hcpcs level ii codes fee schedule new mexico medicaid … · hcpcs level ii codes fee schedule...
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NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
Current Dental Terminology (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright © 2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. Current Procedural Terminology (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright © 2015 American Medical Association. All rights reserved.Some procedure codes may be on other fee schedule tables. As explained in the HCPCS Disclaimer and Agreement, this table is not to be used as a guide to coverage of services by the Medicaid Program. For new equipment use modifier NU and for rentals use modifier RR. The state may request an invoice during the review for pricing on HCPCS with the rate $0.00. The pricing notes “General Fee Schedule” and “General by Report” and “Manual Review Fee Schedule” are for the global or purchase rates. The pricing notes “Rental Fee Schedule” and “Rental by Report” and “Rental Manual Price-Fee Schedule” are for the rental rates. The pricing notes “26 Fee Schedule (FS)” and “26 by Report” are for the professional component rates when modifier 26 is used. The pricing notes “TC Fee Schedule” and “TC by Report” are for the technical component rates when modifier TC is used. Some procedure codes are only payable for Alternative Benefit Plan (ABP) recipients. PleaserefertotheappropriateABPresourcesontheHSDwebsite.
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
A4206 N $0.26 General Fee Schedule 7/1/2004
A4207 N $0.18 General Fee Schedule 7/1/2004
A4208 N $0.18 General Fee Schedule 7/1/2004
A4209 N $0.33 General Fee Schedule 7/1/2004
A4210 Y $49.25 General Fee Schedule 7/1/2004
A4211 N $0.89 General Fee Schedule 7/1/2004
A4212 N $20.76 General Fee Schedule 7/1/2004
A4213 N $1.40 General Fee Schedule 7/1/2004
A4215 N $0.28 General Fee Schedule 7/1/2004
A4216 N $0.51 General Fee Schedule 1/1/2019
A4217 N $3.61 General Fee Schedule 1/1/2019
A4218 N $0.00 General by Report 1/1/2006
A4220 N $0.00 Manual Review Fee Schedule
1/1/1994
A4221 N $20.27 General Fee Schedule 1/1/2019
A4222 N $38.45 General Fee Schedule 1/1/2019
A4223 Y $46.73 General Fee Schedule 1/1/2005
A4224 Y $20.27 General Fee Schedule 1/1/2019
A4225 Y $2.72 General Fee Schedule 1/1/2019
A4230 N $0.00 Manual Review Fee Schedule
1/1/1996
A4231 N $6.16 General Fee Schedule 7/1/2004
A4232 N $2.61 General Fee Schedule 7/1/2004
A4233 N $0.51 General Fee Schedule 1/1/2017
HCPCS FEES11/06/2019 at 7:08:01 AM - 1 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
A4234 N $2.36 General Fee Schedule 1/1/2017
A4235 N $1.00 General Fee Schedule 1/1/2017
A4236 N $1.16 General Fee Schedule 1/1/2017
A4244 N $1.04 General Fee Schedule 7/1/2004
A4245 N $2.62 General Fee Schedule 7/1/2004
A4246 N $10.48 General Fee Schedule 7/1/2004
A4247 N $7.88 General Fee Schedule 7/1/2004
A4248 Y $0.00 Manual Review Fee Schedule
1/1/2012
A4250 N $62.25 General Fee Schedule 7/1/2004
A4252 Y $0.00 General by Report 1/1/2008
A4253 N $8.32 General Fee Schedule 1/1/2017
A4255 N $4.74 General Fee Schedule 1/1/2019
A4256 N $3.38 General Fee Schedule 1/1/2017
A4257 N $14.69 General Fee Schedule 1/1/2019
A4258 N $2.12 General Fee Schedule 1/1/2017
A4259 N $1.42 General Fee Schedule 1/1/2017
A4261 N $46.65 General Fee Schedule 2/1/2008
A4262 N $0.00 Manual Review Fee Schedule
1/1/1997
A4263 N $73.88 General Fee Schedule 7/1/2004
A4264 Y $1,415.00 General Fee Schedule 4/1/2012
A4265 N $3.92 General Fee Schedule 1/1/2019
A4266 N $29.90 General Fee Schedule 7/1/2004
A4267 N $0.40 General Fee Schedule 7/1/2004
A4268 N $2.02 General Fee Schedule 7/1/2004
A4269 N $3.00 General Fee Schedule 2/1/2008
A4270 N $0.00 Manual Review Fee Schedule
1/1/1997
A4280 N $6.15 General Fee Schedule 1/1/2019
A4281 N $0.00 Manual Review Fee Schedule
1/1/2003
A4282 N $0.00 Manual Review Fee Schedule
1/1/2003
A4283 N $0.00 Manual Review Fee Schedule
1/1/2003
HCPCS FEES11/06/2019 at 7:08:01 AM - 2 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
A4284 N $0.00 Manual Review Fee Schedule
1/1/2003
A4285 N $0.00 Manual Review Fee Schedule
1/1/2003
A4286 N $0.00 Manual Review Fee Schedule
1/1/2003
A4290 N $0.00 Manual Review Fee Schedule
7/1/2009
A4300 N $19.72 General Fee Schedule 7/1/2004
A4301 N $19.72 General Fee Schedule 7/1/2004
A4305 N $15.09 General Fee Schedule 7/1/2004
A4306 N $15.09 General Fee Schedule 7/1/2004
A4310 N $8.89 General Fee Schedule 1/1/2019
A4311 N $17.06 General Fee Schedule 1/1/2019
A4312 N $20.77 General Fee Schedule 1/1/2019
A4313 N $21.33 General Fee Schedule 1/1/2019
A4314 N $27.08 General Fee Schedule 1/1/2019
A4315 N $27.08 General Fee Schedule 1/1/2019
A4316 N $27.80 General Fee Schedule 1/1/2019
A4320 N $6.15 General Fee Schedule 1/1/2019
A4321 N $0.00 General by Report 1/1/2005
A4322 N $3.48 General Fee Schedule 1/1/2019
A4326 N $12.42 General Fee Schedule 1/1/2019
A4327 N $51.35 General Fee Schedule 1/1/2019
A4328 N $12.02 General Fee Schedule 1/1/2019
A4330 N $7.01 General Fee Schedule 1/1/2019
A4331 N $3.66 General Fee Schedule 1/1/2019
A4332 N $0.13 General Fee Schedule 2/11/2009
A4333 N $2.55 General Fee Schedule 1/1/2019
A4334 N $5.67 General Fee Schedule 1/1/2019
A4335 N $76.59 General Fee Schedule 3/1/2007
A4336 N $1.66 General Fee Schedule 1/1/2019
A4337 Y $0.00 General by Report 1/1/2016
A4338 N $12.00 General Fee Schedule 1/1/2019
A4340 N $33.34 General Fee Schedule 1/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 3 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
A4344 N $18.43 General Fee Schedule 1/1/2019
A4346 N $22.55 General Fee Schedule 1/1/2019
A4349 N $2.32 General Fee Schedule 1/1/2019
A4351 N $2.09 General Fee Schedule 1/1/2019
A4352 N $6.31 General Fee Schedule 1/1/2019
A4353 N $8.06 General Fee Schedule 1/1/2019
A4354 N $12.47 General Fee Schedule 1/1/2019
A4355 N $8.73 General Fee Schedule 1/1/2019
A4356 N $52.53 General Fee Schedule 1/1/2019
A4357 N $9.50 General Fee Schedule 1/1/2019
A4358 N $7.63 General Fee Schedule 1/1/2019
A4360 N $0.56 General Fee Schedule 1/1/2019
A4361 N $17.98 General Fee Schedule 1/1/2019
A4362 N $3.39 General Fee Schedule 1/1/2019
A4363 N $2.32 General Fee Schedule 1/1/2019
A4364 N $3.39 General Fee Schedule 1/1/2019
A4366 N $1.49 General Fee Schedule 1/1/2019
A4367 N $8.37 General Fee Schedule 1/1/2019
A4368 N $0.29 General Fee Schedule 1/1/2019
A4369 N $2.79 General Fee Schedule 1/1/2019
A4371 N $4.19 General Fee Schedule 1/1/2019
A4372 N $4.83 General Fee Schedule 1/1/2019
A4373 N $7.22 General Fee Schedule 1/1/2019
A4375 N $19.77 General Fee Schedule 1/1/2019
A4376 N $54.79 General Fee Schedule 1/1/2019
A4377 N $4.94 General Fee Schedule 1/1/2019
A4378 N $35.40 General Fee Schedule 1/1/2019
A4379 N $17.29 General Fee Schedule 1/1/2019
A4380 N $42.98 General Fee Schedule 1/1/2019
A4381 N $5.33 General Fee Schedule 1/1/2019
A4382 N $28.34 General Fee Schedule 1/1/2019
A4383 N $32.46 General Fee Schedule 1/1/2019
A4384 N $11.07 General Fee Schedule 1/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 4 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
A4385 N $5.87 General Fee Schedule 1/1/2019
A4387 N $2.59 General Fee Schedule 1/1/2019
A4388 N $5.02 General Fee Schedule 1/1/2019
A4389 N $7.16 General Fee Schedule 1/1/2019
A4390 N $11.06 General Fee Schedule 1/1/2019
A4391 N $8.14 General Fee Schedule 1/1/2019
A4392 N $9.41 General Fee Schedule 1/1/2019
A4393 N $10.41 General Fee Schedule 1/1/2019
A4394 N $2.98 General Fee Schedule 1/1/2019
A4395 N $0.05 General Fee Schedule 1/1/2005
A4396 N $46.61 General Fee Schedule 1/1/2019
A4397 N $4.68 General Fee Schedule 1/1/2019
A4398 N $15.92 General Fee Schedule 1/1/2019
A4399 N $14.12 General Fee Schedule 1/1/2019
A4400 N $56.27 General Fee Schedule 1/1/2019
A4402 N $1.61 General Fee Schedule 1/1/2019
A4404 N $1.93 General Fee Schedule 1/1/2019
A4405 N $3.93 General Fee Schedule 1/1/2019
A4406 N $6.59 General Fee Schedule 1/1/2019
A4407 N $10.09 General Fee Schedule 1/1/2019
A4408 N $11.37 General Fee Schedule 1/1/2019
A4409 N $7.16 General Fee Schedule 1/1/2019
A4410 N $10.41 General Fee Schedule 1/1/2019
A4411 N $5.87 General Fee Schedule 1/1/2019
A4412 N $3.11 General Fee Schedule 1/1/2019
A4413 N $6.34 General Fee Schedule 1/1/2019
A4414 N $5.67 General Fee Schedule 1/1/2019
A4415 N $6.90 General Fee Schedule 1/1/2019
A4416 N $3.17 General Fee Schedule 1/1/2019
A4417 N $4.29 General Fee Schedule 1/1/2019
A4418 N $2.09 General Fee Schedule 1/1/2019
A4419 N $1.99 General Fee Schedule 1/1/2019
A4420 N $0.00 General by Report 1/1/2005
HCPCS FEES11/06/2019 at 7:08:01 AM - 5 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
A4421 N $0.00 Manual Review Fee Schedule
1/1/1991
A4422 N $0.13 General Fee Schedule 2/11/2009
A4423 N $2.14 General Fee Schedule 1/1/2019
A4424 N $5.48 General Fee Schedule 1/1/2019
A4425 N $4.12 General Fee Schedule 1/1/2019
A4426 N $3.14 General Fee Schedule 1/1/2019
A4427 N $3.20 General Fee Schedule 1/1/2019
A4428 N $7.50 General Fee Schedule 1/1/2019
A4429 N $9.49 General Fee Schedule 1/1/2019
A4430 N $9.80 General Fee Schedule 1/1/2019
A4431 N $7.16 General Fee Schedule 1/1/2019
A4432 N $4.13 General Fee Schedule 1/1/2019
A4433 N $3.86 General Fee Schedule 1/1/2019
A4434 N $4.33 General Fee Schedule 1/1/2019
A4435 N $6.64 General Fee Schedule 1/1/2019
A4450 Y $0.12 General Fee Schedule 4/1/2017
A4452 Y $0.44 General Fee Schedule 4/1/2017
A4455 N $1.40 General Fee Schedule 1/1/2019
A4456 N $0.28 General Fee Schedule 1/1/2019
A4458 N $0.00 Manual Review Fee Schedule
1/1/2004
A4459 Y $0.00 Manual Review Fee Schedule
1/1/2018
A4461 N $3.80 General Fee Schedule 1/1/2019
A4463 N $15.32 General Fee Schedule 1/1/2019
A4465 N $5.52 General Fee Schedule 7/1/2004
A4467 Y $0.00 General by Report 1/1/2017
A4470 N $0.00 Manual Review Fee Schedule
7/1/1984
A4480 N $0.00 Manual Review Fee Schedule
7/1/1984
A4481 N $0.43 General Fee Schedule 1/1/2019
A4483 N $0.00 General by Report 1/1/2005
A4553 Y $0.00 General by Report 1/1/2017
HCPCS FEES11/06/2019 at 7:08:01 AM - 6 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
A4554 N $0.33 General Fee Schedule 3/1/2007
A4555 N $0.00 General by Report 1/1/2014
A4556 N $13.98 General Fee Schedule 1/1/2019
A4557 N $9.40 General Fee Schedule 1/1/2017
A4558 N $5.34 General Fee Schedule 1/1/2019
A4559 N $0.11 General Fee Schedule 2/11/2009
A4561 N $23.70 General Fee Schedule 1/1/2019
A4562 N $58.94 General Fee Schedule 1/1/2019
A4565 N $8.86 General Fee Schedule 1/1/2019
A4566 N $0.00 Manual Review Fee Schedule
1/1/2011
A4570 N $0.00 Manual Review Fee Schedule
7/1/1984
A4580 N $0.00 Manual Review Fee Schedule
7/1/1984
A4590 N $137.90 General Fee Schedule 7/1/2004
A4595 N $10.03 General Fee Schedule 1/1/2017
A4600 N $0.00 General by Report 1/1/2007
A4601 N $0.00 General by Report 1/1/2007
A4602 N $4.29 General Fee Schedule 1/1/2019
A4604 N $38.67 General Fee Schedule 1/1/2017
A4605 N $18.88 General Fee Schedule 1/1/2019
A4606 N $0.00 Manual Review Fee Schedule
1/1/2003
A4608 N $57.71 General Fee Schedule 1/1/2019
A4611 N $180.80 General Fee Schedule 1/28/2013
A4612 N $86.55 General Fee Schedule 1/28/2013
A4613 N $150.55 General Fee Schedule 1/28/2013
A4614 N $27.38 General Fee Schedule 1/1/2019
A4615 N $0.84 General Fee Schedule 1/1/2019
A4616 N $0.07 General Fee Schedule 2/11/2009
A4617 N $3.57 General Fee Schedule 1/1/2019
A4618 N $10.17 General Fee Schedule 1/1/2019
A4619 N $2.00 General Fee Schedule 1/1/2019
A4620 N $0.73 General Fee Schedule 1/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 7 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
A4623 N $6.41 General Fee Schedule 1/1/2019
A4624 N $2.58 General Fee Schedule 1/1/2019
A4625 N $7.97 General Fee Schedule 1/1/2019
A4626 N $3.67 General Fee Schedule 1/1/2019
A4627 N $18.94 General Fee Schedule 7/1/2004
A4628 N $4.31 General Fee Schedule 1/1/2019
A4629 N $5.35 General Fee Schedule 1/1/2019
A4630 N $6.11 General Fee Schedule 1/1/2019
A4633 N $47.24 General Fee Schedule 1/1/2019
A4635 N $5.01 General Fee Schedule NU 1/1/2019
A4636 N $3.10 General Fee Schedule NU 1/1/2019
A4637 N $1.72 General Fee Schedule NU 1/1/2019
A4639 N $314.08 General Fee Schedule 2/10/2014
A4640 N $48.58 General Fee Schedule NU 1/1/2017
A4641 Y $23.64 General Fee Schedule 7/1/2004
A4642 Y $0.00 General by Report 1/1/1998
A4648 Y $195.00 General Fee Schedule 11/1/2011
A4649 N $0.00 Manual Review Fee Schedule
1/1/2005
A4650 Y $0.00 General by Report 1/1/2008
A4651 $0.00 Manual Review Fee Schedule
1/1/2002
A4652 $0.00 Manual Review Fee Schedule
1/1/2002
A4653 N $0.00 Manual Review Fee Schedule
1/1/2003
A4657 N $0.00 Manual Review Fee Schedule
1/1/2004
A4660 N $0.00 Manual Review Fee Schedule
7/1/1984
A4663 N $0.00 Manual Review Fee Schedule
6/1/1990
A4670 N $0.00 Manual Review Fee Schedule
6/1/1981
A4671 N $0.00 General by Report 1/1/2004
A4672 N $0.00 General by Report 1/1/2004
A4673 N $0.00 General by Report 1/1/2004
HCPCS FEES11/06/2019 at 7:08:01 AM - 8 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
A4674 N $0.00 General by Report 1/1/2004
A4680 N $0.00 General by Report 6/1/1981
A4690 N $0.00 General by Report 6/1/1981
A4706 $0.00 Manual Review Fee Schedule
1/1/2002
A4707 $0.00 Manual Review Fee Schedule
1/1/2002
A4708 $0.00 Manual Review Fee Schedule
1/1/2002
A4709 $0.00 Manual Review Fee Schedule
1/1/2002
A4714 N $0.00 General by Report 6/1/1981
A4719 $0.00 General by Report 1/1/2002
A4721 $0.00 General by Report 1/1/2002
A4722 $0.00 General by Report 1/1/2002
A4723 $0.00 General by Report 1/1/2002
A4724 $0.00 General by Report 1/1/2002
A4725 $0.00 General by Report 1/1/2002
A4726 $0.00 General by Report 1/1/2002
A4728 N $0.00 General by Report 1/1/2004
A4730 N $0.00 General by Report 6/1/1981
A4736 $0.00 General by Report 1/1/2002
A4737 $0.00 General by Report 1/1/2002
A4740 N $0.00 General by Report 6/1/1981
A4750 N $2.96 General Fee Schedule 7/1/2004
A4755 N $0.00 Manual Review Fee Schedule
5/1/1984
A4760 N $0.00 General by Report 6/1/1981
A4765 N $0.00 Manual Review Fee Schedule
5/1/1984
A4766 $0.00 General by Report 1/1/2002
A4770 N $0.00 General by Report 6/1/1981
A4771 N $0.00 Manual Review Fee Schedule
5/1/1984
A4772 N $46.61 General Fee Schedule 7/1/2004
A4773 N $13.71 General Fee Schedule 7/1/2004
HCPCS FEES11/06/2019 at 7:08:01 AM - 9 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
A4774 N $0.00 Manual Review Fee Schedule
5/1/1984
A4802 N $0.00 Manual Review Fee Schedule
1/1/2007
A4860 N $0.00 Manual Review Fee Schedule
6/1/1990
A4911 $0.00 Manual Review Fee Schedule
1/1/2002
A4913 N $0.00 Manual Review Fee Schedule
5/1/1984
A4918 N $0.00 Manual Review Fee Schedule
5/1/1984
A4927 N $11.50 General Fee Schedule 7/1/2004
A4929 $0.00 Manual Review Fee Schedule
1/1/2002
A4930 N $0.64 General Fee Schedule 3/1/2007
A4931 N $1.39 General Fee Schedule 7/1/2004
A4932 N $1.39 General Fee Schedule 7/1/2004
A5051 N $2.38 General Fee Schedule 1/1/2019
A5052 N $1.71 General Fee Schedule 1/1/2019
A5053 N $1.69 General Fee Schedule 1/1/2019
A5054 N $2.07 General Fee Schedule 1/1/2019
A5055 N $1.66 General Fee Schedule 1/1/2019
A5056 N $5.38 General Fee Schedule 1/1/2019
A5057 N $11.06 General Fee Schedule 1/1/2019
A5061 N $4.06 General Fee Schedule 1/1/2019
A5062 N $2.57 General Fee Schedule 1/1/2019
A5063 N $3.11 General Fee Schedule 1/1/2019
A5071 N $6.92 General Fee Schedule 1/1/2019
A5072 N $4.06 General Fee Schedule 1/1/2019
A5073 N $3.64 General Fee Schedule 1/1/2019
A5081 N $3.25 General Fee Schedule 1/1/2019
A5082 N $13.70 General Fee Schedule 1/1/2019
A5083 N $0.74 General Fee Schedule 1/1/2019
A5093 N $2.11 General Fee Schedule 1/1/2019
A5102 N $25.99 General Fee Schedule 1/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 10 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
A5105 N $44.03 General Fee Schedule 1/1/2019
A5112 N $37.26 General Fee Schedule 1/1/2019
A5113 N $4.62 General Fee Schedule 1/1/2019
A5114 N $10.31 General Fee Schedule 1/1/2019
A5120 N $0.26 General Fee Schedule 1/1/2016
A5121 N $8.58 General Fee Schedule 1/1/2019
A5122 N $14.79 General Fee Schedule 1/1/2019
A5126 N $1.28 General Fee Schedule 1/1/2019
A5131 N $18.25 General Fee Schedule 1/1/2019
A5200 N $13.02 General Fee Schedule 1/1/2019
A5500 N $73.21 General Fee Schedule 1/1/2019
A5501 N $219.59 General Fee Schedule 1/1/2019
A5503 N $36.24 General Fee Schedule 1/1/2019
A5504 N $36.24 General Fee Schedule 1/1/2019
A5505 N $36.24 General Fee Schedule 1/1/2019
A5506 N $36.24 General Fee Schedule 1/1/2019
A5507 N $36.24 General Fee Schedule 1/1/2019
A5508 N $0.00 Manual Review Fee Schedule
10/1/2004
A5510 N $0.00 Manual Review Fee Schedule
10/1/2004
A5512 N $29.86 General Fee Schedule 1/1/2019
A5513 N $44.56 General Fee Schedule 1/1/2019
A5514 N $0.00 Manual Review Fee Schedule
1/1/2019
A6010 N $35.66 General Fee Schedule 1/1/2019
A6011 N $2.63 General Fee Schedule 1/1/2019
A6021 N $24.20 General Fee Schedule 1/1/2019
A6022 N $24.20 General Fee Schedule 1/1/2019
A6023 N $219.12 General Fee Schedule 1/1/2019
A6024 N $7.13 General Fee Schedule 1/1/2019
A6025 N $0.00 General by Report 1/1/1997
A6154 N $16.56 General Fee Schedule 1/1/2019
A6196 N $8.47 General Fee Schedule 1/1/2019
A6197 N $18.93 General Fee Schedule 1/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 11 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
A6198 N $0.00 General by Report 1/1/1997
A6199 N $6.09 General Fee Schedule 1/1/2019
A6203 N $3.88 General Fee Schedule 1/1/2019
A6204 N $7.17 General Fee Schedule 1/1/2019
A6205 N $0.00 Manual Review Fee Schedule
1/1/1997
A6206 N $7.34 General Fee Schedule 1/1/2004
A6207 N $8.45 General Fee Schedule 1/1/2019
A6208 N $0.00 General by Report 1/1/1997
A6209 N $8.60 General Fee Schedule 1/1/2019
A6210 N $22.94 General Fee Schedule 1/1/2019
A6211 N $33.82 General Fee Schedule 1/1/2019
A6212 N $11.18 General Fee Schedule 1/1/2019
A6213 N $9.70 General Fee Schedule 1/1/2004
A6214 N $11.85 General Fee Schedule 1/1/2019
A6215 N $0.00 General by Report 1/1/1997
A6216 N $0.05 General Fee Schedule 1/1/2005
A6217 N $0.00 General by Report 1/1/2005
A6218 N $0.00 General by Report 1/1/1997
A6219 N $1.10 General Fee Schedule 1/1/2019
A6220 N $2.98 General Fee Schedule 1/1/2019
A6221 N $0.00 General by Report 1/1/1997
A6222 N $2.46 General Fee Schedule 1/1/2019
A6223 N $2.79 General Fee Schedule 1/1/2019
A6224 N $4.15 General Fee Schedule 1/1/2019
A6228 N $0.00 General by Report 1/1/1997
A6229 N $4.15 General Fee Schedule 1/1/2019
A6230 N $0.00 General by Report 1/1/1997
A6231 N $5.40 General Fee Schedule 1/1/2019
A6232 N $7.90 General Fee Schedule 1/1/2019
A6233 N $22.08 General Fee Schedule 1/1/2019
A6234 N $7.53 General Fee Schedule 1/1/2019
A6235 N $19.37 General Fee Schedule 1/1/2019
A6236 N $31.38 General Fee Schedule 1/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 12 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
A6237 N $9.11 General Fee Schedule 1/1/2019
A6238 N $26.25 General Fee Schedule 1/1/2019
A6239 N $0.00 General by Report 1/1/1997
A6240 N $14.10 General Fee Schedule 1/1/2019
A6241 N $2.96 General Fee Schedule 1/1/2019
A6242 N $6.98 General Fee Schedule 1/1/2019
A6243 N $14.19 General Fee Schedule 1/1/2019
A6244 N $45.23 General Fee Schedule 1/1/2019
A6245 N $8.37 General Fee Schedule 1/1/2019
A6246 N $11.44 General Fee Schedule 1/1/2019
A6247 N $27.38 General Fee Schedule 1/1/2019
A6248 N $18.71 General Fee Schedule 1/1/2019
A6250 N $0.00 Manual Review Fee Schedule
1/1/1998
A6251 N $2.29 General Fee Schedule 1/1/2019
A6252 N $3.75 General Fee Schedule 1/1/2019
A6253 N $7.29 General Fee Schedule 1/1/2019
A6254 N $1.38 General Fee Schedule 1/1/2019
A6255 N $3.50 General Fee Schedule 1/1/2019
A6256 N $0.00 General by Report 1/1/1997
A6257 N $1.77 General Fee Schedule 1/1/2019
A6258 N $4.96 General Fee Schedule 1/1/2019
A6259 N $12.59 General Fee Schedule 1/1/2019
A6260 N $0.00 General by Report 1/1/2005
A6261 N $0.00 General by Report 1/1/1997
A6262 N $0.00 General by Report 1/1/1997
A6266 N $2.21 General Fee Schedule 1/1/2019
A6402 N $0.13 General Fee Schedule 2/11/2009
A6403 N $0.49 General Fee Schedule 1/1/2019
A6404 N $0.00 General by Report 1/1/1997
A6407 N $2.16 General Fee Schedule 1/1/2019
A6410 N $0.44 General Fee Schedule 1/1/2019
A6411 N $0.31 General Fee Schedule 1/1/2015
A6413 N $0.00 Manual Review Fee 7/1/2009
HCPCS FEES11/06/2019 at 7:08:01 AM - 13 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
Schedule
A6441 N $0.79 General Fee Schedule 1/1/2019
A6442 N $0.18 General Fee Schedule 2/11/2009
A6443 N $0.32 General Fee Schedule 1/1/2019
A6444 N $0.64 General Fee Schedule 1/1/2019
A6445 N $0.37 General Fee Schedule 1/1/2019
A6446 N $0.46 General Fee Schedule 1/1/2019
A6447 N $0.79 General Fee Schedule 1/1/2019
A6448 N $1.33 General Fee Schedule 1/1/2019
A6449 N $2.02 General Fee Schedule 1/1/2019
A6450 Y $2.02 General Fee Schedule 1/1/2019
A6451 Y $2.02 General Fee Schedule 1/1/2019
A6452 N $6.80 General Fee Schedule 1/1/2019
A6453 N $0.72 General Fee Schedule 1/1/2019
A6454 N $0.90 General Fee Schedule 1/1/2019
A6455 N $1.61 General Fee Schedule 1/1/2019
A6456 N $1.46 General Fee Schedule 1/1/2019
A6457 N $1.31 General Fee Schedule 1/1/2019
A6460 N $0.00 General by Report 1/1/2019
A6461 N $0.00 General by Report 1/1/2019
A6501 N $0.00 General by Report 1/1/2005
A6502 N $0.00 Manual Review Fee Schedule
7/1/2009
A6503 N $0.00 General by Report 1/1/2005
A6504 N $0.00 Manual Review Fee Schedule
7/1/2009
A6505 N $0.00 General by Report 1/1/2005
A6506 N $0.00 Manual Review Fee Schedule
7/1/2009
A6507 N $0.00 Manual Review Fee Schedule
7/1/2009
A6508 N $0.00 General by Report 1/1/2005
A6509 N $0.00 Manual Review Fee Schedule
7/1/2009
A6510 N $0.00 General by Report 1/1/2005
HCPCS FEES11/06/2019 at 7:08:01 AM - 14 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
A6511 N $0.00 Manual Review Fee Schedule
7/1/2009
A6512 N $0.00 General by Report 1/1/2003
A6513 N $0.00 Manual Review Fee Schedule
7/1/2009
A6530 N $0.00 Manual Review Fee Schedule
7/1/2009
A6531 N $48.16 General Fee Schedule 1/1/2017
A6532 N $67.86 General Fee Schedule 1/1/2017
A6533 N $0.00 Manual Review Fee Schedule
7/1/2009
A6534 N $0.00 Manual Review Fee Schedule
7/1/2009
A6535 N $0.00 Manual Review Fee Schedule
7/1/2009
A6536 N $0.00 Manual Review Fee Schedule
7/1/2009
A6537 N $0.00 Manual Review Fee Schedule
7/1/2009
A6538 N $0.00 Manual Review Fee Schedule
7/1/2009
A6539 N $0.00 Manual Review Fee Schedule
7/1/2009
A6540 N $0.00 Manual Review Fee Schedule
7/1/2009
A6541 N $0.00 Manual Review Fee Schedule
7/1/2009
A6544 N $0.00 Manual Review Fee Schedule
7/1/2009
A6545 N $94.83 General Fee Schedule 1/1/2017
A6549 N $0.00 Manual Review Fee Schedule
7/1/2009
A6550 N $24.49 General Fee Schedule 1/1/2017
A7000 N $8.22 General Fee Schedule 1/1/2017
A7001 N $33.82 General Fee Schedule 1/1/2019
A7002 N $3.75 General Fee Schedule 1/1/2019
A7003 N $1.51 General Fee Schedule 1/1/2017
A7004 N $1.22 General Fee Schedule 1/1/2017
A7005 N $10.93 General Fee Schedule 1/1/2017
HCPCS FEES11/06/2019 at 7:08:01 AM - 15 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
A7006 N $6.49 General Fee Schedule 1/1/2017
A7007 N $2.90 General Fee Schedule 1/1/2017
A7008 N $10.76 General Fee Schedule 1/1/2019
A7009 N $47.45 General Fee Schedule 1/1/2019
A7010 N $13.75 General Fee Schedule 1/1/2017
A7012 N $2.54 General Fee Schedule 1/1/2017
A7013 N $0.50 General Fee Schedule 1/1/2017
A7014 N $2.98 General Fee Schedule 1/1/2017
A7015 N $1.20 General Fee Schedule 1/1/2017
A7016 N $7.89 General Fee Schedule 1/1/2019
A7017 N $102.16 General Fee Schedule 1/1/2019
A7018 N $0.30 General Fee Schedule 1/1/2017
A7020 N $16.67 General Fee Schedule 1/1/2019
A7025 N $475.63 General Fee Schedule 2/10/2014
A7026 N $33.09 General Fee Schedule 1/1/2019
A7027 N $114.90 General Fee Schedule 1/1/2017
A7028 N $31.91 General Fee Schedule 1/1/2017
A7029 N $15.11 General Fee Schedule 1/1/2017
A7030 N $85.63 General Fee Schedule 1/1/2017
A7031 N $32.56 General Fee Schedule NU 1/1/2017
A7032 N $18.30 General Fee Schedule 1/1/2017
A7033 N $15.13 General Fee Schedule 1/1/2017
A7034 N $54.66 General Fee Schedule 1/1/2017
A7035 N $17.62 General Fee Schedule 1/1/2017
A7036 N $10.15 General Fee Schedule 1/1/2017
A7037 N $11.51 General Fee Schedule 1/1/2017
A7038 N $2.05 General Fee Schedule 1/1/2017
A7039 N $6.00 General Fee Schedule 1/1/2017
A7040 N $46.83 General Fee Schedule 1/1/2019
A7041 N $88.00 General Fee Schedule 1/1/2019
A7044 N $77.81 General Fee Schedule 1/1/2017
A7045 N $11.17 General Fee Schedule 1/1/2017
A7046 N $12.70 General Fee Schedule 1/1/2017
HCPCS FEES11/06/2019 at 7:08:01 AM - 16 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
A7047 N $139.21 General Fee Schedule 1/1/2019
A7048 Y $48.97 General Fee Schedule 1/1/2019
A7501 N $120.92 General Fee Schedule 1/1/2019
A7502 N $57.48 General Fee Schedule 1/1/2019
A7503 N $13.06 General Fee Schedule 1/1/2019
A7504 N $0.79 General Fee Schedule 1/1/2019
A7505 N $5.40 General Fee Schedule 1/1/2019
A7506 N $0.38 General Fee Schedule 1/1/2019
A7507 N $2.86 General Fee Schedule 1/1/2019
A7508 N $3.30 General Fee Schedule 1/1/2019
A7509 N $1.63 General Fee Schedule 1/1/2019
A7520 N $54.67 General Fee Schedule 1/1/2019
A7521 N $54.16 General Fee Schedule 1/1/2019
A7522 N $52.00 General Fee Schedule 1/1/2019
A7524 N $89.13 General Fee Schedule 1/1/2019
A7525 N $2.38 General Fee Schedule 1/1/2019
A7526 N $3.90 General Fee Schedule 1/1/2019
A7527 N $4.12 General Fee Schedule 1/1/2019
A8000 N $176.58 General Fee Schedule NU 1/1/2019
A8000 Y $17.66 Rental Fee Schedule RR 1/1/2019
A8001 N $176.58 General Fee Schedule NU 1/1/2019
A8001 Y $17.66 Rental Fee Schedule RR 1/1/2019
A8002 N $0.00 Manual Review Fee Schedule
NU 7/1/2009
A8003 N $0.00 Manual Review Fee Schedule
NU 7/1/2009
A8004 N $0.00 Manual Review Fee Schedule
7/1/2009
A9152 Y $0.00 General by Report 5/1/2013
A9153 Y $0.00 General by Report 5/1/2013
A9270 Y $0.00 General Fee Schedule 4/1/2010
A9272 N $0.00 General by Report 1/1/2012
A9273 N $0.00 General by Report 1/1/2011
A9274 N $0.00 Manual Review Fee Schedule
7/1/2009
HCPCS FEES11/06/2019 at 7:08:01 AM - 17 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
A9275 N $0.00 Manual Review Fee Schedule
7/1/2009
A9276 Y $0.00 General by Report 5/1/2011
A9277 Y $0.00 General by Report 5/1/2011
A9278 Y $0.00 General by Report 5/1/2011
A9279 N $0.00 General by Report NU 5/1/2011
A9279 Y $0.00 Rental by Report RR 1/1/2007
A9284 N $0.00 Manual Review Fee Schedule
7/1/2009
A9284 Y $0.00 Rental by Report 1/1/2009
A9500 Y $111.82 General Fee Schedule 1/1/2010
A9501 Y $0.00 General by Report 1/1/2008
A9502 Y $106.65 General Fee Schedule 1/1/2010
A9503 Y $19.31 General Fee Schedule 1/1/2010
A9504 Y $0.00 Manual Review Fee Schedule
1/1/2006
A9505 Y $34.20 General Fee Schedule 1/1/2010
A9507 Y $2,500.00 General Fee Schedule 1/1/2010
A9508 Y $402.79 General Fee Schedule 1/1/2010
A9509 Y $0.00 Manual Review Fee Schedule
7/1/2009
A9510 Y $39.90 General Fee Schedule 1/1/2010
A9512 Y $3.93 General Fee Schedule 1/1/2010
A9513 Y $251.75 General Fee Schedule 1/1/2019
A9515 Y $0.00 General by Report 1/1/2017
A9516 Y $28.32 General Fee Schedule 1/1/2010
A9517 Y $21.00 General Fee Schedule 1/1/2010
A9520 Y $0.00 General by Report 1/1/2014
A9521 Y $567.61 General Fee Schedule 1/1/2010
A9524 Y $61.75 General Fee Schedule 1/1/2010
A9526 Y $143.00 General Fee Schedule 1/1/2010
A9527 Y $0.00 Manual Review Fee Schedule
7/1/2009
A9528 Y $46.79 General Fee Schedule 1/1/2010
A9529 Y $109.00 General Fee Schedule 1/1/2010
HCPCS FEES11/06/2019 at 7:08:01 AM - 18 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
A9530 Y $9.66 General Fee Schedule 1/1/2010
A9531 Y $9.59 General Fee Schedule 1/1/2010
A9532 Y $282.00 General Fee Schedule 1/1/2010
A9536 Y $0.00 General by Report 1/1/2006
A9537 Y $40.00 General Fee Schedule 1/1/2010
A9538 Y $40.81 General Fee Schedule 1/1/2010
A9539 Y $13.68 General Fee Schedule 1/1/2010
A9540 Y $20.00 General Fee Schedule 1/1/2010
A9541 Y $33.09 General Fee Schedule 1/1/2010
A9542 Y $2,769.63 General Fee Schedule 1/1/2010
A9543 Y $20,367.00 General Fee Schedule 1/1/2010
A9546 Y $235.83 General Fee Schedule 1/1/2010
A9547 Y $280.35 General Fee Schedule 1/1/2010
A9548 Y $320.39 General Fee Schedule 1/1/2010
A9550 Y $0.00 Manual Review Fee Schedule
7/1/2009
A9551 Y $124.50 General Fee Schedule 1/1/2010
A9552 Y $583.00 General Fee Schedule 12/1/2010
A9553 Y $257.18 General Fee Schedule 1/1/2011
A9554 Y $640.40 General Fee Schedule 1/1/2011
A9555 Y $260.00 General Fee Schedule 1/1/2011
A9556 Y $0.00 Manual Review Fee Schedule
7/1/2009
A9557 Y $424.18 General Fee Schedule 1/1/2011
A9558 Y $42.16 General Fee Schedule 1/1/2011
A9559 Y $88.59 General Fee Schedule 1/1/2011
A9560 Y $0.00 Manual Review Fee Schedule
1/1/2006
A9561 Y $34.00 General Fee Schedule 1/1/2011
A9562 Y $279.00 General Fee Schedule 1/1/2011
A9563 Y $46.57 General Fee Schedule 1/1/2011
A9564 Y $158.88 General Fee Schedule 1/1/2011
A9566 Y $0.00 General by Report 1/1/2006
A9567 Y $0.00 Manual Review Fee Schedule
7/1/2009
HCPCS FEES11/06/2019 at 7:08:01 AM - 19 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
A9568 Y $1,235.00 General Fee Schedule 1/1/2011
A9569 Y $0.00 General by Report 1/1/2008
A9570 Y $0.00 General by Report 1/1/2008
A9571 Y $0.00 General by Report 1/1/2008
A9572 Y $0.00 General by Report 1/1/2008
A9575 Y $0.19 General Fee Schedule 10/1/2019
A9576 Y $1.42 General Fee Schedule 10/1/2019
A9577 Y $1.94 General Fee Schedule 7/1/2019
A9578 Y $1.94 General Fee Schedule 10/1/2019
A9579 Y $1.59 General Fee Schedule 10/1/2019
A9580 Y $0.00 Manual Review Fee Schedule
1/1/2009
A9581 Y $14.78 General Fee Schedule 10/1/2019
A9582 Y $0.00 General by Report 1/1/2010
A9583 Y $18.56 General Fee Schedule 4/1/2017
A9584 Y $0.00 General by Report 1/1/2012
A9585 Y $0.35 General Fee Schedule 10/1/2019
A9586 Y $0.00 General by Report 1/1/2013
A9587 Y $0.00 General by Report 1/1/2017
A9588 Y $0.00 General by Report 1/1/2017
A9589 Y $1,139.50 General Fee Schedule 4/1/2019
A9597 Y $0.00 General by Report 1/1/2017
A9598 Y $0.00 General by Report 1/1/2017
A9600 Y $0.00 Manual Review Fee Schedule
1/1/2007
A9604 Y $0.00 General by Report 1/1/2010
A9606 Y $164.28 General Fee Schedule 10/1/2019
A9698 Y $0.00 Manual Review Fee Schedule
1/1/2006
A9699 Y $0.00 General by Report 1/1/2007
A9700 Y $0.00 Manual Review Fee Schedule
1/1/2007
A9900 N $0.00 Manual Review Fee Schedule
1/1/2004
A9901 N $0.00 Manual Review Fee Schedule
1/1/2004
HCPCS FEES11/06/2019 at 7:08:01 AM - 20 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
A9999 N $0.00 General by Report 1/1/2004
B4034 N $3.02 General Fee Schedule 1/1/2017
B4035 N $5.18 General Fee Schedule 1/1/2017
B4036 N $4.07 General Fee Schedule 1/1/2017
B4081 N $14.83 General Fee Schedule 1/1/2017
B4082 N $10.48 General Fee Schedule 1/1/2017
B4083 N $1.62 General Fee Schedule 1/1/2017
B4087 N $26.47 General Fee Schedule 1/1/2017
B4088 N $31.08 General Fee Schedule 1/1/2017
B4100 N $0.23 General Fee Schedule 7/1/2004
B4102 N $0.00 Manual Review Fee Schedule
6/1/2008
B4103 N $0.00 Manual Review Fee Schedule
6/1/2008
B4104 N $0.00 Manual Review Fee Schedule
6/1/2008
B4105 N $0.00 General by Report 1/1/2019
B4149 N $1.00 General Fee Schedule 1/1/2017
B4150 N $0.37 General Fee Schedule 1/1/2017
B4152 N $0.31 General Fee Schedule 1/1/2017
B4153 N $1.18 General Fee Schedule 1/1/2017
B4154 N $0.66 General Fee Schedule 1/1/2017
B4155 N $0.74 General Fee Schedule 1/1/2017
B4157 N $0.00 Manual Review Fee Schedule
6/1/2008
B4158 N $0.00 Manual Review Fee Schedule
6/1/2008
B4159 N $0.00 Manual Review Fee Schedule
6/1/2008
B4160 N $0.00 Manual Review Fee Schedule
6/1/2008
B4161 N $0.00 Manual Review Fee Schedule
6/1/2008
B4162 N $0.00 Manual Review Fee Schedule
6/1/2008
B4164 N $20.32 General Fee Schedule 1/1/2019
B4168 N $29.63 General Fee Schedule 1/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 21 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
B4172 N $0.00 Manual Review Fee Schedule
6/1/2008
B4176 N $57.32 General Fee Schedule 1/1/2019
B4178 N $68.79 General Fee Schedule 1/1/2019
B4180 N $29.17 General Fee Schedule 1/1/2019
B4185 N $13.43 General Fee Schedule 1/1/2019
B4189 N $212.53 General Fee Schedule 1/1/2019
B4193 N $274.61 General Fee Schedule 1/1/2019
B4197 N $334.34 General Fee Schedule 1/1/2019
B4199 N $382.03 General Fee Schedule 1/1/2019
B4216 N $9.23 General Fee Schedule 1/1/2019
B4220 N $9.57 General Fee Schedule 1/1/2019
B4222 N $11.81 General Fee Schedule 1/1/2019
B4224 N $29.89 General Fee Schedule 1/1/2019
B5000 N $14.22 General Fee Schedule 1/1/2019
B5100 N $5.55 General Fee Schedule 1/1/2019
B5200 N $0.00 General by Report 1/1/2000
B9002 N $616.42 General Fee Schedule 1/1/2017
B9002 Y $61.64 Rental Fee Schedule RR 1/1/2017
B9004 N $3,016.75 General Fee Schedule 1/1/2019
B9004 Y $477.56 Rental Fee Schedule 1/1/2019
B9006 N $3,016.75 General Fee Schedule 1/1/2019
B9006 Y $477.56 Rental Fee Schedule 1/1/2019
B9998 N $0.00 Manual Review Fee Schedule
1/1/2004
B9999 N $0.00 Manual Review Fee Schedule
4/1/1991
E0100 N $24.27 General Fee Schedule NU 1/1/2019
E0100 Y $5.81 Rental Fee Schedule RR 1/1/2019
E0105 N $56.55 General Fee Schedule NU 1/1/2019
E0105 Y $8.68 Rental Fee Schedule RR 1/1/2019
E0110 N $89.34 General Fee Schedule NU 1/1/2019
E0110 Y $15.64 Rental Fee Schedule RR 1/1/2019
E0111 N $61.31 General Fee Schedule NU 1/1/2019
E0111 Y $8.25 Rental Fee Schedule RR 1/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 22 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
E0112 N $36.22 General Fee Schedule NU 1/1/2019
E0112 Y $9.73 Rental Fee Schedule RR 1/1/2019
E0113 N $24.34 General Fee Schedule NU 1/1/2019
E0113 Y $5.03 Rental Fee Schedule RR 1/1/2019
E0114 N $46.19 General Fee Schedule NU 1/1/2019
E0114 Y $8.38 Rental Fee Schedule RR 1/1/2019
E0116 N $31.95 General Fee Schedule NU 1/1/2019
E0116 Y $5.30 Rental Fee Schedule RR 1/1/2019
E0117 N $210.75 General Fee Schedule NU 2/10/2014
E0117 Y $22.18 Rental Fee Schedule RR 1/1/2019
E0118 N $0.00 General by Report NU 1/1/2004
E0118 Y $0.00 Rental by Report RR 1/1/2004
E0130 N $41.78 General Fee Schedule NU 1/1/2017
E0130 Y $4.18 Rental Fee Schedule RR 1/1/2017
E0135 N $41.78 General Fee Schedule NU 1/1/2017
E0135 Y $4.18 Rental Fee Schedule RR 1/1/2017
E0140 N $298.45 General Fee Schedule NU 1/1/2016
E0140 Y $25.09 Rental Fee Schedule RR 1/1/2017
E0141 N $46.63 General Fee Schedule NU 1/1/2017
E0141 Y $4.66 Rental Fee Schedule RR 1/1/2017
E0143 N $46.63 General Fee Schedule NU 1/1/2017
E0143 Y $4.66 Rental Fee Schedule RR 1/1/2017
E0144 N $300.15 General Fee Schedule NU 2/10/2014
E0144 Y $26.83 Rental Fee Schedule RR 1/1/2019
E0147 N $390.33 General Fee Schedule NU 1/1/2019
E0147 Y $39.03 Rental Fee Schedule RR 1/1/2019
E0148 N $75.96 General Fee Schedule NU 1/1/2017
E0148 Y $7.60 Rental Fee Schedule RR 1/1/2017
E0149 N $165.77 General Fee Schedule NU 1/1/2016
E0149 Y $10.82 Rental Fee Schedule RR 1/1/2017
E0153 N $71.10 General Fee Schedule NU 1/1/2019
E0153 Y $7.68 Rental Fee Schedule RR 1/1/2019
E0154 N $44.30 General Fee Schedule NU 1/1/2017
HCPCS FEES11/06/2019 at 7:08:01 AM - 23 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
E0154 Y $4.43 Rental Fee Schedule RR 1/1/2017
E0155 N $19.10 General Fee Schedule NU 1/1/2017
E0155 Y $1.91 Rental Fee Schedule RR 1/1/2017
E0156 N $14.52 General Fee Schedule NU 1/1/2017
E0156 Y $1.45 Rental Fee Schedule RR 1/1/2017
E0157 N $49.22 General Fee Schedule NU 1/1/2017
E0157 Y $4.92 Rental Fee Schedule RR 1/1/2017
E0158 N $19.59 General Fee Schedule NU 1/1/2017
E0158 Y $1.96 Rental Fee Schedule RR 1/1/2017
E0159 N $13.63 General Fee Schedule NU 1/1/2017
E0159 Y $1.36 Rental Fee Schedule RR 1/1/2017
E0160 N $26.46 General Fee Schedule NU 1/1/2017
E0160 Y $2.65 Rental Fee Schedule RR 1/1/2017
E0161 N $22.30 General Fee Schedule NU 1/1/2017
E0161 Y $2.23 Rental Fee Schedule RR 1/1/2017
E0163 N $51.14 General Fee Schedule NU 1/1/2017
E0163 Y $5.12 Rental Fee Schedule RR 1/1/2017
E0165 N $130.90 General Fee Schedule NU 1/1/2005
E0167 N $10.31 General Fee Schedule NU 1/1/2017
E0168 N $108.76 General Fee Schedule NU 1/1/2017
E0168 Y $10.88 Rental Fee Schedule RR 1/1/2017
E0170 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0170 Y $156.02 Rental Fee Schedule RR 1/1/2017
E0171 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0171 Y $29.37 Rental Fee Schedule RR 1/1/2017
E0172 N $0.00 General by Report NU 1/1/2006
E0172 Y $0.00 Rental by Report RR 1/1/2006
E0175 N $76.26 General Fee Schedule NU 1/1/2019
E0181 N $311.26 General Fee Schedule NU 7/1/2004
E0181 Y $15.49 Rental Fee Schedule RR 1/1/2017
E0182 N $210.99 General Fee Schedule NU 7/1/2004
E0182 Y $20.11 Rental Fee Schedule RR 1/1/2017
HCPCS FEES11/06/2019 at 7:08:01 AM - 24 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
E0184 N $148.43 General Fee Schedule NU 1/1/2017
E0184 Y $14.84 Rental Fee Schedule RR 1/1/2017
E0185 N $168.48 General Fee Schedule NU 1/1/2017
E0185 Y $16.85 Rental Fee Schedule RR 1/1/2017
E0186 N $205.96 General Fee Schedule NU 7/1/2004
E0186 Y $17.92 Rental Fee Schedule RR 1/1/2017
E0187 N $208.72 General Fee Schedule NU 7/1/2004
E0187 Y $20.99 Rental Fee Schedule RR 1/1/2017
E0188 N $22.25 General Fee Schedule NU 1/1/2017
E0189 N $49.88 General Fee Schedule NU 1/1/2017
E0190 Y $0.00 General by Report NU 4/1/2010
E0190 Y $0.00 Rental by Report RR 1/1/2004
E0191 N $11.51 General Fee Schedule NU 1/1/2019
E0193 Y $673.38 Rental Fee Schedule RR 1/1/2017
E0196 N $265.95 General Fee Schedule NU 7/1/2004
E0197 N $193.18 General Fee Schedule NU 1/1/2016
E0198 N $205.96 General Fee Schedule NU 2/10/2014
E0199 N $29.93 General Fee Schedule NU 1/1/2017
E0200 N $86.92 General Fee Schedule NU 1/1/2019
E0200 Y $10.53 Rental Fee Schedule RR 1/1/2019
E0202 N $1,048.04 General Fee Schedule NU 7/1/2004
E0202 Y $72.09 Rental Fee Schedule RR 1/1/2019
E0205 N $223.44 General Fee Schedule NU 1/1/2019
E0205 Y $24.58 Rental Fee Schedule RR 1/1/2019
E0210 N $31.95 General Fee Schedule NU 1/1/2019
E0210 Y $3.01 Rental Fee Schedule RR 1/1/2019
E0215 N $69.33 General Fee Schedule NU 1/1/2019
E0215 Y $7.25 Rental Fee Schedule RR 1/1/2019
E0217 N $571.63 General Fee Schedule NU 1/1/2019
E0217 Y $57.16 Rental Fee Schedule RR 1/1/2019
E0218 N $0.00 General by Report NU 1/1/2005
E0221 Y $208.17 Rental Fee Schedule RR 7/1/2004
E0225 N $447.48 General Fee Schedule NU 1/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 25 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
E0225 Y $44.11 Rental Fee Schedule RR 1/1/2019
E0235 Y $16.88 Rental Fee Schedule RR 1/1/2019
E0236 N $365.34 General Fee Schedule NU 7/1/2004
E0236 Y $47.63 Rental Fee Schedule RR 1/1/2019
E0239 N $441.31 General Fee Schedule NU 1/1/2019
E0239 Y $44.15 Rental Fee Schedule RR 1/1/2019
E0240 N $0.00 General by Report NU 1/1/2004
E0240 Y $0.00 Rental by Report RR 1/1/2004
E0241 N $0.00 Manual Review Fee Schedule
NU 1/1/1991
E0242 N $0.00 Manual Review Fee Schedule
NU 6/1/1990
E0242 Y $0.00 Rental Manual Price-Fee Sched
RR 5/1/1984
E0243 N $0.00 Manual Review Fee Schedule
NU 1/1/1986
E0243 Y $0.00 Rental Manual Price-Fee Sched
RR 5/1/1984
E0244 N $0.00 Manual Review Fee Schedule
NU 10/1/2002
E0245 N $0.00 Manual Review Fee Schedule
NU 1/1/1991
E0245 Y $0.00 Rental Manual Price-Fee Sched
RR 1/1/1992
E0246 N $0.00 Manual Review Fee Schedule
NU 1/1/1993
E0246 Y $0.00 Rental Manual Price-Fee Sched
RR 5/1/1984
E0247 N $0.00 General by Report NU 1/1/2004
E0247 Y $0.00 Rental by Report RR 1/1/2004
E0248 N $0.00 General by Report NU 1/1/2004
E0248 Y $0.00 Rental by Report RR 1/1/2004
E0249 N $97.49 General Fee Schedule NU 1/1/2019
E0249 Y $10.71 Rental Fee Schedule RR 1/1/2019
E0250 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0250 Y $60.29 Rental Fee Schedule RR 1/1/2017
E0251 N $0.00 Manual Review Fee NU 1/28/2013
HCPCS FEES11/06/2019 at 7:08:01 AM - 26 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
Schedule
E0251 Y $56.49 Rental Fee Schedule RR 1/1/2017
E0255 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0255 Y $60.52 Rental Fee Schedule RR 1/1/2017
E0256 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0256 Y $59.19 Rental Fee Schedule RR 1/1/2017
E0260 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0260 Y $60.52 Rental Fee Schedule RR 1/1/2017
E0261 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0261 Y $60.52 Rental Fee Schedule RR 1/1/2017
E0265 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0265 Y $143.69 Rental Fee Schedule RR 1/1/2019
E0266 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0266 Y $125.03 Rental Fee Schedule RR 1/1/2019
E0270 Y $0.00 Rental Manual Price-Fee Sched
RR 1/1/1986
E0271 N $116.52 General Fee Schedule NU 1/1/2017
E0271 Y $11.65 Rental Fee Schedule RR 1/1/2017
E0272 N $131.05 General Fee Schedule NU 1/1/2017
E0272 Y $13.11 Rental Fee Schedule RR 1/1/2017
E0273 N $0.00 Manual Review Fee Schedule
NU 5/1/1984
E0273 Y $0.00 Rental Manual Price-Fee Sched
RR 5/1/1984
E0275 N $13.64 General Fee Schedule NU 1/1/2017
E0276 N $11.88 General Fee Schedule NU 1/1/2017
E0277 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0277 Y $200.40 Rental Fee Schedule RR 1/1/2017
E0280 N $30.38 General Fee Schedule NU 1/1/2017
E0280 Y $3.04 Rental Fee Schedule RR 1/1/2017
HCPCS FEES11/06/2019 at 7:08:01 AM - 27 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
E0290 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0290 Y $56.83 Rental Fee Schedule RR 1/1/2017
E0291 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0291 Y $43.98 Rental Fee Schedule RR 1/1/2017
E0292 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0292 Y $60.37 Rental Fee Schedule RR 1/1/2017
E0293 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0293 Y $56.91 Rental Fee Schedule RR 1/1/2017
E0294 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0294 Y $60.52 Rental Fee Schedule RR 1/1/2017
E0295 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0295 Y $60.52 Rental Fee Schedule RR 1/1/2017
E0296 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0296 Y $112.11 Rental Fee Schedule RR 1/1/2019
E0297 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0297 Y $98.94 Rental Fee Schedule RR 1/1/2019
E0300 N $2,675.48 General Fee Schedule NU 2/10/2014
E0300 Y $249.82 Rental Fee Schedule RR 1/1/2019
E0301 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0301 Y $158.57 Rental Fee Schedule RR 1/1/2017
E0302 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0302 Y $459.94 Rental Fee Schedule RR 1/1/2017
E0303 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0303 Y $161.38 Rental Fee Schedule RR 1/1/2017
E0304 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0304 Y $465.39 Rental Fee Schedule RR 1/1/2017
HCPCS FEES11/06/2019 at 7:08:01 AM - 28 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
E0305 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0305 Y $10.53 Rental Fee Schedule RR 1/1/2017
E0310 N $107.08 General Fee Schedule NU 1/1/2017
E0310 Y $10.71 Rental Fee Schedule RR 1/1/2017
E0325 N $9.18 General Fee Schedule NU 1/1/2017
E0326 N $9.48 General Fee Schedule NU 1/1/2017
E0328 N $0.00 General by Report NU 1/1/2008
E0328 Y $0.00 Rental by Report RR 1/1/2008
E0329 N $0.00 General by Report NU 1/1/2008
E0329 Y $0.00 Rental by Report RR 1/1/2008
E0350 N $150.00 General Fee Schedule NU 1/1/2017
E0352 Y $0.00 General by Report NU 4/1/2010
E0371 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0371 Y $200.40 Rental Fee Schedule RR 1/1/2017
E0372 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0372 Y $200.40 Rental Fee Schedule RR 1/1/2017
E0373 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0373 Y $200.40 Rental Fee Schedule RR 1/1/2017
E0424 Y $71.73 Rental Fee Schedule RR 1/1/2019
E0425 Y $0.00 General by Report NU 4/1/2010
E0430 N $430.25 General Fee Schedule NU 7/1/2004
E0431 Y $16.16 Rental Fee Schedule RR 1/1/2019
E0433 Y $34.47 Rental Fee Schedule RR 1/1/2019
E0434 Y $34.47 Rental Fee Schedule RR 1/1/2019
E0435 N $149.03 General Fee Schedule NU 7/1/2004
E0439 Y $71.73 Rental Fee Schedule RR 1/1/2019
E0440 N $88.31 General Fee Schedule NU 7/1/2004
E0441 Y $49.57 General Fee Schedule NU 1/1/2019
E0442 Y $49.57 General Fee Schedule NU 1/1/2019
E0443 Y $44.92 General Fee Schedule NU 1/1/2019
E0444 Y $44.92 General Fee Schedule NU 1/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 29 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
E0445 N $0.00 Manual Review Fee Schedule
NU 1/1/2004
E0445 Y $0.00 Rental Manual Price-Fee Sched
RR 1/1/2004
E0446 N $0.00 General by Report NU 1/1/2011
E0447 N $67.38 General Fee Schedule NU 1/1/2019
E0455 N $0.00 Manual Review Fee Schedule
NU 1/1/2004
E0455 Y $0.00 Rental Manual Price-Fee Sched
RR 1/1/2004
E0457 N $665.34 General Fee Schedule NU 1/28/2013
E0457 Y $66.54 Rental Fee Schedule RR 1/28/2013
E0459 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0459 Y $46.84 Rental Fee Schedule RR 1/28/2013
E0462 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0462 Y $335.52 Rental Fee Schedule RR 1/1/2019
E0465 N $0.00 General by Report NU 1/1/2016
E0465 Y $1,059.43 Rental Fee Schedule RR 1/1/2019
E0466 N $0.00 General by Report NU 1/1/2016
E0466 Y $1,059.43 Rental Fee Schedule RR 1/1/2019
E0467 N $1,225.88 Rental Fee Schedule RR 1/1/2019
E0470 Y $104.16 Rental Fee Schedule RR 1/1/2017
E0471 Y $253.29 Rental Fee Schedule RR 1/1/2017
E0472 Y $385.64 Rental Fee Schedule RR 1/1/2017
E0480 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0480 Y $50.60 Rental Fee Schedule RR 1/1/2019
E0482 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0482 Y $437.69 Rental Fee Schedule RR 1/1/2019
E0483 Y $1,224.07 Rental Fee Schedule RR 1/1/2019
E0484 N $42.53 General Fee Schedule NU 1/1/2019
E0484 Y $4.25 Rental Fee Schedule RR 1/1/2019
E0485 N $0.00 General by Report NU 1/1/2006
E0485 Y $0.00 Rental by Report RR 1/1/2006
HCPCS FEES11/06/2019 at 7:08:01 AM - 30 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
E0486 N $0.00 General by Report NU 1/1/2006
E0486 Y $0.00 Rental by Report RR 1/1/2006
E0487 N $0.00 General by Report NU 1/1/2009
E0487 Y $0.00 Rental by Report RR 1/1/2009
E0500 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0500 Y $126.37 Rental Fee Schedule RR 1/1/2019
E0550 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0550 Y $49.06 Rental Fee Schedule RR 1/1/2019
E0555 N $40.21 General Fee Schedule NU 7/1/2004
E0555 Y $4.03 Rental Fee Schedule RR 7/1/2004
E0560 N $170.20 General Fee Schedule NU 1/1/2019
E0560 Y $18.49 Rental Fee Schedule RR 1/1/2019
E0561 N $66.99 General Fee Schedule NU 1/1/2017
E0561 Y $6.70 Rental Fee Schedule RR 1/1/2017
E0562 N $132.61 General Fee Schedule NU 1/1/2017
E0562 Y $13.26 Rental Fee Schedule RR 1/1/2017
E0565 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0565 Y $41.06 Rental Fee Schedule RR 1/1/2017
E0570 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0570 Y $5.58 Rental Fee Schedule RR 1/1/2017
E0572 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0572 Y $22.77 Rental Fee Schedule RR 1/1/2019
E0574 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0574 Y $41.23 Rental Fee Schedule RR 1/1/2019
E0575 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0575 Y $112.99 Rental Fee Schedule RR 1/1/2019
E0580 N $130.39 General Fee Schedule NU 1/1/2019
E0580 Y $13.04 Rental Fee Schedule RR 1/1/2019
E0585 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
HCPCS FEES11/06/2019 at 7:08:01 AM - 31 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
E0585 Y $25.12 Rental Fee Schedule RR 1/1/2017
E0600 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0600 Y $50.29 Rental Fee Schedule RR 1/1/2019
E0601 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0601 Y $39.75 Rental Fee Schedule RR 1/1/2017
E0602 N $33.98 General Fee Schedule NU 1/1/2019
E0602 Y $3.42 Rental Fee Schedule RR 1/1/2019
E0603 Y $120.00 General Fee Schedule NU 1/1/2018
E0605 N $25.86 General Fee Schedule NU 1/1/2019
E0605 Y $3.01 Rental Fee Schedule RR 1/1/2019
E0606 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0606 Y $26.34 Rental Fee Schedule RR 1/1/2019
E0607 N $76.93 General Fee Schedule NU 1/1/2019
E0607 Y $7.68 Rental Fee Schedule RR 1/1/2019
E0610 N $240.75 General Fee Schedule NU 1/1/2019
E0610 Y $24.55 Rental Fee Schedule RR 1/1/2019
E0615 N $468.59 General Fee Schedule NU 1/1/2019
E0615 Y $57.25 Rental Fee Schedule RR 1/1/2019
E0616 N $2,481.33 General Fee Schedule NU 7/1/2004
E0616 Y $248.13 Rental Fee Schedule RR 7/1/2004
E0617 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0617 Y $350.06 Rental Fee Schedule RR 1/1/2019
E0618 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0618 Y $322.81 Rental Fee Schedule RR 1/1/2019
E0619 N $0.00 Manual Review Fee Schedule
NU 1/1/2003
E0619 Y $0.00 Rental Manual Price-Fee Sched
RR 1/1/2005
E0620 N $956.18 General Fee Schedule NU 2/10/2014
E0620 Y $100.66 Rental Fee Schedule RR 1/1/2019
E0621 N $82.75 General Fee Schedule NU 1/1/2017
HCPCS FEES11/06/2019 at 7:08:01 AM - 32 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
E0621 Y $8.28 Rental Fee Schedule RR 1/1/2017
E0625 N $0.00 Manual Review Fee Schedule
NU 7/1/1984
E0625 Y $34.48 Rental Fee Schedule RR 7/1/2004
E0627 N $248.57 General Fee Schedule NU 1/1/2017
E0627 Y $24.86 Rental Fee Schedule RR 1/1/2017
E0629 N $243.98 General Fee Schedule NU 1/1/2017
E0629 Y $24.40 Rental Fee Schedule RR 1/1/2017
E0630 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0630 Y $56.87 Rental Fee Schedule RR 1/1/2017
E0635 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0635 Y $122.80 Rental Fee Schedule RR 1/1/2017
E0636 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0636 Y $968.40 Rental Fee Schedule RR 1/1/2017
E0637 N $2,073.40 General Fee Schedule NU 1/1/2005
E0637 Y $207.36 Rental Fee Schedule RR 1/1/2005
E0638 N $0.00 General by Report NU 1/1/2004
E0638 Y $0.00 Rental by Report RR 1/1/2004
E0639 N $0.00 General by Report NU 1/1/2005
E0639 Y $127.50 Rental Fee Schedule RR 1/1/2019
E0640 N $0.00 General by Report NU 1/1/2005
E0640 Y $127.50 Rental Fee Schedule RR 1/1/2019
E0641 N $0.00 General by Report NU 1/1/2006
E0641 Y $0.00 Rental by Report RR 1/1/2006
E0642 N $0.00 General by Report NU 1/1/2006
E0642 Y $0.00 Rental by Report RR 1/1/2006
E0650 N $829.23 General Fee Schedule NU 1/1/2019
E0650 Y $102.33 Rental Fee Schedule RR 1/1/2019
E0651 N $1,057.44 General Fee Schedule NU 1/1/2019
E0651 Y $106.11 Rental Fee Schedule RR 1/1/2019
E0652 N $6,103.98 General Fee Schedule NU 1/1/2019
E0652 Y $603.25 Rental Fee Schedule RR 1/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 33 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
E0655 N $124.27 General Fee Schedule NU 1/1/2019
E0655 Y $14.61 Rental Fee Schedule RR 1/1/2019
E0656 N $631.74 General Fee Schedule NU 2/10/2014
E0656 Y $66.54 Rental Fee Schedule RR 1/1/2019
E0657 N $593.51 General Fee Schedule NU 2/10/2014
E0657 Y $62.50 Rental Fee Schedule RR 1/1/2019
E0660 N $182.13 General Fee Schedule NU 1/1/2019
E0660 Y $18.23 Rental Fee Schedule RR 1/1/2019
E0665 N $157.74 General Fee Schedule NU 1/1/2019
E0665 Y $16.19 Rental Fee Schedule RR 1/1/2019
E0666 N $159.00 General Fee Schedule NU 1/1/2019
E0666 Y $16.38 Rental Fee Schedule RR 1/1/2019
E0667 N $372.78 General Fee Schedule NU 1/1/2019
E0667 Y $39.07 Rental Fee Schedule RR 1/1/2019
E0668 N $508.77 General Fee Schedule NU 1/1/2019
E0668 Y $50.21 Rental Fee Schedule RR 1/1/2019
E0669 N $211.07 General Fee Schedule NU 1/1/2019
E0669 Y $21.11 Rental Fee Schedule RR 1/1/2019
E0670 N $1,447.34 General Fee Schedule NU 1/1/2019
E0670 Y $148.26 Rental Fee Schedule RR 1/1/2019
E0671 N $478.23 General Fee Schedule NU 1/1/2019
E0671 Y $47.85 Rental Fee Schedule RR 1/1/2019
E0672 N $371.57 General Fee Schedule NU 1/1/2019
E0672 Y $37.18 Rental Fee Schedule RR 1/1/2019
E0673 N $308.76 General Fee Schedule NU 1/1/2019
E0673 Y $30.88 Rental Fee Schedule RR 1/1/2019
E0675 Y $442.76 Rental Fee Schedule RR 1/1/2019
E0676 N $0.00 General by Report NU 1/1/2007
E0676 Y $0.00 Rental by Report RR 1/1/2007
E0691 N $1,034.61 General Fee Schedule NU 1/1/2019
E0691 Y $103.46 Rental Fee Schedule RR 1/1/2019
E0692 N $1,299.20 General Fee Schedule NU 1/1/2019
E0692 Y $129.90 Rental Fee Schedule RR 1/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 34 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
E0693 N $1,601.54 General Fee Schedule NU 1/1/2019
E0693 Y $160.16 Rental Fee Schedule RR 1/1/2019
E0694 N $5,097.55 General Fee Schedule NU 1/1/2019
E0694 Y $509.75 Rental Fee Schedule RR 1/1/2019
E0700 N $0.00 Manual Review Fee Schedule
NU 7/1/1984
E0700 Y $0.00 Rental Manual Price-Fee Sched
RR 10/1/2002
E0705 N $43.97 General Fee Schedule NU 1/1/2017
E0705 Y $4.40 Rental Fee Schedule RR 1/1/2017
E0710 N $0.00 Manual Review Fee Schedule
NU 7/1/1984
E0710 Y $0.00 Rental Manual Price-Fee Sched
RR 10/1/2002
E0720 N $55.32 General Fee Schedule NU 1/1/2019
E0720 Y $39.80 Rental Fee Schedule RR 1/28/2013
E0730 N $54.95 General Fee Schedule NU 1/1/2019
E0730 Y $40.12 Rental Fee Schedule RR 1/28/2013
E0744 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0744 Y $104.01 Rental Fee Schedule RR 1/1/2019
E0745 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0745 Y $95.01 Rental Fee Schedule RR 1/1/2019
E0747 N $4,508.88 General Fee Schedule NU 1/1/2019
E0747 Y $439.23 Rental Fee Schedule RR 1/1/2019
E0748 N $4,479.68 General Fee Schedule NU 1/1/2019
E0748 Y $447.94 Rental Fee Schedule RR 1/1/2019
E0760 N $3,722.53 General Fee Schedule NU 1/1/2019
E0760 Y $372.26 Rental Fee Schedule RR 1/1/2019
E0766 Y $153.32 General Fee Schedule NU 1/1/2014
E0766 Y $15.33 Rental Fee Schedule RR 1/1/2018
E0770 N $0.00 General by Report NU 1/1/2009
E0770 Y $0.00 Rental by Report RR 1/1/2009
E0776 N $143.96 General Fee Schedule NU 1/1/2019
E0776 Y $14.40 Rental Fee Schedule RR 1/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 35 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
E0779 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0779 Y $17.10 Rental Fee Schedule RR 1/1/2019
E0780 N $11.88 General Fee Schedule NU 1/1/2019
E0780 Y $1.12 Rental Fee Schedule RR 1/28/2013
E0781 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0781 Y $242.39 Rental Fee Schedule RR 1/1/2019
E0782 N $4,943.35 General Fee Schedule NU 1/1/2019
E0782 Y $494.35 Rental Fee Schedule RR 1/1/2019
E0783 N $9,361.70 General Fee Schedule NU 1/1/2019
E0783 Y $936.21 Rental Fee Schedule RR 1/1/2019
E0784 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0784 Y $437.05 Rental Fee Schedule RR 1/1/2019
E0785 N $526.02 General Fee Schedule NU 1/1/2017
E0785 Y $516.71 Rental Fee Schedule RR 2/10/2014
E0786 N $8,862.86 General Fee Schedule NU 1/1/2019
E0786 Y $886.29 Rental Fee Schedule RR 1/1/2019
E0791 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0791 Y $287.96 Rental Fee Schedule RR 1/1/2019
E0830 N $84.15 General Fee Schedule NU 7/1/2004
E0830 Y $11.55 Rental Fee Schedule RR 7/1/2004
E0840 N $78.48 General Fee Schedule NU 1/1/2019
E0840 Y $15.98 Rental Fee Schedule RR 1/1/2019
E0849 N $563.52 General Fee Schedule NU 2/10/2014
E0849 Y $59.34 Rental Fee Schedule RR 1/1/2019
E0850 N $102.81 General Fee Schedule NU 1/1/2019
E0850 Y $14.12 Rental Fee Schedule RR 1/1/2019
E0855 N $549.64 General Fee Schedule NU 2/10/2014
E0855 Y $57.87 Rental Fee Schedule RR 1/1/2019
E0856 N $168.44 General Fee Schedule NU 2/10/2014
E0856 Y $17.72 Rental Fee Schedule RR 1/1/2019
E0860 N $44.37 General Fee Schedule NU 1/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 36 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
E0860 Y $6.38 Rental Fee Schedule RR 1/1/2019
E0870 N $133.92 General Fee Schedule NU 1/1/2019
E0870 Y $15.44 Rental Fee Schedule RR 1/1/2019
E0880 N $122.87 General Fee Schedule NU 1/1/2019
E0880 Y $19.29 Rental Fee Schedule RR 1/1/2019
E0890 N $138.62 General Fee Schedule NU 1/1/2019
E0890 Y $32.13 Rental Fee Schedule RR 1/1/2019
E0900 N $147.53 General Fee Schedule NU 1/1/2019
E0900 Y $27.04 Rental Fee Schedule RR 1/1/2019
E0910 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0910 Y $10.59 Rental Fee Schedule RR 1/1/2017
E0911 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0911 Y $40.37 Rental Fee Schedule RR 1/1/2017
E0912 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0912 Y $79.79 Rental Fee Schedule RR 1/1/2017
E0920 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0920 Y $45.17 Rental Fee Schedule RR 1/1/2019
E0930 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0930 Y $46.28 Rental Fee Schedule RR 1/1/2019
E0935 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0935 Y $22.26 Rental Fee Schedule RR 1/1/2019
E0936 N $0.00 General by Report NU 1/1/2007
E0936 Y $0.00 Rental by Report RR 1/1/2007
E0940 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0940 Y $20.03 Rental Fee Schedule RR 1/1/2017
E0941 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0941 Y $49.97 Rental Fee Schedule RR 1/1/2019
E0942 N $19.41 General Fee Schedule NU 1/1/2019
E0942 Y $2.30 Rental Fee Schedule RR 1/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 37 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
E0944 N $44.89 General Fee Schedule NU 1/1/2019
E0944 Y $4.52 Rental Fee Schedule RR 1/1/2019
E0945 N $43.38 General Fee Schedule NU 1/1/2019
E0945 Y $4.34 Rental Fee Schedule RR 1/1/2019
E0946 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0946 Y $57.90 Rental Fee Schedule RR 1/1/2019
E0947 N $698.27 General Fee Schedule NU 1/1/2019
E0947 Y $72.40 Rental Fee Schedule RR 1/1/2019
E0948 N $630.05 General Fee Schedule NU 1/1/2019
E0948 Y $63.01 Rental Fee Schedule RR 1/1/2019
E0950 N $72.61 General Fee Schedule NU 1/1/2017
E0950 Y $7.26 Rental Fee Schedule RR 1/1/2017
E0951 N $11.80 General Fee Schedule NU 1/1/2017
E0951 Y $1.18 Rental Fee Schedule RR 1/1/2017
E0952 N $16.20 General Fee Schedule NU 1/1/2019
E0953 Y $0.00 General by Report NU 1/1/2018
E0953 Y $7.31 Rental Fee Schedule RR 1/1/2019
E0954 Y $0.00 General by Report NU 1/1/2018
E0954 Y $5.10 Rental Fee Schedule RR 1/1/2019
E0955 N $165.28 General Fee Schedule NU 1/1/2016
E0955 Y $13.67 Rental Fee Schedule RR 1/1/2017
E0956 N $73.12 General Fee Schedule NU 1/1/2017
E0956 Y $7.31 Rental Fee Schedule RR 1/1/2017
E0957 N $117.41 General Fee Schedule NU 1/1/2017
E0957 Y $11.74 Rental Fee Schedule RR 1/1/2017
E0958 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0958 Y $39.66 Rental Fee Schedule RR 1/1/2017
E0959 N $42.33 General Fee Schedule NU 1/1/2017
E0959 Y $4.24 Rental Fee Schedule RR 1/1/2017
E0960 N $69.66 General Fee Schedule NU 1/1/2017
E0960 Y $6.97 Rental Fee Schedule RR 1/1/2017
E0961 N $18.87 General Fee Schedule NU 1/1/2017
HCPCS FEES11/06/2019 at 7:08:01 AM - 38 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
E0966 N $69.08 General Fee Schedule NU 1/1/2017
E0967 N $68.44 General Fee Schedule NU 1/1/2017
E0967 Y $6.84 Rental Fee Schedule RR 1/1/2017
E0968 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0968 Y $20.35 Rental Fee Schedule RR 1/1/2019
E0969 N $180.34 General Fee Schedule NU 1/1/2019
E0969 Y $17.85 Rental Fee Schedule RR 1/1/2019
E0970 N $0.00 Manual Review Fee Schedule
NU 1/1/2004
E0970 Y $0.00 Rental Manual Price-Fee Sched
RR 1/1/2004
E0971 N $27.33 General Fee Schedule NU 1/1/2017
E0971 Y $2.73 Rental Fee Schedule RR 1/1/2017
E0973 N $48.59 General Fee Schedule NU 1/1/2017
E0973 Y $4.86 Rental Fee Schedule RR 1/1/2017
E0974 N $71.91 General Fee Schedule NU 1/1/2017
E0974 Y $7.19 Rental Fee Schedule RR 1/1/2017
E0978 N $21.64 General Fee Schedule NU 1/1/2017
E0978 Y $2.17 Rental Fee Schedule RR 1/1/2017
E0980 N $37.33 General Fee Schedule NU 1/1/2019
E0980 Y $3.74 Rental Fee Schedule RR 1/1/2019
E0981 N $39.77 General Fee Schedule NU 1/1/2019
E0981 Y $4.05 Rental Fee Schedule RR 1/1/2019
E0982 N $43.46 General Fee Schedule NU 1/1/2019
E0982 Y $4.35 Rental Fee Schedule RR 1/1/2019
E0983 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0983 Y $253.69 Rental Fee Schedule RR 1/1/2019
E0984 N $2,089.31 General Fee Schedule NU 2/10/2014
E0984 Y $219.97 Rental Fee Schedule RR 1/1/2019
E0985 N $213.95 General Fee Schedule NU 1/1/2016
E0985 Y $20.44 Rental Fee Schedule RR 1/1/2017
E0986 N $5,319.27 General Fee Schedule NU 2/10/2014
E0986 Y $560.07 Rental Fee Schedule RR 1/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 39 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
E0988 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E0990 N $63.43 General Fee Schedule NU 1/1/2017
E0990 Y $6.34 Rental Fee Schedule RR 1/1/2017
E0992 N $75.15 General Fee Schedule NU 1/1/2017
E0992 Y $7.52 Rental Fee Schedule RR 1/1/2017
E0994 N $20.30 General Fee Schedule NU 1/1/2019
E0994 Y $2.05 Rental Fee Schedule RR 1/1/2019
E0995 N $26.08 General Fee Schedule NU 1/1/2019
E0995 Y $2.61 Rental Fee Schedule RR 1/1/2019
E1002 N $4,432.36 General Fee Schedule NU 2/10/2014
E1002 Y $361.90 Rental Fee Schedule RR 1/1/2019
E1003 N $4,802.09 General Fee Schedule NU 2/10/2014
E1003 Y $423.60 Rental Fee Schedule RR 1/1/2019
E1004 N $5,324.53 General Fee Schedule NU 2/10/2014
E1004 Y $465.59 Rental Fee Schedule RR 1/1/2019
E1005 N $5,763.38 General Fee Schedule NU 2/10/2014
E1005 Y $509.32 Rental Fee Schedule RR 1/1/2019
E1006 N $7,059.60 General Fee Schedule NU 2/10/2014
E1006 Y $627.98 Rental Fee Schedule RR 1/1/2019
E1007 N $9,558.96 General Fee Schedule NU 2/10/2014
E1007 Y $779.50 Rental Fee Schedule RR 1/1/2019
E1008 N $9,559.82 General Fee Schedule NU 2/10/2014
E1008 Y $799.56 Rental Fee Schedule RR 1/1/2019
E1009 N $0.00 General by Report NU 1/1/2005
E1009 Y $0.00 Rental by Report RR 1/1/2005
E1010 N $1,250.78 General Fee Schedule NU 2/10/2014
E1010 Y $108.66 Rental Fee Schedule RR 1/1/2019
E1011 N $0.00 General by Report NU 1/1/2005
E1012 Y $0.00 General by Report NU 1/1/2016
E1012 Y $108.66 Rental Fee Schedule RR 1/1/2019
E1014 N $399.30 General Fee Schedule NU 2/10/2014
E1015 N $112.69 General Fee Schedule NU 1/1/2017
E1016 N $106.76 General Fee Schedule NU 1/1/2017
HCPCS FEES11/06/2019 at 7:08:01 AM - 40 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
E1016 Y $10.68 Rental Fee Schedule RR 1/1/2017
E1017 N $0.00 General by Report NU 1/1/2005
E1017 Y $0.00 Rental by Report RR 1/1/2005
E1018 N $0.00 General by Report NU 1/1/2005
E1020 N $214.61 General Fee Schedule NU 1/1/2016
E1020 Y $17.29 Rental Fee Schedule RR 1/1/2017
E1028 N $164.05 General Fee Schedule NU 1/1/2016
E1028 Y $12.25 Rental Fee Schedule RR 1/1/2017
E1029 N $404.11 General Fee Schedule NU 2/10/2014
E1029 Y $36.61 Rental Fee Schedule RR 1/1/2019
E1030 N $1,274.28 General Fee Schedule NU 2/10/2014
E1030 Y $114.34 Rental Fee Schedule RR 1/1/2019
E1031 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E1031 Y $40.96 Rental Fee Schedule RR 1/1/2017
E1036 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E1036 Y $790.36 Rental Fee Schedule RR 1/1/2017
E1037 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E1037 Y $98.15 Rental Fee Schedule RR 1/1/2017
E1038 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E1038 Y $14.05 Rental Fee Schedule RR 1/1/2017
E1039 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E1039 Y $30.53 Rental Fee Schedule RR 1/1/2017
E1050 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E1050 Y $117.26 Rental Fee Schedule RR 1/1/2019
E1060 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E1060 Y $145.14 Rental Fee Schedule RR 1/1/2019
E1070 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E1070 Y $126.12 Rental Fee Schedule RR 1/1/2019
E1083 N $0.00 Manual Review Fee NU 1/28/2013
HCPCS FEES11/06/2019 at 7:08:01 AM - 41 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
Schedule
E1083 Y $90.66 Rental Fee Schedule RR 1/1/2019
E1084 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E1084 Y $112.95 Rental Fee Schedule RR 1/1/2019
E1085 N $1,705.37 General Fee Schedule NU 7/1/2004
E1085 Y $69.64 Rental Fee Schedule RR 7/1/2004
E1086 N $653.74 General Fee Schedule NU 7/1/2004
E1086 Y $84.57 Rental Fee Schedule RR 7/1/2004
E1087 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E1087 Y $145.69 Rental Fee Schedule RR 1/1/2019
E1088 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E1088 Y $173.60 Rental Fee Schedule RR 1/1/2019
E1089 N $1,439.93 General Fee Schedule NU 7/1/2004
E1089 Y $120.95 Rental Fee Schedule RR 7/1/2004
E1090 N $1,018.10 General Fee Schedule NU 7/1/2004
E1090 Y $137.02 Rental Fee Schedule RR 7/1/2004
E1092 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E1092 Y $147.97 Rental Fee Schedule RR 1/1/2019
E1093 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E1093 Y $127.25 Rental Fee Schedule RR 1/1/2019
E1100 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E1100 Y $119.51 Rental Fee Schedule RR 1/1/2019
E1110 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E1110 Y $117.04 Rental Fee Schedule RR 1/1/2019
E1130 N $386.02 General Fee Schedule NU 7/1/2004
E1130 Y $42.98 Rental Fee Schedule RR 7/1/2004
E1140 N $649.74 General Fee Schedule NU 7/1/2004
E1140 Y $61.84 Rental Fee Schedule RR 7/1/2004
E1150 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
HCPCS FEES11/06/2019 at 7:08:01 AM - 42 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
E1150 Y $85.15 Rental Fee Schedule RR 1/1/2019
E1160 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E1160 Y $66.55 Rental Fee Schedule RR 1/1/2019
E1161 N $2,587.43 General Fee Schedule NU 2/10/2014
E1161 Y $272.42 Rental Fee Schedule RR 1/1/2019
E1170 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E1170 Y $102.84 Rental Fee Schedule RR 1/1/2019
E1171 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E1171 Y $92.28 Rental Fee Schedule RR 1/1/2019
E1172 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E1172 Y $112.80 Rental Fee Schedule RR 1/1/2019
E1180 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E1180 Y $116.67 Rental Fee Schedule RR 1/1/2019
E1190 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E1190 Y $134.80 Rental Fee Schedule RR 1/1/2019
E1195 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E1195 Y $144.64 Rental Fee Schedule RR 1/1/2019
E1200 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E1200 Y $100.18 Rental Fee Schedule RR 1/1/2019
E1220 N $0.00 Manual Review Fee Schedule
NU 1/1/1984
E1220 Y $0.00 Rental Manual Price-Fee Sched
RR 1/1/1984
E1221 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E1221 Y $46.50 Rental Fee Schedule RR 1/1/2019
E1222 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E1222 Y $66.33 Rental Fee Schedule RR 1/1/2019
E1223 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
HCPCS FEES11/06/2019 at 7:08:01 AM - 43 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
E1223 Y $72.44 Rental Fee Schedule RR 1/1/2019
E1224 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E1224 Y $85.13 Rental Fee Schedule RR 1/1/2019
E1225 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E1225 Y $35.03 Rental Fee Schedule RR 1/1/2017
E1226 N $349.98 General Fee Schedule NU 1/1/2017
E1226 Y $35.00 Rental Fee Schedule RR 1/1/2017
E1227 N $319.51 General Fee Schedule NU 1/1/2019
E1227 Y $31.96 Rental Fee Schedule RR 1/1/2019
E1228 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E1228 Y $27.43 Rental Fee Schedule RR 1/1/2019
E1229 N $0.00 General by Report NU 1/1/2005
E1229 Y $0.00 Rental by Report RR 1/1/2005
E1230 N $2,561.35 General Fee Schedule NU 1/1/2019
E1230 Y $256.12 Rental Fee Schedule RR 1/1/2019
E1231 N $0.00 General by Report NU 1/1/2006
E1231 Y $0.00 Rental by Report RR 1/1/2006
E1232 N $2,338.44 General Fee Schedule NU 2/10/2014
E1232 Y $246.23 Rental Fee Schedule RR 1/1/2019
E1233 N $2,423.00 General Fee Schedule NU 2/10/2014
E1233 Y $255.11 Rental Fee Schedule RR 1/1/2019
E1234 N $2,109.40 General Fee Schedule NU 2/10/2014
E1234 Y $222.10 Rental Fee Schedule RR 1/1/2019
E1235 N $2,031.18 General Fee Schedule NU 2/10/2014
E1235 Y $213.88 Rental Fee Schedule RR 1/1/2019
E1236 N $1,792.02 General Fee Schedule NU 2/10/2014
E1236 Y $188.68 Rental Fee Schedule RR 1/1/2019
E1237 N $1,807.68 General Fee Schedule NU 2/10/2014
E1237 Y $190.33 Rental Fee Schedule RR 1/1/2019
E1238 N $1,792.02 General Fee Schedule NU 2/10/2014
E1238 Y $188.68 Rental Fee Schedule RR 1/1/2019
E1239 N $0.00 General by Report NU 1/1/2005
HCPCS FEES11/06/2019 at 7:08:01 AM - 44 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
E1239 Y $0.00 Rental by Report RR 1/1/2005
E1240 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E1240 Y $118.62 Rental Fee Schedule RR 1/1/2019
E1250 N $1,105.73 General Fee Schedule NU 7/1/2004
E1250 Y $74.93 Rental Fee Schedule RR 7/1/2004
E1260 N $668.32 General Fee Schedule NU 7/1/2004
E1260 Y $93.78 Rental Fee Schedule RR 7/1/2004
E1270 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E1270 Y $90.89 Rental Fee Schedule RR 1/1/2019
E1280 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E1280 Y $151.13 Rental Fee Schedule RR 1/1/2019
E1285 N $0.00 Manual Review Fee Schedule
NU 1/1/1984
E1285 Y $114.89 Rental Fee Schedule RR 7/1/2004
E1290 N $884.43 General Fee Schedule NU 7/1/2004
E1290 Y $125.93 Rental Fee Schedule RR 7/1/2004
E1295 N $1,431.79 General Fee Schedule NU 7/1/2004
E1295 Y $139.85 Rental Fee Schedule RR 1/1/2019
E1296 N $566.08 General Fee Schedule NU 1/1/2019
E1296 Y $57.51 Rental Fee Schedule RR 1/1/2019
E1297 N $102.38 General Fee Schedule NU 1/1/2019
E1297 Y $11.37 Rental Fee Schedule RR 1/1/2019
E1298 N $487.80 General Fee Schedule NU 1/1/2019
E1298 Y $49.91 Rental Fee Schedule RR 1/1/2019
E1300 Y $0.00 General by Report NU 1/1/2002
E1300 Y $0.00 Rental by Report RR 1/1/1988
E1352 Y $0.00 General by Report NU 1/1/2014
E1352 Y $0.00 Rental by Report RR 1/1/2014
E1353 Y $0.00 Rental Manual Price-Fee Sched
RR 7/1/2004
E1354 N $0.00 General by Report NU 1/1/2009
E1354 Y $0.00 Rental by Report RR 1/1/2009
HCPCS FEES11/06/2019 at 7:08:01 AM - 45 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
E1356 N $0.00 General by Report NU 1/1/2009
E1356 Y $0.00 Rental by Report RR 1/1/2009
E1357 N $0.00 General by Report NU 1/1/2009
E1357 Y $0.00 Rental by Report RR 1/1/2009
E1358 N $0.00 General by Report NU 1/1/2009
E1358 Y $0.00 Rental by Report RR 1/1/2009
E1372 N $106.68 General Fee Schedule NU 1/1/2019
E1372 Y $10.67 Rental Fee Schedule RR 1/1/2019
E1390 Y $71.73 Rental Fee Schedule RR 1/1/2019
E1391 Y $71.73 Rental Fee Schedule RR 1/1/2019
E1392 Y $34.47 Rental Fee Schedule RR 1/1/2019
E1399 N $0.00 Manual Review Fee Schedule
NU 1/1/1993
E1399 Y $0.00 Rental Manual Price-Fee Sched
RR 1/1/1993
E1405 Y $96.85 Rental Fee Schedule RR 1/1/2019
E1406 Y $77.31 Rental Fee Schedule RR 1/1/2019
E1500 N $0.00 Manual Review Fee Schedule
NU 7/1/1984
E1500 Y $34.48 Rental Fee Schedule RR 7/1/2004
E1510 N $0.00 Manual Review Fee Schedule
NU 7/1/1984
E1510 Y $0.00 Rental Manual Price-Fee Sched
RR 7/1/1984
E1520 N $0.00 Manual Review Fee Schedule
NU 7/1/1984
E1520 Y $0.00 Rental Manual Price-Fee Sched
RR 7/1/1984
E1530 N $0.00 Manual Review Fee Schedule
NU 7/1/1984
E1530 Y $0.00 Rental Manual Price-Fee Sched
RR 7/1/1984
E1540 N $0.00 Manual Review Fee Schedule
NU 7/1/1984
E1540 Y $0.00 Rental Manual Price-Fee Sched
RR 7/1/1984
E1550 N $0.00 Manual Review Fee Schedule
NU 7/1/1984
HCPCS FEES11/06/2019 at 7:08:01 AM - 46 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
E1550 Y $0.00 Rental Manual Price-Fee Sched
RR 7/1/1984
E1560 N $0.00 Manual Review Fee Schedule
NU 7/1/1984
E1560 Y $0.00 Rental Manual Price-Fee Sched
RR 7/1/1984
E1570 N $0.00 Manual Review Fee Schedule
NU 7/1/1984
E1570 Y $0.00 Rental Manual Price-Fee Sched
RR 7/1/1984
E1575 N $0.00 Manual Review Fee Schedule
NU 5/1/1984
E1580 N $0.00 Manual Review Fee Schedule
NU 7/1/1984
E1580 Y $0.00 Rental Manual Price-Fee Sched
RR 7/1/1984
E1590 N $0.00 Manual Review Fee Schedule
NU 10/1/2002
E1590 Y $0.00 Rental Manual Price-Fee Sched
RR 10/1/1975
E1592 N $0.00 Manual Review Fee Schedule
NU 5/1/1984
E1592 Y $0.00 Rental Manual Price-Fee Sched
RR 5/1/1984
E1594 N $0.00 Manual Review Fee Schedule
NU 5/1/1984
E1594 Y $0.00 Rental Manual Price-Fee Sched
RR 5/1/1984
E1600 N $0.00 Manual Review Fee Schedule
NU 7/1/1984
E1600 Y $0.00 Rental Manual Price-Fee Sched
RR 7/1/1984
E1610 N $0.00 Manual Review Fee Schedule
NU 7/1/1984
E1610 Y $0.00 Rental Manual Price-Fee Sched
RR 7/1/1984
E1615 N $0.00 Manual Review Fee Schedule
NU 5/1/1984
E1615 Y $0.00 Rental Manual Price-Fee Sched
RR 5/1/1984
E1620 N $0.00 Manual Review Fee Schedule
NU 7/1/1984
HCPCS FEES11/06/2019 at 7:08:01 AM - 47 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
E1620 Y $0.00 Rental Manual Price-Fee Sched
RR 7/1/1984
E1625 N $0.00 Manual Review Fee Schedule
NU 7/1/1984
E1625 Y $0.00 Rental Manual Price-Fee Sched
RR 7/1/1984
E1630 N $0.00 Manual Review Fee Schedule
NU 7/1/1984
E1630 Y $0.00 Rental Manual Price-Fee Sched
RR 7/1/1984
E1632 N $0.00 Manual Review Fee Schedule
NU 5/1/1984
E1634 N $0.00 General by Report NU 1/1/2004
E1634 Y $0.00 Rental by Report RR 1/1/2004
E1635 N $0.00 Manual Review Fee Schedule
NU 7/1/1984
E1635 Y $0.00 Rental Manual Price-Fee Sched
RR 7/1/1984
E1636 N $0.00 Manual Review Fee Schedule
NU 5/1/1984
E1699 N $0.00 Manual Review Fee Schedule
NU 5/1/1984
E1699 Y $0.00 Rental Manual Price-Fee Sched
RR 5/1/1984
E1700 N $377.09 General Fee Schedule NU 2/10/2014
E1700 Y $39.71 Rental Fee Schedule RR 1/1/2019
E1701 N $12.20 General Fee Schedule NU 1/1/2019
E1702 N $24.64 General Fee Schedule NU 1/1/2019
E1800 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E1800 Y $119.89 Rental Fee Schedule RR 1/1/2019
E1801 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E1801 Y $131.31 Rental Fee Schedule RR 1/1/2019
E1802 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E1802 Y $376.28 Rental Fee Schedule RR 1/1/2019
E1805 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
HCPCS FEES11/06/2019 at 7:08:01 AM - 48 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
E1805 Y $123.66 Rental Fee Schedule RR 1/1/2019
E1806 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E1806 Y $107.78 Rental Fee Schedule RR 1/1/2019
E1810 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E1810 Y $121.93 Rental Fee Schedule RR 1/1/2019
E1811 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E1811 Y $136.53 Rental Fee Schedule RR 1/1/2019
E1812 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E1812 Y $99.01 Rental Fee Schedule RR 1/1/2019
E1815 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E1815 Y $123.66 Rental Fee Schedule RR 1/1/2019
E1816 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E1816 Y $138.67 Rental Fee Schedule RR 1/1/2019
E1818 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E1818 Y $141.56 Rental Fee Schedule RR 1/1/2019
E1820 N $94.12 General Fee Schedule NU 1/1/2019
E1820 Y $9.40 Rental Fee Schedule RR 1/1/2019
E1821 N $121.17 General Fee Schedule NU 1/1/2019
E1821 Y $12.09 Rental Fee Schedule RR 1/1/2019
E1825 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E1825 Y $123.66 Rental Fee Schedule RR 1/1/2019
E1830 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E1830 Y $123.66 Rental Fee Schedule RR 1/1/2019
E1831 Y $76.08 Rental Fee Schedule RR 1/1/2019
E1840 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E1840 Y $382.77 Rental Fee Schedule RR 1/1/2019
E1841 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
HCPCS FEES11/06/2019 at 7:08:01 AM - 49 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
E1841 Y $521.57 Rental Fee Schedule RR 1/1/2019
E1902 N $0.00 General by Report NU 1/1/2004
E1902 Y $0.00 Rental by Report RR 1/1/2004
E2000 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
E2000 Y $52.73 Rental Fee Schedule RR 1/1/2019
E2100 N $740.55 General Fee Schedule NU 1/1/2019
E2100 Y $74.07 Rental Fee Schedule RR 1/1/2019
E2101 N $217.10 General Fee Schedule NU 1/1/2019
E2101 Y $21.71 Rental Fee Schedule RR 1/1/2019
E2201 N $290.55 General Fee Schedule NU 1/1/2017
E2201 Y $29.06 Rental Fee Schedule RR 1/1/2017
E2202 N $414.64 General Fee Schedule NU 1/1/2017
E2202 Y $41.46 Rental Fee Schedule RR 1/1/2017
E2203 N $396.32 General Fee Schedule NU 1/1/2017
E2203 Y $39.63 Rental Fee Schedule RR 1/1/2017
E2204 N $681.12 General Fee Schedule NU 1/1/2017
E2204 Y $68.11 Rental Fee Schedule RR 1/1/2017
E2205 N $32.56 General Fee Schedule NU 1/1/2017
E2205 Y $3.26 Rental Fee Schedule RR 1/1/2017
E2206 N $35.51 General Fee Schedule NU 1/1/2017
E2206 Y $3.55 Rental Fee Schedule RR 1/1/2017
E2207 N $42.83 General Fee Schedule NU 1/1/2017
E2207 Y $4.28 Rental Fee Schedule RR 1/1/2017
E2208 N $71.32 General Fee Schedule NU 1/1/2017
E2208 Y $7.13 Rental Fee Schedule RR 1/1/2017
E2209 N $77.37 General Fee Schedule NU 1/1/2017
E2209 Y $7.74 Rental Fee Schedule RR 1/1/2017
E2210 N $4.98 General Fee Schedule NU 1/1/2017
E2210 Y $0.50 Rental Fee Schedule RR 1/1/2017
E2211 N $31.60 General Fee Schedule NU 1/1/2017
E2211 Y $3.16 Rental Fee Schedule RR 1/1/2017
E2212 N $5.82 General Fee Schedule NU 1/1/2017
E2212 Y $0.58 Rental Fee Schedule RR 1/1/2017
HCPCS FEES11/06/2019 at 7:08:01 AM - 50 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
E2213 N $27.73 General Fee Schedule NU 1/1/2017
E2213 Y $2.77 Rental Fee Schedule RR 1/1/2017
E2214 N $29.89 General Fee Schedule NU 1/1/2017
E2214 Y $2.99 Rental Fee Schedule RR 1/1/2017
E2215 N $9.47 General Fee Schedule NU 1/1/2017
E2215 Y $0.95 Rental Fee Schedule RR 1/1/2017
E2216 Y $41.01 General Fee Schedule NU 4/1/2019
E2216 Y $4.10 Rental Fee Schedule RR 4/1/2019
E2217 Y $36.29 General Fee Schedule NU 4/1/2019
E2217 Y $3.63 Rental Fee Schedule RR 4/1/2019
E2218 Y $41.01 General Fee Schedule NU 4/1/2019
E2218 Y $4.10 Rental Fee Schedule RR 4/1/2019
E2219 N $36.29 General Fee Schedule NU 1/1/2017
E2219 Y $3.63 Rental Fee Schedule RR 1/1/2017
E2220 N $26.34 General Fee Schedule NU 1/1/2017
E2220 Y $2.63 Rental Fee Schedule RR 1/1/2017
E2221 N $24.67 General Fee Schedule NU 1/1/2017
E2221 Y $2.47 Rental Fee Schedule RR 1/1/2017
E2222 N $21.10 General Fee Schedule NU 1/1/2017
E2222 Y $2.11 Rental Fee Schedule RR 1/1/2017
E2224 N $85.53 General Fee Schedule NU 1/1/2017
E2224 Y $8.56 Rental Fee Schedule RR 1/1/2017
E2225 N $17.63 General Fee Schedule NU 1/1/2017
E2225 Y $1.76 Rental Fee Schedule RR 1/1/2017
E2226 N $36.70 General Fee Schedule NU 1/1/2017
E2226 Y $3.67 Rental Fee Schedule RR 1/1/2017
E2227 N $2,045.63 General Fee Schedule NU 2/10/2014
E2227 Y $215.40 Rental Fee Schedule RR 1/1/2019
E2228 N $994.07 General Fee Schedule NU 1/1/2016
E2228 Y $87.89 Rental Fee Schedule RR 1/1/2017
E2230 N $0.00 General by Report NU 1/1/2009
E2230 Y $0.00 Rental by Report RR 1/1/2009
E2231 N $130.64 General Fee Schedule NU 1/1/2017
HCPCS FEES11/06/2019 at 7:08:01 AM - 51 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
E2231 Y $13.07 Rental Fee Schedule RR 1/1/2017
E2291 N $0.00 General by Report NU 1/1/2005
E2291 Y $0.00 Rental by Report RR 1/1/2005
E2292 N $0.00 General by Report NU 1/1/2005
E2292 Y $0.00 Rental by Report RR 1/1/2005
E2293 N $0.00 General by Report NU 1/1/2005
E2293 Y $0.00 Rental by Report RR 1/1/2005
E2294 N $0.00 General by Report NU 1/1/2005
E2294 Y $0.00 Rental by Report RR 1/1/2005
E2295 N $0.00 General by Report NU 1/1/2009
E2295 Y $0.00 Rental by Report RR 1/1/2009
E2300 N $0.00 General by Report NU 1/1/2004
E2300 Y $0.00 Rental by Report RR 1/1/2004
E2301 N $0.00 General by Report NU 1/1/2004
E2301 Y $0.00 Rental by Report RR 1/1/2004
E2310 N $1,279.71 General Fee Schedule NU 2/10/2014
E2310 Y $105.97 Rental Fee Schedule RR 1/1/2019
E2311 N $2,590.82 General Fee Schedule NU 2/10/2014
E2311 Y $213.84 Rental Fee Schedule RR 1/1/2019
E2312 N $2,812.71 General Fee Schedule NU 2/10/2014
E2312 Y $232.19 Rental Fee Schedule RR 1/1/2019
E2313 N $350.21 General Fee Schedule NU 2/10/2014
E2313 Y $36.90 Rental Fee Schedule RR 1/1/2019
E2321 N $2,439.71 General Fee Schedule NU 2/10/2014
E2321 Y $143.99 Rental Fee Schedule RR 1/1/2019
E2322 N $2,583.60 General Fee Schedule NU 2/10/2014
E2322 Y $136.03 Rental Fee Schedule RR 1/1/2019
E2323 N $66.31 General Fee Schedule NU 1/1/2019
E2323 Y $6.63 Rental Fee Schedule RR 1/1/2019
E2324 N $43.48 General Fee Schedule NU 1/1/2019
E2324 Y $4.33 Rental Fee Schedule RR 1/1/2019
E2325 N $1,472.82 General Fee Schedule NU 2/10/2014
E2325 Y $130.02 Rental Fee Schedule RR 1/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 52 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
E2326 N $379.62 General Fee Schedule NU 2/10/2014
E2326 Y $34.10 Rental Fee Schedule RR 1/1/2019
E2327 N $3,740.77 General Fee Schedule NU 2/10/2014
E2327 Y $254.32 Rental Fee Schedule RR 1/1/2019
E2328 N $5,418.87 General Fee Schedule NU 2/10/2014
E2328 Y $480.02 Rental Fee Schedule RR 1/1/2019
E2329 N $1,931.35 General Fee Schedule NU 2/10/2014
E2329 Y $173.35 Rental Fee Schedule RR 1/1/2019
E2330 N $3,742.21 General Fee Schedule NU 2/10/2014
E2330 Y $332.82 Rental Fee Schedule RR 1/1/2019
E2331 N $0.00 General by Report NU 1/1/2004
E2331 Y $0.00 Rental by Report RR 1/1/2004
E2340 N $412.61 General Fee Schedule NU 1/1/2019
E2340 Y $41.28 Rental Fee Schedule RR 1/1/2019
E2341 N $618.96 General Fee Schedule NU 1/1/2019
E2341 Y $61.89 Rental Fee Schedule RR 1/1/2019
E2342 N $515.81 General Fee Schedule NU 1/1/2019
E2342 Y $51.58 Rental Fee Schedule RR 1/1/2019
E2343 N $825.30 General Fee Schedule NU 1/1/2019
E2343 Y $82.52 Rental Fee Schedule RR 1/1/2019
E2351 N $689.45 General Fee Schedule NU 1/1/2019
E2351 Y $68.94 Rental Fee Schedule RR 1/1/2019
E2358 N $0.00 General by Report NU 1/1/2012
E2358 Y $0.00 Rental by Report RR 1/1/2012
E2359 N $157.36 General Fee Schedule NU 1/1/2017
E2359 Y $15.74 Rental Fee Schedule RR 1/1/2017
E2360 N $112.06 General Fee Schedule NU 1/1/2019
E2360 Y $11.21 Rental Fee Schedule RR 1/1/2019
E2361 N $106.00 General Fee Schedule NU 1/1/2017
E2361 Y $10.60 Rental Fee Schedule RR 1/1/2017
E2362 N $101.81 General Fee Schedule NU 1/1/2019
E2362 Y $10.18 Rental Fee Schedule RR 1/1/2019
E2363 N $130.35 General Fee Schedule NU 1/1/2017
HCPCS FEES11/06/2019 at 7:08:01 AM - 53 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
E2363 Y $13.04 Rental Fee Schedule RR 1/1/2017
E2364 N $113.25 General Fee Schedule NU 1/1/2019
E2364 Y $11.33 Rental Fee Schedule RR 1/1/2019
E2365 N $68.23 General Fee Schedule NU 1/1/2017
E2365 Y $6.82 Rental Fee Schedule RR 1/1/2017
E2366 N $140.56 General Fee Schedule NU 1/1/2017
E2366 Y $14.06 Rental Fee Schedule RR 1/1/2017
E2367 N $343.42 General Fee Schedule NU 1/1/2019
E2367 Y $34.34 Rental Fee Schedule RR 1/1/2019
E2368 N $438.53 General Fee Schedule NU 1/1/2016
E2368 Y $38.06 Rental Fee Schedule RR 1/1/2017
E2369 N $381.36 General Fee Schedule NU 1/1/2016
E2369 Y $35.29 Rental Fee Schedule RR 1/1/2017
E2370 N $641.39 General Fee Schedule NU 1/1/2016
E2370 Y $49.57 Rental Fee Schedule RR 1/1/2017
E2371 N $130.64 General Fee Schedule NU 1/1/2017
E2371 Y $13.06 Rental Fee Schedule RR 1/1/2017
E2372 N $0.00 General by Report NU 1/1/2006
E2373 N $1,376.06 General Fee Schedule NU 2/10/2014
E2373 Y $77.20 Rental Fee Schedule RR 1/1/2019
E2374 N $583.97 General Fee Schedule NU 2/10/2014
E2374 Y $48.83 Rental Fee Schedule RR 1/1/2019
E2375 N $747.30 General Fee Schedule NU 1/1/2016
E2375 Y $62.73 Rental Fee Schedule RR 1/1/2017
E2376 N $1,467.82 General Fee Schedule NU 2/10/2014
E2376 Y $121.31 Rental Fee Schedule RR 1/1/2019
E2377 N $531.15 General Fee Schedule NU 2/10/2014
E2377 Y $44.94 Rental Fee Schedule RR 1/1/2019
E2378 Y $559.53 General Fee Schedule NU 2/10/2014
E2378 Y $52.24 Rental Fee Schedule RR 1/1/2017
E2381 N $56.14 General Fee Schedule NU 1/1/2017
E2381 Y $5.62 Rental Fee Schedule RR 1/1/2017
E2382 N $17.80 General Fee Schedule NU 1/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 54 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
E2382 Y $1.78 Rental Fee Schedule RR 1/1/2019
E2383 N $120.33 General Fee Schedule NU 1/1/2017
E2383 Y $12.03 Rental Fee Schedule RR 1/1/2017
E2384 N $56.67 General Fee Schedule NU 1/1/2017
E2384 Y $5.67 Rental Fee Schedule RR 1/1/2017
E2385 N $42.71 General Fee Schedule NU 1/1/2019
E2385 Y $4.27 Rental Fee Schedule RR 1/1/2019
E2386 N $96.64 General Fee Schedule NU 1/1/2017
E2386 Y $9.67 Rental Fee Schedule RR 1/1/2017
E2387 N $45.61 General Fee Schedule NU 1/1/2017
E2387 Y $4.56 Rental Fee Schedule RR 1/1/2017
E2388 N $46.48 General Fee Schedule NU 1/1/2019
E2388 Y $4.65 Rental Fee Schedule RR 1/1/2019
E2389 N $25.98 General Fee Schedule NU 1/1/2019
E2389 Y $2.60 Rental Fee Schedule RR 1/1/2019
E2390 N $40.22 General Fee Schedule NU 1/1/2019
E2390 Y $4.02 Rental Fee Schedule RR 1/1/2019
E2391 N $16.39 General Fee Schedule NU 1/1/2017
E2391 Y $1.64 Rental Fee Schedule RR 1/1/2017
E2392 N $38.47 General Fee Schedule NU 1/1/2017
E2392 Y $3.85 Rental Fee Schedule RR 1/1/2017
E2394 N $54.81 General Fee Schedule NU 1/1/2017
E2394 Y $5.48 Rental Fee Schedule RR 1/1/2017
E2395 N $41.18 General Fee Schedule NU 1/1/2017
E2395 Y $4.12 Rental Fee Schedule RR 1/1/2017
E2396 N $47.74 General Fee Schedule NU 1/1/2017
E2396 Y $4.77 Rental Fee Schedule RR 1/1/2017
E2397 N $415.79 General Fee Schedule NU 1/1/2017
E2397 Y $41.58 Rental Fee Schedule RR 1/1/2017
E2402 Y $623.18 Rental Fee Schedule RR 1/1/2017
E2500 N $450.24 General Fee Schedule NU 1/1/2019
E2500 Y $45.03 Rental Fee Schedule RR 1/1/2019
E2502 N $1,376.80 General Fee Schedule NU 1/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 55 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
E2502 Y $137.69 Rental Fee Schedule RR 1/1/2019
E2504 N $1,816.20 General Fee Schedule NU 1/1/2019
E2504 Y $181.64 Rental Fee Schedule RR 1/1/2019
E2506 N $2,663.09 General Fee Schedule NU 1/1/2019
E2506 Y $266.29 Rental Fee Schedule RR 1/1/2019
E2508 N $4,118.03 General Fee Schedule NU 1/1/2019
E2508 Y $411.80 Rental Fee Schedule RR 1/1/2019
E2510 N $7,792.82 General Fee Schedule NU 1/1/2019
E2510 Y $779.29 Rental Fee Schedule RR 1/1/2019
E2511 N $0.00 General by Report NU 1/1/2005
E2511 Y $0.00 Rental by Report RR 1/1/2005
E2512 N $0.00 General by Report NU 1/1/2005
E2599 N $0.00 Manual Review Fee Schedule
NU 7/1/2004
E2601 N $35.47 General Fee Schedule NU 1/1/2017
E2602 N $76.69 General Fee Schedule NU 1/1/2017
E2602 Y $7.67 Rental Fee Schedule RR 1/1/2017
E2603 N $96.64 General Fee Schedule NU 1/1/2017
E2603 Y $9.67 Rental Fee Schedule RR 1/1/2017
E2604 N $140.86 General Fee Schedule NU 1/1/2017
E2604 Y $14.09 Rental Fee Schedule RR 1/1/2017
E2605 N $198.16 General Fee Schedule NU 1/1/2017
E2605 Y $19.82 Rental Fee Schedule RR 1/1/2017
E2606 N $319.77 General Fee Schedule NU 1/1/2017
E2606 Y $31.98 Rental Fee Schedule RR 1/1/2017
E2607 N $192.35 General Fee Schedule NU 1/1/2017
E2607 Y $19.23 Rental Fee Schedule RR 1/1/2017
E2608 N $245.81 General Fee Schedule NU 1/1/2017
E2608 Y $24.58 Rental Fee Schedule RR 1/1/2017
E2609 N $0.00 General by Report NU 1/1/2005
E2609 Y $0.00 Rental by Report RR 1/1/2005
E2610 N $0.00 General by Report NU 1/1/2005
E2610 Y $0.00 Rental by Report RR 1/1/2005
E2611 N $144.41 General Fee Schedule NU 1/1/2017
HCPCS FEES11/06/2019 at 7:08:01 AM - 56 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
E2611 Y $14.44 Rental Fee Schedule RR 1/1/2017
E2612 N $285.15 General Fee Schedule NU 1/1/2017
E2612 Y $28.52 Rental Fee Schedule RR 1/1/2017
E2613 N $289.76 General Fee Schedule NU 1/1/2017
E2613 Y $28.98 Rental Fee Schedule RR 1/1/2017
E2614 N $427.10 General Fee Schedule NU 1/1/2017
E2614 Y $42.71 Rental Fee Schedule RR 1/1/2017
E2615 N $331.23 General Fee Schedule NU 1/1/2017
E2615 Y $33.12 Rental Fee Schedule RR 1/1/2017
E2616 N $446.02 General Fee Schedule NU 1/1/2017
E2616 Y $44.60 Rental Fee Schedule RR 1/1/2017
E2617 N $0.00 General by Report NU 1/1/2005
E2617 Y $0.00 Rental by Report RR 1/1/2005
E2619 N $47.86 General Fee Schedule NU 1/1/2019
E2619 Y $4.79 Rental Fee Schedule RR 1/1/2019
E2620 N $361.85 General Fee Schedule NU 1/1/2017
E2620 Y $36.19 Rental Fee Schedule RR 1/1/2017
E2621 N $425.84 General Fee Schedule NU 1/1/2017
E2621 Y $42.58 Rental Fee Schedule RR 1/1/2017
E2622 N $303.58 General Fee Schedule NU 1/1/2019
E2622 Y $30.36 Rental Fee Schedule RR 1/1/2019
E2623 N $383.89 General Fee Schedule NU 1/1/2019
E2623 Y $38.39 Rental Fee Schedule RR 1/1/2019
E2624 N $308.48 General Fee Schedule NU 1/1/2019
E2624 Y $30.85 Rental Fee Schedule RR 1/1/2019
E2625 N $381.78 General Fee Schedule NU 1/1/2019
E2625 Y $38.18 Rental Fee Schedule RR 1/1/2019
E2626 N $590.43 General Fee Schedule NU 1/1/2017
E2626 Y $59.04 Rental Fee Schedule RR 1/1/2017
E2627 N $949.64 General Fee Schedule NU 1/1/2017
E2627 Y $94.96 Rental Fee Schedule RR 1/1/2017
E2628 N $705.54 General Fee Schedule NU 1/1/2017
E2628 Y $70.55 Rental Fee Schedule RR 1/1/2017
HCPCS FEES11/06/2019 at 7:08:01 AM - 57 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
E2629 N $917.94 General Fee Schedule NU 1/1/2017
E2629 Y $91.79 Rental Fee Schedule RR 1/1/2017
E2630 N $636.29 General Fee Schedule NU 1/1/2017
E2630 Y $63.63 Rental Fee Schedule RR 1/1/2017
E2631 N $256.68 General Fee Schedule NU 1/1/2019
E2631 Y $25.67 Rental Fee Schedule RR 1/1/2019
E2632 N $162.24 General Fee Schedule NU 1/1/2019
E2632 Y $16.23 Rental Fee Schedule RR 1/1/2019
E2633 N $135.07 General Fee Schedule NU 1/1/2017
E2633 Y $13.51 Rental Fee Schedule RR 1/1/2017
E8000 N $0.00 General by Report NU 1/1/2005
E8000 Y $0.00 Rental by Report RR 1/1/2005
E8001 N $0.00 General by Report NU 1/1/2005
E8001 Y $0.00 Rental by Report RR 1/1/2005
E8002 N $0.00 General by Report NU 1/1/2005
E8002 Y $0.00 Rental by Report RR 1/1/2005
G0103 Y $19.21 General Fee Schedule 1/1/2019
G0104 Y $106.65 General Fee Schedule 12/1/2009
G0105 Y $329.06 General Fee Schedule 12/1/2009
G0106 Y $45.98 26 Fee Schedule (FS) 8/1/2016
G0106 Y $187.65 General Fee Schedule 1/1/2017
G0106 Y $140.91 TC Fee Schedule 1/1/2017
G0108 Y $22.73 General Fee Schedule 1/1/2011
G0109 Y $12.11 General Fee Schedule 8/1/2016
G0120 Y $45.98 26 Fee Schedule (FS) 8/1/2016
G0120 Y $129.02 General Fee Schedule 1/1/2011
G0120 Y $81.12 TC Fee Schedule 1/1/2011
G0121 Y $329.06 General Fee Schedule 12/1/2009
G0122 Y $30.61 26 Fee Schedule (FS) 12/1/2009
G0122 Y $77.01 General Fee Schedule 12/1/2009
G0123 Y $21.16 General Fee Schedule 1/1/2019
G0124 Y $30.04 General Fee Schedule 8/1/2016
G0129 Y $28.29 General Fee Schedule 1/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 58 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
G0130 Y $10.29 26 Fee Schedule (FS) 8/1/2016
G0130 Y $29.02 General Fee Schedule 8/1/2016
G0130 Y $18.73 TC Fee Schedule 8/1/2016
G0141 Y $30.04 General Fee Schedule 8/1/2016
G0143 Y $25.43 General Fee Schedule 1/1/2018
G0144 Y $41.33 General Fee Schedule 1/1/2018
G0147 Y $14.09 General Fee Schedule 1/1/2019
G0148 Y $30.02 General Fee Schedule 1/1/2018
G0151 Y $0.00 General Fee Schedule 1/1/2004
G0152 Y $0.00 General Fee Schedule 1/1/2004
G0153 Y $0.00 General Fee Schedule 1/1/2004
G0155 Y $0.00 General Fee Schedule 1/1/2004
G0157 Y $0.00 General Fee Schedule 1/1/2011
G0158 Y $0.00 General Fee Schedule 1/1/2011
G0159 Y $0.00 General Fee Schedule 1/1/2011
G0160 Y $0.00 General Fee Schedule 1/1/2011
G0161 Y $0.00 General Fee Schedule 1/1/2011
G0175 Y $0.00 General Fee Schedule 1/1/2019
G0179 Y $37.37 General Fee Schedule 1/1/2017
G0180 Y $48.97 General Fee Schedule 1/1/2017
G0186 Y $37.15 General Fee Schedule 12/1/2009
G0219 Y $70.40 26 Fee Schedule (FS) 12/1/2009
G0219 Y $1,880.41 General Fee Schedule 12/1/2009
G0219 Y $1,811.95 TC Fee Schedule 12/1/2009
G0237 Y $8.75 General Fee Schedule 1/1/2017
G0252 Y $0.00 Manual Review Fee Schedule
7/1/2009
G0259 Y $48.12 General Fee Schedule 12/1/2009
G0260 Y $48.12 General Fee Schedule 12/1/2009
G0270 Y $25.63 General Fee Schedule 8/1/2007
G0276 Y $389.90 General Fee Schedule 8/1/2016
G0277 Y $39.08 General Fee Schedule 1/1/2017
G0279 Y $28.19 26 Fee Schedule (FS) 1/1/2017
G0279 Y $50.17 General Fee Schedule 1/1/2017
HCPCS FEES11/06/2019 at 7:08:01 AM - 59 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
G0279 Y $21.98 TC Fee Schedule 1/1/2017
G0297 Y $24.87 26 Fee Schedule (FS) 8/1/2016
G0297 Y $176.93 General Fee Schedule 8/1/2016
G0297 Y $152.05 TC Fee Schedule 8/1/2016
G0306 Y $8.11 General Fee Schedule 1/1/2019
G0307 Y $6.75 General Fee Schedule 1/1/2019
G0328 Y $16.97 General Fee Schedule 1/1/2019
G0341 Y $436.88 General Fee Schedule 12/1/2009
G0342 Y $626.39 General Fee Schedule 12/1/2009
G0343 Y $1,029.58 General Fee Schedule 12/1/2009
G0398 Y $103.32 26 Fee Schedule (FS) 2/6/2012
G0398 Y $51.66 TC Fee Schedule 2/6/2012
G0399 Y $87.83 26 Fee Schedule (FS) 2/6/2012
G0399 Y $36.17 TC Fee Schedule 2/6/2012
G0400 Y $72.33 26 Fee Schedule (FS) 2/6/2012
G0400 Y $31.00 TC Fee Schedule 2/6/2012
G0406 Y $48.43 General Fee Schedule 12/1/2009
G0407 Y $88.85 General Fee Schedule 12/1/2009
G0408 Y $118.48 General Fee Schedule 12/1/2009
G0409 Y $9.07 General Fee Schedule 2/6/2012
G0420 Y $80.91 General Fee Schedule 1/1/2011
G0421 Y $19.18 General Fee Schedule 1/1/2011
G0432 Y $18.40 General Fee Schedule 1/1/2018
G0433 Y $17.19 General Fee Schedule 1/1/2018
G0435 Y $12.52 General Fee Schedule 1/1/2019
G0438 Y $151.03 General Fee Schedule 8/1/2016
G0439 Y $100.31 General Fee Schedule 8/1/2016
G0442 Y $16.36 General Fee Schedule 1/1/2017
G0443 Y $23.58 General Fee Schedule 10/1/2019
G0445 Y $45.58 General Fee Schedule 11/8/2011
G0446 Y $22.79 General Fee Schedule 11/8/2011
G0447 Y $22.79 General Fee Schedule 11/29/2011
G0448 Y $0.00 General by Report 1/1/2012
HCPCS FEES11/06/2019 at 7:08:01 AM - 60 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
G0451 Y $12.05 General Fee Schedule 1/1/2012
G0452 Y $18.28 General Fee Schedule 1/1/2013
G0453 Y $30.59 General Fee Schedule 8/1/2016
G0460 Y $198.23 General Fee Schedule 1/1/2019
G0472 Y $43.57 General Fee Schedule 1/1/2018
G0475 Y $25.15 General Fee Schedule 1/1/2019
G0476 Y $36.65 General Fee Schedule 1/1/2019
G0480 Y $107.56 General Fee Schedule 1/1/2018
G0481 Y $147.19 General Fee Schedule 1/1/2018
G0482 Y $186.82 General Fee Schedule 1/1/2018
G0483 Y $232.10 General Fee Schedule 1/1/2018
G0498 Y $279.45 General Fee Schedule NU 1/1/2017
G0506 Y $57.90 General Fee Schedule 7/1/2019
G0659 Y $60.77 General Fee Schedule NU 1/1/2019
G2010 Y $11.52 General Fee Schedule 1/1/2019
G2011 Y $15.76 General Fee Schedule 1/1/2019
G6001 Y $27.99 26 Fee Schedule (FS) 8/1/2016
G6001 Y $47.29 General Fee Schedule 8/1/2016
G6001 Y $19.35 TC Fee Schedule 8/1/2016
G6002 Y $18.85 26 Fee Schedule (FS) 8/1/2016
G6002 Y $67.57 General Fee Schedule 8/1/2016
G6002 Y $48.41 TC Fee Schedule 8/1/2016
G6003 Y $148.61 General Fee Schedule 1/1/2015
G6004 Y $115.09 General Fee Schedule 1/1/2015
G6005 Y $123.42 General Fee Schedule 8/1/2016
G6006 Y $122.79 General Fee Schedule 8/1/2016
G6007 Y $236.34 General Fee Schedule 1/1/2015
G6008 Y $159.12 General Fee Schedule 1/1/2015
G6009 Y $169.16 General Fee Schedule 8/1/2016
G6010 Y $169.16 General Fee Schedule 8/1/2016
G6011 Y $252.77 General Fee Schedule 1/1/2015
G6012 Y $209.40 General Fee Schedule 1/1/2015
G6013 Y $226.25 General Fee Schedule 8/1/2016
HCPCS FEES11/06/2019 at 7:08:01 AM - 61 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
G6014 Y $226.25 General Fee Schedule 8/1/2016
G6015 Y $300.55 General Fee Schedule 1/1/2017
G6016 Y $299.37 General Fee Schedule 1/1/2017
G6017 Y $53.55 General Fee Schedule 1/1/2019
G9001 Y $0.00 General Fee Schedule 7/1/2006
G9002 Y $0.00 General Fee Schedule 1/1/2004
G9006 Y $0.00 General Fee Schedule 1/1/2004
G9012 Y $0.00 General Fee Schedule 1/1/2004
G9129 Y $0.00 General by Report 4/1/2010
H0008 Y $0.00 General Fee Schedule 1/1/2019
H0009 Y $0.00 General Fee Schedule 1/1/2019
H0010 Y $0.00 General Fee Schedule 1/1/2019
H0011 Y $0.00 General Fee Schedule 1/1/2019
H0014 Y $0.00 General Fee Schedule 1/1/2019
H2025 Y $0.00 General Fee Schedule 1/1/2004
J0120 Y $15.76 General Fee Schedule 7/1/2004
J0129 Y $54.32 General Fee Schedule 10/1/2019
J0130 Y $1,429.07 General Fee Schedule 1/1/2019
J0131 Y $0.00 General by Report 1/1/2012
J0132 Y $1.04 General Fee Schedule 10/1/2019
J0133 Y $0.04 General Fee Schedule 7/1/2019
J0135 Y $909.22 General Fee Schedule 1/1/2017
J0153 Y $0.70 General Fee Schedule 10/1/2019
J0171 Y $0.83 General Fee Schedule 10/1/2019
J0178 Y $952.47 General Fee Schedule 10/1/2019
J0180 Y $183.43 General Fee Schedule 10/1/2019
J0185 Y $2.17 General Fee Schedule 10/1/2019
J0190 Y $3.94 General Fee Schedule 7/1/2004
J0200 Y $17.03 General Fee Schedule 5/1/2004
J0202 Y $1,917.04 General Fee Schedule 10/1/2019
J0205 Y $42.03 General Fee Schedule 1/1/2013
J0207 Y $1,003.59 General Fee Schedule 10/1/2019
J0210 Y $42.40 General Fee Schedule 1/1/2012
HCPCS FEES11/06/2019 at 7:08:01 AM - 62 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
J0215 Y $41.64 General Fee Schedule 7/1/2012
J0220 Y $206.70 General Fee Schedule 1/1/2016
J0221 Y $171.05 General Fee Schedule 10/1/2019
J0256 Y $4.55 General Fee Schedule 10/1/2019
J0257 Y $4.82 General Fee Schedule 10/1/2019
J0270 Y $0.67 General Fee Schedule 4/1/2012
J0275 Y $25.72 General Fee Schedule 1/1/2011
J0278 Y $1.11 General Fee Schedule 10/1/2019
J0280 Y $10.88 General Fee Schedule 10/1/2019
J0282 Y $0.23 General Fee Schedule 7/1/2011
J0285 Y $40.28 General Fee Schedule 7/1/2019
J0287 Y $6.18 General Fee Schedule 10/1/2019
J0288 Y $14.00 General Fee Schedule 4/1/2012
J0289 Y $26.09 General Fee Schedule 10/1/2019
J0290 Y $1.00 General Fee Schedule 10/1/2019
J0295 Y $2.06 General Fee Schedule 10/1/2019
J0300 Y $6.33 General Fee Schedule 4/1/2009
J0330 Y $0.15 General Fee Schedule 1/1/2011
J0348 Y $0.55 General Fee Schedule 7/1/2019
J0350 Y $2,265.46 General Fee Schedule 7/1/2006
J0360 Y $4.21 General Fee Schedule 10/1/2019
J0364 Y $32.69 General Fee Schedule 4/1/2014
J0365 Y $2.65 General Fee Schedule 10/1/2008
J0380 Y $1.14 General Fee Schedule 5/1/2004
J0390 Y $12.80 General Fee Schedule 7/1/2004
J0395 Y $163.20 General Fee Schedule 5/1/2004
J0400 Y $0.76 General Fee Schedule 1/1/2016
J0401 Y $5.70 General Fee Schedule 10/1/2019
J0456 Y $3.05 General Fee Schedule 10/1/2019
J0461 Y $0.07 General Fee Schedule 7/1/2018
J0470 Y $55.29 General Fee Schedule 10/1/2019
J0475 Y $169.51 General Fee Schedule 10/1/2019
J0476 Y $50.05 General Fee Schedule 10/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 63 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
J0480 Y $3,799.93 General Fee Schedule 10/1/2019
J0485 Y $3.78 General Fee Schedule 4/1/2019
J0490 Y $44.82 General Fee Schedule 7/1/2019
J0500 Y $57.58 General Fee Schedule 10/1/2019
J0515 Y $17.74 General Fee Schedule 10/1/2019
J0517 Y $168.50 General Fee Schedule 10/1/2019
J0520 Y $4.78 General Fee Schedule 5/1/2004
J0558 Y $10.89 General Fee Schedule 10/1/2019
J0561 Y $13.82 General Fee Schedule 10/1/2019
J0565 Y $39.83 General Fee Schedule 10/1/2019
J0567 Y $24.73 General Fee Schedule 1/1/2019
J0570 Y $1,303.53 General Fee Schedule 10/1/2019
J0571 Y $2.84 General Fee Schedule 1/1/2015
J0572 Y $3.93 General Fee Schedule 1/1/2015
J0573 Y $7.04 General Fee Schedule 1/1/2015
J0574 Y $7.04 General Fee Schedule 1/1/2015
J0575 Y $14.08 General Fee Schedule 1/1/2015
J0583 Y $0.62 General Fee Schedule 10/1/2019
J0584 Y $353.21 General Fee Schedule 10/1/2019
J0585 Y $6.12 General Fee Schedule 4/1/2019
J0586 Y $8.43 General Fee Schedule 10/1/2019
J0587 Y $11.99 General Fee Schedule 10/1/2019
J0588 Y $5.05 General Fee Schedule 7/1/2019
J0592 Y $4.56 General Fee Schedule 10/1/2019
J0594 Y $4.58 General Fee Schedule 10/1/2019
J0595 Y $2.71 General Fee Schedule 10/1/2019
J0596 Y $28.22 General Fee Schedule 10/1/2019
J0597 Y $51.31 General Fee Schedule 10/1/2019
J0598 Y $57.03 General Fee Schedule 10/1/2019
J0599 Y $9.96 General Fee Schedule 1/1/2019
J0600 Y $5,594.42 General Fee Schedule 4/1/2018
J0604 Y $0.90 General Fee Schedule 1/1/2018
J0606 Y $0.00 General by Report 1/1/2018
HCPCS FEES11/06/2019 at 7:08:01 AM - 64 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
J0610 Y $2.70 General Fee Schedule 10/1/2019
J0620 Y $3.94 General Fee Schedule 7/1/2004
J0630 Y $2,661.05 General Fee Schedule 10/1/2019
J0636 Y $0.61 General Fee Schedule 10/1/2019
J0637 Y $6.85 General Fee Schedule 10/1/2019
J0638 Y $111.01 General Fee Schedule 7/1/2019
J0640 Y $3.02 General Fee Schedule 7/1/2019
J0641 Y $0.40 General Fee Schedule 10/1/2019
J0670 Y $2.45 General Fee Schedule 10/1/2019
J0690 Y $0.77 General Fee Schedule 10/1/2019
J0692 Y $1.91 General Fee Schedule 10/1/2019
J0694 Y $5.23 General Fee Schedule 10/1/2019
J0695 Y $5.60 General Fee Schedule 10/1/2019
J0696 Y $0.54 General Fee Schedule 10/1/2019
J0697 Y $2.03 General Fee Schedule 10/1/2019
J0698 Y $2.33 General Fee Schedule 7/1/2019
J0702 Y $6.96 General Fee Schedule 10/1/2019
J0706 Y $0.55 General Fee Schedule 4/1/2014
J0710 Y $6.90 General Fee Schedule 7/1/2004
J0712 Y $3.19 General Fee Schedule 10/1/2019
J0713 Y $2.00 General Fee Schedule 7/1/2019
J0714 Y $92.05 General Fee Schedule 10/1/2019
J0715 Y $5.24 General Fee Schedule 4/1/2008
J0716 Y $0.00 General by Report 1/1/2013
J0717 Y $8.02 General Fee Schedule 10/1/2019
J0720 Y $38.54 General Fee Schedule 10/1/2019
J0725 Y $22.62 General Fee Schedule 10/1/2019
J0735 Y $13.71 General Fee Schedule 10/1/2019
J0740 Y $623.27 General Fee Schedule 10/1/2019
J0743 Y $6.14 General Fee Schedule 10/1/2019
J0744 Y $1.24 General Fee Schedule 10/1/2019
J0745 Y $1.35 General Fee Schedule 1/1/2011
J0770 Y $19.20 General Fee Schedule 10/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 65 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
J0775 Y $48.76 General Fee Schedule 10/1/2019
J0780 Y $9.69 General Fee Schedule 10/1/2019
J0795 Y $9.04 General Fee Schedule 10/1/2019
J0800 Y $3,946.50 General Fee Schedule 10/1/2019
J0834 Y $39.82 General Fee Schedule 10/1/2019
J0840 Y $3,285.19 General Fee Schedule 10/1/2019
J0841 Y $1,264.42 General Fee Schedule 10/1/2019
J0850 Y $1,129.15 General Fee Schedule 10/1/2018
J0875 Y $14.95 General Fee Schedule 10/1/2019
J0878 Y $0.33 General Fee Schedule 10/1/2019
J0881 Y $3.85 General Fee Schedule 10/1/2019
J0882 Y $3.85 General Fee Schedule 10/1/2019
J0883 Y $5.25 General Fee Schedule 1/1/2017
J0884 Y $5.25 General Fee Schedule 1/1/2017
J0885 Y $11.03 General Fee Schedule 10/1/2019
J0887 Y $1.80 General Fee Schedule 10/1/2019
J0888 Y $1.80 General Fee Schedule 10/1/2019
J0890 Y $8.20 General Fee Schedule 7/1/2013
J0894 Y $7.49 General Fee Schedule 10/1/2019
J0895 Y $8.52 General Fee Schedule 10/1/2019
J0897 Y $19.28 General Fee Schedule 10/1/2019
J0945 Y $0.80 General Fee Schedule 1/1/2007
J1000 Y $21.89 General Fee Schedule 10/1/2019
J1020 Y $3.70 General Fee Schedule 10/1/2019
J1030 Y $6.25 General Fee Schedule 10/1/2019
J1040 Y $11.93 General Fee Schedule 10/1/2019
J1050 Y $0.64 General Fee Schedule 1/1/2017
J1071 Y $0.02 General Fee Schedule 10/1/2019
J1094 Y $0.23 General Fee Schedule 1/1/2007
J1095 Y $2.21 General Fee Schedule 1/1/2019
J1100 Y $0.14 General Fee Schedule 10/1/2019
J1110 Y $57.66 General Fee Schedule 10/1/2019
J1120 Y $17.19 General Fee Schedule 10/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 66 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
J1130 Y $0.00 General by Report 1/1/2017
J1160 Y $5.42 General Fee Schedule 10/1/2019
J1162 Y $3,780.19 General Fee Schedule 10/1/2019
J1165 Y $0.85 General Fee Schedule 10/1/2019
J1170 Y $2.68 General Fee Schedule 10/1/2019
J1180 Y $8.04 General Fee Schedule 7/1/2006
J1190 Y $194.34 General Fee Schedule 10/1/2019
J1200 Y $0.91 General Fee Schedule 10/1/2019
J1205 Y $49.65 General Fee Schedule 10/1/2019
J1212 Y $586.51 General Fee Schedule 10/1/2019
J1230 Y $16.54 General Fee Schedule 10/1/2019
J1240 Y $6.73 General Fee Schedule 10/1/2019
J1245 Y $0.08 General Fee Schedule 10/1/2019
J1250 Y $6.99 General Fee Schedule 10/1/2019
J1260 Y $6.17 General Fee Schedule 10/1/2016
J1265 Y $0.76 General Fee Schedule 7/1/2019
J1267 Y $0.88 General Fee Schedule 7/1/2018
J1270 Y $0.32 General Fee Schedule 10/1/2019
J1290 Y $493.74 General Fee Schedule 10/1/2019
J1300 Y $230.48 General Fee Schedule 4/1/2018
J1301 Y $19.49 General Fee Schedule 10/1/2019
J1320 Y $2.23 General Fee Schedule 7/1/2006
J1322 Y $241.45 General Fee Schedule 10/1/2019
J1324 Y $0.00 General by Report 1/1/2007
J1325 Y $16.19 General Fee Schedule 10/1/2019
J1327 Y $27.58 General Fee Schedule 4/1/2014
J1330 Y $3.94 General Fee Schedule 7/1/2004
J1335 Y $43.47 General Fee Schedule 10/1/2019
J1364 Y $75.76 General Fee Schedule 10/1/2019
J1380 Y $10.75 General Fee Schedule 10/1/2019
J1410 Y $308.93 General Fee Schedule 10/1/2019
J1428 Y $160.00 General Fee Schedule 1/1/2018
J1430 Y $444.10 General Fee Schedule 1/1/2018
HCPCS FEES11/06/2019 at 7:08:01 AM - 67 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
J1435 Y $0.24 General Fee Schedule 4/1/2007
J1436 Y $71.41 General Fee Schedule 1/1/2007
J1438 Y $411.71 General Fee Schedule 7/1/2016
J1439 Y $1.10 General Fee Schedule 10/1/2019
J1442 Y $0.96 General Fee Schedule 10/1/2019
J1443 Y $0.02 General Fee Schedule 1/1/2016
J1444 Y $0.00 General by Report 7/1/2019
J1447 Y $0.57 General Fee Schedule 10/1/2019
J1450 Y $4.71 General Fee Schedule 10/1/2019
J1451 Y $6.70 General Fee Schedule 4/1/2014
J1452 Y $212.00 General Fee Schedule 7/1/2006
J1453 Y $1.97 General Fee Schedule 10/1/2019
J1454 Y $416.87 General Fee Schedule 10/1/2019
J1455 Y $3.50 General Fee Schedule 10/1/2012
J1457 Y $2.08 General Fee Schedule 4/1/2012
J1458 Y $397.92 General Fee Schedule 10/1/2019
J1459 Y $40.12 General Fee Schedule 10/1/2019
J1460 Y $39.91 General Fee Schedule 10/1/2019
J1555 Y $13.79 General Fee Schedule 10/1/2019
J1556 Y $70.52 General Fee Schedule 1/1/2018
J1557 Y $45.82 General Fee Schedule 10/1/2019
J1559 Y $10.44 General Fee Schedule 10/1/2019
J1560 Y $399.09 General Fee Schedule 10/1/2019
J1561 Y $39.14 General Fee Schedule 10/1/2019
J1562 Y $7.25 General Fee Schedule 1/1/2011
J1566 Y $61.20 General Fee Schedule 10/1/2019
J1568 Y $35.68 General Fee Schedule 10/1/2019
J1569 Y $37.47 General Fee Schedule 10/1/2019
J1570 Y $48.41 General Fee Schedule 10/1/2019
J1571 Y $60.06 General Fee Schedule 10/1/2019
J1572 Y $35.59 General Fee Schedule 10/1/2019
J1573 Y $51.29 General Fee Schedule 1/1/2014
J1575 Y $14.56 General Fee Schedule 10/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 68 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
J1580 Y $1.91 General Fee Schedule 10/1/2019
J1595 Y $67.64 General Fee Schedule 1/1/2009
J1599 Y $0.00 General by Report 1/1/2011
J1600 Y $30.15 General Fee Schedule 7/1/2013
J1602 Y $21.36 General Fee Schedule 10/1/2019
J1610 Y $199.27 General Fee Schedule 10/1/2019
J1620 Y $180.30 General Fee Schedule 1/1/2007
J1626 Y $0.40 General Fee Schedule 10/1/2019
J1627 Y $2.74 General Fee Schedule 10/1/2019
J1628 Y $1.68 General Fee Schedule 1/1/2019
J1630 Y $0.97 General Fee Schedule 10/1/2019
J1631 Y $16.48 General Fee Schedule 10/1/2019
J1640 Y $23.72 General Fee Schedule 10/1/2019
J1642 Y $0.25 General Fee Schedule 10/1/2019
J1644 Y $0.21 General Fee Schedule 10/1/2019
J1645 Y $12.58 General Fee Schedule 10/1/2019
J1650 Y $0.83 General Fee Schedule 10/1/2019
J1652 Y $1.73 General Fee Schedule 10/1/2019
J1655 Y $3.49 General Fee Schedule 7/1/2011
J1670 Y $432.66 General Fee Schedule 10/1/2019
J1675 Y $358.54 General Fee Schedule 1/1/2006
J1700 Y $0.30 General Fee Schedule 5/1/2004
J1710 Y $4.98 General Fee Schedule 5/1/2004
J1720 Y $12.90 General Fee Schedule 10/1/2019
J1726 Y $30.57 General Fee Schedule 1/1/2018
J1729 Y $0.00 General by Report 1/1/2018
J1730 Y $111.85 General Fee Schedule 1/1/2007
J1740 Y $43.48 General Fee Schedule 10/1/2019
J1741 Y $1.84 General Fee Schedule 1/1/2013
J1742 Y $278.77 General Fee Schedule 10/1/2019
J1743 Y $542.89 General Fee Schedule 7/1/2019
J1744 Y $0.00 General by Report 1/1/2013
J1745 Y $63.39 General Fee Schedule 10/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 69 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
J1746 Y $60.16 General Fee Schedule 10/1/2019
J1750 Y $14.41 General Fee Schedule 7/1/2019
J1756 Y $0.23 General Fee Schedule 4/1/2019
J1786 Y $42.94 General Fee Schedule 10/1/2019
J1790 Y $2.14 General Fee Schedule 10/1/2013
J1800 Y $8.48 General Fee Schedule 10/1/2019
J1810 Y $5.94 General Fee Schedule 7/1/2006
J1815 Y $0.88 General Fee Schedule 10/1/2019
J1817 Y $10.78 General Fee Schedule 10/1/2019
J1826 Y $0.00 General by Report 1/1/2011
J1830 Y $119.30 General Fee Schedule 1/1/2009
J1833 Y $0.64 General Fee Schedule 1/1/2016
J1835 Y $42.28 General Fee Schedule 1/1/2009
J1840 Y $7.69 General Fee Schedule 1/1/2010
J1850 Y $1.15 General Fee Schedule 1/1/2010
J1885 Y $0.50 General Fee Schedule 10/1/2019
J1890 Y $5.91 General Fee Schedule 7/1/2004
J1930 Y $62.32 General Fee Schedule 10/1/2019
J1931 Y $32.14 General Fee Schedule 10/1/2019
J1940 Y $0.69 General Fee Schedule 10/1/2019
J1942 Y $2.66 General Fee Schedule 7/1/2019
J1945 Y $570.54 General Fee Schedule 1/1/2013
J1950 Y $1,269.23 General Fee Schedule 10/1/2019
J1953 Y $0.11 General Fee Schedule 7/1/2019
J1955 Y $19.40 General Fee Schedule 10/1/2019
J1956 Y $0.22 General Fee Schedule 10/1/2019
J1960 Y $3.37 General Fee Schedule 5/1/2004
J1980 Y $29.47 General Fee Schedule 10/1/2019
J1990 Y $21.05 General Fee Schedule 1/1/2007
J2001 Y $0.03 General Fee Schedule 10/1/2019
J2010 Y $11.18 General Fee Schedule 10/1/2019
J2020 Y $6.30 General Fee Schedule 10/1/2019
J2060 Y $0.66 General Fee Schedule 10/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 70 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
J2062 Y $159.00 General Fee Schedule 1/1/2019
J2150 Y $2.62 General Fee Schedule 10/1/2019
J2170 Y $0.00 General by Report 1/1/2007
J2175 Y $6.07 General Fee Schedule 10/1/2019
J2180 Y $3.79 General Fee Schedule 1/1/2007
J2182 Y $29.72 General Fee Schedule 10/1/2019
J2185 Y $0.90 General Fee Schedule 10/1/2019
J2186 Y $174.90 General Fee Schedule 1/1/2019
J2210 Y $17.39 General Fee Schedule 10/1/2019
J2212 Y $0.00 General by Report 1/1/2013
J2248 Y $1.04 General Fee Schedule 7/1/2019
J2250 Y $0.12 General Fee Schedule 10/1/2019
J2260 Y $1.78 General Fee Schedule 10/1/2019
J2265 Y $0.00 General by Report 1/1/2012
J2270 Y $4.40 General Fee Schedule 10/1/2019
J2274 Y $14.99 General Fee Schedule 10/1/2019
J2278 Y $7.91 General Fee Schedule 7/1/2019
J2280 Y $8.79 General Fee Schedule 10/1/2019
J2300 Y $3.17 General Fee Schedule 10/1/2019
J2310 Y $15.28 General Fee Schedule 10/1/2019
J2315 Y $3.25 General Fee Schedule 10/1/2019
J2320 Y $3.75 General Fee Schedule 10/1/2008
J2323 Y $20.24 General Fee Schedule 10/1/2019
J2325 Y $60.25 General Fee Schedule 4/1/2014
J2326 Y $1,041.57 General Fee Schedule 1/1/2018
J2350 Y $57.42 General Fee Schedule 7/1/2019
J2353 Y $206.57 General Fee Schedule 10/1/2019
J2354 Y $0.78 General Fee Schedule 10/1/2019
J2355 Y $426.92 General Fee Schedule 7/1/2018
J2357 Y $36.78 General Fee Schedule 10/1/2019
J2358 Y $2.92 General Fee Schedule 4/1/2015
J2360 Y $6.44 General Fee Schedule 10/1/2019
J2370 Y $3.34 General Fee Schedule 1/1/2015
HCPCS FEES11/06/2019 at 7:08:01 AM - 71 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
J2400 Y $23.32 General Fee Schedule 10/1/2019
J2405 Y $0.11 General Fee Schedule 10/1/2019
J2407 Y $23.78 General Fee Schedule 10/1/2019
J2410 Y $2.85 General Fee Schedule 10/1/2017
J2425 Y $21.28 General Fee Schedule 10/1/2019
J2426 Y $11.63 General Fee Schedule 10/1/2019
J2430 Y $12.06 General Fee Schedule 10/1/2019
J2440 Y $1.28 General Fee Schedule 1/1/2013
J2460 Y $0.94 General Fee Schedule 1/1/2007
J2469 Y $7.93 General Fee Schedule 10/1/2019
J2501 Y $0.79 General Fee Schedule 10/1/2019
J2502 Y $38.46 General Fee Schedule 1/1/2016
J2503 Y $722.05 General Fee Schedule 10/1/2019
J2504 Y $367.96 General Fee Schedule 7/1/2018
J2505 Y $4,432.56 General Fee Schedule 10/1/2019
J2507 Y $2,512.55 General Fee Schedule 10/1/2019
J2510 Y $29.97 General Fee Schedule 10/1/2019
J2513 Y $12.72 General Fee Schedule 10/1/2006
J2515 Y $37.02 General Fee Schedule 10/1/2019
J2540 Y $1.02 General Fee Schedule 7/1/2019
J2543 Y $1.83 General Fee Schedule 7/1/2019
J2545 Y $105.27 General Fee Schedule 10/1/2019
J2547 Y $1.58 General Fee Schedule 1/1/2016
J2550 Y $2.02 General Fee Schedule 10/1/2019
J2560 Y $42.04 General Fee Schedule 10/1/2019
J2562 Y $347.71 General Fee Schedule 10/1/2019
J2590 Y $0.53 General Fee Schedule 4/1/2014
J2597 Y $12.14 General Fee Schedule 10/1/2019
J2650 Y $0.52 General Fee Schedule 10/1/2010
J2670 Y $3.51 General Fee Schedule 5/1/2004
J2675 Y $2.21 General Fee Schedule 10/1/2019
J2680 Y $10.95 General Fee Schedule 10/1/2019
J2690 Y $77.49 General Fee Schedule 10/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 72 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
J2700 Y $1.37 General Fee Schedule 10/1/2019
J2704 Y $0.11 General Fee Schedule 10/1/2019
J2710 Y $0.09 General Fee Schedule 7/1/2009
J2720 Y $1.09 General Fee Schedule 10/1/2019
J2724 Y $15.10 General Fee Schedule 10/1/2019
J2725 Y $21.78 General Fee Schedule 10/1/2006
J2730 Y $91.90 General Fee Schedule 7/1/2015
J2765 Y $1.54 General Fee Schedule 10/1/2019
J2770 Y $417.49 General Fee Schedule 10/1/2019
J2778 Y $352.17 General Fee Schedule 10/1/2019
J2780 Y $4.10 General Fee Schedule 10/1/2019
J2783 Y $289.82 General Fee Schedule 10/1/2019
J2785 Y $59.22 General Fee Schedule 10/1/2019
J2786 Y $9.62 General Fee Schedule 10/1/2019
J2787 Y $335.67 General Fee Schedule 1/1/2019
J2788 Y $24.92 General Fee Schedule 10/1/2019
J2790 Y $79.56 General Fee Schedule 10/1/2019
J2791 Y $4.76 General Fee Schedule 7/1/2019
J2792 Y $29.78 General Fee Schedule 10/1/2019
J2793 Y $0.00 General by Report 1/1/2010
J2794 Y $10.04 General Fee Schedule 10/1/2019
J2795 Y $0.07 General Fee Schedule 10/1/2019
J2796 Y $74.28 General Fee Schedule 10/1/2019
J2797 Y $1.75 General Fee Schedule 1/1/2019
J2800 Y $9.06 General Fee Schedule 10/1/2019
J2805 Y $109.97 General Fee Schedule 10/1/2019
J2810 Y $0.42 General Fee Schedule 7/1/2019
J2820 Y $43.44 General Fee Schedule 10/1/2019
J2840 Y $0.00 General by Report 1/1/2017
J2850 Y $34.78 General Fee Schedule 10/1/2014
J2860 Y $103.06 General Fee Schedule 10/1/2019
J2910 Y $24.50 General Fee Schedule 7/1/2006
J2916 Y $1.62 General Fee Schedule 10/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 73 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
J2920 Y $4.49 General Fee Schedule 7/1/2019
J2930 Y $6.12 General Fee Schedule 10/1/2019
J2940 Y $45.56 General Fee Schedule 1/1/2002
J2941 Y $51.96 General Fee Schedule 1/1/2009
J2950 Y $0.38 General Fee Schedule 1/1/2007
J2993 Y $2,301.91 General Fee Schedule 10/1/2013
J2995 Y $79.50 General Fee Schedule 7/1/2006
J2997 Y $87.64 General Fee Schedule 10/1/2019
J3000 Y $31.53 General Fee Schedule 10/1/2019
J3010 Y $0.89 General Fee Schedule 10/1/2019
J3030 Y $51.89 General Fee Schedule 10/1/2012
J3060 Y $40.08 General Fee Schedule 10/1/2019
J3070 Y $108.39 General Fee Schedule 4/1/2018
J3090 Y $1.49 General Fee Schedule 10/1/2019
J3095 Y $5.74 General Fee Schedule 10/1/2019
J3101 Y $121.83 General Fee Schedule 10/1/2019
J3105 Y $1.63 General Fee Schedule 10/1/2019
J3110 Y $6.89 General Fee Schedule 1/1/2005
J3121 Y $0.05 General Fee Schedule 1/1/2019
J3145 Y $1.47 General Fee Schedule 10/1/2019
J3230 Y $31.61 General Fee Schedule 10/1/2019
J3240 Y $1,695.12 General Fee Schedule 10/1/2019
J3243 Y $1.57 General Fee Schedule 10/1/2019
J3245 Y $136.49 General Fee Schedule 10/1/2019
J3246 Y $9.31 General Fee Schedule 4/1/2014
J3250 Y $36.79 General Fee Schedule 10/1/2019
J3260 Y $3.60 General Fee Schedule 10/1/2019
J3262 Y $4.96 General Fee Schedule 10/1/2019
J3265 Y $2.19 General Fee Schedule 10/1/2008
J3280 Y $5.06 General Fee Schedule 5/1/2004
J3285 Y $63.85 General Fee Schedule 10/1/2019
J3300 Y $3.85 General Fee Schedule 4/1/2019
J3301 Y $1.57 General Fee Schedule 10/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 74 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
J3302 Y $0.28 General Fee Schedule 1/1/2007
J3303 Y $3.61 General Fee Schedule 10/1/2016
J3304 Y $18.88 General Fee Schedule 1/1/2019
J3305 Y $149.71 General Fee Schedule 10/1/2007
J3310 Y $6.90 General Fee Schedule 7/1/2004
J3315 Y $258.74 General Fee Schedule 10/1/2019
J3316 Y $514.10 General Fee Schedule 1/1/2019
J3320 Y $30.08 General Fee Schedule 4/1/2007
J3350 Y $61.07 General Fee Schedule 7/1/2004
J3355 Y $63.43 General Fee Schedule 4/1/2014
J3357 Y $191.39 General Fee Schedule 10/1/2019
J3358 Y $12.04 General Fee Schedule 10/1/2019
J3360 Y $11.09 General Fee Schedule 10/1/2019
J3364 Y $9.16 General Fee Schedule 1/1/2007
J3365 Y $457.73 General Fee Schedule 1/1/2007
J3370 Y $3.46 General Fee Schedule 10/1/2019
J3380 Y $19.86 General Fee Schedule 10/1/2019
J3385 Y $345.52 General Fee Schedule 10/1/2019
J3396 Y $11.08 General Fee Schedule 10/1/2019
J3397 Y $448.38 General Fee Schedule 1/1/2019
J3398 Y $5,666.67 General Fee Schedule 1/1/2019
J3400 Y $16.74 General Fee Schedule 7/1/2004
J3410 Y $6.59 General Fee Schedule 10/1/2019
J3411 Y $1.91 General Fee Schedule 10/1/2019
J3415 Y $9.45 General Fee Schedule 10/1/2019
J3420 Y $1.89 General Fee Schedule 10/1/2019
J3430 Y $4.28 General Fee Schedule 10/1/2019
J3465 Y $2.05 General Fee Schedule 10/1/2019
J3470 Y $21.20 General Fee Schedule 7/1/2010
J3471 Y $0.43 General Fee Schedule 7/1/2019
J3472 Y $137.80 General Fee Schedule 4/1/2010
J3473 Y $0.36 General Fee Schedule 1/1/2016
J3475 Y $0.85 General Fee Schedule 10/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 75 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
J3480 Y $0.14 General Fee Schedule 10/1/2019
J3485 Y $1.51 General Fee Schedule 1/1/2018
J3486 Y $17.71 General Fee Schedule 10/1/2019
J3489 Y $12.47 General Fee Schedule 10/1/2019
J3490 Y $0.00 General by Report 1/1/1988
J3520 Y $3.94 General Fee Schedule 7/1/2004
J3530 Y $0.00 General by Report 7/1/1975
J3535 Y $0.00 General by Report 1/1/1994
J3590 Y $0.00 General by Report 5/1/2013
J3591 Y $0.00 General by Report 1/1/2019
J7030 Y $2.42 General Fee Schedule 10/1/2019
J7040 Y $1.21 General Fee Schedule 10/1/2019
J7042 Y $0.91 General Fee Schedule 10/1/2019
J7050 Y $0.60 General Fee Schedule 10/1/2019
J7060 Y $1.85 General Fee Schedule 10/1/2019
J7070 Y $3.63 General Fee Schedule 10/1/2019
J7100 Y $17.77 General Fee Schedule 1/1/2015
J7110 Y $14.52 General Fee Schedule 1/1/2012
J7120 Y $2.32 General Fee Schedule 10/1/2019
J7121 Y $0.00 General by Report 1/1/2016
J7131 Y $0.00 General by Report 1/1/2012
J7170 Y $47.35 General Fee Schedule 10/1/2019
J7175 Y $7.51 General Fee Schedule 7/1/2019
J7177 Y $1.17 General Fee Schedule 1/1/2019
J7178 Y $1.20 General Fee Schedule 4/1/2019
J7179 Y $1.83 General Fee Schedule 10/1/2019
J7180 Y $8.47 General Fee Schedule 4/1/2019
J7181 Y $15.52 General Fee Schedule 10/1/2019
J7182 Y $1.31 General Fee Schedule 10/1/2019
J7183 Y $0.97 General Fee Schedule 10/1/2019
J7185 Y $1.27 General Fee Schedule 10/1/2019
J7186 Y $1.06 General Fee Schedule 10/1/2019
J7187 Y $1.16 General Fee Schedule 4/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 76 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
J7188 Y $3.18 General Fee Schedule 10/1/2019
J7189 Y $2.15 General Fee Schedule 10/1/2019
J7190 Y $1.07 General Fee Schedule 10/1/2019
J7191 Y $1.59 General Fee Schedule 7/1/2004
J7192 Y $1.25 General Fee Schedule 10/1/2019
J7193 Y $1.15 General Fee Schedule 10/1/2019
J7194 Y $1.47 General Fee Schedule 10/1/2019
J7195 Y $1.50 General Fee Schedule 10/1/2019
J7196 Y $0.00 General by Report 1/1/2011
J7197 Y $3.32 General Fee Schedule 10/1/2019
J7198 Y $1.90 General Fee Schedule 10/1/2019
J7199 Y $0.00 General by Report 1/1/2000
J7200 Y $1.32 General Fee Schedule 10/1/2019
J7201 Y $3.11 General Fee Schedule 10/1/2019
J7202 Y $4.29 General Fee Schedule 10/1/2019
J7203 Y $4.24 General Fee Schedule 1/1/2019
J7205 Y $2.08 General Fee Schedule 10/1/2019
J7207 Y $1.74 General Fee Schedule 10/1/2019
J7208 Y $2.02 General Fee Schedule 7/1/2019
J7209 Y $1.24 General Fee Schedule 10/1/2019
J7210 Y $1.36 General Fee Schedule 7/1/2019
J7211 Y $1.26 General Fee Schedule 7/1/2019
J7296 Y $953.51 General Fee Schedule 1/14/2019
J7297 Y $625.00 General Fee Schedule 1/1/2016
J7298 Y $953.51 General Fee Schedule 1/14/2019
J7300 Y $808.50 General Fee Schedule 8/15/2017
J7301 Y $793.96 General Fee Schedule 1/14/2019
J7303 Y $51.86 General Fee Schedule 1/1/2010
J7304 Y $18.20 General Fee Schedule 2/1/2008
J7306 Y $0.00 General by Report 1/1/2006
J7307 Y $890.30 General Fee Schedule 6/1/2018
J7308 Y $390.98 General Fee Schedule 10/1/2019
J7309 Y $83.69 General Fee Schedule 7/1/2013
HCPCS FEES11/06/2019 at 7:08:01 AM - 77 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
J7310 Y $16,960.00 General Fee Schedule 10/1/2008
J7311 Y $341.62 General Fee Schedule 10/1/2019
J7312 Y $200.03 General Fee Schedule 10/1/2019
J7313 Y $490.87 General Fee Schedule 10/1/2019
J7315 Y $359.00 General Fee Schedule 1/1/2013
J7316 Y $1,046.93 General Fee Schedule 7/1/2019
J7318 Y $17.23 General Fee Schedule 1/1/2019
J7320 Y $6.25 General Fee Schedule 7/1/2018
J7321 Y $81.57 General Fee Schedule 10/1/2019
J7322 Y $0.00 General by Report 1/1/2017
J7323 Y $145.08 General Fee Schedule 10/1/2019
J7324 Y $143.40 General Fee Schedule 10/1/2019
J7325 Y $11.41 General Fee Schedule 10/1/2019
J7326 Y $537.36 General Fee Schedule 10/1/2018
J7327 Y $769.51 General Fee Schedule 10/1/2019
J7328 Y $0.00 General by Report 1/1/2016
J7329 Y $7.20 General Fee Schedule 1/1/2019
J7330 Y $31,905.54 General Fee Schedule 4/1/2014
J7336 Y $3.15 General Fee Schedule 7/1/2019
J7340 Y $219.45 General Fee Schedule 10/1/2019
J7342 Y $0.00 General by Report 1/1/2017
J7345 Y $1.45 General Fee Schedule 10/1/2019
J7500 Y $0.66 General Fee Schedule 10/1/2019
J7501 Y $217.30 General Fee Schedule 1/1/2014
J7502 Y $2.34 General Fee Schedule 10/1/2019
J7503 Y $1.33 General Fee Schedule 10/1/2019
J7504 Y $2,066.02 General Fee Schedule 10/1/2019
J7505 Y $1,156.08 General Fee Schedule 4/1/2012
J7507 Y $0.39 General Fee Schedule 10/1/2019
J7508 Y $0.48 General Fee Schedule 7/1/2019
J7509 Y $0.36 General Fee Schedule 10/1/2019
J7510 Y $0.09 General Fee Schedule 10/1/2019
J7511 Y $768.56 General Fee Schedule 10/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 78 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
J7512 Y $0.01 General Fee Schedule 10/1/2019
J7513 Y $526.34 General Fee Schedule 7/1/2010
J7515 Y $0.70 General Fee Schedule 10/1/2019
J7516 Y $49.25 General Fee Schedule 10/1/2019
J7517 Y $0.54 General Fee Schedule 10/1/2019
J7518 Y $3.34 General Fee Schedule 10/1/2019
J7520 Y $5.95 General Fee Schedule 10/1/2019
J7525 Y $211.84 General Fee Schedule 10/1/2019
J7527 Y $8.97 General Fee Schedule 10/1/2019
J7599 Y $0.00 General by Report 1/1/1996
J7604 Y $0.00 General by Report 1/1/2008
J7605 Y $10.38 General Fee Schedule 10/1/2019
J7606 Y $12.17 General Fee Schedule 10/1/2019
J7607 Y $0.00 General by Report 5/1/2013
J7608 Y $5.81 General Fee Schedule 10/1/2019
J7609 Y $0.00 General by Report 5/1/2013
J7610 Y $0.00 General by Report 5/1/2013
J7611 Y $0.19 General Fee Schedule 10/1/2019
J7612 Y $0.27 General Fee Schedule 10/1/2019
J7613 Y $0.04 General Fee Schedule 7/1/2019
J7614 Y $0.06 General Fee Schedule 10/1/2019
J7615 Y $0.00 General by Report 5/1/2013
J7620 Y $0.13 General Fee Schedule 7/1/2019
J7622 Y $0.00 General by Report 5/1/2013
J7624 Y $7.88 General Fee Schedule 7/1/2004
J7626 Y $2.16 General Fee Schedule 10/1/2019
J7627 Y $2.76 General Fee Schedule 1/1/2006
J7628 Y $3.94 General Fee Schedule 7/1/2004
J7629 Y $3.94 General Fee Schedule 7/1/2004
J7631 Y $4.75 General Fee Schedule 10/1/2019
J7632 Y $0.00 General by Report 1/1/2008
J7633 Y $0.05 General Fee Schedule 5/1/2004
J7634 Y $0.00 General by Report 1/1/2007
HCPCS FEES11/06/2019 at 7:08:01 AM - 79 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
J7635 Y $0.00 General by Report 1/1/2000
J7636 Y $0.00 General by Report 1/1/2000
J7637 Y $0.00 General by Report 1/1/2000
J7638 Y $0.00 General by Report 1/1/2000
J7639 Y $47.79 General Fee Schedule 10/1/2019
J7640 Y $0.00 General by Report 1/1/2006
J7641 Y $0.63 General Fee Schedule 5/1/2004
J7642 Y $0.00 General by Report 1/1/2000
J7643 Y $0.00 General by Report 1/1/2000
J7644 Y $0.20 General Fee Schedule 4/1/2019
J7645 Y $0.00 General by Report 1/1/2007
J7647 Y $0.00 General by Report 1/1/2007
J7648 Y $3.94 General Fee Schedule 7/1/2004
J7649 Y $3.94 General Fee Schedule 7/1/2004
J7650 Y $0.00 General by Report 1/1/2007
J7657 Y $0.00 General by Report 1/1/2007
J7658 Y $3.94 General Fee Schedule 7/1/2004
J7659 Y $3.94 General Fee Schedule 7/1/2004
J7660 Y $0.00 General by Report 1/1/2007
J7665 Y $0.67 General Fee Schedule 4/1/2013
J7667 Y $0.00 General by Report 1/1/2007
J7668 Y $2.96 General Fee Schedule 7/1/2004
J7669 Y $0.43 General Fee Schedule 4/1/2014
J7670 Y $0.00 General by Report 1/1/2007
J7674 Y $0.67 General Fee Schedule 7/1/2019
J7676 Y $0.00 General by Report 1/1/2008
J7677 Y $0.00 General by Report 7/1/2019
J7680 Y $0.00 General by Report 1/1/2000
J7681 Y $0.00 General by Report 1/1/2000
J7682 Y $36.78 General Fee Schedule 10/1/2019
J7683 Y $0.00 General by Report 1/1/2000
J7684 Y $0.00 General by Report 1/1/2000
J7685 Y $0.00 General by Report 1/1/2007
HCPCS FEES11/06/2019 at 7:08:01 AM - 80 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
J7686 Y $612.96 General Fee Schedule 7/1/2019
J7699 Y $0.00 General by Report 1/1/1993
J7799 Y $0.00 General by Report 1/1/1993
J7999 Y $0.00 General by Report 1/1/2016
J8498 Y $0.00 General by Report 1/1/2006
J8499 Y $0.00 General Fee Schedule 2/1/2008
J8501 Y $4.31 General Fee Schedule 10/1/2019
J8510 Y $24.18 General Fee Schedule 10/1/2019
J8515 Y $14.57 General Fee Schedule 10/1/2010
J8520 Y $1.36 General Fee Schedule 10/1/2019
J8521 Y $3.48 General Fee Schedule 10/1/2019
J8530 Y $3.31 General Fee Schedule 10/1/2019
J8540 Y $0.05 General Fee Schedule 10/1/2019
J8560 Y $75.36 General Fee Schedule 10/1/2019
J8562 Y $81.77 General Fee Schedule 4/1/2012
J8565 Y $0.00 General by Report 5/1/2013
J8597 Y $0.00 General by Report 1/1/2006
J8600 Y $12.00 General Fee Schedule 10/1/2018
J8610 Y $0.24 General Fee Schedule 10/1/2019
J8650 Y $0.00 General by Report 1/1/2007
J8655 Y $245.74 General Fee Schedule 10/1/2019
J8670 Y $2.12 General Fee Schedule 10/1/2019
J8700 Y $0.74 General Fee Schedule 10/1/2019
J8705 Y $103.66 General Fee Schedule 10/1/2019
J8999 Y $0.00 General by Report 5/1/2013
J9000 Y $3.73 General Fee Schedule 10/1/2019
J9015 Y $2,110.63 General Fee Schedule 10/1/2014
J9017 Y $44.31 General Fee Schedule 10/1/2019
J9019 Y $414.83 General Fee Schedule 7/1/2019
J9020 Y $64.56 General Fee Schedule 7/1/2015
J9022 Y $77.01 General Fee Schedule 10/1/2019
J9023 Y $82.97 General Fee Schedule 10/1/2019
J9025 Y $1.16 General Fee Schedule 10/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 81 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
J9027 Y $61.69 General Fee Schedule 10/1/2019
J9030 Y $2.82 General Fee Schedule 7/1/2019
J9032 Y $40.07 General Fee Schedule 10/1/2019
J9033 Y $27.84 General Fee Schedule 10/1/2019
J9034 Y $22.85 General Fee Schedule 10/1/2019
J9035 Y $81.18 General Fee Schedule 10/1/2019
J9036 Y $24.36 General Fee Schedule 10/1/2019
J9039 Y $113.40 General Fee Schedule 10/1/2019
J9040 Y $26.66 General Fee Schedule 10/1/2019
J9041 Y $44.69 General Fee Schedule 10/1/2019
J9042 Y $162.44 General Fee Schedule 10/1/2019
J9043 Y $173.67 General Fee Schedule 10/1/2019
J9044 Y $25.04 General Fee Schedule 10/1/2019
J9045 Y $2.89 General Fee Schedule 7/1/2019
J9047 Y $37.60 General Fee Schedule 10/1/2019
J9050 Y $3,039.01 General Fee Schedule 10/1/2019
J9055 Y $62.05 General Fee Schedule 10/1/2019
J9057 Y $80.80 General Fee Schedule 1/1/2019
J9060 Y $1.88 General Fee Schedule 10/1/2019
J9065 Y $19.00 General Fee Schedule 10/1/2019
J9070 Y $34.14 General Fee Schedule 10/1/2019
J9098 Y $628.37 General Fee Schedule 4/1/2018
J9100 Y $0.56 General Fee Schedule 10/1/2019
J9120 Y $1,098.20 General Fee Schedule 10/1/2019
J9130 Y $4.14 General Fee Schedule 10/1/2019
J9145 Y $53.95 General Fee Schedule 10/1/2019
J9150 Y $46.74 General Fee Schedule 10/1/2019
J9151 Y $57.66 General Fee Schedule 7/1/2010
J9153 Y $192.31 General Fee Schedule 1/1/2019
J9155 Y $3.97 General Fee Schedule 10/1/2019
J9160 Y $1,646.18 General Fee Schedule 1/1/2012
J9165 Y $12.89 General Fee Schedule 5/1/2004
J9171 Y $0.87 General Fee Schedule 10/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 82 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
J9173 Y $74.64 General Fee Schedule 10/1/2019
J9175 Y $4.16 General Fee Schedule 1/1/2014
J9176 Y $6.50 General Fee Schedule 10/1/2019
J9178 Y $0.95 General Fee Schedule 10/1/2019
J9179 Y $114.27 General Fee Schedule 10/1/2019
J9181 Y $0.56 General Fee Schedule 10/1/2019
J9185 Y $56.58 General Fee Schedule 10/1/2019
J9190 Y $1.55 General Fee Schedule 10/1/2019
J9200 Y $82.68 General Fee Schedule 10/1/2019
J9201 Y $5.00 General Fee Schedule 10/1/2019
J9202 Y $497.72 General Fee Schedule 10/1/2019
J9203 Y $199.23 General Fee Schedule 10/1/2019
J9205 Y $49.91 General Fee Schedule 10/1/2019
J9206 Y $2.47 General Fee Schedule 10/1/2019
J9207 Y $91.07 General Fee Schedule 10/1/2019
J9208 Y $26.44 General Fee Schedule 10/1/2019
J9209 Y $1.61 General Fee Schedule 10/1/2019
J9211 Y $32.72 General Fee Schedule 10/1/2019
J9212 Y $6.55 General Fee Schedule 10/1/2010
J9213 Y $40.53 General Fee Schedule 10/1/2008
J9214 Y $34.24 General Fee Schedule 10/1/2019
J9215 Y $7.03 General Fee Schedule 5/1/2004
J9216 Y $430.93 General Fee Schedule 4/1/2010
J9217 Y $224.70 General Fee Schedule 10/1/2019
J9218 Y $16.60 General Fee Schedule 10/1/2019
J9219 Y $4,819.82 General Fee Schedule 1/1/2009
J9225 Y $4,085.61 General Fee Schedule 10/1/2019
J9226 Y $36,647.60 General Fee Schedule 10/1/2019
J9228 Y $153.13 General Fee Schedule 10/1/2019
J9229 Y $2,270.31 General Fee Schedule 10/1/2019
J9230 Y $321.72 General Fee Schedule 4/1/2019
J9245 Y $610.88 General Fee Schedule 10/1/2019
J9250 Y $0.25 General Fee Schedule 10/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 83 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
J9260 Y $2.49 General Fee Schedule 10/1/2019
J9261 Y $152.48 General Fee Schedule 10/1/2019
J9262 Y $3.11 General Fee Schedule 7/1/2019
J9263 Y $0.15 General Fee Schedule 10/1/2019
J9264 Y $12.51 General Fee Schedule 10/1/2019
J9266 Y $17,566.89 General Fee Schedule 10/1/2019
J9267 Y $0.13 General Fee Schedule 10/1/2019
J9268 Y $1,968.61 General Fee Schedule 10/1/2019
J9270 Y $71.90 General Fee Schedule 7/1/2004
J9271 Y $49.39 General Fee Schedule 10/1/2019
J9280 Y $87.75 General Fee Schedule 10/1/2019
J9285 Y $52.13 General Fee Schedule 10/1/2019
J9293 Y $27.39 General Fee Schedule 10/1/2019
J9295 Y $5.74 General Fee Schedule 7/1/2019
J9299 Y $27.81 General Fee Schedule 10/1/2019
J9301 Y $62.86 General Fee Schedule 10/1/2019
J9302 Y $60.09 General Fee Schedule 10/1/2019
J9303 Y $119.07 General Fee Schedule 10/1/2019
J9305 Y $69.47 General Fee Schedule 10/1/2019
J9306 Y $12.29 General Fee Schedule 10/1/2019
J9307 Y $291.26 General Fee Schedule 10/1/2019
J9308 Y $58.42 General Fee Schedule 10/1/2019
J9311 Y $43.53 General Fee Schedule 10/1/2019
J9312 Y $94.67 General Fee Schedule 10/1/2019
J9315 Y $297.59 General Fee Schedule 10/1/2019
J9320 Y $349.70 General Fee Schedule 10/1/2019
J9325 Y $51.47 General Fee Schedule 10/1/2019
J9328 Y $10.39 General Fee Schedule 10/1/2019
J9330 Y $53.14 General Fee Schedule 10/1/2019
J9340 Y $404.28 General Fee Schedule 10/1/2019
J9351 Y $0.87 General Fee Schedule 10/1/2019
J9352 Y $312.91 General Fee Schedule 10/1/2019
J9354 Y $31.36 General Fee Schedule 10/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 84 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
J9355 Y $106.62 General Fee Schedule 10/1/2019
J9356 Y $81.94 General Fee Schedule 10/1/2019
J9357 Y $1,438.59 General Fee Schedule 10/1/2019
J9360 Y $3.80 General Fee Schedule 10/1/2019
J9370 Y $4.81 General Fee Schedule 10/1/2019
J9371 Y $3,080.04 General Fee Schedule 10/1/2019
J9390 Y $11.66 General Fee Schedule 10/1/2019
J9395 Y $94.87 General Fee Schedule 10/1/2019
J9400 Y $8.37 General Fee Schedule 10/1/2019
J9600 Y $3,004.74 General Fee Schedule 7/1/2011
J9999 Y $0.00 General by Report 11/20/1985
K0001 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
K0001 Y $22.27 Rental Fee Schedule RR 1/1/2017
K0002 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
K0002 Y $36.18 Rental Fee Schedule RR 1/1/2017
K0003 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
K0003 Y $34.69 Rental Fee Schedule RR 1/1/2017
K0004 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
K0004 Y $41.14 Rental Fee Schedule RR 1/1/2017
K0005 N $2,128.64 General Fee Schedule NU 1/1/2019
K0005 Y $212.84 Rental Fee Schedule RR 1/1/2019
K0006 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
K0006 Y $59.95 Rental Fee Schedule RR 1/1/2017
K0007 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
K0007 Y $81.34 Rental Fee Schedule RR 1/1/2017
K0008 Y $0.00 General Fee Schedule NU 7/1/2013
K0009 N $0.00 Manual Review Fee Schedule
NU 2/1/1994
K0009 Y $85.61 Rental Fee Schedule RR 1/1/2019
K0010 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
HCPCS FEES11/06/2019 at 7:08:01 AM - 85 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
K0010 Y $490.48 Rental Fee Schedule RR 1/1/2019
K0011 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
K0011 Y $539.08 Rental Fee Schedule RR 1/1/2019
K0012 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
K0012 Y $330.68 Rental Fee Schedule RR 1/1/2019
K0013 Y $0.00 General Fee Schedule NU 7/1/2013
K0014 N $0.00 Manual Review Fee Schedule
NU 2/1/1994
K0014 Y $335.06 Rental Fee Schedule RR 7/1/2004
K0015 N $154.07 General Fee Schedule NU 1/1/2016
K0017 N $46.07 General Fee Schedule NU 1/1/2019
K0018 N $26.04 General Fee Schedule NU 1/1/2019
K0019 N $11.53 General Fee Schedule NU 1/1/2017
K0020 N $45.14 General Fee Schedule NU 1/1/2019
K0037 N $41.52 General Fee Schedule NU 1/1/2019
K0037 Y $4.16 Rental Fee Schedule RR 1/1/2019
K0038 N $23.03 General Fee Schedule NU 1/1/2019
K0038 Y $2.30 Rental Fee Schedule RR 1/1/2019
K0039 N $49.44 General Fee Schedule NU 1/1/2019
K0039 Y $4.94 Rental Fee Schedule RR 1/1/2019
K0040 N $50.09 General Fee Schedule NU 1/1/2017
K0040 Y $5.01 Rental Fee Schedule RR 1/1/2017
K0041 N $47.25 General Fee Schedule NU 1/1/2019
K0041 Y $4.73 Rental Fee Schedule RR 1/1/2019
K0042 N $30.34 General Fee Schedule NU 1/1/2019
K0042 Y $3.04 Rental Fee Schedule RR 1/1/2019
K0043 N $18.73 General Fee Schedule NU 1/1/2019
K0043 Y $1.87 Rental Fee Schedule RR 1/1/2019
K0044 N $16.30 General Fee Schedule NU 1/1/2019
K0044 Y $1.63 Rental Fee Schedule RR 1/1/2019
K0045 N $53.61 General Fee Schedule NU 1/1/2019
K0046 N $18.86 General Fee Schedule NU 1/1/2019
K0047 N $66.63 General Fee Schedule NU 1/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 86 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
K0050 N $30.92 General Fee Schedule NU 1/1/2019
K0051 N $48.91 General Fee Schedule NU 1/1/2019
K0052 N $66.63 General Fee Schedule NU 1/1/2017
K0053 N $79.29 General Fee Schedule NU 1/1/2017
K0056 N $86.79 General Fee Schedule NU 1/1/2017
K0065 N $44.17 General Fee Schedule NU 1/1/2017
K0069 N $88.40 General Fee Schedule NU 1/1/2017
K0070 N $180.85 General Fee Schedule NU 1/1/2016
K0071 N $103.17 General Fee Schedule NU 1/1/2017
K0072 N $64.49 General Fee Schedule NU 1/1/2017
K0073 N $33.19 General Fee Schedule NU 1/1/2017
K0077 N $50.81 General Fee Schedule NU 1/1/2017
K0098 N $22.70 General Fee Schedule NU 1/1/2017
K0105 N $93.87 General Fee Schedule NU 1/1/2017
K0105 Y $9.39 Rental Fee Schedule RR 1/1/2017
K0108 N $0.00 Manual Review Fee Schedule
1/1/1994
K0195 N $0.00 Manual Review Fee Schedule
1/28/2013
K0455 N $0.00 Manual Review Fee Schedule
1/28/2013
K0455 Y $269.56 Rental Fee Schedule RR 1/1/2019
K0462 Y $0.00 Rental Manual Price-Fee Sched
RR 1/1/2006
K0552 N $2.72 General Fee Schedule NU 1/1/2019
K0553 Y $256.89 General Fee Schedule NU 1/1/2019
K0554 Y $270.24 General Fee Schedule NU 1/1/2019
K0554 Y $27.03 Rental Fee Schedule RR 1/1/2019
K0601 N $1.23 General Fee Schedule NU 1/1/2019
K0602 N $6.95 General Fee Schedule NU 1/1/2019
K0603 N $0.62 General Fee Schedule NU 1/1/2019
K0604 N $6.71 General Fee Schedule NU 1/1/2019
K0605 N $16.03 General Fee Schedule NU 1/1/2019
K0606 Y $2,899.50 Rental Fee Schedule RR 1/1/2019
K0669 N $0.00 General by Report NU 7/1/2004
HCPCS FEES11/06/2019 at 7:08:01 AM - 87 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
K0672 N $84.64 General Fee Schedule 1/1/2019
K0730 N $1,885.29 General Fee Schedule 2/10/2014
K0730 Y $198.49 Rental Fee Schedule 1/1/2019
K0733 N $26.95 General Fee Schedule NU 1/1/2017
K0733 Y $2.70 Rental Fee Schedule RR 1/1/2017
K0738 Y $34.47 Rental Fee Schedule RR 1/1/2019
K0739 N $14.29 General Fee Schedule NU 1/28/2013
K0740 N $31.52 General Fee Schedule NU 4/1/2009
K0743 N $0.00 General by Report 7/1/2011
K0744 N $0.00 General by Report 7/1/2011
K0745 N $0.00 General by Report 7/1/2011
K0746 N $0.00 General by Report 7/1/2011
K0800 N $795.20 General Fee Schedule NU 1/1/2017
K0800 Y $79.52 Rental Fee Schedule RR 1/1/2017
K0801 N $1,427.86 General Fee Schedule NU 1/1/2017
K0801 Y $142.78 Rental Fee Schedule RR 1/1/2017
K0802 N $1,929.29 General Fee Schedule NU 1/1/2017
K0802 Y $192.93 Rental Fee Schedule RR 1/1/2017
K0806 N $1,365.68 General Fee Schedule NU 1/1/2019
K0806 Y $136.57 Rental Fee Schedule RR 1/1/2019
K0807 N $2,116.46 General Fee Schedule NU 1/1/2019
K0807 Y $211.64 Rental Fee Schedule RR 1/1/2019
K0808 N $3,271.69 General Fee Schedule NU 1/1/2019
K0808 Y $327.17 Rental Fee Schedule RR 1/1/2019
K0812 N $0.00 General by Report NU 10/1/2006
K0812 Y $0.00 Rental by Report RR 10/1/2006
K0813 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
K0813 Y $253.67 Rental Fee Schedule RR 1/1/2017
K0814 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
K0814 Y $263.86 Rental Fee Schedule RR 1/1/2017
K0815 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
K0815 Y $293.94 Rental Fee Schedule RR 1/1/2017
HCPCS FEES11/06/2019 at 7:08:01 AM - 88 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
K0816 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
K0816 Y $270.23 Rental Fee Schedule RR 1/1/2017
K0820 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
K0820 Y $262.84 Rental Fee Schedule RR 1/1/2017
K0821 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
K0821 Y $270.23 Rental Fee Schedule RR 1/1/2017
K0822 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
K0822 Y $293.94 Rental Fee Schedule RR 1/1/2017
K0823 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
K0823 Y $270.23 Rental Fee Schedule RR 1/1/2017
K0824 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
K0824 Y $417.76 Rental Fee Schedule RR 1/1/2017
K0825 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
K0825 Y $390.94 Rental Fee Schedule RR 1/1/2017
K0826 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
K0826 Y $668.99 Rental Fee Schedule RR 1/1/2017
K0827 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
K0827 Y $593.64 Rental Fee Schedule RR 1/1/2017
K0828 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
K0828 Y $868.62 Rental Fee Schedule RR 1/1/2017
K0829 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
K0829 Y $838.16 Rental Fee Schedule RR 1/1/2017
K0830 N $4,425.90 General Fee Schedule NU 10/1/2006
K0830 Y $391.41 Rental Fee Schedule RR 1/1/2007
K0831 N $4,425.90 General Fee Schedule NU 10/1/2006
K0831 Y $391.41 Rental Fee Schedule RR 1/1/2007
K0835 N $0.00 Manual Review Fee NU 1/28/2013
HCPCS FEES11/06/2019 at 7:08:01 AM - 89 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
Schedule
K0835 Y $350.90 Rental Fee Schedule RR 1/1/2019
K0836 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
K0836 Y $363.95 Rental Fee Schedule RR 1/1/2019
K0837 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
K0837 Y $450.07 Rental Fee Schedule RR 1/1/2019
K0838 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
K0838 Y $398.91 Rental Fee Schedule RR 1/1/2019
K0839 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
K0839 Y $597.84 Rental Fee Schedule RR 1/1/2019
K0840 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
K0840 Y $917.88 Rental Fee Schedule RR 1/1/2019
K0841 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
K0841 Y $395.43 Rental Fee Schedule RR 1/1/2019
K0842 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
K0842 Y $394.86 Rental Fee Schedule RR 1/1/2019
K0843 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
K0843 Y $468.75 Rental Fee Schedule RR 1/1/2019
K0848 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
K0848 Y $786.63 Rental Fee Schedule RR 1/1/2019
K0849 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
K0849 Y $756.28 Rental Fee Schedule RR 1/1/2019
K0850 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
K0850 Y $912.44 Rental Fee Schedule RR 1/1/2019
K0851 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
K0851 Y $877.32 Rental Fee Schedule RR 1/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 90 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
K0852 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
K0852 Y $1,054.27 Rental Fee Schedule RR 1/1/2019
K0853 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
K0853 Y $1,083.01 Rental Fee Schedule RR 1/1/2019
K0854 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
K0854 Y $1,434.75 Rental Fee Schedule RR 1/1/2019
K0855 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
K0855 Y $1,355.33 Rental Fee Schedule RR 1/1/2019
K0856 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
K0856 Y $844.34 Rental Fee Schedule RR 1/1/2019
K0857 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
K0857 Y $861.27 Rental Fee Schedule RR 1/1/2019
K0858 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
K0858 Y $1,047.59 Rental Fee Schedule RR 1/1/2019
K0859 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
K0859 Y $999.08 Rental Fee Schedule RR 1/1/2019
K0860 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
K0860 Y $1,496.62 Rental Fee Schedule RR 1/1/2019
K0861 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
K0861 Y $845.69 Rental Fee Schedule RR 1/1/2019
K0862 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
K0862 Y $1,047.59 Rental Fee Schedule RR 1/1/2019
K0863 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
K0863 Y $1,496.62 Rental Fee Schedule RR 1/1/2019
K0864 N $0.00 Manual Review Fee Schedule
NU 1/28/2013
K0864 Y $1,780.98 Rental Fee Schedule RR 1/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 91 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
K0868 N $0.00 General by Report NU 10/1/2006
K0868 Y $0.00 Rental by Report RR 10/1/2006
K0869 N $0.00 General by Report NU 10/1/2006
K0869 Y $0.00 Rental by Report RR 10/1/2006
K0870 N $0.00 General by Report NU 10/1/2006
K0870 Y $0.00 Rental by Report RR 10/1/2006
K0871 N $0.00 General by Report NU 10/1/2006
K0871 Y $0.00 Rental by Report RR 10/1/2006
K0877 N $0.00 General by Report NU 10/1/2006
K0877 Y $0.00 Rental by Report RR 10/1/2006
K0878 N $0.00 General by Report NU 10/1/2006
K0878 Y $0.00 Rental by Report RR 10/1/2006
K0879 N $0.00 General by Report NU 10/1/2006
K0879 Y $0.00 Rental by Report RR 10/1/2006
K0880 N $0.00 General by Report NU 10/1/2006
K0880 Y $0.00 Rental by Report RR 10/1/2006
K0884 N $0.00 General by Report NU 10/1/2006
K0884 Y $0.00 Rental by Report RR 10/1/2006
K0885 N $0.00 General by Report NU 10/1/2006
K0885 Y $0.00 Rental by Report RR 10/1/2006
K0886 N $0.00 General by Report NU 10/1/2006
K0886 Y $0.00 Rental by Report RR 10/1/2006
K0890 N $0.00 General by Report NU 10/1/2006
K0890 Y $0.00 Rental by Report RR 10/1/2006
K0891 N $0.00 General by Report NU 10/1/2006
K0891 Y $0.00 Rental by Report RR 10/1/2006
K0898 N $0.00 General by Report NU 10/1/2006
K0898 Y $0.00 Rental by Report RR 10/1/2006
K0899 N $0.00 General by Report NU 10/1/2006
K0899 Y $0.00 Rental by Report RR 10/1/2006
K0900 Y $0.00 General Fee Schedule NU 7/1/2013
L0112 Y $1,397.07 General Fee Schedule 1/1/2019
L0113 Y $284.67 General Fee Schedule 1/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 92 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
L0120 Y $24.64 General Fee Schedule 1/1/2019
L0130 Y $151.47 General Fee Schedule 1/1/2019
L0140 Y $60.63 General Fee Schedule 1/1/2019
L0150 Y $100.32 General Fee Schedule 1/1/2019
L0160 Y $193.87 General Fee Schedule 1/1/2019
L0170 Y $635.03 General Fee Schedule 1/1/2019
L0172 Y $130.84 General Fee Schedule 1/1/2019
L0174 Y $255.03 General Fee Schedule 1/1/2019
L0180 Y $382.14 General Fee Schedule 1/1/2019
L0190 Y $494.85 General Fee Schedule 1/1/2019
L0200 Y $552.94 General Fee Schedule 1/1/2019
L0220 Y $151.60 General Fee Schedule 1/1/2019
L0450 Y $161.35 General Fee Schedule 1/1/2019
L0452 Y $0.00 General by Report 1/1/2005
L0454 Y $346.18 General Fee Schedule 1/1/2019
L0455 Y $346.18 General Fee Schedule 1/1/2019
L0456 Y $992.76 General Fee Schedule 1/1/2019
L0457 Y $992.76 General Fee Schedule 1/1/2019
L0458 Y $890.21 General Fee Schedule 1/1/2019
L0460 Y $1,002.02 General Fee Schedule 1/1/2019
L0462 Y $1,246.30 General Fee Schedule 1/1/2019
L0464 Y $1,483.71 General Fee Schedule 1/1/2019
L0466 Y $397.43 General Fee Schedule 1/1/2019
L0467 Y $397.43 General Fee Schedule 1/1/2019
L0468 Y $460.11 General Fee Schedule 1/1/2019
L0469 Y $460.11 General Fee Schedule 1/1/2019
L0470 Y $591.89 General Fee Schedule 1/1/2019
L0472 Y $413.16 General Fee Schedule 1/1/2019
L0480 Y $1,423.59 General Fee Schedule 1/1/2019
L0482 Y $1,439.66 General Fee Schedule 1/1/2019
L0484 Y $1,649.86 General Fee Schedule 1/1/2019
L0486 Y $1,780.32 General Fee Schedule 1/1/2019
L0488 Y $1,002.02 General Fee Schedule 1/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 93 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
L0490 Y $282.35 General Fee Schedule 1/1/2019
L0491 Y $766.59 General Fee Schedule 1/1/2019
L0492 Y $496.83 General Fee Schedule 1/1/2019
L0621 Y $92.73 General Fee Schedule 1/1/2019
L0622 Y $239.84 General Fee Schedule 1/1/2019
L0623 Y $176.67 General Fee Schedule 4/1/2019
L0624 Y $0.00 General by Report 1/1/2006
L0625 Y $55.00 General Fee Schedule 1/1/2019
L0626 Y $77.81 General Fee Schedule 1/1/2019
L0627 Y $410.32 General Fee Schedule 1/1/2019
L0628 Y $83.72 General Fee Schedule 1/1/2019
L0629 Y $0.00 General by Report 1/1/2006
L0630 Y $161.64 General Fee Schedule 1/1/2019
L0631 Y $1,024.73 General Fee Schedule 1/1/2019
L0632 Y $0.00 General by Report 1/1/2006
L0633 Y $286.24 General Fee Schedule 1/1/2019
L0634 Y $0.00 General by Report 1/1/2006
L0635 Y $987.62 General Fee Schedule 1/1/2019
L0636 Y $1,338.86 General Fee Schedule 1/1/2019
L0637 Y $1,212.68 General Fee Schedule 1/1/2019
L0638 Y $1,316.49 General Fee Schedule 1/1/2019
L0639 Y $1,212.68 General Fee Schedule 1/1/2019
L0640 Y $1,044.44 General Fee Schedule 1/1/2019
L0641 Y $77.81 General Fee Schedule 1/1/2019
L0642 Y $410.32 General Fee Schedule 1/1/2019
L0643 Y $161.64 General Fee Schedule 1/1/2019
L0648 Y $1,024.73 General Fee Schedule 1/1/2019
L0649 Y $286.24 General Fee Schedule 1/1/2019
L0650 Y $1,212.68 General Fee Schedule 1/1/2019
L0651 Y $1,212.68 General Fee Schedule 1/1/2019
L0700 Y $1,905.15 General Fee Schedule 1/1/2019
L0710 Y $2,052.34 General Fee Schedule 1/1/2019
L0810 Y $2,542.59 General Fee Schedule 1/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 94 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
L0820 Y $2,144.83 General Fee Schedule 1/1/2019
L0830 Y $3,436.52 General Fee Schedule 1/1/2019
L0859 Y $1,507.98 General Fee Schedule 1/1/2019
L0861 Y $215.16 General Fee Schedule 1/1/2019
L0970 Y $134.98 General Fee Schedule 1/1/2019
L0972 Y $123.42 General Fee Schedule 1/1/2019
L0974 Y $186.57 General Fee Schedule 1/1/2019
L0976 Y $174.72 General Fee Schedule 1/1/2019
L0978 Y $183.05 General Fee Schedule 1/1/2019
L0980 Y $21.62 General Fee Schedule 1/1/2019
L0982 Y $20.16 General Fee Schedule 1/1/2019
L0984 Y $56.37 General Fee Schedule 1/1/2019
L0999 Y $0.00 Manual Review Fee Schedule
1/1/1998
L1000 Y $2,049.17 General Fee Schedule 1/1/2019
L1001 Y $0.00 General by Report 1/1/2007
L1005 Y $3,194.77 General Fee Schedule 1/1/2019
L1010 Y $73.43 General Fee Schedule 1/1/2019
L1020 Y $101.74 General Fee Schedule 1/1/2019
L1025 Y $115.77 General Fee Schedule 1/1/2019
L1030 Y $78.74 General Fee Schedule 1/1/2019
L1040 Y $82.32 General Fee Schedule 1/1/2019
L1050 Y $99.65 General Fee Schedule 1/1/2019
L1060 Y $96.70 General Fee Schedule 1/1/2019
L1070 Y $94.60 General Fee Schedule 1/1/2019
L1080 Y $53.22 General Fee Schedule 1/1/2019
L1085 Y $160.69 General Fee Schedule 1/1/2019
L1090 Y $95.16 General Fee Schedule 1/1/2019
L1100 Y $164.02 General Fee Schedule 1/1/2019
L1110 Y $239.22 General Fee Schedule 1/1/2019
L1120 Y $43.35 General Fee Schedule 1/1/2019
L1200 Y $1,672.93 General Fee Schedule 1/1/2019
L1210 Y $242.92 General Fee Schedule 1/1/2019
L1220 Y $235.09 General Fee Schedule 1/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 95 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
L1230 Y $527.74 General Fee Schedule 1/1/2019
L1240 Y $77.84 General Fee Schedule 1/1/2019
L1250 Y $75.52 General Fee Schedule 1/1/2019
L1260 Y $75.99 General Fee Schedule 1/1/2019
L1270 Y $73.06 General Fee Schedule 1/1/2019
L1280 Y $80.09 General Fee Schedule 1/1/2019
L1290 Y $72.97 General Fee Schedule 1/1/2019
L1300 Y $1,787.56 General Fee Schedule 1/1/2019
L1310 Y $1,721.97 General Fee Schedule 1/1/2019
L1499 Y $0.00 General by Report 1/2/1989
L1600 Y $159.51 General Fee Schedule 1/1/2019
L1610 Y $42.26 General Fee Schedule 1/1/2019
L1620 Y $124.39 General Fee Schedule 1/1/2019
L1630 Y $157.31 General Fee Schedule 1/1/2019
L1640 Y $493.31 General Fee Schedule 1/1/2019
L1650 Y $226.54 General Fee Schedule 1/1/2019
L1652 Y $355.83 General Fee Schedule 1/1/2019
L1660 Y $211.84 General Fee Schedule 1/1/2019
L1680 Y $1,337.21 General Fee Schedule 1/1/2019
L1685 Y $1,104.30 General Fee Schedule 1/1/2019
L1686 Y $846.87 General Fee Schedule 1/1/2019
L1690 Y $1,930.21 General Fee Schedule 1/1/2019
L1700 Y $1,592.50 General Fee Schedule 1/1/2019
L1710 Y $2,047.78 General Fee Schedule 1/1/2019
L1720 Y $1,519.16 General Fee Schedule 1/1/2019
L1730 Y $1,202.52 General Fee Schedule 1/1/2019
L1755 Y $1,469.86 General Fee Schedule 1/1/2019
L1810 Y $99.30 General Fee Schedule 1/1/2019
L1812 Y $99.30 General Fee Schedule 1/1/2019
L1820 Y $133.57 General Fee Schedule 1/1/2019
L1830 Y $81.22 General Fee Schedule 1/1/2019
L1831 Y $293.77 General Fee Schedule 1/1/2019
L1832 Y $564.43 General Fee Schedule 1/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 96 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
L1833 Y $564.43 General Fee Schedule 1/1/2019
L1834 Y $720.67 General Fee Schedule 1/1/2019
L1836 Y $133.17 General Fee Schedule 1/1/2019
L1840 Y $1,048.89 General Fee Schedule 1/1/2019
L1843 Y $895.62 General Fee Schedule 1/1/2019
L1844 Y $1,549.33 General Fee Schedule 1/1/2019
L1845 Y $869.57 General Fee Schedule 1/1/2019
L1846 Y $1,089.69 General Fee Schedule 1/1/2019
L1847 Y $574.13 General Fee Schedule 1/1/2019
L1848 Y $574.13 General Fee Schedule 1/1/2019
L1850 Y $309.03 General Fee Schedule 1/1/2019
L1851 Y $895.62 General Fee Schedule 1/1/2019
L1852 Y $869.57 General Fee Schedule 1/1/2019
L1860 Y $1,015.31 General Fee Schedule 1/1/2019
L1900 Y $321.62 General Fee Schedule 1/1/2019
L1902 Y $98.81 General Fee Schedule 1/1/2019
L1904 Y $436.56 General Fee Schedule 1/1/2019
L1906 Y $111.65 General Fee Schedule 1/1/2019
L1907 Y $561.67 General Fee Schedule 1/1/2019
L1910 Y $279.70 General Fee Schedule 1/1/2019
L1920 Y $336.05 General Fee Schedule 1/1/2019
L1930 Y $292.83 General Fee Schedule 1/1/2019
L1932 Y $890.75 General Fee Schedule 1/1/2019
L1940 Y $470.10 General Fee Schedule 1/1/2019
L1945 Y $859.39 General Fee Schedule 1/1/2019
L1950 Y $693.86 General Fee Schedule 1/1/2019
L1951 Y $838.30 General Fee Schedule 1/1/2019
L1960 Y $514.59 General Fee Schedule 1/1/2019
L1970 Y $660.61 General Fee Schedule 1/1/2019
L1971 Y $467.87 General Fee Schedule 1/1/2019
L1980 Y $356.17 General Fee Schedule 1/1/2019
L1990 Y $413.83 General Fee Schedule 1/1/2019
L2000 Y $941.65 General Fee Schedule 1/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 97 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
L2005 Y $4,090.20 General Fee Schedule 1/1/2019
L2010 Y $919.54 General Fee Schedule 1/1/2019
L2020 Y $1,084.03 General Fee Schedule 1/1/2019
L2030 Y $950.85 General Fee Schedule 1/1/2019
L2034 Y $2,096.13 General Fee Schedule 1/1/2019
L2035 Y $172.92 General Fee Schedule 1/1/2019
L2036 Y $1,809.92 General Fee Schedule 1/1/2019
L2037 Y $1,546.31 General Fee Schedule 1/1/2019
L2038 Y $1,327.34 General Fee Schedule 1/1/2019
L2040 Y $164.83 General Fee Schedule 1/1/2019
L2050 Y $524.60 General Fee Schedule 1/1/2019
L2060 Y $606.97 General Fee Schedule 1/1/2019
L2070 Y $125.79 General Fee Schedule 1/1/2019
L2080 Y $356.78 General Fee Schedule 1/1/2019
L2090 Y $432.41 General Fee Schedule 1/1/2019
L2106 Y $776.88 General Fee Schedule 1/1/2019
L2108 Y $1,079.31 General Fee Schedule 1/1/2019
L2112 Y $525.85 General Fee Schedule 1/1/2019
L2114 Y $608.73 General Fee Schedule 1/1/2019
L2116 Y $729.30 General Fee Schedule 1/1/2019
L2126 Y $1,111.70 General Fee Schedule 1/1/2019
L2128 Y $1,591.93 General Fee Schedule 1/1/2019
L2132 Y $844.87 General Fee Schedule 1/1/2019
L2134 Y $1,056.69 General Fee Schedule 1/1/2019
L2136 Y $1,196.33 General Fee Schedule 1/1/2019
L2180 Y $144.96 General Fee Schedule 1/1/2019
L2182 Y $106.50 General Fee Schedule 1/1/2019
L2184 Y $138.37 General Fee Schedule 1/1/2019
L2186 Y $139.77 General Fee Schedule 1/1/2019
L2188 Y $325.23 General Fee Schedule 1/1/2019
L2190 Y $92.94 General Fee Schedule 1/1/2019
L2192 Y $366.16 General Fee Schedule 1/1/2019
L2200 Y $58.85 General Fee Schedule 1/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 98 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
L2210 Y $62.41 General Fee Schedule 1/1/2019
L2220 Y $81.11 General Fee Schedule 1/1/2019
L2230 Y $74.96 General Fee Schedule 1/1/2019
L2232 Y $96.45 General Fee Schedule 1/1/2019
L2240 Y $77.65 General Fee Schedule 1/1/2019
L2250 Y $329.88 General Fee Schedule 1/1/2019
L2260 Y $192.06 General Fee Schedule 1/1/2019
L2265 Y $145.78 General Fee Schedule 1/1/2019
L2270 Y $49.86 General Fee Schedule 1/1/2019
L2275 Y $121.31 General Fee Schedule 1/1/2019
L2280 Y $420.38 General Fee Schedule 1/1/2019
L2300 Y $333.28 General Fee Schedule 1/1/2019
L2310 Y $152.28 General Fee Schedule 1/1/2019
L2320 Y $208.41 General Fee Schedule 1/1/2019
L2330 Y $386.36 General Fee Schedule 1/1/2019
L2335 Y $210.90 General Fee Schedule 1/1/2019
L2340 Y $514.53 General Fee Schedule 1/1/2019
L2350 Y $881.50 General Fee Schedule 1/1/2019
L2360 Y $64.04 General Fee Schedule 1/1/2019
L2370 Y $272.45 General Fee Schedule 1/1/2019
L2375 Y $139.87 General Fee Schedule 1/1/2019
L2380 Y $152.39 General Fee Schedule 1/1/2019
L2385 Y $160.55 General Fee Schedule 1/1/2019
L2387 Y $153.64 General Fee Schedule 1/1/2019
L2390 Y $101.63 General Fee Schedule 1/1/2019
L2395 Y $193.68 General Fee Schedule 1/1/2019
L2397 Y $108.81 General Fee Schedule 1/1/2019
L2405 Y $87.03 General Fee Schedule 1/1/2019
L2415 Y $121.25 General Fee Schedule 1/1/2019
L2425 Y $143.08 General Fee Schedule 1/1/2019
L2430 Y $143.08 General Fee Schedule 1/1/2019
L2492 Y $105.67 General Fee Schedule 1/1/2019
L2500 Y $341.53 General Fee Schedule 1/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 99 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
L2510 Y $774.62 General Fee Schedule 1/1/2019
L2520 Y $489.00 General Fee Schedule 1/1/2019
L2525 Y $1,131.69 General Fee Schedule 1/1/2019
L2526 Y $635.89 General Fee Schedule 1/1/2019
L2530 Y $219.92 General Fee Schedule 1/1/2019
L2540 Y $417.52 General Fee Schedule 1/1/2019
L2550 Y $266.64 General Fee Schedule 1/1/2019
L2570 Y $589.59 General Fee Schedule 1/1/2019
L2580 Y $430.87 General Fee Schedule 1/1/2019
L2600 Y $254.23 General Fee Schedule 1/1/2019
L2610 Y $300.62 General Fee Schedule 1/1/2019
L2620 Y $290.46 General Fee Schedule 1/1/2019
L2622 Y $379.60 General Fee Schedule 1/1/2019
L2624 Y $330.10 General Fee Schedule 1/1/2019
L2627 Y $1,591.52 General Fee Schedule 1/1/2019
L2628 Y $1,555.40 General Fee Schedule 1/1/2019
L2630 Y $271.84 General Fee Schedule 1/1/2019
L2640 Y $357.36 General Fee Schedule 1/1/2019
L2650 Y $134.21 General Fee Schedule 1/1/2019
L2660 Y $208.99 General Fee Schedule 1/1/2019
L2670 Y $211.15 General Fee Schedule 1/1/2019
L2680 Y $193.70 General Fee Schedule 1/1/2019
L2750 Y $102.04 General Fee Schedule 1/1/2019
L2755 Y $130.46 General Fee Schedule 1/1/2019
L2760 Y $75.21 General Fee Schedule 1/1/2019
L2768 Y $130.03 General Fee Schedule 1/1/2019
L2780 Y $62.83 General Fee Schedule 1/1/2019
L2785 Y $29.42 General Fee Schedule 1/1/2019
L2795 Y $90.93 General Fee Schedule 1/1/2019
L2800 Y $99.03 General Fee Schedule 1/1/2019
L2810 Y $80.71 General Fee Schedule 1/1/2019
L2820 Y $80.62 General Fee Schedule 1/1/2019
L2830 Y $87.22 General Fee Schedule 1/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 100 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
L2840 Y $54.08 General Fee Schedule 1/1/2019
L2850 Y $61.85 General Fee Schedule 1/1/2019
L2861 Y $0.00 General by Report 1/1/2010
L2999 Y $0.00 General by Report 1/1/1990
L3000 Y $313.56 General Fee Schedule 1/1/2019
L3001 Y $132.01 General Fee Schedule 1/1/2019
L3002 Y $161.19 General Fee Schedule 1/1/2019
L3003 Y $173.92 General Fee Schedule 1/1/2019
L3010 Y $173.92 General Fee Schedule 1/1/2019
L3020 Y $198.03 General Fee Schedule 1/1/2019
L3030 Y $76.18 General Fee Schedule 1/1/2019
L3031 Y $122.24 General Fee Schedule 1/1/2019
L3040 Y $46.98 General Fee Schedule 1/1/2019
L3050 Y $46.98 General Fee Schedule 1/1/2019
L3060 Y $73.62 General Fee Schedule 1/1/2019
L3070 Y $31.73 General Fee Schedule 1/1/2019
L3080 Y $31.73 General Fee Schedule 1/1/2019
L3090 Y $40.63 General Fee Schedule 1/1/2019
L3100 Y $43.14 General Fee Schedule 1/1/2019
L3140 Y $88.89 General Fee Schedule 1/1/2019
L3150 Y $81.25 General Fee Schedule 1/1/2019
L3170 Y $50.78 General Fee Schedule 1/1/2019
L3201 Y $76.17 General Fee Schedule 7/1/2004
L3202 Y $76.17 General Fee Schedule 7/1/2004
L3203 Y $157.60 General Fee Schedule 7/1/2004
L3204 Y $76.17 General Fee Schedule 7/1/2004
L3206 Y $76.17 General Fee Schedule 7/1/2004
L3207 Y $76.17 General Fee Schedule 7/1/2004
L3208 Y $0.00 Manual Review Fee Schedule
1/1/1998
L3209 Y $0.00 General by Report 10/1/1975
L3211 Y $0.00 Manual Review Fee Schedule
1/1/1991
L3212 Y $76.17 General Fee Schedule 7/1/2004
HCPCS FEES11/06/2019 at 7:08:01 AM - 101 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
L3213 Y $0.00 General by Report 1/1/2004
L3215 Y $0.00 General by Report 1/1/2004
L3216 Y $0.00 Manual Review Fee Schedule
1/1/1991
L3217 Y $132.48 General Fee Schedule 7/1/2004
L3219 Y $91.13 General Fee Schedule 7/1/2004
L3221 Y $133.90 General Fee Schedule 7/1/2004
L3222 Y $0.00 Manual Review Fee Schedule
1/1/1992
L3224 Y $54.60 General Fee Schedule 1/1/2019
L3225 Y $64.00 General Fee Schedule 1/1/2019
L3230 Y $0.00 Manual Review Fee Schedule
1/1/1992
L3250 Y $262.12 General Fee Schedule 7/1/2004
L3251 Y $326.63 General Fee Schedule 7/1/2004
L3252 Y $212.23 General Fee Schedule 7/1/2004
L3254 Y $0.00 General by Report 1/1/2004
L3255 Y $0.00 General by Report 1/1/2004
L3257 Y $0.00 Manual Review Fee Schedule
1/1/1991
L3260 Y $15.76 General Fee Schedule 7/1/2004
L3300 Y $52.04 General Fee Schedule 1/1/2019
L3310 Y $81.25 General Fee Schedule 1/1/2019
L3320 Y $68.03 General Fee Schedule 7/1/2004
L3330 Y $564.92 General Fee Schedule 1/1/2019
L3332 Y $73.62 General Fee Schedule 1/1/2019
L3334 Y $38.09 General Fee Schedule 1/1/2019
L3340 Y $85.04 General Fee Schedule 1/1/2019
L3350 Y $22.82 General Fee Schedule 1/1/2019
L3360 Y $35.55 General Fee Schedule 1/1/2019
L3370 Y $49.50 General Fee Schedule 1/1/2019
L3380 Y $49.50 General Fee Schedule 1/1/2019
L3390 Y $49.50 General Fee Schedule 1/1/2019
L3400 Y $40.63 General Fee Schedule 1/1/2019
L3410 Y $92.70 General Fee Schedule 1/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 102 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
L3420 Y $54.58 General Fee Schedule 1/1/2019
L3430 Y $159.96 General Fee Schedule 1/1/2019
L3440 Y $76.18 General Fee Schedule 1/1/2019
L3450 Y $105.35 General Fee Schedule 1/1/2019
L3455 Y $40.63 General Fee Schedule 1/1/2019
L3460 Y $34.26 General Fee Schedule 1/1/2019
L3465 Y $58.39 General Fee Schedule 1/1/2019
L3470 Y $62.19 General Fee Schedule 1/1/2019
L3480 Y $62.19 General Fee Schedule 1/1/2019
L3485 Y $21.53 General Fee Schedule 7/1/2004
L3500 Y $29.23 General Fee Schedule 1/1/2019
L3510 Y $29.23 General Fee Schedule 1/1/2019
L3520 Y $31.73 General Fee Schedule 1/1/2019
L3530 Y $31.73 General Fee Schedule 1/1/2019
L3540 Y $50.78 General Fee Schedule 1/1/2019
L3550 Y $8.90 General Fee Schedule 1/1/2019
L3560 Y $22.82 General Fee Schedule 1/1/2019
L3570 Y $85.04 General Fee Schedule 1/1/2019
L3580 Y $64.75 General Fee Schedule 1/1/2019
L3590 Y $53.33 General Fee Schedule 1/1/2019
L3595 Y $41.88 General Fee Schedule 1/1/2019
L3600 Y $76.18 General Fee Schedule 1/1/2019
L3610 Y $100.29 General Fee Schedule 1/1/2019
L3620 Y $76.18 General Fee Schedule 1/1/2019
L3630 Y $100.29 General Fee Schedule 1/1/2019
L3640 Y $43.14 General Fee Schedule 1/1/2019
L3649 Y $0.00 General by Report 1/1/1984
L3650 Y $59.05 General Fee Schedule 1/1/2019
L3660 Y $93.37 General Fee Schedule 1/1/2019
L3670 Y $106.66 General Fee Schedule 1/1/2019
L3671 Y $818.55 General Fee Schedule 1/1/2019
L3674 Y $1,073.80 General Fee Schedule 1/1/2019
L3675 Y $159.43 General Fee Schedule 1/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 103 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
L3677 Y $0.00 General by Report 1/1/2002
L3678 Y $0.00 General by Report 1/1/2014
L3702 Y $262.33 General Fee Schedule 1/1/2019
L3710 Y $134.96 General Fee Schedule 1/1/2019
L3720 Y $689.27 General Fee Schedule 1/1/2019
L3730 Y $1,008.18 General Fee Schedule 1/1/2019
L3740 Y $1,294.56 General Fee Schedule 1/1/2019
L3760 Y $454.29 General Fee Schedule 1/1/2019
L3761 Y $454.29 General Fee Schedule 1/1/2019
L3762 Y $97.70 General Fee Schedule 1/1/2019
L3763 Y $636.00 General Fee Schedule 1/1/2019
L3764 Y $691.06 General Fee Schedule 1/1/2019
L3765 Y $1,164.82 General Fee Schedule 1/1/2019
L3766 Y $1,233.46 General Fee Schedule 1/1/2019
L3806 Y $412.65 General Fee Schedule 1/1/2019
L3807 Y $227.17 General Fee Schedule 1/1/2019
L3808 Y $303.58 General Fee Schedule 1/1/2019
L3809 Y $227.17 General Fee Schedule 1/1/2019
L3891 Y $0.00 General by Report 1/1/2010
L3900 Y $1,187.49 General Fee Schedule 1/1/2019
L3901 Y $1,459.93 General Fee Schedule 1/1/2019
L3904 Y $2,660.40 General Fee Schedule 1/1/2019
L3905 Y $900.86 General Fee Schedule 1/1/2019
L3906 Y $358.97 General Fee Schedule 1/1/2019
L3908 Y $54.43 General Fee Schedule 1/1/2019
L3912 Y $113.26 General Fee Schedule 1/1/2019
L3913 Y $246.04 General Fee Schedule 1/1/2019
L3915 Y $482.91 General Fee Schedule 1/1/2019
L3916 Y $482.91 General Fee Schedule 1/1/2019
L3917 Y $95.94 General Fee Schedule 1/1/2019
L3918 Y $95.94 General Fee Schedule 1/1/2019
L3919 Y $246.04 General Fee Schedule 1/1/2019
L3921 Y $291.77 General Fee Schedule 1/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 104 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
L3923 Y $79.02 General Fee Schedule 1/1/2019
L3924 Y $79.02 General Fee Schedule 1/1/2019
L3925 Y $48.81 General Fee Schedule 1/1/2019
L3927 Y $31.79 General Fee Schedule 1/1/2019
L3929 Y $83.56 General Fee Schedule 1/1/2019
L3930 Y $83.56 General Fee Schedule 1/1/2019
L3931 Y $186.61 General Fee Schedule 1/1/2019
L3933 Y $193.84 General Fee Schedule 1/1/2019
L3935 Y $200.72 General Fee Schedule 1/1/2019
L3956 Y $0.00 General by Report 1/1/2005
L3960 Y $814.06 General Fee Schedule 1/1/2019
L3961 Y $1,526.25 General Fee Schedule 1/1/2019
L3962 Y $651.82 General Fee Schedule 1/1/2019
L3967 Y $1,802.03 General Fee Schedule 1/1/2019
L3971 Y $1,710.51 General Fee Schedule 1/1/2019
L3973 Y $1,802.03 General Fee Schedule 1/1/2019
L3975 Y $1,526.25 General Fee Schedule 1/1/2019
L3976 Y $1,526.25 General Fee Schedule 1/1/2019
L3977 Y $1,710.51 General Fee Schedule 1/1/2019
L3978 Y $1,802.03 General Fee Schedule 1/1/2019
L3980 Y $334.43 General Fee Schedule 1/1/2019
L3981 Y $914.40 General Fee Schedule 1/1/2019
L3982 Y $377.39 General Fee Schedule 1/1/2019
L3984 Y $328.33 General Fee Schedule 1/1/2019
L3995 Y $38.73 General Fee Schedule 1/1/2019
L3999 Y $0.00 General by Report 11/1/1988
L4000 Y $1,250.96 General Fee Schedule 1/1/2019
L4002 Y $0.00 General by Report 1/1/2005
L4010 Y $639.32 General Fee Schedule 1/1/2019
L4020 Y $934.91 General Fee Schedule 1/1/2019
L4030 Y $611.39 General Fee Schedule 1/1/2019
L4040 Y $398.48 General Fee Schedule 1/1/2019
L4045 Y $304.54 General Fee Schedule 1/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 105 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
L4050 Y $383.28 General Fee Schedule 1/1/2019
L4055 Y $252.82 General Fee Schedule 1/1/2019
L4060 Y $295.04 General Fee Schedule 1/1/2019
L4070 Y $328.89 General Fee Schedule 1/1/2019
L4080 Y $93.90 General Fee Schedule 1/1/2019
L4090 Y $106.07 General Fee Schedule 1/1/2019
L4100 Y $108.91 General Fee Schedule 1/1/2019
L4110 Y $87.12 General Fee Schedule 1/1/2019
L4130 Y $536.83 General Fee Schedule 1/1/2019
L4205 Y $21.30 General Fee Schedule 1/28/2013
L4210 Y $0.00 Manual Review Fee Schedule
1/1/1993
L4350 Y $85.35 General Fee Schedule 1/1/2019
L4360 Y $257.06 General Fee Schedule 1/1/2019
L4361 Y $257.06 General Fee Schedule 1/1/2019
L4370 Y $175.27 General Fee Schedule 1/1/2019
L4386 Y $158.26 General Fee Schedule 1/1/2019
L4387 Y $158.26 General Fee Schedule 1/1/2019
L4392 Y $23.51 General Fee Schedule 1/1/2019
L4394 Y $17.16 General Fee Schedule 1/1/2019
L4396 Y $167.55 General Fee Schedule 1/1/2019
L4397 Y $167.55 General Fee Schedule 1/1/2019
L4398 Y $77.11 General Fee Schedule 1/1/2019
L4631 Y $1,476.45 General Fee Schedule 1/1/2019
L5000 Y $666.32 General Fee Schedule 1/1/2019
L5010 Y $1,512.97 General Fee Schedule 1/1/2019
L5020 Y $2,272.86 General Fee Schedule 1/1/2019
L5050 Y $2,861.19 General Fee Schedule 1/1/2019
L5060 Y $3,233.00 General Fee Schedule 1/1/2019
L5100 Y $2,811.59 General Fee Schedule 1/1/2019
L5105 Y $3,436.01 General Fee Schedule 1/1/2019
L5150 Y $4,095.65 General Fee Schedule 1/1/2019
L5160 Y $4,309.11 General Fee Schedule 1/1/2019
L5200 Y $3,744.95 General Fee Schedule 1/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 106 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
L5210 Y $2,768.13 General Fee Schedule 1/1/2019
L5220 Y $3,477.60 General Fee Schedule 1/1/2019
L5230 Y $4,121.92 General Fee Schedule 1/1/2019
L5250 Y $5,580.31 General Fee Schedule 1/1/2019
L5270 Y $5,302.40 General Fee Schedule 1/1/2019
L5280 Y $5,771.99 General Fee Schedule 1/1/2019
L5301 Y $2,727.79 General Fee Schedule 1/1/2019
L5312 Y $3,640.81 General Fee Schedule 1/1/2019
L5321 Y $3,805.67 General Fee Schedule 1/1/2019
L5331 Y $5,729.30 General Fee Schedule 1/1/2019
L5341 Y $5,978.86 General Fee Schedule 1/1/2019
L5400 Y $1,410.57 General Fee Schedule 1/1/2019
L5410 Y $551.00 General Fee Schedule 1/1/2019
L5420 Y $1,806.44 General Fee Schedule 1/1/2019
L5430 Y $663.62 General Fee Schedule 1/1/2019
L5450 Y $537.27 General Fee Schedule 1/1/2019
L5460 Y $719.10 General Fee Schedule 1/1/2019
L5500 Y $1,419.37 General Fee Schedule 1/1/2019
L5505 Y $2,293.76 General Fee Schedule 1/1/2019
L5510 Y $1,687.43 General Fee Schedule 1/1/2019
L5520 Y $1,896.46 General Fee Schedule 1/1/2019
L5530 Y $1,959.88 General Fee Schedule 1/1/2019
L5535 Y $1,963.75 General Fee Schedule 1/1/2019
L5540 Y $2,105.49 General Fee Schedule 1/1/2019
L5560 Y $2,532.21 General Fee Schedule 1/1/2019
L5570 Y $2,500.11 General Fee Schedule 1/1/2019
L5580 Y $2,791.56 General Fee Schedule 1/1/2019
L5585 Y $2,800.76 General Fee Schedule 1/1/2019
L5590 Y $2,740.33 General Fee Schedule 1/1/2019
L5595 Y $3,982.52 General Fee Schedule 1/1/2019
L5600 Y $4,397.90 General Fee Schedule 1/1/2019
L5610 Y $2,373.34 General Fee Schedule 1/1/2019
L5611 Y $1,593.57 General Fee Schedule 1/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 107 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
L5613 Y $2,454.59 General Fee Schedule 1/1/2019
L5614 Y $1,687.63 General Fee Schedule 1/1/2019
L5616 Y $1,791.10 General Fee Schedule 1/1/2019
L5617 Y $559.56 General Fee Schedule 1/1/2019
L5618 Y $298.81 General Fee Schedule 1/1/2019
L5620 Y $366.64 General Fee Schedule 1/1/2019
L5622 Y $478.09 General Fee Schedule 1/1/2019
L5624 Y $479.44 General Fee Schedule 1/1/2019
L5626 Y $526.51 General Fee Schedule 1/1/2019
L5628 Y $568.22 General Fee Schedule 1/1/2019
L5629 Y $419.10 General Fee Schedule 1/1/2019
L5630 Y $511.62 General Fee Schedule 1/1/2019
L5631 Y $579.44 General Fee Schedule 1/1/2019
L5632 Y $219.62 General Fee Schedule 1/1/2019
L5634 Y $300.86 General Fee Schedule 1/1/2019
L5636 Y $252.02 General Fee Schedule 1/1/2019
L5637 Y $380.98 General Fee Schedule 1/1/2019
L5638 Y $499.25 General Fee Schedule 1/1/2019
L5639 Y $1,108.93 General Fee Schedule 1/1/2019
L5640 Y $632.45 General Fee Schedule 1/1/2019
L5642 Y $632.01 General Fee Schedule 1/1/2019
L5643 Y $1,655.73 General Fee Schedule 1/1/2019
L5644 Y $696.90 General Fee Schedule 1/1/2019
L5645 Y $790.78 General Fee Schedule 1/1/2019
L5646 Y $703.47 General Fee Schedule 1/1/2019
L5647 Y $786.77 General Fee Schedule 1/1/2019
L5648 Y $767.32 General Fee Schedule 1/1/2019
L5649 Y $2,403.18 General Fee Schedule 1/1/2019
L5650 Y $566.61 General Fee Schedule 1/1/2019
L5651 Y $1,583.74 General Fee Schedule 1/1/2019
L5652 Y $503.08 General Fee Schedule 1/1/2019
L5653 Y $589.24 General Fee Schedule 1/1/2019
L5654 Y $389.91 General Fee Schedule 1/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 108 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
L5655 Y $303.33 General Fee Schedule 1/1/2019
L5656 Y $375.97 General Fee Schedule 1/1/2019
L5658 Y $359.62 General Fee Schedule 1/1/2019
L5661 Y $601.90 General Fee Schedule 1/1/2019
L5665 Y $541.24 General Fee Schedule 1/1/2019
L5666 Y $92.31 General Fee Schedule 1/1/2019
L5668 Y $133.17 General Fee Schedule 1/1/2019
L5670 Y $357.85 General Fee Schedule 1/1/2019
L5671 Y $568.67 General Fee Schedule 1/1/2019
L5672 Y $294.93 General Fee Schedule 1/1/2019
L5673 Y $724.61 General Fee Schedule 1/1/2019
L5676 Y $466.77 General Fee Schedule 1/1/2019
L5677 Y $650.23 General Fee Schedule 1/1/2019
L5678 Y $52.36 General Fee Schedule 1/1/2019
L5679 Y $603.82 General Fee Schedule 1/1/2019
L5680 Y $322.86 General Fee Schedule 1/1/2019
L5681 Y $1,315.55 General Fee Schedule 1/1/2019
L5682 Y $631.10 General Fee Schedule 1/1/2019
L5683 Y $1,315.55 General Fee Schedule 1/1/2019
L5684 Y $53.24 General Fee Schedule 1/1/2019
L5685 Y $128.08 General Fee Schedule 1/1/2019
L5686 Y $53.43 General Fee Schedule 1/1/2019
L5688 Y $75.96 General Fee Schedule 1/1/2019
L5690 Y $106.71 General Fee Schedule 1/1/2019
L5692 Y $175.24 General Fee Schedule 1/1/2019
L5694 Y $239.25 General Fee Schedule 1/1/2019
L5695 Y $215.07 General Fee Schedule 1/1/2019
L5696 Y $219.54 General Fee Schedule 1/1/2019
L5697 Y $79.40 General Fee Schedule 1/1/2019
L5698 Y $118.37 General Fee Schedule 1/1/2019
L5699 Y $184.42 General Fee Schedule 1/1/2019
L5700 Y $2,833.64 General Fee Schedule 1/1/2019
L5701 Y $3,402.99 General Fee Schedule 1/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 109 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
L5702 Y $4,305.30 General Fee Schedule 1/1/2019
L5703 Y $2,636.11 General Fee Schedule 1/1/2019
L5704 Y $530.12 General Fee Schedule 1/1/2019
L5705 Y $947.20 General Fee Schedule 1/1/2019
L5706 Y $928.52 General Fee Schedule 1/1/2019
L5707 Y $1,224.14 General Fee Schedule 1/1/2019
L5710 Y $423.34 General Fee Schedule 1/1/2019
L5711 Y $536.22 General Fee Schedule 1/1/2019
L5712 Y $561.95 General Fee Schedule 1/1/2019
L5714 Y $474.76 General Fee Schedule 1/1/2019
L5716 Y $839.20 General Fee Schedule 1/1/2019
L5718 Y $925.86 General Fee Schedule 1/1/2019
L5722 Y $900.05 General Fee Schedule 1/1/2019
L5724 Y $1,990.57 General Fee Schedule 1/1/2019
L5726 Y $2,294.09 General Fee Schedule 1/1/2019
L5728 Y $2,450.94 General Fee Schedule 1/1/2019
L5780 Y $1,304.73 General Fee Schedule 1/1/2019
L5785 Y $572.94 General Fee Schedule 1/1/2019
L5790 Y $948.23 General Fee Schedule 1/1/2019
L5795 Y $1,415.95 General Fee Schedule 1/1/2019
L5810 Y $531.67 General Fee Schedule 1/1/2019
L5811 Y $787.57 General Fee Schedule 1/1/2019
L5812 Y $595.97 General Fee Schedule 1/1/2019
L5814 Y $3,714.31 General Fee Schedule 1/1/2019
L5816 Y $958.63 General Fee Schedule 1/1/2019
L5818 Y $961.19 General Fee Schedule 1/1/2019
L5822 Y $1,684.30 General Fee Schedule 1/1/2019
L5824 Y $1,806.89 General Fee Schedule 1/1/2019
L5826 Y $3,123.27 General Fee Schedule 1/1/2019
L5828 Y $2,793.09 General Fee Schedule 1/1/2019
L5830 Y $2,059.85 General Fee Schedule 1/1/2019
L5840 Y $3,469.89 General Fee Schedule 1/1/2019
L5845 Y $1,792.60 General Fee Schedule 1/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 110 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
L5848 Y $1,075.44 General Fee Schedule 1/1/2019
L5850 Y $168.70 General Fee Schedule 1/1/2019
L5855 Y $339.95 General Fee Schedule 1/1/2019
L5856 Y $24,008.73 General Fee Schedule 1/1/2019
L5857 Y $8,519.22 General Fee Schedule 1/1/2019
L5858 Y $18,587.44 General Fee Schedule 1/1/2019
L5859 Y $14,511.05 General Fee Schedule 1/1/2019
L5910 Y $477.63 General Fee Schedule 1/1/2019
L5920 Y $699.73 General Fee Schedule 1/1/2019
L5925 Y $443.12 General Fee Schedule 1/1/2019
L5930 Y $3,366.30 General Fee Schedule 1/1/2019
L5940 Y $661.51 General Fee Schedule 1/1/2019
L5950 Y $1,026.01 General Fee Schedule 1/1/2019
L5960 Y $1,271.34 General Fee Schedule 1/1/2019
L5961 Y $4,715.93 General Fee Schedule 1/1/2019
L5962 Y $627.47 General Fee Schedule 1/1/2019
L5964 Y $926.29 General Fee Schedule 1/1/2019
L5966 Y $1,180.32 General Fee Schedule 1/1/2019
L5968 Y $3,634.35 General Fee Schedule 1/1/2019
L5969 Y $13,782.16 General Fee Schedule 1/1/2014
L5970 Y $225.12 General Fee Schedule 1/1/2019
L5971 Y $225.12 General Fee Schedule 1/1/2019
L5972 Y $423.80 General Fee Schedule 1/1/2019
L5973 Y $17,206.77 General Fee Schedule 1/1/2019
L5974 Y $262.18 General Fee Schedule 1/1/2019
L5975 Y $463.68 General Fee Schedule 1/1/2019
L5976 Y $600.39 General Fee Schedule 1/1/2019
L5978 Y $336.62 General Fee Schedule 1/1/2019
L5979 Y $2,256.84 General Fee Schedule 1/1/2019
L5980 Y $3,878.93 General Fee Schedule 1/1/2019
L5981 Y $2,962.33 General Fee Schedule 1/1/2019
L5982 Y $619.07 General Fee Schedule 1/1/2019
L5984 Y $664.96 General Fee Schedule 1/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 111 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
L5985 Y $282.40 General Fee Schedule 1/1/2019
L5986 Y $661.66 General Fee Schedule 1/1/2019
L5987 Y $7,194.62 General Fee Schedule 1/1/2019
L5988 Y $1,997.94 General Fee Schedule 1/1/2019
L5990 Y $1,814.41 General Fee Schedule 1/1/2019
L5999 Y $0.00 General by Report 1/1/1989
L6000 Y $1,480.41 General Fee Schedule 1/1/2019
L6010 Y $1,489.46 General Fee Schedule 1/1/2019
L6020 Y $1,481.57 General Fee Schedule 1/1/2019
L6026 Y $3,708.24 General Fee Schedule 1/1/2019
L6050 Y $2,276.01 General Fee Schedule 1/1/2019
L6055 Y $2,807.63 General Fee Schedule 1/1/2019
L6100 Y $2,335.13 General Fee Schedule 1/1/2019
L6110 Y $2,478.77 General Fee Schedule 1/1/2019
L6120 Y $2,794.82 General Fee Schedule 1/1/2019
L6130 Y $2,589.73 General Fee Schedule 1/1/2019
L6200 Y $3,150.91 General Fee Schedule 1/1/2019
L6205 Y $3,601.79 General Fee Schedule 1/1/2019
L6250 Y $3,267.52 General Fee Schedule 1/1/2019
L6300 Y $3,934.76 General Fee Schedule 1/1/2019
L6310 Y $3,159.28 General Fee Schedule 1/1/2019
L6320 Y $1,900.68 General Fee Schedule 1/1/2019
L6350 Y $3,874.14 General Fee Schedule 1/1/2019
L6360 Y $3,150.39 General Fee Schedule 1/1/2019
L6370 Y $2,196.38 General Fee Schedule 1/1/2019
L6380 Y $1,298.37 General Fee Schedule 1/1/2019
L6382 Y $1,540.32 General Fee Schedule 1/1/2019
L6384 Y $1,909.49 General Fee Schedule 1/1/2019
L6386 Y $442.16 General Fee Schedule 1/1/2019
L6388 Y $494.15 General Fee Schedule 1/1/2019
L6400 Y $2,480.81 General Fee Schedule 1/1/2019
L6450 Y $3,049.41 General Fee Schedule 1/1/2019
L6500 Y $3,076.91 General Fee Schedule 1/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 112 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
L6550 Y $3,771.60 General Fee Schedule 1/1/2019
L6570 Y $4,329.07 General Fee Schedule 1/1/2019
L6580 Y $1,625.29 General Fee Schedule 1/1/2019
L6582 Y $1,507.30 General Fee Schedule 1/1/2019
L6584 Y $2,201.98 General Fee Schedule 1/1/2019
L6586 Y $2,166.48 General Fee Schedule 1/1/2019
L6588 Y $2,982.73 General Fee Schedule 1/1/2019
L6590 Y $2,925.23 General Fee Schedule 1/1/2019
L6600 Y $247.37 General Fee Schedule 1/1/2019
L6605 Y $244.25 General Fee Schedule 1/1/2019
L6610 Y $200.04 General Fee Schedule 1/1/2019
L6611 Y $411.77 General Fee Schedule 1/1/2019
L6615 Y $192.03 General Fee Schedule 1/1/2019
L6616 Y $81.63 General Fee Schedule 1/1/2019
L6620 Y $331.81 General Fee Schedule 1/1/2019
L6621 Y $2,287.57 General Fee Schedule 1/1/2019
L6623 Y $666.24 General Fee Schedule 1/1/2019
L6624 Y $3,766.55 General Fee Schedule 1/1/2019
L6625 Y $701.39 General Fee Schedule 1/1/2019
L6628 Y $510.55 General Fee Schedule 1/1/2019
L6629 Y $175.55 General Fee Schedule 1/1/2019
L6630 Y $284.22 General Fee Schedule 1/1/2019
L6632 Y $64.26 General Fee Schedule 1/1/2019
L6635 Y $218.83 General Fee Schedule 1/1/2019
L6637 Y $426.41 General Fee Schedule 1/1/2019
L6638 Y $2,501.02 General Fee Schedule 1/1/2019
L6640 Y $356.75 General Fee Schedule 1/1/2019
L6641 Y $192.93 General Fee Schedule 1/1/2019
L6642 Y $229.69 General Fee Schedule 1/1/2019
L6645 Y $398.38 General Fee Schedule 1/1/2019
L6646 Y $3,154.35 General Fee Schedule 1/1/2019
L6647 Y $519.31 General Fee Schedule 1/1/2019
L6648 Y $3,253.28 General Fee Schedule 1/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 113 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
L6650 Y $418.28 General Fee Schedule 1/1/2019
L6655 Y $91.58 General Fee Schedule 1/1/2019
L6660 Y $102.10 General Fee Schedule 1/1/2019
L6665 Y $60.73 General Fee Schedule 1/1/2019
L6670 Y $63.25 General Fee Schedule 1/1/2019
L6672 Y $175.98 General Fee Schedule 1/1/2019
L6675 Y $123.40 General Fee Schedule 1/1/2019
L6676 Y $129.73 General Fee Schedule 1/1/2019
L6677 Y $296.70 General Fee Schedule 1/1/2019
L6680 Y $305.96 General Fee Schedule 1/1/2019
L6682 Y $299.60 General Fee Schedule 1/1/2019
L6684 Y $344.76 General Fee Schedule 1/1/2019
L6686 Y $641.01 General Fee Schedule 1/1/2019
L6687 Y $570.51 General Fee Schedule 1/1/2019
L6688 Y $674.29 General Fee Schedule 1/1/2019
L6689 Y $705.59 General Fee Schedule 1/1/2019
L6690 Y $765.59 General Fee Schedule 1/1/2019
L6691 Y $341.42 General Fee Schedule 1/1/2019
L6692 Y $703.77 General Fee Schedule 1/1/2019
L6693 Y $2,839.32 General Fee Schedule 1/1/2019
L6694 Y $724.61 General Fee Schedule 1/1/2019
L6695 Y $603.82 General Fee Schedule 1/1/2019
L6696 Y $1,315.55 General Fee Schedule 1/1/2019
L6697 Y $1,315.55 General Fee Schedule 1/1/2019
L6698 Y $568.67 General Fee Schedule 1/1/2019
L6703 Y $327.11 General Fee Schedule 1/1/2019
L6704 Y $767.11 General Fee Schedule 1/1/2019
L6706 Y $397.97 General Fee Schedule 1/1/2019
L6707 Y $1,416.09 General Fee Schedule 1/1/2019
L6708 Y $951.73 General Fee Schedule 1/1/2019
L6709 Y $1,396.37 General Fee Schedule 1/1/2019
L6711 Y $672.40 General Fee Schedule 1/1/2019
L6712 Y $1,238.03 General Fee Schedule 1/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 114 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
L6713 Y $1,562.49 General Fee Schedule 1/1/2019
L6714 Y $1,323.43 General Fee Schedule 1/1/2019
L6715 Y $3,157.52 General Fee Schedule 1/1/2019
L6721 Y $2,352.25 General Fee Schedule 1/1/2019
L6722 Y $2,027.80 General Fee Schedule 1/1/2019
L6805 Y $420.89 General Fee Schedule 1/1/2019
L6810 Y $245.99 General Fee Schedule 1/1/2019
L6880 Y $23,895.34 General Fee Schedule 1/1/2019
L6881 Y $4,088.74 General Fee Schedule 1/1/2019
L6883 Y $1,845.59 General Fee Schedule 1/1/2019
L6884 Y $2,769.87 General Fee Schedule 1/1/2019
L6885 Y $3,150.39 General Fee Schedule 1/1/2019
L6890 Y $182.34 General Fee Schedule 1/1/2019
L6895 Y $552.29 General Fee Schedule 1/1/2019
L6900 Y $1,529.27 General Fee Schedule 1/1/2019
L6905 Y $1,452.18 General Fee Schedule 1/1/2019
L6910 Y $1,431.00 General Fee Schedule 1/1/2019
L6915 Y $619.19 General Fee Schedule 1/1/2019
L6920 Y $7,248.06 General Fee Schedule 1/1/2019
L6925 Y $7,653.32 General Fee Schedule 1/1/2019
L6930 Y $7,781.62 General Fee Schedule 1/1/2019
L6935 Y $8,559.71 General Fee Schedule 1/1/2019
L6940 Y $9,725.35 General Fee Schedule 1/1/2019
L6945 Y $11,001.66 General Fee Schedule 1/1/2019
L6950 Y $10,339.92 General Fee Schedule 1/1/2019
L6955 Y $12,975.16 General Fee Schedule 1/1/2019
L6960 Y $12,794.14 General Fee Schedule 1/1/2019
L6965 Y $18,690.43 General Fee Schedule 1/1/2019
L6970 Y $18,997.54 General Fee Schedule 1/1/2019
L6975 Y $19,099.51 General Fee Schedule 1/1/2019
L7007 Y $4,537.98 General Fee Schedule 1/1/2019
L7008 Y $7,142.29 General Fee Schedule 1/1/2019
L7009 Y $4,630.17 General Fee Schedule 1/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 115 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
L7040 Y $3,717.84 General Fee Schedule 1/1/2019
L7045 Y $2,131.57 General Fee Schedule 1/1/2019
L7170 Y $7,732.62 General Fee Schedule 1/1/2019
L7180 Y $40,401.13 General Fee Schedule 1/1/2019
L7181 Y $40,072.86 General Fee Schedule 1/1/2019
L7185 Y $7,830.31 General Fee Schedule 1/1/2019
L7186 Y $11,301.04 General Fee Schedule 1/1/2019
L7190 Y $9,962.59 General Fee Schedule 1/1/2019
L7191 Y $12,012.66 General Fee Schedule 1/1/2019
L7259 Y $3,797.80 General Fee Schedule 1/1/2019
L7360 Y $238.16 General Fee Schedule 1/1/2019
L7362 Y $286.45 General Fee Schedule 1/1/2019
L7364 Y $521.79 General Fee Schedule 1/1/2019
L7366 Y $707.87 General Fee Schedule 1/1/2019
L7367 Y $389.36 General Fee Schedule 1/1/2019
L7368 Y $504.77 General Fee Schedule 1/1/2019
L7400 Y $306.52 General Fee Schedule 1/1/2019
L7401 Y $343.16 General Fee Schedule 1/1/2019
L7402 Y $370.56 General Fee Schedule 1/1/2019
L7403 Y $368.31 General Fee Schedule 1/1/2019
L7404 Y $555.87 General Fee Schedule 1/1/2019
L7405 Y $727.02 General Fee Schedule 1/1/2019
L7499 Y $0.00 General by Report 11/1/1988
L7510 Y $88.26 General Fee Schedule 7/1/2004
L7520 Y $28.91 General Fee Schedule 1/28/2013
L7600 Y $0.00 General by Report 1/1/2006
L7700 Y $111.63 General Fee Schedule 1/1/2019
L8000 Y $37.11 General Fee Schedule 1/1/2019
L8001 Y $125.44 General Fee Schedule 1/1/2019
L8002 Y $165.00 General Fee Schedule 1/1/2019
L8010 Y $0.00 General by Report 7/1/2005
L8015 Y $59.95 General Fee Schedule 1/1/2019
L8020 Y $224.72 General Fee Schedule 1/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 116 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
L8030 Y $329.93 General Fee Schedule 1/1/2019
L8031 Y $329.93 General Fee Schedule 1/1/2019
L8032 Y $39.18 General Fee Schedule 1/1/2019
L8040 Y $2,383.80 General Fee Schedule 1/1/2019
L8041 Y $2,873.28 General Fee Schedule 1/1/2019
L8042 Y $3,228.41 General Fee Schedule 1/1/2019
L8043 Y $3,615.80 General Fee Schedule 1/1/2019
L8044 Y $4,003.21 General Fee Schedule 1/1/2019
L8045 Y $2,506.79 General Fee Schedule 1/1/2019
L8046 Y $2,582.71 General Fee Schedule 1/1/2019
L8047 Y $1,323.66 General Fee Schedule 1/1/2019
L8048 Y $0.00 General by Report 1/1/2001
L8049 Y $21.75 General Fee Schedule 7/1/2004
L8300 Y $83.43 General Fee Schedule 1/1/2019
L8310 Y $131.73 General Fee Schedule 1/1/2019
L8320 Y $60.82 General Fee Schedule 1/1/2019
L8330 Y $65.10 General Fee Schedule 1/1/2019
L8400 Y $15.57 General Fee Schedule 1/1/2019
L8410 Y $22.76 General Fee Schedule 1/1/2019
L8415 Y $23.14 General Fee Schedule 1/1/2019
L8417 Y $75.20 General Fee Schedule 1/1/2019
L8420 Y $20.56 General Fee Schedule 1/1/2019
L8430 Y $22.58 General Fee Schedule 1/1/2019
L8435 Y $23.85 General Fee Schedule 1/1/2019
L8440 Y $43.69 General Fee Schedule 1/1/2019
L8460 Y $76.02 General Fee Schedule 1/1/2019
L8465 Y $54.16 General Fee Schedule 1/1/2019
L8470 Y $7.91 General Fee Schedule 1/1/2019
L8480 Y $10.40 General Fee Schedule 1/1/2019
L8485 Y $11.00 General Fee Schedule 1/1/2019
L8499 Y $0.00 General by Report 11/1/1988
L8500 Y $768.94 General Fee Schedule 1/1/2019
L8501 Y $119.48 General Fee Schedule 1/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 117 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
L8505 Y $6.19 General Fee Schedule 7/1/2004
L8507 Y $41.89 General Fee Schedule 1/1/2019
L8509 Y $109.23 General Fee Schedule 1/1/2019
L8510 Y $252.75 General Fee Schedule 1/1/2019
L8511 Y $72.74 General Fee Schedule 1/1/2019
L8512 Y $2.19 General Fee Schedule 1/1/2019
L8513 Y $5.22 General Fee Schedule 1/1/2019
L8514 Y $94.31 General Fee Schedule 1/1/2019
L8515 Y $63.12 General Fee Schedule 1/1/2019
L8603 Y $433.11 General Fee Schedule 1/1/2019
L8604 Y $0.00 General by Report 1/1/2009
L8605 Y $716.30 General Fee Schedule 1/1/2019
L8606 Y $217.64 General Fee Schedule 1/1/2019
L8607 Y $42.90 General Fee Schedule 1/1/2019
L8609 Y $6,516.20 General Fee Schedule 1/1/2019
L8610 Y $656.14 General Fee Schedule 1/1/2019
L8614 Y $19,143.72 General Fee Schedule 1/1/2019
L8615 Y $451.08 General Fee Schedule 1/1/2019
L8616 Y $105.06 General Fee Schedule 1/1/2019
L8617 Y $91.78 General Fee Schedule 1/1/2019
L8618 Y $26.22 General Fee Schedule 1/1/2019
L8619 Y $8,218.26 General Fee Schedule 1/1/2019
L8621 N $0.61 General Fee Schedule 1/1/2019
L8622 N $0.32 General Fee Schedule 1/1/2019
L8623 Y $64.68 General Fee Schedule 1/1/2019
L8624 Y $161.26 General Fee Schedule 1/1/2019
L8625 Y $188.90 General Fee Schedule 1/1/2019
L8627 Y $6,981.02 General Fee Schedule 1/1/2019
L8628 Y $1,237.24 General Fee Schedule 1/1/2019
L8629 Y $179.08 General Fee Schedule 1/1/2019
L8631 Y $2,171.15 General Fee Schedule 1/1/2019
L8658 Y $301.87 General Fee Schedule 1/1/2019
L8659 Y $1,929.93 General Fee Schedule 1/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 118 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
L8670 Y $550.58 General Fee Schedule 1/1/2019
L8679 Y $8,345.03 General Fee Schedule 1/1/2019
L8680 N $436.32 General Fee Schedule 2/10/2014
L8681 Y $1,067.01 General Fee Schedule 1/1/2019
L8682 N $5,962.37 General Fee Schedule 1/1/2019
L8683 N $5,248.24 General Fee Schedule 1/1/2019
L8684 N $772.15 General Fee Schedule 1/1/2019
L8685 N $12,200.84 General Fee Schedule 1/10/2012
L8686 N $7,785.10 General Fee Schedule 1/10/2012
L8687 N $15,878.18 General Fee Schedule 1/10/2012
L8688 N $10,131.55 General Fee Schedule 1/10/2012
L8689 Y $1,725.18 General Fee Schedule 1/1/2019
L8690 Y $4,757.72 General Fee Schedule 1/1/2019
L8691 Y $1,722.37 General Fee Schedule 1/1/2019
L8692 Y $0.00 General by Report 1/1/2010
L8693 Y $1,516.53 General Fee Schedule 1/1/2019
L8694 N $944.53 General Fee Schedule 1/1/2019
L8695 Y $16.66 General Fee Schedule 1/1/2019
L8696 Y $216.76 General Fee Schedule 1/1/2019
L8699 Y $0.00 General by Report 1/1/1998
L9900 Y $0.00 General by Report 1/1/2000
P2028 Y $5.17 General Fee Schedule 1/1/2019
P2029 Y $5.17 General Fee Schedule 1/1/2019
P2033 Y $5.17 General Fee Schedule 1/1/2019
P2038 Y $5.17 General Fee Schedule 1/1/2019
P3000 Y $14.09 General Fee Schedule 1/1/2019
P3001 Y $30.04 General Fee Schedule 8/1/2016
P7001 Y $10.07 General Fee Schedule 7/1/2004
P9010 Y $0.00 General by Report 4/1/2010
P9011 Y $0.00 General by Report 4/1/2010
P9012 Y $0.00 General by Report 4/1/2010
P9016 Y $0.00 General by Report 4/1/2010
P9017 Y $0.00 General by Report 4/1/2010
HCPCS FEES11/06/2019 at 7:08:01 AM - 119 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
P9019 Y $0.00 General by Report 4/1/2010
P9020 Y $0.00 General by Report 4/1/2010
P9021 Y $0.00 General by Report 4/1/2010
P9022 Y $0.00 General by Report 4/1/2010
P9023 Y $0.00 General by Report 5/1/2013
P9041 Y $10.49 General Fee Schedule 10/1/2018
P9043 Y $9.57 General Fee Schedule 4/1/2014
P9044 Y $0.00 General by Report 5/1/2013
P9045 Y $52.45 General Fee Schedule 10/1/2018
P9046 Y $20.98 General Fee Schedule 10/1/2018
P9047 Y $52.45 General Fee Schedule 10/1/2018
P9048 Y $47.86 General Fee Schedule 4/1/2014
P9059 Y $0.00 General by Report 5/1/2013
P9060 Y $0.00 General by Report 5/1/2013
P9070 Y $0.00 General by Report 1/1/2016
P9071 Y $0.00 General by Report 1/1/2016
P9073 Y $0.00 General by Report 1/1/2018
P9100 Y $0.00 General by Report 1/1/2018
P9612 Y $2.82 General Fee Schedule 1/1/2017
P9615 Y $2.82 General Fee Schedule 1/1/2017
Q0035 Y $7.74 26 Fee Schedule (FS) 8/1/2016
Q0035 Y $17.75 General Fee Schedule 1/1/2011
Q0035 Y $9.69 TC Fee Schedule 1/1/2011
Q0081 Y $0.00 General by Report 4/1/2010
Q0083 Y $0.00 General by Report 4/1/2010
Q0084 Y $0.00 General by Report 4/1/2010
Q0085 Y $0.00 General by Report 4/1/2010
Q0092 Y $10.55 General Fee Schedule 7/1/2006
Q0111 Y $14.09 General Fee Schedule 1/1/2019
Q0112 Y $5.48 General Fee Schedule 1/1/2018
Q0113 Y $4.47 General Fee Schedule 1/1/2019
Q0114 Y $9.16 General Fee Schedule 1/1/2018
Q0115 Y $23.50 General Fee Schedule 1/1/2018
HCPCS FEES11/06/2019 at 7:08:01 AM - 120 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
Q0138 Y $1.00 General Fee Schedule 7/1/2019
Q0139 Y $1.00 General Fee Schedule 7/1/2019
Q0144 Y $0.00 General by Report 5/1/2013
Q0161 Y $0.00 General by Report 1/1/2014
Q0162 Y $0.02 General Fee Schedule 10/1/2019
Q0163 Y $0.28 General Fee Schedule 7/1/2019
Q0164 Y $0.22 General Fee Schedule 10/1/2019
Q0166 Y $0.96 General Fee Schedule 10/1/2019
Q0167 Y $0.62 General Fee Schedule 10/1/2019
Q0169 Y $0.04 General Fee Schedule 4/1/2019
Q0173 Y $0.84 General Fee Schedule 4/1/2011
Q0174 Y $0.00 General by Report 5/1/2013
Q0175 Y $0.55 General Fee Schedule 4/1/2011
Q0177 Y $0.04 General Fee Schedule 1/1/2011
Q0180 Y $101.24 General Fee Schedule 1/1/2017
Q0181 Y $0.00 General by Report 5/1/2013
Q0477 Y $775.95 General Fee Schedule 1/1/2019
Q0478 N $183.79 General Fee Schedule 1/1/2019
Q0479 N $11,976.01 General Fee Schedule 1/1/2019
Q0506 N $854.23 General Fee Schedule 1/1/2019
Q0515 Y $1.80 General Fee Schedule 4/1/2009
Q2004 Y $0.00 General Fee Schedule 1/1/2001
Q2009 Y $1.41 General Fee Schedule 4/1/2014
Q2017 Y $346.95 General Fee Schedule 1/1/2014
Q2026 Y $0.00 General by Report 7/1/2010
Q2033 Y $0.00 General by Report 7/1/2013
Q2034 Y $0.00 General by Report 7/1/2012
Q2035 Y $18.24 General Fee Schedule 10/1/2018
Q2036 Y $8.58 General Fee Schedule 10/1/2013
Q2037 Y $17.69 General Fee Schedule 10/1/2017
Q2038 Y $12.04 General Fee Schedule 10/1/2013
Q2039 Y $13.00 General Fee Schedule 4/1/2011
Q2043 Y $46,374.20 General Fee Schedule 10/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 121 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
Q2049 Y $508.43 General Fee Schedule 10/1/2014
Q2050 Y $355.07 General Fee Schedule 10/1/2019
Q3001 Y $23.64 General Fee Schedule 7/1/2004
Q3027 Y $53.58 General Fee Schedule 10/1/2019
Q3028 Y $31.21 General Fee Schedule 1/1/2014
Q3031 Y $3.36 General Fee Schedule 7/1/2004
Q4074 Y $141.83 General Fee Schedule 1/1/2019
Q4081 Y $1.10 General Fee Schedule 10/1/2019
Q4101 Y $30.71 General Fee Schedule 10/1/2019
Q4102 Y $10.53 General Fee Schedule 10/1/2019
Q4103 Y $9.69 General Fee Schedule 1/1/2014
Q4104 Y $38.89 General Fee Schedule 10/1/2016
Q4105 Y $30.36 General Fee Schedule 10/1/2016
Q4106 Y $33.00 General Fee Schedule 10/1/2019
Q4107 Y $92.59 General Fee Schedule 10/1/2019
Q4108 Y $40.70 General Fee Schedule 10/1/2016
Q4110 Y $47.65 General Fee Schedule 10/1/2019
Q4111 Y $6.97 General Fee Schedule 10/1/2019
Q4112 Y $872.08 General Fee Schedule 7/1/2019
Q4113 Y $919.55 General Fee Schedule 10/1/2019
Q4114 Y $1,577.70 General Fee Schedule 1/1/2016
Q4115 Y $13.50 General Fee Schedule 10/1/2019
Q4116 Y $31.11 General Fee Schedule 4/1/2018
Q4117 Y $0.00 General by Report 1/1/2011
Q4118 Y $0.00 General by Report 1/1/2011
Q4121 Y $41.07 General Fee Schedule 10/1/2019
Q4122 Y $0.00 General by Report 1/1/2012
Q4123 Y $20.19 General Fee Schedule 10/1/2018
Q4124 Y $0.00 General by Report 1/1/2012
Q4125 Y $0.00 General by Report 1/1/2012
Q4126 Y $0.00 General by Report 1/1/2012
Q4127 Y $0.00 General by Report 1/1/2012
Q4128 Y $0.00 General by Report 1/1/2012
HCPCS FEES11/06/2019 at 7:08:01 AM - 122 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
Q4130 Y $0.00 General by Report 1/1/2012
Q4132 Y $117.92 General Fee Schedule 10/1/2019
Q4133 Y $140.56 General Fee Schedule 10/1/2019
Q4134 Y $0.00 General by Report 1/1/2013
Q4135 Y $0.00 General by Report 1/1/2013
Q4136 Y $0.00 General by Report 1/1/2013
Q4137 Y $77.62 General Fee Schedule 10/1/2019
Q4138 Y $0.00 General by Report 1/1/2014
Q4139 Y $0.00 General by Report 1/1/2014
Q4140 Y $0.00 General by Report 1/1/2014
Q4141 Y $0.00 General by Report 1/1/2014
Q4142 Y $0.00 General by Report 1/1/2014
Q4143 Y $0.00 General by Report 1/1/2014
Q4145 Y $21.08 General Fee Schedule 10/1/2019
Q4146 Y $0.00 General by Report 1/1/2014
Q4147 Y $0.00 General by Report 1/1/2014
Q4148 Y $0.00 General by Report 1/1/2014
Q4149 Y $0.00 General by Report 1/1/2014
Q4150 Y $0.00 General by Report 1/1/2015
Q4151 Y $158.28 General Fee Schedule 10/1/2019
Q4152 Y $0.00 General by Report 1/1/2015
Q4153 Y $0.00 General by Report 1/1/2015
Q4154 Y $113.98 General Fee Schedule 10/1/2019
Q4155 Y $0.00 General by Report 1/1/2015
Q4156 Y $0.00 General by Report 1/1/2015
Q4157 Y $0.00 General by Report 1/1/2015
Q4158 Y $0.00 General by Report 1/1/2015
Q4159 Y $644.48 General Fee Schedule 10/1/2019
Q4160 Y $110.16 General Fee Schedule 10/1/2019
Q4161 Y $0.00 General by Report 1/1/2016
Q4162 Y $0.00 General by Report 1/1/2016
Q4163 Y $0.00 General by Report 1/1/2016
Q4164 Y $0.00 General by Report 1/1/2016
HCPCS FEES11/06/2019 at 7:08:01 AM - 123 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
Q4165 Y $0.00 General by Report 1/1/2016
Q4166 Y $0.00 General by Report 1/1/2017
Q4167 Y $0.00 General by Report 1/1/2017
Q4168 Y $0.00 General by Report 1/1/2017
Q4169 Y $0.00 General by Report 1/1/2017
Q4170 Y $132.78 General Fee Schedule 10/1/2019
Q4171 Y $0.00 General by Report 1/1/2017
Q4173 Y $0.00 General by Report 1/1/2017
Q4174 Y $0.00 General by Report 1/1/2017
Q4175 Y $0.00 General by Report 1/1/2017
Q4176 Y $0.00 General by Report 1/1/2018
Q4177 Y $0.00 General by Report 1/1/2018
Q4178 Y $0.00 General by Report 1/1/2018
Q4179 Y $0.00 General by Report 1/1/2018
Q4180 Y $0.00 General by Report 1/1/2018
Q4181 Y $0.00 General by Report 1/1/2018
Q4182 Y $0.00 General by Report 1/1/2018
Q4183 N $0.00 General by Report 1/1/2019
Q4184 N $0.00 General by Report 1/1/2019
Q4185 Y $0.00 General by Report 1/1/2019
Q4186 Y $160.42 General Fee Schedule 10/1/2019
Q4187 N $0.00 General by Report 1/1/2019
Q4188 N $0.00 General by Report 1/1/2019
Q4189 Y $0.00 General by Report 1/1/2019
Q4190 N $0.00 General by Report 1/1/2019
Q4191 N $0.00 General by Report 1/1/2019
Q4192 Y $0.00 General by Report 1/1/2019
Q4193 N $0.00 General by Report 1/1/2019
Q4194 N $0.00 General by Report 1/1/2019
Q4195 Y $89.70 General Fee Schedule 10/1/2019
Q4196 Y $104.83 General Fee Schedule 10/1/2019
Q4197 N $0.00 General by Report 1/1/2019
Q4198 N $0.00 General by Report 1/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 124 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
Q4200 N $0.00 General by Report 1/1/2019
Q4201 N $0.00 General by Report 1/1/2019
Q4202 Y $0.00 General by Report 1/1/2019
Q4203 N $0.00 General by Report 1/1/2019
Q4204 N $0.00 General by Report 1/1/2019
Q5101 Y $0.57 General Fee Schedule 10/1/2019
Q5105 Y $0.96 General Fee Schedule 10/1/2019
Q5106 Y $9.63 General Fee Schedule 10/1/2019
Q5107 Y $69.77 General Fee Schedule 10/1/2019
Q5108 Y $327.41 General Fee Schedule 10/1/2019
Q5109 Y $0.00 General by Report 1/1/2019
Q5110 Y $0.64 General Fee Schedule 10/1/2019
Q5111 Y $347.06 General Fee Schedule 10/1/2019
Q5112 Y $0.00 General by Report 7/1/2019
Q5113 Y $0.00 General by Report 7/1/2019
Q5114 Y $0.00 General by Report 7/1/2019
Q5115 Y $0.00 General by Report 7/1/2019
Q9489 Y $41.67 General Fee Schedule 7/1/2017
Q9490 Y $38.00 General Fee Schedule 7/1/2017
Q9950 Y $19.54 General Fee Schedule 10/1/2019
Q9951 Y $0.00 Manual Review Fee Schedule
1/1/2007
Q9953 Y $62.05 General Fee Schedule 4/1/2010
Q9954 Y $11.66 General Fee Schedule 1/1/2013
Q9955 Y $13.05 General Fee Schedule 4/1/2005
Q9956 Y $32.27 General Fee Schedule 10/1/2019
Q9957 Y $48.41 General Fee Schedule 10/1/2019
Q9958 Y $0.07 General Fee Schedule 7/1/2019
Q9959 Y $0.00 Manual Review Fee Schedule
1/1/2007
Q9960 Y $0.23 General Fee Schedule 10/1/2019
Q9961 Y $0.26 General Fee Schedule 10/1/2018
Q9962 Y $0.18 General Fee Schedule 1/1/2007
Q9963 Y $0.20 General Fee Schedule 10/1/2019
HCPCS FEES11/06/2019 at 7:08:01 AM - 125 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
Q9964 Y $0.29 General Fee Schedule 1/1/2008
Q9965 Y $1.01 General Fee Schedule 10/1/2019
Q9966 Y $0.31 General Fee Schedule 10/1/2019
Q9967 Y $0.12 General Fee Schedule 10/1/2019
Q9968 Y $0.00 General by Report 1/1/2010
Q9969 Y $0.00 General by Report 1/1/2013
Q9976 Y $0.00 General by Report 7/1/2015
Q9982 Y $0.00 General by Report 7/1/2016
Q9983 Y $0.00 General by Report 7/1/2016
Q9991 Y $1,673.36 General Fee Schedule 10/1/2019
Q9992 Y $1,673.36 General Fee Schedule 10/1/2019
R0070 Y $97.40 General Fee Schedule 7/1/2006
R0075 Y $97.40 General Fee Schedule 7/1/2006
S0012 Y $0.00 General by Report 5/1/2013
S0014 Y $0.00 General by Report 5/1/2013
S0017 Y $0.00 General by Report 5/1/2013
S0020 Y $0.00 General by Report 5/1/2013
S0021 Y $0.00 General by Report 5/1/2013
S0023 Y $0.00 General by Report 5/1/2013
S0028 Y $0.00 General by Report 5/1/2013
S0030 Y $0.00 General by Report 5/1/2013
S0032 Y $28.31 General Fee Schedule 1/1/2017
S0034 Y $0.00 General by Report 5/1/2013
S0039 Y $0.00 General by Report 5/1/2013
S0040 N $18.72 General Fee Schedule 7/1/2004
S0073 Y $0.00 General by Report 5/1/2013
S0074 Y $0.00 General by Report 5/1/2013
S0077 Y $0.00 General by Report 5/1/2013
S0078 Y $0.00 General by Report 5/1/2013
S0080 Y $0.00 General by Report 5/1/2013
S0081 Y $0.00 General by Report 5/1/2013
S0088 Y $22.66 General Fee Schedule 7/1/2004
S0090 Y $0.00 General by Report 5/1/2013
HCPCS FEES11/06/2019 at 7:08:01 AM - 126 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
S0091 Y $196.02 General Fee Schedule 7/1/2004
S0092 Y $90.62 General Fee Schedule 7/1/2004
S0093 Y $37.43 General Fee Schedule 7/1/2004
S0104 Y $0.00 General by Report 5/1/2013
S0106 Y $0.00 General by Report 5/1/2013
S0108 Y $0.00 General by Report 5/1/2013
S0109 Y $0.00 Manual Review Fee Schedule
7/1/2009
S0117 Y $0.00 General by Report 5/1/2013
S0119 Y $0.64 General Fee Schedule 1/1/2012
S0122 Y $0.00 General by Report 5/1/2013
S0126 Y $0.00 General by Report 5/1/2013
S0128 Y $0.00 General by Report 5/1/2013
S0132 Y $0.00 General by Report 5/1/2013
S0136 Y $165.59 General Fee Schedule 7/1/2004
S0137 Y $0.00 General by Report 5/1/2013
S0138 Y $0.00 General by Report 5/1/2013
S0139 Y $0.00 General by Report 5/1/2013
S0140 Y $0.00 General by Report 5/1/2013
S0142 Y $0.00 General by Report 5/1/2013
S0145 Y $399.79 General Fee Schedule 7/1/2005
S0148 Y $0.00 General by Report 10/1/2010
S0155 Y $9.85 General Fee Schedule 7/1/2004
S0156 Y $0.00 General by Report 5/1/2013
S0157 Y $0.00 General by Report 5/1/2013
S0160 Y $0.00 General by Report 4/1/2004
S0164 Y $0.00 General by Report 4/1/2004
S0166 Y $0.00 General by Report 7/1/2004
S0169 Y $0.00 General by Report 10/1/2010
S0170 Y $10.84 General Fee Schedule 7/1/2004
S0171 Y $5.91 General Fee Schedule 7/1/2004
S0172 Y $4.92 General Fee Schedule 7/1/2004
S0174 Y $60.08 General Fee Schedule 7/1/2004
S0175 Y $5.91 General Fee Schedule 7/1/2004
HCPCS FEES11/06/2019 at 7:08:01 AM - 127 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
S0176 Y $4.92 General Fee Schedule 7/1/2004
S0177 Y $9.85 General Fee Schedule 7/1/2004
S0178 Y $9.85 General Fee Schedule 7/1/2004
S0179 Y $3.94 General Fee Schedule 7/1/2004
S0182 Y $3.94 General Fee Schedule 7/1/2004
S0183 Y $3.94 General Fee Schedule 7/1/2004
S0187 Y $4.92 General Fee Schedule 7/1/2004
S0189 Y $18.72 General Fee Schedule 7/1/2004
S0190 N $88.65 General Fee Schedule 7/1/2004
S0191 N $1.77 General Fee Schedule 7/1/2004
S0194 Y $0.00 General by Report 5/1/2013
S0197 Y $0.00 General by Report 5/1/2013
S0280 Y $0.00 General Fee Schedule 4/1/2016
S0832 Y $0.00 General by Report 10/1/2014
S1015 N $2.73 General Fee Schedule 7/1/2004
S1034 N $0.00 General by Report 7/1/2014
S1034 N $0.00 Rental by Report 7/1/2014
S1035 Y $0.00 General by Report 7/1/2014
S1036 N $0.00 General by Report 7/1/2014
S1036 N $0.00 Rental by Report 7/1/2014
S1037 N $0.00 General by Report 7/1/2014
S1037 N $0.00 Rental by Report 7/1/2014
S1040 Y $0.00 Manual Review Fee Schedule
10/1/2002
S1090 Y $0.00 General by Report 7/1/2012
S2118 Y $0.00 Manual Review Fee Schedule
7/1/2009
S2225 Y $0.00 Manual Review Fee Schedule
7/1/2009
S2260 Y $0.00 General Fee Schedule 1/1/2002
S2265 Y $0.00 General Fee Schedule 1/1/2004
S2266 Y $0.00 General Fee Schedule 1/1/2004
S2267 Y $0.00 General Fee Schedule 1/1/2004
S2325 Y $945.84 General Fee Schedule 1/1/2011
S2348 Y $462.78 General Fee Schedule 12/1/2009
HCPCS FEES11/06/2019 at 7:08:01 AM - 128 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
S3620 Y $114.00 General Fee Schedule 7/1/2014
S3645 Y $0.00 26 by Report 1/1/2000
S3650 Y $0.00 26 by Report 1/1/2000
S3652 Y $0.00 26 by Report 1/1/2000
S3722 Y $0.00 General by Report 1/1/2012
S4005 Y $0.00 General Fee Schedule 1/1/2019
S4989 N $627.38 General Fee Schedule 2/1/2008
S4990 Y $0.00 General by Report 5/1/2013
S4991 Y $0.00 General by Report 5/1/2013
S4993 Y $23.30 General Fee Schedule 2/1/2008
S4995 Y $0.00 General by Report 5/1/2013
S5000 N $0.00 Manual Review Fee Schedule
1/1/2007
S5001 N $0.00 Manual Review Fee Schedule
1/1/2007
S5010 Y $0.00 General by Report 5/1/2013
S5012 Y $0.00 General by Report 5/1/2013
S5013 Y $0.00 General by Report 5/1/2013
S5014 Y $0.00 General by Report 5/1/2013
S5100 Y $0.00 General Fee Schedule 1/1/2004
S5125 Y $3.43 General Fee Schedule 12/1/2009
S5151 Y $68.95 General Fee Schedule 7/1/2004
S5160 Y $1.00 General Fee Schedule 7/1/2004
S5161 Y $0.00 General Fee Schedule 1/1/2004
S5165 Y $0.00 General Fee Schedule 1/1/2004
S5190 Y $0.00 General Fee Schedule 4/1/2011
S5199 Y $0.00 General Fee Schedule 12/1/2009
S5550 Y $0.00 General by Report 5/1/2013
S5551 Y $0.00 General by Report 5/1/2013
S5552 Y $0.00 General by Report 5/1/2013
S5553 Y $0.00 General by Report 5/1/2013
S5560 Y $0.00 General by Report 5/1/2013
S5561 Y $0.00 General by Report 5/1/2013
S5565 Y $0.00 General by Report 5/1/2013
HCPCS FEES11/06/2019 at 7:08:01 AM - 129 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
S5566 Y $0.00 General by Report 5/1/2013
S5570 Y $0.00 General by Report 5/1/2013
S5571 Y $0.00 General by Report 5/1/2013
S8035 Y $0.00 26 by Report 1/1/2000
S8040 Y $0.00 26 by Report 1/1/2000
S8092 Y $0.00 26 by Report 1/1/2000
S8096 N $0.00 Manual Review Fee Schedule
NU 7/1/2009
S8097 Y $12.62 General Fee Schedule 7/1/2004
S8100 Y $15.16 General Fee Schedule 7/1/2004
S8101 N $0.00 Manual Review Fee Schedule
7/1/2009
S8130 Y $0.00 General by Report 1/1/2012
S8131 Y $0.00 General by Report 1/1/2012
S8210 N $0.00 General by Report 1/1/2007
S8265 N $0.00 Manual Review Fee Schedule
7/1/2009
S8420 N $0.00 General by Report 1/1/2007
S8421 N $0.00 General by Report 1/1/2007
S8422 N $0.00 General by Report 1/1/2007
S8423 N $0.00 Manual Review Fee Schedule
4/1/2010
S8424 N $0.00 General by Report 1/1/2007
S8425 N $0.00 General by Report 1/1/2007
S8426 N $0.00 Manual Review Fee Schedule
4/1/2010
S8427 N $0.00 General by Report 1/1/2007
S8428 N $0.00 Manual Review Fee Schedule
11/1/2009
S8429 N $0.00 General by Report 1/1/2007
S8460 Y $29.64 General Fee Schedule 7/1/2004
S8999 N $194.54 General Fee Schedule 7/1/2004
S9001 Y $64.02 Rental Fee Schedule RR 7/1/2004
S9024 Y $14.52 26 Fee Schedule (FS) 12/1/2009
S9024 Y $36.13 General Fee Schedule 12/1/2009
S9024 Y $21.61 TC Fee Schedule 12/1/2009
HCPCS FEES11/06/2019 at 7:08:01 AM - 130 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
S9122 Y $0.00 General Fee Schedule 3/1/2007
S9443 Y $56.47 General Fee Schedule 1/1/2014
S9446 Y $0.00 General Fee Schedule 1/1/2002
S9470 Y $0.00 General Fee Schedule 1/1/2004
S9480 Y $0.00 General Fee Schedule 1/1/2004
S9562 Y $1,417.00 General Fee Schedule 1/1/2007
T1040 Y $0.00 General by Report 1/1/2017
T2011 Y $0.00 General Fee Schedule 1/1/2004
T2034 Y $0.00 General Fee Schedule 1/1/2004
T4521 Y $0.65 General Fee Schedule 7/1/2006
T4522 N $0.53 General Fee Schedule 7/1/2006
T4523 N $0.98 General Fee Schedule 7/1/2006
T4524 N $0.98 General Fee Schedule 7/1/2006
T4529 N $0.65 General Fee Schedule 7/1/2006
T4530 N $0.45 General Fee Schedule 7/1/2006
T4533 N $0.98 General Fee Schedule 7/1/2006
T4544 Y $0.00 General by Report 1/1/2014
V2020 N $17.50 General Fee Schedule 5/1/2004
V2100 N $5.91 General Fee Schedule 7/1/2004
V2101 N $6.90 General Fee Schedule 7/1/2004
V2102 N $7.88 General Fee Schedule 7/1/2004
V2103 N $6.40 General Fee Schedule 7/1/2004
V2104 N $6.40 General Fee Schedule 7/1/2004
V2105 N $7.39 General Fee Schedule 7/1/2004
V2106 N $8.72 General Fee Schedule 7/1/2004
V2107 N $0.00 General by Report 1/1/2004
V2108 N $0.00 General by Report 1/1/2004
V2109 N $0.00 General by Report 1/1/2004
V2110 N $0.00 General by Report 1/1/2004
V2111 N $0.00 General by Report 1/1/2004
V2112 N $0.00 General by Report 1/1/2004
V2113 N $0.00 General by Report 1/1/2004
V2114 N $0.00 General by Report 1/1/2004
HCPCS FEES11/06/2019 at 7:08:01 AM - 131 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
V2115 N $0.00 General by Report 1/1/2004
V2118 N $0.00 General by Report 1/1/2004
V2121 N $0.00 General by Report 1/1/2004
V2199 N $0.00 General by Report 1/1/2004
V2200 N $11.33 General Fee Schedule 7/1/2004
V2201 N $12.07 General Fee Schedule 7/1/2004
V2202 N $0.00 General by Report 1/1/2004
V2203 N $11.82 General Fee Schedule 7/1/2004
V2204 N $11.82 General Fee Schedule 7/1/2004
V2205 N $12.80 General Fee Schedule 7/1/2004
V2206 N $0.00 General by Report 1/1/2004
V2207 N $0.00 General by Report 1/1/2004
V2208 N $0.00 General by Report 1/1/2004
V2209 N $0.00 General by Report 1/1/2004
V2210 N $0.00 General by Report 1/1/2004
V2211 N $0.00 General by Report 1/1/2004
V2212 N $0.00 General by Report 1/1/2004
V2213 N $0.00 General by Report 1/1/2004
V2214 N $0.00 General by Report 1/1/2004
V2215 N $0.00 General by Report 1/1/2004
V2218 N $0.00 General by Report 1/1/2004
V2219 N $0.00 General by Report 1/1/2004
V2220 N $37.18 General Fee Schedule 7/1/2004
V2221 N $0.00 General by Report 1/1/2004
V2299 N $0.00 General by Report 1/1/2004
V2500 N $81.49 General Fee Schedule 5/1/2004
V2501 N $99.29 General Fee Schedule 5/1/2004
V2502 N $120.47 General Fee Schedule 7/1/2004
V2503 N $112.65 General Fee Schedule 5/1/2004
V2510 N $117.67 General Fee Schedule 5/1/2004
V2511 N $152.60 General Fee Schedule 5/1/2004
V2512 N $177.30 General Fee Schedule 7/1/2004
V2520 N $101.26 General Fee Schedule 5/1/2004
HCPCS FEES11/06/2019 at 7:08:01 AM - 132 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
V2521 N $154.83 General Fee Schedule 5/1/2004
V2522 N $177.30 General Fee Schedule 7/1/2004
V2530 N $177.30 General Fee Schedule 7/1/2004
V2531 N $177.30 General Fee Schedule 7/1/2004
V2599 N $0.00 Manual Review Fee Schedule
1/1/2004
V2623 N $1,124.32 General Fee Schedule 2/10/2014
V2624 Y $75.02 General Fee Schedule 2/10/2014
V2625 Y $360.35 General Fee Schedule 2/10/2014
V2626 Y $249.89 General Fee Schedule 2/10/2014
V2627 N $1,360.43 General Fee Schedule 2/10/2014
V2628 N $353.91 General Fee Schedule 2/10/2014
V2700 N $0.00 General by Report 1/1/2004
V2710 N $0.00 General by Report 1/1/2004
V2715 N $10.53 General Fee Schedule 5/1/2004
V2718 N $26.15 General Fee Schedule 5/1/2004
V2730 N $0.00 General by Report 1/1/2004
V2744 N $0.00 General by Report 1/1/2004
V2782 N $0.00 General by Report 1/1/2004
V2783 N $0.00 General by Report 1/1/2004
V2784 N $0.00 General by Report 1/1/2004
V2785 Y $0.00 Manual Review Fee Schedule
1/1/1996
V2797 N $1.97 General Fee Schedule 7/1/2004
V2799 Y $0.00 General by Report 1/1/2004
V5010 Y $12.18 General Fee Schedule 12/1/2009
V5011 Y $40.00 General Fee Schedule 1/1/2010
V5014 Y $0.00 Manual Review Fee Schedule
1/1/2004
V5030 N $0.00 Manual Review Fee Schedule
5/1/2007
V5030 Y $73.88 Rental Fee Schedule 7/1/2004
V5040 N $0.00 Manual Review Fee Schedule
5/1/2007
V5040 Y $73.88 Rental Fee Schedule 7/1/2004
HCPCS FEES11/06/2019 at 7:08:01 AM - 133 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
V5050 N $0.00 Manual Review Fee Schedule
5/1/2007
V5050 Y $73.88 Rental Fee Schedule 7/1/2004
V5060 N $0.00 Manual Review Fee Schedule
5/1/2007
V5060 Y $73.88 Rental Fee Schedule 7/1/2004
V5090 Y $300.00 General Fee Schedule 5/1/2007
V5100 N $0.00 Manual Review Fee Schedule
5/1/2007
V5100 Y $73.88 Rental Fee Schedule 7/1/2004
V5120 N $0.00 Manual Review Fee Schedule
5/1/2007
V5120 Y $73.88 Rental Fee Schedule 7/1/2004
V5130 N $0.00 Manual Review Fee Schedule
5/1/2007
V5130 Y $73.88 Rental Fee Schedule 7/1/2004
V5140 N $0.00 Manual Review Fee Schedule
5/1/2007
V5140 Y $73.88 Rental Fee Schedule 7/1/2004
V5150 N $0.00 Manual Review Fee Schedule
5/1/2007
V5160 Y $600.00 General Fee Schedule 5/1/2007
V5190 N $0.00 Manual Review Fee Schedule
1/1/2006
V5230 N $0.00 Manual Review Fee Schedule
5/1/2007
V5240 Y $0.00 Manual Review Fee Schedule
10/1/2011
V5241 Y $300.00 General Fee Schedule 5/1/2007
V5242 N $0.00 Manual Review Fee Schedule
5/1/2007
V5243 N $0.00 Manual Review Fee Schedule
5/1/2007
V5244 N $0.00 Manual Review Fee Schedule
5/1/2007
V5245 N $0.00 Manual Review Fee Schedule
5/1/2007
V5246 N $0.00 Manual Review Fee Schedule
5/1/2007
HCPCS FEES11/06/2019 at 7:08:01 AM - 134 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
V5247 N $0.00 Manual Review Fee Schedule
5/1/2007
V5248 N $0.00 Manual Review Fee Schedule
5/1/2007
V5249 N $0.00 Manual Review Fee Schedule
5/1/2007
V5250 N $0.00 Manual Review Fee Schedule
5/1/2007
V5251 N $0.00 Manual Review Fee Schedule
5/1/2007
V5252 N $0.00 Manual Review Fee Schedule
5/1/2007
V5253 N $0.00 Manual Review Fee Schedule
5/1/2007
V5254 N $0.00 Manual Review Fee Schedule
5/1/2007
V5255 N $0.00 Manual Review Fee Schedule
5/1/2007
V5256 N $0.00 Manual Review Fee Schedule
5/1/2007
V5257 N $0.00 Manual Review Fee Schedule
5/1/2007
V5258 N $0.00 Manual Review Fee Schedule
5/1/2007
V5259 N $0.00 Manual Review Fee Schedule
5/1/2007
V5260 N $0.00 Manual Review Fee Schedule
5/1/2007
V5261 N $0.00 Manual Review Fee Schedule
5/1/2007
V5262 N $0.00 Manual Review Fee Schedule
5/1/2007
V5263 N $0.00 Manual Review Fee Schedule
5/1/2007
V5264 N $0.00 Manual Review Fee Schedule
1/1/2004
V5265 N $0.00 Manual Review Fee Schedule
1/1/2004
V5266 N $1.36 General Fee Schedule 7/1/2004
V5267 N $0.00 Manual Review Fee Schedule
1/1/2004
HCPCS FEES11/06/2019 at 7:08:01 AM - 135 - REF-FeeSchedE-1017
NEW MEXICO MEDICAID FEE FOR SERVICEHCPCS LEVEL II CODES FEE SCHEDULE
HCPCS CODE
Tax Rate PRICING NOTE PURCHASE MODIFIER
RENTAL MODIFIER
PRICE START DATE
V5298 N $0.00 Rental Manual Price-Fee Sched
11/1/2011
V5298 Y $0.00 Manual Review Fee Schedule
5/1/2007
V5299 Y $0.00 Manual Review Fee Schedule
1/1/2004
HCPCS FEES11/06/2019 at 7:08:01 AM - 136 - REF-FeeSchedE-1017