298.67
$2,783.14
$3,106.64
$2,266.93
$558.54
$320.83
$183.40
$680.00
$900.16
$1,743.34
$203.32
$76.99
$262.10
$90.60
$173.98
$92.08
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$810.96
$802.77
$506.94
$501.81
$393.05
$389.07
$659.08
$652.43
$1,448.77
$1,434.13
$434.94
$430.55
$628.10
$621.76
$741.06
$733.57
$1,101.03
$1,089.91
$1,973.83
$1,953.90
$503.52
$498.43
$494.51
$489.52
$561.10
$555.43
$881.07
$872.18
$1,122.88
$1,111.53
$918.94
$909.65
$990.33
$980.33
$2,287.28
$2,264.19
$2,769.36
$2,741.39
$3,091.27
$3,060.05
$2,255.71
$2,232.92
$555.77
$550.16
$319.23
$316.02
$182.48
$180.65
$676.64
$669.79
$895.70
$886.66
$1,734.72
$1,717.19
$202.32
$200.27
$76.62
$75.84
$260.80
$258.16
$90.16
$89.24
$173.13
$171.37
$91.62
$90.70
Page 63 of 323
Notes
#
Procedure
Code
27097
27098
27100
27105
27110
27111
27120
27122
27125
27130
27132
27134
27137
27138
27140
27146
27147
27151
27156
27158
27161
27165
27170
27175
27176
27177
27178
27179
27181
27185
27187
27193
27193
1/2/2015
Modifier
Par Fee
$694.05
$706.83
$840.50
$882.07
$986.32
$916.18
$1,326.61
$1,118.15
$1,155.07
$1,382.84
$1,708.14
$1,954.20
$1,502.33
$1,560.49
$913.55
$1,307.25
$1,501.31
$1,624.97
$1,752.11
$1,431.49
$1,239.11
$1,397.98
$1,200.32
$679.61
$935.22
$1,135.77
$935.22
$994.68
$1,145.38
$598.05
$1,009.92
$477.72
$484.16
Nonpar Fee
$659.35
$671.49
$798.48
$837.97
$937.00
$870.37
$1,260.28
$1,062.24
$1,097.32
$1,313.70
$1,622.73
$1,856.49
$1,427.21
$1,482.47
$867.87
$1,241.89
$1,426.24
$1,543.72
$1,664.50
$1,359.92
$1,177.15
$1,328.08
$1,140.30
$645.63
$888.46
$1,078.98
$888.46
$944.95
$1,088.11
$568.15
$959.42
$453.83
$459.95
Limiting
Charge
$758.25
$772.21
$918.25
$963.67
$1,077.55
$1,000.93
$1,449.32
$1,221.58
$1,261.92
$1,510.76
$1,866.14
$2,134.96
$1,641.29
$1,704.84
$998.05
$1,428.17
$1,640.18
$1,775.28
$1,914.18
$1,563.91
$1,353.72
$1,527.29
$1,311.35
$742.47
$1,021.73
$1,240.83
$1,021.73
$1,086.69
$1,251.33
$653.37
$1,103.33
$521.90
$528.94
Charge**
Charge***
$750.67
$746.88
$764.50
$760.63
$909.08
$904.48
$954.03
$949.21
$1,066.77
$1,061.39
$990.92
$985.91
$1,434.83
$1,427.59
$1,209.36
$1,203.26
$1,249.30
$1,242.99
$1,495.64
$1,488.09
$1,847.48
$1,838.15
$2,113.62
$2,102.94
$1,624.88
$1,616.67
$1,687.80
$1,679.26
$988.07
$983.08
$1,413.89
$1,406.75
$1,623.78
$1,615.58
$1,757.52
$1,748.64
$1,895.04
$1,885.46
$1,548.27
$1,540.45
$1,340.19
$1,333.41
$1,512.02
$1,504.38
$1,298.24
$1,291.68
$735.05
$731.34
$1,011.52
$1,006.40
$1,228.42
$1,222.22
$1,011.52
$1,006.40
$1,075.83
$1,070.40
$1,238.81
$1,232.56
$646.84
$643.57
$1,092.30
$1,086.78
$516.68
$514.07
$523.65
$521.01
Arizona
EHR/eRx
Limiting
Charge**
$743.08
$756.77
$899.89
$944.39
$1,056.00
$980.90
$1,420.33
$1,197.15
$1,236.68
$1,480.54
$1,828.82
$2,092.26
$1,608.47
$1,670.74
$978.09
$1,399.61
$1,607.38
$1,739.78
$1,875.89
$1,532.63
$1,326.65
$1,496.75
$1,285.11
$727.63
$1,001.29
$1,216.01
$1,001.29
$1,064.96
$1,226.30
$640.31
$1,081.26
$511.46
$518.36
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$739.42
$731.94
$753.03
$745.42
$895.44
$886.39
$939.72
$930.22
$1,050.78
$1,040.16
$976.05
$966.20
$1,413.30
$1,399.02
$1,191.23
$1,179.20
$1,230.56
$1,218.13
$1,473.21
$1,458.34
$1,819.76
$1,801.39
$2,081.91
$2,060.88
$1,600.51
$1,584.34
$1,662.49
$1,645.68
$973.25
$963.41
$1,392.68
$1,378.61
$1,599.42
$1,583.26
$1,731.16
$1,713.68
$1,866.61
$1,847.75
$1,525.05
$1,509.64
$1,320.09
$1,306.76
$1,489.34
$1,474.30
$1,278.77
$1,265.84
$724.02
$716.71
$996.35
$986.27
$1,210.00
$1,197.77
$996.35
$986.27
$1,059.69
$1,048.98
$1,220.23
$1,207.90
$637.13
$630.71
$1,075.92
$1,065.05
$508.93
$503.79
$515.80
$510.59
Page 64 of 323
Notes
#
#
#
#
#
Procedure
Code
27194
27200
27200
27202
27220
27220
27222
27226
27227
27228
27230
27230
27232
27235
27236
27238
27240
27244
27245
27246
27246
27248
27250
27252
27253
27254
27256
27256
27257
27258
27259
27265
27266
1/2/2015
Modifier
Par Fee
$725.37
$183.00
$190.87
$542.11
$538.52
$533.51
$995.62
$1,078.32
$1,693.22
$1,930.20
$481.61
$478.03
$767.37
$926.33
$1,219.36
$467.31
$974.52
$1,255.21
$1,254.90
$390.82
$392.25
$757.08
$184.23
$773.58
$957.89
$1,297.24
$306.07
$239.21
$347.79
$1,131.79
$1,585.67
$403.11
$591.45
Nonpar Fee
$689.10
$173.85
$181.33
$515.00
$511.59
$506.83
$945.84
$1,024.40
$1,608.56
$1,833.69
$457.53
$454.13
$729.00
$880.01
$1,158.39
$443.94
$925.79
$1,192.45
$1,192.16
$371.28
$372.64
$719.23
$175.02
$734.90
$910.00
$1,232.38
$290.77
$227.25
$330.40
$1,075.20
$1,506.39
$382.95
$561.88
Limiting
Charge
$792.47
$199.93
$208.53
$592.25
$588.33
$582.85
$1,087.72
$1,178.06
$1,849.84
$2,108.74
$526.16
$522.25
$838.35
$1,012.01
$1,332.15
$510.53
$1,064.66
$1,371.32
$1,370.98
$426.97
$428.54
$827.11
$201.27
$845.14
$1,046.50
$1,417.24
$334.39
$261.34
$379.96
$1,236.48
$1,732.35
$440.39
$646.16
Charge**
Charge***
$784.54
$780.57
$197.93
$196.93
$206.45
$205.40
$586.33
$583.37
$582.44
$579.51
$577.02
$574.11
$1,076.84
$1,071.40
$1,166.28
$1,160.38
$1,831.34
$1,822.09
$2,087.65
$2,077.11
$520.89
$518.27
$517.03
$514.42
$829.97
$825.78
$1,001.89
$996.83
$1,318.83
$1,312.16
$505.43
$502.87
$1,054.01
$1,048.69
$1,357.61
$1,350.74
$1,357.28
$1,350.42
$422.71
$420.57
$424.25
$422.11
$818.85
$814.71
$199.26
$198.25
$836.68
$832.46
$1,036.04
$1,030.80
$1,403.07
$1,395.97
$331.04
$329.37
$258.73
$257.42
$376.17
$374.26
$1,224.12
$1,217.93
$1,715.03
$1,706.36
$435.99
$433.79
$639.70
$636.47
Arizona
EHR/eRx
Limiting
Charge**
$776.62
$195.93
$204.36
$580.41
$576.56
$571.19
$1,065.96
$1,154.50
$1,812.85
$2,066.57
$515.64
$511.81
$821.58
$991.77
$1,305.50
$500.32
$1,043.36
$1,343.89
$1,343.57
$418.43
$419.97
$810.58
$197.25
$828.23
$1,025.57
$1,388.89
$327.69
$256.12
$372.36
$1,211.76
$1,697.70
$431.58
$633.24
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$772.78
$764.97
$194.96
$192.98
$203.35
$201.28
$577.53
$571.70
$573.70
$567.92
$568.36
$562.63
$1,060.68
$1,049.97
$1,148.79
$1,137.18
$1,803.87
$1,785.65
$2,056.34
$2,035.57
$513.08
$507.90
$509.28
$504.13
$817.51
$809.26
$986.86
$976.89
$1,299.05
$1,285.92
$497.85
$492.81
$1,038.20
$1,027.71
$1,337.24
$1,323.73
$1,336.92
$1,323.42
$416.37
$412.15
$417.89
$413.67
$806.56
$798.42
$196.27
$194.29
$824.14
$815.81
$1,020.50
$1,010.18
$1,382.02
$1,368.05
$326.07
$322.78
$254.85
$252.28
$370.52
$366.77
$1,205.75
$1,193.57
$1,689.30
$1,672.24
$429.44
$425.11
$630.11
$623.74
Page 65 of 323
Notes
#
#
#
Procedure
Code
27267
27268
27269
27275
27279
27280
27282
27284
27286
27290
27295
27301
27301
27303
27305
27306
27307
27310
27323
27323
27324
27325
27326
27327
27327
27328
27329
27330
27331
27332
27333
27334
27335
1/2/2015
Modifier
Par Fee
$439.64
$547.96
$1,268.49
$185.78
$568.85
$1,095.20
$757.78
$1,556.51
$1,688.36
$1,658.89
$1,281.21
$670.72
$503.03
$647.33
$489.30
$365.60
$487.83
$743.40
$272.84
$180.23
$402.28
$516.60
$522.16
$465.41
$318.10
$630.81
$1,051.92
$421.85
$483.40
$653.99
$595.83
$695.56
$776.65
Nonpar Fee
$417.66
$520.56
$1,205.07
$176.49
$540.41
$1,040.44
$719.89
$1,478.68
$1,603.94
$1,575.95
$1,217.15
$637.18
$477.88
$614.96
$464.84
$347.32
$463.44
$706.23
$259.20
$171.22
$382.17
$490.77
$496.05
$442.14
$302.20
$599.27
$999.32
$400.76
$459.23
$621.29
$566.04
$660.78
$737.82
Limiting
Charge
$480.31
$598.64
$1,385.83
$202.96
$621.47
$1,196.51
$827.87
$1,700.48
$1,844.53
$1,812.34
$1,399.72
$732.76
$549.56
$707.20
$534.57
$399.42
$532.96
$812.16
$298.08
$196.90
$439.50
$564.39
$570.46
$508.46
$347.53
$689.16
$1,149.22
$460.87
$528.11
$714.48
$650.95
$759.90
$848.49
Charge**
Charge***
$475.50
$473.11
$592.65
$589.66
$1,371.97
$1,365.04
$200.94
$199.92
$615.26
$612.15
$1,184.55
$1,178.55
$819.59
$815.45
$1,683.47
$1,674.98
$1,826.09
$1,816.86
$1,794.22
$1,785.16
$1,385.73
$1,378.72
$725.43
$721.76
$544.07
$541.32
$700.13
$696.60
$529.22
$526.55
$395.43
$393.43
$527.63
$524.96
$804.05
$799.99
$295.10
$293.61
$194.94
$193.95
$435.10
$432.91
$558.74
$555.92
$564.75
$561.90
$503.38
$500.84
$344.06
$342.32
$682.27
$678.82
$1,137.73
$1,131.98
$456.26
$453.96
$522.84
$520.19
$707.34
$703.77
$644.44
$641.18
$752.30
$748.50
$840.01
$835.76
Arizona
EHR/eRx
Limiting
Charge**
$470.71
$586.67
$1,358.12
$198.90
$609.04
$1,172.57
$811.31
$1,666.48
$1,807.64
$1,776.09
$1,371.73
$718.11
$538.57
$693.06
$523.87
$391.43
$522.30
$795.93
$292.12
$192.97
$430.71
$553.09
$559.05
$498.30
$340.58
$675.37
$1,126.23
$451.65
$517.56
$700.19
$637.93
$744.69
$831.52
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$468.37
$463.65
$583.76
$577.88
$1,351.39
$1,337.75
$197.93
$195.93
$606.03
$599.91
$1,166.78
$1,154.99
$807.30
$799.15
$1,658.22
$1,641.48
$1,798.69
$1,780.52
$1,767.31
$1,749.45
$1,364.95
$1,351.16
$714.55
$707.33
$535.90
$530.50
$689.63
$682.66
$521.28
$516.02
$389.49
$385.55
$519.72
$514.46
$791.98
$783.99
$290.67
$287.74
$192.02
$190.07
$428.57
$424.25
$550.36
$544.80
$556.28
$550.67
$495.82
$490.82
$338.89
$335.48
$672.04
$665.24
$1,120.66
$1,109.34
$449.42
$444.88
$514.99
$509.80
$696.73
$689.69
$634.77
$628.36
$741.01
$733.53
$827.40
$819.04
Page 66 of 323
Notes
#
#
Procedure
Code
27337
27339
27340
27345
27347
27350
27355
27356
27357
27358
27360
27364
27365
27370
27370
27372
27372
27380
27381
27385
27386
27390
27391
27392
27393
27394
27395
27396
27397
27400
27403
27405
27407
1/2/2015
Modifier
Par Fee
$423.61
$765.37
$377.23
$488.76
$537.49
$662.08
$613.53
$751.54
$827.22
$285.62
$865.79
$1,593.06
$2,107.90
$156.84
$51.72
$616.89
$410.94
$603.38
$809.06
$583.93
$842.36
$455.78
$586.94
$725.16
$518.50
$661.63
$894.36
$626.41
$933.30
$707.50
$651.58
$688.10
$806.61
Nonpar Fee
$402.43
$727.10
$358.37
$464.32
$510.62
$628.98
$582.85
$713.96
$785.86
$271.34
$822.50
$1,513.41
$2,002.51
$149.00
$49.13
$586.05
$390.39
$573.21
$768.61
$554.73
$800.24
$432.99
$557.59
$688.90
$492.58
$628.55
$849.64
$595.09
$886.64
$672.13
$619.00
$653.70
$766.28
Limiting
Charge
$462.79
$836.17
$412.13
$533.97
$587.21
$723.33
$670.28
$821.05
$903.74
$312.04
$945.88
$1,740.42
$2,302.89
$171.35
$56.50
$673.96
$448.95
$659.19
$883.90
$637.94
$920.28
$497.94
$641.23
$792.24
$566.47
$722.83
$977.09
$684.35
$1,019.64
$772.95
$711.85
$751.76
$881.22
Charge**
Charge***
$458.17
$455.85
$827.80
$823.62
$408.01
$405.94
$528.63
$525.96
$581.34
$578.40
$716.09
$712.48
$663.57
$660.23
$812.84
$808.74
$894.70
$890.18
$308.92
$307.36
$936.42
$931.68
$1,723.02
$1,714.32
$2,279.85
$2,268.34
$169.64
$168.79
$55.94
$55.65
$667.22
$663.85
$444.46
$442.21
$652.60
$649.30
$875.06
$870.64
$631.56
$628.37
$911.08
$906.48
$492.96
$490.48
$634.81
$631.61
$784.31
$780.36
$560.80
$557.97
$715.60
$711.99
$967.31
$962.44
$677.51
$674.08
$1,009.44
$1,004.34
$765.22
$761.36
$704.73
$701.18
$744.23
$740.47
$872.41
$868.01
Arizona
EHR/eRx
Limiting
Charge**
$453.54
$819.44
$403.88
$523.28
$575.47
$708.86
$656.87
$804.63
$885.66
$305.80
$926.96
$1,705.61
$2,256.83
$167.92
$55.37
$660.48
$439.97
$646.01
$866.23
$625.19
$901.88
$487.98
$628.41
$776.39
$555.14
$708.38
$957.55
$670.67
$999.25
$757.49
$697.61
$736.72
$863.59
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$451.29
$446.73
$815.38
$807.15
$401.89
$397.82
$520.70
$515.43
$572.62
$566.84
$705.35
$698.22
$653.61
$647.01
$800.65
$792.56
$881.28
$872.38
$304.29
$301.21
$922.38
$913.05
$1,697.18
$1,680.02
$2,245.65
$2,222.97
$167.10
$165.40
$55.10
$54.54
$657.21
$650.58
$437.79
$433.37
$642.82
$636.32
$861.94
$853.23
$622.08
$615.81
$897.41
$888.35
$485.56
$480.67
$625.29
$618.98
$772.55
$764.74
$552.39
$546.81
$704.87
$697.75
$952.80
$943.18
$667.35
$660.61
$994.29
$984.26
$753.74
$746.13
$694.16
$687.15
$733.07
$725.67
$859.33
$850.64
Page 67 of 323
Notes
Procedure
Code
27409
27412
27415
27416
27418
27420
27422
27424
27425
27427
27428
27429
27430
27435
27437
27438
27440
27441
27442
27443
27445
27446
27447
27448
27450
27454
27455
27457
27465
27466
27468
27470
27472
1/2/2015
Modifier
Par Fee
$982.79
$1,688.13
$1,403.18
$998.84
$841.29
$752.29
$755.51
$761.82
$455.55
$726.14
$1,135.49
$1,275.68
$749.47
$819.74
$672.90
$855.29
$812.47
$839.60
$884.75
$831.51
$1,276.27
$1,181.85
$1,382.48
$779.36
$1,027.26
$1,326.38
$960.17
$978.19
$1,273.19
$1,207.92
$1,370.33
$1,197.63
$1,288.78
Nonpar Fee
$933.65
$1,603.72
$1,333.02
$948.90
$799.23
$714.68
$717.73
$723.73
$432.77
$689.83
$1,078.72
$1,211.90
$712.00
$778.75
$639.26
$812.53
$771.85
$797.62
$840.51
$789.93
$1,212.46
$1,122.76
$1,313.36
$740.39
$975.90
$1,260.06
$912.16
$929.28
$1,209.53
$1,147.52
$1,301.81
$1,137.75
$1,224.34
Limiting
Charge
$1,073.70
$1,844.28
$1,532.97
$1,091.24
$919.11
$821.88
$825.39
$832.29
$497.69
$793.30
$1,240.53
$1,393.69
$818.80
$895.56
$735.15
$934.41
$887.63
$917.26
$966.59
$908.42
$1,394.33
$1,291.17
$1,510.36
$851.45
$1,122.29
$1,449.07
$1,048.98
$1,068.67
$1,390.96
$1,319.65
$1,497.08
$1,308.41
$1,407.99
Charge**
Charge***
$1,062.96
$1,057.60
$1,825.83
$1,816.61
$1,517.64
$1,509.97
$1,080.32
$1,074.87
$909.93
$905.33
$813.66
$809.55
$817.13
$813.00
$823.96
$819.80
$492.71
$490.22
$785.37
$781.40
$1,228.12
$1,221.92
$1,379.75
$1,372.78
$810.61
$806.52
$886.60
$882.13
$727.80
$724.12
$925.06
$920.39
$878.75
$874.31
$908.09
$903.51
$956.92
$952.09
$899.33
$894.79
$1,380.39
$1,373.41
$1,278.26
$1,271.81
$1,495.26
$1,487.71
$842.94
$838.67
$1,111.06
$1,105.45
$1,434.58
$1,427.33
$1,038.50
$1,033.25
$1,057.99
$1,052.64
$1,377.04
$1,370.10
$1,306.45
$1,299.86
$1,482.11
$1,474.62
$1,295.33
$1,288.78
$1,393.92
$1,386.87
Arizona
EHR/eRx
Limiting
Charge**
$1,052.23
$1,807.40
$1,502.31
$1,069.41
$900.74
$805.45
$808.89
$815.65
$487.73
$777.43
$1,215.72
$1,365.81
$802.42
$877.66
$720.44
$915.72
$869.87
$898.92
$947.26
$890.25
$1,366.44
$1,265.35
$1,480.15
$834.42
$1,099.84
$1,420.09
$1,028.01
$1,047.29
$1,363.14
$1,293.26
$1,467.14
$1,282.25
$1,379.83
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$1,047.02
$1,036.45
$1,798.44
$1,780.29
$1,494.87
$1,479.77
$1,064.12
$1,053.37
$896.28
$887.23
$801.46
$793.36
$804.87
$796.75
$811.60
$803.41
$485.31
$480.41
$773.59
$765.77
$1,209.70
$1,197.48
$1,359.05
$1,345.33
$798.46
$790.38
$873.31
$864.49
$716.89
$709.63
$911.18
$901.99
$865.57
$856.82
$894.47
$885.43
$942.56
$933.04
$885.85
$876.90
$1,359.68
$1,345.95
$1,259.09
$1,246.37
$1,472.84
$1,457.95
$830.30
$821.91
$1,094.40
$1,083.33
$1,413.06
$1,398.79
$1,022.91
$1,012.59
$1,042.12
$1,031.58
$1,356.39
$1,342.69
$1,286.85
$1,273.86
$1,459.88
$1,445.12
$1,275.89
$1,263.02
$1,373.01
$1,359.13
Page 68 of 323
Notes
#
#
#
#
#
Procedure
Code
27475
27477
27479
27485
27486
27487
27488
27495
27496
27497
27498
27499
27500
27500
27501
27501
27502
27503
27506
27507
27508
27508
27509
27510
27511
27513
27514
27516
27516
27517
27519
27520
27520
1/2/2015
Modifier
Par Fee
$673.62
$746.53
$938.18
$682.69
$1,433.70
$1,792.10
$1,223.78
$1,148.68
$553.59
$599.96
$666.69
$713.18
$527.92
$488.59
$510.89
$506.25
$778.94
$815.82
$1,363.74
$990.52
$532.83
$501.01
$654.43
$695.34
$1,015.96
$1,265.01
$985.34
$516.83
$485.01
$698.43
$909.49
$327.20
$298.23
Nonpar Fee
$639.94
$709.20
$891.27
$648.56
$1,362.02
$1,702.50
$1,162.59
$1,091.25
$525.91
$569.96
$633.36
$677.52
$501.52
$464.16
$485.35
$480.94
$739.99
$775.03
$1,295.55
$940.99
$506.19
$475.96
$621.71
$660.57
$965.16
$1,201.76
$936.07
$490.99
$460.76
$663.51
$864.02
$310.84
$283.32
Limiting
Charge
$735.93
$815.58
$1,024.96
$745.84
$1,566.32
$1,957.88
$1,336.98
$1,254.94
$604.80
$655.45
$728.36
$779.15
$576.75
$533.78
$558.15
$553.08
$850.99
$891.28
$1,489.88
$1,082.14
$582.12
$547.35
$714.97
$759.66
$1,109.93
$1,382.02
$1,076.48
$564.64
$529.87
$763.04
$993.62
$357.47
$325.82
Charge**
Charge***
$728.57
$724.89
$807.43
$803.34
$1,014.71
$1,009.59
$738.38
$734.65
$1,550.66
$1,542.83
$1,938.30
$1,928.50
$1,323.60
$1,316.92
$1,242.39
$1,236.11
$598.75
$595.72
$648.90
$645.62
$721.08
$717.44
$771.35
$767.46
$570.98
$568.10
$528.45
$525.78
$552.58
$549.78
$547.55
$544.79
$842.48
$838.22
$882.37
$877.91
$1,474.98
$1,467.54
$1,071.32
$1,065.91
$576.30
$573.39
$541.88
$539.14
$707.81
$704.24
$752.05
$748.26
$1,098.84
$1,093.28
$1,368.20
$1,361.29
$1,065.72
$1,060.33
$558.99
$556.17
$524.57
$521.93
$755.40
$751.59
$983.69
$978.72
$353.89
$352.11
$322.56
$320.93
Arizona
EHR/eRx
Limiting
Charge**
$721.21
$799.27
$1,004.46
$730.93
$1,535.00
$1,918.72
$1,310.24
$1,229.84
$592.70
$642.34
$713.79
$763.57
$565.21
$523.11
$546.99
$542.02
$833.97
$873.46
$1,460.09
$1,060.50
$570.48
$536.41
$700.67
$744.46
$1,087.74
$1,354.38
$1,054.95
$553.35
$519.27
$747.78
$973.75
$350.31
$319.30
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$717.65
$710.39
$795.32
$787.28
$999.49
$989.39
$727.31
$719.97
$1,527.40
$1,511.97
$1,909.23
$1,889.93
$1,303.76
$1,290.59
$1,223.75
$1,211.40
$589.77
$583.81
$639.17
$632.71
$710.26
$703.09
$759.78
$752.11
$562.41
$556.74
$520.52
$515.27
$544.28
$538.79
$539.34
$533.89
$829.84
$821.46
$869.14
$860.36
$1,452.85
$1,438.19
$1,055.25
$1,044.59
$567.65
$561.92
$533.75
$528.36
$697.20
$690.16
$740.77
$733.30
$1,082.36
$1,071.42
$1,347.67
$1,334.06
$1,049.73
$1,039.13
$550.61
$545.04
$516.71
$511.49
$744.07
$736.56
$968.93
$959.15
$348.58
$345.06
$317.72
$314.51
Page 69 of 323
Notes
#
#
#
#
#
#
Procedure
Code
27524
27530
27530
27532
27532
27535
27536
27538
27538
27540
27550
27550
27552
27556
27557
27558
27560
27560
27562
27566
27570
27580
27590
27591
27592
27594
27596
27598
27600
27601
27602
27603
27603
1/2/2015
Modifier
Par Fee
$766.64
$305.96
$283.44
$627.07
$588.46
$913.77
$1,212.96
$481.15
$450.40
$826.01
$510.34
$473.16
$636.06
$893.70
$1,068.72
$1,219.42
$364.21
$335.61
$491.81
$910.01
$153.91
$1,461.91
$823.83
$984.71
$700.70
$516.95
$736.77
$735.52
$422.04
$455.61
$501.72
$537.51
$394.49
Nonpar Fee
$728.31
$290.66
$269.27
$595.72
$559.04
$868.08
$1,152.31
$457.09
$427.88
$784.71
$484.82
$449.50
$604.26
$849.02
$1,015.28
$1,158.45
$346.00
$318.83
$467.22
$864.51
$146.21
$1,388.81
$782.64
$935.47
$665.67
$491.10
$699.93
$698.74
$400.94
$432.83
$476.63
$510.63
$374.77
Limiting
Charge
$837.56
$334.26
$309.66
$685.08
$642.90
$998.29
$1,325.16
$525.65
$492.06
$902.42
$557.54
$516.93
$694.90
$976.37
$1,167.57
$1,332.22
$397.90
$366.65
$537.30
$994.19
$168.14
$1,597.13
$900.04
$1,075.79
$765.52
$564.77
$804.92
$803.55
$461.08
$497.75
$548.12
$587.22
$430.99
Charge**
Charge***
$829.18
$825.00
$330.91
$329.25
$306.57
$305.01
$678.22
$674.80
$636.47
$633.25
$988.31
$983.32
$1,311.91
$1,305.28
$520.40
$517.76
$487.14
$484.68
$893.39
$888.88
$551.97
$549.18
$511.76
$509.17
$687.95
$684.48
$966.61
$961.72
$1,155.90
$1,150.06
$1,318.90
$1,312.23
$393.92
$391.93
$362.99
$361.16
$531.93
$529.24
$984.24
$979.27
$166.46
$165.62
$1,581.16
$1,573.18
$891.03
$886.54
$1,065.04
$1,059.66
$757.86
$754.03
$559.12
$556.29
$796.87
$792.84
$795.51
$791.50
$456.47
$454.17
$492.78
$490.29
$542.64
$539.90
$581.35
$578.42
$426.67
$424.52
Arizona
EHR/eRx
Limiting
Charge**
$820.80
$327.58
$303.46
$671.38
$630.04
$978.33
$1,298.65
$515.14
$482.22
$884.37
$546.39
$506.59
$681.00
$956.85
$1,144.22
$1,305.57
$389.94
$359.32
$526.56
$974.30
$164.78
$1,565.18
$882.04
$1,054.27
$750.21
$553.47
$788.82
$787.49
$451.86
$487.80
$537.17
$575.48
$422.36
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$816.74
$808.48
$325.94
$322.67
$301.97
$298.91
$668.05
$661.31
$626.92
$620.59
$973.49
$963.65
$1,292.23
$1,279.17
$512.59
$507.41
$479.84
$474.98
$879.99
$871.10
$543.69
$538.19
$504.08
$498.99
$677.64
$670.78
$952.11
$942.49
$1,138.56
$1,127.06
$1,299.12
$1,285.99
$388.01
$384.09
$357.55
$353.92
$523.95
$518.66
$969.47
$959.69
$163.97
$162.31
$1,557.45
$1,541.70
$877.67
$868.81
$1,049.06
$1,038.46
$746.49
$738.96
$550.74
$545.17
$784.92
$776.99
$783.58
$775.68
$449.63
$445.08
$485.38
$480.48
$534.50
$529.10
$572.63
$566.85
$420.27
$416.02
Page 70 of 323
Notes
#
#
#
#
#
#
Procedure
Code
27604
27604
27605
27605
27606
27607
27610
27612
27613
27613
27614
27614
27615
27616
27618
27618
27619
27620
27625
27626
27630
27630
27632
27634
27635
27637
27638
27640
27641
27645
27646
27647
27648
1/2/2015
Modifier
Par Fee
$498.16
$349.42
$346.17
$188.14
$290.74
$621.80
$663.77
$575.69
$253.97
$164.94
$581.97
$408.56
$1,037.29
$1,289.92
$457.05
$312.24
$480.89
$467.07
$594.79
$628.31
$570.83
$371.68
$420.79
$696.87
$598.33
$778.18
$790.75
$852.24
$681.16
$1,818.80
$1,577.89
$1,048.57
$164.66
Nonpar Fee
$473.25
$331.95
$328.86
$178.73
$276.20
$590.71
$630.58
$546.91
$241.27
$156.69
$552.87
$388.13
$985.43
$1,225.42
$434.20
$296.63
$456.85
$443.72
$565.05
$596.89
$542.29
$353.10
$399.75
$662.03
$568.41
$739.27
$751.21
$809.63
$647.10
$1,727.86
$1,499.00
$996.14
$156.43
Limiting
Charge
$544.24
$381.74
$378.19
$205.54
$317.63
$679.32
$725.17
$628.95
$277.46
$180.19
$635.80
$446.35
$1,133.24
$1,409.23
$499.33
$341.12
$525.38
$510.28
$649.81
$686.42
$623.63
$406.07
$459.71
$761.33
$653.67
$850.16
$863.89
$931.07
$744.17
$1,987.04
$1,723.85
$1,145.56
$179.89
Charge**
Charge***
$538.80
$536.07
$377.92
$376.02
$374.41
$372.52
$203.48
$202.46
$314.46
$312.87
$672.52
$669.13
$717.91
$714.29
$622.66
$619.52
$274.69
$273.30
$178.39
$177.49
$629.44
$626.27
$441.89
$439.66
$1,121.92
$1,116.25
$1,395.15
$1,388.10
$494.34
$491.84
$337.71
$336.01
$520.12
$517.50
$505.17
$502.62
$643.31
$640.06
$679.56
$676.13
$617.40
$614.28
$402.01
$399.97
$455.11
$452.81
$753.72
$749.92
$647.14
$643.86
$841.66
$837.41
$855.26
$850.93
$921.76
$917.11
$736.72
$733.00
$1,967.17
$1,957.23
$1,706.61
$1,698.00
$1,134.11
$1,128.38
$178.10
$177.19
Arizona
EHR/eRx
Limiting
Charge**
$533.36
$374.11
$370.62
$201.43
$311.28
$665.74
$710.67
$616.37
$271.91
$176.59
$623.08
$437.43
$1,110.58
$1,381.05
$489.35
$334.31
$514.87
$500.08
$636.81
$672.69
$611.16
$397.95
$450.52
$746.11
$640.60
$833.15
$846.62
$912.46
$729.28
$1,947.30
$1,689.37
$1,122.65
$176.30
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$530.71
$525.35
$372.26
$368.49
$368.79
$365.07
$200.43
$198.41
$309.74
$306.61
$662.43
$655.75
$707.15
$700.01
$613.32
$607.12
$270.57
$267.82
$175.71
$173.95
$620.00
$613.73
$435.26
$430.86
$1,105.09
$1,093.91
$1,374.22
$1,360.34
$486.92
$482.01
$332.65
$329.29
$512.33
$507.14
$497.59
$492.58
$633.66
$627.26
$669.37
$662.61
$608.14
$601.99
$395.98
$391.98
$448.28
$443.76
$742.42
$734.92
$637.43
$630.98
$829.04
$820.65
$842.42
$833.92
$907.94
$898.77
$725.67
$718.35
$1,937.66
$1,918.09
$1,681.01
$1,664.03
$1,117.10
$1,105.82
$175.43
$173.65
Page 71 of 323
Notes
#
#
#
Procedure
Code
27648
27650
27652
27654
27656
27656
27658
27659
27664
27665
27675
27676
27680
27681
27685
27685
27686
27687
27690
27691
27692
27695
27696
27698
27700
27702
27703
27704
27705
27707
27709
27712
27715
1/2/2015
Modifier
Par Fee
$53.10
$671.49
$700.00
$721.37
$647.10
$403.25
$381.02
$488.75
$370.38
$416.83
$491.43
$603.41
$438.65
$556.58
$675.83
$472.02
$573.70
$464.16
$641.26
$764.74
$106.21
$485.44
$561.52
$651.06
$596.13
$988.67
$1,133.55
$586.71
$765.34
$409.95
$1,195.66
$1,127.36
$1,070.10
Nonpar Fee
$50.45
$637.92
$665.00
$685.30
$614.75
$383.09
$361.97
$464.31
$351.86
$395.99
$466.86
$573.24
$416.72
$528.75
$642.04
$448.42
$545.02
$440.95
$609.20
$726.50
$100.90
$461.17
$533.44
$618.51
$566.32
$939.24
$1,076.87
$557.37
$727.07
$389.45
$1,135.88
$1,070.99
$1,016.60
Limiting
Charge
$58.02
$733.61
$764.75
$788.10
$706.96
$440.55
$416.27
$533.96
$404.64
$455.39
$536.89
$659.23
$479.23
$608.06
$738.35
$515.68
$626.77
$507.09
$700.58
$835.48
$116.04
$530.35
$613.46
$711.29
$651.27
$1,080.13
$1,238.40
$640.98
$836.13
$447.87
$1,306.26
$1,231.64
$1,169.09
Charge**
Charge***
$57.44
$57.14
$726.27
$722.60
$757.10
$753.28
$780.22
$776.27
$699.89
$696.36
$436.15
$433.94
$412.10
$410.02
$528.62
$525.95
$400.59
$398.57
$450.83
$448.56
$531.52
$528.84
$652.64
$649.34
$474.43
$472.04
$601.98
$598.94
$730.96
$727.27
$510.53
$507.94
$620.51
$617.37
$502.02
$499.49
$693.58
$690.07
$827.13
$822.94
$114.87
$114.30
$525.04
$522.39
$607.33
$604.26
$704.17
$700.61
$644.76
$641.50
$1,069.33
$1,063.92
$1,226.02
$1,219.83
$634.57
$631.36
$827.77
$823.58
$443.39
$441.15
$1,293.20
$1,286.67
$1,219.32
$1,213.17
$1,157.39
$1,151.55
Arizona
EHR/eRx
Limiting
Charge**
$56.86
$718.93
$749.46
$772.33
$692.83
$431.74
$407.94
$523.27
$396.54
$446.28
$526.15
$646.05
$469.65
$595.91
$723.58
$505.37
$614.24
$496.95
$686.57
$818.77
$113.71
$519.74
$601.19
$697.06
$638.24
$1,058.53
$1,213.63
$628.15
$819.41
$438.91
$1,280.13
$1,207.01
$1,145.71
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$56.58
$56.01
$715.38
$708.15
$745.74
$738.21
$768.51
$760.75
$689.39
$682.43
$429.61
$425.27
$405.92
$401.82
$520.69
$515.42
$394.58
$390.60
$444.07
$439.59
$523.55
$518.26
$642.85
$636.35
$467.31
$462.60
$592.95
$586.97
$720.00
$712.72
$502.87
$497.79
$611.20
$605.03
$494.49
$489.50
$683.17
$676.27
$814.72
$806.48
$113.15
$112.01
$517.17
$511.95
$598.22
$592.17
$693.61
$686.61
$635.09
$628.67
$1,053.29
$1,042.65
$1,207.63
$1,195.43
$625.05
$618.73
$815.35
$807.12
$436.75
$432.33
$1,273.80
$1,260.93
$1,201.04
$1,188.90
$1,140.03
$1,128.53
Page 72 of 323
Notes
#
#
#
#
#
#
#
Procedure
Code
27720
27722
27724
27725
27726
27727
27730
27732
27734
27740
27742
27745
27750
27750
27752
27752
27756
27758
27759
27760
27760
27762
27762
27766
27767
27767
27768
27769
27780
27780
27781
27781
27784
1/2/2015
Modifier
Par Fee
$891.36
$907.42
$1,291.24
$1,245.02
$984.31
$873.25
$596.41
$454.79
$667.63
$721.58
$792.53
$772.68
$351.16
$322.20
$544.77
$502.58
$587.33
$907.77
$1,016.89
$337.65
$307.62
$480.21
$437.30
$623.36
$285.40
$286.83
$447.86
$738.31
$309.58
$280.98
$429.16
$397.70
$730.07
Nonpar Fee
$846.79
$862.05
$1,226.68
$1,182.77
$935.09
$829.59
$566.59
$432.05
$634.25
$685.50
$752.90
$734.05
$333.60
$306.09
$517.53
$477.45
$557.96
$862.38
$966.05
$320.77
$292.24
$456.20
$415.44
$592.19
$271.13
$272.49
$425.47
$701.39
$294.10
$266.93
$407.70
$377.82
$693.57
Limiting
Charge
$973.81
$991.36
$1,410.68
$1,360.19
$1,075.35
$954.03
$651.58
$496.86
$729.39
$788.33
$865.84
$844.16
$383.64
$352.00
$595.16
$549.07
$641.65
$991.74
$1,110.96
$368.89
$336.08
$524.63
$477.76
$681.02
$311.80
$313.36
$489.29
$806.60
$338.22
$306.97
$468.86
$434.49
$797.61
Charge**
Charge***
$964.07
$959.20
$981.44
$976.49
$1,396.57
$1,389.52
$1,346.58
$1,339.78
$1,064.60
$1,059.22
$944.48
$939.72
$645.06
$641.80
$491.89
$489.41
$722.10
$718.45
$780.45
$776.50
$857.18
$852.85
$835.72
$831.50
$379.80
$377.89
$348.48
$346.73
$589.20
$586.24
$543.58
$540.83
$635.24
$632.03
$981.82
$976.86
$1,099.85
$1,094.29
$365.19
$363.35
$332.72
$331.04
$519.39
$516.76
$472.98
$470.59
$674.21
$670.81
$308.68
$307.12
$310.24
$308.66
$484.40
$481.95
$798.54
$794.50
$334.83
$333.14
$303.90
$302.37
$464.16
$461.82
$430.15
$427.97
$789.62
$785.65
Arizona
EHR/eRx
Limiting
Charge**
$954.33
$971.53
$1,382.47
$1,332.98
$1,053.85
$934.95
$638.55
$486.92
$714.81
$772.56
$848.52
$827.28
$375.97
$344.97
$583.26
$538.09
$628.82
$971.90
$1,088.74
$361.50
$329.36
$514.14
$468.20
$667.40
$305.57
$307.10
$479.50
$790.46
$331.45
$300.83
$459.48
$425.80
$781.66
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$949.61
$940.01
$966.72
$956.96
$1,375.62
$1,361.74
$1,326.39
$1,312.98
$1,048.63
$1,038.04
$930.32
$920.93
$635.39
$628.97
$484.51
$479.62
$711.26
$704.09
$768.74
$760.97
$844.32
$835.79
$823.18
$814.87
$374.11
$370.33
$343.25
$339.79
$580.36
$574.51
$535.43
$530.01
$625.70
$619.39
$967.09
$957.32
$1,083.35
$1,072.41
$359.72
$356.07
$327.73
$324.42
$511.60
$506.43
$465.89
$461.17
$664.10
$657.39
$304.05
$300.98
$305.58
$302.48
$477.14
$472.32
$786.55
$778.61
$329.81
$326.49
$299.35
$296.32
$457.21
$452.59
$423.69
$419.42
$777.78
$769.93
Page 73 of 323
Notes
#
#
#
#
#
#
#
#
#
Procedure
Code
27786
27786
27788
27788
27792
27808
27808
27810
27810
27814
27816
27816
27818
27818
27822
27823
27824
27824
27825
27825
27826
27827
27828
27829
27830
27830
27831
27832
27840
27842
27846
27848
27860
1/2/2015
Modifier
Par Fee
$320.58
$289.47
$426.43
$389.61
$665.70
$338.37
$304.04
$473.82
$429.84
$786.66
$325.18
$291.22
$489.78
$439.00
$855.32
$974.01
$316.34
$307.04
$553.53
$502.04
$847.18
$1,101.54
$1,319.70
$696.89
$382.09
$355.63
$406.47
$770.44
$372.40
$504.99
$746.43
$829.36
$176.66
Nonpar Fee
$304.55
$275.00
$405.11
$370.13
$632.42
$321.45
$288.84
$450.13
$408.35
$747.33
$308.92
$276.66
$465.29
$417.05
$812.55
$925.31
$300.52
$291.69
$525.85
$476.94
$804.82
$1,046.46
$1,253.72
$662.05
$362.99
$337.85
$386.15
$731.92
$353.78
$479.74
$709.11
$787.89
$167.83
Limiting
Charge
$350.23
$316.25
$465.88
$425.65
$727.28
$369.67
$332.17
$517.65
$469.60
$859.43
$355.26
$318.16
$535.08
$479.61
$934.43
$1,064.11
$345.60
$335.44
$604.73
$548.48
$925.54
$1,203.43
$1,441.78
$761.36
$417.44
$388.53
$444.07
$841.71
$406.85
$551.70
$815.48
$906.07
$193.00
Charge**
Charge***
$346.73
$344.98
$313.09
$311.51
$461.22
$458.88
$421.39
$419.27
$720.02
$716.37
$365.98
$364.12
$328.84
$327.19
$512.47
$509.89
$464.91
$462.55
$850.84
$846.54
$351.70
$349.93
$314.97
$313.39
$529.74
$527.06
$474.81
$472.41
$925.08
$920.41
$1,053.47
$1,048.14
$342.14
$340.41
$332.09
$330.41
$598.68
$595.65
$543.00
$540.26
$916.29
$911.66
$1,191.40
$1,185.37
$1,427.36
$1,420.15
$753.74
$749.94
$413.26
$411.18
$384.64
$382.70
$439.63
$437.41
$833.29
$829.08
$402.78
$400.74
$546.18
$543.42
$807.32
$803.24
$897.01
$892.48
$191.07
$190.11
Arizona
EHR/eRx
Limiting
Charge**
$343.23
$309.93
$456.56
$417.14
$712.74
$362.27
$325.52
$507.30
$460.21
$842.24
$348.15
$311.80
$524.38
$470.02
$915.75
$1,042.82
$338.69
$328.74
$592.63
$537.51
$907.03
$1,179.36
$1,412.95
$746.13
$409.09
$380.75
$435.19
$824.87
$398.71
$540.67
$799.17
$887.95
$189.14
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$341.53
$338.08
$308.40
$305.28
$454.30
$449.71
$415.07
$410.88
$709.22
$702.04
$360.49
$356.83
$323.91
$320.63
$504.79
$499.69
$457.94
$453.31
$838.07
$829.60
$346.43
$342.93
$310.25
$307.12
$521.79
$516.51
$467.69
$462.97
$911.20
$902.01
$1,037.67
$1,027.18
$337.01
$333.60
$327.11
$323.81
$589.70
$583.74
$534.85
$529.45
$902.54
$893.42
$1,173.53
$1,161.67
$1,405.94
$1,391.75
$742.44
$734.94
$407.07
$402.95
$378.87
$375.04
$433.04
$428.66
$820.79
$812.50
$396.74
$392.73
$537.99
$532.57
$795.21
$787.19
$883.56
$874.63
$188.21
$186.30
Page 74 of 323
Notes
#
#
#
#
#
#
#
#
#
#
Procedure
Code
27870
27871
27880
27881
27882
27884
27886
27888
27889
27892
27893
27894
28001
28001
28002
28002
28003
28003
28005
28008
28008
28010
28010
28011
28011
28020
28020
28022
28022
28024
28024
28035
28035
1/2/2015
Modifier
Par Fee
$1,051.79
$697.57
$943.77
$886.79
$616.39
$591.30
$676.55
$703.31
$663.87
$557.39
$620.60
$880.11
$287.40
$176.20
$452.56
$324.91
$723.97
$577.73
$592.21
$444.77
$300.32
$237.34
$214.10
$329.87
$294.11
$560.37
$371.94
$503.64
$332.73
$476.02
$312.62
$542.17
$363.04
Nonpar Fee
$999.20
$662.69
$896.58
$842.45
$585.57
$561.74
$642.72
$668.14
$630.68
$529.52
$589.57
$836.10
$273.03
$167.39
$429.93
$308.66
$687.77
$548.84
$562.60
$422.53
$285.30
$225.47
$203.40
$313.38
$279.40
$532.35
$353.34
$478.46
$316.09
$452.22
$296.99
$515.06
$344.89
Limiting
Charge
$1,149.08
$762.09
$1,031.07
$968.82
$673.41
$646.00
$739.13
$768.36
$725.28
$608.95
$678.01
$961.52
$313.98
$192.50
$494.42
$354.96
$790.94
$631.17
$646.99
$485.91
$328.10
$259.29
$233.91
$360.39
$321.31
$612.20
$406.34
$550.23
$363.50
$520.05
$341.54
$592.32
$396.62
Charge**
Charge***
$1,137.59
$1,131.84
$754.47
$750.66
$1,020.75
$1,015.60
$959.13
$954.28
$666.67
$663.31
$639.54
$636.31
$731.73
$728.04
$760.68
$756.84
$718.03
$714.40
$602.85
$599.82
$671.22
$667.84
$951.90
$947.09
$310.85
$309.27
$190.58
$189.61
$489.47
$487.00
$351.41
$349.63
$783.02
$779.07
$624.85
$621.70
$640.52
$637.28
$481.05
$478.62
$324.82
$323.17
$256.70
$255.40
$231.58
$230.40
$356.79
$354.98
$318.10
$316.49
$606.08
$603.01
$402.28
$400.25
$544.73
$541.97
$359.87
$358.05
$514.86
$512.26
$338.12
$336.42
$586.40
$583.43
$392.66
$390.68
Arizona
EHR/eRx
Limiting
Charge**
$1,126.10
$746.86
$1,010.45
$949.44
$659.94
$633.09
$724.35
$753.00
$710.78
$596.77
$664.45
$942.29
$307.71
$188.65
$484.53
$347.86
$775.11
$618.54
$634.05
$476.19
$321.53
$254.10
$229.23
$353.18
$314.88
$599.96
$398.21
$539.22
$356.24
$509.66
$334.71
$580.47
$388.69
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$1,120.53
$1,109.21
$743.15
$735.66
$1,005.45
$995.29
$944.75
$935.20
$656.66
$650.04
$629.95
$623.59
$720.76
$713.48
$749.27
$741.70
$707.25
$700.12
$593.81
$587.82
$661.15
$654.48
$937.62
$928.15
$306.19
$303.09
$187.71
$185.82
$482.14
$477.26
$346.14
$342.64
$771.28
$763.49
$615.48
$609.26
$630.91
$624.54
$473.83
$469.05
$319.94
$316.71
$252.85
$250.30
$228.10
$225.79
$351.44
$347.88
$313.33
$310.16
$596.99
$590.95
$396.24
$392.24
$536.56
$531.14
$354.48
$350.89
$507.13
$502.01
$333.05
$329.68
$577.60
$571.77
$386.77
$382.86
Page 75 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
28039
28039
28041
28043
28043
28045
28045
28046
28047
28050
28050
28052
28052
28054
28054
28055
28060
28060
28062
28062
28070
28070
28072
28072
28080
28080
28086
28086
28088
28088
28090
28090
28092
1/2/2015
Modifier
Par Fee
$521.98
$357.15
$467.91
$410.67
$268.01
$508.06
$354.32
$745.86
$1,096.45
$494.87
$316.45
$452.41
$284.72
$386.39
$241.59
$386.99
$531.80
$363.40
$598.84
$413.99
$543.29
$360.59
$530.06
$343.78
$541.67
$376.49
$566.72
$370.78
$451.38
$280.83
$484.91
$315.08
$435.30
Nonpar Fee
$495.88
$339.29
$444.51
$390.14
$254.61
$482.66
$336.60
$708.57
$1,041.63
$470.13
$300.63
$429.79
$270.48
$367.07
$229.51
$367.64
$505.21
$345.23
$568.90
$393.29
$516.13
$342.56
$503.56
$326.59
$514.59
$357.67
$538.38
$352.24
$428.81
$266.79
$460.66
$299.33
$413.54
Limiting
Charge
$570.26
$390.18
$511.19
$448.66
$292.80
$555.06
$387.09
$814.86
$1,197.87
$540.65
$345.72
$494.26
$311.05
$422.13
$263.94
$422.79
$580.99
$397.01
$654.24
$452.28
$593.55
$393.94
$579.09
$375.58
$591.78
$411.32
$619.14
$405.08
$493.13
$306.81
$529.76
$344.23
$475.57
Charge**
Charge***
$564.56
$561.71
$386.29
$384.33
$506.07
$503.52
$444.18
$441.93
$289.87
$288.41
$549.50
$546.73
$383.21
$381.28
$806.70
$802.63
$1,185.89
$1,179.91
$535.24
$532.54
$342.26
$340.54
$489.31
$486.84
$307.95
$306.38
$417.91
$415.79
$261.29
$259.98
$418.55
$416.45
$575.18
$572.27
$393.05
$391.06
$647.69
$644.43
$447.76
$445.50
$587.62
$584.65
$390.00
$388.03
$573.30
$570.41
$371.82
$369.94
$585.86
$582.90
$407.20
$405.15
$612.95
$609.85
$401.03
$399.00
$488.20
$485.74
$303.74
$302.21
$524.46
$521.81
$340.79
$339.07
$470.81
$468.44
Arizona
EHR/eRx
Limiting
Charge**
$558.85
$382.38
$500.96
$439.69
$286.95
$543.96
$379.35
$798.56
$1,173.92
$529.84
$338.81
$484.37
$304.83
$413.69
$258.66
$414.33
$569.38
$389.08
$641.15
$443.23
$581.68
$386.07
$567.51
$368.07
$579.95
$403.10
$606.75
$396.98
$483.26
$300.67
$519.17
$337.34
$466.06
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$556.09
$550.47
$380.49
$376.64
$498.48
$493.45
$437.52
$433.09
$285.52
$282.65
$541.26
$535.80
$377.46
$373.66
$794.60
$786.58
$1,168.10
$1,156.31
$527.22
$521.89
$337.13
$333.73
$481.98
$477.10
$303.32
$300.25
$411.64
$407.48
$257.37
$254.78
$412.28
$408.12
$566.56
$560.83
$387.15
$383.25
$637.97
$631.53
$441.05
$436.59
$578.81
$572.95
$384.15
$380.27
$564.70
$559.00
$366.24
$362.55
$577.07
$571.25
$401.10
$397.05
$603.76
$597.66
$395.01
$391.02
$480.87
$476.02
$299.18
$296.16
$516.59
$511.38
$335.67
$332.28
$463.75
$459.07
Page 76 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
28092
28100
28100
28102
28103
28104
28104
28106
28107
28107
28108
28108
28110
28110
28111
28111
28112
28112
28113
28113
28114
28114
28116
28116
28118
28118
28119
28119
28120
28120
28122
28122
28124
1/2/2015
Modifier
Par Fee
$274.40
$627.60
$423.79
$617.69
$400.09
$547.54
$363.76
$438.17
$531.21
$356.73
$456.26
$296.08
$477.58
$295.95
$509.41
$334.21
$505.52
$320.67
$611.58
$437.10
$1,108.65
$860.15
$775.23
$582.51
$609.81
$421.74
$540.43
$368.45
$694.74
$508.10
$615.43
$449.89
$490.54
Nonpar Fee
$260.68
$596.22
$402.60
$586.81
$380.09
$520.16
$345.57
$416.26
$504.65
$338.89
$433.45
$281.28
$453.70
$281.15
$483.94
$317.50
$480.24
$304.64
$581.00
$415.25
$1,053.22
$817.14
$736.47
$553.38
$579.32
$400.65
$513.41
$350.03
$660.00
$482.70
$584.66
$427.40
$466.01
Limiting
Charge
$299.78
$685.65
$462.99
$674.83
$437.10
$598.18
$397.41
$478.70
$580.35
$389.72
$498.47
$323.47
$521.76
$323.32
$556.53
$365.13
$552.28
$350.34
$668.15
$477.54
$1,211.20
$939.71
$846.94
$636.39
$666.22
$460.75
$590.42
$402.53
$759.00
$555.11
$672.36
$491.51
$535.91
Charge**
Charge***
$296.78
$295.29
$678.80
$675.37
$458.36
$456.04
$668.08
$664.71
$432.73
$430.55
$592.20
$589.21
$393.43
$391.45
$473.92
$471.52
$574.54
$571.64
$385.83
$383.88
$493.49
$490.99
$320.24
$318.62
$516.53
$513.92
$320.09
$318.47
$550.97
$548.18
$361.48
$359.65
$546.76
$544.00
$346.83
$345.08
$661.47
$658.13
$472.77
$470.37
$1,199.09
$1,193.03
$930.32
$925.61
$838.48
$834.23
$630.03
$626.84
$659.56
$656.22
$456.14
$453.84
$584.52
$581.57
$398.51
$396.50
$751.41
$747.62
$549.55
$546.78
$665.63
$662.27
$486.60
$484.14
$530.55
$527.87
Arizona
EHR/eRx
Limiting
Charge**
$293.79
$671.95
$453.73
$661.33
$428.36
$586.22
$389.46
$469.12
$568.74
$381.93
$488.50
$317.00
$511.32
$316.86
$545.40
$357.82
$541.24
$343.33
$654.79
$467.99
$1,186.98
$920.92
$830.00
$623.66
$652.89
$451.54
$578.61
$394.48
$743.82
$544.01
$658.92
$481.68
$525.19
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$292.33
$289.39
$668.62
$661.87
$451.48
$446.92
$658.06
$651.41
$426.25
$421.94
$583.33
$577.43
$387.53
$383.62
$466.81
$462.08
$565.93
$560.21
$380.04
$376.20
$486.08
$481.17
$315.43
$312.25
$508.78
$503.65
$315.28
$312.11
$542.70
$537.22
$356.06
$352.45
$538.56
$533.12
$341.63
$338.18
$651.54
$644.97
$465.67
$460.98
$1,181.11
$1,169.18
$916.37
$907.11
$825.90
$817.55
$620.57
$614.31
$649.67
$643.09
$449.29
$444.76
$575.76
$569.93
$392.53
$388.56
$740.14
$732.67
$541.31
$535.84
$655.65
$649.04
$479.30
$474.46
$522.59
$517.32
Page 77 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
28124
28126
28126
28130
28140
28140
28150
28150
28153
28153
28160
28160
28171
28173
28175
28190
28190
28192
28192
28193
28193
28200
28200
28202
28202
28208
28208
28210
28210
28220
28220
28222
28222
1/2/2015
Modifier
Par Fee
$337.15
$407.22
$253.84
$624.77
$611.07
$448.03
$440.04
$287.72
$424.66
$270.20
$434.58
$276.54
$868.21
$778.78
$501.10
$263.79
$136.86
$483.12
$320.44
$548.61
$378.41
$503.01
$327.46
$609.44
$432.81
$488.76
$318.92
$599.64
$421.58
$464.44
$308.91
$517.54
$354.50
Nonpar Fee
$320.29
$386.86
$241.15
$593.53
$580.52
$425.63
$418.04
$273.33
$403.43
$256.69
$412.85
$262.71
$824.80
$739.84
$476.05
$250.60
$130.02
$458.96
$304.42
$521.18
$359.49
$477.86
$311.09
$578.97
$411.17
$464.32
$302.97
$569.66
$400.50
$441.22
$293.46
$491.66
$336.78
Limiting
Charge
$368.33
$444.89
$277.32
$682.56
$667.60
$489.47
$480.75
$314.33
$463.94
$295.19
$474.78
$302.12
$948.52
$850.82
$547.46
$288.19
$149.52
$527.80
$350.08
$599.36
$413.41
$549.54
$357.75
$665.82
$472.85
$533.97
$348.42
$655.11
$460.58
$507.40
$337.48
$565.41
$387.30
Charge**
Charge***
$364.65
$362.81
$440.44
$438.22
$274.55
$273.16
$675.73
$672.32
$660.92
$657.58
$484.58
$482.14
$475.94
$473.54
$311.19
$309.61
$459.31
$456.99
$292.24
$290.77
$470.03
$467.66
$299.09
$297.59
$939.03
$934.29
$842.31
$838.05
$541.98
$539.25
$285.30
$283.87
$148.03
$147.28
$522.53
$519.89
$346.59
$344.83
$593.37
$590.36
$409.29
$407.22
$544.04
$541.29
$354.18
$352.38
$659.16
$655.83
$468.12
$465.75
$528.63
$525.96
$344.93
$343.19
$648.55
$645.29
$455.98
$453.66
$502.33
$499.79
$334.11
$332.42
$559.75
$556.93
$383.42
$381.49
Arizona
EHR/eRx
Limiting
Charge**
$360.96
$435.99
$271.78
$668.91
$654.25
$479.69
$471.13
$308.04
$454.66
$289.29
$465.28
$296.08
$929.55
$833.80
$536.51
$282.43
$146.53
$517.25
$343.08
$587.37
$405.15
$538.55
$350.60
$652.50
$463.39
$523.28
$341.45
$642.01
$451.36
$497.26
$330.73
$554.10
$379.55
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$359.18
$355.55
$433.84
$429.44
$270.43
$267.71
$665.60
$658.88
$651.00
$644.44
$477.31
$472.49
$468.80
$464.06
$306.52
$303.42
$452.42
$447.84
$287.86
$284.96
$462.98
$458.30
$294.61
$291.64
$924.95
$915.61
$829.67
$821.28
$533.85
$528.46
$281.03
$278.20
$145.81
$144.34
$514.68
$509.48
$341.39
$337.94
$584.46
$578.57
$403.14
$399.07
$535.88
$530.47
$348.86
$345.35
$649.27
$642.71
$461.09
$456.45
$520.70
$515.43
$339.76
$336.33
$638.83
$632.39
$449.13
$444.59
$494.80
$489.80
$329.10
$325.77
$551.36
$545.79
$377.67
$373.85
Page 78 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
28225
28225
28226
28226
28230
28230
28232
28232
28234
28234
28238
28238
28240
28240
28250
28250
28260
28260
28261
28261
28262
28262
28264
28264
28270
28270
28272
28272
28280
28280
28285
28285
28286
1/2/2015
Modifier
Par Fee
$419.65
$263.76
$453.66
$299.20
$450.18
$291.07
$399.05
$248.88
$422.20
$270.24
$695.58
$501.79
$454.07
$296.39
$596.89
$413.47
$705.55
$522.13
$1,024.12
$806.02
$1,505.13
$1,207.65
$868.27
$660.18
$506.63
$341.09
$406.96
$261.08
$528.94
$354.81
$550.04
$385.56
$462.87
Nonpar Fee
$398.67
$250.57
$430.98
$284.24
$427.67
$276.52
$379.10
$236.44
$401.09
$256.73
$660.80
$476.70
$431.37
$281.57
$567.05
$392.80
$670.27
$496.02
$972.91
$765.72
$1,429.87
$1,147.27
$824.86
$627.17
$481.30
$324.04
$386.61
$248.03
$502.49
$337.07
$522.54
$366.28
$439.73
Limiting
Charge
$458.47
$288.16
$495.63
$326.88
$491.82
$318.00
$435.97
$271.91
$461.25
$295.24
$759.92
$548.21
$496.08
$323.81
$652.11
$451.72
$770.81
$570.42
$1,118.85
$880.58
$1,644.35
$1,319.36
$948.59
$721.25
$553.50
$372.65
$444.60
$285.23
$577.86
$387.63
$600.92
$421.22
$505.69
Charge**
Charge***
$453.88
$451.59
$285.27
$283.83
$490.67
$488.20
$323.61
$321.98
$486.90
$484.44
$314.81
$313.23
$431.61
$429.42
$269.19
$267.82
$456.64
$454.33
$292.28
$290.81
$752.32
$748.52
$542.72
$539.98
$491.12
$488.64
$320.56
$318.95
$645.59
$642.32
$447.20
$444.95
$763.11
$759.25
$564.72
$561.87
$1,107.66
$1,102.07
$871.77
$867.36
$1,627.91
$1,619.68
$1,306.17
$1,299.57
$939.10
$934.36
$714.04
$710.42
$547.96
$545.19
$368.92
$367.06
$440.15
$437.93
$282.38
$280.96
$572.09
$569.19
$383.76
$381.81
$594.91
$591.91
$417.01
$414.91
$500.63
$498.10
Arizona
EHR/eRx
Limiting
Charge**
$449.31
$282.39
$485.71
$320.34
$481.99
$311.64
$427.25
$266.47
$452.03
$289.34
$744.72
$537.25
$486.15
$317.33
$639.07
$442.68
$755.39
$559.02
$1,096.47
$862.97
$1,611.46
$1,292.97
$929.61
$706.82
$542.42
$365.19
$435.71
$279.53
$566.31
$379.88
$588.90
$412.79
$495.58
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$447.07
$442.57
$280.99
$278.16
$483.31
$478.42
$318.76
$315.54
$479.60
$474.75
$310.09
$306.97
$425.13
$420.84
$265.16
$262.46
$449.79
$445.25
$287.90
$285.00
$741.04
$733.55
$534.58
$529.18
$483.75
$478.86
$315.76
$312.57
$635.90
$629.48
$440.50
$436.05
$751.66
$744.06
$556.24
$550.63
$1,091.04
$1,080.02
$858.69
$850.02
$1,603.49
$1,587.29
$1,286.57
$1,273.58
$925.01
$915.66
$703.33
$696.22
$539.74
$534.28
$363.39
$359.72
$433.55
$429.18
$278.15
$275.33
$563.51
$557.81
$377.99
$374.19
$585.98
$580.07
$410.76
$406.61
$493.12
$488.15
Page 79 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
28286
28288
28288
28289
28289
28290
28290
28292
28292
28293
28293
28294
28294
28296
28296
28297
28297
28298
28298
28299
28299
28300
28302
28304
28304
28305
28306
28306
28307
28307
28308
28308
28309
1/2/2015
Modifier
Par Fee
$304.83
$620.03
$438.04
$753.33
$559.54
$608.60
$405.87
$811.83
$615.89
$1,073.60
$725.35
$786.65
$552.10
$733.16
$533.29
$832.90
$594.05
$739.56
$515.73
$922.38
$693.55
$666.49
$729.01
$850.97
$621.42
$668.00
$631.22
$412.40
$728.06
$480.28
$580.92
$384.27
$929.96
Nonpar Fee
$289.59
$589.03
$416.14
$715.66
$531.56
$578.17
$385.58
$771.24
$585.10
$1,019.92
$689.08
$747.32
$524.50
$696.50
$506.63
$791.26
$564.35
$702.58
$489.94
$876.26
$658.87
$633.17
$692.56
$808.42
$590.35
$634.60
$599.66
$391.78
$691.66
$456.27
$551.87
$365.06
$883.46
Limiting
Charge
$333.03
$677.38
$478.56
$823.01
$611.29
$664.90
$443.42
$886.93
$672.87
$1,172.91
$792.44
$859.42
$603.18
$800.98
$582.62
$909.95
$649.00
$807.97
$563.43
$1,007.70
$757.70
$728.15
$796.44
$929.68
$678.90
$729.79
$689.61
$450.55
$795.41
$524.71
$634.65
$419.82
$1,015.98
Charge**
Charge***
$329.69
$328.04
$670.61
$667.22
$473.78
$471.39
$814.78
$810.67
$605.18
$602.13
$658.25
$654.93
$438.98
$436.77
$878.06
$873.62
$666.14
$662.77
$1,161.18
$1,155.31
$784.52
$780.55
$850.83
$846.53
$597.15
$594.12
$792.97
$788.96
$576.79
$573.88
$900.85
$896.30
$642.52
$639.26
$799.88
$795.85
$557.80
$554.98
$997.63
$992.59
$750.12
$746.34
$720.87
$717.22
$788.47
$784.50
$920.39
$915.73
$672.12
$668.71
$722.49
$718.84
$682.71
$679.27
$446.04
$443.79
$787.45
$783.48
$519.47
$516.84
$628.30
$625.13
$415.62
$413.52
$1,005.82
$1,000.74
Arizona
EHR/eRx
Limiting
Charge**
$326.37
$663.84
$468.99
$806.55
$599.07
$651.60
$434.55
$869.19
$659.41
$1,149.45
$776.60
$842.23
$591.11
$784.96
$570.98
$891.74
$636.02
$791.81
$552.16
$987.54
$742.54
$713.59
$780.52
$911.09
$665.32
$715.20
$675.82
$441.53
$779.50
$514.21
$621.95
$411.42
$995.66
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$324.75
$321.47
$660.55
$653.88
$466.67
$461.96
$802.55
$794.45
$596.10
$590.09
$648.37
$641.83
$432.39
$428.03
$864.89
$856.15
$656.14
$649.52
$1,143.76
$1,132.21
$772.75
$764.95
$838.06
$829.59
$588.19
$582.25
$781.08
$773.18
$568.15
$562.41
$887.34
$878.37
$632.88
$626.47
$787.89
$779.93
$549.42
$543.88
$982.66
$972.73
$738.88
$731.40
$710.06
$702.88
$776.65
$768.81
$906.58
$897.43
$662.03
$655.34
$711.65
$704.47
$672.47
$665.68
$439.35
$434.91
$775.64
$767.81
$511.67
$506.49
$618.87
$612.63
$409.39
$405.25
$990.74
$980.72
Page 80 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
28310
28310
28312
28312
28313
28313
28315
28315
28320
28322
28322
28340
28340
28341
28341
28344
28344
28345
28345
28360
28400
28400
28405
28405
28406
28415
28420
28430
28430
28435
28435
28436
28445
1/2/2015
Modifier
Par Fee
$563.89
$366.17
$533.27
$330.90
$544.46
$366.40
$496.98
$333.22
$619.99
$810.25
$590.36
$595.53
$422.48
$690.47
$503.47
$568.34
$367.40
$537.92
$373.09
$837.59
$252.99
$231.18
$404.75
$367.21
$536.76
$1,128.62
$1,279.97
$241.24
$214.06
$328.55
$294.22
$457.78
$1,089.11
Nonpar Fee
$535.70
$347.86
$506.61
$314.36
$517.24
$348.08
$472.13
$316.56
$588.99
$769.74
$560.84
$565.75
$401.36
$655.95
$478.30
$539.92
$349.03
$511.02
$354.44
$795.71
$240.34
$219.62
$384.51
$348.85
$509.92
$1,072.19
$1,215.97
$229.18
$203.36
$312.12
$279.51
$434.89
$1,034.65
Limiting
Charge
$616.06
$400.04
$582.60
$361.51
$594.83
$400.29
$542.95
$364.04
$677.34
$885.20
$644.97
$650.61
$461.56
$754.34
$550.05
$620.91
$401.38
$587.67
$407.61
$915.07
$276.39
$252.56
$442.19
$401.18
$586.41
$1,233.02
$1,398.37
$263.56
$233.86
$358.94
$321.44
$500.12
$1,189.85
Charge**
Charge***
$609.89
$606.81
$396.04
$394.04
$576.77
$573.86
$357.90
$356.09
$588.88
$585.90
$396.29
$394.29
$537.52
$534.81
$360.40
$358.58
$670.57
$667.18
$876.35
$871.92
$638.51
$635.29
$644.10
$640.85
$456.95
$454.64
$746.80
$743.03
$544.55
$541.80
$614.70
$611.59
$397.37
$395.36
$581.80
$578.85
$403.54
$401.49
$905.91
$901.34
$273.63
$272.24
$250.03
$248.78
$437.76
$435.55
$397.16
$395.16
$580.54
$577.61
$1,220.69
$1,214.53
$1,384.38
$1,377.39
$260.92
$259.60
$231.53
$230.36
$355.35
$353.56
$318.22
$316.62
$495.12
$492.63
$1,177.95
$1,172.00
Arizona
EHR/eRx
Limiting
Charge**
$603.74
$392.04
$570.95
$354.28
$582.94
$392.29
$532.09
$356.76
$663.79
$867.50
$632.06
$637.61
$452.33
$739.25
$539.04
$608.49
$393.36
$575.92
$399.45
$896.77
$270.86
$247.51
$433.34
$393.15
$574.68
$1,208.36
$1,370.40
$258.29
$229.18
$351.76
$315.01
$490.12
$1,166.05
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$600.74
$594.69
$390.09
$386.16
$568.12
$562.38
$352.53
$348.97
$580.05
$574.20
$390.34
$386.40
$529.46
$524.11
$354.99
$351.42
$660.50
$653.83
$863.20
$854.48
$628.94
$622.59
$634.44
$628.04
$450.10
$445.54
$735.60
$728.17
$536.38
$530.96
$605.48
$599.36
$391.41
$387.46
$573.07
$567.28
$397.49
$393.46
$892.32
$883.32
$269.53
$266.80
$246.28
$243.80
$431.19
$426.85
$391.21
$387.25
$571.84
$566.05
$1,202.38
$1,190.24
$1,363.61
$1,349.85
$257.01
$254.41
$228.06
$225.75
$350.03
$346.48
$313.44
$310.28
$487.69
$482.77
$1,160.28
$1,148.56
Page 81 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
28446
28450
28450
28455
28455
28456
28465
28470
28470
28475
28475
28476
28485
28490
28490
28495
28495
28496
28496
28505
28505
28510
28510
28515
28515
28525
28525
28530
28530
28531
28531
28540
28540
1/2/2015
Modifier
Par Fee
$1,249.40
$219.69
$195.73
$294.02
$263.99
$325.55
$629.60
$223.22
$208.20
$261.17
$231.85
$358.08
$537.51
$148.79
$128.06
$183.66
$154.70
$454.66
$242.63
$692.95
$515.96
$126.67
$123.45
$166.23
$146.56
$573.95
$401.62
$117.86
$104.64
$352.46
$186.56
$196.66
$177.71
Nonpar Fee
$1,186.93
$208.71
$185.94
$279.32
$250.79
$309.27
$598.12
$212.06
$197.79
$248.11
$220.26
$340.18
$510.63
$141.35
$121.66
$174.48
$146.97
$431.93
$230.50
$658.30
$490.16
$120.34
$117.28
$157.92
$139.23
$545.25
$381.54
$111.97
$99.41
$334.84
$177.23
$186.83
$168.82
Limiting
Charge
$1,364.97
$240.02
$213.83
$321.22
$288.41
$355.66
$687.84
$243.87
$227.46
$285.33
$253.30
$391.21
$587.22
$162.55
$139.91
$200.65
$169.02
$496.72
$265.08
$757.05
$563.68
$138.39
$134.87
$181.61
$160.11
$627.04
$438.77
$128.77
$114.32
$385.07
$203.81
$214.85
$194.14
Charge**
Charge***
$1,351.32
$1,344.50
$237.61
$236.42
$211.69
$210.62
$318.01
$316.40
$285.52
$284.08
$352.11
$350.32
$680.96
$677.52
$241.43
$240.21
$225.18
$224.04
$282.47
$281.05
$250.77
$249.50
$387.30
$385.34
$581.35
$578.42
$160.93
$160.11
$138.51
$137.82
$198.65
$197.64
$167.33
$166.49
$491.75
$489.27
$262.43
$261.10
$749.48
$745.69
$558.05
$555.23
$137.01
$136.31
$133.53
$132.85
$179.79
$178.88
$158.52
$157.71
$620.77
$617.63
$434.38
$432.19
$127.48
$126.83
$113.18
$112.61
$381.21
$379.29
$201.78
$200.76
$212.70
$211.63
$192.20
$191.23
Arizona
EHR/eRx
Limiting
Charge**
$1,337.67
$235.22
$209.55
$314.79
$282.64
$348.54
$674.08
$238.99
$222.90
$279.62
$248.23
$383.39
$575.48
$159.30
$137.11
$196.64
$165.63
$486.78
$259.77
$741.90
$552.41
$135.62
$132.17
$177.97
$156.92
$614.50
$430.00
$126.19
$112.03
$377.36
$199.74
$210.55
$190.26
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$1,331.04
$1,317.60
$234.05
$231.69
$208.52
$206.41
$313.24
$310.06
$281.24
$278.39
$346.83
$343.31
$670.75
$663.98
$237.81
$235.41
$221.80
$219.56
$278.24
$275.43
$247.01
$244.50
$381.49
$377.64
$572.63
$566.85
$158.52
$156.91
$136.42
$135.06
$195.67
$193.69
$164.82
$163.15
$484.38
$479.48
$258.50
$255.88
$738.23
$730.77
$549.68
$544.12
$134.95
$133.58
$131.53
$130.19
$177.09
$175.31
$156.14
$154.56
$611.46
$605.28
$427.86
$423.55
$125.57
$124.29
$111.48
$110.35
$375.50
$371.70
$198.75
$196.74
$209.52
$207.39
$189.31
$187.40
Page 82 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
28545
28545
28546
28546
28555
28555
28570
28570
28575
28575
28576
28585
28585
28600
28600
28605
28605
28606
28615
28630
28630
28635
28635
28636
28636
28645
28645
28660
28660
28665
28665
28666
28675
1/2/2015
Modifier
Par Fee
$301.54
$266.50
$592.86
$346.16
$904.08
$683.83
$173.97
$150.02
$369.35
$333.60
$403.34
$875.40
$684.11
$221.16
$190.77
$333.77
$299.80
$401.36
$804.12
$159.57
$111.30
$175.44
$132.17
$358.57
$228.78
$672.47
$494.41
$119.03
$90.43
$158.14
$134.54
$195.30
$606.95
Nonpar Fee
$286.46
$253.18
$563.22
$328.85
$858.88
$649.64
$165.27
$142.52
$350.88
$316.92
$383.17
$831.63
$649.90
$210.10
$181.23
$317.08
$284.81
$381.29
$763.91
$151.59
$105.74
$166.67
$125.56
$340.64
$217.34
$638.85
$469.69
$113.08
$85.91
$150.23
$127.81
$185.54
$576.60
Limiting
Charge
$329.43
$291.16
$647.70
$378.18
$987.71
$747.09
$190.06
$163.90
$403.51
$364.46
$440.65
$956.37
$747.39
$241.62
$208.41
$364.64
$327.53
$438.48
$878.50
$174.33
$121.60
$191.67
$144.39
$391.74
$249.94
$734.68
$540.14
$130.04
$98.80
$172.76
$146.98
$213.37
$663.09
Charge**
Charge***
$326.14
$324.48
$288.25
$286.79
$641.23
$637.99
$374.39
$372.51
$977.83
$972.90
$739.61
$735.89
$188.16
$187.21
$162.25
$161.44
$399.48
$397.46
$360.81
$359.00
$436.24
$434.03
$946.81
$942.03
$739.91
$736.17
$239.20
$237.99
$206.33
$205.29
$361.00
$359.17
$324.25
$322.62
$434.10
$431.91
$869.71
$865.32
$172.58
$171.72
$120.38
$119.77
$189.75
$188.80
$142.95
$142.23
$387.81
$385.86
$247.45
$246.19
$727.33
$723.66
$534.74
$532.04
$128.74
$128.09
$97.81
$97.31
$171.04
$170.18
$145.51
$144.77
$211.23
$210.17
$656.45
$653.14
Arizona
EHR/eRx
Limiting
Charge**
$322.84
$285.34
$634.75
$370.61
$967.96
$732.15
$186.25
$160.62
$395.44
$357.17
$431.84
$937.25
$732.44
$236.79
$204.25
$357.35
$320.98
$429.71
$860.92
$170.84
$119.17
$187.84
$141.51
$383.90
$244.94
$719.98
$529.35
$127.44
$96.82
$169.31
$144.04
$209.10
$649.83
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$321.25
$318.00
$283.92
$281.06
$631.61
$625.23
$368.78
$365.06
$963.17
$953.43
$728.51
$721.17
$185.35
$183.46
$159.82
$158.21
$393.48
$389.51
$355.40
$351.81
$429.70
$425.36
$932.60
$923.20
$728.81
$721.45
$235.61
$233.23
$203.24
$201.19
$355.58
$351.99
$319.39
$316.16
$427.59
$423.27
$856.67
$848.01
$169.99
$168.28
$118.58
$117.39
$186.91
$185.02
$140.81
$139.38
$382.00
$378.14
$243.73
$241.27
$716.42
$709.18
$526.72
$521.41
$126.81
$125.53
$96.34
$95.37
$168.48
$166.77
$143.32
$141.88
$208.06
$205.97
$646.61
$640.08
Page 83 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
28675
28705
28715
28725
28730
28735
28737
28740
28740
28750
28750
28755
28755
28760
28760
28800
28805
28810
28820
28820
28825
28825
28890
28890
29000
29000
29010
29010
29015
29015
29035
29035
29040
1/2/2015
Modifier
Par Fee
$424.95
$1,283.06
$957.99
$793.53
$746.18
$798.03
$707.33
$868.93
$636.53
$837.42
$605.37
$522.55
$336.98
$812.87
$591.55
$557.23
$749.37
$441.61
$581.79
$405.52
$555.68
$380.12
$332.23
$230.33
$307.56
$188.85
$224.17
$143.01
$280.62
$179.08
$227.20
$135.67
$224.24
Nonpar Fee
$403.70
$1,218.91
$910.09
$753.85
$708.87
$758.13
$671.96
$825.48
$604.70
$795.55
$575.10
$496.42
$320.13
$772.23
$561.97
$529.37
$711.90
$419.53
$552.70
$385.24
$527.90
$361.11
$315.62
$218.81
$292.18
$179.41
$212.96
$135.86
$266.59
$170.13
$215.84
$128.89
$213.03
Limiting
Charge
$464.26
$1,401.75
$1,046.60
$866.93
$815.20
$871.85
$772.75
$949.30
$695.41
$914.88
$661.37
$570.88
$368.15
$888.06
$646.27
$608.78
$818.69
$482.46
$635.61
$443.03
$607.09
$415.28
$362.96
$251.63
$336.01
$206.32
$244.90
$156.24
$306.58
$195.65
$248.22
$148.22
$244.98
Charge**
Charge***
$459.61
$457.29
$1,387.73
$1,380.72
$1,036.14
$1,030.91
$858.26
$853.92
$807.05
$802.98
$863.13
$858.77
$765.03
$761.16
$939.81
$935.07
$688.45
$684.97
$905.73
$901.16
$654.75
$651.44
$565.18
$562.32
$364.47
$362.63
$879.19
$874.75
$639.80
$636.57
$602.69
$599.64
$810.50
$806.40
$477.63
$475.23
$629.25
$626.07
$438.60
$436.38
$601.01
$597.98
$411.13
$409.04
$359.33
$357.52
$249.11
$247.86
$332.65
$330.97
$204.26
$203.23
$242.45
$241.24
$154.68
$153.89
$303.51
$301.98
$193.69
$192.72
$245.73
$244.49
$146.74
$146.00
$242.54
$241.30
Arizona
EHR/eRx
Limiting
Charge**
$454.97
$1,373.71
$1,025.67
$849.59
$798.89
$854.42
$757.30
$930.32
$681.50
$896.59
$648.14
$559.46
$360.79
$870.31
$633.34
$596.60
$802.31
$472.81
$622.90
$434.17
$594.94
$406.97
$355.71
$246.59
$329.29
$202.19
$240.01
$153.11
$300.45
$191.74
$243.25
$145.26
$240.09
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$452.72
$448.16
$1,366.91
$1,353.10
$1,020.60
$1,010.29
$845.39
$836.84
$794.94
$786.91
$850.18
$841.60
$753.55
$745.94
$925.72
$916.37
$678.12
$671.28
$892.15
$883.14
$644.93
$638.42
$556.70
$551.07
$359.01
$355.37
$866.00
$857.26
$630.20
$623.84
$593.65
$587.65
$798.34
$790.28
$470.47
$465.72
$619.80
$613.56
$432.02
$427.66
$592.00
$586.02
$404.96
$400.87
$353.94
$350.37
$245.38
$242.89
$327.66
$324.35
$201.20
$199.16
$238.82
$236.41
$152.35
$150.81
$298.95
$295.94
$190.79
$188.86
$242.04
$239.60
$144.54
$143.08
$238.90
$236.49
Page 84 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
29040
29044
29044
29046
29046
29049
29049
29055
29055
29058
29058
29065
29065
29075
29075
29085
29085
29086
29086
29105
29105
29125
29125
29126
29126
29130
29130
29131
29131
29200
29200
29240
29240
1/2/2015
Modifier
Par Fee
$144.15
$264.32
$160.63
$241.67
$156.57
$74.29
$57.85
$226.49
$141.75
$126.77
$97.09
$97.98
$69.73
$88.41
$63.74
$97.31
$69.06
$78.75
$51.22
$89.84
$60.88
$65.17
$39.78
$78.62
$49.66
$41.21
$28.70
$51.89
$33.66
$30.30
$18.50
$29.23
$18.86
Nonpar Fee
$136.94
$251.10
$152.60
$229.59
$148.74
$70.58
$54.96
$215.17
$134.66
$120.43
$92.24
$93.08
$66.24
$83.99
$60.55
$92.44
$65.61
$74.81
$48.66
$85.35
$57.84
$61.91
$37.79
$74.69
$47.18
$39.15
$27.27
$49.30
$31.98
$28.79
$17.58
$27.77
$17.92
Limiting
Charge
$157.48
$288.77
$175.49
$264.03
$171.05
$81.17
$63.20
$247.45
$154.86
$138.49
$106.08
$107.04
$76.18
$96.59
$69.63
$106.31
$75.45
$86.03
$55.96
$98.15
$66.52
$71.20
$43.46
$85.89
$54.26
$45.02
$31.36
$56.70
$36.78
$33.11
$20.22
$31.94
$20.61
Charge**
Charge***
$155.91
$155.12
$285.88
$284.43
$173.73
$172.86
$261.38
$260.07
$169.34
$168.49
$80.35
$79.95
$62.57
$62.26
$244.97
$243.73
$153.31
$152.54
$137.11
$136.41
$105.02
$104.49
$105.97
$105.43
$75.42
$75.04
$95.62
$95.14
$68.93
$68.59
$105.25
$104.71
$74.69
$74.32
$85.17
$84.74
$55.40
$55.12
$97.18
$96.68
$65.85
$65.52
$70.48
$70.13
$43.02
$42.80
$85.03
$84.61
$53.72
$53.44
$44.57
$44.34
$31.05
$30.89
$56.13
$55.84
$36.41
$36.23
$32.78
$32.61
$20.01
$19.92
$31.61
$31.45
$20.40
$20.30
Arizona
EHR/eRx
Limiting
Charge**
$154.33
$282.99
$171.98
$258.75
$167.64
$79.55
$61.94
$242.50
$151.77
$135.72
$103.96
$104.90
$74.66
$94.66
$68.24
$104.18
$73.95
$84.31
$54.84
$96.19
$65.18
$69.77
$42.58
$84.18
$53.18
$44.13
$30.73
$55.56
$36.04
$32.44
$19.81
$31.29
$20.19
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$153.57
$152.02
$281.59
$278.75
$171.12
$169.41
$257.46
$254.87
$166.80
$165.12
$79.14
$78.35
$61.63
$61.01
$241.29
$238.87
$151.01
$149.49
$135.06
$133.69
$103.44
$102.40
$104.39
$103.33
$74.29
$73.54
$94.19
$93.24
$67.90
$67.22
$103.67
$102.61
$73.58
$72.84
$83.89
$83.04
$54.57
$54.02
$95.71
$94.75
$64.86
$64.20
$69.43
$68.72
$42.38
$41.94
$83.75
$82.92
$52.91
$52.38
$43.91
$43.46
$30.59
$30.27
$55.29
$54.73
$35.87
$35.50
$32.28
$31.96
$19.71
$19.52
$31.14
$30.82
$20.09
$19.90
Page 85 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
29260
29260
29280
29280
29305
29305
29325
29325
29345
29345
29355
29355
29358
29358
29365
29365
29405
29405
29425
29425
29435
29435
29440
29440
29445
29445
29450
29450
29505
29505
29515
29515
29520
1/2/2015
Modifier
Par Fee
$29.19
$19.53
$29.54
$19.89
$251.97
$163.30
$278.88
$183.05
$138.97
$103.22
$143.22
$108.54
$163.87
$106.30
$124.89
$89.13
$83.14
$61.33
$79.65
$57.84
$120.28
$85.25
$44.52
$29.50
$138.12
$107.01
$146.47
$115.01
$84.66
$50.69
$72.90
$50.38
$31.38
Nonpar Fee
$27.73
$18.55
$28.06
$18.90
$239.37
$155.14
$264.94
$173.90
$132.02
$98.06
$136.06
$103.11
$155.68
$100.99
$118.65
$84.67
$78.98
$58.26
$75.67
$54.95
$114.27
$80.99
$42.29
$28.03
$131.21
$101.66
$139.15
$109.26
$80.43
$48.16
$69.26
$47.86
$29.81
Limiting
Charge
$31.89
$21.33
$32.27
$21.74
$275.28
$178.41
$304.68
$199.99
$151.82
$112.77
$156.47
$118.58
$179.03
$116.14
$136.45
$97.37
$90.83
$67.00
$87.02
$63.19
$131.41
$93.14
$48.63
$32.23
$150.89
$116.91
$160.02
$125.65
$92.49
$55.38
$79.65
$55.04
$34.28
Charge**
Charge***
$31.57
$31.41
$21.11
$21.01
$31.95
$31.79
$21.52
$21.41
$272.53
$271.15
$176.63
$175.73
$301.63
$300.12
$197.98
$196.98
$150.31
$149.55
$111.64
$111.08
$154.91
$154.12
$117.39
$116.79
$177.24
$176.34
$114.98
$114.40
$135.08
$134.40
$96.39
$95.91
$89.92
$89.47
$66.33
$66.00
$86.15
$85.71
$62.56
$62.25
$130.10
$129.44
$92.21
$91.75
$48.15
$47.91
$31.91
$31.75
$149.39
$148.63
$115.74
$115.16
$158.42
$157.62
$124.40
$123.76
$91.57
$91.10
$54.83
$54.56
$78.86
$78.45
$54.49
$54.21
$33.94
$33.76
Arizona
EHR/eRx
Limiting
Charge**
$31.26
$20.91
$31.63
$21.30
$269.77
$174.85
$298.59
$195.98
$148.79
$110.52
$153.34
$116.21
$175.46
$113.82
$133.72
$95.43
$89.01
$65.65
$85.28
$61.93
$128.78
$91.28
$47.66
$31.59
$147.88
$114.57
$156.83
$123.13
$90.64
$54.28
$78.05
$53.94
$33.59
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$31.10
$30.79
$20.79
$20.60
$31.46
$31.15
$21.19
$20.98
$268.44
$265.72
$173.98
$172.22
$297.11
$294.11
$195.02
$193.04
$148.05
$146.56
$109.96
$108.86
$152.58
$151.04
$115.63
$114.46
$174.58
$172.82
$113.25
$112.11
$133.06
$131.72
$94.94
$94.00
$88.57
$87.68
$65.33
$64.66
$84.86
$84.01
$61.62
$61.00
$128.14
$126.85
$90.83
$89.91
$47.43
$46.94
$31.43
$31.12
$147.14
$145.66
$114.00
$112.86
$156.04
$154.47
$122.53
$121.28
$90.21
$89.29
$54.00
$53.46
$77.67
$76.88
$53.67
$53.13
$33.43
$33.09
Page 86 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
29520
29530
29530
29540
29540
29550
29550
29580
29580
29581
29581
29582
29582
29583
29583
29584
29584
29700
29700
29705
29705
29710
29710
29720
29720
29730
29730
29740
29740
29750
29750
29800
29804
1/2/2015
Modifier
Par Fee
$18.86
$28.52
$18.50
$26.01
$18.15
$19.22
$11.71
$53.01
$35.85
$63.15
$13.45
$71.74
$16.67
$44.92
$12.02
$71.74
$16.67
$62.17
$33.93
$68.39
$48.37
$126.37
$85.97
$86.94
$45.46
$64.95
$45.28
$101.20
$71.88
$97.00
$74.47
$528.40
$654.55
Nonpar Fee
$17.92
$27.09
$17.58
$24.71
$17.24
$18.26
$11.12
$50.36
$34.06
$59.99
$12.78
$68.15
$15.84
$42.67
$11.42
$68.15
$15.84
$59.06
$32.23
$64.97
$45.95
$120.05
$81.67
$82.59
$43.19
$61.70
$43.02
$96.14
$68.29
$92.15
$70.75
$501.98
$621.82
Limiting
Charge
$20.61
$31.15
$20.22
$28.42
$19.83
$21.00
$12.79
$57.91
$39.17
$68.99
$14.70
$78.37
$18.22
$49.07
$13.13
$78.37
$18.22
$67.92
$37.06
$74.72
$52.84
$138.06
$93.92
$94.98
$49.67
$70.96
$49.47
$110.56
$78.53
$105.97
$81.36
$577.28
$715.09
Charge**
Charge***
$20.40
$20.30
$30.84
$30.68
$20.01
$19.92
$28.13
$27.99
$19.63
$19.53
$20.79
$20.69
$12.66
$12.59
$57.34
$57.04
$38.78
$38.58
$68.30
$67.95
$14.55
$14.48
$77.59
$77.20
$18.03
$17.94
$48.58
$48.33
$13.01
$12.94
$77.59
$77.20
$18.03
$17.94
$67.24
$66.90
$36.70
$36.51
$73.97
$73.60
$52.31
$52.05
$136.68
$135.99
$92.98
$92.51
$94.02
$93.55
$49.17
$48.92
$70.24
$69.89
$48.98
$48.73
$109.46
$108.91
$77.75
$77.36
$104.91
$104.39
$80.55
$80.14
$571.50
$568.62
$707.94
$704.36
Arizona
EHR/eRx
Limiting
Charge**
$20.19
$30.53
$19.81
$27.85
$19.44
$20.57
$12.54
$56.75
$38.39
$67.61
$14.40
$76.81
$17.85
$48.09
$12.87
$76.81
$17.85
$66.56
$36.33
$73.22
$51.78
$135.30
$92.05
$93.08
$48.68
$69.54
$48.48
$108.35
$76.96
$103.86
$79.74
$565.73
$700.79
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$20.09
$19.90
$30.38
$30.07
$19.71
$19.52
$27.70
$27.44
$19.33
$19.15
$20.48
$20.26
$12.47
$12.35
$56.48
$55.90
$38.19
$37.81
$67.28
$66.60
$14.33
$14.18
$76.43
$75.66
$17.76
$17.58
$47.85
$47.37
$12.81
$12.67
$76.43
$75.66
$17.76
$17.58
$66.23
$65.56
$36.14
$35.79
$72.86
$72.12
$51.53
$51.00
$134.63
$133.27
$91.59
$90.67
$92.61
$91.69
$48.44
$47.96
$69.18
$68.49
$48.24
$47.76
$107.81
$106.73
$76.59
$75.81
$103.34
$102.30
$79.34
$78.55
$562.94
$557.24
$697.33
$690.28
Page 87 of 323
Notes
Procedure
Code
29805
29806
29807
29819
29820
29821
29822
29823
29824
29825
29826
29827
29828
29830
29834
29835
29836
29837
29838
29840
29843
29844
29845
29846
29847
29848
29850
29851
29855
29856
29860
29861
29862
1/2/2015
Modifier
Par Fee
$480.77
$1,081.40
$1,056.01
$597.53
$544.01
$593.49
$576.55
$628.35
$678.28
$587.85
$179.75
$1,073.45
$925.04
$465.12
$493.71
$512.37
$587.83
$533.19
$596.22
$460.65
$493.10
$501.98
$584.95
$527.83
$553.95
$518.48
$636.33
$951.32
$799.94
$1,016.90
$680.37
$728.98
$821.02
Nonpar Fee
$456.73
$1,027.33
$1,003.21
$567.65
$516.81
$563.82
$547.72
$596.93
$644.37
$558.46
$170.76
$1,019.78
$878.79
$441.86
$469.02
$486.75
$558.44
$506.53
$566.41
$437.62
$468.45
$476.88
$555.70
$501.44
$526.25
$492.56
$604.51
$903.75
$759.94
$966.06
$646.35
$692.53
$779.97
Limiting
Charge
$525.24
$1,181.43
$1,153.69
$652.80
$594.33
$648.39
$629.88
$686.47
$741.03
$642.23
$196.37
$1,172.75
$1,010.61
$508.14
$539.37
$559.76
$642.21
$582.51
$651.37
$503.26
$538.72
$548.41
$639.06
$576.66
$605.19
$566.44
$695.19
$1,039.31
$873.93
$1,110.97
$743.30
$796.41
$896.97
Charge**
Charge***
$519.98
$517.36
$1,169.62
$1,163.71
$1,142.16
$1,136.38
$646.27
$643.01
$588.39
$585.42
$641.91
$638.66
$623.58
$620.43
$679.60
$676.18
$733.62
$729.91
$635.81
$632.59
$194.41
$193.43
$1,161.02
$1,155.15
$1,000.50
$995.45
$503.06
$500.51
$533.98
$531.28
$554.16
$551.37
$635.79
$632.57
$576.68
$573.77
$644.86
$641.60
$498.23
$495.72
$533.34
$530.63
$542.93
$540.19
$632.66
$629.46
$570.89
$568.01
$599.14
$596.11
$560.77
$557.95
$688.23
$684.76
$1,028.92
$1,023.72
$865.19
$860.82
$1,099.86
$1,094.31
$735.87
$732.15
$788.44
$784.46
$888.00
$883.51
Arizona
EHR/eRx
Limiting
Charge**
$514.74
$1,157.80
$1,130.62
$639.75
$582.44
$635.42
$617.29
$672.74
$726.20
$629.38
$192.44
$1,149.29
$990.39
$497.97
$528.59
$548.57
$629.36
$570.86
$638.34
$493.20
$527.94
$537.44
$626.28
$565.12
$593.09
$555.12
$681.28
$1,018.53
$856.45
$1,088.75
$728.43
$780.48
$879.03
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$512.19
$507.02
$1,152.07
$1,140.43
$1,125.02
$1,113.66
$636.57
$630.15
$579.57
$573.70
$632.28
$625.89
$614.23
$608.03
$669.42
$662.65
$722.61
$715.31
$626.28
$619.94
$191.49
$189.55
$1,143.61
$1,132.05
$985.49
$975.53
$495.51
$490.50
$525.98
$520.66
$545.85
$540.34
$626.26
$619.92
$568.03
$562.29
$635.19
$628.76
$490.75
$485.81
$525.33
$520.02
$534.78
$529.38
$623.17
$616.88
$562.33
$556.65
$590.16
$584.19
$552.37
$546.79
$677.90
$671.06
$1,013.48
$1,003.25
$852.21
$843.61
$1,083.36
$1,072.42
$724.83
$717.51
$776.62
$768.78
$874.68
$865.84
Page 88 of 323
Notes
#
#
Procedure
Code
29863
29866
29867
29868
29870
29870
29871
29873
29874
29875
29876
29877
29879
29880
29881
29882
29883
29884
29885
29886
29887
29888
29889
29891
29892
29893
29893
29894
29895
29897
29898
29899
29900
1/2/2015
Modifier
Par Fee
$818.87
$1,071.21
$1,306.31
$1,710.57
$595.26
$420.06
$523.82
$534.54
$547.51
$504.50
$670.85
$633.78
$675.40
$573.12
$551.35
$713.85
$859.67
$625.41
$767.90
$649.70
$760.60
$1,003.35
$1,248.95
$693.40
$640.24
$628.56
$437.99
$511.55
$493.36
$517.41
$577.89
$1,065.52
$427.65
Nonpar Fee
$777.93
$1,017.65
$1,240.99
$1,625.04
$565.50
$399.06
$497.63
$507.81
$520.13
$479.28
$637.31
$602.09
$641.63
$544.46
$523.78
$678.16
$816.69
$594.14
$729.51
$617.22
$722.57
$953.18
$1,186.50
$658.73
$608.23
$597.13
$416.09
$485.97
$468.69
$491.54
$549.00
$1,012.24
$406.27
Limiting
Charge
$894.62
$1,170.30
$1,427.14
$1,868.80
$650.33
$458.92
$572.27
$583.98
$598.15
$551.17
$732.91
$692.40
$737.87
$626.13
$602.35
$779.88
$939.19
$683.26
$838.94
$709.80
$830.96
$1,096.16
$1,364.48
$757.54
$699.46
$686.70
$478.50
$558.87
$538.99
$565.27
$631.35
$1,164.08
$467.21
Charge**
Charge***
$885.67
$881.20
$1,158.59
$1,152.75
$1,412.87
$1,405.74
$1,850.11
$1,840.76
$643.83
$640.57
$454.33
$452.03
$566.55
$563.70
$578.14
$575.22
$592.17
$589.18
$545.66
$542.90
$725.58
$721.91
$685.48
$682.02
$730.49
$726.81
$619.87
$616.73
$596.32
$593.31
$772.09
$768.19
$929.80
$925.11
$676.43
$673.01
$830.54
$826.36
$702.71
$699.15
$822.64
$818.49
$1,085.20
$1,079.71
$1,350.84
$1,344.01
$749.96
$746.18
$692.47
$688.98
$679.83
$676.40
$473.72
$471.33
$553.28
$550.48
$533.60
$530.91
$559.61
$556.80
$625.04
$621.89
$1,152.44
$1,146.62
$462.54
$460.21
Arizona
EHR/eRx
Limiting
Charge**
$876.73
$1,146.90
$1,398.60
$1,831.42
$637.32
$449.74
$560.83
$572.30
$586.19
$540.14
$718.24
$678.56
$723.12
$613.61
$590.30
$764.29
$920.41
$669.60
$822.16
$695.61
$814.34
$1,074.24
$1,337.19
$742.39
$685.48
$672.97
$468.94
$547.69
$528.22
$553.97
$618.72
$1,140.80
$457.86
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$872.39
$863.57
$1,141.21
$1,129.69
$1,391.67
$1,377.62
$1,822.36
$1,803.95
$634.17
$627.76
$447.51
$442.99
$558.05
$552.41
$569.47
$563.72
$583.29
$577.39
$537.48
$532.04
$714.70
$707.47
$675.20
$668.38
$719.53
$712.28
$610.57
$604.41
$587.37
$581.44
$760.51
$752.82
$915.85
$906.60
$666.29
$659.56
$818.09
$809.83
$692.16
$685.18
$810.30
$802.13
$1,068.93
$1,058.13
$1,330.57
$1,317.13
$738.71
$731.26
$682.09
$675.20
$669.63
$662.87
$466.61
$461.90
$544.97
$539.48
$525.60
$520.29
$551.22
$545.65
$615.66
$609.44
$1,135.15
$1,123.69
$455.61
$451.00
Page 89 of 323
Notes
#
#
#
#
#
#
#
#
Procedure
Code
29901
29902
29904
29905
29906
29907
29914
29915
29916
30000
30000
30020
30020
30100
30100
30110
30110
30115
30117
30117
30118
30120
30120
30124
30125
30130
30140
30150
30160
30200
30200
30210
30210
1/2/2015
Modifier
Par Fee
$534.70
$494.11
$651.31
$665.62
$720.51
$894.09
$1,010.15
$1,029.02
$1,031.88
$233.58
$120.24
$236.44
$121.31
$143.83
$70.54
$234.12
$132.94
$437.95
$891.40
$345.42
$775.85
$525.21
$442.25
$288.62
$615.28
$386.14
$446.79
$777.95
$782.60
$115.36
$60.66
$152.64
$101.15
Nonpar Fee
$507.97
$469.40
$618.74
$632.34
$684.48
$849.39
$959.64
$977.57
$980.29
$221.90
$114.23
$224.62
$115.24
$136.64
$67.01
$222.41
$126.29
$416.05
$846.83
$328.15
$737.06
$498.95
$420.14
$274.19
$584.52
$366.83
$424.45
$739.05
$743.47
$109.59
$57.63
$145.01
$96.09
Limiting
Charge
$584.17
$539.81
$711.55
$727.19
$787.15
$976.80
$1,103.59
$1,124.21
$1,127.33
$255.19
$131.36
$258.31
$132.53
$157.14
$77.06
$255.77
$145.23
$478.46
$973.85
$377.37
$847.62
$573.79
$483.16
$315.32
$672.20
$421.85
$488.12
$849.91
$854.99
$126.03
$66.27
$166.76
$110.50
Charge**
Charge***
$578.32
$575.40
$534.42
$531.71
$704.43
$700.88
$719.92
$716.28
$779.29
$775.34
$967.04
$962.15
$1,092.55
$1,087.04
$1,112.96
$1,107.35
$1,116.06
$1,110.43
$252.63
$251.36
$130.05
$129.40
$255.73
$254.44
$131.20
$130.54
$155.56
$154.78
$76.29
$75.90
$253.22
$251.93
$143.78
$143.06
$473.67
$471.28
$964.11
$959.25
$373.60
$371.71
$839.14
$834.90
$568.05
$565.19
$478.33
$475.92
$312.17
$310.59
$665.47
$662.11
$417.63
$415.53
$483.24
$480.79
$841.41
$837.15
$846.45
$842.17
$124.76
$124.14
$65.61
$65.29
$165.09
$164.25
$109.40
$108.85
Arizona
EHR/eRx
Limiting
Charge**
$572.48
$529.01
$697.33
$712.64
$771.41
$957.26
$1,081.52
$1,101.72
$1,104.78
$250.08
$128.74
$253.15
$129.88
$154.00
$75.52
$250.65
$142.32
$468.89
$954.37
$369.83
$830.67
$562.32
$473.50
$309.02
$658.75
$413.41
$478.35
$832.91
$837.89
$123.51
$64.95
$163.43
$108.30
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$569.65
$563.89
$526.40
$521.08
$693.86
$686.86
$709.12
$701.95
$767.60
$759.84
$952.53
$942.90
$1,076.16
$1,065.29
$1,096.26
$1,085.20
$1,099.32
$1,088.21
$248.84
$246.33
$128.10
$126.81
$251.88
$249.35
$129.24
$127.94
$153.23
$151.69
$75.14
$74.38
$249.42
$246.89
$141.62
$140.19
$466.57
$461.85
$949.65
$940.06
$368.00
$364.29
$826.55
$818.21
$559.53
$553.89
$471.16
$466.39
$307.49
$304.38
$655.49
$648.88
$411.37
$407.22
$476.00
$471.18
$828.79
$820.42
$833.75
$825.32
$122.89
$121.66
$64.62
$63.97
$162.62
$160.98
$107.76
$106.67
Page 90 of 323
Notes
#
#
#
#
#
#
#
#
Procedure
Code
30220
30220
30300
30300
30310
30320
30400
30410
30420
30430
30435
30450
30460
30462
30465
30520
30540
30545
30560
30560
30580
30580
30600
30600
30620
30630
30801
30801
30802
30802
30901
30901
30903
1/2/2015
Modifier
Par Fee
$307.19
$126.99
$234.29
$128.46
$207.85
$458.20
$1,018.41
$1,194.85
$1,389.70
$876.40
$1,262.07
$1,512.99
$822.62
$1,429.49
$992.59
$631.19
$696.05
$868.14
$273.05
$139.68
$664.00
$519.91
$578.53
$433.37
$632.52
$633.79
$232.42
$139.10
$295.04
$193.50
$96.55
$57.58
$208.87
Nonpar Fee
$291.83
$120.64
$222.58
$122.04
$197.46
$435.29
$967.49
$1,135.11
$1,320.22
$832.58
$1,198.97
$1,437.34
$781.49
$1,358.02
$942.96
$599.63
$661.25
$824.73
$259.40
$132.70
$630.80
$493.91
$549.60
$411.70
$600.89
$602.10
$220.80
$132.15
$280.29
$183.83
$91.72
$54.70
$198.43
Limiting
Charge
$335.60
$138.74
$255.97
$140.35
$227.08
$500.58
$1,112.61
$1,305.38
$1,518.25
$957.47
$1,378.82
$1,652.94
$898.71
$1,561.72
$1,084.40
$689.57
$760.44
$948.44
$298.31
$152.61
$725.42
$568.00
$632.04
$473.46
$691.02
$692.42
$253.92
$151.97
$322.33
$211.40
$105.48
$62.91
$228.19
Charge**
Charge***
$332.25
$330.57
$137.34
$136.65
$253.40
$252.13
$138.94
$138.24
$224.81
$223.68
$495.58
$493.07
$1,101.49
$1,095.93
$1,292.32
$1,285.79
$1,503.07
$1,495.48
$947.89
$943.10
$1,365.03
$1,358.14
$1,636.42
$1,628.15
$889.73
$885.24
$1,546.11
$1,538.30
$1,073.56
$1,068.14
$682.67
$679.24
$752.84
$749.03
$938.95
$934.21
$295.33
$293.84
$151.08
$150.32
$718.16
$714.54
$562.32
$559.48
$625.72
$622.56
$468.72
$466.35
$684.11
$680.66
$685.49
$682.03
$251.38
$250.11
$150.45
$149.70
$319.11
$317.50
$209.29
$208.23
$104.42
$103.89
$62.27
$61.96
$225.92
$224.77
Arizona
EHR/eRx
Limiting
Charge**
$328.89
$135.96
$250.85
$137.54
$222.54
$490.57
$1,090.36
$1,279.27
$1,487.89
$938.32
$1,351.24
$1,619.88
$880.74
$1,530.49
$1,062.72
$675.79
$745.23
$929.48
$292.34
$149.56
$710.91
$556.63
$619.40
$463.99
$677.20
$678.57
$248.84
$148.94
$315.88
$207.17
$103.37
$61.65
$223.63
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$327.27
$323.96
$135.29
$133.93
$249.60
$247.09
$136.86
$135.48
$221.44
$219.20
$488.15
$483.21
$1,084.97
$1,074.01
$1,272.94
$1,260.08
$1,480.52
$1,465.57
$933.67
$924.24
$1,344.56
$1,330.98
$1,611.87
$1,595.58
$876.38
$867.53
$1,522.91
$1,507.54
$1,057.46
$1,046.78
$672.44
$665.65
$741.54
$734.06
$924.86
$915.54
$290.90
$287.96
$148.81
$147.32
$707.39
$700.25
$553.89
$548.29
$616.33
$610.11
$461.69
$457.03
$673.85
$667.05
$675.21
$668.39
$247.61
$245.10
$148.20
$146.71
$314.33
$311.14
$206.15
$204.07
$102.86
$101.82
$61.34
$60.73
$222.53
$220.27
Page 91 of 323
Notes
#
#
#
#
#
#
Procedure
Code
30903
30905
30905
30906
30906
30915
30920
30930
31000
31000
31002
31020
31020
31030
31030
31032
31040
31050
31051
31070
31075
31080
31081
31084
31085
31086
31087
31090
31200
31201
31205
31225
31230
1/2/2015
Modifier
Par Fee
$80.51
$261.12
$101.65
$284.50
$133.26
$582.97
$844.82
$125.06
$186.61
$107.95
$195.86
$494.61
$366.25
$703.50
$537.59
$581.98
$777.86
$490.66
$652.87
$444.48
$789.83
$1,042.25
$1,533.24
$1,165.63
$1,490.87
$1,133.44
$1,093.98
$1,035.80
$576.53
$749.28
$906.18
$1,900.74
$2,102.88
Nonpar Fee
$76.48
$248.06
$96.57
$270.28
$126.60
$553.82
$802.58
$118.81
$177.28
$102.55
$186.07
$469.88
$347.94
$668.33
$510.71
$552.88
$738.97
$466.13
$620.23
$422.26
$750.34
$990.14
$1,456.58
$1,107.35
$1,416.33
$1,076.77
$1,039.28
$984.01
$547.70
$711.82
$860.87
$1,805.70
$1,997.74
Limiting
Charge
$87.95
$285.27
$111.06
$310.82
$145.59
$636.89
$922.97
$136.63
$203.87
$117.93
$213.98
$540.36
$400.13
$768.58
$587.32
$635.81
$849.82
$536.05
$713.26
$485.60
$862.89
$1,138.66
$1,675.07
$1,273.45
$1,628.78
$1,238.29
$1,195.17
$1,131.61
$629.86
$818.59
$990.00
$2,076.56
$2,297.40
Charge**
Charge***
$87.08
$86.63
$282.42
$280.99
$109.94
$109.39
$307.72
$306.16
$144.13
$143.41
$630.52
$627.34
$913.73
$909.12
$135.26
$134.58
$201.84
$200.81
$116.75
$116.16
$211.84
$210.77
$534.96
$532.25
$396.13
$394.13
$760.90
$757.06
$581.44
$578.51
$629.45
$626.28
$841.32
$837.07
$530.69
$528.01
$706.13
$702.57
$480.75
$478.32
$854.27
$849.94
$1,127.28
$1,121.58
$1,658.31
$1,649.94
$1,260.72
$1,254.35
$1,612.50
$1,604.35
$1,225.90
$1,219.71
$1,183.22
$1,177.24
$1,120.30
$1,114.64
$623.55
$620.40
$810.41
$806.31
$980.10
$975.15
$2,055.79
$2,045.40
$2,274.42
$2,262.94
Arizona
EHR/eRx
Limiting
Charge**
$86.19
$279.57
$108.84
$304.60
$142.68
$624.15
$904.51
$133.89
$199.79
$115.58
$209.70
$529.55
$392.13
$753.20
$575.58
$623.09
$832.82
$525.33
$699.00
$475.88
$845.63
$1,115.89
$1,641.57
$1,247.98
$1,596.20
$1,213.51
$1,171.26
$1,108.98
$617.26
$802.22
$970.20
$2,035.03
$2,251.46
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$85.77
$84.90
$278.19
$275.37
$108.30
$107.20
$303.11
$300.04
$141.97
$140.54
$621.07
$614.79
$900.02
$890.94
$133.24
$131.88
$198.81
$196.79
$115.00
$113.84
$208.67
$206.55
$526.93
$521.61
$390.18
$386.25
$749.49
$741.91
$572.72
$566.94
$620.01
$613.74
$828.70
$820.33
$522.73
$517.45
$695.54
$688.52
$473.54
$468.74
$841.46
$832.95
$1,110.37
$1,099.15
$1,633.44
$1,616.95
$1,241.82
$1,229.26
$1,588.31
$1,572.26
$1,207.51
$1,195.31
$1,165.48
$1,153.69
$1,103.49
$1,092.35
$614.20
$608.01
$798.25
$790.19
$965.40
$955.65
$2,024.95
$2,004.51
$2,240.30
$2,217.68
Page 92 of 323
Notes
#
#
#
#
#
#
#
#
Procedure
Code
31231
31231
31233
31233
31235
31235
31237
31237
31238
31238
31239
31240
31254
31255
31256
31267
31276
31287
31288
31290
31291
31292
31293
31294
31295
31295
31296
31296
31297
31297
31300
31320
31360
1/2/2015
Modifier
Par Fee
$212.75
$66.52
$266.40
$139.47
$303.36
$164.99
$261.88
$164.27
$261.40
$172.37
$623.54
$163.87
$278.40
$407.72
$202.05
$323.99
$513.80
$236.74
$274.47
$1,178.47
$1,254.98
$1,015.60
$1,101.74
$1,261.19
$2,085.24
$170.58
$2,114.21
$203.48
$2,076.39
$166.73
$1,282.20
$665.99
$2,111.54
Nonpar Fee
$202.11
$63.19
$253.08
$132.50
$288.19
$156.74
$248.79
$156.06
$248.33
$163.75
$592.36
$155.68
$264.48
$387.33
$191.95
$307.79
$488.11
$224.90
$260.75
$1,119.55
$1,192.23
$964.82
$1,046.65
$1,198.13
$1,980.98
$162.05
$2,008.50
$193.31
$1,972.57
$158.39
$1,218.09
$632.69
$2,005.96
Limiting
Charge
$232.43
$72.67
$291.04
$152.38
$331.42
$180.25
$286.11
$179.47
$285.58
$188.31
$681.21
$179.03
$304.15
$445.43
$220.74
$353.96
$561.33
$258.64
$299.86
$1,287.48
$1,371.06
$1,109.54
$1,203.65
$1,377.85
$2,278.13
$186.36
$2,309.78
$222.31
$2,268.46
$182.15
$1,400.80
$727.59
$2,306.85
Charge**
Charge***
$230.10
$228.94
$71.94
$71.58
$288.13
$286.67
$150.86
$150.09
$328.11
$326.45
$178.45
$177.55
$283.25
$281.82
$177.68
$176.78
$282.73
$281.30
$186.43
$185.48
$674.41
$670.99
$177.24
$176.34
$301.12
$299.59
$440.98
$438.75
$218.53
$217.43
$350.42
$348.65
$555.71
$552.91
$256.05
$254.76
$296.86
$295.37
$1,274.60
$1,268.17
$1,357.36
$1,350.50
$1,098.45
$1,092.90
$1,191.61
$1,185.59
$1,364.07
$1,357.18
$2,255.35
$2,243.96
$184.49
$183.56
$2,286.68
$2,275.13
$220.09
$218.97
$2,245.77
$2,234.43
$180.33
$179.41
$1,386.80
$1,379.79
$720.31
$716.68
$2,283.79
$2,272.25
Arizona
EHR/eRx
Limiting
Charge**
$227.78
$71.22
$285.22
$149.33
$324.79
$176.65
$280.38
$175.88
$279.86
$184.55
$667.59
$175.46
$298.07
$436.52
$216.33
$346.87
$550.10
$253.46
$293.87
$1,261.73
$1,343.65
$1,087.35
$1,179.58
$1,350.30
$2,232.56
$182.63
$2,263.58
$217.86
$2,223.09
$178.50
$1,372.79
$713.05
$2,260.72
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$226.65
$224.37
$70.86
$70.15
$283.81
$280.95
$148.59
$147.09
$323.18
$319.92
$175.77
$174.01
$279.00
$276.17
$175.01
$173.25
$278.48
$275.67
$183.63
$181.78
$664.29
$657.57
$174.58
$172.82
$296.60
$293.60
$434.37
$429.97
$215.26
$213.08
$345.16
$341.68
$547.38
$541.85
$252.21
$249.65
$292.41
$289.47
$1,255.48
$1,242.81
$1,337.00
$1,323.49
$1,081.97
$1,071.04
$1,173.74
$1,161.88
$1,343.61
$1,330.04
$2,221.51
$2,199.08
$181.72
$179.89
$2,252.38
$2,229.63
$216.79
$214.59
$2,212.08
$2,189.74
$177.63
$175.82
$1,365.99
$1,352.19
$709.50
$702.35
$2,249.53
$2,226.80
Page 93 of 323
Notes
#
#
#
#
#
#
Procedure
Code
31365
31367
31368
31370
31375
31380
31382
31390
31395
31400
31420
31500
31502
31505
31505
31510
31510
31511
31511
31512
31512
31513
31515
31515
31520
31525
31525
31526
31527
31528
31529
31530
31531
1/2/2015
Modifier
Par Fee
$2,612.38
$2,237.98
$2,480.80
$2,103.52
$1,997.17
$1,968.25
$2,158.68
$2,896.53
$3,049.09
$1,014.04
$846.48
$112.07
$35.45
$84.07
$49.75
$215.40
$125.30
$214.51
$132.27
$210.30
$133.43
$135.53
$210.52
$113.63
$160.70
$256.84
$163.87
$161.06
$200.98
$148.27
$166.29
$201.69
$218.32
Nonpar Fee
$2,481.76
$2,126.08
$2,356.76
$1,998.34
$1,897.31
$1,869.84
$2,050.75
$2,751.70
$2,896.64
$963.34
$804.16
$106.47
$33.68
$79.87
$47.26
$204.63
$119.04
$203.78
$125.66
$199.79
$126.76
$128.75
$199.99
$107.95
$152.67
$244.00
$155.68
$153.01
$190.93
$140.86
$157.98
$191.61
$207.40
Limiting
Charge
$2,854.02
$2,444.99
$2,710.27
$2,298.09
$2,181.91
$2,150.32
$2,358.36
$3,164.46
$3,331.14
$1,107.84
$924.78
$122.44
$38.73
$91.85
$54.35
$235.32
$136.90
$234.35
$144.51
$229.76
$145.77
$148.06
$229.99
$124.14
$175.57
$280.60
$179.03
$175.96
$219.57
$161.99
$181.68
$220.35
$238.51
Charge**
Charge***
$2,825.48
$2,811.21
$2,420.54
$2,408.32
$2,683.17
$2,669.62
$2,275.11
$2,263.61
$2,160.09
$2,149.18
$2,128.81
$2,118.06
$2,334.78
$2,322.99
$3,132.81
$3,116.98
$3,297.82
$3,281.17
$1,096.77
$1,091.22
$915.54
$910.92
$121.22
$120.60
$38.34
$38.15
$90.93
$90.47
$53.81
$53.53
$232.97
$231.79
$135.53
$134.84
$232.00
$230.83
$143.06
$142.35
$227.46
$226.31
$144.31
$143.59
$146.58
$145.84
$227.69
$226.54
$122.90
$122.28
$173.81
$172.94
$277.79
$276.39
$177.24
$176.34
$174.20
$173.32
$217.37
$216.28
$160.37
$159.56
$179.86
$178.95
$218.14
$217.05
$236.13
$234.93
Arizona
EHR/eRx
Limiting
Charge**
$2,796.94
$2,396.09
$2,656.06
$2,252.13
$2,138.26
$2,107.31
$2,311.20
$3,101.17
$3,264.52
$1,085.68
$906.29
$119.99
$37.96
$90.01
$53.26
$230.62
$134.16
$229.66
$141.62
$225.16
$142.85
$145.11
$225.39
$121.66
$172.06
$274.99
$175.46
$172.44
$215.18
$158.75
$178.04
$215.95
$233.74
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$2,783.10
$2,754.99
$2,384.24
$2,360.16
$2,642.92
$2,616.23
$2,240.98
$2,218.34
$2,127.68
$2,106.19
$2,096.88
$2,075.69
$2,299.76
$2,276.53
$3,085.82
$3,054.65
$3,248.35
$3,215.55
$1,080.31
$1,069.40
$901.81
$892.70
$119.40
$118.19
$37.77
$37.39
$89.56
$88.67
$53.00
$52.46
$229.47
$227.16
$133.49
$132.15
$228.52
$226.21
$140.91
$139.50
$224.04
$221.78
$142.15
$140.71
$144.38
$142.93
$224.27
$222.01
$121.06
$119.83
$171.20
$169.49
$273.63
$270.86
$174.58
$172.82
$171.59
$169.86
$214.11
$211.95
$157.96
$156.37
$177.16
$175.38
$214.87
$212.70
$232.59
$230.23
Page 94 of 323
Notes
#
#
#
#
#
#
Procedure
Code
31535
31536
31540
31541
31545
31546
31560
31561
31570
31570
31571
31575
31575
31576
31576
31577
31577
31578
31578
31579
31579
31580
31582
31584
31587
31588
31590
31595
31600
31601
31603
31605
31610
1/2/2015
Modifier
Par Fee
$194.94
$216.53
$248.63
$271.65
$371.74
$565.38
$322.21
$352.25
$345.17
$236.11
$256.81
$116.21
$78.31
$227.24
$126.77
$245.84
$153.95
$282.45
$175.90
$213.79
$144.43
$1,240.89
$1,926.84
$1,534.58
$1,017.65
$1,158.12
$904.90
$776.60
$404.88
$278.16
$227.81
$187.40
$727.49
Nonpar Fee
$185.19
$205.70
$236.20
$258.07
$353.15
$537.11
$306.10
$334.64
$327.91
$224.30
$243.97
$110.40
$74.39
$215.88
$120.43
$233.55
$146.25
$268.33
$167.11
$203.10
$137.21
$1,178.85
$1,830.50
$1,457.85
$966.77
$1,100.21
$859.66
$737.77
$384.64
$264.25
$216.42
$178.03
$691.12
Limiting
Charge
$212.97
$236.56
$271.63
$296.78
$406.12
$617.68
$352.02
$384.84
$377.10
$257.95
$280.57
$126.96
$85.55
$248.26
$138.49
$268.58
$168.19
$308.58
$192.18
$233.57
$157.79
$1,355.68
$2,105.08
$1,676.53
$1,111.79
$1,265.24
$988.61
$848.44
$442.34
$303.89
$248.88
$204.73
$794.79
Charge**
Charge***
$210.84
$209.77
$234.19
$233.00
$268.92
$267.56
$293.81
$292.33
$402.06
$400.03
$611.50
$608.41
$348.50
$346.74
$380.98
$379.06
$373.32
$371.44
$255.37
$254.08
$277.76
$276.36
$125.70
$125.05
$84.70
$84.26
$245.78
$244.54
$137.11
$136.41
$265.89
$264.56
$166.51
$165.67
$305.50
$303.96
$190.26
$189.29
$231.23
$230.06
$156.22
$155.42
$1,342.12
$1,335.35
$2,084.03
$2,073.50
$1,659.76
$1,651.38
$1,100.67
$1,095.11
$1,252.59
$1,246.27
$978.72
$973.79
$839.95
$835.71
$437.91
$435.70
$300.85
$299.33
$246.40
$245.15
$202.69
$201.66
$786.84
$782.86
Arizona
EHR/eRx
Limiting
Charge**
$208.71
$231.83
$266.20
$290.85
$398.00
$605.33
$344.98
$377.14
$369.55
$252.78
$274.95
$124.42
$83.84
$243.29
$135.72
$263.21
$164.83
$302.40
$188.34
$228.90
$154.64
$1,328.56
$2,062.97
$1,642.99
$1,089.54
$1,239.94
$968.84
$831.46
$433.49
$297.82
$243.90
$200.64
$778.90
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$207.68
$205.59
$230.68
$228.36
$264.88
$262.21
$289.41
$286.49
$396.04
$392.04
$602.32
$596.24
$343.26
$339.80
$375.27
$371.48
$367.72
$364.01
$251.54
$248.99
$273.60
$270.83
$123.81
$122.56
$83.43
$82.58
$242.09
$239.65
$135.06
$133.69
$261.90
$259.27
$164.01
$162.36
$300.92
$297.87
$187.40
$185.51
$227.76
$225.46
$153.87
$152.32
$1,321.98
$1,308.63
$2,052.77
$2,032.03
$1,634.86
$1,618.35
$1,084.15
$1,073.20
$1,233.80
$1,221.35
$964.03
$954.30
$827.34
$818.98
$431.34
$427.00
$296.34
$293.35
$242.71
$240.25
$199.65
$197.63
$775.04
$767.21
Page 95 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
31611
31612
31612
31613
31614
31615
31615
31620
31620
31622
31622
31623
31623
31624
31624
31625
31625
31626
31626
31627
31627
31628
31628
31629
31629
31630
31631
31632
31632
31633
31633
31634
31634
1/2/2015
Modifier
Par Fee
$549.26
$87.35
$51.23
$461.69
$769.71
$184.65
$131.37
$292.57
$69.46
$317.57
$148.81
$336.02
$150.10
$318.15
$151.53
$337.95
$174.55
$454.12
$217.42
$1,433.91
$99.55
$377.64
$194.57
$598.38
$209.73
$204.95
$236.65
$72.27
$50.11
$89.26
$64.95
$1,910.72
$212.02
Nonpar Fee
$521.80
$82.98
$48.67
$438.61
$731.22
$175.42
$124.80
$277.94
$65.99
$301.69
$141.37
$319.22
$142.60
$302.24
$143.95
$321.05
$165.82
$431.41
$206.55
$1,362.21
$94.57
$358.76
$184.84
$568.46
$199.24
$194.70
$224.82
$68.66
$47.60
$84.80
$61.70
$1,815.18
$201.42
Limiting
Charge
$600.07
$95.43
$55.97
$504.40
$840.90
$201.73
$143.52
$319.63
$75.89
$346.94
$162.58
$367.10
$163.99
$347.58
$165.54
$369.21
$190.69
$496.12
$237.53
$1,566.54
$108.76
$412.57
$212.57
$653.73
$229.13
$223.91
$258.54
$78.96
$54.74
$97.52
$70.96
$2,087.46
$231.63
Charge**
Charge***
$594.07
$591.07
$94.47
$94.00
$55.41
$55.13
$499.35
$496.83
$832.50
$828.29
$199.72
$198.71
$142.08
$141.37
$316.43
$314.84
$75.13
$74.75
$343.47
$341.73
$160.95
$160.14
$363.43
$361.59
$162.35
$161.53
$344.10
$342.37
$163.89
$163.06
$365.52
$363.66
$188.78
$187.83
$491.17
$488.68
$235.15
$233.97
$1,550.88
$1,543.05
$107.66
$107.12
$408.45
$406.39
$210.44
$209.38
$647.20
$643.92
$226.84
$225.69
$221.66
$220.55
$255.96
$254.67
$78.17
$77.77
$54.19
$53.92
$96.54
$96.06
$70.24
$69.89
$2,066.58
$2,056.14
$229.32
$228.16
Arizona
EHR/eRx
Limiting
Charge**
$588.06
$93.52
$54.86
$494.32
$824.09
$197.70
$140.65
$313.24
$74.37
$340.01
$159.32
$359.77
$160.71
$340.63
$162.23
$361.82
$186.88
$486.20
$232.78
$1,535.22
$106.58
$404.32
$208.31
$640.65
$224.55
$219.43
$253.37
$77.38
$53.65
$95.57
$69.54
$2,045.71
$227.00
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$585.15
$579.24
$93.06
$92.12
$54.58
$54.03
$491.87
$486.90
$820.01
$811.73
$196.72
$194.73
$139.96
$138.54
$311.68
$308.53
$74.00
$73.26
$338.32
$334.91
$158.54
$156.93
$357.98
$354.37
$159.91
$158.30
$338.94
$335.52
$161.43
$159.79
$360.03
$356.40
$185.96
$184.07
$483.79
$478.91
$231.62
$229.29
$1,527.61
$1,512.19
$106.05
$104.98
$402.32
$398.26
$207.29
$205.18
$637.49
$631.04
$223.43
$221.18
$218.34
$216.14
$252.11
$249.57
$76.99
$76.22
$53.37
$52.84
$95.09
$94.13
$69.18
$68.49
$2,035.58
$2,015.03
$225.88
$223.59
Page 96 of 323
Notes
#
#
#
#
#
Procedure
Code
31635
31635
31636
31637
31638
31640
31641
31643
31645
31645
31646
31646
31647
31648
31649
31651
31660
31661
31717
31717
31720
31725
31730
31730
31750
31755
31760
31766
31770
31775
31780
31781
31785
1/2/2015
Modifier
Par Fee
$354.72
$193.10
$226.81
$75.99
$259.54
$260.43
$263.55
$180.94
$328.38
$165.34
$295.26
$143.31
$228.06
$208.12
$69.60
$75.99
$213.79
$223.72
$265.31
$110.85
$52.16
$91.14
$1,245.24
$151.50
$1,399.76
$1,751.36
$1,405.52
$1,739.18
$1,365.38
$1,264.60
$1,207.47
$1,419.08
$1,094.78
Nonpar Fee
$336.98
$183.45
$215.47
$72.19
$246.56
$247.41
$250.37
$171.89
$311.96
$157.07
$280.50
$136.14
$216.66
$197.71
$66.12
$72.19
$203.10
$212.53
$252.04
$105.31
$49.55
$86.58
$1,182.98
$143.93
$1,329.77
$1,663.79
$1,335.24
$1,652.22
$1,297.11
$1,201.37
$1,147.10
$1,348.13
$1,040.04
Limiting
Charge
$387.53
$210.97
$247.79
$83.02
$283.54
$284.52
$287.93
$197.67
$358.75
$180.63
$322.58
$156.56
$249.16
$227.37
$76.04
$83.02
$233.57
$244.41
$289.85
$121.11
$56.98
$99.57
$1,360.43
$165.52
$1,529.24
$1,913.36
$1,535.53
$1,900.05
$1,491.68
$1,381.58
$1,319.17
$1,550.35
$1,196.05
Charge**
Charge***
$383.65
$381.72
$208.86
$207.81
$245.32
$244.08
$82.19
$81.78
$280.70
$279.29
$281.68
$280.26
$285.05
$283.60
$195.70
$194.71
$355.17
$353.37
$178.83
$177.92
$319.36
$317.73
$155.00
$154.22
$246.66
$245.42
$225.09
$223.95
$75.28
$74.90
$82.19
$81.78
$231.23
$230.06
$241.96
$240.74
$286.95
$285.50
$119.90
$119.29
$56.41
$56.13
$98.57
$98.07
$1,346.82
$1,340.03
$163.86
$163.04
$1,513.94
$1,506.29
$1,894.22
$1,884.65
$1,520.17
$1,512.49
$1,881.06
$1,871.56
$1,476.76
$1,469.30
$1,367.76
$1,360.85
$1,305.97
$1,299.37
$1,534.85
$1,527.10
$1,184.09
$1,178.11
Arizona
EHR/eRx
Limiting
Charge**
$379.78
$206.75
$242.83
$81.36
$277.87
$278.83
$282.16
$193.72
$351.58
$177.02
$316.12
$153.43
$244.18
$222.82
$74.52
$81.36
$228.90
$239.52
$284.05
$118.68
$55.84
$97.58
$1,333.22
$162.21
$1,498.65
$1,875.09
$1,504.82
$1,862.06
$1,461.85
$1,353.94
$1,292.78
$1,519.35
$1,172.13
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$377.90
$374.08
$205.74
$203.64
$241.64
$239.19
$80.96
$80.14
$276.49
$273.71
$277.46
$274.64
$280.77
$277.93
$192.76
$190.81
$349.84
$346.30
$176.15
$174.36
$314.56
$311.39
$152.67
$151.13
$242.96
$240.52
$221.71
$219.48
$74.15
$73.40
$80.96
$80.14
$227.76
$225.46
$238.33
$235.93
$282.65
$279.80
$118.11
$116.90
$55.56
$55.00
$97.08
$96.12
$1,326.62
$1,313.22
$161.40
$159.77
$1,491.23
$1,476.16
$1,865.81
$1,846.96
$1,497.37
$1,482.25
$1,852.83
$1,834.12
$1,454.61
$1,439.92
$1,347.25
$1,333.63
$1,286.39
$1,273.40
$1,511.82
$1,496.55
$1,166.33
$1,154.54
Page 97 of 323
Notes
#
#
#
#
#
Procedure
Code
31786
31800
31805
31820
31820
31825
31825
31830
31830
32035
32036
32096
32097
32098
32100
32110
32120
32124
32140
32141
32150
32151
32160
32200
32215
32220
32225
32310
32320
32400
32400
32405
32405
1/2/2015
Modifier
Par Fee
$1,612.30
$724.48
$835.10
$440.55
$332.93
$612.46
$488.75
$449.85
$348.31
$739.73
$794.22
$821.73
$821.78
$779.04
$825.98
$1,492.46
$887.71
$947.13
$1,017.95
$1,555.64
$1,027.60
$1,032.71
$804.47
$1,169.59
$817.58
$1,616.46
$1,013.69
$922.35
$1,631.53
$154.38
$90.03
$456.82
$107.14
Nonpar Fee
$1,531.69
$688.26
$793.35
$418.52
$316.28
$581.84
$464.31
$427.36
$330.89
$702.74
$754.51
$780.64
$780.69
$740.09
$784.68
$1,417.84
$843.32
$899.77
$967.05
$1,477.86
$976.22
$981.07
$764.25
$1,111.11
$776.70
$1,535.64
$963.01
$876.23
$1,549.95
$146.66
$85.53
$433.98
$101.78
Limiting
Charge
$1,761.44
$791.50
$912.35
$481.30
$363.72
$669.12
$533.96
$491.46
$380.52
$808.15
$867.69
$897.74
$897.79
$851.10
$902.38
$1,630.52
$969.82
$1,034.74
$1,112.11
$1,699.54
$1,122.65
$1,128.23
$878.89
$1,277.78
$893.21
$1,765.99
$1,107.46
$1,007.66
$1,782.44
$168.66
$98.36
$499.08
$117.05
Charge**
Charge***
$1,743.83
$1,735.02
$783.59
$779.63
$903.23
$898.67
$476.48
$474.08
$360.09
$358.27
$662.42
$659.08
$528.62
$525.95
$486.55
$484.09
$376.72
$374.82
$800.07
$796.03
$859.00
$854.67
$888.75
$884.27
$888.81
$884.33
$842.59
$838.34
$893.35
$888.85
$1,614.21
$1,606.06
$960.12
$955.27
$1,024.39
$1,019.21
$1,100.99
$1,095.42
$1,682.54
$1,674.04
$1,111.43
$1,105.82
$1,116.95
$1,111.30
$870.10
$865.71
$1,265.00
$1,258.61
$884.27
$879.81
$1,748.32
$1,739.50
$1,096.39
$1,090.84
$997.59
$992.55
$1,764.62
$1,755.71
$166.97
$166.13
$97.37
$96.89
$494.09
$491.59
$115.87
$115.29
Arizona
EHR/eRx
Limiting
Charge**
$1,726.22
$775.66
$894.10
$471.67
$356.44
$655.73
$523.27
$481.63
$372.91
$791.99
$850.33
$879.78
$879.84
$834.08
$884.34
$1,597.90
$950.42
$1,014.04
$1,089.87
$1,665.55
$1,100.21
$1,105.67
$861.32
$1,252.22
$875.35
$1,730.67
$1,085.31
$987.52
$1,746.79
$165.29
$96.39
$489.10
$114.70
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$1,717.66
$1,700.32
$771.83
$764.03
$889.69
$880.69
$469.34
$464.60
$354.68
$351.10
$652.49
$645.90
$520.69
$515.42
$479.25
$474.41
$371.07
$367.32
$788.06
$780.11
$846.12
$837.58
$875.43
$866.58
$875.48
$866.64
$829.96
$821.57
$879.96
$871.08
$1,590.00
$1,573.94
$945.73
$936.16
$1,009.02
$998.82
$1,084.47
$1,073.51
$1,657.30
$1,640.57
$1,094.75
$1,083.70
$1,100.19
$1,089.08
$857.05
$848.40
$1,246.03
$1,233.44
$871.01
$862.21
$1,722.10
$1,704.71
$1,079.94
$1,069.03
$982.63
$972.70
$1,738.14
$1,720.60
$164.46
$162.81
$95.91
$94.94
$486.68
$481.76
$114.14
$112.98
Page 98 of 323
Notes
#
#
#
#
#
#
#
#
Procedure
Code
32440
32442
32445
32480
32482
32484
32486
32488
32491
32501
32503
32504
32505
32506
32507
32540
32550
32550
32551
32552
32552
32553
32553
32554
32554
32555
32555
32556
32556
32557
32557
32560
32560
1/2/2015
Modifier
Par Fee
$1,596.72
$3,143.62
$3,626.04
$1,508.51
$1,617.95
$1,467.84
$2,403.16
$2,467.00
$1,509.55
$250.49
$1,849.51
$2,121.86
$951.92
$160.68
$160.36
$1,769.29
$794.43
$228.43
$173.85
$189.17
$163.79
$600.48
$200.03
$203.32
$91.41
$292.62
$115.99
$562.26
$126.41
$517.84
$158.50
$246.99
$80.02
Nonpar Fee
$1,516.88
$2,986.44
$3,444.74
$1,433.08
$1,537.05
$1,394.45
$2,283.00
$2,343.65
$1,434.07
$237.97
$1,757.03
$2,015.77
$904.32
$152.65
$152.34
$1,680.83
$754.71
$217.01
$165.16
$179.71
$155.60
$570.46
$190.03
$193.15
$86.84
$277.99
$110.19
$534.15
$120.09
$491.95
$150.58
$234.64
$76.02
Limiting
Charge
$1,744.41
$3,434.41
$3,961.45
$1,648.04
$1,767.61
$1,603.62
$2,625.45
$2,695.20
$1,649.18
$273.67
$2,020.58
$2,318.14
$1,039.97
$175.55
$175.19
$1,932.95
$867.92
$249.56
$189.93
$206.67
$178.94
$656.03
$218.53
$222.12
$99.87
$319.69
$126.72
$614.27
$138.10
$565.74
$173.17
$269.84
$87.42
Charge**
Charge***
$1,726.97
$1,718.25
$3,400.07
$3,382.89
$3,921.83
$3,902.03
$1,631.56
$1,623.32
$1,749.93
$1,741.09
$1,587.59
$1,579.56
$2,599.20
$2,586.07
$2,668.24
$2,654.78
$1,632.69
$1,624.44
$270.93
$269.56
$2,000.38
$1,990.27
$2,294.95
$2,283.36
$1,029.57
$1,024.37
$173.79
$172.91
$173.44
$172.56
$1,913.62
$1,903.96
$859.23
$854.90
$247.07
$245.81
$188.04
$187.08
$204.60
$203.56
$177.15
$176.26
$649.47
$646.19
$216.35
$215.26
$219.90
$218.79
$98.87
$98.37
$316.49
$314.89
$125.45
$124.82
$608.13
$605.06
$136.72
$136.03
$560.08
$557.26
$171.43
$170.57
$267.13
$265.79
$86.55
$86.11
Arizona
EHR/eRx
Limiting
Charge**
$1,709.52
$3,365.72
$3,882.23
$1,615.08
$1,732.26
$1,571.54
$2,572.94
$2,641.30
$1,616.20
$268.19
$1,980.17
$2,271.77
$1,019.16
$172.04
$171.68
$1,894.29
$850.56
$244.57
$186.14
$202.54
$175.36
$642.91
$214.16
$217.68
$97.87
$313.29
$124.19
$601.99
$135.34
$554.43
$169.71
$264.44
$85.68
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$1,701.06
$1,683.88
$3,349.06
$3,315.23
$3,863.01
$3,823.99
$1,607.09
$1,590.85
$1,723.68
$1,706.28
$1,563.77
$1,547.97
$2,560.21
$2,534.35
$2,628.22
$2,601.68
$1,608.19
$1,591.96
$266.87
$264.17
$1,970.38
$1,950.47
$2,260.53
$2,237.69
$1,014.13
$1,003.88
$171.18
$169.46
$170.84
$169.11
$1,884.92
$1,865.88
$846.34
$837.81
$243.36
$240.90
$185.22
$183.34
$201.53
$199.50
$174.49
$172.73
$639.73
$633.26
$213.11
$210.96
$216.60
$214.42
$97.38
$96.39
$311.74
$308.59
$123.57
$122.33
$599.01
$592.96
$134.68
$133.31
$551.68
$546.11
$168.85
$167.16
$263.13
$260.48
$85.25
$84.39
Page 99 of 323
Notes
#
#
Procedure
Code
32561
32561
32562
32562
32601
32604
32606
32607
32608
32609
32650
32651
32652
32653
32654
32655
32656
32658
32659
32661
32662
32663
32664
32665
32666
32667
32668
32669
32670
32671
32672
32673
32674
1/2/2015
Modifier
Par Fee
$94.36
$70.40
$85.38
$63.57
$315.04
$494.19
$471.56
$315.67
$387.16
$265.19
$679.29
$1,120.01
$1,696.15
$1,081.21
$1,170.17
$975.52
$819.85
$732.10
$748.36
$818.74
$913.20
$1,430.91
$869.57
$1,265.28
$889.82
$161.04
$160.68
$1,373.95
$1,639.46
$1,824.66
$1,553.54
$1,244.74
$221.03
Nonpar Fee
$89.64
$66.88
$81.11
$60.39
$299.29
$469.48
$447.98
$299.89
$367.80
$251.93
$645.33
$1,064.01
$1,611.34
$1,027.15
$1,111.66
$926.74
$778.86
$695.50
$710.94
$777.80
$867.54
$1,359.36
$826.09
$1,202.02
$845.33
$152.99
$152.65
$1,305.25
$1,557.49
$1,733.43
$1,475.86
$1,182.50
$209.98
Limiting
Charge
$103.09
$76.91
$93.28
$69.45
$344.18
$539.90
$515.18
$344.87
$422.97
$289.72
$742.13
$1,223.61
$1,853.04
$1,181.22
$1,278.41
$1,065.75
$895.69
$799.83
$817.58
$894.47
$997.67
$1,563.26
$950.00
$1,382.32
$972.13
$175.94
$175.55
$1,501.04
$1,791.11
$1,993.44
$1,697.24
$1,359.88
$241.48
Charge**
Charge***
$102.05
$101.55
$76.14
$75.76
$92.35
$91.87
$68.76
$68.40
$340.75
$339.02
$534.51
$531.81
$510.03
$507.45
$341.42
$339.70
$418.74
$416.62
$286.82
$285.37
$734.71
$731.00
$1,211.38
$1,205.26
$1,834.51
$1,825.25
$1,169.41
$1,163.50
$1,265.62
$1,259.24
$1,055.09
$1,049.77
$886.73
$882.26
$791.83
$787.83
$809.40
$805.32
$885.52
$881.05
$987.69
$982.71
$1,547.64
$1,539.82
$940.50
$935.76
$1,368.50
$1,361.59
$962.41
$957.55
$174.18
$173.31
$173.79
$172.91
$1,486.03
$1,478.52
$1,773.21
$1,764.25
$1,973.52
$1,963.54
$1,680.27
$1,671.78
$1,346.28
$1,339.47
$239.06
$237.85
Arizona
EHR/eRx
Limiting
Charge**
$101.03
$75.37
$91.41
$68.06
$337.30
$529.10
$504.87
$337.97
$414.51
$283.92
$727.28
$1,199.14
$1,815.98
$1,157.60
$1,252.84
$1,044.44
$877.77
$783.83
$801.23
$876.58
$977.72
$1,532.00
$931.01
$1,354.68
$952.68
$172.42
$172.04
$1,471.02
$1,755.29
$1,953.57
$1,663.29
$1,332.68
$236.65
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$100.52
$99.51
$75.00
$74.24
$90.97
$90.05
$67.72
$67.03
$335.64
$332.24
$526.49
$521.17
$502.38
$497.29
$336.31
$332.90
$412.46
$408.28
$282.52
$279.67
$723.70
$716.37
$1,193.21
$1,181.15
$1,807.00
$1,788.73
$1,151.87
$1,140.24
$1,246.63
$1,234.05
$1,039.27
$1,028.78
$873.43
$864.60
$779.95
$772.08
$797.26
$789.21
$872.24
$863.43
$972.88
$963.06
$1,524.42
$1,509.02
$926.39
$917.04
$1,347.97
$1,334.36
$947.98
$938.39
$171.57
$169.83
$171.18
$169.46
$1,463.74
$1,448.95
$1,746.61
$1,728.96
$1,943.91
$1,924.27
$1,655.06
$1,638.34
$1,326.09
$1,312.69
$235.47
$233.09
Page 100 of 323
Notes
#
#
Procedure
Code
32701
32800
32810
32815
32820
32851
32852
32853
32854
32900
32905
32906
32940
32960
32960
32997
32998
32998
33010
33011
33015
33020
33025
33030
33031
33050
33120
33130
33140
33141
33202
33203
33206
1/2/2015
Modifier
Par Fee
$219.06
$974.99
$924.96
$2,864.24
$1,433.97
$3,364.94
$3,686.85
$4,701.92
$4,991.34
$1,457.41
$1,371.05
$1,692.99
$1,267.20
$128.46
$93.78
$350.48
$3,001.87
$294.53
$122.67
$123.57
$519.46
$900.51
$815.66
$2,046.61
$2,519.38
$1,028.01
$2,144.74
$1,418.40
$1,619.95
$134.12
$792.50
$822.86
$471.01
Nonpar Fee
$208.11
$926.24
$878.71
$2,721.03
$1,362.27
$3,196.69
$3,502.51
$4,466.82
$4,741.77
$1,384.54
$1,302.50
$1,608.34
$1,203.84
$122.04
$89.09
$332.96
$2,851.78
$279.80
$116.54
$117.39
$493.49
$855.48
$774.88
$1,944.28
$2,393.41
$976.61
$2,037.50
$1,347.48
$1,538.95
$127.41
$752.88
$781.72
$447.46
Limiting
Charge
$239.33
$1,065.18
$1,010.52
$3,129.18
$1,566.61
$3,676.19
$4,027.89
$5,136.84
$5,453.04
$1,592.22
$1,497.88
$1,849.59
$1,384.42
$140.35
$102.45
$382.90
$3,279.55
$321.77
$134.02
$135.00
$567.51
$983.80
$891.11
$2,235.92
$2,752.42
$1,123.10
$2,343.13
$1,549.60
$1,769.79
$146.52
$865.81
$898.98
$514.58
Charge**
Charge***
$236.93
$235.74
$1,054.53
$1,049.20
$1,000.41
$995.36
$3,097.89
$3,082.24
$1,550.95
$1,543.12
$3,639.43
$3,621.05
$3,987.60
$3,967.47
$5,085.47
$5,059.79
$5,398.50
$5,371.24
$1,576.29
$1,568.34
$1,482.90
$1,475.40
$1,831.10
$1,821.84
$1,370.57
$1,363.65
$138.94
$138.24
$101.43
$100.91
$379.07
$377.17
$3,246.75
$3,230.35
$318.55
$316.94
$132.68
$132.01
$133.65
$132.97
$561.84
$559.00
$973.97
$969.05
$882.20
$877.75
$2,213.57
$2,202.39
$2,724.90
$2,711.14
$1,111.87
$1,106.25
$2,319.70
$2,307.98
$1,534.11
$1,526.36
$1,752.09
$1,743.25
$145.06
$144.33
$857.15
$852.83
$889.99
$885.49
$509.44
$506.86
Arizona
EHR/eRx
Limiting
Charge**
$234.54
$1,043.88
$990.31
$3,066.60
$1,535.27
$3,602.67
$3,947.33
$5,034.10
$5,343.97
$1,560.38
$1,467.92
$1,812.60
$1,356.72
$137.54
$100.41
$375.25
$3,213.95
$315.33
$131.34
$132.30
$556.16
$964.13
$873.29
$2,191.20
$2,697.37
$1,100.64
$2,296.26
$1,518.61
$1,734.40
$143.59
$848.49
$881.00
$504.29
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$233.38
$231.02
$1,038.71
$1,028.22
$985.40
$975.45
$3,051.42
$3,020.60
$1,527.68
$1,512.24
$3,584.84
$3,548.64
$3,927.79
$3,888.12
$5,009.19
$4,958.59
$5,317.52
$5,263.81
$1,552.65
$1,536.98
$1,460.66
$1,445.90
$1,803.64
$1,785.41
$1,350.01
$1,336.37
$136.86
$135.48
$99.91
$98.90
$373.39
$369.62
$3,198.05
$3,165.74
$313.78
$310.60
$130.69
$129.38
$131.65
$130.31
$553.41
$547.83
$959.36
$949.66
$868.96
$860.19
$2,180.37
$2,158.33
$2,684.03
$2,656.91
$1,095.19
$1,084.13
$2,284.90
$2,261.82
$1,511.10
$1,495.83
$1,725.82
$1,708.38
$142.89
$141.44
$844.30
$835.76
$876.63
$867.79
$501.80
$496.72
Page 101 of 323
Notes
Procedure
Code
33207
33208
33210
33211
33212
33213
33214
33215
33216
33217
33218
33220
33221
33222
33223
33224
33225
33226
33227
33228
33229
33230
33231
33233
33234
33235
33236
33237
33238
33240
33241
33243
33244
1/2/2015
Modifier
Par Fee
$501.37
$542.50
$182.40
$185.89
$339.40
$354.46
$497.47
$315.75
$389.60
$382.09
$408.33
$408.51
$379.27
$354.95
$427.82
$524.67
$476.43
$504.01
$357.32
$372.12
$390.49
$401.58
$423.44
$247.57
$506.51
$659.04
$799.78
$859.02
$957.09
$384.46
$233.00
$1,399.56
$886.19
Nonpar Fee
$476.30
$515.38
$173.28
$176.60
$322.43
$336.74
$472.60
$299.96
$370.12
$362.99
$387.91
$388.08
$360.31
$337.20
$406.43
$498.44
$452.61
$478.81
$339.45
$353.51
$370.97
$381.50
$402.27
$235.19
$481.18
$626.09
$759.79
$816.07
$909.24
$365.24
$221.35
$1,329.58
$841.88
Limiting
Charge
$547.75
$592.69
$199.27
$203.09
$370.79
$387.25
$543.49
$344.95
$425.64
$417.44
$446.10
$446.29
$414.36
$387.78
$467.39
$573.21
$520.50
$550.63
$390.37
$406.54
$426.62
$438.73
$462.61
$270.47
$553.36
$720.00
$873.76
$938.48
$1,045.63
$420.03
$254.55
$1,529.02
$968.16
Charge**
Charge***
$542.27
$539.53
$586.76
$583.80
$197.28
$196.28
$201.05
$200.04
$367.09
$365.23
$383.38
$381.44
$538.05
$535.34
$341.50
$339.78
$421.38
$419.26
$413.26
$411.18
$441.63
$439.40
$441.83
$439.60
$410.22
$408.15
$383.90
$381.96
$462.73
$460.38
$567.48
$564.60
$515.29
$512.69
$545.12
$542.37
$386.47
$384.51
$402.47
$400.44
$422.35
$420.22
$434.34
$432.15
$457.99
$455.68
$267.77
$266.41
$547.83
$545.05
$712.80
$709.21
$865.02
$860.65
$929.10
$924.40
$1,035.17
$1,029.94
$415.83
$413.72
$252.01
$250.73
$1,513.72
$1,506.09
$958.48
$953.64
Arizona
EHR/eRx
Limiting
Charge**
$536.79
$580.83
$195.28
$199.03
$363.38
$379.51
$532.62
$338.05
$417.13
$409.09
$437.17
$437.37
$406.07
$380.03
$458.05
$561.74
$510.09
$539.61
$382.56
$398.41
$418.08
$429.95
$453.35
$265.06
$542.29
$705.61
$856.28
$919.71
$1,024.72
$411.63
$249.46
$1,498.44
$948.80
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$534.14
$528.74
$577.97
$572.11
$194.33
$192.35
$198.04
$196.04
$361.58
$357.93
$377.63
$373.82
$529.98
$524.63
$336.39
$332.98
$415.06
$410.87
$407.07
$402.95
$435.01
$430.62
$435.21
$430.81
$404.06
$399.97
$378.14
$374.33
$455.78
$451.18
$558.97
$553.31
$507.56
$502.45
$536.95
$531.52
$380.67
$376.82
$396.43
$392.43
$416.01
$411.82
$427.82
$423.50
$451.12
$446.56
$263.75
$261.08
$539.60
$534.16
$702.11
$695.03
$852.05
$843.43
$915.16
$905.91
$1,019.65
$1,009.34
$409.60
$405.46
$248.23
$245.72
$1,491.02
$1,475.97
$944.10
$934.56
Page 102 of 323
Notes
Procedure
Code
33249
33250
33251
33254
33255
33256
33257
33258
33259
33261
33262
33263
33264
33265
33266
33270
33271
33272
33273
33282
33284
33300
33305
33310
33315
33320
33321
33322
33330
33335
33361
33362
33363
1/2/2015
Modifier
Par Fee
$944.40
$1,510.63
$1,657.77
$1,391.44
$1,675.11
$1,992.58
$595.02
$672.15
$862.32
$1,657.77
$391.52
$407.62
$424.52
$1,388.42
$1,890.86
$600.83
$505.56
$372.07
$408.92
$243.19
$215.78
$2,501.42
$4,193.98
$1,225.12
$1,959.13
$1,088.56
$1,231.56
$1,417.00
$1,465.26
$1,932.67
$1,388.45
$1,517.40
$1,594.06
Nonpar Fee
$897.18
$1,435.10
$1,574.88
$1,321.87
$1,591.35
$1,892.95
$565.27
$638.54
$819.20
$1,574.88
$371.94
$387.24
$403.29
$1,319.00
$1,796.32
$570.79
$480.28
$353.47
$388.47
$231.03
$204.99
$2,376.35
$3,984.28
$1,163.86
$1,861.17
$1,034.13
$1,169.98
$1,346.15
$1,392.00
$1,836.04
$1,319.03
$1,441.53
$1,514.36
Limiting
Charge
$1,031.76
$1,650.37
$1,811.11
$1,520.15
$1,830.05
$2,176.89
$650.06
$734.32
$942.08
$1,811.11
$427.73
$445.33
$463.78
$1,516.85
$2,065.77
$656.41
$552.32
$406.49
$446.74
$265.68
$235.74
$2,732.80
$4,581.92
$1,338.44
$2,140.35
$1,189.25
$1,345.48
$1,548.07
$1,600.80
$2,111.45
$1,516.88
$1,657.76
$1,741.51
Charge**
Charge***
$1,021.44
$1,016.28
$1,633.86
$1,625.61
$1,793.00
$1,783.95
$1,504.95
$1,497.35
$1,811.76
$1,802.60
$2,155.12
$2,144.24
$643.56
$640.31
$726.97
$723.30
$932.66
$927.95
$1,793.00
$1,783.95
$423.45
$421.31
$440.88
$438.64
$459.15
$456.83
$1,501.68
$1,494.10
$2,045.11
$2,034.79
$649.84
$646.56
$546.80
$544.04
$402.43
$400.40
$442.28
$440.04
$263.03
$261.69
$233.38
$232.21
$2,705.48
$2,691.81
$4,536.11
$4,513.20
$1,325.05
$1,318.36
$2,118.94
$2,108.24
$1,177.36
$1,171.41
$1,332.02
$1,325.29
$1,532.59
$1,524.85
$1,584.79
$1,576.79
$2,090.33
$2,079.78
$1,501.72
$1,494.13
$1,641.18
$1,632.90
$1,724.10
$1,715.39
Arizona
EHR/eRx
Limiting
Charge**
$1,011.13
$1,617.36
$1,774.89
$1,489.74
$1,793.45
$2,133.35
$637.05
$719.64
$923.24
$1,774.89
$419.18
$436.43
$454.50
$1,486.51
$2,024.45
$643.28
$541.27
$398.36
$437.81
$260.37
$231.02
$2,678.14
$4,490.28
$1,311.67
$2,097.54
$1,165.47
$1,318.57
$1,517.11
$1,568.78
$2,069.22
$1,486.55
$1,624.61
$1,706.68
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$1,006.12
$995.96
$1,609.36
$1,593.10
$1,766.10
$1,748.26
$1,482.37
$1,467.40
$1,784.58
$1,766.55
$2,122.80
$2,101.35
$633.91
$627.50
$716.07
$708.84
$918.67
$909.40
$1,766.10
$1,748.26
$417.11
$412.88
$434.26
$429.88
$452.26
$447.68
$1,479.15
$1,464.21
$2,014.43
$1,994.08
$640.09
$633.63
$538.60
$533.15
$396.39
$392.38
$435.64
$431.24
$259.08
$256.46
$229.89
$227.56
$2,664.90
$2,637.97
$4,468.06
$4,422.92
$1,305.18
$1,291.99
$2,087.16
$2,066.08
$1,159.69
$1,147.99
$1,312.05
$1,298.79
$1,509.61
$1,494.36
$1,561.02
$1,545.26
$2,058.97
$2,038.18
$1,479.19
$1,464.25
$1,616.56
$1,600.24
$1,698.24
$1,681.08
Page 103 of 323
Notes
Procedure
Code
33364
33365
33366
33367
33368
33369
33400
33401
33403
33404
33405
33406
33410
33411
33412
33413
33414
33415
33416
33417
33418
33419
33420
33422
33425
33426
33427
33430
33460
33463
33464
33465
33468
1/2/2015
Modifier
Par Fee
$1,651.57
$1,819.25
$1,968.49
$637.39
$765.08
$1,009.90
$2,329.15
$1,478.30
$1,516.08
$1,814.68
$2,318.78
$2,937.66
$2,594.43
$3,428.99
$3,247.75
$3,349.94
$2,194.22
$2,078.38
$2,076.51
$1,696.60
$1,899.66
$446.12
$1,483.26
$1,712.66
$2,790.39
$2,432.64
$2,497.43
$2,858.47
$2,495.99
$3,161.91
$2,495.05
$2,817.84
$2,502.12
Nonpar Fee
$1,568.99
$1,728.29
$1,870.07
$605.52
$726.83
$959.41
$2,212.69
$1,404.39
$1,440.28
$1,723.95
$2,202.84
$2,790.78
$2,464.71
$3,257.54
$3,085.36
$3,182.44
$2,084.51
$1,974.46
$1,972.68
$1,611.77
$1,804.68
$423.81
$1,409.10
$1,627.03
$2,650.87
$2,311.01
$2,372.56
$2,715.55
$2,371.19
$3,003.81
$2,370.30
$2,676.95
$2,377.01
Limiting
Charge
$1,804.34
$1,987.53
$2,150.58
$696.35
$835.85
$1,103.32
$2,544.59
$1,615.05
$1,656.32
$1,982.54
$2,533.27
$3,209.40
$2,834.42
$3,746.17
$3,548.16
$3,659.81
$2,397.19
$2,270.63
$2,268.58
$1,853.54
$2,075.38
$487.38
$1,620.47
$1,871.08
$3,048.50
$2,657.66
$2,728.44
$3,122.88
$2,726.87
$3,454.38
$2,725.85
$3,078.49
$2,733.56
Charge**
Charge***
$1,786.30
$1,777.28
$1,967.66
$1,957.73
$2,129.08
$2,118.32
$689.38
$685.91
$827.49
$823.32
$1,092.29
$1,086.77
$2,519.14
$2,506.43
$1,598.90
$1,590.82
$1,639.76
$1,631.48
$1,962.72
$1,952.80
$2,507.93
$2,495.27
$3,177.30
$3,161.26
$2,806.07
$2,791.90
$3,708.70
$3,689.98
$3,512.69
$3,494.94
$3,623.21
$3,604.91
$2,373.21
$2,361.23
$2,247.93
$2,236.57
$2,245.89
$2,234.55
$1,835.00
$1,825.73
$2,054.62
$2,044.25
$482.51
$480.07
$1,604.26
$1,596.15
$1,852.37
$1,843.01
$3,018.01
$3,002.78
$2,631.09
$2,617.79
$2,701.15
$2,687.52
$3,091.65
$3,076.04
$2,699.60
$2,685.96
$3,419.84
$3,402.56
$2,698.59
$2,684.96
$3,047.71
$3,032.32
$2,706.23
$2,692.55
Arizona
EHR/eRx
Limiting
Charge**
$1,768.25
$1,947.78
$2,107.57
$682.42
$819.13
$1,081.25
$2,493.71
$1,582.75
$1,623.19
$1,942.89
$2,482.60
$3,145.20
$2,777.73
$3,671.25
$3,477.20
$3,586.61
$2,349.24
$2,225.22
$2,223.21
$1,816.46
$2,033.88
$477.63
$1,588.06
$1,833.66
$2,987.53
$2,604.51
$2,673.88
$3,060.43
$2,672.34
$3,385.29
$2,671.32
$3,016.92
$2,678.89
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$1,759.50
$1,741.73
$1,938.14
$1,918.56
$2,097.14
$2,075.96
$679.04
$672.19
$815.09
$806.85
$1,075.91
$1,065.04
$2,481.36
$2,456.30
$1,574.91
$1,559.01
$1,615.16
$1,598.85
$1,933.28
$1,913.75
$2,470.32
$2,445.36
$3,129.64
$3,098.03
$2,763.98
$2,736.07
$3,653.08
$3,616.18
$3,459.99
$3,425.05
$3,568.86
$3,532.81
$2,337.62
$2,314.01
$2,214.21
$2,191.84
$2,212.21
$2,189.86
$1,807.48
$1,789.22
$2,023.80
$2,003.37
$475.27
$470.47
$1,580.19
$1,564.24
$1,824.59
$1,806.16
$2,972.74
$2,942.71
$2,591.62
$2,565.44
$2,660.64
$2,633.76
$3,045.27
$3,014.52
$2,659.11
$2,632.25
$3,368.53
$3,334.51
$2,658.11
$2,631.26
$3,001.99
$2,971.67
$2,665.63
$2,638.71
Page 104 of 323
Notes
Procedure
Code
33470
33471
33474
33475
33476
33478
33496
33500
33501
33502
33503
33504
33505
33506
33507
33508
33510
33511
33512
33513
33514
33516
33517
33518
33519
33521
33522
33523
33530
33533
33534
33535
33536
1/2/2015
Modifier
Par Fee
$1,262.46
$1,294.84
$2,222.06
$2,398.43
$1,560.64
$1,603.40
$1,713.60
$1,605.50
$1,148.06
$1,303.32
$1,352.31
$1,494.40
$2,105.49
$2,213.33
$1,758.82
$16.18
$1,973.77
$2,169.14
$2,466.67
$2,538.65
$2,682.84
$2,808.49
$191.66
$421.18
$556.69
$667.21
$749.69
$856.33
$538.68
$1,909.49
$2,246.62
$2,506.63
$2,704.42
Nonpar Fee
$1,199.34
$1,230.10
$2,110.96
$2,278.51
$1,482.61
$1,523.23
$1,627.92
$1,525.23
$1,090.66
$1,238.15
$1,284.69
$1,419.68
$2,000.22
$2,102.66
$1,670.88
$15.37
$1,875.08
$2,060.68
$2,343.34
$2,411.72
$2,548.70
$2,668.07
$182.08
$400.12
$528.86
$633.85
$712.21
$813.51
$511.75
$1,814.02
$2,134.29
$2,381.30
$2,569.20
Limiting
Charge
$1,379.24
$1,414.62
$2,427.60
$2,620.29
$1,705.00
$1,751.71
$1,872.11
$1,754.01
$1,254.26
$1,423.87
$1,477.39
$1,632.63
$2,300.25
$2,418.06
$1,921.51
$17.68
$2,156.34
$2,369.78
$2,694.84
$2,773.48
$2,931.01
$3,068.28
$209.39
$460.14
$608.19
$728.93
$819.04
$935.54
$588.51
$2,086.12
$2,454.43
$2,738.50
$2,954.58
Charge**
Charge***
$1,365.45
$1,358.55
$1,400.47
$1,393.40
$2,403.33
$2,391.20
$2,594.08
$2,580.98
$1,687.95
$1,679.43
$1,734.20
$1,725.44
$1,853.39
$1,844.03
$1,736.48
$1,727.70
$1,241.71
$1,235.45
$1,409.64
$1,402.52
$1,462.62
$1,455.23
$1,616.30
$1,608.14
$2,277.25
$2,265.75
$2,393.87
$2,381.79
$1,902.30
$1,892.69
$17.50
$17.41
$2,134.78
$2,123.99
$2,346.08
$2,334.24
$2,667.90
$2,654.42
$2,745.74
$2,731.87
$2,901.69
$2,887.04
$3,037.60
$3,022.26
$207.30
$206.25
$455.54
$453.24
$602.11
$599.07
$721.64
$717.99
$810.85
$806.76
$926.18
$921.51
$582.62
$579.68
$2,065.26
$2,054.83
$2,429.89
$2,417.62
$2,711.11
$2,697.42
$2,925.04
$2,910.26
Arizona
EHR/eRx
Limiting
Charge**
$1,351.65
$1,386.33
$2,379.05
$2,567.88
$1,670.90
$1,716.69
$1,834.66
$1,718.94
$1,229.18
$1,395.40
$1,447.85
$1,599.98
$2,254.25
$2,369.70
$1,883.08
$17.32
$2,113.22
$2,322.39
$2,640.94
$2,718.01
$2,872.39
$3,006.92
$205.21
$450.94
$596.02
$714.35
$802.67
$916.83
$576.75
$2,044.40
$2,405.34
$2,683.72
$2,895.49
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$1,344.97
$1,331.38
$1,379.46
$1,365.53
$2,367.28
$2,343.37
$2,555.16
$2,529.37
$1,662.62
$1,645.85
$1,708.19
$1,690.94
$1,825.59
$1,807.14
$1,710.43
$1,693.16
$1,223.08
$1,210.74
$1,388.49
$1,374.47
$1,440.67
$1,426.14
$1,592.06
$1,575.98
$2,243.10
$2,220.44
$2,357.97
$2,334.16
$1,873.76
$1,854.84
$17.24
$17.05
$2,102.76
$2,081.52
$2,310.89
$2,287.56
$2,627.88
$2,601.32
$2,704.56
$2,677.25
$2,858.16
$2,829.30
$2,992.04
$2,961.81
$204.19
$202.12
$448.71
$444.18
$593.08
$587.09
$710.82
$703.63
$798.69
$790.63
$912.28
$903.07
$573.88
$568.10
$2,034.28
$2,013.73
$2,393.45
$2,369.26
$2,670.45
$2,643.46
$2,881.16
$2,852.06
Page 105 of 323
Notes
Procedure
Code
33542
33545
33548
33572
33600
33602
33606
33608
33610
33611
33612
33615
33617
33619
33620
33621
33622
33641
33645
33647
33660
33665
33670
33675
33676
33677
33681
33684
33688
33690
33692
33694
33697
1/2/2015
Modifier
Par Fee
$2,681.36
$3,163.97
$3,028.71
$235.87
$1,768.41
$1,715.25
$1,744.18
$1,836.28
$1,826.98
$1,920.65
$2,045.52
$2,055.03
$2,207.40
$2,676.44
$1,541.85
$956.31
$3,469.56
$1,670.54
$1,766.10
$1,854.84
$1,809.60
$1,954.01
$2,030.42
$2,030.68
$1,992.84
$2,070.61
$1,882.28
$1,945.06
$1,923.70
$1,234.42
$1,929.37
$1,992.23
$2,147.48
Nonpar Fee
$2,547.29
$3,005.77
$2,877.27
$224.08
$1,679.99
$1,629.49
$1,656.97
$1,744.47
$1,735.63
$1,824.62
$1,943.24
$1,952.28
$2,097.03
$2,542.62
$1,464.76
$908.49
$3,296.08
$1,587.01
$1,677.80
$1,762.10
$1,719.12
$1,856.31
$1,928.90
$1,929.15
$1,893.20
$1,967.08
$1,788.17
$1,847.81
$1,827.52
$1,172.70
$1,832.90
$1,892.62
$2,040.11
Limiting
Charge
$2,929.38
$3,456.64
$3,308.86
$257.69
$1,931.99
$1,873.91
$1,905.52
$2,006.14
$1,995.97
$2,098.31
$2,234.73
$2,245.12
$2,411.58
$2,924.01
$1,684.47
$1,044.76
$3,790.49
$1,825.06
$1,929.47
$2,026.42
$1,976.99
$2,134.76
$2,218.24
$2,218.52
$2,177.18
$2,262.14
$2,056.40
$2,124.98
$2,101.65
$1,348.61
$2,107.84
$2,176.51
$2,346.13
Charge**
Charge***
$2,900.09
$2,885.44
$3,422.07
$3,404.78
$3,275.78
$3,259.23
$255.12
$253.83
$1,912.67
$1,903.01
$1,855.18
$1,845.81
$1,886.46
$1,876.94
$1,986.08
$1,976.05
$1,976.01
$1,966.04
$2,077.33
$2,066.84
$2,212.38
$2,201.20
$2,222.67
$2,211.45
$2,387.47
$2,375.41
$2,894.77
$2,880.15
$1,667.63
$1,659.21
$1,034.32
$1,029.09
$3,752.59
$3,733.64
$1,806.81
$1,797.68
$1,910.17
$1,900.52
$2,006.15
$1,996.02
$1,957.22
$1,947.33
$2,113.41
$2,102.74
$2,196.05
$2,184.97
$2,196.34
$2,185.24
$2,155.41
$2,144.52
$2,239.52
$2,228.21
$2,035.83
$2,025.55
$2,103.73
$2,093.10
$2,080.63
$2,070.13
$1,335.12
$1,328.38
$2,086.76
$2,076.22
$2,154.74
$2,143.86
$2,322.67
$2,310.94
Arizona
EHR/eRx
Limiting
Charge**
$2,870.79
$3,387.50
$3,242.68
$252.54
$1,893.35
$1,836.44
$1,867.40
$1,966.02
$1,956.06
$2,056.35
$2,190.04
$2,200.21
$2,363.35
$2,865.54
$1,650.78
$1,023.87
$3,714.68
$1,788.56
$1,890.88
$1,985.89
$1,937.45
$2,092.06
$2,173.87
$2,174.16
$2,133.64
$2,216.90
$2,015.27
$2,082.48
$2,059.62
$1,321.64
$2,065.68
$2,132.99
$2,299.21
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$2,856.59
$2,827.72
$3,370.73
$3,336.69
$3,226.64
$3,194.03
$251.29
$248.76
$1,883.98
$1,864.94
$1,827.35
$1,808.89
$1,858.16
$1,839.39
$1,956.29
$1,936.53
$1,946.38
$1,926.72
$2,046.16
$2,025.51
$2,179.19
$2,157.18
$2,189.34
$2,167.21
$2,351.66
$2,327.90
$2,851.34
$2,822.55
$1,642.61
$1,626.02
$1,018.81
$1,008.52
$3,696.30
$3,658.97
$1,779.71
$1,761.73
$1,881.52
$1,862.52
$1,976.06
$1,956.10
$1,927.86
$1,908.39
$2,081.71
$2,060.67
$2,163.12
$2,141.27
$2,163.39
$2,141.54
$2,123.08
$2,101.64
$2,205.93
$2,183.64
$2,005.30
$1,985.04
$2,072.17
$2,051.24
$2,049.42
$2,028.73
$1,315.09
$1,301.81
$2,055.45
$2,034.70
$2,122.42
$2,100.99
$2,287.82
$2,264.72
Page 106 of 323
Notes
Procedure
Code
33702
33710
33720
33722
33724
33726
33730
33732
33735
33736
33737
33750
33755
33762
33764
33766
33767
33768
33770
33771
33774
33775
33776
33777
33778
33779
33780
33781
33782
33783
33786
33788
33800
1/2/2015
Modifier
Par Fee
$1,577.52
$2,144.89
$1,591.82
$1,671.18
$1,571.13
$2,093.76
$2,063.39
$1,696.16
$1,333.58
$1,433.73
$1,269.58
$1,361.11
$1,287.10
$1,256.00
$1,287.10
$1,436.62
$1,450.60
$412.69
$2,086.57
$2,150.04
$1,852.01
$1,819.14
$1,922.30
$1,859.19
$2,311.40
$2,294.41
$2,336.03
$2,281.99
$3,321.74
$3,443.05
$2,241.94
$1,577.30
$1,066.01
Nonpar Fee
$1,498.64
$2,037.65
$1,512.23
$1,587.62
$1,492.57
$1,989.07
$1,960.22
$1,611.35
$1,266.90
$1,362.04
$1,206.10
$1,293.05
$1,222.75
$1,193.20
$1,222.75
$1,364.79
$1,378.07
$392.06
$1,982.24
$2,042.54
$1,759.41
$1,728.18
$1,826.19
$1,766.23
$2,195.83
$2,179.69
$2,219.23
$2,167.89
$3,155.65
$3,270.90
$2,129.84
$1,498.44
$1,012.71
Limiting
Charge
$1,723.44
$2,343.30
$1,739.06
$1,825.76
$1,716.46
$2,287.43
$2,254.25
$1,853.05
$1,456.94
$1,566.35
$1,387.02
$1,487.01
$1,406.16
$1,372.18
$1,406.16
$1,569.51
$1,584.78
$450.87
$2,279.58
$2,348.92
$2,023.32
$1,987.41
$2,100.12
$2,031.16
$2,525.20
$2,506.64
$2,552.11
$2,493.07
$3,629.00
$3,761.54
$2,449.32
$1,723.21
$1,164.62
Charge**
Charge***
$1,706.20
$1,697.58
$2,319.86
$2,308.15
$1,721.68
$1,712.98
$1,807.50
$1,798.38
$1,699.29
$1,690.71
$2,264.56
$2,253.11
$2,231.71
$2,220.44
$1,834.53
$1,825.26
$1,442.36
$1,435.09
$1,550.68
$1,542.85
$1,373.15
$1,366.21
$1,472.14
$1,464.70
$1,392.10
$1,385.07
$1,358.46
$1,351.60
$1,392.10
$1,385.07
$1,553.81
$1,545.97
$1,568.93
$1,561.01
$446.36
$444.11
$2,256.78
$2,245.39
$2,325.43
$2,313.69
$2,003.09
$1,992.97
$1,967.54
$1,957.60
$2,079.12
$2,068.62
$2,010.86
$2,000.70
$2,499.95
$2,487.32
$2,481.57
$2,469.04
$2,526.60
$2,513.83
$2,468.14
$2,455.68
$3,592.70
$3,574.57
$3,723.92
$3,705.12
$2,424.82
$2,412.57
$1,705.98
$1,697.35
$1,152.97
$1,147.15
Arizona
EHR/eRx
Limiting
Charge**
$1,688.97
$2,296.44
$1,704.29
$1,789.25
$1,682.13
$2,241.68
$2,209.17
$1,815.99
$1,427.79
$1,535.02
$1,359.28
$1,457.27
$1,378.05
$1,344.74
$1,378.05
$1,538.11
$1,553.09
$441.85
$2,233.99
$2,301.94
$1,982.85
$1,947.66
$2,058.12
$1,990.55
$2,474.70
$2,456.52
$2,501.08
$2,443.21
$3,556.42
$3,686.30
$2,400.33
$1,688.74
$1,141.33
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$1,680.61
$1,663.64
$2,285.06
$2,261.99
$1,695.85
$1,678.72
$1,780.38
$1,762.41
$1,673.80
$1,656.90
$2,230.59
$2,208.06
$2,198.24
$2,176.03
$1,807.01
$1,788.74
$1,420.73
$1,406.38
$1,527.42
$1,512.00
$1,352.55
$1,338.89
$1,450.06
$1,435.41
$1,371.21
$1,357.38
$1,338.08
$1,324.57
$1,371.21
$1,357.38
$1,530.50
$1,515.04
$1,545.40
$1,529.79
$439.67
$435.23
$2,222.93
$2,200.48
$2,290.55
$2,267.41
$1,973.04
$1,953.11
$1,938.03
$1,918.45
$2,047.93
$2,027.24
$1,980.69
$1,960.69
$2,462.45
$2,437.57
$2,444.35
$2,419.67
$2,488.69
$2,463.56
$2,431.12
$2,406.56
$3,538.81
$3,503.07
$3,668.06
$3,631.01
$2,388.45
$2,364.32
$1,680.39
$1,663.41
$1,135.67
$1,124.21
Page 107 of 323
Notes
Procedure
Code
33802
33803
33813
33814
33820
33822
33824
33840
33845
33851
33852
33853
33860
33863
33864
33870
33875
33877
33880
33881
33883
33884
33886
33889
33891
33910
33915
33916
33917
33920
33922
33924
33925
1/2/2015
Modifier
Par Fee
$1,171.41
$1,127.31
$1,212.68
$1,567.49
$988.68
$1,001.09
$1,203.13
$1,211.61
$1,360.41
$1,244.69
$1,426.18
$1,869.59
$3,282.35
$3,220.71
$3,300.74
$2,577.15
$2,810.27
$3,734.00
$1,859.54
$1,598.00
$1,158.12
$427.32
$999.28
$817.98
$1,003.21
$2,694.23
$1,310.16
$4,310.89
$1,499.13
$1,861.14
$1,416.30
$292.12
$1,768.43
Nonpar Fee
$1,112.84
$1,070.94
$1,152.05
$1,489.12
$939.25
$951.04
$1,142.97
$1,151.03
$1,292.39
$1,182.46
$1,354.87
$1,776.11
$3,118.23
$3,059.67
$3,135.70
$2,448.29
$2,669.76
$3,547.30
$1,766.56
$1,518.10
$1,100.21
$405.95
$949.32
$777.08
$953.05
$2,559.52
$1,244.65
$4,095.35
$1,424.17
$1,768.08
$1,345.49
$277.51
$1,680.01
Limiting
Charge
$1,279.77
$1,231.58
$1,324.86
$1,712.49
$1,080.14
$1,093.70
$1,314.42
$1,323.68
$1,486.25
$1,359.83
$1,558.10
$2,042.53
$3,585.96
$3,518.62
$3,606.06
$2,815.53
$3,070.22
$4,079.40
$2,031.54
$1,745.82
$1,265.24
$466.84
$1,091.72
$893.64
$1,096.01
$2,943.45
$1,431.35
$4,709.65
$1,637.80
$2,033.29
$1,547.31
$319.14
$1,932.01
Charge**
Charge***
$1,266.97
$1,260.57
$1,219.26
$1,213.11
$1,311.61
$1,304.99
$1,695.36
$1,686.80
$1,069.34
$1,063.93
$1,082.76
$1,077.29
$1,301.27
$1,294.70
$1,310.45
$1,303.82
$1,471.39
$1,463.95
$1,346.24
$1,339.43
$1,542.52
$1,534.73
$2,022.10
$2,011.89
$3,550.11
$3,532.18
$3,483.43
$3,465.84
$3,569.99
$3,551.96
$2,787.38
$2,773.31
$3,039.52
$3,024.17
$4,038.60
$4,018.20
$2,011.22
$2,001.07
$1,728.36
$1,719.63
$1,252.59
$1,246.27
$462.17
$459.84
$1,080.80
$1,075.34
$884.71
$880.23
$1,085.05
$1,079.56
$2,914.01
$2,899.30
$1,417.03
$1,409.88
$4,662.56
$4,639.01
$1,621.42
$1,613.23
$2,012.96
$2,002.79
$1,531.85
$1,524.11
$315.94
$314.35
$1,912.69
$1,903.03
Arizona
EHR/eRx
Limiting
Charge**
$1,254.17
$1,206.95
$1,298.36
$1,678.24
$1,058.54
$1,071.82
$1,288.13
$1,297.21
$1,456.52
$1,332.63
$1,526.94
$2,001.68
$3,514.25
$3,448.25
$3,533.94
$2,759.22
$3,008.81
$3,997.80
$1,990.91
$1,710.90
$1,239.94
$457.50
$1,069.88
$875.77
$1,074.09
$2,884.58
$1,402.72
$4,615.46
$1,605.04
$1,992.63
$1,516.37
$312.75
$1,893.37
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$1,247.96
$1,235.35
$1,200.98
$1,188.85
$1,291.93
$1,278.88
$1,669.94
$1,653.07
$1,053.30
$1,042.66
$1,066.52
$1,055.75
$1,281.76
$1,268.81
$1,290.79
$1,277.75
$1,449.32
$1,434.67
$1,326.04
$1,312.64
$1,519.38
$1,504.03
$1,991.77
$1,971.65
$3,496.85
$3,461.53
$3,431.17
$3,396.53
$3,516.44
$3,480.94
$2,745.57
$2,717.83
$2,993.92
$2,963.68
$3,978.02
$3,937.83
$1,981.06
$1,961.05
$1,702.44
$1,685.23
$1,233.80
$1,221.35
$455.24
$450.64
$1,064.59
$1,053.84
$871.44
$862.64
$1,068.78
$1,057.98
$2,870.30
$2,841.32
$1,395.78
$1,381.68
$4,592.62
$4,546.23
$1,597.10
$1,580.96
$1,982.76
$1,962.74
$1,508.87
$1,493.62
$311.20
$308.06
$1,884.00
$1,864.97
Page 108 of 323
Notes
Procedure
Code
33926
33935
33945
33946
33947
33948
33949
33951
33952
33953
33954
33955
33956
33957
33958
33959
33962
33963
33964
33965
33966
33967
33968
33969
33970
33971
33973
33974
33975
33976
33977
33978
33979
1/2/2015
Modifier
Par Fee
$2,601.24
$5,080.96
$4,970.36
$316.47
$349.55
$250.16
$243.46
$452.62
$440.05
$504.97
$491.60
$912.20
$862.14
$202.65
$195.86
$257.42
$241.33
$514.08
$525.98
$202.65
$243.07
$265.15
$34.15
$298.68
$363.33
$727.31
$527.89
$914.24
$1,342.96
$1,635.45
$1,158.44
$1,373.27
$2,001.81
Nonpar Fee
$2,471.18
$4,826.91
$4,721.84
$300.65
$332.07
$237.65
$231.29
$429.99
$418.05
$479.72
$467.02
$866.59
$819.03
$192.52
$186.07
$244.55
$229.26
$488.38
$499.68
$192.52
$230.92
$251.89
$32.44
$283.75
$345.16
$690.94
$501.50
$868.53
$1,275.81
$1,553.68
$1,100.52
$1,304.61
$1,901.72
Limiting
Charge
$2,841.86
$5,550.95
$5,430.12
$345.75
$381.88
$273.30
$265.98
$494.49
$480.76
$551.68
$537.07
$996.58
$941.88
$221.40
$213.98
$281.23
$263.65
$561.64
$574.63
$221.40
$265.56
$289.67
$37.31
$326.31
$396.93
$794.58
$576.73
$998.81
$1,467.18
$1,786.73
$1,265.60
$1,500.30
$2,186.98
Charge**
Charge***
$2,813.44
$2,799.23
$5,495.44
$5,467.69
$5,375.81
$5,348.66
$342.29
$340.56
$378.06
$376.15
$270.56
$269.20
$263.33
$261.99
$489.54
$487.07
$475.95
$473.55
$546.16
$543.40
$531.70
$529.01
$986.61
$981.63
$932.47
$927.75
$219.18
$218.07
$211.84
$210.77
$278.42
$277.01
$261.02
$259.69
$556.03
$553.21
$568.88
$566.01
$219.18
$218.07
$262.90
$261.58
$286.78
$285.33
$36.94
$36.74
$323.05
$321.41
$392.97
$390.98
$786.63
$782.67
$570.96
$568.08
$988.82
$983.83
$1,452.51
$1,445.17
$1,768.86
$1,759.93
$1,252.94
$1,246.61
$1,485.29
$1,477.80
$2,165.11
$2,154.17
Arizona
EHR/eRx
Limiting
Charge**
$2,785.02
$5,439.93
$5,321.51
$338.84
$374.24
$267.84
$260.66
$484.60
$471.14
$540.65
$526.33
$976.65
$923.05
$216.97
$209.70
$275.61
$258.37
$550.40
$563.14
$216.97
$260.25
$283.88
$36.56
$319.79
$389.00
$778.69
$565.19
$978.83
$1,437.83
$1,751.00
$1,240.29
$1,470.30
$2,143.24
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$2,771.24
$2,743.24
$5,413.00
$5,358.32
$5,295.18
$5,241.69
$337.16
$333.75
$372.39
$368.63
$266.50
$263.82
$259.38
$256.75
$482.20
$477.33
$468.81
$464.07
$537.97
$532.54
$523.72
$518.43
$971.81
$962.00
$918.48
$909.20
$215.89
$213.72
$208.67
$206.55
$274.24
$271.48
$257.11
$254.50
$547.69
$542.14
$560.35
$554.69
$215.89
$213.72
$258.96
$256.35
$282.47
$279.62
$36.39
$36.01
$318.21
$315.00
$387.07
$383.17
$774.84
$767.00
$562.40
$556.72
$973.98
$964.15
$1,430.72
$1,416.27
$1,742.33
$1,724.74
$1,234.15
$1,221.68
$1,463.02
$1,448.24
$2,132.63
$2,111.09
Page 109 of 323
Notes
Procedure
Code
33980
33981
33982
33983
33984
33985
33986
33987
33988
33989
33990
33991
33992
33993
34001
34051
34101
34111
34151
34201
34203
34401
34421
34451
34471
34490
34501
34502
34510
34520
34530
34800
34802
1/2/2015
Modifier
Par Fee
$1,825.65
$856.60
$2,013.10
$2,377.90
$292.70
$562.41
$533.67
$214.01
$795.92
$506.08
$449.12
$649.95
$218.66
$192.82
$1,022.98
$924.86
$624.55
$621.33
$1,455.34
$1,071.54
$989.63
$1,511.31
$755.45
$1,705.14
$1,121.18
$633.13
$928.57
$1,581.47
$1,224.00
$1,027.73
$1,137.35
$1,170.33
$1,294.43
Nonpar Fee
$1,734.37
$813.77
$1,912.45
$2,259.01
$278.07
$534.29
$506.99
$203.31
$756.12
$480.78
$426.66
$617.45
$207.73
$183.18
$971.83
$878.62
$593.32
$590.26
$1,382.57
$1,017.96
$940.15
$1,435.74
$717.68
$1,619.88
$1,065.12
$601.47
$882.14
$1,502.40
$1,162.80
$976.34
$1,080.48
$1,111.81
$1,229.71
Limiting
Charge
$1,994.53
$935.84
$2,199.32
$2,597.86
$319.78
$614.43
$583.04
$233.81
$869.54
$552.90
$490.66
$710.07
$238.89
$210.66
$1,117.60
$1,010.41
$682.32
$678.80
$1,589.96
$1,170.65
$1,081.17
$1,651.10
$825.33
$1,862.86
$1,224.89
$691.69
$1,014.46
$1,727.76
$1,337.22
$1,122.79
$1,242.55
$1,278.58
$1,414.17
Charge**
Charge***
$1,974.58
$1,964.60
$926.47
$921.79
$2,177.33
$2,166.32
$2,571.88
$2,558.89
$316.58
$314.99
$608.29
$605.22
$577.21
$574.30
$231.47
$230.30
$860.84
$856.50
$547.37
$544.61
$485.75
$483.30
$702.97
$699.42
$236.50
$235.30
$208.55
$207.49
$1,106.43
$1,100.84
$1,000.30
$995.26
$675.50
$672.08
$672.01
$668.62
$1,574.05
$1,566.10
$1,158.95
$1,153.09
$1,070.36
$1,064.96
$1,634.59
$1,626.33
$817.08
$812.95
$1,844.23
$1,834.92
$1,212.64
$1,206.51
$684.78
$681.32
$1,004.32
$999.25
$1,710.49
$1,701.84
$1,323.85
$1,317.16
$1,111.57
$1,105.94
$1,230.13
$1,223.91
$1,265.79
$1,259.40
$1,400.02
$1,392.95
Arizona
EHR/eRx
Limiting
Charge**
$1,954.63
$917.11
$2,155.33
$2,545.90
$313.39
$602.14
$571.38
$229.13
$852.15
$541.83
$480.85
$695.87
$234.12
$206.45
$1,095.25
$990.21
$668.67
$665.22
$1,558.16
$1,147.24
$1,059.55
$1,618.08
$808.83
$1,825.60
$1,200.39
$677.86
$994.18
$1,693.20
$1,310.47
$1,100.33
$1,217.70
$1,253.01
$1,385.89
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$1,944.96
$1,925.31
$912.58
$903.36
$2,144.67
$2,123.00
$2,533.30
$2,507.71
$311.83
$308.68
$599.17
$593.11
$568.55
$562.81
$228.00
$225.69
$847.93
$839.37
$539.15
$533.70
$478.46
$473.64
$692.43
$685.42
$232.96
$230.61
$205.42
$203.35
$1,089.83
$1,078.82
$985.30
$975.35
$665.37
$658.64
$661.93
$655.24
$1,550.44
$1,534.79
$1,141.56
$1,130.04
$1,054.31
$1,043.66
$1,610.07
$1,593.81
$804.82
$796.70
$1,816.56
$1,798.22
$1,194.45
$1,182.38
$674.51
$667.69
$989.25
$979.26
$1,684.83
$1,667.80
$1,303.99
$1,290.82
$1,094.89
$1,083.83
$1,211.67
$1,199.44
$1,246.81
$1,234.21
$1,379.02
$1,365.10
Page 110 of 323
Notes
Procedure
Code
34803
34804
34805
34806
34808
34812
34813
34820
34825
34826
34830
34831
34832
34833
34834
34900
35001
35002
35005
35011
35013
35021
35022
35045
35081
35082
35091
35092
35102
35103
35111
35112
35121
1/2/2015
Modifier
Par Fee
$1,335.93
$1,292.16
$1,244.78
$103.68
$216.12
$349.88
$245.71
$508.73
$721.60
$213.25
$1,833.69
$1,971.71
$1,971.71
$634.00
$282.46
$928.02
$1,173.28
$1,180.41
$1,193.20
$1,039.52
$1,292.52
$1,303.59
$1,492.57
$1,030.70
$1,814.62
$2,278.45
$1,863.46
$2,712.40
$1,964.44
$2,340.24
$1,381.07
$1,937.93
$1,707.42
Nonpar Fee
$1,269.13
$1,227.55
$1,182.54
$98.50
$205.31
$332.39
$233.42
$483.29
$685.52
$202.59
$1,742.01
$1,873.12
$1,873.12
$602.30
$268.34
$881.62
$1,114.62
$1,121.39
$1,133.54
$987.54
$1,227.89
$1,238.41
$1,417.94
$979.17
$1,723.89
$2,164.53
$1,770.29
$2,576.78
$1,866.22
$2,223.23
$1,312.02
$1,841.03
$1,622.05
Limiting
Charge
$1,459.50
$1,411.68
$1,359.92
$113.28
$236.11
$382.25
$268.43
$555.78
$788.35
$232.98
$2,003.31
$2,154.09
$2,154.09
$692.65
$308.59
$1,013.86
$1,281.81
$1,289.60
$1,303.57
$1,135.67
$1,412.07
$1,424.17
$1,630.63
$1,126.05
$1,982.47
$2,489.21
$2,035.83
$2,963.30
$2,146.15
$2,556.71
$1,508.82
$2,117.18
$1,865.36
Charge**
Charge***
$1,444.91
$1,437.60
$1,397.56
$1,390.51
$1,346.32
$1,339.52
$112.15
$111.57
$233.75
$232.56
$378.43
$376.51
$265.75
$264.41
$550.23
$547.45
$780.46
$776.53
$230.64
$229.48
$1,983.28
$1,973.26
$2,132.55
$2,121.77
$2,132.55
$2,121.77
$685.72
$682.26
$305.51
$303.96
$1,003.72
$998.66
$1,268.99
$1,262.59
$1,276.71
$1,270.26
$1,290.53
$1,284.02
$1,124.31
$1,118.64
$1,397.95
$1,390.89
$1,409.93
$1,402.80
$1,614.32
$1,606.17
$1,114.79
$1,109.15
$1,962.65
$1,952.73
$2,464.31
$2,451.87
$2,015.48
$2,005.30
$2,933.66
$2,918.85
$2,124.69
$2,113.96
$2,531.15
$2,518.36
$1,493.74
$1,486.19
$2,096.01
$2,085.42
$1,846.70
$1,837.38
Arizona
EHR/eRx
Limiting
Charge**
$1,430.31
$1,383.45
$1,332.72
$111.01
$231.38
$374.60
$263.06
$544.66
$772.58
$228.32
$1,963.25
$2,111.01
$2,111.01
$678.79
$302.42
$993.59
$1,256.18
$1,263.80
$1,277.50
$1,112.96
$1,383.83
$1,395.69
$1,598.02
$1,103.53
$1,942.82
$2,439.43
$1,995.11
$2,904.03
$2,103.24
$2,505.59
$1,478.65
$2,074.84
$1,828.05
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$1,423.23
$1,408.85
$1,376.60
$1,362.70
$1,326.12
$1,312.74
$110.47
$109.34
$230.24
$227.91
$372.75
$368.98
$261.76
$259.12
$541.97
$536.50
$768.75
$760.99
$227.18
$224.89
$1,953.53
$1,933.79
$2,100.56
$2,079.35
$2,100.56
$2,079.35
$675.44
$668.61
$300.93
$297.88
$988.67
$978.68
$1,249.96
$1,237.34
$1,257.56
$1,244.85
$1,271.18
$1,258.34
$1,107.45
$1,096.26
$1,376.99
$1,363.07
$1,388.79
$1,374.76
$1,590.11
$1,574.05
$1,098.07
$1,086.98
$1,933.21
$1,913.68
$2,427.35
$2,402.83
$1,985.25
$1,965.19
$2,889.65
$2,860.46
$2,092.83
$2,071.69
$2,493.19
$2,468.00
$1,471.33
$1,456.46
$2,064.57
$2,043.72
$1,819.00
$1,800.64
Page 111 of 323
Notes
Procedure
Code
35122
35131
35132
35141
35142
35151
35152
35180
35182
35184
35188
35189
35190
35201
35206
35207
35211
35216
35221
35226
35231
35236
35241
35246
35251
35256
35261
35266
35271
35276
35281
35286
35301
1/2/2015
Modifier
Par Fee
$2,235.81
$1,443.54
$1,700.20
$1,151.78
$1,371.16
$1,291.90
$1,453.27
$934.96
$1,678.95
$1,154.04
$1,099.41
$1,569.91
$787.45
$990.10
$801.76
$769.40
$1,413.38
$2,103.70
$1,498.52
$862.17
$1,267.08
$1,016.44
$1,479.61
$1,623.25
$1,765.38
$1,055.98
$1,110.77
$896.99
$1,420.28
$1,507.41
$1,680.40
$968.57
$1,175.61
Nonpar Fee
$2,124.02
$1,371.36
$1,615.19
$1,094.19
$1,302.60
$1,227.31
$1,380.61
$888.21
$1,595.00
$1,096.34
$1,044.44
$1,491.41
$748.08
$940.60
$761.67
$730.93
$1,342.71
$1,998.52
$1,423.59
$819.06
$1,203.73
$965.62
$1,405.63
$1,542.09
$1,677.11
$1,003.18
$1,055.23
$852.14
$1,349.27
$1,432.04
$1,596.38
$920.14
$1,116.83
Limiting
Charge
$2,442.62
$1,577.06
$1,857.47
$1,258.32
$1,497.99
$1,411.41
$1,587.70
$1,021.44
$1,834.25
$1,260.79
$1,201.11
$1,715.12
$860.29
$1,081.69
$875.92
$840.57
$1,544.12
$2,298.30
$1,637.13
$941.92
$1,384.29
$1,110.46
$1,616.47
$1,773.40
$1,928.68
$1,153.66
$1,213.51
$979.96
$1,551.66
$1,646.85
$1,835.84
$1,058.16
$1,284.35
Charge**
Charge***
$2,418.20
$2,405.98
$1,561.30
$1,553.41
$1,838.90
$1,829.60
$1,245.74
$1,239.45
$1,483.01
$1,475.52
$1,397.30
$1,390.24
$1,571.82
$1,563.89
$1,011.23
$1,006.12
$1,815.91
$1,806.74
$1,248.19
$1,241.87
$1,189.10
$1,183.09
$1,697.98
$1,689.40
$851.69
$847.39
$1,070.87
$1,065.46
$867.16
$862.78
$832.16
$827.97
$1,528.67
$1,520.96
$2,275.31
$2,263.82
$1,620.75
$1,612.58
$932.50
$927.79
$1,370.44
$1,363.52
$1,099.35
$1,093.81
$1,600.31
$1,592.23
$1,755.67
$1,746.80
$1,909.39
$1,899.74
$1,142.12
$1,136.35
$1,201.38
$1,195.31
$970.16
$965.26
$1,536.15
$1,528.38
$1,630.38
$1,622.14
$1,817.48
$1,808.29
$1,047.58
$1,042.29
$1,271.51
$1,265.09
Arizona
EHR/eRx
Limiting
Charge**
$2,393.77
$1,545.52
$1,820.32
$1,233.16
$1,468.03
$1,383.17
$1,555.95
$1,001.02
$1,797.57
$1,235.57
$1,177.08
$1,680.82
$843.09
$1,060.06
$858.41
$823.76
$1,513.24
$2,252.33
$1,604.39
$923.08
$1,356.61
$1,088.26
$1,584.15
$1,737.94
$1,890.11
$1,130.59
$1,189.25
$960.37
$1,520.62
$1,613.91
$1,799.12
$1,037.00
$1,258.66
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$2,381.93
$2,357.87
$1,537.88
$1,522.34
$1,811.31
$1,793.02
$1,227.05
$1,214.66
$1,460.76
$1,446.01
$1,376.33
$1,362.43
$1,548.25
$1,532.62
$996.06
$986.00
$1,788.66
$1,770.60
$1,229.47
$1,217.03
$1,171.26
$1,159.43
$1,672.50
$1,655.61
$838.91
$830.44
$1,054.80
$1,044.15
$854.15
$845.53
$819.69
$811.41
$1,505.74
$1,490.54
$2,241.18
$2,218.55
$1,596.44
$1,580.32
$918.52
$909.24
$1,349.88
$1,336.27
$1,082.86
$1,071.94
$1,576.31
$1,560.39
$1,729.34
$1,711.87
$1,880.74
$1,861.76
$1,124.99
$1,113.63
$1,183.36
$1,171.41
$955.62
$945.96
$1,513.10
$1,497.82
$1,605.92
$1,589.70
$1,790.22
$1,772.13
$1,031.87
$1,021.44
$1,252.44
$1,239.78
Page 112 of 323
Notes
#
#
#
#
Procedure
Code
35302
35303
35304
35305
35306
35311
35321
35331
35341
35351
35355
35361
35363
35371
35372
35390
35400
35450
35452
35458
35460
35471
35471
35472
35472
35475
35475
35476
35476
35500
35501
35506
35508
1/2/2015
Modifier
Par Fee
$1,171.01
$1,290.29
$1,334.73
$1,271.56
$464.16
$1,613.56
$922.61
$1,512.12
$1,412.88
$1,330.04
$1,075.92
$1,582.92
$1,821.31
$851.80
$1,020.35
$165.87
$154.91
$520.84
$354.31
$508.28
$324.98
$2,595.71
$538.75
$1,900.11
$369.10
$1,583.56
$345.37
$1,448.25
$279.43
$331.64
$1,563.10
$1,326.26
$1,382.36
Nonpar Fee
$1,112.46
$1,225.78
$1,267.99
$1,207.98
$440.95
$1,532.88
$876.48
$1,436.51
$1,342.24
$1,263.54
$1,022.12
$1,503.77
$1,730.24
$809.21
$969.33
$157.58
$147.16
$494.80
$336.59
$482.87
$308.73
$2,465.92
$511.81
$1,805.10
$350.65
$1,504.38
$328.10
$1,375.84
$265.46
$315.06
$1,484.95
$1,259.95
$1,313.24
Limiting
Charge
$1,279.33
$1,409.65
$1,458.19
$1,389.18
$507.09
$1,762.81
$1,007.95
$1,651.99
$1,543.58
$1,453.07
$1,175.44
$1,729.34
$1,989.78
$930.59
$1,114.73
$181.22
$169.23
$569.02
$387.08
$555.30
$355.04
$2,835.81
$588.58
$2,075.87
$403.25
$1,730.04
$377.32
$1,582.22
$305.28
$362.32
$1,707.69
$1,448.94
$1,510.23
Charge**
Charge***
$1,266.54
$1,260.14
$1,395.55
$1,388.50
$1,443.61
$1,436.32
$1,375.29
$1,368.34
$502.02
$499.49
$1,745.18
$1,736.37
$997.88
$992.83
$1,635.46
$1,627.20
$1,528.14
$1,520.43
$1,438.54
$1,431.28
$1,163.69
$1,157.81
$1,712.04
$1,703.39
$1,969.88
$1,959.93
$921.29
$916.63
$1,103.59
$1,098.01
$179.40
$178.50
$167.54
$166.69
$563.33
$560.49
$383.20
$381.27
$549.75
$546.97
$351.49
$349.72
$2,807.45
$2,793.27
$582.69
$579.75
$2,055.11
$2,044.72
$399.21
$397.20
$1,712.74
$1,704.08
$373.54
$371.66
$1,566.39
$1,558.48
$302.23
$300.70
$358.70
$356.88
$1,690.62
$1,682.08
$1,434.45
$1,427.21
$1,495.13
$1,487.57
Arizona
EHR/eRx
Limiting
Charge**
$1,253.74
$1,381.45
$1,429.02
$1,361.39
$496.95
$1,727.55
$987.79
$1,618.95
$1,512.71
$1,424.01
$1,151.93
$1,694.74
$1,949.99
$911.98
$1,092.43
$177.59
$165.85
$557.64
$379.34
$544.19
$347.94
$2,779.09
$576.81
$2,034.35
$395.19
$1,695.43
$369.77
$1,550.57
$299.17
$355.07
$1,673.54
$1,419.96
$1,480.03
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$1,247.54
$1,234.94
$1,374.62
$1,360.73
$1,421.95
$1,407.59
$1,354.65
$1,340.97
$494.49
$489.50
$1,719.01
$1,701.64
$982.91
$972.98
$1,610.93
$1,594.66
$1,505.22
$1,490.02
$1,416.96
$1,402.66
$1,146.23
$1,134.65
$1,686.36
$1,669.32
$1,940.34
$1,920.74
$907.47
$898.30
$1,087.04
$1,076.04
$176.71
$174.93
$165.03
$163.37
$554.88
$549.27
$377.45
$373.65
$541.50
$536.03
$346.22
$342.72
$2,765.34
$2,737.40
$573.95
$568.16
$2,024.28
$2,003.84
$393.22
$389.26
$1,687.05
$1,670.01
$367.94
$364.23
$1,542.90
$1,527.32
$297.70
$294.69
$353.31
$349.75
$1,665.26
$1,648.43
$1,412.94
$1,398.66
$1,472.70
$1,457.83
Page 113 of 323
Notes
Procedure
Code
35509
35510
35511
35512
35515
35516
35518
35521
35522
35523
35525
35526
35531
35533
35535
35536
35537
35538
35539
35540
35556
35558
35560
35563
35565
35566
35570
35571
35572
35583
35585
35587
35600
1/2/2015
Modifier
Par Fee
$1,471.78
$1,280.07
$1,166.11
$1,433.59
$1,586.16
$1,269.88
$1,188.56
$1,276.05
$1,263.07
$1,344.24
$1,195.10
$1,796.45
$2,101.38
$1,567.10
$1,980.16
$1,758.36
$2,463.64
$2,428.54
$2,281.40
$2,668.48
$1,457.00
$1,277.35
$1,773.43
$1,576.74
$1,381.75
$1,738.66
$1,579.33
$1,383.68
$358.42
$1,511.36
$1,748.27
$1,427.76
$262.25
Nonpar Fee
$1,398.19
$1,216.07
$1,107.80
$1,361.91
$1,506.85
$1,206.39
$1,129.13
$1,212.25
$1,199.92
$1,277.03
$1,135.35
$1,706.63
$1,996.31
$1,488.75
$1,881.15
$1,670.44
$2,340.46
$2,307.11
$2,167.33
$2,535.06
$1,384.15
$1,213.48
$1,684.76
$1,497.90
$1,312.66
$1,651.73
$1,500.36
$1,314.50
$340.50
$1,435.79
$1,660.86
$1,356.37
$249.14
Limiting
Charge
$1,607.92
$1,398.48
$1,273.97
$1,566.20
$1,732.88
$1,387.35
$1,298.50
$1,394.09
$1,379.91
$1,468.58
$1,305.65
$1,962.62
$2,295.76
$1,712.06
$2,163.32
$1,921.01
$2,691.53
$2,653.18
$2,492.43
$2,915.32
$1,591.77
$1,395.50
$1,937.47
$1,722.59
$1,509.56
$1,899.49
$1,725.41
$1,511.68
$391.58
$1,651.16
$1,909.99
$1,559.83
$286.51
Charge**
Charge***
$1,591.84
$1,583.80
$1,384.50
$1,377.50
$1,261.23
$1,254.86
$1,550.53
$1,542.70
$1,715.55
$1,706.89
$1,373.48
$1,366.53
$1,285.52
$1,279.02
$1,380.15
$1,373.18
$1,366.11
$1,359.21
$1,453.90
$1,446.55
$1,292.60
$1,286.07
$1,942.99
$1,933.18
$2,272.80
$2,261.33
$1,694.94
$1,686.38
$2,141.69
$2,130.87
$1,901.80
$1,892.19
$2,664.62
$2,651.15
$2,626.65
$2,613.38
$2,467.51
$2,455.04
$2,886.17
$2,871.58
$1,575.86
$1,567.90
$1,381.55
$1,374.57
$1,918.10
$1,908.41
$1,705.36
$1,696.74
$1,494.46
$1,486.92
$1,880.49
$1,870.99
$1,708.16
$1,699.53
$1,496.56
$1,489.00
$387.67
$385.70
$1,634.64
$1,626.39
$1,890.89
$1,881.34
$1,544.23
$1,536.42
$283.65
$282.21
Arizona
EHR/eRx
Limiting
Charge**
$1,575.76
$1,370.51
$1,248.49
$1,534.87
$1,698.22
$1,359.60
$1,272.53
$1,366.21
$1,352.31
$1,439.21
$1,279.54
$1,923.38
$2,249.84
$1,677.83
$2,120.06
$1,882.58
$2,637.70
$2,600.12
$2,442.58
$2,857.01
$1,559.94
$1,367.59
$1,898.72
$1,688.13
$1,479.37
$1,861.51
$1,690.90
$1,481.44
$383.74
$1,618.13
$1,871.79
$1,528.63
$280.78
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$1,567.97
$1,552.13
$1,363.73
$1,349.95
$1,242.31
$1,229.76
$1,527.28
$1,511.85
$1,689.81
$1,672.74
$1,352.88
$1,339.21
$1,266.23
$1,253.44
$1,359.45
$1,345.72
$1,345.62
$1,332.02
$1,432.10
$1,417.63
$1,273.21
$1,260.34
$1,913.85
$1,894.52
$2,238.71
$2,216.08
$1,669.51
$1,652.67
$2,109.56
$2,088.26
$1,873.27
$1,854.34
$2,624.65
$2,598.14
$2,587.25
$2,561.12
$2,430.50
$2,405.94
$2,842.87
$2,814.15
$1,552.22
$1,536.54
$1,360.83
$1,347.08
$1,889.32
$1,870.23
$1,679.78
$1,662.81
$1,472.05
$1,457.18
$1,852.28
$1,833.58
$1,682.54
$1,665.53
$1,474.12
$1,459.22
$381.85
$377.98
$1,610.13
$1,593.85
$1,862.53
$1,843.71
$1,521.07
$1,505.70
$279.39
$276.58
Page 114 of 323
Notes
Procedure
Code
35601
35606
35612
35616
35621
35623
35626
35631
35632
35633
35634
35636
35637
35638
35642
35645
35646
35647
35650
35654
35656
35661
35663
35665
35666
35671
35681
35682
35683
35685
35686
35691
35693
1/2/2015
Modifier
Par Fee
$1,459.38
$1,225.20
$1,086.48
$1,146.84
$1,145.84
$1,366.40
$1,630.63
$1,926.04
$1,880.32
$2,094.99
$1,905.47
$1,658.88
$1,810.95
$1,835.49
$1,192.52
$983.74
$1,786.99
$1,612.89
$1,133.54
$1,428.62
$1,128.67
$1,129.87
$1,314.12
$1,220.23
$1,316.30
$1,163.62
$83.16
$367.45
$426.30
$206.77
$167.79
$982.72
$867.54
Nonpar Fee
$1,386.41
$1,163.94
$1,032.16
$1,089.50
$1,088.55
$1,298.08
$1,549.10
$1,829.74
$1,786.30
$1,990.24
$1,810.20
$1,575.94
$1,720.40
$1,743.72
$1,132.89
$934.55
$1,697.64
$1,532.25
$1,076.86
$1,357.19
$1,072.24
$1,073.38
$1,248.41
$1,159.22
$1,250.49
$1,105.44
$79.00
$349.08
$404.99
$196.43
$159.40
$933.58
$824.16
Limiting
Charge
$1,594.37
$1,338.53
$1,186.98
$1,252.93
$1,251.83
$1,492.79
$1,781.47
$2,104.20
$2,054.25
$2,288.78
$2,081.73
$1,812.33
$1,978.46
$2,005.28
$1,302.82
$1,074.73
$1,952.29
$1,762.09
$1,238.39
$1,560.77
$1,233.08
$1,234.39
$1,435.67
$1,333.10
$1,438.06
$1,271.26
$90.85
$401.44
$465.74
$225.89
$183.31
$1,073.62
$947.78
Charge**
Charge***
$1,578.43
$1,570.45
$1,325.15
$1,318.45
$1,175.12
$1,169.18
$1,240.40
$1,234.13
$1,239.31
$1,233.05
$1,477.87
$1,470.40
$1,763.65
$1,754.74
$2,083.16
$2,072.63
$2,033.71
$2,023.44
$2,265.89
$2,254.45
$2,060.92
$2,050.51
$1,794.21
$1,785.15
$1,958.68
$1,948.78
$1,985.22
$1,975.19
$1,289.79
$1,283.29
$1,063.98
$1,058.61
$1,932.76
$1,923.01
$1,744.47
$1,735.66
$1,226.00
$1,219.82
$1,545.16
$1,537.35
$1,220.75
$1,214.58
$1,222.05
$1,215.87
$1,421.32
$1,414.13
$1,319.77
$1,313.10
$1,423.69
$1,416.49
$1,258.55
$1,252.19
$89.94
$89.49
$397.43
$395.42
$461.08
$458.76
$223.64
$222.50
$181.48
$180.56
$1,062.88
$1,057.52
$938.31
$933.57
Arizona
EHR/eRx
Limiting
Charge**
$1,562.48
$1,311.76
$1,163.25
$1,227.87
$1,226.80
$1,462.94
$1,745.84
$2,062.12
$2,013.16
$2,243.01
$2,040.10
$1,776.08
$1,938.89
$1,965.18
$1,276.76
$1,053.24
$1,913.24
$1,726.85
$1,213.62
$1,529.56
$1,208.42
$1,209.70
$1,406.96
$1,306.45
$1,409.30
$1,245.83
$89.03
$393.42
$456.42
$221.38
$179.64
$1,052.15
$928.83
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$1,554.75
$1,539.05
$1,305.27
$1,292.08
$1,157.49
$1,145.80
$1,221.79
$1,209.44
$1,220.73
$1,208.40
$1,455.69
$1,441.00
$1,737.20
$1,719.65
$2,051.91
$2,031.19
$2,003.20
$1,982.96
$2,231.90
$2,209.36
$2,030.00
$2,009.50
$1,767.30
$1,749.44
$1,929.30
$1,909.81
$1,955.45
$1,935.70
$1,270.45
$1,257.62
$1,048.02
$1,037.44
$1,903.77
$1,884.54
$1,718.31
$1,700.95
$1,207.62
$1,195.41
$1,521.99
$1,506.62
$1,202.44
$1,190.30
$1,203.72
$1,191.55
$1,400.00
$1,385.85
$1,299.98
$1,286.85
$1,402.33
$1,388.17
$1,239.67
$1,227.14
$88.60
$87.70
$391.47
$387.52
$454.17
$449.58
$220.28
$218.05
$178.76
$176.95
$1,046.94
$1,036.37
$924.23
$914.89
Page 115 of 323
Notes
#
#
#
#
#
Procedure
Code
35694
35695
35697
35700
35701
35721
35741
35761
35800
35820
35840
35860
35870
35875
35876
35879
35881
35883
35884
35901
35903
35905
35907
36002
36002
36005
36005
36010
36010
36011
36011
36012
36012
1/2/2015
Modifier
Par Fee
$1,026.49
$1,066.05
$153.53
$158.80
$584.76
$473.43
$530.20
$404.79
$736.32
$2,056.76
$1,216.62
$869.67
$1,294.29
$617.49
$981.98
$959.05
$1,058.84
$1,257.83
$1,290.89
$512.19
$586.94
$1,827.27
$1,986.62
$165.66
$110.24
$327.57
$49.75
$508.42
$126.20
$847.33
$162.63
$875.53
$179.75
Nonpar Fee
$975.17
$1,012.75
$145.85
$150.86
$555.52
$449.76
$503.69
$384.55
$699.50
$1,953.92
$1,155.79
$826.19
$1,229.58
$586.62
$932.88
$911.10
$1,005.90
$1,194.94
$1,226.35
$486.58
$557.59
$1,735.91
$1,887.29
$157.38
$104.73
$311.19
$47.26
$483.00
$119.89
$804.96
$154.50
$831.75
$170.76
Limiting
Charge
$1,121.45
$1,164.66
$167.73
$173.49
$638.85
$517.22
$579.24
$442.23
$804.43
$2,247.01
$1,329.16
$950.12
$1,414.02
$674.61
$1,072.81
$1,047.77
$1,156.79
$1,374.18
$1,410.30
$559.57
$641.23
$1,996.30
$2,170.38
$180.99
$120.44
$357.87
$54.35
$555.45
$137.87
$925.70
$177.68
$956.51
$196.37
Charge**
Charge***
$1,110.23
$1,104.62
$1,153.01
$1,147.19
$166.05
$165.21
$171.75
$170.89
$632.45
$629.27
$512.05
$509.46
$573.45
$570.55
$437.81
$435.60
$796.39
$792.36
$2,224.54
$2,213.30
$1,315.86
$1,309.22
$940.62
$935.87
$1,399.87
$1,392.81
$667.86
$664.49
$1,062.08
$1,056.72
$1,037.29
$1,032.04
$1,145.22
$1,139.43
$1,360.44
$1,353.57
$1,396.20
$1,389.14
$553.97
$551.17
$634.81
$631.61
$1,976.33
$1,966.35
$2,148.68
$2,137.83
$179.18
$178.27
$119.23
$118.63
$354.29
$352.50
$53.81
$53.53
$549.90
$547.12
$136.49
$135.80
$916.45
$911.82
$175.90
$175.01
$946.94
$942.16
$194.41
$193.43
Arizona
EHR/eRx
Limiting
Charge**
$1,099.02
$1,141.38
$164.37
$170.02
$626.07
$506.87
$567.66
$433.39
$788.34
$2,202.07
$1,302.57
$931.12
$1,385.74
$661.12
$1,051.35
$1,026.81
$1,133.65
$1,346.70
$1,382.09
$548.38
$628.41
$1,956.37
$2,126.97
$177.36
$118.04
$350.72
$53.26
$544.34
$135.11
$907.19
$174.12
$937.39
$192.44
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$1,093.58
$1,082.53
$1,135.72
$1,124.25
$163.55
$161.91
$169.18
$167.46
$622.97
$616.68
$504.37
$499.27
$564.85
$559.15
$431.24
$426.89
$784.44
$776.51
$2,191.16
$2,169.04
$1,296.13
$1,283.03
$926.51
$917.15
$1,378.87
$1,364.96
$657.85
$651.21
$1,046.16
$1,035.59
$1,021.73
$1,011.41
$1,128.04
$1,116.64
$1,340.04
$1,326.49
$1,375.26
$1,361.36
$545.65
$540.16
$625.29
$618.98
$1,946.69
$1,927.02
$2,116.45
$2,095.07
$176.49
$174.71
$117.44
$116.27
$348.98
$345.46
$53.00
$52.46
$541.65
$536.18
$134.45
$133.09
$902.70
$893.58
$173.27
$171.51
$932.74
$923.32
$191.49
$189.55
Page 116 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
36013
36013
36014
36014
36015
36015
36100
36100
36120
36120
36140
36140
36147
36147
36148
36148
36160
36160
36200
36200
36215
36215
36216
36216
36217
36217
36218
36218
36221
36221
36222
36222
36223
1/2/2015
Modifier
Par Fee
$792.70
$128.74
$825.25
$155.92
$875.66
$176.30
$497.26
$158.31
$425.96
$103.45
$443.03
$105.50
$847.51
$192.13
$265.76
$50.87
$502.78
$128.07
$633.53
$157.99
$1,142.68
$243.10
$1,187.85
$281.46
$1,921.68
$333.81
$186.88
$53.87
$1,109.62
$221.11
$1,284.26
$303.15
$1,542.06
Nonpar Fee
$753.07
$122.30
$783.99
$148.12
$831.88
$167.49
$472.40
$150.39
$404.66
$98.28
$420.88
$100.23
$805.13
$182.52
$252.47
$48.33
$477.64
$121.67
$601.85
$150.09
$1,085.55
$230.95
$1,128.46
$267.39
$1,825.60
$317.12
$177.54
$51.18
$1,054.14
$210.05
$1,220.05
$287.99
$1,464.96
Limiting
Charge
$866.03
$140.65
$901.59
$170.34
$956.66
$192.61
$543.26
$172.95
$465.36
$113.02
$484.01
$115.26
$925.90
$209.90
$290.34
$55.58
$549.29
$139.92
$692.13
$172.60
$1,248.38
$265.59
$1,297.73
$307.50
$2,099.44
$364.69
$204.17
$58.86
$1,212.26
$241.56
$1,403.06
$331.19
$1,684.70
Charge**
Charge***
$857.37
$853.04
$139.24
$138.54
$892.57
$888.06
$168.64
$167.79
$947.09
$942.31
$190.69
$189.73
$537.83
$535.11
$171.22
$170.35
$460.70
$458.38
$111.90
$111.33
$479.17
$476.76
$114.11
$113.54
$916.64
$912.01
$207.79
$206.75
$287.44
$285.98
$55.03
$54.75
$543.79
$541.05
$138.52
$137.82
$685.20
$681.74
$170.88
$170.02
$1,235.89
$1,229.66
$262.94
$261.61
$1,284.76
$1,278.26
$304.43
$302.89
$2,078.44
$2,067.95
$361.04
$359.21
$202.12
$201.11
$58.27
$57.97
$1,200.14
$1,194.08
$239.14
$237.94
$1,389.03
$1,382.01
$327.88
$326.22
$1,667.86
$1,659.44
Arizona
EHR/eRx
Limiting
Charge**
$848.71
$137.83
$883.56
$166.93
$937.53
$188.76
$532.39
$169.49
$456.06
$110.76
$474.33
$112.96
$907.38
$205.70
$284.53
$54.46
$538.30
$137.13
$678.28
$169.15
$1,223.42
$260.28
$1,271.77
$301.35
$2,057.45
$357.40
$200.09
$57.68
$1,188.02
$236.73
$1,375.00
$324.56
$1,651.01
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$844.51
$835.98
$137.15
$135.76
$879.19
$870.31
$166.11
$164.43
$932.89
$923.46
$187.83
$185.93
$529.76
$524.41
$168.66
$166.95
$453.79
$449.21
$110.22
$109.10
$471.98
$467.21
$112.40
$111.27
$902.89
$893.77
$204.68
$202.62
$283.13
$280.27
$54.20
$53.65
$535.64
$530.23
$136.44
$135.07
$674.92
$668.10
$168.31
$166.61
$1,217.36
$1,205.06
$258.99
$256.38
$1,265.48
$1,252.70
$299.86
$296.83
$2,047.26
$2,026.59
$355.63
$352.04
$199.09
$197.09
$57.40
$56.82
$1,182.14
$1,170.19
$235.55
$233.17
$1,368.19
$1,354.38
$322.95
$319.70
$1,642.84
$1,626.25
Page 117 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
36223
36224
36224
36225
36225
36226
36226
36227
36227
36228
36228
36245
36245
36246
36246
36247
36247
36248
36248
36251
36251
36252
36252
36253
36253
36254
36254
36260
36261
36262
36400
36400
36405
1/2/2015
Modifier
Par Fee
$331.76
$1,923.76
$374.51
$1,487.81
$330.78
$1,878.84
$372.50
$264.84
$118.97
$1,279.06
$241.82
$1,388.86
$260.09
$904.31
$277.17
$1,600.37
$328.22
$155.01
$50.96
$1,443.27
$289.83
$1,566.08
$384.74
$2,301.82
$390.02
$2,235.78
$446.61
$658.55
$369.17
$311.76
$28.52
$19.58
$26.73
Nonpar Fee
$315.17
$1,827.57
$355.78
$1,413.42
$314.24
$1,784.90
$353.88
$251.60
$113.02
$1,215.11
$229.73
$1,319.42
$247.09
$859.09
$263.31
$1,520.35
$311.81
$147.26
$48.41
$1,371.11
$275.34
$1,487.78
$365.50
$2,186.73
$370.52
$2,123.99
$424.28
$625.62
$350.71
$296.17
$27.09
$18.60
$25.39
Limiting
Charge
$362.45
$2,101.71
$409.15
$1,625.43
$361.38
$2,052.64
$406.96
$289.34
$129.97
$1,397.38
$264.19
$1,517.33
$284.15
$987.95
$302.81
$1,748.40
$358.58
$169.35
$55.67
$1,576.78
$316.64
$1,710.95
$420.33
$2,514.74
$426.10
$2,442.59
$487.92
$719.46
$403.32
$340.60
$31.15
$21.39
$29.20
Charge**
Charge***
$358.82
$357.01
$2,080.68
$2,070.18
$405.05
$403.01
$1,609.18
$1,601.05
$357.77
$355.96
$2,032.11
$2,021.85
$402.89
$400.86
$286.44
$285.00
$128.67
$128.02
$1,383.40
$1,376.41
$261.54
$260.22
$1,502.16
$1,494.57
$281.31
$279.89
$978.08
$973.13
$299.78
$298.26
$1,730.92
$1,722.17
$354.99
$353.20
$167.66
$166.81
$55.12
$54.83
$1,561.01
$1,553.12
$313.48
$311.89
$1,693.84
$1,685.28
$416.13
$414.02
$2,489.59
$2,477.02
$421.83
$419.70
$2,418.16
$2,405.95
$483.05
$480.61
$712.26
$708.68
$399.28
$397.27
$337.19
$335.49
$30.84
$30.68
$21.17
$21.07
$28.91
$28.76
Arizona
EHR/eRx
Limiting
Charge**
$355.20
$2,059.67
$400.96
$1,592.92
$354.15
$2,011.58
$398.82
$283.56
$127.37
$1,369.43
$258.91
$1,486.98
$278.47
$968.20
$296.75
$1,713.43
$351.41
$165.96
$54.56
$1,545.24
$310.30
$1,676.72
$411.92
$2,464.45
$417.58
$2,393.74
$478.16
$705.08
$395.26
$333.79
$30.53
$20.96
$28.61
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$353.44
$349.88
$2,049.47
$2,028.77
$398.98
$394.94
$1,585.05
$1,569.03
$352.39
$348.84
$2,001.62
$1,981.40
$396.84
$392.84
$282.14
$279.30
$126.74
$125.47
$1,362.66
$1,348.89
$257.62
$255.02
$1,479.64
$1,464.67
$277.09
$274.30
$963.40
$953.67
$295.29
$292.30
$1,704.96
$1,687.73
$349.67
$346.14
$165.14
$163.47
$54.29
$53.74
$1,537.60
$1,522.06
$308.78
$305.65
$1,668.43
$1,651.57
$409.88
$405.74
$2,452.25
$2,427.49
$415.51
$411.31
$2,381.89
$2,357.83
$475.80
$470.98
$701.58
$694.50
$393.29
$389.32
$332.13
$328.79
$30.38
$30.07
$20.85
$20.65
$28.47
$28.19
Page 118 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
36405
36406
36406
36410
36410
36420
36425
36430
36440
36450
36455
36460
36470
36470
36471
36471
36475
36475
36476
36476
36478
36478
36479
36479
36481
36481
36500
36510
36510
36511
36512
36513
36514
1/2/2015
Modifier
Par Fee
$16.36
$20.61
$10.24
$17.07
$9.57
$51.94
$40.68
$34.95
$56.87
$120.92
$130.46
$353.58
$151.75
$85.96
$177.10
$102.73
$1,556.17
$289.02
$299.71
$139.17
$1,217.08
$287.45
$311.68
$140.06
$2,094.12
$363.95
$185.88
$93.73
$59.05
$94.00
$96.64
$98.57
$541.25
Nonpar Fee
$15.54
$19.58
$9.73
$16.22
$9.09
$49.34
$38.65
$33.20
$54.03
$114.87
$123.94
$335.90
$144.16
$81.66
$168.25
$97.59
$1,478.36
$274.57
$284.72
$132.21
$1,156.23
$273.08
$296.10
$133.06
$1,989.41
$345.75
$176.59
$89.04
$56.10
$89.30
$91.81
$93.64
$514.19
Limiting
Charge
$17.87
$22.52
$11.19
$18.65
$10.45
$56.74
$44.45
$38.18
$62.13
$132.10
$142.53
$386.29
$165.78
$93.91
$193.49
$112.23
$1,700.11
$315.76
$327.43
$152.04
$1,329.66
$314.04
$340.52
$153.02
$2,287.82
$397.61
$203.08
$102.40
$64.52
$102.70
$105.58
$107.69
$591.32
Charge**
Charge***
$17.69
$17.61
$22.29
$22.18
$11.07
$11.02
$18.47
$18.38
$10.35
$10.29
$56.18
$55.89
$44.00
$43.78
$37.80
$37.61
$61.51
$61.20
$130.78
$130.12
$141.11
$140.39
$382.42
$380.49
$164.13
$163.30
$92.97
$92.51
$191.56
$190.59
$111.10
$110.55
$1,683.12
$1,674.61
$312.59
$311.02
$324.15
$322.52
$150.52
$149.76
$1,316.37
$1,309.72
$310.90
$309.33
$337.11
$335.41
$151.49
$150.72
$2,264.95
$2,253.51
$393.63
$391.64
$201.04
$200.03
$101.37
$100.86
$63.87
$63.55
$101.67
$101.15
$104.52
$103.99
$106.61
$106.08
$585.41
$582.45
Arizona
EHR/eRx
Limiting
Charge**
$17.51
$22.07
$10.97
$18.29
$10.25
$55.60
$43.56
$37.42
$60.89
$129.46
$139.68
$378.56
$162.47
$92.03
$189.62
$109.99
$1,666.11
$309.44
$320.88
$149.01
$1,303.08
$307.76
$333.71
$149.96
$2,242.06
$389.67
$199.02
$100.35
$63.23
$100.64
$103.47
$105.54
$579.50
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$17.42
$17.25
$21.95
$21.74
$10.91
$10.81
$18.19
$18.01
$10.20
$10.10
$55.34
$54.76
$43.34
$42.91
$37.24
$36.86
$60.59
$59.98
$128.81
$127.51
$138.99
$137.59
$376.68
$372.88
$161.67
$160.03
$91.57
$90.65
$188.68
$186.78
$109.43
$108.34
$1,657.87
$1,641.12
$307.90
$304.80
$319.29
$316.07
$148.27
$146.77
$1,296.63
$1,283.53
$306.23
$303.15
$332.05
$328.70
$149.21
$147.71
$2,230.98
$2,208.44
$387.73
$383.82
$198.03
$196.03
$99.85
$98.84
$62.92
$62.28
$100.14
$99.13
$102.96
$101.91
$105.01
$103.95
$576.62
$570.80
Page 119 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
36514
36515
36515
36516
36516
36522
36522
36555
36555
36556
36556
36557
36557
36558
36558
36560
36560
36561
36561
36563
36563
36565
36565
36566
36566
36568
36568
36569
36569
36570
36570
36571
36571
1/2/2015
Modifier
Par Fee
$94.67
$2,081.52
$92.84
$2,101.01
$70.86
$1,410.00
$103.52
$257.54
$119.88
$236.45
$123.82
$1,036.48
$336.76
$794.65
$285.51
$1,088.86
$364.12
$1,193.43
$362.85
$1,355.65
$389.92
$978.79
$356.66
$5,624.17
$395.76
$308.09
$101.78
$253.83
$94.36
$1,209.03
$314.80
$1,327.65
$331.52
Nonpar Fee
$89.94
$1,977.44
$88.20
$1,995.96
$67.32
$1,339.50
$98.34
$244.66
$113.89
$224.63
$117.63
$984.66
$319.92
$754.92
$271.23
$1,034.42
$345.91
$1,133.76
$344.71
$1,287.87
$370.42
$929.85
$338.83
$5,342.96
$375.97
$292.69
$96.69
$241.14
$89.64
$1,148.58
$299.06
$1,261.27
$314.94
Limiting
Charge
$103.43
$2,274.06
$101.43
$2,295.35
$77.42
$1,540.43
$113.09
$281.36
$130.97
$258.32
$135.27
$1,132.36
$367.91
$868.16
$311.91
$1,189.58
$397.80
$1,303.82
$396.42
$1,481.05
$425.98
$1,069.33
$389.65
$6,144.40
$432.37
$336.59
$111.19
$277.31
$103.09
$1,320.87
$343.92
$1,450.46
$362.18
Charge**
Charge***
$102.40
$101.88
$2,251.32
$2,239.95
$100.42
$99.91
$2,272.40
$2,260.92
$76.65
$76.26
$1,525.03
$1,517.32
$111.96
$111.39
$278.54
$277.14
$129.66
$129.01
$255.74
$254.45
$133.92
$133.25
$1,121.03
$1,115.37
$364.23
$362.39
$859.48
$855.14
$308.80
$307.23
$1,177.69
$1,171.74
$393.82
$391.83
$1,290.78
$1,284.26
$392.45
$390.47
$1,466.24
$1,458.83
$421.73
$419.59
$1,058.63
$1,053.29
$385.76
$383.81
$6,082.96
$6,052.24
$428.04
$425.88
$333.22
$331.55
$110.08
$109.53
$274.54
$273.15
$102.05
$101.55
$1,307.65
$1,301.05
$340.48
$338.76
$1,435.96
$1,428.70
$358.56
$356.75
Arizona
EHR/eRx
Limiting
Charge**
$101.36
$2,228.57
$99.41
$2,249.45
$75.87
$1,509.62
$110.83
$275.74
$128.35
$253.16
$132.57
$1,109.72
$360.55
$850.79
$305.68
$1,165.79
$389.84
$1,277.74
$388.49
$1,451.43
$417.46
$1,047.94
$381.86
$6,021.52
$423.72
$329.87
$108.97
$271.77
$101.03
$1,294.45
$337.04
$1,421.45
$354.94
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$100.86
$99.84
$2,217.55
$2,195.14
$98.91
$97.91
$2,238.31
$2,215.71
$75.50
$74.73
$1,502.15
$1,486.97
$110.29
$109.16
$274.37
$271.60
$127.72
$126.43
$251.90
$249.37
$131.91
$130.58
$1,104.22
$1,093.08
$358.77
$355.14
$846.58
$838.03
$304.16
$301.09
$1,160.03
$1,148.30
$387.91
$384.00
$1,271.42
$1,258.57
$386.56
$382.66
$1,444.25
$1,429.66
$415.40
$411.19
$1,042.75
$1,032.22
$379.97
$376.13
$5,991.72
$5,931.19
$421.62
$417.36
$328.22
$324.92
$108.42
$107.34
$270.42
$267.70
$100.52
$99.51
$1,288.03
$1,275.04
$335.37
$331.98
$1,414.42
$1,400.13
$353.18
$349.61
Page 120 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
36575
36575
36576
36576
36578
36578
36580
36580
36581
36581
36582
36582
36583
36583
36584
36584
36585
36585
36589
36589
36590
36590
36591
36592
36593
36595
36595
36596
36596
36597
36597
36598
36598
1/2/2015
Modifier
Par Fee
$168.72
$36.07
$394.11
$203.18
$529.66
$223.24
$218.47
$69.02
$779.93
$202.49
$1,113.92
$314.44
$1,386.35
$345.53
$207.61
$68.52
$1,176.88
$291.95
$167.98
$141.88
$297.57
$210.33
$23.55
$26.41
$31.06
$594.14
$190.11
$135.43
$46.04
$130.25
$63.74
$111.65
$37.64
Nonpar Fee
$160.28
$34.27
$374.40
$193.02
$503.18
$212.08
$207.55
$65.57
$740.93
$192.37
$1,058.22
$298.72
$1,317.03
$328.25
$197.23
$65.09
$1,118.04
$277.35
$159.58
$134.79
$282.69
$199.81
$22.37
$25.09
$29.51
$564.43
$180.60
$128.66
$43.74
$123.74
$60.55
$106.07
$35.76
Limiting
Charge
$184.32
$39.41
$430.56
$221.97
$578.66
$243.89
$238.68
$75.41
$852.07
$221.23
$1,216.95
$343.53
$1,514.58
$377.49
$226.81
$74.85
$1,285.75
$318.95
$183.52
$155.01
$325.09
$229.78
$25.73
$28.85
$33.94
$649.09
$207.69
$147.96
$50.30
$142.30
$69.63
$121.98
$41.12
Charge**
Charge***
$182.48
$181.56
$39.02
$38.82
$426.26
$424.10
$219.75
$218.64
$572.87
$569.97
$241.45
$240.24
$236.29
$235.11
$74.65
$74.28
$843.55
$839.29
$219.02
$217.90
$1,204.79
$1,198.70
$340.09
$338.38
$1,499.44
$1,491.86
$373.72
$371.83
$224.55
$223.41
$74.11
$73.73
$1,272.89
$1,266.46
$315.77
$314.17
$181.68
$180.77
$153.46
$152.69
$321.84
$320.22
$227.48
$226.33
$25.47
$25.33
$28.57
$28.42
$33.59
$33.43
$642.61
$639.35
$205.61
$204.57
$146.48
$145.74
$49.80
$49.54
$140.88
$140.16
$68.93
$68.59
$120.76
$120.15
$40.71
$40.50
Arizona
EHR/eRx
Limiting
Charge**
$180.63
$38.62
$421.95
$217.53
$567.09
$239.02
$233.91
$73.90
$835.03
$216.80
$1,192.62
$336.66
$1,484.29
$369.94
$222.28
$73.36
$1,260.03
$312.57
$179.85
$151.90
$318.60
$225.18
$25.21
$28.28
$33.26
$636.11
$203.54
$145.00
$49.30
$139.46
$68.24
$119.54
$40.30
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$179.75
$177.92
$38.43
$38.04
$419.87
$415.62
$216.45
$214.27
$564.28
$558.58
$237.83
$235.43
$232.75
$230.40
$73.53
$72.80
$830.90
$822.50
$215.73
$213.54
$1,186.72
$1,174.73
$334.98
$331.61
$1,476.95
$1,462.03
$368.12
$364.39
$221.18
$218.95
$72.99
$72.25
$1,253.80
$1,241.13
$311.03
$307.88
$178.95
$177.15
$151.16
$149.63
$317.01
$313.81
$224.07
$221.80
$25.09
$24.83
$28.14
$27.85
$33.09
$32.76
$632.97
$626.57
$202.53
$200.49
$144.28
$142.83
$49.05
$48.56
$138.76
$137.37
$67.90
$67.22
$118.94
$117.75
$40.10
$39.69
Page 121 of 323
Notes
#
#
#
Procedure
Code
36600
36600
36620
36625
36640
36660
36680
36800
36810
36815
36818
36819
36820
36821
36823
36825
36830
36831
36832
36833
36835
36838
36860
36860
36861
36870
36870
37140
37145
37160
37180
37181
37182
1/2/2015
Modifier
Par Fee
$32.09
$15.64
$52.12
$105.14
$122.34
$62.09
$59.95
$126.42
$220.07
$141.72
$718.16
$761.17
$755.98
$689.33
$1,418.11
$831.36
$693.13
$641.22
$785.98
$840.79
$516.61
$1,187.77
$210.96
$113.35
$135.19
$1,862.16
$310.40
$2,360.54
$2,188.87
$2,248.24
$2,163.25
$2,360.54
$865.79
Nonpar Fee
$30.49
$14.86
$49.51
$99.88
$116.22
$58.99
$56.95
$120.10
$209.07
$134.63
$682.25
$723.11
$718.18
$654.86
$1,347.20
$789.79
$658.47
$609.16
$746.68
$798.75
$490.78
$1,128.38
$200.41
$107.68
$128.43
$1,769.05
$294.88
$2,242.51
$2,079.43
$2,135.83
$2,055.09
$2,242.51
$822.50
Limiting
Charge
$35.06
$17.09
$56.94
$114.86
$133.65
$67.84
$65.49
$138.12
$240.43
$154.82
$784.59
$831.58
$825.91
$753.09
$1,549.28
$908.26
$757.24
$700.53
$858.68
$918.56
$564.40
$1,297.64
$230.47
$123.83
$147.69
$2,034.41
$339.11
$2,578.89
$2,391.34
$2,456.20
$2,363.35
$2,578.89
$945.88
Charge**
Charge***
$34.72
$34.53
$16.92
$16.84
$56.36
$56.09
$113.71
$113.14
$132.32
$131.65
$67.16
$66.83
$64.84
$64.52
$136.74
$136.05
$238.03
$236.82
$153.27
$152.50
$776.74
$772.82
$823.26
$819.10
$817.65
$813.52
$745.56
$741.80
$1,533.79
$1,526.04
$899.17
$894.63
$749.67
$745.88
$693.53
$690.02
$850.09
$845.80
$909.37
$904.79
$558.75
$555.93
$1,284.67
$1,278.17
$228.17
$227.01
$122.59
$121.97
$146.22
$145.48
$2,014.06
$2,003.89
$335.72
$334.03
$2,553.09
$2,540.20
$2,367.44
$2,355.48
$2,431.64
$2,419.36
$2,339.72
$2,327.90
$2,553.09
$2,540.20
$936.42
$931.68
Arizona
EHR/eRx
Limiting
Charge**
$34.36
$16.74
$55.80
$112.56
$130.99
$66.48
$64.18
$135.36
$235.62
$151.73
$768.90
$814.95
$809.39
$738.02
$1,518.30
$890.09
$742.10
$686.53
$841.51
$900.20
$553.10
$1,271.68
$225.86
$121.36
$144.74
$1,993.72
$332.33
$2,527.31
$2,343.52
$2,407.08
$2,316.09
$2,527.31
$926.96
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$34.20
$33.84
$16.66
$16.49
$55.51
$54.96
$112.01
$110.87
$130.33
$129.02
$66.15
$65.48
$63.86
$63.22
$134.69
$133.32
$234.46
$232.09
$150.97
$149.45
$765.10
$757.37
$810.91
$802.72
$805.39
$797.25
$734.38
$726.95
$1,510.78
$1,495.53
$885.68
$876.74
$738.43
$730.96
$683.12
$676.23
$837.34
$828.89
$895.74
$886.70
$550.37
$544.81
$1,265.39
$1,252.60
$224.74
$222.47
$120.75
$119.54
$144.03
$142.57
$1,983.85
$1,963.81
$330.68
$327.35
$2,514.80
$2,489.41
$2,331.92
$2,308.36
$2,395.16
$2,370.97
$2,304.62
$2,281.35
$2,514.80
$2,489.41
$922.38
$913.05
Page 122 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
37183
37183
37184
37184
37185
37185
37186
37186
37187
37187
37188
37188
37191
37191
37192
37192
37193
37193
37197
37197
37200
37202
37211
37212
37213
37214
37215
37217
37218
37220
37220
37221
37221
1/2/2015
Modifier
Par Fee
$6,006.93
$408.46
$2,308.46
$475.67
$729.85
$172.79
$1,399.69
$256.61
$2,097.15
$420.97
$1,790.97
$303.22
$2,677.72
$247.12
$1,707.34
$387.99
$1,628.12
$378.85
$1,545.08
$327.63
$228.64
$308.39
$413.07
$362.24
$255.97
$140.77
$1,120.48
$1,156.25
$846.54
$3,207.37
$429.58
$4,731.39
$527.71
Nonpar Fee
$5,706.58
$388.04
$2,193.04
$451.89
$693.36
$164.15
$1,329.71
$243.78
$1,992.29
$399.92
$1,701.42
$288.06
$2,543.83
$234.76
$1,621.97
$368.59
$1,546.71
$359.91
$1,467.83
$311.25
$217.21
$292.97
$392.42
$344.13
$243.17
$133.73
$1,064.46
$1,098.44
$804.21
$3,047.00
$408.10
$4,494.82
$501.32
Limiting
Charge
$6,562.57
$446.25
$2,522.00
$519.67
$797.36
$188.77
$1,529.17
$280.35
$2,291.13
$459.91
$1,956.63
$331.27
$2,925.40
$269.97
$1,865.27
$423.88
$1,778.72
$413.90
$1,688.00
$357.94
$249.79
$336.92
$451.28
$395.75
$279.65
$153.79
$1,224.13
$1,263.21
$924.84
$3,504.05
$469.32
$5,169.04
$576.52
Charge**
Charge***
$6,496.94
$6,464.13
$441.78
$439.55
$2,496.78
$2,484.16
$514.48
$511.88
$789.39
$785.40
$186.89
$185.94
$1,513.87
$1,506.22
$277.54
$276.14
$2,268.23
$2,256.77
$455.31
$453.01
$1,937.07
$1,927.29
$327.96
$326.30
$2,896.15
$2,881.52
$267.27
$265.93
$1,846.61
$1,837.29
$419.64
$417.52
$1,760.93
$1,752.04
$409.76
$407.69
$1,671.12
$1,662.68
$354.36
$352.57
$247.30
$246.04
$333.55
$331.87
$446.78
$444.51
$391.79
$389.82
$276.85
$275.45
$152.25
$151.48
$1,211.89
$1,205.76
$1,250.58
$1,244.25
$915.60
$910.97
$3,469.01
$3,451.50
$464.62
$462.28
$5,117.35
$5,091.51
$570.76
$567.87
Arizona
EHR/eRx
Limiting
Charge**
$6,431.32
$437.32
$2,471.56
$509.28
$781.41
$185.00
$1,498.59
$274.74
$2,245.31
$450.71
$1,917.50
$324.65
$2,866.89
$264.57
$1,827.96
$415.40
$1,743.15
$405.62
$1,654.24
$350.78
$244.80
$330.18
$442.26
$387.84
$274.06
$150.72
$1,199.65
$1,237.94
$906.35
$3,433.97
$459.93
$5,065.66
$564.98
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$6,399.49
$6,334.84
$435.16
$430.77
$2,459.32
$2,434.48
$506.76
$501.64
$777.55
$769.70
$184.08
$182.23
$1,491.16
$1,476.11
$273.38
$270.62
$2,234.20
$2,211.62
$448.48
$443.95
$1,908.01
$1,888.74
$323.04
$319.78
$2,852.70
$2,823.89
$263.26
$260.60
$1,818.91
$1,800.54
$413.34
$409.17
$1,734.51
$1,717.00
$403.62
$399.53
$1,646.05
$1,629.42
$349.05
$345.52
$243.58
$241.13
$328.54
$325.22
$440.07
$435.62
$385.92
$382.02
$272.70
$269.95
$149.96
$148.45
$1,193.71
$1,181.65
$1,231.82
$1,219.37
$901.86
$892.76
$3,416.97
$3,382.46
$457.65
$453.03
$5,040.59
$4,989.68
$562.20
$556.51
Page 123 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
37222
37222
37223
37223
37224
37224
37225
37225
37226
37226
37227
37227
37228
37228
37229
37229
37230
37230
37231
37231
37232
37232
37233
37233
37234
37234
37235
37235
37236
37236
37237
37237
37238
1/2/2015
Modifier
Par Fee
$898.53
$193.45
$2,637.51
$222.28
$3,892.61
$473.75
$11,208.26
$639.53
$9,216.87
$556.01
$15,137.47
$769.09
$5,537.05
$577.87
$11,055.88
$746.37
$8,450.62
$736.18
$13,583.85
$800.11
$1,234.09
$209.72
$1,491.34
$340.75
$3,941.95
$294.62
$4,232.31
$405.13
$4,213.99
$470.11
$2,526.31
$222.64
$4,179.00
Nonpar Fee
$853.60
$183.78
$2,505.63
$211.17
$3,697.98
$450.06
$10,647.85
$607.55
$8,756.03
$528.21
$14,380.60
$730.64
$5,260.20
$548.98
$10,503.09
$709.05
$8,028.09
$699.37
$12,904.66
$760.10
$1,172.39
$199.23
$1,416.77
$323.71
$3,744.85
$279.89
$4,020.69
$384.87
$4,003.29
$446.60
$2,399.99
$211.51
$3,970.05
Limiting
Charge
$981.64
$211.35
$2,881.47
$242.85
$4,252.68
$517.57
$12,245.03
$698.68
$10,069.43
$607.44
$16,537.69
$840.24
$6,049.23
$631.33
$12,078.55
$815.41
$9,232.30
$804.28
$14,840.36
$874.12
$1,348.25
$229.11
$1,629.29
$372.27
$4,306.58
$321.87
$4,623.79
$442.60
$4,603.78
$513.59
$2,759.99
$243.24
$4,565.56
Charge**
Charge***
$971.82
$966.92
$209.23
$208.17
$2,852.66
$2,838.26
$240.42
$239.20
$4,210.15
$4,188.89
$512.39
$509.81
$12,122.58
$12,061.35
$691.69
$688.21
$9,968.74
$9,918.39
$601.37
$598.33
$16,372.31
$16,289.62
$831.83
$827.63
$5,988.74
$5,958.50
$625.01
$621.86
$11,957.77
$11,897.37
$807.25
$803.17
$9,139.98
$9,093.82
$796.24
$792.21
$14,691.95
$14,617.75
$865.38
$861.01
$1,334.77
$1,328.02
$226.83
$225.68
$1,612.99
$1,604.85
$368.54
$366.68
$4,263.51
$4,241.98
$318.65
$317.04
$4,577.55
$4,554.44
$438.17
$435.97
$4,557.75
$4,534.73
$508.45
$505.89
$2,732.39
$2,718.59
$240.80
$239.59
$4,519.90
$4,497.08
Arizona
EHR/eRx
Limiting
Charge**
$962.01
$207.12
$2,823.85
$237.99
$4,167.62
$507.22
$12,000.12
$684.71
$9,868.05
$595.30
$16,206.94
$823.43
$5,928.25
$618.70
$11,836.98
$799.10
$9,047.66
$788.19
$14,543.56
$856.64
$1,321.28
$224.54
$1,596.69
$364.83
$4,220.44
$315.43
$4,531.32
$433.75
$4,511.70
$503.32
$2,704.79
$238.37
$4,474.25
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$957.24
$947.58
$206.09
$204.01
$2,809.86
$2,781.49
$236.81
$234.43
$4,147.00
$4,105.11
$504.71
$499.61
$11,940.74
$11,820.13
$681.32
$674.44
$9,819.21
$9,720.03
$592.35
$586.37
$16,126.73
$15,963.84
$819.35
$811.08
$5,898.91
$5,839.33
$615.64
$609.42
$11,778.40
$11,659.42
$795.14
$787.12
$9,002.88
$8,911.95
$784.29
$776.37
$14,471.58
$14,325.40
$852.39
$843.79
$1,314.75
$1,301.47
$223.42
$221.17
$1,588.79
$1,572.74
$363.01
$359.35
$4,199.56
$4,157.14
$313.87
$310.71
$4,508.89
$4,463.36
$431.60
$427.24
$4,489.38
$4,444.03
$500.83
$495.77
$2,691.40
$2,664.22
$237.19
$234.80
$4,452.10
$4,407.13
Page 124 of 323
Notes
#
#
#
#
#
#
#
Procedure
Code
37238
37239
37239
37241
37241
37242
37242
37243
37243
37244
37244
37250
37251
37500
37565
37600
37605
37606
37607
37609
37609
37615
37616
37617
37618
37619
37650
37660
37700
37718
37722
37735
37760
1/2/2015
Modifier
Par Fee
$329.29
$2,062.02
$155.58
$4,668.08
$459.04
$7,871.09
$511.70
$9,936.65
$609.68
$6,950.71
$711.51
$110.20
$82.80
$662.87
$756.29
$743.68
$816.48
$498.93
$389.43
$315.80
$212.83
$520.94
$1,134.64
$1,378.68
$393.44
$1,675.86
$478.14
$1,338.41
$257.90
$451.48
$493.55
$604.93
$633.39
Nonpar Fee
$312.83
$1,958.92
$147.80
$4,434.68
$436.09
$7,477.54
$486.12
$9,439.82
$579.20
$6,603.17
$675.93
$104.69
$78.66
$629.73
$718.48
$706.50
$775.66
$473.98
$369.96
$300.01
$202.19
$494.89
$1,077.91
$1,309.75
$373.77
$1,592.07
$454.23
$1,271.49
$245.01
$428.91
$468.87
$574.68
$601.72
Limiting
Charge
$359.75
$2,252.76
$169.97
$5,099.88
$501.50
$8,599.17
$559.04
$10,855.79
$666.08
$7,593.65
$777.32
$120.39
$90.46
$724.19
$826.25
$812.48
$892.01
$545.08
$425.45
$345.01
$232.52
$569.12
$1,239.60
$1,506.21
$429.84
$1,830.88
$522.36
$1,462.21
$281.76
$493.25
$539.20
$660.88
$691.98
Charge**
Charge***
$356.16
$354.36
$2,230.23
$2,218.97
$168.27
$167.42
$5,048.88
$5,023.38
$496.49
$493.98
$8,513.17
$8,470.19
$553.45
$550.65
$10,747.23
$10,692.95
$659.42
$656.09
$7,517.71
$7,479.74
$769.55
$765.66
$119.19
$118.59
$89.55
$89.10
$716.94
$713.32
$818.00
$813.86
$804.36
$800.29
$883.09
$878.63
$539.63
$536.90
$421.20
$419.07
$341.56
$339.84
$230.20
$229.03
$563.43
$560.59
$1,227.20
$1,221.00
$1,491.15
$1,483.62
$425.53
$423.38
$1,812.57
$1,803.42
$517.14
$514.53
$1,447.60
$1,440.28
$278.94
$277.53
$488.31
$485.85
$533.81
$531.12
$654.27
$650.97
$685.06
$681.59
Arizona
EHR/eRx
Limiting
Charge**
$352.56
$2,207.70
$166.57
$4,997.89
$491.48
$8,427.19
$547.86
$10,638.67
$652.76
$7,441.78
$761.77
$117.99
$88.65
$709.71
$809.73
$796.23
$874.17
$534.18
$416.94
$338.11
$227.87
$557.74
$1,214.80
$1,476.09
$421.23
$1,794.26
$511.92
$1,432.97
$276.13
$483.38
$528.41
$647.67
$678.14
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$350.81
$347.27
$2,196.78
$2,174.58
$165.75
$164.07
$4,973.15
$4,922.92
$489.04
$484.10
$8,385.48
$8,300.78
$545.15
$539.64
$10,586.03
$10,479.09
$649.53
$642.98
$7,404.94
$7,330.15
$758.00
$750.34
$117.40
$116.22
$88.21
$87.32
$706.19
$699.06
$805.72
$797.58
$792.29
$784.28
$869.84
$861.06
$531.53
$526.16
$414.89
$410.69
$336.43
$333.04
$226.75
$224.46
$554.98
$549.38
$1,208.79
$1,196.58
$1,468.78
$1,453.96
$419.15
$414.92
$1,785.39
$1,767.35
$509.38
$504.24
$1,425.89
$1,411.48
$274.76
$271.99
$480.99
$476.13
$525.80
$520.49
$644.46
$637.95
$674.77
$667.97
Page 125 of 323
Notes
#
#
#
#
#
#
Procedure
Code
37761
37765
37765
37766
37766
37780
37785
37785
37788
37790
38100
38101
38102
38115
38120
38200
38205
38206
38220
38220
38221
38221
38230
38232
38240
38241
38242
38243
38300
38300
38305
38308
38380
1/2/2015
Modifier
Par Fee
$574.10
$668.64
$464.48
$793.50
$567.17
$266.57
$366.91
$272.51
$1,285.08
$495.36
$1,173.34
$1,185.74
$267.03
$1,299.23
$1,071.23
$138.26
$83.94
$84.66
$166.36
$62.67
$169.75
$76.79
$201.87
$206.44
$228.40
$171.86
$121.62
$121.67
$278.61
$187.79
$469.93
$450.93
$571.58
Nonpar Fee
$545.40
$635.21
$441.26
$753.83
$538.81
$253.24
$348.56
$258.88
$1,220.83
$470.59
$1,114.67
$1,126.45
$253.68
$1,234.27
$1,017.67
$131.35
$79.74
$80.43
$158.04
$59.54
$161.26
$72.95
$191.78
$196.12
$216.98
$163.27
$115.54
$115.59
$264.68
$178.40
$446.43
$428.38
$543.00
Limiting
Charge
$627.21
$730.49
$507.45
$866.90
$619.63
$291.23
$400.84
$297.71
$1,403.95
$541.18
$1,281.87
$1,295.42
$291.73
$1,419.41
$1,170.32
$151.05
$91.70
$92.49
$181.75
$68.47
$185.45
$83.89
$220.55
$225.54
$249.53
$187.76
$132.87
$132.93
$304.38
$205.16
$513.39
$492.64
$624.45
Charge**
Charge***
$620.94
$617.80
$723.19
$719.53
$502.38
$499.84
$858.23
$853.90
$613.43
$610.34
$288.32
$286.86
$396.83
$394.83
$294.73
$293.25
$1,389.91
$1,382.90
$535.76
$533.06
$1,269.05
$1,262.64
$1,282.47
$1,275.98
$288.81
$287.35
$1,405.22
$1,398.12
$1,158.61
$1,152.76
$149.55
$148.79
$90.78
$90.32
$91.57
$91.10
$179.93
$179.02
$67.78
$67.45
$183.60
$182.67
$83.05
$82.64
$218.34
$217.24
$223.28
$222.16
$247.03
$245.79
$185.89
$184.94
$131.54
$130.88
$131.59
$130.94
$301.33
$299.82
$203.11
$202.08
$508.27
$505.69
$487.72
$485.24
$618.21
$615.09
Arizona
EHR/eRx
Limiting
Charge**
$614.66
$715.89
$497.29
$849.56
$607.23
$285.41
$392.83
$291.76
$1,375.87
$530.36
$1,256.24
$1,269.51
$285.90
$1,391.02
$1,146.92
$148.03
$89.87
$90.64
$178.11
$67.10
$181.73
$82.21
$216.13
$221.03
$244.54
$184.00
$130.21
$130.27
$298.30
$201.05
$503.13
$482.78
$611.96
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$611.63
$605.44
$712.34
$705.15
$494.85
$489.83
$845.37
$836.82
$604.23
$598.13
$283.99
$281.13
$390.87
$386.94
$290.32
$287.37
$1,369.06
$1,355.23
$527.72
$522.40
$1,250.02
$1,237.39
$1,263.23
$1,250.46
$284.48
$281.61
$1,384.14
$1,370.16
$1,141.24
$1,129.71
$147.30
$145.81
$89.42
$88.53
$90.21
$89.29
$177.23
$175.44
$66.77
$66.09
$180.85
$179.01
$81.81
$80.98
$215.06
$212.89
$219.94
$217.72
$243.33
$240.87
$183.10
$181.24
$129.56
$128.26
$129.62
$128.32
$296.82
$293.83
$200.07
$198.04
$500.64
$495.58
$480.40
$475.54
$608.94
$602.78
Page 126 of 323
Notes
#
#
#
Procedure
Code
38381
38382
38500
38500
38505
38505
38510
38510
38520
38525
38530
38542
38550
38555
38562
38564
38570
38571
38572
38700
38720
38724
38740
38745
38746
38747
38760
38765
38770
38780
38790
38792
38794
1/2/2015
Modifier
Par Fee
$819.05
$690.69
$335.53
$258.66
$129.26
$73.48
$527.70
$427.94
$471.93
$443.11
$555.85
$527.70
$516.33
$1,022.94
$716.90
$716.21
$547.56
$813.91
$1,002.44
$823.62
$1,371.50
$1,485.38
$705.13
$889.32
$220.36
$272.17
$855.78
$1,314.58
$822.33
$1,046.07
$85.51
$40.50
$309.04
Nonpar Fee
$778.10
$656.16
$318.75
$245.73
$122.80
$69.81
$501.32
$406.54
$448.33
$420.95
$528.06
$501.32
$490.51
$971.79
$681.06
$680.40
$520.18
$773.21
$952.32
$782.44
$1,302.93
$1,411.11
$669.87
$844.85
$209.34
$258.56
$812.99
$1,248.85
$781.21
$993.77
$81.23
$38.48
$293.59
Limiting
Charge
$894.82
$754.58
$366.56
$282.59
$141.22
$80.28
$576.52
$467.52
$515.58
$484.09
$607.27
$576.52
$564.09
$1,117.56
$783.22
$782.46
$598.21
$889.19
$1,095.17
$899.81
$1,498.37
$1,622.78
$770.35
$971.58
$240.74
$297.34
$934.94
$1,436.18
$898.39
$1,142.84
$93.41
$44.25
$337.63
Charge**
Charge***
$885.87
$881.39
$747.04
$743.27
$362.89
$361.07
$279.76
$278.35
$139.81
$139.10
$79.48
$79.07
$570.76
$567.87
$462.84
$460.51
$510.43
$507.85
$479.25
$476.84
$601.20
$598.16
$570.76
$567.87
$558.44
$555.62
$1,106.38
$1,100.79
$775.39
$771.47
$774.64
$770.72
$592.23
$589.24
$880.30
$875.85
$1,084.22
$1,078.75
$890.81
$886.31
$1,483.39
$1,475.90
$1,606.55
$1,598.43
$762.65
$758.79
$961.86
$957.01
$238.34
$237.13
$294.37
$292.88
$925.59
$920.92
$1,421.81
$1,414.64
$889.41
$884.91
$1,131.40
$1,125.69
$92.48
$92.01
$43.82
$43.59
$334.25
$332.57
Arizona
EHR/eRx
Limiting
Charge**
$876.92
$739.50
$359.24
$276.94
$138.39
$78.67
$564.98
$458.17
$505.26
$474.41
$595.13
$564.98
$552.81
$1,095.20
$767.56
$766.81
$586.25
$871.41
$1,073.26
$881.81
$1,468.40
$1,590.32
$754.94
$952.14
$235.92
$291.40
$916.24
$1,407.45
$880.43
$1,119.97
$91.55
$43.37
$330.88
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$872.59
$863.77
$735.84
$728.40
$357.45
$353.84
$275.56
$272.79
$137.71
$136.31
$78.28
$77.49
$562.20
$556.51
$455.89
$451.29
$502.77
$497.69
$472.06
$467.29
$592.18
$586.20
$562.20
$556.51
$550.07
$544.51
$1,089.79
$1,078.77
$763.76
$756.04
$763.03
$755.31
$583.35
$577.45
$867.10
$858.34
$1,067.96
$1,057.16
$877.45
$868.58
$1,461.13
$1,446.38
$1,582.46
$1,566.47
$751.20
$743.61
$947.43
$937.86
$234.76
$232.38
$289.95
$287.03
$911.71
$902.50
$1,400.48
$1,386.34
$876.07
$867.23
$1,114.43
$1,103.17
$91.09
$90.18
$43.16
$42.71
$329.23
$325.91
Page 127 of 323
Notes
#
#
#
#
#
#
#
#
Procedure
Code
38900
39000
39010
39200
39220
39400
39501
39503
39540
39541
39545
39560
39561
40490
40490
40500
40500
40510
40510
40520
40520
40525
40527
40530
40530
40650
40650
40652
40652
40654
40654
40700
40701
1/2/2015
Modifier
Par Fee
$140.11
$507.84
$805.14
$898.37
$1,164.58
$520.01
$865.67
$6,264.53
$884.64
$964.48
$911.45
$812.47
$1,262.38
$130.87
$74.74
$517.60
$373.15
$496.11
$365.96
$501.47
$368.46
$564.16
$632.96
$552.12
$413.39
$447.60
$305.65
$503.97
$364.17
$581.48
$435.24
$1,028.92
$1,004.08
Nonpar Fee
$133.10
$482.45
$764.88
$853.45
$1,106.35
$494.01
$822.39
$5,951.30
$840.41
$916.26
$865.88
$771.85
$1,199.26
$124.33
$71.00
$491.72
$354.49
$471.30
$347.66
$476.40
$350.04
$535.95
$601.31
$524.51
$392.72
$425.22
$290.37
$478.77
$345.96
$552.41
$413.48
$977.47
$953.88
Limiting
Charge
$153.07
$554.82
$879.61
$981.47
$1,272.30
$568.11
$945.75
$6,844.00
$966.47
$1,053.70
$995.76
$887.63
$1,379.15
$142.98
$81.65
$565.48
$407.66
$542.00
$399.81
$547.86
$402.55
$616.34
$691.51
$603.19
$451.63
$489.00
$333.93
$550.59
$397.85
$635.27
$475.50
$1,124.09
$1,096.96
Charge**
Charge***
$151.54
$150.77
$549.27
$546.49
$870.81
$866.42
$971.66
$966.75
$1,259.58
$1,253.21
$562.43
$559.59
$936.30
$931.56
$6,775.56
$6,741.33
$956.81
$951.97
$1,043.17
$1,037.90
$985.80
$980.82
$878.75
$874.31
$1,365.36
$1,358.46
$141.55
$140.84
$80.83
$80.43
$559.82
$556.99
$403.59
$401.55
$536.58
$533.86
$395.81
$393.82
$542.39
$539.64
$398.52
$396.51
$610.18
$607.10
$684.60
$681.13
$597.15
$594.14
$447.11
$444.85
$484.12
$481.67
$330.59
$328.91
$545.08
$542.33
$393.88
$391.89
$628.92
$625.74
$470.75
$468.37
$1,112.86
$1,107.23
$1,085.99
$1,080.51
Arizona
EHR/eRx
Limiting
Charge**
$150.01
$543.72
$862.02
$961.84
$1,246.85
$556.75
$926.83
$6,707.11
$947.14
$1,032.62
$975.84
$869.87
$1,351.56
$140.12
$80.02
$554.17
$399.51
$531.15
$391.82
$536.90
$394.50
$604.01
$677.67
$591.12
$442.60
$479.23
$327.24
$539.57
$389.90
$622.56
$465.99
$1,101.61
$1,075.02
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$149.26
$147.75
$541.04
$535.57
$857.75
$849.09
$957.09
$947.40
$1,240.69
$1,228.15
$553.99
$548.40
$922.25
$912.93
$6,673.92
$6,606.51
$942.46
$932.94
$1,027.51
$1,017.13
$971.01
$961.20
$865.57
$856.82
$1,344.88
$1,331.29
$139.43
$138.01
$79.63
$78.82
$551.43
$545.86
$397.54
$393.52
$528.53
$523.18
$389.87
$385.94
$534.26
$528.85
$392.54
$388.57
$601.02
$594.95
$674.33
$667.51
$588.19
$582.26
$440.40
$435.97
$476.86
$472.04
$325.63
$322.33
$536.90
$531.47
$387.96
$384.04
$619.49
$613.23
$463.69
$459.00
$1,096.16
$1,085.08
$1,069.70
$1,058.90
Page 128 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
40702
40720
40761
40800
40800
40801
40801
40804
40804
40805
40805
40806
40806
40808
40808
40810
40810
40812
40812
40814
40814
40816
40816
40818
40818
40819
40819
40820
40820
40830
40830
40831
40831
1/2/2015
Modifier
Par Fee
$957.63
$1,051.37
$998.75
$219.77
$137.54
$328.44
$231.90
$219.77
$136.46
$335.10
$243.21
$111.69
$34.46
$193.80
$113.35
$213.92
$133.47
$299.38
$206.06
$400.49
$317.90
$417.08
$329.48
$373.13
$284.10
$326.07
$248.48
$275.91
$179.37
$275.55
$172.94
$348.99
$232.79
Nonpar Fee
$909.75
$998.80
$948.81
$208.78
$130.66
$312.02
$220.31
$208.78
$129.64
$318.35
$231.05
$106.11
$32.74
$184.11
$107.68
$203.22
$126.80
$284.41
$195.76
$380.47
$302.01
$396.23
$313.01
$354.47
$269.90
$309.77
$236.06
$262.11
$170.40
$261.77
$164.29
$331.54
$221.15
Limiting
Charge
$1,046.21
$1,148.62
$1,091.13
$240.10
$150.26
$358.82
$253.36
$240.10
$149.09
$366.10
$265.71
$122.03
$37.65
$211.73
$123.83
$233.70
$145.82
$327.07
$225.12
$437.54
$347.31
$455.66
$359.96
$407.64
$310.39
$356.24
$271.47
$301.43
$195.96
$301.04
$188.93
$381.27
$254.32
Charge**
Charge***
$1,035.75
$1,030.52
$1,137.13
$1,131.39
$1,080.22
$1,074.77
$237.69
$236.50
$148.75
$148.01
$355.24
$353.44
$250.83
$249.56
$237.69
$236.50
$147.59
$146.86
$362.45
$360.61
$263.05
$261.72
$120.81
$120.20
$37.27
$37.09
$209.61
$208.55
$122.59
$121.97
$231.37
$230.20
$144.36
$143.64
$323.81
$322.16
$222.87
$221.74
$433.17
$430.97
$343.84
$342.10
$451.11
$448.83
$356.36
$354.56
$403.57
$401.52
$307.28
$305.73
$352.67
$350.89
$268.76
$267.40
$298.41
$296.91
$194.01
$193.02
$298.02
$296.52
$187.05
$186.10
$377.45
$375.56
$251.78
$250.50
Arizona
EHR/eRx
Limiting
Charge**
$1,025.29
$1,125.64
$1,069.30
$235.29
$147.26
$351.65
$248.29
$235.29
$146.11
$358.78
$260.39
$119.59
$36.90
$207.49
$121.36
$229.03
$142.90
$320.53
$220.62
$428.79
$340.37
$446.56
$352.76
$399.49
$304.18
$349.11
$266.04
$295.40
$192.04
$295.01
$185.15
$373.65
$249.24
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$1,020.21
$1,009.92
$1,120.08
$1,108.76
$1,064.01
$1,053.26
$234.13
$231.76
$146.52
$145.05
$349.91
$346.37
$247.07
$244.56
$234.13
$231.76
$145.37
$143.91
$357.01
$353.40
$259.11
$256.48
$118.99
$117.79
$36.71
$36.35
$206.47
$204.38
$120.75
$119.54
$227.90
$225.60
$142.20
$140.76
$318.95
$315.72
$219.52
$217.30
$426.67
$422.36
$338.69
$335.26
$444.35
$439.86
$351.01
$347.47
$397.52
$393.50
$302.67
$299.61
$347.38
$343.87
$264.72
$262.05
$293.94
$290.97
$191.10
$189.16
$293.55
$290.58
$184.24
$182.38
$371.80
$368.05
$248.01
$245.50
Page 129 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
40840
40840
40842
40842
40843
40843
40844
40844
40845
40845
41000
41000
41005
41005
41006
41006
41007
41007
41008
41008
41009
41009
41010
41010
41015
41015
41016
41016
41017
41017
41018
41018
41019
1/2/2015
Modifier
Par Fee
$837.92
$648.78
$844.90
$674.35
$1,121.51
$888.75
$1,329.63
$1,081.84
$1,507.59
$1,266.60
$168.55
$117.07
$234.79
$130.03
$397.32
$277.90
$390.97
$269.76
$393.74
$280.40
$417.44
$304.45
$209.18
$112.28
$470.00
$364.88
$456.81
$366.00
$463.52
$368.77
$523.64
$428.54
$475.01
Nonpar Fee
$796.02
$616.34
$802.66
$640.63
$1,065.43
$844.31
$1,263.15
$1,027.75
$1,432.21
$1,203.27
$160.12
$111.22
$223.05
$123.53
$377.45
$264.01
$371.42
$256.27
$374.05
$266.38
$396.57
$289.23
$198.72
$106.67
$446.50
$346.64
$433.97
$347.70
$440.34
$350.33
$497.46
$407.11
$451.26
Limiting
Charge
$915.42
$708.79
$923.06
$736.72
$1,225.24
$970.96
$1,452.62
$1,181.91
$1,647.04
$1,383.76
$184.14
$127.90
$256.51
$142.06
$434.07
$303.61
$427.13
$294.71
$430.16
$306.34
$456.06
$332.61
$228.53
$122.67
$513.48
$398.64
$499.07
$399.86
$506.39
$402.88
$572.08
$468.18
$518.95
Charge**
Charge***
$906.27
$901.69
$701.71
$698.15
$913.82
$909.21
$729.35
$725.67
$1,213.00
$1,206.87
$961.25
$956.40
$1,438.10
$1,430.83
$1,170.09
$1,164.18
$1,630.57
$1,622.34
$1,369.93
$1,363.00
$182.30
$181.38
$126.63
$125.98
$253.94
$252.66
$140.63
$139.93
$429.73
$427.56
$300.58
$299.06
$422.87
$420.73
$291.77
$290.29
$425.86
$423.71
$303.28
$301.74
$451.49
$449.21
$329.29
$327.62
$226.24
$225.10
$121.44
$120.83
$508.35
$505.77
$394.65
$392.66
$494.07
$491.58
$395.85
$393.85
$501.33
$498.79
$398.85
$396.84
$566.36
$563.50
$463.50
$461.15
$513.76
$511.16
Arizona
EHR/eRx
Limiting
Charge**
$897.12
$694.61
$904.60
$721.99
$1,200.74
$951.53
$1,423.57
$1,158.28
$1,614.11
$1,356.08
$180.46
$125.35
$251.38
$139.22
$425.39
$297.54
$418.59
$288.81
$421.56
$300.21
$446.94
$325.97
$223.96
$120.22
$503.21
$390.67
$489.08
$391.86
$496.26
$394.82
$560.64
$458.82
$508.56
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$892.68
$883.66
$691.18
$684.19
$900.12
$891.03
$718.42
$711.16
$1,194.80
$1,182.73
$946.83
$937.26
$1,416.52
$1,402.22
$1,152.54
$1,140.90
$1,606.11
$1,589.90
$1,349.38
$1,335.74
$179.56
$177.76
$124.73
$123.48
$250.14
$247.61
$138.53
$137.13
$423.28
$419.00
$296.07
$293.08
$416.52
$412.31
$287.39
$284.48
$419.47
$415.23
$298.72
$295.70
$444.72
$440.23
$324.35
$321.08
$222.85
$220.60
$119.62
$118.42
$500.72
$495.66
$388.72
$384.80
$486.67
$481.75
$389.92
$385.99
$493.81
$488.82
$392.87
$388.90
$557.87
$552.23
$456.54
$451.94
$506.06
$500.94
Page 130 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
41100
41100
41105
41105
41108
41108
41110
41110
41112
41112
41113
41113
41114
41115
41115
41116
41116
41120
41130
41135
41140
41145
41150
41153
41155
41250
41250
41251
41251
41252
41252
41500
41510
1/2/2015
Modifier
Par Fee
$173.87
$112.02
$176.69
$115.91
$153.36
$94.00
$219.19
$136.96
$347.34
$263.32
$380.29
$291.62
$657.63
$255.17
$151.13
$342.65
$228.23
$1,081.34
$1,337.30
$2,217.25
$2,229.08
$2,820.15
$2,239.19
$2,444.10
$3,074.49
$278.01
$159.66
$302.16
$190.24
$325.76
$217.07
$472.05
$413.34
Nonpar Fee
$165.18
$106.42
$167.86
$110.11
$145.69
$89.30
$208.23
$130.11
$329.97
$250.15
$361.28
$277.04
$624.75
$242.41
$143.57
$325.52
$216.82
$1,027.27
$1,270.44
$2,106.39
$2,117.63
$2,679.14
$2,127.23
$2,321.90
$2,920.77
$264.11
$151.68
$287.05
$180.73
$309.47
$206.22
$448.45
$392.67
Limiting
Charge
$189.96
$122.38
$193.04
$126.63
$167.54
$102.70
$239.46
$149.63
$379.47
$287.67
$415.47
$318.60
$718.46
$278.77
$165.11
$374.35
$249.34
$1,181.36
$1,461.01
$2,422.35
$2,435.27
$3,081.01
$2,446.31
$2,670.19
$3,358.89
$303.73
$174.43
$330.11
$207.84
$355.89
$237.15
$515.72
$451.57
Charge**
Charge***
$188.06
$187.11
$121.16
$120.54
$191.11
$190.14
$125.36
$124.73
$165.86
$165.03
$101.67
$101.15
$237.07
$235.88
$148.13
$147.38
$375.67
$373.77
$284.80
$283.36
$411.32
$409.24
$315.41
$313.81
$711.28
$707.69
$275.99
$274.59
$163.45
$162.63
$370.60
$368.74
$246.85
$245.61
$1,169.55
$1,163.64
$1,446.40
$1,439.09
$2,398.13
$2,386.01
$2,410.92
$2,398.75
$3,050.20
$3,034.79
$2,421.85
$2,409.62
$2,643.48
$2,630.13
$3,325.29
$3,308.50
$300.69
$299.17
$172.68
$171.81
$326.81
$325.15
$205.76
$204.72
$352.34
$350.55
$234.78
$233.60
$510.57
$507.98
$447.05
$444.80
Arizona
EHR/eRx
Limiting
Charge**
$186.16
$119.93
$189.18
$124.10
$164.20
$100.64
$234.68
$146.64
$371.88
$281.92
$407.16
$312.23
$704.10
$273.19
$161.81
$366.86
$244.35
$1,157.73
$1,431.78
$2,373.90
$2,386.57
$3,019.39
$2,397.39
$2,616.78
$3,291.70
$297.65
$170.95
$323.51
$203.69
$348.77
$232.42
$505.40
$442.54
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$185.24
$183.37
$119.35
$118.14
$188.24
$186.33
$123.48
$122.23
$163.38
$161.74
$100.14
$99.13
$233.52
$231.16
$145.91
$144.44
$370.04
$366.30
$280.53
$277.69
$405.15
$401.05
$310.68
$307.54
$700.60
$693.54
$271.85
$269.10
$161.00
$159.38
$365.04
$361.35
$243.14
$240.68
$1,152.01
$1,140.36
$1,424.70
$1,410.30
$2,362.16
$2,338.30
$2,374.75
$2,350.77
$3,004.44
$2,974.11
$2,385.53
$2,361.43
$2,603.83
$2,577.53
$3,275.42
$3,242.32
$296.18
$293.19
$170.10
$168.38
$321.91
$318.65
$202.68
$200.63
$347.05
$343.54
$231.27
$228.93
$502.91
$497.82
$440.35
$435.91
Page 131 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
41512
41520
41520
41530
41530
41800
41800
41805
41805
41806
41806
41822
41822
41823
41823
41825
41825
41826
41826
41827
41827
41828
41828
41830
41830
41872
41872
41874
41874
42000
42000
42100
42100
1/2/2015
Modifier
Par Fee
$655.99
$367.95
$269.27
$3,302.22
$428.26
$278.50
$151.92
$258.21
$178.83
$369.42
$271.81
$322.18
$191.32
$471.29
$344.72
$219.59
$127.71
$327.90
$222.07
$460.30
$321.57
$319.51
$224.04
$410.06
$297.43
$388.24
$272.40
$392.76
$266.90
$162.96
$107.19
$155.68
$113.85
Nonpar Fee
$623.19
$349.55
$255.81
$3,137.11
$406.85
$264.58
$144.32
$245.30
$169.89
$350.95
$258.22
$306.07
$181.75
$447.73
$327.48
$208.61
$121.32
$311.51
$210.97
$437.29
$305.49
$303.53
$212.84
$389.56
$282.56
$368.83
$258.78
$373.12
$253.56
$154.81
$101.83
$147.90
$108.16
Limiting
Charge
$716.67
$401.98
$294.18
$3,607.68
$467.88
$304.27
$165.97
$282.10
$195.37
$403.59
$296.95
$351.98
$209.01
$514.89
$376.60
$239.90
$139.52
$358.24
$242.62
$502.88
$351.31
$349.06
$244.77
$447.99
$324.94
$424.15
$297.60
$429.09
$291.59
$178.03
$117.10
$170.09
$124.38
Charge**
Charge***
$709.50
$705.92
$397.96
$395.96
$291.24
$289.77
$3,571.60
$3,553.56
$463.20
$460.86
$301.22
$299.70
$164.31
$163.48
$279.28
$277.86
$193.42
$192.44
$399.56
$397.54
$293.99
$292.50
$348.46
$346.70
$206.92
$205.87
$509.74
$507.16
$372.84
$370.96
$237.50
$236.30
$138.13
$137.43
$354.65
$352.87
$240.19
$238.98
$497.86
$495.34
$347.81
$346.05
$345.56
$343.83
$242.32
$241.10
$443.51
$441.28
$321.69
$320.07
$419.91
$417.80
$294.62
$293.14
$424.80
$422.65
$288.67
$287.22
$176.25
$175.36
$115.93
$115.35
$168.38
$167.53
$123.14
$122.52
Arizona
EHR/eRx
Limiting
Charge**
$702.34
$393.94
$288.29
$3,535.53
$458.52
$298.18
$162.64
$276.45
$191.46
$395.52
$291.02
$344.94
$204.84
$504.60
$369.07
$235.11
$136.72
$351.07
$237.76
$492.82
$344.29
$342.08
$239.87
$439.04
$318.45
$415.67
$291.64
$420.51
$285.76
$174.47
$114.76
$166.68
$121.90
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$698.87
$691.81
$391.99
$388.03
$286.87
$283.97
$3,518.02
$3,482.49
$456.25
$451.64
$296.70
$293.71
$161.85
$160.21
$275.09
$272.30
$190.52
$188.59
$393.56
$389.59
$289.58
$286.65
$343.23
$339.77
$203.81
$201.77
$502.09
$497.03
$367.25
$363.54
$233.93
$231.58
$136.06
$134.68
$349.32
$345.81
$236.59
$234.20
$490.39
$485.43
$342.59
$339.12
$340.38
$336.95
$238.68
$236.27
$436.86
$432.45
$316.86
$313.67
$413.61
$409.43
$290.20
$287.27
$418.43
$414.21
$284.34
$281.47
$173.60
$171.84
$114.20
$113.03
$165.85
$164.19
$121.29
$120.07
Page 132 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
42104
42104
42106
42106
42107
42107
42120
42140
42140
42145
42160
42160
42180
42180
42182
42182
42200
42205
42210
42215
42220
42225
42226
42227
42235
42260
42260
42280
42280
42281
42281
42300
42300
1/2/2015
Modifier
Par Fee
$222.99
$144.69
$283.83
$186.22
$475.99
$358.00
$1,025.21
$260.94
$160.83
$725.52
$240.11
$152.87
$250.44
$189.66
$328.63
$263.55
$872.90
$911.13
$1,107.32
$739.20
$550.35
$905.37
$920.79
$863.13
$756.74
$887.38
$742.21
$170.44
$115.37
$210.75
$156.05
$215.35
$157.79
Nonpar Fee
$211.84
$137.46
$269.64
$176.91
$452.19
$340.10
$973.95
$247.89
$152.79
$689.24
$228.10
$145.23
$237.92
$180.18
$312.20
$250.37
$829.26
$865.57
$1,051.95
$702.24
$522.83
$860.10
$874.75
$819.97
$718.90
$843.01
$705.10
$161.92
$109.60
$200.21
$148.25
$204.58
$149.90
Limiting
Charge
$243.62
$158.08
$310.09
$203.45
$520.02
$391.12
$1,120.04
$285.07
$175.71
$792.63
$262.32
$167.01
$273.61
$207.21
$359.03
$287.93
$953.65
$995.41
$1,209.74
$807.58
$601.25
$989.12
$1,005.96
$942.97
$826.74
$969.46
$810.87
$186.21
$126.04
$230.24
$170.49
$235.27
$172.39
Charge**
Charge***
$241.18
$239.96
$156.50
$155.71
$306.98
$305.44
$201.41
$200.40
$514.82
$512.22
$387.21
$385.25
$1,108.84
$1,103.24
$282.22
$280.80
$173.95
$173.08
$784.70
$780.74
$259.69
$258.38
$165.35
$164.51
$270.87
$269.50
$205.14
$204.10
$355.44
$353.65
$285.05
$283.60
$944.12
$939.34
$985.45
$980.48
$1,197.64
$1,191.60
$799.50
$795.47
$595.24
$592.24
$979.23
$974.28
$995.90
$990.87
$933.54
$928.82
$818.47
$814.34
$959.77
$954.91
$802.76
$798.70
$184.35
$183.41
$124.78
$124.15
$227.94
$226.79
$168.79
$167.93
$232.91
$231.74
$170.66
$169.80
Arizona
EHR/eRx
Limiting
Charge**
$238.74
$154.92
$303.89
$199.38
$509.62
$383.30
$1,097.64
$279.37
$172.19
$776.78
$257.07
$163.68
$268.13
$203.07
$351.85
$282.16
$934.57
$975.50
$1,185.55
$791.43
$589.23
$969.34
$985.85
$924.11
$810.20
$950.07
$794.65
$182.48
$123.52
$225.64
$167.08
$230.56
$168.94
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$237.56
$235.16
$154.16
$152.59
$302.38
$299.33
$198.39
$196.39
$507.09
$501.98
$381.40
$377.55
$1,092.21
$1,081.17
$277.99
$275.18
$171.34
$169.60
$772.93
$765.13
$255.79
$253.22
$162.86
$161.23
$266.81
$264.11
$202.06
$200.02
$350.11
$346.58
$280.77
$277.93
$929.96
$920.55
$970.67
$960.87
$1,179.68
$1,167.77
$787.51
$779.56
$586.32
$580.38
$964.54
$954.80
$980.96
$971.06
$919.53
$910.25
$806.18
$798.04
$945.37
$935.82
$790.72
$782.74
$181.59
$179.75
$122.90
$121.67
$224.53
$222.26
$166.26
$164.58
$229.41
$227.10
$168.10
$166.41
Page 133 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
42305
42310
42310
42320
42320
42330
42330
42335
42335
42340
42340
42400
42400
42405
42405
42408
42408
42409
42409
42410
42415
42420
42425
42426
42440
42450
42450
42500
42500
42505
42505
42507
42509
1/2/2015
Modifier
Par Fee
$442.76
$166.28
$128.38
$256.61
$181.17
$239.13
$170.84
$386.05
$265.20
$480.64
$347.99
$109.37
$56.81
$306.41
$233.11
$465.35
$335.20
$343.14
$229.08
$636.86
$1,082.75
$1,216.40
$856.87
$1,384.62
$423.18
$466.69
$370.16
$446.80
$353.13
$571.87
$466.76
$527.63
$868.07
Nonpar Fee
$420.62
$157.97
$121.96
$243.78
$172.11
$227.17
$162.30
$366.75
$251.94
$456.61
$330.59
$103.90
$53.97
$291.09
$221.45
$442.08
$318.44
$325.98
$217.63
$605.02
$1,028.61
$1,155.58
$814.03
$1,315.39
$402.02
$443.36
$351.65
$424.46
$335.47
$543.28
$443.42
$501.25
$824.67
Limiting
Charge
$483.71
$181.67
$140.25
$280.35
$197.93
$261.25
$186.65
$421.76
$289.73
$525.10
$380.18
$119.49
$62.07
$334.75
$254.67
$508.39
$366.21
$374.88
$250.27
$695.77
$1,182.90
$1,328.92
$936.13
$1,512.70
$462.32
$509.86
$404.40
$488.13
$385.79
$624.77
$509.93
$576.44
$948.37
Charge**
Charge***
$478.87
$476.46
$179.85
$178.94
$138.85
$138.15
$277.54
$276.14
$195.95
$194.96
$258.64
$257.32
$184.78
$183.85
$417.54
$415.44
$286.83
$285.38
$519.85
$517.22
$376.37
$374.47
$118.29
$117.69
$61.44
$61.13
$331.41
$329.73
$252.13
$250.85
$503.31
$500.77
$362.55
$360.71
$371.13
$369.25
$247.77
$246.53
$688.82
$685.33
$1,171.07
$1,165.16
$1,315.62
$1,308.99
$926.77
$922.09
$1,497.58
$1,490.01
$457.70
$455.39
$504.77
$502.22
$400.35
$398.34
$483.25
$480.80
$381.94
$380.01
$618.53
$615.40
$504.84
$502.29
$570.68
$567.79
$938.88
$934.15
Arizona
EHR/eRx
Limiting
Charge**
$474.04
$178.03
$137.45
$274.74
$193.97
$256.02
$182.91
$413.33
$283.94
$514.60
$372.58
$117.09
$60.82
$328.06
$249.57
$498.23
$358.88
$367.38
$245.27
$681.86
$1,159.25
$1,302.34
$917.41
$1,482.44
$453.08
$499.66
$396.31
$478.37
$378.07
$612.27
$499.73
$564.91
$929.41
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$471.68
$466.93
$177.15
$175.36
$136.77
$135.39
$273.38
$270.62
$193.00
$191.06
$254.76
$252.18
$182.01
$180.16
$411.27
$407.13
$282.53
$279.68
$512.05
$506.89
$370.73
$366.99
$116.52
$115.33
$60.52
$59.92
$326.44
$323.14
$248.34
$245.82
$495.77
$490.75
$357.11
$353.50
$365.56
$361.87
$244.05
$241.59
$678.49
$671.63
$1,153.51
$1,141.86
$1,295.89
$1,282.80
$912.87
$903.65
$1,475.12
$1,460.20
$450.83
$446.28
$497.20
$492.17
$394.35
$390.37
$476.01
$471.19
$376.21
$372.40
$609.25
$603.08
$497.27
$492.23
$562.12
$556.44
$924.80
$915.47
Page 134 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
42510
42550
42550
42600
42600
42650
42650
42660
42660
42665
42665
42700
42700
42720
42720
42725
42800
42800
42804
42804
42806
42806
42808
42808
42809
42809
42810
42810
42815
42820
42821
42825
42826
1/2/2015
Modifier
Par Fee
$646.04
$138.20
$65.26
$492.71
$357.55
$86.04
$60.66
$130.08
$91.47
$320.48
$212.14
$195.51
$140.45
$465.73
$402.44
$840.59
$163.50
$115.59
$200.82
$116.80
$225.27
$135.89
$232.70
$166.91
$178.21
$137.10
$399.68
$297.78
$576.09
$297.61
$308.97
$268.78
$258.05
Nonpar Fee
$613.74
$131.29
$62.00
$468.07
$339.67
$81.74
$57.63
$123.58
$86.90
$304.46
$201.53
$185.73
$133.43
$442.44
$382.32
$798.56
$155.33
$109.81
$190.78
$110.96
$214.01
$129.10
$221.07
$158.56
$169.30
$130.25
$379.70
$282.89
$547.29
$282.73
$293.52
$255.34
$245.15
Limiting
Charge
$705.80
$150.98
$71.30
$538.28
$390.62
$94.00
$66.27
$142.12
$99.94
$350.13
$231.76
$213.59
$153.44
$508.81
$439.67
$918.34
$178.63
$126.28
$219.40
$127.60
$246.11
$148.47
$254.23
$182.34
$194.70
$149.79
$436.66
$325.32
$629.38
$325.14
$337.55
$293.64
$281.92
Charge**
Charge***
$698.74
$695.21
$149.48
$148.72
$70.59
$70.23
$532.90
$530.21
$386.71
$384.76
$93.06
$92.59
$65.61
$65.29
$140.69
$139.99
$98.93
$98.44
$346.63
$344.87
$229.44
$228.29
$211.45
$210.38
$151.92
$151.14
$503.72
$501.17
$435.28
$433.08
$909.16
$904.57
$176.85
$175.95
$125.02
$124.38
$217.20
$216.11
$126.33
$125.70
$243.65
$242.42
$146.98
$146.23
$251.69
$250.41
$180.52
$179.61
$192.75
$191.77
$148.29
$147.55
$432.29
$430.10
$322.07
$320.45
$623.09
$619.94
$321.89
$320.26
$334.17
$332.49
$290.71
$289.24
$279.11
$277.69
Arizona
EHR/eRx
Limiting
Charge**
$691.69
$147.96
$69.87
$527.52
$382.81
$92.13
$64.95
$139.28
$97.93
$343.13
$227.13
$209.32
$150.37
$498.63
$430.87
$899.98
$175.05
$123.75
$215.00
$125.05
$241.19
$145.50
$249.15
$178.70
$190.80
$146.80
$427.93
$318.81
$616.79
$318.64
$330.80
$287.76
$276.29
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$688.26
$681.32
$147.23
$145.74
$69.53
$68.83
$524.91
$519.60
$380.91
$377.07
$91.67
$90.75
$64.62
$63.97
$138.58
$137.18
$97.45
$96.46
$341.44
$337.97
$226.00
$223.72
$208.28
$206.18
$149.64
$148.12
$496.17
$491.15
$428.74
$424.41
$895.52
$886.48
$174.19
$172.43
$123.14
$121.90
$213.95
$211.78
$124.43
$123.18
$239.99
$237.57
$144.77
$143.31
$247.92
$245.41
$177.81
$176.02
$189.87
$187.93
$146.07
$144.60
$425.80
$421.51
$317.24
$314.03
$613.74
$607.53
$317.06
$313.86
$329.15
$325.84
$286.35
$283.45
$274.92
$272.15
Page 135 of 323
Notes
Procedure
Code
42830
42831
42835
42836
42842
42844
42845
42860
42870
42890
42892
42894
42900
42950
42953
42955
42960
42961
42962
42970
42971
42972
43020
43030
43045
43100
43101
43107
43108
43112
43113
43116
43117
1/2/2015
Modifier
Par Fee
$213.57
$229.53
$198.69
$247.46
$1,023.88
$1,407.63
$2,274.07
$194.08
$596.09
$1,448.27
$1,925.75
$2,413.87
$347.68
$816.23
$982.55
$773.55
$175.45
$435.02
$533.23
$425.68
$469.84
$525.67
$577.04
$532.17
$1,335.32
$643.42
$1,085.00
$2,615.40
$4,789.96
$2,756.28
$4,471.87
$5,359.89
$2,521.39
Nonpar Fee
$202.89
$218.05
$188.76
$235.09
$972.69
$1,337.25
$2,160.37
$184.38
$566.29
$1,375.86
$1,829.46
$2,293.18
$330.30
$775.42
$933.42
$734.87
$166.68
$413.27
$506.57
$404.40
$446.35
$499.39
$548.19
$505.56
$1,268.55
$611.25
$1,030.75
$2,484.63
$4,550.46
$2,618.47
$4,248.28
$5,091.90
$2,395.32
Limiting
Charge
$233.32
$250.76
$217.07
$270.35
$1,118.59
$1,537.84
$2,484.43
$212.04
$651.23
$1,582.24
$2,103.88
$2,637.16
$379.85
$891.73
$1,073.43
$845.10
$191.68
$475.26
$582.56
$465.06
$513.30
$574.30
$630.42
$581.39
$1,458.83
$702.94
$1,185.36
$2,857.32
$5,233.03
$3,011.24
$4,885.52
$5,855.69
$2,754.62
Charge**
Charge***
$230.99
$229.83
$248.25
$247.00
$214.90
$213.82
$267.65
$266.29
$1,107.40
$1,101.82
$1,522.46
$1,514.77
$2,459.59
$2,447.15
$209.92
$208.85
$644.72
$641.47
$1,566.42
$1,558.50
$2,082.85
$2,072.32
$2,610.79
$2,597.60
$376.05
$374.15
$882.82
$878.36
$1,062.70
$1,057.33
$836.65
$832.43
$189.76
$188.81
$470.51
$468.13
$576.73
$573.82
$460.41
$458.08
$508.17
$505.60
$568.56
$565.69
$624.12
$620.97
$575.58
$572.68
$1,444.24
$1,436.95
$695.91
$692.39
$1,173.51
$1,167.58
$2,828.75
$2,814.46
$5,180.70
$5,154.53
$2,981.13
$2,966.07
$4,836.67
$4,812.24
$5,797.13
$5,767.85
$2,727.08
$2,713.30
Arizona
EHR/eRx
Limiting
Charge**
$228.65
$245.74
$212.73
$264.95
$1,096.23
$1,507.09
$2,434.73
$207.79
$638.20
$1,550.59
$2,061.80
$2,584.42
$372.24
$873.90
$1,051.96
$828.20
$187.85
$465.75
$570.91
$455.76
$503.03
$562.81
$617.81
$569.77
$1,429.66
$688.88
$1,161.66
$2,800.18
$5,128.37
$2,951.02
$4,787.81
$5,738.57
$2,699.52
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$227.53
$225.23
$244.52
$242.05
$211.68
$209.54
$263.64
$260.97
$1,090.80
$1,079.78
$1,499.62
$1,484.48
$2,422.69
$2,398.21
$206.77
$204.68
$635.05
$628.64
$1,542.92
$1,527.33
$2,051.60
$2,030.88
$2,571.63
$2,545.65
$370.42
$366.65
$869.57
$860.79
$1,046.76
$1,036.18
$824.10
$815.78
$186.91
$185.04
$463.45
$458.77
$568.08
$562.34
$453.50
$448.93
$500.55
$495.49
$560.03
$554.37
$614.76
$608.55
$566.94
$561.22
$1,422.57
$1,408.21
$685.47
$678.55
$1,155.90
$1,144.24
$2,786.31
$2,758.18
$5,103.00
$5,051.44
$2,936.42
$2,906.75
$4,764.12
$4,715.99
$5,710.18
$5,652.49
$2,686.17
$2,659.03
Page 136 of 323
Notes
#
#
#
#
#
#
#
Procedure
Code
43118
43121
43122
43123
43124
43130
43135
43180
43191
43192
43193
43194
43195
43196
43197
43197
43198
43198
43200
43200
43201
43201
43202
43202
43204
43205
43206
43206
43211
43212
43213
43213
43214
1/2/2015
Modifier
Par Fee
$3,905.21
$2,936.56
$2,613.69
$4,852.98
$3,913.37
$806.07
$1,524.94
$571.65
$157.57
$174.87
$174.51
$196.60
$190.78
$202.18
$191.75
$84.84
$215.49
$101.79
$276.04
$96.91
$281.95
$113.90
$370.57
$114.21
$149.35
$153.99
$336.61
$145.32
$256.99
$204.25
$1,260.49
$277.60
$207.32
Nonpar Fee
$3,709.95
$2,789.73
$2,483.01
$4,610.33
$3,717.70
$765.77
$1,448.69
$543.07
$149.69
$166.13
$165.78
$186.77
$181.24
$192.07
$182.16
$80.60
$204.72
$96.70
$262.24
$92.06
$267.85
$108.21
$352.04
$108.50
$141.88
$146.29
$319.78
$138.05
$244.14
$194.04
$1,197.47
$263.72
$196.95
Limiting
Charge
$4,266.44
$3,208.19
$2,855.46
$5,301.88
$4,275.36
$880.64
$1,665.99
$624.53
$172.14
$191.05
$190.65
$214.79
$208.43
$220.88
$209.48
$92.69
$235.43
$111.21
$301.58
$105.87
$308.03
$124.44
$404.85
$124.78
$163.16
$168.23
$367.75
$158.76
$280.76
$223.15
$1,377.09
$303.28
$226.49
Charge**
Charge***
$4,223.78
$4,202.45
$3,176.10
$3,160.06
$2,826.91
$2,812.62
$5,248.86
$5,222.36
$4,232.60
$4,211.22
$871.83
$867.42
$1,649.33
$1,641.00
$618.29
$615.16
$170.42
$169.56
$189.14
$188.19
$188.74
$187.78
$212.64
$211.57
$206.34
$205.30
$218.67
$217.57
$207.39
$206.34
$91.76
$91.30
$233.07
$231.90
$110.09
$109.54
$298.56
$297.06
$104.81
$104.28
$304.95
$303.40
$123.20
$122.58
$400.80
$398.77
$123.53
$122.90
$161.53
$160.71
$166.55
$165.72
$364.07
$362.23
$157.17
$156.38
$277.96
$276.55
$220.92
$219.80
$1,363.33
$1,356.44
$300.24
$298.72
$224.23
$223.10
Arizona
EHR/eRx
Limiting
Charge**
$4,181.11
$3,144.03
$2,798.35
$5,195.84
$4,189.85
$863.02
$1,632.68
$612.04
$168.71
$187.23
$186.83
$210.48
$204.26
$216.46
$205.30
$90.84
$230.72
$108.99
$295.55
$103.75
$301.86
$121.96
$396.75
$122.28
$159.90
$164.86
$360.39
$155.58
$275.15
$218.68
$1,349.55
$297.22
$221.96
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$4,160.42
$4,118.39
$3,128.46
$3,096.87
$2,784.51
$2,756.38
$5,170.14
$5,117.90
$4,169.11
$4,127.01
$858.75
$850.07
$1,624.59
$1,608.18
$609.02
$602.86
$167.87
$166.18
$186.30
$184.43
$185.91
$184.02
$209.45
$207.32
$203.25
$201.20
$215.40
$213.22
$204.27
$202.22
$90.38
$89.48
$229.57
$227.26
$108.43
$107.35
$294.09
$291.12
$103.24
$102.20
$300.37
$297.33
$121.35
$120.13
$394.78
$390.80
$121.68
$120.45
$159.10
$157.49
$164.06
$162.39
$358.60
$354.98
$154.81
$153.25
$273.78
$271.02
$217.60
$215.41
$1,342.88
$1,329.31
$295.73
$292.76
$220.87
$218.63
Page 137 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
43215
43215
43216
43216
43217
43217
43220
43220
43226
43226
43227
43227
43229
43229
43231
43231
43232
43232
43233
43235
43235
43236
43236
43237
43238
43239
43239
43240
43241
43242
43243
43244
43245
1/2/2015
Modifier
Par Fee
$417.51
$154.00
$428.95
$147.92
$456.62
$174.52
$1,160.26
$129.81
$388.46
$142.82
$403.08
$179.97
$744.18
$214.30
$412.24
$174.83
$489.87
$214.20
$244.47
$319.98
$135.13
$398.87
$152.16
$212.29
$252.47
$408.88
$151.80
$420.46
$155.65
$284.79
$256.41
$266.06
$630.26
Nonpar Fee
$396.63
$146.30
$407.50
$140.52
$433.79
$165.79
$1,102.25
$123.32
$369.04
$135.68
$382.93
$170.97
$706.97
$203.59
$391.63
$166.09
$465.38
$203.49
$232.25
$303.98
$128.37
$378.93
$144.55
$201.68
$239.85
$388.44
$144.21
$399.44
$147.87
$270.55
$243.59
$252.76
$598.75
Limiting
Charge
$456.12
$168.25
$468.63
$161.60
$498.86
$190.66
$1,267.59
$141.82
$424.40
$156.03
$440.37
$196.62
$813.02
$234.13
$450.37
$191.00
$535.19
$234.01
$267.09
$349.58
$147.63
$435.77
$166.23
$231.93
$275.83
$446.71
$165.84
$459.36
$170.05
$311.13
$280.13
$290.67
$688.56
Charge**
Charge***
$451.56
$449.28
$166.57
$165.73
$463.94
$461.60
$159.98
$159.17
$493.87
$491.37
$188.75
$187.80
$1,254.91
$1,248.58
$140.40
$139.69
$420.15
$418.03
$154.47
$153.69
$435.97
$433.77
$194.65
$193.67
$804.89
$800.83
$231.78
$230.62
$445.87
$443.62
$189.09
$188.14
$529.84
$527.16
$231.68
$230.51
$264.42
$263.09
$346.08
$344.33
$146.15
$145.41
$431.41
$429.24
$164.57
$163.74
$229.61
$228.45
$273.07
$271.69
$442.24
$440.00
$164.19
$163.36
$454.77
$452.47
$168.35
$167.50
$308.02
$306.46
$277.32
$275.93
$287.76
$286.32
$681.67
$678.24
Arizona
EHR/eRx
Limiting
Charge**
$447.01
$164.88
$459.25
$158.37
$488.88
$186.84
$1,242.24
$138.98
$415.91
$152.92
$431.56
$192.68
$796.75
$229.45
$441.37
$187.19
$524.48
$229.33
$261.75
$342.59
$144.67
$427.05
$162.91
$227.30
$270.31
$437.77
$162.53
$450.17
$166.65
$304.91
$274.53
$284.86
$674.80
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$444.79
$440.30
$164.07
$162.40
$456.99
$452.36
$157.57
$155.99
$486.46
$481.54
$185.92
$184.03
$1,236.09
$1,223.61
$138.30
$136.90
$413.85
$409.68
$152.16
$150.63
$429.42
$425.09
$191.73
$189.80
$792.81
$784.81
$228.31
$226.01
$439.17
$434.75
$186.25
$184.38
$521.89
$516.61
$228.21
$225.89
$260.45
$257.83
$340.89
$337.44
$143.96
$142.50
$424.94
$420.65
$162.09
$160.47
$226.17
$223.89
$268.97
$266.25
$435.61
$431.20
$161.72
$160.09
$447.95
$443.42
$165.82
$164.15
$303.39
$300.33
$273.16
$270.41
$283.45
$280.58
$671.45
$664.68
Page 138 of 323
Notes
#
#
#
#
#
#
#
#
#
Procedure
Code
43245
43246
43247
43247
43248
43248
43249
43249
43250
43250
43251
43251
43252
43252
43253
43254
43255
43255
43257
43259
43260
43261
43262
43263
43264
43265
43266
43270
43270
43273
43274
43275
43276
1/2/2015
Modifier
Par Fee
$190.47
$215.87
$416.53
$192.71
$421.04
$181.84
$1,107.67
$168.03
$467.26
$184.44
$513.30
$212.96
$376.53
$184.17
$284.79
$291.77
$441.07
$218.32
$251.31
$245.23
$347.42
$363.69
$383.80
$384.79
$391.23
$464.09
$244.61
$774.94
$252.20
$126.59
$495.20
$403.96
$515.36
Nonpar Fee
$180.95
$205.08
$395.70
$183.07
$399.99
$172.75
$1,052.29
$159.63
$443.90
$175.22
$487.64
$202.31
$357.70
$174.96
$270.55
$277.18
$419.02
$207.40
$238.74
$232.97
$330.05
$345.51
$364.61
$365.55
$371.67
$440.89
$232.38
$736.19
$239.59
$120.26
$470.44
$383.76
$489.59
Limiting
Charge
$208.09
$235.84
$455.06
$210.53
$459.99
$198.66
$1,210.13
$183.57
$510.49
$201.50
$560.79
$232.66
$411.36
$201.20
$311.13
$318.76
$481.87
$238.51
$274.55
$267.92
$379.56
$397.34
$419.30
$420.38
$427.42
$507.02
$267.24
$846.62
$275.53
$138.30
$541.01
$441.32
$563.03
Charge**
Charge***
$206.01
$204.98
$233.48
$232.30
$450.50
$448.22
$208.43
$207.37
$455.39
$453.09
$196.67
$195.68
$1,198.04
$1,191.99
$181.73
$180.83
$505.38
$502.83
$199.49
$198.48
$555.17
$552.38
$230.33
$229.17
$407.24
$405.18
$199.19
$198.19
$308.02
$306.46
$315.57
$313.97
$477.05
$474.64
$236.13
$234.93
$271.80
$270.43
$265.24
$263.90
$375.76
$373.87
$393.36
$391.38
$415.10
$413.01
$416.17
$414.08
$423.14
$421.00
$501.95
$499.42
$264.57
$263.22
$838.15
$833.92
$272.77
$271.40
$136.92
$136.23
$535.60
$532.89
$436.91
$434.70
$557.39
$554.59
Arizona
EHR/eRx
Limiting
Charge**
$203.93
$231.13
$445.96
$206.32
$450.79
$194.70
$1,185.93
$179.91
$500.27
$197.48
$549.57
$228.00
$403.13
$197.18
$304.91
$312.39
$472.24
$233.74
$269.07
$262.56
$371.97
$389.39
$410.92
$411.98
$418.88
$496.88
$261.89
$829.69
$270.02
$135.53
$530.18
$432.49
$551.77
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$202.92
$200.87
$229.98
$227.67
$443.74
$439.27
$205.30
$203.23
$448.56
$444.03
$193.72
$191.77
$1,180.06
$1,168.14
$179.01
$177.20
$497.80
$492.76
$196.50
$194.51
$546.85
$541.33
$226.88
$224.58
$401.13
$397.08
$196.20
$194.22
$303.39
$300.33
$310.83
$307.71
$469.90
$465.15
$232.59
$230.23
$267.72
$265.03
$261.26
$258.62
$370.13
$366.39
$387.46
$383.55
$408.88
$404.75
$409.93
$405.80
$416.79
$412.60
$494.42
$489.43
$260.60
$257.96
$825.59
$817.25
$268.67
$265.97
$134.86
$133.49
$527.56
$522.23
$430.35
$426.01
$549.03
$543.49
Page 139 of 323
Notes
Procedure
Code
43277
43278
43279
43280
43281
43282
43283
43300
43305
43310
43312
43313
43314
43320
43325
43327
43328
43330
43331
43332
43333
43334
43335
43336
43337
43338
43340
43341
43351
43352
43360
43361
43400
1/2/2015
Modifier
Par Fee
$406.11
$463.73
$1,317.31
$1,101.01
$1,572.49
$1,768.08
$162.11
$631.17
$1,119.22
$1,509.97
$1,639.76
$2,676.17
$2,887.72
$1,422.01
$1,370.37
$831.79
$1,159.33
$1,358.57
$1,376.99
$1,183.32
$1,288.02
$1,281.59
$1,376.38
$1,551.39
$1,667.45
$118.61
$1,403.45
$1,510.24
$1,420.20
$1,096.45
$2,428.34
$2,617.53
$1,549.78
Nonpar Fee
$385.80
$440.54
$1,251.44
$1,045.96
$1,493.87
$1,679.68
$154.00
$599.61
$1,063.26
$1,434.47
$1,557.77
$2,542.36
$2,743.33
$1,350.91
$1,301.85
$790.20
$1,101.36
$1,290.64
$1,308.14
$1,124.15
$1,223.62
$1,217.51
$1,307.56
$1,473.82
$1,584.08
$112.68
$1,333.28
$1,434.73
$1,349.19
$1,041.63
$2,306.92
$2,486.65
$1,472.29
Limiting
Charge
$443.67
$506.62
$1,439.16
$1,202.85
$1,717.95
$1,931.63
$177.10
$689.55
$1,222.75
$1,649.64
$1,791.44
$2,923.71
$3,154.83
$1,553.55
$1,497.13
$908.73
$1,266.56
$1,484.24
$1,504.36
$1,292.77
$1,407.16
$1,400.14
$1,503.69
$1,694.89
$1,821.69
$129.58
$1,533.27
$1,649.94
$1,551.57
$1,197.87
$2,652.96
$2,859.65
$1,693.13
Charge**
Charge***
$439.23
$437.01
$501.55
$499.02
$1,424.77
$1,417.57
$1,190.83
$1,184.81
$1,700.77
$1,692.18
$1,912.31
$1,902.65
$175.33
$174.44
$682.65
$679.21
$1,210.52
$1,204.41
$1,633.15
$1,624.89
$1,773.52
$1,764.56
$2,894.48
$2,879.85
$3,123.29
$3,107.51
$1,538.01
$1,530.25
$1,482.15
$1,474.67
$899.65
$895.10
$1,253.90
$1,247.57
$1,469.39
$1,461.97
$1,489.32
$1,481.80
$1,279.85
$1,273.38
$1,393.09
$1,386.06
$1,386.13
$1,379.14
$1,488.65
$1,481.14
$1,677.94
$1,669.47
$1,803.48
$1,794.37
$128.28
$127.64
$1,517.94
$1,510.27
$1,633.44
$1,625.19
$1,536.06
$1,528.29
$1,185.89
$1,179.91
$2,626.43
$2,613.17
$2,831.05
$2,816.75
$1,676.21
$1,667.74
Arizona
EHR/eRx
Limiting
Charge**
$434.79
$496.49
$1,410.37
$1,178.80
$1,683.59
$1,893.00
$173.56
$675.76
$1,198.29
$1,616.65
$1,755.60
$2,865.24
$3,091.73
$1,522.47
$1,467.18
$890.56
$1,241.23
$1,454.55
$1,474.28
$1,266.92
$1,379.02
$1,372.13
$1,473.62
$1,660.99
$1,785.26
$126.99
$1,502.60
$1,616.95
$1,520.54
$1,173.92
$2,599.90
$2,802.46
$1,659.27
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$432.64
$428.27
$494.03
$489.04
$1,403.40
$1,389.21
$1,172.97
$1,161.11
$1,675.26
$1,658.33
$1,883.63
$1,864.61
$172.70
$170.96
$672.42
$665.63
$1,192.37
$1,180.31
$1,608.65
$1,592.39
$1,746.92
$1,729.27
$2,851.07
$2,822.26
$3,076.43
$3,045.35
$1,514.94
$1,499.63
$1,459.93
$1,445.17
$886.16
$877.20
$1,235.09
$1,222.61
$1,447.34
$1,432.74
$1,466.97
$1,452.16
$1,260.65
$1,247.91
$1,372.19
$1,358.33
$1,365.34
$1,351.55
$1,466.32
$1,451.52
$1,652.77
$1,636.07
$1,776.43
$1,758.48
$126.36
$125.09
$1,495.17
$1,480.06
$1,608.93
$1,592.69
$1,513.01
$1,497.74
$1,168.10
$1,156.31
$2,587.03
$2,560.90
$2,788.58
$2,760.43
$1,651.07
$1,634.38
Page 140 of 323
Notes
#
#
Procedure
Code
43401
43405
43410
43415
43420
43425
43450
43450
43453
43453
43460
43500
43501
43502
43510
43520
43605
43610
43611
43620
43621
43622
43631
43632
43633
43634
43635
43640
43641
43644
43645
43651
43652
1/2/2015
Modifier
Par Fee
$1,599.63
$1,571.04
$1,073.55
$2,622.10
$1,043.94
$1,482.91
$217.90
$89.89
$997.30
$96.64
$225.70
$798.29
$1,371.21
$1,552.91
$962.64
$698.61
$849.94
$998.77
$1,242.50
$2,004.04
$2,310.82
$2,356.21
$1,476.10
$2,067.70
$1,954.37
$2,165.98
$114.81
$1,198.24
$1,223.73
$1,762.79
$1,883.54
$666.51
$778.45
Nonpar Fee
$1,519.65
$1,492.49
$1,019.87
$2,491.00
$991.74
$1,408.76
$207.01
$85.40
$947.44
$91.81
$214.42
$758.38
$1,302.65
$1,475.26
$914.51
$663.68
$807.44
$948.83
$1,180.38
$1,903.84
$2,195.28
$2,238.40
$1,402.30
$1,964.32
$1,856.65
$2,057.68
$109.07
$1,138.33
$1,162.54
$1,674.65
$1,789.36
$633.18
$739.53
Limiting
Charge
$1,747.60
$1,716.36
$1,172.85
$2,864.65
$1,140.50
$1,620.07
$238.06
$98.21
$1,089.56
$105.58
$246.58
$872.14
$1,498.05
$1,696.55
$1,051.69
$763.23
$928.56
$1,091.15
$1,357.44
$2,189.42
$2,524.57
$2,574.16
$1,612.65
$2,258.97
$2,135.15
$2,366.33
$125.43
$1,309.08
$1,336.92
$1,925.85
$2,057.76
$728.16
$850.46
Charge**
Charge***
$1,730.12
$1,721.39
$1,699.21
$1,690.62
$1,161.12
$1,155.26
$2,836.00
$2,821.69
$1,129.09
$1,123.39
$1,603.87
$1,595.77
$235.68
$234.49
$97.23
$96.74
$1,078.67
$1,073.21
$104.52
$103.99
$244.12
$242.88
$863.42
$859.05
$1,483.06
$1,475.58
$1,679.59
$1,671.10
$1,041.16
$1,035.91
$755.60
$751.78
$919.28
$914.63
$1,080.24
$1,074.79
$1,343.87
$1,337.07
$2,167.52
$2,156.57
$2,499.33
$2,486.70
$2,548.42
$2,535.54
$1,596.52
$1,588.46
$2,236.38
$2,225.09
$2,113.79
$2,103.12
$2,342.67
$2,330.83
$124.18
$123.54
$1,295.99
$1,289.45
$1,323.55
$1,316.87
$1,906.59
$1,896.96
$2,037.19
$2,026.90
$720.88
$717.23
$841.95
$837.71
Arizona
EHR/eRx
Limiting
Charge**
$1,712.65
$1,682.04
$1,149.39
$2,807.36
$1,117.70
$1,587.67
$233.30
$96.24
$1,067.76
$103.47
$241.65
$854.69
$1,468.09
$1,662.61
$1,030.65
$747.97
$909.98
$1,069.33
$1,330.29
$2,145.62
$2,474.08
$2,522.67
$1,580.39
$2,213.78
$2,092.45
$2,319.01
$122.92
$1,282.89
$1,310.18
$1,887.33
$2,016.61
$713.60
$833.45
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$1,704.16
$1,686.96
$1,673.72
$1,656.81
$1,143.70
$1,132.15
$2,793.47
$2,765.24
$1,112.15
$1,100.93
$1,579.81
$1,563.85
$232.15
$229.80
$95.77
$94.79
$1,062.49
$1,051.74
$102.96
$101.91
$240.47
$238.03
$850.47
$841.87
$1,460.82
$1,446.07
$1,654.39
$1,637.67
$1,025.55
$1,015.20
$744.26
$736.75
$905.49
$896.33
$1,064.04
$1,053.29
$1,323.71
$1,310.33
$2,135.01
$2,113.44
$2,461.84
$2,436.97
$2,510.20
$2,484.84
$1,572.58
$1,556.69
$2,202.84
$2,180.57
$2,082.09
$2,061.06
$2,307.52
$2,284.22
$122.31
$121.08
$1,276.56
$1,263.65
$1,303.70
$1,290.53
$1,877.98
$1,859.02
$2,006.64
$1,986.36
$710.07
$702.89
$829.32
$820.95
Page 141 of 323
Notes
#
#
#
#
#
#
Procedure
Code
43653
43752
43753
43754
43754
43755
43755
43756
43756
43757
43757
43760
43760
43761
43761
43770
43771
43772
43773
43774
43800
43810
43820
43825
43830
43831
43832
43840
43843
43845
43846
43847
43848
1/2/2015
Modifier
Par Fee
$582.59
$42.15
$21.95
$133.06
$37.23
$141.29
$63.35
$210.11
$53.51
$300.26
$81.44
$499.24
$48.73
$119.17
$105.94
$1,138.19
$1,292.74
$968.01
$1,302.45
$976.14
$945.66
$1,036.95
$1,364.15
$1,332.86
$711.34
$605.70
$1,059.52
$1,381.90
$1,304.07
$1,998.26
$1,641.06
$1,835.90
$1,958.74
Nonpar Fee
$553.46
$40.04
$20.85
$126.41
$35.37
$134.23
$60.18
$199.60
$50.83
$285.25
$77.37
$474.28
$46.29
$113.21
$100.64
$1,081.28
$1,228.10
$919.61
$1,237.33
$927.33
$898.38
$985.10
$1,295.94
$1,266.22
$675.77
$575.42
$1,006.54
$1,312.81
$1,238.87
$1,898.35
$1,559.01
$1,744.11
$1,860.80
Limiting
Charge
$636.48
$46.05
$23.98
$145.37
$40.68
$154.36
$69.21
$229.54
$58.45
$328.04
$88.98
$545.42
$53.23
$130.19
$115.74
$1,243.47
$1,412.32
$1,057.55
$1,422.93
$1,066.43
$1,033.14
$1,132.87
$1,490.33
$1,456.15
$777.14
$661.73
$1,157.52
$1,509.73
$1,424.70
$2,183.10
$1,792.86
$2,005.73
$2,139.92
Charge**
Charge***
$630.12
$626.93
$45.59
$45.36
$23.74
$23.62
$143.92
$143.19
$40.27
$40.07
$152.82
$152.05
$68.52
$68.17
$227.24
$226.10
$57.87
$57.58
$324.76
$323.12
$88.09
$87.64
$539.97
$537.25
$52.70
$52.44
$128.89
$128.24
$114.57
$114.00
$1,231.04
$1,224.82
$1,398.19
$1,391.13
$1,046.97
$1,041.69
$1,408.70
$1,401.59
$1,055.77
$1,050.43
$1,022.81
$1,017.64
$1,121.54
$1,115.87
$1,475.43
$1,467.98
$1,441.59
$1,434.31
$769.36
$765.47
$655.12
$651.81
$1,145.94
$1,140.16
$1,494.63
$1,487.09
$1,410.45
$1,403.33
$2,161.28
$2,150.35
$1,774.93
$1,765.96
$1,985.67
$1,975.64
$2,118.52
$2,107.82
Arizona
EHR/eRx
Limiting
Charge**
$623.75
$45.13
$23.49
$142.46
$39.86
$151.28
$67.83
$224.95
$57.28
$321.48
$87.19
$534.51
$52.16
$127.59
$113.42
$1,218.60
$1,384.07
$1,036.40
$1,394.47
$1,045.10
$1,012.47
$1,110.21
$1,460.52
$1,427.04
$761.59
$648.50
$1,134.37
$1,479.53
$1,396.20
$2,139.44
$1,757.00
$1,965.61
$2,097.12
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$620.67
$614.39
$44.91
$44.45
$23.38
$23.14
$141.76
$140.32
$39.66
$39.26
$150.54
$149.02
$67.49
$66.82
$223.84
$221.58
$57.01
$56.42
$319.88
$316.66
$86.77
$85.88
$531.88
$526.49
$51.91
$51.38
$126.96
$125.68
$112.86
$111.72
$1,212.57
$1,200.32
$1,377.22
$1,363.31
$1,031.26
$1,020.86
$1,387.58
$1,373.55
$1,039.93
$1,029.42
$1,007.47
$997.28
$1,104.71
$1,093.56
$1,453.30
$1,438.62
$1,419.97
$1,405.63
$757.82
$750.17
$645.29
$638.77
$1,128.75
$1,117.35
$1,472.21
$1,457.34
$1,389.29
$1,375.26
$2,128.86
$2,107.34
$1,748.31
$1,730.65
$1,955.89
$1,936.13
$2,086.74
$2,065.66
Page 142 of 323
Notes
Procedure
Code
43850
43855
43860
43865
43870
43880
43886
43887
43888
44005
44010
44015
44020
44021
44025
44050
44055
44100
44110
44111
44120
44121
44125
44126
44127
44128
44130
44139
44140
44141
44143
44144
44145
1/2/2015
Modifier
Par Fee
$1,658.60
$1,721.01
$1,666.45
$1,741.04
$725.78
$1,622.59
$368.76
$332.59
$467.82
$1,112.85
$883.54
$145.30
$991.88
$993.22
$1,004.70
$951.46
$1,515.07
$114.12
$867.46
$1,001.21
$1,244.51
$246.96
$1,202.03
$2,512.67
$2,905.33
$248.84
$1,336.24
$123.70
$1,365.97
$1,859.46
$1,695.62
$1,802.87
$1,689.75
Nonpar Fee
$1,575.67
$1,634.96
$1,583.13
$1,653.99
$689.49
$1,541.46
$350.32
$315.96
$444.43
$1,057.21
$839.36
$138.04
$942.29
$943.56
$954.47
$903.89
$1,439.32
$108.41
$824.09
$951.15
$1,182.28
$234.61
$1,141.93
$2,387.04
$2,760.06
$236.40
$1,269.43
$117.52
$1,297.67
$1,766.49
$1,610.84
$1,712.73
$1,605.26
Limiting
Charge
$1,812.02
$1,880.20
$1,820.60
$1,902.09
$792.91
$1,772.68
$402.87
$363.35
$511.09
$1,215.79
$965.26
$158.75
$1,083.63
$1,085.09
$1,097.64
$1,039.47
$1,655.22
$124.67
$947.70
$1,093.82
$1,359.62
$269.80
$1,313.22
$2,745.10
$3,174.07
$271.86
$1,459.84
$135.15
$1,492.32
$2,031.46
$1,852.47
$1,969.64
$1,846.05
Charge**
Charge***
$1,793.90
$1,784.83
$1,861.40
$1,852.01
$1,802.40
$1,793.29
$1,883.07
$1,873.56
$784.99
$781.02
$1,754.96
$1,746.09
$398.84
$396.83
$359.72
$357.90
$505.99
$503.42
$1,203.64
$1,197.55
$955.62
$950.79
$157.16
$156.37
$1,072.80
$1,067.38
$1,074.24
$1,068.82
$1,086.67
$1,081.17
$1,029.08
$1,023.88
$1,638.67
$1,630.39
$123.43
$122.80
$938.23
$933.49
$1,082.89
$1,077.41
$1,346.03
$1,339.23
$267.10
$265.75
$1,300.09
$1,293.52
$2,717.65
$2,703.91
$3,142.33
$3,126.46
$269.15
$267.78
$1,445.25
$1,437.95
$133.79
$133.12
$1,477.39
$1,469.93
$2,011.15
$2,000.99
$1,833.94
$1,824.68
$1,949.94
$1,940.10
$1,827.59
$1,818.36
Arizona
EHR/eRx
Limiting
Charge**
$1,775.78
$1,842.60
$1,784.19
$1,864.05
$777.06
$1,737.22
$394.81
$356.09
$500.87
$1,191.48
$945.96
$155.57
$1,061.96
$1,063.39
$1,075.69
$1,018.68
$1,622.11
$122.18
$928.75
$1,071.95
$1,332.42
$264.41
$1,286.95
$2,690.20
$3,110.59
$266.42
$1,430.65
$132.45
$1,462.48
$1,990.83
$1,815.41
$1,930.25
$1,809.12
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$1,766.99
$1,749.15
$1,833.48
$1,814.96
$1,775.36
$1,757.43
$1,854.82
$1,836.09
$773.21
$765.39
$1,728.63
$1,711.17
$392.86
$388.88
$354.33
$350.75
$498.40
$493.36
$1,185.58
$1,173.61
$941.29
$931.76
$154.80
$153.24
$1,056.71
$1,046.03
$1,058.13
$1,047.44
$1,070.37
$1,059.55
$1,013.64
$1,003.40
$1,614.09
$1,597.78
$121.58
$120.35
$924.15
$914.83
$1,066.65
$1,055.87
$1,325.84
$1,312.44
$263.10
$260.44
$1,280.58
$1,267.65
$2,676.88
$2,649.84
$3,095.19
$3,063.93
$265.11
$262.42
$1,423.57
$1,409.19
$131.78
$130.46
$1,455.23
$1,440.54
$1,980.99
$1,960.97
$1,806.43
$1,788.18
$1,920.70
$1,901.30
$1,800.18
$1,781.98
Page 143 of 323
Notes
Procedure
Code
44146
44147
44150
44151
44155
44156
44157
44158
44160
44180
44186
44187
44188
44202
44203
44204
44205
44206
44207
44208
44210
44211
44212
44213
44227
44300
44310
44312
44314
44316
44320
44322
44340
1/2/2015
Modifier
Par Fee
$2,165.17
$1,980.58
$1,908.07
$2,191.74
$2,123.78
$2,357.95
$2,223.12
$2,169.41
$1,264.39
$935.23
$663.96
$1,130.90
$1,249.56
$1,410.72
$248.84
$1,568.19
$1,364.56
$1,788.01
$1,859.21
$2,031.75
$1,819.83
$2,224.39
$2,097.37
$192.81
$1,700.90
$855.66
$1,063.97
$602.19
$1,024.07
$1,439.98
$1,223.70
$1,020.00
$636.49
Nonpar Fee
$2,056.91
$1,881.55
$1,812.67
$2,082.15
$2,017.59
$2,240.05
$2,111.96
$2,060.94
$1,201.17
$888.47
$630.76
$1,074.36
$1,187.08
$1,340.18
$236.40
$1,489.78
$1,296.33
$1,698.61
$1,766.25
$1,930.16
$1,728.84
$2,113.17
$1,992.50
$183.17
$1,615.86
$812.88
$1,010.77
$572.08
$972.87
$1,367.98
$1,162.52
$969.00
$604.67
Limiting
Charge
$2,365.45
$2,163.78
$2,084.57
$2,394.47
$2,320.23
$2,576.06
$2,428.75
$2,370.08
$1,381.35
$1,021.74
$725.37
$1,235.51
$1,365.14
$1,541.21
$271.86
$1,713.25
$1,490.78
$1,953.40
$2,031.19
$2,219.68
$1,988.17
$2,430.15
$2,291.38
$210.65
$1,858.24
$934.81
$1,162.39
$657.89
$1,118.80
$1,573.18
$1,336.90
$1,114.35
$695.37
Charge**
Charge***
$2,341.79
$2,329.97
$2,142.14
$2,131.33
$2,063.72
$2,053.30
$2,370.53
$2,358.56
$2,297.02
$2,285.43
$2,550.30
$2,537.42
$2,404.47
$2,392.32
$2,346.38
$2,334.53
$1,367.53
$1,360.62
$1,011.53
$1,006.41
$718.12
$714.50
$1,223.16
$1,216.98
$1,351.49
$1,344.66
$1,525.80
$1,518.09
$269.15
$267.78
$1,696.11
$1,687.54
$1,475.88
$1,468.42
$1,933.86
$1,924.10
$2,010.88
$2,000.72
$2,197.49
$2,186.39
$1,968.28
$1,958.35
$2,405.85
$2,393.69
$2,268.47
$2,257.00
$208.54
$207.48
$1,839.66
$1,830.36
$925.46
$920.79
$1,150.76
$1,144.95
$651.31
$648.03
$1,107.61
$1,102.02
$1,557.45
$1,549.58
$1,323.52
$1,316.84
$1,103.21
$1,097.64
$688.41
$684.94
Arizona
EHR/eRx
Limiting
Charge**
$2,318.14
$2,120.51
$2,042.88
$2,346.59
$2,273.83
$2,524.54
$2,380.18
$2,322.68
$1,353.72
$1,001.31
$710.86
$1,210.80
$1,337.84
$1,510.39
$266.42
$1,678.98
$1,460.96
$1,914.34
$1,990.57
$2,175.29
$1,948.40
$2,381.55
$2,245.55
$206.44
$1,821.07
$916.11
$1,139.13
$644.74
$1,096.42
$1,541.71
$1,310.16
$1,092.06
$681.47
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$2,306.66
$2,283.36
$2,110.01
$2,088.70
$2,032.76
$2,012.24
$2,334.97
$2,311.39
$2,262.57
$2,239.72
$2,512.05
$2,486.67
$2,368.40
$2,344.47
$2,311.19
$2,287.83
$1,347.02
$1,333.41
$996.36
$986.29
$707.34
$700.20
$1,204.82
$1,192.64
$1,331.22
$1,317.77
$1,502.91
$1,487.73
$265.11
$262.42
$1,670.67
$1,653.79
$1,453.74
$1,439.04
$1,904.86
$1,885.62
$1,980.71
$1,960.72
$2,164.53
$2,142.67
$1,938.76
$1,919.18
$2,369.76
$2,345.83
$2,234.44
$2,211.86
$205.41
$203.34
$1,812.06
$1,793.76
$911.58
$902.37
$1,133.50
$1,122.04
$641.54
$635.06
$1,090.99
$1,079.98
$1,534.09
$1,518.59
$1,303.67
$1,290.51
$1,086.66
$1,075.69
$678.09
$671.24
Page 144 of 323
Notes
#
#
#
#
#
#
#
Procedure
Code
44345
44346
44360
44361
44363
44364
44365
44366
44369
44370
44372
44373
44376
44377
44378
44379
44380
44382
44385
44385
44386
44386
44388
44388
44389
44389
44390
44390
44391
44391
44392
44392
44394
1/2/2015
Modifier
Par Fee
$1,071.92
$1,205.36
$157.53
$173.75
$207.99
$221.90
$193.64
$260.38
$266.42
$287.96
$259.14
$207.91
$304.95
$322.88
$413.13
$439.95
$69.42
$82.52
$269.88
$109.70
$359.76
$129.50
$357.63
$169.56
$400.84
$187.39
$469.90
$228.20
$504.90
$254.62
$445.19
$222.08
$502.89
Nonpar Fee
$1,018.32
$1,145.09
$149.65
$165.06
$197.59
$210.81
$183.96
$247.36
$253.10
$273.56
$246.18
$197.51
$289.70
$306.74
$392.47
$417.95
$65.95
$78.39
$256.39
$104.22
$341.77
$123.03
$339.75
$161.08
$380.80
$178.02
$446.41
$216.79
$479.66
$241.89
$422.93
$210.98
$477.75
Limiting
Charge
$1,171.07
$1,316.85
$172.10
$189.82
$227.23
$242.43
$211.55
$284.46
$291.07
$314.59
$283.11
$227.14
$333.16
$352.75
$451.34
$480.64
$75.84
$90.15
$294.85
$119.85
$393.04
$141.48
$390.71
$185.24
$437.92
$204.72
$513.37
$249.31
$551.61
$278.17
$486.37
$242.63
$549.41
Charge**
Charge***
$1,159.36
$1,153.51
$1,303.69
$1,297.10
$170.37
$169.52
$187.92
$186.97
$224.95
$223.82
$240.01
$238.80
$209.44
$208.38
$281.62
$280.20
$288.16
$286.70
$311.44
$309.88
$280.28
$278.86
$224.86
$223.73
$329.82
$328.15
$349.22
$347.46
$446.83
$444.57
$475.84
$473.43
$75.08
$74.70
$89.25
$88.79
$291.90
$290.42
$118.66
$118.06
$389.10
$387.14
$140.07
$139.36
$386.80
$384.85
$183.39
$182.46
$433.54
$431.35
$202.68
$201.65
$508.24
$505.67
$246.81
$245.57
$546.09
$543.34
$275.39
$274.00
$481.51
$479.08
$240.20
$238.99
$543.92
$541.17
Arizona
EHR/eRx
Limiting
Charge**
$1,147.64
$1,290.52
$168.66
$186.02
$222.69
$237.58
$207.32
$278.77
$285.25
$308.30
$277.45
$222.59
$326.50
$345.70
$442.31
$471.03
$74.32
$88.34
$288.95
$117.46
$385.17
$138.66
$382.90
$181.54
$429.16
$200.63
$503.10
$244.32
$540.58
$272.61
$476.64
$237.77
$538.43
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$1,141.97
$1,130.43
$1,284.14
$1,271.16
$167.82
$166.13
$185.10
$183.23
$221.58
$219.35
$236.41
$234.01
$206.30
$204.22
$277.40
$274.59
$283.83
$280.97
$306.77
$303.68
$276.07
$273.29
$221.49
$219.26
$324.88
$321.60
$343.98
$340.52
$440.13
$435.68
$468.69
$463.97
$73.96
$73.21
$87.92
$87.02
$287.52
$284.61
$116.87
$115.70
$383.26
$379.40
$137.97
$136.57
$381.00
$377.17
$180.64
$178.81
$427.04
$422.72
$199.64
$197.62
$500.62
$495.56
$243.11
$240.65
$537.90
$532.47
$271.26
$268.51
$474.28
$469.49
$236.60
$234.21
$535.76
$530.36
Page 145 of 323
Notes
#
#
Procedure
Code
44394
44500
44602
44603
44604
44605
44615
44620
44625
44626
44640
44650
44660
44661
44680
44700
44701
44720
44721
44800
44820
44850
44900
44950
44955
44960
44970
45000
45005
45005
45020
45100
45108
1/2/2015
Modifier
Par Fee
$259.76
$25.21
$1,435.55
$1,650.17
$1,077.98
$1,330.02
$1,091.70
$885.50
$1,038.83
$1,632.59
$1,427.84
$1,479.61
$1,363.09
$1,581.78
$1,086.07
$1,041.50
$171.58
$280.40
$392.04
$779.73
$863.31
$765.13
$788.38
$652.83
$85.43
$888.34
$610.71
$429.45
$275.88
$163.97
$580.24
$305.94
$375.38
Nonpar Fee
$246.77
$23.95
$1,363.77
$1,567.66
$1,024.08
$1,263.52
$1,037.12
$841.23
$986.89
$1,550.96
$1,356.45
$1,405.63
$1,294.94
$1,502.69
$1,031.77
$989.43
$163.00
$266.38
$372.44
$740.74
$820.14
$726.87
$748.96
$620.19
$81.16
$843.92
$580.17
$407.98
$262.09
$155.77
$551.23
$290.64
$356.61
Limiting
Charge
$283.79
$27.54
$1,568.34
$1,802.81
$1,177.69
$1,453.05
$1,192.69
$967.41
$1,134.92
$1,783.60
$1,559.92
$1,616.47
$1,489.18
$1,728.09
$1,186.54
$1,137.84
$187.45
$306.34
$428.31
$851.85
$943.16
$835.90
$861.30
$713.22
$93.33
$970.51
$667.20
$469.18
$301.40
$179.14
$633.91
$334.24
$410.10
Charge**
Charge***
$280.95
$279.53
$27.27
$27.13
$1,552.65
$1,544.81
$1,784.78
$1,775.77
$1,165.92
$1,160.03
$1,438.51
$1,431.26
$1,180.76
$1,174.79
$957.74
$952.90
$1,123.57
$1,117.90
$1,765.77
$1,756.86
$1,544.32
$1,536.52
$1,600.31
$1,592.23
$1,474.29
$1,466.85
$1,710.81
$1,702.17
$1,174.67
$1,168.73
$1,126.47
$1,120.78
$185.58
$184.64
$303.28
$301.74
$424.03
$421.88
$843.33
$839.07
$933.73
$929.02
$827.54
$823.37
$852.69
$848.39
$706.09
$702.52
$92.40
$91.93
$960.80
$955.95
$660.53
$657.19
$464.49
$462.14
$298.39
$296.88
$177.34
$176.44
$627.58
$624.40
$330.89
$329.22
$406.00
$403.95
Arizona
EHR/eRx
Limiting
Charge**
$278.10
$26.99
$1,536.96
$1,766.76
$1,154.14
$1,423.99
$1,168.84
$948.07
$1,112.22
$1,747.93
$1,528.72
$1,584.15
$1,459.40
$1,693.54
$1,162.80
$1,115.09
$183.70
$300.21
$419.74
$834.82
$924.30
$819.18
$844.08
$698.96
$91.47
$951.10
$653.86
$459.79
$295.38
$175.55
$621.24
$327.55
$401.90
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$276.74
$273.93
$26.85
$26.59
$1,529.36
$1,513.91
$1,758.01
$1,740.26
$1,148.42
$1,136.83
$1,416.94
$1,402.63
$1,163.05
$1,151.30
$943.38
$933.85
$1,106.71
$1,095.54
$1,739.28
$1,721.71
$1,521.16
$1,505.79
$1,576.31
$1,560.39
$1,452.17
$1,437.50
$1,685.15
$1,668.13
$1,157.05
$1,145.35
$1,109.58
$1,098.37
$182.79
$180.94
$298.72
$295.70
$417.67
$413.45
$830.68
$822.30
$919.72
$910.43
$815.13
$806.90
$839.90
$831.42
$695.50
$688.47
$91.01
$90.10
$946.39
$936.82
$650.61
$644.05
$457.52
$452.89
$293.92
$290.95
$174.69
$172.91
$618.16
$611.93
$325.92
$322.64
$399.90
$395.88
Page 146 of 323
Notes
#
#
#
#
#
#
#
Procedure
Code
45110
45111
45112
45113
45114
45116
45119
45120
45121
45123
45126
45130
45135
45136
45150
45160
45171
45172
45190
45300
45300
45303
45303
45305
45305
45307
45307
45308
45308
45309
45309
45315
45315
1/2/2015
Modifier
Par Fee
$1,887.07
$1,108.97
$1,922.33
$1,934.42
$1,851.46
$1,586.92
$1,993.62
$1,620.10
$1,685.44
$1,145.82
$2,779.95
$1,112.33
$1,402.33
$1,847.16
$366.80
$1,041.46
$613.13
$827.25
$708.65
$125.69
$55.25
$984.84
$94.90
$198.54
$80.91
$227.20
$104.92
$223.09
$91.15
$225.05
$92.40
$251.92
$114.27
Nonpar Fee
$1,792.72
$1,053.52
$1,826.21
$1,837.70
$1,758.89
$1,507.57
$1,893.94
$1,539.10
$1,601.17
$1,088.53
$2,640.95
$1,056.71
$1,332.21
$1,754.80
$348.46
$989.39
$582.47
$785.89
$673.22
$119.41
$52.49
$935.60
$90.16
$188.61
$76.86
$215.84
$99.67
$211.94
$86.59
$213.80
$87.78
$239.32
$108.56
Limiting
Charge
$2,061.63
$1,211.55
$2,100.14
$2,113.36
$2,022.72
$1,733.71
$2,178.03
$1,769.97
$1,841.35
$1,251.81
$3,037.09
$1,215.22
$1,532.04
$2,018.02
$400.73
$1,137.80
$669.84
$903.77
$774.20
$137.32
$60.36
$1,075.94
$103.68
$216.90
$88.39
$248.22
$114.62
$243.73
$99.58
$245.87
$100.95
$275.22
$124.84
Charge**
Charge***
$2,041.01
$2,030.70
$1,199.43
$1,193.38
$2,079.14
$2,068.64
$2,092.22
$2,081.65
$2,002.50
$1,992.39
$1,716.36
$1,707.70
$2,156.25
$2,145.36
$1,752.27
$1,743.41
$1,822.93
$1,813.72
$1,239.29
$1,233.03
$3,006.72
$2,991.54
$1,203.06
$1,196.99
$1,516.72
$1,509.06
$1,997.84
$1,987.75
$396.73
$394.71
$1,126.43
$1,120.73
$663.15
$659.79
$894.73
$890.22
$766.46
$762.59
$135.95
$135.26
$59.77
$59.46
$1,065.18
$1,059.81
$102.65
$102.13
$214.73
$213.65
$87.50
$87.07
$245.73
$244.49
$113.47
$112.90
$241.29
$240.07
$98.58
$98.08
$243.41
$242.18
$99.94
$99.43
$272.47
$271.09
$123.59
$122.97
Arizona
EHR/eRx
Limiting
Charge**
$2,020.40
$1,187.32
$2,058.14
$2,071.09
$1,982.27
$1,699.03
$2,134.47
$1,734.57
$1,804.52
$1,226.77
$2,976.35
$1,190.92
$1,501.41
$1,977.66
$392.71
$1,115.04
$656.44
$885.70
$758.72
$134.57
$59.16
$1,054.42
$101.61
$212.57
$86.62
$243.25
$112.33
$238.86
$97.59
$240.95
$98.92
$269.71
$122.35
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$2,010.40
$1,990.10
$1,181.44
$1,169.50
$2,047.95
$2,027.27
$2,060.83
$2,040.03
$1,972.46
$1,952.53
$1,690.62
$1,673.55
$2,123.91
$2,102.45
$1,725.98
$1,708.56
$1,795.59
$1,777.45
$1,220.70
$1,208.37
$2,961.62
$2,931.71
$1,185.02
$1,173.06
$1,493.98
$1,478.89
$1,967.87
$1,947.99
$390.78
$386.83
$1,109.53
$1,098.32
$653.20
$646.60
$881.31
$872.41
$754.96
$747.34
$133.92
$132.55
$58.87
$58.27
$1,049.20
$1,038.61
$101.11
$100.08
$211.51
$209.38
$86.19
$85.32
$242.04
$239.60
$111.77
$110.64
$237.67
$235.27
$97.09
$96.13
$239.76
$237.34
$98.44
$97.44
$268.39
$265.66
$121.74
$120.51
Page 147 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
45317
45317
45320
45320
45321
45327
45330
45330
45331
45331
45332
45332
45333
45333
45334
45335
45335
45337
45338
45338
45340
45340
45341
45342
45378
45378
45378
45378
45379
45379
45380
45380
45381
1/2/2015
Modifier
53
53
Par Fee
$246.42
$120.20
$248.75
$112.88
$109.39
$125.25
$139.14
$64.77
$165.15
$76.48
$296.20
$112.42
$301.21
$112.07
$165.57
$278.95
$93.74
$144.61
$323.11
$142.91
$494.24
$117.74
$157.84
$239.64
$392.98
$218.86
$139.14
$64.77
$506.34
$275.01
$468.34
$261.68
$470.67
Nonpar Fee
$234.10
$114.19
$236.31
$107.24
$103.92
$118.99
$132.18
$61.53
$156.89
$72.66
$281.39
$106.80
$286.15
$106.47
$157.29
$265.00
$89.05
$137.38
$306.95
$135.76
$469.53
$111.85
$149.95
$227.66
$373.33
$207.92
$132.18
$61.53
$481.02
$261.26
$444.92
$248.60
$447.14
Limiting
Charge
$269.22
$131.32
$271.76
$123.33
$119.51
$136.84
$152.01
$70.76
$180.42
$83.56
$323.60
$122.82
$329.07
$122.44
$180.88
$304.75
$102.41
$157.99
$352.99
$156.12
$539.96
$128.63
$172.44
$261.81
$429.33
$239.11
$152.01
$70.76
$553.17
$300.45
$511.66
$285.89
$514.21
Charge**
Charge***
$266.52
$265.18
$130.01
$129.35
$269.04
$267.69
$122.10
$121.47
$118.31
$117.71
$135.47
$134.79
$150.49
$149.73
$70.05
$69.70
$178.62
$177.72
$82.72
$82.31
$320.37
$318.75
$121.59
$120.98
$325.78
$324.14
$121.22
$120.60
$179.08
$178.17
$301.70
$300.18
$101.38
$100.87
$156.41
$155.62
$349.46
$347.70
$154.56
$153.78
$534.55
$531.86
$127.34
$126.70
$170.72
$169.86
$259.19
$257.89
$425.04
$422.89
$236.72
$235.52
$150.49
$149.73
$70.05
$69.70
$547.64
$544.87
$297.45
$295.94
$506.54
$503.99
$283.03
$281.60
$509.07
$506.49
Arizona
EHR/eRx
Limiting
Charge**
$263.83
$128.70
$266.32
$120.87
$117.12
$134.10
$148.97
$69.35
$176.81
$81.89
$317.12
$120.36
$322.49
$119.99
$177.26
$298.66
$100.36
$154.82
$345.93
$153.00
$529.16
$126.05
$168.99
$256.58
$420.74
$234.32
$148.97
$69.35
$542.11
$294.43
$501.42
$280.17
$503.93
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$262.52
$259.88
$128.05
$126.76
$265.01
$262.33
$120.27
$119.05
$116.54
$115.36
$133.43
$132.09
$148.24
$146.74
$69.00
$68.31
$175.94
$174.16
$81.48
$80.66
$315.56
$312.36
$119.76
$118.55
$320.90
$317.65
$119.40
$118.19
$176.39
$174.60
$297.17
$294.17
$99.87
$98.85
$154.07
$152.50
$344.22
$340.75
$152.24
$150.70
$526.54
$521.23
$125.43
$124.17
$168.15
$166.46
$255.30
$252.72
$418.67
$414.43
$233.16
$230.81
$148.24
$146.74
$69.00
$68.31
$539.43
$533.98
$292.99
$290.02
$498.94
$493.90
$278.78
$275.98
$501.43
$496.37
Page 148 of 323
Notes
#
#
#
#
#
#
Procedure
Code
45381
45382
45382
45384
45384
45385
45385
45386
45386
45391
45392
45395
45397
45400
45402
45500
45505
45520
45520
45540
45541
45550
45560
45562
45563
45800
45805
45820
45825
45900
45905
45910
45915
1/2/2015
Modifier
Par Fee
$247.91
$608.51
$332.13
$469.07
$274.20
$528.56
$310.45
$674.83
$268.66
$298.25
$379.51
$2,024.28
$2,205.31
$1,163.78
$1,553.43
$536.75
$606.60
$161.70
$41.21
$1,082.84
$957.28
$1,491.42
$703.72
$1,165.20
$1,679.14
$1,259.67
$1,412.85
$1,148.78
$1,480.30
$208.27
$172.91
$198.83
$337.16
Nonpar Fee
$235.51
$578.08
$315.52
$445.62
$260.49
$502.13
$294.93
$641.09
$255.23
$283.34
$360.53
$1,923.07
$2,095.04
$1,105.59
$1,475.76
$509.91
$576.27
$153.62
$39.15
$1,028.70
$909.42
$1,416.85
$668.53
$1,106.94
$1,595.18
$1,196.69
$1,342.21
$1,091.34
$1,406.29
$197.86
$164.26
$188.89
$320.30
Limiting
Charge
$270.84
$664.79
$362.85
$512.46
$299.56
$577.45
$339.17
$737.25
$293.51
$325.84
$414.61
$2,211.53
$2,409.30
$1,271.43
$1,697.12
$586.40
$662.71
$176.66
$45.02
$1,183.01
$1,045.83
$1,629.38
$768.81
$1,272.98
$1,834.46
$1,376.19
$1,543.54
$1,255.04
$1,617.23
$227.54
$188.90
$217.22
$368.35
Charge**
Charge***
$268.12
$266.78
$658.15
$654.82
$359.21
$357.41
$507.33
$504.78
$296.57
$295.07
$571.68
$568.79
$335.78
$334.09
$729.88
$726.19
$290.58
$289.11
$322.59
$320.95
$410.46
$408.39
$2,189.42
$2,178.35
$2,385.20
$2,373.15
$1,258.71
$1,252.36
$1,680.15
$1,671.66
$580.53
$577.60
$656.09
$652.77
$174.89
$174.02
$44.57
$44.34
$1,171.17
$1,165.26
$1,035.38
$1,030.15
$1,613.08
$1,604.94
$761.12
$757.28
$1,260.25
$1,253.89
$1,816.11
$1,806.94
$1,362.43
$1,355.55
$1,528.11
$1,520.39
$1,242.49
$1,236.22
$1,601.06
$1,592.98
$225.26
$224.12
$187.01
$186.07
$215.05
$213.97
$364.67
$362.83
Arizona
EHR/eRx
Limiting
Charge**
$265.42
$651.50
$355.59
$502.22
$293.57
$565.90
$332.38
$722.51
$287.65
$319.32
$406.32
$2,167.30
$2,361.11
$1,246.00
$1,663.18
$574.67
$649.45
$173.13
$44.13
$1,159.35
$1,024.91
$1,596.79
$753.43
$1,247.52
$1,797.77
$1,348.67
$1,512.68
$1,229.94
$1,584.88
$222.99
$185.12
$212.88
$360.97
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$264.10
$261.44
$648.28
$641.72
$353.82
$350.26
$499.72
$494.68
$292.12
$289.17
$563.10
$557.42
$330.74
$327.39
$718.93
$711.68
$286.22
$283.34
$317.75
$314.53
$404.31
$400.22
$2,156.57
$2,134.79
$2,349.43
$2,325.69
$1,239.83
$1,227.31
$1,654.95
$1,638.23
$571.83
$566.04
$646.24
$639.71
$172.27
$170.53
$43.91
$43.46
$1,153.60
$1,141.96
$1,019.85
$1,009.54
$1,588.89
$1,572.83
$749.70
$742.13
$1,241.34
$1,228.81
$1,788.87
$1,770.80
$1,341.99
$1,328.45
$1,505.19
$1,489.99
$1,223.85
$1,211.49
$1,577.05
$1,561.11
$221.88
$219.64
$184.21
$182.34
$211.83
$209.68
$359.19
$355.56
Page 149 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
45915
45990
46020
46020
46030
46030
46040
46040
46045
46050
46050
46060
46070
46080
46080
46083
46083
46200
46200
46220
46220
46221
46221
46230
46230
46250
46250
46255
46255
46257
46258
46260
46261
1/2/2015
Modifier
Par Fee
$232.04
$110.06
$280.76
$238.93
$141.65
$92.31
$543.95
$421.67
$442.33
$204.94
$99.46
$485.32
$225.49
$250.94
$161.92
$178.43
$108.35
$454.40
$332.12
$209.63
$121.32
$274.76
$196.10
$277.18
$176.35
$470.73
$320.20
$515.56
$360.03
$428.55
$473.41
$484.35
$530.74
Nonpar Fee
$220.44
$104.56
$266.72
$226.98
$134.57
$87.69
$516.75
$400.59
$420.21
$194.69
$94.49
$461.05
$214.22
$238.39
$153.82
$169.51
$102.93
$431.68
$315.51
$199.15
$115.25
$261.02
$186.30
$263.32
$167.53
$447.19
$304.19
$489.78
$342.03
$407.12
$449.74
$460.13
$504.20
Limiting
Charge
$253.51
$120.24
$306.73
$261.03
$154.76
$100.84
$594.26
$460.68
$483.24
$223.89
$108.66
$530.21
$246.35
$274.15
$176.89
$194.94
$118.37
$496.43
$362.84
$229.02
$132.54
$300.17
$214.25
$302.82
$192.66
$514.27
$349.82
$563.25
$393.33
$468.19
$517.20
$529.15
$579.83
Charge**
Charge***
$250.98
$249.70
$119.04
$118.44
$303.66
$302.13
$258.42
$257.12
$153.20
$152.43
$99.83
$99.33
$588.32
$585.35
$456.07
$453.77
$478.41
$476.00
$221.65
$220.54
$107.58
$107.03
$524.91
$522.25
$243.89
$242.66
$271.41
$270.03
$175.12
$174.24
$192.98
$192.02
$117.19
$116.60
$491.46
$488.98
$359.20
$357.40
$226.73
$225.58
$131.22
$130.55
$297.17
$295.67
$212.11
$211.04
$299.79
$298.28
$190.73
$189.77
$509.13
$506.55
$346.32
$344.57
$557.61
$554.79
$389.40
$387.44
$463.51
$461.16
$512.03
$509.44
$523.86
$521.21
$574.03
$571.14
Arizona
EHR/eRx
Limiting
Charge**
$248.43
$117.84
$300.60
$255.81
$151.66
$98.83
$582.38
$451.47
$473.58
$219.42
$106.49
$519.60
$241.43
$268.66
$173.35
$191.04
$116.00
$486.51
$355.58
$224.45
$129.89
$294.17
$209.96
$296.76
$188.81
$503.99
$342.83
$551.98
$385.47
$458.83
$506.86
$518.57
$568.24
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$247.22
$244.71
$117.25
$116.07
$299.10
$296.09
$254.54
$251.97
$150.90
$149.39
$98.34
$97.35
$579.50
$573.64
$449.22
$444.69
$471.24
$466.47
$218.33
$216.13
$105.97
$104.89
$517.03
$511.81
$240.24
$237.81
$267.34
$264.64
$172.50
$170.75
$190.08
$188.17
$115.43
$114.26
$484.09
$479.21
$353.81
$350.24
$223.33
$221.08
$129.25
$127.95
$292.71
$289.75
$208.92
$206.80
$295.30
$292.31
$187.86
$185.98
$501.49
$496.43
$341.12
$337.69
$549.25
$543.70
$383.56
$379.68
$456.55
$451.95
$504.34
$499.26
$516.01
$510.80
$565.42
$559.72
Page 150 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
46262
46270
46270
46275
46275
46280
46285
46285
46288
46320
46320
46500
46500
46505
46505
46600
46600
46604
46604
46606
46606
46608
46608
46610
46610
46611
46611
46612
46612
46614
46614
46615
46615
1/2/2015
Modifier
Par Fee
$564.31
$516.55
$398.92
$548.19
$421.97
$478.88
$543.00
$420.36
$561.04
$186.39
$113.10
$243.73
$132.18
$288.98
$242.86
$89.79
$41.53
$637.88
$67.95
$229.07
$77.82
$241.41
$85.88
$229.79
$83.19
$177.45
$83.41
$279.09
$97.10
$130.92
$66.20
$146.44
$94.95
Nonpar Fee
$536.09
$490.72
$378.97
$520.78
$400.87
$454.94
$515.85
$399.34
$532.99
$177.07
$107.45
$231.54
$125.57
$274.53
$230.72
$85.30
$39.45
$605.99
$64.55
$217.62
$73.93
$229.34
$81.59
$218.30
$79.03
$168.58
$79.24
$265.14
$92.25
$124.37
$62.89
$139.12
$90.20
Limiting
Charge
$616.50
$564.33
$435.82
$598.90
$461.00
$523.18
$593.23
$459.24
$612.94
$203.63
$123.57
$266.27
$144.41
$315.71
$265.33
$98.10
$45.37
$696.89
$74.23
$250.26
$85.02
$263.74
$93.83
$251.05
$90.88
$193.87
$91.13
$304.91
$106.09
$143.03
$72.32
$159.99
$103.73
Charge**
Charge***
$610.34
$607.26
$558.68
$555.86
$431.46
$429.28
$592.91
$589.92
$456.39
$454.09
$517.95
$515.34
$587.29
$584.33
$454.65
$452.35
$606.81
$603.75
$201.60
$200.57
$122.34
$121.72
$263.60
$262.28
$142.96
$142.24
$312.55
$310.97
$262.67
$261.35
$97.12
$96.62
$44.92
$44.69
$689.92
$686.44
$73.49
$73.12
$247.76
$246.51
$84.17
$83.74
$261.11
$259.79
$92.89
$92.43
$248.54
$247.28
$89.98
$89.52
$191.92
$190.96
$90.22
$89.76
$301.86
$300.33
$105.03
$104.50
$141.60
$140.88
$71.60
$71.24
$158.39
$157.58
$102.70
$102.18
Arizona
EHR/eRx
Limiting
Charge**
$604.18
$553.05
$427.10
$586.91
$451.78
$512.72
$581.36
$450.05
$600.68
$199.56
$121.10
$260.95
$141.52
$309.40
$260.03
$96.13
$44.46
$682.95
$72.75
$245.26
$83.32
$258.46
$91.95
$246.02
$89.07
$189.99
$89.31
$298.82
$103.97
$140.16
$70.87
$156.79
$101.66
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$601.19
$595.11
$550.30
$544.76
$424.98
$420.69
$584.02
$578.11
$449.55
$445.00
$510.17
$505.02
$578.48
$572.64
$447.83
$443.30
$597.71
$591.68
$198.57
$196.57
$120.50
$119.28
$259.65
$257.04
$140.82
$139.39
$307.86
$304.75
$258.73
$256.13
$95.66
$94.69
$44.24
$43.79
$679.57
$672.70
$72.38
$71.66
$244.04
$241.58
$82.90
$82.06
$257.19
$254.59
$91.49
$90.57
$244.81
$242.33
$88.63
$87.73
$189.05
$187.14
$88.86
$87.98
$297.33
$294.33
$103.45
$102.41
$139.47
$138.06
$70.53
$69.82
$156.01
$154.43
$101.15
$100.13
Page 151 of 323
Notes
#
#
#
#
#
#
Procedure
Code
46700
46705
46706
46707
46710
46712
46715
46716
46730
46735
46740
46742
46744
46746
46748
46750
46751
46753
46754
46754
46760
46761
46762
46900
46900
46910
46910
46916
46916
46917
46917
46922
46922
1/2/2015
Modifier
Par Fee
$667.21
$495.10
$178.73
$482.42
$1,070.75
$2,056.25
$550.08
$1,095.16
$1,995.37
$2,079.90
$2,181.08
$2,286.40
$3,582.74
$3,559.90
$3,903.38
$769.52
$588.93
$590.08
$302.28
$233.27
$1,118.13
$943.99
$943.75
$247.26
$140.71
$259.96
$136.25
$232.07
$145.90
$458.62
$135.40
$271.27
$138.26
Nonpar Fee
$633.85
$470.35
$169.79
$458.30
$1,017.21
$1,953.44
$522.58
$1,040.40
$1,895.60
$1,975.91
$2,072.03
$2,172.08
$3,403.60
$3,381.91
$3,708.21
$731.04
$559.48
$560.58
$287.17
$221.61
$1,062.22
$896.79
$896.56
$234.90
$133.67
$246.96
$129.44
$220.47
$138.61
$435.69
$128.63
$257.71
$131.35
Limiting
Charge
$728.93
$540.90
$195.26
$527.05
$1,169.79
$2,246.46
$600.97
$1,196.46
$2,179.94
$2,272.30
$2,382.83
$2,497.89
$3,914.14
$3,889.20
$4,264.44
$840.70
$643.40
$644.67
$330.25
$254.85
$1,221.55
$1,031.31
$1,031.04
$270.14
$153.72
$284.00
$148.86
$253.54
$159.40
$501.04
$147.92
$296.37
$151.05
Charge**
Charge***
$721.64
$717.99
$535.50
$532.78
$193.30
$192.33
$521.78
$519.14
$1,158.10
$1,152.24
$2,224.00
$2,212.76
$594.95
$591.95
$1,184.50
$1,178.51
$2,158.14
$2,147.25
$2,249.57
$2,238.21
$2,359.01
$2,347.09
$2,472.91
$2,460.43
$3,874.99
$3,855.43
$3,850.30
$3,830.86
$4,221.80
$4,200.48
$832.29
$828.08
$636.97
$633.75
$638.22
$635.00
$326.95
$325.29
$252.30
$251.03
$1,209.34
$1,203.23
$1,020.99
$1,015.84
$1,020.73
$1,015.58
$267.43
$266.09
$152.18
$151.41
$281.16
$279.75
$147.37
$146.63
$251.01
$249.73
$157.80
$157.01
$496.03
$493.52
$146.44
$145.71
$293.40
$291.92
$149.55
$148.79
Arizona
EHR/eRx
Limiting
Charge**
$714.35
$530.08
$191.35
$516.50
$1,146.40
$2,201.53
$588.95
$1,172.53
$2,136.34
$2,226.85
$2,335.18
$2,447.94
$3,835.86
$3,811.41
$4,179.16
$823.88
$630.53
$631.78
$323.64
$249.76
$1,197.13
$1,010.68
$1,010.42
$264.73
$150.65
$278.32
$145.88
$248.47
$156.22
$491.03
$144.97
$290.44
$148.03
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$710.82
$703.63
$527.47
$522.13
$190.41
$188.47
$513.95
$508.75
$1,140.72
$1,129.21
$2,190.64
$2,168.50
$586.03
$580.12
$1,166.73
$1,154.95
$2,125.76
$2,104.29
$2,215.83
$2,193.44
$2,323.62
$2,300.15
$2,435.82
$2,411.22
$3,816.87
$3,778.33
$3,792.55
$3,754.24
$4,158.47
$4,116.47
$819.80
$811.52
$627.42
$621.08
$628.65
$622.30
$322.05
$318.79
$248.52
$246.01
$1,191.20
$1,179.18
$1,005.68
$995.52
$1,005.42
$995.27
$263.42
$260.76
$149.90
$148.40
$276.94
$274.15
$145.16
$143.69
$247.25
$244.74
$155.43
$153.87
$488.59
$483.67
$144.24
$142.80
$289.00
$286.09
$147.30
$145.81
Page 152 of 323
Notes
#
#
#
#
#
#
#
Procedure
Code
46924
46924
46930
46930
46940
46940
46942
46942
46945
46945
46946
46946
46947
47000
47000
47001
47010
47015
47100
47120
47122
47125
47130
47135
47136
47140
47141
47142
47146
47147
47300
47350
47360
1/2/2015
Modifier
Par Fee
$545.78
$188.24
$210.30
$151.66
$233.33
$149.66
$221.03
$134.86
$314.27
$230.24
$320.75
$231.01
$387.84
$369.23
$106.43
$106.00
$1,225.50
$1,183.26
$860.65
$2,370.25
$3,491.34
$3,125.54
$3,358.16
$4,972.06
$4,272.16
$3,299.92
$4,341.71
$4,786.41
$336.51
$390.47
$1,154.73
$1,394.49
$1,902.02
Nonpar Fee
$518.49
$178.83
$199.79
$144.08
$221.66
$142.18
$209.98
$128.12
$298.56
$218.73
$304.71
$219.46
$368.45
$350.77
$101.11
$100.70
$1,164.23
$1,124.10
$817.62
$2,251.74
$3,316.77
$2,969.26
$3,190.25
$4,723.46
$4,058.55
$3,134.92
$4,124.62
$4,547.09
$319.68
$370.95
$1,096.99
$1,324.77
$1,806.92
Limiting
Charge
$596.26
$205.65
$229.76
$165.69
$254.91
$163.51
$241.48
$147.34
$343.34
$251.54
$350.42
$252.38
$423.72
$403.39
$116.28
$115.81
$1,338.86
$1,292.72
$940.26
$2,589.50
$3,814.29
$3,414.65
$3,668.79
$5,431.98
$4,667.33
$3,605.16
$4,743.31
$5,229.15
$367.63
$426.59
$1,261.54
$1,523.49
$2,077.96
Charge**
Charge***
$590.31
$587.32
$203.60
$202.57
$227.46
$226.31
$164.04
$163.21
$252.36
$251.09
$161.87
$161.06
$239.06
$237.85
$145.87
$145.13
$339.91
$338.19
$249.02
$247.77
$346.91
$345.16
$249.86
$248.60
$419.49
$417.36
$399.35
$397.34
$115.12
$114.53
$114.64
$114.07
$1,325.48
$1,318.79
$1,279.79
$1,273.33
$930.86
$926.16
$2,563.60
$2,550.65
$3,776.14
$3,757.07
$3,380.51
$3,363.43
$3,632.10
$3,613.76
$5,377.66
$5,350.50
$4,620.65
$4,597.32
$3,569.11
$3,551.09
$4,695.88
$4,672.16
$5,176.86
$5,150.71
$363.95
$362.11
$422.33
$420.20
$1,248.92
$1,242.62
$1,508.25
$1,500.64
$2,057.18
$2,046.79
Arizona
EHR/eRx
Limiting
Charge**
$584.34
$201.54
$225.16
$162.38
$249.81
$160.24
$236.65
$144.39
$336.48
$246.51
$343.41
$247.33
$415.24
$395.31
$113.95
$113.49
$1,312.09
$1,266.86
$921.46
$2,537.72
$3,737.99
$3,346.35
$3,595.42
$5,323.34
$4,573.99
$3,533.05
$4,648.45
$5,124.57
$360.28
$418.06
$1,236.31
$1,493.01
$2,036.40
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$581.45
$575.58
$200.54
$198.51
$224.04
$221.78
$161.58
$159.94
$248.57
$246.07
$159.45
$157.84
$235.47
$233.09
$143.68
$142.23
$334.81
$331.43
$245.28
$242.81
$341.71
$338.26
$246.11
$243.62
$413.20
$409.01
$393.36
$389.38
$113.39
$112.24
$112.92
$111.79
$1,305.60
$1,292.42
$1,260.60
$1,247.87
$916.90
$907.64
$2,525.15
$2,499.65
$3,719.50
$3,681.92
$3,329.80
$3,296.15
$3,577.62
$3,541.48
$5,297.00
$5,243.49
$4,551.34
$4,505.38
$3,515.57
$3,480.06
$4,625.44
$4,578.73
$5,099.22
$5,047.71
$358.49
$354.88
$415.99
$411.79
$1,230.19
$1,217.76
$1,485.63
$1,470.62
$2,026.32
$2,005.85
Page 153 of 323
Notes
#
#
#
#
Procedure
Code
47361
47362
47370
47371
47380
47381
47382
47382
47383
47383
47400
47420
47425
47460
47480
47490
47500
47505
47510
47511
47525
47525
47530
47530
47550
47552
47553
47554
47555
47556
47560
47561
47562
1/2/2015
Modifier
Par Fee
$3,085.33
$1,476.49
$1,268.25
$1,278.50
$1,465.58
$1,380.84
$5,085.86
$796.72
$7,701.45
$491.87
$2,194.49
$1,365.30
$1,391.29
$1,290.92
$891.72
$341.89
$99.28
$38.31
$484.09
$592.44
$528.51
$86.94
$1,399.57
$361.97
$168.86
$323.63
$321.12
$494.05
$381.38
$433.23
$273.70
$300.56
$668.61
Nonpar Fee
$2,931.06
$1,402.67
$1,204.84
$1,214.58
$1,392.30
$1,311.80
$4,831.57
$756.88
$7,316.38
$467.28
$2,084.77
$1,297.04
$1,321.73
$1,226.37
$847.13
$324.80
$94.32
$36.39
$459.89
$562.82
$502.08
$82.59
$1,329.59
$343.87
$160.42
$307.45
$305.06
$469.35
$362.31
$411.57
$260.02
$285.53
$635.18
Limiting
Charge
$3,370.72
$1,613.07
$1,385.57
$1,396.77
$1,601.15
$1,508.57
$5,556.31
$870.41
$8,413.84
$537.37
$2,397.49
$1,491.60
$1,519.99
$1,410.33
$974.20
$373.52
$108.47
$41.85
$528.87
$647.24
$577.39
$94.98
$1,529.03
$395.45
$184.48
$353.57
$350.82
$539.75
$416.66
$473.31
$299.02
$328.36
$730.46
Charge**
Charge***
$3,337.01
$3,320.15
$1,596.94
$1,588.87
$1,371.71
$1,364.79
$1,382.79
$1,375.81
$1,585.14
$1,577.13
$1,493.48
$1,485.94
$5,500.74
$5,472.97
$861.71
$857.36
$8,329.70
$8,287.62
$532.00
$529.31
$2,373.51
$2,361.53
$1,476.68
$1,469.22
$1,504.79
$1,497.19
$1,396.23
$1,389.17
$964.46
$959.58
$369.78
$367.92
$107.39
$106.85
$41.43
$41.22
$523.58
$520.94
$640.77
$637.54
$571.62
$568.73
$94.02
$93.55
$1,513.73
$1,506.10
$391.49
$389.52
$182.64
$181.71
$350.04
$348.27
$347.31
$345.55
$534.36
$531.66
$412.49
$410.41
$468.57
$466.21
$296.03
$294.54
$325.07
$323.44
$723.15
$719.50
Arizona
EHR/eRx
Limiting
Charge**
$3,303.31
$1,580.81
$1,357.85
$1,368.83
$1,569.12
$1,478.39
$5,445.18
$853.00
$8,245.56
$526.62
$2,349.53
$1,461.77
$1,489.60
$1,382.12
$954.72
$366.05
$106.29
$41.01
$518.29
$634.29
$565.85
$93.08
$1,498.45
$387.54
$180.79
$346.50
$343.80
$528.95
$408.32
$463.84
$293.04
$321.79
$715.85
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$3,286.95
$3,253.75
$1,572.98
$1,557.10
$1,351.14
$1,337.48
$1,362.05
$1,348.31
$1,561.36
$1,545.58
$1,471.08
$1,456.22
$5,418.23
$5,363.51
$848.78
$840.20
$8,204.76
$8,121.88
$524.02
$518.72
$2,337.90
$2,314.28
$1,454.53
$1,439.83
$1,482.21
$1,467.25
$1,375.29
$1,361.38
$949.99
$940.40
$364.24
$360.56
$105.78
$104.70
$40.81
$40.40
$515.73
$510.52
$631.15
$624.78
$563.04
$557.36
$92.61
$91.69
$1,491.03
$1,475.98
$385.62
$381.73
$179.91
$178.08
$344.78
$341.30
$342.10
$338.65
$526.34
$521.02
$406.31
$402.19
$461.54
$456.88
$291.59
$288.65
$320.19
$316.96
$712.31
$705.11
Page 154 of 323
Notes
#
Procedure
Code
47563
47564
47570
47600
47605
47610
47612
47620
47630
47700
47701
47711
47712
47715
47720
47721
47740
47741
47760
47765
47780
47785
47800
47801
47802
47900
48000
48001
48020
48100
48102
48102
48105
1/2/2015
Modifier
Par Fee
$725.83
$1,130.69
$789.10
$1,085.58
$1,141.96
$1,276.35
$1,291.77
$1,403.37
$547.97
$1,070.96
$1,766.69
$1,579.22
$2,035.38
$1,354.18
$1,174.86
$1,378.77
$1,336.61
$1,503.01
$2,296.50
$3,095.69
$2,513.82
$3,304.50
$1,608.55
$1,026.34
$1,554.06
$1,398.30
$1,913.92
$2,352.27
$1,198.74
$897.14
$543.19
$250.72
$2,898.55
Nonpar Fee
$689.54
$1,074.16
$749.65
$1,031.30
$1,084.86
$1,212.53
$1,227.18
$1,333.20
$520.57
$1,017.41
$1,678.36
$1,500.26
$1,933.61
$1,286.47
$1,116.12
$1,309.83
$1,269.78
$1,427.86
$2,181.68
$2,940.91
$2,388.13
$3,139.28
$1,528.12
$975.02
$1,476.36
$1,328.39
$1,818.22
$2,234.66
$1,138.80
$852.28
$516.03
$238.18
$2,753.62
Limiting
Charge
$792.97
$1,235.28
$862.10
$1,186.00
$1,247.59
$1,394.41
$1,411.26
$1,533.18
$598.66
$1,170.02
$1,930.11
$1,725.30
$2,223.65
$1,479.44
$1,283.54
$1,506.30
$1,460.25
$1,642.04
$2,508.93
$3,382.05
$2,746.35
$3,610.17
$1,757.34
$1,121.27
$1,697.81
$1,527.65
$2,090.95
$2,569.86
$1,309.62
$980.12
$593.43
$273.91
$3,166.66
Charge**
Charge***
$785.04
$781.08
$1,222.93
$1,216.76
$853.47
$849.17
$1,174.14
$1,168.20
$1,235.11
$1,228.88
$1,380.46
$1,373.49
$1,397.15
$1,390.09
$1,517.85
$1,510.18
$592.66
$589.67
$1,158.33
$1,152.47
$1,910.82
$1,901.16
$1,708.05
$1,699.42
$2,201.41
$2,190.30
$1,464.65
$1,457.25
$1,270.70
$1,264.29
$1,491.24
$1,483.71
$1,445.64
$1,438.34
$1,625.62
$1,617.41
$2,483.84
$2,471.29
$3,348.23
$3,331.32
$2,718.89
$2,705.16
$3,574.07
$3,556.02
$1,739.77
$1,730.98
$1,110.06
$1,104.45
$1,680.84
$1,672.34
$1,512.38
$1,504.73
$2,070.05
$2,059.59
$2,544.16
$2,531.31
$1,296.52
$1,289.98
$970.32
$965.43
$587.50
$584.53
$271.17
$269.80
$3,134.99
$3,119.17
Arizona
EHR/eRx
Limiting
Charge**
$777.11
$1,210.58
$844.86
$1,162.27
$1,222.63
$1,366.52
$1,383.04
$1,502.52
$586.68
$1,146.62
$1,891.51
$1,690.79
$2,179.18
$1,449.85
$1,257.87
$1,476.17
$1,431.04
$1,609.20
$2,458.76
$3,314.40
$2,691.43
$3,537.96
$1,722.19
$1,098.85
$1,663.85
$1,497.09
$2,049.14
$2,518.47
$1,283.42
$960.51
$581.57
$268.43
$3,103.33
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$773.26
$765.45
$1,204.59
$1,192.42
$840.67
$832.19
$1,156.53
$1,144.84
$1,216.59
$1,204.29
$1,359.75
$1,346.03
$1,376.19
$1,362.29
$1,495.08
$1,479.98
$583.77
$577.89
$1,140.95
$1,129.42
$1,882.16
$1,863.14
$1,682.43
$1,665.43
$2,168.39
$2,146.50
$1,442.69
$1,428.10
$1,251.65
$1,239.00
$1,468.87
$1,454.04
$1,423.95
$1,409.57
$1,601.24
$1,585.06
$2,446.58
$2,421.88
$3,298.00
$3,264.69
$2,678.11
$2,651.05
$3,520.46
$3,484.89
$1,713.67
$1,696.37
$1,093.41
$1,082.37
$1,655.63
$1,638.90
$1,489.69
$1,474.63
$2,039.00
$2,018.40
$2,506.00
$2,480.69
$1,277.08
$1,264.17
$955.77
$946.11
$578.69
$572.84
$267.10
$264.41
$3,087.97
$3,056.78
Page 155 of 323
Notes
#
#
Procedure
Code
48120
48140
48145
48146
48148
48150
48152
48153
48154
48155
48400
48500
48510
48520
48540
48545
48547
48548
48552
48554
48556
49000
49002
49010
49020
49040
49060
49062
49082
49082
49083
49083
49084
1/2/2015
Modifier
Par Fee
$1,126.13
$1,590.05
$1,663.06
$1,913.53
$1,271.03
$3,165.72
$2,939.60
$3,149.00
$2,952.92
$1,846.51
$109.49
$1,171.81
$1,117.45
$1,113.43
$1,334.47
$1,369.25
$1,826.51
$1,697.53
$241.11
$2,605.23
$1,297.38
$783.94
$1,064.88
$948.73
$1,621.55
$1,018.29
$1,118.87
$753.59
$196.26
$76.84
$297.36
$112.15
$111.05
Nonpar Fee
$1,069.82
$1,510.55
$1,579.91
$1,817.85
$1,207.48
$3,007.43
$2,792.62
$2,991.55
$2,805.27
$1,754.18
$104.02
$1,113.22
$1,061.58
$1,057.76
$1,267.75
$1,300.79
$1,735.18
$1,612.65
$229.05
$2,474.97
$1,232.51
$744.74
$1,011.64
$901.29
$1,540.47
$967.38
$1,062.93
$715.91
$186.45
$73.00
$282.49
$106.54
$105.50
Limiting
Charge
$1,230.29
$1,737.13
$1,816.90
$2,090.53
$1,388.60
$3,458.54
$3,211.51
$3,440.28
$3,226.06
$2,017.31
$119.62
$1,280.20
$1,220.82
$1,216.42
$1,457.91
$1,495.91
$1,995.46
$1,854.55
$263.41
$2,846.22
$1,417.39
$856.45
$1,163.39
$1,036.48
$1,771.54
$1,112.49
$1,222.37
$823.30
$214.42
$83.95
$324.86
$122.52
$121.33
Charge**
Charge***
$1,217.99
$1,211.84
$1,719.76
$1,711.07
$1,798.73
$1,789.64
$2,069.62
$2,059.17
$1,374.72
$1,367.78
$3,423.96
$3,406.67
$3,179.39
$3,163.34
$3,405.87
$3,388.68
$3,193.80
$3,177.67
$1,997.14
$1,987.05
$118.43
$117.83
$1,267.40
$1,261.00
$1,208.60
$1,202.51
$1,204.26
$1,198.17
$1,443.33
$1,436.04
$1,480.95
$1,473.47
$1,975.50
$1,965.52
$1,836.00
$1,826.73
$260.77
$259.45
$2,817.75
$2,803.53
$1,403.21
$1,396.12
$847.88
$843.61
$1,151.75
$1,145.94
$1,026.12
$1,020.94
$1,753.83
$1,744.96
$1,101.37
$1,095.80
$1,210.15
$1,204.04
$815.06
$810.95
$212.28
$211.20
$83.11
$82.70
$321.62
$319.99
$121.29
$120.68
$120.12
$119.51
Arizona
EHR/eRx
Limiting
Charge**
$1,205.68
$1,702.39
$1,780.56
$2,048.71
$1,360.83
$3,389.37
$3,147.29
$3,371.48
$3,161.53
$1,976.97
$117.23
$1,254.60
$1,196.40
$1,192.09
$1,428.76
$1,465.99
$1,955.55
$1,817.46
$258.14
$2,789.29
$1,389.04
$839.33
$1,140.12
$1,015.75
$1,736.11
$1,090.23
$1,197.92
$806.83
$210.13
$82.27
$318.37
$120.07
$118.90
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$1,199.71
$1,187.59
$1,693.96
$1,676.85
$1,771.75
$1,753.85
$2,038.57
$2,017.99
$1,354.10
$1,340.42
$3,372.61
$3,338.53
$3,131.70
$3,100.08
$3,354.79
$3,320.90
$3,145.89
$3,114.11
$1,967.18
$1,947.31
$116.66
$115.47
$1,248.39
$1,235.79
$1,190.48
$1,178.45
$1,186.19
$1,174.21
$1,421.68
$1,407.32
$1,458.73
$1,444.00
$1,945.87
$1,926.22
$1,808.46
$1,790.19
$256.86
$254.27
$2,775.49
$2,747.45
$1,382.16
$1,368.20
$835.16
$826.74
$1,134.48
$1,123.02
$1,010.74
$1,000.51
$1,727.52
$1,710.07
$1,084.84
$1,073.88
$1,192.00
$1,179.95
$802.84
$794.73
$209.09
$206.98
$81.87
$81.04
$316.79
$313.59
$119.47
$118.27
$118.31
$117.12
Page 156 of 323
Notes
#
#
#
#
#
#
#
Procedure
Code
49180
49180
49203
49204
49205
49215
49220
49250
49255
49320
49321
49322
49323
49324
49325
49326
49327
49400
49400
49402
49405
49405
49406
49406
49407
49407
49411
49411
49412
49418
49418
49419
49421
1/2/2015
Modifier
Par Fee
$166.58
$88.64
$1,219.90
$1,559.26
$1,787.85
$2,241.42
$988.40
$594.70
$803.73
$330.85
$350.39
$374.34
$650.48
$397.07
$423.36
$193.04
$133.05
$139.10
$97.27
$870.18
$887.69
$219.43
$888.76
$219.79
$743.15
$233.29
$556.86
$203.60
$83.96
$1,454.58
$225.33
$454.05
$234.98
Nonpar Fee
$158.25
$84.21
$1,158.91
$1,481.30
$1,698.46
$2,129.35
$938.98
$564.97
$763.54
$314.31
$332.87
$355.62
$617.96
$377.22
$402.19
$183.39
$126.40
$132.15
$92.41
$826.67
$843.31
$208.46
$844.32
$208.80
$705.99
$221.63
$529.02
$193.42
$79.76
$1,381.85
$214.06
$431.35
$223.23
Limiting
Charge
$181.99
$96.84
$1,332.75
$1,703.50
$1,953.23
$2,448.75
$1,079.83
$649.72
$878.07
$361.46
$382.80
$408.96
$710.65
$433.80
$462.52
$210.90
$145.36
$151.97
$106.27
$950.67
$969.81
$239.73
$970.97
$240.12
$811.89
$254.87
$608.37
$222.43
$91.72
$1,589.13
$246.17
$496.05
$256.71
Charge**
Charge***
$180.17
$179.26
$95.88
$95.39
$1,319.42
$1,312.76
$1,686.46
$1,677.94
$1,933.70
$1,923.93
$2,424.27
$2,412.02
$1,069.03
$1,063.64
$643.22
$639.98
$869.29
$864.90
$357.85
$356.04
$378.97
$377.06
$404.87
$402.83
$703.55
$699.99
$429.47
$427.29
$457.90
$455.58
$208.79
$207.74
$143.91
$143.18
$150.45
$149.70
$105.21
$104.67
$941.16
$936.41
$960.11
$955.26
$237.34
$236.13
$961.26
$956.41
$237.72
$236.52
$803.77
$799.71
$252.32
$251.06
$602.29
$599.24
$220.21
$219.10
$90.80
$90.34
$1,573.23
$1,565.29
$243.71
$242.48
$491.10
$488.61
$254.15
$252.86
Arizona
EHR/eRx
Limiting
Charge**
$178.35
$94.91
$1,306.09
$1,669.42
$1,914.16
$2,399.77
$1,058.23
$636.72
$860.51
$354.22
$375.14
$400.79
$696.44
$425.13
$453.27
$206.68
$142.45
$148.94
$104.14
$931.66
$950.41
$234.93
$951.54
$235.31
$795.65
$249.78
$596.21
$217.98
$89.88
$1,557.34
$241.25
$486.13
$251.59
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$177.47
$175.67
$94.44
$93.48
$1,299.63
$1,286.49
$1,661.16
$1,644.37
$1,904.70
$1,885.45
$2,387.91
$2,363.78
$1,053.00
$1,042.36
$633.57
$627.16
$856.24
$847.61
$352.48
$348.91
$373.29
$369.52
$398.80
$394.77
$692.99
$686.00
$423.03
$418.75
$451.03
$446.48
$205.67
$203.57
$141.75
$140.31
$148.20
$146.71
$103.64
$102.58
$927.04
$917.69
$945.71
$936.15
$233.77
$231.41
$946.84
$937.27
$234.15
$231.78
$791.72
$783.71
$248.54
$246.03
$593.25
$587.26
$216.91
$214.72
$89.45
$88.54
$1,549.64
$1,533.99
$240.05
$237.62
$483.72
$478.84
$250.34
$247.81
Page 157 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
49422
49423
49423
49424
49424
49425
49426
49427
49428
49429
49435
49436
49440
49440
49441
49441
49442
49442
49446
49446
49450
49450
49451
49451
49452
49452
49460
49460
49465
49465
49491
49492
49495
1/2/2015
Modifier
Par Fee
$386.47
$557.83
$74.78
$148.43
$39.38
$742.93
$621.14
$46.44
$539.48
$466.64
$121.87
$190.30
$1,056.36
$229.71
$1,182.18
$264.36
$983.01
$229.66
$1,015.77
$168.38
$677.65
$69.46
$738.93
$93.91
$914.04
$145.32
$745.05
$49.62
$164.97
$31.96
$758.39
$880.22
$381.66
Nonpar Fee
$367.15
$529.94
$71.04
$141.01
$37.41
$705.78
$590.08
$44.12
$512.51
$443.31
$115.78
$180.79
$1,003.54
$218.22
$1,123.07
$251.14
$933.86
$218.18
$964.98
$159.96
$643.77
$65.99
$701.98
$89.21
$868.34
$138.05
$707.80
$47.14
$156.72
$30.36
$720.47
$836.21
$362.58
Limiting
Charge
$422.22
$609.43
$81.70
$162.16
$43.02
$811.65
$678.59
$50.74
$589.39
$509.81
$133.15
$207.91
$1,154.07
$250.95
$1,291.53
$288.81
$1,073.94
$250.91
$1,109.73
$183.95
$740.34
$75.89
$807.28
$102.59
$998.59
$158.76
$813.97
$54.21
$180.23
$34.91
$828.54
$961.64
$416.97
Charge**
Charge***
$418.00
$415.89
$603.34
$600.29
$80.88
$80.47
$160.54
$159.72
$42.60
$42.38
$803.53
$799.47
$671.81
$668.41
$50.23
$49.98
$583.49
$580.54
$504.71
$502.16
$131.81
$131.15
$205.83
$204.79
$1,142.53
$1,136.76
$248.45
$247.19
$1,278.62
$1,272.15
$285.92
$284.48
$1,063.20
$1,057.83
$248.40
$247.15
$1,098.63
$1,093.09
$182.11
$181.19
$732.93
$729.23
$75.13
$74.75
$799.20
$795.17
$101.57
$101.05
$988.61
$983.61
$157.17
$156.38
$805.83
$801.76
$53.67
$53.39
$178.42
$177.53
$34.57
$34.39
$820.26
$816.11
$952.03
$947.22
$412.79
$410.71
Arizona
EHR/eRx
Limiting
Charge**
$413.78
$597.24
$80.06
$158.92
$42.16
$795.41
$665.02
$49.73
$577.60
$499.61
$130.48
$203.75
$1,130.99
$245.94
$1,265.70
$283.04
$1,052.46
$245.89
$1,087.53
$180.27
$725.52
$74.37
$791.13
$100.54
$978.62
$155.58
$797.69
$53.13
$176.63
$34.21
$811.97
$942.41
$408.63
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$411.73
$407.57
$594.29
$588.28
$79.67
$78.87
$158.14
$156.54
$41.95
$41.53
$791.48
$783.48
$661.73
$655.05
$49.47
$48.98
$574.74
$568.94
$497.15
$492.11
$129.84
$128.52
$202.75
$200.69
$1,125.39
$1,114.03
$244.72
$242.25
$1,259.43
$1,246.72
$281.64
$278.79
$1,047.25
$1,036.67
$244.67
$242.20
$1,082.15
$1,071.21
$179.38
$177.57
$721.94
$714.64
$74.00
$73.26
$787.22
$779.26
$100.05
$99.04
$973.79
$963.94
$154.81
$153.25
$793.74
$785.73
$52.87
$52.34
$175.74
$173.98
$34.05
$33.70
$807.96
$799.79
$937.74
$928.28
$406.61
$402.50
Page 158 of 323
Notes
Procedure
Code
49496
49500
49501
49505
49507
49520
49521
49525
49540
49550
49553
49555
49557
49560
49561
49565
49566
49568
49570
49572
49580
49582
49585
49587
49590
49600
49605
49606
49610
49611
49650
49651
49652
1/2/2015
Modifier
Par Fee
$560.59
$417.58
$615.77
$528.54
$594.57
$641.92
$727.26
$581.61
$683.68
$584.65
$641.25
$605.48
$735.13
$748.90
$945.74
$780.59
$953.88
$272.49
$421.51
$523.94
$337.82
$490.19
$451.65
$482.63
$581.52
$705.63
$5,026.46
$1,152.70
$698.97
$553.44
$434.70
$565.24
$756.19
Nonpar Fee
$532.56
$396.70
$584.98
$502.11
$564.84
$609.82
$690.90
$552.53
$649.50
$555.42
$609.19
$575.21
$698.37
$711.46
$898.45
$741.56
$906.19
$258.87
$400.43
$497.74
$320.93
$465.68
$429.07
$458.50
$552.44
$670.35
$4,775.14
$1,095.07
$664.02
$525.77
$412.97
$536.98
$718.38
Limiting
Charge
$612.44
$456.21
$672.73
$577.43
$649.57
$701.29
$794.54
$635.41
$746.93
$638.73
$700.57
$661.49
$803.13
$818.18
$1,033.22
$852.79
$1,042.12
$297.70
$460.49
$572.40
$369.07
$535.53
$493.43
$527.28
$635.31
$770.90
$5,491.41
$1,259.33
$763.62
$604.64
$474.92
$617.53
$826.14
Charge**
Charge***
$606.31
$603.26
$451.64
$449.36
$666.00
$662.64
$571.65
$568.77
$643.07
$639.83
$694.28
$690.77
$786.59
$782.62
$629.05
$625.88
$739.46
$735.72
$632.35
$629.15
$693.57
$690.06
$654.88
$651.57
$795.10
$791.07
$810.00
$805.91
$1,022.89
$1,017.72
$844.26
$840.01
$1,031.70
$1,026.49
$294.72
$293.24
$455.89
$453.58
$566.67
$563.81
$365.38
$363.54
$530.17
$527.49
$488.50
$486.02
$522.01
$519.36
$628.96
$625.77
$763.20
$759.33
$5,436.50
$5,409.04
$1,246.74
$1,240.44
$755.99
$752.17
$598.59
$595.56
$470.17
$467.80
$611.35
$608.27
$817.88
$813.74
Arizona
EHR/eRx
Limiting
Charge**
$600.20
$447.09
$659.27
$565.88
$636.57
$687.26
$778.64
$622.70
$731.99
$625.96
$686.56
$648.27
$787.06
$801.81
$1,012.55
$835.74
$1,021.28
$291.74
$451.28
$560.96
$361.69
$524.83
$483.56
$516.73
$622.60
$755.48
$5,381.59
$1,234.15
$748.35
$592.54
$465.42
$605.18
$809.61
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$597.22
$591.19
$444.87
$440.38
$656.01
$649.38
$563.07
$557.39
$633.42
$627.03
$683.86
$676.96
$774.79
$766.96
$619.62
$613.36
$728.36
$721.00
$622.86
$616.57
$683.16
$676.26
$645.06
$638.54
$783.17
$775.25
$797.85
$789.79
$1,007.55
$997.36
$831.60
$823.20
$1,016.22
$1,005.96
$290.31
$287.36
$449.05
$444.51
$558.18
$552.54
$359.89
$356.26
$522.22
$516.95
$481.17
$476.31
$514.18
$508.98
$619.53
$613.26
$751.76
$744.15
$5,354.95
$5,300.87
$1,228.04
$1,215.63
$744.65
$737.13
$589.61
$583.65
$463.12
$458.44
$602.19
$596.10
$805.61
$797.47
Page 159 of 323
Notes
#
Procedure
Code
49653
49654
49655
49656
49657
49900
49904
49905
50010
50020
50040
50045
50060
50065
50070
50075
50080
50081
50100
50120
50125
50130
50135
50200
50200
50205
50220
50225
50230
50234
50236
50240
50250
1/2/2015
Modifier
Par Fee
$943.68
$859.46
$1,050.08
$933.81
$1,342.20
$829.40
$1,449.29
$359.83
$756.45
$1,029.48
$942.81
$948.21
$1,159.65
$1,230.10
$1,205.69
$1,482.74
$884.70
$1,298.84
$1,096.81
$965.87
$999.89
$1,051.25
$1,142.26
$624.03
$147.06
$764.54
$1,063.35
$1,220.50
$1,303.68
$1,322.50
$1,492.17
$1,346.18
$1,237.29
Nonpar Fee
$896.50
$816.49
$997.58
$887.12
$1,275.09
$787.93
$1,376.83
$341.84
$718.63
$978.01
$895.67
$900.80
$1,101.67
$1,168.60
$1,145.41
$1,408.60
$840.47
$1,233.90
$1,041.97
$917.58
$949.90
$998.69
$1,085.15
$592.83
$139.71
$726.31
$1,010.18
$1,159.48
$1,238.50
$1,256.38
$1,417.56
$1,278.87
$1,175.43
Limiting
Charge
$1,030.98
$938.96
$1,147.22
$1,020.19
$1,466.35
$906.12
$1,583.35
$393.12
$826.42
$1,124.71
$1,030.02
$1,035.92
$1,266.92
$1,343.89
$1,317.22
$1,619.89
$966.54
$1,418.99
$1,198.27
$1,055.22
$1,092.39
$1,148.49
$1,247.92
$681.75
$160.67
$835.26
$1,161.71
$1,333.40
$1,424.28
$1,444.84
$1,630.19
$1,470.70
$1,351.74
Charge**
Charge***
$1,020.67
$1,015.51
$929.58
$924.88
$1,135.74
$1,130.01
$1,009.99
$1,004.88
$1,451.69
$1,444.35
$897.06
$892.53
$1,567.52
$1,559.61
$389.18
$387.22
$818.16
$814.03
$1,113.46
$1,107.84
$1,019.72
$1,014.56
$1,025.56
$1,020.38
$1,254.25
$1,247.91
$1,330.45
$1,323.73
$1,304.05
$1,297.46
$1,603.69
$1,595.59
$956.88
$952.04
$1,404.79
$1,397.70
$1,186.28
$1,180.29
$1,044.66
$1,039.39
$1,081.46
$1,076.00
$1,137.01
$1,131.27
$1,235.45
$1,229.20
$674.94
$671.53
$159.06
$158.25
$826.91
$822.73
$1,150.09
$1,144.28
$1,320.07
$1,313.40
$1,410.04
$1,402.91
$1,430.39
$1,423.16
$1,613.89
$1,605.75
$1,455.99
$1,448.64
$1,338.23
$1,331.47
Arizona
EHR/eRx
Limiting
Charge**
$1,010.36
$920.18
$1,124.27
$999.79
$1,437.03
$888.00
$1,551.68
$385.25
$809.90
$1,102.22
$1,009.42
$1,015.20
$1,241.59
$1,317.01
$1,290.88
$1,587.49
$947.21
$1,390.60
$1,174.30
$1,034.11
$1,070.54
$1,125.53
$1,222.97
$668.12
$157.46
$818.55
$1,138.48
$1,306.73
$1,395.79
$1,415.94
$1,597.59
$1,441.28
$1,324.71
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$1,005.36
$995.20
$915.64
$906.38
$1,118.71
$1,107.42
$994.84
$984.79
$1,429.91
$1,415.48
$883.60
$874.68
$1,544.00
$1,528.41
$383.34
$379.48
$805.89
$797.76
$1,096.77
$1,085.68
$1,004.42
$994.28
$1,010.17
$999.97
$1,235.43
$1,222.97
$1,310.49
$1,297.26
$1,284.49
$1,271.51
$1,579.63
$1,563.68
$942.53
$933.01
$1,383.73
$1,369.74
$1,168.49
$1,156.68
$1,028.99
$1,018.60
$1,065.23
$1,054.48
$1,119.95
$1,108.65
$1,216.92
$1,204.63
$664.82
$658.10
$156.68
$155.10
$814.50
$806.27
$1,132.84
$1,121.40
$1,300.27
$1,287.14
$1,388.89
$1,374.85
$1,408.93
$1,394.70
$1,589.68
$1,573.63
$1,434.15
$1,419.66
$1,318.15
$1,304.84
Page 160 of 323
Notes
#
#
#
#
#
#
#
#
Procedure
Code
50280
50290
50320
50327
50328
50329
50340
50360
50365
50370
50380
50382
50382
50384
50384
50385
50385
50386
50386
50387
50387
50389
50389
50390
50391
50391
50392
50393
50394
50394
50395
50396
50398
1/2/2015
Modifier
Par Fee
$971.25
$913.53
$1,528.14
$221.03
$193.62
$186.34
$963.47
$2,459.85
$2,885.85
$1,219.26
$2,036.61
$1,204.66
$280.04
$958.53
$253.45
$1,158.49
$239.23
$753.15
$180.72
$551.93
$100.71
$301.29
$56.01
$99.64
$124.22
$100.98
$184.12
$223.81
$105.53
$51.18
$184.03
$122.07
$507.10
Nonpar Fee
$922.69
$867.85
$1,451.73
$209.98
$183.94
$177.02
$915.30
$2,336.86
$2,741.56
$1,158.30
$1,934.78
$1,144.43
$266.04
$910.60
$240.78
$1,100.57
$227.27
$715.49
$171.68
$524.33
$95.67
$286.23
$53.21
$94.66
$118.01
$95.93
$174.91
$212.62
$100.25
$48.62
$174.83
$115.97
$481.75
Limiting
Charge
$1,061.09
$998.03
$1,669.49
$241.48
$211.53
$203.57
$1,052.60
$2,687.39
$3,152.79
$1,332.05
$2,225.00
$1,316.09
$305.95
$1,047.19
$276.90
$1,265.66
$261.36
$822.81
$197.43
$602.98
$110.02
$329.16
$61.19
$108.86
$135.71
$110.32
$201.15
$244.51
$115.29
$55.91
$201.05
$133.37
$554.01
Charge**
Charge***
$1,050.48
$1,045.18
$988.05
$983.05
$1,652.79
$1,644.44
$239.06
$237.85
$209.42
$208.36
$201.54
$200.51
$1,042.07
$1,036.81
$2,660.51
$2,647.08
$3,121.26
$3,105.51
$1,318.73
$1,312.07
$2,202.74
$2,191.62
$1,302.94
$1,296.35
$302.89
$301.36
$1,036.71
$1,031.48
$274.13
$272.75
$1,252.99
$1,246.67
$258.75
$257.44
$814.59
$810.47
$195.45
$194.47
$596.95
$593.94
$108.92
$108.36
$325.88
$324.23
$60.58
$60.27
$107.77
$107.23
$134.35
$133.68
$109.22
$108.66
$199.13
$198.13
$242.06
$240.84
$114.14
$113.56
$55.35
$55.07
$199.04
$198.04
$132.03
$131.36
$548.47
$545.70
Arizona
EHR/eRx
Limiting
Charge**
$1,039.88
$978.06
$1,636.11
$236.65
$207.30
$199.50
$1,031.54
$2,633.64
$3,089.74
$1,305.40
$2,180.49
$1,289.77
$299.83
$1,026.25
$271.35
$1,240.34
$256.13
$806.36
$193.49
$590.92
$107.82
$322.59
$59.97
$106.69
$133.00
$108.11
$197.12
$239.63
$112.99
$54.80
$197.03
$130.70
$542.94
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$1,034.72
$1,024.28
$973.22
$963.39
$1,628.00
$1,611.56
$235.47
$233.09
$206.28
$204.19
$198.51
$196.51
$1,026.44
$1,016.07
$2,620.61
$2,594.14
$3,074.44
$3,043.39
$1,298.95
$1,285.82
$2,169.71
$2,147.79
$1,283.40
$1,270.43
$298.34
$295.33
$1,021.17
$1,010.85
$270.01
$267.28
$1,234.20
$1,221.74
$254.87
$252.29
$802.37
$794.26
$192.52
$190.59
$588.00
$582.05
$107.28
$106.20
$320.99
$317.75
$59.67
$59.08
$106.15
$105.09
$132.34
$131.01
$107.58
$106.49
$196.14
$194.17
$238.43
$236.03
$112.42
$111.30
$54.52
$53.98
$196.05
$194.07
$130.05
$128.74
$540.25
$534.80
Page 161 of 323
Notes
#
#
#
#
#
#
Procedure
Code
50398
50400
50405
50500
50520
50525
50526
50540
50541
50542
50543
50544
50545
50546
50547
50548
50551
50551
50553
50553
50555
50555
50557
50557
50561
50561
50562
50570
50572
50574
50575
50576
50580
1/2/2015
Modifier
Par Fee
$75.18
$1,176.32
$1,421.50
$1,173.46
$1,054.11
$1,553.42
$1,455.75
$1,167.42
$934.54
$1,185.89
$1,512.95
$1,266.80
$1,363.04
$1,223.04
$1,633.44
$1,370.82
$364.83
$300.83
$390.36
$320.28
$418.34
$348.97
$425.49
$353.26
$481.50
$401.76
$591.78
$500.91
$541.99
$576.01
$727.94
$574.58
$619.23
Nonpar Fee
$71.42
$1,117.50
$1,350.43
$1,114.79
$1,001.40
$1,475.75
$1,382.96
$1,109.05
$887.81
$1,126.60
$1,437.30
$1,203.46
$1,294.89
$1,161.89
$1,551.77
$1,302.28
$346.59
$285.79
$370.84
$304.27
$397.42
$331.52
$404.22
$335.60
$457.43
$381.67
$562.19
$475.86
$514.89
$547.21
$691.54
$545.85
$588.27
Limiting
Charge
$82.13
$1,285.13
$1,552.99
$1,282.01
$1,151.61
$1,697.11
$1,590.40
$1,275.41
$1,020.98
$1,295.59
$1,652.90
$1,383.98
$1,489.12
$1,336.17
$1,784.54
$1,497.62
$398.58
$328.66
$426.47
$349.91
$457.03
$381.25
$464.85
$385.94
$526.04
$438.92
$646.52
$547.24
$592.12
$629.29
$795.27
$627.73
$676.51
Charge**
Charge***
$81.32
$80.90
$1,272.28
$1,265.85
$1,537.47
$1,529.70
$1,269.19
$1,262.78
$1,140.10
$1,134.34
$1,680.14
$1,671.65
$1,574.50
$1,566.55
$1,262.65
$1,256.27
$1,010.77
$1,005.66
$1,282.63
$1,276.16
$1,636.37
$1,628.10
$1,370.14
$1,363.22
$1,474.23
$1,466.79
$1,322.81
$1,316.13
$1,766.69
$1,757.76
$1,482.65
$1,475.16
$394.59
$392.60
$325.37
$323.73
$422.20
$420.07
$346.41
$344.67
$452.47
$450.18
$377.43
$375.53
$460.21
$457.88
$382.08
$380.16
$520.79
$518.16
$434.53
$432.33
$640.06
$636.82
$541.77
$539.03
$586.20
$583.25
$623.00
$619.85
$787.31
$783.35
$621.45
$618.31
$669.75
$666.37
Arizona
EHR/eRx
Limiting
Charge**
$80.49
$1,259.42
$1,521.93
$1,256.36
$1,128.58
$1,663.18
$1,558.60
$1,249.90
$1,000.56
$1,269.68
$1,619.83
$1,356.30
$1,459.34
$1,309.45
$1,748.84
$1,467.66
$390.61
$322.08
$417.93
$342.91
$447.89
$373.62
$455.56
$378.22
$515.52
$430.15
$633.59
$536.29
$580.28
$616.71
$779.37
$615.17
$662.98
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$80.10
$79.28
$1,253.20
$1,240.53
$1,514.41
$1,499.11
$1,250.15
$1,237.52
$1,123.00
$1,111.65
$1,654.94
$1,638.23
$1,550.88
$1,535.22
$1,243.71
$1,231.16
$995.61
$985.55
$1,263.39
$1,250.64
$1,611.83
$1,595.53
$1,349.59
$1,335.96
$1,452.12
$1,437.45
$1,302.97
$1,289.81
$1,740.19
$1,722.61
$1,460.41
$1,445.65
$388.67
$384.76
$320.49
$317.25
$415.86
$411.67
$341.22
$337.77
$445.68
$441.17
$371.77
$368.02
$453.31
$448.73
$376.35
$372.55
$512.98
$507.79
$428.01
$423.69
$630.45
$624.09
$533.63
$528.24
$577.40
$571.57
$613.65
$607.46
$775.50
$767.67
$612.12
$605.95
$659.70
$653.03
Page 162 of 323
Notes
#
#
#
#
#
#
Procedure
Code
50590
50590
50592
50592
50593
50593
50600
50605
50610
50620
50630
50650
50660
50684
50684
50686
50686
50688
50690
50690
50700
50715
50722
50725
50727
50728
50740
50750
50760
50770
50780
50782
50783
1/2/2015
Modifier
Par Fee
$728.54
$577.29
$3,191.65
$374.89
$4,703.78
$495.80
$955.55
$999.48
$961.94
$920.14
$908.48
$1,052.90
$1,163.18
$107.31
$51.18
$160.15
$96.15
$81.75
$99.99
$72.46
$941.82
$1,240.47
$1,049.47
$1,130.21
$516.42
$709.87
$1,244.16
$1,173.46
$1,147.89
$1,173.46
$1,128.25
$1,141.36
$1,147.22
Nonpar Fee
$692.11
$548.43
$3,032.07
$356.15
$4,468.59
$471.01
$907.77
$949.51
$913.84
$874.13
$863.06
$1,000.26
$1,105.02
$101.94
$48.62
$152.14
$91.34
$77.66
$94.99
$68.84
$894.73
$1,178.45
$997.00
$1,073.70
$490.60
$674.38
$1,181.95
$1,114.79
$1,090.50
$1,114.79
$1,071.84
$1,084.29
$1,089.86
Limiting
Charge
$795.93
$630.69
$3,486.88
$409.57
$5,138.88
$541.66
$1,043.94
$1,091.94
$1,050.92
$1,005.25
$992.52
$1,150.30
$1,270.77
$117.23
$55.91
$174.96
$105.04
$89.31
$109.24
$79.17
$1,028.94
$1,355.22
$1,146.55
$1,234.76
$564.19
$775.54
$1,359.24
$1,282.01
$1,254.08
$1,282.01
$1,232.62
$1,246.93
$1,253.34
Charge**
Charge***
$787.97
$783.99
$624.39
$621.23
$3,452.01
$3,434.58
$405.48
$403.43
$5,087.49
$5,061.79
$536.25
$533.53
$1,033.49
$1,028.27
$1,081.01
$1,075.56
$1,040.41
$1,035.15
$995.20
$990.17
$982.59
$977.63
$1,138.80
$1,133.05
$1,258.07
$1,251.71
$116.06
$115.47
$55.35
$55.07
$173.21
$172.34
$103.99
$103.47
$88.41
$87.98
$108.15
$107.61
$78.37
$77.98
$1,018.65
$1,013.51
$1,341.67
$1,334.89
$1,135.08
$1,129.36
$1,222.40
$1,216.23
$558.54
$555.73
$767.79
$763.90
$1,345.65
$1,338.85
$1,269.19
$1,262.78
$1,241.54
$1,235.26
$1,269.19
$1,262.78
$1,220.29
$1,214.12
$1,234.47
$1,228.23
$1,240.80
$1,234.54
Arizona
EHR/eRx
Limiting
Charge**
$780.01
$618.08
$3,417.14
$401.38
$5,036.10
$530.83
$1,023.05
$1,070.10
$1,029.89
$985.15
$972.67
$1,127.29
$1,245.36
$114.89
$54.80
$171.47
$102.94
$87.53
$107.05
$77.58
$1,008.37
$1,328.11
$1,123.62
$1,210.06
$552.91
$760.02
$1,332.06
$1,256.36
$1,228.99
$1,256.36
$1,207.96
$1,221.99
$1,228.27
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$776.15
$768.32
$615.03
$608.81
$3,400.23
$3,365.89
$399.40
$395.36
$5,011.17
$4,960.56
$528.21
$522.87
$1,017.99
$1,007.71
$1,064.80
$1,054.04
$1,024.80
$1,014.45
$980.27
$970.37
$967.85
$958.08
$1,121.72
$1,110.38
$1,239.19
$1,226.68
$114.32
$113.16
$54.52
$53.98
$170.61
$168.89
$102.43
$101.40
$87.09
$86.22
$106.52
$105.44
$77.20
$76.42
$1,003.36
$993.24
$1,321.55
$1,308.19
$1,118.05
$1,106.76
$1,204.07
$1,191.92
$550.16
$544.62
$756.27
$748.63
$1,325.47
$1,312.08
$1,250.15
$1,237.52
$1,222.92
$1,210.56
$1,250.15
$1,237.52
$1,201.98
$1,189.84
$1,215.95
$1,203.66
$1,222.20
$1,209.85
Page 163 of 323
Notes
#
#
#
#
#
Procedure
Code
50785
50800
50810
50815
50820
50825
50830
50840
50845
50860
50900
50920
50930
50940
50945
50947
50948
50951
50951
50953
50953
50955
50955
50957
50957
50961
50961
50970
50972
50974
50976
50980
51020
1/2/2015
Modifier
Par Fee
$1,234.13
$942.37
$1,421.01
$1,243.73
$1,339.80
$1,684.07
$1,833.81
$1,250.12
$1,270.10
$961.98
$864.36
$896.50
$1,121.70
$902.53
$990.55
$1,412.92
$1,297.68
$381.10
$313.53
$403.81
$333.73
$431.43
$360.28
$435.73
$362.43
$392.46
$324.52
$378.70
$365.96
$482.14
$475.43
$364.17
$475.37
Nonpar Fee
$1,172.42
$895.25
$1,349.96
$1,181.54
$1,272.81
$1,599.87
$1,742.12
$1,187.61
$1,206.60
$913.88
$821.14
$851.68
$1,065.62
$857.40
$941.02
$1,342.27
$1,232.80
$362.05
$297.85
$383.62
$317.04
$409.86
$342.27
$413.94
$344.31
$372.84
$308.29
$359.77
$347.66
$458.03
$451.66
$345.96
$451.60
Limiting
Charge
$1,348.28
$1,029.54
$1,552.45
$1,358.77
$1,463.73
$1,839.85
$2,003.44
$1,365.75
$1,387.59
$1,050.96
$944.31
$979.43
$1,225.46
$986.01
$1,082.17
$1,543.61
$1,417.72
$416.36
$342.53
$441.16
$364.60
$471.34
$393.61
$476.03
$395.96
$428.77
$354.53
$413.74
$399.81
$526.73
$519.41
$397.85
$519.34
Charge**
Charge***
$1,334.81
$1,328.05
$1,019.25
$1,014.09
$1,536.93
$1,529.17
$1,345.18
$1,338.39
$1,449.09
$1,441.78
$1,821.45
$1,812.25
$1,983.41
$1,973.39
$1,352.09
$1,345.27
$1,373.71
$1,366.78
$1,040.45
$1,035.20
$934.87
$930.14
$969.63
$964.74
$1,213.20
$1,207.09
$976.15
$971.22
$1,071.35
$1,065.94
$1,528.18
$1,520.46
$1,403.54
$1,396.46
$412.19
$410.11
$339.10
$337.39
$436.75
$434.55
$360.95
$359.12
$466.62
$464.27
$389.68
$387.71
$471.27
$468.89
$392.00
$390.02
$424.48
$422.34
$350.99
$349.22
$409.60
$407.53
$395.81
$393.82
$521.47
$518.83
$514.21
$511.62
$393.88
$391.89
$514.14
$511.55
Arizona
EHR/eRx
Limiting
Charge**
$1,321.32
$1,008.95
$1,521.40
$1,331.60
$1,434.45
$1,803.05
$1,963.37
$1,338.44
$1,359.84
$1,029.94
$925.43
$959.85
$1,200.96
$966.29
$1,060.53
$1,512.73
$1,389.36
$408.03
$335.67
$432.34
$357.31
$461.91
$385.73
$466.51
$388.03
$420.19
$347.44
$405.46
$391.82
$516.20
$509.02
$389.90
$508.96
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$1,314.78
$1,301.50
$1,003.96
$993.82
$1,513.87
$1,498.59
$1,325.00
$1,311.62
$1,427.36
$1,412.94
$1,794.13
$1,776.00
$1,953.65
$1,933.92
$1,331.80
$1,318.36
$1,353.10
$1,339.44
$1,024.85
$1,014.50
$920.85
$911.55
$955.09
$945.45
$1,195.01
$1,182.95
$961.52
$951.80
$1,055.29
$1,044.63
$1,505.26
$1,490.04
$1,382.48
$1,368.52
$406.01
$401.91
$334.02
$330.64
$430.19
$425.86
$355.53
$351.95
$459.62
$454.99
$383.84
$379.95
$464.20
$459.52
$386.12
$382.21
$418.11
$413.89
$345.72
$342.23
$403.45
$399.37
$389.87
$385.94
$513.65
$508.46
$506.49
$501.39
$387.96
$384.04
$506.43
$501.32
Page 164 of 323
Notes
#
#
#
#
Procedure
Code
51030
51040
51045
51050
51060
51065
51080
51100
51100
51101
51101
51102
51102
51500
51520
51525
51530
51535
51550
51555
51565
51570
51575
51580
51585
51590
51595
51596
51597
51600
51600
51605
51610
1/2/2015
Modifier
Par Fee
$477.83
$293.49
$497.97
$479.53
$590.43
$587.93
$414.72
$62.89
$40.01
$126.40
$53.10
$229.66
$148.14
$646.76
$603.89
$873.97
$796.68
$792.66
$980.24
$1,290.24
$1,322.95
$1,505.19
$1,853.35
$1,929.16
$2,148.01
$1,966.85
$2,227.13
$2,391.40
$2,334.34
$185.53
$45.73
$38.71
$108.21
Nonpar Fee
$453.94
$278.82
$473.07
$455.55
$560.91
$558.53
$393.98
$59.75
$38.01
$120.08
$50.45
$218.18
$140.73
$614.42
$573.70
$830.27
$756.85
$753.03
$931.23
$1,225.73
$1,256.80
$1,429.93
$1,760.68
$1,832.70
$2,040.61
$1,868.51
$2,115.77
$2,271.83
$2,217.62
$176.25
$43.44
$36.77
$102.80
Limiting
Charge
$522.03
$320.64
$544.03
$523.88
$645.05
$642.31
$453.08
$68.71
$43.71
$138.09
$58.02
$250.91
$161.84
$706.58
$659.76
$954.81
$870.38
$865.98
$1,070.91
$1,409.59
$1,445.32
$1,644.42
$2,024.78
$2,107.61
$2,346.70
$2,148.79
$2,433.14
$2,612.60
$2,550.26
$202.69
$49.96
$42.29
$118.22
Charge**
Charge***
$516.81
$514.20
$317.43
$315.84
$538.59
$535.87
$518.64
$516.03
$638.60
$635.38
$635.88
$632.67
$448.55
$446.28
$68.02
$67.68
$43.27
$43.06
$136.71
$136.02
$57.44
$57.14
$248.40
$247.15
$160.22
$159.41
$699.52
$695.98
$653.15
$649.85
$945.27
$940.49
$861.67
$857.33
$857.33
$852.99
$1,060.21
$1,054.85
$1,395.49
$1,388.44
$1,430.86
$1,423.64
$1,627.97
$1,619.75
$2,004.53
$1,994.41
$2,086.53
$2,075.99
$2,323.23
$2,311.50
$2,127.29
$2,116.55
$2,408.80
$2,396.63
$2,586.48
$2,573.41
$2,524.76
$2,512.01
$200.66
$199.65
$49.46
$49.21
$41.86
$41.65
$117.04
$116.45
Arizona
EHR/eRx
Limiting
Charge**
$511.59
$314.23
$533.15
$513.41
$632.14
$629.46
$444.02
$67.34
$42.84
$135.33
$56.86
$245.89
$158.61
$692.45
$646.56
$935.71
$852.97
$848.67
$1,049.50
$1,381.40
$1,416.41
$1,611.53
$1,984.29
$2,065.46
$2,299.77
$2,105.81
$2,384.47
$2,560.35
$2,499.26
$198.64
$48.96
$41.43
$115.85
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$509.06
$503.92
$312.67
$309.51
$530.51
$525.16
$510.86
$505.70
$629.02
$622.66
$626.35
$620.02
$441.82
$437.36
$67.00
$66.33
$42.63
$42.19
$134.67
$133.30
$56.58
$56.01
$244.67
$242.20
$157.81
$156.23
$689.03
$682.07
$643.36
$636.87
$931.09
$921.68
$848.75
$840.17
$844.47
$835.94
$1,044.30
$1,033.76
$1,374.56
$1,360.68
$1,409.41
$1,395.17
$1,603.56
$1,587.36
$1,974.46
$1,954.53
$2,055.22
$2,034.48
$2,288.39
$2,265.27
$2,095.38
$2,074.22
$2,372.67
$2,348.70
$2,547.68
$2,521.94
$2,486.89
$2,461.77
$197.65
$195.66
$48.71
$48.22
$41.23
$40.81
$115.28
$114.11
Page 165 of 323
Notes
#
#
#
#
#
#
#
#
#
Procedure
Code
51610
51700
51700
51701
51701
51702
51702
51703
51703
51705
51705
51710
51710
51715
51715
51720
51720
51725
51725
51725
51726
51726
51726
51727
51727
51727
51728
51728
51728
51729
51729
51729
51736
1/2/2015
Modifier
TC
26
TC
26
TC
26
TC
26
TC
26
Par Fee
$66.02
$83.94
$45.68
$54.84
$28.03
$70.57
$30.53
$130.87
$82.96
$91.81
$52.83
$129.84
$81.58
$293.76
$204.37
$110.14
$81.53
$189.20
$111.15
$78.04
$264.95
$177.66
$87.30
$313.76
$204.47
$109.29
$316.35
$209.84
$106.52
$342.55
$213.37
$129.18
$15.64
Nonpar Fee
$62.72
$79.74
$43.40
$52.10
$26.63
$67.04
$29.00
$124.33
$78.81
$87.22
$50.19
$123.35
$77.50
$279.07
$194.15
$104.63
$77.45
$179.74
$105.59
$74.14
$251.70
$168.78
$82.94
$298.07
$194.25
$103.83
$300.53
$199.35
$101.19
$325.42
$202.70
$122.72
$14.86
Limiting
Charge
$72.13
$91.70
$49.91
$59.92
$30.62
$77.10
$33.35
$142.98
$90.63
$100.30
$57.72
$141.85
$89.13
$320.93
$223.27
$120.32
$89.07
$206.70
$121.43
$85.26
$289.46
$194.10
$95.38
$342.78
$223.39
$119.40
$345.61
$229.25
$116.37
$374.23
$233.11
$141.13
$17.09
Charge**
Charge***
$71.40
$71.05
$90.78
$90.32
$49.42
$49.16
$59.32
$59.02
$30.31
$30.16
$76.33
$75.93
$33.02
$32.86
$141.55
$140.84
$89.72
$89.27
$99.30
$98.80
$57.14
$56.86
$140.44
$139.73
$88.24
$87.79
$317.72
$316.11
$221.04
$219.93
$119.12
$118.52
$88.18
$87.73
$204.63
$203.60
$120.21
$119.61
$84.41
$83.98
$286.56
$285.11
$192.15
$191.19
$94.43
$93.96
$339.35
$337.64
$221.16
$220.04
$118.21
$117.61
$342.15
$340.42
$226.96
$225.81
$115.21
$114.62
$370.50
$368.62
$230.77
$229.61
$139.71
$139.01
$16.92
$16.84
Arizona
EHR/eRx
Limiting
Charge**
$70.69
$89.87
$48.91
$58.72
$30.02
$75.56
$32.68
$140.12
$88.81
$98.30
$56.57
$139.01
$87.34
$314.51
$218.81
$117.92
$87.29
$202.57
$119.00
$83.56
$283.67
$190.21
$93.47
$335.93
$218.93
$117.01
$338.70
$224.66
$114.05
$366.75
$228.45
$138.31
$16.74
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$70.33
$69.63
$89.42
$88.53
$48.68
$48.17
$58.43
$57.83
$29.85
$29.57
$75.18
$74.42
$32.52
$32.19
$139.43
$138.01
$88.38
$87.48
$97.81
$96.83
$56.28
$55.72
$138.33
$136.93
$86.92
$86.03
$312.96
$309.80
$217.73
$215.53
$117.33
$116.15
$86.86
$85.97
$201.56
$199.54
$118.40
$117.22
$83.15
$82.31
$282.26
$279.42
$189.27
$187.36
$93.01
$92.07
$334.26
$330.89
$217.84
$215.64
$116.44
$115.25
$337.02
$333.62
$223.56
$221.29
$113.48
$112.33
$364.94
$361.25
$227.31
$225.02
$137.62
$136.24
$16.66
$16.49
Page 166 of 323
Notes
Procedure
Code
51736
51736
51741
51741
51741
51784
51784
51784
51785
51785
51785
51792
51792
51792
51797
51797
51797
51798
51800
51820
51840
51841
51845
51860
51865
51880
51900
51920
51925
51940
51960
51980
51990
1/2/2015
Modifier
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
Par Fee
$7.11
$8.54
$16.00
$7.46
$8.54
$193.85
$115.44
$78.40
$254.06
$169.03
$85.03
$212.61
$156.52
$56.10
$112.68
$72.18
$40.50
$18.91
$1,061.71
$1,232.89
$666.65
$787.43
$595.71
$757.24
$912.21
$476.01
$847.37
$776.07
$1,136.81
$1,670.12
$1,412.25
$724.71
$764.05
Nonpar Fee
$6.75
$8.11
$15.20
$7.09
$8.11
$184.16
$109.67
$74.48
$241.36
$160.58
$80.78
$201.98
$148.69
$53.30
$107.05
$68.57
$38.48
$17.96
$1,008.62
$1,171.25
$633.32
$748.06
$565.92
$719.38
$866.60
$452.21
$805.00
$737.27
$1,079.97
$1,586.61
$1,341.64
$688.47
$725.85
Limiting
Charge
$7.76
$9.33
$17.48
$8.15
$9.33
$211.78
$126.12
$85.65
$277.56
$184.67
$92.90
$232.28
$170.99
$61.30
$123.11
$78.86
$44.25
$20.65
$1,159.91
$1,346.94
$728.32
$860.27
$650.81
$827.29
$996.59
$520.04
$925.75
$847.86
$1,241.97
$1,824.60
$1,542.89
$791.74
$834.73
Charge**
Charge***
$7.68
$7.65
$9.23
$9.19
$17.31
$17.22
$8.07
$8.03
$9.23
$9.19
$209.67
$208.61
$124.86
$124.22
$84.80
$84.36
$274.79
$273.40
$182.82
$181.90
$91.97
$91.51
$229.95
$228.79
$169.28
$168.43
$60.69
$60.38
$121.88
$121.26
$78.06
$77.67
$43.82
$43.59
$20.45
$20.34
$1,148.31
$1,142.51
$1,333.47
$1,326.73
$721.04
$717.39
$851.67
$847.37
$644.30
$641.04
$819.02
$814.88
$986.62
$981.64
$514.84
$512.24
$916.49
$911.87
$839.39
$835.14
$1,229.55
$1,223.34
$1,806.35
$1,797.23
$1,527.45
$1,519.75
$783.83
$779.86
$826.38
$822.20
Arizona
EHR/eRx
Limiting
Charge**
$7.61
$9.14
$17.14
$7.99
$9.14
$207.55
$123.60
$83.94
$272.01
$180.98
$91.03
$227.63
$167.58
$60.06
$120.65
$77.28
$43.37
$20.24
$1,136.72
$1,320.00
$713.75
$843.07
$637.79
$810.74
$976.66
$509.65
$907.24
$830.90
$1,217.13
$1,788.11
$1,512.03
$775.91
$818.03
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$7.57
$7.50
$9.10
$9.00
$17.04
$16.88
$7.95
$7.88
$9.10
$9.00
$206.53
$204.44
$122.98
$121.75
$83.52
$82.69
$270.68
$267.93
$180.08
$178.26
$90.59
$89.67
$226.50
$224.22
$166.74
$165.06
$59.78
$59.17
$120.05
$118.84
$76.89
$76.12
$43.16
$42.71
$20.14
$19.94
$1,131.08
$1,119.66
$1,313.47
$1,300.20
$710.23
$703.04
$838.89
$830.42
$634.64
$628.22
$806.74
$798.58
$971.82
$962.01
$507.12
$502.00
$902.75
$893.63
$826.79
$818.43
$1,211.10
$1,198.86
$1,779.26
$1,761.29
$1,504.55
$1,489.35
$772.08
$764.27
$813.98
$805.76
Page 167 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
51992
52000
52000
52001
52001
52005
52005
52007
52007
52010
52010
52204
52204
52214
52214
52224
52224
52234
52235
52240
52250
52260
52265
52265
52270
52270
52275
52275
52276
52277
52281
52281
52282
1/2/2015
Modifier
Par Fee
$856.37
$206.23
$128.65
$375.24
$293.37
$267.33
$135.75
$446.51
$169.05
$368.97
$168.74
$371.60
$144.92
$663.37
$179.25
$694.84
$208.21
$250.90
$294.44
$400.02
$244.51
$215.05
$368.57
$165.84
$358.07
$185.37
$482.90
$253.72
$270.03
$330.20
$273.95
$155.24
$343.92
Nonpar Fee
$813.55
$195.92
$122.22
$356.48
$278.70
$253.96
$128.96
$424.18
$160.60
$350.52
$160.30
$353.02
$137.67
$630.20
$170.29
$660.10
$197.80
$238.36
$279.72
$380.02
$232.28
$204.30
$350.14
$157.55
$340.17
$176.10
$458.76
$241.03
$256.53
$313.69
$260.25
$147.48
$326.72
Limiting
Charge
$935.58
$225.31
$140.55
$409.95
$320.51
$292.05
$148.30
$487.81
$184.69
$403.10
$184.35
$405.97
$158.32
$724.73
$195.83
$759.12
$227.47
$274.11
$321.68
$437.02
$267.12
$234.95
$402.66
$181.18
$391.20
$202.52
$527.57
$277.18
$295.01
$360.74
$299.29
$169.60
$375.73
Charge**
Charge***
$926.22
$921.55
$223.05
$221.93
$139.15
$138.45
$405.86
$403.80
$317.30
$315.70
$289.13
$287.67
$146.82
$146.08
$482.93
$480.49
$182.84
$181.92
$399.06
$397.05
$182.51
$181.59
$401.91
$399.88
$156.73
$155.94
$717.49
$713.86
$193.88
$192.90
$751.53
$747.73
$225.19
$224.05
$271.38
$270.00
$318.46
$316.85
$432.65
$430.47
$264.45
$263.12
$232.60
$231.43
$398.64
$396.62
$179.37
$178.47
$387.29
$385.33
$200.49
$199.48
$522.30
$519.66
$274.41
$273.02
$292.05
$290.58
$357.13
$355.33
$296.30
$294.80
$167.91
$167.06
$371.97
$370.09
Arizona
EHR/eRx
Limiting
Charge**
$916.87
$220.80
$137.75
$401.75
$314.10
$286.21
$145.34
$478.06
$181.00
$395.04
$180.65
$397.85
$155.16
$710.24
$191.91
$743.94
$222.92
$268.63
$315.25
$428.28
$261.77
$230.24
$394.61
$177.56
$383.38
$198.47
$517.02
$271.64
$289.11
$353.53
$293.31
$166.21
$368.22
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$912.33
$903.12
$219.71
$217.49
$137.07
$135.68
$399.77
$395.73
$312.54
$309.38
$284.80
$281.92
$144.61
$143.15
$475.69
$470.88
$180.10
$178.28
$393.07
$389.11
$179.77
$177.94
$395.89
$391.89
$154.39
$152.84
$706.72
$699.59
$190.97
$189.04
$740.26
$732.78
$221.81
$219.57
$267.31
$264.60
$313.69
$310.52
$426.17
$421.85
$260.49
$257.85
$229.11
$226.79
$392.66
$388.69
$176.67
$174.89
$381.48
$377.63
$197.48
$195.49
$514.46
$509.27
$270.30
$267.57
$287.67
$284.77
$351.77
$348.23
$291.86
$288.90
$165.39
$163.71
$366.39
$362.70
Page 168 of 323
Notes
#
#
#
#
#
#
#
#
Procedure
Code
52283
52283
52285
52285
52287
52287
52290
52300
52301
52305
52310
52310
52315
52315
52317
52317
52318
52320
52325
52327
52330
52330
52332
52332
52334
52341
52342
52343
52344
52345
52346
52351
52352
1/2/2015
Modifier
Par Fee
$278.51
$205.22
$281.37
$199.85
$313.42
$172.54
$249.11
$286.30
$296.54
$284.16
$244.94
$154.48
$416.85
$280.27
$809.36
$354.92
$483.16
$251.57
$327.34
$267.40
$496.72
$268.96
$491.65
$158.77
$261.18
$289.52
$315.67
$351.48
$377.27
$402.48
$456.21
$308.97
$362.07
Nonpar Fee
$264.58
$194.96
$267.30
$189.86
$297.75
$163.91
$236.65
$271.99
$281.71
$269.95
$232.69
$146.76
$396.01
$266.26
$768.89
$337.17
$459.00
$238.99
$310.97
$254.03
$471.88
$255.51
$467.07
$150.83
$248.12
$275.04
$299.89
$333.91
$358.41
$382.36
$433.40
$293.52
$343.97
Limiting
Charge
$304.27
$224.20
$307.40
$218.34
$342.41
$188.50
$272.15
$312.79
$323.97
$310.44
$267.59
$168.77
$455.41
$306.20
$884.22
$387.75
$527.85
$274.84
$357.62
$292.13
$542.66
$293.84
$537.13
$173.45
$285.34
$316.30
$344.87
$384.00
$412.17
$439.71
$498.41
$337.55
$395.57
Charge**
Charge***
$301.22
$299.70
$221.96
$220.85
$304.32
$302.78
$216.15
$215.06
$338.99
$337.27
$186.61
$185.67
$269.42
$268.07
$309.66
$308.10
$320.72
$319.10
$307.34
$305.79
$264.91
$263.58
$167.08
$166.24
$450.86
$448.58
$303.14
$301.61
$875.38
$870.96
$383.87
$381.93
$522.57
$519.94
$272.09
$270.72
$354.04
$352.26
$289.21
$287.75
$537.23
$534.52
$290.89
$289.43
$531.76
$529.07
$171.72
$170.86
$282.49
$281.06
$313.13
$311.55
$341.42
$339.70
$380.16
$378.24
$408.05
$405.98
$435.32
$433.11
$493.43
$490.94
$334.17
$332.49
$391.61
$389.63
Arizona
EHR/eRx
Limiting
Charge**
$298.18
$219.72
$301.24
$213.97
$335.57
$184.72
$266.71
$306.53
$317.49
$304.23
$262.25
$165.39
$446.30
$300.07
$866.54
$379.99
$517.29
$269.34
$350.46
$286.29
$531.81
$287.96
$526.39
$169.98
$279.63
$309.97
$337.97
$376.31
$403.93
$430.92
$488.44
$330.80
$387.65
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$296.70
$293.71
$218.63
$216.42
$299.76
$296.72
$212.91
$210.76
$333.90
$330.53
$183.82
$181.95
$265.39
$262.71
$305.01
$301.93
$315.92
$312.73
$302.73
$299.67
$260.94
$258.31
$164.58
$162.91
$444.10
$439.61
$298.60
$295.57
$862.25
$853.54
$378.11
$374.29
$514.73
$509.53
$268.01
$265.31
$348.73
$345.21
$284.88
$282.00
$529.17
$523.83
$286.53
$283.64
$523.78
$518.49
$169.14
$167.43
$278.25
$275.44
$308.44
$305.33
$336.31
$332.90
$374.45
$370.67
$401.94
$397.87
$428.79
$424.45
$486.02
$481.11
$329.15
$325.84
$385.73
$381.83
Page 169 of 323
Notes
#
#
#
#
#
#
Procedure
Code
52353
52354
52355
52356
52400
52402
52441
52441
52442
52442
52450
52500
52601
52630
52640
52647
52647
52648
52648
52649
52700
53000
53010
53020
53025
53040
53060
53060
53080
53085
53200
53200
53210
1/2/2015
Modifier
Par Fee
$400.02
$425.19
$476.15
$424.11
$486.29
$272.05
$1,245.55
$231.55
$953.68
$61.96
$477.12
$496.16
$859.93
$406.18
$319.82
$1,790.77
$658.07
$1,842.94
$701.65
$837.04
$447.57
$151.13
$299.26
$98.56
$69.55
$398.67
$186.62
$168.03
$435.17
$659.90
$158.77
$145.19
$785.60
Nonpar Fee
$380.02
$403.93
$452.34
$402.90
$461.98
$258.45
$1,183.27
$219.97
$906.00
$58.86
$453.26
$471.35
$816.93
$385.87
$303.83
$1,701.23
$625.17
$1,750.79
$666.57
$795.19
$425.19
$143.57
$284.30
$93.63
$66.07
$378.74
$177.29
$159.63
$413.41
$626.91
$150.83
$137.93
$746.32
Limiting
Charge
$437.02
$464.52
$520.19
$463.34
$531.28
$297.22
$1,360.76
$252.97
$1,041.90
$67.69
$521.25
$542.05
$939.47
$443.75
$349.40
$1,956.41
$718.95
$2,013.41
$766.56
$914.47
$488.97
$165.11
$326.95
$107.67
$75.98
$435.55
$203.88
$183.57
$475.42
$720.95
$173.45
$158.62
$858.27
Charge**
Charge***
$432.65
$430.47
$459.87
$457.55
$514.99
$512.38
$458.70
$456.39
$525.96
$523.31
$294.25
$292.76
$1,347.16
$1,340.35
$250.44
$249.17
$1,031.48
$1,026.27
$67.01
$66.68
$516.04
$513.43
$536.64
$533.92
$930.07
$925.38
$439.31
$437.09
$345.91
$344.16
$1,936.85
$1,927.07
$711.76
$708.16
$1,993.27
$1,983.21
$758.89
$755.06
$905.33
$900.75
$484.08
$481.63
$163.45
$162.63
$323.68
$322.05
$106.59
$106.06
$75.22
$74.84
$431.19
$429.02
$201.85
$200.82
$181.73
$180.83
$470.67
$468.29
$713.74
$710.14
$171.72
$170.86
$157.03
$156.24
$849.69
$845.40
Arizona
EHR/eRx
Limiting
Charge**
$428.28
$455.23
$509.78
$454.07
$520.65
$291.27
$1,333.54
$247.91
$1,021.06
$66.33
$510.82
$531.21
$920.68
$434.87
$342.41
$1,917.29
$704.57
$1,973.14
$751.23
$896.18
$479.19
$161.81
$320.40
$105.52
$74.46
$426.85
$199.80
$179.91
$465.91
$706.53
$169.98
$155.45
$841.10
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$426.17
$421.85
$452.97
$448.40
$507.27
$502.14
$451.82
$447.26
$518.08
$512.84
$289.83
$286.90
$1,326.95
$1,313.54
$246.68
$244.19
$1,016.01
$1,005.74
$66.01
$65.33
$508.30
$503.16
$528.59
$523.24
$916.12
$906.87
$432.72
$428.35
$340.72
$337.27
$1,907.80
$1,888.53
$701.09
$694.00
$1,963.37
$1,943.53
$747.50
$739.96
$891.74
$882.74
$476.82
$472.01
$161.00
$159.38
$318.83
$315.59
$105.00
$103.94
$74.09
$73.35
$424.73
$420.44
$198.82
$196.80
$179.01
$177.20
$463.61
$458.92
$703.03
$695.92
$169.14
$167.43
$154.68
$153.11
$836.95
$828.48
Page 170 of 323
Notes
#
#
#
Procedure
Code
53215
53220
53230
53235
53240
53250
53260
53260
53265
53265
53270
53270
53275
53400
53405
53410
53415
53420
53425
53430
53431
53440
53442
53444
53445
53446
53447
53448
53449
53450
53460
53500
53502
1/2/2015
Modifier
Par Fee
$944.19
$462.91
$616.54
$642.87
$431.30
$401.89
$203.69
$182.96
$220.81
$189.35
$208.34
$186.89
$267.35
$814.61
$888.67
$996.36
$1,149.72
$855.02
$952.42
$980.14
$1,174.17
$765.75
$796.10
$806.47
$765.88
$652.48
$822.16
$1,302.15
$621.59
$415.61
$464.96
$761.33
$494.69
Nonpar Fee
$896.98
$439.76
$585.71
$610.73
$409.74
$381.80
$193.51
$173.81
$209.77
$179.88
$197.92
$177.55
$253.98
$773.88
$844.24
$946.54
$1,092.23
$812.27
$904.80
$931.13
$1,115.46
$727.46
$756.30
$766.15
$727.59
$619.86
$781.05
$1,237.04
$590.51
$394.83
$441.71
$723.26
$469.96
Limiting
Charge
$1,031.53
$505.72
$673.57
$702.34
$471.20
$439.07
$222.54
$199.88
$241.24
$206.86
$227.61
$204.18
$292.08
$889.96
$970.88
$1,088.52
$1,256.06
$934.11
$1,040.52
$1,070.80
$1,282.78
$836.58
$869.75
$881.07
$836.73
$712.84
$898.21
$1,422.60
$679.09
$454.05
$507.97
$831.75
$540.45
Charge**
Charge***
$1,021.21
$1,016.06
$500.66
$498.13
$666.83
$663.46
$695.31
$691.81
$466.49
$464.13
$434.68
$432.48
$220.31
$219.20
$197.88
$196.88
$238.82
$237.61
$204.79
$203.76
$225.33
$224.19
$202.14
$201.12
$289.16
$287.70
$881.06
$876.61
$961.17
$956.32
$1,077.63
$1,072.19
$1,243.51
$1,237.23
$924.77
$920.10
$1,030.11
$1,024.91
$1,060.09
$1,054.73
$1,269.96
$1,263.54
$828.22
$824.03
$861.05
$856.70
$872.26
$867.86
$828.36
$824.18
$705.71
$702.14
$889.23
$884.73
$1,408.37
$1,401.25
$672.29
$668.90
$449.51
$447.25
$502.88
$500.34
$823.43
$819.27
$535.05
$532.35
Arizona
EHR/eRx
Limiting
Charge**
$1,010.90
$495.60
$660.10
$688.30
$461.78
$430.28
$218.09
$195.88
$236.41
$202.72
$223.05
$200.10
$286.24
$872.16
$951.46
$1,066.75
$1,230.95
$915.42
$1,019.71
$1,049.39
$1,257.12
$819.85
$852.35
$863.45
$820.00
$698.58
$880.24
$1,394.15
$665.51
$444.97
$497.81
$815.11
$529.64
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$1,005.89
$995.73
$493.15
$488.18
$656.82
$650.20
$684.88
$677.97
$459.49
$454.86
$428.16
$423.83
$217.01
$214.82
$194.91
$192.95
$235.23
$232.86
$201.72
$199.69
$221.95
$219.71
$199.10
$197.10
$284.82
$281.95
$867.85
$859.07
$946.75
$937.19
$1,061.46
$1,050.76
$1,224.85
$1,212.48
$910.90
$901.69
$1,014.66
$1,004.41
$1,044.19
$1,033.64
$1,250.91
$1,238.26
$815.80
$807.55
$848.14
$839.56
$859.18
$850.51
$815.94
$807.69
$695.13
$688.10
$875.89
$867.04
$1,387.25
$1,373.24
$662.20
$655.52
$442.77
$438.30
$495.34
$490.35
$811.08
$802.88
$527.02
$521.70
Page 171 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
53505
53510
53515
53520
53600
53600
53601
53601
53605
53620
53620
53621
53621
53660
53660
53661
53661
53665
53850
53850
53852
53852
53855
53855
53860
53860
54000
54000
54001
54001
54015
54050
54050
1/2/2015
Modifier
Par Fee
$493.97
$641.44
$809.29
$565.31
$84.12
$65.17
$81.75
$54.58
$65.84
$117.20
$88.95
$110.54
$73.35
$70.84
$42.24
$69.41
$40.81
$39.65
$2,084.89
$617.16
$1,921.50
$632.90
$780.45
$83.95
$1,576.23
$229.35
$149.74
$110.05
$186.57
$141.16
$311.33
$133.73
$107.28
Nonpar Fee
$469.27
$609.37
$768.83
$537.04
$79.91
$61.91
$77.66
$51.85
$62.55
$111.34
$84.50
$105.01
$69.68
$67.30
$40.13
$65.94
$38.77
$37.67
$1,980.65
$586.30
$1,825.43
$601.26
$741.43
$79.75
$1,497.42
$217.88
$142.25
$104.55
$177.24
$134.10
$295.76
$127.04
$101.92
Limiting
Charge
$539.66
$700.78
$884.15
$617.60
$91.90
$71.20
$89.31
$59.63
$71.93
$128.04
$97.18
$120.76
$80.13
$77.40
$46.15
$75.83
$44.59
$43.32
$2,277.75
$674.25
$2,099.24
$691.45
$852.64
$91.71
$1,722.03
$250.56
$163.59
$120.23
$203.83
$154.22
$340.12
$146.10
$117.21
Charge**
Charge***
$534.27
$531.56
$693.77
$690.26
$875.31
$870.90
$611.42
$608.33
$90.98
$90.52
$70.48
$70.13
$88.41
$87.98
$59.03
$58.73
$71.21
$70.85
$126.76
$126.12
$96.21
$95.71
$119.55
$118.94
$79.33
$78.92
$76.62
$76.23
$45.69
$45.46
$75.07
$74.69
$44.14
$43.92
$42.88
$42.67
$2,254.97
$2,243.58
$667.51
$664.14
$2,078.26
$2,067.76
$684.54
$681.08
$844.12
$839.86
$90.79
$90.33
$1,704.82
$1,696.20
$248.06
$246.80
$161.95
$161.14
$119.03
$118.43
$201.79
$200.77
$152.67
$151.90
$336.72
$335.02
$144.64
$143.90
$116.04
$115.45
Arizona
EHR/eRx
Limiting
Charge**
$528.86
$686.76
$866.47
$605.25
$90.06
$69.77
$87.53
$58.43
$70.50
$125.48
$95.23
$118.35
$78.53
$75.84
$45.23
$74.31
$43.69
$42.46
$2,232.20
$660.76
$2,057.26
$677.61
$835.59
$89.88
$1,687.59
$245.55
$160.32
$117.83
$199.76
$151.13
$333.32
$143.18
$114.86
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$526.25
$520.93
$683.36
$676.45
$862.18
$853.47
$602.24
$596.17
$89.61
$88.71
$69.43
$68.72
$87.09
$86.22
$58.14
$57.56
$70.14
$69.44
$124.87
$123.59
$94.77
$93.81
$117.76
$116.58
$78.14
$77.36
$75.47
$74.70
$45.00
$44.55
$73.95
$73.20
$43.47
$43.03
$42.24
$41.83
$2,221.14
$2,198.71
$657.49
$650.84
$2,047.08
$2,026.40
$674.27
$667.45
$831.46
$823.06
$89.44
$88.54
$1,679.24
$1,662.28
$244.33
$241.87
$159.53
$157.92
$117.24
$116.06
$198.77
$196.75
$150.39
$148.87
$331.67
$328.31
$142.46
$141.02
$114.30
$113.14
Page 172 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
54055
54055
54056
54056
54057
54057
54060
54060
54065
54065
54100
54100
54105
54105
54110
54111
54112
54115
54115
54120
54125
54130
54135
54150
54150
54160
54160
54161
54162
54162
54163
54164
54200
1/2/2015
Modifier
Par Fee
$120.19
$94.45
$143.39
$112.64
$136.64
$96.24
$180.98
$132.35
$220.32
$175.62
$200.24
$128.02
$267.12
$217.06
$634.33
$814.56
$953.85
$458.16
$430.99
$642.74
$825.87
$1,213.55
$1,538.30
$155.95
$99.46
$221.83
$146.75
$200.03
$259.02
$202.53
$222.20
$196.72
$108.17
Nonpar Fee
$114.18
$89.73
$136.22
$107.01
$129.81
$91.43
$171.93
$125.73
$209.30
$166.84
$190.23
$121.62
$253.76
$206.21
$602.61
$773.83
$906.16
$435.25
$409.44
$610.60
$784.58
$1,152.87
$1,461.39
$148.15
$94.49
$210.74
$139.41
$190.03
$246.07
$192.40
$211.09
$186.88
$102.76
Limiting
Charge
$131.31
$103.19
$156.65
$123.06
$149.28
$105.14
$197.72
$144.59
$240.70
$191.87
$218.76
$139.86
$291.82
$237.14
$693.00
$889.90
$1,042.08
$500.54
$470.86
$702.19
$902.27
$1,325.80
$1,680.60
$170.37
$108.66
$242.35
$160.32
$218.53
$282.98
$221.26
$242.75
$214.91
$118.17
Charge**
Charge***
$130.00
$129.34
$102.15
$101.64
$155.09
$154.31
$121.83
$121.21
$147.79
$147.04
$104.10
$103.57
$195.74
$194.75
$143.14
$142.42
$238.29
$237.08
$189.95
$188.99
$216.58
$215.49
$138.46
$137.77
$288.90
$287.44
$234.77
$233.59
$686.07
$682.61
$881.00
$876.55
$1,031.67
$1,026.46
$495.54
$493.03
$466.15
$463.80
$695.16
$691.66
$893.24
$888.73
$1,312.54
$1,305.92
$1,663.80
$1,655.39
$168.67
$167.82
$107.58
$107.03
$239.92
$238.72
$158.72
$157.92
$216.35
$215.26
$280.15
$278.74
$219.05
$217.94
$240.33
$239.11
$212.76
$211.69
$116.99
$116.40
Arizona
EHR/eRx
Limiting
Charge**
$128.69
$101.13
$153.53
$120.60
$146.29
$103.04
$193.76
$141.70
$235.88
$188.03
$214.39
$137.07
$285.98
$232.40
$679.14
$872.10
$1,021.25
$490.53
$461.44
$688.15
$884.22
$1,299.28
$1,646.98
$166.97
$106.49
$237.51
$157.11
$214.16
$277.32
$216.83
$237.90
$210.61
$115.81
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$128.04
$126.75
$100.63
$99.61
$152.77
$151.23
$120.00
$118.80
$145.57
$144.10
$102.53
$101.50
$192.81
$190.85
$140.99
$139.58
$234.72
$232.33
$187.09
$185.21
$213.34
$211.17
$136.38
$135.01
$284.57
$281.69
$231.25
$228.92
$675.77
$668.96
$867.79
$859.02
$1,016.19
$1,005.93
$488.11
$483.17
$459.16
$454.51
$684.73
$677.82
$879.84
$870.96
$1,292.85
$1,279.79
$1,638.84
$1,622.28
$166.14
$164.46
$105.97
$104.89
$236.33
$233.94
$156.34
$154.76
$213.11
$210.96
$275.95
$273.16
$215.76
$213.58
$236.73
$234.34
$209.56
$207.45
$115.23
$114.07
Page 173 of 323
Notes
#
#
#
#
#
Procedure
Code
54200
54205
54220
54220
54230
54230
54231
54231
54235
54235
54240
54240
54240
54250
54250
54250
54300
54304
54308
54312
54316
54318
54322
54324
54326
54328
54332
54336
54340
54344
54348
54352
54360
1/2/2015
Modifier
TC
26
TC
26
Par Fee
$85.28
$540.91
$206.73
$137.01
$98.02
$81.58
$142.01
$118.77
$91.63
$75.18
$100.70
$35.35
$65.35
$122.88
$11.04
$111.84
$652.35
$762.93
$726.86
$832.08
$1,015.53
$733.84
$794.09
$986.08
$962.43
$956.04
$1,031.85
$1,210.07
$579.44
$964.22
$1,044.53
$1,441.35
$733.07
Nonpar Fee
$81.02
$513.86
$196.39
$130.16
$93.12
$77.50
$134.91
$112.83
$87.05
$71.42
$95.67
$33.58
$62.08
$116.74
$10.49
$106.25
$619.73
$724.78
$690.52
$790.48
$964.75
$697.15
$754.39
$936.78
$914.31
$908.24
$980.26
$1,149.57
$550.47
$916.01
$992.30
$1,369.28
$696.42
Limiting
Charge
$93.17
$590.94
$225.85
$149.68
$107.09
$89.13
$155.15
$129.75
$100.11
$82.13
$110.02
$38.62
$71.39
$134.25
$12.06
$122.19
$712.69
$833.50
$794.10
$909.05
$1,109.46
$801.72
$867.55
$1,077.30
$1,051.46
$1,044.48
$1,127.30
$1,322.01
$633.04
$1,053.41
$1,141.15
$1,574.67
$800.88
Charge**
Charge***
$92.24
$91.77
$585.03
$582.07
$223.59
$222.46
$148.19
$147.44
$106.02
$105.48
$88.24
$87.79
$153.59
$152.82
$128.46
$127.81
$99.11
$98.60
$81.32
$80.90
$108.92
$108.36
$38.23
$38.04
$70.68
$70.32
$132.91
$132.24
$11.95
$11.88
$120.97
$120.36
$705.56
$701.99
$825.16
$821.00
$786.15
$782.18
$899.97
$895.41
$1,098.37
$1,092.82
$793.71
$789.69
$858.88
$854.53
$1,066.52
$1,061.14
$1,040.95
$1,035.69
$1,034.03
$1,028.81
$1,116.03
$1,110.39
$1,308.78
$1,302.18
$626.72
$623.54
$1,042.88
$1,037.61
$1,129.74
$1,124.03
$1,558.93
$1,551.05
$792.88
$788.87
Arizona
EHR/eRx
Limiting
Charge**
$91.31
$579.12
$221.33
$146.69
$104.95
$87.34
$152.04
$127.16
$98.11
$80.49
$107.82
$37.85
$69.97
$131.57
$11.82
$119.75
$698.44
$816.82
$778.22
$890.87
$1,087.28
$785.69
$850.20
$1,055.75
$1,030.42
$1,023.59
$1,104.75
$1,295.57
$620.38
$1,032.34
$1,118.32
$1,543.17
$784.86
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$90.86
$89.94
$576.25
$570.43
$220.24
$218.01
$145.97
$144.50
$104.43
$103.37
$86.92
$86.03
$151.29
$149.76
$126.52
$125.25
$97.62
$96.63
$80.10
$79.28
$107.28
$106.20
$37.65
$37.28
$69.62
$68.92
$130.92
$129.59
$11.76
$11.65
$119.15
$117.96
$694.98
$687.96
$812.79
$804.57
$774.36
$766.54
$886.47
$877.51
$1,081.89
$1,070.97
$781.80
$773.90
$846.00
$837.44
$1,050.53
$1,039.91
$1,025.33
$1,014.97
$1,018.52
$1,008.24
$1,099.29
$1,088.18
$1,289.15
$1,276.13
$617.32
$611.08
$1,027.24
$1,016.85
$1,112.79
$1,101.54
$1,535.55
$1,520.02
$780.99
$773.09
Page 174 of 323
Notes
#
Procedure
Code
54380
54385
54390
54400
54401
54405
54406
54408
54410
54411
54415
54416
54417
54420
54430
54435
54450
54450
54500
54505
54512
54520
54522
54530
54535
54550
54560
54600
54620
54640
54650
54660
54670
1/2/2015
Modifier
Par Fee
$812.91
$1,056.99
$1,276.65
$538.23
$666.01
$822.07
$743.04
$803.74
$873.97
$1,044.00
$537.91
$721.40
$914.24
$716.22
$650.69
$423.21
$70.62
$58.47
$76.21
$213.21
$550.30
$331.72
$599.96
$513.10
$757.21
$500.36
$694.74
$460.04
$305.30
$487.32
$723.37
$362.96
$411.50
Nonpar Fee
$772.26
$1,004.14
$1,212.82
$511.32
$632.71
$780.97
$705.89
$763.55
$830.27
$991.80
$511.01
$685.33
$868.53
$680.41
$618.16
$402.05
$67.09
$55.55
$72.40
$202.55
$522.79
$315.13
$569.96
$487.45
$719.35
$475.34
$660.00
$437.04
$290.04
$462.95
$687.20
$344.81
$390.93
Limiting
Charge
$888.10
$1,154.76
$1,394.74
$588.02
$727.62
$898.12
$811.77
$878.08
$954.81
$1,140.57
$587.66
$788.13
$998.81
$782.47
$710.88
$462.36
$77.15
$63.88
$83.26
$232.93
$601.21
$362.40
$655.45
$560.57
$827.25
$546.64
$759.00
$502.60
$333.55
$532.39
$790.28
$396.53
$449.57
Charge**
Charge***
$879.22
$874.78
$1,143.22
$1,137.44
$1,380.79
$1,373.82
$582.14
$579.20
$720.34
$716.70
$889.13
$884.65
$803.65
$799.60
$869.30
$864.92
$945.27
$940.49
$1,129.16
$1,123.46
$581.79
$578.84
$780.25
$776.31
$988.82
$983.83
$774.65
$770.73
$703.78
$700.22
$457.73
$455.42
$76.38
$75.99
$63.24
$62.93
$82.43
$82.01
$230.60
$229.44
$595.19
$592.19
$358.78
$356.96
$648.90
$645.62
$554.97
$552.16
$818.98
$814.84
$541.18
$538.44
$751.41
$747.62
$497.57
$495.05
$330.21
$328.54
$527.07
$524.41
$782.38
$778.42
$392.56
$390.59
$445.07
$442.83
Arizona
EHR/eRx
Limiting
Charge**
$870.33
$1,131.67
$1,366.84
$576.25
$713.07
$880.15
$795.54
$860.52
$935.71
$1,117.75
$575.91
$772.36
$978.83
$766.82
$696.67
$453.11
$75.61
$62.61
$81.59
$228.28
$589.18
$355.15
$642.34
$549.36
$810.70
$535.70
$743.82
$492.55
$326.88
$521.74
$774.48
$388.60
$440.58
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$866.03
$857.28
$1,126.07
$1,114.70
$1,360.08
$1,346.34
$573.41
$567.61
$709.53
$702.37
$875.79
$866.95
$791.60
$783.60
$856.26
$847.62
$931.09
$921.68
$1,112.22
$1,100.99
$573.06
$567.27
$768.55
$760.78
$973.98
$964.15
$763.04
$755.32
$693.22
$686.22
$450.87
$446.32
$75.23
$74.47
$62.30
$61.66
$81.19
$80.37
$227.14
$224.85
$586.27
$580.35
$353.40
$349.83
$639.17
$632.71
$546.64
$541.11
$806.70
$798.55
$533.06
$527.67
$740.14
$732.67
$490.11
$485.16
$325.25
$321.98
$519.17
$513.91
$770.65
$762.86
$386.68
$382.77
$438.39
$433.96
Page 175 of 323
Notes
#
#
#
#
#
Procedure
Code
54680
54690
54692
54700
54800
54830
54840
54860
54861
54865
54900
54901
55000
55000
55040
55041
55060
55100
55100
55110
55120
55150
55175
55180
55200
55200
55250
55250
55300
55400
55450
55450
55500
1/2/2015
Modifier
Par Fee
$800.48
$668.62
$772.37
$218.58
$128.60
$378.42
$325.99
$425.63
$575.51
$364.39
$825.56
$1,087.57
$118.67
$86.85
$343.87
$518.69
$386.87
$217.77
$169.50
$393.53
$363.67
$501.26
$368.54
$700.85
$439.73
$283.48
$387.38
$231.14
$190.69
$506.71
$362.19
$262.07
$402.08
Nonpar Fee
$760.46
$635.19
$733.75
$207.65
$122.17
$359.50
$309.69
$404.35
$546.73
$346.17
$784.28
$1,033.19
$112.74
$82.51
$326.68
$492.76
$367.53
$206.88
$161.03
$373.85
$345.49
$476.20
$350.11
$665.81
$417.74
$269.31
$368.01
$219.58
$181.16
$481.37
$344.08
$248.97
$381.98
Limiting
Charge
$874.53
$730.47
$843.81
$238.80
$140.50
$413.43
$356.14
$465.00
$628.74
$398.10
$901.92
$1,188.17
$129.65
$94.89
$375.68
$566.67
$422.66
$237.91
$185.18
$429.93
$397.31
$547.63
$402.63
$765.68
$480.40
$309.71
$423.21
$252.52
$208.33
$553.58
$395.69
$286.32
$439.28
Charge**
Charge***
$865.79
$861.41
$723.17
$719.51
$835.37
$831.15
$236.41
$235.22
$139.09
$138.39
$409.30
$407.23
$352.58
$350.80
$460.36
$458.02
$622.45
$619.31
$394.12
$392.13
$892.91
$888.40
$1,176.29
$1,170.34
$128.35
$127.71
$93.93
$93.46
$371.92
$370.05
$561.00
$558.18
$418.43
$416.32
$235.53
$234.35
$183.33
$182.40
$425.63
$423.48
$393.35
$391.36
$542.16
$539.42
$398.60
$396.59
$758.02
$754.19
$475.59
$473.19
$306.61
$305.06
$418.98
$416.86
$249.99
$248.73
$206.25
$205.21
$548.04
$545.27
$391.74
$389.76
$283.45
$282.03
$434.88
$432.69
Arizona
EHR/eRx
Limiting
Charge**
$857.04
$715.86
$826.94
$234.03
$137.69
$405.16
$349.03
$455.70
$616.17
$390.14
$883.88
$1,164.41
$127.06
$92.99
$368.17
$555.34
$414.21
$233.15
$181.48
$421.33
$389.37
$536.68
$394.58
$750.36
$470.80
$303.51
$414.75
$247.47
$204.17
$542.50
$387.78
$280.59
$430.49
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$852.81
$844.18
$712.32
$705.12
$822.84
$814.53
$232.86
$230.52
$137.01
$135.62
$403.16
$399.08
$347.29
$343.79
$453.46
$448.87
$613.11
$606.92
$388.21
$384.28
$879.51
$870.62
$1,158.65
$1,146.94
$126.43
$125.15
$92.52
$91.60
$366.34
$362.65
$552.59
$547.01
$412.15
$408.00
$232.00
$229.66
$180.58
$178.76
$419.24
$415.00
$387.45
$383.53
$534.03
$528.63
$392.62
$388.65
$746.65
$739.11
$468.46
$463.74
$302.01
$298.95
$412.70
$408.53
$246.24
$243.75
$203.16
$201.11
$539.82
$534.36
$385.86
$381.96
$279.20
$276.38
$428.36
$424.03
Page 176 of 323
Notes
#
#
#
Procedure
Code
55520
55530
55535
55540
55550
55600
55605
55650
55680
55700
55700
55705
55706
55720
55725
55801
55810
55812
55815
55821
55831
55840
55842
55845
55860
55862
55865
55866
55870
55870
55873
55873
55875
1/2/2015
Modifier
Par Fee
$460.05
$358.45
$437.34
$561.54
$435.19
$428.13
$539.36
$728.65
$358.02
$219.69
$142.10
$271.24
$378.74
$458.93
$645.81
$1,111.64
$1,339.93
$1,637.27
$1,794.16
$888.63
$961.94
$1,191.92
$1,190.94
$1,387.44
$890.06
$1,128.79
$1,357.67
$1,763.94
$177.86
$144.96
$7,160.71
$781.00
$775.58
Nonpar Fee
$437.05
$340.53
$415.47
$533.46
$413.43
$406.72
$512.39
$692.22
$340.12
$208.71
$135.00
$257.68
$359.80
$435.98
$613.52
$1,056.06
$1,272.93
$1,555.41
$1,704.45
$844.20
$913.84
$1,132.32
$1,131.39
$1,318.07
$845.56
$1,072.35
$1,289.79
$1,675.74
$168.97
$137.71
$6,802.67
$741.95
$736.80
Limiting
Charge
$502.61
$391.61
$477.79
$613.48
$475.44
$467.73
$589.25
$796.05
$391.14
$240.02
$155.25
$296.33
$413.77
$501.38
$705.55
$1,214.47
$1,463.87
$1,788.72
$1,960.12
$970.83
$1,050.92
$1,302.17
$1,301.10
$1,515.78
$972.39
$1,233.20
$1,483.26
$1,927.10
$194.32
$158.37
$7,823.07
$853.24
$847.32
Charge**
Charge***
$497.58
$495.06
$387.69
$385.73
$473.02
$470.63
$607.35
$604.28
$470.70
$468.31
$463.05
$460.71
$583.36
$580.41
$788.10
$784.12
$387.23
$385.27
$237.61
$236.42
$153.70
$152.93
$293.37
$291.88
$409.63
$407.56
$496.36
$493.86
$698.49
$694.97
$1,202.33
$1,196.25
$1,449.23
$1,441.92
$1,770.84
$1,761.89
$1,940.52
$1,930.71
$961.12
$956.27
$1,040.41
$1,035.15
$1,289.15
$1,282.64
$1,288.09
$1,281.58
$1,500.62
$1,493.05
$962.67
$957.81
$1,220.87
$1,214.70
$1,468.42
$1,461.01
$1,907.83
$1,898.19
$192.37
$191.41
$156.78
$155.99
$7,744.84
$7,705.72
$844.71
$840.44
$838.84
$834.61
Arizona
EHR/eRx
Limiting
Charge**
$492.56
$383.78
$468.23
$601.21
$465.93
$458.38
$577.46
$780.14
$383.32
$235.22
$152.15
$290.41
$405.49
$491.35
$691.44
$1,190.18
$1,434.59
$1,752.95
$1,920.91
$951.42
$1,029.89
$1,276.12
$1,275.07
$1,485.47
$952.95
$1,208.54
$1,453.59
$1,888.56
$190.43
$155.20
$7,666.61
$836.18
$830.37
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$490.12
$485.17
$381.87
$378.02
$465.92
$461.21
$598.24
$592.19
$463.63
$458.94
$456.10
$451.50
$574.61
$568.80
$776.27
$768.43
$381.42
$377.57
$234.05
$231.69
$151.40
$149.87
$288.96
$286.05
$403.49
$399.41
$488.92
$483.98
$688.01
$681.06
$1,184.29
$1,172.33
$1,427.50
$1,413.07
$1,744.27
$1,726.66
$1,911.42
$1,892.10
$946.70
$937.15
$1,024.80
$1,014.45
$1,269.82
$1,256.97
$1,268.77
$1,255.95
$1,478.12
$1,463.18
$948.22
$938.65
$1,202.57
$1,190.41
$1,446.40
$1,431.78
$1,879.22
$1,860.24
$189.49
$187.58
$154.43
$152.88
$7,628.66
$7,551.61
$832.04
$823.63
$826.26
$817.91
Page 177 of 323
Notes
#
#
#
#
#
#
#
#
Procedure
Code
55876
55876
55920
56405
56405
56420
56420
56440
56441
56441
56442
56501
56501
56515
56515
56605
56605
56606
56606
56620
56625
56630
56631
56632
56633
56634
56637
56640
56700
56740
56800
56805
56810
1/2/2015
Modifier
Par Fee
$136.86
$102.54
$453.29
$110.63
$109.92
$122.88
$92.13
$183.94
$146.48
$141.12
$47.96
$132.08
$115.99
$228.64
$203.61
$83.01
$61.20
$37.95
$29.73
$525.25
$636.88
$937.71
$1,191.27
$1,396.82
$1,226.77
$1,320.82
$1,531.71
$1,546.68
$188.32
$303.56
$243.39
$1,150.72
$262.12
Nonpar Fee
$130.02
$97.41
$430.63
$105.10
$104.42
$116.74
$87.52
$174.74
$139.16
$134.06
$45.56
$125.48
$110.19
$217.21
$193.43
$78.86
$58.14
$36.05
$28.24
$498.99
$605.04
$890.82
$1,131.71
$1,326.98
$1,165.43
$1,254.78
$1,455.12
$1,469.35
$178.90
$288.38
$231.22
$1,093.18
$249.01
Limiting
Charge
$149.52
$112.02
$495.22
$120.87
$120.08
$134.25
$100.65
$200.95
$160.03
$154.17
$52.39
$144.30
$126.72
$249.79
$222.44
$90.69
$66.86
$41.46
$32.48
$573.84
$695.80
$1,024.44
$1,301.47
$1,526.03
$1,340.24
$1,443.00
$1,673.39
$1,689.75
$205.74
$331.64
$265.90
$1,257.16
$286.36
Charge**
Charge***
$148.03
$147.28
$110.91
$110.34
$490.27
$487.80
$119.66
$119.05
$118.89
$118.28
$132.91
$132.24
$99.64
$99.14
$198.94
$197.94
$158.44
$157.63
$152.63
$151.86
$51.87
$51.61
$142.86
$142.14
$125.45
$124.82
$247.30
$246.04
$220.23
$219.11
$89.78
$89.33
$66.19
$65.86
$41.04
$40.84
$32.15
$31.99
$568.10
$565.24
$688.84
$685.35
$1,014.20
$1,009.08
$1,288.45
$1,281.94
$1,510.77
$1,503.14
$1,326.85
$1,320.14
$1,428.56
$1,421.35
$1,656.66
$1,648.28
$1,672.86
$1,664.41
$203.68
$202.65
$328.33
$326.66
$263.25
$261.91
$1,244.59
$1,238.30
$283.50
$282.06
Arizona
EHR/eRx
Limiting
Charge**
$146.53
$109.78
$485.32
$118.45
$117.68
$131.57
$98.64
$196.94
$156.84
$151.09
$51.35
$141.42
$124.19
$244.80
$217.99
$88.87
$65.53
$40.63
$31.83
$562.36
$681.88
$1,003.95
$1,275.44
$1,495.51
$1,313.44
$1,414.13
$1,639.92
$1,655.95
$201.62
$325.00
$260.59
$1,232.02
$280.63
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$145.81
$144.34
$109.24
$108.13
$482.92
$478.04
$117.86
$116.68
$117.10
$115.92
$130.92
$129.59
$98.14
$97.15
$195.96
$193.98
$156.06
$154.48
$150.34
$148.82
$51.08
$50.58
$140.73
$139.30
$123.57
$122.33
$243.58
$241.13
$216.92
$214.73
$88.44
$87.54
$65.21
$64.55
$40.42
$40.02
$31.67
$31.35
$559.58
$553.92
$678.51
$671.66
$998.98
$988.90
$1,269.12
$1,256.31
$1,488.10
$1,473.07
$1,306.94
$1,293.74
$1,407.14
$1,392.91
$1,631.80
$1,615.32
$1,647.77
$1,631.11
$200.62
$198.59
$323.40
$320.13
$259.30
$256.68
$1,225.92
$1,213.54
$279.24
$276.43
Page 178 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
56820
56820
56821
56821
57000
57010
57020
57020
57022
57023
57061
57061
57065
57065
57100
57100
57105
57105
57106
57107
57109
57110
57111
57112
57120
57130
57130
57135
57135
57150
57150
57155
57155
1/2/2015
Modifier
Par Fee
$113.00
$87.62
$149.16
$116.98
$186.08
$436.04
$93.24
$81.44
$169.41
$313.17
$115.05
$99.68
$197.62
$176.88
$89.98
$67.81
$137.54
$127.89
$498.60
$1,471.73
$1,768.87
$900.71
$1,612.30
$1,893.24
$512.80
$178.48
$160.61
$193.28
$174.69
$45.50
$29.05
$431.51
$293.13
Nonpar Fee
$107.35
$83.24
$141.70
$111.13
$176.78
$414.24
$88.58
$77.37
$160.94
$297.51
$109.30
$94.70
$187.74
$168.04
$85.48
$64.42
$130.66
$121.50
$473.67
$1,398.14
$1,680.43
$855.67
$1,531.69
$1,798.58
$487.16
$169.56
$152.58
$183.62
$165.96
$43.23
$27.60
$409.93
$278.47
Limiting
Charge
$123.45
$95.73
$162.96
$127.80
$203.30
$476.38
$101.87
$88.98
$185.08
$342.14
$125.70
$108.91
$215.90
$193.25
$98.30
$74.08
$150.26
$139.73
$544.72
$1,607.86
$1,932.49
$984.02
$1,761.44
$2,068.37
$560.23
$194.99
$175.47
$211.16
$190.85
$49.71
$31.74
$471.42
$320.24
Charge**
Charge***
$122.22
$121.60
$94.77
$94.29
$161.32
$160.51
$126.52
$125.88
$201.26
$200.25
$471.62
$469.23
$100.84
$100.34
$88.09
$87.64
$183.23
$182.31
$338.71
$337.01
$124.44
$123.81
$107.81
$107.27
$213.74
$212.66
$191.31
$190.35
$97.32
$96.83
$73.35
$72.97
$148.75
$148.01
$138.33
$137.63
$539.27
$536.54
$1,591.78
$1,583.75
$1,913.17
$1,903.50
$974.18
$969.25
$1,743.83
$1,735.02
$2,047.68
$2,037.34
$554.63
$551.83
$193.04
$192.07
$173.71
$172.83
$209.05
$208.00
$188.95
$187.99
$49.22
$48.97
$31.42
$31.27
$466.70
$464.35
$317.04
$315.43
Arizona
EHR/eRx
Limiting
Charge**
$120.98
$93.82
$159.70
$125.25
$199.23
$466.85
$99.83
$87.19
$181.38
$335.29
$123.18
$106.73
$211.59
$189.38
$96.34
$72.60
$147.26
$136.93
$533.83
$1,575.71
$1,893.84
$964.34
$1,726.22
$2,027.00
$549.03
$191.10
$171.96
$206.94
$187.04
$48.73
$31.11
$461.99
$313.84
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$120.39
$119.16
$93.35
$92.41
$158.91
$157.31
$124.63
$123.37
$198.24
$196.24
$464.54
$459.85
$99.33
$98.34
$86.77
$85.88
$180.48
$178.65
$333.63
$330.27
$122.58
$121.33
$106.19
$105.13
$210.53
$208.41
$188.44
$186.54
$95.86
$94.89
$72.24
$71.51
$146.52
$145.05
$136.26
$134.87
$531.19
$525.83
$1,567.91
$1,552.07
$1,884.48
$1,865.44
$959.56
$949.88
$1,717.66
$1,700.32
$2,016.96
$1,996.60
$546.32
$540.80
$190.14
$188.23
$171.10
$169.38
$205.91
$203.84
$186.12
$184.23
$48.48
$47.99
$30.95
$30.64
$459.70
$455.06
$312.28
$309.13
Page 179 of 323
Notes
#
#
#
#
Procedure
Code
57156
57156
57160
57160
57170
57170
57180
57180
57200
57210
57220
57230
57240
57250
57260
57265
57267
57268
57270
57280
57282
57283
57284
57285
57287
57288
57289
57291
57292
57295
57296
57300
57305
1/2/2015
Modifier
Par Fee
$198.54
$147.77
$77.10
$47.79
$61.01
$48.86
$142.05
$107.01
$304.90
$370.61
$321.21
$396.98
$676.67
$681.54
$839.74
$919.40
$258.77
$486.92
$803.49
$961.77
$504.12
$694.60
$822.44
$677.74
$686.76
$722.26
$741.30
$532.96
$821.46
$480.97
$941.70
$573.07
$948.34
Nonpar Fee
$188.61
$140.38
$73.25
$45.40
$57.96
$46.42
$134.95
$101.66
$289.66
$352.08
$305.15
$377.13
$642.84
$647.46
$797.75
$873.43
$245.83
$462.57
$763.32
$913.68
$478.91
$659.87
$781.32
$643.85
$652.42
$686.15
$704.24
$506.31
$780.39
$456.92
$894.62
$544.42
$900.92
Limiting
Charge
$216.90
$161.44
$84.24
$52.21
$66.65
$53.38
$155.19
$116.91
$333.11
$404.89
$350.92
$433.70
$739.27
$744.58
$917.41
$1,004.44
$282.70
$531.96
$877.82
$1,050.73
$550.75
$758.85
$898.52
$740.43
$750.28
$789.07
$809.88
$582.26
$897.45
$525.46
$1,028.81
$626.08
$1,036.06
Charge**
Charge***
$214.73
$213.65
$159.83
$159.01
$83.40
$82.97
$51.69
$51.43
$65.99
$65.65
$52.85
$52.58
$153.64
$152.87
$115.74
$115.16
$329.77
$328.12
$400.84
$398.82
$347.42
$345.66
$429.36
$427.19
$731.87
$728.18
$737.14
$733.41
$908.24
$903.65
$994.41
$989.38
$279.88
$278.46
$526.63
$523.97
$869.04
$864.65
$1,040.22
$1,034.97
$545.24
$542.49
$751.26
$747.47
$889.54
$885.04
$733.02
$729.32
$742.79
$739.02
$781.18
$777.24
$801.78
$797.73
$576.44
$573.53
$888.48
$883.98
$520.20
$517.58
$1,018.52
$1,013.38
$619.83
$616.69
$1,025.70
$1,020.52
Arizona
EHR/eRx
Limiting
Charge**
$212.57
$158.21
$82.56
$51.16
$65.32
$52.31
$152.09
$114.57
$326.45
$396.80
$343.91
$425.03
$724.48
$729.69
$899.07
$984.35
$277.05
$521.32
$860.26
$1,029.72
$539.73
$743.67
$880.54
$725.62
$735.28
$773.29
$793.68
$570.61
$879.50
$514.95
$1,008.24
$613.56
$1,015.34
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$211.51
$209.38
$157.44
$155.84
$82.14
$81.32
$50.92
$50.39
$65.00
$64.34
$52.06
$51.53
$151.34
$149.81
$114.00
$112.86
$324.83
$321.55
$394.83
$390.84
$342.21
$338.74
$422.92
$418.66
$720.89
$713.61
$726.09
$718.74
$894.61
$885.58
$979.49
$969.59
$275.68
$272.90
$518.73
$513.50
$856.00
$847.35
$1,024.62
$1,014.28
$537.06
$531.63
$739.99
$732.52
$876.20
$867.33
$722.03
$714.74
$731.64
$724.25
$769.47
$761.69
$789.75
$781.78
$567.79
$562.05
$875.15
$866.31
$512.39
$507.22
$1,003.24
$993.12
$610.54
$604.36
$1,010.31
$1,000.11
Page 180 of 323
Notes
#
#
#
#
#
#
#
#
#
#
Procedure
Code
57307
57308
57310
57311
57320
57330
57335
57400
57410
57415
57420
57420
57421
57421
57423
57425
57426
57452
57452
57454
57454
57455
57455
57456
57456
57460
57460
57461
57461
57500
57500
57505
57505
1/2/2015
Modifier
Par Fee
$1,088.85
$643.14
$467.51
$532.32
$535.68
$751.85
$1,133.08
$134.23
$109.34
$161.68
$119.31
$93.56
$159.04
$125.79
$920.96
$976.79
$850.60
$109.92
$93.47
$154.21
$137.77
$144.33
$112.15
$135.89
$104.42
$284.45
$164.32
$321.91
$189.98
$129.09
$76.88
$102.63
$92.97
Nonpar Fee
$1,034.41
$610.98
$444.13
$505.70
$508.90
$714.26
$1,076.43
$127.52
$103.87
$153.60
$113.34
$88.88
$151.09
$119.50
$874.91
$927.95
$808.07
$104.42
$88.80
$146.50
$130.88
$137.11
$106.54
$129.10
$99.20
$270.23
$156.10
$305.81
$180.48
$122.64
$73.04
$97.50
$88.32
Limiting
Charge
$1,189.57
$702.63
$510.75
$581.56
$585.24
$821.40
$1,237.89
$146.65
$119.45
$176.64
$130.34
$102.21
$173.75
$137.43
$1,006.15
$1,067.14
$929.28
$120.08
$102.12
$168.48
$150.51
$157.68
$122.52
$148.47
$114.08
$310.76
$179.52
$351.68
$207.55
$141.04
$84.00
$112.13
$101.57
Charge**
Charge***
$1,177.68
$1,171.72
$695.60
$692.09
$505.64
$503.09
$575.74
$572.83
$579.38
$576.46
$813.19
$809.08
$1,225.52
$1,219.32
$145.18
$144.45
$118.25
$117.66
$174.87
$174.00
$129.04
$128.39
$101.19
$100.68
$172.02
$171.14
$136.06
$135.37
$996.08
$991.06
$1,056.47
$1,051.13
$919.99
$915.34
$118.89
$118.28
$101.10
$100.59
$166.80
$165.95
$149.01
$148.26
$156.10
$155.31
$121.29
$120.68
$146.98
$146.23
$112.94
$112.37
$307.66
$306.11
$177.72
$176.82
$348.16
$346.40
$205.48
$204.44
$139.62
$138.92
$83.16
$82.73
$111.01
$110.45
$100.56
$100.05
Arizona
EHR/eRx
Limiting
Charge**
$1,165.78
$688.57
$500.54
$569.93
$573.53
$804.97
$1,213.14
$143.72
$117.06
$173.11
$127.73
$100.17
$170.28
$134.68
$986.02
$1,045.80
$910.70
$117.68
$100.07
$165.11
$147.50
$154.53
$120.07
$145.50
$111.80
$304.55
$175.93
$344.64
$203.40
$138.22
$82.32
$109.88
$99.53
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$1,160.02
$1,148.29
$685.17
$678.25
$498.05
$493.03
$567.10
$561.38
$570.69
$564.93
$800.99
$792.89
$1,207.13
$1,194.94
$143.00
$141.57
$116.48
$115.30
$172.25
$170.51
$127.11
$125.81
$99.67
$98.66
$169.44
$167.73
$134.02
$132.65
$981.15
$971.23
$1,040.62
$1,030.11
$906.19
$897.03
$117.10
$115.92
$99.58
$98.57
$164.29
$162.63
$146.77
$145.29
$153.76
$152.20
$119.47
$118.27
$144.77
$143.31
$111.25
$110.12
$303.05
$299.99
$175.05
$173.29
$342.94
$339.47
$202.40
$200.35
$137.53
$136.15
$81.91
$81.09
$109.34
$108.24
$99.05
$98.04
Page 181 of 323
Notes
#
#
#
#
#
#
#
#
#
#
Procedure
Code
57510
57510
57511
57511
57513
57513
57520
57520
57522
57522
57530
57531
57540
57545
57550
57555
57556
57558
57558
57700
57720
57800
57800
58100
58100
58110
58110
58120
58120
58140
58145
58146
58150
1/2/2015
Modifier
Par Fee
$131.95
$116.58
$146.52
$133.65
$146.39
$135.67
$308.74
$277.63
$264.93
$245.98
$351.21
$1,867.00
$809.74
$826.42
$409.13
$604.48
$571.62
$125.96
$114.52
$312.27
$308.60
$61.37
$49.57
$109.65
$88.19
$48.54
$41.75
$260.24
$221.27
$929.29
$551.92
$1,158.72
$1,022.82
Nonpar Fee
$125.35
$110.75
$139.19
$126.97
$139.07
$128.89
$293.30
$263.75
$251.68
$233.68
$333.65
$1,773.65
$769.25
$785.10
$388.67
$574.26
$543.04
$119.66
$108.79
$296.66
$293.17
$58.30
$47.09
$104.17
$83.78
$46.11
$39.66
$247.23
$210.21
$882.83
$524.32
$1,100.78
$971.68
Limiting
Charge
$144.15
$127.36
$160.07
$146.02
$159.93
$148.22
$337.30
$303.31
$289.43
$268.73
$383.70
$2,039.70
$884.64
$902.87
$446.97
$660.40
$624.50
$137.61
$125.11
$341.16
$337.15
$67.05
$54.15
$119.80
$96.35
$53.03
$45.61
$284.31
$241.74
$1,015.25
$602.97
$1,265.90
$1,117.43
Charge**
Charge***
$142.72
$141.99
$126.09
$125.45
$158.47
$157.67
$144.56
$143.83
$158.33
$157.53
$146.74
$146.00
$333.93
$332.24
$300.28
$298.76
$286.53
$285.09
$266.04
$264.70
$379.86
$377.95
$2,019.30
$2,009.11
$875.79
$871.37
$893.84
$889.32
$442.50
$440.27
$653.80
$650.50
$618.25
$615.12
$136.23
$135.55
$123.86
$123.23
$337.74
$336.04
$333.78
$332.09
$66.38
$66.04
$53.61
$53.34
$118.60
$118.00
$95.38
$94.90
$52.50
$52.23
$45.15
$44.93
$281.47
$280.05
$239.33
$238.12
$1,005.10
$1,000.03
$596.94
$593.93
$1,253.24
$1,246.91
$1,106.25
$1,100.67
Arizona
EHR/eRx
Limiting
Charge**
$141.27
$124.82
$156.87
$143.09
$156.73
$145.26
$330.54
$297.25
$283.65
$263.36
$376.03
$1,998.91
$866.95
$884.81
$438.04
$647.19
$612.01
$134.86
$122.60
$334.34
$330.41
$65.70
$53.07
$117.40
$94.42
$51.97
$44.70
$278.63
$236.91
$994.95
$590.90
$1,240.57
$1,095.09
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$140.58
$139.15
$124.20
$122.95
$156.09
$154.51
$142.38
$140.94
$155.95
$154.39
$144.54
$143.08
$328.91
$325.59
$295.77
$292.79
$282.23
$279.39
$262.05
$259.41
$374.16
$370.39
$1,989.01
$1,968.93
$862.66
$853.94
$880.43
$871.54
$435.86
$431.47
$643.99
$637.48
$608.98
$602.83
$134.18
$132.84
$121.99
$120.76
$332.67
$329.33
$328.77
$325.45
$65.38
$64.71
$52.81
$52.28
$116.82
$115.64
$93.96
$93.00
$51.72
$51.19
$44.47
$44.03
$277.25
$274.46
$235.74
$233.36
$990.02
$980.02
$587.98
$582.04
$1,234.43
$1,221.97
$1,089.66
$1,078.67
Page 182 of 323
Notes
#
#
#
#
#
#
Procedure
Code
58152
58180
58200
58210
58240
58260
58262
58263
58267
58270
58275
58280
58285
58290
58291
58292
58293
58294
58301
58301
58321
58321
58322
58322
58323
58323
58340
58340
58345
58346
58350
58350
58353
1/2/2015
Modifier
Par Fee
$1,262.72
$971.80
$1,383.36
$1,863.23
$2,947.56
$831.96
$928.79
$995.57
$1,062.40
$887.71
$994.01
$1,057.52
$1,444.85
$1,155.55
$1,251.39
$1,320.09
$1,372.48
$1,223.49
$95.48
$68.30
$76.75
$49.22
$86.27
$59.09
$15.60
$12.38
$119.70
$58.91
$280.63
$447.60
$97.35
$79.47
$1,011.27
Nonpar Fee
$1,199.58
$923.21
$1,314.19
$1,770.07
$2,800.18
$790.36
$882.35
$945.79
$1,009.28
$843.32
$944.31
$1,004.64
$1,372.61
$1,097.77
$1,188.82
$1,254.09
$1,303.86
$1,162.32
$90.71
$64.89
$72.91
$46.76
$81.96
$56.14
$14.82
$11.76
$113.72
$55.96
$266.60
$425.22
$92.48
$75.50
$960.71
Limiting
Charge
$1,379.52
$1,061.69
$1,511.32
$2,035.58
$3,220.21
$908.91
$1,014.70
$1,087.66
$1,160.67
$969.82
$1,085.96
$1,155.34
$1,578.50
$1,262.44
$1,367.14
$1,442.20
$1,499.44
$1,336.67
$104.32
$74.62
$83.85
$53.77
$94.25
$64.56
$17.04
$13.52
$130.78
$64.35
$306.59
$489.00
$106.35
$86.83
$1,104.82
Charge**
Charge***
$1,365.72
$1,358.83
$1,051.08
$1,045.76
$1,496.21
$1,488.65
$2,015.23
$2,005.05
$3,188.01
$3,171.91
$899.83
$895.28
$1,004.56
$999.48
$1,076.78
$1,071.34
$1,149.07
$1,143.26
$960.12
$955.27
$1,075.10
$1,069.67
$1,143.78
$1,138.01
$1,562.71
$1,554.82
$1,249.81
$1,243.50
$1,353.47
$1,346.64
$1,427.78
$1,420.57
$1,484.44
$1,476.95
$1,323.31
$1,316.62
$103.27
$102.75
$73.88
$73.51
$83.01
$82.59
$53.23
$52.97
$93.31
$92.84
$63.92
$63.60
$16.87
$16.79
$13.39
$13.32
$129.47
$128.81
$63.71
$63.39
$303.52
$301.99
$484.12
$481.67
$105.29
$104.75
$85.96
$85.53
$1,093.77
$1,088.25
Arizona
EHR/eRx
Limiting
Charge**
$1,351.93
$1,040.46
$1,481.10
$1,994.87
$3,155.81
$890.73
$994.41
$1,065.90
$1,137.45
$950.42
$1,064.23
$1,132.23
$1,546.93
$1,237.18
$1,339.80
$1,413.36
$1,469.45
$1,309.93
$102.24
$73.13
$82.17
$52.69
$92.37
$63.27
$16.70
$13.25
$128.17
$63.07
$300.46
$479.23
$104.22
$85.09
$1,082.73
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$1,345.24
$1,331.65
$1,035.31
$1,024.86
$1,473.76
$1,458.88
$1,984.99
$1,964.95
$3,140.19
$3,108.47
$886.33
$877.37
$989.49
$979.49
$1,060.63
$1,049.92
$1,131.83
$1,120.39
$945.73
$936.16
$1,058.98
$1,048.27
$1,126.62
$1,115.25
$1,539.28
$1,523.73
$1,231.06
$1,218.62
$1,333.17
$1,319.69
$1,406.37
$1,392.16
$1,462.18
$1,447.40
$1,303.46
$1,290.28
$101.72
$100.71
$72.77
$72.04
$81.77
$80.94
$52.44
$51.90
$91.91
$90.99
$62.96
$62.32
$16.62
$16.45
$13.19
$13.05
$127.52
$126.25
$62.76
$62.12
$298.97
$295.95
$476.86
$472.04
$103.72
$102.66
$84.67
$83.81
$1,077.35
$1,066.49
Page 183 of 323
Notes
#
#
#
#
#
#
#
Procedure
Code
58353
58356
58356
58400
58410
58520
58540
58541
58542
58543
58544
58545
58546
58548
58550
58552
58553
58554
58555
58555
58558
58558
58559
58560
58561
58562
58562
58563
58563
58565
58565
58570
58571
1/2/2015
Modifier
Par Fee
$220.73
$1,889.34
$347.95
$441.99
$808.00
$806.75
$913.45
$721.95
$824.72
$834.46
$910.47
$912.22
$1,130.34
$1,919.74
$888.24
$996.12
$1,140.27
$1,335.32
$305.24
$191.54
$399.16
$269.01
$343.75
$388.76
$550.36
$413.91
$292.70
$1,671.68
$344.46
$1,879.33
$434.84
$784.90
$905.14
Nonpar Fee
$209.69
$1,794.87
$330.55
$419.89
$767.60
$766.41
$867.78
$685.85
$783.48
$792.74
$864.95
$866.61
$1,073.82
$1,823.75
$843.83
$946.31
$1,083.26
$1,268.55
$289.98
$181.96
$379.20
$255.56
$326.56
$369.32
$522.84
$393.21
$278.07
$1,588.10
$327.24
$1,785.36
$413.10
$745.66
$859.88
Limiting
Charge
$241.14
$2,064.10
$380.13
$482.87
$882.74
$881.37
$997.95
$788.73
$901.00
$911.65
$994.69
$996.60
$1,234.89
$2,097.31
$970.40
$1,088.26
$1,245.75
$1,458.83
$333.48
$209.25
$436.08
$293.89
$375.54
$424.72
$601.27
$452.19
$319.78
$1,826.32
$376.33
$2,053.16
$475.07
$857.51
$988.86
Charge**
Charge***
$238.73
$237.52
$2,043.46
$2,033.14
$376.33
$374.43
$478.04
$475.63
$873.91
$869.50
$872.56
$868.15
$987.97
$982.97
$780.84
$776.89
$892.00
$887.49
$902.53
$897.98
$984.75
$979.78
$986.63
$981.65
$1,222.54
$1,216.37
$2,076.34
$2,065.85
$960.70
$955.85
$1,077.38
$1,071.94
$1,233.29
$1,227.06
$1,444.24
$1,436.95
$330.14
$328.47
$207.16
$206.11
$431.72
$429.54
$290.95
$289.49
$371.78
$369.91
$420.47
$418.35
$595.25
$592.25
$447.67
$445.41
$316.58
$314.99
$1,808.05
$1,798.92
$372.57
$370.68
$2,032.64
$2,022.37
$470.32
$467.94
$848.93
$844.65
$978.97
$974.03
Arizona
EHR/eRx
Limiting
Charge**
$236.33
$2,022.82
$372.53
$473.21
$865.09
$863.74
$977.98
$772.95
$882.98
$893.42
$974.80
$976.67
$1,210.19
$2,055.37
$950.99
$1,066.49
$1,220.83
$1,429.66
$326.81
$205.07
$427.36
$288.02
$368.03
$416.22
$589.24
$443.15
$313.39
$1,789.79
$368.81
$2,012.10
$465.57
$840.36
$969.08
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$235.15
$232.78
$2,012.81
$1,992.48
$370.68
$366.94
$470.87
$466.12
$860.80
$852.12
$859.48
$850.78
$973.14
$963.31
$769.13
$761.36
$878.62
$869.73
$889.00
$880.03
$969.98
$960.18
$971.83
$962.02
$1,204.20
$1,192.03
$2,045.19
$2,024.54
$946.29
$936.73
$1,061.22
$1,050.49
$1,214.79
$1,202.52
$1,422.57
$1,408.21
$325.19
$321.91
$204.06
$202.00
$425.25
$420.96
$286.59
$283.69
$366.21
$362.51
$414.17
$409.98
$586.33
$580.39
$440.96
$436.51
$311.83
$308.68
$1,780.94
$1,762.94
$366.98
$363.27
$2,002.15
$1,981.92
$463.27
$458.59
$836.20
$827.76
$964.29
$954.55
Page 184 of 323
Notes
#
Procedure
Code
58572
58573
58600
58605
58611
58615
58660
58661
58662
58670
58671
58672
58673
58700
58720
58740
58750
58752
58760
58770
58800
58800
58805
58820
58822
58825
58900
58920
58925
58940
58943
58950
58951
1/2/2015
Modifier
Par Fee
$1,025.40
$1,222.79
$365.73
$331.36
$77.87
$245.27
$678.88
$654.12
$714.99
$366.72
$366.09
$738.76
$803.53
$788.32
$741.83
$891.09
$918.14
$880.14
$813.95
$856.77
$319.60
$299.93
$406.23
$313.52
$703.58
$764.55
$415.08
$718.87
$753.49
$530.57
$1,185.64
$1,142.05
$1,465.85
Nonpar Fee
$974.13
$1,161.65
$347.44
$314.79
$73.98
$233.01
$644.94
$621.41
$679.24
$348.38
$347.79
$701.82
$763.35
$748.90
$704.74
$846.54
$872.23
$836.13
$773.25
$813.93
$303.62
$284.93
$385.92
$297.84
$668.40
$726.32
$394.33
$682.93
$715.82
$504.04
$1,126.36
$1,084.95
$1,392.56
Limiting
Charge
$1,120.25
$1,335.90
$399.56
$362.01
$85.08
$267.96
$741.68
$714.62
$781.13
$400.64
$399.96
$807.09
$877.85
$861.24
$810.45
$973.52
$1,003.06
$961.55
$889.24
$936.02
$349.16
$327.67
$443.81
$342.52
$768.66
$835.27
$453.48
$785.37
$823.19
$579.65
$1,295.31
$1,247.69
$1,601.44
Charge**
Charge***
$1,109.05
$1,103.45
$1,322.53
$1,315.86
$395.57
$393.56
$358.39
$356.58
$84.23
$83.80
$265.28
$263.94
$734.26
$730.56
$707.48
$703.90
$773.32
$769.41
$396.64
$394.62
$395.96
$393.96
$799.02
$794.98
$869.08
$864.69
$852.62
$848.32
$802.34
$798.30
$963.78
$958.92
$993.04
$988.02
$951.94
$947.13
$880.35
$875.90
$926.66
$921.98
$345.67
$343.93
$324.39
$322.76
$439.37
$437.15
$339.09
$337.38
$760.98
$757.13
$826.92
$822.74
$448.95
$446.68
$777.52
$773.59
$814.96
$810.84
$573.85
$570.95
$1,282.37
$1,275.88
$1,235.22
$1,228.98
$1,585.42
$1,577.42
Arizona
EHR/eRx
Limiting
Charge**
$1,097.85
$1,309.18
$391.56
$354.76
$83.38
$262.60
$726.85
$700.33
$765.51
$392.62
$391.95
$790.95
$860.29
$844.01
$794.25
$954.05
$983.01
$942.32
$871.46
$917.30
$342.18
$321.11
$434.93
$335.66
$753.28
$818.56
$444.41
$769.66
$806.73
$568.05
$1,269.40
$1,222.74
$1,569.42
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$1,092.41
$1,081.38
$1,302.70
$1,289.54
$389.63
$385.69
$353.02
$349.44
$82.96
$82.12
$261.30
$258.66
$723.25
$715.94
$696.87
$689.83
$761.71
$754.03
$390.69
$386.73
$390.02
$386.08
$787.04
$779.08
$856.04
$847.39
$839.83
$831.35
$790.30
$782.33
$949.33
$939.75
$978.14
$968.27
$937.65
$928.19
$867.15
$858.38
$912.76
$903.54
$340.48
$337.05
$319.53
$316.30
$432.78
$428.41
$334.01
$330.63
$749.56
$741.98
$814.51
$806.28
$442.21
$437.74
$765.85
$758.11
$802.73
$794.63
$565.25
$559.53
$1,263.13
$1,250.36
$1,216.69
$1,204.40
$1,561.64
$1,545.88
Page 185 of 323
Notes
#
#
#
#
#
#
Procedure
Code
58952
58953
58954
58956
58957
58958
58960
58970
58970
58976
58976
59000
59000
59001
59012
59015
59015
59020
59020
59020
59025
59025
59025
59030
59050
59051
59070
59070
59072
59074
59074
59076
59100
1/2/2015
Modifier
TC
26
TC
26
Par Fee
$1,661.88
$2,053.54
$2,226.77
$1,397.94
$1,606.68
$1,764.83
$986.31
$223.99
$202.54
$246.95
$212.27
$127.58
$82.53
$183.84
$207.26
$158.35
$135.10
$72.19
$34.28
$37.91
$48.77
$18.55
$30.22
$102.72
$51.86
$42.79
$416.19
$317.15
$478.13
$399.03
$317.51
$478.13
$849.34
Nonpar Fee
$1,578.79
$1,950.86
$2,115.43
$1,328.04
$1,526.35
$1,676.59
$936.99
$212.79
$192.41
$234.60
$201.66
$121.20
$78.40
$174.65
$196.90
$150.43
$128.35
$68.58
$32.57
$36.01
$46.33
$17.62
$28.71
$97.58
$49.27
$40.65
$395.38
$301.29
$454.22
$379.08
$301.63
$454.22
$806.87
Limiting
Charge
$1,815.61
$2,243.49
$2,432.74
$1,527.25
$1,755.30
$1,928.08
$1,077.54
$244.71
$221.27
$269.79
$231.91
$139.38
$90.16
$200.85
$226.44
$172.99
$147.60
$78.87
$37.46
$41.41
$53.28
$20.26
$33.02
$112.22
$56.66
$46.75
$454.69
$346.48
$522.35
$435.94
$346.87
$522.35
$927.90
Charge**
Charge***
$1,797.45
$1,788.38
$2,221.05
$2,209.84
$2,408.42
$2,396.26
$1,511.97
$1,504.34
$1,737.75
$1,728.97
$1,908.79
$1,899.16
$1,066.76
$1,061.38
$242.26
$241.04
$219.06
$217.95
$267.09
$265.74
$229.59
$228.44
$137.99
$137.29
$89.26
$88.80
$198.84
$197.83
$224.17
$223.04
$171.27
$170.40
$146.13
$145.38
$78.07
$77.68
$37.08
$36.89
$41.00
$40.79
$52.75
$52.49
$20.06
$19.96
$32.68
$32.52
$111.09
$110.54
$56.10
$55.81
$46.28
$46.05
$450.14
$447.87
$343.02
$341.29
$517.13
$514.52
$431.58
$429.40
$343.40
$341.68
$517.13
$514.52
$918.62
$913.99
Arizona
EHR/eRx
Limiting
Charge**
$1,779.29
$2,198.62
$2,384.09
$1,496.70
$1,720.19
$1,889.52
$1,055.99
$239.81
$216.84
$264.40
$227.27
$136.60
$88.35
$196.83
$221.90
$169.53
$144.65
$77.29
$36.71
$40.58
$52.21
$19.86
$32.36
$109.97
$55.52
$45.82
$445.59
$339.55
$511.91
$427.23
$339.94
$511.91
$909.34
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$1,770.49
$1,752.60
$2,187.74
$2,165.63
$2,372.30
$2,348.32
$1,489.30
$1,474.25
$1,711.68
$1,694.39
$1,880.16
$1,861.17
$1,050.77
$1,040.15
$238.63
$236.21
$215.77
$213.59
$263.09
$260.43
$226.15
$223.87
$135.92
$134.55
$87.93
$87.03
$195.86
$193.88
$220.81
$218.58
$168.71
$166.99
$143.93
$142.47
$76.90
$76.13
$36.52
$36.16
$40.39
$39.97
$51.96
$51.43
$19.76
$19.56
$32.19
$31.88
$109.42
$108.33
$55.26
$54.69
$45.59
$45.13
$443.39
$438.91
$337.88
$334.45
$509.37
$504.23
$425.11
$420.82
$338.25
$334.85
$509.37
$504.23
$904.84
$895.70
Page 186 of 323
Notes
#
#
#
#
#
#
Procedure
Code
59120
59121
59130
59135
59136
59140
59150
59151
59160
59160
59200
59200
59300
59300
59320
59325
59350
59400
59409
59410
59412
59414
59425
59425
59426
59426
59430
59430
59510
59514
59515
59525
59610
1/2/2015
Modifier
Par Fee
$808.34
$809.01
$858.14
$847.46
$894.49
$407.81
$783.71
$761.18
$207.03
$176.64
$73.09
$45.92
$196.70
$152.00
$155.85
$247.72
$287.43
$2,131.17
$833.12
$1,063.09
$105.96
$93.57
$463.18
$364.86
$829.93
$643.29
$188.56
$142.79
$2,353.50
$935.68
$1,285.78
$495.59
$2,231.42
Nonpar Fee
$767.92
$768.56
$815.23
$805.09
$849.77
$387.42
$744.52
$723.12
$196.68
$167.81
$69.44
$43.62
$186.87
$144.40
$148.06
$235.33
$273.06
$2,024.61
$791.46
$1,009.94
$100.66
$88.89
$440.02
$346.62
$788.43
$611.13
$179.13
$135.65
$2,235.83
$888.90
$1,221.49
$470.81
$2,119.85
Limiting
Charge
$883.11
$883.84
$937.51
$925.85
$977.24
$445.53
$856.20
$831.59
$226.18
$192.98
$79.86
$50.16
$214.90
$166.06
$170.27
$270.63
$314.02
$2,328.30
$910.18
$1,161.43
$115.76
$102.22
$506.02
$398.61
$906.69
$702.80
$206.00
$156.00
$2,571.20
$1,022.24
$1,404.71
$541.43
$2,437.83
Charge**
Charge***
$874.28
$869.86
$875.00
$870.58
$928.14
$923.45
$916.60
$911.96
$967.46
$962.57
$441.08
$438.85
$847.63
$843.35
$823.27
$819.11
$223.92
$222.79
$191.05
$190.08
$79.06
$78.66
$49.66
$49.42
$212.75
$211.68
$164.40
$163.56
$168.57
$167.72
$267.93
$266.57
$310.88
$309.30
$2,305.01
$2,293.38
$901.08
$896.53
$1,149.82
$1,144.01
$114.60
$114.02
$101.20
$100.69
$500.96
$498.43
$394.62
$392.63
$897.63
$893.09
$695.77
$692.25
$203.94
$202.91
$154.43
$153.66
$2,545.49
$2,532.63
$1,012.01
$1,006.91
$1,390.67
$1,383.65
$536.02
$533.31
$2,413.45
$2,401.26
Arizona
EHR/eRx
Limiting
Charge**
$865.44
$866.17
$918.77
$907.34
$957.69
$436.62
$839.07
$814.96
$221.66
$189.12
$78.26
$49.16
$210.60
$162.74
$166.87
$265.21
$307.74
$2,281.74
$891.97
$1,138.20
$113.45
$100.18
$495.90
$390.64
$888.56
$688.75
$201.88
$152.88
$2,519.78
$1,001.79
$1,376.62
$530.60
$2,389.07
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$861.17
$852.46
$861.88
$853.17
$914.22
$904.99
$902.84
$893.73
$952.95
$943.32
$434.47
$430.07
$834.91
$826.49
$810.92
$802.73
$220.56
$218.34
$188.19
$186.28
$77.88
$77.08
$48.91
$48.43
$209.56
$207.44
$161.94
$160.30
$166.04
$164.36
$263.91
$261.23
$306.22
$303.13
$2,270.43
$2,247.51
$887.57
$878.60
$1,132.57
$1,121.12
$112.88
$111.75
$99.68
$98.67
$493.45
$488.46
$388.70
$384.78
$884.17
$875.23
$685.33
$678.42
$200.88
$198.86
$152.12
$150.59
$2,507.31
$2,481.98
$996.83
$986.76
$1,369.81
$1,355.97
$527.98
$522.64
$2,377.25
$2,353.23
Page 187 of 323
Notes
#
#
#
#
#
#
#
Procedure
Code
59612
59614
59618
59620
59622
59812
59812
59820
59820
59821
59821
59830
59840
59840
59841
59841
59850
59851
59852
59855
59856
59857
59866
59870
59871
60000
60000
60100
60100
60200
60210
60212
60220
1/2/2015
Modifier
Par Fee
$934.49
$1,162.98
$2,385.61
$967.79
$1,319.90
$322.77
$300.96
$385.17
$361.93
$387.77
$362.38
$443.89
$221.02
$212.08
$388.49
$367.04
$354.67
$404.68
$513.12
$421.94
$495.80
$527.70
$221.16
$479.01
$136.31
$161.85
$146.12
$115.10
$81.49
$671.87
$719.50
$1,027.28
$719.89
Nonpar Fee
$887.77
$1,104.83
$2,266.33
$919.40
$1,253.91
$306.63
$285.91
$365.91
$343.83
$368.38
$344.26
$421.70
$209.97
$201.48
$369.07
$348.69
$336.94
$384.45
$487.46
$400.84
$471.01
$501.32
$210.10
$455.06
$129.49
$153.76
$138.81
$109.35
$77.42
$638.28
$683.53
$975.92
$683.90
Limiting
Charge
$1,020.94
$1,270.55
$2,606.28
$1,057.31
$1,442.00
$352.62
$328.80
$420.80
$395.40
$423.64
$395.90
$484.96
$241.47
$231.70
$424.43
$400.99
$387.48
$442.12
$560.58
$460.97
$541.66
$576.52
$241.62
$523.32
$148.91
$176.82
$159.63
$125.75
$89.03
$734.02
$786.06
$1,122.31
$786.49
Charge**
Charge***
$1,010.72
$1,005.62
$1,257.85
$1,251.50
$2,580.22
$2,567.19
$1,046.74
$1,041.45
$1,427.58
$1,420.37
$349.09
$347.33
$325.51
$323.86
$416.59
$414.48
$391.45
$389.47
$419.41
$417.28
$391.94
$389.97
$480.10
$477.68
$239.05
$237.84
$229.39
$228.23
$420.19
$418.06
$396.98
$394.98
$383.61
$381.67
$437.70
$435.48
$554.98
$552.17
$456.35
$454.05
$536.25
$533.53
$570.76
$567.87
$239.20
$237.99
$518.09
$515.46
$147.43
$146.68
$175.05
$174.17
$158.03
$157.24
$124.50
$123.87
$88.15
$87.70
$726.69
$723.02
$778.19
$774.27
$1,111.08
$1,105.47
$778.62
$774.69
Arizona
EHR/eRx
Limiting
Charge**
$1,000.51
$1,245.14
$2,554.15
$1,036.16
$1,413.15
$345.58
$322.22
$412.38
$387.49
$415.16
$387.98
$475.26
$236.64
$227.07
$415.94
$392.98
$379.73
$433.27
$549.37
$451.74
$530.83
$564.98
$236.79
$512.85
$145.94
$173.28
$156.43
$123.23
$87.25
$719.34
$770.34
$1,099.86
$770.75
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$995.57
$985.50
$1,238.98
$1,226.46
$2,541.51
$2,515.84
$1,031.04
$1,020.61
$1,406.16
$1,391.96
$343.86
$340.39
$320.62
$317.39
$410.34
$406.19
$385.57
$381.69
$413.11
$408.93
$386.07
$382.16
$472.90
$468.13
$235.46
$233.08
$225.95
$223.66
$413.89
$409.70
$391.02
$387.08
$377.86
$374.04
$431.14
$426.78
$546.65
$541.12
$449.51
$444.97
$528.21
$522.87
$562.20
$556.51
$235.61
$233.23
$510.31
$505.16
$145.22
$143.75
$172.43
$170.68
$155.66
$154.09
$122.64
$121.38
$86.83
$85.94
$715.78
$708.55
$766.52
$758.78
$1,094.42
$1,083.36
$766.94
$759.20
Page 188 of 323
Notes
#
Procedure
Code
60225
60240
60252
60254
60260
60270
60271
60280
60281
60300
60300
60500
60502
60505
60512
60520
60521
60522
60540
60545
60600
60605
60650
61000
61001
61020
61026
61050
61055
61070
61105
61107
61108
1/2/2015
Modifier
Par Fee
$949.54
$935.60
$1,343.83
$1,708.06
$1,113.06
$1,394.27
$1,076.95
$452.28
$600.32
$120.68
$51.32
$981.70
$1,310.23
$1,414.63
$248.74
$1,064.52
$1,146.34
$1,388.69
$1,075.83
$1,238.25
$1,427.69
$2,037.31
$1,211.66
$109.64
$83.58
$107.48
$105.68
$87.52
$124.23
$58.96
$479.55
$325.38
$941.01
Nonpar Fee
$902.06
$888.82
$1,276.64
$1,622.66
$1,057.41
$1,324.56
$1,023.10
$429.67
$570.30
$114.65
$48.75
$932.62
$1,244.72
$1,343.90
$236.30
$1,011.29
$1,089.02
$1,319.26
$1,022.04
$1,176.34
$1,356.31
$1,935.44
$1,151.08
$104.16
$79.40
$102.11
$100.40
$83.14
$118.02
$56.01
$455.57
$309.11
$893.96
Limiting
Charge
$1,037.37
$1,022.14
$1,468.14
$1,866.06
$1,216.02
$1,523.24
$1,176.57
$494.12
$655.85
$131.85
$56.06
$1,072.51
$1,431.43
$1,545.49
$271.75
$1,162.98
$1,252.37
$1,517.15
$1,175.35
$1,352.79
$1,559.76
$2,225.76
$1,323.74
$119.78
$91.31
$117.43
$115.46
$95.61
$135.72
$64.41
$523.91
$355.48
$1,028.05
Charge**
Charge***
$1,027.00
$1,021.81
$1,011.92
$1,006.81
$1,453.45
$1,446.11
$1,847.39
$1,838.07
$1,203.87
$1,197.78
$1,508.01
$1,500.39
$1,164.80
$1,158.91
$489.18
$486.70
$649.29
$646.01
$130.53
$129.87
$55.50
$55.22
$1,061.78
$1,056.42
$1,417.11
$1,409.96
$1,530.03
$1,522.30
$269.03
$267.67
$1,151.36
$1,145.54
$1,239.85
$1,233.58
$1,501.98
$1,494.39
$1,163.59
$1,157.72
$1,339.27
$1,332.49
$1,544.16
$1,536.37
$2,203.50
$2,192.37
$1,310.51
$1,303.88
$118.59
$117.99
$90.40
$89.94
$116.25
$115.67
$114.31
$113.72
$94.66
$94.17
$134.37
$133.69
$63.77
$63.45
$518.66
$516.05
$351.92
$350.14
$1,017.77
$1,012.63
Arizona
EHR/eRx
Limiting
Charge**
$1,016.62
$1,001.70
$1,438.78
$1,828.74
$1,191.70
$1,492.78
$1,153.04
$484.24
$642.72
$129.21
$54.95
$1,051.07
$1,402.80
$1,514.57
$266.31
$1,139.72
$1,227.33
$1,486.80
$1,151.84
$1,325.73
$1,528.56
$2,181.24
$1,297.27
$117.39
$89.48
$115.08
$113.15
$93.70
$133.01
$63.12
$513.43
$348.37
$1,007.49
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$1,011.59
$1,001.37
$996.74
$986.67
$1,431.65
$1,417.19
$1,819.68
$1,801.31
$1,185.81
$1,173.83
$1,485.39
$1,470.39
$1,147.33
$1,135.74
$481.84
$476.97
$639.55
$633.09
$128.57
$127.27
$54.67
$54.12
$1,045.86
$1,035.30
$1,395.86
$1,381.76
$1,507.08
$1,491.85
$264.99
$262.32
$1,134.08
$1,122.62
$1,221.25
$1,208.91
$1,479.45
$1,464.50
$1,146.14
$1,134.57
$1,319.18
$1,305.85
$1,521.00
$1,505.63
$2,170.45
$2,148.52
$1,290.85
$1,277.81
$116.81
$115.63
$89.04
$88.14
$114.51
$113.36
$112.60
$111.45
$93.24
$92.30
$132.35
$131.02
$62.81
$62.18
$510.88
$505.72
$346.64
$343.15
$1,002.50
$992.38
Page 189 of 323
Notes
Procedure
Code
61120
61140
61150
61151
61154
61156
61210
61215
61250
61253
61304
61305
61312
61313
61314
61315
61316
61320
61321
61322
61323
61330
61332
61333
61340
61343
61345
61450
61458
61460
61480
61500
61501
1/2/2015
Modifier
Par Fee
$773.53
$1,301.40
$1,403.86
$1,029.70
$1,309.84
$1,290.39
$382.57
$519.78
$898.33
$954.62
$1,690.13
$2,082.43
$2,146.58
$2,045.46
$1,881.63
$2,134.81
$91.13
$1,955.86
$2,207.22
$2,453.03
$2,474.75
$1,578.34
$1,825.43
$1,865.65
$1,497.80
$2,266.04
$2,114.85
$1,993.68
$2,071.41
$2,181.25
$2,011.61
$1,356.67
$1,191.55
Nonpar Fee
$734.85
$1,236.33
$1,333.67
$978.22
$1,244.35
$1,225.87
$363.44
$493.79
$853.41
$906.89
$1,605.62
$1,978.31
$2,039.25
$1,943.19
$1,787.55
$2,028.07
$86.57
$1,858.07
$2,096.86
$2,330.38
$2,351.01
$1,499.42
$1,734.16
$1,772.37
$1,422.91
$2,152.74
$2,009.11
$1,894.00
$1,967.84
$2,072.19
$1,911.03
$1,288.84
$1,131.97
Limiting
Charge
$845.08
$1,421.78
$1,533.72
$1,124.95
$1,431.00
$1,409.75
$417.96
$567.86
$981.42
$1,042.92
$1,846.46
$2,275.06
$2,345.14
$2,234.67
$2,055.68
$2,332.28
$99.56
$2,136.78
$2,411.39
$2,679.94
$2,703.66
$1,724.33
$1,994.28
$2,038.23
$1,636.35
$2,475.65
$2,310.48
$2,178.10
$2,263.02
$2,383.02
$2,197.68
$1,482.17
$1,301.77
Charge**
Charge***
$836.63
$832.40
$1,407.57
$1,400.46
$1,518.38
$1,510.71
$1,113.71
$1,108.08
$1,416.70
$1,409.53
$1,395.65
$1,388.60
$413.78
$411.69
$562.18
$559.34
$971.61
$966.70
$1,032.49
$1,027.28
$1,827.99
$1,818.77
$2,252.31
$2,240.94
$2,321.69
$2,309.96
$2,212.32
$2,201.15
$2,035.12
$2,024.85
$2,308.96
$2,297.30
$98.56
$98.06
$2,115.41
$2,104.73
$2,387.27
$2,375.22
$2,653.14
$2,639.73
$2,676.63
$2,663.10
$1,707.09
$1,698.47
$1,974.34
$1,964.37
$2,017.85
$2,007.65
$1,619.98
$1,611.81
$2,450.89
$2,438.52
$2,287.37
$2,275.82
$2,156.32
$2,145.43
$2,240.38
$2,229.07
$2,359.19
$2,347.28
$2,175.71
$2,164.71
$1,467.34
$1,459.94
$1,288.75
$1,282.24
Arizona
EHR/eRx
Limiting
Charge**
$828.17
$1,393.34
$1,503.05
$1,102.46
$1,402.38
$1,381.55
$409.60
$556.50
$961.79
$1,022.06
$1,809.54
$2,229.55
$2,298.24
$2,189.98
$2,014.57
$2,285.64
$97.57
$2,094.05
$2,363.16
$2,626.34
$2,649.59
$1,689.84
$1,954.40
$1,997.46
$1,603.62
$2,426.14
$2,264.27
$2,134.54
$2,217.75
$2,335.36
$2,153.73
$1,452.52
$1,275.73
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$824.08
$815.75
$1,386.45
$1,372.44
$1,495.61
$1,480.51
$1,097.00
$1,085.92
$1,395.44
$1,381.35
$1,374.72
$1,360.83
$407.57
$403.45
$553.75
$548.15
$957.04
$947.36
$1,017.00
$1,006.73
$1,800.58
$1,782.40
$2,218.52
$2,196.11
$2,286.87
$2,263.76
$2,179.14
$2,157.14
$2,004.59
$1,984.35
$2,274.32
$2,251.36
$97.07
$96.11
$2,083.69
$2,062.64
$2,351.46
$2,327.72
$2,613.34
$2,586.94
$2,636.48
$2,609.84
$1,681.48
$1,664.50
$1,944.73
$1,925.09
$1,987.58
$1,967.50
$1,595.68
$1,579.56
$2,414.13
$2,389.75
$2,253.06
$2,230.31
$2,123.97
$2,102.52
$2,206.78
$2,184.48
$2,323.81
$2,300.33
$2,143.07
$2,121.43
$1,445.33
$1,430.73
$1,269.42
$1,256.59
Page 190 of 323
Notes
Procedure
Code
61510
61512
61514
61516
61517
61518
61519
61520
61521
61522
61524
61526
61530
61531
61533
61534
61535
61536
61537
61538
61539
61540
61541
61543
61544
61545
61546
61548
61550
61552
61556
61557
61558
1/2/2015
Modifier
Par Fee
$2,254.17
$2,628.75
$1,970.05
$1,920.72
$91.08
$2,841.75
$3,041.06
$3,874.22
$3,263.27
$2,267.10
$2,158.00
$3,785.67
$3,191.07
$1,265.24
$1,574.22
$1,704.33
$1,034.61
$2,674.18
$2,536.08
$2,768.18
$2,447.57
$2,262.72
$2,227.48
$2,251.81
$1,971.46
$3,301.04
$2,392.57
$1,618.31
$995.64
$1,143.63
$1,765.55
$1,740.98
$1,718.83
Nonpar Fee
$2,141.46
$2,497.31
$1,871.55
$1,824.68
$86.53
$2,699.66
$2,889.01
$3,680.51
$3,100.11
$2,153.75
$2,050.10
$3,596.39
$3,031.52
$1,201.98
$1,495.51
$1,619.11
$982.88
$2,540.47
$2,409.28
$2,629.77
$2,325.19
$2,149.58
$2,116.11
$2,139.22
$1,872.89
$3,135.99
$2,272.94
$1,537.39
$945.86
$1,086.45
$1,677.27
$1,653.93
$1,632.89
Limiting
Charge
$2,462.68
$2,871.91
$2,152.28
$2,098.38
$99.51
$3,104.61
$3,322.36
$4,232.59
$3,565.13
$2,476.81
$2,357.62
$4,135.85
$3,486.25
$1,382.28
$1,719.84
$1,861.98
$1,130.31
$2,921.54
$2,770.67
$3,024.24
$2,673.97
$2,472.02
$2,433.53
$2,460.10
$2,153.82
$3,606.39
$2,613.88
$1,768.00
$1,087.74
$1,249.42
$1,928.86
$1,902.02
$1,877.82
Charge**
Charge***
$2,438.06
$2,425.74
$2,843.19
$2,828.83
$2,130.75
$2,120.00
$2,077.39
$2,066.91
$98.51
$98.01
$3,073.56
$3,058.05
$3,289.14
$3,272.52
$4,190.26
$4,169.10
$3,529.48
$3,511.65
$2,452.04
$2,439.66
$2,334.04
$2,322.25
$4,094.49
$4,073.81
$3,451.38
$3,433.96
$1,368.45
$1,361.54
$1,702.63
$1,694.04
$1,843.36
$1,834.04
$1,119.01
$1,113.36
$2,892.33
$2,877.71
$2,742.97
$2,729.11
$2,993.99
$2,978.87
$2,647.23
$2,633.86
$2,447.29
$2,434.94
$2,409.19
$2,397.03
$2,435.50
$2,423.20
$2,132.28
$2,121.52
$3,570.32
$3,552.29
$2,587.74
$2,574.68
$1,750.32
$1,741.48
$1,076.86
$1,071.42
$1,236.93
$1,230.67
$1,909.58
$1,899.93
$1,883.00
$1,873.49
$1,859.04
$1,849.66
Arizona
EHR/eRx
Limiting
Charge**
$2,413.42
$2,814.46
$2,109.24
$2,056.42
$97.52
$3,042.52
$3,255.91
$4,147.94
$3,493.83
$2,427.28
$2,310.47
$4,053.13
$3,416.52
$1,354.63
$1,685.44
$1,824.74
$1,107.70
$2,863.11
$2,715.25
$2,963.75
$2,620.49
$2,422.58
$2,384.86
$2,410.91
$2,110.74
$3,534.26
$2,561.60
$1,732.64
$1,065.98
$1,224.43
$1,890.28
$1,863.98
$1,840.26
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$2,401.49
$2,377.22
$2,800.54
$2,772.25
$2,098.80
$2,077.60
$2,046.23
$2,025.58
$97.04
$96.06
$3,027.46
$2,996.88
$3,239.80
$3,207.07
$4,127.40
$4,085.72
$3,476.53
$3,441.42
$2,415.26
$2,390.87
$2,299.03
$2,275.80
$4,033.07
$3,992.33
$3,399.61
$3,365.28
$1,347.93
$1,334.31
$1,677.09
$1,660.16
$1,815.71
$1,797.37
$1,102.22
$1,091.09
$2,848.94
$2,820.17
$2,701.82
$2,674.52
$2,949.08
$2,919.29
$2,607.52
$2,581.19
$2,410.58
$2,386.24
$2,373.06
$2,349.08
$2,398.97
$2,374.74
$2,100.30
$2,079.09
$3,516.77
$3,481.25
$2,548.93
$2,523.18
$1,724.07
$1,706.65
$1,060.70
$1,050.00
$1,218.38
$1,206.06
$1,880.93
$1,861.92
$1,854.75
$1,836.02
$1,831.16
$1,812.66
Page 191 of 323
Notes
Procedure
Code
61559
61563
61564
61566
61567
61570
61571
61575
61576
61580
61581
61582
61583
61584
61585
61586
61590
61591
61592
61595
61596
61597
61598
61600
61601
61605
61606
61607
61608
61610
61611
61612
61613
1/2/2015
Modifier
Par Fee
$2,477.73
$2,051.98
$2,494.24
$2,330.77
$2,427.76
$1,935.50
$2,060.97
$2,597.67
$3,499.71
$2,560.47
$2,701.72
$3,106.28
$2,980.99
$2,939.86
$3,325.06
$2,493.61
$3,112.66
$3,188.70
$3,279.26
$2,421.95
$2,504.18
$2,978.32
$2,935.60
$2,181.62
$2,479.30
$2,225.67
$3,135.81
$2,750.23
$3,360.32
$1,928.49
$382.48
$1,434.93
$3,401.21
Nonpar Fee
$2,353.84
$1,949.38
$2,369.53
$2,214.23
$2,306.37
$1,838.73
$1,957.92
$2,467.79
$3,324.72
$2,432.45
$2,566.63
$2,950.97
$2,831.94
$2,792.87
$3,158.81
$2,368.93
$2,957.03
$3,029.27
$3,115.30
$2,300.85
$2,378.97
$2,829.40
$2,788.82
$2,072.54
$2,355.34
$2,114.39
$2,979.02
$2,612.72
$3,192.30
$1,832.07
$363.36
$1,363.18
$3,231.15
Limiting
Charge
$2,706.92
$2,241.79
$2,724.96
$2,546.36
$2,652.33
$2,114.54
$2,251.61
$2,837.96
$3,823.43
$2,797.32
$2,951.62
$3,393.62
$3,256.73
$3,211.80
$3,632.63
$2,724.27
$3,400.58
$3,483.66
$3,582.60
$2,645.98
$2,735.82
$3,253.81
$3,207.14
$2,383.42
$2,708.64
$2,431.55
$3,425.87
$3,004.63
$3,671.15
$2,106.88
$417.86
$1,567.66
$3,715.82
Charge**
Charge***
$2,679.85
$2,666.31
$2,219.37
$2,208.16
$2,697.70
$2,684.09
$2,520.90
$2,508.17
$2,625.81
$2,612.54
$2,093.39
$2,082.82
$2,229.09
$2,217.83
$2,809.58
$2,795.39
$3,785.19
$3,766.08
$2,769.35
$2,755.35
$2,922.10
$2,907.35
$3,359.68
$3,342.72
$3,224.16
$3,207.88
$3,179.68
$3,163.63
$3,596.30
$3,578.14
$2,697.03
$2,683.41
$3,366.58
$3,349.57
$3,448.83
$3,431.40
$3,546.77
$3,528.86
$2,619.52
$2,606.29
$2,708.46
$2,694.78
$3,221.28
$3,205.00
$3,175.07
$3,159.04
$2,359.58
$2,347.67
$2,681.56
$2,668.01
$2,407.24
$2,395.07
$3,391.61
$3,374.48
$2,974.58
$2,959.56
$3,634.44
$3,616.08
$2,085.81
$2,075.28
$413.69
$411.60
$1,551.98
$1,544.14
$3,678.67
$3,660.08
Arizona
EHR/eRx
Limiting
Charge**
$2,652.77
$2,196.95
$2,670.46
$2,495.44
$2,599.28
$2,072.25
$2,206.57
$2,781.19
$3,746.96
$2,741.37
$2,892.60
$3,325.74
$3,191.60
$3,147.56
$3,559.97
$2,669.78
$3,332.57
$3,413.98
$3,510.94
$2,593.05
$2,681.10
$3,188.73
$3,143.00
$2,335.75
$2,654.46
$2,382.92
$3,357.36
$2,944.54
$3,597.72
$2,064.74
$409.50
$1,536.31
$3,641.51
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$2,639.65
$2,612.98
$2,186.08
$2,163.99
$2,657.24
$2,630.41
$2,483.09
$2,458.01
$2,586.42
$2,560.29
$2,061.98
$2,041.17
$2,195.65
$2,173.48
$2,767.43
$2,739.47
$3,728.42
$3,690.76
$2,727.81
$2,700.25
$2,878.28
$2,849.21
$3,309.29
$3,275.86
$3,175.81
$3,143.72
$3,131.99
$3,100.34
$3,542.36
$3,506.58
$2,656.57
$2,629.74
$3,316.08
$3,282.58
$3,397.10
$3,362.77
$3,493.57
$3,458.28
$2,580.22
$2,554.16
$2,667.83
$2,640.88
$3,172.95
$3,140.90
$3,127.45
$3,095.85
$2,324.18
$2,300.71
$2,641.33
$2,614.65
$2,371.13
$2,347.17
$3,340.74
$3,307.00
$2,929.96
$2,900.37
$3,579.92
$3,543.75
$2,054.52
$2,033.78
$407.48
$403.36
$1,528.71
$1,513.26
$3,623.49
$3,586.88
Page 192 of 323
Notes
Procedure
Code
61615
61616
61618
61619
61623
61624
61626
61630
61635
61680
61682
61684
61686
61690
61692
61697
61698
61700
61702
61703
61705
61708
61710
61711
61720
61735
61750
61751
61760
61770
61781
61782
61783
1/2/2015
Modifier
Par Fee
$2,782.59
$3,417.61
$1,332.87
$1,479.61
$576.72
$1,167.77
$884.40
$1,351.76
$1,430.53
$2,321.70
$4,314.40
$2,949.56
$4,670.34
$2,266.07
$3,798.33
$4,364.58
$4,810.78
$3,521.86
$4,178.84
$1,407.61
$2,699.49
$2,639.75
$2,230.76
$2,677.72
$1,315.78
$1,647.64
$1,449.96
$1,424.46
$1,638.25
$1,683.24
$244.00
$180.15
$241.00
Nonpar Fee
$2,643.46
$3,246.73
$1,266.23
$1,405.63
$547.88
$1,109.38
$840.18
$1,284.17
$1,359.00
$2,205.62
$4,098.68
$2,802.08
$4,436.82
$2,152.77
$3,608.41
$4,146.35
$4,570.24
$3,345.77
$3,969.90
$1,337.23
$2,564.52
$2,507.76
$2,119.22
$2,543.83
$1,249.99
$1,565.26
$1,377.46
$1,353.24
$1,556.34
$1,599.08
$231.80
$171.14
$228.95
Limiting
Charge
$3,039.98
$3,733.74
$1,456.16
$1,616.47
$630.06
$1,275.79
$966.21
$1,476.80
$1,562.85
$2,536.46
$4,713.48
$3,222.39
$5,102.34
$2,475.69
$4,149.67
$4,768.30
$5,255.78
$3,847.64
$4,565.39
$1,537.81
$2,949.20
$2,883.92
$2,437.10
$2,925.40
$1,437.49
$1,800.05
$1,584.08
$1,556.23
$1,789.79
$1,838.94
$266.57
$196.81
$263.29
Charge**
Charge***
$3,009.58
$2,994.38
$3,696.40
$3,677.73
$1,441.61
$1,434.33
$1,600.31
$1,592.23
$623.76
$620.61
$1,263.03
$1,256.65
$956.55
$951.72
$1,462.03
$1,454.65
$1,547.22
$1,539.41
$2,511.09
$2,498.42
$4,666.34
$4,642.78
$3,190.17
$3,174.06
$5,051.32
$5,025.81
$2,450.93
$2,438.55
$4,108.18
$4,087.42
$4,720.62
$4,696.77
$5,203.22
$5,176.94
$3,809.16
$3,789.92
$4,519.73
$4,496.90
$1,522.44
$1,514.75
$2,919.70
$2,904.96
$2,855.08
$2,840.66
$2,412.73
$2,400.54
$2,896.15
$2,881.52
$1,423.11
$1,415.93
$1,782.05
$1,773.05
$1,568.24
$1,560.32
$1,540.67
$1,532.88
$1,771.90
$1,762.94
$1,820.55
$1,811.35
$263.90
$262.57
$194.84
$193.86
$260.66
$259.35
Arizona
EHR/eRx
Limiting
Charge**
$2,979.18
$3,659.07
$1,427.05
$1,584.15
$617.46
$1,250.27
$946.89
$1,447.26
$1,531.59
$2,485.74
$4,619.22
$3,157.95
$5,000.29
$2,426.17
$4,066.68
$4,672.93
$5,150.67
$3,770.68
$4,474.08
$1,507.06
$2,890.21
$2,826.24
$2,388.37
$2,866.89
$1,408.74
$1,764.04
$1,552.40
$1,525.11
$1,753.99
$1,802.17
$261.23
$192.88
$258.03
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$2,964.44
$2,934.49
$3,640.96
$3,604.18
$1,419.99
$1,405.65
$1,576.31
$1,560.39
$614.40
$608.20
$1,244.09
$1,231.51
$942.20
$932.68
$1,440.10
$1,425.55
$1,524.01
$1,508.62
$2,473.43
$2,448.45
$4,596.34
$4,549.93
$3,142.32
$3,110.58
$4,975.54
$4,925.29
$2,414.16
$2,389.77
$4,046.56
$4,005.68
$4,649.82
$4,602.84
$5,125.17
$5,073.41
$3,752.02
$3,714.12
$4,451.94
$4,406.96
$1,499.60
$1,484.45
$2,875.91
$2,846.86
$2,812.26
$2,783.85
$2,376.54
$2,352.54
$2,852.70
$2,823.89
$1,401.77
$1,387.61
$1,755.33
$1,737.58
$1,544.71
$1,529.11
$1,517.55
$1,502.23
$1,745.32
$1,727.68
$1,793.24
$1,775.13
$259.95
$257.31
$191.92
$189.98
$256.75
$254.15
Page 193 of 323
Notes
Procedure
Code
61790
61791
61796
61797
61798
61799
61800
61850
61860
61863
61864
61867
61868
61870
61880
61885
61886
61888
62000
62005
62010
62100
62115
62117
62120
62121
62140
62141
62142
62143
62145
62146
62147
1/2/2015
Modifier
Par Fee
$907.00
$1,164.11
$1,048.61
$229.43
$1,430.82
$316.08
$160.29
$1,016.74
$1,622.02
$1,555.15
$296.19
$2,353.37
$517.83
$1,225.64
$586.13
$529.69
$870.25
$406.28
$1,066.41
$1,316.49
$1,586.82
$1,652.36
$1,408.98
$2,033.93
$1,701.38
$1,653.12
$1,065.47
$1,177.97
$912.26
$1,076.09
$1,456.19
$1,269.28
$1,510.33
Nonpar Fee
$861.65
$1,105.90
$996.18
$217.96
$1,359.28
$300.28
$152.28
$965.90
$1,540.92
$1,477.39
$281.38
$2,235.70
$491.94
$1,164.36
$556.82
$503.21
$826.74
$385.97
$1,013.09
$1,250.67
$1,507.48
$1,569.74
$1,338.53
$1,932.23
$1,616.31
$1,570.46
$1,012.20
$1,119.07
$866.65
$1,022.29
$1,383.38
$1,205.82
$1,434.81
Limiting
Charge
$990.90
$1,271.79
$1,145.61
$250.65
$1,563.17
$345.32
$175.12
$1,110.79
$1,772.06
$1,699.00
$323.59
$2,571.06
$565.73
$1,339.01
$640.34
$578.69
$950.75
$443.87
$1,165.05
$1,438.27
$1,733.60
$1,805.20
$1,539.31
$2,222.06
$1,858.76
$1,806.03
$1,164.03
$1,286.93
$996.65
$1,175.63
$1,590.89
$1,386.69
$1,650.03
Charge**
Charge***
$980.98
$976.04
$1,259.07
$1,252.71
$1,134.15
$1,128.43
$248.15
$246.89
$1,547.54
$1,539.72
$341.87
$340.15
$173.37
$172.50
$1,099.68
$1,094.12
$1,754.34
$1,745.48
$1,682.01
$1,673.51
$320.36
$318.73
$2,545.34
$2,532.48
$560.07
$557.24
$1,325.63
$1,318.92
$633.94
$630.74
$572.91
$570.01
$941.24
$936.49
$439.43
$437.21
$1,153.40
$1,147.57
$1,423.88
$1,416.70
$1,716.27
$1,707.60
$1,787.15
$1,778.12
$1,523.91
$1,516.22
$2,199.85
$2,188.74
$1,840.17
$1,830.88
$1,787.97
$1,778.94
$1,152.39
$1,146.57
$1,274.06
$1,267.62
$986.68
$981.70
$1,163.88
$1,158.00
$1,574.98
$1,567.02
$1,372.82
$1,365.89
$1,633.53
$1,625.28
Arizona
EHR/eRx
Limiting
Charge**
$971.08
$1,246.35
$1,122.70
$245.64
$1,531.90
$338.41
$171.61
$1,088.57
$1,736.62
$1,665.02
$317.11
$2,519.64
$554.42
$1,312.23
$627.53
$567.12
$931.74
$434.99
$1,141.75
$1,409.51
$1,698.93
$1,769.10
$1,508.52
$2,177.63
$1,821.58
$1,769.91
$1,140.75
$1,261.19
$976.72
$1,152.12
$1,559.07
$1,358.96
$1,617.03
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$966.26
$956.51
$1,240.18
$1,227.65
$1,117.14
$1,105.86
$244.42
$241.96
$1,524.33
$1,508.93
$336.74
$333.34
$170.78
$169.04
$1,083.19
$1,072.24
$1,728.02
$1,710.57
$1,656.78
$1,640.04
$315.55
$312.35
$2,507.16
$2,481.85
$551.67
$546.10
$1,305.74
$1,292.54
$624.43
$618.11
$564.32
$558.61
$927.12
$917.77
$432.84
$428.47
$1,136.11
$1,124.63
$1,402.53
$1,388.37
$1,690.52
$1,673.45
$1,760.34
$1,742.56
$1,501.05
$1,485.89
$2,166.85
$2,144.97
$1,812.57
$1,794.25
$1,761.16
$1,743.35
$1,135.11
$1,123.64
$1,254.95
$1,242.28
$971.88
$962.07
$1,146.42
$1,134.83
$1,551.36
$1,535.68
$1,352.23
$1,338.57
$1,609.02
$1,592.77
Page 194 of 323
Notes
#
#
#
#
Procedure
Code
62148
62160
62161
62162
62163
62164
62165
62180
62190
62192
62194
62200
62201
62220
62223
62225
62230
62252
62252
62252
62256
62258
62263
62263
62264
62264
62267
62267
62268
62269
62270
62270
62272
1/2/2015
Modifier
TC
26
Par Fee
$131.77
$197.82
$1,573.95
$1,957.90
$1,268.15
$2,164.60
$1,587.85
$1,658.68
$602.13
$1,008.13
$503.25
$1,426.00
$1,243.95
$1,057.32
$1,080.59
$542.00
$869.43
$86.77
$39.64
$47.13
$619.67
$1,158.05
$642.14
$341.08
$424.93
$242.93
$253.93
$164.90
$269.62
$276.73
$162.12
$80.24
$204.23
Nonpar Fee
$125.18
$187.93
$1,495.25
$1,860.01
$1,204.74
$2,056.37
$1,508.46
$1,575.75
$572.02
$957.72
$478.09
$1,354.70
$1,181.75
$1,004.45
$1,026.56
$514.90
$825.96
$82.43
$37.66
$44.77
$588.69
$1,100.15
$610.03
$324.03
$403.68
$230.78
$241.23
$156.66
$256.14
$262.89
$154.01
$76.23
$194.02
Limiting
Charge
$143.96
$216.12
$1,719.54
$2,139.01
$1,385.45
$2,364.83
$1,734.73
$1,812.11
$657.82
$1,101.38
$549.80
$1,557.91
$1,359.01
$1,155.12
$1,180.54
$592.14
$949.85
$94.79
$43.31
$51.49
$676.99
$1,265.17
$701.53
$372.63
$464.23
$265.40
$277.41
$180.16
$294.56
$302.32
$177.11
$87.66
$223.12
Charge**
Charge***
$142.52
$141.80
$213.96
$212.88
$1,702.35
$1,693.74
$2,117.62
$2,106.93
$1,371.59
$1,364.67
$2,341.18
$2,329.35
$1,717.39
$1,708.70
$1,793.99
$1,784.93
$651.25
$647.96
$1,090.36
$1,084.85
$544.31
$541.56
$1,542.32
$1,534.54
$1,345.42
$1,338.62
$1,143.57
$1,137.79
$1,168.73
$1,162.83
$586.21
$583.26
$940.36
$935.61
$93.85
$93.37
$42.87
$42.67
$50.97
$50.72
$670.22
$666.84
$1,252.52
$1,246.20
$694.52
$691.01
$368.91
$367.05
$459.59
$457.26
$262.74
$261.42
$274.64
$273.25
$178.35
$177.46
$291.62
$290.15
$299.30
$297.79
$175.34
$174.46
$86.79
$86.35
$220.89
$219.78
Arizona
EHR/eRx
Limiting
Charge**
$141.08
$211.80
$1,685.15
$2,096.23
$1,357.75
$2,317.53
$1,700.03
$1,775.88
$644.67
$1,079.36
$538.81
$1,526.75
$1,331.84
$1,132.01
$1,156.93
$580.29
$930.86
$92.90
$42.45
$50.45
$663.46
$1,239.87
$687.50
$365.18
$454.95
$260.08
$271.87
$176.56
$288.67
$296.27
$173.57
$85.92
$218.66
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$140.38
$138.97
$210.75
$208.62
$1,676.82
$1,659.88
$2,085.86
$2,064.79
$1,351.02
$1,337.38
$2,306.06
$2,282.76
$1,691.63
$1,674.54
$1,767.08
$1,749.24
$641.48
$635.00
$1,074.01
$1,063.16
$536.14
$530.73
$1,519.18
$1,503.86
$1,325.24
$1,311.86
$1,126.41
$1,115.03
$1,151.21
$1,139.58
$577.42
$571.58
$926.24
$916.90
$92.45
$91.51
$42.23
$41.81
$50.21
$49.69
$660.17
$653.51
$1,233.73
$1,221.28
$684.10
$677.19
$363.38
$359.71
$452.70
$448.13
$258.80
$256.19
$270.53
$267.79
$175.67
$173.91
$287.25
$284.34
$294.81
$291.84
$172.71
$170.97
$85.49
$84.63
$217.58
$215.38
Page 195 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
62272
62273
62273
62280
62280
62281
62281
62282
62282
62284
62284
62287
62290
62290
62291
62291
62292
62294
62302
62302
62303
62303
62304
62304
62305
62305
62310
62310
62311
62311
62318
62318
62319
1/2/2015
Modifier
Par Fee
$85.88
$175.79
$116.44
$303.89
$161.59
$236.68
$156.58
$298.71
$149.61
$185.49
$88.60
$584.94
$339.11
$176.43
$342.46
$176.20
$596.85
$810.69
$247.31
$127.89
$256.96
$129.67
$244.09
$125.74
$266.57
$131.78
$243.50
$111.21
$224.28
$91.63
$232.42
$101.55
$169.85
Nonpar Fee
$81.59
$167.00
$110.62
$288.70
$153.51
$224.85
$148.75
$283.77
$142.13
$176.22
$84.17
$555.69
$322.15
$167.61
$325.34
$167.39
$567.01
$770.16
$234.94
$121.50
$244.11
$123.19
$231.89
$119.45
$253.24
$125.19
$231.33
$105.65
$213.07
$87.05
$220.80
$96.47
$161.36
Limiting
Charge
$93.83
$192.05
$127.21
$332.01
$176.54
$258.58
$171.06
$326.34
$163.45
$202.65
$96.80
$639.04
$370.47
$192.75
$374.14
$192.50
$652.06
$885.68
$270.18
$139.73
$280.73
$141.67
$266.67
$137.37
$291.23
$143.97
$266.03
$121.50
$245.03
$100.11
$253.92
$110.94
$185.56
Charge**
Charge***
$92.89
$92.43
$190.13
$189.18
$125.94
$125.30
$328.68
$327.03
$174.77
$173.89
$255.99
$254.70
$169.35
$168.50
$323.07
$321.44
$161.82
$161.00
$200.63
$199.62
$95.83
$95.35
$632.65
$629.45
$366.77
$364.92
$190.82
$189.87
$370.40
$368.53
$190.58
$189.61
$645.54
$642.28
$876.83
$872.40
$267.48
$266.13
$138.33
$137.63
$277.92
$276.52
$140.25
$139.54
$264.01
$262.67
$136.00
$135.31
$288.32
$286.86
$142.53
$141.81
$263.37
$262.04
$120.28
$119.68
$242.58
$241.35
$99.11
$98.60
$251.38
$250.11
$109.84
$109.27
$183.71
$182.78
Arizona
EHR/eRx
Limiting
Charge**
$91.95
$188.21
$124.67
$325.37
$173.01
$253.40
$167.65
$319.80
$160.18
$198.61
$94.86
$626.27
$363.07
$188.90
$366.65
$188.65
$639.02
$867.97
$264.78
$136.93
$275.11
$138.84
$261.34
$134.62
$285.41
$141.09
$260.71
$119.07
$240.13
$98.11
$248.84
$108.72
$181.85
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$91.49
$90.57
$187.28
$185.39
$124.05
$122.80
$323.75
$320.49
$172.14
$170.41
$252.15
$249.60
$166.81
$165.13
$318.23
$315.01
$159.39
$157.78
$197.62
$195.63
$94.39
$93.44
$623.16
$616.87
$361.27
$357.62
$187.96
$186.07
$364.85
$361.16
$187.71
$185.82
$635.86
$629.43
$863.67
$854.96
$263.47
$260.81
$136.26
$134.87
$273.75
$270.99
$138.15
$136.76
$260.05
$257.42
$133.96
$132.60
$283.99
$281.13
$140.39
$138.98
$259.42
$256.80
$118.47
$117.29
$238.95
$236.53
$97.62
$96.63
$247.61
$245.10
$108.19
$107.09
$180.95
$179.12
Page 196 of 323
Notes
#
#
#
#
#
Procedure
Code
62319
62350
62351
62355
62360
62361
62362
62365
62367
62367
62368
62368
62369
62369
62370
62370
63001
63003
63005
63011
63012
63015
63016
63017
63020
63030
63035
63040
63042
63045
63046
63047
63048
1/2/2015
Modifier
Par Fee
$97.98
$410.05
$883.80
$276.53
$311.49
$441.46
$395.67
$305.01
$41.30
$25.57
$57.30
$35.85
$122.37
$36.21
$129.04
$47.87
$1,277.18
$1,272.74
$1,213.48
$1,129.78
$1,220.31
$1,526.66
$1,562.01
$1,287.85
$1,196.70
$993.21
$197.43
$1,429.94
$1,328.41
$1,308.86
$1,239.08
$1,131.67
$218.32
Nonpar Fee
$93.08
$389.55
$839.61
$262.70
$295.92
$419.39
$375.89
$289.76
$39.24
$24.29
$54.44
$34.06
$116.25
$34.40
$122.59
$45.48
$1,213.32
$1,209.10
$1,152.81
$1,073.29
$1,159.29
$1,450.33
$1,483.91
$1,223.46
$1,136.87
$943.55
$187.56
$1,358.44
$1,261.99
$1,243.42
$1,177.13
$1,075.09
$207.40
Limiting
Charge
$107.04
$447.98
$965.55
$302.11
$340.31
$482.30
$432.27
$333.22
$45.13
$27.93
$62.61
$39.17
$133.69
$39.56
$140.98
$52.30
$1,395.32
$1,390.47
$1,325.73
$1,234.28
$1,333.18
$1,667.88
$1,706.50
$1,406.98
$1,307.40
$1,085.08
$215.69
$1,562.21
$1,451.29
$1,429.93
$1,353.70
$1,236.35
$238.51
Charge**
Charge***
$105.97
$105.43
$443.50
$441.27
$955.89
$951.07
$299.08
$297.57
$336.90
$335.20
$477.48
$475.07
$427.95
$425.79
$329.89
$328.22
$44.68
$44.45
$27.66
$27.52
$61.99
$61.66
$38.78
$38.58
$132.35
$131.69
$39.17
$38.96
$139.56
$138.86
$51.78
$51.52
$1,381.37
$1,374.39
$1,376.56
$1,369.60
$1,312.47
$1,305.85
$1,221.94
$1,215.77
$1,319.86
$1,313.19
$1,651.20
$1,642.87
$1,689.43
$1,680.90
$1,392.91
$1,385.88
$1,294.33
$1,287.79
$1,074.23
$1,068.81
$213.53
$212.46
$1,546.59
$1,538.77
$1,436.78
$1,429.52
$1,415.64
$1,408.49
$1,340.16
$1,333.39
$1,223.99
$1,217.80
$236.13
$234.93
Arizona
EHR/eRx
Limiting
Charge**
$104.90
$439.02
$946.24
$296.07
$333.50
$472.65
$423.63
$326.55
$44.23
$27.37
$61.35
$38.39
$131.02
$38.77
$138.16
$51.26
$1,367.41
$1,362.66
$1,299.21
$1,209.59
$1,306.52
$1,634.52
$1,672.36
$1,378.84
$1,281.25
$1,063.38
$211.38
$1,530.96
$1,422.26
$1,401.33
$1,326.63
$1,211.63
$233.74
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$104.39
$103.33
$436.85
$432.43
$941.55
$932.05
$294.60
$291.63
$331.86
$328.50
$470.32
$465.57
$421.53
$417.27
$324.94
$321.66
$44.01
$43.56
$27.24
$26.96
$61.05
$60.43
$38.19
$37.81
$130.36
$129.05
$38.58
$38.18
$137.47
$136.09
$51.00
$50.49
$1,360.65
$1,346.89
$1,355.91
$1,342.22
$1,292.78
$1,279.72
$1,203.61
$1,191.45
$1,300.05
$1,286.92
$1,626.43
$1,610.00
$1,664.08
$1,647.28
$1,372.02
$1,358.16
$1,274.91
$1,262.03
$1,058.12
$1,047.43
$210.32
$208.21
$1,523.39
$1,508.00
$1,415.22
$1,400.93
$1,394.41
$1,380.31
$1,320.06
$1,306.73
$1,205.63
$1,193.46
$232.59
$230.23
Page 197 of 323
Notes
Procedure
Code
63050
63051
63055
63056
63057
63064
63066
63075
63076
63077
63078
63081
63082
63085
63086
63087
63088
63090
63091
63101
63102
63103
63170
63172
63173
63180
63182
63185
63190
63191
63194
63195
63196
1/2/2015
Modifier
Par Fee
$1,525.68
$1,756.74
$1,677.07
$1,522.12
$329.37
$1,819.70
$214.54
$1,389.48
$254.18
$1,540.84
$195.76
$1,803.03
$274.56
$1,963.85
$196.32
$2,472.85
$269.69
$1,999.03
$182.13
$2,385.87
$2,335.80
$303.26
$1,650.40
$1,469.10
$1,788.39
$1,539.87
$1,690.02
$1,172.11
$1,291.70
$1,427.46
$1,654.91
$1,196.91
$1,390.98
Nonpar Fee
$1,449.40
$1,668.90
$1,593.22
$1,446.01
$312.90
$1,728.72
$203.81
$1,320.01
$241.47
$1,463.80
$185.97
$1,712.88
$260.83
$1,865.66
$186.50
$2,349.21
$256.21
$1,899.08
$173.02
$2,266.58
$2,219.01
$288.10
$1,567.88
$1,395.65
$1,698.97
$1,462.88
$1,605.52
$1,113.50
$1,227.12
$1,356.09
$1,572.16
$1,137.06
$1,321.43
Limiting
Charge
$1,666.81
$1,919.24
$1,832.20
$1,662.91
$359.84
$1,988.03
$234.38
$1,518.01
$277.69
$1,683.37
$213.87
$1,969.81
$299.95
$2,145.51
$214.48
$2,701.59
$294.64
$2,183.94
$198.97
$2,606.57
$2,551.86
$331.32
$1,803.06
$1,605.00
$1,953.82
$1,682.31
$1,846.35
$1,280.53
$1,411.19
$1,559.50
$1,807.98
$1,307.62
$1,519.64
Charge**
Charge***
$1,650.15
$1,641.81
$1,900.04
$1,890.45
$1,813.88
$1,804.72
$1,646.28
$1,637.97
$356.24
$354.44
$1,968.14
$1,958.21
$232.04
$230.86
$1,502.83
$1,495.24
$274.92
$273.53
$1,666.53
$1,658.12
$211.73
$210.66
$1,950.11
$1,940.27
$296.95
$295.46
$2,124.05
$2,113.33
$212.34
$211.26
$2,674.58
$2,661.07
$291.70
$290.23
$2,162.10
$2,151.18
$196.98
$195.98
$2,580.50
$2,567.47
$2,526.34
$2,513.58
$328.00
$326.35
$1,785.03
$1,776.01
$1,588.94
$1,580.93
$1,934.28
$1,924.51
$1,665.49
$1,657.08
$1,827.88
$1,818.66
$1,267.73
$1,261.32
$1,397.08
$1,390.02
$1,543.91
$1,536.11
$1,789.91
$1,780.87
$1,294.54
$1,288.00
$1,504.45
$1,496.85
Arizona
EHR/eRx
Limiting
Charge**
$1,633.47
$1,880.85
$1,795.56
$1,629.65
$352.64
$1,948.27
$229.69
$1,487.65
$272.14
$1,649.70
$209.59
$1,930.41
$293.95
$2,102.60
$210.19
$2,647.56
$288.75
$2,140.27
$194.99
$2,554.44
$2,500.82
$324.69
$1,767.00
$1,572.90
$1,914.74
$1,648.66
$1,809.42
$1,254.91
$1,382.97
$1,528.32
$1,771.83
$1,281.47
$1,489.25
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$1,625.40
$1,608.97
$1,871.54
$1,852.64
$1,786.67
$1,768.63
$1,621.59
$1,605.20
$350.89
$347.35
$1,938.62
$1,919.05
$228.55
$226.24
$1,480.29
$1,465.34
$270.79
$268.05
$1,641.53
$1,624.95
$208.55
$206.45
$1,920.86
$1,901.46
$292.50
$289.55
$2,092.20
$2,071.06
$209.15
$207.03
$2,634.45
$2,607.86
$287.33
$284.42
$2,129.67
$2,108.16
$194.03
$192.07
$2,541.79
$2,516.12
$2,488.45
$2,463.31
$323.08
$319.82
$1,758.26
$1,740.49
$1,565.10
$1,549.30
$1,905.26
$1,886.02
$1,640.51
$1,623.94
$1,800.46
$1,782.28
$1,248.70
$1,236.09
$1,376.12
$1,362.22
$1,520.75
$1,505.40
$1,763.05
$1,745.25
$1,275.12
$1,262.25
$1,481.89
$1,466.92
Page 198 of 323
Notes
Procedure
Code
63197
63198
63199
63200
63250
63251
63252
63265
63266
63267
63268
63270
63271
63272
63273
63275
63276
63277
63278
63280
63281
63282
63283
63285
63286
63287
63290
63295
63300
63301
63302
63303
63304
1/2/2015
Modifier
Par Fee
$1,773.10
$1,638.43
$1,718.84
$1,578.74
$3,079.11
$3,147.38
$3,147.02
$1,716.65
$1,769.99
$1,408.24
$1,490.42
$2,152.05
$2,139.05
$1,945.17
$1,933.04
$1,858.18
$1,841.27
$1,597.05
$1,645.93
$2,189.54
$2,158.09
$2,031.00
$1,968.31
$2,712.85
$2,682.58
$2,847.03
$2,895.73
$346.89
$1,892.76
$2,230.59
$2,258.19
$2,399.90
$2,436.51
Nonpar Fee
$1,684.45
$1,556.51
$1,632.90
$1,499.80
$2,925.15
$2,990.01
$2,989.67
$1,630.82
$1,681.49
$1,337.83
$1,415.90
$2,044.45
$2,032.10
$1,847.91
$1,836.39
$1,765.27
$1,749.21
$1,517.20
$1,563.63
$2,080.06
$2,050.19
$1,929.45
$1,869.89
$2,577.21
$2,548.45
$2,704.68
$2,750.94
$329.55
$1,798.12
$2,119.06
$2,145.28
$2,279.91
$2,314.68
Limiting
Charge
$1,937.12
$1,789.99
$1,877.84
$1,724.77
$3,363.92
$3,438.51
$3,438.12
$1,875.44
$1,933.71
$1,538.50
$1,628.29
$2,351.12
$2,336.92
$2,125.10
$2,111.85
$2,030.06
$2,011.59
$1,744.78
$1,798.17
$2,392.07
$2,357.72
$2,218.87
$2,150.37
$2,963.79
$2,930.72
$3,110.38
$3,163.58
$378.98
$2,067.84
$2,436.92
$2,467.07
$2,621.90
$2,661.88
Charge**
Charge***
$1,917.75
$1,908.06
$1,772.08
$1,763.13
$1,859.06
$1,849.67
$1,707.52
$1,698.90
$3,330.29
$3,313.46
$3,404.13
$3,386.93
$3,403.74
$3,386.54
$1,856.69
$1,847.31
$1,914.38
$1,904.71
$1,523.12
$1,515.42
$1,612.00
$1,603.86
$2,327.61
$2,315.85
$2,313.55
$2,301.86
$2,103.84
$2,093.22
$2,090.73
$2,080.17
$2,009.76
$1,999.61
$1,991.48
$1,981.42
$1,727.33
$1,718.61
$1,780.19
$1,771.21
$2,368.15
$2,356.19
$2,334.14
$2,322.36
$2,196.68
$2,185.59
$2,128.87
$2,118.12
$2,934.16
$2,919.33
$2,901.42
$2,886.75
$3,079.27
$3,063.73
$3,131.94
$3,116.13
$375.19
$373.30
$2,047.16
$2,036.82
$2,412.55
$2,400.36
$2,442.40
$2,430.07
$2,595.68
$2,582.57
$2,635.26
$2,621.95
Arizona
EHR/eRx
Limiting
Charge**
$1,898.37
$1,754.19
$1,840.28
$1,690.27
$3,296.65
$3,369.74
$3,369.36
$1,837.93
$1,895.04
$1,507.73
$1,595.72
$2,304.09
$2,290.18
$2,082.59
$2,069.61
$1,989.45
$1,971.36
$1,709.89
$1,762.21
$2,344.23
$2,310.57
$2,174.49
$2,107.36
$2,904.52
$2,872.10
$3,048.18
$3,100.31
$371.40
$2,026.48
$2,388.18
$2,417.73
$2,569.46
$2,608.65
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$1,888.99
$1,869.90
$1,745.50
$1,727.88
$1,831.17
$1,812.68
$1,681.91
$1,664.91
$3,280.33
$3,247.20
$3,353.07
$3,319.20
$3,352.68
$3,318.82
$1,828.83
$1,810.36
$1,885.67
$1,866.61
$1,500.27
$1,485.11
$1,587.82
$1,571.79
$2,292.70
$2,269.54
$2,278.84
$2,255.83
$2,072.29
$2,051.36
$2,059.37
$2,038.57
$1,979.62
$1,959.61
$1,961.60
$1,941.80
$1,701.43
$1,684.24
$1,753.49
$1,735.78
$2,332.63
$2,309.06
$2,299.13
$2,275.91
$2,163.74
$2,141.88
$2,096.93
$2,075.75
$2,890.15
$2,860.95
$2,857.90
$2,829.02
$3,033.09
$3,002.45
$3,084.97
$3,053.80
$369.56
$365.84
$2,016.46
$1,996.09
$2,376.36
$2,352.36
$2,405.77
$2,381.45
$2,556.74
$2,530.92
$2,595.73
$2,569.51
Page 199 of 323
Notes
#
#
#
#
Procedure
Code
63305
63306
63307
63308
63600
63610
63615
63620
63621
63650
63650
63655
63661
63661
63662
63663
63663
63664
63685
63688
63700
63702
63704
63706
63707
63709
63710
63740
63741
63744
63746
64400
64400
1/2/2015
Modifier
Par Fee
$2,593.60
$2,040.53
$2,249.63
$333.95
$930.31
$399.16
$1,102.35
$1,151.23
$262.29
$1,346.75
$422.13
$848.46
$587.68
$328.46
$859.55
$799.27
$461.75
$879.57
$375.33
$378.90
$1,195.27
$1,445.80
$1,521.07
$1,725.77
$941.35
$1,128.55
$1,108.87
$986.99
$698.12
$697.82
$620.48
$128.82
$71.97
Nonpar Fee
$2,463.92
$1,938.50
$2,137.15
$317.25
$883.79
$379.20
$1,047.23
$1,093.67
$249.18
$1,279.41
$401.02
$806.04
$558.30
$312.04
$816.57
$759.31
$438.66
$835.59
$356.56
$359.96
$1,135.51
$1,373.51
$1,445.02
$1,639.48
$894.28
$1,072.12
$1,053.43
$937.64
$663.21
$662.93
$589.46
$122.38
$68.37
Limiting
Charge
$2,833.51
$2,229.28
$2,457.72
$364.84
$1,016.36
$436.08
$1,204.31
$1,257.72
$286.56
$1,471.32
$461.17
$926.95
$642.05
$358.85
$939.06
$873.21
$504.46
$960.93
$410.04
$413.95
$1,305.84
$1,579.54
$1,661.77
$1,885.40
$1,028.42
$1,232.94
$1,211.44
$1,078.29
$762.69
$762.37
$677.88
$140.74
$78.63
Charge**
Charge***
$2,805.17
$2,791.00
$2,206.99
$2,195.83
$2,433.15
$2,420.85
$361.19
$359.36
$1,006.19
$1,001.11
$431.72
$429.54
$1,192.27
$1,186.25
$1,245.14
$1,238.85
$283.69
$282.26
$1,456.61
$1,449.25
$456.56
$454.25
$917.68
$913.04
$635.63
$632.42
$355.26
$353.46
$929.66
$924.97
$864.48
$860.11
$499.41
$496.89
$951.31
$946.52
$405.94
$403.89
$409.81
$407.74
$1,292.77
$1,286.25
$1,563.74
$1,555.85
$1,645.16
$1,636.84
$1,866.55
$1,857.12
$1,018.14
$1,013.00
$1,220.61
$1,214.45
$1,199.34
$1,193.27
$1,067.50
$1,062.12
$755.07
$751.25
$754.75
$750.94
$671.11
$667.71
$139.33
$138.62
$77.84
$77.44
Arizona
EHR/eRx
Limiting
Charge**
$2,776.84
$2,184.69
$2,408.57
$357.55
$996.03
$427.36
$1,180.23
$1,232.57
$280.83
$1,441.89
$451.95
$908.41
$629.20
$351.67
$920.28
$855.74
$494.37
$941.71
$401.84
$405.67
$1,279.72
$1,547.95
$1,628.54
$1,847.69
$1,007.85
$1,208.28
$1,187.21
$1,056.72
$747.44
$747.12
$664.32
$137.92
$77.05
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$2,763.09
$2,735.18
$2,173.88
$2,151.91
$2,396.65
$2,372.44
$355.78
$352.19
$991.10
$981.09
$425.25
$420.96
$1,174.39
$1,162.54
$1,226.46
$1,214.08
$279.44
$276.62
$1,434.76
$1,420.26
$449.71
$445.18
$903.91
$894.78
$626.09
$619.76
$349.93
$346.39
$915.71
$906.48
$851.51
$842.90
$491.92
$486.96
$937.04
$927.59
$399.86
$395.82
$403.66
$399.59
$1,273.38
$1,260.53
$1,540.28
$1,524.73
$1,620.48
$1,604.11
$1,838.55
$1,819.98
$1,002.87
$992.73
$1,202.30
$1,190.16
$1,181.35
$1,169.40
$1,051.49
$1,040.88
$743.74
$736.23
$743.43
$735.91
$661.04
$654.35
$137.24
$135.85
$76.67
$75.90
Page 200 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
64402
64402
64405
64405
64408
64408
64410
64410
64412
64412
64413
64413
64415
64415
64416
64417
64417
64418
64418
64420
64420
64421
64421
64425
64425
64430
64430
64435
64435
64445
64445
64446
64447
1/2/2015
Modifier
Par Fee
$131.46
$79.26
$102.14
$64.24
$118.09
$87.70
$121.80
$69.95
$144.10
$73.31
$130.61
$83.77
$118.89
$65.98
$80.50
$130.69
$71.70
$148.44
$78.36
$113.93
$69.24
$151.66
$93.38
$132.97
$94.72
$141.60
$84.75
$136.86
$85.02
$136.59
$73.31
$80.86
$120.68
Nonpar Fee
$124.89
$75.30
$97.03
$61.03
$112.19
$83.32
$115.71
$66.45
$136.90
$69.64
$124.08
$79.58
$112.95
$62.68
$76.48
$124.16
$68.12
$141.02
$74.44
$108.23
$65.78
$144.08
$88.71
$126.32
$89.98
$134.52
$80.51
$130.02
$80.77
$129.76
$69.64
$76.82
$114.65
Limiting
Charge
$143.62
$86.60
$111.58
$70.18
$129.02
$95.82
$133.07
$76.42
$157.44
$80.09
$142.69
$91.52
$129.89
$72.08
$87.95
$142.78
$78.34
$162.17
$85.61
$124.46
$75.65
$165.69
$102.02
$145.27
$103.48
$154.70
$92.59
$149.52
$92.89
$149.22
$80.09
$88.34
$131.85
Charge**
Charge***
$142.19
$141.47
$85.73
$85.30
$110.47
$109.91
$69.48
$69.13
$127.73
$127.09
$94.86
$94.38
$131.73
$131.07
$75.66
$75.27
$155.86
$155.08
$79.28
$78.89
$141.27
$140.55
$90.60
$90.15
$128.59
$127.95
$71.36
$71.00
$87.08
$86.63
$141.36
$140.65
$77.56
$77.17
$160.55
$159.74
$84.76
$84.32
$123.22
$122.60
$74.89
$74.51
$164.04
$163.21
$100.99
$100.49
$143.82
$143.09
$102.44
$101.92
$153.15
$152.38
$91.66
$91.20
$148.03
$147.28
$91.95
$91.49
$147.73
$146.98
$79.28
$78.89
$87.46
$87.02
$130.53
$129.87
Arizona
EHR/eRx
Limiting
Charge**
$140.75
$84.86
$109.35
$68.78
$126.44
$93.90
$130.41
$74.89
$154.28
$78.49
$139.84
$89.69
$127.29
$70.64
$86.19
$139.93
$76.77
$158.93
$83.89
$121.98
$74.13
$162.38
$99.98
$142.36
$101.41
$151.60
$90.74
$146.53
$91.02
$146.23
$78.49
$86.57
$129.21
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$140.06
$138.63
$84.44
$83.58
$108.81
$107.71
$68.44
$67.75
$125.81
$124.55
$93.44
$92.49
$129.75
$128.46
$74.52
$73.76
$153.53
$151.97
$78.10
$77.31
$139.15
$137.75
$89.24
$88.34
$126.66
$125.38
$70.29
$69.59
$85.77
$84.90
$139.24
$137.83
$76.39
$75.62
$158.15
$156.55
$83.48
$82.64
$121.37
$120.15
$73.76
$73.01
$161.58
$159.94
$99.48
$98.49
$141.66
$140.22
$100.90
$99.89
$150.85
$149.33
$90.28
$89.38
$145.81
$144.34
$90.57
$89.65
$145.51
$144.04
$78.10
$77.31
$86.15
$85.27
$128.57
$127.27
Page 201 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
64447
64448
64449
64450
64450
64455
64455
64479
64479
64480
64480
64483
64483
64484
64484
64486
64486
64487
64487
64488
64488
64489
64489
64490
64490
64491
64491
64492
64492
64493
64493
64494
64494
1/2/2015
Modifier
Par Fee
$67.05
$72.05
$85.06
$81.21
$46.53
$48.05
$35.18
$238.63
$135.66
$114.29
$64.59
$221.69
$115.50
$88.36
$52.97
$125.77
$64.28
$153.62
$73.89
$154.65
$80.64
$214.94
$90.51
$192.69
$109.38
$95.38
$61.77
$95.74
$62.49
$174.58
$93.42
$87.92
$53.24
Nonpar Fee
$63.70
$68.45
$80.81
$77.15
$44.20
$45.65
$33.42
$226.70
$128.88
$108.58
$61.36
$210.61
$109.73
$83.94
$50.32
$119.48
$61.07
$145.94
$70.20
$146.92
$76.61
$204.19
$85.98
$183.06
$103.91
$90.61
$58.68
$90.95
$59.37
$165.85
$88.75
$83.52
$50.58
Limiting
Charge
$73.26
$78.72
$92.93
$88.72
$50.83
$52.50
$38.43
$260.71
$148.21
$124.87
$70.56
$242.20
$126.19
$96.53
$57.87
$137.40
$70.23
$167.83
$80.73
$168.96
$88.10
$234.82
$98.88
$210.52
$119.50
$104.20
$67.48
$104.59
$68.28
$190.73
$102.06
$96.05
$58.17
Charge**
Charge***
$72.52
$72.15
$77.94
$77.53
$92.00
$91.54
$87.84
$87.39
$50.32
$50.07
$51.97
$51.72
$38.05
$37.86
$258.09
$256.80
$146.73
$145.99
$123.61
$122.99
$69.86
$69.51
$239.78
$238.57
$124.92
$124.29
$95.57
$95.08
$57.29
$57.01
$136.03
$135.34
$69.53
$69.17
$166.15
$165.31
$79.93
$79.52
$167.27
$166.43
$87.22
$86.78
$232.47
$231.30
$97.89
$97.39
$208.41
$207.36
$118.30
$117.70
$103.16
$102.64
$66.80
$66.47
$103.55
$103.03
$67.60
$67.25
$188.82
$187.86
$101.04
$100.53
$95.08
$94.61
$57.58
$57.29
Arizona
EHR/eRx
Limiting
Charge**
$71.79
$77.14
$91.07
$86.95
$49.82
$51.45
$37.66
$255.50
$145.25
$122.37
$69.15
$237.36
$123.67
$94.60
$56.71
$134.65
$68.83
$164.47
$79.12
$165.58
$86.34
$230.13
$96.90
$206.31
$117.10
$102.12
$66.14
$102.50
$66.91
$186.91
$100.03
$94.13
$57.01
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$71.43
$70.71
$76.76
$75.98
$90.62
$89.70
$86.51
$85.65
$49.57
$49.07
$51.19
$50.68
$37.48
$37.10
$254.22
$251.67
$144.53
$143.07
$121.76
$120.53
$68.82
$68.11
$236.18
$233.80
$123.05
$121.82
$94.13
$93.18
$56.43
$55.86
$134.00
$132.63
$68.48
$67.79
$163.66
$162.00
$78.73
$77.94
$164.76
$163.09
$85.91
$85.04
$228.99
$226.68
$96.42
$95.45
$205.29
$203.22
$116.53
$115.35
$101.60
$100.59
$65.80
$65.15
$101.99
$100.96
$66.59
$65.91
$185.99
$184.10
$99.52
$98.53
$93.66
$92.71
$56.72
$56.15
Page 202 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
64495
64495
64505
64505
64508
64508
64510
64510
64517
64517
64520
64520
64530
64530
64550
64550
64553
64553
64555
64555
64561
64561
64565
64565
64566
64566
64568
64569
64570
64575
64580
64581
64585
1/2/2015
Modifier
Par Fee
$88.28
$53.95
$105.89
$88.37
$63.17
$74.26
$128.99
$75.36
$183.03
$125.11
$188.26
$82.78
$193.17
$94.49
$16.05
$8.89
$216.91
$163.64
$214.59
$157.38
$826.74
$308.30
$192.06
$135.21
$122.73
$30.84
$676.96
$805.68
$684.33
$324.85
$305.68
$675.42
$248.38
Nonpar Fee
$83.87
$51.25
$100.60
$83.95
$60.01
$70.55
$122.54
$71.59
$173.88
$118.85
$178.85
$78.64
$183.51
$89.77
$15.25
$8.45
$206.06
$155.46
$203.86
$149.51
$785.40
$292.89
$182.46
$128.45
$116.59
$29.30
$643.11
$765.40
$650.11
$308.61
$290.40
$641.65
$235.96
Limiting
Charge
$96.45
$58.94
$115.69
$96.54
$69.01
$81.13
$140.92
$82.33
$199.96
$136.68
$205.68
$90.44
$211.04
$103.24
$17.54
$9.72
$236.97
$178.78
$234.44
$171.94
$903.21
$336.82
$209.83
$147.72
$134.08
$33.70
$739.58
$880.21
$747.63
$354.90
$333.96
$737.90
$271.35
Charge**
Charge***
$95.48
$95.00
$58.35
$58.05
$114.53
$113.95
$95.58
$95.09
$68.32
$67.98
$80.32
$79.91
$139.51
$138.81
$81.50
$81.10
$197.96
$196.96
$135.31
$134.63
$203.62
$202.60
$89.53
$89.08
$208.92
$207.87
$102.20
$101.68
$17.37
$17.27
$9.63
$9.57
$234.60
$233.42
$177.00
$176.10
$232.09
$230.92
$170.21
$169.36
$894.18
$889.66
$333.45
$331.78
$207.74
$206.68
$146.25
$145.50
$132.73
$132.07
$33.36
$33.19
$732.18
$728.48
$871.41
$867.01
$740.15
$736.41
$351.35
$349.58
$330.63
$328.95
$730.51
$726.83
$268.64
$267.28
Arizona
EHR/eRx
Limiting
Charge**
$94.52
$57.76
$113.38
$94.61
$67.63
$79.51
$138.10
$80.68
$195.96
$133.94
$201.56
$88.63
$206.82
$101.17
$17.19
$9.52
$232.23
$175.20
$229.75
$168.50
$885.14
$330.08
$205.63
$144.76
$131.40
$33.02
$724.79
$862.60
$732.68
$347.81
$327.28
$723.14
$265.93
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$94.05
$93.10
$57.48
$56.90
$112.82
$111.68
$94.14
$93.20
$67.30
$66.62
$79.11
$78.32
$137.41
$136.03
$80.28
$79.48
$194.99
$193.02
$133.29
$131.93
$200.56
$198.54
$88.18
$87.30
$205.78
$203.71
$100.67
$99.65
$17.10
$16.94
$9.48
$9.38
$231.08
$228.75
$174.34
$172.57
$228.61
$226.30
$167.66
$165.97
$880.77
$871.86
$328.45
$325.13
$204.62
$202.55
$144.05
$142.59
$130.74
$129.43
$32.86
$32.52
$721.20
$713.92
$858.34
$849.67
$729.05
$721.68
$346.08
$342.59
$325.67
$322.37
$719.56
$712.30
$264.62
$261.94
Page 203 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
64585
64590
64590
64595
64595
64600
64600
64605
64605
64610
64610
64611
64611
64612
64612
64615
64615
64616
64616
64617
64617
64620
64620
64630
64630
64632
64632
64633
64633
64634
64634
64635
64635
1/2/2015
Modifier
Par Fee
$146.48
$268.18
$164.14
$248.87
$129.09
$387.36
$222.89
$592.98
$360.57
$735.96
$495.69
$118.02
$103.36
$132.40
$118.82
$147.54
$127.51
$125.45
$109.36
$192.52
$117.07
$208.82
$176.29
$236.15
$196.82
$86.85
$70.40
$422.33
$232.11
$188.70
$69.64
$418.75
$229.25
Nonpar Fee
$139.16
$254.77
$155.93
$236.43
$122.64
$367.99
$211.75
$563.33
$342.54
$699.16
$470.91
$112.12
$98.19
$125.78
$112.88
$140.16
$121.13
$119.18
$103.89
$182.89
$111.22
$198.38
$167.48
$224.34
$186.98
$82.51
$66.88
$401.21
$220.50
$179.27
$66.16
$397.81
$217.79
Limiting
Charge
$160.03
$292.99
$179.32
$271.89
$141.04
$423.19
$243.51
$647.83
$393.92
$804.03
$541.55
$128.94
$112.92
$144.65
$129.81
$161.18
$139.30
$137.06
$119.47
$210.32
$127.90
$228.14
$192.60
$257.99
$215.03
$94.89
$76.91
$461.39
$253.58
$206.16
$76.08
$457.48
$250.46
Charge**
Charge***
$158.44
$157.63
$290.05
$288.59
$177.53
$176.63
$269.18
$267.81
$139.62
$138.92
$418.96
$416.84
$241.07
$239.86
$641.36
$638.11
$389.98
$388.01
$796.00
$791.97
$536.13
$533.43
$127.65
$127.01
$111.79
$111.23
$143.20
$142.47
$128.51
$127.87
$159.57
$158.77
$137.91
$137.21
$135.69
$135.00
$118.28
$117.68
$208.22
$207.17
$126.63
$125.98
$225.86
$224.71
$190.68
$189.72
$255.42
$254.12
$212.88
$211.81
$93.93
$93.46
$76.14
$75.76
$456.78
$454.47
$251.05
$249.77
$204.10
$203.07
$75.33
$74.95
$452.90
$450.62
$247.95
$246.70
Arizona
EHR/eRx
Limiting
Charge**
$156.84
$287.12
$175.73
$266.46
$138.22
$414.72
$238.65
$634.87
$386.04
$787.96
$530.71
$126.36
$110.66
$141.75
$127.21
$157.96
$136.52
$134.32
$117.08
$206.11
$125.35
$223.57
$188.75
$252.83
$210.73
$92.99
$75.37
$452.17
$248.50
$202.03
$74.57
$448.33
$245.44
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$156.06
$154.48
$285.71
$282.81
$174.86
$173.10
$265.14
$262.45
$137.53
$136.15
$412.68
$408.50
$237.46
$235.07
$631.73
$625.35
$384.12
$380.25
$784.06
$776.14
$528.09
$522.76
$125.74
$124.46
$110.11
$109.01
$141.05
$139.62
$126.58
$125.30
$157.18
$155.60
$135.84
$134.47
$133.65
$132.31
$116.51
$115.32
$205.09
$203.02
$124.73
$123.48
$222.47
$220.21
$187.82
$185.92
$251.59
$249.03
$209.68
$207.56
$92.52
$91.60
$75.00
$74.24
$449.93
$445.38
$247.28
$244.78
$201.04
$199.00
$74.20
$73.45
$446.11
$441.60
$244.24
$241.76
Page 204 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
64636
64636
64640
64640
64642
64642
64643
64643
64644
64644
64645
64645
64646
64646
64647
64647
64650
64650
64653
64653
64680
64680
64681
64681
64702
64704
64708
64712
64713
64714
64716
64718
64719
1/2/2015
Modifier
Par Fee
$172.66
$61.46
$135.07
$95.03
$142.78
$110.24
$94.50
$74.84
$164.32
$121.06
$115.11
$84.72
$155.03
$119.99
$179.08
$138.67
$78.85
$42.38
$95.84
$54.36
$318.01
$172.13
$409.86
$235.73
$507.57
$322.10
$507.36
$581.39
$733.79
$659.60
$543.91
$601.32
$405.80
Nonpar Fee
$164.03
$58.39
$128.32
$90.28
$135.64
$104.73
$89.78
$71.10
$156.10
$115.01
$109.35
$80.48
$147.28
$113.99
$170.13
$131.74
$74.91
$40.26
$91.05
$51.64
$302.11
$163.52
$389.37
$223.94
$482.19
$306.00
$481.99
$552.32
$697.10
$626.62
$516.71
$571.25
$385.51
Limiting
Charge
$188.63
$67.15
$147.57
$103.82
$155.99
$120.44
$103.25
$81.77
$179.52
$132.26
$125.75
$92.55
$169.37
$131.09
$195.65
$151.50
$86.15
$46.30
$104.71
$59.39
$347.43
$188.05
$447.78
$257.53
$554.52
$351.90
$554.29
$635.17
$801.67
$720.61
$594.22
$656.94
$443.34
Charge**
Charge***
$186.75
$185.81
$66.48
$66.14
$146.10
$145.36
$102.79
$102.27
$154.42
$153.65
$119.23
$118.63
$102.21
$101.69
$80.95
$80.53
$177.72
$176.82
$130.94
$130.27
$124.50
$123.87
$91.63
$91.16
$167.68
$166.83
$129.78
$129.12
$193.69
$192.72
$149.98
$149.22
$85.28
$84.86
$45.84
$45.61
$103.66
$103.13
$58.79
$58.50
$343.95
$342.22
$186.16
$185.23
$443.30
$441.06
$254.96
$253.67
$548.98
$546.20
$348.38
$346.62
$548.75
$545.97
$628.82
$625.65
$793.65
$789.64
$713.40
$709.80
$588.27
$585.30
$650.37
$647.08
$438.90
$436.69
Arizona
EHR/eRx
Limiting
Charge**
$184.86
$65.80
$144.61
$101.74
$152.87
$118.04
$101.18
$80.13
$175.93
$129.62
$123.23
$90.70
$165.98
$128.47
$191.74
$148.48
$84.42
$45.37
$102.61
$58.20
$340.48
$184.29
$438.82
$252.38
$543.43
$344.86
$543.20
$622.46
$785.63
$706.20
$582.34
$643.80
$434.47
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$183.94
$182.09
$65.48
$64.81
$143.90
$142.44
$101.25
$100.21
$152.11
$150.58
$117.44
$116.27
$100.68
$99.66
$79.73
$78.92
$175.05
$173.29
$128.97
$127.67
$122.64
$121.38
$90.25
$89.34
$165.16
$163.50
$127.83
$126.53
$190.79
$188.86
$147.73
$146.25
$84.01
$83.16
$45.15
$44.69
$102.11
$101.07
$57.90
$57.33
$338.79
$335.37
$183.37
$181.53
$436.66
$432.24
$251.13
$248.60
$540.74
$535.28
$343.16
$339.69
$540.51
$535.05
$619.39
$613.12
$781.75
$773.85
$702.70
$695.61
$579.45
$573.60
$640.62
$634.14
$432.32
$427.95
Page 205 of 323
Notes
#
Procedure
Code
64721
64721
64722
64726
64727
64732
64734
64736
64738
64740
64742
64744
64746
64755
64760
64763
64766
64771
64772
64774
64776
64778
64782
64783
64784
64786
64787
64788
64790
64792
64795
64802
64804
1/2/2015
Modifier
Par Fee
$436.33
$433.11
$377.59
$281.02
$188.34
$386.48
$514.10
$405.57
$469.04
$465.06
$465.78
$508.74
$440.07
$934.84
$522.24
$517.23
$579.36
$606.85
$578.68
$423.37
$395.50
$145.58
$458.62
$224.58
$741.28
$1,103.77
$250.20
$415.51
$856.82
$1,101.31
$195.68
$681.10
$952.96
Nonpar Fee
$414.51
$411.45
$358.71
$266.97
$178.92
$367.16
$488.40
$385.29
$445.59
$441.81
$442.49
$483.30
$418.07
$888.10
$496.13
$491.37
$550.39
$576.51
$549.75
$402.20
$375.73
$138.30
$435.69
$213.35
$704.22
$1,048.58
$237.69
$394.73
$813.98
$1,046.24
$185.90
$647.05
$905.31
Limiting
Charge
$476.69
$473.17
$412.52
$307.02
$205.76
$422.23
$561.66
$443.08
$512.43
$508.08
$508.86
$555.80
$480.78
$1,021.32
$570.55
$565.08
$632.95
$662.99
$632.21
$462.53
$432.09
$159.05
$501.04
$245.35
$809.85
$1,205.87
$273.34
$453.94
$936.08
$1,203.18
$213.79
$744.11
$1,041.11
Charge**
Charge***
$471.91
$469.53
$468.44
$466.07
$408.39
$406.33
$303.95
$302.42
$203.70
$202.68
$418.01
$415.90
$556.05
$553.23
$438.66
$436.44
$507.30
$504.75
$503.00
$500.46
$503.78
$501.23
$550.24
$547.46
$475.97
$473.57
$1,011.10
$1,006.00
$564.85
$561.99
$559.43
$556.60
$626.62
$623.45
$656.35
$653.04
$625.89
$622.73
$457.91
$455.60
$427.77
$425.60
$157.46
$156.66
$496.03
$493.52
$242.90
$241.67
$801.76
$797.71
$1,193.80
$1,187.78
$270.61
$269.24
$449.40
$447.13
$926.72
$922.04
$1,191.15
$1,185.13
$211.65
$210.58
$736.67
$732.94
$1,030.70
$1,025.49
Arizona
EHR/eRx
Limiting
Charge**
$467.15
$463.70
$404.27
$300.87
$201.64
$413.79
$550.42
$434.22
$502.18
$497.92
$498.69
$544.67
$471.17
$1,000.89
$559.14
$553.77
$620.29
$649.73
$619.57
$453.28
$423.45
$155.86
$491.03
$240.44
$793.66
$1,181.75
$267.88
$444.87
$917.36
$1,179.12
$209.51
$729.23
$1,020.28
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$464.83
$460.15
$461.41
$456.75
$402.26
$398.21
$299.39
$296.37
$200.64
$198.62
$411.75
$407.58
$547.71
$542.17
$432.08
$427.71
$499.69
$494.65
$495.45
$490.45
$496.23
$491.21
$541.98
$536.51
$468.83
$464.09
$995.93
$985.87
$556.37
$550.76
$551.03
$545.47
$617.23
$610.98
$646.51
$639.99
$616.50
$610.28
$451.04
$446.49
$421.35
$417.11
$155.10
$153.53
$488.59
$483.67
$239.26
$236.83
$789.73
$781.76
$1,175.90
$1,164.03
$266.55
$263.87
$442.66
$438.20
$912.81
$903.59
$1,173.28
$1,161.43
$208.47
$206.37
$725.62
$718.29
$1,015.24
$1,004.97
Page 206 of 323
Notes
Procedure
Code
64809
64818
64820
64821
64822
64823
64831
64832
64834
64835
64836
64837
64840
64856
64857
64858
64859
64861
64862
64864
64865
64866
64868
64872
64874
64876
64885
64886
64890
64891
64892
64893
64895
1/2/2015
Modifier
Par Fee
$1,123.60
$564.94
$740.51
$699.02
$699.02
$802.95
$696.44
$344.61
$750.31
$831.20
$834.75
$387.61
$986.86
$1,031.15
$1,069.19
$1,202.79
$258.42
$1,292.78
$1,178.09
$888.74
$1,133.06
$1,175.08
$1,037.31
$120.75
$168.53
$173.83
$1,142.41
$1,324.48
$1,114.31
$1,187.09
$1,072.79
$1,157.09
$1,376.49
Nonpar Fee
$1,067.42
$536.69
$703.48
$664.07
$664.07
$762.80
$661.62
$327.38
$712.79
$789.64
$793.01
$368.23
$937.52
$979.59
$1,015.73
$1,142.65
$245.50
$1,228.14
$1,119.19
$844.30
$1,076.41
$1,116.33
$985.44
$114.71
$160.10
$165.14
$1,085.29
$1,258.26
$1,058.59
$1,127.74
$1,019.15
$1,099.24
$1,307.67
Limiting
Charge
$1,227.53
$617.19
$809.00
$763.68
$763.68
$877.22
$760.86
$376.49
$819.71
$908.09
$911.96
$423.46
$1,078.15
$1,126.53
$1,168.09
$1,314.05
$282.33
$1,412.36
$1,287.07
$970.95
$1,237.87
$1,283.78
$1,133.26
$131.92
$184.12
$189.91
$1,248.08
$1,447.00
$1,217.38
$1,296.90
$1,172.02
$1,264.13
$1,503.82
Charge**
Charge***
$1,215.26
$1,209.12
$611.02
$607.94
$800.92
$796.87
$756.04
$752.23
$756.04
$752.23
$868.45
$864.06
$753.25
$749.46
$372.73
$370.84
$811.51
$807.42
$899.00
$894.47
$902.84
$898.28
$419.23
$417.12
$1,067.36
$1,061.98
$1,115.26
$1,109.64
$1,156.41
$1,150.56
$1,300.90
$1,294.34
$279.51
$278.09
$1,398.24
$1,391.18
$1,274.20
$1,267.76
$961.24
$956.39
$1,225.50
$1,219.30
$1,270.95
$1,264.53
$1,121.93
$1,116.26
$130.59
$129.94
$182.28
$181.36
$188.01
$187.06
$1,235.61
$1,229.36
$1,432.53
$1,425.30
$1,205.20
$1,199.12
$1,283.93
$1,277.44
$1,160.30
$1,154.44
$1,251.49
$1,245.16
$1,488.78
$1,481.26
Arizona
EHR/eRx
Limiting
Charge**
$1,202.98
$604.85
$792.82
$748.41
$748.41
$859.67
$745.65
$368.95
$803.31
$889.93
$893.72
$415.00
$1,056.59
$1,104.00
$1,144.73
$1,287.77
$276.68
$1,384.12
$1,261.33
$951.52
$1,213.11
$1,258.10
$1,110.59
$129.28
$180.44
$186.12
$1,223.12
$1,418.05
$1,193.03
$1,270.97
$1,148.59
$1,238.85
$1,473.75
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$1,197.04
$1,184.94
$601.85
$595.78
$788.90
$780.93
$744.71
$737.18
$744.71
$737.18
$855.42
$846.78
$741.96
$734.46
$367.14
$363.42
$799.34
$791.26
$885.51
$876.58
$889.30
$880.31
$412.94
$408.78
$1,051.35
$1,040.74
$1,098.53
$1,087.44
$1,139.06
$1,127.56
$1,281.39
$1,268.45
$275.31
$272.53
$1,377.26
$1,363.36
$1,255.09
$1,242.41
$946.82
$937.25
$1,207.12
$1,194.92
$1,251.88
$1,239.23
$1,105.10
$1,093.93
$128.64
$127.34
$179.54
$177.73
$185.20
$183.32
$1,217.07
$1,204.77
$1,411.04
$1,396.78
$1,187.12
$1,175.14
$1,264.67
$1,251.90
$1,142.90
$1,131.36
$1,232.72
$1,220.27
$1,466.45
$1,451.65
Page 207 of 323
Notes
#
#
#
#
#
Procedure
Code
64896
64897
64898
64901
64902
64905
64907
64910
64911
65091
65093
65101
65103
65105
65110
65112
65114
65125
65125
65130
65135
65140
65150
65155
65175
65205
65205
65210
65210
65220
65220
65222
65222
1/2/2015
Modifier
Par Fee
$1,638.01
$1,292.93
$1,402.51
$573.34
$663.87
$1,044.31
$1,488.63
$839.76
$1,034.11
$638.08
$630.93
$742.09
$772.97
$853.83
$1,228.17
$1,424.29
$1,493.58
$459.82
$294.28
$735.61
$746.29
$811.82
$580.38
$850.25
$660.56
$56.32
$44.52
$69.14
$53.77
$57.97
$42.24
$67.36
$52.70
Nonpar Fee
$1,556.11
$1,228.28
$1,332.38
$544.67
$630.68
$992.09
$1,414.20
$797.77
$982.40
$606.18
$599.38
$704.99
$734.32
$811.14
$1,166.76
$1,353.08
$1,418.90
$436.83
$279.57
$698.83
$708.98
$771.23
$551.36
$807.74
$627.53
$53.50
$42.29
$65.68
$51.08
$55.07
$40.13
$63.99
$50.07
Limiting
Charge
$1,789.53
$1,412.52
$1,532.24
$626.37
$725.28
$1,140.90
$1,626.33
$917.44
$1,129.76
$697.11
$689.29
$810.74
$844.47
$932.81
$1,341.77
$1,556.04
$1,631.74
$502.35
$321.51
$803.65
$815.33
$886.91
$634.06
$928.90
$721.66
$61.53
$48.63
$75.53
$58.74
$63.33
$46.15
$73.59
$57.58
Charge**
Charge***
$1,771.63
$1,762.69
$1,398.40
$1,391.34
$1,516.92
$1,509.25
$620.10
$616.98
$718.03
$714.40
$1,129.50
$1,123.79
$1,610.07
$1,601.94
$908.26
$903.67
$1,118.47
$1,112.81
$690.14
$686.65
$682.40
$678.95
$802.63
$798.58
$836.03
$831.81
$923.48
$918.82
$1,328.35
$1,321.65
$1,540.48
$1,532.70
$1,615.42
$1,607.26
$497.33
$494.82
$318.29
$316.69
$795.62
$791.60
$807.17
$803.10
$878.05
$873.61
$627.73
$624.55
$919.61
$914.96
$714.44
$710.84
$60.92
$60.61
$48.15
$47.91
$74.77
$74.39
$58.16
$57.86
$62.70
$62.38
$45.69
$45.46
$72.85
$72.48
$57.01
$56.72
Arizona
EHR/eRx
Limiting
Charge**
$1,753.74
$1,384.27
$1,501.59
$613.85
$710.78
$1,118.09
$1,593.81
$899.08
$1,107.16
$683.17
$675.50
$794.52
$827.57
$914.16
$1,314.93
$1,524.92
$1,599.10
$492.30
$315.08
$787.58
$799.02
$869.18
$621.38
$910.33
$707.23
$60.29
$47.66
$74.03
$57.57
$62.07
$45.23
$72.12
$56.43
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$1,745.06
$1,727.44
$1,377.42
$1,363.50
$1,494.16
$1,479.06
$610.80
$604.64
$707.25
$700.12
$1,112.56
$1,101.32
$1,585.92
$1,569.90
$894.63
$885.59
$1,101.69
$1,090.56
$679.79
$672.92
$672.16
$665.37
$790.59
$782.61
$823.49
$815.17
$909.63
$900.45
$1,308.42
$1,295.21
$1,517.38
$1,502.05
$1,591.19
$1,575.11
$489.87
$484.92
$313.51
$310.35
$783.68
$775.77
$795.06
$787.04
$864.88
$856.14
$618.31
$612.06
$905.82
$896.68
$703.72
$696.62
$60.01
$59.39
$47.43
$46.94
$73.65
$72.91
$57.28
$56.71
$61.76
$61.13
$45.00
$44.55
$71.76
$71.04
$56.15
$55.58
Page 208 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
65235
65260
65265
65270
65270
65272
65272
65273
65275
65275
65280
65285
65286
65286
65290
65400
65400
65410
65410
65420
65420
65426
65426
65430
65430
65435
65435
65436
65436
65450
65450
65600
65600
1/2/2015
Modifier
Par Fee
$716.80
$964.19
$1,085.90
$268.57
$142.00
$505.55
$353.24
$383.09
$581.85
$465.65
$677.11
$1,116.34
$708.69
$499.53
$493.81
$683.76
$607.96
$144.01
$105.39
$519.54
$380.10
$656.62
$482.50
$115.41
$104.32
$79.87
$69.86
$389.97
$374.24
$327.44
$323.87
$396.99
$346.57
Nonpar Fee
$680.96
$915.98
$1,031.61
$255.14
$134.90
$480.27
$335.58
$363.94
$552.76
$442.37
$643.25
$1,060.52
$673.26
$474.55
$469.12
$649.57
$577.56
$136.81
$100.12
$493.56
$361.10
$623.79
$458.38
$109.64
$99.10
$75.88
$66.37
$370.47
$355.53
$311.07
$307.68
$377.14
$329.24
Limiting
Charge
$783.10
$1,053.38
$1,186.35
$293.41
$155.14
$552.31
$385.92
$418.53
$635.67
$508.73
$739.74
$1,219.60
$774.25
$545.73
$539.49
$747.01
$664.19
$157.33
$115.14
$567.59
$415.27
$717.36
$527.14
$126.09
$113.97
$87.26
$76.33
$426.04
$408.86
$357.73
$353.83
$433.71
$378.63
Charge**
Charge***
$775.27
$771.36
$1,042.84
$1,037.58
$1,174.48
$1,168.56
$290.48
$289.01
$153.58
$152.81
$546.79
$544.03
$382.05
$380.13
$414.35
$412.25
$629.31
$626.14
$503.64
$501.09
$732.34
$728.64
$1,207.40
$1,201.30
$766.51
$762.63
$540.27
$537.54
$534.09
$531.39
$739.53
$735.80
$657.55
$654.24
$155.76
$154.97
$113.99
$113.41
$561.91
$559.08
$411.11
$409.03
$710.18
$706.59
$521.87
$519.23
$124.82
$124.20
$112.83
$112.25
$86.39
$85.95
$75.57
$75.18
$421.79
$419.65
$404.77
$402.73
$354.15
$352.36
$350.29
$348.52
$429.38
$427.20
$374.84
$372.95
Arizona
EHR/eRx
Limiting
Charge**
$767.44
$1,032.31
$1,162.63
$287.55
$152.03
$541.26
$378.20
$410.16
$622.96
$498.55
$724.95
$1,195.21
$758.76
$534.82
$528.70
$732.07
$650.91
$154.18
$112.84
$556.24
$406.96
$703.01
$516.59
$123.57
$111.69
$85.51
$74.80
$417.52
$400.68
$350.58
$346.76
$425.04
$371.06
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$763.65
$755.93
$1,027.20
$1,016.83
$1,156.87
$1,145.19
$286.12
$283.23
$151.28
$149.75
$538.59
$533.14
$376.33
$372.53
$408.14
$404.01
$619.87
$613.61
$496.09
$491.07
$721.36
$714.07
$1,189.28
$1,177.28
$755.01
$747.37
$532.16
$526.79
$526.08
$520.77
$728.43
$721.08
$647.68
$641.15
$153.42
$151.87
$112.27
$111.15
$553.48
$547.89
$404.95
$400.86
$699.53
$692.46
$514.04
$508.84
$122.95
$121.72
$111.14
$110.01
$85.09
$84.23
$74.43
$73.67
$415.46
$411.25
$398.69
$394.67
$348.84
$345.32
$345.03
$341.56
$422.94
$418.67
$369.22
$365.49
Page 209 of 323
Notes
#
#
#
#
#
#
#
Procedure
Code
65710
65730
65750
65755
65756
65770
65772
65772
65775
65778
65778
65779
65779
65780
65781
65782
65800
65800
65810
65815
65815
65820
65850
65855
65855
65860
65860
65865
65870
65875
65880
65900
65920
1/2/2015
Modifier
Par Fee
$1,113.79
$1,235.45
$1,242.07
$1,235.32
$1,193.13
$1,416.30
$453.93
$409.24
$555.57
$1,391.27
$70.84
$1,235.12
$285.48
$895.44
$1,342.50
$1,158.53
$120.01
$92.48
$468.95
$642.01
$481.11
$753.04
$844.85
$340.18
$299.42
$310.95
$255.17
$476.51
$595.13
$633.97
$667.72
$970.27
$793.76
Nonpar Fee
$1,058.10
$1,173.68
$1,179.97
$1,173.55
$1,133.47
$1,345.49
$431.23
$388.78
$527.79
$1,321.71
$67.30
$1,173.36
$271.21
$850.67
$1,275.38
$1,100.60
$114.01
$87.86
$445.50
$609.91
$457.05
$715.39
$802.61
$323.17
$284.45
$295.40
$242.41
$452.68
$565.37
$602.27
$634.33
$921.76
$754.07
Limiting
Charge
$1,216.82
$1,349.73
$1,356.97
$1,349.58
$1,303.49
$1,547.31
$495.91
$447.10
$606.96
$1,519.97
$77.40
$1,349.36
$311.89
$978.27
$1,466.69
$1,265.69
$131.11
$101.04
$512.33
$701.40
$525.61
$822.70
$923.00
$371.65
$327.12
$339.71
$278.77
$520.58
$650.18
$692.61
$729.48
$1,060.02
$867.18
Charge**
Charge***
$1,204.65
$1,198.56
$1,336.23
$1,329.48
$1,343.40
$1,336.61
$1,336.08
$1,329.34
$1,290.46
$1,283.94
$1,531.85
$1,524.11
$490.96
$488.47
$442.62
$440.39
$600.89
$597.85
$1,504.76
$1,497.16
$76.62
$76.23
$1,335.87
$1,329.12
$308.78
$307.21
$968.48
$963.60
$1,452.02
$1,444.69
$1,253.03
$1,246.70
$129.80
$129.15
$100.03
$99.52
$507.21
$504.64
$694.38
$690.87
$520.35
$517.72
$814.48
$810.36
$913.77
$909.16
$367.93
$366.07
$323.85
$322.21
$336.32
$334.62
$275.99
$274.59
$515.37
$512.77
$643.68
$640.42
$685.69
$682.23
$722.19
$718.54
$1,049.42
$1,044.12
$858.51
$854.17
Arizona
EHR/eRx
Limiting
Charge**
$1,192.48
$1,322.74
$1,329.83
$1,322.59
$1,277.42
$1,516.37
$486.00
$438.15
$594.81
$1,489.57
$75.84
$1,322.37
$305.66
$958.71
$1,437.35
$1,240.38
$128.49
$99.02
$502.08
$687.37
$515.10
$806.24
$904.54
$364.22
$320.57
$332.91
$273.19
$510.17
$637.17
$678.75
$714.89
$1,038.82
$849.84
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$1,186.58
$1,174.60
$1,316.19
$1,302.90
$1,323.25
$1,309.87
$1,316.04
$1,302.75
$1,271.11
$1,258.26
$1,508.87
$1,493.62
$483.60
$478.71
$435.99
$431.58
$591.87
$585.89
$1,482.19
$1,467.23
$75.47
$74.70
$1,315.84
$1,302.54
$304.14
$301.07
$953.96
$944.33
$1,430.24
$1,415.79
$1,234.24
$1,221.77
$127.86
$126.56
$98.53
$97.53
$499.59
$494.55
$683.96
$677.05
$512.54
$507.37
$802.26
$794.14
$900.06
$890.97
$362.41
$358.75
$319.00
$315.77
$331.27
$327.92
$271.85
$269.10
$507.64
$502.53
$634.02
$627.61
$675.41
$668.58
$711.36
$704.17
$1,033.68
$1,023.24
$845.63
$837.10
Page 210 of 323
Notes
#
#
#
#
Procedure
Code
65930
66020
66020
66030
66030
66130
66130
66150
66155
66160
66170
66172
66174
66175
66179
66180
66183
66184
66185
66220
66225
66250
66250
66500
66505
66600
66605
66625
66630
66635
66680
66682
66700
1/2/2015
Modifier
Par Fee
$642.29
$187.23
$132.52
$166.89
$111.83
$700.12
$573.19
$877.61
$881.90
$994.36
$1,208.68
$1,524.32
$954.09
$999.28
$1,085.32
$1,145.39
$1,037.31
$790.32
$850.79
$748.57
$938.09
$753.61
$561.25
$356.32
$390.51
$837.74
$1,063.78
$432.03
$573.36
$579.04
$521.38
$641.61
$453.17
Nonpar Fee
$610.18
$177.87
$125.89
$158.55
$106.24
$665.11
$544.53
$833.73
$837.81
$944.64
$1,148.25
$1,448.10
$906.39
$949.32
$1,031.05
$1,088.12
$985.44
$750.80
$808.25
$711.14
$891.19
$715.93
$533.19
$338.50
$370.98
$795.85
$1,010.59
$410.43
$544.69
$550.09
$495.31
$609.53
$430.51
Limiting
Charge
$701.71
$204.55
$144.77
$182.33
$122.18
$764.88
$626.21
$958.79
$963.48
$1,086.34
$1,320.49
$1,665.32
$1,042.35
$1,091.72
$1,185.71
$1,251.34
$1,133.26
$863.42
$929.49
$817.81
$1,024.87
$823.32
$613.17
$389.28
$426.63
$915.23
$1,162.18
$471.99
$626.39
$632.60
$569.61
$700.96
$495.09
Charge**
Charge***
$694.69
$691.18
$202.50
$201.48
$143.32
$142.60
$180.50
$179.60
$120.96
$120.35
$757.23
$753.40
$619.94
$616.81
$949.20
$944.40
$953.84
$949.03
$1,075.47
$1,070.04
$1,307.29
$1,300.68
$1,648.66
$1,640.34
$1,031.93
$1,026.71
$1,080.80
$1,075.34
$1,173.85
$1,167.92
$1,238.83
$1,232.57
$1,121.93
$1,116.26
$854.78
$850.47
$920.20
$915.55
$809.63
$805.54
$1,014.62
$1,009.49
$815.09
$810.97
$607.04
$603.97
$385.39
$383.43
$422.36
$420.23
$906.07
$901.50
$1,150.55
$1,144.74
$467.28
$464.91
$620.13
$617.00
$626.28
$623.12
$563.91
$561.06
$693.94
$690.45
$490.13
$487.66
Arizona
EHR/eRx
Limiting
Charge**
$687.68
$200.46
$141.88
$178.69
$119.74
$749.58
$613.69
$939.62
$944.21
$1,064.61
$1,294.08
$1,632.01
$1,021.50
$1,069.88
$1,161.99
$1,226.31
$1,110.59
$846.15
$910.90
$801.46
$1,004.38
$806.85
$600.91
$381.49
$418.09
$896.92
$1,138.94
$462.55
$613.87
$619.95
$558.21
$686.94
$485.19
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$684.27
$677.36
$199.47
$197.46
$141.17
$139.75
$177.80
$176.01
$119.14
$117.94
$745.87
$738.33
$610.64
$604.49
$934.96
$925.52
$939.54
$930.04
$1,059.33
$1,048.64
$1,287.68
$1,274.67
$1,623.94
$1,607.53
$1,016.45
$1,006.18
$1,064.59
$1,053.84
$1,156.24
$1,144.56
$1,220.24
$1,207.91
$1,105.10
$1,093.93
$841.96
$833.45
$906.40
$897.24
$797.49
$789.44
$999.41
$989.31
$802.86
$794.75
$597.93
$591.89
$379.60
$375.76
$416.02
$411.83
$892.48
$883.46
$1,133.29
$1,121.85
$460.28
$455.62
$610.82
$604.66
$616.88
$610.65
$555.45
$549.84
$683.54
$676.64
$482.78
$477.91
Page 211 of 323
Notes
#
#
#
#
#
#
#
#
Procedure
Code
66700
66710
66710
66711
66720
66720
66740
66740
66761
66761
66762
66762
66770
66770
66820
66821
66821
66825
66830
66840
66850
66852
66920
66930
66940
66982
66983
66984
66985
66986
66990
67005
67010
1/2/2015
Modifier
Par Fee
$395.97
$442.80
$395.97
$646.13
$478.24
$427.12
$439.94
$395.61
$297.94
$237.52
$477.80
$428.82
$531.84
$487.50
$395.96
$332.09
$313.50
$764.75
$717.07
$701.73
$797.88
$850.17
$759.39
$862.28
$787.55
$800.60
$739.23
$644.48
$775.21
$914.31
$91.41
$475.79
$546.59
Nonpar Fee
$376.17
$420.66
$376.17
$613.82
$454.33
$405.76
$417.94
$375.83
$283.04
$225.64
$453.91
$407.38
$505.25
$463.13
$376.16
$315.49
$297.83
$726.51
$681.22
$666.64
$757.99
$807.66
$721.42
$819.17
$748.17
$760.57
$702.27
$612.26
$736.45
$868.59
$86.84
$452.00
$519.26
Limiting
Charge
$432.60
$483.76
$432.60
$705.89
$522.48
$466.62
$480.63
$432.20
$325.50
$259.49
$522.00
$468.49
$581.04
$532.60
$432.58
$362.81
$342.50
$835.49
$783.40
$766.64
$871.69
$928.81
$829.63
$942.05
$860.40
$874.66
$807.61
$704.10
$846.92
$998.88
$99.87
$519.80
$597.15
Charge**
Charge***
$428.27
$426.11
$478.92
$476.50
$428.27
$426.11
$698.83
$695.30
$517.26
$514.65
$461.96
$459.62
$475.82
$473.42
$427.88
$425.72
$322.24
$320.61
$256.89
$255.60
$516.78
$514.17
$463.81
$461.46
$575.23
$572.32
$527.28
$524.61
$428.26
$426.10
$359.19
$357.37
$339.08
$337.36
$827.13
$822.95
$775.57
$771.65
$758.97
$755.14
$862.97
$858.61
$919.52
$914.88
$821.34
$817.19
$932.63
$927.91
$851.79
$847.49
$865.90
$861.53
$799.54
$795.50
$697.06
$693.54
$838.45
$834.21
$988.89
$983.89
$98.87
$98.37
$514.60
$512.00
$591.18
$588.19
Arizona
EHR/eRx
Limiting
Charge**
$423.95
$474.09
$423.95
$691.77
$512.03
$457.29
$471.02
$423.56
$318.99
$254.30
$511.55
$459.11
$569.42
$521.95
$423.94
$355.56
$335.65
$818.78
$767.74
$751.31
$854.25
$910.24
$813.04
$923.21
$843.19
$857.16
$791.45
$690.01
$829.98
$978.90
$97.87
$509.40
$585.20
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$421.84
$417.59
$471.73
$466.98
$421.84
$417.59
$688.34
$681.40
$509.50
$504.34
$455.02
$450.43
$468.68
$463.96
$421.46
$417.21
$317.41
$314.20
$253.03
$250.48
$509.02
$503.88
$456.85
$452.23
$566.61
$560.88
$519.36
$514.12
$421.83
$417.58
$353.80
$350.22
$333.99
$330.61
$814.72
$806.50
$763.93
$756.23
$747.58
$740.04
$850.02
$841.44
$905.73
$896.59
$809.03
$800.85
$918.64
$909.36
$839.02
$830.54
$852.92
$844.31
$787.54
$779.59
$686.61
$679.66
$825.87
$817.52
$974.05
$964.22
$97.38
$96.39
$506.89
$501.77
$582.31
$576.43
Page 212 of 323
Notes
#
#
#
#
#
#
#
#
#
Procedure
Code
67015
67025
67025
67027
67028
67028
67030
67031
67031
67036
67039
67040
67041
67042
67043
67101
67101
67105
67105
67107
67108
67110
67110
67112
67113
67115
67120
67120
67121
67141
67141
67145
67145
1/2/2015
Modifier
Par Fee
$584.45
$731.09
$637.77
$857.64
$102.53
$100.75
$536.13
$390.82
$358.64
$907.20
$972.24
$1,050.50
$1,161.44
$1,161.44
$1,225.45
$788.79
$678.67
$723.81
$649.08
$1,223.21
$1,615.61
$874.52
$779.77
$1,335.13
$1,756.00
$503.23
$661.36
$562.32
$914.67
$527.55
$491.44
$530.72
$501.40
Nonpar Fee
$555.23
$694.54
$605.88
$814.76
$97.40
$95.71
$509.32
$371.28
$340.71
$861.84
$923.63
$997.98
$1,103.37
$1,103.37
$1,164.18
$749.35
$644.74
$687.62
$616.63
$1,162.05
$1,534.83
$830.79
$740.78
$1,268.37
$1,668.20
$478.07
$628.29
$534.20
$868.94
$501.17
$466.87
$504.18
$476.33
Limiting
Charge
$638.51
$798.72
$696.76
$936.97
$112.01
$110.07
$585.72
$426.97
$391.82
$991.12
$1,062.17
$1,147.68
$1,268.88
$1,268.88
$1,338.81
$861.75
$741.45
$790.76
$709.12
$1,336.36
$1,765.05
$955.41
$851.90
$1,458.63
$1,918.43
$549.78
$722.53
$614.33
$999.28
$576.35
$536.90
$579.81
$547.78
Charge**
Charge***
$632.13
$628.94
$790.73
$786.74
$689.79
$686.31
$927.60
$922.92
$110.89
$110.33
$108.96
$108.41
$579.86
$576.93
$422.71
$420.57
$387.90
$385.94
$981.20
$976.25
$1,051.55
$1,046.25
$1,136.20
$1,130.46
$1,256.19
$1,249.84
$1,256.19
$1,249.84
$1,325.42
$1,318.73
$853.14
$848.83
$734.03
$730.33
$782.85
$778.91
$702.03
$698.49
$1,322.99
$1,316.31
$1,747.40
$1,738.58
$945.85
$941.08
$843.38
$839.12
$1,444.04
$1,436.74
$1,899.25
$1,889.66
$544.28
$541.54
$715.31
$711.70
$608.19
$605.12
$989.29
$984.30
$570.58
$567.70
$531.53
$528.85
$574.01
$571.11
$542.31
$539.57
Arizona
EHR/eRx
Limiting
Charge**
$625.75
$782.75
$682.82
$918.23
$109.77
$107.87
$574.00
$418.43
$383.99
$971.29
$1,040.93
$1,124.72
$1,243.50
$1,243.50
$1,312.04
$844.51
$726.63
$774.95
$694.95
$1,309.63
$1,729.75
$936.30
$834.85
$1,429.45
$1,880.07
$538.79
$708.08
$602.05
$979.29
$564.82
$526.16
$568.22
$536.82
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$622.64
$616.37
$778.87
$771.01
$679.44
$672.58
$913.69
$904.45
$109.23
$108.12
$107.33
$106.25
$571.17
$565.39
$416.37
$412.15
$382.08
$378.22
$966.48
$956.72
$1,035.77
$1,025.32
$1,119.16
$1,107.85
$1,237.34
$1,224.84
$1,237.34
$1,224.84
$1,305.54
$1,292.36
$840.34
$831.84
$723.03
$715.73
$771.11
$763.32
$691.50
$684.53
$1,303.15
$1,289.99
$1,721.19
$1,703.81
$931.66
$922.25
$830.73
$822.33
$1,422.38
$1,408.01
$1,870.76
$1,851.87
$536.12
$530.70
$704.58
$697.45
$599.07
$593.02
$974.45
$964.61
$562.03
$556.35
$523.56
$518.27
$565.40
$559.69
$534.18
$528.77
Page 213 of 323
Notes
#
#
#
#
#
#
#
#
Procedure
Code
67208
67208
67210
67210
67218
67220
67220
67221
67221
67225
67225
67227
67227
67228
67228
67229
67250
67255
67311
67312
67314
67316
67318
67320
67331
67332
67334
67335
67340
67343
67345
67345
67346
1/2/2015
Modifier
Par Fee
$602.91
$581.46
$522.10
$504.22
$1,391.46
$538.54
$504.22
$288.83
$215.89
$29.90
$28.11
$615.11
$575.06
$1,006.75
$953.47
$1,174.31
$785.67
$688.10
$602.55
$716.62
$677.95
$807.40
$709.64
$325.13
$308.37
$334.69
$304.12
$150.45
$361.69
$657.93
$244.19
$220.23
$196.08
Nonpar Fee
$572.76
$552.39
$496.00
$479.01
$1,321.89
$511.61
$479.01
$274.39
$205.10
$28.41
$26.70
$584.35
$546.31
$956.41
$905.80
$1,115.59
$746.39
$653.70
$572.42
$680.79
$644.05
$767.03
$674.16
$308.87
$292.95
$317.96
$288.91
$142.93
$343.61
$625.03
$231.98
$209.22
$186.28
Limiting
Charge
$658.67
$635.25
$570.40
$550.86
$1,520.17
$588.35
$550.86
$315.55
$235.87
$32.67
$30.71
$672.00
$628.26
$1,099.87
$1,041.67
$1,282.93
$858.35
$751.76
$658.28
$782.91
$740.66
$882.08
$775.28
$355.20
$336.89
$365.65
$332.25
$164.37
$395.15
$718.78
$266.78
$240.60
$214.22
Charge**
Charge***
$652.08
$648.80
$628.90
$625.72
$564.70
$561.84
$545.35
$542.59
$1,504.97
$1,497.37
$582.46
$579.53
$545.35
$542.59
$312.40
$310.81
$233.51
$232.32
$32.35
$32.18
$30.39
$30.25
$665.29
$661.92
$621.98
$618.84
$1,088.88
$1,083.37
$1,031.25
$1,026.04
$1,270.09
$1,263.69
$849.77
$845.47
$744.23
$740.47
$651.71
$648.40
$775.08
$771.17
$733.25
$729.55
$873.26
$868.85
$767.53
$763.66
$351.65
$349.88
$333.52
$331.84
$362.00
$360.17
$328.92
$327.27
$162.73
$161.91
$391.20
$389.23
$711.60
$708.00
$264.11
$262.78
$238.20
$236.99
$212.08
$211.01
Arizona
EHR/eRx
Limiting
Charge**
$645.50
$622.54
$558.99
$539.84
$1,489.77
$576.59
$539.84
$309.24
$231.15
$32.02
$30.10
$658.56
$615.69
$1,077.87
$1,020.83
$1,257.27
$841.18
$736.72
$645.12
$767.25
$725.85
$864.44
$759.78
$348.09
$330.15
$358.34
$325.60
$161.08
$387.25
$704.41
$261.44
$235.80
$209.93
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$642.30
$635.81
$619.47
$613.20
$556.22
$550.61
$537.18
$531.75
$1,482.40
$1,467.42
$573.72
$567.94
$537.18
$531.75
$307.72
$304.60
$230.00
$227.69
$31.87
$31.53
$29.93
$29.65
$655.30
$648.68
$612.65
$606.45
$1,072.55
$1,061.70
$1,015.78
$1,005.51
$1,251.04
$1,238.41
$837.03
$828.56
$733.07
$725.67
$641.93
$635.44
$763.45
$755.73
$722.26
$714.96
$860.17
$851.47
$756.02
$748.39
$346.37
$342.87
$328.52
$325.20
$356.57
$352.97
$323.99
$320.71
$160.29
$158.67
$385.33
$381.44
$700.93
$693.84
$260.15
$257.52
$234.62
$232.25
$208.90
$206.78
Page 214 of 323
Notes
#
#
#
#
#
#
#
#
#
Procedure
Code
67400
67405
67412
67413
67414
67415
67420
67430
67440
67445
67450
67500
67500
67505
67505
67515
67515
67550
67560
67570
67700
67700
67710
67710
67715
67715
67800
67800
67801
67801
67805
67805
67808
1/2/2015
Modifier
Par Fee
$935.58
$797.88
$856.43
$859.73
$1,333.39
$105.66
$1,628.41
$1,254.04
$1,213.37
$1,410.76
$1,261.16
$78.89
$72.81
$89.71
$82.20
$97.53
$90.02
$969.87
$994.49
$1,160.63
$269.15
$117.19
$224.23
$98.02
$239.07
$109.28
$127.92
$104.32
$163.14
$134.89
$202.70
$166.58
$370.98
Nonpar Fee
$888.80
$757.99
$813.61
$816.74
$1,266.72
$100.38
$1,546.99
$1,191.34
$1,152.70
$1,340.22
$1,198.10
$74.95
$69.17
$85.22
$78.09
$92.65
$85.52
$921.38
$944.77
$1,102.60
$255.69
$111.33
$213.02
$93.12
$227.12
$103.82
$121.52
$99.10
$154.98
$128.15
$192.57
$158.25
$352.43
Limiting
Charge
$1,022.12
$871.69
$935.65
$939.25
$1,456.73
$115.44
$1,779.04
$1,370.04
$1,325.61
$1,541.25
$1,377.82
$86.19
$79.55
$98.00
$89.80
$106.55
$98.35
$1,059.59
$1,086.49
$1,267.99
$294.04
$128.03
$244.97
$107.09
$261.19
$119.39
$139.75
$113.97
$178.23
$147.37
$221.46
$181.99
$405.29
Charge**
Charge***
$1,011.90
$1,006.79
$862.97
$858.61
$926.29
$921.62
$929.86
$925.16
$1,442.16
$1,434.88
$114.29
$113.70
$1,761.25
$1,752.36
$1,356.34
$1,349.49
$1,312.35
$1,305.72
$1,525.84
$1,518.14
$1,364.04
$1,357.15
$85.33
$84.90
$78.75
$78.35
$97.03
$96.53
$88.91
$88.46
$105.48
$104.95
$97.36
$96.88
$1,049.00
$1,043.69
$1,075.62
$1,070.19
$1,255.31
$1,248.97
$291.10
$289.63
$126.75
$126.11
$242.52
$241.29
$106.02
$105.48
$258.58
$257.27
$118.20
$117.60
$138.35
$137.66
$112.83
$112.25
$176.44
$175.56
$145.90
$145.16
$219.24
$218.13
$180.17
$179.26
$401.25
$399.21
Arizona
EHR/eRx
Limiting
Charge**
$1,001.67
$854.25
$916.94
$920.47
$1,427.60
$113.13
$1,743.46
$1,342.64
$1,299.10
$1,510.43
$1,350.26
$84.47
$77.96
$96.05
$88.01
$104.42
$96.38
$1,038.39
$1,064.75
$1,242.63
$288.17
$125.47
$240.07
$104.95
$255.97
$117.00
$136.95
$111.69
$174.66
$144.43
$217.03
$178.35
$397.19
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$996.72
$986.64
$850.02
$841.44
$912.40
$903.19
$915.91
$906.66
$1,420.53
$1,406.19
$112.57
$111.42
$1,734.83
$1,717.31
$1,336.00
$1,322.50
$1,292.66
$1,279.62
$1,502.96
$1,487.78
$1,343.58
$1,330.01
$84.05
$83.20
$77.57
$76.79
$95.57
$94.61
$87.57
$86.69
$103.89
$102.86
$95.90
$94.93
$1,033.26
$1,022.82
$1,059.48
$1,048.78
$1,236.48
$1,223.99
$286.73
$283.84
$124.86
$123.58
$238.89
$236.47
$104.43
$103.37
$254.70
$252.13
$116.43
$115.24
$136.28
$134.90
$111.14
$110.01
$173.80
$172.04
$143.72
$142.27
$215.95
$213.77
$177.47
$175.67
$395.23
$391.23
Page 215 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
67810
67810
67820
67820
67825
67825
67830
67830
67835
67840
67840
67850
67850
67875
67875
67880
67880
67882
67882
67900
67900
67901
67901
67902
67903
67903
67904
67904
67906
67908
67908
67909
67909
1/2/2015
Modifier
Par Fee
$172.44
$72.32
$50.24
$53.81
$129.71
$122.91
$267.54
$139.54
$441.91
$276.40
$159.83
$215.17
$137.22
$171.90
$98.24
$460.81
$370.71
$566.88
$475.70
$643.49
$512.63
$760.41
$581.28
$728.65
$595.93
$486.52
$736.28
$601.84
$511.95
$496.03
$427.03
$539.66
$442.05
Nonpar Fee
$163.82
$68.70
$47.73
$51.12
$123.22
$116.76
$254.16
$132.56
$419.81
$262.58
$151.84
$204.41
$130.36
$163.31
$93.33
$437.77
$352.17
$538.54
$451.92
$611.32
$487.00
$722.39
$552.22
$692.22
$566.13
$462.19
$699.47
$571.75
$486.35
$471.23
$405.68
$512.68
$419.95
Limiting
Charge
$188.39
$79.01
$54.89
$58.79
$141.70
$134.27
$292.28
$152.44
$482.78
$301.97
$174.62
$235.07
$149.91
$187.81
$107.33
$503.44
$405.00
$619.32
$519.71
$703.02
$560.05
$830.75
$635.05
$796.05
$651.05
$531.52
$804.39
$657.51
$559.30
$541.91
$466.53
$589.58
$482.94
Charge**
Charge***
$186.51
$185.56
$78.21
$77.82
$54.34
$54.06
$58.20
$57.90
$140.29
$139.58
$132.93
$132.26
$289.36
$287.90
$150.91
$150.16
$477.95
$475.54
$298.94
$297.44
$172.87
$171.99
$232.73
$231.54
$148.42
$147.66
$185.93
$184.99
$106.26
$105.72
$498.40
$495.88
$400.95
$398.92
$613.12
$610.03
$514.51
$511.91
$695.99
$692.47
$554.45
$551.66
$822.45
$818.28
$628.71
$625.53
$788.10
$784.12
$644.54
$641.29
$526.21
$523.55
$796.35
$792.33
$650.93
$647.65
$553.71
$550.91
$536.50
$533.78
$461.86
$459.53
$583.68
$580.74
$478.11
$475.70
Arizona
EHR/eRx
Limiting
Charge**
$184.62
$77.43
$53.80
$57.62
$138.87
$131.58
$286.44
$149.40
$473.12
$295.93
$171.12
$230.37
$146.91
$184.05
$105.18
$493.36
$396.90
$606.94
$509.31
$688.95
$548.85
$814.13
$622.36
$780.14
$638.03
$520.89
$788.30
$644.37
$548.11
$531.08
$457.21
$577.79
$473.28
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$183.71
$181.85
$77.04
$76.27
$53.52
$52.99
$57.33
$56.75
$138.18
$136.79
$130.94
$129.61
$285.03
$282.14
$148.65
$147.15
$470.79
$466.03
$294.46
$291.49
$170.28
$168.56
$229.23
$226.92
$146.19
$144.70
$183.14
$181.29
$104.66
$103.60
$490.92
$485.96
$394.93
$390.94
$603.92
$597.83
$506.79
$501.68
$685.55
$678.62
$546.14
$540.62
$810.11
$801.92
$619.28
$613.02
$776.27
$768.43
$634.87
$628.46
$518.32
$513.08
$784.40
$776.48
$641.17
$634.71
$545.41
$539.89
$528.45
$523.11
$454.94
$450.35
$574.93
$569.12
$470.94
$466.19
Page 216 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
67911
67912
67912
67914
67914
67915
67915
67916
67916
67917
67917
67921
67921
67922
67922
67923
67923
67924
67924
67930
67930
67935
67935
67938
67938
67950
67950
67961
67961
67966
67966
67971
67973
1/2/2015
Modifier
Par Fee
$566.04
$886.40
$494.18
$472.79
$330.13
$293.60
$199.21
$595.17
$434.27
$605.81
$461.36
$462.60
$312.43
$290.74
$198.49
$594.23
$433.69
$633.74
$461.40
$366.28
$242.93
$597.55
$445.59
$242.11
$115.89
$575.28
$466.59
$578.28
$458.50
$772.75
$662.99
$728.91
$937.74
Nonpar Fee
$537.74
$842.08
$469.47
$449.15
$313.62
$278.92
$189.25
$565.41
$412.56
$575.52
$438.29
$439.47
$296.81
$276.20
$188.57
$564.52
$412.01
$602.05
$438.33
$347.97
$230.78
$567.67
$423.31
$230.00
$110.10
$546.52
$443.26
$549.37
$435.58
$734.11
$629.84
$692.46
$890.85
Limiting
Charge
$618.40
$968.39
$539.89
$516.52
$360.66
$320.76
$217.64
$650.22
$474.44
$661.85
$504.03
$505.39
$341.33
$317.63
$216.86
$649.20
$473.81
$692.36
$504.08
$400.17
$265.40
$652.82
$486.81
$264.50
$126.62
$628.50
$509.75
$631.78
$500.92
$844.23
$724.32
$796.33
$1,024.48
Charge**
Charge***
$612.21
$609.12
$958.71
$953.87
$534.50
$531.79
$511.36
$508.77
$357.05
$355.26
$317.55
$315.95
$215.46
$214.37
$643.72
$640.47
$469.69
$467.33
$655.22
$651.92
$499.00
$496.48
$500.34
$497.81
$337.92
$336.21
$314.46
$312.87
$214.68
$213.60
$642.70
$639.46
$469.07
$466.70
$685.43
$681.97
$499.04
$496.52
$396.16
$394.16
$262.74
$261.42
$646.29
$643.02
$481.94
$479.50
$261.86
$260.53
$125.35
$124.72
$622.21
$619.07
$504.65
$502.10
$625.46
$622.30
$495.90
$493.41
$835.79
$831.57
$717.07
$713.45
$788.37
$784.38
$1,014.23
$1,009.11
Arizona
EHR/eRx
Limiting
Charge**
$606.04
$949.03
$529.09
$506.20
$353.45
$314.34
$213.29
$637.22
$464.96
$648.61
$493.95
$495.28
$334.50
$311.28
$212.52
$636.21
$464.34
$678.51
$493.99
$392.16
$260.08
$639.77
$477.07
$259.21
$124.09
$615.93
$499.55
$619.14
$490.90
$827.34
$709.83
$780.40
$1,003.98
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$603.03
$596.95
$944.33
$934.79
$526.48
$521.16
$503.69
$498.61
$351.69
$348.15
$312.79
$309.63
$212.23
$210.09
$634.06
$627.66
$462.65
$457.99
$645.39
$638.88
$491.51
$486.54
$492.83
$487.85
$332.84
$329.49
$309.74
$306.61
$211.46
$209.33
$633.06
$626.67
$462.04
$457.37
$675.15
$668.33
$491.56
$486.59
$390.22
$386.27
$258.80
$256.19
$636.59
$630.18
$474.71
$469.91
$257.92
$255.32
$123.48
$122.22
$612.87
$606.69
$497.09
$492.05
$616.08
$609.85
$488.46
$483.54
$823.25
$814.94
$706.32
$699.18
$776.55
$768.69
$999.02
$988.92
Page 217 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
67974
67975
68020
68020
68040
68040
68100
68100
68110
68110
68115
68115
68130
68130
68135
68135
68200
68200
68320
68320
68325
68326
68328
68330
68330
68335
68340
68340
68360
68360
68362
68371
68400
1/2/2015
Modifier
Par Fee
$935.68
$690.43
$120.41
$111.47
$62.71
$51.27
$170.47
$98.24
$226.43
$150.63
$312.46
$185.53
$541.17
$414.60
$157.78
$152.77
$41.34
$34.91
$728.31
$543.10
$664.86
$650.87
$712.91
$607.37
$464.71
$653.01
$547.61
$402.09
$533.26
$414.20
$661.91
$415.67
$285.87
Nonpar Fee
$888.90
$655.91
$114.39
$105.90
$59.57
$48.71
$161.95
$93.33
$215.11
$143.10
$296.84
$176.25
$514.11
$393.87
$149.89
$145.13
$39.27
$33.16
$691.89
$515.95
$631.62
$618.33
$677.26
$577.00
$441.47
$620.36
$520.23
$381.99
$506.60
$393.49
$628.81
$394.89
$271.58
Limiting
Charge
$1,022.24
$754.30
$131.55
$121.79
$68.51
$56.02
$186.24
$107.33
$247.38
$164.57
$341.37
$202.69
$591.23
$452.95
$172.37
$166.90
$45.16
$38.13
$795.67
$593.34
$726.36
$711.08
$778.85
$663.55
$507.69
$713.41
$598.26
$439.29
$582.59
$452.51
$723.13
$454.12
$312.32
Charge**
Charge***
$1,012.01
$1,006.91
$746.75
$742.98
$130.24
$129.57
$120.57
$119.96
$67.82
$67.48
$55.45
$55.18
$184.38
$183.45
$106.26
$105.72
$244.90
$243.66
$162.92
$162.09
$337.95
$336.25
$200.66
$199.65
$585.32
$582.36
$448.42
$446.15
$170.65
$169.79
$165.23
$164.39
$44.71
$44.48
$37.75
$37.56
$787.72
$783.74
$587.41
$584.44
$719.10
$715.47
$703.97
$700.42
$771.06
$767.17
$656.91
$653.60
$502.62
$500.08
$706.28
$702.71
$592.28
$589.29
$434.90
$432.70
$576.76
$573.85
$447.99
$445.73
$715.90
$712.29
$449.58
$447.32
$309.19
$307.64
Arizona
EHR/eRx
Limiting
Charge**
$1,001.79
$739.21
$128.92
$119.35
$67.14
$54.90
$182.52
$105.18
$242.43
$161.28
$334.54
$198.64
$579.40
$443.89
$168.92
$163.56
$44.25
$37.38
$779.76
$581.47
$711.84
$696.85
$763.27
$650.28
$497.54
$699.14
$586.30
$430.50
$570.94
$443.46
$708.66
$445.04
$306.07
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$996.83
$986.76
$735.55
$728.12
$128.28
$126.98
$118.76
$117.55
$66.80
$66.13
$54.63
$54.07
$181.62
$179.78
$104.66
$103.60
$241.24
$238.80
$160.47
$158.86
$332.88
$329.52
$197.65
$195.66
$576.54
$570.71
$441.69
$437.23
$168.08
$166.39
$162.75
$161.12
$44.05
$43.59
$37.19
$36.81
$775.91
$768.06
$578.60
$572.76
$708.31
$701.17
$693.42
$686.40
$759.49
$751.81
$647.06
$640.53
$495.08
$490.07
$695.69
$688.65
$583.40
$577.51
$428.38
$424.04
$568.11
$562.37
$441.28
$436.82
$705.16
$698.04
$442.84
$438.37
$304.55
$301.48
Page 218 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
68400
68420
68420
68440
68440
68500
68505
68510
68510
68520
68525
68530
68530
68540
68550
68700
68705
68705
68720
68745
68750
68760
68760
68761
68761
68770
68801
68801
68810
68810
68811
68815
68815
1/2/2015
Modifier
Par Fee
$133.55
$322.39
$170.07
$102.71
$99.85
$982.02
$977.38
$448.70
$294.96
$691.37
$266.35
$429.97
$259.42
$935.41
$1,073.84
$608.50
$237.42
$168.06
$761.09
$764.84
$791.44
$201.84
$147.50
$148.70
$120.10
$634.11
$125.28
$108.47
$242.83
$189.20
$207.66
$451.87
$259.15
Nonpar Fee
$126.87
$306.27
$161.57
$97.57
$94.86
$932.92
$928.51
$426.27
$280.21
$656.80
$253.03
$408.47
$246.45
$888.64
$1,020.15
$578.08
$225.55
$159.66
$723.04
$726.60
$751.87
$191.75
$140.13
$141.27
$114.10
$602.40
$119.02
$103.05
$230.69
$179.74
$197.28
$429.28
$246.19
Limiting
Charge
$145.90
$352.21
$185.81
$112.21
$109.09
$1,072.86
$1,067.79
$490.21
$322.24
$755.32
$290.98
$469.74
$283.42
$1,021.94
$1,173.17
$664.79
$259.38
$183.61
$831.50
$835.59
$864.65
$220.51
$161.15
$162.46
$131.22
$692.76
$136.87
$118.51
$265.29
$206.70
$226.87
$493.67
$283.12
Charge**
Charge***
$144.44
$143.72
$348.69
$346.93
$183.94
$183.02
$111.08
$110.53
$108.00
$107.46
$1,062.13
$1,056.77
$1,057.10
$1,051.77
$485.31
$482.86
$319.02
$317.41
$747.76
$743.99
$288.08
$286.61
$465.05
$462.69
$280.59
$279.16
$1,011.71
$1,006.61
$1,161.44
$1,155.58
$658.15
$654.82
$256.78
$255.50
$181.77
$180.86
$823.18
$819.02
$827.23
$823.06
$856.00
$851.68
$218.30
$217.20
$159.54
$158.73
$160.84
$160.02
$129.90
$129.25
$685.84
$682.36
$135.50
$134.81
$117.32
$116.73
$262.64
$261.31
$204.63
$203.60
$224.61
$223.47
$488.74
$486.27
$280.29
$278.88
Arizona
EHR/eRx
Limiting
Charge**
$142.98
$345.16
$182.09
$109.96
$106.90
$1,051.40
$1,046.43
$480.40
$315.80
$740.21
$285.17
$460.35
$277.75
$1,001.50
$1,149.71
$651.50
$254.20
$179.94
$814.87
$818.88
$847.35
$216.11
$157.93
$159.21
$128.59
$678.90
$134.14
$116.14
$259.99
$202.57
$222.33
$483.79
$277.46
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$142.28
$140.84
$343.46
$339.99
$181.18
$179.35
$109.41
$108.32
$106.38
$105.31
$1,046.20
$1,035.63
$1,041.24
$1,030.73
$478.03
$473.19
$314.24
$311.06
$736.55
$729.11
$283.75
$280.89
$458.07
$453.45
$276.38
$273.59
$996.53
$986.48
$1,144.02
$1,132.46
$648.28
$641.72
$252.93
$250.38
$179.04
$177.24
$810.83
$802.64
$814.82
$806.60
$843.16
$834.65
$215.03
$212.87
$157.15
$155.56
$158.42
$156.81
$127.96
$126.66
$675.54
$668.71
$133.47
$132.12
$115.56
$114.40
$258.69
$256.09
$201.56
$199.54
$221.24
$218.99
$481.41
$476.54
$276.08
$273.30
Page 219 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
68816
68816
68840
68840
68850
68850
69000
69000
69005
69005
69020
69020
69100
69100
69105
69105
69110
69110
69120
69140
69145
69145
69150
69155
69200
69200
69205
69210
69210
69220
69220
69222
69222
1/2/2015
Modifier
Par Fee
$746.26
$252.13
$128.68
$117.95
$61.55
$56.54
$189.38
$121.09
$217.77
$160.56
$236.09
$145.27
$101.46
$49.62
$142.85
$64.90
$465.30
$329.43
$410.50
$896.10
$404.41
$254.24
$1,069.13
$1,699.67
$124.70
$58.91
$103.66
$49.75
$33.30
$139.32
$63.16
$223.21
$139.91
Nonpar Fee
$708.95
$239.52
$122.25
$112.05
$58.47
$53.71
$179.91
$115.04
$206.88
$152.53
$224.29
$138.01
$96.39
$47.14
$135.71
$61.66
$442.04
$312.96
$389.98
$851.30
$384.19
$241.53
$1,015.67
$1,614.69
$118.47
$55.96
$98.48
$47.26
$31.64
$132.35
$60.00
$212.05
$132.91
Limiting
Charge
$815.29
$275.45
$140.59
$128.86
$67.24
$61.77
$206.90
$132.30
$237.91
$175.41
$257.93
$158.71
$110.85
$54.21
$156.07
$70.91
$508.35
$359.90
$448.48
$979.00
$441.82
$277.76
$1,168.02
$1,856.89
$136.24
$64.35
$113.25
$54.35
$36.39
$152.20
$69.00
$243.86
$152.85
Charge**
Charge***
$807.14
$803.07
$272.69
$271.32
$139.18
$138.48
$127.57
$126.93
$66.57
$66.23
$61.15
$60.84
$204.83
$203.79
$130.97
$130.31
$235.53
$234.35
$173.65
$172.78
$255.36
$254.07
$157.12
$156.33
$109.74
$109.18
$53.67
$53.39
$154.50
$153.72
$70.20
$69.85
$503.26
$500.72
$356.30
$354.51
$443.99
$441.75
$969.21
$964.31
$437.40
$435.19
$274.98
$273.60
$1,156.34
$1,150.49
$1,838.32
$1,829.04
$134.88
$134.19
$63.71
$63.39
$112.13
$111.55
$53.81
$53.53
$36.02
$35.85
$150.68
$149.91
$68.31
$67.97
$241.42
$240.20
$151.32
$150.56
Arizona
EHR/eRx
Limiting
Charge**
$798.99
$269.94
$137.78
$126.28
$65.90
$60.54
$202.76
$129.65
$233.15
$171.90
$252.77
$155.54
$108.63
$53.13
$152.95
$69.49
$498.18
$352.71
$439.51
$959.41
$432.99
$272.21
$1,144.66
$1,819.76
$133.52
$63.07
$110.99
$53.26
$35.66
$149.16
$67.62
$238.98
$149.79
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$795.03
$787.00
$268.59
$265.89
$137.09
$135.71
$125.66
$124.38
$65.57
$64.91
$60.23
$59.63
$201.76
$199.72
$129.01
$127.71
$232.00
$229.66
$171.05
$169.33
$251.53
$248.98
$154.77
$153.20
$108.10
$107.00
$52.87
$52.34
$152.18
$150.66
$69.14
$68.45
$495.72
$490.71
$350.96
$347.42
$437.33
$432.92
$954.67
$945.02
$430.84
$426.49
$270.85
$268.12
$1,138.99
$1,127.49
$1,810.74
$1,792.46
$132.86
$131.51
$62.76
$62.12
$110.45
$109.32
$53.00
$52.46
$35.48
$35.12
$148.42
$146.91
$67.29
$66.61
$237.80
$235.39
$149.05
$147.55
Page 220 of 323
Notes
#
#
#
#
#
#
Procedure
Code
69300
69300
69310
69320
69420
69420
69421
69424
69424
69433
69433
69436
69440
69450
69501
69502
69505
69511
69530
69535
69540
69540
69550
69552
69554
69601
69602
69603
69604
69605
69610
69610
69620
1/2/2015
Modifier
Par Fee
$744.04
$484.46
$1,113.25
$1,561.05
$194.65
$123.50
$152.56
$130.02
$63.16
$205.65
$135.21
$164.22
$703.33
$556.27
$747.06
$993.89
$1,230.01
$1,259.74
$1,688.46
$2,734.81
$211.95
$129.71
$1,064.00
$1,603.31
$2,574.36
$1,068.94
$1,111.67
$1,287.99
$1,135.67
$1,593.96
$390.76
$297.08
$706.93
Nonpar Fee
$706.84
$460.24
$1,057.59
$1,483.00
$184.92
$117.33
$144.93
$123.52
$60.00
$195.37
$128.45
$156.01
$668.16
$528.46
$709.71
$944.20
$1,168.51
$1,196.75
$1,604.04
$2,598.07
$201.35
$123.22
$1,010.80
$1,523.14
$2,445.64
$1,015.49
$1,056.09
$1,223.59
$1,078.89
$1,514.26
$371.22
$282.23
$671.58
Limiting
Charge
$812.87
$529.28
$1,216.23
$1,705.45
$212.66
$134.93
$166.67
$142.05
$69.00
$224.68
$147.72
$179.41
$768.38
$607.73
$816.17
$1,085.83
$1,343.79
$1,376.26
$1,844.65
$2,987.78
$231.55
$141.70
$1,162.42
$1,751.61
$2,812.49
$1,167.81
$1,214.50
$1,407.13
$1,240.72
$1,741.40
$426.90
$324.56
$772.32
Charge**
Charge***
$804.74
$800.68
$523.99
$521.34
$1,204.06
$1,197.99
$1,688.40
$1,679.87
$210.53
$209.47
$133.58
$132.91
$165.00
$164.17
$140.62
$139.92
$68.31
$67.97
$222.43
$221.31
$146.25
$145.50
$177.62
$176.72
$760.70
$756.86
$601.66
$598.61
$808.00
$803.92
$1,074.97
$1,069.55
$1,330.34
$1,323.63
$1,362.50
$1,355.62
$1,826.20
$1,816.98
$2,957.90
$2,942.97
$229.24
$228.08
$140.29
$139.58
$1,150.79
$1,144.99
$1,734.10
$1,725.33
$2,784.36
$2,770.30
$1,156.14
$1,150.30
$1,202.36
$1,196.29
$1,393.05
$1,386.03
$1,228.32
$1,222.12
$1,723.99
$1,715.28
$422.64
$420.50
$321.32
$319.70
$764.59
$760.74
Arizona
EHR/eRx
Limiting
Charge**
$796.61
$518.70
$1,191.91
$1,671.34
$208.40
$132.23
$163.33
$139.21
$67.62
$220.18
$144.76
$175.82
$753.02
$595.57
$799.85
$1,064.12
$1,316.91
$1,348.74
$1,807.75
$2,928.03
$226.92
$138.87
$1,139.17
$1,716.58
$2,756.24
$1,144.46
$1,190.22
$1,378.99
$1,215.91
$1,706.57
$418.37
$318.08
$756.87
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$792.66
$784.66
$516.13
$510.91
$1,186.00
$1,174.02
$1,663.07
$1,646.27
$207.37
$205.28
$131.58
$130.25
$162.53
$160.89
$138.52
$137.11
$67.29
$66.61
$219.10
$216.88
$144.05
$142.59
$174.95
$173.19
$749.29
$741.73
$592.63
$586.64
$795.88
$787.85
$1,058.85
$1,048.16
$1,310.39
$1,297.15
$1,342.06
$1,328.51
$1,798.81
$1,780.64
$2,913.54
$2,884.11
$225.80
$223.51
$138.18
$136.79
$1,133.53
$1,122.08
$1,708.08
$1,690.83
$2,742.59
$2,714.90
$1,138.80
$1,127.29
$1,184.33
$1,172.37
$1,372.16
$1,358.30
$1,209.89
$1,197.67
$1,698.12
$1,680.97
$416.30
$412.09
$316.50
$313.31
$753.12
$745.52
Page 221 of 323
Notes
#
#
Procedure
Code
69620
69631
69632
69633
69635
69636
69637
69641
69642
69643
69644
69645
69646
69650
69660
69661
69662
69666
69667
69670
69676
69700
69711
69714
69715
69717
69718
69720
69725
69740
69745
69801
69801
1/2/2015
Modifier
Par Fee
$499.20
$903.76
$1,100.67
$1,065.67
$1,259.20
$1,410.51
$1,433.06
$1,063.61
$1,366.50
$1,251.13
$1,513.99
$1,487.35
$1,577.06
$820.99
$948.88
$1,233.53
$1,185.70
$828.09
$827.38
$963.53
$849.28
$699.67
$880.57
$1,101.71
$1,357.14
$1,154.15
$1,370.95
$1,225.15
$1,920.72
$1,192.63
$1,268.31
$199.22
$128.78
Nonpar Fee
$474.24
$858.57
$1,045.64
$1,012.39
$1,196.24
$1,339.98
$1,361.41
$1,010.43
$1,298.18
$1,188.57
$1,438.29
$1,412.98
$1,498.21
$779.94
$901.44
$1,171.85
$1,126.42
$786.69
$786.01
$915.35
$806.82
$664.69
$836.54
$1,046.62
$1,289.28
$1,096.44
$1,302.40
$1,163.89
$1,824.68
$1,133.00
$1,204.89
$189.26
$122.34
Limiting
Charge
$545.38
$987.36
$1,202.49
$1,164.25
$1,375.68
$1,540.98
$1,565.62
$1,161.99
$1,492.91
$1,366.86
$1,654.03
$1,624.93
$1,722.94
$896.93
$1,036.66
$1,347.63
$1,295.38
$904.69
$903.91
$1,052.65
$927.84
$764.39
$962.02
$1,203.61
$1,482.67
$1,260.91
$1,497.76
$1,338.47
$2,098.38
$1,302.95
$1,385.62
$217.65
$140.69
Charge**
Charge***
$539.93
$537.20
$977.48
$972.54
$1,190.46
$1,184.45
$1,152.61
$1,146.78
$1,361.92
$1,355.05
$1,525.57
$1,517.86
$1,549.97
$1,542.14
$1,150.38
$1,144.56
$1,477.98
$1,470.52
$1,353.18
$1,346.35
$1,637.50
$1,629.23
$1,608.68
$1,600.56
$1,705.71
$1,697.10
$887.96
$883.48
$1,026.29
$1,021.11
$1,334.15
$1,327.41
$1,282.43
$1,275.95
$895.64
$891.12
$894.87
$890.35
$1,042.13
$1,036.86
$918.56
$913.93
$756.75
$752.93
$952.40
$947.59
$1,191.57
$1,185.56
$1,467.85
$1,460.43
$1,248.30
$1,241.99
$1,482.79
$1,475.29
$1,325.09
$1,318.39
$2,077.39
$2,066.91
$1,289.92
$1,283.41
$1,371.77
$1,364.84
$215.48
$214.38
$139.29
$138.58
Arizona
EHR/eRx
Limiting
Charge**
$534.47
$967.61
$1,178.44
$1,140.96
$1,348.17
$1,510.16
$1,534.31
$1,138.75
$1,463.05
$1,339.52
$1,620.95
$1,592.43
$1,688.49
$878.99
$1,015.92
$1,320.67
$1,269.47
$886.60
$885.83
$1,031.60
$909.28
$749.11
$942.78
$1,179.54
$1,453.01
$1,235.69
$1,467.80
$1,311.70
$2,056.42
$1,276.89
$1,357.91
$213.29
$137.87
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$531.83
$526.46
$962.81
$953.10
$1,172.60
$1,160.76
$1,135.33
$1,123.85
$1,341.50
$1,327.95
$1,502.68
$1,487.50
$1,526.72
$1,511.30
$1,133.13
$1,121.68
$1,455.81
$1,441.11
$1,332.88
$1,319.43
$1,612.93
$1,596.64
$1,584.55
$1,568.54
$1,680.13
$1,663.16
$874.64
$865.80
$1,010.90
$1,000.68
$1,314.14
$1,300.86
$1,263.19
$1,250.43
$882.21
$873.31
$881.45
$872.55
$1,026.50
$1,016.12
$904.79
$895.64
$745.40
$737.87
$938.11
$928.64
$1,173.70
$1,161.85
$1,445.83
$1,431.22
$1,229.58
$1,217.15
$1,460.55
$1,445.78
$1,305.22
$1,292.03
$2,046.23
$2,025.58
$1,270.57
$1,257.73
$1,351.19
$1,337.54
$212.24
$210.09
$137.20
$135.80
Page 222 of 323
Notes
Procedure
Code
69805
69806
69820
69840
69905
69910
69915
69930
69950
69955
69960
69970
69990
70010
70015
70015
70015
70030
70030
70030
70100
70100
70100
70110
70110
70110
70120
70120
70120
70130
70130
70130
70134
1/2/2015
Modifier
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
Par Fee
$1,076.41
$965.82
$874.94
$934.15
$937.03
$1,038.64
$1,571.03
$1,251.38
$1,821.32
$2,021.48
$1,967.13
$2,189.06
$226.52
$72.15
$154.82
$93.99
$60.83
$27.44
$18.91
$8.54
$32.81
$23.55
$9.25
$37.81
$24.98
$12.83
$33.88
$24.63
$9.25
$54.57
$37.14
$17.43
$51.40
Nonpar Fee
$1,022.59
$917.53
$831.19
$887.44
$890.18
$986.71
$1,492.48
$1,188.81
$1,730.25
$1,920.41
$1,868.77
$2,079.61
$215.19
$68.54
$147.08
$89.29
$57.79
$26.07
$17.96
$8.11
$31.17
$22.37
$8.79
$35.92
$23.73
$12.19
$32.19
$23.40
$8.79
$51.84
$35.28
$16.56
$48.83
Limiting
Charge
$1,175.98
$1,055.16
$955.87
$1,020.56
$1,023.71
$1,134.72
$1,716.35
$1,367.13
$1,989.79
$2,208.47
$2,149.09
$2,391.55
$247.47
$78.82
$169.14
$102.68
$66.46
$29.98
$20.65
$9.33
$35.85
$25.73
$10.11
$41.31
$27.29
$14.02
$37.02
$26.91
$10.11
$59.62
$40.57
$19.04
$56.15
Charge**
Charge***
$1,164.21
$1,158.34
$1,044.60
$1,039.34
$946.31
$941.53
$1,010.36
$1,005.25
$1,013.47
$1,008.35
$1,123.37
$1,117.70
$1,699.19
$1,690.60
$1,353.46
$1,346.63
$1,969.89
$1,959.95
$2,186.39
$2,175.34
$2,127.59
$2,116.85
$2,367.63
$2,355.68
$245.00
$243.75
$78.03
$77.64
$167.45
$166.60
$101.66
$101.14
$65.79
$65.46
$29.68
$29.53
$20.45
$20.34
$9.23
$9.19
$35.49
$35.31
$25.47
$25.33
$10.01
$9.96
$40.89
$40.69
$27.01
$26.88
$13.88
$13.81
$36.65
$36.47
$26.65
$26.51
$10.01
$9.96
$59.02
$58.72
$40.17
$39.96
$18.85
$18.76
$55.59
$55.32
Arizona
EHR/eRx
Limiting
Charge**
$1,152.46
$1,034.06
$936.76
$1,000.14
$1,003.24
$1,112.03
$1,682.02
$1,339.78
$1,950.00
$2,164.30
$2,106.10
$2,343.72
$242.52
$77.25
$165.76
$100.63
$65.12
$29.38
$20.24
$9.14
$35.13
$25.21
$9.90
$40.48
$26.75
$13.74
$36.28
$26.37
$9.90
$58.42
$39.76
$18.66
$55.03
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$1,146.75
$1,135.18
$1,028.93
$1,018.54
$932.12
$922.70
$995.20
$985.14
$998.27
$988.18
$1,106.52
$1,095.35
$1,673.71
$1,656.79
$1,333.16
$1,319.68
$1,940.35
$1,920.75
$2,153.59
$2,131.84
$2,095.68
$2,074.51
$2,332.12
$2,308.57
$241.32
$238.89
$76.85
$76.08
$164.94
$163.28
$100.13
$99.12
$64.80
$64.15
$29.23
$28.95
$20.14
$19.94
$9.10
$9.00
$34.96
$34.60
$25.09
$24.83
$9.86
$9.75
$40.28
$39.87
$26.61
$26.35
$13.67
$13.54
$36.10
$35.74
$26.24
$25.98
$9.86
$9.75
$58.13
$57.55
$39.57
$39.16
$18.56
$18.39
$54.75
$54.20
Page 223 of 323
Notes
Procedure
Code
70134
70134
70140
70140
70140
70150
70150
70150
70160
70160
70160
70170
70190
70190
70190
70200
70200
70200
70210
70210
70210
70220
70220
70220
70240
70240
70240
70250
70250
70250
70260
70260
70260
1/2/2015
Modifier
TC
26
TC
26
TC
26
TC
26
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
Par Fee
$33.57
$17.83
$29.59
$18.91
$10.68
$41.39
$27.84
$13.54
$32.45
$23.55
$8.89
$15.60
$34.95
$23.55
$11.40
$42.10
$27.84
$14.26
$29.59
$20.69
$8.89
$37.10
$24.27
$12.83
$29.90
$19.62
$10.28
$35.67
$22.84
$12.83
$44.96
$27.49
$17.48
Nonpar Fee
$31.89
$16.94
$28.11
$17.96
$10.15
$39.32
$26.45
$12.86
$30.83
$22.37
$8.45
$14.82
$33.20
$22.37
$10.83
$40.00
$26.45
$13.55
$28.11
$19.66
$8.45
$35.25
$23.06
$12.19
$28.41
$18.64
$9.77
$33.89
$21.70
$12.19
$42.71
$26.12
$16.61
Limiting
Charge
$36.67
$19.48
$32.33
$20.65
$11.67
$45.22
$30.42
$14.79
$35.45
$25.73
$9.72
$17.04
$38.18
$25.73
$12.45
$46.00
$30.42
$15.58
$32.33
$22.61
$9.72
$40.54
$26.52
$14.02
$32.67
$21.44
$11.24
$38.97
$24.96
$14.02
$49.12
$30.04
$19.10
Charge**
Charge***
$36.31
$36.12
$19.29
$19.19
$32.00
$31.84
$20.45
$20.34
$11.56
$11.50
$44.77
$44.54
$30.12
$29.96
$14.64
$14.57
$35.10
$34.93
$25.47
$25.33
$9.63
$9.57
$16.87
$16.79
$37.80
$37.61
$25.47
$25.33
$12.33
$12.27
$45.54
$45.31
$30.12
$29.96
$15.42
$15.35
$32.00
$31.84
$22.38
$22.28
$9.63
$9.57
$40.14
$39.93
$26.25
$26.12
$13.88
$13.81
$32.35
$32.18
$21.22
$21.11
$11.12
$11.06
$38.58
$38.39
$24.70
$24.58
$13.88
$13.81
$48.62
$48.38
$29.74
$29.59
$18.91
$18.81
Arizona
EHR/eRx
Limiting
Charge**
$35.94
$19.09
$31.68
$20.24
$11.44
$44.31
$29.81
$14.49
$34.74
$25.21
$9.52
$16.70
$37.42
$25.21
$12.20
$45.08
$29.81
$15.27
$31.68
$22.16
$9.52
$39.73
$25.99
$13.74
$32.02
$21.01
$11.01
$38.19
$24.46
$13.74
$48.14
$29.44
$18.72
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$35.77
$35.40
$19.00
$18.80
$31.52
$31.21
$20.14
$19.94
$11.39
$11.27
$44.10
$43.64
$29.67
$29.36
$14.42
$14.27
$34.57
$34.22
$25.09
$24.83
$9.48
$9.38
$16.62
$16.45
$37.24
$36.86
$25.09
$24.83
$12.14
$12.02
$44.86
$44.40
$29.67
$29.36
$15.19
$15.04
$31.52
$31.21
$22.05
$21.83
$9.48
$9.38
$39.54
$39.13
$25.86
$25.60
$13.67
$13.54
$31.87
$31.53
$20.90
$20.70
$10.95
$10.84
$38.01
$37.62
$24.33
$24.09
$13.67
$13.54
$47.90
$47.41
$29.29
$29.00
$18.62
$18.45
Page 224 of 323
Notes
Procedure
Code
70300
70300
70300
70310
70310
70310
70320
70320
70320
70328
70328
70328
70330
70330
70330
70332
70332
70332
70336
70336
70336
70350
70350
70350
70355
70355
70355
70360
70360
70360
70370
70370
70370
1/2/2015
Modifier
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
Par Fee
$14.93
$8.89
$6.03
$38.53
$29.99
$8.54
$53.46
$40.72
$12.74
$31.02
$21.41
$9.61
$47.06
$33.92
$13.14
$81.93
$49.66
$32.27
$320.37
$245.95
$74.42
$19.53
$9.25
$10.28
$20.25
$8.89
$11.35
$27.80
$19.26
$8.54
$80.63
$64.31
$16.32
Nonpar Fee
$14.18
$8.45
$5.73
$36.60
$28.49
$8.11
$50.79
$38.68
$12.10
$29.47
$20.34
$9.13
$44.71
$32.22
$12.48
$77.83
$47.18
$30.66
$304.35
$233.65
$70.70
$18.55
$8.79
$9.77
$19.24
$8.45
$10.78
$26.41
$18.30
$8.11
$76.60
$61.09
$15.50
Limiting
Charge
$16.31
$9.72
$6.59
$42.09
$32.76
$9.33
$58.41
$44.48
$13.92
$33.89
$23.39
$10.50
$51.42
$37.05
$14.35
$89.50
$54.26
$35.26
$350.00
$268.70
$81.31
$21.33
$10.11
$11.24
$22.13
$9.72
$12.40
$30.37
$21.05
$9.33
$88.09
$70.25
$17.83
Charge**
Charge***
$16.15
$16.07
$9.63
$9.57
$6.52
$6.49
$41.66
$41.46
$32.44
$32.27
$9.23
$9.19
$57.82
$57.53
$44.03
$43.82
$13.78
$13.71
$33.56
$33.38
$23.16
$23.03
$10.40
$10.34
$50.90
$50.65
$36.69
$36.50
$14.21
$14.13
$88.61
$88.16
$53.72
$53.44
$34.90
$34.73
$346.51
$344.75
$266.01
$264.67
$80.49
$80.09
$21.11
$21.01
$10.01
$9.96
$11.12
$11.06
$21.91
$21.79
$9.63
$9.57
$12.27
$12.21
$30.07
$29.91
$20.84
$20.73
$9.23
$9.19
$87.20
$86.77
$69.55
$69.20
$17.65
$17.56
Arizona
EHR/eRx
Limiting
Charge**
$15.99
$9.52
$6.46
$41.25
$32.11
$9.14
$57.24
$43.60
$13.64
$33.21
$22.92
$10.29
$50.39
$36.32
$14.06
$87.71
$53.18
$34.56
$343.00
$263.33
$79.68
$20.91
$9.90
$11.01
$21.69
$9.52
$12.14
$29.76
$20.62
$9.14
$86.33
$68.85
$17.47
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$15.90
$15.74
$9.48
$9.38
$6.42
$6.37
$41.04
$40.63
$31.96
$31.63
$9.10
$9.00
$56.96
$56.37
$43.38
$42.94
$13.57
$13.43
$33.05
$32.72
$22.82
$22.57
$10.24
$10.14
$50.14
$49.63
$36.13
$35.78
$14.00
$13.86
$87.27
$86.40
$52.91
$52.38
$34.37
$34.04
$341.31
$337.86
$262.02
$259.38
$79.28
$78.49
$20.79
$20.60
$9.86
$9.75
$10.95
$10.84
$21.57
$21.37
$9.48
$9.38
$12.09
$11.96
$29.62
$29.31
$20.53
$20.31
$9.10
$9.00
$85.89
$85.03
$68.51
$67.82
$17.39
$17.20
Page 225 of 323
Notes
C
C
Procedure
Code
70371
70371
70371
70373
70373
70373
70380
70380
70380
70390
70390
70390
70450
70450
70450
70460
70460
70460
70470
70470
70470
70480
70480
70480
70481
70481
70481
70482
70482
70482
70486
70486
70486
1/2/2015
Modifier
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
Par Fee
$90.28
$47.51
$42.77
$76.38
$53.95
$22.44
$35.98
$26.41
$9.57
$93.90
$74.68
$19.22
$115.98
$72.90
$43.09
$162.02
$104.72
$57.30
$191.69
$127.24
$64.45
$184.90
$120.09
$64.81
$275.67
$205.90
$69.77
$301.78
$228.43
$73.35
$139.94
$96.85
$43.09
Nonpar Fee
$85.77
$45.13
$40.63
$72.56
$51.25
$21.32
$34.18
$25.09
$9.09
$89.21
$70.95
$18.26
$110.18
$69.26
$40.94
$153.92
$99.48
$54.44
$182.11
$120.88
$61.23
$175.66
$114.09
$61.57
$261.89
$195.61
$66.28
$286.69
$217.01
$69.68
$132.94
$92.01
$40.94
Limiting
Charge
$98.64
$51.90
$46.72
$83.44
$58.94
$24.52
$39.31
$28.85
$10.45
$102.59
$81.59
$21.00
$126.71
$79.65
$47.08
$177.01
$114.40
$62.61
$209.43
$139.01
$70.41
$202.01
$131.20
$70.81
$301.17
$224.95
$76.22
$329.69
$249.56
$80.13
$152.88
$105.81
$47.08
Charge**
Charge***
$97.65
$97.15
$51.38
$51.12
$46.25
$46.02
$82.60
$82.19
$58.35
$58.05
$24.28
$24.15
$38.92
$38.72
$28.57
$28.42
$10.35
$10.29
$101.57
$101.05
$80.78
$80.37
$20.79
$20.69
$125.44
$124.81
$78.86
$78.45
$46.61
$46.38
$175.24
$174.35
$113.26
$112.69
$61.99
$61.66
$207.33
$206.29
$137.62
$136.93
$69.71
$69.36
$199.99
$198.98
$129.89
$129.24
$70.09
$69.75
$298.16
$296.65
$222.70
$221.58
$75.46
$75.08
$326.39
$324.75
$247.07
$245.81
$79.33
$78.92
$151.35
$150.59
$104.75
$104.22
$46.61
$46.38
Arizona
EHR/eRx
Limiting
Charge**
$96.66
$50.86
$45.79
$81.78
$57.76
$24.02
$38.53
$28.28
$10.25
$100.54
$79.96
$20.57
$124.18
$78.05
$46.14
$173.47
$112.11
$61.35
$205.24
$136.23
$69.01
$197.97
$128.58
$69.39
$295.15
$220.46
$74.69
$323.10
$244.57
$78.53
$149.82
$103.70
$46.14
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$96.19
$95.21
$50.61
$50.11
$45.56
$45.10
$81.36
$80.55
$57.48
$56.90
$23.91
$23.67
$38.33
$37.95
$28.14
$27.85
$10.20
$10.10
$100.05
$99.04
$79.57
$78.76
$20.48
$20.26
$123.56
$122.31
$77.67
$76.88
$45.91
$45.45
$172.60
$170.87
$111.56
$110.43
$61.05
$60.43
$204.23
$202.16
$135.55
$134.18
$68.67
$67.98
$196.98
$195.01
$127.95
$126.65
$69.05
$68.34
$293.69
$290.72
$219.36
$217.14
$74.34
$73.58
$321.49
$318.26
$243.36
$240.90
$78.14
$77.36
$149.09
$147.58
$103.18
$102.14
$45.91
$45.45
Page 226 of 323
Notes
C
C
C
C
C
C
Procedure
Code
70487
70487
70487
70488
70488
70488
70490
70490
70490
70491
70491
70491
70492
70492
70492
70496
70496
70496
70498
70498
70498
70540
70540
70540
70542
70542
70542
70543
70543
70543
70544
70544
70544
1/2/2015
Modifier
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
Par Fee
$168.45
$111.15
$57.30
$204.92
$140.83
$64.09
$184.90
$120.09
$64.81
$235.63
$165.50
$70.13
$277.82
$204.47
$73.35
$295.52
$206.57
$88.95
$293.73
$205.14
$88.59
$353.98
$286.31
$67.67
$403.19
$320.99
$82.20
$492.49
$383.92
$108.57
$347.18
$286.31
$60.88
Nonpar Fee
$160.03
$105.59
$54.44
$194.67
$133.79
$60.89
$175.66
$114.09
$61.57
$223.85
$157.23
$66.62
$263.93
$194.25
$69.68
$280.74
$196.24
$84.50
$279.04
$194.88
$84.16
$336.28
$271.99
$64.29
$383.03
$304.94
$78.09
$467.87
$364.72
$103.14
$329.82
$271.99
$57.84
Limiting
Charge
$184.03
$121.43
$62.61
$223.87
$153.86
$70.02
$202.01
$131.20
$70.81
$257.43
$180.81
$76.61
$303.52
$223.39
$80.13
$322.85
$225.68
$97.18
$320.90
$224.11
$96.78
$386.72
$312.79
$73.93
$440.48
$350.68
$89.80
$538.05
$419.43
$118.61
$379.29
$312.79
$66.52
Charge**
Charge***
$182.19
$181.27
$120.21
$119.61
$61.99
$61.66
$221.63
$220.51
$152.32
$151.55
$69.32
$68.98
$199.99
$198.98
$129.89
$129.24
$70.09
$69.75
$254.85
$253.56
$179.01
$178.10
$75.84
$75.46
$300.48
$298.97
$221.16
$220.04
$79.33
$78.92
$319.62
$318.01
$223.42
$222.30
$96.21
$95.71
$317.69
$316.08
$221.87
$220.75
$95.82
$95.34
$382.86
$380.93
$309.66
$308.10
$73.20
$72.83
$436.08
$433.87
$347.17
$345.43
$88.91
$88.46
$532.67
$529.98
$415.23
$413.14
$117.43
$116.83
$375.50
$373.60
$309.66
$308.10
$65.85
$65.52
Arizona
EHR/eRx
Limiting
Charge**
$180.35
$119.00
$61.35
$219.40
$150.78
$68.62
$197.97
$128.58
$69.39
$252.28
$177.20
$75.08
$297.45
$218.93
$78.53
$316.40
$221.17
$95.23
$314.48
$219.63
$94.85
$378.98
$306.53
$72.45
$431.68
$343.67
$88.01
$527.29
$411.04
$116.24
$371.70
$306.53
$65.18
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$179.46
$177.65
$118.40
$117.22
$61.05
$60.43
$218.30
$216.11
$150.03
$148.51
$68.29
$67.59
$196.98
$195.01
$127.95
$126.65
$69.05
$68.34
$251.03
$248.49
$176.33
$174.55
$74.70
$73.96
$295.98
$292.99
$217.84
$215.64
$78.14
$77.36
$314.82
$311.65
$220.08
$217.86
$94.77
$93.81
$312.93
$309.76
$218.55
$216.34
$94.38
$93.43
$377.12
$373.30
$305.01
$301.93
$72.11
$71.37
$429.54
$425.20
$341.96
$338.51
$87.57
$86.69
$524.68
$519.37
$409.00
$404.88
$115.67
$114.49
$369.86
$366.13
$305.01
$301.93
$64.86
$64.20
Page 227 of 323
Notes
C
C
C
C
C
C
Procedure
Code
70545
70545
70545
70546
70546
70546
70547
70547
70547
70548
70548
70548
70549
70549
70549
70551
70551
70551
70552
70552
70552
70553
70553
70553
70554
70554
70554
70555
70557
70558
70559
71010
71010
1/2/2015
Modifier
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
26
26
26
26
TC
Par Fee
$386.56
$326.04
$60.52
$574.41
$482.96
$91.45
$346.87
$286.31
$60.56
$414.05
$353.17
$60.88
$574.41
$482.96
$91.45
$229.91
$155.13
$74.78
$320.19
$229.46
$90.73
$377.67
$261.64
$116.03
$451.55
$342.80
$108.75
$131.95
$151.75
$167.71
$168.03
$22.44
$13.19
Nonpar Fee
$367.23
$309.74
$57.49
$545.69
$458.81
$86.88
$329.53
$271.99
$57.53
$393.35
$335.51
$57.84
$545.69
$458.81
$86.88
$218.41
$147.37
$71.04
$304.18
$217.99
$86.19
$358.79
$248.56
$110.23
$428.97
$325.66
$103.31
$125.35
$144.16
$159.32
$159.63
$21.32
$12.53
Limiting
Charge
$422.31
$356.20
$66.11
$627.54
$527.63
$99.91
$378.96
$312.79
$66.16
$452.35
$385.84
$66.52
$627.54
$527.63
$99.91
$251.17
$169.48
$81.70
$349.81
$250.69
$99.12
$412.61
$285.84
$126.76
$493.32
$374.51
$118.81
$144.15
$165.78
$183.22
$183.57
$24.52
$14.41
Charge**
Charge***
$418.09
$415.98
$352.64
$350.85
$65.46
$65.12
$621.26
$618.13
$522.35
$519.72
$98.91
$98.42
$375.16
$373.28
$309.66
$308.10
$65.49
$65.17
$447.83
$445.57
$381.97
$380.05
$65.85
$65.52
$621.26
$618.13
$522.35
$519.72
$98.91
$98.42
$248.66
$247.40
$167.79
$166.93
$80.88
$80.47
$346.31
$344.56
$248.18
$246.93
$98.13
$97.64
$408.48
$406.42
$282.98
$281.55
$125.50
$124.87
$488.38
$485.92
$370.76
$368.90
$117.62
$117.02
$142.72
$141.99
$164.13
$163.30
$181.39
$180.47
$181.73
$180.83
$24.28
$24.15
$14.26
$14.19
Arizona
EHR/eRx
Limiting
Charge**
$413.87
$349.08
$64.79
$615.00
$517.07
$97.91
$371.38
$306.53
$64.84
$443.30
$378.12
$65.18
$615.00
$517.07
$97.91
$246.15
$166.08
$80.06
$342.82
$245.67
$97.14
$404.35
$280.13
$124.23
$483.45
$367.02
$116.43
$141.27
$162.47
$179.55
$179.91
$24.02
$14.12
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$411.83
$407.66
$347.35
$343.85
$64.48
$63.81
$611.95
$605.77
$514.52
$509.32
$97.43
$96.44
$369.54
$365.82
$305.01
$301.93
$64.52
$63.86
$441.12
$436.66
$376.25
$372.45
$64.86
$64.20
$611.95
$605.77
$514.52
$509.32
$97.43
$96.44
$244.94
$242.45
$165.27
$163.59
$79.67
$78.87
$341.11
$337.67
$244.46
$241.99
$96.66
$95.68
$402.35
$398.29
$278.74
$275.93
$123.61
$122.37
$481.06
$476.19
$365.19
$361.51
$115.86
$114.68
$140.58
$139.15
$161.67
$160.03
$178.66
$176.86
$179.01
$177.20
$23.91
$23.67
$14.04
$13.92
Page 228 of 323
Notes
Procedure
Code
71010
71015
71015
71015
71020
71020
71020
71021
71021
71021
71022
71022
71022
71023
71023
71023
71030
71030
71030
71034
71034
71034
71035
71035
71035
71100
71100
71100
71101
71101
71101
71110
71110
1/2/2015
Modifier
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
Par Fee
$9.25
$27.44
$16.40
$11.04
$27.80
$16.76
$11.04
$33.88
$19.98
$13.90
$41.75
$24.98
$16.76
$63.47
$43.93
$19.53
$41.39
$25.70
$15.69
$84.21
$60.74
$23.47
$32.45
$23.20
$9.25
$30.30
$18.91
$11.40
$36.02
$22.48
$13.54
$37.10
$23.20
Nonpar Fee
$8.79
$26.07
$15.58
$10.49
$26.41
$15.92
$10.49
$32.19
$18.98
$13.21
$39.66
$23.73
$15.92
$60.30
$41.73
$18.55
$39.32
$24.42
$14.91
$80.00
$57.70
$22.30
$30.83
$22.04
$8.79
$28.79
$17.96
$10.83
$34.22
$21.36
$12.86
$35.25
$22.04
Limiting
Charge
$10.11
$29.98
$17.92
$12.06
$30.37
$18.31
$12.06
$37.02
$21.83
$15.19
$45.61
$27.29
$18.31
$69.35
$47.99
$21.33
$45.22
$28.08
$17.15
$92.00
$66.36
$25.65
$35.45
$25.35
$10.11
$33.11
$20.65
$12.45
$39.35
$24.56
$14.79
$40.54
$25.35
Charge**
Charge***
$10.01
$9.96
$29.68
$29.53
$17.73
$17.65
$11.95
$11.88
$30.07
$29.91
$18.12
$18.03
$11.95
$11.88
$36.65
$36.47
$21.61
$21.51
$15.04
$14.96
$45.15
$44.93
$27.01
$26.88
$18.12
$18.03
$68.66
$68.31
$47.51
$47.27
$21.11
$21.01
$44.77
$44.54
$27.81
$27.66
$16.97
$16.89
$91.08
$90.62
$65.69
$65.35
$25.39
$25.27
$35.10
$34.93
$25.09
$24.97
$10.01
$9.96
$32.78
$32.61
$20.45
$20.34
$12.33
$12.27
$38.96
$38.77
$24.32
$24.20
$14.64
$14.57
$40.14
$39.93
$25.09
$24.97
Arizona
EHR/eRx
Limiting
Charge**
$9.90
$29.38
$17.56
$11.82
$29.76
$17.94
$11.82
$36.28
$21.39
$14.89
$44.70
$26.75
$17.94
$67.95
$47.04
$20.91
$44.31
$27.52
$16.80
$90.16
$65.03
$25.13
$34.74
$24.84
$9.90
$32.44
$20.24
$12.20
$38.57
$24.07
$14.49
$39.73
$24.84
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$9.86
$9.75
$29.23
$28.95
$17.47
$17.30
$11.76
$11.65
$29.62
$29.31
$17.85
$17.68
$11.76
$11.65
$36.10
$35.74
$21.29
$21.07
$14.81
$14.67
$44.47
$44.03
$26.61
$26.35
$17.85
$17.68
$67.62
$66.93
$46.79
$46.33
$20.79
$20.60
$44.10
$43.64
$27.39
$27.11
$16.72
$16.55
$89.71
$88.80
$64.70
$64.06
$25.01
$24.75
$34.57
$34.22
$24.71
$24.47
$9.86
$9.75
$32.28
$31.96
$20.14
$19.94
$12.14
$12.02
$38.38
$38.00
$23.95
$23.71
$14.42
$14.27
$39.54
$39.13
$24.71
$24.47
Page 229 of 323
Notes
C
C
C
C
Procedure
Code
71110
71111
71111
71111
71120
71120
71120
71130
71130
71130
71250
71250
71250
71260
71260
71260
71270
71270
71270
71275
71275
71275
71550
71550
71550
71551
71551
71551
71552
71552
71552
71555
71555
1/2/2015
Modifier
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
Par Fee
$13.90
$47.11
$30.71
$16.40
$29.23
$18.91
$10.32
$35.98
$24.27
$11.71
$171.72
$120.09
$51.62
$229.24
$166.22
$63.02
$274.96
$205.19
$69.77
$300.17
$207.65
$92.52
$360.01
$286.31
$73.70
$458.16
$370.33
$87.83
$580.67
$465.44
$115.23
$398.49
$307.40
Nonpar Fee
$13.21
$44.75
$29.17
$15.58
$27.77
$17.96
$9.80
$34.18
$23.06
$11.12
$163.13
$114.09
$49.04
$217.78
$157.91
$59.87
$261.21
$194.93
$66.28
$285.16
$197.27
$87.89
$342.01
$271.99
$70.02
$435.25
$351.81
$83.44
$551.64
$442.17
$109.47
$378.57
$292.03
Limiting
Charge
$15.19
$51.46
$33.55
$17.92
$31.94
$20.65
$11.27
$39.31
$26.52
$12.79
$187.60
$131.20
$56.40
$250.45
$181.60
$68.85
$300.39
$224.17
$76.22
$327.93
$226.86
$101.07
$393.31
$312.79
$80.52
$500.54
$404.58
$95.96
$634.39
$508.50
$125.89
$435.36
$335.83
Charge**
Charge***
$15.04
$14.96
$50.95
$50.69
$33.21
$33.04
$17.73
$17.65
$31.61
$31.45
$20.45
$20.34
$11.16
$11.10
$38.92
$38.72
$26.25
$26.12
$12.66
$12.59
$185.73
$184.78
$129.89
$129.24
$55.83
$55.55
$247.94
$246.69
$179.78
$178.87
$68.16
$67.82
$297.39
$295.88
$221.93
$220.81
$75.46
$75.08
$324.66
$323.01
$224.60
$223.46
$100.06
$99.56
$389.38
$387.41
$309.66
$308.10
$79.72
$79.32
$495.54
$493.03
$400.53
$398.51
$95.00
$94.52
$628.04
$624.88
$503.41
$500.87
$124.64
$124.00
$431.00
$428.82
$332.48
$330.80
Arizona
EHR/eRx
Limiting
Charge**
$14.89
$50.44
$32.88
$17.56
$31.29
$20.24
$11.04
$38.53
$25.99
$12.54
$183.85
$128.58
$55.27
$245.43
$177.96
$67.47
$294.39
$219.68
$74.69
$321.38
$222.32
$99.05
$385.45
$306.53
$78.91
$490.53
$396.49
$94.04
$621.70
$498.33
$123.37
$426.65
$329.12
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$14.81
$14.67
$50.19
$49.68
$32.72
$32.38
$17.47
$17.30
$31.14
$30.82
$20.14
$19.94
$10.98
$10.88
$38.33
$37.95
$25.86
$25.60
$12.47
$12.35
$182.94
$181.09
$127.95
$126.65
$54.99
$54.44
$244.23
$241.75
$177.09
$175.29
$67.14
$66.46
$292.93
$289.97
$218.60
$216.38
$74.34
$73.58
$319.79
$316.56
$221.23
$218.98
$98.56
$97.57
$383.54
$379.66
$305.01
$301.93
$78.52
$77.73
$488.11
$483.17
$394.53
$390.54
$93.58
$92.62
$618.62
$612.38
$495.86
$490.85
$122.76
$121.52
$424.53
$420.26
$327.49
$324.19
Page 230 of 323
Notes
Procedure
Code
71555
72010
72010
72010
72020
72020
72020
72040
72040
72040
72050
72050
72050
72052
72052
72052
72069
72069
72069
72070
72070
72070
72072
72072
72072
72074
72074
72074
72080
72080
72080
72090
72090
1/2/2015
Modifier
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
Par Fee
$91.09
$70.26
$46.44
$23.82
$21.72
$13.90
$7.82
$33.12
$21.41
$11.71
$44.56
$28.56
$16.00
$55.96
$37.14
$18.82
$32.05
$20.34
$11.71
$31.33
$19.62
$11.71
$34.24
$23.20
$11.04
$38.88
$27.84
$11.04
$33.43
$21.41
$12.02
$42.69
$27.13
Nonpar Fee
$86.54
$66.75
$44.12
$22.63
$20.63
$13.21
$7.43
$31.46
$20.34
$11.12
$42.33
$27.13
$15.20
$53.16
$35.28
$17.88
$30.45
$19.32
$11.12
$29.76
$18.64
$11.12
$32.53
$22.04
$10.49
$36.94
$26.45
$10.49
$31.76
$20.34
$11.42
$40.56
$25.77
Limiting
Charge
$99.52
$76.76
$50.74
$26.02
$23.72
$15.19
$8.54
$36.18
$23.39
$12.79
$48.68
$31.20
$17.48
$61.13
$40.57
$20.56
$35.02
$22.22
$12.79
$34.22
$21.44
$12.79
$37.41
$25.35
$12.06
$42.48
$30.42
$12.06
$36.52
$23.39
$13.13
$46.64
$29.64
Charge**
Charge***
$98.52
$98.03
$75.99
$75.61
$50.23
$49.98
$25.76
$25.63
$23.48
$23.37
$15.04
$14.96
$8.46
$8.42
$35.82
$35.64
$23.16
$23.03
$12.66
$12.59
$48.20
$47.96
$30.89
$30.73
$17.31
$17.22
$60.52
$60.21
$40.17
$39.96
$20.36
$20.25
$34.67
$34.49
$22.00
$21.88
$12.66
$12.59
$33.88
$33.71
$21.22
$21.11
$12.66
$12.59
$37.03
$36.85
$25.09
$24.97
$11.95
$11.88
$42.06
$41.85
$30.12
$29.96
$11.95
$11.88
$36.16
$35.97
$23.16
$23.03
$13.01
$12.94
$46.17
$45.94
$29.34
$29.19
Arizona
EHR/eRx
Limiting
Charge**
$97.53
$75.23
$49.73
$25.51
$23.25
$14.89
$8.37
$35.45
$22.92
$12.54
$47.70
$30.58
$17.14
$59.92
$39.76
$20.15
$34.32
$21.77
$12.54
$33.53
$21.01
$12.54
$36.66
$24.84
$11.82
$41.63
$29.81
$11.82
$35.79
$22.92
$12.87
$45.71
$29.04
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$97.04
$96.07
$74.85
$74.11
$49.47
$48.98
$25.37
$25.13
$23.13
$22.91
$14.81
$14.67
$8.34
$8.25
$35.28
$34.93
$22.82
$22.57
$12.47
$12.35
$47.47
$46.99
$30.43
$30.12
$17.04
$16.88
$59.62
$59.02
$39.57
$39.16
$20.04
$19.85
$34.16
$33.80
$21.67
$21.45
$12.47
$12.35
$33.37
$33.03
$20.90
$20.70
$12.47
$12.35
$36.48
$36.11
$24.71
$24.47
$11.76
$11.65
$41.42
$41.01
$29.67
$29.36
$11.76
$11.65
$35.62
$35.25
$22.82
$22.57
$12.81
$12.67
$45.48
$45.02
$28.90
$28.60
Page 231 of 323
Notes
C
C
C
C
C
C
Procedure
Code
72090
72100
72100
72100
72110
72110
72110
72114
72114
72114
72120
72120
72120
72125
72125
72125
72126
72126
72126
72127
72127
72127
72128
72128
72128
72129
72129
72129
72130
72130
72130
72131
72131
1/2/2015
Modifier
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
Par Fee
$15.56
$34.91
$23.20
$11.71
$48.81
$32.49
$16.32
$62.39
$45.36
$17.03
$40.23
$28.20
$12.02
$174.22
$120.09
$54.13
$229.19
$167.29
$61.91
$270.36
$206.26
$64.09
$170.64
$120.09
$50.55
$229.24
$167.65
$61.59
$270.71
$206.62
$64.09
$170.64
$120.09
Nonpar Fee
$14.78
$33.16
$22.04
$11.12
$46.37
$30.87
$15.50
$59.27
$43.09
$16.18
$38.22
$26.79
$11.42
$165.51
$114.09
$51.42
$217.73
$158.93
$58.81
$256.84
$195.95
$60.89
$162.11
$114.09
$48.02
$217.78
$159.27
$58.51
$257.17
$196.29
$60.89
$162.11
$114.09
Limiting
Charge
$17.00
$38.13
$25.35
$12.79
$53.33
$35.50
$17.83
$68.16
$49.55
$18.61
$43.95
$30.81
$13.13
$190.34
$131.20
$59.13
$250.39
$182.77
$67.63
$295.37
$225.34
$70.02
$186.43
$131.20
$55.22
$250.45
$183.16
$67.29
$295.75
$225.73
$70.02
$186.43
$131.20
Charge**
Charge***
$16.82
$16.74
$37.75
$37.56
$25.09
$24.97
$12.66
$12.59
$52.80
$52.52
$35.14
$34.97
$17.65
$17.56
$67.48
$67.14
$49.06
$48.81
$18.42
$18.33
$43.52
$43.30
$30.50
$30.35
$13.01
$12.94
$188.43
$187.48
$129.89
$129.24
$58.55
$58.25
$247.88
$246.63
$180.94
$180.03
$66.95
$66.62
$292.41
$290.94
$223.09
$221.96
$69.32
$68.98
$184.56
$183.63
$129.89
$129.24
$54.67
$54.40
$247.94
$246.69
$181.33
$180.41
$66.61
$66.27
$292.79
$291.31
$223.48
$222.35
$69.32
$68.98
$184.56
$183.63
$129.89
$129.24
Arizona
EHR/eRx
Limiting
Charge**
$16.65
$37.38
$24.84
$12.54
$52.26
$34.79
$17.47
$66.79
$48.56
$18.24
$43.08
$30.19
$12.87
$186.53
$128.58
$57.95
$245.39
$179.11
$66.27
$289.46
$220.83
$68.62
$182.70
$128.58
$54.12
$245.43
$179.49
$65.94
$289.83
$221.21
$68.62
$182.70
$128.58
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$16.57
$16.40
$37.19
$36.81
$24.71
$24.47
$12.47
$12.35
$52.00
$51.47
$34.62
$34.27
$17.39
$17.20
$66.47
$65.79
$48.32
$47.84
$18.15
$17.96
$42.86
$42.44
$30.04
$29.74
$12.81
$12.67
$185.60
$183.74
$127.95
$126.65
$57.67
$57.07
$244.17
$241.71
$178.23
$176.42
$65.95
$65.29
$288.03
$285.11
$219.74
$217.52
$68.29
$67.59
$181.79
$179.96
$127.95
$126.65
$53.85
$53.30
$244.23
$241.75
$178.61
$176.80
$65.61
$64.95
$288.40
$285.49
$220.13
$217.89
$68.29
$67.59
$181.79
$179.96
$127.95
$126.65
Page 232 of 323
Notes
Procedure
Code
72131
72132
72132
72132
72133
72133
72133
72141
72141
72141
72142
72142
72142
72146
72146
72146
72147
72147
72147
72148
72148
72148
72149
72149
72149
72156
72156
72156
72157
72157
72157
72158
72158
1/2/2015
Modifier
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
Par Fee
$50.55
$228.48
$166.57
$61.91
$270.67
$206.26
$64.41
$223.12
$148.34
$74.78
$323.81
$233.08
$90.73
$223.12
$148.34
$74.78
$321.67
$230.93
$90.73
$222.04
$146.91
$75.13
$319.88
$229.14
$90.73
$379.81
$263.78
$116.03
$380.80
$264.14
$116.66
$378.65
$261.99
Nonpar Fee
$48.02
$217.06
$158.24
$58.81
$257.14
$195.95
$61.19
$211.96
$140.92
$71.04
$307.62
$221.43
$86.19
$211.96
$140.92
$71.04
$305.59
$219.38
$86.19
$210.94
$139.56
$71.37
$303.89
$217.68
$86.19
$360.82
$250.59
$110.23
$361.76
$250.93
$110.83
$359.72
$248.89
Limiting
Charge
$55.22
$249.62
$181.98
$67.63
$295.71
$225.34
$70.37
$243.75
$162.06
$81.70
$353.76
$254.64
$99.12
$243.75
$162.06
$81.70
$351.43
$252.29
$99.12
$242.58
$160.49
$82.08
$349.47
$250.33
$99.12
$414.94
$288.18
$126.76
$416.02
$288.57
$127.45
$413.68
$286.22
Charge**
Charge***
$54.67
$54.40
$247.12
$245.87
$180.16
$179.25
$66.95
$66.62
$292.76
$291.27
$223.09
$221.96
$69.67
$69.31
$241.32
$240.10
$160.44
$159.63
$80.88
$80.47
$350.22
$348.46
$252.10
$250.83
$98.13
$97.64
$241.32
$240.10
$160.44
$159.63
$80.88
$80.47
$347.91
$346.16
$249.77
$248.50
$98.13
$97.64
$240.15
$238.95
$158.88
$158.09
$81.26
$80.85
$345.98
$344.23
$247.83
$246.57
$98.13
$97.64
$410.79
$408.72
$285.29
$283.85
$125.50
$124.87
$411.86
$409.78
$285.68
$284.25
$126.18
$125.55
$409.54
$407.47
$283.36
$281.93
Arizona
EHR/eRx
Limiting
Charge**
$54.12
$244.63
$178.34
$66.27
$289.80
$220.83
$68.97
$238.88
$158.82
$80.06
$346.69
$249.55
$97.14
$238.88
$158.82
$80.06
$344.40
$247.24
$97.14
$237.73
$157.29
$80.43
$342.48
$245.33
$97.14
$406.64
$282.42
$124.23
$407.70
$282.80
$124.90
$405.41
$280.50
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$53.85
$53.30
$243.42
$240.96
$177.46
$175.66
$65.95
$65.29
$288.36
$285.45
$219.74
$217.52
$68.62
$67.93
$237.69
$235.29
$158.03
$156.43
$79.67
$78.87
$344.97
$341.49
$248.32
$245.81
$96.66
$95.68
$237.69
$235.29
$158.03
$156.43
$79.67
$78.87
$342.69
$339.24
$246.02
$243.54
$96.66
$95.68
$236.56
$234.16
$156.50
$154.93
$80.04
$79.22
$340.79
$337.34
$244.11
$241.65
$96.66
$95.68
$404.63
$400.55
$281.01
$278.19
$123.61
$122.37
$405.69
$401.58
$281.39
$278.55
$124.28
$123.03
$403.40
$399.33
$279.11
$276.29
Page 233 of 323
Notes
C
C
Procedure
Code
72158
72159
72159
72159
72170
72170
72170
72190
72190
72190
72191
72191
72191
72192
72192
72192
72193
72193
72193
72194
72194
72194
72195
72195
72195
72196
72196
72196
72197
72197
72197
72198
72198
1/2/2015
Modifier
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
Par Fee
$116.66
$418.07
$325.64
$92.43
$27.40
$18.19
$9.21
$38.13
$26.77
$11.35
$304.46
$213.01
$91.45
$146.33
$91.13
$55.20
$225.66
$166.93
$58.73
$260.34
$198.75
$61.59
$360.37
$286.31
$74.06
$411.72
$323.49
$88.23
$506.66
$391.43
$115.23
$402.43
$311.69
Nonpar Fee
$110.83
$397.17
$309.36
$87.81
$26.03
$17.28
$8.75
$36.22
$25.43
$10.78
$289.24
$202.36
$86.88
$139.01
$86.57
$52.44
$214.38
$158.58
$55.79
$247.32
$188.81
$58.51
$342.35
$271.99
$70.36
$391.13
$307.32
$83.82
$481.33
$371.86
$109.47
$382.31
$296.11
Limiting
Charge
$127.45
$456.75
$355.76
$100.98
$29.93
$19.87
$10.06
$41.65
$29.24
$12.40
$332.63
$232.71
$99.91
$159.86
$99.56
$60.31
$246.54
$182.37
$64.16
$284.42
$217.13
$67.29
$393.70
$312.79
$80.91
$449.80
$353.42
$96.39
$553.53
$427.64
$125.89
$439.66
$340.53
Charge**
Charge***
$126.18
$125.55
$452.18
$449.89
$352.21
$350.43
$99.97
$99.46
$29.64
$29.49
$19.68
$19.57
$9.96
$9.91
$41.24
$41.03
$28.96
$28.81
$12.27
$12.21
$329.30
$327.64
$230.39
$229.22
$98.91
$98.42
$158.26
$157.46
$98.56
$98.06
$59.71
$59.40
$244.08
$242.83
$180.54
$179.63
$63.51
$63.19
$281.58
$280.15
$214.96
$213.88
$66.61
$66.27
$389.77
$387.79
$309.66
$308.10
$80.11
$79.70
$445.30
$443.05
$349.89
$348.12
$95.43
$94.94
$548.00
$545.23
$423.36
$421.22
$124.64
$124.00
$435.26
$433.07
$337.12
$335.42
Arizona
EHR/eRx
Limiting
Charge**
$124.90
$447.61
$348.65
$98.96
$29.34
$19.47
$9.87
$40.83
$28.66
$12.14
$325.98
$228.06
$97.91
$156.66
$97.57
$59.10
$241.60
$178.72
$62.87
$278.73
$212.78
$65.94
$385.83
$306.53
$79.29
$440.81
$346.35
$94.46
$542.46
$419.08
$123.37
$430.86
$333.72
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$124.28
$123.03
$445.40
$440.90
$346.93
$343.41
$98.47
$97.47
$29.19
$28.90
$19.38
$19.18
$9.81
$9.72
$40.62
$40.22
$28.52
$28.23
$12.09
$11.96
$324.36
$321.09
$226.93
$224.64
$97.43
$96.44
$155.89
$154.32
$97.07
$96.11
$58.81
$58.21
$240.42
$237.98
$177.84
$176.04
$62.56
$61.93
$277.36
$274.54
$211.74
$209.59
$65.61
$64.95
$383.93
$380.04
$305.01
$301.93
$78.91
$78.11
$438.62
$434.19
$344.64
$341.15
$94.00
$93.05
$539.78
$534.31
$417.01
$412.79
$122.76
$121.52
$428.73
$424.40
$332.06
$328.72
Page 234 of 323
Notes
Procedure
Code
72198
72200
72200
72200
72202
72202
72202
72220
72220
72220
72240
72240
72240
72255
72255
72255
72265
72265
72265
72270
72270
72270
72275
72275
72275
72285
72285
72285
72295
72295
72295
73000
73000
1/2/2015
Modifier
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
Par Fee
$90.73
$28.16
$19.26
$8.89
$32.81
$23.20
$9.61
$27.80
$18.91
$8.89
$98.38
$51.80
$46.57
$97.70
$51.09
$46.62
$91.98
$49.66
$42.33
$127.29
$59.67
$67.63
$115.63
$75.76
$39.87
$114.42
$52.52
$61.91
$98.11
$54.66
$43.44
$27.76
$18.91
Nonpar Fee
$86.19
$26.75
$18.30
$8.45
$31.17
$22.04
$9.13
$26.41
$17.96
$8.45
$93.46
$49.21
$44.24
$92.82
$48.54
$44.29
$87.38
$47.18
$40.21
$120.93
$56.69
$64.25
$109.85
$71.97
$37.88
$108.70
$49.89
$58.81
$93.20
$51.93
$41.27
$26.37
$17.96
Limiting
Charge
$99.12
$30.76
$21.05
$9.72
$35.85
$25.35
$10.50
$30.37
$20.65
$9.72
$107.48
$56.59
$50.88
$106.74
$55.82
$50.93
$100.49
$54.26
$46.24
$139.07
$65.19
$73.89
$126.33
$82.77
$43.56
$125.01
$57.37
$67.63
$107.18
$59.72
$47.46
$30.33
$20.65
Charge**
Charge***
$98.13
$97.64
$30.45
$30.30
$20.84
$20.73
$9.63
$9.57
$35.49
$35.31
$25.09
$24.97
$10.40
$10.34
$30.07
$29.91
$20.45
$20.34
$9.63
$9.57
$106.41
$105.87
$56.03
$55.74
$50.37
$50.12
$105.67
$105.14
$55.26
$54.98
$50.43
$50.17
$99.49
$98.98
$53.72
$53.44
$45.78
$45.55
$137.68
$136.99
$64.54
$64.22
$73.15
$72.78
$125.06
$124.43
$81.94
$81.52
$43.13
$42.91
$123.75
$123.13
$56.80
$56.51
$66.95
$66.62
$106.11
$105.57
$59.12
$58.82
$46.99
$46.75
$30.03
$29.87
$20.45
$20.34
Arizona
EHR/eRx
Limiting
Charge**
$97.14
$30.15
$20.62
$9.52
$35.13
$24.84
$10.29
$29.76
$20.24
$9.52
$105.33
$55.46
$49.86
$104.60
$54.71
$49.91
$98.47
$53.18
$45.32
$136.29
$63.89
$72.42
$123.80
$81.11
$42.69
$122.51
$56.22
$66.27
$105.04
$58.52
$46.51
$29.72
$20.24
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$96.66
$95.68
$29.99
$29.70
$20.53
$20.31
$9.48
$9.38
$34.96
$34.60
$24.71
$24.47
$10.24
$10.14
$29.62
$29.31
$20.14
$19.94
$9.48
$9.38
$104.81
$103.75
$55.19
$54.64
$49.61
$49.12
$104.09
$103.04
$54.43
$53.89
$49.67
$49.16
$97.99
$97.00
$52.91
$52.38
$45.09
$44.64
$135.61
$134.24
$63.57
$62.94
$72.06
$71.33
$123.19
$121.95
$80.71
$79.89
$42.48
$42.04
$121.90
$120.67
$55.95
$55.38
$65.95
$65.29
$104.52
$103.47
$58.24
$57.65
$46.29
$45.80
$29.58
$29.27
$20.14
$19.94
Page 235 of 323
Notes
Procedure
Code
73000
73010
73010
73010
73020
73020
73020
73030
73030
73030
73040
73040
73040
73050
73050
73050
73060
73060
73060
73070
73070
73070
73080
73080
73080
73085
73085
73085
73090
73090
73090
73092
73092
1/2/2015
Modifier
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
Par Fee
$8.85
$29.90
$20.34
$9.57
$23.11
$14.97
$8.14
$28.83
$18.91
$9.92
$100.61
$72.54
$28.07
$35.62
$24.63
$11.00
$26.68
$17.48
$9.21
$27.40
$18.91
$8.49
$31.33
$22.12
$9.21
$98.51
$69.68
$28.83
$25.66
$17.12
$8.54
$27.09
$18.91
Nonpar Fee
$8.41
$28.41
$19.32
$9.09
$21.95
$14.22
$7.73
$27.39
$17.96
$9.42
$95.58
$68.91
$26.67
$33.84
$23.40
$10.45
$25.35
$16.61
$8.75
$26.03
$17.96
$8.07
$29.76
$21.01
$8.75
$93.58
$66.20
$27.39
$24.38
$16.26
$8.11
$25.74
$17.96
Limiting
Charge
$9.67
$32.67
$22.22
$10.45
$25.24
$16.35
$8.89
$31.50
$20.65
$10.83
$109.92
$79.25
$30.67
$38.92
$26.91
$12.02
$29.15
$19.10
$10.06
$29.93
$20.65
$9.28
$34.22
$24.16
$10.06
$107.62
$76.13
$31.50
$28.04
$18.70
$9.33
$29.60
$20.65
Charge**
Charge***
$9.58
$9.52
$32.35
$32.18
$22.00
$21.88
$10.35
$10.29
$24.99
$24.86
$16.19
$16.11
$8.80
$8.75
$31.19
$31.03
$20.45
$20.34
$10.73
$10.67
$108.81
$108.27
$78.45
$78.06
$30.36
$30.21
$38.53
$38.33
$26.65
$26.51
$11.90
$11.83
$28.87
$28.72
$18.91
$18.81
$9.96
$9.91
$29.64
$29.49
$20.45
$20.34
$9.19
$9.14
$33.88
$33.71
$23.92
$23.79
$9.96
$9.91
$106.54
$106.01
$75.37
$74.99
$31.19
$31.03
$27.76
$27.61
$18.52
$18.42
$9.23
$9.19
$29.30
$29.15
$20.45
$20.34
Arizona
EHR/eRx
Limiting
Charge**
$9.48
$32.02
$21.77
$10.25
$24.74
$16.03
$8.72
$30.87
$20.24
$10.61
$107.72
$77.66
$30.06
$38.13
$26.37
$11.78
$28.57
$18.72
$9.87
$29.34
$20.24
$9.10
$33.53
$23.68
$9.87
$105.47
$74.61
$30.87
$27.47
$18.32
$9.14
$29.01
$20.24
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$9.44
$9.34
$31.87
$31.53
$21.67
$21.45
$10.20
$10.10
$24.61
$24.37
$15.95
$15.79
$8.67
$8.59
$30.72
$30.41
$20.14
$19.94
$10.57
$10.45
$107.18
$106.10
$77.28
$76.50
$29.90
$29.61
$37.95
$37.56
$26.24
$25.98
$11.72
$11.60
$28.43
$28.14
$18.62
$18.45
$9.81
$9.72
$29.19
$28.90
$20.14
$19.94
$9.05
$8.96
$33.37
$33.03
$23.56
$23.32
$9.81
$9.72
$104.94
$103.88
$74.24
$73.50
$30.72
$30.41
$27.35
$27.06
$18.24
$18.04
$9.10
$9.00
$28.87
$28.58
$20.14
$19.94
Page 236 of 323
Notes
C
C
C
C
Procedure
Code
73092
73100
73100
73100
73110
73110
73110
73115
73115
73115
73120
73120
73120
73130
73130
73130
73140
73140
73140
73200
73200
73200
73201
73201
73201
73202
73202
73202
73206
73206
73206
73218
73218
1/2/2015
Modifier
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
Par Fee
$8.18
$29.19
$20.34
$8.85
$35.27
$26.06
$9.21
$107.04
$78.26
$28.79
$26.01
$17.48
$8.54
$30.30
$21.41
$8.89
$31.02
$23.91
$7.11
$170.64
$120.09
$50.55
$222.44
$163.71
$58.73
$277.86
$216.27
$61.59
$326.63
$235.54
$91.09
$354.33
$286.31
Nonpar Fee
$7.77
$27.73
$19.32
$8.41
$33.51
$24.76
$8.75
$101.69
$74.35
$27.35
$24.71
$16.61
$8.11
$28.79
$20.34
$8.45
$29.47
$22.71
$6.75
$162.11
$114.09
$48.02
$211.32
$155.52
$55.79
$263.97
$205.46
$58.51
$310.30
$223.76
$86.54
$336.61
$271.99
Limiting
Charge
$8.94
$31.89
$22.22
$9.67
$38.54
$28.47
$10.06
$116.94
$85.50
$31.45
$28.42
$19.10
$9.33
$33.11
$23.39
$9.72
$33.89
$26.12
$7.76
$186.43
$131.20
$55.22
$243.02
$178.85
$64.16
$303.57
$236.28
$67.29
$356.85
$257.32
$99.52
$387.10
$312.79
Charge**
Charge***
$8.84
$8.80
$31.57
$31.41
$22.00
$21.88
$9.58
$9.52
$38.15
$37.96
$28.19
$28.05
$9.96
$9.91
$115.77
$115.18
$84.65
$84.21
$31.14
$30.98
$28.13
$27.99
$18.91
$18.81
$9.23
$9.19
$32.78
$32.61
$23.16
$23.03
$9.63
$9.57
$33.56
$33.38
$25.85
$25.73
$7.68
$7.65
$184.56
$183.63
$129.89
$129.24
$54.67
$54.40
$240.59
$239.37
$177.05
$176.17
$63.51
$63.19
$300.53
$299.01
$233.92
$232.74
$66.61
$66.27
$353.28
$351.50
$254.75
$253.46
$98.52
$98.03
$383.23
$381.29
$309.66
$308.10
Arizona
EHR/eRx
Limiting
Charge**
$8.75
$31.26
$21.77
$9.48
$37.77
$27.90
$9.87
$114.61
$83.79
$30.82
$27.85
$18.72
$9.14
$32.44
$22.92
$9.52
$33.21
$25.60
$7.61
$182.70
$128.58
$54.12
$238.15
$175.27
$62.87
$297.49
$231.55
$65.94
$349.70
$252.17
$97.53
$379.36
$306.53
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$8.71
$8.63
$31.10
$30.79
$21.67
$21.45
$9.44
$9.34
$37.57
$37.20
$27.76
$27.49
$9.81
$9.72
$114.03
$112.90
$83.39
$82.54
$30.67
$30.36
$27.70
$27.44
$18.62
$18.45
$9.10
$9.00
$32.28
$31.96
$22.82
$22.57
$9.48
$9.38
$33.05
$32.72
$25.46
$25.22
$7.57
$7.50
$181.79
$179.96
$127.95
$126.65
$53.85
$53.30
$236.98
$234.58
$174.40
$172.64
$62.56
$61.93
$296.02
$293.03
$230.41
$228.08
$65.61
$64.95
$347.98
$344.46
$250.93
$248.39
$97.04
$96.07
$377.48
$373.67
$305.01
$301.93
Page 237 of 323
Notes
Procedure
Code
73218
73219
73219
73219
73220
73220
73220
73221
73221
73221
73222
73222
73222
73223
73223
73223
73225
73225
73225
73500
73500
73500
73510
73510
73510
73520
73520
73520
73525
73525
73525
73530
73540
1/2/2015
Modifier
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
26
Par Fee
$68.03
$404.17
$321.35
$82.82
$499.95
$390.71
$109.24
$235.63
$166.57
$69.06
$378.92
$296.36
$82.56
$469.56
$360.32
$109.24
$404.17
$317.77
$86.40
$26.33
$17.12
$9.21
$37.05
$25.70
$11.35
$39.51
$25.34
$14.17
$101.68
$72.54
$29.14
$14.93
$39.20
Nonpar Fee
$64.63
$383.96
$305.28
$78.68
$474.95
$371.17
$103.78
$223.85
$158.24
$65.61
$359.97
$281.54
$78.43
$446.08
$342.30
$103.78
$383.96
$301.88
$82.08
$25.01
$16.26
$8.75
$35.20
$24.42
$10.78
$37.53
$24.07
$13.46
$96.60
$68.91
$27.68
$14.18
$37.24
Limiting
Charge
$74.32
$441.55
$351.07
$90.48
$546.19
$426.85
$119.35
$257.43
$181.98
$75.45
$413.97
$323.77
$90.19
$512.99
$393.65
$119.35
$441.55
$347.16
$94.39
$28.76
$18.70
$10.06
$40.48
$28.08
$12.40
$43.16
$27.68
$15.48
$111.09
$79.25
$31.83
$16.31
$42.83
Charge**
Charge***
$73.58
$73.21
$437.14
$434.93
$347.56
$345.81
$89.57
$89.13
$540.73
$538.00
$422.58
$420.44
$118.15
$117.55
$254.85
$253.56
$180.16
$179.25
$74.69
$74.32
$409.83
$407.76
$320.53
$318.92
$89.30
$88.84
$507.86
$505.30
$389.71
$387.75
$118.15
$117.55
$437.14
$434.93
$343.69
$341.95
$93.45
$92.98
$28.47
$28.32
$18.52
$18.42
$9.96
$9.91
$40.08
$39.87
$27.81
$27.66
$12.27
$12.21
$42.72
$42.52
$27.40
$27.27
$15.33
$15.25
$109.97
$109.42
$78.45
$78.06
$31.51
$31.35
$16.15
$16.07
$42.40
$42.18
Arizona
EHR/eRx
Limiting
Charge**
$72.84
$432.72
$344.05
$88.68
$535.27
$418.31
$116.96
$252.28
$178.34
$73.95
$405.69
$317.30
$88.39
$502.73
$385.77
$116.96
$432.72
$340.22
$92.51
$28.19
$18.32
$9.87
$39.68
$27.52
$12.14
$42.30
$27.13
$15.17
$108.87
$77.66
$31.20
$15.99
$41.98
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$72.47
$71.75
$430.58
$426.24
$342.36
$338.88
$88.23
$87.34
$532.62
$527.24
$416.24
$412.03
$116.38
$115.20
$251.03
$248.49
$177.46
$175.66
$73.58
$72.84
$403.67
$399.60
$315.72
$312.54
$87.96
$87.07
$500.25
$495.19
$383.87
$379.98
$116.38
$115.20
$430.58
$426.24
$338.54
$335.11
$92.05
$91.11
$28.05
$27.76
$18.24
$18.04
$9.81
$9.72
$39.48
$39.08
$27.39
$27.11
$12.09
$11.96
$42.08
$41.66
$26.99
$26.73
$15.10
$14.94
$108.33
$107.24
$77.28
$76.50
$31.04
$30.73
$15.90
$15.74
$41.77
$41.34
Page 238 of 323
Notes
Procedure
Code
73540
73540
73550
73550
73550
73560
73560
73560
73562
73562
73562
73564
73564
73564
73565
73565
73565
73580
73580
73580
73590
73590
73590
73592
73592
73592
73600
73600
73600
73610
73610
73610
73615
1/2/2015
Modifier
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
Par Fee
$28.92
$10.28
$27.04
$17.83
$9.21
$29.19
$19.62
$9.57
$34.19
$24.27
$9.92
$39.87
$27.84
$12.02
$32.76
$23.20
$9.57
$114.95
$86.48
$28.47
$26.37
$17.48
$8.89
$27.09
$18.91
$8.18
$27.09
$18.55
$8.54
$31.33
$22.12
$9.21
$98.78
Nonpar Fee
$27.47
$9.77
$25.69
$16.94
$8.75
$27.73
$18.64
$9.09
$32.48
$23.06
$9.42
$37.88
$26.45
$11.42
$31.12
$22.04
$9.09
$109.20
$82.16
$27.05
$25.05
$16.61
$8.45
$25.74
$17.96
$7.77
$25.74
$17.62
$8.11
$29.76
$21.01
$8.75
$93.84
Limiting
Charge
$31.59
$11.24
$29.54
$19.48
$10.06
$31.89
$21.44
$10.45
$37.35
$26.52
$10.83
$43.56
$30.42
$13.13
$35.79
$25.35
$10.45
$125.58
$94.48
$31.11
$28.81
$19.10
$9.72
$29.60
$20.65
$8.94
$29.60
$20.26
$9.33
$34.22
$24.16
$10.06
$107.92
Charge**
Charge***
$31.28
$31.12
$11.12
$11.06
$29.24
$29.10
$19.29
$19.19
$9.96
$9.91
$31.57
$31.41
$21.22
$21.11
$10.35
$10.29
$36.98
$36.79
$26.25
$26.12
$10.73
$10.67
$43.13
$42.91
$30.12
$29.96
$13.01
$12.94
$35.43
$35.25
$25.09
$24.97
$10.35
$10.29
$124.33
$123.69
$93.54
$93.07
$30.80
$30.64
$28.52
$28.37
$18.91
$18.81
$9.63
$9.57
$29.30
$29.15
$20.45
$20.34
$8.84
$8.80
$29.30
$29.15
$20.06
$19.96
$9.23
$9.19
$33.88
$33.71
$23.92
$23.79
$9.96
$9.91
$106.84
$106.29
Arizona
EHR/eRx
Limiting
Charge**
$30.96
$11.01
$28.96
$19.09
$9.87
$31.26
$21.01
$10.25
$36.60
$25.99
$10.61
$42.69
$29.81
$12.87
$35.08
$24.84
$10.25
$123.07
$92.60
$30.49
$28.23
$18.72
$9.52
$29.01
$20.24
$8.75
$29.01
$19.86
$9.14
$33.53
$23.68
$9.87
$105.75
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$30.81
$30.50
$10.95
$10.84
$28.81
$28.52
$19.00
$18.80
$9.81
$9.72
$31.10
$30.79
$20.90
$20.70
$10.20
$10.10
$36.43
$36.05
$25.86
$25.60
$10.57
$10.45
$42.48
$42.04
$29.67
$29.36
$12.81
$12.67
$34.90
$34.55
$24.71
$24.47
$10.20
$10.10
$122.46
$121.22
$92.14
$91.21
$30.34
$30.03
$28.09
$27.81
$18.62
$18.45
$9.48
$9.38
$28.87
$28.58
$20.14
$19.94
$8.71
$8.63
$28.87
$28.58
$19.76
$19.56
$9.10
$9.00
$33.37
$33.03
$23.56
$23.32
$9.81
$9.72
$105.24
$104.17
Page 239 of 323
Notes
C
C
C
C
Procedure
Code
73615
73615
73620
73620
73620
73630
73630
73630
73650
73650
73650
73660
73660
73660
73700
73700
73700
73701
73701
73701
73702
73702
73702
73706
73706
73706
73718
73718
73718
73719
73719
73719
73720
1/2/2015
Modifier
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
Par Fee
$69.32
$29.46
$25.66
$17.83
$7.82
$28.87
$20.34
$8.54
$26.73
$18.55
$8.18
$27.80
$21.05
$6.75
$170.64
$120.09
$50.55
$225.66
$166.93
$58.73
$273.26
$212.34
$60.92
$351.34
$255.92
$95.43
$354.33
$286.31
$68.03
$404.97
$322.78
$82.20
$503.17
Nonpar Fee
$65.85
$27.99
$24.38
$16.94
$7.43
$27.43
$19.32
$8.11
$25.39
$17.62
$7.77
$26.41
$20.00
$6.41
$162.11
$114.09
$48.02
$214.38
$158.58
$55.79
$259.60
$201.72
$57.87
$333.77
$243.12
$90.66
$336.61
$271.99
$64.63
$384.72
$306.64
$78.09
$478.01
Limiting
Charge
$75.73
$32.19
$28.04
$19.48
$8.54
$31.54
$22.22
$9.33
$29.20
$20.26
$8.94
$30.37
$23.00
$7.37
$186.43
$131.20
$55.22
$246.54
$182.37
$64.16
$298.54
$231.98
$66.55
$383.84
$279.59
$104.26
$387.10
$312.79
$74.32
$442.43
$352.64
$89.80
$549.71
Charge**
Charge***
$74.97
$74.59
$31.87
$31.71
$27.76
$27.61
$19.29
$19.19
$8.46
$8.42
$31.23
$31.07
$22.00
$21.88
$9.23
$9.19
$28.91
$28.76
$20.06
$19.96
$8.84
$8.80
$30.07
$29.91
$22.77
$22.66
$7.30
$7.26
$184.56
$183.63
$129.89
$129.24
$54.67
$54.40
$244.08
$242.83
$180.54
$179.63
$63.51
$63.19
$295.55
$294.07
$229.66
$228.49
$65.88
$65.55
$379.99
$378.07
$276.79
$275.39
$103.21
$102.70
$383.23
$381.29
$309.66
$308.10
$73.58
$73.21
$438.00
$435.79
$349.11
$347.35
$88.91
$88.46
$544.21
$541.47
Arizona
EHR/eRx
Limiting
Charge**
$74.21
$31.54
$27.47
$19.09
$8.37
$30.91
$21.77
$9.14
$28.61
$19.86
$8.75
$29.76
$22.54
$7.22
$182.70
$128.58
$54.12
$241.60
$178.72
$62.87
$292.57
$227.34
$65.22
$376.15
$274.00
$102.18
$379.36
$306.53
$72.84
$433.58
$345.59
$88.01
$538.72
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$73.84
$73.09
$31.38
$31.07
$27.35
$27.06
$19.00
$18.80
$8.34
$8.25
$30.76
$30.45
$21.67
$21.45
$9.10
$9.00
$28.47
$28.19
$19.76
$19.56
$8.71
$8.63
$29.62
$29.31
$22.43
$22.21
$7.19
$7.12
$181.79
$179.96
$127.95
$126.65
$53.85
$53.30
$240.42
$237.98
$177.84
$176.04
$62.56
$61.93
$291.12
$288.18
$226.21
$223.93
$64.89
$64.24
$374.29
$370.51
$272.64
$269.89
$101.66
$100.65
$377.48
$373.67
$305.01
$301.93
$72.47
$71.75
$431.43
$427.08
$343.87
$340.40
$87.57
$86.69
$536.05
$530.63
Page 240 of 323
Notes
Procedure
Code
73720
73720
73721
73721
73721
73722
73722
73722
73723
73723
73723
73725
73725
73725
74000
74000
74000
74010
74010
74010
74020
74020
74020
74022
74022
74022
74150
74150
74150
74160
74160
74160
74170
1/2/2015
Modifier
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
Par Fee
$393.93
$109.24
$235.27
$166.57
$68.70
$382.09
$299.22
$82.87
$471.70
$362.46
$109.24
$403.50
$312.05
$91.45
$23.51
$14.26
$9.25
$34.95
$23.20
$11.76
$37.10
$23.55
$13.54
$43.89
$27.84
$16.05
$149.86
$89.70
$60.16
$230.67
$166.22
$64.45
$262.45
Nonpar Fee
$374.23
$103.78
$223.51
$158.24
$65.27
$362.99
$284.26
$78.73
$448.12
$344.34
$103.78
$383.33
$296.45
$86.88
$22.33
$13.55
$8.79
$33.20
$22.04
$11.17
$35.25
$22.37
$12.86
$41.70
$26.45
$15.25
$142.37
$85.22
$57.15
$219.14
$157.91
$61.23
$249.33
Limiting
Charge
$430.36
$119.35
$257.04
$181.98
$75.06
$417.44
$326.90
$90.54
$515.34
$395.99
$119.35
$440.83
$340.92
$99.91
$25.68
$15.58
$10.11
$38.18
$25.35
$12.85
$40.54
$25.73
$14.79
$47.96
$30.42
$17.54
$163.73
$98.00
$65.72
$252.01
$181.60
$70.41
$286.73
Charge**
Charge***
$426.06
$423.91
$118.15
$117.55
$254.46
$253.18
$180.16
$179.25
$74.31
$73.93
$413.26
$411.18
$323.63
$322.00
$89.63
$89.18
$510.19
$507.61
$392.04
$390.05
$118.15
$117.55
$436.43
$434.22
$337.51
$335.80
$98.91
$98.42
$25.43
$25.30
$15.42
$15.35
$10.01
$9.96
$37.80
$37.61
$25.09
$24.97
$12.72
$12.65
$40.14
$39.93
$25.47
$25.33
$14.64
$14.57
$47.47
$47.23
$30.12
$29.96
$17.37
$17.27
$162.09
$161.26
$97.03
$96.53
$65.07
$64.73
$249.49
$248.23
$179.78
$178.87
$69.71
$69.36
$283.87
$282.43
Arizona
EHR/eRx
Limiting
Charge**
$421.76
$116.96
$251.90
$178.34
$73.55
$409.09
$320.36
$88.73
$505.03
$388.07
$116.96
$432.01
$334.10
$97.91
$25.16
$15.27
$9.90
$37.42
$24.84
$12.59
$39.73
$25.21
$14.49
$47.00
$29.81
$17.19
$160.45
$96.05
$64.41
$246.97
$177.96
$69.01
$280.99
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$419.67
$415.44
$116.38
$115.20
$250.64
$248.11
$177.46
$175.66
$73.20
$72.45
$407.07
$402.95
$318.78
$315.55
$88.29
$87.40
$502.54
$497.46
$386.16
$382.25
$116.38
$115.20
$429.88
$425.53
$332.45
$329.08
$97.43
$96.44
$25.05
$24.78
$15.19
$15.04
$9.86
$9.75
$37.24
$36.86
$24.71
$24.47
$12.52
$12.41
$39.54
$39.13
$25.09
$24.83
$14.42
$14.27
$46.76
$46.30
$29.67
$29.36
$17.10
$16.94
$159.67
$158.04
$95.57
$94.61
$64.09
$63.45
$245.76
$243.27
$177.09
$175.29
$68.67
$67.98
$279.61
$276.77
Page 241 of 323
Notes
Procedure
Code
74170
74170
74174
74174
74174
74175
74175
74175
74176
74176
74176
74177
74177
74177
74178
74178
74178
74181
74181
74181
74182
74182
74182
74183
74183
74183
74185
74185
74185
74190
74210
74210
74210
1/2/2015
Modifier
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
26
TC
26
Par Fee
$191.60
$70.84
$389.34
$277.73
$111.61
$306.96
$215.16
$91.81
$200.46
$111.87
$88.59
$311.97
$219.13
$92.84
$353.09
$250.95
$102.13
$332.88
$259.18
$73.70
$455.34
$367.47
$87.87
$507.73
$392.50
$115.23
$403.50
$312.77
$90.73
$24.14
$77.46
$59.31
$18.15
Nonpar Fee
$182.02
$67.30
$369.87
$263.84
$106.03
$291.61
$204.40
$87.22
$190.44
$106.28
$84.16
$296.37
$208.17
$88.20
$335.44
$238.40
$97.02
$316.24
$246.22
$70.02
$432.57
$349.10
$83.48
$482.34
$372.88
$109.47
$383.33
$297.13
$86.19
$22.93
$73.59
$56.34
$17.24
Limiting
Charge
$209.32
$77.40
$425.35
$303.42
$121.93
$335.35
$235.06
$100.30
$219.01
$122.22
$96.78
$340.83
$239.40
$101.43
$385.76
$274.16
$111.57
$363.68
$283.15
$80.52
$497.46
$401.47
$96.00
$554.69
$428.81
$125.89
$440.83
$341.70
$99.12
$26.37
$84.63
$64.79
$19.83
Charge**
Charge***
$207.23
$206.18
$76.62
$76.23
$421.10
$418.97
$300.38
$298.86
$120.72
$120.11
$331.99
$330.33
$232.71
$231.53
$99.30
$98.80
$216.82
$215.72
$121.00
$120.39
$95.82
$95.34
$337.42
$335.71
$237.00
$235.81
$100.42
$99.91
$381.90
$379.97
$271.42
$270.04
$110.46
$109.89
$360.04
$358.23
$280.32
$278.91
$79.72
$79.32
$492.48
$489.99
$397.45
$395.44
$95.05
$94.56
$549.15
$546.37
$424.52
$422.38
$124.64
$124.00
$436.43
$434.22
$338.28
$336.57
$98.13
$97.64
$26.11
$25.98
$83.78
$83.36
$64.15
$63.81
$19.63
$19.53
Arizona
EHR/eRx
Limiting
Charge**
$205.14
$75.84
$416.84
$297.34
$119.50
$328.65
$230.36
$98.30
$214.62
$119.77
$94.85
$334.01
$234.61
$99.41
$378.04
$268.67
$109.34
$356.41
$277.50
$78.91
$487.51
$393.44
$94.08
$543.59
$420.23
$123.37
$432.01
$334.87
$97.14
$25.84
$82.94
$63.49
$19.44
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$204.13
$202.06
$75.47
$74.70
$414.78
$410.58
$295.87
$292.88
$118.91
$117.70
$327.01
$323.71
$229.22
$226.91
$97.81
$96.83
$213.57
$211.40
$119.19
$117.98
$94.38
$93.43
$332.36
$328.99
$233.45
$231.09
$98.91
$97.91
$376.18
$372.37
$267.35
$264.65
$108.80
$107.70
$354.64
$351.06
$276.12
$273.33
$78.52
$77.73
$485.09
$480.19
$391.49
$387.54
$93.62
$92.67
$540.91
$535.44
$418.15
$413.93
$122.76
$121.52
$429.88
$425.53
$333.21
$329.84
$96.66
$95.68
$25.71
$25.45
$82.52
$81.70
$63.18
$62.54
$19.33
$19.15
Page 242 of 323
Notes
C
C
C
C
C
C
Procedure
Code
74220
74220
74220
74230
74230
74230
74235
74240
74240
74240
74241
74241
74241
74245
74245
74245
74246
74246
74246
74247
74247
74247
74249
74249
74249
74250
74250
74250
74251
74251
74251
74260
74260
1/2/2015
Modifier
TC
26
TC
26
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
Par Fee
$88.50
$65.03
$23.47
$128.54
$101.50
$27.04
$64.05
$113.79
$78.26
$35.53
$117.46
$82.55
$34.91
$171.36
$125.10
$46.26
$128.05
$92.20
$35.85
$141.01
$105.79
$35.22
$183.52
$137.25
$46.26
$104.23
$80.05
$24.18
$186.42
$151.20
$35.22
$127.47
$101.86
Nonpar Fee
$84.08
$61.78
$22.30
$122.11
$96.43
$25.69
$60.85
$108.10
$74.35
$33.75
$111.59
$78.42
$33.16
$162.79
$118.85
$43.95
$121.65
$87.59
$34.06
$133.96
$100.50
$33.46
$174.34
$130.39
$43.95
$99.02
$76.05
$22.97
$177.10
$143.64
$33.46
$121.10
$96.77
Limiting
Charge
$96.69
$71.05
$25.65
$140.43
$110.89
$29.54
$69.98
$124.32
$85.50
$38.81
$128.33
$90.18
$38.13
$187.21
$136.68
$50.54
$139.90
$100.73
$39.17
$154.05
$115.58
$38.48
$200.49
$149.95
$50.54
$113.87
$87.46
$26.42
$203.67
$165.19
$38.48
$139.27
$111.29
Charge**
Charge***
$95.73
$95.24
$70.33
$69.98
$25.39
$25.27
$139.02
$138.32
$109.79
$109.23
$29.24
$29.10
$69.28
$68.93
$123.07
$122.45
$84.65
$84.21
$38.42
$38.23
$127.04
$126.41
$89.29
$88.83
$37.75
$37.56
$185.33
$184.40
$135.31
$134.63
$50.04
$49.78
$138.49
$137.80
$99.72
$99.22
$38.78
$38.58
$152.51
$151.74
$114.43
$113.84
$38.10
$37.90
$198.49
$197.48
$148.45
$147.69
$50.04
$49.78
$112.73
$112.16
$86.58
$86.15
$26.15
$26.02
$201.63
$200.61
$163.53
$162.71
$38.10
$37.90
$137.87
$137.17
$110.17
$109.62
Arizona
EHR/eRx
Limiting
Charge**
$94.76
$69.62
$25.13
$137.62
$108.68
$28.96
$68.57
$121.83
$83.79
$38.04
$125.76
$88.38
$37.38
$183.46
$133.94
$49.53
$137.10
$98.72
$38.39
$150.97
$113.26
$37.71
$196.48
$146.95
$49.53
$111.60
$85.71
$25.89
$199.59
$161.89
$37.71
$136.48
$109.05
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$94.29
$93.33
$69.28
$68.57
$25.01
$24.75
$136.94
$135.55
$108.15
$107.04
$28.81
$28.52
$68.24
$67.55
$121.22
$120.00
$83.39
$82.54
$37.85
$37.47
$125.13
$123.88
$87.95
$87.06
$37.19
$36.81
$182.55
$180.71
$133.29
$131.93
$49.29
$48.78
$136.41
$135.04
$98.22
$97.23
$38.19
$37.81
$150.22
$148.71
$112.71
$111.56
$37.52
$37.15
$195.51
$193.53
$146.22
$144.74
$49.29
$48.78
$111.04
$109.92
$85.28
$84.42
$25.76
$25.50
$198.61
$196.60
$161.08
$159.46
$37.52
$37.15
$135.80
$134.44
$108.51
$107.42
Page 243 of 323
Notes
C
C
C
C
C
C
Procedure
Code
74260
74261
74261
74261
74262
74262
74262
74270
74270
74270
74280
74280
74280
74283
74283
74283
74290
74290
74290
74300
74301
74305
74320
74320
74320
74327
74327
74327
74328
74329
74330
74340
74355
1/2/2015
Modifier
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
26
26
26
TC
26
TC
26
26
26
26
26
26
Par Fee
$25.61
$242.79
$120.09
$122.69
$368.60
$240.94
$127.66
$149.95
$114.73
$35.22
$201.35
$150.84
$50.51
$207.26
$101.86
$105.40
$69.95
$53.59
$16.36
$18.77
$10.95
$21.28
$93.14
$66.46
$26.68
$134.58
$99.71
$34.86
$36.92
$36.61
$46.89
$27.71
$39.74
Nonpar Fee
$24.33
$230.65
$114.09
$116.56
$350.17
$228.89
$121.28
$142.45
$108.99
$33.46
$191.28
$143.30
$47.98
$196.90
$96.77
$100.13
$66.45
$50.91
$15.54
$17.83
$10.40
$20.22
$88.48
$63.14
$25.35
$127.85
$94.72
$33.12
$35.07
$34.78
$44.55
$26.32
$37.75
Limiting
Charge
$27.98
$265.25
$131.20
$134.04
$402.70
$263.22
$139.47
$163.82
$125.34
$38.48
$219.97
$164.80
$55.18
$226.44
$111.29
$115.15
$76.42
$58.55
$17.87
$20.50
$11.96
$23.25
$101.75
$72.61
$29.15
$147.03
$108.93
$38.09
$40.33
$40.00
$51.23
$30.27
$43.41
Charge**
Charge***
$27.70
$27.57
$262.59
$261.27
$129.89
$129.24
$132.70
$132.03
$398.67
$396.66
$260.59
$259.28
$138.08
$137.38
$162.18
$161.36
$124.09
$123.46
$38.10
$37.90
$217.78
$216.67
$163.15
$162.32
$54.63
$54.35
$224.17
$223.04
$110.17
$109.62
$114.00
$113.42
$75.66
$75.27
$57.96
$57.67
$17.69
$17.61
$20.30
$20.19
$11.85
$11.78
$23.02
$22.91
$100.74
$100.22
$71.89
$71.52
$28.87
$28.72
$145.56
$144.82
$107.84
$107.30
$37.71
$37.51
$39.93
$39.72
$39.59
$39.40
$50.72
$50.46
$29.97
$29.82
$42.98
$42.76
Arizona
EHR/eRx
Limiting
Charge**
$27.42
$259.95
$128.58
$131.36
$394.65
$257.96
$136.68
$160.54
$122.83
$37.71
$215.57
$161.49
$54.07
$221.90
$109.05
$112.85
$74.89
$57.37
$17.51
$20.09
$11.72
$22.79
$99.72
$71.16
$28.57
$144.08
$106.75
$37.33
$39.53
$39.19
$50.21
$29.66
$42.55
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$27.29
$27.00
$258.65
$256.05
$127.95
$126.65
$130.71
$129.40
$392.69
$388.72
$256.68
$254.09
$136.01
$134.63
$159.75
$158.14
$122.22
$120.99
$37.52
$37.15
$214.51
$212.34
$160.70
$159.07
$53.81
$53.26
$220.81
$218.58
$108.51
$107.42
$112.29
$111.16
$74.52
$73.76
$57.09
$56.51
$17.42
$17.25
$20.00
$19.79
$11.67
$11.55
$22.68
$22.45
$99.23
$98.22
$70.81
$70.09
$28.43
$28.14
$143.37
$141.92
$106.21
$105.16
$37.15
$36.77
$39.33
$38.93
$39.00
$38.61
$49.96
$49.46
$29.52
$29.21
$42.33
$41.92
Page 244 of 323
Notes
Procedure
Code
74360
74363
74400
74400
74400
74410
74410
74410
74415
74415
74415
74420
74425
74430
74430
74430
74440
74440
74440
74445
74450
74455
74455
74455
74470
74475
74475
74475
74480
74480
74480
74485
74485
1/2/2015
Modifier
26
26
TC
26
TC
26
TC
26
26
26
TC
26
TC
26
26
26
TC
26
26
TC
26
TC
26
TC
Par Fee
$28.74
$44.66
$109.28
$84.69
$24.58
$106.46
$82.55
$23.91
$136.45
$111.87
$24.58
$18.15
$18.10
$37.10
$21.05
$16.05
$79.65
$61.10
$18.55
$58.51
$16.72
$81.43
$65.03
$16.40
$26.60
$92.43
$65.74
$26.68
$92.43
$65.74
$26.68
$91.80
$65.74
Nonpar Fee
$27.30
$42.43
$103.82
$80.46
$23.35
$101.14
$78.42
$22.71
$129.63
$106.28
$23.35
$17.24
$17.20
$35.25
$20.00
$15.25
$75.67
$58.05
$17.62
$55.58
$15.88
$77.36
$61.78
$15.58
$25.27
$87.81
$62.45
$25.35
$87.81
$62.45
$25.35
$87.21
$62.45
Limiting
Charge
$31.40
$48.79
$119.39
$92.53
$26.85
$116.31
$90.18
$26.12
$149.07
$122.22
$26.85
$19.83
$19.78
$40.54
$23.00
$17.54
$87.02
$66.76
$20.26
$63.92
$18.26
$88.96
$71.05
$17.92
$29.06
$100.98
$71.82
$29.15
$100.98
$71.82
$29.15
$100.29
$71.82
Charge**
Charge***
$31.08
$30.92
$48.31
$48.06
$118.20
$117.60
$91.61
$91.14
$26.59
$26.45
$115.15
$114.56
$89.29
$88.83
$25.85
$25.73
$147.58
$146.84
$121.00
$120.39
$26.59
$26.45
$19.63
$19.53
$19.58
$19.48
$40.14
$39.93
$22.77
$22.66
$17.37
$17.27
$86.15
$85.71
$66.09
$65.76
$20.06
$19.96
$63.27
$62.96
$18.08
$17.99
$88.08
$87.63
$70.33
$69.98
$17.73
$17.65
$28.77
$28.62
$99.97
$99.46
$71.10
$70.74
$28.87
$28.72
$99.97
$99.46
$71.10
$70.74
$28.87
$28.72
$99.29
$98.79
$71.10
$70.74
Arizona
EHR/eRx
Limiting
Charge**
$30.76
$47.82
$117.00
$90.68
$26.31
$113.99
$88.38
$25.60
$146.10
$119.77
$26.31
$19.44
$19.39
$39.73
$22.54
$17.19
$85.28
$65.42
$19.86
$62.64
$17.89
$87.18
$69.62
$17.56
$28.47
$98.96
$70.38
$28.57
$98.96
$70.38
$28.57
$98.29
$70.38
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$30.61
$30.30
$47.59
$47.10
$116.43
$115.24
$90.24
$89.32
$26.19
$25.92
$113.42
$112.27
$87.95
$87.06
$25.46
$25.22
$145.37
$143.90
$119.19
$117.98
$26.19
$25.92
$19.33
$19.15
$19.29
$19.10
$39.54
$39.13
$22.43
$22.21
$17.10
$16.94
$84.86
$84.01
$65.10
$64.45
$19.76
$19.56
$62.32
$61.70
$17.80
$17.63
$86.76
$85.87
$69.28
$68.57
$17.47
$17.30
$28.34
$28.05
$98.47
$97.47
$70.04
$69.32
$28.43
$28.14
$98.47
$97.47
$70.04
$69.32
$28.43
$28.14
$97.80
$96.82
$70.04
$69.32
Page 245 of 323
Notes
C
C
C
C
C
C
Procedure
Code
74485
74710
74710
74710
74740
74740
74740
74742
74775
75557
75557
75557
75559
75559
75559
75561
75561
75561
75563
75563
75563
75565
75565
75565
75571
75571
75571
75572
75572
75572
75573
75573
75573
1/2/2015
Modifier
26
TC
26
TC
26
26
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
Par Fee
$26.06
$39.91
$22.12
$17.79
$75.27
$55.73
$19.53
$31.60
$31.96
$318.36
$200.54
$117.82
$431.03
$286.35
$144.68
$424.82
$294.57
$130.25
$504.15
$354.60
$149.55
$55.33
$42.86
$12.47
$58.46
$29.27
$29.19
$284.84
$196.92
$87.92
$342.72
$216.23
$126.49
Nonpar Fee
$24.76
$37.91
$21.01
$16.90
$71.51
$52.94
$18.55
$30.02
$30.36
$302.44
$190.51
$111.93
$409.48
$272.03
$137.45
$403.58
$279.84
$123.74
$478.94
$336.87
$142.07
$52.56
$40.72
$11.85
$55.54
$27.81
$27.73
$270.60
$187.07
$83.52
$325.58
$205.42
$120.17
Limiting
Charge
$28.47
$43.60
$24.16
$19.44
$82.24
$60.88
$21.33
$34.52
$34.91
$347.81
$219.09
$128.72
$470.90
$312.83
$158.07
$464.12
$321.82
$142.30
$550.78
$387.40
$163.38
$60.44
$46.83
$13.63
$63.87
$31.98
$31.89
$311.19
$215.13
$96.05
$374.42
$236.23
$138.20
Charge**
Charge***
$28.19
$28.05
$43.16
$42.94
$23.92
$23.79
$19.24
$19.15
$81.41
$81.01
$60.27
$59.97
$21.11
$21.01
$34.18
$34.01
$34.57
$34.39
$344.33
$342.59
$216.89
$215.80
$127.43
$126.79
$466.20
$463.84
$309.71
$308.14
$156.49
$155.70
$459.47
$457.16
$318.60
$316.99
$140.88
$140.16
$545.27
$542.52
$383.53
$381.59
$161.75
$160.93
$59.83
$59.54
$46.36
$46.13
$13.49
$13.42
$63.23
$62.92
$31.66
$31.50
$31.57
$31.41
$308.07
$306.52
$212.98
$211.90
$95.08
$94.61
$370.67
$368.81
$233.88
$232.69
$136.82
$136.13
Arizona
EHR/eRx
Limiting
Charge**
$27.90
$42.72
$23.68
$19.04
$80.59
$59.66
$20.91
$33.83
$34.21
$340.85
$214.71
$126.14
$461.48
$306.58
$154.91
$454.84
$315.38
$139.46
$539.76
$379.65
$160.11
$59.24
$45.90
$13.35
$62.59
$31.34
$31.26
$304.97
$210.83
$94.13
$366.93
$231.51
$135.44
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$27.76
$27.49
$42.52
$42.08
$23.56
$23.32
$18.95
$18.76
$80.19
$79.38
$59.36
$58.77
$20.79
$20.60
$33.66
$33.33
$34.05
$33.70
$339.17
$335.73
$213.64
$211.49
$125.52
$124.25
$459.21
$454.56
$305.06
$301.98
$154.15
$152.58
$452.58
$448.02
$313.81
$310.65
$138.76
$137.37
$537.10
$531.67
$377.78
$373.96
$159.32
$157.71
$58.94
$58.35
$45.67
$45.21
$13.28
$13.16
$62.28
$61.65
$31.19
$30.87
$31.10
$30.79
$303.45
$300.39
$209.78
$207.67
$93.66
$92.71
$365.11
$361.42
$230.37
$228.03
$134.77
$133.40
Page 246 of 323
Notes
C
C
Procedure
Code
75574
75574
75574
75600
75600
75600
75605
75605
75605
75625
75625
75625
75630
75630
75630
75635
75635
75635
75658
75658
75658
75705
75705
75705
75710
75710
75710
75716
75716
75716
75726
75726
75726
1/2/2015
Modifier
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
Par Fee
$335.57
$215.91
$119.65
$200.46
$174.44
$26.02
$139.59
$82.55
$57.04
$139.41
$82.19
$57.22
$172.40
$82.19
$90.21
$380.04
$259.09
$120.95
$167.04
$101.10
$65.94
$236.93
$128.63
$108.30
$161.57
$106.82
$54.75
$186.96
$121.84
$65.13
$150.71
$93.63
$57.08
Nonpar Fee
$318.79
$205.11
$113.67
$190.44
$165.72
$24.72
$132.61
$78.42
$54.19
$132.44
$78.08
$54.36
$163.78
$78.08
$85.70
$361.04
$246.14
$114.90
$158.69
$96.05
$62.64
$225.08
$122.20
$102.89
$153.49
$101.48
$52.01
$177.61
$115.75
$61.87
$143.17
$88.95
$54.23
Limiting
Charge
$366.61
$235.88
$130.72
$219.01
$190.58
$28.43
$152.50
$90.18
$62.32
$152.31
$89.79
$62.51
$188.35
$89.79
$98.56
$415.20
$283.06
$132.14
$182.49
$110.46
$72.04
$258.84
$140.53
$118.32
$176.51
$116.70
$59.81
$204.25
$133.11
$71.15
$164.65
$102.29
$62.36
Charge**
Charge***
$362.94
$361.11
$233.52
$232.33
$129.41
$128.75
$216.82
$215.72
$188.67
$187.71
$28.14
$28.00
$150.97
$150.21
$89.29
$88.83
$61.70
$61.39
$150.79
$150.02
$88.90
$88.45
$61.89
$61.57
$186.46
$185.52
$88.90
$88.45
$97.57
$97.07
$411.04
$408.96
$280.23
$278.82
$130.81
$130.16
$180.67
$179.76
$109.35
$108.80
$71.31
$70.96
$256.25
$254.96
$139.13
$138.43
$117.14
$116.55
$174.75
$173.87
$115.54
$114.95
$59.21
$58.91
$202.20
$201.19
$131.78
$131.11
$70.44
$70.08
$163.00
$162.17
$101.27
$100.76
$61.74
$61.43
Arizona
EHR/eRx
Limiting
Charge**
$359.27
$231.16
$128.11
$214.62
$186.77
$27.86
$149.45
$88.38
$61.08
$149.26
$88.00
$61.26
$184.58
$88.00
$96.59
$406.89
$277.40
$129.49
$178.85
$108.25
$70.60
$253.67
$137.72
$115.95
$172.98
$114.37
$58.62
$200.17
$130.46
$69.72
$161.36
$100.25
$61.12
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$357.50
$353.88
$230.01
$227.69
$127.47
$126.19
$213.57
$211.40
$185.84
$183.97
$27.72
$27.45
$148.71
$147.21
$87.95
$87.06
$60.78
$60.16
$148.52
$147.02
$87.56
$86.68
$60.96
$60.34
$183.67
$181.80
$87.56
$86.68
$96.11
$95.14
$404.88
$400.79
$276.02
$273.24
$128.85
$127.55
$177.95
$176.17
$107.71
$106.63
$70.24
$69.54
$252.41
$249.86
$137.05
$135.65
$115.38
$114.22
$172.13
$170.38
$113.80
$112.65
$58.33
$57.74
$199.17
$197.17
$129.80
$128.50
$69.38
$68.68
$160.55
$158.94
$99.75
$98.74
$60.81
$60.20
Page 247 of 323
Notes
Procedure
Code
75731
75731
75731
75733
75733
75733
75736
75736
75736
75741
75741
75741
75743
75743
75743
75746
75746
75746
75756
75756
75756
75774
75774
75774
75791
75791
75791
75801
75803
75805
75807
75809
75809
1/2/2015
Modifier
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
26
26
26
26
TC
Par Fee
$171.36
$113.97
$57.39
$183.47
$118.98
$64.50
$163.23
$104.67
$58.56
$152.59
$87.91
$64.68
$170.74
$88.99
$81.75
$153.88
$97.57
$56.32
$169.90
$111.11
$58.79
$88.09
$70.04
$18.06
$321.22
$238.08
$83.14
$45.29
$61.01
$41.88
$61.01
$99.27
$75.40
Nonpar Fee
$162.79
$108.27
$54.52
$174.30
$113.03
$61.28
$155.07
$99.44
$55.63
$144.96
$83.51
$61.45
$162.20
$84.54
$77.66
$146.19
$92.69
$53.50
$161.41
$105.55
$55.85
$83.69
$66.54
$17.16
$305.16
$226.18
$78.98
$43.03
$57.96
$39.79
$57.96
$94.31
$71.63
Limiting
Charge
$187.21
$124.51
$62.70
$200.45
$129.98
$70.47
$178.33
$114.36
$63.97
$166.70
$96.04
$70.67
$186.53
$97.22
$89.31
$168.12
$106.59
$61.53
$185.62
$121.38
$64.23
$96.24
$76.52
$19.73
$350.93
$260.11
$90.83
$49.48
$66.65
$45.76
$66.65
$108.46
$82.37
Charge**
Charge***
$185.33
$184.40
$123.27
$122.65
$62.07
$61.76
$198.44
$197.44
$128.69
$128.03
$69.77
$69.41
$176.55
$175.65
$113.22
$112.64
$63.33
$63.02
$165.04
$164.21
$95.07
$94.60
$69.97
$69.61
$184.67
$183.74
$96.24
$95.76
$88.41
$87.98
$166.44
$165.60
$105.52
$105.00
$60.92
$60.61
$183.77
$182.84
$120.16
$119.57
$63.58
$63.26
$95.28
$94.79
$75.75
$75.37
$19.54
$19.44
$347.43
$345.67
$257.51
$256.21
$89.92
$89.47
$48.99
$48.74
$65.99
$65.65
$45.30
$45.07
$65.99
$65.65
$107.38
$106.84
$81.55
$81.14
Arizona
EHR/eRx
Limiting
Charge**
$183.46
$122.02
$61.44
$196.43
$127.39
$69.06
$174.77
$112.07
$62.70
$163.37
$94.12
$69.25
$182.80
$95.28
$87.53
$164.76
$104.47
$60.29
$181.91
$118.96
$62.94
$94.32
$74.99
$19.34
$343.92
$254.91
$89.01
$48.50
$65.32
$44.84
$65.32
$106.28
$80.73
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$182.55
$180.71
$121.42
$120.19
$61.13
$60.52
$195.47
$193.49
$126.75
$125.48
$68.72
$68.02
$173.90
$172.14
$111.52
$110.39
$62.38
$61.76
$162.56
$160.92
$93.64
$92.70
$68.92
$68.22
$181.90
$180.07
$94.79
$93.85
$87.09
$86.22
$163.94
$162.29
$103.94
$102.90
$60.01
$59.39
$181.01
$179.18
$118.36
$117.17
$62.63
$62.00
$93.85
$92.91
$74.61
$73.86
$19.25
$19.06
$342.22
$338.76
$253.64
$251.09
$88.57
$87.68
$48.25
$47.77
$65.00
$64.34
$44.62
$44.17
$65.00
$64.34
$105.77
$104.68
$80.33
$79.52
Page 248 of 323
Notes
Procedure
Code
75809
75810
75820
75820
75820
75822
75822
75822
75825
75825
75825
75827
75827
75827
75831
75831
75831
75833
75833
75833
75840
75840
75840
75842
75842
75842
75860
75860
75860
75870
75870
75870
75872
1/2/2015
Modifier
26
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
Par Fee
$23.87
$59.58
$115.85
$80.40
$35.45
$137.93
$85.05
$52.88
$137.35
$80.05
$57.31
$138.51
$82.19
$56.32
$141.24
$86.12
$55.11
$168.43
$91.49
$76.94
$149.46
$91.13
$58.33
$181.51
$105.07
$76.43
$144.64
$87.56
$57.08
$149.10
$90.77
$58.33
$149.82
Nonpar Fee
$22.68
$56.60
$110.06
$76.38
$33.68
$131.03
$80.80
$50.24
$130.48
$76.05
$54.44
$131.58
$78.08
$53.50
$134.18
$81.81
$52.35
$160.01
$86.92
$73.09
$141.99
$86.57
$55.41
$172.43
$99.82
$72.61
$137.41
$83.18
$54.23
$141.65
$86.23
$55.41
$142.33
Limiting
Charge
$26.08
$65.09
$126.57
$87.84
$38.73
$150.68
$92.92
$57.78
$150.05
$87.46
$62.61
$151.32
$89.79
$61.53
$154.31
$94.08
$60.20
$184.01
$99.96
$84.05
$163.29
$99.56
$63.72
$198.29
$114.79
$83.50
$158.02
$95.66
$62.36
$162.90
$99.16
$63.72
$163.68
Charge**
Charge***
$25.82
$25.69
$64.43
$64.11
$125.30
$124.67
$86.96
$86.51
$38.34
$38.15
$149.18
$148.42
$91.99
$91.53
$57.20
$56.91
$148.56
$147.80
$86.58
$86.15
$61.99
$61.66
$149.80
$149.05
$88.90
$88.45
$60.92
$60.61
$152.77
$152.00
$93.14
$92.67
$59.60
$59.29
$182.17
$181.25
$98.96
$98.46
$83.21
$82.79
$161.66
$160.84
$98.56
$98.06
$63.09
$62.77
$196.32
$195.32
$113.64
$113.07
$82.66
$82.25
$156.45
$155.65
$94.70
$94.22
$61.74
$61.43
$161.26
$160.46
$98.18
$97.68
$63.09
$62.77
$162.05
$161.23
Arizona
EHR/eRx
Limiting
Charge**
$25.56
$63.79
$124.04
$86.08
$37.96
$147.67
$91.06
$56.63
$147.05
$85.71
$61.35
$148.29
$88.00
$60.29
$151.23
$92.20
$59.00
$180.33
$97.96
$82.37
$160.02
$97.57
$62.45
$194.33
$112.49
$81.83
$154.86
$93.75
$61.12
$159.64
$97.19
$62.45
$160.40
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$25.43
$25.19
$63.47
$62.84
$123.43
$122.18
$85.66
$84.79
$37.77
$37.39
$146.94
$145.45
$90.61
$89.69
$56.34
$55.78
$146.33
$144.84
$85.28
$84.42
$61.05
$60.43
$147.56
$146.07
$87.56
$86.68
$60.01
$59.39
$150.48
$148.96
$91.75
$90.82
$58.71
$58.11
$179.43
$177.63
$97.47
$96.49
$81.96
$81.14
$159.23
$157.62
$97.07
$96.11
$62.15
$61.51
$193.37
$191.42
$111.94
$110.80
$81.42
$80.60
$154.10
$152.54
$93.28
$92.35
$60.81
$60.20
$158.85
$157.25
$96.70
$95.73
$62.15
$61.51
$159.62
$158.00
Page 249 of 323
Notes
Procedure
Code
75872
75872
75880
75880
75880
75885
75885
75885
75887
75887
75887
75889
75889
75889
75891
75891
75891
75893
75893
75893
75894
75896
75898
75901
75901
75901
75902
75902
75902
75945
75946
75952
75953
1/2/2015
Modifier
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
26
26
26
TC
26
TC
26
26
26
26
26
Par Fee
$91.49
$58.33
$146.46
$110.08
$36.38
$158.62
$88.27
$70.35
$160.77
$89.34
$71.43
$144.81
$88.99
$55.83
$146.60
$89.70
$56.90
$119.24
$91.85
$27.40
$67.19
$69.43
$86.23
$175.42
$151.91
$23.51
$71.69
$52.52
$19.18
$20.12
$20.07
$230.46
$69.88
Nonpar Fee
$86.92
$55.41
$139.14
$104.58
$34.56
$150.69
$83.86
$66.83
$152.73
$84.87
$67.86
$137.57
$84.54
$53.04
$139.27
$85.22
$54.06
$113.28
$87.26
$26.03
$63.83
$65.96
$81.92
$166.65
$144.31
$22.33
$68.11
$49.89
$18.22
$19.11
$19.07
$218.94
$66.39
Limiting
Charge
$99.96
$63.72
$160.01
$120.27
$39.74
$173.29
$96.44
$76.85
$175.64
$97.60
$78.04
$158.21
$97.22
$61.00
$160.16
$98.00
$62.17
$130.27
$100.35
$29.93
$73.40
$75.85
$94.21
$191.65
$165.96
$25.68
$78.33
$57.37
$20.95
$21.98
$21.93
$251.78
$76.35
Charge**
Charge***
$98.96
$98.46
$63.09
$62.77
$158.41
$157.61
$119.06
$118.46
$39.34
$39.15
$171.56
$170.69
$95.47
$94.99
$76.08
$75.70
$173.88
$173.01
$96.62
$96.14
$77.26
$76.87
$156.62
$155.84
$96.24
$95.76
$60.39
$60.08
$158.56
$157.76
$97.03
$96.53
$61.55
$61.24
$128.97
$128.32
$99.35
$98.84
$29.64
$29.49
$72.67
$72.30
$75.10
$74.72
$93.27
$92.79
$189.73
$188.77
$164.30
$163.47
$25.43
$25.30
$77.54
$77.15
$56.80
$56.51
$20.75
$20.64
$21.76
$21.64
$21.71
$21.60
$249.26
$248.01
$75.59
$75.20
Arizona
EHR/eRx
Limiting
Charge**
$97.96
$62.45
$156.81
$117.86
$38.95
$169.83
$94.51
$75.31
$172.13
$95.65
$76.48
$155.04
$95.28
$59.78
$156.95
$96.05
$60.93
$127.66
$98.34
$29.34
$71.93
$74.34
$92.32
$187.82
$162.63
$25.16
$76.76
$56.22
$20.54
$21.54
$21.49
$246.74
$74.82
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$97.47
$96.49
$62.15
$61.51
$156.03
$154.46
$117.28
$116.09
$38.76
$38.36
$168.98
$167.28
$94.04
$93.09
$74.95
$74.19
$171.27
$169.54
$95.17
$94.21
$76.10
$75.33
$154.27
$152.72
$94.79
$93.85
$59.48
$58.88
$156.18
$154.59
$95.57
$94.61
$60.63
$60.02
$127.04
$125.74
$97.85
$96.86
$29.19
$28.90
$71.58
$70.85
$73.97
$73.22
$91.86
$90.94
$186.89
$185.00
$161.84
$160.20
$25.05
$24.78
$76.38
$75.61
$55.95
$55.38
$20.44
$20.23
$21.44
$21.22
$21.39
$21.17
$245.53
$243.04
$74.45
$73.69
Page 250 of 323
Notes
Procedure
Code
75954
75956
75957
75958
75959
75962
75962
75962
75964
75964
75964
75966
75966
75966
75968
75968
75968
75970
75978
75978
75978
75980
75982
75984
75984
75984
75989
75989
75989
76000
76000
76000
76001
1/2/2015
Modifier
26
26
26
26
26
TC
26
TC
26
TC
26
TC
26
26
TC
26
26
26
TC
26
TC
26
TC
26
26
Par Fee
$116.55
$358.86
$307.54
$204.71
$175.88
$138.87
$112.90
$25.97
$86.31
$68.96
$17.34
$171.72
$107.18
$64.55
$88.90
$71.11
$17.79
$41.17
$137.44
$111.47
$25.97
$73.40
$72.68
$106.69
$71.11
$35.58
$121.48
$61.81
$59.67
$47.06
$38.21
$8.85
$36.75
Nonpar Fee
$110.72
$340.92
$292.16
$194.47
$167.09
$131.93
$107.26
$24.67
$81.99
$65.51
$16.47
$163.13
$101.82
$61.32
$84.46
$67.55
$16.90
$39.11
$130.57
$105.90
$24.67
$69.73
$69.05
$101.36
$67.55
$33.80
$115.41
$58.72
$56.69
$44.71
$36.30
$8.41
$34.91
Limiting
Charge
$127.33
$392.06
$335.98
$223.64
$192.15
$151.72
$123.35
$28.37
$94.29
$75.34
$18.94
$187.60
$117.09
$70.52
$97.13
$77.68
$19.44
$44.98
$150.16
$121.79
$28.37
$80.19
$79.41
$116.56
$77.68
$38.87
$132.72
$67.53
$65.19
$51.42
$41.75
$9.67
$40.15
Charge**
Charge***
$126.05
$125.42
$388.14
$386.18
$332.63
$330.95
$221.41
$220.28
$190.23
$189.27
$150.20
$149.44
$122.12
$121.50
$28.08
$27.95
$93.35
$92.87
$74.58
$74.21
$18.76
$18.65
$185.73
$184.78
$115.92
$115.33
$69.82
$69.46
$96.16
$95.67
$76.90
$76.52
$19.24
$19.15
$44.53
$44.30
$148.65
$147.90
$120.57
$119.96
$28.08
$27.95
$79.38
$78.98
$78.61
$78.21
$115.40
$114.82
$76.90
$76.52
$38.48
$38.28
$131.40
$130.73
$66.85
$66.52
$64.54
$64.22
$50.90
$50.65
$41.33
$41.12
$9.58
$9.52
$39.74
$39.55
Arizona
EHR/eRx
Limiting
Charge**
$124.79
$384.22
$329.27
$219.17
$188.31
$148.68
$120.88
$27.81
$92.40
$73.83
$18.56
$183.85
$114.75
$69.10
$95.19
$76.13
$19.04
$44.08
$147.15
$119.35
$27.81
$78.59
$77.82
$114.23
$76.13
$38.09
$130.07
$66.18
$63.89
$50.39
$40.91
$9.48
$39.34
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$124.17
$122.91
$382.32
$378.45
$327.64
$324.33
$218.09
$215.88
$187.38
$185.48
$147.95
$146.45
$120.29
$119.06
$27.66
$27.39
$91.94
$91.01
$73.46
$72.73
$18.48
$18.29
$182.94
$181.09
$114.18
$113.02
$68.77
$68.07
$94.73
$93.76
$75.75
$74.99
$18.95
$18.76
$43.86
$43.42
$146.42
$144.95
$118.76
$117.55
$27.66
$27.39
$78.19
$77.41
$77.43
$76.65
$113.67
$112.52
$75.75
$74.99
$37.90
$37.51
$129.43
$128.11
$65.85
$65.19
$63.57
$62.94
$50.14
$49.63
$40.71
$40.30
$9.44
$9.34
$39.15
$38.76
Page 251 of 323
Notes
C
C
Procedure
Code
76010
76010
76010
76080
76080
76080
76098
76098
76098
76100
76100
76100
76101
76101
76101
76102
76102
76102
76120
76120
76120
76125
76376
76376
76376
76377
76377
76377
76380
76380
76380
76506
76506
1/2/2015
Modifier
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
26
TC
26
TC
26
TC
26
TC
Par Fee
$26.01
$16.76
$9.25
$55.24
$28.56
$26.68
$16.36
$8.18
$8.18
$92.70
$60.38
$32.32
$132.66
$97.21
$35.45
$174.44
$139.00
$35.45
$90.95
$70.75
$20.20
$14.84
$22.80
$12.83
$9.97
$64.14
$24.27
$39.87
$108.79
$59.31
$49.48
$119.56
$87.20
Nonpar Fee
$24.71
$15.92
$8.79
$52.48
$27.13
$25.35
$15.54
$7.77
$7.77
$88.07
$57.36
$30.70
$126.03
$92.35
$33.68
$165.72
$132.05
$33.68
$86.40
$67.21
$19.19
$14.10
$21.66
$12.19
$9.47
$60.93
$23.06
$37.88
$103.35
$56.34
$47.01
$113.58
$82.84
Limiting
Charge
$28.42
$18.31
$10.11
$60.35
$31.20
$29.15
$17.87
$8.94
$8.94
$101.28
$65.96
$35.31
$144.93
$106.20
$38.73
$190.58
$151.86
$38.73
$99.36
$77.29
$22.07
$16.22
$24.91
$14.02
$10.89
$70.07
$26.52
$43.56
$118.85
$64.79
$54.06
$130.62
$95.27
Charge**
Charge***
$28.13
$27.99
$18.12
$18.03
$10.01
$9.96
$59.75
$59.44
$30.89
$30.73
$28.87
$28.72
$17.69
$17.61
$8.84
$8.80
$8.84
$8.80
$100.27
$99.76
$65.31
$64.98
$34.95
$34.78
$143.49
$142.76
$105.14
$104.60
$38.34
$38.15
$188.67
$187.71
$150.34
$149.58
$38.34
$38.15
$98.37
$97.87
$76.52
$76.13
$21.85
$21.74
$16.05
$15.97
$24.66
$24.54
$13.88
$13.81
$10.79
$10.73
$69.37
$69.02
$26.25
$26.12
$43.13
$42.91
$117.67
$117.07
$64.15
$63.81
$53.52
$53.25
$129.31
$128.66
$94.31
$93.84
Arizona
EHR/eRx
Limiting
Charge**
$27.85
$17.94
$9.90
$59.14
$30.58
$28.57
$17.51
$8.75
$8.75
$99.26
$64.64
$34.60
$142.04
$104.08
$37.96
$186.77
$148.82
$37.96
$97.37
$75.75
$21.63
$15.89
$24.41
$13.74
$10.67
$68.67
$25.99
$42.69
$116.47
$63.49
$52.98
$128.01
$93.36
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$27.70
$27.44
$17.85
$17.68
$9.86
$9.75
$58.86
$58.26
$30.43
$30.12
$28.43
$28.14
$17.42
$17.25
$8.71
$8.63
$8.71
$8.63
$98.76
$97.77
$64.33
$63.68
$34.42
$34.09
$141.34
$139.91
$103.57
$102.51
$37.77
$37.39
$185.84
$183.97
$148.09
$146.59
$37.77
$37.39
$96.90
$95.91
$75.37
$74.61
$21.53
$21.31
$15.81
$15.65
$24.29
$24.05
$13.67
$13.54
$10.63
$10.51
$68.33
$67.63
$25.86
$25.60
$42.48
$42.04
$115.91
$114.72
$63.18
$62.54
$52.72
$52.19
$127.36
$126.09
$92.90
$91.95
Page 252 of 323
Notes
Procedure
Code
76506
76510
76510
76510
76511
76511
76511
76512
76512
76512
76513
76513
76513
76514
76514
76514
76516
76516
76516
76519
76519
76519
76529
76529
76529
76536
76536
76536
76604
76604
76604
76641
76641
1/2/2015
Modifier
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
Par Fee
$32.36
$171.53
$81.83
$89.70
$103.60
$49.66
$53.95
$93.59
$40.00
$53.59
$96.81
$60.38
$36.43
$15.29
$5.32
$9.97
$79.29
$47.87
$31.42
$85.01
$53.59
$31.42
$80.36
$47.51
$32.85
$117.14
$88.99
$28.16
$88.85
$61.10
$27.76
$109.15
$71.82
Nonpar Fee
$30.74
$162.95
$77.74
$85.22
$98.42
$47.18
$51.25
$88.91
$38.00
$50.91
$91.97
$57.36
$34.61
$14.53
$5.05
$9.47
$75.33
$45.48
$29.85
$80.76
$50.91
$29.85
$76.34
$45.13
$31.21
$111.28
$84.54
$26.75
$84.41
$58.05
$26.37
$103.69
$68.23
Limiting
Charge
$35.35
$187.39
$89.40
$98.00
$113.18
$54.26
$58.94
$102.25
$43.70
$58.55
$105.77
$65.96
$39.80
$16.71
$5.81
$10.89
$86.63
$52.30
$34.33
$92.87
$58.55
$34.33
$87.79
$51.90
$35.89
$127.97
$97.22
$30.76
$97.07
$66.76
$30.33
$119.24
$78.46
Charge**
Charge***
$34.99
$34.82
$185.52
$184.59
$88.50
$88.06
$97.03
$96.53
$112.06
$111.48
$53.72
$53.44
$58.35
$58.05
$101.22
$100.72
$43.26
$43.04
$57.96
$57.67
$104.71
$104.18
$65.31
$64.98
$39.40
$39.20
$16.54
$16.46
$5.75
$5.72
$10.79
$10.73
$85.77
$85.33
$51.78
$51.52
$33.98
$33.81
$91.94
$91.48
$57.96
$57.67
$33.98
$33.81
$86.92
$86.47
$51.38
$51.12
$35.54
$35.35
$126.70
$126.05
$96.24
$95.76
$30.45
$30.30
$96.11
$95.61
$66.09
$65.76
$30.03
$29.87
$118.05
$117.45
$77.68
$77.29
Arizona
EHR/eRx
Limiting
Charge**
$34.65
$183.64
$87.62
$96.05
$110.92
$53.18
$57.76
$100.20
$42.83
$57.37
$103.65
$64.64
$39.01
$16.38
$5.69
$10.67
$84.89
$51.26
$33.64
$91.01
$57.37
$33.64
$86.03
$50.86
$35.18
$125.41
$95.28
$30.15
$95.13
$65.42
$29.72
$116.86
$76.90
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$34.47
$34.13
$182.74
$180.88
$87.18
$86.31
$95.57
$94.61
$110.38
$109.25
$52.91
$52.38
$57.48
$56.90
$99.71
$98.69
$42.62
$42.18
$57.09
$56.51
$103.13
$102.10
$64.33
$63.68
$38.81
$38.42
$16.28
$16.13
$5.67
$5.61
$10.63
$10.51
$84.48
$83.62
$51.00
$50.49
$33.48
$33.13
$90.56
$89.64
$57.09
$56.51
$33.48
$33.13
$85.62
$84.74
$50.61
$50.11
$35.01
$34.65
$124.80
$123.52
$94.79
$93.85
$29.99
$29.70
$94.67
$93.70
$65.10
$64.45
$29.58
$29.27
$116.28
$115.12
$76.52
$75.75
Page 253 of 323
Notes
Procedure
Code
76641
76642
76642
76642
76700
76700
76700
76705
76705
76705
76770
76770
76770
76775
76775
76775
76776
76776
76776
76800
76800
76800
76801
76801
76801
76802
76802
76802
76805
76805
76805
76810
76810
1/2/2015
Modifier
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
Par Fee
$37.32
$89.84
$55.02
$34.82
$123.85
$82.91
$40.94
$92.43
$62.53
$29.90
$113.88
$76.83
$37.05
$57.79
$28.92
$28.87
$157.82
$119.38
$38.44
$138.87
$81.48
$57.39
$125.42
$73.61
$51.81
$66.15
$22.84
$43.31
$144.01
$92.20
$51.81
$95.74
$44.29
Nonpar Fee
$35.45
$85.35
$52.27
$33.08
$117.66
$78.76
$38.89
$87.81
$59.40
$28.41
$108.19
$72.99
$35.20
$54.90
$27.47
$27.43
$149.93
$113.41
$36.52
$131.93
$77.41
$54.52
$119.15
$69.93
$49.22
$62.84
$21.70
$41.14
$136.81
$87.59
$49.22
$90.95
$42.08
Limiting
Charge
$40.77
$98.15
$60.11
$38.04
$135.31
$90.57
$44.72
$100.98
$68.31
$32.67
$124.42
$83.94
$40.48
$63.14
$31.59
$31.54
$172.42
$130.42
$42.00
$151.72
$89.02
$62.70
$137.02
$80.42
$56.60
$72.27
$24.96
$47.31
$157.33
$100.73
$56.60
$104.59
$48.39
Charge**
Charge***
$40.37
$40.16
$97.18
$96.68
$59.51
$59.21
$37.66
$37.47
$133.95
$133.29
$89.67
$89.22
$44.28
$44.06
$99.97
$99.46
$67.63
$67.29
$32.35
$32.18
$123.18
$122.56
$83.10
$82.69
$40.08
$39.87
$62.50
$62.19
$31.28
$31.12
$31.23
$31.07
$170.69
$169.83
$129.12
$128.47
$41.57
$41.37
$150.20
$149.44
$88.14
$87.69
$62.07
$61.76
$135.65
$134.96
$79.61
$79.21
$56.04
$55.75
$71.54
$71.19
$24.70
$24.58
$46.84
$46.60
$155.76
$154.97
$99.72
$99.22
$56.04
$55.75
$103.55
$103.03
$47.91
$47.67
Arizona
EHR/eRx
Limiting
Charge**
$39.95
$96.19
$58.90
$37.28
$132.61
$88.76
$43.83
$98.96
$66.94
$32.02
$121.93
$82.26
$39.68
$61.87
$30.96
$30.91
$168.97
$127.81
$41.16
$148.68
$87.24
$61.44
$134.29
$78.81
$55.48
$70.82
$24.46
$46.37
$154.18
$98.72
$55.48
$102.50
$47.43
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$39.76
$39.35
$95.71
$94.75
$58.62
$58.02
$37.10
$36.72
$131.94
$130.62
$88.32
$87.42
$43.61
$43.17
$98.47
$97.47
$66.62
$65.94
$31.87
$31.53
$121.33
$120.11
$81.86
$81.03
$39.48
$39.08
$61.56
$60.94
$30.81
$30.50
$30.76
$30.45
$168.13
$166.44
$127.19
$125.89
$40.95
$40.54
$147.95
$146.45
$86.81
$85.93
$61.13
$60.52
$133.62
$132.27
$78.42
$77.63
$55.20
$54.65
$70.47
$69.76
$24.33
$24.09
$46.14
$45.68
$153.42
$151.87
$98.22
$97.23
$55.20
$54.65
$101.99
$100.96
$47.20
$46.71
Page 254 of 323
Notes
Procedure
Code
76810
76811
76811
76811
76812
76812
76812
76813
76813
76813
76814
76814
76814
76815
76815
76815
76816
76816
76816
76817
76817
76817
76818
76818
76818
76819
76819
76819
76820
76820
76820
76821
76821
1/2/2015
Modifier
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
Par Fee
$51.45
$183.66
$83.94
$99.72
$208.37
$114.37
$94.00
$122.83
$60.74
$62.09
$82.51
$30.35
$52.16
$85.55
$51.80
$33.75
$116.21
$71.82
$44.39
$98.38
$59.31
$39.07
$122.87
$67.53
$55.34
$89.79
$49.66
$40.14
$47.69
$21.77
$25.93
$93.73
$57.16
Nonpar Fee
$48.88
$174.48
$79.74
$94.73
$197.95
$108.65
$89.30
$116.69
$57.70
$58.99
$78.38
$28.83
$49.55
$81.27
$49.21
$32.06
$110.40
$68.23
$42.17
$93.46
$56.34
$37.12
$116.73
$64.15
$52.57
$85.30
$47.18
$38.13
$45.31
$20.68
$24.63
$89.04
$54.30
Limiting
Charge
$56.21
$200.65
$91.70
$108.94
$227.64
$124.95
$102.70
$134.19
$66.36
$67.84
$90.14
$33.15
$56.98
$93.46
$56.59
$36.87
$126.96
$78.46
$48.50
$107.48
$64.79
$42.69
$134.24
$73.77
$60.46
$98.10
$54.26
$43.85
$52.11
$23.78
$28.32
$102.40
$62.45
Charge**
Charge***
$55.65
$55.37
$198.65
$197.64
$90.78
$90.32
$107.85
$107.31
$225.37
$224.23
$123.69
$123.07
$101.67
$101.15
$132.85
$132.18
$65.69
$65.35
$67.16
$66.83
$89.24
$88.78
$32.82
$32.66
$56.41
$56.13
$92.53
$92.06
$56.03
$55.74
$36.50
$36.32
$125.70
$125.05
$77.68
$77.29
$48.01
$47.77
$106.41
$105.87
$64.15
$63.81
$42.26
$42.04
$132.89
$132.23
$73.04
$72.67
$59.85
$59.55
$97.12
$96.62
$53.72
$53.44
$43.41
$43.19
$51.59
$51.32
$23.54
$23.43
$28.04
$27.90
$101.37
$100.86
$61.82
$61.51
Arizona
EHR/eRx
Limiting
Charge**
$55.09
$196.64
$89.87
$106.77
$223.09
$122.45
$100.64
$131.51
$65.03
$66.48
$88.33
$32.49
$55.84
$91.59
$55.46
$36.13
$124.42
$76.90
$47.53
$105.33
$63.49
$41.84
$131.56
$72.30
$59.25
$96.13
$53.18
$42.98
$51.06
$23.31
$27.76
$100.35
$61.19
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$54.81
$54.26
$195.67
$193.69
$89.42
$88.53
$106.23
$105.17
$221.98
$219.74
$121.84
$120.61
$100.14
$99.13
$130.86
$129.54
$64.70
$64.06
$66.15
$65.48
$87.91
$87.01
$32.33
$32.00
$55.56
$55.00
$91.14
$90.22
$55.19
$54.64
$35.95
$35.59
$123.81
$122.56
$76.52
$75.75
$47.29
$46.82
$104.81
$103.75
$63.18
$62.54
$41.63
$41.20
$130.90
$129.58
$71.94
$71.22
$58.95
$58.36
$95.66
$94.69
$52.91
$52.38
$42.76
$42.33
$50.82
$50.29
$23.18
$22.97
$27.61
$27.35
$99.85
$98.84
$60.89
$60.27
Page 255 of 323
Notes
Procedure
Code
76821
76825
76825
76825
76826
76826
76826
76827
76827
76827
76828
76828
76828
76830
76830
76830
76831
76831
76831
76856
76856
76856
76857
76857
76857
76870
76870
76870
76872
76872
76872
76873
76873
1/2/2015
Modifier
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
Par Fee
$36.56
$279.97
$193.70
$86.27
$165.95
$123.31
$42.64
$77.01
$47.51
$29.50
$54.13
$25.34
$28.79
$123.45
$87.91
$35.53
$119.83
$82.19
$37.64
$110.66
$76.11
$34.55
$47.47
$22.84
$24.63
$67.09
$35.35
$31.73
$94.26
$60.38
$33.88
$167.43
$89.34
Nonpar Fee
$34.73
$265.97
$184.02
$81.96
$157.65
$117.14
$40.51
$73.16
$45.13
$28.03
$51.42
$24.07
$27.35
$117.28
$83.51
$33.75
$113.84
$78.08
$35.76
$105.13
$72.30
$32.82
$45.10
$21.70
$23.40
$63.74
$33.58
$30.14
$89.55
$57.36
$32.19
$159.06
$84.87
Limiting
Charge
$39.94
$305.87
$211.62
$94.25
$181.30
$134.71
$46.59
$84.13
$51.90
$32.23
$59.13
$27.68
$31.45
$134.87
$96.04
$38.81
$130.92
$89.79
$41.12
$120.90
$83.15
$37.74
$51.87
$24.96
$26.91
$73.30
$38.62
$34.66
$102.98
$65.96
$37.02
$182.92
$97.60
Charge**
Charge***
$39.54
$39.34
$302.81
$301.28
$209.51
$208.45
$93.31
$92.84
$179.48
$178.58
$133.37
$132.69
$46.12
$45.89
$83.29
$82.87
$51.38
$51.12
$31.91
$31.75
$58.55
$58.25
$27.40
$27.27
$31.14
$30.98
$133.53
$132.85
$95.07
$94.60
$38.42
$38.23
$129.61
$128.95
$88.90
$88.45
$40.71
$40.50
$119.69
$119.08
$82.32
$81.90
$37.36
$37.18
$51.35
$51.08
$24.70
$24.58
$26.65
$26.51
$72.57
$72.20
$38.23
$38.04
$34.32
$34.14
$101.95
$101.44
$65.31
$64.98
$36.65
$36.47
$181.09
$180.17
$96.62
$96.14
Arizona
EHR/eRx
Limiting
Charge**
$39.15
$299.75
$207.39
$92.37
$177.68
$132.02
$45.66
$82.46
$50.86
$31.59
$57.95
$27.13
$30.82
$132.17
$94.12
$38.04
$128.29
$88.00
$40.30
$118.48
$81.48
$36.98
$50.83
$24.46
$26.37
$71.84
$37.85
$33.97
$100.92
$64.64
$36.28
$179.26
$95.65
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$38.94
$38.56
$298.26
$295.25
$206.37
$204.27
$91.91
$90.99
$176.79
$175.01
$131.36
$130.04
$45.43
$44.97
$82.04
$81.21
$50.61
$50.11
$31.43
$31.12
$57.67
$57.07
$26.99
$26.73
$30.67
$30.36
$131.53
$130.19
$93.64
$92.70
$37.85
$37.47
$127.66
$126.37
$87.56
$86.68
$40.10
$39.69
$117.90
$116.70
$81.09
$80.26
$36.80
$36.43
$50.58
$50.07
$24.33
$24.09
$26.24
$25.98
$71.47
$70.76
$37.65
$37.28
$33.80
$33.47
$100.42
$99.41
$64.33
$63.68
$36.10
$35.74
$178.38
$176.57
$95.17
$94.21
Page 256 of 323
Notes
C
C
Procedure
Code
76873
76881
76881
76881
76882
76882
76882
76885
76885
76885
76886
76886
76886
76930
76932
76936
76936
76936
76937
76937
76937
76940
76941
76942
76942
76942
76945
76946
76946
76946
76948
76948
76948
1/2/2015
Modifier
26
TC
26
TC
26
TC
26
TC
26
26
26
TC
26
TC
26
26
26
TC
26
26
TC
26
TC
26
Par Fee
$78.08
$117.46
$85.41
$32.05
$36.29
$11.40
$24.90
$128.63
$91.85
$36.78
$107.40
$75.76
$31.65
$33.75
$33.43
$275.29
$174.04
$101.25
$32.36
$17.48
$14.89
$106.21
$69.33
$60.56
$27.13
$33.43
$35.45
$33.08
$13.19
$19.89
$33.08
$13.19
$19.89
Nonpar Fee
$74.18
$111.59
$81.14
$30.45
$34.48
$10.83
$23.66
$122.20
$87.26
$34.94
$102.03
$71.97
$30.07
$32.06
$31.76
$261.53
$165.34
$96.19
$30.74
$16.61
$14.15
$100.90
$65.86
$57.53
$25.77
$31.76
$33.68
$31.43
$12.53
$18.90
$31.43
$12.53
$18.90
Limiting
Charge
$85.31
$128.33
$93.31
$35.02
$39.65
$12.45
$27.21
$140.53
$100.35
$40.18
$117.33
$82.77
$34.58
$36.87
$36.52
$300.76
$190.14
$110.62
$35.35
$19.10
$16.27
$116.04
$75.74
$66.16
$29.64
$36.52
$38.73
$36.14
$14.41
$21.74
$36.14
$14.41
$21.74
Charge**
Charge***
$84.46
$84.03
$127.04
$126.41
$92.38
$91.91
$34.67
$34.49
$39.26
$39.05
$12.33
$12.27
$26.93
$26.81
$139.13
$138.43
$99.35
$98.84
$39.78
$39.58
$116.16
$115.58
$81.94
$81.52
$34.24
$34.06
$36.50
$36.32
$36.16
$35.97
$297.75
$296.25
$188.24
$187.29
$109.51
$108.96
$34.99
$34.82
$18.91
$18.81
$16.11
$16.03
$114.87
$114.30
$74.98
$74.60
$65.49
$65.17
$29.34
$29.19
$36.16
$35.97
$38.34
$38.15
$35.79
$35.60
$14.26
$14.19
$21.52
$21.41
$35.79
$35.60
$14.26
$14.19
$21.52
$21.41
Arizona
EHR/eRx
Limiting
Charge**
$83.61
$125.76
$91.45
$34.32
$38.86
$12.20
$26.67
$137.72
$98.34
$39.38
$114.99
$81.11
$33.89
$36.13
$35.79
$294.75
$186.33
$108.41
$34.65
$18.72
$15.95
$113.71
$74.22
$64.84
$29.04
$35.79
$37.96
$35.42
$14.12
$21.30
$35.42
$14.12
$21.30
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$83.19
$82.35
$125.13
$123.88
$91.00
$90.08
$34.16
$33.80
$38.67
$38.27
$12.14
$12.02
$26.53
$26.27
$137.05
$135.65
$97.85
$96.86
$39.18
$38.79
$114.41
$113.26
$80.71
$79.89
$33.72
$33.38
$35.95
$35.59
$35.62
$35.25
$293.28
$290.33
$185.41
$183.54
$107.87
$106.79
$34.47
$34.13
$18.62
$18.45
$15.87
$15.71
$113.15
$112.01
$73.85
$73.11
$64.52
$63.86
$28.90
$28.60
$35.62
$35.25
$37.77
$37.39
$35.25
$34.89
$14.04
$13.92
$21.19
$20.98
$35.25
$34.89
$14.04
$13.92
$21.19
$20.98
Page 257 of 323
Notes
Procedure
Code
76965
76965
76965
76970
76970
76970
76975
76977
76977
76977
76998
77001
77001
77001
77002
77002
77002
77003
77003
77003
77011
77011
77011
77012
77012
77012
77013
77014
77014
77014
77021
77021
77021
1/2/2015
Modifier
TC
26
TC
26
26
TC
26
26
TC
26
TC
26
TC
26
TC
26
TC
26
26
TC
26
TC
26
Par Fee
$90.55
$23.55
$67.00
$93.77
$73.25
$20.52
$44.25
$7.06
$4.25
$2.82
$65.00
$70.30
$51.44
$18.86
$92.43
$64.31
$28.11
$85.64
$55.02
$30.62
$220.34
$157.99
$62.35
$124.83
$66.82
$58.02
$202.85
$117.06
$73.25
$43.80
$412.53
$336.05
$76.48
Nonpar Fee
$86.02
$22.37
$63.65
$89.08
$69.59
$19.49
$42.04
$6.71
$4.04
$2.68
$61.75
$66.79
$48.87
$17.92
$87.81
$61.09
$26.70
$81.36
$52.27
$29.09
$209.32
$150.09
$59.23
$118.59
$63.48
$55.12
$192.71
$111.21
$69.59
$41.61
$391.90
$319.25
$72.66
Limiting
Charge
$98.92
$25.73
$73.20
$102.44
$80.03
$22.41
$48.35
$7.72
$4.65
$3.08
$71.01
$76.81
$56.20
$20.61
$100.98
$70.25
$30.71
$93.56
$60.11
$33.45
$240.72
$172.60
$68.11
$136.38
$73.00
$63.39
$221.62
$127.89
$80.03
$47.85
$450.69
$367.14
$83.56
Charge**
Charge***
$97.93
$97.44
$25.47
$25.33
$72.46
$72.11
$101.42
$100.90
$79.22
$78.83
$22.20
$22.08
$47.86
$47.62
$7.64
$7.60
$4.60
$4.58
$3.05
$3.04
$70.30
$69.94
$76.04
$75.66
$55.64
$55.36
$20.40
$20.30
$99.97
$99.46
$69.55
$69.20
$30.39
$30.25
$92.63
$92.16
$59.51
$59.21
$33.12
$32.95
$238.31
$237.11
$170.88
$170.02
$67.44
$67.09
$135.01
$134.33
$72.28
$71.91
$62.76
$62.43
$219.40
$218.29
$126.62
$125.97
$79.22
$78.83
$47.37
$47.14
$446.18
$443.92
$363.47
$361.63
$82.72
$82.31
Arizona
EHR/eRx
Limiting
Charge**
$96.95
$25.21
$71.74
$100.40
$78.43
$21.97
$47.38
$7.57
$4.55
$3.02
$69.60
$75.27
$55.07
$20.19
$98.96
$68.85
$30.10
$91.69
$58.90
$32.79
$235.90
$169.15
$66.76
$133.65
$71.54
$62.12
$217.19
$125.34
$78.43
$46.90
$441.67
$359.80
$81.89
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$96.46
$95.50
$25.09
$24.83
$71.37
$70.66
$99.90
$98.89
$78.04
$77.26
$21.86
$21.63
$47.15
$46.67
$7.52
$7.45
$4.53
$4.49
$3.00
$2.98
$69.24
$68.55
$74.90
$74.14
$54.80
$54.25
$20.09
$19.90
$98.47
$97.47
$68.51
$67.82
$29.93
$29.65
$91.24
$90.31
$58.62
$58.02
$32.63
$32.29
$234.74
$232.36
$168.31
$166.61
$66.42
$65.76
$132.99
$131.65
$71.20
$70.47
$61.81
$61.19
$216.11
$213.93
$124.72
$123.46
$78.04
$77.26
$46.66
$46.20
$439.48
$435.05
$358.02
$354.41
$81.48
$80.66
Page 258 of 323
Notes
Procedure
Code
77022
77051
77051
77051
77052
77052
77052
77053
77053
77053
77054
77054
77054
77055
77055
77055
77056
77056
77056
77057
77057
77057
77058
77058
77058
77059
77059
77059
77063
77063
77063
77071
77072
1/2/2015
Modifier
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
Par Fee
$220.86
$8.85
$5.68
$3.17
$8.85
$5.68
$3.17
$58.15
$40.00
$18.15
$76.34
$53.23
$23.11
$89.88
$54.30
$35.58
$115.58
$71.47
$44.12
$82.37
$46.79
$35.58
$542.23
$459.36
$82.87
$536.51
$453.64
$82.87
$55.96
$25.70
$30.26
$48.32
$23.15
Nonpar Fee
$209.82
$8.41
$5.40
$3.01
$8.41
$5.40
$3.01
$55.24
$38.00
$17.24
$72.52
$50.57
$21.95
$85.39
$51.59
$33.80
$109.80
$67.90
$41.91
$78.25
$44.45
$33.80
$515.12
$436.39
$78.73
$509.68
$430.96
$78.73
$53.16
$24.42
$28.75
$45.90
$21.99
Limiting
Charge
$241.29
$9.67
$6.21
$3.46
$9.67
$6.21
$3.46
$63.53
$43.70
$19.83
$83.40
$58.16
$25.24
$98.20
$59.33
$38.87
$126.27
$78.09
$48.20
$89.99
$51.12
$38.87
$592.39
$501.85
$90.54
$586.13
$495.60
$90.54
$61.13
$28.08
$33.06
$52.79
$25.29
Charge**
Charge***
$238.88
$237.67
$9.58
$9.52
$6.15
$6.12
$3.43
$3.40
$9.58
$9.52
$6.15
$6.12
$3.43
$3.40
$62.89
$62.57
$43.26
$43.04
$19.63
$19.53
$82.56
$82.14
$57.57
$57.28
$24.99
$24.86
$97.22
$96.73
$58.73
$58.44
$38.48
$38.28
$125.01
$124.37
$77.30
$76.91
$47.71
$47.47
$89.09
$88.64
$50.61
$50.35
$38.48
$38.28
$586.47
$583.50
$496.83
$494.32
$89.63
$89.18
$580.27
$577.33
$490.65
$488.18
$89.63
$89.18
$60.52
$60.21
$27.81
$27.66
$32.73
$32.57
$52.26
$51.99
$25.04
$24.91
Arizona
EHR/eRx
Limiting
Charge**
$236.46
$9.48
$6.08
$3.39
$9.48
$6.08
$3.39
$62.26
$42.83
$19.44
$81.73
$56.99
$24.74
$96.23
$58.14
$38.09
$123.74
$76.52
$47.23
$88.19
$50.09
$38.09
$580.54
$491.81
$88.73
$574.41
$485.69
$88.73
$59.92
$27.52
$32.41
$51.73
$24.78
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$235.29
$232.92
$9.44
$9.34
$6.06
$5.99
$3.38
$3.35
$9.44
$9.34
$6.06
$5.99
$3.38
$3.35
$61.95
$61.33
$42.62
$42.18
$19.33
$19.15
$81.32
$80.50
$56.71
$56.14
$24.61
$24.37
$95.76
$94.78
$57.85
$57.27
$37.90
$37.51
$123.13
$121.89
$76.14
$75.37
$47.00
$46.52
$87.76
$86.87
$49.85
$49.35
$37.90
$37.51
$577.67
$571.84
$489.38
$484.44
$88.29
$87.40
$571.56
$565.80
$483.29
$478.40
$88.29
$87.40
$59.62
$59.02
$27.39
$27.11
$32.23
$31.92
$51.47
$50.96
$24.66
$24.41
Page 259 of 323
Notes
C
C
C
C
Procedure
Code
77072
77072
77073
77073
77073
77074
77074
77074
77075
77075
77075
77076
77076
77076
77077
77077
77077
77078
77078
77078
77080
77080
77080
77081
77081
77081
77084
77084
77084
77085
77085
77085
77086
1/2/2015
Modifier
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
Par Fee
$13.54
$9.61
$36.29
$21.41
$14.89
$63.87
$41.07
$22.80
$87.07
$59.67
$27.40
$95.25
$59.67
$35.58
$37.68
$20.69
$16.99
$71.78
$59.31
$12.47
$41.39
$31.06
$10.32
$28.16
$17.12
$11.04
$368.42
$286.31
$82.11
$56.40
$41.07
$15.33
$35.67
Nonpar Fee
$12.86
$9.13
$34.48
$20.34
$14.15
$60.68
$39.02
$21.66
$82.72
$56.69
$26.03
$90.49
$56.69
$33.80
$35.80
$19.66
$16.14
$68.19
$56.34
$11.85
$39.32
$29.51
$9.80
$26.75
$16.26
$10.49
$350.00
$271.99
$78.00
$53.58
$39.02
$14.56
$33.89
Limiting
Charge
$14.79
$10.50
$39.65
$23.39
$16.27
$69.78
$44.87
$24.91
$95.13
$65.19
$29.93
$104.06
$65.19
$38.87
$41.17
$22.61
$18.56
$78.42
$64.79
$13.63
$45.22
$33.94
$11.27
$30.76
$18.70
$12.06
$402.50
$312.79
$89.70
$61.62
$44.87
$16.74
$38.97
Charge**
Charge***
$14.64
$14.57
$10.40
$10.34
$39.26
$39.05
$23.16
$23.03
$16.11
$16.03
$69.08
$68.74
$44.42
$44.19
$24.66
$24.54
$94.17
$93.70
$64.54
$64.22
$29.64
$29.49
$103.03
$102.50
$64.54
$64.22
$38.48
$38.28
$40.76
$40.55
$22.38
$22.28
$18.38
$18.29
$77.64
$77.25
$64.15
$63.81
$13.49
$13.42
$44.77
$44.54
$33.59
$33.43
$11.16
$11.10
$30.45
$30.30
$18.52
$18.42
$11.95
$11.88
$398.48
$396.46
$309.66
$308.10
$88.80
$88.35
$61.00
$60.70
$44.42
$44.19
$16.57
$16.49
$38.58
$38.39
Arizona
EHR/eRx
Limiting
Charge**
$14.49
$10.29
$38.86
$22.92
$15.95
$68.39
$43.98
$24.41
$93.23
$63.89
$29.34
$101.98
$63.89
$38.09
$40.34
$22.16
$18.19
$76.85
$63.49
$13.35
$44.31
$33.26
$11.04
$30.15
$18.32
$11.82
$394.45
$306.53
$87.91
$60.39
$43.98
$16.41
$38.19
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$14.42
$14.27
$10.24
$10.14
$38.67
$38.27
$22.82
$22.57
$15.87
$15.71
$68.05
$67.37
$43.76
$43.32
$24.29
$24.05
$92.76
$91.83
$63.57
$62.94
$29.19
$28.90
$101.49
$100.45
$63.57
$62.94
$37.90
$37.51
$40.15
$39.73
$22.05
$21.83
$18.10
$17.92
$76.48
$75.70
$63.18
$62.54
$13.28
$13.16
$44.10
$43.64
$33.09
$32.76
$10.98
$10.88
$29.99
$29.70
$18.24
$18.04
$11.76
$11.65
$392.50
$388.54
$305.01
$301.93
$87.47
$86.58
$60.08
$59.48
$43.76
$43.32
$16.32
$16.17
$38.01
$37.62
Page 260 of 323
Notes
#
#
Procedure
Code
77086
77086
77261
77262
77263
77280
77280
77280
77285
77285
77285
77290
77290
77290
77293
77293
77293
77295
77295
77295
77300
77300
77300
77301
77301
77301
77301
77301
77306
77306
77306
77307
77307
1/2/2015
Modifier
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
26
TC
26
TC
Par Fee
$26.77
$8.89
$75.76
$112.68
$164.85
$271.20
$235.22
$35.98
$427.41
$373.24
$54.17
$510.63
$430.44
$80.18
$463.93
$360.68
$103.25
$487.98
$266.51
$221.47
$63.11
$31.06
$32.05
$1,938.31
$1,937.95
$1,526.30
$412.01
$411.65
$145.21
$73.25
$71.96
$284.22
$134.31
Nonpar Fee
$25.43
$8.45
$71.97
$107.05
$156.61
$257.64
$223.46
$34.18
$406.04
$354.58
$51.46
$485.10
$408.92
$76.17
$440.73
$342.65
$98.09
$463.58
$253.18
$210.40
$59.95
$29.51
$30.45
$1,841.39
$1,841.05
$1,449.99
$391.41
$391.07
$137.95
$69.59
$68.36
$270.01
$127.59
Limiting
Charge
$29.24
$9.72
$82.77
$123.11
$180.10
$296.29
$256.98
$39.31
$466.95
$407.77
$59.18
$557.87
$470.26
$87.60
$506.84
$394.05
$112.80
$533.12
$291.16
$241.96
$68.94
$33.94
$35.02
$2,117.60
$2,117.21
$1,667.49
$450.12
$449.73
$158.64
$80.03
$78.61
$310.51
$146.73
Charge**
Charge***
$28.96
$28.81
$9.63
$9.57
$81.94
$81.52
$121.88
$121.26
$178.30
$177.40
$293.32
$291.85
$254.41
$253.13
$38.92
$38.72
$462.28
$459.94
$403.68
$401.65
$58.59
$58.29
$552.29
$549.49
$465.55
$463.21
$86.72
$86.28
$501.77
$499.24
$390.10
$388.14
$111.68
$111.11
$527.78
$525.12
$288.25
$286.79
$239.55
$238.33
$68.25
$67.91
$33.59
$33.43
$34.67
$34.49
$2,096.43
$2,085.84
$2,096.04
$2,085.44
$1,650.81
$1,642.48
$445.63
$443.37
$445.23
$442.98
$157.06
$156.26
$79.22
$78.83
$77.83
$77.43
$307.41
$305.85
$145.26
$144.53
Arizona
EHR/eRx
Limiting
Charge**
$28.66
$9.52
$81.11
$120.65
$176.50
$290.36
$251.84
$38.53
$457.61
$399.61
$57.99
$546.71
$460.85
$85.85
$496.71
$386.17
$110.55
$522.46
$285.34
$237.12
$67.56
$33.26
$34.32
$2,075.24
$2,074.86
$1,634.14
$441.12
$440.74
$155.47
$78.43
$77.04
$304.30
$143.80
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$28.52
$28.23
$9.48
$9.38
$80.71
$79.89
$120.05
$118.84
$175.62
$173.86
$288.91
$286.01
$250.60
$248.07
$38.33
$37.95
$455.34
$450.74
$397.62
$393.62
$57.72
$57.12
$544.01
$538.51
$458.57
$453.94
$85.42
$84.56
$494.25
$489.26
$384.25
$380.37
$110.00
$108.89
$519.87
$514.63
$283.92
$281.06
$235.96
$233.57
$67.23
$66.55
$33.09
$32.76
$34.16
$33.80
$2,064.99
$2,044.11
$2,064.60
$2,043.75
$1,626.05
$1,609.63
$438.94
$434.50
$438.55
$434.13
$154.70
$153.13
$78.04
$77.26
$76.66
$75.89
$302.80
$299.74
$143.08
$141.63
Page 261 of 323
Notes
Procedure
Code
77307
77316
77316
77316
77317
77317
77317
77318
77318
77318
77321
77321
77321
77331
77331
77331
77332
77332
77332
77333
77333
77333
77334
77334
77334
77336
77338
77338
77338
77370
77372
77373
77401
1/2/2015
Modifier
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
Par Fee
$149.91
$186.24
$114.28
$71.96
$243.63
$148.92
$94.71
$352.06
$202.15
$149.91
$92.03
$43.22
$48.81
$63.78
$18.91
$44.88
$82.46
$54.30
$28.16
$52.70
$9.25
$43.44
$152.05
$88.27
$63.78
$76.78
$504.79
$283.31
$221.47
$116.74
$1,062.72
$1,349.43
$20.69
Nonpar Fee
$142.41
$176.93
$108.57
$68.36
$231.45
$141.47
$89.97
$334.46
$192.04
$142.41
$87.43
$41.06
$46.37
$60.59
$17.96
$42.64
$78.34
$51.59
$26.75
$50.07
$8.79
$41.27
$144.45
$83.86
$60.59
$72.94
$479.55
$269.14
$210.40
$110.90
$1,009.58
$1,281.96
$19.66
Limiting
Charge
$163.77
$203.47
$124.86
$78.61
$266.17
$162.69
$103.47
$384.63
$220.85
$163.77
$100.54
$47.22
$53.33
$69.68
$20.65
$49.04
$90.09
$59.33
$30.76
$57.58
$10.11
$47.46
$166.12
$96.44
$69.68
$83.88
$551.48
$309.51
$241.96
$127.54
$1,161.02
$1,474.25
$22.61
Charge**
Charge***
$162.14
$161.31
$201.43
$200.42
$123.60
$122.98
$77.83
$77.43
$263.51
$262.18
$161.07
$160.25
$102.43
$101.91
$380.79
$378.86
$218.64
$217.53
$162.14
$161.31
$99.54
$99.04
$46.75
$46.51
$52.80
$52.52
$68.98
$68.63
$20.45
$20.34
$48.54
$48.30
$89.19
$88.73
$58.73
$58.44
$30.45
$30.30
$57.01
$56.72
$10.01
$9.96
$46.99
$46.75
$164.46
$163.62
$95.47
$94.99
$68.98
$68.63
$83.04
$82.63
$545.96
$543.21
$306.42
$304.87
$239.55
$238.33
$126.26
$125.63
$1,149.40
$1,143.61
$1,459.51
$1,452.14
$22.38
$22.28
Arizona
EHR/eRx
Limiting
Charge**
$160.49
$199.40
$122.36
$77.04
$260.84
$159.44
$101.40
$376.94
$216.43
$160.49
$98.53
$46.28
$52.26
$68.29
$20.24
$48.06
$88.29
$58.14
$30.15
$56.43
$9.90
$46.51
$162.79
$94.51
$68.29
$82.20
$540.45
$303.32
$237.12
$124.98
$1,137.80
$1,444.77
$22.16
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$159.71
$158.09
$198.41
$196.41
$121.75
$120.52
$76.66
$75.89
$259.56
$256.93
$158.65
$157.04
$100.89
$99.88
$375.07
$371.28
$215.36
$213.19
$159.71
$158.09
$98.05
$97.05
$46.05
$45.59
$52.00
$51.47
$67.94
$67.26
$20.14
$19.94
$47.82
$47.33
$87.86
$86.96
$57.85
$57.27
$29.99
$29.70
$56.15
$55.58
$9.86
$9.75
$46.29
$45.80
$161.99
$160.36
$94.04
$93.09
$67.94
$67.26
$81.80
$80.97
$537.77
$532.35
$301.82
$298.77
$235.96
$233.57
$124.36
$123.11
$1,132.16
$1,120.73
$1,437.62
$1,423.10
$22.05
$21.83
Page 262 of 323
Notes
#
#
Procedure
Code
77417
77422
77423
77427
77431
77432
77432
77435
77435
77469
77470
77470
77470
77600
77600
77600
77605
77605
77605
77610
77610
77610
77615
77615
77615
77620
77620
77620
77750
77750
77750
77761
77761
1/2/2015
Modifier
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
Par Fee
$10.68
$33.57
$65.34
$185.45
$101.64
$415.96
$415.60
$627.70
$627.34
$320.39
$155.36
$47.47
$107.90
$403.54
$323.05
$80.50
$764.18
$657.00
$107.18
$1,031.04
$953.04
$77.99
$1,012.81
$904.91
$107.90
$464.61
$377.75
$86.86
$370.26
$112.09
$258.17
$387.64
$191.07
Nonpar Fee
$10.15
$31.89
$62.07
$176.18
$96.56
$395.16
$394.82
$596.32
$595.97
$304.37
$147.59
$45.10
$102.51
$383.36
$306.90
$76.48
$725.97
$624.15
$101.82
$979.49
$905.39
$74.09
$962.17
$859.66
$102.51
$441.38
$358.86
$82.52
$351.75
$106.49
$245.26
$368.26
$181.52
Limiting
Charge
$11.67
$36.67
$71.38
$202.61
$111.04
$454.43
$454.04
$685.77
$685.37
$350.03
$169.73
$51.87
$117.89
$440.86
$352.94
$87.95
$834.87
$717.77
$117.09
$1,126.41
$1,041.20
$85.20
$1,106.50
$988.61
$117.89
$507.59
$412.69
$94.90
$404.51
$122.46
$282.05
$423.50
$208.75
Charge**
Charge***
$11.56
$11.50
$36.31
$36.12
$70.67
$70.31
$200.58
$199.57
$109.93
$109.38
$449.89
$447.61
$449.50
$447.24
$678.91
$675.49
$678.51
$675.08
$346.53
$344.77
$168.03
$167.19
$51.35
$51.08
$116.70
$116.12
$436.46
$434.25
$349.40
$347.65
$87.08
$86.63
$826.52
$822.34
$710.60
$707.01
$115.92
$115.33
$1,115.16
$1,109.52
$1,030.79
$1,025.58
$84.35
$83.93
$1,095.43
$1,089.90
$978.72
$973.79
$116.70
$116.12
$502.52
$499.97
$408.56
$406.50
$93.94
$93.47
$400.46
$398.44
$121.24
$120.62
$279.23
$277.82
$419.27
$417.15
$206.66
$205.62
Arizona
EHR/eRx
Limiting
Charge**
$11.44
$35.94
$69.95
$198.56
$108.82
$445.35
$444.96
$672.05
$671.66
$343.02
$166.34
$50.83
$115.53
$432.04
$345.87
$86.19
$818.17
$703.42
$114.75
$1,103.89
$1,020.37
$83.50
$1,084.37
$968.84
$115.53
$497.43
$404.43
$93.00
$396.43
$120.01
$276.40
$415.02
$204.57
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$11.39
$11.27
$35.77
$35.40
$69.61
$68.91
$197.57
$195.58
$108.28
$107.19
$443.14
$438.67
$442.76
$438.29
$668.73
$661.96
$668.33
$661.58
$341.33
$337.88
$165.51
$163.84
$50.58
$50.07
$114.95
$113.79
$429.92
$425.56
$344.16
$340.69
$85.77
$84.90
$814.12
$805.90
$699.94
$692.86
$114.18
$113.02
$1,098.42
$1,087.33
$1,015.32
$1,005.07
$83.09
$82.25
$1,079.00
$1,068.11
$964.03
$954.30
$114.95
$113.79
$494.98
$489.97
$402.43
$398.36
$92.53
$91.61
$394.46
$390.48
$119.43
$118.21
$275.05
$272.25
$412.98
$408.80
$203.55
$201.50
Page 263 of 323
Notes
#
#
#
#
Procedure
Code
77761
77762
77762
77762
77763
77763
77763
77763
77763
77776
77776
77776
77777
77777
77777
77778
77778
77778
77778
77778
77785
77785
77785
77786
77786
77786
77787
77787
77787
77789
77789
77789
77790
1/2/2015
Modifier
26
TC
26
TC
26
26
TC
26
TC
26
TC
26
26
TC
26
TC
26
TC
26
TC
26
Par Fee
$196.57
$543.65
$219.99
$323.67
$730.41
$730.06
$284.21
$446.20
$445.85
$468.18
$229.64
$238.54
$585.74
$196.03
$389.71
$870.76
$870.40
$288.86
$581.90
$581.54
$239.16
$166.13
$73.03
$489.94
$321.89
$168.06
$781.13
$528.69
$252.45
$118.84
$60.02
$58.82
$96.63
Nonpar Fee
$186.74
$516.47
$208.99
$307.49
$693.89
$693.56
$270.00
$423.89
$423.56
$444.77
$218.16
$226.61
$556.45
$186.23
$370.22
$827.22
$826.88
$274.42
$552.81
$552.46
$227.20
$157.82
$69.38
$465.44
$305.80
$159.66
$742.07
$502.26
$239.83
$112.90
$57.02
$55.88
$91.80
Limiting
Charge
$214.75
$593.94
$240.34
$353.61
$797.97
$797.59
$310.50
$487.47
$487.09
$511.49
$250.88
$260.60
$639.92
$214.16
$425.75
$951.30
$950.91
$315.58
$635.73
$635.33
$261.28
$181.49
$79.79
$535.26
$351.67
$183.61
$853.38
$577.60
$275.80
$129.84
$65.57
$64.26
$105.57
Charge**
Charge***
$212.60
$211.53
$588.01
$585.03
$237.94
$236.74
$350.08
$348.31
$789.99
$786.00
$789.61
$785.63
$307.40
$305.84
$482.60
$480.16
$482.22
$479.79
$506.37
$503.82
$248.38
$247.12
$257.99
$256.69
$633.52
$630.32
$212.03
$210.96
$421.50
$419.37
$941.79
$937.03
$941.40
$936.65
$312.43
$310.85
$629.37
$626.20
$628.98
$625.80
$258.67
$257.36
$179.68
$178.77
$78.99
$78.59
$529.91
$527.23
$348.15
$346.39
$181.77
$180.86
$844.85
$840.58
$571.83
$568.94
$273.04
$271.66
$128.54
$127.89
$64.92
$64.58
$63.62
$63.30
$104.51
$103.98
Arizona
EHR/eRx
Limiting
Charge**
$210.46
$582.06
$235.53
$346.54
$782.01
$781.64
$304.29
$477.72
$477.35
$501.25
$245.87
$255.39
$627.12
$209.89
$417.24
$932.28
$931.89
$309.27
$623.01
$622.62
$256.06
$177.86
$78.19
$524.55
$344.63
$179.94
$836.31
$566.04
$270.28
$127.24
$64.26
$62.97
$103.45
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$209.42
$207.30
$579.19
$573.33
$234.37
$232.00
$344.83
$341.34
$778.15
$770.28
$777.77
$769.91
$302.78
$299.72
$475.36
$470.56
$474.98
$470.19
$498.78
$493.73
$244.65
$242.18
$254.12
$251.56
$624.02
$617.71
$208.84
$206.74
$415.17
$410.99
$927.67
$918.30
$927.28
$917.91
$307.74
$304.64
$619.93
$613.66
$619.55
$613.28
$254.79
$252.22
$176.99
$175.19
$77.81
$77.02
$521.96
$516.68
$342.93
$339.46
$179.04
$177.24
$832.17
$823.77
$563.25
$557.55
$268.95
$266.23
$126.60
$125.33
$63.94
$63.30
$62.66
$62.03
$102.95
$101.90
Page 264 of 323
Notes
Procedure
Code
77790
77790
78012
78012
78012
78013
78013
78013
78014
78014
78014
78015
78015
78015
78016
78016
78016
78018
78018
78018
78020
78020
78020
78070
78070
78070
78071
78071
78071
78072
78072
78072
78075
1/2/2015
Modifier
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
Par Fee
$43.18
$53.46
$82.46
$72.85
$9.61
$196.88
$178.69
$18.19
$249.71
$225.12
$24.58
$228.25
$195.45
$32.81
$293.33
$258.33
$35.00
$322.96
$281.26
$41.70
$86.35
$58.19
$28.16
$311.47
$271.60
$39.87
$371.10
$311.65
$59.45
$424.64
$347.36
$77.28
$469.06
Nonpar Fee
$41.02
$50.79
$78.34
$69.21
$9.13
$187.04
$169.76
$17.28
$237.22
$213.86
$23.35
$216.84
$185.68
$31.17
$278.66
$245.41
$33.25
$306.81
$267.20
$39.62
$82.03
$55.28
$26.75
$295.90
$258.02
$37.88
$352.55
$296.07
$56.48
$403.41
$329.99
$73.42
$445.61
Limiting
Charge
$47.17
$58.41
$90.09
$79.59
$10.50
$215.10
$195.22
$19.87
$272.80
$245.94
$26.85
$249.37
$213.53
$35.85
$320.46
$282.22
$38.24
$352.83
$307.28
$45.56
$94.33
$63.57
$30.76
$340.29
$296.72
$43.56
$405.43
$340.48
$64.95
$463.92
$379.49
$84.43
$512.45
Charge**
Charge***
$46.70
$46.46
$57.82
$57.53
$89.19
$88.73
$78.80
$78.40
$10.40
$10.34
$212.95
$211.86
$193.27
$192.29
$19.68
$19.57
$270.08
$268.71
$243.48
$242.25
$26.59
$26.45
$246.87
$245.63
$211.39
$210.32
$35.49
$35.31
$317.25
$315.65
$279.40
$277.99
$37.86
$37.66
$349.30
$347.54
$304.21
$302.67
$45.10
$44.88
$93.39
$92.92
$62.94
$62.62
$30.45
$30.30
$336.88
$335.18
$293.76
$292.27
$43.13
$42.91
$401.37
$399.35
$337.08
$335.37
$64.31
$63.97
$459.29
$456.96
$375.69
$373.80
$83.59
$83.17
$507.32
$504.77
Arizona
EHR/eRx
Limiting
Charge**
$46.23
$57.24
$88.29
$78.00
$10.29
$210.80
$191.31
$19.47
$267.35
$241.02
$26.31
$244.38
$209.27
$35.13
$314.05
$276.58
$37.48
$345.77
$301.14
$44.65
$92.45
$62.30
$30.15
$333.48
$290.79
$42.69
$397.33
$333.67
$63.65
$454.64
$371.90
$82.74
$502.21
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$46.00
$45.54
$56.96
$56.37
$87.86
$86.96
$77.61
$76.83
$10.24
$10.14
$209.75
$207.63
$190.37
$188.44
$19.38
$19.18
$266.03
$263.34
$239.82
$237.41
$26.19
$25.92
$243.17
$240.71
$208.22
$206.13
$34.96
$34.60
$312.49
$309.34
$275.22
$272.42
$37.29
$36.92
$344.06
$340.58
$299.64
$296.62
$44.42
$43.99
$91.99
$91.06
$62.00
$61.36
$29.99
$29.70
$331.83
$328.47
$289.35
$286.43
$42.48
$42.04
$395.35
$391.37
$332.02
$328.67
$63.34
$62.70
$452.40
$447.82
$370.06
$366.32
$82.34
$81.50
$499.71
$494.67
Page 265 of 323
Notes
Procedure
Code
78075
78075
78102
78102
78102
78103
78103
78103
78104
78104
78104
78110
78110
78110
78111
78111
78111
78120
78120
78120
78121
78121
78121
78122
78122
78122
78130
78130
78130
78135
78135
78135
78140
1/2/2015
Modifier
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
Par Fee
$431.34
$37.72
$175.69
$148.65
$27.04
$228.65
$192.94
$35.71
$253.68
$215.47
$38.21
$106.42
$96.45
$9.97
$99.62
$88.58
$11.04
$97.12
$85.37
$11.76
$108.92
$92.87
$16.05
$99.27
$78.21
$21.05
$162.82
$133.55
$29.27
$363.63
$330.91
$32.72
$140.34
Nonpar Fee
$409.77
$35.83
$166.91
$141.22
$25.69
$217.22
$183.29
$33.92
$241.00
$204.70
$36.30
$101.10
$91.63
$9.47
$94.64
$84.15
$10.49
$92.26
$81.10
$11.17
$103.47
$88.23
$15.25
$94.31
$74.30
$20.00
$154.68
$126.87
$27.81
$345.45
$314.36
$31.08
$133.32
Limiting
Charge
$471.24
$41.20
$191.95
$162.40
$29.54
$249.80
$210.78
$39.01
$277.15
$235.41
$41.75
$116.27
$105.37
$10.89
$108.84
$96.77
$12.06
$106.10
$93.27
$12.85
$118.99
$101.46
$17.54
$108.46
$85.45
$23.00
$177.88
$145.90
$31.98
$397.27
$361.51
$35.74
$153.32
Charge**
Charge***
$466.52
$464.16
$40.79
$40.58
$190.03
$189.07
$160.78
$159.97
$29.24
$29.10
$247.31
$246.05
$208.68
$207.62
$38.62
$38.42
$274.38
$273.00
$233.05
$231.87
$41.33
$41.12
$115.10
$114.52
$104.32
$103.80
$10.79
$10.73
$107.74
$107.20
$95.81
$95.32
$11.95
$11.88
$105.04
$104.51
$92.33
$91.86
$12.72
$12.65
$117.81
$117.21
$100.45
$99.95
$17.37
$17.27
$107.38
$106.84
$84.59
$84.17
$22.77
$22.66
$176.10
$175.21
$144.44
$143.72
$31.66
$31.50
$393.30
$391.31
$357.90
$356.09
$35.39
$35.20
$151.79
$151.02
Arizona
EHR/eRx
Limiting
Charge**
$461.81
$40.38
$188.11
$159.16
$28.96
$244.81
$206.56
$38.23
$271.61
$230.70
$40.91
$113.94
$103.27
$10.67
$106.66
$94.84
$11.82
$103.97
$91.40
$12.59
$116.61
$99.44
$17.19
$106.28
$83.73
$22.54
$174.33
$142.98
$31.34
$389.32
$354.28
$35.03
$150.25
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$459.52
$454.88
$40.18
$39.77
$187.17
$185.29
$158.37
$156.77
$28.81
$28.52
$243.59
$241.14
$205.55
$203.47
$38.04
$37.65
$270.26
$267.54
$229.55
$227.24
$40.71
$40.30
$113.38
$112.23
$102.75
$101.72
$10.63
$10.51
$106.12
$105.06
$94.37
$93.41
$11.76
$11.65
$103.47
$102.41
$90.95
$90.03
$12.52
$12.41
$116.04
$114.86
$98.95
$97.95
$17.10
$16.94
$105.77
$104.68
$83.33
$82.48
$22.43
$22.21
$173.45
$171.72
$142.28
$140.84
$31.19
$30.87
$387.40
$383.48
$352.53
$348.97
$34.86
$34.50
$149.51
$147.99
Page 266 of 323
Notes
C
C
Procedure
Code
78140
78140
78185
78185
78185
78190
78190
78190
78191
78191
78191
78195
78195
78195
78201
78201
78201
78202
78202
78202
78205
78205
78205
78206
78206
78206
78215
78215
78215
78216
78216
78216
78226
1/2/2015
Modifier
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
Par Fee
$109.99
$30.35
$219.67
$199.38
$20.29
$335.43
$280.18
$55.24
$172.34
$141.06
$31.29
$368.91
$309.46
$59.45
$194.96
$173.28
$21.68
$207.92
$184.00
$23.91
$217.84
$183.65
$34.19
$356.03
$308.39
$47.65
$201.08
$176.85
$24.23
$129.88
$101.77
$28.11
$343.65
Nonpar Fee
$104.49
$28.83
$208.69
$189.41
$19.28
$318.66
$266.17
$52.48
$163.72
$134.01
$29.73
$350.46
$293.99
$56.48
$185.21
$164.62
$20.60
$197.52
$174.80
$22.71
$206.95
$174.47
$32.48
$338.23
$292.97
$45.27
$191.03
$168.01
$23.02
$123.39
$96.68
$26.70
$326.47
Limiting
Charge
$120.16
$33.15
$239.99
$217.82
$22.17
$366.46
$306.10
$60.35
$188.28
$154.11
$34.19
$403.03
$338.09
$64.95
$212.99
$189.31
$23.69
$227.15
$201.02
$26.12
$237.99
$200.64
$37.35
$388.96
$336.92
$52.06
$219.68
$193.21
$26.47
$141.90
$111.18
$30.71
$375.44
Charge**
Charge***
$118.97
$118.36
$32.82
$32.66
$237.59
$236.39
$215.65
$214.56
$21.95
$21.84
$362.79
$360.96
$303.04
$301.51
$59.75
$59.44
$186.39
$185.45
$152.57
$151.80
$33.84
$33.67
$399.00
$396.98
$334.71
$333.02
$64.31
$63.97
$210.86
$209.79
$187.42
$186.47
$23.45
$23.33
$224.87
$223.74
$199.01
$198.01
$25.85
$25.73
$235.61
$234.43
$198.64
$197.63
$36.98
$36.79
$385.08
$383.13
$333.55
$331.87
$51.54
$51.28
$217.49
$216.38
$191.28
$190.31
$26.21
$26.07
$140.48
$139.77
$110.07
$109.51
$30.39
$30.25
$371.69
$369.81
Arizona
EHR/eRx
Limiting
Charge**
$117.76
$32.49
$235.20
$213.46
$21.72
$359.13
$299.98
$59.14
$184.52
$151.03
$33.51
$394.97
$331.33
$63.65
$208.74
$185.53
$23.22
$222.61
$197.00
$25.60
$233.23
$196.63
$36.60
$381.19
$330.18
$51.01
$215.29
$189.35
$25.94
$139.06
$108.96
$30.10
$367.93
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$117.19
$115.99
$32.33
$32.00
$234.03
$231.67
$212.42
$210.27
$21.62
$21.40
$357.35
$353.75
$298.49
$295.48
$58.86
$58.26
$183.60
$181.75
$150.28
$148.76
$33.34
$33.01
$393.02
$389.05
$329.68
$326.36
$63.34
$62.70
$207.70
$205.61
$184.61
$182.75
$23.09
$22.87
$221.50
$219.27
$196.02
$194.04
$25.46
$25.22
$232.08
$229.74
$195.66
$193.68
$36.43
$36.05
$379.30
$375.48
$328.54
$325.22
$50.77
$50.24
$214.22
$212.06
$188.42
$186.51
$25.82
$25.55
$138.38
$136.98
$108.41
$107.33
$29.93
$29.65
$366.11
$362.41
Page 267 of 323
Notes
C
C
Procedure
Code
78226
78226
78227
78227
78227
78230
78230
78230
78231
78231
78231
78232
78232
78232
78258
78258
78258
78261
78261
78261
78262
78262
78262
78264
78264
78264
78270
78270
78270
78271
78271
78271
78272
1/2/2015
Modifier
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
Par Fee
$306.64
$37.01
$417.98
$373.10
$44.88
$179.00
$156.52
$22.48
$133.90
$107.85
$26.06
$101.99
$81.39
$20.61
$227.94
$191.51
$36.43
$262.13
$226.91
$35.22
$252.57
$219.04
$33.52
$300.03
$260.16
$39.87
$104.99
$94.30
$10.68
$93.55
$83.22
$10.32
$100.34
Nonpar Fee
$291.31
$35.16
$397.08
$354.45
$42.64
$170.05
$148.69
$21.36
$127.21
$102.46
$24.76
$96.89
$77.32
$19.58
$216.54
$181.93
$34.61
$249.02
$215.56
$33.46
$239.94
$208.09
$31.84
$285.03
$247.15
$37.88
$99.74
$89.59
$10.15
$88.87
$79.06
$9.80
$95.32
Limiting
Charge
$335.01
$40.43
$456.64
$407.62
$49.04
$195.56
$170.99
$24.56
$146.29
$117.83
$28.47
$111.42
$88.92
$22.52
$249.02
$209.22
$39.80
$286.37
$247.89
$38.48
$275.93
$239.30
$36.62
$327.78
$284.22
$43.56
$114.70
$103.03
$11.67
$102.20
$90.92
$11.27
$109.62
Charge**
Charge***
$331.66
$329.98
$40.03
$39.82
$452.08
$449.79
$403.55
$401.50
$48.54
$48.30
$193.60
$192.63
$169.28
$168.43
$24.32
$24.20
$144.83
$144.10
$116.66
$116.06
$28.19
$28.05
$110.31
$109.76
$88.03
$87.58
$22.29
$22.18
$246.53
$245.28
$207.13
$206.08
$39.40
$39.20
$283.51
$282.07
$245.41
$244.18
$38.10
$37.90
$273.17
$271.79
$236.91
$235.72
$36.25
$36.06
$324.51
$322.86
$281.38
$279.96
$43.13
$42.91
$113.55
$112.98
$101.99
$101.49
$11.56
$11.50
$101.18
$100.67
$90.01
$89.55
$11.16
$11.10
$108.53
$107.97
Arizona
EHR/eRx
Limiting
Charge**
$328.30
$39.63
$447.51
$399.46
$48.06
$191.65
$167.58
$24.07
$143.37
$115.47
$27.90
$109.19
$87.14
$22.07
$244.04
$205.03
$39.01
$280.65
$242.94
$37.71
$270.41
$234.52
$35.88
$321.23
$278.54
$42.69
$112.41
$100.97
$11.44
$100.15
$89.10
$11.04
$107.42
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$326.68
$323.38
$39.43
$39.03
$445.29
$440.80
$397.50
$393.47
$47.82
$47.33
$190.69
$188.77
$166.74
$165.06
$23.95
$23.71
$142.66
$141.22
$114.91
$113.74
$27.76
$27.49
$108.65
$107.56
$86.71
$85.82
$21.95
$21.74
$242.82
$240.38
$204.02
$201.96
$38.81
$38.42
$279.25
$276.44
$241.73
$239.29
$37.52
$37.15
$269.08
$266.35
$233.36
$231.00
$35.71
$35.34
$319.64
$316.41
$277.16
$274.37
$42.48
$42.04
$111.85
$110.72
$100.46
$99.45
$11.39
$11.27
$99.66
$98.65
$88.67
$87.77
$10.98
$10.88
$106.89
$105.81
Page 268 of 323
Notes
Procedure
Code
78272
78272
78278
78278
78278
78282
78290
78290
78290
78291
78291
78291
78300
78300
78300
78305
78305
78305
78306
78306
78306
78315
78315
78315
78320
78320
78320
78414
78428
78428
78428
78445
78445
1/2/2015
Modifier
TC
26
TC
26
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
26
TC
26
TC
Par Fee
$86.80
$13.54
$362.11
$312.32
$49.79
$19.53
$345.04
$310.89
$34.15
$257.80
$215.11
$42.69
$186.73
$155.09
$31.65
$238.89
$197.59
$41.30
$261.06
$218.33
$42.73
$360.01
$309.10
$50.91
$235.99
$185.08
$50.91
$22.75
$187.09
$148.97
$38.13
$186.06
$162.19
Nonpar Fee
$82.46
$12.86
$344.00
$296.70
$47.30
$18.55
$327.79
$295.35
$32.44
$244.91
$204.35
$40.56
$177.39
$147.34
$30.07
$226.95
$187.71
$39.24
$248.01
$207.41
$40.59
$342.01
$293.65
$48.36
$224.19
$175.83
$48.36
$21.61
$177.74
$141.52
$36.22
$176.76
$154.08
Limiting
Charge
$94.83
$14.79
$395.60
$341.21
$54.40
$21.33
$376.96
$339.65
$37.31
$281.65
$235.00
$46.64
$204.00
$169.44
$34.58
$260.99
$215.87
$45.13
$285.21
$238.52
$46.68
$393.31
$337.70
$55.61
$257.82
$202.20
$55.61
$24.85
$204.40
$162.75
$41.65
$203.27
$177.19
Charge**
Charge***
$93.89
$93.40
$14.64
$14.57
$391.64
$389.67
$337.79
$336.09
$53.85
$53.58
$21.11
$21.01
$373.19
$371.30
$336.26
$334.56
$36.94
$36.74
$278.83
$277.43
$232.66
$231.47
$46.17
$45.94
$201.96
$200.94
$167.75
$166.90
$34.24
$34.06
$258.38
$257.08
$213.70
$212.62
$44.68
$44.45
$282.36
$280.93
$236.14
$234.95
$46.21
$45.98
$389.38
$387.41
$334.32
$332.64
$55.06
$54.77
$255.24
$253.95
$200.18
$199.17
$55.06
$54.77
$24.60
$24.48
$202.35
$201.33
$161.12
$160.31
$41.24
$41.03
$201.24
$200.23
$175.42
$174.54
Arizona
EHR/eRx
Limiting
Charge**
$92.93
$14.49
$387.69
$334.39
$53.30
$20.91
$369.41
$332.86
$36.56
$276.01
$230.30
$45.71
$199.92
$166.05
$33.89
$255.77
$211.55
$44.23
$279.51
$233.75
$45.75
$385.45
$330.95
$54.50
$252.67
$198.16
$54.50
$24.36
$200.32
$159.49
$40.83
$199.20
$173.65
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$92.48
$91.54
$14.42
$14.27
$385.77
$381.87
$332.72
$329.37
$53.05
$52.50
$20.79
$20.60
$367.59
$363.87
$331.21
$327.87
$36.39
$36.01
$274.64
$271.87
$229.17
$226.85
$45.48
$45.02
$198.94
$196.91
$165.23
$163.55
$33.72
$33.38
$254.51
$251.93
$210.50
$208.38
$44.01
$43.56
$278.13
$275.31
$232.60
$230.24
$45.52
$45.06
$383.54
$379.66
$329.30
$325.98
$54.23
$53.68
$251.41
$248.87
$197.18
$195.19
$54.23
$53.68
$24.23
$23.99
$199.32
$197.32
$158.70
$157.10
$40.62
$40.22
$198.23
$196.21
$172.79
$171.05
Page 269 of 323
Notes
Procedure
Code
78445
78451
78451
78451
78452
78452
78452
78453
78453
78453
78454
78454
78454
78456
78456
78456
78457
78457
78457
78458
78458
78458
78459
78466
78466
78466
78468
78468
78468
78469
78469
78469
78472
1/2/2015
Modifier
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
26
TC
26
TC
26
TC
26
Par Fee
$23.87
$353.58
$285.86
$67.71
$489.71
$409.89
$79.83
$315.45
$265.88
$49.57
$451.54
$384.54
$67.00
$332.21
$283.00
$49.21
$181.37
$143.60
$37.77
$212.48
$167.20
$45.28
$73.17
$201.79
$166.53
$35.27
$199.96
$160.76
$39.20
$235.72
$189.73
$45.99
$238.18
Nonpar Fee
$22.68
$335.90
$271.57
$64.32
$465.22
$389.40
$75.84
$299.68
$252.59
$47.09
$428.96
$365.31
$63.65
$315.60
$268.85
$46.75
$172.30
$136.42
$35.88
$201.86
$158.84
$43.02
$69.51
$191.70
$158.20
$33.51
$189.96
$152.72
$37.24
$223.93
$180.24
$43.69
$226.27
Limiting
Charge
$26.08
$386.29
$312.31
$73.97
$535.00
$447.81
$87.22
$344.63
$290.48
$54.15
$493.30
$420.11
$73.20
$362.94
$309.18
$53.76
$198.15
$156.88
$41.26
$232.14
$182.67
$49.47
$79.94
$220.46
$181.93
$38.54
$218.45
$175.63
$42.83
$257.52
$207.28
$50.24
$260.21
Charge**
Charge***
$25.82
$25.69
$382.42
$380.49
$309.18
$307.63
$73.23
$72.86
$529.66
$526.98
$443.34
$441.09
$86.34
$85.91
$341.18
$339.46
$287.57
$286.12
$53.61
$53.34
$488.37
$485.91
$415.91
$413.80
$72.46
$72.11
$359.31
$357.50
$306.08
$304.54
$53.22
$52.96
$196.17
$195.18
$155.32
$154.53
$40.85
$40.64
$229.82
$228.65
$180.84
$179.93
$48.98
$48.73
$79.13
$78.74
$218.25
$217.14
$180.11
$179.20
$38.15
$37.96
$216.27
$215.18
$173.87
$172.99
$42.40
$42.18
$254.94
$253.66
$205.21
$204.17
$49.74
$49.48
$257.61
$256.31
Arizona
EHR/eRx
Limiting
Charge**
$25.56
$378.56
$306.06
$72.48
$524.31
$438.85
$85.47
$337.74
$284.67
$53.07
$483.44
$411.70
$71.74
$355.68
$302.99
$52.69
$194.18
$153.74
$40.43
$227.49
$179.01
$48.48
$78.34
$216.05
$178.30
$37.77
$214.08
$172.12
$41.98
$252.37
$203.14
$49.24
$255.00
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$25.43
$25.19
$376.68
$372.88
$304.54
$301.47
$72.13
$71.39
$521.71
$516.44
$436.69
$432.27
$85.04
$84.19
$336.06
$332.67
$283.26
$280.40
$52.81
$52.28
$481.05
$476.18
$409.68
$405.52
$71.37
$70.66
$353.91
$350.35
$301.50
$298.45
$52.43
$51.90
$193.22
$191.27
$152.98
$151.43
$40.24
$39.82
$226.37
$224.08
$178.12
$176.33
$48.24
$47.76
$77.95
$77.17
$214.97
$212.81
$177.41
$175.62
$37.57
$37.20
$213.03
$210.88
$171.26
$169.53
$41.77
$41.34
$251.11
$248.58
$202.12
$200.09
$48.99
$48.51
$253.75
$251.17
Page 270 of 323
Notes
Procedure
Code
78472
78472
78473
78473
78473
78481
78481
78481
78483
78483
78483
78491
78492
78494
78494
78494
78496
78496
78496
78579
78579
78579
78580
78580
78580
78582
78582
78582
78597
78597
78597
78598
78598
1/2/2015
Modifier
TC
26
TC
26
TC
26
TC
26
26
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
Par Fee
$189.73
$48.45
$298.92
$227.27
$71.65
$180.70
$132.56
$48.14
$246.04
$174.04
$72.00
$73.53
$92.43
$231.74
$173.28
$58.46
$45.63
$21.05
$24.58
$191.16
$167.60
$23.55
$247.20
$210.51
$36.70
$347.18
$293.77
$53.41
$209.26
$172.96
$36.29
$317.55
$275.54
Nonpar Fee
$180.24
$46.03
$283.97
$215.91
$68.07
$171.67
$125.93
$45.73
$233.74
$165.34
$68.40
$69.85
$87.81
$220.15
$164.62
$55.54
$43.35
$20.00
$23.35
$181.60
$159.22
$22.37
$234.84
$199.98
$34.87
$329.82
$279.08
$50.74
$198.80
$164.31
$34.48
$301.67
$261.76
Limiting
Charge
$207.28
$52.93
$326.57
$248.30
$78.28
$197.42
$144.82
$52.59
$268.80
$190.14
$78.66
$80.33
$100.98
$253.17
$189.31
$63.87
$49.85
$23.00
$26.85
$208.84
$183.10
$25.73
$270.07
$229.98
$40.10
$379.29
$320.94
$58.35
$228.62
$188.96
$39.65
$346.92
$301.02
Charge**
Charge***
$205.21
$204.17
$52.41
$52.14
$323.30
$321.67
$245.81
$244.57
$77.50
$77.11
$195.44
$194.45
$143.37
$142.65
$52.06
$51.80
$266.11
$264.76
$188.24
$187.29
$77.88
$77.48
$79.52
$79.12
$99.97
$99.46
$250.64
$249.38
$187.42
$186.47
$63.23
$62.92
$49.36
$49.11
$22.77
$22.66
$26.59
$26.45
$206.75
$205.71
$181.27
$180.35
$25.47
$25.33
$267.36
$266.02
$227.68
$226.53
$39.70
$39.50
$375.50
$373.60
$317.73
$316.12
$57.76
$57.48
$226.33
$225.19
$187.07
$186.13
$39.26
$39.05
$343.45
$341.71
$298.01
$296.50
Arizona
EHR/eRx
Limiting
Charge**
$203.14
$51.88
$320.03
$243.33
$76.72
$193.48
$141.92
$51.54
$263.43
$186.33
$77.08
$78.72
$98.96
$248.11
$185.53
$62.59
$48.85
$22.54
$26.31
$204.67
$179.45
$25.21
$264.66
$225.38
$39.30
$371.70
$314.53
$57.19
$224.04
$185.17
$38.86
$339.99
$295.00
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$202.12
$200.09
$51.62
$51.09
$318.45
$315.24
$242.12
$239.68
$76.34
$75.57
$192.51
$190.58
$141.22
$139.79
$51.28
$50.77
$262.12
$259.47
$185.41
$183.54
$76.71
$75.92
$78.33
$77.53
$98.47
$97.47
$246.88
$244.39
$184.61
$182.75
$62.28
$61.65
$48.62
$48.12
$22.43
$22.21
$26.19
$25.92
$203.64
$201.60
$178.56
$176.76
$25.09
$24.83
$263.35
$260.69
$224.26
$222.00
$39.10
$38.71
$369.86
$366.13
$312.97
$309.81
$56.90
$56.33
$222.94
$220.69
$184.26
$182.39
$38.67
$38.27
$338.30
$334.89
$293.54
$290.57
Page 271 of 323
Notes
Procedure
Code
78598
78600
78600
78600
78601
78601
78601
78605
78605
78605
78606
78606
78606
78607
78607
78607
78608
78610
78610
78610
78630
78630
78630
78635
78635
78635
78645
78645
78645
78647
78647
78647
78650
1/2/2015
Modifier
26
TC
26
TC
26
TC
26
TC
26
TC
26
26
TC
26
TC
26
TC
26
TC
26
TC
26
Par Fee
$42.01
$190.75
$168.63
$22.12
$222.49
$197.23
$25.25
$205.73
$179.00
$26.73
$345.13
$313.39
$31.73
$365.37
$305.53
$59.85
$74.20
$180.39
$165.41
$14.97
$352.19
$318.04
$34.15
$353.26
$321.97
$31.29
$335.79
$307.67
$28.11
$364.12
$319.47
$44.65
$346.47
Nonpar Fee
$39.91
$181.21
$160.20
$21.01
$211.37
$187.37
$23.99
$195.44
$170.05
$25.39
$327.87
$297.72
$30.14
$347.10
$290.25
$56.86
$70.49
$171.37
$157.14
$14.22
$334.58
$302.14
$32.44
$335.60
$305.87
$29.73
$319.00
$292.29
$26.70
$345.91
$303.50
$42.42
$329.15
Limiting
Charge
$45.90
$208.39
$184.23
$24.16
$243.08
$215.48
$27.59
$224.76
$195.56
$29.20
$377.05
$342.38
$34.66
$399.17
$333.79
$65.39
$81.06
$197.08
$180.71
$16.35
$384.77
$347.46
$37.31
$385.94
$351.75
$34.19
$366.85
$336.13
$30.71
$397.80
$349.03
$48.78
$378.52
Charge**
Charge***
$45.44
$45.21
$206.31
$205.26
$182.39
$181.47
$23.92
$23.79
$240.65
$239.43
$213.33
$212.24
$27.31
$27.17
$222.51
$221.39
$193.60
$192.63
$28.91
$28.76
$373.28
$371.39
$338.95
$337.24
$34.32
$34.14
$395.17
$393.17
$330.45
$328.79
$64.73
$64.41
$80.26
$79.84
$195.11
$194.12
$178.91
$178.00
$16.19
$16.11
$380.91
$378.99
$343.99
$342.25
$36.94
$36.74
$382.08
$380.16
$348.23
$346.47
$33.84
$33.67
$363.18
$361.35
$332.78
$331.10
$30.39
$30.25
$393.82
$391.83
$345.54
$343.79
$48.30
$48.05
$374.74
$372.84
Arizona
EHR/eRx
Limiting
Charge**
$44.98
$204.23
$180.55
$23.68
$238.21
$211.16
$27.04
$220.26
$191.65
$28.61
$369.51
$335.54
$33.97
$391.18
$327.12
$64.08
$79.44
$193.13
$177.10
$16.03
$377.07
$340.52
$36.56
$378.22
$344.71
$33.51
$359.51
$329.41
$30.10
$389.84
$342.04
$47.81
$370.96
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$44.76
$44.30
$203.22
$201.17
$179.65
$177.85
$23.56
$23.32
$237.04
$234.63
$210.13
$208.00
$26.90
$26.63
$219.18
$216.96
$190.69
$188.77
$28.47
$28.19
$367.68
$363.96
$333.87
$330.50
$33.80
$33.47
$389.25
$385.32
$325.50
$322.21
$63.77
$63.11
$79.05
$78.25
$192.19
$190.23
$176.23
$174.44
$15.95
$15.79
$375.20
$371.42
$338.82
$335.41
$36.39
$36.01
$376.35
$372.55
$343.01
$339.54
$33.34
$33.01
$357.73
$354.12
$327.78
$324.46
$29.93
$29.65
$387.91
$384.00
$340.35
$336.92
$47.58
$47.09
$369.12
$365.39
Page 272 of 323
Notes
Procedure
Code
78650
78650
78660
78660
78660
78700
78700
78700
78701
78701
78701
78707
78707
78707
78708
78708
78708
78709
78709
78709
78710
78710
78710
78725
78725
78725
78730
78730
78730
78740
78740
78740
78761
1/2/2015
Modifier
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
Par Fee
$315.90
$30.57
$182.57
$156.52
$26.06
$177.57
$155.44
$22.12
$217.88
$194.02
$23.87
$240.32
$193.30
$47.02
$179.45
$119.29
$60.16
$374.31
$305.88
$68.43
$204.70
$174.71
$29.99
$111.74
$93.55
$18.19
$79.29
$71.47
$7.82
$226.46
$198.31
$28.16
$218.15
Nonpar Fee
$300.11
$29.04
$173.44
$148.69
$24.76
$168.69
$147.67
$21.01
$206.99
$184.32
$22.68
$228.30
$183.64
$44.67
$170.48
$113.33
$57.15
$355.59
$290.59
$65.01
$194.47
$165.97
$28.49
$106.15
$88.87
$17.28
$75.33
$67.90
$7.43
$215.14
$188.39
$26.75
$207.24
Limiting
Charge
$345.13
$33.40
$199.46
$170.99
$28.47
$193.99
$169.82
$24.16
$238.04
$211.97
$26.08
$262.55
$211.19
$51.37
$196.05
$130.33
$65.72
$408.93
$334.18
$74.76
$223.64
$190.87
$32.76
$122.07
$102.20
$19.87
$86.63
$78.09
$8.54
$247.41
$216.65
$30.76
$238.33
Charge**
Charge***
$341.68
$339.95
$33.06
$32.89
$197.47
$196.47
$169.28
$168.43
$28.19
$28.05
$192.05
$191.08
$168.12
$167.27
$23.92
$23.79
$235.66
$234.47
$209.85
$208.79
$25.82
$25.69
$259.92
$258.61
$209.07
$208.02
$50.85
$50.60
$194.10
$193.11
$129.03
$128.37
$65.07
$64.73
$404.83
$402.80
$330.83
$329.16
$74.01
$73.63
$221.41
$220.28
$188.96
$188.00
$32.44
$32.27
$120.85
$120.24
$101.18
$100.67
$19.68
$19.57
$85.77
$85.33
$77.30
$76.91
$8.46
$8.42
$244.94
$243.70
$214.49
$213.39
$30.45
$30.30
$235.95
$234.75
Arizona
EHR/eRx
Limiting
Charge**
$338.23
$32.73
$195.47
$167.58
$27.90
$190.12
$166.43
$23.68
$233.28
$207.72
$25.56
$257.29
$206.97
$50.35
$192.13
$127.72
$64.41
$400.75
$327.50
$73.27
$219.17
$187.05
$32.11
$119.63
$100.15
$19.47
$84.89
$76.52
$8.37
$242.47
$212.31
$30.15
$233.57
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$336.55
$333.16
$32.57
$32.23
$194.50
$192.53
$166.74
$165.06
$27.76
$27.49
$189.18
$187.27
$165.60
$163.93
$23.56
$23.32
$232.13
$229.78
$206.70
$204.61
$25.43
$25.19
$256.02
$253.43
$205.93
$203.86
$50.09
$49.59
$191.19
$189.24
$127.10
$125.80
$64.09
$63.45
$398.76
$394.74
$325.86
$322.59
$72.90
$72.16
$218.09
$215.88
$186.13
$184.24
$31.96
$31.63
$119.04
$117.84
$99.66
$98.65
$19.38
$19.18
$84.48
$83.62
$76.14
$75.37
$8.34
$8.25
$241.27
$238.83
$211.27
$209.13
$29.99
$29.70
$232.40
$230.06
Page 273 of 323
Notes
Procedure
Code
78761
78761
78800
78800
78800
78801
78801
78801
78802
78802
78802
78803
78803
78803
78804
78804
78804
78805
78805
78805
78806
78806
78806
78807
78807
78807
78808
78811
78812
78813
78814
78815
78816
1/2/2015
Modifier
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
26
26
26
26
26
26
Par Fee
$181.86
$36.29
$197.10
$163.67
$33.43
$269.60
$229.41
$40.18
$336.41
$293.73
$42.69
$353.22
$300.52
$52.70
$591.26
$538.56
$52.70
$188.16
$151.87
$36.29
$345.75
$303.38
$42.37
$353.66
$301.59
$52.07
$45.28
$79.47
$97.58
$101.82
$113.13
$124.17
$124.93
Nonpar Fee
$172.77
$34.48
$187.25
$155.49
$31.76
$256.12
$217.94
$38.17
$319.59
$279.04
$40.56
$335.56
$285.49
$50.07
$561.70
$511.63
$50.07
$178.75
$144.28
$34.48
$328.46
$288.21
$40.25
$335.98
$286.51
$49.47
$43.02
$75.50
$92.70
$96.73
$107.47
$117.96
$118.68
Limiting
Charge
$198.69
$39.65
$215.34
$178.81
$36.52
$294.54
$250.63
$43.90
$367.53
$320.90
$46.64
$385.89
$328.31
$57.58
$645.96
$588.37
$57.58
$205.56
$165.92
$39.65
$377.73
$331.44
$46.29
$386.38
$329.49
$56.89
$49.47
$86.83
$106.61
$111.24
$123.59
$135.65
$136.48
Charge**
Charge***
$196.70
$195.71
$39.26
$39.05
$213.19
$212.11
$177.03
$176.13
$36.16
$35.97
$291.59
$290.12
$248.12
$246.87
$43.46
$43.24
$363.85
$362.02
$317.69
$316.08
$46.17
$45.94
$382.03
$380.11
$325.04
$323.39
$57.01
$56.72
$639.49
$636.26
$582.49
$579.55
$57.01
$56.72
$203.50
$202.48
$164.27
$163.44
$39.26
$39.05
$373.96
$372.06
$328.13
$326.47
$45.83
$45.60
$382.51
$380.58
$326.19
$324.54
$56.33
$56.04
$48.98
$48.73
$85.96
$85.53
$105.54
$105.01
$110.12
$109.57
$122.36
$121.74
$134.30
$133.62
$135.11
$134.44
Arizona
EHR/eRx
Limiting
Charge**
$194.71
$38.86
$211.04
$175.24
$35.79
$288.65
$245.62
$43.02
$360.18
$314.48
$45.71
$378.18
$321.75
$56.43
$633.04
$576.61
$56.43
$201.46
$162.60
$38.86
$370.17
$324.82
$45.37
$378.65
$322.90
$55.75
$48.48
$85.09
$104.48
$109.02
$121.12
$132.94
$133.76
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$193.74
$191.79
$38.67
$38.27
$209.99
$207.87
$174.37
$172.60
$35.62
$35.25
$287.22
$284.33
$244.40
$241.94
$42.80
$42.38
$358.39
$354.78
$312.93
$309.76
$45.48
$45.02
$376.30
$372.51
$320.16
$316.92
$56.15
$55.58
$629.90
$623.54
$573.75
$567.96
$56.15
$55.58
$200.46
$198.43
$161.81
$160.16
$38.67
$38.27
$368.35
$364.62
$323.21
$319.94
$45.14
$44.69
$376.77
$372.97
$321.30
$318.06
$55.49
$54.91
$48.24
$47.76
$84.67
$83.81
$103.95
$102.91
$108.47
$107.39
$120.52
$119.30
$132.28
$130.95
$133.09
$131.76
Page 274 of 323
Notes
#
#
#
Procedure
Code
79005
79005
79005
79101
79101
79101
79200
79200
79200
79300
79403
79403
79403
79440
79440
79440
79445
80500
80500
80502
80502
83020
84165
84166
84181
84182
85060
85097
85097
85390
85396
85576
86077
1/2/2015
Modifier
TC
26
TC
26
TC
26
26
TC
26
TC
26
26
26
26
26
26
26
26
26
Par Fee
$137.66
$49.30
$88.36
$143.74
$48.22
$95.51
$137.08
$52.11
$84.96
$72.99
$191.79
$81.03
$110.76
$129.71
$40.36
$89.35
$119.57
$23.15
$19.93
$73.03
$69.82
$18.86
$18.86
$18.86
$18.86
$18.86
$24.94
$89.21
$49.52
$18.86
$20.65
$18.86
$56.27
Nonpar Fee
$130.78
$46.84
$83.94
$136.55
$45.81
$90.73
$130.23
$49.50
$80.71
$69.34
$182.20
$76.98
$105.22
$123.22
$38.34
$84.88
$113.59
$21.99
$18.93
$69.38
$66.33
$17.92
$17.92
$17.92
$17.92
$17.92
$23.69
$84.75
$47.04
$17.92
$19.62
$17.92
$53.46
Limiting
Charge
$150.40
$53.87
$96.53
$157.03
$52.68
$104.34
$149.76
$56.93
$92.82
$79.74
$209.53
$88.53
$121.00
$141.70
$44.09
$97.61
$130.63
$25.29
$21.77
$79.79
$76.28
$20.61
$20.61
$20.61
$20.61
$20.61
$27.24
$97.46
$54.10
$20.61
$22.56
$20.61
$61.48
Charge**
Charge***
$148.89
$148.14
$53.33
$53.06
$95.57
$95.08
$155.46
$154.68
$52.15
$51.89
$103.29
$102.78
$148.27
$147.52
$56.36
$56.07
$91.89
$91.43
$78.95
$78.55
$207.44
$206.39
$87.64
$87.20
$119.80
$119.19
$140.29
$139.58
$43.65
$43.42
$96.63
$96.15
$129.32
$128.67
$25.04
$24.91
$21.55
$21.45
$78.99
$78.59
$75.52
$75.14
$20.40
$20.30
$20.40
$20.30
$20.40
$20.30
$20.40
$20.30
$20.40
$20.30
$26.97
$26.83
$96.49
$96.00
$53.56
$53.28
$20.40
$20.30
$22.33
$22.23
$20.40
$20.30
$60.87
$60.56
Arizona
EHR/eRx
Limiting
Charge**
$147.38
$52.79
$94.60
$153.89
$51.62
$102.26
$146.77
$55.79
$90.97
$78.14
$205.34
$86.76
$118.59
$138.87
$43.21
$95.66
$128.02
$24.78
$21.33
$78.19
$74.75
$20.19
$20.19
$20.19
$20.19
$20.19
$26.70
$95.52
$53.02
$20.19
$22.11
$20.19
$60.25
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$146.66
$145.18
$52.52
$51.99
$94.13
$93.18
$153.12
$151.58
$51.37
$50.85
$101.74
$100.73
$146.05
$144.58
$55.51
$54.95
$90.51
$89.60
$77.76
$76.97
$204.32
$202.26
$86.33
$85.46
$118.00
$116.81
$138.18
$136.79
$43.00
$42.56
$95.19
$94.22
$127.37
$126.10
$24.66
$24.41
$21.23
$21.01
$77.81
$77.02
$74.38
$73.63
$20.09
$19.90
$20.09
$19.90
$20.09
$19.90
$20.09
$19.90
$20.09
$19.90
$26.57
$26.30
$95.04
$94.08
$52.75
$52.22
$20.09
$19.90
$22.00
$21.78
$20.09
$19.90
$59.96
$59.34
Page 275 of 323
Notes
#
#
#
Procedure
Code
86077
86078
86078
86079
86079
86153
86255
86256
86320
86325
86327
86334
86335
86486
86490
86510
86580
87164
87207
88104
88104
88104
88106
88106
88106
88108
88108
88108
88112
88112
88112
88120
88120
1/2/2015
Modifier
26
26
26
26
26
26
26
26
26
26
TC
26
TC
26
TC
26
TC
26
TC
Par Fee
$52.34
$55.91
$51.98
$54.84
$51.27
$35.22
$18.86
$18.86
$18.86
$18.86
$21.68
$18.86
$18.86
$4.96
$6.75
$6.03
$7.82
$18.86
$18.86
$75.00
$45.36
$29.63
$87.87
$67.89
$19.98
$84.65
$61.10
$23.55
$64.63
$36.07
$28.56
$623.03
$564.12
Nonpar Fee
$49.72
$53.11
$49.38
$52.10
$48.71
$33.46
$17.92
$17.92
$17.92
$17.92
$20.60
$17.92
$17.92
$4.71
$6.41
$5.73
$7.43
$17.92
$17.92
$71.25
$43.09
$28.15
$83.48
$64.50
$18.98
$80.42
$58.05
$22.37
$61.40
$34.27
$27.13
$591.88
$535.91
Limiting
Charge
$57.18
$61.08
$56.79
$59.92
$56.02
$38.48
$20.61
$20.61
$20.61
$20.61
$23.69
$20.61
$20.61
$5.42
$7.37
$6.59
$8.54
$20.61
$20.61
$81.94
$49.55
$32.37
$96.00
$74.18
$21.83
$92.48
$66.76
$25.73
$70.61
$39.41
$31.20
$680.66
$616.30
Charge**
Charge***
$56.60
$56.32
$60.47
$60.16
$56.22
$55.94
$59.32
$59.02
$55.45
$55.18
$38.10
$37.90
$20.40
$20.30
$20.40
$20.30
$20.40
$20.30
$20.40
$20.30
$23.45
$23.33
$20.40
$20.30
$20.40
$20.30
$5.36
$5.34
$7.30
$7.26
$6.52
$6.49
$8.46
$8.42
$20.40
$20.30
$20.40
$20.30
$81.12
$80.71
$49.06
$48.81
$32.05
$31.89
$95.05
$94.56
$73.44
$73.06
$21.61
$21.51
$91.56
$91.09
$66.09
$65.76
$25.47
$25.33
$69.91
$69.55
$39.02
$38.82
$30.89
$30.73
$673.85
$670.45
$610.13
$607.05
Arizona
EHR/eRx
Limiting
Charge**
$56.04
$59.86
$55.65
$58.72
$54.90
$37.71
$20.19
$20.19
$20.19
$20.19
$23.22
$20.19
$20.19
$5.31
$7.22
$6.46
$8.37
$20.19
$20.19
$80.30
$48.56
$31.73
$94.08
$72.69
$21.39
$90.63
$65.42
$25.21
$69.20
$38.62
$30.58
$667.05
$603.97
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$55.75
$55.20
$59.56
$58.96
$55.38
$54.81
$58.43
$57.83
$54.63
$54.07
$37.52
$37.15
$20.09
$19.90
$20.09
$19.90
$20.09
$19.90
$20.09
$19.90
$23.09
$22.87
$20.09
$19.90
$20.09
$19.90
$5.28
$5.23
$7.19
$7.12
$6.42
$6.37
$8.34
$8.25
$20.09
$19.90
$20.09
$19.90
$79.90
$79.10
$48.32
$47.84
$31.57
$31.26
$93.62
$92.67
$72.34
$71.60
$21.29
$21.07
$90.19
$89.27
$65.10
$64.45
$25.09
$24.83
$68.86
$68.16
$38.43
$38.04
$30.43
$30.12
$663.75
$657.04
$600.98
$594.91
Page 276 of 323
Notes
Procedure
Code
88120
88121
88121
88121
88125
88125
88125
88141
88160
88160
88160
88161
88161
88161
88162
88162
88162
88172
88172
88172
88173
88173
88173
88177
88177
88177
88182
88182
88182
88184
88185
88187
88188
1/2/2015
Modifier
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
Par Fee
$58.91
$554.07
$502.67
$51.40
$26.33
$11.76
$14.57
$32.45
$67.13
$40.36
$26.77
$60.70
$35.00
$25.70
$99.98
$58.95
$41.03
$56.76
$19.62
$37.14
$151.47
$79.29
$72.18
$30.66
$7.82
$22.84
$108.52
$72.45
$36.07
$93.99
$57.16
$71.96
$91.49
Nonpar Fee
$55.96
$526.37
$477.54
$48.83
$25.01
$11.17
$13.84
$30.83
$63.77
$38.34
$25.43
$57.67
$33.25
$24.42
$94.98
$56.00
$38.98
$53.92
$18.64
$35.28
$143.90
$75.33
$68.57
$29.13
$7.43
$21.70
$103.09
$68.83
$34.27
$89.29
$54.30
$68.36
$86.92
Limiting
Charge
$64.35
$605.33
$549.17
$56.15
$28.76
$12.85
$15.92
$35.45
$73.34
$44.09
$29.24
$66.32
$38.24
$28.08
$109.23
$64.40
$44.83
$62.01
$21.44
$40.57
$165.49
$86.63
$78.86
$33.50
$8.54
$24.96
$118.55
$79.15
$39.41
$102.68
$62.45
$78.61
$99.96
Charge**
Charge***
$63.71
$63.39
$599.28
$596.24
$543.67
$540.94
$55.59
$55.32
$28.47
$28.32
$12.72
$12.65
$15.76
$15.67
$35.10
$34.93
$72.60
$72.23
$43.65
$43.42
$28.96
$28.81
$65.65
$65.32
$37.86
$37.66
$27.81
$27.66
$108.13
$107.59
$63.76
$63.43
$44.38
$44.16
$61.39
$61.08
$21.22
$21.11
$40.17
$39.96
$163.83
$163.00
$85.77
$85.33
$78.06
$77.67
$33.17
$32.99
$8.46
$8.42
$24.70
$24.58
$117.37
$116.77
$78.36
$77.97
$39.02
$38.82
$101.66
$101.14
$61.82
$61.51
$77.83
$77.43
$98.96
$98.46
Arizona
EHR/eRx
Limiting
Charge**
$63.07
$593.22
$538.19
$55.03
$28.19
$12.59
$15.59
$34.74
$71.86
$43.21
$28.66
$65.00
$37.48
$27.52
$107.04
$63.11
$43.93
$60.77
$21.01
$39.76
$162.17
$84.89
$77.28
$32.83
$8.37
$24.46
$116.18
$77.57
$38.62
$100.63
$61.19
$77.04
$97.96
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$62.76
$62.12
$590.28
$584.32
$535.52
$530.12
$54.75
$54.20
$28.05
$27.76
$12.52
$12.41
$15.51
$15.36
$34.57
$34.22
$71.51
$70.78
$43.00
$42.56
$28.52
$28.23
$64.66
$64.02
$37.29
$36.92
$27.39
$27.11
$106.51
$105.43
$62.80
$62.17
$43.71
$43.27
$60.47
$59.86
$20.90
$20.70
$39.57
$39.16
$161.37
$159.74
$84.48
$83.62
$76.89
$76.12
$32.67
$32.34
$8.34
$8.25
$24.33
$24.09
$115.61
$114.44
$77.19
$76.41
$38.43
$38.04
$100.13
$99.12
$60.89
$60.27
$76.66
$75.89
$97.47
$96.49
Page 277 of 323
Notes
Procedure
Code
88189
88291
88300
88300
88300
88302
88302
88302
88304
88304
88304
88305
88305
88305
88307
88307
88307
88309
88309
88309
88311
88311
88311
88312
88312
88312
88313
88313
88313
88314
88314
88314
88319
1/2/2015
Modifier
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
Par Fee
$112.90
$31.73
$15.29
$10.68
$4.60
$32.09
$24.98
$7.11
$45.68
$33.92
$11.76
$72.85
$33.92
$38.93
$305.88
$220.16
$85.72
$464.15
$312.77
$151.38
$21.01
$8.18
$12.83
$97.52
$69.68
$27.84
$67.85
$55.38
$12.47
$74.64
$51.80
$22.84
$88.54
Nonpar Fee
$107.26
$30.14
$14.53
$10.15
$4.37
$30.49
$23.73
$6.75
$43.40
$32.22
$11.17
$69.21
$32.22
$36.98
$290.59
$209.15
$81.43
$440.94
$297.13
$143.81
$19.96
$7.77
$12.19
$92.64
$66.20
$26.45
$64.46
$52.61
$11.85
$70.91
$49.21
$21.70
$84.11
Limiting
Charge
$123.35
$34.66
$16.71
$11.67
$5.03
$35.06
$27.29
$7.76
$49.91
$37.05
$12.85
$79.59
$37.05
$42.53
$334.18
$240.52
$93.64
$507.08
$341.70
$165.38
$22.95
$8.94
$14.02
$106.54
$76.13
$30.42
$74.13
$60.50
$13.63
$81.55
$56.59
$24.96
$96.73
Charge**
Charge***
$122.12
$121.50
$34.32
$34.14
$16.54
$16.46
$11.56
$11.50
$4.98
$4.95
$34.72
$34.53
$27.01
$26.88
$7.68
$7.65
$49.42
$49.16
$36.69
$36.50
$12.72
$12.65
$78.80
$78.40
$36.69
$36.50
$42.10
$41.89
$330.83
$329.16
$238.12
$236.91
$92.71
$92.24
$502.01
$499.48
$338.28
$336.57
$163.73
$162.90
$22.72
$22.61
$8.84
$8.80
$13.88
$13.81
$105.47
$104.94
$75.37
$74.99
$30.12
$29.96
$73.39
$73.01
$59.89
$59.59
$13.49
$13.42
$80.73
$80.33
$56.03
$55.74
$24.70
$24.58
$95.76
$95.28
Arizona
EHR/eRx
Limiting
Charge**
$120.88
$33.97
$16.38
$11.44
$4.92
$34.36
$26.75
$7.61
$48.91
$36.32
$12.59
$78.00
$36.32
$41.68
$327.50
$235.72
$91.77
$496.94
$334.87
$162.07
$22.49
$8.75
$13.74
$104.41
$74.61
$29.81
$72.65
$59.29
$13.35
$79.91
$55.46
$24.46
$94.79
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$120.29
$119.06
$33.80
$33.47
$16.28
$16.13
$11.39
$11.27
$4.91
$4.85
$34.20
$33.84
$26.61
$26.35
$7.57
$7.50
$48.68
$48.17
$36.13
$35.78
$12.52
$12.41
$77.61
$76.83
$36.13
$35.78
$41.47
$41.06
$325.86
$322.59
$234.54
$232.19
$91.32
$90.39
$494.48
$489.49
$333.21
$329.84
$161.26
$159.64
$22.38
$22.16
$8.71
$8.63
$13.67
$13.54
$103.88
$102.84
$74.24
$73.50
$29.67
$29.36
$72.29
$71.55
$59.00
$58.41
$13.28
$13.16
$79.52
$78.72
$55.19
$54.64
$24.33
$24.09
$94.32
$93.37
Page 278 of 323
Notes
#
#
#
Procedure
Code
88319
88319
88321
88321
88323
88323
88323
88325
88325
88329
88329
88331
88331
88331
88332
88332
88332
88333
88333
88333
88334
88334
88334
88341
88341
88341
88342
88342
88342
88344
88344
88344
88346
1/2/2015
Modifier
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
Par Fee
$60.38
$28.16
$96.23
$86.22
$152.18
$62.88
$89.30
$215.07
$136.06
$58.86
$36.70
$103.24
$38.93
$64.31
$45.32
$13.54
$31.78
$108.92
$44.29
$64.63
$66.73
$27.13
$39.60
$67.49
$45.72
$21.77
$90.37
$53.95
$36.43
$116.83
$76.83
$40.00
$110.39
Nonpar Fee
$57.36
$26.75
$91.42
$81.91
$144.57
$59.74
$84.84
$204.32
$129.26
$55.92
$34.87
$98.08
$36.98
$61.09
$43.05
$12.86
$30.19
$103.47
$42.08
$61.40
$63.39
$25.77
$37.62
$64.12
$43.43
$20.68
$85.85
$51.25
$34.61
$110.99
$72.99
$38.00
$104.87
Limiting
Charge
$65.96
$30.76
$105.13
$94.20
$166.26
$68.70
$97.57
$234.97
$148.65
$64.31
$40.10
$112.79
$42.53
$70.25
$49.51
$14.79
$34.72
$118.99
$48.39
$70.61
$72.90
$29.64
$43.26
$73.74
$49.94
$23.78
$98.73
$58.94
$39.80
$127.64
$83.94
$43.70
$120.60
Charge**
Charge***
$65.31
$64.98
$30.45
$30.30
$104.09
$103.56
$93.25
$92.78
$164.59
$163.76
$68.01
$67.67
$96.59
$96.11
$232.62
$231.45
$147.17
$146.42
$63.66
$63.34
$39.70
$39.50
$111.67
$111.10
$42.10
$41.89
$69.55
$69.20
$49.01
$48.76
$14.64
$14.57
$34.37
$34.20
$117.81
$117.21
$47.91
$47.67
$69.91
$69.55
$72.17
$71.81
$29.34
$29.19
$42.83
$42.62
$73.00
$72.63
$49.45
$49.20
$23.54
$23.43
$97.74
$97.24
$58.35
$58.05
$39.40
$39.20
$126.36
$125.73
$83.10
$82.69
$43.26
$43.04
$119.39
$118.80
Arizona
EHR/eRx
Limiting
Charge**
$64.64
$30.15
$103.03
$92.31
$162.93
$67.33
$95.61
$230.26
$145.67
$63.02
$39.30
$110.54
$41.68
$68.85
$48.52
$14.49
$34.03
$116.61
$47.43
$69.20
$71.44
$29.04
$42.40
$72.27
$48.94
$23.31
$96.75
$57.76
$39.01
$125.09
$82.26
$42.83
$118.19
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$64.33
$63.68
$29.99
$29.70
$102.52
$101.49
$91.85
$90.93
$162.12
$160.48
$66.99
$66.32
$95.14
$94.17
$229.14
$226.81
$144.96
$143.49
$62.71
$62.08
$39.10
$38.71
$109.99
$108.88
$41.47
$41.06
$68.51
$67.82
$48.28
$47.79
$14.42
$14.27
$33.86
$33.52
$116.04
$114.86
$47.20
$46.71
$68.86
$68.16
$71.09
$70.37
$28.90
$28.60
$42.18
$41.77
$71.91
$71.19
$48.71
$48.21
$23.18
$22.97
$96.28
$95.30
$57.48
$56.90
$38.81
$38.42
$124.46
$123.21
$81.86
$81.03
$42.62
$42.18
$117.60
$116.41
Page 279 of 323
Notes
#
Procedure
Code
88346
88346
88347
88347
88347
88348
88348
88348
88355
88355
88355
88356
88356
88356
88358
88358
88358
88360
88360
88360
88361
88361
88361
88362
88362
88362
88363
88363
88364
88364
88364
88365
88365
1/2/2015
Modifier
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
Par Fee
$66.82
$43.58
$92.87
$50.01
$42.86
$346.60
$268.70
$77.90
$174.71
$91.44
$83.26
$205.41
$83.18
$122.24
$84.29
$38.93
$45.36
$135.78
$80.40
$55.38
$169.39
$109.37
$60.02
$295.35
$183.20
$112.14
$22.80
$19.58
$97.16
$70.04
$27.13
$156.52
$111.87
Nonpar Fee
$63.48
$41.40
$88.23
$47.51
$40.72
$329.27
$255.27
$74.01
$165.97
$86.87
$79.10
$195.14
$79.02
$116.13
$80.08
$36.98
$43.09
$128.99
$76.38
$52.61
$160.92
$103.90
$57.02
$280.58
$174.04
$106.53
$21.66
$18.60
$92.30
$66.54
$25.77
$148.69
$106.28
Limiting
Charge
$73.00
$47.61
$101.46
$54.64
$46.83
$378.66
$293.56
$85.11
$190.87
$99.90
$90.97
$224.41
$90.87
$133.55
$92.09
$42.53
$49.55
$148.34
$87.84
$60.50
$185.06
$119.49
$65.57
$322.67
$200.15
$122.51
$24.91
$21.39
$106.15
$76.52
$29.64
$170.99
$122.22
Charge**
Charge***
$72.28
$71.91
$47.14
$46.90
$100.45
$99.95
$54.08
$53.82
$46.36
$46.13
$374.88
$372.98
$290.63
$289.16
$84.26
$83.84
$188.96
$188.00
$98.90
$98.41
$90.06
$89.60
$222.17
$221.04
$89.96
$89.50
$132.22
$131.55
$91.17
$90.71
$42.10
$41.89
$49.06
$48.81
$146.86
$146.12
$86.96
$86.51
$59.89
$59.59
$183.21
$182.29
$118.29
$117.69
$64.92
$64.58
$319.44
$317.83
$198.15
$197.14
$121.28
$120.67
$24.66
$24.54
$21.17
$21.07
$105.09
$104.56
$75.75
$75.37
$29.34
$29.19
$169.28
$168.43
$121.00
$120.39
Arizona
EHR/eRx
Limiting
Charge**
$71.54
$46.66
$99.44
$53.54
$45.90
$371.08
$287.68
$83.41
$187.05
$97.90
$89.15
$219.93
$89.06
$130.88
$90.25
$41.68
$48.56
$145.37
$86.08
$59.29
$181.36
$117.09
$64.26
$316.22
$196.14
$120.06
$24.41
$20.96
$104.02
$74.99
$29.04
$167.58
$119.77
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$71.20
$70.47
$46.44
$45.95
$98.95
$97.95
$53.27
$52.74
$45.67
$45.21
$369.25
$365.52
$286.27
$283.37
$83.00
$82.16
$186.13
$184.24
$97.42
$96.43
$88.71
$87.81
$218.83
$216.63
$88.62
$87.72
$130.24
$128.92
$89.80
$88.90
$41.47
$41.06
$48.32
$47.84
$144.65
$143.19
$85.66
$84.79
$59.00
$58.41
$180.46
$178.63
$116.52
$115.33
$63.94
$63.30
$314.64
$311.48
$195.18
$193.20
$119.46
$118.25
$24.29
$24.05
$20.85
$20.65
$103.51
$102.45
$74.61
$73.86
$28.90
$28.60
$166.74
$165.06
$119.19
$117.98
Page 280 of 323
Notes
Procedure
Code
88365
88366
88366
88366
88367
88367
88367
88368
88368
88368
88369
88369
88369
88371
88372
88373
88373
88373
88374
88374
88374
88375
88377
88377
88377
88380
88380
88380
88381
88381
88381
88387
88387
1/2/2015
Modifier
26
TC
26
TC
26
TC
26
TC
26
26
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
Par Fee
$44.65
$149.37
$86.48
$62.88
$107.18
$71.82
$35.35
$108.61
$67.53
$41.07
$73.57
$48.58
$24.98
$18.86
$18.86
$60.34
$39.29
$21.05
$204.43
$159.42
$45.01
$47.69
$213.73
$148.34
$65.39
$132.56
$76.11
$56.45
$124.29
$98.24
$26.06
$42.82
$9.97
Nonpar Fee
$42.42
$141.90
$82.16
$59.74
$101.82
$68.23
$33.58
$103.18
$64.15
$39.02
$69.89
$46.15
$23.73
$17.92
$17.92
$57.32
$37.33
$20.00
$194.21
$151.45
$42.76
$45.31
$203.04
$140.92
$62.12
$125.93
$72.30
$53.63
$118.08
$93.33
$24.76
$40.68
$9.47
Limiting
Charge
$48.78
$163.19
$94.48
$68.70
$117.09
$78.46
$38.62
$118.66
$73.77
$44.87
$80.37
$53.07
$27.29
$20.61
$20.61
$65.92
$42.93
$23.00
$223.34
$174.17
$49.17
$52.11
$233.50
$162.06
$71.44
$144.82
$83.15
$61.67
$135.79
$107.33
$28.47
$46.78
$10.89
Charge**
Charge***
$48.30
$48.05
$161.55
$160.74
$93.54
$93.07
$68.01
$67.67
$115.92
$115.33
$77.68
$77.29
$38.23
$38.04
$117.47
$116.87
$73.04
$72.67
$44.42
$44.19
$79.57
$79.17
$52.54
$52.28
$27.01
$26.88
$20.40
$20.30
$20.40
$20.30
$65.26
$64.93
$42.50
$42.29
$22.77
$22.66
$221.11
$220.00
$172.43
$171.56
$48.68
$48.44
$51.59
$51.32
$231.16
$229.99
$160.44
$159.63
$70.73
$70.37
$143.37
$142.65
$82.32
$81.90
$61.05
$60.75
$134.44
$133.76
$106.26
$105.72
$28.19
$28.05
$46.31
$46.08
$10.79
$10.73
Arizona
EHR/eRx
Limiting
Charge**
$47.81
$159.92
$92.60
$67.33
$114.75
$76.90
$37.85
$116.29
$72.30
$43.98
$78.76
$52.01
$26.75
$20.19
$20.19
$64.60
$42.07
$22.54
$218.88
$170.68
$48.19
$51.06
$228.83
$158.82
$70.01
$141.92
$81.48
$60.44
$133.08
$105.18
$27.90
$45.85
$10.67
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$47.58
$47.09
$159.13
$157.52
$92.14
$91.21
$66.99
$66.32
$114.18
$113.02
$76.52
$75.75
$37.65
$37.28
$115.71
$114.54
$71.94
$71.22
$43.76
$43.32
$78.37
$77.58
$51.75
$51.23
$26.61
$26.35
$20.09
$19.90
$20.09
$19.90
$64.29
$63.63
$41.87
$41.43
$22.43
$22.21
$217.80
$215.60
$169.84
$168.12
$47.96
$47.46
$50.82
$50.29
$227.69
$225.40
$158.03
$156.43
$69.67
$68.97
$141.22
$139.79
$81.09
$80.26
$60.13
$59.54
$132.42
$131.08
$104.66
$103.60
$27.76
$27.49
$45.62
$45.16
$10.63
$10.51
Page 281 of 323
Notes
#
#
#
#
#
#
#
#
#
Procedure
Code
88387
88388
88388
88388
89049
89049
89060
89220
89230
90460
90461
90471
90472
90473
90474
90785
90791
90791
90792
90792
90832
90832
90833
90833
90834
90834
90836
90836
90837
90837
90838
90838
90839
1/2/2015
Modifier
26
TC
26
26
Par Fee
$32.85
$34.24
$9.61
$24.63
$241.17
$62.40
$18.86
$15.69
$2.46
$25.34
$12.83
$25.34
$12.83
$25.34
$12.83
$14.26
$130.78
$126.85
$146.69
$142.40
$63.78
$63.07
$65.57
$64.85
$84.47
$83.76
$83.00
$82.64
$126.85
$126.13
$109.68
$108.97
$132.57
Nonpar Fee
$31.21
$32.53
$9.13
$23.40
$229.11
$59.28
$17.92
$14.91
$2.34
$24.07
$12.19
$24.07
$12.19
$24.07
$12.19
$13.55
$124.24
$120.51
$139.36
$135.28
$60.59
$59.92
$62.29
$61.61
$80.25
$79.57
$78.85
$78.51
$120.51
$119.82
$104.20
$103.52
$125.94
Limiting
Charge
$35.89
$37.41
$10.50
$26.91
$263.48
$68.17
$20.61
$17.15
$2.69
$27.68
$14.02
$27.68
$14.02
$27.68
$14.02
$15.58
$142.88
$138.59
$160.26
$155.57
$69.68
$68.91
$71.63
$70.85
$92.29
$91.51
$90.68
$90.29
$138.59
$137.79
$119.83
$119.05
$144.83
Charge**
Charge***
$35.54
$35.35
$37.03
$36.85
$10.40
$10.34
$26.65
$26.51
$260.84
$259.52
$67.49
$67.15
$20.40
$20.30
$16.97
$16.89
$2.67
$2.65
$27.40
$27.27
$13.88
$13.81
$27.40
$27.27
$13.88
$13.81
$27.40
$27.27
$13.88
$13.81
$15.42
$15.35
$141.45
$140.74
$137.20
$136.51
$158.67
$157.86
$154.02
$153.24
$68.98
$68.63
$68.22
$67.87
$70.92
$70.56
$70.14
$69.79
$91.37
$90.91
$90.59
$90.14
$89.77
$89.32
$89.38
$88.93
$137.20
$136.51
$136.41
$135.72
$118.63
$118.04
$117.85
$117.27
$143.38
$142.66
Arizona
EHR/eRx
Limiting
Charge**
$35.18
$36.66
$10.29
$26.37
$258.21
$66.80
$20.19
$16.80
$2.63
$27.13
$13.74
$27.13
$13.74
$27.13
$13.74
$15.27
$140.02
$135.82
$157.06
$152.46
$68.29
$67.53
$70.20
$69.44
$90.45
$89.68
$88.86
$88.48
$135.82
$135.03
$117.44
$116.67
$141.93
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$35.01
$34.65
$36.48
$36.11
$10.24
$10.14
$26.24
$25.98
$256.93
$254.33
$66.48
$65.80
$20.09
$19.90
$16.72
$16.55
$2.63
$2.60
$26.99
$26.73
$13.67
$13.54
$26.99
$26.73
$13.67
$13.54
$26.99
$26.73
$13.67
$13.54
$15.19
$15.04
$139.33
$137.92
$135.14
$133.78
$156.29
$154.70
$151.71
$150.17
$67.94
$67.26
$67.19
$66.52
$69.85
$69.14
$69.09
$68.39
$90.00
$89.09
$89.23
$88.33
$88.42
$87.53
$88.03
$87.16
$135.14
$133.78
$134.37
$133.01
$116.85
$115.68
$116.08
$114.92
$141.23
$139.81
Page 282 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
90839
90840
90840
90845
90845
90846
90846
90847
90847
90849
90849
90853
90853
90865
90865
90870
90870
90880
90880
90901
90901
90911
90911
90935
90937
90945
90947
90951
90951
90954
90954
90955
90955
1/2/2015
Modifier
Par Fee
$131.50
$63.42
$63.07
$90.87
$90.51
$102.31
$101.59
$106.51
$105.80
$35.27
$31.69
$25.66
$25.30
$168.68
$127.92
$178.02
$110.80
$101.24
$94.08
$38.17
$20.29
$84.83
$44.79
$72.90
$104.59
$86.13
$124.48
$943.33
$942.98
$821.22
$820.86
$459.66
$459.31
Nonpar Fee
$124.93
$60.25
$59.92
$86.33
$85.98
$97.19
$96.51
$101.18
$100.51
$33.51
$30.11
$24.38
$24.04
$160.25
$121.52
$169.12
$105.26
$96.18
$89.38
$36.26
$19.28
$80.59
$42.55
$69.26
$99.36
$81.82
$118.26
$896.16
$895.83
$780.16
$779.82
$436.68
$436.34
Limiting
Charge
$143.67
$69.29
$68.91
$99.28
$98.88
$111.77
$110.99
$116.36
$115.59
$38.54
$34.63
$28.04
$27.65
$184.29
$139.75
$194.49
$121.05
$110.61
$102.79
$41.70
$22.17
$92.68
$48.93
$79.65
$114.26
$94.09
$136.00
$1,030.58
$1,030.20
$897.18
$896.79
$502.18
$501.79
Charge**
Charge***
$142.23
$141.52
$68.60
$68.25
$68.22
$67.87
$98.29
$97.80
$97.89
$97.39
$110.65
$110.09
$109.87
$109.32
$115.20
$114.61
$114.43
$113.85
$38.15
$37.96
$34.28
$34.11
$27.76
$27.61
$27.37
$27.23
$182.45
$181.53
$138.35
$137.66
$192.54
$191.57
$119.84
$119.23
$109.50
$108.95
$101.76
$101.25
$41.29
$41.08
$21.95
$21.84
$91.75
$91.29
$48.44
$48.20
$78.86
$78.45
$113.13
$112.55
$93.15
$92.68
$134.64
$133.96
$1,020.28
$1,015.13
$1,019.90
$1,014.75
$888.21
$883.73
$887.82
$883.34
$497.16
$494.65
$496.78
$494.26
Arizona
EHR/eRx
Limiting
Charge**
$140.79
$67.91
$67.53
$97.29
$96.90
$109.54
$108.77
$114.03
$113.28
$37.77
$33.94
$27.47
$27.09
$180.61
$136.95
$190.60
$118.62
$108.40
$100.73
$40.86
$21.72
$90.83
$47.96
$78.05
$111.98
$92.21
$133.27
$1,009.98
$1,009.60
$879.24
$878.85
$492.14
$491.75
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$140.09
$138.68
$67.57
$66.88
$67.19
$66.52
$96.82
$95.83
$96.42
$95.45
$109.00
$107.89
$108.23
$107.13
$113.47
$112.32
$112.71
$111.57
$37.57
$37.20
$33.76
$33.43
$27.35
$27.06
$26.96
$26.69
$179.71
$177.89
$136.28
$134.90
$189.66
$187.74
$118.05
$116.84
$107.86
$106.78
$100.23
$99.22
$40.66
$40.25
$21.62
$21.40
$90.37
$89.47
$47.71
$47.23
$77.67
$76.88
$111.42
$110.30
$91.76
$90.83
$132.62
$131.27
$1,004.97
$994.83
$1,004.61
$994.45
$874.89
$866.05
$874.51
$865.67
$489.70
$484.76
$489.33
$484.38
Page 283 of 323
Notes
#
#
#
#
#
Procedure
Code
90956
90957
90957
90958
90958
90959
90960
90961
90962
90963
90963
90964
90964
90965
90965
90966
90967
90968
90969
90970
90997
91010
91010
91010
91013
91013
91013
91020
91020
91020
91022
91022
91022
1/2/2015
Modifier
TC
26
TC
26
TC
26
TC
26
Par Fee
$321.68
$647.39
$647.04
$436.96
$436.60
$297.14
$285.08
$239.84
$184.78
$547.49
$547.14
$477.10
$476.74
$455.06
$454.70
$238.86
$18.15
$15.64
$15.29
$7.82
$94.98
$179.41
$110.44
$68.97
$24.23
$14.62
$9.61
$236.75
$160.45
$76.30
$172.07
$95.42
$76.65
Nonpar Fee
$305.60
$615.02
$614.69
$415.11
$414.77
$282.28
$270.83
$227.85
$175.54
$520.12
$519.78
$453.25
$452.90
$432.31
$431.97
$226.92
$17.24
$14.86
$14.53
$7.43
$90.23
$170.44
$104.92
$65.52
$23.02
$13.89
$9.13
$224.91
$152.43
$72.49
$163.47
$90.65
$72.82
Limiting
Charge
$351.44
$707.27
$706.89
$477.38
$476.99
$324.62
$311.45
$262.03
$201.87
$598.14
$597.75
$521.24
$520.84
$497.16
$496.77
$260.96
$19.83
$17.09
$16.71
$8.54
$103.76
$196.01
$120.66
$75.35
$26.47
$15.97
$10.50
$258.65
$175.29
$83.36
$187.99
$104.25
$83.74
Charge**
Charge***
$347.92
$346.17
$700.20
$696.66
$699.82
$696.29
$472.60
$470.21
$472.21
$469.83
$321.38
$319.76
$308.34
$306.79
$259.41
$258.09
$199.85
$198.85
$592.16
$589.17
$591.77
$588.78
$516.03
$513.42
$515.63
$513.03
$492.19
$489.70
$491.80
$489.31
$258.35
$257.05
$19.63
$19.53
$16.92
$16.84
$16.54
$16.46
$8.46
$8.42
$102.73
$102.21
$194.05
$193.06
$119.45
$118.85
$74.59
$74.22
$26.21
$26.07
$15.81
$15.73
$10.40
$10.34
$256.06
$254.77
$173.55
$172.66
$82.54
$82.11
$186.12
$185.17
$103.20
$102.68
$82.90
$82.49
Arizona
EHR/eRx
Limiting
Charge**
$344.41
$693.13
$692.76
$467.83
$467.44
$318.12
$305.22
$256.78
$197.83
$586.18
$585.79
$510.82
$510.42
$487.21
$486.83
$255.74
$19.44
$16.74
$16.38
$8.37
$101.69
$192.08
$118.24
$73.84
$25.94
$15.65
$10.29
$253.47
$171.79
$81.70
$184.23
$102.17
$82.06
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$342.70
$339.25
$689.70
$682.73
$689.32
$682.36
$465.52
$460.82
$465.13
$460.43
$316.56
$313.35
$303.72
$300.64
$255.52
$252.93
$196.85
$194.87
$583.28
$577.38
$582.89
$577.00
$508.29
$503.16
$507.89
$502.76
$484.81
$479.91
$484.43
$479.53
$254.47
$251.90
$19.33
$19.15
$16.66
$16.49
$16.28
$16.13
$8.34
$8.25
$101.19
$100.17
$191.14
$189.20
$117.66
$116.47
$73.47
$72.74
$25.82
$25.55
$15.57
$15.42
$10.24
$10.14
$252.22
$249.67
$170.95
$169.21
$81.29
$80.47
$183.32
$181.47
$101.65
$100.64
$81.66
$80.83
Page 284 of 323
Notes
Procedure
Code
91030
91030
91030
91034
91034
91034
91035
91035
91035
91037
91037
91037
91038
91038
91038
91040
91040
91040
91065
91065
91065
91110
91110
91110
91111
91111
91111
91112
91112
91112
91117
91120
91120
1/2/2015
Modifier
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
Par Fee
$138.95
$90.77
$48.18
$190.00
$139.04
$50.95
$489.40
$404.70
$84.70
$163.45
$111.51
$51.94
$460.44
$400.77
$59.67
$444.97
$393.62
$51.35
$82.15
$71.47
$10.68
$904.20
$709.69
$194.52
$742.05
$688.95
$53.10
$1,100.40
$988.22
$112.19
$142.99
$435.77
$383.96
Nonpar Fee
$132.00
$86.23
$45.77
$180.50
$132.09
$48.40
$464.93
$384.47
$80.47
$155.28
$105.93
$49.34
$437.42
$380.73
$56.69
$422.72
$373.94
$48.78
$78.04
$67.90
$10.15
$858.99
$674.21
$184.79
$704.95
$654.50
$50.45
$1,045.38
$938.81
$106.58
$135.84
$413.98
$364.76
Limiting
Charge
$151.80
$99.16
$52.64
$207.58
$151.90
$55.66
$534.67
$442.14
$92.54
$178.57
$121.82
$56.74
$503.03
$437.84
$65.19
$486.13
$430.03
$56.10
$89.75
$78.09
$11.67
$987.84
$775.34
$212.51
$810.69
$752.68
$58.02
$1,202.19
$1,079.63
$122.57
$156.22
$476.08
$419.47
Charge**
Charge***
$150.28
$149.52
$98.18
$97.68
$52.11
$51.84
$205.51
$204.46
$150.39
$149.63
$55.11
$54.82
$529.32
$526.65
$437.72
$435.51
$91.62
$91.15
$176.79
$175.89
$120.60
$119.99
$56.18
$55.89
$498.01
$495.49
$433.46
$431.27
$64.54
$64.22
$481.26
$478.84
$425.73
$423.58
$55.53
$55.26
$88.85
$88.40
$77.30
$76.91
$11.56
$11.50
$977.96
$973.03
$767.59
$763.72
$210.38
$209.32
$802.59
$798.54
$745.15
$741.38
$57.44
$57.14
$1,190.17
$1,184.16
$1,068.83
$1,063.44
$121.34
$120.73
$154.65
$153.87
$471.32
$468.94
$415.28
$413.18
Arizona
EHR/eRx
Limiting
Charge**
$148.76
$97.19
$51.58
$203.42
$148.87
$54.54
$523.97
$433.30
$90.69
$175.00
$119.38
$55.60
$492.97
$429.09
$63.89
$476.41
$421.43
$54.97
$87.95
$76.52
$11.44
$968.08
$759.84
$208.25
$794.48
$737.62
$56.86
$1,178.14
$1,058.03
$120.12
$153.09
$466.56
$411.08
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$148.03
$146.53
$96.70
$95.73
$51.32
$50.81
$202.42
$200.38
$148.13
$146.64
$54.28
$53.73
$521.39
$516.12
$431.16
$426.80
$90.24
$89.33
$174.13
$172.37
$118.80
$117.59
$55.34
$54.76
$490.53
$485.58
$426.96
$422.65
$63.57
$62.94
$474.04
$469.27
$419.35
$415.10
$54.71
$54.14
$87.52
$86.63
$76.14
$75.37
$11.39
$11.27
$963.29
$953.56
$756.08
$748.44
$207.23
$205.13
$790.54
$782.56
$733.98
$726.56
$56.58
$56.01
$1,172.32
$1,160.47
$1,052.80
$1,042.16
$119.52
$118.31
$152.33
$150.79
$464.24
$459.55
$409.04
$404.92
Page 285 of 323
Notes
#
#
#
#
#
Procedure
Code
91120
91122
91122
91122
91132
91132
91132
91133
91133
91133
91200
91200
91200
92002
92002
92004
92004
92012
92012
92014
92014
92018
92019
92020
92020
92025
92025
92025
92060
92060
92060
92065
92065
1/2/2015
Modifier
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
Par Fee
$51.81
$227.59
$136.85
$90.73
$150.75
$122.95
$27.80
$174.71
$139.76
$34.95
$36.02
$21.41
$14.62
$81.39
$48.14
$148.83
$100.21
$85.68
$52.79
$123.85
$80.23
$146.15
$72.36
$26.77
$21.05
$38.17
$17.83
$20.34
$65.34
$26.77
$38.57
$53.90
$35.71
Nonpar Fee
$49.22
$216.21
$130.01
$86.19
$143.21
$116.80
$26.41
$165.97
$132.77
$33.20
$34.22
$20.34
$13.89
$77.32
$45.73
$141.39
$95.20
$81.40
$50.15
$117.66
$76.22
$138.84
$68.74
$25.43
$20.00
$36.26
$16.94
$19.32
$62.07
$25.43
$36.64
$51.21
$33.92
Limiting
Charge
$56.60
$248.64
$149.51
$99.12
$164.69
$134.32
$30.37
$190.87
$152.69
$38.18
$39.35
$23.39
$15.97
$88.92
$52.59
$162.60
$109.48
$93.61
$57.67
$135.31
$87.65
$159.67
$79.05
$29.24
$23.00
$41.70
$19.48
$22.22
$71.38
$29.24
$42.14
$58.89
$39.01
Charge**
Charge***
$56.04
$55.75
$246.16
$244.92
$148.02
$147.27
$98.13
$97.64
$163.05
$162.22
$132.97
$132.31
$30.07
$29.91
$188.96
$188.00
$151.16
$150.40
$37.80
$37.61
$38.96
$38.77
$23.16
$23.03
$15.81
$15.73
$88.03
$87.58
$52.06
$51.80
$160.98
$160.16
$108.39
$107.84
$92.68
$92.21
$57.10
$56.81
$133.95
$133.29
$86.78
$86.34
$158.07
$157.27
$78.26
$77.87
$28.96
$28.81
$22.77
$22.66
$41.29
$41.08
$19.29
$19.19
$22.00
$21.88
$70.67
$70.31
$28.96
$28.81
$41.71
$41.50
$58.31
$58.01
$38.62
$38.42
Arizona
EHR/eRx
Limiting
Charge**
$55.48
$243.67
$146.52
$97.14
$161.40
$131.63
$29.76
$187.05
$149.63
$37.42
$38.57
$22.92
$15.65
$87.14
$51.54
$159.34
$107.30
$91.74
$56.52
$132.61
$85.91
$156.47
$77.48
$28.66
$22.54
$40.86
$19.09
$21.77
$69.95
$28.66
$41.30
$57.72
$38.23
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$55.20
$54.65
$242.47
$240.02
$145.80
$144.33
$96.66
$95.68
$160.60
$158.98
$130.99
$129.65
$29.62
$29.31
$186.13
$184.24
$148.89
$147.38
$37.24
$36.86
$38.38
$38.00
$22.82
$22.57
$15.57
$15.42
$86.71
$85.82
$51.28
$50.77
$158.56
$156.95
$106.77
$105.69
$91.29
$90.36
$56.25
$55.67
$131.94
$130.62
$85.48
$84.62
$155.70
$154.12
$77.08
$76.31
$28.52
$28.23
$22.43
$22.21
$40.66
$40.25
$19.00
$18.80
$21.67
$21.45
$69.61
$68.91
$28.52
$28.23
$41.09
$40.68
$57.43
$56.86
$38.04
$37.65
Page 286 of 323
Notes
#
#
#
#
Procedure
Code
92065
92071
92071
92072
92072
92081
92081
92081
92082
92082
92082
92083
92083
92083
92100
92100
92132
92132
92132
92133
92133
92133
92134
92134
92134
92136
92136
92136
92140
92140
92145
92145
92145
1/2/2015
Modifier
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
Par Fee
$18.19
$38.17
$33.88
$135.25
$103.42
$34.24
$17.83
$16.40
$48.18
$26.41
$21.77
$64.63
$36.43
$28.20
$80.72
$34.24
$34.95
$15.69
$19.26
$44.25
$16.05
$28.20
$45.32
$16.40
$28.92
$90.73
$59.31
$31.42
$63.20
$26.73
$15.64
$6.75
$8.89
Nonpar Fee
$17.28
$36.26
$32.19
$128.49
$98.25
$32.53
$16.94
$15.58
$45.77
$25.09
$20.68
$61.40
$34.61
$26.79
$76.68
$32.53
$33.20
$14.91
$18.30
$42.04
$15.25
$26.79
$43.05
$15.58
$27.47
$86.19
$56.34
$29.85
$60.04
$25.39
$14.86
$6.41
$8.45
Limiting
Charge
$19.87
$41.70
$37.02
$147.76
$112.99
$37.41
$19.48
$17.92
$52.64
$28.85
$23.78
$70.61
$39.80
$30.81
$88.18
$37.41
$38.18
$17.15
$21.05
$48.35
$17.54
$30.81
$49.51
$17.92
$31.59
$99.12
$64.79
$34.33
$69.05
$29.20
$17.09
$7.37
$9.72
Charge**
Charge***
$19.68
$19.57
$41.29
$41.08
$36.65
$36.47
$146.29
$145.54
$111.86
$111.30
$37.03
$36.85
$19.29
$19.19
$17.73
$17.65
$52.11
$51.84
$28.57
$28.42
$23.54
$23.43
$69.91
$69.55
$39.40
$39.20
$30.50
$30.35
$87.30
$86.86
$37.03
$36.85
$37.80
$37.61
$16.97
$16.89
$20.84
$20.73
$47.86
$47.62
$17.37
$17.27
$30.50
$30.35
$49.01
$48.76
$17.73
$17.65
$31.28
$31.12
$98.13
$97.64
$64.15
$63.81
$33.98
$33.81
$68.36
$68.01
$28.91
$28.76
$16.92
$16.84
$7.30
$7.26
$9.63
$9.57
Arizona
EHR/eRx
Limiting
Charge**
$19.47
$40.86
$36.28
$144.81
$110.73
$36.66
$19.09
$17.56
$51.58
$28.28
$23.31
$69.20
$39.01
$30.19
$86.42
$36.66
$37.42
$16.80
$20.62
$47.38
$17.19
$30.19
$48.52
$17.56
$30.96
$97.14
$63.49
$33.64
$67.67
$28.61
$16.74
$7.22
$9.52
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$19.38
$19.18
$40.66
$40.25
$36.10
$35.74
$144.10
$142.63
$110.18
$109.08
$36.48
$36.11
$19.00
$18.80
$17.47
$17.30
$51.32
$50.81
$28.14
$27.85
$23.18
$22.97
$68.86
$68.16
$38.81
$38.42
$30.04
$29.74
$85.99
$85.12
$36.48
$36.11
$37.24
$36.86
$16.72
$16.55
$20.53
$20.31
$47.15
$46.67
$17.10
$16.94
$30.04
$29.74
$48.28
$47.79
$17.47
$17.30
$30.81
$30.50
$96.66
$95.68
$63.18
$62.54
$33.48
$33.13
$67.33
$66.65
$28.47
$28.19
$16.66
$16.49
$7.19
$7.12
$9.48
$9.38
Page 287 of 323
Notes
#
#
#
#
Procedure
Code
92225
92225
92226
92226
92227
92228
92228
92228
92230
92230
92235
92235
92235
92240
92240
92240
92250
92250
92250
92260
92260
92265
92265
92265
92270
92270
92270
92275
92275
92275
92283
92283
92283
1/2/2015
Modifier
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
Par Fee
$27.13
$21.41
$24.98
$19.26
$14.62
$35.67
$13.90
$21.77
$58.15
$33.48
$110.39
$62.88
$47.51
$256.27
$191.96
$64.31
$79.29
$55.02
$24.27
$18.55
$11.04
$86.44
$39.29
$47.15
$92.43
$50.73
$41.70
$147.53
$93.59
$53.95
$56.40
$46.79
$9.61
Nonpar Fee
$25.77
$20.34
$23.73
$18.30
$13.89
$33.89
$13.21
$20.68
$55.24
$31.81
$104.87
$59.74
$45.13
$243.46
$182.36
$61.09
$75.33
$52.27
$23.06
$17.62
$10.49
$82.12
$37.33
$44.79
$87.81
$48.19
$39.62
$140.15
$88.91
$51.25
$53.58
$44.45
$9.13
Limiting
Charge
$29.64
$23.39
$27.29
$21.05
$15.97
$38.97
$15.19
$23.78
$63.53
$36.58
$120.60
$68.70
$51.90
$279.98
$209.71
$70.25
$86.63
$60.11
$26.52
$20.26
$12.06
$94.44
$42.93
$51.51
$100.98
$55.42
$45.56
$161.17
$102.25
$58.94
$61.62
$51.12
$10.50
Charge**
Charge***
$29.34
$29.19
$23.16
$23.03
$27.01
$26.88
$20.84
$20.73
$15.81
$15.73
$38.58
$38.39
$15.04
$14.96
$23.54
$23.43
$62.89
$62.57
$36.21
$36.03
$119.39
$118.80
$68.01
$67.67
$51.38
$51.12
$277.18
$275.78
$207.62
$206.56
$69.55
$69.20
$85.77
$85.33
$59.51
$59.21
$26.25
$26.12
$20.06
$19.96
$11.95
$11.88
$93.50
$93.02
$42.50
$42.29
$50.99
$50.74
$99.97
$99.46
$54.87
$54.59
$45.10
$44.88
$159.56
$158.76
$101.22
$100.72
$58.35
$58.05
$61.00
$60.70
$50.61
$50.35
$10.40
$10.34
Arizona
EHR/eRx
Limiting
Charge**
$29.04
$22.92
$26.75
$20.62
$15.65
$38.19
$14.89
$23.31
$62.26
$35.85
$118.19
$67.33
$50.86
$274.38
$205.52
$68.85
$84.89
$58.90
$25.99
$19.86
$11.82
$92.55
$42.07
$50.47
$98.96
$54.31
$44.65
$157.95
$100.20
$57.76
$60.39
$50.09
$10.29
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$28.90
$28.60
$22.82
$22.57
$26.61
$26.35
$20.53
$20.31
$15.57
$15.42
$38.01
$37.62
$14.81
$14.67
$23.18
$22.97
$61.95
$61.33
$35.67
$35.31
$117.60
$116.41
$66.99
$66.32
$50.61
$50.11
$273.02
$270.26
$204.50
$202.43
$68.51
$67.82
$84.48
$83.62
$58.62
$58.02
$25.86
$25.60
$19.76
$19.56
$11.76
$11.65
$92.09
$91.16
$41.87
$41.43
$50.22
$49.71
$98.47
$97.47
$54.04
$53.50
$44.42
$43.99
$157.17
$155.58
$99.71
$98.69
$57.48
$56.90
$60.08
$59.48
$49.85
$49.35
$10.24
$10.14
Page 288 of 323
Notes
#
#
#
#
#
#
#
#
Procedure
Code
92284
92284
92284
92285
92285
92285
92286
92286
92286
92287
92287
92287
92311
92311
92312
92312
92313
92313
92315
92315
92316
92316
92317
92317
92325
92326
92502
92504
92504
92507
92508
92511
92511
1/2/2015
Modifier
TC
26
TC
26
TC
26
TC
26
Par Fee
$62.84
$50.01
$12.83
$20.65
$17.48
$3.17
$38.53
$16.05
$22.48
$138.64
$91.49
$47.15
$101.37
$55.96
$118.17
$64.90
$97.84
$47.78
$73.25
$21.77
$92.16
$33.16
$76.47
$22.12
$42.50
$35.35
$97.89
$30.35
$9.61
$79.56
$23.55
$137.48
$49.17
Nonpar Fee
$59.70
$47.51
$12.19
$19.62
$16.61
$3.01
$36.60
$15.25
$21.36
$131.71
$86.92
$44.79
$96.30
$53.16
$112.26
$61.66
$92.95
$45.39
$69.59
$20.68
$87.55
$31.50
$72.65
$21.01
$40.38
$33.58
$93.00
$28.83
$9.13
$75.58
$22.37
$130.61
$46.71
Limiting
Charge
$68.66
$54.64
$14.02
$22.56
$19.10
$3.46
$42.09
$17.54
$24.56
$151.47
$99.96
$51.51
$110.75
$61.13
$129.10
$70.91
$106.89
$52.20
$80.03
$23.78
$100.68
$36.23
$83.55
$24.16
$46.44
$38.62
$106.95
$33.15
$10.50
$86.92
$25.73
$150.20
$53.72
Charge**
Charge***
$67.97
$67.62
$54.08
$53.82
$13.88
$13.81
$22.33
$22.23
$18.91
$18.81
$3.43
$3.40
$41.66
$41.46
$17.37
$17.27
$24.32
$24.20
$149.95
$149.19
$98.96
$98.46
$50.99
$50.74
$109.64
$109.09
$60.52
$60.21
$127.81
$127.17
$70.20
$69.85
$105.82
$105.29
$51.68
$51.42
$79.22
$78.83
$23.54
$23.43
$99.67
$99.18
$35.87
$35.68
$82.71
$82.29
$23.92
$23.79
$45.98
$45.74
$38.23
$38.04
$105.88
$105.35
$32.82
$32.66
$10.40
$10.34
$86.04
$85.62
$25.47
$25.33
$148.70
$147.95
$53.18
$52.91
Arizona
EHR/eRx
Limiting
Charge**
$67.29
$53.54
$13.74
$22.11
$18.72
$3.39
$41.25
$17.19
$24.07
$148.44
$97.96
$50.47
$108.53
$59.92
$126.51
$69.49
$104.75
$51.15
$78.43
$23.31
$98.67
$35.50
$81.88
$23.68
$45.51
$37.85
$104.81
$32.49
$10.29
$85.18
$25.21
$147.20
$52.65
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$66.94
$66.27
$53.27
$52.74
$13.67
$13.54
$22.00
$21.78
$18.62
$18.45
$3.38
$3.35
$41.04
$40.63
$17.10
$16.94
$23.95
$23.71
$147.69
$146.21
$97.47
$96.49
$50.22
$49.71
$108.00
$106.89
$59.62
$59.02
$125.89
$124.61
$69.14
$68.45
$104.24
$103.18
$50.91
$50.38
$78.04
$77.26
$23.18
$22.97
$98.18
$97.19
$35.33
$34.97
$81.47
$80.65
$23.56
$23.32
$45.29
$44.83
$37.65
$37.28
$104.29
$103.24
$32.33
$32.00
$10.24
$10.14
$84.76
$83.90
$25.09
$24.83
$146.46
$144.99
$52.38
$51.85
Page 289 of 323
Notes
#
#
#
Procedure
Code
92512
92512
92516
92516
92520
92520
92521
92522
92523
92524
92526
92540
92540
92540
92541
92541
92541
92542
92542
92542
92543
92543
92543
92544
92544
92544
92545
92545
92545
92546
92546
92546
92547
1/2/2015
Modifier
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
Par Fee
$61.72
$28.83
$71.06
$22.80
$75.58
$41.61
$108.39
$92.70
$188.84
$90.33
$86.35
$102.40
$22.48
$79.91
$22.44
$1.39
$21.05
$26.37
$1.39
$24.98
$16.00
$10.32
$5.68
$15.64
$1.39
$14.26
$14.57
$1.39
$13.19
$103.60
$88.63
$14.97
$6.39
Nonpar Fee
$58.63
$27.39
$67.51
$21.66
$71.80
$39.53
$102.97
$88.07
$179.40
$85.81
$82.03
$97.28
$21.36
$75.91
$21.32
$1.32
$20.00
$25.05
$1.32
$23.73
$15.20
$9.80
$5.40
$14.86
$1.32
$13.55
$13.84
$1.32
$12.53
$98.42
$84.20
$14.22
$6.07
Limiting
Charge
$67.42
$31.50
$77.64
$24.91
$82.57
$45.46
$118.42
$101.28
$206.31
$98.68
$94.33
$111.87
$24.56
$87.30
$24.52
$1.52
$23.00
$28.81
$1.52
$27.29
$17.48
$11.27
$6.21
$17.09
$1.52
$15.58
$15.92
$1.52
$14.41
$113.18
$96.83
$16.35
$6.98
Charge**
Charge***
$66.75
$66.41
$31.19
$31.03
$76.85
$76.48
$24.66
$24.54
$81.74
$81.33
$45.00
$44.78
$117.23
$116.64
$100.27
$99.76
$204.25
$203.22
$97.69
$97.20
$93.39
$92.92
$110.76
$110.19
$24.32
$24.20
$86.42
$85.99
$24.28
$24.15
$1.51
$1.50
$22.77
$22.66
$28.52
$28.37
$1.51
$1.50
$27.01
$26.88
$17.31
$17.22
$11.16
$11.10
$6.15
$6.12
$16.92
$16.84
$1.51
$1.50
$15.42
$15.35
$15.76
$15.67
$1.51
$1.50
$14.26
$14.19
$112.06
$111.48
$95.86
$95.38
$16.19
$16.11
$6.91
$6.88
Arizona
EHR/eRx
Limiting
Charge**
$66.08
$30.87
$76.08
$24.41
$80.91
$44.55
$116.05
$99.26
$202.18
$96.70
$92.45
$109.63
$24.07
$85.55
$24.02
$1.48
$22.54
$28.23
$1.48
$26.75
$17.14
$11.04
$6.08
$16.74
$1.48
$15.27
$15.59
$1.48
$14.12
$110.92
$94.90
$16.03
$6.84
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$65.75
$65.09
$30.72
$30.41
$75.70
$74.95
$24.29
$24.05
$80.51
$79.70
$44.32
$43.88
$115.47
$114.31
$98.76
$97.77
$201.19
$199.15
$96.23
$95.25
$91.99
$91.06
$109.10
$107.99
$23.95
$23.71
$85.12
$84.26
$23.91
$23.67
$1.48
$1.46
$22.43
$22.21
$28.09
$27.81
$1.48
$1.46
$26.61
$26.35
$17.04
$16.88
$10.98
$10.88
$6.06
$5.99
$16.66
$16.49
$1.48
$1.46
$15.19
$15.04
$15.51
$15.36
$1.48
$1.46
$14.04
$13.92
$110.38
$109.25
$94.43
$93.47
$15.95
$15.79
$6.81
$6.74
Page 290 of 323
Notes
#
#
#
#
#
Procedure
Code
92548
92548
92548
92550
92552
92553
92555
92556
92557
92557
92561
92562
92563
92564
92565
92567
92567
92568
92568
92570
92570
92571
92572
92575
92576
92577
92579
92579
92582
92583
92584
92585
92585
1/2/2015
Modifier
TC
26
TC
Par Fee
$103.91
$77.54
$26.37
$21.05
$31.42
$37.14
$23.20
$37.50
$37.45
$32.45
$37.86
$46.44
$31.06
$28.56
$15.69
$14.62
$11.04
$15.69
$15.33
$32.09
$29.95
$27.49
$31.42
$71.47
$35.35
$16.05
$45.32
$38.17
$71.82
$51.09
$74.33
$136.14
$109.37
Nonpar Fee
$98.71
$73.66
$25.05
$20.00
$29.85
$35.28
$22.04
$35.63
$35.58
$30.83
$35.97
$44.12
$29.51
$27.13
$14.91
$13.89
$10.49
$14.91
$14.56
$30.49
$28.45
$26.12
$29.85
$67.90
$33.58
$15.25
$43.05
$36.26
$68.23
$48.54
$70.61
$129.33
$103.90
Limiting
Charge
$113.52
$84.71
$28.81
$23.00
$34.33
$40.57
$25.35
$40.97
$40.92
$35.45
$41.37
$50.74
$33.94
$31.20
$17.15
$15.97
$12.06
$17.15
$16.74
$35.06
$32.72
$30.04
$34.33
$78.09
$38.62
$17.54
$49.51
$41.70
$78.46
$55.82
$81.20
$148.73
$119.49
Charge**
Charge***
$112.38
$111.81
$83.86
$83.44
$28.52
$28.37
$22.77
$22.66
$33.98
$33.81
$40.17
$39.96
$25.09
$24.97
$40.56
$40.37
$40.50
$40.31
$35.10
$34.93
$40.95
$40.74
$50.23
$49.98
$33.59
$33.43
$30.89
$30.73
$16.97
$16.89
$15.81
$15.73
$11.95
$11.88
$16.97
$16.89
$16.57
$16.49
$34.72
$34.53
$32.40
$32.22
$29.74
$29.59
$33.98
$33.81
$77.30
$76.91
$38.23
$38.04
$17.37
$17.27
$49.01
$48.76
$41.29
$41.08
$77.68
$77.29
$55.26
$54.98
$80.39
$79.98
$147.25
$146.50
$118.29
$117.69
Arizona
EHR/eRx
Limiting
Charge**
$111.25
$83.02
$28.23
$22.54
$33.64
$39.76
$24.84
$40.16
$40.10
$34.74
$40.54
$49.73
$33.26
$30.58
$16.80
$15.65
$11.82
$16.80
$16.41
$34.36
$32.06
$29.44
$33.64
$76.52
$37.85
$17.19
$48.52
$40.86
$76.90
$54.71
$79.58
$145.75
$117.09
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$110.69
$109.58
$82.60
$81.78
$28.09
$27.81
$22.43
$22.21
$33.48
$33.13
$39.57
$39.16
$24.71
$24.47
$39.95
$39.56
$39.89
$39.50
$34.57
$34.22
$40.34
$39.93
$49.47
$48.98
$33.09
$32.76
$30.43
$30.12
$16.72
$16.55
$15.57
$15.42
$11.76
$11.65
$16.72
$16.55
$16.32
$16.17
$34.20
$33.84
$31.91
$31.58
$29.29
$29.00
$33.48
$33.13
$76.14
$75.37
$37.65
$37.28
$17.10
$16.94
$48.28
$47.79
$40.66
$40.25
$76.52
$75.75
$54.43
$53.89
$79.18
$78.38
$145.04
$143.57
$116.52
$115.33
Page 291 of 323
Notes
#
#
#
#
#
#
#
#
Procedure
Code
92585
92586
92587
92587
92587
92588
92588
92588
92596
92597
92601
92601
92602
92602
92603
92603
92604
92604
92607
92608
92609
92610
92610
92611
92612
92612
92613
92614
92614
92615
92616
92616
92617
1/2/2015
Modifier
26
TC
26
TC
26
Par Fee
$26.77
$83.98
$21.72
$3.17
$18.55
$33.16
$3.89
$29.27
$42.15
$72.32
$138.02
$118.72
$89.93
$68.47
$150.13
$122.96
$89.21
$68.12
$124.75
$53.54
$111.38
$85.23
$73.08
$86.85
$174.18
$68.70
$38.71
$145.21
$67.98
$33.79
$206.89
$101.77
$42.01
Nonpar Fee
$25.43
$79.78
$20.63
$3.01
$17.62
$31.50
$3.70
$27.81
$40.04
$68.70
$131.12
$112.78
$85.43
$65.05
$142.62
$116.81
$84.75
$64.71
$118.51
$50.86
$105.81
$80.97
$69.43
$82.51
$165.47
$65.27
$36.77
$137.95
$64.58
$32.10
$196.55
$96.68
$39.91
Limiting
Charge
$29.24
$91.75
$23.72
$3.46
$20.26
$36.23
$4.26
$31.98
$46.05
$79.01
$150.79
$129.70
$98.24
$74.81
$164.01
$134.33
$97.46
$74.42
$136.29
$58.49
$121.68
$93.12
$79.84
$94.89
$190.29
$75.06
$42.29
$158.64
$74.27
$36.92
$226.03
$111.18
$45.90
Charge**
Charge***
$28.96
$28.81
$90.83
$90.37
$23.48
$23.37
$3.43
$3.40
$20.06
$19.96
$35.87
$35.68
$4.21
$4.19
$31.66
$31.50
$45.59
$45.36
$78.21
$77.82
$149.28
$148.52
$128.40
$127.75
$97.27
$96.77
$74.06
$73.68
$162.37
$161.55
$132.99
$132.32
$96.49
$96.00
$73.67
$73.30
$134.92
$134.24
$57.90
$57.62
$120.46
$119.85
$92.18
$91.72
$79.05
$78.65
$93.93
$93.46
$188.39
$187.44
$74.31
$73.93
$41.86
$41.65
$157.06
$156.26
$73.52
$73.15
$36.55
$36.36
$223.77
$222.64
$110.07
$109.51
$45.44
$45.21
Arizona
EHR/eRx
Limiting
Charge**
$28.66
$89.91
$23.25
$3.39
$19.86
$35.50
$4.17
$31.34
$45.13
$77.43
$147.78
$127.10
$96.28
$73.31
$160.74
$131.64
$95.52
$72.93
$133.56
$57.32
$119.24
$91.25
$78.25
$92.99
$186.48
$73.55
$41.43
$155.47
$72.78
$36.18
$221.51
$108.96
$44.98
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$28.52
$28.23
$89.47
$88.56
$23.13
$22.91
$3.38
$3.35
$19.76
$19.56
$35.33
$34.97
$4.15
$4.12
$31.19
$30.87
$44.91
$44.45
$77.04
$76.27
$147.04
$145.56
$126.48
$125.19
$95.81
$94.83
$72.94
$72.21
$159.93
$158.32
$131.00
$129.66
$95.04
$94.08
$72.57
$71.84
$132.89
$131.56
$57.03
$56.45
$118.66
$117.45
$90.80
$89.88
$77.87
$77.07
$92.52
$91.60
$185.56
$183.69
$73.20
$72.45
$41.23
$40.81
$154.70
$153.13
$72.42
$71.69
$36.00
$35.64
$220.41
$218.19
$108.41
$107.33
$44.76
$44.30
Page 292 of 323
Notes
#
#
#
#
#
#
#
#
Procedure
Code
92620
92620
92621
92621
92625
92625
92626
92626
92627
92627
92640
92640
92920
92924
92928
92933
92937
92941
92943
92950
92950
92953
92960
92960
92961
92970
92971
92973
92974
92975
92977
92978
92979
1/2/2015
Modifier
26
26
Par Fee
$94.53
$83.09
$22.48
$19.26
$70.26
$62.75
$90.24
$76.65
$22.12
$17.83
$114.20
$96.32
$556.28
$659.87
$617.00
$690.36
$616.64
$691.43
$690.81
$306.89
$189.62
$11.35
$208.10
$124.08
$265.32
$190.25
$102.64
$180.88
$165.14
$399.32
$57.44
$99.38
$79.40
Nonpar Fee
$89.80
$78.94
$21.36
$18.30
$66.75
$59.61
$85.73
$72.82
$21.01
$16.94
$108.49
$91.50
$528.47
$626.88
$586.15
$655.84
$585.81
$656.86
$656.27
$291.55
$180.14
$10.78
$197.70
$117.88
$252.05
$180.74
$97.51
$171.84
$156.88
$379.35
$54.57
$94.41
$75.43
Limiting
Charge
$103.27
$90.78
$24.56
$21.05
$76.76
$68.55
$98.59
$83.74
$24.16
$19.48
$124.76
$105.23
$607.74
$720.91
$674.07
$754.22
$673.68
$755.39
$754.71
$335.28
$207.16
$12.40
$227.36
$135.56
$289.86
$207.85
$112.14
$197.62
$180.41
$436.25
$62.76
$108.57
$86.74
Charge**
Charge***
$102.24
$101.72
$89.87
$89.42
$24.32
$24.20
$20.84
$20.73
$75.99
$75.61
$67.86
$67.53
$97.60
$97.11
$82.90
$82.49
$23.92
$23.79
$19.29
$19.19
$123.52
$122.89
$104.18
$103.65
$601.67
$598.62
$713.70
$710.10
$667.33
$663.96
$746.67
$742.90
$666.94
$663.57
$747.83
$744.06
$747.17
$743.39
$331.92
$330.26
$205.09
$204.06
$12.27
$12.21
$225.08
$223.94
$134.21
$133.53
$286.96
$285.51
$205.77
$204.73
$111.01
$110.46
$195.64
$194.65
$178.61
$177.71
$431.89
$429.71
$62.12
$61.81
$107.49
$106.94
$85.88
$85.45
Arizona
EHR/eRx
Limiting
Charge**
$101.20
$88.96
$24.07
$20.62
$75.23
$67.18
$96.62
$82.06
$23.68
$19.09
$122.27
$103.12
$595.59
$706.49
$660.59
$739.13
$660.20
$740.28
$739.61
$328.58
$203.02
$12.14
$222.81
$132.85
$284.06
$203.70
$109.89
$193.66
$176.80
$427.52
$61.50
$106.40
$85.01
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$100.71
$99.68
$88.53
$87.63
$23.95
$23.71
$20.53
$20.31
$74.85
$74.11
$66.84
$66.17
$96.14
$95.17
$81.66
$80.83
$23.56
$23.32
$19.00
$18.80
$121.67
$120.44
$102.61
$101.57
$592.64
$586.65
$703.00
$695.89
$657.33
$650.68
$735.47
$728.04
$656.94
$650.30
$736.62
$729.17
$735.95
$728.51
$326.95
$323.64
$202.01
$199.97
$12.09
$11.96
$221.70
$219.47
$132.19
$130.86
$282.66
$279.80
$202.69
$200.64
$109.34
$108.25
$192.71
$190.75
$175.93
$174.14
$425.42
$421.11
$61.19
$60.58
$105.88
$104.80
$84.59
$83.73
Page 293 of 323
Notes
Procedure
Code
92986
92987
92990
92997
92998
93000
93005
93010
93015
93016
93017
93018
93024
93024
93024
93025
93025
93025
93040
93041
93042
93224
93225
93226
93227
93228
93229
93260
93260
93260
93261
93261
93261
1/2/2015
Modifier
TC
26
TC
26
TC
26
TC
26
Par Fee
$1,358.34
$1,400.97
$1,108.25
$675.25
$330.38
$17.07
$8.54
$8.54
$76.70
$22.44
$39.64
$14.62
$113.08
$55.33
$57.75
$164.65
$127.24
$37.41
$12.78
$5.68
$7.11
$92.43
$27.13
$38.21
$27.09
$26.33
$679.83
$67.40
$22.48
$44.92
$61.68
$22.48
$39.20
Nonpar Fee
$1,290.42
$1,330.92
$1,052.84
$641.49
$313.86
$16.22
$8.11
$8.11
$72.87
$21.32
$37.66
$13.89
$107.43
$52.56
$54.86
$156.42
$120.88
$35.54
$12.14
$5.40
$6.75
$87.81
$25.77
$36.30
$25.74
$25.01
$645.84
$64.03
$21.36
$42.67
$58.60
$21.36
$37.24
Limiting
Charge
$1,483.98
$1,530.56
$1,210.77
$737.71
$360.94
$18.65
$9.33
$9.33
$83.80
$24.52
$43.31
$15.97
$123.54
$60.44
$63.09
$179.88
$139.01
$40.87
$13.96
$6.21
$7.76
$100.98
$29.64
$41.75
$29.60
$28.76
$742.72
$73.63
$24.56
$49.07
$67.39
$24.56
$42.83
Charge**
Charge***
$1,469.15
$1,461.72
$1,515.25
$1,507.60
$1,198.66
$1,192.61
$730.34
$726.65
$357.33
$355.52
$18.47
$18.38
$9.23
$9.19
$9.23
$9.19
$82.96
$82.55
$24.28
$24.15
$42.87
$42.67
$15.81
$15.73
$122.31
$121.69
$59.83
$59.54
$62.46
$62.15
$178.09
$177.18
$137.62
$136.93
$40.46
$40.26
$13.82
$13.75
$6.15
$6.12
$7.68
$7.65
$99.97
$99.46
$29.34
$29.19
$41.33
$41.12
$29.30
$29.15
$28.47
$28.32
$735.29
$731.57
$72.90
$72.53
$24.32
$24.20
$48.58
$48.33
$66.71
$66.38
$24.32
$24.20
$42.40
$42.18
Arizona
EHR/eRx
Limiting
Charge**
$1,454.30
$1,499.95
$1,186.55
$722.96
$353.72
$18.29
$9.14
$9.14
$82.12
$24.02
$42.45
$15.65
$121.07
$59.24
$61.82
$176.28
$136.23
$40.05
$13.69
$6.08
$7.61
$98.96
$29.04
$40.91
$29.01
$28.19
$727.86
$72.16
$24.07
$48.09
$66.04
$24.07
$41.98
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$1,447.11
$1,432.49
$1,492.53
$1,477.45
$1,180.68
$1,168.75
$719.38
$712.11
$351.97
$348.42
$18.19
$18.01
$9.10
$9.00
$9.10
$9.00
$81.72
$80.89
$23.91
$23.67
$42.23
$41.81
$15.57
$15.42
$120.47
$119.26
$58.94
$58.35
$61.53
$60.89
$175.42
$173.64
$135.55
$134.18
$39.85
$39.46
$13.62
$13.48
$6.06
$5.99
$7.57
$7.50
$98.47
$97.47
$28.90
$28.60
$40.71
$40.30
$28.87
$28.58
$28.05
$27.76
$724.26
$716.94
$71.81
$71.08
$23.95
$23.71
$47.85
$47.37
$65.71
$65.06
$23.95
$23.71
$41.77
$41.34
Page 294 of 323
Notes
Procedure
Code
93268
93270
93271
93272
93278
93278
93278
93279
93279
93279
93280
93280
93280
93281
93281
93281
93282
93282
93282
93283
93283
93283
93284
93284
93284
93285
93285
93285
93286
93286
93286
93287
93287
1/2/2015
Modifier
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
Par Fee
$206.44
$9.25
$171.53
$25.66
$30.66
$18.19
$12.47
$49.92
$17.48
$32.45
$58.82
$19.98
$38.84
$68.47
$23.20
$45.28
$63.82
$20.69
$43.13
$82.02
$23.91
$58.10
$90.24
$27.13
$63.11
$42.42
$16.05
$26.37
$27.44
$12.11
$15.33
$36.34
$13.19
Nonpar Fee
$196.12
$8.79
$162.95
$24.38
$29.13
$17.28
$11.85
$47.42
$16.61
$30.83
$55.88
$18.98
$36.90
$65.05
$22.04
$43.02
$60.63
$19.66
$40.97
$77.92
$22.71
$55.20
$85.73
$25.77
$59.95
$40.30
$15.25
$25.05
$26.07
$11.50
$14.56
$34.52
$12.53
Limiting
Charge
$225.54
$10.11
$187.39
$28.04
$33.50
$19.87
$13.63
$54.53
$19.10
$35.45
$64.26
$21.83
$42.44
$74.81
$25.35
$49.47
$69.72
$22.61
$47.12
$89.61
$26.12
$63.48
$98.59
$29.64
$68.94
$46.35
$17.54
$28.81
$29.98
$13.23
$16.74
$39.70
$14.41
Charge**
Charge***
$223.28
$222.16
$10.01
$9.96
$185.52
$184.59
$27.76
$27.61
$33.17
$32.99
$19.68
$19.57
$13.49
$13.42
$53.99
$53.72
$18.91
$18.81
$35.10
$34.93
$63.62
$63.30
$21.61
$21.51
$42.01
$41.80
$74.06
$73.68
$25.09
$24.97
$48.98
$48.73
$69.02
$68.68
$22.38
$22.28
$46.64
$46.41
$88.71
$88.26
$25.85
$25.73
$62.85
$62.53
$97.60
$97.11
$29.34
$29.19
$68.25
$67.91
$45.89
$45.66
$17.37
$17.27
$28.52
$28.37
$29.68
$29.53
$13.10
$13.03
$16.57
$16.49
$39.30
$39.10
$14.26
$14.19
Arizona
EHR/eRx
Limiting
Charge**
$221.03
$9.90
$183.64
$27.47
$32.83
$19.47
$13.35
$53.44
$18.72
$34.74
$62.97
$21.39
$41.58
$73.31
$24.84
$48.48
$68.33
$22.16
$46.17
$87.81
$25.60
$62.22
$96.62
$29.04
$67.56
$45.41
$17.19
$28.23
$29.38
$12.96
$16.41
$38.90
$14.12
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$219.94
$217.72
$9.86
$9.75
$182.74
$180.88
$27.35
$27.06
$32.67
$32.34
$19.38
$19.18
$13.28
$13.16
$53.19
$52.64
$18.62
$18.45
$34.57
$34.22
$62.66
$62.03
$21.29
$21.07
$41.38
$40.96
$72.94
$72.21
$24.71
$24.47
$48.24
$47.76
$67.99
$67.31
$22.05
$21.83
$45.94
$45.48
$87.38
$86.49
$25.46
$25.22
$61.90
$61.28
$96.14
$95.17
$28.90
$28.60
$67.23
$66.55
$45.20
$44.74
$17.10
$16.94
$28.09
$27.81
$29.23
$28.95
$12.90
$12.77
$16.32
$16.17
$38.71
$38.32
$14.04
$13.92
Page 295 of 323
Notes
Procedure
Code
93287
93288
93288
93288
93289
93289
93289
93290
93290
93290
93291
93291
93291
93292
93292
93292
93293
93293
93293
93294
93295
93296
93297
93298
93303
93303
93303
93304
93304
93304
93306
93306
93306
1/2/2015
Modifier
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
Par Fee
$23.15
$37.77
$16.05
$21.72
$65.61
$19.62
$45.99
$31.02
$9.61
$21.41
$36.02
$14.62
$21.41
$32.45
$11.04
$21.41
$53.90
$38.21
$15.69
$34.15
$67.90
$26.06
$26.68
$26.68
$238.94
$174.75
$64.18
$155.76
$119.02
$36.74
$228.57
$164.74
$63.82
Nonpar Fee
$21.99
$35.88
$15.25
$20.63
$62.33
$18.64
$43.69
$29.47
$9.13
$20.34
$34.22
$13.89
$20.34
$30.83
$10.49
$20.34
$51.21
$36.30
$14.91
$32.44
$64.51
$24.76
$25.35
$25.35
$226.99
$166.01
$60.97
$147.97
$113.07
$34.90
$217.14
$156.50
$60.63
Limiting
Charge
$25.29
$41.26
$17.54
$23.72
$71.68
$21.44
$50.24
$33.89
$10.50
$23.39
$39.35
$15.97
$23.39
$35.45
$12.06
$23.39
$58.89
$41.75
$17.15
$37.31
$74.19
$28.47
$29.15
$29.15
$261.04
$190.91
$70.12
$170.17
$130.03
$40.14
$249.71
$179.98
$69.72
Charge**
Charge***
$25.04
$24.91
$40.85
$40.64
$17.37
$17.27
$23.48
$23.37
$70.97
$70.61
$21.22
$21.11
$49.74
$49.48
$33.56
$33.38
$10.40
$10.34
$23.16
$23.03
$38.96
$38.77
$15.81
$15.73
$23.16
$23.03
$35.10
$34.93
$11.95
$11.88
$23.16
$23.03
$58.31
$58.01
$41.33
$41.12
$16.97
$16.89
$36.94
$36.74
$73.44
$73.07
$28.19
$28.05
$28.87
$28.72
$28.87
$28.72
$258.43
$257.13
$189.00
$188.05
$69.41
$69.07
$168.46
$167.61
$128.73
$128.08
$39.73
$39.54
$247.22
$245.96
$178.18
$177.27
$69.02
$68.68
Arizona
EHR/eRx
Limiting
Charge**
$24.78
$40.43
$17.19
$23.25
$70.24
$21.01
$49.24
$33.21
$10.29
$22.92
$38.57
$15.65
$22.92
$34.74
$11.82
$22.92
$57.72
$40.91
$16.80
$36.56
$72.70
$27.90
$28.57
$28.57
$255.82
$187.09
$68.71
$166.76
$127.43
$39.33
$244.72
$176.38
$68.33
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$24.66
$24.41
$40.24
$39.82
$17.10
$16.94
$23.13
$22.91
$69.90
$69.18
$20.90
$20.70
$48.99
$48.51
$33.05
$32.72
$10.24
$10.14
$22.82
$22.57
$38.38
$38.00
$15.57
$15.42
$22.82
$22.57
$34.57
$34.22
$11.76
$11.65
$22.82
$22.57
$57.43
$56.86
$40.71
$40.30
$16.72
$16.55
$36.39
$36.01
$72.34
$71.61
$27.76
$27.49
$28.43
$28.14
$28.43
$28.14
$254.55
$251.98
$186.16
$184.29
$68.37
$67.68
$165.93
$164.25
$126.80
$125.52
$39.13
$38.74
$243.51
$241.05
$175.51
$173.73
$67.99
$67.31
Page 296 of 323
Notes
Procedure
Code
93307
93307
93307
93308
93308
93308
93312
93312
93312
93313
93314
93314
93314
93315
93316
93317
93318
93320
93320
93320
93321
93321
93321
93325
93325
93325
93350
93350
93350
93351
93351
93351
93352
1/2/2015
Modifier
TC
26
TC
26
TC
26
TC
26
26
26
26
TC
26
TC
26
TC
26
TC
26
TC
26
Par Fee
$131.04
$85.41
$45.63
$125.37
$99.35
$26.01
$307.63
$185.08
$122.56
$22.71
$295.79
$195.80
$99.98
$146.66
$38.35
$109.34
$120.78
$54.97
$36.43
$18.55
$27.80
$20.34
$7.46
$26.37
$22.84
$3.53
$242.11
$170.10
$72.00
$272.10
$185.84
$86.26
$34.24
Nonpar Fee
$124.49
$81.14
$43.35
$119.10
$94.38
$24.71
$292.25
$175.83
$116.43
$21.57
$281.00
$186.01
$94.98
$139.33
$36.43
$103.87
$114.74
$52.22
$34.61
$17.62
$26.41
$19.32
$7.09
$25.05
$21.70
$3.35
$230.00
$161.60
$68.40
$258.50
$176.55
$81.95
$32.53
Limiting
Charge
$143.16
$93.31
$49.85
$136.97
$108.54
$28.42
$336.09
$202.20
$133.89
$24.81
$323.15
$213.91
$109.23
$160.23
$41.89
$119.45
$131.95
$60.05
$39.80
$20.26
$30.37
$22.22
$8.15
$28.81
$24.96
$3.85
$264.50
$185.84
$78.66
$297.28
$203.03
$94.24
$37.41
Charge**
Charge***
$141.74
$141.01
$92.38
$91.91
$49.36
$49.11
$135.60
$134.91
$107.46
$106.90
$28.13
$27.99
$332.73
$331.05
$200.18
$199.17
$132.56
$131.88
$24.55
$24.44
$319.92
$318.31
$211.77
$210.70
$108.13
$107.59
$158.63
$157.83
$41.48
$41.26
$118.25
$117.66
$130.63
$129.97
$59.46
$59.16
$39.40
$39.20
$20.06
$19.96
$30.07
$29.91
$22.00
$21.88
$8.07
$8.03
$28.52
$28.37
$24.70
$24.58
$3.82
$3.80
$261.86
$260.53
$183.98
$183.06
$77.88
$77.48
$294.31
$292.81
$201.00
$199.99
$93.30
$92.83
$37.03
$36.85
Arizona
EHR/eRx
Limiting
Charge**
$140.30
$91.45
$48.85
$134.23
$106.36
$27.85
$329.37
$198.16
$131.22
$24.31
$316.69
$209.63
$107.04
$157.02
$41.06
$117.06
$129.32
$58.86
$39.01
$19.86
$29.76
$21.77
$7.99
$28.23
$24.46
$3.77
$259.21
$182.13
$77.08
$291.33
$198.97
$92.36
$36.66
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$139.61
$138.20
$91.00
$90.08
$48.62
$48.12
$133.56
$132.22
$105.85
$104.77
$27.70
$27.44
$327.74
$324.43
$197.18
$195.19
$130.57
$129.25
$24.18
$23.94
$315.12
$311.94
$208.60
$206.49
$106.51
$105.43
$156.25
$154.66
$40.86
$40.43
$116.48
$115.30
$128.67
$127.37
$58.56
$57.97
$38.81
$38.42
$19.76
$19.56
$29.62
$29.31
$21.67
$21.45
$7.95
$7.88
$28.09
$27.81
$24.33
$24.09
$3.76
$3.71
$257.92
$255.32
$181.22
$179.39
$76.71
$75.92
$289.89
$286.96
$197.98
$195.98
$91.90
$90.98
$36.48
$36.11
Page 297 of 323
Notes
Procedure
Code
93355
93451
93451
93451
93452
93452
93452
93453
93453
93453
93454
93454
93454
93455
93455
93455
93456
93456
93456
93457
93457
93457
93458
93458
93458
93459
93459
93459
93460
93460
93460
93461
93461
1/2/2015
Modifier
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
Par Fee
$228.50
$791.65
$644.53
$147.12
$893.49
$634.83
$258.66
$1,150.14
$809.98
$340.16
$904.13
$643.77
$260.36
$1,052.84
$751.39
$301.45
$1,131.64
$796.80
$334.84
$1,277.62
$903.30
$374.32
$1,083.45
$766.36
$317.09
$1,196.85
$839.30
$357.55
$1,284.78
$885.78
$398.99
$1,469.19
$1,028.76
Nonpar Fee
$217.08
$752.07
$612.30
$139.76
$848.82
$603.09
$245.73
$1,092.63
$769.48
$323.15
$858.92
$611.58
$247.34
$1,000.20
$713.82
$286.38
$1,075.06
$756.96
$318.10
$1,213.74
$858.14
$355.60
$1,029.28
$728.04
$301.24
$1,137.01
$797.34
$339.67
$1,220.54
$841.49
$379.04
$1,395.73
$977.32
Limiting
Charge
$249.64
$864.88
$704.15
$160.72
$976.14
$693.55
$282.59
$1,256.52
$884.90
$371.62
$987.76
$703.32
$284.44
$1,150.23
$820.89
$329.34
$1,236.32
$870.50
$365.82
$1,395.80
$986.86
$408.94
$1,183.67
$837.25
$346.43
$1,307.56
$916.94
$390.62
$1,403.62
$967.71
$435.90
$1,605.09
$1,123.92
Charge**
Charge***
$247.15
$245.89
$856.23
$851.91
$697.11
$693.59
$159.11
$158.31
$966.38
$961.50
$686.62
$683.15
$279.76
$278.35
$1,243.96
$1,237.68
$876.06
$871.63
$367.91
$366.05
$977.88
$972.95
$696.28
$692.77
$281.60
$280.17
$1,138.73
$1,132.98
$812.68
$808.58
$326.05
$324.39
$1,223.96
$1,217.77
$861.80
$857.45
$362.16
$360.33
$1,381.84
$1,374.86
$976.99
$972.06
$404.85
$402.81
$1,171.84
$1,165.92
$828.87
$824.69
$342.96
$341.23
$1,294.49
$1,287.94
$907.78
$903.19
$386.71
$384.76
$1,389.58
$1,382.56
$958.04
$953.20
$431.54
$429.35
$1,589.04
$1,581.01
$1,112.68
$1,107.06
Arizona
EHR/eRx
Limiting
Charge**
$244.65
$847.58
$690.06
$157.50
$956.62
$679.68
$276.94
$1,231.40
$867.20
$364.19
$968.00
$689.25
$278.75
$1,127.23
$804.47
$322.75
$1,211.59
$853.09
$358.50
$1,367.89
$967.13
$400.76
$1,159.99
$820.50
$339.50
$1,281.41
$898.60
$382.81
$1,375.55
$948.36
$427.18
$1,572.99
$1,101.44
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$243.44
$240.98
$843.39
$834.87
$686.65
$679.71
$156.72
$155.15
$951.89
$942.26
$676.32
$669.48
$275.56
$272.79
$1,225.29
$1,212.93
$862.91
$854.20
$362.39
$358.73
$963.22
$953.48
$685.84
$678.91
$277.38
$274.56
$1,121.65
$1,110.33
$800.49
$792.41
$321.16
$317.91
$1,205.60
$1,193.42
$848.87
$840.29
$356.73
$353.12
$1,361.12
$1,347.37
$962.34
$952.63
$398.77
$394.75
$1,154.27
$1,142.59
$816.44
$808.20
$337.82
$334.41
$1,275.07
$1,262.19
$894.16
$885.12
$380.91
$377.07
$1,368.74
$1,354.92
$943.67
$934.13
$425.06
$420.77
$1,565.20
$1,549.40
$1,096.00
$1,084.91
Page 298 of 323
Notes
#
#
#
#
Procedure
Code
93461
93462
93463
93464
93464
93464
93503
93505
93505
93505
93530
93531
93532
93532
93533
93561
93562
93563
93564
93565
93566
93566
93567
93567
93568
93568
93571
93572
93580
93581
93582
93583
93600
1/2/2015
Modifier
26
TC
26
TC
26
26
26
26
26
26
26
26
26
26
26
Par Fee
$440.44
$211.95
$100.21
$277.10
$188.70
$88.41
$131.15
$771.52
$534.04
$237.47
$228.80
$447.09
$551.46
$551.10
$369.64
$24.81
$8.18
$60.17
$62.81
$47.16
$172.57
$47.08
$142.77
$53.38
$155.05
$48.15
$99.38
$79.35
$994.88
$1,358.01
$685.70
$764.43
$122.27
Nonpar Fee
$418.42
$201.35
$95.20
$263.25
$179.27
$83.99
$124.59
$732.94
$507.34
$225.60
$217.36
$424.74
$523.89
$523.55
$351.16
$23.57
$7.77
$57.16
$59.67
$44.80
$163.94
$44.73
$135.63
$50.71
$147.30
$45.74
$94.41
$75.38
$945.14
$1,290.11
$651.42
$726.21
$116.16
Limiting
Charge
$481.18
$231.55
$109.48
$302.74
$206.16
$96.59
$143.28
$842.88
$583.44
$259.44
$249.96
$488.45
$602.47
$602.08
$403.83
$27.11
$8.94
$65.73
$68.62
$51.52
$188.53
$51.44
$155.97
$58.32
$169.40
$52.60
$108.57
$86.69
$1,086.91
$1,483.63
$749.13
$835.14
$133.58
Charge**
Charge***
$476.38
$473.96
$229.24
$228.08
$108.39
$107.84
$299.71
$298.20
$204.10
$203.07
$95.62
$95.14
$141.84
$141.13
$834.45
$830.24
$577.61
$574.69
$256.84
$255.55
$247.47
$246.22
$483.56
$481.13
$596.45
$593.43
$596.06
$593.06
$399.80
$397.77
$26.83
$26.70
$8.84
$8.80
$65.08
$64.75
$67.93
$67.59
$51.00
$50.75
$186.65
$185.70
$50.92
$50.67
$154.41
$153.64
$57.73
$57.44
$167.70
$166.85
$52.07
$51.81
$107.49
$106.94
$85.82
$85.39
$1,076.04
$1,070.60
$1,468.79
$1,461.37
$741.65
$737.90
$826.79
$822.62
$132.25
$131.58
Arizona
EHR/eRx
Limiting
Charge**
$471.56
$226.92
$107.30
$296.69
$202.03
$94.66
$140.42
$826.02
$571.77
$254.25
$244.96
$478.69
$590.42
$590.04
$395.76
$26.57
$8.75
$64.42
$67.25
$50.49
$184.76
$50.42
$152.86
$57.16
$166.00
$51.55
$106.40
$84.95
$1,065.18
$1,453.96
$734.15
$818.44
$130.92
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$469.23
$464.49
$225.80
$223.51
$106.77
$105.69
$295.22
$292.24
$201.04
$199.00
$94.19
$93.24
$139.71
$138.31
$821.94
$813.64
$568.95
$563.19
$252.99
$250.44
$243.75
$241.28
$476.31
$471.51
$587.50
$581.57
$587.12
$581.19
$393.81
$389.83
$26.43
$26.16
$8.71
$8.63
$64.10
$63.46
$66.91
$66.24
$50.23
$49.73
$183.85
$181.99
$50.16
$49.66
$152.10
$150.57
$56.87
$56.29
$165.19
$163.51
$51.29
$50.78
$105.88
$104.80
$84.54
$83.67
$1,059.90
$1,049.20
$1,446.76
$1,432.15
$730.53
$723.13
$814.40
$806.16
$130.27
$128.95
Page 299 of 323
Notes
#
Procedure
Code
93602
93603
93609
93610
93612
93613
93615
93616
93618
93619
93620
93620
93621
93622
93623
93624
93631
93640
93641
93642
93642
93642
93644
93644
93644
93650
93653
93654
93655
93656
93657
93660
93660
1/2/2015
Modifier
26
26
26
26
26
26
26
26
26
26
26
26
26
26
26
26
26
26
TC
26
TC
26
TC
Par Fee
$119.81
$119.81
$286.74
$169.66
$168.63
$403.78
$52.65
$65.66
$243.16
$417.47
$663.75
$663.39
$120.89
$176.37
$164.79
$265.02
$411.93
$198.81
$338.02
$429.22
$153.26
$275.96
$300.12
$106.82
$193.30
$614.12
$863.72
$1,149.04
$431.50
$1,154.04
$431.15
$159.07
$63.91
Nonpar Fee
$113.82
$113.82
$272.40
$161.18
$160.20
$383.59
$50.02
$62.38
$231.00
$396.60
$630.56
$630.22
$114.85
$167.55
$156.55
$251.77
$391.33
$188.87
$321.12
$407.76
$145.60
$262.16
$285.11
$101.48
$183.64
$583.41
$820.53
$1,091.59
$409.93
$1,096.34
$409.59
$151.12
$60.71
Limiting
Charge
$130.89
$130.89
$313.26
$185.36
$184.23
$441.13
$57.52
$71.74
$265.65
$456.09
$725.14
$724.75
$132.08
$192.68
$180.03
$289.54
$450.03
$217.20
$369.29
$468.92
$167.44
$301.48
$327.88
$116.70
$211.19
$670.92
$943.61
$1,255.33
$471.42
$1,260.79
$471.03
$173.79
$69.82
Charge**
Charge***
$129.58
$128.93
$129.58
$128.93
$310.13
$308.56
$183.51
$182.57
$182.39
$181.47
$436.71
$434.52
$56.95
$56.66
$71.02
$70.66
$262.99
$261.67
$451.52
$449.25
$717.89
$714.27
$717.51
$713.89
$130.76
$130.10
$190.75
$189.80
$178.23
$177.33
$286.64
$285.19
$445.53
$443.28
$215.03
$213.95
$365.60
$363.75
$464.23
$461.89
$165.76
$164.93
$298.47
$296.96
$324.60
$322.95
$115.54
$114.95
$209.07
$208.02
$664.22
$660.86
$934.17
$929.45
$1,242.77
$1,236.50
$466.70
$464.35
$1,248.19
$1,241.87
$466.31
$463.97
$172.05
$171.18
$69.12
$68.77
Arizona
EHR/eRx
Limiting
Charge**
$128.27
$128.27
$306.99
$181.65
$180.55
$432.31
$56.37
$70.30
$260.34
$446.97
$710.64
$710.26
$129.43
$188.83
$176.43
$283.74
$441.03
$212.85
$361.91
$459.54
$164.09
$295.46
$321.32
$114.37
$206.97
$657.50
$924.74
$1,230.22
$461.99
$1,235.57
$461.61
$170.32
$68.43
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$127.64
$126.35
$127.64
$126.35
$305.47
$302.39
$180.76
$178.93
$179.65
$177.85
$430.16
$425.82
$56.10
$55.52
$69.95
$69.24
$259.05
$256.43
$444.75
$440.27
$707.12
$699.98
$706.74
$699.61
$128.79
$127.49
$187.89
$186.00
$175.56
$173.79
$282.34
$279.48
$438.85
$434.41
$211.81
$209.66
$360.11
$356.48
$457.26
$452.65
$163.28
$161.63
$294.00
$291.03
$319.73
$316.50
$113.80
$112.65
$205.93
$203.86
$654.26
$647.63
$920.16
$910.87
$1,224.13
$1,211.77
$459.70
$455.06
$1,229.47
$1,217.03
$459.32
$454.69
$169.48
$167.76
$68.08
$67.40
Page 300 of 323
Notes
#
#
#
C
C
C
C
C
Procedure
Code
93660
93662
93701
93702
93724
93724
93724
93750
93750
93784
93786
93788
93790
93797
93797
93798
93798
93880
93880
93880
93882
93882
93882
93886
93886
93886
93888
93888
93888
93890
93890
93890
93892
1/2/2015
Modifier
26
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
Par Fee
$95.16
$147.19
$24.63
$114.37
$275.73
$28.56
$247.17
$56.05
$46.76
$54.22
$29.99
$5.32
$18.91
$16.40
$8.89
$25.30
$14.21
$203.85
$164.03
$39.83
$129.88
$105.07
$24.81
$236.79
$189.77
$47.02
$150.71
$125.10
$25.61
$186.06
$134.75
$51.31
$194.24
Nonpar Fee
$90.40
$139.83
$23.40
$108.65
$261.94
$27.13
$234.81
$53.25
$44.42
$51.51
$28.49
$5.05
$17.96
$15.58
$8.45
$24.04
$13.50
$193.66
$155.83
$37.84
$123.39
$99.82
$23.57
$224.95
$180.28
$44.67
$143.17
$118.85
$24.33
$176.76
$128.01
$48.74
$184.53
Limiting
Charge
$103.96
$160.80
$26.91
$124.95
$301.23
$31.20
$270.03
$61.24
$51.08
$59.24
$32.76
$5.81
$20.65
$17.92
$9.72
$27.65
$15.53
$222.71
$179.20
$43.52
$141.90
$114.79
$27.11
$258.69
$207.32
$51.37
$164.65
$136.68
$27.98
$203.27
$147.21
$56.05
$212.21
Charge**
Charge***
$102.93
$102.40
$159.19
$158.39
$26.65
$26.51
$123.69
$123.07
$298.22
$296.71
$30.89
$30.73
$267.33
$265.98
$60.63
$60.32
$50.58
$50.31
$58.64
$58.35
$32.44
$32.27
$5.75
$5.72
$20.45
$20.34
$17.73
$17.65
$9.63
$9.57
$27.37
$27.23
$15.38
$15.30
$220.48
$219.37
$177.41
$176.51
$43.08
$42.86
$140.48
$139.77
$113.64
$113.07
$26.83
$26.70
$256.11
$254.82
$205.25
$204.22
$50.85
$50.60
$163.00
$162.17
$135.31
$134.63
$27.70
$27.57
$201.24
$200.23
$145.74
$145.00
$55.49
$55.21
$210.08
$209.02
Arizona
EHR/eRx
Limiting
Charge**
$101.88
$157.58
$26.37
$122.45
$295.21
$30.58
$264.63
$60.02
$50.06
$58.05
$32.11
$5.69
$20.24
$17.56
$9.52
$27.09
$15.21
$218.26
$175.62
$42.64
$139.06
$112.49
$26.57
$253.52
$203.17
$50.35
$161.36
$133.94
$27.42
$199.20
$144.27
$54.94
$207.97
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$101.38
$100.35
$156.80
$155.22
$26.24
$25.98
$121.84
$120.61
$293.74
$290.78
$30.43
$30.12
$263.32
$260.66
$59.72
$59.12
$49.82
$49.31
$57.76
$57.18
$31.96
$31.63
$5.67
$5.61
$20.14
$19.94
$17.47
$17.30
$9.48
$9.38
$26.96
$26.69
$15.15
$14.98
$217.17
$214.98
$174.75
$172.98
$42.44
$42.00
$138.38
$136.98
$111.94
$110.80
$26.43
$26.16
$252.26
$249.71
$202.17
$200.12
$50.09
$49.59
$160.55
$158.94
$133.29
$131.93
$27.29
$27.00
$198.23
$196.21
$143.55
$142.11
$54.66
$54.11
$206.93
$204.85
Page 301 of 323
Notes
C
C
C
C
C
Procedure
Code
93892
93892
93893
93893
93893
93922
93922
93922
93923
93923
93923
93924
93924
93924
93925
93925
93925
93926
93926
93926
93930
93930
93930
93931
93931
93931
93965
93965
93965
93970
93970
93970
93971
1/2/2015
Modifier
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
Par Fee
$134.75
$59.49
$194.24
$134.75
$59.49
$90.33
$77.90
$12.43
$139.94
$117.59
$22.35
$174.58
$149.72
$24.85
$229.55
$189.77
$39.78
$154.82
$129.75
$25.08
$211.32
$171.53
$39.78
$131.31
$106.15
$25.17
$121.79
$104.36
$17.43
$199.16
$164.03
$35.13
$122.42
Nonpar Fee
$128.01
$56.52
$184.53
$128.01
$56.52
$85.81
$74.01
$11.81
$132.94
$111.71
$21.23
$165.85
$142.23
$23.61
$218.07
$180.28
$37.79
$147.08
$123.26
$23.83
$200.75
$162.95
$37.79
$124.74
$100.84
$23.91
$115.70
$99.14
$16.56
$189.20
$155.83
$33.37
$116.30
Limiting
Charge
$147.21
$65.00
$212.21
$147.21
$65.00
$98.68
$85.11
$13.58
$152.88
$128.47
$24.41
$190.73
$163.56
$27.15
$250.78
$207.32
$43.46
$169.14
$141.75
$27.40
$230.86
$187.39
$43.46
$143.45
$115.97
$27.50
$133.06
$114.01
$19.04
$217.58
$179.20
$38.38
$133.75
Charge**
Charge***
$145.74
$145.00
$64.34
$64.02
$210.08
$209.02
$145.74
$145.00
$64.34
$64.02
$97.69
$97.20
$84.26
$83.84
$13.44
$13.37
$151.35
$150.59
$127.18
$126.53
$24.17
$24.05
$188.82
$187.86
$161.93
$161.12
$26.88
$26.75
$248.27
$247.02
$205.25
$204.22
$43.02
$42.80
$167.45
$166.60
$140.33
$139.62
$27.13
$26.99
$228.55
$227.40
$185.52
$184.59
$43.02
$42.80
$142.01
$141.30
$114.80
$114.23
$27.22
$27.08
$131.72
$131.05
$112.87
$112.30
$18.85
$18.76
$215.41
$214.31
$177.41
$176.51
$38.00
$37.80
$132.41
$131.74
Arizona
EHR/eRx
Limiting
Charge**
$144.27
$63.70
$207.97
$144.27
$63.70
$96.70
$83.41
$13.31
$149.82
$125.90
$23.93
$186.91
$160.30
$26.61
$245.77
$203.17
$42.58
$165.76
$138.91
$26.85
$226.25
$183.64
$42.58
$140.59
$113.64
$26.94
$130.40
$111.73
$18.66
$213.23
$175.62
$37.61
$131.07
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$143.55
$142.11
$63.38
$62.74
$206.93
$204.85
$143.55
$142.11
$63.38
$62.74
$96.23
$95.25
$83.00
$82.16
$13.24
$13.11
$149.09
$147.58
$125.27
$124.02
$23.81
$23.58
$185.99
$184.10
$159.51
$157.90
$26.47
$26.21
$244.55
$242.08
$202.17
$200.12
$42.38
$41.94
$164.94
$163.28
$138.23
$136.83
$26.73
$26.45
$225.12
$222.86
$182.74
$180.88
$42.38
$41.94
$139.89
$138.48
$113.08
$111.94
$26.81
$26.54
$129.74
$128.44
$111.18
$110.06
$18.56
$18.39
$212.18
$210.04
$174.75
$172.98
$37.42
$37.04
$130.42
$129.10
Page 302 of 323
Notes
C
C
C
C
Procedure
Code
93971
93971
93975
93975
93975
93976
93976
93976
93978
93978
93978
93979
93979
93979
93980
93980
93980
93981
93981
93981
93982
93990
93990
93990
94002
94003
94004
94010
94010
94010
94011
94012
94013
1/2/2015
Modifier
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
Par Fee
$99.71
$22.71
$247.38
$189.77
$57.61
$164.92
$124.38
$40.54
$192.68
$153.30
$39.38
$121.66
$96.85
$24.81
$120.67
$59.31
$61.37
$72.45
$51.09
$21.36
$43.80
$160.10
$134.75
$25.35
$93.33
$67.45
$49.08
$36.38
$27.84
$8.54
$101.02
$166.63
$31.29
Nonpar Fee
$94.72
$21.57
$235.01
$180.28
$54.73
$156.67
$118.16
$38.51
$183.05
$145.64
$37.41
$115.58
$92.01
$23.57
$114.64
$56.34
$58.30
$68.83
$48.54
$20.29
$41.61
$152.10
$128.01
$24.08
$88.66
$64.08
$46.63
$34.56
$26.45
$8.11
$95.97
$158.30
$29.73
Limiting
Charge
$108.93
$24.81
$270.26
$207.32
$62.94
$180.17
$135.88
$44.29
$210.51
$167.49
$43.02
$132.92
$105.81
$27.11
$131.84
$64.79
$67.05
$79.15
$55.82
$23.33
$47.85
$174.92
$147.21
$27.69
$101.96
$73.69
$53.62
$39.74
$30.42
$9.33
$110.37
$182.05
$34.19
Charge**
Charge***
$107.84
$107.30
$24.55
$24.44
$267.56
$266.20
$205.25
$204.22
$62.31
$62.00
$178.37
$177.47
$134.53
$133.85
$43.84
$43.62
$208.40
$207.35
$165.81
$164.98
$42.60
$42.38
$131.58
$130.93
$104.75
$104.22
$26.83
$26.70
$130.51
$129.86
$64.15
$63.81
$66.38
$66.04
$78.36
$77.97
$55.26
$54.98
$23.10
$22.99
$47.37
$47.14
$173.17
$172.29
$145.74
$145.00
$27.42
$27.28
$100.94
$100.43
$72.96
$72.59
$53.08
$52.82
$39.34
$39.15
$30.12
$29.96
$9.23
$9.19
$109.26
$108.71
$180.23
$179.32
$33.84
$33.67
Arizona
EHR/eRx
Limiting
Charge**
$106.75
$24.31
$264.86
$203.17
$61.69
$176.57
$133.17
$43.40
$206.30
$164.14
$42.16
$130.26
$103.70
$26.57
$129.20
$63.49
$65.70
$77.57
$54.71
$22.86
$46.90
$171.42
$144.27
$27.14
$99.92
$72.22
$52.56
$38.95
$29.81
$9.14
$108.16
$178.40
$33.51
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$106.21
$105.16
$24.18
$23.94
$263.55
$260.89
$202.17
$200.12
$61.38
$60.77
$175.69
$173.93
$132.51
$131.17
$43.18
$42.75
$205.28
$203.21
$163.32
$161.68
$41.95
$41.53
$129.61
$128.31
$103.18
$102.14
$26.43
$26.16
$128.56
$127.26
$63.18
$62.54
$65.38
$64.71
$77.19
$76.41
$54.43
$53.89
$22.76
$22.52
$46.66
$46.20
$170.57
$168.84
$143.55
$142.11
$27.00
$26.74
$99.42
$98.43
$71.86
$71.14
$52.29
$51.76
$38.76
$38.36
$29.67
$29.36
$9.10
$9.00
$107.62
$106.54
$177.53
$175.72
$33.34
$33.01
Page 303 of 323
Notes
Procedure
Code
94014
94015
94016
94060
94060
94060
94070
94070
94070
94200
94200
94200
94250
94250
94250
94375
94375
94375
94400
94400
94400
94450
94450
94450
94452
94452
94452
94453
94453
94453
94610
94620
94620
1/2/2015
Modifier
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
Par Fee
$56.36
$30.71
$25.66
$61.41
$48.22
$13.19
$59.94
$31.06
$28.87
$25.66
$19.98
$5.68
$26.37
$21.05
$5.32
$39.60
$24.63
$14.97
$57.12
$37.50
$19.62
$67.13
$47.51
$19.62
$58.19
$43.58
$14.62
$80.67
$61.45
$19.22
$56.81
$56.36
$25.70
Nonpar Fee
$53.54
$29.17
$24.38
$58.34
$45.81
$12.53
$56.94
$29.51
$27.43
$24.38
$18.98
$5.40
$25.05
$20.00
$5.05
$37.62
$23.40
$14.22
$54.26
$35.63
$18.64
$63.77
$45.13
$18.64
$55.28
$41.40
$13.89
$76.64
$58.38
$18.26
$53.97
$53.54
$24.42
Limiting
Charge
$61.57
$33.55
$28.04
$67.09
$52.68
$14.41
$65.48
$33.94
$31.54
$28.04
$21.83
$6.21
$28.81
$23.00
$5.81
$43.26
$26.91
$16.35
$62.40
$40.97
$21.44
$73.34
$51.90
$21.44
$63.57
$47.61
$15.97
$88.14
$67.14
$21.00
$62.07
$61.57
$28.08
Charge**
Charge***
$60.95
$60.65
$33.21
$33.04
$27.76
$27.61
$66.42
$66.08
$52.15
$51.89
$14.26
$14.19
$64.83
$64.50
$33.59
$33.43
$31.23
$31.07
$27.76
$27.61
$21.61
$21.51
$6.15
$6.12
$28.52
$28.37
$22.77
$22.66
$5.75
$5.72
$42.83
$42.62
$26.65
$26.51
$16.19
$16.11
$61.78
$61.47
$40.56
$40.37
$21.22
$21.11
$72.60
$72.23
$51.38
$51.12
$21.22
$21.11
$62.94
$62.62
$47.14
$46.90
$15.81
$15.73
$87.25
$86.81
$66.47
$66.13
$20.79
$20.69
$61.44
$61.13
$60.95
$60.65
$27.81
$27.66
Arizona
EHR/eRx
Limiting
Charge**
$60.34
$32.88
$27.47
$65.75
$51.62
$14.12
$64.17
$33.26
$30.91
$27.47
$21.39
$6.08
$28.23
$22.54
$5.69
$42.40
$26.37
$16.03
$61.15
$40.16
$21.01
$71.86
$50.86
$21.01
$62.30
$46.66
$15.65
$86.38
$65.79
$20.57
$60.82
$60.34
$27.52
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$60.04
$59.43
$32.72
$32.38
$27.35
$27.06
$65.42
$64.76
$51.37
$50.85
$14.04
$13.92
$63.85
$63.20
$33.09
$32.76
$30.76
$30.45
$27.35
$27.06
$21.29
$21.07
$6.06
$5.99
$28.09
$27.81
$22.43
$22.21
$5.67
$5.61
$42.18
$41.77
$26.24
$25.98
$15.95
$15.79
$60.85
$60.23
$39.95
$39.56
$20.90
$20.70
$71.51
$70.78
$50.61
$50.11
$20.90
$20.70
$62.00
$61.36
$46.44
$45.95
$15.57
$15.42
$85.94
$85.08
$65.47
$64.80
$20.48
$20.26
$60.52
$59.92
$60.04
$59.43
$27.39
$27.11
Page 304 of 323
Notes
#
Procedure
Code
94620
94621
94621
94621
94640
94644
94645
94660
94660
94662
94664
94667
94668
94669
94680
94680
94680
94681
94681
94681
94690
94690
94690
94726
94726
94726
94727
94727
94727
94728
94728
94728
94729
1/2/2015
Modifier
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
Par Fee
$30.66
$165.24
$95.73
$69.50
$18.55
$43.93
$13.90
$63.07
$38.04
$34.37
$17.48
$26.37
$28.92
$35.67
$57.83
$45.01
$12.83
$53.90
$43.93
$9.97
$49.97
$46.08
$3.89
$53.19
$40.72
$12.47
$42.46
$29.99
$12.47
$39.60
$27.13
$12.47
$54.97
Nonpar Fee
$29.13
$156.98
$90.94
$66.03
$17.62
$41.73
$13.21
$59.92
$36.14
$32.65
$16.61
$25.05
$27.47
$33.89
$54.94
$42.76
$12.19
$51.21
$41.73
$9.47
$47.47
$43.78
$3.70
$50.53
$38.68
$11.85
$40.34
$28.49
$11.85
$37.62
$25.77
$11.85
$52.22
Limiting
Charge
$33.50
$180.53
$104.58
$75.93
$20.26
$47.99
$15.19
$68.91
$41.56
$37.55
$19.10
$28.81
$31.59
$38.97
$63.18
$49.17
$14.02
$58.89
$47.99
$10.89
$54.59
$50.35
$4.26
$58.11
$44.48
$13.63
$46.39
$32.76
$13.63
$43.26
$29.64
$13.63
$60.05
Charge**
Charge***
$33.17
$32.99
$178.72
$177.82
$103.53
$103.02
$75.18
$74.80
$20.06
$19.96
$47.51
$47.27
$15.04
$14.96
$68.22
$67.87
$41.15
$40.94
$37.17
$36.98
$18.91
$18.81
$28.52
$28.37
$31.28
$31.12
$38.58
$38.39
$62.55
$62.24
$48.68
$48.44
$13.88
$13.81
$58.31
$58.01
$47.51
$47.27
$10.79
$10.73
$54.05
$53.77
$49.84
$49.59
$4.21
$4.19
$57.52
$57.24
$44.03
$43.82
$13.49
$13.42
$45.93
$45.69
$32.44
$32.27
$13.49
$13.42
$42.83
$42.62
$29.34
$29.19
$13.49
$13.42
$59.46
$59.16
Arizona
EHR/eRx
Limiting
Charge**
$32.83
$176.92
$102.49
$74.42
$19.86
$47.04
$14.89
$67.53
$40.73
$36.80
$18.72
$28.23
$30.96
$38.19
$61.92
$48.19
$13.74
$57.72
$47.04
$10.67
$53.50
$49.34
$4.17
$56.95
$43.60
$13.35
$45.46
$32.11
$13.35
$42.40
$29.04
$13.35
$58.86
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$32.67
$32.34
$176.04
$174.26
$101.98
$100.95
$74.05
$73.30
$19.76
$19.56
$46.79
$46.33
$14.81
$14.67
$67.19
$66.52
$40.53
$40.12
$36.62
$36.25
$18.62
$18.45
$28.09
$27.81
$30.81
$30.50
$38.01
$37.62
$61.61
$60.98
$47.96
$47.46
$13.67
$13.54
$57.43
$56.86
$46.79
$46.33
$10.63
$10.51
$53.25
$52.69
$49.09
$48.60
$4.15
$4.12
$56.66
$56.10
$43.38
$42.94
$13.28
$13.16
$45.24
$44.78
$31.96
$31.63
$13.28
$13.16
$42.18
$41.77
$28.90
$28.60
$13.28
$13.16
$58.56
$57.97
Page 305 of 323
Notes
#
#
#
#
#
#
Procedure
Code
94729
94729
94750
94750
94750
94760
94761
94762
94770
94780
94780
94781
94781
95004
95012
95017
95017
95018
95018
95024
95024
95027
95028
95044
95052
95056
95060
95065
95070
95071
95076
95076
95079
1/2/2015
Modifier
TC
26
TC
26
Par Fee
$45.72
$9.25
$81.79
$70.39
$11.40
$3.17
$4.96
$24.63
$7.46
$63.15
$25.25
$23.20
$8.89
$6.39
$19.62
$7.82
$3.53
$18.91
$7.11
$7.82
$1.03
$4.60
$13.54
$5.68
$6.75
$44.65
$35.35
$25.34
$30.35
$35.00
$116.70
$73.43
$83.13
Nonpar Fee
$43.43
$8.79
$77.70
$66.87
$10.83
$3.01
$4.71
$23.40
$7.09
$59.99
$23.99
$22.04
$8.45
$6.07
$18.64
$7.43
$3.35
$17.96
$6.75
$7.43
$0.98
$4.37
$12.86
$5.40
$6.41
$42.42
$33.58
$24.07
$28.83
$33.25
$110.87
$69.76
$78.97
Limiting
Charge
$49.94
$10.11
$89.36
$76.90
$12.45
$3.46
$5.42
$26.91
$8.15
$68.99
$27.59
$25.35
$9.72
$6.98
$21.44
$8.54
$3.85
$20.65
$7.76
$8.54
$1.13
$5.03
$14.79
$6.21
$7.37
$48.78
$38.62
$27.68
$33.15
$38.24
$127.50
$80.22
$90.82
Charge**
Charge***
$49.45
$49.20
$10.01
$9.96
$88.46
$88.01
$76.13
$75.75
$12.33
$12.27
$3.43
$3.40
$5.36
$5.34
$26.65
$26.51
$8.07
$8.03
$68.30
$67.95
$27.31
$27.17
$25.09
$24.97
$9.63
$9.57
$6.91
$6.88
$21.22
$21.11
$8.46
$8.42
$3.82
$3.80
$20.45
$20.34
$7.68
$7.65
$8.46
$8.42
$1.12
$1.12
$4.98
$4.95
$14.64
$14.57
$6.15
$6.12
$7.30
$7.26
$48.30
$48.05
$38.23
$38.04
$27.40
$27.27
$32.82
$32.66
$37.86
$37.66
$126.22
$125.59
$79.42
$79.02
$89.91
$89.46
Arizona
EHR/eRx
Limiting
Charge**
$48.94
$9.90
$87.57
$75.36
$12.20
$3.39
$5.31
$26.37
$7.99
$67.61
$27.04
$24.84
$9.52
$6.84
$21.01
$8.37
$3.77
$20.24
$7.61
$8.37
$1.10
$4.92
$14.49
$6.08
$7.22
$47.81
$37.85
$27.13
$32.49
$37.48
$124.95
$78.61
$89.00
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$48.71
$48.21
$9.86
$9.75
$87.14
$86.26
$74.99
$74.23
$12.14
$12.02
$3.38
$3.35
$5.28
$5.23
$26.24
$25.98
$7.95
$7.88
$67.28
$66.60
$26.90
$26.63
$24.71
$24.47
$9.48
$9.38
$6.81
$6.74
$20.90
$20.70
$8.34
$8.25
$3.76
$3.71
$20.14
$19.94
$7.57
$7.50
$8.34
$8.25
$1.10
$1.09
$4.91
$4.85
$14.42
$14.27
$6.06
$5.99
$7.19
$7.12
$47.58
$47.09
$37.65
$37.28
$26.99
$26.73
$32.33
$32.00
$37.29
$36.92
$124.33
$123.07
$78.22
$77.43
$88.56
$87.66
Page 306 of 323
Notes
#
#
#
#
#
#
#
#
#
#
Procedure
Code
95079
95115
95117
95144
95144
95145
95145
95146
95146
95147
95147
95148
95148
95149
95149
95165
95165
95170
95170
95180
95180
95250
95251
95782
95782
95782
95783
95783
95783
95800
95800
95800
95801
1/2/2015
Modifier
TC
26
TC
26
TC
26
Par Fee
$67.40
$8.89
$10.32
$12.47
$3.17
$22.12
$3.17
$39.29
$3.17
$35.35
$3.17
$52.87
$3.17
$70.75
$3.17
$12.83
$3.17
$9.61
$3.17
$134.49
$101.95
$158.66
$43.44
$918.69
$795.51
$123.18
$1,253.58
$1,104.39
$149.20
$181.06
$128.67
$52.38
$92.38
Nonpar Fee
$64.03
$8.45
$9.80
$11.85
$3.01
$21.01
$3.01
$37.33
$3.01
$33.58
$3.01
$50.23
$3.01
$67.21
$3.01
$12.19
$3.01
$9.13
$3.01
$127.77
$96.85
$150.73
$41.27
$872.76
$755.73
$117.02
$1,190.90
$1,049.17
$141.74
$172.01
$122.24
$49.76
$87.76
Limiting
Charge
$73.63
$9.72
$11.27
$13.63
$3.46
$24.16
$3.46
$42.93
$3.46
$38.62
$3.46
$57.76
$3.46
$77.29
$3.46
$14.02
$3.46
$10.50
$3.46
$146.94
$111.38
$173.34
$47.46
$1,003.67
$869.09
$134.57
$1,369.54
$1,206.55
$163.00
$197.81
$140.58
$57.22
$100.92
Charge**
Charge***
$72.90
$72.53
$9.63
$9.57
$11.16
$11.10
$13.49
$13.42
$3.43
$3.40
$23.92
$23.79
$3.43
$3.40
$42.50
$42.29
$3.43
$3.40
$38.23
$38.04
$3.43
$3.40
$57.19
$56.90
$3.43
$3.40
$76.52
$76.13
$3.43
$3.40
$13.88
$13.81
$3.43
$3.40
$10.40
$10.34
$3.43
$3.40
$145.46
$144.73
$110.26
$109.71
$171.60
$170.74
$46.99
$46.75
$993.63
$988.62
$860.40
$856.05
$133.23
$132.55
$1,355.84
$1,349.00
$1,194.48
$1,188.44
$161.37
$160.55
$195.83
$194.84
$139.17
$138.47
$56.65
$56.36
$99.91
$99.41
Arizona
EHR/eRx
Limiting
Charge**
$72.16
$9.52
$11.04
$13.35
$3.39
$23.68
$3.39
$42.07
$3.39
$37.85
$3.39
$56.61
$3.39
$75.75
$3.39
$13.74
$3.39
$10.29
$3.39
$143.99
$109.15
$169.88
$46.51
$983.60
$851.71
$131.88
$1,342.14
$1,182.42
$159.75
$193.86
$137.77
$56.07
$98.90
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$71.81
$71.08
$9.48
$9.38
$10.98
$10.88
$13.28
$13.16
$3.38
$3.35
$23.56
$23.32
$3.38
$3.35
$41.87
$41.43
$3.38
$3.35
$37.65
$37.28
$3.38
$3.35
$56.33
$55.76
$3.38
$3.35
$75.37
$74.61
$3.38
$3.35
$13.67
$13.54
$3.38
$3.35
$10.24
$10.14
$3.38
$3.35
$143.28
$141.83
$108.61
$107.51
$169.03
$167.33
$46.29
$45.80
$978.73
$968.84
$847.49
$838.94
$131.23
$129.90
$1,335.51
$1,322.01
$1,176.57
$1,164.69
$158.95
$157.35
$192.90
$190.95
$137.08
$135.70
$55.80
$55.23
$98.42
$97.42
Page 307 of 323
Notes
Procedure
Code
95801
95801
95803
95803
95803
95805
95805
95805
95806
95806
95806
95807
95807
95807
95808
95808
95808
95810
95810
95810
95811
95811
95811
95812
95812
95812
95813
95813
95813
95816
95816
95816
95819
1/2/2015
Modifier
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
Par Fee
$42.50
$49.88
$142.49
$99.00
$43.49
$422.18
$362.65
$59.53
$169.26
$107.94
$61.32
$471.52
$409.13
$62.39
$606.27
$518.85
$87.42
$624.92
$502.32
$122.60
$656.34
$529.09
$127.25
$421.20
$363.14
$58.06
$503.93
$410.65
$93.28
$361.17
$303.11
$58.06
$411.90
Nonpar Fee
$40.38
$47.39
$135.37
$94.05
$41.32
$401.07
$344.52
$56.55
$160.80
$102.54
$58.25
$447.94
$388.67
$59.27
$575.96
$492.91
$83.05
$593.67
$477.20
$116.47
$623.52
$502.64
$120.89
$400.14
$344.98
$55.16
$478.73
$390.12
$88.62
$343.11
$287.95
$55.16
$391.31
Limiting
Charge
$46.44
$54.50
$155.68
$108.16
$47.52
$461.23
$396.20
$65.03
$184.92
$117.92
$66.99
$515.13
$446.97
$68.16
$662.35
$566.85
$95.51
$682.72
$548.78
$133.94
$717.05
$578.04
$139.02
$460.16
$396.73
$63.43
$550.54
$448.64
$101.91
$394.58
$331.14
$63.43
$450.01
Charge**
Charge***
$45.98
$45.74
$53.96
$53.68
$154.12
$153.34
$107.08
$106.54
$47.05
$46.81
$456.62
$454.31
$392.23
$390.25
$64.38
$64.06
$183.07
$182.15
$116.74
$116.15
$66.32
$65.99
$509.98
$507.40
$442.50
$440.27
$67.48
$67.14
$655.73
$652.42
$561.18
$558.35
$94.55
$94.07
$675.89
$672.47
$543.29
$540.55
$132.61
$131.93
$709.87
$706.30
$572.25
$569.37
$137.63
$136.94
$455.56
$453.26
$392.76
$390.78
$62.80
$62.48
$545.03
$542.28
$444.15
$441.91
$100.89
$100.38
$390.63
$388.65
$327.83
$326.17
$62.80
$62.48
$445.51
$443.26
Arizona
EHR/eRx
Limiting
Charge**
$45.51
$53.41
$152.56
$106.00
$46.56
$452.01
$388.27
$63.73
$181.22
$115.56
$65.65
$504.83
$438.04
$66.79
$649.11
$555.51
$93.60
$669.07
$537.81
$131.26
$702.71
$566.48
$136.24
$450.96
$388.79
$62.17
$539.53
$439.67
$99.88
$386.69
$324.52
$62.17
$441.00
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$45.29
$44.83
$53.15
$52.60
$151.81
$150.27
$105.47
$104.41
$46.35
$45.86
$449.77
$445.22
$386.34
$382.46
$63.41
$62.78
$180.32
$178.50
$114.99
$113.83
$65.32
$64.66
$502.33
$497.26
$435.86
$431.47
$66.47
$65.79
$645.90
$639.37
$552.76
$547.17
$93.14
$92.20
$665.75
$659.03
$535.14
$529.75
$130.62
$129.29
$699.22
$692.16
$563.67
$557.98
$135.56
$134.19
$448.73
$444.20
$386.87
$382.96
$61.86
$61.24
$536.85
$531.44
$437.49
$433.08
$99.37
$98.38
$384.77
$380.89
$322.91
$319.65
$61.86
$61.24
$438.83
$434.39
Page 308 of 323
Notes
#
#
#
#
#
#
#
#
Procedure
Code
95819
95819
95822
95822
95822
95824
95827
95827
95827
95829
95829
95829
95830
95830
95831
95831
95832
95832
95833
95833
95834
95834
95851
95851
95852
95852
95857
95857
95860
95860
95860
95861
95861
1/2/2015
Modifier
TC
26
TC
26
26
TC
26
TC
26
TC
26
TC
Par Fee
$353.84
$58.06
$372.57
$314.51
$58.06
$40.50
$789.52
$731.82
$57.70
$1,897.22
$1,562.98
$334.24
$247.48
$92.30
$30.97
$15.24
$30.57
$16.27
$37.81
$21.72
$50.95
$31.65
$18.55
$7.82
$16.40
$6.03
$54.22
$29.54
$123.85
$71.47
$52.38
$173.77
$90.77
Nonpar Fee
$336.15
$55.16
$353.94
$298.78
$55.16
$38.48
$750.04
$695.23
$54.82
$1,802.36
$1,484.83
$317.53
$235.11
$87.69
$29.42
$14.48
$29.04
$15.46
$35.92
$20.63
$48.40
$30.07
$17.62
$7.43
$15.58
$5.73
$51.51
$28.06
$117.66
$67.90
$49.76
$165.08
$86.23
Limiting
Charge
$386.57
$63.43
$407.03
$343.60
$63.43
$44.25
$862.55
$799.51
$63.04
$2,072.71
$1,707.55
$365.16
$270.38
$100.84
$33.83
$16.65
$33.40
$17.78
$41.31
$23.72
$55.66
$34.58
$20.26
$8.54
$17.92
$6.59
$59.24
$32.27
$135.31
$78.09
$57.22
$189.84
$99.16
Charge**
Charge***
$382.71
$380.78
$62.80
$62.48
$402.96
$400.92
$340.16
$338.45
$62.80
$62.48
$43.82
$43.59
$853.92
$849.61
$791.52
$787.52
$62.41
$62.10
$2,051.99
$2,041.62
$1,690.48
$1,681.94
$361.50
$359.69
$267.67
$266.32
$99.83
$99.33
$33.50
$33.33
$16.49
$16.40
$33.06
$32.89
$17.61
$17.51
$40.89
$40.69
$23.48
$23.37
$55.11
$54.82
$34.24
$34.06
$20.06
$19.96
$8.46
$8.42
$17.73
$17.65
$6.52
$6.49
$58.64
$58.35
$31.95
$31.79
$133.95
$133.29
$77.30
$76.91
$56.65
$56.36
$187.94
$186.99
$98.18
$97.68
Arizona
EHR/eRx
Limiting
Charge**
$378.84
$62.17
$398.89
$336.72
$62.17
$43.37
$845.30
$783.53
$61.78
$2,031.26
$1,673.40
$357.86
$264.97
$98.83
$33.15
$16.32
$32.73
$17.42
$40.48
$23.25
$54.54
$33.89
$19.86
$8.37
$17.56
$6.46
$58.05
$31.63
$132.61
$76.52
$56.07
$186.05
$97.19
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$376.97
$373.16
$61.86
$61.24
$396.91
$392.91
$335.05
$331.67
$61.86
$61.24
$43.16
$42.71
$841.11
$832.61
$779.65
$771.78
$61.48
$60.85
$2,021.21
$2,000.79
$1,665.12
$1,648.30
$356.07
$352.49
$263.66
$260.99
$98.34
$97.35
$32.99
$32.66
$16.24
$16.08
$32.57
$32.23
$17.34
$17.16
$40.28
$39.87
$23.13
$22.91
$54.28
$53.73
$33.72
$33.38
$19.76
$19.56
$8.34
$8.25
$17.47
$17.30
$6.42
$6.37
$57.76
$57.18
$31.46
$31.15
$131.94
$130.62
$76.14
$75.37
$55.80
$55.23
$185.13
$183.25
$96.70
$95.73
Page 309 of 323
Notes
Procedure
Code
95861
95863
95863
95863
95864
95864
95864
95865
95865
95865
95866
95866
95866
95867
95867
95867
95868
95868
95868
95869
95869
95869
95870
95870
95870
95872
95872
95872
95873
95873
95873
95874
95874
1/2/2015
Modifier
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
Par Fee
$83.00
$214.76
$112.94
$101.82
$244.08
$135.82
$108.25
$145.08
$60.38
$84.70
$134.17
$65.74
$68.43
$93.86
$51.80
$42.06
$133.06
$69.32
$63.74
$82.10
$62.17
$19.93
$88.94
$69.32
$19.62
$199.21
$43.58
$155.63
$75.35
$54.66
$20.69
$72.49
$52.52
Nonpar Fee
$78.85
$204.02
$107.29
$96.73
$231.88
$129.03
$102.84
$137.83
$57.36
$80.47
$127.46
$62.45
$65.01
$89.17
$49.21
$39.96
$126.41
$65.85
$60.55
$78.00
$59.06
$18.93
$84.49
$65.85
$18.64
$189.25
$41.40
$147.85
$71.58
$51.93
$19.66
$68.87
$49.89
Limiting
Charge
$90.68
$234.62
$123.38
$111.24
$266.66
$148.38
$118.27
$158.50
$65.96
$92.54
$146.58
$71.82
$74.76
$102.55
$56.59
$45.95
$145.37
$75.73
$69.63
$89.70
$67.92
$21.77
$97.16
$75.73
$21.44
$217.64
$47.61
$170.03
$82.32
$59.72
$22.61
$79.20
$57.37
Charge**
Charge***
$89.77
$89.32
$232.28
$231.10
$122.15
$121.53
$110.12
$109.57
$263.99
$262.66
$146.90
$146.15
$117.08
$116.50
$156.92
$156.12
$65.31
$64.98
$91.62
$91.15
$145.12
$144.38
$71.10
$70.74
$74.01
$73.63
$101.52
$101.00
$56.03
$55.74
$45.49
$45.26
$143.92
$143.19
$74.97
$74.59
$68.93
$68.59
$88.80
$88.35
$67.24
$66.90
$21.55
$21.45
$96.20
$95.70
$74.97
$74.59
$21.22
$21.11
$215.46
$214.37
$47.14
$46.90
$168.33
$167.47
$81.49
$81.09
$59.12
$58.82
$22.38
$22.28
$78.41
$78.02
$56.80
$56.51
Arizona
EHR/eRx
Limiting
Charge**
$88.86
$229.93
$120.91
$109.02
$261.33
$145.42
$115.90
$155.33
$64.64
$90.69
$143.65
$70.38
$73.27
$100.50
$55.46
$45.03
$142.46
$74.21
$68.24
$87.91
$66.56
$21.33
$95.22
$74.21
$21.01
$213.29
$46.66
$166.62
$80.67
$58.52
$22.16
$77.61
$56.22
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$88.42
$87.53
$228.79
$226.48
$120.32
$119.09
$108.47
$107.39
$260.04
$257.40
$144.69
$143.23
$115.32
$114.16
$154.56
$153.00
$64.33
$63.68
$90.24
$89.33
$142.95
$141.50
$70.04
$69.32
$72.90
$72.16
$100.00
$98.99
$55.19
$54.64
$44.82
$44.36
$141.76
$140.32
$73.84
$73.09
$67.90
$67.22
$87.47
$86.58
$66.23
$65.56
$21.23
$21.01
$94.76
$93.79
$73.84
$73.09
$20.90
$20.70
$212.23
$210.09
$46.44
$45.95
$165.80
$164.13
$80.27
$79.47
$58.24
$57.65
$22.05
$21.83
$77.23
$76.45
$55.95
$55.38
Page 310 of 323
Notes
Procedure
Code
95874
95875
95875
95875
95885
95885
95885
95886
95886
95886
95887
95887
95887
95905
95905
95905
95907
95907
95907
95908
95908
95908
95909
95909
95909
95910
95910
95910
95911
95911
95911
95912
95912
1/2/2015
Modifier
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
Par Fee
$19.98
$121.66
$62.88
$58.78
$58.91
$40.00
$18.91
$91.71
$45.36
$46.35
$82.06
$43.58
$38.48
$72.14
$69.32
$2.82
$97.75
$43.93
$53.81
$125.59
$57.52
$68.07
$148.79
$67.53
$81.26
$197.64
$88.99
$108.66
$235.10
$99.71
$135.38
$262.14
$101.50
Nonpar Fee
$18.98
$115.58
$59.74
$55.84
$55.96
$38.00
$17.96
$87.12
$43.09
$44.03
$77.96
$41.40
$36.56
$68.53
$65.85
$2.68
$92.86
$41.73
$51.12
$119.31
$54.64
$64.67
$141.35
$64.15
$77.20
$187.76
$84.54
$103.23
$223.35
$94.72
$128.61
$249.03
$96.43
Limiting
Charge
$21.83
$132.92
$68.70
$64.22
$64.35
$43.70
$20.65
$100.19
$49.55
$50.63
$89.65
$47.61
$42.04
$78.81
$75.73
$3.08
$106.79
$47.99
$58.79
$137.21
$62.84
$74.37
$162.55
$73.77
$88.78
$215.92
$97.22
$118.71
$256.85
$108.93
$147.90
$286.38
$110.89
Charge**
Charge***
$21.61
$21.51
$131.58
$130.93
$68.01
$67.67
$63.57
$63.25
$63.71
$63.39
$43.26
$43.04
$20.45
$20.34
$99.19
$98.68
$49.06
$48.81
$50.13
$49.88
$88.76
$88.31
$47.14
$46.90
$41.62
$41.41
$78.02
$77.63
$74.97
$74.59
$3.05
$3.04
$105.72
$105.19
$47.51
$47.27
$58.20
$57.90
$135.84
$135.15
$62.20
$61.89
$73.62
$73.26
$160.93
$160.11
$73.04
$72.67
$87.89
$87.45
$213.76
$212.68
$96.24
$95.76
$117.53
$116.93
$254.29
$253.00
$107.84
$107.30
$146.42
$145.68
$283.52
$282.08
$109.79
$109.23
Arizona
EHR/eRx
Limiting
Charge**
$21.39
$130.26
$67.33
$62.93
$63.07
$42.83
$20.24
$98.19
$48.56
$49.62
$87.86
$46.66
$41.20
$77.23
$74.21
$3.02
$104.65
$47.04
$57.62
$134.46
$61.58
$72.89
$159.30
$72.30
$87.01
$211.60
$95.28
$116.35
$251.71
$106.75
$144.95
$280.66
$108.68
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$21.29
$21.07
$129.61
$128.31
$66.99
$66.32
$62.62
$61.99
$62.76
$62.12
$42.62
$42.18
$20.14
$19.94
$97.70
$96.72
$48.32
$47.84
$49.38
$48.88
$87.42
$86.54
$46.44
$45.95
$41.00
$40.58
$76.84
$76.07
$73.84
$73.09
$3.00
$2.98
$104.13
$103.09
$46.79
$46.33
$57.33
$56.75
$133.80
$132.45
$61.27
$60.66
$72.52
$71.79
$158.52
$156.91
$71.94
$71.22
$86.57
$85.71
$210.55
$208.43
$94.79
$93.85
$115.77
$114.60
$250.47
$247.94
$106.21
$105.16
$144.22
$142.77
$279.27
$276.45
$108.15
$107.04
Page 311 of 323
Notes
Procedure
Code
95912
95913
95913
95913
95921
95921
95921
95922
95922
95922
95923
95923
95923
95924
95924
95924
95925
95925
95925
95926
95926
95926
95927
95927
95927
95928
95928
95928
95929
95929
95929
95930
95930
1/2/2015
Modifier
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
Par Fee
$160.64
$297.09
$107.58
$189.51
$88.14
$42.15
$45.99
$101.01
$52.16
$48.85
$192.90
$146.55
$46.35
$154.15
$64.67
$89.48
$158.17
$129.70
$28.47
$144.99
$117.55
$27.44
$153.57
$125.77
$27.80
$260.61
$179.76
$80.86
$260.48
$181.19
$79.29
$129.30
$110.75
Nonpar Fee
$152.61
$282.24
$102.20
$180.03
$83.73
$40.04
$43.69
$95.96
$49.55
$46.41
$183.26
$139.22
$44.03
$146.44
$61.44
$85.01
$150.26
$123.22
$27.05
$137.74
$111.67
$26.07
$145.89
$119.48
$26.41
$247.58
$170.77
$76.82
$247.46
$172.13
$75.33
$122.84
$105.21
Limiting
Charge
$175.50
$324.58
$117.53
$207.03
$96.29
$46.05
$50.24
$110.35
$56.98
$53.37
$210.75
$160.10
$50.63
$168.41
$70.66
$97.76
$172.80
$141.70
$31.11
$158.40
$128.42
$29.98
$167.77
$137.40
$30.37
$284.72
$196.39
$88.34
$284.58
$197.95
$86.63
$141.27
$120.99
Charge**
Charge***
$173.74
$172.87
$321.33
$319.71
$116.36
$115.77
$204.96
$203.93
$95.32
$94.84
$45.59
$45.36
$49.74
$49.48
$109.25
$108.70
$56.41
$56.13
$52.84
$52.57
$208.64
$207.59
$158.50
$157.70
$50.13
$49.88
$166.73
$165.88
$69.95
$69.60
$96.78
$96.29
$171.07
$170.21
$140.29
$139.58
$30.80
$30.64
$156.81
$156.02
$127.13
$126.49
$29.68
$29.53
$166.09
$165.26
$136.03
$135.34
$30.07
$29.91
$281.87
$280.45
$194.42
$193.44
$87.46
$87.02
$281.74
$280.31
$195.97
$194.98
$85.77
$85.33
$139.85
$139.15
$119.78
$119.17
Arizona
EHR/eRx
Limiting
Charge**
$171.99
$318.09
$115.18
$202.89
$94.37
$45.13
$49.24
$108.15
$55.84
$52.30
$206.53
$156.91
$49.62
$165.04
$69.24
$95.81
$169.34
$138.87
$30.49
$155.24
$125.86
$29.38
$164.42
$134.65
$29.76
$279.02
$192.45
$86.57
$278.89
$193.99
$84.89
$138.44
$118.58
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$171.13
$169.42
$316.51
$313.32
$114.61
$113.46
$201.89
$199.85
$93.90
$92.95
$44.91
$44.45
$48.99
$48.51
$107.62
$106.52
$55.56
$55.00
$52.05
$51.52
$205.52
$203.44
$156.12
$154.55
$49.38
$48.88
$164.23
$162.56
$68.91
$68.21
$95.34
$94.37
$168.51
$166.80
$138.18
$136.79
$30.34
$30.03
$154.46
$152.92
$125.22
$123.97
$29.23
$28.95
$163.60
$161.95
$134.00
$132.63
$29.62
$29.31
$277.63
$274.84
$191.50
$189.57
$86.15
$85.27
$277.52
$274.70
$193.03
$191.08
$84.48
$83.62
$137.76
$136.36
$117.99
$116.79
Page 312 of 323
Notes
Procedure
Code
95930
95933
95933
95933
95937
95937
95937
95938
95938
95938
95939
95939
95939
95940
95950
95950
95950
95951
95953
95953
95953
95954
95954
95954
95955
95955
95955
95956
95956
95956
95957
95957
95957
1/2/2015
Modifier
26
TC
26
TC
26
TC
26
TC
26
TC
26
26
TC
26
TC
26
TC
26
TC
26
TC
26
Par Fee
$18.55
$84.56
$52.87
$31.69
$83.49
$48.58
$34.91
$343.70
$297.70
$45.99
$505.81
$383.52
$122.29
$33.03
$330.69
$250.19
$80.50
$329.20
$421.07
$255.56
$165.51
$461.96
$335.92
$126.04
$214.98
$160.85
$54.13
$1,679.56
$1,486.20
$193.36
$318.36
$211.94
$106.42
Nonpar Fee
$17.62
$80.33
$50.23
$30.11
$79.32
$46.15
$33.16
$326.52
$282.82
$43.69
$480.52
$364.34
$116.18
$31.38
$314.16
$237.68
$76.48
$312.74
$400.02
$242.78
$157.23
$438.86
$319.12
$119.74
$204.23
$152.81
$51.42
$1,595.58
$1,411.89
$183.69
$302.44
$201.34
$101.10
Limiting
Charge
$20.26
$92.38
$57.76
$34.63
$91.22
$53.07
$38.13
$375.50
$325.24
$50.24
$552.60
$418.99
$133.61
$36.09
$361.28
$273.33
$87.95
$359.65
$460.02
$279.20
$180.81
$504.69
$366.99
$137.70
$234.86
$175.73
$59.13
$1,834.92
$1,623.67
$211.24
$347.81
$231.54
$116.27
Charge**
Charge***
$20.06
$19.96
$91.46
$91.00
$57.19
$56.90
$34.28
$34.11
$90.31
$89.85
$52.54
$52.28
$37.75
$37.56
$371.74
$369.86
$321.99
$320.37
$49.74
$49.48
$547.07
$544.31
$414.81
$412.70
$132.27
$131.61
$35.73
$35.55
$357.67
$355.87
$270.60
$269.23
$87.08
$86.63
$356.05
$354.26
$455.42
$453.12
$276.40
$275.01
$179.01
$178.10
$499.64
$497.12
$363.32
$361.48
$136.32
$135.63
$232.52
$231.35
$173.97
$173.10
$58.55
$58.25
$1,816.56
$1,807.40
$1,607.44
$1,599.32
$209.13
$208.07
$344.33
$342.59
$229.23
$228.07
$115.10
$114.52
Arizona
EHR/eRx
Limiting
Charge**
$19.86
$90.53
$56.61
$33.94
$89.39
$52.01
$37.38
$367.99
$318.73
$49.24
$541.55
$410.61
$130.94
$35.36
$354.06
$267.87
$86.19
$352.46
$450.82
$273.61
$177.20
$494.59
$359.65
$134.95
$230.17
$172.21
$57.95
$1,798.22
$1,591.20
$207.02
$340.85
$226.91
$113.94
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$19.76
$19.56
$90.09
$89.17
$56.33
$55.76
$33.76
$33.43
$88.95
$88.04
$51.75
$51.23
$37.19
$36.81
$366.16
$362.47
$317.16
$313.95
$48.99
$48.51
$538.86
$533.43
$408.58
$404.44
$130.28
$128.97
$35.19
$34.83
$352.30
$348.75
$266.54
$263.86
$85.77
$84.90
$350.72
$347.17
$448.59
$444.06
$272.25
$269.50
$176.33
$174.55
$492.14
$487.17
$357.87
$354.26
$134.27
$132.93
$229.03
$226.72
$171.36
$169.63
$57.67
$57.07
$1,789.32
$1,771.24
$1,583.32
$1,567.34
$205.99
$203.92
$339.17
$335.73
$225.79
$223.50
$113.38
$112.23
Page 313 of 323
Notes
#
#
#
#
#
#
#
#
#
#
Procedure
Code
95958
95958
95958
95961
95961
95961
95962
95962
95962
95965
95965
95966
95967
95970
95970
95971
95971
95972
95972
95973
95973
95974
95974
95975
95975
95978
95978
95979
95979
95980
95981
95981
95982
1/2/2015
Modifier
TC
26
TC
26
TC
26
26
26
26
26
Par Fee
$584.79
$358.40
$226.39
$291.73
$132.61
$159.12
$258.07
$87.91
$170.15
$435.59
$435.23
$219.47
$192.11
$67.40
$24.14
$57.66
$40.85
$55.47
$41.88
$40.58
$26.28
$209.28
$165.66
$112.33
$93.73
$250.53
$194.04
$109.11
$90.51
$46.14
$32.05
$17.75
$53.24
Nonpar Fee
$555.55
$340.48
$215.07
$277.14
$125.98
$151.16
$245.17
$83.51
$161.64
$413.81
$413.47
$208.50
$182.50
$64.03
$22.93
$54.78
$38.81
$52.70
$39.79
$38.55
$24.97
$198.82
$157.38
$106.71
$89.04
$238.00
$184.34
$103.65
$85.98
$43.83
$30.45
$16.86
$50.58
Limiting
Charge
$638.88
$391.55
$247.33
$318.71
$144.88
$173.83
$281.95
$96.04
$185.89
$475.88
$475.49
$239.78
$209.88
$73.63
$26.37
$63.00
$44.63
$60.61
$45.76
$44.33
$28.72
$228.64
$180.99
$122.72
$102.40
$273.70
$211.99
$119.20
$98.88
$50.40
$35.02
$19.39
$58.17
Charge**
Charge***
$632.49
$629.30
$387.64
$385.68
$244.86
$243.62
$315.53
$313.93
$143.43
$142.70
$172.10
$171.22
$279.13
$277.71
$95.07
$94.60
$184.02
$183.10
$471.12
$468.74
$470.74
$468.36
$237.38
$236.18
$207.78
$206.72
$72.90
$72.53
$26.11
$25.98
$62.36
$62.05
$44.18
$43.96
$60.00
$59.70
$45.30
$45.07
$43.88
$43.67
$28.43
$28.29
$226.35
$225.22
$179.18
$178.27
$121.49
$120.88
$101.37
$100.86
$270.96
$269.59
$209.88
$208.81
$118.00
$117.42
$97.89
$97.39
$49.90
$49.65
$34.67
$34.49
$19.19
$19.10
$57.58
$57.29
Arizona
EHR/eRx
Limiting
Charge**
$626.11
$383.72
$242.39
$312.34
$141.98
$170.36
$276.31
$94.12
$182.17
$466.36
$465.98
$234.98
$205.68
$72.16
$25.84
$61.73
$43.73
$59.40
$44.84
$43.45
$28.14
$224.07
$177.36
$120.27
$100.35
$268.23
$207.75
$116.82
$96.90
$49.39
$34.32
$19.00
$57.01
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$623.00
$616.71
$381.82
$377.96
$241.19
$238.75
$310.79
$307.66
$141.28
$139.85
$169.52
$167.81
$274.94
$272.17
$93.64
$92.70
$181.26
$179.43
$464.05
$459.37
$463.68
$458.99
$233.82
$231.46
$204.67
$202.60
$71.81
$71.08
$25.71
$25.45
$61.43
$60.80
$43.52
$43.08
$59.10
$58.51
$44.62
$44.17
$43.23
$42.79
$28.00
$27.72
$222.96
$220.71
$176.49
$174.71
$119.67
$118.46
$99.85
$98.84
$266.90
$264.20
$206.72
$204.63
$116.23
$115.07
$96.42
$95.45
$49.15
$48.66
$34.16
$33.80
$18.91
$18.71
$56.72
$56.15
Page 314 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
95982
95990
95991
95991
95992
95992
96000
96001
96002
96003
96004
96020
96101
96101
96102
96102
96103
96103
96105
96111
96111
96116
96116
96118
96118
96119
96119
96120
96120
96125
96127
96150
96150
1/2/2015
Modifier
26
Par Fee
$37.15
$90.69
$121.70
$39.83
$42.77
$37.41
$96.01
$101.91
$22.04
$19.26
$118.32
$169.68
$79.83
$79.11
$63.87
$23.11
$27.40
$26.68
$104.45
$128.55
$121.75
$93.24
$87.16
$97.70
$78.75
$81.43
$23.87
$48.14
$25.97
$117.59
$5.32
$21.72
$21.36
Nonpar Fee
$35.29
$86.16
$115.62
$37.84
$40.63
$35.54
$91.21
$96.81
$20.94
$18.30
$112.40
$161.20
$75.84
$75.15
$60.68
$21.95
$26.03
$25.35
$99.23
$122.12
$115.66
$88.58
$82.80
$92.82
$74.81
$77.36
$22.68
$45.73
$24.67
$111.71
$5.05
$20.63
$20.29
Limiting
Charge
$40.58
$99.08
$132.96
$43.52
$46.72
$40.87
$104.89
$111.33
$24.08
$21.05
$129.26
$185.38
$87.22
$86.42
$69.78
$25.24
$29.93
$29.15
$114.11
$140.44
$133.01
$101.87
$95.22
$106.74
$86.03
$88.96
$26.08
$52.59
$28.37
$128.47
$5.81
$23.72
$23.33
Charge**
Charge***
$40.18
$39.97
$98.10
$97.60
$131.63
$130.97
$43.08
$42.86
$46.25
$46.02
$40.46
$40.26
$103.85
$103.32
$110.22
$109.66
$23.84
$23.72
$20.84
$20.73
$127.97
$127.32
$183.53
$182.60
$86.34
$85.91
$85.56
$85.12
$69.08
$68.74
$24.99
$24.86
$29.64
$29.49
$28.87
$28.72
$112.98
$112.40
$139.04
$138.33
$131.68
$131.02
$100.84
$100.34
$94.27
$93.79
$105.67
$105.14
$85.17
$84.74
$88.08
$87.63
$25.82
$25.69
$52.06
$51.80
$28.08
$27.95
$127.18
$126.53
$5.75
$5.72
$23.48
$23.37
$23.10
$22.99
Arizona
EHR/eRx
Limiting
Charge**
$39.77
$97.11
$130.31
$42.64
$45.79
$40.05
$102.80
$109.10
$23.60
$20.62
$126.67
$181.68
$85.47
$84.70
$68.39
$24.74
$29.34
$28.57
$111.84
$137.63
$130.35
$99.83
$93.31
$104.60
$84.31
$87.18
$25.56
$51.54
$27.81
$125.90
$5.69
$23.25
$22.86
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$39.58
$39.17
$96.62
$95.65
$129.65
$128.35
$42.44
$42.00
$45.56
$45.10
$39.85
$39.46
$102.29
$101.26
$108.56
$107.47
$23.48
$23.24
$20.53
$20.31
$126.05
$124.78
$180.78
$178.95
$85.04
$84.19
$84.27
$83.43
$68.05
$67.37
$24.61
$24.37
$29.19
$28.90
$28.43
$28.14
$111.29
$110.16
$136.95
$135.56
$129.70
$128.40
$99.33
$98.34
$92.85
$91.91
$104.09
$103.04
$83.89
$83.04
$86.76
$85.87
$25.43
$25.19
$51.28
$50.77
$27.66
$27.39
$125.27
$124.02
$5.67
$5.61
$23.13
$22.91
$22.76
$22.52
Page 315 of 323
Notes
#
#
#
#
#
#
Procedure
Code
96151
96151
96152
96152
96153
96153
96154
96154
96360
96361
96365
96366
96367
96368
96369
96370
96371
96372
96373
96374
96375
96401
96402
96405
96405
96406
96406
96409
96411
96413
96415
96416
96417
1/2/2015
Modifier
Par Fee
$20.65
$20.29
$19.62
$19.26
$4.60
$4.25
$19.26
$18.91
$57.79
$15.33
$69.90
$18.91
$30.35
$20.69
$195.80
$15.33
$90.42
$25.34
$19.62
$57.08
$22.48
$74.91
$32.49
$82.15
$29.95
$119.24
$46.66
$110.93
$62.08
$135.56
$28.20
$140.57
$62.80
Nonpar Fee
$19.62
$19.28
$18.64
$18.30
$4.37
$4.04
$18.30
$17.96
$54.90
$14.56
$66.41
$17.96
$28.83
$19.66
$186.01
$14.56
$85.90
$24.07
$18.64
$54.23
$21.36
$71.16
$30.87
$78.04
$28.45
$113.28
$44.33
$105.38
$58.98
$128.78
$26.79
$133.54
$59.66
Limiting
Charge
$22.56
$22.17
$21.44
$21.05
$5.03
$4.65
$21.05
$20.65
$63.14
$16.74
$76.37
$20.65
$33.15
$22.61
$213.91
$16.74
$98.79
$27.68
$21.44
$62.36
$24.56
$81.83
$35.50
$89.75
$32.72
$130.27
$50.98
$121.19
$67.83
$148.10
$30.81
$153.57
$68.61
Charge**
Charge***
$22.33
$22.23
$21.95
$21.84
$21.22
$21.11
$20.84
$20.73
$4.98
$4.95
$4.60
$4.58
$20.84
$20.73
$20.45
$20.34
$62.50
$62.19
$16.57
$16.49
$75.61
$75.22
$20.45
$20.34
$32.82
$32.66
$22.38
$22.28
$211.77
$210.70
$16.57
$16.49
$97.80
$97.30
$27.40
$27.27
$21.22
$21.11
$61.74
$61.43
$24.32
$24.20
$81.02
$80.60
$35.14
$34.97
$88.85
$88.40
$32.40
$32.22
$128.97
$128.32
$50.47
$50.22
$119.98
$119.37
$67.15
$66.82
$146.61
$145.88
$30.50
$30.35
$152.03
$151.27
$67.92
$67.59
Arizona
EHR/eRx
Limiting
Charge**
$22.11
$21.72
$21.01
$20.62
$4.92
$4.55
$20.62
$20.24
$61.87
$16.41
$74.84
$20.24
$32.49
$22.16
$209.63
$16.41
$96.81
$27.13
$21.01
$61.12
$24.07
$80.20
$34.79
$87.95
$32.06
$127.66
$49.96
$118.76
$66.47
$145.13
$30.19
$150.50
$67.24
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$22.00
$21.78
$21.62
$21.40
$20.90
$20.70
$20.53
$20.31
$4.91
$4.85
$4.53
$4.49
$20.53
$20.31
$20.14
$19.94
$61.56
$60.94
$16.32
$16.17
$74.47
$73.72
$20.14
$19.94
$32.33
$32.00
$22.05
$21.83
$208.60
$206.49
$16.32
$16.17
$96.32
$95.36
$26.99
$26.73
$20.90
$20.70
$60.81
$60.20
$23.95
$23.71
$79.80
$78.99
$34.62
$34.27
$87.52
$86.63
$31.91
$31.58
$127.04
$125.74
$49.71
$49.21
$118.19
$116.98
$66.14
$65.47
$144.42
$142.96
$30.04
$29.74
$149.75
$148.25
$66.90
$66.23
Page 316 of 323
Notes
#
#
#
#
#
#
#
Procedure
Code
96420
96422
96423
96425
96440
96440
96446
96446
96450
96450
96521
96522
96523
96542
96542
96567
96570
96571
96900
96904
96910
96912
96913
96920
96920
96921
96921
96922
96922
97001
97002
97003
97004
1/2/2015
Modifier
Par Fee
$104.14
$170.47
$79.16
$180.75
$863.52
$140.91
$201.14
$28.45
$182.89
$81.35
$138.42
$114.11
$24.98
$120.27
$42.33
$135.47
$57.44
$26.64
$20.69
$63.24
$71.82
$92.20
$129.70
$156.07
$67.40
$172.48
$76.30
$238.45
$123.32
$75.27
$42.10
$85.23
$52.83
Nonpar Fee
$98.93
$161.95
$75.20
$171.71
$820.34
$133.86
$191.08
$27.03
$173.75
$77.28
$131.50
$108.40
$23.73
$114.26
$40.21
$128.70
$54.57
$25.31
$19.66
$60.08
$68.23
$87.59
$123.22
$148.27
$64.03
$163.86
$72.49
$226.53
$117.15
$71.51
$40.00
$80.97
$50.19
Limiting
Charge
$113.77
$186.24
$86.48
$197.47
$943.39
$153.94
$219.74
$31.08
$199.81
$88.87
$151.23
$124.66
$27.29
$131.40
$46.24
$148.01
$62.76
$29.11
$22.61
$69.09
$78.46
$100.73
$141.70
$170.51
$73.63
$188.44
$83.36
$260.51
$134.72
$82.24
$46.00
$93.12
$57.72
Charge**
Charge***
$112.63
$112.07
$184.38
$183.45
$85.62
$85.18
$195.49
$194.50
$933.96
$929.23
$152.40
$151.63
$217.55
$216.44
$30.77
$30.61
$197.81
$196.81
$87.99
$87.54
$149.72
$148.96
$123.42
$122.79
$27.01
$26.88
$130.09
$129.43
$45.78
$45.55
$146.52
$145.79
$62.12
$61.81
$28.82
$28.67
$22.38
$22.28
$68.40
$68.06
$77.68
$77.29
$99.72
$99.22
$140.29
$139.58
$168.81
$167.96
$72.90
$72.53
$186.55
$185.61
$82.54
$82.11
$257.90
$256.60
$133.38
$132.70
$81.41
$81.01
$45.54
$45.31
$92.18
$91.72
$57.14
$56.86
Arizona
EHR/eRx
Limiting
Charge**
$111.49
$182.52
$84.76
$193.52
$924.52
$150.86
$215.35
$30.46
$195.82
$87.09
$148.20
$122.16
$26.75
$128.77
$45.32
$145.05
$61.50
$28.52
$22.16
$67.71
$76.90
$98.72
$138.87
$167.10
$72.16
$184.67
$81.70
$255.30
$132.03
$80.59
$45.08
$91.25
$56.57
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$110.94
$109.83
$181.62
$179.78
$84.33
$83.48
$192.56
$190.62
$919.95
$910.65
$150.11
$148.59
$214.28
$212.12
$30.31
$30.00
$194.84
$192.89
$86.66
$85.78
$147.48
$145.98
$121.57
$120.34
$26.61
$26.35
$128.13
$126.83
$45.09
$44.64
$144.33
$142.88
$61.19
$60.58
$28.38
$28.09
$22.05
$21.83
$67.38
$66.70
$76.52
$75.75
$98.22
$97.23
$138.18
$136.79
$166.28
$164.59
$71.81
$71.08
$183.76
$181.90
$81.29
$80.47
$254.04
$251.47
$131.38
$130.05
$80.19
$79.38
$44.86
$44.40
$90.80
$89.88
$56.28
$55.72
Page 317 of 323
Notes
#
#
#
#
Procedure
Code
97012
97016
97018
97022
97024
97026
97028
97032
97033
97034
97035
97036
97110
97112
97113
97116
97124
97140
97150
97530
97532
97533
97535
97537
97542
97597
97597
97598
97598
97605
97605
97606
97606
1/2/2015
Modifier
Par Fee
$16.05
$19.26
$11.04
$23.55
$6.39
$6.03
$7.46
$19.26
$32.85
$18.19
$12.83
$33.52
$32.45
$33.57
$43.22
$28.56
$26.73
$29.99
$17.48
$35.00
$26.77
$29.27
$35.00
$30.35
$30.71
$76.70
$24.14
$25.25
$11.67
$43.58
$27.49
$51.72
$30.27
Nonpar Fee
$15.25
$18.30
$10.49
$22.37
$6.07
$5.73
$7.09
$18.30
$31.21
$17.28
$12.19
$31.84
$30.83
$31.89
$41.06
$27.13
$25.39
$28.49
$16.61
$33.25
$25.43
$27.81
$33.25
$28.83
$29.17
$72.87
$22.93
$23.99
$11.09
$41.40
$26.12
$49.13
$28.76
Limiting
Charge
$17.54
$21.05
$12.06
$25.73
$6.98
$6.59
$8.15
$21.05
$35.89
$19.87
$14.02
$36.62
$35.45
$36.67
$47.22
$31.20
$29.20
$32.76
$19.10
$38.24
$29.24
$31.98
$38.24
$33.15
$33.55
$83.80
$26.37
$27.59
$12.75
$47.61
$30.04
$56.50
$33.07
Charge**
Charge***
$17.37
$17.27
$20.84
$20.73
$11.95
$11.88
$25.47
$25.33
$6.91
$6.88
$6.52
$6.49
$8.07
$8.03
$20.84
$20.73
$35.54
$35.35
$19.68
$19.57
$13.88
$13.81
$36.25
$36.06
$35.10
$34.93
$36.31
$36.12
$46.75
$46.51
$30.89
$30.73
$28.91
$28.76
$32.44
$32.27
$18.91
$18.81
$37.86
$37.66
$28.96
$28.81
$31.66
$31.50
$37.86
$37.66
$32.82
$32.66
$33.21
$33.04
$82.96
$82.55
$26.11
$25.98
$27.31
$27.17
$12.63
$12.56
$47.14
$46.90
$29.74
$29.59
$55.94
$55.65
$32.74
$32.58
Arizona
EHR/eRx
Limiting
Charge**
$17.19
$20.62
$11.82
$25.21
$6.84
$6.46
$7.99
$20.62
$35.18
$19.47
$13.74
$35.88
$34.74
$35.94
$46.28
$30.58
$28.61
$32.11
$18.72
$37.48
$28.66
$31.34
$37.48
$32.49
$32.88
$82.12
$25.84
$27.04
$12.50
$46.66
$29.44
$55.37
$32.41
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$17.10
$16.94
$20.53
$20.31
$11.76
$11.65
$25.09
$24.83
$6.81
$6.74
$6.42
$6.37
$7.95
$7.88
$20.53
$20.31
$35.01
$34.65
$19.38
$19.18
$13.67
$13.54
$35.71
$35.34
$34.57
$34.22
$35.77
$35.40
$46.05
$45.59
$30.43
$30.12
$28.47
$28.19
$31.96
$31.63
$18.62
$18.45
$37.29
$36.92
$28.52
$28.23
$31.19
$30.87
$37.29
$36.92
$32.33
$32.00
$32.72
$32.38
$81.72
$80.89
$25.71
$25.45
$26.90
$26.63
$12.44
$12.32
$46.44
$45.95
$29.29
$29.00
$55.10
$54.54
$32.25
$31.92
Page 318 of 323
Notes
#
#
#
#
#
#
#
#
#
#
#
#
#
Procedure
Code
97610
97610
97750
97755
97760
97761
97762
97802
97802
97803
97803
97804
97804
98925
98925
98926
98926
98927
98927
98928
98928
98929
98929
98940
98940
98941
98941
98942
98942
99170
99170
99175
99183
1/2/2015
Modifier
Par Fee
$122.33
$17.93
$33.16
$36.02
$38.17
$33.16
$48.22
$34.95
$32.81
$29.99
$27.49
$16.05
$15.33
$31.38
$23.87
$45.63
$35.98
$59.53
$47.74
$73.08
$60.21
$87.34
$72.32
$28.20
$22.48
$41.03
$34.95
$53.50
$47.06
$160.81
$81.44
$17.12
$111.48
Nonpar Fee
$116.21
$17.03
$31.50
$34.22
$36.26
$31.50
$45.81
$33.20
$31.17
$28.49
$26.12
$15.25
$14.56
$29.81
$22.68
$43.35
$34.18
$56.55
$45.35
$69.43
$57.20
$82.97
$68.70
$26.79
$21.36
$38.98
$33.20
$50.83
$44.71
$152.77
$77.37
$16.26
$105.91
Limiting
Charge
$133.64
$19.58
$36.23
$39.35
$41.70
$36.23
$52.68
$38.18
$35.85
$32.76
$30.04
$17.54
$16.74
$34.28
$26.08
$49.85
$39.31
$65.03
$52.15
$79.84
$65.78
$95.42
$79.01
$30.81
$24.56
$44.83
$38.18
$58.45
$51.42
$175.69
$88.98
$18.70
$121.80
Charge**
Charge***
$132.31
$131.64
$19.39
$19.29
$35.87
$35.68
$38.96
$38.77
$41.29
$41.08
$35.87
$35.68
$52.15
$51.89
$37.80
$37.61
$35.49
$35.31
$32.44
$32.27
$29.74
$29.59
$17.37
$17.27
$16.57
$16.49
$33.94
$33.76
$25.82
$25.69
$49.36
$49.11
$38.92
$38.72
$64.38
$64.06
$51.64
$51.37
$79.05
$78.65
$65.12
$64.79
$94.46
$93.99
$78.21
$77.82
$30.50
$30.35
$24.32
$24.20
$44.38
$44.16
$37.80
$37.61
$57.87
$57.58
$50.90
$50.65
$173.93
$173.05
$88.09
$87.64
$18.52
$18.42
$120.58
$119.97
Arizona
EHR/eRx
Limiting
Charge**
$130.97
$19.19
$35.50
$38.57
$40.86
$35.50
$51.62
$37.42
$35.13
$32.11
$29.44
$17.19
$16.41
$33.59
$25.56
$48.85
$38.53
$63.73
$51.11
$78.25
$64.47
$93.51
$77.43
$30.19
$24.07
$43.93
$37.42
$57.28
$50.39
$172.17
$87.19
$18.32
$119.36
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$130.32
$129.01
$19.10
$18.91
$35.33
$34.97
$38.38
$38.00
$40.66
$40.25
$35.33
$34.97
$51.37
$50.85
$37.24
$36.86
$34.96
$34.60
$31.96
$31.63
$29.29
$29.00
$17.10
$16.94
$16.32
$16.17
$33.43
$33.09
$25.43
$25.19
$48.62
$48.12
$38.33
$37.95
$63.41
$62.78
$50.86
$50.34
$77.87
$77.07
$64.15
$63.50
$93.05
$92.10
$77.04
$76.27
$30.04
$29.74
$23.95
$23.71
$43.71
$43.27
$37.24
$36.86
$57.01
$56.42
$50.14
$49.63
$171.32
$169.58
$86.77
$85.88
$18.24
$18.04
$118.77
$117.56
Page 319 of 323
Notes
#
#
#
#
#
#
#
#
#
#
Procedure
Code
99184
99195
99201
99201
99202
99202
99203
99203
99204
99204
99205
99205
99211
99211
99212
99212
99213
99213
99214
99214
99215
99215
99217
99218
99219
99220
99221
99222
99223
99224
99225
99226
99231
1/2/2015
Modifier
Par Fee
$234.94
$100.92
$43.80
$26.64
$74.78
$50.11
$108.39
$76.93
$164.93
$130.25
$207.17
$169.27
$19.98
$9.25
$43.80
$25.57
$72.68
$50.87
$107.90
$78.58
$145.53
$111.57
$72.90
$100.48
$136.15
$186.57
$101.78
$137.45
$203.56
$39.47
$72.90
$105.58
$39.11
Nonpar Fee
$223.19
$95.87
$41.61
$25.31
$71.04
$47.60
$102.97
$73.08
$156.68
$123.74
$196.81
$160.81
$18.98
$8.79
$41.61
$24.29
$69.05
$48.33
$102.51
$74.65
$138.25
$105.99
$69.26
$95.46
$129.34
$177.24
$96.69
$130.58
$193.38
$37.50
$69.26
$100.30
$37.15
Limiting
Charge
$256.67
$110.25
$47.85
$29.11
$81.70
$54.74
$118.42
$84.04
$180.18
$142.30
$226.33
$184.93
$21.83
$10.11
$47.85
$27.93
$79.41
$55.58
$117.89
$85.85
$158.99
$121.89
$79.65
$109.78
$148.74
$203.83
$111.19
$150.17
$222.39
$43.13
$79.65
$115.35
$42.72
Charge**
Charge***
$254.10
$252.82
$109.15
$108.59
$47.37
$47.14
$28.82
$28.67
$80.88
$80.47
$54.19
$53.92
$117.23
$116.64
$83.20
$82.78
$178.38
$177.48
$140.88
$140.16
$224.07
$222.94
$183.08
$182.16
$21.61
$21.51
$10.01
$9.96
$47.37
$47.14
$27.66
$27.52
$78.61
$78.21
$55.03
$54.75
$116.70
$116.12
$84.99
$84.56
$157.40
$156.61
$120.67
$120.06
$78.86
$78.45
$108.69
$108.13
$147.26
$146.51
$201.79
$200.77
$110.08
$109.53
$148.66
$147.91
$220.17
$219.05
$42.70
$42.48
$78.86
$78.45
$114.20
$113.62
$42.30
$42.08
Arizona
EHR/eRx
Limiting
Charge**
$251.54
$108.04
$46.90
$28.52
$80.06
$53.65
$116.05
$82.36
$176.58
$139.46
$221.80
$181.23
$21.39
$9.90
$46.90
$27.37
$77.82
$54.46
$115.53
$84.13
$155.81
$119.45
$78.05
$107.58
$145.76
$199.76
$108.97
$147.17
$217.94
$42.26
$78.05
$113.03
$41.87
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$250.30
$247.77
$107.51
$106.42
$46.66
$46.20
$28.38
$28.09
$79.67
$78.87
$53.37
$52.84
$115.47
$114.31
$81.95
$81.13
$175.70
$173.94
$138.76
$137.37
$220.71
$218.48
$180.33
$178.51
$21.29
$21.07
$9.86
$9.75
$46.66
$46.20
$27.24
$26.96
$77.43
$76.65
$54.20
$53.65
$114.95
$113.79
$83.71
$82.87
$155.04
$153.48
$118.86
$117.66
$77.67
$76.88
$107.05
$105.97
$145.05
$143.58
$198.77
$196.75
$108.42
$107.34
$146.43
$144.96
$216.87
$214.67
$42.06
$41.63
$77.67
$76.88
$112.48
$111.34
$41.66
$41.24
Page 320 of 323
Notes
#
#
Procedure
Code
99232
99233
99234
99235
99236
99238
99239
99281
99282
99283
99284
99285
99291
99291
99292
99292
99304
99305
99306
99307
99308
99309
99310
99315
99316
99318
99324
99325
99326
99327
99328
99334
99335
1/2/2015
Modifier
Par Fee
$72.54
$104.50
$134.23
$169.54
$218.57
$73.26
$107.81
$20.96
$41.17
$62.04
$118.01
$174.60
$276.05
$224.57
$122.88
$112.15
$91.76
$130.92
$166.85
$44.52
$68.74
$91.14
$135.57
$72.99
$105.35
$96.10
$55.16
$80.37
$139.10
$185.72
$217.32
$60.16
$95.03
Nonpar Fee
$68.91
$99.28
$127.52
$161.06
$207.64
$69.60
$102.42
$19.91
$39.11
$58.94
$112.11
$165.87
$262.25
$213.34
$116.74
$106.54
$87.17
$124.37
$158.51
$42.29
$65.30
$86.58
$128.79
$69.34
$100.08
$91.30
$52.40
$76.35
$132.15
$176.43
$206.45
$57.15
$90.28
Limiting
Charge
$79.25
$114.17
$146.65
$185.22
$238.79
$80.04
$117.78
$22.90
$44.98
$67.78
$128.93
$190.75
$301.59
$245.34
$134.25
$122.52
$100.25
$143.03
$182.29
$48.63
$75.10
$99.57
$148.11
$79.74
$115.09
$105.00
$60.26
$87.80
$151.97
$202.89
$237.42
$65.72
$103.82
Charge**
Charge***
$78.45
$78.06
$113.03
$112.46
$145.18
$144.45
$183.37
$182.44
$236.39
$235.21
$79.24
$78.84
$116.61
$116.01
$22.67
$22.55
$44.53
$44.30
$67.10
$66.77
$127.64
$126.99
$188.84
$187.89
$298.57
$297.07
$242.89
$241.66
$132.91
$132.24
$121.29
$120.68
$99.25
$98.74
$141.60
$140.88
$180.46
$179.55
$48.15
$47.91
$74.35
$73.97
$98.57
$98.07
$146.63
$145.89
$78.95
$78.55
$113.94
$113.37
$103.95
$103.42
$59.66
$59.35
$86.93
$86.48
$150.45
$149.70
$200.87
$199.85
$235.05
$233.85
$65.07
$64.73
$102.79
$102.27
Arizona
EHR/eRx
Limiting
Charge**
$77.66
$111.88
$143.72
$181.52
$234.01
$78.44
$115.43
$22.44
$44.08
$66.42
$126.35
$186.93
$295.56
$240.43
$131.57
$120.07
$98.24
$140.16
$178.64
$47.66
$73.59
$97.58
$145.14
$78.14
$112.79
$102.89
$59.05
$86.04
$148.94
$198.84
$232.67
$64.41
$101.74
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$77.28
$76.50
$111.34
$110.20
$143.00
$141.57
$180.62
$178.79
$232.85
$230.51
$78.05
$77.27
$114.86
$113.69
$22.32
$22.10
$43.86
$43.42
$66.09
$65.42
$125.73
$124.45
$186.01
$184.13
$294.10
$291.12
$239.25
$236.82
$130.92
$129.59
$119.47
$118.27
$97.76
$96.77
$139.47
$138.06
$177.76
$175.96
$47.43
$46.94
$73.23
$72.48
$97.08
$96.12
$144.43
$142.97
$77.76
$76.97
$112.23
$111.10
$102.38
$101.35
$58.77
$58.17
$85.63
$84.76
$148.20
$146.71
$197.86
$195.86
$231.52
$229.18
$64.09
$63.45
$101.25
$100.21
Page 321 of 323
Notes
#
#
#
#
#
Procedure
Code
99336
99337
99341
99342
99343
99344
99345
99347
99348
99349
99350
99354
99354
99355
99355
99356
99357
99406
99406
99407
99407
99460
99461
99461
99462
99463
99464
99465
99466
99467
99468
99469
99471
1/2/2015
Modifier
Par Fee
$134.49
$192.51
$54.80
$79.61
$129.76
$182.10
$220.49
$55.51
$83.94
$128.06
$177.13
$99.94
$92.79
$97.08
$89.57
$92.12
$91.09
$14.21
$12.43
$27.40
$25.61
$99.63
$90.15
$62.98
$41.66
$120.19
$74.69
$151.21
$247.04
$124.04
$920.09
$398.70
$873.01
Nonpar Fee
$127.77
$182.88
$52.06
$75.63
$123.27
$173.00
$209.47
$52.73
$79.74
$121.66
$168.27
$94.94
$88.15
$92.23
$85.09
$87.51
$86.54
$13.50
$11.81
$26.03
$24.33
$94.65
$85.64
$59.83
$39.58
$114.18
$70.96
$143.65
$234.69
$117.84
$874.09
$378.77
$829.36
Limiting
Charge
$146.94
$210.31
$59.87
$86.97
$141.76
$198.95
$240.89
$60.64
$91.70
$139.91
$193.51
$109.18
$101.37
$106.06
$97.85
$100.64
$99.52
$15.53
$13.58
$29.93
$27.98
$108.85
$98.49
$68.80
$45.52
$131.31
$81.60
$165.20
$269.89
$135.52
$1,005.20
$435.59
$953.76
Charge**
Charge***
$145.46
$144.73
$208.21
$207.16
$59.27
$58.97
$86.10
$85.68
$140.35
$139.63
$196.96
$195.97
$238.49
$237.28
$60.03
$59.73
$90.78
$90.32
$138.51
$137.82
$191.58
$190.61
$108.09
$107.55
$100.36
$99.85
$105.01
$104.48
$96.88
$96.38
$99.62
$99.13
$98.52
$98.03
$15.38
$15.30
$13.44
$13.37
$29.64
$29.49
$27.70
$27.57
$107.76
$107.21
$97.50
$97.01
$68.11
$67.77
$45.06
$44.84
$130.00
$129.34
$80.79
$80.39
$163.54
$162.73
$267.19
$265.85
$134.16
$133.48
$995.15
$990.13
$431.23
$429.05
$944.23
$939.46
Arizona
EHR/eRx
Limiting
Charge**
$143.99
$206.10
$58.67
$85.24
$138.92
$194.97
$236.07
$59.43
$89.87
$137.11
$189.64
$107.00
$99.35
$103.95
$95.90
$98.62
$97.53
$15.21
$13.31
$29.34
$27.42
$106.67
$96.52
$67.42
$44.61
$128.69
$79.97
$161.90
$264.50
$132.80
$985.10
$426.87
$934.69
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$143.28
$141.83
$205.08
$203.01
$58.39
$57.79
$84.81
$83.96
$138.24
$136.84
$194.01
$192.05
$234.91
$232.53
$59.13
$58.54
$89.42
$88.53
$136.42
$135.06
$188.70
$186.79
$106.47
$105.39
$98.85
$97.85
$103.43
$102.38
$95.43
$94.46
$98.13
$97.14
$97.04
$96.07
$15.15
$14.98
$13.24
$13.11
$29.19
$28.90
$27.29
$27.00
$106.13
$105.08
$96.04
$95.07
$67.09
$66.41
$44.38
$43.94
$128.04
$126.75
$79.58
$78.78
$161.09
$159.47
$263.18
$260.53
$132.15
$130.81
$980.23
$970.32
$424.76
$420.46
$930.06
$920.67
Page 322 of 323
Notes
#
#
#
Procedure
Code
99472
99475
99476
99477
99478
99479
99480
99490
99490
99495
99495
99496
99496
1/2/2015
Modifier
Par Fee
$408.99
$577.41
$347.88
$361.47
$141.83
$124.84
$119.83
$42.69
$32.67
$164.93
$111.30
$231.57
$160.42
Nonpar Fee
$388.54
$548.54
$330.49
$343.40
$134.74
$118.60
$113.84
$40.56
$31.04
$156.68
$105.74
$219.99
$152.40
Limiting
Charge
$446.82
$630.82
$380.06
$394.91
$154.95
$136.39
$130.92
$46.64
$35.70
$180.18
$121.60
$252.99
$175.26
Charge**
Charge***
$442.35
$440.12
$624.51
$621.36
$376.27
$374.36
$390.97
$388.99
$153.40
$152.63
$135.02
$134.34
$129.61
$128.95
$46.17
$45.94
$35.34
$35.16
$178.38
$177.48
$120.38
$119.77
$250.46
$249.19
$173.51
$172.63
Arizona
EHR/eRx
Limiting
Charge**
$437.89
$618.21
$372.46
$387.01
$151.86
$133.66
$128.29
$45.71
$34.98
$176.58
$119.17
$247.93
$171.75
EHR + PQRS
EHR/eRx +
Charge****
Charge****
$435.71
$431.32
$615.14
$608.94
$370.62
$366.87
$385.10
$381.20
$151.10
$149.58
$133.00
$131.66
$127.66
$126.37
$45.48
$45.02
$34.81
$34.45
$175.70
$173.94
$118.58
$117.39
$246.70
$244.21
$170.91
$169.18
Page 323 of 323

Arizona, Area 00, 2015 Medicare Part B Fee Schedule

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