Arizona, Area 00, 2015 Medicare Part B Fee Schedule
Transcription
Arizona, Area 00, 2015 Medicare Part B Fee Schedule
NOTE: Should you have landed here as a result of a search engine (or other) link, be advised that these files contain material that is copyrighted by the American Medical Association. You are forbidden to download the files unless you read, agree to, and abide by the provisions of the copyright statement. 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 # # # 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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 # - 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 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 EHR Limiting PQRS Limiting 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 + Limiting PQRS Limiting 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