colorado - tricare west001=physician rate 004=non-physician a0225 00 f 2018-01-01 9901-01-01 co...

60
COLORADO State Prevailing Rates TRICARE West Region CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING AMOUNT 001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO $447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO $447.37 004 A0430 00 2021-01-01 9901-01-01 CO $4,382.76 001 A0430 00 F 2021-01-01 9901-01-01 CO $4,382.76 001 A0430 00 2021-01-01 9901-01-01 CO $4,382.76 004 A0430 00 F 2021-01-01 9901-01-01 CO $4,382.76 004 A0430 00 2020-01-01 2021-01-01 CO $5,156.19 001 A0430 00 F 2020-01-01 2021-01-01 CO $5,156.19 001 A0430 00 2020-01-01 2021-01-01 CO $5,156.19 004 A0430 00 F 2020-01-01 2021-01-01 CO $5,156.19 004 A0430 00 2019-01-01 2020-01-01 CO $6,066.11 001 A0430 00 F 2019-01-01 2020-01-01 CO $6,066.11 001 A0430 00 2019-01-01 2020-01-01 CO $6,066.11 004 A0430 00 F 2019-01-01 2020-01-01 CO $6,066.11 004 A0430 00 2018-01-01 2019-01-01 CO $7,136.60 001 A0430 00 F 2018-01-01 2019-01-01 CO $7,136.60 001 A0430 00 2018-01-01 2019-01-01 CO $7,136.60 004 A0430 00 F 2018-01-01 2019-01-01 CO $7,136.60 004 A0430 00 2017-01-01 2018-01-01 CO $8,396.00 001 A0430 00 F 2017-01-01 2018-01-01 CO $8,396.00 001 A0430 00 2017-01-01 2018-01-01 CO $8,396.00 004 A0430 00 F 2017-01-01 2018-01-01 CO $8,396.00 004 A0430 00 F 2016-01-01 2017-01-01 CO $9,877.65 001 A0430 00 F 2016-01-01 2017-01-01 CO $9,877.65 004 A0431 00 2021-01-01 9901-01-01 CO $3,959.27 001 A0431 00 F 2021-01-01 9901-01-01 CO $3,959.27 001 A0431 00 2021-01-01 9901-01-01 CO $3,959.27 004 A0431 00 F 2021-01-01 9901-01-01 CO $3,959.27 004 A0431 00 2020-01-01 2021-01-01 CO $4,657.96 001 A0431 00 F 2020-01-01 2021-01-01 CO $4,657.96 001 A0431 00 2020-01-01 2021-01-01 CO $4,657.96 004 A0431 00 F 2020-01-01 2021-01-01 CO $4,657.96 004 A0431 00 2019-01-01 2020-01-01 CO $5,479.95 001 A0431 00 F 2019-01-01 2020-01-01 CO $5,479.95 001 A0431 00 2019-01-01 2020-01-01 CO $5,479.95 004 A0431 00 F 2019-01-01 2020-01-01 CO $5,479.95 004 A0431 00 2018-01-01 2019-01-01 CO $6,447.00 001 A0431 00 F 2018-01-01 2019-01-01 CO $6,447.00 001 A0431 00 2018-01-01 2019-01-01 CO $6,447.00 004 A0431 00 F 2018-01-01 2019-01-01 CO $6,447.00 004 A0431 00 2017-01-01 2018-01-01 CO $7,584.71 001 A0431 00 F 2017-01-01 2018-01-01 CO $7,584.71 001 A0431 00 2017-01-01 2018-01-01 CO $7,584.71 004 A0431 00 F 2017-01-01 2018-01-01 CO $7,584.71 004 A0431 00 F 2016-01-01 2017-01-01 CO $8,923.19 001 A0431 00 F 2016-01-01 2017-01-01 CO $8,923.19 004 A0435 00 2021-01-01 9901-01-01 CO $22.70 001 A0435 00 F 2021-01-01 9901-01-01 CO $22.70 001 A0435 00 2021-01-01 9901-01-01 CO $22.70 004 A0435 00 F 2021-01-01 9901-01-01 CO $22.70 004 A0435 00 2020-01-01 2021-01-01 CO $26.71 001 A0435 00 F 2020-01-01 2021-01-01 CO $26.71 001 A0435 00 2020-01-01 2021-01-01 CO $26.71 004 Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial. Revised: 7/13/2021 Page 1 of 60

Upload: others

Post on 25-Feb-2021

2 views

Category:

Documents


0 download

TRANSCRIPT

Page 1: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

A0225 00 F 2018-01-01 9901-01-01 CO $447.37 001A0225 00 F 2018-01-01 9901-01-01 CO $447.37 004A0430 00 2021-01-01 9901-01-01 CO $4,382.76 001A0430 00 F 2021-01-01 9901-01-01 CO $4,382.76 001A0430 00 2021-01-01 9901-01-01 CO $4,382.76 004A0430 00 F 2021-01-01 9901-01-01 CO $4,382.76 004A0430 00 2020-01-01 2021-01-01 CO $5,156.19 001A0430 00 F 2020-01-01 2021-01-01 CO $5,156.19 001A0430 00 2020-01-01 2021-01-01 CO $5,156.19 004A0430 00 F 2020-01-01 2021-01-01 CO $5,156.19 004A0430 00 2019-01-01 2020-01-01 CO $6,066.11 001A0430 00 F 2019-01-01 2020-01-01 CO $6,066.11 001A0430 00 2019-01-01 2020-01-01 CO $6,066.11 004A0430 00 F 2019-01-01 2020-01-01 CO $6,066.11 004A0430 00 2018-01-01 2019-01-01 CO $7,136.60 001A0430 00 F 2018-01-01 2019-01-01 CO $7,136.60 001A0430 00 2018-01-01 2019-01-01 CO $7,136.60 004A0430 00 F 2018-01-01 2019-01-01 CO $7,136.60 004A0430 00 2017-01-01 2018-01-01 CO $8,396.00 001A0430 00 F 2017-01-01 2018-01-01 CO $8,396.00 001A0430 00 2017-01-01 2018-01-01 CO $8,396.00 004A0430 00 F 2017-01-01 2018-01-01 CO $8,396.00 004A0430 00 F 2016-01-01 2017-01-01 CO $9,877.65 001A0430 00 F 2016-01-01 2017-01-01 CO $9,877.65 004A0431 00 2021-01-01 9901-01-01 CO $3,959.27 001A0431 00 F 2021-01-01 9901-01-01 CO $3,959.27 001A0431 00 2021-01-01 9901-01-01 CO $3,959.27 004A0431 00 F 2021-01-01 9901-01-01 CO $3,959.27 004A0431 00 2020-01-01 2021-01-01 CO $4,657.96 001A0431 00 F 2020-01-01 2021-01-01 CO $4,657.96 001A0431 00 2020-01-01 2021-01-01 CO $4,657.96 004A0431 00 F 2020-01-01 2021-01-01 CO $4,657.96 004A0431 00 2019-01-01 2020-01-01 CO $5,479.95 001A0431 00 F 2019-01-01 2020-01-01 CO $5,479.95 001A0431 00 2019-01-01 2020-01-01 CO $5,479.95 004A0431 00 F 2019-01-01 2020-01-01 CO $5,479.95 004A0431 00 2018-01-01 2019-01-01 CO $6,447.00 001A0431 00 F 2018-01-01 2019-01-01 CO $6,447.00 001A0431 00 2018-01-01 2019-01-01 CO $6,447.00 004A0431 00 F 2018-01-01 2019-01-01 CO $6,447.00 004A0431 00 2017-01-01 2018-01-01 CO $7,584.71 001A0431 00 F 2017-01-01 2018-01-01 CO $7,584.71 001A0431 00 2017-01-01 2018-01-01 CO $7,584.71 004A0431 00 F 2017-01-01 2018-01-01 CO $7,584.71 004A0431 00 F 2016-01-01 2017-01-01 CO $8,923.19 001A0431 00 F 2016-01-01 2017-01-01 CO $8,923.19 004A0435 00 2021-01-01 9901-01-01 CO $22.70 001A0435 00 F 2021-01-01 9901-01-01 CO $22.70 001A0435 00 2021-01-01 9901-01-01 CO $22.70 004A0435 00 F 2021-01-01 9901-01-01 CO $22.70 004A0435 00 2020-01-01 2021-01-01 CO $26.71 001A0435 00 F 2020-01-01 2021-01-01 CO $26.71 001A0435 00 2020-01-01 2021-01-01 CO $26.71 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 1 of 60

Page 2: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

A0435 00 F 2020-01-01 2021-01-01 CO $26.71 004A0435 00 2019-01-01 2020-01-01 CO $31.42 001A0435 00 F 2019-01-01 2020-01-01 CO $31.42 001A0435 00 2019-01-01 2020-01-01 CO $31.42 004A0435 00 F 2019-01-01 2020-01-01 CO $31.42 004A0435 00 2018-01-01 2019-01-01 CO $36.96 001A0435 00 F 2018-01-01 2019-01-01 CO $36.96 001A0435 00 2018-01-01 2019-01-01 CO $36.96 004A0435 00 F 2018-01-01 2019-01-01 CO $36.96 004A0435 00 2017-01-01 2018-01-01 CO $43.48 001A0435 00 F 2017-01-01 2018-01-01 CO $43.48 001A0435 00 2017-01-01 2018-01-01 CO $43.48 004A0435 00 F 2017-01-01 2018-01-01 CO $43.48 004A0435 00 F 2016-01-01 2017-01-01 CO $51.15 001A0435 00 F 2016-01-01 2017-01-01 CO $51.15 004A0436 00 2021-01-01 9901-01-01 CO $43.28 001A0436 00 F 2021-01-01 9901-01-01 CO $43.28 001A0436 00 2021-01-01 9901-01-01 CO $43.28 004A0436 00 F 2021-01-01 9901-01-01 CO $43.28 004A0436 00 2020-01-01 2021-01-01 CO $50.92 001A0436 00 F 2020-01-01 2021-01-01 CO $50.92 001A0436 00 2020-01-01 2021-01-01 CO $50.92 004A0436 00 F 2020-01-01 2021-01-01 CO $50.92 004A0436 00 2019-01-01 2020-01-01 CO $59.90 001A0436 00 F 2019-01-01 2020-01-01 CO $59.90 001A0436 00 2019-01-01 2020-01-01 CO $59.90 004A0436 00 F 2019-01-01 2020-01-01 CO $59.90 004A0436 00 2018-01-01 2019-01-01 CO $70.47 001A0436 00 F 2018-01-01 2019-01-01 CO $70.47 001A0436 00 2018-01-01 2019-01-01 CO $70.47 004A0436 00 F 2018-01-01 2019-01-01 CO $70.47 004A0436 00 2017-01-01 2018-01-01 CO $82.91 001A0436 00 F 2017-01-01 2018-01-01 CO $82.91 001A0436 00 2017-01-01 2018-01-01 CO $82.91 004A0436 00 F 2017-01-01 2018-01-01 CO $82.91 004A0436 00 F 2016-01-01 2017-01-01 CO $97.54 001A0436 00 F 2016-01-01 2017-01-01 CO $97.54 004A4206 00 G 2021-03-01 9901-01-01 CO $0.99 001A4206 00 G 2021-03-01 9901-01-01 CO $0.99 004A4206 00 G 2020-03-01 2021-03-01 CO $0.71 001A4206 00 G 2020-03-01 2021-03-01 CO $0.71 004A4206 00 G 2019-03-01 2020-03-01 CO $50.00 001A4206 00 G 2019-03-01 2020-03-01 CO $50.00 004A4206 00 G 2018-03-01 2019-03-01 CO $50.00 001A4206 00 G 2018-03-01 2019-03-01 CO $50.00 004A4206 00 G 2018-01-01 2018-03-01 CO $20.00 001A4206 00 G 2018-01-01 2018-03-01 CO $20.00 004A4206 00 G 2017-03-01 2018-01-01 CO $20.00 001A4206 00 G 2017-03-01 2018-01-01 CO $20.00 004A4206 00 G 2016-04-01 2017-03-01 CO $20.00 001A4206 00 G 2016-04-01 2017-03-01 CO $20.00 004A4208 00 G 2020-03-01 9901-01-01 CO $0.50 001A4208 00 G 2020-03-01 9901-01-01 CO $0.50 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 2 of 60

Page 3: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

A4208 00 G 2019-03-01 2020-03-01 CO $3.00 001A4208 00 G 2019-03-01 2020-03-01 CO $3.00 004A4208 00 G 2018-03-01 2019-03-01 CO $3.00 001A4208 00 G 2018-03-01 2019-03-01 CO $3.00 004A4208 00 G 2018-01-01 2018-03-01 CO $3.00 001A4208 00 G 2018-01-01 2018-03-01 CO $3.00 004A4208 00 G 2017-03-01 2018-01-01 CO $3.00 001A4208 00 G 2017-03-01 2018-01-01 CO $3.00 004A4208 00 G 2016-04-01 2017-03-01 CO $3.00 001A4208 00 G 2016-04-01 2017-03-01 CO $3.00 004A4209 00 G 2021-03-01 9901-01-01 CO $1.30 001A4209 00 G 2021-03-01 9901-01-01 CO $1.30 004A4209 00 G 2020-03-01 2021-03-01 CO $3.51 001A4209 00 G 2020-03-01 2021-03-01 CO $3.51 004A4209 00 G 2019-03-01 2020-03-01 CO $7.50 001A4209 00 G 2019-03-01 2020-03-01 CO $7.50 004A4209 00 G 2018-03-01 2019-03-01 CO $7.50 001A4209 00 G 2018-03-01 2019-03-01 CO $7.50 004A4209 00 G 2018-01-01 2018-03-01 CO $7.50 001A4209 00 G 2018-01-01 2018-03-01 CO $7.50 004A4209 00 G 2017-03-01 2018-01-01 CO $7.50 001A4209 00 G 2017-03-01 2018-01-01 CO $7.50 004A4209 00 G 2016-04-01 2017-03-01 CO $7.50 001A4209 00 G 2016-04-01 2017-03-01 CO $7.50 004A4210 00 G 2018-01-01 9901-01-01 CO $3.54 001A4210 00 G 2018-01-01 9901-01-01 CO $3.54 004A4211 00 G 2021-03-01 9901-01-01 CO $222.48 001A4211 00 G 2021-03-01 9901-01-01 CO $222.48 004A4211 00 G 2018-01-01 2021-03-01 CO $33.48 001A4211 00 G 2018-01-01 2021-03-01 CO $33.48 004A4211 00 G 2017-03-01 2018-01-01 CO $33.48 001A4211 00 G 2017-03-01 2018-01-01 CO $33.48 004A4211 00 G 2016-04-01 2017-03-01 CO $33.48 001A4211 00 G 2016-04-01 2017-03-01 CO $33.48 004A4212 00 G 2018-03-01 9901-01-01 CO $31.00 001A4212 00 G 2018-03-01 9901-01-01 CO $31.00 004A4212 00 G 2018-01-01 2018-03-01 CO $15.00 001A4212 00 G 2018-01-01 2018-03-01 CO $15.00 004A4213 00 G 2021-03-01 9901-01-01 CO $1.93 001A4213 00 G 2021-03-01 9901-01-01 CO $1.93 004A4213 00 G 2020-03-01 2021-03-01 CO $10.08 001A4213 00 G 2020-03-01 2021-03-01 CO $10.08 004A4213 00 G 2019-03-01 2020-03-01 CO $10.15 001A4213 00 G 2019-03-01 2020-03-01 CO $10.15 004A4213 00 G 2018-03-01 2019-03-01 CO $10.15 001A4213 00 G 2018-03-01 2019-03-01 CO $10.15 004A4213 00 G 2018-01-01 2018-03-01 CO $8.25 001A4213 00 G 2018-01-01 2018-03-01 CO $8.25 004A4213 00 G 2017-03-01 2018-01-01 CO $8.25 001A4213 00 G 2017-03-01 2018-01-01 CO $8.25 004A4213 00 G 2016-04-01 2017-03-01 CO $8.25 001A4213 00 G 2016-04-01 2017-03-01 CO $8.25 004A4215 00 G 2020-03-01 9901-01-01 CO $63.00 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 3 of 60

Page 4: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

A4215 00 G 2020-03-01 9901-01-01 CO $63.00 004A4215 00 G 2019-03-01 2020-03-01 CO $63.00 001A4215 00 G 2019-03-01 2020-03-01 CO $63.00 004A4215 00 G 2018-03-01 2019-03-01 CO $63.00 001A4215 00 G 2018-03-01 2019-03-01 CO $63.00 004A4215 00 G 2018-01-01 2018-03-01 CO $63.00 001A4215 00 G 2018-01-01 2018-03-01 CO $63.00 004A4215 00 G 2017-03-01 2018-01-01 CO $63.00 001A4215 00 G 2017-03-01 2018-01-01 CO $63.00 004A4215 00 G 2016-04-01 2017-03-01 CO $63.00 001A4215 00 G 2016-04-01 2017-03-01 CO $63.00 004A4218 00 G 2018-01-01 9901-01-01 CO $5.76 001A4218 00 G 2018-01-01 9901-01-01 CO $5.76 004A4220 00 G 2018-01-01 9901-01-01 CO $120.00 001A4220 00 G 2018-01-01 9901-01-01 CO $120.00 004A4220 00 G 2017-03-01 2018-01-01 CO $120.00 001A4220 00 G 2017-03-01 2018-01-01 CO $120.00 004A4220 00 G 2016-04-01 2017-03-01 CO $120.00 001A4223 00 G 2021-03-01 9901-01-01 CO $200.00 001A4223 00 G 2021-03-01 9901-01-01 CO $200.00 004A4223 00 G 2020-03-01 2021-03-01 CO $200.00 001A4223 00 G 2020-03-01 2021-03-01 CO $200.00 004A4223 00 G 2019-03-01 2020-03-01 CO $225.00 001A4223 00 G 2019-03-01 2020-03-01 CO $225.00 004A4223 00 G 2018-03-01 2019-03-01 CO $225.00 001A4223 00 G 2018-03-01 2019-03-01 CO $225.00 004A4223 00 G 2018-01-01 2018-03-01 CO $225.00 001A4223 00 G 2018-01-01 2018-03-01 CO $225.00 004A4223 00 G 2017-03-01 2018-01-01 CO $225.00 001A4223 00 G 2017-03-01 2018-01-01 CO $225.00 004A4223 00 G 2016-04-01 2017-03-01 CO $225.00 001A4223 00 G 2016-04-01 2017-03-01 CO $225.00 004A4230 NU G 2021-03-01 9901-01-01 CO $17.82 001A4230 NU G 2021-03-01 9901-01-01 CO $17.82 004A4230 NU G 2018-01-01 2021-03-01 CO $12.70 001A4230 NU G 2018-01-01 2021-03-01 CO $12.70 004A4230 00 G 2021-03-01 9901-01-01 CO $35.00 001A4230 00 G 2021-03-01 9901-01-01 CO $35.00 004A4230 00 G 2018-01-01 2021-03-01 CO $12.70 001A4230 00 G 2018-01-01 2021-03-01 CO $12.70 004A4231 00 G 2018-01-01 9901-01-01 CO $7.77 001A4231 00 G 2018-01-01 9901-01-01 CO $7.77 004A4232 NU G 2021-03-01 9901-01-01 CO $4.29 001A4232 NU G 2021-03-01 9901-01-01 CO $4.29 004A4232 NU G 2018-01-01 2021-03-01 CO $4.56 001A4232 NU G 2018-01-01 2021-03-01 CO $4.56 004A4232 00 G 2021-03-01 9901-01-01 CO $8.25 001A4232 00 G 2021-03-01 9901-01-01 CO $8.25 004A4232 00 G 2018-01-01 2021-03-01 CO $4.56 001A4232 00 G 2018-01-01 2021-03-01 CO $4.56 004A4244 00 G 2021-03-01 9901-01-01 CO $1.02 001A4244 00 G 2021-03-01 9901-01-01 CO $1.02 004A4244 00 G 2020-03-01 2021-03-01 CO $1.02 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 4 of 60

Page 5: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

A4244 00 G 2020-03-01 2021-03-01 CO $1.02 004A4244 00 G 2018-03-01 2020-03-01 CO $3.73 001A4244 00 G 2018-03-01 2020-03-01 CO $3.73 004A4244 00 G 2018-01-01 2018-03-01 CO $3.73 001A4244 00 G 2018-01-01 2018-03-01 CO $3.73 004A4244 00 G 2017-03-01 2018-01-01 CO $3.73 001A4244 00 G 2017-03-01 2018-01-01 CO $3.73 004A4244 00 G 2016-04-01 2017-03-01 CO $3.73 001A4244 00 G 2016-04-01 2017-03-01 CO $3.73 004A4245 00 G 2021-03-01 9901-01-01 CO $19.95 001A4245 00 G 2021-03-01 9901-01-01 CO $19.95 004A4245 00 G 2019-03-01 2021-03-01 CO $2.00 001A4245 00 G 2019-03-01 2021-03-01 CO $2.00 004A4245 00 G 2018-03-01 2019-03-01 CO $2.00 001A4245 00 G 2018-03-01 2019-03-01 CO $2.00 004A4245 00 G 2018-01-01 2018-03-01 CO $2.00 001A4245 00 G 2018-01-01 2018-03-01 CO $2.00 004A4245 00 G 2017-03-01 2018-01-01 CO $2.00 001A4245 00 G 2017-03-01 2018-01-01 CO $2.00 004A4245 00 G 2016-04-01 2017-03-01 CO $2.00 001A4245 00 G 2016-04-01 2017-03-01 CO $2.00 004A4247 00 G 2021-03-01 9901-01-01 CO $10.36 001A4247 00 G 2021-03-01 9901-01-01 CO $10.36 004A4247 00 G 2020-03-01 2021-03-01 CO $2.73 001A4247 00 G 2020-03-01 2021-03-01 CO $2.73 004A4247 00 G 2019-03-01 2020-03-01 CO $0.51 001A4247 00 G 2019-03-01 2020-03-01 CO $0.51 004A4247 00 G 2018-03-01 2019-03-01 CO $0.51 001A4247 00 G 2018-03-01 2019-03-01 CO $0.51 004A4247 00 G 2018-01-01 2018-03-01 CO $0.51 001A4247 00 G 2018-01-01 2018-03-01 CO $0.51 004A4247 00 G 2017-03-01 2018-01-01 CO $0.51 001A4247 00 G 2017-03-01 2018-01-01 CO $0.51 004A4247 00 G 2016-04-01 2017-03-01 CO $0.51 001A4247 00 G 2016-04-01 2017-03-01 CO $0.51 004A4250 00 G 2021-03-01 9901-01-01 CO $39.95 001A4250 00 G 2021-03-01 9901-01-01 CO $39.95 004A4250 00 G 2020-03-01 2021-03-01 CO $5.00 001A4250 00 G 2020-03-01 2021-03-01 CO $5.00 004A4250 00 G 2018-01-01 2020-03-01 CO $16.00 001A4250 00 G 2018-01-01 2020-03-01 CO $16.00 004A4262 00 G 2018-03-01 9901-01-01 CO $41.88 001A4262 00 G 2018-03-01 9901-01-01 CO $41.88 004A4262 00 G 2018-01-01 2018-03-01 CO $41.88 001A4262 00 G 2018-01-01 2018-03-01 CO $41.88 004A4262 00 G 2016-04-01 2018-01-01 CO $41.88 001A4262 00 G 2016-04-01 2018-01-01 CO $41.88 004A4263 00 G 2020-03-01 9901-01-01 CO $109.00 001A4263 00 G 2020-03-01 9901-01-01 CO $109.00 004A4263 00 G 2019-03-01 2020-03-01 CO $80.00 001A4263 00 G 2019-03-01 2020-03-01 CO $80.00 004A4263 00 G 2018-03-01 2019-03-01 CO $80.00 001A4263 00 G 2018-03-01 2019-03-01 CO $80.00 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 5 of 60

Page 6: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

A4263 00 G 2018-01-01 2018-03-01 CO $80.00 001A4263 00 G 2018-01-01 2018-03-01 CO $65.00 004A4263 00 G 2017-03-01 2018-01-01 CO $80.00 001A4263 00 G 2017-03-01 2018-01-01 CO $65.00 004A4263 00 G 2016-04-01 2017-03-01 CO $80.00 001A4264 00 G 2018-01-01 9901-01-01 CO $5,577.26 001A4264 00 G 2018-01-01 9901-01-01 CO $5,577.26 004A4264 00 G 2016-04-01 2018-01-01 CO $5,577.26 001A4264 00 G 2016-04-01 2018-01-01 CO $5,577.26 004A4267 00 G 2018-01-01 9901-01-01 CO $0.05 001A4267 00 G 2018-01-01 9901-01-01 CO $0.05 004A4268 00 G 2018-01-01 9901-01-01 CO $0.59 001A4268 00 G 2018-01-01 9901-01-01 CO $0.59 004A4270 00 G 2018-01-01 9901-01-01 CO $35.00 001A4270 00 G 2018-01-01 9901-01-01 CO $35.00 004A4290 00 G 2018-01-01 9901-01-01 CO $500.00 001A4290 00 G 2018-01-01 9901-01-01 CO $500.00 004A4300 00 G 2018-01-01 9901-01-01 CO $49.40 001A4300 00 G 2018-01-01 9901-01-01 CO $49.40 004A4301 00 G 2018-01-01 9901-01-01 CO $644.15 001A4301 00 G 2018-01-01 9901-01-01 CO $644.15 004A4305 00 G 2021-03-01 9901-01-01 CO $200.00 001A4305 00 G 2021-03-01 9901-01-01 CO $200.00 004A4305 00 G 2020-03-01 2021-03-01 CO $200.00 001A4305 00 G 2020-03-01 2021-03-01 CO $200.00 004A4305 00 G 2019-03-01 2020-03-01 CO $200.00 001A4305 00 G 2019-03-01 2020-03-01 CO $200.00 004A4305 00 G 2018-03-01 2019-03-01 CO $200.00 001A4305 00 G 2018-03-01 2019-03-01 CO $200.00 004A4305 00 G 2018-01-01 2018-03-01 CO $200.00 001A4305 00 G 2018-01-01 2018-03-01 CO $200.00 004A4305 00 G 2017-03-01 2018-01-01 CO $200.00 001A4305 00 G 2017-03-01 2018-01-01 CO $200.00 004A4305 00 G 2016-04-01 2017-03-01 CO $196.47 001A4305 00 G 2016-04-01 2017-03-01 CO $196.47 004A4306 00 G 2021-03-01 9901-01-01 CO $200.00 001A4306 00 G 2021-03-01 9901-01-01 CO $200.00 004A4306 00 G 2020-03-01 2021-03-01 CO $435.43 001A4306 00 G 2020-03-01 2021-03-01 CO $435.43 004A4306 00 G 2019-03-01 2020-03-01 CO $483.13 001A4306 00 G 2019-03-01 2020-03-01 CO $483.13 004A4306 00 G 2018-03-01 2019-03-01 CO $483.13 001A4306 00 G 2018-03-01 2019-03-01 CO $483.13 004A4306 00 G 2018-01-01 2018-03-01 CO $483.13 001A4306 00 G 2018-01-01 2018-03-01 CO $483.13 004A4306 00 G 2017-03-01 2018-01-01 CO $483.13 001A4306 00 G 2017-03-01 2018-01-01 CO $483.13 004A4306 00 G 2016-04-01 2017-03-01 CO $483.13 001A4306 00 G 2016-04-01 2017-03-01 CO $483.13 004A4459 00 G 2020-04-25 9901-01-01 CO $4,612.50 001A4459 00 G 2020-04-25 9901-01-01 CO $4,612.50 004A4465 00 G 2018-01-01 9901-01-01 CO $31.95 001A4465 00 G 2018-01-01 9901-01-01 CO $31.95 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 6 of 60

Page 7: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

A4466 00 G 2016-04-01 9901-01-01 CO $75.00 001A4466 00 G 2016-04-01 9901-01-01 CO $75.00 004A4467 00 G 2020-03-01 9901-01-01 CO $44.00 001A4467 00 G 2020-03-01 9901-01-01 CO $44.00 004A4467 00 G 2019-03-01 2020-03-01 CO $44.00 001A4467 00 G 2019-03-01 2020-03-01 CO $44.00 004A4467 00 G 2018-03-01 2019-03-01 CO $35.00 001A4467 00 G 2018-03-01 2019-03-01 CO $35.00 004A4467 00 G 2018-01-01 2018-03-01 CO $35.00 001A4467 00 G 2018-01-01 2018-03-01 CO $35.00 004A4467 00 G 2017-04-12 2018-01-01 CO $35.00 001A4467 00 G 2017-04-12 2018-01-01 CO $35.00 004A4480 00 G 2018-01-01 9901-01-01 CO $50.00 001A4480 00 G 2018-01-01 9901-01-01 CO $50.00 004A4483 00 G 2021-03-01 9901-01-01 CO $8.16 001A4483 00 G 2021-03-01 9901-01-01 CO $8.16 004A4483 00 G 2018-01-01 2021-03-01 CO $28.80 001A4483 00 G 2018-01-01 2021-03-01 CO $28.80 004A4495 00 G 2018-01-01 9901-01-01 CO $49.67 001A4495 00 G 2018-01-01 9901-01-01 CO $49.67 004A4500 00 G 2018-01-01 9901-01-01 CO $50.00 001A4500 00 G 2018-01-01 9901-01-01 CO $50.00 004A4510 00 G 2018-01-01 9901-01-01 CO $86.73 001A4510 00 G 2018-01-01 9901-01-01 CO $86.73 004A4550 00 G 2020-03-01 9901-01-01 CO $114.50 001A4550 00 G 2020-03-01 9901-01-01 CO $114.50 004A4550 00 G 2019-03-01 2020-03-01 CO $118.00 001A4550 00 G 2019-03-01 2020-03-01 CO $118.00 004A4550 00 G 2018-03-01 2019-03-01 CO $114.50 001A4550 00 G 2018-03-01 2019-03-01 CO $114.50 004A4550 00 G 2018-01-01 2018-03-01 CO $114.50 001A4550 00 G 2018-01-01 2018-03-01 CO $114.50 004A4550 00 G 2017-03-01 2018-01-01 CO $114.50 001A4550 00 G 2017-03-01 2018-01-01 CO $114.50 004A4550 00 G 2016-04-01 2017-03-01 CO $90.00 001A4550 00 G 2016-04-01 2017-03-01 CO $90.00 004A4553 00 G 2019-12-07 9901-01-01 CO $22.95 001A4553 00 G 2019-12-07 9901-01-01 CO $22.95 004A4554 00 G 2020-03-01 9901-01-01 CO $1.39 001A4554 00 G 2020-03-01 9901-01-01 CO $1.39 004A4554 00 G 2019-03-01 2020-03-01 CO $2.00 001A4554 00 G 2019-03-01 2020-03-01 CO $2.00 004A4554 00 G 2018-03-01 2019-03-01 CO $2.00 001A4554 00 G 2018-03-01 2019-03-01 CO $2.00 004A4554 00 G 2018-01-01 2018-03-01 CO $2.00 001A4554 00 G 2018-01-01 2018-03-01 CO $2.00 004A4554 00 G 2017-03-01 2018-01-01 CO $2.00 001A4554 00 G 2017-03-01 2018-01-01 CO $2.00 004A4554 00 G 2016-04-01 2017-03-01 CO $2.00 001A4554 00 G 2016-04-01 2017-03-01 CO $2.00 004A4570 00 G 2021-03-01 9901-01-01 CO $61.00 001A4570 00 G 2021-03-01 9901-01-01 CO $61.00 004A4570 00 G 2020-03-01 2021-03-01 CO $34.00 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 7 of 60

Page 8: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

A4570 00 G 2020-03-01 2021-03-01 CO $34.00 004A4570 00 G 2019-03-01 2020-03-01 CO $49.44 001A4570 00 G 2019-03-01 2020-03-01 CO $49.44 004A4570 00 G 2018-03-01 2019-03-01 CO $34.00 001A4570 00 G 2018-03-01 2019-03-01 CO $34.00 004A4570 00 G 2018-01-01 2018-03-01 CO $34.00 001A4570 00 G 2018-01-01 2018-03-01 CO $34.00 004A4570 00 G 2017-03-01 2018-01-01 CO $34.00 001A4570 00 G 2017-03-01 2018-01-01 CO $34.00 004A4570 00 G 2016-04-01 2017-03-01 CO $34.00 001A4570 00 G 2016-04-01 2017-03-01 CO $34.00 004A4580 00 G 2018-03-01 9901-01-01 CO $100.00 001A4580 00 G 2018-03-01 9901-01-01 CO $100.00 004A4580 00 G 2018-01-01 2018-03-01 CO $100.00 001A4580 00 G 2018-01-01 2018-03-01 CO $100.00 004A4580 00 G 2017-03-01 2018-01-01 CO $100.00 001A4580 00 G 2017-03-01 2018-01-01 CO $100.00 004A4580 00 G 2016-04-01 2017-03-01 CO $100.00 001A4590 00 G 2021-03-01 9901-01-01 CO $49.00 001A4590 00 G 2021-03-01 9901-01-01 CO $49.00 004A4590 00 G 2020-03-01 2021-03-01 CO $46.00 001A4590 00 G 2020-03-01 2021-03-01 CO $46.00 004A4590 00 G 2018-03-01 2020-03-01 CO $95.00 001A4590 00 G 2018-03-01 2020-03-01 CO $95.00 004A4590 00 G 2018-01-01 2018-03-01 CO $95.00 001A4590 00 G 2018-01-01 2018-03-01 CO $95.00 004A4590 00 G 2017-03-01 2018-01-01 CO $95.00 001A4590 00 G 2017-03-01 2018-01-01 CO $95.00 004A4590 00 G 2016-04-01 2017-03-01 CO $95.00 001A4590 00 G 2016-04-01 2017-03-01 CO $95.00 004A4600 00 G 2018-01-01 9901-01-01 CO $196.60 001A4600 00 G 2018-01-01 9901-01-01 CO $196.60 004A4601 NU G 2021-03-01 9901-01-01 CO $99.00 001A4601 NU G 2021-03-01 9901-01-01 CO $99.00 004A4601 NU G 2020-04-25 2021-03-01 CO $99.00 001A4601 NU G 2020-04-25 2021-03-01 CO $99.00 004A4606 NU G 2021-03-01 9901-01-01 CO $50.00 001A4606 NU G 2021-03-01 9901-01-01 CO $50.00 004A4606 NU G 2020-03-01 2021-03-01 CO $92.78 001A4606 NU G 2020-03-01 2021-03-01 CO $92.78 004A4606 NU G 2019-03-01 2020-03-01 CO $271.85 001A4606 NU G 2019-03-01 2020-03-01 CO $271.85 004A4606 NU G 2018-03-01 2019-03-01 CO $271.85 001A4606 NU G 2018-03-01 2019-03-01 CO $271.85 004A4606 NU G 2018-01-01 2018-03-01 CO $271.85 001A4606 NU G 2018-01-01 2018-03-01 CO $271.85 004A4606 00 G 2021-03-01 9901-01-01 CO $83.10 001A4606 00 G 2021-03-01 9901-01-01 CO $83.10 004A4606 00 G 2020-03-01 2021-03-01 CO $262.90 001A4606 00 G 2020-03-01 2021-03-01 CO $262.90 004A4606 00 G 2019-03-01 2020-03-01 CO $271.85 001A4606 00 G 2019-03-01 2020-03-01 CO $271.85 004A4606 00 G 2018-03-01 2019-03-01 CO $271.85 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 8 of 60

Page 9: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

A4606 00 G 2018-03-01 2019-03-01 CO $271.85 004A4606 00 G 2018-01-01 2018-03-01 CO $271.85 001A4606 00 G 2018-01-01 2018-03-01 CO $271.85 004A4606 00 G 2017-03-01 2018-01-01 CO $271.85 001A4606 00 G 2017-03-01 2018-01-01 CO $271.85 004A4606 00 G 2016-04-01 2017-03-01 CO $265.46 001A4611 NU G 2020-04-25 9901-01-01 CO $636.98 001A4611 NU G 2020-04-25 9901-01-01 CO $636.98 004A4612 NU G 2020-04-25 9901-01-01 CO $269.46 001A4612 NU G 2020-04-25 9901-01-01 CO $269.46 004A4613 00 G 2018-01-01 9901-01-01 CO $75.58 001A4613 00 G 2018-01-01 9901-01-01 CO $75.58 004A4627 00 G 2021-03-01 9901-01-01 CO $39.00 001A4627 00 G 2021-03-01 9901-01-01 CO $39.00 004A4627 00 G 2020-03-01 2021-03-01 CO $88.00 001A4627 00 G 2020-03-01 2021-03-01 CO $88.00 004A4627 00 G 2019-03-01 2020-03-01 CO $88.00 001A4627 00 G 2019-03-01 2020-03-01 CO $88.00 004A4627 00 G 2018-03-01 2019-03-01 CO $88.00 001A4627 00 G 2018-03-01 2019-03-01 CO $88.00 004A4627 00 G 2018-01-01 2018-03-01 CO $88.00 001A4627 00 G 2018-01-01 2018-03-01 CO $88.00 004A4627 00 G 2017-03-01 2018-01-01 CO $88.00 001A4627 00 G 2017-03-01 2018-01-01 CO $88.00 004A4627 00 G 2016-04-01 2017-03-01 CO $40.00 001A4641 00 G 2018-01-01 9901-01-01 CO $201.00 001A4641 00 G 2018-01-01 9901-01-01 CO $201.00 004A4642 00 G 2018-01-01 9901-01-01 CO $29.73 001A4642 00 G 2018-01-01 9901-01-01 CO $29.73 004A4648 00 G 2019-03-01 9901-01-01 CO $885.00 001A4648 00 G 2019-03-01 9901-01-01 CO $885.00 004A4648 00 G 2018-03-01 2019-03-01 CO $885.00 001A4648 00 G 2018-03-01 2019-03-01 CO $885.00 004A4648 00 G 2018-01-01 2018-03-01 CO $885.00 001A4648 00 G 2018-01-01 2018-03-01 CO $885.00 004A4648 00 G 2017-03-01 2018-01-01 CO $885.00 001A4648 00 G 2017-03-01 2018-01-01 CO $885.00 004A4648 00 G 2016-04-01 2017-03-01 CO $590.00 001A4648 00 G 2016-04-01 2017-03-01 CO $590.00 004A4651 00 G 2018-01-01 9901-01-01 CO $2.97 001A4651 00 G 2018-01-01 9901-01-01 CO $2.97 004A4652 00 G 2018-01-01 9901-01-01 CO $16.76 001A4652 00 G 2018-01-01 9901-01-01 CO $16.76 004A4657 00 G 2021-03-01 9901-01-01 CO $111.52 001A4657 00 G 2021-03-01 9901-01-01 CO $111.52 004A4657 00 G 2020-03-01 2021-03-01 CO $106.21 001A4657 00 G 2020-03-01 2021-03-01 CO $106.21 004A4657 00 G 2019-03-01 2020-03-01 CO $94.80 001A4657 00 G 2019-03-01 2020-03-01 CO $94.80 004A4657 00 G 2018-03-01 2019-03-01 CO $94.80 001A4657 00 G 2018-03-01 2019-03-01 CO $94.80 004A4657 00 G 2018-01-01 2018-03-01 CO $90.25 001A4657 00 G 2018-01-01 2018-03-01 CO $90.25 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 9 of 60

Page 10: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

A4657 00 G 2017-03-01 2018-01-01 CO $90.25 001A4657 00 G 2017-03-01 2018-01-01 CO $90.25 004A4657 00 G 2016-04-01 2017-03-01 CO $74.06 001A4657 00 G 2016-04-01 2017-03-01 CO $74.06 004A4660 00 G 2018-01-01 9901-01-01 CO $106.37 001A4660 00 G 2018-01-01 9901-01-01 CO $106.37 004A4663 00 G 2018-01-01 9901-01-01 CO $32.65 001A4663 00 G 2018-01-01 9901-01-01 CO $32.65 004A4670 00 G 2018-01-01 9901-01-01 CO $150.00 001A4670 00 G 2018-01-01 9901-01-01 CO $150.00 004A4671 00 G 2018-01-01 9901-01-01 CO $73.49 001A4671 00 G 2018-01-01 9901-01-01 CO $73.49 004A4714 00 G 2018-01-01 9901-01-01 CO $1.36 001A4714 00 G 2018-01-01 9901-01-01 CO $1.36 004A4721 00 G 2018-01-01 9901-01-01 CO $22.90 001A4721 00 G 2018-01-01 9901-01-01 CO $22.90 004A4722 00 G 2018-01-01 9901-01-01 CO $31.13 001A4722 00 G 2018-01-01 9901-01-01 CO $31.13 004A4723 00 G 2018-01-01 9901-01-01 CO $29.74 001A4723 00 G 2018-01-01 9901-01-01 CO $29.74 004A4726 00 G 2018-01-01 9901-01-01 CO $38.92 001A4726 00 G 2018-01-01 9901-01-01 CO $38.92 004A4730 00 G 2018-01-01 9901-01-01 CO $1.50 001A4730 00 G 2018-01-01 9901-01-01 CO $1.50 004A4750 00 G 2018-01-01 9901-01-01 CO $45.00 001A4750 00 G 2018-01-01 9901-01-01 CO $45.00 004A4755 00 G 2018-01-01 9901-01-01 CO $25.20 001A4755 00 G 2018-01-01 9901-01-01 CO $25.20 004A4770 00 G 2018-01-01 9901-01-01 CO $25.00 001A4770 00 G 2018-01-01 9901-01-01 CO $25.00 004A4771 00 G 2018-01-01 9901-01-01 CO $24.45 001A4771 00 G 2018-01-01 9901-01-01 CO $24.45 004A4772 00 G 2018-01-01 9901-01-01 CO $3.92 001A4772 00 G 2018-01-01 9901-01-01 CO $3.92 004A4860 00 G 2018-01-01 9901-01-01 CO $47.38 001A4860 00 G 2018-01-01 9901-01-01 CO $47.38 004A4911 00 G 2018-01-01 9901-01-01 CO $9.76 001A4911 00 G 2018-01-01 9901-01-01 CO $9.76 004A4927 NU G 2021-03-01 9901-01-01 CO $35.90 001A4927 NU G 2021-03-01 9901-01-01 CO $35.90 004A4927 NU G 2020-03-01 2021-03-01 CO $27.32 001A4927 NU G 2020-03-01 2021-03-01 CO $27.32 004A4927 NU G 2019-03-01 2020-03-01 CO $22.80 001A4927 NU G 2019-03-01 2020-03-01 CO $22.80 004A4927 NU G 2018-03-01 2019-03-01 CO $22.80 001A4927 NU G 2018-03-01 2019-03-01 CO $22.80 004A4927 NU G 2018-01-01 2018-03-01 CO $12.54 001A4927 NU G 2018-01-01 2018-03-01 CO $12.54 004A4927 00 G 2021-03-01 9901-01-01 CO $22.95 001A4927 00 G 2021-03-01 9901-01-01 CO $22.95 004A4927 00 G 2020-03-01 2021-03-01 CO $24.98 001A4927 00 G 2020-03-01 2021-03-01 CO $24.98 004A4927 00 G 2019-03-01 2020-03-01 CO $22.80 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 10 of 60

Page 11: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

A4927 00 G 2019-03-01 2020-03-01 CO $22.80 004A4927 00 G 2018-03-01 2019-03-01 CO $22.80 001A4927 00 G 2018-03-01 2019-03-01 CO $22.80 004A4927 00 G 2018-01-01 2018-03-01 CO $12.54 001A4927 00 G 2018-01-01 2018-03-01 CO $12.54 004A4927 00 G 2017-03-01 2018-01-01 CO $12.54 001A4927 00 G 2017-03-01 2018-01-01 CO $12.54 004A4927 00 G 2016-04-01 2017-03-01 CO $12.54 001A4928 00 G 2018-01-01 9901-01-01 CO $9.32 001A4928 00 G 2018-01-01 9901-01-01 CO $9.32 004A4929 00 G 2018-01-01 9901-01-01 CO $6.05 001A4929 00 G 2018-01-01 9901-01-01 CO $6.05 004A4930 00 G 2021-03-01 9901-01-01 CO $1.75 001A4930 00 G 2021-03-01 9901-01-01 CO $1.75 004A4930 00 G 2020-03-01 2021-03-01 CO $1.75 001A4930 00 G 2020-03-01 2021-03-01 CO $1.75 004A4930 00 G 2018-03-01 2020-03-01 CO $3.54 001A4930 00 G 2018-03-01 2020-03-01 CO $3.54 004A4930 00 G 2018-01-01 2018-03-01 CO $3.54 001A4930 00 G 2018-01-01 2018-03-01 CO $3.54 004A5510 00 G 2018-01-01 9901-01-01 CO $247.75 001A5510 00 G 2018-01-01 9901-01-01 CO $247.75 004A6025 00 G 2018-01-01 9901-01-01 CO $50.00 001A6025 00 G 2018-01-01 9901-01-01 CO $50.00 004A6198 00 G 2018-01-01 9901-01-01 CO $120.54 001A6198 00 G 2018-01-01 9901-01-01 CO $120.54 004A6205 00 G 2018-01-01 9901-01-01 CO $100.17 001A6205 00 G 2018-01-01 9901-01-01 CO $100.17 004A6206 00 G 2018-01-01 9901-01-01 CO $21.75 001A6206 00 G 2018-01-01 9901-01-01 CO $21.75 004A6208 00 G 2018-01-01 9901-01-01 CO $5.25 001A6208 00 G 2018-01-01 9901-01-01 CO $5.25 004A6213 00 G 2018-01-01 9901-01-01 CO $30.57 001A6213 00 G 2018-01-01 9901-01-01 CO $30.57 004A6215 00 G 2018-01-01 9901-01-01 CO $4.72 001A6215 00 G 2018-01-01 9901-01-01 CO $4.72 004A6217 00 G 2018-01-01 9901-01-01 CO $2.24 001A6217 00 G 2018-01-01 9901-01-01 CO $2.24 004A6218 00 G 2018-01-01 9901-01-01 CO $78.00 001A6218 00 G 2018-01-01 9901-01-01 CO $78.00 004A6221 00 G 2018-01-01 9901-01-01 CO $2.38 001A6221 00 G 2018-01-01 9901-01-01 CO $2.38 004A6239 00 G 2018-01-01 9901-01-01 CO $36.55 001A6239 00 G 2018-01-01 9901-01-01 CO $36.55 004A6250 00 G 2021-03-01 9901-01-01 CO $16.55 001A6250 00 G 2021-03-01 9901-01-01 CO $16.55 004A6250 00 G 2020-03-01 2021-03-01 CO $16.55 001A6250 00 G 2020-03-01 2021-03-01 CO $16.55 004A6250 00 G 2019-03-01 2020-03-01 CO $19.49 001A6250 00 G 2019-03-01 2020-03-01 CO $19.49 004A6250 00 G 2018-03-01 2019-03-01 CO $12.80 001A6250 00 G 2018-03-01 2019-03-01 CO $12.80 004A6250 00 G 2018-01-01 2018-03-01 CO $10.49 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 11 of 60

Page 12: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

A6250 00 G 2018-01-01 2018-03-01 CO $10.49 004A6250 00 G 2017-03-01 2018-01-01 CO $10.49 001A6250 00 G 2017-03-01 2018-01-01 CO $10.49 004A6250 00 G 2016-04-01 2017-03-01 CO $10.49 001A6256 00 G 2018-01-01 9901-01-01 CO $101.39 001A6256 00 G 2018-01-01 9901-01-01 CO $101.39 004A6260 00 G 2018-01-01 9901-01-01 CO $17.50 001A6260 00 G 2018-01-01 9901-01-01 CO $17.50 004A6260 00 G 2017-03-01 2018-01-01 CO $17.50 001A6260 00 G 2017-03-01 2018-01-01 CO $17.50 004A6260 00 G 2016-04-01 2017-03-01 CO $17.50 001A6260 00 G 2016-04-01 2017-03-01 CO $17.50 004A6261 00 G 2018-01-01 9901-01-01 CO $2.70 001A6261 00 G 2018-01-01 9901-01-01 CO $2.70 004A6262 00 G 2018-01-01 9901-01-01 CO $3.35 001A6262 00 G 2018-01-01 9901-01-01 CO $3.35 004A6404 00 G 2018-01-01 9901-01-01 CO $18.00 001A6404 00 G 2018-01-01 9901-01-01 CO $18.00 004A6412 00 G 2018-01-01 9901-01-01 CO $1.00 001A6412 00 G 2018-01-01 9901-01-01 CO $1.00 004A6413 00 G 2018-01-01 9901-01-01 CO $5.00 001A6413 00 G 2018-01-01 9901-01-01 CO $5.00 004A6413 00 G 2017-03-01 2018-01-01 CO $5.00 001A6413 00 G 2017-03-01 2018-01-01 CO $5.00 004A6450 00 G 2016-04-01 2018-01-01 CO $12.00 001A6450 00 G 2016-04-01 2018-01-01 CO $12.00 004A6504 00 G 2018-01-01 9901-01-01 CO $752.00 001A6504 00 G 2018-01-01 9901-01-01 CO $752.00 004A6530 00 G 2021-03-01 9901-01-01 CO $72.60 001A6530 00 G 2021-03-01 9901-01-01 CO $72.60 004A6530 00 G 2020-03-01 2021-03-01 CO $45.00 001A6530 00 G 2020-03-01 2021-03-01 CO $45.00 004A6530 00 G 2019-03-01 2020-03-01 CO $135.00 001A6530 00 G 2019-03-01 2020-03-01 CO $135.00 004A6530 00 G 2018-03-01 2019-03-01 CO $135.00 001A6530 00 G 2018-03-01 2019-03-01 CO $135.00 004A6530 00 G 2018-01-01 2018-03-01 CO $135.00 001A6530 00 G 2018-01-01 2018-03-01 CO $135.00 004A6530 00 G 2016-04-01 2018-01-01 CO $135.00 001A6530 00 G 2016-04-01 2018-01-01 CO $135.00 004A6533 00 G 2021-03-01 9901-01-01 CO $81.82 001A6533 00 G 2021-03-01 9901-01-01 CO $81.82 004A6533 00 G 2020-03-01 2021-03-01 CO $75.00 001A6533 00 G 2020-03-01 2021-03-01 CO $75.00 004A6533 00 G 2019-03-01 2020-03-01 CO $100.00 001A6533 00 G 2019-03-01 2020-03-01 CO $100.00 004A6533 00 G 2018-03-01 2019-03-01 CO $75.00 001A6533 00 G 2018-03-01 2019-03-01 CO $75.00 004A6533 00 G 2018-01-01 2018-03-01 CO $56.00 001A6533 00 G 2018-01-01 2018-03-01 CO $56.00 004A6534 00 G 2021-03-01 9901-01-01 CO $99.80 001A6534 00 G 2021-03-01 9901-01-01 CO $99.80 004A6534 00 G 2020-03-01 2021-03-01 CO $99.80 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 12 of 60

Page 13: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

A6534 00 G 2020-03-01 2021-03-01 CO $99.80 004A6534 00 G 2019-03-01 2020-03-01 CO $99.80 001A6534 00 G 2019-03-01 2020-03-01 CO $99.80 004A6534 00 G 2018-03-01 2019-03-01 CO $99.80 001A6534 00 G 2018-03-01 2019-03-01 CO $99.80 004A6534 00 G 2018-01-01 2018-03-01 CO $99.80 001A6534 00 G 2018-01-01 2018-03-01 CO $99.80 004A6534 00 G 2017-03-01 2018-01-01 CO $99.80 001A6534 00 G 2017-03-01 2018-01-01 CO $99.80 004A6534 00 G 2016-04-01 2017-03-01 CO $99.80 001A6535 00 G 2018-01-01 9901-01-01 CO $65.50 001A6535 00 G 2018-01-01 9901-01-01 CO $65.50 004A6536 00 G 2018-01-01 9901-01-01 CO $138.52 001A6536 00 G 2018-01-01 9901-01-01 CO $138.52 004A6537 00 G 2018-01-01 9901-01-01 CO $131.25 001A6537 00 G 2018-01-01 9901-01-01 CO $131.25 004A6539 00 G 2018-01-01 9901-01-01 CO $257.52 001A6539 00 G 2018-01-01 9901-01-01 CO $257.52 004A6539 00 G 2017-03-01 2018-01-01 CO $257.52 001A6539 00 G 2017-03-01 2018-01-01 CO $257.52 004A6539 00 G 2016-04-01 2017-03-01 CO $232.72 001A6539 00 G 2016-04-01 2017-03-01 CO $232.72 004A6540 00 G 2021-03-01 9901-01-01 CO $119.80 001A6540 00 G 2021-03-01 9901-01-01 CO $119.80 004A6540 00 G 2020-03-01 2021-03-01 CO $119.80 001A6540 00 G 2020-03-01 2021-03-01 CO $119.80 004A6540 00 G 2018-03-01 2020-03-01 CO $119.80 001A6540 00 G 2018-03-01 2020-03-01 CO $119.80 004A6540 00 G 2018-01-01 2018-03-01 CO $119.80 001A6540 00 G 2018-01-01 2018-03-01 CO $119.80 004A6540 00 G 2017-03-01 2018-01-01 CO $119.80 001A6540 00 G 2017-03-01 2018-01-01 CO $119.80 004A6540 00 G 2016-04-01 2017-03-01 CO $119.80 001A6541 00 G 2018-01-01 9901-01-01 CO $331.99 001A6541 00 G 2018-01-01 9901-01-01 CO $331.99 004A9150 00 G 2018-01-01 9901-01-01 CO $2.00 001A9150 00 G 2018-01-01 9901-01-01 CO $2.00 004A9150 00 G 2017-03-01 2018-01-01 CO $2.00 001A9150 00 G 2017-03-01 2018-01-01 CO $2.00 004A9150 00 G 2016-04-01 2017-03-01 CO $2.00 001A9150 00 G 2016-04-01 2017-03-01 CO $2.00 004A9273 00 G 2020-03-01 9901-01-01 CO $22.00 001A9273 00 G 2020-03-01 9901-01-01 CO $22.00 004A9273 00 G 2019-03-01 2020-03-01 CO $886.28 001A9273 00 G 2019-03-01 2020-03-01 CO $886.28 004A9273 00 G 2018-03-01 2019-03-01 CO $50.00 001A9273 00 G 2018-03-01 2019-03-01 CO $50.00 004A9273 00 G 2018-01-01 2018-03-01 CO $50.00 001A9273 00 G 2018-01-01 2018-03-01 CO $50.00 004A9273 00 G 2017-03-01 2018-01-01 CO $50.00 001A9273 00 G 2017-03-01 2018-01-01 CO $50.00 004A9273 00 G 2016-04-01 2017-03-01 CO $50.00 001A9273 00 G 2016-04-01 2017-03-01 CO $50.00 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 13 of 60

Page 14: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

A9274 NU G 2021-03-01 9901-01-01 CO $45.00 001A9274 NU G 2021-03-01 9901-01-01 CO $45.00 004A9274 NU G 2020-04-25 2021-03-01 CO $45.00 001A9274 NU G 2020-04-25 2021-03-01 CO $45.00 004A9274 00 G 2021-03-01 9901-01-01 CO $75.00 001A9274 00 G 2021-03-01 9901-01-01 CO $75.00 004A9274 00 G 2020-04-25 2021-03-01 CO $75.00 001A9274 00 G 2020-04-25 2021-03-01 CO $75.00 004A9276 00 G 2021-03-01 9901-01-01 CO $75.00 001A9276 00 G 2021-03-01 9901-01-01 CO $75.00 004A9276 00 G 2018-01-01 2021-03-01 CO $14.00 001A9276 00 G 2018-01-01 2021-03-01 CO $14.00 004A9277 00 G 2021-03-01 9901-01-01 CO $1,499.00 001A9277 00 G 2021-03-01 9901-01-01 CO $1,499.00 004A9277 00 G 2018-01-01 2021-03-01 CO $649.00 001A9277 00 G 2018-01-01 2021-03-01 CO $649.00 004A9278 00 G 2021-03-01 9901-01-01 CO $1,399.00 001A9278 00 G 2021-03-01 9901-01-01 CO $1,399.00 004A9278 00 G 2018-01-01 2021-03-01 CO $649.00 001A9278 00 G 2018-01-01 2021-03-01 CO $649.00 004A9282 00 G 2021-01-01 9901-01-01 CO $2,388.00 001A9282 00 G 2021-01-01 9901-01-01 CO $2,388.00 004A9282 00 G 2020-01-01 2021-01-01 CO $2,348.00 001A9282 00 G 2020-01-01 2021-01-01 CO $2,348.00 004A9282 00 G 2019-01-01 2020-01-01 CO $2,295.00 001A9282 00 G 2019-01-01 2020-01-01 CO $2,295.00 004A9282 00 G 2018-01-01 2019-01-01 CO $2,246.00 001A9282 00 G 2018-01-01 2019-01-01 CO $2,246.00 004A9282 00 G 2017-01-01 2018-01-01 CO $2,213.00 001A9282 00 G 2017-01-01 2018-01-01 CO $2,213.00 004A9282 00 G 2016-01-01 2017-01-01 CO $2,213.00 001A9282 00 G 2016-01-01 2017-01-01 CO $2,213.00 004A9282 00 G 2015-01-01 2016-01-01 CO $2,176.00 001A9282 00 G 2015-01-01 2016-01-01 CO $2,176.00 004A9282 00 G 2014-01-01 2015-01-01 CO $2,131.00 001A9282 00 G 2014-01-01 2015-01-01 CO $2,131.00 004A9282 00 G 2013-01-01 2014-01-01 CO $2,095.00 001A9282 00 G 2013-01-01 2014-01-01 CO $2,095.00 004A9282 00 G 2012-01-01 2013-01-01 CO $2,022.00 001A9282 00 G 2012-01-01 2013-01-01 CO $2,022.00 004A9283 00 G 2018-01-01 9901-01-01 CO $3.30 001A9283 00 G 2018-01-01 9901-01-01 CO $3.30 004A9284 00 G 2018-01-01 9901-01-01 CO $10.00 001A9284 00 G 2018-01-01 9901-01-01 CO $10.00 004A9500 00 6 2021-03-01 9901-01-01 CO $241.00 001A9500 00 6 2021-03-01 9901-01-01 CO $241.00 004A9500 00 6 2019-03-01 2021-03-01 CO $652.17 001A9500 00 6 2018-03-01 2019-03-01 CO $623.31 001A9500 00 6 2018-01-01 2018-03-01 CO $623.31 001A9500 00 6 2018-01-01 2021-03-01 CO $591.72 004A9500 00 6 2017-03-01 2018-01-01 CO $623.31 001A9500 00 6 2017-03-01 2018-01-01 CO $591.72 004A9500 00 6 2016-04-01 2017-03-01 CO $623.31 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 14 of 60

Page 15: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

A9500 00 6 2016-04-01 2017-03-01 CO $591.72 004A9502 00 6 2019-03-01 9901-01-01 CO $508.43 001A9502 00 6 2018-03-01 2019-03-01 CO $508.43 001A9502 00 6 2018-01-01 2018-03-01 CO $508.43 001A9502 00 6 2018-01-01 9901-01-01 CO $422.56 004A9502 00 6 2017-03-01 2018-01-01 CO $508.43 001A9502 00 6 2016-04-01 2017-03-01 CO $422.56 001A9502 00 6 2016-04-01 2018-01-01 CO $422.56 004A9503 00 6 2021-03-01 9901-01-01 CO $38.57 001A9503 00 6 2021-03-01 9901-01-01 CO $38.57 004A9503 00 6 2019-03-01 2021-03-01 CO $297.67 001A9503 00 6 2018-03-01 2019-03-01 CO $297.67 001A9503 00 6 2018-01-01 2018-03-01 CO $264.00 001A9503 00 6 2018-01-01 2021-03-01 CO $134.70 004A9503 00 6 2017-03-01 2018-01-01 CO $264.00 001A9503 00 6 2016-04-01 2017-03-01 CO $238.49 001A9505 00 6 2018-01-01 9901-01-01 CO $115.00 001A9505 00 6 2018-01-01 9901-01-01 CO $115.00 004A9507 00 6 2018-01-01 9901-01-01 CO $1,643.24 001A9507 00 6 2018-01-01 9901-01-01 CO $1,643.24 004A9508 00 6 2018-01-01 9901-01-01 CO $309.45 001A9508 00 6 2018-01-01 9901-01-01 CO $309.45 004A9509 00 6 2018-01-01 9901-01-01 CO $493.00 001A9509 00 6 2018-01-01 9901-01-01 CO $493.00 004A9510 00 6 2018-01-01 9901-01-01 CO $261.25 001A9510 00 6 2018-01-01 9901-01-01 CO $261.25 004A9512 00 6 2018-01-01 9901-01-01 CO $82.06 001A9512 00 6 2018-01-01 9901-01-01 CO $82.06 004A9512 00 6 2017-03-01 2018-01-01 CO $82.06 001A9512 00 6 2017-03-01 2018-01-01 CO $82.06 004A9516 00 6 2019-03-01 9901-01-01 CO $491.99 001A9516 00 6 2018-03-01 2019-03-01 CO $464.45 001A9516 00 6 2018-01-01 2018-03-01 CO $439.12 001A9516 00 6 2018-01-01 9901-01-01 CO $141.01 004A9516 00 6 2017-03-01 2018-01-01 CO $439.12 001A9516 00 6 2016-04-01 2017-03-01 CO $412.36 001A9517 00 6 2019-03-01 9901-01-01 CO $208.75 001A9517 00 6 2018-03-01 2019-03-01 CO $112.24 001A9517 00 6 2018-01-01 2018-03-01 CO $109.52 001A9517 00 6 2018-01-01 9901-01-01 CO $73.34 004A9517 00 6 2017-03-01 2018-01-01 CO $109.52 001A9517 00 6 2016-04-01 2017-03-01 CO $99.65 001A9520 00 6 2018-03-01 9901-01-01 CO $2,236.50 001A9520 00 6 2018-01-01 2018-03-01 CO $2,236.50 001A9520 00 6 2018-01-01 9901-01-01 CO $1,437.62 004A9520 00 6 2017-03-01 2018-01-01 CO $2,236.50 001A9521 00 6 2021-03-01 9901-01-01 CO $1,994.30 001A9521 00 6 2020-03-01 2021-03-01 CO $1,994.30 001A9521 00 6 2019-03-01 2020-03-01 CO $1,994.30 001A9521 00 6 2018-03-01 2019-03-01 CO $1,994.30 001A9521 00 6 2018-01-01 2018-03-01 CO $1,994.30 001A9521 00 6 2018-01-01 9901-01-01 CO $1,994.30 004A9521 00 6 2017-03-01 2018-01-01 CO $1,994.30 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 15 of 60

Page 16: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

A9521 00 6 2016-04-29 2017-03-01 CO $1,994.30 001A9521 00 6 2016-04-29 2018-01-01 CO $1,994.30 004A9526 00 6 2018-01-01 9901-01-01 CO $25.00 001A9526 00 6 2018-01-01 9901-01-01 CO $25.00 004A9528 00 6 2018-03-01 9901-01-01 CO $328.55 001A9528 00 6 2018-01-01 2018-03-01 CO $150.00 001A9528 00 6 2018-01-01 9901-01-01 CO $150.00 004A9528 00 6 2017-03-01 2018-01-01 CO $150.00 001A9528 00 6 2017-03-01 2018-01-01 CO $150.00 004A9529 00 6 2018-01-01 9901-01-01 CO $43.14 001A9529 00 6 2018-01-01 9901-01-01 CO $43.14 004A9530 00 6 2018-01-01 9901-01-01 CO $81.04 001A9530 00 6 2018-01-01 9901-01-01 CO $81.04 004A9531 00 6 2018-01-01 9901-01-01 CO $45.00 001A9531 00 6 2018-01-01 9901-01-01 CO $45.00 004A9536 00 6 2018-01-01 9901-01-01 CO $173.78 001A9536 00 6 2018-01-01 9901-01-01 CO $173.78 004A9537 00 6 2021-03-01 9901-01-01 CO $100.00 001A9537 00 6 2021-03-01 9901-01-01 CO $100.00 004A9537 00 6 2019-03-01 2021-03-01 CO $234.50 001A9537 00 6 2019-03-01 2021-03-01 CO $214.99 004A9537 00 6 2018-03-01 2019-03-01 CO $234.50 001A9537 00 6 2018-03-01 2019-03-01 CO $214.99 004A9537 00 6 2018-01-01 2018-03-01 CO $234.50 001A9537 00 6 2018-01-01 2018-03-01 CO $214.99 004A9537 00 6 2017-03-01 2018-01-01 CO $234.50 001A9537 00 6 2017-03-01 2018-01-01 CO $214.99 004A9537 00 6 2016-04-01 2017-03-01 CO $214.99 001A9537 00 6 2016-04-01 2017-03-01 CO $214.99 004A9538 00 6 2018-01-01 9901-01-01 CO $186.35 001A9538 00 6 2018-01-01 9901-01-01 CO $186.35 004A9539 00 6 2018-01-01 9901-01-01 CO $337.03 001A9539 00 6 2018-01-01 9901-01-01 CO $289.45 004A9539 00 6 2017-03-01 2018-01-01 CO $337.03 001A9539 00 6 2016-04-01 2017-03-01 CO $337.03 001A9540 00 6 2019-03-01 9901-01-01 CO $642.42 001A9540 00 6 2018-03-01 2019-03-01 CO $491.13 001A9540 00 6 2018-01-01 2018-03-01 CO $257.20 001A9540 00 6 2018-01-01 9901-01-01 CO $219.70 004A9540 00 6 2017-03-01 2018-01-01 CO $257.20 001A9540 00 6 2016-04-01 2017-03-01 CO $225.06 001A9541 00 6 2021-03-01 9901-01-01 CO $133.60 001A9541 00 6 2021-03-01 9901-01-01 CO $133.60 004A9541 00 6 2019-03-01 2021-03-01 CO $406.78 001A9541 00 6 2018-03-01 2019-03-01 CO $405.83 001A9541 00 6 2018-01-01 2018-03-01 CO $405.83 001A9541 00 6 2018-01-01 2021-03-01 CO $278.01 004A9541 00 6 2017-03-01 2018-01-01 CO $405.83 001A9541 00 6 2017-03-01 2018-01-01 CO $278.01 004A9541 00 6 2016-04-01 2017-03-01 CO $405.83 001A9547 00 6 2018-01-01 9901-01-01 CO $1,848.75 001A9547 00 6 2018-01-01 9901-01-01 CO $1,848.75 004A9551 00 6 2018-01-01 9901-01-01 CO $696.00 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 16 of 60

Page 17: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

A9551 00 6 2018-01-01 9901-01-01 CO $696.00 004A9552 00 6 2021-03-01 9901-01-01 CO $700.00 001A9552 00 6 2021-03-01 9901-01-01 CO $700.00 004A9552 00 6 2019-03-01 2021-03-01 CO $3,623.27 001A9552 00 6 2018-03-01 2019-03-01 CO $3,224.70 001A9552 00 6 2018-01-01 2018-03-01 CO $3,042.17 001A9552 00 6 2018-01-01 2021-03-01 CO $3,042.17 004A9552 00 6 2017-03-01 2018-01-01 CO $3,042.17 001A9552 00 6 2017-03-01 2018-01-01 CO $3,042.17 004A9552 00 6 2016-04-01 2017-03-01 CO $2,869.97 001A9552 00 6 2016-04-01 2017-03-01 CO $2,869.97 004A9554 00 6 2018-01-01 9901-01-01 CO $339.58 001A9554 00 6 2018-01-01 9901-01-01 CO $339.58 004A9555 00 6 2018-01-01 9901-01-01 CO $2,636.01 001A9555 00 6 2018-01-01 9901-01-01 CO $1,250.00 004A9555 00 6 2017-03-01 2018-01-01 CO $2,636.01 001A9555 00 6 2016-04-01 2017-03-01 CO $2,486.80 001A9556 00 6 2018-01-01 9901-01-01 CO $61.67 001A9556 00 6 2018-01-01 9901-01-01 CO $61.67 004A9557 00 6 2018-01-01 9901-01-01 CO $27.98 001A9557 00 6 2018-01-01 9901-01-01 CO $27.98 004A9558 00 6 2018-03-01 9901-01-01 CO $202.26 001A9558 00 6 2018-01-01 2018-03-01 CO $181.00 001A9558 00 6 2018-01-01 9901-01-01 CO $96.13 004A9558 00 6 2016-04-01 2018-01-01 CO $181.00 001A9560 00 6 2018-01-01 9901-01-01 CO $211.08 001A9560 00 6 2018-01-01 9901-01-01 CO $211.08 004A9561 00 6 2019-03-01 9901-01-01 CO $245.73 001A9561 00 6 2018-03-01 2019-03-01 CO $233.76 001A9561 00 6 2018-01-01 2018-03-01 CO $219.32 001A9561 00 6 2018-01-01 9901-01-01 CO $179.81 004A9561 00 6 2017-03-01 2018-01-01 CO $219.32 001A9561 00 6 2016-04-01 2017-03-01 CO $205.95 001A9562 00 6 2021-03-01 9901-01-01 CO $312.50 001A9562 00 6 2021-03-01 9901-01-01 CO $312.50 004A9562 00 6 2019-03-01 2021-03-01 CO $1,071.84 001A9562 00 6 2018-03-01 2019-03-01 CO $1,035.31 001A9562 00 6 2018-01-01 2018-03-01 CO $1,035.31 001A9562 00 6 2018-01-01 2021-03-01 CO $900.00 004A9562 00 6 2017-03-01 2018-01-01 CO $1,035.31 001A9562 00 6 2016-04-01 2017-03-01 CO $900.00 001A9562 00 6 2016-04-01 2018-01-01 CO $900.00 004A9563 00 6 2018-01-01 9901-01-01 CO $110.05 001A9563 00 6 2018-01-01 9901-01-01 CO $110.05 004A9567 00 6 2019-03-01 9901-01-01 CO $585.45 001A9567 00 6 2018-03-01 2019-03-01 CO $498.71 001A9567 00 6 2018-01-01 2018-03-01 CO $342.64 001A9567 00 6 2018-01-01 9901-01-01 CO $147.90 004A9567 00 6 2017-03-01 2018-01-01 CO $342.64 001A9567 00 6 2016-04-01 2017-03-01 CO $321.76 001A9570 00 6 2018-01-01 9901-01-01 CO $1,303.49 001A9570 00 6 2018-01-01 9901-01-01 CO $1,303.49 004A9572 00 6 2018-01-01 9901-01-01 CO $3,235.32 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 17 of 60

Page 18: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

A9572 00 6 2018-01-01 9901-01-01 CO $3,235.32 004A9580 00 6 2018-01-01 9901-01-01 CO $371.63 001A9580 00 6 2018-01-01 9901-01-01 CO $371.63 004A9584 00 6 2018-01-01 9901-01-01 CO $6,314.71 001A9584 00 6 2018-01-01 9901-01-01 CO $6,314.71 004A9600 00 6 2018-01-01 9901-01-01 CO $388.43 001A9600 00 6 2018-01-01 9901-01-01 CO $388.43 004A9604 00 6 2018-01-01 9901-01-01 CO $2,774.00 001A9604 00 6 2018-01-01 9901-01-01 CO $2,774.00 004A9700 00 6 2018-01-01 9901-01-01 CO $172.00 001A9700 00 6 2018-01-01 9901-01-01 CO $172.00 004A9901 00 G 2021-03-01 9901-01-01 CO $160.31 001A9901 00 G 2021-03-01 9901-01-01 CO $160.31 004A9901 00 G 2019-03-01 2021-03-01 CO $100.00 001A9901 00 G 2019-03-01 2021-03-01 CO $100.00 004A9901 00 G 2018-07-28 2019-03-01 CO $100.00 001A9901 00 G 2018-07-28 2019-03-01 CO $100.00 004B4100 00 G 2021-03-01 9901-01-01 CO $8.45 001B4100 00 G 2021-03-01 9901-01-01 CO $8.45 004B4100 00 G 2020-03-01 2021-03-01 CO $20.78 001B4100 00 G 2020-03-01 2021-03-01 CO $20.78 004B4100 00 G 2019-03-01 2020-03-01 CO $6.90 001B4100 00 G 2019-03-01 2020-03-01 CO $6.90 004B4100 00 G 2018-03-01 2019-03-01 CO $4.42 001B4100 00 G 2018-03-01 2019-03-01 CO $4.42 004B4100 00 G 2018-01-01 2018-03-01 CO $4.42 001B4100 00 G 2018-01-01 2018-03-01 CO $4.42 004B4100 00 G 2017-03-01 2018-01-01 CO $4.42 001B4100 00 G 2017-03-01 2018-01-01 CO $4.42 004B4100 00 G 2016-04-01 2017-03-01 CO $4.42 001B4100 00 G 2016-04-01 2017-03-01 CO $4.42 004B4102 00 G 2020-03-01 9901-01-01 CO $26.69 001B4102 00 G 2020-03-01 9901-01-01 CO $26.69 004B4102 00 G 2018-03-01 2020-03-01 CO $25.74 001B4102 00 G 2018-03-01 2020-03-01 CO $25.74 004B4102 00 G 2018-01-01 2018-03-01 CO $14.80 001B4102 00 G 2018-01-01 2018-03-01 CO $14.80 004B4102 00 G 2017-03-01 2018-01-01 CO $14.80 001B4102 00 G 2017-03-01 2018-01-01 CO $14.80 004B4102 00 G 2016-04-01 2017-03-01 CO $10.25 001B4103 00 G 2021-03-01 9901-01-01 CO $12.45 001B4103 00 G 2021-03-01 9901-01-01 CO $12.45 004B4103 00 G 2020-03-01 2021-03-01 CO $13.45 001B4103 00 G 2020-03-01 2021-03-01 CO $13.45 004B4103 00 G 2019-03-01 2020-03-01 CO $47.81 001B4103 00 G 2019-03-01 2020-03-01 CO $47.81 004B4103 00 G 2018-03-01 2019-03-01 CO $47.81 001B4103 00 G 2018-03-01 2019-03-01 CO $47.81 004B4103 00 G 2018-01-01 2018-03-01 CO $47.81 001B4103 00 G 2018-01-01 2018-03-01 CO $47.81 004B4103 00 G 2017-03-01 2018-01-01 CO $47.81 001B4103 00 G 2017-03-01 2018-01-01 CO $47.81 004B4103 00 G 2016-04-01 2017-03-01 CO $47.81 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 18 of 60

Page 19: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

B4103 00 G 2016-04-01 2017-03-01 CO $47.81 004B4104 00 G 2018-01-01 9901-01-01 CO $45.67 001B4104 00 G 2018-01-01 9901-01-01 CO $45.67 004B4104 00 G 2017-03-01 2018-01-01 CO $45.67 001B4104 00 G 2017-03-01 2018-01-01 CO $45.67 004B4104 00 G 2016-04-01 2017-03-01 CO $42.60 001B4104 00 G 2016-04-01 2017-03-01 CO $42.60 004B4157 00 G 2018-03-01 9901-01-01 CO $41.37 001B4157 00 G 2018-03-01 9901-01-01 CO $41.37 004B4157 00 G 2018-01-01 2018-03-01 CO $41.37 001B4157 00 G 2018-01-01 2018-03-01 CO $41.37 004B4157 00 G 2017-03-01 2018-01-01 CO $41.37 001B4157 00 G 2017-03-01 2018-01-01 CO $41.37 004B4157 00 G 2016-04-01 2017-03-01 CO $40.90 001B4157 00 G 2016-04-01 2017-03-01 CO $40.90 004B4158 00 G 2021-03-01 9901-01-01 CO $6.98 001B4158 00 G 2021-03-01 9901-01-01 CO $6.98 004B4158 00 G 2020-03-01 2021-03-01 CO $5.05 001B4158 00 G 2020-03-01 2021-03-01 CO $5.05 004B4158 00 G 2019-03-01 2020-03-01 CO $9.30 001B4158 00 G 2019-03-01 2020-03-01 CO $9.30 004B4158 00 G 2018-03-01 2019-03-01 CO $9.30 001B4158 00 G 2018-03-01 2019-03-01 CO $9.30 004B4158 00 G 2018-01-01 2018-03-01 CO $9.30 001B4158 00 G 2018-01-01 2018-03-01 CO $9.30 004B4158 00 G 2017-03-01 2018-01-01 CO $9.30 001B4158 00 G 2017-03-01 2018-01-01 CO $9.30 004B4158 00 G 2016-04-01 2017-03-01 CO $9.30 001B4158 00 G 2016-04-01 2017-03-01 CO $9.30 004B4159 00 G 2020-03-01 9901-01-01 CO $6.88 001B4159 00 G 2020-03-01 9901-01-01 CO $6.88 004B4159 00 G 2018-01-01 2020-03-01 CO $4.03 001B4159 00 G 2018-01-01 2020-03-01 CO $4.03 004B4160 00 G 2021-03-01 9901-01-01 CO $3.31 001B4160 00 G 2021-03-01 9901-01-01 CO $3.31 004B4160 00 G 2020-03-01 2021-03-01 CO $4.40 001B4160 00 G 2020-03-01 2021-03-01 CO $4.40 004B4160 00 G 2019-03-01 2020-03-01 CO $6.66 001B4160 00 G 2019-03-01 2020-03-01 CO $6.66 004B4160 00 G 2018-03-01 2019-03-01 CO $6.66 001B4160 00 G 2018-03-01 2019-03-01 CO $6.66 004B4160 00 G 2018-01-01 2018-03-01 CO $6.66 001B4160 00 G 2018-01-01 2018-03-01 CO $6.66 004B4160 00 G 2017-03-01 2018-01-01 CO $6.66 001B4160 00 G 2017-03-01 2018-01-01 CO $6.66 004B4160 00 G 2016-04-01 2017-03-01 CO $6.66 001B4160 00 G 2016-04-01 2017-03-01 CO $6.66 004B4161 00 G 2021-03-01 9901-01-01 CO $10.70 001B4161 00 G 2021-03-01 9901-01-01 CO $10.70 004B4161 00 G 2020-03-01 2021-03-01 CO $11.66 001B4161 00 G 2020-03-01 2021-03-01 CO $11.66 004B4161 00 G 2019-03-01 2020-03-01 CO $18.35 001B4161 00 G 2019-03-01 2020-03-01 CO $18.35 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 19 of 60

Page 20: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

B4161 00 G 2018-03-01 2019-03-01 CO $18.35 001B4161 00 G 2018-03-01 2019-03-01 CO $18.35 004B4161 00 G 2018-01-01 2018-03-01 CO $18.35 001B4161 00 G 2018-01-01 2018-03-01 CO $18.35 004B4161 00 G 2017-03-01 2018-01-01 CO $18.35 001B4161 00 G 2017-03-01 2018-01-01 CO $18.35 004B4161 00 G 2016-04-01 2017-03-01 CO $16.90 001B4161 00 G 2016-04-01 2017-03-01 CO $16.90 004B4162 00 G 2021-03-01 9901-01-01 CO $10.50 001B4162 00 G 2021-03-01 9901-01-01 CO $10.50 004B4162 00 G 2020-03-01 2021-03-01 CO $17.14 001B4162 00 G 2020-03-01 2021-03-01 CO $17.14 004B4162 00 G 2018-03-01 2020-03-01 CO $22.14 001B4162 00 G 2018-03-01 2020-03-01 CO $22.14 004B4162 00 G 2018-01-01 2018-03-01 CO $22.14 001B4162 00 G 2018-01-01 2018-03-01 CO $22.14 004B4162 00 G 2017-03-01 2018-01-01 CO $22.14 001B4162 00 G 2017-03-01 2018-01-01 CO $22.14 004B4162 00 G 2016-04-01 2017-03-01 CO $22.14 001B4162 00 G 2016-04-01 2017-03-01 CO $22.14 004B5200 00 G 2019-03-01 9901-01-01 CO $266.45 001B5200 00 G 2019-03-01 9901-01-01 CO $266.45 004B5200 00 G 2018-03-01 2019-03-01 CO $266.45 001B5200 00 G 2018-03-01 2019-03-01 CO $266.45 004B5200 00 G 2018-01-01 2018-03-01 CO $99.10 001B5200 00 G 2018-01-01 2018-03-01 CO $99.10 004B5200 00 G 2017-03-01 2018-01-01 CO $99.10 001B5200 00 G 2017-03-01 2018-01-01 CO $99.10 004B5200 00 G 2016-04-01 2017-03-01 CO $99.10 001B5200 00 G 2016-04-01 2017-03-01 CO $99.10 004C1713 00 G 2018-01-01 9901-01-01 CO $1,978.24 001C1713 00 G 2018-01-01 9901-01-01 CO $1,978.24 004C1713 00 G 2017-03-01 2018-01-01 CO $1,978.24 001C1713 00 G 2017-03-01 2018-01-01 CO $1,978.24 004C1713 00 G 2016-04-01 2017-03-01 CO $1,821.42 001C1713 00 G 2016-04-01 2017-03-01 CO $1,821.42 004C1714 00 G 2018-01-01 9901-01-01 CO $19,908.00 001C1714 00 G 2018-01-01 9901-01-01 CO $19,908.00 004C1714 00 G 2017-01-24 2018-01-01 CO $19,908.00 001C1714 00 G 2017-01-24 2018-01-01 CO $19,908.00 004C1715 00 G 2018-01-01 9901-01-01 CO $300.00 001C1715 00 G 2018-01-01 9901-01-01 CO $300.00 004C1716 00 G 2018-01-01 9901-01-01 CO $188.41 001C1716 00 G 2018-01-01 9901-01-01 CO $188.41 004C1717 00 G 2018-01-01 9901-01-01 CO $216.90 001C1717 00 G 2018-01-01 9901-01-01 CO $216.90 004C1717 00 G 2017-03-01 2018-01-01 CO $216.90 001C1717 00 G 2017-03-01 2018-01-01 CO $216.90 004C1719 00 G 2018-01-01 9901-01-01 CO $27.82 001C1719 00 G 2018-01-01 9901-01-01 CO $27.82 004C1721 00 G 2018-01-01 9901-01-01 CO $73,160.00 001C1721 00 G 2018-01-01 9901-01-01 CO $73,160.00 004C1721 00 G 2016-04-01 2018-01-01 CO $73,160.00 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 20 of 60

Page 21: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

C1721 00 G 2016-04-01 2018-01-01 CO $73,160.00 004C1722 00 G 2018-01-01 9901-01-01 CO $91,120.00 001C1722 00 G 2018-01-01 9901-01-01 CO $91,120.00 004C1725 00 G 2018-01-01 9901-01-01 CO $1,780.42 001C1725 00 G 2018-01-01 9901-01-01 CO $1,780.42 004C1725 00 G 2017-03-01 2018-01-01 CO $1,780.42 001C1725 00 G 2017-03-01 2018-01-01 CO $1,780.42 004C1725 00 G 2016-04-01 2017-03-01 CO $1,165.82 001C1725 00 G 2016-04-01 2017-03-01 CO $1,165.82 004C1726 00 G 2018-01-01 9901-01-01 CO $1,871.64 001C1726 00 G 2018-01-01 9901-01-01 CO $1,871.64 004C1726 00 G 2017-03-01 2018-01-01 CO $1,871.64 001C1726 00 G 2017-03-01 2018-01-01 CO $1,871.64 004C1726 00 G 2016-04-01 2017-03-01 CO $1,871.64 001C1726 00 G 2016-04-01 2017-03-01 CO $1,871.64 004C1727 00 G 2018-01-01 9901-01-01 CO $2,471.52 001C1727 00 G 2018-01-01 9901-01-01 CO $2,471.52 004C1727 00 G 2016-04-01 2018-01-01 CO $2,471.52 001C1727 00 G 2016-04-01 2018-01-01 CO $2,471.52 004C1728 00 G 2018-01-01 9901-01-01 CO $300.00 001C1728 00 G 2018-01-01 9901-01-01 CO $300.00 004C1729 00 G 2018-01-01 9901-01-01 CO $577.75 001C1729 00 G 2018-01-01 9901-01-01 CO $577.75 004C1729 00 G 2017-03-01 2018-01-01 CO $577.75 001C1729 00 G 2017-03-01 2018-01-01 CO $577.75 004C1729 00 G 2016-04-01 2017-03-01 CO $455.57 001C1729 00 G 2016-04-01 2017-03-01 CO $455.57 004C1730 00 G 2018-01-01 9901-01-01 CO $2,483.47 001C1730 00 G 2018-01-01 9901-01-01 CO $2,483.47 004C1730 00 G 2017-03-01 2018-01-01 CO $2,483.47 001C1730 00 G 2017-03-01 2018-01-01 CO $2,483.47 004C1730 00 G 2016-04-01 2017-03-01 CO $2,342.90 001C1730 00 G 2016-04-01 2017-03-01 CO $2,342.90 004C1731 00 G 2018-01-01 9901-01-01 CO $4,988.17 001C1731 00 G 2018-01-01 9901-01-01 CO $4,988.17 004C1731 00 G 2017-03-01 2018-01-01 CO $4,988.17 001C1731 00 G 2017-03-01 2018-01-01 CO $4,988.17 004C1731 00 G 2016-04-01 2017-03-01 CO $4,988.17 001C1731 00 G 2016-04-01 2017-03-01 CO $4,988.17 004C1732 00 G 2018-01-01 9901-01-01 CO $9,067.00 001C1732 00 G 2018-01-01 9901-01-01 CO $9,067.00 004C1732 00 G 2017-03-01 2018-01-01 CO $9,067.00 001C1732 00 G 2017-03-01 2018-01-01 CO $9,067.00 004C1732 00 G 2016-04-01 2017-03-01 CO $7,205.13 001C1732 00 G 2016-04-01 2017-03-01 CO $7,205.13 004C1733 00 G 2018-01-01 9901-01-01 CO $6,144.00 001C1733 00 G 2018-01-01 9901-01-01 CO $6,144.00 004C1733 00 G 2017-03-01 2018-01-01 CO $6,144.00 001C1733 00 G 2017-03-01 2018-01-01 CO $6,144.00 004C1733 00 G 2016-04-01 2017-03-01 CO $4,645.00 001C1733 00 G 2016-04-01 2017-03-01 CO $4,645.00 004C1750 00 G 2018-01-01 9901-01-01 CO $2,279.00 001C1750 00 G 2018-01-01 9901-01-01 CO $2,279.00 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 21 of 60

Page 22: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

C1750 00 G 2016-04-01 2018-01-01 CO $2,279.00 001C1750 00 G 2016-04-01 2018-01-01 CO $2,279.00 004C1751 00 G 2018-01-01 9901-01-01 CO $1,349.17 001C1751 00 G 2018-01-01 9901-01-01 CO $1,349.17 004C1751 00 G 2017-03-01 2018-01-01 CO $1,349.17 001C1751 00 G 2017-03-01 2018-01-01 CO $1,349.17 004C1751 00 G 2016-04-01 2017-03-01 CO $1,272.80 001C1751 00 G 2016-04-01 2017-03-01 CO $1,272.80 004C1752 00 G 2018-01-01 9901-01-01 CO $1,650.00 001C1752 00 G 2018-01-01 9901-01-01 CO $1,650.00 004C1752 00 G 2017-02-23 2018-01-01 CO $1,650.00 001C1752 00 G 2017-02-23 2018-01-01 CO $1,650.00 004C1753 00 G 2018-01-01 9901-01-01 CO $5,347.57 001C1753 00 G 2018-01-01 9901-01-01 CO $5,347.57 004C1753 00 G 2017-03-01 2018-01-01 CO $5,347.57 001C1753 00 G 2017-03-01 2018-01-01 CO $5,347.57 004C1753 00 G 2016-04-01 2017-03-01 CO $3,854.00 001C1753 00 G 2016-04-01 2017-03-01 CO $3,854.00 004C1755 00 G 2018-01-01 9901-01-01 CO $222.81 001C1755 00 G 2018-01-01 9901-01-01 CO $222.81 004C1755 00 G 2016-04-01 2018-01-01 CO $222.81 001C1755 00 G 2016-04-01 2018-01-01 CO $222.81 004C1757 00 G 2018-01-01 9901-01-01 CO $2,400.00 001C1757 00 G 2018-01-01 9901-01-01 CO $2,400.00 004C1757 00 G 2016-04-01 2018-01-01 CO $2,400.00 001C1757 00 G 2016-04-01 2018-01-01 CO $2,400.00 004C1758 00 G 2018-01-01 9901-01-01 CO $50.00 001C1758 00 G 2018-01-01 9901-01-01 CO $50.00 004C1758 00 G 2017-03-01 2018-01-01 CO $50.00 001C1758 00 G 2017-03-01 2018-01-01 CO $50.00 004C1758 00 G 2016-04-01 2017-03-01 CO $50.00 001C1758 00 G 2016-04-01 2017-03-01 CO $50.00 004C1759 00 G 2018-01-01 9901-01-01 CO $10,537.33 001C1759 00 G 2018-01-01 9901-01-01 CO $10,537.33 004C1759 00 G 2017-03-01 2018-01-01 CO $10,537.33 001C1759 00 G 2017-03-01 2018-01-01 CO $10,537.33 004C1759 00 G 2016-04-01 2017-03-01 CO $9,940.88 001C1759 00 G 2016-04-01 2017-03-01 CO $9,940.88 004C1760 00 G 2018-01-01 9901-01-01 CO $1,770.00 001C1760 00 G 2018-01-01 9901-01-01 CO $1,770.00 004C1760 00 G 2017-03-01 2018-01-01 CO $1,770.00 001C1760 00 G 2017-03-01 2018-01-01 CO $1,770.00 004C1760 00 G 2016-04-01 2017-03-01 CO $1,220.00 001C1760 00 G 2016-04-01 2017-03-01 CO $1,220.00 004C1762 00 G 2018-01-01 9901-01-01 CO $8,260.00 001C1762 00 G 2018-01-01 9901-01-01 CO $8,260.00 004C1762 00 G 2017-03-01 2018-01-01 CO $8,260.00 001C1762 00 G 2017-03-01 2018-01-01 CO $8,260.00 004C1762 00 G 2016-04-01 2017-03-01 CO $8,260.00 001C1762 00 G 2016-04-01 2017-03-01 CO $8,260.00 004C1763 00 G 2018-01-01 9901-01-01 CO $1,402.95 001C1763 00 G 2018-01-01 9901-01-01 CO $1,402.95 004C1764 00 G 2018-01-01 9901-01-01 CO $31,860.00 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 22 of 60

Page 23: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

C1764 00 G 2018-01-01 9901-01-01 CO $31,860.00 004C1764 00 G 2017-03-01 2018-01-01 CO $31,860.00 001C1764 00 G 2017-03-01 2018-01-01 CO $31,860.00 004C1764 00 G 2016-04-01 2017-03-01 CO $26,688.15 001C1764 00 G 2016-04-01 2017-03-01 CO $26,688.15 004C1765 00 G 2018-01-01 9901-01-01 CO $1,770.00 001C1765 00 G 2018-01-01 9901-01-01 CO $1,770.00 004C1765 00 G 2017-03-01 2018-01-01 CO $1,770.00 001C1765 00 G 2017-03-01 2018-01-01 CO $1,770.00 004C1765 00 G 2016-04-01 2017-03-01 CO $1,770.00 001C1765 00 G 2016-04-01 2017-03-01 CO $1,770.00 004C1766 00 G 2018-01-01 9901-01-01 CO $4,200.00 001C1766 00 G 2018-01-01 9901-01-01 CO $4,200.00 004C1766 00 G 2017-03-01 2018-01-01 CO $4,200.00 001C1766 00 G 2017-03-01 2018-01-01 CO $4,200.00 004C1766 00 G 2016-04-01 2017-03-01 CO $4,200.00 001C1766 00 G 2016-04-01 2017-03-01 CO $4,200.00 004C1767 00 G 2018-01-01 9901-01-01 CO $96,846.21 001C1767 00 G 2018-01-01 9901-01-01 CO $96,846.21 004C1767 00 G 2017-03-01 2018-01-01 CO $96,846.21 001C1767 00 G 2017-03-01 2018-01-01 CO $96,846.21 004C1767 00 G 2016-04-01 2017-03-01 CO $96,298.72 001C1767 00 G 2016-04-01 2017-03-01 CO $96,298.72 004C1768 00 G 2018-01-01 9901-01-01 CO $5,265.85 001C1768 00 G 2018-01-01 9901-01-01 CO $5,265.85 004C1769 00 G 2018-01-01 9901-01-01 CO $667.94 001C1769 00 G 2018-01-01 9901-01-01 CO $667.94 004C1769 00 G 2017-03-01 2018-01-01 CO $667.94 001C1769 00 G 2017-03-01 2018-01-01 CO $667.94 004C1769 00 G 2016-04-01 2017-03-01 CO $593.85 001C1769 00 G 2016-04-01 2017-03-01 CO $593.85 004C1771 00 G 2018-01-01 9901-01-01 CO $7,111.00 001C1771 00 G 2018-01-01 9901-01-01 CO $7,111.00 004C1771 00 G 2017-03-01 2018-01-01 CO $7,111.00 001C1771 00 G 2017-03-01 2018-01-01 CO $7,111.00 004C1771 00 G 2016-04-01 2017-03-01 CO $7,111.00 001C1771 00 G 2016-04-01 2017-03-01 CO $7,111.00 004C1772 00 G 2018-01-01 9901-01-01 CO $10,976.79 001C1772 00 G 2018-01-01 9901-01-01 CO $10,976.79 004C1773 00 G 2018-01-01 9901-01-01 CO $3,282.00 001C1773 00 G 2018-01-01 9901-01-01 CO $3,282.00 004C1773 00 G 2017-03-01 2018-01-01 CO $3,282.00 001C1773 00 G 2017-03-01 2018-01-01 CO $3,282.00 004C1773 00 G 2016-04-01 2017-03-01 CO $1,200.00 001C1776 00 G 2018-01-01 9901-01-01 CO $9,292.50 001C1776 00 G 2018-01-01 9901-01-01 CO $9,292.50 004C1776 00 G 2017-03-01 2018-01-01 CO $9,292.50 001C1776 00 G 2017-03-01 2018-01-01 CO $9,292.50 004C1776 00 G 2016-04-01 2017-03-01 CO $6,789.40 001C1776 00 G 2016-04-01 2017-03-01 CO $6,789.40 004C1777 00 G 2018-01-01 9901-01-01 CO $27,435.00 001C1777 00 G 2018-01-01 9901-01-01 CO $27,435.00 004C1778 00 G 2018-01-01 9901-01-01 CO $27,495.00 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 23 of 60

Page 24: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

C1778 00 G 2018-01-01 9901-01-01 CO $27,495.00 004C1778 00 G 2017-03-01 2018-01-01 CO $27,495.00 001C1778 00 G 2017-03-01 2018-01-01 CO $27,495.00 004C1778 00 G 2016-04-01 2017-03-01 CO $27,495.00 001C1778 00 G 2016-04-01 2017-03-01 CO $27,495.00 004C1779 00 G 2018-01-01 9901-01-01 CO $2,950.00 001C1779 00 G 2018-01-01 9901-01-01 CO $2,950.00 004C1780 00 G 2018-01-01 9901-01-01 CO $965.29 001C1780 00 G 2018-01-01 9901-01-01 CO $965.29 004C1781 00 G 2018-01-01 9901-01-01 CO $2,680.13 001C1781 00 G 2018-01-01 9901-01-01 CO $2,680.13 004C1781 00 G 2017-03-01 2018-01-01 CO $2,680.13 001C1781 00 G 2017-03-01 2018-01-01 CO $2,680.13 004C1781 00 G 2016-04-01 2017-03-01 CO $2,680.13 001C1781 00 G 2016-04-01 2017-03-01 CO $2,680.13 004C1782 00 G 2018-01-01 9901-01-01 CO $3,300.00 001C1782 00 S 2018-01-01 9901-01-01 CO $3,300.00 001C1782 00 G 2018-01-01 9901-01-01 CO $3,300.00 004C1782 00 S 2018-01-01 9901-01-01 CO $3,300.00 004C1782 00 G 2017-03-01 2018-01-01 CO $3,300.00 001C1782 00 G 2017-03-01 2018-01-01 CO $3,300.00 004C1782 00 G 2016-04-01 2017-03-01 CO $3,300.00 001C1782 00 G 2016-04-01 2017-03-01 CO $3,300.00 004C1785 00 G 2018-01-01 9901-01-01 CO $27,435.00 001C1785 00 G 2018-01-01 9901-01-01 CO $27,435.00 004C1785 00 G 2017-03-01 2018-01-01 CO $27,435.00 001C1785 00 G 2017-03-01 2018-01-01 CO $27,435.00 004C1785 00 G 2016-04-01 2017-03-01 CO $27,435.00 001C1786 00 G 2018-02-01 9901-01-01 CO $23,010.00 001C1786 00 G 2018-02-01 9901-01-01 CO $23,010.00 004C1787 00 G 2018-01-01 9901-01-01 CO $9,216.00 001C1787 00 G 2018-01-01 9901-01-01 CO $9,216.00 004C1787 00 G 2017-03-01 2018-01-01 CO $9,216.00 001C1787 00 G 2017-03-01 2018-01-01 CO $9,216.00 004C1787 00 G 2016-04-01 2017-03-01 CO $8,375.00 001C1787 00 G 2016-04-01 2017-03-01 CO $8,375.00 004C1788 00 G 2018-01-01 9901-01-01 CO $3,219.91 001C1788 00 G 2018-01-01 9901-01-01 CO $3,219.91 004C1788 00 G 2017-03-01 2018-01-01 CO $3,219.91 001C1788 00 G 2017-03-01 2018-01-01 CO $3,219.91 004C1788 00 G 2016-04-01 2017-03-01 CO $3,219.91 001C1788 00 G 2016-04-01 2017-03-01 CO $3,219.91 004C1789 00 G 2018-01-01 9901-01-01 CO $8,260.00 001C1789 00 G 2018-01-01 9901-01-01 CO $8,260.00 004C1789 00 G 2017-03-01 2018-01-01 CO $8,260.00 001C1789 00 G 2017-03-01 2018-01-01 CO $8,260.00 004C1789 00 G 2016-04-01 2017-03-01 CO $6,490.00 001C1789 00 G 2016-04-01 2017-03-01 CO $6,490.00 004C1813 00 G 2018-01-01 9901-01-01 CO $71,688.12 001C1813 00 G 2018-01-01 9901-01-01 CO $71,688.12 004C1813 00 G 2017-11-01 2018-01-01 CO $71,688.12 001C1813 00 G 2017-11-01 2018-01-01 CO $71,688.12 004C1814 00 G 2018-01-01 9901-01-01 CO $2,071.04 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 24 of 60

Page 25: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

C1814 00 G 2018-01-01 9901-01-01 CO $2,071.04 004C1817 00 G 2018-01-01 9901-01-01 CO $37,858.00 001C1817 00 G 2018-01-01 9901-01-01 CO $37,858.00 004C1817 00 G 2017-03-01 2018-01-01 CO $37,858.00 001C1817 00 G 2017-03-01 2018-01-01 CO $37,858.00 004C1819 00 G 2018-01-01 9901-01-01 CO $474.76 001C1819 00 G 2018-01-01 9901-01-01 CO $474.76 004C1820 00 G 2018-01-01 9901-01-01 CO $80,592.00 001C1820 00 G 2018-01-01 9901-01-01 CO $80,592.00 004C1820 00 G 2017-03-01 2018-01-01 CO $80,592.00 001C1820 00 G 2017-03-01 2018-01-01 CO $80,592.00 004C1820 00 G 2016-04-01 2017-03-01 CO $80,592.00 001C1820 00 G 2016-04-01 2017-03-01 CO $80,592.00 004C1830 00 6 2018-01-01 9901-01-01 CO $1,204.00 001C1830 00 6 2018-01-01 9901-01-01 CO $959.00 004C1830 00 6 2017-03-01 2018-01-01 CO $1,204.00 001C1830 00 6 2016-04-01 2017-03-01 CO $1,074.00 001C1874 00 G 2018-01-01 9901-01-01 CO $11,210.00 001C1874 00 G 2018-01-01 9901-01-01 CO $11,210.00 004C1874 00 G 2017-03-01 2018-01-01 CO $11,210.00 001C1874 00 G 2017-03-01 2018-01-01 CO $11,210.00 004C1874 00 G 2016-04-01 2017-03-01 CO $7,938.00 001C1874 00 G 2016-04-01 2017-03-01 CO $7,938.00 004C1876 00 G 2018-01-01 9901-01-01 CO $7,235.46 001C1876 00 G 2018-01-01 9901-01-01 CO $7,235.46 004C1876 00 G 2017-03-01 2018-01-01 CO $7,235.46 001C1876 00 G 2017-03-01 2018-01-01 CO $7,235.46 004C1876 00 G 2016-04-01 2017-03-01 CO $5,050.00 001C1876 00 G 2016-04-01 2017-03-01 CO $5,050.00 004C1877 00 G 2018-01-01 9901-01-01 CO $2,780.52 001C1877 00 G 2018-01-01 9901-01-01 CO $2,780.52 004C1878 00 G 2018-01-01 9901-01-01 CO $4,000.00 001C1878 00 G 2018-01-01 9901-01-01 CO $4,000.00 004C1880 00 G 2018-01-01 9901-01-01 CO $6,490.00 001C1880 00 G 2018-01-01 9901-01-01 CO $6,490.00 004C1882 00 G 2018-01-01 9901-01-01 CO $74,728.00 001C1882 00 G 2018-01-01 9901-01-01 CO $74,728.00 004C1883 00 G 2018-01-01 9901-01-01 CO $4,720.00 001C1883 00 G 2018-01-01 9901-01-01 CO $4,720.00 004C1883 00 G 2016-04-01 2018-01-01 CO $4,720.00 001C1883 00 G 2016-04-01 2018-01-01 CO $4,720.00 004C1884 00 G 2018-01-01 9901-01-01 CO $3,494.38 001C1884 00 G 2018-01-01 9901-01-01 CO $3,494.38 004C1887 00 G 2018-01-01 9901-01-01 CO $600.00 001C1887 00 G 2018-01-01 9901-01-01 CO $600.00 004C1887 00 G 2017-03-01 2018-01-01 CO $600.00 001C1887 00 G 2017-03-01 2018-01-01 CO $600.00 004C1887 00 G 2016-04-01 2017-03-01 CO $419.46 001C1887 00 G 2016-04-01 2017-03-01 CO $419.46 004C1889 00 G 2019-03-01 9901-01-01 CO $39,338.00 001C1889 00 G 2019-03-01 9901-01-01 CO $39,338.00 004C1889 00 G 2018-08-18 2019-03-01 CO $39,338.00 001C1889 00 G 2018-08-18 2019-03-01 CO $39,338.00 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 25 of 60

Page 26: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

C1892 00 G 2018-01-01 9901-01-01 CO $803.00 001C1892 00 G 2018-01-01 9901-01-01 CO $803.00 004C1892 00 G 2016-04-01 2018-01-01 CO $803.00 001C1892 00 G 2016-04-01 2018-01-01 CO $803.00 004C1893 00 G 2018-01-01 9901-01-01 CO $1,163.18 001C1893 00 G 2018-01-01 9901-01-01 CO $1,163.18 004C1893 00 G 2017-03-01 2018-01-01 CO $1,163.18 001C1893 00 G 2017-03-01 2018-01-01 CO $1,163.18 004C1893 00 G 2016-04-01 2017-03-01 CO $1,163.18 001C1893 00 G 2016-04-01 2017-03-01 CO $1,163.18 004C1894 00 G 2018-01-01 9901-01-01 CO $542.19 001C1894 00 G 2018-01-01 9901-01-01 CO $542.19 004C1894 00 G 2017-03-01 2018-01-01 CO $542.19 001C1894 00 G 2017-03-01 2018-01-01 CO $542.19 004C1894 00 G 2016-04-01 2017-03-01 CO $300.00 001C1894 00 G 2016-04-01 2017-03-01 CO $300.00 004C1895 00 G 2018-01-01 9901-01-01 CO $31,620.00 001C1895 00 G 2018-01-01 9901-01-01 CO $31,620.00 004C1895 00 G 2017-10-03 2018-01-01 CO $31,620.00 001C1895 00 G 2017-10-03 2018-01-01 CO $31,620.00 004C1897 00 G 2018-01-01 9901-01-01 CO $4,800.00 001C1897 00 G 2018-01-01 9901-01-01 CO $4,800.00 004C1897 00 G 2016-04-01 2018-01-01 CO $4,800.00 001C1897 00 G 2016-04-01 2018-01-01 CO $4,800.00 004C1898 00 G 2018-01-01 9901-01-01 CO $4,121.74 001C1898 00 G 2018-01-01 9901-01-01 CO $4,121.74 004C1898 00 G 2017-03-01 2018-01-01 CO $4,121.74 001C1898 00 G 2017-03-01 2018-01-01 CO $4,121.74 004C1898 00 G 2016-04-01 2017-03-01 CO $4,121.74 001C1898 00 G 2016-04-01 2017-03-01 CO $4,121.74 004C2614 00 G 2018-01-01 9901-01-01 CO $516.47 001C2614 00 G 2018-01-01 9901-01-01 CO $516.47 004C2616 00 G 2018-01-01 9901-01-01 CO $16,419.71 001C2616 00 G 2018-01-01 9901-01-01 CO $16,419.71 004C2617 00 G 2018-01-01 9901-01-01 CO $762.16 001C2617 00 G 2018-01-01 9901-01-01 CO $762.16 004C2617 00 G 2017-03-01 2018-01-01 CO $762.16 001C2617 00 G 2017-03-01 2018-01-01 CO $762.16 004C2617 00 G 2016-04-01 2017-03-01 CO $665.00 001C2617 00 G 2016-04-01 2017-03-01 CO $665.00 004C2618 00 G 2018-01-01 9901-01-01 CO $3,300.00 001C2618 00 G 2018-01-01 9901-01-01 CO $3,300.00 004C2625 00 G 2018-01-01 9901-01-01 CO $590.00 001C2625 00 G 2018-01-01 9901-01-01 CO $590.00 004C2625 00 G 2017-03-01 2018-01-01 CO $590.00 001C2625 00 G 2017-03-01 2018-01-01 CO $590.00 004C2625 00 G 2016-04-01 2017-03-01 CO $590.00 001C2625 00 G 2016-04-01 2017-03-01 CO $590.00 004C2626 00 G 2018-01-01 9901-01-01 CO $825.00 001C2626 00 G 2018-01-01 9901-01-01 CO $825.00 004C2626 00 G 2017-03-01 2018-01-01 CO $825.00 001C2626 00 G 2017-03-01 2018-01-01 CO $825.00 004C2627 00 G 2018-01-01 9901-01-01 CO $63.10 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 26 of 60

Page 27: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

C2627 00 G 2018-01-01 9901-01-01 CO $63.10 004C2628 00 G 2018-01-01 9901-01-01 CO $2,529.87 001C2628 00 G 2018-01-01 9901-01-01 CO $2,529.87 004C2628 00 G 2017-03-01 2018-01-01 CO $2,529.87 001C2628 00 G 2017-03-01 2018-01-01 CO $2,529.87 004C2628 00 G 2016-04-01 2017-03-01 CO $2,529.87 001C2628 00 G 2016-04-01 2017-03-01 CO $2,529.87 004C2629 00 G 2018-01-01 9901-01-01 CO $375.67 001C2629 00 G 2018-01-01 9901-01-01 CO $375.67 004C2630 00 G 2018-01-01 9901-01-01 CO $7,140.00 001C2630 00 G 2018-01-01 9901-01-01 CO $7,140.00 004C2630 00 G 2017-03-01 2018-01-01 CO $7,140.00 001C2630 00 G 2017-03-01 2018-01-01 CO $7,140.00 004C2630 00 G 2016-04-01 2017-03-01 CO $7,140.00 001C2630 00 G 2016-04-01 2017-03-01 CO $7,140.00 004C2631 00 G 2018-01-01 9901-01-01 CO $4,165.00 001C2631 00 G 2018-01-01 9901-01-01 CO $4,165.00 004C2634 00 G 2018-01-01 9901-01-01 CO $55.73 001C2634 00 G 2018-01-01 9901-01-01 CO $55.73 004C2635 00 G 2018-01-01 9901-01-01 CO $28.39 001C2635 00 G 2018-01-01 9901-01-01 CO $28.39 004C2636 00 G 2018-01-01 9901-01-01 CO $36.82 001C2636 00 G 2018-01-01 9901-01-01 CO $36.82 004C2638 00 G 2018-01-01 9901-01-01 CO $41.25 001C2638 00 G 2018-01-01 9901-01-01 CO $41.25 004C2639 00 G 2018-01-01 9901-01-01 CO $36.22 001C2639 00 G 2018-01-01 9901-01-01 CO $36.22 004C2640 00 G 2018-01-01 9901-01-01 CO $72.08 001C2640 00 G 2018-01-01 9901-01-01 CO $72.08 004C2641 00 G 2018-01-01 9901-01-01 CO $64.97 001C2641 00 G 2018-01-01 9901-01-01 CO $64.97 004C2642 00 G 2018-01-01 9901-01-01 CO $123.16 001C2642 00 G 2018-01-01 9901-01-01 CO $123.16 004C2643 00 G 2018-01-01 9901-01-01 CO $65.97 001C2643 00 G 2018-01-01 9901-01-01 CO $65.97 004C2698 00 G 2018-01-01 9901-01-01 CO $41.25 001C2698 00 G 2018-01-01 9901-01-01 CO $41.25 004C8900 00 5 2018-01-01 9901-01-01 CO $433.05 001C8900 00 5 2018-01-01 9901-01-01 CO $433.05 004C8901 00 5 2018-01-01 9901-01-01 CO $339.84 001C8901 00 5 2018-01-01 9901-01-01 CO $339.84 004C8902 00 5 2018-01-01 9901-01-01 CO $528.80 001C8902 00 5 2018-01-01 9901-01-01 CO $528.80 004C8903 00 5 2018-01-01 9901-01-01 CO $433.05 001C8903 00 5 2018-01-01 9901-01-01 CO $433.05 004C8904 00 5 2018-01-01 9901-01-01 CO $339.84 001C8904 00 5 2018-01-01 9901-01-01 CO $339.84 004C8905 00 5 2018-01-01 9901-01-01 CO $528.80 001C8905 00 5 2018-01-01 9901-01-01 CO $528.80 004C8906 00 5 2018-01-01 9901-01-01 CO $433.05 001C8906 00 5 2018-01-01 9901-01-01 CO $433.05 004C8907 00 5 2018-01-01 9901-01-01 CO $339.84 001C8907 00 5 2018-01-01 9901-01-01 CO $339.84 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 27 of 60

Page 28: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

C8908 00 5 2018-01-01 9901-01-01 CO $528.80 001C8908 00 5 2018-01-01 9901-01-01 CO $528.80 004C8909 00 5 2018-01-01 9901-01-01 CO $433.05 001C8909 00 5 2018-01-01 9901-01-01 CO $433.05 004C8910 00 5 2018-01-01 9901-01-01 CO $339.84 001C8910 00 5 2018-01-01 9901-01-01 CO $339.84 004C8911 00 5 2018-01-01 9901-01-01 CO $528.80 001C8911 00 5 2018-01-01 9901-01-01 CO $528.80 004C8912 00 5 2018-01-01 9901-01-01 CO $433.05 001C8912 00 5 2018-01-01 9901-01-01 CO $433.05 004C8913 00 5 2018-01-01 9901-01-01 CO $339.84 001C8913 00 5 2018-01-01 9901-01-01 CO $339.84 004C8914 00 5 2018-01-01 9901-01-01 CO $528.80 001C8914 00 5 2018-01-01 9901-01-01 CO $528.80 004C8918 00 5 2018-01-01 9901-01-01 CO $433.05 001C8918 00 5 2018-01-01 9901-01-01 CO $433.05 004C8919 00 5 2018-01-01 9901-01-01 CO $339.84 001C8919 00 5 2018-01-01 9901-01-01 CO $339.84 004C8920 00 5 2018-01-01 9901-01-01 CO $528.80 001C8920 00 5 2018-01-01 9901-01-01 CO $528.80 004C8921 00 5 2018-01-01 9901-01-01 CO $494.54 001C8921 00 5 2018-01-01 9901-01-01 CO $494.54 004C8922 00 5 2018-01-01 9901-01-01 CO $494.54 001C8922 00 5 2018-01-01 9901-01-01 CO $494.54 004C8923 00 5 2018-01-01 9901-01-01 CO $494.54 001C8923 00 5 2018-01-01 9901-01-01 CO $494.54 004C8924 00 5 2018-01-01 9901-01-01 CO $494.54 001C8924 00 5 2018-01-01 9901-01-01 CO $494.54 004C8925 00 5 2018-01-01 9901-01-01 CO $494.54 001C8925 00 5 2018-01-01 9901-01-01 CO $494.54 004C8926 00 5 2018-01-01 9901-01-01 CO $494.54 001C8926 00 5 2018-01-01 9901-01-01 CO $494.54 004C8927 00 5 2018-01-01 9901-01-01 CO $494.54 001C8927 00 5 2018-01-01 9901-01-01 CO $494.54 004C8928 00 5 2018-01-01 9901-01-01 CO $494.54 001C8928 00 5 2018-01-01 9901-01-01 CO $494.54 004C8929 00 5 2018-01-01 9901-01-01 CO $494.54 001C8929 00 5 2018-01-01 9901-01-01 CO $494.54 004C8930 00 5 2018-01-01 9901-01-01 CO $494.54 001C8930 00 5 2018-01-01 9901-01-01 CO $494.54 004C8931 00 5 2018-01-01 9901-01-01 CO $554.42 001C8931 00 5 2018-01-01 9901-01-01 CO $554.42 004C8932 00 5 2018-01-01 9901-01-01 CO $554.42 001C8932 00 5 2018-01-01 9901-01-01 CO $554.42 004C8933 00 5 2018-01-01 9901-01-01 CO $554.42 001C8933 00 5 2018-01-01 9901-01-01 CO $554.42 004C8934 00 5 2018-01-01 9901-01-01 CO $545.97 001C8934 00 5 2018-01-01 9901-01-01 CO $545.97 004C8935 00 5 2018-01-01 9901-01-01 CO $545.97 001C8935 00 5 2018-01-01 9901-01-01 CO $545.97 004C8936 00 5 2018-01-01 9901-01-01 CO $545.97 001C8936 00 5 2018-01-01 9901-01-01 CO $545.97 004C8937 00 P 2019-04-13 9901-01-01 CO $82.80 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 28 of 60

Page 29: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

C8957 00 6 2018-01-01 9901-01-01 CO $204.01 001C8957 00 6 2018-01-01 9901-01-01 CO $204.01 004C9113 00 6 2018-01-01 9901-01-01 CO $242.90 001C9113 00 6 2018-01-01 9901-01-01 CO $141.75 004C9113 00 6 2017-03-01 2018-01-01 CO $242.90 001C9113 00 6 2017-03-01 2018-01-01 CO $141.75 004C9113 00 6 2016-04-01 2017-03-01 CO $242.90 001C9275 00 6 2018-01-01 9901-01-01 CO $636.00 001C9275 00 6 2018-01-01 9901-01-01 CO $636.00 004C9356 00 G 2018-01-01 9901-01-01 CO $26.38 001C9358 00 G 2018-01-01 9901-01-01 CO $11.36 001C9358 00 G 2018-01-01 9901-01-01 CO $11.36 004C9359 00 G 2018-01-01 9901-01-01 CO $63.12 001C9360 00 6 2018-01-01 9901-01-01 CO $11.72 001C9360 00 6 2018-01-01 9901-01-01 CO $11.72 004C9361 00 6 2018-01-01 9901-01-01 CO $266.75 001C9361 00 6 2018-01-01 9901-01-01 CO $266.75 004C9362 00 6 2018-01-01 9901-01-01 CO $49.46 001C9362 00 6 2018-01-01 9901-01-01 CO $49.46 004C9363 00 6 2018-01-01 9901-01-01 CO $18.88 001C9363 00 6 2018-01-01 9901-01-01 CO $18.88 004C9364 00 6 2018-01-01 9901-01-01 CO $18.56 001C9364 00 6 2018-01-01 9901-01-01 CO $18.56 004C9466 00 6 2018-11-24 9901-01-01 CO $601.93 001C9483 26 P 2017-06-23 9901-01-01 CO $260.03 001C9483 26 P 2017-06-23 9901-01-01 CO $260.03 004C9600 00 6 2018-01-01 9901-01-01 CO $30,945.15 001C9600 00 6 2018-01-01 9901-01-01 CO $20,891.50 004C9600 00 6 2017-03-01 2018-01-01 CO $30,945.15 001C9600 00 6 2016-04-01 2017-03-01 CO $29,193.54 001C9725 00 2 2018-01-01 9901-01-01 CO $410.61 001C9725 00 2 2018-01-01 9901-01-01 CO $410.61 004C9726 00 2 2018-01-01 9901-01-01 CO $1,645.05 001C9727 00 2 2018-01-01 9901-01-01 CO $540.55 001C9727 00 2 2018-01-01 9901-01-01 CO $540.55 004C9728 00 2 2018-01-01 9901-01-01 CO $918.40 001C9728 00 2 2018-01-01 9901-01-01 CO $918.40 004C9803 00 P 2020-08-08 9901-01-01 CO $63.00 001C9898 00 6 2018-01-01 9901-01-01 CO $1.00 001C9898 00 6 2018-01-01 9901-01-01 CO $1.00 004D0120 00 7 2021-03-01 9901-01-01 CO $48.00 001D0120 00 7 2021-03-01 9901-01-01 CO $48.00 004D0120 00 7 2020-03-01 2021-03-01 CO $58.00 001D0120 00 7 2018-03-01 2020-03-01 CO $61.00 001D0120 00 7 2018-01-01 2018-03-01 CO $53.00 001D0120 00 7 2018-01-01 2021-03-01 CO $49.00 004D0120 00 7 2017-03-01 2018-01-01 CO $53.00 001D0120 00 7 2016-04-01 2017-03-01 CO $53.00 001D0140 00 7 2021-03-01 9901-01-01 CO $116.00 001D0140 00 7 2020-03-01 2021-03-01 CO $267.00 001D0140 00 7 2018-03-01 2020-03-01 CO $104.00 001D0140 00 7 2018-01-01 2018-03-01 CO $100.00 001D0140 00 7 2018-01-01 9901-01-01 CO $98.00 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 29 of 60

Page 30: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

D0140 00 7 2017-03-01 2018-01-01 CO $100.00 001D0140 00 7 2016-04-01 2017-03-01 CO $100.00 001D0145 00 7 2021-03-01 9901-01-01 CO $51.00 001D0145 00 7 2020-03-01 2021-03-01 CO $51.00 001D0145 00 7 2020-03-01 9901-01-01 CO $51.00 004D0145 00 7 2019-03-01 2020-03-01 CO $58.00 001D0145 00 7 2018-03-01 2019-03-01 CO $58.00 001D0145 00 7 2018-01-01 2018-03-01 CO $58.00 001D0145 00 7 2018-01-01 2020-03-01 CO $55.00 004D0145 00 7 2017-03-01 2018-01-01 CO $58.00 001D0145 00 7 2016-04-01 2017-03-01 CO $57.00 001D0150 00 7 2020-03-01 9901-01-01 CO $232.00 001D0150 00 7 2018-03-01 2020-03-01 CO $100.00 001D0150 00 7 2018-01-01 2018-03-01 CO $100.00 001D0150 00 7 2018-01-01 9901-01-01 CO $80.00 004D0150 00 7 2017-03-01 2018-01-01 CO $100.00 001D0150 00 7 2016-04-01 2017-03-01 CO $100.00 001D0160 00 7 2018-01-01 9901-01-01 CO $229.00 001D0160 00 7 2018-01-01 9901-01-01 CO $229.00 004D0160 00 7 2017-03-01 2018-01-01 CO $229.00 001D0160 00 7 2016-04-01 2017-03-01 CO $229.00 001D0170 00 7 2020-03-01 9901-01-01 CO $267.00 001D0170 00 7 2018-01-01 2020-03-01 CO $189.00 001D0170 00 7 2018-01-01 9901-01-01 CO $189.00 004D0190 00 7 2021-03-01 9901-01-01 CO $25.00 001D0190 00 7 2020-03-01 2021-03-01 CO $40.00 001D0190 00 7 2019-03-01 2020-03-01 CO $60.00 001D0190 00 7 2018-03-01 2019-03-01 CO $60.00 001D0190 00 7 2018-01-01 2018-03-01 CO $60.00 001D0190 00 7 2018-01-01 9901-01-01 CO $25.00 004D0190 00 7 2017-03-01 2018-01-01 CO $60.00 001D0190 00 7 2016-04-01 2017-03-01 CO $60.00 001D0210 00 7 2018-01-01 9901-01-01 CO $146.00 001D0210 00 7 2018-01-01 9901-01-01 CO $146.00 004D0210 00 7 2016-04-22 2018-01-01 CO $146.00 001D0210 00 7 2016-04-22 2018-01-01 CO $146.00 004D0220 00 7 2018-03-01 9901-01-01 CO $36.00 001D0220 00 7 2018-03-01 9901-01-01 CO $34.00 004D0220 00 7 2018-01-01 2018-03-01 CO $36.00 001D0220 00 7 2018-01-01 2018-03-01 CO $34.00 004D0220 00 7 2017-03-01 2018-01-01 CO $36.00 001D0220 00 7 2017-03-01 2018-01-01 CO $34.00 004D0220 00 7 2016-04-01 2017-03-01 CO $36.00 001D0230 00 7 2018-01-01 9901-01-01 CO $25.00 001D0230 00 7 2018-01-01 9901-01-01 CO $25.00 004D0230 00 7 2017-03-01 2018-01-01 CO $25.00 001D0230 00 7 2017-03-01 2018-01-01 CO $25.00 004D0230 00 7 2016-01-15 2017-03-01 CO $25.00 001D0230 00 7 2016-01-15 2017-03-01 CO $25.00 004D0272 00 7 2018-01-01 9901-01-01 CO $48.00 001D0272 00 7 2018-01-01 9901-01-01 CO $48.00 004D0274 00 7 2018-03-01 9901-01-01 CO $69.00 001D0274 00 7 2018-01-01 2018-03-01 CO $66.00 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 30 of 60

Page 31: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

D0274 00 7 2018-01-01 9901-01-01 CO $64.00 004D0274 00 7 2017-03-01 2018-01-01 CO $66.00 001D0274 00 7 2016-04-01 2017-03-01 CO $66.00 001D0321 00 7 2018-01-01 9901-01-01 CO $109.00 001D0321 00 7 2018-01-01 9901-01-01 CO $109.00 004D0322 00 7 2018-01-01 9901-01-01 CO $383.15 001D0322 00 7 2018-01-01 9901-01-01 CO $383.15 004D0330 00 7 2021-03-01 9901-01-01 CO $141.00 001D0330 00 7 2020-03-01 2021-03-01 CO $125.00 001D0330 00 7 2018-01-01 2020-03-01 CO $123.88 001D0330 00 7 2018-01-01 9901-01-01 CO $123.88 004D0350 00 7 2018-01-01 9901-01-01 CO $86.00 001D0350 00 7 2018-01-01 9901-01-01 CO $86.00 004D0364 00 7 2018-01-01 9901-01-01 CO $189.00 001D0364 00 7 2018-01-01 9901-01-01 CO $189.00 004D0364 00 7 2017-07-25 2018-01-01 CO $189.00 001D0364 00 7 2017-07-25 2018-01-01 CO $189.00 004D0470 00 7 2021-03-01 9901-01-01 CO $229.00 001D0470 00 7 2020-03-01 2021-03-01 CO $229.00 001D0470 00 7 2019-03-01 2020-03-01 CO $250.00 001D0470 00 7 2018-03-01 2019-03-01 CO $250.00 001D0470 00 7 2018-01-01 2018-03-01 CO $229.00 001D0470 00 7 2018-01-01 9901-01-01 CO $101.93 004D0470 00 7 2017-03-01 2018-01-01 CO $229.00 001D0470 00 7 2016-04-01 2017-03-01 CO $229.00 001D0474 00 7 2018-01-01 9901-01-01 CO $220.00 001D0474 00 7 2018-01-01 9901-01-01 CO $220.00 004D1110 00 7 2021-03-01 9901-01-01 CO $89.00 001D1110 00 7 2020-03-01 2021-03-01 CO $107.00 001D1110 00 7 2018-03-01 2020-03-01 CO $105.00 001D1110 00 7 2018-01-01 2018-03-01 CO $93.00 001D1110 00 7 2018-01-01 9901-01-01 CO $78.00 004D1110 00 7 2017-03-01 2018-01-01 CO $93.00 001D1110 00 7 2016-04-01 2017-03-01 CO $93.00 001D1120 00 7 2018-01-01 9901-01-01 CO $71.00 001D1120 00 7 2018-01-01 9901-01-01 CO $71.00 004D1206 00 7 2021-03-01 9901-01-01 CO $42.00 001D1206 00 7 2020-03-01 2021-03-01 CO $42.00 001D1206 00 7 2019-03-01 2020-03-01 CO $44.00 001D1206 00 7 2018-03-01 2019-03-01 CO $44.00 001D1206 00 7 2018-03-01 9901-01-01 CO $40.00 004D1206 00 7 2018-01-01 2018-03-01 CO $44.00 001D1206 00 7 2018-01-01 2018-03-01 CO $40.00 004D1206 00 7 2017-03-01 2018-01-01 CO $44.00 001D1206 00 7 2017-03-01 2018-01-01 CO $40.00 004D1206 00 7 2016-04-01 2017-03-01 CO $44.00 001D1206 00 7 2016-04-01 2017-03-01 CO $40.00 004D1208 00 7 2018-01-01 9901-01-01 CO $2,379.09 001D1208 00 7 2018-01-01 9901-01-01 CO $2,379.09 004D1351 00 7 2018-01-01 9901-01-01 CO $65.00 001D1351 00 7 2018-01-01 9901-01-01 CO $65.00 004D1510 00 7 2018-01-01 9901-01-01 CO $2,901.71 001D1510 00 7 2018-01-01 9901-01-01 CO $2,901.71 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 31 of 60

Page 32: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

D2330 00 7 2018-01-01 9901-01-01 CO $3,978.25 001D2330 00 7 2018-01-01 9901-01-01 CO $3,978.25 004D2331 00 7 2018-01-01 9901-01-01 CO $1,253.71 001D2331 00 7 2018-01-01 9901-01-01 CO $1,253.71 004D2331 00 7 2017-01-05 2018-01-01 CO $1,253.71 001D2331 00 7 2017-01-05 2018-01-01 CO $1,253.71 004D2335 00 7 2018-01-01 9901-01-01 CO $2,002.53 001D2335 00 7 2018-01-01 9901-01-01 CO $2,002.53 004D2390 00 7 2018-01-01 9901-01-01 CO $5,223.03 001D2390 00 7 2018-01-01 9901-01-01 CO $5,223.03 004D2391 00 7 2018-01-01 9901-01-01 CO $3,615.72 001D2391 00 7 2018-01-01 9901-01-01 CO $3,615.72 004D2391 00 7 2017-03-01 2018-01-01 CO $3,615.72 001D2391 00 7 2017-03-01 2018-01-01 CO $3,615.72 004D2392 00 7 2021-03-01 9901-01-01 CO $295.00 001D2392 00 7 2021-03-01 9901-01-01 CO $295.00 004D2392 00 7 2018-01-01 2021-03-01 CO $854.17 001D2392 00 7 2018-01-01 2021-03-01 CO $854.17 004D2392 00 7 2017-02-17 2018-01-01 CO $854.17 001D2392 00 7 2017-02-17 2018-01-01 CO $854.17 004D2393 00 7 2018-01-01 9901-01-01 CO $340.17 001D2740 00 7 2018-01-01 9901-01-01 CO $1,748.00 001D2740 00 7 2018-01-01 9901-01-01 CO $1,748.00 004D2750 00 7 2018-01-01 9901-01-01 CO $1,002.76 001D2751 00 7 2018-01-01 9901-01-01 CO $884.96 001D2751 00 7 2018-01-01 9901-01-01 CO $884.96 004D2930 00 7 2018-01-01 9901-01-01 CO $338.52 001D2930 00 7 2018-01-01 9901-01-01 CO $154.66 004D2932 00 7 2018-01-01 9901-01-01 CO $154.66 001D2932 00 7 2018-01-01 9901-01-01 CO $154.66 004D2934 00 7 2018-01-01 9901-01-01 CO $4,751.10 001D2934 00 7 2018-01-01 9901-01-01 CO $4,751.10 004D2950 00 7 2018-01-01 9901-01-01 CO $275.00 001D2950 00 7 2018-01-01 9901-01-01 CO $275.00 004D2950 00 7 2016-03-22 2018-01-01 CO $275.00 001D2950 00 7 2016-03-22 2018-01-01 CO $275.00 004D2971 00 7 2018-01-01 9901-01-01 CO $84.24 001D2971 00 7 2018-01-01 9901-01-01 CO $84.24 004D3220 00 7 2018-01-01 9901-01-01 CO $4,751.10 001D3220 00 7 2018-01-01 9901-01-01 CO $4,751.10 004D3330 00 7 2018-01-01 9901-01-01 CO $1,253.71 001D3330 00 7 2018-01-01 9901-01-01 CO $1,253.71 004D4341 00 7 2018-03-01 9901-01-01 CO $325.00 001D4341 00 7 2018-03-01 9901-01-01 CO $325.00 004D4341 00 7 2018-02-01 2018-03-01 CO $325.00 001D4341 00 7 2018-02-01 2018-03-01 CO $325.00 004D4910 00 7 2018-01-01 9901-01-01 CO $142.00 001D4910 00 7 2018-01-01 9901-01-01 CO $137.00 004D4910 00 7 2016-04-01 2018-01-01 CO $142.00 001D6010 00 7 2018-01-01 9901-01-01 CO $1,950.00 001D6056 00 7 2018-01-01 9901-01-01 CO $616.40 001D6056 00 7 2018-01-01 9901-01-01 CO $616.40 004D6076 00 7 2018-01-01 9901-01-01 CO $1,150.00 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 32 of 60

Page 33: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

D6076 00 7 2018-01-01 9901-01-01 CO $1,150.00 004D7111 00 7 2018-01-01 9901-01-01 CO $3,934.90 001D7111 00 7 2018-01-01 9901-01-01 CO $3,934.90 004D7140 00 7 2020-03-01 9901-01-01 CO $160.00 001D7140 00 7 2018-03-01 2020-03-01 CO $200.00 001D7140 00 7 2018-01-01 2018-03-01 CO $200.00 001D7140 00 7 2018-01-01 9901-01-01 CO $152.00 004D7140 00 7 2016-04-01 2018-01-01 CO $200.00 001D7210 00 7 2021-03-01 9901-01-01 CO $376.00 001D7210 00 7 2020-03-01 2021-03-01 CO $320.00 001D7210 00 7 2018-03-01 2020-03-01 CO $323.00 001D7210 00 7 2018-01-01 2018-03-01 CO $305.00 001D7210 00 7 2018-01-01 9901-01-01 CO $265.00 004D7210 00 7 2017-03-01 2018-01-01 CO $305.00 001D7210 00 7 2017-03-01 2018-01-01 CO $265.00 004D7210 00 7 2016-04-01 2017-03-01 CO $305.00 001D7210 00 7 2016-04-01 2017-03-01 CO $265.00 004D7220 00 7 2021-03-01 9901-01-01 CO $350.00 001D7220 00 7 2021-03-01 9901-01-01 CO $350.00 004D7220 00 7 2018-01-01 2021-03-01 CO $394.00 001D7220 00 7 2018-01-01 2021-03-01 CO $394.00 004D7220 00 7 2017-08-22 2018-01-01 CO $394.00 001D7220 00 7 2017-08-22 2018-01-01 CO $394.00 004D7230 00 7 2021-03-01 9901-01-01 CO $444.00 001D7230 00 7 2020-03-01 2021-03-01 CO $521.00 001D7230 00 7 2018-03-01 2020-03-01 CO $491.00 001D7230 00 7 2018-01-01 2018-03-01 CO $491.00 001D7230 00 7 2018-01-01 9901-01-01 CO $410.00 004D7230 00 7 2017-03-01 2018-01-01 CO $491.00 001D7230 00 7 2016-04-01 2017-03-01 CO $410.00 001D7230 00 7 2016-04-01 2018-01-01 CO $410.00 004D7240 00 7 2021-03-01 9901-01-01 CO $494.00 001D7240 00 7 2021-03-01 9901-01-01 CO $494.00 004D7240 00 7 2020-03-01 2021-03-01 CO $545.00 001D7240 00 7 2020-03-01 2021-03-01 CO $545.00 004D7240 00 7 2019-03-01 2020-03-01 CO $560.00 001D7240 00 7 2019-03-01 2020-03-01 CO $560.00 004D7240 00 7 2018-03-01 2019-03-01 CO $560.00 001D7240 00 7 2018-03-01 2019-03-01 CO $560.00 004D7240 00 7 2018-01-01 2018-03-01 CO $560.00 001D7240 00 7 2018-01-01 2018-03-01 CO $560.00 004D7240 00 7 2017-03-01 2018-01-01 CO $560.00 001D7240 00 7 2017-03-01 2018-01-01 CO $560.00 004D7240 00 7 2016-04-01 2017-03-01 CO $560.00 001D7240 00 7 2016-04-01 2017-03-01 CO $560.00 004D7270 00 7 2020-10-03 9901-01-01 CO $852.00 001D7283 00 7 2020-10-03 9901-01-01 CO $230.00 001D7285 00 7 2021-03-01 9901-01-01 CO $915.00 001D7285 00 7 2021-03-01 9901-01-01 CO $915.00 004D7285 00 7 2019-08-03 2021-03-01 CO $915.00 001D7880 00 7 2021-03-01 9901-01-01 CO $2,300.00 001D7880 00 7 2020-03-01 2021-03-01 CO $2,300.00 001D7880 00 7 2019-03-01 2020-03-01 CO $2,280.00 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 33 of 60

Page 34: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

D7880 00 7 2019-03-01 9901-01-01 CO $2,280.00 004D7880 00 7 2018-03-01 2019-03-01 CO $2,280.00 001D7880 00 7 2018-03-01 2019-03-01 CO $2,280.00 004D7880 00 7 2018-01-01 2018-03-01 CO $1,470.00 001D7881 00 7 2021-03-01 9901-01-01 CO $100.00 001D7881 00 7 2020-03-01 2021-03-01 CO $100.00 001D7881 00 7 2018-03-01 2020-03-01 CO $100.00 001D7881 00 7 2018-01-01 2018-03-01 CO $90.00 001D7881 00 7 2018-01-01 9901-01-01 CO $90.00 004D7881 00 7 2017-03-01 2018-01-01 CO $90.00 001D7881 00 7 2016-06-24 2017-03-01 CO $90.00 001D7881 00 7 2016-06-24 2018-01-01 CO $90.00 004D7953 00 7 2018-01-01 9901-01-01 CO $107.03 001D8060 00 7 2018-01-01 9901-01-01 CO $2,514.30 001D8080 00 7 2018-01-01 9901-01-01 CO $1,734.25 001D8090 00 7 2018-01-01 9901-01-01 CO $1,734.25 001D8670 00 7 2021-03-01 9901-01-01 CO $302.08 001D8670 00 7 2020-03-01 2021-03-01 CO $250.00 001D8670 00 7 2018-01-01 2020-03-01 CO $200.00 001D8670 00 7 2018-01-01 9901-01-01 CO $200.00 004D8690 00 7 2018-01-01 9901-01-01 CO $272.53 001D8690 00 7 2018-01-01 9901-01-01 CO $272.53 004D9223 00 7 2021-03-01 9901-01-01 CO $271.00 001D9223 00 7 2020-03-01 2021-03-01 CO $255.00 001D9223 00 7 2020-03-01 9901-01-01 CO $255.00 004D9223 00 7 2018-03-01 2020-03-01 CO $278.00 001D9223 00 7 2018-03-01 2020-03-01 CO $278.00 004D9223 00 7 2018-01-01 2018-03-01 CO $278.00 001D9223 00 7 2018-01-01 2018-03-01 CO $278.00 004D9223 00 7 2017-09-12 2018-01-01 CO $278.00 001D9223 00 7 2017-09-12 2018-01-01 CO $278.00 004D9243 00 7 2021-03-01 9901-01-01 CO $165.00 001D9243 00 7 2020-03-01 2021-03-01 CO $165.00 001D9243 00 7 2020-03-01 9901-01-01 CO $165.00 004D9243 00 7 2019-03-01 2020-03-01 CO $249.00 001D9243 00 7 2019-03-01 2020-03-01 CO $249.00 004D9243 00 7 2018-03-01 2019-03-01 CO $249.00 001D9243 00 7 2018-03-01 2019-03-01 CO $249.00 004D9243 00 7 2018-01-01 2018-03-01 CO $249.00 001D9243 00 7 2018-01-01 2018-03-01 CO $249.00 004D9243 00 7 2017-01-10 2018-01-01 CO $249.00 001D9243 00 7 2017-01-10 2018-01-01 CO $249.00 004D9310 00 7 2021-03-01 9901-01-01 CO $225.00 001D9310 00 7 2020-03-01 2021-03-01 CO $397.00 001D9310 00 7 2018-03-01 2020-03-01 CO $215.00 001D9310 00 7 2018-01-01 2018-03-01 CO $215.00 001D9310 00 7 2018-01-01 9901-01-01 CO $165.00 004D9310 00 7 2017-03-01 2018-01-01 CO $215.00 001D9310 00 7 2017-03-01 2018-01-01 CO $165.00 004D9310 00 7 2016-04-01 2017-03-01 CO $215.00 001D9310 00 7 2016-04-01 2017-03-01 CO $165.00 004D9610 00 7 2021-03-01 9901-01-01 CO $86.00 001D9610 00 7 2020-03-01 2021-03-01 CO $40.00 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 34 of 60

Page 35: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

D9610 00 7 2020-03-01 9901-01-01 CO $40.00 004D9610 00 7 2018-01-01 2020-03-01 CO $118.00 001D9610 00 7 2018-01-01 2020-03-01 CO $79.00 004D9613 00 7 2020-11-21 9901-01-01 CO $350.00 001D9630 00 7 2018-03-01 9901-01-01 CO $55.95 001D9630 00 7 2018-01-01 2018-03-01 CO $29.95 001D9630 00 7 2018-01-01 9901-01-01 CO $29.95 004D9630 00 7 2017-09-06 2018-01-01 CO $29.95 001D9630 00 7 2017-09-06 2018-01-01 CO $29.95 004D9930 00 7 2018-01-01 9901-01-01 CO $98.60 001D9940 00 7 2018-01-01 2019-01-01 CO $850.00 001D9943 00 7 2020-03-01 9901-01-01 CO $267.00 001D9943 00 7 2020-03-01 9901-01-01 CO $267.00 004D9943 00 7 2018-09-01 2020-03-01 CO $267.00 001D9944 00 7 2021-03-01 9901-01-01 CO $678.00 001D9944 00 7 2021-03-01 9901-01-01 CO $678.00 004D9944 00 7 2019-09-07 2021-03-01 CO $950.00 001D9950 00 7 2018-01-01 9901-01-01 CO $210.00 001D9950 00 7 2018-01-01 9901-01-01 CO $210.00 004D9950 00 7 2017-09-28 2018-01-01 CO $210.00 001D9950 00 7 2017-09-28 2018-01-01 CO $210.00 004D9951 00 7 2018-01-01 9901-01-01 CO $75.00 001D9951 00 7 2018-01-01 9901-01-01 CO $38.00 004D9951 00 7 2017-03-01 2018-01-01 CO $75.00 001D9951 00 7 2016-04-01 2017-03-01 CO $38.00 001D9952 00 7 2018-01-01 9901-01-01 CO $38.00 001D9952 00 7 2018-01-01 9901-01-01 CO $38.00 004D9971 00 7 2018-01-01 9901-01-01 CO $80.00 001E0118 NU G 2021-03-01 9901-01-01 CO $950.00 001E0118 NU G 2021-03-01 9901-01-01 CO $950.00 004E0118 NU G 2020-03-01 2021-03-01 CO $927.00 001E0118 NU G 2020-03-01 2021-03-01 CO $927.00 004E0118 NU G 2018-03-01 2020-03-01 CO $925.00 001E0118 NU G 2018-03-01 2020-03-01 CO $925.00 004E0118 NU G 2018-01-01 2018-03-01 CO $925.00 001E0118 NU G 2018-01-01 2018-03-01 CO $925.00 004E0118 NU G 2017-03-01 2018-01-01 CO $925.00 001E0118 NU G 2017-03-01 2018-01-01 CO $925.00 004E0118 RR H 2021-03-01 9901-01-01 CO $155.00 001E0118 RR H 2021-03-01 9901-01-01 CO $155.00 004E0118 RR H 2020-03-01 2021-03-01 CO $150.59 001E0118 RR H 2020-03-01 2021-03-01 CO $150.59 004E0118 RR H 2019-03-01 2020-03-01 CO $199.00 001E0118 RR H 2019-03-01 2020-03-01 CO $199.00 004E0118 RR H 2018-03-01 2019-03-01 CO $150.00 001E0118 RR H 2018-03-01 2019-03-01 CO $150.00 004E0118 RR H 2018-01-01 2018-03-01 CO $150.00 001E0118 RR H 2018-01-01 2018-03-01 CO $150.00 004E0118 RR H 2017-03-01 2018-01-01 CO $150.00 001E0118 RR H 2017-03-01 2018-01-01 CO $150.00 004E0118 RR H 2016-04-01 2017-03-01 CO $150.00 001E0118 00 7 2018-01-01 9901-01-01 CO $1,885.00 001E0118 00 7 2018-01-01 9901-01-01 CO $1,885.00 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 35 of 60

Page 36: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

E0190 00 G 2020-03-01 9901-01-01 CO $264.00 001E0190 00 G 2020-03-01 9901-01-01 CO $264.00 004E0190 00 G 2018-01-01 2020-03-01 CO $166.25 001E0190 00 G 2018-01-01 2020-03-01 CO $166.25 004E0218 RR H 2018-01-01 9901-01-01 CO $66.05 001E0218 RR H 2018-01-01 9901-01-01 CO $66.05 004E0218 00 G 2018-01-01 9901-01-01 CO $1,974.00 001E0218 00 G 2018-01-01 9901-01-01 CO $1,974.00 004E0240 RR H 2018-01-01 9901-01-01 CO $15.25 001E0240 RR H 2018-01-01 9901-01-01 CO $15.25 004E0240 00 G 2018-01-01 9901-01-01 CO $3,992.00 001E0240 00 G 2018-01-01 9901-01-01 CO $3,992.00 004E0244 00 G 2018-01-01 9901-01-01 CO $440.00 001E0244 00 G 2018-01-01 9901-01-01 CO $440.00 004E0245 RR H 2018-01-01 9901-01-01 CO $2.31 001E0245 RR H 2018-01-01 9901-01-01 CO $2.31 004E0245 00 G 2018-01-01 9901-01-01 CO $94.95 001E0245 00 G 2018-01-01 9901-01-01 CO $94.95 004E0247 RR H 2018-01-01 9901-01-01 CO $14.26 001E0247 RR H 2018-01-01 9901-01-01 CO $14.26 004E0247 00 G 2018-01-01 9901-01-01 CO $249.07 001E0247 00 G 2018-01-01 9901-01-01 CO $249.07 004E0274 RR H 2018-01-01 9901-01-01 CO $118.92 001E0274 RR H 2018-01-01 9901-01-01 CO $118.92 004E0274 00 G 2018-01-01 9901-01-01 CO $1,545.96 001E0274 00 G 2018-01-01 9901-01-01 CO $1,545.96 004E0328 00 G 2018-01-01 9901-01-01 CO $18,460.80 001E0328 00 G 2018-01-01 9901-01-01 CO $18,460.80 004E0329 RR H 2018-01-01 9901-01-01 CO $232.24 001E0329 RR H 2018-01-01 9901-01-01 CO $232.24 004E0352 00 G 2018-01-01 9901-01-01 CO $85.67 001E0352 00 G 2018-01-01 9901-01-01 CO $85.67 004E0445 RR H 2021-03-01 9901-01-01 CO $1,282.31 001E0445 RR H 2021-03-01 9901-01-01 CO $1,282.31 004E0445 RR H 2020-03-01 2021-03-01 CO $1,282.31 001E0445 RR H 2020-03-01 2021-03-01 CO $1,282.31 004E0445 RR H 2019-03-01 2020-03-01 CO $1,282.31 001E0445 RR H 2019-03-01 2020-03-01 CO $1,282.31 004E0445 RR H 2018-01-01 2019-03-01 CO $475.00 001E0445 RR H 2018-01-01 2019-03-01 CO $475.00 004E0481 RR H 2018-01-01 9901-01-01 CO $10,428.93 001E0481 RR H 2018-01-01 9901-01-01 CO $10,428.93 004E0481 RR H 2017-11-28 2018-01-01 CO $10,428.93 001E0481 RR H 2017-11-28 2018-01-01 CO $10,428.93 004E0485 00 G 2020-03-01 9901-01-01 CO $950.00 001E0485 00 G 2020-03-01 9901-01-01 CO $950.00 004E0485 00 G 2019-03-01 2020-03-01 CO $2,500.00 001E0485 00 G 2019-03-01 2020-03-01 CO $2,500.00 004E0485 00 G 2018-01-01 2019-03-01 CO $2,500.00 001E0485 00 G 2018-01-01 2019-03-01 CO $2,500.00 004E0486 RR H 2018-01-01 9901-01-01 CO $217.26 001E0486 RR H 2018-01-01 9901-01-01 CO $217.26 004E0486 00 G 2021-03-01 9901-01-01 CO $4,389.00 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 36 of 60

Page 37: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

E0486 00 G 2021-03-01 9901-01-01 CO $4,389.00 004E0486 00 G 2020-03-01 2021-03-01 CO $4,389.00 001E0486 00 G 2020-03-01 2021-03-01 CO $4,389.00 004E0486 00 G 2019-03-01 2020-03-01 CO $5,000.00 001E0486 00 G 2019-03-01 2020-03-01 CO $5,000.00 004E0486 00 G 2018-03-01 2019-03-01 CO $3,800.00 001E0486 00 G 2018-03-01 2019-03-01 CO $3,800.00 004E0486 00 G 2018-01-01 2018-03-01 CO $3,800.00 001E0486 00 G 2018-01-01 2018-03-01 CO $3,800.00 004E0486 00 G 2017-03-01 2018-01-01 CO $3,800.00 001E0486 00 G 2017-03-01 2018-01-01 CO $3,800.00 004E0486 00 G 2016-04-01 2017-03-01 CO $3,500.00 001E0487 00 G 2018-01-01 9901-01-01 CO $60.00 001E0487 00 G 2018-01-01 9901-01-01 CO $60.00 004E0555 RR H 2018-01-01 9901-01-01 CO $6.07 001E0555 RR H 2018-01-01 9901-01-01 CO $6.07 004E0555 00 G 2018-01-01 9901-01-01 CO $12.70 001E0555 00 G 2018-01-01 9901-01-01 CO $12.70 004E0619 RR H 2018-01-01 9901-01-01 CO $776.16 001E0619 RR H 2018-01-01 9901-01-01 CO $776.16 004E0619 00 G 2018-01-01 9901-01-01 CO $9,009.00 001E0619 00 G 2018-01-01 9901-01-01 CO $9,009.00 004E0637 00 G 2018-01-01 9901-01-01 CO $8,620.20 001E0637 00 G 2018-01-01 9901-01-01 CO $8,620.20 004E0641 RR H 2018-01-01 9901-01-01 CO $352.74 001E0641 RR H 2018-01-01 9901-01-01 CO $352.74 004E0641 00 G 2018-01-01 9901-01-01 CO $5,110.70 001E0641 00 G 2018-01-01 9901-01-01 CO $5,110.70 004E0700 00 G 2018-01-01 9901-01-01 CO $31.55 001E0700 00 G 2018-01-01 9901-01-01 CO $31.55 004E0770 RR H 2018-01-01 9901-01-01 CO $472.63 001E0770 RR H 2018-01-01 9901-01-01 CO $472.63 004E0770 00 G 2018-01-01 9901-01-01 CO $6,144.20 001E0770 00 G 2018-01-01 9901-01-01 CO $6,144.20 004E0830 00 G 2018-01-01 9901-01-01 CO $1,005.94 001E0830 00 G 2018-01-01 9901-01-01 CO $1,005.94 004E0936 RR H 2021-03-01 9901-01-01 CO $85.50 001E0936 RR H 2021-03-01 9901-01-01 CO $85.50 004E0936 RR H 2020-03-01 2021-03-01 CO $80.00 001E0936 RR H 2020-03-01 2021-03-01 CO $80.00 004E0936 RR H 2019-03-01 2020-03-01 CO $119.04 001E0936 RR H 2019-03-01 2020-03-01 CO $119.04 004E0936 RR H 2018-03-01 2019-03-01 CO $119.04 001E0936 RR H 2018-03-01 2019-03-01 CO $119.04 004E0936 RR H 2018-01-01 2018-03-01 CO $119.04 001E0936 RR H 2018-01-01 2018-03-01 CO $119.04 004E0936 RR H 2017-03-01 2018-01-01 CO $119.04 001E0936 RR H 2017-03-01 2018-01-01 CO $119.04 004E0936 RR H 2016-04-01 2017-03-01 CO $119.04 001E0936 RR H 2016-04-01 2017-03-01 CO $119.04 004E0936 00 G 2018-01-01 9901-01-01 CO $975.00 001E0936 00 G 2018-01-01 9901-01-01 CO $975.00 004E1130 RR H 2018-01-01 9901-01-01 CO $159.61 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 37 of 60

Page 38: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

E1130 RR H 2018-01-01 9901-01-01 CO $159.61 004E1130 00 G 2018-01-01 9901-01-01 CO $2,074.93 001E1130 00 G 2018-01-01 9901-01-01 CO $2,074.93 004E1140 RR H 2018-01-01 9901-01-01 CO $192.19 001E1140 RR H 2018-01-01 9901-01-01 CO $192.19 004E1140 00 G 2018-01-01 9901-01-01 CO $2,009.80 001E1140 00 G 2018-01-01 9901-01-01 CO $2,009.80 004E1229 RR H 2018-01-01 9901-01-01 CO $100.00 001E1229 RR H 2018-01-01 9901-01-01 CO $100.00 004E1250 RR H 2018-01-01 9901-01-01 CO $23.40 001E1250 RR H 2018-01-01 9901-01-01 CO $23.40 004E1260 RR H 2018-01-01 9901-01-01 CO $232.96 001E1260 RR H 2018-01-01 9901-01-01 CO $232.96 004E1260 00 G 2018-01-01 9901-01-01 CO $2,679.69 001E1260 00 G 2018-01-01 9901-01-01 CO $2,679.69 004E1354 00 G 2018-01-01 9901-01-01 CO $28.12 001E1354 00 G 2018-01-01 9901-01-01 CO $28.12 004E1356 RR H 2021-03-01 9901-01-01 CO $180.00 001E1356 RR H 2021-03-01 9901-01-01 CO $180.00 004E1356 RR H 2020-04-25 2021-03-01 CO $378.56 001E1356 RR H 2020-04-25 2021-03-01 CO $378.56 004E1639 NU G 2021-04-17 9901-01-01 CO $100.00 001E1639 NU G 2021-04-17 9901-01-01 CO $100.00 004E2291 NU G 2021-05-22 9901-01-01 CO $610.00 001E2291 NU G 2021-05-22 9901-01-01 CO $610.00 004E2292 00 G 2018-01-09 9901-01-01 CO $820.00 001E2292 00 G 2018-01-09 9901-01-01 CO $820.00 004E2293 RR H 2018-01-01 9901-01-01 CO $63.50 001E2293 RR H 2018-01-01 9901-01-01 CO $63.50 004E2293 00 G 2018-01-01 9901-01-01 CO $825.50 001E2293 00 G 2018-01-01 9901-01-01 CO $825.50 004E2294 RR H 2018-01-01 9901-01-01 CO $43.44 001E2294 RR H 2018-01-01 9901-01-01 CO $43.44 004E2294 00 G 2018-01-01 9901-01-01 CO $564.78 001E2294 00 G 2018-01-01 9901-01-01 CO $564.78 004E2300 00 G 2018-01-01 9901-01-01 CO $4,847.40 001E2300 00 G 2018-01-01 9901-01-01 CO $4,847.40 004E2512 00 G 2018-01-01 9901-01-01 CO $1,971.00 001E2512 00 G 2018-01-01 9901-01-01 CO $1,971.00 004E2609 RR H 2018-01-01 9901-01-01 CO $91.10 001E2609 RR H 2018-01-01 9901-01-01 CO $91.10 004E2609 00 G 2018-01-01 9901-01-01 CO $1,184.25 001E2609 00 G 2018-01-01 9901-01-01 CO $1,184.25 004E2617 RR H 2018-01-01 9901-01-01 CO $88.05 001E2617 RR H 2018-01-01 9901-01-01 CO $88.05 004E2617 00 G 2018-01-01 9901-01-01 CO $1,310.00 001E2617 00 G 2018-01-01 9901-01-01 CO $1,310.00 004E8000 RR H 2018-01-01 9901-01-01 CO $247.04 001E8000 RR H 2018-01-01 9901-01-01 CO $247.04 004E8000 00 G 2018-01-01 9901-01-01 CO $3,211.50 001E8000 00 G 2018-01-01 9901-01-01 CO $3,211.50 004E8001 RR H 2018-01-01 9901-01-01 CO $261.85 001E8001 RR H 2018-01-01 9901-01-01 CO $261.85 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 38 of 60

Page 39: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

E8001 00 G 2018-01-01 9901-01-01 CO $3,585.00 001E8001 00 G 2018-01-01 9901-01-01 CO $3,585.00 004G0129 00 D 2018-01-01 9901-01-01 CO $227.93 001G0155 00 6 2016-04-01 2018-01-01 CO $120.00 001G0160 00 D 2018-03-01 9901-01-01 CO $140.00 001G0160 00 D 2018-01-01 2018-03-01 CO $140.00 001G0160 00 D 2018-01-01 9901-01-01 CO $140.00 004G0160 00 D 2016-11-30 2018-01-01 CO $140.00 001G0160 00 D 2016-11-30 2018-01-01 CO $140.00 004G0161 00 6 2018-03-01 2019-03-01 CO $140.00 001G0161 00 6 2018-01-01 2018-03-01 CO $140.00 001G0161 00 6 2018-01-01 2019-03-01 CO $140.00 004G0161 00 6 2017-01-06 2018-01-01 CO $140.00 001G0161 00 6 2017-01-06 2018-01-01 CO $140.00 004G0162 00 6 2018-01-01 9901-01-01 CO $276.00 001G0162 00 6 2018-01-01 9901-01-01 CO $276.00 004G0163 00 6 2016-04-01 9901-01-01 CO $105.00 001G0163 00 6 2016-04-01 9901-01-01 CO $82.50 004G0176 00 C 2019-03-01 9901-01-01 CO $346.85 001G0176 00 C 2019-03-01 9901-01-01 CO $346.85 004G0176 00 C 2018-03-01 2019-03-01 CO $346.85 001G0176 00 C 2018-03-01 2019-03-01 CO $346.85 004G0176 00 C 2018-01-01 2018-03-01 CO $346.85 001G0176 00 C 2018-01-01 2018-03-01 CO $346.85 004G0177 00 6 2018-03-01 2019-03-01 CO $137.50 001G0177 00 6 2018-03-01 2019-03-01 CO $137.50 004G0177 00 6 2018-01-01 2018-03-01 CO $137.50 001G0177 00 6 2018-01-01 2018-03-01 CO $137.50 004G0177 00 6 2017-03-01 2018-01-01 CO $137.50 001G0177 00 6 2017-03-01 2018-01-01 CO $137.50 004G0177 00 6 2016-04-01 2017-03-01 CO $137.50 001G0177 00 6 2016-04-01 2017-03-01 CO $137.50 004G0259 00 2 2018-01-01 9901-01-01 CO $174.99 001G0259 00 2 2018-01-01 9901-01-01 CO $148.74 004G0299 00 6 2016-01-22 2018-01-01 CO $175.00 001G0299 00 6 2016-01-22 2018-01-01 CO $175.00 004G0339 00 E 2018-01-01 9901-01-01 CO $24,519.85 001G0340 00 E 2018-01-01 2018-03-01 CO $17,763.00 001G0340 00 E 2016-04-01 2018-01-01 CO $17,763.00 001G0340 00 E 2016-04-01 2018-01-01 CO $7,500.00 004G0378 00 6 2021-03-01 9901-01-01 CO $480.00 001G0378 00 6 2019-03-01 2021-03-01 CO $354.34 001G0378 00 6 2019-03-01 9901-01-01 CO $334.69 004G0378 00 6 2018-03-01 2019-03-01 CO $354.34 001G0378 00 6 2018-01-01 2018-03-01 CO $334.69 001G0378 00 6 2018-01-01 2019-03-01 CO $334.69 004G0378 00 6 2017-03-01 2018-01-01 CO $334.69 001G0378 00 6 2017-03-01 2018-01-01 CO $334.69 004G0378 00 6 2016-04-01 2017-03-01 CO $314.29 001G0378 00 6 2016-04-01 2017-03-01 CO $314.29 004G0379 00 6 2019-03-01 9901-01-01 CO $1,613.70 001G0379 00 6 2018-03-01 2019-03-01 CO $1,240.19 001G0379 00 6 2018-01-01 2018-03-01 CO $542.55 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 39 of 60

Page 40: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

G0379 00 6 2018-01-01 9901-01-01 CO $404.26 004G0379 00 6 2017-03-01 2018-01-01 CO $542.55 001G0379 00 6 2016-04-01 2017-03-01 CO $404.26 001G0379 00 6 2016-04-01 2018-01-01 CO $404.26 004G0380 00 6 2019-03-01 9901-01-01 CO $276.47 001G0380 00 6 2018-03-01 2019-03-01 CO $276.47 001G0380 00 6 2018-01-01 2018-03-01 CO $276.47 001G0380 00 6 2018-01-01 9901-01-01 CO $129.00 004G0380 00 6 2016-04-01 2018-01-01 CO $276.47 001G0381 00 6 2021-03-01 9901-01-01 CO $212.00 001G0381 00 6 2021-03-01 9901-01-01 CO $212.00 004G0381 00 6 2019-03-01 2021-03-01 CO $353.13 001G0381 00 6 2019-03-01 2021-03-01 CO $353.13 004G0381 00 6 2018-03-01 2019-03-01 CO $314.28 001G0381 00 6 2018-01-01 2018-03-01 CO $295.16 001G0381 00 6 2018-01-01 2019-03-01 CO $295.16 004G0381 00 6 2017-03-01 2018-01-01 CO $295.16 001G0381 00 6 2017-03-01 2018-01-01 CO $295.16 004G0381 00 6 2016-04-01 2017-03-01 CO $278.45 001G0381 00 6 2016-04-01 2017-03-01 CO $278.45 004G0382 00 6 2021-03-01 9901-01-01 CO $274.00 001G0382 00 6 2021-03-01 9901-01-01 CO $274.00 004G0382 00 6 2019-03-01 2021-03-01 CO $508.16 001G0382 00 6 2019-03-01 2021-03-01 CO $508.16 004G0382 00 6 2018-03-01 2019-03-01 CO $452.26 001G0382 00 6 2018-01-01 2018-03-01 CO $423.59 001G0382 00 6 2018-01-01 2019-03-01 CO $423.59 004G0382 00 6 2017-03-01 2018-01-01 CO $423.59 001G0382 00 6 2017-03-01 2018-01-01 CO $423.59 004G0382 00 6 2016-04-01 2017-03-01 CO $374.24 001G0382 00 6 2016-04-01 2017-03-01 CO $374.24 004G0383 00 6 2019-03-01 9901-01-01 CO $3,492.00 001G0383 00 6 2018-03-01 2019-03-01 CO $2,834.00 001G0383 00 6 2018-01-01 2018-03-01 CO $2,391.83 001G0383 00 6 2018-01-01 9901-01-01 CO $2,391.83 004G0383 00 6 2017-03-01 2018-01-01 CO $2,391.83 001G0383 00 6 2017-03-01 2018-01-01 CO $2,391.83 004G0383 00 6 2016-04-01 2017-03-01 CO $2,391.83 001G0383 00 6 2016-04-01 2017-03-01 CO $2,391.83 004G0384 00 6 2019-03-01 9901-01-01 CO $7,843.00 001G0384 00 6 2019-03-01 9901-01-01 CO $6,366.00 004G0384 00 6 2018-03-01 2019-03-01 CO $7,843.00 001G0384 00 6 2018-01-01 2018-03-01 CO $6,366.00 001G0384 00 6 2018-01-01 2019-03-01 CO $6,366.00 004G0384 00 6 2017-03-01 2018-01-01 CO $6,366.00 001G0384 00 6 2017-03-01 2018-01-01 CO $6,366.00 004G0384 00 6 2016-04-01 2017-03-01 CO $6,366.00 001G0384 00 6 2016-04-01 2017-03-01 CO $6,366.00 004G0390 00 6 2018-01-01 9901-01-01 CO $15,519.00 001G0410 00 C 2019-03-01 9901-01-01 CO $271.54 001G0410 00 C 2019-03-01 9901-01-01 CO $271.54 004G0410 00 C 2018-03-01 2019-03-01 CO $271.54 001G0410 00 C 2018-03-01 2019-03-01 CO $271.54 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 40 of 60

Page 41: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

G0410 00 C 2018-01-01 2018-03-01 CO $271.54 001G0410 00 C 2018-01-01 2018-03-01 CO $271.54 004G0410 00 C 2017-03-01 2018-01-01 CO $271.54 001G0410 00 C 2017-03-01 2018-01-01 CO $271.54 004G0410 00 C 2016-04-01 2017-03-01 CO $271.54 001G0410 00 C 2016-04-01 2017-03-01 CO $271.54 004G0411 00 C 2019-03-01 9901-01-01 CO $266.67 001G0411 00 C 2019-03-01 9901-01-01 CO $266.67 004G0411 00 C 2018-03-01 2019-03-01 CO $242.00 001G0411 00 C 2018-01-01 2018-03-01 CO $242.00 001G0411 00 C 2018-01-01 2019-03-01 CO $242.00 004G0411 00 C 2017-03-01 2018-01-01 CO $242.00 001G0411 00 C 2017-03-01 2018-01-01 CO $242.00 004G0411 00 C 2016-04-01 2017-03-01 CO $242.00 001G0411 00 C 2016-04-01 2017-03-01 CO $242.00 004G0463 00 6 2019-03-01 9901-01-01 CO $624.95 001G0463 00 6 2019-03-01 9901-01-01 CO $624.95 004G0463 00 6 2018-03-01 2019-03-01 CO $624.95 001G0463 00 6 2018-03-01 2019-03-01 CO $624.95 004G0463 00 6 2018-01-01 2018-03-01 CO $624.95 001G0463 00 6 2018-01-01 2018-03-01 CO $624.95 004G0463 00 6 2017-03-01 2018-01-01 CO $624.95 001G0463 00 6 2017-03-01 2018-01-01 CO $624.95 004G0463 00 6 2016-04-01 2017-03-01 CO $624.95 001G0463 00 6 2016-04-01 2017-03-01 CO $624.95 004G0476 00 8 2016-07-26 2018-01-01 CO $66.35 001G0476 00 8 2016-07-26 2018-01-01 CO $66.35 004G0477 00 8 2016-02-25 9901-01-01 CO $50.00 001G0477 00 8 2016-02-25 9901-01-01 CO $50.00 004G0479 00 8 2016-02-19 9901-01-01 CO $638.00 001G0479 00 8 2016-02-19 9901-01-01 CO $638.00 004G0482 00 8 2016-03-11 2018-01-01 CO $401.08 001G0482 00 8 2016-03-11 2018-01-01 CO $401.08 004G0491 00 6 2020-12-19 9901-01-01 CO $7,629.42 001G0498 00 6 2018-01-01 2018-03-01 CO $1,101.42 001G0498 00 6 2018-01-01 2018-03-01 CO $1,101.42 004G0498 00 6 2017-08-15 2018-01-01 CO $1,101.42 001G0498 00 6 2017-08-15 2018-01-01 CO $1,101.42 004G2066 00 6 2020-02-15 2021-03-01 CO $314.65 001G8511 00 6 2018-01-01 9901-01-01 CO $15.00 001G8511 00 6 2018-01-01 9901-01-01 CO $15.00 004G8511 00 6 2016-08-26 2018-01-01 CO $15.00 001G8511 00 6 2016-08-26 2018-01-01 CO $15.00 004G8539 00 6 2018-01-01 9901-01-01 CO $50.00 001G8539 00 6 2018-01-01 9901-01-01 CO $31.25 004G8542 00 6 2018-01-01 9901-01-01 CO $50.00 001G8542 00 6 2018-01-01 9901-01-01 CO $31.25 004G9277 00 6 2020-03-01 9901-01-01 CO $1.00 001G9277 00 6 2020-03-01 9901-01-01 CO $1.00 004G9277 00 6 2019-05-18 2020-03-01 CO $1.00 001G9278 00 6 2020-03-01 9901-01-01 CO $1.00 001G9278 00 6 2020-03-01 9901-01-01 CO $1.00 004G9278 00 6 2019-05-11 2020-03-01 CO $1.00 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 41 of 60

Page 42: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

G9695 00 6 2018-10-06 2018-10-13 CO $0.01 001H0002 00 C 2018-01-01 9901-01-01 CO $197.20 001H0002 00 C 2018-01-01 9901-01-01 CO $197.20 004H0006 00 C 2020-09-05 9901-01-01 CO $300.00 001H0017 00 C 2020-01-04 9901-01-01 CO $1,870.00 001H0018 00 C 2018-01-01 9901-01-01 CO $425.00 001H0018 00 C 2018-01-01 9901-01-01 CO $425.00 004H0019 00 C 2018-01-01 9901-01-01 CO $383.00 001H0019 00 C 2018-01-01 9901-01-01 CO $383.00 004H0019 00 C 2016-04-01 2018-01-01 CO $383.00 001H0019 00 C 2016-04-01 2018-01-01 CO $383.00 004H0023 00 C 2018-01-01 9901-01-01 CO $33.00 001H0023 00 C 2018-01-01 9901-01-01 CO $33.00 004H0025 00 C 2018-01-01 9901-01-01 CO $160.00 001H0025 00 C 2018-01-01 9901-01-01 CO $160.00 004H0025 00 C 2016-08-25 2018-01-01 CO $160.00 001H0025 00 C 2016-08-25 2018-01-01 CO $160.00 004H0031 00 C 2018-01-01 9901-01-01 CO $12.33 004H0032 29 C 2021-03-01 9901-01-01 CO $100.00 001H0032 29 C 2020-03-01 2021-03-01 CO $100.00 001H0032 29 C 2020-03-01 9901-01-01 CO $100.00 004H0032 29 C 2019-02-09 2020-03-01 CO $100.00 001H0034 00 6 2018-01-01 9901-01-01 CO $52.00 001H0034 00 6 2018-01-01 9901-01-01 CO $52.00 004H0034 00 6 2016-04-01 2018-01-01 CO $52.00 001H0035 00 C 2021-03-01 9901-01-01 CO $1,800.00 001H0035 00 C 2020-03-01 2021-03-01 CO $1,210.00 001H0035 00 C 2019-03-01 2020-03-01 CO $1,382.79 001H0035 00 C 2018-01-01 2019-03-01 CO $1,382.79 001H0035 00 C 2018-01-01 9901-01-01 CO $272.00 004H0035 00 C 2017-03-01 2018-01-01 CO $1,382.79 001H0035 00 C 2016-04-01 2017-03-01 CO $1,382.79 001H0037 00 C 2019-03-01 9901-01-01 CO $700.00 001H0037 00 C 2018-01-01 2019-03-01 CO $362.00 001H0037 00 C 2018-01-01 9901-01-01 CO $362.00 004H0037 00 C 2017-03-01 2018-01-01 CO $362.00 001H0037 00 C 2017-03-01 2018-01-01 CO $362.00 004H0037 00 C 2016-04-01 2017-03-01 CO $362.00 001H0037 00 C 2016-04-01 2017-03-01 CO $362.00 004H0048 00 C 2018-01-01 9901-01-01 CO $20.00 001H0048 00 C 2018-01-01 9901-01-01 CO $20.00 004H0049 00 8 2018-01-01 9901-01-01 CO $50.00 001H0049 00 8 2018-01-01 9901-01-01 CO $50.00 004H0049 00 8 2017-03-01 2018-01-01 CO $50.00 001H0049 00 8 2016-04-01 2017-03-01 CO $50.00 001H1005 00 3 2018-01-01 9901-01-01 CO $850.00 001H1005 00 3 2018-01-01 9901-01-01 CO $850.00 004H2014 00 C 2018-01-01 9901-01-01 CO $16.85 004H2017 00 C 2018-01-01 9901-01-01 CO $8.67 004H2019 00 6 2018-01-01 2020-03-01 CO $18.75 001H2019 00 6 2018-01-01 2020-03-01 CO $12.50 004H2021 00 C 2018-01-01 9901-01-01 CO $16.25 001H2021 00 C 2018-01-01 9901-01-01 CO $16.25 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 42 of 60

Page 43: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

H2036 00 C 2020-10-03 9901-01-01 CO $1,995.00 001K0669 00 G 2018-01-01 9901-01-01 CO $17,370.00 001K0669 00 G 2018-01-01 9901-01-01 CO $17,370.00 004L2861 00 G 2018-01-01 9901-01-01 CO $470.00 001L2861 00 G 2018-01-01 9901-01-01 CO $470.00 004L2861 00 G 2017-03-08 2018-01-01 CO $470.00 001L2861 00 G 2017-03-08 2018-01-01 CO $470.00 004L3202 00 G 2018-01-01 9901-01-01 CO $51.00 001L3202 00 G 2018-01-01 9901-01-01 CO $51.00 004L3203 00 G 2018-01-01 9901-01-01 CO $53.00 001L3203 00 G 2018-01-01 9901-01-01 CO $53.00 004L3204 00 G 2018-01-01 9901-01-01 CO $51.00 001L3204 00 G 2018-01-01 9901-01-01 CO $51.00 004L3206 00 G 2018-01-01 9901-01-01 CO $117.08 001L3206 00 G 2018-01-01 9901-01-01 CO $117.08 004L3221 00 G 2018-01-01 9901-01-01 CO $190.00 001L3221 00 G 2018-01-01 9901-01-01 CO $190.00 004L3260 00 G 2021-03-01 9901-01-01 CO $62.00 001L3260 00 G 2021-03-01 9901-01-01 CO $62.00 004L3260 00 G 2020-03-01 2021-03-01 CO $44.00 001L3260 00 G 2020-03-01 2021-03-01 CO $44.00 004L3260 00 G 2019-03-01 2020-03-01 CO $55.00 001L3260 00 G 2019-03-01 2020-03-01 CO $55.00 004L3260 00 G 2018-03-01 2019-03-01 CO $55.00 001L3260 00 G 2018-03-01 2019-03-01 CO $55.00 004L3260 00 G 2018-01-01 2018-03-01 CO $55.00 001L3260 00 G 2018-01-01 2018-03-01 CO $55.00 004L3260 00 G 2017-03-01 2018-01-01 CO $55.00 001L3260 00 G 2017-03-01 2018-01-01 CO $55.00 004L3260 00 G 2016-04-01 2017-03-01 CO $41.00 001L3260 00 G 2016-04-01 2017-03-01 CO $41.00 004L3265 00 G 2018-03-01 9901-01-01 CO $106.00 001L3265 00 G 2018-03-01 9901-01-01 CO $106.00 004L3265 00 G 2018-01-01 2018-03-01 CO $106.00 001L3265 00 G 2018-01-01 2018-03-01 CO $106.00 004L3265 00 G 2017-03-01 2018-01-01 CO $106.00 001L3265 00 G 2017-03-01 2018-01-01 CO $106.00 004L3320 00 G 2018-01-01 9901-01-01 CO $147.90 001L3485 00 G 2018-01-01 9901-01-01 CO $55.63 001L3485 00 G 2018-01-01 9901-01-01 CO $55.63 004L3677 00 G 2018-01-01 9901-01-01 CO $150.00 001L3677 00 G 2018-01-01 9901-01-01 CO $150.00 004L3891 00 G 2018-01-01 9901-01-01 CO $350.00 001L3891 00 G 2018-01-01 9901-01-01 CO $350.00 004L4002 00 G 2018-01-01 9901-01-01 CO $51.50 001L4002 00 G 2018-01-01 9901-01-01 CO $51.50 004L4210 00 G 2018-01-01 9901-01-01 CO $43.75 001L4210 00 G 2018-01-01 9901-01-01 CO $43.75 004L7900 NU G 2020-04-25 9901-01-01 CO $700.00 001L7900 NU G 2020-04-25 9901-01-01 CO $700.00 004L8010 00 G 2018-01-01 9901-01-01 CO $98.00 001L8010 00 G 2018-01-01 9901-01-01 CO $98.00 004L8505 00 G 2018-01-01 9901-01-01 CO $37.16 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 43 of 60

Page 44: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

L8505 00 G 2018-01-01 9901-01-01 CO $37.16 004L8604 00 G 2018-01-01 9901-01-01 CO $4,953.75 001L8604 00 G 2018-01-01 9901-01-01 CO $4,953.75 004L8680 00 G 2020-03-01 9901-01-01 CO $3,555.00 001L8680 00 G 2020-03-01 9901-01-01 CO $3,555.00 004L8680 00 G 2018-03-01 2020-03-01 CO $14,560.00 001L8680 00 G 2018-03-01 2020-03-01 CO $14,560.00 004L8680 00 G 2018-01-01 2018-03-01 CO $14,560.00 001L8680 00 G 2018-01-01 2018-03-01 CO $14,560.00 004L8680 00 G 2017-03-01 2018-01-01 CO $14,560.00 001L8680 00 G 2017-03-01 2018-01-01 CO $14,560.00 004L8680 00 G 2016-04-01 2017-03-01 CO $14,560.00 001L8692 00 G 2018-01-01 9901-01-01 CO $4,350.00 001L8692 00 G 2018-01-01 9901-01-01 CO $4,350.00 004L8692 00 G 2016-04-01 2018-01-01 CO $4,350.00 001M0076 00 2 2018-01-01 9901-01-01 CO $279.04 001P9011 00 1 2020-03-01 9901-01-01 CO $579.87 001P9011 00 1 2019-03-01 2020-03-01 CO $393.37 001P9011 00 1 2018-03-01 2019-03-01 CO $343.48 001P9011 00 1 2018-01-01 2018-03-01 CO $343.48 001P9011 00 1 2018-01-01 9901-01-01 CO $266.62 004P9011 00 1 2017-03-01 2018-01-01 CO $343.48 001P9011 00 1 2016-04-01 2017-03-01 CO $343.48 001P9011 00 1 2016-04-01 2018-01-01 CO $266.62 004P9012 00 1 2018-01-01 9901-01-01 CO $238.25 001P9012 00 1 2018-01-01 9901-01-01 CO $238.25 004P9016 00 1 2019-03-01 9901-01-01 CO $1,296.17 001P9016 00 1 2018-03-01 2019-03-01 CO $1,157.72 001P9016 00 1 2018-01-01 2018-03-01 CO $625.00 001P9016 00 1 2018-01-01 9901-01-01 CO $625.00 004P9017 00 1 2018-03-01 9901-01-01 CO $413.90 001P9017 00 1 2018-01-01 2018-03-01 CO $302.00 001P9017 00 1 2018-01-01 9901-01-01 CO $302.00 004P9019 00 1 2018-01-01 9901-01-01 CO $220.60 001P9019 00 1 2018-01-01 9901-01-01 CO $220.60 004P9021 00 1 2018-01-01 9901-01-01 CO $492.50 001P9021 00 1 2018-01-01 9901-01-01 CO $492.50 004P9022 00 1 2018-01-01 9901-01-01 CO $520.28 001P9022 00 1 2018-01-01 9901-01-01 CO $520.28 004P9032 00 1 2018-01-01 9901-01-01 CO $180.36 001P9032 00 1 2018-01-01 9901-01-01 CO $180.36 004P9033 00 1 2018-01-01 9901-01-01 CO $198.25 001P9033 00 1 2018-01-01 9901-01-01 CO $198.25 004P9034 00 1 2018-01-01 9901-01-01 CO $1,390.74 001P9034 00 1 2018-01-01 9901-01-01 CO $1,390.74 004P9035 00 1 2019-03-01 9901-01-01 CO $3,648.90 001P9035 00 1 2018-03-01 2019-03-01 CO $3,634.39 001P9035 00 1 2018-01-01 2018-03-01 CO $3,174.63 001P9035 00 1 2018-01-01 9901-01-01 CO $2,354.33 004P9035 00 1 2016-04-01 2018-01-01 CO $3,174.63 001P9037 00 1 2019-03-01 9901-01-01 CO $4,125.99 001P9037 00 1 2018-03-01 2019-03-01 CO $3,975.79 001P9037 00 1 2018-01-01 2018-03-01 CO $3,975.79 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 44 of 60

Page 45: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

P9037 00 1 2018-01-01 9901-01-01 CO $2,692.75 004P9037 00 1 2017-03-01 2018-01-01 CO $3,975.79 001P9037 00 1 2016-04-01 2017-03-01 CO $3,012.61 001P9038 00 1 2018-01-01 9901-01-01 CO $400.20 001P9038 00 1 2018-01-01 9901-01-01 CO $400.20 004P9040 00 1 2019-03-01 9901-01-01 CO $1,731.00 001P9040 00 1 2018-03-01 2019-03-01 CO $1,633.02 001P9040 00 1 2018-01-01 2018-03-01 CO $1,313.88 001P9040 00 1 2018-01-01 9901-01-01 CO $1,124.03 004P9040 00 1 2017-03-01 2018-01-01 CO $1,313.88 001P9040 00 1 2016-04-01 2017-03-01 CO $1,257.30 001P9044 00 8 2018-01-01 9901-01-01 CO $184.00 001P9044 00 8 2018-01-01 9901-01-01 CO $184.00 004P9051 00 1 2018-01-01 9901-01-01 CO $632.00 001P9051 00 1 2018-01-01 9901-01-01 CO $632.00 004P9052 00 1 2018-01-01 9901-01-01 CO $2,007.96 001P9052 00 1 2018-01-01 9901-01-01 CO $2,007.96 004P9053 00 1 2018-01-01 9901-01-01 CO $1,346.47 001P9053 00 1 2018-01-01 9901-01-01 CO $1,346.47 004P9055 00 1 2018-01-01 9901-01-01 CO $1,908.00 001P9055 00 1 2018-01-01 9901-01-01 CO $1,908.00 004P9056 00 1 2018-01-01 9901-01-01 CO $890.00 001P9056 00 1 2018-01-01 9901-01-01 CO $890.00 004P9058 00 1 2018-01-01 9901-01-01 CO $778.57 001P9058 00 1 2018-01-01 9901-01-01 CO $778.57 004P9059 00 1 2018-01-01 9901-01-01 CO $393.43 001P9059 00 1 2018-01-01 9901-01-01 CO $393.43 004P9072 00 1 2017-07-12 9901-01-01 CO $2,050.50 001P9072 00 1 2017-07-12 9901-01-01 CO $2,050.50 004P9603 00 8 2020-03-01 9901-01-01 CO $3.07 001P9603 00 8 2019-03-01 2020-03-01 CO $2.98 001P9603 00 8 2019-03-01 9901-01-01 CO $2.98 004P9603 00 8 2018-03-01 2019-03-01 CO $2.98 001P9603 00 8 2018-03-01 2019-03-01 CO $2.98 004P9603 00 8 2018-01-01 2018-03-01 CO $2.98 001P9603 00 8 2018-01-01 2018-03-01 CO $2.98 004P9603 00 8 2017-03-01 2018-01-01 CO $2.98 001P9603 00 8 2017-03-01 2018-01-01 CO $2.98 004P9603 00 8 2016-04-01 2017-03-01 CO $2.93 001P9603 00 8 2016-04-01 2017-03-01 CO $2.93 004P9604 00 8 2020-03-01 9901-01-01 CO $6.67 001P9604 00 8 2020-03-01 9901-01-01 CO $6.67 004P9604 00 8 2018-01-01 2020-03-01 CO $50.75 001P9604 00 8 2018-01-01 2020-03-01 CO $49.55 004P9604 00 8 2017-03-01 2018-01-01 CO $50.75 001Q0081 00 6 2018-03-01 2020-03-01 CO $300.00 001Q0081 00 6 2018-03-01 2020-03-01 CO $220.00 004Q0081 00 6 2018-01-01 2018-03-01 CO $300.00 001Q0081 00 6 2018-01-01 2018-03-01 CO $220.00 004Q0081 00 6 2017-03-01 2018-01-01 CO $300.00 001Q0081 00 6 2017-03-01 2018-01-01 CO $220.00 004Q0081 00 6 2016-04-01 2017-03-01 CO $256.00 001Q0081 00 6 2016-04-01 2017-03-01 CO $220.00 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 45 of 60

Page 46: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

Q0083 00 6 2018-01-01 9901-01-01 CO $66.85 001Q0083 00 6 2018-01-01 9901-01-01 CO $56.82 004Q0084 00 6 2018-01-01 2020-03-01 CO $106.24 001Q0084 00 6 2018-01-01 2020-03-01 CO $90.31 004Q0508 00 G 2018-01-01 9901-01-01 CO $2,090.32 001Q0508 00 G 2018-01-01 9901-01-01 CO $2,090.32 004Q0508 00 G 2017-03-01 2018-01-01 CO $2,090.32 001Q0508 00 G 2017-03-01 2018-01-01 CO $2,090.32 004Q0508 00 G 2016-08-19 2017-03-01 CO $2,090.32 001Q0508 00 G 2016-08-19 2017-03-01 CO $2,090.32 004Q0513 00 G 2018-01-01 9901-01-01 CO $73.95 001Q4155 00 6 2021-03-01 9901-01-01 CO $8,892.00 001Q4155 00 6 2020-03-01 2021-03-01 CO $8,892.00 001Q4155 00 6 2020-03-01 9901-01-01 CO $8,892.00 004Q4155 00 6 2019-06-22 2020-03-01 CO $8,892.00 001Q4159 00 6 2020-05-02 9901-01-01 CO $500.00 001Q4159 00 6 2018-12-01 2019-05-01 CO $500.00 001Q4169 00 6 2021-03-01 9901-01-01 CO $220.00 001Q4169 00 6 2021-03-01 9901-01-01 CO $220.00 004Q4169 00 6 2020-04-25 2021-03-01 CO $220.00 001Q5002 00 6 2020-03-01 9901-01-01 CO $224.00 001Q5002 00 6 2020-03-01 9901-01-01 CO $224.00 004Q5002 00 6 2018-01-01 2020-03-01 CO $175.00 001Q5003 00 6 2020-10-03 9901-01-01 CO $224.00 001Q5006 00 6 2020-03-01 9901-01-01 CO $999.00 001Q5006 00 6 2019-03-01 2020-03-01 CO $999.00 001Q5006 00 6 2018-03-01 2019-03-01 CO $999.00 001Q5006 00 6 2018-01-01 2018-03-01 CO $865.00 001Q5006 00 6 2018-01-01 9901-01-01 CO $865.00 004Q5006 00 6 2017-03-01 2018-01-01 CO $865.00 001Q5006 00 6 2017-03-01 2018-01-01 CO $865.00 004Q9951 00 6 2018-01-01 9901-01-01 CO $0.79 001Q9951 00 6 2018-01-01 9901-01-01 CO $0.79 004Q9959 00 6 2018-01-01 9901-01-01 CO $3.96 001Q9959 00 6 2018-01-01 9901-01-01 CO $3.96 004Q9962 00 6 2018-01-01 9901-01-01 CO $10.00 001Q9964 00 6 2018-01-01 9901-01-01 CO $0.90 001Q9964 00 6 2018-01-01 9901-01-01 CO $0.90 004Q9969 00 6 2019-09-07 9901-01-01 CO $10.40 001Q9984 00 6 2017-11-07 9901-01-01 CO $2,574.00 001Q9984 00 6 2017-11-07 9901-01-01 CO $2,574.00 004R0070 00 5 2021-03-01 9901-01-01 CO $640.23 001R0070 00 5 2018-03-01 2021-03-01 CO $635.45 001R0070 00 5 2018-01-01 2018-03-01 CO $626.03 001R0070 00 5 2018-01-01 9901-01-01 CO $608.90 004R0070 00 5 2017-03-01 2018-01-01 CO $626.03 001R0070 00 5 2016-04-01 2017-03-01 CO $626.03 001R0075 00 5 2018-01-01 9901-01-01 CO $180.00 001R0075 00 5 2018-01-01 9901-01-01 CO $180.00 004R0076 00 5 2018-01-01 9901-01-01 CO $310.52 001R0076 00 5 2018-01-01 9901-01-01 CO $310.52 004S0191 00 6 2018-01-01 9901-01-01 CO $12.50 001S0191 00 6 2018-01-01 9901-01-01 CO $12.50 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 46 of 60

Page 47: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

S0191 00 6 2016-11-30 2018-01-01 CO $12.50 001S0191 00 6 2016-11-30 2018-01-01 CO $12.50 004S0201 00 C 2020-03-01 9901-01-01 CO $2,400.00 001S0201 00 C 2019-03-01 2020-03-01 CO $2,000.00 001S0201 00 C 2019-03-01 9901-01-01 CO $2,000.00 004S0201 00 C 2018-07-28 2019-03-01 CO $2,000.00 001S0310 00 6 2020-03-01 9901-01-01 CO $90.00 001S0310 00 6 2018-01-01 2020-03-01 CO $90.00 001S0310 00 6 2018-01-01 9901-01-01 CO $90.00 004S0395 00 G 2018-01-01 9901-01-01 CO $100.00 001S0395 00 G 2018-01-01 9901-01-01 CO $100.00 004S0395 00 G 2017-03-01 2018-01-01 CO $100.00 001S0395 00 G 2017-03-01 2018-01-01 CO $100.00 004S0590 00 G 2021-01-23 9901-01-01 CO $35.00 001S0590 00 G 2021-01-23 9901-01-01 CO $35.00 004S0592 00 6 2018-01-01 9901-01-01 CO $40.00 001S0592 00 6 2018-01-01 9901-01-01 CO $40.00 004S0621 00 6 2020-03-01 9901-01-01 CO $211.20 001S0621 00 6 2018-03-01 2020-03-01 CO $205.56 001S0621 00 6 2018-01-01 2018-03-01 CO $178.75 001S0621 00 6 2018-01-01 9901-01-01 CO $160.48 004S0621 00 6 2017-03-01 2018-01-01 CO $178.75 001S0630 00 6 2020-03-01 9901-01-01 CO $52.00 001S0630 00 6 2020-03-01 9901-01-01 CO $52.00 004S0630 00 6 2018-01-01 2020-03-01 CO $98.00 001S0630 00 6 2018-01-01 2020-03-01 CO $98.00 004S0630 00 6 2017-03-01 2018-01-01 CO $98.00 001S0630 00 6 2017-03-01 2018-01-01 CO $98.00 004S1015 00 G 2018-01-01 9901-01-01 CO $65.00 001S1015 00 G 2018-01-01 9901-01-01 CO $65.00 004S1016 00 G 2018-01-01 9901-01-01 CO $20.00 001S1016 00 G 2018-01-01 9901-01-01 CO $20.00 004S1040 00 G 2020-03-01 9901-01-01 CO $4,200.00 001S1040 00 G 2020-03-01 9901-01-01 CO $4,200.00 004S1040 00 G 2018-01-01 2020-03-01 CO $3,995.00 001S1040 00 G 2018-01-01 2020-03-01 CO $3,995.00 004S1090 26 P 2018-01-01 9901-01-01 CO $5,594.80 001S1090 26 P 2018-01-01 9901-01-01 CO $5,594.80 004S2066 00 2 2018-01-01 9901-01-01 CO $2,790.82 001S2067 00 2 2018-01-01 9901-01-01 CO $2,790.82 001S2900 00 2 2018-01-01 9901-01-01 CO $21,135.50 001S2900 00 2 2018-01-01 9901-01-01 CO $1,500.00 004S2900 00 2 2017-03-01 2018-01-01 CO $21,135.50 001S2900 00 2 2016-04-01 2017-03-01 CO $21,135.50 001S3600 00 8 2020-03-01 9901-01-01 CO $60.00 001S3600 00 8 2018-01-01 2020-03-01 CO $50.00 001S3600 00 8 2018-01-01 9901-01-01 CO $50.00 004S4005 00 6 2018-02-01 9901-01-01 CO $190.00 001S4005 00 6 2018-02-01 9901-01-01 CO $190.00 004S5108 00 6 2018-01-01 9901-01-01 CO $31.25 001S5108 00 6 2018-01-01 9901-01-01 CO $31.25 004S5110 00 6 2018-01-01 9901-01-01 CO $31.25 001S5110 00 6 2018-01-01 9901-01-01 CO $31.25 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 47 of 60

Page 48: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

S5115 00 6 2018-01-01 9901-01-01 CO $31.25 001S5115 00 6 2018-01-01 9901-01-01 CO $31.25 004S5115 00 6 2016-04-01 2018-01-01 CO $31.25 001S5115 00 6 2016-04-01 2018-01-01 CO $31.25 004S8096 00 G 2018-03-01 9901-01-01 CO $41.00 001S8096 00 G 2018-03-01 9901-01-01 CO $41.00 004S8096 00 G 2018-01-01 2018-03-01 CO $41.00 001S8096 00 G 2018-01-01 2018-03-01 CO $41.00 004S8100 00 G 2018-01-01 9901-01-01 CO $25.00 001S8100 00 G 2018-01-01 9901-01-01 CO $25.00 004S8101 00 G 2018-01-01 9901-01-01 CO $25.00 001S8101 00 G 2018-01-01 9901-01-01 CO $25.00 004S8120 00 G 2018-01-01 9901-01-01 CO $19.00 001S8120 00 G 2018-01-01 9901-01-01 CO $19.00 004S8120 00 G 2017-03-01 2018-01-01 CO $19.00 001S8120 00 G 2017-03-01 2018-01-01 CO $19.00 004S8186 00 G 2018-01-01 9901-01-01 CO $3.50 001S8186 00 G 2018-01-01 9901-01-01 CO $3.50 004S8186 00 G 2016-04-01 2018-01-01 CO $3.50 001S8265 00 2 2018-01-01 9901-01-01 CO $118.88 001S8265 00 2 2018-01-01 9901-01-01 CO $118.88 004S8270 00 G 2018-01-01 9901-01-01 CO $182.00 001S8270 00 G 2018-01-01 9901-01-01 CO $182.00 004S8415 00 G 2020-03-01 9901-01-01 CO $150.00 001S8415 00 G 2020-03-01 9901-01-01 CO $150.00 004S8415 00 G 2018-01-01 2020-03-01 CO $150.00 001S8415 00 G 2018-01-01 2020-03-01 CO $150.00 004S8415 00 G 2017-12-01 2018-01-01 CO $150.00 001S8415 00 G 2017-12-01 2018-01-01 CO $150.00 004S8450 00 G 2018-01-01 9901-01-01 CO $31.50 001S8450 00 G 2018-01-01 9901-01-01 CO $31.50 004S8450 00 G 2016-03-11 2018-01-01 CO $31.50 001S8450 00 G 2016-03-11 2018-01-01 CO $31.50 004S8451 00 G 2018-01-01 9901-01-01 CO $80.00 001S8451 00 G 2018-01-01 9901-01-01 CO $80.00 004S8930 00 6 2021-06-12 9901-01-01 CO $40.00 001S8940 00 6 2018-01-01 9901-01-01 CO $250.00 001S8940 00 6 2018-01-01 9901-01-01 CO $195.00 004S8950 00 D 2018-03-01 9901-01-01 CO $76.92 001S8950 00 D 2018-01-01 2018-03-01 CO $76.92 001S8950 00 D 2018-01-01 9901-01-01 CO $76.92 004S8950 00 D 2017-05-09 2018-01-01 CO $76.92 001S8950 00 D 2017-05-09 2018-01-01 CO $76.92 004S9083 00 6 2019-03-01 9901-01-01 CO $270.00 001S9083 00 6 2018-03-01 2019-03-01 CO $246.00 001S9083 00 6 2018-01-01 2018-03-01 CO $200.00 001S9083 00 6 2018-01-01 9901-01-01 CO $200.00 004S9083 00 6 2017-03-01 2018-01-01 CO $200.00 001S9083 00 6 2016-04-01 2017-03-01 CO $200.00 001S9088 00 6 2020-03-01 9901-01-01 CO $88.00 001S9088 00 6 2020-03-01 9901-01-01 CO $88.00 004S9088 00 6 2019-03-01 2020-03-01 CO $100.00 001S9088 00 6 2019-03-01 2020-03-01 CO $100.00 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 48 of 60

Page 49: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

S9088 00 6 2018-03-01 2019-03-01 CO $88.00 001S9088 00 6 2018-03-01 2019-03-01 CO $88.00 004S9088 00 6 2018-01-01 2018-03-01 CO $88.00 001S9088 00 6 2018-01-01 2018-03-01 CO $88.00 004S9088 00 6 2017-03-01 2018-01-01 CO $88.00 001S9088 00 6 2017-03-01 2018-01-01 CO $88.00 004S9088 00 6 2016-04-01 2017-03-01 CO $88.00 001S9088 00 6 2016-04-01 2017-03-01 CO $88.00 004S9126 00 6 2020-03-01 9901-01-01 CO $260.00 001S9126 00 6 2019-03-01 2020-03-01 CO $260.00 001S9126 00 6 2018-03-01 2019-03-01 CO $260.00 001S9126 00 6 2018-01-01 2018-03-01 CO $260.00 001S9126 00 6 2018-01-01 9901-01-01 CO $260.00 004S9126 00 6 2017-03-01 2018-01-01 CO $260.00 001S9126 00 6 2016-12-29 2017-03-01 CO $260.00 001S9126 00 6 2016-12-29 2018-01-01 CO $260.00 004S9128 00 6 2018-03-01 9901-01-01 CO $140.00 001S9128 00 6 2018-01-01 2018-03-01 CO $140.00 001S9128 00 6 2018-01-01 9901-01-01 CO $140.00 004S9128 00 6 2016-11-30 2018-01-01 CO $140.00 001S9128 00 6 2016-11-30 2018-01-01 CO $140.00 004S9129 00 D 2018-01-01 9901-01-01 CO $140.00 001S9129 00 D 2018-01-01 9901-01-01 CO $110.00 004S9129 00 D 2017-03-01 2018-01-01 CO $140.00 001S9129 00 D 2016-04-01 2017-03-01 CO $110.00 001S9129 00 D 2016-04-01 2018-01-01 CO $110.00 004S9131 00 D 2018-03-01 9901-01-01 CO $230.00 001S9131 00 D 2018-01-01 2018-03-01 CO $230.00 001S9131 00 D 2018-01-01 9901-01-01 CO $120.00 004S9131 00 D 2017-03-01 2018-01-01 CO $230.00 001S9131 00 D 2017-03-01 2018-01-01 CO $120.00 004S9131 00 D 2016-04-01 2017-03-01 CO $230.00 001S9329 00 6 2020-10-03 9901-01-01 CO $100.00 001S9370 00 6 2020-10-03 9901-01-01 CO $275.00 001S9430 00 6 2021-03-01 9901-01-01 CO $323.40 001S9430 00 6 2020-03-01 2021-03-01 CO $323.40 001S9430 00 6 2019-03-01 2020-03-01 CO $323.40 001S9430 00 6 2018-03-01 2019-03-01 CO $323.40 001S9430 00 6 2018-03-01 9901-01-01 CO $242.00 004S9430 00 6 2018-01-01 2018-03-01 CO $323.40 001S9430 00 6 2018-01-01 2018-03-01 CO $242.00 004S9430 00 6 2017-03-01 2018-01-01 CO $323.40 001S9430 00 6 2016-04-01 2017-03-01 CO $294.00 001S9435 NU G 2020-04-25 9901-01-01 CO $556.72 001S9435 NU G 2020-04-25 9901-01-01 CO $556.72 004S9476 00 D 2020-03-01 9901-01-01 CO $400.00 001S9476 00 D 2020-03-01 9901-01-01 CO $400.00 004S9476 00 D 2018-03-01 2020-03-01 CO $450.00 001S9476 00 D 2018-01-01 2018-03-01 CO $450.00 001S9476 00 D 2018-01-01 2020-03-01 CO $450.00 004S9476 00 D 2017-07-12 2018-01-01 CO $450.00 001S9476 00 D 2017-07-12 2018-01-01 CO $450.00 004S9500 00 6 2020-03-01 9901-01-01 CO $539.00 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 49 of 60

Page 50: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

S9500 00 6 2019-03-01 2020-03-01 CO $300.00 001S9500 00 6 2018-01-01 2019-03-01 CO $300.00 001S9500 00 6 2018-01-01 9901-01-01 CO $300.00 004S9500 00 6 2016-04-01 2018-01-01 CO $300.00 001S9501 00 6 2018-01-01 9901-01-01 CO $171.42 001S9501 00 6 2018-01-01 9901-01-01 CO $171.42 004T1000 00 6 2020-03-01 9901-01-01 CO $150.00 001T1000 00 6 2019-03-01 2020-03-01 CO $150.00 001T1000 00 6 2018-01-01 2019-03-01 CO $8.83 001T1000 00 6 2018-01-01 9901-01-01 CO $8.83 004T1016 00 6 2018-03-01 9901-01-01 CO $75.00 001T1016 00 6 2018-01-01 2018-03-01 CO $52.00 001T1016 00 6 2018-01-01 9901-01-01 CO $52.00 004T1016 00 6 2016-04-01 2018-01-01 CO $52.00 001T1016 00 6 2016-04-01 2018-01-01 CO $52.00 004T1017 00 6 2020-03-01 9901-01-01 CO $40.00 001T1017 00 6 2019-03-01 2020-03-01 CO $85.05 001T1017 00 6 2018-03-01 2019-03-01 CO $85.05 001T1017 00 6 2018-01-01 2018-03-01 CO $85.05 001T1017 00 6 2018-01-01 9901-01-01 CO $24.78 004T1017 00 6 2017-03-01 2018-01-01 CO $85.05 001T1017 00 6 2016-04-01 2017-03-01 CO $85.05 001T1030 00 6 2018-01-01 9901-01-01 CO $226.00 001T1030 00 6 2018-01-01 9901-01-01 CO $226.00 004T2042 00 6 2020-03-01 9901-01-01 CO $189.83 001T2042 00 6 2018-03-01 2020-03-01 CO $179.66 001T2042 00 6 2018-03-01 9901-01-01 CO $179.66 004T2042 00 6 2018-01-01 2018-03-01 CO $179.66 001T2042 00 6 2018-01-01 2018-03-01 CO $179.66 004T2042 00 6 2017-03-01 2018-01-01 CO $179.66 001T2042 00 6 2017-03-01 2018-01-01 CO $179.66 004T2048 00 C 2018-01-01 9901-01-01 CO $47.46 004T4521 00 G 2021-03-01 9901-01-01 CO $2.08 001T4521 00 G 2021-03-01 9901-01-01 CO $2.08 004T4521 00 G 2020-03-01 2021-03-01 CO $1.84 001T4521 00 G 2020-03-01 2021-03-01 CO $1.84 004T4521 00 G 2019-03-01 2020-03-01 CO $2.50 001T4521 00 G 2019-03-01 2020-03-01 CO $2.50 004T4521 00 G 2018-08-18 2019-03-01 CO $2.50 001T4521 00 G 2018-08-18 2019-03-01 CO $2.50 004T4533 00 G 2018-01-01 9901-01-01 CO $0.70 001T4533 00 G 2018-01-01 9901-01-01 CO $0.70 004T4533 00 G 2016-05-13 2018-01-01 CO $0.70 001T4533 00 G 2016-05-13 2018-01-01 CO $0.70 004T4541 00 G 2018-01-01 9901-01-01 CO $0.58 001T4541 00 G 2018-01-01 9901-01-01 CO $0.58 004T5001 RR H 2021-05-29 9901-01-01 CO $399.00 001T5001 RR H 2021-05-29 9901-01-01 CO $399.00 004U0005 00 8 2021-01-30 2021-03-01 CO $42.00 001V2025 00 G 2018-01-01 9901-01-01 CO $174.00 001V2025 00 G 2018-01-01 9901-01-01 CO $174.00 004V2025 00 G 2017-07-27 2018-01-01 CO $174.00 001V2025 00 G 2017-07-27 2018-01-01 CO $174.00 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 50 of 60

Page 51: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

V2702 00 G 2018-01-01 9901-01-01 CO $8.00 001V2702 00 G 2018-01-01 9901-01-01 CO $8.00 004V2781 00 G 2020-03-01 9901-01-01 CO $200.00 001V2781 00 G 2020-03-01 9901-01-01 CO $200.00 004V2781 00 G 2019-03-01 2020-03-01 CO $224.50 001V2781 00 G 2019-03-01 2020-03-01 CO $224.50 004V2781 00 G 2018-03-01 2019-03-01 CO $224.50 001V2781 00 G 2018-03-01 2019-03-01 CO $224.50 004V2781 00 G 2018-01-01 2018-03-01 CO $224.50 001V2781 00 G 2018-01-01 2018-03-01 CO $224.50 004V2781 00 G 2017-03-01 2018-01-01 CO $224.50 001V2781 00 G 2017-03-01 2018-01-01 CO $224.50 004V2781 00 G 2016-04-01 2017-03-01 CO $224.50 001V2781 00 G 2016-04-01 2017-03-01 CO $224.50 004V2785 00 G 2018-03-01 9901-01-01 CO $10,823.22 001V2785 00 G 2018-03-01 9901-01-01 CO $10,823.22 004V2785 00 G 2018-01-01 2018-03-01 CO $10,823.22 001V2785 00 G 2018-01-01 2018-03-01 CO $10,823.22 004V2785 00 G 2017-03-01 2018-01-01 CO $10,823.22 001V2785 00 G 2017-03-01 2018-01-01 CO $10,823.22 004V2785 00 G 2016-04-01 2017-03-01 CO $10,823.22 001V2785 00 G 2016-04-01 2017-03-01 CO $10,823.22 004V2787 00 G 2018-03-01 9901-01-01 CO $3,134.86 001V2787 00 G 2018-03-01 9901-01-01 CO $3,134.86 004V2787 00 G 2018-01-01 2018-03-01 CO $1,980.00 001V2787 00 G 2018-01-01 2018-03-01 CO $1,980.00 004V2787 00 G 2017-03-01 2018-01-01 CO $1,980.00 001V2787 00 G 2017-03-01 2018-01-01 CO $1,980.00 004V2788 00 G 2018-01-01 9901-01-01 CO $3,828.50 001V2788 00 G 2018-01-01 9901-01-01 CO $3,828.50 004V2790 00 G 2018-01-01 9901-01-01 CO $1,464.21 001V5110 00 G 2018-01-01 9901-01-01 CO $495.50 001V5110 00 G 2018-01-01 9901-01-01 CO $495.50 004V5140 00 G 2018-01-01 9901-01-01 CO $3,850.00 001V5140 00 G 2018-01-01 9901-01-01 CO $3,850.00 004V5160 00 G 2021-03-01 9901-01-01 CO $400.00 001V5160 00 G 2021-03-01 9901-01-01 CO $400.00 004V5160 00 G 2020-03-01 2021-03-01 CO $400.00 001V5160 00 G 2020-03-01 2021-03-01 CO $400.00 004V5160 00 G 2018-01-01 2020-03-01 CO $1,000.00 001V5160 00 G 2018-01-01 2020-03-01 CO $1,000.00 004V5241 00 G 2018-01-01 9901-01-01 CO $720.00 001V5241 00 G 2018-01-01 9901-01-01 CO $720.00 004V5254 00 G 2018-01-01 9901-01-01 CO $4,607.69 001V5254 00 G 2018-01-01 9901-01-01 CO $4,607.69 004V5254 00 G 2016-02-05 2018-01-01 CO $4,607.69 001V5254 00 G 2016-02-05 2018-01-01 CO $4,607.69 004V5256 00 G 2018-01-01 9901-01-01 CO $2,180.20 001V5256 00 G 2018-01-01 9901-01-01 CO $2,180.20 004V5257 00 G 2020-03-01 9901-01-01 CO $4,455.00 001V5257 00 G 2020-03-01 9901-01-01 CO $4,455.00 004V5257 00 G 2019-03-01 2020-03-01 CO $3,095.00 001V5257 00 G 2019-03-01 2020-03-01 CO $3,095.00 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 51 of 60

Page 52: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

V5257 00 G 2018-03-01 2019-03-01 CO $3,095.00 001V5257 00 G 2018-03-01 2019-03-01 CO $3,095.00 004V5257 00 G 2018-01-01 2018-03-01 CO $2,925.00 001V5257 00 G 2018-01-01 2018-03-01 CO $2,925.00 004V5257 00 G 2017-03-01 2018-01-01 CO $2,925.00 001V5257 00 G 2017-03-01 2018-01-01 CO $2,925.00 004V5258 00 G 2018-01-01 9901-01-01 CO $5,331.58 001V5258 00 G 2018-01-01 9901-01-01 CO $5,331.58 004V5259 00 G 2018-01-01 9901-01-01 CO $2,514.30 001V5260 00 G 2018-01-01 9901-01-01 CO $7,187.00 001V5260 00 G 2018-01-01 9901-01-01 CO $7,187.00 004V5260 00 G 2017-11-27 2018-01-01 CO $7,187.00 001V5260 00 G 2017-11-27 2018-01-01 CO $7,187.00 004V5261 00 G 2021-03-01 9901-01-01 CO $12,000.00 001V5261 00 G 2021-03-01 9901-01-01 CO $12,000.00 004V5261 00 G 2020-03-01 2021-03-01 CO $12,000.00 001V5261 00 G 2020-03-01 2021-03-01 CO $12,000.00 004V5261 00 G 2019-03-01 2020-03-01 CO $8,880.00 001V5261 00 G 2019-03-01 2020-03-01 CO $8,880.00 004V5261 00 G 2018-03-01 2019-03-01 CO $8,880.00 001V5261 00 G 2018-03-01 2019-03-01 CO $8,880.00 004V5261 00 G 2018-01-01 2018-03-01 CO $8,880.00 001V5261 00 G 2018-01-01 2018-03-01 CO $8,880.00 004V5261 00 G 2017-03-01 2018-01-01 CO $8,880.00 001V5261 00 G 2017-03-01 2018-01-01 CO $8,880.00 004V5261 00 G 2016-04-01 2017-03-01 CO $8,880.00 001V5261 00 G 2016-04-01 2017-03-01 CO $8,880.00 004V5264 00 G 2021-03-01 9901-01-01 CO $229.00 001V5264 00 G 2021-03-01 9901-01-01 CO $229.00 004V5264 00 G 2020-03-01 2021-03-01 CO $184.00 001V5264 00 G 2020-03-01 2021-03-01 CO $184.00 004V5264 00 G 2018-03-01 2020-03-01 CO $150.00 001V5264 00 G 2018-03-01 2020-03-01 CO $150.00 004V5264 00 G 2018-01-01 2018-03-01 CO $150.00 001V5264 00 G 2018-01-01 2018-03-01 CO $150.00 004V5265 00 G 2018-01-01 9901-01-01 CO $85.00 001V5265 00 G 2018-01-01 9901-01-01 CO $85.00 004V5266 00 G 2021-03-01 9901-01-01 CO $6.00 001V5266 00 G 2021-03-01 9901-01-01 CO $6.00 004V5266 00 G 2019-03-01 2021-03-01 CO $1.00 001V5266 00 G 2019-03-01 2021-03-01 CO $1.00 004V5266 00 G 2018-03-01 2019-03-01 CO $1.00 001V5266 00 G 2018-03-01 2019-03-01 CO $1.00 004V5266 00 G 2018-01-01 2018-03-01 CO $1.00 001V5266 00 G 2018-01-01 2018-03-01 CO $1.00 004V5266 00 G 2017-03-01 2018-01-01 CO $1.00 001V5266 00 G 2017-03-01 2018-01-01 CO $1.00 004V5266 00 G 2016-04-01 2017-03-01 CO $1.00 001V5267 00 G 2021-03-01 9901-01-01 CO $526.00 001V5267 00 G 2021-03-01 9901-01-01 CO $526.00 004V5267 00 G 2019-03-01 2021-03-01 CO $440.00 001V5267 00 G 2019-03-01 2021-03-01 CO $440.00 004V5267 00 G 2018-01-01 2019-03-01 CO $105.00 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 52 of 60

Page 53: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

V5267 00 G 2018-01-01 2019-03-01 CO $105.00 004V5275 00 G 2021-03-01 9901-01-01 CO $95.00 001V5275 00 G 2021-03-01 9901-01-01 CO $95.00 004V5275 00 G 2020-03-01 2021-03-01 CO $95.00 001V5275 00 G 2020-03-01 2021-03-01 CO $95.00 004V5275 00 G 2019-03-01 2020-03-01 CO $150.00 001V5275 00 G 2019-03-01 2020-03-01 CO $150.00 004V5275 00 G 2018-03-01 2019-03-01 CO $150.00 001V5275 00 G 2018-03-01 2019-03-01 CO $150.00 004V5275 00 G 2018-01-01 2018-03-01 CO $150.00 001V5275 00 G 2018-01-01 2018-03-01 CO $150.00 004V5275 00 G 2017-03-01 2018-01-01 CO $150.00 001V5275 00 G 2017-03-01 2018-01-01 CO $150.00 004V5275 00 G 2016-04-01 2017-03-01 CO $150.00 001V5275 00 G 2016-04-01 2017-03-01 CO $150.00 004V5281 00 G 2019-06-08 9901-01-01 CO $50.00 001V5281 00 G 2019-06-08 9901-01-01 CO $50.00 0040213T 00 2 2018-01-01 9901-01-01 CO $1,200.00 0010213T 00 2 2018-01-01 9901-01-01 CO $1,200.00 0040214T 00 2 2018-01-01 9901-01-01 CO $700.00 0010214T 00 2 2018-01-01 9901-01-01 CO $700.00 0040215T 00 2 2018-01-01 9901-01-01 CO $700.00 0010215T 00 2 2018-01-01 9901-01-01 CO $700.00 0040215T 00 2 2016-08-25 2018-01-01 CO $700.00 0010215T 00 2 2016-08-25 2018-01-01 CO $700.00 0040216T 00 2 2018-01-01 9901-01-01 CO $1,000.00 0010216T 00 2 2018-01-01 9901-01-01 CO $1,000.00 0040217T 00 2 2018-01-01 9901-01-01 CO $600.00 0010217T 00 2 2018-01-01 9901-01-01 CO $600.00 0040389T 26 P 2018-02-01 9901-01-01 CO $45.00 0010389T 26 P 2018-02-01 9901-01-01 CO $45.00 0040399T 26 P 2018-03-01 9901-01-01 CO $395.00 0010399T 26 P 2018-01-01 2018-03-01 CO $395.00 0010399T 26 P 2018-01-01 9901-01-01 CO $395.00 0040399T 26 P 2017-01-19 2018-01-01 CO $395.00 0010399T 26 P 2017-01-19 2018-01-01 CO $395.00 0040402T 00 2 2018-01-01 2019-03-01 CO $7,000.00 0010402T 00 2 2018-01-01 2019-03-01 CO $7,000.00 0040402T 00 2 2017-10-19 2018-01-01 CO $7,000.00 0010402T 00 2 2017-10-19 2018-01-01 CO $7,000.00 00437195 00 2 2018-01-01 9901-01-01 CO $1,124.97 00137195 00 2 2018-01-01 9901-01-01 CO $1,124.97 00444705 00 2 2018-01-01 2018-03-01 CO $332.10 00144705 00 2 2018-01-01 2018-03-01 CO $332.10 00444705 00 2 2016-12-01 2018-01-01 CO $332.10 00144705 00 2 2016-12-01 2018-01-01 CO $332.10 00458974 00 2 2018-01-01 9901-01-01 CO $1,300.00 00158974 00 2 2018-01-01 9901-01-01 CO $1,300.00 00474300 TC 5 2018-01-01 9901-01-01 CO $721.15 00174300 00 5 2019-03-01 9901-01-01 CO $2,883.71 00174300 00 5 2018-03-01 2019-03-01 CO $1,454.69 00174300 00 5 2018-01-01 2018-03-01 CO $1,296.50 00174300 00 5 2018-01-01 9901-01-01 CO $1,296.50 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 53 of 60

Page 54: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

74300 00 5 2017-03-01 2018-01-01 CO $1,296.50 00174300 00 5 2017-03-01 2018-01-01 CO $1,296.50 00474300 00 5 2016-04-01 2017-03-01 CO $1,296.50 00174328 TC 5 2018-01-01 9901-01-01 CO $687.44 00174328 00 5 2019-03-01 9901-01-01 CO $4,715.99 00174328 00 5 2019-03-01 9901-01-01 CO $1,778.78 00474328 00 5 2018-03-01 2019-03-01 CO $4,715.99 00174328 00 5 2018-01-01 2018-03-01 CO $4,117.87 00174328 00 5 2018-01-01 2019-03-01 CO $1,778.78 00474328 00 5 2017-03-01 2018-01-01 CO $4,117.87 00174328 00 5 2016-04-01 2017-03-01 CO $4,117.87 00174330 TC 5 2018-01-01 9901-01-01 CO $946.31 00174330 00 5 2019-03-01 9901-01-01 CO $5,553.84 00174330 00 5 2018-03-01 2019-03-01 CO $1,586.42 00174330 00 5 2018-01-01 2018-03-01 CO $1,496.62 00174330 00 5 2018-01-01 9901-01-01 CO $1,411.91 00474330 00 5 2017-03-01 2018-01-01 CO $1,496.62 00174330 00 5 2016-04-01 2017-03-01 CO $1,411.91 00174330 00 5 2016-04-01 2018-01-01 CO $1,411.91 00474340 TC 5 2018-01-01 9901-01-01 CO $1,239.00 00174340 00 5 2018-01-01 9901-01-01 CO $66.00 00174360 TC 5 2018-01-01 9901-01-01 CO $951.49 00174360 00 5 2018-01-01 9901-01-01 CO $979.93 00175894 TC 5 2018-01-01 9901-01-01 CO $2,833.76 00175894 00 5 2018-03-01 9901-01-01 CO $58,279.88 00175894 00 5 2018-01-01 2018-03-01 CO $45,871.61 00175894 00 5 2018-01-01 9901-01-01 CO $41,701.46 00475970 00 5 2018-01-01 9901-01-01 CO $140.00 00177013 00 5 2018-01-01 9901-01-01 CO $768.09 00177061 26 P 2019-03-01 2020-03-01 CO $98.00 00177061 26 P 2018-03-01 2019-03-01 CO $97.00 00177061 26 P 2018-03-01 2020-03-01 CO $97.00 00477061 26 P 2018-01-01 2018-03-01 CO $97.00 00177061 26 P 2018-01-01 2018-03-01 CO $97.00 00477061 26 P 2017-03-01 2018-01-01 CO $97.00 00177061 26 P 2017-03-01 2018-01-01 CO $97.00 00477061 26 P 2016-04-01 2017-03-01 CO $97.00 00177062 26 P 2018-03-01 2019-03-01 CO $120.00 00177062 26 P 2018-03-01 2019-03-01 CO $120.00 00477062 26 P 2018-01-01 2018-03-01 CO $120.00 00177062 26 P 2018-01-01 2018-03-01 CO $120.00 00477062 26 P 2017-03-01 2018-01-01 CO $120.00 00177062 26 P 2017-03-01 2018-01-01 CO $120.00 00477062 26 P 2016-04-01 2017-03-01 CO $120.00 00177067 00 5 2017-02-09 2018-01-01 CO $443.35 00177067 00 5 2017-02-09 2018-01-01 CO $443.35 00477371 00 5 2018-01-01 9901-01-01 CO $92,464.41 00177371 00 5 2018-01-01 9901-01-01 CO $92,464.41 00477520 00 E 2018-01-01 2020-03-01 CO $3,560.00 00181216 00 8 2018-01-01 2018-03-01 CO $2,090.00 00181216 00 8 2018-01-01 2018-03-01 CO $2,090.00 00481302 00 8 2018-02-01 2018-03-01 CO $1,272.78 00181302 00 8 2018-02-01 2018-03-01 CO $1,272.78 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 54 of 60

Page 55: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

81407 00 8 2018-01-01 2018-03-01 CO $5,722.26 00181407 00 8 2018-01-01 2018-03-01 CO $5,722.26 00481407 00 8 2016-07-27 2018-01-01 CO $5,722.26 00181407 00 8 2016-07-27 2018-01-01 CO $5,722.26 00481420 00 8 2016-03-24 2018-01-01 CO $2,762.00 00181420 00 8 2016-03-24 2018-01-01 CO $2,762.00 00481503 00 8 2018-01-01 2018-03-01 CO $773.00 00181503 00 8 2018-01-01 2018-03-01 CO $773.00 00481507 00 8 2018-02-01 2018-03-01 CO $2,495.00 00181507 00 8 2018-02-01 2018-03-01 CO $2,495.00 00486860 00 8 2018-01-01 9901-01-01 CO $169.46 00186860 00 8 2018-01-01 9901-01-01 CO $169.46 00486921 00 8 2018-01-01 9901-01-01 CO $97.00 00186921 00 8 2018-01-01 9901-01-01 CO $97.00 00486932 00 8 2018-01-01 9901-01-01 CO $75.00 00186932 00 8 2018-01-01 9901-01-01 CO $75.00 00486970 00 8 2018-01-01 9901-01-01 CO $62.40 00186970 00 8 2018-01-01 9901-01-01 CO $62.40 00486976 00 8 2018-01-01 9901-01-01 CO $141.71 00186976 00 8 2018-01-01 9901-01-01 CO $141.71 00486978 00 8 2018-01-01 9901-01-01 CO $168.00 00186978 00 8 2018-01-01 9901-01-01 CO $168.00 00487426 00 8 2020-06-25 2021-03-01 CO $68.97 00187426 00 8 2020-06-25 2021-03-01 CO $68.97 00489290 00 P 2020-07-18 9901-01-01 CO $3,200.00 00189353 00 8 2018-01-01 9901-01-01 CO $189.00 00189353 00 8 2018-01-01 9901-01-01 CO $189.00 00490620 00 6 2019-11-01 2020-02-01 CO $181.00 00190620 00 6 2019-11-01 2020-02-01 CO $181.00 00490620 00 6 2019-08-15 2019-11-01 CO $181.00 00190620 00 6 2019-08-15 2019-11-01 CO $181.00 00490621 00 6 2019-11-01 2020-02-01 CO $147.89 00190621 00 6 2019-11-01 2020-02-01 CO $147.89 00490621 00 6 2019-08-15 2019-11-01 CO $147.89 00190621 00 6 2019-08-15 2019-11-01 CO $147.89 00490633 00 6 2019-11-01 2020-02-01 CO $35.08 00190633 00 6 2019-11-01 2020-02-01 CO $35.08 00490633 00 6 2019-08-15 2019-11-01 CO $34.74 00190633 00 6 2019-08-15 2019-11-01 CO $34.74 00490636 00 6 2019-11-01 2020-02-01 CO $110.24 00190636 00 6 2019-11-01 2020-02-01 CO $110.24 00490636 00 6 2019-08-15 2019-11-01 CO $110.24 00190636 00 6 2019-08-15 2019-11-01 CO $110.24 00490647 00 6 2019-11-01 2020-02-01 CO $27.81 00190647 00 6 2019-11-01 2020-02-01 CO $27.81 00490647 00 6 2019-08-15 2019-11-01 CO $27.81 00190647 00 6 2019-08-15 2019-11-01 CO $27.81 00490648 00 6 2019-11-01 2020-02-01 CO $14.50 00190648 00 6 2019-11-01 2020-02-01 CO $14.50 00490648 00 6 2019-08-15 2019-11-01 CO $14.50 00190648 00 6 2019-08-15 2019-11-01 CO $14.50 00490651 00 6 2019-11-01 2020-02-01 CO $241.61 00190651 00 6 2019-11-01 2020-02-01 CO $241.61 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 55 of 60

Page 56: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

90651 00 6 2019-08-15 2019-11-01 CO $230.14 00190651 00 6 2019-08-15 2019-11-01 CO $230.14 00490660 00 6 2018-01-01 9901-01-01 CO $52.00 00190660 00 6 2018-01-01 9901-01-01 CO $52.00 00490680 00 6 2019-11-01 2020-02-01 CO $89.60 00190680 00 6 2019-11-01 2020-02-01 CO $89.60 00490680 00 6 2019-08-15 2019-11-01 CO $87.86 00190680 00 6 2019-08-15 2019-11-01 CO $87.86 00490681 00 6 2019-11-01 2020-02-01 CO $128.21 00190681 00 6 2019-11-01 2020-02-01 CO $128.21 00490681 00 6 2019-08-15 2019-11-01 CO $128.21 00190681 00 6 2019-08-15 2019-11-01 CO $128.21 00490694 00 6 2020-01-25 2020-11-01 CO $40.00 00190696 00 6 2019-11-01 2020-02-01 CO $55.60 00190696 00 6 2019-11-01 2020-02-01 CO $55.60 00490696 00 6 2019-08-15 2019-11-01 CO $55.60 00190696 00 6 2019-08-15 2019-11-01 CO $55.60 00490698 00 6 2019-11-01 2020-02-01 CO $101.91 00190698 00 6 2019-11-01 2020-02-01 CO $101.91 00490698 00 6 2019-08-15 2019-11-01 CO $101.91 00190698 00 6 2019-08-15 2019-11-01 CO $101.91 00490700 00 6 2019-11-01 2020-02-01 CO $28.36 00190700 00 6 2019-11-01 2020-02-01 CO $28.36 00490700 00 6 2019-08-15 2019-11-01 CO $28.36 00190700 00 6 2019-08-15 2019-11-01 CO $28.36 00490707 00 6 2019-11-01 2020-02-01 CO $83.40 00190707 00 6 2019-11-01 2020-02-01 CO $83.40 00490707 00 6 2019-08-15 2019-11-01 CO $79.54 00190707 00 6 2019-08-15 2019-11-01 CO $79.54 00490710 00 6 2019-11-01 2020-02-01 CO $238.43 00190710 00 6 2019-11-01 2020-02-01 CO $238.43 00490710 00 6 2019-08-15 2019-11-01 CO $227.23 00190710 00 6 2019-08-15 2019-11-01 CO $227.23 00490713 00 6 2019-11-01 2020-02-01 CO $35.54 00190713 00 6 2019-11-01 2020-02-01 CO $35.54 00490713 00 6 2019-08-15 2019-11-01 CO $35.54 00190713 00 6 2019-08-15 2019-11-01 CO $35.54 00490716 00 6 2019-11-01 2020-02-01 CO $143.87 00190716 00 6 2019-11-01 2020-02-01 CO $143.87 00490716 00 6 2019-08-15 2019-11-01 CO $137.06 00190716 00 6 2019-08-15 2019-11-01 CO $137.06 00490723 00 6 2019-11-01 2020-02-01 CO $83.90 00190723 00 6 2019-11-01 2020-02-01 CO $83.90 00490723 00 6 2019-08-15 2019-11-01 CO $83.90 00190723 00 6 2019-08-15 2019-11-01 CO $83.90 00490734 00 6 2019-11-01 2020-02-01 CO $134.12 00190734 00 6 2019-11-01 2020-02-01 CO $134.12 00490734 00 6 2019-08-15 2019-11-01 CO $134.12 00190734 00 6 2019-08-15 2019-11-01 CO $134.12 00490750 00 6 2019-11-01 2020-02-01 CO $152.85 00190750 00 6 2019-11-01 2020-02-01 CO $152.85 00490750 00 6 2019-08-15 2019-11-01 CO $152.85 00190750 00 6 2019-08-15 2019-11-01 CO $152.85 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 56 of 60

Page 57: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

90839 00 C 2018-01-01 2018-03-01 CO $165.00 00190839 00 C 2018-01-01 2018-03-01 CO $165.00 00490840 00 C 2018-01-01 2018-03-01 CO $150.00 00190840 00 C 2018-01-01 2018-03-01 CO $150.00 00490867 00 C 2016-12-29 2018-01-01 CO $450.00 00190867 00 C 2016-12-29 2018-01-01 CO $450.00 00490868 00 C 2016-12-29 2018-01-01 CO $400.00 00190868 00 C 2016-12-29 2018-01-01 CO $400.00 00490869 00 C 2017-06-22 2018-01-01 CO $900.00 00190869 00 C 2017-06-22 2018-01-01 CO $900.00 00490882 00 C 2018-01-01 9901-01-01 CO $120.00 00190882 00 C 2018-01-01 9901-01-01 CO $120.00 00490993 00 6 2018-03-01 9901-01-01 CO $5,917.24 00190993 00 6 2018-01-01 2018-03-01 CO $5,917.24 00190993 00 6 2018-01-01 9901-01-01 CO $3,629.00 00490993 00 6 2017-03-01 2018-01-01 CO $5,917.24 00190993 00 6 2016-04-01 2017-03-01 CO $5,556.58 00191303 00 6 2021-04-17 9901-01-01 CO $75.00 00192921 00 6 2018-01-01 9901-01-01 CO $6,793.07 00192921 00 6 2018-01-01 9901-01-01 CO $6,793.07 00492929 00 6 2018-01-01 9901-01-01 CO $1,200.00 00192929 00 6 2018-01-01 9901-01-01 CO $1,200.00 00492929 00 6 2016-02-26 2018-01-01 CO $1,200.00 00192929 00 6 2016-02-26 2018-01-01 CO $1,200.00 00492978 TC 6 2018-01-01 9901-01-01 CO $2,145.54 00192978 00 6 2018-03-01 9901-01-01 CO $7,284.01 00192978 00 6 2018-03-01 9901-01-01 CO $7,284.01 00492978 00 6 2018-01-01 2018-03-01 CO $7,284.01 00192978 00 6 2018-01-01 2018-03-01 CO $7,284.01 00492978 00 6 2017-03-01 2018-01-01 CO $7,284.01 00192978 00 6 2017-03-01 2018-01-01 CO $7,284.01 00492979 00 6 2018-01-01 9901-01-01 CO $197.20 00193299 00 6 2019-03-01 9901-01-01 CO $734.27 00193299 00 6 2019-03-01 9901-01-01 CO $734.27 00493299 00 6 2018-03-01 2019-03-01 CO $734.27 00193299 00 6 2018-03-01 2019-03-01 CO $734.27 00493299 00 6 2018-01-01 2018-03-01 CO $734.27 00193299 00 6 2018-01-01 2018-03-01 CO $734.27 00493299 00 6 2017-03-01 2018-01-01 CO $734.27 00193299 00 6 2017-03-01 2018-01-01 CO $734.27 00493317 00 6 2018-01-01 9901-01-01 CO $304.00 00193531 TC 6 2018-01-01 9901-01-01 CO $6,113.20 00193531 00 6 2018-01-01 9901-01-01 CO $12,028.61 00193531 00 6 2018-01-01 9901-01-01 CO $12,028.61 00493531 00 6 2017-03-01 2018-01-01 CO $12,028.61 00193531 00 6 2017-03-01 2018-01-01 CO $12,028.61 00493533 00 6 2018-03-01 9901-01-01 CO $15,120.21 00193533 00 6 2018-01-01 2018-03-01 CO $13,148.01 00193533 00 6 2018-01-01 9901-01-01 CO $10,904.50 00493533 00 6 2016-04-01 2018-01-01 CO $13,148.01 00193561 00 6 2018-01-01 9901-01-01 CO $147.90 00193562 00 6 2018-01-01 9901-01-01 CO $78.88 00193571 TC 6 2018-01-01 9901-01-01 CO $1,045.57 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 57 of 60

Page 58: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

93571 00 6 2020-03-01 9901-01-01 CO $9,331.02 00193571 00 6 2019-03-01 2020-03-01 CO $5,418.00 00193571 00 6 2018-03-01 2019-03-01 CO $5,176.67 00193571 00 6 2018-01-01 2018-03-01 CO $4,930.16 00193571 00 6 2018-01-01 9901-01-01 CO $4,708.26 00493571 00 6 2017-03-01 2018-01-01 CO $4,930.16 00193571 00 6 2016-04-01 2017-03-01 CO $4,708.26 00193571 00 6 2016-04-01 2018-01-01 CO $4,708.26 00493609 TC 6 2018-01-01 9901-01-01 CO $8,473.82 00193609 00 6 2018-01-01 9901-01-01 CO $8,754.65 00193620 TC 6 2018-01-01 9901-01-01 CO $3,432.27 00193620 00 6 2020-03-01 9901-01-01 CO $13,225.00 00193620 00 6 2020-03-01 9901-01-01 CO $13,225.00 00493620 00 6 2018-03-01 2020-03-01 CO $16,394.68 00193620 00 6 2018-03-01 2020-03-01 CO $16,394.68 00493620 00 6 2018-01-01 2018-03-01 CO $16,394.68 00193620 00 6 2018-01-01 2018-03-01 CO $16,394.68 00493620 00 6 2017-03-01 2018-01-01 CO $16,394.68 00193620 00 6 2017-03-01 2018-01-01 CO $16,394.68 00493620 00 6 2016-04-01 2017-03-01 CO $16,394.68 00193620 00 6 2016-04-01 2017-03-01 CO $16,394.68 00493621 TC 6 2018-01-01 9901-01-01 CO $4,908.31 00193621 00 6 2019-03-01 9901-01-01 CO $12,584.72 00193621 00 6 2018-03-01 2019-03-01 CO $12,584.72 00193621 00 6 2018-01-01 2018-03-01 CO $11,985.45 00193621 00 6 2018-01-01 9901-01-01 CO $11,377.90 00493621 00 6 2017-03-01 2018-01-01 CO $11,985.45 00193621 00 6 2016-04-01 2017-03-01 CO $11,446.01 00193623 TC 6 2018-01-01 9901-01-01 CO $1,251.23 00193623 00 6 2019-03-01 9901-01-01 CO $9,119.37 00193623 00 6 2018-03-01 2019-03-01 CO $7,080.26 00193623 00 6 2018-01-01 2018-03-01 CO $7,080.26 00193623 00 6 2018-01-01 9901-01-01 CO $5,798.74 00493623 00 6 2017-03-01 2018-01-01 CO $7,080.26 00193623 00 6 2016-04-01 2017-03-01 CO $6,436.60 00193641 00 6 2018-01-01 9901-01-01 CO $4,144.92 00193641 00 6 2018-01-01 9901-01-01 CO $4,144.92 00493662 TC 6 2018-01-01 9901-01-01 CO $1,575.73 00193662 00 6 2019-03-01 9901-01-01 CO $10,200.75 00193662 00 6 2018-03-01 2019-03-01 CO $10,200.75 00193662 00 6 2018-01-01 2018-03-01 CO $10,200.75 00193662 00 6 2018-01-01 9901-01-01 CO $7,231.00 00493662 00 6 2017-03-01 2018-01-01 CO $10,200.75 00193662 00 6 2016-04-01 2017-03-01 CO $10,200.75 00194776 00 6 2018-01-01 9901-01-01 CO $564.87 00194776 00 6 2018-01-01 9901-01-01 CO $564.87 00495700 00 6 2020-02-22 2021-03-01 CO $1,537.00 00195708 00 6 2020-06-06 2021-03-01 CO $4,353.00 00195712 00 6 2021-04-10 9901-01-01 CO $2,961.00 00195715 00 6 2020-05-16 2021-03-01 CO $5,947.00 00196377 00 6 2018-01-01 2018-03-01 CO $44.56 00196377 00 6 2018-01-01 2018-03-01 CO $44.56 00496377 00 6 2017-03-16 2018-01-01 CO $44.56 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 58 of 60

Page 59: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

96377 00 6 2017-03-16 2018-01-01 CO $44.56 00497607 00 D 2018-01-01 2018-03-01 CO $137.00 00197607 00 D 2018-01-01 2018-03-01 CO $137.00 00497607 00 D 2017-03-01 2018-01-01 CO $137.00 00197607 00 D 2017-03-01 2018-01-01 CO $137.00 00497607 00 D 2016-03-04 2017-03-01 CO $137.00 00197607 00 D 2016-03-04 2017-03-01 CO $137.00 00497608 00 D 2018-03-01 2020-03-01 CO $187.00 00197608 00 D 2018-01-09 2018-03-01 CO $187.00 00197608 00 D 2018-01-09 2020-03-01 CO $187.00 00499000 00 6 2021-03-01 9901-01-01 CO $25.00 00199000 00 6 2020-03-01 2021-03-01 CO $25.00 00199000 00 6 2019-03-01 2020-03-01 CO $25.00 00199000 00 6 2019-03-01 9901-01-01 CO $25.00 00499000 00 6 2018-03-01 2019-03-01 CO $25.00 00199000 00 6 2018-03-01 2019-03-01 CO $24.00 00499000 00 6 2018-01-01 2018-03-01 CO $25.00 00199000 00 6 2018-01-01 2018-03-01 CO $24.00 00499000 00 6 2017-03-01 2018-01-01 CO $25.00 00199000 00 6 2017-03-01 2018-01-01 CO $24.00 00499000 00 6 2016-04-01 2017-03-01 CO $23.00 00199000 00 6 2016-04-01 2017-03-01 CO $23.00 00499001 00 6 2021-03-01 9901-01-01 CO $30.00 00199001 00 6 2021-03-01 9901-01-01 CO $30.00 00499001 00 6 2020-03-01 2021-03-01 CO $50.00 00199001 00 6 2019-03-01 2020-03-01 CO $40.00 00199001 00 6 2018-03-01 2019-03-01 CO $40.00 00199001 00 6 2018-01-01 2018-03-01 CO $40.00 00199001 00 6 2018-01-01 2021-03-01 CO $40.00 00499001 00 6 2017-03-01 2018-01-01 CO $40.00 00199001 00 6 2016-04-01 2017-03-01 CO $40.00 00199001 00 6 2016-04-01 2018-01-01 CO $40.00 00499002 00 6 2018-01-01 9901-01-01 CO $35.00 00199002 00 6 2018-01-01 9901-01-01 CO $35.00 00499071 00 6 2020-03-01 9901-01-01 CO $16.50 00199071 00 6 2019-03-01 2020-03-01 CO $18.00 00199071 00 6 2018-03-01 2019-03-01 CO $18.00 00199071 00 6 2018-01-01 2018-03-01 CO $18.00 00199071 00 6 2018-01-01 9901-01-01 CO $16.50 00499071 00 6 2017-03-01 2018-01-01 CO $18.00 00199071 00 6 2017-03-01 2018-01-01 CO $16.50 00499071 00 6 2016-04-01 2017-03-01 CO $18.00 00199071 00 6 2016-04-01 2017-03-01 CO $16.50 00499072 00 6 2020-09-08 9901-01-01 CO $50.00 00199072 00 6 2020-09-08 9901-01-01 CO $50.00 00499177 00 6 2018-01-01 2018-03-01 CO $50.00 00199177 00 6 2018-01-01 2018-03-01 CO $50.00 00499177 00 6 2017-03-01 2018-01-01 CO $50.00 00199177 00 6 2016-06-02 2017-03-01 CO $50.00 00199177 00 6 2016-06-02 2018-01-01 CO $50.00 00499188 00 6 2018-01-01 2018-03-01 CO $1,134.92 00199188 00 6 2018-01-01 2018-03-01 CO $1,134.92 00499188 00 6 2017-03-01 2018-01-01 CO $1,134.92 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 59 of 60

Page 60: COLORADO - TRICARE West001=PHYSICIAN RATE 004=NON-PHYSICIAN A0225 00 F 2018-01-01 9901-01-01 CO 447.37 001 A0225 00 F 2018-01-01 9901-01-01 CO 447.37 004 A0430 00 2021-01-01 9901-01-01

COLORADO State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

99188 00 6 2017-03-01 2018-01-01 CO $1,134.92 00499188 00 6 2016-01-22 2017-03-01 CO $1,134.92 00199188 00 6 2016-01-22 2017-03-01 CO $1,134.92 00499190 00 6 2018-01-01 9901-01-01 CO $495.50 00199190 00 6 2018-01-01 9901-01-01 CO $495.50 00499417 00 6 2021-01-23 2021-03-01 CO $75.00 00199455 00 6 2018-01-01 9901-01-01 CO $355.00 00199455 00 6 2018-01-01 9901-01-01 CO $355.00 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 60 of 60