appendix b for administrative order no. 18-053 physician ...appendix b for administrative order no....

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040 Effective April 1, 2018 Link to medical fee and payment rules HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days 10021 $329.30 $188.85 N/A 11446 $1,057.19 $886.37 010 10022 $379.60 $178.41 N/A 11450 $924.96 $614.95 090 10030 $1,522.20 $377.70 000 11451 $1,170.94 $786.80 090 10035 $1,395.98 $236.30 000 11462 $903.05 $587.15 090 10036 $1,224.21 $116.73 ZZZ 11463 $1,183.57 $791.01 090 10040 $297.04 $194.55 010 11470 $995.72 $681.50 090 10060 $320.76 $264.77 010 11471 $1,231.59 $848.30 090 10061 $557.06 $487.79 010 11600 $523.85 $326.46 010 10080 $485.89 $279.01 010 11601 $619.70 $406.17 010 10081 $728.83 $462.16 010 11602 $671.89 $446.98 010 10120 $415.66 $281.85 010 11603 $769.64 $536.19 010 10121 $743.07 $503.92 010 11604 $853.15 $589.33 010 10140 $445.08 $322.66 010 11606 $1,220.41 $876.88 010 10160 $352.08 $259.08 010 11620 $527.64 $330.25 010 10180 $669.99 $486.84 010 11621 $622.54 $409.02 010 11000 $148.04 $77.82 000 11622 $694.67 $467.86 010 11001 $57.89 $38.91 ZZZ 11623 $815.19 $580.79 010 11004 $1,583.88 $1,583.88 000 11624 $918.63 $657.66 010 11005 $2,148.54 $2,148.54 000 11626 $1,103.69 $803.80 010 11006 $1,939.76 $1,939.76 000 11640 $543.78 $341.64 010 11008 $755.40 $755.40 ZZZ 11641 $643.42 $426.10 010 11010 $1,369.41 $778.18 010 11642 $734.53 $502.02 010 11011 $1,469.05 $823.73 000 11643 $865.49 $629.19 010 11012 $1,921.73 $1,165.37 000 11644 $1,068.57 $780.08 010 11042 $317.92 $168.92 000 11646 $1,391.23 $1,079.96 010 11043 $619.70 $424.20 000 11719 $38.91 $20.88 000 11044 $848.41 $629.19 000 11720 $89.21 $39.86 000 11045 $111.98 $72.12 ZZZ 11721 $122.42 $67.38 000 11046 $198.34 $153.74 ZZZ 11730 $285.65 $150.89 000 11047 $335.95 $271.41 ZZZ 11732 $85.41 $48.40 ZZZ 11055 $130.01 $43.65 000 11740 $135.71 $89.21 000 11056 $158.48 $61.69 000 11750 $414.71 $276.16 010 11057 $179.36 $81.61 000 11755 $355.88 $209.73 000 11100 $284.70 $133.81 000 11760 $507.72 $309.37 010 11101 $88.26 $68.33 ZZZ 11762 $756.35 $498.23 010 11200 $242.00 $200.24 010 11765 $452.67 $254.33 010 11201 $52.20 $46.50 ZZZ 11770 $748.76 $503.92 010 11300 $264.77 $96.80 000 11771 $1,389.12 $1,056.37 090 11301 $324.56 $146.15 000 11772 $1,673.01 $1,394.17 090 11302 $382.45 $172.72 000 11900 $151.84 $85.41 000 11303 $422.31 $203.09 000 11901 $190.75 $132.86 000 11305 $267.62 $106.29 000 11920 $465.96 $311.27 000 11306 $330.25 $142.35 000 11921 $534.29 $364.42 000 11307 $391.94 $183.16 000 11922 $166.08 $81.61 ZZZ 11308 $409.02 $202.14 000 11950 $189.80 $129.06 000 11310 $308.43 $130.01 000 11951 $273.31 $195.49 000 11311 $301.78 $179.36 000 11952 $353.03 $263.82 000 11312 $434.64 $213.53 000 11954 $422.31 $308.43 000 11313 $503.92 $275.21 000 11960 $2,303.96 $2,303.96 090 11400 $339.74 $220.17 010 11970 $1,474.20 $1,474.20 090 11401 $405.22 $282.80 010 11971 $1,130.50 $769.11 090 11402 $451.72 $312.22 010 11976 $389.09 $255.28 000 11403 $521.95 $402.38 010 11980 $257.18 $153.74 000 11404 $591.23 $442.23 010 11981 $384.35 $227.76 N/A 11406 $853.15 $674.74 010 11982 $429.90 $272.36 N/A 11420 $332.15 $221.12 010 11983 $620.65 $484.94 N/A 11421 $425.15 $298.94 010 12001 $245.79 $120.52 000 11422 $478.30 $372.01 010 12002 $298.94 $159.43 000 11423 $544.73 $426.10 010 12004 $349.23 $198.34 000 11424 $632.98 $489.68 010 12005 $439.39 $258.13 000 11426 $907.24 $752.56 010 12006 $521.95 $316.97 000 11440 $367.26 $280.90 010 12007 $602.62 $398.58 000 11441 $455.52 $357.77 010 12011 $299.88 $149.94 000 11442 $509.61 $394.78 010 12013 $314.12 $157.53 000 11443 $605.46 $483.99 010 12014 $366.31 $203.09 000 11444 $761.10 $617.80 010 12015 $441.29 $255.28 000 Appendix B for Administrative Order No. 18-053 Physician Fee Schedule CPT only copyright 2017 American Medical Association. All rights reserved. *ZZZ means the code is related to another service that is always included in the global period of the other service Page 1 of 84

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Page 1: Appendix B for Administrative Order No. 18-053 Physician ...Appendix B for Administrative Order No. 18-053 Physician Fee Schedule Effective April 1, 2018 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days10021 $329.30 $188.85 N/A 11446 $1,057.19 $886.37 01010022 $379.60 $178.41 N/A 11450 $924.96 $614.95 09010030 $1,522.20 $377.70 000 11451 $1,170.94 $786.80 09010035 $1,395.98 $236.30 000 11462 $903.05 $587.15 09010036 $1,224.21 $116.73 ZZZ 11463 $1,183.57 $791.01 09010040 $297.04 $194.55 010 11470 $995.72 $681.50 09010060 $320.76 $264.77 010 11471 $1,231.59 $848.30 09010061 $557.06 $487.79 010 11600 $523.85 $326.46 01010080 $485.89 $279.01 010 11601 $619.70 $406.17 01010081 $728.83 $462.16 010 11602 $671.89 $446.98 01010120 $415.66 $281.85 010 11603 $769.64 $536.19 01010121 $743.07 $503.92 010 11604 $853.15 $589.33 01010140 $445.08 $322.66 010 11606 $1,220.41 $876.88 01010160 $352.08 $259.08 010 11620 $527.64 $330.25 01010180 $669.99 $486.84 010 11621 $622.54 $409.02 01011000 $148.04 $77.82 000 11622 $694.67 $467.86 01011001 $57.89 $38.91 ZZZ 11623 $815.19 $580.79 01011004 $1,583.88 $1,583.88 000 11624 $918.63 $657.66 01011005 $2,148.54 $2,148.54 000 11626 $1,103.69 $803.80 01011006 $1,939.76 $1,939.76 000 11640 $543.78 $341.64 01011008 $755.40 $755.40 ZZZ 11641 $643.42 $426.10 01011010 $1,369.41 $778.18 010 11642 $734.53 $502.02 01011011 $1,469.05 $823.73 000 11643 $865.49 $629.19 01011012 $1,921.73 $1,165.37 000 11644 $1,068.57 $780.08 01011042 $317.92 $168.92 000 11646 $1,391.23 $1,079.96 01011043 $619.70 $424.20 000 11719 $38.91 $20.88 00011044 $848.41 $629.19 000 11720 $89.21 $39.86 00011045 $111.98 $72.12 ZZZ 11721 $122.42 $67.38 00011046 $198.34 $153.74 ZZZ 11730 $285.65 $150.89 00011047 $335.95 $271.41 ZZZ 11732 $85.41 $48.40 ZZZ11055 $130.01 $43.65 000 11740 $135.71 $89.21 00011056 $158.48 $61.69 000 11750 $414.71 $276.16 01011057 $179.36 $81.61 000 11755 $355.88 $209.73 00011100 $284.70 $133.81 000 11760 $507.72 $309.37 01011101 $88.26 $68.33 ZZZ 11762 $756.35 $498.23 01011200 $242.00 $200.24 010 11765 $452.67 $254.33 01011201 $52.20 $46.50 ZZZ 11770 $748.76 $503.92 01011300 $264.77 $96.80 000 11771 $1,389.12 $1,056.37 09011301 $324.56 $146.15 000 11772 $1,673.01 $1,394.17 09011302 $382.45 $172.72 000 11900 $151.84 $85.41 00011303 $422.31 $203.09 000 11901 $190.75 $132.86 00011305 $267.62 $106.29 000 11920 $465.96 $311.27 00011306 $330.25 $142.35 000 11921 $534.29 $364.42 00011307 $391.94 $183.16 000 11922 $166.08 $81.61 ZZZ11308 $409.02 $202.14 000 11950 $189.80 $129.06 00011310 $308.43 $130.01 000 11951 $273.31 $195.49 00011311 $301.78 $179.36 000 11952 $353.03 $263.82 00011312 $434.64 $213.53 000 11954 $422.31 $308.43 00011313 $503.92 $275.21 000 11960 $2,303.96 $2,303.96 09011400 $339.74 $220.17 010 11970 $1,474.20 $1,474.20 09011401 $405.22 $282.80 010 11971 $1,130.50 $769.11 09011402 $451.72 $312.22 010 11976 $389.09 $255.28 00011403 $521.95 $402.38 010 11980 $257.18 $153.74 00011404 $591.23 $442.23 010 11981 $384.35 $227.76 N/A11406 $853.15 $674.74 010 11982 $429.90 $272.36 N/A11420 $332.15 $221.12 010 11983 $620.65 $484.94 N/A11421 $425.15 $298.94 010 12001 $245.79 $120.52 00011422 $478.30 $372.01 010 12002 $298.94 $159.43 00011423 $544.73 $426.10 010 12004 $349.23 $198.34 00011424 $632.98 $489.68 010 12005 $439.39 $258.13 00011426 $907.24 $752.56 010 12006 $521.95 $316.97 00011440 $367.26 $280.90 010 12007 $602.62 $398.58 00011441 $455.52 $357.77 010 12011 $299.88 $149.94 00011442 $509.61 $394.78 010 12013 $314.12 $157.53 00011443 $605.46 $483.99 010 12014 $366.31 $203.09 00011444 $761.10 $617.80 010 12015 $441.29 $255.28 000

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 1 of 84

Page 2: Appendix B for Administrative Order No. 18-053 Physician ...Appendix B for Administrative Order No. 18-053 Physician Fee Schedule Effective April 1, 2018 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

12016 $556.11 $347.33 000 15150 $1,678.06 $1,537.38 09012017 $416.61 $416.61 000 15151 $329.30 $303.68 ZZZ12018 $471.65 $471.65 000 15152 $428.00 $402.38 ZZZ12020 $759.20 $513.41 010 15155 $1,925.73 $1,779.15 09012021 $443.18 $376.75 010 15156 $441.29 $415.66 ZZZ12031 $643.42 $418.51 010 15157 $492.53 $454.57 ZZZ12032 $817.09 $532.39 010 15200 $1,999.86 $1,630.04 09012034 $846.51 $568.45 010 15201 $399.53 $216.37 ZZZ12035 $1,029.67 $656.71 010 15220 $1,851.60 $1,490.21 09012036 $1,144.49 $766.79 010 15221 $368.21 $195.49 ZZZ12037 $1,302.03 $897.75 010 15240 $2,240.78 $1,940.89 09012041 $642.47 $410.92 010 15241 $497.28 $302.73 ZZZ12042 $781.98 $547.57 010 15260 $2,432.85 $2,083.26 09012044 $973.67 $588.38 010 15261 $579.84 $381.50 ZZZ12045 $1,081.86 $735.48 010 15271 $382.45 $230.61 00012046 $1,300.13 $851.25 010 15272 $74.02 $48.40 ZZZ12047 $1,432.04 $950.90 010 15273 $815.19 $558.01 00012051 $698.46 $468.81 010 15274 $192.65 $126.22 ZZZ12052 $796.21 $558.01 010 15275 $404.27 $260.98 00012053 $934.77 $596.92 010 15276 $93.95 $69.28 ZZZ12054 $974.62 $608.31 010 15277 $892.06 $629.19 00012055 $1,259.32 $831.32 010 15278 $230.61 $158.48 ZZZ12056 $1,505.11 $1,050.54 010 15570 $2,196.98 $1,781.68 09012057 $1,597.17 $1,178.66 010 15572 $2,138.01 $1,807.79 09013100 $905.35 $563.71 010 15574 $2,184.34 $1,846.54 09013101 $1,069.52 $692.77 010 15576 $1,933.31 $1,621.62 09013102 $329.30 $204.04 ZZZ 15600 $776.69 $499.54 09013120 $947.10 $647.22 010 15610 $854.19 $582.94 09013121 $1,153.98 $731.68 010 15620 $1,046.26 $781.75 09013122 $359.67 $235.35 ZZZ 15630 $1,098.49 $834.82 09013131 $1,042.00 $685.18 010 15650 $1,208.00 $923.27 09013132 $1,286.84 $861.69 010 15730 $3,726.78 $2,225.62 09013133 $482.09 $359.67 ZZZ 15731 $2,692.31 $2,423.58 09013151 $1,139.75 $785.77 010 15733 $2,541.52 $2,541.52 09013152 $1,368.46 $952.80 010 15734 $3,669.49 $3,669.49 09013153 $522.90 $387.19 ZZZ 15736 $2,983.78 $2,983.78 09013160 $1,935.84 $1,935.84 090 15738 $3,207.86 $3,207.86 09014000 $1,493.58 $1,214.74 090 15740 $2,438.75 $2,057.14 09014001 $1,929.10 $1,590.45 090 15750 $2,213.83 $2,213.83 09014020 $1,670.48 $1,373.95 090 15756 $5,579.22 $5,579.22 09014021 $2,089.99 $1,740.40 090 15757 $5,485.71 $5,485.71 09014040 $1,828.01 $1,530.64 090 15758 $5,540.46 $5,540.46 09014041 $2,264.37 $1,886.13 090 15760 $2,042.82 $1,710.07 09014060 $1,865.07 $1,630.89 090 15770 $1,604.77 $1,604.77 09014061 $2,436.22 $2,017.55 090 15775 $819.94 $611.16 00014301 $2,585.33 $2,135.48 090 15776 $1,309.62 $969.88 00014302 $605.46 $605.46 ZZZ 15777 $593.13 $593.13 ZZZ14350 $1,657.00 $1,657.00 090 15780 $2,253.42 $1,725.24 09015002 $942.36 $619.70 000 15781 $1,335.20 $1,047.10 09015003 $204.98 $126.22 ZZZ 15782 $1,453.14 $1,046.26 09015004 $1,079.96 $733.58 000 15783 $1,167.57 $908.11 09015005 $337.84 $249.59 ZZZ 15786 $674.74 $375.80 01015040 $679.48 $345.44 000 15787 $134.76 $48.40 ZZZ15050 $1,345.31 $1,073.22 090 15788 $1,111.13 $595.58 09015100 $2,059.67 $1,729.45 090 15789 $1,340.26 $1,008.35 09015101 $501.07 $302.73 ZZZ 15792 $1,052.16 $620.85 09015110 $1,911.41 $1,669.64 090 15793 $1,186.10 $888.73 09015111 $320.76 $289.45 ZZZ 15819 $1,914.78 $1,914.78 09015115 $1,891.19 $1,653.63 090 15820 $1,341.94 $1,205.47 09015116 $460.27 $418.51 ZZZ 15821 $1,463.25 $1,310.77 09015120 $2,039.45 $1,685.64 090 15822 $1,073.22 $939.28 09015121 $560.86 $363.47 ZZZ 15823 $1,463.25 $1,309.09 09015130 $1,583.71 $1,340.26 090 15824 80% of billed 80% of billed 00015131 $272.36 $250.54 ZZZ 15825 80% of billed 80% of billed 00015135 $2,037.77 $1,793.47 090 15826 80% of billed 80% of billed 00015136 $269.52 $250.54 ZZZ 15828 80% of billed 80% of billed 000

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 2 of 84

Page 3: Appendix B for Administrative Order No. 18-053 Physician ...Appendix B for Administrative Order No. 18-053 Physician Fee Schedule Effective April 1, 2018 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

15829 80% of billed 80% of billed 000 17272 $504.87 $348.28 01015830 $2,846.47 $2,846.47 090 17273 $560.86 $393.84 01015832 $2,206.25 $2,206.25 090 17274 $663.35 $482.09 01015833 $2,107.68 $2,107.68 090 17276 $767.74 $576.99 01015834 $2,147.28 $2,147.28 090 17280 $382.45 $247.69 01015835 $2,267.74 $2,267.74 090 17281 $482.09 $340.69 01015836 $1,908.88 $1,908.88 090 17282 $552.32 $391.94 01015837 $2,081.57 $1,742.93 090 17283 $661.45 $490.63 01015838 $1,541.59 $1,541.59 090 17284 $757.30 $573.20 01015839 $2,119.48 $1,779.99 090 17286 $966.08 $765.84 01015840 $2,414.32 $2,414.32 090 17311 $1,786.02 $1,033.46 00015841 $4,315.62 $4,315.62 090 17312 $1,050.54 $551.37 ZZZ15842 $6,579.14 $6,579.14 090 17313 $1,670.24 $928.12 00015845 $2,419.37 $2,419.37 090 17314 $1,003.09 $512.46 ZZZ15847 80% of billed 80% of billed N/A 17315 $216.37 $145.20 ZZZ15850 $241.05 $112.93 N/A 17340 $142.35 $132.86 01015851 $268.57 $125.27 000 17360 $346.39 $266.67 01015852 $127.17 $127.17 000 17380 80% of billed 80% of billed 00015860 $296.09 $296.09 000 17999 80% of billed 80% of billed N/A15876 80% of billed 80% of billed 000 19000 $303.68 $119.57 00015877 80% of billed 80% of billed 000 19001 $73.07 $58.84 ZZZ15878 80% of billed 80% of billed 000 19020 $1,142.29 $743.84 09015879 80% of billed 80% of billed 000 19030 $444.13 $212.58 00015920 $1,465.78 $1,465.78 090 19081 $1,862.89 $460.27 00015922 $1,888.66 $1,888.66 090 19082 $1,538.33 $232.51 ZZZ15931 $1,667.11 $1,667.11 090 19083 $1,811.64 $432.74 00015933 $2,045.35 $2,045.35 090 19084 $1,476.64 $216.37 ZZZ15934 $2,264.37 $2,264.37 090 19085 $2,706.55 $502.02 00015935 $2,639.24 $2,639.24 090 19086 $2,193.14 $252.43 ZZZ15936 $2,152.33 $2,152.33 090 19100 $407.12 $191.70 00015937 $2,498.56 $2,498.56 090 19101 $924.33 $604.51 01015940 $1,686.48 $1,686.48 090 19105 $7,990.58 $581.74 00015941 $2,178.45 $2,178.45 090 19110 $1,173.46 $831.45 09015944 $2,145.59 $2,145.59 090 19112 $1,108.60 $756.48 09015945 $2,379.78 $2,379.78 090 19120 $1,192.84 $1,002.46 09015946 $3,951.70 $3,951.70 090 19125 $1,320.88 $1,111.97 09015950 $1,436.29 $1,436.29 090 19126 $443.18 $443.18 ZZZ15951 $2,122.85 $2,122.85 090 19260 $2,920.60 $2,920.60 09015952 $2,185.19 $2,185.19 090 19271 $3,939.90 $3,939.90 09015953 $2,404.21 $2,404.21 090 19272 $4,300.45 $4,300.45 09015956 $2,785.82 $2,785.82 090 19281 $648.17 $276.16 00015958 $2,848.15 $2,848.15 090 19282 $449.83 $138.55 ZZZ15999 80% of billed 80% of billed N/A 19283 $732.63 $278.06 00016000 $186.00 $126.22 000 19284 $551.37 $141.40 ZZZ16020 $223.02 $148.99 000 19285 $1,397.88 $237.25 00016025 $400.48 $304.63 000 19286 $1,223.26 $118.63 ZZZ16030 $506.77 $368.21 000 19287 $2,318.41 $352.08 00016035 $532.39 $532.39 000 19288 $1,873.33 $177.46 ZZZ16036 $223.96 $223.96 ZZZ 19294 $447.93 $447.93 ZZZ17000 $178.41 $143.30 010 19296 $10,738.88 $577.94 00017003 $14.24 $6.64 ZZZ 19297 $260.03 $260.03 ZZZ17004 $390.04 $270.47 010 19298 $2,701.80 $866.44 00017106 $826.39 $669.71 090 19300 $1,267.81 $1,004.14 09017107 $1,054.68 $845.77 090 19301 $1,581.18 $1,581.18 09017108 $1,551.70 $1,282.13 090 19302 $2,180.13 $2,180.13 09017110 $301.78 $189.80 010 19303 $2,327.55 $2,327.55 09017111 $356.82 $233.45 010 19304 $1,398.38 $1,398.38 09017250 $217.32 $101.54 000 19305 $2,740.33 $2,740.33 09017260 $258.13 $190.75 010 19306 $2,912.18 $2,912.18 09017261 $390.04 $249.59 010 19307 $2,902.91 $2,902.91 09017262 $474.50 $316.97 010 19316 $1,863.39 $1,863.39 09017263 $517.21 $351.13 010 19318 $2,667.04 $2,667.04 09017264 $555.17 $376.75 010 19324 $1,282.98 $1,282.98 09017266 $627.29 $439.39 010 19325 $1,553.39 $1,553.39 09017270 $409.02 $272.36 010 19328 $1,199.58 $1,199.58 09017271 $442.23 $301.78 010 19330 $1,534.85 $1,534.85 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 3 of 84

Page 4: Appendix B for Administrative Order No. 18-053 Physician ...Appendix B for Administrative Order No. 18-053 Physician Fee Schedule Effective April 1, 2018 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

19340 $2,426.95 $2,426.95 090 20805 $7,992.69 $7,992.69 09019342 $2,233.20 $2,233.20 090 20808 $9,661.49 $9,661.49 09019350 $1,985.54 $1,628.36 090 20816 $5,029.97 $5,029.97 09019355 $1,815.37 $1,503.68 090 20822 $4,320.67 $4,320.67 09019357 $3,645.06 $3,645.06 090 20824 $5,038.39 $5,038.39 09019361 $3,817.76 $3,817.76 090 20827 $4,436.08 $4,436.08 09019364 $6,687.81 $6,687.81 090 20838 $6,158.79 $6,158.79 09019366 $3,425.20 $3,425.20 090 20900 $1,128.36 $516.26 00019367 $4,346.78 $4,346.78 090 20902 $781.98 $781.98 00019368 $5,338.29 $5,338.29 090 20910 $1,132.19 $1,132.19 09019369 $4,954.15 $4,954.15 090 20912 $1,138.92 $1,138.92 09019370 $1,661.21 $1,661.21 090 20920 $956.12 $956.12 09019371 $1,897.08 $1,897.08 090 20922 $1,425.34 $1,184.41 09019380 $1,872.66 $1,872.66 090 20924 $1,228.22 $1,228.22 09019396 $790.52 $398.58 000 20926 $1,021.83 $1,021.83 09019499 80% of billed 80% of billed N/A 20930 80% of billed 80% of billed N/A20005 $853.15 $643.42 010 20931 $310.32 $310.32 ZZZ20100 $1,656.95 $1,656.95 010 20936 80% of billed 80% of billed N/A20101 $1,225.16 $573.20 010 20937 $465.01 $465.01 ZZZ20102 $1,328.60 $700.36 010 20938 $512.46 $512.46 ZZZ20103 $1,586.73 $952.80 010 20939 $184.11 $184.11 ZZZ20150 $2,453.07 $2,453.07 090 20950 $675.69 $247.69 00020200 $558.96 $260.03 000 20955 $6,014.74 $6,014.74 09020205 $784.82 $428.00 000 20956 $6,454.47 $6,454.47 09020206 $635.83 $161.33 000 20957 $6,710.56 $6,710.56 09020220 $452.67 $196.44 000 20962 $6,494.90 $6,494.90 09020225 $1,401.67 $293.24 000 20969 $6,649.06 $6,649.06 09020240 $415.66 $415.66 000 20970 $6,980.97 $6,980.97 09020245 $965.13 $965.13 000 20972 $6,968.33 $6,968.33 09020250 $1,062.88 $1,062.88 010 20973 $7,355.84 $7,355.84 09020251 $1,164.42 $1,164.42 010 20974 $208.78 $138.55 00020500 $284.70 $229.66 010 20975 $490.63 $490.63 00020501 $317.92 $103.44 000 20979 $139.50 $88.26 00020520 $555.17 $400.48 010 20982 $10,567.12 $1,002.14 00020525 $1,299.18 $675.69 010 20983 $16,194.69 $985.06 00020526 $209.73 $157.53 000 20985 $404.27 $404.27 ZZZ20527 $228.71 $181.26 000 20999 80% of billed 80% of billed N/A20550 $143.30 $107.24 000 21010 $1,849.07 $1,849.07 09020551 $164.18 $116.73 000 21011 $834.82 $625.90 09020552 $148.99 $103.44 000 21012 $822.18 $822.18 09020553 $171.77 $117.68 000 21013 $1,250.12 $971.29 09020555 $891.11 $891.11 000 21014 $1,266.13 $1,266.13 09020600 $130.01 $96.80 000 21015 $1,714.28 $1,714.28 09020604 $194.55 $126.22 000 21016 $2,456.44 $2,456.44 09020605 $136.66 $102.49 000 21025 $2,142.22 $1,814.53 09020606 $216.37 $145.20 000 21026 $1,483.47 $1,205.47 09020610 $163.23 $126.22 000 21029 $1,860.02 $1,548.33 09020611 $244.84 $167.02 000 21030 $1,251.81 $1,009.20 09020612 $163.23 $114.83 000 21031 $960.34 $716.88 09020615 $651.96 $439.39 010 21032 $967.92 $705.09 09020650 $574.15 $432.74 010 21034 $3,144.68 $2,776.55 09020660 $675.69 $675.69 000 21040 $1,260.23 $1,010.88 09020661 $1,220.64 $1,220.64 090 21044 $2,102.63 $2,102.63 09020662 $1,240.01 $1,240.01 090 21045 $2,953.45 $2,953.45 09020663 $1,137.24 $1,137.24 090 21046 $2,701.58 $2,701.58 09020664 $2,127.90 $2,127.90 090 21047 $3,173.32 $3,173.32 09020665 $291.34 $248.64 010 21048 $2,753.81 $2,753.81 09020670 $1,025.87 $399.53 010 21049 $2,891.96 $2,891.96 09020680 $1,489.36 $1,025.20 090 21050 $2,185.19 $2,185.19 09020690 $1,444.72 $1,444.72 090 21060 $1,986.38 $1,986.38 09020692 $2,710.84 $2,710.84 090 21070 $1,557.60 $1,557.60 09020693 $1,074.06 $1,074.06 090 21073 $929.17 $612.42 09020694 $1,026.89 $820.50 090 21076 $2,681.87 $2,251.03 01020696 $2,921.44 $2,921.44 090 21077 $5,991.99 $5,055.24 09020697 $5,736.71 $5,736.71 000 21079 $4,043.52 $3,373.81 09020802 $6,711.40 $6,711.40 090 21080 $4,553.17 $3,763.00 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 4 of 84

Page 5: Appendix B for Administrative Order No. 18-053 Physician ...Appendix B for Administrative Order No. 18-053 Physician Fee Schedule Effective April 1, 2018 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

21081 $4,187.57 $3,447.94 090 21260 $3,419.30 $3,419.30 09021082 $3,944.12 $3,223.02 090 21261 $6,045.90 $6,045.90 09021083 $3,758.79 $2,994.73 090 21263 $5,592.69 $5,592.69 09021084 $4,312.25 $3,464.79 090 21267 $4,003.08 $4,003.08 09021085 $2,040.35 $1,533.58 010 21268 $5,006.38 $5,006.38 09021086 $4,445.34 $3,730.15 090 21270 $2,460.65 $1,829.69 09021087 $4,452.08 $3,706.56 090 21275 $2,031.03 $2,031.03 09021088 80% of billed 80% of billed 090 21280 $1,375.64 $1,375.64 09021089 80% of billed 80% of billed N/A 21282 $920.74 $920.74 09021100 $1,740.40 $989.82 090 21295 $447.31 $447.31 09021110 $1,924.04 $1,612.35 090 21296 $994.03 $994.03 09021116 $444.13 $130.96 000 21299 80% of billed 80% of billed N/A21120 $1,657.84 $1,316.67 090 21310 $367.26 $74.02 00021121 $1,854.96 $1,585.40 090 21315 $738.32 $408.07 01021122 $1,924.88 $1,924.88 090 21320 $683.28 $362.52 01021123 $2,228.15 $2,228.15 090 21325 $1,127.13 $1,127.13 09021125 $7,111.54 $1,868.44 090 21330 $1,359.63 $1,359.63 09021127 $9,097.08 $2,153.17 090 21335 $1,729.45 $1,729.45 09021137 $1,824.64 $1,824.64 090 21336 $1,542.43 $1,542.43 09021138 $2,229.83 $2,229.83 090 21337 $966.23 $706.77 09021139 $2,732.75 $2,732.75 090 21338 $1,581.18 $1,581.18 09021141 $3,303.05 $3,303.05 090 21339 $1,796.00 $1,796.00 09021142 $3,395.71 $3,395.71 090 21340 $1,779.15 $1,779.15 09021143 $3,563.35 $3,563.35 090 21343 $2,578.59 $2,578.59 09021145 $3,876.72 $3,876.72 090 21344 $3,309.79 $3,309.79 09021146 $4,041.84 $4,041.84 090 21345 $1,849.07 $1,494.42 09021147 $4,260.86 $4,260.86 090 21346 $2,147.28 $2,147.28 09021150 $4,006.45 $4,006.45 090 21347 $2,415.16 $2,415.16 09021151 $4,292.03 $4,292.03 090 21348 $2,582.80 $2,582.80 09021154 $4,740.18 $4,740.18 090 21355 $1,141.65 $858.85 01021155 $5,257.42 $5,257.42 090 21356 $1,357.07 $1,025.87 01021159 $6,299.47 $6,299.47 090 21360 $1,297.30 $1,297.30 09021160 $6,831.02 $6,831.02 090 21365 $2,690.63 $2,690.63 09021172 $5,065.35 $5,065.35 090 21366 $3,094.98 $3,094.98 09021175 $5,368.62 $5,368.62 090 21385 $1,851.60 $1,851.60 09021179 $3,686.34 $3,686.34 090 21386 $1,689.85 $1,689.85 09021180 $4,130.29 $4,130.29 090 21387 $1,930.78 $1,930.78 09021181 $1,795.15 $1,795.15 090 21390 $1,924.04 $1,924.04 09021182 $5,163.07 $5,163.07 090 21395 $2,448.01 $2,448.01 09021183 $5,626.39 $5,626.39 090 21400 $464.16 $379.08 09021184 $6,059.38 $6,059.38 090 21401 $1,250.96 $778.38 09021188 $4,093.22 $4,093.22 090 21406 $1,390.80 $1,390.80 09021193 $3,101.72 $3,101.72 090 21407 $1,554.23 $1,554.23 09021194 $3,552.40 $3,552.40 090 21408 $2,184.34 $2,184.34 09021195 $3,481.64 $3,481.64 090 21421 $1,781.68 $1,505.37 09021196 $3,587.78 $3,587.78 090 21422 $1,626.67 $1,626.67 09021198 $2,831.31 $2,831.31 090 21423 $1,906.35 $1,906.35 09021199 $2,618.18 $2,618.18 090 21431 $1,739.56 $1,739.56 09021206 $2,907.96 $2,907.96 090 21432 $1,742.93 $1,742.93 09021208 $4,265.07 $2,018.39 090 21433 $4,227.16 $4,227.16 09021209 $2,138.01 $1,619.94 090 21435 $3,410.04 $3,410.04 09021210 $5,374.51 $2,070.62 090 21436 $4,961.74 $4,961.74 09021215 $9,369.17 $2,160.76 090 21440 $1,398.38 $1,134.71 09021230 $1,792.63 $1,792.63 090 21445 $1,870.97 $1,514.64 09021235 $1,737.87 $1,361.32 090 21450 $1,362.16 $1,117.86 09021240 $2,715.90 $2,715.90 090 21451 $1,809.48 $1,520.53 09021242 $2,519.62 $2,519.62 090 21452 $1,541.59 $902.21 09021243 $4,150.50 $4,150.50 090 21453 $2,201.19 $1,886.13 09021244 $2,555.84 $2,555.84 090 21454 $1,367.22 $1,367.22 09021245 $2,912.18 $2,314.92 090 21461 $5,147.06 $2,266.06 09021246 $2,138.85 $2,138.85 090 21462 $5,489.08 $2,533.94 09021247 $3,978.66 $3,978.66 090 21465 $2,255.10 $2,255.10 09021248 $2,664.51 $2,180.13 090 21470 $2,916.39 $2,916.39 09021249 $3,758.79 $3,091.61 090 21480 $267.62 $87.31 00021255 $3,453.84 $3,453.84 090 21485 $1,874.34 $1,539.06 09021256 $3,021.69 $3,021.69 090 21490 $2,225.62 $2,225.62 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 5 of 84

Page 6: Appendix B for Administrative Order No. 18-053 Physician ...Appendix B for Administrative Order No. 18-053 Physician Fee Schedule Effective April 1, 2018 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

21497 $1,619.94 $1,367.22 090 22318 $4,010.67 $4,010.67 09021499 80% of billed 80% of billed N/A 22319 $4,501.79 $4,501.79 09021501 $1,090.07 $776.69 090 22325 $3,519.55 $3,519.55 09021502 $1,221.48 $1,221.48 090 22326 $3,656.86 $3,656.86 09021510 $1,070.69 $1,070.69 090 22327 $3,673.71 $3,673.71 09021550 $708.90 $428.95 010 22328 $782.93 $782.93 ZZZ21552 $1,084.17 $1,084.17 090 22505 $361.57 $361.57 01021554 $1,773.25 $1,773.25 090 22510 $4,554.25 $1,194.79 01021555 $1,000.77 $739.63 090 22511 $4,496.36 $1,116.97 01021556 $1,274.55 $1,274.55 090 22512 $2,579.38 $571.30 ZZZ21557 $2,309.02 $2,309.02 090 22513 $19,317.84 $1,427.30 01021558 $3,257.56 $3,257.56 090 22514 $19,226.74 $1,328.60 01021600 $1,339.42 $1,339.42 090 22515 $11,639.49 $615.90 ZZZ21610 $2,952.61 $2,952.61 090 22526 $6,319.39 $925.28 01021615 $1,496.10 $1,496.10 090 22527 $5,338.13 $437.49 ZZZ21616 $1,740.40 $1,740.40 090 22532 $4,388.06 $4,388.06 09021620 $1,223.16 $1,223.16 090 22533 $4,055.31 $4,055.31 09021627 $1,306.56 $1,306.56 090 22534 $999.30 $999.30 ZZZ21630 $2,979.57 $2,979.57 090 22548 $4,834.53 $4,834.53 09021632 $2,932.39 $2,932.39 090 22551 $4,187.57 $4,187.57 09021685 $2,367.14 $2,367.14 090 22552 $1,104.64 $1,104.64 ZZZ21700 $875.25 $875.25 090 22554 $3,066.34 $3,066.34 09021705 $1,308.25 $1,308.25 090 22556 $4,083.11 $4,083.11 09021720 $1,277.92 $1,277.92 090 22558 $3,752.05 $3,752.05 09021725 $1,312.46 $1,312.46 090 22585 $909.14 $909.14 ZZZ21740 $2,513.72 $2,513.72 090 22586 $4,910.35 $4,910.35 09021742 80% of billed 80% of billed 090 22590 $3,868.30 $3,868.30 09021743 80% of billed 80% of billed 090 22595 $3,692.24 $3,692.24 09021750 $1,660.37 $1,660.37 090 22600 $3,154.79 $3,154.79 09021811 $1,638.92 $1,638.92 000 22610 $3,092.45 $3,092.45 09021812 $1,995.75 $1,995.75 000 22612 $3,883.46 $3,883.46 09021813 $2,719.83 $2,719.83 000 22614 $1,084.71 $1,084.71 ZZZ21820 $342.86 $347.91 090 22630 $3,854.82 $3,854.82 09021825 $1,306.56 $1,306.56 090 22632 $893.96 $893.96 ZZZ21899 80% of billed 80% of billed N/A 22633 $4,538.01 $4,538.01 09021920 $696.57 $435.59 010 22634 $1,376.05 $1,376.05 ZZZ21925 $1,084.17 $861.78 090 22800 $3,301.37 $3,301.37 09021930 $1,143.98 $885.36 090 22802 $5,150.43 $5,150.43 09021931 $1,142.29 $1,142.29 090 22804 $5,937.24 $5,937.24 09021932 $1,607.30 $1,607.30 090 22808 $4,544.75 $4,544.75 09021933 $1,792.63 $1,792.63 090 22810 $4,822.74 $4,822.74 09021935 $2,494.35 $2,494.35 090 22812 $5,398.10 $5,398.10 09021936 $3,445.42 $3,445.42 090 22818 $5,303.75 $5,303.75 09022010 $2,319.97 $2,319.97 090 22819 $6,096.45 $6,096.45 09022015 $2,301.44 $2,301.44 090 22830 $1,988.06 $1,988.06 09022100 $2,211.30 $2,211.30 090 22840 $2,108.68 $2,108.68 ZZZ22101 $2,195.29 $2,195.29 090 22841 80% of billed 80% of billed N/A22102 $1,931.62 $1,931.62 090 22842 $2,117.22 $2,117.22 ZZZ22103 $389.09 $389.09 ZZZ 22843 $2,265.26 $2,265.26 ZZZ22110 $2,544.05 $2,544.05 090 22844 $2,735.97 $2,735.97 ZZZ22112 $2,749.59 $2,749.59 090 22845 $2,026.12 $2,026.12 ZZZ22114 $2,749.59 $2,749.59 090 22846 $2,102.98 $2,102.98 ZZZ22116 $391.94 $391.94 ZZZ 22847 $2,234.90 $2,234.90 ZZZ22206 $5,972.62 $5,972.62 090 22848 $997.40 $997.40 ZZZ22207 $5,879.11 $5,879.11 090 22849 $3,178.38 $3,178.38 09022208 $1,644.62 $1,644.62 ZZZ 22850 $1,765.67 $1,765.67 09022210 $4,382.16 $4,382.16 090 22852 $1,694.91 $1,694.91 09022212 $3,630.74 $3,630.74 090 22853 $691.82 $691.82 ZZZ22214 $3,640.01 $3,640.01 090 22854 $894.91 $894.91 ZZZ22216 $1,006.89 $1,006.89 ZZZ 22855 $2,709.16 $2,709.16 09022220 $3,917.16 $3,917.16 090 22856 $4,007.30 $4,007.30 09022222 $4,287.82 $4,287.82 090 22857 $4,137.03 $4,137.03 09022224 $3,868.30 $3,868.30 090 22858 $1,417.81 $1,417.81 ZZZ22226 $1,004.99 $1,004.99 ZZZ 22859 $894.91 $894.91 ZZZ22310 $748.05 $687.40 090 22861 $5,740.96 $5,740.96 09022315 $2,142.22 $1,871.81 090 22862 $5,714.00 $5,714.00 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 6 of 84

Page 7: Appendix B for Administrative Order No. 18-053 Physician ...Appendix B for Administrative Order No. 18-053 Physician Fee Schedule Effective April 1, 2018 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

22864 $5,120.95 $5,120.95 090 23415 $1,689.01 $1,689.01 09022865 $4,977.74 $4,977.74 090 23420 $2,351.98 $2,351.98 09022867 $2,275.32 $2,275.32 090 23430 $1,802.74 $1,802.74 09022868 $652.91 $652.91 ZZZ 23440 $1,827.17 $1,827.17 09022869 $1,291.40 $1,291.40 090 23450 $2,304.81 $2,304.81 09022870 $375.80 $375.80 ZZZ 23455 $2,419.37 $2,419.37 09022899 80% of billed 80% of billed N/A 23460 $2,649.35 $2,649.35 09022900 $1,371.43 $1,371.43 090 23462 $2,586.17 $2,586.17 09022901 $1,619.09 $1,619.09 090 23465 $2,718.42 $2,718.42 09022902 $1,058.90 $801.96 090 23466 $2,732.75 $2,732.75 09022903 $1,067.32 $1,067.32 090 23470 $2,913.02 $2,913.02 09022904 $2,555.00 $2,555.00 090 23472 $3,538.92 $3,538.92 09022905 $3,243.24 $3,243.24 090 23473 $3,950.01 $3,950.01 09022999 80% of billed 80% of billed N/A 23474 $4,265.91 $4,265.91 09023000 $1,400.91 $894.63 090 23480 $1,993.96 $1,993.96 09023020 $1,671.32 $1,671.32 090 23485 $2,308.18 $2,308.18 09023030 $1,214.72 $703.21 010 23490 $2,094.21 $2,094.21 09023031 $1,135.00 $590.28 010 23491 $2,464.86 $2,464.86 09023035 $1,646.89 $1,646.89 090 23500 $528.18 $534.08 09023040 $1,737.87 $1,737.87 090 23505 $850.82 $799.44 09023044 $1,372.27 $1,372.27 090 23515 $1,743.77 $1,743.77 09023065 $591.23 $457.42 010 23520 $561.04 $566.94 09023066 $1,348.68 $866.83 090 23525 $931.69 $860.09 09023071 $1,020.15 $1,020.15 090 23530 $1,387.43 $1,387.43 09023073 $1,686.48 $1,686.48 090 23532 $1,513.79 $1,513.79 09023075 $1,138.92 $794.38 090 23540 $543.35 $549.24 09023076 $1,309.93 $1,309.93 090 23545 $825.55 $747.21 09023077 $2,770.65 $2,770.65 090 23550 $1,361.32 $1,361.32 09023078 $3,495.96 $3,495.96 090 23552 $1,584.55 $1,584.55 09023100 $1,214.74 $1,214.74 090 23570 $561.88 $576.20 09023101 $1,106.07 $1,106.07 090 23575 $971.29 $908.11 09023105 $1,547.49 $1,547.49 090 23585 $2,377.25 $2,377.25 09023106 $1,203.79 $1,203.79 090 23600 $788.49 $740.47 09023107 $1,603.09 $1,603.09 090 23605 $1,117.86 $1,020.99 09023120 $1,415.23 $1,415.23 090 23615 $2,145.59 $2,145.59 09023125 $1,721.02 $1,721.02 090 23616 $3,011.58 $3,011.58 09023130 $1,477.57 $1,477.57 090 23620 $650.33 $616.64 09023140 $1,294.77 $1,294.77 090 23625 $912.32 $844.93 09023145 $1,685.64 $1,685.64 090 23630 $1,889.50 $1,889.50 09023146 $1,506.21 $1,506.21 090 23650 $759.84 $694.14 09023150 $1,608.14 $1,608.14 090 23655 $970.44 $970.44 09023155 $1,924.88 $1,924.88 090 23660 $1,411.86 $1,411.86 09023156 $1,643.52 $1,643.52 090 23665 $1,026.04 $952.75 09023170 $1,359.63 $1,359.63 090 23670 $2,120.32 $2,120.32 09023172 $1,373.11 $1,373.11 090 23675 $1,323.41 $1,202.10 09023174 $1,838.96 $1,838.96 090 23680 $2,254.26 $2,254.26 09023180 $1,586.24 $1,586.24 090 23700 $536.19 $536.19 01023182 $1,588.77 $1,588.77 090 23800 $2,491.82 $2,491.82 09023184 $1,769.04 $1,769.04 090 23802 $3,122.78 $3,122.78 09023190 $1,386.59 $1,386.59 090 23900 $3,378.02 $3,378.02 09023195 $1,833.90 $1,833.90 090 23920 $2,742.01 $2,742.01 09023200 $3,691.40 $3,691.40 090 23921 $1,133.87 $1,133.87 09023210 $4,338.36 $4,338.36 090 23929 80% of billed 80% of billed N/A23220 $4,765.46 $4,765.46 090 23930 $974.62 $593.13 01023330 $743.07 $454.57 010 23931 $785.77 $435.59 01023333 $1,127.97 $1,127.97 090 23935 $1,222.32 $1,222.32 09023334 $2,613.12 $2,613.12 090 24000 $1,154.09 $1,154.09 09023335 $3,110.98 $3,110.98 090 24006 $1,721.02 $1,721.02 09023350 $351.13 $139.50 000 24065 $697.52 $456.47 01023395 $3,111.83 $3,111.83 090 24066 $1,497.79 $1,002.46 09023397 $2,759.70 $2,759.70 090 24071 $987.29 $987.29 09023400 $2,358.72 $2,358.72 090 24073 $1,683.96 $1,683.96 09023405 $1,500.31 $1,500.31 090 24075 $1,186.10 $801.12 09023406 $1,866.76 $1,866.76 090 24076 $1,320.04 $1,320.04 09023410 $1,991.43 $1,991.43 090 24077 $2,517.93 $2,517.93 09023412 $2,066.41 $2,066.41 090 24079 $3,230.60 $3,230.60 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 7 of 84

Page 8: Appendix B for Administrative Order No. 18-053 Physician ...Appendix B for Administrative Order No. 18-053 Physician Fee Schedule Effective April 1, 2018 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

24100 $1,011.72 $1,011.72 090 24538 $1,802.74 $1,802.74 09024101 $1,208.00 $1,208.00 090 24545 $2,255.95 $2,255.95 09024102 $1,491.05 $1,491.05 090 24546 $2,522.15 $2,522.15 09024105 $848.30 $848.30 090 24560 $775.85 $692.45 09024110 $1,421.13 $1,421.13 090 24565 $1,290.56 $1,182.73 09024115 $1,789.26 $1,789.26 090 24566 $1,737.87 $1,737.87 09024116 $2,093.36 $2,093.36 090 24575 $1,779.15 $1,779.15 09024120 $1,283.82 $1,283.82 090 24576 $822.18 $735.42 09024125 $1,504.53 $1,504.53 090 24577 $1,330.15 $1,216.43 09024126 $1,574.45 $1,574.45 090 24579 $2,025.97 $2,025.97 09024130 $1,230.75 $1,230.75 090 24582 $1,960.26 $1,960.26 09024134 $1,813.69 $1,813.69 090 24586 $2,631.66 $2,631.66 09024136 $1,529.80 $1,529.80 090 24587 $2,655.24 $2,655.24 09024138 $1,635.94 $1,635.94 090 24600 $881.15 $803.65 09024140 $1,702.49 $1,702.49 090 24605 $1,137.24 $1,137.24 09024145 $1,435.45 $1,435.45 090 24615 $1,727.76 $1,727.76 09024147 $1,508.74 $1,508.74 090 24620 $1,332.68 $1,332.68 09024149 $2,850.68 $2,850.68 090 24635 $1,632.57 $1,632.57 09024150 $3,789.96 $3,789.96 090 24640 $269.52 $210.68 01024152 $3,290.41 $3,290.41 090 24650 $632.64 $577.89 09024155 $2,073.15 $2,073.15 090 24655 $1,057.21 $959.49 09024160 $3,068.02 $3,068.02 090 24665 $1,582.87 $1,582.87 09024164 $1,769.04 $1,769.04 090 24666 $1,775.78 $1,775.78 09024200 $563.71 $379.60 010 24670 $702.56 $631.80 09024201 $1,330.99 $880.31 090 24675 $1,096.80 $997.40 09024220 $424.20 $186.95 000 24685 $1,584.55 $1,584.55 09024300 $1,004.98 $1,004.98 090 24800 $2,014.18 $2,014.18 09024301 $1,819.58 $1,819.58 090 24802 $2,432.85 $2,432.85 09024305 $1,396.70 $1,396.70 090 24900 $1,795.15 $1,795.15 09024310 $1,133.87 $1,133.87 090 24920 $1,777.46 $1,777.46 09024320 $1,895.40 $1,895.40 090 24925 $1,357.95 $1,357.95 09024330 $1,742.08 $1,742.08 090 24930 $1,879.39 $1,879.39 09024331 $1,908.88 $1,908.88 090 24931 $2,266.90 $2,266.90 09024332 $1,485.15 $1,485.15 090 24935 $2,799.30 $2,799.30 09024340 $1,484.31 $1,484.31 090 24940 80% of billed 80% of billed 09024341 $1,804.42 $1,804.42 090 24999 80% of billed 80% of billed N/A24342 $1,879.39 $1,879.39 090 25000 $814.60 $814.60 09024343 $1,710.91 $1,710.91 090 25001 $831.45 $831.45 09024344 $2,672.09 $2,672.09 090 25020 $1,387.43 $1,387.43 09024345 $1,701.65 $1,701.65 090 25023 $2,685.57 $2,685.57 09024346 $2,667.88 $2,667.88 090 25024 $1,878.55 $1,878.55 09024357 $1,015.09 $1,015.09 090 25025 $2,946.72 $2,946.72 09024358 $1,266.13 $1,266.13 090 25028 $1,272.02 $1,272.02 09024359 $1,598.88 $1,598.88 090 25031 $852.51 $852.51 09024360 $2,184.34 $2,184.34 090 25035 $1,416.07 $1,416.07 09024361 $2,444.64 $2,444.64 090 25040 $1,362.16 $1,362.16 09024362 $2,576.06 $2,576.06 090 25065 $688.97 $443.18 01024363 $3,539.76 $3,539.76 090 25066 $867.67 $867.67 09024365 $1,550.86 $1,550.86 090 25071 $1,031.94 $1,031.94 09024366 $1,647.73 $1,647.73 090 25073 $1,293.08 $1,293.08 09024370 $3,752.89 $3,752.89 090 25075 $1,154.93 $767.43 09024371 $4,377.11 $4,377.11 090 25076 $1,256.02 $1,256.02 09024400 $1,987.22 $1,987.22 090 25077 $2,148.12 $2,148.12 09024410 $2,567.64 $2,567.64 090 25078 $2,832.99 $2,832.99 09024420 $2,415.16 $2,415.16 090 25085 $1,087.54 $1,087.54 09024430 $2,561.74 $2,561.74 090 25100 $836.50 $836.50 09024435 $2,608.91 $2,608.91 090 25101 $975.50 $975.50 09024470 $1,627.52 $1,627.52 090 25105 $1,165.88 $1,165.88 09024495 $1,787.57 $1,787.57 090 25107 $1,493.58 $1,493.58 09024498 $2,100.95 $2,100.95 090 25109 $1,303.19 $1,303.19 09024500 $865.99 $785.96 090 25110 $823.87 $823.87 09024505 $1,197.89 $1,079.96 090 25111 $775.01 $775.01 09024515 $2,124.53 $2,124.53 090 25112 $935.91 $935.91 09024516 $2,084.94 $2,084.94 090 25115 $1,839.80 $1,839.80 09024530 $919.06 $830.61 090 25116 $1,453.98 $1,453.98 09024535 $1,491.05 $1,373.95 090 25118 $922.43 $922.43 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 8 of 84

Page 9: Appendix B for Administrative Order No. 18-053 Physician ...Appendix B for Administrative Order No. 18-053 Physician Fee Schedule Effective April 1, 2018 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

25119 $1,208.84 $1,208.84 090 25447 $2,007.44 $2,007.44 09025120 $1,202.10 $1,202.10 090 25449 $2,502.77 $2,502.77 09025125 $1,436.29 $1,436.29 090 25450 $1,492.73 $1,492.73 09025126 $1,446.40 $1,446.40 090 25455 $1,758.09 $1,758.09 09025130 $1,080.80 $1,080.80 090 25490 $1,743.77 $1,743.77 09025135 $1,353.74 $1,353.74 090 25491 $1,793.47 $1,793.47 09025136 $1,194.52 $1,194.52 090 25492 $2,194.45 $2,194.45 09025145 $1,252.65 $1,252.65 090 25500 $660.44 $603.16 09025150 $1,374.80 $1,374.80 090 25505 $1,199.58 $1,095.12 09025151 $1,411.02 $1,411.02 090 25515 $1,620.78 $1,620.78 09025170 $3,599.58 $3,599.58 090 25520 $1,374.80 $1,302.35 09025210 $1,179.36 $1,179.36 090 25525 $1,901.30 $1,901.30 09025215 $1,496.10 $1,496.10 090 25526 $2,317.44 $2,317.44 09025230 $1,047.95 $1,047.95 090 25530 $635.17 $571.99 09025240 $1,036.99 $1,036.99 090 25535 $1,172.62 $1,085.85 09025246 $435.59 $204.98 000 25545 $1,505.37 $1,505.37 09025248 $997.40 $997.40 090 25560 $672.24 $605.69 09025250 $1,284.66 $1,284.66 090 25565 $1,246.75 $1,122.92 09025251 $1,745.45 $1,745.45 090 25574 $1,630.89 $1,630.89 09025259 $1,005.83 $1,005.83 090 25575 $2,182.66 $2,182.66 09025260 $1,524.74 $1,524.74 090 25600 $793.54 $748.05 09025263 $1,519.69 $1,519.69 090 25605 $1,309.09 $1,228.22 09025265 $1,833.90 $1,833.90 090 25606 $1,605.61 $1,605.61 09025270 $1,186.10 $1,186.10 090 25607 $1,779.15 $1,779.15 09025272 $1,349.52 $1,349.52 090 25608 $1,997.33 $1,997.33 09025274 $1,630.89 $1,630.89 090 25609 $2,538.99 $2,538.99 09025275 $1,625.83 $1,625.83 090 25622 $737.94 $670.55 09025280 $1,364.69 $1,364.69 090 25624 $1,157.46 $1,052.16 09025290 $1,056.37 $1,056.37 090 25628 $1,742.93 $1,742.93 09025295 $1,270.34 $1,270.34 090 25630 $738.78 $676.45 09025300 $1,671.32 $1,671.32 090 25635 $1,102.70 $1,004.14 09025301 $1,558.44 $1,558.44 090 25645 $1,379.01 $1,379.01 09025310 $1,501.16 $1,501.16 090 25650 $771.64 $721.09 09025312 $1,738.71 $1,738.71 090 25651 $1,172.62 $1,172.62 09025315 $1,869.29 $1,869.29 090 25652 $1,508.74 $1,508.74 09025316 $2,217.20 $2,217.20 090 25660 $999.93 $999.93 09025320 $2,391.57 $2,391.57 090 25670 $1,461.56 $1,461.56 09025332 $2,041.14 $2,041.14 090 25671 $1,286.34 $1,286.34 09025335 $2,288.80 $2,288.80 090 25675 $1,045.42 $948.54 09025337 $2,164.13 $2,164.13 090 25676 $1,524.74 $1,524.74 09025350 $1,634.26 $1,634.26 090 25680 $1,260.23 $1,260.23 09025355 $1,858.33 $1,858.33 090 25685 $1,784.20 $1,784.20 09025360 $1,583.71 $1,583.71 090 25690 $1,163.35 $1,163.35 09025365 $2,219.72 $2,219.72 090 25695 $1,534.85 $1,534.85 09025370 $2,441.28 $2,441.28 090 25800 $1,774.94 $1,774.94 09025375 $2,312.39 $2,312.39 090 25805 $2,049.56 $2,049.56 09025390 $1,865.07 $1,865.07 090 25810 $2,103.47 $2,103.47 09025391 $2,416.85 $2,416.85 090 25820 $1,491.89 $1,491.89 09025392 $2,460.65 $2,460.65 090 25825 $1,837.27 $1,837.27 09025393 $2,746.22 $2,746.22 090 25830 $2,306.49 $2,306.49 09025394 $1,902.14 $1,902.14 090 25900 $1,710.91 $1,710.91 09025400 $1,948.47 $1,948.47 090 25905 $1,699.96 $1,699.96 09025405 $2,513.72 $2,513.72 090 25907 $1,485.15 $1,485.15 09025415 $2,347.77 $2,347.77 090 25909 $1,659.53 $1,659.53 09025420 $2,837.20 $2,837.20 090 25915 $2,847.31 $2,847.31 09025425 $2,335.98 $2,335.98 090 25920 $1,687.33 $1,687.33 09025426 $2,730.22 $2,730.22 090 25922 $1,480.94 $1,480.94 09025430 $1,773.25 $1,773.25 090 25924 $1,648.58 $1,648.58 09025431 $1,914.78 $1,914.78 090 25927 $1,962.79 $1,962.79 09025440 $1,865.07 $1,865.07 090 25929 $1,445.56 $1,445.56 09025441 $2,272.80 $2,272.80 090 25931 $1,803.58 $1,803.58 09025442 $1,952.68 $1,952.68 090 25999 80% of billed 80% of billed N/A25443 $1,894.56 $1,894.56 090 26010 $719.34 $373.91 01025444 $2,004.91 $2,004.91 090 26011 $1,060.98 $503.92 01025445 $1,749.66 $1,749.66 090 26020 $1,047.95 $1,047.95 09025446 $2,845.63 $2,845.63 090 26025 $1,020.15 $1,020.15 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 9 of 84

Page 10: Appendix B for Administrative Order No. 18-053 Physician ...Appendix B for Administrative Order No. 18-053 Physician Fee Schedule Effective April 1, 2018 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

26030 $1,193.68 $1,193.68 090 26440 $1,478.41 $1,478.41 09026034 $1,311.62 $1,311.62 090 26442 $2,305.65 $2,305.65 09026035 $2,080.73 $2,080.73 090 26445 $1,375.64 $1,375.64 09026037 $1,371.43 $1,371.43 090 26449 $1,665.42 $1,665.42 09026040 $753.95 $753.95 090 26450 $972.13 $972.13 09026045 $1,130.50 $1,130.50 090 26455 $963.71 $963.71 09026055 $1,345.31 $749.74 090 26460 $941.80 $941.80 09026060 $629.27 $629.27 090 26471 $1,471.67 $1,471.67 09026070 $771.64 $771.64 090 26474 $1,436.29 $1,436.29 09026075 $804.49 $804.49 090 26476 $1,416.07 $1,416.07 09026080 $944.33 $944.33 090 26477 $1,385.75 $1,385.75 09026100 $811.23 $811.23 090 26478 $1,475.04 $1,475.04 09026105 $816.29 $816.29 090 26479 $1,496.94 $1,496.94 09026110 $777.54 $777.54 090 26480 $1,796.00 $1,796.00 09026111 $1,013.41 $1,013.41 090 26483 $2,012.49 $2,012.49 09026113 $1,330.15 $1,330.15 090 26485 $1,924.04 $1,924.04 09026115 $1,215.58 $806.18 090 26489 $2,240.78 $2,240.78 09026116 $1,277.92 $1,277.92 090 26490 $1,905.51 $1,905.51 09026117 $1,807.79 $1,807.79 090 26492 $2,113.58 $2,113.58 09026118 $2,555.00 $2,555.00 090 26494 $1,914.78 $1,914.78 09026121 $1,448.09 $1,448.09 090 26496 $2,078.20 $2,078.20 09026123 $2,020.92 $2,020.92 090 26497 $2,073.15 $2,073.15 09026125 $751.61 $751.61 ZZZ 26498 $2,742.01 $2,742.01 09026130 $1,113.65 $1,113.65 090 26499 $1,986.38 $1,986.38 09026135 $1,334.36 $1,334.36 090 26500 $1,487.68 $1,487.68 09026140 $1,218.95 $1,218.95 090 26502 $1,698.28 $1,698.28 09026145 $1,240.01 $1,240.01 090 26508 $1,504.53 $1,504.53 09026160 $1,384.91 $807.86 090 26510 $1,420.29 $1,420.29 09026170 $983.92 $983.92 090 26516 $1,672.16 $1,672.16 09026180 $1,073.22 $1,073.22 090 26517 $1,973.74 $1,973.74 09026185 $1,334.36 $1,334.36 090 26518 $2,001.54 $2,001.54 09026200 $1,087.54 $1,087.54 090 26520 $1,549.17 $1,549.17 09026205 $1,458.19 $1,458.19 090 26525 $1,554.23 $1,554.23 09026210 $1,069.85 $1,069.85 090 26530 $1,302.35 $1,302.35 09026215 $1,364.69 $1,364.69 090 26531 $1,511.27 $1,511.27 09026230 $1,210.53 $1,210.53 090 26535 $1,030.26 $1,030.26 09026235 $1,192.84 $1,192.84 090 26536 $1,696.59 $1,696.59 09026236 $1,067.32 $1,067.32 090 26540 $1,568.55 $1,568.55 09026250 $2,602.17 $2,602.17 090 26541 $1,913.93 $1,913.93 09026260 $1,951.00 $1,951.00 090 26542 $1,617.41 $1,617.41 09026262 $1,538.22 $1,538.22 090 26545 $1,672.16 $1,672.16 09026320 $838.19 $838.19 090 26546 $2,375.57 $2,375.57 09026340 $804.49 $804.49 090 26548 $1,817.90 $1,817.90 09026341 $269.52 $204.04 010 26550 $3,958.44 $3,958.44 09026350 $1,699.12 $1,699.12 090 26551 $7,980.05 $7,980.05 09026352 $1,954.37 $1,954.37 090 26553 $7,926.14 $7,926.14 09026356 $1,919.83 $1,919.83 090 26554 $9,247.87 $9,247.87 09026357 $2,149.80 $2,149.80 090 26555 $3,295.47 $3,295.47 09026358 $2,380.62 $2,380.62 090 26556 $8,234.46 $8,234.46 09026370 $1,807.79 $1,807.79 090 26560 $1,411.86 $1,411.86 09026372 $2,117.79 $2,117.79 090 26561 $2,266.06 $2,266.06 09026373 $2,031.87 $2,031.87 090 26562 $3,225.55 $3,225.55 09026390 $2,002.38 $2,002.38 090 26565 $1,631.73 $1,631.73 09026392 $2,333.45 $2,333.45 090 26567 $1,624.99 $1,624.99 09026410 $1,348.68 $1,348.68 090 26568 $2,154.86 $2,154.86 09026412 $1,635.94 $1,635.94 090 26580 $3,639.17 $3,639.17 09026415 $1,947.63 $1,947.63 090 26587 $2,520.46 $2,520.46 09026416 $2,119.48 $2,119.48 090 26590 $3,386.45 $3,386.45 09026418 $1,376.48 $1,376.48 090 26591 $1,042.05 $1,042.05 09026420 $1,709.23 $1,709.23 090 26593 $1,432.08 $1,432.08 09026426 $1,211.37 $1,211.37 090 26596 $1,829.69 $1,829.69 09026428 $1,809.48 $1,809.48 090 26600 $710.14 $666.34 09026432 $1,189.47 $1,189.47 090 26605 $775.85 $705.09 09026433 $1,265.28 $1,265.28 090 26607 $1,108.60 $1,108.60 09026434 $1,548.33 $1,548.33 090 26608 $1,149.03 $1,149.03 09026437 $1,486.84 $1,486.84 090 26615 $1,394.17 $1,394.17 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 10 of 84

Page 11: Appendix B for Administrative Order No. 18-053 Physician ...Appendix B for Administrative Order No. 18-053 Physician Fee Schedule Effective April 1, 2018 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

26641 $924.11 $839.03 090 27054 $1,658.69 $1,658.69 09026645 $1,034.47 $948.54 090 27057 $2,465.70 $2,465.70 09026650 $1,150.72 $1,150.72 090 27059 $4,435.24 $4,435.24 09026665 $1,516.32 $1,516.32 090 27060 $1,127.97 $1,127.97 09026670 $824.71 $743.84 090 27062 $1,103.54 $1,103.54 09026675 $1,099.33 $1,009.20 090 27065 $1,258.55 $1,258.55 09026676 $1,210.53 $1,210.53 090 27066 $1,955.21 $1,955.21 09026685 $1,395.01 $1,395.01 090 27067 $2,512.04 $2,512.04 09026686 $1,510.42 $1,510.42 090 27070 $2,048.72 $2,048.72 09026700 $780.06 $729.52 090 27071 $2,223.09 $2,223.09 09026705 $997.40 $913.16 090 27075 $5,120.95 $5,120.95 09026706 $1,061.42 $1,061.42 090 27076 $6,201.75 $6,201.75 09026715 $1,386.59 $1,386.59 090 27077 $6,917.79 $6,917.79 09026720 $478.48 $443.10 090 27078 $5,049.35 $5,049.35 09026725 $811.23 $729.52 090 27080 $1,243.38 $1,243.38 09026727 $1,133.87 $1,133.87 090 27086 $807.60 $458.37 01026735 $1,443.03 $1,443.03 090 27087 $1,480.94 $1,480.94 09026740 $556.83 $519.76 090 27090 $2,012.49 $2,012.49 09026742 $892.94 $807.02 090 27091 $3,882.62 $3,882.62 09026746 $1,797.68 $1,797.68 090 27093 $505.82 $191.70 00026750 $444.79 $443.10 090 27095 $664.30 $227.76 00026755 $758.16 $656.23 090 27096 $429.90 $227.76 00026756 $1,004.98 $1,004.98 090 27097 $1,652.79 $1,652.79 09026765 $1,210.53 $1,210.53 090 27098 $1,682.27 $1,682.27 09026770 $665.50 $612.42 090 27100 $2,004.91 $2,004.91 09026775 $919.90 $831.45 090 27105 $2,104.32 $2,104.32 09026776 $1,070.69 $1,070.69 090 27110 $2,353.67 $2,353.67 09026785 $1,323.41 $1,323.41 090 27111 $2,184.34 $2,184.34 09026820 $1,884.45 $1,884.45 090 27120 $3,163.21 $3,163.21 09026841 $1,731.13 $1,731.13 090 27122 $2,671.25 $2,671.25 09026842 $1,867.60 $1,867.60 090 27125 $2,755.49 $2,755.49 09026843 $1,765.67 $1,765.67 090 27130 $3,298.84 $3,298.84 09026844 $1,960.26 $1,960.26 090 27132 $4,073.85 $4,073.85 09026850 $1,650.26 $1,650.26 090 27134 $4,663.53 $4,663.53 09026852 $1,900.45 $1,900.45 090 27137 $3,582.73 $3,582.73 09026860 $1,347.84 $1,347.84 090 27138 $3,723.41 $3,723.41 09026861 $282.80 $282.80 ZZZ 27140 $2,169.18 $2,169.18 09026862 $1,734.50 $1,734.50 090 27146 $3,116.04 $3,116.04 09026863 $631.09 $631.09 ZZZ 27147 $3,580.20 $3,580.20 09026910 $1,728.60 $1,728.60 090 27151 $3,877.57 $3,877.57 09026951 $1,556.76 $1,556.76 090 27156 $4,180.83 $4,180.83 09026952 $1,538.22 $1,538.22 090 27158 $3,413.40 $3,413.40 09026989 80% of billed 80% of billed N/A 27161 $2,947.56 $2,947.56 09026990 $1,519.69 $1,519.69 090 27165 $3,330.01 $3,330.01 09026991 $1,711.76 $1,271.18 090 27170 $2,857.42 $2,857.42 09026992 $2,323.34 $2,323.34 090 27175 $1,618.25 $1,618.25 09027000 $994.03 $994.03 090 27176 $2,229.83 $2,229.83 09027001 $1,304.88 $1,304.88 090 27177 $2,710.00 $2,710.00 09027003 $1,444.72 $1,444.72 090 27178 $2,229.83 $2,229.83 09027005 $1,752.19 $1,752.19 090 27179 $2,372.20 $2,372.20 09027006 $1,769.04 $1,769.04 090 27181 $2,732.75 $2,732.75 09027025 $2,230.68 $2,230.68 090 27185 $1,742.08 $1,742.08 09027027 $2,134.64 $2,134.64 090 27187 $2,406.74 $2,406.74 09027030 $2,271.95 $2,271.95 090 27197 $327.41 $327.41 00027033 $2,354.51 $2,354.51 090 27198 $819.94 $819.94 00027035 $2,772.34 $2,772.34 090 27200 $440.58 $455.74 09027036 $2,453.91 $2,453.91 090 27202 $1,293.08 $1,293.08 09027040 $936.66 $543.78 010 27215 $1,518.85 $1,518.85 09027041 $1,683.96 $1,683.96 090 27216 $2,249.21 $2,249.21 09027043 $1,140.61 $1,140.61 090 27217 $2,111.05 $2,111.05 09027045 $1,811.16 $1,811.16 090 27218 $2,914.70 $2,914.70 09027047 $1,123.76 $876.10 090 27220 $1,287.19 $1,272.87 09027048 $1,480.94 $1,480.94 090 27222 $2,360.40 $2,360.40 09027049 $3,264.30 $3,264.30 090 27226 $2,557.53 $2,557.53 09027050 $973.81 $973.81 090 27227 $4,039.31 $4,039.31 09027052 $1,405.12 $1,405.12 090 27228 $4,586.03 $4,586.03 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 11 of 84

Page 12: Appendix B for Administrative Order No. 18-053 Physician ...Appendix B for Administrative Order No. 18-053 Physician Fee Schedule Effective April 1, 2018 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

27230 $1,151.56 $1,140.61 090 27380 $1,435.45 $1,435.45 09027232 $1,806.11 $1,806.11 090 27381 $1,933.31 $1,933.31 09027235 $2,207.93 $2,207.93 090 27385 $1,389.96 $1,389.96 09027236 $2,906.28 $2,906.28 090 27386 $2,009.12 $2,009.12 09027238 $1,113.65 $1,113.65 090 27390 $1,087.54 $1,087.54 09027240 $2,327.55 $2,327.55 090 27391 $1,388.28 $1,388.28 09027244 $2,992.20 $2,992.20 090 27392 $1,728.60 $1,728.60 09027245 $2,992.20 $2,992.20 090 27393 $1,233.27 $1,233.27 09027246 $932.54 $934.22 090 27394 $1,555.91 $1,555.91 09027248 $1,803.58 $1,803.58 090 27395 $2,132.11 $2,132.11 09027250 $491.58 $491.58 000 27396 $1,492.73 $1,492.73 09027252 $1,835.59 $1,835.59 090 27397 $2,226.46 $2,226.46 09027253 $2,278.69 $2,278.69 090 27400 $1,683.96 $1,683.96 09027254 $3,086.55 $3,086.55 090 27403 $1,547.49 $1,547.49 09027256 $825.63 $640.58 010 27405 $1,634.26 $1,634.26 09027257 $996.45 $996.45 010 27407 $1,923.20 $1,923.20 09027258 $2,699.89 $2,699.89 090 27409 $2,344.40 $2,344.40 09027259 $3,781.53 $3,781.53 090 27412 $4,028.36 $4,028.36 09027265 $964.55 $964.55 090 27415 $3,314.00 $3,314.00 09027266 $1,407.65 $1,407.65 090 27416 $2,383.15 $2,383.15 09027267 $1,046.26 $1,046.26 090 27418 $1,999.02 $1,999.02 09027268 $1,306.56 $1,306.56 090 27420 $1,800.21 $1,800.21 09027269 $3,023.37 $3,023.37 090 27422 $1,799.37 $1,799.37 09027275 $499.17 $499.17 010 27424 $1,815.37 $1,815.37 09027279 $1,684.80 $1,684.80 090 27425 $1,085.01 $1,085.01 09027280 $3,304.74 $3,304.74 090 27427 $1,719.34 $1,719.34 09027282 $2,077.36 $2,077.36 090 27428 $2,713.37 $2,713.37 09027284 $3,945.80 $3,945.80 090 27429 $3,017.48 $3,017.48 09027286 $4,027.51 $4,027.51 090 27430 $1,791.78 $1,791.78 09027290 $3,956.75 $3,956.75 090 27435 $1,956.90 $1,956.90 09027295 $3,078.97 $3,078.97 090 27437 $1,603.09 $1,603.09 09027299 80% of billed 80% of billed N/A 27438 $2,034.40 $2,034.40 09027301 $1,629.20 $1,220.64 090 27440 $1,938.36 $1,938.36 09027303 $1,547.49 $1,547.49 090 27441 $2,002.38 $2,002.38 09027305 $1,158.30 $1,158.30 090 27442 $2,107.68 $2,107.68 09027306 $840.72 $840.72 090 27443 $1,972.90 $1,972.90 09027307 $1,032.78 $1,032.78 090 27445 $3,043.59 $3,043.59 09027310 $1,771.57 $1,771.57 090 27446 $2,817.83 $2,817.83 09027323 $740.22 $487.79 010 27447 $3,295.47 $3,295.47 09027324 $971.29 $971.29 090 27448 $1,883.61 $1,883.61 09027325 $1,351.21 $1,351.21 090 27450 $2,437.06 $2,437.06 09027326 $1,245.91 $1,245.91 090 27454 $3,163.21 $3,163.21 09027327 $1,107.76 $760.69 090 27455 $2,287.96 $2,287.96 09027328 $1,510.42 $1,510.42 090 27457 $2,309.02 $2,309.02 09027329 $2,521.30 $2,521.30 090 27465 $2,934.92 $2,934.92 09027330 $1,005.83 $1,005.83 090 27466 $2,879.32 $2,879.32 09027331 $1,147.35 $1,147.35 090 27468 $3,267.67 $3,267.67 09027332 $1,560.12 $1,560.12 090 27470 $2,856.58 $2,856.58 09027333 $1,419.44 $1,419.44 090 27472 $3,067.18 $3,067.18 09027334 $1,657.00 $1,657.00 090 27475 $1,604.77 $1,604.77 09027335 $1,848.23 $1,848.23 090 27477 $1,779.15 $1,779.15 09027337 $1,016.78 $1,016.78 090 27479 $2,235.73 $2,235.73 09027339 $1,828.85 $1,828.85 090 27485 $1,625.83 $1,625.83 09027340 $898.84 $898.84 090 27486 $3,420.14 $3,420.14 09027345 $1,162.51 $1,162.51 090 27487 $4,277.71 $4,277.71 09027347 $1,280.45 $1,280.45 090 27488 $2,918.92 $2,918.92 09027350 $1,578.66 $1,578.66 090 27495 $2,733.59 $2,733.59 09027355 $1,461.56 $1,461.56 090 27496 $1,319.20 $1,319.20 09027356 $1,793.47 $1,793.47 090 27497 $1,413.55 $1,413.55 09027357 $1,976.27 $1,976.27 090 27498 $1,589.61 $1,589.61 09027358 $766.79 $766.79 ZZZ 27499 $1,699.12 $1,699.12 09027360 $2,063.88 $2,063.88 090 27500 $1,256.02 $1,160.83 09027364 $3,809.33 $3,809.33 090 27501 $1,221.48 $1,208.00 09027365 $5,029.13 $5,029.13 090 27502 $1,838.96 $1,838.96 09027370 $418.51 $137.61 000 27503 $1,944.26 $1,944.26 09027372 $1,435.45 $963.71 090 27506 $3,251.66 $3,251.66 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 12 of 84

Page 13: Appendix B for Administrative Order No. 18-053 Physician ...Appendix B for Administrative Order No. 18-053 Physician Fee Schedule Effective April 1, 2018 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

27507 $2,362.09 $2,362.09 090 27650 $1,593.82 $1,593.82 09027508 $1,269.50 $1,192.00 090 27652 $1,641.84 $1,641.84 09027509 $1,555.91 $1,555.91 090 27654 $1,716.81 $1,716.81 09027510 $1,654.47 $1,654.47 090 27656 $1,539.06 $962.02 09027511 $2,421.90 $2,421.90 090 27658 $898.84 $898.84 09027513 $3,015.79 $3,015.79 090 27659 $1,149.03 $1,149.03 09027514 $2,348.61 $2,348.61 090 27664 $876.10 $876.10 09027516 $1,229.06 $1,155.77 090 27665 $999.93 $999.93 09027517 $1,662.06 $1,662.06 090 27675 $1,186.10 $1,186.10 09027519 $2,168.34 $2,168.34 090 27676 $1,468.30 $1,468.30 09027520 $780.90 $710.14 090 27680 $1,032.78 $1,032.78 09027524 $1,822.95 $1,822.95 090 27681 $1,326.78 $1,326.78 09027530 $731.20 $676.45 090 27685 $1,608.98 $1,124.60 09027532 $1,489.36 $1,395.86 090 27686 $1,336.05 $1,336.05 09027535 $2,178.45 $2,178.45 090 27687 $1,096.80 $1,096.80 09027536 $2,890.27 $2,890.27 090 27690 $1,539.06 $1,539.06 09027538 $1,146.51 $1,070.69 090 27691 $1,808.63 $1,808.63 09027540 $1,958.58 $1,958.58 090 27692 $286.60 $286.60 ZZZ27550 $1,238.33 $1,146.51 090 27695 $1,154.09 $1,154.09 09027552 $1,509.58 $1,509.58 090 27696 $1,354.58 $1,354.58 09027556 $2,132.11 $2,132.11 090 27698 $1,554.23 $1,554.23 09027557 $2,550.79 $2,550.79 090 27700 $1,531.48 $1,531.48 09027558 $2,909.65 $2,909.65 090 27702 $2,330.92 $2,330.92 09027560 $878.62 $807.86 090 27703 $2,687.26 $2,687.26 09027562 $1,171.78 $1,171.78 090 27704 $1,382.38 $1,382.38 09027566 $2,173.39 $2,173.39 090 27705 $1,852.44 $1,852.44 09027570 $410.92 $410.92 010 27707 $964.55 $964.55 09027580 $3,490.91 $3,490.91 090 27709 $2,838.05 $2,838.05 09027590 $1,942.57 $1,942.57 090 27712 $2,688.94 $2,688.94 09027591 $2,349.45 $2,349.45 090 27715 $2,603.86 $2,603.86 09027592 $1,655.32 $1,655.32 090 27720 $2,116.95 $2,116.95 09027594 $1,224.85 $1,224.85 090 27722 $2,163.28 $2,163.28 09027596 $1,751.35 $1,751.35 090 27724 $3,074.76 $3,074.76 09027598 $1,739.56 $1,739.56 090 27725 $2,967.78 $2,967.78 09027599 80% of billed 80% of billed N/A 27726 $2,333.45 $2,333.45 09027600 $981.40 $981.40 090 27727 $2,520.46 $2,520.46 09027601 $1,085.01 $1,085.01 090 27730 $1,421.97 $1,421.97 09027602 $1,181.89 $1,181.89 090 27732 $1,085.01 $1,085.01 09027603 $1,277.08 $939.28 090 27734 $1,592.14 $1,592.14 09027604 $1,155.77 $813.76 090 27740 $1,717.65 $1,717.65 09027605 $941.41 $507.72 010 27742 $1,889.50 $1,889.50 09027606 $764.89 $764.89 010 27745 $1,833.06 $1,833.06 09027607 $1,470.83 $1,470.83 090 27750 $837.35 $765.74 09027610 $1,574.45 $1,574.45 090 27752 $1,293.93 $1,192.00 09027612 $1,360.48 $1,360.48 090 27756 $1,404.28 $1,404.28 09027613 $689.92 $444.13 010 27758 $2,162.44 $2,162.44 09027614 $1,405.12 $987.29 090 27759 $2,425.27 $2,425.27 09027615 $2,491.82 $2,491.82 090 27760 $805.33 $732.05 09027616 $3,092.45 $3,092.45 090 27762 $1,134.71 $1,031.10 09027618 $1,089.22 $748.89 090 27766 $1,471.67 $1,471.67 09027619 $1,126.29 $1,126.29 090 27767 $678.13 $682.34 09027620 $1,085.85 $1,085.85 090 27768 $1,066.48 $1,066.48 09027625 $1,405.97 $1,405.97 090 27769 $1,774.09 $1,774.09 09027626 $1,464.09 $1,464.09 090 27780 $740.47 $671.39 09027630 $1,352.89 $882.84 090 27781 $1,033.62 $956.12 09027632 $1,005.83 $1,005.83 090 27784 $1,725.24 $1,725.24 09027634 $1,654.47 $1,654.47 090 27786 $761.53 $687.40 09027635 $1,419.44 $1,419.44 090 27788 $1,015.93 $924.96 09027637 $1,855.81 $1,855.81 090 27792 $1,575.29 $1,575.29 09027638 $1,876.87 $1,876.87 090 27808 $807.02 $721.94 09027640 $2,019.23 $2,019.23 090 27810 $1,124.60 $1,017.62 09027641 $1,614.88 $1,614.88 090 27814 $1,868.44 $1,868.44 09027645 $4,338.36 $4,338.36 090 27816 $777.54 $694.98 09027646 $3,763.00 $3,763.00 090 27818 $1,168.41 $1,044.58 09027647 $2,475.81 $2,475.81 090 27822 $2,079.89 $2,079.89 09027648 $453.62 $144.25 000 27823 $2,356.19 $2,356.19 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 13 of 84

Page 14: Appendix B for Administrative Order No. 18-053 Physician ...Appendix B for Administrative Order No. 18-053 Physician Fee Schedule Effective April 1, 2018 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

27824 $759.00 $735.42 090 28112 $1,191.15 $758.16 09027825 $1,322.57 $1,198.74 090 28113 $1,437.13 $1,027.73 09027826 $2,047.03 $2,047.03 090 28114 $2,612.28 $2,029.34 09027827 $2,664.51 $2,664.51 090 28116 $1,881.08 $1,410.18 09027828 $3,185.11 $3,185.11 090 28118 $1,453.14 $1,004.98 09027829 $1,684.80 $1,684.80 090 28119 $1,277.08 $871.88 09027830 $924.96 $858.41 090 28120 $1,647.73 $1,205.47 09027831 $969.60 $969.60 090 28122 $1,459.04 $1,067.32 09027832 $1,836.43 $1,836.43 090 28124 $1,163.35 $800.28 09027840 $894.63 $894.63 090 28126 $965.39 $603.16 09027842 $1,194.52 $1,194.52 090 28130 $1,769.88 $1,769.88 09027846 $1,742.93 $1,742.93 090 28140 $1,453.14 $1,066.48 09027848 $1,939.20 $1,939.20 090 28150 $1,033.62 $677.29 09027860 $476.40 $476.40 010 28153 $1,006.67 $641.91 09027870 $2,496.87 $2,496.87 090 28160 $1,017.62 $649.49 09027871 $1,658.69 $1,658.69 090 28171 $2,716.74 $2,716.74 09027880 $2,228.15 $2,228.15 090 28173 $1,827.17 $1,827.17 09027881 $2,104.32 $2,104.32 090 28175 $1,155.77 $1,155.77 09027882 $1,459.04 $1,459.04 090 28190 $708.90 $366.31 01027884 $1,390.80 $1,390.80 090 28192 $1,140.61 $758.16 09027886 $1,598.88 $1,598.88 090 28193 $1,293.08 $892.94 09027888 $1,641.84 $1,641.84 090 28200 $1,202.95 $784.27 09027889 $1,580.34 $1,580.34 090 28202 $1,460.72 $1,036.99 09027892 $1,357.11 $1,357.11 090 28208 $1,170.09 $764.06 09027893 $1,479.25 $1,479.25 090 28210 $1,437.98 $1,016.78 09027894 $2,038.61 $2,038.61 090 28220 $1,097.65 $731.20 09027899 80% of billed 80% of billed N/A 28222 $1,243.38 $851.67 09028001 $754.46 $459.32 010 28225 $1,008.35 $634.33 09028002 $1,204.28 $863.59 010 28226 $1,491.05 $956.12 09028003 $1,696.59 $1,353.74 090 28230 $1,059.74 $686.56 09028005 $1,393.33 $1,393.33 090 28232 $942.65 $588.00 09028008 $1,052.16 $710.99 090 28234 $991.50 $636.01 09028010 $561.04 $504.60 090 28238 $1,632.57 $1,179.36 09028011 $774.17 $691.61 090 28240 $1,122.92 $730.36 09028020 $1,318.36 $879.47 090 28250 $1,417.76 $983.08 09028022 $1,179.36 $782.59 090 28260 $1,672.16 $1,236.64 09028024 $1,117.86 $736.26 090 28261 $2,477.50 $1,946.79 09028035 $1,287.19 $862.62 090 28262 $3,593.68 $2,884.38 09028039 $1,229.06 $841.56 090 28264 $2,460.65 $1,868.44 09028041 $1,106.07 $1,106.07 090 28270 $1,202.95 $812.07 09028043 $976.34 $637.70 090 28272 $957.81 $613.27 09028045 $1,209.69 $844.93 090 28280 $1,260.23 $846.61 09028046 $1,771.57 $1,771.57 090 28285 $1,304.88 $916.53 09028047 $2,553.31 $2,553.31 090 28286 $1,100.17 $724.46 09028050 $1,031.94 $677.29 090 28288 $1,474.20 $1,042.89 09028052 $1,099.33 $699.19 090 28289 $1,813.69 $1,122.92 09028054 $914.00 $570.30 090 28291 $1,769.88 $1,150.72 09028055 $920.74 $920.74 090 28292 $1,832.22 $1,180.20 09028060 $1,263.60 $865.14 090 28295 $2,291.33 $1,302.35 09028062 $1,426.18 $986.45 090 28296 $2,219.72 $1,248.44 09028070 $1,316.67 $875.25 090 28297 $2,546.58 $1,456.51 09028072 $1,228.22 $799.44 090 28298 $2,079.04 $1,204.63 09028080 $1,277.92 $889.57 090 28299 $2,453.07 $1,409.34 09028086 $1,329.31 $872.73 090 28300 $1,577.82 $1,577.82 09028088 $1,093.44 $688.24 090 28302 $1,737.87 $1,737.87 09028090 $1,146.51 $746.37 090 28304 $2,015.02 $1,473.36 09028092 $1,033.62 $652.02 090 28305 $1,620.78 $1,620.78 09028100 $1,492.73 $1,008.35 090 28306 $1,499.47 $981.40 09028102 $1,471.67 $1,471.67 090 28307 $1,623.30 $1,086.70 09028103 $947.70 $947.70 090 28308 $1,383.22 $916.53 09028104 $1,288.87 $858.41 090 28309 $2,168.34 $2,168.34 09028106 $1,036.99 $1,036.99 090 28310 $1,332.68 $866.83 09028107 $1,255.18 $843.24 090 28312 $1,234.12 $769.11 09028108 $1,073.22 $699.19 090 28313 $1,272.87 $860.09 09028110 $1,132.19 $702.56 090 28315 $1,177.68 $791.01 09028111 $1,197.05 $787.64 090 28320 $1,478.41 $1,478.41 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 14 of 84

Page 15: Appendix B for Administrative Order No. 18-053 Physician ...Appendix B for Administrative Order No. 18-053 Physician Fee Schedule Effective April 1, 2018 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

28322 $1,921.51 $1,400.91 090 28820 $1,371.43 $957.81 09028340 $1,408.49 $1,000.77 090 28825 $1,311.62 $898.84 09028341 $1,632.57 $1,190.31 090 28890 $795.23 $541.66 09028344 $1,099.33 $700.03 090 28899 80% of billed 80% of billed N/A28345 $1,271.18 $882.84 090 29000 $953.75 $544.73 00028360 $2,636.71 $2,636.71 090 29010 $747.81 $443.18 00028400 $603.16 $549.24 090 29015 $803.80 $500.12 00028405 $945.17 $855.88 090 29035 $699.41 $395.73 00028406 $1,259.39 $1,259.39 090 29040 $801.91 $478.30 00028415 $2,714.21 $2,714.21 090 29044 $785.77 $462.16 00028420 $3,075.60 $3,075.60 090 29046 $861.69 $519.10 00028430 $570.30 $504.60 090 29049 $270.47 $191.70 00028435 $876.94 $780.90 090 29055 $608.31 $380.55 00028436 $1,090.91 $1,090.91 090 29058 $338.79 $259.08 00028445 $2,560.90 $2,560.90 090 29065 $261.92 $186.00 00028446 $2,978.73 $2,978.73 090 29075 $236.30 $169.87 00028450 $520.60 $461.64 090 29085 $260.03 $184.11 00028455 $696.66 $624.22 090 29086 $217.32 $141.40 00028456 $775.01 $775.01 090 29105 $239.15 $161.33 00028465 $1,533.17 $1,533.17 090 29125 $176.51 $108.19 00028470 $530.71 $492.80 090 29126 $209.73 $132.86 00028475 $616.64 $545.88 090 29130 $112.93 $78.77 00028476 $848.30 $848.30 090 29131 $142.35 $93.00 00028485 $1,314.14 $1,314.14 090 29200 $84.46 $51.25 00028490 $354.65 $302.42 090 29240 $81.61 $51.25 00028495 $431.31 $360.55 090 29260 $80.67 $53.14 00028496 $1,116.18 $589.68 090 29280 $81.61 $55.04 00028505 $1,624.15 $1,211.37 090 29305 $675.69 $436.54 00028510 $300.74 $289.79 090 29325 $748.76 $490.63 00028515 $392.56 $343.70 090 29345 $370.11 $275.21 00028525 $1,384.91 $967.92 090 29355 $381.50 $289.45 00028530 $282.20 $250.19 090 29358 $438.44 $285.65 00028531 $834.82 $441.42 090 29365 $335.00 $240.10 00028540 $465.00 $420.36 090 29405 $221.12 $163.23 00028545 $721.94 $636.85 090 29425 $212.58 $153.74 00028546 $1,409.34 $825.55 090 29435 $321.71 $228.71 00028555 $2,116.11 $1,602.24 090 29440 $118.63 $78.77 00028570 $548.40 $463.32 090 29445 $354.93 $280.90 00028575 $888.73 $801.12 090 29450 $396.68 $310.32 00028576 $961.18 $961.18 090 29505 $231.56 $137.61 00028585 $2,100.10 $1,640.15 090 29515 $195.49 $135.71 00028600 $527.34 $450.68 090 29520 $89.21 $52.20 00028605 $797.75 $714.36 090 29530 $80.67 $51.25 00028606 $972.97 $972.97 090 29540 $71.18 $49.35 00028615 $1,951.84 $1,951.84 090 29550 $51.25 $31.32 00028630 $428.95 $297.99 010 29580 $166.08 $78.77 00028635 $484.94 $362.52 010 29581 $229.66 $75.92 00028636 $893.01 $576.04 010 29584 $213.53 $44.60 00028645 $1,589.61 $1,170.09 090 29700 $176.51 $92.05 00028660 $316.97 $241.05 010 29705 $180.31 $128.12 00028665 $425.15 $359.67 010 29710 $337.84 $228.71 00028666 $489.68 $489.68 010 29720 $232.51 $121.47 00028675 $1,403.44 $984.77 090 29730 $171.77 $120.52 00028705 $3,030.96 $3,030.96 090 29740 $271.41 $193.60 00028715 $2,278.69 $2,278.69 090 29750 $294.19 $215.42 00028725 $1,889.50 $1,889.50 090 29799 80% of billed 80% of billed N/A28730 $1,785.05 $1,785.05 090 29800 $1,282.13 $1,282.13 09028735 $1,897.93 $1,897.93 090 29804 $1,555.91 $1,555.91 09028737 $1,687.33 $1,687.33 090 29805 $1,144.82 $1,144.82 09028740 $2,059.67 $1,510.42 090 29806 $2,576.90 $2,576.90 09028750 $1,966.16 $1,423.66 090 29807 $2,517.09 $2,517.09 09028755 $1,243.38 $803.65 090 29819 $1,417.76 $1,417.76 09028760 $1,937.52 $1,409.34 090 29820 $1,294.77 $1,294.77 09028800 $1,301.51 $1,301.51 090 29821 $1,418.60 $1,418.60 09028805 $1,769.04 $1,769.04 090 29822 $1,376.48 $1,376.48 09028810 $1,043.73 $1,043.73 090 29823 $1,499.47 $1,499.47 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 15 of 84

Page 16: Appendix B for Administrative Order No. 18-053 Physician ...Appendix B for Administrative Order No. 18-053 Physician Fee Schedule Effective April 1, 2018 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

29824 $1,616.57 $1,616.57 090 30000 $612.11 $316.97 01029825 $1,397.54 $1,397.54 090 30020 $617.80 $316.97 01029826 $1,577.28 $1,577.28 090 30100 $372.96 $183.16 00029827 $2,558.37 $2,558.37 090 30110 $611.16 $348.28 01029828 $2,207.09 $2,207.09 090 30115 $1,018.46 $1,018.46 09029830 $1,107.76 $1,107.76 090 30117 $2,064.72 $804.49 09029834 $1,179.36 $1,179.36 090 30118 $1,827.17 $1,827.17 09029835 $1,234.12 $1,234.12 090 30120 $1,244.22 $1,050.47 09029836 $1,413.55 $1,413.55 090 30124 $672.24 $672.24 09029837 $1,270.34 $1,270.34 090 30125 $1,431.24 $1,431.24 09029838 $1,427.03 $1,427.03 090 30130 $899.68 $899.68 09029840 $1,096.80 $1,096.80 090 30140 $741.17 $485.89 00029843 $1,176.83 $1,176.83 090 30150 $1,820.43 $1,820.43 09029844 $1,204.63 $1,204.63 090 30160 $1,823.80 $1,823.80 09029845 $1,397.54 $1,397.54 090 30200 $298.94 $157.53 00029846 $1,263.60 $1,263.60 090 30210 $399.53 $264.77 01029847 $1,320.88 $1,320.88 090 30220 $801.91 $334.05 01029848 $1,241.70 $1,241.70 090 30300 $476.40 $284.70 01029850 $1,516.32 $1,516.32 090 30310 $539.03 $539.03 01029851 $2,267.74 $2,267.74 090 30320 $1,063.95 $1,063.95 09029855 $1,900.45 $1,900.45 090 30400 $2,516.25 $2,516.25 09029856 $2,424.43 $2,424.43 090 30410 $2,965.25 $2,965.25 09029860 $1,621.62 $1,621.62 090 30420 $3,235.66 $3,235.66 09029861 $1,752.19 $1,752.19 090 30430 $2,207.93 $2,207.93 09029862 $1,955.21 $1,955.21 090 30435 $2,772.34 $2,772.34 09029863 $1,952.68 $1,952.68 090 30450 $3,679.60 $3,679.60 09029866 $2,553.31 $2,553.31 090 30460 $1,963.63 $1,963.63 09029867 $3,114.35 $3,114.35 090 30462 $3,767.21 $3,767.21 09029868 $4,079.74 $4,079.74 090 30465 $2,314.92 $2,314.92 09029870 $1,396.70 $991.50 090 30520 $1,468.30 $1,468.30 09029871 $1,250.12 $1,250.12 090 30540 $1,619.94 $1,619.94 09029873 $1,274.55 $1,274.55 090 30545 $2,218.04 $2,218.04 09029874 $1,301.51 $1,301.51 090 30560 $709.85 $364.42 01029875 $1,202.95 $1,202.95 090 30580 $1,555.07 $1,223.16 09029876 $1,596.35 $1,596.35 090 30600 $1,400.07 $1,090.91 09029877 $1,507.90 $1,507.90 090 30620 $1,468.30 $1,468.30 09029879 $1,608.14 $1,608.14 090 30630 $1,467.46 $1,467.46 09029880 $1,365.53 $1,365.53 090 30801 $608.31 $363.47 01029881 $1,314.14 $1,314.14 090 30802 $768.69 $503.92 01029882 $1,698.28 $1,698.28 090 30901 $367.26 $153.74 00029883 $2,048.72 $2,048.72 090 30903 $564.66 $213.53 00029884 $1,489.36 $1,489.36 090 30905 $873.08 $285.65 00029885 $1,832.22 $1,832.22 090 30906 $906.30 $368.21 00029886 $1,549.17 $1,549.17 090 30915 $1,357.11 $1,357.11 09029887 $1,823.80 $1,823.80 090 30920 $1,969.53 $1,969.53 09029888 $2,390.73 $2,390.73 090 30930 $328.35 $328.35 01029889 $2,977.88 $2,977.88 090 30999 80% of billed 80% of billed N/A29891 $1,628.36 $1,628.36 090 31000 $488.74 $283.75 01029892 $1,656.16 $1,656.16 090 31002 $502.02 $502.02 01029893 $1,486.84 $1,034.47 090 31020 $1,148.19 $849.98 09029894 $1,190.31 $1,190.31 090 31030 $1,631.73 $1,252.65 09029895 $1,138.92 $1,138.92 090 31032 $1,358.79 $1,358.79 09029897 $1,218.11 $1,218.11 090 31040 $1,806.95 $1,806.95 09029898 $1,364.69 $1,364.69 090 31050 $1,141.45 $1,141.45 09029899 $2,508.67 $2,508.67 090 31051 $1,518.00 $1,518.00 09029900 $1,202.95 $1,202.95 090 31070 $1,032.78 $1,032.78 09029901 $1,296.45 $1,296.45 090 31075 $1,840.64 $1,840.64 09029902 $1,377.32 $1,377.32 090 31080 $2,425.27 $2,425.27 09029904 $1,551.70 $1,551.70 090 31081 $2,901.23 $2,901.23 09029905 $1,333.52 $1,333.52 090 31084 $2,715.90 $2,715.90 09029906 $1,688.17 $1,688.17 090 31085 $3,096.66 $3,096.66 09029907 $2,132.11 $2,132.11 090 31086 $2,637.55 $2,637.55 09029914 $2,383.15 $2,383.15 090 31087 $2,548.26 $2,548.26 09029915 $2,442.96 $2,442.96 090 31090 $2,423.58 $2,423.58 09029916 $2,458.12 $2,458.12 090 31200 $1,373.11 $1,373.11 09029999 80% of billed 80% of billed N/A 31201 $1,763.99 $1,763.99 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 16 of 84

Page 17: Appendix B for Administrative Order No. 18-053 Physician ...Appendix B for Administrative Order No. 18-053 Physician Fee Schedule Effective April 1, 2018 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

31205 $2,161.60 $2,161.60 090 31551 $3,450.47 $3,450.47 09031225 $4,454.61 $4,454.61 090 31552 $3,460.58 $3,460.58 09031230 $4,906.98 $4,906.98 090 31553 $3,807.65 $3,807.65 09031231 $565.60 $175.57 000 31554 $3,972.76 $3,972.76 09031233 $694.67 $365.37 000 31560 $847.46 $847.46 00031235 $795.26 $433.69 000 31561 $926.22 $926.22 00031237 $705.11 $432.74 000 31570 $903.45 $621.60 00031238 $703.21 $452.67 000 31571 $674.74 $674.74 00031239 $1,666.44 $1,666.44 010 31572 $1,328.60 $488.74 00031240 $430.85 $430.85 000 31573 $708.90 $402.38 00031241 $1,217.57 $1,217.57 000 31574 $2,733.12 $402.38 00031253 $1,364.66 $1,364.66 000 31575 $303.68 $181.26 00031254 $1,095.15 $663.35 000 31576 $710.80 $320.76 00031255 $881.62 $881.62 000 31577 $738.32 $362.52 00031256 $490.63 $490.63 000 31578 $807.60 $402.38 00031257 $1,214.72 $1,214.72 000 31579 $483.04 $323.61 00031259 $1,287.79 $1,287.79 000 31580 $2,976.20 $2,976.20 09031267 $723.14 $723.14 000 31584 $3,296.31 $3,296.31 09031276 $1,029.67 $1,029.67 000 31587 $2,752.96 $2,752.96 09031287 $548.52 $548.52 000 31590 $2,090.84 $2,090.84 09031288 $637.73 $637.73 000 31591 $2,489.29 $2,489.29 09031290 $3,103.23 $3,103.23 010 31592 $4,055.31 $4,055.31 09031291 $3,322.45 $3,322.45 010 31595 $1,802.74 $1,802.74 09031292 $2,670.49 $2,670.49 010 31599 80% of billed 80% of billed N/A31293 $2,897.30 $2,897.30 010 31600 $880.67 $880.67 00031294 $3,318.65 $3,318.65 010 31601 $1,225.16 $1,225.16 00031295 $5,415.94 $428.95 000 31603 $879.72 $879.72 00031296 $5,485.22 $489.68 000 31605 $913.89 $913.89 00031297 $5,377.98 $390.04 000 31610 $2,270.27 $2,270.27 09031298 $10,423.82 $695.62 000 31611 $1,276.24 $1,276.24 09031299 80% of billed 80% of billed N/A 31612 $223.96 $131.91 00031300 $3,095.82 $3,095.82 090 31613 $1,081.64 $1,081.64 09031360 $5,029.13 $5,029.13 090 31614 $1,789.26 $1,789.26 09031365 $6,197.54 $6,197.54 090 31615 $451.72 $311.27 00031367 $5,320.60 $5,320.60 090 31622 $651.01 $359.67 00031368 $5,914.49 $5,914.49 090 31623 $735.48 $366.31 00031370 $5,003.86 $5,003.86 090 31624 $686.13 $371.06 00031375 $4,744.40 $4,744.40 090 31625 $896.81 $428.00 00031380 $4,677.85 $4,677.85 090 31626 $2,288.99 $546.62 00031382 $5,136.11 $5,136.11 090 31627 $3,787.46 $266.67 ZZZ31390 $6,899.26 $6,899.26 090 31628 $953.75 $483.04 00031395 $7,302.77 $7,302.77 090 31629 $1,175.81 $511.51 00031400 $2,351.14 $2,351.14 090 31630 $545.68 $545.68 00031420 $1,972.90 $1,972.90 090 31631 $625.39 $625.39 00031500 $385.29 $385.29 000 31632 $172.72 $134.76 ZZZ31502 $94.90 $94.90 000 31633 $217.32 $173.67 ZZZ31505 $221.12 $131.91 000 31634 $4,810.48 $515.31 00031510 $563.71 $327.41 000 31635 $759.20 $480.19 00031511 $565.60 $353.98 000 31636 $605.46 $605.46 00031512 $549.47 $349.23 000 31637 $203.09 $203.09 ZZZ31513 $354.93 $354.93 000 31638 $684.23 $684.23 00031515 $548.52 $298.94 000 31640 $688.03 $688.03 00031520 $422.31 $422.31 000 31641 $704.16 $704.16 00031525 $674.74 $432.74 000 31643 $484.94 $484.94 00031526 $424.20 $424.20 000 31645 $700.36 $401.43 00031527 $528.59 $528.59 000 31646 $388.14 $388.14 00031528 $390.04 $390.04 000 31647 $581.74 $581.74 00031529 $436.54 $436.54 000 31648 $533.34 $533.34 00031530 $540.93 $540.93 000 31649 $185.06 $185.06 ZZZ31531 $575.09 $575.09 000 31651 $203.09 $203.09 ZZZ31535 $514.36 $514.36 000 31652 $2,242.49 $607.36 00031536 $570.35 $570.35 000 31653 $2,370.60 $673.79 00031540 $653.86 $653.86 000 31654 $339.74 $185.06 ZZZ31541 $713.65 $713.65 000 31660 $534.29 $534.29 00031545 $980.32 $980.32 000 31661 $565.60 $565.60 00031546 $1,489.93 $1,489.93 000 31717 $725.99 $301.78 000

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 17 of 84

Page 18: Appendix B for Administrative Order No. 18-053 Physician ...Appendix B for Administrative Order No. 18-053 Physician Fee Schedule Effective April 1, 2018 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

31720 $135.71 $135.71 000 32561 $252.43 $186.95 00031725 $216.37 $216.37 000 32562 $226.81 $167.97 00031730 $3,345.23 $409.97 000 32601 $846.51 $846.51 00031750 $3,346.86 $3,346.86 090 32604 $1,322.91 $1,322.91 00031755 $4,227.16 $4,227.16 090 32606 $1,268.81 $1,268.81 00031760 $3,336.75 $3,336.75 090 32607 $845.56 $845.56 00031766 $4,330.78 $4,330.78 090 32608 $1,036.31 $1,036.31 00031770 $3,244.08 $3,244.08 090 32609 $708.90 $708.90 00031775 $3,406.67 $3,406.67 090 32650 $1,618.25 $1,618.25 09031780 $2,860.79 $2,860.79 090 32651 $2,662.83 $2,662.83 09031781 $3,372.97 $3,372.97 090 32652 $4,039.31 $4,039.31 09031785 $2,560.90 $2,560.90 090 32653 $2,575.22 $2,575.22 09031786 $3,512.81 $3,512.81 090 32654 $2,803.51 $2,803.51 09031800 $1,743.77 $1,743.77 090 32655 $2,324.18 $2,324.18 09031805 $1,983.01 $1,983.01 090 32656 $1,945.10 $1,945.10 09031820 $1,031.10 $780.90 090 32658 $1,736.19 $1,736.19 09031825 $1,424.50 $1,140.61 090 32659 $1,774.94 $1,774.94 09031830 $1,053.00 $817.97 090 32661 $1,944.26 $1,944.26 09031899 80% of billed 80% of billed N/A 32662 $2,164.97 $2,164.97 09032035 $1,766.51 $1,766.51 090 32663 $3,404.14 $3,404.14 09032036 $1,879.39 $1,879.39 090 32664 $2,064.72 $2,064.72 09032096 $1,956.05 $1,956.05 090 32665 $3,004.84 $3,004.84 09032097 $1,954.37 $1,954.37 090 32666 $2,116.11 $2,116.11 09032098 $1,854.96 $1,854.96 090 32667 $430.85 $430.85 ZZZ32100 $1,967.85 $1,967.85 090 32668 $430.85 $430.85 ZZZ32110 $3,565.04 $3,565.04 090 32669 $3,271.04 $3,271.04 09032120 $2,118.64 $2,118.64 090 32670 $3,904.52 $3,904.52 09032124 $2,252.58 $2,252.58 090 32671 $4,335.83 $4,335.83 09032140 $2,415.16 $2,415.16 090 32672 $3,720.88 $3,720.88 09032141 $3,706.56 $3,706.56 090 32673 $2,965.25 $2,965.25 09032150 $2,437.06 $2,437.06 090 32674 $591.23 $591.23 ZZZ32151 $2,450.54 $2,450.54 090 32701 $588.38 $588.38 N/A32160 $1,921.51 $1,921.51 090 32800 $2,295.54 $2,295.54 09032200 $2,772.34 $2,772.34 090 32810 $2,193.61 $2,193.61 09032215 $1,956.90 $1,956.90 090 32815 $6,783.85 $6,783.85 09032220 $3,848.93 $3,848.93 090 32820 $3,239.87 $3,239.87 09032225 $2,416.85 $2,416.85 090 32850 80% of billed 80% of billed N/A32310 $2,218.04 $2,218.04 090 32851 $8,009.54 $8,009.54 09032320 $3,880.09 $3,880.09 090 32852 $8,712.10 $8,712.10 09032400 $407.12 $238.20 000 32853 $11,155.06 $11,155.06 09032405 $1,056.24 $248.64 000 32854 $11,832.35 $11,832.35 09032440 $3,803.44 $3,803.44 090 32855 80% of billed 80% of billed N/A32442 $7,468.72 $7,468.72 090 32856 80% of billed 80% of billed N/A32445 $8,605.12 $8,605.12 090 32900 $3,449.63 $3,449.63 09032480 $3,593.68 $3,593.68 090 32905 $3,258.40 $3,258.40 09032482 $3,845.56 $3,845.56 090 32906 $4,023.30 $4,023.30 09032484 $3,490.06 $3,490.06 090 32940 $3,009.05 $3,009.05 09032486 $5,729.16 $5,729.16 090 32960 $343.54 $250.54 00032488 $5,844.57 $5,844.57 090 32994 $16,623.63 $1,330.50 00032491 $3,532.18 $3,532.18 090 32997 $935.71 $935.71 00032501 $671.89 $671.89 ZZZ 32998 $9,766.16 $1,229.90 00032503 $4,380.48 $4,380.48 090 32999 80% of billed 80% of billed N/A32504 $4,991.22 $4,991.22 090 33010 $296.09 $296.09 00032505 $2,262.69 $2,262.69 090 33011 $297.99 $297.99 00032506 $429.90 $429.90 ZZZ 33015 $1,245.91 $1,245.91 09032507 $429.90 $429.90 ZZZ 33020 $2,142.22 $2,142.22 09032540 $4,201.89 $4,201.89 090 33025 $1,942.57 $1,942.57 09032550 $1,917.93 $570.35 000 33030 $4,876.65 $4,876.65 09032551 $430.85 $430.85 000 33031 $6,020.63 $6,020.63 09032552 $498.23 $431.80 010 33050 $2,462.34 $2,462.34 09032553 $1,411.16 $493.48 000 33120 $5,105.79 $5,105.79 09032554 $548.52 $245.79 000 33130 $3,353.59 $3,353.59 09032555 $783.87 $305.58 000 33140 $3,832.92 $3,832.92 09032556 $1,508.91 $335.95 000 33141 $361.57 $361.57 ZZZ32557 $1,379.85 $416.61 000 33202 $1,892.03 $1,892.03 09032560 $663.35 $213.53 000 33203 $1,972.90 $1,972.90 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 18 of 84

Page 19: Appendix B for Administrative Order No. 18-053 Physician ...Appendix B for Administrative Order No. 18-053 Physician Fee Schedule Effective April 1, 2018 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

33206 $1,105.23 $1,105.23 090 33362 $4,088.29 $4,088.29 00033207 $1,176.83 $1,176.83 090 33363 $4,240.13 $4,240.13 00033208 $1,274.55 $1,274.55 090 33364 $4,465.99 $4,465.99 00033210 $453.62 $453.62 000 33365 $4,912.02 $4,912.02 00033211 $467.86 $467.86 000 33366 $5,312.50 $5,312.50 00033212 $783.43 $783.43 090 33367 $1,732.87 $1,732.87 ZZZ33213 $819.66 $819.66 090 33368 $2,059.33 $2,059.33 ZZZ33214 $1,170.09 $1,170.09 090 33369 $2,718.89 $2,718.89 ZZZ33215 $759.84 $759.84 090 33390 $4,628.99 $4,628.99 09033216 $905.58 $905.58 090 33391 $5,491.61 $5,491.61 09033217 $889.57 $889.57 090 33404 $4,295.40 $4,295.40 09033218 $948.54 $948.54 090 33405 $5,527.83 $5,527.83 09033220 $956.97 $956.97 090 33406 $6,995.29 $6,995.29 09033221 $880.31 $880.31 090 33410 $6,200.06 $6,200.06 09033222 $824.71 $824.71 090 33411 $8,166.23 $8,166.23 09033223 $999.09 $999.09 090 33412 $7,745.03 $7,745.03 09033224 $1,422.55 $1,422.55 000 33413 $7,921.93 $7,921.93 09033225 $1,297.28 $1,297.28 ZZZ 33414 $5,259.10 $5,259.10 09033226 $1,367.51 $1,367.51 000 33415 $4,947.42 $4,947.42 09033227 $826.39 $826.39 090 33416 $4,940.68 $4,940.68 09033228 $865.14 $865.14 090 33417 $4,074.69 $4,074.69 09033229 $915.69 $915.69 090 33418 $4,407.44 $4,407.44 09033230 $934.22 $934.22 090 33419 $1,172.96 $1,172.96 ZZZ33231 $981.40 $981.40 090 33420 $3,560.82 $3,560.82 09033233 $561.88 $561.88 090 33422 $4,087.32 $4,087.32 09033234 $1,186.10 $1,186.10 090 33425 $6,663.38 $6,663.38 09033235 $1,560.12 $1,560.12 090 33426 $5,804.98 $5,804.98 09033236 $1,907.19 $1,907.19 090 33427 $5,959.14 $5,959.14 09033237 $2,047.87 $2,047.87 090 33430 $6,815.02 $6,815.02 09033238 $2,295.54 $2,295.54 090 33460 $5,909.44 $5,909.44 09033240 $893.79 $893.79 090 33463 $7,523.47 $7,523.47 09033241 $526.50 $526.50 090 33464 $5,951.56 $5,951.56 09033243 $3,340.96 $3,340.96 090 33465 $6,718.98 $6,718.98 09033244 $2,105.16 $2,105.16 090 33468 $5,996.20 $5,996.20 09033249 $2,243.31 $2,243.31 090 33470 $3,024.22 $3,024.22 09033250 $3,574.30 $3,574.30 090 33471 $3,237.34 $3,237.34 09033251 $3,955.91 $3,955.91 090 33474 $5,325.65 $5,325.65 09033254 $3,319.90 $3,319.90 090 33475 $5,707.26 $5,707.26 09033255 $3,996.35 $3,996.35 090 33476 $3,720.88 $3,720.88 09033256 $4,742.71 $4,742.71 090 33477 $3,762.79 $3,762.79 00033257 $1,598.12 $1,598.12 ZZZ 33478 $3,844.71 $3,844.71 09033258 $1,805.95 $1,805.95 ZZZ 33496 $4,088.17 $4,088.17 09033259 $2,318.41 $2,318.41 ZZZ 33500 $3,832.92 $3,832.92 09033261 $3,956.75 $3,956.75 090 33501 $2,736.96 $2,736.96 09033262 $910.63 $910.63 090 33502 $3,118.56 $3,118.56 09033263 $950.23 $950.23 090 33503 $3,241.56 $3,241.56 09033264 $989.82 $989.82 090 33504 $3,583.57 $3,583.57 09033265 $3,311.47 $3,311.47 090 33505 $5,049.35 $5,049.35 09033266 $4,497.57 $4,497.57 090 33506 $5,028.29 $5,028.29 09033270 $1,390.80 $1,390.80 090 33507 $4,217.90 $4,217.90 09033271 $1,117.86 $1,117.86 090 33508 $44.60 $44.60 ZZZ33272 $855.04 $855.04 090 33510 $4,708.17 $4,708.17 09033273 $984.77 $984.77 090 33511 $5,174.02 $5,174.02 09033282 $551.77 $551.77 090 33512 $5,883.32 $5,883.32 09033284 $483.54 $483.54 090 33513 $6,052.64 $6,052.64 09033300 $5,970.93 $5,970.93 090 33514 $6,417.40 $6,417.40 09033305 $9,994.23 $9,994.23 090 33516 $6,644.85 $6,644.85 09033310 $2,869.21 $2,869.21 090 33517 $515.31 $515.31 ZZZ33315 $4,655.10 $4,655.10 090 33518 $1,132.16 $1,132.16 ZZZ33320 $2,574.37 $2,574.37 090 33519 $1,496.57 $1,496.57 ZZZ33321 $2,915.55 $2,915.55 090 33521 $1,793.61 $1,793.61 ZZZ33322 $3,383.08 $3,383.08 090 33522 $2,015.68 $2,015.68 ZZZ33330 $3,497.64 $3,497.64 090 33523 $2,299.43 $2,299.43 ZZZ33335 $4,612.14 $4,612.14 090 33530 $1,446.28 $1,446.28 ZZZ33340 $2,191.24 $2,191.24 000 33533 $4,554.01 $4,554.01 09033361 $3,744.75 $3,744.75 000 33534 $5,357.66 $5,357.66 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 19 of 84

Page 20: Appendix B for Administrative Order No. 18-053 Physician ...Appendix B for Administrative Order No. 18-053 Physician Fee Schedule Effective April 1, 2018 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

33535 $5,969.25 $5,969.25 090 33788 $3,749.52 $3,749.52 09033536 $6,411.51 $6,411.51 090 33800 $2,414.32 $2,414.32 09033542 $6,389.60 $6,389.60 090 33802 $2,651.03 $2,651.03 09033545 $7,540.32 $7,540.32 090 33803 $2,814.46 $2,814.46 09033548 $7,255.59 $7,255.59 090 33813 $3,030.11 $3,030.11 09033572 $632.98 $632.98 ZZZ 33814 $3,725.09 $3,725.09 09033600 $4,201.89 $4,201.89 090 33820 $2,368.83 $2,368.83 09033602 $4,077.22 $4,077.22 090 33822 $2,499.40 $2,499.40 09033606 $4,346.78 $4,346.78 090 33824 $2,883.54 $2,883.54 09033608 $4,401.54 $4,401.54 090 33840 $3,028.43 $3,028.43 09033610 $4,340.04 $4,340.04 090 33845 $3,262.62 $3,262.62 09033611 $4,777.25 $4,777.25 090 33851 $3,110.14 $3,110.14 09033612 $4,902.77 $4,902.77 090 33852 $3,419.30 $3,419.30 09033615 $4,882.55 $4,882.55 090 33853 $4,482.41 $4,482.41 09033617 $5,288.59 $5,288.59 090 33860 $7,829.27 $7,829.27 09033619 $6,663.38 $6,663.38 090 33863 $7,681.00 $7,681.00 09033620 $4,038.47 $4,038.47 090 33864 $7,866.33 $7,866.33 09033621 $2,277.01 $2,277.01 090 33870 $6,150.36 $6,150.36 09033622 $8,391.15 $8,391.15 090 33875 $6,699.61 $6,699.61 09033641 $4,011.51 $4,011.51 090 33877 $8,841.83 $8,841.83 09033645 $4,235.59 $4,235.59 090 33880 $4,394.80 $4,394.80 09033647 $4,447.87 $4,447.87 090 33881 $3,774.79 $3,774.79 09033660 $4,298.77 $4,298.77 090 33883 $2,740.33 $2,740.33 09033665 $4,684.59 $4,684.59 090 33884 $1,146.39 $1,146.39 ZZZ33670 $4,828.64 $4,828.64 090 33886 $2,376.41 $2,376.41 09033675 $4,826.95 $4,826.95 090 33889 $2,188.39 $2,188.39 00033676 $4,955.00 $4,955.00 090 33891 $2,661.00 $2,661.00 00033677 $5,146.22 $5,146.22 090 33910 $6,425.83 $6,425.83 09033681 $4,496.73 $4,496.73 090 33915 $3,382.24 $3,382.24 09033684 $4,623.09 $4,623.09 090 33916 $10,314.35 $10,314.35 09033688 $4,613.82 $4,613.82 090 33917 $3,563.35 $3,563.35 09033690 $2,933.24 $2,933.24 090 33920 $4,426.81 $4,426.81 09033692 $4,789.89 $4,789.89 090 33922 $3,395.71 $3,395.71 09033694 $4,777.25 $4,777.25 090 33924 $790.52 $790.52 ZZZ33697 $5,032.50 $5,032.50 090 33925 $4,205.26 $4,205.26 09033702 $3,780.69 $3,780.69 090 33926 $5,914.49 $5,914.49 09033710 $5,023.23 $5,023.23 090 33927 $7,006.47 $7,006.47 N/A33720 $3,784.06 $3,784.06 090 33928 80% of billed 80% of billed N/A33722 $3,976.13 $3,976.13 090 33929 80% of billed 80% of billed ZZZ33724 $3,767.21 $3,767.21 090 33930 80% of billed 80% of billed N/A33726 $4,977.74 $4,977.74 090 33933 80% of billed 80% of billed N/A33730 $4,903.61 $4,903.61 090 33935 $12,007.57 $12,007.57 09033732 $4,027.51 $4,027.51 090 33940 80% of billed 80% of billed N/A33735 $3,167.42 $3,167.42 090 33944 80% of billed 80% of billed N/A33736 $3,436.15 $3,436.15 090 33945 $11,808.76 $11,808.76 09033737 $3,172.48 $3,172.48 090 33946 $850.30 $850.30 N/A33750 $3,085.71 $3,085.71 090 33947 $948.05 $948.05 N/A33755 $3,219.65 $3,219.65 090 33948 $658.61 $658.61 N/A33762 $3,135.41 $3,135.41 090 33949 $638.68 $638.68 N/A33764 $3,219.65 $3,219.65 090 33951 $1,174.86 $1,174.86 00033766 $3,256.72 $3,256.72 090 33952 $1,179.61 $1,179.61 00033767 $3,479.95 $3,479.95 090 33953 $1,313.42 $1,313.42 00033768 $1,148.29 $1,148.29 ZZZ 33954 $1,318.16 $1,318.16 00033770 $5,180.76 $5,180.76 090 33955 $2,301.33 $2,301.33 00033771 $5,332.39 $5,332.39 090 33956 $2,296.58 $2,296.58 00033774 $4,399.01 $4,399.01 090 33957 $511.51 $511.51 00033775 $4,532.95 $4,532.95 090 33958 $512.46 $512.46 00033776 $4,792.41 $4,792.41 090 33959 $649.12 $649.12 00033777 $4,626.46 $4,626.46 090 33962 $651.01 $651.01 00033778 $5,746.01 $5,746.01 090 33963 $1,297.28 $1,297.28 00033779 $5,691.25 $5,691.25 090 33964 $1,369.41 $1,369.41 00033780 $5,797.40 $5,797.40 090 33965 $511.51 $511.51 00033781 $5,659.24 $5,659.24 090 33966 $653.86 $653.86 00033782 $7,895.81 $7,895.81 090 33967 $716.50 $716.50 00033783 $8,528.46 $8,528.46 090 33968 $93.00 $93.00 00033786 $5,569.11 $5,569.11 090 33969 $757.30 $757.30 000

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 20 of 84

Page 21: Appendix B for Administrative Order No. 18-053 Physician ...Appendix B for Administrative Order No. 18-053 Physician Fee Schedule Effective April 1, 2018 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

33970 $978.42 $978.42 000 34839 80% of billed 80% of billed N/A33971 $1,729.45 $1,729.45 090 34841 80% of billed 80% of billed N/A33973 $1,427.30 $1,427.30 000 34842 80% of billed 80% of billed N/A33974 $2,174.23 $2,174.23 090 34843 80% of billed 80% of billed N/A33975 $3,602.40 $3,602.40 N/A 34844 80% of billed 80% of billed N/A33976 $4,401.46 $4,401.46 N/A 34845 80% of billed 80% of billed N/A33977 $3,094.69 $3,094.69 N/A 34846 80% of billed 80% of billed N/A33978 $3,692.56 $3,692.56 N/A 34847 80% of billed 80% of billed N/A33979 $5,374.19 $5,374.19 N/A 34848 80% of billed 80% of billed N/A33980 $4,914.87 $4,914.87 N/A 35001 $2,747.91 $2,747.91 09033981 $2,306.07 $2,306.07 N/A 35002 $2,774.02 $2,774.02 09033982 $5,417.84 $5,417.84 N/A 35005 $2,426.95 $2,426.95 09033983 $6,366.84 $6,366.84 N/A 35011 $2,463.18 $2,463.18 09033984 $785.77 $785.77 000 35013 $3,079.81 $3,079.81 09033985 $1,425.40 $1,425.40 000 35021 $3,083.18 $3,083.18 09033986 $1,439.63 $1,439.63 000 35022 $3,532.18 $3,532.18 09033987 $577.94 $577.94 ZZZ 35045 $2,414.32 $2,414.32 09033988 $2,155.18 $2,155.18 000 35081 $4,264.23 $4,264.23 09033989 $1,369.41 $1,369.41 000 35082 $5,371.98 $5,371.98 09033990 $1,175.81 $1,175.81 N/A 35091 $4,383.85 $4,383.85 09033991 $1,733.82 $1,733.82 N/A 35092 $6,366.86 $6,366.86 09033992 $552.32 $552.32 N/A 35102 $4,612.98 $4,612.98 09033993 $483.04 $483.04 N/A 35103 $5,492.45 $5,492.45 09033999 80% of billed 80% of billed N/A 35111 $3,247.45 $3,247.45 09034001 $2,238.26 $2,238.26 090 35112 $3,996.35 $3,996.35 09034051 $2,424.43 $2,424.43 090 35121 $4,047.73 $4,047.73 09034101 $1,468.30 $1,468.30 090 35122 $4,623.09 $4,623.09 09034111 $1,467.46 $1,467.46 090 35131 $3,413.40 $3,413.40 09034151 $3,420.99 $3,420.99 090 35132 $3,996.35 $3,996.35 09034201 $2,523.83 $2,523.83 090 35141 $2,710.84 $2,710.84 09034203 $2,336.82 $2,336.82 090 35142 $3,254.19 $3,254.19 09034401 $3,607.16 $3,607.16 090 35151 $3,046.12 $3,046.12 09034421 $1,801.05 $1,801.05 090 35152 $3,416.77 $3,416.77 09034451 $3,510.28 $3,510.28 090 35180 $2,137.17 $2,137.17 09034471 $2,636.71 $2,636.71 090 35182 $4,367.00 $4,367.00 09034490 $1,512.95 $1,512.95 090 35184 $2,357.04 $2,357.04 09034501 $2,180.97 $2,180.97 090 35188 $3,175.01 $3,175.01 09034502 $3,779.01 $3,779.01 090 35189 $3,688.87 $3,688.87 09034510 $2,493.50 $2,493.50 090 35190 $1,869.29 $1,869.29 09034520 $2,416.85 $2,416.85 090 35201 $2,297.22 $2,297.22 09034530 $2,292.17 $2,292.17 090 35206 $1,913.09 $1,913.09 09034701 $3,009.05 $3,009.05 090 35207 $1,838.12 $1,838.12 09034702 $4,495.05 $4,495.05 090 35211 $3,372.13 $3,372.13 09034703 $3,390.66 $3,390.66 090 35216 $5,019.02 $5,019.02 09034704 $5,639.87 $5,639.87 090 35221 $3,575.99 $3,575.99 09034705 $3,735.20 $3,735.20 090 35226 $2,043.66 $2,043.66 09034706 $5,622.18 $5,622.18 090 35231 $3,030.96 $3,030.96 09034707 $2,806.03 $2,806.03 090 35236 $2,440.43 $2,440.43 09034708 $4,516.11 $4,516.11 090 35241 $3,544.82 $3,544.82 09034709 $890.16 $890.16 ZZZ 35246 $3,840.50 $3,840.50 09034710 $1,958.58 $1,958.58 090 35251 $4,268.44 $4,268.44 09034711 $821.83 $821.83 ZZZ 35256 $2,507.82 $2,507.82 09034712 $1,673.85 $1,673.85 090 35261 $2,582.80 $2,582.80 09034713 $354.93 $354.93 ZZZ 35266 $2,119.48 $2,119.48 09034714 $744.97 $744.97 ZZZ 35271 $3,376.34 $3,376.34 09034715 $832.27 $832.27 ZZZ 35276 $3,571.78 $3,571.78 09034716 $1,033.46 $1,033.46 ZZZ 35281 $3,948.33 $3,948.33 09034808 $575.09 $575.09 ZZZ 35286 $2,282.90 $2,282.90 09034812 $571.30 $571.30 ZZZ 35301 $2,777.39 $2,777.39 09034813 $652.91 $652.91 ZZZ 35302 $2,754.65 $2,754.65 09034820 $974.62 $974.62 ZZZ 35303 $3,045.28 $3,045.28 09034830 $4,309.72 $4,309.72 090 35304 $3,148.05 $3,148.05 09034831 $4,728.39 $4,728.39 090 35305 $3,026.74 $3,026.74 09034832 $4,634.88 $4,634.88 090 35306 $1,230.85 $1,230.85 ZZZ34833 $1,117.92 $1,117.92 ZZZ 35311 $3,823.65 $3,823.65 09034834 $359.67 $359.67 ZZZ 35321 $2,184.34 $2,184.34 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 21 of 84

Page 22: Appendix B for Administrative Order No. 18-053 Physician ...Appendix B for Administrative Order No. 18-053 Physician Fee Schedule Effective April 1, 2018 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

35331 $3,563.35 $3,563.35 090 35654 $3,360.33 $3,360.33 09035341 $3,372.97 $3,372.97 090 35656 $2,657.77 $2,657.77 09035351 $3,144.68 $3,144.68 090 35661 $2,661.98 $2,661.98 09035355 $2,532.25 $2,532.25 090 35663 $2,976.20 $2,976.20 09035361 $3,720.04 $3,720.04 090 35665 $2,879.32 $2,879.32 09035363 $4,316.46 $4,316.46 090 35666 $3,105.09 $3,105.09 09035371 $2,006.60 $2,006.60 090 35671 $2,738.64 $2,738.64 09035372 $2,409.26 $2,409.26 090 35681 $222.07 $222.07 ZZZ35390 $440.34 $440.34 ZZZ 35682 $976.52 $976.52 ZZZ35400 $412.82 $412.82 ZZZ 35683 $1,128.36 $1,128.36 ZZZ35500 $884.47 $884.47 ZZZ 35685 $548.52 $548.52 ZZZ35501 $3,572.62 $3,572.62 090 35686 $445.08 $445.08 ZZZ35506 $3,117.72 $3,117.72 090 35691 $2,311.55 $2,311.55 09035508 $3,249.14 $3,249.14 090 35693 $2,037.77 $2,037.77 09035509 $3,459.74 $3,459.74 090 35694 $2,411.79 $2,411.79 09035510 $3,009.90 $3,009.90 090 35695 $2,505.30 $2,505.30 09035511 $2,741.17 $2,741.17 090 35697 $409.97 $409.97 ZZZ35512 $2,950.93 $2,950.93 090 35700 $422.31 $422.31 ZZZ35515 $3,249.14 $3,249.14 090 35701 $1,375.64 $1,375.64 09035516 $2,984.62 $2,984.62 090 35721 $1,123.76 $1,123.76 09035518 $2,794.24 $2,794.24 090 35741 $1,264.44 $1,264.44 09035521 $2,999.79 $2,999.79 090 35761 $958.65 $958.65 09035522 $2,968.62 $2,968.62 090 35800 $1,751.35 $1,751.35 09035523 $3,125.30 $3,125.30 090 35820 $4,913.72 $4,913.72 09035525 $2,797.61 $2,797.61 090 35840 $2,923.97 $2,923.97 09035526 $4,252.44 $4,252.44 090 35860 $2,056.30 $2,056.30 09035531 $4,992.06 $4,992.06 090 35870 $3,041.91 $3,041.91 09035533 $3,682.13 $3,682.13 090 35875 $1,463.25 $1,463.25 09035535 $4,655.94 $4,655.94 090 35876 $2,329.24 $2,329.24 09035536 $4,133.66 $4,133.66 090 35879 $2,273.64 $2,273.64 09035537 $5,099.05 $5,099.05 090 35881 $2,500.24 $2,500.24 09035538 $5,707.26 $5,707.26 090 35883 $2,956.82 $2,956.82 09035539 $5,362.72 $5,362.72 090 35884 $3,035.17 $3,035.17 09035540 $5,976.83 $5,976.83 090 35901 $1,149.03 $1,149.03 09035556 $3,435.31 $3,435.31 090 35903 $1,380.69 $1,380.69 09035558 $3,020.85 $3,020.85 090 35905 $4,108.38 $4,108.38 09035560 $4,169.04 $4,169.04 090 35907 $4,693.01 $4,693.01 09035563 $3,234.82 $3,234.82 090 36000 $70.23 $25.62 N/A35565 $3,245.77 $3,245.77 090 36002 $435.59 $291.34 00035566 $4,099.96 $4,099.96 090 36005 $874.98 $132.86 00035570 $3,725.94 $3,725.94 090 36010 $1,297.28 $301.78 N/A35571 $3,254.19 $3,254.19 090 36011 $2,232.05 $432.74 N/A35572 $958.49 $958.49 ZZZ 36012 $2,288.99 $478.30 N/A35583 $3,549.03 $3,549.03 090 36013 $2,065.97 $335.95 N/A35585 $4,110.07 $4,110.07 090 36014 $2,139.05 $414.71 N/A35587 $3,357.81 $3,357.81 090 36015 $2,326.00 $472.60 N/A35600 $702.26 $702.26 ZZZ 36100 $1,306.77 $427.05 N/A35601 $3,423.51 $3,423.51 090 36140 $1,150.19 $249.59 N/A35606 $2,879.32 $2,879.32 090 36160 $1,325.75 $340.69 N/A35612 $2,552.47 $2,552.47 090 36200 $1,508.91 $385.29 00035616 $2,696.52 $2,696.52 090 36215 $2,717.94 $586.48 00035621 $2,696.52 $2,696.52 090 36216 $2,947.59 $754.46 00035623 $3,212.07 $3,212.07 090 36217 $5,005.98 $900.60 00035626 $3,876.72 $3,876.72 090 36218 $680.43 $143.30 ZZZ35631 $4,542.22 $4,542.22 090 36221 $2,762.54 $554.22 00035632 $4,420.07 $4,420.07 090 36222 $3,253.17 $779.13 00035633 $4,902.77 $4,902.77 090 36223 $4,075.96 $867.39 00035634 $4,324.88 $4,324.88 090 36224 $5,177.74 $984.11 00035636 $3,899.47 $3,899.47 090 36225 $3,922.22 $864.54 00035637 $4,223.79 $4,223.79 090 36226 $5,020.21 $975.57 00035638 $4,312.25 $4,312.25 090 36227 $693.72 $320.76 ZZZ35642 $2,410.95 $2,410.95 090 36228 $3,565.39 $663.35 ZZZ35645 $2,313.23 $2,313.23 090 36245 $3,524.59 $657.66 N/A35646 $4,212.00 $4,212.00 090 36246 $2,213.07 $703.21 00035647 $3,810.18 $3,810.18 090 36247 $4,034.20 $836.07 00035650 $2,662.83 $2,662.83 090 36248 $410.92 $134.76 ZZZ

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 22 of 84

Page 23: Appendix B for Administrative Order No. 18-053 Physician ...Appendix B for Administrative Order No. 18-053 Physician Fee Schedule Effective April 1, 2018 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

36251 $3,722.93 $718.39 000 36589 $444.13 $374.86 01036252 $4,025.66 $997.40 000 36590 $600.72 $522.90 01036253 $5,944.54 $989.81 000 36591 $64.53 $64.53 N/A36254 $5,813.57 $1,164.42 000 36592 $72.12 $72.12 N/A36260 $1,577.82 $1,577.82 090 36593 $85.41 $85.41 N/A36261 $976.34 $976.34 090 36595 $1,591.47 $503.92 00036262 $741.31 $741.31 090 36596 $353.98 $122.42 00036299 80% of billed 80% of billed N/A 36597 $344.49 $167.02 00036400 $71.18 $50.30 N/A 36598 $301.78 $100.59 00036405 $62.63 $41.76 N/A 36600 $88.26 $42.71 N/A36406 $44.60 $23.73 N/A 36620 $120.52 $120.52 00036410 $45.55 $25.62 N/A 36625 $288.50 $288.50 00036415 80% of billed 80% of billed N/A 36640 $313.17 $313.17 00036416 80% of billed 80% of billed N/A 36660 $187.90 $187.90 00036420 $128.12 $128.12 N/A 36680 $160.38 $160.38 00036425 $110.08 $110.08 N/A 36800 $335.95 $335.95 00036430 $94.90 $94.90 N/A 36810 $582.69 $582.69 00036440 $138.55 $138.55 N/A 36815 $373.91 $373.91 00036450 $468.81 $468.81 N/A 36818 $1,702.49 $1,702.49 09036455 $349.23 $349.23 N/A 36819 $1,793.47 $1,793.47 09036456 $297.04 $297.04 N/A 36820 $1,800.21 $1,800.21 09036460 $938.56 $938.56 N/A 36821 $1,628.36 $1,628.36 09036465 $4,281.89 $328.35 000 36823 $3,400.77 $3,400.77 09036466 $4,473.59 $417.56 000 36825 $1,956.05 $1,956.05 09036468 80% of billed 80% of billed 000 36830 $1,634.26 $1,634.26 09036470 $284.70 $105.34 000 36831 $1,512.95 $1,512.95 09036471 $511.51 $209.73 000 36832 $1,855.81 $1,855.81 09036473 $4,063.62 $486.84 000 36833 $1,992.28 $1,992.28 09036474 $746.86 $243.89 ZZZ 36835 $1,162.51 $1,162.51 09036475 $4,084.50 $772.49 000 36838 $2,811.09 $2,811.09 09036476 $793.36 $374.86 ZZZ 36860 $597.87 $328.35 00036478 $3,258.87 $766.79 000 36861 $381.50 $381.50 00036479 $837.97 $375.80 ZZZ 36901 $1,611.40 $465.01 00036481 $5,293.52 $924.33 000 36902 $3,353.77 $662.40 00036482 $5,699.69 $486.84 000 36903 $15,092.90 $876.88 00036483 $387.19 $242.94 ZZZ 36904 $4,874.06 $1,023.02 00036500 $503.92 $503.92 000 36905 $6,177.99 $1,228.01 00036510 $220.17 $146.15 000 36906 $18,317.60 $1,418.76 00036511 $296.09 $296.09 000 36907 $2,029.91 $406.17 ZZZ36512 $297.04 $297.04 000 36908 $7,283.58 $578.89 ZZZ36513 $304.63 $304.63 000 36909 $5,293.52 $573.20 ZZZ36514 $2,098.24 $264.77 000 37140 $5,660.09 $5,660.09 09036516 $5,882.85 $235.35 000 37145 $5,251.52 $5,251.52 09036522 $6,697.09 $266.67 000 37160 $5,392.20 $5,392.20 09036555 $500.12 $236.30 000 37180 $5,189.18 $5,189.18 09036556 $566.55 $267.62 000 37181 $5,660.09 $5,660.09 09036557 $2,527.19 $871.18 010 37182 $2,268.11 $2,268.11 00036558 $1,926.47 $719.34 010 37183 $15,643.32 $1,034.41 00036560 $3,522.69 $1,046.75 010 37184 $5,959.72 $1,242.24 00036561 $2,925.77 $929.07 010 37185 $1,895.15 $465.01 ZZZ36563 $3,328.14 $1,012.58 010 37186 $3,587.22 $677.59 ZZZ36565 $2,388.63 $918.63 010 37187 $5,337.18 $1,083.76 00036566 $13,895.26 $1,010.69 010 37188 $4,502.06 $771.54 00036568 $588.38 $202.14 000 37191 $6,901.13 $619.70 00036569 $667.15 $233.45 000 37192 $3,640.36 $968.93 00036570 $3,767.53 $906.30 010 37193 $4,118.66 $967.03 00036571 $3,300.62 $852.20 010 37195 80% of billed 80% of billed N/A36575 $445.08 $95.85 000 37197 $3,904.19 $832.27 00036576 $850.30 $504.87 010 37200 $598.82 $598.82 00036578 $1,213.77 $557.06 010 37211 $1,063.83 $1,063.83 00036580 $577.94 $182.21 000 37212 $931.92 $931.92 00036581 $1,902.75 $502.97 010 37213 $644.37 $644.37 00036582 $2,705.60 $796.21 010 37214 $337.84 $337.84 00036583 $3,421.15 $895.86 010 37215 $2,458.12 $2,458.12 09036584 $553.27 $181.26 000 37216 $2,469.07 $2,469.07 09036585 $2,857.44 $744.97 010 37217 $2,656.09 $2,656.09 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 23 of 84

Page 24: Appendix B for Administrative Order No. 18-053 Physician ...Appendix B for Administrative Order No. 18-053 Physician Fee Schedule Effective April 1, 2018 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

37218 $1,990.59 $1,990.59 090 38204 $288.50 $288.50 N/A37220 $8,228.78 $1,112.23 000 38205 $228.71 $228.71 00037221 $12,206.99 $1,372.25 000 38206 $227.76 $227.76 00037222 $2,312.71 $517.21 ZZZ 38207 $129.06 $129.06 N/A37223 $6,840.39 $591.23 ZZZ 38208 $81.61 $81.61 N/A37224 $9,992.02 $1,230.85 000 38209 $34.16 $34.16 N/A37225 $29,341.18 $1,678.78 000 38210 $227.76 $227.76 N/A37226 $23,987.87 $1,447.23 000 38211 $205.93 $205.93 N/A37227 $39,704.26 $2,017.57 000 38212 $136.66 $136.66 N/A37228 $14,299.53 $1,507.01 000 38213 $34.16 $34.16 N/A37229 $28,934.06 $1,956.84 000 38214 $117.68 $117.68 N/A37230 $22,114.55 $1,936.91 000 38215 $136.66 $136.66 N/A37231 $35,865.56 $2,103.93 000 38220 $459.32 $189.80 N/A37232 $3,190.54 $558.96 ZZZ 38221 $413.76 $191.70 N/A37233 $3,860.53 $911.04 ZZZ 38222 $459.32 $212.58 N/A37234 $10,462.73 $790.52 ZZZ 38230 $568.45 $568.45 00037235 $11,056.80 $1,108.43 ZZZ 38232 $546.62 $546.62 00037236 $10,342.20 $1,233.70 000 38240 $618.75 $618.75 N/A37237 $6,508.24 $590.28 ZZZ 38241 $463.11 $463.11 N/A37238 $11,203.89 $828.48 000 38242 $326.46 $326.46 00037239 $5,424.48 $420.41 ZZZ 38243 $295.14 $295.14 00037241 $12,733.68 $1,225.16 000 38300 $857.90 $553.27 01037242 $19,703.14 $1,323.86 000 38305 $1,175.15 $1,175.15 09037243 $26,098.45 $1,554.46 000 38308 $1,084.17 $1,084.17 09037244 $18,192.33 $1,838.21 000 38380 $1,358.79 $1,358.79 09037246 $5,751.89 $962.29 000 38381 $1,952.68 $1,952.68 09037247 $2,324.10 $472.60 ZZZ 38382 $1,636.78 $1,636.78 09037248 $3,990.55 $823.73 000 38500 $902.50 $696.57 01037249 $1,707.25 $400.48 ZZZ 38505 $339.74 $193.60 00037252 $3,684.97 $252.43 ZZZ 38510 $1,403.57 $1,143.55 01037253 $556.11 $203.09 ZZZ 38520 $1,125.45 $1,125.45 09037500 $1,555.07 $1,555.07 090 38525 $1,063.11 $1,063.11 09037501 80% of billed 80% of billed N/A 38530 $1,357.95 $1,357.95 09037565 $1,766.51 $1,766.51 090 38542 $1,247.59 $1,247.59 09037600 $1,754.72 $1,754.72 090 38550 $1,236.64 $1,236.64 09037605 $1,806.11 $1,806.11 090 38555 $2,453.07 $2,453.07 09037606 $1,758.09 $1,758.09 090 38562 $1,717.65 $1,717.65 09037607 $918.22 $918.22 090 38564 $1,711.76 $1,711.76 09037609 $837.97 $566.55 010 38570 $1,391.23 $1,391.23 01037615 $1,274.55 $1,274.55 090 38571 $1,824.93 $1,824.93 01037616 $2,717.58 $2,717.58 090 38572 $2,538.58 $2,538.58 01037617 $3,271.04 $3,271.04 090 38573 $3,187.69 $3,187.69 01037618 $935.06 $935.06 090 38589 80% of billed 80% of billed N/A37619 $4,212.00 $4,212.00 090 38700 $1,931.62 $1,931.62 09037650 $1,121.23 $1,121.23 090 38720 $3,233.13 $3,233.13 09037660 $3,212.91 $3,212.91 090 38724 $3,485.85 $3,485.85 09037700 $603.16 $603.16 090 38740 $1,690.70 $1,690.70 09037718 $1,055.53 $1,055.53 090 38745 $2,135.48 $2,135.48 09037722 $1,159.14 $1,159.14 090 38746 $591.23 $591.23 ZZZ37735 $1,418.60 $1,418.60 090 38747 $735.48 $735.48 ZZZ37760 $1,509.58 $1,509.58 090 38760 $2,050.40 $2,050.40 09037761 $1,329.31 $1,329.31 090 38765 $3,153.95 $3,153.95 09037765 $1,567.71 $1,095.12 090 38770 $1,971.22 $1,971.22 09037766 $1,865.92 $1,339.42 090 38780 $2,500.24 $2,500.24 09037780 $571.99 $571.99 090 38790 $227.76 $227.76 00037785 $850.82 $635.17 090 38792 $108.19 $108.19 00037788 $3,085.71 $3,085.71 090 38794 $726.15 $726.15 09037790 $1,190.31 $1,190.31 090 38900 $378.65 $378.65 ZZZ37799 80% of billed 80% of billed N/A 38999 80% of billed 80% of billed N/A38100 $2,813.62 $2,813.62 090 39000 $1,207.16 $1,207.16 09038101 $2,844.78 $2,844.78 090 39010 $1,913.93 $1,913.93 09038102 $725.99 $725.99 ZZZ 39200 $2,131.27 $2,131.27 09038115 $3,114.35 $3,114.35 090 39220 $2,768.97 $2,768.97 09038120 $2,565.11 $2,565.11 090 39401 $854.10 $854.10 00038129 80% of billed 80% of billed N/A 39402 $1,115.08 $1,115.08 00038200 $364.42 $364.42 000 39499 80% of billed 80% of billed N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 24 of 84

Page 25: Appendix B for Administrative Order No. 18-053 Physician ...Appendix B for Administrative Order No. 18-053 Physician Fee Schedule Effective April 1, 2018 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

39501 $2,068.93 $2,068.93 090 41120 $2,612.28 $2,612.28 09039503 $14,119.47 $14,119.47 090 41130 $3,216.28 $3,216.28 09039540 $2,114.42 $2,114.42 090 41135 $5,285.22 $5,285.22 09039541 $2,282.90 $2,282.90 090 41140 $5,307.12 $5,307.12 09039545 $2,169.18 $2,169.18 090 41145 $6,724.88 $6,724.88 09039560 $1,947.63 $1,947.63 090 41150 $5,343.34 $5,343.34 09039561 $3,025.06 $3,025.06 090 41153 $5,791.50 $5,791.50 09039599 80% of billed 80% of billed N/A 41155 $7,338.99 $7,338.99 09040490 $349.23 $200.24 000 41250 $733.58 $423.25 01040500 $1,218.11 $880.31 090 41251 $811.40 $509.61 01040510 $1,162.51 $859.25 090 41252 $859.79 $578.89 01040520 $1,178.52 $866.83 090 41500 $1,138.92 $1,138.92 09040525 $1,334.36 $1,334.36 090 41510 $1,101.86 $1,101.86 09040527 $1,477.57 $1,477.57 090 41512 $1,595.51 $1,595.51 09040530 $1,287.19 $967.08 090 41520 $838.19 $594.73 09040650 $1,062.27 $726.15 090 41530 $2,630.63 $1,018.28 00040652 $1,188.63 $857.56 090 41599 80% of billed 80% of billed N/A40654 $1,381.54 $1,034.47 090 41800 $772.49 $411.87 01040700 $2,456.44 $2,456.44 090 41805 $768.69 $515.31 01040701 $2,909.65 $2,909.65 090 41806 $1,064.78 $755.40 01040702 $2,442.12 $2,442.12 090 41820 80% of billed 80% of billed 00040720 $2,509.51 $2,509.51 090 41821 80% of billed 80% of billed 00040761 $2,646.82 $2,646.82 090 41822 $826.58 $499.17 01040799 80% of billed 80% of billed N/A 41823 $1,082.48 $804.49 09040800 $580.79 $361.57 010 41825 $580.79 $336.90 01040801 $855.05 $610.21 010 41826 $865.49 $587.43 01040804 $500.12 $313.17 010 41827 $1,068.16 $750.58 09040805 $872.13 $634.88 010 41828 $860.74 $580.79 01040806 $282.80 $93.00 000 41830 $1,101.79 $780.08 01040808 $507.72 $296.09 010 41850 80% of billed 80% of billed 00040810 $562.76 $349.23 010 41870 80% of billed 80% of billed 00040812 $787.67 $540.93 010 41872 $840.72 $594.73 09040814 $935.91 $743.00 090 41874 $932.54 $630.96 09040816 $973.81 $769.11 090 41899 80% of billed 80% of billed N/A40818 $877.78 $668.87 090 42000 $414.71 $279.96 01040819 $770.80 $586.31 090 42100 $407.12 $299.88 01040820 $721.24 $471.65 010 42104 $584.58 $380.55 01040830 $736.42 $459.32 010 42106 $747.81 $490.63 01040831 $930.02 $621.60 010 42107 $1,117.02 $841.56 09040840 $1,961.11 $1,520.53 090 42120 $2,454.75 $2,454.75 09040842 $1,912.25 $1,496.10 090 42140 $606.53 $372.34 09040843 $2,593.75 $2,043.66 090 42145 $1,689.01 $1,689.01 09040844 $3,224.71 $2,644.29 090 42160 $627.29 $400.48 01040845 $3,513.65 $2,957.67 090 42180 $655.76 $496.33 01040899 80% of billed 80% of billed N/A 42182 $861.69 $692.77 01041000 $442.23 $308.43 010 42200 $2,321.65 $2,321.65 09041005 $607.36 $351.13 010 42205 $2,420.22 $2,420.22 09041006 $874.41 $642.75 090 42210 $2,694.84 $2,694.84 09041007 $857.56 $622.53 090 42215 $1,764.83 $1,764.83 09041008 $923.27 $658.76 090 42220 $1,456.51 $1,456.51 09041009 $983.92 $717.72 090 42225 $2,421.06 $2,421.06 09041010 $547.57 $294.19 010 42226 $2,134.64 $2,134.64 09041015 $1,036.99 $832.29 090 42227 $2,004.07 $2,004.07 09041016 $1,072.38 $860.09 090 42235 $1,753.88 $1,753.88 09041017 $1,088.38 $867.67 090 42260 $1,940.05 $1,581.18 09041018 $1,234.96 $1,011.72 090 42280 $476.40 $301.78 01041019 $1,296.33 $1,296.33 000 42281 $617.80 $450.78 01041100 $458.37 $293.24 010 42299 80% of billed 80% of billed N/A41105 $466.91 $305.58 010 42300 $564.66 $414.71 01041108 $404.27 $246.74 010 42305 $1,037.84 $1,037.84 09041110 $576.99 $358.72 010 42310 $483.04 $371.06 01041112 $811.23 $615.79 090 42320 $670.94 $473.55 01041113 $887.89 $682.34 090 42330 $627.29 $446.98 01041114 $1,536.54 $1,536.54 090 42335 $898.00 $620.01 09041115 $667.15 $394.78 010 42340 $1,119.55 $812.92 09041116 $801.12 $534.08 090 42400 $282.80 $148.04 000

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 25 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

42405 $806.65 $614.00 010 43113 $10,601.60 $10,601.60 09042408 $1,203.79 $860.09 090 43116 $12,118.77 $12,118.77 09042409 $797.75 $532.40 090 43117 $7,921.93 $7,921.93 09042410 $1,496.10 $1,496.10 090 43118 $8,856.15 $8,856.15 09042415 $2,533.10 $2,533.10 090 43121 $6,976.76 $6,976.76 09042420 $2,845.63 $2,845.63 090 43122 $6,237.13 $6,237.13 09042425 $2,009.12 $2,009.12 090 43123 $10,987.42 $10,987.42 09042426 $3,240.71 $3,240.71 090 43124 $9,284.09 $9,284.09 09042440 $988.98 $988.98 090 43130 $1,892.03 $1,892.03 09042450 $1,089.22 $863.46 090 43135 $3,636.64 $3,636.64 09042500 $1,041.21 $823.87 090 43180 $1,320.04 $1,320.04 09042505 $1,332.68 $1,089.22 090 43191 $422.31 $422.31 00042507 $1,227.38 $1,227.38 090 43192 $460.27 $460.27 00042509 $2,024.29 $2,024.29 090 43193 $462.16 $462.16 00042510 $1,503.68 $1,503.68 090 43194 $528.59 $528.59 00042550 $368.21 $173.67 000 43195 $505.82 $505.82 00042600 $1,145.66 $834.82 090 43196 $538.08 $538.08 00042650 $224.91 $157.53 000 43197 $517.21 $226.81 00042660 $353.03 $246.74 000 43198 $570.35 $269.52 00042665 $750.58 $495.33 090 43200 $581.74 $241.05 00042699 80% of billed 80% of billed N/A 43201 $595.02 $285.65 00042700 $511.51 $368.21 010 43202 $830.38 $286.60 00042720 $1,229.90 $1,065.73 010 43204 $376.75 $376.75 00042725 $1,977.96 $1,977.96 090 43205 $393.84 $393.84 00042800 $426.10 $302.73 010 43206 $721.24 $371.06 00042804 $523.85 $305.58 010 43210 $1,236.55 $1,236.55 00042806 $590.28 $357.77 010 43211 $654.81 $654.81 00042808 $610.21 $438.44 010 43212 $527.64 $527.64 00042809 $546.62 $331.20 010 43213 $3,104.18 $718.39 00042810 $929.17 $694.14 090 43214 $535.24 $535.24 00042815 $1,337.73 $1,337.73 090 43215 $973.67 $392.89 00042820 $694.98 $694.98 090 43216 $967.98 $371.06 00042821 $721.09 $721.09 090 43217 $1,026.82 $447.93 00042825 $627.59 $627.59 090 43220 $2,895.40 $327.41 00042826 $603.16 $603.16 090 43226 $856.00 $360.62 00042830 $496.17 $496.17 090 43227 $1,703.46 $460.27 00042831 $535.77 $535.77 090 43229 $1,752.80 $550.42 00042835 $460.79 $460.79 090 43231 $905.35 $444.13 00042836 $577.04 $577.04 090 43232 $1,097.04 $553.27 00042842 $2,449.70 $2,449.70 090 43233 $636.78 $636.78 00042844 $3,372.97 $3,372.97 090 43235 $693.72 $342.59 00042845 $5,420.84 $5,420.84 090 43236 $890.16 $386.24 00042860 $449.84 $449.84 090 43237 $547.57 $547.57 00042870 $1,439.66 $1,439.66 090 43238 $649.12 $649.12 00042890 $3,480.80 $3,480.80 090 43239 $928.12 $385.29 00042892 $4,569.18 $4,569.18 090 43240 $1,094.20 $1,094.20 00042894 $5,762.02 $5,762.02 090 43241 $396.68 $396.68 00042900 $914.84 $914.84 010 43242 $733.58 $733.58 00042950 $1,977.96 $1,977.96 090 43243 $661.45 $661.45 00042953 $2,372.20 $2,372.20 090 43244 $684.23 $684.23 00042955 $1,866.76 $1,866.76 090 43245 $1,497.52 $490.63 00042960 $459.32 $459.32 010 43246 $558.01 $558.01 00042961 $1,010.04 $1,010.04 090 43247 $947.10 $495.38 00042962 $1,246.75 $1,246.75 090 43248 $947.10 $463.11 00042970 $993.19 $993.19 090 43249 $2,754.95 $427.05 00042971 $1,095.96 $1,095.96 090 43250 $1,077.12 $475.45 00042972 $1,226.53 $1,226.53 090 43251 $1,193.84 $548.52 00042999 80% of billed 80% of billed N/A 43252 $820.89 $469.76 00043020 $1,357.11 $1,357.11 090 43253 $733.58 $733.58 00043030 $1,246.75 $1,246.75 090 43254 $754.46 $754.46 00043045 $3,170.79 $3,170.79 090 43255 $1,801.20 $560.86 00043100 $1,501.16 $1,501.16 090 43257 $648.17 $648.17 00043101 $2,451.38 $2,451.38 090 43259 $631.09 $631.09 00043107 $7,274.12 $7,274.12 090 43260 $900.60 $900.60 00043108 $10,850.95 $10,850.95 090 43261 $946.15 $946.15 00043112 $8,525.09 $8,525.09 090 43262 $996.45 $996.45 000

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 26 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

43263 $997.40 $997.40 000 43611 $2,987.15 $2,987.15 09043264 $1,016.38 $1,016.38 000 43620 $4,822.74 $4,822.74 09043265 $1,208.08 $1,208.08 000 43621 $5,538.78 $5,538.78 09043266 $608.31 $608.31 000 43622 $5,649.98 $5,649.98 09043270 $1,806.90 $626.34 000 43631 $3,534.71 $3,534.71 09043273 $333.10 $333.10 ZZZ 43632 $4,960.05 $4,960.05 09043274 $1,291.59 $1,291.59 000 43633 $4,688.80 $4,688.80 09043275 $1,051.49 $1,051.49 000 43634 $5,196.77 $5,196.77 09043276 $1,344.73 $1,344.73 000 43635 $311.27 $311.27 ZZZ43277 $1,057.19 $1,057.19 000 43640 $2,875.95 $2,875.95 09043278 $1,209.03 $1,209.03 000 43641 $2,936.61 $2,936.61 09043279 $3,145.52 $3,145.52 090 43644 $4,224.64 $4,224.64 09043280 $2,637.55 $2,637.55 090 43645 $4,499.26 $4,499.26 09043281 $3,767.21 $3,767.21 090 43647 80% of billed 80% of billed N/A43282 $4,236.43 $4,236.43 090 43648 80% of billed 80% of billed N/A43283 $436.54 $436.54 ZZZ 43651 $1,596.35 $1,596.35 09043284 $1,586.24 $1,586.24 090 43652 $1,865.07 $1,865.07 09043285 $1,519.69 $1,519.69 090 43653 $1,396.70 $1,396.70 09043286 $7,670.89 $7,670.89 090 43659 80% of billed 80% of billed N/A43287 $8,760.96 $8,760.96 090 43752 $111.98 $111.98 00043288 $9,140.88 $9,140.88 090 43753 $59.79 $59.79 00043289 80% of billed 80% of billed N/A 43754 $363.47 $100.59 00043300 $1,474.20 $1,474.20 090 43755 $372.01 $167.02 00043305 $2,615.65 $2,615.65 090 43756 $560.86 $141.40 00043310 $3,619.79 $3,619.79 090 43757 $794.31 $213.53 00043312 $3,898.63 $3,898.63 090 43760 $1,338.09 $129.06 00043313 $6,665.91 $6,665.91 090 43761 $319.81 $282.80 00043314 $7,175.56 $7,175.56 090 43770 $2,733.59 $2,733.59 09043320 $3,409.19 $3,409.19 090 43771 $3,111.83 $3,111.83 09043325 $3,316.53 $3,316.53 090 43772 $2,326.71 $2,326.71 09043327 $2,004.91 $2,004.91 090 43773 $3,119.41 $3,119.41 09043328 $2,753.81 $2,753.81 090 43774 $2,341.03 $2,341.03 09043330 $3,260.93 $3,260.93 090 43775 $2,723.48 $2,723.48 09043331 $3,272.72 $3,272.72 090 43800 $2,265.21 $2,265.21 09043332 $2,830.46 $2,830.46 090 43810 $2,485.92 $2,485.92 09043333 $3,084.03 $3,084.03 090 43820 $3,276.09 $3,276.09 09043334 $3,048.65 $3,048.65 090 43825 $3,196.91 $3,196.91 09043335 $3,271.04 $3,271.04 090 43830 $1,705.02 $1,705.02 09043336 $3,671.18 $3,671.18 090 43831 $1,448.93 $1,448.93 09043337 $3,780.69 $3,780.69 090 43832 $2,526.36 $2,526.36 09043338 $319.81 $319.81 ZZZ 43840 $3,316.53 $3,316.53 09043340 $3,367.07 $3,367.07 090 43842 $2,911.33 $2,911.33 09043341 $3,418.46 $3,418.46 090 43843 $3,126.99 $3,126.99 09043351 $3,207.86 $3,207.86 090 43845 $4,801.68 $4,801.68 09043352 $2,601.33 $2,601.33 090 43846 $3,948.33 $3,948.33 09043360 $5,502.56 $5,502.56 090 43847 $4,403.22 $4,403.22 09043361 $6,578.30 $6,578.30 090 43848 $4,696.38 $4,696.38 09043400 $3,717.51 $3,717.51 090 43850 $3,978.66 $3,978.66 09043401 $3,837.97 $3,837.97 090 43855 $4,126.92 $4,126.92 09043405 $3,549.87 $3,549.87 090 43860 $3,993.82 $3,993.82 09043410 $2,465.70 $2,465.70 090 43865 $4,176.62 $4,176.62 09043415 $6,302.84 $6,302.84 090 43870 $1,731.13 $1,731.13 09043420 $2,438.75 $2,438.75 090 43880 $3,899.47 $3,899.47 09043425 $3,522.92 $3,522.92 090 43881 80% of billed 80% of billed N/A43450 $425.15 $221.12 000 43882 80% of billed 80% of billed N/A43453 $2,466.45 $238.20 000 43886 $883.68 $883.68 09043460 $595.02 $595.02 000 43887 $796.91 $796.91 09043496 80% of billed 80% of billed 090 43888 $1,124.60 $1,124.60 09043499 80% of billed 80% of billed N/A 43999 80% of billed 80% of billed N/A43500 $1,913.09 $1,913.09 090 44005 $2,672.94 $2,672.94 09043501 $3,279.46 $3,279.46 090 44010 $2,098.42 $2,098.42 09043502 $3,725.09 $3,725.09 090 44015 $391.94 $391.94 ZZZ43510 $2,307.33 $2,307.33 090 44020 $2,373.04 $2,373.04 09043520 $1,666.27 $1,666.27 090 44021 $2,376.41 $2,376.41 09043605 $2,040.29 $2,040.29 090 44025 $2,396.63 $2,396.63 09043610 $2,386.52 $2,386.52 090 44050 $2,278.69 $2,278.69 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 27 of 84

Page 28: Appendix B for Administrative Order No. 18-053 Physician ...Appendix B for Administrative Order No. 18-053 Physician Fee Schedule Effective April 1, 2018 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

44055 $3,637.48 $3,637.48 090 44372 $669.05 $669.05 00044100 $299.88 $299.88 000 44373 $536.19 $536.19 00044110 $2,073.15 $2,073.15 090 44376 $793.36 $793.36 00044111 $2,394.94 $2,394.94 090 44377 $836.07 $836.07 00044120 $2,987.99 $2,987.99 090 44378 $1,073.32 $1,073.32 00044121 $667.15 $667.15 ZZZ 44379 $1,141.65 $1,141.65 00044125 $2,879.32 $2,879.32 090 44380 $455.52 $157.53 00044126 $6,024.00 $6,024.00 090 44381 $2,497.77 $233.45 00044127 $6,965.81 $6,965.81 090 44382 $715.55 $204.04 00044128 $672.84 $672.84 ZZZ 44384 $426.10 $426.10 00044130 $3,203.65 $3,203.65 090 44385 $520.05 $200.24 00044132 80% of billed 80% of billed N/A 44386 $774.38 $247.69 00044133 80% of billed 80% of billed N/A 44388 $782.93 $436.54 00044135 80% of billed 80% of billed N/A 44388 53 $389.09 $214.47 00044136 80% of billed 80% of billed N/A 44389 $1,027.77 $480.19 00044137 80% of billed 80% of billed N/A 44390 $1,020.18 $589.33 00044139 $335.00 $335.00 ZZZ 44391 $1,878.07 $640.58 00044140 $3,274.41 $3,274.41 090 44392 $953.75 $554.22 00044141 $4,458.82 $4,458.82 090 44394 $1,095.15 $630.14 00044143 $4,064.58 $4,064.58 090 44401 $8,637.80 $673.79 00044144 $4,318.98 $4,318.98 090 44402 $730.73 $730.73 00044145 $4,046.89 $4,046.89 090 44403 $848.41 $848.41 00044146 $5,175.71 $5,175.71 090 44404 $984.11 $482.09 00044147 $4,740.18 $4,740.18 090 44405 $1,453.87 $511.51 00044150 $4,564.97 $4,564.97 090 44406 $641.52 $641.52 00044151 $5,276.79 $5,276.79 090 44407 $769.64 $769.64 00044155 $5,083.04 $5,083.04 090 44408 $647.22 $647.22 00044156 $5,652.50 $5,652.50 090 44500 $53.14 $53.14 00044157 $5,356.82 $5,356.82 090 44602 $3,445.42 $3,445.42 09044158 $5,493.29 $5,493.29 090 44603 $3,956.75 $3,956.75 09044160 $3,030.96 $3,030.96 090 44604 $2,583.64 $2,583.64 09044180 $2,243.31 $2,243.31 090 44605 $3,182.59 $3,182.59 09044186 $1,585.40 $1,585.40 090 44615 $2,624.08 $2,624.08 09044187 $2,694.84 $2,694.84 090 44620 $2,117.79 $2,117.79 09044188 $2,993.05 $2,993.05 090 44625 $2,481.71 $2,481.71 09044202 $3,379.71 $3,379.71 090 44626 $3,911.26 $3,911.26 09044203 $673.79 $673.79 ZZZ 44640 $3,420.14 $3,420.14 09044204 $3,756.26 $3,756.26 090 44650 $3,527.97 $3,527.97 09044205 $3,265.98 $3,265.98 090 44660 $3,260.93 $3,260.93 09044206 $4,276.02 $4,276.02 090 44661 $3,787.43 $3,787.43 09044207 $4,444.50 $4,444.50 090 44680 $2,589.54 $2,589.54 09044208 $4,848.85 $4,848.85 090 44700 $2,467.39 $2,467.39 09044210 $4,351.00 $4,351.00 090 44701 $470.70 $470.70 ZZZ44211 $5,224.56 $5,224.56 090 44705 $310.32 $205.93 N/A44212 $4,992.90 $4,992.90 090 44715 80% of billed 80% of billed N/A44213 $519.10 $519.10 ZZZ 44720 $758.25 $758.25 N/A44227 $4,065.42 $4,065.42 090 44721 $1,060.98 $1,060.98 N/A44238 80% of billed 80% of billed N/A 44799 80% of billed 80% of billed N/A44300 $2,055.46 $2,055.46 090 44800 $1,861.70 $1,861.70 09044310 $2,549.10 $2,549.10 090 44820 $2,063.04 $2,063.04 09044312 $1,443.03 $1,443.03 090 44850 $1,825.48 $1,825.48 09044314 $2,452.23 $2,452.23 090 44899 80% of billed 80% of billed N/A44316 $3,453.84 $3,453.84 090 44900 $1,891.19 $1,891.19 09044320 $2,932.39 $2,932.39 090 44950 $1,565.18 $1,565.18 09044322 $2,442.12 $2,442.12 090 44955 $231.56 $231.56 ZZZ44340 $1,520.53 $1,520.53 090 44960 $2,132.11 $2,132.11 09044345 $2,567.64 $2,567.64 090 44970 $1,465.78 $1,465.78 09044346 $2,889.43 $2,889.43 090 44979 80% of billed 80% of billed N/A44360 $400.48 $400.48 000 45000 $1,038.68 $1,038.68 09044361 $442.23 $442.23 000 45005 $752.56 $442.23 01044363 $536.19 $536.19 000 45020 $1,400.91 $1,400.91 09044364 $571.30 $571.30 000 45100 $729.52 $729.52 09044365 $505.82 $505.82 000 45108 $900.53 $900.53 09044366 $669.99 $669.99 000 45110 $4,506.00 $4,506.00 09044369 $685.18 $685.18 000 45111 $2,649.35 $2,649.35 09044370 $743.07 $743.07 000 45112 $4,568.34 $4,568.34 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 28 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

45113 $4,638.25 $4,638.25 090 45520 $424.20 $111.03 00045114 $4,441.13 $4,441.13 090 45540 $2,578.59 $2,578.59 09045116 $3,816.91 $3,816.91 090 45541 $2,295.54 $2,295.54 09045119 $4,655.94 $4,655.94 090 45550 $3,560.82 $3,560.82 09045120 $3,885.99 $3,885.99 090 45560 $1,667.95 $1,667.95 09045121 $4,246.54 $4,246.54 090 45562 $2,718.42 $2,718.42 09045123 $2,740.33 $2,740.33 090 45563 $4,026.67 $4,026.67 09045126 $6,697.08 $6,697.08 090 45800 $3,041.06 $3,041.06 09045130 $2,657.77 $2,657.77 090 45805 $3,570.93 $3,570.93 09045135 $3,187.64 $3,187.64 090 45820 $3,085.71 $3,085.71 09045136 $4,431.02 $4,431.02 090 45825 $3,727.62 $3,727.62 09045150 $1,010.88 $1,010.88 090 45900 $578.89 $578.89 01045160 $2,495.19 $2,495.19 090 45905 $464.06 $464.06 01045171 $1,466.62 $1,466.62 090 45910 $530.49 $530.49 01045172 $1,982.17 $1,982.17 090 45915 $911.04 $623.49 01045190 $1,694.91 $1,694.91 090 45990 $294.19 $294.19 00045300 $339.74 $148.99 000 45999 80% of billed 80% of billed N/A45303 $2,438.93 $237.25 000 46020 $753.51 $642.47 01045305 $390.04 $202.14 000 46030 $381.50 $246.74 01045307 $450.78 $265.72 000 46040 $1,301.51 $1,010.04 09045308 $437.49 $230.61 000 46045 $1,053.84 $1,053.84 09045309 $454.57 $245.79 000 46050 $553.27 $266.67 01045315 $502.97 $291.34 000 46060 $1,159.14 $1,159.14 09045317 $499.17 $308.43 000 46070 $625.06 $625.06 09045320 $487.79 $288.50 000 46080 $680.43 $437.49 01045321 $283.75 $283.75 000 46083 $485.89 $292.29 01045327 $323.61 $323.61 000 46200 $1,083.33 $792.70 09045330 $456.47 $155.64 000 46220 $563.71 $324.56 01045331 $698.46 $199.29 000 46221 $732.63 $521.00 01045332 $682.33 $292.29 000 46230 $745.91 $473.55 01045333 $797.16 $260.98 000 46250 $1,124.60 $767.43 09045334 $1,493.73 $327.41 000 46255 $1,228.22 $860.09 09045335 $634.88 $184.11 000 46257 $1,033.62 $1,033.62 09045337 $320.76 $320.76 000 46258 $1,133.03 $1,133.03 09045338 $728.83 $335.95 000 46260 $1,158.30 $1,158.30 09045340 $1,171.07 $216.37 000 46261 $1,274.55 $1,274.55 09045341 $343.54 $343.54 000 46262 $1,345.31 $1,345.31 09045342 $473.55 $473.55 000 46270 $1,232.43 $952.75 09045346 $8,300.90 $447.93 000 46275 $1,308.25 $1,007.51 09045347 $429.90 $429.90 000 46280 $1,143.14 $1,143.14 09045349 $555.17 $555.17 000 46285 $1,303.19 $1,010.04 09045350 $1,429.19 $280.90 000 46288 $1,334.36 $1,334.36 09045378 $856.00 $516.26 000 46320 $503.92 $303.68 01045378 53 $428.95 $258.13 000 46500 $513.41 $339.74 01045379 $1,103.69 $666.20 000 46505 $780.08 $653.86 01045380 $1,096.10 $560.86 000 46600 $242.00 $112.93 00045381 $1,048.65 $560.86 000 46601 $368.21 $258.13 00045382 $1,952.09 $723.14 000 46604 $1,693.97 $182.21 00045384 $1,217.57 $636.78 000 46606 $619.70 $208.78 00045385 $1,151.14 $709.85 000 46607 $520.05 $348.28 00045386 $1,583.88 $591.23 000 46608 $650.07 $230.61 00045388 $8,708.02 $755.40 000 46610 $625.39 $223.02 00045389 $809.50 $809.50 000 46611 $484.94 $223.96 00045390 $929.07 $929.07 000 46612 $751.61 $260.98 00045391 $719.34 $719.34 000 46614 $353.98 $178.41 00045392 $849.36 $849.36 000 46615 $392.89 $253.38 00045393 $705.11 $705.11 000 46700 $1,595.51 $1,595.51 09045395 $4,826.95 $4,826.95 090 46705 $1,342.79 $1,342.79 09045397 $5,258.26 $5,258.26 090 46706 $483.04 $483.04 01045398 $1,850.55 $654.81 000 46707 $1,175.15 $1,175.15 09045399 80% of billed 80% of billed N/A 46710 $2,697.36 $2,697.36 09045400 $2,786.66 $2,786.66 090 46712 $5,443.59 $5,443.59 09045402 $3,709.09 $3,709.09 090 46715 $1,316.67 $1,316.67 09045499 80% of billed 80% of billed N/A 46716 $2,943.35 $2,943.35 09045500 $1,348.68 $1,348.68 090 46730 $4,783.99 $4,783.99 09045505 $1,442.19 $1,442.19 090 46735 $5,520.25 $5,520.25 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 29 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

46740 $5,229.62 $5,229.62 090 47534 $3,968.72 $1,027.77 00046742 $6,056.01 $6,056.01 090 47535 $2,740.71 $546.62 00046744 $8,584.06 $8,584.06 090 47536 $1,859.09 $366.31 00046746 $9,457.62 $9,457.62 090 47537 $988.86 $265.72 00046748 $10,253.69 $10,253.69 090 47538 $11,656.57 $652.91 00046750 $1,827.17 $1,827.17 090 47539 $12,914.94 $1,183.40 00046751 $1,586.24 $1,586.24 090 47540 $13,196.79 $1,221.36 00046753 $1,485.99 $1,485.99 090 47541 $3,165.86 $919.58 00046754 $839.87 $641.52 010 47542 $1,246.04 $374.86 ZZZ46760 $2,667.88 $2,667.88 090 47543 $1,285.90 $398.58 ZZZ46761 $2,231.52 $2,231.52 090 47544 $2,899.20 $441.29 ZZZ46762 $2,252.58 $2,252.58 090 47550 $455.52 $455.52 ZZZ46900 $659.56 $373.91 010 47552 $848.41 $848.41 00046910 $702.26 $367.26 010 47553 $836.07 $836.07 00046916 $628.24 $393.84 010 47554 $1,422.55 $1,422.55 00046917 $1,228.01 $364.42 010 47555 $894.91 $894.91 00046922 $729.78 $371.06 010 47556 $1,013.53 $1,013.53 00046924 $1,423.50 $499.17 010 47562 $1,603.93 $1,603.93 09046930 $502.07 $358.86 090 47563 $1,741.24 $1,741.24 09046940 $622.54 $399.53 010 47564 $2,713.37 $2,713.37 09046942 $594.07 $360.62 010 47570 $1,892.03 $1,892.03 09046945 $748.05 $546.72 090 47579 80% of billed 80% of billed N/A46946 $760.69 $547.56 090 47600 $2,602.17 $2,602.17 09046947 $930.85 $930.85 090 47605 $2,740.33 $2,740.33 09046999 80% of billed 80% of billed N/A 47610 $3,059.60 $3,059.60 09047000 $826.58 $245.79 000 47612 $3,104.24 $3,104.24 09047001 $287.55 $287.55 ZZZ 47620 $3,366.23 $3,366.23 09047010 $2,934.92 $2,934.92 090 47700 $2,566.79 $2,566.79 09047015 $2,837.20 $2,837.20 090 47701 $4,234.74 $4,234.74 09047100 $2,057.14 $2,057.14 090 47711 $3,794.17 $3,794.17 09047120 $5,681.15 $5,681.15 090 47712 $4,884.24 $4,884.24 09047122 $8,343.13 $8,343.13 090 47715 $3,247.45 $3,247.45 09047125 $7,504.10 $7,504.10 090 47720 $2,816.14 $2,816.14 09047130 $8,059.24 $8,059.24 090 47721 $3,306.42 $3,306.42 09047133 80% of billed 80% of billed N/A 47740 $3,204.49 $3,204.49 09047135 $13,055.51 $13,055.51 090 47741 $3,604.63 $3,604.63 09047140 $8,701.15 $8,701.15 090 47760 $5,509.30 $5,509.30 09047141 $10,387.63 $10,387.63 090 47765 $7,420.70 $7,420.70 09047142 $11,443.16 $11,443.16 090 47780 $6,039.17 $6,039.17 09047143 80% of billed 80% of billed N/A 47785 $7,893.29 $7,893.29 09047144 80% of billed 80% of billed 090 47800 $3,848.93 $3,848.93 09047145 80% of billed 80% of billed N/A 47801 $2,608.91 $2,608.91 09047146 $910.09 $910.09 N/A 47802 $3,726.78 $3,726.78 09047147 $1,057.19 $1,057.19 N/A 47900 $3,354.44 $3,354.44 09047300 $2,755.49 $2,755.49 090 47999 80% of billed 80% of billed N/A47350 $3,339.27 $3,339.27 090 48000 $4,609.61 $4,609.61 09047360 $4,582.66 $4,582.66 090 48001 $5,640.71 $5,640.71 09047361 $7,373.53 $7,373.53 090 48020 $2,874.27 $2,874.27 09047362 $3,538.92 $3,538.92 090 48100 $2,162.44 $2,162.44 09047370 $3,043.59 $3,043.59 090 48102 $1,437.74 $661.45 01047371 $3,067.18 $3,067.18 090 48105 $6,939.69 $6,939.69 09047379 80% of billed 80% of billed N/A 48120 $2,690.63 $2,690.63 09047380 $3,511.12 $3,511.12 090 48140 $3,814.39 $3,814.39 09047381 $3,615.58 $3,615.58 090 48145 $3,988.76 $3,988.76 09047382 $13,037.36 $2,055.53 010 48146 $4,588.55 $4,588.55 09047383 $18,513.09 $1,248.88 010 48148 $3,050.33 $3,050.33 09047399 80% of billed 80% of billed N/A 48150 $7,589.18 $7,589.18 09047400 $5,262.47 $5,262.47 090 48152 $7,047.52 $7,047.52 09047420 $3,265.98 $3,265.98 090 48153 $7,552.12 $7,552.12 09047425 $3,338.43 $3,338.43 090 48154 $7,077.00 $7,077.00 09047460 $3,095.82 $3,095.82 090 48155 $4,433.55 $4,433.55 09047480 $2,136.33 $2,136.33 090 48160 80% of billed 80% of billed N/A47490 $903.45 $903.45 010 48400 $297.04 $297.04 ZZZ47531 $854.10 $196.44 000 48500 $2,809.40 $2,809.40 09047532 $2,148.54 $586.48 000 48510 $2,678.83 $2,678.83 09047533 $3,322.45 $737.37 000 48520 $2,663.67 $2,663.67 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 30 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

48540 $3,201.96 $3,201.96 090 49465 $442.23 $84.46 00048545 $3,287.04 $3,287.04 090 49491 $1,934.15 $1,934.15 09048547 $4,381.32 $4,381.32 090 49492 $2,332.61 $2,332.61 09048548 $4,051.94 $4,051.94 090 49495 $999.09 $999.09 09048550 80% of billed 80% of billed N/A 49496 $1,496.94 $1,496.94 09048551 80% of billed 80% of billed N/A 49500 $1,003.30 $1,003.30 09048552 $651.01 $651.01 N/A 49501 $1,475.04 $1,475.04 09048554 $6,208.49 $6,208.49 090 49505 $1,266.13 $1,266.13 09048556 $3,109.30 $3,109.30 090 49507 $1,427.03 $1,427.03 09048999 80% of billed 80% of billed N/A 49520 $1,538.22 $1,538.22 09049000 $1,876.02 $1,876.02 090 49521 $1,744.61 $1,744.61 09049002 $2,549.94 $2,549.94 090 49525 $1,393.33 $1,393.33 09049010 $2,272.80 $2,272.80 090 49540 $1,635.94 $1,635.94 09049020 $3,877.57 $3,877.57 090 49550 $1,401.75 $1,401.75 09049040 $2,437.06 $2,437.06 090 49553 $1,538.22 $1,538.22 09049060 $2,680.52 $2,680.52 090 49555 $1,457.35 $1,457.35 09049062 $1,826.32 $1,826.32 090 49557 $1,762.30 $1,762.30 09049082 $527.64 $203.09 000 49560 $1,796.84 $1,796.84 09049083 $797.16 $297.04 000 49561 $2,265.21 $2,265.21 09049084 $298.94 $298.94 000 49565 $1,870.13 $1,870.13 09049180 $442.23 $234.40 000 49566 $2,285.43 $2,285.43 09049185 $2,554.71 $330.25 000 49568 $736.42 $736.42 ZZZ49203 $2,919.76 $2,919.76 090 49570 $1,016.78 $1,016.78 09049204 $3,738.57 $3,738.57 090 49572 $1,254.33 $1,254.33 09049205 $4,292.03 $4,292.03 090 49580 $809.55 $809.55 09049215 $5,419.16 $5,419.16 090 49582 $1,175.15 $1,175.15 09049220 $2,369.67 $2,369.67 090 49585 $1,083.33 $1,083.33 09049250 $1,430.40 $1,430.40 090 49587 $1,157.46 $1,157.46 09049255 $1,929.10 $1,929.10 090 49590 $1,393.33 $1,393.33 09049320 $894.91 $894.91 010 49600 $1,779.99 $1,779.99 09049321 $947.10 $947.10 010 49605 $12,015.15 $12,015.15 09049322 $1,014.48 $1,014.48 010 49606 $2,763.91 $2,763.91 09049323 $1,550.86 $1,550.86 090 49610 $1,674.69 $1,674.69 09049324 $1,067.63 $1,067.63 010 49611 $1,475.88 $1,475.88 09049325 $1,135.00 $1,135.00 010 49650 $1,043.73 $1,043.73 09049326 $520.05 $520.05 ZZZ 49651 $1,352.89 $1,352.89 09049327 $359.67 $359.67 ZZZ 49652 $1,812.00 $1,812.00 09049329 80% of billed 80% of billed N/A 49653 $2,259.32 $2,259.32 09049400 $365.37 $255.28 000 49654 $2,060.51 $2,060.51 09049402 $2,088.31 $2,088.31 090 49655 $2,514.56 $2,514.56 09049405 $2,178.90 $542.83 000 49656 $2,235.73 $2,235.73 09049406 $2,177.96 $542.83 000 49657 $3,216.28 $3,216.28 09049407 $1,760.40 $576.04 000 49659 80% of billed 80% of billed N/A49411 $1,302.98 $505.82 000 49900 $1,985.54 $1,985.54 09049412 $227.76 $227.76 ZZZ 49904 $3,454.68 $3,454.68 09049418 $3,673.58 $559.91 000 49905 $972.73 $972.73 ZZZ49419 $1,082.48 $1,082.48 090 49906 80% of billed 80% of billed 09049421 $631.09 $631.09 000 49999 80% of billed 80% of billed N/A49422 $1,042.95 $1,042.95 010 50010 $1,785.89 $1,785.89 09049423 $1,474.75 $196.44 000 50020 $2,470.76 $2,470.76 09049424 $393.84 $104.39 000 50040 $2,255.95 $2,255.95 09049425 $1,742.08 $1,742.08 090 50045 $2,275.32 $2,275.32 09049426 $1,496.10 $1,496.10 090 50060 $2,784.13 $2,784.13 09049427 $126.22 $126.22 000 50065 $2,953.45 $2,953.45 09049428 $1,187.20 $1,187.20 010 50070 $2,895.33 $2,895.33 09049429 $1,262.17 $1,262.17 010 50075 $3,559.14 $3,559.14 09049435 $328.35 $328.35 ZZZ 50080 $2,122.85 $2,122.85 09049436 $510.56 $510.56 010 50081 $3,117.72 $3,117.72 09049440 $2,607.85 $567.50 010 50100 $2,631.66 $2,631.66 09049441 $2,952.34 $665.25 010 50120 $2,317.44 $2,317.44 09049442 $2,453.17 $573.20 010 50125 $2,398.31 $2,398.31 09049446 $2,512.00 $409.02 000 50130 $2,522.15 $2,522.15 09049450 $1,797.41 $183.16 000 50135 $2,740.33 $2,740.33 09049451 $1,962.53 $248.64 000 50200 $1,450.07 $353.98 00049452 $2,428.49 $382.45 000 50205 $1,839.80 $1,839.80 09049460 $1,991.00 $131.91 000 50220 $2,557.53 $2,557.53 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 31 of 84

Page 32: Appendix B for Administrative Order No. 18-053 Physician ...Appendix B for Administrative Order No. 18-053 Physician Fee Schedule Effective April 1, 2018 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

50225 $2,931.55 $2,931.55 090 50593 $12,206.99 $1,268.81 01050230 $3,129.52 $3,129.52 090 50600 $2,292.17 $2,292.17 09050234 $3,176.69 $3,176.69 090 50605 $2,410.95 $2,410.95 09050236 $3,586.94 $3,586.94 090 50606 $1,891.36 $423.25 ZZZ50240 $3,233.13 $3,233.13 090 50610 $2,308.18 $2,308.18 09050250 $2,970.30 $2,970.30 090 50620 $2,208.77 $2,208.77 09050280 $2,328.39 $2,328.39 090 50630 $2,180.97 $2,180.97 09050290 $2,194.45 $2,194.45 090 50650 $2,530.57 $2,530.57 09050300 80% of billed 80% of billed N/A 50660 $2,793.40 $2,793.40 09050320 $3,664.44 $3,664.44 090 50684 $291.34 $138.55 00050323 80% of billed 80% of billed N/A 50686 $395.73 $243.89 00050325 80% of billed 80% of billed N/A 50688 $216.37 $216.37 01050327 $596.92 $596.92 N/A 50690 $270.47 $192.65 00050328 $523.85 $523.85 N/A 50693 $2,665.74 $563.71 00050329 $494.43 $494.43 N/A 50694 $2,925.77 $738.32 00050340 $2,308.18 $2,308.18 090 50695 $3,592.91 $945.20 00050360 $5,895.12 $5,895.12 090 50700 $2,259.32 $2,259.32 09050365 $6,967.49 $6,967.49 090 50705 $5,210.96 $540.93 ZZZ50370 $2,938.29 $2,938.29 090 50706 $2,664.79 $505.82 ZZZ50380 $4,877.50 $4,877.50 090 50715 $2,973.67 $2,973.67 09050382 $3,001.69 $708.90 000 50722 $2,460.65 $2,460.65 09050384 $2,357.32 $636.78 000 50725 $2,692.31 $2,692.31 09050385 $2,937.16 $603.56 000 50727 $1,241.70 $1,241.70 09050386 $1,895.15 $450.78 000 50728 $1,705.86 $1,705.86 09050387 $1,322.91 $231.56 000 50740 $2,984.62 $2,984.62 09050389 $803.80 $148.99 000 50750 $2,817.83 $2,817.83 09050390 $263.82 $263.82 000 50760 $2,744.54 $2,744.54 09050391 $332.15 $269.52 000 50770 $2,817.83 $2,817.83 09050395 $489.68 $489.68 000 50780 $2,704.95 $2,704.95 09050396 $321.71 $321.71 000 50782 $2,625.76 $2,625.76 09050400 $2,830.46 $2,830.46 090 50783 $2,754.65 $2,754.65 09050405 $3,408.35 $3,408.35 090 50785 $2,961.88 $2,961.88 09050430 $1,238.45 $424.20 000 50800 $2,257.63 $2,257.63 09050431 $440.34 $181.26 000 50810 $3,408.35 $3,408.35 09050432 $2,084.00 $568.45 000 50815 $2,985.47 $2,985.47 09050433 $2,849.85 $709.85 000 50820 $3,207.86 $3,207.86 09050434 $2,232.05 $534.29 000 50825 $4,028.36 $4,028.36 09050435 $1,273.56 $276.16 000 50830 $4,401.54 $4,401.54 09050500 $3,137.10 $3,137.10 090 50840 $3,001.47 $3,001.47 09050520 $2,822.04 $2,822.04 090 50845 $3,050.33 $3,050.33 09050525 $3,583.57 $3,583.57 090 50860 $2,307.33 $2,307.33 09050526 $3,841.34 $3,841.34 090 50900 $2,061.35 $2,061.35 09050540 $2,803.51 $2,803.51 090 50920 $2,152.33 $2,152.33 09050541 $2,244.15 $2,244.15 090 50930 $2,691.47 $2,691.47 09050542 $2,846.47 $2,846.47 090 50940 $2,166.65 $2,166.65 09050543 $3,633.27 $3,633.27 090 50945 $2,377.25 $2,377.25 09050544 $3,042.75 $3,042.75 090 50947 $3,383.08 $3,383.08 09050545 $3,272.72 $3,272.72 090 50948 $3,114.35 $3,114.35 09050546 $2,938.29 $2,938.29 090 50949 80% of billed 80% of billed N/A50547 $3,925.58 $3,925.58 090 50951 $1,033.46 $844.61 00050548 $3,289.57 $3,289.57 090 50953 $1,100.84 $904.40 00050549 80% of billed 80% of billed N/A 50955 $1,170.12 $971.78 00050551 $990.76 $811.40 000 50957 $1,181.51 $977.47 00050553 $1,061.93 $867.39 000 50961 $1,065.73 $874.98 00050555 $1,135.00 $941.41 000 50970 $1,022.07 $1,022.07 00050557 $1,153.98 $953.75 000 50972 $987.91 $987.91 00050561 $1,307.72 $1,086.61 000 50974 $1,303.93 $1,303.93 00050562 $1,421.97 $1,421.97 090 50976 $1,284.95 $1,284.95 00050570 $1,355.17 $1,355.17 000 50980 $983.16 $983.16 00050572 $1,466.21 $1,466.21 000 51020 $1,145.66 $1,145.66 09050574 $1,559.21 $1,559.21 000 51030 $1,149.03 $1,149.03 09050575 $1,968.23 $1,968.23 000 51040 $706.77 $706.77 09050576 $1,555.41 $1,555.41 000 51045 $1,192.84 $1,192.84 09050580 $1,674.99 $1,674.99 000 51050 $1,154.09 $1,154.09 09050590 $1,753.03 $1,387.43 090 51060 $1,418.60 $1,418.60 09050592 $8,958.56 $945.20 010 51065 $1,412.70 $1,412.70 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 32 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

51080 $998.24 $998.24 090 51820 $2,645.14 $2,645.14 09051100 $167.97 $106.29 000 51840 $1,596.35 $1,596.35 09051101 $336.90 $143.30 000 51841 $1,865.07 $1,865.07 09051102 $617.80 $396.68 000 51845 $1,424.50 $1,424.50 09051500 $1,555.07 $1,555.07 090 51860 $1,817.90 $1,817.90 09051520 $1,450.61 $1,450.61 090 51865 $2,182.66 $2,182.66 09051525 $2,095.89 $2,095.89 090 51880 $1,138.92 $1,138.92 09051530 $1,905.51 $1,905.51 090 51900 $2,013.34 $2,013.34 09051535 $1,904.67 $1,904.67 090 51920 $1,864.23 $1,864.23 09051550 $2,354.51 $2,354.51 090 51925 $2,446.33 $2,446.33 09051555 $3,089.92 $3,089.92 090 51940 $4,008.98 $4,008.98 09051565 $3,149.73 $3,149.73 090 51960 $3,383.92 $3,383.92 09051570 $3,603.79 $3,603.79 090 51980 $1,742.08 $1,742.08 09051575 $4,450.40 $4,450.40 090 51990 $1,828.85 $1,828.85 09051580 $4,630.67 $4,630.67 090 51992 $2,031.87 $2,031.87 09051585 $5,156.33 $5,156.33 090 51999 80% of billed 80% of billed N/A51590 $4,727.55 $4,727.55 090 52000 $448.88 $225.86 00051595 $5,345.87 $5,345.87 090 52001 $1,019.23 $791.47 00051596 $5,747.70 $5,747.70 090 52005 $727.88 $366.31 00051597 $5,610.38 $5,610.38 090 52007 $1,213.77 $455.52 00051600 $499.17 $122.42 000 52010 $1,005.94 $456.47 00051605 $106.29 $106.29 000 52204 $1,009.74 $390.04 00051610 $290.39 $175.57 000 52214 $1,814.49 $484.94 00051700 $200.24 $83.51 000 52224 $1,895.15 $561.81 00051701 $128.12 $70.23 000 52234 $678.54 $678.54 00051702 $173.67 $71.18 000 52235 $795.26 $795.26 00051703 $343.54 $211.63 000 52240 $1,079.96 $1,079.96 00051705 $248.64 $143.30 000 52250 $660.50 $660.50 00051710 $351.13 $220.17 000 52260 $579.84 $579.84 00051715 $795.26 $550.42 000 52265 $994.55 $445.08 00051720 $228.71 $143.30 000 52270 $974.62 $501.07 00051725 $509.61 $509.61 000 52275 $1,313.42 $685.18 00051725 TC $300.83 $300.83 000 52276 $728.83 $728.83 00051725 26 $208.78 $208.78 000 52277 $891.11 $891.11 00051726 $720.29 $720.29 000 52281 $745.91 $418.51 00051726 TC $486.84 $486.84 000 52282 $928.12 $928.12 00051726 26 $233.45 $233.45 000 52283 $758.25 $555.17 00051727 $847.46 $847.46 000 52285 $763.95 $539.03 00051727 TC $556.11 $556.11 000 52287 $851.25 $465.01 00051727 26 $291.34 $291.34 000 52290 $673.79 $673.79 00051728 $863.59 $863.59 000 52300 $773.44 $773.44 00051728 TC $576.99 $576.99 000 52301 $800.01 $800.01 00051728 26 $286.60 $286.60 000 52305 $766.79 $766.79 00051729 $927.17 $927.17 000 52310 $667.15 $416.61 00051729 TC $581.74 $581.74 000 52315 $1,132.16 $756.35 00051729 26 $345.44 $345.44 000 52317 $2,201.68 $957.54 00051736 $41.76 $41.76 N/A 52318 $1,304.88 $1,304.88 00051736 TC $18.98 $18.98 N/A 52320 $680.43 $680.43 00051736 26 $22.78 $22.78 N/A 52325 $884.47 $884.47 00051741 $42.71 $42.71 N/A 52327 $723.14 $723.14 00051741 TC $19.93 $19.93 N/A 52330 $1,353.27 $727.88 00051741 26 $22.78 $22.78 N/A 52332 $1,339.04 $428.95 00051784 $187.90 $187.90 N/A 52334 $706.06 $706.06 00051784 TC $85.41 $85.41 N/A 52341 $782.93 $782.93 00051784 26 $102.49 $102.49 N/A 52342 $851.25 $851.25 00051785 $745.91 $745.91 N/A 52343 $949.00 $949.00 00051785 TC $498.23 $498.23 N/A 52344 $1,019.23 $1,019.23 00051785 26 $247.69 $247.69 N/A 52345 $1,086.61 $1,086.61 00051792 $577.94 $577.94 000 52346 $1,230.85 $1,230.85 00051792 TC $427.05 $427.05 000 52351 $835.12 $835.12 00051792 26 $150.89 $150.89 000 52352 $977.47 $977.47 00051797 $307.48 $307.48 ZZZ 52353 $1,079.96 $1,079.96 00051797 TC $197.39 $197.39 ZZZ 52354 $1,150.19 $1,150.19 00051797 26 $110.08 $110.08 ZZZ 52355 $1,288.74 $1,288.74 00051798 $42.71 $42.71 N/A 52356 $1,146.39 $1,146.39 00051800 $2,539.84 $2,539.84 090 52400 $1,167.57 $1,167.57 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 33 of 84

Page 34: Appendix B for Administrative Order No. 18-053 Physician ...Appendix B for Administrative Order No. 18-053 Physician Fee Schedule Effective April 1, 2018 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

52402 $735.48 $735.48 000 53855 $2,130.51 $227.76 00052441 $3,394.57 $624.44 000 53860 $3,815.23 $549.24 09052442 $2,600.26 $166.08 ZZZ 53899 80% of billed 80% of billed N/A52450 $1,147.35 $1,147.35 090 54000 $408.07 $297.99 01052500 $1,191.15 $1,191.15 090 54001 $506.77 $381.50 01052601 $1,781.68 $1,781.68 090 54015 $844.61 $844.61 01052630 $977.18 $977.18 090 54050 $363.47 $289.45 01052640 $770.80 $770.80 090 54055 $326.46 $254.33 01052647 $4,326.57 $1,581.18 090 54056 $388.14 $303.68 01052648 $4,451.24 $1,685.64 090 54057 $379.60 $263.82 01052649 $2,009.97 $2,009.97 090 54060 $493.48 $358.72 01052700 $1,076.59 $1,076.59 090 54065 $597.87 $471.65 01053000 $408.07 $408.07 010 54100 $541.88 $345.44 00053010 $719.41 $719.41 090 54105 $725.99 $586.48 01053020 $267.62 $267.62 000 54110 $1,524.74 $1,524.74 09053025 $188.85 $188.85 000 54111 $1,955.21 $1,955.21 09053040 $958.65 $958.65 090 54112 $2,288.80 $2,288.80 09053060 $497.28 $446.03 010 54115 $1,103.54 $1,036.99 09053080 $1,026.04 $1,026.04 090 54120 $1,544.96 $1,544.96 09053085 $1,584.55 $1,584.55 090 54125 $1,985.54 $1,985.54 09053200 $430.85 $391.94 000 54130 $2,913.86 $2,913.86 09053210 $1,880.24 $1,880.24 090 54135 $3,693.08 $3,693.08 09053215 $2,265.21 $2,265.21 090 54150 $425.15 $269.52 00053220 $1,102.70 $1,102.70 090 54160 $601.67 $394.78 01053230 $1,476.73 $1,476.73 090 54161 $540.93 $540.93 01053235 $1,545.80 $1,545.80 090 54162 $706.06 $548.52 01053240 $1,037.84 $1,037.84 090 54163 $601.67 $601.67 01053250 $966.23 $966.23 090 54164 $532.39 $532.39 01053260 $551.37 $493.48 010 54200 $296.09 $230.61 01053265 $597.87 $510.56 010 54205 $1,299.82 $1,299.82 09053270 $565.60 $504.87 010 54220 $562.76 $368.21 00053275 $722.19 $722.19 010 54230 $267.62 $220.17 00053400 $1,952.68 $1,952.68 090 54231 $387.19 $320.76 00053405 $2,132.96 $2,132.96 090 54235 $249.59 $202.14 00053410 $2,388.20 $2,388.20 090 54240 $288.50 $288.50 00053415 $2,763.07 $2,763.07 090 54240 TC $98.70 $98.70 00053420 $2,054.61 $2,054.61 090 54240 26 $189.80 $189.80 00053425 $2,286.27 $2,286.27 090 54250 $331.20 $331.20 00053430 $2,363.77 $2,363.77 090 54250 TC $30.37 $30.37 00053431 $2,819.51 $2,819.51 090 54250 26 $300.83 $300.83 00053440 $1,838.96 $1,838.96 090 54300 $1,568.55 $1,568.55 09053442 $1,912.25 $1,912.25 090 54304 $1,833.06 $1,833.06 09053444 $1,936.68 $1,936.68 090 54308 $1,747.14 $1,747.14 09053445 $1,839.80 $1,839.80 090 54312 $1,998.17 $1,998.17 09053446 $1,567.71 $1,567.71 090 54316 $2,437.91 $2,437.91 09053447 $1,974.59 $1,974.59 090 54318 $1,737.03 $1,737.03 09053448 $3,126.99 $3,126.99 090 54322 $1,906.35 $1,906.35 09053449 $1,492.73 $1,492.73 090 54324 $2,364.62 $2,364.62 09053450 $998.24 $998.24 090 54326 $2,309.02 $2,309.02 09053460 $1,119.55 $1,119.55 090 54328 $2,293.86 $2,293.86 09053500 $1,821.27 $1,821.27 090 54332 $2,477.50 $2,477.50 09053502 $1,186.94 $1,186.94 090 54336 $2,905.44 $2,905.44 09053505 $1,186.10 $1,186.10 090 54340 $1,392.49 $1,392.49 09053510 $1,542.43 $1,542.43 090 54344 $2,314.07 $2,314.07 09053515 $1,942.57 $1,942.57 090 54348 $2,477.50 $2,477.50 09053520 $1,358.79 $1,358.79 090 54352 $3,458.05 $3,458.05 09053600 $226.81 $175.57 000 54360 $1,759.77 $1,759.77 09053601 $222.07 $148.04 000 54380 $1,951.84 $1,951.84 09053605 $178.41 $178.41 000 54385 $2,266.06 $2,266.06 09053620 $317.92 $240.10 000 54390 $3,029.27 $3,029.27 09053621 $298.94 $199.29 000 54400 $1,293.08 $1,293.08 09053660 $192.65 $114.83 000 54401 $1,601.40 $1,601.40 09053661 $188.85 $111.98 000 54405 $1,973.74 $1,973.74 09053665 $106.29 $106.29 000 54406 $1,785.05 $1,785.05 09053850 $5,032.50 $1,481.78 090 54408 $1,929.10 $1,929.10 09053852 $4,644.99 $1,521.37 090 54410 $2,098.42 $2,098.42 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 34 of 84

Page 35: Appendix B for Administrative Order No. 18-053 Physician ...Appendix B for Administrative Order No. 18-053 Physician Fee Schedule Effective April 1, 2018 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

54411 $2,504.46 $2,504.46 090 55706 $1,023.97 $1,023.97 01054415 $1,290.56 $1,290.56 090 55720 $1,105.23 $1,105.23 09054416 $1,734.50 $1,734.50 090 55725 $1,448.93 $1,448.93 09054417 $2,195.29 $2,195.29 090 55801 $2,671.25 $2,671.25 09054420 $1,721.87 $1,721.87 090 55810 $3,201.96 $3,201.96 09054430 $1,564.34 $1,564.34 090 55812 $3,930.64 $3,930.64 09054435 $1,018.46 $1,018.46 090 55815 $4,306.35 $4,306.35 09054437 $1,646.05 $1,646.05 090 55821 $2,132.96 $2,132.96 09054438 $3,265.98 $3,265.98 090 55831 $2,307.33 $2,307.33 09054440 80% of billed 80% of billed 090 55840 $2,862.48 $2,862.48 09054450 $193.60 $159.43 000 55842 $2,863.32 $2,863.32 09054500 $205.93 $205.93 000 55845 $3,330.85 $3,330.85 09054505 $576.99 $576.99 010 55860 $2,137.17 $2,137.17 09054512 $1,320.04 $1,320.04 090 55862 $2,678.83 $2,678.83 09054520 $797.75 $797.75 090 55865 $3,258.40 $3,258.40 09054522 $1,442.19 $1,442.19 090 55866 $3,527.13 $3,527.13 09054530 $1,234.12 $1,234.12 090 55870 $481.14 $391.94 00054535 $1,817.90 $1,817.90 090 55873 $17,152.95 $1,865.92 09054550 $1,201.26 $1,201.26 090 55874 $10,010.05 $456.47 00054560 $1,677.22 $1,677.22 090 55875 $1,865.07 $1,865.07 09054600 $1,108.60 $1,108.60 090 55876 $373.91 $277.11 00054620 $824.68 $824.68 010 55899 80% of billed 80% of billed N/A54640 $1,169.25 $1,169.25 090 55920 $1,230.85 $1,230.85 00054650 $1,738.71 $1,738.71 090 55970 80% of billed 80% of billed N/A54660 $872.73 $872.73 090 55980 80% of billed 80% of billed N/A54670 $990.66 $990.66 090 56405 $294.19 $292.29 01054680 $1,922.36 $1,922.36 090 56420 $329.30 $244.84 01054690 $1,607.30 $1,607.30 090 56440 $489.68 $489.68 01054692 $1,854.12 $1,854.12 090 56441 $390.99 $374.86 01054699 80% of billed 80% of billed N/A 56442 $129.06 $129.06 00054700 $587.43 $587.43 010 56501 $355.88 $310.32 01054800 $347.33 $347.33 000 56515 $612.11 $543.78 01054830 $910.63 $910.63 090 56605 $221.12 $163.23 00054840 $785.12 $785.12 090 56606 $102.49 $80.67 ZZZ54860 $1,024.36 $1,024.36 090 56620 $1,260.23 $1,260.23 09054861 $1,383.22 $1,383.22 090 56625 $1,526.43 $1,526.43 09054865 $876.94 $876.94 090 56630 $2,257.63 $2,257.63 09054900 $1,955.21 $1,955.21 090 56631 $2,884.38 $2,884.38 09054901 $2,579.43 $2,579.43 090 56632 $3,356.96 $3,356.96 09055000 $323.61 $233.45 000 56633 $2,942.50 $2,942.50 09055040 $825.55 $825.55 090 56634 $3,189.33 $3,189.33 09055041 $1,245.07 $1,245.07 090 56637 $3,731.83 $3,731.83 09055060 $930.01 $930.01 090 56640 $3,733.52 $3,733.52 09055100 $591.23 $456.47 010 56700 $500.12 $500.12 01055110 $946.86 $946.86 090 56740 $809.50 $809.50 01055120 $864.30 $864.30 090 56800 $647.22 $647.22 01055150 $1,199.58 $1,199.58 090 56805 $2,713.37 $2,713.37 09055175 $887.05 $887.05 090 56810 $699.41 $699.41 01055180 $1,673.01 $1,673.01 090 56820 $303.68 $234.40 00055200 $1,062.27 $680.66 090 56821 $398.58 $312.22 00055250 $936.75 $555.14 090 57000 $505.82 $505.82 01055300 $515.31 $515.31 000 57010 $1,029.41 $1,029.41 09055400 $1,217.27 $1,217.27 090 57020 $248.64 $218.27 00055500 $964.55 $964.55 090 57022 $448.88 $448.88 01055520 $1,102.70 $1,102.70 090 57023 $829.43 $829.43 01055530 $859.25 $859.25 090 57061 $307.48 $264.77 01055535 $1,051.32 $1,051.32 090 57065 $526.70 $470.70 01055540 $1,345.31 $1,345.31 090 57100 $241.05 $182.21 00055550 $1,047.10 $1,047.10 090 57105 $368.21 $342.59 01055559 80% of billed 80% of billed N/A 57106 $1,189.47 $1,189.47 09055600 $1,030.26 $1,030.26 090 57107 $3,492.59 $3,492.59 09055605 $1,272.87 $1,272.87 090 57109 $4,269.28 $4,269.28 09055650 $1,752.19 $1,752.19 090 57110 $2,125.38 $2,125.38 09055680 $845.77 $845.77 090 57111 $4,269.28 $4,269.28 09055700 $677.59 $359.67 000 57112 $4,571.70 $4,571.70 09055705 $731.68 $731.68 010 57120 $1,211.37 $1,211.37 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 35 of 84

Page 36: Appendix B for Administrative Order No. 18-053 Physician ...Appendix B for Administrative Order No. 18-053 Physician Fee Schedule Effective April 1, 2018 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

57130 $474.50 $426.10 010 57555 $1,424.50 $1,424.50 09057135 $518.15 $466.91 010 57556 $1,347.84 $1,347.84 09057150 $121.47 $77.82 000 57558 $333.10 $303.68 01057155 $995.50 $763.00 000 57700 $737.10 $737.10 09057156 $541.88 $402.38 000 57720 $728.68 $728.68 09057160 $204.04 $126.22 000 57800 $161.33 $131.91 00057170 $162.28 $130.01 000 58100 $292.29 $235.35 00057180 $377.70 $282.80 010 58110 $130.01 $111.03 ZZZ57200 $723.62 $723.62 090 58120 $696.57 $590.28 01057210 $877.78 $877.78 090 58140 $2,187.71 $2,187.71 09057220 $759.84 $759.84 090 58145 $1,312.46 $1,312.46 09057230 $936.75 $936.75 090 58146 $2,731.06 $2,731.06 09057240 $1,412.70 $1,412.70 090 58150 $2,438.75 $2,438.75 09057250 $1,418.60 $1,418.60 090 58152 $2,982.10 $2,982.10 09057260 $1,817.90 $1,817.90 090 58180 $2,300.59 $2,300.59 09057265 $2,041.98 $2,041.98 090 58200 $3,330.85 $3,330.85 09057267 $691.82 $691.82 ZZZ 58210 $4,486.62 $4,486.62 09057268 $1,154.93 $1,154.93 090 58240 $7,058.47 $7,058.47 09057270 $1,922.36 $1,922.36 090 58260 $1,963.63 $1,963.63 09057280 $2,279.53 $2,279.53 090 58262 $2,187.71 $2,187.71 09057282 $1,195.37 $1,195.37 090 58263 $2,350.30 $2,350.30 09057283 $1,639.31 $1,639.31 090 58267 $2,496.87 $2,496.87 09057284 $1,949.31 $1,949.31 090 58270 $2,096.73 $2,096.73 09057285 $1,607.30 $1,607.30 090 58275 $2,341.87 $2,341.87 09057287 $1,636.78 $1,636.78 090 58280 $2,490.13 $2,490.13 09057288 $1,718.50 $1,718.50 090 58285 $3,488.38 $3,488.38 09057289 $1,807.79 $1,807.79 090 58290 $2,727.69 $2,727.69 09057291 $1,256.02 $1,256.02 090 58291 $2,960.19 $2,960.19 09057292 $1,935.84 $1,935.84 090 58292 $3,110.98 $3,110.98 09057295 $1,141.45 $1,141.45 090 58293 $3,234.82 $3,234.82 09057296 $2,245.00 $2,245.00 090 58294 $2,882.69 $2,882.69 09057300 $1,353.74 $1,353.74 090 58300 $198.34 $146.15 N/A57305 $2,255.95 $2,255.95 090 58301 $256.23 $182.21 00057307 $2,474.13 $2,474.13 090 58321 $205.93 $131.91 00057308 $1,599.72 $1,599.72 090 58322 $231.56 $157.53 00057310 $1,125.45 $1,125.45 090 58323 $41.76 $33.22 00057311 $1,279.61 $1,279.61 090 58340 $322.66 $157.53 00057320 $1,285.50 $1,285.50 090 58345 $744.02 $744.02 01057330 $1,805.26 $1,805.26 090 58346 $1,086.70 $1,086.70 09057335 $2,740.33 $2,740.33 090 58350 $260.03 $210.68 01057400 $358.72 $358.72 000 58353 $2,696.11 $585.53 01057410 $291.34 $291.34 000 58356 $5,023.06 $923.38 01057415 $432.74 $432.74 010 58400 $1,052.16 $1,052.16 09057420 $318.86 $249.59 000 58410 $1,904.67 $1,904.67 09057421 $425.15 $335.95 000 58520 $1,864.23 $1,864.23 09057423 $2,177.60 $2,177.60 090 58540 $2,150.65 $2,150.65 09057425 $2,316.60 $2,316.60 090 58541 $1,705.02 $1,705.02 09057426 $2,002.38 $2,002.38 090 58542 $1,945.10 $1,945.10 09057452 $293.24 $249.59 000 58543 $1,968.69 $1,968.69 09057454 $409.02 $364.42 000 58544 $2,142.22 $2,142.22 09057455 $383.40 $297.99 000 58545 $2,154.02 $2,154.02 09057456 $361.57 $277.11 000 58546 $2,664.51 $2,664.51 09057460 $756.35 $436.54 000 58548 $4,610.46 $4,610.46 09057461 $856.00 $504.87 000 58550 $2,096.73 $2,096.73 09057500 $342.59 $204.04 000 58552 $2,358.72 $2,358.72 09057505 $276.16 $248.64 010 58553 $2,679.67 $2,679.67 09057510 $353.98 $310.32 010 58554 $3,169.11 $3,169.11 09057511 $390.99 $353.98 010 58555 $721.24 $414.71 00057513 $394.78 $363.47 010 58558 $3,655.55 $632.98 00057520 $737.10 $660.44 090 58559 $783.87 $783.87 00057522 $629.27 $581.26 090 58560 $854.10 $854.10 00057530 $827.24 $827.24 090 58561 $977.47 $977.47 00057531 $4,011.51 $4,011.51 090 58562 $912.94 $607.36 00057540 $1,845.70 $1,845.70 090 58563 $4,265.76 $672.84 00057545 $1,947.63 $1,947.63 090 58565 $4,437.76 $1,026.89 09057550 $966.23 $966.23 090 58570 $1,864.23 $1,864.23 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 36 of 84

Page 37: Appendix B for Administrative Order No. 18-053 Physician ...Appendix B for Administrative Order No. 18-053 Physician Fee Schedule Effective April 1, 2018 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

58571 $2,153.17 $2,153.17 090 59100 $2,020.08 $2,020.08 09058572 $2,452.23 $2,452.23 090 59120 $1,923.20 $1,923.20 09058573 $2,923.13 $2,923.13 090 59121 $1,925.73 $1,925.73 09058575 $4,516.95 $4,516.95 090 59130 $2,249.21 $2,249.21 09058578 80% of billed 80% of billed N/A 59135 $2,222.25 $2,222.25 09058579 80% of billed 80% of billed N/A 59136 $2,128.74 $2,128.74 09058600 $863.46 $863.46 090 59140 $969.60 $969.60 09058605 $780.90 $780.90 090 59150 $1,865.07 $1,865.07 09058611 $206.88 $206.88 ZZZ 59151 $1,808.63 $1,808.63 09058615 $651.01 $651.01 010 59160 $557.06 $473.55 01058660 $1,608.14 $1,608.14 090 59200 $196.44 $122.42 00058661 $1,750.91 $1,750.91 010 59300 $527.64 $407.12 00058662 $1,697.44 $1,697.44 090 59320 $417.56 $417.56 00058670 $865.99 $865.99 090 59325 $664.30 $664.30 00058671 $864.30 $864.30 090 59350 $770.59 $770.59 00058672 $1,741.24 $1,741.24 090 59400 $5,686.41 $5,686.41 N/A58673 $1,892.87 $1,892.87 090 59409 $2,224.46 $2,224.46 N/A58674 $1,934.99 $1,934.99 090 59410 $2,841.31 $2,841.31 N/A58679 80% of billed 80% of billed N/A 59412 $282.80 $282.80 N/A58700 $1,864.23 $1,864.23 090 59414 $251.49 $251.49 N/A58720 $1,769.88 $1,769.88 090 59425 $1,235.60 $973.67 N/A58740 $2,126.22 $2,126.22 090 59426 $2,208.32 $1,711.05 N/A58750 $2,133.80 $2,133.80 090 59430 $500.12 $377.70 N/A58752 $2,127.90 $2,127.90 090 59510 $6,307.05 $6,307.05 N/A58760 $1,917.30 $1,917.30 090 59514 $2,504.41 $2,504.41 N/A58770 $2,018.39 $2,018.39 090 59515 $3,451.51 $3,451.51 N/A58800 $755.63 $708.46 090 59525 $1,329.55 $1,329.55 ZZZ58805 $958.65 $958.65 090 59610 $5,986.29 $5,986.29 N/A58820 $739.63 $739.63 090 59612 $2,506.31 $2,506.31 N/A58822 $1,657.84 $1,657.84 090 59614 $3,116.52 $3,116.52 N/A58825 $1,646.05 $1,646.05 090 59618 $6,388.67 $6,388.67 N/A58900 $980.55 $980.55 090 59620 $2,595.52 $2,595.52 N/A58920 $1,658.69 $1,658.69 090 59622 $3,538.82 $3,538.82 N/A58925 $1,787.57 $1,787.57 090 59812 $767.43 $715.20 09058940 $1,266.13 $1,266.13 090 59820 $917.37 $860.93 09058943 $2,847.31 $2,847.31 090 59821 $924.96 $864.30 09058950 $2,746.22 $2,746.22 090 59830 $1,055.53 $1,055.53 09058951 $3,532.18 $3,532.18 090 59840 $592.18 $566.55 01058952 $3,990.45 $3,990.45 090 59841 $1,042.00 $982.22 01058953 $4,946.57 $4,946.57 090 59850 $919.06 $919.06 09058954 $5,379.57 $5,379.57 090 59851 $963.71 $963.71 09058956 $3,356.12 $3,356.12 090 59852 $1,225.69 $1,225.69 09058957 $3,858.19 $3,858.19 090 59855 $1,004.98 $1,004.98 09058958 $4,026.67 $4,026.67 090 59856 $1,181.04 $1,181.04 09058960 $2,362.09 $2,362.09 090 59857 $1,257.70 $1,257.70 09058970 $595.02 $536.19 000 59866 $593.13 $593.13 00058974 80% of billed 80% of billed 000 59870 $1,140.61 $1,140.61 09058976 $660.50 $579.84 000 59871 $365.37 $365.37 00058999 80% of billed 80% of billed N/A 59897 80% of billed 80% of billed N/A59000 $342.59 $220.17 000 59898 80% of billed 80% of billed N/A59001 $491.58 $491.58 000 59899 80% of billed 80% of billed N/A59012 $554.22 $554.22 000 60000 $456.47 $409.97 01059015 $426.10 $361.57 000 60100 $305.58 $216.37 00059020 $191.70 $191.70 000 60200 $1,589.61 $1,589.61 09059020 TC $90.16 $90.16 000 60210 $1,706.70 $1,706.70 09059020 26 $101.54 $101.54 000 60212 $2,502.77 $2,502.77 09059025 $130.96 $130.96 000 60220 $1,699.96 $1,699.96 09059025 TC $49.35 $49.35 000 60225 $2,244.15 $2,244.15 09059025 26 $81.61 $81.61 000 60240 $2,218.04 $2,218.04 09059030 $309.37 $309.37 000 60252 $3,188.48 $3,188.48 09059050 $139.50 $139.50 N/A 60254 $4,022.46 $4,022.46 09059051 $115.78 $115.78 N/A 60260 $2,635.87 $2,635.87 09059070 $1,104.64 $850.30 000 60270 $3,307.26 $3,307.26 09059072 $1,434.89 $1,434.89 000 60271 $2,549.94 $2,549.94 09059074 $1,065.73 $850.30 000 60280 $1,056.37 $1,056.37 09059076 $1,434.89 $1,434.89 000 60281 $1,400.91 $1,400.91 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 37 of 84

Page 38: Appendix B for Administrative Order No. 18-053 Physician ...Appendix B for Administrative Order No. 18-053 Physician Fee Schedule Effective April 1, 2018 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

60300 $318.86 $136.66 000 61521 $7,850.33 $7,850.33 09060500 $2,335.98 $2,335.98 090 61522 $5,405.68 $5,405.68 09060502 $3,121.09 $3,121.09 090 61524 $5,146.22 $5,146.22 09060505 $3,349.38 $3,349.38 090 61526 $8,727.26 $8,727.26 09060512 $665.25 $665.25 ZZZ 61530 $7,589.18 $7,589.18 09060520 $2,544.05 $2,544.05 090 61531 $3,016.63 $3,016.63 09060521 $2,724.32 $2,724.32 090 61533 $3,752.89 $3,752.89 09060522 $3,319.06 $3,319.06 090 61534 $4,065.42 $4,065.42 09060540 $2,585.33 $2,585.33 090 61535 $2,469.07 $2,469.07 09060545 $2,960.19 $2,960.19 090 61536 $6,371.07 $6,371.07 09060600 $3,356.12 $3,356.12 090 61537 $6,068.65 $6,068.65 09060605 $4,067.11 $4,067.11 090 61538 $6,593.46 $6,593.46 09060650 $2,905.44 $2,905.44 090 61539 $5,833.62 $5,833.62 09060659 80% of billed 80% of billed N/A 61540 $5,394.73 $5,394.73 09060699 80% of billed 80% of billed N/A 61541 $5,310.49 $5,310.49 09061000 $316.97 $316.97 000 61543 $5,368.62 $5,368.62 09061001 $300.83 $300.83 000 61544 $4,703.96 $4,703.96 09061020 $272.36 $272.36 000 61545 $7,846.96 $7,846.96 09061026 $288.50 $288.50 000 61546 $5,702.21 $5,702.21 09061050 $236.30 $236.30 000 61548 $3,858.19 $3,858.19 09061055 $339.74 $339.74 000 61550 $2,924.81 $2,924.81 09061070 $156.59 $156.59 000 61552 $3,656.02 $3,656.02 09061105 $1,141.45 $1,141.45 090 61556 $4,211.16 $4,211.16 09061107 $874.03 $874.03 000 61557 $4,151.35 $4,151.35 09061108 $2,203.72 $2,203.72 090 61558 $4,640.78 $4,640.78 09061120 $1,842.33 $1,842.33 090 61559 $5,905.22 $5,905.22 09061140 $3,107.61 $3,107.61 090 61563 $4,894.34 $4,894.34 09061150 $3,349.38 $3,349.38 090 61564 $5,945.66 $5,945.66 09061151 $2,455.60 $2,455.60 090 61566 $5,555.63 $5,555.63 09061154 $3,124.46 $3,124.46 090 61567 $6,326.42 $6,326.42 09061156 $3,080.66 $3,080.66 090 61570 $4,615.51 $4,615.51 09061210 $1,030.61 $1,030.61 000 61571 $4,915.40 $4,915.40 09061215 $1,245.91 $1,245.91 090 61575 $6,189.11 $6,189.11 09061250 $2,140.54 $2,140.54 090 61576 $10,305.08 $10,305.08 09061253 $2,455.60 $2,455.60 090 61580 $5,916.18 $5,916.18 09061304 $4,028.36 $4,028.36 090 61581 $6,308.73 $6,308.73 09061305 $4,966.79 $4,966.79 090 61582 $7,389.53 $7,389.53 09061312 $5,116.74 $5,116.74 090 61583 $7,026.46 $7,026.46 09061313 $4,877.50 $4,877.50 090 61584 $6,975.07 $6,975.07 09061314 $4,500.94 $4,500.94 090 61585 $7,905.92 $7,905.92 09061315 $5,087.25 $5,087.25 090 61586 $5,936.39 $5,936.39 09061316 $246.74 $246.74 ZZZ 61590 $7,385.32 $7,385.32 09061320 $4,678.69 $4,678.69 090 61591 $7,440.92 $7,440.92 09061321 $5,263.32 $5,263.32 090 61592 $7,724.81 $7,724.81 09061322 $5,842.89 $5,842.89 090 61595 $5,646.61 $5,646.61 09061323 $5,913.65 $5,913.65 090 61596 $5,847.94 $5,847.94 09061330 $4,437.76 $4,437.76 090 61597 $7,306.98 $7,306.98 09061332 $4,906.98 $4,906.98 090 61598 $6,979.28 $6,979.28 09061333 $5,013.96 $5,013.96 090 61600 $5,152.96 $5,152.96 09061340 $3,573.46 $3,573.46 090 61601 $5,847.10 $5,847.10 09061343 $5,399.78 $5,399.78 090 61605 $5,186.66 $5,186.66 09061345 $5,043.45 $5,043.45 090 61606 $7,178.09 $7,178.09 09061450 $4,755.35 $4,755.35 090 61607 $7,039.94 $7,039.94 09061458 $4,945.73 $4,945.73 090 61608 $7,945.52 $7,945.52 09061460 $5,201.82 $5,201.82 090 61610 $5,258.41 $5,258.41 ZZZ61480 $4,799.15 $4,799.15 090 61611 $1,316.26 $1,316.26 ZZZ61500 $3,224.71 $3,224.71 090 61612 $4,940.49 $4,940.49 ZZZ61501 $2,780.76 $2,780.76 090 61613 $8,077.77 $8,077.77 09061510 $5,371.98 $5,371.98 090 61615 $6,883.25 $6,883.25 09061512 $6,264.93 $6,264.93 090 61616 $8,118.21 $8,118.21 09061514 $4,675.32 $4,675.32 090 61618 $3,159.84 $3,159.84 09061516 $4,584.34 $4,584.34 090 61619 $3,497.64 $3,497.64 09061517 $245.79 $245.79 ZZZ 61623 $1,594.32 $1,594.32 00061518 $6,769.53 $6,769.53 090 61624 $3,186.74 $3,186.74 00061519 $7,217.68 $7,217.68 090 61626 $2,390.53 $2,390.53 00061520 $9,168.68 $9,168.68 090 61630 $3,777.97 $3,777.97 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 38 of 84

Page 39: Appendix B for Administrative Order No. 18-053 Physician ...Appendix B for Administrative Order No. 18-053 Physician Fee Schedule Effective April 1, 2018 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

61635 $4,025.66 $4,025.66 N/A 62161 $3,745.31 $3,745.31 09061640 $1,329.55 $1,329.55 000 62162 $4,671.11 $4,671.11 09061641 $466.91 $466.91 ZZZ 62163 $3,021.69 $3,021.69 09061642 $933.82 $933.82 ZZZ 62164 $5,162.23 $5,162.23 09061645 $2,281.40 $2,281.40 000 62165 $3,745.31 $3,745.31 09061650 $1,486.13 $1,486.13 000 62180 $3,955.91 $3,955.91 09061651 $631.09 $631.09 ZZZ 62190 $2,279.53 $2,279.53 09061680 $5,516.04 $5,516.04 090 62192 $2,404.21 $2,404.21 09061682 $10,213.26 $10,213.26 090 62194 $1,348.53 $1,348.53 01061684 $7,018.03 $7,018.03 090 62200 $3,402.45 $3,402.45 09061686 $10,911.61 $10,911.61 090 62201 $2,965.25 $2,965.25 09061690 $5,402.31 $5,402.31 090 62220 $2,485.92 $2,485.92 09061692 $9,004.41 $9,004.41 090 62223 $2,560.05 $2,560.05 09061697 $10,319.40 $10,319.40 090 62225 $1,279.61 $1,279.61 09061698 $11,187.91 $11,187.91 090 62230 $2,064.72 $2,064.72 09061700 $8,366.72 $8,366.72 090 62252 $230.61 $230.61 N/A61702 $9,875.45 $9,875.45 090 62252 TC $102.49 $102.49 N/A61703 $3,356.96 $3,356.96 090 62252 26 $128.12 $128.12 N/A61705 $6,430.04 $6,430.04 090 62256 $1,469.99 $1,469.99 09061708 $6,289.36 $6,289.36 090 62258 $2,742.01 $2,742.01 09061710 $5,291.96 $5,291.96 090 62263 $1,614.25 $868.34 01061711 $6,424.14 $6,424.14 090 62264 $1,134.06 $648.17 01061720 $3,138.78 $3,138.78 090 62267 $670.94 $431.80 00061735 $3,927.27 $3,927.27 090 62268 $706.06 $706.06 00061750 $3,482.48 $3,482.48 090 62269 $715.55 $715.55 00061751 $3,402.45 $3,402.45 090 62270 $428.00 $213.53 00061760 $3,894.42 $3,894.42 090 62272 $548.52 $228.71 00061770 $4,014.88 $4,014.88 090 62273 $469.76 $309.37 00061781 $659.56 $659.56 ZZZ 62280 $847.46 $451.72 01061782 $475.45 $475.45 ZZZ 62281 $646.27 $427.05 01061783 $646.27 $646.27 ZZZ 62282 $782.93 $393.84 01061790 $2,165.81 $2,165.81 090 62284 $513.41 $240.10 00061791 $2,777.39 $2,777.39 090 62287 $1,393.33 $1,393.33 09061796 $2,501.09 $2,501.09 090 62290 $880.67 $462.16 00061797 $618.75 $618.75 ZZZ 62291 $874.98 $457.42 00061798 $3,407.51 $3,407.51 090 62292 $1,390.80 $1,390.80 09061799 $850.30 $850.30 ZZZ 62294 $2,344.40 $2,344.40 09061800 $429.90 $429.90 ZZZ 62302 $655.76 $335.00 00061850 $2,425.27 $2,425.27 090 62303 $670.94 $335.00 00061860 $3,867.46 $3,867.46 090 62304 $647.22 $328.35 00061863 $3,697.29 $3,697.29 090 62305 $704.16 $342.59 00061864 $794.31 $794.31 ZZZ 62320 $448.88 $272.36 00061867 $5,617.97 $5,617.97 090 62321 $669.05 $292.29 00061868 $1,397.88 $1,397.88 ZZZ 62322 $421.36 $236.30 00061870 $2,923.13 $2,923.13 090 62323 $660.50 $270.47 00061880 $1,394.17 $1,394.17 090 62324 $392.89 $246.74 00061885 $1,258.55 $1,258.55 090 62325 $595.02 $284.70 00061886 $2,070.62 $2,070.62 090 62326 $413.76 $244.84 00061888 $1,098.94 $1,098.94 010 62327 $606.41 $260.03 00062000 $2,543.21 $2,543.21 090 62350 $1,092.30 $1,092.30 01062005 $3,139.62 $3,139.62 090 62351 $2,094.21 $2,094.21 09062010 $3,785.75 $3,785.75 090 62355 $733.58 $733.58 01062100 $3,881.78 $3,881.78 090 62360 $853.15 $853.15 01062115 $4,128.60 $4,128.60 090 62361 $1,182.45 $1,182.45 01062117 $4,852.22 $4,852.22 090 62362 $1,050.54 $1,050.54 01062120 $5,242.26 $5,242.26 090 62365 $811.40 $811.40 01062121 $4,165.67 $4,165.67 090 62367 $114.83 $69.28 N/A62140 $2,515.41 $2,515.41 090 62368 $154.69 $95.85 N/A62141 $2,786.66 $2,786.66 090 62369 $323.61 $95.85 N/A62142 $2,175.08 $2,175.08 090 62370 $341.64 $127.17 N/A62143 $2,551.63 $2,551.63 090 62380 80% of billed 80% of billed 09062145 $3,466.48 $3,466.48 090 63001 $3,039.38 $3,039.38 09062146 $3,032.64 $3,032.64 090 63003 $3,046.12 $3,046.12 09062147 $3,605.47 $3,605.47 090 63005 $2,896.17 $2,896.17 09062148 $354.93 $354.93 ZZZ 63011 $2,666.20 $2,666.20 09062160 $532.39 $532.39 ZZZ 63012 $2,918.07 $2,918.07 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 39 of 84

Page 40: Appendix B for Administrative Order No. 18-053 Physician ...Appendix B for Administrative Order No. 18-053 Physician Fee Schedule Effective April 1, 2018 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

63015 $3,635.80 $3,635.80 090 63280 $5,195.08 $5,195.08 09063016 $3,750.36 $3,750.36 090 63281 $5,144.54 $5,144.54 09063017 $3,080.66 $3,080.66 090 63282 $4,837.06 $4,837.06 09063020 $2,836.36 $2,836.36 090 63283 $4,694.70 $4,694.70 09063030 $2,374.73 $2,374.73 090 63285 $6,459.52 $6,459.52 09063035 $529.54 $529.54 ZZZ 63286 $6,380.34 $6,380.34 09063040 $3,426.04 $3,426.04 090 63287 $6,776.27 $6,776.27 09063042 $3,172.48 $3,172.48 090 63290 $6,889.99 $6,889.99 09063043 80% of billed 80% of billed ZZZ 63295 $932.87 $932.87 ZZZ63044 80% of billed 80% of billed ZZZ 63300 $4,494.20 $4,494.20 09063045 $3,148.89 $3,148.89 090 63301 $5,450.33 $5,450.33 09063046 $2,997.26 $2,997.26 090 63302 $5,382.09 $5,382.09 09063047 $2,695.68 $2,695.68 090 63303 $5,719.05 $5,719.05 09063048 $586.48 $586.48 ZZZ 63304 $5,805.82 $5,805.82 09063050 $3,876.72 $3,876.72 090 63305 $6,178.16 $6,178.16 09063051 $4,181.67 $4,181.67 090 63306 $6,071.18 $6,071.18 09063055 $3,988.76 $3,988.76 090 63307 $5,946.50 $5,946.50 09063056 $3,641.70 $3,641.70 090 63308 $891.11 $891.11 ZZZ63057 $887.32 $887.32 ZZZ 63600 $2,561.74 $2,561.74 09063064 $4,366.16 $4,366.16 090 63610 $1,629.43 $1,629.43 00063066 $579.84 $579.84 ZZZ 63615 $3,058.75 $3,058.75 09063075 $3,307.26 $3,307.26 090 63620 $2,763.91 $2,763.91 09063076 $684.23 $684.23 ZZZ 63621 $711.75 $711.75 ZZZ63077 $3,645.06 $3,645.06 090 63650 $3,567.29 $1,122.67 01063078 $582.69 $582.69 ZZZ 63655 $2,027.66 $2,027.66 09063081 $4,307.19 $4,307.19 090 63661 $1,587.68 $885.42 01063082 $739.27 $739.27 ZZZ 63662 $2,049.56 $2,049.56 09063085 $4,681.22 $4,681.22 090 63663 $2,134.30 $1,231.80 01063086 $528.59 $528.59 ZZZ 63664 $2,133.80 $2,133.80 09063087 $5,917.86 $5,917.86 090 63685 $993.60 $993.60 01063088 $684.23 $684.23 ZZZ 63688 $1,021.12 $1,021.12 01063090 $4,800.84 $4,800.84 090 63700 $3,205.33 $3,205.33 09063091 $492.53 $492.53 ZZZ 63702 $3,511.12 $3,511.12 09063101 $5,695.47 $5,695.47 090 63704 $4,069.63 $4,069.63 09063102 $5,551.42 $5,551.42 090 63706 $4,531.27 $4,531.27 09063103 $815.19 $815.19 ZZZ 63707 $2,258.47 $2,258.47 09063170 $3,934.01 $3,934.01 090 63709 $2,690.63 $2,690.63 09063172 $3,487.54 $3,487.54 090 63710 $2,647.66 $2,647.66 09063173 $4,265.07 $4,265.07 090 63740 $2,398.31 $2,398.31 09063180 $3,672.02 $3,672.02 090 63741 $1,662.90 $1,662.90 09063182 $4,031.73 $4,031.73 090 63744 $1,611.51 $1,611.51 09063185 $2,773.18 $2,773.18 090 63746 $1,477.57 $1,477.57 09063190 $3,044.43 $3,044.43 090 64400 $354.93 $196.44 00063191 $3,404.14 $3,404.14 090 64402 $381.50 $225.86 00063194 $3,946.64 $3,946.64 090 64405 $278.06 $173.67 00063195 $3,800.91 $3,800.91 090 64408 $314.12 $234.40 00063196 $4,404.07 $4,404.07 090 64410 $417.56 $229.66 00063197 $4,228.85 $4,228.85 090 64413 $344.49 $222.07 00063198 $5,169.81 $5,169.81 090 64415 $319.81 $177.46 00063199 $5,416.63 $5,416.63 090 64416 $215.42 $215.42 00063200 $3,767.21 $3,767.21 090 64417 $350.18 $191.70 00063250 $7,323.83 $7,323.83 090 64418 $316.97 $168.92 00063251 $7,483.04 $7,483.04 090 64420 $301.78 $183.16 00063252 $7,482.20 $7,482.20 090 64421 $408.07 $250.54 00063265 $4,101.65 $4,101.65 090 64425 $362.52 $255.28 00063266 $4,220.42 $4,220.42 090 64430 $371.06 $219.22 00063267 $3,352.75 $3,352.75 090 64435 $369.16 $223.02 00063268 $3,558.30 $3,558.30 090 64445 $371.06 $198.34 00063270 $5,133.59 $5,133.59 090 64446 $215.42 $215.42 00063271 $5,078.83 $5,078.83 090 64447 $328.35 $181.26 00063272 $4,655.94 $4,655.94 090 64448 $194.55 $194.55 00063273 $4,608.77 $4,608.77 090 64449 $230.61 $230.61 00063275 $4,420.92 $4,420.92 090 64450 $216.37 $123.37 00063276 $4,380.48 $4,380.48 090 64455 $129.06 $94.90 00063277 $3,808.49 $3,808.49 090 64461 $400.48 $237.25 00063278 $3,925.58 $3,925.58 090 64462 $220.17 $146.15 ZZZ

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 40 of 84

Page 41: Appendix B for Administrative Order No. 18-053 Physician ...Appendix B for Administrative Order No. 18-053 Physician Fee Schedule Effective April 1, 2018 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

64463 $428.00 $234.40 000 64714 $1,723.55 $1,723.55 09064479 $633.93 $358.72 000 64716 $1,278.76 $1,278.76 09064480 $305.58 $171.77 ZZZ 64718 $1,435.45 $1,435.45 09064483 $588.38 $305.58 000 64719 $969.60 $969.60 09064484 $248.64 $141.40 ZZZ 64721 $1,039.52 $1,033.62 09064486 $316.02 $163.23 000 64722 $867.67 $867.67 09064487 $360.62 $181.26 000 64726 $656.23 $656.23 09064488 $363.47 $194.55 000 64727 $505.82 $505.82 ZZZ64489 $492.53 $216.37 000 64732 $1,079.96 $1,079.96 09064490 $510.56 $288.50 000 64734 $1,223.16 $1,223.16 09064491 $251.49 $164.18 ZZZ 64736 $938.43 $938.43 09064492 $253.38 $166.08 ZZZ 64738 $1,123.76 $1,123.76 09064493 $463.11 $246.74 000 64740 $1,194.52 $1,194.52 09064494 $232.51 $141.40 ZZZ 64742 $1,191.15 $1,191.15 09064495 $232.51 $143.30 ZZZ 64744 $1,210.53 $1,210.53 09064505 $296.09 $246.74 000 64746 $1,043.73 $1,043.73 09064508 $133.81 $163.23 000 64755 $2,240.78 $2,240.78 09064510 $343.54 $200.24 000 64760 $1,250.96 $1,250.96 09064517 $513.41 $342.59 000 64763 $1,238.33 $1,238.33 09064520 $505.82 $220.17 000 64766 $1,525.59 $1,525.59 09064530 $508.66 $247.69 000 64771 $1,439.66 $1,439.66 09064550 $48.40 $24.67 000 64772 $1,370.58 $1,370.58 09064553 $3,050.09 $1,037.26 010 64774 $998.24 $998.24 09064555 $3,259.82 $924.33 010 64776 $946.86 $946.86 09064561 $2,248.18 $831.32 010 64778 $503.92 $503.92 ZZZ64566 $349.23 $83.51 000 64782 $1,104.39 $1,104.39 09064568 $1,560.12 $1,560.12 090 64783 $602.62 $602.62 ZZZ64569 $1,881.92 $1,881.92 090 64784 $1,762.30 $1,762.30 09064570 $1,809.48 $1,809.48 090 64786 $2,436.22 $2,436.22 09064575 $781.75 $781.75 090 64787 $662.40 $662.40 ZZZ64580 $742.15 $742.15 090 64788 $958.65 $958.65 09064581 $1,615.72 $1,615.72 090 64790 $2,042.82 $2,042.82 09064585 $664.30 $391.94 010 64792 $2,932.39 $2,932.39 09064590 $723.14 $441.29 010 64795 $535.24 $535.24 00064595 $667.15 $346.39 010 64802 $2,042.82 $2,042.82 09064600 $1,097.99 $616.85 010 64804 $2,914.70 $2,914.70 09064605 $1,473.80 $925.28 010 64809 $2,679.67 $2,679.67 09064610 $2,010.93 $1,342.84 010 64818 $1,531.48 $1,531.48 09064611 $327.41 $281.85 010 64820 $1,726.92 $1,726.92 09064612 $361.57 $319.81 010 64821 $1,681.43 $1,681.43 09064615 $399.53 $341.64 010 64822 $1,681.43 $1,681.43 09064616 $354.93 $302.73 010 64823 $1,914.78 $1,914.78 09064617 $434.64 $297.99 010 64831 $1,665.42 $1,665.42 09064620 $554.22 $468.81 010 64832 $928.12 $928.12 ZZZ64630 $622.54 $521.00 010 64834 $1,796.00 $1,796.00 09064632 $231.56 $187.90 010 64835 $1,981.32 $1,981.32 09064633 $1,131.21 $613.05 010 64836 $1,981.32 $1,981.32 09064634 $508.66 $186.00 ZZZ 64837 $1,015.43 $1,015.43 ZZZ64635 $1,118.87 $604.51 010 64840 $2,340.19 $2,340.19 09064636 $462.16 $162.28 ZZZ 64856 $2,462.34 $2,462.34 09064640 $357.77 $253.38 010 64857 $2,573.53 $2,573.53 09064642 $390.99 $297.99 000 64858 $2,869.21 $2,869.21 09064643 $251.49 $197.39 ZZZ 64859 $689.92 $689.92 ZZZ64644 $446.98 $324.56 000 64861 $3,737.73 $3,737.73 09064645 $310.32 $227.76 ZZZ 64862 $3,360.33 $3,360.33 09064646 $408.07 $318.86 000 64864 $2,116.95 $2,116.95 09064647 $484.94 $379.60 000 64865 $2,643.45 $2,643.45 09064650 $211.63 $115.78 000 64866 $3,124.46 $3,124.46 09064653 $260.03 $148.99 000 64868 $2,420.22 $2,420.22 09064680 $817.09 $445.08 010 64872 $321.71 $321.71 ZZZ64681 $1,403.57 $665.25 010 64874 $483.99 $483.99 ZZZ64702 $1,212.21 $1,212.21 090 64876 $547.57 $547.57 ZZZ64704 $772.48 $772.48 090 64885 $2,715.06 $2,715.06 09064708 $1,208.84 $1,208.84 090 64886 $3,114.35 $3,114.35 09064712 $1,400.91 $1,400.91 090 64890 $2,632.50 $2,632.50 09064713 $1,864.23 $1,864.23 090 64891 $2,800.14 $2,800.14 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 41 of 84

Page 42: Appendix B for Administrative Order No. 18-053 Physician ...Appendix B for Administrative Order No. 18-053 Physician Fee Schedule Effective April 1, 2018 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

64892 $2,559.21 $2,559.21 090 65775 $1,324.25 $1,324.25 09064893 $2,731.90 $2,731.90 090 65778 $3,815.93 $151.84 00064895 $3,239.03 $3,239.03 090 65779 $3,270.25 $412.82 00064896 $3,493.43 $3,493.43 090 65780 $1,600.56 $1,600.56 09064897 $3,093.29 $3,093.29 090 65781 $3,201.96 $3,201.96 09064898 $3,353.59 $3,353.59 090 65782 $2,763.07 $2,763.07 09064901 $1,655.06 $1,655.06 ZZZ 65785 $6,020.63 $1,063.11 09064902 $1,916.03 $1,916.03 ZZZ 65800 $324.56 $247.69 00064905 $2,468.23 $2,468.23 090 65810 $1,117.86 $1,117.86 09064907 $3,176.69 $3,176.69 090 65815 $1,535.70 $1,148.19 09064910 $1,945.10 $1,945.10 090 65820 $1,798.52 $1,798.52 09064911 $2,495.19 $2,495.19 090 65850 $2,015.02 $2,015.02 09064912 $1,886.13 $1,886.13 090 65855 $664.30 $562.76 01064913 $430.85 $430.85 ZZZ 65860 $743.84 $609.06 09064999 80% of billed 80% of billed N/A 65865 $1,135.56 $1,135.56 09065091 $1,523.90 $1,523.90 090 65870 $1,418.60 $1,418.60 09065093 $1,507.05 $1,507.05 090 65875 $1,513.79 $1,513.79 09065101 $1,770.72 $1,770.72 090 65880 $1,592.98 $1,592.98 09065103 $1,848.23 $1,848.23 090 65900 $2,313.23 $2,313.23 09065105 $2,036.92 $2,036.92 090 65920 $1,892.03 $1,892.03 09065110 $2,929.02 $2,929.02 090 65930 $1,529.80 $1,529.80 09065112 $3,397.40 $3,397.40 090 66020 $506.77 $355.88 01065114 $3,562.51 $3,562.51 090 66030 $452.67 $301.78 01065125 $1,101.02 $703.40 090 66130 $1,673.85 $1,365.53 09065130 $1,756.40 $1,756.40 090 66150 $2,105.16 $2,105.16 09065135 $1,781.68 $1,781.68 090 66155 $2,103.47 $2,103.47 09065140 $1,936.68 $1,936.68 090 66160 $2,371.36 $2,371.36 09065150 $1,386.59 $1,386.59 090 66170 $2,626.60 $2,626.60 09065155 $2,029.34 $2,029.34 090 66172 $2,860.79 $2,860.79 09065175 $1,576.13 $1,576.13 090 66174 $2,275.32 $2,275.32 09065205 $153.74 $119.57 000 66175 $2,382.31 $2,382.31 09065210 $186.95 $143.30 000 66179 $2,587.85 $2,587.85 09065220 $160.38 $114.83 000 66180 $2,730.22 $2,730.22 09065222 $183.16 $141.40 000 66183 $2,473.29 $2,473.29 09065235 $1,705.02 $1,705.02 090 66184 $1,885.29 $1,885.29 09065260 $2,305.65 $2,305.65 090 66185 $2,027.66 $2,027.66 09065265 $2,587.01 $2,587.01 090 66220 $1,793.47 $1,793.47 09065270 $725.99 $382.45 010 66225 $2,237.41 $2,237.41 09065272 $1,208.84 $842.40 090 66250 $1,801.05 $1,338.57 09065273 $914.00 $914.00 090 66500 $849.14 $849.14 09065275 $1,390.80 $1,110.28 090 66505 $931.69 $931.69 09065280 $1,613.20 $1,613.20 090 66600 $1,999.86 $1,999.86 09065285 $2,661.98 $2,661.98 090 66605 $2,534.78 $2,534.78 09065286 $1,694.91 $1,191.15 090 66625 $1,031.10 $1,031.10 09065290 $1,178.52 $1,178.52 090 66630 $1,367.22 $1,367.22 09065400 $1,634.26 $1,448.93 090 66635 $1,380.69 $1,380.69 09065410 $390.04 $282.80 000 66680 $1,242.54 $1,242.54 09065420 $1,243.38 $907.26 090 66682 $1,532.33 $1,532.33 09065426 $1,568.55 $1,150.72 090 66700 $1,085.01 $945.17 09065430 $313.17 $279.96 000 66710 $1,061.42 $944.33 09065435 $220.17 $188.85 000 66711 $1,544.12 $1,544.12 09065436 $932.54 $892.10 090 66720 $1,107.76 $983.08 09065450 $784.27 $774.17 090 66740 $1,053.84 $945.17 09065600 $947.70 $825.55 090 66761 $804.75 $638.68 01065710 $2,652.72 $2,652.72 090 66762 $1,143.98 $1,023.52 09065730 $2,945.87 $2,945.87 090 66770 $1,270.34 $1,159.98 09065750 $2,959.35 $2,959.35 090 66820 $948.54 $948.54 09065755 $2,945.03 $2,945.03 090 66821 $791.86 $747.21 09065756 $2,843.10 $2,843.10 090 66825 $1,823.80 $1,823.80 09065757 80% of billed 80% of billed ZZZ 66830 $1,709.23 $1,709.23 09065760 80% of billed 80% of billed N/A 66840 $1,673.01 $1,673.01 09065765 80% of billed 80% of billed N/A 66850 $1,903.82 $1,903.82 09065767 80% of billed 80% of billed N/A 66852 $2,027.66 $2,027.66 09065770 $3,362.86 $3,362.86 090 66920 $1,810.32 $1,810.32 09065771 80% of billed 80% of billed N/A 66930 $2,056.30 $2,056.30 09065772 $1,085.01 $976.34 090 66940 $1,878.55 $1,878.55 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 42 of 84

Page 43: Appendix B for Administrative Order No. 18-053 Physician ...Appendix B for Administrative Order No. 18-053 Physician Fee Schedule Effective April 1, 2018 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

66982 $1,908.04 $1,908.04 090 67430 $2,992.20 $2,992.20 09066983 $1,789.26 $1,789.26 090 67440 $2,894.49 $2,894.49 09066984 $1,535.70 $1,535.70 090 67445 $3,361.18 $3,361.18 09066985 $1,849.91 $1,849.91 090 67450 $3,009.90 $3,009.90 09066986 $2,181.82 $2,181.82 090 67500 $215.42 $199.29 00066990 $243.89 $243.89 ZZZ 67505 $236.30 $216.37 00066999 80% of billed 80% of billed N/A 67515 $261.92 $241.05 00067005 $1,134.71 $1,134.71 090 67550 $2,314.92 $2,314.92 09067010 $1,303.19 $1,303.19 090 67560 $2,373.88 $2,373.88 09067015 $1,393.33 $1,393.33 090 67570 $2,790.87 $2,790.87 09067025 $1,746.30 $1,520.53 090 67599 80% of billed 80% of billed N/A67027 $2,046.19 $2,046.19 090 67700 $728.83 $316.02 01067028 $275.21 $271.41 000 67710 $607.36 $263.82 01067030 $1,279.61 $1,279.61 090 67715 $651.96 $293.24 01067031 $935.91 $855.88 090 67800 $345.44 $279.96 01067036 $2,164.13 $2,164.13 090 67801 $440.34 $361.57 01067039 $2,317.44 $2,317.44 090 67805 $547.57 $445.08 01067040 $2,504.46 $2,504.46 090 67808 $885.36 $885.36 09067041 $2,767.28 $2,767.28 090 67810 $464.06 $194.55 00067042 $2,767.28 $2,767.28 090 67820 $109.14 $115.78 00067043 $2,923.97 $2,923.97 090 67825 $347.33 $329.30 01067101 $888.26 $771.54 010 67830 $723.14 $374.86 01067105 $802.85 $744.97 010 67835 $1,053.84 $1,053.84 09067107 $2,718.42 $2,718.42 090 67840 $746.86 $428.00 01067108 $2,882.69 $2,882.69 090 67850 $580.79 $368.21 01067110 $2,105.16 $1,953.53 090 67875 $467.86 $263.82 00067113 $3,217.13 $3,217.13 090 67880 $1,101.86 $884.52 09067115 $1,200.42 $1,200.42 090 67882 $1,357.11 $1,136.40 09067120 $1,576.13 $1,337.73 090 67900 $1,536.54 $1,223.16 09067121 $2,180.97 $2,180.97 090 67901 $1,816.21 $1,384.91 09067141 $1,260.23 $1,172.62 090 67902 $1,736.19 $1,736.19 09067145 $1,268.65 $1,197.05 090 67903 $1,425.34 $1,161.67 09067208 $1,438.82 $1,388.28 090 67904 $1,759.77 $1,436.29 09067210 $1,244.22 $1,202.95 090 67906 $1,220.64 $1,220.64 09067218 $3,319.90 $3,319.90 090 67908 $1,186.10 $1,020.15 09067220 $1,282.98 $1,202.95 090 67909 $1,289.71 $1,054.68 09067221 $775.33 $577.94 000 67911 $1,350.37 $1,350.37 09067225 $80.67 $75.92 ZZZ 67912 $2,105.16 $1,172.62 09067227 $788.62 $695.62 010 67914 $1,127.97 $786.80 09067228 $925.28 $830.38 010 67915 $705.09 $476.80 09067229 $2,799.30 $2,799.30 090 67916 $1,421.97 $1,036.15 09067250 $1,874.34 $1,874.34 090 67917 $1,448.93 $1,101.02 09067255 $1,641.84 $1,641.84 090 67921 $1,106.91 $746.37 09067299 80% of billed 80% of billed N/A 67922 $698.35 $475.11 09067311 $1,434.61 $1,434.61 090 67923 $1,421.13 $1,035.31 09067312 $1,707.54 $1,707.54 090 67924 $1,516.32 $1,101.86 09067314 $1,614.04 $1,614.04 090 67930 $986.96 $651.01 01067316 $1,925.73 $1,925.73 090 67935 $1,427.03 $1,062.27 09067318 $1,695.75 $1,695.75 090 67938 $662.40 $316.02 01067320 $874.03 $874.03 ZZZ 67950 $1,375.64 $1,113.65 09067331 $828.48 $828.48 ZZZ 67961 $1,382.38 $1,094.28 09067332 $898.70 $898.70 ZZZ 67966 $1,844.86 $1,579.50 09067334 $817.09 $817.09 ZZZ 67971 $1,737.87 $1,737.87 09067335 $401.43 $401.43 ZZZ 67973 $2,235.73 $2,235.73 09067340 $971.78 $971.78 ZZZ 67974 $2,229.83 $2,229.83 09067343 $1,564.34 $1,564.34 090 67975 $1,644.36 $1,644.36 09067345 $662.40 $594.07 010 67999 80% of billed 80% of billed N/A67346 $525.75 $525.75 000 68020 $326.46 $298.94 01067399 80% of billed 80% of billed N/A 68040 $168.92 $134.76 00067400 $2,232.36 $2,232.36 090 68100 $463.11 $263.82 00067405 $1,897.08 $1,897.08 090 68110 $612.11 $402.38 01067412 $2,043.66 $2,043.66 090 68115 $844.61 $498.23 01067413 $2,051.24 $2,051.24 090 68130 $1,294.77 $990.66 09067414 $3,178.38 $3,178.38 090 68135 $426.10 $409.02 01067415 $283.75 $283.75 000 68200 $111.98 $94.90 00067420 $3,879.25 $3,879.25 090 68320 $1,741.24 $1,296.45 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 43 of 84

Page 44: Appendix B for Administrative Order No. 18-053 Physician ...Appendix B for Administrative Order No. 18-053 Physician Fee Schedule Effective April 1, 2018 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

68325 $1,580.34 $1,580.34 090 69501 $1,740.40 $1,740.40 09068326 $1,551.70 $1,551.70 090 69502 $2,312.39 $2,312.39 09068328 $1,702.49 $1,702.49 090 69505 $2,858.26 $2,858.26 09068330 $1,453.14 $1,108.60 090 69511 $2,928.18 $2,928.18 09068335 $1,558.44 $1,558.44 090 69530 $3,928.95 $3,928.95 09068340 $1,309.93 $959.49 090 69535 $6,435.94 $6,435.94 09068360 $1,275.39 $988.98 090 69540 $556.11 $340.69 01068362 $1,576.97 $1,576.97 090 69550 $2,472.44 $2,472.44 09068371 $1,116.97 $1,116.97 010 69552 $3,733.52 $3,733.52 09068399 80% of billed 80% of billed N/A 69554 $6,002.10 $6,002.10 09068400 $770.59 $357.77 010 69601 $2,486.76 $2,486.76 09068420 $871.18 $456.47 010 69602 $2,586.17 $2,586.17 09068440 $276.16 $268.57 010 69603 $2,994.73 $2,994.73 09068500 $2,341.87 $2,341.87 090 69604 $2,644.29 $2,644.29 09068505 $2,330.08 $2,330.08 090 69605 $3,707.40 $3,707.40 09068510 $1,205.23 $789.57 000 69610 $1,027.77 $781.98 01068520 $1,650.26 $1,650.26 090 69620 $1,640.15 $1,161.67 09068525 $714.60 $714.60 000 69631 $2,100.95 $2,100.95 09068530 $1,156.83 $696.57 010 69632 $2,560.05 $2,560.05 09068540 $2,229.83 $2,229.83 090 69633 $2,483.40 $2,483.40 09068550 $2,733.59 $2,733.59 090 69635 $2,943.35 $2,943.35 09068700 $1,451.46 $1,451.46 090 69636 $3,279.46 $3,279.46 09068705 $642.47 $449.83 010 69637 $3,309.79 $3,309.79 09068720 $1,817.06 $1,817.06 090 69641 $2,474.97 $2,474.97 09068745 $1,825.48 $1,825.48 090 69642 $3,176.69 $3,176.69 09068750 $1,888.66 $1,888.66 090 69643 $2,909.65 $2,909.65 09068760 $546.62 $395.73 010 69644 $3,513.65 $3,513.65 09068761 $401.43 $322.66 010 69645 $3,445.42 $3,445.42 09068770 $1,511.27 $1,511.27 090 69646 $3,676.23 $3,676.23 09068801 $239.15 $212.58 010 69650 $1,910.56 $1,910.56 09068810 $418.51 $347.33 010 69660 $2,204.56 $2,204.56 09068811 $369.16 $369.16 010 69661 $2,873.43 $2,873.43 09068815 $1,075.22 $600.72 010 69662 $2,757.18 $2,757.18 09068816 $1,752.80 $427.05 010 69666 $1,929.94 $1,929.94 09068840 $347.33 $315.07 010 69667 $1,932.47 $1,932.47 09068850 $168.92 $151.84 000 69670 $2,255.95 $2,255.95 09068899 80% of billed 80% of billed N/A 69676 $1,974.59 $1,974.59 09069000 $502.97 $321.71 010 69700 $1,629.20 $1,629.20 09069005 $572.25 $421.36 010 69710 80% of billed 80% of billed N/A69020 $617.80 $380.55 010 69711 $2,048.72 $2,048.72 09069090 80% of billed 80% of billed N/A 69714 $2,565.95 $2,565.95 09069100 $272.36 $133.81 000 69715 $3,163.21 $3,163.21 09069105 $372.96 $170.82 000 69717 $2,688.10 $2,688.10 09069110 $1,094.28 $776.69 090 69718 $3,196.91 $3,196.91 09069120 $967.08 $967.08 090 69720 $2,904.60 $2,904.60 09069140 $2,083.26 $2,083.26 090 69725 $4,479.04 $4,479.04 09069145 $935.91 $591.36 090 69740 $2,779.08 $2,779.08 09069150 $2,490.13 $2,490.13 090 69745 $2,955.98 $2,955.98 09069155 $3,955.91 $3,955.91 090 69799 80% of billed 80% of billed N/A69200 $221.12 $128.12 000 69801 $522.90 $337.84 00069205 $270.47 $270.47 010 69805 $2,510.35 $2,510.35 09069209 $37.96 $37.96 000 69806 $2,246.68 $2,246.68 09069210 $130.96 $89.21 000 69905 $2,180.97 $2,180.97 09069220 $220.17 $139.50 000 69910 $2,421.06 $2,421.06 09069222 $581.74 $365.37 010 69915 $3,666.97 $3,666.97 09069300 $1,691.12 $1,311.52 N/A 69930 $2,915.55 $2,915.55 09069310 $2,589.54 $2,589.54 090 69949 80% of billed 80% of billed N/A69320 $3,630.74 $3,630.74 090 69950 $4,249.91 $4,249.91 09069399 80% of billed 80% of billed N/A 69955 $4,715.76 $4,715.76 09069420 $511.51 $322.66 010 69960 $4,589.40 $4,589.40 09069421 $398.58 $398.58 010 69970 $5,107.47 $5,107.47 09069424 $341.64 $166.08 000 69979 80% of billed 80% of billed N/A69433 $539.98 $354.93 010 69990 $609.26 $609.26 ZZZ69436 $428.95 $428.95 010 70010 $130.46 $130.46 N/A69440 $1,634.26 $1,634.26 090 70015 $308.43 $308.43 N/A69450 $1,298.14 $1,298.14 090 70015 TC $180.23 $180.23 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 44 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

70015 26 $128.20 $128.20 N/A 70330 26 $26.39 $26.39 N/A70030 $59.57 $59.57 N/A 70332 $150.82 $150.82 N/A70030 TC $41.48 $41.48 N/A 70332 TC $92.75 $92.75 N/A70030 26 $18.10 $18.10 N/A 70332 26 $58.07 $58.07 N/A70100 $70.13 $70.13 N/A 70336 $687.74 $687.74 N/A70100 TC $50.52 $50.52 N/A 70336 TC $530.13 $530.13 N/A70100 26 $19.61 $19.61 N/A 70336 26 $157.61 $157.61 N/A70110 $80.69 $80.69 N/A 70350 $41.48 $41.48 N/A70110 TC $53.54 $53.54 N/A 70350 TC $20.36 $20.36 N/A70110 26 $27.15 $27.15 N/A 70350 26 $21.11 $21.11 N/A70120 $70.89 $70.89 N/A 70355 $44.49 $44.49 N/A70120 TC $51.28 $51.28 N/A 70355 TC $20.36 $20.36 N/A70120 26 $19.61 $19.61 N/A 70355 26 $24.13 $24.13 N/A70130 $115.38 $115.38 N/A 70360 $60.33 $60.33 N/A70130 TC $78.43 $78.43 N/A 70360 TC $42.23 $42.23 N/A70130 26 $36.95 $36.95 N/A 70360 26 $18.10 $18.10 N/A70134 $106.33 $106.33 N/A 70370 $153.08 $153.08 N/A70134 TC $69.38 $69.38 N/A 70370 TC $119.15 $119.15 N/A70134 26 $36.95 $36.95 N/A 70370 26 $33.93 $33.93 N/A70140 $63.34 $63.34 N/A 70371 $190.03 $190.03 N/A70140 TC $40.72 $40.72 N/A 70371 TC $100.30 $100.30 N/A70140 26 $22.62 $22.62 N/A 70371 26 $89.74 $89.74 N/A70150 $88.23 $88.23 N/A 70380 $68.62 $68.62 N/A70150 TC $59.57 $59.57 N/A 70380 TC $50.52 $50.52 N/A70150 26 $28.66 $28.66 N/A 70380 26 $18.10 $18.10 N/A70160 $70.13 $70.13 N/A 70390 $200.59 $200.59 N/A70160 TC $51.28 $51.28 N/A 70390 TC $159.87 $159.87 N/A70160 26 $18.85 $18.85 N/A 70390 26 $40.72 $40.72 N/A70170 80% of billed 80% of billed N/A 70450 $247.34 $247.34 N/A70170 TC 80% of billed 80% of billed N/A 70450 TC $156.10 $156.10 N/A70170 26 $32.43 $32.43 N/A 70450 26 $91.25 $91.25 N/A70190 $76.16 $76.16 N/A 70460 $348.39 $348.39 N/A70190 TC $52.03 $52.03 N/A 70460 TC $226.23 $226.23 N/A70190 26 $24.13 $24.13 N/A 70460 26 $122.16 $122.16 N/A70200 $90.49 $90.49 N/A 70470 $408.72 $408.72 N/A70200 TC $59.57 $59.57 N/A 70470 TC $272.23 $272.23 N/A70200 26 $30.92 $30.92 N/A 70470 26 $136.49 $136.49 N/A70210 $63.34 $63.34 N/A 70480 $496.95 $496.95 N/A70210 TC $44.49 $44.49 N/A 70480 TC $359.71 $359.71 N/A70210 26 $18.85 $18.85 N/A 70480 26 $137.25 $137.25 N/A70220 $79.93 $79.93 N/A 70481 $588.20 $588.20 N/A70220 TC $52.79 $52.79 N/A 70481 TC $439.64 $439.64 N/A70220 26 $27.15 $27.15 N/A 70481 26 $148.56 $148.56 N/A70240 $65.61 $65.61 N/A 70482 $640.99 $640.99 N/A70240 TC $44.49 $44.49 N/A 70482 TC $485.64 $485.64 N/A70240 26 $21.11 $21.11 N/A 70482 26 $155.34 $155.34 N/A70250 $77.67 $77.67 N/A 70486 $297.12 $297.12 N/A70250 TC $50.52 $50.52 N/A 70486 TC $205.12 $205.12 N/A70250 26 $27.15 $27.15 N/A 70486 26 $92.00 $92.00 N/A70260 $97.28 $97.28 N/A 70487 $357.44 $357.44 N/A70260 TC $59.57 $59.57 N/A 70487 TC $236.79 $236.79 N/A70260 26 $37.71 $37.71 N/A 70487 26 $120.66 $120.66 N/A70300 $31.67 $31.67 N/A 70488 $435.87 $435.87 N/A70300 TC $18.85 $18.85 N/A 70488 TC $299.38 $299.38 N/A70300 26 $12.82 $12.82 N/A 70488 26 $136.49 $136.49 N/A70310 $79.18 $79.18 N/A 70490 $358.95 $358.95 N/A70310 TC $61.84 $61.84 N/A 70490 TC $220.95 $220.95 N/A70310 26 $17.34 $17.34 N/A 70490 26 $138.00 $138.00 N/A70320 $112.36 $112.36 N/A 70491 $433.61 $433.61 N/A70320 TC $85.97 $85.97 N/A 70491 TC $285.05 $285.05 N/A70320 26 $26.39 $26.39 N/A 70491 26 $148.56 $148.56 N/A70328 $64.85 $64.85 N/A 70492 $522.59 $522.59 N/A70328 TC $45.25 $45.25 N/A 70492 TC $348.39 $348.39 N/A70328 26 $19.61 $19.61 N/A 70492 26 $174.20 $174.20 N/A70330 $100.30 $100.30 N/A 70496 $625.15 $625.15 N/A70330 TC $73.90 $73.90 N/A 70496 TC $437.38 $437.38 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 45 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

70496 26 $187.77 $187.77 N/A 71048 26 $34.69 $34.69 N/A70498 $623.64 $623.64 N/A 71100 $70.89 $70.89 N/A70498 TC $435.87 $435.87 N/A 71100 TC $46.75 $46.75 N/A70498 26 $187.77 $187.77 N/A 71100 26 $24.13 $24.13 N/A70540 $579.15 $579.15 N/A 71101 $81.44 $81.44 N/A70540 TC $434.36 $434.36 N/A 71101 TC $52.03 $52.03 N/A70540 26 $144.79 $144.79 N/A 71101 26 $29.41 $29.41 N/A70542 $686.99 $686.99 N/A 71110 $85.21 $85.21 N/A70542 TC $512.79 $512.79 N/A 71110 TC $53.54 $53.54 N/A70542 26 $174.20 $174.20 N/A 71110 26 $31.67 $31.67 N/A70543 $862.69 $862.69 N/A 71111 $100.30 $100.30 N/A70543 TC $633.44 $633.44 N/A 71111 TC $64.85 $64.85 N/A70543 26 $229.25 $229.25 N/A 71111 26 $35.44 $35.44 N/A70544 $699.80 $699.80 N/A 71120 $63.34 $63.34 N/A70544 TC $570.85 $570.85 N/A 71120 TC $41.48 $41.48 N/A70544 26 $128.95 $128.95 N/A 71120 26 $21.87 $21.87 N/A70545 $693.77 $693.77 N/A 71130 $76.92 $76.92 N/A70545 TC $564.82 $564.82 N/A 71130 TC $52.79 $52.79 N/A70545 26 $128.95 $128.95 N/A 71130 26 $24.13 $24.13 N/A70546 $1,033.12 $1,033.12 N/A 71250 $347.64 $347.64 N/A70546 TC $874.76 $874.76 N/A 71250 TC $222.46 $222.46 N/A70546 26 $158.36 $158.36 N/A 71250 26 $125.18 $125.18 N/A70547 $703.58 $703.58 N/A 71260 $419.28 $419.28 N/A70547 TC $573.87 $573.87 N/A 71260 TC $285.80 $285.80 N/A70547 26 $129.71 $129.71 N/A 71260 26 $133.48 $133.48 N/A70548 $768.43 $768.43 N/A 71270 $502.23 $502.23 N/A70548 TC $607.05 $607.05 N/A 71270 TC $353.67 $353.67 N/A70548 26 $161.38 $161.38 N/A 71270 26 $148.56 $148.56 N/A70549 $1,073.84 $1,073.84 N/A 71275 $640.23 $640.23 N/A70549 TC $880.79 $880.79 N/A 71275 TC $444.92 $444.92 N/A70549 26 $193.05 $193.05 N/A 71275 26 $195.31 $195.31 N/A70551 $493.94 $493.94 N/A 71550 $886.82 $886.82 N/A70551 TC $334.07 $334.07 N/A 71550 TC $729.97 $729.97 N/A70551 26 $159.87 $159.87 N/A 71550 26 $156.85 $156.85 N/A70552 $684.72 $684.72 N/A 71551 $976.56 $976.56 N/A70552 TC $493.18 $493.18 N/A 71551 TC $791.05 $791.05 N/A70552 26 $191.54 $191.54 N/A 71551 26 $185.51 $185.51 N/A70553 $807.64 $807.64 N/A 71552 $1,237.48 $1,237.48 N/A70553 TC $562.56 $562.56 N/A 71552 TC $995.41 $995.41 N/A70553 26 $245.08 $245.08 N/A 71552 26 $242.07 $242.07 N/A70554 $960.72 $960.72 N/A 71555 $853.64 $853.64 N/A70554 TC $733.74 $733.74 N/A 71555 TC $661.35 $661.35 N/A70554 26 $226.98 $226.98 N/A 71555 26 $192.30 $192.30 N/A70555 80% of billed 80% of billed N/A 72020 $47.51 $47.51 N/A70555 TC 80% of billed 80% of billed N/A 72020 TC $30.92 $30.92 N/A70555 26 $268.46 $268.46 N/A 72020 26 $16.59 $16.59 N/A70557 80% of billed 80% of billed N/A 72040 $70.89 $70.89 N/A70557 TC 80% of billed 80% of billed N/A 72040 TC $46.75 $46.75 N/A70557 26 $336.33 $336.33 N/A 72040 26 $24.13 $24.13 N/A70558 80% of billed 80% of billed N/A 72050 $96.52 $96.52 N/A70558 TC 80% of billed 80% of billed N/A 72050 TC $62.59 $62.59 N/A70558 26 $370.26 $370.26 N/A 72050 26 $33.93 $33.93 N/A70559 80% of billed 80% of billed N/A 72052 $119.15 $119.15 N/A70559 TC 80% of billed 80% of billed N/A 72052 TC $79.93 $79.93 N/A70559 26 $349.15 $349.15 N/A 72052 26 $39.21 $39.21 N/A71045 $42.23 $42.23 N/A 72070 $72.39 $72.39 N/A71045 TC $22.62 $22.62 N/A 72070 TC $48.26 $48.26 N/A71045 26 $19.61 $19.61 N/A 72070 26 $24.13 $24.13 N/A71046 $64.85 $64.85 N/A 72072 $73.90 $73.90 N/A71046 TC $41.48 $41.48 N/A 72072 TC $50.52 $50.52 N/A71046 26 $23.38 $23.38 N/A 72072 26 $23.38 $23.38 N/A71047 $82.95 $82.95 N/A 72074 $82.95 $82.95 N/A71047 TC $52.79 $52.79 N/A 72074 TC $59.57 $59.57 N/A71047 26 $30.16 $30.16 N/A 72074 26 $23.38 $23.38 N/A71048 $88.98 $88.98 N/A 72080 $71.64 $71.64 N/A71048 TC $54.30 $54.30 N/A 72080 TC $47.51 $47.51 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 46 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

72080 26 $24.13 $24.13 N/A 72148 26 $159.87 $159.87 N/A72081 $82.20 $82.20 N/A 72149 $688.49 $688.49 N/A72081 TC $53.54 $53.54 N/A 72149 TC $496.20 $496.20 N/A72081 26 $28.66 $28.66 N/A 72149 26 $192.30 $192.30 N/A72082 $132.72 $132.72 N/A 72156 $812.17 $812.17 N/A72082 TC $98.03 $98.03 N/A 72156 TC $567.08 $567.08 N/A72082 26 $34.69 $34.69 N/A 72156 26 $245.08 $245.08 N/A72083 $159.87 $159.87 N/A 72157 $813.67 $813.67 N/A72083 TC $120.66 $120.66 N/A 72157 TC $568.59 $568.59 N/A72083 26 $39.21 $39.21 N/A 72157 26 $245.08 $245.08 N/A72084 $186.26 $186.26 N/A 72158 $810.66 $810.66 N/A72084 TC $140.26 $140.26 N/A 72158 TC $564.82 $564.82 N/A72084 26 $46.00 $46.00 N/A 72158 26 $245.84 $245.84 N/A72100 $74.66 $74.66 N/A 72159 $872.49 $872.49 N/A72100 TC $50.52 $50.52 N/A 72159 TC $680.20 $680.20 N/A72100 26 $24.13 $24.13 N/A 72159 26 $192.30 $192.30 N/A72110 $104.07 $104.07 N/A 72170 $67.87 $67.87 N/A72110 TC $70.13 $70.13 N/A 72170 TC $49.02 $49.02 N/A72110 26 $33.93 $33.93 N/A 72170 26 $18.85 $18.85 N/A72114 $131.21 $131.21 N/A 72190 $80.69 $80.69 N/A72114 TC $95.77 $95.77 N/A 72190 TC $57.31 $57.31 N/A72114 26 $35.44 $35.44 N/A 72190 26 $23.38 $23.38 N/A72120 $86.72 $86.72 N/A 72191 $652.30 $652.30 N/A72120 TC $62.59 $62.59 N/A 72191 TC $459.25 $459.25 N/A72120 26 $24.13 $24.13 N/A 72191 26 $193.05 $193.05 N/A72125 $393.64 $393.64 N/A 72192 $311.44 $311.44 N/A72125 TC $279.02 $279.02 N/A 72192 TC $194.56 $194.56 N/A72125 26 $114.62 $114.62 N/A 72192 26 $116.89 $116.89 N/A72126 $486.39 $486.39 N/A 72193 $481.87 $481.87 N/A72126 TC $355.18 $355.18 N/A 72193 TC $356.69 $356.69 N/A72126 26 $131.21 $131.21 N/A 72193 26 $125.18 $125.18 N/A72127 $576.13 $576.13 N/A 72194 $555.02 $555.02 N/A72127 TC $440.39 $440.39 N/A 72194 TC $423.80 $423.80 N/A72127 26 $135.74 $135.74 N/A 72194 26 $131.21 $131.21 N/A72128 $385.35 $385.35 N/A 72195 $676.43 $676.43 N/A72128 TC $277.51 $277.51 N/A 72195 TC $519.57 $519.57 N/A72128 26 $107.84 $107.84 N/A 72195 26 $156.85 $156.85 N/A72129 $488.66 $488.66 N/A 72196 $742.79 $742.79 N/A72129 TC $357.44 $357.44 N/A 72196 TC $556.53 $556.53 N/A72129 26 $131.21 $131.21 N/A 72196 26 $186.26 $186.26 N/A72130 $579.90 $579.90 N/A 72197 $910.20 $910.20 N/A72130 TC $443.41 $443.41 N/A 72197 TC $674.17 $674.17 N/A72130 26 $136.49 $136.49 N/A 72197 26 $236.03 $236.03 N/A72131 $383.84 $383.84 N/A 72198 $855.90 $855.90 N/A72131 TC $276.00 $276.00 N/A 72198 TC $665.12 $665.12 N/A72131 26 $107.84 $107.84 N/A 72198 26 $190.79 $190.79 N/A72132 $486.39 $486.39 N/A 72200 $60.33 $60.33 N/A72132 TC $355.18 $355.18 N/A 72200 TC $41.48 $41.48 N/A72132 26 $131.21 $131.21 N/A 72200 26 $18.85 $18.85 N/A72133 $574.62 $574.62 N/A 72202 $70.13 $70.13 N/A72133 TC $438.13 $438.13 N/A 72202 TC $49.77 $49.77 N/A72133 26 $136.49 $136.49 N/A 72202 26 $20.36 $20.36 N/A72141 $850.79 $850.79 N/A 72220 $60.33 $60.33 N/A72141 TC $690.92 $690.92 N/A 72220 TC $41.48 $41.48 N/A72141 26 $159.87 $159.87 N/A 72220 26 $18.85 $18.85 N/A72142 $697.54 $697.54 N/A 72240 $208.89 $208.89 N/A72142 TC $505.25 $505.25 N/A 72240 TC $111.61 $111.61 N/A72142 26 $192.30 $192.30 N/A 72240 26 $97.28 $97.28 N/A72146 $481.12 $481.12 N/A 72255 $209.64 $209.64 N/A72146 TC $321.25 $321.25 N/A 72255 TC $110.10 $110.10 N/A72146 26 $159.87 $159.87 N/A 72255 26 $99.54 $99.54 N/A72147 $692.26 $692.26 N/A 72265 $196.07 $196.07 N/A72147 TC $500.72 $500.72 N/A 72265 TC $107.84 $107.84 N/A72147 26 $191.54 $191.54 N/A 72265 26 $88.23 $88.23 N/A72148 $856.74 $856.74 N/A 72270 $272.98 $272.98 N/A72148 TC $696.87 $696.87 N/A 72270 TC $128.20 $128.20 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 47 of 84

Page 48: Appendix B for Administrative Order No. 18-053 Physician ...Appendix B for Administrative Order No. 18-053 Physician Fee Schedule Effective April 1, 2018 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

72270 26 $144.79 $144.79 N/A 73200 26 $107.84 $107.84 N/A72275 $246.59 $246.59 N/A 73201 $475.08 $475.08 N/A72275 TC $162.89 $162.89 N/A 73201 TC $349.90 $349.90 N/A72275 26 $83.71 $83.71 N/A 73201 26 $125.18 $125.18 N/A72285 $239.05 $239.05 N/A 73202 $592.72 $592.72 N/A72285 TC $110.85 $110.85 N/A 73202 TC $461.51 $461.51 N/A72285 26 $128.20 $128.20 N/A 73202 26 $131.21 $131.21 N/A72295 $207.38 $207.38 N/A 73206 $699.80 $699.80 N/A72295 TC $114.62 $114.62 N/A 73206 TC $507.51 $507.51 N/A72295 26 $92.75 $92.75 N/A 73206 26 $192.30 $192.30 N/A73000 $59.57 $59.57 N/A 73218 $783.51 $783.51 N/A73000 TC $41.48 $41.48 N/A 73218 TC $637.97 $637.97 N/A73000 26 $18.10 $18.10 N/A 73218 26 $145.54 $145.54 N/A73010 $64.85 $64.85 N/A 73219 $861.18 $861.18 N/A73010 TC $45.25 $45.25 N/A 73219 TC $686.99 $686.99 N/A73010 26 $19.61 $19.61 N/A 73219 26 $174.20 $174.20 N/A73020 $49.02 $49.02 N/A 73220 $1,067.81 $1,067.81 N/A73020 TC $31.67 $31.67 N/A 73220 TC $837.05 $837.05 N/A73020 26 $17.34 $17.34 N/A 73220 26 $230.75 $230.75 N/A73030 $62.59 $62.59 N/A 73221 $899.97 $899.97 N/A73030 TC $42.23 $42.23 N/A 73221 TC $753.67 $753.67 N/A73030 26 $20.36 $20.36 N/A 73221 26 $146.30 $146.30 N/A73040 $215.67 $215.67 N/A 73222 $810.66 $810.66 N/A73040 TC $156.85 $156.85 N/A 73222 TC $635.71 $635.71 N/A73040 26 $58.82 $58.82 N/A 73222 26 $174.95 $174.95 N/A73050 $76.16 $76.16 N/A 73223 $1,005.22 $1,005.22 N/A73050 TC $53.54 $53.54 N/A 73223 TC $774.46 $774.46 N/A73050 26 $22.62 $22.62 N/A 73223 26 $230.75 $230.75 N/A73060 $61.84 $61.84 N/A 73225 $871.74 $871.74 N/A73060 TC $43.74 $43.74 N/A 73225 TC $687.74 $687.74 N/A73060 26 $18.10 $18.10 N/A 73225 26 $184.00 $184.00 N/A73070 $58.07 $58.07 N/A 73501 $64.10 $64.10 N/A73070 TC $40.72 $40.72 N/A 73501 TC $43.74 $43.74 N/A73070 26 $17.34 $17.34 N/A 73501 26 $20.36 $20.36 N/A73080 $67.11 $67.11 N/A 73502 $88.23 $88.23 N/A73080 TC $48.26 $48.26 N/A 73502 TC $64.10 $64.10 N/A73080 26 $18.85 $18.85 N/A 73502 26 $24.13 $24.13 N/A73085 $204.36 $204.36 N/A 73503 $110.10 $110.10 N/A73085 TC $142.52 $142.52 N/A 73503 TC $79.18 $79.18 N/A73085 26 $61.84 $61.84 N/A 73503 26 $30.92 $30.92 N/A73090 $55.05 $55.05 N/A 73521 $79.93 $79.93 N/A73090 TC $36.95 $36.95 N/A 73521 TC $55.80 $55.80 N/A73090 26 $18.10 $18.10 N/A 73521 26 $24.13 $24.13 N/A73092 $58.07 $58.07 N/A 73522 $104.07 $104.07 N/A73092 TC $40.72 $40.72 N/A 73522 TC $71.64 $71.64 N/A73092 26 $17.34 $17.34 N/A 73522 26 $32.43 $32.43 N/A73100 $67.11 $67.11 N/A 73523 $120.66 $120.66 N/A73100 TC $48.26 $48.26 N/A 73523 TC $85.97 $85.97 N/A73100 26 $18.85 $18.85 N/A 73523 26 $34.69 $34.69 N/A73110 $74.66 $74.66 N/A 73525 $220.20 $220.20 N/A73110 TC $55.80 $55.80 N/A 73525 TC $157.61 $157.61 N/A73110 26 $18.85 $18.85 N/A 73525 26 $62.59 $62.59 N/A73115 $227.74 $227.74 N/A 73551 $59.57 $59.57 N/A73115 TC $166.66 $166.66 N/A 73551 TC $41.48 $41.48 N/A73115 26 $61.08 $61.08 N/A 73551 26 $18.10 $18.10 N/A73120 $60.33 $60.33 N/A 73552 $70.13 $70.13 N/A73120 TC $42.23 $42.23 N/A 73552 TC $49.77 $49.77 N/A73120 26 $18.10 $18.10 N/A 73552 26 $20.36 $20.36 N/A73130 $67.87 $67.87 N/A 73560 $66.36 $66.36 N/A73130 TC $49.02 $49.02 N/A 73560 TC $48.26 $48.26 N/A73130 26 $18.85 $18.85 N/A 73560 26 $18.10 $18.10 N/A73140 $68.62 $68.62 N/A 73562 $76.16 $76.16 N/A73140 TC $53.54 $53.54 N/A 73562 TC $55.80 $55.80 N/A73140 26 $15.08 $15.08 N/A 73562 26 $20.36 $20.36 N/A73200 $383.08 $383.08 N/A 73564 $84.46 $84.46 N/A73200 TC $275.25 $275.25 N/A 73564 TC $60.33 $60.33 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 48 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

73564 26 $24.13 $24.13 N/A 73725 26 $193.05 $193.05 N/A73565 $76.16 $76.16 N/A 74018 $58.07 $58.07 N/A73565 TC $57.31 $57.31 N/A 74018 TC $38.46 $38.46 N/A73565 26 $18.85 $18.85 N/A 74018 26 $19.61 $19.61 N/A73580 $249.61 $249.61 N/A 74019 $70.89 $70.89 N/A73580 TC $187.77 $187.77 N/A 74019 TC $46.00 $46.00 N/A73580 26 $61.84 $61.84 N/A 74019 26 $24.89 $24.89 N/A73590 $61.08 $61.08 N/A 74021 $82.95 $82.95 N/A73590 TC $42.98 $42.98 N/A 74021 TC $53.54 $53.54 N/A73590 26 $18.10 $18.10 N/A 74021 26 $29.41 $29.41 N/A73592 $58.07 $58.07 N/A 74022 $95.02 $95.02 N/A73592 TC $40.72 $40.72 N/A 74022 TC $60.33 $60.33 N/A73592 26 $17.34 $17.34 N/A 74022 26 $34.69 $34.69 N/A73600 $63.34 $63.34 N/A 74150 $319.74 $319.74 N/A73600 TC $45.25 $45.25 N/A 74150 TC $191.54 $191.54 N/A73600 26 $18.10 $18.10 N/A 74150 26 $128.20 $128.20 N/A73610 $67.11 $67.11 N/A 74160 $492.43 $492.43 N/A73610 TC $48.26 $48.26 N/A 74160 TC $355.94 $355.94 N/A73610 26 $18.85 $18.85 N/A 74160 26 $136.49 $136.49 N/A73615 $227.74 $227.74 N/A 74170 $560.30 $560.30 N/A73615 TC $165.90 $165.90 N/A 74170 TC $409.48 $409.48 N/A73615 26 $61.84 $61.84 N/A 74170 26 $150.82 $150.82 N/A73620 $55.80 $55.80 N/A 74174 $828.00 $828.00 N/A73620 TC $39.21 $39.21 N/A 74174 TC $594.23 $594.23 N/A73620 26 $16.59 $16.59 N/A 74174 26 $233.77 $233.77 N/A73630 $62.59 $62.59 N/A 74175 $655.31 $655.31 N/A73630 TC $44.49 $44.49 N/A 74175 TC $461.51 $461.51 N/A73630 26 $18.10 $18.10 N/A 74175 26 $193.80 $193.80 N/A73650 $58.07 $58.07 N/A 74176 $428.33 $428.33 N/A73650 TC $40.72 $40.72 N/A 74176 TC $241.31 $241.31 N/A73650 26 $17.34 $17.34 N/A 74176 26 $187.02 $187.02 N/A73660 $60.33 $60.33 N/A 74177 $665.12 $665.12 N/A73660 TC $46.00 $46.00 N/A 74177 TC $469.05 $469.05 N/A73660 26 $14.33 $14.33 N/A 74177 26 $196.07 $196.07 N/A73700 $383.84 $383.84 N/A 74178 $753.35 $753.35 N/A73700 TC $276.00 $276.00 N/A 74178 TC $538.43 $538.43 N/A73700 26 $107.84 $107.84 N/A 74178 26 $214.92 $214.92 N/A73701 $481.87 $481.87 N/A 74181 $603.28 $603.28 N/A73701 TC $356.69 $356.69 N/A 74181 TC $446.43 $446.43 N/A73701 26 $125.18 $125.18 N/A 74181 26 $156.85 $156.85 N/A73702 $585.18 $585.18 N/A 74182 $818.20 $818.20 N/A73702 TC $454.72 $454.72 N/A 74182 TC $631.94 $631.94 N/A73702 26 $130.46 $130.46 N/A 74182 26 $186.26 $186.26 N/A73706 $758.62 $758.62 N/A 74183 $912.46 $912.46 N/A73706 TC $555.77 $555.77 N/A 74183 TC $676.43 $676.43 N/A73706 26 $202.85 $202.85 N/A 74183 26 $236.03 $236.03 N/A73718 $656.07 $656.07 N/A 74185 $861.18 $861.18 N/A73718 TC $510.53 $510.53 N/A 74185 TC $669.64 $669.64 N/A73718 26 $145.54 $145.54 N/A 74185 26 $191.54 $191.54 N/A73719 $730.72 $730.72 N/A 74190 80% of billed 80% of billed N/A73719 TC $556.53 $556.53 N/A 74190 TC 80% of billed 80% of billed N/A73719 26 $174.20 $174.20 N/A 74190 26 $50.52 $50.52 N/A73720 $908.69 $908.69 N/A 74210 $165.90 $165.90 N/A73720 TC $678.69 $678.69 N/A 74210 TC $127.44 $127.44 N/A73720 26 $230.00 $230.00 N/A 74210 26 $38.46 $38.46 N/A73721 $919.13 $919.13 N/A 74220 $188.53 $188.53 N/A73721 TC $772.83 $772.83 N/A 74220 TC $138.75 $138.75 N/A73721 26 $146.30 $146.30 N/A 74220 26 $49.77 $49.77 N/A73722 $815.94 $815.94 N/A 74230 $275.25 $275.25 N/A73722 TC $640.99 $640.99 N/A 74230 TC $217.93 $217.93 N/A73722 26 $174.95 $174.95 N/A 74230 26 $57.31 $57.31 N/A73723 $1,003.71 $1,003.71 N/A 74235 80% of billed 80% of billed N/A73723 TC $773.71 $773.71 N/A 74235 TC 80% of billed 80% of billed N/A73723 26 $230.00 $230.00 N/A 74235 26 $132.72 $132.72 N/A73725 $856.66 $856.66 N/A 74240 $240.56 $240.56 N/A73725 TC $663.61 $663.61 N/A 74240 TC $165.90 $165.90 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 49 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

74240 26 $74.66 $74.66 N/A 74355 26 $84.46 $84.46 N/A74241 $249.61 $249.61 N/A 74360 80% of billed 80% of billed N/A74241 TC $175.71 $175.71 N/A 74360 TC 80% of billed 80% of billed N/A74241 26 $73.90 $73.90 N/A 74360 26 $60.33 $60.33 N/A74245 $364.23 $364.23 N/A 74363 80% of billed 80% of billed N/A74245 TC $266.20 $266.20 N/A 74363 TC 80% of billed 80% of billed N/A74245 26 $98.03 $98.03 N/A 74363 26 $91.25 $91.25 N/A74246 $269.21 $269.21 N/A 74400 $233.77 $233.77 N/A74246 TC $195.31 $195.31 N/A 74400 TC $180.98 $180.98 N/A74246 26 $73.90 $73.90 N/A 74400 26 $52.79 $52.79 N/A74247 $300.89 $300.89 N/A 74410 $236.79 $236.79 N/A74247 TC $226.98 $226.98 N/A 74410 TC $184.00 $184.00 N/A74247 26 $73.90 $73.90 N/A 74410 26 $52.79 $52.79 N/A74249 $390.62 $390.62 N/A 74415 $290.33 $290.33 N/A74249 TC $292.59 $292.59 N/A 74415 TC $237.54 $237.54 N/A74249 26 $98.03 $98.03 N/A 74415 26 $52.79 $52.79 N/A74250 $220.20 $220.20 N/A 74420 80% of billed 80% of billed N/A74250 TC $169.67 $169.67 N/A 74420 TC 80% of billed 80% of billed N/A74250 26 $50.52 $50.52 N/A 74420 26 $37.71 $37.71 N/A74251 $892.10 $892.10 N/A 74425 80% of billed 80% of billed N/A74251 TC $818.20 $818.20 N/A 74425 TC 80% of billed 80% of billed N/A74251 26 $73.90 $73.90 N/A 74425 26 $37.71 $37.71 N/A74260 $741.28 $741.28 N/A 74430 $81.44 $81.44 N/A74260 TC $686.99 $686.99 N/A 74430 TC $46.75 $46.75 N/A74260 26 $54.30 $54.30 N/A 74430 26 $34.69 $34.69 N/A74261 $1,037.64 $1,037.64 N/A 74440 $171.18 $171.18 N/A74261 TC $779.74 $779.74 N/A 74440 TC $131.97 $131.97 N/A74261 26 $257.90 $257.90 N/A 74440 26 $39.21 $39.21 N/A74262 $1,162.07 $1,162.07 N/A 74445 80% of billed 80% of billed N/A74262 TC $893.61 $893.61 N/A 74445 TC 80% of billed 80% of billed N/A74262 26 $268.46 $268.46 N/A 74445 26 $119.90 $119.90 N/A74263 $1,626.59 $1,626.59 N/A 74450 80% of billed 80% of billed N/A74263 TC $1,383.02 $1,383.02 N/A 74450 TC 80% of billed 80% of billed N/A74263 26 $243.57 $243.57 N/A 74450 26 $35.44 $35.44 N/A74270 $319.74 $319.74 N/A 74455 $175.71 $175.71 N/A74270 TC $245.84 $245.84 N/A 74455 TC $140.26 $140.26 N/A74270 26 $73.90 $73.90 N/A 74455 26 $35.44 $35.44 N/A74280 $453.97 $453.97 N/A 74470 80% of billed 80% of billed N/A74280 TC $347.64 $347.64 N/A 74470 TC 80% of billed 80% of billed N/A74280 26 $106.33 $106.33 N/A 74470 26 $56.56 $56.56 N/A74283 $447.94 $447.94 N/A 74485 $197.57 $197.57 N/A74283 TC $226.98 $226.98 N/A 74485 TC $141.77 $141.77 N/A74283 26 $220.95 $220.95 N/A 74485 26 $55.80 $55.80 N/A74290 $148.56 $148.56 N/A 74710 $77.67 $77.67 N/A74290 TC $113.87 $113.87 N/A 74710 TC $40.72 $40.72 N/A74290 26 $34.69 $34.69 N/A 74710 26 $36.95 $36.95 N/A74300 80% of billed 80% of billed N/A 74712 $1,052.72 $1,052.72 N/A74300 TC 80% of billed 80% of billed N/A 74712 TC $729.97 $729.97 N/A74300 26 $39.21 $39.21 N/A 74712 26 $322.75 $322.75 N/A74301 80% of billed 80% of billed ZZZ 74713 $509.02 $509.02 ZZZ74301 TC 80% of billed 80% of billed ZZZ 74713 TC $309.18 $309.18 ZZZ74301 26 $22.62 $22.62 ZZZ 74713 26 $199.84 $199.84 ZZZ74328 80% of billed 80% of billed N/A 74740 $159.12 $159.12 N/A74328 TC 80% of billed 80% of billed N/A 74740 TC $118.39 $118.39 N/A74328 26 $76.16 $76.16 N/A 74740 26 $40.72 $40.72 N/A74329 80% of billed 80% of billed N/A 74742 80% of billed 80% of billed N/A74329 TC 80% of billed 80% of billed N/A 74742 TC 80% of billed 80% of billed N/A74329 26 $76.92 $76.92 N/A 74742 26 $66.36 $66.36 N/A74330 80% of billed 80% of billed N/A 74775 80% of billed 80% of billed N/A74330 TC 80% of billed 80% of billed N/A 74775 TC 80% of billed 80% of billed N/A74330 26 $98.03 $98.03 N/A 74775 26 $67.11 $67.11 N/A74340 80% of billed 80% of billed N/A 75557 $703.58 $703.58 N/A74340 TC 80% of billed 80% of billed N/A 75557 TC $455.48 $455.48 N/A74340 26 $58.07 $58.07 N/A 75557 26 $248.10 $248.10 N/A74355 80% of billed 80% of billed N/A 75559 $949.41 $949.41 N/A74355 TC 80% of billed 80% of billed N/A 75559 TC $643.25 $643.25 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 50 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

75559 26 $306.16 $306.16 N/A 75746 26 $119.15 $119.15 N/A75561 $926.79 $926.79 N/A 75756 $368.00 $368.00 N/A75561 TC $653.05 $653.05 N/A 75756 TC $245.84 $245.84 N/A75561 26 $273.74 $273.74 N/A 75756 26 $122.16 $122.16 N/A75563 $1,102.49 $1,102.49 N/A 75774 $184.75 $184.75 ZZZ75563 TC $788.03 $788.03 N/A 75774 TC $147.80 $147.80 ZZZ75563 26 $314.46 $314.46 N/A 75774 26 $36.95 $36.95 ZZZ75565 $116.89 $116.89 ZZZ 75801 80% of billed 80% of billed N/A75565 TC $90.49 $90.49 ZZZ 75801 TC 80% of billed 80% of billed N/A75565 26 $26.39 $26.39 ZZZ 75801 26 $95.77 $95.77 N/A75571 $220.20 $220.20 N/A 75803 80% of billed 80% of billed N/A75571 TC $158.36 $158.36 N/A 75803 TC 80% of billed 80% of billed N/A75571 26 $61.84 $61.84 N/A 75803 26 $128.95 $128.95 N/A75572 $609.31 $609.31 N/A 75805 80% of billed 80% of billed N/A75572 TC $423.05 $423.05 N/A 75805 TC 80% of billed 80% of billed N/A75572 26 $186.26 $186.26 N/A 75805 26 $84.46 $84.46 N/A75573 $831.02 $831.02 N/A 75807 80% of billed 80% of billed N/A75573 TC $561.05 $561.05 N/A 75807 TC 80% of billed 80% of billed N/A75573 26 $269.97 $269.97 N/A 75807 26 $121.41 $121.41 N/A75574 $905.67 $905.67 N/A 75809 $211.15 $211.15 N/A75574 TC $652.30 $652.30 N/A 75809 TC $159.87 $159.87 N/A75574 26 $253.38 $253.38 N/A 75809 26 $51.28 $51.28 N/A75600 $427.57 $427.57 N/A 75810 80% of billed 80% of billed N/A75600 TC $375.54 $375.54 N/A 75810 TC 80% of billed 80% of billed N/A75600 26 $52.03 $52.03 N/A 75810 26 $116.89 $116.89 N/A75605 $294.10 $294.10 N/A 75820 $246.59 $246.59 N/A75605 TC $174.95 $174.95 N/A 75820 TC $171.93 $171.93 N/A75605 26 $119.15 $119.15 N/A 75820 26 $74.66 $74.66 N/A75625 $292.59 $292.59 N/A 75822 $289.57 $289.57 N/A75625 TC $172.69 $172.69 N/A 75822 TC $177.97 $177.97 N/A75625 26 $119.90 $119.90 N/A 75822 26 $111.61 $111.61 N/A75630 $363.48 $363.48 N/A 75825 $287.31 $287.31 N/A75630 TC $174.95 $174.95 N/A 75825 TC $167.41 $167.41 N/A75630 26 $188.53 $188.53 N/A 75825 26 $119.90 $119.90 N/A75635 $941.12 $941.12 N/A 75827 $296.36 $296.36 N/A75635 TC $686.99 $686.99 N/A 75827 TC $175.71 $175.71 N/A75635 26 $254.13 $254.13 N/A 75827 26 $120.66 $120.66 N/A75705 $540.69 $540.69 N/A 75831 $299.38 $299.38 N/A75705 TC $293.34 $293.34 N/A 75831 TC $180.98 $180.98 N/A75705 26 $247.34 $247.34 N/A 75831 26 $118.39 $118.39 N/A75710 $367.25 $367.25 N/A 75833 $354.43 $354.43 N/A75710 TC $182.49 $182.49 N/A 75833 TC $198.33 $198.33 N/A75710 26 $184.75 $184.75 N/A 75833 26 $156.10 $156.10 N/A75716 $417.02 $417.02 N/A 75840 $316.72 $316.72 N/A75716 TC $210.39 $210.39 N/A 75840 TC $193.80 $193.80 N/A75716 26 $206.62 $206.62 N/A 75840 26 $122.92 $122.92 N/A75726 $318.23 $318.23 N/A 75842 $379.31 $379.31 N/A75726 TC $199.84 $199.84 N/A 75842 TC $218.69 $218.69 N/A75726 26 $118.39 $118.39 N/A 75842 26 $160.62 $160.62 N/A75731 $367.25 $367.25 N/A 75860 $307.67 $307.67 N/A75731 TC $244.33 $244.33 N/A 75860 TC $187.77 $187.77 N/A75731 26 $122.92 $122.92 N/A 75860 26 $119.90 $119.90 N/A75733 $394.39 $394.39 N/A 75870 $316.72 $316.72 N/A75733 TC $257.90 $257.90 N/A 75870 TC $193.80 $193.80 N/A75733 26 $136.49 $136.49 N/A 75870 26 $122.92 $122.92 N/A75736 $340.85 $340.85 N/A 75872 $316.72 $316.72 N/A75736 TC $223.21 $223.21 N/A 75872 TC $193.80 $193.80 N/A75736 26 $117.64 $117.64 N/A 75872 26 $122.92 $122.92 N/A75741 $319.74 $319.74 N/A 75880 $268.46 $268.46 N/A75741 TC $184.75 $184.75 N/A 75880 TC $193.05 $193.05 N/A75741 26 $134.98 $134.98 N/A 75880 26 $75.41 $75.41 N/A75743 $359.71 $359.71 N/A 75885 $334.07 $334.07 N/A75743 TC $187.02 $187.02 N/A 75885 TC $187.77 $187.77 N/A75743 26 $172.69 $172.69 N/A 75885 26 $146.30 $146.30 N/A75746 $323.51 $323.51 N/A 75887 $334.82 $334.82 N/A75746 TC $204.36 $204.36 N/A 75887 TC $188.53 $188.53 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 51 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

75887 26 $146.30 $146.30 N/A 76102 26 $74.66 $74.66 N/A75889 $306.16 $306.16 N/A 76120 $197.57 $197.57 N/A75889 TC $189.28 $189.28 N/A 76120 TC $159.12 $159.12 N/A75889 26 $116.89 $116.89 N/A 76120 26 $38.46 $38.46 N/A75891 $308.43 $308.43 N/A 76125 80% of billed 80% of billed ZZZ75891 TC $190.03 $190.03 N/A 76125 TC 80% of billed 80% of billed ZZZ75891 26 $118.39 $118.39 N/A 76125 26 $30.16 $30.16 ZZZ75893 $256.39 $256.39 N/A 76140 80% of billed 80% of billed N/A75893 TC $198.33 $198.33 N/A 76376 $49.77 $49.77 N/A75893 26 $58.07 $58.07 N/A 76376 TC $28.66 $28.66 N/A75894 80% of billed 80% of billed N/A 76376 26 $21.11 $21.11 N/A75894 TC 80% of billed 80% of billed N/A 76377 $151.57 $151.57 N/A75894 26 $154.59 $154.59 N/A 76377 TC $66.36 $66.36 N/A75898 80% of billed 80% of billed N/A 76377 26 $85.21 $85.21 N/A75898 TC 80% of billed 80% of billed N/A 76380 $309.94 $309.94 N/A75898 26 $193.05 $193.05 N/A 76380 TC $205.12 $205.12 N/A75901 $382.33 $382.33 N/A 76380 26 $104.82 $104.82 N/A75901 TC $331.80 $331.80 N/A 76390 $959.22 $959.22 N/A75901 26 $50.52 $50.52 N/A 76390 TC $809.15 $809.15 N/A75902 $153.84 $153.84 N/A 76390 26 $150.07 $150.07 N/A75902 TC $113.12 $113.12 N/A 76496 80% of billed 80% of billed N/A75902 26 $40.72 $40.72 N/A 76496 TC 80% of billed 80% of billed N/A75956 80% of billed 80% of billed N/A 76496 26 80% of billed 80% of billed N/A75956 TC 80% of billed 80% of billed N/A 76497 80% of billed 80% of billed N/A75956 26 $744.30 $744.30 N/A 76497 TC 80% of billed 80% of billed N/A75957 80% of billed 80% of billed N/A 76497 26 80% of billed 80% of billed N/A75957 TC 80% of billed 80% of billed N/A 76498 80% of billed 80% of billed N/A75957 26 $637.97 $637.97 N/A 76498 TC 80% of billed 80% of billed N/A75958 80% of billed 80% of billed N/A 76498 26 80% of billed 80% of billed N/A75958 TC 80% of billed 80% of billed N/A 76499 80% of billed 80% of billed N/A75958 26 $424.56 $424.56 N/A 76499 TC 80% of billed 80% of billed N/A75959 80% of billed 80% of billed N/A 76499 26 80% of billed 80% of billed N/A75959 TC 80% of billed 80% of billed N/A 76506 $251.87 $251.87 N/A75959 26 $372.53 $372.53 N/A 76506 TC $183.25 $183.25 N/A75970 80% of billed 80% of billed N/A 76506 26 $68.62 $68.62 N/A75970 TC 80% of billed 80% of billed N/A 76510 $293.34 $293.34 N/A75970 26 $85.21 $85.21 N/A 76510 TC $139.51 $139.51 N/A75984 $226.23 $226.23 N/A 76510 26 $153.84 $153.84 N/A75984 TC $151.57 $151.57 N/A 76511 $175.71 $175.71 N/A75984 26 $74.66 $74.66 N/A 76511 TC $83.71 $83.71 N/A75989 $259.41 $259.41 N/A 76511 26 $92.00 $92.00 N/A75989 TC $134.23 $134.23 N/A 76512 $160.62 $160.62 N/A75989 26 $125.18 $125.18 N/A 76512 TC $68.62 $68.62 N/A76000 $101.80 $101.80 N/A 76512 26 $92.00 $92.00 N/A76000 TC $82.95 $82.95 N/A 76513 $205.12 $205.12 N/A76000 26 $18.85 $18.85 N/A 76513 TC $128.20 $128.20 N/A76001 80% of billed 80% of billed N/A 76513 26 $76.92 $76.92 N/A76001 TC 80% of billed 80% of billed N/A 76514 $33.18 $33.18 N/A76001 26 $79.18 $79.18 N/A 76514 TC $12.07 $12.07 N/A76010 $55.80 $55.80 N/A 76514 26 $21.11 $21.11 N/A76010 TC $36.20 $36.20 N/A 76516 $135.74 $135.74 N/A76010 26 $19.61 $19.61 N/A 76516 TC $82.20 $82.20 N/A76080 $116.89 $116.89 N/A 76516 26 $53.54 $53.54 N/A76080 TC $61.08 $61.08 N/A 76519 $159.12 $159.12 N/A76080 26 $55.80 $55.80 N/A 76519 TC $92.00 $92.00 N/A76098 $36.20 $36.20 N/A 76519 26 $67.11 $67.11 N/A76098 TC $18.85 $18.85 N/A 76529 $171.93 $171.93 N/A76098 26 $17.34 $17.34 N/A 76529 TC $101.05 $101.05 N/A76100 $195.31 $195.31 N/A 76529 26 $70.89 $70.89 N/A76100 TC $127.44 $127.44 N/A 76536 $250.36 $250.36 N/A76100 26 $67.87 $67.87 N/A 76536 TC $190.03 $190.03 N/A76101 $226.98 $226.98 N/A 76536 26 $60.33 $60.33 N/A76101 TC $165.90 $165.90 N/A 76604 $191.54 $191.54 N/A76101 26 $61.08 $61.08 N/A 76604 TC $133.48 $133.48 N/A76102 $363.48 $363.48 N/A 76604 26 $58.07 $58.07 N/A76102 TC $288.82 $288.82 N/A 76641 $230.75 $230.75 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 52 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

76641 TC $152.33 $152.33 N/A 76820 TC $48.26 $48.26 N/A76641 26 $78.43 $78.43 N/A 76820 26 $55.05 $55.05 N/A76642 $189.28 $189.28 N/A 76821 $200.59 $200.59 N/A76642 TC $116.13 $116.13 N/A 76821 TC $122.92 $122.92 N/A76642 26 $73.15 $73.15 N/A 76821 26 $77.67 $77.67 N/A76700 $263.18 $263.18 N/A 76825 $598.00 $598.00 N/A76700 TC $176.46 $176.46 N/A 76825 TC $417.77 $417.77 N/A76700 26 $86.72 $86.72 N/A 76825 26 $180.23 $180.23 N/A76705 $196.82 $196.82 N/A 76826 $352.92 $352.92 N/A76705 TC $133.48 $133.48 N/A 76826 TC $263.94 $263.94 N/A76705 26 $63.34 $63.34 N/A 76826 26 $88.98 $88.98 N/A76706 $202.85 $202.85 N/A 76827 $162.13 $162.13 N/A76706 TC $143.28 $143.28 N/A 76827 TC $100.30 $100.30 N/A76706 26 $59.57 $59.57 N/A 76827 26 $61.84 $61.84 N/A76770 $243.57 $243.57 N/A 76828 $114.62 $114.62 N/A76770 TC $164.39 $164.39 N/A 76828 TC $53.54 $53.54 N/A76770 26 $79.18 $79.18 N/A 76828 26 $61.08 $61.08 N/A76775 $124.43 $124.43 N/A 76830 $262.43 $262.43 N/A76775 TC $62.59 $62.59 N/A 76830 TC $187.77 $187.77 N/A76775 26 $61.84 $61.84 N/A 76830 26 $74.66 $74.66 N/A76776 $337.08 $337.08 N/A 76831 $257.15 $257.15 N/A76776 TC $255.64 $255.64 N/A 76831 TC $177.97 $177.97 N/A76776 26 $81.44 $81.44 N/A 76831 26 $79.18 $79.18 N/A76800 $312.95 $312.95 N/A 76856 $236.79 $236.79 N/A76800 TC $184.75 $184.75 N/A 76856 TC $162.89 $162.89 N/A76800 26 $128.20 $128.20 N/A 76856 26 $73.90 $73.90 N/A76801 $265.44 $265.44 N/A 76857 $104.07 $104.07 N/A76801 TC $158.36 $158.36 N/A 76857 TC $50.52 $50.52 N/A76801 26 $107.08 $107.08 N/A 76857 26 $53.54 $53.54 N/A76802 $139.51 $139.51 ZZZ 76870 $145.54 $145.54 N/A76802 TC $48.26 $48.26 ZZZ 76870 TC $76.92 $76.92 N/A76802 26 $91.25 $91.25 ZZZ 76870 26 $68.62 $68.62 N/A76805 $306.16 $306.16 N/A 76872 $207.38 $207.38 N/A76805 TC $197.57 $197.57 N/A 76872 TC $134.98 $134.98 N/A76805 26 $108.59 $108.59 N/A 76872 26 $72.39 $72.39 N/A76810 $200.59 $200.59 ZZZ 76873 $371.77 $371.77 N/A76810 TC $92.75 $92.75 ZZZ 76873 TC $204.36 $204.36 N/A76810 26 $107.84 $107.84 ZZZ 76873 26 $167.41 $167.41 N/A76811 $393.64 $393.64 N/A 76881 $217.93 $217.93 N/A76811 TC $183.25 $183.25 N/A 76881 TC $150.07 $150.07 N/A76811 26 $210.39 $210.39 N/A 76881 26 $67.87 $67.87 N/A76812 $439.64 $439.64 ZZZ 76882 $123.67 $123.67 N/A76812 TC $242.07 $242.07 ZZZ 76882 TC $70.89 $70.89 N/A76812 26 $197.57 $197.57 ZZZ 76882 26 $52.79 $52.79 N/A76813 $262.43 $262.43 N/A 76885 $310.69 $310.69 N/A76813 TC $131.97 $131.97 N/A 76885 TC $230.75 $230.75 N/A76813 26 $130.46 $130.46 N/A 76885 26 $79.93 $79.93 N/A76814 $174.20 $174.20 N/A 76886 $226.98 $226.98 N/A76814 TC $63.34 $63.34 N/A 76886 TC $159.87 $159.87 N/A76814 26 $110.85 $110.85 N/A 76886 26 $67.11 $67.11 N/A76815 $181.74 $181.74 N/A 76930 80% of billed 80% of billed N/A76815 TC $111.61 $111.61 N/A 76930 TC 80% of billed 80% of billed N/A76815 26 $70.13 $70.13 N/A 76930 26 $70.89 $70.89 N/A76816 $248.85 $248.85 N/A 76932 80% of billed 80% of billed N/A76816 TC $154.59 $154.59 N/A 76932 TC 80% of billed 80% of billed N/A76816 26 $94.26 $94.26 N/A 76932 26 $70.13 $70.13 N/A76817 $208.89 $208.89 N/A 76936 $583.67 $583.67 N/A76817 TC $127.44 $127.44 N/A 76936 TC $374.03 $374.03 N/A76817 26 $81.44 $81.44 N/A 76936 26 $209.64 $209.64 N/A76818 $265.44 $265.44 N/A 76937 $67.11 $67.11 ZZZ76818 TC $148.56 $148.56 N/A 76937 TC $36.20 $36.20 ZZZ76818 26 $116.89 $116.89 N/A 76937 26 $30.92 $30.92 ZZZ76819 $193.05 $193.05 N/A 76940 80% of billed 80% of billed N/A76819 TC $108.59 $108.59 N/A 76940 TC 80% of billed 80% of billed N/A76819 26 $84.46 $84.46 N/A 76940 26 $221.71 $221.71 N/A76820 $103.31 $103.31 N/A 76941 80% of billed 80% of billed N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 53 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

76941 TC 80% of billed 80% of billed N/A 77058 TC $981.84 $981.84 N/A76941 26 $146.30 $146.30 N/A 77058 26 $174.95 $174.95 N/A76942 $128.20 $128.20 N/A 77059 $1,151.51 $1,151.51 N/A76942 TC $58.82 $58.82 N/A 77059 TC $976.56 $976.56 N/A76942 26 $69.38 $69.38 N/A 77059 26 $174.95 $174.95 N/A76945 80% of billed 80% of billed N/A 77061 80% of billed 80% of billed N/A76945 TC 80% of billed 80% of billed N/A 77061 TC 80% of billed 80% of billed N/A76945 26 $73.15 $73.15 N/A 77061 26 80% of billed 80% of billed N/A76946 $70.13 $70.13 N/A 77062 80% of billed 80% of billed N/A76946 TC $27.90 $27.90 N/A 77062 TC 80% of billed 80% of billed N/A76946 26 $42.23 $42.23 N/A 77062 26 80% of billed 80% of billed N/A76948 $153.08 $153.08 N/A 77063 $117.64 $117.64 ZZZ76948 TC $78.43 $78.43 N/A 77063 TC $53.54 $53.54 ZZZ76948 26 $74.66 $74.66 N/A 77063 26 $64.10 $64.10 ZZZ76965 $196.82 $196.82 N/A 77065 $285.80 $285.80 N/A76965 TC $52.03 $52.03 N/A 77065 TC $201.34 $201.34 N/A76965 26 $144.79 $144.79 N/A 77065 26 $84.46 $84.46 N/A76970 $197.57 $197.57 N/A 77066 $361.97 $356.69 N/A76970 TC $156.85 $156.85 N/A 77066 TC $257.15 $257.15 N/A76970 26 $40.72 $40.72 N/A 77066 26 $104.82 $99.54 N/A76975 80% of billed 80% of billed N/A 77067 $292.59 $292.59 N/A76975 TC 80% of billed 80% of billed N/A 77067 TC $212.66 $212.66 N/A76975 26 $91.25 $91.25 N/A 77067 26 $79.93 $79.93 N/A76977 $15.84 $15.84 N/A 77071 $103.31 $103.31 N/A76977 TC $9.80 $9.80 N/A 77072 $49.02 $49.02 N/A76977 26 $6.03 $6.03 N/A 77072 TC $28.66 $28.66 N/A76998 80% of billed 80% of billed N/A 77072 26 $20.36 $20.36 N/A76998 TC 80% of billed 80% of billed N/A 77073 $76.92 $76.92 N/A76998 26 $136.49 $136.49 N/A 77073 TC $46.00 $46.00 N/A76999 80% of billed 80% of billed N/A 77073 26 $30.92 $30.92 N/A76999 TC 80% of billed 80% of billed N/A 77074 $137.25 $137.25 N/A76999 26 80% of billed 80% of billed N/A 77074 TC $88.23 $88.23 N/A77001 $179.48 $179.48 ZZZ 77074 26 $49.02 $49.02 N/A77001 TC $139.51 $139.51 ZZZ 77075 $186.26 $186.26 N/A77001 26 $39.97 $39.97 ZZZ 77075 TC $128.20 $128.20 N/A77002 $201.34 $201.34 ZZZ 77075 26 $58.07 $58.07 N/A77002 TC $141.02 $141.02 ZZZ 77076 $204.36 $204.36 N/A77002 26 $60.33 $60.33 ZZZ 77076 TC $128.95 $128.95 N/A77003 $201.34 $201.34 ZZZ 77076 26 $75.41 $75.41 N/A77003 TC $137.25 $137.25 ZZZ 77077 $79.18 $79.18 N/A77003 26 $64.10 $64.10 ZZZ 77077 TC $44.49 $44.49 N/A77011 $483.38 $483.38 N/A 77077 26 $34.69 $34.69 N/A77011 TC $349.15 $349.15 N/A 77078 $245.84 $245.84 N/A77011 26 $134.23 $134.23 N/A 77078 TC $219.44 $219.44 N/A77012 $266.20 $266.20 N/A 77078 26 $26.39 $26.39 N/A77012 TC $143.28 $143.28 N/A 77080 $89.74 $89.74 N/A77012 26 $122.92 $122.92 N/A 77080 TC $67.87 $67.87 N/A77013 80% of billed 80% of billed N/A 77080 26 $21.87 $21.87 N/A77013 TC 80% of billed 80% of billed N/A 77081 $60.33 $60.33 N/A77013 26 $413.25 $413.25 N/A 77081 TC $36.95 $36.95 N/A77014 $256.39 $256.39 N/A 77081 26 $23.38 $23.38 N/A77014 TC $161.38 $161.38 N/A 77084 $831.77 $831.77 N/A77014 26 $95.02 $95.02 N/A 77084 TC $659.08 $659.08 N/A77021 $834.03 $834.03 N/A 77084 26 $172.69 $172.69 N/A77021 TC $676.43 $676.43 N/A 77085 $121.41 $121.41 N/A77021 26 $157.61 $157.61 N/A 77085 TC $88.98 $88.98 N/A77022 80% of billed 80% of billed N/A 77085 26 $32.43 $32.43 N/A77022 TC 80% of billed 80% of billed N/A 77086 $77.67 $77.67 N/A77022 26 $463.77 $463.77 N/A 77086 TC $58.82 $58.82 N/A77053 $124.43 $124.43 N/A 77086 26 $18.85 $18.85 N/A77053 TC $85.97 $85.97 N/A 77261 $153.08 $153.08 N/A77053 26 $38.46 $38.46 N/A 77262 $230.75 $230.75 N/A77054 $162.89 $162.89 N/A 77263 $357.44 $357.44 N/A77054 TC $113.87 $113.87 N/A 77280 $601.77 $601.77 N/A77054 26 $49.02 $49.02 N/A 77280 TC $523.35 $523.35 N/A77058 $1,156.79 $1,156.79 N/A 77280 26 $78.43 $78.43 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 54 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

77285 $982.59 $982.59 N/A 77402 80% of billed 80% of billed N/A77285 TC $862.69 $862.69 N/A 77407 80% of billed 80% of billed N/A77285 26 $119.90 $119.90 N/A 77412 80% of billed 80% of billed N/A77290 $1,128.13 $1,128.13 N/A 77417 $24.13 $24.13 N/A77290 TC $953.18 $953.18 N/A 77423 80% of billed 80% of billed N/A77290 26 $174.95 $174.95 N/A 77424 80% of billed 80% of billed N/A77293 $1,015.77 $1,015.77 ZZZ 77425 80% of billed 80% of billed N/A77293 TC $792.56 $792.56 ZZZ 77427 $400.43 $400.43 N/A77293 26 $223.21 $223.21 ZZZ 77431 $220.20 $220.20 N/A77295 $1,066.30 $1,066.30 N/A 77432 $901.15 $901.15 N/A77295 TC $587.44 $587.44 N/A 77435 $1,358.89 $1,358.89 N/A77295 26 $478.85 $478.85 N/A 77469 $686.99 $686.99 N/A77299 80% of billed 80% of billed N/A 77470 $293.34 $293.34 N/A77299 TC 80% of billed 80% of billed N/A 77470 TC $67.11 $67.11 N/A77299 26 80% of billed 80% of billed N/A 77470 26 $226.23 $226.23 N/A77300 $144.03 $144.03 N/A 77499 80% of billed 80% of billed N/A77300 TC $74.66 $74.66 N/A 77499 TC 80% of billed 80% of billed N/A77300 26 $69.38 $69.38 N/A 77499 26 80% of billed 80% of billed N/A77301 $4,259.16 $4,259.16 N/A 77520 80% of billed 80% of billed N/A77301 TC $3,368.56 $3,368.56 N/A 77522 80% of billed 80% of billed N/A77301 26 $890.59 $890.59 N/A 77523 80% of billed 80% of billed N/A77306 $325.02 $325.02 N/A 77525 80% of billed 80% of billed N/A77306 TC $168.16 $168.16 N/A 77600 $926.79 $926.79 N/A77306 26 $156.85 $156.85 N/A 77600 TC $775.21 $775.21 N/A77307 $626.66 $626.66 N/A 77600 26 $151.57 $151.57 N/A77307 TC $303.90 $303.90 N/A 77605 $1,634.13 $1,634.13 N/A77307 26 $322.75 $322.75 N/A 77605 TC $1,415.45 $1,415.45 N/A77316 $409.48 $409.48 N/A 77605 26 $218.69 $218.69 N/A77316 TC $252.62 $252.62 N/A 77610 $1,643.18 $1,643.18 N/A77316 26 $156.85 $156.85 N/A 77610 TC $1,501.41 $1,501.41 N/A77317 $533.90 $533.90 N/A 77610 26 $141.77 $141.77 N/A77317 TC $330.30 $330.30 N/A 77615 $2,239.68 $2,239.68 N/A77317 26 $203.61 $203.61 N/A 77615 TC $2,035.32 $2,035.32 N/A77318 $771.44 $771.44 N/A 77615 26 $204.36 $204.36 N/A77318 TC $448.69 $448.69 N/A 77620 $1,015.77 $1,015.77 N/A77318 26 $322.75 $322.75 N/A 77620 TC $830.26 $830.26 N/A77321 $202.10 $202.10 N/A 77620 26 $185.51 $185.51 N/A77321 TC $95.77 $95.77 N/A 77750 $805.38 $805.38 09077321 26 $106.33 $106.33 N/A 77750 TC $248.10 $248.10 09077331 $138.75 $138.75 N/A 77750 26 $557.28 $557.28 09077331 TC $41.48 $41.48 N/A 77761 $848.36 $848.36 09077331 26 $97.28 $97.28 N/A 77761 TC $418.53 $418.53 09077332 $126.69 $126.69 N/A 77761 26 $429.84 $429.84 09077332 TC $75.41 $75.41 N/A 77762 $1,124.36 $1,124.36 09077332 26 $51.28 $51.28 N/A 77762 TC $481.12 $481.12 09077333 $210.39 $210.39 N/A 77762 26 $643.25 $643.25 09077333 TC $126.69 $126.69 N/A 77763 $1,608.50 $1,608.50 09077333 26 $83.71 $83.71 N/A 77763 TC $636.46 $636.46 09077334 $278.26 $278.26 N/A 77763 26 $972.03 $972.03 09077334 TC $149.31 $149.31 N/A 77767 $489.41 $489.41 N/A77334 26 $128.95 $128.95 N/A 77767 TC $372.53 $372.53 N/A77336 $173.44 $173.44 N/A 77767 26 $116.89 $116.89 N/A77338 $1,104.76 $1,104.76 N/A 77768 $768.43 $768.43 N/A77338 TC $625.90 $625.90 N/A 77768 TC $611.58 $611.58 N/A77338 26 $478.85 $478.85 N/A 77768 26 $156.85 $156.85 N/A77370 $266.95 $266.95 N/A 77770 $700.56 $700.56 N/A77371 80% of billed 80% of billed N/A 77770 TC $483.38 $483.38 N/A77372 $2,342.99 $2,342.99 N/A 77770 26 $217.18 $217.18 N/A77373 $2,980.20 $2,980.20 N/A 77771 $1,302.33 $1,302.33 N/A77385 80% of billed 80% of billed N/A 77771 TC $877.77 $877.77 N/A77386 80% of billed 80% of billed N/A 77771 26 $424.56 $424.56 N/A77387 80% of billed 80% of billed N/A 77772 $1,987.05 $1,987.05 N/A77399 80% of billed 80% of billed N/A 77772 TC $1,386.04 $1,386.04 N/A77399 TC 80% of billed 80% of billed N/A 77772 26 $601.02 $601.02 N/A77399 26 80% of billed 80% of billed N/A 77778 $1,781.18 $1,781.18 00077401 $53.54 $53.54 N/A 77778 TC $805.38 $805.38 000

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 55 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

77778 26 $975.81 $975.81 000 78122 TC $165.15 $165.15 N/A77789 $261.67 $261.67 000 78122 26 $45.25 $45.25 N/A77789 TC $133.48 $133.48 000 78130 $300.13 $300.13 N/A77789 26 $128.20 $128.20 000 78130 TC $245.84 $245.84 N/A77790 $32.43 $32.43 N/A 78130 26 $54.30 $54.30 N/A77799 80% of billed 80% of billed N/A 78135 $631.18 $631.18 N/A77799 TC 80% of billed 80% of billed N/A 78135 TC $573.87 $573.87 N/A77799 26 80% of billed 80% of billed N/A 78135 26 $57.31 $57.31 N/A78012 $178.72 $178.72 N/A 78140 $248.10 $248.10 N/A78012 TC $158.36 $158.36 N/A 78140 TC $193.80 $193.80 N/A78012 26 $20.36 $20.36 N/A 78140 26 $54.30 $54.30 N/A78013 $424.56 $424.56 N/A 78185 $378.56 $378.56 N/A78013 TC $385.35 $385.35 N/A 78185 TC $342.36 $342.36 N/A78013 26 $39.21 $39.21 N/A 78185 26 $36.20 $36.20 N/A78014 $533.90 $533.90 N/A 78191 $300.13 $300.13 N/A78014 TC $481.12 $481.12 N/A 78191 TC $245.84 $245.84 N/A78014 26 $52.79 $52.79 N/A 78191 26 $54.30 $54.30 N/A78015 $492.43 $492.43 N/A 78195 $787.28 $787.28 N/A78015 TC $421.54 $421.54 N/A 78195 TC $661.35 $661.35 N/A78015 26 $70.89 $70.89 N/A 78195 26 $125.93 $125.93 N/A78016 $622.89 $622.89 N/A 78199 80% of billed 80% of billed N/A78016 TC $549.74 $549.74 N/A 78199 TC 80% of billed 80% of billed N/A78016 26 $73.15 $73.15 N/A 78199 26 80% of billed 80% of billed N/A78018 $691.51 $691.51 N/A 78201 $418.53 $418.53 N/A78018 TC $603.28 $603.28 N/A 78201 TC $373.28 $373.28 N/A78018 26 $88.23 $88.23 N/A 78201 26 $45.25 $45.25 N/A78020 $184.75 $184.75 ZZZ 78202 $441.15 $441.15 N/A78020 TC $125.18 $125.18 ZZZ 78202 TC $390.62 $390.62 N/A78020 26 $59.57 $59.57 ZZZ 78202 26 $50.52 $50.52 N/A78070 $663.61 $663.61 N/A 78205 $466.03 $466.03 N/A78070 TC $579.90 $579.90 N/A 78205 TC $394.39 $394.39 N/A78070 26 $83.71 $83.71 N/A 78205 26 $71.64 $71.64 N/A78071 $790.30 $790.30 N/A 78206 $760.89 $760.89 N/A78071 TC $664.36 $664.36 N/A 78206 TC $660.59 $660.59 N/A78071 26 $125.93 $125.93 N/A 78206 26 $100.30 $100.30 N/A78072 $915.48 $915.48 N/A 78215 $429.84 $429.84 N/A78072 TC $750.33 $750.33 N/A 78215 TC $377.80 $377.80 N/A78072 26 $165.15 $165.15 N/A 78215 26 $52.03 $52.03 N/A78075 $1,000.69 $1,000.69 N/A 78216 $279.02 $279.02 N/A78075 TC $920.76 $920.76 N/A 78216 TC $220.20 $220.20 N/A78075 26 $79.93 $79.93 N/A 78216 26 $58.82 $58.82 N/A78099 80% of billed 80% of billed N/A 78226 $732.23 $732.23 N/A78099 TC 80% of billed 80% of billed N/A 78226 TC $653.80 $653.80 N/A78099 26 80% of billed 80% of billed N/A 78226 26 $78.43 $78.43 N/A78102 $374.03 $374.03 N/A 78227 $992.40 $992.40 N/A78102 TC $317.48 $317.48 N/A 78227 TC $896.62 $896.62 N/A78102 26 $56.56 $56.56 N/A 78227 26 $95.77 $95.77 N/A78103 $478.10 $478.10 N/A 78230 $384.59 $384.59 N/A78103 TC $402.69 $402.69 N/A 78230 TC $335.57 $335.57 N/A78103 26 $75.41 $75.41 N/A 78230 26 $49.02 $49.02 N/A78104 $545.97 $545.97 N/A 78231 $231.51 $231.51 N/A78104 TC $463.02 $463.02 N/A 78231 TC $184.75 $184.75 N/A78104 26 $82.95 $82.95 N/A 78231 26 $46.75 $46.75 N/A78110 $178.72 $178.72 N/A 78232 $220.95 $220.95 N/A78110 TC $161.38 $161.38 N/A 78232 TC $178.72 $178.72 N/A78110 26 $17.34 $17.34 N/A 78232 26 $42.23 $42.23 N/A78111 $171.18 $171.18 N/A 78258 $496.95 $496.95 N/A78111 TC $150.82 $150.82 N/A 78258 TC $418.53 $418.53 N/A78111 26 $20.36 $20.36 N/A 78258 26 $78.43 $78.43 N/A78120 $168.16 $168.16 N/A 78261 $445.67 $445.67 N/A78120 TC $147.05 $147.05 N/A 78261 TC $383.84 $383.84 N/A78120 26 $21.11 $21.11 N/A 78261 26 $61.84 $61.84 N/A78121 $187.02 $187.02 N/A 78262 $533.15 $533.15 N/A78121 TC $158.36 $158.36 N/A 78262 TC $462.26 $462.26 N/A78121 26 $28.66 $28.66 N/A 78262 26 $70.89 $70.89 N/A78122 $210.39 $210.39 N/A 78264 $742.79 $742.79 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 56 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

78264 TC $659.84 $659.84 N/A 78451 TC $608.56 $608.56 N/A78264 26 $82.95 $82.95 N/A 78451 26 $144.03 $144.03 N/A78265 $881.54 $881.54 N/A 78452 $1,048.20 $1,048.20 N/A78265 TC $778.23 $778.23 N/A 78452 TC $878.53 $878.53 N/A78265 26 $103.31 $103.31 N/A 78452 26 $169.67 $169.67 N/A78266 $1,050.46 $1,050.46 N/A 78453 $671.90 $671.90 N/A78266 TC $935.84 $935.84 N/A 78453 TC $566.33 $566.33 N/A78266 26 $114.62 $114.62 N/A 78453 26 $105.57 $105.57 N/A78267 80% of billed 80% of billed N/A 78454 $966.00 $966.00 N/A78268 80% of billed 80% of billed N/A 78454 TC $823.48 $823.48 N/A78270 $226.23 $226.23 N/A 78454 26 $142.52 $142.52 N/A78270 TC $203.61 $203.61 N/A 78456 $684.72 $684.72 N/A78270 26 $22.62 $22.62 N/A 78456 TC $580.66 $580.66 N/A78271 $160.62 $160.62 N/A 78456 26 $104.07 $104.07 N/A78271 TC $142.52 $142.52 N/A 78457 $423.80 $423.80 N/A78271 26 $18.10 $18.10 N/A 78457 TC $343.12 $343.12 N/A78272 $176.46 $176.46 N/A 78457 26 $80.69 $80.69 N/A78272 TC $151.57 $151.57 N/A 78458 $450.95 $450.95 N/A78272 26 $24.89 $24.89 N/A 78458 TC $354.43 $354.43 N/A78278 $771.44 $771.44 N/A 78458 26 $96.52 $96.52 N/A78278 TC $666.62 $666.62 N/A 78459 80% of billed 80% of billed N/A78278 26 $104.82 $104.82 N/A 78459 TC 80% of billed 80% of billed N/A78282 80% of billed 80% of billed N/A 78459 26 $151.57 $151.57 N/A78282 TC 80% of billed 80% of billed N/A 78466 $435.87 $435.87 N/A78282 26 $40.72 $40.72 N/A 78466 TC $360.46 $360.46 N/A78290 $732.23 $732.23 N/A 78466 26 $75.41 $75.41 N/A78290 TC $660.59 $660.59 N/A 78468 $425.31 $425.31 N/A78290 26 $71.64 $71.64 N/A 78468 TC $342.36 $342.36 N/A78291 $566.33 $566.33 N/A 78468 26 $82.95 $82.95 N/A78291 TC $475.08 $475.08 N/A 78469 $506.00 $506.00 N/A78291 26 $91.25 $91.25 N/A 78469 TC $409.48 $409.48 N/A78299 80% of billed 80% of billed N/A 78469 26 $96.52 $96.52 N/A78299 TC 80% of billed 80% of billed N/A 78472 $506.00 $506.00 N/A78299 26 80% of billed 80% of billed N/A 78472 TC $402.69 $402.69 N/A78300 $510.53 $510.53 N/A 78472 26 $103.31 $103.31 N/A78300 TC $443.41 $443.41 N/A 78473 $637.97 $637.97 N/A78300 26 $67.11 $67.11 N/A 78473 TC $485.64 $485.64 N/A78305 $622.13 $622.13 N/A 78473 26 $152.33 $152.33 N/A78305 TC $533.90 $533.90 N/A 78481 $386.10 $386.10 N/A78305 26 $88.23 $88.23 N/A 78481 TC $283.54 $283.54 N/A78306 $671.15 $671.15 N/A 78481 26 $102.56 $102.56 N/A78306 TC $579.90 $579.90 N/A 78483 $532.39 $532.39 N/A78306 26 $91.25 $91.25 N/A 78483 TC $380.07 $380.07 N/A78315 $765.41 $765.41 N/A 78483 26 $152.33 $152.33 N/A78315 TC $658.33 $658.33 N/A 78491 80% of billed 80% of billed N/A78315 26 $107.08 $107.08 N/A 78491 TC 80% of billed 80% of billed N/A78320 $504.49 $504.49 N/A 78491 26 $152.33 $152.33 N/A78320 TC $396.66 $396.66 N/A 78492 80% of billed 80% of billed N/A78320 26 $107.84 $107.84 N/A 78492 TC 80% of billed 80% of billed N/A78350 $71.64 $71.64 N/A 78492 26 $192.30 $192.30 N/A78350 TC $47.51 $47.51 N/A 78494 $496.95 $496.95 N/A78350 26 $24.13 $24.13 N/A 78494 TC $372.53 $372.53 N/A78351 $33.18 $33.18 N/A 78494 26 $124.43 $124.43 N/A78399 80% of billed 80% of billed N/A 78496 $95.77 $95.77 ZZZ78399 TC 80% of billed 80% of billed N/A 78496 TC $43.74 $43.74 ZZZ78399 26 80% of billed 80% of billed N/A 78496 26 $52.03 $52.03 ZZZ78414 80% of billed 80% of billed N/A 78499 80% of billed 80% of billed N/A78414 TC 80% of billed 80% of billed N/A 78499 TC 80% of billed 80% of billed N/A78414 26 $47.51 $47.51 N/A 78499 26 80% of billed 80% of billed N/A78428 $402.69 $402.69 N/A 78579 $413.25 $413.25 N/A78428 TC $322.00 $322.00 N/A 78579 TC $361.97 $361.97 N/A78428 26 $80.69 $80.69 N/A 78579 26 $51.28 $51.28 N/A78445 $412.49 $412.49 N/A 78580 $527.87 $527.87 N/A78445 TC $359.71 $359.71 N/A 78580 TC $449.44 $449.44 N/A78445 26 $52.79 $52.79 N/A 78580 26 $78.43 $78.43 N/A78451 $752.59 $752.59 N/A 78582 $739.02 $739.02 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 57 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

78582 TC $625.90 $625.90 N/A 78708 TC $260.16 $260.16 N/A78582 26 $113.12 $113.12 N/A 78708 26 $126.69 $126.69 N/A78597 $448.69 $448.69 N/A 78709 $809.90 $809.90 N/A78597 TC $372.53 $372.53 N/A 78709 TC $663.61 $663.61 N/A78597 26 $76.16 $76.16 N/A 78709 26 $146.30 $146.30 N/A78598 $674.17 $674.17 N/A 78710 $445.67 $445.67 N/A78598 TC $585.94 $585.94 N/A 78710 TC $381.57 $381.57 N/A78598 26 $88.23 $88.23 N/A 78710 26 $64.10 $64.10 N/A78599 80% of billed 80% of billed N/A 78725 $236.03 $236.03 N/A78599 TC 80% of billed 80% of billed N/A 78725 TC $196.82 $196.82 N/A78599 26 80% of billed 80% of billed N/A 78725 26 $39.21 $39.21 N/A78600 $407.97 $407.97 N/A 78730 $172.69 $172.69 ZZZ78600 TC $360.46 $360.46 N/A 78730 TC $155.34 $155.34 ZZZ78600 26 $47.51 $47.51 N/A 78730 26 $17.34 $17.34 ZZZ78601 $474.33 $474.33 N/A 78740 $481.87 $481.87 N/A78601 TC $420.79 $420.79 N/A 78740 TC $423.05 $423.05 N/A78601 26 $53.54 $53.54 N/A 78740 26 $58.82 $58.82 N/A78605 $439.64 $439.64 N/A 78761 $465.28 $465.28 N/A78605 TC $382.33 $382.33 N/A 78761 TC $389.12 $389.12 N/A78605 26 $57.31 $57.31 N/A 78761 26 $76.16 $76.16 N/A78606 $728.46 $728.46 N/A 78799 80% of billed 80% of billed N/A78606 TC $661.35 $661.35 N/A 78799 TC 80% of billed 80% of billed N/A78606 26 $67.11 $67.11 N/A 78799 26 80% of billed 80% of billed N/A78607 $774.46 $774.46 N/A 78800 $426.07 $426.07 N/A78607 TC $647.77 $647.77 N/A 78800 TC $353.67 $353.67 N/A78607 26 $126.69 $126.69 N/A 78800 26 $72.39 $72.39 N/A78608 80% of billed 80% of billed N/A 78801 $573.87 $573.87 N/A78608 TC 80% of billed 80% of billed N/A 78801 TC $489.41 $489.41 N/A78608 26 $153.84 $153.84 N/A 78801 26 $84.46 $84.46 N/A78609 $159.87 $159.87 N/A 78802 $715.64 $715.64 N/A78609 TC 80% of billed 80% of billed N/A 78802 TC $626.66 $626.66 N/A78609 26 $159.87 $159.87 N/A 78802 26 $88.98 $88.98 N/A78610 $386.85 $386.85 N/A 78803 $757.12 $757.12 N/A78610 TC $354.43 $354.43 N/A 78803 TC $646.26 $646.26 N/A78610 26 $32.43 $32.43 N/A 78803 26 $110.85 $110.85 N/A78630 $748.82 $748.82 N/A 78804 $1,255.58 $1,255.58 N/A78630 TC $676.43 $676.43 N/A 78804 TC $1,143.97 $1,143.97 N/A78630 26 $72.39 $72.39 N/A 78804 26 $111.61 $111.61 N/A78635 $749.58 $749.58 N/A 78805 $404.20 $404.20 N/A78635 TC $683.21 $683.21 N/A 78805 TC $327.28 $327.28 N/A78635 26 $66.36 $66.36 N/A 78805 26 $76.92 $76.92 N/A78645 $719.41 $719.41 N/A 78806 $738.26 $738.26 N/A78645 TC $659.84 $659.84 N/A 78806 TC $648.53 $648.53 N/A78645 26 $59.57 $59.57 N/A 78806 26 $89.74 $89.74 N/A78647 $776.72 $776.72 N/A 78807 $758.62 $758.62 N/A78647 TC $679.44 $679.44 N/A 78807 TC $647.02 $647.02 N/A78647 26 $97.28 $97.28 N/A 78807 26 $111.61 $111.61 N/A78650 $602.53 $602.53 N/A 78808 $84.46 $84.46 N/A78650 TC $548.23 $548.23 N/A 78811 80% of billed 80% of billed N/A78650 26 $54.30 $54.30 N/A 78811 TC 80% of billed 80% of billed N/A78660 $398.16 $398.16 N/A 78811 26 $163.64 $163.64 N/A78660 TC $342.36 $342.36 N/A 78812 80% of billed 80% of billed N/A78660 26 $55.80 $55.80 N/A 78812 TC 80% of billed 80% of billed N/A78699 80% of billed 80% of billed N/A 78812 26 $199.84 $199.84 N/A78699 TC 80% of billed 80% of billed N/A 78813 80% of billed 80% of billed N/A78699 26 80% of billed 80% of billed N/A 78813 TC 80% of billed 80% of billed N/A78700 $380.82 $380.82 N/A 78813 26 $206.62 $206.62 N/A78700 TC $333.31 $333.31 N/A 78814 80% of billed 80% of billed N/A78700 26 $47.51 $47.51 N/A 78814 TC 80% of billed 80% of billed N/A78701 $474.33 $474.33 N/A 78814 26 $230.00 $230.00 N/A78701 TC $423.05 $423.05 N/A 78815 80% of billed 80% of billed N/A78701 26 $51.28 $51.28 N/A 78815 TC 80% of billed 80% of billed N/A78707 $513.54 $513.54 N/A 78815 26 $254.89 $254.89 N/A78707 TC $414.00 $414.00 N/A 78816 80% of billed 80% of billed N/A78707 26 $99.54 $99.54 N/A 78816 TC 80% of billed 80% of billed N/A78708 $386.85 $386.85 N/A 78816 26 $257.90 $257.90 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 58 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

78999 80% of billed 80% of billed N/A 80195 80% of billed 80% of billed N/A78999 TC 80% of billed 80% of billed N/A 80197 80% of billed 80% of billed N/A78999 26 80% of billed 80% of billed N/A 80198 80% of billed 80% of billed N/A79005 $294.10 $294.10 N/A 80199 80% of billed 80% of billed N/A79005 TC $105.57 $105.57 N/A 80200 80% of billed 80% of billed N/A79005 26 $188.53 $188.53 N/A 80201 80% of billed 80% of billed N/A79101 $310.69 $310.69 N/A 80202 80% of billed 80% of billed N/A79101 TC $104.07 $104.07 N/A 80203 80% of billed 80% of billed N/A79101 26 $206.62 $206.62 N/A 80299 $50.47 $50.47 N/A79200 $287.31 $287.31 N/A 80300 $45.32 $45.32 N/A79200 TC $109.34 $109.34 N/A 80301 $26.78 $26.78 N/A79200 26 $177.97 $177.97 N/A 80305 $21.75 $21.75 N/A79300 80% of billed 80% of billed N/A 80306 $29.00 $29.00 N/A79300 TC 80% of billed 80% of billed N/A 80307 $116.00 $116.00 N/A79300 26 $171.93 $171.93 N/A 80320 $46.35 $46.35 N/A79403 $414.00 $414.00 N/A 80321 80% of billed 80% of billed N/A79403 TC $178.72 $178.72 N/A 80322 80% of billed 80% of billed N/A79403 26 $235.28 $235.28 N/A 80323 80% of billed 80% of billed N/A79440 $266.20 $266.20 N/A 80324 $45.32 $45.32 N/A79440 TC $88.23 $88.23 N/A 80325 80% of billed 80% of billed N/A79440 26 $177.97 $177.97 N/A 80326 80% of billed 80% of billed N/A79445 80% of billed 80% of billed N/A 80327 80% of billed 80% of billed N/A79445 TC 80% of billed 80% of billed N/A 80328 80% of billed 80% of billed N/A79445 26 $245.84 $245.84 N/A 80329 80% of billed 80% of billed N/A79999 80% of billed 80% of billed N/A 80330 80% of billed 80% of billed N/A79999 TC 80% of billed 80% of billed N/A 80331 80% of billed 80% of billed N/A79999 26 80% of billed 80% of billed N/A 80332 80% of billed 80% of billed N/A80047 80% of billed 80% of billed N/A 80333 80% of billed 80% of billed N/A80048 80% of billed 80% of billed N/A 80334 80% of billed 80% of billed N/A80050 80% of billed 80% of billed N/A 80335 80% of billed 80% of billed N/A80051 80% of billed 80% of billed N/A 80336 80% of billed 80% of billed N/A80053 80% of billed 80% of billed N/A 80337 80% of billed 80% of billed N/A80055 80% of billed 80% of billed N/A 80338 80% of billed 80% of billed N/A80061 80% of billed 80% of billed N/A 80339 80% of billed 80% of billed N/A80069 80% of billed 80% of billed N/A 80340 80% of billed 80% of billed N/A80074 80% of billed 80% of billed N/A 80341 80% of billed 80% of billed N/A80076 80% of billed 80% of billed N/A 80342 80% of billed 80% of billed N/A80081 80% of billed 80% of billed N/A 80343 80% of billed 80% of billed N/A80150 80% of billed 80% of billed N/A 80344 80% of billed 80% of billed N/A80155 80% of billed 80% of billed N/A 80345 80% of billed 80% of billed N/A80156 80% of billed 80% of billed N/A 80346 $54.59 $54.59 N/A80157 80% of billed 80% of billed N/A 80347 80% of billed 80% of billed N/A80158 80% of billed 80% of billed N/A 80348 80% of billed 80% of billed N/A80159 80% of billed 80% of billed N/A 80349 80% of billed 80% of billed N/A80162 80% of billed 80% of billed N/A 80350 80% of billed 80% of billed N/A80163 80% of billed 80% of billed N/A 80351 80% of billed 80% of billed N/A80164 80% of billed 80% of billed N/A 80352 80% of billed 80% of billed N/A80165 80% of billed 80% of billed N/A 80353 $44.29 $44.29 N/A80168 80% of billed 80% of billed N/A 80354 80% of billed 80% of billed N/A80169 80% of billed 80% of billed N/A 80355 80% of billed 80% of billed N/A80170 80% of billed 80% of billed N/A 80356 80% of billed 80% of billed N/A80171 80% of billed 80% of billed N/A 80357 80% of billed 80% of billed N/A80173 80% of billed 80% of billed N/A 80358 $56.65 $56.65 N/A80175 80% of billed 80% of billed N/A 80359 80% of billed 80% of billed N/A80176 80% of billed 80% of billed N/A 80360 80% of billed 80% of billed N/A80177 80% of billed 80% of billed N/A 80361 80% of billed 80% of billed N/A80178 80% of billed 80% of billed N/A 80362 80% of billed 80% of billed N/A80180 80% of billed 80% of billed N/A 80363 80% of billed 80% of billed N/A80183 80% of billed 80% of billed N/A 80364 80% of billed 80% of billed N/A80184 80% of billed 80% of billed N/A 80365 80% of billed 80% of billed N/A80185 80% of billed 80% of billed N/A 80366 80% of billed 80% of billed N/A80186 80% of billed 80% of billed N/A 80367 80% of billed 80% of billed N/A80188 80% of billed 80% of billed N/A 80368 80% of billed 80% of billed N/A80190 80% of billed 80% of billed N/A 80369 80% of billed 80% of billed N/A80192 80% of billed 80% of billed N/A 80370 80% of billed 80% of billed N/A80194 80% of billed 80% of billed N/A 80371 80% of billed 80% of billed N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 59 of 84

Page 60: Appendix B for Administrative Order No. 18-053 Physician ...Appendix B for Administrative Order No. 18-053 Physician Fee Schedule Effective April 1, 2018 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

80372 80% of billed 80% of billed N/A 81210 80% of billed 80% of billed N/A80373 80% of billed 80% of billed N/A 81211 80% of billed 80% of billed N/A80374 80% of billed 80% of billed N/A 81212 80% of billed 80% of billed N/A80375 80% of billed 80% of billed N/A 81213 80% of billed 80% of billed N/A80376 80% of billed 80% of billed N/A 81214 80% of billed 80% of billed N/A80377 80% of billed 80% of billed N/A 81215 80% of billed 80% of billed N/A80400 80% of billed 80% of billed N/A 81216 80% of billed 80% of billed N/A80402 80% of billed 80% of billed N/A 81217 80% of billed 80% of billed N/A80406 80% of billed 80% of billed N/A 81218 80% of billed 80% of billed N/A80408 80% of billed 80% of billed N/A 81219 80% of billed 80% of billed N/A80410 80% of billed 80% of billed N/A 81220 80% of billed 80% of billed N/A80412 80% of billed 80% of billed N/A 81221 80% of billed 80% of billed N/A80414 80% of billed 80% of billed N/A 81222 80% of billed 80% of billed N/A80415 80% of billed 80% of billed N/A 81223 80% of billed 80% of billed N/A80416 80% of billed 80% of billed N/A 81224 80% of billed 80% of billed N/A80417 80% of billed 80% of billed N/A 81225 80% of billed 80% of billed N/A80418 80% of billed 80% of billed N/A 81226 80% of billed 80% of billed N/A80420 80% of billed 80% of billed N/A 81227 80% of billed 80% of billed N/A80422 80% of billed 80% of billed N/A 81228 80% of billed 80% of billed N/A80424 80% of billed 80% of billed N/A 81229 80% of billed 80% of billed N/A80426 80% of billed 80% of billed N/A 81230 80% of billed 80% of billed N/A80428 80% of billed 80% of billed N/A 81231 80% of billed 80% of billed N/A80430 80% of billed 80% of billed N/A 81232 80% of billed 80% of billed N/A80432 80% of billed 80% of billed N/A 81235 80% of billed 80% of billed N/A80434 80% of billed 80% of billed N/A 81238 80% of billed 80% of billed N/A80435 80% of billed 80% of billed N/A 81240 80% of billed 80% of billed N/A80436 80% of billed 80% of billed N/A 81241 80% of billed 80% of billed N/A80438 80% of billed 80% of billed N/A 81242 80% of billed 80% of billed N/A80439 80% of billed 80% of billed N/A 81243 80% of billed 80% of billed N/A80500 $37.98 $32.22 N/A 81244 80% of billed 80% of billed N/A80502 $120.83 $116.23 N/A 81245 80% of billed 80% of billed N/A81000 80% of billed 80% of billed N/A 81246 80% of billed 80% of billed N/A81001 80% of billed 80% of billed N/A 81247 80% of billed 80% of billed N/A81002 80% of billed 80% of billed N/A 81248 80% of billed 80% of billed N/A81003 $15.45 $15.45 N/A 81249 80% of billed 80% of billed N/A81005 $6.18 $6.18 N/A 81250 80% of billed 80% of billed N/A81007 80% of billed 80% of billed N/A 81251 80% of billed 80% of billed N/A81015 80% of billed 80% of billed N/A 81252 80% of billed 80% of billed N/A81020 80% of billed 80% of billed N/A 81253 80% of billed 80% of billed N/A81025 80% of billed 80% of billed N/A 81254 80% of billed 80% of billed N/A81050 80% of billed 80% of billed N/A 81255 80% of billed 80% of billed N/A81099 80% of billed 80% of billed N/A 81256 80% of billed 80% of billed N/A81105 80% of billed 80% of billed N/A 81257 80% of billed 80% of billed N/A81106 80% of billed 80% of billed N/A 81258 80% of billed 80% of billed N/A81107 80% of billed 80% of billed N/A 81259 80% of billed 80% of billed N/A81108 80% of billed 80% of billed N/A 81260 80% of billed 80% of billed N/A81109 80% of billed 80% of billed N/A 81261 80% of billed 80% of billed N/A81110 80% of billed 80% of billed N/A 81262 80% of billed 80% of billed N/A81111 80% of billed 80% of billed N/A 81263 80% of billed 80% of billed N/A81112 80% of billed 80% of billed N/A 81264 80% of billed 80% of billed N/A81120 80% of billed 80% of billed N/A 81265 80% of billed 80% of billed N/A81121 80% of billed 80% of billed N/A 81266 80% of billed 80% of billed N/A81161 80% of billed 80% of billed N/A 81267 80% of billed 80% of billed N/A81162 80% of billed 80% of billed N/A 81268 80% of billed 80% of billed N/A81170 80% of billed 80% of billed N/A 81269 80% of billed 80% of billed N/A81175 80% of billed 80% of billed N/A 81270 80% of billed 80% of billed N/A81176 80% of billed 80% of billed N/A 81272 80% of billed 80% of billed N/A81200 80% of billed 80% of billed N/A 81273 80% of billed 80% of billed N/A81201 80% of billed 80% of billed N/A 81275 80% of billed 80% of billed N/A81202 80% of billed 80% of billed N/A 81276 80% of billed 80% of billed N/A81203 80% of billed 80% of billed N/A 81283 80% of billed 80% of billed N/A81205 80% of billed 80% of billed N/A 81287 80% of billed 80% of billed N/A81206 80% of billed 80% of billed N/A 81288 80% of billed 80% of billed N/A81207 80% of billed 80% of billed N/A 81290 80% of billed 80% of billed N/A81208 80% of billed 80% of billed N/A 81291 80% of billed 80% of billed N/A81209 80% of billed 80% of billed N/A 81292 80% of billed 80% of billed N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 60 of 84

Page 61: Appendix B for Administrative Order No. 18-053 Physician ...Appendix B for Administrative Order No. 18-053 Physician Fee Schedule Effective April 1, 2018 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

81293 80% of billed 80% of billed N/A 81408 80% of billed 80% of billed N/A81294 80% of billed 80% of billed N/A 81410 80% of billed 80% of billed N/A81295 80% of billed 80% of billed N/A 81411 80% of billed 80% of billed N/A81296 80% of billed 80% of billed N/A 81412 80% of billed 80% of billed N/A81297 80% of billed 80% of billed N/A 81413 80% of billed 80% of billed N/A81298 80% of billed 80% of billed N/A 81414 80% of billed 80% of billed N/A81299 80% of billed 80% of billed N/A 81415 80% of billed 80% of billed N/A81300 80% of billed 80% of billed N/A 81416 80% of billed 80% of billed N/A81301 80% of billed 80% of billed N/A 81417 80% of billed 80% of billed N/A81302 80% of billed 80% of billed N/A 81420 80% of billed 80% of billed N/A81303 80% of billed 80% of billed N/A 81422 80% of billed 80% of billed N/A81304 80% of billed 80% of billed N/A 81425 80% of billed 80% of billed N/A81310 80% of billed 80% of billed N/A 81426 80% of billed 80% of billed N/A81311 80% of billed 80% of billed N/A 81427 80% of billed 80% of billed N/A81313 80% of billed 80% of billed N/A 81430 80% of billed 80% of billed N/A81314 80% of billed 80% of billed N/A 81431 80% of billed 80% of billed N/A81315 80% of billed 80% of billed N/A 81432 80% of billed 80% of billed N/A81316 80% of billed 80% of billed N/A 81433 80% of billed 80% of billed N/A81317 80% of billed 80% of billed N/A 81434 80% of billed 80% of billed N/A81318 80% of billed 80% of billed N/A 81435 80% of billed 80% of billed N/A81319 80% of billed 80% of billed N/A 81436 80% of billed 80% of billed N/A81321 80% of billed 80% of billed N/A 81437 80% of billed 80% of billed N/A81322 80% of billed 80% of billed N/A 81438 80% of billed 80% of billed N/A81323 80% of billed 80% of billed N/A 81439 80% of billed 80% of billed N/A81324 80% of billed 80% of billed N/A 81440 80% of billed 80% of billed N/A81325 80% of billed 80% of billed N/A 81442 80% of billed 80% of billed N/A81326 80% of billed 80% of billed N/A 81445 80% of billed 80% of billed N/A81327 80% of billed 80% of billed N/A 81448 80% of billed 80% of billed N/A81328 80% of billed 80% of billed N/A 81450 80% of billed 80% of billed N/A81330 80% of billed 80% of billed N/A 81455 80% of billed 80% of billed N/A81331 80% of billed 80% of billed N/A 81460 80% of billed 80% of billed N/A81332 80% of billed 80% of billed N/A 81465 80% of billed 80% of billed N/A81334 80% of billed 80% of billed N/A 81470 80% of billed 80% of billed N/A81335 80% of billed 80% of billed N/A 81471 80% of billed 80% of billed N/A81340 80% of billed 80% of billed N/A 81479 80% of billed 80% of billed N/A81341 80% of billed 80% of billed N/A 81490 80% of billed 80% of billed N/A81342 80% of billed 80% of billed N/A 81493 80% of billed 80% of billed N/A81346 80% of billed 80% of billed N/A 81500 80% of billed 80% of billed N/A81350 80% of billed 80% of billed N/A 81503 80% of billed 80% of billed N/A81355 80% of billed 80% of billed N/A 81504 80% of billed 80% of billed N/A81361 80% of billed 80% of billed N/A 81506 80% of billed 80% of billed N/A81362 80% of billed 80% of billed N/A 81507 80% of billed 80% of billed N/A81363 80% of billed 80% of billed N/A 81508 80% of billed 80% of billed N/A81364 80% of billed 80% of billed N/A 81509 80% of billed 80% of billed N/A81370 80% of billed 80% of billed N/A 81510 80% of billed 80% of billed N/A81371 80% of billed 80% of billed N/A 81511 80% of billed 80% of billed N/A81372 80% of billed 80% of billed N/A 81512 80% of billed 80% of billed N/A81373 80% of billed 80% of billed N/A 81519 80% of billed 80% of billed N/A81374 80% of billed 80% of billed N/A 81520 80% of billed 80% of billed N/A81375 80% of billed 80% of billed N/A 81521 80% of billed 80% of billed N/A81376 80% of billed 80% of billed N/A 81525 80% of billed 80% of billed N/A81377 80% of billed 80% of billed N/A 81528 80% of billed 80% of billed N/A81378 80% of billed 80% of billed N/A 81535 80% of billed 80% of billed N/A81379 80% of billed 80% of billed N/A 81536 80% of billed 80% of billed N/A81380 80% of billed 80% of billed N/A 81538 80% of billed 80% of billed N/A81381 80% of billed 80% of billed N/A 81539 80% of billed 80% of billed N/A81382 80% of billed 80% of billed N/A 81540 80% of billed 80% of billed N/A81383 80% of billed 80% of billed N/A 81541 80% of billed 80% of billed N/A81400 80% of billed 80% of billed N/A 81545 80% of billed 80% of billed N/A81401 80% of billed 80% of billed N/A 81551 80% of billed 80% of billed N/A81402 80% of billed 80% of billed N/A 81595 80% of billed 80% of billed N/A81403 80% of billed 80% of billed N/A 81599 80% of billed 80% of billed N/A81404 80% of billed 80% of billed N/A 82009 80% of billed 80% of billed N/A81405 80% of billed 80% of billed N/A 82010 80% of billed 80% of billed N/A81406 80% of billed 80% of billed N/A 82013 80% of billed 80% of billed N/A81407 80% of billed 80% of billed N/A 82016 80% of billed 80% of billed N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 61 of 84

Page 62: Appendix B for Administrative Order No. 18-053 Physician ...Appendix B for Administrative Order No. 18-053 Physician Fee Schedule Effective April 1, 2018 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

82017 80% of billed 80% of billed N/A 82382 80% of billed 80% of billed N/A82024 80% of billed 80% of billed N/A 82383 80% of billed 80% of billed N/A82030 80% of billed 80% of billed N/A 82384 80% of billed 80% of billed N/A82040 80% of billed 80% of billed N/A 82387 80% of billed 80% of billed N/A82042 80% of billed 80% of billed N/A 82390 80% of billed 80% of billed N/A82043 80% of billed 80% of billed N/A 82397 80% of billed 80% of billed N/A82044 80% of billed 80% of billed N/A 82415 80% of billed 80% of billed N/A82045 80% of billed 80% of billed N/A 82435 80% of billed 80% of billed N/A82075 80% of billed 80% of billed N/A 82436 80% of billed 80% of billed N/A82085 80% of billed 80% of billed N/A 82438 80% of billed 80% of billed N/A82088 80% of billed 80% of billed N/A 82441 80% of billed 80% of billed N/A82103 80% of billed 80% of billed N/A 82465 80% of billed 80% of billed N/A82104 80% of billed 80% of billed N/A 82480 80% of billed 80% of billed N/A82105 80% of billed 80% of billed N/A 82482 80% of billed 80% of billed N/A82106 80% of billed 80% of billed N/A 82485 80% of billed 80% of billed N/A82107 80% of billed 80% of billed N/A 82495 80% of billed 80% of billed N/A82108 80% of billed 80% of billed N/A 82507 80% of billed 80% of billed N/A82120 80% of billed 80% of billed N/A 82523 80% of billed 80% of billed N/A82127 80% of billed 80% of billed N/A 82525 80% of billed 80% of billed N/A82128 80% of billed 80% of billed N/A 82528 80% of billed 80% of billed N/A82131 80% of billed 80% of billed N/A 82530 80% of billed 80% of billed N/A82135 80% of billed 80% of billed N/A 82533 80% of billed 80% of billed N/A82136 80% of billed 80% of billed N/A 82540 80% of billed 80% of billed N/A82139 80% of billed 80% of billed N/A 82542 80% of billed 80% of billed N/A82140 80% of billed 80% of billed N/A 82550 80% of billed 80% of billed N/A82143 80% of billed 80% of billed N/A 82552 80% of billed 80% of billed N/A82150 80% of billed 80% of billed N/A 82553 80% of billed 80% of billed N/A82154 80% of billed 80% of billed N/A 82554 80% of billed 80% of billed N/A82157 80% of billed 80% of billed N/A 82565 80% of billed 80% of billed N/A82160 80% of billed 80% of billed N/A 82570 $19.57 $19.57 N/A82163 80% of billed 80% of billed N/A 82575 80% of billed 80% of billed N/A82164 80% of billed 80% of billed N/A 82585 80% of billed 80% of billed N/A82172 80% of billed 80% of billed N/A 82595 80% of billed 80% of billed N/A82175 80% of billed 80% of billed N/A 82600 80% of billed 80% of billed N/A82180 80% of billed 80% of billed N/A 82607 80% of billed 80% of billed N/A82190 80% of billed 80% of billed N/A 82608 80% of billed 80% of billed N/A82232 80% of billed 80% of billed N/A 82610 80% of billed 80% of billed N/A82239 80% of billed 80% of billed N/A 82615 80% of billed 80% of billed N/A82240 80% of billed 80% of billed N/A 82626 80% of billed 80% of billed N/A82247 80% of billed 80% of billed N/A 82627 80% of billed 80% of billed N/A82248 80% of billed 80% of billed N/A 82633 80% of billed 80% of billed N/A82252 80% of billed 80% of billed N/A 82634 80% of billed 80% of billed N/A82261 80% of billed 80% of billed N/A 82638 80% of billed 80% of billed N/A82270 80% of billed 80% of billed N/A 82652 80% of billed 80% of billed N/A82271 80% of billed 80% of billed N/A 82656 80% of billed 80% of billed N/A82272 80% of billed 80% of billed N/A 82657 80% of billed 80% of billed N/A82274 80% of billed 80% of billed N/A 82658 80% of billed 80% of billed N/A82286 80% of billed 80% of billed N/A 82664 80% of billed 80% of billed N/A82300 80% of billed 80% of billed N/A 82668 80% of billed 80% of billed N/A82306 80% of billed 80% of billed N/A 82670 80% of billed 80% of billed N/A82308 80% of billed 80% of billed N/A 82671 80% of billed 80% of billed N/A82310 80% of billed 80% of billed N/A 82672 80% of billed 80% of billed N/A82330 80% of billed 80% of billed N/A 82677 80% of billed 80% of billed N/A82331 80% of billed 80% of billed N/A 82679 80% of billed 80% of billed N/A82340 80% of billed 80% of billed N/A 82693 80% of billed 80% of billed N/A82355 80% of billed 80% of billed N/A 82696 80% of billed 80% of billed N/A82360 80% of billed 80% of billed N/A 82705 80% of billed 80% of billed N/A82365 80% of billed 80% of billed N/A 82710 80% of billed 80% of billed N/A82370 80% of billed 80% of billed N/A 82715 80% of billed 80% of billed N/A82373 80% of billed 80% of billed N/A 82725 80% of billed 80% of billed N/A82374 80% of billed 80% of billed N/A 82726 80% of billed 80% of billed N/A82375 80% of billed 80% of billed N/A 82728 80% of billed 80% of billed N/A82376 80% of billed 80% of billed N/A 82731 80% of billed 80% of billed N/A82378 80% of billed 80% of billed N/A 82735 80% of billed 80% of billed N/A82379 80% of billed 80% of billed N/A 82746 80% of billed 80% of billed N/A82380 80% of billed 80% of billed N/A 82747 80% of billed 80% of billed N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 62 of 84

Page 63: Appendix B for Administrative Order No. 18-053 Physician ...Appendix B for Administrative Order No. 18-053 Physician Fee Schedule Effective April 1, 2018 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

82757 80% of billed 80% of billed N/A 83497 80% of billed 80% of billed N/A82759 80% of billed 80% of billed N/A 83498 80% of billed 80% of billed N/A82760 80% of billed 80% of billed N/A 83500 80% of billed 80% of billed N/A82775 80% of billed 80% of billed N/A 83505 80% of billed 80% of billed N/A82776 80% of billed 80% of billed N/A 83516 80% of billed 80% of billed N/A82777 80% of billed 80% of billed N/A 83518 80% of billed 80% of billed N/A82784 80% of billed 80% of billed N/A 83519 80% of billed 80% of billed N/A82785 80% of billed 80% of billed N/A 83520 80% of billed 80% of billed N/A82787 80% of billed 80% of billed N/A 83525 80% of billed 80% of billed N/A82800 80% of billed 80% of billed N/A 83527 80% of billed 80% of billed N/A82803 80% of billed 80% of billed N/A 83528 80% of billed 80% of billed N/A82805 80% of billed 80% of billed N/A 83540 80% of billed 80% of billed N/A82810 80% of billed 80% of billed N/A 83550 80% of billed 80% of billed N/A82820 80% of billed 80% of billed N/A 83570 80% of billed 80% of billed N/A82930 80% of billed 80% of billed N/A 83582 80% of billed 80% of billed N/A82938 80% of billed 80% of billed N/A 83586 80% of billed 80% of billed N/A82941 80% of billed 80% of billed N/A 83593 80% of billed 80% of billed N/A82943 80% of billed 80% of billed N/A 83605 80% of billed 80% of billed N/A82945 80% of billed 80% of billed N/A 83615 80% of billed 80% of billed N/A82946 80% of billed 80% of billed N/A 83625 80% of billed 80% of billed N/A82947 80% of billed 80% of billed N/A 83630 80% of billed 80% of billed N/A82948 80% of billed 80% of billed N/A 83631 80% of billed 80% of billed N/A82950 80% of billed 80% of billed N/A 83632 80% of billed 80% of billed N/A82951 80% of billed 80% of billed N/A 83633 80% of billed 80% of billed N/A82952 80% of billed 80% of billed N/A 83655 80% of billed 80% of billed N/A82955 80% of billed 80% of billed N/A 83661 80% of billed 80% of billed N/A82960 80% of billed 80% of billed N/A 83662 80% of billed 80% of billed N/A82962 80% of billed 80% of billed N/A 83663 80% of billed 80% of billed N/A82963 80% of billed 80% of billed N/A 83664 80% of billed 80% of billed N/A82965 80% of billed 80% of billed N/A 83670 80% of billed 80% of billed N/A82977 80% of billed 80% of billed N/A 83690 80% of billed 80% of billed N/A82978 80% of billed 80% of billed N/A 83695 80% of billed 80% of billed N/A82979 80% of billed 80% of billed N/A 83698 80% of billed 80% of billed N/A82985 80% of billed 80% of billed N/A 83700 80% of billed 80% of billed N/A83001 80% of billed 80% of billed N/A 83701 80% of billed 80% of billed N/A83002 80% of billed 80% of billed N/A 83704 80% of billed 80% of billed N/A83003 80% of billed 80% of billed N/A 83718 80% of billed 80% of billed N/A83006 80% of billed 80% of billed N/A 83719 80% of billed 80% of billed N/A83009 80% of billed 80% of billed N/A 83721 80% of billed 80% of billed N/A83010 80% of billed 80% of billed N/A 83727 80% of billed 80% of billed N/A83012 80% of billed 80% of billed N/A 83735 80% of billed 80% of billed N/A83013 80% of billed 80% of billed N/A 83775 80% of billed 80% of billed N/A83014 80% of billed 80% of billed N/A 83785 80% of billed 80% of billed N/A83015 80% of billed 80% of billed N/A 83789 80% of billed 80% of billed N/A83018 80% of billed 80% of billed N/A 83825 80% of billed 80% of billed N/A83020 80% of billed 80% of billed N/A 83835 80% of billed 80% of billed N/A83020 26 $29.92 $29.92 N/A 83857 80% of billed 80% of billed N/A83021 80% of billed 80% of billed N/A 83861 80% of billed 80% of billed N/A83026 80% of billed 80% of billed N/A 83864 80% of billed 80% of billed N/A83030 80% of billed 80% of billed N/A 83872 80% of billed 80% of billed N/A83033 80% of billed 80% of billed N/A 83873 80% of billed 80% of billed N/A83036 80% of billed 80% of billed N/A 83874 80% of billed 80% of billed N/A83037 80% of billed 80% of billed N/A 83876 80% of billed 80% of billed N/A83045 80% of billed 80% of billed N/A 83880 80% of billed 80% of billed N/A83050 80% of billed 80% of billed N/A 83883 80% of billed 80% of billed N/A83051 80% of billed 80% of billed N/A 83885 80% of billed 80% of billed N/A83060 80% of billed 80% of billed N/A 83915 80% of billed 80% of billed N/A83065 80% of billed 80% of billed N/A 83916 80% of billed 80% of billed N/A83068 80% of billed 80% of billed N/A 83918 80% of billed 80% of billed N/A83069 80% of billed 80% of billed N/A 83919 80% of billed 80% of billed N/A83070 80% of billed 80% of billed N/A 83921 80% of billed 80% of billed N/A83080 80% of billed 80% of billed N/A 83930 80% of billed 80% of billed N/A83088 80% of billed 80% of billed N/A 83935 80% of billed 80% of billed N/A83090 80% of billed 80% of billed N/A 83937 80% of billed 80% of billed N/A83150 80% of billed 80% of billed N/A 83945 80% of billed 80% of billed N/A83491 80% of billed 80% of billed N/A 83950 80% of billed 80% of billed N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 63 of 84

Page 64: Appendix B for Administrative Order No. 18-053 Physician ...Appendix B for Administrative Order No. 18-053 Physician Fee Schedule Effective April 1, 2018 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

83951 80% of billed 80% of billed N/A 84270 80% of billed 80% of billed N/A83970 80% of billed 80% of billed N/A 84275 80% of billed 80% of billed N/A83986 80% of billed 80% of billed N/A 84285 80% of billed 80% of billed N/A83987 80% of billed 80% of billed N/A 84295 80% of billed 80% of billed N/A83992 $37.08 $37.08 N/A 84300 80% of billed 80% of billed N/A83993 80% of billed 80% of billed N/A 84302 80% of billed 80% of billed N/A84030 80% of billed 80% of billed N/A 84305 80% of billed 80% of billed N/A84035 80% of billed 80% of billed N/A 84307 80% of billed 80% of billed N/A84060 80% of billed 80% of billed N/A 84311 80% of billed 80% of billed N/A84066 80% of billed 80% of billed N/A 84315 80% of billed 80% of billed N/A84075 80% of billed 80% of billed N/A 84375 80% of billed 80% of billed N/A84078 80% of billed 80% of billed N/A 84376 80% of billed 80% of billed N/A84080 80% of billed 80% of billed N/A 84377 80% of billed 80% of billed N/A84081 80% of billed 80% of billed N/A 84378 80% of billed 80% of billed N/A84085 80% of billed 80% of billed N/A 84379 80% of billed 80% of billed N/A84087 80% of billed 80% of billed N/A 84392 80% of billed 80% of billed N/A84100 80% of billed 80% of billed N/A 84402 80% of billed 80% of billed N/A84105 80% of billed 80% of billed N/A 84403 80% of billed 80% of billed N/A84106 80% of billed 80% of billed N/A 84410 80% of billed 80% of billed N/A84110 80% of billed 80% of billed N/A 84425 80% of billed 80% of billed N/A84112 80% of billed 80% of billed N/A 84430 80% of billed 80% of billed N/A84119 80% of billed 80% of billed N/A 84431 80% of billed 80% of billed N/A84120 80% of billed 80% of billed N/A 84432 80% of billed 80% of billed N/A84126 80% of billed 80% of billed N/A 84436 80% of billed 80% of billed N/A84132 80% of billed 80% of billed N/A 84437 80% of billed 80% of billed N/A84133 80% of billed 80% of billed N/A 84439 80% of billed 80% of billed N/A84134 80% of billed 80% of billed N/A 84442 80% of billed 80% of billed N/A84135 80% of billed 80% of billed N/A 84443 80% of billed 80% of billed N/A84138 80% of billed 80% of billed N/A 84445 80% of billed 80% of billed N/A84140 80% of billed 80% of billed N/A 84446 80% of billed 80% of billed N/A84143 80% of billed 80% of billed N/A 84449 80% of billed 80% of billed N/A84144 80% of billed 80% of billed N/A 84450 80% of billed 80% of billed N/A84145 80% of billed 80% of billed N/A 84460 80% of billed 80% of billed N/A84146 80% of billed 80% of billed N/A 84466 80% of billed 80% of billed N/A84150 80% of billed 80% of billed N/A 84478 80% of billed 80% of billed N/A84152 80% of billed 80% of billed N/A 84479 80% of billed 80% of billed N/A84153 80% of billed 80% of billed N/A 84480 80% of billed 80% of billed N/A84154 80% of billed 80% of billed N/A 84481 80% of billed 80% of billed N/A84155 80% of billed 80% of billed N/A 84482 80% of billed 80% of billed N/A84156 80% of billed 80% of billed N/A 84484 80% of billed 80% of billed N/A84157 80% of billed 80% of billed N/A 84485 80% of billed 80% of billed N/A84160 80% of billed 80% of billed N/A 84488 80% of billed 80% of billed N/A84163 80% of billed 80% of billed N/A 84490 80% of billed 80% of billed N/A84165 80% of billed 80% of billed N/A 84510 80% of billed 80% of billed N/A84165 26 $29.92 $29.92 N/A 84512 80% of billed 80% of billed N/A84166 80% of billed 80% of billed N/A 84520 80% of billed 80% of billed N/A84166 26 $29.92 $29.92 N/A 84525 80% of billed 80% of billed N/A84181 80% of billed 80% of billed N/A 84540 80% of billed 80% of billed N/A84181 26 $29.92 $29.92 N/A 84545 80% of billed 80% of billed N/A84182 80% of billed 80% of billed N/A 84550 80% of billed 80% of billed N/A84182 26 $29.92 $29.92 N/A 84560 80% of billed 80% of billed N/A84202 80% of billed 80% of billed N/A 84577 80% of billed 80% of billed N/A84203 80% of billed 80% of billed N/A 84578 80% of billed 80% of billed N/A84206 80% of billed 80% of billed N/A 84580 80% of billed 80% of billed N/A84207 80% of billed 80% of billed N/A 84583 80% of billed 80% of billed N/A84210 80% of billed 80% of billed N/A 84585 80% of billed 80% of billed N/A84220 80% of billed 80% of billed N/A 84586 80% of billed 80% of billed N/A84228 80% of billed 80% of billed N/A 84588 80% of billed 80% of billed N/A84233 80% of billed 80% of billed N/A 84590 80% of billed 80% of billed N/A84234 80% of billed 80% of billed N/A 84591 80% of billed 80% of billed N/A84235 80% of billed 80% of billed N/A 84597 80% of billed 80% of billed N/A84238 80% of billed 80% of billed N/A 84600 80% of billed 80% of billed N/A84244 80% of billed 80% of billed N/A 84620 80% of billed 80% of billed N/A84252 80% of billed 80% of billed N/A 84630 80% of billed 80% of billed N/A84255 80% of billed 80% of billed N/A 84681 80% of billed 80% of billed N/A84260 80% of billed 80% of billed N/A 84702 80% of billed 80% of billed N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 64 of 84

Page 65: Appendix B for Administrative Order No. 18-053 Physician ...Appendix B for Administrative Order No. 18-053 Physician Fee Schedule Effective April 1, 2018 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

84703 80% of billed 80% of billed N/A 85396 $33.95 $33.95 N/A84704 80% of billed 80% of billed N/A 85397 80% of billed 80% of billed N/A84830 80% of billed 80% of billed N/A 85400 80% of billed 80% of billed N/A84999 80% of billed 80% of billed N/A 85410 80% of billed 80% of billed N/A85002 80% of billed 80% of billed N/A 85415 80% of billed 80% of billed N/A85004 80% of billed 80% of billed N/A 85420 80% of billed 80% of billed N/A85007 80% of billed 80% of billed N/A 85421 80% of billed 80% of billed N/A85008 80% of billed 80% of billed N/A 85441 80% of billed 80% of billed N/A85009 80% of billed 80% of billed N/A 85445 80% of billed 80% of billed N/A85013 80% of billed 80% of billed N/A 85460 80% of billed 80% of billed N/A85014 80% of billed 80% of billed N/A 85461 80% of billed 80% of billed N/A85018 80% of billed 80% of billed N/A 85475 80% of billed 80% of billed N/A85025 80% of billed 80% of billed N/A 85520 80% of billed 80% of billed N/A85027 80% of billed 80% of billed N/A 85525 80% of billed 80% of billed N/A85032 80% of billed 80% of billed N/A 85530 80% of billed 80% of billed N/A85041 80% of billed 80% of billed N/A 85536 80% of billed 80% of billed N/A85044 80% of billed 80% of billed N/A 85540 80% of billed 80% of billed N/A85045 80% of billed 80% of billed N/A 85547 80% of billed 80% of billed N/A85046 80% of billed 80% of billed N/A 85549 80% of billed 80% of billed N/A85048 80% of billed 80% of billed N/A 85555 80% of billed 80% of billed N/A85049 80% of billed 80% of billed N/A 85557 80% of billed 80% of billed N/A85055 80% of billed 80% of billed N/A 85576 80% of billed 80% of billed N/A85060 $40.85 $40.85 N/A 85576 26 $29.92 $29.92 N/A85097 $149.60 $82.28 N/A 85597 80% of billed 80% of billed N/A85130 80% of billed 80% of billed N/A 85598 80% of billed 80% of billed N/A85170 80% of billed 80% of billed N/A 85610 80% of billed 80% of billed N/A85175 80% of billed 80% of billed N/A 85611 80% of billed 80% of billed N/A85210 80% of billed 80% of billed N/A 85612 80% of billed 80% of billed N/A85220 80% of billed 80% of billed N/A 85613 80% of billed 80% of billed N/A85230 80% of billed 80% of billed N/A 85635 80% of billed 80% of billed N/A85240 80% of billed 80% of billed N/A 85651 80% of billed 80% of billed N/A85244 80% of billed 80% of billed N/A 85652 80% of billed 80% of billed N/A85245 80% of billed 80% of billed N/A 85660 80% of billed 80% of billed N/A85246 80% of billed 80% of billed N/A 85670 80% of billed 80% of billed N/A85247 80% of billed 80% of billed N/A 85675 80% of billed 80% of billed N/A85250 80% of billed 80% of billed N/A 85705 80% of billed 80% of billed N/A85260 80% of billed 80% of billed N/A 85730 80% of billed 80% of billed N/A85270 80% of billed 80% of billed N/A 85732 80% of billed 80% of billed N/A85280 80% of billed 80% of billed N/A 85810 80% of billed 80% of billed N/A85290 80% of billed 80% of billed N/A 85999 80% of billed 80% of billed N/A85291 80% of billed 80% of billed N/A 86000 80% of billed 80% of billed N/A85292 80% of billed 80% of billed N/A 86001 80% of billed 80% of billed N/A85293 80% of billed 80% of billed N/A 86003 80% of billed 80% of billed N/A85300 80% of billed 80% of billed N/A 86005 80% of billed 80% of billed N/A85301 80% of billed 80% of billed N/A 86008 80% of billed 80% of billed N/A85302 80% of billed 80% of billed N/A 86021 80% of billed 80% of billed N/A85303 80% of billed 80% of billed N/A 86022 80% of billed 80% of billed N/A85305 80% of billed 80% of billed N/A 86023 80% of billed 80% of billed N/A85306 80% of billed 80% of billed N/A 86038 80% of billed 80% of billed N/A85307 80% of billed 80% of billed N/A 86039 80% of billed 80% of billed N/A85335 80% of billed 80% of billed N/A 86060 80% of billed 80% of billed N/A85337 80% of billed 80% of billed N/A 86063 80% of billed 80% of billed N/A85345 80% of billed 80% of billed N/A 86077 $92.06 $85.73 N/A85347 80% of billed 80% of billed N/A 86078 $92.06 $85.73 N/A85348 80% of billed 80% of billed N/A 86079 $91.49 $85.16 N/A85360 80% of billed 80% of billed N/A 86140 80% of billed 80% of billed N/A85362 80% of billed 80% of billed N/A 86141 80% of billed 80% of billed N/A85366 80% of billed 80% of billed N/A 86146 80% of billed 80% of billed N/A85370 80% of billed 80% of billed N/A 86147 80% of billed 80% of billed N/A85378 80% of billed 80% of billed N/A 86148 80% of billed 80% of billed N/A85379 80% of billed 80% of billed N/A 86152 80% of billed 80% of billed N/A85380 80% of billed 80% of billed N/A 86153 26 $56.39 $56.39 N/A85384 80% of billed 80% of billed N/A 86155 80% of billed 80% of billed N/A85385 80% of billed 80% of billed N/A 86156 80% of billed 80% of billed N/A85390 80% of billed 80% of billed N/A 86157 80% of billed 80% of billed N/A85390 26 $29.92 $29.92 N/A 86160 80% of billed 80% of billed N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 65 of 84

Page 66: Appendix B for Administrative Order No. 18-053 Physician ...Appendix B for Administrative Order No. 18-053 Physician Fee Schedule Effective April 1, 2018 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

86161 80% of billed 80% of billed N/A 86510 $10.36 $10.36 N/A86162 80% of billed 80% of billed N/A 86580 $13.23 $13.23 N/A86171 80% of billed 80% of billed N/A 86590 80% of billed 80% of billed N/A86200 80% of billed 80% of billed N/A 86592 80% of billed 80% of billed N/A86215 80% of billed 80% of billed N/A 86593 80% of billed 80% of billed N/A86225 80% of billed 80% of billed N/A 86602 80% of billed 80% of billed N/A86226 80% of billed 80% of billed N/A 86603 80% of billed 80% of billed N/A86235 80% of billed 80% of billed N/A 86606 80% of billed 80% of billed N/A86255 80% of billed 80% of billed N/A 86609 80% of billed 80% of billed N/A86255 26 $29.92 $29.92 N/A 86611 80% of billed 80% of billed N/A86256 80% of billed 80% of billed N/A 86612 80% of billed 80% of billed N/A86256 26 $29.92 $29.92 N/A 86615 80% of billed 80% of billed N/A86277 80% of billed 80% of billed N/A 86617 80% of billed 80% of billed N/A86280 80% of billed 80% of billed N/A 86618 80% of billed 80% of billed N/A86294 80% of billed 80% of billed N/A 86619 80% of billed 80% of billed N/A86300 80% of billed 80% of billed N/A 86622 80% of billed 80% of billed N/A86301 80% of billed 80% of billed N/A 86625 80% of billed 80% of billed N/A86304 80% of billed 80% of billed N/A 86628 80% of billed 80% of billed N/A86305 80% of billed 80% of billed N/A 86631 80% of billed 80% of billed N/A86308 80% of billed 80% of billed N/A 86632 80% of billed 80% of billed N/A86309 80% of billed 80% of billed N/A 86635 80% of billed 80% of billed N/A86310 80% of billed 80% of billed N/A 86638 80% of billed 80% of billed N/A86316 80% of billed 80% of billed N/A 86641 80% of billed 80% of billed N/A86317 80% of billed 80% of billed N/A 86644 80% of billed 80% of billed N/A86318 80% of billed 80% of billed N/A 86645 80% of billed 80% of billed N/A86320 80% of billed 80% of billed N/A 86648 80% of billed 80% of billed N/A86320 26 $29.92 $29.92 N/A 86651 80% of billed 80% of billed N/A86325 80% of billed 80% of billed N/A 86652 80% of billed 80% of billed N/A86325 26 $29.92 $29.92 N/A 86653 80% of billed 80% of billed N/A86327 80% of billed 80% of billed N/A 86654 80% of billed 80% of billed N/A86327 26 $33.95 $33.95 N/A 86658 80% of billed 80% of billed N/A86329 80% of billed 80% of billed N/A 86663 80% of billed 80% of billed N/A86331 80% of billed 80% of billed N/A 86664 80% of billed 80% of billed N/A86332 80% of billed 80% of billed N/A 86665 80% of billed 80% of billed N/A86334 80% of billed 80% of billed N/A 86666 80% of billed 80% of billed N/A86334 26 $29.92 $29.92 N/A 86668 80% of billed 80% of billed N/A86335 80% of billed 80% of billed N/A 86671 80% of billed 80% of billed N/A86335 26 $29.92 $29.92 N/A 86674 80% of billed 80% of billed N/A86336 80% of billed 80% of billed N/A 86677 80% of billed 80% of billed N/A86337 80% of billed 80% of billed N/A 86682 80% of billed 80% of billed N/A86340 80% of billed 80% of billed N/A 86684 80% of billed 80% of billed N/A86341 80% of billed 80% of billed N/A 86687 80% of billed 80% of billed N/A86343 80% of billed 80% of billed N/A 86688 80% of billed 80% of billed N/A86344 80% of billed 80% of billed N/A 86689 80% of billed 80% of billed N/A86352 80% of billed 80% of billed N/A 86692 80% of billed 80% of billed N/A86353 80% of billed 80% of billed N/A 86694 80% of billed 80% of billed N/A86355 80% of billed 80% of billed N/A 86695 80% of billed 80% of billed N/A86356 80% of billed 80% of billed N/A 86696 80% of billed 80% of billed N/A86357 80% of billed 80% of billed N/A 86698 80% of billed 80% of billed N/A86359 80% of billed 80% of billed N/A 86701 80% of billed 80% of billed N/A86360 80% of billed 80% of billed N/A 86702 80% of billed 80% of billed N/A86361 80% of billed 80% of billed N/A 86703 80% of billed 80% of billed N/A86367 80% of billed 80% of billed N/A 86704 80% of billed 80% of billed N/A86376 80% of billed 80% of billed N/A 86705 80% of billed 80% of billed N/A86382 80% of billed 80% of billed N/A 86706 80% of billed 80% of billed N/A86384 80% of billed 80% of billed N/A 86707 80% of billed 80% of billed N/A86386 80% of billed 80% of billed N/A 86708 80% of billed 80% of billed N/A86403 80% of billed 80% of billed N/A 86709 80% of billed 80% of billed N/A86406 80% of billed 80% of billed N/A 86710 80% of billed 80% of billed N/A86430 80% of billed 80% of billed N/A 86711 80% of billed 80% of billed N/A86431 80% of billed 80% of billed N/A 86713 80% of billed 80% of billed N/A86480 80% of billed 80% of billed N/A 86717 80% of billed 80% of billed N/A86481 80% of billed 80% of billed N/A 86720 80% of billed 80% of billed N/A86485 80% of billed 80% of billed N/A 86723 80% of billed 80% of billed N/A86486 $8.06 $8.06 N/A 86727 80% of billed 80% of billed N/A86490 $146.15 $146.15 N/A 86732 80% of billed 80% of billed N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 66 of 84

Page 67: Appendix B for Administrative Order No. 18-053 Physician ...Appendix B for Administrative Order No. 18-053 Physician Fee Schedule Effective April 1, 2018 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

86735 80% of billed 80% of billed N/A 86922 80% of billed 80% of billed N/A86738 80% of billed 80% of billed N/A 86923 80% of billed 80% of billed N/A86741 80% of billed 80% of billed N/A 86927 80% of billed 80% of billed N/A86744 80% of billed 80% of billed N/A 86930 80% of billed 80% of billed N/A86747 80% of billed 80% of billed N/A 86931 80% of billed 80% of billed N/A86750 80% of billed 80% of billed N/A 86932 80% of billed 80% of billed N/A86753 80% of billed 80% of billed N/A 86940 80% of billed 80% of billed N/A86756 80% of billed 80% of billed N/A 86941 80% of billed 80% of billed N/A86757 80% of billed 80% of billed N/A 86945 80% of billed 80% of billed N/A86759 80% of billed 80% of billed N/A 86950 80% of billed 80% of billed N/A86762 80% of billed 80% of billed N/A 86960 80% of billed 80% of billed N/A86765 80% of billed 80% of billed N/A 86965 80% of billed 80% of billed N/A86768 80% of billed 80% of billed N/A 86970 80% of billed 80% of billed N/A86771 80% of billed 80% of billed N/A 86971 80% of billed 80% of billed N/A86774 80% of billed 80% of billed N/A 86972 80% of billed 80% of billed N/A86777 80% of billed 80% of billed N/A 86975 80% of billed 80% of billed N/A86778 80% of billed 80% of billed N/A 86976 80% of billed 80% of billed N/A86780 80% of billed 80% of billed N/A 86977 80% of billed 80% of billed N/A86784 80% of billed 80% of billed N/A 86978 80% of billed 80% of billed N/A86787 80% of billed 80% of billed N/A 86985 80% of billed 80% of billed N/A86788 80% of billed 80% of billed N/A 86999 80% of billed 80% of billed N/A86789 80% of billed 80% of billed N/A 87003 80% of billed 80% of billed N/A86790 80% of billed 80% of billed N/A 87015 80% of billed 80% of billed N/A86793 80% of billed 80% of billed N/A 87040 80% of billed 80% of billed N/A86794 80% of billed 80% of billed N/A 87045 80% of billed 80% of billed N/A86800 80% of billed 80% of billed N/A 87046 80% of billed 80% of billed N/A86803 80% of billed 80% of billed N/A 87070 80% of billed 80% of billed N/A86804 80% of billed 80% of billed N/A 87071 80% of billed 80% of billed N/A86805 80% of billed 80% of billed N/A 87073 80% of billed 80% of billed N/A86806 80% of billed 80% of billed N/A 87075 80% of billed 80% of billed N/A86807 80% of billed 80% of billed N/A 87076 80% of billed 80% of billed N/A86808 80% of billed 80% of billed N/A 87077 80% of billed 80% of billed N/A86812 80% of billed 80% of billed N/A 87081 80% of billed 80% of billed N/A86813 80% of billed 80% of billed N/A 87084 80% of billed 80% of billed N/A86816 80% of billed 80% of billed N/A 87086 80% of billed 80% of billed N/A86817 80% of billed 80% of billed N/A 87088 80% of billed 80% of billed N/A86821 80% of billed 80% of billed N/A 87101 80% of billed 80% of billed N/A86825 80% of billed 80% of billed N/A 87102 80% of billed 80% of billed N/A86826 80% of billed 80% of billed N/A 87103 80% of billed 80% of billed N/A86828 80% of billed 80% of billed N/A 87106 80% of billed 80% of billed N/A86829 80% of billed 80% of billed N/A 87107 80% of billed 80% of billed N/A86830 80% of billed 80% of billed N/A 87109 80% of billed 80% of billed N/A86831 80% of billed 80% of billed N/A 87110 80% of billed 80% of billed N/A86832 80% of billed 80% of billed N/A 87116 80% of billed 80% of billed N/A86833 80% of billed 80% of billed N/A 87118 80% of billed 80% of billed N/A86834 80% of billed 80% of billed N/A 87140 80% of billed 80% of billed N/A86835 80% of billed 80% of billed N/A 87143 80% of billed 80% of billed N/A86849 80% of billed 80% of billed N/A 87147 80% of billed 80% of billed N/A86850 80% of billed 80% of billed N/A 87149 80% of billed 80% of billed N/A86860 80% of billed 80% of billed N/A 87150 80% of billed 80% of billed N/A86870 80% of billed 80% of billed N/A 87152 80% of billed 80% of billed N/A86880 80% of billed 80% of billed N/A 87153 80% of billed 80% of billed N/A86885 80% of billed 80% of billed N/A 87158 80% of billed 80% of billed N/A86886 80% of billed 80% of billed N/A 87164 80% of billed 80% of billed N/A86890 80% of billed 80% of billed N/A 87164 26 $29.92 $29.92 N/A86891 80% of billed 80% of billed N/A 87166 80% of billed 80% of billed N/A86900 80% of billed 80% of billed N/A 87168 80% of billed 80% of billed N/A86901 80% of billed 80% of billed N/A 87169 80% of billed 80% of billed N/A86902 80% of billed 80% of billed N/A 87172 80% of billed 80% of billed N/A86904 80% of billed 80% of billed N/A 87176 80% of billed 80% of billed N/A86905 80% of billed 80% of billed N/A 87177 80% of billed 80% of billed N/A86906 80% of billed 80% of billed N/A 87181 80% of billed 80% of billed N/A86910 80% of billed 80% of billed N/A 87184 80% of billed 80% of billed N/A86911 80% of billed 80% of billed N/A 87185 80% of billed 80% of billed N/A86920 80% of billed 80% of billed N/A 87186 80% of billed 80% of billed N/A86921 80% of billed 80% of billed N/A 87187 80% of billed 80% of billed N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 67 of 84

Page 68: Appendix B for Administrative Order No. 18-053 Physician ...Appendix B for Administrative Order No. 18-053 Physician Fee Schedule Effective April 1, 2018 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

87188 80% of billed 80% of billed N/A 87472 80% of billed 80% of billed N/A87190 80% of billed 80% of billed N/A 87475 80% of billed 80% of billed N/A87197 80% of billed 80% of billed N/A 87476 80% of billed 80% of billed N/A87205 80% of billed 80% of billed N/A 87480 80% of billed 80% of billed N/A87206 80% of billed 80% of billed N/A 87481 80% of billed 80% of billed N/A87207 80% of billed 80% of billed N/A 87482 80% of billed 80% of billed N/A87207 26 $29.92 $29.92 N/A 87483 80% of billed 80% of billed N/A87209 80% of billed 80% of billed N/A 87485 80% of billed 80% of billed N/A87210 80% of billed 80% of billed N/A 87486 80% of billed 80% of billed N/A87220 80% of billed 80% of billed N/A 87487 80% of billed 80% of billed N/A87230 80% of billed 80% of billed N/A 87490 80% of billed 80% of billed N/A87250 80% of billed 80% of billed N/A 87491 80% of billed 80% of billed N/A87252 80% of billed 80% of billed N/A 87492 80% of billed 80% of billed N/A87253 80% of billed 80% of billed N/A 87493 80% of billed 80% of billed N/A87254 80% of billed 80% of billed N/A 87495 80% of billed 80% of billed N/A87255 80% of billed 80% of billed N/A 87496 80% of billed 80% of billed N/A87260 80% of billed 80% of billed N/A 87497 80% of billed 80% of billed N/A87265 80% of billed 80% of billed N/A 87498 80% of billed 80% of billed N/A87267 80% of billed 80% of billed N/A 87500 80% of billed 80% of billed N/A87269 80% of billed 80% of billed N/A 87501 80% of billed 80% of billed N/A87270 80% of billed 80% of billed N/A 87502 80% of billed 80% of billed N/A87271 80% of billed 80% of billed N/A 87503 80% of billed 80% of billed N/A87272 80% of billed 80% of billed N/A 87505 80% of billed 80% of billed N/A87273 80% of billed 80% of billed N/A 87506 80% of billed 80% of billed N/A87274 80% of billed 80% of billed N/A 87507 80% of billed 80% of billed N/A87275 80% of billed 80% of billed N/A 87510 80% of billed 80% of billed N/A87276 80% of billed 80% of billed N/A 87511 80% of billed 80% of billed N/A87278 80% of billed 80% of billed N/A 87512 80% of billed 80% of billed N/A87279 80% of billed 80% of billed N/A 87516 80% of billed 80% of billed N/A87280 80% of billed 80% of billed N/A 87517 80% of billed 80% of billed N/A87281 80% of billed 80% of billed N/A 87520 80% of billed 80% of billed N/A87283 80% of billed 80% of billed N/A 87521 80% of billed 80% of billed N/A87285 80% of billed 80% of billed N/A 87522 80% of billed 80% of billed N/A87290 80% of billed 80% of billed N/A 87525 80% of billed 80% of billed N/A87299 80% of billed 80% of billed N/A 87526 80% of billed 80% of billed N/A87300 80% of billed 80% of billed N/A 87527 80% of billed 80% of billed N/A87301 80% of billed 80% of billed N/A 87528 80% of billed 80% of billed N/A87305 80% of billed 80% of billed N/A 87529 80% of billed 80% of billed N/A87320 80% of billed 80% of billed N/A 87530 80% of billed 80% of billed N/A87324 80% of billed 80% of billed N/A 87531 80% of billed 80% of billed N/A87327 80% of billed 80% of billed N/A 87532 80% of billed 80% of billed N/A87328 80% of billed 80% of billed N/A 87533 80% of billed 80% of billed N/A87329 80% of billed 80% of billed N/A 87534 80% of billed 80% of billed N/A87332 80% of billed 80% of billed N/A 87535 80% of billed 80% of billed N/A87335 80% of billed 80% of billed N/A 87536 80% of billed 80% of billed N/A87336 80% of billed 80% of billed N/A 87537 80% of billed 80% of billed N/A87337 80% of billed 80% of billed N/A 87538 80% of billed 80% of billed N/A87338 80% of billed 80% of billed N/A 87539 80% of billed 80% of billed N/A87339 80% of billed 80% of billed N/A 87540 80% of billed 80% of billed N/A87340 80% of billed 80% of billed N/A 87541 80% of billed 80% of billed N/A87341 80% of billed 80% of billed N/A 87542 80% of billed 80% of billed N/A87350 80% of billed 80% of billed N/A 87550 80% of billed 80% of billed N/A87380 80% of billed 80% of billed N/A 87551 80% of billed 80% of billed N/A87385 80% of billed 80% of billed N/A 87552 80% of billed 80% of billed N/A87389 80% of billed 80% of billed N/A 87555 80% of billed 80% of billed N/A87390 80% of billed 80% of billed N/A 87556 80% of billed 80% of billed N/A87391 80% of billed 80% of billed N/A 87557 80% of billed 80% of billed N/A87400 80% of billed 80% of billed N/A 87560 80% of billed 80% of billed N/A87420 80% of billed 80% of billed N/A 87561 80% of billed 80% of billed N/A87425 80% of billed 80% of billed N/A 87562 80% of billed 80% of billed N/A87427 80% of billed 80% of billed N/A 87580 80% of billed 80% of billed N/A87430 80% of billed 80% of billed N/A 87581 80% of billed 80% of billed N/A87449 80% of billed 80% of billed N/A 87582 80% of billed 80% of billed N/A87450 80% of billed 80% of billed N/A 87590 80% of billed 80% of billed N/A87451 80% of billed 80% of billed N/A 87591 80% of billed 80% of billed N/A87471 80% of billed 80% of billed N/A 87592 80% of billed 80% of billed N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 68 of 84

Page 69: Appendix B for Administrative Order No. 18-053 Physician ...Appendix B for Administrative Order No. 18-053 Physician Fee Schedule Effective April 1, 2018 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

87623 80% of billed 80% of billed N/A 88108 26 $37.98 $37.98 N/A87624 80% of billed 80% of billed N/A 88112 $112.20 $112.20 N/A87625 80% of billed 80% of billed N/A 88112 TC $65.02 $65.02 N/A87631 80% of billed 80% of billed N/A 88112 26 $47.18 $47.18 N/A87632 80% of billed 80% of billed N/A 88120 $1,038.60 $1,038.60 N/A87633 80% of billed 80% of billed N/A 88120 TC $941.35 $941.35 N/A87634 80% of billed 80% of billed N/A 88120 26 $97.24 $97.24 N/A87640 80% of billed 80% of billed N/A 88121 $865.98 $865.98 N/A87641 80% of billed 80% of billed N/A 88121 TC $782.54 $782.54 N/A87650 80% of billed 80% of billed N/A 88121 26 $83.43 $83.43 N/A87651 80% of billed 80% of billed N/A 88125 $43.73 $43.73 N/A87652 80% of billed 80% of billed N/A 88125 TC $20.14 $20.14 N/A87653 80% of billed 80% of billed N/A 88125 26 $23.59 $23.59 N/A87660 80% of billed 80% of billed N/A 88130 80% of billed 80% of billed N/A87661 80% of billed 80% of billed N/A 88140 80% of billed 80% of billed N/A87662 80% of billed 80% of billed N/A 88141 $52.94 $52.94 N/A87797 80% of billed 80% of billed N/A 88142 80% of billed 80% of billed N/A87798 80% of billed 80% of billed N/A 88143 80% of billed 80% of billed N/A87799 80% of billed 80% of billed N/A 88147 80% of billed 80% of billed N/A87800 80% of billed 80% of billed N/A 88148 80% of billed 80% of billed N/A87801 80% of billed 80% of billed N/A 88150 80% of billed 80% of billed N/A87802 80% of billed 80% of billed N/A 88152 80% of billed 80% of billed N/A87803 80% of billed 80% of billed N/A 88153 80% of billed 80% of billed N/A87804 80% of billed 80% of billed N/A 88155 80% of billed 80% of billed N/A87806 80% of billed 80% of billed N/A 88160 $118.53 $118.53 N/A87807 80% of billed 80% of billed N/A 88160 TC $74.80 $74.80 N/A87808 80% of billed 80% of billed N/A 88160 26 $43.73 $43.73 N/A87809 80% of billed 80% of billed N/A 88161 $107.60 $107.60 N/A87810 80% of billed 80% of billed N/A 88161 TC $65.60 $65.60 N/A87850 80% of billed 80% of billed N/A 88161 26 $42.00 $42.00 N/A87880 80% of billed 80% of billed N/A 88162 $158.24 $158.24 N/A87899 80% of billed 80% of billed N/A 88162 TC $93.21 $93.21 N/A87900 80% of billed 80% of billed N/A 88162 26 $65.02 $65.02 N/A87901 80% of billed 80% of billed N/A 88164 80% of billed 80% of billed N/A87902 80% of billed 80% of billed N/A 88165 80% of billed 80% of billed N/A87903 80% of billed 80% of billed N/A 88166 80% of billed 80% of billed N/A87904 80% of billed 80% of billed N/A 88167 80% of billed 80% of billed N/A87905 80% of billed 80% of billed N/A 88172 $94.37 $94.37 N/A87906 80% of billed 80% of billed N/A 88172 TC $33.37 $33.37 N/A87910 80% of billed 80% of billed N/A 88172 26 $60.99 $60.99 N/A87912 80% of billed 80% of billed N/A 88173 $252.60 $252.60 N/A87999 80% of billed 80% of billed N/A 88173 TC $132.92 $132.92 N/A88000 80% of billed 80% of billed N/A 88173 26 $119.68 $119.68 N/A88005 80% of billed 80% of billed N/A 88174 80% of billed 80% of billed N/A88007 80% of billed 80% of billed N/A 88175 80% of billed 80% of billed N/A88012 80% of billed 80% of billed N/A 88177 $50.06 $50.06 ZZZ88014 80% of billed 80% of billed N/A 88177 TC $12.66 $12.66 ZZZ88016 80% of billed 80% of billed N/A 88177 26 $37.40 $37.40 ZZZ88020 80% of billed 80% of billed N/A 88182 $214.05 $214.05 N/A88025 80% of billed 80% of billed N/A 88182 TC $149.03 $149.03 N/A88027 80% of billed 80% of billed N/A 88182 26 $65.02 $65.02 N/A88028 80% of billed 80% of billed N/A 88184 $108.75 $108.75 N/A88029 80% of billed 80% of billed N/A 88185 $48.91 $48.91 ZZZ88036 80% of billed 80% of billed N/A 88187 $77.10 $77.10 N/A88037 80% of billed 80% of billed N/A 88188 $106.45 $106.45 N/A88040 80% of billed 80% of billed N/A 88189 $142.12 $142.12 N/A88045 80% of billed 80% of billed N/A 88199 80% of billed 80% of billed N/A88099 80% of billed 80% of billed N/A 88199 TC 80% of billed 80% of billed N/A88104 $118.53 $118.53 N/A 88199 26 80% of billed 80% of billed N/A88104 TC $70.77 $70.77 N/A 88230 80% of billed 80% of billed N/A88104 26 $47.76 $47.76 N/A 88233 80% of billed 80% of billed N/A88106 $105.30 $105.30 N/A 88235 80% of billed 80% of billed N/A88106 TC $72.50 $72.50 N/A 88237 80% of billed 80% of billed N/A88106 26 $32.80 $32.80 N/A 88239 80% of billed 80% of billed N/A88108 $99.54 $99.54 N/A 88240 80% of billed 80% of billed N/A88108 TC $61.57 $61.57 N/A 88241 80% of billed 80% of billed N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 69 of 84

Page 70: Appendix B for Administrative Order No. 18-053 Physician ...Appendix B for Administrative Order No. 18-053 Physician Fee Schedule Effective April 1, 2018 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

88245 80% of billed 80% of billed N/A 88333 TC $40.28 $40.28 N/A88248 80% of billed 80% of billed N/A 88333 26 $106.45 $106.45 N/A88249 80% of billed 80% of billed N/A 88334 $90.91 $90.91 ZZZ88261 80% of billed 80% of billed N/A 88334 TC $25.89 $25.89 ZZZ88262 80% of billed 80% of billed N/A 88334 26 $65.02 $65.02 ZZZ88263 80% of billed 80% of billed N/A 88341 $151.33 $151.33 ZZZ88264 80% of billed 80% of billed N/A 88341 TC $103.57 $103.57 ZZZ88267 80% of billed 80% of billed N/A 88341 26 $47.76 $47.76 ZZZ88269 80% of billed 80% of billed N/A 88342 $178.37 $178.37 N/A88271 80% of billed 80% of billed N/A 88342 TC $118.53 $118.53 N/A88272 80% of billed 80% of billed N/A 88342 26 $59.84 $59.84 N/A88273 80% of billed 80% of billed N/A 88344 $285.40 $285.40 N/A88274 80% of billed 80% of billed N/A 88344 TC $219.80 $219.80 N/A88275 80% of billed 80% of billed N/A 88344 26 $65.60 $65.60 N/A88280 80% of billed 80% of billed N/A 88346 $153.06 $153.06 N/A88283 80% of billed 80% of billed N/A 88346 TC $92.64 $92.64 N/A88285 80% of billed 80% of billed N/A 88346 26 $60.42 $60.42 N/A88289 80% of billed 80% of billed N/A 88348 $566.19 $566.19 N/A88291 $54.09 $54.09 N/A 88348 TC $438.45 $438.45 N/A88299 80% of billed 80% of billed N/A 88348 26 $127.74 $127.74 N/A88300 $27.04 $27.04 N/A 88350 $117.96 $117.96 ZZZ88300 TC $19.56 $19.56 N/A 88350 TC $69.62 $69.62 ZZZ88300 26 $7.48 $7.48 N/A 88350 26 $48.33 $48.33 ZZZ88302 $50.64 $50.64 N/A 88355 $214.62 $214.62 N/A88302 TC $38.55 $38.55 N/A 88355 TC $77.68 $77.68 N/A88302 26 $12.08 $12.08 N/A 88355 26 $136.95 $136.95 N/A88304 $66.75 $66.75 N/A 88356 $360.20 $360.20 N/A88304 TC $47.18 $47.18 N/A 88356 TC $153.06 $153.06 N/A88304 26 $19.56 $19.56 N/A 88356 26 $207.14 $207.14 N/A88305 $112.20 $112.20 N/A 88358 $154.78 $154.78 N/A88305 TC $48.33 $48.33 N/A 88358 TC $76.53 $76.53 N/A88305 26 $63.87 $63.87 N/A 88358 26 $78.25 $78.25 N/A88307 $431.55 $431.55 N/A 88360 $218.08 $218.08 N/A88307 TC $291.15 $291.15 N/A 88360 TC $143.27 $143.27 N/A88307 26 $140.40 $140.40 N/A 88360 26 $74.80 $74.80 N/A88309 $655.38 $655.38 N/A 88361 $237.06 $237.06 N/A88309 TC $406.23 $406.23 N/A 88361 TC $157.66 $157.66 N/A88309 26 $249.15 $249.15 N/A 88361 26 $79.41 $79.41 N/A88311 $36.25 $36.25 N/A 88362 $341.21 $341.21 N/A88311 TC $14.96 $14.96 N/A 88362 TC $155.93 $155.93 N/A88311 26 $21.29 $21.29 N/A 88362 26 $185.28 $185.28 N/A88312 $158.81 $158.81 N/A 88363 $39.13 $33.37 N/A88312 TC $113.93 $113.93 N/A 88364 $215.78 $215.78 ZZZ88312 26 $44.88 $44.88 N/A 88364 TC $157.08 $157.08 ZZZ88313 $115.08 $115.08 N/A 88364 26 $58.69 $58.69 ZZZ88313 TC $94.94 $94.94 N/A 88365 $293.45 $293.45 N/A88313 26 $20.14 $20.14 N/A 88365 TC $219.23 $219.23 N/A88314 $139.25 $139.25 N/A 88365 26 $74.23 $74.23 N/A88314 TC $101.27 $101.27 N/A 88366 $428.67 $428.67 N/A88314 26 $37.98 $37.98 N/A 88366 TC $323.95 $323.95 N/A88319 $143.85 $143.85 N/A 88366 26 $104.72 $104.72 N/A88319 TC $98.97 $98.97 N/A 88367 $174.92 $174.92 N/A88319 26 $44.88 $44.88 N/A 88367 TC $116.81 $116.81 N/A88321 $168.02 $140.97 N/A 88367 26 $58.12 $58.12 N/A88323 $199.66 $199.66 N/A 88368 $197.36 $197.36 N/A88323 TC $53.51 $53.51 N/A 88368 TC $127.74 $127.74 N/A88323 26 $146.15 $146.15 N/A 88368 26 $69.62 $69.62 N/A88325 $303.24 $251.45 N/A 88369 $178.37 $178.37 ZZZ88329 $85.16 $60.99 N/A 88369 TC $124.29 $124.29 ZZZ88331 $159.39 $159.39 N/A 88369 26 $54.09 $54.09 ZZZ88331 TC $52.94 $52.94 N/A 88371 80% of billed 80% of billed N/A88331 26 $106.45 $106.45 N/A 88371 26 $29.92 $29.92 N/A88332 $86.89 $86.89 N/A 88372 80% of billed 80% of billed N/A88332 TC $34.52 $34.52 N/A 88372 26 $29.92 $29.92 N/A88332 26 $52.36 $52.36 N/A 88373 $128.31 $128.31 ZZZ88333 $146.73 $146.73 N/A 88373 TC $82.28 $82.28 ZZZ

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 70 of 84

Page 71: Appendix B for Administrative Order No. 18-053 Physician ...Appendix B for Administrative Order No. 18-053 Physician Fee Schedule Effective April 1, 2018 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

88373 26 $46.03 $46.03 ZZZ 89335 80% of billed 80% of billed N/A88374 $561.59 $561.59 N/A 89337 80% of billed 80% of billed N/A88374 TC $487.94 $487.94 N/A 89342 80% of billed 80% of billed N/A88374 26 $73.65 $73.65 N/A 89343 80% of billed 80% of billed N/A88375 $83.43 $83.43 N/A 89344 80% of billed 80% of billed N/A88377 $667.46 $667.46 N/A 89346 80% of billed 80% of billed N/A88377 TC $560.44 $560.44 N/A 89352 80% of billed 80% of billed N/A88377 26 $107.02 $107.02 N/A 89353 80% of billed 80% of billed N/A88380 $223.83 $223.83 N/A 89354 80% of billed 80% of billed N/A88380 TC $131.77 $131.77 N/A 89356 80% of billed 80% of billed N/A88380 26 $92.06 $92.06 N/A 89398 80% of billed 80% of billed N/A88381 $199.66 $199.66 N/A 90281 80% of billed 80% of billed N/A88381 TC $157.66 $157.66 N/A 90283 80% of billed 80% of billed N/A88381 26 $42.00 $42.00 N/A 90284 80% of billed 80% of billed N/A88387 $56.96 $56.96 N/A 90287 80% of billed 80% of billed N/A88387 TC $9.78 $9.78 N/A 90288 80% of billed 80% of billed N/A88387 26 $47.18 $47.18 N/A 90291 80% of billed 80% of billed N/A88388 $56.39 $56.39 N/A 90296 80% of billed 80% of billed N/A88388 TC $16.11 $16.11 N/A 90371 80% of billed 80% of billed N/A88388 26 $40.28 $40.28 N/A 90375 80% of billed 80% of billed N/A88399 80% of billed 80% of billed N/A 90376 80% of billed 80% of billed N/A88399 TC 80% of billed 80% of billed N/A 90378 80% of billed 80% of billed N/A88399 26 80% of billed 80% of billed N/A 90384 80% of billed 80% of billed N/A88720 80% of billed 80% of billed N/A 90385 80% of billed 80% of billed N/A88738 80% of billed 80% of billed N/A 90386 80% of billed 80% of billed N/A88740 80% of billed 80% of billed N/A 90389 80% of billed 80% of billed N/A88741 80% of billed 80% of billed N/A 90393 80% of billed 80% of billed N/A88749 80% of billed 80% of billed N/A 90396 80% of billed 80% of billed N/A89049 $396.45 $101.85 N/A 90399 80% of billed 80% of billed N/A89050 80% of billed 80% of billed N/A 90460 $39.23 $39.23 N/A89051 80% of billed 80% of billed N/A 90461 $24.35 $24.35 ZZZ89055 80% of billed 80% of billed N/A 90471 $39.23 $39.23 N/A89060 80% of billed 80% of billed N/A 90472 $24.35 $24.35 ZZZ89060 26 $29.92 $29.92 N/A 90473 $39.23 $39.23 N/A89125 80% of billed 80% of billed N/A 90474 $24.35 $24.35 ZZZ89160 80% of billed 80% of billed N/A 90476 80% of billed 80% of billed N/A89190 80% of billed 80% of billed N/A 90477 80% of billed 80% of billed N/A89220 $26.47 $26.47 N/A 90581 80% of billed 80% of billed N/A89230 $5.75 $5.75 N/A 90585 80% of billed 80% of billed N/A89240 80% of billed 80% of billed N/A 90586 80% of billed 80% of billed N/A89250 80% of billed 80% of billed N/A 90587 80% of billed 80% of billed N/A89251 80% of billed 80% of billed N/A 90620 80% of billed 80% of billed N/A89253 80% of billed 80% of billed N/A 90621 80% of billed 80% of billed N/A89254 80% of billed 80% of billed N/A 90625 80% of billed 80% of billed N/A89255 80% of billed 80% of billed N/A 90630 80% of billed 80% of billed N/A89257 80% of billed 80% of billed N/A 90632 80% of billed 80% of billed N/A89258 80% of billed 80% of billed N/A 90633 80% of billed 80% of billed N/A89259 80% of billed 80% of billed N/A 90634 80% of billed 80% of billed N/A89260 80% of billed 80% of billed N/A 90636 80% of billed 80% of billed N/A89261 80% of billed 80% of billed N/A 90644 80% of billed 80% of billed N/A89264 80% of billed 80% of billed N/A 90647 80% of billed 80% of billed N/A89268 80% of billed 80% of billed N/A 90648 80% of billed 80% of billed N/A89272 80% of billed 80% of billed N/A 90649 80% of billed 80% of billed N/A89280 80% of billed 80% of billed N/A 90650 80% of billed 80% of billed N/A89281 80% of billed 80% of billed N/A 90651 80% of billed 80% of billed N/A89290 80% of billed 80% of billed N/A 90653 80% of billed 80% of billed N/A89291 80% of billed 80% of billed N/A 90654 80% of billed 80% of billed N/A89300 80% of billed 80% of billed N/A 90655 80% of billed 80% of billed N/A89310 80% of billed 80% of billed N/A 90656 80% of billed 80% of billed N/A89320 80% of billed 80% of billed N/A 90657 80% of billed 80% of billed N/A89321 80% of billed 80% of billed N/A 90658 80% of billed 80% of billed N/A89322 80% of billed 80% of billed N/A 90660 80% of billed 80% of billed N/A89325 80% of billed 80% of billed N/A 90661 80% of billed 80% of billed N/A89329 80% of billed 80% of billed N/A 90662 80% of billed 80% of billed N/A89330 80% of billed 80% of billed N/A 90664 80% of billed 80% of billed N/A89331 80% of billed 80% of billed N/A 90666 80% of billed 80% of billed N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 71 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

90667 80% of billed 80% of billed N/A 90870 $335.44 $211.68 00090668 80% of billed 80% of billed N/A 90875 $119.71 $117.68 N/A90670 80% of billed 80% of billed N/A 90876 $207.62 $185.31 N/A90672 80% of billed 80% of billed N/A 90880 $198.16 $175.84 N/A90673 80% of billed 80% of billed N/A 90882 80% of billed 80% of billed N/A90674 80% of billed 80% of billed N/A 90885 $95.36 $95.36 N/A90675 80% of billed 80% of billed N/A 90887 $169.07 $145.40 N/A90676 80% of billed 80% of billed N/A 90889 80% of billed 80% of billed N/A90680 80% of billed 80% of billed N/A 90899 80% of billed 80% of billed N/A90681 80% of billed 80% of billed N/A 90901 $75.75 $37.87 00090682 80% of billed 80% of billed N/A 90911 $166.37 $85.89 00090685 80% of billed 80% of billed N/A 90935 $139.32 $139.32 00090686 80% of billed 80% of billed N/A 90937 $198.83 $198.83 00090687 80% of billed 80% of billed N/A 90940 80% of billed 80% of billed N/A90688 80% of billed 80% of billed N/A 90945 $163.66 $163.66 00090690 80% of billed 80% of billed N/A 90947 $236.70 $236.70 00090691 80% of billed 80% of billed N/A 90951 $1,805.04 $1,805.04 N/A90696 80% of billed 80% of billed N/A 90952 80% of billed 80% of billed N/A90697 80% of billed 80% of billed N/A 90953 80% of billed 80% of billed N/A90698 80% of billed 80% of billed N/A 90954 $1,555.49 $1,555.49 N/A90700 80% of billed 80% of billed N/A 90955 $873.10 $873.10 N/A90702 80% of billed 80% of billed N/A 90956 $606.64 $606.64 N/A90707 80% of billed 80% of billed N/A 90957 $1,230.19 $1,230.19 N/A90710 80% of billed 80% of billed N/A 90958 $834.55 $834.55 N/A90713 80% of billed 80% of billed N/A 90959 $566.74 $566.74 N/A90714 80% of billed 80% of billed N/A 90960 $541.72 $541.72 N/A90715 80% of billed 80% of billed N/A 90961 $455.83 $455.83 N/A90716 80% of billed 80% of billed N/A 90962 $352.35 $352.35 N/A90717 80% of billed 80% of billed N/A 90963 $1,043.53 $1,043.53 N/A90723 80% of billed 80% of billed N/A 90964 $910.98 $910.98 N/A90732 80% of billed 80% of billed N/A 90965 $866.34 $866.34 N/A90733 80% of billed 80% of billed N/A 90966 $454.47 $454.47 N/A90734 80% of billed 80% of billed N/A 90967 $34.49 $34.49 N/A90736 80% of billed 80% of billed N/A 90968 $29.76 $29.76 N/A90738 80% of billed 80% of billed N/A 90969 $29.08 $29.08 N/A90739 80% of billed 80% of billed N/A 90970 $14.88 $14.88 N/A90740 80% of billed 80% of billed N/A 90989 80% of billed 80% of billed N/A90743 80% of billed 80% of billed N/A 90993 80% of billed 80% of billed N/A90744 80% of billed 80% of billed N/A 90997 $170.43 $170.43 00090746 80% of billed 80% of billed N/A 90999 80% of billed 80% of billed N/A90747 80% of billed 80% of billed N/A 91010 $340.18 $340.18 00090748 80% of billed 80% of billed N/A 91010 TC $211.01 $211.01 00090749 80% of billed 80% of billed N/A 91010 26 $129.17 $129.17 00090750 80% of billed 80% of billed N/A 91013 $48.69 $48.69 ZZZ90756 80% of billed 80% of billed N/A 91013 TC $30.43 $30.43 ZZZ90785 $27.73 $26.38 ZZZ 91013 26 $18.26 $18.26 ZZZ90791 $256.32 $240.76 N/A 91020 $453.12 $453.12 00090792 $286.75 $271.20 N/A 91020 TC $308.39 $308.39 00090832 $124.44 $119.71 N/A 91020 26 $144.73 $144.73 00090833 $129.85 $125.12 ZZZ 91022 $325.98 $325.98 00090834 $166.37 $159.61 N/A 91022 TC $181.25 $181.25 00090836 $163.66 $157.58 ZZZ 91022 26 $144.73 $144.73 00090837 $249.55 $240.09 N/A 91030 $263.76 $263.76 00090838 $216.42 $208.30 ZZZ 91030 TC $171.78 $171.78 00090839 $260.38 $250.23 N/A 91030 26 $91.98 $91.98 00090840 $124.44 $119.71 ZZZ 91034 $361.82 $361.82 00090845 $178.54 $171.78 N/A 91034 TC $263.76 $263.76 00090846 $200.86 $193.42 N/A 91034 26 $98.06 $98.06 00090847 $208.98 $201.54 N/A 91035 $927.21 $927.21 00090849 $70.34 $60.19 N/A 91035 TC $765.57 $765.57 00090853 $50.05 $47.34 N/A 91035 26 $161.64 $161.64 00090863 $50.05 $47.34 N/A 91037 $310.42 $310.42 00090865 $320.57 $244.82 N/A 91037 TC $213.03 $213.03 00090867 80% of billed 80% of billed 000 91037 26 $97.39 $97.39 00090868 80% of billed 80% of billed 000 91038 $862.96 $862.96 00090869 80% of billed 80% of billed 000 91038 TC $752.05 $752.05 000

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 72 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

91038 26 $110.91 $110.91 000 92132 26 $31.79 $31.79 N/A91040 $861.61 $861.61 000 92133 $72.36 $72.36 N/A91040 TC $767.60 $767.60 000 92133 TC $29.08 $29.08 N/A91040 26 $94.01 $94.01 000 92133 26 $43.28 $43.28 N/A91065 $138.64 $138.64 000 92134 $79.80 $79.80 N/A91065 TC $119.03 $119.03 000 92134 TC $29.76 $29.76 N/A91065 26 $19.61 $19.61 000 92134 26 $50.05 $50.05 N/A91110 $1,740.12 $1,740.12 N/A 92136 $150.81 $150.81 N/A91110 TC $1,490.57 $1,490.57 N/A 92136 TC $90.62 $90.62 N/A91110 26 $249.55 $249.55 N/A 92136 26 $60.19 $60.19 N/A91111 $1,433.76 $1,433.76 N/A 92145 $33.81 $33.81 N/A91111 TC $1,332.99 $1,332.99 N/A 92145 TC $15.55 $15.55 N/A91111 26 $100.77 $100.77 N/A 92145 26 $18.26 $18.26 N/A91112 $2,064.07 $2,064.07 N/A 92225 $52.08 $41.25 N/A91112 TC $1,853.74 $1,853.74 N/A 92226 $48.02 $36.52 N/A91112 26 $210.33 $210.33 N/A 92227 $28.40 $28.40 N/A91117 $269.17 $269.17 000 92228 $64.92 $64.92 N/A91120 $818.32 $818.32 N/A 92228 TC $25.70 $25.70 N/A91120 TC $722.29 $722.29 N/A 92228 26 $39.23 $39.23 N/A91120 26 $96.03 $96.03 N/A 92230 $110.91 $63.57 N/A91122 $442.98 $442.98 000 92235 $165.02 $165.02 N/A91122 TC $268.49 $268.49 000 92235 TC $81.16 $81.16 N/A91122 26 $174.49 $174.49 000 92235 26 $83.86 $83.86 N/A91132 $289.46 $289.46 N/A 92240 $402.40 $402.40 N/A91132 TC $237.38 $237.38 N/A 92240 TC $312.45 $312.45 N/A91132 26 $52.08 $52.08 N/A 92240 26 $89.95 $89.95 N/A91133 $332.74 $332.74 N/A 92242 $438.24 $438.24 N/A91133 TC $266.46 $266.46 N/A 92242 TC $332.74 $332.74 N/A91133 26 $66.28 $66.28 N/A 92242 26 $105.50 $105.50 N/A91200 $77.10 $77.10 N/A 92250 $109.56 $109.56 N/A91200 TC $50.05 $50.05 N/A 92250 TC $67.63 $67.63 N/A91200 26 $27.05 $27.05 N/A 92250 26 $41.93 $41.93 N/A91299 80% of billed 80% of billed N/A 92260 $35.17 $20.97 N/A91299 TC 80% of billed 80% of billed N/A 92265 $169.07 $169.07 N/A91299 26 80% of billed 80% of billed N/A 92265 TC $78.45 $78.45 N/A92002 $159.61 $91.98 N/A 92265 26 $90.62 $90.62 N/A92004 $288.78 $190.72 N/A 92270 $178.54 $178.54 N/A92012 $167.72 $101.44 N/A 92270 TC $99.42 $99.42 N/A92014 $241.44 $152.84 N/A 92270 26 $79.13 $79.13 N/A92015 $37.87 $37.20 N/A 92275 $287.43 $287.43 N/A92018 $279.31 $279.31 N/A 92275 TC $182.60 $182.60 N/A92019 $139.32 $139.32 N/A 92275 26 $104.83 $104.83 N/A92020 $51.40 $40.58 N/A 92283 $105.50 $105.50 N/A92025 $73.04 $73.04 N/A 92283 TC $87.92 $87.92 N/A92025 TC $34.49 $34.49 N/A 92283 26 $17.58 $17.58 N/A92025 26 $38.55 $38.55 N/A 92284 $120.38 $120.38 N/A92060 $124.44 $124.44 N/A 92284 TC $96.03 $96.03 N/A92060 TC $50.72 $50.72 N/A 92284 26 $24.35 $24.35 N/A92060 26 $73.72 $73.72 N/A 92285 $39.90 $39.90 N/A92065 $103.47 $103.47 N/A 92285 TC $33.81 $33.81 N/A92065 TC $68.98 $68.98 N/A 92285 26 $6.09 $6.09 N/A92065 26 $34.49 $34.49 N/A 92286 $73.72 $73.72 N/A92071 $72.36 $64.92 N/A 92286 TC $31.11 $31.11 N/A92072 $254.97 $194.10 N/A 92286 26 $42.61 $42.61 N/A92081 $66.28 $66.28 N/A 92287 $265.79 $265.79 N/A92081 TC $34.49 $34.49 N/A 92287 TC $175.84 $175.84 N/A92081 26 $31.79 $31.79 N/A 92287 26 $89.95 $89.95 N/A92082 $92.65 $92.65 N/A 92310 $186.66 $114.97 N/A92082 TC $50.72 $50.72 N/A 92311 $195.45 $106.18 N/A92082 26 $41.93 $41.93 N/A 92312 $226.56 $122.41 N/A92083 $123.09 $123.09 N/A 92313 $185.31 $89.27 N/A92083 TC $69.66 $69.66 N/A 92314 $155.55 $67.63 N/A92083 26 $53.43 $53.43 N/A 92315 $144.05 $42.61 N/A92100 $155.55 $65.60 N/A 92316 $179.90 $63.57 N/A92132 $60.19 $60.19 N/A 92317 $150.81 $42.61 N/A92132 TC $28.40 $28.40 N/A 92325 $83.18 $83.18 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 73 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

92326 $70.34 $70.34 N/A 92558 $18.94 $16.91 N/A92340 $68.31 $35.84 N/A 92559 80% of billed 80% of billed N/A92341 $78.45 $45.99 N/A 92560 80% of billed 80% of billed N/A92342 $83.86 $52.08 N/A 92561 $75.07 $75.07 N/A92352 $77.77 $35.84 N/A 92562 $89.27 $89.27 N/A92353 $90.62 $48.69 N/A 92563 $59.51 $59.51 N/A92354 $26.38 $26.38 N/A 92564 $50.05 $50.05 N/A92355 $40.58 $40.58 N/A 92565 $29.76 $29.76 N/A92358 $22.32 $22.32 N/A 92567 $27.73 $20.97 N/A92370 $59.51 $31.11 N/A 92568 $30.43 $29.76 N/A92371 $22.32 $22.32 N/A 92570 $61.54 $57.49 N/A92499 80% of billed 80% of billed N/A 92571 $52.75 $52.75 N/A92499 TC 80% of billed 80% of billed N/A 92572 $101.44 $101.44 N/A92499 26 80% of billed 80% of billed N/A 92575 $90.62 $90.62 N/A92502 $185.31 $185.31 000 92576 $72.36 $72.36 N/A92504 $56.13 $18.26 N/A 92577 $27.73 $27.73 N/A92507 $150.14 $150.14 N/A 92579 $87.92 $73.72 N/A92508 $43.96 $43.96 N/A 92582 $130.53 $130.53 N/A92511 $208.98 $72.36 000 92583 $94.68 $94.68 N/A92512 $113.62 $54.78 N/A 92584 $142.02 $142.02 N/A92516 $131.20 $43.96 N/A 92585 $259.70 $259.70 N/A92520 $147.43 $78.45 N/A 92585 TC $208.30 $208.30 N/A92521 $218.44 $218.44 N/A 92585 26 $51.40 $51.40 N/A92522 $175.84 $175.84 N/A 92586 $171.10 $171.10 N/A92523 $378.73 $378.73 N/A 92587 $41.25 $41.25 N/A92524 $168.40 $168.40 N/A 92587 TC $6.09 $6.09 N/A92526 $164.34 $164.34 N/A 92587 26 $35.17 $35.17 N/A92531 80% of billed 80% of billed N/A 92588 $62.90 $62.90 N/A92532 80% of billed 80% of billed N/A 92588 TC $7.44 $7.44 N/A92533 80% of billed 80% of billed N/A 92588 26 $55.46 $55.46 N/A92534 80% of billed 80% of billed N/A 92590 80% of billed 80% of billed N/A92537 $77.77 $77.77 N/A 92591 80% of billed 80% of billed N/A92537 TC $16.91 $16.91 N/A 92592 80% of billed 80% of billed N/A92537 26 $60.87 $60.87 N/A 92593 80% of billed 80% of billed N/A92538 $39.90 $39.90 N/A 92594 80% of billed 80% of billed N/A92538 TC $9.47 $9.47 N/A 92595 80% of billed 80% of billed N/A92538 26 $30.43 $30.43 N/A 92596 $131.20 $131.20 N/A92540 $194.77 $194.77 N/A 92597 $137.97 $137.97 N/A92540 TC $41.93 $41.93 N/A 92601 $316.51 $242.12 N/A92540 26 $152.84 $152.84 N/A 92602 $196.13 $137.29 N/A92541 $47.34 $47.34 N/A 92603 $293.51 $234.68 N/A92541 TC $6.76 $6.76 N/A 92604 $173.81 $131.20 N/A92541 26 $40.58 $40.58 N/A 92605 $178.54 $171.10 N/A92542 $54.10 $54.10 N/A 92606 $158.93 $137.29 N/A92542 TC $6.09 $6.09 N/A 92607 $250.91 $250.91 N/A92542 26 $48.02 $48.02 N/A 92608 $100.77 $100.77 ZZZ92544 $32.46 $32.46 N/A 92609 $210.33 $210.33 N/A92544 TC $4.73 $4.73 N/A 92610 $164.34 $139.32 N/A92544 26 $27.73 $27.73 N/A 92611 $167.72 $167.72 N/A92545 $30.43 $30.43 N/A 92612 $365.88 $130.53 N/A92545 TC $4.73 $4.73 N/A 92613 $73.04 $73.04 N/A92545 26 $25.70 $25.70 N/A 92614 $276.61 $127.82 N/A92546 $200.18 $200.18 N/A 92615 $63.57 $63.57 N/A92546 TC $171.10 $171.10 N/A 92616 $396.31 $191.39 N/A92546 26 $29.08 $29.08 N/A 92617 $79.80 $79.13 N/A92547 $11.50 $11.50 ZZZ 92618 $64.92 $63.57 ZZZ92548 $189.36 $189.36 N/A 92620 $181.25 $158.25 N/A92548 TC $139.32 $139.32 N/A 92621 $43.28 $36.52 ZZZ92548 26 $50.05 $50.05 N/A 92625 $134.58 $120.38 N/A92550 $41.25 $41.25 N/A 92626 $172.46 $146.08 N/A92551 $23.67 $23.67 N/A 92627 $43.28 $34.49 ZZZ92552 $60.87 $60.87 N/A 92630 80% of billed 80% of billed N/A92553 $73.04 $73.04 N/A 92633 80% of billed 80% of billed N/A92555 $45.99 $45.99 N/A 92640 $220.47 $185.31 N/A92556 $73.04 $73.04 N/A 92700 80% of billed 80% of billed N/A92557 $72.36 $62.90 N/A 92920 $1,046.24 $1,046.24 000

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 74 of 84

Page 75: Appendix B for Administrative Order No. 18-053 Physician ...Appendix B for Administrative Order No. 18-053 Physician Fee Schedule Effective April 1, 2018 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

92921 80% of billed 80% of billed ZZZ 93268 $394.28 $394.28 N/A92924 $1,247.10 $1,247.10 000 93270 $17.58 $17.58 N/A92925 80% of billed 80% of billed ZZZ 93271 $328.01 $328.01 N/A92928 $1,163.91 $1,163.91 000 93272 $48.69 $48.69 N/A92929 80% of billed 80% of billed ZZZ 93278 $59.51 $59.51 N/A92933 $1,304.58 $1,304.58 000 93278 TC $35.17 $35.17 N/A92934 80% of billed 80% of billed ZZZ 93278 26 $24.35 $24.35 N/A92937 $1,162.56 $1,162.56 000 93279 $94.68 $94.68 N/A92938 80% of billed 80% of billed ZZZ 93279 TC $32.46 $32.46 N/A92941 $1,307.29 $1,307.29 000 93279 26 $62.22 $62.22 N/A92943 $1,307.29 $1,307.29 000 93280 $111.59 $111.59 N/A92944 80% of billed 80% of billed ZZZ 93280 TC $37.87 $37.87 N/A92950 $584.32 $361.14 000 93280 26 $73.72 $73.72 N/A92953 $2.03 $2.03 000 93281 $121.06 $121.06 N/A92960 $306.36 $212.36 000 93281 TC $38.55 $38.55 N/A92961 $490.99 $490.99 000 93281 26 $82.51 $82.51 N/A92970 $388.20 $388.20 000 93282 $117.00 $117.00 N/A92971 $196.80 $196.80 000 93282 TC $35.17 $35.17 N/A92973 $348.29 $348.29 ZZZ 93282 26 $81.83 $81.83 N/A92974 $319.21 $319.21 ZZZ 93283 $149.46 $149.46 N/A92975 $741.22 $741.22 000 93283 TC $38.55 $38.55 N/A92977 $110.91 $110.91 N/A 93283 26 $110.91 $110.91 N/A92978 80% of billed 80% of billed ZZZ 93284 $162.99 $162.99 N/A92978 TC 80% of billed 80% of billed ZZZ 93284 TC $41.93 $41.93 N/A92978 26 $187.34 $187.34 ZZZ 93284 26 $121.06 $121.06 N/A92979 80% of billed 80% of billed ZZZ 93285 $81.83 $81.83 N/A92979 TC 80% of billed 80% of billed ZZZ 93285 TC $31.11 $31.11 N/A92979 26 $150.81 $150.81 ZZZ 93285 26 $50.72 $50.72 N/A92986 $2,592.26 $2,592.26 090 93286 $57.49 $57.49 N/A92987 $2,674.09 $2,674.09 090 93286 TC $28.40 $28.40 N/A92990 $2,136.43 $2,136.43 090 93286 26 $29.08 $29.08 N/A92992 80% of billed 80% of billed 090 93287 $73.04 $73.04 N/A92993 80% of billed 80% of billed 090 93287 TC $28.40 $28.40 N/A92997 $1,288.35 $1,288.35 000 93287 26 $44.64 $44.64 N/A92998 $639.10 $639.10 ZZZ 93288 $73.72 $73.72 N/A93000 $32.46 $32.46 N/A 93288 TC $32.46 $32.46 N/A93005 $16.23 $16.23 N/A 93288 26 $41.25 $41.25 N/A93010 $16.23 $16.23 N/A 93289 $104.15 $104.15 N/A93015 $136.61 $136.61 N/A 93289 TC $32.46 $32.46 N/A93016 $42.61 $42.61 N/A 93289 26 $71.69 $71.69 N/A93017 $65.60 $65.60 N/A 93290 $70.34 $70.34 N/A93018 $28.40 $28.40 N/A 93290 TC $28.40 $28.40 N/A93024 $213.71 $213.71 N/A 93290 26 $41.93 $41.93 N/A93024 TC $104.15 $104.15 N/A 93291 $62.90 $62.90 N/A93024 26 $109.56 $109.56 N/A 93291 TC $27.73 $27.73 N/A93025 $313.13 $313.13 N/A 93291 26 $35.17 $35.17 N/A93025 TC $242.12 $242.12 N/A 93292 $70.34 $70.34 N/A93025 26 $71.01 $71.01 N/A 93292 TC $29.08 $29.08 N/A93040 $24.35 $24.35 N/A 93292 26 $41.25 $41.25 N/A93041 $10.82 $10.82 N/A 93293 $102.12 $102.12 N/A93042 $13.53 $13.53 N/A 93293 TC $73.04 $73.04 N/A93050 $31.79 $31.79 N/A 93293 26 $29.08 $29.08 N/A93050 TC $15.55 $15.55 N/A 93294 $58.84 $58.84 N/A93050 26 $16.23 $16.23 N/A 93295 $105.50 $105.50 N/A93224 $174.49 $174.49 N/A 93296 $50.72 $50.72 N/A93225 $50.72 $50.72 N/A 93297 $50.72 $50.72 N/A93226 $72.36 $72.36 N/A 93298 $51.40 $51.40 N/A93227 $51.40 $51.40 N/A 93299 80% of billed 80% of billed N/A93228 $50.05 $50.05 N/A 93303 $463.27 $463.27 N/A93229 $1,396.56 $1,396.56 N/A 93303 TC $340.86 $340.86 N/A93260 $125.12 $125.12 N/A 93303 26 $122.41 $122.41 N/A93260 TC $41.93 $41.93 N/A 93304 $308.39 $308.39 N/A93260 26 $83.18 $83.18 N/A 93304 TC $238.06 $238.06 N/A93261 $113.62 $113.62 N/A 93304 26 $70.34 $70.34 N/A93261 TC $41.25 $41.25 N/A 93306 $401.72 $401.72 N/A93261 26 $72.36 $72.36 N/A 93306 TC $261.05 $261.05 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 75 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

93306 26 $140.67 $140.67 N/A 93459 TC $1,494.62 $1,494.62 00093307 $273.23 $273.23 N/A 93459 26 $662.77 $662.77 00093307 TC $186.66 $186.66 N/A 93460 $2,324.44 $2,324.44 00093307 26 $86.57 $86.57 N/A 93460 TC $1,582.54 $1,582.54 00093308 $202.89 $202.89 N/A 93460 26 $741.90 $741.90 00093308 TC $153.52 $153.52 N/A 93461 $2,660.56 $2,660.56 00093308 26 $49.37 $49.37 N/A 93461 TC $1,841.56 $1,841.56 00093312 $475.44 $475.44 N/A 93461 26 $819.00 $819.00 00093312 TC $265.11 $265.11 N/A 93462 $413.22 $413.22 ZZZ93312 26 $210.33 $210.33 N/A 93463 $190.04 $190.04 ZZZ93313 $22.32 $22.32 N/A 93464 $490.99 $490.99 ZZZ93314 $459.21 $459.21 N/A 93464 TC $322.60 $322.60 ZZZ93314 TC $282.69 $282.69 N/A 93464 26 $168.40 $168.40 ZZZ93314 26 $176.51 $176.51 N/A 93503 $202.21 $202.21 00093315 80% of billed 80% of billed N/A 93505 $1,351.25 $1,351.25 00093315 TC 80% of billed 80% of billed N/A 93505 TC $922.47 $922.47 00093315 26 $248.20 $248.20 N/A 93505 26 $428.77 $428.77 00093316 $52.75 $52.75 N/A 93530 80% of billed 80% of billed 00093317 80% of billed 80% of billed N/A 93530 TC 80% of billed 80% of billed 00093317 TC 80% of billed 80% of billed N/A 93530 26 $402.40 $402.40 00093317 26 $179.22 $179.22 N/A 93531 80% of billed 80% of billed 00093318 80% of billed 80% of billed N/A 93531 TC 80% of billed 80% of billed 00093318 TC 80% of billed 80% of billed N/A 93531 26 $837.26 $837.26 00093318 26 $202.21 $202.21 N/A 93532 80% of billed 80% of billed 00093320 $104.15 $104.15 ZZZ 93532 TC 80% of billed 80% of billed 00093320 TC $68.98 $68.98 ZZZ 93532 26 $1,008.36 $1,008.36 00093320 26 $35.17 $35.17 ZZZ 93533 80% of billed 80% of billed 00093321 $52.75 $52.75 ZZZ 93533 TC 80% of billed 80% of billed 00093321 TC $38.55 $38.55 ZZZ 93533 26 $679.01 $679.01 00093321 26 $14.20 $14.20 ZZZ 93561 80% of billed 80% of billed 00093325 $49.37 $49.37 ZZZ 93561 TC 80% of billed 80% of billed 00093325 TC $43.28 $43.28 ZZZ 93561 26 $23.67 $23.67 00093325 26 $6.09 $6.09 ZZZ 93562 80% of billed 80% of billed 00093350 $398.34 $398.34 N/A 93562 TC 80% of billed 80% of billed 00093350 TC $261.73 $261.73 N/A 93562 26 $2.03 $2.03 00093350 26 $136.61 $136.61 N/A 93563 $114.29 $114.29 ZZZ93351 $449.06 $449.06 N/A 93564 $120.38 $120.38 ZZZ93351 TC $285.40 $285.40 N/A 93565 $88.60 $88.60 ZZZ93351 26 $163.66 $163.66 N/A 93566 $312.45 $91.30 ZZZ93352 $64.92 $64.92 ZZZ 93567 $263.08 $103.47 ZZZ93355 $438.92 $438.92 N/A 93568 $279.31 $93.33 ZZZ93451 $1,399.26 $1,399.26 000 93571 80% of billed 80% of billed ZZZ93451 TC $1,142.95 $1,142.95 000 93571 TC 80% of billed 80% of billed ZZZ93451 26 $256.32 $256.32 000 93571 26 $187.34 $187.34 ZZZ93452 $1,591.33 $1,591.33 000 93572 80% of billed 80% of billed ZZZ93452 TC $1,123.33 $1,123.33 000 93572 TC 80% of billed 80% of billed ZZZ93452 26 $468.00 $468.00 000 93572 26 $150.81 $150.81 ZZZ93453 $2,068.13 $2,068.13 000 93580 $1,922.04 $1,922.04 00093453 TC $1,441.87 $1,441.87 000 93581 $2,618.63 $2,618.63 00093453 26 $626.25 $626.25 000 93582 $1,309.32 $1,309.32 00093454 $1,614.33 $1,614.33 000 93583 $1,461.48 $1,461.48 00093454 TC $1,141.59 $1,141.59 000 93590 $2,101.26 $2,101.26 00093454 26 $472.73 $472.73 000 93591 $1,744.85 $1,744.85 00093455 $1,889.58 $1,889.58 000 93592 $767.60 $767.60 ZZZ93455 TC $1,337.72 $1,337.72 000 93600 80% of billed 80% of billed 00093455 26 $551.86 $551.86 000 93600 TC 80% of billed 80% of billed 00093456 $2,043.78 $2,043.78 000 93600 26 $234.00 $234.00 00093456 TC $1,428.35 $1,428.35 000 93602 80% of billed 80% of billed 00093456 26 $615.43 $615.43 000 93602 TC 80% of billed 80% of billed 00093457 $2,314.30 $2,314.30 000 93602 26 $227.24 $227.24 00093457 TC $1,621.77 $1,621.77 000 93603 80% of billed 80% of billed 00093457 26 $692.53 $692.53 000 93603 TC 80% of billed 80% of billed 00093458 $1,946.39 $1,946.39 000 93603 26 $227.24 $227.24 00093458 TC $1,362.07 $1,362.07 000 93609 80% of billed 80% of billed ZZZ93458 26 $584.32 $584.32 000 93609 TC 80% of billed 80% of billed ZZZ93459 $2,157.40 $2,157.40 000 93609 26 $547.13 $547.13 ZZZ

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 76 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

93610 80% of billed 80% of billed 000 93724 26 $467.32 $467.32 00093610 TC 80% of billed 80% of billed 000 93740 $15.55 $15.55 N/A93610 26 $321.92 $321.92 000 93745 80% of billed 80% of billed N/A93612 80% of billed 80% of billed 000 93745 TC 80% of billed 80% of billed N/A93612 TC 80% of billed 80% of billed 000 93745 26 80% of billed 80% of billed N/A93612 26 $319.21 $319.21 000 93750 $106.86 $89.27 N/A93613 $634.37 $634.37 ZZZ 93770 $15.55 $15.55 N/A93615 80% of billed 80% of billed 000 93784 $102.80 $102.80 N/A93615 TC 80% of billed 80% of billed 000 93786 $56.81 $56.81 N/A93615 26 $74.39 $74.39 000 93788 $10.14 $10.14 N/A93616 80% of billed 80% of billed 000 93790 $35.84 $35.84 N/A93616 TC 80% of billed 80% of billed 000 93792 $103.47 $103.47 N/A93616 26 $119.71 $119.71 000 93793 $22.99 $22.99 N/A93618 80% of billed 80% of billed 000 93797 $31.11 $16.91 00093618 TC 80% of billed 80% of billed 000 93798 $48.02 $27.05 00093618 26 $435.54 $435.54 000 93799 80% of billed 80% of billed N/A93619 80% of billed 80% of billed 000 93799 TC 80% of billed 80% of billed N/A93619 TC 80% of billed 80% of billed 000 93799 26 80% of billed 80% of billed N/A93619 26 $768.95 $768.95 000 93880 $392.93 $392.93 N/A93620 80% of billed 80% of billed 000 93880 TC $315.83 $315.83 N/A93620 TC 80% of billed 80% of billed 000 93880 26 $77.10 $77.10 N/A93620 26 $1,234.92 $1,234.92 000 93882 $251.58 $251.58 N/A93621 80% of billed 80% of billed ZZZ 93882 TC $202.89 $202.89 N/A93621 TC 80% of billed 80% of billed ZZZ 93882 26 $48.69 $48.69 N/A93621 26 $230.62 $230.62 ZZZ 93886 $526.16 $526.16 N/A93622 80% of billed 80% of billed ZZZ 93886 TC $435.54 $435.54 N/A93622 TC 80% of billed 80% of billed ZZZ 93886 26 $90.62 $90.62 N/A93622 26 $338.83 $338.83 ZZZ 93888 $298.92 $298.92 N/A93623 80% of billed 80% of billed ZZZ 93888 TC $248.88 $248.88 N/A93623 TC 80% of billed 80% of billed ZZZ 93888 26 $50.05 $50.05 N/A93623 26 $312.45 $312.45 ZZZ 93890 $538.33 $538.33 N/A93624 80% of billed 80% of billed 000 93890 TC $439.59 $439.59 N/A93624 TC 80% of billed 80% of billed 000 93890 26 $98.74 $98.74 N/A93624 26 $490.32 $490.32 000 93892 $617.46 $617.46 N/A93631 80% of billed 80% of billed 000 93892 TC $501.81 $501.81 N/A93631 TC 80% of billed 80% of billed 000 93892 26 $115.65 $115.65 N/A93631 26 $778.42 $778.42 000 93893 $669.54 $669.54 N/A93640 80% of billed 80% of billed 000 93893 TC $554.57 $554.57 N/A93640 TC 80% of billed 80% of billed 000 93893 26 $114.97 $114.97 N/A93640 26 $351.68 $351.68 000 93895 80% of billed 80% of billed N/A93641 80% of billed 80% of billed 000 93895 TC 80% of billed 80% of billed N/A93641 TC 80% of billed 80% of billed 000 93895 26 80% of billed 80% of billed N/A93641 26 $614.76 $614.76 000 93922 $169.75 $169.75 N/A93642 $664.13 $664.13 000 93922 TC $145.40 $145.40 N/A93642 TC $159.61 $159.61 000 93922 26 $24.35 $24.35 N/A93642 26 $504.52 $504.52 000 93923 $263.08 $263.08 N/A93644 $392.93 $392.93 000 93923 TC $220.47 $220.47 N/A93644 TC $104.15 $104.15 000 93923 26 $42.61 $42.61 N/A93644 26 $288.78 $288.78 000 93924 $327.33 $327.33 N/A93650 $1,163.24 $1,163.24 000 93924 TC $279.99 $279.99 N/A93653 $1,645.44 $1,645.44 000 93924 26 $47.34 $47.34 N/A93654 $2,204.06 $2,204.06 000 93925 $503.84 $503.84 N/A93655 $838.61 $838.61 ZZZ 93925 TC $427.42 $427.42 N/A93656 $2,210.15 $2,210.15 000 93925 26 $76.42 $76.42 N/A93657 $837.94 $837.94 ZZZ 93926 $294.87 $294.87 N/A93660 $307.04 $307.04 000 93926 TC $248.20 $248.20 N/A93660 TC $126.47 $126.47 000 93926 26 $46.66 $46.66 N/A93660 26 $180.57 $180.57 000 93930 $403.75 $403.75 N/A93662 80% of billed 80% of billed ZZZ 93930 TC $326.65 $326.65 N/A93662 TC 80% of billed 80% of billed ZZZ 93930 26 $77.10 $77.10 N/A93662 26 $275.93 $275.93 ZZZ 93931 $250.91 $250.91 N/A93668 $37.20 $37.20 N/A 93931 TC $203.57 $203.57 N/A93701 $46.66 $46.66 N/A 93931 26 $47.34 $47.34 N/A93702 $236.70 $236.70 N/A 93970 $379.40 $379.40 N/A93724 $522.78 $522.78 000 93970 TC $313.13 $313.13 N/A93724 TC $55.46 $55.46 000 93970 26 $66.28 $66.28 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 77 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

93971 $232.65 $232.65 N/A 94453 TC $117.00 $117.00 N/A93971 TC $189.36 $189.36 N/A 94453 26 $36.52 $36.52 N/A93971 26 $43.28 $43.28 N/A 94610 $107.53 $107.53 N/A93975 $546.45 $546.45 N/A 94617 $182.60 $182.60 N/A93975 TC $434.86 $434.86 N/A 94617 TC $118.35 $118.35 N/A93975 26 $111.59 $111.59 N/A 94617 26 $64.25 $64.25 N/A93976 $317.86 $317.86 N/A 94618 $65.60 $65.60 N/A93976 TC $241.44 $241.44 N/A 94618 TC $21.64 $21.64 N/A93976 26 $76.42 $76.42 N/A 94618 26 $43.96 $43.96 N/A93978 $370.61 $370.61 N/A 94621 $316.51 $316.51 N/A93978 TC $294.19 $294.19 N/A 94621 TC $183.95 $183.95 N/A93978 26 $76.42 $76.42 N/A 94621 26 $132.55 $132.55 N/A93979 $234.00 $234.00 N/A 94640 $35.84 $35.84 N/A93979 TC $185.98 $185.98 N/A 94642 80% of billed 80% of billed N/A93979 26 $48.02 $48.02 N/A 94644 $86.57 $86.57 N/A93980 $242.79 $242.79 N/A 94645 $31.11 $31.11 N/A93980 TC $123.76 $123.76 N/A 94660 $124.44 $73.72 N/A93980 26 $119.03 $119.03 N/A 94662 $69.66 $69.66 N/A93981 $148.11 $148.11 N/A 94664 $33.14 $33.14 N/A93981 TC $106.18 $106.18 N/A 94667 $51.40 $51.40 N/A93981 26 $41.93 $41.93 N/A 94668 $61.54 $61.54 N/A93990 $307.72 $307.72 N/A 94669 $62.90 $62.90 N/A93990 TC $260.38 $260.38 N/A 94680 $112.27 $112.27 N/A93990 26 $47.34 $47.34 N/A 94680 TC $87.92 $87.92 N/A93998 80% of billed 80% of billed N/A 94680 26 $24.35 $24.35 N/A94002 $177.87 $177.87 N/A 94681 $109.56 $109.56 N/A94003 $128.50 $128.50 N/A 94681 TC $89.95 $89.95 N/A94004 $94.68 $94.68 N/A 94681 26 $19.61 $19.61 N/A94005 $177.87 $177.87 N/A 94690 $106.86 $106.86 N/A94010 $68.98 $68.98 N/A 94690 TC $99.42 $99.42 N/A94010 TC $52.75 $52.75 N/A 94690 26 $7.44 $7.44 N/A94010 26 $16.23 $16.23 N/A 94726 $105.50 $105.50 N/A94011 $167.05 $167.05 N/A 94726 TC $81.83 $81.83 N/A94012 $271.87 $271.87 N/A 94726 26 $23.67 $23.67 N/A94013 $37.20 $37.20 N/A 94727 $84.54 $84.54 N/A94014 $108.21 $108.21 N/A 94727 TC $60.87 $60.87 N/A94015 $59.51 $59.51 N/A 94727 26 $23.67 $23.67 N/A94016 $48.69 $48.69 N/A 94728 $79.13 $79.13 N/A94060 $116.32 $116.32 N/A 94728 TC $54.78 $54.78 N/A94060 TC $91.30 $91.30 N/A 94728 26 $24.35 $24.35 N/A94060 26 $25.02 $25.02 N/A 94729 $104.83 $104.83 ZZZ94070 $116.32 $116.32 N/A 94729 TC $87.24 $87.24 ZZZ94070 TC $60.87 $60.87 N/A 94729 26 $17.58 $17.58 ZZZ94070 26 $55.46 $55.46 N/A 94750 $158.25 $158.25 N/A94150 $49.37 $49.37 N/A 94750 TC $137.29 $137.29 N/A94150 TC $41.93 $41.93 N/A 94750 26 $20.97 $20.97 N/A94150 26 $7.44 $7.44 N/A 94760 $5.41 $5.41 N/A94200 $52.75 $52.75 N/A 94761 $8.79 $8.79 N/A94200 TC $41.93 $41.93 N/A 94762 $47.34 $47.34 N/A94200 26 $10.82 $10.82 N/A 94770 $14.20 $14.20 N/A94250 $54.10 $54.10 N/A 94772 80% of billed 80% of billed N/A94250 TC $43.28 $43.28 N/A 94772 TC 80% of billed 80% of billed N/A94250 26 $10.82 $10.82 N/A 94772 26 80% of billed 80% of billed N/A94375 $76.42 $76.42 N/A 94774 80% of billed 80% of billed N/A94375 TC $48.02 $48.02 N/A 94775 80% of billed 80% of billed N/A94375 26 $28.40 $28.40 N/A 94776 80% of billed 80% of billed N/A94400 $110.91 $110.91 N/A 94777 80% of billed 80% of billed N/A94400 TC $73.04 $73.04 N/A 94780 $100.09 $45.99 N/A94400 26 $37.87 $37.87 N/A 94781 $39.90 $16.23 ZZZ94450 $137.29 $137.29 N/A 94799 80% of billed 80% of billed N/A94450 TC $98.74 $98.74 N/A 94799 TC 80% of billed 80% of billed N/A94450 26 $38.55 $38.55 N/A 94799 26 80% of billed 80% of billed N/A94452 $110.91 $110.91 N/A 95004 $10.14 $10.14 N/A94452 TC $83.18 $83.18 N/A 95012 $38.55 $38.55 N/A94452 26 $27.73 $27.73 N/A 95017 $14.88 $7.44 N/A94453 $153.52 $153.52 N/A 95018 $40.58 $13.53 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 78 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

95024 $15.55 $2.03 N/A 95811 26 $243.47 $243.47 N/A95027 $8.79 $8.79 N/A 95812 $619.49 $619.49 N/A95028 $25.02 $25.02 N/A 95812 TC $507.90 $507.90 N/A95044 $10.82 $10.82 N/A 95812 26 $111.59 $111.59 N/A95052 $12.85 $12.85 N/A 95813 $778.42 $778.42 N/A95056 $87.92 $87.92 N/A 95813 TC $611.38 $611.38 N/A95060 $67.63 $67.63 N/A 95813 26 $167.05 $167.05 N/A95065 $48.02 $48.02 N/A 95816 $698.62 $698.62 N/A95070 $59.51 $59.51 N/A 95816 TC $587.03 $587.03 N/A95071 $67.63 $67.63 N/A 95816 26 $111.59 $111.59 N/A95076 $229.27 $142.70 N/A 95819 $812.24 $812.24 N/A95079 $160.96 $130.53 ZZZ 95819 TC $700.65 $700.65 N/A95115 $16.91 $16.91 N/A 95819 26 $111.59 $111.59 N/A95117 $19.61 $19.61 N/A 95822 $731.76 $731.76 N/A95120 80% of billed 80% of billed N/A 95822 TC $620.17 $620.17 N/A95125 80% of billed 80% of billed N/A 95822 26 $111.59 $111.59 N/A95130 80% of billed 80% of billed N/A 95824 80% of billed 80% of billed N/A95131 80% of billed 80% of billed N/A 95824 TC 80% of billed 80% of billed N/A95132 80% of billed 80% of billed N/A 95824 26 $76.42 $76.42 N/A95133 80% of billed 80% of billed N/A 95827 $1,203.14 $1,203.14 N/A95134 80% of billed 80% of billed N/A 95827 TC $1,094.25 $1,094.25 N/A95144 $25.70 $6.09 N/A 95827 26 $108.88 $108.88 N/A95145 $49.37 $6.09 N/A 95829 $3,670.28 $3,670.28 N/A95146 $90.62 $6.09 N/A 95829 TC $3,019.00 $3,019.00 N/A95147 $96.71 $6.09 N/A 95829 26 $651.28 $651.28 N/A95148 $137.97 $6.09 N/A 95830 $449.74 $177.87 N/A95149 $181.25 $6.09 N/A 95831 $62.90 $29.76 N/A95165 $25.02 $6.09 N/A 95832 $62.22 $32.46 N/A95170 $18.94 $6.09 N/A 95833 $78.45 $42.61 N/A95180 $261.05 $196.80 N/A 95834 $104.15 $60.87 N/A95199 80% of billed 80% of billed N/A 95851 $38.55 $14.88 N/A95249 $105.50 $105.50 N/A 95852 $35.17 $11.50 N/A95250 $294.19 $294.19 N/A 95857 $103.47 $57.49 N/A95251 $68.98 $68.98 N/A 95860 $236.70 $236.70 N/A95782 $1,757.70 $1,757.70 N/A 95860 TC $136.61 $136.61 N/A95782 TC $1,514.91 $1,514.91 N/A 95860 26 $100.09 $100.09 N/A95782 26 $242.79 $242.79 N/A 95861 $335.44 $335.44 N/A95783 $1,874.70 $1,874.70 N/A 95861 TC $175.84 $175.84 N/A95783 TC $1,610.27 $1,610.27 N/A 95861 26 $159.61 $159.61 N/A95783 26 $264.43 $264.43 N/A 95863 $428.10 $428.10 N/A95800 $339.50 $339.50 N/A 95863 TC $235.35 $235.35 N/A95800 TC $239.41 $239.41 N/A 95863 26 $192.75 $192.75 N/A95800 26 $100.09 $100.09 N/A 95864 $478.82 $478.82 N/A95801 $173.81 $173.81 N/A 95864 TC $273.23 $273.23 N/A95801 TC $79.13 $79.13 N/A 95864 26 $205.60 $205.60 N/A95801 26 $94.68 $94.68 N/A 95865 $282.69 $282.69 N/A95803 $274.58 $274.58 N/A 95865 TC $121.06 $121.06 N/A95803 TC $190.04 $190.04 N/A 95865 26 $161.64 $161.64 N/A95803 26 $84.54 $84.54 N/A 95866 $259.02 $259.02 N/A95805 $827.79 $827.79 N/A 95866 TC $129.17 $129.17 N/A95805 TC $714.17 $714.17 N/A 95866 26 $129.85 $129.85 N/A95805 26 $113.62 $113.62 N/A 95867 $195.45 $195.45 N/A95806 $325.98 $325.98 N/A 95867 TC $113.62 $113.62 N/A95806 TC $208.30 $208.30 N/A 95867 26 $81.83 $81.83 N/A95806 26 $117.68 $117.68 N/A 95868 $260.38 $260.38 N/A95807 $882.57 $882.57 N/A 95868 TC $138.64 $138.64 N/A95807 TC $762.87 $762.87 N/A 95868 26 $121.73 $121.73 N/A95807 26 $119.71 $119.71 N/A 95869 $179.90 $179.90 N/A95808 $1,343.13 $1,343.13 N/A 95869 TC $141.35 $141.35 N/A95808 TC $1,172.70 $1,172.70 N/A 95869 26 $38.55 $38.55 N/A95808 26 $170.43 $170.43 N/A 95870 $182.60 $182.60 N/A95810 $1,200.43 $1,200.43 N/A 95870 TC $144.05 $144.05 N/A95810 TC $966.43 $966.43 N/A 95870 26 $38.55 $38.55 N/A95810 26 $234.00 $234.00 N/A 95872 $379.40 $379.40 N/A95811 $1,260.62 $1,260.62 N/A 95872 TC $81.16 $81.16 N/A95811 TC $1,017.16 $1,017.16 N/A 95872 26 $298.25 $298.25 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 79 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

95873 $141.35 $141.35 ZZZ 95929 $420.66 $420.66 N/A95873 TC $102.80 $102.80 ZZZ 95929 TC $265.11 $265.11 N/A95873 26 $38.55 $38.55 ZZZ 95929 26 $155.55 $155.55 N/A95874 $144.05 $144.05 ZZZ 95930 $133.91 $133.91 N/A95874 TC $105.50 $105.50 ZZZ 95930 TC $97.39 $97.39 N/A95874 26 $38.55 $38.55 ZZZ 95930 26 $36.52 $36.52 N/A95875 $250.91 $250.91 N/A 95933 $150.14 $150.14 N/A95875 TC $136.61 $136.61 N/A 95933 TC $89.27 $89.27 N/A95875 26 $114.29 $114.29 N/A 95933 26 $60.87 $60.87 N/A95885 $113.62 $113.62 ZZZ 95937 $157.58 $157.58 N/A95885 TC $77.10 $77.10 ZZZ 95937 TC $91.30 $91.30 N/A95885 26 $36.52 $36.52 ZZZ 95937 26 $66.28 $66.28 N/A95886 $175.84 $175.84 ZZZ 95938 $662.77 $662.77 N/A95886 TC $86.57 $86.57 ZZZ 95938 TC $573.50 $573.50 N/A95886 26 $89.27 $89.27 ZZZ 95938 26 $89.27 $89.27 N/A95887 $155.55 $155.55 ZZZ 95939 $973.87 $973.87 N/A95887 TC $81.83 $81.83 ZZZ 95939 TC $742.58 $742.58 N/A95887 26 $73.72 $73.72 ZZZ 95939 26 $231.29 $231.29 N/A95905 $139.32 $139.32 N/A 95940 $62.90 $62.90 N/A95905 TC $133.91 $133.91 N/A 95941 80% of billed 80% of billed N/A95905 26 $5.41 $5.41 N/A 95943 80% of billed 80% of billed N/A95907 $188.01 $188.01 N/A 95943 TC 80% of billed 80% of billed N/A95907 TC $84.54 $84.54 N/A 95943 26 80% of billed 80% of billed N/A95907 26 $103.47 $103.47 N/A 95950 $658.04 $658.04 N/A95908 $243.47 $243.47 N/A 95950 TC $503.17 $503.17 N/A95908 TC $112.94 $112.94 N/A 95950 26 $154.87 $154.87 N/A95908 26 $130.53 $130.53 N/A 95951 80% of billed 80% of billed N/A95909 $290.13 $290.13 N/A 95951 TC 80% of billed 80% of billed N/A95909 TC $134.58 $134.58 N/A 95951 26 $617.46 $617.46 N/A95909 26 $155.55 $155.55 N/A 95953 $831.85 $831.85 N/A95910 $382.11 $382.11 N/A 95953 TC $515.34 $515.34 N/A95910 TC $174.49 $174.49 N/A 95953 26 $316.51 $316.51 N/A95910 26 $207.62 $207.62 N/A 95954 $819.68 $819.68 N/A95911 $455.83 $455.83 N/A 95954 TC $587.03 $587.03 N/A95911 TC $196.80 $196.80 N/A 95954 26 $232.65 $232.65 N/A95911 26 $259.02 $259.02 N/A 95955 $411.87 $411.87 N/A95912 $505.87 $505.87 N/A 95955 TC $307.72 $307.72 N/A95912 TC $198.16 $198.16 N/A 95955 26 $104.15 $104.15 N/A95912 26 $307.72 $307.72 N/A 95956 $3,059.58 $3,059.58 N/A95913 $583.65 $583.65 N/A 95956 TC $2,690.32 $2,690.32 N/A95913 TC $219.12 $219.12 N/A 95956 26 $369.26 $369.26 N/A95913 26 $364.53 $364.53 N/A 95957 $552.54 $552.54 N/A95921 $160.28 $160.28 N/A 95957 TC $351.68 $351.68 N/A95921 TC $73.04 $73.04 N/A 95957 26 $200.86 $200.86 N/A95921 26 $87.24 $87.24 N/A 95958 $1,117.25 $1,117.25 N/A95922 $187.34 $187.34 N/A 95958 TC $678.33 $678.33 N/A95922 TC $94.01 $94.01 N/A 95958 26 $438.92 $438.92 N/A95922 26 $93.33 $93.33 N/A 95961 $585.00 $585.00 N/A95923 $249.55 $249.55 N/A 95961 TC $273.23 $273.23 N/A95923 TC $160.96 $160.96 N/A 95961 26 $311.77 $311.77 N/A95923 26 $88.60 $88.60 N/A 95962 $505.20 $505.20 ZZZ95924 $290.13 $290.13 N/A 95962 TC $170.43 $170.43 ZZZ95924 TC $118.35 $118.35 N/A 95962 26 $334.77 $334.77 ZZZ95924 26 $171.78 $171.78 N/A 95965 80% of billed 80% of billed N/A95925 $254.29 $254.29 N/A 95965 TC 80% of billed 80% of billed N/A95925 TC $200.86 $200.86 N/A 95965 26 $816.29 $816.29 N/A95925 26 $53.43 $53.43 N/A 95966 80% of billed 80% of billed N/A95926 $249.55 $249.55 N/A 95966 TC 80% of billed 80% of billed N/A95926 TC $196.80 $196.80 N/A 95966 26 $415.25 $415.25 N/A95926 26 $52.75 $52.75 N/A 95967 80% of billed 80% of billed ZZZ95927 $261.73 $261.73 N/A 95967 TC 80% of billed 80% of billed ZZZ95927 TC $208.98 $208.98 N/A 95967 26 $365.88 $365.88 ZZZ95927 26 $52.75 $52.75 N/A 95970 $133.23 $46.66 N/A95928 $409.16 $409.16 N/A 95971 $98.06 $79.13 N/A95928 TC $254.97 $254.97 N/A 95972 $112.94 $80.48 N/A95928 26 $154.20 $154.20 N/A 95974 $399.69 $316.51 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 80 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

95975 $215.06 $179.22 ZZZ 96422 $354.38 $354.38 N/A95978 $484.91 $372.64 N/A 96423 $160.96 $160.96 ZZZ95979 $208.30 $172.46 ZZZ 96425 $370.61 $370.61 N/A95980 $89.27 $89.27 N/A 96440 $1,510.18 $242.79 00095981 $64.25 $34.49 N/A 96446 $398.34 $55.46 N/A95982 $103.47 $71.01 N/A 96450 $351.00 $154.87 00095990 $179.22 $179.22 N/A 96521 $282.02 $282.02 N/A95991 $229.27 $76.42 N/A 96522 $228.59 $228.59 N/A95992 $83.18 $72.36 N/A 96523 $53.43 $53.43 N/A95999 80% of billed 80% of billed N/A 96542 $256.32 $81.16 N/A96000 $185.98 $185.98 N/A 96549 80% of billed 80% of billed N/A96001 $249.55 $249.55 N/A 96567 $219.12 $219.12 N/A96002 $42.61 $42.61 N/A 96570 $100.09 $100.09 ZZZ96003 $33.14 $33.14 N/A 96571 $56.81 $56.81 ZZZ96004 $221.83 $221.83 N/A 96573 $363.17 $363.17 00096020 80% of billed 80% of billed N/A 96574 $468.00 $468.00 00096020 TC 80% of billed 80% of billed N/A 96900 $39.90 $39.90 N/A96020 26 $311.10 $311.10 N/A 96902 $41.25 $39.90 N/A96040 $90.62 $90.62 N/A 96904 $119.71 $119.71 N/A96101 $157.58 $151.49 N/A 96910 $217.09 $217.09 N/A96102 $117.68 $45.31 N/A 96912 $183.28 $183.28 N/A96103 $52.75 $50.72 N/A 96913 $255.64 $255.64 N/A96105 $207.62 $207.62 N/A 96920 $315.83 $129.17 00096110 $19.61 $19.61 N/A 96921 $346.27 $145.40 00096111 $259.02 $242.79 N/A 96922 $471.38 $234.00 00096116 $179.22 $163.66 N/A 96931 $323.27 $323.27 N/A96118 $185.31 $150.14 N/A 96932 $234.68 $234.68 N/A96119 $152.17 $45.31 N/A 96933 $78.45 $78.45 N/A96120 $91.30 $49.37 N/A 96934 $142.02 $142.02 ZZZ96125 $227.24 $227.24 N/A 96935 $66.95 $66.95 ZZZ96127 $12.17 $12.17 N/A 96936 $75.07 $75.07 ZZZ96150 $42.61 $40.58 N/A 96999 80% of billed 80% of billed N/A96151 $41.25 $39.23 N/A 97010 $10.74 $10.74 N/A96152 $39.23 $37.20 N/A 97012 $25.06 $25.06 N/A96153 $8.79 $8.12 N/A 97014 $26.25 $26.25 N/A96154 $37.87 $35.84 N/A 97016 $26.85 $26.85 N/A96155 $43.28 $43.28 N/A 97018 $14.91 $14.91 N/A96160 $7.44 $7.44 ZZZ 97022 $32.22 $32.22 N/A96161 $7.44 $7.44 ZZZ 97024 $11.93 $11.93 N/A96360 $89.27 $89.27 N/A 97026 $10.74 $10.74 N/A96361 $26.38 $26.38 ZZZ 97028 $13.72 $13.72 N/A96365 $139.32 $139.32 N/A 97032 $26.25 $26.25 N/A96366 $41.93 $41.93 ZZZ 97033 $35.20 $35.20 N/A96367 $60.19 $60.19 ZZZ 97034 $25.65 $25.65 N/A96368 $39.90 $39.90 ZZZ 97035 $22.67 $22.67 N/A96369 $332.06 $332.06 N/A 97036 $60.26 $60.26 N/A96370 $29.76 $29.76 ZZZ 97039 80% of billed 80% of billed N/A96371 $121.73 $121.73 ZZZ 97110 $51.90 $51.90 N/A96372 $39.23 $39.23 N/A 97112 $59.06 $59.06 N/A96373 $36.52 $36.52 N/A 97113 $66.22 $66.22 N/A96374 $88.60 $88.60 N/A 97116 $51.31 $51.31 N/A96375 $34.49 $34.49 ZZZ 97124 $51.90 $51.90 N/A96376 80% of billed 80% of billed ZZZ 97127 80% of billed 80% of billed N/A96377 $39.23 $39.23 N/A 97139 80% of billed 80% of billed N/A96379 80% of billed 80% of billed N/A 97140 $47.13 $47.13 N/A96401 $153.52 $153.52 N/A 97150 $31.02 $31.02 N/A96402 $58.84 $58.84 N/A 97161 $141.99 $141.99 N/A96405 $154.87 $57.49 000 97162 $141.99 $141.99 N/A96406 $227.24 $89.27 000 97163 $141.99 $141.99 N/A96409 $209.65 $209.65 N/A 97164 $96.05 $96.05 N/A96411 $112.27 $112.27 ZZZ 97165 $153.33 $153.33 N/A96413 $271.87 $271.87 N/A 97166 $153.33 $153.33 N/A96415 $59.51 $59.51 ZZZ 97167 $153.33 $153.33 N/A96416 $276.61 $276.61 N/A 97168 $104.40 $104.40 N/A96417 $130.53 $130.53 ZZZ 97169 80% of billed 80% of billed N/A96420 $202.89 $202.89 N/A 97170 80% of billed 80% of billed N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 81 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

97171 80% of billed 80% of billed N/A 98941 $79.58 $79.58 00097172 80% of billed 80% of billed N/A 98942 $101.56 $101.56 00097530 $68.61 $68.61 N/A 98943 $53.82 $53.82 N/A97533 $57.87 $57.87 N/A 98960 $53.43 $53.43 N/A97535 $58.47 $58.47 N/A 98961 $26.38 $26.38 N/A97537 $56.08 $56.08 N/A 98962 $18.94 $18.94 N/A97542 $56.68 $56.68 N/A 98966 $27.05 $24.35 N/A97545 80% of billed 80% of billed N/A 98967 $51.40 $48.69 N/A97546 80% of billed 80% of billed ZZZ 98968 $75.75 $73.04 N/A97597 $141.39 $40.57 000 98969 80% of billed 80% of billed N/A97598 $47.13 $19.09 ZZZ 99000 80% of billed 80% of billed N/A97602 80% of billed 80% of billed N/A 99001 80% of billed 80% of billed N/A97605 $74.57 $44.15 N/A 99002 80% of billed 80% of billed N/A97606 $88.30 $47.73 N/A 99024 80% of billed 80% of billed N/A97607 80% of billed 80% of billed N/A 99026 80% of billed 80% of billed N/A97608 80% of billed 80% of billed N/A 99027 80% of billed 80% of billed N/A97610 $226.11 $28.64 N/A 99050 80% of billed 80% of billed N/A97642 $63.74 $63.74 N/A 99051 80% of billed 80% of billed N/A97643 $32.22 $32.22 N/A 99053 80% of billed 80% of billed N/A97644 $101.56 $101.56 N/A 99056 80% of billed 80% of billed N/A97645 $51.13 $51.13 N/A 99058 80% of billed 80% of billed N/A97646 $63.74 $63.74 N/A 99060 80% of billed 80% of billed N/A97647 $32.22 $32.22 N/A 99070 80% of billed 80% of billed N/A97648 $105.06 $105.06 N/A 99071 80% of billed 80% of billed N/A97649 $52.53 $52.53 N/A 99075 80% of billed 80% of billed N/A97650 $56.73 $56.73 N/A 99078 80% of billed 80% of billed N/A97651 $28.72 $28.72 N/A 99080 80% of billed 80% of billed N/A97652 $37.82 $37.82 N/A 99082 80% of billed 80% of billed N/A97653 $19.61 $19.61 N/A 99090 80% of billed 80% of billed N/A97654 $28.72 $28.72 N/A 99091 $110.24 $110.24 N/A97655 $27.32 $27.32 N/A 99100 80% of billed 80% of billed ZZZ97656 $54.63 $54.63 N/A 99116 80% of billed 80% of billed ZZZ97657 $94.55 $94.55 N/A 99135 80% of billed 80% of billed ZZZ97658 $47.63 $47.63 N/A 99140 80% of billed 80% of billed ZZZ97659 $120.47 $120.47 N/A 99151 $148.79 $47.34 N/A97660 $60.23 $60.23 N/A 99152 $98.74 $24.35 N/A97661 $162.49 $162.49 N/A 99153 $20.97 $20.97 ZZZ97662 $65.84 $65.84 N/A 99155 $185.31 $185.31 N/A97663 $32.92 $32.92 N/A 99156 $145.40 $145.40 N/A97664 $88.98 $88.98 N/A 99157 $110.91 $110.91 ZZZ97665 $44.13 $44.13 N/A 99170 $303.66 $167.05 00097666 $71.44 $71.44 N/A 99172 80% of billed 80% of billed N/A97667 $36.42 $36.42 N/A 99173 $6.09 $6.09 N/A97668 $74.94 $74.94 N/A 99174 $11.50 $11.50 N/A97669 $37.82 $37.82 N/A 99175 $49.37 $49.37 N/A97670 $468.65 $468.65 N/A 99177 $9.47 $9.47 N/A97671 $529.50 $529.50 N/A 99183 $212.36 $212.36 N/A97750 $63.84 $63.84 N/A 99184 $427.42 $427.42 N/A97755 $66.22 $66.22 N/A 99188 $23.67 $19.61 N/A97760 $79.35 $79.35 N/A 99190 80% of billed 80% of billed N/A97761 $68.61 $68.61 N/A 99191 80% of billed 80% of billed N/A97763 $81.73 $81.73 N/A 99192 80% of billed 80% of billed N/A97799 80% of billed 80% of billed N/A 99193 $56.03 $56.03 N/A97802 $66.28 $62.22 N/A 99195 $195.45 $195.45 N/A97803 $57.49 $52.75 N/A 99196 $168.10 $168.10 N/A97804 $30.43 $29.08 N/A 99197 $560.32 $560.32 N/A97810 $69.66 $58.84 N/A 99198 $1,120.64 $1,120.64 N/A97811 $52.75 $48.69 ZZZ 99199 80% of billed 80% of billed N/A97813 $74.39 $63.57 N/A 99201 $88.99 $53.68 N/A97814 $59.51 $53.43 ZZZ 99202 $149.74 $101.00 N/A98925 $60.87 $45.99 000 99203 $215.42 $153.27 N/A98926 $87.92 $68.98 000 99204 $328.43 $258.51 N/A98927 $114.97 $91.30 000 99205 $413.19 $337.61 N/A98928 $139.32 $114.29 000 99211 $43.08 $18.36 N/A98929 $166.37 $138.64 000 99212 $87.58 $50.85 N/A98940 $56.84 $56.84 000 99213 $145.50 $102.41 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 82 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

99214 $214.72 $156.80 N/A 99349 $257.09 $257.09 N/A99215 $289.58 $221.78 N/A 99350 $357.39 $357.39 N/A99217 $146.20 $146.20 N/A 99354 $260.62 $243.67 ZZZ99218 $199.88 $199.88 N/A 99355 $197.06 $182.93 ZZZ99219 $271.93 $271.93 N/A 99356 $184.34 $184.34 ZZZ99220 $372.22 $372.22 N/A 99357 $185.05 $185.05 ZZZ99221 $202.71 $202.71 N/A 99358 $223.19 $223.19 N/A99222 $273.34 $273.34 N/A 99359 $107.36 $107.36 ZZZ99223 $405.42 $405.42 N/A 99360 $122.90 $122.90 N/A99224 $79.81 $79.81 N/A 99366 $85.46 $84.05 N/A99225 $146.20 $146.20 N/A 99367 $113.01 $113.01 N/A99226 $209.77 $209.77 N/A 99368 $73.46 $73.46 N/A99231 $78.40 $78.40 N/A 99374 $139.85 $113.01 N/A99232 $145.50 $145.50 N/A 99375 $209.06 $176.57 N/A99233 $208.36 $208.36 N/A 99377 $139.85 $113.01 N/A99234 $266.28 $266.28 N/A 99378 $209.06 $176.57 N/A99235 $338.32 $338.32 N/A 99379 $139.85 $113.01 N/A99236 $436.49 $436.49 N/A 99380 $209.06 $176.57 N/A99238 $146.20 $146.20 N/A 99381 $221.07 $153.27 N/A99239 $215.42 $215.42 N/A 99382 $230.96 $163.86 N/A99241 $94.64 $64.98 N/A 99383 $240.14 $173.75 N/A99242 $177.99 $136.32 N/A 99384 $271.22 $204.12 N/A99243 $243.67 $190.70 N/A 99385 $262.74 $195.65 N/A99244 $364.45 $306.53 N/A 99386 $305.12 $238.02 N/A99245 $444.26 $379.28 N/A 99387 $330.55 $254.97 N/A99251 $97.47 $97.47 N/A 99391 $198.47 $139.85 N/A99252 $149.03 $149.03 N/A 99392 $211.89 $153.27 N/A99253 $229.55 $229.55 N/A 99393 $211.18 $153.27 N/A99254 $333.37 $333.37 N/A 99394 $231.67 $173.75 N/A99255 $401.18 $401.18 N/A 99395 $236.61 $178.69 N/A99281 $42.38 $42.38 N/A 99396 $252.15 $193.53 N/A99282 $82.64 $82.64 N/A 99397 $271.93 $204.12 N/A99283 $123.60 $123.60 N/A 99401 $75.57 $49.44 N/A99284 $234.49 $234.49 N/A 99402 $125.72 $100.29 N/A99285 $345.38 $345.38 N/A 99403 $175.16 $149.74 N/A99288 80% of billed 80% of billed N/A 99404 $225.31 $199.18 N/A99291 $548.09 $444.97 N/A 99406 $28.96 $24.72 N/A99292 $245.09 $223.19 ZZZ 99407 $55.80 $51.56 N/A99304 $182.23 $182.23 N/A 99408 $70.63 $66.39 N/A99305 $260.62 $260.62 N/A 99409 $137.02 $133.49 N/A99306 $333.37 $333.37 N/A 99411 $36.02 $15.54 N/A99307 $88.99 $88.99 N/A 99412 $45.20 $25.43 N/A99308 $138.43 $138.43 N/A 99415 $19.78 $19.78 ZZZ99309 $182.93 $182.93 N/A 99416 $9.18 $9.18 ZZZ99310 $271.93 $271.93 N/A 99429 80% of billed 80% of billed N/A99315 $145.50 $145.50 N/A 99441 $28.25 $25.43 N/A99316 $211.89 $211.89 N/A 99442 $53.68 $50.85 N/A99318 $192.11 $192.11 N/A 99443 $79.11 $76.28 N/A99324 $110.18 $110.18 N/A 99444 80% of billed 80% of billed N/A99325 $160.33 $160.33 N/A 99446 $36.02 $36.02 N/A99326 $278.28 $278.28 N/A 99447 $71.34 $71.34 N/A99327 $372.22 $372.22 N/A 99448 $107.36 $107.36 N/A99328 $435.79 $435.79 N/A 99449 $143.38 $143.38 N/A99334 $120.07 $120.07 N/A 99450 80% of billed 80% of billed N/A99335 $189.29 $189.29 N/A 99455 80% of billed 80% of billed N/A99336 $270.51 $270.51 N/A 99456 80% of billed 80% of billed N/A99337 $386.35 $386.35 N/A 99460 $191.41 $191.41 N/A99339 $154.68 $154.68 N/A 99461 $181.52 $125.72 N/A99340 $216.83 $216.83 N/A 99462 $83.34 $83.34 N/A99341 $109.48 $109.48 N/A 99463 $221.78 $221.78 N/A99342 $158.92 $158.92 N/A 99464 $149.74 $149.74 N/A99343 $260.62 $260.62 N/A 99465 $291.70 $291.70 N/A99344 $365.16 $365.16 N/A 99466 $477.46 $477.46 N/A99345 $443.56 $443.56 N/A 99467 $238.73 $238.73 ZZZ99347 $110.18 $110.18 N/A 99468 $1,839.21 $1,839.21 N/A99348 $168.10 $168.10 N/A 99469 $796.00 $796.00 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 83 of 84

Page 84: Appendix B for Administrative Order No. 18-053 Physician ...Appendix B for Administrative Order No. 18-053 Physician Fee Schedule Effective April 1, 2018 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2018 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 18-053

Physician Fee Schedule

CPT only copyright 2017 American Medical Association. All rights reserved.

99471 $1,592.00 $1,592.00 N/A N0001 $119.77 $119.77 N/A99472 $823.55 $823.55 N/A N0002 $238.84 $238.84 N/A99475 $1,120.90 $1,120.90 N/A P0001 $299.07 $299.07 N/A99476 $690.76 $690.76 N/A P0003 $299.07 $299.07 N/A99477 $697.82 $697.82 N/A P0004 $358.60 $358.60 N/A99478 $274.04 $274.04 N/A P0005 $151.99 $151.99 N/A99479 $248.62 $248.62 N/A R0001 $10.00 1st pg $10.00 1st pg N/A99480 $239.44 $239.44 N/A 99483 $474.63 $351.03 N/A R0002 $35.00 $35.00 N/A99484 $95.35 $64.27 N/A W0001 as billed as billed N/A99485 $153.27 $153.27 N/A99486 $133.49 $133.49 N/A99487 $185.76 $104.53 N/A99489 $92.53 $52.27 ZZZ99490 $84.05 $64.27 N/A99492 $316.42 $177.28 N/A99493 $252.86 $160.33 N/A99494 $130.67 $85.46 ZZZ99495 $327.72 $220.37 N/A99496 $464.04 $319.95 N/A99497 $168.81 $158.21 N/A99498 $149.03 $148.32 ZZZ99499 80% of billed 80% of billed N/A99500 80% of billed 80% of billed N/A99501 80% of billed 80% of billed N/A99502 80% of billed 80% of billed N/A99503 80% of billed 80% of billed N/A99504 80% of billed 80% of billed N/A99505 80% of billed 80% of billed N/A99506 80% of billed 80% of billed N/A99507 80% of billed 80% of billed N/A99509 80% of billed 80% of billed N/A99510 80% of billed 80% of billed N/A99511 80% of billed 80% of billed N/A99512 80% of billed 80% of billed N/A99600 80% of billed 80% of billed N/A99601 80% of billed 80% of billed N/A99602 80% of billed 80% of billed N/A99605 80% of billed 80% of billed N/A99606 80% of billed 80% of billed N/A99607 80% of billed 80% of billed N/AAR001 $358.60 $358.60 N/AAR002 $477.67 $477.67 N/AAR003 $597.44 $597.44 N/AAR004 $179.30 $179.30 N/AAR011 $61.64 $61.64 N/AAR012 $92.45 $92.45 N/AAR013 $123.97 $123.97 N/AAR021 $61.64 $61.64 N/AAR022 $154.79 $154.79 N/AAR023 $371.21 $371.21 N/AAR024 $716.51 $716.51 N/AAR025 $956.05 $956.05 N/AAR031 $61.64 $61.64 N/AAR032 $123.97 $123.97 N/ACE001 80% of billed 80% of billed N/ACR001 80% of billed 80% of billed N/AD0001 as billed as billed N/AD0002 as billed as billed N/AD0003 as billed as billed N/AD0019 as billed as billed N/AD0030 as billed as billed N/AG0480 $127.75 $127.75 N/AG0481 $196.53 $196.53 N/AG0482 $265.32 $265.32 N/AG0483 $343.93 $343.93 N/A

$.50 for each page thereafter

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 84 of 84