Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0001A NOCOV DEF SYSMAN Description: ADM SARSCOV2 30MCG/0.3ML 1ST Category: Non Covered Services CMS Add: 12/11/2020 CMS Term: 10/31/2023 0001F NOCOV DEF SYSMAN Description: HEART FAILURE COMPOSITE Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: 0001U NOCOV DEF SYSMAN Description: RBC DNA HEA 35 AG 11 BLD GRP Category: Non Covered Services CMS Add: 02/01/2017 CMS Term: 0002A NOCOV DEF SYSMAN Description: ADM SARSCOV2 30MCG/0.3ML 2ND Category: Non Covered Services CMS Add: 12/11/2020 CMS Term: 10/31/2023 0002M NOCOV DEF SYSMAN Description: LIVER DIS 10 ASSAYS W/ASH Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 0002U NOCOV DEF SYSMAN Description: ONC CLRCT 3 UR METAB ALG PLP Category: Non Covered Services CMS Add: 02/01/2017 CMS Term: 0003A NOCOV DEF SYSMAN Description: ADM SARSCOV2 30MCG/0.3ML 3RD Category: Non Covered Services CMS Add: 08/12/2021 CMS Term: 10/31/2023 0003M NOCOV DEF SYSMAN Description: LIVER DIS 10 ASSAYS W/NASH Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 0003U NOCOV DEF SYSMAN Description: ONC OVAR 5 PRTN SER ALG SCOR Category: Non Covered Services CMS Add: 02/01/2017 CMS Term: 0004A NOCOV DEF SYSMAN Description: ADM SARSCOV2 30MCG/0.3ML BST Category: Non Covered Services CMS Add: 09/22/2021 CMS Term: 10/31/2023 0004M NOCOV DEF SYSMAN Description: SCOLIOSIS DNA ALYS Category: Non Covered Services CMS Add: 07/01/2013 CMS Term: 0005F NOCOV DEF SYSMAN Description: OSTEOARTHRITIS COMPOSITE Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: 0005U NOCOV DEF SYSMAN Description: ONCO PRST8 3 GENE UR ALG Category: Non Covered Services CMS Add: 05/01/2017 CMS Term: 0006M NOCOV DEF SYSMAN Description: ONC HEP GENE RISK CLASSIFIER Category: Non Covered Services CMS Add: 07/01/2014 CMS Term: 0007M NOCOV DEF SYSMAN Description: ONC GASTRO 51 GENE NOMOGRAM Category: Non Covered Services CMS Add: 07/01/2014 CMS Term: 0007U NOCOV DEF SYSMAN Description: RX TEST PRSMV UR W/DEF CONF Category: Non Covered Services CMS Add: 08/01/2017 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0008M NOCOV DEF SYSMAN Description: ONC BREAST RISK SCORE Category: Non Covered Services CMS Add: 07/01/2014 CMS Term: 12/31/2017 0008U NOCOV DEF SYSMAN Description: HPYLORI DETCJ ABX RSTNC DNA Category: Non Covered Services CMS Add: 08/01/2017 CMS Term: 0009U NOCOV DEF SYSMAN Description: ONC BRST CA ERBB2 AMP/NONAMP Category: Non Covered Services CMS Add: 08/01/2017 CMS Term: 00100 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH SALIVARY GLAND Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00102 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH REPAIR OF CLEFT LIP Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00103 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH BLEPHAROPLASTY Category: Anesthesia CMS Add: 01/01/1994 CMS Term: 00104 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH ELECTROSHOCK Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0010U NOCOV DEF SYSMAN Description: NFCT DS STRN TYP WHL GEN SEQ Category: Non Covered Services CMS Add: 08/01/2017 CMS Term: 0011A NOCOV DEF SYSMAN Description: ADM SARSCOV2 100MCG/0.5ML1ST Category: Non Covered Services CMS Add: 12/18/2020 CMS Term: 10/31/2023 0011M NOCOV DEF SYSMAN Description: ONC PRST8 CA MRNA 12 GEN ALG Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 0011U NOCOV DEF SYSMAN Description: RX MNTR LC-MS/MS ORAL FLUID Category: Non Covered Services CMS Add: 08/01/2017 CMS Term: 00120 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH EAR SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00124 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH EAR EXAM Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00126 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH TYMPANOTOMY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0012A NOCOV DEF SYSMAN Description: ADM SARSCOV2 100MCG/0.5ML2ND Category: Non Covered Services CMS Add: 12/18/2020 CMS Term: 10/31/2023 0012F NOCOV DEF SYSMAN Description: CAP BACTERIAL ASSESS Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 3 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0012M NOCOV DEF SYSMAN Description: ONC MRNA 5 GEN RSK URTHL CA Category: Non Covered Services CMS Add: 04/01/2018 CMS Term: 0013A NOCOV DEF SYSMAN Description: ADM SARSCOV2 100MCG/0.5ML3RD Category: Non Covered Services CMS Add: 08/12/2021 CMS Term: 10/31/2023 0013M NOCOV DEF SYSMAN Description: ONC MRNA 5 GEN RECR URTHL CA Category: Non Covered Services CMS Add: 04/01/2018 CMS Term: 00140 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH PROCEDURES ON EYE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00142 ANEST DEF ANESTH 02/01/2015 0.00 4.0 Description: ANESTH LENS SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00144 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH CORNEAL TRANSPLANT Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00145 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH VITREORETINAL SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00147 ANEST DEF ANESTH 02/01/2015 0.00 4.0 Description: ANESTH IRIDECTOMY Category: Anesthesia CMS Add: 01/01/1991 CMS Term: 00148 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH EYE EXAM Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0014F NOCOV DEF SYSMAN Description: COMP PREOP ASSESS CAT SURG Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 0015F NOCOV DEF SYSMAN Description: MELAN FOLLOW-UP COMPLETE Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 0015M NOCOV DEF SYSMAN Description: ADRNL CORTCL TUM BCHM ASY 25 Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 00160 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH NOSE/SINUS SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00162 ANEST DEF ANESTH 01/01/1900 0.00 7.0 Description: ANESTH NOSE/SINUS SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00164 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH BIOPSY OF NOSE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0016M NOCOV DEF SYSMAN Description: ONC BLADDER MRNA 219 GEN ALG Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 4 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0016U NOCOV DEF SYSMAN Description: ONC HMTLMF NEO RNA BCR/ABL1 Category: Non Covered Services CMS Add: 08/01/2017 CMS Term: 00170 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH PROCEDURE ON MOUTH Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00172 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH CLEFT PALATE REPAIR Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00174 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH PHARYNGEAL SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00176 ANEST DEF ANESTH 01/01/1900 0.00 7.0 Description: ANESTH PHARYNGEAL SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0017M NOCOV DEF SYSMAN Description: ONC DLBCL MRNA 20 GENES ALG Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0017U NOCOV DEF SYSMAN Description: ONC HMTLMF NEO JAK2 MUT DNA Category: Non Covered Services CMS Add: 08/01/2017 CMS Term: 0018M NOCOV DEF SYSMAN Description: TRNSPLJ RNL MEAS CD154+CLL Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0018U NOCOV DEF SYSMAN Description: ONC THYR 10 MICRORNA SEQ ALG Category: Non Covered Services CMS Add: 10/01/2017 CMS Term: 00190 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH FACE/SKULL BONE SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00192 ANEST DEF ANESTH 01/01/1900 0.00 7.0 Description: ANESTH FACIAL BONE SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0019M NOCOV DEF SYSMAN Description: CV DS PLASMA ALYS PRTN BMRK Category: Non Covered Services CMS Add: 10/01/2023 CMS Term: 0019U NOCOV DEF SYSMAN Description: ONC RNA TISS PREDICT ALG Category: Non Covered Services CMS Add: 10/01/2017 CMS Term: 00210 ANEST DEF ANESTH 01/01/1900 0.00 11.0 Description: ANESTH CRANIAL SURG NOS Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00211 ANEST DEF ANESTH 01/01/1900 0.00 10.0 Description: ANESTH CRAN SURG HEMOTOMA Category: Anesthesia CMS Add: 01/01/2009 CMS Term: 00212 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH SKULL DRAINAGE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 5 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 00214 ANEST DEF ANESTH 01/01/1900 0.00 9.0 Description: ANESTH SKULL DRAINAGE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00215 ANEST DEF ANESTH 01/01/1900 0.00 9.0 Description: ANESTH SKULL REPAIR/FRACT Category: Anesthesia CMS Add: 01/01/1994 CMS Term: 00216 ANEST DEF ANESTH 01/01/1900 0.00 15.0 Description: ANESTH HEAD VESSEL SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00218 ANEST DEF ANESTH 01/01/1900 0.00 13.0 Description: ANESTH SPECIAL HEAD SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0021A NOCOV DEF SYSMAN Description: FEE COVID-19 VAC 3 DOSE 1 Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 01/01/2021 0021U NOCOV DEF SYSMAN Description: ONC PRST8 DETCJ 8 AUTOANTB Category: Non Covered Services CMS Add: 10/01/2017 CMS Term: 00220 ANEST DEF ANESTH 01/01/1900 0.00 10.0 Description: ANESTH INTRCRN NERVE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00222 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH HEAD NERVE SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0022A NOCOV DEF SYSMAN Description: FEE COVID-19 VAC 3 DOSE 2 Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 01/01/2021 0022U NOCOV DEF SYSMAN Description: TGSAP NSM LUNG NEO DNA&RNA23 Category: Non Covered Services CMS Add: 10/01/2017 CMS Term: 0023U NOCOV DEF SYSMAN Description: ONC AML DNA DETCJ/NONDETCJ Category: Non Covered Services CMS Add: 10/01/2017 CMS Term: 0024T NOCOV DEF SYSMAN Description: TRANSCATH CARDIAC REDUCTION Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: 12/31/2007 0024U NOCOV DEF SYSMAN Description: GLYCA NUC MR SPECTRSC QUAN Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 0025U NOCOV DEF SYSMAN Description: TENOFOVIR LIQ CHROM UR QUAN Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 0026U LAB L60 MAXFEE 01/20/2023 3600.00 0.0 Y Description: ONC THYR DNA&MRNA 112 GENES Category: Laboratory CMS Add: 01/01/2018 CMS Term: 0027U NOCOV DEF SYSMAN Description: JAK2 GENE TRGT SEQ ALYS Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 6 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0029U NOCOV DEF SYSMAN Description: RX METAB ADVRS TRGT SEQ ALYS Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 00300 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH HEAD/NECK/PTRUNK Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0030U NOCOV DEF SYSMAN Description: RX METAB WARF TRGT SEQ ALYS Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 0031A NOCOV DEF SYSMAN Description: ADM SARSCOV2 VAC AD26 .5ML Category: Non Covered Services CMS Add: 02/27/2021 CMS Term: 10/31/2023 0031U NOCOV DEF SYSMAN Description: CYP1A2 GENE Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 00320 ANEST DEF ANESTH 01/01/1900 0.00 6.0 1-999years Description: ANESTH NECK ORGAN 1YR/> Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00322 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH BIOPSY OF THYROID Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00326 ANEST DEF ANESTH 02/01/2015 0.00 7.0 0-364days Description: ANESTH LARYNX/TRACH < 1 YR Category: Anesthesia CMS Add: 01/01/2003 CMS Term: 0032U NOCOV DEF SYSMAN Description: COMT GENE Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 0033U NOCOV DEF SYSMAN Description: HTR2A HTR2C GENES Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 0034A NOCOV DEF SYSMAN Description: ADM SARSCOV2 VAC AD26 .5ML B Category: Non Covered Services CMS Add: 10/20/2021 CMS Term: 10/31/2023 0034U NOCOV DEF SYSMAN Description: TPMT NUDT15 GENES Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 00350 ANEST DEF ANESTH 01/01/1900 0.00 10.0 Description: ANESTH NECK VESSEL SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00352 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH NECK VESSEL SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0035U NOCOV DEF SYSMAN Description: NEURO CSF PRION PRTN QUAL Category: Non Covered Services CMS Add: 04/01/2018 CMS Term: 0036U NOCOV DEF SYSMAN Description: XOME TUM & NML SPEC SEQ ALYS Category: Non Covered Services CMS Add: 04/01/2018 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 7 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0037U NOCOV DEF SYSMAN Description: TRGT GEN SEQ DNA 324 GENES Category: Non Covered Services CMS Add: 04/01/2018 CMS Term: 0038U NOCOV DEF SYSMAN Description: VITAMIN D SRM MICROSAMP QUAN Category: Non Covered Services CMS Add: 04/01/2018 CMS Term: 0039U NOCOV DEF SYSMAN Description: DNA ANTB 2STRAND HI AVIDITY Category: Non Covered Services CMS Add: 04/01/2018 CMS Term: 00400 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH SKIN EXT/PER/ATRUNK Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00402 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH SURGERY OF BREAST Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00404 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH SURGERY OF BREAST Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00406 ANEST DEF ANESTH 01/01/1900 0.00 13.0 Description: ANESTH SURGERY OF BREAST Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0040U NOCOV DEF SYSMAN Description: BCR/ABL1 GENE MAJOR BP QUAN Category: Non Covered Services CMS Add: 04/01/2018 CMS Term: 00410 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH CORRECT HEART RHYTHM Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0041A NOCOV DEF SYSMAN Description: ADM SARSCOV2 5MCG/0.5ML 1ST Category: Non Covered Services CMS Add: 07/13/2022 CMS Term: 10/31/2023 0041U NOCOV DEF SYSMAN Description: B BRGDRFERI ANTB 5 PRTN IGM Category: Non Covered Services CMS Add: 04/01/2018 CMS Term: 0042A NOCOV DEF SYSMAN Description: ADM SARSCOV2 5MCG/0.5ML 2ND Category: Non Covered Services CMS Add: 07/13/2022 CMS Term: 10/31/2023 0042T MEDSV DEF MAXFEE 01/01/2024 288.10 0.0 Y Description: CT PERFUSION W/CONTRAST CBF Category: Medical Services CMS Add: 01/01/2003 CMS Term: 0042U NOCOV DEF SYSMAN Description: B BRGDRFERI ANTB 12 PRTN IGG Category: Non Covered Services CMS Add: 04/01/2018 CMS Term: 0043U NOCOV DEF SYSMAN Description: TBRF B GRP ANTB 4 PRTN IGM Category: Non Covered Services CMS Add: 04/01/2018 CMS Term: 0044A NOCOV DEF SYSMAN Description: ADM SARSCOV2 5MCG/0.5ML BST Category: Non Covered Services CMS Add: 10/19/2022 CMS Term: 10/31/2023 *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 8 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0044U NOCOV DEF SYSMAN Description: TBRF B GRP ANTB 4 PRTN IGG Category: Non Covered Services CMS Add: 04/01/2018 CMS Term: 00450 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH SURGERY OF SHOULDER Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00454 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH COLLAR BONE BIOPSY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0045U NOCOV DEF SYSMAN Description: ONC BRST DUX CARC IS 12 GENE Category: Non Covered Services CMS Add: 07/01/2018 CMS Term: 0046U NOCOV DEF SYSMAN Description: FLT3 GENE ITD VARIANTS QUAN Category: Non Covered Services CMS Add: 07/01/2018 CMS Term: 00470 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH REMOVAL OF RIB Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00472 ANEST DEF ANESTH 01/01/1900 0.00 10.0 Description: ANESTH CHEST WALL REPAIR Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00474 ANEST DEF ANESTH 01/01/1900 0.00 13.0 Description: ANESTH SURGERY OF RIB Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0047U NOCOV DEF SYSMAN Description: ONC PRST8 MRNA 17 GENE ALG Category: Non Covered Services CMS Add: 07/01/2018 CMS Term: 0048U NOCOV DEF SYSMAN Description: ONC SLD ORG NEO DNA 468 GENE Category: Non Covered Services CMS Add: 07/01/2018 CMS Term: 0049U NOCOV DEF SYSMAN Description: NPM1 GENE ANALYSIS QUAN Category: Non Covered Services CMS Add: 07/01/2018 CMS Term: 00500 ANEST DEF ANESTH 01/01/1900 0.00 15.0 Description: ANESTH ESOPHAGEAL SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0050U NOCOV DEF SYSMAN Description: TRGT GEN SEQ DNA 194 GENES Category: Non Covered Services CMS Add: 07/01/2018 CMS Term: 0051A NOCOV DEF SYSMAN Description: ADM SARSCV2 30MCG TRS-SUCR 1 Category: Non Covered Services CMS Add: 01/03/2022 CMS Term: 10/31/2023 0051U NOCOV DEF SYSMAN Description: RX MNTR LC-MS/MS UR/BLD 31 Category: Non Covered Services CMS Add: 07/01/2018 CMS Term: 00520 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH CHEST PROCEDURE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 9 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 00522 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH CHEST LINING BIOPSY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00524 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH CHEST DRAINAGE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00528 ANEST DEF ANESTH 01/01/1900 0.00 8.0 Description: ANES MEDIASCPY & DX THORSCPY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00529 ANEST DEF ANESTH 01/01/1900 0.00 11.0 Description: ANES MEDSCPY&THORSCPY 1 LUNG Category: Anesthesia CMS Add: 01/01/2004 CMS Term: 0052A NOCOV DEF SYSMAN Description: ADM SARSCV2 30MCG TRS-SUCR 2 Category: Non Covered Services CMS Add: 01/03/2022 CMS Term: 10/31/2023 0052U NOCOV DEF SYSMAN Description: LPOPRTN BLD W/5 MAJ CLASSES Category: Non Covered Services CMS Add: 07/01/2018 CMS Term: 00530 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH PACEMAKER INSERTION Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00532 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH VASCULAR ACCESS Category: Anesthesia CMS Add: 01/01/1992 CMS Term: 00534 ANEST DEF ANESTH 01/01/1900 0.00 7.0 Description: ANESTH CARDIOVERTER/DEFIB Category: Anesthesia CMS Add: 01/01/1993 CMS Term: 00537 ANEST DEF ANESTH 01/01/2024 0.00 7.0 Description: ANESTH CARDIAC ELECTROPHYS Category: Anesthesia CMS Add: 01/01/2001 CMS Term: 00537 ANEST DEF ANESTH 02/01/2015 12/31/2023 0.00 7.0 Description: ANESTH CARDIAC ELECTROPHYS Category: Anesthesia CMS Add: 01/01/2001 CMS Term: 00539 ANEST DEF ANESTH 01/01/1900 0.00 18.0 Description: ANESTH TRACH-BRONCH RECONST Category: Anesthesia CMS Add: 01/01/2003 CMS Term: 0053A NOCOV DEF SYSMAN Description: ADM SARSCV2 30MCG TRS-SUCR 3 Category: Non Covered Services CMS Add: 01/03/2022 CMS Term: 10/31/2023 00540 ANEST DEF ANESTH 02/01/2015 0.00 12.0 Description: ANESTH CHEST SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00541 ANEST DEF ANESTH 01/01/1900 0.00 15.0 Description: ANESTH ONE LUNG VENTILATION Category: Anesthesia CMS Add: 01/01/2003 CMS Term: 00542 ANEST DEF ANESTH 01/01/1900 0.00 15.0 Description: ANESTHESIA REMOVAL PLEURA Category: Anesthesia CMS Add: 01/01/1989 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 10 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 00546 ANEST DEF ANESTH 01/01/1900 0.00 15.0 Description: ANESTH LUNG CHEST WALL SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00548 ANEST DEF ANESTH 01/01/1900 0.00 17.0 Description: ANESTH TRACHEA BRONCHI SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0054A NOCOV DEF SYSMAN Description: ADM SARSCV2 30MCG TRS-SUCR B Category: Non Covered Services CMS Add: 01/03/2022 CMS Term: 10/31/2023 0054T NOCOV DEF SYSMAN Description: BONE SRGRY CMPTR FLUOR IMAGE Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: 0054U NOCOV DEF SYSMAN Description: RX MNTR 14+ DRUGS & SBSTS Category: Non Covered Services CMS Add: 07/01/2018 CMS Term: 00550 ANEST DEF ANESTH 01/01/1900 0.00 10.0 Description: ANESTH STERNAL DEBRIDEMENT Category: Anesthesia CMS Add: 01/01/2001 CMS Term: 0055T NOCOV DEF SYSMAN Description: BONE SRGRY CMPTR CT/MRI IMAG Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: 0055U NOCOV DEF SYSMAN Description: CARD HRT TRNSPL 96 DNA SEQ Category: Non Covered Services CMS Add: 07/01/2018 CMS Term: 00560 ANEST DEF ANESTH 01/01/1900 0.00 15.0 Description: ANESTH HEART SURG W/O PUMP Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00561 ANEST DEF ANESTH 01/01/1900 0.00 25.0 0-364days Description: ANESTH HEART SURG <1 YR Category: Anesthesia CMS Add: 01/01/2005 CMS Term: 00562 ANEST DEF ANESTH 01/01/1900 0.00 20.0 1-999years Description: ANESTH HRT SURG W/PMP AGE 1+ Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00563 ANEST DEF ANESTH 01/01/1900 0.00 25.0 Description: ANESTH HEART SURG W/ARREST Category: Anesthesia CMS Add: 01/01/2001 CMS Term: 00566 ANEST DEF ANESTH 01/01/1900 0.00 25.0 Description: ANESTH CABG W/O PUMP Category: Anesthesia CMS Add: 01/01/2001 CMS Term: 00567 ANEST DEF ANESTH 01/01/1900 0.00 18.0 Description: ANESTH CABG W/PUMP Category: Anesthesia CMS Add: 01/01/2009 CMS Term: 00580 ANEST DEF ANESTH 01/01/1900 0.00 20.0 Description: ANESTH HEART/LUNG TRANSPLNT Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0058U NOCOV DEF SYSMAN Description: ONC MERKEL CLL CARC SRM QUAN Category: Non Covered Services CMS Add: 07/01/2018 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 11 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0059U NOCOV DEF SYSMAN Description: ONC MERKEL CLL CARC SRM +/- Category: Non Covered Services CMS Add: 07/01/2018 CMS Term: 00600 ANEST DEF ANESTH 01/01/1900 0.00 10.0 Description: ANESTH SPINE CORD SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00604 ANEST DEF ANESTH 01/01/1900 0.00 13.0 Description: ANESTH SITTING PROCEDURE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0060U NOCOV DEF SYSMAN Description: TWN ZYG GEN SEQ ALYS CHRMS2 Category: Non Covered Services CMS Add: 07/01/2018 CMS Term: 0061U NOCOV DEF SYSMAN Description: TC MEAS 5 BMRK SFDI M-S ALYS Category: Non Covered Services CMS Add: 07/01/2018 CMS Term: 00620 ANEST DEF ANESTH 01/01/1900 0.00 10.0 Description: ANESTH SPINE CORD SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00625 ANEST DEF ANESTH 01/01/1900 0.00 13.0 Description: ANES SPINE TRANTHOR W/O VENT Category: Anesthesia CMS Add: 01/01/2007 CMS Term: 00626 ANEST DEF ANESTH 01/01/1900 0.00 15.0 Description: ANES SPINE TRANSTHOR W/VENT Category: Anesthesia CMS Add: 01/01/2007 CMS Term: 0062U NOCOV DEF SYSMAN Description: AI SLE IGG&IGM ALYS 80 BMRK Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: 00630 ANEST DEF ANESTH 01/01/1900 0.00 8.0 Description: ANESTH SPINE CORD SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00632 ANEST DEF ANESTH 01/01/1900 0.00 7.0 Description: ANESTH REMOVAL OF NERVES Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00635 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH LUMBAR PUNCTURE Category: Anesthesia CMS Add: 01/01/2001 CMS Term: 0063U NOCOV DEF SYSMAN Description: NEURO AUTISM 32 AMINES ALG Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: 00640 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH SPINE MANIPULATION Category: Anesthesia CMS Add: 01/01/2003 CMS Term: 0064A NOCOV DEF SYSMAN Description: ADM SARSCOV2 50MCG/0.25MLBST Category: Non Covered Services CMS Add: 10/20/2021 CMS Term: 10/31/2023 0064U NOCOV DEF SYSMAN Description: ANTB TP TOTAL&RPR IA QUAL Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 12 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0065U NOCOV DEF SYSMAN Description: SYFLS TST NONTREPONEMAL ANTB Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: 00670 ANEST DEF ANESTH 01/01/1900 0.00 13.0 Description: ANESTH SPINE CORD SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0067U NOCOV DEF SYSMAN Description: ONC BRST IMHCHEM PRFL 4 BMRK Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: 0068U NOCOV DEF SYSMAN Description: CANDIDA SPECIES PNL AMP PRB Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: 0069U NOCOV DEF SYSMAN Description: ONC CLRCT MICRORNA MIR-31-3P Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: 00700 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH ABDOMINAL WALL SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00702 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH FOR LIVER BIOPSY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0070U NOCOV DEF SYSMAN Description: CYP2D6 GEN COM&SLCT RAR VRNT Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: 0071A NOCOV DEF SYSMAN Description: ADM SARSCV2 10MCG TRS-SUCR 1 Category: Non Covered Services CMS Add: 10/29/2021 CMS Term: 10/31/2023 0071T MEDSV DEF MAXFEE 01/01/2005 12/31/2023 471.16 0.0 Description: US LEIOMYOMATA ABLATE <200 Category: Medical Services CMS Add: 01/01/2005 CMS Term: 0071T MEDSV DEF MAXFEE 01/01/2024 1774.53 0.0 Description: US LEIOMYOMATA ABLATE <200 Category: Medical Services CMS Add: 01/01/2005 CMS Term: 0071U NOCOV DEF SYSMAN Description: CYP2D6 FULL GENE SEQUENCE Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: 0072A NOCOV DEF SYSMAN Description: ADM SARSCV2 10MCG TRS-SUCR 2 Category: Non Covered Services CMS Add: 10/29/2021 CMS Term: 10/31/2023 0072T MEDSV DEF MAXFEE 01/01/2005 12/31/2023 471.16 0.0 Y Description: FCSD US ABLTJ LEIOMYOM>=200 Category: Medical Services CMS Add: 01/01/2005 CMS Term: 0072T MEDSV DEF MAXFEE 01/01/2024 610.62 0.0 Y Description: FCSD US ABLTJ LEIOMYOM>=200 Category: Medical Services CMS Add: 01/01/2005 CMS Term: 0072U NOCOV DEF SYSMAN Description: CYP2D6 GEN CYP2D6-2D7 HYBRID Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 13 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 00730 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH ABDOMINAL WALL SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00731 ANEST DEF ANESTH 01/01/2018 0.00 5.0 Description: ANES UPR GI NDSC PX NOS Category: Anesthesia CMS Add: 01/01/2018 CMS Term: 00732 ANEST DEF ANESTH 01/01/2018 0.00 6.0 Description: ANES UPR GI NDSC PX ERCP Category: Anesthesia CMS Add: 01/01/2018 CMS Term: 0073A NOCOV DEF SYSMAN Description: ADM SARSCV2 10MCG TRS-SUCR 3 Category: Non Covered Services CMS Add: 01/03/2022 CMS Term: 10/31/2023 0073U NOCOV DEF SYSMAN Description: CYP2D6 GEN CYP2D7-2D6 HYBRID Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: 0074A NOCOV DEF SYSMAN Description: ADM SARSCV2 10MCG TRS-SUCR B Category: Non Covered Services CMS Add: 05/17/2022 CMS Term: 10/31/2023 0074U NOCOV DEF SYSMAN Description: CYP2D6 NONDUPLICATED GENE Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: 00750 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANES HRNA RPR UPR ABD NOS Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00752 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANES HRNA RPR LMBR&VNT&/DEHS Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00754 ANEST DEF ANESTH 01/01/1900 0.00 7.0 Description: ANES HRNA RPR OMPHALOCELE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00756 ANEST DEF ANESTH 01/01/1900 0.00 7.0 Description: ANES HRNA RPR DIPHRG HRNA Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0075T NOCOV DEF SYSMAN Description: PERQ STENT/CHEST VERT ART Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: 0075U NOCOV DEF SYSMAN Description: CYP2D6 5' GENE DUP/MLT Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: 0076T NOCOV DEF SYSMAN Description: S&I STENT/CHEST VERT ART Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: 0076U NOCOV DEF SYSMAN Description: CYP2D6 3' GENE DUP/MLT Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: 00770 ANEST DEF ANESTH 01/01/1900 0.00 15.0 Description: ANES PX MAJ ABD BLOOD VESSEL Category: Anesthesia CMS Add: 01/01/1989 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 14 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0077U NOCOV DEF SYSMAN Description: IG PARAPROTEIN QUAL BLD/UR Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: 0078U NOCOV DEF SYSMAN Description: PAIN MGT OPI USE GNOTYP PNL Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: 00790 ANEST DEF ANESTH 01/01/1900 0.00 7.0 Description: ANES IPER UPR ABD NOS Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00792 ANEST DEF ANESTH 01/01/1900 0.00 13.0 Description: ANES IPER UPR ABD PRTL HPTC Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00794 ANEST DEF ANESTH 01/01/1900 0.00 8.0 Description: ANES IPER UPR ABD PNCRTECT Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00796 ANEST DEF ANESTH 01/01/1900 0.00 30.0 Description: ANES IPER UPR ABD LVR TRNSPL Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00797 ANEST DEF ANESTH 02/01/2015 0.00 11.0 Description: ANES IPER UPR ABD GSTR PX MO Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 0079U NOCOV DEF SYSMAN Description: CMPRTV DNA ALYS MLT SNPS Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: 00800 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH ABDOMINAL WALL SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00802 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH FAT LAYER REMOVAL Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0080U NOCOV DEF SYSMAN Description: ONC LNG 5 CLIN RSK FACTR ALG Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 00811 ANEST DEF ANESTH 01/01/2018 0.00 4.0 Description: ANES LWR INTST NDSC NOS Category: Anesthesia CMS Add: 01/01/2018 CMS Term: 00812 ANEST DEF ANESTH 01/01/2018 0.00 3.0 Description: ANES LWR INTST SCR COLSC Category: Anesthesia CMS Add: 01/01/2018 CMS Term: 00813 ANEST DEF ANESTH 01/01/2018 0.00 5.0 Description: ANES UPR LWR GI NDSC PX Category: Anesthesia CMS Add: 01/01/2018 CMS Term: 0081A NOCOV DEF SYSMAN Description: ADM SARSCV2 3MCG TRS-SUCR 1 Category: Non Covered Services CMS Add: 06/17/2022 CMS Term: 10/31/2023 00820 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH ABDOMINAL WALL SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 15 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0082A NOCOV DEF SYSMAN Description: ADM SARSCV2 3MCG TRS-SUCR 2 Category: Non Covered Services CMS Add: 06/17/2022 CMS Term: 10/31/2023 0082U NOCOV DEF SYSMAN Description: RX TEST DEF 90+ RX/SBSTS UR Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 00830 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH REPAIR OF HERNIA Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00832 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH REPAIR OF HERNIA Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00834 ANEST DEF ANESTH 01/01/1900 0.00 5.0 0-364days Description: ANESTH HERNIA REPAIR < 1 YR Category: Anesthesia CMS Add: 01/01/2003 CMS Term: 00836 ANEST DEF ANESTH 01/01/1900 0.00 6.0 0-6months Description: ANESTH HERNIA REPAIR PREEMIE Category: Anesthesia CMS Add: 01/01/2003 CMS Term: 0083A NOCOV DEF SYSMAN Description: ADM SARSCV2 3MCG TRS-SUCR 3 Category: Non Covered Services CMS Add: 06/17/2022 CMS Term: 10/31/2023 0083U NOCOV DEF SYSMAN Description: ONC RSPSE CHEMO CNTRST TOMOG Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 00840 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH SURG LOWER ABDOMEN Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00842 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH AMNIOCENTESIS Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00844 ANEST DEF ANESTH 01/01/1900 0.00 7.0 Description: ANESTH PELVIS SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00846 ANEST DEF ANESTH 01/01/1900 0.00 8.0 Y Description: ANESTH HYSTERECTOMY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00848 ANEST DEF ANESTH 01/01/1900 0.00 8.0 Description: ANESTH PELVIC ORGAN SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0084U NOCOV DEF SYSMAN Description: RBC DNA GNOTYP 10 BLD GROUPS Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 00851 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Y Description: ANESTH TUBAL LIGATION Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 00860 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH SURGERY OF ABDOMEN Category: Anesthesia CMS Add: 01/01/1989 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 16 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 00862 ANEST DEF ANESTH 01/01/1900 0.00 7.0 Description: ANESTH KIDNEY/URETER SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00864 ANEST DEF ANESTH 01/01/1900 0.00 8.0 Description: ANESTH REMOVAL OF BLADDER Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00865 ANEST DEF ANESTH 01/01/1900 0.00 7.0 Description: ANESTH REMOVAL OF PROSTATE Category: Anesthesia CMS Add: 01/01/1996 CMS Term: 00866 ANEST DEF ANESTH 01/01/1900 0.00 10.0 Description: ANESTH REMOVAL OF ADRENAL Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00868 ANEST DEF ANESTH 01/01/1900 0.00 10.0 Description: ANESTH KIDNEY TRANSPLANT Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00869 NOCOV DEF SYSMAN Description: ANESTH, VASECTOMY Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: 12/31/2002 0086U NOCOV DEF SYSMAN Description: NFCT DS BACT&FNG ORG ID 6+ Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 00870 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH BLADDER STONE SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00872 ANEST DEF ANESTH 01/01/1900 0.00 7.0 Description: ANESTH KIDNEY STONE DESTRUCT Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00873 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH KIDNEY STONE DESTRUCT Category: Anesthesia CMS Add: 01/01/1991 CMS Term: 0087U NOCOV DEF SYSMAN Description: CRD HRT TRNSPL MRNA 1283 GEN Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 00880 ANEST DEF ANESTH 01/01/1900 0.00 15.0 Description: ANESTH ABDOMEN VESSEL SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00882 ANEST DEF ANESTH 01/01/1900 0.00 10.0 Description: ANESTH MAJOR VEIN LIGATION Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0088U NOCOV DEF SYSMAN Description: TRNSPLJ KDN ALGRFT REJ 1494 Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 0089U NOCOV DEF SYSMAN Description: ONC MLNMA PRAME & LINC00518 Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 00902 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH ANORECTAL SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 17 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 00904 ANEST DEF ANESTH 01/01/1900 0.00 7.0 Description: ANESTH PERINEAL SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00906 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH REMOVAL OF VULVA Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00908 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH REMOVAL OF PROSTATE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0090U NOCOV DEF SYSMAN Description: ONC CUTAN MLNMA MRNA 23 GENE Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 00910 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH BLADDER SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00912 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH BLADDER TUMOR SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00914 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH REMOVAL OF PROSTATE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00916 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH BLEEDING CONTROL Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00918 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH STONE REMOVAL Category: Anesthesia CMS Add: 01/01/1990 CMS Term: 0091A NOCOV DEF SYSMAN Description: ADM SARSCOV2 50 MCG/.5 ML1ST Category: Non Covered Services CMS Add: 06/17/2022 CMS Term: 10/31/2023 0091U NOCOV DEF SYSMAN Description: ONC CLRCT SCR WHL BLD ALG Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 00920 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH GENITALIA SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00921 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Y Description: ANESTH VASECTOMY Category: Anesthesia CMS Add: 01/01/2003 CMS Term: 00922 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH SPERM DUCT SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00924 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH TESTIS EXPLORATION Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00926 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH REMOVAL OF TESTIS Category: Anesthesia CMS Add: 01/01/1989 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 18 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 00928 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH REMOVAL OF TESTIS Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0092A NOCOV DEF SYSMAN Description: ADM SARSCOV2 50 MCG/.5 ML2ND Category: Non Covered Services CMS Add: 06/17/2022 CMS Term: 10/31/2023 0092U NOCOV DEF SYSMAN Description: ONC LNG 3 PRTN BMRK PLSM ALG Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 00930 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH TESTIS SUSPENSION Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00932 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH AMPUTATION OF PENIS Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00934 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH PENIS NODES REMOVAL Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00936 ANEST DEF ANESTH 01/01/1900 0.00 8.0 Description: ANESTH PENIS NODES REMOVAL Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00938 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH INSERT PENIS DEVICE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0093A NOCOV DEF SYSMAN Description: ADM SARSCOV2 50 MCG/.5 ML3RD Category: Non Covered Services CMS Add: 06/17/2022 CMS Term: 10/31/2023 0093U NOCOV DEF SYSMAN Description: RX MNTR 65 COM DRUGS URINE Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 00940 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH VAGINAL PROCEDURES Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00942 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH SURG ON VAG/URETHRAL Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00944 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Y Description: ANESTH VAGINAL HYSTERECTOMY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00948 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH REPAIR OF CERVIX Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0094A NOCOV DEF SYSMAN Description: ADM SARSCOV2 50 MCG/.5 MLBST Category: Non Covered Services CMS Add: 03/29/2022 CMS Term: 10/31/2023 0094U NOCOV DEF SYSMAN Description: GENOME RAPID SEQUENCE ALYS Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 19 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 00950 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH VAGINAL ENDOSCOPY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00952 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH HYSTEROSCOPE/GRAPH Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0095T NOCOV DEF SYSMAN Description: RMVL ARTIFIC DISC ADDL CRVCL Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 0095U NOCOV DEF SYSMAN Description: EE&MJ BSC PRTN ELISA EST DEV Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 0096U NOCOV DEF SYSMAN Description: HPV HI RISK TYPES MALE URINE Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 0098T NOCOV DEF SYSMAN Description: REV ARTIFIC DISC ADDL Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 0100T NOCOV DEF SYSMAN Description: PROSTH RETINA RECEIVE&GEN Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 0101T NOCOV DEF SYSMAN Description: ESW MUSCSKEL SYS NOS Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 0101U NOCOV DEF SYSMAN Description: HERED COLON CA DO 15 GENES Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 0102T NOCOV DEF SYSMAN Description: ESW PHY ANES LAT HMRL EPCNDL Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 0102U NOCOV DEF SYSMAN Description: HERED BRST CA RLTD DO 17 GEN Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 0103U NOCOV DEF SYSMAN Description: HERED OVA CA PNL 24 GENES Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 0104A NOCOV DEF SYSMAN Description: ADM SARSCOV2 5MCG/.5ML AS03B Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 01/01/2021 0105U NOCOV DEF SYSMAN Description: NEPH CKD MULT ECLIA TUM NEC Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 0106T NOCOV DEF SYSMAN Description: TOUCH QUANT SENSORY TEST Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 0106U NOCOV DEF SYSMAN Description: GSTR EMPTG 7 TIMED BRTH SPEC Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 20 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0107T NOCOV DEF SYSMAN Description: VIBRATE QUANT SENSORY TEST Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 0107U NOCOV DEF SYSMAN Description: C DIFF TOX AG DETCJ IA STOOL Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 0108T NOCOV DEF SYSMAN Description: COOL QUANT SENSORY TEST Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 0108U NOCOV DEF SYSMAN Description: GI BARRETT ESOPH 9 PRTN BMRK Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 0109T NOCOV DEF SYSMAN Description: HEAT QUANT SENSORY TEST Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 0109U NOCOV DEF SYSMAN Description: ID ASPERGILLUS DNA 4 SPECIES Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 0110T NOCOV DEF SYSMAN Description: NOS QUANT SENSORY TEST Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 0110U NOCOV DEF SYSMAN Description: RX MNTR 1+ORAL ONC RX&SBSTS Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 01112 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH BONE ASPIRATE/BX Category: Anesthesia CMS Add: 01/01/2001 CMS Term: 0111A NOCOV DEF SYSMAN Description: ADM SARSCOV2 25MCG/0.25ML1ST Category: Non Covered Services CMS Add: 06/17/2022 CMS Term: 10/31/2023 0111U NOCOV DEF SYSMAN Description: ONC COLON CA KRAS&NRAS ALYS Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 01120 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH PELVIS SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0112A NOCOV DEF SYSMAN Description: ADM SARSCOV2 25MCG/0.25ML2ND Category: Non Covered Services CMS Add: 06/17/2022 CMS Term: 10/31/2023 0112U NOCOV DEF SYSMAN Description: IADI 16S&18S RRNA GENES Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 01130 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH BODY CAST PROCEDURE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0113A NOCOV DEF SYSMAN Description: ADM SARSCOV2 25MCG/0.25ML3RD Category: Non Covered Services CMS Add: 06/17/2022 CMS Term: 10/31/2023 *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 21 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0113U NOCOV DEF SYSMAN Description: ONC PRST8 PCA3&TMPRSS2-ERG Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 01140 ANEST DEF ANESTH 01/01/1900 0.00 15.0 Description: ANESTH AMPUTATION AT PELVIS Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0114U NOCOV DEF SYSMAN Description: GI BARRETTS ESOPH VIM&CCNA1 Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 01150 ANEST DEF ANESTH 01/01/1900 0.00 10.0 Description: ANESTH PELVIC TUMOR SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0115U NOCOV DEF SYSMAN Description: RESPIR IADNA 18 VIRAL&2 BACT Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 01160 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH PELVIS PROCEDURE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0116U NOCOV DEF SYSMAN Description: RX MNTR NZM IA 35+ORAL FLU Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 01170 ANEST DEF ANESTH 01/01/1900 0.00 8.0 Description: ANESTH PELVIS SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01173 ANEST DEF ANESTH 01/01/1900 0.00 12.0 Description: ANESTH FX REPAIR PELVIS Category: Anesthesia CMS Add: 01/01/2004 CMS Term: 0117U NOCOV DEF SYSMAN Description: PAIN MGMT 11 ENDOGENOUS ANAL Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 0118U NOCOV DEF SYSMAN Description: TRNSPLJ DON-DRV CLL-FR DNA Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 0119U NOCOV DEF SYSMAN Description: CRD CERAMIDES LIQ CHROM PLSM Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 01200 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH HIP JOINT PROCEDURE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01202 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH ARTHROSCOPY OF HIP Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0120U NOCOV DEF SYSMAN Description: ONC B CLL LYMPHM MRNA 58 GEN Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 01210 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH HIP JOINT SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 22 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 01212 ANEST DEF ANESTH 01/01/1900 0.00 10.0 Description: ANESTH HIP DISARTICULATION Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01214 ANEST DEF ANESTH 01/01/1900 0.00 8.0 Description: ANESTH HIP ARTHROPLASTY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01215 ANEST DEF ANESTH 01/01/1900 0.00 10.0 Description: ANESTH REVISE HIP REPAIR Category: Anesthesia CMS Add: 01/01/2001 CMS Term: 0121A NOCOV DEF SYSMAN Description: ADM SARSCV2 BVL 30MCG/.3ML 1 Category: Non Covered Services CMS Add: 04/18/2023 CMS Term: 10/31/2023 0121U NOCOV DEF SYSMAN Description: SC DIS VCAM-1 WHOLE BLOOD Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 01220 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH PROCEDURE ON FEMUR Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0122U NOCOV DEF SYSMAN Description: SC DIS P-SELECTIN WHL BLOOD Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 01230 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH SURGERY OF FEMUR Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01232 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH AMPUTATION OF FEMUR Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01234 ANEST DEF ANESTH 01/01/1900 0.00 8.0 Description: ANESTH RADICAL FEMUR SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0123U NOCOV DEF SYSMAN Description: MCHNL FRAGILITY RBC PRFLG Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 0124A NOCOV DEF SYSMAN Description: ADM SARSCV2 BVL 30MCG/.3ML A Category: Non Covered Services CMS Add: 08/31/2022 CMS Term: 10/31/2023 0124T NOCOV DEF SYSMAN Description: CONJUNCTIVAL DRUG PLACEMENT Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 12/31/2013 01250 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH UPPER LEG SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01260 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH UPPER LEG VEINS SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01270 ANEST DEF ANESTH 01/01/1900 0.00 8.0 Description: ANESTH THIGH ARTERIES SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 23 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 01272 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH FEMORAL ARTERY SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01274 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH FEMORAL EMBOLECTOMY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0129U NOCOV DEF SYSMAN Description: HERED BRST CA RLTD DO PANEL Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 0130U NOCOV DEF SYSMAN Description: HERED COLON CA DO MRNA PNL Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 0131U NOCOV DEF SYSMAN Description: HERED BRST CA RLTD DO PNL 13 Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 01320 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH KNEE AREA SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0132U NOCOV DEF SYSMAN Description: HERED OVA CA RLTD DO PNL 17 Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 0133U NOCOV DEF SYSMAN Description: HERED PRST8 CA RLTD DO 11 Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 01340 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH KNEE AREA PROCEDURE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0134A NOCOV DEF SYSMAN Description: ADM SARSCV2 BVL 50MCG/.5ML A Category: Non Covered Services CMS Add: 08/31/2022 CMS Term: 10/31/2023 0134U NOCOV DEF SYSMAN Description: HERED PAN CA MRNA PNL 18 GEN Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 0135U NOCOV DEF SYSMAN Description: HERED GYN CA MRNA PNL 12 GEN Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 01360 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH KNEE AREA SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0136U NOCOV DEF SYSMAN Description: ATM MRNA SEQ ALYS Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 0137U NOCOV DEF SYSMAN Description: PALB2 MRNA SEQ ALYS Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 01380 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH KNEE JOINT PROCEDURE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 24 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 01382 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH DX KNEE ARTHROSCOPY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0138U NOCOV DEF SYSMAN Description: BRCA1 BRCA2 MRNA SEQ ALYS Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 01390 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH KNEE AREA PROCEDURE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01392 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH KNEE AREA SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01400 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH KNEE JOINT SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01402 ANEST DEF ANESTH 01/01/1900 0.00 7.0 Description: ANESTH KNEE ARTHROPLASTY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01404 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH AMPUTATION AT KNEE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0140U NOCOV DEF SYSMAN Description: NFCT DS FUNGI DNA 15 TRGT Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0141A NOCOV DEF SYSMAN Description: ADM SRSCV2 BVL 25MCG/.25ML 1 Category: Non Covered Services CMS Add: 04/18/2023 CMS Term: 10/31/2023 0141U NOCOV DEF SYSMAN Description: NFCT DS BACT&FNG GRAM POS Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 01420 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH KNEE JOINT CASTING Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0142A NOCOV DEF SYSMAN Description: ADM SRSCV2 BVL 25MCG/.25ML 2 Category: Non Covered Services CMS Add: 04/18/2023 CMS Term: 10/31/2023 0142U NOCOV DEF SYSMAN Description: NFCT DS BACT&FNG GRAM NEG Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 01430 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH KNEE VEINS SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01432 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH KNEE VESSEL SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01440 ANEST DEF ANESTH 01/01/1900 0.00 8.0 Description: ANESTH KNEE ARTERIES SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 25 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 01442 ANEST DEF ANESTH 01/01/1900 0.00 8.0 Description: ANESTH KNEE ARTERY SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01444 ANEST DEF ANESTH 01/01/1900 0.00 8.0 Description: ANESTH KNEE ARTERY REPAIR Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0144A NOCOV DEF SYSMAN Description: ADM SRSCV2 BVL 25MCG/.25ML A Category: Non Covered Services CMS Add: 10/12/2022 CMS Term: 10/31/2023 01462 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH LOWER LEG PROCEDURE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01464 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH ANKLE/FT ARTHROSCOPY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01470 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH LOWER LEG SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01472 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH ACHILLES TENDON SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01474 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH LOWER LEG SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01480 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH LOWER LEG BONE SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01482 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH RADICAL LEG SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01484 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH LOWER LEG REVISION Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01486 ANEST DEF ANESTH 01/01/1900 0.00 7.0 Description: ANESTH ANKLE REPLACEMENT Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01490 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH LOWER LEG CASTING Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01500 ANEST DEF ANESTH 01/01/1900 0.00 8.0 Description: ANESTH LEG ARTERIES SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01502 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH LWR LEG EMBOLECTOMY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0151A NOCOV DEF SYSMAN Description: ADM SARSCV2 BVL 10MCG/.2ML 1 Category: Non Covered Services CMS Add: 04/18/2023 CMS Term: 10/31/2023 *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 26 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 01520 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH LOWER LEG VEIN SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01522 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH LOWER LEG VEIN SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0152T NOCOV DEF SYSMAN Description: COMPUTER CHEST ADD-ON Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 12/31/2006 0152U NOCOV DEF SYSMAN Description: NFCT DS DNA UNTRGT NGNRJ SEQ Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0153U NOCOV DEF SYSMAN Description: ONC BREAST MRNA 101 GENES Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0154A NOCOV DEF SYSMAN Description: ADM SARSCV2 BVL 10MCG/.2ML A Category: Non Covered Services CMS Add: 10/12/2022 CMS Term: 10/31/2023 0154U NOCOV DEF SYSMAN Description: ONC URTHL CA RNA FGFR3 GENE Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0155U NOCOV DEF SYSMAN Description: ONC BRST CA DNA PIK3CA GENE Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0156U NOCOV DEF SYSMAN Description: COPY NUMBER SEQUENCE ALYS Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0157U NOCOV DEF SYSMAN Description: APC MRNA SEQ ALYS Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0158U NOCOV DEF SYSMAN Description: MLH1 MRNA SEQ ALYS Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0159U NOCOV DEF SYSMAN Description: MSH2 MRNA SEQ ALYS Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0160U NOCOV DEF SYSMAN Description: MSH6 MRNA SEQ ALYS Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 01610 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH SURGERY OF SHOULDER Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0161U NOCOV DEF SYSMAN Description: PMS2 MRNA SEQ ALYS Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 01620 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH SHOULDER PROCEDURE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 27 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 01622 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANES DX SHOULDER ARTHROSCOPY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0162U NOCOV DEF SYSMAN Description: HERED COLON CA TRGT MRNA PNL Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 01630 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH SURGERY OF SHOULDER Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01634 ANEST DEF ANESTH 01/01/1900 0.00 9.0 Description: ANESTH SHOULDER JOINT AMPUT Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01636 ANEST DEF ANESTH 01/01/1900 0.00 15.0 Description: ANESTH FOREQUARTER AMPUT Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01638 ANEST DEF ANESTH 01/01/1900 0.00 10.0 Description: ANESTH SHOULDER REPLACEMENT Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0163U NOCOV DEF SYSMAN Description: ONC CLRCT SCR 3 PRTN ALG Category: Non Covered Services CMS Add: 04/01/2020 CMS Term: 0164A NOCOV DEF SYSMAN Description: ADM SRSCV2 BVL 10MCG/0.2ML A Category: Non Covered Services CMS Add: 12/08/2022 CMS Term: 10/31/2023 0164T NOCOV DEF SYSMAN Description: REMOVE LUMB ARTIF DISC ADDL Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 0164U NOCOV DEF SYSMAN Description: GI IBS IA ANTI-CDTB&VINCULIN Category: Non Covered Services CMS Add: 04/01/2020 CMS Term: 01650 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH SHOULDER ARTERY SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01652 ANEST DEF ANESTH 01/01/1900 0.00 10.0 Description: ANESTH SHOULDER VESSEL SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01654 ANEST DEF ANESTH 01/01/1900 0.00 8.0 Description: ANESTH SHOULDER VESSEL SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01656 ANEST DEF ANESTH 01/01/1900 0.00 10.0 Description: ANESTH ARM-LEG VESSEL SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0165T NOCOV DEF SYSMAN Description: REVISE LUMB ARTIF DISC ADDL Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 0165U NOCOV DEF SYSMAN Description: PEANUT ALLG ASMT EPI Category: Non Covered Services CMS Add: 04/01/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 28 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0166U NOCOV DEF SYSMAN Description: LIVER DS 10 BIOCHEM ASY SRM Category: Non Covered Services CMS Add: 04/01/2020 CMS Term: 01670 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH SHOULDER VEIN SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0167U NOCOV DEF SYSMAN Description: CHORNC GONADOTROPIN HCG IA Category: Non Covered Services CMS Add: 04/01/2020 CMS Term: 01680 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH SHOULDER CASTING Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0169U NOCOV DEF SYSMAN Description: NUDT15&TPMT GENE COM VRNT Category: Non Covered Services CMS Add: 04/01/2020 CMS Term: 0170U NOCOV DEF SYSMAN Description: NEURO ASD RNA NEXT GEN SEQ Category: Non Covered Services CMS Add: 04/01/2020 CMS Term: 01710 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH ELBOW AREA SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01712 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH UPPR ARM TENDON SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01714 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH UPPR ARM TENDON SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01716 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH BICEPS TENDON REPAIR Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0171A NOCOV DEF SYSMAN Description: ADM SARSCV2 BVL 3MCG/0.2ML 1 Category: Non Covered Services CMS Add: 04/18/2023 CMS Term: 10/31/2023 0171U NOCOV DEF SYSMAN Description: TRGT GEN SEQ ALYS PNL DNA 23 Category: Non Covered Services CMS Add: 04/01/2020 CMS Term: 0172A NOCOV DEF SYSMAN Description: ADM SARSCV2 BVL 3MCG/0.2ML 2 Category: Non Covered Services CMS Add: 04/18/2023 CMS Term: 10/31/2023 0172U NOCOV DEF SYSMAN Description: ONC SLD TUM ALYS BRCA1 BRCA2 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 01730 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH UPPR ARM PROCEDURE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01732 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH DX ELBOW ARTHROSCOPY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 29 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0173A NOCOV DEF SYSMAN Description: ADM SARSCV2 BVL 3MCG/0.2ML 3 Category: Non Covered Services CMS Add: 12/08/2022 CMS Term: 10/31/2023 0173U NOCOV DEF SYSMAN Description: PSYC GEN ALYS PANEL 14 GENES Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 01740 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH UPPER ARM SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01742 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH HUMERUS SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01744 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH HUMERUS REPAIR Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0174A NOCOV DEF SYSMAN Description: ADM SARSCV2 BVL 3MCG/0.2ML A Category: Non Covered Services CMS Add: 03/14/2023 CMS Term: 10/31/2023 0174T NOCOV DEF SYSMAN Description: CAD CXR WITH INTERP Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 0174U NOCOV DEF SYSMAN Description: ONC SOLID TUMOR 30 PRTN TRGT Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 01756 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH RADICAL HUMERUS SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01758 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH HUMERAL LESION SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0175T NOCOV DEF SYSMAN Description: CAD CXR REMOTE Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 0175U NOCOV DEF SYSMAN Description: PSYC GEN ALYS PANEL 15 GENES Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 01760 ANEST DEF ANESTH 01/01/1900 0.00 7.0 Description: ANESTH ELBOW REPLACEMENT Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0176U NOCOV DEF SYSMAN Description: CDTB&VINCULIN IGG ANTB IA Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 01770 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH UPPR ARM ARTERY SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01772 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH UPPR ARM EMBOLECTOMY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 30 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0177U NOCOV DEF SYSMAN Description: ONC BRST CA DNA PIK3CA 11 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 01780 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH UPPER ARM VEIN SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01782 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH UPPR ARM VEIN REPAIR Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0178U NOCOV DEF SYSMAN Description: PEANUT ALLG ASMT EPI CLIN RX Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0179U NOCOV DEF SYSMAN Description: ONC NONSM CLL LNG CA ALYS 23 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0180U NOCOV DEF SYSMAN Description: ABO GNOTYP ABO 7 EXONS Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 01810 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH LOWER ARM SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0181U NOCOV DEF SYSMAN Description: CO GNOTYP AQP1 EXON 1 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 01820 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH LOWER ARM PROCEDURE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01829 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH DX WRIST ARTHROSCOPY Category: Anesthesia CMS Add: 01/01/2003 CMS Term: 0182U NOCOV DEF SYSMAN Description: CROM GNOTYP CD55 EXONS 1-10 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 01830 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH LOWER ARM SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01832 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH WRIST REPLACEMENT Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0183T NOCOV DEF SYSMAN Description: WOUND ULTRASOUND Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 12/31/2013 0183U NOCOV DEF SYSMAN Description: DI GNOTYP SLC4A1 EXON 19 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 01840 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH LWR ARM ARTERY SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 31 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 01842 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH LWR ARM EMBOLECTOMY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01844 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH VASCULAR SHUNT SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0184T NOCOV DEF SYSMAN Description: EXC RECTAL TUMOR ENDOSCOPIC Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 0184U NOCOV DEF SYSMAN Description: DO GNOTYP ART4 EXON 2 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 01850 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH LOWER ARM VEIN SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01852 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH LWR ARM VEIN REPAIR Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0185T NOCOV DEF SYSMAN Description: COMPTR PROBABILITY ANALYSIS Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 12/31/2013 0185U NOCOV DEF SYSMAN Description: FUT1 GNOTYP FUT1 EXON 4 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 01860 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH LOWER ARM CASTING Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0186T NOCOV DEF SYSMAN Description: SUPRACHOROIDAL DRUG DELIVERY Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 12/31/2013 0186U NOCOV DEF SYSMAN Description: FUT2 GNOTYP FUT2 EXON 2 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0187U NOCOV DEF SYSMAN Description: FY GNOTYP ACKR1 EXONS 1-2 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0188U NOCOV DEF SYSMAN Description: GE GNOTYP GYPC EXONS 1-4 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0189U NOCOV DEF SYSMAN Description: GYPA GNOTYP NTRNS 1 5 EXON 2 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0190U NOCOV DEF SYSMAN Description: GYPB GNOTYP NTRNS 1 5 SEUX 3 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 01916 ANEST DEF ANESTH 02/01/2015 0.00 5.0 Description: ANESTH DX ARTERIOGRAPHY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 32 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0191U NOCOV DEF SYSMAN Description: IN GNOTYP CD44 EXONS 2 3 6 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 01920 ANEST DEF ANESTH 01/01/1900 0.00 7.0 Description: ANESTH CATHETERIZE HEART Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01922 ANEST DEF ANESTH 01/01/1900 0.00 7.0 Description: ANESTH CAT OR MRI SCAN Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01924 ANEST DEF ANESTH 02/01/2015 0.00 5.0 Description: ANES THER INTERVEN RAD ARTRL Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 01925 ANEST DEF ANESTH 02/01/2015 0.00 7.0 Description: ANES THER INTERVEN RAD CARD Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 01926 ANEST DEF ANESTH 02/01/2015 0.00 8.0 Description: ANES TX INTERV RAD HRT/CRAN Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 0192T NOCOV DEF SYSMAN Description: INSERT ANT SEGMENT DRAIN EXT Category: Non Covered Services CMS Add: 07/01/2008 CMS Term: 12/31/2013 0192U NOCOV DEF SYSMAN Description: JK GNOTYP SLC14A1 EXON 9 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 01930 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANES THER INTERVEN RAD VEIN Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 01931 ANEST DEF ANESTH 01/01/1900 0.00 7.0 Description: ANES THER INTERVEN RAD TIPS Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 01932 ANEST DEF ANESTH 02/01/2015 0.00 6.0 Description: ANES TX INTERV RAD TH VEIN Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 01933 ANEST DEF ANESTH 02/01/2015 0.00 7.0 Description: ANES TX INTERV RAD CRAN VEIN Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 01937 ANEST DEF ANESTH 01/01/2022 0.00 4.0 Description: ANES DRG/ASPIR CRV/THRC Category: Anesthesia CMS Add: 01/01/2022 CMS Term: 01938 ANEST DEF ANESTH 01/01/2022 0.00 4.0 Description: ANES DRG/ASPIR LMBR/SAC Category: Anesthesia CMS Add: 01/01/2022 CMS Term: 01939 ANEST DEF ANESTH 01/01/2022 0.00 4.0 Description: ANES NULYT AGT CRV/THRC Category: Anesthesia CMS Add: 01/01/2022 CMS Term: 0193U NOCOV DEF SYSMAN Description: JR GNOTYP ABCG2 EXONS 2-26 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 33 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 01940 ANEST DEF ANESTH 01/01/2022 0.00 4.0 Description: ANES NULYT AGT LMBR/SAC Category: Anesthesia CMS Add: 01/01/2022 CMS Term: 01941 ANEST DEF ANESTH 01/01/2022 0.00 5.0 Description: ANES NEUROMD/NTRVRT CRV/THRC Category: Anesthesia CMS Add: 01/01/2022 CMS Term: 01942 ANEST DEF ANESTH 01/01/2022 0.00 5.0 Description: ANES NEUROMD/NTRVRT LMBR/SAC Category: Anesthesia CMS Add: 01/01/2022 CMS Term: 0194U NOCOV DEF SYSMAN Description: KEL GNOTYP KEL EXON 8 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 01951 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH BURN LESS 4 PERCENT Category: Anesthesia CMS Add: 01/01/2001 CMS Term: 01952 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH BURN 4-9 PERCENT Category: Anesthesia CMS Add: 01/01/2001 CMS Term: 01953 ANEST DEF ANESTH 01/01/2024 0.00 1.0 Description: ANESTH BURN EACH 9 PERCENT Category: Anesthesia CMS Add: 01/01/2001 CMS Term: 01953 ANEST DEF ANESTH 05/18/2018 12/31/2023 16.26 0.0 Description: ANESTH BURN EACH 9 PERCENT Category: Anesthesia CMS Add: 01/01/2001 CMS Term: 01958 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANES XTRNL CEPHALIC VERSION Category: Anesthesia CMS Add: 01/01/2004 CMS Term: 0195U NOCOV DEF SYSMAN Description: KLF1 TARGETED SEQUENCING Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 01960 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANES VAGINAL DELIVERY ONLY Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 01961 ANEST DEF ANESTH 01/01/1900 0.00 7.0 Description: ANES CESAREAN DELIVERY ONLY Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 01962 ANEST DEF ANESTH 01/01/1900 0.00 8.0 Y Description: ANES URGENT HYSTERECTOMY Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 01963 ANEST DEF ANESTH 02/01/2015 0.00 8.0 Y Description: ANES CESAREAN HYSTERECTOMY Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 01965 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANES INCOMPL/MISSED AB PX Category: Anesthesia CMS Add: 01/01/2006 CMS Term: 01966 ANEST DEF ANESTH 11/15/2014 0.00 4.0 Y Description: ANES INDUCED ABORTION PX Category: Anesthesia CMS Add: 01/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 34 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 01967 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: NEURAXL LBR ANES VAG DLVR Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 01968 ANEST DEF ANESTH 02/01/2015 0.00 2.0 Description: ANES/ANALG CS DLVR NEURAXIAL Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 01969 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Y Description: ANES C HYST FLWG NEURAXIAL Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 0196U NOCOV DEF SYSMAN Description: LU GNOTYP BCAM EXON 3 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0197U NOCOV DEF SYSMAN Description: LW GNOTYP ICAM4 EXON 1 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0198T NOCOV DEF SYSMAN Description: OCULAR BLOOD FLOW MEASURE Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 0198U NOCOV DEF SYSMAN Description: RHD&RHCE GNTYP RHD1-10&RHCE5 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 01990 ANEST DEF ANESTH 01/01/1900 0.00 7.0 Description: SUPPORT FOR ORGAN DONOR Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01991 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH NERVE BLOCK/INJ Category: Anesthesia CMS Add: 01/01/2003 CMS Term: 01992 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH N BLOCK/INJ PRONE Category: Anesthesia CMS Add: 01/01/2003 CMS Term: 01996 ANEST DEF ANESTH 01/01/1900 12/31/2023 41.64 0.0 Description: HOSP MANAGE CONT DRUG ADMIN Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01996 ANEST DEF ANESTH 01/01/2024 0.00 3.0 Description: HOSP MANAGE CONT DRUG ADMIN Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01999 ANEST DEF ANESTH 02/01/2015 0.00 0.0 Description: UNLISTED ANES PROCEDURE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0199U NOCOV DEF SYSMAN Description: SC GNOTYP ERMAP EXONS 4 12 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0200T NOCOV DEF SYSMAN Description: PERQ SACRAL AUGMT UNILAT INJ Category: Non Covered Services CMS Add: 07/01/2009 CMS Term: 0200U NOCOV DEF SYSMAN Description: XK GNOTYP XK EXONS 1-3 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 35 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0201T NOCOV DEF SYSMAN Description: PERQ SACRAL AUGMT BILAT INJ Category: Non Covered Services CMS Add: 07/01/2009 CMS Term: 0201U NOCOV DEF SYSMAN Description: YT GNOTYP ACHE EXON 2 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0202T NOCOV DEF SYSMAN Description: POST VERT ARTHRPLST 1 LUMBAR Category: Non Covered Services CMS Add: 07/01/2009 CMS Term: 0202U NOCOV DEF SYSMAN Description: NFCT DS 22 TRGT SARS-COV-2 Category: Non Covered Services CMS Add: 05/20/2020 CMS Term: 0203U NOCOV DEF SYSMAN Description: AI IBD MRNA XPRSN PRFL 17 Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 0204U NOCOV DEF SYSMAN Description: ONC THYR MRNA XPRSN ALYS 593 Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 0205U NOCOV DEF SYSMAN Description: OPH AMD ALYS 3 GENE VARIANTS Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 0206U NOCOV DEF SYSMAN Description: NEURO ALZHEIMER CELL AGGREGJ Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 0207T NOCOV DEF SYSMAN Description: CLEAR EYELID GLAND W/HEAT Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 0207U NOCOV DEF SYSMAN Description: NEURO ALZHEIMER QUAN IMAGING Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 0208T NOCOV DEF SYSMAN Description: AUDIOMETRY AIR ONLY Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 0209T NOCOV DEF SYSMAN Description: AUDIOMETRY AIR & BONE Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 0209U NOCOV DEF SYSMAN Description: CYTOG CONST ALYS INTERROG Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 02100 NOCOV DEF SYSMAN Description: ANESTH DIAG NERVE BLK Category: Non Covered Services CMS Add: 10/16/2003 CMS Term: 06/30/2015 02101 NOCOV DEF SYSMAN Description: ANESTH DIAG NRV BLK PRONE Category: Non Covered Services CMS Add: 10/16/2003 CMS Term: 06/30/2015 0210T NOCOV DEF SYSMAN Description: SPEECH AUDIOMETRY THRESHOLD Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 36 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0210U NOCOV DEF SYSMAN Description: SYPHILIS TST ANTB IA QUAN Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 0211T NOCOV DEF SYSMAN Description: SPEECH AUDIOM THRESH & RECOG Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 0211U NOCOV DEF SYSMAN Description: ONC PAN-TUM DNA&RNA GNRJ SEQ Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 0212T NOCOV DEF SYSMAN Description: COMPRE AUDIOMETRY EVALUATION Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 0212U NOCOV DEF SYSMAN Description: RARE DS GEN DNA ALYS PROBAND Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 0213T NOCOV DEF SYSMAN 0-1 Description: NJX PARAVERT W/US CER/THOR Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 0213U NOCOV DEF SYSMAN Description: RARE DS GEN DNA ALYS EA COMP Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 0214T NOCOV DEF SYSMAN Description: NJX PARAVERT W/US CER/THOR Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 0214U NOCOV DEF SYSMAN Description: RARE DS XOM DNA ALYS PROBAND Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 0215T NOCOV DEF SYSMAN Description: NJX PARAVERT W/US CER/THOR Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 0215U NOCOV DEF SYSMAN Description: RARE DS XOM DNA ALYS EA COMP Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 0216T NOCOV DEF SYSMAN 0-1 Description: NJX PARAVERT W/US LUMB/SAC Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 0216U NOCOV DEF SYSMAN Description: NEURO INH ATAXIA DNA 12 COM Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 0217T NOCOV DEF SYSMAN Description: NJX PARAVERT W/US LUMB/SAC Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 0217U NOCOV DEF SYSMAN Description: NEURO INH ATAXIA DNA 51 GENE Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 0218T NOCOV DEF SYSMAN Description: NJX PARAVERT W/US LUMB/SAC Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 37 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0218U NOCOV DEF SYSMAN Description: NEURO MUSC DYS DMD SEQ ALYS Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 0219T NOCOV DEF SYSMAN Description: PLMT POST FACET IMPLT CERV Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 0219U NOCOV DEF SYSMAN Description: NFCT AGT HIV GNRJ SEQ ALYS Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 0220T NOCOV DEF SYSMAN Description: PLMT POST FACET IMPLT THOR Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 0220U NOCOV DEF SYSMAN Description: ONC BRST CA AI ASSMT 12 FEAT Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 0221T NOCOV DEF SYSMAN Description: PLMT POST FACET IMPLT LUMB Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 0221U NOCOV DEF SYSMAN Description: ABO GNOTYP NEXT GNRJ SEQ ABO Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 0222T NOCOV DEF SYSMAN Description: PLMT POST FACET IMPLT ADDL Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 0222U NOCOV DEF SYSMAN Description: RHD&RHCE GNTYP NEXT GNRJ SEQ Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 0223U NOCOV DEF SYSMAN Description: NFCT DS 22 TRGT SARS-COV-2 Category: Non Covered Services CMS Add: 06/25/2020 CMS Term: 0224U NOCOV DEF SYSMAN Description: ANTIBODY SARS-COV-2 TITER(S) Category: Non Covered Services CMS Add: 06/25/2020 CMS Term: 0225U NOCOV DEF SYSMAN Description: NFCT DS DNA&RNA 21 SARSCOV2 Category: Non Covered Services CMS Add: 08/10/2020 CMS Term: 0226U NOCOV DEF SYSMAN Description: SVNT SARSCOV2 ELISA PLSM SRM Category: Non Covered Services CMS Add: 08/10/2020 CMS Term: 0227U NOCOV DEF SYSMAN Description: RX ASY PRSMV 30+RX/METABLT Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0228U NOCOV DEF SYSMAN Description: ONC PRST8 MA MOLEC PRFL ALG Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0229U NOCOV DEF SYSMAN Description: BCAT1&IKZF1 PRMTR MTHYLN ALY Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 38 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0230U NOCOV DEF SYSMAN Description: AR FULL SEQUENCE ANALYSIS Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0231U NOCOV DEF SYSMAN Description: CACNA1A FULL GENE ANALYSIS Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0232T NOCOV DEF SYSMAN Description: NJX PLATELET PLASMA Category: Non Covered Services CMS Add: 07/01/2010 CMS Term: 0232U NOCOV DEF SYSMAN Description: CSTB FULL GENE ANALYSIS Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0233U NOCOV DEF SYSMAN Description: FXN GENE ANALYSIS Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0234T MEDSV DEF MAXFEE 01/01/2024 1879.23 0.0 Description: TRLUML PERIP ATHRC RENAL ART Category: Medical Services CMS Add: 01/01/2011 CMS Term: 0234U NOCOV DEF SYSMAN Description: MECP2 FULL GENE ANALYSIS Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0235T MEDSV DEF BILL40 Description: TRLUML PERIP ATHRC VISCERAL Category: Medical Services CMS Add: 01/01/2011 CMS Term: 0235U NOCOV DEF SYSMAN Description: PTEN FULL GENE ANALYSIS Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0236T MEDSV DEF MAXFEE 01/01/2024 1879.23 0.0 Description: TRLUML PERIP ATHRC ABD AORTA Category: Medical Services CMS Add: 01/01/2011 CMS Term: 0236U NOCOV DEF SYSMAN Description: SMN1&SMN2 FULL GENE ANALYSIS Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0237T MEDSV DEF MAXFEE 01/01/2024 1879.23 0.0 Description: TRLUML PERIP ATHRC BRCHIOCPH Category: Medical Services CMS Add: 01/01/2011 CMS Term: 0237U NOCOV DEF SYSMAN Description: CAR ION CHNLPTHY GEN SEQ PNL Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0238T MEDSV DEF MAXFEE 01/01/2024 1879.23 0.0 Description: TRLUML PERIP ATHRC ILIAC ART Category: Medical Services CMS Add: 01/01/2011 CMS Term: 0238U NOCOV DEF SYSMAN Description: ONC LNCH SYN GEN DNA SEQ ALY Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0239U NOCOV DEF SYSMAN Description: TRGT GEN SEQ ALYS PNL 311+ Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 39 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0240U LAB DEF MAXFEE 12/24/2021 142.63 0.0 Description: NFCT DS VIR RESP RNA 3 TRGT Category: Laboratory CMS Add: 10/06/2020 CMS Term: 0241U LAB DEF MAXFEE 12/24/2021 142.63 0.0 Description: NFCT DS VIR RESP RNA 4 TRGT Category: Laboratory CMS Add: 10/06/2020 CMS Term: 0242U LAB L60 MAXFEE 07/24/2023 5000.00 0.0 Y Description: TRGT GEN SEQ ALYS PNL 55-74 Category: Laboratory CMS Add: 04/01/2021 CMS Term: 0243U NOCOV DEF SYSMAN Description: OB PE BIOCHEM ASSAY PGF ALG Category: Non Covered Services CMS Add: 04/01/2021 CMS Term: 0244U NOCOV DEF SYSMAN Description: ONC SOLID ORGN DNA 257 GENES Category: Non Covered Services CMS Add: 04/01/2021 CMS Term: 0245U NOCOV DEF SYSMAN Description: ONC THYR MUT ALYS 10 GEN&37 Category: Non Covered Services CMS Add: 04/01/2021 CMS Term: 0246U NOCOV DEF SYSMAN Description: RBC DNA GNOTYP 16 BLD GROUPS Category: Non Covered Services CMS Add: 04/01/2021 CMS Term: 0247U NOCOV DEF SYSMAN Description: OB PRTRM BRTH IBP4 SHBG MEAS Category: Non Covered Services CMS Add: 04/01/2021 CMS Term: 0248U NOCOV DEF SYSMAN Description: ONC BRN SPHRD CLL 12 RX PNL Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0249U NOCOV DEF SYSMAN Description: ONC BRST ALYS 32 PHSPRTN ALG Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0250U NOCOV DEF SYSMAN Description: ONC SLD ORG NEO DNA 505 GENE Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0251U NOCOV DEF SYSMAN Description: HEPCIDIN-25 ELISA SERUM/PLSM Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0252U NOCOV DEF SYSMAN Description: FTL ANEUPLOIDY STR ALYS DNA Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0253T NOCOV DEF SYSMAN Description: INSERT AQUEOUS DRAIN DEVICE Category: Non Covered Services CMS Add: 01/01/2011 CMS Term: 0253U NOCOV DEF SYSMAN Description: RPRDTVE MED RNA GEN PRFL 238 Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0254U NOCOV DEF SYSMAN Description: REPRDTVE MED ALYS 24 CHRMSM Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 40 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0255U NOCOV DEF SYSMAN Description: ANDROLOGY INFERTILITY ASSMT Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0256U NOCOV DEF SYSMAN Description: TMA/TMAO PRFL MS/MS UR ALG Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0257U NOCOV DEF SYSMAN Description: VLCAD LEUK NZM ACTV WHL BLD Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0258U NOCOV DEF SYSMAN Description: AI PSOR MRNA 50-100 GEN ALG Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0259U NOCOV DEF SYSMAN Description: NEPH CKD NUC MRS MEAS GFR Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0260T NOCOV DEF SYSMAN Description: HYPTHRM BDY NEONATE 28D/< Category: Non Covered Services CMS Add: 01/01/2011 CMS Term: 12/31/2013 0260U NOCOV DEF SYSMAN Description: RARE DS ID OPT GENOME MAPG Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0261T NOCOV DEF SYSMAN Description: HYPTHRM HEAD NEONATE 28D/< Category: Non Covered Services CMS Add: 01/01/2011 CMS Term: 12/31/2013 0261U NOCOV DEF SYSMAN Description: ONC CLRCT CA IMG ALYS W/AI Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0262U NOCOV DEF SYSMAN Description: ONC SLD TUM RT-PCR 7 GEN Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0263T NOCOV DEF SYSMAN Description: IM B1 MRW CEL THER CMPL Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: 0263U NOCOV DEF SYSMAN Description: NEURO ASD MEAS 16 C METBLT Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0264T NOCOV DEF SYSMAN Description: IM B1 MRW CEL THER XCL HRVST Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: 0264U NOCOV DEF SYSMAN Description: RARE DS ID OPT GENOME MAPG Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0265T NOCOV DEF SYSMAN Description: IM B1 MRW CEL THER HRVST ONL Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: 0265U NOCOV DEF SYSMAN Description: RAR DO WHL GN&MTCDRL DNA ALS Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 41 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0266T NOCOV DEF SYSMAN Description: IMPLT/RPL CRTD SNS DEV TOTAL Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: 0266U NOCOV DEF SYSMAN Description: UNXPL CNST HRTBL DO GN XPRSN Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0267T NOCOV DEF SYSMAN Description: IMPLT/RPL CRTD SNS DEV LEAD Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: 0267U NOCOV DEF SYSMAN Description: RARE DO ID OPT GEN MAPG&SEQ Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0268T NOCOV DEF SYSMAN Description: IMPLT/RPL CRTD SNS DEV GEN Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: 0268U NOCOV DEF SYSMAN Description: HEM AHUS GEN SEQ ALYS 15 GEN Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0269T NOCOV DEF SYSMAN Description: REV/REMVL CRTD SNS DEV TOTAL Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: 0269U NOCOV DEF SYSMAN Description: HEM AUT DM CGEN TRMBCTPNA 22 Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0270T NOCOV DEF SYSMAN Description: REV/REMVL CRTD SNS DEV LEAD Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: 0270U NOCOV DEF SYSMAN Description: HEM CGEN COAGJ DO 20 GENES Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0271T NOCOV DEF SYSMAN Description: REV/REMVL CRTD SNS DEV GEN Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: 0271U NOCOV DEF SYSMAN Description: HEM CGEN NEUTROPENIA 24 GEN Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0272T NOCOV DEF SYSMAN Description: INTERROGATE CRTD SNS DEV Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: 0272U NOCOV DEF SYSMAN Description: HEM GENETIC BLD DO 60 GENES Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0273T NOCOV DEF SYSMAN Description: INTERROGATE CRTD SNS W/PGRMG Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: 0273U NOCOV DEF SYSMAN Description: HEM GEN HYPRFIBRNLYSIS 8 GEN Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 42 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0274T NOCOV DEF SYSMAN Description: PERQ LAMOT/LAM CRV/THRC Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: 0274U NOCOV DEF SYSMAN Description: HEM GEN PLTLT DO 62 GENES Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0275T NOCOV DEF SYSMAN Description: PERQ LAMOT/LAM LUMBAR Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: 0275U NOCOV DEF SYSMAN Description: HEM HEPRN NDUC TRMBCTPNA SRM Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0276U NOCOV DEF SYSMAN Description: HEM INH THROMBOCYTOPENIA 42 Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0277U NOCOV DEF SYSMAN Description: HEM GEN PLTLT FUNCJ DO 40 Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0278T NOCOV DEF SYSMAN Description: TEMPR Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 0278U NOCOV DEF SYSMAN Description: HEM GEN THROMBOSIS 14 GENES Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0279U NOCOV DEF SYSMAN Description: HEM VW FACTOR&CLGN III BNDG Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0280U NOCOV DEF SYSMAN Description: HEM VW FACTOR&CLGN IV BNDG Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0281U NOCOV DEF SYSMAN Description: HEM VWD PROPEPTIDE AG LVL Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0282U NOCOV DEF SYSMAN Description: RBC DNA GNTYP 12 BLD GRP GEN Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0283U NOCOV DEF SYSMAN Description: VW FACTOR TYPE 2B EVAL PLSM Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0284U NOCOV DEF SYSMAN Description: VW FACTOR TYPE 2N EVAL PLSM Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0285U NOCOV DEF SYSMAN Description: ONC RSPS RADJ CLL FR DNA TOX Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0286U NOCOV DEF SYSMAN Description: CEP72 NUDT15&TPMT GENE ALYS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 43 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0287U LAB L60 MAXFEE 01/20/2023 3600.00 0.0 Y Description: ONC THYR DNA&MRNA 112 GENES Category: Laboratory CMS Add: 01/01/2022 CMS Term: 0288U NOCOV DEF SYSMAN Description: ONC LUNG MRNA QUAN PCR 11&3 Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0289U NOCOV DEF SYSMAN Description: NEURO ALZHEIMER MRNA 24 GEN Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0290U NOCOV DEF SYSMAN Description: PAIN MGMT MRNA GEN XPRSN 36 Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0291U NOCOV DEF SYSMAN Description: PSYC MOOD DO MRNA 144 GENES Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0292U NOCOV DEF SYSMAN Description: PSYC STRS DO MRNA 72 GENES Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0293U NOCOV DEF SYSMAN Description: PSYC SUICIDAL IDEA MRNA 54 Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0294U NOCOV DEF SYSMAN Description: LNGVTY&MRTLTY RSK MRNA 18GEN Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0295U NOCOV DEF SYSMAN Description: ONC BRST DUX CARC 7 PROTEINS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0296U NOCOV DEF SYSMAN Description: ONC ORL&/OROP CA 20 MLC FEAT Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0297U NOCOV DEF SYSMAN Description: ONC PAN TUM WHL GEN SEQ DNA Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0298U NOCOV DEF SYSMAN Description: ONC PAN TUM WHL TRNS SEQ RNA Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0299U NOCOV DEF SYSMAN Description: ONC PAN TUM WHL GEN OPT MAPG Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0300U NOCOV DEF SYSMAN Description: ONC PAN TUM WHL GEN SEQ&OPT Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0301U NOCOV DEF SYSMAN Description: IADNA BARTONELLA DDPCR Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0302U NOCOV DEF SYSMAN Description: IADNA BRTNLA DDPCR FLWG LIQ Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 44 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0303U NOCOV DEF SYSMAN Description: HEM RBC ADS WHL BLD HYPOXIC Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0304U NOCOV DEF SYSMAN Description: HEM RBC ADS WHL BLD NORMOXIC Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0305U NOCOV DEF SYSMAN Description: HEM RBC FNCLTY&DFRM SHR STRS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0306U NOCOV DEF SYSMAN Description: ONC MRD NXT-GNRJ ALYS 1ST Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: 0307U NOCOV DEF SYSMAN Description: ONC MRD NXT-GNRJ ALYS SBSQ Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: 0308T NOCOV DEF SYSMAN Description: INSJ OCULAR TELESCOPE PROSTH Category: Non Covered Services CMS Add: 07/01/2012 CMS Term: 0308U NOCOV DEF SYSMAN Description: CRD CAD ALYS 3 PRTN 3 PARAM Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: 0309U NOCOV DEF SYSMAN Description: CRD CV DS ALY 4 PRTN PLM ALG Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: 0310U NOCOV DEF SYSMAN Description: PED VSCLTS KD ALYS 3 BMRKS Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: 0311U NOCOV DEF SYSMAN Description: NFCT DS BCT QUAN ANTMCRB SC Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: 0312U NOCOV DEF SYSMAN Description: AI DS SLE ALYS 8 IGG AUTOANT Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: 0313U NOCOV DEF SYSMAN Description: ONC PNCRS DNA&MRNA SEQ 74 Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: 0314U NOCOV DEF SYSMAN Description: ONC CUTAN MLNMA MRNA 35 GENE Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: 0315U NOCOV DEF SYSMAN Description: ONC CUTAN SQ CLL CA MRNA 40 Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: 0316U NOCOV DEF SYSMAN Description: B BRGDRFERI LYME DS OSPA EVL Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: 0317U NOCOV DEF SYSMAN Description: ONC LUNG CA 4-PRB FISH ASSAY Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 45 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0318T NOCOV DEF SYSMAN Description: REPLACE AORTIC VALVE TTHORAC Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 12/31/2013 0318U NOCOV DEF SYSMAN Description: PED WHL GEN MTHYLTN ALYS 50+ Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: 0319U NOCOV DEF SYSMAN Description: NEPH RNA PRETRNSPL PERPH BLD Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: 0320U NOCOV DEF SYSMAN Description: NEPH RNA PSTTRNSPL PERPH BLD Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: 0321U NOCOV DEF SYSMAN Description: IADNA GU PTHGN 20BCT&FNG ORG Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: 0322U NOCOV DEF SYSMAN Description: NEURO ASD MEAS 14 ACYL CARN Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: 0323U NOCOV DEF SYSMAN Description: IADNA CNS PTHGN NEXT GEN SEQ Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0326U LAB DEF BILL90 Y Description: TRGT GEN SEQ ALYS PNL 83+ Category: Laboratory CMS Add: 07/01/2022 CMS Term: 0327U NOCOV DEF SYSMAN Description: FTL ANEUPLOIDY TRSMY DNA SEQ Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0328U NOCOV DEF SYSMAN Description: DRUG ASSAY 120+ RX&METABLT Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0329T NOCOV DEF SYSMAN Description: MNTR IO PRESS 24HRS/> UNI/BI Category: Non Covered Services CMS Add: 07/01/2013 CMS Term: 0329U NOCOV DEF SYSMAN Description: ONC NEO XOME&TRNS SEQ ALYS Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0330T NOCOV DEF SYSMAN Description: TEAR FILM IMG UNI/BI W/I&R Category: Non Covered Services CMS Add: 07/01/2013 CMS Term: 0330U NOCOV DEF SYSMAN Description: IADNA VAG PTHGN PANEL 27 ORG Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0331T NOCOV DEF SYSMAN Description: HEART SYMP IMAGE PLNR Category: Non Covered Services CMS Add: 07/01/2013 CMS Term: 0331U NOCOV DEF SYSMAN Description: ONC HL NEO OPT GEN MAPPING Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 46 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0332T NOCOV DEF SYSMAN Description: HEART SYMP IMAGE PLNR SPECT Category: Non Covered Services CMS Add: 07/01/2013 CMS Term: 0332U NOCOV DEF SYSMAN Description: ONC PAN TUM GEN PRFLG 8 DNA Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0333T NOCOV DEF SYSMAN Description: VISUAL EP SCR ACUITY AUTO Category: Non Covered Services CMS Add: 07/01/2013 CMS Term: 0333U NOCOV DEF SYSMAN Description: ONC LVR SURVEILANC HCC CFDNA Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0334U NOCOV DEF SYSMAN Description: ONC SLD ORGN TGSA DNA 84/+ Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0335T NOCOV DEF SYSMAN Description: INSJ SINUS TARSI IMPLANT Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: 0335U NOCOV DEF SYSMAN Description: RARE DS WHL GEN SEQ FETA Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0336U NOCOV DEF SYSMAN Description: RARE DS WHL GEN SEQ BLD/SLV Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0337U NOCOV DEF SYSMAN Description: ONC PLSM CELL DO&MYELOMA ID Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0338T NOCOV DEF SYSMAN Description: TRNSCTH RENAL SYMP DENRV UNL Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: 0338U NOCOV DEF SYSMAN Description: ONC SLD TUM CRCG TUM CL SLCT Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0339T NOCOV DEF SYSMAN Description: TRNSCTH RENAL SYMP DENRV BIL Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: 0339U NOCOV DEF SYSMAN Description: ONC PRST8 MRNA HOXC6 & DLX1 Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0340U NOCOV DEF SYSMAN Description: ONC PAN CA ALYS MRD PLASMA Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0341U NOCOV DEF SYSMAN Description: FTL ANEUP DNA SEQ CMPR ALYS Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0342T NOCOV DEF SYSMAN Description: THXP APHERESIS W/HDL DELIP Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 47 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0342U NOCOV DEF SYSMAN Description: ONC PNCRTC CA MULT IA ECLIA Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0343U NOCOV DEF SYSMAN Description: ONC PRST8 XOM ALY 442 SNCRNA Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0344U NOCOV DEF SYSMAN Description: HEP NAFLD SEMIQ EVL 28 LIPID Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0345T NOCOV DEF SYSMAN Description: TRANSCATH MTRAL VLVE REPAIR Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: 0345U NOCOV DEF SYSMAN Description: PSYC GENOM ALYS PNL 15 GEN Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0346U NOCOV DEF SYSMAN Description: BETA AMYL AB40&AB42 LC-MS/MS Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0347T NOCOV DEF SYSMAN Description: INS BONE DEVICE FOR RSA Category: Non Covered Services CMS Add: 07/01/2014 CMS Term: 0347U NOCOV DEF SYSMAN Description: RX METAB/PCX DNA 16 GEN ALYS Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0348T NOCOV DEF SYSMAN Description: RSA SPINE EXAM Category: Non Covered Services CMS Add: 07/01/2014 CMS Term: 0348U NOCOV DEF SYSMAN Description: RX METAB/PCX DNA 25 GEN ALYS Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0349T NOCOV DEF SYSMAN Description: RSA UPPER EXTR EXAM Category: Non Covered Services CMS Add: 07/01/2014 CMS Term: 0349U NOCOV DEF SYSMAN Description: RX METAB/PCX DNA 27GEN RX IA Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0350T NOCOV DEF SYSMAN Description: RSA LOWER EXTR EXAM Category: Non Covered Services CMS Add: 07/01/2014 CMS Term: 0350U NOCOV DEF SYSMAN Description: RX METAB/PCX DNA 27 GEN ALYS Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0351T NOCOV DEF SYSMAN Description: INTRAOP OCT BRST/NODE SPEC Category: Non Covered Services CMS Add: 07/01/2014 CMS Term: 0351U NOCOV DEF SYSMAN Description: NFCT DS BCT/VIRAL TRAIL IP10 Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 48 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0352T NOCOV DEF SYSMAN Description: OCT BRST/NODE I&R PER SPEC Category: Non Covered Services CMS Add: 07/01/2014 CMS Term: 0352U NOCOV DEF SYSMAN Description: NFCT DS BV&VAGINITIS AMP PRB Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0353T NOCOV DEF SYSMAN Description: INTRAOP OCT BREAST CAVITY Category: Non Covered Services CMS Add: 07/01/2014 CMS Term: 0353U NOCOV DEF SYSMAN Description: IADNA CHLMYD&GONORR AMP PRB Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0354T NOCOV DEF SYSMAN Description: OCT BREAST SURG CAVITY I&R Category: Non Covered Services CMS Add: 07/01/2014 CMS Term: 0354U NOCOV DEF SYSMAN Description: HPV HI RSK QUAL MRNA E6/E7 Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 03/31/2024 0355U NOCOV DEF SYSMAN Description: APOL1 RISK VARIANTS Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0356U NOCOV DEF SYSMAN Description: ONC OROP/ANAL 17 DNA DDPCR Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0358T NOCOV DEF SYSMAN Description: BIA WHOLE BODY Category: Non Covered Services CMS Add: 07/01/2014 CMS Term: 0358U NOCOV DEF SYSMAN Description: NEURO ALYS B-AMYL 1-42&1-40 Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0359U NOCOV DEF SYSMAN Description: ONC PRST8 CA ALYS ALL PSA Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0360U NOCOV DEF SYSMAN Description: ONC LUNG ELISA 7 AUTOANT ALG Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0361U NOCOV DEF SYSMAN Description: NEURFLMNT LT CHN DIG IA QUAN Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0362T U1 MENTL DEF MAXFEE 01/01/2024 28.54 0.0 Y 0-999years Description: BHV ID SUPRT ASSMT EA 15 MIN Category: Mental Health CMS Add: 07/01/2014 CMS Term: 0362U NOCOV DEF SYSMAN Description: ONC PAP THYR CA RNA 82&10 Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0363U NOCOV DEF SYSMAN Description: ONC URTHL MRNA 5 GEN ALG Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 49 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0364U NOCOV DEF SYSMAN Description: ONC HL NEO GEN SEQ ALYS ALG Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0365U NOCOV DEF SYSMAN Description: ONC BLDR 10 PRB BLDR CA Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0366U NOCOV DEF SYSMAN Description: ONC BLDR 10 PRB RECR BLDR CA Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0367U NOCOV DEF SYSMAN Description: ONC BLDR 10 FLWG TRURL RESCJ Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0368U NOCOV DEF SYSMAN Description: ONC CLRCT CA MUT&MTHYLTN MRK Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0369U NOCOV DEF SYSMAN Description: IADNA GI PTHGN 31 ORG&21 ARG Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0370U NOCOV DEF SYSMAN Description: IADNA SURG WND PTHGN 34&21 Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0371U NOCOV DEF SYSMAN Description: IADNA GU PTHGN SEMIQ DNA16&1 Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0372U NOCOV DEF SYSMAN Description: NFCT DS GU PTHGN ARG DETCJ Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0373T U1 MENTL DEF MAXFEE 01/01/2024 28.54 0.0 Y 0-999years Description: ADAPT BHV TX EA 15 MIN Category: Mental Health CMS Add: 07/01/2014 CMS Term: 0373U NOCOV DEF SYSMAN Description: IADNA RSP TR NFCT 17 8 13&16 Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0374U NOCOV DEF SYSMAN Description: IADNA GU PTHGN 21 ORG&21ARG Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0375U NOCOV DEF SYSMAN Description: ONC OVRN BCHM ASY 7 PRTN ALG Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0376U NOCOV DEF SYSMAN Description: ONC PRST8 CA IMG ALYS 128 Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0377U NOCOV DEF SYSMAN Description: CV DS QUAN ADVSRM/PLSM LPRTN Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0378T NOCOV DEF SYSMAN Description: VISUAL FIELD ASSMNT REV/RPRT Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 50 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0378U NOCOV DEF SYSMAN Description: RFC1 REPEAT XPNSJ VRNT ALYS Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0379T NOCOV DEF SYSMAN Description: VIS FIELD ASSMNT TECH SUPPT Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 0379U NOCOV DEF SYSMAN Description: TGSAP SL OR NEO DNA523&RNA55 Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0380U NOCOV DEF SYSMAN Description: RX METB ADVRS TRGT SQ ALY 20 Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0381U NOCOV DEF SYSMAN Description: MAPLE SYRUP UR DS MNTR QUAN Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0382U NOCOV DEF SYSMAN Description: HYPRPHENYLALNINMIA MNTR QUAN Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0383U NOCOV DEF SYSMAN Description: TYROSINEMIA TYP I MNTR QUAN Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0384U NOCOV DEF SYSMAN Description: NEPH CKD RSK HI STG KDN DS Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0385U NOCOV DEF SYSMAN Description: NEPH CKD ALG RSK DBTC KDN DS Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0387U NOCOV DEF SYSMAN Description: ONC MLNMA AMBRA1&AMLO Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0388U NOCOV DEF SYSMAN Description: ONC NONSM CLL LNG CA 37 GEN Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0389U NOCOV DEF SYSMAN Description: PED FBRL KD IFI27&MCEMP1 RNA Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0390U NOCOV DEF SYSMAN Description: OB PE KDR ENG&RBP4 IA ALG Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0391U NOCOV DEF SYSMAN Description: ONC SLD TUM DNA&RNA 437 GEN Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0392U NOCOV DEF SYSMAN Description: RX METAB GENRX IA 16 GENES Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0393U NOCOV DEF SYSMAN Description: NEU PRKSN MSFL A-SYNCLN PRTN Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 51 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0394T NOCOV DEF SYSMAN Description: HDR ELCTRNC SKN SURF BRCHYTX Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0394U NOCOV DEF SYSMAN Description: PFAS 16 PFAS COMPND LC MS/MS Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0395T NOCOV DEF SYSMAN Description: HDR ELCTR NTRST/NTRCV BRCHTX Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0395U NOCOV DEF SYSMAN Description: ONC LNG MULTIOMICS PLSM ALG Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0396U NOCOV DEF SYSMAN Description: OB PREIMPLTJ TST 300000 DNA Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0397T NOCOV DEF SYSMAN Description: ERCP W/OPTICAL ENDOMICROSCPY Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0398T MEDSV PRF MAXFEE 01/01/2024 1349.13 0.0 Y Description: MRGFUS STRTCTC LES ABLTJ Category: Medical Services CMS Add: 01/01/2016 CMS Term: 0398U NOCOV DEF SYSMAN Description: GI BARET ESPH DNA MTHYLN ALY Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0399U NOCOV DEF SYSMAN Description: NEURO CERE FOLATE DEFNCY SRM Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0400U NOCOV DEF SYSMAN Description: OB XPND CAR SCR 145 GENES Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0401U NOCOV DEF SYSMAN Description: CRD C HRT DS 9 GEN 12 VRNTS Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0402T NOCOV DEF SYSMAN Description: COLGN CRS-LINK CRN&PACHYMTRY Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0402U NOCOV DEF SYSMAN Description: NFCT AGT STI MULT AMP PRB TQ Category: Non Covered Services CMS Add: 10/01/2023 CMS Term: 0403T NOCOV DEF SYSMAN Description: DIABETES PREV STANDARD CURR Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0403U NOCOV DEF SYSMAN Description: ONC PRST8 MRNA 18 GEN DRE UR Category: Non Covered Services CMS Add: 10/01/2023 CMS Term: 0404U NOCOV DEF SYSMAN Description: ONC BRST SEMIQ MEAS THYM KN Category: Non Covered Services CMS Add: 10/01/2023 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 52 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0405U NOCOV DEF SYSMAN Description: ONC PNCRTC 59 MTHLTN BLK MRK Category: Non Covered Services CMS Add: 10/01/2023 CMS Term: 0406U NOCOV DEF SYSMAN Description: ONC LUNG FLOW CYTMTRY 5 MRK Category: Non Covered Services CMS Add: 10/01/2023 CMS Term: 0407U NOCOV DEF SYSMAN Description: NEPH DBTC CKD MULT ECLIA ALG Category: Non Covered Services CMS Add: 10/01/2023 CMS Term: 0408T NOCOV DEF SYSMAN Description: INSJ/RPLC CARDIAC MODULJ SYS Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0408U NOCOV DEF SYSMAN Description: IAAD BLK AC WV BSNSR SARSCV2 Category: Non Covered Services CMS Add: 10/01/2023 CMS Term: 0409T NOCOV DEF SYSMAN Description: INSJ/RPLC CAR MODULJ PLS GN Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0409U NOCOV DEF SYSMAN Description: ONC SLD TUM DNA 80 & RNA 36 Category: Non Covered Services CMS Add: 10/01/2023 CMS Term: 0410T NOCOV DEF SYSMAN Description: INSJ/RPLC CAR MODULJ ATR ELT Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0410U NOCOV DEF SYSMAN Description: ONC PNCRTC DNA WHL GN SEQ 5- Category: Non Covered Services CMS Add: 10/01/2023 CMS Term: 0411T NOCOV DEF SYSMAN Description: INSJ/RPLC CAR MODULJ VNT ELT Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0411U NOCOV DEF SYSMAN Description: PSYC GENOM ALYS PNL 15 GEN Category: Non Covered Services CMS Add: 10/01/2023 CMS Term: 0412T NOCOV DEF SYSMAN Description: RMVL CARDIAC MODULJ PLS GEN Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0412U NOCOV DEF SYSMAN Description: BETA AMYLOID AB42/40 IMPRCIP Category: Non Covered Services CMS Add: 10/01/2023 CMS Term: 0413T NOCOV DEF SYSMAN Description: RMVL CAR MODULJ TRANVNS ELT Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0413U NOCOV DEF SYSMAN Description: ONC HL NEO OPT GEN MAPG DNA Category: Non Covered Services CMS Add: 10/01/2023 CMS Term: 0414T NOCOV DEF SYSMAN Description: RMVL & RPL CAR MODULJ PLS GN Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 53 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0414U NOCOV DEF SYSMAN Description: ONC LNG AUG ALG ALY WHL SLD8 Category: Non Covered Services CMS Add: 10/01/2023 CMS Term: 0415T NOCOV DEF SYSMAN Description: REPOS CAR MODULJ TRANVNS ELT Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0415U NOCOV DEF SYSMAN Description: CV DS ACS BLD ALG 5 YR SCORE Category: Non Covered Services CMS Add: 10/01/2023 CMS Term: 0416T NOCOV DEF SYSMAN Description: RELOC SKIN POCKET PLS GEN Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0416U NOCOV DEF SYSMAN Description: IADNA GU PTHGN 20BCT&FNG ORG Category: Non Covered Services CMS Add: 10/01/2023 CMS Term: 03/31/2024 0417T NOCOV DEF SYSMAN Description: PRGRMG EVAL CARDIAC MODULJ Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0417U NOCOV DEF SYSMAN Description: RARE DS ALYS 335 NUC GENES Category: Non Covered Services CMS Add: 10/01/2023 CMS Term: 0418T NOCOV DEF SYSMAN Description: INTERRO EVAL CARDIAC MODULJ Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0418U NOCOV DEF SYSMAN Description: ONC BRST AUG ALG ALY WHL SL8 Category: Non Covered Services CMS Add: 10/01/2023 CMS Term: 0419T NOCOV DEF SYSMAN Description: DSTRJ NEUROFIBROMA XTNSV Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0419U NOCOV DEF SYSMAN Description: NRPSYC GEN SEQ VRNT ALY 13 Category: Non Covered Services CMS Add: 10/01/2023 CMS Term: 0420T NOCOV DEF SYSMAN Description: DSTRJ NEUROFIBROMA XTNSV Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0420U NOCOV DEF SYSMAN Description: ONC URTHL MRNA XPRSN 6 SNP Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0421T NOCOV DEF SYSMAN Description: WATERJET PROSTATE ABLTJ CMPL Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0421U NOCOV DEF SYSMAN Description: ONC CLRCT SCR SGL AMP 8 RNA Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0422T NOCOV DEF SYSMAN Description: TACTILE BREAST IMG UNI/BI Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 54 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0422U NOCOV DEF SYSMAN Description: ONC PAN SOLID TUM ALYS DNA Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0423U NOCOV DEF SYSMAN Description: PSYC GENOMIC ALYS PNL 26 GEN Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0424U NOCOV DEF SYSMAN Description: ONC PRST8 XOM ALYS 53 SNCRNA Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0425U NOCOV DEF SYSMAN Description: GENOM RPD SEQ ALYS EA CMPRTR Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0426U NOCOV DEF SYSMAN Description: GENOME ULTRA-RAPID SEQ ALYS Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0427U NOCOV DEF SYSMAN Description: MONOCYTE DSTRBJ WDTH WHL BLD Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0428U NOCOV DEF SYSMAN Description: ONC BRST CTDNA ALYS 56/> GEN Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0429U NOCOV DEF SYSMAN Description: HPV OROP SWAB 14 HI-RISK TYP Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0430U NOCOV DEF SYSMAN Description: GI MALABS AAT CALPRO PNCRTC Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0431U NOCOV DEF SYSMAN Description: GLY RCPTR ALPHA1 IGG SRM/CSF Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0432U NOCOV DEF SYSMAN Description: KLHL11 ANTB SR/CSF ASY QUAL Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0433U NOCOV DEF SYSMAN Description: ONC PRST8 5 DNA REG MRK PCR Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0434U NOCOV DEF SYSMAN Description: RX METAB ADVRS VRNT ALYS 25 Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0435U NOCOV DEF SYSMAN Description: ONC CHEMO RX CYTOX CSC 14 RX Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0436U NOCOV DEF SYSMAN Description: ONC LNG PLSM ALYS 388 PRTN Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0437T NOCOV DEF SYSMAN Description: IMPLTJ SYNTH RNFCMT ABDL WAL Category: Non Covered Services CMS Add: 07/01/2016 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 55 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0437U NOCOV DEF SYSMAN Description: PSYC ANXIETY DO MRNA 15 BMRK Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0438U NOCOV DEF SYSMAN Description: RX METAB ADVRS VRNT ALYS 33 Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0439T NOCOV DEF SYSMAN Description: MYOCRD CONTRAST PRFUJ ECHO Category: Non Covered Services CMS Add: 07/01/2016 CMS Term: 0440T NOCOV DEF SYSMAN Description: ABLTJ PERC UXTR/PERPH NRV Category: Non Covered Services CMS Add: 07/01/2016 CMS Term: 0441T NOCOV DEF SYSMAN Description: ABLTJ PERC LXTR/PERPH NRV Category: Non Covered Services CMS Add: 07/01/2016 CMS Term: 0442T NOCOV DEF SYSMAN Description: ABLTJ PERC PLEX/TRNCL NRV Category: Non Covered Services CMS Add: 07/01/2016 CMS Term: 0443T NOCOV DEF SYSMAN Description: R-T SPCTRL ALYS PRST8 TISS Category: Non Covered Services CMS Add: 07/01/2016 CMS Term: 0444T NOCOV DEF SYSMAN Description: 1ST PLMT DRUG ELUT OC INS Category: Non Covered Services CMS Add: 07/01/2016 CMS Term: 0445T NOCOV DEF SYSMAN Description: SBSQT PLMT DRUG ELUT OC INS Category: Non Covered Services CMS Add: 07/01/2016 CMS Term: 0446T NOCOV DEF SYSMAN Description: INSJ IMPLTBL GLUCOSE SENSOR Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: 0447T NOCOV DEF SYSMAN Description: RMVL IMPLTBL GLUCOSE SENSOR Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: 0448T NOCOV DEF SYSMAN Description: REMVL INSJ IMPLTBL GLUC SENS Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: 0449T NOCOV DEF SYSMAN Description: INSJ AQUEOUS DRAIN DEV 1ST Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: 0450T NOCOV DEF SYSMAN Description: INSJ AQUEOUS DRAIN DEV EACH Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: 0464T NOCOV DEF SYSMAN Description: VISUAL EP TEST FOR GLAUCOMA Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: 0469T NOCOV DEF SYSMAN Description: RTA POLARIZE SCAN OC SCR BI Category: Non Covered Services CMS Add: 07/01/2017 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 56 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0472T NOCOV DEF SYSMAN Description: PRGRMG IO RTA ELTRD RA Category: Non Covered Services CMS Add: 07/01/2017 CMS Term: 0473T NOCOV DEF SYSMAN Description: REPRGRMG IO RTA ELTRD RA Category: Non Covered Services CMS Add: 07/01/2017 CMS Term: 0474T MEDSV PRF MAXFEE 01/01/2024 630.32 0.0 Description: INSJ AQUEOUS DRG DEV IO RSVR Category: Medical Services CMS Add: 07/01/2017 CMS Term: 0479T NOCOV DEF SYSMAN Description: FXJL ABL LSR 1ST 100 SQ CM Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 0480T NOCOV DEF SYSMAN Description: FXJL ABL LSR EA ADDL 100SQCM Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 0481T NOCOV DEF SYSMAN Description: NJX AUTOL WBC CONCENTRATE Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 0483T NOCOV DEF SYSMAN Description: TMVI PERCUTANEOUS APPROACH Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 0484T NOCOV DEF SYSMAN Description: TMVI TRANSTHORACIC EXPOSURE Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 0485T NOCOV DEF SYSMAN Description: OCT MID EAR I&R UNILATERAL Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 0486T NOCOV DEF SYSMAN Description: OCT MID EAR I&R BILATERAL Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 0488T NOCOV DEF SYSMAN Description: DIABETES PREV ONLINE/ELEC Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 0489T MEDSV DEF BILL90 Y Description: REGN CELL TX SCLDR HANDS Category: Medical Services CMS Add: 01/01/2018 CMS Term: 0490T MEDSV DEF BILL90 Y Description: REGN CELL TX SCLDR H MLT INJ Category: Medical Services CMS Add: 01/01/2018 CMS Term: 0494T MEDSV DEF BILL90 Y Description: PREP & CANNULJ CDVR DON LUNG Category: Medical Services CMS Add: 01/01/2018 CMS Term: 0495T MEDSV DEF BILL90 Y Description: MNTR CDVR DON LNG 1ST 2 HRS Category: Medical Services CMS Add: 01/01/2018 CMS Term: 0496T MEDSV DEF BILL90 Y Description: MNTR CDVR DON LNG EA ADDL HR Category: Medical Services CMS Add: 01/01/2018 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 57 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0500F NOCOV DEF SYSMAN Description: INITIAL PRENATAL CARE VISIT Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: 0500T MEDSV DEF BILL90 Description: HPV 5+ HI RISK HPV TYPES Category: Medical Services CMS Add: 01/01/2018 CMS Term: 0501F NOCOV DEF SYSMAN Description: PRENATAL FLOW SHEET Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: 0501T MEDSV DEF MAXFEE 01/01/2024 895.34 0.0 Description: COR FFR DERIVED COR CTA DATA Category: Medical Services CMS Add: 01/01/2018 CMS Term: 12/31/2023 0502F NOCOV DEF SYSMAN Description: SUBSEQUENT PRENATAL CARE Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: 0503F NOCOV DEF SYSMAN Description: POSTPARTUM CARE VISIT Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: 0503T MEDSV DEF MAXFEE 01/01/2024 820.41 0.0 Description: COR FFR ALYS GNRJ FFR MDL Category: Medical Services CMS Add: 01/01/2018 CMS Term: 12/31/2023 0504T MEDSV DEF MAXFEE 01/01/2024 40.83 0.0 Description: COR FFR DATA REVIEW I&R Category: Medical Services CMS Add: 01/01/2018 CMS Term: 12/31/2023 0505F NOCOV DEF SYSMAN Description: HEMODIALYSIS PLAN DOCD Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 0505T NOCOV DEF SYSMAN Description: EV FEMPOP ARTL REVSC Category: Non Covered Services CMS Add: 07/01/2018 CMS Term: 0506T NOCOV DEF SYSMAN Description: MAC PGMT OPT DNS MEAS HFP Category: Non Covered Services CMS Add: 07/01/2018 CMS Term: 0507F NOCOV DEF SYSMAN Description: PERITON DIALYSIS PLAN DOCD Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 0507T NOCOV DEF SYSMAN Description: NEAR IFR 2IMG MIBMN GLND I&R Category: Non Covered Services CMS Add: 07/01/2018 CMS Term: 0508T NOCOV DEF SYSMAN Description: PLS ECHO US B1 DNS MEAS TIB Category: Non Covered Services CMS Add: 07/01/2018 CMS Term: 12/31/2023 0509F NOCOV DEF SYSMAN Description: URINE INCON PLAN DOCD Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 0509T NOCOV DEF SYSMAN Description: PATTERN ERG W/I&R Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 58 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0510T NOCOV DEF SYSMAN Description: RMVL SINUS TARSI IMPLANT Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0511T NOCOV DEF SYSMAN Description: RMVL&RINSJ SINUS TARSI IMPLT Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0512T NOCOV DEF SYSMAN Description: ESW INTEG WND HLG 1ST WND Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0513F NOCOV DEF SYSMAN Description: ELEV BP PLAN OF CARE DOCD Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 0513T NOCOV DEF SYSMAN Description: ESW INTEG WND HLG EA ADDL Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0514F NOCOV DEF SYSMAN Description: CARE PLAN HGB DOCD ESA PT Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 0515T NOCOV DEF SYSMAN Description: INSJ WCS LV COMPL SYS Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0516F NOCOV DEF SYSMAN Description: ANEMIA PLAN OF CARE DOCD Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 0516T NOCOV DEF SYSMAN Description: INSJ WCS LV ELTRD ONLY Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0517F NOCOV DEF SYSMAN Description: GLAUCOMA PLAN OF CARE DOCD Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 0517T NOCOV DEF SYSMAN Description: INSJ WCS LV BOTH COMPNT PG Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0518F NOCOV DEF SYSMAN Description: FALL PLAN OF CARE DOCD Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 0518T NOCOV DEF SYSMAN Description: RMVL PG WCS LV BATTERY ONLY Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0519F NOCOV DEF SYSMAN Description: PLAND CHEMO DOCD B/4 TXMNT Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 0519T NOCOV DEF SYSMAN Description: RMV&RPLCMT PG WCS LV BOTH Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0520F NOCOV DEF SYSMAN Description: RAD DOS LIMTS B/4 3D RAD Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 59 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0520T NOCOV DEF SYSMAN Description: RMV&RPLCMT PG WCS LV BATTERY Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0521F NOCOV DEF SYSMAN Description: PLAN OF CARE 4 PAIN DOCD Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 0521T NOCOV DEF SYSMAN Description: INTERROG DEV EVAL WCS IP Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0522T NOCOV DEF SYSMAN Description: PRGRMG DEV EVAL WCS IP Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0523T NOCOV DEF SYSMAN Description: NTRAPX C FFR W/3D FUNCJL MAP Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0524T NOCOV DEF SYSMAN Description: EV CATH DIR CHEM ABLTJ W/IMG Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0525F NOCOV DEF SYSMAN Description: INITIAL VISIT FOR EPISODE Category: Non Covered Services CMS Add: 04/01/2008 CMS Term: 0525T NOCOV DEF SYSMAN Description: INSJ/RPLCMT COMPL IIMS Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0526F NOCOV DEF SYSMAN Description: SUBS VISIT FOR EPISODE Category: Non Covered Services CMS Add: 04/01/2008 CMS Term: 0526T NOCOV DEF SYSMAN Description: INSJ/RPLCMT IIMS ELTRD ONLY Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0527T NOCOV DEF SYSMAN Description: INSJ/RPLCMT IIMS IMPLT MNTR Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0528F NOCOV DEF SYSMAN Description: RCMND FLW-UP 10 YRS DOCD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 0528T NOCOV DEF SYSMAN Description: PRGRMG DEV EVAL IIMS IP Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0529F NOCOV DEF SYSMAN Description: INTRVL 3/>YR PTS CLNSCP DOCD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 0529T NOCOV DEF SYSMAN Description: INTERROG DEV EVAL IIMS IP Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0530T NOCOV DEF SYSMAN Description: REMOVAL COMPLETE IIMS Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 60 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0531T NOCOV DEF SYSMAN Description: REMOVAL IIMS ELECTRODE ONLY Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0532T NOCOV DEF SYSMAN Description: REMOVAL IIMS IMPLT MNTR ONLY Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0535F NOCOV DEF SYSMAN Description: DYSPNEA MNGMNT PLAN DOCD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 0540F NOCOV DEF SYSMAN Description: GLUCO MNGMNT PLAN DOCD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 0540T MEDSV DEF BILL90 Y Description: CAR-T CLL ADMN AUTOLOGOUS Category: Medical Services CMS Add: 01/01/2019 CMS Term: 0541T NOCOV DEF SYSMAN Description: MYOCARDIAL IMAGING MCG Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0542T NOCOV DEF SYSMAN Description: MYOCARDIAL IMAGING MCG I&R Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0543T NOCOV DEF SYSMAN Description: TA MV RPR W/ARTIF CHORD TEND Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 0544T NOCOV DEF SYSMAN Description: TCAT MV ANNULUS RCNSTJ Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 0545F NOCOV DEF SYSMAN Description: FOLLOW UP CARE PLAN MDD DOCD Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 0545T NOCOV DEF SYSMAN Description: TCAT TV ANNULUS RCNSTJ Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 0546T NOCOV DEF SYSMAN Description: RF SPECTRSC NTRAOP MRGN ASMT Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 0547T NOCOV DEF SYSMAN Description: B1 MATRL QUAL TST MCRIND TIB Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 0552T NOCOV DEF SYSMAN Description: LOW-LEVEL LASER THERAPY Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 0553T NOCOV DEF SYSMAN Description: PERQ TCAT ILIAC ANAST IMPLT Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 0554T MEDSV DEF BILL90 Description: B1 STR & FX RSK ANALYSIS Category: Medical Services CMS Add: 07/01/2019 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 61 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0555F NOCOV DEF SYSMAN Description: SYMPTOM MGMNT PLAN CARE DOCD Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 0555T MEDSV DEF BILL90 Description: B1 STR&FX RSK TRANSMIS DATA Category: Medical Services CMS Add: 07/01/2019 CMS Term: 0556F NOCOV DEF SYSMAN Description: PLAN CARE LIPID CONTROL DOCD Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 0556T MEDSV DEF BILL90 Description: B1 STR & FX RSK ASSESSMENT Category: Medical Services CMS Add: 07/01/2019 CMS Term: 0557F NOCOV DEF SYSMAN Description: PLAN CAREMNG ANGNL SYMPTDOCD Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 0557T MEDSV DEF BILL90 Description: B1 STR & FX RSK I&R Category: Medical Services CMS Add: 07/01/2019 CMS Term: 0558T NOCOV DEF SYSMAN Description: CT SCAN F/BIOMCHN CT ALYS Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 0559T NOCOV DEF SYSMAN Description: ANTMC MDL 3D PRINT 1ST CMPNT Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 0560T NOCOV DEF SYSMAN Description: ANTMC MDL 3D PRINT EA ADDL Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 0561T NOCOV DEF SYSMAN Description: ANTMC GUIDE 3D PRINT 1ST GD Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 0562T NOCOV DEF SYSMAN Description: ANTMC GUIDE 3D PRINT EA ADDL Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 0563T NOCOV DEF SYSMAN Description: EVAC MEIBOMIAN GLND HEAT BI Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0564T NOCOV DEF SYSMAN Description: ONC CHEMO RX CYTOTOX CSC 14 Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0565T NOCOV DEF SYSMAN Description: AUTOL CELL IMPLT ADPS HRVG Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0566T NOCOV DEF SYSMAN Description: AUTOL CELL IMPLT ADPS NJX Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0567T MEDSV DEF BILL90 Y 21-999years Description: PERM FLP TUBE OCCLS W/IMPLT Category: Medical Services CMS Add: 01/01/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 62 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0568T NOCOV DEF SYSMAN Description: INTRO MIX SALINE&AIR F/SSG Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0569T NOCOV DEF SYSMAN Description: TTVR PERQ APPR 1ST PROSTH Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0570T NOCOV DEF SYSMAN Description: TTVR PERQ EA ADDL PROSTH Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0571T MEDSV DEF BILL90 Y Description: INSJ/RPLCMT ICDS SS ELTRD Category: Medical Services CMS Add: 01/01/2020 CMS Term: 0572T MEDSV DEF BILL90 Y Description: INSERTION SS DFB ELECTRODE Category: Medical Services CMS Add: 01/01/2020 CMS Term: 0573T MEDSV DEF BILL90 Y Description: REMOVAL SS DFB ELECTRODE Category: Medical Services CMS Add: 01/01/2020 CMS Term: 0574T MEDSV DEF BILL90 Y Description: REPOS PREV SS IMPL DFB ELTRD Category: Medical Services CMS Add: 01/01/2020 CMS Term: 0575F NOCOV DEF SYSMAN Description: HIV RNA PLAN CARE DOCD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 0575T MEDSV DEF MAXFEE 01/01/2024 71.57 0.0 Y Description: PRGRMG DEV EVAL ICDS SS IP Category: Medical Services CMS Add: 01/01/2020 CMS Term: 0576T MEDSV DEF MAXFEE 01/01/2024 65.59 0.0 Y Description: INTERROG DEV EVAL ICDS SS IP Category: Medical Services CMS Add: 01/01/2020 CMS Term: 0577T MEDSV DEF MAXFEE 01/01/2024 286.99 0.0 Y Description: EPHYS EVAL ICDS SS Category: Medical Services CMS Add: 01/01/2020 CMS Term: 0578T MEDSV DEF BILL90 Y Description: REM INTERROG DEV ICDS PHYS Category: Medical Services CMS Add: 01/01/2020 CMS Term: 0579T MEDSV DEF BILL90 Y Description: REM INTERROG DEV ICDS TECH Category: Medical Services CMS Add: 01/01/2020 CMS Term: 0580F NOCOV DEF SYSMAN Description: MULTIDISCIPLINARY CARE PLAN Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 0580T MEDSV DEF BILL90 Description: RMVL SS IMPL DFB PG ONLY Category: Medical Services CMS Add: 01/01/2020 CMS Term: 0581F NOCOV DEF SYSMAN Description: PT TRNSFRD FROM ANESTH TO CC Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 63 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0581T NOCOV DEF SYSMAN Description: ABLTJ MAL BRST TUM PERQ CRTX Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0582F NOCOV DEF SYSMAN Description: NO TRNSFR FROM ANESTH TO CC Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 0582T MEDSV DEF BILL90 Description: TRURL ABLTJ MAL PRST8 TISS Category: Medical Services CMS Add: 01/01/2020 CMS Term: 0583F NOCOV DEF SYSMAN Description: TRANSFER CARE CHECKLIST USED Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 0583T MEDSV DEF BILL90 Y Description: TMPST AUTO TUBE DLVR SYS Category: Medical Services CMS Add: 01/01/2020 CMS Term: 0584F NOCOV DEF SYSMAN Description: NO TRANSFERCARE CHKLIST USED Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 0584T NOCOV DEF SYSMAN Description: PERQ ISLET CELL TRANSPLANT Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0585T NOCOV DEF SYSMAN Description: LAPS ISLET CELL TRANSPLANT Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0586T NOCOV DEF SYSMAN Description: OPEN ISLET CELL TRANSPLANT Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0587T MEDSV DEF BILL90 Y Description: PERQ IMPLTJ/RPLCMT ISDNS PTN Category: Medical Services CMS Add: 01/01/2020 CMS Term: 0588T MEDSV DEF BILL90 Y Description: REVISION/REMOVAL ISDNS PTN Category: Medical Services CMS Add: 01/01/2020 CMS Term: 0589T MEDSV DEF BILL90 Y Description: ELEC ALYS SMPL PRGRMG IINS Category: Medical Services CMS Add: 01/01/2020 CMS Term: 0590T MEDSV DEF BILL90 Y Description: ELEC ALYS CPLX PRGRMG IINS Category: Medical Services CMS Add: 01/01/2020 CMS Term: 0591T NOCOV DEF SYSMAN Description: HLTH&WB COACHING INDIV 1ST Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0592T NOCOV DEF SYSMAN Description: HLTH&WB COACHING INDIV F-UP Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0593T NOCOV DEF SYSMAN Description: HLTH&WB COACHING GROUP Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 64 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0594T MEDSV DEF BILL90 Y Description: OSTEOT HUM XTRNL LNGTH DEV Category: Medical Services CMS Add: 07/01/2020 CMS Term: 0596T NOCOV DEF SYSMAN Description: TEMP FML IU VLV-PMP 1ST INSJ Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0597T NOCOV DEF SYSMAN Description: TEMP FML IU VALVE-PMP RPLCMT Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0598T NOCOV DEF SYSMAN Description: NCNTC R-T FLUOR WND IMG 1ST Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0599T NOCOV DEF SYSMAN Description: NCNTC R-T FLUOR WND IMG EA Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0600T NOCOV DEF SYSMAN Description: IRE ABLTJ 1+TUM ORGAN PERQ Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0601T NOCOV DEF SYSMAN Description: IRE ABLTJ 1+TUMORS OPEN Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0602T NOCOV DEF SYSMAN Description: TRANSDERMAL GFR MEASUREMENTS Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0603T NOCOV DEF SYSMAN Description: TRANSDERMAL GFR MONITORING Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0604T NOCOV DEF SYSMAN Description: REM OCT RTA DEV SETUP&EDUCAJ Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0605T NOCOV DEF SYSMAN Description: REM OCT RTA TECHL SPRT MIN 8 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0606T NOCOV DEF SYSMAN Description: REM OCT RTA PHYS/QHP EA 30D Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0607T MEDSV DEF BILL90 Description: REM MNTR PULM FLU MNTR SETUP Category: Medical Services CMS Add: 07/01/2020 CMS Term: 0608T MEDSV DEF BILL90 Description: REM MNTR PULM FLU MNTR ALYS Category: Medical Services CMS Add: 07/01/2020 CMS Term: 0609T NOCOV DEF SYSMAN Description: MRS DISC PAIN ACQUISJ DATA Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0610T NOCOV DEF SYSMAN Description: MRS DISC PAIN TRANSMIS DATA Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 65 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0611T NOCOV DEF SYSMAN Description: MRS DISC PAIN ALG ALYS DATA Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0612T NOCOV DEF SYSMAN Description: MRS DISCOGENIC PAIN I&R Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0613T NOCOV DEF SYSMAN Description: PERQ TCAT INTRATRL SEPTL SHT Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0614T MEDSV DEF BILL90 Description: RMVL&RPLCMT SS IMPL DFB PG Category: Medical Services CMS Add: 07/01/2020 CMS Term: 0615T MEDSV DEF MAXFEE 07/01/2020 111.95 0.0 Description: EYE MVMT ALYS W/O CALBRJ I&R Category: Medical Services CMS Add: 07/01/2020 CMS Term: 0616T NOCOV DEF SYSMAN Description: INSERTION OF IRIS PROSTHESIS Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0617T NOCOV DEF SYSMAN Description: INSJ IRIS PROSTH W/RMVL&INSJ Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0618T NOCOV DEF SYSMAN Description: INSJ IRIS PROSTH SEC IO LENS Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0619T MEDSV DEF BILL90 Description: CYSTO W/PRST8 COMMISSUROTOMY Category: Medical Services CMS Add: 07/01/2020 CMS Term: 0620T NOCOV DEF SYSMAN Description: EVASC VEN ARTLZ TIBL/PRNL VN Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0621T NOCOV DEF SYSMAN Description: TRABECULOSTOMY INTERNO LASER Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0622T NOCOV DEF SYSMAN Description: TRABECULOSTOMY INT LSR W/SCP Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0623T NOCOV DEF SYSMAN Description: AUTO QUANTIFICATION C PLAQUE Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0624T NOCOV DEF SYSMAN Description: AUTO QUAN C PLAQ DATA PREP Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0625T NOCOV DEF SYSMAN Description: AUTO QUAN C PLAQ CPTR ALYS Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0626T NOCOV DEF SYSMAN Description: AUTO QUAN C PLAQ I&R Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 66 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0627T NOCOV DEF SYSMAN Description: PERQ NJX ALGC FLUOR LMBR 1ST Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0628T NOCOV DEF SYSMAN Description: PERQ NJX ALGC FLUOR LMBR EA Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0629T NOCOV DEF SYSMAN Description: PERQ NJX ALGC CT LMBR 1ST Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0630T NOCOV DEF SYSMAN Description: PERQ NJX ALGC CT LMBR EA Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0631T NOCOV DEF SYSMAN Description: TC VIS LIT HYPERSPECTRAL IMG Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0632T NOCOV DEF SYSMAN Description: PERQ TCAT US ABLTJ NRV P-ART Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0633T NOCOV DEF SYSMAN Description: CT BREAST W/3D UNI C- Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0634T NOCOV DEF SYSMAN Description: CT BREAST W/3D UNI C+ Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0635T NOCOV DEF SYSMAN Description: CT BREAST W/3D UNI C-/C+ Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0636T NOCOV DEF SYSMAN Description: CT BREAST W/3D BI C- Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0637T NOCOV DEF SYSMAN Description: CT BREAST W/3D BI C+ Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0638T NOCOV DEF SYSMAN Description: CT BREAST W/3D BI C-/C+ Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0639T NOCOV DEF SYSMAN Description: WRLS SKN SNR ANISOTROPY MEAS Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0640T NOCOV DEF SYSMAN Description: NCNTC IFR SPCTRSC O/T PAD 1 Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0643T NOCOV DEF SYSMAN Description: TCAT L VENTR RSTRJ DEV IMPLT Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0644T NOCOV DEF SYSMAN Description: TCAT RMVL/DBLK ICAR MAS PERQ Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 67 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0645T NOCOV DEF SYSMAN Description: TCAT IMPLTJ C SINS RDCTJ DEV Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0646T NOCOV DEF SYSMAN Description: TTVI/RPLCMT W/PRSTC VLV PERQ Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0647T NOCOV DEF SYSMAN Description: INSJ GTUBE PERQ MAG GASTRPXY Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0648T NOCOV DEF SYSMAN Description: QUAN MR TIS WO MRI 1ORGN Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0649T NOCOV DEF SYSMAN Description: QUAN MR TISS W/MRI 1ORGN Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0650T NOCOV DEF SYSMAN Description: PRGRMG DEV EVAL SCRMS REMOTE Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0651T NOCOV DEF SYSMAN Description: MAG CTRLD CAPSULE ENDOSCOPY Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0652T NOCOV DEF SYSMAN Description: EGD FLX TRANSNASAL DX BR/WA Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0653T NOCOV DEF SYSMAN Description: EGD FLX TRANSNASAL BX 1/MLT Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0654T NOCOV DEF SYSMAN Description: EGD FLX TRANSNASAL TUBE/CATH Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0655T MEDSV DEF BILL90 Y Description: TPRNL FOCAL ABLTJ MAL PRST8 Category: Medical Services CMS Add: 07/01/2021 CMS Term: 0656T NOCOV DEF SYSMAN Description: VRT BDY TETHERING ANT <7 SEG Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0657T NOCOV DEF SYSMAN Description: VRT BDY TETHERING ANT 8+ SEG Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0658T NOCOV DEF SYSMAN Description: ELEC IMPD SPECTRSC 1+SKN LES Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0659T NOCOV DEF SYSMAN Description: TCAT INTRA-C NFS SUPERSAT O2 Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0660T NOCOV DEF SYSMAN Description: IMPLT ANT SGM IO NBIO RX SYS Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 68 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0661T NOCOV DEF SYSMAN Description: RMVL&RIMPLTJ ANT SGM IMPLT Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0662T NOCOV DEF SYSMAN Description: SCALP COOL 1ST MEAS&CALBRJ Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0663T NOCOV DEF SYSMAN Description: SCALP COOL PLMT MNTR RMVL Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0664T NOCOV DEF SYSMAN Description: DON HYSTERECTOMY OPEN CDVR Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0665T NOCOV DEF SYSMAN Description: DON HYSTERECTOMY OPEN LIV Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0666T NOCOV DEF SYSMAN Description: DON HYSTERECTOMY LAPS LIV Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0667T NOCOV DEF SYSMAN Description: DON HYSTERECTOMY RCP UTER Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0668T NOCOV DEF SYSMAN Description: BKBENCH PREP DON UTER ALGRFT Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0669T NOCOV DEF SYSMAN Description: BKBENCH RCNSTJ DON UTER VEN Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0670T NOCOV DEF SYSMAN Description: BKBENCH RCNSTJ DON UTER ARTL Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0671T MEDSV DEF MAXFEE 01/01/2024 958.93 0.0 Description: INSJ ANT SGM AQ DRG DEV 1+ Category: Medical Services CMS Add: 01/01/2022 CMS Term: 0672T NOCOV DEF SYSMAN Description: NDOVAG CRYG RF REMDL TISS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0673T MEDSV DEF BILL90 Y Description: ABLTJ B9 THYR NDUL PERQ LASR Category: Medical Services CMS Add: 01/01/2022 CMS Term: 0674T MEDSV DEF BILL90 Description: LAPS INSJ NW/RPCMT PRM ISDSS Category: Medical Services CMS Add: 01/01/2022 CMS Term: 0675T MEDSV DEF BILL90 Description: LAPS INSJ NW/RPCMT ISDSS 1LD Category: Medical Services CMS Add: 01/01/2022 CMS Term: 0676T MEDSV DEF BILL90 Description: LAPS INSJ NW/RPCMT ISDSS EA Category: Medical Services CMS Add: 01/01/2022 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 69 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0677T MEDSV DEF BILL90 Description: LAPS REPOS LEAD ISDSS 1ST LD Category: Medical Services CMS Add: 01/01/2022 CMS Term: 0678T NOCOV DEF SYSMAN Description: LAPS REPOS LEAD ISDSS EA ADD Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0679T NOCOV DEF SYSMAN Description: LAPS RMVL LEAD ISDSS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0680T NOCOV DEF SYSMAN Description: INSJ/RPLCMT PG ONLY ISDSS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0681T NOCOV DEF SYSMAN Description: RLCJ PULSE GEN ONLY ISDSS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0682T NOCOV DEF SYSMAN Description: REMOVAL PULSE GEN ONLY ISDSS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0683T NOCOV DEF SYSMAN Description: PRGRMG DEV EVAL ISDSS IP Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0684T NOCOV DEF SYSMAN Description: PERI-PX DEV EVAL ISDSS IP Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0685T NOCOV DEF SYSMAN Description: INTERROG DEV EVAL ISDSS IP Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0686T NOCOV DEF SYSMAN Description: HISTOTRIPSY MAL HEPATCEL TIS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0687T NOCOV DEF SYSMAN Description: TX AMBLYOPIA DEV SETUP 1ST Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0688T NOCOV DEF SYSMAN Description: TX AMBLYOPIA ASSMT W/REPORT Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0689T NOCOV DEF SYSMAN Description: QUAN US TIS CHARAC W/O DX US Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0690T NOCOV DEF SYSMAN Description: QUAN US TIS CHARAC W/DX US Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0691T NOCOV DEF SYSMAN Description: AUTO ALYS XST CT STD VRT FX Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0692T NOCOV DEF SYSMAN Description: THERAPEUTIC ULTRAFILTRATION Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 70 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0693T NOCOV DEF SYSMAN Description: COMPRE FUL BDY 3D MTN ALYS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0694T NOCOV DEF SYSMAN Description: 3D VOL IMG&RCNSTJ BRST/AX Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0695T NOCOV DEF SYSMAN Description: BDY SRF MPG PM/CVDFB TM IMPL Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0696T NOCOV DEF SYSMAN Description: BDY SURF MAPG PM/CVDFB F/UP Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0697T NOCOV DEF SYSMAN Description: QUAN MR TIS WO MRI MLT ORGN Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0698T NOCOV DEF SYSMAN Description: QUAN MR TISS W/MRI MLT ORGN Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0699T MEDSV DEF BILL90 Description: NJX PST CHMBR EYE MEDICATION Category: Medical Services CMS Add: 01/01/2022 CMS Term: 0700T NOCOV DEF SYSMAN Description: MOLEC FLUOR IMG SUS NEV 1ST Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0701T NOCOV DEF SYSMAN Description: MOLEC FLUOR IMG SUS NEV EA Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0704T NOCOV DEF SYSMAN Description: REM TX AMBLYOPIA SETUP&EDU Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0705T NOCOV DEF SYSMAN Description: REM TX AMBLYOPIA TECH SPRT Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0706T NOCOV DEF SYSMAN Description: REM TX AMBLYOPIA I&R PHY/QHP Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0707T NOCOV DEF SYSMAN Description: NJX B1 SUB MTRL SBCHDRL DFCT Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0708T NOCOV DEF SYSMAN Description: ID CA IMMNTX PREP & 1ST NJX Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0709T NOCOV DEF SYSMAN Description: ID CA IMMNTX EACH ADDL NJX Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0710T NOCOV DEF SYSMAN Description: N-INVAS ARTL PLAQ ALYS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 71 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0711T NOCOV DEF SYSMAN Description: N-NVS ARTL PLAQ ALYS DAT PRP Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0712T NOCOV DEF SYSMAN Description: N-NVS ARTL PLAQ ALYS QUAN Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0713T NOCOV DEF SYSMAN Description: N-NVS ARTL PLAQ ALYS RVW I&R Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0714T NOCOV DEF SYSMAN Description: TPRNL LSR ABLT B9 PRST8 HYPR Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0716T NOCOV DEF SYSMAN Description: CAR ACOUS WAVFRM REC CAD RSK Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0717T NOCOV DEF SYSMAN Description: ADRC THER PRTL RC TEAR Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0718T NOCOV DEF SYSMAN Description: ADRC THER PRTL RC TEAR NJX Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0719T NOCOV DEF SYSMAN Description: PST VRT JT RPLCMT LMBR 1 SGM Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0720T NOCOV DEF SYSMAN Description: PRQ ELC NRV STIM CN WO IMPLT Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0721T NOCOV DEF SYSMAN Description: QUAN CT TISS CHARAC W/O CT Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0722T NOCOV DEF SYSMAN Description: QUAN CT TISS CHARAC W/CT Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0723T NOCOV DEF SYSMAN Description: QMRCP W/O DX MRI SM ANAT SES Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0724T NOCOV DEF SYSMAN Description: QMRCP W/DX MRI SAME ANATOMY Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0725T NOCOV DEF SYSMAN Description: VESTIBULAR DEV IMPLTJ UNI Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0726T NOCOV DEF SYSMAN Description: RMVL IMPLT VSTIBULAR DEV UNI Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0727T NOCOV DEF SYSMAN Description: RMVL&RPLCMT IMPLT VSTBLR DEV Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 72 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0728T NOCOV DEF SYSMAN Description: DX ALYS VSTBLR IMPLT UNI 1ST Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0729T NOCOV DEF SYSMAN Description: DX ALYS VSTBLR IMPLT UNI SBQ Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0730T MEDSV DEF BILL90 Description: TRABECULOTOMY LSR W/OCT GDN Category: Medical Services CMS Add: 07/01/2022 CMS Term: 0731T NOCOV DEF SYSMAN Description: AUGMNT AI-BASED FCL PHNT A/R Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0732T NOCOV DEF SYSMAN Description: IMMNTX ADMN ELECTROPORATN IM Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0733T NOCOV DEF SYSMAN Description: REM R-T MTN NREHAB THER SPLY Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0734T NOCOV DEF SYSMAN Description: REM R-T MTN NREHAB TX MGMT Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0735T NOCOV DEF SYSMAN Description: PREP TUM CAV IORT PRIM CRNOT Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0736T NOCOV DEF SYSMAN Description: COLONIC LAVAGE 35+L WATER Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0737T NOCOV DEF SYSMAN Description: XENOGRAFT IMPLTJ ARTCLR SURF Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0738T NOCOV DEF SYSMAN Description: TX PLN MAG FLD ABLTJ PRST8 Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0739T NOCOV DEF SYSMAN Description: ABLTJ MAL PRST8 MAG FLD NDCT Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0740T NOCOV DEF SYSMAN Description: REM AUTON ALG NSLN CAL SETUP Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0741T NOCOV DEF SYSMAN Description: REM AUTON ALG NSLN DATA COLL Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0742T RADIO DEF BILL90 Description: AQMBF SPECT XERS/STRS & REST Category: Radiology CMS Add: 01/01/2023 CMS Term: 0743T RADIO DEF BILL90 Description: B1 STR & FX RSK VRT FX ASSMT Category: Radiology CMS Add: 01/01/2023 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 73 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0744T NOCOV DEF SYSMAN Description: INSJ BIOPROSTC VLV FEM VN Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0745T MEDSV DEF BILL90 Description: CAR ABLT RAD ARR N-INVAS LOC Category: Medical Services CMS Add: 01/01/2023 CMS Term: 0746T MEDSV DEF BILL90 Description: CAR ABLT RAD ARR CNV LOC MAP Category: Medical Services CMS Add: 01/01/2023 CMS Term: 0747T NOCOV DEF SYSMAN Description: CAR ABLT RAD ARRHYT DLVR RAD Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0748T NOCOV DEF SYSMAN Description: NJX STM CL PRDCT ANL SFT TIS Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0749T RADIO DEF BILL90 Description: B1 STR&FX RSK ASSMT DXR-BMD Category: Radiology CMS Add: 01/01/2023 CMS Term: 0750T RADIO DEF BILL90 Description: B1 STR&FX RSK ASMT DXRBMD1VW Category: Radiology CMS Add: 01/01/2023 CMS Term: 0751T NOCOV DEF SYSMAN Description: DGTZ GLS MCRSCP SLD LEVEL II Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0752T NOCOV DEF SYSMAN Description: DGTZ GLS MCRSCP SLD LVL III Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0753T NOCOV DEF SYSMAN Description: DGTZ GLS MCRSCP SLD LEVEL IV Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0754T NOCOV DEF SYSMAN Description: DGTZ GLS MCRSCP SLD LEVEL V Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0755T NOCOV DEF SYSMAN Description: DGTZ GLS MCRSCP SLD LEVEL VI Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0756T NOCOV DEF SYSMAN Description: DGTZ GLS MCRSCP SLD SPC GRPI Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0757T NOCOV DEF SYSMAN Description: DGTZ GLS MCRSCP SL SPC GRPII Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0758T NOCOV DEF SYSMAN Description: DGTZ GLS MCRSCP SL SPC HCHEM Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0759T NOCOV DEF SYSMAN Description: DGTZ GLS MCRSCP SL SP GRPIII Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 74 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0760T NOCOV DEF SYSMAN Description: DGTZ GLS MCRSCP SL IMM 1ST Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0761T NOCOV DEF SYSMAN Description: DGTZ GLS MCRSCP SL IMM EA 1 Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0762T NOCOV DEF SYSMAN Description: DGTZ GLS MCRSCP SL IMM EA M Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0763T NOCOV DEF SYSMAN Description: DGTZ GLS MCRSCP MPHMTRC ALYS Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0764T NOCOV DEF SYSMAN Description: ASSTV ALG ECG RSK ASMT CNCRT Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0765T NOCOV DEF SYSMAN Description: ASSTV ALG ECG RSK ASMT PREV Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0766T NOCOV DEF SYSMAN Description: TC MAG STIMJ PN 1ST NERVE Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0767T NOCOV DEF SYSMAN Description: TC MAG STIMJ PN EA ADDL NRV Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0770T NOCOV DEF SYSMAN Description: VR TECHNOLOGY ASSIST THERAPY Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0771T NOCOV DEF SYSMAN Description: VR PX DISSOC SVC SM PHY 1ST Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0772T NOCOV DEF SYSMAN Description: VR PX DISSOC SVC SM PHY EA Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0773T NOCOV DEF SYSMAN Description: VR PX DISSOC SVC OTH PHY 1ST Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0774T NOCOV DEF SYSMAN Description: VR PX DISSOC SVC OTH PHY EA Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0776T NOCOV DEF SYSMAN Description: THER INDCTJ NTRABRN HYPTHRM Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0777T MEDSV DEF BILL90 Description: R-T PRS SENSING EDRL GDN SYS Category: Medical Services CMS Add: 01/01/2023 CMS Term: 0778T NOCOV DEF SYSMAN Description: SMMG CNCRNT APPL IMU SNR Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 75 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0779T NOCOV DEF SYSMAN Description: GI MYOELECTRICAL ACTV STUDY Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0780T NOCOV DEF SYSMAN Description: INSTLJ FECAL MICROBIOTA SSP Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0781T NOCOV DEF SYSMAN Description: BRNCHSC RF DSTRJ PULM NRV BI Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0782T NOCOV DEF SYSMAN Description: BRNCHSC RF DSTRJ PLM NRV UNI Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0783T NOCOV DEF SYSMAN Description: TC AURICULR NEUROSTIMULATION Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0784T NOCOV DEF SYSMAN Description: INS/RPLMT ELTRD RA SPI NSTIM Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0785T NOCOV DEF SYSMAN Description: REVJ/RMVL NEA SPI W/NSTIM Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0786T NOCOV DEF SYSMAN Description: INSJ/RPLCMT PRQ RA SAC NSTIM Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0787T NOCOV DEF SYSMAN Description: REVJ/RMVL NEA SAC W/NSTIM Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0788T NOCOV DEF SYSMAN Description: ELEC ALY SMP IINS SP/SAC NRV Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0789T NOCOV DEF SYSMAN Description: ELEC ALY CPX IINS SP/SAC NRV Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0790T NOCOV DEF SYSMAN Description: REVJ RPLCMT/RMVL VRT TETHRG Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0791T NOCOV DEF SYSMAN Description: MOTR COG VR GAIT TRAIN EA 15 Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0792T NOCOV DEF SYSMAN Description: APPL SLVR DIAMN FLUORIDE 38% Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0793T NOCOV DEF SYSMAN Description: PRQ TCAT THRM ABLT NRV P-ART Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0794T NOCOV DEF SYSMAN Description: PT SPEC ALG RX-ONC TX OPTION Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 76 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0795T NOCOV DEF SYSMAN Description: TCAT INS 2CHMBR LDLS PM CMPL Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0796T NOCOV DEF SYSMAN Description: TCAT INS 2CHMBR LDLS PM RA Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0797T NOCOV DEF SYSMAN Description: TCAT INS 2CHMBR LDLS PM RV Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0798T NOCOV DEF SYSMAN Description: TCAT RMV 2CHMBR LDLS PM CMPL Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0799T NOCOV DEF SYSMAN Description: TCAT RMVL 2CHMBR LDLS PM RA Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0800T NOCOV DEF SYSMAN Description: TCAT RMVL 2CHMBR LDLS PM RV Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0801T NOCOV DEF SYSMAN Description: TCAT RMV&RPL 2CHMBR LDLS PM Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0802T NOCOV DEF SYSMAN Description: TCAT RMV&RPL2CHMB LDLS PM RA Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0803T NOCOV DEF SYSMAN Description: TCAT RMV&RPL2CHMB LDLS PM RV Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0804T NOCOV DEF SYSMAN Description: PRGRMG EVL LDLS PM 2CHMBR IP Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0805T NOCOV DEF SYSMAN Description: TCAT S&IVC PRSTC VL IMPL PRQ Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0806T NOCOV DEF SYSMAN Description: TCAT S&IVC PRSTC VL IMPL OPN Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0807T NOCOV DEF SYSMAN Description: PULM TISS VNTJ ALYS PREV CT Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0808T NOCOV DEF SYSMAN Description: PULM TISS VNTJ ALYS W/CT Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0810T NOCOV DEF SYSMAN Description: SUBRTA NJX RX AGT W/VTRC Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0811T NOCOV DEF SYSMAN Description: REM MLT DAY UROFLOW SETUP Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 77 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0812T NOCOV DEF SYSMAN Description: REM MLT DAY UROFLOW DEV SPLY Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0813T NOCOV DEF SYSMAN Description: EGD VOL ADJMT BARIATRIC BALO Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0814T NOCOV DEF SYSMAN Description: PRQ NJX BIOD OSTEO MATRL FEM Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0815T NOCOV DEF SYSMAN Description: US REMS B1 DNS HIPS PLVS/SPI Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0816T NOCOV DEF SYSMAN Description: OPN INSJ/RPLCMT INS PTN SUBQ Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0817T NOCOV DEF SYSMAN Description: OPN INSJ/RPLCMT INS PTN SUBF Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0818T NOCOV DEF SYSMAN Description: REVJ/RMVL INS PTN SUBQ Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0819T NOCOV DEF SYSMAN Description: REVJ/RMVL INS PTN SUBF Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0820T NOCOV DEF SYSMAN Description: MNTR PSYCHDLC MED 1STPHY/QHP Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0821T NOCOV DEF SYSMAN Description: MNTR PSYCHDLC MED 2NDPHY/QHP Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0822T NOCOV DEF SYSMAN Description: MNTR PSYCHDLC MED CLN STAFF Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0823T NOCOV DEF SYSMAN Description: TCAT INS 1CHMBR LDLS PM RA Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0824T NOCOV DEF SYSMAN Description: TCAT RMV 1CHMBR LDLS PM RA Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0825T NOCOV DEF SYSMAN Description: TCAT RMV&RPL1CHMB LDLS PM RA Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0826T NOCOV DEF SYSMAN Description: PRGRMG EVL LDLS PM 1CHMBR IP Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0827T NOCOV DEF SYSMAN Description: DGTZ GLS MCRSCP CYTP SMEARS Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 78 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0828T NOCOV DEF SYSMAN Description: DGTZ GLS MCRSCP CYTP SMPL FL Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0829T NOCOV DEF SYSMAN Description: DGTZ GLS MCRSCP CYTP CONCTRJ Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0830T NOCOV DEF SYSMAN Description: DGTZ GLS MCRSCP CYTP SLCTV Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0831T NOCOV DEF SYSMAN Description: DGTZ GLS MCRSCP CYTP C/V Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0832T NOCOV DEF SYSMAN Description: DGTZ GLS MCRSCP CYTP OTH SCR Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0833T NOCOV DEF SYSMAN Description: DGTZ GLS MCRSCP CYTP OTH PRP Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0834T NOCOV DEF SYSMAN Description: DGTZ GLS MCRSCP CYTP OTH XTN Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0835T NOCOV DEF SYSMAN Description: DGTZ GLS MCRSCP FNA 1ST EA Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0836T NOCOV DEF SYSMAN Description: DGTZ GLS MCRSCP FNA EA ADDL Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0837T NOCOV DEF SYSMAN Description: DGTZ GLS MCRSCP FNA I&R Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0838T NOCOV DEF SYSMAN Description: DGTZ GLS MCRSCP CSLT SLD ELS Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0839T NOCOV DEF SYSMAN Description: DGTZ GLS MCRSCP CSLT MAT PRP Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0840T NOCOV DEF SYSMAN Description: DGTZ GLS MCRSCP CSLT COMPRE Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0841T NOCOV DEF SYSMAN Description: DGTZ GLS MCRSCP PTH CSLT 1ST Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0842T NOCOV DEF SYSMAN Description: DGTZ GLS MCRSCP PTH CSLT EA Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0843T NOCOV DEF SYSMAN Description: DGTZ GLS MCRSCP CSLT CYT 1ST Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 79 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0844T NOCOV DEF SYSMAN Description: DGTZ GLS MCRSCP CSLT CYT EA Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0845T NOCOV DEF SYSMAN Description: DGTZ GLS MCRSCP IMFLUOR 1ST Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0846T NOCOV DEF SYSMAN Description: DGTZ GLS MCRSCP IMFLUOR EA Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0847T NOCOV DEF SYSMAN Description: DGTZ GLS MCRSCP XM ARCH TISS Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0848T NOCOV DEF SYSMAN Description: DGTZ GLS MCRSCP ISH 1ST Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0849T NOCOV DEF SYSMAN Description: DGTZ GLS MCRSCP ISH EA ADL 1 Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0850T NOCOV DEF SYSMAN Description: DGTZ GLS MCRSCP ISH EA MULT Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0851T NOCOV DEF SYSMAN Description: DGTZ GLS MCRSCP MPHMTRC 1ST Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0852T NOCOV DEF SYSMAN Description: DGTZ GLS MCRSCP MPHMTRC EA 1 Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0853T NOCOV DEF SYSMAN Description: DGTZ GLS MCRSCP MPHMTRC EA M Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0854T NOCOV DEF SYSMAN Description: DGTZ GLS MCRSCP BLD SMR PRPH Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0855T NOCOV DEF SYSMAN Description: DGTZ GLS MCRSCP B1 MAROW SMR Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0856T NOCOV DEF SYSMAN Description: DGTZ GLS MCRSCP ELECTRON MIC Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0857T NOCOV DEF SYSMAN Description: OPTO-ACOUSTIC IMG BREAST UNI Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0858T NOCOV DEF SYSMAN Description: EXT TRNSCRANL MAG STIMJ MEAS Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0859T NOCOV DEF SYSMAN Description: NCNTC IFR SPCTRSC O/T PAD EA Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 80 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0860T NOCOV DEF SYSMAN Description: NCNTC IFR SPCTRSC SCR PAD Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0861T NOCOV DEF SYSMAN Description: RMVL PG WCS LV BOTH COMPNT Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0862T NOCOV DEF SYSMAN Description: RLCJ PG WCS LV BATTERY ONLY Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0863T NOCOV DEF SYSMAN Description: RLCJ PG WCS LV TRNSMTR ONLY Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0864T NOCOV DEF SYSMAN Description: LOW NTSTY ESWT CORPUS CVRNSM Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0865T NOCOV DEF SYSMAN Description: QUAN MRI ALYS BRN W/O DX MRI Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 0866T NOCOV DEF SYSMAN Description: QUAN MRI ALYS BRN W/DX MRI Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 10004 MEDSV DEF RBRVS 01/01/2019 12/31/2023 37.68 Description: FNA BX W/O IMG GDN EA ADDL Category: Medical Services CMS Add: 01/01/2019 CMS Term: 10004 MEDSV DEF RBRVS 01/01/2024 47.71 Description: FNA BX W/O IMG GDN EA ADDL Category: Medical Services CMS Add: 01/01/2019 CMS Term: 10005 MEDSV DEF RBRVS 01/01/2019 12/31/2023 90.75 Description: FNA BX W/US GDN 1ST LES Category: Medical Services CMS Add: 01/01/2019 CMS Term: 10005 MEDSV DEF RBRVS 01/01/2024 127.54 Description: FNA BX W/US GDN 1ST LES Category: Medical Services CMS Add: 01/01/2019 CMS Term: 10006 MEDSV DEF RBRVS 01/01/2019 12/31/2023 43.63 Description: FNA BX W/US GDN EA ADDL Category: Medical Services CMS Add: 01/01/2019 CMS Term: 10006 MEDSV DEF RBRVS 01/01/2024 56.80 Description: FNA BX W/US GDN EA ADDL Category: Medical Services CMS Add: 01/01/2019 CMS Term: 10007 MEDSV DEF RBRVS 01/01/2019 12/31/2023 202.63 Description: FNA BX W/FLUOR GDN 1ST LES Category: Medical Services CMS Add: 01/01/2019 CMS Term: 10007 MEDSV DEF RBRVS 01/01/2024 277.41 Description: FNA BX W/FLUOR GDN 1ST LES Category: Medical Services CMS Add: 01/01/2019 CMS Term: 10008 MEDSV DEF RBRVS 01/01/2019 12/31/2023 114.44 Description: FNA BX W/FLUOR GDN EA ADDL Category: Medical Services CMS Add: 01/01/2019 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 81 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 10008 MEDSV DEF RBRVS 01/01/2024 134.10 Description: FNA BX W/FLUOR GDN EA ADDL Category: Medical Services CMS Add: 01/01/2019 CMS Term: 10009 MEDSV DEF RBRVS 01/01/2019 12/31/2023 330.90 Description: FNA BX W/CT GDN 1ST LES Category: Medical Services CMS Add: 01/01/2019 CMS Term: 10009 MEDSV DEF RBRVS 01/01/2024 407.05 Description: FNA BX W/CT GDN 1ST LES Category: Medical Services CMS Add: 01/01/2019 CMS Term: 1000F NOCOV DEF SYSMAN Description: TOBACCO USE ASSESSED Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: 10010 MEDSV DEF RBRVS 01/01/2019 12/31/2023 199.81 Description: FNA BX W/CT GDN EA ADDL Category: Medical Services CMS Add: 01/01/2019 CMS Term: 10010 MEDSV DEF RBRVS 01/01/2024 223.21 Description: FNA BX W/CT GDN EA ADDL Category: Medical Services CMS Add: 01/01/2019 CMS Term: 10011 MEDSV DEF BILL20 Description: FNA BX W/MR GDN 1ST LES Category: Medical Services CMS Add: 01/01/2019 CMS Term: 10012 MEDSV DEF BILL20 Description: FNA BX W/MR GDN EA ADDL Category: Medical Services CMS Add: 01/01/2019 CMS Term: 10021 26 MEDSV DEF MAXFEE 01/01/2024 63.37 0.0 Description: FNA BX W/O IMG GDN 1ST LES Category: Medical Services CMS Add: 01/01/2002 CMS Term: 10021 26 MEDSV DEF RBRVS 02/01/2015 61.14 Description: FNA BX W/O IMG GDN 1ST LES Category: Medical Services CMS Add: 01/01/2002 CMS Term: 10021 MEDSV DEF RBRVS 01/01/2024 95.20 Description: FNA BX W/O IMG GDN 1ST LES Category: Medical Services CMS Add: 01/01/2002 CMS Term: 10021 MEDSV DEF RBRVS 09/01/2019 12/31/2023 104.97 Description: FNA BX W/O IMG GDN 1ST LES Category: Medical Services CMS Add: 01/01/2002 CMS Term: 10021 TC MEDSV DEF MAXFEE 01/01/2024 15.73 0.0 Description: FNA BX W/O IMG GDN 1ST LES Category: Medical Services CMS Add: 01/01/2002 CMS Term: 10021 TC MEDSV DEF RBRVS 02/01/2015 14.99 Description: FNA BX W/O IMG GDN 1ST LES Category: Medical Services CMS Add: 01/01/2002 CMS Term: 1002F NOCOV DEF SYSMAN Description: ASSESS ANGINAL SYMPTOM/LEVEL Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: 10030 MEDSV DEF RBRVS 01/01/2024 606.00 Description: IMG GID FLU COLL DRG SFT TIS Category: Medical Services CMS Add: 01/01/2014 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 82 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 10030 MEDSV DEF RBRVS 09/15/2017 12/31/2023 490.96 Description: IMG GID FLU COLL DRG SFT TIS Category: Medical Services CMS Add: 01/01/2014 CMS Term: 10035 MEDSV DEF RBRVS 01/01/2016 12/31/2023 378.19 0-1 Description: PLMT SFT TISS LOCLZJ DEV 1ST Category: Medical Services CMS Add: 01/01/2016 CMS Term: 10035 MEDSV DEF RBRVS 01/01/2024 346.06 0-1 Description: PLMT SFT TISS LOCLZJ DEV 1ST Category: Medical Services CMS Add: 01/01/2016 CMS Term: 10036 MEDSV DEF RBRVS 01/01/2024 286.65 Description: PLMT SFT TISS LOCLZJ DEV EA Category: Medical Services CMS Add: 01/01/2016 CMS Term: 10036 MEDSV DEF RBRVS 09/01/2019 12/31/2023 327.77 Description: PLMT SFT TISS LOCLZJ DEV EA Category: Medical Services CMS Add: 01/01/2016 CMS Term: 1003F NOCOV DEF SYSMAN Description: LEVEL OF ACTIVITY ASSESS Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 10040 NOCOV DEF SYSMAN 0-1 Description: ACNE SURGERY Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: 1004F NOCOV DEF SYSMAN Description: CLIN SYMP VOL OVRLD ASSESS Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 1005F NOCOV DEF SYSMAN Description: ASTHMA SYMPTOMS EVALUATE Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 10060 MEDSV DEF RBRVS 01/01/2024 117.98 0-1 Description: I&D ABSCESS SIMPLE/SINGLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 10060 MEDSV DEF RBRVS 09/01/2019 12/31/2023 82.16 0-1 Description: I&D ABSCESS SIMPLE/SINGLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 10061 MEDSV DEF RBRVS 01/01/2024 199.61 0-1 Description: I&D ABSCESS COMP/MULTIPLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 10061 MEDSV DEF RBRVS 09/01/2019 12/31/2023 145.92 0-1 Description: I&D ABSCESS COMP/MULTIPLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 1006F NOCOV DEF SYSMAN Description: OSTEOARTHRITIS ASSESS Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 1007F NOCOV DEF SYSMAN Description: ANTI-INFLM/ANLGSC OTC ASSESS Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 10080 MEDSV DEF RBRVS 01/01/2024 234.88 Description: I&D PILONIDAL CYST SIMPLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 83 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 10080 MEDSV DEF RBRVS 09/01/2019 12/31/2023 125.34 Description: I&D PILONIDAL CYST SIMPLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 10081 MEDSV DEF RBRVS 01/01/2024 320.56 Description: I&D PILONIDAL CYST COMP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 10081 MEDSV DEF RBRVS 09/01/2019 12/31/2023 190.20 Description: I&D PILONIDAL CYST COMP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 1008F NOCOV DEF SYSMAN Description: GI/RENAL RISK ASSESS Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 1010F NOCOV DEF SYSMAN Description: SEVERITY ANGINA BY ACTVTY Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 1011F NOCOV DEF SYSMAN Description: ANGINA PRESENT Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 10120 MEDSV DEF RBRVS 01/01/2024 141.32 Description: INC&RMVL FB SUBQ TISS SMPL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 10120 MEDSV DEF RBRVS 09/01/2019 12/31/2023 106.85 Description: INC&RMVL FB SUBQ TISS SMPL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 10121 MEDSV DEF RBRVS 01/01/2024 247.46 Description: INC&RMVL FB SUBQ TISS COMP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 10121 MEDSV DEF RBRVS 09/01/2019 12/31/2023 193.76 Description: INC&RMVL FB SUBQ TISS COMP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 1012F NOCOV DEF SYSMAN Description: ANGINA ABSENT Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 10140 MEDSV DEF RBRVS 01/01/2024 158.33 Description: I&D HMTMA SEROMA/FLUID COLLJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 10140 MEDSV DEF RBRVS 09/01/2019 12/31/2023 114.95 Description: I&D HMTMA SEROMA/FLUID COLLJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 1015F NOCOV DEF SYSMAN Description: COPD SYMPTOMS ASSESS Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 10160 MEDSV DEF RBRVS 01/01/2024 121.66 Description: PNXR ASPIR ABSC HMTMA BULLA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 10160 MEDSV DEF RBRVS 09/01/2019 12/31/2023 91.80 Description: PNXR ASPIR ABSC HMTMA BULLA Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 84 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 10180 MEDSV DEF RBRVS 01/01/2024 243.59 Description: I&D COMPLEX PO WOUND INFCTJ Category: Medical Services CMS Add: 01/01/1985 CMS Term: 10180 MEDSV DEF RBRVS 09/01/2019 12/31/2023 172.94 Description: I&D COMPLEX PO WOUND INFCTJ Category: Medical Services CMS Add: 01/01/1985 CMS Term: 1018F NOCOV DEF SYSMAN Description: ASSESS DYSPNEA NOT PRESENT Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 1019F NOCOV DEF SYSMAN Description: ASSESS DYSPNEA PRESENT Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 1022F NOCOV DEF SYSMAN Description: PNEUMO IMM STATUS ASSESS Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 1026F NOCOV DEF SYSMAN Description: CO-MORBID CONDITION ASSESS Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 1030F NOCOV DEF SYSMAN Description: INFLUENZA IMM STATUS ASSESS Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 1031F NOCOV DEF SYSMAN Description: SMOKING & 2ND HAND ASSESSED Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 1032F NOCOV DEF SYSMAN Description: SMOKER/EXPOSED 2ND HND SMOKE Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 1033F NOCOV DEF SYSMAN Description: TOBACCO NONSMOKER NOR 2NDHND Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 1034F NOCOV DEF SYSMAN Description: CURRENT TOBACCO SMOKER Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 1035F NOCOV DEF SYSMAN Description: SMOKELESS TOBACCO USER Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 1036F NOCOV DEF SYSMAN Description: TOBACCO NON-USER Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 1038F NOCOV DEF SYSMAN Description: PERSISTENT ASTHMA Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 1039F NOCOV DEF SYSMAN Description: INTERMITTENT ASTHMA Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 1040F NOCOV DEF SYSMAN Description: DSM-5 INFO MDD DOCD Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 85 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 1050F NOCOV DEF SYSMAN Description: HISTORY OF MOLE CHANGES Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 1052F NOCOV DEF SYSMAN Description: TYPE LOCATION ACTIVITYASSESS Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 1055F NOCOV DEF SYSMAN Description: VISUAL FUNCT STATUS ASSESS Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 1060F NOCOV DEF SYSMAN Description: DOC PERM/CONT/PAROX ATR FIB Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 1061F NOCOV DEF SYSMAN Description: DOC LACK PERM&CONT&PAROX FIB Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 1065F NOCOV DEF SYSMAN Description: ISCHM STROKE SYMP LT3 HRSB/4 Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 1066F NOCOV DEF SYSMAN Description: ISCHM STROKE SX ONSET>=3HR Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 1070F NOCOV DEF SYSMAN Description: ALARM SYMP ASSESSED-ABSENT Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 1071F NOCOV DEF SYSMAN Description: ALARM SYMP ASSESSED-1+ PRSNT Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 1090F NOCOV DEF SYSMAN Description: PRES/ABSN URINE INCON ASSESS Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 1091F NOCOV DEF SYSMAN Description: URINE INCON CHARACTERIZED Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 11000 MEDSV DEF RBRVS 01/01/2024 54.63 0-1 Description: DBRDMT ECZ/INFECTED SKIN<10% Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11000 MEDSV DEF RBRVS 09/01/2019 12/31/2023 38.75 0-1 Description: DBRDMT ECZ/INFECTED SKIN<10% Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11001 MEDSV DEF RBRVS 01/01/2024 25.63 0-9 Description: DBRDMT ECZ/INFCT SKN EA ADDL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11001 MEDSV DEF RBRVS 02/01/2015 12/31/2023 15.24 0-9 Description: DBRDMT ECZ/INFCT SKN EA ADDL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11004 MEDSV DEF RBRVS 01/01/2024 521.07 Description: DBRDMT SKIN XTRNL GENT&PER Category: Medical Services CMS Add: 01/01/2005 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 86 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 11004 MEDSV DEF RBRVS 02/01/2015 12/31/2023 418.91 Description: DBRDMT SKIN XTRNL GENT&PER Category: Medical Services CMS Add: 01/01/2005 CMS Term: 11005 MEDSV DEF RBRVS 01/01/2024 700.69 Description: DBRDMT SKIN ABDOMINAL WALL Category: Medical Services CMS Add: 01/01/2005 CMS Term: 11005 MEDSV DEF RBRVS 02/01/2015 12/31/2023 560.31 Description: DBRDMT SKIN ABDOMINAL WALL Category: Medical Services CMS Add: 01/01/2005 CMS Term: 11006 MEDSV DEF RBRVS 01/01/2024 638.37 Description: DBRDMT SKIN XTRNL GENT PER Category: Medical Services CMS Add: 01/01/2005 CMS Term: 11006 MEDSV DEF RBRVS 02/01/2015 12/31/2023 507.38 Description: DBRDMT SKIN XTRNL GENT PER Category: Medical Services CMS Add: 01/01/2005 CMS Term: 11008 MEDSV DEF RBRVS 01/01/2024 246.79 Description: RMV PRSTC MTRL/MESH ABD WALL Category: Medical Services CMS Add: 01/01/2005 CMS Term: 11008 MEDSV DEF RBRVS 02/01/2015 12/31/2023 196.44 Description: RMV PRSTC MTRL/MESH ABD WALL Category: Medical Services CMS Add: 01/01/2005 CMS Term: 1100F NOCOV DEF SYSMAN Description: PTFALLS ASSESS-DOCD GE2>/YR Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 11010 MEDSV DEF RBRVS 01/01/2019 12/31/2023 342.62 Description: DEBRIDE SKIN AT FX SITE Category: Medical Services CMS Add: 01/01/1997 CMS Term: 11010 MEDSV DEF RBRVS 01/01/2024 421.55 Description: DEBRIDE SKIN AT FX SITE Category: Medical Services CMS Add: 01/01/1997 CMS Term: 11011 MEDSV DEF RBRVS 01/01/2019 12/31/2023 378.38 Description: DEBRIDE SKIN MUSC AT FX SITE Category: Medical Services CMS Add: 01/01/1997 CMS Term: 11011 MEDSV DEF RBRVS 01/01/2024 461.77 Description: DEBRIDE SKIN MUSC AT FX SITE Category: Medical Services CMS Add: 01/01/1997 CMS Term: 11012 MEDSV DEF RBRVS 01/01/2019 12/31/2023 500.75 Description: DEB SKIN BONE AT FX SITE Category: Medical Services CMS Add: 01/01/1997 CMS Term: 11012 MEDSV DEF RBRVS 01/01/2024 604.90 Description: DEB SKIN BONE AT FX SITE Category: Medical Services CMS Add: 01/01/1997 CMS Term: 1101F NOCOV DEF SYSMAN Description: PT FALLS ASSESS-DOCD LE1/YR Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 11042 MEDSV DEF RBRVS 01/01/2024 120.44 Description: DBRDMT SUBQ TIS 1ST 20SQCM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 87 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 11042 MEDSV DEF RBRVS 09/01/2019 12/31/2023 82.13 Description: DBRDMT SUBQ TIS 1ST 20SQCM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11043 MEDSV DEF RBRVS 01/01/2024 216.17 Description: DBRDMT MUSC&/FSCA 1ST 20/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11043 MEDSV DEF RBRVS 09/01/2019 12/31/2023 162.88 Description: DBRDMT MUSC&/FSCA 1ST 20/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11044 MEDSV DEF RBRVS 01/01/2024 288.63 Description: DBRDMT BONE 1ST 20 SQ CM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11044 MEDSV DEF RBRVS 09/01/2019 12/31/2023 225.84 Description: DBRDMT BONE 1ST 20 SQ CM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11045 MEDSV DEF RBRVS 01/01/2024 37.06 Description: DBRDMT SUBQ TISS EACH ADDL Category: Medical Services CMS Add: 01/01/2011 CMS Term: 11045 MEDSV DEF RBRVS 02/01/2015 12/31/2023 29.87 Description: DBRDMT SUBQ TISS EACH ADDL Category: Medical Services CMS Add: 01/01/2011 CMS Term: 11046 MEDSV DEF RBRVS 01/01/2024 67.29 Description: DBRDMT MUSC&/FSCA EA ADDL Category: Medical Services CMS Add: 01/01/2011 CMS Term: 11046 MEDSV DEF RBRVS 02/01/2015 12/31/2023 52.28 Description: DBRDMT MUSC&/FSCA EA ADDL Category: Medical Services CMS Add: 01/01/2011 CMS Term: 11047 MEDSV DEF RBRVS 01/01/2024 111.39 Description: DBRDMT BONE EACH ADDL Category: Medical Services CMS Add: 01/01/2011 CMS Term: 11047 MEDSV DEF RBRVS 02/01/2015 12/31/2023 89.07 Description: DBRDMT BONE EACH ADDL Category: Medical Services CMS Add: 01/01/2011 CMS Term: 11055 MEDSV DEF RBRVS 01/01/2024 66.84 Description: PARING/CUTG B9 HYPRKER LES 1 Category: Medical Services CMS Add: 01/01/1998 CMS Term: 11055 MEDSV DEF RBRVS 02/01/2015 12/31/2023 33.51 Description: PARING/CUTG B9 HYPRKER LES 1 Category: Medical Services CMS Add: 01/01/1998 CMS Term: 11056 MEDSV DEF RBRVS 01/01/2024 77.17 Description: PARNG/CUTG B9 HYPRKR LES 2-4 Category: Medical Services CMS Add: 01/01/1998 CMS Term: 11056 MEDSV DEF RBRVS 02/01/2015 12/31/2023 41.18 Description: PARNG/CUTG B9 HYPRKR LES 2-4 Category: Medical Services CMS Add: 01/01/1998 CMS Term: 11057 MEDSV DEF RBRVS 01/01/2024 84.41 Description: PARNG/CUTG B9 HYPRKR LES >4 Category: Medical Services CMS Add: 01/01/1998 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 88 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 11057 MEDSV DEF RBRVS 02/01/2015 12/31/2023 46.61 Description: PARNG/CUTG B9 HYPRKR LES >4 Category: Medical Services CMS Add: 01/01/1998 CMS Term: 11102 MEDSV DEF RBRVS 01/01/2019 12/31/2023 70.00 0-1 Description: TANGNTL BX SKIN SINGLE LES Category: Medical Services CMS Add: 01/01/2019 CMS Term: 11102 MEDSV DEF RBRVS 01/01/2024 95.11 0-1 Description: TANGNTL BX SKIN SINGLE LES Category: Medical Services CMS Add: 01/01/2019 CMS Term: 11103 MEDSV DEF RBRVS 01/01/2019 12/31/2023 37.79 Description: TANGNTL BX SKIN EA SEP/ADDL Category: Medical Services CMS Add: 01/01/2019 CMS Term: 11103 MEDSV DEF RBRVS 01/01/2024 47.17 Description: TANGNTL BX SKIN EA SEP/ADDL Category: Medical Services CMS Add: 01/01/2019 CMS Term: 11104 MEDSV DEF RBRVS 01/01/2019 12/31/2023 88.03 0-1 Description: PUNCH BX SKIN SINGLE LESION Category: Medical Services CMS Add: 01/01/2019 CMS Term: 11104 MEDSV DEF RBRVS 01/01/2024 117.72 0-1 Description: PUNCH BX SKIN SINGLE LESION Category: Medical Services CMS Add: 01/01/2019 CMS Term: 11105 MEDSV DEF RBRVS 01/01/2019 12/31/2023 43.30 Description: PUNCH BX SKIN EA SEP/ADDL Category: Medical Services CMS Add: 01/01/2019 CMS Term: 11105 MEDSV DEF RBRVS 01/01/2024 55.42 Description: PUNCH BX SKIN EA SEP/ADDL Category: Medical Services CMS Add: 01/01/2019 CMS Term: 11106 MEDSV DEF RBRVS 01/01/2019 12/31/2023 106.49 0-1 Description: INCAL BX SKN SINGLE LES Category: Medical Services CMS Add: 01/01/2019 CMS Term: 11106 MEDSV DEF RBRVS 01/01/2024 145.75 0-1 Description: INCAL BX SKN SINGLE LES Category: Medical Services CMS Add: 01/01/2019 CMS Term: 11107 MEDSV DEF RBRVS 01/01/2019 12/31/2023 51.09 Description: INCAL BX SKN EA SEP/ADDL Category: Medical Services CMS Add: 01/01/2019 CMS Term: 11107 MEDSV DEF RBRVS 01/01/2024 66.97 Description: INCAL BX SKN EA SEP/ADDL Category: Medical Services CMS Add: 01/01/2019 CMS Term: 1110F NOCOV DEF SYSMAN Description: PT LFT INPT FAC W/IN 60 DAYS Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 1111F NOCOV DEF SYSMAN Description: DSCHRG MED/CURRENT MED MERGE Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 1116F NOCOV DEF SYSMAN Description: AURIC/PERI PAIN ASSESSED Category: Non Covered Services CMS Add: 10/01/2007 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 89 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 1118F NOCOV DEF SYSMAN Description: GERD SYMPS ASSESSED 12 MONTH Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 1119F NOCOV DEF SYSMAN Description: INIT EVAL FOR CONDITION Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 11200 MEDSV DEF RBRVS 01/01/2024 85.58 0-1 Description: RMVL SKIN TAGS UP TO&INC 15 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11200 MEDSV DEF RBRVS 02/01/2015 12/31/2023 61.75 0-1 Description: RMVL SKIN TAGS UP TO&INC 15 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11201 MEDSV DEF RBRVS 01/01/2024 17.26 Description: RMVL SKIN TAGS EA ADDL 10 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11201 MEDSV DEF RBRVS 02/01/2015 12/31/2023 13.65 Description: RMVL SKIN TAGS EA ADDL 10 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 1121F NOCOV DEF SYSMAN Description: SUBS EVAL FOR CONDITION Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 1123F NOCOV DEF SYSMAN Description: ACP DISCUSS/DSCN MKR DOCD Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 1124F NOCOV DEF SYSMAN Description: ACP DISCUSS-NO DSCNMKR DOCD Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 1125F NOCOV DEF SYSMAN Description: AMNT PAIN NOTED PAIN PRSNT Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 1126F NOCOV DEF SYSMAN Description: AMNT PAIN NOTED NONE PRSNT Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 1127F NOCOV DEF SYSMAN Description: NEW EPISODE FOR CONDITION Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: 1128F NOCOV DEF SYSMAN Description: SUBS EPISODE FOR CONDITION Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: 11300 MEDSV DEF RBRVS 01/01/2016 12/31/2023 66.99 Description: SHAVE SKIN LESION 0.5 CM/< Category: Medical Services CMS Add: 01/01/1993 CMS Term: 11300 MEDSV DEF RBRVS 01/01/2024 94.93 Description: SHAVE SKIN LESION 0.5 CM/< Category: Medical Services CMS Add: 01/01/1993 CMS Term: 11301 MEDSV DEF RBRVS 01/01/2016 12/31/2023 82.72 Description: SHAVE SKIN LESION 0.6-1.0 CM Category: Medical Services CMS Add: 01/01/1993 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 90 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 11301 MEDSV DEF RBRVS 01/01/2024 114.53 Description: SHAVE SKIN LESION 0.6-1.0 CM Category: Medical Services CMS Add: 01/01/1993 CMS Term: 11302 MEDSV DEF RBRVS 01/01/2016 12/31/2023 97.49 Description: SHAVE SKIN LESION 1.1-2.0 CM Category: Medical Services CMS Add: 01/01/1993 CMS Term: 11302 MEDSV DEF RBRVS 01/01/2024 129.04 Description: SHAVE SKIN LESION 1.1-2.0 CM Category: Medical Services CMS Add: 01/01/1993 CMS Term: 11303 MEDSV DEF RBRVS 01/01/2019 12/31/2023 108.23 Description: SHAVE SKIN LESION >2.0 CM Category: Medical Services CMS Add: 01/01/1993 CMS Term: 11303 MEDSV DEF RBRVS 01/01/2024 143.09 Description: SHAVE SKIN LESION >2.0 CM Category: Medical Services CMS Add: 01/01/1993 CMS Term: 11305 MEDSV DEF RBRVS 01/01/2016 12/31/2023 69.06 Description: SHAVE SKIN LESION 0.5 CM/< Category: Medical Services CMS Add: 01/01/1993 CMS Term: 11305 MEDSV DEF RBRVS 01/01/2024 99.55 Description: SHAVE SKIN LESION 0.5 CM/< Category: Medical Services CMS Add: 01/01/1993 CMS Term: 11306 MEDSV DEF RBRVS 01/01/2016 12/31/2023 84.58 Description: SHAVE SKIN LESION 0.6-1.0 CM Category: Medical Services CMS Add: 01/01/1993 CMS Term: 11306 MEDSV DEF RBRVS 01/01/2024 115.64 Description: SHAVE SKIN LESION 0.6-1.0 CM Category: Medical Services CMS Add: 01/01/1993 CMS Term: 11307 MEDSV DEF RBRVS 01/01/2016 12/31/2023 99.95 Description: SHAVE SKIN LESION 1.1-2.0 CM Category: Medical Services CMS Add: 01/01/1993 CMS Term: 11307 MEDSV DEF RBRVS 01/01/2024 131.20 Description: SHAVE SKIN LESION 1.1-2.0 CM Category: Medical Services CMS Add: 01/01/1993 CMS Term: 11308 MEDSV DEF RBRVS 01/01/2016 12/31/2023 105.78 Description: SHAVE SKIN LESION >2.0 CM Category: Medical Services CMS Add: 01/01/1993 CMS Term: 11308 MEDSV DEF RBRVS 01/01/2024 138.77 Description: SHAVE SKIN LESION >2.0 CM Category: Medical Services CMS Add: 01/01/1993 CMS Term: 1130F NOCOV DEF SYSMAN Description: BK PAIN & FXN ASSESSED Category: Non Covered Services CMS Add: 04/01/2008 CMS Term: 11310 MEDSV DEF RBRVS 01/01/2016 12/31/2023 78.55 Description: SHAVE SKIN LESION 0.5 CM/< Category: Medical Services CMS Add: 01/01/1993 CMS Term: 11310 MEDSV DEF RBRVS 01/01/2024 109.29 Description: SHAVE SKIN LESION 0.5 CM/< Category: Medical Services CMS Add: 01/01/1993 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 91 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 11311 MEDSV DEF RBRVS 01/01/2016 12/31/2023 77.45 Description: SHAVE SKIN LESION 0.6-1.0 CM Category: Medical Services CMS Add: 01/01/1993 CMS Term: 11311 MEDSV DEF RBRVS 01/01/2024 128.73 Description: SHAVE SKIN LESION 0.6-1.0 CM Category: Medical Services CMS Add: 01/01/1993 CMS Term: 11312 MEDSV DEF RBRVS 01/01/2016 12/31/2023 111.39 Description: SHAVE SKIN LESION 1.1-2.0 CM Category: Medical Services CMS Add: 01/01/1993 CMS Term: 11312 MEDSV DEF RBRVS 01/01/2024 146.81 Description: SHAVE SKIN LESION 1.1-2.0 CM Category: Medical Services CMS Add: 01/01/1993 CMS Term: 11313 MEDSV DEF RBRVS 01/01/2016 12/31/2023 129.61 Description: SHAVE SKIN LESION >2.0 CM Category: Medical Services CMS Add: 01/01/1993 CMS Term: 11313 MEDSV DEF RBRVS 01/01/2024 170.51 Description: SHAVE SKIN LESION >2.0 CM Category: Medical Services CMS Add: 01/01/1993 CMS Term: 1134F NOCOV DEF SYSMAN Description: EPSD BK PAIN FOR 6 WKS/< Category: Non Covered Services CMS Add: 04/01/2008 CMS Term: 1135F NOCOV DEF SYSMAN Description: EPSD BK PAIN FOR >6 WKS Category: Non Covered Services CMS Add: 04/01/2008 CMS Term: 1136F NOCOV DEF SYSMAN Description: EPSD BK PAIN FOR 12 WKS/< Category: Non Covered Services CMS Add: 04/01/2008 CMS Term: 1137F NOCOV DEF SYSMAN Description: EPSD BK PAIN FOR >12 WKS Category: Non Covered Services CMS Add: 04/01/2008 CMS Term: 11400 MEDSV DEF RBRVS 01/01/2024 119.80 Description: EXC TR-EXT B9+MARG 0.5 CM< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11400 MEDSV DEF RBRVS 02/01/2015 12/31/2023 85.70 Description: EXC TR-EXT B9+MARG 0.5 CM< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11401 MEDSV DEF RBRVS 01/01/2024 146.30 Description: EXC TR-EXT B9+MARG 0.6-1 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11401 MEDSV DEF RBRVS 02/01/2015 12/31/2023 103.67 Description: EXC TR-EXT B9+MARG 0.6-1 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11402 MEDSV DEF RBRVS 01/01/2024 160.86 Description: EXC TR-EXT B9+MARG 1.1-2 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11402 MEDSV DEF RBRVS 02/01/2015 12/31/2023 115.34 Description: EXC TR-EXT B9+MARG 1.1-2 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 92 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 11403 MEDSV DEF RBRVS 01/01/2024 184.94 Description: EXC TR-EXT B9+MARG 2.1-3CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11403 MEDSV DEF RBRVS 02/01/2015 12/31/2023 133.66 Description: EXC TR-EXT B9+MARG 2.1-3CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11404 MEDSV DEF RBRVS 01/01/2024 209.26 Description: EXC TR-EXT B9+MARG 3.1-4 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11404 MEDSV DEF RBRVS 02/01/2015 12/31/2023 151.65 Description: EXC TR-EXT B9+MARG 3.1-4 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11406 MEDSV DEF RBRVS 01/01/2024 295.83 Description: EXC TR-EXT B9+MARG >4.0 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11406 MEDSV DEF RBRVS 02/01/2015 12/31/2023 219.10 Description: EXC TR-EXT B9+MARG >4.0 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11420 MEDSV DEF RBRVS 01/01/2024 119.72 Description: EXC H-F-NK-SP B9+MARG 0.5/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11420 MEDSV DEF RBRVS 02/01/2015 12/31/2023 85.72 Description: EXC H-F-NK-SP B9+MARG 0.5/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11421 MEDSV DEF RBRVS 01/01/2024 150.26 Description: EXC H-F-NK-SP B9+MARG 0.6-1 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11421 MEDSV DEF RBRVS 02/01/2015 12/31/2023 110.10 Description: EXC H-F-NK-SP B9+MARG 0.6-1 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11422 MEDSV DEF RBRVS 01/01/2024 168.21 Description: EXC H-F-NK-SP B9+MARG 1.1-2 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11422 MEDSV DEF RBRVS 02/01/2015 12/31/2023 122.84 Description: EXC H-F-NK-SP B9+MARG 1.1-2 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11423 MEDSV DEF RBRVS 01/01/2024 191.77 Description: EXC H-F-NK-SP B9+MARG 2.1-3 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11423 MEDSV DEF RBRVS 02/01/2015 12/31/2023 141.64 Description: EXC H-F-NK-SP B9+MARG 2.1-3 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11424 MEDSV DEF RBRVS 01/01/2024 220.57 Description: EXC H-F-NK-SP B9+MARG 3.1-4 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11424 MEDSV DEF RBRVS 02/01/2015 12/31/2023 163.49 Description: EXC H-F-NK-SP B9+MARG 3.1-4 Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 93 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 11426 MEDSV DEF RBRVS 01/01/2024 308.36 Description: EXC H-F-NK-SP B9+MARG >4 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11426 MEDSV DEF RBRVS 02/01/2015 12/31/2023 234.58 Description: EXC H-F-NK-SP B9+MARG >4 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11440 MEDSV DEF RBRVS 01/01/2024 134.60 Description: EXC FACE-MM B9+MARG 0.5 CM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11440 MEDSV DEF RBRVS 02/01/2015 12/31/2023 94.60 Description: EXC FACE-MM B9+MARG 0.5 CM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11441 MEDSV DEF RBRVS 01/01/2024 163.26 Description: EXC FACE-MM B9+MARG 0.6-1 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11441 MEDSV DEF RBRVS 02/01/2015 12/31/2023 117.74 Description: EXC FACE-MM B9+MARG 0.6-1 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11442 MEDSV DEF RBRVS 01/01/2024 181.30 Description: EXC FACE-MM B9+MARG 1.1-2 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11442 MEDSV DEF RBRVS 02/01/2015 12/31/2023 131.70 Description: EXC FACE-MM B9+MARG 1.1-2 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11443 MEDSV DEF RBRVS 01/01/2024 213.95 Description: EXC FACE-MM B9+MARG 2.1-3 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11443 MEDSV DEF RBRVS 02/01/2015 12/31/2023 157.25 Description: EXC FACE-MM B9+MARG 2.1-3 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11444 MEDSV DEF RBRVS 01/01/2024 265.22 Description: EXC FACE-MM B9+MARG 3.1-4 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11444 MEDSV DEF RBRVS 02/01/2015 12/31/2023 198.75 Description: EXC FACE-MM B9+MARG 3.1-4 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11446 MEDSV DEF RBRVS 01/01/2024 358.66 Description: EXC FACE-MM B9+MARG >4 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11446 MEDSV DEF RBRVS 02/01/2015 12/31/2023 276.44 Description: EXC FACE-MM B9+MARG >4 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11450 MEDSV DEF RBRVS 01/01/2024 400.72 Description: EXC SKN HDRDNT AX SMPL/NTRM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11450 MEDSV DEF RBRVS 09/01/2019 12/31/2023 263.96 Description: EXC SKN HDRDNT AX SMPL/NTRM Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 94 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 11451 MEDSV DEF RBRVS 01/01/2024 490.33 Description: EXC SKN HDRDNT AX COMPLEX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11451 MEDSV DEF RBRVS 09/01/2019 12/31/2023 338.09 Description: EXC SKN HDRDNT AX COMPLEX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11462 MEDSV DEF RBRVS 01/01/2024 388.11 Description: EXC SKN HDRDNT ING SMPL/NTRM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11462 MEDSV DEF RBRVS 09/01/2019 12/31/2023 257.72 Description: EXC SKN HDRDNT ING SMPL/NTRM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11463 MEDSV DEF RBRVS 01/01/2024 497.41 Description: EXC SKN HDRDNT ING COMPLEX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11463 MEDSV DEF RBRVS 09/01/2019 12/31/2023 346.18 Description: EXC SKN HDRDNT ING COMPLEX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11470 MEDSV DEF RBRVS 01/01/2024 425.91 Description: EXC SKN H/P/P/U SMPL/NTRM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11470 MEDSV DEF RBRVS 09/01/2019 12/31/2023 290.57 Description: EXC SKN H/P/P/U SMPL/NTRM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11471 MEDSV DEF RBRVS 01/01/2024 504.50 Description: EXC SKN H/P/P/U COMPLEX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11471 MEDSV DEF RBRVS 09/01/2019 12/31/2023 360.77 Description: EXC SKN H/P/P/U COMPLEX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 1150F NOCOV DEF SYSMAN Description: DOC PT RSK DEATH W/IN 1YR Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 1151F NOCOV DEF SYSMAN Description: DOC NO PT RSK DEATH W/IN 1YR Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 1152F NOCOV DEF SYSMAN Description: DOC ADVNCD DIS COMFORT 1ST Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 1153F NOCOV DEF SYSMAN Description: DOC ADVNCD DIS CMFRT NOT 1ST Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 1157F NOCOV DEF SYSMAN Description: ADVNC CARE PLAN IN RCRD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 1158F NOCOV DEF SYSMAN Description: ADVNC CARE PLAN TLK DOCD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 95 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 1159F NOCOV DEF SYSMAN Description: MED LIST DOCD IN RCRD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 11600 MEDSV DEF RBRVS 01/01/2024 185.04 Description: EXC TR-EXT MAL+MARG 0.5 CM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11600 MEDSV DEF RBRVS 02/01/2015 12/31/2023 134.62 Description: EXC TR-EXT MAL+MARG 0.5 CM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11601 MEDSV DEF RBRVS 01/01/2024 214.33 Description: EXC TR-EXT MAL+MARG 0.6-1 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11601 MEDSV DEF RBRVS 02/01/2015 12/31/2023 159.41 Description: EXC TR-EXT MAL+MARG 0.6-1 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11602 MEDSV DEF RBRVS 01/01/2024 229.75 Description: EXC TR-EXT MAL+MARG 1.1-2 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11602 MEDSV DEF RBRVS 02/01/2015 12/31/2023 172.96 Description: EXC TR-EXT MAL+MARG 1.1-2 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11603 MEDSV DEF RBRVS 01/01/2024 261.73 Description: EXC TR-EXT MAL+MARG 2.1-3 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11603 MEDSV DEF RBRVS 02/01/2015 12/31/2023 197.56 Description: EXC TR-EXT MAL+MARG 2.1-3 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11604 MEDSV DEF RBRVS 01/01/2024 291.08 Description: EXC TR-EXT MAL+MARG 3.1-4 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11604 MEDSV DEF RBRVS 02/01/2015 12/31/2023 220.26 Description: EXC TR-EXT MAL+MARG 3.1-4 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11606 MEDSV DEF RBRVS 01/01/2024 416.55 Description: EXC TR-EXT MAL+MARG >4 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11606 MEDSV DEF RBRVS 02/01/2015 12/31/2023 315.71 Description: EXC TR-EXT MAL+MARG >4 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 1160F NOCOV DEF SYSMAN Description: RVW MEDS BY RX/DR IN RCRD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 11620 MEDSV DEF RBRVS 01/01/2024 186.00 Description: EXC H-F-NK-SP MAL+MARG 0.5/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11620 MEDSV DEF RBRVS 02/01/2015 12/31/2023 136.13 Description: EXC H-F-NK-SP MAL+MARG 0.5/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 96 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 11621 MEDSV DEF RBRVS 01/01/2024 215.44 Description: EXC S/N/H/F/G MAL+MRG 0.6-1 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11621 MEDSV DEF RBRVS 02/01/2015 12/31/2023 160.42 Description: EXC S/N/H/F/G MAL+MRG 0.6-1 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11622 MEDSV DEF RBRVS 01/01/2024 237.28 Description: EXC S/N/H/F/G MAL+MRG 1.1-2 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11622 MEDSV DEF RBRVS 02/01/2015 12/31/2023 179.03 Description: EXC S/N/H/F/G MAL+MRG 1.1-2 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11623 MEDSV DEF RBRVS 01/01/2024 277.61 Description: EXC S/N/H/F/G MAL+MRG 2.1-3 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11623 MEDSV DEF RBRVS 02/01/2015 12/31/2023 210.72 Description: EXC S/N/H/F/G MAL+MRG 2.1-3 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11624 MEDSV DEF RBRVS 01/01/2024 315.49 Description: EXC S/N/H/F/G MAL+MRG 3.1-4 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11624 MEDSV DEF RBRVS 02/01/2015 12/31/2023 237.72 Description: EXC S/N/H/F/G MAL+MRG 3.1-4 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11626 MEDSV DEF RBRVS 01/01/2024 379.14 Description: EXC S/N/H/F/G MAL+MRG >4 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11626 MEDSV DEF RBRVS 02/01/2015 12/31/2023 287.44 Description: EXC S/N/H/F/G MAL+MRG >4 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11640 MEDSV DEF RBRVS 01/01/2024 190.40 Description: EXC F/E/E/N/L MAL+MRG 0.5CM< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11640 MEDSV DEF RBRVS 02/01/2015 12/31/2023 140.16 Description: EXC F/E/E/N/L MAL+MRG 0.5CM< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11641 MEDSV DEF RBRVS 01/01/2024 222.36 Description: EXC F/E/E/N/L MAL+MRG 0.6-1 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11641 MEDSV DEF RBRVS 02/01/2015 12/31/2023 166.39 Description: EXC F/E/E/N/L MAL+MRG 0.6-1 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11642 MEDSV DEF RBRVS 01/01/2024 251.22 Description: EXC F/E/E/N/L MAL+MRG 1.1-2 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11642 MEDSV DEF RBRVS 02/01/2015 12/31/2023 189.71 Description: EXC F/E/E/N/L MAL+MRG 1.1-2 Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 97 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 11643 MEDSV DEF RBRVS 01/01/2024 295.24 Description: EXC F/E/E/N/L MAL+MRG 2.1-3 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11643 MEDSV DEF RBRVS 02/01/2015 12/31/2023 225.33 Description: EXC F/E/E/N/L MAL+MRG 2.1-3 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11644 MEDSV DEF RBRVS 01/01/2024 363.57 Description: EXC F/E/E/N/L MAL+MRG 3.1-4 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11644 MEDSV DEF RBRVS 02/01/2015 12/31/2023 277.95 Description: EXC F/E/E/N/L MAL+MRG 3.1-4 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11646 MEDSV DEF RBRVS 01/01/2024 471.78 Description: EXC F/E/E/N/L MAL+MRG >4 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11646 MEDSV DEF RBRVS 02/01/2015 12/31/2023 364.30 Description: EXC F/E/E/N/L MAL+MRG >4 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 1170F NOCOV DEF SYSMAN Description: FXNL STATUS ASSESSED Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 11719 MEDSV DEF RBRVS 01/01/2024 13.33 Description: TRIM NAIL(S) ANY NUMBER Category: Medical Services CMS Add: 01/01/1998 CMS Term: 11719 MEDSV DEF RBRVS 02/01/2015 12/31/2023 9.93 Description: TRIM NAIL(S) ANY NUMBER Category: Medical Services CMS Add: 01/01/1998 CMS Term: 11720 MEDSV DEF RBRVS 01/01/2019 12/31/2023 22.97 Description: DEBRIDE NAIL 1-5 Category: Medical Services CMS Add: 01/01/1997 CMS Term: 11720 MEDSV DEF RBRVS 01/01/2024 30.63 Description: DEBRIDE NAIL 1-5 Category: Medical Services CMS Add: 01/01/1997 CMS Term: 11721 MEDSV DEF RBRVS 01/01/2019 12/31/2023 32.01 Description: DEBRIDE NAIL 6 OR MORE Category: Medical Services CMS Add: 01/01/1997 CMS Term: 11721 MEDSV DEF RBRVS 01/01/2024 41.79 Description: DEBRIDE NAIL 6 OR MORE Category: Medical Services CMS Add: 01/01/1997 CMS Term: 11730 MEDSV DEF RBRVS 01/01/2024 108.20 0-1 Description: REMOVAL OF NAIL PLATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11730 MEDSV DEF RBRVS 09/01/2019 12/31/2023 70.51 0-1 Description: REMOVAL OF NAIL PLATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11732 MEDSV DEF RBRVS 01/01/2024 31.43 0-10 Description: REMOVE NAIL PLATE ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 98 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 11732 MEDSV DEF RBRVS 02/01/2015 12/31/2023 25.45 0-10 Description: REMOVE NAIL PLATE ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11740 MEDSV DEF RBRVS 01/01/2024 53.31 Description: DRAIN BLOOD FROM UNDER NAIL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11740 MEDSV DEF RBRVS 09/01/2019 12/31/2023 34.96 Description: DRAIN BLOOD FROM UNDER NAIL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11750 MEDSV DEF RBRVS 01/01/2024 150.25 Description: REMOVAL OF NAIL BED Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11750 MEDSV DEF RBRVS 09/01/2019 12/31/2023 159.57 Description: REMOVAL OF NAIL BED Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11755 MEDSV DEF RBRVS 01/01/2024 115.59 Description: BIOPSY NAIL UNIT Category: Medical Services CMS Add: 01/01/1994 CMS Term: 11755 MEDSV DEF RBRVS 09/01/2019 12/31/2023 94.98 Description: BIOPSY NAIL UNIT Category: Medical Services CMS Add: 01/01/1994 CMS Term: 1175F NOCOV DEF SYSMAN Description: FUNCTION STAT ASSESSED RVWD Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 11760 MEDSV DEF RBRVS 01/01/2024 175.30 Description: REPAIR OF NAIL BED Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11760 MEDSV DEF RBRVS 09/01/2019 12/31/2023 163.11 Description: REPAIR OF NAIL BED Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11762 MEDSV DEF RBRVS 01/01/2024 270.40 Description: RECONSTRUCTION OF NAIL BED Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11762 MEDSV DEF RBRVS 09/01/2019 12/31/2023 200.62 Description: RECONSTRUCTION OF NAIL BED Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11765 MEDSV DEF RBRVS 01/01/2024 155.01 Description: EXCISION OF NAIL FOLD TOE Category: Medical Services CMS Add: 01/01/1989 CMS Term: 11765 MEDSV DEF RBRVS 09/01/2019 12/31/2023 117.33 Description: EXCISION OF NAIL FOLD TOE Category: Medical Services CMS Add: 01/01/1989 CMS Term: 11770 MEDSV DEF RBRVS 01/01/2024 330.24 Description: REMOVE PILONIDAL CYST SIMPLE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 11770 MEDSV DEF RBRVS 09/01/2019 12/31/2023 194.42 Description: REMOVE PILONIDAL CYST SIMPLE Category: Medical Services CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 99 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 11771 MEDSV DEF RBRVS 01/01/2024 582.68 Description: REMOVE PILONIDAL CYST EXTEN Category: Medical Services CMS Add: 01/01/1986 CMS Term: 11771 MEDSV DEF RBRVS 09/01/2019 12/31/2023 400.53 Description: REMOVE PILONIDAL CYST EXTEN Category: Medical Services CMS Add: 01/01/1986 CMS Term: 11772 MEDSV DEF RBRVS 01/01/2024 716.75 Description: REMOVE PILONIDAL CYST COMPL Category: Medical Services CMS Add: 01/01/1986 CMS Term: 11772 MEDSV DEF RBRVS 09/01/2019 12/31/2023 486.57 Description: REMOVE PILONIDAL CYST COMPL Category: Medical Services CMS Add: 01/01/1986 CMS Term: 1180F NOCOV DEF SYSMAN Description: THROMBOEMB RISK ASSESSED Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 1181F NOCOV DEF SYSMAN Description: NEUROPSYCHIA SYMPTS ASSESSED Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 1182F NOCOV DEF SYSMAN Description: NEUROPSYCHI SYMPT 1+PRESENT Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 1183F NOCOV DEF SYSMAN Description: NEUROPSYCHIATRIC SYMP ABSENT Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 11900 MEDSV DEF RBRVS 01/01/2024 53.47 0-1 Description: INJECT SKIN LESIONS 7 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11901 MEDSV DEF RBRVS 09/01/2019 12/31/2023 49.07 0-1 Description: INJECT SKIN LESIONS >7 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11920 MEDSV DEF RBRVS 01/01/2019 12/31/2023 120.30 0-1 Description: CORRECT SKIN COLOR 6.0 CM/< Category: Medical Services CMS Add: 01/01/1982 CMS Term: 11920 MEDSV DEF RBRVS 01/01/2024 179.14 0-1 Description: CORRECT SKIN COLOR 6.0 CM/< Category: Medical Services CMS Add: 01/01/1982 CMS Term: 11921 MEDSV DEF RBRVS 01/01/2019 12/31/2023 139.88 Y 0-1 Description: CORRECT SKN COLOR 6.1-20.0CM Category: Medical Services CMS Add: 01/01/1982 CMS Term: 11921 MEDSV DEF RBRVS 01/01/2024 207.80 Y 0-1 Description: CORRECT SKN COLOR 6.1-20.0CM Category: Medical Services CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 100 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 11922 MEDSV DEF RBRVS 01/01/2019 12/31/2023 43.22 Y Description: CORRECT SKIN COLOR EA 20.0CM Category: Medical Services CMS Add: 01/01/1982 CMS Term: 11922 MEDSV DEF RBRVS 01/01/2024 56.49 Y Description: CORRECT SKIN COLOR EA 20.0CM Category: Medical Services CMS Add: 01/01/1982 CMS Term: 11950 NOCOV DEF SYSMAN 0-1 Description: TX CONTOUR DEFECTS 1 CC/< Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 11951 NOCOV DEF SYSMAN 0-1 Description: TX CONTOUR DEFECTS 1.1-5.0CC Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 11952 NOCOV DEF SYSMAN 0-1 Description: TX CONTOUR DEFECTS 5.1-10CC Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 11954 NOCOV DEF SYSMAN 0-1 Description: TX CONTOUR DEFECTS >10.0 CC Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 11960 MEDSV DEF RBRVS 01/01/2024 943.11 Description: INSERT TISSUE EXPANDER(S) Category: Medical Services CMS Add: 01/01/1985 CMS Term: 11960 MEDSV DEF RBRVS 09/01/2019 12/31/2023 666.75 Description: INSERT TISSUE EXPANDER(S) Category: Medical Services CMS Add: 01/01/1985 CMS Term: 11970 MEDSV DEF RBRVS 01/01/2024 522.35 Description: RPLCMT TISS XPNDR PERM IMPLT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 11970 MEDSV DEF RBRVS 09/01/2019 12/31/2023 437.91 Description: RPLCMT TISS XPNDR PERM IMPLT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 11971 MEDSV DEF RBRVS 01/01/2024 512.86 Description: RMVL TIS XPNDR WO INSJ IMPLT Category: Medical Services CMS Add: 01/01/1988 CMS Term: 11971 MEDSV DEF RBRVS 09/01/2019 12/31/2023 331.08 Description: RMVL TIS XPNDR WO INSJ IMPLT Category: Medical Services CMS Add: 01/01/1988 CMS Term: 11976 MEDSV DEF RBRVS 01/01/2019 12/31/2023 102.90 Description: REMOVE CONTRACEPTIVE CAPSULE Category: Medical Services CMS Add: 01/01/1992 CMS Term: 11976 MEDSV DEF RBRVS 01/01/2024 135.06 Description: REMOVE CONTRACEPTIVE CAPSULE Category: Medical Services CMS Add: 01/01/1992 CMS Term: 11980 MEDSV DEF RBRVS 01/01/2024 87.86 Description: IMPLANT HORMONE PELLET(S) Category: Medical Services CMS Add: 01/01/2000 CMS Term: 11980 MEDSV DEF RBRVS 02/01/2015 12/31/2023 73.62 Description: IMPLANT HORMONE PELLET(S) Category: Medical Services CMS Add: 01/01/2000 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 101 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 11981 MEDSV DEF RBRVS 01/01/2024 93.41 Description: INSERTION DRUG DLVR IMPLANT Category: Medical Services CMS Add: 01/01/2002 CMS Term: 11981 MEDSV DEF RBRVS 02/01/2015 12/31/2023 97.07 Description: INSERTION DRUG DLVR IMPLANT Category: Medical Services CMS Add: 01/01/2002 CMS Term: 11982 MEDSV DEF RBRVS 01/01/2024 104.38 Description: REMOVE DRUG IMPLANT DEVICE Category: Medical Services CMS Add: 01/01/2002 CMS Term: 11982 MEDSV DEF RBRVS 02/01/2015 12/31/2023 110.33 Description: REMOVE DRUG IMPLANT DEVICE Category: Medical Services CMS Add: 01/01/2002 CMS Term: 11983 MEDSV DEF RBRVS 01/01/2024 132.25 Description: REMOVE/INSERT DRUG IMPLANT Category: Medical Services CMS Add: 01/01/2002 CMS Term: 11983 MEDSV DEF RBRVS 02/01/2015 12/31/2023 155.30 Description: REMOVE/INSERT DRUG IMPLANT Category: Medical Services CMS Add: 01/01/2002 CMS Term: 12001 MEDSV DEF RBRVS 01/01/2024 87.39 Description: RPR S/N/AX/GEN/TRNK 2.5CM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12001 MEDSV DEF RBRVS 09/01/2019 12/31/2023 63.11 Description: RPR S/N/AX/GEN/TRNK 2.5CM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12002 MEDSV DEF RBRVS 01/01/2024 105.77 Description: RPR S/N/AX/GEN/TRNK2.6-7.5CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12002 MEDSV DEF RBRVS 09/01/2019 12/31/2023 76.71 Description: RPR S/N/AX/GEN/TRNK2.6-7.5CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12004 MEDSV DEF RBRVS 01/01/2024 122.91 Description: RPR S/N/AX/GEN/TRK7.6-12.5CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12004 MEDSV DEF RBRVS 09/01/2019 12/31/2023 90.55 Description: RPR S/N/AX/GEN/TRK7.6-12.5CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12005 MEDSV DEF RBRVS 01/01/2024 164.40 Description: RPR S/N/A/GEN/TRK12.6-20.0CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12005 MEDSV DEF RBRVS 09/01/2019 12/31/2023 117.91 Description: RPR S/N/A/GEN/TRK12.6-20.0CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12006 MEDSV DEF RBRVS 01/01/2024 190.89 Description: RPR S/N/A/GEN/TRK20.1-30.0CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12006 MEDSV DEF RBRVS 09/01/2019 12/31/2023 141.75 Description: RPR S/N/A/GEN/TRK20.1-30.0CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 102 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 12007 MEDSV DEF RBRVS 01/01/2024 215.03 Description: RPR S/N/AX/GEN/TRNK >30.0 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12007 MEDSV DEF RBRVS 09/01/2019 12/31/2023 164.62 Description: RPR S/N/AX/GEN/TRNK >30.0 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 1200F NOCOV DEF SYSMAN Description: SEIZURE TYPE& FREQU DOCD Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 12011 MEDSV DEF RBRVS 01/01/2024 104.62 Description: RPR F/E/E/N/L/M 2.5 CM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12011 MEDSV DEF RBRVS 09/01/2019 12/31/2023 77.05 Description: RPR F/E/E/N/L/M 2.5 CM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12013 MEDSV DEF RBRVS 01/01/2024 109.27 Description: RPR F/E/E/N/L/M 2.6-5.0 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12013 MEDSV DEF RBRVS 09/01/2019 12/31/2023 84.47 Description: RPR F/E/E/N/L/M 2.6-5.0 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12014 MEDSV DEF RBRVS 01/01/2024 133.05 Description: RPR F/E/E/N/L/M 5.1-7.5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12014 MEDSV DEF RBRVS 09/01/2019 12/31/2023 99.82 Description: RPR F/E/E/N/L/M 5.1-7.5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12015 MEDSV DEF RBRVS 01/01/2024 160.27 Description: RPR F/E/E/N/L/M 7.6-12.5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12015 MEDSV DEF RBRVS 09/01/2019 12/31/2023 121.90 Description: RPR F/E/E/N/L/M 7.6-12.5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12016 MEDSV DEF RBRVS 01/01/2024 204.30 Description: RPR FE/E/EN/L/M 12.6-20.0 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12016 MEDSV DEF RBRVS 09/01/2019 12/31/2023 150.86 Description: RPR FE/E/EN/L/M 12.6-20.0 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12017 MEDSV DEF RBRVS 01/01/2024 140.92 Description: RPR FE/E/EN/L/M 20.1-30.0 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12017 MEDSV DEF RBRVS 09/01/2019 12/31/2023 111.95 Description: RPR FE/E/EN/L/M 20.1-30.0 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12018 MEDSV DEF RBRVS 01/01/2024 159.10 Description: RPR F/E/E/N/L/M >30.0 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 103 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 12018 MEDSV DEF RBRVS 09/01/2019 12/31/2023 126.64 Description: RPR F/E/E/N/L/M >30.0 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12020 MEDSV DEF RBRVS 01/01/2024 280.47 Description: TX SUPFC WND DEHSN SMPL CLSR Category: Medical Services CMS Add: 01/01/1985 CMS Term: 12020 MEDSV DEF RBRVS 09/01/2019 12/31/2023 201.71 Description: TX SUPFC WND DEHSN SMPL CLSR Category: Medical Services CMS Add: 01/01/1985 CMS Term: 12021 MEDSV DEF RBRVS 01/01/2024 165.50 Description: TX SUPFC WND DEHSN W/PACKING Category: Medical Services CMS Add: 01/01/1985 CMS Term: 12021 MEDSV DEF RBRVS 09/01/2019 12/31/2023 118.16 Description: TX SUPFC WND DEHSN W/PACKING Category: Medical Services CMS Add: 01/01/1985 CMS Term: 12031 MEDSV DEF RBRVS 01/01/2024 246.84 Description: INTMD RPR S/A/T/EXT 2.5 CM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12031 MEDSV DEF RBRVS 09/01/2019 12/31/2023 165.13 Description: INTMD RPR S/A/T/EXT 2.5 CM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12032 MEDSV DEF RBRVS 01/01/2024 285.17 Description: INTMD RPR S/A/T/EXT 2.6-7.5 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12032 MEDSV DEF RBRVS 09/01/2019 12/31/2023 210.64 Description: INTMD RPR S/A/T/EXT 2.6-7.5 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12034 MEDSV DEF RBRVS 01/01/2024 313.30 Description: INTMD RPR S/TR/EXT 7.6-12.5 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12034 MEDSV DEF RBRVS 09/01/2019 12/31/2023 217.78 Description: INTMD RPR S/TR/EXT 7.6-12.5 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12035 MEDSV DEF RBRVS 01/01/2024 362.60 Description: INTMD RPR S/A/T/EXT 12.6-20 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12035 MEDSV DEF RBRVS 09/01/2019 12/31/2023 269.75 Description: INTMD RPR S/A/T/EXT 12.6-20 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12036 MEDSV DEF RBRVS 01/01/2024 401.36 Description: INTMD RPR S/A/T/EXT 20.1-30 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12036 MEDSV DEF RBRVS 09/01/2019 12/31/2023 297.54 Description: INTMD RPR S/A/T/EXT 20.1-30 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12037 MEDSV DEF RBRVS 01/01/2024 449.33 Description: INTMD RPR S/TR/EXT >30.0 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 104 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 12037 MEDSV DEF RBRVS 09/01/2019 12/31/2023 335.08 Description: INTMD RPR S/TR/EXT >30.0 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12041 MEDSV DEF RBRVS 01/01/2024 247.92 Description: INTMD RPR N-HF/GENIT 2.5CM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12041 MEDSV DEF RBRVS 09/01/2019 12/31/2023 168.56 Description: INTMD RPR N-HF/GENIT 2.5CM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12042 MEDSV DEF RBRVS 01/01/2024 291.25 Description: INTMD RPR N-HF/GENIT2.6-7.5 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12042 MEDSV DEF RBRVS 09/01/2019 12/31/2023 201.54 Description: INTMD RPR N-HF/GENIT2.6-7.5 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12044 MEDSV DEF RBRVS 01/01/2024 357.21 Description: INTMD RPR N-HF/GENIT7.6-12.5 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12044 MEDSV DEF RBRVS 09/01/2019 12/31/2023 251.27 Description: INTMD RPR N-HF/GENIT7.6-12.5 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12045 MEDSV DEF RBRVS 01/01/2024 386.68 Description: INTMD RPR N-HF/GENIT12.6-20 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12045 MEDSV DEF RBRVS 09/01/2019 12/31/2023 281.51 Description: INTMD RPR N-HF/GENIT12.6-20 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12046 MEDSV DEF RBRVS 01/01/2024 461.01 Description: INTMD RPR N-HF/GENIT20.1-30 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12046 MEDSV DEF RBRVS 09/01/2019 12/31/2023 334.10 Description: INTMD RPR N-HF/GENIT20.1-30 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12047 MEDSV DEF RBRVS 01/01/2024 504.91 Description: INTMD RPR N-HF/GENIT >30.0CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12047 MEDSV DEF RBRVS 09/01/2019 12/31/2023 367.42 Description: INTMD RPR N-HF/GENIT >30.0CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12051 MEDSV DEF RBRVS 01/01/2024 266.24 Description: INTMD RPR FACE/MM 2.5 CM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12051 MEDSV DEF RBRVS 09/01/2019 12/31/2023 180.43 Description: INTMD RPR FACE/MM 2.5 CM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12052 MEDSV DEF RBRVS 01/01/2024 296.76 Description: INTMD RPR FACE/MM 2.6-5.0 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 105 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 12052 MEDSV DEF RBRVS 09/01/2019 12/31/2023 205.59 Description: INTMD RPR FACE/MM 2.6-5.0 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12053 MEDSV DEF RBRVS 01/01/2024 341.85 Description: INTMD RPR FACE/MM 5.1-7.5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12053 MEDSV DEF RBRVS 09/01/2019 12/31/2023 241.48 Description: INTMD RPR FACE/MM 5.1-7.5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12054 MEDSV DEF RBRVS 01/01/2024 360.38 Description: INTMD RPR FACE/MM 7.6-12.5CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12054 MEDSV DEF RBRVS 09/01/2019 12/31/2023 257.86 Description: INTMD RPR FACE/MM 7.6-12.5CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12055 MEDSV DEF RBRVS 01/01/2024 473.48 Description: INTMD RPR FACE/MM 12.6-20 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12055 MEDSV DEF RBRVS 09/01/2019 12/31/2023 334.60 Description: INTMD RPR FACE/MM 12.6-20 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12056 MEDSV DEF RBRVS 01/01/2024 540.96 Description: INTMD RPR FACE/MM 20.1-30.0 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12056 MEDSV DEF RBRVS 09/01/2019 12/31/2023 387.06 Description: INTMD RPR FACE/MM 20.1-30.0 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12057 MEDSV DEF RBRVS 01/01/2024 568.63 Description: INTMD RPR FACE/MM >30.0 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12057 MEDSV DEF RBRVS 09/01/2019 12/31/2023 396.70 Description: INTMD RPR FACE/MM >30.0 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 1205F NOCOV DEF SYSMAN Description: EPI ETIOL SYND RVWD AND DOCD Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 1220F NOCOV DEF SYSMAN Description: PT SCREENED FOR DEPRESSION Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 13100 MEDSV DEF RBRVS 01/01/2024 320.32 Description: CMPLX RPR TRUNK 1.1-2.5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 13100 MEDSV DEF RBRVS 09/01/2019 12/31/2023 233.45 Description: CMPLX RPR TRUNK 1.1-2.5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 13101 MEDSV DEF RBRVS 01/01/2024 373.41 Description: CMPLX RPR TRUNK 2.6-7.5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 106 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 13101 MEDSV DEF RBRVS 09/01/2019 12/31/2023 276.03 Description: CMPLX RPR TRUNK 2.6-7.5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 13102 MEDSV DEF RBRVS 01/01/2024 108.98 Description: CMPLX RPR TRUNK ADDL 5CM/< Category: Medical Services CMS Add: 01/01/2000 CMS Term: 13102 MEDSV DEF RBRVS 09/01/2019 12/31/2023 85.50 Description: CMPLX RPR TRUNK ADDL 5CM/< Category: Medical Services CMS Add: 01/01/2000 CMS Term: 13120 MEDSV DEF RBRVS 01/01/2024 334.15 Description: CMPLX RPR S/A/L 1.1-2.5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 13120 MEDSV DEF RBRVS 09/01/2019 12/31/2023 244.33 Description: CMPLX RPR S/A/L 1.1-2.5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 13121 MEDSV DEF RBRVS 01/01/2024 400.10 Description: CMPLX RPR S/A/L 2.6-7.5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 13121 MEDSV DEF RBRVS 09/01/2019 12/31/2023 298.13 Description: CMPLX RPR S/A/L 2.6-7.5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 13122 MEDSV DEF RBRVS 01/01/2024 119.02 Description: CMPLX RPR S/A/L ADDL 5 CM/> Category: Medical Services CMS Add: 01/01/2000 CMS Term: 13122 MEDSV DEF RBRVS 09/01/2019 12/31/2023 93.85 Description: CMPLX RPR S/A/L ADDL 5 CM/> Category: Medical Services CMS Add: 01/01/2000 CMS Term: 13131 MEDSV DEF RBRVS 01/01/2024 365.02 Description: CMPLX RPR F/C/C/M/N/AX/G/H/F Category: Medical Services CMS Add: 01/01/1984 CMS Term: 13131 MEDSV DEF RBRVS 09/01/2019 12/31/2023 269.57 Description: CMPLX RPR F/C/C/M/N/AX/G/H/F Category: Medical Services CMS Add: 01/01/1984 CMS Term: 13132 MEDSV DEF RBRVS 01/01/2024 443.43 Description: CMPLX RPR F/C/C/M/N/AX/G/H/F Category: Medical Services CMS Add: 01/01/1984 CMS Term: 13132 MEDSV DEF RBRVS 09/01/2019 12/31/2023 333.13 Description: CMPLX RPR F/C/C/M/N/AX/G/H/F Category: Medical Services CMS Add: 01/01/1984 CMS Term: 13133 MEDSV DEF RBRVS 01/01/2024 157.90 Description: CMPLX RPR F/C/C/M/N/AX/G/H/F Category: Medical Services CMS Add: 01/01/2000 CMS Term: 13133 MEDSV DEF RBRVS 09/01/2019 12/31/2023 125.97 Description: CMPLX RPR F/C/C/M/N/AX/G/H/F Category: Medical Services CMS Add: 01/01/2000 CMS Term: 13151 MEDSV DEF RBRVS 01/01/2024 398.10 Description: CMPLX RPR E/N/E/L 1.1-2.5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 107 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 13151 MEDSV DEF RBRVS 09/01/2019 12/31/2023 296.04 Description: CMPLX RPR E/N/E/L 1.1-2.5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 13152 MEDSV DEF RBRVS 01/01/2024 467.10 Description: CMPLX RPR E/N/E/L 2.6-7.5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 13152 MEDSV DEF RBRVS 09/01/2019 12/31/2023 355.11 Description: CMPLX RPR E/N/E/L 2.6-7.5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 13153 MEDSV DEF RBRVS 01/01/2024 173.50 Description: CMPLX RPR E/N/E/L ADDL 5CM/< Category: Medical Services CMS Add: 01/01/2000 CMS Term: 13153 MEDSV DEF RBRVS 09/01/2019 12/31/2023 137.27 Description: CMPLX RPR E/N/E/L ADDL 5CM/< Category: Medical Services CMS Add: 01/01/2000 CMS Term: 13160 MEDSV DEF RBRVS 01/01/2024 739.22 Description: SEC CLSR SURG WND/DEHSN XTN Category: Medical Services CMS Add: 01/01/1985 CMS Term: 13160 MEDSV DEF RBRVS 09/01/2019 12/31/2023 580.63 Description: SEC CLSR SURG WND/DEHSN XTN Category: Medical Services CMS Add: 01/01/1985 CMS Term: 14000 MEDSV DEF RBRVS 01/01/2024 591.37 Description: TIS TRNFR TRUNK 10 SQ CM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 14000 MEDSV DEF RBRVS 09/01/2019 12/31/2023 437.45 Description: TIS TRNFR TRUNK 10 SQ CM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 14001 MEDSV DEF RBRVS 01/01/2024 752.70 Description: TIS TRNFR TRUNK 10.1-30SQCM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 14001 MEDSV DEF RBRVS 09/01/2019 12/31/2023 561.90 Description: TIS TRNFR TRUNK 10.1-30SQCM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 1400F NOCOV DEF SYSMAN Description: PRKNS DIAG RVIEWED Category: Non Covered Services CMS Add: 10/01/2010 CMS Term: 14020 MEDSV DEF RBRVS 01/01/2024 656.54 Description: TIS TRNFR S/A/L 10 SQ CM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 14020 MEDSV DEF RBRVS 09/01/2019 12/31/2023 490.84 Description: TIS TRNFR S/A/L 10 SQ CM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 14021 MEDSV DEF RBRVS 01/01/2024 809.99 Description: TIS TRNFR S/A/L 10.1-30 SQCM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 14021 MEDSV DEF RBRVS 09/01/2019 12/31/2023 613.82 Description: TIS TRNFR S/A/L 10.1-30 SQCM Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 108 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 14040 MEDSV DEF RBRVS 01/01/2024 711.08 Description: TIS TRNFR F/C/C/M/N/A/G/H/F Category: Medical Services CMS Add: 01/01/1984 CMS Term: 14040 MEDSV DEF RBRVS 09/01/2019 12/31/2023 538.73 Description: TIS TRNFR F/C/C/M/N/A/G/H/F Category: Medical Services CMS Add: 01/01/1984 CMS Term: 14041 MEDSV DEF RBRVS 01/01/2024 864.43 Description: TIS TRNFR F/C/C/M/N/A/G/H/F Category: Medical Services CMS Add: 01/01/1984 CMS Term: 14041 MEDSV DEF RBRVS 09/01/2019 12/31/2023 665.12 Description: TIS TRNFR F/C/C/M/N/A/G/H/F Category: Medical Services CMS Add: 01/01/1984 CMS Term: 14060 MEDSV DEF RBRVS 01/01/2024 720.40 Description: TIS TRNFR E/N/E/L 10 SQ CM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 14060 MEDSV DEF RBRVS 09/01/2019 12/31/2023 550.62 Description: TIS TRNFR E/N/E/L 10 SQ CM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 14061 MEDSV DEF RBRVS 01/01/2024 931.73 Description: TIS TRNFR E/N/E/L10.1-30SQCM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 14061 MEDSV DEF RBRVS 09/01/2019 12/31/2023 714.78 Description: TIS TRNFR E/N/E/L10.1-30SQCM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 14301 MEDSV DEF RBRVS 01/01/2024 1011.13 Description: TIS TRNFR ANY 30.1-60 SQ CM Category: Medical Services CMS Add: 01/01/2010 CMS Term: 14301 MEDSV DEF RBRVS 02/01/2015 12/31/2023 761.66 Description: TIS TRNFR ANY 30.1-60 SQ CM Category: Medical Services CMS Add: 01/01/2010 CMS Term: 14302 MEDSV DEF RBRVS 01/01/2019 12/31/2023 160.66 Description: TIS TRNFR ADDL 30 SQ CM Category: Medical Services CMS Add: 01/01/2010 CMS Term: 14302 MEDSV DEF RBRVS 01/01/2024 199.07 Description: TIS TRNFR ADDL 30 SQ CM Category: Medical Services CMS Add: 01/01/2010 CMS Term: 14350 MEDSV DEF RBRVS 01/01/2024 637.44 Description: FILLETED FINGER/TOE FLAP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 14350 MEDSV DEF RBRVS 09/01/2019 12/31/2023 513.56 Description: FILLETED FINGER/TOE FLAP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 1450F NOCOV DEF SYSMAN Description: SYMPTOMS IMPROVED/CONSIST Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 1451F NOCOV DEF SYSMAN Description: SYMPT SHOW CLIN IMPORT DROP Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 109 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 1460F NOCOV DEF SYSMAN Description: QUAL CARD DIAG PRIOR 12 MONS Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 1461F NOCOV DEF SYSMAN Description: NO QUAL CARD DIAG PRIOR12MON Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 1490F NOCOV DEF SYSMAN Description: DEM SEVERITY CLASSIFIED MILD Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 1491F NOCOV DEF SYSMAN Description: DEM SEVERITY CLASSIFIED MOD Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 1493F NOCOV DEF SYSMAN Description: DEM SEVERITY CLASS SEVERE Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 1494F NOCOV DEF SYSMAN Description: COGNIT ASSESSED AND REVIEWED Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 15002 MEDSV DEF RBRVS 01/01/2024 320.92 Description: WOUND PREP TRK/ARM/LEG Category: Medical Services CMS Add: 01/01/2007 CMS Term: 15002 MEDSV DEF RBRVS 02/01/2015 12/31/2023 245.05 Description: WOUND PREP TRK/ARM/LEG Category: Medical Services CMS Add: 01/01/2007 CMS Term: 15003 MEDSV DEF RBRVS 01/01/2024 63.97 Description: WOUND PREP ADDL 100 CM Category: Medical Services CMS Add: 01/01/2007 CMS Term: 15003 MEDSV DEF RBRVS 02/01/2015 12/31/2023 53.45 Description: WOUND PREP ADDL 100 CM Category: Medical Services CMS Add: 01/01/2007 CMS Term: 15004 MEDSV DEF RBRVS 01/01/2024 368.64 Description: WOUND PREP F/N/HF/G Category: Medical Services CMS Add: 01/01/2007 CMS Term: 15004 MEDSV DEF RBRVS 02/01/2015 12/31/2023 285.72 Description: WOUND PREP F/N/HF/G Category: Medical Services CMS Add: 01/01/2007 CMS Term: 15005 MEDSV DEF RBRVS 01/01/2024 107.37 Description: WND PREP F/N/HF/G ADDL CM Category: Medical Services CMS Add: 01/01/2007 CMS Term: 15005 MEDSV DEF RBRVS 02/01/2015 12/31/2023 88.82 Description: WND PREP F/N/HF/G ADDL CM Category: Medical Services CMS Add: 01/01/2007 CMS Term: 1500F NOCOV DEF SYSMAN Description: SYMPTOM&SIGN SYMM POLYNEURO Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 1501F NOCOV DEF SYSMAN Description: NOT INITIAL EVAL FOR COND Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 110 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 1502F NOCOV DEF SYSMAN Description: PT QUERIED PAIN FXN W/ INSTR Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 1503F NOCOV DEF SYSMAN Description: PT QUERIED SYMP RESP INSUFF Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 15040 MEDSV DEF RBRVS 01/01/2024 244.76 Description: HARVEST CULTURED SKIN GRAFT Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15040 MEDSV DEF RBRVS 02/01/2015 12/31/2023 180.40 Description: HARVEST CULTURED SKIN GRAFT Category: Medical Services CMS Add: 01/01/2006 CMS Term: 1504F NOCOV DEF SYSMAN Description: PT HAS RESP INSUFFICIENCY Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 15050 MEDSV DEF RBRVS 01/01/2024 552.45 Description: PINCH GRAFT UP TO 2 CM DIAM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15050 MEDSV DEF RBRVS 09/01/2019 12/31/2023 400.18 Description: PINCH GRAFT UP TO 2 CM DIAM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 1505F NOCOV DEF SYSMAN Description: PT HAS NO RESP INSUFFICIENCY Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 15100 MEDSV DEF RBRVS 01/01/2024 806.60 Description: SKIN SPLT GRFT TRNK/ARM/LEG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15100 MEDSV DEF RBRVS 09/01/2019 12/31/2023 607.60 Description: SKIN SPLT GRFT TRNK/ARM/LEG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15101 MEDSV DEF RBRVS 01/01/2024 172.44 Description: SKIN SPLT GRFT T/A/L ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15101 MEDSV DEF RBRVS 02/01/2015 12/31/2023 130.44 Description: SKIN SPLT GRFT T/A/L ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15110 MEDSV DEF RBRVS 01/01/2024 773.79 Description: EPIDRM AUTOGRFT TRNK/ARM/LEG Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15110 MEDSV DEF RBRVS 02/01/2015 12/31/2023 613.39 Description: EPIDRM AUTOGRFT TRNK/ARM/LEG Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15111 MEDSV DEF RBRVS 01/01/2024 103.25 Description: EPIDRM AUTOGRFT T/A/L ADD-ON Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15111 MEDSV DEF RBRVS 02/01/2015 12/31/2023 81.17 Description: EPIDRM AUTOGRFT T/A/L ADD-ON Category: Medical Services CMS Add: 01/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 111 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 15115 MEDSV DEF RBRVS 01/01/2024 749.65 Description: EPIDRM A-GRFT FACE/NCK/HF/G Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15115 MEDSV DEF RBRVS 02/01/2015 12/31/2023 619.41 Description: EPIDRM A-GRFT FACE/NCK/HF/G Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15116 MEDSV DEF RBRVS 01/01/2024 141.73 Description: EPIDRM A-GRFT F/N/HF/G ADDL Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15116 MEDSV DEF RBRVS 02/01/2015 12/31/2023 107.88 Description: EPIDRM A-GRFT F/N/HF/G ADDL Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15120 MEDSV DEF RBRVS 01/01/2024 788.50 Description: SKN SPLT A-GRFT FAC/NCK/HF/G Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15120 MEDSV DEF RBRVS 09/01/2019 12/31/2023 605.89 Description: SKN SPLT A-GRFT FAC/NCK/HF/G Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15121 MEDSV DEF RBRVS 01/01/2019 12/31/2023 145.97 Description: SKN SPLT A-GRFT F/N/HF/G ADD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15121 MEDSV DEF RBRVS 01/01/2024 193.68 Description: SKN SPLT A-GRFT F/N/HF/G ADD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15130 MEDSV DEF RBRVS 01/01/2024 671.89 Description: DERM AUTOGRAFT TRNK/ARM/LEG Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15130 MEDSV DEF RBRVS 02/01/2015 12/31/2023 479.93 Description: DERM AUTOGRAFT TRNK/ARM/LEG Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15131 MEDSV DEF RBRVS 01/01/2024 90.06 Description: DERM AUTOGRAFT T/A/L ADD-ON Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15131 MEDSV DEF RBRVS 02/01/2015 12/31/2023 72.51 Description: DERM AUTOGRAFT T/A/L ADD-ON Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15135 MEDSV DEF RBRVS 01/01/2024 822.20 Description: DERM AUTOGRAFT FACE/NCK/HF/G Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15135 MEDSV DEF RBRVS 02/01/2015 12/31/2023 609.47 Description: DERM AUTOGRAFT FACE/NCK/HF/G Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15136 MEDSV DEF RBRVS 01/01/2024 88.83 Description: DERM AUTOGRAFT F/N/HF/G ADD Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15136 MEDSV DEF RBRVS 02/01/2015 12/31/2023 67.47 Description: DERM AUTOGRAFT F/N/HF/G ADD Category: Medical Services CMS Add: 01/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 112 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 15150 MEDSV DEF RBRVS 01/01/2024 647.30 Description: CULT SKIN GRFT T/ARM/LEG Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15150 MEDSV DEF RBRVS 02/01/2015 12/31/2023 488.04 Description: CULT SKIN GRFT T/ARM/LEG Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15151 MEDSV DEF RBRVS 01/01/2024 107.47 Description: CULT SKIN GRFT T/A/L ADDL Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15151 MEDSV DEF RBRVS 02/01/2015 12/31/2023 84.62 Description: CULT SKIN GRFT T/A/L ADDL Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15152 MEDSV DEF RBRVS 01/01/2024 138.00 Description: CULT SKIN GRAFT T/A/L +% Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15152 MEDSV DEF RBRVS 02/01/2015 12/31/2023 108.13 Description: CULT SKIN GRAFT T/A/L +% Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15155 MEDSV DEF RBRVS 01/01/2024 740.29 Description: CULT SKIN GRAFT F/N/HF/G Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15155 MEDSV DEF RBRVS 02/01/2015 12/31/2023 508.43 Description: CULT SKIN GRAFT F/N/HF/G Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15156 MEDSV DEF RBRVS 01/01/2024 144.43 Description: CULT SKIN GRFT F/N/HFG ADD Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15156 MEDSV DEF RBRVS 02/01/2015 12/31/2023 114.35 Description: CULT SKIN GRFT F/N/HFG ADD Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15157 MEDSV DEF RBRVS 01/01/2024 160.97 Description: CULT EPIDERM GRFT F/N/HFG +% Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15157 MEDSV DEF RBRVS 02/01/2015 12/31/2023 119.99 Description: CULT EPIDERM GRFT F/N/HFG +% Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15200 MEDSV DEF RBRVS 01/01/2024 779.29 Y Description: FTH GRF FR TRNK 20 SQ CM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15200 MEDSV DEF RBRVS 09/01/2019 12/31/2023 587.03 Y Description: FTH GRF FR TRNK 20 SQ CM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15201 MEDSV DEF RBRVS 01/01/2024 130.87 Description: FTH GRF FR TRNK EACH ADDL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15201 MEDSV DEF RBRVS 02/01/2015 12/31/2023 104.50 Description: FTH GRF FR TRNK EACH ADDL Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 113 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 15220 MEDSV DEF RBRVS 01/01/2024 718.67 Description: FTH GRF FR S/A/L 20 SQ CM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15220 MEDSV DEF RBRVS 09/01/2019 12/31/2023 543.52 Description: FTH GRF FR S/A/L 20 SQ CM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15221 MEDSV DEF RBRVS 01/01/2024 121.03 Description: FTH GRF FR S/A/L EACH ADDL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15221 MEDSV DEF RBRVS 02/01/2015 12/31/2023 96.30 Description: FTH GRF FR S/A/L EACH ADDL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15240 MEDSV DEF RBRVS 01/01/2024 868.61 Description: FTH GR FR F/C/C/M/N/AX/G/H/F Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15240 MEDSV DEF RBRVS 09/01/2019 12/31/2023 659.61 Description: FTH GR FR F/C/C/M/N/AX/G/H/F Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15241 MEDSV DEF RBRVS 01/01/2024 161.55 Description: FTH GR F/C/C/M/N/AX/G/H/F EA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15241 MEDSV DEF RBRVS 02/01/2015 12/31/2023 130.81 Description: FTH GR F/C/C/M/N/AX/G/H/F EA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15260 MEDSV DEF RBRVS 01/01/2024 936.51 Description: FTH GRF FR N/E/E/L 20 SQCM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15260 MEDSV DEF RBRVS 09/01/2019 12/31/2023 716.69 Description: FTH GRF FR N/E/E/L 20 SQCM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15261 MEDSV DEF RBRVS 01/01/2024 192.31 Description: FTH GRF FR N/E/E/L EACH ADDL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15261 MEDSV DEF RBRVS 02/01/2015 12/31/2023 152.64 Description: FTH GRF FR N/E/E/L EACH ADDL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15271 MEDSV DEF RBRVS 01/01/2024 143.28 Description: SKIN SUB GRAFT TRNK/ARM/LEG Category: Medical Services CMS Add: 01/01/2012 CMS Term: 15271 MEDSV DEF RBRVS 02/01/2015 12/31/2023 100.25 Description: SKIN SUB GRAFT TRNK/ARM/LEG Category: Medical Services CMS Add: 01/01/2012 CMS Term: 15272 MEDSV DEF RBRVS 01/01/2024 22.63 Description: SKIN SUB GRAFT T/A/L ADD-ON Category: Medical Services CMS Add: 01/01/2012 CMS Term: 15272 MEDSV DEF RBRVS 02/01/2015 12/31/2023 18.94 Description: SKIN SUB GRAFT T/A/L ADD-ON Category: Medical Services CMS Add: 01/01/2012 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 114 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 15273 MEDSV DEF RBRVS 01/01/2024 288.67 Description: SKIN SUB GRFT T/ARM/LG CHILD Category: Medical Services CMS Add: 01/01/2012 CMS Term: 15273 MEDSV DEF RBRVS 02/01/2015 12/31/2023 209.31 Description: SKIN SUB GRFT T/ARM/LG CHILD Category: Medical Services CMS Add: 01/01/2012 CMS Term: 15274 MEDSV DEF RBRVS 01/01/2024 76.31 Description: SKN SUB GRFT T/A/L CHILD ADD Category: Medical Services CMS Add: 01/01/2012 CMS Term: 15274 MEDSV DEF RBRVS 02/01/2015 12/31/2023 49.16 Description: SKN SUB GRFT T/A/L CHILD ADD Category: Medical Services CMS Add: 01/01/2012 CMS Term: 15275 MEDSV DEF RBRVS 01/01/2024 149.04 Description: SKIN SUB GRAFT FACE/NK/HF/G Category: Medical Services CMS Add: 01/01/2012 CMS Term: 15275 MEDSV DEF RBRVS 02/01/2015 12/31/2023 108.37 Description: SKIN SUB GRAFT FACE/NK/HF/G Category: Medical Services CMS Add: 01/01/2012 CMS Term: 15276 MEDSV DEF RBRVS 01/01/2024 30.42 Description: SKIN SUB GRAFT F/N/HF/G ADDL Category: Medical Services CMS Add: 01/01/2012 CMS Term: 15276 MEDSV DEF RBRVS 02/01/2015 12/31/2023 24.58 Description: SKIN SUB GRAFT F/N/HF/G ADDL Category: Medical Services CMS Add: 01/01/2012 CMS Term: 15277 MEDSV DEF RBRVS 01/01/2024 320.63 Description: SKN SUB GRFT F/N/HF/G CHILD Category: Medical Services CMS Add: 01/01/2012 CMS Term: 15277 MEDSV DEF RBRVS 02/01/2015 12/31/2023 224.97 Description: SKN SUB GRFT F/N/HF/G CHILD Category: Medical Services CMS Add: 01/01/2012 CMS Term: 15278 MEDSV DEF RBRVS 01/01/2024 88.50 Description: SKN SUB GRFT F/N/HF/G CH ADD Category: Medical Services CMS Add: 01/01/2012 CMS Term: 15278 MEDSV DEF RBRVS 02/01/2015 12/31/2023 58.82 Description: SKN SUB GRFT F/N/HF/G CH ADD Category: Medical Services CMS Add: 01/01/2012 CMS Term: 15570 MEDSV DEF RBRVS 01/01/2024 843.08 Description: SKIN PEDICLE FLAP TRUNK Category: Medical Services CMS Add: 01/01/1992 CMS Term: 15570 MEDSV DEF RBRVS 09/01/2019 12/31/2023 646.65 Description: SKIN PEDICLE FLAP TRUNK Category: Medical Services CMS Add: 01/01/1992 CMS Term: 15572 MEDSV DEF RBRVS 01/01/2024 820.12 Description: SKIN PEDICLE FLAP ARMS/LEGS Category: Medical Services CMS Add: 01/01/1992 CMS Term: 15572 MEDSV DEF RBRVS 09/01/2019 12/31/2023 627.63 Description: SKIN PEDICLE FLAP ARMS/LEGS Category: Medical Services CMS Add: 01/01/1992 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 115 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 15574 MEDSV DEF RBRVS 01/01/2024 819.62 Description: PEDCLE FH/CH/CH/M/N/AX/G/H/F Category: Medical Services CMS Add: 01/01/1992 CMS Term: 15574 MEDSV DEF RBRVS 09/01/2019 12/31/2023 649.65 Description: PEDCLE FH/CH/CH/M/N/AX/G/H/F Category: Medical Services CMS Add: 01/01/1992 CMS Term: 15576 MEDSV DEF RBRVS 01/01/2024 733.48 Description: PEDICLE E/N/E/L/NTRORAL Category: Medical Services CMS Add: 01/01/1992 CMS Term: 15576 MEDSV DEF RBRVS 09/01/2019 12/31/2023 575.27 Description: PEDICLE E/N/E/L/NTRORAL Category: Medical Services CMS Add: 01/01/1992 CMS Term: 15600 MEDSV DEF RBRVS 01/01/2024 315.01 Description: DELAY FLAP TRUNK Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15600 MEDSV DEF RBRVS 09/01/2019 12/31/2023 224.19 Description: DELAY FLAP TRUNK Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15610 MEDSV DEF RBRVS 01/01/2024 343.30 Description: DELAY FLAP ARMS/LEGS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15610 MEDSV DEF RBRVS 09/01/2019 12/31/2023 248.21 Description: DELAY FLAP ARMS/LEGS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15620 MEDSV DEF RBRVS 01/01/2024 417.96 Description: DELAY FLAP F/C/C/N/AX/G/H/F Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15620 MEDSV DEF RBRVS 09/01/2019 12/31/2023 309.75 Description: DELAY FLAP F/C/C/N/AX/G/H/F Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15630 MEDSV DEF RBRVS 01/01/2024 432.36 Description: DELAY FLAP EYE/NOS/EAR/LIP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15630 MEDSV DEF RBRVS 09/01/2019 12/31/2023 323.24 Description: DELAY FLAP EYE/NOS/EAR/LIP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15650 MEDSV DEF RBRVS 01/01/2024 503.79 Description: TRANSFER SKIN PEDICLE FLAP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15650 MEDSV DEF RBRVS 09/01/2019 12/31/2023 357.55 Description: TRANSFER SKIN PEDICLE FLAP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15730 MEDSV DEF RBRVS 01/01/2018 12/31/2023 1109.17 Description: MDFC FLAP W/PRSRV VASC PEDCL Category: Medical Services CMS Add: 01/01/2018 CMS Term: 15730 MEDSV DEF RBRVS 01/01/2024 1338.15 Description: MDFC FLAP W/PRSRV VASC PEDCL Category: Medical Services CMS Add: 01/01/2018 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 116 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 15731 MEDSV DEF RBRVS 01/01/2024 1050.41 Description: FOREHEAD FLAP W/VASC PEDICLE Category: Medical Services CMS Add: 01/01/2007 CMS Term: 15731 MEDSV DEF RBRVS 02/01/2015 12/31/2023 808.31 Description: FOREHEAD FLAP W/VASC PEDICLE Category: Medical Services CMS Add: 01/01/2007 CMS Term: 15733 MEDSV DEF RBRVS 01/01/2018 12/31/2023 762.56 Description: MUSC MYOQ/FSCQ FLP H&N PEDCL Category: Medical Services CMS Add: 01/01/2018 CMS Term: 15733 MEDSV DEF RBRVS 01/01/2024 959.63 Description: MUSC MYOQ/FSCQ FLP H&N PEDCL Category: Medical Services CMS Add: 01/01/2018 CMS Term: 15734 MEDSV DEF RBRVS 01/01/2024 1380.12 Description: MUSCLE-SKIN GRAFT TRUNK Category: Medical Services CMS Add: 01/01/1990 CMS Term: 15734 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1066.86 Description: MUSCLE-SKIN GRAFT TRUNK Category: Medical Services CMS Add: 01/01/1990 CMS Term: 15736 MEDSV DEF RBRVS 01/01/2024 1124.46 Description: MUSCLE-SKIN GRAFT ARM Category: Medical Services CMS Add: 01/01/1990 CMS Term: 15736 MEDSV DEF RBRVS 09/01/2019 12/31/2023 939.90 Description: MUSCLE-SKIN GRAFT ARM Category: Medical Services CMS Add: 01/01/1990 CMS Term: 15738 MEDSV DEF RBRVS 01/01/2024 1173.62 Description: MUSCLE-SKIN GRAFT LEG Category: Medical Services CMS Add: 01/01/1990 CMS Term: 15738 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1003.46 Description: MUSCLE-SKIN GRAFT LEG Category: Medical Services CMS Add: 01/01/1990 CMS Term: 15740 MEDSV DEF RBRVS 01/01/2024 943.90 Description: ISLAND PEDICLE FLAP GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15740 MEDSV DEF RBRVS 09/01/2019 12/31/2023 720.74 Description: ISLAND PEDICLE FLAP GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15750 MEDSV DEF RBRVS 01/01/2024 856.60 Description: NEUROVASCULAR PEDICLE FLAP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15750 MEDSV DEF RBRVS 09/01/2019 12/31/2023 657.12 Description: NEUROVASCULAR PEDICLE FLAP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15756 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1692.40 Description: FREE MYO/SKIN FLAP MICROVASC Category: Medical Services CMS Add: 01/01/1997 CMS Term: 15756 MEDSV DEF RBRVS 01/01/2024 2127.84 Description: FREE MYO/SKIN FLAP MICROVASC Category: Medical Services CMS Add: 01/01/1997 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 117 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 15757 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1674.26 Description: FREE SKIN FLAP MICROVASC Category: Medical Services CMS Add: 01/01/1997 CMS Term: 15757 MEDSV DEF RBRVS 01/01/2024 2118.92 Description: FREE SKIN FLAP MICROVASC Category: Medical Services CMS Add: 01/01/1997 CMS Term: 15758 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1674.73 Description: FREE FASCIAL FLAP MICROVASC Category: Medical Services CMS Add: 01/01/1997 CMS Term: 15758 MEDSV DEF RBRVS 01/01/2024 2112.08 Description: FREE FASCIAL FLAP MICROVASC Category: Medical Services CMS Add: 01/01/1997 CMS Term: 15760 MEDSV DEF RBRVS 01/01/2024 792.83 Description: COMPOSITE SKIN GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15760 MEDSV DEF RBRVS 09/01/2019 12/31/2023 607.68 Description: COMPOSITE SKIN GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15769 MEDSV DEF RBRVS 01/01/2020 12/31/2023 347.93 Y Description: GRFG AUTOL SOFT TISS DIR EXC Category: Medical Services CMS Add: 01/01/2020 CMS Term: 15769 MEDSV DEF RBRVS 01/01/2024 445.77 Y Description: GRFG AUTOL SOFT TISS DIR EXC Category: Medical Services CMS Add: 01/01/2020 CMS Term: 15770 MEDSV DEF RBRVS 01/01/2024 627.44 Description: DERMA-FAT-FASCIA GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15770 MEDSV DEF RBRVS 09/01/2019 12/31/2023 486.72 Description: DERMA-FAT-FASCIA GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15771 MEDSV DEF RBRVS 01/01/2020 12/31/2023 414.59 Y Description: GRFG AUTOL FAT LIPO 50 CC/< Category: Medical Services CMS Add: 01/01/2020 CMS Term: 15771 MEDSV DEF RBRVS 01/01/2024 563.54 Y Description: GRFG AUTOL FAT LIPO 50 CC/< Category: Medical Services CMS Add: 01/01/2020 CMS Term: 15772 MEDSV DEF RBRVS 01/01/2020 12/31/2023 131.00 Y Description: GRFG AUTOL FAT LIPO EA ADDL Category: Medical Services CMS Add: 01/01/2020 CMS Term: 15772 MEDSV DEF RBRVS 01/01/2024 177.31 Y Description: GRFG AUTOL FAT LIPO EA ADDL Category: Medical Services CMS Add: 01/01/2020 CMS Term: 15773 MEDSV DEF RBRVS 01/01/2020 12/31/2023 418.51 Y Description: GRFG AUTOL FAT LIPO 25 CC/< Category: Medical Services CMS Add: 01/01/2020 CMS Term: 15773 MEDSV DEF RBRVS 01/01/2024 555.73 Y Description: GRFG AUTOL FAT LIPO 25 CC/< Category: Medical Services CMS Add: 01/01/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 118 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 15774 MEDSV DEF RBRVS 01/01/2020 12/31/2023 127.09 Y Description: GFRG AUTOL FAT LIPO EA ADDL Category: Medical Services CMS Add: 01/01/2020 CMS Term: 15774 MEDSV DEF RBRVS 01/01/2024 173.34 Y Description: GFRG AUTOL FAT LIPO EA ADDL Category: Medical Services CMS Add: 01/01/2020 CMS Term: 15775 NOCOV DEF SYSMAN Description: HAIR TRNSPL 1-15 PUNCH GRFTS Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 15776 NOCOV DEF SYSMAN Description: HAIR TRNSPL >15 PUNCH GRAFTS Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 15777 MEDSV DEF RBRVS 01/01/2016 12/31/2023 153.15 Description: ACELLULAR DERM MATRIX IMPLT Category: Medical Services CMS Add: 01/01/2012 CMS Term: 15777 MEDSV DEF RBRVS 01/01/2024 197.46 Description: ACELLULAR DERM MATRIX IMPLT Category: Medical Services CMS Add: 01/01/2012 CMS Term: 15778 MEDSV DEF RBRVS 01/01/2023 351.38 Description: IMPL ABSRB MSH/PRSTH DLY CLS Category: Medical Services CMS Add: 01/01/2023 CMS Term: 15780 MEDSV DEF RBRVS 01/01/2024 795.00 Y Description: DERMABRASION TOTAL FACE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15780 MEDSV DEF RBRVS 09/01/2019 12/31/2023 592.43 Y Description: DERMABRASION TOTAL FACE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15781 MEDSV DEF RBRVS 01/01/2024 503.27 Y Description: DERMABRASION SEGMENTAL FACE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15781 MEDSV DEF RBRVS 09/01/2019 12/31/2023 389.45 Y Description: DERMABRASION SEGMENTAL FACE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15782 MEDSV DEF RBRVS 01/01/2024 455.45 Y Description: DERMABRASION OTHER THAN FACE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15782 MEDSV DEF RBRVS 09/01/2019 12/31/2023 445.78 Y Description: DERMABRASION OTHER THAN FACE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15783 MEDSV DEF RBRVS 01/01/2024 422.02 Y Description: DERMABRASION SUPRFL ANY SITE Category: Medical Services CMS Add: 01/01/1988 CMS Term: 15783 MEDSV DEF RBRVS 09/01/2019 12/31/2023 338.46 Y Description: DERMABRASION SUPRFL ANY SITE Category: Medical Services CMS Add: 01/01/1988 CMS Term: 15786 NOCOV DEF SYSMAN Description: ABRASION LESION SINGLE Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 119 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 15787 NOCOV DEF SYSMAN Description: ABRASION LESIONS ADD-ON Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 15788 NOCOV DEF SYSMAN Description: CHEMICAL PEEL FACE EPIDERM Category: Non Covered Services CMS Add: 01/01/1994 CMS Term: 15789 NOCOV DEF SYSMAN Description: CHEMICAL PEEL FACE DERMAL Category: Non Covered Services CMS Add: 01/01/1994 CMS Term: 15792 NOCOV DEF SYSMAN Description: CHEMICAL PEEL NONFACIAL Category: Non Covered Services CMS Add: 01/01/1994 CMS Term: 15793 NOCOV DEF SYSMAN Description: CHEMICAL PEEL NONFACIAL Category: Non Covered Services CMS Add: 01/01/1994 CMS Term: 15819 NOCOV DEF SYSMAN Description: PLASTIC SURGERY NECK Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: 15820 MEDSV DEF RBRVS 01/01/2024 544.19 Y Description: REVISION OF LOWER EYELID Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15820 MEDSV DEF RBRVS 09/01/2019 12/31/2023 416.51 Y Description: REVISION OF LOWER EYELID Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15821 MEDSV DEF RBRVS 01/01/2024 581.69 Y Description: REVISION OF LOWER EYELID Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15821 MEDSV DEF RBRVS 09/01/2019 12/31/2023 444.54 Y Description: REVISION OF LOWER EYELID Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15822 MEDSV DEF RBRVS 01/01/2024 433.04 Y Description: REVISION OF UPPER EYELID Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15822 MEDSV DEF RBRVS 09/01/2019 12/31/2023 322.30 Y Description: REVISION OF UPPER EYELID Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15823 MEDSV DEF RBRVS 01/01/2024 583.70 Y Description: REVISION OF UPPER EYELID Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15823 MEDSV DEF RBRVS 09/01/2019 12/31/2023 445.47 Y Description: REVISION OF UPPER EYELID Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15824 NOCOV DEF SYSMAN Description: REMOVAL OF FOREHEAD WRINKLES Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 15825 NOCOV DEF SYSMAN Description: REMOVAL OF NECK WRINKLES Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 120 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 15826 NOCOV DEF SYSMAN Description: REMOVAL OF BROW WRINKLES Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 15828 NOCOV DEF SYSMAN Description: REMOVAL OF FACE WRINKLES Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 15829 NOCOV DEF SYSMAN Description: REMOVAL OF SKIN WRINKLES Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: 15830 MEDSV DEF RBRVS 01/01/2024 1084.12 Y Description: EXC SKIN ABD Category: Medical Services CMS Add: 01/01/2007 CMS Term: 15830 MEDSV DEF RBRVS 02/01/2015 12/31/2023 841.70 Y Description: EXC SKIN ABD Category: Medical Services CMS Add: 01/01/2007 CMS Term: 15832 MEDSV DEF RBRVS 01/01/2024 855.05 Y Description: EXCISE EXCESSIVE SKIN THIGH Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15832 MEDSV DEF RBRVS 09/01/2019 12/31/2023 658.87 Y Description: EXCISE EXCESSIVE SKIN THIGH Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15833 MEDSV DEF RBRVS 01/01/2024 814.95 Y Description: EXCISE EXCESSIVE SKIN LEG Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15833 MEDSV DEF RBRVS 09/01/2019 12/31/2023 628.56 Y Description: EXCISE EXCESSIVE SKIN LEG Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15834 MEDSV DEF RBRVS 01/01/2024 829.54 Y Description: EXCISE EXCESSIVE SKIN HIP Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15834 MEDSV DEF RBRVS 09/01/2019 12/31/2023 640.93 Y Description: EXCISE EXCESSIVE SKIN HIP Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15835 MEDSV DEF RBRVS 01/01/2024 864.53 Y Description: EXCISE EXCESSIVE SKIN BUTTCK Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15835 MEDSV DEF RBRVS 09/01/2019 12/31/2023 676.83 Y Description: EXCISE EXCESSIVE SKIN BUTTCK Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15836 MEDSV DEF RBRVS 01/01/2024 740.53 Y Description: EXCISE EXCESSIVE SKIN ARM Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15836 MEDSV DEF RBRVS 09/01/2019 12/31/2023 547.08 Y Description: EXCISE EXCESSIVE SKIN ARM Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15837 MEDSV DEF RBRVS 01/01/2024 806.97 Y Description: EXCISE EXCESS SKIN ARM/HAND Category: Medical Services CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 121 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 15837 MEDSV DEF RBRVS 09/01/2019 12/31/2023 561.29 Y Description: EXCISE EXCESS SKIN ARM/HAND Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15838 MEDSV DEF RBRVS 01/01/2024 603.78 Y Description: EXCISE EXCESS SKIN FAT PAD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15838 MEDSV DEF RBRVS 09/01/2019 12/31/2023 413.97 Y Description: EXCISE EXCESS SKIN FAT PAD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15839 MEDSV DEF RBRVS 01/01/2024 829.72 Y Description: EXCISE EXCESS SKIN & TISSUE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15839 MEDSV DEF RBRVS 09/01/2019 12/31/2023 628.51 Y Description: EXCISE EXCESS SKIN & TISSUE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15840 MEDSV DEF RBRVS 01/01/2024 946.16 Description: NERVE PALSY FASCIAL GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15840 MEDSV DEF RBRVS 09/01/2019 12/31/2023 738.49 Description: NERVE PALSY FASCIAL GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15841 MEDSV DEF RBRVS 01/01/2024 1649.27 Description: NERVE PALSY MUSCLE GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15841 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1167.72 Description: NERVE PALSY MUSCLE GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15842 MEDSV DEF RBRVS 01/01/2024 2497.78 Description: NERVE PALSY MICROSURG GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15842 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1926.67 Description: NERVE PALSY MICROSURG GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15845 MEDSV DEF RBRVS 01/01/2024 985.22 Description: SKIN AND MUSCLE REPAIR FACE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15845 MEDSV DEF RBRVS 09/01/2019 12/31/2023 740.06 Description: SKIN AND MUSCLE REPAIR FACE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15847 MEDSV DEF MAXFEE 01/01/2024 289.83 0.0 Y Description: EXC SKIN ABD ADD-ON Category: Medical Services CMS Add: 01/01/2007 CMS Term: 15851 MEDSV DEF RBRVS 01/01/2024 53.72 Description: REMOVAL SUTR/STAPLE REQ ANES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15851 MEDSV DEF RBRVS 09/01/2019 12/31/2023 69.76 Description: REMOVAL SUTR/STAPLE REQ ANES Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 122 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 15852 MEDSV DEF RBRVS 01/01/2024 42.38 Description: DRESSING CHANGE NOT FOR BURN Category: Medical Services CMS Add: 01/01/1989 CMS Term: 15852 MEDSV DEF RBRVS 09/01/2019 12/31/2023 33.92 Description: DRESSING CHANGE NOT FOR BURN Category: Medical Services CMS Add: 01/01/1989 CMS Term: 15853 MEDSV DEF RBRVS 01/01/2023 12/31/2023 8.34 Description: REMOVAL SUTR/STAPL XREQ ANES Category: Medical Services CMS Add: 01/01/2023 CMS Term: 15853 MEDSV DEF RBRVS 01/01/2024 10.35 Description: REMOVAL SUTR/STAPL XREQ ANES Category: Medical Services CMS Add: 01/01/2023 CMS Term: 15854 MEDSV DEF RBRVS 01/01/2023 12/31/2023 11.73 Description: REMOVAL SUTR&STAPL XREQ ANES Category: Medical Services CMS Add: 01/01/2023 CMS Term: 15854 MEDSV DEF RBRVS 01/01/2024 14.52 Description: REMOVAL SUTR&STAPL XREQ ANES Category: Medical Services CMS Add: 01/01/2023 CMS Term: 15860 MEDSV DEF RBRVS 01/01/2024 98.12 Description: TEST FOR BLOOD FLOW IN GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15860 MEDSV DEF RBRVS 09/01/2019 12/31/2023 80.39 Description: TEST FOR BLOOD FLOW IN GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15876 NOCOV DEF SYSMAN Description: SUCTION LIPECTOMY HEAD&NECK Category: Non Covered Services CMS Add: 01/01/1990 CMS Term: 15877 NOCOV DEF SYSMAN Description: SUCTION LIPECTOMY TRUNK Category: Non Covered Services CMS Add: 01/01/1990 CMS Term: 15878 NOCOV DEF SYSMAN Description: SUCTION LIPECTOMY UPR EXTREM Category: Non Covered Services CMS Add: 01/01/1990 CMS Term: 15879 NOCOV DEF SYSMAN Description: SUCTION LIPECTOMY LWR EXTREM Category: Non Covered Services CMS Add: 01/01/1990 CMS Term: 15920 MEDSV DEF RBRVS 01/01/2024 592.22 Description: REMOVAL OF TAIL BONE ULCER Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15920 MEDSV DEF RBRVS 09/01/2019 12/31/2023 432.39 Description: REMOVAL OF TAIL BONE ULCER Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15922 MEDSV DEF RBRVS 01/01/2024 741.97 Description: REMOVAL OF TAIL BONE ULCER Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15922 MEDSV DEF RBRVS 09/01/2019 12/31/2023 562.37 Description: REMOVAL OF TAIL BONE ULCER Category: Medical Services CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 123 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 15931 MEDSV DEF RBRVS 01/01/2024 648.89 Description: REMOVE SACRUM PRESSURE SORE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15931 MEDSV DEF RBRVS 09/01/2019 12/31/2023 487.57 Description: REMOVE SACRUM PRESSURE SORE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15933 MEDSV DEF RBRVS 01/01/2024 803.45 Description: REMOVE SACRUM PRESSURE SORE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15933 MEDSV DEF RBRVS 09/01/2019 12/31/2023 608.14 Description: REMOVE SACRUM PRESSURE SORE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15934 MEDSV DEF RBRVS 01/01/2024 876.81 Description: REMOVE SACRUM PRESSURE SORE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15934 MEDSV DEF RBRVS 09/01/2019 12/31/2023 659.46 Description: REMOVE SACRUM PRESSURE SORE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15935 MEDSV DEF RBRVS 01/01/2024 1074.08 Description: REMOVE SACRUM PRESSURE SORE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15935 MEDSV DEF RBRVS 09/01/2019 12/31/2023 781.11 Description: REMOVE SACRUM PRESSURE SORE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15936 MEDSV DEF RBRVS 01/01/2024 832.89 Description: REMOVE SACRUM PRESSURE SORE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15936 MEDSV DEF RBRVS 09/01/2019 12/31/2023 640.45 Description: REMOVE SACRUM PRESSURE SORE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15937 MEDSV DEF RBRVS 01/01/2024 966.96 Description: REMOVE SACRUM PRESSURE SORE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15937 MEDSV DEF RBRVS 09/01/2019 12/31/2023 746.25 Description: REMOVE SACRUM PRESSURE SORE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15940 MEDSV DEF RBRVS 01/01/2024 655.17 Description: REMOVE HIP PRESSURE SORE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15940 MEDSV DEF RBRVS 09/01/2019 12/31/2023 500.23 Description: REMOVE HIP PRESSURE SORE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15941 MEDSV DEF RBRVS 01/01/2024 868.11 Description: REMOVE HIP PRESSURE SORE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15941 MEDSV DEF RBRVS 09/01/2019 12/31/2023 647.05 Description: REMOVE HIP PRESSURE SORE Category: Medical Services CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 124 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 15944 MEDSV DEF RBRVS 01/01/2024 869.29 Description: REMOVE HIP PRESSURE SORE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15944 MEDSV DEF RBRVS 09/01/2019 12/31/2023 637.29 Description: REMOVE HIP PRESSURE SORE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15945 MEDSV DEF RBRVS 01/01/2024 948.25 Description: REMOVE HIP PRESSURE SORE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15945 MEDSV DEF RBRVS 09/01/2019 12/31/2023 702.04 Description: REMOVE HIP PRESSURE SORE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15946 MEDSV DEF RBRVS 01/01/2024 1496.68 Description: REMOVE HIP PRESSURE SORE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15946 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1179.01 Description: REMOVE HIP PRESSURE SORE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15950 MEDSV DEF RBRVS 01/01/2024 592.74 Description: REMOVE THIGH PRESSURE SORE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15950 MEDSV DEF RBRVS 09/01/2019 12/31/2023 421.94 Description: REMOVE THIGH PRESSURE SORE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15951 MEDSV DEF RBRVS 01/01/2024 836.48 Description: REMOVE THIGH PRESSURE SORE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15951 MEDSV DEF RBRVS 09/01/2019 12/31/2023 632.59 Description: REMOVE THIGH PRESSURE SORE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15952 MEDSV DEF RBRVS 01/01/2024 852.21 Description: REMOVE THIGH PRESSURE SORE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15952 MEDSV DEF RBRVS 09/01/2019 12/31/2023 655.02 Description: REMOVE THIGH PRESSURE SORE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15953 MEDSV DEF RBRVS 01/01/2024 938.58 Description: REMOVE THIGH PRESSURE SORE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15953 MEDSV DEF RBRVS 09/01/2019 12/31/2023 716.86 Description: REMOVE THIGH PRESSURE SORE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15956 MEDSV DEF RBRVS 01/01/2024 1077.87 Description: REMOVE THIGH PRESSURE SORE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15956 MEDSV DEF RBRVS 09/01/2019 12/31/2023 833.10 Description: REMOVE THIGH PRESSURE SORE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 125 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 15958 MEDSV DEF RBRVS 01/01/2024 1093.91 Description: REMOVE THIGH PRESSURE SORE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15958 MEDSV DEF RBRVS 09/01/2019 12/31/2023 843.92 Description: REMOVE THIGH PRESSURE SORE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15999 MEDSV DEF BILL20 Description: UNLISTED PX EXC PRESSURE ULC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 16000 MEDSV DEF RBRVS 01/01/2024 73.16 Description: INITIAL TREATMENT OF BURN(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 16000 MEDSV DEF RBRVS 09/01/2019 12/31/2023 49.26 Description: INITIAL TREATMENT OF BURN(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 16020 MEDSV DEF RBRVS 01/01/2024 79.40 Description: DRESS/DEBRID P-THICK BURN S Category: Medical Services CMS Add: 01/01/1984 CMS Term: 16020 MEDSV DEF RBRVS 09/01/2019 12/31/2023 57.64 Description: DRESS/DEBRID P-THICK BURN S Category: Medical Services CMS Add: 01/01/1984 CMS Term: 16025 MEDSV DEF RBRVS 01/01/2024 145.74 Description: DRESS/DEBRID P-THICK BURN M Category: Medical Services CMS Add: 01/01/1984 CMS Term: 16025 MEDSV DEF RBRVS 09/01/2019 12/31/2023 104.63 Description: DRESS/DEBRID P-THICK BURN M Category: Medical Services CMS Add: 01/01/1984 CMS Term: 16030 MEDSV DEF RBRVS 01/01/2024 182.19 Description: DRESS/DEBRID P-THICK BURN L Category: Medical Services CMS Add: 01/01/1984 CMS Term: 16030 MEDSV DEF RBRVS 09/01/2019 12/31/2023 132.27 Description: DRESS/DEBRID P-THICK BURN L Category: Medical Services CMS Add: 01/01/1984 CMS Term: 16035 MEDSV DEF RBRVS 01/01/2024 181.12 Description: INCISION OF BURN SCAB INITI Category: Medical Services CMS Add: 01/01/1984 CMS Term: 16035 MEDSV DEF RBRVS 09/01/2019 12/31/2023 144.09 Description: INCISION OF BURN SCAB INITI Category: Medical Services CMS Add: 01/01/1984 CMS Term: 16036 MEDSV DEF RBRVS 01/01/2024 75.58 Description: ESCHAROTOMY ADDL INCISION Category: Medical Services CMS Add: 01/01/2001 CMS Term: 16036 MEDSV DEF RBRVS 02/01/2015 12/31/2023 59.21 Description: ESCHAROTOMY ADDL INCISION Category: Medical Services CMS Add: 01/01/2001 CMS Term: 17000 MEDSV DEF RBRVS 01/01/2024 63.00 0-1 Description: DESTRUCT PREMALG LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 126 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 17000 MEDSV DEF RBRVS 02/01/2015 12/31/2023 52.64 0-1 Description: DESTRUCT PREMALG LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 17003 MEDSV DEF RBRVS 01/01/2024 6.29 Description: DESTRUCT PREMALG LES 2-14 Category: Medical Services CMS Add: 01/01/1998 CMS Term: 17003 MEDSV DEF RBRVS 02/01/2015 12/31/2023 6.94 Description: DESTRUCT PREMALG LES 2-14 Category: Medical Services CMS Add: 01/01/1998 CMS Term: 17004 MEDSV DEF RBRVS 01/01/2024 158.14 Description: DESTROY PREMAL LESIONS 15/> Category: Medical Services CMS Add: 01/01/1998 CMS Term: 17004 MEDSV DEF RBRVS 02/01/2015 12/31/2023 104.60 Description: DESTROY PREMAL LESIONS 15/> Category: Medical Services CMS Add: 01/01/1998 CMS Term: 17106 MEDSV DEF RBRVS 01/01/2024 322.28 0-1 Description: DESTRUCTION OF SKIN LESIONS Category: Medical Services CMS Add: 01/01/1991 CMS Term: 17106 MEDSV DEF RBRVS 09/01/2019 12/31/2023 237.86 0-1 Description: DESTRUCTION OF SKIN LESIONS Category: Medical Services CMS Add: 01/01/1991 CMS Term: 17107 MEDSV DEF RBRVS 01/01/2024 417.98 0-1 Description: DESTRUCTION OF SKIN LESIONS Category: Medical Services CMS Add: 01/01/1991 CMS Term: 17107 MEDSV DEF RBRVS 09/01/2019 12/31/2023 307.47 0-1 Description: DESTRUCTION OF SKIN LESIONS Category: Medical Services CMS Add: 01/01/1991 CMS Term: 17108 MEDSV DEF RBRVS 01/01/2024 591.89 0-1 Description: DESTRUCTION OF SKIN LESIONS Category: Medical Services CMS Add: 01/01/1991 CMS Term: 17108 MEDSV DEF RBRVS 09/01/2019 12/31/2023 446.81 0-1 Description: DESTRUCTION OF SKIN LESIONS Category: Medical Services CMS Add: 01/01/1991 CMS Term: 17110 MEDSV DEF RBRVS 01/01/2024 106.35 0-1 Description: DESTRUCT B9 LESION 1-14 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 17110 MEDSV DEF RBRVS 09/01/2019 12/31/2023 76.36 0-1 Description: DESTRUCT B9 LESION 1-14 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 17111 MEDSV DEF RBRVS 01/01/2024 124.32 Description: DESTRUCT LESION 15 OR MORE Category: Medical Services CMS Add: 01/01/1998 CMS Term: 17111 MEDSV DEF RBRVS 02/01/2015 12/31/2023 90.80 Description: DESTRUCT LESION 15 OR MORE Category: Medical Services CMS Add: 01/01/1998 CMS Term: 17250 MEDSV DEF RBRVS 01/01/2024 81.52 Description: CHEM CAUT OF GRANLTJ TISSUE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 127 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 17250 MEDSV DEF RBRVS 09/01/2019 12/31/2023 55.46 Description: CHEM CAUT OF GRANLTJ TISSUE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 17260 MEDSV DEF RBRVS 01/01/2019 12/31/2023 65.76 Description: DSTRJ MAL LES T/A/L 0.5 CM/< Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17260 MEDSV DEF RBRVS 01/01/2024 94.03 Description: DSTRJ MAL LES T/A/L 0.5 CM/< Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17261 MEDSV DEF RBRVS 01/01/2019 12/31/2023 99.74 Description: DSTRJ MAL LES T/A/L .6-1.0CM Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17261 MEDSV DEF RBRVS 01/01/2024 138.97 Description: DSTRJ MAL LES T/A/L .6-1.0CM Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17262 MEDSV DEF RBRVS 01/01/2019 12/31/2023 121.74 Description: DSTRJ MAL LES T/A/L 1.1-2.0 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17262 MEDSV DEF RBRVS 01/01/2024 167.73 Description: DSTRJ MAL LES T/A/L 1.1-2.0 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17263 MEDSV DEF RBRVS 01/01/2019 12/31/2023 133.08 Description: DSTRJ MAL LES T/A/L 2.1-3.0 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17263 MEDSV DEF RBRVS 01/01/2024 181.49 Description: DSTRJ MAL LES T/A/L 2.1-3.0 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17264 MEDSV DEF RBRVS 01/01/2019 12/31/2023 143.06 Description: DSTRJ MAL LES T/A/L 3.1-4.0 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17264 MEDSV DEF RBRVS 01/01/2024 194.45 Description: DSTRJ MAL LES T/A/L 3.1-4.0 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17266 MEDSV DEF RBRVS 01/01/2019 12/31/2023 162.56 Description: DSTRJ MAL LES T/A/L >4.0 CM Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17266 MEDSV DEF RBRVS 01/01/2024 221.77 Description: DSTRJ MAL LES T/A/L >4.0 CM Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17270 MEDSV DEF RBRVS 01/01/2019 12/31/2023 104.60 Description: DSTR MAL LES S/N/H/F/G .5 /< Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17270 MEDSV DEF RBRVS 01/01/2024 140.54 Description: DSTR MAL LES S/N/H/F/G .5 /< Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17271 MEDSV DEF RBRVS 01/01/2019 12/31/2023 113.88 Description: DSTR MAL LES S/N/H/F/G 0.6-1 Category: Medical Services CMS Add: 01/01/1992 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 128 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 17271 MEDSV DEF RBRVS 01/01/2024 156.49 Description: DSTR MAL LES S/N/H/F/G 0.6-1 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17272 MEDSV DEF RBRVS 01/01/2019 12/31/2023 129.82 Description: DSTR MAL LES S/N/H/F/G 1.1-2 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17272 MEDSV DEF RBRVS 01/01/2024 177.41 Description: DSTR MAL LES S/N/H/F/G 1.1-2 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17273 MEDSV DEF RBRVS 01/01/2019 12/31/2023 145.19 Description: DSTR MAL LES S/N/H/F/G 2.1-3 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17273 MEDSV DEF RBRVS 01/01/2024 196.65 Description: DSTR MAL LES S/N/H/F/G 2.1-3 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17274 MEDSV DEF RBRVS 01/01/2019 12/31/2023 171.83 Description: DSTR MAL LES S/N/H/F/G 3.1-4 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17274 MEDSV DEF RBRVS 01/01/2024 230.57 Description: DSTR MAL LES S/N/H/F/G 3.1-4 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17276 MEDSV DEF RBRVS 01/01/2019 12/31/2023 199.70 Description: DSTR MAL LES S/N/H/F/G >4.0 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17276 MEDSV DEF RBRVS 01/01/2024 267.65 Description: DSTR MAL LES S/N/H/F/G >4.0 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17280 MEDSV DEF RBRVS 01/01/2019 12/31/2023 98.01 Description: DSTR MAL LS F/E/E/N/L/M .5/< Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17280 MEDSV DEF RBRVS 01/01/2024 131.57 Description: DSTR MAL LS F/E/E/N/L/M .5/< Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17281 MEDSV DEF RBRVS 01/01/2019 12/31/2023 124.02 Description: DSTR MAL LS F/E/E/N/L/M .6-1 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17281 MEDSV DEF RBRVS 01/01/2024 169.24 Description: DSTR MAL LS F/E/E/N/L/M .6-1 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17282 MEDSV DEF RBRVS 01/01/2019 12/31/2023 142.69 Description: DSTR MAL LS F/E/E/N/L/M1.1-2 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17282 MEDSV DEF RBRVS 01/01/2024 193.53 Description: DSTR MAL LS F/E/E/N/L/M1.1-2 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17283 MEDSV DEF RBRVS 01/01/2019 12/31/2023 171.36 Description: DSTR MAL LS F/E/E/N/L/M2.1-3 Category: Medical Services CMS Add: 01/01/1992 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 129 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 17283 MEDSV DEF RBRVS 01/01/2024 228.87 Description: DSTR MAL LS F/E/E/N/L/M2.1-3 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17284 MEDSV DEF RBRVS 01/01/2019 12/31/2023 196.21 Description: DSTR MAL LS F/E/E/N/L/M3.1-4 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17284 MEDSV DEF RBRVS 01/01/2024 260.24 Description: DSTR MAL LS F/E/E/N/L/M3.1-4 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17286 MEDSV DEF RBRVS 01/01/2019 12/31/2023 253.06 Description: DSTR MAL LS F/E/E/N/L/M>4.0 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17286 MEDSV DEF RBRVS 01/01/2024 333.33 Description: DSTR MAL LS F/E/E/N/L/M>4.0 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17311 MEDSV DEF RBRVS 01/01/2024 636.40 Description: MOHS 1 STAGE H/N/HF/G Category: Medical Services CMS Add: 01/01/2007 CMS Term: 17311 MEDSV DEF RBRVS 02/01/2015 12/31/2023 459.96 Description: MOHS 1 STAGE H/N/HF/G Category: Medical Services CMS Add: 01/01/2007 CMS Term: 17312 MEDSV DEF RBRVS 01/01/2024 385.73 Description: MOHS ADDL STAGE Category: Medical Services CMS Add: 01/01/2007 CMS Term: 17312 MEDSV DEF RBRVS 02/01/2015 12/31/2023 269.41 Description: MOHS ADDL STAGE Category: Medical Services CMS Add: 01/01/2007 CMS Term: 17313 MEDSV DEF RBRVS 01/01/2024 597.22 Description: MOHS 1 STAGE T/A/L Category: Medical Services CMS Add: 01/01/2007 CMS Term: 17313 MEDSV DEF RBRVS 02/01/2015 12/31/2023 429.80 Description: MOHS 1 STAGE T/A/L Category: Medical Services CMS Add: 01/01/2007 CMS Term: 17314 MEDSV DEF RBRVS 01/01/2024 369.69 Description: MOHS ADDL STAGE T/A/L Category: Medical Services CMS Add: 01/01/2007 CMS Term: 17314 MEDSV DEF RBRVS 02/01/2015 12/31/2023 258.26 Description: MOHS ADDL STAGE T/A/L Category: Medical Services CMS Add: 01/01/2007 CMS Term: 17315 MEDSV DEF RBRVS 01/01/2024 74.00 Description: MOHS SURG ADDL BLOCK Category: Medical Services CMS Add: 01/01/2007 CMS Term: 17315 MEDSV DEF RBRVS 02/01/2015 12/31/2023 55.66 Description: MOHS SURG ADDL BLOCK Category: Medical Services CMS Add: 01/01/2007 CMS Term: 17340 NOCOV DEF SYSMAN Description: CRYOTHERAPY OF SKIN Category: Non Covered Services CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 130 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 17360 NOCOV DEF SYSMAN Description: SKIN PEEL THERAPY Category: Non Covered Services CMS Add: 01/01/1985 CMS Term: 17380 NOCOV DEF SYSMAN Description: HAIR REMOVAL BY ELECTROLYSIS Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 17999 MEDSV DEF BILL20 Y Description: UNLISTD PX SKN MUC MEMB SUBQ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19000 MEDSV DEF RBRVS 01/01/2024 95.37 Description: PUNCTURE ASPIR CYST BREAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19000 MEDSV DEF RBRVS 09/01/2019 12/31/2023 79.13 Description: PUNCTURE ASPIR CYST BREAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19001 MEDSV DEF RBRVS 01/01/2016 12/31/2023 19.29 Description: PUNCTURE ASPIR CYST BRST EA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19001 MEDSV DEF RBRVS 01/01/2024 24.76 Description: PUNCTURE ASPIR CYST BRST EA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19020 MEDSV DEF RBRVS 01/01/2024 435.85 Description: MASTOTOMY EXPL DRG ABSC DP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19020 MEDSV DEF RBRVS 09/01/2019 12/31/2023 328.82 Description: MASTOTOMY EXPL DRG ABSC DP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19030 MEDSV DEF RBRVS 01/01/2024 155.22 Description: NJX PX ONLY MAM DUCTO/GLCTO Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19030 MEDSV DEF RBRVS 09/01/2019 12/31/2023 116.08 Description: NJX PX ONLY MAM DUCTO/GLCTO Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19081 MEDSV DEF RBRVS 01/01/2024 473.52 Description: BX BREAST 1ST LESION STRTCTC Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19081 MEDSV DEF RBRVS 02/01/2015 12/31/2023 472.52 Description: BX BREAST 1ST LESION STRTCTC Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19082 MEDSV DEF RBRVS 01/01/2024 365.67 Description: BX BREAST ADD LESION STRTCTC Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19082 MEDSV DEF RBRVS 02/01/2015 12/31/2023 382.46 Description: BX BREAST ADD LESION STRTCTC Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19083 MEDSV DEF RBRVS 01/01/2024 473.39 Description: BX BREAST 1ST LESION US IMAG Category: Medical Services CMS Add: 01/01/2014 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 131 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 19083 MEDSV DEF RBRVS 02/01/2015 12/31/2023 469.48 Description: BX BREAST 1ST LESION US IMAG Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19084 MEDSV DEF RBRVS 01/01/2024 360.27 Description: BX BREAST ADD LESION US IMAG Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19084 MEDSV DEF RBRVS 02/01/2015 12/31/2023 377.22 Description: BX BREAST ADD LESION US IMAG Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19085 MEDSV DEF RBRVS 01/01/2024 726.01 Description: BX BREAST 1ST LESION MR IMAG Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19085 MEDSV DEF RBRVS 02/01/2015 12/31/2023 710.40 Description: BX BREAST 1ST LESION MR IMAG Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19086 MEDSV DEF RBRVS 01/01/2024 562.67 Description: BX BREAST ADD LESION MR IMAG Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19086 MEDSV DEF RBRVS 02/01/2015 12/31/2023 568.36 Description: BX BREAST ADD LESION MR IMAG Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19100 MEDSV DEF RBRVS 01/01/2024 139.55 Description: BX BREAST PERCUT W/O IMAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19100 MEDSV DEF RBRVS 09/01/2019 12/31/2023 105.13 Description: BX BREAST PERCUT W/O IMAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19101 MEDSV DEF RBRVS 01/01/2024 304.92 Description: BIOPSY OF BREAST OPEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19101 MEDSV DEF RBRVS 09/01/2019 12/31/2023 237.56 Description: BIOPSY OF BREAST OPEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19105 NOCOV DEF SYSMAN Description: CRYOSURG ABLATE FA EACH Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 19110 MEDSV DEF RBRVS 01/01/2024 450.33 Description: NIPPLE EXPLORATION Category: Medical Services CMS Add: 01/01/1987 CMS Term: 19110 MEDSV DEF RBRVS 09/01/2019 12/31/2023 338.61 Description: NIPPLE EXPLORATION Category: Medical Services CMS Add: 01/01/1987 CMS Term: 19112 MEDSV DEF RBRVS 01/01/2024 426.26 Description: EXCISE BREAST DUCT FISTULA Category: Medical Services CMS Add: 01/01/1987 CMS Term: 19112 MEDSV DEF RBRVS 09/01/2019 12/31/2023 320.69 Description: EXCISE BREAST DUCT FISTULA Category: Medical Services CMS Add: 01/01/1987 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 132 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 19120 MEDSV DEF RBRVS 01/01/2024 478.48 Description: REMOVAL OF BREAST LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19120 MEDSV DEF RBRVS 09/01/2019 12/31/2023 346.09 Description: REMOVAL OF BREAST LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19125 MEDSV DEF RBRVS 01/01/2024 526.64 0-2 Description: EXCISION BREAST LESION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 19125 MEDSV DEF RBRVS 09/01/2019 12/31/2023 383.79 0-2 Description: EXCISION BREAST LESION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 19126 MEDSV DEF RBRVS 01/01/2019 12/31/2023 115.14 Description: EXCISION ADDL BREAST LESION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 19126 MEDSV DEF RBRVS 01/01/2024 144.84 Description: EXCISION ADDL BREAST LESION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 19281 MEDSV DEF RBRVS 01/01/2024 227.50 Description: PERQ DEVICE BREAST 1ST IMAG Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19281 MEDSV DEF RBRVS 02/01/2015 12/31/2023 172.56 Description: PERQ DEVICE BREAST 1ST IMAG Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19282 MEDSV DEF RBRVS 01/01/2024 160.83 Description: PERQ DEVICE BREAST EA IMAG Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19282 MEDSV DEF RBRVS 02/01/2015 12/31/2023 119.76 Description: PERQ DEVICE BREAST EA IMAG Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19283 MEDSV DEF RBRVS 01/01/2024 245.11 Description: PERQ DEV BREAST 1ST STRTCTC Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19283 MEDSV DEF RBRVS 02/01/2015 12/31/2023 195.59 Description: PERQ DEV BREAST 1ST STRTCTC Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19284 MEDSV DEF RBRVS 01/01/2024 179.83 Description: PERQ DEV BREAST ADD STRTCTC Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19284 MEDSV DEF RBRVS 02/01/2015 12/31/2023 143.29 Description: PERQ DEV BREAST ADD STRTCTC Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19285 MEDSV DEF RBRVS 01/01/2024 349.15 Description: PERQ DEV BREAST 1ST US IMAG Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19285 MEDSV DEF RBRVS 02/01/2015 12/31/2023 328.73 Description: PERQ DEV BREAST 1ST US IMAG Category: Medical Services CMS Add: 01/01/2014 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 133 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 19286 MEDSV DEF RBRVS 01/01/2024 285.72 Description: PERQ DEV BREAST ADD US IMAG Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19286 MEDSV DEF RBRVS 02/01/2015 12/31/2023 275.26 Description: PERQ DEV BREAST ADD US IMAG Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19287 MEDSV DEF RBRVS 01/01/2024 602.11 Description: PERQ DEV BREAST 1ST MR GUIDE Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19287 MEDSV DEF RBRVS 02/01/2015 12/31/2023 605.73 Description: PERQ DEV BREAST 1ST MR GUIDE Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19288 MEDSV DEF RBRVS 01/01/2024 465.00 Description: PERQ DEV BREAST ADD MR GUIDE Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19288 MEDSV DEF RBRVS 02/01/2015 12/31/2023 483.91 Description: PERQ DEV BREAST ADD MR GUIDE Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19294 MEDSV DEF RBRVS 01/01/2018 12/31/2023 118.59 Description: PREPJ TUM CAV IORT PRTL MAST Category: Medical Services CMS Add: 01/01/2018 CMS Term: 19294 MEDSV DEF RBRVS 01/01/2024 148.46 Description: PREPJ TUM CAV IORT PRTL MAST Category: Medical Services CMS Add: 01/01/2018 CMS Term: 19296 MEDSV DEF RBRVS 01/01/2024 3462.93 Description: PLACE PO BREAST CATH FOR RAD Category: Medical Services CMS Add: 01/01/2005 CMS Term: 19296 MEDSV DEF RBRVS 02/01/2015 12/31/2023 2752.21 Description: PLACE PO BREAST CATH FOR RAD Category: Medical Services CMS Add: 01/01/2005 CMS Term: 19297 MEDSV DEF RBRVS 01/01/2016 12/31/2023 67.27 Description: PLACE BREAST CATH FOR RAD Category: Medical Services CMS Add: 01/01/2005 CMS Term: 19297 MEDSV DEF RBRVS 01/01/2024 85.42 Description: PLACE BREAST CATH FOR RAD Category: Medical Services CMS Add: 01/01/2005 CMS Term: 19298 MEDSV DEF RBRVS 01/01/2024 825.22 Description: PLACE BREAST RAD TUBE/CATHS Category: Medical Services CMS Add: 01/01/2005 CMS Term: 19298 MEDSV DEF RBRVS 09/15/2017 12/31/2023 694.59 Description: PLACE BREAST RAD TUBE/CATHS Category: Medical Services CMS Add: 01/01/2005 CMS Term: 19300 MEDSV DEF RBRVS 01/01/2024 539.79 Y Description: REMOVAL OF BREAST TISSUE Category: Medical Services CMS Add: 01/01/2007 CMS Term: 19300 MEDSV DEF RBRVS 02/01/2015 12/31/2023 365.86 Y Description: REMOVAL OF BREAST TISSUE Category: Medical Services CMS Add: 01/01/2007 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 134 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 19301 MEDSV DEF RBRVS 01/01/2024 604.85 Y Description: PARTIAL MASTECTOMY Category: Medical Services CMS Add: 01/01/2007 CMS Term: 19301 MEDSV DEF RBRVS 02/01/2015 12/31/2023 461.52 Y Description: PARTIAL MASTECTOMY Category: Medical Services CMS Add: 01/01/2007 CMS Term: 19302 MEDSV DEF RBRVS 01/01/2024 830.14 Description: P-MASTECTOMY W/LN REMOVAL Category: Medical Services CMS Add: 01/01/2007 CMS Term: 19302 MEDSV DEF RBRVS 02/01/2015 12/31/2023 635.50 Description: P-MASTECTOMY W/LN REMOVAL Category: Medical Services CMS Add: 01/01/2007 CMS Term: 19303 MEDSV DEF RBRVS 01/01/2024 876.40 Y 0-2 Description: MAST SIMPLE COMPLETE Category: Medical Services CMS Add: 01/01/2007 CMS Term: 19303 MEDSV DEF RBRVS 02/01/2015 12/31/2023 714.79 Y 0-2 Description: MAST SIMPLE COMPLETE Category: Medical Services CMS Add: 01/01/2007 CMS Term: 19305 MEDSV DEF RBRVS 01/01/2024 1054.18 0-2 Description: MAST RADICAL Category: Medical Services CMS Add: 01/01/2007 CMS Term: 19305 MEDSV DEF RBRVS 02/01/2015 12/31/2023 800.08 0-2 Description: MAST RADICAL Category: Medical Services CMS Add: 01/01/2007 CMS Term: 19306 MEDSV DEF RBRVS 01/01/2024 1116.87 0-2 Description: MAST RAD URBAN TYPE Category: Medical Services CMS Add: 01/01/2007 CMS Term: 19306 MEDSV DEF RBRVS 02/01/2015 12/31/2023 847.72 0-2 Description: MAST RAD URBAN TYPE Category: Medical Services CMS Add: 01/01/2007 CMS Term: 19307 MEDSV DEF RBRVS 01/01/2024 1080.10 0-2 Description: MAST MOD RAD Category: Medical Services CMS Add: 01/01/2007 CMS Term: 19307 MEDSV DEF RBRVS 02/01/2015 12/31/2023 845.95 0-2 Description: MAST MOD RAD Category: Medical Services CMS Add: 01/01/2007 CMS Term: 19316 MEDSV DEF RBRVS 01/01/2024 734.40 Y Description: SUSPENSION OF BREAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19316 MEDSV DEF RBRVS 09/01/2019 12/31/2023 553.95 Y Description: SUSPENSION OF BREAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19318 MEDSV DEF RBRVS 01/01/2024 1014.40 Y Description: BREAST REDUCTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19318 MEDSV DEF RBRVS 09/01/2019 12/31/2023 798.15 Y Description: BREAST REDUCTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 135 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 19325 MEDSV DEF RBRVS 01/01/2024 571.89 Y Description: BREAST AUGMENTATION W/IMPLT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19325 MEDSV DEF RBRVS 09/01/2019 12/31/2023 464.25 Y Description: BREAST AUGMENTATION W/IMPLT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19328 MEDSV DEF RBRVS 01/01/2024 515.13 Description: RMVL INTACT BREAST IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19328 MEDSV DEF RBRVS 09/01/2019 12/31/2023 356.01 Description: RMVL INTACT BREAST IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19330 MEDSV DEF RBRVS 01/01/2024 601.06 Description: RMVL RUPTURED BREAST IMPLANT Category: Medical Services CMS Add: 01/01/1982 CMS Term: 19330 MEDSV DEF RBRVS 09/01/2019 12/31/2023 455.62 Description: RMVL RUPTURED BREAST IMPLANT Category: Medical Services CMS Add: 01/01/1982 CMS Term: 19340 MEDSV DEF RBRVS 01/01/2024 704.69 Y Description: INSJ BREAST IMPLT SM D MAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19340 MEDSV DEF RBRVS 09/01/2019 12/31/2023 724.76 Y Description: INSJ BREAST IMPLT SM D MAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19342 MEDSV DEF RBRVS 01/01/2024 707.56 Y Description: INSJ/RPLCMT BRST IMPLT SEP D Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19342 MEDSV DEF RBRVS 09/01/2019 12/31/2023 665.92 Y Description: INSJ/RPLCMT BRST IMPLT SEP D Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19350 MEDSV DEF RBRVS 01/01/2024 773.19 Y Description: BREAST RECONSTRUCTION Category: Medical Services CMS Add: 01/01/1982 CMS Term: 19350 MEDSV DEF RBRVS 09/01/2019 12/31/2023 586.21 Y Description: BREAST RECONSTRUCTION Category: Medical Services CMS Add: 01/01/1982 CMS Term: 19355 NOCOV DEF SYSMAN Description: CORRECT INVERTED NIPPLE(S) Category: Non Covered Services CMS Add: 01/01/1988 CMS Term: 19357 MEDSV DEF RBRVS 01/01/2024 1075.83 Description: TISS XPNDR PLMT BRST RCNSTJ Category: Medical Services CMS Add: 01/01/1992 CMS Term: 19357 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1081.84 Description: TISS XPNDR PLMT BRST RCNSTJ Category: Medical Services CMS Add: 01/01/1992 CMS Term: 19361 MEDSV DEF RBRVS 01/01/2024 1444.41 Description: BRST RCNSTJ LATSMS DRSI FLAP Category: Medical Services CMS Add: 01/01/1992 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 136 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 19361 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1141.99 Description: BRST RCNSTJ LATSMS DRSI FLAP Category: Medical Services CMS Add: 01/01/1992 CMS Term: 19364 MEDSV DEF RBRVS 01/01/2024 2518.67 Description: BRST RCNSTJ FREE FLAP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19364 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2003.15 Description: BRST RCNSTJ FREE FLAP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19367 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1299.98 Description: BRST RCNSTJ 1 PDCL TRAM FLAP Category: Medical Services CMS Add: 01/01/1995 CMS Term: 19367 MEDSV DEF RBRVS 01/01/2024 1641.47 Description: BRST RCNSTJ 1 PDCL TRAM FLAP Category: Medical Services CMS Add: 01/01/1995 CMS Term: 19368 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1600.32 Description: BRST RCNSTJ 1PDCL TRAM ANAST Category: Medical Services CMS Add: 01/01/1995 CMS Term: 19368 MEDSV DEF RBRVS 01/01/2024 2010.72 Description: BRST RCNSTJ 1PDCL TRAM ANAST Category: Medical Services CMS Add: 01/01/1995 CMS Term: 19369 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1484.82 Description: BRST RCNSTJ 2 PDCL TRAM FLAP Category: Medical Services CMS Add: 01/01/1995 CMS Term: 19369 MEDSV DEF RBRVS 01/01/2024 1868.31 Description: BRST RCNSTJ 2 PDCL TRAM FLAP Category: Medical Services CMS Add: 01/01/1995 CMS Term: 19370 MEDSV DEF RBRVS 01/01/2024 624.11 Description: REVJ PERI-IMPLT CAPSULE BRST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19370 MEDSV DEF RBRVS 09/01/2019 12/31/2023 493.77 Description: REVJ PERI-IMPLT CAPSULE BRST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19371 MEDSV DEF RBRVS 01/01/2024 662.32 Description: PERI-IMPLT CAPSLC BRST COMPL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19371 MEDSV DEF RBRVS 09/01/2019 12/31/2023 565.51 Description: PERI-IMPLT CAPSLC BRST COMPL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19380 MEDSV DEF RBRVS 01/01/2024 750.47 Description: REVJ RECONSTRUCTED BREAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19380 MEDSV DEF RBRVS 09/01/2019 12/31/2023 556.98 Description: REVJ RECONSTRUCTED BREAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19396 NOCOV DEF SYSMAN Description: DESIGN CUSTOM BREAST IMPLANT Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 137 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 19499 MEDSV DEF BILL20 Y Description: UNLISTED PROCEDURE BREAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 2000F NOCOV DEF SYSMAN Description: BLOOD PRESSURE MEASURE Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: 2001F NOCOV DEF SYSMAN Description: WEIGHT RECORD Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 2002F NOCOV DEF SYSMAN Description: CLIN SIGN VOL OVRLD ASSESS Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 2004F NOCOV DEF SYSMAN Description: INITIAL EXAM INVOLVED JOINTS Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 20100 MEDSV DEF RBRVS 01/01/2024 551.64 Description: EXPLORE WOUND NECK Category: Medical Services CMS Add: 01/01/1996 CMS Term: 20100 MEDSV DEF RBRVS 02/01/2015 12/31/2023 435.12 Description: EXPLORE WOUND NECK Category: Medical Services CMS Add: 01/01/1996 CMS Term: 20101 MEDSV DEF RBRVS 01/01/2019 12/31/2023 315.18 Description: EXPLORE WOUND CHEST Category: Medical Services CMS Add: 01/01/1996 CMS Term: 20101 MEDSV DEF RBRVS 01/01/2024 539.71 Description: EXPLORE WOUND CHEST Category: Medical Services CMS Add: 01/01/1996 CMS Term: 20102 MEDSV DEF RBRVS 01/01/2019 12/31/2023 344.58 Description: EXPLORE WOUND ABDOMEN Category: Medical Services CMS Add: 01/01/1996 CMS Term: 20102 MEDSV DEF RBRVS 01/01/2024 564.27 Description: EXPLORE WOUND ABDOMEN Category: Medical Services CMS Add: 01/01/1996 CMS Term: 20103 MEDSV DEF RBRVS 01/01/2024 524.89 Description: EXPLORE WOUND EXTREMITY Category: Medical Services CMS Add: 01/01/1996 CMS Term: 20103 MEDSV DEF RBRVS 02/01/2015 12/31/2023 410.35 Description: EXPLORE WOUND EXTREMITY Category: Medical Services CMS Add: 01/01/1996 CMS Term: 2010F NOCOV DEF SYSMAN Description: VITAL SIGNS RECORDED Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 2014F NOCOV DEF SYSMAN Description: MENTAL STATUS ASSESS Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 20150 MEDSV DEF RBRVS 01/01/2019 12/31/2023 654.35 Description: EXCISE EPIPHYSEAL BAR Category: Medical Services CMS Add: 01/01/1997 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 138 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 20150 MEDSV DEF RBRVS 01/01/2024 928.43 Description: EXCISE EPIPHYSEAL BAR Category: Medical Services CMS Add: 01/01/1997 CMS Term: 2015F NOCOV DEF SYSMAN Description: ASTHMA IMPAIRMENT ASSESSED Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 2016F NOCOV DEF SYSMAN Description: ASTHMA RISK ASSESSED Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 2018F NOCOV DEF SYSMAN Description: HYDRATION STATUS ASSESS Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 2019F NOCOV DEF SYSMAN Description: DILATED MACUL EXAM DONE Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 20200 MEDSV DEF RBRVS 01/01/2024 201.76 Description: MUSCLE BIOPSY SUPERFICIAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20200 MEDSV DEF RBRVS 09/01/2019 12/31/2023 144.59 Description: MUSCLE BIOPSY SUPERFICIAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20205 MEDSV DEF RBRVS 01/01/2024 280.26 Description: DEEP MUSCLE BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20205 MEDSV DEF RBRVS 09/01/2019 12/31/2023 201.12 Description: DEEP MUSCLE BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20206 MEDSV DEF RBRVS 01/01/2024 209.58 Description: BIOPSY MUSCLE PERQ NEEDLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20206 MEDSV DEF RBRVS 09/01/2019 12/31/2023 164.99 Description: BIOPSY MUSCLE PERQ NEEDLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 2020F NOCOV DEF SYSMAN Description: DILATED FUNDUS EVAL DONE Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 2021F NOCOV DEF SYSMAN Description: DILAT MACULAR EXAM DONE Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 20220 MEDSV DEF RBRVS 01/01/2024 221.34 Description: BONE BIOPSY TROCAR/NDL SUPFC Category: Medical Services CMS Add: 01/01/1985 CMS Term: 20220 MEDSV DEF RBRVS 09/01/2019 12/31/2023 119.17 Description: BONE BIOPSY TROCAR/NDL SUPFC Category: Medical Services CMS Add: 01/01/1985 CMS Term: 20225 MEDSV DEF RBRVS 01/01/2024 362.11 Description: BONE BIOPSY TROCAR/NDL DEEP Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 139 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 20225 MEDSV DEF RBRVS 09/01/2019 12/31/2023 369.22 Description: BONE BIOPSY TROCAR/NDL DEEP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 2022F NOCOV DEF SYSMAN Description: DILAT RTA XM EVC RTNOPTHY Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 2023F NOCOV DEF SYSMAN Description: DILAT RTA XM W/O RTNOPTHY Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 20240 MEDSV DEF RBRVS 01/01/2024 131.39 Description: BONE BIOPSY OPEN SUPERFICIAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20240 MEDSV DEF RBRVS 09/01/2019 12/31/2023 158.31 Description: BONE BIOPSY OPEN SUPERFICIAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20245 MEDSV DEF RBRVS 01/01/2024 318.69 Description: BONE BIOPSY OPEN DEEP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20245 MEDSV DEF RBRVS 09/01/2019 12/31/2023 445.42 Description: BONE BIOPSY OPEN DEEP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 2024F NOCOV DEF SYSMAN Description: 7 FLD RTA PHOTO EVC RTNOPTHY Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 20250 MEDSV DEF RBRVS 01/01/2024 355.81 Description: BIOPSY VRT BDY OPEN THORACIC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20250 MEDSV DEF RBRVS 09/01/2019 12/31/2023 275.20 Description: BIOPSY VRT BDY OPEN THORACIC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20251 MEDSV DEF RBRVS 01/01/2024 385.18 Description: BIOPSY VRT BDY OPEN LMBR/CRV Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20251 MEDSV DEF RBRVS 09/01/2019 12/31/2023 299.84 Description: BIOPSY VRT BDY OPEN LMBR/CRV Category: Medical Services CMS Add: 01/01/1984 CMS Term: 2025F NOCOV DEF SYSMAN Description: 7 FLD RTA PHOTO W/O RTNOPTHY Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 2026F NOCOV DEF SYSMAN Description: EYE IMG VALID EVC RTNOPTHY Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 2027F NOCOV DEF SYSMAN Description: OPTIC NERVE HEAD EVAL DONE Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 2028F NOCOV DEF SYSMAN Description: FOOT EXAM PERFORMED Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 140 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 2029F NOCOV DEF SYSMAN Description: COMPLETE PHYS SKIN EXAM DONE Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 2030F NOCOV DEF SYSMAN Description: H2O STAT DOCD NORMAL Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 2031F NOCOV DEF SYSMAN Description: H2O STAT DOCD DEHYDRATED Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 2033F NOCOV DEF SYSMAN Description: EYE IMG VALID W/O RTNOPTHY Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 2035F NOCOV DEF SYSMAN Description: TYMP MEMB MOTION EXAMD Category: Non Covered Services CMS Add: 10/01/2007 CMS Term: 2040F NOCOV DEF SYSMAN Description: BK PN XM ON INIT VISIT DATE Category: Non Covered Services CMS Add: 04/01/2008 CMS Term: 2044F NOCOV DEF SYSMAN Description: DOC MNTL TST B/4 BK TRXMNT Category: Non Covered Services CMS Add: 04/01/2008 CMS Term: 20500 MEDSV DEF RBRVS 01/01/2024 116.19 Description: INJECTION OF SINUS TRACT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 20500 MEDSV DEF RBRVS 09/01/2019 12/31/2023 75.10 Description: INJECTION OF SINUS TRACT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 20501 MEDSV DEF RBRVS 01/01/2024 134.93 Description: INJECT SINUS TRACT FOR X-RAY Category: Medical Services CMS Add: 01/01/1985 CMS Term: 20501 MEDSV DEF RBRVS 09/01/2019 12/31/2023 83.01 Description: INJECT SINUS TRACT FOR X-RAY Category: Medical Services CMS Add: 01/01/1985 CMS Term: 2050F NOCOV DEF SYSMAN Description: WOUND CHAR SIZE ETC DOCD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 20520 MEDSV DEF RBRVS 01/01/2024 202.71 Description: REMOVAL OF FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20520 MEDSV DEF RBRVS 09/01/2019 12/31/2023 144.03 Description: REMOVAL OF FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20525 MEDSV DEF RBRVS 01/01/2024 433.58 Description: REMOVAL OF FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20525 MEDSV DEF RBRVS 09/01/2019 12/31/2023 337.05 Description: REMOVAL OF FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 141 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 20526 ANEST DEF RBRVS 01/01/2016 12/31/2023 54.16 Description: THER INJECTION CARP TUNNEL Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 20526 ANEST DEF RBRVS 01/01/2024 76.12 Description: THER INJECTION CARP TUNNEL Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 20527 MEDSV DEF RBRVS 01/01/2024 81.40 Description: INJ DUPUYTREN CORD W/ENZYME Category: Medical Services CMS Add: 01/01/2012 CMS Term: 20527 MEDSV DEF RBRVS 02/01/2015 12/31/2023 58.91 Description: INJ DUPUYTREN CORD W/ENZYME Category: Medical Services CMS Add: 01/01/2012 CMS Term: 20550 ANEST DEF RBRVS 01/01/2024 54.19 Description: INJ TENDON SHEATH/LIGAMENT Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 20550 ANEST DEF RBRVS 09/01/2019 12/31/2023 41.78 Description: INJ TENDON SHEATH/LIGAMENT Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 20551 MEDSV DEF RBRVS 01/01/2024 54.19 Description: INJ TENDON ORIGIN/INSERTION Category: Medical Services CMS Add: 01/01/2002 CMS Term: 20551 MEDSV DEF RBRVS 02/01/2015 12/31/2023 43.27 Description: INJ TENDON ORIGIN/INSERTION Category: Medical Services CMS Add: 01/01/2002 CMS Term: 20552 ANEST DEF RBRVS 01/01/2024 49.59 Description: INJ TRIGGER POINT 1/2 MUSCL Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 20552 ANEST DEF RBRVS 02/01/2015 12/31/2023 39.45 Description: INJ TRIGGER POINT 1/2 MUSCL Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 20553 ANEST DEF RBRVS 01/01/2024 57.28 Description: INJECT TRIGGER POINTS 3/> Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 20553 ANEST DEF RBRVS 02/01/2015 12/31/2023 45.58 Description: INJECT TRIGGER POINTS 3/> Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 20555 MEDSV DEF RBRVS 01/01/2024 318.47 Description: PLACE NDL MUSC/TIS FOR RT Category: Medical Services CMS Add: 01/01/2008 CMS Term: 20555 MEDSV DEF RBRVS 02/01/2015 12/31/2023 241.88 Description: PLACE NDL MUSC/TIS FOR RT Category: Medical Services CMS Add: 01/01/2008 CMS Term: 20560 NOCOV DEF SYSMAN Description: NDL INSJ W/O NJX 1 OR 2 MUSC Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 20561 NOCOV DEF SYSMAN Description: NDL INSJ W/O NJX 3+ MUSC Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 142 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 20600 MEDSV DEF RBRVS 01/01/2024 49.59 Description: DRAIN/INJ JOINT/BURSA W/O US Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20600 MEDSV DEF RBRVS 09/01/2019 12/31/2023 34.25 Description: DRAIN/INJ JOINT/BURSA W/O US Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20604 MEDSV DEF RBRVS 01/01/2024 77.15 Description: DRAIN/INJ JOINT/BURSA W/US Category: Medical Services CMS Add: 01/01/2015 CMS Term: 20604 MEDSV DEF RBRVS 02/01/2015 12/31/2023 51.82 Description: DRAIN/INJ JOINT/BURSA W/US Category: Medical Services CMS Add: 01/01/2015 CMS Term: 20605 MEDSV DEF RBRVS 01/01/2024 51.51 Description: DRAIN/INJ JOINT/BURSA W/O US Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20605 MEDSV DEF RBRVS 09/01/2019 12/31/2023 35.69 Description: DRAIN/INJ JOINT/BURSA W/O US Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20606 MEDSV DEF RBRVS 01/01/2024 83.67 Description: DRAIN/INJ JOINT/BURSA W/US Category: Medical Services CMS Add: 01/01/2015 CMS Term: 20606 MEDSV DEF RBRVS 02/01/2015 12/31/2023 57.34 Description: DRAIN/INJ JOINT/BURSA W/US Category: Medical Services CMS Add: 01/01/2015 CMS Term: 2060F NOCOV DEF SYSMAN Description: PT INTRVWD ON/BEFORE DX MDD Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 20610 MEDSV DEF RBRVS 01/01/2024 60.19 Description: DRAIN/INJ JOINT/BURSA W/O US Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20610 MEDSV DEF RBRVS 09/01/2019 12/31/2023 42.86 Description: DRAIN/INJ JOINT/BURSA W/O US Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20611 MEDSV DEF RBRVS 01/01/2024 93.11 Description: DRAIN/INJ JOINT/BURSA W/US Category: Medical Services CMS Add: 01/01/2015 CMS Term: 20611 MEDSV DEF RBRVS 02/01/2015 12/31/2023 65.80 Description: DRAIN/INJ JOINT/BURSA W/US Category: Medical Services CMS Add: 01/01/2015 CMS Term: 20612 MEDSV DEF RBRVS 01/01/2024 59.91 Description: ASPIRATE/INJ GANGLION CYST Category: Medical Services CMS Add: 01/01/2003 CMS Term: 20612 MEDSV DEF RBRVS 02/01/2015 12/31/2023 42.92 Description: ASPIRATE/INJ GANGLION CYST Category: Medical Services CMS Add: 01/01/2003 CMS Term: 20615 MEDSV DEF RBRVS 01/01/2024 237.22 Description: TREATMENT OF BONE CYST Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 143 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 20615 MEDSV DEF RBRVS 09/01/2019 12/31/2023 173.00 Description: TREATMENT OF BONE CYST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20650 MEDSV DEF RBRVS 01/01/2024 211.63 Description: INSERT AND REMOVE BONE PIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20650 MEDSV DEF RBRVS 09/01/2019 12/31/2023 145.65 Description: INSERT AND REMOVE BONE PIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20660 MEDSV DEF RBRVS 01/01/2024 215.89 Description: APPLY REM FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20660 MEDSV DEF RBRVS 09/01/2019 12/31/2023 171.39 Description: APPLY REM FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20661 MEDSV DEF RBRVS 01/01/2024 472.10 Description: APPLICATION HALO CRANIAL Category: Medical Services CMS Add: 01/01/1985 CMS Term: 20661 MEDSV DEF RBRVS 09/01/2019 12/31/2023 352.97 Description: APPLICATION HALO CRANIAL Category: Medical Services CMS Add: 01/01/1985 CMS Term: 20662 MEDSV DEF RBRVS 01/01/2024 485.63 Description: APPLICATION HALO PELVIC Category: Medical Services CMS Add: 01/01/1985 CMS Term: 20662 MEDSV DEF RBRVS 09/01/2019 12/31/2023 317.98 Description: APPLICATION HALO PELVIC Category: Medical Services CMS Add: 01/01/1985 CMS Term: 20663 MEDSV DEF RBRVS 01/01/2024 447.64 Description: APPLICATION HALO FEMORAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20663 MEDSV DEF RBRVS 09/01/2019 12/31/2023 320.86 Description: APPLICATION HALO FEMORAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20664 MEDSV DEF RBRVS 01/01/2024 798.79 Description: APPL HALO CRANIAL 6+PINS Category: Medical Services CMS Add: 01/01/1998 CMS Term: 20664 MEDSV DEF RBRVS 02/01/2015 12/31/2023 603.99 Description: APPL HALO CRANIAL 6+PINS Category: Medical Services CMS Add: 01/01/1998 CMS Term: 20665 MEDSV DEF RBRVS 01/01/2024 111.14 Description: RMVL TONGS/HALO ANTHR INDIV Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20665 MEDSV DEF RBRVS 09/01/2019 12/31/2023 75.51 Description: RMVL TONGS/HALO ANTHR INDIV Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20670 MEDSV DEF RBRVS 01/01/2024 333.58 Description: REMOVAL IMPLANT SUPERFICIAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 144 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 20670 MEDSV DEF RBRVS 09/01/2019 12/31/2023 265.67 Description: REMOVAL IMPLANT SUPERFICIAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20680 MEDSV DEF RBRVS 01/01/2024 560.75 Description: REMOVAL OF IMPLANT DEEP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20680 MEDSV DEF RBRVS 09/01/2019 12/31/2023 438.90 Description: REMOVAL OF IMPLANT DEEP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20690 MEDSV DEF RBRVS 01/01/2024 554.09 Description: APPL UNIPLN UNI EXT FIXJ SYS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20690 MEDSV DEF RBRVS 09/01/2019 12/31/2023 424.75 Description: APPL UNIPLN UNI EXT FIXJ SYS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20692 MEDSV DEF RBRVS 01/01/2024 1045.60 Description: APPL MLTPLN UNI EXT FIXJ SYS Category: Medical Services CMS Add: 01/01/1991 CMS Term: 20692 MEDSV DEF RBRVS 09/01/2019 12/31/2023 803.69 Description: APPL MLTPLN UNI EXT FIXJ SYS Category: Medical Services CMS Add: 01/01/1991 CMS Term: 20693 MEDSV DEF RBRVS 01/01/2024 414.68 Description: ADJMT/REVJ EXT FIXJ SYS ANES Category: Medical Services CMS Add: 01/01/1991 CMS Term: 20693 MEDSV DEF RBRVS 09/01/2019 12/31/2023 322.02 Description: ADJMT/REVJ EXT FIXJ SYS ANES Category: Medical Services CMS Add: 01/01/1991 CMS Term: 20694 MEDSV DEF RBRVS 01/01/2024 402.24 Description: RMVL EXT FIXJ SYS UNDER ANES Category: Medical Services CMS Add: 01/01/1991 CMS Term: 20694 MEDSV DEF RBRVS 09/01/2019 12/31/2023 300.70 Description: RMVL EXT FIXJ SYS UNDER ANES Category: Medical Services CMS Add: 01/01/1991 CMS Term: 20696 MEDSV DEF RBRVS 01/01/2024 1090.22 Description: APP MLTPLN UNI XTRNL FIX 1ST Category: Medical Services CMS Add: 01/01/2009 CMS Term: 20696 MEDSV DEF RBRVS 02/01/2015 12/31/2023 826.52 Description: APP MLTPLN UNI XTRNL FIX 1ST Category: Medical Services CMS Add: 01/01/2009 CMS Term: 20697 MEDSV DEF RBRVS 01/01/2024 1694.24 Description: APP MLTPLN UNI XTRNL FIX XCH Category: Medical Services CMS Add: 01/01/2009 CMS Term: 20697 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1286.30 Description: APP MLTPLN UNI XTRNL FIX XCH Category: Medical Services CMS Add: 01/01/2009 CMS Term: 20700 MEDSV DEF RBRVS 01/01/2020 12/31/2023 61.36 Description: MNL PREP&INSJ DP RX DLVR DEV Category: Medical Services CMS Add: 01/01/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 145 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 20700 MEDSV DEF RBRVS 01/01/2024 78.02 Description: MNL PREP&INSJ DP RX DLVR DEV Category: Medical Services CMS Add: 01/01/2020 CMS Term: 20701 MEDSV DEF RBRVS 01/01/2020 12/31/2023 45.88 Description: RMVL DEEP RX DELIVERY DEVICE Category: Medical Services CMS Add: 01/01/2020 CMS Term: 20701 MEDSV DEF RBRVS 01/01/2024 59.43 Description: RMVL DEEP RX DELIVERY DEVICE Category: Medical Services CMS Add: 01/01/2020 CMS Term: 20702 MEDSV DEF RBRVS 01/01/2020 12/31/2023 102.02 Description: MNL PREP&INSJ IMED RX DEV Category: Medical Services CMS Add: 01/01/2020 CMS Term: 20702 MEDSV DEF RBRVS 01/01/2024 130.89 Description: MNL PREP&INSJ IMED RX DEV Category: Medical Services CMS Add: 01/01/2020 CMS Term: 20703 MEDSV DEF RBRVS 01/01/2020 12/31/2023 73.30 Description: RMVL IMED RX DELIVERY DEVICE Category: Medical Services CMS Add: 01/01/2020 CMS Term: 20703 MEDSV DEF RBRVS 01/01/2024 94.41 Description: RMVL IMED RX DELIVERY DEVICE Category: Medical Services CMS Add: 01/01/2020 CMS Term: 20704 MEDSV DEF RBRVS 01/01/2020 12/31/2023 106.27 Description: MNL PREP&INSJ I-ARTIC RX DEV Category: Medical Services CMS Add: 01/01/2020 CMS Term: 20704 MEDSV DEF RBRVS 01/01/2024 135.20 Description: MNL PREP&INSJ I-ARTIC RX DEV Category: Medical Services CMS Add: 01/01/2020 CMS Term: 20705 MEDSV DEF RBRVS 01/01/2020 12/31/2023 87.58 Description: RMVL I-ARTIC RX DELIVERY DEV Category: Medical Services CMS Add: 01/01/2020 CMS Term: 20705 MEDSV DEF RBRVS 01/01/2024 114.35 Description: RMVL I-ARTIC RX DELIVERY DEV Category: Medical Services CMS Add: 01/01/2020 CMS Term: 20802 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1708.82 Description: REPLANTATION ARM COMPLETE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20802 MEDSV DEF RBRVS 01/01/2024 2525.03 Description: REPLANTATION ARM COMPLETE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20805 MEDSV DEF RBRVS 01/01/2019 12/31/2023 2197.07 Description: REPLANT FOREARM COMPLETE Category: Medical Services CMS Add: 01/01/1987 CMS Term: 20805 MEDSV DEF RBRVS 01/01/2024 2998.97 Description: REPLANT FOREARM COMPLETE Category: Medical Services CMS Add: 01/01/1987 CMS Term: 20808 MEDSV DEF RBRVS 01/01/2019 12/31/2023 2848.43 Description: REPLANTATION HAND COMPLETE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 146 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 20808 MEDSV DEF RBRVS 01/01/2024 3616.57 Description: REPLANTATION HAND COMPLETE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20816 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1444.45 Description: REPLANTATION DIGIT COMPLETE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20816 MEDSV DEF RBRVS 01/01/2024 1890.84 Description: REPLANTATION DIGIT COMPLETE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20822 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1307.37 Description: REPLANTATION DIGIT COMPLETE Category: Medical Services CMS Add: 01/01/1987 CMS Term: 20822 MEDSV DEF RBRVS 01/01/2024 1634.14 Description: REPLANTATION DIGIT COMPLETE Category: Medical Services CMS Add: 01/01/1987 CMS Term: 20824 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1532.82 Description: REPLANTATION THUMB COMPLETE Category: Medical Services CMS Add: 01/01/1987 CMS Term: 20824 MEDSV DEF RBRVS 01/01/2024 1894.23 Description: REPLANTATION THUMB COMPLETE Category: Medical Services CMS Add: 01/01/1987 CMS Term: 20827 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1305.21 Description: REPLANTATION THUMB COMPLETE Category: Medical Services CMS Add: 01/01/1987 CMS Term: 20827 MEDSV DEF RBRVS 01/01/2024 1677.95 Description: REPLANTATION THUMB COMPLETE Category: Medical Services CMS Add: 01/01/1987 CMS Term: 20838 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1913.40 Description: REPLANTATION FOOT COMPLETE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20838 MEDSV DEF RBRVS 01/01/2024 2563.66 Description: REPLANTATION FOOT COMPLETE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20900 MEDSV DEF RBRVS 01/01/2024 364.25 Description: REMOVAL OF BONE FOR GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20900 MEDSV DEF RBRVS 09/01/2019 12/31/2023 296.12 Description: REMOVAL OF BONE FOR GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20902 MEDSV DEF RBRVS 01/01/2024 254.69 Description: REMOVAL OF BONE FOR GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20902 MEDSV DEF RBRVS 09/01/2019 12/31/2023 206.37 Description: REMOVAL OF BONE FOR GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20910 MEDSV DEF RBRVS 01/01/2024 443.13 Description: REMOVE CARTILAGE FOR GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 147 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 20910 MEDSV DEF RBRVS 09/01/2019 12/31/2023 296.80 Description: REMOVE CARTILAGE FOR GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20912 MEDSV DEF RBRVS 01/01/2024 452.26 Description: REMOVE CARTILAGE FOR GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20912 MEDSV DEF RBRVS 09/01/2019 12/31/2023 347.96 Description: REMOVE CARTILAGE FOR GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20920 MEDSV DEF RBRVS 01/01/2024 376.33 Description: REMOVAL OF FASCIA FOR GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20920 MEDSV DEF RBRVS 09/01/2019 12/31/2023 286.27 Description: REMOVAL OF FASCIA FOR GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20922 MEDSV DEF RBRVS 01/01/2024 562.90 Description: REMOVAL OF FASCIA FOR GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20922 MEDSV DEF RBRVS 09/01/2019 12/31/2023 436.23 Description: REMOVAL OF FASCIA FOR GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20924 MEDSV DEF RBRVS 01/01/2024 470.89 Description: REMOVAL OF TENDON FOR GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20924 MEDSV DEF RBRVS 09/01/2019 12/31/2023 360.97 Description: REMOVAL OF TENDON FOR GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20930 NOCOV DEF SYSMAN Description: SP BONE ALGRFT MORSEL ADD-ON Category: Non Covered Services CMS Add: 01/01/1996 CMS Term: 20931 MEDSV DEF RBRVS 01/01/2019 12/31/2023 79.35 Description: SP BONE ALGRFT STRUCT ADD-ON Category: Medical Services CMS Add: 01/01/1996 CMS Term: 20931 MEDSV DEF RBRVS 01/01/2024 98.46 Description: SP BONE ALGRFT STRUCT ADD-ON Category: Medical Services CMS Add: 01/01/1996 CMS Term: 20932 MEDSV DEF RBRVS 01/01/2019 12/31/2023 519.16 Description: OSTEOART ALGRFT W/SURF & B1 Category: Medical Services CMS Add: 01/01/2019 CMS Term: 20932 MEDSV DEF RBRVS 01/01/2024 691.28 Description: OSTEOART ALGRFT W/SURF & B1 Category: Medical Services CMS Add: 01/01/2019 CMS Term: 20933 MEDSV DEF RBRVS 01/01/2019 12/31/2023 476.29 Description: HEMICRT INTRCLRY ALGRFT PRTL Category: Medical Services CMS Add: 01/01/2019 CMS Term: 20933 MEDSV DEF RBRVS 01/01/2024 634.81 Description: HEMICRT INTRCLRY ALGRFT PRTL Category: Medical Services CMS Add: 01/01/2019 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 148 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 20934 MEDSV DEF RBRVS 01/01/2019 12/31/2023 518.89 Description: INTERCALARY ALGRFT COMPL Category: Medical Services CMS Add: 01/01/2019 CMS Term: 20934 MEDSV DEF RBRVS 01/01/2024 690.94 Description: INTERCALARY ALGRFT COMPL Category: Medical Services CMS Add: 01/01/2019 CMS Term: 20936 NOCOV DEF SYSMAN Description: SP BONE AGRFT LOCAL ADD-ON Category: Non Covered Services CMS Add: 01/01/1996 CMS Term: 20937 MEDSV DEF RBRVS 01/01/2016 12/31/2023 119.88 Description: SP BONE AGRFT MORSEL ADD-ON Category: Medical Services CMS Add: 01/01/1996 CMS Term: 20937 MEDSV DEF RBRVS 01/01/2024 150.32 Description: SP BONE AGRFT MORSEL ADD-ON Category: Medical Services CMS Add: 01/01/1996 CMS Term: 20938 MEDSV DEF RBRVS 01/01/2016 12/31/2023 130.61 Description: SP BONE AGRFT STRUCT ADD-ON Category: Medical Services CMS Add: 01/01/1996 CMS Term: 20938 MEDSV DEF RBRVS 01/01/2024 163.45 Description: SP BONE AGRFT STRUCT ADD-ON Category: Medical Services CMS Add: 01/01/1996 CMS Term: 20939 MEDSV DEF RBRVS 01/01/2018 12/31/2023 48.92 Description: BONE MARROW ASPIR BONE GRFG Category: Medical Services CMS Add: 01/01/2018 CMS Term: 20939 MEDSV DEF RBRVS 01/01/2024 63.00 Description: BONE MARROW ASPIR BONE GRFG Category: Medical Services CMS Add: 01/01/2018 CMS Term: 20950 MEDSV DEF RBRVS 01/01/2024 245.36 Description: FLUID PRESSURE MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20950 MEDSV DEF RBRVS 09/01/2019 12/31/2023 175.71 Description: FLUID PRESSURE MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20955 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1821.73 Description: FIBULA BONE GRAFT MICROVASC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20955 MEDSV DEF RBRVS 01/01/2024 2295.73 Description: FIBULA BONE GRAFT MICROVASC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20956 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1900.38 Description: ILIAC BONE GRAFT MICROVASC Category: Medical Services CMS Add: 01/01/1997 CMS Term: 20956 MEDSV DEF RBRVS 01/01/2024 2429.12 Description: ILIAC BONE GRAFT MICROVASC Category: Medical Services CMS Add: 01/01/1997 CMS Term: 20957 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1648.73 Description: MT BONE GRAFT MICROVASC Category: Medical Services CMS Add: 01/01/1997 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 149 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 20957 MEDSV DEF RBRVS 01/01/2024 2529.94 Description: MT BONE GRAFT MICROVASC Category: Medical Services CMS Add: 01/01/1997 CMS Term: 20962 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1579.34 Description: OTHER BONE GRAFT MICROVASC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20962 MEDSV DEF RBRVS 01/01/2024 2456.72 Description: OTHER BONE GRAFT MICROVASC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20969 MEDSV DEF RBRVS 01/01/2019 12/31/2023 2026.78 Description: BONE/SKIN GRAFT MICROVASC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20969 MEDSV DEF RBRVS 01/01/2024 2537.47 Description: BONE/SKIN GRAFT MICROVASC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20970 MEDSV DEF RBRVS 01/01/2019 12/31/2023 2056.14 Description: BONE/SKIN GRAFT ILIAC CREST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20970 MEDSV DEF RBRVS 01/01/2024 2619.19 Description: BONE/SKIN GRAFT ILIAC CREST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20972 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1629.55 Description: BONE/SKIN GRAFT METATARSAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20972 MEDSV DEF RBRVS 01/01/2024 2611.71 Description: BONE/SKIN GRAFT METATARSAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20973 MEDSV DEF RBRVS 01/01/2019 12/31/2023 2073.21 Description: BONE/SKIN GRAFT GREAT TOE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20973 MEDSV DEF RBRVS 01/01/2024 2758.40 Description: BONE/SKIN GRAFT GREAT TOE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20974 MEDSV DEF RBRVS 01/01/2024 75.92 Description: ELECTRICAL BONE STIMULATION Category: Medical Services CMS Add: 01/01/1982 CMS Term: 20974 MEDSV DEF RBRVS 02/01/2015 12/31/2023 53.16 Description: ELECTRICAL BONE STIMULATION Category: Medical Services CMS Add: 01/01/1982 CMS Term: 20975 MEDSV DEF RBRVS 01/01/2024 159.39 Description: ELECTRICAL BONE STIMULATION Category: Medical Services CMS Add: 01/01/1982 CMS Term: 20975 MEDSV DEF RBRVS 02/01/2015 12/31/2023 125.93 Description: ELECTRICAL BONE STIMULATION Category: Medical Services CMS Add: 01/01/1982 CMS Term: 20979 NOCOV DEF SYSMAN Description: US BONE STIMULATION Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 150 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 20982 MEDSV DEF RBRVS 01/01/2024 3280.33 Description: ABLATE BONE TUMOR(S) PERQ Category: Medical Services CMS Add: 01/01/2004 CMS Term: 20982 MEDSV DEF RBRVS 09/15/2017 12/31/2023 1206.80 Description: ABLATE BONE TUMOR(S) PERQ Category: Medical Services CMS Add: 01/01/2004 CMS Term: 20983 MEDSV DEF MAXFEE 01/01/2024 4782.98 0.0 Description: ABLATE BONE TUMOR(S) PERQ Category: Medical Services CMS Add: 01/01/2015 CMS Term: 20985 MEDSV DEF RBRVS 01/01/2024 132.75 Description: CPTR-ASST DIR MS PX Category: Medical Services CMS Add: 01/01/2008 CMS Term: 20985 MEDSV DEF RBRVS 02/01/2015 12/31/2023 106.15 Description: CPTR-ASST DIR MS PX Category: Medical Services CMS Add: 01/01/2008 CMS Term: 20999 MEDSV DEF BILL20 Description: UNLISTED PX MUSCSKEL GENERAL Category: Medical Services CMS Add: 01/01/1982 CMS Term: 21010 MEDSV DEF RBRVS 01/01/2024 701.78 Y Description: INCISION OF JAW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21010 MEDSV DEF RBRVS 09/01/2019 12/31/2023 542.28 Y Description: INCISION OF JAW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21011 MEDSV DEF RBRVS 01/01/2024 348.78 Description: EXC FACE LES SC <2 CM Category: Medical Services CMS Add: 01/01/2010 CMS Term: 21011 MEDSV DEF RBRVS 02/01/2015 12/31/2023 243.99 Description: EXC FACE LES SC <2 CM Category: Medical Services CMS Add: 01/01/2010 CMS Term: 21012 MEDSV DEF RBRVS 01/01/2024 315.01 Description: EXC FACE LES SBQ 2 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 21012 MEDSV DEF RBRVS 02/01/2015 12/31/2023 239.71 Description: EXC FACE LES SBQ 2 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 21013 MEDSV DEF RBRVS 01/01/2024 501.04 Description: EXC FACE TUM DEEP < 2 CM Category: Medical Services CMS Add: 01/01/2010 CMS Term: 21013 MEDSV DEF RBRVS 02/01/2015 12/31/2023 365.35 Description: EXC FACE TUM DEEP < 2 CM Category: Medical Services CMS Add: 01/01/2010 CMS Term: 21014 MEDSV DEF RBRVS 01/01/2024 486.37 Description: EXC FACE TUM DEEP 2 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 21014 MEDSV DEF RBRVS 02/01/2015 12/31/2023 370.92 Description: EXC FACE TUM DEEP 2 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 151 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21015 MEDSV DEF RBRVS 01/01/2024 651.60 Description: RESECT FACE/SCALP TUM < 2 CM Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21015 MEDSV DEF RBRVS 09/01/2019 12/31/2023 510.14 Description: RESECT FACE/SCALP TUM < 2 CM Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21016 MEDSV DEF RBRVS 01/01/2024 935.90 Description: RESECT FACE/SCALP TUM 2 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 21016 MEDSV DEF RBRVS 02/01/2015 12/31/2023 744.02 Description: RESECT FACE/SCALP TUM 2 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 21025 MEDSV DEF RBRVS 01/01/2024 744.21 Description: EXCISION OF BONE LOWER JAW Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21025 MEDSV DEF RBRVS 09/01/2019 12/31/2023 641.80 Description: EXCISION OF BONE LOWER JAW Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21026 MEDSV DEF RBRVS 01/01/2024 501.94 Description: EXCISION OF FACIAL BONE(S) Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21026 MEDSV DEF RBRVS 09/01/2019 12/31/2023 442.89 Description: EXCISION OF FACIAL BONE(S) Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21029 MEDSV DEF RBRVS 01/01/2024 719.80 Description: CONTOUR OF FACE BONE LESION Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21029 MEDSV DEF RBRVS 09/01/2019 12/31/2023 556.71 Description: CONTOUR OF FACE BONE LESION Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21030 MEDSV DEF RBRVS 01/01/2024 432.65 Description: EXCISE MAX/ZYGOMA B9 TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21030 MEDSV DEF RBRVS 09/01/2019 12/31/2023 373.36 Description: EXCISE MAX/ZYGOMA B9 TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21031 MEDSV DEF RBRVS 01/01/2024 359.64 Description: REMOVE EXOSTOSIS MANDIBLE Category: Medical Services CMS Add: 01/01/1990 CMS Term: 21031 MEDSV DEF RBRVS 09/01/2019 12/31/2023 281.63 Description: REMOVE EXOSTOSIS MANDIBLE Category: Medical Services CMS Add: 01/01/1990 CMS Term: 21032 MEDSV DEF RBRVS 01/01/2024 348.03 Description: REMOVE EXOSTOSIS MAXILLA Category: Medical Services CMS Add: 01/01/1990 CMS Term: 21032 MEDSV DEF RBRVS 09/01/2019 12/31/2023 286.59 Description: REMOVE EXOSTOSIS MAXILLA Category: Medical Services CMS Add: 01/01/1990 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 152 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21034 MEDSV DEF RBRVS 01/01/2024 1217.85 Description: EXCISE MAX/ZYGOMA MAL TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21034 MEDSV DEF RBRVS 09/01/2019 12/31/2023 952.57 Description: EXCISE MAX/ZYGOMA MAL TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21040 MEDSV DEF RBRVS 01/01/2024 438.22 Description: EXCISE MANDIBLE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21040 MEDSV DEF RBRVS 09/01/2019 12/31/2023 376.17 Description: EXCISE MANDIBLE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21044 MEDSV DEF RBRVS 01/01/2024 809.68 Description: REMOVAL OF JAW BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21044 MEDSV DEF RBRVS 09/01/2019 12/31/2023 640.26 Description: REMOVAL OF JAW BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21045 MEDSV DEF RBRVS 01/01/2024 1126.43 Description: EXTENSIVE JAW SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21045 MEDSV DEF RBRVS 09/01/2019 12/31/2023 891.07 Description: EXTENSIVE JAW SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21046 MEDSV DEF RBRVS 01/01/2019 12/31/2023 805.64 Description: REMOVE MANDIBLE CYST COMPLEX Category: Medical Services CMS Add: 01/01/2003 CMS Term: 21046 MEDSV DEF RBRVS 01/01/2024 933.49 Description: REMOVE MANDIBLE CYST COMPLEX Category: Medical Services CMS Add: 01/01/2003 CMS Term: 21047 MEDSV DEF RBRVS 01/01/2024 1146.07 Description: EXCISE LWR JAW CYST W/REPAIR Category: Medical Services CMS Add: 01/01/2003 CMS Term: 21047 MEDSV DEF RBRVS 02/01/2015 12/31/2023 950.78 Description: EXCISE LWR JAW CYST W/REPAIR Category: Medical Services CMS Add: 01/01/2003 CMS Term: 21048 MEDSV DEF RBRVS 01/01/2019 12/31/2023 827.66 Description: REMOVE MAXILLA CYST COMPLEX Category: Medical Services CMS Add: 01/01/2003 CMS Term: 21048 MEDSV DEF RBRVS 01/01/2024 939.99 Description: REMOVE MAXILLA CYST COMPLEX Category: Medical Services CMS Add: 01/01/2003 CMS Term: 21049 MEDSV DEF RBRVS 01/01/2024 1084.70 Description: EXCIS UPPR JAW CYST W/REPAIR Category: Medical Services CMS Add: 01/01/2003 CMS Term: 21049 MEDSV DEF RBRVS 02/01/2015 12/31/2023 887.36 Description: EXCIS UPPR JAW CYST W/REPAIR Category: Medical Services CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 153 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21050 MEDSV DEF RBRVS 01/01/2024 816.05 Description: REMOVAL OF JAW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21050 MEDSV DEF RBRVS 09/01/2019 12/31/2023 621.08 Description: REMOVAL OF JAW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21060 MEDSV DEF RBRVS 01/01/2024 740.77 Description: REMOVE JAW JOINT CARTILAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21060 MEDSV DEF RBRVS 09/01/2019 12/31/2023 594.28 Description: REMOVE JAW JOINT CARTILAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21070 MEDSV DEF RBRVS 01/01/2024 574.61 Description: REMOVE CORONOID PROCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21070 MEDSV DEF RBRVS 09/01/2019 12/31/2023 445.88 Description: REMOVE CORONOID PROCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21073 MEDSV DEF RBRVS 01/01/2024 352.55 Description: MNPJ OF TMJ W/ANESTH Category: Medical Services CMS Add: 01/01/2008 CMS Term: 21073 MEDSV DEF RBRVS 02/01/2015 12/31/2023 278.81 Description: MNPJ OF TMJ W/ANESTH Category: Medical Services CMS Add: 01/01/2008 CMS Term: 21076 MEDSV DEF RBRVS 01/01/2024 813.98 Description: PREPARE FACE/ORAL PROSTHESIS Category: Medical Services CMS Add: 01/01/1996 CMS Term: 21076 MEDSV DEF RBRVS 02/01/2015 12/31/2023 722.36 Description: PREPARE FACE/ORAL PROSTHESIS Category: Medical Services CMS Add: 01/01/1996 CMS Term: 21077 MEDSV DEF RBRVS 01/01/2024 1997.69 Description: PREPARE FACE/ORAL PROSTHESIS Category: Medical Services CMS Add: 01/01/1996 CMS Term: 21077 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1814.32 Description: PREPARE FACE/ORAL PROSTHESIS Category: Medical Services CMS Add: 01/01/1996 CMS Term: 21079 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1217.64 Description: PREPARE FACE/ORAL PROSTHESIS Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21079 MEDSV DEF RBRVS 01/01/2024 1366.03 Description: PREPARE FACE/ORAL PROSTHESIS Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21080 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1368.65 Description: PREPARE FACE/ORAL PROSTHESIS Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21080 MEDSV DEF RBRVS 01/01/2024 1570.10 Description: PREPARE FACE/ORAL PROSTHESIS Category: Medical Services CMS Add: 01/01/1991 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 154 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21081 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1264.19 Description: PREPARE FACE/ORAL PROSTHESIS Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21081 MEDSV DEF RBRVS 01/01/2024 1447.51 Description: PREPARE FACE/ORAL PROSTHESIS Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21082 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1198.79 Description: PREPARE FACE/ORAL PROSTHESIS Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21082 MEDSV DEF RBRVS 01/01/2024 1336.20 Description: PREPARE FACE/ORAL PROSTHESIS Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21083 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1124.48 Description: PREPARE FACE/ORAL PROSTHESIS Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21083 MEDSV DEF RBRVS 01/01/2024 1275.02 Description: PREPARE FACE/ORAL PROSTHESIS Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21084 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1301.73 Description: PREPARE FACE/ORAL PROSTHESIS Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21084 MEDSV DEF RBRVS 01/01/2024 1455.92 Description: PREPARE FACE/ORAL PROSTHESIS Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21085 MEDSV DEF RBRVS 01/01/2019 12/31/2023 583.49 Description: PREPARE FACE/ORAL PROSTHESIS Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21085 MEDSV DEF RBRVS 01/01/2024 635.86 Description: PREPARE FACE/ORAL PROSTHESIS Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21086 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1351.18 Description: PREPARE FACE/ORAL PROSTHESIS Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21086 MEDSV DEF RBRVS 01/01/2024 1485.71 Description: PREPARE FACE/ORAL PROSTHESIS Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21087 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1351.18 Description: PREPARE FACE/ORAL PROSTHESIS Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21087 MEDSV DEF RBRVS 01/01/2024 1485.71 Description: PREPARE FACE/ORAL PROSTHESIS Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21088 MEDSV DEF BILL20 Description: PREPARE FACE/ORAL PROSTHESIS Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21089 MEDSV DEF BILL20 Description: UNLISTED MAXLFCL PROSTH PX Category: Medical Services CMS Add: 01/01/1991 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 155 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21100 MEDSV DEF RBRVS 01/01/2024 581.66 Description: MAXILLOFACIAL FIXATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21100 MEDSV DEF RBRVS 09/01/2019 12/31/2023 505.26 Description: MAXILLOFACIAL FIXATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21110 MEDSV DEF RBRVS 01/01/2024 810.91 Y Description: INTERDENTAL FIXATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21110 MEDSV DEF RBRVS 09/01/2019 12/31/2023 575.28 Y Description: INTERDENTAL FIXATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21116 MEDSV DEF RBRVS 01/01/2024 202.54 Description: INJECTION JAW JOINT X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21116 MEDSV DEF RBRVS 09/01/2019 12/31/2023 101.61 Description: INJECTION JAW JOINT X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21120 MEDSV DEF RBRVS 01/01/2024 618.13 Y Description: RECONSTRUCTION OF CHIN Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21120 MEDSV DEF RBRVS 09/01/2019 12/31/2023 473.10 Y Description: RECONSTRUCTION OF CHIN Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21121 MEDSV DEF RBRVS 01/01/2024 597.01 Y Description: RECONSTRUCTION OF CHIN Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21121 MEDSV DEF RBRVS 09/01/2019 12/31/2023 552.10 Y Description: RECONSTRUCTION OF CHIN Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21122 MEDSV DEF RBRVS 01/01/2024 697.21 Y Description: RECONSTRUCTION OF CHIN Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21122 MEDSV DEF RBRVS 09/01/2019 12/31/2023 504.44 Y Description: RECONSTRUCTION OF CHIN Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21123 MEDSV DEF RBRVS 01/01/2024 800.40 Y Description: RECONSTRUCTION OF CHIN Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21123 MEDSV DEF RBRVS 09/01/2019 12/31/2023 638.43 Y Description: RECONSTRUCTION OF CHIN Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21125 MEDSV DEF RBRVS 01/01/2024 2454.93 Y Description: AUGMENTATION LOWER JAW BONE Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21125 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2165.30 Y Description: AUGMENTATION LOWER JAW BONE Category: Medical Services CMS Add: 01/01/1991 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 156 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21127 MEDSV DEF RBRVS 01/01/2024 3746.70 Y Description: AUGMENTATION LOWER JAW BONE Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21127 MEDSV DEF RBRVS 09/01/2019 12/31/2023 3007.91 Y Description: AUGMENTATION LOWER JAW BONE Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21137 MEDSV DEF RBRVS 01/01/2019 12/31/2023 543.74 Y Description: REDUCTION OF FOREHEAD Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21137 MEDSV DEF RBRVS 01/01/2024 698.62 Y Description: REDUCTION OF FOREHEAD Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21138 MEDSV DEF RBRVS 01/01/2019 12/31/2023 661.38 Y Description: REDUCTION OF FOREHEAD Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21138 MEDSV DEF RBRVS 01/01/2024 850.10 Y Description: REDUCTION OF FOREHEAD Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21139 MEDSV DEF RBRVS 01/01/2019 12/31/2023 784.62 Y Description: REDUCTION OF FOREHEAD Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21139 MEDSV DEF RBRVS 01/01/2024 1013.51 Y Description: REDUCTION OF FOREHEAD Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21141 MEDSV DEF RBRVS 01/01/2024 1257.97 Description: LEFORT I-1 PIECE W/O GRAFT Category: Medical Services CMS Add: 01/01/1996 CMS Term: 21141 MEDSV DEF RBRVS 02/01/2015 12/31/2023 985.66 Description: LEFORT I-1 PIECE W/O GRAFT Category: Medical Services CMS Add: 01/01/1996 CMS Term: 21142 MEDSV DEF RBRVS 01/01/2024 1291.33 Description: LEFORT I-2 PIECE W/O GRAFT Category: Medical Services CMS Add: 01/01/1996 CMS Term: 21142 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1013.91 Description: LEFORT I-2 PIECE W/O GRAFT Category: Medical Services CMS Add: 01/01/1996 CMS Term: 21143 MEDSV DEF RBRVS 01/01/2024 1330.59 Description: LEFORT I-3/> PIECE W/O GRAFT Category: Medical Services CMS Add: 01/01/1996 CMS Term: 21143 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1025.35 Description: LEFORT I-3/> PIECE W/O GRAFT Category: Medical Services CMS Add: 01/01/1996 CMS Term: 21145 MEDSV DEF RBRVS 01/01/2024 1463.77 Description: LEFORT I-1 PIECE W/ GRAFT Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21145 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1111.39 Description: LEFORT I-1 PIECE W/ GRAFT Category: Medical Services CMS Add: 01/01/1991 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 157 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21146 MEDSV DEF RBRVS 01/01/2024 1528.21 Description: LEFORT I-2 PIECE W/ GRAFT Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21146 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1253.74 Description: LEFORT I-2 PIECE W/ GRAFT Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21147 MEDSV DEF RBRVS 01/01/2024 1609.26 Description: LEFORT I-3/> PIECE W/ GRAFT Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21147 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1117.44 Description: LEFORT I-3/> PIECE W/ GRAFT Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21150 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1321.07 Description: LEFORT II ANTERIOR INTRUSION Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21150 MEDSV DEF RBRVS 01/01/2024 1542.33 Description: LEFORT II ANTERIOR INTRUSION Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21151 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1480.91 Description: LEFORT II W/BONE GRAFTS Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21151 MEDSV DEF RBRVS 01/01/2024 1697.56 Description: LEFORT II W/BONE GRAFTS Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21154 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1612.42 Description: LEFORT III W/O LEFORT I Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21154 MEDSV DEF RBRVS 01/01/2024 1826.71 Description: LEFORT III W/O LEFORT I Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21155 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1650.12 Description: LEFORT III W/ LEFORT I Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21155 MEDSV DEF RBRVS 01/01/2024 2026.01 Description: LEFORT III W/ LEFORT I Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21159 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1822.64 Description: LEFORT III W/FHDW/O LEFORT I Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21159 MEDSV DEF RBRVS 01/01/2024 2427.58 Description: LEFORT III W/FHDW/O LEFORT I Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21160 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1935.73 Description: LEFORT III W/FHD W/ LEFORT I Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21160 MEDSV DEF RBRVS 01/01/2024 2632.97 Description: LEFORT III W/FHD W/ LEFORT I Category: Medical Services CMS Add: 01/01/1991 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 158 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21172 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1362.77 Description: RECONSTRUCT ORBIT/FOREHEAD Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21172 MEDSV DEF RBRVS 01/01/2024 1889.45 Description: RECONSTRUCT ORBIT/FOREHEAD Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21175 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1497.68 Description: RECONSTRUCT ORBIT/FOREHEAD Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21175 MEDSV DEF RBRVS 01/01/2024 2049.33 Description: RECONSTRUCT ORBIT/FOREHEAD Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21179 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1120.52 Description: RECONSTRUCT ENTIRE FOREHEAD Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21179 MEDSV DEF RBRVS 01/01/2024 1410.35 Description: RECONSTRUCT ENTIRE FOREHEAD Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21180 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1119.55 Description: RECONSTRUCT ENTIRE FOREHEAD Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21180 MEDSV DEF RBRVS 01/01/2024 1574.97 Description: RECONSTRUCT ENTIRE FOREHEAD Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21181 MEDSV DEF RBRVS 01/01/2019 12/31/2023 524.50 Description: CONTOUR CRANIAL BONE LESION Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21181 MEDSV DEF RBRVS 01/01/2024 689.79 Description: CONTOUR CRANIAL BONE LESION Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21182 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1401.43 Description: RECONSTRUCT CRANIAL BONE Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21182 MEDSV DEF RBRVS 01/01/2024 1959.82 Description: RECONSTRUCT CRANIAL BONE Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21183 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1717.06 Description: RECONSTRUCT CRANIAL BONE Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21183 MEDSV DEF RBRVS 01/01/2024 2131.83 Description: RECONSTRUCT CRANIAL BONE Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21184 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1598.75 Description: RECONSTRUCT CRANIAL BONE Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21184 MEDSV DEF RBRVS 01/01/2024 2292.40 Description: RECONSTRUCT CRANIAL BONE Category: Medical Services CMS Add: 01/01/1991 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 159 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21188 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1142.70 Description: RECONSTRUCTION OF MIDFACE Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21188 MEDSV DEF RBRVS 01/01/2024 1492.21 Description: RECONSTRUCTION OF MIDFACE Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21193 MEDSV DEF RBRVS 01/01/2024 1162.99 Description: RECONST LWR JAW W/O GRAFT Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21193 MEDSV DEF RBRVS 09/01/2019 12/31/2023 931.50 Description: RECONST LWR JAW W/O GRAFT Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21194 MEDSV DEF RBRVS 01/01/2024 1345.17 Description: RECONST LWR JAW W/GRAFT Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21194 MEDSV DEF RBRVS 09/01/2019 12/31/2023 995.90 Description: RECONST LWR JAW W/GRAFT Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21195 MEDSV DEF RBRVS 01/01/2024 1265.66 Description: RECONST LWR JAW W/O FIXATION Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21195 MEDSV DEF RBRVS 09/01/2019 12/31/2023 970.09 Description: RECONST LWR JAW W/O FIXATION Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21196 MEDSV DEF RBRVS 01/01/2024 1352.45 Y Description: RECONST LWR JAW W/FIXATION Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21196 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1075.16 Y Description: RECONST LWR JAW W/FIXATION Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21198 MEDSV DEF RBRVS 01/01/2024 962.29 Description: RECONSTR LWR JAW SEGMENT Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21198 MEDSV DEF RBRVS 09/01/2019 12/31/2023 843.13 Description: RECONSTR LWR JAW SEGMENT Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21199 MEDSV DEF RBRVS 01/01/2024 961.49 Y Y Description: RECONSTR LWR JAW W/ADVANCE Category: Medical Services CMS Add: 01/01/2001 CMS Term: 21199 MEDSV DEF RBRVS 02/01/2015 12/31/2023 766.17 Y Y Description: RECONSTR LWR JAW W/ADVANCE Category: Medical Services CMS Add: 01/01/2001 CMS Term: 21206 MEDSV DEF RBRVS 01/01/2024 918.44 Y Description: RECONSTRUCT UPPER JAW BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21206 MEDSV DEF RBRVS 09/01/2019 12/31/2023 864.85 Y Description: RECONSTRUCT UPPER JAW BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 160 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21208 MEDSV DEF RBRVS 01/01/2024 1542.61 Y Description: AUGMENTATION OF FACIAL BONES Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21208 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1355.00 Y Description: AUGMENTATION OF FACIAL BONES Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21209 MEDSV DEF RBRVS 01/01/2024 770.63 Y Description: REDUCTION OF FACIAL BONES Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21209 MEDSV DEF RBRVS 09/01/2019 12/31/2023 594.07 Y Description: REDUCTION OF FACIAL BONES Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21210 MEDSV DEF RBRVS 01/01/2024 1655.81 Y Description: FACE BONE GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21210 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1636.39 Y Description: FACE BONE GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21215 MEDSV DEF RBRVS 01/01/2024 3826.33 Y Description: LOWER JAW BONE GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21215 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2928.70 Y Description: LOWER JAW BONE GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21230 MEDSV DEF RBRVS 01/01/2024 700.26 Y Description: RIB CARTILAGE GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21230 MEDSV DEF RBRVS 09/01/2019 12/31/2023 530.58 Y Description: RIB CARTILAGE GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21235 MEDSV DEF RBRVS 01/01/2024 689.19 Y Description: EAR CARTILAGE GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21235 MEDSV DEF RBRVS 09/01/2019 12/31/2023 520.07 Y Description: EAR CARTILAGE GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21240 MEDSV DEF RBRVS 01/01/2024 993.61 Description: RECONSTRUCTION OF JAW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21240 MEDSV DEF RBRVS 09/01/2019 12/31/2023 802.60 Description: RECONSTRUCTION OF JAW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21242 MEDSV DEF RBRVS 01/01/2024 955.06 Description: RECONSTRUCTION OF JAW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21242 MEDSV DEF RBRVS 09/01/2019 12/31/2023 735.59 Description: RECONSTRUCTION OF JAW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 161 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21243 MEDSV DEF RBRVS 01/01/2024 1581.51 Description: RECONSTRUCTION OF JAW JOINT Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21243 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1218.99 Description: RECONSTRUCTION OF JAW JOINT Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21244 MEDSV DEF RBRVS 01/01/2024 947.06 Y Description: RECONSTRUCTION OF LOWER JAW Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21244 MEDSV DEF RBRVS 09/01/2019 12/31/2023 774.51 Y Description: RECONSTRUCTION OF LOWER JAW Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21245 MEDSV DEF RBRVS 01/01/2024 1156.58 Y Description: RECONSTRUCTION OF JAW Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21245 MEDSV DEF RBRVS 09/01/2019 12/31/2023 803.52 Y Description: RECONSTRUCTION OF JAW Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21246 MEDSV DEF RBRVS 01/01/2024 802.49 Y Description: RECONSTRUCTION OF JAW Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21246 MEDSV DEF RBRVS 09/01/2019 12/31/2023 598.90 Y Description: RECONSTRUCTION OF JAW Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21247 MEDSV DEF RBRVS 01/01/2024 1491.95 Y Description: RECONSTRUCT LOWER JAW BONE Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21247 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1141.88 Y Description: RECONSTRUCT LOWER JAW BONE Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21248 MEDSV DEF RBRVS 01/01/2024 924.76 Y Description: RECONSTRUCTION OF JAW Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21248 MEDSV DEF RBRVS 09/01/2019 12/31/2023 799.33 Y Description: RECONSTRUCTION OF JAW Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21249 MEDSV DEF RBRVS 01/01/2024 1255.44 Y Description: RECONSTRUCTION OF JAW Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21249 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1098.42 Y Description: RECONSTRUCTION OF JAW Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21255 MEDSV DEF RBRVS 01/01/2024 1261.50 Y Description: RECONSTRUCT LOWER JAW BONE Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21255 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1005.78 Y Description: RECONSTRUCT LOWER JAW BONE Category: Medical Services CMS Add: 01/01/1991 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 162 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21256 MEDSV DEF RBRVS 01/01/2024 1150.67 Description: RECONSTRUCTION OF ORBIT Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21256 MEDSV DEF RBRVS 09/01/2019 12/31/2023 893.87 Description: RECONSTRUCTION OF ORBIT Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21260 MEDSV DEF RBRVS 01/01/2024 1272.13 Description: REVISE EYE SOCKETS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21260 MEDSV DEF RBRVS 09/01/2019 12/31/2023 979.25 Description: REVISE EYE SOCKETS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21261 MEDSV DEF RBRVS 01/01/2024 2251.44 Description: REVISE EYE SOCKETS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21261 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1565.59 Description: REVISE EYE SOCKETS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21263 MEDSV DEF RBRVS 01/01/2024 2082.85 Description: REVISE EYE SOCKETS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21263 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1382.60 Description: REVISE EYE SOCKETS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21267 MEDSV DEF RBRVS 01/01/2024 1487.87 Description: REVISE EYE SOCKETS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21267 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1191.55 Description: REVISE EYE SOCKETS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21268 MEDSV DEF RBRVS 01/01/2024 1865.67 Description: REVISE EYE SOCKETS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21268 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1288.82 Description: REVISE EYE SOCKETS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21270 MEDSV DEF RBRVS 01/01/2024 944.19 Y Description: AUGMENTATION CHEEK BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21270 MEDSV DEF RBRVS 09/01/2019 12/31/2023 692.11 Y Description: AUGMENTATION CHEEK BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21275 MEDSV DEF RBRVS 01/01/2024 784.87 Description: REVISION ORBITOFACIAL BONES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21275 MEDSV DEF RBRVS 09/01/2019 12/31/2023 606.22 Description: REVISION ORBITOFACIAL BONES Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 163 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21280 MEDSV DEF RBRVS 01/01/2024 550.51 Description: REVISION OF EYELID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21280 MEDSV DEF RBRVS 09/01/2019 12/31/2023 421.78 Description: REVISION OF EYELID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21282 MEDSV DEF RBRVS 01/01/2024 372.72 Description: REVISION OF EYELID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21282 MEDSV DEF RBRVS 09/01/2019 12/31/2023 277.48 Description: REVISION OF EYELID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21295 MEDSV DEF RBRVS 01/01/2024 184.50 Y Description: REVISION OF JAW MUSCLE/BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21295 MEDSV DEF RBRVS 09/01/2019 12/31/2023 146.01 Y Description: REVISION OF JAW MUSCLE/BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21296 MEDSV DEF RBRVS 01/01/2024 383.62 Y Description: REVISION OF JAW MUSCLE/BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21296 MEDSV DEF RBRVS 09/01/2019 12/31/2023 333.21 Y Description: REVISION OF JAW MUSCLE/BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21299 MEDSV DEF BILL20 Y Y Description: UNLISTED CRANFCL&MAXLFCL PX Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21315 MEDSV DEF RBRVS 01/01/2024 141.16 Description: CLSD TX NSL FX MNPJ WO STBLJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21315 MEDSV DEF RBRVS 09/01/2019 12/31/2023 197.72 Description: CLSD TX NSL FX MNPJ WO STBLJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21320 MEDSV DEF RBRVS 01/01/2024 203.91 Description: CLSD TX NSL FX W/MNPJ&STABLJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21320 MEDSV DEF RBRVS 09/01/2019 12/31/2023 183.37 Description: CLSD TX NSL FX W/MNPJ&STABLJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21325 MEDSV DEF RBRVS 01/01/2024 418.49 Description: OPEN TX NOSE FX UNCOMPLICATD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21325 MEDSV DEF RBRVS 09/01/2019 12/31/2023 336.66 Description: OPEN TX NOSE FX UNCOMPLICATD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21330 MEDSV DEF RBRVS 01/01/2024 503.30 Description: OPEN TX NOSE FX W/SKELE FIXJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 164 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21330 MEDSV DEF RBRVS 09/01/2019 12/31/2023 404.44 Description: OPEN TX NOSE FX W/SKELE FIXJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21335 MEDSV DEF RBRVS 01/01/2024 672.20 Description: OPEN TX NOSE & SEPTAL FX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21335 MEDSV DEF RBRVS 09/01/2019 12/31/2023 526.98 Description: OPEN TX NOSE & SEPTAL FX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21336 MEDSV DEF RBRVS 01/01/2024 597.73 Description: OPEN TX SEPTAL FX W/WO STABJ Category: Medical Services CMS Add: 01/01/1993 CMS Term: 21336 MEDSV DEF RBRVS 09/01/2019 12/31/2023 464.54 Description: OPEN TX SEPTAL FX W/WO STABJ Category: Medical Services CMS Add: 01/01/1993 CMS Term: 21337 MEDSV DEF RBRVS 01/01/2024 392.28 Description: CLOSED TX SEPTAL&NOSE FX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21337 MEDSV DEF RBRVS 09/01/2019 12/31/2023 289.34 Description: CLOSED TX SEPTAL&NOSE FX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21338 MEDSV DEF RBRVS 01/01/2024 631.53 Description: OPEN NASOETHMOID FX W/O FIXJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21338 MEDSV DEF RBRVS 09/01/2019 12/31/2023 512.73 Description: OPEN NASOETHMOID FX W/O FIXJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21339 MEDSV DEF RBRVS 01/01/2024 714.24 Description: OPEN NASOETHMOID FX W/ FIXJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21339 MEDSV DEF RBRVS 09/01/2019 12/31/2023 554.13 Description: OPEN NASOETHMOID FX W/ FIXJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21340 MEDSV DEF RBRVS 01/01/2024 708.57 Description: PERQ TX NASOETHMOID FX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21340 MEDSV DEF RBRVS 09/01/2019 12/31/2023 545.94 Description: PERQ TX NASOETHMOID FX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21343 MEDSV DEF RBRVS 01/01/2024 1022.99 Description: OPEN TX DPRSD FRONT SINUS FX Category: Medical Services CMS Add: 01/01/1990 CMS Term: 21343 MEDSV DEF RBRVS 09/01/2019 12/31/2023 873.42 Description: OPEN TX DPRSD FRONT SINUS FX Category: Medical Services CMS Add: 01/01/1990 CMS Term: 21344 MEDSV DEF RBRVS 01/01/2024 1311.50 Description: OPEN TX COMPL FRONT SINUS FX Category: Medical Services CMS Add: 01/01/1993 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 165 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21344 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1090.96 Description: OPEN TX COMPL FRONT SINUS FX Category: Medical Services CMS Add: 01/01/1993 CMS Term: 21345 MEDSV DEF RBRVS 01/01/2024 754.88 Description: CLOSED TX NOSE/JAW FX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21345 MEDSV DEF RBRVS 09/01/2019 12/31/2023 558.44 Description: CLOSED TX NOSE/JAW FX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21346 MEDSV DEF RBRVS 01/01/2024 963.59 Description: OPN TX NASOMAX FX W/FIXJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21346 MEDSV DEF RBRVS 09/01/2019 12/31/2023 658.07 Description: OPN TX NASOMAX FX W/FIXJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21347 MEDSV DEF RBRVS 01/01/2024 977.63 Description: OPN TX NASOMAX FX MULTPLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21347 MEDSV DEF RBRVS 09/01/2019 12/31/2023 799.09 Description: OPN TX NASOMAX FX MULTPLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21348 MEDSV DEF RBRVS 01/01/2024 1028.77 Description: OPN TX NASOMAX FX W/GRAFT Category: Medical Services CMS Add: 01/01/1993 CMS Term: 21348 MEDSV DEF RBRVS 09/01/2019 12/31/2023 858.24 Description: OPN TX NASOMAX FX W/GRAFT Category: Medical Services CMS Add: 01/01/1993 CMS Term: 21355 MEDSV DEF RBRVS 01/01/2024 421.51 Description: PERQ TX MALAR FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21355 MEDSV DEF RBRVS 09/01/2019 12/31/2023 309.81 Description: PERQ TX MALAR FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21356 MEDSV DEF RBRVS 01/01/2024 508.46 Description: OPN TX DPRSD ZYGOMATIC ARCH Category: Medical Services CMS Add: 01/01/1993 CMS Term: 21356 MEDSV DEF RBRVS 09/01/2019 12/31/2023 357.75 Description: OPN TX DPRSD ZYGOMATIC ARCH Category: Medical Services CMS Add: 01/01/1993 CMS Term: 21360 MEDSV DEF RBRVS 01/01/2024 493.76 Description: OPN TX DPRSD MALAR FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21360 MEDSV DEF RBRVS 09/01/2019 12/31/2023 387.89 Description: OPN TX DPRSD MALAR FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21365 MEDSV DEF RBRVS 01/01/2024 1014.74 Description: OPN TX COMPLX MALAR FX Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 166 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21365 MEDSV DEF RBRVS 09/01/2019 12/31/2023 809.69 Description: OPN TX COMPLX MALAR FX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21366 MEDSV DEF RBRVS 01/01/2024 1184.96 Description: OPN TX COMPLX MALAR W/GRFT Category: Medical Services CMS Add: 01/01/1993 CMS Term: 21366 MEDSV DEF RBRVS 09/01/2019 12/31/2023 857.21 Description: OPN TX COMPLX MALAR W/GRFT Category: Medical Services CMS Add: 01/01/1993 CMS Term: 21385 MEDSV DEF RBRVS 01/01/2024 682.62 Description: OPN TX ORBIT FX TRANSANTRAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21385 MEDSV DEF RBRVS 09/01/2019 12/31/2023 496.42 Description: OPN TX ORBIT FX TRANSANTRAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21386 MEDSV DEF RBRVS 01/01/2024 643.72 Description: OPN TX ORBIT FX PERIORBITAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21386 MEDSV DEF RBRVS 09/01/2019 12/31/2023 503.86 Description: OPN TX ORBIT FX PERIORBITAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21387 MEDSV DEF RBRVS 01/01/2024 712.55 Description: OPN TX ORBIT FX COMBINED Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21387 MEDSV DEF RBRVS 09/01/2019 12/31/2023 528.61 Description: OPN TX ORBIT FX COMBINED Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21390 MEDSV DEF RBRVS 01/01/2024 753.40 Description: OPN TX ORBIT PERIORBTL IMPLT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21390 MEDSV DEF RBRVS 09/01/2019 12/31/2023 583.55 Description: OPN TX ORBIT PERIORBTL IMPLT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21395 MEDSV DEF RBRVS 01/01/2024 937.18 Description: OPN TX ORBIT PERIORBT W/GRFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21395 MEDSV DEF RBRVS 09/01/2019 12/31/2023 716.00 Description: OPN TX ORBIT PERIORBT W/GRFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21400 MEDSV DEF RBRVS 01/01/2024 200.42 Description: CLOSED TX ORBIT W/O MANIPULJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21400 MEDSV DEF RBRVS 09/01/2019 12/31/2023 136.99 Description: CLOSED TX ORBIT W/O MANIPULJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21401 MEDSV DEF RBRVS 01/01/2024 475.53 Description: CLOSED TX ORBIT W/MANIPULJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 167 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21401 MEDSV DEF RBRVS 09/01/2019 12/31/2023 350.56 Description: CLOSED TX ORBIT W/MANIPULJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21406 MEDSV DEF RBRVS 01/01/2024 543.74 Description: OPN TX ORBIT FX W/O IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21406 MEDSV DEF RBRVS 09/01/2019 12/31/2023 373.18 Description: OPN TX ORBIT FX W/O IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21407 MEDSV DEF RBRVS 01/01/2024 607.56 Description: OPN TX ORBIT FX W/IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21407 MEDSV DEF RBRVS 09/01/2019 12/31/2023 473.31 Description: OPN TX ORBIT FX W/IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21408 MEDSV DEF RBRVS 01/01/2024 839.63 Description: OPN TX ORBIT FX W/BONE GRFT Category: Medical Services CMS Add: 01/01/1993 CMS Term: 21408 MEDSV DEF RBRVS 09/01/2019 12/31/2023 652.70 Description: OPN TX ORBIT FX W/BONE GRFT Category: Medical Services CMS Add: 01/01/1993 CMS Term: 21421 MEDSV DEF RBRVS 01/01/2024 606.01 Description: TREAT MOUTH ROOF FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21421 MEDSV DEF RBRVS 09/01/2019 12/31/2023 546.53 Description: TREAT MOUTH ROOF FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21422 MEDSV DEF RBRVS 01/01/2024 590.97 Description: TREAT MOUTH ROOF FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21422 MEDSV DEF RBRVS 09/01/2019 12/31/2023 483.76 Description: TREAT MOUTH ROOF FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21423 MEDSV DEF RBRVS 01/01/2024 742.51 Description: TREAT MOUTH ROOF FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 21423 MEDSV DEF RBRVS 09/01/2019 12/31/2023 595.89 Description: TREAT MOUTH ROOF FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 21431 MEDSV DEF RBRVS 01/01/2024 654.71 Description: TREAT CRANIOFACIAL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21431 MEDSV DEF RBRVS 09/01/2019 12/31/2023 518.11 Description: TREAT CRANIOFACIAL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21432 MEDSV DEF RBRVS 01/01/2024 666.84 Description: TREAT CRANIOFACIAL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 168 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21432 MEDSV DEF RBRVS 09/01/2019 12/31/2023 473.14 Description: TREAT CRANIOFACIAL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21433 MEDSV DEF RBRVS 01/01/2024 1607.77 Description: TREAT CRANIOFACIAL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21433 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1266.13 Description: TREAT CRANIOFACIAL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21435 MEDSV DEF RBRVS 01/01/2024 1306.24 Description: TREAT CRANIOFACIAL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21435 MEDSV DEF RBRVS 09/01/2019 12/31/2023 922.11 Description: TREAT CRANIOFACIAL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21436 MEDSV DEF RBRVS 01/01/2024 1888.30 Description: TREAT CRANIOFACIAL FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 21436 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1484.85 Description: TREAT CRANIOFACIAL FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 21440 MEDSV DEF RBRVS 01/01/2024 644.25 Description: TREAT DENTAL RIDGE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21440 MEDSV DEF RBRVS 09/01/2019 12/31/2023 415.86 Description: TREAT DENTAL RIDGE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21445 MEDSV DEF RBRVS 01/01/2024 739.07 Description: TREAT DENTAL RIDGE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21445 MEDSV DEF RBRVS 09/01/2019 12/31/2023 553.72 Description: TREAT DENTAL RIDGE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21450 MEDSV DEF RBRVS 01/01/2024 555.53 Description: TREAT LOWER JAW FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21450 MEDSV DEF RBRVS 09/01/2019 12/31/2023 436.16 Description: TREAT LOWER JAW FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21451 MEDSV DEF RBRVS 01/01/2024 723.11 Description: TREAT LOWER JAW FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21451 MEDSV DEF RBRVS 09/01/2019 12/31/2023 548.15 Description: TREAT LOWER JAW FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21452 MEDSV DEF RBRVS 01/01/2024 697.22 Description: TREAT LOWER JAW FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 169 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21452 MEDSV DEF RBRVS 09/01/2019 12/31/2023 444.89 Description: TREAT LOWER JAW FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21453 MEDSV DEF RBRVS 01/01/2024 1024.08 Description: TREAT LOWER JAW FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21453 MEDSV DEF RBRVS 09/01/2019 12/31/2023 655.42 Description: TREAT LOWER JAW FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21454 MEDSV DEF RBRVS 01/01/2024 461.18 Description: TREAT LOWER JAW FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21454 MEDSV DEF RBRVS 09/01/2019 12/31/2023 425.73 Description: TREAT LOWER JAW FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21461 MEDSV DEF RBRVS 01/01/2024 1713.68 Description: TREAT LOWER JAW FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21461 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1535.37 Description: TREAT LOWER JAW FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21462 MEDSV DEF RBRVS 01/01/2024 1855.83 Description: TREAT LOWER JAW FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21462 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1619.52 Description: TREAT LOWER JAW FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21465 MEDSV DEF RBRVS 01/01/2024 753.82 Description: TREAT LOWER JAW FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21465 MEDSV DEF RBRVS 09/01/2019 12/31/2023 707.33 Description: TREAT LOWER JAW FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21470 MEDSV DEF RBRVS 01/01/2024 1088.28 Description: TREAT LOWER JAW FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21470 MEDSV DEF RBRVS 09/01/2019 12/31/2023 881.41 Description: TREAT LOWER JAW FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21480 MEDSV DEF RBRVS 01/01/2024 132.20 Description: RESET DISLOCATED JAW Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21480 MEDSV DEF RBRVS 09/01/2019 12/31/2023 71.05 Description: RESET DISLOCATED JAW Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21485 MEDSV DEF RBRVS 01/01/2024 909.81 Description: RESET DISLOCATED JAW Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 170 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21485 MEDSV DEF RBRVS 09/01/2019 12/31/2023 503.86 Description: RESET DISLOCATED JAW Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21490 MEDSV DEF RBRVS 01/01/2024 742.64 Description: REPAIR DISLOCATED JAW Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21490 MEDSV DEF RBRVS 09/01/2019 12/31/2023 673.04 Description: REPAIR DISLOCATED JAW Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21497 MEDSV DEF RBRVS 01/01/2024 665.67 Description: INTERDENTAL WIRING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21497 MEDSV DEF RBRVS 09/01/2019 12/31/2023 526.55 Description: INTERDENTAL WIRING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21499 MEDSV DEF BILL20 Y Description: UNLISTED MUSCSKEL PX HEAD Category: Medical Services CMS Add: 01/01/1982 CMS Term: 21501 MEDSV DEF RBRVS 01/01/2024 454.45 Description: DRAIN NECK/CHEST LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21501 MEDSV DEF RBRVS 09/01/2019 12/31/2023 321.95 Description: DRAIN NECK/CHEST LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21502 MEDSV DEF RBRVS 01/01/2024 465.27 Description: DRAIN CHEST LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21502 MEDSV DEF RBRVS 09/01/2019 12/31/2023 379.15 Description: DRAIN CHEST LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21510 MEDSV DEF RBRVS 01/01/2024 415.15 Description: DRAINAGE OF BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21510 MEDSV DEF RBRVS 09/01/2019 12/31/2023 316.54 Description: DRAINAGE OF BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21550 MEDSV DEF RBRVS 01/01/2024 250.14 Description: BIOPSY OF NECK/CHEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21550 MEDSV DEF RBRVS 09/01/2019 12/31/2023 186.33 Description: BIOPSY OF NECK/CHEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21552 MEDSV DEF RBRVS 01/01/2024 412.62 Description: EXC NECK LES SC 3 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 21552 MEDSV DEF RBRVS 02/01/2015 12/31/2023 316.65 Description: EXC NECK LES SC 3 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 171 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21554 MEDSV DEF RBRVS 01/01/2024 676.16 Description: EXC NECK TUM DEEP 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 21554 MEDSV DEF RBRVS 02/01/2015 12/31/2023 521.17 Description: EXC NECK TUM DEEP 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 21555 MEDSV DEF RBRVS 01/01/2024 404.68 Description: EXC NECK LES SC < 3 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21555 MEDSV DEF RBRVS 09/01/2019 12/31/2023 293.18 Description: EXC NECK LES SC < 3 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21556 MEDSV DEF RBRVS 01/01/2024 494.25 Description: EXC NECK TUM DEEP < 5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21556 MEDSV DEF RBRVS 09/01/2019 12/31/2023 381.69 Description: EXC NECK TUM DEEP < 5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21557 MEDSV DEF RBRVS 01/01/2024 881.57 Description: RESECT NECK THORAX TUMOR<5CM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21557 MEDSV DEF RBRVS 09/01/2019 12/31/2023 689.86 Description: RESECT NECK THORAX TUMOR<5CM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21558 MEDSV DEF RBRVS 01/01/2024 1237.06 Description: RESECT NECK TUMOR 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 21558 MEDSV DEF RBRVS 02/01/2015 12/31/2023 967.00 Description: RESECT NECK TUMOR 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 21600 MEDSV DEF RBRVS 01/01/2024 522.30 Description: PARTIAL REMOVAL OF RIB Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21600 MEDSV DEF RBRVS 09/01/2019 12/31/2023 400.67 Description: PARTIAL REMOVAL OF RIB Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21601 MEDSV DEF RBRVS 01/01/2020 12/31/2023 849.47 Description: EXC CHEST WALL TUMOR W/RIBS Category: Medical Services CMS Add: 01/01/2020 CMS Term: 21601 MEDSV DEF RBRVS 01/01/2024 1041.88 Description: EXC CHEST WALL TUMOR W/RIBS Category: Medical Services CMS Add: 01/01/2020 CMS Term: 21602 MEDSV DEF RBRVS 01/01/2020 12/31/2023 1140.21 Description: EXC CH WAL TUM W/O LYMPHADEC Category: Medical Services CMS Add: 01/01/2020 CMS Term: 21602 MEDSV DEF RBRVS 01/01/2024 1406.37 Description: EXC CH WAL TUM W/O LYMPHADEC Category: Medical Services CMS Add: 01/01/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 172 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21603 MEDSV DEF RBRVS 01/01/2020 12/31/2023 1260.99 Description: EXC CH WAL TUM W/LYMPHADEC Category: Medical Services CMS Add: 01/01/2020 CMS Term: 21603 MEDSV DEF RBRVS 01/01/2024 1531.79 Description: EXC CH WAL TUM W/LYMPHADEC Category: Medical Services CMS Add: 01/01/2020 CMS Term: 21610 MEDSV DEF RBRVS 01/01/2024 1025.84 Description: PARTIAL REMOVAL OF RIB Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21610 MEDSV DEF RBRVS 09/01/2019 12/31/2023 834.42 Description: PARTIAL REMOVAL OF RIB Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21615 MEDSV DEF RBRVS 01/01/2024 566.30 Description: REMOVAL OF RIB Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21615 MEDSV DEF RBRVS 09/01/2019 12/31/2023 452.37 Description: REMOVAL OF RIB Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21616 MEDSV DEF RBRVS 01/01/2024 645.24 Description: REMOVAL OF RIB AND NERVES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21616 MEDSV DEF RBRVS 09/01/2019 12/31/2023 607.51 Description: REMOVAL OF RIB AND NERVES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21620 MEDSV DEF RBRVS 01/01/2024 463.44 Description: PARTIAL REMOVAL OF STERNUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21620 MEDSV DEF RBRVS 09/01/2019 12/31/2023 363.39 Description: PARTIAL REMOVAL OF STERNUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21627 MEDSV DEF RBRVS 01/01/2024 502.37 Description: STERNAL DEBRIDEMENT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 21627 MEDSV DEF RBRVS 09/01/2019 12/31/2023 387.21 Description: STERNAL DEBRIDEMENT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 21630 MEDSV DEF RBRVS 01/01/2024 1219.96 Description: EXTENSIVE STERNUM SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21630 MEDSV DEF RBRVS 09/01/2019 12/31/2023 873.38 Description: EXTENSIVE STERNUM SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21632 MEDSV DEF RBRVS 01/01/2024 1101.61 Description: EXTENSIVE STERNUM SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21632 MEDSV DEF RBRVS 09/01/2019 12/31/2023 867.33 Description: EXTENSIVE STERNUM SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 173 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21685 MEDSV DEF RBRVS 01/01/2024 924.19 Description: HYOID MYOTOMY & SUSPENSION Category: Medical Services CMS Add: 01/01/2004 CMS Term: 21685 MEDSV DEF RBRVS 02/01/2015 12/31/2023 729.97 Description: HYOID MYOTOMY & SUSPENSION Category: Medical Services CMS Add: 01/01/2004 CMS Term: 21700 MEDSV DEF RBRVS 01/01/2024 322.28 Description: REVISION OF NECK MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21700 MEDSV DEF RBRVS 09/01/2019 12/31/2023 265.74 Description: REVISION OF NECK MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21705 MEDSV DEF RBRVS 01/01/2024 480.84 Description: REVISION OF NECK MUSCLE/RIB Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21705 MEDSV DEF RBRVS 09/01/2019 12/31/2023 397.42 Description: REVISION OF NECK MUSCLE/RIB Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21720 MEDSV DEF RBRVS 01/01/2024 480.72 Description: REVISION OF NECK MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21720 MEDSV DEF RBRVS 09/01/2019 12/31/2023 338.66 Description: REVISION OF NECK MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21725 MEDSV DEF RBRVS 01/01/2024 505.62 Description: REVISION OF NECK MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21725 MEDSV DEF RBRVS 09/01/2019 12/31/2023 337.03 Description: REVISION OF NECK MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21740 MEDSV DEF RBRVS 01/01/2024 928.82 Description: RECONSTRUCTION OF STERNUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21740 MEDSV DEF RBRVS 09/01/2019 12/31/2023 734.00 Description: RECONSTRUCTION OF STERNUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21742 MEDSV DEF MAXFEE 01/01/2024 750.06 0.0 Description: REPAIR STERN/NUSS W/O SCOPE Category: Medical Services CMS Add: 01/01/2003 CMS Term: 21743 MEDSV DEF MAXFEE 01/01/2024 944.40 0.0 Description: REPAIR STERNUM/NUSS W/SCOPE Category: Medical Services CMS Add: 01/01/2003 CMS Term: 21750 MEDSV DEF RBRVS 01/01/2024 615.43 Description: REPAIR OF STERNUM SEPARATION Category: Medical Services CMS Add: 01/01/1992 CMS Term: 21750 MEDSV DEF RBRVS 09/01/2019 12/31/2023 493.25 Description: REPAIR OF STERNUM SEPARATION Category: Medical Services CMS Add: 01/01/1992 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 174 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21811 MEDSV DEF RBRVS 01/01/2024 537.88 Description: OPTX OF RIB FX W/FIXJ SCOPE Category: Medical Services CMS Add: 01/01/2015 CMS Term: 21811 MEDSV DEF RBRVS 02/01/2015 12/31/2023 436.65 Description: OPTX OF RIB FX W/FIXJ SCOPE Category: Medical Services CMS Add: 01/01/2015 CMS Term: 21812 MEDSV DEF RBRVS 01/01/2024 652.16 Description: TREATMENT OF RIB FRACTURE Category: Medical Services CMS Add: 01/01/2015 CMS Term: 21812 MEDSV DEF RBRVS 02/01/2015 12/31/2023 523.52 Description: TREATMENT OF RIB FRACTURE Category: Medical Services CMS Add: 01/01/2015 CMS Term: 21813 MEDSV DEF RBRVS 01/01/2024 887.23 Description: TREATMENT OF RIB FRACTURE Category: Medical Services CMS Add: 01/01/2015 CMS Term: 21813 MEDSV DEF RBRVS 02/01/2015 12/31/2023 712.54 Description: TREATMENT OF RIB FRACTURE Category: Medical Services CMS Add: 01/01/2015 CMS Term: 21820 MEDSV DEF RBRVS 01/01/2024 141.81 Description: TREAT STERNUM FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21820 MEDSV DEF RBRVS 09/01/2019 12/31/2023 101.11 Description: TREAT STERNUM FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21825 MEDSV DEF RBRVS 01/01/2024 505.55 Description: TREAT STERNUM FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21825 MEDSV DEF RBRVS 09/01/2019 12/31/2023 390.82 Description: TREAT STERNUM FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21899 MEDSV DEF BILL20 Description: UNLISTED PX NECK/THORAX Category: Medical Services CMS Add: 01/01/1982 CMS Term: 21920 MEDSV DEF RBRVS 01/01/2024 240.26 Description: BIOPSY SOFT TISSUE OF BACK Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21920 MEDSV DEF RBRVS 09/01/2019 12/31/2023 182.78 Description: BIOPSY SOFT TISSUE OF BACK Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21925 MEDSV DEF RBRVS 01/01/2024 458.85 Description: BIOPSY SOFT TISSUE OF BACK Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21925 MEDSV DEF RBRVS 09/01/2019 12/31/2023 313.99 Description: BIOPSY SOFT TISSUE OF BACK Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21930 MEDSV DEF RBRVS 01/01/2024 467.25 Description: EXC BACK LES SC < 3 CM Category: Medical Services CMS Add: 01/01/1988 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 175 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21930 MEDSV DEF RBRVS 09/01/2019 12/31/2023 332.72 Description: EXC BACK LES SC < 3 CM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21931 MEDSV DEF RBRVS 01/01/2024 432.70 Description: EXC BACK LES SC 3 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 21931 MEDSV DEF RBRVS 02/01/2015 12/31/2023 333.65 Description: EXC BACK LES SC 3 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 21932 MEDSV DEF RBRVS 01/01/2024 613.48 Description: EXC BACK TUM DEEP < 5 CM Category: Medical Services CMS Add: 01/01/2010 CMS Term: 21932 MEDSV DEF RBRVS 02/01/2015 12/31/2023 469.13 Description: EXC BACK TUM DEEP < 5 CM Category: Medical Services CMS Add: 01/01/2010 CMS Term: 21933 MEDSV DEF RBRVS 01/01/2024 679.69 Description: EXC BACK TUM DEEP 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 21933 MEDSV DEF RBRVS 02/01/2015 12/31/2023 522.74 Description: EXC BACK TUM DEEP 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 21935 MEDSV DEF RBRVS 01/01/2024 936.86 Description: RESECT BACK TUM < 5 CM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21935 MEDSV DEF RBRVS 09/01/2019 12/31/2023 733.43 Description: RESECT BACK TUM < 5 CM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21936 MEDSV DEF RBRVS 01/01/2024 1294.59 Description: RESECT BACK TUM 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 21936 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1008.26 Description: RESECT BACK TUM 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 22010 MEDSV DEF RBRVS 01/01/2024 881.45 Description: I&D P-SPINE C/T/CERV-THOR Category: Medical Services CMS Add: 01/01/2006 CMS Term: 22010 MEDSV DEF RBRVS 02/01/2015 12/31/2023 672.04 Description: I&D P-SPINE C/T/CERV-THOR Category: Medical Services CMS Add: 01/01/2006 CMS Term: 22015 MEDSV DEF RBRVS 01/01/2024 869.53 Description: I&D ABSCESS P-SPINE L/S/LS Category: Medical Services CMS Add: 01/01/2006 CMS Term: 22015 MEDSV DEF RBRVS 02/01/2015 12/31/2023 637.54 Description: I&D ABSCESS P-SPINE L/S/LS Category: Medical Services CMS Add: 01/01/2006 CMS Term: 22100 MEDSV DEF RBRVS 01/01/2024 788.54 Description: REMOVE PART OF NECK VERTEBRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 176 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 22100 MEDSV DEF RBRVS 09/01/2019 12/31/2023 610.58 Description: REMOVE PART OF NECK VERTEBRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 22101 MEDSV DEF RBRVS 01/01/2024 794.64 Description: REMOVE PART THORAX VERTEBRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 22101 MEDSV DEF RBRVS 09/01/2019 12/31/2023 621.07 Description: REMOVE PART THORAX VERTEBRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 22102 MEDSV DEF RBRVS 01/01/2024 721.18 Description: REMOVE PART LUMBAR VERTEBRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22102 MEDSV DEF RBRVS 09/01/2019 12/31/2023 580.35 Description: REMOVE PART LUMBAR VERTEBRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22103 MEDSV DEF RBRVS 01/01/2024 122.44 Description: REMOVE EXTRA SPINE SEGMENT Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22103 MEDSV DEF RBRVS 09/01/2019 12/31/2023 101.19 Description: REMOVE EXTRA SPINE SEGMENT Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22110 MEDSV DEF RBRVS 01/01/2024 962.29 Description: REMOVE PART OF NECK VERTEBRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22110 MEDSV DEF RBRVS 09/01/2019 12/31/2023 756.75 Description: REMOVE PART OF NECK VERTEBRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22112 MEDSV DEF RBRVS 01/01/2024 1019.41 Description: REMOVE PART THORAX VERTEBRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22112 MEDSV DEF RBRVS 09/01/2019 12/31/2023 747.16 Description: REMOVE PART THORAX VERTEBRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22114 MEDSV DEF RBRVS 01/01/2024 1019.41 Description: REMOVE PART LUMBAR VERTEBRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22114 MEDSV DEF RBRVS 09/01/2019 12/31/2023 711.30 Description: REMOVE PART LUMBAR VERTEBRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22116 MEDSV DEF RBRVS 01/01/2024 125.58 Description: REMOVE EXTRA SPINE SEGMENT Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22116 MEDSV DEF RBRVS 09/01/2019 12/31/2023 99.74 Description: REMOVE EXTRA SPINE SEGMENT Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22206 MEDSV DEF RBRVS 01/01/2024 2209.96 Description: INCIS SPINE 3 COLUMN THORAC Category: Medical Services CMS Add: 01/01/2008 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 177 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 22206 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1693.74 Description: INCIS SPINE 3 COLUMN THORAC Category: Medical Services CMS Add: 01/01/2008 CMS Term: 22207 MEDSV DEF RBRVS 01/01/2024 2172.97 Description: INCIS SPINE 3 COLUMN LUMBAR Category: Medical Services CMS Add: 01/01/2008 CMS Term: 22207 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1702.12 Description: INCIS SPINE 3 COLUMN LUMBAR Category: Medical Services CMS Add: 01/01/2008 CMS Term: 22208 MEDSV DEF RBRVS 01/01/2024 524.01 Description: INCIS SPINE 3 COLUMN ADL SEG Category: Medical Services CMS Add: 01/01/2008 CMS Term: 22208 MEDSV DEF RBRVS 02/01/2015 12/31/2023 418.43 Description: INCIS SPINE 3 COLUMN ADL SEG Category: Medical Services CMS Add: 01/01/2008 CMS Term: 22210 MEDSV DEF RBRVS 01/01/2024 1619.29 Description: INCIS 1 VERTEBRAL SEG CERV Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22210 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1254.08 Description: INCIS 1 VERTEBRAL SEG CERV Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22212 MEDSV DEF RBRVS 01/01/2024 1377.48 Description: INCIS 1 VERTEBRAL SEG THORAC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22212 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1047.44 Description: INCIS 1 VERTEBRAL SEG THORAC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22214 MEDSV DEF RBRVS 01/01/2024 1377.59 Description: INCIS 1 VERTEBRAL SEG LUMBAR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22214 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1053.94 Description: INCIS 1 VERTEBRAL SEG LUMBAR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22216 MEDSV DEF RBRVS 01/01/2016 12/31/2023 259.62 Description: INCIS ADDL SPINE SEGMENT Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22216 MEDSV DEF RBRVS 01/01/2024 325.42 Description: INCIS ADDL SPINE SEGMENT Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22220 MEDSV DEF RBRVS 01/01/2024 1473.11 Description: OSTEOT DSC ANT 1 VRT SGM CRV Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22220 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1142.61 Description: OSTEOT DSC ANT 1 VRT SGM CRV Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22222 MEDSV DEF RBRVS 01/01/2024 1573.54 Description: OSTEOT DSC ANT 1VRT SGM THRC Category: Medical Services CMS Add: 01/01/1988 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 178 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 22222 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1119.79 Description: OSTEOT DSC ANT 1VRT SGM THRC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22224 MEDSV DEF RBRVS 01/01/2024 1452.64 Description: OSTEOT DSC ANT 1VRT SGM LMBR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22224 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1131.28 Description: OSTEOT DSC ANT 1VRT SGM LMBR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22226 MEDSV DEF RBRVS 01/01/2016 12/31/2023 260.03 Description: OSTEOT DSC ANT 1VRT SGM EA Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22226 MEDSV DEF RBRVS 01/01/2024 323.19 Description: OSTEOT DSC ANT 1VRT SGM EA Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22310 MEDSV DEF RBRVS 01/01/2024 289.82 Description: CLOSED TX VERT FX W/O MANJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22310 MEDSV DEF RBRVS 09/01/2019 12/31/2023 218.22 Description: CLOSED TX VERT FX W/O MANJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22315 MEDSV DEF RBRVS 01/01/2024 820.50 Description: CLOSED TX VERT FX W/MANJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22315 MEDSV DEF RBRVS 09/01/2019 12/31/2023 623.32 Description: CLOSED TX VERT FX W/MANJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22318 MEDSV DEF RBRVS 01/01/2024 1477.44 Description: TREAT ODONTOID FX W/O GRAFT Category: Medical Services CMS Add: 01/01/2000 CMS Term: 22318 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1142.41 Description: TREAT ODONTOID FX W/O GRAFT Category: Medical Services CMS Add: 01/01/2000 CMS Term: 22319 MEDSV DEF RBRVS 01/01/2024 1633.37 0-1 Description: TREAT ODONTOID FX W/GRAFT Category: Medical Services CMS Add: 01/01/2000 CMS Term: 22319 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1270.84 0-1 Description: TREAT ODONTOID FX W/GRAFT Category: Medical Services CMS Add: 01/01/2000 CMS Term: 22325 MEDSV DEF RBRVS 01/01/2024 1334.36 Description: TREAT SPINE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22325 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1016.86 Description: TREAT SPINE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22326 MEDSV DEF RBRVS 01/01/2024 1362.39 Description: TREAT NECK SPINE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 179 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 22326 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1046.81 Description: TREAT NECK SPINE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22327 MEDSV DEF RBRVS 01/01/2024 1388.60 Description: TREAT THORAX SPINE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22327 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1051.77 Description: TREAT THORAX SPINE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22328 MEDSV DEF RBRVS 01/01/2024 251.22 Description: TREAT EACH ADD SPINE FX Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22328 MEDSV DEF RBRVS 02/01/2015 12/31/2023 200.06 Description: TREAT EACH ADD SPINE FX Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22505 MEDSV DEF RBRVS 01/01/2024 120.26 Description: MANIPULATION OF SPINE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22505 MEDSV DEF RBRVS 09/01/2019 12/31/2023 88.31 Description: MANIPULATION OF SPINE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22510 MEDSV DEF RBRVS 01/01/2024 1702.57 Description: PERQ CERVICOTHORACIC INJECT Category: Medical Services CMS Add: 01/01/2015 CMS Term: 22510 MEDSV DEF RBRVS 09/15/2017 12/31/2023 1192.22 Description: PERQ CERVICOTHORACIC INJECT Category: Medical Services CMS Add: 01/01/2015 CMS Term: 22511 MEDSV DEF RBRVS 01/01/2024 1693.53 Description: PERQ LUMBOSACRAL INJECTION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 22511 MEDSV DEF RBRVS 09/15/2017 12/31/2023 1180.45 Description: PERQ LUMBOSACRAL INJECTION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 22512 MEDSV DEF RBRVS 01/01/2024 683.18 Description: VERTEBROPLASTY ADDL INJECT Category: Medical Services CMS Add: 01/01/2015 CMS Term: 22512 MEDSV DEF RBRVS 09/15/2017 12/31/2023 676.89 Description: VERTEBROPLASTY ADDL INJECT Category: Medical Services CMS Add: 01/01/2015 CMS Term: 22513 MEDSV DEF RBRVS 01/01/2024 5367.56 Description: PERQ VERTEBRAL AUGMENTATION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 22513 MEDSV DEF RBRVS 09/15/2017 12/31/2023 5050.05 Description: PERQ VERTEBRAL AUGMENTATION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 22514 MEDSV DEF RBRVS 01/01/2024 5341.41 Description: PERQ VERTEBRAL AUGMENTATION Category: Medical Services CMS Add: 01/01/2015 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 180 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 22514 MEDSV DEF RBRVS 09/15/2017 12/31/2023 5020.59 Description: PERQ VERTEBRAL AUGMENTATION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 22515 MEDSV DEF MAXFEE 01/01/2024 2756.58 0.0 Description: PERQ VERTEBRAL AUGMENTATION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 22526 MEDSV DEF RBRVS 01/01/2024 1859.80 Description: IDET SINGLE LEVEL Category: Medical Services CMS Add: 01/01/2007 CMS Term: 22526 MEDSV DEF RBRVS 09/15/2017 12/31/2023 1630.75 Description: IDET SINGLE LEVEL Category: Medical Services CMS Add: 01/01/2007 CMS Term: 22527 MEDSV DEF RBRVS 01/01/2024 1527.89 Description: IDET 1 OR MORE LEVELS Category: Medical Services CMS Add: 01/01/2007 CMS Term: 22527 MEDSV DEF RBRVS 09/15/2017 12/31/2023 1375.06 Description: IDET 1 OR MORE LEVELS Category: Medical Services CMS Add: 01/01/2007 CMS Term: 22532 MEDSV DEF RBRVS 01/01/2024 1623.24 Description: ARTHRD LAT XTRCVTRY TQ THRC Category: Medical Services CMS Add: 01/01/2004 CMS Term: 22532 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1264.04 Description: ARTHRD LAT XTRCVTRY TQ THRC Category: Medical Services CMS Add: 01/01/2004 CMS Term: 22533 MEDSV DEF RBRVS 01/01/2024 1514.64 Description: ARTHRD LAT XTRCVTRY TQ LMBR Category: Medical Services CMS Add: 01/01/2004 CMS Term: 22533 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1190.42 Description: ARTHRD LAT XTRCVTRY TQ LMBR Category: Medical Services CMS Add: 01/01/2004 CMS Term: 22534 MEDSV DEF RBRVS 01/01/2024 322.99 Description: ARTHRD LAT XTRCVTRY TQ EA AD Category: Medical Services CMS Add: 01/01/2004 CMS Term: 22534 MEDSV DEF RBRVS 02/01/2015 12/31/2023 258.13 Description: ARTHRD LAT XTRCVTRY TQ EA AD Category: Medical Services CMS Add: 01/01/2004 CMS Term: 22548 MEDSV DEF RBRVS 01/01/2024 1751.26 Description: ARTHRD ANT TORAL/XORAL C1-C2 Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22548 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1365.47 Description: ARTHRD ANT TORAL/XORAL C1-C2 Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22551 MEDSV DEF RBRVS 01/01/2024 1533.73 Description: ARTHRD ANT NTRBDY CERVICAL Category: Medical Services CMS Add: 01/01/2011 CMS Term: 22551 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1208.71 Description: ARTHRD ANT NTRBDY CERVICAL Category: Medical Services CMS Add: 01/01/2011 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 181 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 22552 MEDSV DEF RBRVS 01/01/2024 353.15 Description: ARTHRD ANT NTRBD CERVICAL EA Category: Medical Services CMS Add: 01/01/2011 CMS Term: 22552 MEDSV DEF RBRVS 02/01/2015 12/31/2023 280.26 Description: ARTHRD ANT NTRBD CERVICAL EA Category: Medical Services CMS Add: 01/01/2011 CMS Term: 22554 MEDSV DEF RBRVS 01/01/2024 1141.92 Description: ARTHRD ANT NTRBD MIN DSC CRV Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22554 MEDSV DEF RBRVS 09/01/2019 12/31/2023 894.38 Description: ARTHRD ANT NTRBD MIN DSC CRV Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22556 MEDSV DEF RBRVS 01/01/2024 1515.62 Description: ARTHRD ANT NTRBD MIN DSC THC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22556 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1182.55 Description: ARTHRD ANT NTRBD MIN DSC THC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22558 MEDSV DEF RBRVS 01/01/2024 1389.96 Description: ARTHRD ANT NTRBD MIN DSC LUM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22558 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1097.85 Description: ARTHRD ANT NTRBD MIN DSC LUM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22585 MEDSV DEF RBRVS 01/01/2024 291.99 Description: ARTHRD ANT NTRBD MIN DSC EA Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22585 MEDSV DEF RBRVS 02/01/2015 12/31/2023 237.58 Description: ARTHRD ANT NTRBD MIN DSC EA Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22586 NOCOV DEF SYSMAN Description: ARTHRD PRE-SAC NTRBDY L5-S1 Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 22590 MEDSV DEF RBRVS 01/01/2024 1429.02 Description: ARTHRD PST TQ CRANIOCERVICAL Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22590 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1107.94 Description: ARTHRD PST TQ CRANIOCERVICAL Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22595 MEDSV DEF RBRVS 01/01/2024 1364.66 Description: ARTHRD PST TQ ATLAS-AXIS Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22595 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1055.89 Description: ARTHRD PST TQ ATLAS-AXIS Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22600 MEDSV DEF RBRVS 01/01/2024 1176.73 Description: ARTHRD PST TQ 1NTRSPC CRV Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 182 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 22600 MEDSV DEF RBRVS 09/01/2019 12/31/2023 907.06 Description: ARTHRD PST TQ 1NTRSPC CRV Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22610 MEDSV DEF RBRVS 01/01/2024 1160.55 Description: ARTHRD PST TQ 1NTRSPC THRC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22610 MEDSV DEF RBRVS 09/01/2019 12/31/2023 891.12 Description: ARTHRD PST TQ 1NTRSPC THRC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22612 MEDSV DEF RBRVS 01/01/2024 1440.60 Description: ARTHRD PST TQ 1NTRSPC LUMBAR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22612 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1131.71 Description: ARTHRD PST TQ 1NTRSPC LUMBAR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22614 MEDSV DEF RBRVS 01/01/2024 349.04 Description: ARTHRD PST TQ 1NTRSPC EA ADD Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22614 MEDSV DEF RBRVS 02/01/2015 12/31/2023 278.21 Description: ARTHRD PST TQ 1NTRSPC EA ADD Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22630 MEDSV DEF RBRVS 01/01/2024 1401.93 Description: ARTHRD PST TQ 1NTRSPC LUM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22630 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1095.91 Description: ARTHRD PST TQ 1NTRSPC LUM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22632 MEDSV DEF RBRVS 01/01/2024 284.72 Description: ARTHRD PST TQ 1NTRSPC LM EA Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22632 MEDSV DEF RBRVS 02/01/2015 12/31/2023 226.30 Description: ARTHRD PST TQ 1NTRSPC LM EA Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22633 MEDSV DEF RBRVS 01/01/2024 1634.91 Description: ARTHRD CMBN 1NTRSPC LUMBAR Category: Medical Services CMS Add: 01/01/2012 CMS Term: 22633 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1309.59 Description: ARTHRD CMBN 1NTRSPC LUMBAR Category: Medical Services CMS Add: 01/01/2012 CMS Term: 22634 MEDSV DEF RBRVS 01/01/2024 432.23 Description: ARTHRD CMBN 1NTRSPC EA ADDL Category: Medical Services CMS Add: 01/01/2012 CMS Term: 22634 MEDSV DEF RBRVS 02/01/2015 12/31/2023 352.86 Description: ARTHRD CMBN 1NTRSPC EA ADDL Category: Medical Services CMS Add: 01/01/2012 CMS Term: 22800 MEDSV DEF RBRVS 01/01/2024 1246.05 Description: ARTHRD PST DFRM<6 VRT SGM Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 183 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 22800 MEDSV DEF RBRVS 09/01/2019 12/31/2023 965.54 Description: ARTHRD PST DFRM<6 VRT SGM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22802 MEDSV DEF RBRVS 01/01/2024 1924.57 Description: ARTHRD PST DFRM 7-12 VRT SGM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22802 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1497.58 Description: ARTHRD PST DFRM 7-12 VRT SGM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22804 MEDSV DEF RBRVS 01/01/2024 2212.23 Description: ARTHRD PST DFRM 13+ VRT SGM Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22804 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1725.47 Description: ARTHRD PST DFRM 13+ VRT SGM Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22808 MEDSV DEF RBRVS 01/01/2024 1654.47 Description: ARTHRD ANT DFRM 2-3 VRT SGM Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22808 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1295.38 Description: ARTHRD ANT DFRM 2-3 VRT SGM Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22810 MEDSV DEF RBRVS 01/01/2024 1850.36 Description: ARTHRD ANT DFRM 4-7 VRT SGM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22810 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1454.11 Description: ARTHRD ANT DFRM 4-7 VRT SGM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22812 MEDSV DEF RBRVS 01/01/2024 2027.73 Description: ARTHRD ANT DFRM 8+ VRT SGM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22812 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1612.29 Description: ARTHRD ANT DFRM 8+ VRT SGM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22818 MEDSV DEF RBRVS 01/01/2024 1979.35 Description: KYPHECTOMY 1-2 SEGMENTS Category: Medical Services CMS Add: 01/01/1998 CMS Term: 22818 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1561.92 Description: KYPHECTOMY 1-2 SEGMENTS Category: Medical Services CMS Add: 01/01/1998 CMS Term: 22819 MEDSV DEF RBRVS 01/01/2024 2279.28 Description: KYPHECTOMY 3 OR MORE Category: Medical Services CMS Add: 01/01/1998 CMS Term: 22819 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1910.78 Description: KYPHECTOMY 3 OR MORE Category: Medical Services CMS Add: 01/01/1998 CMS Term: 22830 MEDSV DEF RBRVS 01/01/2024 749.90 Description: EXPLORATION OF SPINAL FUSION Category: Medical Services CMS Add: 01/01/1988 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 184 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 22830 MEDSV DEF RBRVS 09/01/2019 12/31/2023 576.11 Description: EXPLORATION OF SPINAL FUSION Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22836 NOCOV DEF SYSMAN Description: ANT THRC VRT BODY TETHRG <7 Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 22837 NOCOV DEF SYSMAN Description: ANT THRC VRT BODY TETHRG 8+ Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 22838 NOCOV DEF SYSMAN Description: REV RPLC/RMV THRC VRT TETHRG Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 22840 MEDSV DEF RBRVS 01/01/2024 678.06 Description: INSERT SPINE FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22840 MEDSV DEF RBRVS 02/01/2015 12/31/2023 542.26 Description: INSERT SPINE FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22841 NOCOV DEF SYSMAN Description: INSERT SPINE FIXATION DEVICE Category: Non Covered Services CMS Add: 01/01/1996 CMS Term: 22842 MEDSV DEF RBRVS 01/01/2024 681.65 Description: INSERT SPINE FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22842 MEDSV DEF RBRVS 02/01/2015 12/31/2023 543.17 Description: INSERT SPINE FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22843 MEDSV DEF RBRVS 01/01/2024 729.56 Description: INSERT SPINE FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22843 MEDSV DEF RBRVS 02/01/2015 12/31/2023 579.20 Description: INSERT SPINE FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22844 MEDSV DEF RBRVS 01/01/2024 886.23 Description: INSERT SPINE FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22844 MEDSV DEF RBRVS 02/01/2015 12/31/2023 701.87 Description: INSERT SPINE FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22845 MEDSV DEF RBRVS 01/01/2019 12/31/2023 520.81 Description: INSERT SPINE FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22845 MEDSV DEF RBRVS 01/01/2024 648.22 Description: INSERT SPINE FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22846 MEDSV DEF RBRVS 01/01/2024 674.11 Description: INSERT SPINE FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1996 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 185 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 22846 MEDSV DEF RBRVS 02/01/2015 12/31/2023 540.69 Description: INSERT SPINE FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22847 MEDSV DEF RBRVS 01/01/2024 732.28 Description: INSERT SPINE FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22847 MEDSV DEF RBRVS 02/01/2015 12/31/2023 615.84 Description: INSERT SPINE FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22848 MEDSV DEF RBRVS 01/01/2024 323.11 Description: INSERT PELV FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22848 MEDSV DEF RBRVS 02/01/2015 12/31/2023 256.48 Description: INSERT PELV FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22849 MEDSV DEF RBRVS 01/01/2024 1186.01 Description: REINSERT SPINAL FIXATION Category: Medical Services CMS Add: 01/01/1987 CMS Term: 22849 MEDSV DEF RBRVS 09/01/2019 12/31/2023 923.57 Description: REINSERT SPINAL FIXATION Category: Medical Services CMS Add: 01/01/1987 CMS Term: 22850 MEDSV DEF RBRVS 01/01/2024 671.02 Description: REMOVE SPINE FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22850 MEDSV DEF RBRVS 09/01/2019 12/31/2023 512.48 Description: REMOVE SPINE FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22852 MEDSV DEF RBRVS 01/01/2024 646.26 Description: REMOVE SPINE FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22852 MEDSV DEF RBRVS 09/01/2019 12/31/2023 490.64 Description: REMOVE SPINE FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22853 MEDSV DEF RBRVS 01/01/2017 12/31/2023 186.94 Description: INSJ BIOMECHANICAL DEVICE Category: Medical Services CMS Add: 01/01/2017 CMS Term: 22853 MEDSV DEF RBRVS 01/01/2024 230.55 Description: INSJ BIOMECHANICAL DEVICE Category: Medical Services CMS Add: 01/01/2017 CMS Term: 22854 MEDSV DEF RBRVS 01/01/2017 12/31/2023 242.00 Description: INSJ BIOMECHANICAL DEVICE Category: Medical Services CMS Add: 01/01/2017 CMS Term: 22854 MEDSV DEF RBRVS 01/01/2024 298.84 Description: INSJ BIOMECHANICAL DEVICE Category: Medical Services CMS Add: 01/01/2017 CMS Term: 22855 MEDSV DEF RBRVS 01/01/2024 1006.48 Description: REMOVAL ANTERIOR INSTRMJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 186 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 22855 MEDSV DEF RBRVS 09/01/2019 12/31/2023 788.97 Description: REMOVAL ANTERIOR INSTRMJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22856 MEDSV DEF RBRVS 01/01/2024 1469.68 Y Description: TOT DISC ARTHRP 1NTRSPC CRV Category: Medical Services CMS Add: 01/01/2009 CMS Term: 22856 MEDSV DEF RBRVS 03/29/2019 12/31/2023 1168.73 Y Description: TOT DISC ARTHRP 1NTRSPC CRV Category: Medical Services CMS Add: 01/01/2009 CMS Term: 22857 MEDSV DEF RBRVS 01/01/2024 1628.99 Y Description: TOT DISC ARTHRP 1NTRSPC LMBR Category: Medical Services CMS Add: 01/01/2007 CMS Term: 22857 MEDSV DEF RBRVS 07/19/2018 12/31/2023 1218.70 Y Description: TOT DISC ARTHRP 1NTRSPC LMBR Category: Medical Services CMS Add: 01/01/2007 CMS Term: 22858 MEDSV DEF RBRVS 01/01/2024 453.91 Description: TOT DISC ARTHRP 2ND LVL CRV Category: Medical Services CMS Add: 01/01/2015 CMS Term: 22858 MEDSV DEF RBRVS 12/03/2019 12/31/2023 366.33 Description: TOT DISC ARTHRP 2ND LVL CRV Category: Medical Services CMS Add: 01/01/2015 CMS Term: 22859 MEDSV DEF RBRVS 01/01/2017 12/31/2023 242.00 Description: INSJ BIOMECHANICAL DEVICE Category: Medical Services CMS Add: 01/01/2017 CMS Term: 22859 MEDSV DEF RBRVS 01/01/2024 297.85 Description: INSJ BIOMECHANICAL DEVICE Category: Medical Services CMS Add: 01/01/2017 CMS Term: 22860 MEDSV DEF BILL20 Y Description: TOT DISC ARTHRP 2NTRSPC LMBR Category: Medical Services CMS Add: 01/01/2023 CMS Term: 22861 NOCOV DEF SYSMAN Description: REV RPLCM ARTHRP 1NTRSPC CRV Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 22862 NOCOV DEF SYSMAN Description: REV RPLCM RTHRP 1NTRSPC LMBR Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 22864 NOCOV DEF SYSMAN Description: RMVL TOT ARTHRP 1NTRSPC CRV Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 22865 NOCOV DEF SYSMAN Description: RMVL TOT ARTHRP 1NTRSPC LMBR Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 22867 MEDSV DEF RBRVS 01/01/2019 12/31/2023 700.30 Y Description: INSJ STABLJ DEV W/DCMPRN Category: Medical Services CMS Add: 01/01/2017 CMS Term: 22867 MEDSV DEF RBRVS 01/01/2024 974.82 Y Description: INSJ STABLJ DEV W/DCMPRN Category: Medical Services CMS Add: 01/01/2017 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 187 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 22868 MEDSV DEF RBRVS 01/01/2017 12/31/2023 175.19 Y Description: INSJ STABLJ DEV W/DCMPRN Category: Medical Services CMS Add: 01/01/2017 CMS Term: 22868 MEDSV DEF RBRVS 01/01/2024 217.28 Y Description: INSJ STABLJ DEV W/DCMPRN Category: Medical Services CMS Add: 01/01/2017 CMS Term: 22869 MEDSV DEF RBRVS 01/01/2019 12/31/2023 387.48 Y Description: INSJ STABLJ DEV W/O DCMPRN Category: Medical Services CMS Add: 01/01/2017 CMS Term: 22869 MEDSV DEF RBRVS 01/01/2024 408.00 Y Description: INSJ STABLJ DEV W/O DCMPRN Category: Medical Services CMS Add: 01/01/2017 CMS Term: 22870 MEDSV DEF RBRVS 01/01/2017 12/31/2023 102.26 Y Description: INSJ STABLJ DEV W/O DCMPRN Category: Medical Services CMS Add: 01/01/2017 CMS Term: 22870 MEDSV DEF RBRVS 01/01/2024 111.55 Y Description: INSJ STABLJ DEV W/O DCMPRN Category: Medical Services CMS Add: 01/01/2017 CMS Term: 22899 MEDSV DEF BILL20 Description: UNLISTED PROCEDURE SPINE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 22900 MEDSV DEF RBRVS 01/01/2024 521.38 Description: EXC ABDL TUM DEEP < 5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22900 MEDSV DEF RBRVS 09/01/2019 12/31/2023 400.00 Description: EXC ABDL TUM DEEP < 5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22901 MEDSV DEF RBRVS 01/01/2024 612.13 Description: EXC ABDL TUM DEEP 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 22901 MEDSV DEF RBRVS 02/01/2015 12/31/2023 470.31 Description: EXC ABDL TUM DEEP 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 22902 MEDSV DEF RBRVS 01/01/2024 437.25 Description: EXC ABD LES SC < 3 CM Category: Medical Services CMS Add: 01/01/2010 CMS Term: 22902 MEDSV DEF RBRVS 02/01/2015 12/31/2023 305.12 Description: EXC ABD LES SC < 3 CM Category: Medical Services CMS Add: 01/01/2010 CMS Term: 22903 MEDSV DEF RBRVS 01/01/2024 405.40 Description: EXC ABD LES SC 3 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 22903 MEDSV DEF RBRVS 02/01/2015 12/31/2023 308.26 Description: EXC ABD LES SC 3 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 22904 MEDSV DEF RBRVS 01/01/2024 963.54 Description: RADICAL RESECT ABD TUMOR<5CM Category: Medical Services CMS Add: 01/01/2010 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 188 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 22904 MEDSV DEF RBRVS 02/01/2015 12/31/2023 746.44 Description: RADICAL RESECT ABD TUMOR<5CM Category: Medical Services CMS Add: 01/01/2010 CMS Term: 22905 MEDSV DEF RBRVS 01/01/2024 1216.84 Description: RAD RESECT ABD TUMOR 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 22905 MEDSV DEF RBRVS 02/01/2015 12/31/2023 950.99 Description: RAD RESECT ABD TUMOR 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 22999 MEDSV DEF BILL20 Description: UNLISTED PX ABDOMEN MUSCSKEL Category: Medical Services CMS Add: 01/01/1982 CMS Term: 23000 MEDSV DEF RBRVS 01/01/2024 513.97 Description: REMOVAL OF CALCIUM DEPOSITS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23000 MEDSV DEF RBRVS 09/01/2019 12/31/2023 409.62 Description: REMOVAL OF CALCIUM DEPOSITS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23020 MEDSV DEF RBRVS 01/01/2024 643.94 Description: RELEASE SHOULDER JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23020 MEDSV DEF RBRVS 09/01/2019 12/31/2023 491.94 Description: RELEASE SHOULDER JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23030 MEDSV DEF RBRVS 01/01/2024 410.24 Description: DRAIN SHOULDER LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23030 MEDSV DEF RBRVS 09/01/2019 12/31/2023 309.82 Description: DRAIN SHOULDER LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23031 MEDSV DEF RBRVS 01/01/2024 404.25 Description: DRAIN SHOULDER BURSA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23031 MEDSV DEF RBRVS 09/01/2019 12/31/2023 297.91 Description: DRAIN SHOULDER BURSA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23035 MEDSV DEF RBRVS 01/01/2024 635.77 Description: DRAIN SHOULDER BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23035 MEDSV DEF RBRVS 09/01/2019 12/31/2023 487.56 Description: DRAIN SHOULDER BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23040 MEDSV DEF RBRVS 01/01/2024 669.40 Description: EXPLORATORY SHOULDER SURGERY Category: Medical Services CMS Add: 01/01/1985 CMS Term: 23040 MEDSV DEF RBRVS 09/01/2019 12/31/2023 512.66 Description: EXPLORATORY SHOULDER SURGERY Category: Medical Services CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 189 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 23044 MEDSV DEF RBRVS 01/01/2024 530.06 Description: EXPLORATORY SHOULDER SURGERY Category: Medical Services CMS Add: 01/01/1985 CMS Term: 23044 MEDSV DEF RBRVS 09/01/2019 12/31/2023 404.17 Description: EXPLORATORY SHOULDER SURGERY Category: Medical Services CMS Add: 01/01/1985 CMS Term: 23065 MEDSV DEF RBRVS 01/01/2024 210.60 Description: BIOPSY SHOULDER TISSUES Category: Medical Services CMS Add: 01/01/1985 CMS Term: 23065 MEDSV DEF RBRVS 09/01/2019 12/31/2023 153.20 Description: BIOPSY SHOULDER TISSUES Category: Medical Services CMS Add: 01/01/1985 CMS Term: 23066 MEDSV DEF RBRVS 01/01/2024 526.62 Description: BIOPSY SHOULDER TISSUES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23066 MEDSV DEF RBRVS 09/01/2019 12/31/2023 389.84 Description: BIOPSY SHOULDER TISSUES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23071 MEDSV DEF RBRVS 01/01/2024 388.08 Description: EXC SHOULDER LES SC 3 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 23071 MEDSV DEF RBRVS 02/01/2015 12/31/2023 297.35 Description: EXC SHOULDER LES SC 3 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 23073 MEDSV DEF RBRVS 01/01/2024 643.90 Description: EXC SHOULDER TUM DEEP 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 23073 MEDSV DEF RBRVS 02/01/2015 12/31/2023 492.40 Description: EXC SHOULDER TUM DEEP 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 23075 MEDSV DEF RBRVS 01/01/2024 480.05 Description: EXC SHOULDER LES SC < 3 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23075 MEDSV DEF RBRVS 09/01/2019 12/31/2023 328.79 Description: EXC SHOULDER LES SC < 3 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23076 MEDSV DEF RBRVS 01/01/2024 504.07 Description: EXC SHOULDER TUM DEEP < 5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23076 MEDSV DEF RBRVS 09/01/2019 12/31/2023 383.15 Description: EXC SHOULDER TUM DEEP < 5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23077 MEDSV DEF RBRVS 01/01/2024 1034.47 Description: RESECT SHOULDER TUMOR < 5 CM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 23077 MEDSV DEF RBRVS 09/01/2019 12/31/2023 817.26 Description: RESECT SHOULDER TUMOR < 5 CM Category: Medical Services CMS Add: 01/01/1988 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 190 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 23078 MEDSV DEF RBRVS 01/01/2024 1317.09 Description: RESECT SHOULDER TUMOR 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 23078 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1030.06 Description: RESECT SHOULDER TUMOR 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 23100 MEDSV DEF RBRVS 01/01/2024 474.41 Description: BIOPSY OF SHOULDER JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 23100 MEDSV DEF RBRVS 09/01/2019 12/31/2023 355.35 Description: BIOPSY OF SHOULDER JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 23101 MEDSV DEF RBRVS 01/01/2024 428.28 Description: SHOULDER JOINT SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23101 MEDSV DEF RBRVS 09/01/2019 12/31/2023 323.87 Description: SHOULDER JOINT SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23105 MEDSV DEF RBRVS 01/01/2024 597.03 Description: REMOVE SHOULDER JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23105 MEDSV DEF RBRVS 09/01/2019 12/31/2023 454.75 Description: REMOVE SHOULDER JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23106 MEDSV DEF RBRVS 01/01/2024 470.64 Description: INCISION OF COLLARBONE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23106 MEDSV DEF RBRVS 09/01/2019 12/31/2023 352.31 Description: INCISION OF COLLARBONE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23107 MEDSV DEF RBRVS 01/01/2024 617.85 Description: EXPLORE TREAT SHOULDER JOINT Category: Medical Services CMS Add: 01/01/1989 CMS Term: 23107 MEDSV DEF RBRVS 09/01/2019 12/31/2023 471.76 Description: EXPLORE TREAT SHOULDER JOINT Category: Medical Services CMS Add: 01/01/1989 CMS Term: 23120 MEDSV DEF RBRVS 01/01/2024 549.31 Description: PARTIAL REMOVAL COLLAR BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23120 MEDSV DEF RBRVS 09/01/2019 12/31/2023 416.63 Description: PARTIAL REMOVAL COLLAR BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23125 MEDSV DEF RBRVS 01/01/2024 661.98 Description: REMOVAL OF COLLAR BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23125 MEDSV DEF RBRVS 09/01/2019 12/31/2023 504.67 Description: REMOVAL OF COLLAR BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 191 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 23130 MEDSV DEF RBRVS 01/01/2024 577.99 Description: REMOVE SHOULDER BONE PART Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23130 MEDSV DEF RBRVS 09/01/2019 12/31/2023 433.12 Description: REMOVE SHOULDER BONE PART Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23140 MEDSV DEF RBRVS 01/01/2024 519.45 Description: REMOVAL OF BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23140 MEDSV DEF RBRVS 09/01/2019 12/31/2023 376.76 Description: REMOVAL OF BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23145 MEDSV DEF RBRVS 01/01/2024 649.19 Description: REMOVAL OF BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23145 MEDSV DEF RBRVS 09/01/2019 12/31/2023 494.83 Description: REMOVAL OF BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23146 MEDSV DEF RBRVS 01/01/2024 582.67 Description: REMOVAL OF BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23146 MEDSV DEF RBRVS 09/01/2019 12/31/2023 441.36 Description: REMOVAL OF BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23150 MEDSV DEF RBRVS 01/01/2024 622.94 Description: REMOVAL OF HUMERUS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23150 MEDSV DEF RBRVS 09/01/2019 12/31/2023 470.35 Description: REMOVAL OF HUMERUS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23155 MEDSV DEF RBRVS 01/01/2024 743.16 Description: REMOVAL OF HUMERUS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23155 MEDSV DEF RBRVS 09/01/2019 12/31/2023 564.94 Description: REMOVAL OF HUMERUS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23156 MEDSV DEF RBRVS 01/01/2024 633.77 Description: REMOVAL OF HUMERUS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23156 MEDSV DEF RBRVS 09/01/2019 12/31/2023 482.50 Description: REMOVAL OF HUMERUS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23170 MEDSV DEF RBRVS 01/01/2024 527.91 Description: REMOVE COLLAR BONE LESION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 23170 MEDSV DEF RBRVS 09/01/2019 12/31/2023 398.25 Description: REMOVE COLLAR BONE LESION Category: Medical Services CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 192 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 23172 MEDSV DEF RBRVS 01/01/2024 533.63 Description: REMOVE SHOULDER BLADE LESION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 23172 MEDSV DEF RBRVS 09/01/2019 12/31/2023 402.84 Description: REMOVE SHOULDER BLADE LESION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 23174 MEDSV DEF RBRVS 01/01/2024 712.36 Description: REMOVE HUMERUS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23174 MEDSV DEF RBRVS 09/01/2019 12/31/2023 539.38 Description: REMOVE HUMERUS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23180 MEDSV DEF RBRVS 01/01/2024 613.98 Description: REMOVE COLLAR BONE LESION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 23180 MEDSV DEF RBRVS 09/01/2019 12/31/2023 474.24 Description: REMOVE COLLAR BONE LESION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 23182 MEDSV DEF RBRVS 01/01/2024 627.40 Description: REMOVE SHOULDER BLADE LESION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 23182 MEDSV DEF RBRVS 09/01/2019 12/31/2023 470.63 Description: REMOVE SHOULDER BLADE LESION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 23184 MEDSV DEF RBRVS 01/01/2024 690.72 Description: REMOVE HUMERUS LESION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 23184 MEDSV DEF RBRVS 09/01/2019 12/31/2023 523.62 Description: REMOVE HUMERUS LESION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 23190 MEDSV DEF RBRVS 01/01/2024 538.00 Description: PARTIAL REMOVAL OF SCAPULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23190 MEDSV DEF RBRVS 09/01/2019 12/31/2023 405.74 Description: PARTIAL REMOVAL OF SCAPULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23195 MEDSV DEF RBRVS 01/01/2024 693.35 Description: REMOVAL OF HEAD OF HUMERUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23195 MEDSV DEF RBRVS 09/01/2019 12/31/2023 538.05 Description: REMOVAL OF HEAD OF HUMERUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23200 MEDSV DEF RBRVS 01/01/2024 1389.25 Description: RESECT CLAVICLE TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23200 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1085.64 Description: RESECT CLAVICLE TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 193 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 23210 MEDSV DEF RBRVS 01/01/2024 1628.48 Description: RESECT SCAPULA TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23210 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1277.06 Description: RESECT SCAPULA TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23220 MEDSV DEF RBRVS 01/01/2024 1784.69 Description: RESECT PROX HUMERUS TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23220 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1401.02 Description: RESECT PROX HUMERUS TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23330 MEDSV DEF RBRVS 01/01/2024 280.88 Description: REMOVE SHOULDER FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23330 MEDSV DEF RBRVS 09/01/2019 12/31/2023 169.71 Description: REMOVE SHOULDER FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23333 MEDSV DEF RBRVS 01/01/2024 442.13 Description: REMOVE SHOULDER FB DEEP Category: Medical Services CMS Add: 01/01/2014 CMS Term: 23333 MEDSV DEF RBRVS 02/01/2015 12/31/2023 325.61 Description: REMOVE SHOULDER FB DEEP Category: Medical Services CMS Add: 01/01/2014 CMS Term: 23334 MEDSV DEF RBRVS 01/01/2024 981.61 Description: SHOULDER PROSTHESIS REMOVAL Category: Medical Services CMS Add: 01/01/2014 CMS Term: 23334 MEDSV DEF RBRVS 02/01/2015 12/31/2023 769.29 Description: SHOULDER PROSTHESIS REMOVAL Category: Medical Services CMS Add: 01/01/2014 CMS Term: 23335 MEDSV DEF RBRVS 01/01/2024 1173.10 Description: SHOULDER PROSTHESIS REMOVAL Category: Medical Services CMS Add: 01/01/2014 CMS Term: 23335 MEDSV DEF RBRVS 02/01/2015 12/31/2023 917.67 Description: SHOULDER PROSTHESIS REMOVAL Category: Medical Services CMS Add: 01/01/2014 CMS Term: 23350 MEDSV DEF RBRVS 01/01/2024 154.66 Description: INJECTION FOR SHOULDER X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23350 MEDSV DEF RBRVS 09/01/2019 12/31/2023 91.93 Description: INJECTION FOR SHOULDER X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23395 MEDSV DEF RBRVS 01/01/2024 1187.86 Description: MUSCLE TRANSFER SHOULDER/ARM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23395 MEDSV DEF RBRVS 09/01/2019 12/31/2023 920.67 Description: MUSCLE TRANSFER SHOULDER/ARM Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 194 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 23397 MEDSV DEF RBRVS 01/01/2024 1055.29 Description: MUSCLE TRANSFERS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23397 MEDSV DEF RBRVS 09/01/2019 12/31/2023 815.78 Description: MUSCLE TRANSFERS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23400 MEDSV DEF RBRVS 01/01/2024 903.14 Description: FIXATION OF SHOULDER BLADE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23400 MEDSV DEF RBRVS 09/01/2019 12/31/2023 693.13 Description: FIXATION OF SHOULDER BLADE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23405 MEDSV DEF RBRVS 01/01/2024 576.90 Description: INCISION OF TENDON & MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23405 MEDSV DEF RBRVS 09/01/2019 12/31/2023 448.93 Description: INCISION OF TENDON & MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23406 MEDSV DEF RBRVS 01/01/2024 700.13 Description: INCISE TENDON(S) & MUSCLE(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23406 MEDSV DEF RBRVS 09/01/2019 12/31/2023 551.22 Description: INCISE TENDON(S) & MUSCLE(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23410 MEDSV DEF RBRVS 01/01/2024 763.32 Description: REPAIR ROTATOR CUFF ACUTE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23410 MEDSV DEF RBRVS 09/01/2019 12/31/2023 586.78 Description: REPAIR ROTATOR CUFF ACUTE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23412 MEDSV DEF RBRVS 01/01/2024 792.65 Description: REPAIR ROTATOR CUFF CHRONIC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23412 MEDSV DEF RBRVS 09/01/2019 12/31/2023 609.46 Description: REPAIR ROTATOR CUFF CHRONIC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23415 MEDSV DEF RBRVS 01/01/2024 651.27 Description: RELEASE OF SHOULDER LIGAMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23415 MEDSV DEF RBRVS 09/01/2019 12/31/2023 496.04 Description: RELEASE OF SHOULDER LIGAMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23420 MEDSV DEF RBRVS 01/01/2024 905.01 Description: REPAIR OF SHOULDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23420 MEDSV DEF RBRVS 09/01/2019 12/31/2023 692.44 Description: REPAIR OF SHOULDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 195 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 23430 MEDSV DEF RBRVS 01/01/2024 694.16 Description: REPAIR BICEPS TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23430 MEDSV DEF RBRVS 09/01/2019 12/31/2023 534.18 Description: REPAIR BICEPS TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23440 MEDSV DEF RBRVS 01/01/2024 704.00 Description: REMOVE/TRANSPLANT TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23440 MEDSV DEF RBRVS 09/01/2019 12/31/2023 540.29 Description: REMOVE/TRANSPLANT TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23450 MEDSV DEF RBRVS 01/01/2024 877.59 Description: REPAIR SHOULDER CAPSULE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23450 MEDSV DEF RBRVS 09/01/2019 12/31/2023 677.17 Description: REPAIR SHOULDER CAPSULE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23455 MEDSV DEF RBRVS 01/01/2024 918.66 Description: REPAIR SHOULDER CAPSULE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23455 MEDSV DEF RBRVS 09/01/2019 12/31/2023 717.35 Description: REPAIR SHOULDER CAPSULE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23460 MEDSV DEF RBRVS 01/01/2024 1010.53 Description: REPAIR SHOULDER CAPSULE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23460 MEDSV DEF RBRVS 09/01/2019 12/31/2023 778.64 Description: REPAIR SHOULDER CAPSULE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23462 MEDSV DEF RBRVS 01/01/2024 988.92 Description: REPAIR SHOULDER CAPSULE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23462 MEDSV DEF RBRVS 09/01/2019 12/31/2023 766.62 Description: REPAIR SHOULDER CAPSULE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23465 MEDSV DEF RBRVS 01/01/2024 1036.12 Description: REPAIR SHOULDER CAPSULE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23465 MEDSV DEF RBRVS 09/01/2019 12/31/2023 798.80 Description: REPAIR SHOULDER CAPSULE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23466 MEDSV DEF RBRVS 01/01/2024 1040.52 Description: REPAIR SHOULDER CAPSULE Category: Medical Services CMS Add: 01/01/1987 CMS Term: 23466 MEDSV DEF RBRVS 09/01/2019 12/31/2023 801.71 Description: REPAIR SHOULDER CAPSULE Category: Medical Services CMS Add: 01/01/1987 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 196 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 23470 MEDSV DEF RBRVS 01/01/2024 1109.86 Description: RECONSTRUCT SHOULDER JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23470 MEDSV DEF RBRVS 09/01/2019 12/31/2023 864.39 Description: RECONSTRUCT SHOULDER JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23472 MEDSV DEF RBRVS 01/01/2024 1336.84 Description: RECONSTRUCT SHOULDER JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23472 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1049.00 Description: RECONSTRUCT SHOULDER JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23473 MEDSV DEF RBRVS 01/01/2024 1488.16 0-1 Description: REVIS RECONST SHOULDER JOINT Category: Medical Services CMS Add: 01/01/2013 CMS Term: 23473 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1169.96 0-1 Description: REVIS RECONST SHOULDER JOINT Category: Medical Services CMS Add: 01/01/2013 CMS Term: 23474 MEDSV DEF RBRVS 01/01/2024 1606.11 0-1 Description: REVIS RECONST SHOULDER JOINT Category: Medical Services CMS Add: 01/01/2013 CMS Term: 23474 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1264.43 0-1 Description: REVIS RECONST SHOULDER JOINT Category: Medical Services CMS Add: 01/01/2013 CMS Term: 23480 MEDSV DEF RBRVS 01/01/2024 762.90 Description: REVISION OF COLLAR BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23480 MEDSV DEF RBRVS 09/01/2019 12/31/2023 585.28 Description: REVISION OF COLLAR BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23485 MEDSV DEF RBRVS 01/01/2024 885.62 Description: REVISION OF COLLAR BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23485 MEDSV DEF RBRVS 09/01/2019 12/31/2023 683.22 Description: REVISION OF COLLAR BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23490 MEDSV DEF RBRVS 01/01/2024 800.04 Description: REINFORCE CLAVICLE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 23490 MEDSV DEF RBRVS 09/01/2019 12/31/2023 615.15 Description: REINFORCE CLAVICLE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 23491 MEDSV DEF RBRVS 01/01/2024 942.28 Description: REINFORCE SHOULDER BONES Category: Medical Services CMS Add: 01/01/1986 CMS Term: 23491 MEDSV DEF RBRVS 09/01/2019 12/31/2023 724.26 Description: REINFORCE SHOULDER BONES Category: Medical Services CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 197 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 23500 MEDSV DEF RBRVS 01/01/2024 213.18 Description: CLTX CLAVICULAR FX W/O MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23500 MEDSV DEF RBRVS 09/01/2019 12/31/2023 154.75 Description: CLTX CLAVICULAR FX W/O MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23505 MEDSV DEF RBRVS 01/01/2024 340.98 Description: CLTX CLAVICULAR FX W/MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23505 MEDSV DEF RBRVS 09/01/2019 12/31/2023 249.55 Description: CLTX CLAVICULAR FX W/MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23515 MEDSV DEF RBRVS 01/01/2024 672.45 Description: OPTX CLAVICULAR FX W/INT FIX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23515 MEDSV DEF RBRVS 09/01/2019 12/31/2023 514.68 Description: OPTX CLAVICULAR FX W/INT FIX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23520 MEDSV DEF RBRVS 01/01/2024 229.47 Description: CLTX STRNCLAV DISLC W/O MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23520 MEDSV DEF RBRVS 09/01/2019 12/31/2023 162.60 Description: CLTX STRNCLAV DISLC W/O MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23525 MEDSV DEF RBRVS 01/01/2024 376.36 Description: CLTX STRNCLAV DISLC W/MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23525 MEDSV DEF RBRVS 09/01/2019 12/31/2023 270.44 Description: CLTX STRNCLAV DISLC W/MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23530 MEDSV DEF RBRVS 01/01/2024 538.80 Description: OPTX STRNCLAV DISLC AQT/CHRN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23530 MEDSV DEF RBRVS 09/01/2019 12/31/2023 406.99 Description: OPTX STRNCLAV DISLC AQT/CHRN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23532 MEDSV DEF RBRVS 01/01/2024 585.52 Description: OPTX STRCLV DSLC AQ/CHRN GRF Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23532 MEDSV DEF RBRVS 09/01/2019 12/31/2023 443.68 Description: OPTX STRCLV DSLC AQ/CHRN GRF Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23540 MEDSV DEF RBRVS 01/01/2024 228.46 Description: CLTX ACROMCLAV DISLC WO MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23540 MEDSV DEF RBRVS 09/01/2019 12/31/2023 158.70 Description: CLTX ACROMCLAV DISLC WO MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 198 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 23545 MEDSV DEF RBRVS 01/01/2024 341.76 Description: CLTX ACROMCLAV DISLC W/MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23545 MEDSV DEF RBRVS 09/01/2019 12/31/2023 241.04 Description: CLTX ACROMCLAV DISLC W/MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23550 MEDSV DEF RBRVS 01/01/2024 536.16 Description: OPTX ACROMCLV DISLC AQT/CHRN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23550 MEDSV DEF RBRVS 09/01/2019 12/31/2023 408.05 Description: OPTX ACROMCLV DISLC AQT/CHRN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23552 MEDSV DEF RBRVS 01/01/2024 606.08 Description: OPTX ACRCLV DSLC AQ/CHRN GRF Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23552 MEDSV DEF RBRVS 09/01/2019 12/31/2023 467.27 Description: OPTX ACRCLV DSLC AQ/CHRN GRF Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23570 MEDSV DEF RBRVS 01/01/2024 223.82 Description: CLTX SCAPULAR FX W/O MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23570 MEDSV DEF RBRVS 09/01/2019 12/31/2023 163.49 Description: CLTX SCAPULAR FX W/O MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23575 MEDSV DEF RBRVS 01/01/2024 389.02 Description: CLTX SCAP FX W/MNPJ +-TRACTJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23575 MEDSV DEF RBRVS 09/01/2019 12/31/2023 282.27 Description: CLTX SCAP FX W/MNPJ +-TRACTJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23585 MEDSV DEF RBRVS 01/01/2024 907.28 Description: OPTX SCAPULAR FX W/INT FIXJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23585 MEDSV DEF RBRVS 09/01/2019 12/31/2023 701.89 Description: OPTX SCAPULAR FX W/INT FIXJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23600 MEDSV DEF RBRVS 01/01/2024 317.53 Description: CLTX PROX HUMRL FX W/O MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23600 MEDSV DEF RBRVS 09/01/2019 12/31/2023 230.14 Description: CLTX PROX HUMRL FX W/O MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23605 MEDSV DEF RBRVS 01/01/2024 445.19 Description: CLTX PRX HMRL FX MNPJ+-TRACT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23605 MEDSV DEF RBRVS 09/01/2019 12/31/2023 328.60 Description: CLTX PRX HMRL FX MNPJ+-TRACT Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 199 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 23615 MEDSV DEF RBRVS 01/01/2024 821.59 Description: OPTX PROX HUMRL FX W/INT FIX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23615 MEDSV DEF RBRVS 09/01/2019 12/31/2023 632.53 Description: OPTX PROX HUMRL FX W/INT FIX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23616 MEDSV DEF RBRVS 01/01/2024 1144.33 Description: OPTX PRX HMRL FX FIX RPR RPL Category: Medical Services CMS Add: 01/01/1993 CMS Term: 23616 MEDSV DEF RBRVS 09/01/2019 12/31/2023 889.92 Description: OPTX PRX HMRL FX FIX RPR RPL Category: Medical Services CMS Add: 01/01/1993 CMS Term: 23620 MEDSV DEF RBRVS 01/01/2024 258.70 Description: CLTX GR HMRL TBRS FX WO MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23620 MEDSV DEF RBRVS 09/01/2019 12/31/2023 189.98 Description: CLTX GR HMRL TBRS FX WO MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23625 MEDSV DEF RBRVS 01/01/2024 368.54 Description: CLTX GR HMRL TBRS FX W/MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23625 MEDSV DEF RBRVS 09/01/2019 12/31/2023 268.70 Description: CLTX GR HMRL TBRS FX W/MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23630 MEDSV DEF RBRVS 01/01/2024 727.70 Description: OPTX GR HMRL TBRS FX INT FIX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23630 MEDSV DEF RBRVS 09/01/2019 12/31/2023 558.72 Description: OPTX GR HMRL TBRS FX INT FIX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23650 MEDSV DEF RBRVS 01/01/2024 315.20 Description: CLTX SHO DSLC W/MNPJ WO ANES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23650 MEDSV DEF RBRVS 09/01/2019 12/31/2023 222.34 Description: CLTX SHO DSLC W/MNPJ WO ANES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23655 MEDSV DEF RBRVS 01/01/2024 384.49 Description: CLTX SHO DSLC W/MNPJ W/ANES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23655 MEDSV DEF RBRVS 09/01/2019 12/31/2023 283.46 Description: CLTX SHO DSLC W/MNPJ W/ANES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23660 MEDSV DEF RBRVS 01/01/2024 549.07 Description: OPTX ACUTE SHOULDER DISLC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23660 MEDSV DEF RBRVS 09/01/2019 12/31/2023 415.71 Description: OPTX ACUTE SHOULDER DISLC Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 200 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 23665 MEDSV DEF RBRVS 01/01/2024 411.51 Description: CLTX SHO DSLC FX GR HMRL TBR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23665 MEDSV DEF RBRVS 09/01/2019 12/31/2023 301.33 Description: CLTX SHO DSLC FX GR HMRL TBR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23670 MEDSV DEF RBRVS 01/01/2024 810.39 Description: OPTX SHO DISLC FX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23670 MEDSV DEF RBRVS 09/01/2019 12/31/2023 627.29 Description: OPTX SHO DISLC FX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23675 MEDSV DEF RBRVS 01/01/2024 520.60 Description: CLTX SHO DISLC NECK FX MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23675 MEDSV DEF RBRVS 09/01/2019 12/31/2023 389.10 Description: CLTX SHO DISLC NECK FX MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23680 MEDSV DEF RBRVS 01/01/2024 863.65 Description: OPTX SHO DISLC NECK FX FIXJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23680 MEDSV DEF RBRVS 09/01/2019 12/31/2023 663.96 Description: OPTX SHO DISLC NECK FX FIXJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23700 MEDSV DEF RBRVS 01/01/2024 182.81 Description: MNPJ ANES SHO JT FIXJ APRATS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23700 MEDSV DEF RBRVS 09/01/2019 12/31/2023 139.24 Description: MNPJ ANES SHO JT FIXJ APRATS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23800 MEDSV DEF RBRVS 01/01/2024 952.45 Description: ARTHRODESIS GLENOHUMERAL JT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23800 MEDSV DEF RBRVS 09/01/2019 12/31/2023 732.83 Description: ARTHRODESIS GLENOHUMERAL JT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23802 MEDSV DEF RBRVS 01/01/2024 1187.59 Description: ARTHRD GLENOHUMERAL JT W/GRF Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23802 MEDSV DEF RBRVS 09/01/2019 12/31/2023 917.19 Description: ARTHRD GLENOHUMERAL JT W/GRF Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23900 MEDSV DEF RBRVS 01/01/2024 1279.73 Description: INTERTHORACOSCPLR AMPUTATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23900 MEDSV DEF RBRVS 09/01/2019 12/31/2023 993.52 Description: INTERTHORACOSCPLR AMPUTATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 201 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 23920 MEDSV DEF RBRVS 01/01/2024 1039.76 Description: DISARTICULATION SHOULDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23920 MEDSV DEF RBRVS 09/01/2019 12/31/2023 805.18 Description: DISARTICULATION SHOULDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23921 MEDSV DEF RBRVS 01/01/2024 440.94 Description: DISARTICULATION SHO SEC CLSR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23921 MEDSV DEF RBRVS 09/01/2019 12/31/2023 335.68 Description: DISARTICULATION SHO SEC CLSR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23929 MEDSV DEF BILL20 Description: UNLISTED PROCEDURE SHOULDER Category: Medical Services CMS Add: 01/01/1982 CMS Term: 23930 MEDSV DEF RBRVS 01/01/2024 335.44 Description: I&D UPR A/E DP ABSC/HMTMA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23930 MEDSV DEF RBRVS 09/01/2019 12/31/2023 247.46 Description: I&D UPR A/E DP ABSC/HMTMA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23931 MEDSV DEF RBRVS 01/01/2024 283.78 Description: I&D UPR A/E BURSA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23931 MEDSV DEF RBRVS 09/01/2019 12/31/2023 202.53 Description: I&D UPR A/E BURSA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23935 MEDSV DEF RBRVS 01/01/2024 481.41 Description: INC DP OPN B1 CRTX HUM/ELBW Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23935 MEDSV DEF RBRVS 09/01/2019 12/31/2023 362.00 Description: INC DP OPN B1 CRTX HUM/ELBW Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24000 MEDSV DEF RBRVS 01/01/2024 448.39 Description: ARTHRT ELBW EXPL DRG/RMVL FB Category: Medical Services CMS Add: 01/01/1985 CMS Term: 24000 MEDSV DEF RBRVS 09/01/2019 12/31/2023 339.40 Description: ARTHRT ELBW EXPL DRG/RMVL FB Category: Medical Services CMS Add: 01/01/1985 CMS Term: 24006 MEDSV DEF RBRVS 01/01/2024 665.17 Description: ARTHRT ELBW CAPSL EXC RLS Category: Medical Services CMS Add: 01/01/1993 CMS Term: 24006 MEDSV DEF RBRVS 09/01/2019 12/31/2023 507.93 Description: ARTHRT ELBW CAPSL EXC RLS Category: Medical Services CMS Add: 01/01/1993 CMS Term: 24065 MEDSV DEF RBRVS 01/01/2024 242.17 Description: BIOPSY ARM/ELBOW SOFT TISSUE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 202 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 24065 MEDSV DEF RBRVS 09/01/2019 12/31/2023 180.34 Description: BIOPSY ARM/ELBOW SOFT TISSUE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24066 MEDSV DEF RBRVS 01/01/2024 581.20 Description: BIOPSY ARM/ELBOW SOFT TISSUE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24066 MEDSV DEF RBRVS 09/01/2019 12/31/2023 433.49 Description: BIOPSY ARM/ELBOW SOFT TISSUE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24071 MEDSV DEF RBRVS 01/01/2024 374.91 Description: EXC ARM/ELBOW LES SC 3 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 24071 MEDSV DEF RBRVS 02/01/2015 12/31/2023 288.40 Description: EXC ARM/ELBOW LES SC 3 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 24073 MEDSV DEF RBRVS 01/01/2024 640.93 Description: EX ARM/ELBOW TUM DEEP 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 24073 MEDSV DEF RBRVS 02/01/2015 12/31/2023 492.15 Description: EX ARM/ELBOW TUM DEEP 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 24075 MEDSV DEF RBRVS 01/01/2024 497.28 Description: EXC ARM/ELBOW LES SC < 3 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24075 MEDSV DEF RBRVS 09/01/2019 12/31/2023 343.89 Description: EXC ARM/ELBOW LES SC < 3 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24076 MEDSV DEF RBRVS 01/01/2024 509.28 Description: EX ARM/ELBOW TUM DEEP < 5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24076 MEDSV DEF RBRVS 09/01/2019 12/31/2023 386.29 Description: EX ARM/ELBOW TUM DEEP < 5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24077 MEDSV DEF RBRVS 01/01/2024 952.05 Description: RAD RESCJ TUM TISS A/E <5CM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 24077 MEDSV DEF RBRVS 09/01/2019 12/31/2023 740.36 Description: RAD RESCJ TUM TISS A/E <5CM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 24079 MEDSV DEF RBRVS 01/01/2024 1216.86 Description: RAD RESCJ TUM TISS A/E 5 CM+ Category: Medical Services CMS Add: 01/01/2010 CMS Term: 24079 MEDSV DEF RBRVS 02/01/2015 12/31/2023 946.73 Description: RAD RESCJ TUM TISS A/E 5 CM+ Category: Medical Services CMS Add: 01/01/2010 CMS Term: 24100 MEDSV DEF RBRVS 01/01/2024 393.83 Description: ARTHRT ELBW SYNOVIAL BX ONLY Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 203 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 24100 MEDSV DEF RBRVS 09/01/2019 12/31/2023 296.41 Description: ARTHRT ELBW SYNOVIAL BX ONLY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24101 MEDSV DEF RBRVS 01/01/2024 473.45 Description: ARTHRT ELBW JT EXPL BX RMVL Category: Medical Services CMS Add: 01/01/1985 CMS Term: 24101 MEDSV DEF RBRVS 09/01/2019 12/31/2023 355.14 Description: ARTHRT ELBW JT EXPL BX RMVL Category: Medical Services CMS Add: 01/01/1985 CMS Term: 24102 MEDSV DEF RBRVS 01/01/2024 576.69 Description: ARTHRT ELBOW W/SYNOVECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24102 MEDSV DEF RBRVS 09/01/2019 12/31/2023 439.10 Description: ARTHRT ELBOW W/SYNOVECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24105 MEDSV DEF RBRVS 01/01/2024 338.82 Description: EXCISION OLECRANON BURSA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24105 MEDSV DEF RBRVS 09/01/2019 12/31/2023 247.47 Description: EXCISION OLECRANON BURSA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24110 MEDSV DEF RBRVS 01/01/2024 552.39 Description: EXC/CURTG B1 CST/B9 TUM HUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24110 MEDSV DEF RBRVS 09/01/2019 12/31/2023 417.77 Description: EXC/CURTG B1 CST/B9 TUM HUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24115 MEDSV DEF RBRVS 01/01/2024 687.41 Description: EXC/CRTG B1 CST/TUM HUM AGRF Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24115 MEDSV DEF RBRVS 09/01/2019 12/31/2023 525.24 Description: EXC/CRTG B1 CST/TUM HUM AGRF Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24116 MEDSV DEF RBRVS 01/01/2024 799.49 Description: EXC/CRTG B1 CST/TUM HUM ALGR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24116 MEDSV DEF RBRVS 09/01/2019 12/31/2023 614.80 Description: EXC/CRTG B1 CST/TUM HUM ALGR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24120 MEDSV DEF RBRVS 01/01/2024 499.62 Description: EXC/CRTG B1 CST/B9 TUM RDS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24120 MEDSV DEF RBRVS 09/01/2019 12/31/2023 376.21 Description: EXC/CRTG B1 CST/B9 TUM RDS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24125 MEDSV DEF RBRVS 01/01/2024 582.08 Description: EXC/CRTG B1 CST/TUM RDS AGRF Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 204 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 24125 MEDSV DEF RBRVS 09/01/2019 12/31/2023 440.99 Description: EXC/CRTG B1 CST/TUM RDS AGRF Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24126 MEDSV DEF RBRVS 01/01/2024 607.67 Description: EXC/CRTG B1 CST/TUM RDS ALGR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24126 MEDSV DEF RBRVS 09/01/2019 12/31/2023 461.74 Description: EXC/CRTG B1 CST/TUM RDS ALGR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24130 MEDSV DEF RBRVS 01/01/2024 481.40 Description: EXCISION RADIAL HEAD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24130 MEDSV DEF RBRVS 09/01/2019 12/31/2023 360.93 Description: EXCISION RADIAL HEAD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24134 MEDSV DEF RBRVS 01/01/2024 696.68 Description: SEQUESTRECTOMY SHFT/DSTL HUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24134 MEDSV DEF RBRVS 09/01/2019 12/31/2023 532.06 Description: SEQUESTRECTOMY SHFT/DSTL HUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24136 MEDSV DEF RBRVS 01/01/2024 590.93 Description: SEQUESTRECTOMY RADIAL H/N Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24136 MEDSV DEF RBRVS 09/01/2019 12/31/2023 453.18 Description: SEQUESTRECTOMY RADIAL H/N Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24138 MEDSV DEF RBRVS 01/01/2024 642.80 Description: SEQUESTRECTOMY OLECRN PROCES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24138 MEDSV DEF RBRVS 09/01/2019 12/31/2023 479.07 Description: SEQUESTRECTOMY OLECRN PROCES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24140 MEDSV DEF RBRVS 01/01/2024 656.74 Description: PARTIAL EXC BONE HUMERUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24140 MEDSV DEF RBRVS 09/01/2019 12/31/2023 498.70 Description: PARTIAL EXC BONE HUMERUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24145 MEDSV DEF RBRVS 01/01/2024 555.73 Description: PRTL EXC BONE RADIAL H/N Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24145 MEDSV DEF RBRVS 09/01/2019 12/31/2023 420.90 Description: PRTL EXC BONE RADIAL H/N Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24147 MEDSV DEF RBRVS 01/01/2024 588.98 Description: PRTL EXC BONE OLECRN PROCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 205 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 24147 MEDSV DEF RBRVS 09/01/2019 12/31/2023 442.26 Description: PRTL EXC BONE OLECRN PROCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24149 MEDSV DEF RBRVS 01/01/2019 12/31/2023 838.59 Description: RADICAL RESECTION OF ELBOW Category: Medical Services CMS Add: 01/01/1997 CMS Term: 24149 MEDSV DEF RBRVS 01/01/2024 1097.81 Description: RADICAL RESECTION OF ELBOW Category: Medical Services CMS Add: 01/01/1997 CMS Term: 24150 MEDSV DEF RBRVS 01/01/2024 1424.95 Description: RAD RESCJ TUM DSTL/SHFT HUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24150 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1114.95 Description: RAD RESCJ TUM DSTL/SHFT HUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24152 MEDSV DEF RBRVS 01/01/2024 1240.68 Description: RAD RESECTION TUM RADIAL H/N Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24152 MEDSV DEF RBRVS 09/01/2019 12/31/2023 984.89 Description: RAD RESECTION TUM RADIAL H/N Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24155 MEDSV DEF RBRVS 01/01/2024 791.95 Description: RESECTION OF ELBOW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24155 MEDSV DEF RBRVS 09/01/2019 12/31/2023 608.97 Description: RESECTION OF ELBOW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24160 MEDSV DEF RBRVS 01/01/2024 1164.05 Description: RMVL PROSTHHUMRL&ULNAR CMPNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24160 MEDSV DEF RBRVS 09/01/2019 12/31/2023 903.27 Description: RMVL PROSTHHUMRL&ULNAR CMPNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24164 MEDSV DEF RBRVS 01/01/2024 675.00 Description: REMOVAL PROSTH RADIAL HEAD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24164 MEDSV DEF RBRVS 09/01/2019 12/31/2023 519.87 Description: REMOVAL PROSTH RADIAL HEAD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24200 MEDSV DEF RBRVS 01/01/2024 201.85 Description: RMVL FB UPPER ARM/ELBW SUBQ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24200 MEDSV DEF RBRVS 09/01/2019 12/31/2023 144.99 Description: RMVL FB UPPER ARM/ELBW SUBQ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24201 MEDSV DEF RBRVS 01/01/2024 512.00 Description: RMVL FB UPPER ARM/ELBW DEEP Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 206 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 24201 MEDSV DEF RBRVS 09/01/2019 12/31/2023 394.15 Description: RMVL FB UPPER ARM/ELBW DEEP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24220 MEDSV DEF RBRVS 01/01/2024 180.01 Description: INJECTION PX FOR ELBOW ARTHG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24220 MEDSV DEF RBRVS 09/01/2019 12/31/2023 113.31 Description: INJECTION PX FOR ELBOW ARTHG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24300 MEDSV DEF RBRVS 01/01/2016 12/31/2023 291.86 Description: MNPJ ELBOW UNDER ANES Category: Medical Services CMS Add: 01/01/2002 CMS Term: 24300 MEDSV DEF RBRVS 01/01/2024 411.22 Description: MNPJ ELBOW UNDER ANES Category: Medical Services CMS Add: 01/01/2002 CMS Term: 24301 MEDSV DEF RBRVS 01/01/2024 701.50 Description: MUSC/TDN TRANSFER UPR A/E 1 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24301 MEDSV DEF RBRVS 09/01/2019 12/31/2023 536.85 Description: MUSC/TDN TRANSFER UPR A/E 1 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24305 MEDSV DEF RBRVS 01/01/2024 543.16 Description: TENDON LNGTH UPR A/E EA TDN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24305 MEDSV DEF RBRVS 09/01/2019 12/31/2023 411.00 Description: TENDON LNGTH UPR A/E EA TDN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24310 MEDSV DEF RBRVS 01/01/2024 446.33 Description: TNOT OPN ELBW TO SHO EA TDN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24310 MEDSV DEF RBRVS 09/01/2019 12/31/2023 338.42 Description: TNOT OPN ELBW TO SHO EA TDN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24320 MEDSV DEF RBRVS 01/01/2024 726.49 Description: TENOPLASTY ELBOW TO SHO 1 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24320 MEDSV DEF RBRVS 09/01/2019 12/31/2023 556.52 Description: TENOPLASTY ELBOW TO SHO 1 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24330 MEDSV DEF RBRVS 01/01/2024 669.71 Description: FLEXOR-PLASTY ELBOW Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24330 MEDSV DEF RBRVS 09/01/2019 12/31/2023 510.93 Description: FLEXOR-PLASTY ELBOW Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24331 MEDSV DEF RBRVS 01/01/2024 730.93 Description: FLEXOR-PLASTY ELBW W/ADVMNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 207 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 24331 MEDSV DEF RBRVS 09/01/2019 12/31/2023 560.51 Description: FLEXOR-PLASTY ELBW W/ADVMNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24332 MEDSV DEF RBRVS 01/01/2016 12/31/2023 435.39 0-2 Description: TENOLYSIS TRICEPS Category: Medical Services CMS Add: 01/01/2002 CMS Term: 24332 MEDSV DEF RBRVS 01/01/2024 575.35 0-2 Description: TENOLYSIS TRICEPS Category: Medical Services CMS Add: 01/01/2002 CMS Term: 24340 MEDSV DEF RBRVS 01/01/2024 562.95 Description: TENODESIS BICEPS TDN AT ELBW Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24340 MEDSV DEF RBRVS 09/01/2019 12/31/2023 437.98 Description: TENODESIS BICEPS TDN AT ELBW Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24341 MEDSV DEF RBRVS 01/01/2019 12/31/2023 532.18 Description: RPR TDN/MUSC UPR A/E EACH Category: Medical Services CMS Add: 01/01/1997 CMS Term: 24341 MEDSV DEF RBRVS 01/01/2024 698.64 Description: RPR TDN/MUSC UPR A/E EACH Category: Medical Services CMS Add: 01/01/1997 CMS Term: 24342 MEDSV DEF RBRVS 01/01/2024 722.25 Description: REPAIR OF RUPTURED TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24342 MEDSV DEF RBRVS 09/01/2019 12/31/2023 554.87 Description: REPAIR OF RUPTURED TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24343 MEDSV DEF RBRVS 01/01/2024 668.28 0-2 Description: REPR ELBOW LAT LIGMNT W/TISS Category: Medical Services CMS Add: 01/01/2002 CMS Term: 24343 MEDSV DEF RBRVS 02/01/2015 12/31/2023 502.91 0-2 Description: REPR ELBOW LAT LIGMNT W/TISS Category: Medical Services CMS Add: 01/01/2002 CMS Term: 24344 MEDSV DEF RBRVS 01/01/2024 1016.64 0-2 Description: RECONSTRUCT ELBOW LAT LIGMNT Category: Medical Services CMS Add: 01/01/2002 CMS Term: 24344 MEDSV DEF RBRVS 02/01/2015 12/31/2023 783.47 0-2 Description: RECONSTRUCT ELBOW LAT LIGMNT Category: Medical Services CMS Add: 01/01/2002 CMS Term: 24345 MEDSV DEF RBRVS 01/01/2024 664.43 0-2 Description: REPR ELBW MED LIGMNT W/TISSU Category: Medical Services CMS Add: 01/01/2002 CMS Term: 24345 MEDSV DEF RBRVS 02/01/2015 12/31/2023 500.19 0-2 Description: REPR ELBW MED LIGMNT W/TISSU Category: Medical Services CMS Add: 01/01/2002 CMS Term: 24346 MEDSV DEF RBRVS 01/01/2024 1025.28 0-2 Description: RECONSTRUCT ELBOW MED LIGMNT Category: Medical Services CMS Add: 01/01/2002 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 208 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 24346 MEDSV DEF RBRVS 02/01/2015 12/31/2023 783.47 0-2 Description: RECONSTRUCT ELBOW MED LIGMNT Category: Medical Services CMS Add: 01/01/2002 CMS Term: 24357 MEDSV DEF RBRVS 01/01/2024 396.41 Description: REPAIR ELBOW PERC Category: Medical Services CMS Add: 01/01/2008 CMS Term: 24357 MEDSV DEF RBRVS 02/01/2015 12/31/2023 313.13 Description: REPAIR ELBOW PERC Category: Medical Services CMS Add: 01/01/2008 CMS Term: 24358 MEDSV DEF RBRVS 01/01/2024 496.34 Description: REPAIR ELBOW W/DEB OPEN Category: Medical Services CMS Add: 01/01/2008 CMS Term: 24358 MEDSV DEF RBRVS 02/01/2015 12/31/2023 372.16 Description: REPAIR ELBOW W/DEB OPEN Category: Medical Services CMS Add: 01/01/2008 CMS Term: 24359 MEDSV DEF RBRVS 01/01/2024 620.17 Description: REPAIR ELBOW DEB/ATTCH OPEN Category: Medical Services CMS Add: 01/01/2008 CMS Term: 24359 MEDSV DEF RBRVS 02/01/2015 12/31/2023 470.83 Description: REPAIR ELBOW DEB/ATTCH OPEN Category: Medical Services CMS Add: 01/01/2008 CMS Term: 24360 MEDSV DEF RBRVS 01/01/2024 839.00 Description: RECONSTRUCT ELBOW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24360 MEDSV DEF RBRVS 09/01/2019 12/31/2023 641.15 Description: RECONSTRUCT ELBOW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24361 MEDSV DEF RBRVS 01/01/2024 934.92 Description: RECONSTRUCT ELBOW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24361 MEDSV DEF RBRVS 09/01/2019 12/31/2023 718.46 Description: RECONSTRUCT ELBOW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24362 MEDSV DEF RBRVS 01/01/2024 983.65 Description: RECONSTRUCT ELBOW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24362 MEDSV DEF RBRVS 09/01/2019 12/31/2023 757.44 Description: RECONSTRUCT ELBOW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24363 MEDSV DEF RBRVS 01/01/2024 1340.59 Description: REPLACE ELBOW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24363 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1046.58 Description: REPLACE ELBOW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24365 MEDSV DEF RBRVS 01/01/2024 598.41 Description: RECONSTRUCT HEAD OF RADIUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 209 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 24365 MEDSV DEF RBRVS 09/01/2019 12/31/2023 454.80 Description: RECONSTRUCT HEAD OF RADIUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24366 MEDSV DEF RBRVS 01/01/2024 635.86 Description: RECONSTRUCT HEAD OF RADIUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24366 MEDSV DEF RBRVS 09/01/2019 12/31/2023 485.99 Description: RECONSTRUCT HEAD OF RADIUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24370 MEDSV DEF RBRVS 01/01/2024 1423.85 0-1 Description: REVISE RECONST ELBOW JOINT Category: Medical Services CMS Add: 01/01/2013 CMS Term: 24370 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1107.96 0-1 Description: REVISE RECONST ELBOW JOINT Category: Medical Services CMS Add: 01/01/2013 CMS Term: 24371 MEDSV DEF RBRVS 01/01/2024 1633.71 0-1 Description: REVISE RECONST ELBOW JOINT Category: Medical Services CMS Add: 01/01/2013 CMS Term: 24371 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1279.90 0-1 Description: REVISE RECONST ELBOW JOINT Category: Medical Services CMS Add: 01/01/2013 CMS Term: 24400 MEDSV DEF RBRVS 01/01/2024 770.56 Description: REVISION OF HUMERUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24400 MEDSV DEF RBRVS 09/01/2019 12/31/2023 583.93 Description: REVISION OF HUMERUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24410 MEDSV DEF RBRVS 01/01/2024 981.13 Description: REVISION OF HUMERUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24410 MEDSV DEF RBRVS 09/01/2019 12/31/2023 754.69 Description: REVISION OF HUMERUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24420 MEDSV DEF RBRVS 01/01/2024 990.98 Description: REVISION OF HUMERUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24420 MEDSV DEF RBRVS 09/01/2019 12/31/2023 708.44 Description: REVISION OF HUMERUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24430 MEDSV DEF RBRVS 01/01/2024 979.82 Description: REPAIR OF HUMERUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24430 MEDSV DEF RBRVS 09/01/2019 12/31/2023 757.29 Description: REPAIR OF HUMERUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24435 MEDSV DEF RBRVS 01/01/2024 1002.31 Description: REPAIR HUMERUS WITH GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 210 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 24435 MEDSV DEF RBRVS 09/01/2019 12/31/2023 770.54 Description: REPAIR HUMERUS WITH GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24470 MEDSV DEF RBRVS 01/01/2024 627.48 Description: REVISION OF ELBOW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24470 MEDSV DEF RBRVS 09/01/2019 12/31/2023 418.21 Description: REVISION OF ELBOW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24495 MEDSV DEF RBRVS 01/01/2024 865.41 Description: DECOMPRESSION OF FOREARM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24495 MEDSV DEF RBRVS 09/01/2019 12/31/2023 461.21 Description: DECOMPRESSION OF FOREARM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24498 MEDSV DEF RBRVS 01/01/2024 805.66 Description: REINFORCE HUMERUS Category: Medical Services CMS Add: 01/01/1986 CMS Term: 24498 MEDSV DEF RBRVS 09/01/2019 12/31/2023 619.61 Description: REINFORCE HUMERUS Category: Medical Services CMS Add: 01/01/1986 CMS Term: 24500 MEDSV DEF RBRVS 01/01/2024 344.75 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24500 MEDSV DEF RBRVS 09/01/2019 12/31/2023 252.06 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24505 MEDSV DEF RBRVS 01/01/2024 476.94 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24505 MEDSV DEF RBRVS 09/01/2019 12/31/2023 352.82 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24515 MEDSV DEF RBRVS 01/01/2024 819.80 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24515 MEDSV DEF RBRVS 09/01/2019 12/31/2023 625.96 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24516 MEDSV DEF RBRVS 01/01/2024 799.03 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 24516 MEDSV DEF RBRVS 09/01/2019 12/31/2023 614.88 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 24530 MEDSV DEF RBRVS 01/01/2024 364.77 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 211 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 24530 MEDSV DEF RBRVS 09/01/2019 12/31/2023 267.84 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24535 MEDSV DEF RBRVS 01/01/2024 585.30 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24535 MEDSV DEF RBRVS 09/01/2019 12/31/2023 436.11 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24538 MEDSV DEF RBRVS 01/01/2024 737.87 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24538 MEDSV DEF RBRVS 09/01/2019 12/31/2023 528.47 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24545 MEDSV DEF RBRVS 01/01/2024 861.91 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24545 MEDSV DEF RBRVS 09/01/2019 12/31/2023 664.78 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24546 MEDSV DEF RBRVS 01/01/2024 962.54 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 24546 MEDSV DEF RBRVS 09/01/2019 12/31/2023 744.36 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 24560 MEDSV DEF RBRVS 01/01/2024 317.77 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 24560 MEDSV DEF RBRVS 09/01/2019 12/31/2023 226.72 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 24565 MEDSV DEF RBRVS 01/01/2024 511.68 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 24565 MEDSV DEF RBRVS 09/01/2019 12/31/2023 376.18 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 24566 MEDSV DEF RBRVS 01/01/2024 673.27 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 24566 MEDSV DEF RBRVS 09/01/2019 12/31/2023 509.64 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 24575 MEDSV DEF RBRVS 01/01/2024 683.76 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 212 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 24575 MEDSV DEF RBRVS 09/01/2019 12/31/2023 523.47 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24576 MEDSV DEF RBRVS 01/01/2024 334.85 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 24576 MEDSV DEF RBRVS 09/01/2019 12/31/2023 238.86 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 24577 MEDSV DEF RBRVS 01/01/2024 525.82 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 24577 MEDSV DEF RBRVS 09/01/2019 12/31/2023 387.48 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 24579 MEDSV DEF RBRVS 01/01/2024 777.97 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24579 MEDSV DEF RBRVS 09/01/2019 12/31/2023 596.21 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24582 MEDSV DEF RBRVS 01/01/2024 762.03 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 24582 MEDSV DEF RBRVS 09/01/2019 12/31/2023 574.33 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 24586 MEDSV DEF RBRVS 01/01/2024 1008.34 Description: TREAT ELBOW FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24586 MEDSV DEF RBRVS 09/01/2019 12/31/2023 776.40 Description: TREAT ELBOW FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24587 MEDSV DEF RBRVS 01/01/2024 1008.89 Description: TREAT ELBOW FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24587 MEDSV DEF RBRVS 09/01/2019 12/31/2023 775.43 Description: TREAT ELBOW FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24600 MEDSV DEF RBRVS 01/01/2024 358.75 Description: TREAT ELBOW DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24600 MEDSV DEF RBRVS 09/01/2019 12/31/2023 259.27 Description: TREAT ELBOW DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24605 MEDSV DEF RBRVS 01/01/2024 449.95 Description: TREAT ELBOW DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 213 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 24605 MEDSV DEF RBRVS 09/01/2019 12/31/2023 332.95 Description: TREAT ELBOW DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24615 MEDSV DEF RBRVS 01/01/2024 666.55 Description: TREAT ELBOW DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24615 MEDSV DEF RBRVS 09/01/2019 12/31/2023 507.71 Description: TREAT ELBOW DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24620 MEDSV DEF RBRVS 01/01/2024 551.40 Description: TREAT ELBOW FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24620 MEDSV DEF RBRVS 09/01/2019 12/31/2023 394.06 Description: TREAT ELBOW FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24635 MEDSV DEF RBRVS 01/01/2024 632.14 Description: TREAT ELBOW FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24635 MEDSV DEF RBRVS 09/01/2019 12/31/2023 479.87 Description: TREAT ELBOW FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24640 MEDSV DEF RBRVS 01/01/2024 98.92 Description: TREAT ELBOW DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24640 MEDSV DEF RBRVS 09/01/2019 12/31/2023 98.40 Description: TREAT ELBOW DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24650 MEDSV DEF RBRVS 01/01/2024 252.07 Description: TREAT RADIUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24650 MEDSV DEF RBRVS 09/01/2019 12/31/2023 184.36 Description: TREAT RADIUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24655 MEDSV DEF RBRVS 01/01/2024 424.97 Description: TREAT RADIUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24655 MEDSV DEF RBRVS 09/01/2019 12/31/2023 310.08 Description: TREAT RADIUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24665 MEDSV DEF RBRVS 01/01/2024 614.99 Description: TREAT RADIUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24665 MEDSV DEF RBRVS 09/01/2019 12/31/2023 464.00 Description: TREAT RADIUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24666 MEDSV DEF RBRVS 01/01/2024 683.93 Description: TREAT RADIUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 214 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 24666 MEDSV DEF RBRVS 09/01/2019 12/31/2023 522.71 Description: TREAT RADIUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24670 MEDSV DEF RBRVS 01/01/2024 279.05 Description: TREAT ULNAR FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24670 MEDSV DEF RBRVS 09/01/2019 12/31/2023 205.05 Description: TREAT ULNAR FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24675 MEDSV DEF RBRVS 01/01/2024 436.82 Description: TREAT ULNAR FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24675 MEDSV DEF RBRVS 09/01/2019 12/31/2023 321.51 Description: TREAT ULNAR FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24685 MEDSV DEF RBRVS 01/01/2024 611.18 Description: TREAT ULNAR FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24685 MEDSV DEF RBRVS 09/01/2019 12/31/2023 466.00 Description: TREAT ULNAR FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24800 MEDSV DEF RBRVS 01/01/2024 775.75 Description: FUSION OF ELBOW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24800 MEDSV DEF RBRVS 09/01/2019 12/31/2023 591.03 Description: FUSION OF ELBOW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24802 MEDSV DEF RBRVS 01/01/2024 930.32 Description: FUSION/GRAFT OF ELBOW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24802 MEDSV DEF RBRVS 09/01/2019 12/31/2023 714.88 Description: FUSION/GRAFT OF ELBOW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24900 MEDSV DEF RBRVS 01/01/2024 685.76 Description: AMPUTATION OF UPPER ARM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24900 MEDSV DEF RBRVS 09/01/2019 12/31/2023 523.96 Description: AMPUTATION OF UPPER ARM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24920 MEDSV DEF RBRVS 01/01/2024 682.97 Description: AMPUTATION OF UPPER ARM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24920 MEDSV DEF RBRVS 09/01/2019 12/31/2023 521.79 Description: AMPUTATION OF UPPER ARM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24925 MEDSV DEF RBRVS 01/01/2024 532.68 Description: AMPUTATION FOLLOW-UP SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 215 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 24925 MEDSV DEF RBRVS 09/01/2019 12/31/2023 401.99 Description: AMPUTATION FOLLOW-UP SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24930 MEDSV DEF RBRVS 01/01/2024 719.74 Description: AMPUTATION FOLLOW-UP SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24930 MEDSV DEF RBRVS 09/01/2019 12/31/2023 551.75 Description: AMPUTATION FOLLOW-UP SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24931 MEDSV DEF RBRVS 01/01/2024 863.65 Description: AMPUTATE UPPER ARM & IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24931 MEDSV DEF RBRVS 09/01/2019 12/31/2023 567.61 Description: AMPUTATE UPPER ARM & IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24935 MEDSV DEF RBRVS 01/01/2024 1135.53 Description: REVISION OF AMPUTATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24935 MEDSV DEF RBRVS 09/01/2019 12/31/2023 747.34 Description: REVISION OF AMPUTATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24940 MEDSV PRF MAXFEE 01/01/2024 1764.79 0.0 Description: REVISION OF UPPER ARM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24999 MEDSV DEF BILL20 Description: UNLISTED PX HUMERUS/ELBOW Category: Medical Services CMS Add: 01/01/1982 CMS Term: 25000 MEDSV DEF RBRVS 01/01/2024 326.03 Description: INCISION OF TENDON SHEATH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25000 MEDSV DEF RBRVS 09/01/2019 12/31/2023 237.24 Description: INCISION OF TENDON SHEATH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25001 MEDSV DEF RBRVS 01/01/2024 326.62 0-2 Description: INCISE FLEXOR CARPI RADIALIS Category: Medical Services CMS Add: 01/01/2002 CMS Term: 25001 MEDSV DEF RBRVS 02/01/2015 12/31/2023 242.70 0-2 Description: INCISE FLEXOR CARPI RADIALIS Category: Medical Services CMS Add: 01/01/2002 CMS Term: 25020 MEDSV DEF RBRVS 01/01/2024 697.11 Description: DECOMPRESS FOREARM 1 SPACE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25020 MEDSV DEF RBRVS 09/01/2019 12/31/2023 405.91 Description: DECOMPRESS FOREARM 1 SPACE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25023 MEDSV DEF RBRVS 01/01/2024 1218.96 Description: DECOMPRESS FOREARM 1 SPACE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 216 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 25023 MEDSV DEF RBRVS 09/01/2019 12/31/2023 783.96 Description: DECOMPRESS FOREARM 1 SPACE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25024 MEDSV DEF RBRVS 01/01/2024 721.43 0-2 Description: DECOMPRESS FOREARM 2 SPACES Category: Medical Services CMS Add: 01/01/2002 CMS Term: 25024 MEDSV DEF RBRVS 02/01/2015 12/31/2023 553.32 0-2 Description: DECOMPRESS FOREARM 2 SPACES Category: Medical Services CMS Add: 01/01/2002 CMS Term: 25025 MEDSV DEF RBRVS 01/01/2024 1136.05 0-2 Description: DECOMPRESS FOREARM 2 SPACES Category: Medical Services CMS Add: 01/01/2002 CMS Term: 25025 MEDSV DEF RBRVS 02/01/2015 12/31/2023 867.22 0-2 Description: DECOMPRESS FOREARM 2 SPACES Category: Medical Services CMS Add: 01/01/2002 CMS Term: 25028 MEDSV DEF RBRVS 01/01/2024 648.89 Description: DRAINAGE OF FOREARM LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25028 MEDSV DEF RBRVS 09/01/2019 12/31/2023 369.00 Description: DRAINAGE OF FOREARM LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25031 MEDSV DEF RBRVS 01/01/2024 346.05 Description: DRAINAGE OF FOREARM BURSA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25031 MEDSV DEF RBRVS 09/01/2019 12/31/2023 257.81 Description: DRAINAGE OF FOREARM BURSA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25035 MEDSV DEF RBRVS 01/01/2024 549.30 Description: TREAT FOREARM BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25035 MEDSV DEF RBRVS 09/01/2019 12/31/2023 412.80 Description: TREAT FOREARM BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25040 MEDSV DEF RBRVS 01/01/2024 524.12 Description: EXPLORE/TREAT WRIST JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 25040 MEDSV DEF RBRVS 09/01/2019 12/31/2023 400.10 Description: EXPLORE/TREAT WRIST JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 25065 MEDSV DEF RBRVS 01/01/2024 239.58 Description: BIOPSY FOREARM SOFT TISSUES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25065 MEDSV DEF RBRVS 09/01/2019 12/31/2023 178.01 Description: BIOPSY FOREARM SOFT TISSUES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25066 MEDSV DEF RBRVS 01/01/2024 344.98 Description: BIOPSY FOREARM SOFT TISSUES Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 217 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 25066 MEDSV DEF RBRVS 09/01/2019 12/31/2023 253.04 Description: BIOPSY FOREARM SOFT TISSUES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25071 MEDSV DEF RBRVS 01/01/2024 393.43 Description: EXC FOREARM LES SC 3 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 25071 MEDSV DEF RBRVS 02/01/2015 12/31/2023 302.14 Description: EXC FOREARM LES SC 3 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 25073 MEDSV DEF RBRVS 01/01/2024 500.19 Description: EXC FOREARM TUM DEEP 3 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 25073 MEDSV DEF RBRVS 02/01/2015 12/31/2023 377.53 Description: EXC FOREARM TUM DEEP 3 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 25075 MEDSV DEF RBRVS 01/01/2024 485.26 Description: EXC FOREARM LES SC < 3 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25075 MEDSV DEF RBRVS 09/01/2019 12/31/2023 335.95 Description: EXC FOREARM LES SC < 3 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25076 MEDSV DEF RBRVS 01/01/2024 486.09 Description: EXC FOREARM TUM DEEP < 3 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25076 MEDSV DEF RBRVS 09/01/2019 12/31/2023 367.71 Description: EXC FOREARM TUM DEEP < 3 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25077 MEDSV DEF RBRVS 01/01/2024 820.88 Description: RESECT FOREARM/WRIST TUM<3CM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 25077 MEDSV DEF RBRVS 09/01/2019 12/31/2023 630.72 Description: RESECT FOREARM/WRIST TUM<3CM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 25078 MEDSV DEF RBRVS 01/01/2024 1074.51 Description: RESECT FORARM/WRIST TUM 3CM> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 25078 MEDSV DEF RBRVS 02/01/2015 12/31/2023 833.92 Description: RESECT FORARM/WRIST TUM 3CM> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 25085 MEDSV DEF RBRVS 01/01/2024 421.64 Description: INCISION OF WRIST CAPSULE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25085 MEDSV DEF RBRVS 09/01/2019 12/31/2023 319.49 Description: INCISION OF WRIST CAPSULE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25100 MEDSV DEF RBRVS 01/01/2024 329.08 Description: BIOPSY OF WRIST JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 218 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 25100 MEDSV DEF RBRVS 09/01/2019 12/31/2023 245.00 Description: BIOPSY OF WRIST JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 25101 MEDSV DEF RBRVS 01/01/2024 380.84 Description: EXPLORE/TREAT WRIST JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25101 MEDSV DEF RBRVS 09/01/2019 12/31/2023 286.41 Description: EXPLORE/TREAT WRIST JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25105 MEDSV DEF RBRVS 01/01/2024 458.66 Description: REMOVE WRIST JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25105 MEDSV DEF RBRVS 09/01/2019 12/31/2023 343.08 Description: REMOVE WRIST JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25107 MEDSV DEF RBRVS 01/01/2024 579.52 Description: REMOVE WRIST JOINT CARTILAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25107 MEDSV DEF RBRVS 09/01/2019 12/31/2023 437.92 Description: REMOVE WRIST JOINT CARTILAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25109 MEDSV DEF RBRVS 01/01/2024 503.68 Description: EXCISE TENDON FOREARM/WRIST Category: Medical Services CMS Add: 01/01/2007 CMS Term: 25109 MEDSV DEF RBRVS 02/01/2015 12/31/2023 382.99 Description: EXCISE TENDON FOREARM/WRIST Category: Medical Services CMS Add: 01/01/2007 CMS Term: 25110 MEDSV DEF RBRVS 01/01/2024 327.10 Description: REMOVE WRIST TENDON LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25110 MEDSV DEF RBRVS 09/01/2019 12/31/2023 241.08 Description: REMOVE WRIST TENDON LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25111 MEDSV DEF RBRVS 01/01/2024 306.21 Description: REMOVE WRIST TENDON LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25111 MEDSV DEF RBRVS 09/01/2019 12/31/2023 226.30 Description: REMOVE WRIST TENDON LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25112 MEDSV DEF RBRVS 01/01/2024 367.52 Description: REREMOVE WRIST TENDON LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25112 MEDSV DEF RBRVS 09/01/2019 12/31/2023 274.19 Description: REREMOVE WRIST TENDON LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25115 MEDSV DEF RBRVS 01/01/2024 708.05 Description: REMOVE WRIST/FOREARM LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 219 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 25115 MEDSV DEF RBRVS 09/01/2019 12/31/2023 540.29 Description: REMOVE WRIST/FOREARM LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25116 MEDSV DEF RBRVS 01/01/2024 566.74 Description: REMOVE WRIST/FOREARM LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25116 MEDSV DEF RBRVS 09/01/2019 12/31/2023 426.48 Description: REMOVE WRIST/FOREARM LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25118 MEDSV DEF RBRVS 01/01/2024 360.83 Description: EXCISE WRIST TENDON SHEATH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25118 MEDSV DEF RBRVS 09/01/2019 12/31/2023 269.89 Description: EXCISE WRIST TENDON SHEATH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25119 MEDSV DEF RBRVS 01/01/2024 471.05 Description: PARTIAL REMOVAL OF ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25119 MEDSV DEF RBRVS 09/01/2019 12/31/2023 352.89 Description: PARTIAL REMOVAL OF ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25120 MEDSV DEF RBRVS 01/01/2024 471.64 Description: REMOVAL OF FOREARM LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25120 MEDSV DEF RBRVS 09/01/2019 12/31/2023 353.43 Description: REMOVAL OF FOREARM LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25125 MEDSV DEF RBRVS 01/01/2024 557.15 Description: REMOVE/GRAFT FOREARM LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25125 MEDSV DEF RBRVS 09/01/2019 12/31/2023 421.10 Description: REMOVE/GRAFT FOREARM LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25126 MEDSV DEF RBRVS 01/01/2024 560.92 Description: REMOVE/GRAFT FOREARM LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25126 MEDSV DEF RBRVS 09/01/2019 12/31/2023 424.14 Description: REMOVE/GRAFT FOREARM LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25130 MEDSV DEF RBRVS 01/01/2024 425.14 Description: REMOVAL OF WRIST LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25130 MEDSV DEF RBRVS 09/01/2019 12/31/2023 317.65 Description: REMOVAL OF WRIST LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25135 MEDSV DEF RBRVS 01/01/2024 524.86 Description: REMOVE & GRAFT WRIST LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 220 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 25135 MEDSV DEF RBRVS 09/01/2019 12/31/2023 396.00 Description: REMOVE & GRAFT WRIST LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25136 MEDSV DEF RBRVS 01/01/2024 466.97 Description: REMOVE & GRAFT WRIST LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25136 MEDSV DEF RBRVS 09/01/2019 12/31/2023 349.85 Description: REMOVE & GRAFT WRIST LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25145 MEDSV DEF RBRVS 01/01/2024 488.44 Description: REMOVE FOREARM BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25145 MEDSV DEF RBRVS 09/01/2019 12/31/2023 366.79 Description: REMOVE FOREARM BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25150 MEDSV DEF RBRVS 01/01/2024 532.09 Description: PARTIAL REMOVAL OF ULNA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 25150 MEDSV DEF RBRVS 09/01/2019 12/31/2023 401.58 Description: PARTIAL REMOVAL OF ULNA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 25151 MEDSV DEF RBRVS 01/01/2024 548.31 Description: PARTIAL REMOVAL OF RADIUS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 25151 MEDSV DEF RBRVS 09/01/2019 12/31/2023 415.18 Description: PARTIAL REMOVAL OF RADIUS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 25170 MEDSV DEF RBRVS 01/01/2024 1354.95 Description: RESECT RADIUS/ULNAR TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25170 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1058.66 Description: RESECT RADIUS/ULNAR TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25210 MEDSV DEF RBRVS 01/01/2024 463.90 Description: REMOVAL OF WRIST BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25210 MEDSV DEF RBRVS 09/01/2019 12/31/2023 346.67 Description: REMOVAL OF WRIST BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25215 MEDSV DEF RBRVS 01/01/2024 581.08 Description: REMOVAL OF WRIST BONES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25215 MEDSV DEF RBRVS 09/01/2019 12/31/2023 438.76 Description: REMOVAL OF WRIST BONES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25230 MEDSV DEF RBRVS 01/01/2024 407.67 Description: PARTIAL REMOVAL OF RADIUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 221 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 25230 MEDSV DEF RBRVS 09/01/2019 12/31/2023 305.38 Description: PARTIAL REMOVAL OF RADIUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25240 MEDSV DEF RBRVS 01/01/2024 404.71 Description: PARTIAL REMOVAL OF ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25240 MEDSV DEF RBRVS 09/01/2019 12/31/2023 303.93 Description: PARTIAL REMOVAL OF ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25246 MEDSV DEF RBRVS 01/01/2024 185.68 Description: INJECTION FOR WRIST X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25246 MEDSV DEF RBRVS 09/01/2019 12/31/2023 115.17 Description: INJECTION FOR WRIST X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25248 MEDSV DEF RBRVS 01/01/2024 389.33 Description: REMOVE FOREARM FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25248 MEDSV DEF RBRVS 09/01/2019 12/31/2023 294.19 Description: REMOVE FOREARM FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25250 MEDSV DEF RBRVS 01/01/2024 499.81 Description: REMOVAL OF WRIST PROSTHESIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25250 MEDSV DEF RBRVS 09/01/2019 12/31/2023 378.59 Description: REMOVAL OF WRIST PROSTHESIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25251 MEDSV DEF RBRVS 01/01/2024 671.03 Description: REMOVAL OF WRIST PROSTHESIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25251 MEDSV DEF RBRVS 09/01/2019 12/31/2023 512.14 Description: REMOVAL OF WRIST PROSTHESIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25259 MEDSV DEF RBRVS 01/01/2016 12/31/2023 293.59 Description: MANIPULATE WRIST W/ANESTHES Category: Medical Services CMS Add: 01/01/2002 CMS Term: 25259 MEDSV DEF RBRVS 01/01/2024 407.37 Description: MANIPULATE WRIST W/ANESTHES Category: Medical Services CMS Add: 01/01/2002 CMS Term: 25260 MEDSV DEF RBRVS 01/01/2024 595.61 Description: REPAIR FOREARM TENDON/MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25260 MEDSV DEF RBRVS 09/01/2019 12/31/2023 448.79 Description: REPAIR FOREARM TENDON/MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25263 MEDSV DEF RBRVS 01/01/2024 593.19 Description: REPAIR FOREARM TENDON/MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 222 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 25263 MEDSV DEF RBRVS 09/01/2019 12/31/2023 444.09 Description: REPAIR FOREARM TENDON/MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25265 MEDSV DEF RBRVS 01/01/2024 701.76 Description: REPAIR FOREARM TENDON/MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25265 MEDSV DEF RBRVS 09/01/2019 12/31/2023 532.30 Description: REPAIR FOREARM TENDON/MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25270 MEDSV DEF RBRVS 01/01/2024 464.83 Description: REPAIR FOREARM TENDON/MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25270 MEDSV DEF RBRVS 09/01/2019 12/31/2023 349.34 Description: REPAIR FOREARM TENDON/MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25272 MEDSV DEF RBRVS 01/01/2024 524.21 Description: REPAIR FOREARM TENDON/MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25272 MEDSV DEF RBRVS 09/01/2019 12/31/2023 393.63 Description: REPAIR FOREARM TENDON/MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25274 MEDSV DEF RBRVS 01/01/2024 624.45 Description: REPAIR FOREARM TENDON/MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25274 MEDSV DEF RBRVS 09/01/2019 12/31/2023 476.69 Description: REPAIR FOREARM TENDON/MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25275 MEDSV DEF RBRVS 01/01/2016 12/31/2023 478.22 Description: REPAIR FOREARM TENDON SHEATH Category: Medical Services CMS Add: 01/01/2002 CMS Term: 25275 MEDSV DEF RBRVS 01/01/2024 629.65 Description: REPAIR FOREARM TENDON SHEATH Category: Medical Services CMS Add: 01/01/2002 CMS Term: 25280 MEDSV DEF RBRVS 01/01/2024 531.31 Description: REVISE WRIST/FOREARM TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25280 MEDSV DEF RBRVS 09/01/2019 12/31/2023 400.53 Description: REVISE WRIST/FOREARM TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25290 MEDSV DEF RBRVS 01/01/2024 410.32 Description: INCISE WRIST/FOREARM TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25290 MEDSV DEF RBRVS 09/01/2019 12/31/2023 309.80 Description: INCISE WRIST/FOREARM TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25295 MEDSV DEF RBRVS 01/01/2024 495.43 Description: RELEASE WRIST/FOREARM TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 223 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 25295 MEDSV DEF RBRVS 09/01/2019 12/31/2023 371.63 Description: RELEASE WRIST/FOREARM TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25300 MEDSV DEF RBRVS 01/01/2024 645.05 Description: FUSION OF TENDONS AT WRIST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25300 MEDSV DEF RBRVS 09/01/2019 12/31/2023 487.68 Description: FUSION OF TENDONS AT WRIST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25301 MEDSV DEF RBRVS 01/01/2024 603.02 Description: FUSION OF TENDONS AT WRIST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25301 MEDSV DEF RBRVS 09/01/2019 12/31/2023 457.46 Description: FUSION OF TENDONS AT WRIST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25310 MEDSV DEF RBRVS 01/01/2024 582.89 Y Description: TRANSPLANT FOREARM TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25310 MEDSV DEF RBRVS 09/01/2019 12/31/2023 440.21 Y Description: TRANSPLANT FOREARM TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25312 MEDSV DEF RBRVS 01/01/2024 671.26 Y Description: TRANSPLANT FOREARM TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25312 MEDSV DEF RBRVS 09/01/2019 12/31/2023 510.66 Y Description: TRANSPLANT FOREARM TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25315 MEDSV DEF RBRVS 01/01/2024 716.97 Description: REVISE PALSY HAND TENDON(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25315 MEDSV DEF RBRVS 09/01/2019 12/31/2023 548.79 Description: REVISE PALSY HAND TENDON(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25316 MEDSV DEF RBRVS 01/01/2024 851.46 Description: REVISE PALSY HAND TENDON(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25316 MEDSV DEF RBRVS 09/01/2019 12/31/2023 636.84 Description: REVISE PALSY HAND TENDON(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25320 MEDSV DEF RBRVS 01/01/2024 922.62 Description: REPAIR/REVISE WRIST JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25320 MEDSV DEF RBRVS 09/01/2019 12/31/2023 701.51 Description: REPAIR/REVISE WRIST JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25332 MEDSV DEF RBRVS 01/01/2024 789.03 Description: REVISE WRIST JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 224 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 25332 MEDSV DEF RBRVS 09/01/2019 12/31/2023 601.96 Description: REVISE WRIST JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25335 MEDSV DEF RBRVS 01/01/2024 877.40 Description: REALIGNMENT OF HAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25335 MEDSV DEF RBRVS 09/01/2019 12/31/2023 645.79 Description: REALIGNMENT OF HAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25337 MEDSV DEF RBRVS 01/01/2019 12/31/2023 631.50 Description: RECONSTRUCT ULNA/RADIOULNAR Category: Medical Services CMS Add: 01/01/1995 CMS Term: 25337 MEDSV DEF RBRVS 01/01/2024 829.73 Description: RECONSTRUCT ULNA/RADIOULNAR Category: Medical Services CMS Add: 01/01/1995 CMS Term: 25350 MEDSV DEF RBRVS 01/01/2024 632.22 Description: REVISION OF RADIUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25350 MEDSV DEF RBRVS 09/01/2019 12/31/2023 480.23 Description: REVISION OF RADIUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25355 MEDSV DEF RBRVS 01/01/2024 712.62 Description: REVISION OF RADIUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25355 MEDSV DEF RBRVS 09/01/2019 12/31/2023 545.51 Description: REVISION OF RADIUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25360 MEDSV DEF RBRVS 01/01/2024 614.01 Description: REVISION OF ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25360 MEDSV DEF RBRVS 09/01/2019 12/31/2023 466.53 Description: REVISION OF ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25365 MEDSV DEF RBRVS 01/01/2024 852.42 Description: REVISE RADIUS & ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25365 MEDSV DEF RBRVS 09/01/2019 12/31/2023 652.23 Description: REVISE RADIUS & ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25370 MEDSV DEF RBRVS 01/01/2024 940.59 Description: REVISE RADIUS OR ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25370 MEDSV DEF RBRVS 09/01/2019 12/31/2023 717.56 Description: REVISE RADIUS OR ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25375 MEDSV DEF RBRVS 01/01/2024 885.92 Description: REVISE RADIUS & ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 225 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 25375 MEDSV DEF RBRVS 09/01/2019 12/31/2023 652.31 Description: REVISE RADIUS & ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25390 MEDSV DEF RBRVS 01/01/2024 718.77 Description: SHORTEN RADIUS OR ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25390 MEDSV DEF RBRVS 09/01/2019 12/31/2023 548.09 Description: SHORTEN RADIUS OR ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25391 MEDSV DEF RBRVS 01/01/2024 924.64 Description: LENGTHEN RADIUS OR ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25391 MEDSV DEF RBRVS 09/01/2019 12/31/2023 710.83 Description: LENGTHEN RADIUS OR ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25392 MEDSV DEF RBRVS 01/01/2024 940.71 Description: SHORTEN RADIUS & ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25392 MEDSV DEF RBRVS 09/01/2019 12/31/2023 723.60 Description: SHORTEN RADIUS & ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25393 MEDSV DEF RBRVS 01/01/2024 1046.04 Description: LENGTHEN RADIUS & ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25393 MEDSV DEF RBRVS 09/01/2019 12/31/2023 807.44 Description: LENGTHEN RADIUS & ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25394 MEDSV DEF RBRVS 01/01/2024 730.30 0-2 Description: REPAIR CARPAL BONE SHORTEN Category: Medical Services CMS Add: 01/01/2002 CMS Term: 25394 MEDSV DEF RBRVS 02/01/2015 12/31/2023 558.48 0-2 Description: REPAIR CARPAL BONE SHORTEN Category: Medical Services CMS Add: 01/01/2002 CMS Term: 25400 MEDSV DEF RBRVS 01/01/2024 749.34 Description: REPAIR RADIUS OR ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25400 MEDSV DEF RBRVS 09/01/2019 12/31/2023 572.59 Description: REPAIR RADIUS OR ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25405 MEDSV DEF RBRVS 01/01/2024 964.17 Description: REPAIR/GRAFT RADIUS OR ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25405 MEDSV DEF RBRVS 09/01/2019 12/31/2023 740.60 Description: REPAIR/GRAFT RADIUS OR ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25415 MEDSV DEF RBRVS 01/01/2024 899.05 Description: REPAIR RADIUS & ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 226 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 25415 MEDSV DEF RBRVS 09/01/2019 12/31/2023 689.93 Description: REPAIR RADIUS & ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25420 MEDSV DEF RBRVS 01/01/2024 1079.65 Description: REPAIR/GRAFT RADIUS & ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25420 MEDSV DEF RBRVS 09/01/2019 12/31/2023 834.21 Description: REPAIR/GRAFT RADIUS & ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25425 MEDSV DEF RBRVS 01/01/2024 894.94 Description: REPAIR/GRAFT RADIUS OR ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25425 MEDSV DEF RBRVS 09/01/2019 12/31/2023 686.62 Description: REPAIR/GRAFT RADIUS OR ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25426 MEDSV DEF RBRVS 01/01/2024 1040.14 Description: REPAIR/GRAFT RADIUS & ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25426 MEDSV DEF RBRVS 09/01/2019 12/31/2023 802.58 Description: REPAIR/GRAFT RADIUS & ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25430 MEDSV DEF RBRVS 01/01/2016 12/31/2023 508.93 Description: VASC GRAFT INTO CARPAL BONE Category: Medical Services CMS Add: 01/01/2002 CMS Term: 25430 MEDSV DEF RBRVS 01/01/2024 682.58 Description: VASC GRAFT INTO CARPAL BONE Category: Medical Services CMS Add: 01/01/2002 CMS Term: 25431 MEDSV DEF RBRVS 01/01/2024 733.68 0-2 Description: REPAIR NONUNION CARPAL BONE Category: Medical Services CMS Add: 01/01/2002 CMS Term: 25431 MEDSV DEF RBRVS 02/01/2015 12/31/2023 561.95 0-2 Description: REPAIR NONUNION CARPAL BONE Category: Medical Services CMS Add: 01/01/2002 CMS Term: 25440 MEDSV DEF RBRVS 01/01/2024 718.23 Description: REPAIR/GRAFT WRIST BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25440 MEDSV DEF RBRVS 09/01/2019 12/31/2023 547.97 Description: REPAIR/GRAFT WRIST BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25441 MEDSV DEF RBRVS 01/01/2024 871.98 Description: RECONSTRUCT WRIST JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25441 MEDSV DEF RBRVS 09/01/2019 12/31/2023 662.59 Description: RECONSTRUCT WRIST JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25442 MEDSV DEF RBRVS 01/01/2024 756.06 Description: RECONSTRUCT WRIST JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 227 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 25442 MEDSV DEF RBRVS 09/01/2019 12/31/2023 566.22 Description: RECONSTRUCT WRIST JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25443 MEDSV DEF RBRVS 01/01/2024 731.87 Description: RECONSTRUCT WRIST JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 25443 MEDSV DEF RBRVS 09/01/2019 12/31/2023 555.93 Description: RECONSTRUCT WRIST JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 25444 MEDSV DEF RBRVS 01/01/2024 772.30 Description: RECONSTRUCT WRIST JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 25444 MEDSV DEF RBRVS 09/01/2019 12/31/2023 565.53 Description: RECONSTRUCT WRIST JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 25445 MEDSV DEF RBRVS 01/01/2024 674.38 Description: RECONSTRUCT WRIST JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25445 MEDSV DEF RBRVS 09/01/2019 12/31/2023 513.09 Description: RECONSTRUCT WRIST JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25446 MEDSV DEF RBRVS 01/01/2024 1089.86 Description: WRIST REPLACEMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25446 MEDSV DEF RBRVS 09/01/2019 12/31/2023 838.38 Description: WRIST REPLACEMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25447 MEDSV DEF RBRVS 01/01/2024 777.57 Description: REPAIR WRIST JOINTS Category: Medical Services CMS Add: 01/01/1987 CMS Term: 25447 MEDSV DEF RBRVS 09/01/2019 12/31/2023 589.56 Description: REPAIR WRIST JOINTS Category: Medical Services CMS Add: 01/01/1987 CMS Term: 25449 MEDSV DEF RBRVS 01/01/2024 961.62 Description: REMOVE WRIST JOINT IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25449 MEDSV DEF RBRVS 09/01/2019 12/31/2023 741.78 Description: REMOVE WRIST JOINT IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25450 MEDSV DEF RBRVS 01/01/2024 577.67 Description: REVISION OF WRIST JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25450 MEDSV DEF RBRVS 09/01/2019 12/31/2023 437.44 Description: REVISION OF WRIST JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25455 MEDSV DEF RBRVS 01/01/2024 681.65 Description: REVISION OF WRIST JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 228 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 25455 MEDSV DEF RBRVS 09/01/2019 12/31/2023 496.30 Description: REVISION OF WRIST JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25490 MEDSV DEF RBRVS 01/01/2024 670.60 Description: REINFORCE RADIUS Category: Medical Services CMS Add: 01/01/1986 CMS Term: 25490 MEDSV DEF RBRVS 09/01/2019 12/31/2023 500.97 Description: REINFORCE RADIUS Category: Medical Services CMS Add: 01/01/1986 CMS Term: 25491 MEDSV DEF RBRVS 01/01/2024 688.90 Description: REINFORCE ULNA Category: Medical Services CMS Add: 01/01/1986 CMS Term: 25491 MEDSV DEF RBRVS 09/01/2019 12/31/2023 526.30 Description: REINFORCE ULNA Category: Medical Services CMS Add: 01/01/1986 CMS Term: 25492 MEDSV DEF RBRVS 01/01/2024 842.67 Description: REINFORCE RADIUS AND ULNA Category: Medical Services CMS Add: 01/01/1986 CMS Term: 25492 MEDSV DEF RBRVS 09/01/2019 12/31/2023 644.10 Description: REINFORCE RADIUS AND ULNA Category: Medical Services CMS Add: 01/01/1986 CMS Term: 25500 MEDSV DEF RBRVS 01/01/2024 271.65 Description: TREAT FRACTURE OF RADIUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25500 MEDSV DEF RBRVS 09/01/2019 12/31/2023 192.15 Description: TREAT FRACTURE OF RADIUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25505 MEDSV DEF RBRVS 01/01/2024 481.13 Description: TREAT FRACTURE OF RADIUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25505 MEDSV DEF RBRVS 09/01/2019 12/31/2023 355.01 Description: TREAT FRACTURE OF RADIUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25515 MEDSV DEF RBRVS 01/01/2024 626.71 Description: TREAT FRACTURE OF RADIUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25515 MEDSV DEF RBRVS 09/01/2019 12/31/2023 476.65 Description: TREAT FRACTURE OF RADIUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25520 MEDSV DEF RBRVS 01/01/2024 544.97 Description: TREAT FRACTURE OF RADIUS Category: Medical Services CMS Add: 01/01/1993 CMS Term: 25520 MEDSV DEF RBRVS 09/01/2019 12/31/2023 400.89 Description: TREAT FRACTURE OF RADIUS Category: Medical Services CMS Add: 01/01/1993 CMS Term: 25525 MEDSV DEF RBRVS 01/01/2024 738.57 Description: TREAT FRACTURE OF RADIUS Category: Medical Services CMS Add: 01/01/1993 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 229 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 25525 MEDSV DEF RBRVS 09/01/2019 12/31/2023 559.91 Description: TREAT FRACTURE OF RADIUS Category: Medical Services CMS Add: 01/01/1993 CMS Term: 25526 MEDSV DEF RBRVS 01/01/2024 889.29 Description: TREAT FRACTURE OF RADIUS Category: Medical Services CMS Add: 01/01/1993 CMS Term: 25526 MEDSV DEF RBRVS 09/01/2019 12/31/2023 680.31 Description: TREAT FRACTURE OF RADIUS Category: Medical Services CMS Add: 01/01/1993 CMS Term: 25530 MEDSV DEF RBRVS 01/01/2024 252.31 Description: TREAT FRACTURE OF ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25530 MEDSV DEF RBRVS 09/01/2019 12/31/2023 184.29 Description: TREAT FRACTURE OF ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25535 MEDSV DEF RBRVS 01/01/2024 469.41 Description: TREAT FRACTURE OF ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25535 MEDSV DEF RBRVS 09/01/2019 12/31/2023 345.49 Description: TREAT FRACTURE OF ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25545 MEDSV DEF RBRVS 01/01/2024 585.59 Description: TREAT FRACTURE OF ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25545 MEDSV DEF RBRVS 09/01/2019 12/31/2023 443.22 Description: TREAT FRACTURE OF ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25560 MEDSV DEF RBRVS 01/01/2024 277.03 Description: TREAT FRACTURE RADIUS & ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25560 MEDSV DEF RBRVS 09/01/2019 12/31/2023 196.58 Description: TREAT FRACTURE RADIUS & ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25565 MEDSV DEF RBRVS 01/01/2024 493.22 Description: TREAT FRACTURE RADIUS & ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25565 MEDSV DEF RBRVS 09/01/2019 12/31/2023 367.74 Description: TREAT FRACTURE RADIUS & ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25574 MEDSV DEF RBRVS 01/01/2024 632.28 Description: TREAT FRACTURE RADIUS & ULNA Category: Medical Services CMS Add: 01/01/1993 CMS Term: 25574 MEDSV DEF RBRVS 09/01/2019 12/31/2023 479.12 Description: TREAT FRACTURE RADIUS & ULNA Category: Medical Services CMS Add: 01/01/1993 CMS Term: 25575 MEDSV DEF RBRVS 01/01/2024 842.24 Description: TREAT FRACTURE RADIUS/ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 230 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 25575 MEDSV DEF RBRVS 09/01/2019 12/31/2023 642.42 Description: TREAT FRACTURE RADIUS/ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25600 MEDSV DEF RBRVS 01/01/2024 323.01 Description: TREAT FRACTURE RADIUS/ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25600 MEDSV DEF RBRVS 09/01/2019 12/31/2023 230.84 Description: TREAT FRACTURE RADIUS/ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25605 MEDSV DEF RBRVS 01/01/2024 511.30 Description: TREAT FRACTURE RADIUS/ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25605 MEDSV DEF RBRVS 09/01/2019 12/31/2023 388.31 Description: TREAT FRACTURE RADIUS/ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25606 MEDSV DEF RBRVS 01/01/2024 625.50 Description: TREAT FX DISTAL RADIAL Category: Medical Services CMS Add: 01/01/2007 CMS Term: 25606 MEDSV DEF RBRVS 02/01/2015 12/31/2023 470.42 Description: TREAT FX DISTAL RADIAL Category: Medical Services CMS Add: 01/01/2007 CMS Term: 25607 MEDSV DEF RBRVS 01/01/2024 692.09 Description: TREAT FX RAD EXTRA-ARTICUL Category: Medical Services CMS Add: 01/01/2007 CMS Term: 25607 MEDSV DEF RBRVS 02/01/2015 12/31/2023 523.16 Description: TREAT FX RAD EXTRA-ARTICUL Category: Medical Services CMS Add: 01/01/2007 CMS Term: 25608 MEDSV DEF RBRVS 01/01/2024 772.77 Description: TREAT FX RAD INTRA-ARTICUL Category: Medical Services CMS Add: 01/01/2007 CMS Term: 25608 MEDSV DEF RBRVS 02/01/2015 12/31/2023 587.26 Description: TREAT FX RAD INTRA-ARTICUL Category: Medical Services CMS Add: 01/01/2007 CMS Term: 25609 MEDSV DEF RBRVS 01/01/2024 980.42 Description: TREAT FX RADIAL 3+ FRAG Category: Medical Services CMS Add: 01/01/2007 CMS Term: 25609 MEDSV DEF RBRVS 02/01/2015 12/31/2023 747.13 Description: TREAT FX RADIAL 3+ FRAG Category: Medical Services CMS Add: 01/01/2007 CMS Term: 25622 MEDSV DEF RBRVS 01/01/2024 293.86 Description: TREAT WRIST BONE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25622 MEDSV DEF RBRVS 09/01/2019 12/31/2023 214.26 Description: TREAT WRIST BONE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25624 MEDSV DEF RBRVS 01/01/2024 465.12 Description: TREAT WRIST BONE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 231 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 25624 MEDSV DEF RBRVS 09/01/2019 12/31/2023 335.75 Description: TREAT WRIST BONE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25628 MEDSV DEF RBRVS 01/01/2024 673.39 Description: TREAT WRIST BONE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25628 MEDSV DEF RBRVS 09/01/2019 12/31/2023 513.40 Description: TREAT WRIST BONE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25630 MEDSV DEF RBRVS 01/01/2024 291.99 Description: TREAT WRIST BONE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25630 MEDSV DEF RBRVS 09/01/2019 12/31/2023 215.43 Description: TREAT WRIST BONE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25635 MEDSV DEF RBRVS 01/01/2024 441.30 Description: TREAT WRIST BONE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25635 MEDSV DEF RBRVS 09/01/2019 12/31/2023 313.70 Description: TREAT WRIST BONE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25645 MEDSV DEF RBRVS 01/01/2024 535.21 Description: TREAT WRIST BONE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25645 MEDSV DEF RBRVS 09/01/2019 12/31/2023 404.23 Description: TREAT WRIST BONE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25650 MEDSV DEF RBRVS 01/01/2024 315.48 Description: TREAT WRIST BONE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25650 MEDSV DEF RBRVS 09/01/2019 12/31/2023 226.74 Description: TREAT WRIST BONE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25651 MEDSV DEF RBRVS 01/01/2016 12/31/2023 344.14 Description: PIN ULNAR STYLOID FRACTURE Category: Medical Services CMS Add: 01/01/2002 CMS Term: 25651 MEDSV DEF RBRVS 01/01/2024 460.83 Description: PIN ULNAR STYLOID FRACTURE Category: Medical Services CMS Add: 01/01/2002 CMS Term: 25652 MEDSV DEF RBRVS 01/01/2016 12/31/2023 442.97 Description: TREAT FRACTURE ULNAR STYLOID Category: Medical Services CMS Add: 01/01/2002 CMS Term: 25652 MEDSV DEF RBRVS 01/01/2024 583.95 Description: TREAT FRACTURE ULNAR STYLOID Category: Medical Services CMS Add: 01/01/2002 CMS Term: 25660 MEDSV DEF RBRVS 01/01/2024 423.80 Description: TREAT WRIST DISLOCATION Category: Medical Services CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 232 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 25660 MEDSV DEF RBRVS 09/01/2019 12/31/2023 287.47 Description: TREAT WRIST DISLOCATION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 25670 MEDSV DEF RBRVS 01/01/2024 569.54 Description: TREAT WRIST DISLOCATION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 25670 MEDSV DEF RBRVS 09/01/2019 12/31/2023 431.48 Description: TREAT WRIST DISLOCATION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 25671 MEDSV DEF RBRVS 01/01/2016 12/31/2023 375.62 Description: PIN RADIOULNAR DISLOCATION Category: Medical Services CMS Add: 01/01/2002 CMS Term: 25671 MEDSV DEF RBRVS 01/01/2024 498.97 Description: PIN RADIOULNAR DISLOCATION Category: Medical Services CMS Add: 01/01/2002 CMS Term: 25675 MEDSV DEF RBRVS 01/01/2024 433.08 Description: TREAT WRIST DISLOCATION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 25675 MEDSV DEF RBRVS 09/01/2019 12/31/2023 309.33 Description: TREAT WRIST DISLOCATION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 25676 MEDSV DEF RBRVS 01/01/2024 590.98 Description: TREAT WRIST DISLOCATION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 25676 MEDSV DEF RBRVS 09/01/2019 12/31/2023 447.42 Description: TREAT WRIST DISLOCATION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 25680 MEDSV DEF RBRVS 01/01/2024 499.05 Description: TREAT WRIST FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25680 MEDSV DEF RBRVS 09/01/2019 12/31/2023 336.75 Description: TREAT WRIST FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25685 MEDSV DEF RBRVS 01/01/2024 685.47 Description: TREAT WRIST FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25685 MEDSV DEF RBRVS 09/01/2019 12/31/2023 523.36 Description: TREAT WRIST FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25690 MEDSV DEF RBRVS 01/01/2024 463.17 Description: TREAT WRIST DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25690 MEDSV DEF RBRVS 09/01/2019 12/31/2023 340.38 Description: TREAT WRIST DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25695 MEDSV DEF RBRVS 01/01/2024 592.82 Description: TREAT WRIST DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 233 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 25695 MEDSV DEF RBRVS 09/01/2019 12/31/2023 450.36 Description: TREAT WRIST DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25800 MEDSV DEF RBRVS 01/01/2024 684.85 Description: FUSION OF WRIST JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25800 MEDSV DEF RBRVS 09/01/2019 12/31/2023 521.83 Description: FUSION OF WRIST JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25805 MEDSV DEF RBRVS 01/01/2024 788.96 Description: FUSION/GRAFT OF WRIST JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25805 MEDSV DEF RBRVS 09/01/2019 12/31/2023 601.69 Description: FUSION/GRAFT OF WRIST JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25810 MEDSV DEF RBRVS 01/01/2024 809.45 Description: FUSION/GRAFT OF WRIST JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25810 MEDSV DEF RBRVS 09/01/2019 12/31/2023 619.16 Description: FUSION/GRAFT OF WRIST JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25820 MEDSV DEF RBRVS 01/01/2024 609.62 Description: FUSION OF HAND BONES Category: Medical Services CMS Add: 01/01/1987 CMS Term: 25820 MEDSV DEF RBRVS 09/01/2019 12/31/2023 436.72 Description: FUSION OF HAND BONES Category: Medical Services CMS Add: 01/01/1987 CMS Term: 25825 MEDSV DEF RBRVS 01/01/2024 743.67 Description: FUSE HAND BONES WITH GRAFT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 25825 MEDSV DEF RBRVS 09/01/2019 12/31/2023 539.04 Description: FUSE HAND BONES WITH GRAFT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 25830 MEDSV DEF RBRVS 01/01/2019 12/31/2023 673.40 Description: FUSION RADIOULNAR JNT/ULNA Category: Medical Services CMS Add: 01/01/1995 CMS Term: 25830 MEDSV DEF RBRVS 01/01/2024 949.92 Description: FUSION RADIOULNAR JNT/ULNA Category: Medical Services CMS Add: 01/01/1995 CMS Term: 25900 MEDSV DEF RBRVS 01/01/2024 668.48 Description: AMPUTATION OF FOREARM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25900 MEDSV DEF RBRVS 09/01/2019 12/31/2023 504.44 Description: AMPUTATION OF FOREARM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25905 MEDSV DEF RBRVS 01/01/2024 654.26 Description: AMPUTATION OF FOREARM Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 234 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 25905 MEDSV DEF RBRVS 09/01/2019 12/31/2023 453.04 Description: AMPUTATION OF FOREARM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25907 MEDSV DEF RBRVS 01/01/2024 574.36 Description: AMPUTATION FOLLOW-UP SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25907 MEDSV DEF RBRVS 09/01/2019 12/31/2023 435.44 Description: AMPUTATION FOLLOW-UP SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25909 MEDSV DEF RBRVS 01/01/2024 639.65 Description: AMPUTATION FOLLOW-UP SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25909 MEDSV DEF RBRVS 09/01/2019 12/31/2023 487.54 Description: AMPUTATION FOLLOW-UP SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25915 MEDSV DEF RBRVS 01/01/2019 12/31/2023 748.51 Description: AMPUTATION OF FOREARM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25915 MEDSV DEF RBRVS 01/01/2024 1079.78 Description: AMPUTATION OF FOREARM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25920 MEDSV DEF RBRVS 01/01/2024 682.44 Description: AMPUTATE HAND AT WRIST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25920 MEDSV DEF RBRVS 09/01/2019 12/31/2023 494.88 Description: AMPUTATE HAND AT WRIST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25922 MEDSV DEF RBRVS 01/01/2024 605.09 Description: AMPUTATE HAND AT WRIST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25922 MEDSV DEF RBRVS 09/01/2019 12/31/2023 359.37 Description: AMPUTATE HAND AT WRIST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25924 MEDSV DEF RBRVS 01/01/2024 666.77 Description: AMPUTATION FOLLOW-UP SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25924 MEDSV DEF RBRVS 09/01/2019 12/31/2023 436.95 Description: AMPUTATION FOLLOW-UP SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25927 MEDSV DEF RBRVS 01/01/2024 809.36 Description: AMPUTATION OF HAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25927 MEDSV DEF RBRVS 09/01/2019 12/31/2023 574.11 Description: AMPUTATION OF HAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25929 MEDSV DEF RBRVS 01/01/2024 559.78 Description: AMPUTATION FOLLOW-UP SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 235 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 25929 MEDSV DEF RBRVS 09/01/2019 12/31/2023 423.89 Description: AMPUTATION FOLLOW-UP SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25931 MEDSV DEF RBRVS 01/01/2024 749.40 Description: AMPUTATION FOLLOW-UP SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25931 MEDSV DEF RBRVS 09/01/2019 12/31/2023 475.55 Description: AMPUTATION FOLLOW-UP SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25999 MEDSV DEF BILL20 Description: UNLISTED PX FOREARM/WRIST Category: Medical Services CMS Add: 01/01/1982 CMS Term: 26010 MEDSV DEF RBRVS 01/01/2024 322.79 Description: DRAINAGE OF FINGER ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26010 MEDSV DEF RBRVS 09/01/2019 12/31/2023 184.74 Description: DRAINAGE OF FINGER ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26011 MEDSV DEF RBRVS 01/01/2024 451.11 Description: DRAINAGE OF FINGER ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26011 MEDSV DEF RBRVS 09/01/2019 12/31/2023 272.15 Description: DRAINAGE OF FINGER ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26020 MEDSV DEF RBRVS 01/01/2024 521.90 Description: DRAIN HAND TENDON SHEATH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26020 MEDSV DEF RBRVS 09/01/2019 12/31/2023 307.00 Description: DRAIN HAND TENDON SHEATH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26025 MEDSV DEF RBRVS 01/01/2024 393.82 Description: DRAINAGE OF PALM BURSA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26025 MEDSV DEF RBRVS 09/01/2019 12/31/2023 298.50 Description: DRAINAGE OF PALM BURSA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26030 MEDSV DEF RBRVS 01/01/2024 460.93 Description: DRAINAGE OF PALM BURSAS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26030 MEDSV DEF RBRVS 09/01/2019 12/31/2023 350.25 Description: DRAINAGE OF PALM BURSAS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26034 MEDSV DEF RBRVS 01/01/2024 517.08 Description: TREAT HAND BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26034 MEDSV DEF RBRVS 09/01/2019 12/31/2023 380.03 Description: TREAT HAND BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 236 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 26035 MEDSV DEF RBRVS 01/01/2024 801.57 Description: DECOMPRESS FINGERS/HAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26035 MEDSV DEF RBRVS 09/01/2019 12/31/2023 616.13 Description: DECOMPRESS FINGERS/HAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26037 MEDSV DEF RBRVS 01/01/2024 525.60 Description: DECOMPRESS FINGERS/HAND Category: Medical Services CMS Add: 01/01/1990 CMS Term: 26037 MEDSV DEF RBRVS 09/01/2019 12/31/2023 403.80 Description: DECOMPRESS FINGERS/HAND Category: Medical Services CMS Add: 01/01/1990 CMS Term: 26040 MEDSV DEF RBRVS 01/01/2024 298.58 Description: RELEASE PALM CONTRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26040 MEDSV DEF RBRVS 09/01/2019 12/31/2023 219.79 Description: RELEASE PALM CONTRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26045 MEDSV DEF RBRVS 01/01/2024 443.88 Description: RELEASE PALM CONTRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26045 MEDSV DEF RBRVS 09/01/2019 12/31/2023 332.15 Description: RELEASE PALM CONTRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26055 MEDSV DEF RBRVS 01/01/2024 554.02 Description: INCISE FINGER TENDON SHEATH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26055 MEDSV DEF RBRVS 09/01/2019 12/31/2023 389.24 Description: INCISE FINGER TENDON SHEATH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26060 MEDSV DEF RBRVS 01/01/2024 241.54 Description: INCISION OF FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26060 MEDSV DEF RBRVS 09/01/2019 12/31/2023 187.35 Description: INCISION OF FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26070 MEDSV DEF RBRVS 01/01/2024 304.89 Description: EXPLORE/TREAT HAND JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26070 MEDSV DEF RBRVS 09/01/2019 12/31/2023 223.09 Description: EXPLORE/TREAT HAND JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26075 MEDSV DEF RBRVS 01/01/2024 319.44 Description: EXPLORE/TREAT FINGER JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26075 MEDSV DEF RBRVS 09/01/2019 12/31/2023 233.79 Description: EXPLORE/TREAT FINGER JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 237 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 26080 MEDSV DEF RBRVS 01/01/2024 375.53 Description: EXPLORE/TREAT FINGER JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26080 MEDSV DEF RBRVS 09/01/2019 12/31/2023 276.41 Description: EXPLORE/TREAT FINGER JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26100 MEDSV DEF RBRVS 01/01/2024 319.56 Description: BIOPSY HAND JOINT LINING Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26100 MEDSV DEF RBRVS 09/01/2019 12/31/2023 236.75 Description: BIOPSY HAND JOINT LINING Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26105 MEDSV DEF RBRVS 01/01/2024 321.85 Description: BIOPSY FINGER JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26105 MEDSV DEF RBRVS 09/01/2019 12/31/2023 236.18 Description: BIOPSY FINGER JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26110 MEDSV DEF RBRVS 01/01/2024 307.35 Description: BIOPSY FINGER JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26110 MEDSV DEF RBRVS 09/01/2019 12/31/2023 227.29 Description: BIOPSY FINGER JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26111 MEDSV DEF RBRVS 01/01/2024 389.02 Description: EXC HAND LES SC 1.5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 26111 MEDSV DEF RBRVS 02/01/2015 12/31/2023 296.32 Description: EXC HAND LES SC 1.5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 26113 MEDSV DEF RBRVS 01/01/2024 512.45 Description: EXC HAND TUM DEEP 1.5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 26113 MEDSV DEF RBRVS 02/01/2015 12/31/2023 390.24 Description: EXC HAND TUM DEEP 1.5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 26115 MEDSV DEF RBRVS 01/01/2024 515.47 Description: EXC HAND LES SC < 1.5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26115 MEDSV DEF RBRVS 09/01/2019 12/31/2023 352.96 Description: EXC HAND LES SC < 1.5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26116 MEDSV DEF RBRVS 01/01/2024 492.55 Description: EXC HAND TUM DEEP < 1.5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26116 MEDSV DEF RBRVS 09/01/2019 12/31/2023 374.23 Description: EXC HAND TUM DEEP < 1.5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 238 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 26117 MEDSV DEF RBRVS 01/01/2024 691.70 Description: RAD RESECT HAND TUMOR < 3 CM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 26117 MEDSV DEF RBRVS 09/01/2019 12/31/2023 532.03 Description: RAD RESECT HAND TUMOR < 3 CM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 26118 MEDSV DEF RBRVS 01/01/2024 979.66 Description: RAD RESECT HAND TUMOR 3 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 26118 MEDSV DEF RBRVS 02/01/2015 12/31/2023 751.75 Description: RAD RESECT HAND TUMOR 3 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 26121 MEDSV DEF RBRVS 01/01/2024 562.51 Description: RELEASE PALM CONTRACTURE Category: Medical Services CMS Add: 01/01/1990 CMS Term: 26121 MEDSV DEF RBRVS 09/01/2019 12/31/2023 424.28 Description: RELEASE PALM CONTRACTURE Category: Medical Services CMS Add: 01/01/1990 CMS Term: 26123 MEDSV DEF RBRVS 01/01/2024 783.85 Description: RELEASE PALM CONTRACTURE Category: Medical Services CMS Add: 01/01/1990 CMS Term: 26123 MEDSV DEF RBRVS 09/01/2019 12/31/2023 592.73 Description: RELEASE PALM CONTRACTURE Category: Medical Services CMS Add: 01/01/1990 CMS Term: 26125 MEDSV DEF RBRVS 01/01/2024 247.82 Description: RELEASE PALM CONTRACTURE Category: Medical Services CMS Add: 01/01/1990 CMS Term: 26125 MEDSV DEF RBRVS 02/01/2015 12/31/2023 197.41 Description: RELEASE PALM CONTRACTURE Category: Medical Services CMS Add: 01/01/1990 CMS Term: 26130 MEDSV DEF RBRVS 01/01/2024 440.39 Description: REMOVE WRIST JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26130 MEDSV DEF RBRVS 09/01/2019 12/31/2023 326.90 Description: REMOVE WRIST JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26135 MEDSV DEF RBRVS 01/01/2024 520.64 Description: REVISE FINGER JOINT EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26135 MEDSV DEF RBRVS 09/01/2019 12/31/2023 391.40 Description: REVISE FINGER JOINT EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26140 MEDSV DEF RBRVS 01/01/2024 477.55 Description: REVISE FINGER JOINT EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26140 MEDSV DEF RBRVS 09/01/2019 12/31/2023 357.78 Description: REVISE FINGER JOINT EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 239 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 26145 MEDSV DEF RBRVS 01/01/2024 484.98 Description: TENDON EXCISION PALM/FINGER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26145 MEDSV DEF RBRVS 09/01/2019 12/31/2023 362.97 Description: TENDON EXCISION PALM/FINGER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26160 MEDSV DEF RBRVS 01/01/2024 577.69 Description: REMOVE TENDON SHEATH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26160 MEDSV DEF RBRVS 09/01/2019 12/31/2023 400.44 Description: REMOVE TENDON SHEATH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26170 MEDSV DEF RBRVS 01/01/2024 384.93 Description: REMOVAL OF PALM TENDON EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26170 MEDSV DEF RBRVS 09/01/2019 12/31/2023 288.15 Description: REMOVAL OF PALM TENDON EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26180 MEDSV DEF RBRVS 01/01/2024 423.81 Description: REMOVAL OF FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26180 MEDSV DEF RBRVS 09/01/2019 12/31/2023 314.26 Description: REMOVAL OF FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26185 MEDSV DEF RBRVS 01/01/2019 12/31/2023 390.53 Description: REMOVE FINGER BONE Category: Medical Services CMS Add: 01/01/1997 CMS Term: 26185 MEDSV DEF RBRVS 01/01/2024 522.03 Description: REMOVE FINGER BONE Category: Medical Services CMS Add: 01/01/1997 CMS Term: 26200 MEDSV DEF RBRVS 01/01/2024 424.62 Description: REMOVE HAND BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26200 MEDSV DEF RBRVS 09/01/2019 12/31/2023 319.51 Description: REMOVE HAND BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26205 MEDSV DEF RBRVS 01/01/2024 565.84 Description: REMOVE/GRAFT BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26205 MEDSV DEF RBRVS 09/01/2019 12/31/2023 427.84 Description: REMOVE/GRAFT BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26210 MEDSV DEF RBRVS 01/01/2024 422.18 Description: REMOVAL OF FINGER LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26210 MEDSV DEF RBRVS 09/01/2019 12/31/2023 313.04 Description: REMOVAL OF FINGER LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 240 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 26215 MEDSV DEF RBRVS 01/01/2024 531.35 Description: REMOVE/GRAFT FINGER LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26215 MEDSV DEF RBRVS 09/01/2019 12/31/2023 399.95 Description: REMOVE/GRAFT FINGER LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26230 MEDSV DEF RBRVS 01/01/2024 470.10 Description: PARTIAL REMOVAL OF HAND BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26230 MEDSV DEF RBRVS 09/01/2019 12/31/2023 354.92 Description: PARTIAL REMOVAL OF HAND BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26235 MEDSV DEF RBRVS 01/01/2024 463.01 Description: PARTIAL REMOVAL FINGER BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26235 MEDSV DEF RBRVS 09/01/2019 12/31/2023 350.41 Description: PARTIAL REMOVAL FINGER BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26236 MEDSV DEF RBRVS 01/01/2024 414.45 Description: PARTIAL REMOVAL FINGER BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26236 MEDSV DEF RBRVS 09/01/2019 12/31/2023 312.84 Description: PARTIAL REMOVAL FINGER BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26250 MEDSV DEF RBRVS 01/01/2024 987.00 Description: EXTENSIVE HAND SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26250 MEDSV DEF RBRVS 09/01/2019 12/31/2023 779.75 Description: EXTENSIVE HAND SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26260 MEDSV DEF RBRVS 01/01/2024 740.56 Description: RESECT PROX FINGER TUMOR Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26260 MEDSV DEF RBRVS 09/01/2019 12/31/2023 582.33 Description: RESECT PROX FINGER TUMOR Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26262 MEDSV DEF RBRVS 01/01/2024 588.12 Description: RESECT DISTAL FINGER TUMOR Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26262 MEDSV DEF RBRVS 09/01/2019 12/31/2023 454.44 Description: RESECT DISTAL FINGER TUMOR Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26320 MEDSV DEF RBRVS 01/01/2024 329.45 Description: REMOVAL OF IMPLANT FROM HAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26320 MEDSV DEF RBRVS 09/01/2019 12/31/2023 245.25 Description: REMOVAL OF IMPLANT FROM HAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 241 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 26340 MEDSV DEF RBRVS 01/01/2016 12/31/2023 234.60 Description: MANIPULATE FINGER W/ANESTH Category: Medical Services CMS Add: 01/01/2002 CMS Term: 26340 MEDSV DEF RBRVS 01/01/2024 334.63 Description: MANIPULATE FINGER W/ANESTH Category: Medical Services CMS Add: 01/01/2002 CMS Term: 26341 MEDSV DEF RBRVS 01/01/2024 109.68 Description: MANIPULAT PALM CORD POST INJ Category: Medical Services CMS Add: 01/01/2012 CMS Term: 26341 MEDSV DEF RBRVS 02/01/2015 12/31/2023 68.96 Description: MANIPULAT PALM CORD POST INJ Category: Medical Services CMS Add: 01/01/2012 CMS Term: 26350 MEDSV DEF RBRVS 01/01/2024 703.75 Description: REPAIR FINGER/HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26350 MEDSV DEF RBRVS 09/01/2019 12/31/2023 494.09 Description: REPAIR FINGER/HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26352 MEDSV DEF RBRVS 01/01/2024 785.07 Description: REPAIR/GRAFT HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26352 MEDSV DEF RBRVS 09/01/2019 12/31/2023 569.57 Description: REPAIR/GRAFT HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26356 MEDSV DEF RBRVS 01/01/2024 746.05 Description: REPAIR FINGER/HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26356 MEDSV DEF RBRVS 09/01/2019 12/31/2023 764.09 Description: REPAIR FINGER/HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26357 MEDSV DEF RBRVS 01/01/2024 831.90 Description: REPAIR FINGER/HAND TENDON Category: Medical Services CMS Add: 01/01/1988 CMS Term: 26357 MEDSV DEF RBRVS 09/01/2019 12/31/2023 607.79 Description: REPAIR FINGER/HAND TENDON Category: Medical Services CMS Add: 01/01/1988 CMS Term: 26358 MEDSV DEF RBRVS 01/01/2024 916.26 Description: REPAIR/GRAFT HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26358 MEDSV DEF RBRVS 09/01/2019 12/31/2023 641.39 Description: REPAIR/GRAFT HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26370 MEDSV DEF RBRVS 01/01/2024 739.51 Description: REPAIR FINGER/HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26370 MEDSV DEF RBRVS 09/01/2019 12/31/2023 528.45 Description: REPAIR FINGER/HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 242 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 26372 MEDSV DEF RBRVS 01/01/2024 859.42 Description: REPAIR/GRAFT HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26372 MEDSV DEF RBRVS 09/01/2019 12/31/2023 618.20 Description: REPAIR/GRAFT HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26373 MEDSV DEF RBRVS 01/01/2024 827.74 Description: REPAIR FINGER/HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26373 MEDSV DEF RBRVS 09/01/2019 12/31/2023 592.67 Description: REPAIR FINGER/HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26390 MEDSV DEF RBRVS 01/01/2024 823.56 Description: REVISE HAND/FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26390 MEDSV DEF RBRVS 09/01/2019 12/31/2023 585.72 Description: REVISE HAND/FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26392 MEDSV DEF RBRVS 01/01/2024 938.82 Description: REPAIR/GRAFT HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26392 MEDSV DEF RBRVS 09/01/2019 12/31/2023 681.44 Description: REPAIR/GRAFT HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26410 MEDSV DEF RBRVS 01/01/2024 568.03 Description: REPAIR HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26410 MEDSV DEF RBRVS 09/01/2019 12/31/2023 392.06 Description: REPAIR HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26412 MEDSV DEF RBRVS 01/01/2024 676.35 Description: REPAIR/GRAFT HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26412 MEDSV DEF RBRVS 09/01/2019 12/31/2023 473.60 Description: REPAIR/GRAFT HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26415 MEDSV DEF RBRVS 01/01/2024 799.66 Description: EXCISION HAND/FINGER TENDON Category: Medical Services CMS Add: 01/01/1989 CMS Term: 26415 MEDSV DEF RBRVS 09/01/2019 12/31/2023 560.50 Description: EXCISION HAND/FINGER TENDON Category: Medical Services CMS Add: 01/01/1989 CMS Term: 26416 MEDSV DEF RBRVS 01/01/2024 864.09 Description: GRAFT HAND OR FINGER TENDON Category: Medical Services CMS Add: 01/01/1989 CMS Term: 26416 MEDSV DEF RBRVS 09/01/2019 12/31/2023 532.82 Description: GRAFT HAND OR FINGER TENDON Category: Medical Services CMS Add: 01/01/1989 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 243 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 26418 MEDSV DEF RBRVS 01/01/2024 589.46 Description: REPAIR FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26418 MEDSV DEF RBRVS 09/01/2019 12/31/2023 400.52 Description: REPAIR FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26420 MEDSV DEF RBRVS 01/01/2024 700.33 Description: REPAIR/GRAFT FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26420 MEDSV DEF RBRVS 09/01/2019 12/31/2023 494.96 Description: REPAIR/GRAFT FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26426 MEDSV DEF RBRVS 01/01/2024 473.65 Description: REPAIR FINGER/HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26426 MEDSV DEF RBRVS 09/01/2019 12/31/2023 355.76 Description: REPAIR FINGER/HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26428 MEDSV DEF RBRVS 01/01/2024 749.40 Description: REPAIR/GRAFT FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26428 MEDSV DEF RBRVS 09/01/2019 12/31/2023 528.04 Description: REPAIR/GRAFT FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26432 MEDSV DEF RBRVS 01/01/2024 514.56 Description: REPAIR FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26432 MEDSV DEF RBRVS 09/01/2019 12/31/2023 345.78 Description: REPAIR FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26433 MEDSV DEF RBRVS 01/01/2024 541.11 Description: REPAIR FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26433 MEDSV DEF RBRVS 09/01/2019 12/31/2023 368.71 Description: REPAIR FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26434 MEDSV DEF RBRVS 01/01/2024 655.04 Description: REPAIR/GRAFT FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26434 MEDSV DEF RBRVS 09/01/2019 12/31/2023 451.17 Description: REPAIR/GRAFT FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26437 MEDSV DEF RBRVS 01/01/2024 629.44 Description: REALIGNMENT OF TENDONS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26437 MEDSV DEF RBRVS 09/01/2019 12/31/2023 432.69 Description: REALIGNMENT OF TENDONS Category: Medical Services CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 244 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 26440 MEDSV DEF RBRVS 01/01/2024 614.78 Description: RELEASE PALM/FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26440 MEDSV DEF RBRVS 09/01/2019 12/31/2023 428.80 Description: RELEASE PALM/FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26442 MEDSV DEF RBRVS 01/01/2024 931.24 Description: RELEASE PALM & FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26442 MEDSV DEF RBRVS 09/01/2019 12/31/2023 673.34 Description: RELEASE PALM & FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26445 MEDSV DEF RBRVS 01/01/2024 573.35 Description: RELEASE HAND/FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26445 MEDSV DEF RBRVS 09/01/2019 12/31/2023 398.99 Description: RELEASE HAND/FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26449 MEDSV DEF RBRVS 01/01/2024 655.33 Description: RELEASE FOREARM/HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26449 MEDSV DEF RBRVS 09/01/2019 12/31/2023 492.39 Description: RELEASE FOREARM/HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26450 MEDSV DEF RBRVS 01/01/2024 439.31 Description: INCISION OF PALM TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26450 MEDSV DEF RBRVS 09/01/2019 12/31/2023 283.24 Description: INCISION OF PALM TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26455 MEDSV DEF RBRVS 01/01/2024 436.75 Description: INCISION OF FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26455 MEDSV DEF RBRVS 09/01/2019 12/31/2023 280.87 Description: INCISION OF FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26460 MEDSV DEF RBRVS 01/01/2024 424.75 Description: INCISE HAND/FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26460 MEDSV DEF RBRVS 09/01/2019 12/31/2023 274.30 Description: INCISE HAND/FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26471 MEDSV DEF RBRVS 01/01/2024 623.26 Description: FUSION OF FINGER TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26471 MEDSV DEF RBRVS 09/01/2019 12/31/2023 428.29 Description: FUSION OF FINGER TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 245 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 26474 MEDSV DEF RBRVS 01/01/2024 614.35 Description: FUSION OF FINGER TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26474 MEDSV DEF RBRVS 09/01/2019 12/31/2023 418.18 Description: FUSION OF FINGER TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26476 MEDSV DEF RBRVS 01/01/2024 606.49 Description: TENDON LENGTHENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26476 MEDSV DEF RBRVS 09/01/2019 12/31/2023 405.91 Description: TENDON LENGTHENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26477 MEDSV DEF RBRVS 01/01/2024 591.05 Description: TENDON SHORTENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26477 MEDSV DEF RBRVS 09/01/2019 12/31/2023 404.86 Description: TENDON SHORTENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26478 MEDSV DEF RBRVS 01/01/2024 626.29 Description: LENGTHENING OF HAND TENDON Category: Medical Services CMS Add: 01/01/1988 CMS Term: 26478 MEDSV DEF RBRVS 09/01/2019 12/31/2023 432.73 Description: LENGTHENING OF HAND TENDON Category: Medical Services CMS Add: 01/01/1988 CMS Term: 26479 MEDSV DEF RBRVS 01/01/2024 636.19 Description: SHORTENING OF HAND TENDON Category: Medical Services CMS Add: 01/01/1988 CMS Term: 26479 MEDSV DEF RBRVS 09/01/2019 12/31/2023 430.46 Description: SHORTENING OF HAND TENDON Category: Medical Services CMS Add: 01/01/1988 CMS Term: 26480 MEDSV DEF RBRVS 01/01/2024 740.63 Y Description: TRANSPLANT HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26480 MEDSV DEF RBRVS 09/01/2019 12/31/2023 523.85 Y Description: TRANSPLANT HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26483 MEDSV DEF RBRVS 01/01/2024 819.69 Y Description: TRANSPLANT/GRAFT HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26483 MEDSV DEF RBRVS 09/01/2019 12/31/2023 588.27 Y Description: TRANSPLANT/GRAFT HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26485 MEDSV DEF RBRVS 01/01/2024 787.43 Y Description: TRANSPLANT PALM TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26485 MEDSV DEF RBRVS 09/01/2019 12/31/2023 561.11 Y Description: TRANSPLANT PALM TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 246 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 26489 MEDSV DEF RBRVS 01/01/2024 905.17 Y Description: TRANSPLANT/GRAFT PALM TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26489 MEDSV DEF RBRVS 09/01/2019 12/31/2023 649.96 Y Description: TRANSPLANT/GRAFT PALM TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26490 MEDSV DEF RBRVS 01/01/2024 787.90 Description: REVISE THUMB TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26490 MEDSV DEF RBRVS 09/01/2019 12/31/2023 553.84 Description: REVISE THUMB TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26492 MEDSV DEF RBRVS 01/01/2024 870.23 Description: TENDON TRANSFER WITH GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26492 MEDSV DEF RBRVS 09/01/2019 12/31/2023 615.98 Description: TENDON TRANSFER WITH GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26494 MEDSV DEF RBRVS 01/01/2024 791.02 Description: HAND TENDON/MUSCLE TRANSFER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26494 MEDSV DEF RBRVS 09/01/2019 12/31/2023 558.92 Description: HAND TENDON/MUSCLE TRANSFER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26496 MEDSV DEF RBRVS 01/01/2024 850.89 Description: REVISE THUMB TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26496 MEDSV DEF RBRVS 09/01/2019 12/31/2023 589.10 Description: REVISE THUMB TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26497 MEDSV DEF RBRVS 01/01/2024 849.91 Description: FINGER TENDON TRANSFER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26497 MEDSV DEF RBRVS 09/01/2019 12/31/2023 605.98 Description: FINGER TENDON TRANSFER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26498 MEDSV DEF RBRVS 01/01/2024 1102.40 Description: FINGER TENDON TRANSFER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26498 MEDSV DEF RBRVS 09/01/2019 12/31/2023 803.58 Description: FINGER TENDON TRANSFER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26499 MEDSV DEF RBRVS 01/01/2024 818.57 Y Description: REVISION OF FINGER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26499 MEDSV DEF RBRVS 09/01/2019 12/31/2023 580.88 Y Description: REVISION OF FINGER Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 247 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 26500 MEDSV DEF RBRVS 01/01/2024 625.39 Description: HAND TENDON RECONSTRUCTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26500 MEDSV DEF RBRVS 09/01/2019 12/31/2023 434.14 Description: HAND TENDON RECONSTRUCTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26502 MEDSV DEF RBRVS 01/01/2024 710.53 Description: HAND TENDON RECONSTRUCTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26502 MEDSV DEF RBRVS 09/01/2019 12/31/2023 492.26 Description: HAND TENDON RECONSTRUCTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26508 MEDSV DEF RBRVS 01/01/2024 638.66 Description: RELEASE THUMB CONTRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26508 MEDSV DEF RBRVS 09/01/2019 12/31/2023 445.72 Description: RELEASE THUMB CONTRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26510 MEDSV DEF RBRVS 01/01/2024 606.61 Description: THUMB TENDON TRANSFER Category: Medical Services CMS Add: 01/01/1987 CMS Term: 26510 MEDSV DEF RBRVS 09/01/2019 12/31/2023 416.18 Description: THUMB TENDON TRANSFER Category: Medical Services CMS Add: 01/01/1987 CMS Term: 26516 MEDSV DEF RBRVS 01/01/2024 700.89 Description: FUSION OF KNUCKLE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26516 MEDSV DEF RBRVS 09/01/2019 12/31/2023 488.49 Description: FUSION OF KNUCKLE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26517 MEDSV DEF RBRVS 01/01/2024 813.66 Description: FUSION OF KNUCKLE JOINTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26517 MEDSV DEF RBRVS 09/01/2019 12/31/2023 577.31 Description: FUSION OF KNUCKLE JOINTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26518 MEDSV DEF RBRVS 01/01/2024 823.83 Description: FUSION OF KNUCKLE JOINTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26518 MEDSV DEF RBRVS 09/01/2019 12/31/2023 583.24 Description: FUSION OF KNUCKLE JOINTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26520 MEDSV DEF RBRVS 01/01/2024 644.46 Description: RELEASE KNUCKLE CONTRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26520 MEDSV DEF RBRVS 09/01/2019 12/31/2023 451.25 Description: RELEASE KNUCKLE CONTRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 248 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 26525 MEDSV DEF RBRVS 01/01/2024 647.04 Description: RELEASE FINGER CONTRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26525 MEDSV DEF RBRVS 09/01/2019 12/31/2023 451.15 Description: RELEASE FINGER CONTRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26530 MEDSV DEF RBRVS 01/01/2024 507.19 Description: REVISE KNUCKLE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26530 MEDSV DEF RBRVS 09/01/2019 12/31/2023 381.29 Description: REVISE KNUCKLE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26531 MEDSV DEF RBRVS 01/01/2024 592.62 Description: REVISE KNUCKLE WITH IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26531 MEDSV DEF RBRVS 09/01/2019 12/31/2023 443.28 Description: REVISE KNUCKLE WITH IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26535 MEDSV DEF RBRVS 01/01/2024 412.87 Description: REVISE FINGER JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26535 MEDSV DEF RBRVS 09/01/2019 12/31/2023 298.36 Description: REVISE FINGER JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26536 MEDSV DEF RBRVS 01/01/2024 706.85 Description: REVISE/IMPLANT FINGER JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26536 MEDSV DEF RBRVS 09/01/2019 12/31/2023 496.06 Description: REVISE/IMPLANT FINGER JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26540 MEDSV DEF RBRVS 01/01/2024 660.20 Description: REPAIR HAND JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26540 MEDSV DEF RBRVS 09/01/2019 12/31/2023 458.57 Description: REPAIR HAND JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26541 MEDSV DEF RBRVS 01/01/2024 784.46 Description: REPAIR HAND JOINT WITH GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26541 MEDSV DEF RBRVS 09/01/2019 12/31/2023 559.15 Description: REPAIR HAND JOINT WITH GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26542 MEDSV DEF RBRVS 01/01/2024 680.59 Description: REPAIR HAND JOINT WITH GRAFT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 26542 MEDSV DEF RBRVS 09/01/2019 12/31/2023 475.08 Description: REPAIR HAND JOINT WITH GRAFT Category: Medical Services CMS Add: 01/01/1987 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 249 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 26545 MEDSV DEF RBRVS 01/01/2024 691.13 Description: RECONSTRUCT FINGER JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26545 MEDSV DEF RBRVS 09/01/2019 12/31/2023 483.01 Description: RECONSTRUCT FINGER JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26546 MEDSV DEF RBRVS 01/01/2019 12/31/2023 694.27 Description: REPAIR NONUNION HAND Category: Medical Services CMS Add: 01/01/1997 CMS Term: 26546 MEDSV DEF RBRVS 01/01/2024 975.10 Description: REPAIR NONUNION HAND Category: Medical Services CMS Add: 01/01/1997 CMS Term: 26548 MEDSV DEF RBRVS 01/01/2024 753.44 Description: RECONSTRUCT FINGER JOINT Category: Medical Services CMS Add: 01/01/1988 CMS Term: 26548 MEDSV DEF RBRVS 09/01/2019 12/31/2023 533.06 Description: RECONSTRUCT FINGER JOINT Category: Medical Services CMS Add: 01/01/1988 CMS Term: 26550 MEDSV DEF RBRVS 01/01/2024 1538.81 Description: CONSTRUCT THUMB REPLACEMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26550 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1160.52 Description: CONSTRUCT THUMB REPLACEMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26551 MEDSV DEF RBRVS 01/01/2019 12/31/2023 2106.10 Description: GREAT TOE-HAND TRANSFER Category: Medical Services CMS Add: 01/01/1997 CMS Term: 26551 MEDSV DEF RBRVS 01/01/2024 3046.37 Description: GREAT TOE-HAND TRANSFER Category: Medical Services CMS Add: 01/01/1997 CMS Term: 26553 MEDSV DEF RBRVS 01/01/2019 12/31/2023 2235.45 Description: SINGLE TRANSFER TOE-HAND Category: Medical Services CMS Add: 01/01/1997 CMS Term: 26553 MEDSV DEF RBRVS 01/01/2024 3026.26 Description: SINGLE TRANSFER TOE-HAND Category: Medical Services CMS Add: 01/01/1997 CMS Term: 26554 MEDSV DEF RBRVS 01/01/2019 12/31/2023 2337.71 Description: DOUBLE TRANSFER TOE-HAND Category: Medical Services CMS Add: 01/01/1997 CMS Term: 26554 MEDSV DEF RBRVS 01/01/2024 3520.87 Description: DOUBLE TRANSFER TOE-HAND Category: Medical Services CMS Add: 01/01/1997 CMS Term: 26555 MEDSV DEF RBRVS 01/01/2019 12/31/2023 968.06 Description: POSITIONAL CHANGE OF FINGER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26555 MEDSV DEF RBRVS 01/01/2024 1294.81 Description: POSITIONAL CHANGE OF FINGER Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 250 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 26556 MEDSV DEF RBRVS 01/01/2019 12/31/2023 2002.94 Description: TOE JOINT TRANSFER Category: Medical Services CMS Add: 01/01/1997 CMS Term: 26556 MEDSV DEF RBRVS 01/01/2024 3147.15 Description: TOE JOINT TRANSFER Category: Medical Services CMS Add: 01/01/1997 CMS Term: 26560 MEDSV DEF RBRVS 01/01/2024 599.31 Description: REPAIR OF WEB FINGER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26560 MEDSV DEF RBRVS 09/01/2019 12/31/2023 398.09 Description: REPAIR OF WEB FINGER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26561 MEDSV DEF RBRVS 01/01/2024 920.81 Description: REPAIR OF WEB FINGER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26561 MEDSV DEF RBRVS 09/01/2019 12/31/2023 662.14 Description: REPAIR OF WEB FINGER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26562 MEDSV DEF RBRVS 01/01/2024 1283.98 Description: REPAIR OF WEB FINGER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26562 MEDSV DEF RBRVS 09/01/2019 12/31/2023 916.66 Description: REPAIR OF WEB FINGER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26565 MEDSV DEF RBRVS 01/01/2024 672.92 Description: CORRECT METACARPAL FLAW Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26565 MEDSV DEF RBRVS 09/01/2019 12/31/2023 474.66 Description: CORRECT METACARPAL FLAW Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26567 MEDSV DEF RBRVS 01/01/2024 678.41 Description: CORRECT FINGER DEFORMITY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26567 MEDSV DEF RBRVS 09/01/2019 12/31/2023 475.00 Description: CORRECT FINGER DEFORMITY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26568 MEDSV DEF RBRVS 01/01/2024 873.84 Description: LENGTHEN METACARPAL/FINGER Category: Medical Services CMS Add: 01/01/1987 CMS Term: 26568 MEDSV DEF RBRVS 09/01/2019 12/31/2023 629.07 Description: LENGTHEN METACARPAL/FINGER Category: Medical Services CMS Add: 01/01/1987 CMS Term: 26580 MEDSV DEF RBRVS 01/01/2024 1435.33 Description: REPAIR HAND DEFORMITY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26580 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1076.37 Description: REPAIR HAND DEFORMITY Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 251 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 26587 MEDSV DEF RBRVS 01/01/2024 969.48 Description: RECONSTRUCT EXTRA FINGER Category: Medical Services CMS Add: 01/01/1989 CMS Term: 26587 MEDSV DEF RBRVS 02/01/2015 12/31/2023 669.10 Description: RECONSTRUCT EXTRA FINGER Category: Medical Services CMS Add: 01/01/1989 CMS Term: 26590 MEDSV DEF RBRVS 01/01/2019 12/31/2023 993.85 Description: REPAIR FINGER DEFORMITY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26590 MEDSV DEF RBRVS 01/01/2024 1335.17 Description: REPAIR FINGER DEFORMITY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26591 MEDSV DEF RBRVS 01/01/2024 460.41 Description: REPAIR MUSCLES OF HAND Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26591 MEDSV DEF RBRVS 09/01/2019 12/31/2023 302.28 Description: REPAIR MUSCLES OF HAND Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26593 MEDSV DEF RBRVS 01/01/2024 608.59 Description: RELEASE MUSCLES OF HAND Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26593 MEDSV DEF RBRVS 09/01/2019 12/31/2023 415.64 Description: RELEASE MUSCLES OF HAND Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26596 MEDSV DEF RBRVS 01/01/2024 766.77 Description: EXCISION CONSTRICTING TISSUE Category: Medical Services CMS Add: 01/01/1987 CMS Term: 26596 MEDSV DEF RBRVS 09/01/2019 12/31/2023 537.22 Description: EXCISION CONSTRICTING TISSUE Category: Medical Services CMS Add: 01/01/1987 CMS Term: 26600 MEDSV DEF RBRVS 01/01/2024 287.40 Description: TREAT METACARPAL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26600 MEDSV DEF RBRVS 09/01/2019 12/31/2023 207.26 Description: TREAT METACARPAL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26605 MEDSV DEF RBRVS 01/01/2024 314.84 Description: TREAT METACARPAL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26605 MEDSV DEF RBRVS 09/01/2019 12/31/2023 226.57 Description: TREAT METACARPAL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26607 MEDSV DEF RBRVS 01/01/2024 478.63 Description: TREAT METACARPAL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26607 MEDSV DEF RBRVS 09/01/2019 12/31/2023 322.95 Description: TREAT METACARPAL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 252 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 26608 MEDSV DEF RBRVS 01/01/2024 453.96 Description: TREAT METACARPAL FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 26608 MEDSV DEF RBRVS 09/01/2019 12/31/2023 337.88 Description: TREAT METACARPAL FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 26615 MEDSV DEF RBRVS 01/01/2024 539.91 Description: TREAT METACARPAL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26615 MEDSV DEF RBRVS 09/01/2019 12/31/2023 408.45 Description: TREAT METACARPAL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26641 MEDSV DEF RBRVS 01/01/2024 397.65 Description: TREAT THUMB DISLOCATION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26641 MEDSV DEF RBRVS 09/01/2019 12/31/2023 262.82 Description: TREAT THUMB DISLOCATION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26645 MEDSV DEF RBRVS 01/01/2024 410.65 Description: TREAT THUMB FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26645 MEDSV DEF RBRVS 09/01/2019 12/31/2023 300.92 Description: TREAT THUMB FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26650 MEDSV DEF RBRVS 01/01/2024 454.85 Description: TREAT THUMB FRACTURE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26650 MEDSV DEF RBRVS 09/01/2019 12/31/2023 337.79 Description: TREAT THUMB FRACTURE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26665 MEDSV DEF RBRVS 01/01/2024 589.76 Description: TREAT THUMB FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26665 MEDSV DEF RBRVS 09/01/2019 12/31/2023 446.93 Description: TREAT THUMB FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26670 MEDSV DEF RBRVS 01/01/2024 331.72 Description: TREAT HAND DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26670 MEDSV DEF RBRVS 09/01/2019 12/31/2023 240.06 Description: TREAT HAND DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26675 MEDSV DEF RBRVS 01/01/2024 437.99 Description: TREAT HAND DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26675 MEDSV DEF RBRVS 09/01/2019 12/31/2023 320.19 Description: TREAT HAND DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 253 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 26676 MEDSV DEF RBRVS 01/01/2024 481.08 Description: PIN HAND DISLOCATION Category: Medical Services CMS Add: 01/01/1987 CMS Term: 26676 MEDSV DEF RBRVS 09/01/2019 12/31/2023 354.46 Description: PIN HAND DISLOCATION Category: Medical Services CMS Add: 01/01/1987 CMS Term: 26685 MEDSV DEF RBRVS 01/01/2024 540.05 Description: TREAT HAND DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26685 MEDSV DEF RBRVS 09/01/2019 12/31/2023 411.34 Description: TREAT HAND DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26686 MEDSV DEF RBRVS 01/01/2024 582.18 Description: TREAT HAND DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26686 MEDSV DEF RBRVS 09/01/2019 12/31/2023 443.12 Description: TREAT HAND DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26700 MEDSV DEF RBRVS 01/01/2024 324.00 Description: TREAT KNUCKLE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26700 MEDSV DEF RBRVS 09/01/2019 12/31/2023 231.31 Description: TREAT KNUCKLE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26705 MEDSV DEF RBRVS 01/01/2024 415.28 Description: TREAT KNUCKLE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26705 MEDSV DEF RBRVS 09/01/2019 12/31/2023 292.08 Description: TREAT KNUCKLE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26706 MEDSV DEF RBRVS 01/01/2024 422.57 Description: PIN KNUCKLE DISLOCATION Category: Medical Services CMS Add: 01/01/1987 CMS Term: 26706 MEDSV DEF RBRVS 09/01/2019 12/31/2023 312.03 Description: PIN KNUCKLE DISLOCATION Category: Medical Services CMS Add: 01/01/1987 CMS Term: 26715 MEDSV DEF RBRVS 01/01/2024 538.39 Description: TREAT KNUCKLE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26715 MEDSV DEF RBRVS 09/01/2019 12/31/2023 407.21 Description: TREAT KNUCKLE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26720 MEDSV DEF RBRVS 01/01/2024 192.00 Description: TREAT FINGER FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26720 MEDSV DEF RBRVS 09/01/2019 12/31/2023 140.02 Description: TREAT FINGER FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 254 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 26725 MEDSV DEF RBRVS 01/01/2024 325.98 Description: TREAT FINGER FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26725 MEDSV DEF RBRVS 09/01/2019 12/31/2023 237.84 Description: TREAT FINGER FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26727 MEDSV DEF RBRVS 01/01/2024 447.51 Description: TREAT FINGER FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26727 MEDSV DEF RBRVS 09/01/2019 12/31/2023 331.99 Description: TREAT FINGER FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26735 MEDSV DEF RBRVS 01/01/2024 557.98 Description: TREAT FINGER FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26735 MEDSV DEF RBRVS 09/01/2019 12/31/2023 423.63 Description: TREAT FINGER FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26740 MEDSV DEF RBRVS 01/01/2024 222.43 Description: TREAT FINGER FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26740 MEDSV DEF RBRVS 09/01/2019 12/31/2023 161.39 Description: TREAT FINGER FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26742 MEDSV DEF RBRVS 01/01/2024 356.29 Description: TREAT FINGER FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26742 MEDSV DEF RBRVS 09/01/2019 12/31/2023 260.29 Description: TREAT FINGER FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26746 MEDSV DEF RBRVS 01/01/2024 694.64 Description: TREAT FINGER FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26746 MEDSV DEF RBRVS 09/01/2019 12/31/2023 527.46 Description: TREAT FINGER FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26750 MEDSV DEF RBRVS 01/01/2024 179.62 Description: TREAT FINGER FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26750 MEDSV DEF RBRVS 09/01/2019 12/31/2023 130.44 Description: TREAT FINGER FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26755 MEDSV DEF RBRVS 01/01/2024 305.29 Description: TREAT FINGER FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26755 MEDSV DEF RBRVS 09/01/2019 12/31/2023 222.37 Description: TREAT FINGER FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 255 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 26756 MEDSV DEF RBRVS 01/01/2024 401.35 Description: PIN FINGER FRACTURE EACH Category: Medical Services CMS Add: 01/01/1987 CMS Term: 26756 MEDSV DEF RBRVS 09/01/2019 12/31/2023 295.14 Description: PIN FINGER FRACTURE EACH Category: Medical Services CMS Add: 01/01/1987 CMS Term: 26765 MEDSV DEF RBRVS 01/01/2024 473.13 Description: TREAT FINGER FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26765 MEDSV DEF RBRVS 09/01/2019 12/31/2023 355.70 Description: TREAT FINGER FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26770 MEDSV DEF RBRVS 01/01/2024 274.46 Description: TREAT FINGER DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26770 MEDSV DEF RBRVS 09/01/2019 12/31/2023 196.03 Description: TREAT FINGER DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26775 MEDSV DEF RBRVS 01/01/2024 376.37 Description: TREAT FINGER DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26775 MEDSV DEF RBRVS 09/01/2019 12/31/2023 269.27 Description: TREAT FINGER DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26776 MEDSV DEF RBRVS 01/01/2024 424.41 Description: PIN FINGER DISLOCATION Category: Medical Services CMS Add: 01/01/1987 CMS Term: 26776 MEDSV DEF RBRVS 09/01/2019 12/31/2023 312.92 Description: PIN FINGER DISLOCATION Category: Medical Services CMS Add: 01/01/1987 CMS Term: 26785 MEDSV DEF RBRVS 01/01/2024 514.97 Description: TREAT FINGER DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26785 MEDSV DEF RBRVS 09/01/2019 12/31/2023 387.97 Description: TREAT FINGER DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26820 MEDSV DEF RBRVS 01/01/2024 779.71 Description: THUMB FUSION WITH GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26820 MEDSV DEF RBRVS 09/01/2019 12/31/2023 550.56 Description: THUMB FUSION WITH GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26841 MEDSV DEF RBRVS 01/01/2024 727.25 Description: FUSION OF THUMB Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26841 MEDSV DEF RBRVS 09/01/2019 12/31/2023 508.04 Description: FUSION OF THUMB Category: Medical Services CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 256 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 26842 MEDSV DEF RBRVS 01/01/2024 782.00 Description: THUMB FUSION WITH GRAFT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26842 MEDSV DEF RBRVS 09/01/2019 12/31/2023 550.39 Description: THUMB FUSION WITH GRAFT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26843 MEDSV DEF RBRVS 01/01/2024 735.46 Description: FUSION OF HAND JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26843 MEDSV DEF RBRVS 09/01/2019 12/31/2023 515.71 Description: FUSION OF HAND JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26844 MEDSV DEF RBRVS 01/01/2024 808.08 Description: FUSION/GRAFT OF HAND JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26844 MEDSV DEF RBRVS 09/01/2019 12/31/2023 570.82 Description: FUSION/GRAFT OF HAND JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26850 MEDSV DEF RBRVS 01/01/2024 692.62 Description: FUSION OF KNUCKLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26850 MEDSV DEF RBRVS 09/01/2019 12/31/2023 482.74 Description: FUSION OF KNUCKLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26852 MEDSV DEF RBRVS 01/01/2024 784.73 Description: FUSION OF KNUCKLE WITH GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26852 MEDSV DEF RBRVS 09/01/2019 12/31/2023 555.31 Description: FUSION OF KNUCKLE WITH GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26860 MEDSV DEF RBRVS 01/01/2024 578.26 Description: FUSION OF FINGER JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26860 MEDSV DEF RBRVS 09/01/2019 12/31/2023 390.81 Description: FUSION OF FINGER JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26861 MEDSV DEF RBRVS 01/01/2024 93.28 Description: FUSION OF FINGER JNT ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26861 MEDSV DEF RBRVS 02/01/2015 12/31/2023 74.74 Description: FUSION OF FINGER JNT ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26862 MEDSV DEF RBRVS 01/01/2024 721.86 Description: FUSION/GRAFT OF FINGER JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26862 MEDSV DEF RBRVS 09/01/2019 12/31/2023 505.17 Description: FUSION/GRAFT OF FINGER JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 257 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 26863 MEDSV DEF RBRVS 01/01/2024 209.93 Description: FUSE/GRAFT ADDED JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26863 MEDSV DEF RBRVS 02/01/2015 12/31/2023 164.96 Description: FUSE/GRAFT ADDED JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26910 MEDSV DEF RBRVS 01/01/2024 717.69 Description: AMPUTATE METACARPAL BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26910 MEDSV DEF RBRVS 09/01/2019 12/31/2023 501.45 Description: AMPUTATE METACARPAL BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26951 MEDSV DEF RBRVS 01/01/2024 659.86 Description: AMPUTATION OF FINGER/THUMB Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26951 MEDSV DEF RBRVS 09/01/2019 12/31/2023 455.00 Description: AMPUTATION OF FINGER/THUMB Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26952 MEDSV DEF RBRVS 01/01/2024 645.17 Description: AMPUTATION OF FINGER/THUMB Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26952 MEDSV DEF RBRVS 09/01/2019 12/31/2023 450.64 Description: AMPUTATION OF FINGER/THUMB Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26989 MEDSV DEF BILL20 Description: UNLISTED PX HANDS/FINGERS Category: Medical Services CMS Add: 01/01/1982 CMS Term: 26990 MEDSV DEF RBRVS 01/01/2024 634.31 Description: DRAINAGE OF PELVIS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26990 MEDSV DEF RBRVS 09/01/2019 12/31/2023 442.66 Description: DRAINAGE OF PELVIS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26991 MEDSV DEF RBRVS 01/01/2024 662.67 Description: DRAINAGE OF PELVIS BURSA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26991 MEDSV DEF RBRVS 09/01/2019 12/31/2023 497.27 Description: DRAINAGE OF PELVIS BURSA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26992 MEDSV DEF RBRVS 01/01/2024 935.72 Description: DRAINAGE OF BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26992 MEDSV DEF RBRVS 09/01/2019 12/31/2023 687.44 Description: DRAINAGE OF BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27000 MEDSV DEF RBRVS 01/01/2024 373.65 Description: INCISION OF HIP TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 258 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27000 MEDSV DEF RBRVS 09/01/2019 12/31/2023 300.05 Description: INCISION OF HIP TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27001 MEDSV DEF RBRVS 01/01/2024 505.00 Description: INCISION OF HIP TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27001 MEDSV DEF RBRVS 09/01/2019 12/31/2023 385.64 Description: INCISION OF HIP TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27003 MEDSV DEF RBRVS 01/01/2024 559.75 Description: INCISION OF HIP TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27003 MEDSV DEF RBRVS 09/01/2019 12/31/2023 423.62 Description: INCISION OF HIP TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27005 MEDSV DEF RBRVS 01/01/2024 667.29 Description: INCISION OF HIP TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27005 MEDSV DEF RBRVS 09/01/2019 12/31/2023 518.61 Description: INCISION OF HIP TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27006 MEDSV DEF RBRVS 01/01/2024 668.25 Description: INCISION OF HIP TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27006 MEDSV DEF RBRVS 09/01/2019 12/31/2023 524.97 Description: INCISION OF HIP TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27025 MEDSV DEF RBRVS 01/01/2024 855.57 Description: INCISION OF HIP/THIGH FASCIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27025 MEDSV DEF RBRVS 09/01/2019 12/31/2023 654.74 Description: INCISION OF HIP/THIGH FASCIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27027 MEDSV DEF RBRVS 01/01/2024 827.85 Description: BUTTOCK FASCIOTOMY Category: Medical Services CMS Add: 01/01/2009 CMS Term: 27027 MEDSV DEF RBRVS 02/01/2015 12/31/2023 619.13 Description: BUTTOCK FASCIOTOMY Category: Medical Services CMS Add: 01/01/2009 CMS Term: 27030 MEDSV DEF RBRVS 01/01/2024 868.62 Description: DRAINAGE OF HIP JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 27030 MEDSV DEF RBRVS 09/01/2019 12/31/2023 656.09 Description: DRAINAGE OF HIP JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 27033 MEDSV DEF RBRVS 01/01/2024 901.24 Description: EXPLORATION OF HIP JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 259 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27033 MEDSV DEF RBRVS 09/01/2019 12/31/2023 696.52 Description: EXPLORATION OF HIP JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 27035 MEDSV DEF RBRVS 01/01/2024 1073.44 Description: DENERVATION OF HIP JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27035 MEDSV DEF RBRVS 09/01/2019 12/31/2023 841.67 Description: DENERVATION OF HIP JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27036 MEDSV DEF RBRVS 01/01/2019 12/31/2023 723.26 Description: EXCISION OF HIP JOINT/MUSCLE Category: Medical Services CMS Add: 01/01/1997 CMS Term: 27036 MEDSV DEF RBRVS 01/01/2024 943.63 Description: EXCISION OF HIP JOINT/MUSCLE Category: Medical Services CMS Add: 01/01/1997 CMS Term: 27040 MEDSV DEF RBRVS 01/01/2024 317.65 Description: BIOPSY OF SOFT TISSUES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27040 MEDSV DEF RBRVS 09/01/2019 12/31/2023 243.85 Description: BIOPSY OF SOFT TISSUES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27041 MEDSV DEF RBRVS 01/01/2024 661.01 Description: BIOPSY OF SOFT TISSUES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27041 MEDSV DEF RBRVS 09/01/2019 12/31/2023 493.33 Description: BIOPSY OF SOFT TISSUES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27043 MEDSV DEF RBRVS 01/01/2024 432.70 Description: EXC HIP PELVIS LES SC 3 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 27043 MEDSV DEF RBRVS 02/01/2015 12/31/2023 332.66 Description: EXC HIP PELVIS LES SC 3 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 27045 MEDSV DEF RBRVS 01/01/2024 680.34 Description: EXC HIP/PELV TUM DEEP 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 27045 MEDSV DEF RBRVS 02/01/2015 12/31/2023 533.64 Description: EXC HIP/PELV TUM DEEP 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 27047 MEDSV DEF RBRVS 01/01/2024 459.23 Description: EXC HIP/PELVIS LES SC < 3 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27047 MEDSV DEF RBRVS 09/01/2019 12/31/2023 329.50 Description: EXC HIP/PELVIS LES SC < 3 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27048 MEDSV DEF RBRVS 01/01/2024 565.62 Description: EXC HIP/PELV TUM DEEP < 5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 260 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27048 MEDSV DEF RBRVS 09/01/2019 12/31/2023 434.06 Description: EXC HIP/PELV TUM DEEP < 5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27049 MEDSV DEF RBRVS 01/01/2024 1229.11 Description: RESECT HIP/PELV TUM < 5 CM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 27049 MEDSV DEF RBRVS 09/01/2019 12/31/2023 976.85 Description: RESECT HIP/PELV TUM < 5 CM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 27050 MEDSV DEF RBRVS 01/01/2024 379.98 Description: BIOPSY OF SACROILIAC JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27050 MEDSV DEF RBRVS 09/01/2019 12/31/2023 284.74 Description: BIOPSY OF SACROILIAC JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27052 MEDSV DEF RBRVS 01/01/2024 540.46 Description: BIOPSY OF HIP JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27052 MEDSV DEF RBRVS 09/01/2019 12/31/2023 410.91 Description: BIOPSY OF HIP JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27054 MEDSV DEF RBRVS 01/01/2024 642.73 Description: REMOVAL OF HIP JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27054 MEDSV DEF RBRVS 09/01/2019 12/31/2023 488.82 Description: REMOVAL OF HIP JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27057 MEDSV DEF RBRVS 01/01/2024 934.19 Description: BUTTOCK FASCIOTOMY W/DBRDMT Category: Medical Services CMS Add: 01/01/2009 CMS Term: 27057 MEDSV DEF RBRVS 02/01/2015 12/31/2023 695.21 Description: BUTTOCK FASCIOTOMY W/DBRDMT Category: Medical Services CMS Add: 01/01/2009 CMS Term: 27059 MEDSV DEF RBRVS 01/01/2024 1665.72 Description: RESECT HIP/PELV TUM 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 27059 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1294.60 Description: RESECT HIP/PELV TUM 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 27060 MEDSV DEF RBRVS 01/01/2024 436.17 Description: REMOVAL OF ISCHIAL BURSA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27060 MEDSV DEF RBRVS 09/01/2019 12/31/2023 330.29 Description: REMOVAL OF ISCHIAL BURSA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27062 MEDSV DEF RBRVS 01/01/2024 425.74 Description: REMOVE FEMUR LESION/BURSA Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 261 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27062 MEDSV DEF RBRVS 09/01/2019 12/31/2023 323.93 Description: REMOVE FEMUR LESION/BURSA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27065 MEDSV DEF RBRVS 01/01/2024 492.97 Description: REMOVE HIP BONE LES SUPER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27065 MEDSV DEF RBRVS 09/01/2019 12/31/2023 365.08 Description: REMOVE HIP BONE LES SUPER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27066 MEDSV DEF RBRVS 01/01/2024 762.77 Description: REMOVE HIP BONE LES DEEP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27066 MEDSV DEF RBRVS 09/01/2019 12/31/2023 580.10 Description: REMOVE HIP BONE LES DEEP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27067 MEDSV DEF RBRVS 01/01/2024 960.76 Description: REMOVE/GRAFT HIP BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27067 MEDSV DEF RBRVS 09/01/2019 12/31/2023 738.43 Description: REMOVE/GRAFT HIP BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27070 MEDSV DEF RBRVS 01/01/2024 825.39 Description: PART REMOVE HIP BONE SUPER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27070 MEDSV DEF RBRVS 09/01/2019 12/31/2023 607.28 Description: PART REMOVE HIP BONE SUPER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27071 MEDSV DEF RBRVS 01/01/2024 907.41 Description: PART REMOVAL HIP BONE DEEP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27071 MEDSV DEF RBRVS 09/01/2019 12/31/2023 654.52 Description: PART REMOVAL HIP BONE DEEP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27075 MEDSV DEF RBRVS 01/01/2024 1916.69 Description: RESECT HIP TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27075 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1507.74 Description: RESECT HIP TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27076 MEDSV DEF RBRVS 01/01/2024 2315.40 Description: RESECT HIP TUM INCL ACETABUL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27076 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1813.46 Description: RESECT HIP TUM INCL ACETABUL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27077 MEDSV DEF RBRVS 01/01/2024 2581.19 Description: RESECT HIP TUM W/INNOM BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 262 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27077 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2038.88 Description: RESECT HIP TUM W/INNOM BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27078 MEDSV DEF RBRVS 01/01/2024 1889.94 Description: RSECT HIP TUM INCL FEMUR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27078 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1486.46 Description: RSECT HIP TUM INCL FEMUR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27080 MEDSV DEF RBRVS 01/01/2024 473.04 Description: REMOVAL OF TAIL BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27080 MEDSV DEF RBRVS 09/01/2019 12/31/2023 363.89 Description: REMOVAL OF TAIL BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27086 MEDSV DEF RBRVS 01/01/2024 290.37 Description: REMOVE HIP FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27086 MEDSV DEF RBRVS 09/01/2019 12/31/2023 205.42 Description: REMOVE HIP FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27087 MEDSV DEF RBRVS 01/01/2024 568.84 Description: REMOVE HIP FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27087 MEDSV DEF RBRVS 09/01/2019 12/31/2023 448.22 Description: REMOVE HIP FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27090 MEDSV DEF RBRVS 01/01/2024 773.08 Description: REMOVAL OF HIP PROSTHESIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27090 MEDSV DEF RBRVS 09/01/2019 12/31/2023 591.78 Description: REMOVAL OF HIP PROSTHESIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27091 MEDSV DEF RBRVS 01/01/2024 1469.73 Description: REMOVAL OF HIP PROSTHESIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27091 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1148.45 Description: REMOVAL OF HIP PROSTHESIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27093 MEDSV DEF RBRVS 01/01/2024 219.67 Description: INJECTION FOR HIP X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27093 MEDSV DEF RBRVS 09/01/2019 12/31/2023 131.95 Description: INJECTION FOR HIP X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27095 MEDSV DEF RBRVS 01/01/2024 292.70 Description: INJECTION FOR HIP X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 263 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27095 MEDSV DEF RBRVS 09/01/2019 12/31/2023 168.21 Description: INJECTION FOR HIP X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27096 MEDSV DEF RBRVS 01/01/2024 152.74 Description: INJECT SACROILIAC JOINT Category: Medical Services CMS Add: 01/01/2000 CMS Term: 27096 MEDSV DEF RBRVS 02/01/2015 12/31/2023 116.31 Description: INJECT SACROILIAC JOINT Category: Medical Services CMS Add: 01/01/2000 CMS Term: 27097 MEDSV DEF RBRVS 01/01/2024 637.36 Description: REVISION OF HIP TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27097 MEDSV DEF RBRVS 09/01/2019 12/31/2023 485.64 Description: REVISION OF HIP TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27098 MEDSV DEF RBRVS 01/01/2024 648.63 Description: TRANSFER TENDON TO PELVIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27098 MEDSV DEF RBRVS 09/01/2019 12/31/2023 494.00 Description: TRANSFER TENDON TO PELVIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27100 MEDSV DEF RBRVS 01/01/2024 772.80 Description: TRANSFER OF ABDOMINAL MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27100 MEDSV DEF RBRVS 09/01/2019 12/31/2023 583.89 Description: TRANSFER OF ABDOMINAL MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27105 MEDSV DEF RBRVS 01/01/2024 809.38 Description: TRANSFER OF SPINAL MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27105 MEDSV DEF RBRVS 09/01/2019 12/31/2023 617.54 Description: TRANSFER OF SPINAL MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27110 MEDSV DEF RBRVS 01/01/2024 901.12 Description: TRANSFER OF ILIOPSOAS MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27110 MEDSV DEF RBRVS 09/01/2019 12/31/2023 691.35 Description: TRANSFER OF ILIOPSOAS MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27111 MEDSV DEF RBRVS 01/01/2024 839.08 Description: TRANSFER OF ILIOPSOAS MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27111 MEDSV DEF RBRVS 09/01/2019 12/31/2023 641.17 Description: TRANSFER OF ILIOPSOAS MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27120 MEDSV DEF RBRVS 01/01/2024 1200.84 Description: RECONSTRUCTION OF HIP SOCKET Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 264 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27120 MEDSV DEF RBRVS 09/01/2019 12/31/2023 930.16 Description: RECONSTRUCTION OF HIP SOCKET Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27122 MEDSV DEF RBRVS 01/01/2024 1021.25 Description: RECONSTRUCTION OF HIP SOCKET Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27122 MEDSV DEF RBRVS 09/01/2019 12/31/2023 787.13 Description: RECONSTRUCTION OF HIP SOCKET Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27125 MEDSV DEF RBRVS 01/01/2024 1047.20 Description: PARTIAL HIP REPLACEMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27125 MEDSV DEF RBRVS 09/01/2019 12/31/2023 812.31 Description: PARTIAL HIP REPLACEMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27130 MEDSV DEF RBRVS 01/01/2024 1186.05 Description: TOTAL HIP ARTHROPLASTY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27130 MEDSV DEF RBRVS 09/01/2019 12/31/2023 975.85 Description: TOTAL HIP ARTHROPLASTY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27132 MEDSV DEF RBRVS 01/01/2024 1540.94 Description: TOTAL HIP ARTHROPLASTY Category: Medical Services CMS Add: 01/01/1987 CMS Term: 27132 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1205.67 Description: TOTAL HIP ARTHROPLASTY Category: Medical Services CMS Add: 01/01/1987 CMS Term: 27134 MEDSV DEF RBRVS 01/01/2024 1753.74 Description: REVISE HIP JOINT REPLACEMENT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 27134 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1380.85 Description: REVISE HIP JOINT REPLACEMENT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 27137 MEDSV DEF RBRVS 01/01/2024 1350.93 Description: REVISE HIP JOINT REPLACEMENT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 27137 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1059.69 Description: REVISE HIP JOINT REPLACEMENT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 27138 MEDSV DEF RBRVS 01/01/2024 1403.31 Description: REVISE HIP JOINT REPLACEMENT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 27138 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1101.75 Description: REVISE HIP JOINT REPLACEMENT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 27140 MEDSV DEF RBRVS 01/01/2024 832.08 Y Description: TRANSPLANT FEMUR RIDGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 265 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27140 MEDSV DEF RBRVS 09/01/2019 12/31/2023 638.58 Y Description: TRANSPLANT FEMUR RIDGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27146 MEDSV DEF RBRVS 01/01/2024 1171.62 Description: INCISION OF HIP BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27146 MEDSV DEF RBRVS 09/01/2019 12/31/2023 919.73 Description: INCISION OF HIP BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27147 MEDSV DEF RBRVS 01/01/2024 1349.87 Description: REVISION OF HIP BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27147 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1052.92 Description: REVISION OF HIP BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27151 MEDSV DEF RBRVS 01/01/2024 1458.99 Description: INCISION OF HIP BONES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27151 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1140.37 Description: INCISION OF HIP BONES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27156 MEDSV DEF RBRVS 01/01/2024 1571.21 Description: REVISION OF HIP BONES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27156 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1229.84 Description: REVISION OF HIP BONES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27158 MEDSV DEF RBRVS 01/01/2024 1292.14 Description: REVISION OF PELVIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27158 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1003.94 Description: REVISION OF PELVIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27161 MEDSV DEF RBRVS 01/01/2024 1128.64 Description: INCISION OF NECK OF FEMUR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27161 MEDSV DEF RBRVS 09/01/2019 12/31/2023 871.58 Description: INCISION OF NECK OF FEMUR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27165 MEDSV DEF RBRVS 01/01/2024 1271.40 Description: INCISION/FIXATION OF FEMUR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27165 MEDSV DEF RBRVS 09/01/2019 12/31/2023 987.75 Description: INCISION/FIXATION OF FEMUR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27170 MEDSV DEF RBRVS 01/01/2024 1082.87 Description: REPAIR/GRAFT FEMUR HEAD/NECK Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 266 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27170 MEDSV DEF RBRVS 09/01/2019 12/31/2023 843.58 Description: REPAIR/GRAFT FEMUR HEAD/NECK Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27175 MEDSV DEF RBRVS 01/01/2024 620.11 Description: TREAT SLIPPED EPIPHYSIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27175 MEDSV DEF RBRVS 09/01/2019 12/31/2023 421.96 Description: TREAT SLIPPED EPIPHYSIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27176 MEDSV DEF RBRVS 01/01/2024 856.46 Description: TREAT SLIPPED EPIPHYSIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27176 MEDSV DEF RBRVS 09/01/2019 12/31/2023 655.38 Description: TREAT SLIPPED EPIPHYSIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27177 MEDSV DEF RBRVS 01/01/2024 1033.61 Description: TREAT SLIPPED EPIPHYSIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27177 MEDSV DEF RBRVS 09/01/2019 12/31/2023 795.96 Description: TREAT SLIPPED EPIPHYSIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27178 MEDSV DEF RBRVS 01/01/2024 856.46 Description: TREAT SLIPPED EPIPHYSIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27178 MEDSV DEF RBRVS 09/01/2019 12/31/2023 655.38 Description: TREAT SLIPPED EPIPHYSIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27179 MEDSV DEF RBRVS 01/01/2024 908.08 Description: REVISE HEAD/NECK OF FEMUR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27179 MEDSV DEF RBRVS 09/01/2019 12/31/2023 696.97 Description: REVISE HEAD/NECK OF FEMUR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27181 MEDSV DEF RBRVS 01/01/2024 1037.13 Description: TREAT SLIPPED EPIPHYSIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27181 MEDSV DEF RBRVS 09/01/2019 12/31/2023 730.26 Description: TREAT SLIPPED EPIPHYSIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27185 MEDSV DEF RBRVS 01/01/2024 669.71 Description: REVISION OF FEMUR EPIPHYSIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27185 MEDSV DEF RBRVS 09/01/2019 12/31/2023 430.74 Description: REVISION OF FEMUR EPIPHYSIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27187 MEDSV DEF RBRVS 01/01/2024 924.01 Description: REINFORCE HIP BONES Category: Medical Services CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 267 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27187 MEDSV DEF RBRVS 09/01/2019 12/31/2023 709.99 Description: REINFORCE HIP BONES Category: Medical Services CMS Add: 01/01/1986 CMS Term: 27197 MEDSV DEF RBRVS 01/01/2017 12/31/2023 84.46 Description: CLSD TX PELVIC RING FX Category: Medical Services CMS Add: 01/01/2017 CMS Term: 27197 MEDSV DEF RBRVS 01/01/2024 124.28 Description: CLSD TX PELVIC RING FX Category: Medical Services CMS Add: 01/01/2017 CMS Term: 27198 MEDSV DEF RBRVS 01/01/2017 12/31/2023 215.40 Description: CLSD TX PELVIC RING FX Category: Medical Services CMS Add: 01/01/2017 CMS Term: 27198 MEDSV DEF RBRVS 01/01/2024 293.49 Description: CLSD TX PELVIC RING FX Category: Medical Services CMS Add: 01/01/2017 CMS Term: 27200 MEDSV DEF RBRVS 01/01/2024 176.91 Description: TREAT TAIL BONE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27200 MEDSV DEF RBRVS 09/01/2019 12/31/2023 127.64 Description: TREAT TAIL BONE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27202 MEDSV DEF RBRVS 01/01/2024 491.65 Description: TREAT TAIL BONE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27202 MEDSV DEF RBRVS 09/01/2019 12/31/2023 379.80 Description: TREAT TAIL BONE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27215 MEDSV DEF RBRVS 01/01/2024 572.77 Description: TREAT PELVIC FRACTURE(S) Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27215 MEDSV DEF RBRVS 09/01/2019 12/31/2023 441.95 Description: TREAT PELVIC FRACTURE(S) Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27216 MEDSV DEF RBRVS 01/01/2024 846.96 Description: TREAT PELVIC RING FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27216 MEDSV DEF RBRVS 09/01/2019 12/31/2023 655.98 Description: TREAT PELVIC RING FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27217 MEDSV DEF RBRVS 01/01/2024 795.95 Description: TREAT PELVIC RING FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27217 MEDSV DEF RBRVS 09/01/2019 12/31/2023 615.48 Description: TREAT PELVIC RING FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27218 MEDSV DEF RBRVS 01/01/2024 1093.44 Description: TREAT PELVIC RING FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 268 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27218 MEDSV DEF RBRVS 09/01/2019 12/31/2023 851.01 Description: TREAT PELVIC RING FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27220 MEDSV DEF RBRVS 01/01/2024 391.94 Description: TREAT HIP SOCKET FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27220 MEDSV DEF RBRVS 09/01/2019 12/31/2023 377.64 Description: TREAT HIP SOCKET FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27222 MEDSV DEF RBRVS 01/01/2024 914.40 Description: TREAT HIP SOCKET FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27222 MEDSV DEF RBRVS 09/01/2019 12/31/2023 697.18 Description: TREAT HIP SOCKET FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27226 MEDSV DEF RBRVS 01/01/2024 977.49 Description: TREAT HIP WALL FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27226 MEDSV DEF RBRVS 09/01/2019 12/31/2023 758.62 Description: TREAT HIP WALL FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27227 MEDSV DEF RBRVS 01/01/2024 1521.54 Description: TREAT HIP FRACTURE(S) Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27227 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1192.86 Description: TREAT HIP FRACTURE(S) Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27228 MEDSV DEF RBRVS 01/01/2024 1730.09 Description: TREAT HIP FRACTURE(S) Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27228 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1359.21 Description: TREAT HIP FRACTURE(S) Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27230 MEDSV DEF RBRVS 01/01/2024 457.73 Description: TREAT THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27230 MEDSV DEF RBRVS 09/01/2019 12/31/2023 337.35 Description: TREAT THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27232 MEDSV DEF RBRVS 01/01/2024 673.93 Description: TREAT THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27232 MEDSV DEF RBRVS 09/01/2019 12/31/2023 545.36 Description: TREAT THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27235 MEDSV DEF RBRVS 01/01/2024 841.08 Description: TREAT THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 269 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27235 MEDSV DEF RBRVS 09/01/2019 12/31/2023 650.10 Description: TREAT THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27236 MEDSV DEF RBRVS 01/01/2024 1103.65 Description: TREAT THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27236 MEDSV DEF RBRVS 09/01/2019 12/31/2023 858.19 Description: TREAT THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27238 MEDSV DEF RBRVS 01/01/2024 438.87 Description: TREAT THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27238 MEDSV DEF RBRVS 09/01/2019 12/31/2023 326.90 Description: TREAT THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27240 MEDSV DEF RBRVS 01/01/2024 887.65 Description: TREAT THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27240 MEDSV DEF RBRVS 09/01/2019 12/31/2023 684.00 Description: TREAT THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27244 MEDSV DEF RBRVS 01/01/2024 1135.10 Description: TREAT THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27244 MEDSV DEF RBRVS 09/01/2019 12/31/2023 882.42 Description: TREAT THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27245 MEDSV DEF RBRVS 01/01/2024 1134.31 Description: TREAT THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27245 MEDSV DEF RBRVS 09/01/2019 12/31/2023 882.67 Description: TREAT THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27246 MEDSV DEF RBRVS 01/01/2024 367.75 Description: TREAT THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27246 MEDSV DEF RBRVS 09/01/2019 12/31/2023 273.29 Description: TREAT THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27248 MEDSV DEF RBRVS 01/01/2024 691.95 Description: TREAT THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27248 MEDSV DEF RBRVS 09/01/2019 12/31/2023 532.24 Description: TREAT THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27250 MEDSV DEF RBRVS 01/01/2024 165.78 Description: TREAT HIP DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 270 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27250 MEDSV DEF RBRVS 09/01/2019 12/31/2023 133.02 Description: TREAT HIP DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27252 MEDSV DEF RBRVS 01/01/2024 700.17 Description: TREAT HIP DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27252 MEDSV DEF RBRVS 09/01/2019 12/31/2023 543.00 Description: TREAT HIP DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27253 MEDSV DEF RBRVS 01/01/2024 872.10 Description: TREAT HIP DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27253 MEDSV DEF RBRVS 09/01/2019 12/31/2023 674.27 Description: TREAT HIP DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27254 MEDSV DEF RBRVS 01/01/2024 1175.78 Description: TREAT HIP DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27254 MEDSV DEF RBRVS 09/01/2019 12/31/2023 907.96 Description: TREAT HIP DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27256 MEDSV DEF RBRVS 01/01/2024 292.27 Description: TREAT HIP DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27256 MEDSV DEF RBRVS 09/01/2019 12/31/2023 214.58 Description: TREAT HIP DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27257 MEDSV DEF RBRVS 01/01/2024 334.30 Description: TREAT HIP DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27257 MEDSV DEF RBRVS 09/01/2019 12/31/2023 258.67 Description: TREAT HIP DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27258 MEDSV DEF RBRVS 01/01/2024 1029.41 Description: TREAT HIP DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27258 MEDSV DEF RBRVS 09/01/2019 12/31/2023 793.68 Description: TREAT HIP DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27259 MEDSV DEF RBRVS 01/01/2024 1424.32 Description: TREAT HIP DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27259 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1111.81 Description: TREAT HIP DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27265 MEDSV DEF RBRVS 01/01/2024 391.28 Description: TREAT HIP DISLOCATION Category: Medical Services CMS Add: 01/01/1989 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 271 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27265 MEDSV DEF RBRVS 09/01/2019 12/31/2023 285.54 Description: TREAT HIP DISLOCATION Category: Medical Services CMS Add: 01/01/1989 CMS Term: 27266 MEDSV DEF RBRVS 01/01/2024 546.06 Description: TREAT HIP DISLOCATION Category: Medical Services CMS Add: 01/01/1989 CMS Term: 27266 MEDSV DEF RBRVS 09/01/2019 12/31/2023 414.06 Description: TREAT HIP DISLOCATION Category: Medical Services CMS Add: 01/01/1989 CMS Term: 27267 MEDSV DEF RBRVS 01/01/2024 413.98 Description: CLTX THIGH FX Category: Medical Services CMS Add: 01/01/2008 CMS Term: 27267 MEDSV DEF RBRVS 02/01/2015 12/31/2023 311.10 Description: CLTX THIGH FX Category: Medical Services CMS Add: 01/01/2008 CMS Term: 27268 MEDSV DEF RBRVS 01/01/2024 509.26 Description: CLTX THIGH FX W/MNPJ Category: Medical Services CMS Add: 01/01/2008 CMS Term: 27268 MEDSV DEF RBRVS 02/01/2015 12/31/2023 382.87 Description: CLTX THIGH FX W/MNPJ Category: Medical Services CMS Add: 01/01/2008 CMS Term: 27269 MEDSV DEF RBRVS 01/01/2024 1146.14 Description: OPTX THIGH FX Category: Medical Services CMS Add: 01/01/2008 CMS Term: 27269 MEDSV DEF RBRVS 02/01/2015 12/31/2023 892.75 Description: OPTX THIGH FX Category: Medical Services CMS Add: 01/01/2008 CMS Term: 27275 MEDSV DEF RBRVS 01/01/2024 171.52 Description: MANIPULATION OF HIP JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27275 MEDSV DEF RBRVS 09/01/2019 12/31/2023 129.63 Description: MANIPULATION OF HIP JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27278 MEDSV DEF BILL20 Description: ARTHRD SI JT PRQ WO TFXJ DEV Category: Medical Services CMS Add: 01/01/2024 CMS Term: 27279 MEDSV DEF RBRVS 01/01/2024 752.02 Description: ARTHRD SI JT PERQ/MIN NVAS Category: Medical Services CMS Add: 01/01/2015 CMS Term: 27279 MEDSV DEF RBRVS 02/01/2015 12/31/2023 407.10 Description: ARTHRD SI JT PERQ/MIN NVAS Category: Medical Services CMS Add: 01/01/2015 CMS Term: 27280 MEDSV DEF RBRVS 01/01/2024 1236.35 Description: ARTHR SI JT OPN B1GRF INSTRM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27280 MEDSV DEF RBRVS 09/01/2019 12/31/2023 743.38 Description: ARTHR SI JT OPN B1GRF INSTRM Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 272 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27282 MEDSV DEF RBRVS 01/01/2024 799.54 Description: ARTHRODESIS SYMPHYSIS PUBIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27282 MEDSV DEF RBRVS 09/01/2019 12/31/2023 609.29 Description: ARTHRODESIS SYMPHYSIS PUBIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27284 MEDSV DEF RBRVS 01/01/2024 1477.69 Description: ARTHRODESIS HIP JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27284 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1161.41 Description: ARTHRODESIS HIP JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27286 MEDSV DEF RBRVS 01/01/2024 1515.09 Description: ARTHRD HIP JT SBTRCHC OSTEOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27286 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1185.01 Description: ARTHRD HIP JT SBTRCHC OSTEOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27290 MEDSV DEF RBRVS 01/01/2024 1499.24 Description: AMPUTATION OF LEG AT HIP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27290 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1164.06 Description: AMPUTATION OF LEG AT HIP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27295 MEDSV DEF RBRVS 01/01/2024 1161.41 Description: AMPUTATION OF LEG AT HIP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27295 MEDSV DEF RBRVS 09/01/2019 12/31/2023 906.58 Description: AMPUTATION OF LEG AT HIP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27299 MEDSV DEF BILL20 Description: UNLISTED PX PELVIS/HIP JOINT Category: Medical Services CMS Add: 01/01/1982 CMS Term: 27301 MEDSV DEF RBRVS 01/01/2024 627.21 Description: DRAIN THIGH/KNEE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27301 MEDSV DEF RBRVS 09/01/2019 12/31/2023 464.90 Description: DRAIN THIGH/KNEE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27303 MEDSV DEF RBRVS 01/01/2024 593.68 Description: DRAINAGE OF BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27303 MEDSV DEF RBRVS 09/01/2019 12/31/2023 455.32 Description: DRAINAGE OF BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27305 MEDSV DEF RBRVS 01/01/2024 453.02 Description: INCISE THIGH TENDON & FASCIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 273 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27305 MEDSV DEF RBRVS 09/01/2019 12/31/2023 344.40 Description: INCISE THIGH TENDON & FASCIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27306 MEDSV DEF RBRVS 01/01/2024 319.16 Description: INCISION OF THIGH TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27306 MEDSV DEF RBRVS 09/01/2019 12/31/2023 263.19 Description: INCISION OF THIGH TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27307 MEDSV DEF RBRVS 01/01/2024 389.01 Description: INCISION OF THIGH TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27307 MEDSV DEF RBRVS 09/01/2019 12/31/2023 340.85 Description: INCISION OF THIGH TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27310 MEDSV DEF RBRVS 01/01/2024 682.70 Description: EXPLORATION OF KNEE JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 27310 MEDSV DEF RBRVS 09/01/2019 12/31/2023 521.77 Description: EXPLORATION OF KNEE JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 27323 MEDSV DEF RBRVS 01/01/2024 256.38 Description: BIOPSY THIGH SOFT TISSUES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27323 MEDSV DEF RBRVS 09/01/2019 12/31/2023 191.17 Description: BIOPSY THIGH SOFT TISSUES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27324 MEDSV DEF RBRVS 01/01/2024 381.62 Description: BIOPSY THIGH SOFT TISSUES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27324 MEDSV DEF RBRVS 09/01/2019 12/31/2023 280.50 Description: BIOPSY THIGH SOFT TISSUES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27325 MEDSV DEF RBRVS 01/01/2024 528.19 Description: NEURECTOMY HAMSTRING Category: Medical Services CMS Add: 01/01/2007 CMS Term: 27325 MEDSV DEF RBRVS 02/01/2015 12/31/2023 396.00 Description: NEURECTOMY HAMSTRING Category: Medical Services CMS Add: 01/01/2007 CMS Term: 27326 MEDSV DEF RBRVS 01/01/2024 489.31 Description: NEURECTOMY POPLITEAL Category: Medical Services CMS Add: 01/01/2007 CMS Term: 27326 MEDSV DEF RBRVS 02/01/2015 12/31/2023 364.75 Description: NEURECTOMY POPLITEAL Category: Medical Services CMS Add: 01/01/2007 CMS Term: 27327 MEDSV DEF RBRVS 01/01/2024 467.38 Description: EXC THIGH/KNEE LES SC < 3 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 274 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27327 MEDSV DEF RBRVS 09/01/2019 12/31/2023 322.99 Description: EXC THIGH/KNEE LES SC < 3 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27328 MEDSV DEF RBRVS 01/01/2024 577.63 Description: EXC THIGH/KNEE TUM DEEP <5CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27328 MEDSV DEF RBRVS 09/01/2019 12/31/2023 440.75 Description: EXC THIGH/KNEE TUM DEEP <5CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27329 MEDSV DEF RBRVS 01/01/2024 958.55 Description: RESECT THIGH/KNEE TUM < 5 CM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 27329 MEDSV DEF RBRVS 09/01/2019 12/31/2023 742.34 Description: RESECT THIGH/KNEE TUM < 5 CM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 27330 MEDSV DEF RBRVS 01/01/2024 395.96 Description: BIOPSY KNEE JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27330 MEDSV DEF RBRVS 09/01/2019 12/31/2023 296.99 Description: BIOPSY KNEE JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27331 MEDSV DEF RBRVS 01/01/2024 446.82 Description: EXPLORE/TREAT KNEE JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 27331 MEDSV DEF RBRVS 09/01/2019 12/31/2023 338.45 Description: EXPLORE/TREAT KNEE JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 27332 MEDSV DEF RBRVS 01/01/2024 602.84 Description: REMOVAL OF KNEE CARTILAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27332 MEDSV DEF RBRVS 09/01/2019 12/31/2023 456.03 Description: REMOVAL OF KNEE CARTILAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27333 MEDSV DEF RBRVS 01/01/2024 550.91 Description: REMOVAL OF KNEE CARTILAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27333 MEDSV DEF RBRVS 09/01/2019 12/31/2023 416.22 Description: REMOVAL OF KNEE CARTILAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27334 MEDSV DEF RBRVS 01/01/2024 640.96 Description: REMOVE KNEE JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27334 MEDSV DEF RBRVS 09/01/2019 12/31/2023 487.79 Description: REMOVE KNEE JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27335 MEDSV DEF RBRVS 01/01/2024 712.99 Description: REMOVE KNEE JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 275 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27335 MEDSV DEF RBRVS 09/01/2019 12/31/2023 545.55 Description: REMOVE KNEE JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27337 MEDSV DEF RBRVS 01/01/2024 387.46 Description: EXC THIGH/KNEE LES SC 3 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 27337 MEDSV DEF RBRVS 02/01/2015 12/31/2023 296.85 Description: EXC THIGH/KNEE LES SC 3 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 27339 MEDSV DEF RBRVS 01/01/2024 695.37 Description: EXC THIGH/KNEE TUM DEP 5CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 27339 MEDSV DEF RBRVS 02/01/2015 12/31/2023 534.38 Description: EXC THIGH/KNEE TUM DEP 5CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 27340 MEDSV DEF RBRVS 01/01/2024 351.79 Description: REMOVAL OF KNEECAP BURSA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27340 MEDSV DEF RBRVS 09/01/2019 12/31/2023 263.55 Description: REMOVAL OF KNEECAP BURSA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27345 MEDSV DEF RBRVS 01/01/2024 455.06 Description: REMOVAL OF KNEE CYST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27345 MEDSV DEF RBRVS 09/01/2019 12/31/2023 341.90 Description: REMOVAL OF KNEE CYST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27347 MEDSV DEF RBRVS 01/01/2024 494.12 Description: REMOVE KNEE CYST Category: Medical Services CMS Add: 01/01/1999 CMS Term: 27347 MEDSV DEF RBRVS 02/01/2015 12/31/2023 376.27 Description: REMOVE KNEE CYST Category: Medical Services CMS Add: 01/01/1999 CMS Term: 27350 MEDSV DEF RBRVS 01/01/2024 611.34 Description: REMOVAL OF KNEECAP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27350 MEDSV DEF RBRVS 09/01/2019 12/31/2023 465.78 Description: REMOVAL OF KNEECAP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27355 MEDSV DEF RBRVS 01/01/2024 568.21 Description: REMOVE FEMUR LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27355 MEDSV DEF RBRVS 09/01/2019 12/31/2023 429.64 Description: REMOVE FEMUR LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27356 MEDSV DEF RBRVS 01/01/2024 689.79 Description: REMOVE FEMUR LESION/GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 276 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27356 MEDSV DEF RBRVS 09/01/2019 12/31/2023 526.33 Description: REMOVE FEMUR LESION/GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27357 MEDSV DEF RBRVS 01/01/2024 762.32 Description: REMOVE FEMUR LESION/GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27357 MEDSV DEF RBRVS 09/01/2019 12/31/2023 580.52 Description: REMOVE FEMUR LESION/GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27358 MEDSV DEF RBRVS 01/01/2024 251.52 Description: REMOVE FEMUR LESION/FIXATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27358 MEDSV DEF RBRVS 09/01/2019 12/31/2023 200.66 Description: REMOVE FEMUR LESION/FIXATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27360 MEDSV DEF RBRVS 01/01/2024 842.12 Description: PARTIAL REMOVAL LEG BONE(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27360 MEDSV DEF RBRVS 09/01/2019 12/31/2023 607.90 Description: PARTIAL REMOVAL LEG BONE(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27364 MEDSV DEF RBRVS 01/01/2024 1438.02 Description: RESECT THIGH/KNEE TUM 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 27364 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1119.43 Description: RESECT THIGH/KNEE TUM 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 27365 MEDSV DEF RBRVS 01/01/2024 1888.88 Description: RESECT FEMUR/KNEE TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27365 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1486.55 Description: RESECT FEMUR/KNEE TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27369 MEDSV DEF RBRVS 01/01/2020 12/31/2023 101.44 Description: NJX CNTRST KNE ARTHG/CT/MRI Category: Medical Services CMS Add: 01/01/2019 CMS Term: 27369 MEDSV DEF RBRVS 01/01/2024 174.03 Description: NJX CNTRST KNE ARTHG/CT/MRI Category: Medical Services CMS Add: 01/01/2019 CMS Term: 27372 MEDSV DEF RBRVS 01/01/2024 549.25 Description: REMOVAL OF FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27372 MEDSV DEF RBRVS 09/01/2019 12/31/2023 428.82 Description: REMOVAL OF FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27380 MEDSV DEF RBRVS 01/01/2024 583.76 Description: REPAIR OF KNEECAP TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 277 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27380 MEDSV DEF RBRVS 09/01/2019 12/31/2023 423.12 Description: REPAIR OF KNEECAP TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27381 MEDSV DEF RBRVS 01/01/2024 765.80 Description: REPAIR/GRAFT KNEECAP TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27381 MEDSV DEF RBRVS 09/01/2019 12/31/2023 570.35 Description: REPAIR/GRAFT KNEECAP TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27385 MEDSV DEF RBRVS 01/01/2024 568.82 Description: REPAIR OF THIGH MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27385 MEDSV DEF RBRVS 09/01/2019 12/31/2023 409.06 Description: REPAIR OF THIGH MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27386 MEDSV DEF RBRVS 01/01/2024 798.44 Description: REPAIR/GRAFT OF THIGH MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27386 MEDSV DEF RBRVS 09/01/2019 12/31/2023 592.43 Description: REPAIR/GRAFT OF THIGH MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27390 MEDSV DEF RBRVS 01/01/2024 421.83 Description: INCISION OF THIGH TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27390 MEDSV DEF RBRVS 09/01/2019 12/31/2023 318.10 Description: INCISION OF THIGH TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27391 MEDSV DEF RBRVS 01/01/2024 542.38 Description: INCISION OF THIGH TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27391 MEDSV DEF RBRVS 09/01/2019 12/31/2023 409.99 Description: INCISION OF THIGH TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27392 MEDSV DEF RBRVS 01/01/2024 665.04 Description: INCISION OF THIGH TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27392 MEDSV DEF RBRVS 09/01/2019 12/31/2023 506.87 Description: INCISION OF THIGH TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27393 MEDSV DEF RBRVS 01/01/2024 470.50 Description: LENGTHENING OF THIGH TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27393 MEDSV DEF RBRVS 09/01/2019 12/31/2023 362.36 Description: LENGTHENING OF THIGH TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27394 MEDSV DEF RBRVS 01/01/2024 610.52 Description: LENGTHENING OF THIGH TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 278 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27394 MEDSV DEF RBRVS 09/01/2019 12/31/2023 464.73 Description: LENGTHENING OF THIGH TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27395 MEDSV DEF RBRVS 01/01/2024 820.20 Description: LENGTHENING OF THIGH TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27395 MEDSV DEF RBRVS 09/01/2019 12/31/2023 626.21 Description: LENGTHENING OF THIGH TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27396 MEDSV DEF RBRVS 01/01/2024 577.49 Y Description: TRANSPLANT OF THIGH TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27396 MEDSV DEF RBRVS 09/01/2019 12/31/2023 438.13 Y Description: TRANSPLANT OF THIGH TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27397 MEDSV DEF RBRVS 01/01/2024 849.77 Y Description: TRANSPLANTS OF THIGH TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27397 MEDSV DEF RBRVS 09/01/2019 12/31/2023 653.27 Y Description: TRANSPLANTS OF THIGH TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27400 MEDSV DEF RBRVS 01/01/2024 648.97 Description: REVISE THIGH MUSCLES/TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27400 MEDSV DEF RBRVS 09/01/2019 12/31/2023 494.27 Description: REVISE THIGH MUSCLES/TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27403 MEDSV DEF RBRVS 01/01/2024 601.80 Description: REPAIR OF KNEE CARTILAGE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 27403 MEDSV DEF RBRVS 09/01/2019 12/31/2023 456.70 Description: REPAIR OF KNEE CARTILAGE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 27405 MEDSV DEF RBRVS 01/01/2024 630.86 Description: REPAIR OF KNEE LIGAMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27405 MEDSV DEF RBRVS 09/01/2019 12/31/2023 482.44 Description: REPAIR OF KNEE LIGAMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27407 MEDSV DEF RBRVS 01/01/2024 742.03 Description: REPAIR OF KNEE LIGAMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27407 MEDSV DEF RBRVS 09/01/2019 12/31/2023 564.43 Description: REPAIR OF KNEE LIGAMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27409 MEDSV DEF RBRVS 01/01/2024 898.00 Description: REPAIR OF KNEE LIGAMENTS Category: Medical Services CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 279 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27409 MEDSV DEF RBRVS 09/01/2019 12/31/2023 688.83 Description: REPAIR OF KNEE LIGAMENTS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 27412 MEDSV DEF RBRVS 01/01/2024 1521.14 Description: AUTOCHONDROCYTE IMPLANT KNEE Category: Medical Services CMS Add: 01/01/2005 CMS Term: 27412 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1185.18 Description: AUTOCHONDROCYTE IMPLANT KNEE Category: Medical Services CMS Add: 01/01/2005 CMS Term: 27415 MEDSV DEF RBRVS 01/01/2024 1269.28 Description: OSTEOCHONDRAL KNEE ALLOGRAFT Category: Medical Services CMS Add: 01/01/2005 CMS Term: 27415 MEDSV DEF RBRVS 02/01/2015 12/31/2023 983.43 Description: OSTEOCHONDRAL KNEE ALLOGRAFT Category: Medical Services CMS Add: 01/01/2005 CMS Term: 27416 MEDSV DEF RBRVS 01/01/2024 909.30 Description: OSTEOCHONDRAL KNEE AUTOGRAFT Category: Medical Services CMS Add: 01/01/2008 CMS Term: 27416 MEDSV DEF RBRVS 02/01/2015 12/31/2023 700.51 Description: OSTEOCHONDRAL KNEE AUTOGRAFT Category: Medical Services CMS Add: 01/01/2008 CMS Term: 27418 MEDSV DEF RBRVS 01/01/2024 772.60 Description: REPAIR DEGENERATED KNEECAP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27418 MEDSV DEF RBRVS 09/01/2019 12/31/2023 593.58 Description: REPAIR DEGENERATED KNEECAP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27420 MEDSV DEF RBRVS 01/01/2024 695.41 Description: REVISION OF UNSTABLE KNEECAP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27420 MEDSV DEF RBRVS 09/01/2019 12/31/2023 524.71 Description: REVISION OF UNSTABLE KNEECAP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27422 MEDSV DEF RBRVS 01/01/2024 691.69 Description: REVISION OF UNSTABLE KNEECAP Category: Medical Services CMS Add: 01/01/1985 CMS Term: 27422 MEDSV DEF RBRVS 09/01/2019 12/31/2023 530.88 Description: REVISION OF UNSTABLE KNEECAP Category: Medical Services CMS Add: 01/01/1985 CMS Term: 27424 MEDSV DEF RBRVS 01/01/2024 697.68 Description: REVISION/REMOVAL OF KNEECAP Category: Medical Services CMS Add: 01/01/1985 CMS Term: 27424 MEDSV DEF RBRVS 09/01/2019 12/31/2023 532.59 Description: REVISION/REMOVAL OF KNEECAP Category: Medical Services CMS Add: 01/01/1985 CMS Term: 27425 MEDSV DEF RBRVS 01/01/2024 426.00 Description: LAT RETINACULAR RELEASE OPEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 280 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27425 MEDSV DEF RBRVS 09/01/2019 12/31/2023 317.56 Description: LAT RETINACULAR RELEASE OPEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27427 MEDSV DEF RBRVS 01/01/2024 662.85 Description: RECONSTRUCTION KNEE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 27427 MEDSV DEF RBRVS 09/01/2019 12/31/2023 510.18 Description: RECONSTRUCTION KNEE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 27428 MEDSV DEF RBRVS 01/01/2024 1036.16 Description: RECONSTRUCTION KNEE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 27428 MEDSV DEF RBRVS 09/01/2019 12/31/2023 795.22 Description: RECONSTRUCTION KNEE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 27429 MEDSV DEF RBRVS 01/01/2024 1167.37 Description: RECONSTRUCTION KNEE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 27429 MEDSV DEF RBRVS 09/01/2019 12/31/2023 894.46 Description: RECONSTRUCTION KNEE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 27430 MEDSV DEF RBRVS 01/01/2024 691.55 Description: REVISION OF THIGH MUSCLES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27430 MEDSV DEF RBRVS 09/01/2019 12/31/2023 528.79 Description: REVISION OF THIGH MUSCLES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27435 MEDSV DEF RBRVS 01/01/2024 754.78 Description: INCISION OF KNEE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27435 MEDSV DEF RBRVS 09/01/2019 12/31/2023 577.78 Description: INCISION OF KNEE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27437 MEDSV DEF RBRVS 01/01/2024 616.97 Description: REVISE KNEECAP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27437 MEDSV DEF RBRVS 09/01/2019 12/31/2023 470.23 Description: REVISE KNEECAP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27438 MEDSV DEF RBRVS 01/01/2024 781.56 Description: REVISE KNEECAP WITH IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27438 MEDSV DEF RBRVS 09/01/2019 12/31/2023 602.28 Description: REVISE KNEECAP WITH IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27440 MEDSV DEF RBRVS 01/01/2024 742.19 Description: REVISION OF KNEE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 281 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27440 MEDSV DEF RBRVS 09/01/2019 12/31/2023 568.64 Description: REVISION OF KNEE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27441 MEDSV DEF RBRVS 01/01/2024 766.29 Description: REVISION OF KNEE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27441 MEDSV DEF RBRVS 09/01/2019 12/31/2023 587.75 Description: REVISION OF KNEE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27442 MEDSV DEF RBRVS 01/01/2024 809.80 Description: REVISION OF KNEE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27442 MEDSV DEF RBRVS 09/01/2019 12/31/2023 622.44 Description: REVISION OF KNEE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27443 MEDSV DEF RBRVS 01/01/2024 759.08 Description: REVISION OF KNEE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27443 MEDSV DEF RBRVS 09/01/2019 12/31/2023 582.36 Description: REVISION OF KNEE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27445 MEDSV DEF RBRVS 01/01/2024 1159.47 Description: REVISION OF KNEE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27445 MEDSV DEF RBRVS 09/01/2019 12/31/2023 898.21 Description: REVISION OF KNEE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27446 MEDSV DEF RBRVS 01/01/2024 1061.09 Description: REVISION OF KNEE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27446 MEDSV DEF RBRVS 09/01/2019 12/31/2023 833.81 Description: REVISION OF KNEE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27447 MEDSV DEF RBRVS 01/01/2024 1184.96 Description: TOTAL KNEE ARTHROPLASTY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27447 MEDSV DEF RBRVS 09/01/2019 12/31/2023 975.44 Description: TOTAL KNEE ARTHROPLASTY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27448 MEDSV DEF RBRVS 01/01/2024 769.72 Description: INCISION OF THIGH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27448 MEDSV DEF RBRVS 09/01/2019 12/31/2023 577.23 Description: INCISION OF THIGH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27450 MEDSV DEF RBRVS 01/01/2024 942.32 Description: INCISION OF THIGH Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 282 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27450 MEDSV DEF RBRVS 09/01/2019 12/31/2023 724.66 Description: INCISION OF THIGH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27454 MEDSV DEF RBRVS 01/01/2024 1196.28 Description: REALIGNMENT OF THIGH BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27454 MEDSV DEF RBRVS 09/01/2019 12/31/2023 929.91 Description: REALIGNMENT OF THIGH BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27455 MEDSV DEF RBRVS 01/01/2024 892.73 Description: REALIGNMENT OF KNEE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27455 MEDSV DEF RBRVS 09/01/2019 12/31/2023 672.57 Description: REALIGNMENT OF KNEE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27457 MEDSV DEF RBRVS 01/01/2024 890.52 Description: REALIGNMENT OF KNEE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27457 MEDSV DEF RBRVS 09/01/2019 12/31/2023 684.63 Description: REALIGNMENT OF KNEE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27465 MEDSV DEF RBRVS 01/01/2024 1153.89 Description: SHORTENING OF THIGH BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27465 MEDSV DEF RBRVS 09/01/2019 12/31/2023 897.18 Description: SHORTENING OF THIGH BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27466 MEDSV DEF RBRVS 01/01/2024 1096.63 Description: LENGTHENING OF THIGH BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27466 MEDSV DEF RBRVS 09/01/2019 12/31/2023 843.54 Description: LENGTHENING OF THIGH BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27468 MEDSV DEF RBRVS 01/01/2024 1239.39 Description: SHORTEN/LENGTHEN THIGHS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27468 MEDSV DEF RBRVS 09/01/2019 12/31/2023 863.72 Description: SHORTEN/LENGTHEN THIGHS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27470 MEDSV DEF RBRVS 01/01/2024 1093.09 Description: REPAIR OF THIGH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27470 MEDSV DEF RBRVS 09/01/2019 12/31/2023 843.00 Description: REPAIR OF THIGH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27472 MEDSV DEF RBRVS 01/01/2024 1170.15 Description: REPAIR/GRAFT OF THIGH Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 283 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27472 MEDSV DEF RBRVS 09/01/2019 12/31/2023 906.26 Description: REPAIR/GRAFT OF THIGH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27475 MEDSV DEF RBRVS 01/01/2024 618.84 Description: SURGERY TO STOP LEG GROWTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27475 MEDSV DEF RBRVS 09/01/2019 12/31/2023 471.22 Description: SURGERY TO STOP LEG GROWTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27477 MEDSV DEF RBRVS 01/01/2024 683.31 Description: SURGERY TO STOP LEG GROWTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27477 MEDSV DEF RBRVS 09/01/2019 12/31/2023 522.06 Description: SURGERY TO STOP LEG GROWTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27479 MEDSV DEF RBRVS 01/01/2024 852.58 Description: SURGERY TO STOP LEG GROWTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27479 MEDSV DEF RBRVS 09/01/2019 12/31/2023 630.85 Description: SURGERY TO STOP LEG GROWTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27485 MEDSV DEF RBRVS 01/01/2024 626.89 Description: SURGERY TO STOP LEG GROWTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27485 MEDSV DEF RBRVS 09/01/2019 12/31/2023 477.75 Description: SURGERY TO STOP LEG GROWTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27486 MEDSV DEF RBRVS 01/01/2024 1296.70 Description: REVISE/REPLACE KNEE JOINT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 27486 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1011.54 Description: REVISE/REPLACE KNEE JOINT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 27487 MEDSV DEF RBRVS 01/01/2024 1615.79 Description: REVISE/REPLACE KNEE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27487 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1266.12 Description: REVISE/REPLACE KNEE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27488 MEDSV DEF RBRVS 01/01/2024 1110.59 Description: REMOVAL OF KNEE PROSTHESIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27488 MEDSV DEF RBRVS 09/01/2019 12/31/2023 861.89 Description: REMOVAL OF KNEE PROSTHESIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27495 MEDSV DEF RBRVS 01/01/2024 1046.59 Description: REINFORCE THIGH Category: Medical Services CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 284 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27495 MEDSV DEF RBRVS 09/01/2019 12/31/2023 808.14 Description: REINFORCE THIGH Category: Medical Services CMS Add: 01/01/1986 CMS Term: 27496 MEDSV DEF RBRVS 01/01/2024 513.11 Description: DECOMPRESSION OF THIGH/KNEE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27496 MEDSV DEF RBRVS 09/01/2019 12/31/2023 385.96 Description: DECOMPRESSION OF THIGH/KNEE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27497 MEDSV DEF RBRVS 01/01/2024 541.93 Description: DECOMPRESSION OF THIGH/KNEE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27497 MEDSV DEF RBRVS 09/01/2019 12/31/2023 414.42 Description: DECOMPRESSION OF THIGH/KNEE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27498 MEDSV DEF RBRVS 01/01/2024 613.20 Description: DECOMPRESSION OF THIGH/KNEE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27498 MEDSV DEF RBRVS 09/01/2019 12/31/2023 465.78 Description: DECOMPRESSION OF THIGH/KNEE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27499 MEDSV DEF RBRVS 01/01/2024 654.69 Y Description: DECOMPRESSION OF THIGH/KNEE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27499 MEDSV DEF RBRVS 09/01/2019 12/31/2023 498.53 Y Description: DECOMPRESSION OF THIGH/KNEE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27500 MEDSV DEF RBRVS 01/01/2024 492.16 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27500 MEDSV DEF RBRVS 09/01/2019 12/31/2023 367.44 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27501 MEDSV DEF RBRVS 01/01/2024 474.72 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27501 MEDSV DEF RBRVS 09/01/2019 12/31/2023 357.52 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27502 MEDSV DEF RBRVS 01/01/2024 702.75 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27502 MEDSV DEF RBRVS 09/01/2019 12/31/2023 551.79 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27503 MEDSV DEF RBRVS 01/01/2024 745.84 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 285 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27503 MEDSV DEF RBRVS 09/01/2019 12/31/2023 573.32 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27506 MEDSV DEF RBRVS 01/01/2024 1237.59 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27506 MEDSV DEF RBRVS 09/01/2019 12/31/2023 959.41 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27507 MEDSV DEF RBRVS 01/01/2024 895.93 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27507 MEDSV DEF RBRVS 09/01/2019 12/31/2023 697.88 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27508 MEDSV DEF RBRVS 01/01/2024 494.45 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27508 MEDSV DEF RBRVS 09/01/2019 12/31/2023 373.59 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27509 MEDSV DEF RBRVS 01/01/2024 632.84 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27509 MEDSV DEF RBRVS 09/01/2019 12/31/2023 458.58 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27510 MEDSV DEF RBRVS 01/01/2024 635.78 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27510 MEDSV DEF RBRVS 09/01/2019 12/31/2023 489.97 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27511 MEDSV DEF RBRVS 01/01/2024 921.53 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27511 MEDSV DEF RBRVS 09/01/2019 12/31/2023 715.88 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27513 MEDSV DEF RBRVS 01/01/2024 1141.26 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27513 MEDSV DEF RBRVS 09/01/2019 12/31/2023 891.52 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27514 MEDSV DEF RBRVS 01/01/2024 893.82 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 286 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27514 MEDSV DEF RBRVS 09/01/2019 12/31/2023 693.67 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27516 MEDSV DEF RBRVS 01/01/2024 488.55 Description: TREAT THIGH FX GROWTH PLATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27516 MEDSV DEF RBRVS 09/01/2019 12/31/2023 359.27 Description: TREAT THIGH FX GROWTH PLATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27517 MEDSV DEF RBRVS 01/01/2024 644.45 Description: TREAT THIGH FX GROWTH PLATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27517 MEDSV DEF RBRVS 09/01/2019 12/31/2023 487.72 Description: TREAT THIGH FX GROWTH PLATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27519 MEDSV DEF RBRVS 01/01/2024 824.77 Description: TREAT THIGH FX GROWTH PLATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27519 MEDSV DEF RBRVS 09/01/2019 12/31/2023 637.58 Description: TREAT THIGH FX GROWTH PLATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27520 MEDSV DEF RBRVS 01/01/2024 310.09 Description: TREAT KNEECAP FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27520 MEDSV DEF RBRVS 09/01/2019 12/31/2023 228.16 Description: TREAT KNEECAP FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27524 MEDSV DEF RBRVS 01/01/2024 701.76 Description: TREAT KNEECAP FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27524 MEDSV DEF RBRVS 09/01/2019 12/31/2023 537.33 Description: TREAT KNEECAP FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27530 MEDSV DEF RBRVS 01/01/2024 293.12 Description: TREAT KNEE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27530 MEDSV DEF RBRVS 09/01/2019 12/31/2023 212.81 Description: TREAT KNEE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27532 MEDSV DEF RBRVS 01/01/2024 582.07 Description: TREAT KNEE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27532 MEDSV DEF RBRVS 09/01/2019 12/31/2023 436.87 Description: TREAT KNEE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27535 MEDSV DEF RBRVS 01/01/2024 830.51 Description: TREAT KNEE FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 287 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27535 MEDSV DEF RBRVS 09/01/2019 12/31/2023 643.45 Description: TREAT KNEE FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27536 MEDSV DEF RBRVS 01/01/2024 1098.50 Description: TREAT KNEE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27536 MEDSV DEF RBRVS 09/01/2019 12/31/2023 853.60 Description: TREAT KNEE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27538 MEDSV DEF RBRVS 01/01/2024 457.47 Description: TREAT KNEE FRACTURE(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27538 MEDSV DEF RBRVS 09/01/2019 12/31/2023 335.26 Description: TREAT KNEE FRACTURE(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27540 MEDSV DEF RBRVS 01/01/2024 758.12 Description: TREAT KNEE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27540 MEDSV DEF RBRVS 09/01/2019 12/31/2023 580.89 Description: TREAT KNEE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27550 MEDSV DEF RBRVS 01/01/2024 485.75 Description: TREAT KNEE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27550 MEDSV DEF RBRVS 09/01/2019 12/31/2023 359.84 Description: TREAT KNEE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27552 MEDSV DEF RBRVS 01/01/2024 592.23 Description: TREAT KNEE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27552 MEDSV DEF RBRVS 09/01/2019 12/31/2023 445.62 Description: TREAT KNEE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27556 MEDSV DEF RBRVS 01/01/2024 811.65 Description: TREAT KNEE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27556 MEDSV DEF RBRVS 09/01/2019 12/31/2023 625.00 Description: TREAT KNEE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27557 MEDSV DEF RBRVS 01/01/2024 965.55 Description: TREAT KNEE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27557 MEDSV DEF RBRVS 09/01/2019 12/31/2023 750.48 Description: TREAT KNEE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27558 MEDSV DEF RBRVS 01/01/2024 1097.96 Description: TREAT KNEE DISLOCATION Category: Medical Services CMS Add: 01/01/1993 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 288 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27558 MEDSV DEF RBRVS 09/01/2019 12/31/2023 855.95 Description: TREAT KNEE DISLOCATION Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27560 MEDSV DEF RBRVS 01/01/2024 355.38 Description: TREAT KNEECAP DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27560 MEDSV DEF RBRVS 09/01/2019 12/31/2023 255.75 Description: TREAT KNEECAP DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27562 MEDSV DEF RBRVS 01/01/2024 460.60 Description: TREAT KNEECAP DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27562 MEDSV DEF RBRVS 09/01/2019 12/31/2023 343.08 Description: TREAT KNEECAP DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27566 MEDSV DEF RBRVS 01/01/2024 828.62 Description: TREAT KNEECAP DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27566 MEDSV DEF RBRVS 09/01/2019 12/31/2023 637.36 Description: TREAT KNEECAP DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27570 MEDSV DEF RBRVS 01/01/2024 143.01 Description: FIXATION OF KNEE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27570 MEDSV DEF RBRVS 09/01/2019 12/31/2023 107.05 Description: FIXATION OF KNEE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27580 MEDSV DEF RBRVS 01/01/2024 1365.33 Description: FUSION OF KNEE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27580 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1029.33 Description: FUSION OF KNEE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27590 MEDSV DEF RBRVS 01/01/2024 713.56 Description: AMPUTATE LEG AT THIGH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27590 MEDSV DEF RBRVS 09/01/2019 12/31/2023 582.64 Description: AMPUTATE LEG AT THIGH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27591 MEDSV DEF RBRVS 01/01/2024 894.25 Description: AMPUTATE LEG AT THIGH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27591 MEDSV DEF RBRVS 09/01/2019 12/31/2023 692.95 Description: AMPUTATE LEG AT THIGH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27592 MEDSV DEF RBRVS 01/01/2024 611.79 Description: AMPUTATE LEG AT THIGH Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 289 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27592 MEDSV DEF RBRVS 09/01/2019 12/31/2023 493.03 Description: AMPUTATE LEG AT THIGH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27594 MEDSV DEF RBRVS 01/01/2024 461.92 Description: AMPUTATION FOLLOW-UP SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27594 MEDSV DEF RBRVS 09/01/2019 12/31/2023 366.47 Description: AMPUTATION FOLLOW-UP SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27596 MEDSV DEF RBRVS 01/01/2024 653.33 Description: AMPUTATION FOLLOW-UP SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27596 MEDSV DEF RBRVS 09/01/2019 12/31/2023 523.65 Description: AMPUTATION FOLLOW-UP SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27598 MEDSV DEF RBRVS 01/01/2024 636.59 Description: AMPUTATE LOWER LEG AT KNEE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27598 MEDSV DEF RBRVS 09/01/2019 12/31/2023 525.32 Description: AMPUTATE LOWER LEG AT KNEE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27599 MEDSV DEF BILL20 Description: UNLISTED PX FEMUR/KNEE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 27600 MEDSV DEF RBRVS 01/01/2024 372.00 Description: DECOMPRESSION OF LOWER LEG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27600 MEDSV DEF RBRVS 09/01/2019 12/31/2023 296.94 Description: DECOMPRESSION OF LOWER LEG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27601 MEDSV DEF RBRVS 01/01/2024 410.62 Description: DECOMPRESSION OF LOWER LEG Category: Medical Services CMS Add: 01/01/1987 CMS Term: 27601 MEDSV DEF RBRVS 09/01/2019 12/31/2023 315.81 Description: DECOMPRESSION OF LOWER LEG Category: Medical Services CMS Add: 01/01/1987 CMS Term: 27602 MEDSV DEF RBRVS 01/01/2024 436.14 Description: DECOMPRESSION OF LOWER LEG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27602 MEDSV DEF RBRVS 09/01/2019 12/31/2023 358.66 Description: DECOMPRESSION OF LOWER LEG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27603 MEDSV DEF RBRVS 01/01/2024 492.91 Description: DRAIN LOWER LEG LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27603 MEDSV DEF RBRVS 09/01/2019 12/31/2023 373.79 Description: DRAIN LOWER LEG LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 290 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27604 MEDSV DEF RBRVS 01/01/2024 421.34 Description: DRAIN LOWER LEG BURSA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27604 MEDSV DEF RBRVS 09/01/2019 12/31/2023 329.43 Description: DRAIN LOWER LEG BURSA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27605 MEDSV DEF RBRVS 01/01/2024 309.21 Description: INCISION OF ACHILLES TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27605 MEDSV DEF RBRVS 09/01/2019 12/31/2023 243.19 Description: INCISION OF ACHILLES TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27606 MEDSV DEF RBRVS 01/01/2024 253.52 Description: INCISION OF ACHILLES TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27606 MEDSV DEF RBRVS 09/01/2019 12/31/2023 205.45 Description: INCISION OF ACHILLES TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27607 MEDSV DEF RBRVS 01/01/2024 559.14 Description: TREAT LOWER LEG BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27607 MEDSV DEF RBRVS 09/01/2019 12/31/2023 437.87 Description: TREAT LOWER LEG BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27610 MEDSV DEF RBRVS 01/01/2024 603.08 Description: EXPLORE/TREAT ANKLE JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 27610 MEDSV DEF RBRVS 09/01/2019 12/31/2023 469.24 Description: EXPLORE/TREAT ANKLE JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 27612 MEDSV DEF RBRVS 01/01/2024 531.97 Description: EXPLORATION OF ANKLE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27612 MEDSV DEF RBRVS 09/01/2019 12/31/2023 407.74 Description: EXPLORATION OF ANKLE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27613 MEDSV DEF RBRVS 01/01/2024 235.65 Description: BIOPSY LOWER LEG SOFT TISSUE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27613 MEDSV DEF RBRVS 09/01/2019 12/31/2023 179.05 Description: BIOPSY LOWER LEG SOFT TISSUE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27614 MEDSV DEF RBRVS 01/01/2024 550.20 Description: BIOPSY LOWER LEG SOFT TISSUE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27614 MEDSV DEF RBRVS 09/01/2019 12/31/2023 411.48 Description: BIOPSY LOWER LEG SOFT TISSUE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 291 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27615 MEDSV DEF RBRVS 01/01/2024 946.52 Description: RESECT LEG/ANKLE TUM < 5 CM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 27615 MEDSV DEF RBRVS 09/01/2019 12/31/2023 733.01 Description: RESECT LEG/ANKLE TUM < 5 CM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 27616 MEDSV DEF RBRVS 01/01/2024 1167.79 Description: RESECT LEG/ANKLE TUM 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 27616 MEDSV DEF RBRVS 02/01/2015 12/31/2023 907.02 Description: RESECT LEG/ANKLE TUM 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 27618 MEDSV DEF RBRVS 01/01/2024 454.82 Description: EXC LEG/ANKLE TUM < 3 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27618 MEDSV DEF RBRVS 09/01/2019 12/31/2023 315.64 Description: EXC LEG/ANKLE TUM < 3 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27619 MEDSV DEF RBRVS 01/01/2024 437.90 Description: EXC LEG/ANKLE TUM DEEP <5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27619 MEDSV DEF RBRVS 09/01/2019 12/31/2023 338.75 Description: EXC LEG/ANKLE TUM DEEP <5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27620 MEDSV DEF RBRVS 01/01/2024 417.54 Description: EXPLORE/TREAT ANKLE JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 27620 MEDSV DEF RBRVS 09/01/2019 12/31/2023 326.42 Description: EXPLORE/TREAT ANKLE JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 27625 MEDSV DEF RBRVS 01/01/2024 537.20 Description: REMOVE ANKLE JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27625 MEDSV DEF RBRVS 09/01/2019 12/31/2023 418.27 Description: REMOVE ANKLE JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27626 MEDSV DEF RBRVS 01/01/2024 572.90 Description: REMOVE ANKLE JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27626 MEDSV DEF RBRVS 09/01/2019 12/31/2023 450.52 Description: REMOVE ANKLE JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27630 MEDSV DEF RBRVS 01/01/2024 501.10 Description: REMOVAL OF TENDON LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27630 MEDSV DEF RBRVS 09/01/2019 12/31/2023 400.26 Description: REMOVAL OF TENDON LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 292 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27632 MEDSV DEF RBRVS 01/01/2024 380.15 Description: EXC LEG/ANKLE LES SC 3 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 27632 MEDSV DEF RBRVS 02/01/2015 12/31/2023 295.04 Description: EXC LEG/ANKLE LES SC 3 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 27634 MEDSV DEF RBRVS 01/01/2024 628.28 Description: EXC LEG/ANKLE TUM DEP 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 27634 MEDSV DEF RBRVS 02/01/2015 12/31/2023 489.34 Description: EXC LEG/ANKLE TUM DEP 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 27635 MEDSV DEF RBRVS 01/01/2024 542.37 Description: REMOVE LOWER LEG BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27635 MEDSV DEF RBRVS 09/01/2019 12/31/2023 422.18 Description: REMOVE LOWER LEG BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27637 MEDSV DEF RBRVS 01/01/2024 690.55 Description: REMOVE/GRAFT LEG BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27637 MEDSV DEF RBRVS 09/01/2019 12/31/2023 537.86 Description: REMOVE/GRAFT LEG BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27638 MEDSV DEF RBRVS 01/01/2024 698.72 Description: REMOVE/GRAFT LEG BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27638 MEDSV DEF RBRVS 09/01/2019 12/31/2023 551.18 Description: REMOVE/GRAFT LEG BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27640 MEDSV DEF RBRVS 01/01/2024 775.24 Description: PARTIAL REMOVAL OF TIBIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27640 MEDSV DEF RBRVS 09/01/2019 12/31/2023 598.63 Description: PARTIAL REMOVAL OF TIBIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27641 MEDSV DEF RBRVS 01/01/2024 610.94 Description: PARTIAL REMOVAL OF FIBULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27641 MEDSV DEF RBRVS 09/01/2019 12/31/2023 481.55 Description: PARTIAL REMOVAL OF FIBULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27645 MEDSV DEF RBRVS 01/01/2024 1628.48 Description: RESECT TIBIA TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27645 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1277.06 Description: RESECT TIBIA TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 293 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27646 MEDSV DEF RBRVS 01/01/2024 1415.83 Description: RESECT FIBULA TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27646 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1106.75 Description: RESECT FIBULA TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27647 MEDSV DEF RBRVS 01/01/2024 947.52 Description: RESECT TALUS/CALCANEUS TUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27647 MEDSV DEF RBRVS 09/01/2019 12/31/2023 768.36 Description: RESECT TALUS/CALCANEUS TUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27648 MEDSV DEF RBRVS 01/01/2024 200.86 Description: INJECTION FOR ANKLE X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27648 MEDSV DEF RBRVS 09/01/2019 12/31/2023 115.05 Description: INJECTION FOR ANKLE X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27650 MEDSV DEF RBRVS 01/01/2024 617.56 Description: REPAIR ACHILLES TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27650 MEDSV DEF RBRVS 09/01/2019 12/31/2023 477.34 Description: REPAIR ACHILLES TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27652 MEDSV DEF RBRVS 01/01/2024 625.64 Description: REPAIR/GRAFT ACHILLES TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27652 MEDSV DEF RBRVS 09/01/2019 12/31/2023 499.45 Description: REPAIR/GRAFT ACHILLES TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27654 MEDSV DEF RBRVS 01/01/2024 670.88 Description: REPAIR OF ACHILLES TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27654 MEDSV DEF RBRVS 09/01/2019 12/31/2023 512.31 Description: REPAIR OF ACHILLES TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27656 MEDSV DEF RBRVS 01/01/2024 503.48 Description: REPAIR LEG FASCIA DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27656 MEDSV DEF RBRVS 09/01/2019 12/31/2023 446.60 Description: REPAIR LEG FASCIA DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27658 MEDSV DEF RBRVS 01/01/2024 347.64 Description: REPAIR OF LEG TENDON EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27658 MEDSV DEF RBRVS 09/01/2019 12/31/2023 269.35 Description: REPAIR OF LEG TENDON EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 294 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27659 MEDSV DEF RBRVS 01/01/2024 443.41 Description: REPAIR OF LEG TENDON EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27659 MEDSV DEF RBRVS 09/01/2019 12/31/2023 352.11 Description: REPAIR OF LEG TENDON EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27664 MEDSV DEF RBRVS 01/01/2024 341.22 Description: REPAIR OF LEG TENDON EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27664 MEDSV DEF RBRVS 09/01/2019 12/31/2023 259.62 Description: REPAIR OF LEG TENDON EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27665 MEDSV DEF RBRVS 01/01/2024 395.23 Description: REPAIR OF LEG TENDON EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27665 MEDSV DEF RBRVS 09/01/2019 12/31/2023 298.04 Description: REPAIR OF LEG TENDON EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27675 MEDSV DEF RBRVS 01/01/2024 468.31 Description: REPAIR LOWER LEG TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27675 MEDSV DEF RBRVS 09/01/2019 12/31/2023 351.64 Description: REPAIR LOWER LEG TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27676 MEDSV DEF RBRVS 01/01/2024 567.96 Description: REPAIR LOWER LEG TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27676 MEDSV DEF RBRVS 09/01/2019 12/31/2023 440.33 Description: REPAIR LOWER LEG TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27680 MEDSV DEF RBRVS 01/01/2024 393.08 Description: RELEASE OF LOWER LEG TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27680 MEDSV DEF RBRVS 09/01/2019 12/31/2023 308.02 Description: RELEASE OF LOWER LEG TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27681 MEDSV DEF RBRVS 01/01/2024 473.80 Description: RELEASE OF LOWER LEG TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27681 MEDSV DEF RBRVS 09/01/2019 12/31/2023 388.50 Description: RELEASE OF LOWER LEG TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27685 MEDSV DEF RBRVS 01/01/2024 615.04 Description: REVISION OF LOWER LEG TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27685 MEDSV DEF RBRVS 09/01/2019 12/31/2023 477.01 Description: REVISION OF LOWER LEG TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 295 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27686 MEDSV DEF RBRVS 01/01/2024 494.91 Description: REVISE LOWER LEG TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27686 MEDSV DEF RBRVS 09/01/2019 12/31/2023 397.24 Description: REVISE LOWER LEG TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27687 MEDSV DEF RBRVS 01/01/2024 426.66 Description: REVISION OF CALF TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27687 MEDSV DEF RBRVS 09/01/2019 12/31/2023 327.87 Description: REVISION OF CALF TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27690 MEDSV DEF RBRVS 01/01/2024 599.34 Description: REVISE LOWER LEG TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27690 MEDSV DEF RBRVS 09/01/2019 12/31/2023 456.69 Description: REVISE LOWER LEG TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27691 MEDSV DEF RBRVS 01/01/2024 695.27 Description: REVISE LOWER LEG TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27691 MEDSV DEF RBRVS 09/01/2019 12/31/2023 541.21 Description: REVISE LOWER LEG TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27692 MEDSV DEF RBRVS 01/01/2016 12/31/2023 76.75 Description: REVISE ADDITIONAL LEG TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27692 MEDSV DEF RBRVS 01/01/2024 92.89 Description: REVISE ADDITIONAL LEG TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27695 MEDSV DEF RBRVS 01/01/2024 454.93 Description: REPAIR OF ANKLE LIGAMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27695 MEDSV DEF RBRVS 09/01/2019 12/31/2023 345.16 Description: REPAIR OF ANKLE LIGAMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27696 MEDSV DEF RBRVS 01/01/2024 517.46 Description: REPAIR OF ANKLE LIGAMENTS Category: Medical Services CMS Add: 01/01/1986 CMS Term: 27696 MEDSV DEF RBRVS 09/01/2019 12/31/2023 406.65 Description: REPAIR OF ANKLE LIGAMENTS Category: Medical Services CMS Add: 01/01/1986 CMS Term: 27698 MEDSV DEF RBRVS 01/01/2024 600.01 Description: REPAIR OF ANKLE LIGAMENT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 27698 MEDSV DEF RBRVS 09/01/2019 12/31/2023 463.31 Description: REPAIR OF ANKLE LIGAMENT Category: Medical Services CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 296 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27700 MEDSV DEF RBRVS 01/01/2024 576.23 Description: REVISION OF ANKLE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27700 MEDSV DEF RBRVS 09/01/2019 12/31/2023 431.38 Description: REVISION OF ANKLE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27702 MEDSV DEF RBRVS 01/01/2024 894.76 Description: RECONSTRUCT ANKLE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27702 MEDSV DEF RBRVS 09/01/2019 12/31/2023 698.49 Description: RECONSTRUCT ANKLE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27703 MEDSV DEF RBRVS 01/01/2024 1032.97 Description: RECONSTRUCTION ANKLE JOINT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 27703 MEDSV DEF RBRVS 09/01/2019 12/31/2023 805.84 Description: RECONSTRUCTION ANKLE JOINT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 27704 MEDSV DEF RBRVS 01/01/2024 531.35 Description: REMOVAL OF ANKLE IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27704 MEDSV DEF RBRVS 09/01/2019 12/31/2023 413.38 Description: REMOVAL OF ANKLE IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27705 MEDSV DEF RBRVS 01/01/2024 703.19 Description: INCISION OF TIBIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27705 MEDSV DEF RBRVS 09/01/2019 12/31/2023 544.22 Description: INCISION OF TIBIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27707 MEDSV DEF RBRVS 01/01/2024 380.03 Description: INCISION OF FIBULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27707 MEDSV DEF RBRVS 09/01/2019 12/31/2023 288.04 Description: INCISION OF FIBULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27709 MEDSV DEF RBRVS 01/01/2024 1053.81 Description: INCISION OF TIBIA & FIBULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27709 MEDSV DEF RBRVS 09/01/2019 12/31/2023 838.60 Description: INCISION OF TIBIA & FIBULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27712 MEDSV DEF RBRVS 01/01/2024 1020.56 Description: REALIGNMENT OF LOWER LEG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27712 MEDSV DEF RBRVS 09/01/2019 12/31/2023 790.05 Description: REALIGNMENT OF LOWER LEG Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 297 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27715 MEDSV DEF RBRVS 01/01/2024 993.47 Description: REVISION OF LOWER LEG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27715 MEDSV DEF RBRVS 09/01/2019 12/31/2023 765.41 Description: REVISION OF LOWER LEG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27720 MEDSV DEF RBRVS 01/01/2024 812.16 Description: REPAIR OF TIBIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27720 MEDSV DEF RBRVS 09/01/2019 12/31/2023 626.96 Description: REPAIR OF TIBIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27722 MEDSV DEF RBRVS 01/01/2024 831.03 Description: REPAIR/GRAFT OF TIBIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27722 MEDSV DEF RBRVS 09/01/2019 12/31/2023 635.08 Description: REPAIR/GRAFT OF TIBIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27724 MEDSV DEF RBRVS 01/01/2024 1159.97 Description: REPAIR/GRAFT OF TIBIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27724 MEDSV DEF RBRVS 09/01/2019 12/31/2023 910.97 Description: REPAIR/GRAFT OF TIBIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27725 MEDSV DEF RBRVS 01/01/2024 1125.27 Description: REPAIR OF LOWER LEG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27725 MEDSV DEF RBRVS 09/01/2019 12/31/2023 872.14 Description: REPAIR OF LOWER LEG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27726 MEDSV DEF RBRVS 01/01/2024 889.83 Description: REPAIR FIBULA NONUNION Category: Medical Services CMS Add: 01/01/2008 CMS Term: 27726 MEDSV DEF RBRVS 02/01/2015 12/31/2023 695.52 Description: REPAIR FIBULA NONUNION Category: Medical Services CMS Add: 01/01/2008 CMS Term: 27727 MEDSV DEF RBRVS 01/01/2024 963.45 Description: REPAIR OF LOWER LEG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27727 MEDSV DEF RBRVS 09/01/2019 12/31/2023 659.66 Description: REPAIR OF LOWER LEG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27730 MEDSV DEF RBRVS 01/01/2024 549.52 Description: REPAIR OF TIBIA EPIPHYSIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27730 MEDSV DEF RBRVS 09/01/2019 12/31/2023 416.87 Description: REPAIR OF TIBIA EPIPHYSIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 298 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27732 MEDSV DEF RBRVS 01/01/2024 425.47 Description: REPAIR OF FIBULA EPIPHYSIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27732 MEDSV DEF RBRVS 09/01/2019 12/31/2023 272.96 Description: REPAIR OF FIBULA EPIPHYSIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27734 MEDSV DEF RBRVS 01/01/2024 613.89 Description: REPAIR LOWER LEG EPIPHYSES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27734 MEDSV DEF RBRVS 09/01/2019 12/31/2023 449.53 Description: REPAIR LOWER LEG EPIPHYSES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27740 MEDSV DEF RBRVS 01/01/2024 660.04 Description: REPAIR OF LEG EPIPHYSES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27740 MEDSV DEF RBRVS 09/01/2019 12/31/2023 443.66 Description: REPAIR OF LEG EPIPHYSES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27742 MEDSV DEF RBRVS 01/01/2024 723.45 Description: REPAIR OF LEG EPIPHYSES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27742 MEDSV DEF RBRVS 09/01/2019 12/31/2023 488.41 Description: REPAIR OF LEG EPIPHYSES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27745 MEDSV DEF RBRVS 01/01/2024 703.20 Description: REINFORCE TIBIA Category: Medical Services CMS Add: 01/01/1986 CMS Term: 27745 MEDSV DEF RBRVS 09/01/2019 12/31/2023 541.21 Description: REINFORCE TIBIA Category: Medical Services CMS Add: 01/01/1986 CMS Term: 27750 MEDSV DEF RBRVS 01/01/2024 330.57 Description: TREATMENT OF TIBIA FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27750 MEDSV DEF RBRVS 09/01/2019 12/31/2023 244.79 Description: TREATMENT OF TIBIA FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27752 MEDSV DEF RBRVS 01/01/2024 505.35 Description: TREATMENT OF TIBIA FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27752 MEDSV DEF RBRVS 09/01/2019 12/31/2023 381.34 Description: TREATMENT OF TIBIA FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27756 MEDSV DEF RBRVS 01/01/2024 540.06 Description: TREATMENT OF TIBIA FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27756 MEDSV DEF RBRVS 09/01/2019 12/31/2023 409.57 Description: TREATMENT OF TIBIA FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 299 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27758 MEDSV DEF RBRVS 01/01/2024 832.85 Description: TREATMENT OF TIBIA FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27758 MEDSV DEF RBRVS 09/01/2019 12/31/2023 637.41 Description: TREATMENT OF TIBIA FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27759 MEDSV DEF RBRVS 01/01/2024 924.54 Description: TREATMENT OF TIBIA FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27759 MEDSV DEF RBRVS 09/01/2019 12/31/2023 715.32 Description: TREATMENT OF TIBIA FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27760 MEDSV DEF RBRVS 01/01/2024 316.44 Description: CLTX MEDIAL ANKLE FX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27760 MEDSV DEF RBRVS 09/01/2019 12/31/2023 236.69 Description: CLTX MEDIAL ANKLE FX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27762 MEDSV DEF RBRVS 01/01/2024 457.73 Description: CLTX MED ANKLE FX W/MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27762 MEDSV DEF RBRVS 09/01/2019 12/31/2023 339.61 Description: CLTX MED ANKLE FX W/MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27766 MEDSV DEF RBRVS 01/01/2024 567.49 Description: OPTX MEDIAL ANKLE FX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27766 MEDSV DEF RBRVS 09/01/2019 12/31/2023 435.19 Description: OPTX MEDIAL ANKLE FX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27767 MEDSV DEF RBRVS 01/01/2024 277.64 Description: CLTX POST ANKLE FX Category: Medical Services CMS Add: 01/01/2008 CMS Term: 27767 MEDSV DEF RBRVS 02/01/2015 12/31/2023 199.99 Description: CLTX POST ANKLE FX Category: Medical Services CMS Add: 01/01/2008 CMS Term: 27768 MEDSV DEF RBRVS 01/01/2024 421.99 Description: CLTX POST ANKLE FX W/MNPJ Category: Medical Services CMS Add: 01/01/2008 CMS Term: 27768 MEDSV DEF RBRVS 02/01/2015 12/31/2023 312.08 Description: CLTX POST ANKLE FX W/MNPJ Category: Medical Services CMS Add: 01/01/2008 CMS Term: 27769 MEDSV DEF RBRVS 01/01/2024 677.53 Description: OPTX POST ANKLE FX Category: Medical Services CMS Add: 01/01/2008 CMS Term: 27769 MEDSV DEF RBRVS 02/01/2015 12/31/2023 521.57 Description: OPTX POST ANKLE FX Category: Medical Services CMS Add: 01/01/2008 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 300 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27780 MEDSV DEF RBRVS 01/01/2024 294.76 Description: TREATMENT OF FIBULA FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27780 MEDSV DEF RBRVS 09/01/2019 12/31/2023 216.49 Description: TREATMENT OF FIBULA FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27781 MEDSV DEF RBRVS 01/01/2024 415.31 Description: TREATMENT OF FIBULA FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27781 MEDSV DEF RBRVS 09/01/2019 12/31/2023 296.56 Description: TREATMENT OF FIBULA FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27784 MEDSV DEF RBRVS 01/01/2024 662.64 Description: TREATMENT OF FIBULA FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27784 MEDSV DEF RBRVS 09/01/2019 12/31/2023 512.74 Description: TREATMENT OF FIBULA FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27786 MEDSV DEF RBRVS 01/01/2024 298.73 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27786 MEDSV DEF RBRVS 09/01/2019 12/31/2023 224.24 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27788 MEDSV DEF RBRVS 01/01/2024 403.71 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27788 MEDSV DEF RBRVS 09/01/2019 12/31/2023 298.90 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27792 MEDSV DEF RBRVS 01/01/2024 603.20 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27792 MEDSV DEF RBRVS 09/01/2019 12/31/2023 467.46 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27808 MEDSV DEF RBRVS 01/01/2024 319.15 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27808 MEDSV DEF RBRVS 09/01/2019 12/31/2023 236.73 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27810 MEDSV DEF RBRVS 01/01/2024 448.94 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27810 MEDSV DEF RBRVS 09/01/2019 12/31/2023 332.86 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 301 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27814 MEDSV DEF RBRVS 01/01/2024 712.99 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27814 MEDSV DEF RBRVS 09/01/2019 12/31/2023 553.13 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27816 MEDSV DEF RBRVS 01/01/2024 314.34 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27816 MEDSV DEF RBRVS 09/01/2019 12/31/2023 225.83 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27818 MEDSV DEF RBRVS 01/01/2024 465.69 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27818 MEDSV DEF RBRVS 09/01/2019 12/31/2023 345.03 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27822 MEDSV DEF RBRVS 01/01/2024 816.23 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27822 MEDSV DEF RBRVS 09/01/2019 12/31/2023 602.42 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27823 MEDSV DEF RBRVS 01/01/2024 917.76 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27823 MEDSV DEF RBRVS 09/01/2019 12/31/2023 684.21 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27824 MEDSV DEF RBRVS 01/01/2024 302.42 Description: TREAT LOWER LEG FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27824 MEDSV DEF RBRVS 09/01/2019 12/31/2023 222.62 Description: TREAT LOWER LEG FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27825 MEDSV DEF RBRVS 01/01/2024 514.05 Description: TREAT LOWER LEG FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27825 MEDSV DEF RBRVS 09/01/2019 12/31/2023 387.67 Description: TREAT LOWER LEG FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27826 MEDSV DEF RBRVS 01/01/2024 798.41 Description: TREAT LOWER LEG FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27826 MEDSV DEF RBRVS 09/01/2019 12/31/2023 599.63 Description: TREAT LOWER LEG FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 302 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27827 MEDSV DEF RBRVS 01/01/2024 1043.33 Description: TREAT LOWER LEG FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27827 MEDSV DEF RBRVS 09/01/2019 12/31/2023 775.57 Description: TREAT LOWER LEG FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27828 MEDSV DEF RBRVS 01/01/2024 1233.67 Description: TREAT LOWER LEG FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27828 MEDSV DEF RBRVS 09/01/2019 12/31/2023 929.10 Description: TREAT LOWER LEG FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27829 MEDSV DEF RBRVS 01/01/2024 661.69 Description: TREAT LOWER LEG JOINT Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27829 MEDSV DEF RBRVS 09/01/2019 12/31/2023 489.86 Description: TREAT LOWER LEG JOINT Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27830 MEDSV DEF RBRVS 01/01/2024 369.80 Description: TREAT LOWER LEG DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27830 MEDSV DEF RBRVS 09/01/2019 12/31/2023 268.57 Description: TREAT LOWER LEG DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27831 MEDSV DEF RBRVS 01/01/2024 385.19 Description: TREAT LOWER LEG DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27831 MEDSV DEF RBRVS 09/01/2019 12/31/2023 283.15 Description: TREAT LOWER LEG DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27832 MEDSV DEF RBRVS 01/01/2024 705.63 Description: TREAT LOWER LEG DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27832 MEDSV DEF RBRVS 09/01/2019 12/31/2023 538.72 Description: TREAT LOWER LEG DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27840 MEDSV DEF RBRVS 01/01/2024 365.25 Description: TREAT ANKLE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27840 MEDSV DEF RBRVS 09/01/2019 12/31/2023 264.82 Description: TREAT ANKLE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27842 MEDSV DEF RBRVS 01/01/2024 461.43 Description: TREAT ANKLE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27842 MEDSV DEF RBRVS 09/01/2019 12/31/2023 352.75 Description: TREAT ANKLE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 303 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27846 MEDSV DEF RBRVS 01/01/2024 671.70 Description: TREAT ANKLE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27846 MEDSV DEF RBRVS 09/01/2019 12/31/2023 524.42 Description: TREAT ANKLE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27848 MEDSV DEF RBRVS 01/01/2024 733.18 Description: TREAT ANKLE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27848 MEDSV DEF RBRVS 09/01/2019 12/31/2023 584.91 Description: TREAT ANKLE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27860 MEDSV DEF RBRVS 01/01/2024 154.38 Description: FIXATION OF ANKLE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27860 MEDSV DEF RBRVS 09/01/2019 12/31/2023 127.55 Description: FIXATION OF ANKLE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27870 MEDSV DEF RBRVS 01/01/2024 941.02 Description: FUSION OF ANKLE JOINT OPEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27870 MEDSV DEF RBRVS 09/01/2019 12/31/2023 744.91 Description: FUSION OF ANKLE JOINT OPEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27871 MEDSV DEF RBRVS 01/01/2024 644.90 Description: FUSION OF TIBIOFIBULAR JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27871 MEDSV DEF RBRVS 09/01/2019 12/31/2023 492.65 Description: FUSION OF TIBIOFIBULAR JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27880 MEDSV DEF RBRVS 01/01/2024 819.41 Description: AMPUTATION OF LOWER LEG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27880 MEDSV DEF RBRVS 09/01/2019 12/31/2023 664.98 Description: AMPUTATION OF LOWER LEG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27881 MEDSV DEF RBRVS 01/01/2024 780.60 Description: AMPUTATION OF LOWER LEG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27881 MEDSV DEF RBRVS 09/01/2019 12/31/2023 634.08 Description: AMPUTATION OF LOWER LEG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27882 MEDSV DEF RBRVS 01/01/2024 538.27 Description: AMPUTATION OF LOWER LEG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27882 MEDSV DEF RBRVS 09/01/2019 12/31/2023 436.78 Description: AMPUTATION OF LOWER LEG Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 304 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27884 MEDSV DEF RBRVS 01/01/2024 529.56 Description: AMPUTATION FOLLOW-UP SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27884 MEDSV DEF RBRVS 09/01/2019 12/31/2023 415.63 Description: AMPUTATION FOLLOW-UP SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27886 MEDSV DEF RBRVS 01/01/2024 593.13 Description: AMPUTATION FOLLOW-UP SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27886 MEDSV DEF RBRVS 09/01/2019 12/31/2023 475.49 Description: AMPUTATION FOLLOW-UP SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27888 MEDSV DEF RBRVS 01/01/2024 594.25 Description: AMPUTATION OF FOOT AT ANKLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27888 MEDSV DEF RBRVS 09/01/2019 12/31/2023 486.54 Description: AMPUTATION OF FOOT AT ANKLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27889 MEDSV DEF RBRVS 01/01/2024 583.15 Description: AMPUTATION OF FOOT AT ANKLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27889 MEDSV DEF RBRVS 09/01/2019 12/31/2023 478.16 Description: AMPUTATION OF FOOT AT ANKLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27892 MEDSV DEF RBRVS 01/01/2024 496.54 Description: DECOMPRESSION OF LEG Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27892 MEDSV DEF RBRVS 09/01/2019 12/31/2023 397.39 Description: DECOMPRESSION OF LEG Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27893 MEDSV DEF RBRVS 01/01/2024 573.00 Description: DECOMPRESSION OF LEG Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27893 MEDSV DEF RBRVS 09/01/2019 12/31/2023 435.62 Description: DECOMPRESSION OF LEG Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27894 MEDSV DEF RBRVS 01/01/2024 751.79 Description: DECOMPRESSION OF LEG Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27894 MEDSV DEF RBRVS 09/01/2019 12/31/2023 614.15 Description: DECOMPRESSION OF LEG Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27899 MEDSV DEF BILL20 Description: UNLISTED PX LEG/ANKLE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 28001 MEDSV DEF RBRVS 01/01/2024 161.12 Description: DRAINAGE OF BURSA OF FOOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 305 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 28001 MEDSV DEF RBRVS 09/01/2019 12/31/2023 199.46 Description: DRAINAGE OF BURSA OF FOOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28002 MEDSV DEF RBRVS 01/01/2024 231.62 Description: TREATMENT OF FOOT INFECTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28002 MEDSV DEF RBRVS 09/01/2019 12/31/2023 322.82 Description: TREATMENT OF FOOT INFECTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28003 MEDSV DEF RBRVS 01/01/2024 357.45 Description: TREATMENT OF FOOT INFECTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28003 MEDSV DEF RBRVS 09/01/2019 12/31/2023 516.49 Description: TREATMENT OF FOOT INFECTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28005 MEDSV DEF RBRVS 01/01/2024 540.59 Description: TREAT FOOT BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28005 MEDSV DEF RBRVS 09/01/2019 12/31/2023 424.89 Description: TREAT FOOT BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28008 MEDSV DEF RBRVS 01/01/2024 401.39 Description: INCISION OF FOOT FASCIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28008 MEDSV DEF RBRVS 09/01/2019 12/31/2023 312.58 Description: INCISION OF FOOT FASCIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28010 MEDSV DEF RBRVS 01/01/2024 220.13 Description: INCISION OF TOE TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28010 MEDSV DEF RBRVS 09/01/2019 12/31/2023 169.06 Description: INCISION OF TOE TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28011 MEDSV DEF RBRVS 01/01/2024 296.71 Description: INCISION OF TOE TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28011 MEDSV DEF RBRVS 09/01/2019 12/31/2023 235.22 Description: INCISION OF TOE TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28020 MEDSV DEF RBRVS 01/01/2024 510.70 Description: EXPLORATION OF FOOT JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 28020 MEDSV DEF RBRVS 09/01/2019 12/31/2023 388.73 Description: EXPLORATION OF FOOT JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 28022 MEDSV DEF RBRVS 01/01/2024 454.00 Description: EXPLORATION OF FOOT JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 306 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 28022 MEDSV DEF RBRVS 09/01/2019 12/31/2023 352.76 Description: EXPLORATION OF FOOT JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 28024 MEDSV DEF RBRVS 01/01/2024 428.83 Description: EXPLORATION OF TOE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28024 MEDSV DEF RBRVS 09/01/2019 12/31/2023 332.17 Description: EXPLORATION OF TOE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28035 MEDSV DEF RBRVS 01/01/2024 493.63 Description: DECOMPRESSION OF TIBIA NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28035 MEDSV DEF RBRVS 09/01/2019 12/31/2023 382.37 Description: DECOMPRESSION OF TIBIA NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28039 MEDSV DEF RBRVS 01/01/2024 450.05 Description: EXC FOOT/TOE TUM SC 1.5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 28039 MEDSV DEF RBRVS 02/01/2015 12/31/2023 370.22 Description: EXC FOOT/TOE TUM SC 1.5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 28041 MEDSV DEF RBRVS 01/01/2024 424.30 Description: EXC FOOT/TOE TUM DEP 1.5CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 28041 MEDSV DEF RBRVS 02/01/2015 12/31/2023 335.90 Description: EXC FOOT/TOE TUM DEP 1.5CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 28043 MEDSV DEF RBRVS 01/01/2024 359.33 Description: EXC FOOT/TOE TUM SC < 1.5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28043 MEDSV DEF RBRVS 09/01/2019 12/31/2023 288.14 Description: EXC FOOT/TOE TUM SC < 1.5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28045 MEDSV DEF RBRVS 01/01/2024 450.99 Description: EXC FOOT/TOE TUM DEEP <1.5CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28045 MEDSV DEF RBRVS 09/01/2019 12/31/2023 359.47 Description: EXC FOOT/TOE TUM DEEP <1.5CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28046 MEDSV DEF RBRVS 01/01/2024 669.73 Description: RESECT FOOT/TOE TUMOR < 3 CM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 28046 MEDSV DEF RBRVS 09/01/2019 12/31/2023 536.25 Description: RESECT FOOT/TOE TUMOR < 3 CM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 28047 MEDSV DEF RBRVS 01/01/2024 961.24 Description: RESECT FOOT/TOE TUMOR 3 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 307 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 28047 MEDSV DEF RBRVS 02/01/2015 12/31/2023 756.36 Description: RESECT FOOT/TOE TUMOR 3 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 28050 MEDSV DEF RBRVS 01/01/2024 389.02 Description: BIOPSY OF FOOT JOINT LINING Category: Medical Services CMS Add: 01/01/1985 CMS Term: 28050 MEDSV DEF RBRVS 09/01/2019 12/31/2023 308.61 Description: BIOPSY OF FOOT JOINT LINING Category: Medical Services CMS Add: 01/01/1985 CMS Term: 28052 MEDSV DEF RBRVS 01/01/2024 364.07 Description: BIOPSY OF FOOT JOINT LINING Category: Medical Services CMS Add: 01/01/1985 CMS Term: 28052 MEDSV DEF RBRVS 09/01/2019 12/31/2023 316.26 Description: BIOPSY OF FOOT JOINT LINING Category: Medical Services CMS Add: 01/01/1985 CMS Term: 28054 MEDSV DEF RBRVS 01/01/2024 342.35 Description: BIOPSY OF TOE JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28054 MEDSV DEF RBRVS 09/01/2019 12/31/2023 271.38 Description: BIOPSY OF TOE JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28055 MEDSV DEF RBRVS 01/01/2016 12/31/2023 277.00 Description: NEURECTOMY FOOT Category: Medical Services CMS Add: 01/01/2007 CMS Term: 28055 MEDSV DEF RBRVS 01/01/2024 363.27 Description: NEURECTOMY FOOT Category: Medical Services CMS Add: 01/01/2007 CMS Term: 28060 MEDSV DEF RBRVS 01/01/2024 483.12 Description: PARTIAL REMOVAL FOOT FASCIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28060 MEDSV DEF RBRVS 09/01/2019 12/31/2023 373.89 Description: PARTIAL REMOVAL FOOT FASCIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28062 MEDSV DEF RBRVS 01/01/2024 540.14 Description: REMOVAL OF FOOT FASCIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28062 MEDSV DEF RBRVS 09/01/2019 12/31/2023 425.23 Description: REMOVAL OF FOOT FASCIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28070 MEDSV DEF RBRVS 01/01/2024 473.52 Description: REMOVAL OF FOOT JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28070 MEDSV DEF RBRVS 09/01/2019 12/31/2023 383.80 Description: REMOVAL OF FOOT JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28072 MEDSV DEF RBRVS 01/01/2024 456.67 Description: REMOVAL OF FOOT JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 308 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 28072 MEDSV DEF RBRVS 09/01/2019 12/31/2023 365.78 Description: REMOVAL OF FOOT JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28080 MEDSV DEF RBRVS 01/01/2024 496.74 Description: REMOVAL OF FOOT LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28080 MEDSV DEF RBRVS 09/01/2019 12/31/2023 376.97 Description: REMOVAL OF FOOT LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28086 MEDSV DEF RBRVS 01/01/2024 494.85 Description: EXCISE FOOT TENDON SHEATH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28086 MEDSV DEF RBRVS 09/01/2019 12/31/2023 391.80 Description: EXCISE FOOT TENDON SHEATH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28088 MEDSV DEF RBRVS 01/01/2024 428.14 Description: EXCISE FOOT TENDON SHEATH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28088 MEDSV DEF RBRVS 09/01/2019 12/31/2023 334.75 Description: EXCISE FOOT TENDON SHEATH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28090 MEDSV DEF RBRVS 01/01/2024 434.49 Description: REMOVAL OF FOOT LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28090 MEDSV DEF RBRVS 09/01/2019 12/31/2023 339.41 Description: REMOVAL OF FOOT LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28092 MEDSV DEF RBRVS 01/01/2024 393.06 Description: REMOVAL OF TOE LESIONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28092 MEDSV DEF RBRVS 09/01/2019 12/31/2023 304.60 Description: REMOVAL OF TOE LESIONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28100 MEDSV DEF RBRVS 01/01/2024 570.89 Description: REMOVAL OF ANKLE/HEEL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28100 MEDSV DEF RBRVS 09/01/2019 12/31/2023 435.49 Description: REMOVAL OF ANKLE/HEEL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28102 MEDSV DEF RBRVS 01/01/2024 570.13 Description: REMOVE/GRAFT FOOT LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28102 MEDSV DEF RBRVS 09/01/2019 12/31/2023 416.58 Description: REMOVE/GRAFT FOOT LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28103 MEDSV DEF RBRVS 01/01/2024 367.91 Description: REMOVE/GRAFT FOOT LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 309 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 28103 MEDSV DEF RBRVS 09/01/2019 12/31/2023 288.45 Description: REMOVE/GRAFT FOOT LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28104 MEDSV DEF RBRVS 01/01/2024 488.43 Description: REMOVAL OF FOOT LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28104 MEDSV DEF RBRVS 09/01/2019 12/31/2023 378.31 Description: REMOVAL OF FOOT LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28106 MEDSV DEF RBRVS 01/01/2024 403.80 Description: REMOVE/GRAFT FOOT LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28106 MEDSV DEF RBRVS 09/01/2019 12/31/2023 327.78 Description: REMOVE/GRAFT FOOT LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28107 MEDSV DEF RBRVS 01/01/2024 473.54 Description: REMOVE/GRAFT FOOT LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28107 MEDSV DEF RBRVS 09/01/2019 12/31/2023 397.87 Description: REMOVE/GRAFT FOOT LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28108 MEDSV DEF RBRVS 01/01/2024 405.59 Description: REMOVAL OF TOE LESIONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28108 MEDSV DEF RBRVS 09/01/2019 12/31/2023 319.15 Description: REMOVAL OF TOE LESIONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28110 MEDSV DEF RBRVS 01/01/2024 428.08 Description: PART REMOVAL OF METATARSAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28110 MEDSV DEF RBRVS 09/01/2019 12/31/2023 333.60 Description: PART REMOVAL OF METATARSAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28111 MEDSV DEF RBRVS 01/01/2024 445.76 Description: PART REMOVAL OF METATARSAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28111 MEDSV DEF RBRVS 09/01/2019 12/31/2023 358.84 Description: PART REMOVAL OF METATARSAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28112 MEDSV DEF RBRVS 01/01/2024 450.05 Description: PART REMOVAL OF METATARSAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28112 MEDSV DEF RBRVS 09/01/2019 12/31/2023 353.12 Description: PART REMOVAL OF METATARSAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28113 MEDSV DEF RBRVS 01/01/2024 546.87 Description: PART REMOVAL OF METATARSAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 310 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 28113 MEDSV DEF RBRVS 09/01/2019 12/31/2023 428.47 Description: PART REMOVAL OF METATARSAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28114 MEDSV DEF RBRVS 01/01/2024 994.27 Description: REMOVAL OF METATARSAL HEADS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28114 MEDSV DEF RBRVS 09/01/2019 12/31/2023 774.09 Description: REMOVAL OF METATARSAL HEADS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28116 MEDSV DEF RBRVS 01/01/2024 730.17 Description: REVISION OF FOOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28116 MEDSV DEF RBRVS 09/01/2019 12/31/2023 540.02 Description: REVISION OF FOOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28118 MEDSV DEF RBRVS 01/01/2024 561.26 Description: REMOVAL OF HEEL BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28118 MEDSV DEF RBRVS 09/01/2019 12/31/2023 424.55 Description: REMOVAL OF HEEL BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28119 MEDSV DEF RBRVS 01/01/2024 489.78 Description: REMOVAL OF HEEL SPUR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28119 MEDSV DEF RBRVS 09/01/2019 12/31/2023 380.50 Description: REMOVAL OF HEEL SPUR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28120 MEDSV DEF RBRVS 01/01/2024 626.36 Description: PART REMOVAL OF ANKLE/HEEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28120 MEDSV DEF RBRVS 09/01/2019 12/31/2023 489.37 Description: PART REMOVAL OF ANKLE/HEEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28122 MEDSV DEF RBRVS 01/01/2024 552.78 Description: PARTIAL REMOVAL OF FOOT BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28122 MEDSV DEF RBRVS 09/01/2019 12/31/2023 433.55 Description: PARTIAL REMOVAL OF FOOT BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28124 MEDSV DEF RBRVS 01/01/2024 444.79 Description: PARTIAL REMOVAL OF TOE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28124 MEDSV DEF RBRVS 09/01/2019 12/31/2023 345.31 Description: PARTIAL REMOVAL OF TOE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28126 MEDSV DEF RBRVS 01/01/2024 363.62 Description: PARTIAL REMOVAL OF TOE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 311 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 28126 MEDSV DEF RBRVS 09/01/2019 12/31/2023 286.56 Description: PARTIAL REMOVAL OF TOE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28130 MEDSV DEF RBRVS 01/01/2024 571.34 Description: REMOVAL OF ANKLE BONE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 28130 MEDSV DEF RBRVS 09/01/2019 12/31/2023 476.63 Description: REMOVAL OF ANKLE BONE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 28140 MEDSV DEF RBRVS 01/01/2024 532.59 Description: REMOVAL OF METATARSAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28140 MEDSV DEF RBRVS 09/01/2019 12/31/2023 434.68 Description: REMOVAL OF METATARSAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28150 MEDSV DEF RBRVS 01/01/2024 390.58 Description: REMOVAL OF TOE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28150 MEDSV DEF RBRVS 09/01/2019 12/31/2023 309.02 Description: REMOVAL OF TOE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28153 MEDSV DEF RBRVS 01/01/2024 378.29 Description: PARTIAL REMOVAL OF TOE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28153 MEDSV DEF RBRVS 09/01/2019 12/31/2023 298.12 Description: PARTIAL REMOVAL OF TOE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28160 MEDSV DEF RBRVS 01/01/2024 380.85 Description: PARTIAL REMOVAL OF TOE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28160 MEDSV DEF RBRVS 09/01/2019 12/31/2023 303.41 Description: PARTIAL REMOVAL OF TOE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28171 MEDSV DEF RBRVS 01/01/2024 1023.50 Description: RESECT TARSAL TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28171 MEDSV DEF RBRVS 09/01/2019 12/31/2023 629.41 Description: RESECT TARSAL TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28173 MEDSV DEF RBRVS 01/01/2024 689.42 Description: RESECT METATARSAL TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28173 MEDSV DEF RBRVS 09/01/2019 12/31/2023 567.23 Description: RESECT METATARSAL TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28175 MEDSV DEF RBRVS 01/01/2024 445.13 Description: RESECT PHALANX OF TOE TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 312 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 28175 MEDSV DEF RBRVS 09/01/2019 12/31/2023 358.32 Description: RESECT PHALANX OF TOE TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28190 MEDSV DEF RBRVS 01/01/2024 225.22 Description: REMOVAL OF FOOT FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28190 MEDSV DEF RBRVS 09/01/2019 12/31/2023 184.22 Description: REMOVAL OF FOOT FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28192 MEDSV DEF RBRVS 01/01/2024 428.69 Description: REMOVAL OF FOOT FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28192 MEDSV DEF RBRVS 09/01/2019 12/31/2023 340.80 Description: REMOVAL OF FOOT FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28193 MEDSV DEF RBRVS 01/01/2024 488.45 Description: REMOVAL OF FOOT FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28193 MEDSV DEF RBRVS 09/01/2019 12/31/2023 386.42 Description: REMOVAL OF FOOT FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28200 MEDSV DEF RBRVS 01/01/2024 461.05 Description: REPAIR OF FOOT TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28200 MEDSV DEF RBRVS 09/01/2019 12/31/2023 351.21 Description: REPAIR OF FOOT TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28202 MEDSV DEF RBRVS 01/01/2024 562.62 Description: REPAIR/GRAFT OF FOOT TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28202 MEDSV DEF RBRVS 09/01/2019 12/31/2023 433.38 Description: REPAIR/GRAFT OF FOOT TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28208 MEDSV DEF RBRVS 01/01/2024 453.73 Description: REPAIR OF FOOT TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28208 MEDSV DEF RBRVS 09/01/2019 12/31/2023 341.48 Description: REPAIR OF FOOT TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28210 MEDSV DEF RBRVS 01/01/2024 556.86 Description: REPAIR/GRAFT OF FOOT TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28210 MEDSV DEF RBRVS 09/01/2019 12/31/2023 409.43 Description: REPAIR/GRAFT OF FOOT TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28220 MEDSV DEF RBRVS 01/01/2024 420.79 Description: RELEASE OF FOOT TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 313 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 28220 MEDSV DEF RBRVS 09/01/2019 12/31/2023 324.14 Description: RELEASE OF FOOT TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28222 MEDSV DEF RBRVS 01/01/2024 493.17 Description: RELEASE OF FOOT TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28222 MEDSV DEF RBRVS 09/01/2019 12/31/2023 369.28 Description: RELEASE OF FOOT TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28225 MEDSV DEF RBRVS 01/01/2024 385.21 Description: RELEASE OF FOOT TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28225 MEDSV DEF RBRVS 09/01/2019 12/31/2023 295.03 Description: RELEASE OF FOOT TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28226 MEDSV DEF RBRVS 01/01/2024 573.17 Description: RELEASE OF FOOT TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28226 MEDSV DEF RBRVS 09/01/2019 12/31/2023 424.22 Description: RELEASE OF FOOT TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28230 MEDSV DEF RBRVS 01/01/2024 405.18 Description: INCISION OF FOOT TENDON(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28230 MEDSV DEF RBRVS 09/01/2019 12/31/2023 315.73 Description: INCISION OF FOOT TENDON(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28232 MEDSV DEF RBRVS 01/01/2024 351.91 Description: INCISION OF TOE TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28232 MEDSV DEF RBRVS 09/01/2019 12/31/2023 280.34 Description: INCISION OF TOE TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28234 MEDSV DEF RBRVS 01/01/2024 381.21 Description: INCISION OF FOOT TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28234 MEDSV DEF RBRVS 09/01/2019 12/31/2023 294.03 Description: INCISION OF FOOT TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28238 MEDSV DEF RBRVS 01/01/2024 631.06 Description: REVISION OF FOOT TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28238 MEDSV DEF RBRVS 09/01/2019 12/31/2023 488.75 Description: REVISION OF FOOT TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28240 MEDSV DEF RBRVS 01/01/2024 414.20 Description: RELEASE OF BIG TOE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 314 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 28240 MEDSV DEF RBRVS 09/01/2019 12/31/2023 318.04 Description: RELEASE OF BIG TOE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28250 MEDSV DEF RBRVS 01/01/2024 547.03 Description: REVISION OF FOOT FASCIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28250 MEDSV DEF RBRVS 09/01/2019 12/31/2023 417.64 Description: REVISION OF FOOT FASCIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28260 MEDSV DEF RBRVS 01/01/2024 670.81 Description: RELEASE OF MIDFOOT JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28260 MEDSV DEF RBRVS 09/01/2019 12/31/2023 495.01 Description: RELEASE OF MIDFOOT JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28261 MEDSV DEF RBRVS 01/01/2024 1113.44 Description: REVISION OF FOOT TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28261 MEDSV DEF RBRVS 09/01/2019 12/31/2023 703.83 Description: REVISION OF FOOT TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28262 MEDSV DEF RBRVS 01/01/2024 1298.02 Description: REVISION OF FOOT AND ANKLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28262 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1045.28 Description: REVISION OF FOOT AND ANKLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28264 MEDSV DEF RBRVS 01/01/2024 818.15 Description: RELEASE OF MIDFOOT JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28264 MEDSV DEF RBRVS 09/01/2019 12/31/2023 697.84 Description: RELEASE OF MIDFOOT JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28270 MEDSV DEF RBRVS 01/01/2024 454.03 Description: RELEASE OF FOOT CONTRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28270 MEDSV DEF RBRVS 09/01/2019 12/31/2023 355.15 Description: RELEASE OF FOOT CONTRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28272 MEDSV DEF RBRVS 01/01/2024 357.78 Description: RELEASE OF TOE JOINT EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28272 MEDSV DEF RBRVS 09/01/2019 12/31/2023 285.16 Description: RELEASE OF TOE JOINT EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28280 MEDSV DEF RBRVS 01/01/2024 476.27 Description: FUSION OF TOES Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 315 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 28280 MEDSV DEF RBRVS 09/01/2019 12/31/2023 376.55 Description: FUSION OF TOES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28285 MEDSV DEF RBRVS 01/01/2024 502.32 Description: REPAIR OF HAMMERTOE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28285 MEDSV DEF RBRVS 09/01/2019 12/31/2023 386.08 Description: REPAIR OF HAMMERTOE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28286 MEDSV DEF RBRVS 01/01/2024 412.36 Description: REPAIR OF HAMMERTOE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28286 MEDSV DEF RBRVS 09/01/2019 12/31/2023 328.83 Description: REPAIR OF HAMMERTOE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28288 MEDSV DEF RBRVS 01/01/2024 563.00 Description: PARTIAL REMOVAL OF FOOT BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28288 MEDSV DEF RBRVS 09/01/2019 12/31/2023 436.63 Description: PARTIAL REMOVAL OF FOOT BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28289 MEDSV DEF RBRVS 01/01/2017 12/31/2023 542.68 Description: CORRJ HALUX RIGDUS W/O IMPLT Category: Medical Services CMS Add: 01/01/1999 CMS Term: 28289 MEDSV DEF RBRVS 01/01/2024 642.31 Description: CORRJ HALUX RIGDUS W/O IMPLT Category: Medical Services CMS Add: 01/01/1999 CMS Term: 28291 MEDSV DEF RBRVS 01/01/2017 12/31/2023 534.10 Description: CORRJ HALUX RIGDUS W/IMPLT Category: Medical Services CMS Add: 01/01/2017 CMS Term: 28291 MEDSV DEF RBRVS 01/01/2024 653.04 Description: CORRJ HALUX RIGDUS W/IMPLT Category: Medical Services CMS Add: 01/01/2017 CMS Term: 28292 MEDSV DEF RBRVS 01/01/2024 650.53 Description: COR HLX VLGS RSC PRX PHLX BS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28292 MEDSV DEF RBRVS 09/01/2019 12/31/2023 544.55 Description: COR HLX VLGS RSC PRX PHLX BS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28295 MEDSV DEF RBRVS 01/01/2017 12/31/2023 683.25 Description: COR HLX VLGS PRX MTAR OSTEOT Category: Medical Services CMS Add: 01/01/2017 CMS Term: 28295 MEDSV DEF RBRVS 01/01/2024 996.47 Description: COR HLX VLGS PRX MTAR OSTEOT Category: Medical Services CMS Add: 01/01/2017 CMS Term: 28296 MEDSV DEF RBRVS 01/01/2024 827.57 Description: COR HLX VLGS DSTL MTAR OSTEO Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 316 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 28296 MEDSV DEF RBRVS 09/01/2019 12/31/2023 517.56 Description: COR HLX VLGS DSTL MTAR OSTEO Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28297 MEDSV DEF RBRVS 01/01/2024 958.75 Description: COR HLX VLGS JT ARTHRD Category: Medical Services CMS Add: 01/01/1987 CMS Term: 28297 MEDSV DEF RBRVS 09/01/2019 12/31/2023 760.14 Description: COR HLX VLGS JT ARTHRD Category: Medical Services CMS Add: 01/01/1987 CMS Term: 28298 MEDSV DEF RBRVS 01/01/2024 776.30 Description: COR HLX VLGS PRX PHLX OSTEOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28298 MEDSV DEF RBRVS 09/01/2019 12/31/2023 522.71 Description: COR HLX VLGS PRX PHLX OSTEOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28299 MEDSV DEF RBRVS 01/01/2024 940.63 Y Description: COR HLX VLGS DOUBLE OSTEOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28299 MEDSV DEF RBRVS 09/01/2019 12/31/2023 649.16 Y Description: COR HLX VLGS DOUBLE OSTEOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28300 MEDSV DEF RBRVS 01/01/2024 608.89 Description: INCISION OF HEEL BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28300 MEDSV DEF RBRVS 09/01/2019 12/31/2023 473.14 Description: INCISION OF HEEL BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28302 MEDSV DEF RBRVS 01/01/2024 666.93 Description: INCISION OF ANKLE BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28302 MEDSV DEF RBRVS 09/01/2019 12/31/2023 509.83 Description: INCISION OF ANKLE BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28304 MEDSV DEF RBRVS 01/01/2024 774.03 Description: INCISION OF MIDFOOT BONES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28304 MEDSV DEF RBRVS 09/01/2019 12/31/2023 586.58 Description: INCISION OF MIDFOOT BONES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28305 MEDSV DEF RBRVS 01/01/2024 630.60 Description: INCISE/GRAFT MIDFOOT BONES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28305 MEDSV DEF RBRVS 09/01/2019 12/31/2023 469.21 Description: INCISE/GRAFT MIDFOOT BONES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28306 MEDSV DEF RBRVS 01/01/2024 566.58 Description: INCISION OF METATARSAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 317 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 28306 MEDSV DEF RBRVS 09/01/2019 12/31/2023 442.78 Description: INCISION OF METATARSAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28307 MEDSV DEF RBRVS 01/01/2024 728.65 Description: INCISION OF METATARSAL Category: Medical Services CMS Add: 01/01/1989 CMS Term: 28307 MEDSV DEF RBRVS 09/01/2019 12/31/2023 499.48 Description: INCISION OF METATARSAL Category: Medical Services CMS Add: 01/01/1989 CMS Term: 28308 MEDSV DEF RBRVS 01/01/2024 531.12 Description: INCISION OF METATARSAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28308 MEDSV DEF RBRVS 09/01/2019 12/31/2023 405.77 Description: INCISION OF METATARSAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28309 MEDSV DEF RBRVS 01/01/2024 841.54 Description: INCISION OF METATARSALS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28309 MEDSV DEF RBRVS 09/01/2019 12/31/2023 649.23 Description: INCISION OF METATARSALS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28310 MEDSV DEF RBRVS 01/01/2024 507.12 Description: REVISION OF BIG TOE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28310 MEDSV DEF RBRVS 09/01/2019 12/31/2023 391.84 Description: REVISION OF BIG TOE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28312 MEDSV DEF RBRVS 01/01/2024 496.74 Description: REVISION OF TOE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28312 MEDSV DEF RBRVS 09/01/2019 12/31/2023 368.77 Description: REVISION OF TOE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28313 MEDSV DEF RBRVS 01/01/2024 492.31 Description: REPAIR DEFORMITY OF TOE Category: Medical Services CMS Add: 01/01/1989 CMS Term: 28313 MEDSV DEF RBRVS 09/01/2019 12/31/2023 383.11 Description: REPAIR DEFORMITY OF TOE Category: Medical Services CMS Add: 01/01/1989 CMS Term: 28315 MEDSV DEF RBRVS 01/01/2024 448.08 Description: REMOVAL OF SESAMOID BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28315 MEDSV DEF RBRVS 09/01/2019 12/31/2023 347.21 Description: REMOVAL OF SESAMOID BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28320 MEDSV DEF RBRVS 01/01/2024 574.02 Description: REPAIR OF FOOT BONES Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 318 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 28320 MEDSV DEF RBRVS 09/01/2019 12/31/2023 448.36 Description: REPAIR OF FOOT BONES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28322 MEDSV DEF RBRVS 01/01/2024 733.83 Description: REPAIR OF METATARSALS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28322 MEDSV DEF RBRVS 09/01/2019 12/31/2023 570.62 Description: REPAIR OF METATARSALS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28340 MEDSV DEF RBRVS 01/01/2024 531.77 Description: RESECT ENLARGED TOE TISSUE Category: Medical Services CMS Add: 01/01/1989 CMS Term: 28340 MEDSV DEF RBRVS 09/01/2019 12/31/2023 422.15 Description: RESECT ENLARGED TOE TISSUE Category: Medical Services CMS Add: 01/01/1989 CMS Term: 28341 MEDSV DEF RBRVS 01/01/2024 618.08 Description: RESECT ENLARGED TOE Category: Medical Services CMS Add: 01/01/1989 CMS Term: 28341 MEDSV DEF RBRVS 09/01/2019 12/31/2023 490.84 Description: RESECT ENLARGED TOE Category: Medical Services CMS Add: 01/01/1989 CMS Term: 28344 MEDSV DEF RBRVS 01/01/2024 391.83 Description: REPAIR EXTRA TOE(S) Category: Medical Services CMS Add: 01/01/1989 CMS Term: 28344 MEDSV DEF RBRVS 09/01/2019 12/31/2023 314.16 Description: REPAIR EXTRA TOE(S) Category: Medical Services CMS Add: 01/01/1989 CMS Term: 28345 MEDSV DEF RBRVS 01/01/2024 480.20 Description: REPAIR WEBBED TOE(S) Category: Medical Services CMS Add: 01/01/1989 CMS Term: 28345 MEDSV DEF RBRVS 09/01/2019 12/31/2023 380.29 Description: REPAIR WEBBED TOE(S) Category: Medical Services CMS Add: 01/01/1989 CMS Term: 28360 MEDSV DEF RBRVS 01/01/2019 12/31/2023 637.37 Description: RECONSTRUCT CLEFT FOOT Category: Medical Services CMS Add: 01/01/1989 CMS Term: 28360 MEDSV DEF RBRVS 01/01/2024 1020.20 Description: RECONSTRUCT CLEFT FOOT Category: Medical Services CMS Add: 01/01/1989 CMS Term: 28400 MEDSV DEF RBRVS 01/01/2024 234.73 Description: TREATMENT OF HEEL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28400 MEDSV DEF RBRVS 09/01/2019 12/31/2023 177.58 Description: TREATMENT OF HEEL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28405 MEDSV DEF RBRVS 01/01/2024 425.67 Description: TREATMENT OF HEEL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 319 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 28405 MEDSV DEF RBRVS 09/01/2019 12/31/2023 279.04 Description: TREATMENT OF HEEL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28406 MEDSV DEF RBRVS 01/01/2024 528.87 Description: TREATMENT OF HEEL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28406 MEDSV DEF RBRVS 09/01/2019 12/31/2023 378.56 Description: TREATMENT OF HEEL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28415 MEDSV DEF RBRVS 01/01/2024 1051.27 Description: TREAT HEEL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28415 MEDSV DEF RBRVS 09/01/2019 12/31/2023 798.81 Description: TREAT HEEL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28420 MEDSV DEF RBRVS 01/01/2024 1204.19 Description: TREAT/GRAFT HEEL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28420 MEDSV DEF RBRVS 09/01/2019 12/31/2023 896.23 Description: TREAT/GRAFT HEEL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28430 MEDSV DEF RBRVS 01/01/2024 227.81 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28430 MEDSV DEF RBRVS 09/01/2019 12/31/2023 167.90 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28435 MEDSV DEF RBRVS 01/01/2024 349.81 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28435 MEDSV DEF RBRVS 09/01/2019 12/31/2023 232.10 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28436 MEDSV DEF RBRVS 01/01/2024 465.84 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1987 CMS Term: 28436 MEDSV DEF RBRVS 09/01/2019 12/31/2023 318.85 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1987 CMS Term: 28445 MEDSV DEF RBRVS 01/01/2024 969.70 Description: TREAT ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28445 MEDSV DEF RBRVS 09/01/2019 12/31/2023 763.89 Description: TREAT ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28446 MEDSV DEF RBRVS 01/01/2024 1133.64 Description: OSTEOCHONDRAL TALUS AUTOGRFT Category: Medical Services CMS Add: 01/01/2008 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 320 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 28446 MEDSV DEF RBRVS 02/01/2015 12/31/2023 875.99 Description: OSTEOCHONDRAL TALUS AUTOGRFT Category: Medical Services CMS Add: 01/01/2008 CMS Term: 28450 MEDSV DEF RBRVS 01/01/2024 200.02 Description: TREAT MIDFOOT FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28450 MEDSV DEF RBRVS 09/01/2019 12/31/2023 154.45 Description: TREAT MIDFOOT FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28455 MEDSV DEF RBRVS 01/01/2024 278.75 Description: TREAT MIDFOOT FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28455 MEDSV DEF RBRVS 09/01/2019 12/31/2023 214.13 Description: TREAT MIDFOOT FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28456 MEDSV DEF RBRVS 01/01/2024 348.90 Description: TREAT MIDFOOT FRACTURE Category: Medical Services CMS Add: 01/01/1987 CMS Term: 28456 MEDSV DEF RBRVS 09/01/2019 12/31/2023 225.47 Description: TREAT MIDFOOT FRACTURE Category: Medical Services CMS Add: 01/01/1987 CMS Term: 28465 MEDSV DEF RBRVS 01/01/2024 597.22 Description: TREAT MIDFOOT FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28465 MEDSV DEF RBRVS 09/01/2019 12/31/2023 452.12 Description: TREAT MIDFOOT FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28470 MEDSV DEF RBRVS 01/01/2024 206.81 Description: TREAT METATARSAL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28470 MEDSV DEF RBRVS 09/01/2019 12/31/2023 157.18 Description: TREAT METATARSAL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28475 MEDSV DEF RBRVS 01/01/2024 245.63 Description: TREAT METATARSAL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28475 MEDSV DEF RBRVS 09/01/2019 12/31/2023 183.92 Description: TREAT METATARSAL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28476 MEDSV DEF RBRVS 01/01/2024 366.39 Description: TREAT METATARSAL FRACTURE Category: Medical Services CMS Add: 01/01/1987 CMS Term: 28476 MEDSV DEF RBRVS 09/01/2019 12/31/2023 250.06 Description: TREAT METATARSAL FRACTURE Category: Medical Services CMS Add: 01/01/1987 CMS Term: 28485 MEDSV DEF RBRVS 01/01/2024 529.51 Description: TREAT METATARSAL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 321 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 28485 MEDSV DEF RBRVS 09/01/2019 12/31/2023 380.15 Description: TREAT METATARSAL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28490 MEDSV DEF RBRVS 01/01/2024 134.07 Description: TREAT BIG TOE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28490 MEDSV DEF RBRVS 09/01/2019 12/31/2023 103.52 Description: TREAT BIG TOE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28495 MEDSV DEF RBRVS 01/01/2024 168.96 Description: TREAT BIG TOE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28495 MEDSV DEF RBRVS 09/01/2019 12/31/2023 126.80 Description: TREAT BIG TOE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28496 MEDSV DEF RBRVS 01/01/2024 422.96 Description: TREAT BIG TOE FRACTURE Category: Medical Services CMS Add: 01/01/1987 CMS Term: 28496 MEDSV DEF RBRVS 09/01/2019 12/31/2023 310.88 Description: TREAT BIG TOE FRACTURE Category: Medical Services CMS Add: 01/01/1987 CMS Term: 28505 MEDSV DEF RBRVS 01/01/2024 610.20 Description: TREAT BIG TOE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28505 MEDSV DEF RBRVS 09/01/2019 12/31/2023 477.92 Description: TREAT BIG TOE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28510 MEDSV DEF RBRVS 01/01/2024 114.76 Description: TREATMENT OF TOE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28510 MEDSV DEF RBRVS 09/01/2019 12/31/2023 88.33 Description: TREATMENT OF TOE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28515 MEDSV DEF RBRVS 01/01/2024 155.48 Description: TREATMENT OF TOE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28515 MEDSV DEF RBRVS 09/01/2019 12/31/2023 115.07 Description: TREATMENT OF TOE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28525 MEDSV DEF RBRVS 01/01/2024 530.32 Description: TREAT TOE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28525 MEDSV DEF RBRVS 09/01/2019 12/31/2023 410.69 Description: TREAT TOE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28530 MEDSV DEF RBRVS 01/01/2024 109.77 Description: TREAT SESAMOID BONE FRACTURE Category: Medical Services CMS Add: 01/01/1989 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 322 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 28530 MEDSV DEF RBRVS 09/01/2019 12/31/2023 82.17 Description: TREAT SESAMOID BONE FRACTURE Category: Medical Services CMS Add: 01/01/1989 CMS Term: 28531 MEDSV DEF RBRVS 01/01/2024 307.17 Description: TREAT SESAMOID BONE FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 28531 MEDSV DEF RBRVS 09/01/2019 12/31/2023 251.12 Description: TREAT SESAMOID BONE FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 28540 MEDSV DEF RBRVS 01/01/2024 185.78 Description: TREAT FOOT DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28540 MEDSV DEF RBRVS 09/01/2019 12/31/2023 147.03 Description: TREAT FOOT DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28545 MEDSV DEF RBRVS 01/01/2024 292.36 Description: TREAT FOOT DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28545 MEDSV DEF RBRVS 09/01/2019 12/31/2023 208.83 Description: TREAT FOOT DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28546 MEDSV DEF RBRVS 01/01/2024 546.78 Description: TREAT FOOT DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28546 MEDSV DEF RBRVS 09/01/2019 12/31/2023 407.85 Description: TREAT FOOT DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28555 MEDSV DEF RBRVS 01/01/2024 808.83 Description: REPAIR FOOT DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28555 MEDSV DEF RBRVS 09/01/2019 12/31/2023 622.35 Description: REPAIR FOOT DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28570 MEDSV DEF RBRVS 01/01/2024 222.41 Description: TREAT FOOT DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28570 MEDSV DEF RBRVS 09/01/2019 12/31/2023 155.13 Description: TREAT FOOT DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28575 MEDSV DEF RBRVS 01/01/2024 357.22 Description: TREAT FOOT DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28575 MEDSV DEF RBRVS 09/01/2019 12/31/2023 257.84 Description: TREAT FOOT DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28576 MEDSV DEF RBRVS 01/01/2024 362.24 Description: TREAT FOOT DISLOCATION Category: Medical Services CMS Add: 01/01/1993 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 323 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 28576 MEDSV DEF RBRVS 09/01/2019 12/31/2023 280.98 Description: TREAT FOOT DISLOCATION Category: Medical Services CMS Add: 01/01/1993 CMS Term: 28585 MEDSV DEF RBRVS 01/01/2024 829.68 Description: REPAIR FOOT DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28585 MEDSV DEF RBRVS 09/01/2019 12/31/2023 624.13 Description: REPAIR FOOT DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28600 MEDSV DEF RBRVS 01/01/2024 207.24 Description: TREAT FOOT DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28600 MEDSV DEF RBRVS 09/01/2019 12/31/2023 156.99 Description: TREAT FOOT DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28605 MEDSV DEF RBRVS 01/01/2024 323.06 Description: TREAT FOOT DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28605 MEDSV DEF RBRVS 09/01/2019 12/31/2023 230.99 Description: TREAT FOOT DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28606 MEDSV DEF RBRVS 01/01/2024 361.81 Description: TREAT FOOT DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28606 MEDSV DEF RBRVS 09/01/2019 12/31/2023 286.46 Description: TREAT FOOT DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28615 MEDSV DEF RBRVS 01/01/2024 773.71 Description: REPAIR FOOT DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28615 MEDSV DEF RBRVS 09/01/2019 12/31/2023 568.32 Description: REPAIR FOOT DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28630 MEDSV DEF RBRVS 01/01/2024 144.99 Description: TREAT TOE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28630 MEDSV DEF RBRVS 09/01/2019 12/31/2023 112.83 Description: TREAT TOE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28635 MEDSV DEF RBRVS 01/01/2024 165.82 Description: TREAT TOE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28635 MEDSV DEF RBRVS 09/01/2019 12/31/2023 126.23 Description: TREAT TOE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28636 MEDSV DEF RBRVS 01/01/2024 290.78 Description: TREAT TOE DISLOCATION Category: Medical Services CMS Add: 01/01/1993 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 324 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 28636 MEDSV DEF RBRVS 09/01/2019 12/31/2023 186.31 Description: TREAT TOE DISLOCATION Category: Medical Services CMS Add: 01/01/1993 CMS Term: 28645 MEDSV DEF RBRVS 01/01/2024 607.53 Description: REPAIR TOE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28645 MEDSV DEF RBRVS 09/01/2019 12/31/2023 474.45 Description: REPAIR TOE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28660 MEDSV DEF RBRVS 01/01/2024 116.69 Description: TREAT TOE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28660 MEDSV DEF RBRVS 09/01/2019 12/31/2023 83.11 Description: TREAT TOE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28665 MEDSV DEF RBRVS 01/01/2024 140.97 Description: TREAT TOE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28665 MEDSV DEF RBRVS 09/01/2019 12/31/2023 110.98 Description: TREAT TOE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28666 MEDSV DEF RBRVS 01/01/2024 167.76 Description: TREAT TOE DISLOCATION Category: Medical Services CMS Add: 01/01/1993 CMS Term: 28666 MEDSV DEF RBRVS 09/01/2019 12/31/2023 135.96 Description: TREAT TOE DISLOCATION Category: Medical Services CMS Add: 01/01/1993 CMS Term: 28675 MEDSV DEF RBRVS 01/01/2024 538.06 Description: REPAIR OF TOE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28675 MEDSV DEF RBRVS 09/01/2019 12/31/2023 407.88 Description: REPAIR OF TOE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28705 MEDSV DEF RBRVS 01/01/2024 1140.73 Description: FUSION OF FOOT BONES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28705 MEDSV DEF RBRVS 09/01/2019 12/31/2023 917.97 Description: FUSION OF FOOT BONES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28715 MEDSV DEF RBRVS 01/01/2024 876.58 Description: FUSION OF FOOT BONES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28715 MEDSV DEF RBRVS 09/01/2019 12/31/2023 674.51 Description: FUSION OF FOOT BONES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28725 MEDSV DEF RBRVS 01/01/2024 726.69 Description: FUSION OF FOOT BONES Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 325 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 28725 MEDSV DEF RBRVS 09/01/2019 12/31/2023 558.59 Description: FUSION OF FOOT BONES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28730 MEDSV DEF RBRVS 01/01/2024 682.08 Description: FUSION OF FOOT BONES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28730 MEDSV DEF RBRVS 09/01/2019 12/31/2023 531.57 Description: FUSION OF FOOT BONES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28735 MEDSV DEF RBRVS 01/01/2024 731.26 Description: FUSION OF FOOT BONES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28735 MEDSV DEF RBRVS 09/01/2019 12/31/2023 567.73 Description: FUSION OF FOOT BONES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28737 MEDSV DEF RBRVS 01/01/2024 645.72 Description: REVISION OF FOOT BONES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28737 MEDSV DEF RBRVS 09/01/2019 12/31/2023 503.53 Description: REVISION OF FOOT BONES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28740 MEDSV DEF RBRVS 01/01/2020 12/31/2023 613.91 Description: FUSION OF FOOT BONES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28740 MEDSV DEF RBRVS 01/01/2024 772.23 Description: FUSION OF FOOT BONES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28750 MEDSV DEF RBRVS 01/01/2024 729.99 Description: FUSION OF BIG TOE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28750 MEDSV DEF RBRVS 09/01/2019 12/31/2023 587.55 Description: FUSION OF BIG TOE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28755 MEDSV DEF RBRVS 01/01/2024 470.59 Description: FUSION OF BIG TOE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28755 MEDSV DEF RBRVS 09/01/2019 12/31/2023 367.52 Description: FUSION OF BIG TOE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28760 MEDSV DEF RBRVS 01/01/2024 712.15 Description: FUSION OF BIG TOE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28760 MEDSV DEF RBRVS 09/01/2019 12/31/2023 566.53 Description: FUSION OF BIG TOE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28800 MEDSV DEF RBRVS 01/01/2024 496.71 Description: AMPUTATION OF MIDFOOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 326 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 28800 MEDSV DEF RBRVS 09/01/2019 12/31/2023 396.77 Description: AMPUTATION OF MIDFOOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28805 MEDSV DEF RBRVS 01/01/2024 663.61 Description: AMPUTATION THRU METATARSAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28805 MEDSV DEF RBRVS 09/01/2019 12/31/2023 541.07 Description: AMPUTATION THRU METATARSAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28810 MEDSV DEF RBRVS 01/01/2024 394.22 Description: AMPUTATION TOE & METATARSAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28810 MEDSV DEF RBRVS 09/01/2019 12/31/2023 315.48 Description: AMPUTATION TOE & METATARSAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28820 MEDSV DEF RBRVS 01/01/2024 278.83 Description: AMPUTATION OF TOE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28820 MEDSV DEF RBRVS 09/01/2019 12/31/2023 410.03 Description: AMPUTATION OF TOE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28825 MEDSV DEF RBRVS 01/01/2024 273.25 Description: PARTIAL AMPUTATION OF TOE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28825 MEDSV DEF RBRVS 09/01/2019 12/31/2023 391.01 Description: PARTIAL AMPUTATION OF TOE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28890 NOCOV DEF SYSMAN Description: HI ENRGY ESWT PLANTAR FASCIA Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 28899 MEDSV DEF BILL20 Description: UNLISTED PX FOOT/TOES Category: Medical Services CMS Add: 01/01/1982 CMS Term: 29000 MEDSV DEF RBRVS 01/01/2024 323.66 Description: APPLICATION OF BODY CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29000 MEDSV DEF RBRVS 09/01/2019 12/31/2023 213.87 Description: APPLICATION OF BODY CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29010 MEDSV DEF RBRVS 01/01/2024 255.00 Description: APPLICATION OF BODY CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29010 MEDSV DEF RBRVS 09/01/2019 12/31/2023 173.18 Description: APPLICATION OF BODY CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29015 MEDSV DEF RBRVS 01/01/2024 273.86 Description: APPLICATION OF BODY CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 327 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 29015 MEDSV DEF RBRVS 09/01/2019 12/31/2023 197.53 Description: APPLICATION OF BODY CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29035 MEDSV DEF RBRVS 01/01/2024 239.58 Description: APPLICATION OF BODY CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29035 MEDSV DEF RBRVS 09/01/2019 12/31/2023 164.23 Description: APPLICATION OF BODY CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29040 MEDSV DEF RBRVS 01/01/2024 273.40 Description: APPLICATION OF BODY CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29040 MEDSV DEF RBRVS 09/01/2019 12/31/2023 246.59 Description: APPLICATION OF BODY CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29044 MEDSV DEF RBRVS 01/01/2024 268.31 Description: APPLICATION OF BODY CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29044 MEDSV DEF RBRVS 09/01/2019 12/31/2023 187.26 Description: APPLICATION OF BODY CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29046 MEDSV DEF RBRVS 01/01/2024 293.61 Description: APPLICATION OF BODY CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29046 MEDSV DEF RBRVS 09/01/2019 12/31/2023 195.46 Description: APPLICATION OF BODY CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29049 MEDSV DEF RBRVS 01/01/2024 92.64 Description: APPLICATION OF FIGURE EIGHT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29049 MEDSV DEF RBRVS 09/01/2019 12/31/2023 69.82 Description: APPLICATION OF FIGURE EIGHT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29055 MEDSV DEF RBRVS 01/01/2024 208.12 Description: APPLICATION OF SHOULDER CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29055 MEDSV DEF RBRVS 09/01/2019 12/31/2023 156.82 Description: APPLICATION OF SHOULDER CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29058 MEDSV DEF RBRVS 01/01/2024 114.95 Description: APPLICATION OF SHOULDER CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29058 MEDSV DEF RBRVS 09/01/2019 12/31/2023 87.14 Description: APPLICATION OF SHOULDER CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29065 MEDSV DEF RBRVS 01/01/2024 90.11 Description: APPLICATION OF LONG ARM CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 328 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 29065 MEDSV DEF RBRVS 09/01/2019 12/31/2023 68.21 Description: APPLICATION OF LONG ARM CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29075 MEDSV DEF RBRVS 01/01/2024 81.62 Description: APPLICATION OF FOREARM CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29075 MEDSV DEF RBRVS 09/01/2019 12/31/2023 61.48 Description: APPLICATION OF FOREARM CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29085 MEDSV DEF RBRVS 01/01/2024 89.64 Description: APPLY HAND/WRIST CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29085 MEDSV DEF RBRVS 09/01/2019 12/31/2023 67.39 Description: APPLY HAND/WRIST CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29086 MEDSV DEF RBRVS 01/01/2024 71.84 Description: APPLY FINGER CAST Category: Medical Services CMS Add: 01/01/2002 CMS Term: 29086 MEDSV DEF RBRVS 02/01/2015 12/31/2023 55.88 Description: APPLY FINGER CAST Category: Medical Services CMS Add: 01/01/2002 CMS Term: 29105 MEDSV DEF RBRVS 01/01/2024 77.08 Description: APPLY LONG ARM SPLINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29105 MEDSV DEF RBRVS 09/01/2019 12/31/2023 62.43 Description: APPLY LONG ARM SPLINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29125 MEDSV DEF RBRVS 01/01/2024 61.77 Description: APPLY FOREARM SPLINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29125 MEDSV DEF RBRVS 09/01/2019 12/31/2023 45.72 Description: APPLY FOREARM SPLINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29126 MEDSV DEF RBRVS 01/01/2024 72.50 Description: APPLY FOREARM SPLINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29126 MEDSV DEF RBRVS 09/01/2019 12/31/2023 54.35 Description: APPLY FOREARM SPLINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29130 MEDSV DEF RBRVS 01/01/2024 38.93 Description: APPLICATION OF FINGER SPLINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29130 MEDSV DEF RBRVS 09/01/2019 12/31/2023 29.45 Description: APPLICATION OF FINGER SPLINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29131 MEDSV DEF RBRVS 01/01/2024 49.88 Description: APPLICATION OF FINGER SPLINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 329 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 29131 MEDSV DEF RBRVS 09/01/2019 12/31/2023 36.66 Description: APPLICATION OF FINGER SPLINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29200 MEDSV DEF RBRVS 01/01/2024 30.83 Description: STRAPPING OF CHEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29200 MEDSV DEF RBRVS 09/01/2019 12/31/2023 37.86 Description: STRAPPING OF CHEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29240 MEDSV DEF RBRVS 01/01/2024 28.66 Description: STRAPPING OF SHOULDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29240 MEDSV DEF RBRVS 09/01/2019 12/31/2023 40.96 Description: STRAPPING OF SHOULDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29260 MEDSV DEF RBRVS 01/01/2024 27.75 Description: STRAPPING OF ELBOW OR WRIST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29260 MEDSV DEF RBRVS 09/01/2019 12/31/2023 36.41 Description: STRAPPING OF ELBOW OR WRIST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29280 MEDSV DEF RBRVS 01/01/2024 28.06 Description: STRAPPING OF HAND OR FINGER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29280 MEDSV DEF RBRVS 09/01/2019 12/31/2023 35.91 Description: STRAPPING OF HAND OR FINGER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29305 MEDSV DEF RBRVS 01/01/2024 230.67 Description: APPLICATION OF HIP CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29305 MEDSV DEF RBRVS 09/01/2019 12/31/2023 174.35 Description: APPLICATION OF HIP CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29325 MEDSV DEF RBRVS 01/01/2024 254.58 Description: APPLICATION OF HIP CASTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29325 MEDSV DEF RBRVS 09/01/2019 12/31/2023 193.05 Description: APPLICATION OF HIP CASTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29345 MEDSV DEF RBRVS 01/01/2024 126.19 Description: APPLICATION OF LONG LEG CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29345 MEDSV DEF RBRVS 09/01/2019 12/31/2023 96.90 Description: APPLICATION OF LONG LEG CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29355 MEDSV DEF RBRVS 01/01/2024 132.46 Description: APPLICATION OF LONG LEG CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 330 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 29355 MEDSV DEF RBRVS 09/01/2019 12/31/2023 100.97 Description: APPLICATION OF LONG LEG CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29358 MEDSV DEF RBRVS 01/01/2024 149.44 Description: APPLY LONG LEG CAST BRACE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29358 MEDSV DEF RBRVS 09/01/2019 12/31/2023 113.65 Description: APPLY LONG LEG CAST BRACE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29365 MEDSV DEF RBRVS 01/01/2024 115.31 Description: APPLICATION OF LONG LEG CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29365 MEDSV DEF RBRVS 09/01/2019 12/31/2023 87.36 Description: APPLICATION OF LONG LEG CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29405 MEDSV DEF RBRVS 01/01/2024 74.73 Description: APPLY SHORT LEG CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29405 MEDSV DEF RBRVS 09/01/2019 12/31/2023 58.24 Description: APPLY SHORT LEG CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29425 MEDSV DEF RBRVS 01/01/2024 70.40 Description: APPLY SHORT LEG CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29425 MEDSV DEF RBRVS 09/01/2019 12/31/2023 56.09 Description: APPLY SHORT LEG CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29435 MEDSV DEF RBRVS 01/01/2024 107.42 Description: APPLY SHORT LEG CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29435 MEDSV DEF RBRVS 09/01/2019 12/31/2023 81.91 Description: APPLY SHORT LEG CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29440 MEDSV DEF RBRVS 01/01/2024 40.33 Description: ADDITION OF WALKER TO CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29440 MEDSV DEF RBRVS 09/01/2019 12/31/2023 32.24 Description: ADDITION OF WALKER TO CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29445 MEDSV DEF RBRVS 01/01/2019 12/31/2023 97.70 Description: APPLY RIGID LEG CAST Category: Medical Services CMS Add: 01/01/1995 CMS Term: 29445 MEDSV DEF RBRVS 01/01/2024 120.49 Description: APPLY RIGID LEG CAST Category: Medical Services CMS Add: 01/01/1995 CMS Term: 29450 MEDSV DEF RBRVS 01/01/2024 136.56 Description: APPLICATION OF LEG CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 331 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 29450 MEDSV DEF RBRVS 09/01/2019 12/31/2023 102.95 Description: APPLICATION OF LEG CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29505 MEDSV DEF RBRVS 01/01/2024 82.43 Description: APPLICATION LONG LEG SPLINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29505 MEDSV DEF RBRVS 09/01/2019 12/31/2023 59.00 Description: APPLICATION LONG LEG SPLINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29515 MEDSV DEF RBRVS 01/01/2024 66.95 Description: APPLICATION LOWER LEG SPLINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29515 MEDSV DEF RBRVS 09/01/2019 12/31/2023 51.24 Description: APPLICATION LOWER LEG SPLINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29520 MEDSV DEF RBRVS 01/01/2024 32.99 Description: STRAPPING OF HIP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29520 MEDSV DEF RBRVS 09/01/2019 12/31/2023 34.24 Description: STRAPPING OF HIP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29530 MEDSV DEF RBRVS 01/01/2024 28.36 Description: STRAPPING OF KNEE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29530 MEDSV DEF RBRVS 09/01/2019 12/31/2023 36.21 Description: STRAPPING OF KNEE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29540 MEDSV DEF RBRVS 01/01/2024 26.52 Description: STRAPPING OF ANKLE AND/OR FT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29540 MEDSV DEF RBRVS 09/01/2019 12/31/2023 26.58 Description: STRAPPING OF ANKLE AND/OR FT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29550 MEDSV DEF RBRVS 01/01/2024 18.06 Description: STRAPPING OF TOES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29550 MEDSV DEF RBRVS 09/01/2019 12/31/2023 22.24 Description: STRAPPING OF TOES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29580 MEDSV DEF RBRVS 01/01/2024 58.97 Description: APPLICATION OF PASTE BOOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29580 MEDSV DEF RBRVS 09/01/2019 12/31/2023 37.48 Description: APPLICATION OF PASTE BOOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29581 MEDSV DEF RBRVS 01/01/2024 84.09 Description: APPLY MULTLAY COMPRS LWR LEG Category: Medical Services CMS Add: 01/01/2010 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 332 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 29581 MEDSV DEF RBRVS 02/01/2015 12/31/2023 43.54 Description: APPLY MULTLAY COMPRS LWR LEG Category: Medical Services CMS Add: 01/01/2010 CMS Term: 29584 MEDSV DEF RBRVS 01/01/2024 76.54 Description: APPL MULTLAY COMPRS ARM/HAND Category: Medical Services CMS Add: 01/01/2012 CMS Term: 29584 MEDSV DEF RBRVS 02/01/2015 12/31/2023 49.70 Description: APPL MULTLAY COMPRS ARM/HAND Category: Medical Services CMS Add: 01/01/2012 CMS Term: 29700 MEDSV DEF RBRVS 01/01/2024 57.97 Description: REMOVAL/REVISION OF CAST Category: Medical Services CMS Add: 01/01/1985 CMS Term: 29700 MEDSV DEF RBRVS 09/01/2019 12/31/2023 43.97 Description: REMOVAL/REVISION OF CAST Category: Medical Services CMS Add: 01/01/1985 CMS Term: 29705 MEDSV DEF RBRVS 01/01/2024 58.56 Description: REMOVAL/REVISION OF CAST Category: Medical Services CMS Add: 01/01/1985 CMS Term: 29705 MEDSV DEF RBRVS 09/01/2019 12/31/2023 47.50 Description: REMOVAL/REVISION OF CAST Category: Medical Services CMS Add: 01/01/1985 CMS Term: 29710 MEDSV DEF RBRVS 01/01/2024 113.35 Description: REMOVAL/REVISION OF CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29710 MEDSV DEF RBRVS 09/01/2019 12/31/2023 82.41 Description: REMOVAL/REVISION OF CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29720 MEDSV DEF RBRVS 01/01/2024 79.63 Description: REPAIR OF BODY CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29720 MEDSV DEF RBRVS 09/01/2019 12/31/2023 59.72 Description: REPAIR OF BODY CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29730 MEDSV DEF RBRVS 01/01/2024 59.45 Description: WINDOWING OF CAST Category: Medical Services CMS Add: 01/01/1989 CMS Term: 29730 MEDSV DEF RBRVS 09/01/2019 12/31/2023 46.24 Description: WINDOWING OF CAST Category: Medical Services CMS Add: 01/01/1989 CMS Term: 29740 MEDSV DEF RBRVS 01/01/2024 91.51 Description: WEDGING OF CAST Category: Medical Services CMS Add: 01/01/1985 CMS Term: 29740 MEDSV DEF RBRVS 09/01/2019 12/31/2023 69.81 Description: WEDGING OF CAST Category: Medical Services CMS Add: 01/01/1985 CMS Term: 29750 MEDSV DEF RBRVS 01/01/2024 99.20 Description: WEDGING OF CLUBFOOT CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 333 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 29750 MEDSV DEF RBRVS 09/01/2019 12/31/2023 61.27 Description: WEDGING OF CLUBFOOT CAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29799 MEDSV DEF BILL20 Y Description: UNLISTED PX CASTING/STRPG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 29800 MEDSV DEF RBRVS 01/01/2024 494.78 Y Description: JAW ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1991 CMS Term: 29800 MEDSV DEF RBRVS 09/01/2019 12/31/2023 371.96 Y Description: JAW ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1991 CMS Term: 29804 MEDSV DEF RBRVS 01/01/2024 563.55 Description: JAW ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1991 CMS Term: 29804 MEDSV DEF RBRVS 09/01/2019 12/31/2023 468.87 Description: JAW ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1991 CMS Term: 29805 MEDSV DEF RBRVS 01/01/2024 438.64 Description: SHO ARTHRS DX +- SYNOVIAL BX Category: Medical Services CMS Add: 01/01/2002 CMS Term: 29805 MEDSV DEF RBRVS 02/01/2015 12/31/2023 336.24 Description: SHO ARTHRS DX +- SYNOVIAL BX Category: Medical Services CMS Add: 01/01/2002 CMS Term: 29806 MEDSV DEF RBRVS 01/01/2024 981.77 Description: SHO ARTHRS SRG CAPSULORRAPHY Category: Medical Services CMS Add: 01/01/2002 CMS Term: 29806 MEDSV DEF RBRVS 09/01/2019 12/31/2023 759.54 Description: SHO ARTHRS SRG CAPSULORRAPHY Category: Medical Services CMS Add: 01/01/2002 CMS Term: 29807 MEDSV DEF RBRVS 01/01/2024 960.54 Description: SHO ARTHRS SRG RPR SLAP LES Category: Medical Services CMS Add: 01/01/2002 CMS Term: 29807 MEDSV DEF RBRVS 09/01/2019 12/31/2023 740.14 Description: SHO ARTHRS SRG RPR SLAP LES Category: Medical Services CMS Add: 01/01/2002 CMS Term: 29819 MEDSV DEF RBRVS 01/01/2019 12/31/2023 418.30 Description: SHO ARTHRS SRG RMVL LOOSE/FB Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29819 MEDSV DEF RBRVS 01/01/2024 547.61 Description: SHO ARTHRS SRG RMVL LOOSE/FB Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29820 MEDSV DEF RBRVS 01/01/2024 498.37 Description: SHO ARTHRS SRG PRTL SYNVCT Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29820 MEDSV DEF RBRVS 02/01/2015 12/31/2023 386.03 Description: SHO ARTHRS SRG PRTL SYNVCT Category: Medical Services CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 334 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 29821 MEDSV DEF RBRVS 01/01/2024 553.95 Description: SHO ARTHRS SRG COMPL SYNVCT Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29821 MEDSV DEF RBRVS 02/01/2015 12/31/2023 421.97 Description: SHO ARTHRS SRG COMPL SYNVCT Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29822 MEDSV DEF RBRVS 01/01/2024 505.24 Description: SHO ARTHRS SRG LMTD DBRDMT Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29822 MEDSV DEF RBRVS 02/01/2015 12/31/2023 410.38 Description: SHO ARTHRS SRG LMTD DBRDMT Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29823 MEDSV DEF RBRVS 01/01/2024 553.29 Description: SHO ARTHRS SRG XTNSV DBRDMT Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29823 MEDSV DEF RBRVS 02/01/2015 12/31/2023 448.06 Description: SHO ARTHRS SRG XTNSV DBRDMT Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29824 MEDSV DEF RBRVS 01/01/2024 631.77 Description: SHO ARTHRS SRG DSTL CLAVICLC Category: Medical Services CMS Add: 01/01/2002 CMS Term: 29824 MEDSV DEF RBRVS 09/01/2019 12/31/2023 483.71 Description: SHO ARTHRS SRG DSTL CLAVICLC Category: Medical Services CMS Add: 01/01/2002 CMS Term: 29825 MEDSV DEF RBRVS 01/01/2024 547.61 Description: SHO ARTHRS SRG LSS&RESCJ ADS Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29825 MEDSV DEF RBRVS 02/01/2015 12/31/2023 418.54 Description: SHO ARTHRS SRG LSS&RESCJ ADS Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29826 MEDSV DEF RBRVS 01/01/2024 158.23 Description: SHO ARTHRS SRG DECOMPRESSION Category: Medical Services CMS Add: 01/01/1990 CMS Term: 29826 MEDSV DEF RBRVS 09/01/2019 12/31/2023 127.26 Description: SHO ARTHRS SRG DECOMPRESSION Category: Medical Services CMS Add: 01/01/1990 CMS Term: 29827 MEDSV DEF RBRVS 01/01/2024 991.97 Description: SHO ARTHRS SRG RT8TR CUF RPR Category: Medical Services CMS Add: 01/01/2003 CMS Term: 29827 MEDSV DEF RBRVS 09/01/2019 12/31/2023 769.81 Description: SHO ARTHRS SRG RT8TR CUF RPR Category: Medical Services CMS Add: 01/01/2003 CMS Term: 29828 MEDSV DEF RBRVS 01/01/2024 851.11 Description: SHO ARTHRS SRG BICP TENODSIS Category: Medical Services CMS Add: 01/01/2008 CMS Term: 29828 MEDSV DEF RBRVS 02/01/2015 12/31/2023 661.83 Description: SHO ARTHRS SRG BICP TENODSIS Category: Medical Services CMS Add: 01/01/2008 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 335 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 29830 MEDSV DEF RBRVS 01/01/2024 426.22 Description: ELBOW ARTHROSCOPY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29830 MEDSV DEF RBRVS 09/01/2019 12/31/2023 324.37 Description: ELBOW ARTHROSCOPY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29834 MEDSV DEF RBRVS 01/01/2024 460.85 Description: ELBOW ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29834 MEDSV DEF RBRVS 02/01/2015 12/31/2023 350.36 Description: ELBOW ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29835 MEDSV DEF RBRVS 01/01/2024 475.57 Description: ELBOW ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29835 MEDSV DEF RBRVS 02/01/2015 12/31/2023 361.43 Description: ELBOW ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29836 MEDSV DEF RBRVS 01/01/2024 546.91 Description: ELBOW ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29836 MEDSV DEF RBRVS 02/01/2015 12/31/2023 412.20 Description: ELBOW ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29837 MEDSV DEF RBRVS 01/01/2024 493.42 Description: ELBOW ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29837 MEDSV DEF RBRVS 02/01/2015 12/31/2023 377.52 Description: ELBOW ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29838 MEDSV DEF RBRVS 01/01/2019 12/31/2023 420.38 Description: ELBOW ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29838 MEDSV DEF RBRVS 01/01/2024 555.14 Description: ELBOW ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29840 MEDSV DEF RBRVS 01/01/2024 424.07 Description: WRIST ARTHROSCOPY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 29840 MEDSV DEF RBRVS 09/01/2019 12/31/2023 321.80 Description: WRIST ARTHROSCOPY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 29843 MEDSV DEF RBRVS 01/01/2024 454.65 Description: WRIST ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 29843 MEDSV DEF RBRVS 02/01/2015 12/31/2023 344.42 Description: WRIST ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 336 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 29844 MEDSV DEF RBRVS 01/01/2024 468.68 Description: WRIST ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 29844 MEDSV DEF RBRVS 02/01/2015 12/31/2023 355.58 Description: WRIST ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 29845 MEDSV DEF RBRVS 01/01/2024 548.36 Description: WRIST ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 29845 MEDSV DEF RBRVS 02/01/2015 12/31/2023 413.30 Description: WRIST ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 29846 MEDSV DEF RBRVS 01/01/2019 12/31/2023 371.90 Description: WRIST ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 29846 MEDSV DEF RBRVS 01/01/2024 489.94 Description: WRIST ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 29847 MEDSV DEF RBRVS 01/01/2024 507.87 Description: WRIST ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 29847 MEDSV DEF RBRVS 02/01/2015 12/31/2023 388.37 Description: WRIST ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 29848 MEDSV DEF RBRVS 01/01/2024 479.58 Description: WRIST ENDOSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 29848 MEDSV DEF RBRVS 09/01/2019 12/31/2023 363.34 Description: WRIST ENDOSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 29850 MEDSV DEF RBRVS 01/01/2024 581.57 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1993 CMS Term: 29850 MEDSV DEF RBRVS 09/01/2019 12/31/2023 444.74 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1993 CMS Term: 29851 MEDSV DEF RBRVS 01/01/2024 862.16 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1993 CMS Term: 29851 MEDSV DEF RBRVS 09/01/2019 12/31/2023 666.34 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1993 CMS Term: 29855 MEDSV DEF RBRVS 01/01/2024 726.74 Description: TIBIAL ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1993 CMS Term: 29855 MEDSV DEF RBRVS 09/01/2019 12/31/2023 562.67 Description: TIBIAL ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1993 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 337 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 29856 MEDSV DEF RBRVS 01/01/2024 920.01 Description: TIBIAL ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1993 CMS Term: 29856 MEDSV DEF RBRVS 09/01/2019 12/31/2023 712.82 Description: TIBIAL ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1993 CMS Term: 29860 MEDSV DEF RBRVS 01/01/2024 601.95 Description: HIP ARTHROSCOPY DX Category: Medical Services CMS Add: 01/01/1998 CMS Term: 29860 MEDSV DEF RBRVS 02/01/2015 12/31/2023 475.99 Description: HIP ARTHROSCOPY DX Category: Medical Services CMS Add: 01/01/1998 CMS Term: 29861 MEDSV DEF RBRVS 01/01/2024 662.43 Description: HIP ARTHRO W/FB REMOVAL Category: Medical Services CMS Add: 01/01/1998 CMS Term: 29861 MEDSV DEF RBRVS 02/01/2015 12/31/2023 519.17 Description: HIP ARTHRO W/FB REMOVAL Category: Medical Services CMS Add: 01/01/1998 CMS Term: 29862 MEDSV DEF RBRVS 01/01/2024 755.95 Description: HIP ARTHR0 W/DEBRIDEMENT Category: Medical Services CMS Add: 01/01/1998 CMS Term: 29862 MEDSV DEF RBRVS 02/01/2015 12/31/2023 584.09 Description: HIP ARTHR0 W/DEBRIDEMENT Category: Medical Services CMS Add: 01/01/1998 CMS Term: 29863 MEDSV DEF RBRVS 01/01/2024 754.56 Description: HIP ARTHR0 W/SYNOVECTOMY Category: Medical Services CMS Add: 01/01/1998 CMS Term: 29863 MEDSV DEF RBRVS 02/01/2015 12/31/2023 585.74 Description: HIP ARTHR0 W/SYNOVECTOMY Category: Medical Services CMS Add: 01/01/1998 CMS Term: 29866 MEDSV DEF RBRVS 01/01/2024 976.03 Description: AUTGRFT IMPLNT KNEE W/SCOPE Category: Medical Services CMS Add: 01/01/2005 CMS Term: 29866 MEDSV DEF RBRVS 09/01/2019 12/31/2023 749.97 Description: AUTGRFT IMPLNT KNEE W/SCOPE Category: Medical Services CMS Add: 01/01/2005 CMS Term: 29867 MEDSV DEF RBRVS 01/01/2024 1183.47 Description: ALLGRFT IMPLNT KNEE W/SCOPE Category: Medical Services CMS Add: 01/01/2005 CMS Term: 29867 MEDSV DEF RBRVS 09/01/2019 12/31/2023 914.90 Description: ALLGRFT IMPLNT KNEE W/SCOPE Category: Medical Services CMS Add: 01/01/2005 CMS Term: 29868 MEDSV DEF RBRVS 01/01/2024 1540.65 Description: MENISCAL TRNSPL KNEE W/SCPE Category: Medical Services CMS Add: 01/01/2005 CMS Term: 29868 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1200.14 Description: MENISCAL TRNSPL KNEE W/SCPE Category: Medical Services CMS Add: 01/01/2005 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 338 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 29870 MEDSV DEF RBRVS 01/01/2024 513.31 Description: KNEE ARTHROSCOPY DX Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29870 MEDSV DEF RBRVS 09/01/2019 12/31/2023 413.01 Description: KNEE ARTHROSCOPY DX Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29871 MEDSV DEF RBRVS 01/01/2024 481.34 Description: KNEE ARTHROSCOPY/DRAINAGE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29871 MEDSV DEF RBRVS 02/01/2015 12/31/2023 366.86 Description: KNEE ARTHROSCOPY/DRAINAGE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29873 MEDSV DEF RBRVS 01/01/2024 501.36 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/2003 CMS Term: 29873 MEDSV DEF RBRVS 09/01/2019 12/31/2023 373.51 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/2003 CMS Term: 29874 MEDSV DEF RBRVS 01/01/2019 12/31/2023 384.26 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29874 MEDSV DEF RBRVS 01/01/2024 500.32 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29875 MEDSV DEF RBRVS 01/01/2019 12/31/2023 353.56 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29875 MEDSV DEF RBRVS 01/01/2024 463.60 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29876 MEDSV DEF RBRVS 01/01/2019 12/31/2023 469.36 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29876 MEDSV DEF RBRVS 01/01/2024 607.81 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29877 MEDSV DEF RBRVS 01/01/2019 12/31/2023 445.29 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29877 MEDSV DEF RBRVS 01/01/2024 578.86 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29879 MEDSV DEF RBRVS 01/01/2019 12/31/2023 474.32 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29879 MEDSV DEF RBRVS 01/01/2024 615.92 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 339 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 29880 MEDSV DEF RBRVS 01/01/2019 12/31/2023 402.59 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 29880 MEDSV DEF RBRVS 01/01/2024 524.44 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 29881 MEDSV DEF RBRVS 01/01/2019 12/31/2023 387.14 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29881 MEDSV DEF RBRVS 01/01/2024 505.24 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29882 MEDSV DEF RBRVS 01/01/2019 12/31/2023 500.62 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29882 MEDSV DEF RBRVS 01/01/2024 642.20 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29883 MEDSV DEF RBRVS 01/01/2019 12/31/2023 603.26 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 29883 MEDSV DEF RBRVS 01/01/2024 783.67 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 29884 MEDSV DEF RBRVS 01/01/2024 577.40 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29884 MEDSV DEF RBRVS 02/01/2015 12/31/2023 443.27 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29885 MEDSV DEF RBRVS 01/01/2024 703.44 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 29885 MEDSV DEF RBRVS 02/01/2015 12/31/2023 537.24 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 29886 MEDSV DEF RBRVS 01/01/2019 12/31/2023 454.03 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29886 MEDSV DEF RBRVS 01/01/2024 593.07 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29887 MEDSV DEF RBRVS 01/01/2024 700.66 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29887 MEDSV DEF RBRVS 02/01/2015 12/31/2023 534.99 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 340 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 29888 MEDSV DEF RBRVS 01/01/2024 905.76 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 29888 MEDSV DEF RBRVS 09/01/2019 12/31/2023 708.65 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 29889 MEDSV DEF RBRVS 01/01/2024 1134.23 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 29889 MEDSV DEF RBRVS 09/01/2019 12/31/2023 874.78 Description: KNEE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 29891 MEDSV DEF RBRVS 01/01/2024 627.53 Description: ANKLE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1998 CMS Term: 29891 MEDSV DEF RBRVS 02/01/2015 12/31/2023 494.24 Description: ANKLE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1998 CMS Term: 29892 MEDSV DEF RBRVS 01/01/2024 605.85 Description: ANKLE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1998 CMS Term: 29892 MEDSV DEF RBRVS 02/01/2015 12/31/2023 446.62 Description: ANKLE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1998 CMS Term: 29893 MEDSV DEF RBRVS 01/01/2019 12/31/2023 441.55 Description: SCOPE PLANTAR FASCIOTOMY Category: Medical Services CMS Add: 01/01/1998 CMS Term: 29893 MEDSV DEF RBRVS 01/01/2024 622.79 Description: SCOPE PLANTAR FASCIOTOMY Category: Medical Services CMS Add: 01/01/1998 CMS Term: 29894 MEDSV DEF RBRVS 01/01/2024 465.45 Description: ANKLE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29894 MEDSV DEF RBRVS 09/01/2019 12/31/2023 366.43 Description: ANKLE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29895 MEDSV DEF RBRVS 01/01/2024 436.44 Description: ANKLE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29895 MEDSV DEF RBRVS 09/01/2019 12/31/2023 342.93 Description: ANKLE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29897 MEDSV DEF RBRVS 01/01/2024 467.22 Description: ANKLE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29897 MEDSV DEF RBRVS 09/01/2019 12/31/2023 368.43 Description: ANKLE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 341 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 29898 MEDSV DEF RBRVS 01/01/2024 526.85 Description: ANKLE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29898 MEDSV DEF RBRVS 09/01/2019 12/31/2023 408.94 Description: ANKLE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 29899 MEDSV DEF RBRVS 01/01/2024 936.72 Description: ANKLE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/2003 CMS Term: 29899 MEDSV DEF RBRVS 02/01/2015 12/31/2023 744.42 Description: ANKLE ARTHROSCOPY/SURGERY Category: Medical Services CMS Add: 01/01/2003 CMS Term: 29900 MEDSV DEF RBRVS 01/01/2024 471.56 Description: MCP JOINT ARTHROSCOPY DX Category: Medical Services CMS Add: 01/01/2002 CMS Term: 29900 MEDSV DEF RBRVS 02/01/2015 12/31/2023 340.30 Description: MCP JOINT ARTHROSCOPY DX Category: Medical Services CMS Add: 01/01/2002 CMS Term: 29901 MEDSV DEF RBRVS 01/01/2024 505.43 Description: MCP JOINT ARTHROSCOPY SURG Category: Medical Services CMS Add: 01/01/2002 CMS Term: 29901 MEDSV DEF RBRVS 02/01/2015 12/31/2023 379.20 Description: MCP JOINT ARTHROSCOPY SURG Category: Medical Services CMS Add: 01/01/2002 CMS Term: 29902 MEDSV DEF RBRVS 01/01/2024 535.48 Description: MCP JOINT ARTHROSCOPY SURG Category: Medical Services CMS Add: 01/01/2002 CMS Term: 29902 MEDSV DEF RBRVS 02/01/2015 12/31/2023 424.25 Description: MCP JOINT ARTHROSCOPY SURG Category: Medical Services CMS Add: 01/01/2002 CMS Term: 29904 MEDSV DEF RBRVS 01/01/2024 595.27 Description: SUBTALAR ARTHRO W/FB RMVL Category: Medical Services CMS Add: 01/01/2008 CMS Term: 29904 MEDSV DEF RBRVS 02/01/2015 12/31/2023 455.11 Description: SUBTALAR ARTHRO W/FB RMVL Category: Medical Services CMS Add: 01/01/2008 CMS Term: 29905 MEDSV DEF RBRVS 01/01/2024 488.45 Description: SUBTALAR ARTHRO W/EXC Category: Medical Services CMS Add: 01/01/2008 CMS Term: 29905 MEDSV DEF RBRVS 02/01/2015 12/31/2023 492.22 Description: SUBTALAR ARTHRO W/EXC Category: Medical Services CMS Add: 01/01/2008 CMS Term: 29906 MEDSV DEF RBRVS 01/01/2024 604.50 Description: SUBTALAR ARTHRO W/DEB Category: Medical Services CMS Add: 01/01/2008 CMS Term: 29906 MEDSV DEF RBRVS 02/01/2015 12/31/2023 518.31 Description: SUBTALAR ARTHRO W/DEB Category: Medical Services CMS Add: 01/01/2008 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 342 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 29907 MEDSV DEF RBRVS 01/01/2024 814.61 Description: SUBTALAR ARTHRO W/FUSION Category: Medical Services CMS Add: 01/01/2008 CMS Term: 29907 MEDSV DEF RBRVS 02/01/2015 12/31/2023 626.09 Description: SUBTALAR ARTHRO W/FUSION Category: Medical Services CMS Add: 01/01/2008 CMS Term: 29914 MEDSV DEF RBRVS 01/01/2024 923.43 Description: HIP ARTHRO W/FEMOROPLASTY Category: Medical Services CMS Add: 01/01/2011 CMS Term: 29914 MEDSV DEF RBRVS 02/01/2015 12/31/2023 723.96 Description: HIP ARTHRO W/FEMOROPLASTY Category: Medical Services CMS Add: 01/01/2011 CMS Term: 29915 MEDSV DEF RBRVS 01/01/2024 944.10 Description: HIP ARTHRO ACETABULOPLASTY Category: Medical Services CMS Add: 01/01/2011 CMS Term: 29915 MEDSV DEF RBRVS 02/01/2015 12/31/2023 738.93 Description: HIP ARTHRO ACETABULOPLASTY Category: Medical Services CMS Add: 01/01/2011 CMS Term: 29916 MEDSV DEF RBRVS 01/01/2024 945.03 Description: HIP ARTHRO W/LABRAL REPAIR Category: Medical Services CMS Add: 01/01/2011 CMS Term: 29916 MEDSV DEF RBRVS 02/01/2015 12/31/2023 739.18 Description: HIP ARTHRO W/LABRAL REPAIR Category: Medical Services CMS Add: 01/01/2011 CMS Term: 29999 MEDSV DEF BILL20 Description: UNLISTED PX ARTHROSCOPY Category: Medical Services CMS Add: 01/01/2002 CMS Term: 30000 MEDSV DEF RBRVS 01/01/2024 251.89 Description: DRAINAGE OF NOSE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30000 MEDSV DEF RBRVS 09/01/2019 12/31/2023 165.60 Description: DRAINAGE OF NOSE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30020 MEDSV DEF RBRVS 01/01/2024 254.67 Description: DRAINAGE OF NOSE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30020 MEDSV DEF RBRVS 09/01/2019 12/31/2023 166.76 Description: DRAINAGE OF NOSE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3006F NOCOV DEF SYSMAN Description: CXR DOC REV Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 3008F NOCOV DEF SYSMAN Description: BODY MASS INDEX DOCD Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 30100 MEDSV DEF RBRVS 01/01/2024 132.88 Description: INTRANASAL BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 343 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 30100 MEDSV DEF RBRVS 09/01/2019 12/31/2023 100.64 Description: INTRANASAL BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30110 MEDSV DEF RBRVS 01/01/2024 234.13 Description: REMOVAL OF NOSE POLYP(S) Category: Medical Services CMS Add: 01/01/1985 CMS Term: 30110 MEDSV DEF RBRVS 09/01/2019 12/31/2023 164.95 Description: REMOVAL OF NOSE POLYP(S) Category: Medical Services CMS Add: 01/01/1985 CMS Term: 30115 MEDSV DEF RBRVS 01/01/2024 442.16 Description: REMOVAL OF NOSE POLYP(S) Category: Medical Services CMS Add: 01/01/1985 CMS Term: 30115 MEDSV DEF RBRVS 09/01/2019 12/31/2023 308.30 Description: REMOVAL OF NOSE POLYP(S) Category: Medical Services CMS Add: 01/01/1985 CMS Term: 30117 MEDSV DEF RBRVS 01/01/2024 910.34 Description: REMOVAL OF INTRANASAL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30117 MEDSV DEF RBRVS 09/01/2019 12/31/2023 620.67 Description: REMOVAL OF INTRANASAL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30118 MEDSV DEF RBRVS 01/01/2024 751.22 Description: REMOVAL OF INTRANASAL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30118 MEDSV DEF RBRVS 09/01/2019 12/31/2023 553.72 Description: REMOVAL OF INTRANASAL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3011F NOCOV DEF SYSMAN Description: LIPID PANEL DOC REV Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 30120 MEDSV DEF RBRVS 01/01/2024 477.37 Y Description: REVISION OF NOSE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30120 MEDSV DEF RBRVS 09/01/2019 12/31/2023 368.84 Y Description: REVISION OF NOSE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30124 MEDSV DEF RBRVS 01/01/2024 287.47 Description: REMOVAL OF NOSE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30124 MEDSV DEF RBRVS 09/01/2019 12/31/2023 205.62 Description: REMOVAL OF NOSE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30125 MEDSV DEF RBRVS 01/01/2024 620.08 Description: REMOVAL OF NOSE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30125 MEDSV DEF RBRVS 09/01/2019 12/31/2023 437.99 Description: REMOVAL OF NOSE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 344 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 30130 MEDSV DEF RBRVS 01/01/2024 394.36 Description: EXCISE INFERIOR TURBINATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30130 MEDSV DEF RBRVS 09/01/2019 12/31/2023 271.34 Description: EXCISE INFERIOR TURBINATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30140 MEDSV DEF RBRVS 01/01/2024 278.99 Description: RESECT INFERIOR TURBINATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30140 MEDSV DEF RBRVS 09/01/2019 12/31/2023 314.57 Description: RESECT INFERIOR TURBINATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3014F NOCOV DEF SYSMAN Description: SCREEN MAMMO DOC REV Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 30150 MEDSV DEF RBRVS 01/01/2024 758.65 Description: PARTIAL REMOVAL OF NOSE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30150 MEDSV DEF RBRVS 09/01/2019 12/31/2023 554.26 Description: PARTIAL REMOVAL OF NOSE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3015F NOCOV DEF SYSMAN Description: CERV CANCER SCREEN DOCD Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 30160 MEDSV DEF RBRVS 01/01/2024 771.35 Description: REMOVAL OF NOSE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30160 MEDSV DEF RBRVS 09/01/2019 12/31/2023 558.07 Description: REMOVAL OF NOSE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3016F NOCOV DEF SYSMAN Description: PT SCRND UNHLTHY OH USE Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 3017F NOCOV DEF SYSMAN Description: COLORECTAL CA SCREEN DOC REV Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 3018F NOCOV DEF SYSMAN Description: PRE-PRXD RSK ET AL DOCD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 3019F NOCOV DEF SYSMAN Description: LVEF ASSESS PLANPOST DSCHRGE Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 30200 MEDSV DEF RBRVS 01/01/2024 104.45 Description: INJECTION TREATMENT OF NOSE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30200 MEDSV DEF RBRVS 09/01/2019 12/31/2023 81.56 Description: INJECTION TREATMENT OF NOSE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 345 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 3020F NOCOV DEF SYSMAN Description: LVF ASSESS Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 30210 MEDSV DEF RBRVS 01/01/2024 141.67 Description: NASAL SINUS THERAPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30210 MEDSV DEF RBRVS 09/01/2019 12/31/2023 107.32 Description: NASAL SINUS THERAPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3021F NOCOV DEF SYSMAN Description: LVEF MOD/SEVER DEPRS SYST Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 30220 MEDSV DEF RBRVS 01/01/2024 287.10 Description: INSERT NASAL SEPTAL BUTTON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30220 MEDSV DEF RBRVS 09/01/2019 12/31/2023 216.62 Description: INSERT NASAL SEPTAL BUTTON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3022F NOCOV DEF SYSMAN Description: LVEF >=40% SYSTOLIC Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 3023F NOCOV DEF SYSMAN Description: SPIROM DOC REV Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 3025F NOCOV DEF SYSMAN Description: SPIROM FEV/FVC <70% W/COPD Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 3027F NOCOV DEF SYSMAN Description: SPIROM FEV/FVC>=70%/W/OCOPD Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 3028F NOCOV DEF SYSMAN Description: O2 SATURATION DOC REV Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 30300 MEDSV DEF RBRVS 01/01/2024 197.43 Description: REMOVE NASAL FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30300 MEDSV DEF RBRVS 09/01/2019 12/31/2023 164.46 Description: REMOVE NASAL FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30310 MEDSV DEF RBRVS 01/01/2024 196.56 Description: REMOVE NASAL FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30310 MEDSV DEF RBRVS 09/01/2019 12/31/2023 148.80 Description: REMOVE NASAL FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30320 MEDSV DEF RBRVS 01/01/2024 462.37 Description: REMOVE NASAL FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 346 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 30320 MEDSV DEF RBRVS 09/01/2019 12/31/2023 323.83 Description: REMOVE NASAL FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3035F NOCOV DEF SYSMAN Description: O2 SATURATION<=88%/PAO<=55 Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 3037F NOCOV DEF SYSMAN Description: O2 SATURATION >88%/PAO>55 HG Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 3038F NOCOV DEF SYSMAN Description: PULM FX W/IN 12 MON B/4 SURG Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 30400 MEDSV DEF RBRVS 01/01/2024 1154.67 Y Description: RECONSTRUCTION OF NOSE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 30400 MEDSV DEF RBRVS 02/01/2015 12/31/2023 723.97 Y Description: RECONSTRUCTION OF NOSE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 3040F NOCOV DEF SYSMAN Description: FEV <40% PREDICTED VALUE Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 30410 MEDSV DEF RBRVS 01/01/2019 12/31/2023 851.19 Y Description: RECONSTRUCTION OF NOSE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 30410 MEDSV DEF RBRVS 01/01/2024 1327.35 Y Description: RECONSTRUCTION OF NOSE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 30420 MEDSV DEF RBRVS 01/01/2024 1372.81 Y Description: RECONSTRUCTION OF NOSE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 30420 MEDSV DEF RBRVS 02/01/2015 12/31/2023 986.74 Y Description: RECONSTRUCTION OF NOSE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 3042F NOCOV DEF SYSMAN Description: FEV >=40% PREDICTED VALUE Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 30430 MEDSV DEF RBRVS 01/01/2019 12/31/2023 688.67 Y Description: REVISION OF NOSE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 30430 MEDSV DEF RBRVS 01/01/2024 1010.64 Y Description: REVISION OF NOSE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 30435 MEDSV DEF RBRVS 01/01/2019 12/31/2023 799.81 Y Description: REVISION OF NOSE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 30435 MEDSV DEF RBRVS 01/01/2024 1257.31 Y Description: REVISION OF NOSE Category: Medical Services CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 347 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 3044F NOCOV DEF SYSMAN Description: HG A1C LEVEL LT 7.0% Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 30450 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1079.81 Y Description: REVISION OF NOSE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 30450 MEDSV DEF RBRVS 01/01/2024 1639.31 Y Description: REVISION OF NOSE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 30460 MEDSV DEF RBRVS 01/01/2024 775.89 Description: REVISION OF NOSE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 30460 MEDSV DEF RBRVS 09/01/2019 12/31/2023 537.88 Description: REVISION OF NOSE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 30462 MEDSV DEF RBRVS 01/01/2024 1491.22 Description: REVISION OF NOSE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 30462 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1121.66 Description: REVISION OF NOSE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 30465 MEDSV DEF RBRVS 01/01/2024 971.07 Description: REPAIR NASAL STENOSIS Category: Medical Services CMS Add: 01/01/2001 CMS Term: 30465 MEDSV DEF RBRVS 02/01/2015 12/31/2023 708.04 Description: REPAIR NASAL STENOSIS Category: Medical Services CMS Add: 01/01/2001 CMS Term: 30468 MEDSV DEF MAXFEE 01/01/2024 2395.98 0.0 Description: RPR NSL VLV COLLAPSE W/IMPLT Category: Medical Services CMS Add: 01/01/2021 CMS Term: 30469 MEDSV DEF RBRVS 01/01/2023 2334.20 Description: RPR NSL VLV COLLAPSE W/RMDLG Category: Medical Services CMS Add: 01/01/2023 CMS Term: 3046F NOCOV DEF SYSMAN Description: HEMOGLOBIN A1C LEVEL >9.0% Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 3048F NOCOV DEF SYSMAN Description: LDL-C <100 MG/DL Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 3049F NOCOV DEF SYSMAN Description: LDL-C 100-129 MG/DL Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 3050F NOCOV DEF SYSMAN Description: LDL-C >= 130 MG/DL Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 3051F NOCOV DEF SYSMAN Description: HG A1C>EQUAL 7.0%<8.0% Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 348 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 30520 MEDSV DEF RBRVS 01/01/2024 637.99 Description: REPAIR OF NASAL SEPTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30520 MEDSV DEF RBRVS 09/01/2019 12/31/2023 449.02 Description: REPAIR OF NASAL SEPTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3052F NOCOV DEF SYSMAN Description: HG A1C>EQUAL 8.0%= 140 MM HG Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 3078F NOCOV DEF SYSMAN Description: DIAST BP <80 MM HG Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 3079F NOCOV DEF SYSMAN Description: DIAST BP 80-89 MM HG Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 30801 MEDSV DEF RBRVS 01/01/2024 205.91 Description: ABLATE INF TURBINATE SUPERF Category: Medical Services CMS Add: 01/01/1992 CMS Term: 30801 MEDSV DEF RBRVS 09/01/2019 12/31/2023 162.08 Description: ABLATE INF TURBINATE SUPERF Category: Medical Services CMS Add: 01/01/1992 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 350 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 30802 MEDSV DEF RBRVS 01/01/2024 262.23 Description: ABLATE INF TURBINATE SUBMUC Category: Medical Services CMS Add: 01/01/1992 CMS Term: 30802 MEDSV DEF RBRVS 09/01/2019 12/31/2023 206.58 Description: ABLATE INF TURBINATE SUBMUC Category: Medical Services CMS Add: 01/01/1992 CMS Term: 3080F NOCOV DEF SYSMAN Description: DIAST BP >= 90 MM HG Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 3082F NOCOV DEF SYSMAN Description: KT/V <1.2 Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 3083F NOCOV DEF SYSMAN Description: KT/V =/> 1.2 & <1.7 Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 3084F NOCOV DEF SYSMAN Description: KT/V >= 1.7 Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 3085F NOCOV DEF SYSMAN Description: SUICIDE RISK ASSESSED Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 3088F NOCOV DEF SYSMAN Description: MDD MILD Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 3089F NOCOV DEF SYSMAN Description: MDD MODERATE Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 30901 MEDSV DEF RBRVS 01/01/2024 147.15 Description: CONTROL OF NOSEBLEED Category: Medical Services CMS Add: 01/01/1985 CMS Term: 30901 MEDSV DEF RBRVS 09/01/2019 12/31/2023 68.45 Description: CONTROL OF NOSEBLEED Category: Medical Services CMS Add: 01/01/1985 CMS Term: 30903 MEDSV DEF RBRVS 01/01/2024 230.49 Description: CONTROL OF NOSEBLEED Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30903 MEDSV DEF RBRVS 09/01/2019 12/31/2023 147.07 Description: CONTROL OF NOSEBLEED Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30905 MEDSV DEF RBRVS 01/01/2024 329.24 Description: CONTROL OF NOSEBLEED Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30905 MEDSV DEF RBRVS 09/01/2019 12/31/2023 182.82 Description: CONTROL OF NOSEBLEED Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30906 MEDSV DEF RBRVS 01/01/2024 350.00 Description: REPEAT CONTROL OF NOSEBLEED Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 351 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 30906 MEDSV DEF RBRVS 09/01/2019 12/31/2023 201.66 Description: REPEAT CONTROL OF NOSEBLEED Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3090F NOCOV DEF SYSMAN Description: MDD SEVERE W/O PSYCH Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 30915 MEDSV DEF RBRVS 01/01/2024 570.79 Description: LIGATION NASAL SINUS ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30915 MEDSV DEF RBRVS 09/01/2019 12/31/2023 416.48 Description: LIGATION NASAL SINUS ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3091F NOCOV DEF SYSMAN Description: MDD SEVERE W/PSYCH Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 30920 MEDSV DEF RBRVS 01/01/2024 825.72 Description: LIGATION UPPER JAW ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30920 MEDSV DEF RBRVS 09/01/2019 12/31/2023 603.59 Description: LIGATION UPPER JAW ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3092F NOCOV DEF SYSMAN Description: MDD IN REMISSION Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 30930 MEDSV DEF RBRVS 01/01/2021 12/31/2023 89.03 Description: THER FX NASAL INF TURBINATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 30930 MEDSV DEF RBRVS 01/01/2024 110.74 Description: THER FX NASAL INF TURBINATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3093F NOCOV DEF SYSMAN Description: DOC NEW DIAG 1ST/ADDL MDD Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 3095F NOCOV DEF SYSMAN Description: CENTRAL DEXA RESULTS DOCD Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 3096F NOCOV DEF SYSMAN Description: CENTRAL DEXA ORDERED Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 30999 MEDSV DEF BILL20 Description: UNLISTED PROCEDURE NOSE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31000 MEDSV DEF RBRVS 01/01/2024 174.15 Description: IRRIGATION MAXILLARY SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31000 MEDSV DEF RBRVS 09/01/2019 12/31/2023 130.25 Description: IRRIGATION MAXILLARY SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 352 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 31002 MEDSV DEF RBRVS 01/01/2024 181.10 Description: IRRIGATION SPHENOID SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31002 MEDSV DEF RBRVS 09/01/2019 12/31/2023 144.23 Description: IRRIGATION SPHENOID SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3100F NOCOV DEF SYSMAN Description: IMAGE TEST REF CAROT DIAM Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 31020 MEDSV DEF RBRVS 01/01/2024 411.44 Description: EXPLORATION MAXILLARY SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31020 MEDSV DEF RBRVS 09/01/2019 12/31/2023 342.50 Description: EXPLORATION MAXILLARY SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31030 MEDSV DEF RBRVS 01/01/2024 600.95 Description: EXPLORATION MAXILLARY SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31030 MEDSV DEF RBRVS 09/01/2019 12/31/2023 491.43 Description: EXPLORATION MAXILLARY SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31032 MEDSV DEF RBRVS 01/01/2024 563.33 Description: EXPLORE SINUS REMOVE POLYPS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31032 MEDSV DEF RBRVS 09/01/2019 12/31/2023 411.94 Description: EXPLORE SINUS REMOVE POLYPS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31040 MEDSV DEF RBRVS 01/01/2024 761.26 Description: EXPLORATION BEHIND UPPER JAW Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31040 MEDSV DEF RBRVS 09/01/2019 12/31/2023 550.02 Description: EXPLORATION BEHIND UPPER JAW Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31050 MEDSV DEF RBRVS 01/01/2024 489.48 Description: EXPLORATION SPHENOID SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31050 MEDSV DEF RBRVS 09/01/2019 12/31/2023 347.49 Description: EXPLORATION SPHENOID SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31051 MEDSV DEF RBRVS 01/01/2024 657.10 Description: SPHENOID SINUS SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 31051 MEDSV DEF RBRVS 09/01/2019 12/31/2023 462.82 Description: SPHENOID SINUS SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 31070 MEDSV DEF RBRVS 01/01/2024 450.83 Description: EXPLORATION OF FRONTAL SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 353 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 31070 MEDSV DEF RBRVS 09/01/2019 12/31/2023 314.74 Description: EXPLORATION OF FRONTAL SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31075 MEDSV DEF RBRVS 01/01/2024 783.44 Description: EXPLORATION OF FRONTAL SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31075 MEDSV DEF RBRVS 09/01/2019 12/31/2023 561.94 Description: EXPLORATION OF FRONTAL SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31080 MEDSV DEF RBRVS 01/01/2024 1031.20 Description: REMOVAL OF FRONTAL SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31080 MEDSV DEF RBRVS 09/01/2019 12/31/2023 741.12 Description: REMOVAL OF FRONTAL SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31081 MEDSV DEF RBRVS 01/01/2024 1104.71 Description: REMOVAL OF FRONTAL SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31081 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1035.42 Description: REMOVAL OF FRONTAL SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31084 MEDSV DEF RBRVS 01/01/2024 1143.02 Description: REMOVAL OF FRONTAL SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31084 MEDSV DEF RBRVS 09/01/2019 12/31/2023 830.64 Description: REMOVAL OF FRONTAL SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31085 MEDSV DEF RBRVS 01/01/2024 1178.54 Description: REMOVAL OF FRONTAL SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31085 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1099.73 Description: REMOVAL OF FRONTAL SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31086 MEDSV DEF RBRVS 01/01/2024 1113.42 Description: REMOVAL OF FRONTAL SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31086 MEDSV DEF RBRVS 09/01/2019 12/31/2023 806.69 Description: REMOVAL OF FRONTAL SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31087 MEDSV DEF RBRVS 01/01/2024 1059.44 Description: REMOVAL OF FRONTAL SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31087 MEDSV DEF RBRVS 09/01/2019 12/31/2023 779.31 Description: REMOVAL OF FRONTAL SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31090 MEDSV DEF RBRVS 01/01/2024 1047.47 Description: EXPLORATION OF SINUSES Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 354 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 31090 MEDSV DEF RBRVS 09/01/2019 12/31/2023 737.58 Description: EXPLORATION OF SINUSES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3110F NOCOV DEF SYSMAN Description: PRES/ABSN HMRHG/LESION DOCD Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 3111F NOCOV DEF SYSMAN Description: CT/MRI BRAIN DONE W/IN 24HRS Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 3112F NOCOV DEF SYSMAN Description: CT/MRI BRAIN DONE 24 HRS Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 3115F NOCOV DEF SYSMAN Description: QUANT RESULTS ACTIVITY &SYMP Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 3117F NOCOV DEF SYSMAN Description: HF ASSESSMENT TOOL COMPLETED Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 3118F NOCOV DEF SYSMAN Description: NY HEART ASSOC CLASS DOCD Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 3119F NOCOV DEF SYSMAN Description: NO EVAL ACTIVITY CLIN SYMP Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 31200 MEDSV DEF RBRVS 01/01/2024 590.31 Description: REMOVAL OF ETHMOID SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31200 MEDSV DEF RBRVS 09/01/2019 12/31/2023 409.27 Description: REMOVAL OF ETHMOID SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31201 MEDSV DEF RBRVS 01/01/2024 751.49 Description: REMOVAL OF ETHMOID SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31201 MEDSV DEF RBRVS 09/01/2019 12/31/2023 533.20 Description: REMOVAL OF ETHMOID SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31205 MEDSV DEF RBRVS 01/01/2024 888.88 Description: REMOVAL OF ETHMOID SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31205 MEDSV DEF RBRVS 09/01/2019 12/31/2023 652.45 Description: REMOVAL OF ETHMOID SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3120F NOCOV DEF SYSMAN Description: 12-LEAD ECG PERFORMED Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 31225 MEDSV DEF RBRVS 01/01/2024 1694.96 Description: REMOVAL OF UPPER JAW Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 355 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 31225 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1353.51 Description: REMOVAL OF UPPER JAW Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31230 MEDSV DEF RBRVS 01/01/2024 1890.54 Description: REMOVAL OF UPPER JAW Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31230 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1503.27 Description: REMOVAL OF UPPER JAW Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31231 MEDSV DEF RBRVS 01/01/2024 176.77 Description: NASAL ENDOSCOPY DX Category: Medical Services CMS Add: 01/01/1994 CMS Term: 31231 MEDSV DEF RBRVS 09/01/2019 12/31/2023 148.04 Description: NASAL ENDOSCOPY DX Category: Medical Services CMS Add: 01/01/1994 CMS Term: 31233 MEDSV DEF RBRVS 01/01/2020 12/31/2023 189.04 Description: NSL/SINS NDSC DX MAX SINUSC Category: Medical Services CMS Add: 01/01/1994 CMS Term: 31233 MEDSV DEF RBRVS 01/01/2024 257.76 Description: NSL/SINS NDSC DX MAX SINUSC Category: Medical Services CMS Add: 01/01/1994 CMS Term: 31235 MEDSV DEF RBRVS 01/01/2020 12/31/2023 214.69 Description: NSL/SINS NDSC DX SPHN SINUSC Category: Medical Services CMS Add: 01/01/1994 CMS Term: 31235 MEDSV DEF RBRVS 01/01/2024 292.20 Description: NSL/SINS NDSC DX SPHN SINUSC Category: Medical Services CMS Add: 01/01/1994 CMS Term: 31237 MEDSV DEF RBRVS 01/01/2020 12/31/2023 184.88 Description: NSL/SINS NDSC SURG BX POLYPC Category: Medical Services CMS Add: 01/01/1994 CMS Term: 31237 MEDSV DEF RBRVS 01/01/2024 240.70 Description: NSL/SINS NDSC SURG BX POLYPC Category: Medical Services CMS Add: 01/01/1994 CMS Term: 31238 MEDSV DEF RBRVS 01/01/2020 12/31/2023 184.35 Description: NSL/SINS NDSC SRG NSL HEMRRG Category: Medical Services CMS Add: 01/01/1994 CMS Term: 31238 MEDSV DEF RBRVS 01/01/2024 235.11 Description: NSL/SINS NDSC SRG NSL HEMRRG Category: Medical Services CMS Add: 01/01/1994 CMS Term: 31239 MEDSV DEF RBRVS 01/01/2020 12/31/2023 451.63 Description: NSL/SINUS ENDOSCOPY SURG DCR Category: Medical Services CMS Add: 01/01/1994 CMS Term: 31239 MEDSV DEF RBRVS 01/01/2024 571.23 Description: NSL/SINUS ENDOSCOPY SURG DCR Category: Medical Services CMS Add: 01/01/1994 CMS Term: 31240 MEDSV DEF RBRVS 01/01/2020 12/31/2023 117.69 Description: NSL/SNS NDSC CNCH BULL RESCJ Category: Medical Services CMS Add: 01/01/1994 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 356 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 31240 MEDSV DEF RBRVS 01/01/2024 148.43 Description: NSL/SNS NDSC CNCH BULL RESCJ Category: Medical Services CMS Add: 01/01/1994 CMS Term: 31241 MEDSV DEF RBRVS 01/01/2020 12/31/2023 324.52 Description: NSL/SNS NDSC LIG SPHNPTN ART Category: Medical Services CMS Add: 01/01/2018 CMS Term: 31241 MEDSV DEF RBRVS 01/01/2024 415.24 Description: NSL/SNS NDSC LIG SPHNPTN ART Category: Medical Services CMS Add: 01/01/2018 CMS Term: 31242 NOCOV DEF SYSMAN Description: NSL/SINUS NDSC RF ABLTJ PNN Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 31243 NOCOV DEF SYSMAN Description: NSL/SINUS NDSC CRYOABLTJ PNN Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 31253 MEDSV DEF RBRVS 01/01/2020 12/31/2023 364.35 Description: NSL/SINS NDSC TOTAL Category: Medical Services CMS Add: 01/01/2018 CMS Term: 31253 MEDSV DEF RBRVS 01/01/2024 467.29 Description: NSL/SINS NDSC TOTAL Category: Medical Services CMS Add: 01/01/2018 CMS Term: 31254 MEDSV DEF RBRVS 01/01/2020 12/31/2023 199.48 Description: NSL/SINS NDSC W/PRTL ETHMDCT Category: Medical Services CMS Add: 01/01/1988 CMS Term: 31254 MEDSV DEF RBRVS 01/01/2024 412.28 Description: NSL/SINS NDSC W/PRTL ETHMDCT Category: Medical Services CMS Add: 01/01/1988 CMS Term: 31255 MEDSV DEF RBRVS 01/01/2020 12/31/2023 292.51 Description: NSL/SINS NDSC W/TOT ETHMDCT Category: Medical Services CMS Add: 01/01/1988 CMS Term: 31255 MEDSV DEF RBRVS 01/01/2024 302.21 Description: NSL/SINS NDSC W/TOT ETHMDCT Category: Medical Services CMS Add: 01/01/1988 CMS Term: 31256 MEDSV DEF RBRVS 01/01/2020 12/31/2023 144.38 Description: EXPLORATION MAXILLARY SINUS Category: Medical Services CMS Add: 01/01/1988 CMS Term: 31256 MEDSV DEF RBRVS 01/01/2024 168.35 Description: EXPLORATION MAXILLARY SINUS Category: Medical Services CMS Add: 01/01/1988 CMS Term: 31257 MEDSV DEF RBRVS 01/01/2020 12/31/2023 324.44 Description: NSL/SINS NDSC TOT W/SPHENDT Category: Medical Services CMS Add: 01/01/2018 CMS Term: 31257 MEDSV DEF RBRVS 01/01/2024 416.48 Description: NSL/SINS NDSC TOT W/SPHENDT Category: Medical Services CMS Add: 01/01/2018 CMS Term: 31259 MEDSV DEF RBRVS 01/01/2020 12/31/2023 343.86 Description: NSL/SINS NDSC SPHN TISS RMVL Category: Medical Services CMS Add: 01/01/2018 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 357 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 31259 MEDSV DEF RBRVS 01/01/2024 440.66 Description: NSL/SINS NDSC SPHN TISS RMVL Category: Medical Services CMS Add: 01/01/2018 CMS Term: 31267 MEDSV DEF RBRVS 01/01/2020 12/31/2023 231.89 Description: ENDOSCOPY MAXILLARY SINUS Category: Medical Services CMS Add: 01/01/1988 CMS Term: 31267 MEDSV DEF RBRVS 01/01/2024 247.94 Description: ENDOSCOPY MAXILLARY SINUS Category: Medical Services CMS Add: 01/01/1988 CMS Term: 3126F NOCOV DEF SYSMAN Description: ESOPH BX RPRT W/DYSPL INFO Category: Non Covered Services CMS Add: 07/01/2014 CMS Term: 31276 MEDSV DEF RBRVS 01/01/2020 12/31/2023 369.22 Description: NSL/SINS NDSC FRNT TISS RMVL Category: Medical Services CMS Add: 01/01/1995 CMS Term: 31276 MEDSV DEF RBRVS 01/01/2024 352.86 Description: NSL/SINS NDSC FRNT TISS RMVL Category: Medical Services CMS Add: 01/01/1995 CMS Term: 31287 MEDSV DEF RBRVS 01/01/2020 12/31/2023 169.71 Description: NASAL/SINUS ENDOSCOPY SURG Category: Medical Services CMS Add: 01/01/1994 CMS Term: 31287 MEDSV DEF RBRVS 01/01/2024 188.40 Description: NASAL/SINUS ENDOSCOPY SURG Category: Medical Services CMS Add: 01/01/1994 CMS Term: 31288 MEDSV DEF RBRVS 01/01/2020 12/31/2023 196.61 Description: NASAL/SINUS ENDOSCOPY SURG Category: Medical Services CMS Add: 01/01/1994 CMS Term: 31288 MEDSV DEF RBRVS 01/01/2024 218.82 Description: NASAL/SINUS ENDOSCOPY SURG Category: Medical Services CMS Add: 01/01/1994 CMS Term: 31290 MEDSV DEF RBRVS 01/01/2020 12/31/2023 841.37 Description: NASAL/SINUS ENDOSCOPY SURG Category: Medical Services CMS Add: 01/01/1994 CMS Term: 31290 MEDSV DEF RBRVS 01/01/2024 1072.85 Description: NASAL/SINUS ENDOSCOPY SURG Category: Medical Services CMS Add: 01/01/1994 CMS Term: 31291 MEDSV DEF RBRVS 01/01/2020 12/31/2023 890.43 Description: NASAL/SINUS ENDOSCOPY SURG Category: Medical Services CMS Add: 01/01/1994 CMS Term: 31291 MEDSV DEF RBRVS 01/01/2024 1135.34 Description: NASAL/SINUS ENDOSCOPY SURG Category: Medical Services CMS Add: 01/01/1994 CMS Term: 31292 MEDSV DEF RBRVS 01/01/2020 12/31/2023 727.43 Description: NSL/SINS NDSC MED/INF DCMPRN Category: Medical Services CMS Add: 01/01/1994 CMS Term: 31292 MEDSV DEF RBRVS 01/01/2024 933.02 Description: NSL/SINS NDSC MED/INF DCMPRN Category: Medical Services CMS Add: 01/01/1994 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 358 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 31293 MEDSV DEF RBRVS 01/01/2020 12/31/2023 789.68 Description: NSL/SINS NDSC MED&INF DCMPRN Category: Medical Services CMS Add: 01/01/1994 CMS Term: 31293 MEDSV DEF RBRVS 01/01/2024 1010.41 Description: NSL/SINS NDSC MED&INF DCMPRN Category: Medical Services CMS Add: 01/01/1994 CMS Term: 31294 MEDSV DEF RBRVS 01/01/2020 12/31/2023 904.55 Description: NSL/SINS NDSC SURG ON DCMPRN Category: Medical Services CMS Add: 01/01/1994 CMS Term: 31294 MEDSV DEF RBRVS 01/01/2024 1154.15 Description: NSL/SINS NDSC SURG ON DCMPRN Category: Medical Services CMS Add: 01/01/1994 CMS Term: 31295 MEDSV DEF MAXFEE 01/01/2024 1570.63 0.0 Description: NSL/SINS NDSC SURG MAX SINS Category: Medical Services CMS Add: 01/01/2011 CMS Term: 31296 MEDSV DEF MAXFEE 01/01/2024 1594.57 0.0 Description: NSL/SINS NDSC SURG FRNT SINS Category: Medical Services CMS Add: 01/01/2011 CMS Term: 31297 MEDSV DEF MAXFEE 01/01/2024 1557.17 0.0 Description: NSL/SINS NDSC SURG SPHN SINS Category: Medical Services CMS Add: 01/01/2011 CMS Term: 31298 MEDSV DEF MAXFEE 01/01/2024 2955.88 0.0 Description: NSL/SINS NDSC SURG FRNT&SPHN Category: Medical Services CMS Add: 01/01/2018 CMS Term: 31299 MEDSV DEF BILL20 Description: UNLISTED PX ACCESSORY SINUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31300 MEDSV DEF RBRVS 01/01/2024 1177.67 Description: REMOVAL OF LARYNX LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31300 MEDSV DEF RBRVS 09/01/2019 12/31/2023 907.87 Description: REMOVAL OF LARYNX LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3130F NOCOV DEF SYSMAN Description: UPPER GI ENDOSCOPY PERFORMED Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 3132F NOCOV DEF SYSMAN Description: DOC REF UPPER GI ENDOSCOPY Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 31360 MEDSV DEF RBRVS 01/01/2024 1929.90 Description: REMOVAL OF LARYNX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31360 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1507.14 Description: REMOVAL OF LARYNX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31365 MEDSV DEF RBRVS 01/01/2024 2381.76 Description: REMOVAL OF LARYNX Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 359 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 31365 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1867.15 Description: REMOVAL OF LARYNX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31367 MEDSV DEF RBRVS 01/01/2024 2043.51 Description: PARTIAL REMOVAL OF LARYNX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31367 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1593.32 Description: PARTIAL REMOVAL OF LARYNX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31368 MEDSV DEF RBRVS 01/01/2024 2259.45 Description: PARTIAL REMOVAL OF LARYNX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31368 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1766.88 Description: PARTIAL REMOVAL OF LARYNX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31370 MEDSV DEF RBRVS 01/01/2024 1918.11 Description: PARTIAL REMOVAL OF LARYNX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31370 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1495.30 Description: PARTIAL REMOVAL OF LARYNX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31375 MEDSV DEF RBRVS 01/01/2024 1823.15 Description: PARTIAL REMOVAL OF LARYNX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31375 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1419.32 Description: PARTIAL REMOVAL OF LARYNX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31380 MEDSV DEF RBRVS 01/01/2024 1797.67 Description: PARTIAL REMOVAL OF LARYNX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31380 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1398.95 Description: PARTIAL REMOVAL OF LARYNX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31382 MEDSV DEF RBRVS 01/01/2024 1968.60 Description: PARTIAL REMOVAL OF LARYNX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31382 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1536.12 Description: PARTIAL REMOVAL OF LARYNX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31390 MEDSV DEF RBRVS 01/01/2024 2629.37 Description: REMOVAL OF LARYNX & PHARYNX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31390 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2075.31 Description: REMOVAL OF LARYNX & PHARYNX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31395 MEDSV DEF RBRVS 01/01/2024 2759.96 Description: RECONSTRUCT LARYNX & PHARYNX Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 360 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 31395 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2177.51 Description: RECONSTRUCT LARYNX & PHARYNX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31400 MEDSV DEF RBRVS 01/01/2024 952.96 Description: REVISION OF LARYNX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31400 MEDSV DEF RBRVS 09/01/2019 12/31/2023 716.02 Description: REVISION OF LARYNX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3140F NOCOV DEF SYSMAN Description: UPPER GI ENDO SHOWS BARRTTS Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 3141F NOCOV DEF SYSMAN Description: UPPER GI ENDO NOT BARRTTS Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 31420 MEDSV DEF RBRVS 01/01/2024 783.86 Description: REMOVAL OF EPIGLOTTIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31420 MEDSV DEF RBRVS 09/01/2019 12/31/2023 603.87 Description: REMOVAL OF EPIGLOTTIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3142F NOCOV DEF SYSMAN Description: BARIUM SWALLOW TEST ORDERED Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 31500 MEDSV DEF RBRVS 01/01/2024 131.43 Description: INSERT EMERGENCY AIRWAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31500 MEDSV DEF RBRVS 02/01/2015 12/31/2023 81.18 Description: INSERT EMERGENCY AIRWAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31502 MEDSV DEF RBRVS 01/01/2024 32.59 Description: CHANGE OF WINDPIPE AIRWAY Category: Medical Services CMS Add: 01/01/1991 CMS Term: 31502 MEDSV DEF RBRVS 09/01/2019 12/31/2023 25.80 Description: CHANGE OF WINDPIPE AIRWAY Category: Medical Services CMS Add: 01/01/1991 CMS Term: 31505 MEDSV DEF RBRVS 01/01/2024 84.94 Description: DIAGNOSTIC LARYNGOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31505 MEDSV DEF RBRVS 09/01/2019 12/31/2023 59.41 Description: DIAGNOSTIC LARYNGOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3150F NOCOV DEF SYSMAN Description: FORCEPS ESOPH BIOPSY DONE Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 31510 MEDSV DEF RBRVS 01/01/2019 12/31/2023 150.34 Description: LARYNGOSCOPY WITH BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 361 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 31510 MEDSV DEF RBRVS 01/01/2024 202.77 Description: LARYNGOSCOPY WITH BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31511 MEDSV DEF RBRVS 01/01/2024 197.81 Description: REMOVE FOREIGN BODY LARYNX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31511 MEDSV DEF RBRVS 02/01/2015 12/31/2023 150.43 Description: REMOVE FOREIGN BODY LARYNX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31512 MEDSV DEF RBRVS 01/01/2024 203.55 Description: REMOVAL OF LARYNX LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31512 MEDSV DEF RBRVS 02/01/2015 12/31/2023 148.59 Description: REMOVAL OF LARYNX LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31513 MEDSV DEF RBRVS 01/01/2019 12/31/2023 96.88 Description: INJECTION INTO VOCAL CORD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31513 MEDSV DEF RBRVS 01/01/2024 122.14 Description: INJECTION INTO VOCAL CORD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31515 MEDSV DEF RBRVS 01/01/2024 201.78 Description: LARYNGOSCOPY FOR ASPIRATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31515 MEDSV DEF RBRVS 09/01/2019 12/31/2023 149.27 Description: LARYNGOSCOPY FOR ASPIRATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31520 MEDSV DEF RBRVS 01/01/2024 145.64 0-28days Description: DX LARYNGOSCOPY NEWBORN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31520 MEDSV DEF RBRVS 09/01/2019 12/31/2023 115.44 0-28days Description: DX LARYNGOSCOPY NEWBORN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31525 MEDSV DEF RBRVS 01/01/2024 234.93 Description: DX LARYNGOSCOPY EXCL NB Category: Medical Services CMS Add: 01/01/1985 CMS Term: 31525 MEDSV DEF RBRVS 09/01/2019 12/31/2023 182.14 Description: DX LARYNGOSCOPY EXCL NB Category: Medical Services CMS Add: 01/01/1985 CMS Term: 31526 MEDSV DEF RBRVS 01/01/2024 146.14 Description: DX LARYNGOSCOPY W/OPER SCOPE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 31526 MEDSV DEF RBRVS 09/01/2019 12/31/2023 115.70 Description: DX LARYNGOSCOPY W/OPER SCOPE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 31527 MEDSV DEF RBRVS 01/01/2024 181.81 Description: LARYNGOSCOPY FOR TREATMENT Category: Medical Services CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 362 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 31527 MEDSV DEF RBRVS 02/01/2015 12/31/2023 143.59 Description: LARYNGOSCOPY FOR TREATMENT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 31528 MEDSV DEF RBRVS 01/01/2019 12/31/2023 106.28 Description: LARYNGOSCOPY AND DILATION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 31528 MEDSV DEF RBRVS 01/01/2024 134.41 Description: LARYNGOSCOPY AND DILATION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 31529 MEDSV DEF RBRVS 01/01/2024 149.87 Description: LARYNGOSCOPY AND DILATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31529 MEDSV DEF RBRVS 02/01/2015 12/31/2023 119.07 Description: LARYNGOSCOPY AND DILATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31530 MEDSV DEF RBRVS 01/01/2024 185.11 Description: LARYNGOSCOPY W/FB REMOVAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31530 MEDSV DEF RBRVS 02/01/2015 12/31/2023 145.31 Description: LARYNGOSCOPY W/FB REMOVAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31531 MEDSV DEF RBRVS 01/01/2019 12/31/2023 156.30 Description: LARYNGOSCOPY W/FB & OP SCOPE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31531 MEDSV DEF RBRVS 01/01/2024 197.44 Description: LARYNGOSCOPY W/FB & OP SCOPE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31535 MEDSV DEF RBRVS 01/01/2024 175.91 Description: LARYNGOSCOPY W/BIOPSY Category: Medical Services CMS Add: 01/01/1985 CMS Term: 31535 MEDSV DEF RBRVS 02/01/2015 12/31/2023 139.15 Description: LARYNGOSCOPY W/BIOPSY Category: Medical Services CMS Add: 01/01/1985 CMS Term: 31536 MEDSV DEF RBRVS 01/01/2024 196.12 Description: LARYNGOSCOPY W/BX & OP SCOPE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 31536 MEDSV DEF RBRVS 02/01/2015 12/31/2023 155.00 Description: LARYNGOSCOPY W/BX & OP SCOPE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 31540 MEDSV DEF RBRVS 01/01/2024 225.06 Description: LARYNGOSCOPY W/EXC OF TUMOR Category: Medical Services CMS Add: 01/01/1985 CMS Term: 31540 MEDSV DEF RBRVS 02/01/2015 12/31/2023 178.08 Description: LARYNGOSCOPY W/EXC OF TUMOR Category: Medical Services CMS Add: 01/01/1985 CMS Term: 31541 MEDSV DEF RBRVS 01/01/2024 245.44 Description: LARYNSCOP W/TUMR EXC + SCOPE Category: Medical Services CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 363 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 31541 MEDSV DEF RBRVS 02/01/2015 12/31/2023 194.35 Description: LARYNSCOP W/TUMR EXC + SCOPE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 31545 MEDSV DEF RBRVS 01/01/2016 12/31/2023 267.45 Description: REMOVE VC LESION W/SCOPE Category: Medical Services CMS Add: 01/01/2005 CMS Term: 31545 MEDSV DEF RBRVS 01/01/2024 336.64 Description: REMOVE VC LESION W/SCOPE Category: Medical Services CMS Add: 01/01/2005 CMS Term: 31546 MEDSV DEF RBRVS 01/01/2016 12/31/2023 406.34 Description: REMOVE VC LESION SCOPE/GRAFT Category: Medical Services CMS Add: 01/01/2005 CMS Term: 31546 MEDSV DEF RBRVS 01/01/2024 510.45 Description: REMOVE VC LESION SCOPE/GRAFT Category: Medical Services CMS Add: 01/01/2005 CMS Term: 31551 MEDSV DEF RBRVS 01/01/2017 12/31/2023 1030.41 0-11years Description: LARYNGOPLASTY LARYNGEAL STEN Category: Medical Services CMS Add: 01/01/2017 CMS Term: 31551 MEDSV DEF RBRVS 01/01/2024 1451.90 0-11years Description: LARYNGOPLASTY LARYNGEAL STEN Category: Medical Services CMS Add: 01/01/2017 CMS Term: 31552 MEDSV DEF RBRVS 01/01/2017 12/31/2023 1040.61 12-999years Description: LARYNGOPLASTY LARYNGEAL STEN Category: Medical Services CMS Add: 01/01/2017 CMS Term: 31552 MEDSV DEF RBRVS 01/01/2024 1402.17 12-999years Description: LARYNGOPLASTY LARYNGEAL STEN Category: Medical Services CMS Add: 01/01/2017 CMS Term: 31553 MEDSV DEF RBRVS 01/01/2017 12/31/2023 1134.18 0-11years Description: LARYNGOPLASTY LARYNGEAL STEN Category: Medical Services CMS Add: 01/01/2017 CMS Term: 31553 MEDSV DEF RBRVS 01/01/2024 1583.26 0-11years Description: LARYNGOPLASTY LARYNGEAL STEN Category: Medical Services CMS Add: 01/01/2017 CMS Term: 31554 MEDSV DEF RBRVS 01/01/2017 12/31/2023 1193.13 12-999years Description: LARYNGOPLASTY LARYNGEAL STEN Category: Medical Services CMS Add: 01/01/2017 CMS Term: 31554 MEDSV DEF RBRVS 01/01/2024 1584.19 12-999years Description: LARYNGOPLASTY LARYNGEAL STEN Category: Medical Services CMS Add: 01/01/2017 CMS Term: 3155F NOCOV DEF SYSMAN Description: CYTOGEN TEST MARROW B/4 TX Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 31560 MEDSV DEF RBRVS 01/01/2024 290.78 Description: LARYNGOSCOP W/ARYTENOIDECTOM Category: Medical Services CMS Add: 01/01/1985 CMS Term: 31560 MEDSV DEF RBRVS 02/01/2015 12/31/2023 230.65 Description: LARYNGOSCOP W/ARYTENOIDECTOM Category: Medical Services CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 364 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 31561 MEDSV DEF RBRVS 01/01/2019 12/31/2023 252.76 Description: LARYNSCOP REMVE CART + SCOP Category: Medical Services CMS Add: 01/01/1985 CMS Term: 31561 MEDSV DEF RBRVS 01/01/2024 317.92 Description: LARYNSCOP REMVE CART + SCOP Category: Medical Services CMS Add: 01/01/1985 CMS Term: 31570 MEDSV DEF RBRVS 01/01/2024 321.21 Description: LARYNGOSCOPE W/VC INJ Category: Medical Services CMS Add: 01/01/1985 CMS Term: 31570 MEDSV DEF RBRVS 02/01/2015 12/31/2023 244.91 Description: LARYNGOSCOPE W/VC INJ Category: Medical Services CMS Add: 01/01/1985 CMS Term: 31571 MEDSV DEF RBRVS 01/01/2024 231.65 Description: LARYNGOSCOP W/VC INJ + SCOPE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 31571 MEDSV DEF RBRVS 02/01/2015 12/31/2023 183.74 Description: LARYNGOSCOP W/VC INJ + SCOPE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 31572 MEDSV DEF RBRVS 01/01/2017 12/31/2023 353.28 Description: LARGSC W/LASER DSTRJ LES Category: Medical Services CMS Add: 01/01/2017 CMS Term: 31572 MEDSV DEF RBRVS 01/01/2024 494.19 Description: LARGSC W/LASER DSTRJ LES Category: Medical Services CMS Add: 01/01/2017 CMS Term: 31573 MEDSV DEF RBRVS 01/01/2017 12/31/2023 188.73 Description: LARGSC W/THER INJECTION Category: Medical Services CMS Add: 01/01/2017 CMS Term: 31573 MEDSV DEF RBRVS 01/01/2024 269.81 Description: LARGSC W/THER INJECTION Category: Medical Services CMS Add: 01/01/2017 CMS Term: 31574 MEDSV DEF RBRVS 01/01/2017 12/31/2023 724.54 Description: LARGSC W/NJX AUGMENTATION Category: Medical Services CMS Add: 01/01/2017 CMS Term: 31574 MEDSV DEF RBRVS 01/01/2024 888.78 Description: LARGSC W/NJX AUGMENTATION Category: Medical Services CMS Add: 01/01/2017 CMS Term: 31575 MEDSV DEF RBRVS 01/01/2024 121.16 Description: DIAGNOSTIC LARYNGOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31575 MEDSV DEF RBRVS 09/01/2019 12/31/2023 81.66 Description: DIAGNOSTIC LARYNGOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31576 MEDSV DEF RBRVS 01/01/2024 252.53 Description: LARYNGOSCOPY WITH BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31576 MEDSV DEF RBRVS 02/01/2015 12/31/2023 161.02 Description: LARYNGOSCOPY WITH BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 365 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 31577 MEDSV DEF RBRVS 01/01/2019 12/31/2023 173.96 Description: LARGSC W/RMVL FOREIGN BDY(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31577 MEDSV DEF RBRVS 01/01/2024 259.36 Description: LARGSC W/RMVL FOREIGN BDY(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31578 MEDSV DEF RBRVS 01/01/2024 287.41 Description: LARGSC W/REMOVAL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31578 MEDSV DEF RBRVS 02/01/2015 12/31/2023 201.15 Description: LARGSC W/REMOVAL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31579 MEDSV DEF RBRVS 01/01/2024 186.28 Description: LARYNGOSCOPY TELESCOPIC Category: Medical Services CMS Add: 01/01/1989 CMS Term: 31579 MEDSV DEF RBRVS 02/01/2015 12/31/2023 152.46 Description: LARYNGOSCOPY TELESCOPIC Category: Medical Services CMS Add: 01/01/1989 CMS Term: 31580 MEDSV DEF RBRVS 01/01/2024 1208.94 Description: LARYNGOPLASTY LARYNGEAL WEB Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31580 MEDSV DEF RBRVS 09/01/2019 12/31/2023 878.42 Description: LARYNGOPLASTY LARYNGEAL WEB Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31584 MEDSV DEF RBRVS 01/01/2024 1330.88 Description: LARYNGOPLASTY FX RDCTJ FIXJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31584 MEDSV DEF RBRVS 09/01/2019 12/31/2023 998.24 Description: LARYNGOPLASTY FX RDCTJ FIXJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31587 MEDSV DEF RBRVS 01/01/2024 1136.62 Description: LARYNGOPLASTY CRICOID SPLIT Category: Medical Services CMS Add: 01/01/1989 CMS Term: 31587 MEDSV DEF RBRVS 09/01/2019 12/31/2023 728.34 Description: LARYNGOPLASTY CRICOID SPLIT Category: Medical Services CMS Add: 01/01/1989 CMS Term: 31590 MEDSV DEF RBRVS 01/01/2019 12/31/2023 634.59 Description: REINNERVATE LARYNX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31590 MEDSV DEF RBRVS 01/01/2024 869.52 Description: REINNERVATE LARYNX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31591 MEDSV DEF RBRVS 01/01/2022 12/31/2023 752.59 Description: LARYNGOPLASTY MEDIALIZATION Category: Medical Services CMS Add: 01/01/2017 CMS Term: 31591 MEDSV DEF RBRVS 01/01/2024 1036.85 Description: LARYNGOPLASTY MEDIALIZATION Category: Medical Services CMS Add: 01/01/2017 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 366 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 31592 MEDSV DEF RBRVS 01/01/2017 12/31/2023 1221.14 Description: CRICOTRACHEAL RESECTION Category: Medical Services CMS Add: 01/01/2017 CMS Term: 31592 MEDSV DEF RBRVS 01/01/2024 1630.74 Description: CRICOTRACHEAL RESECTION Category: Medical Services CMS Add: 01/01/2017 CMS Term: 31599 MEDSV DEF BILL20 Description: UNLISTED PROCEDURE LARYNX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31600 MEDSV DEF RBRVS 01/01/2024 280.80 Description: INCISION OF WINDPIPE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31600 MEDSV DEF RBRVS 09/01/2019 12/31/2023 287.69 Description: INCISION OF WINDPIPE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31601 MEDSV DEF RBRVS 01/01/2024 420.18 0-1years Description: INCISION OF WINDPIPE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31601 MEDSV DEF RBRVS 09/01/2019 12/31/2023 189.89 0-1years Description: INCISION OF WINDPIPE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31603 MEDSV DEF RBRVS 01/01/2024 295.43 Description: INCISION OF WINDPIPE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31603 MEDSV DEF RBRVS 09/01/2019 12/31/2023 163.75 Description: INCISION OF WINDPIPE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31605 MEDSV DEF RBRVS 01/01/2024 304.62 Description: INCISION OF WINDPIPE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31605 MEDSV DEF RBRVS 09/01/2019 12/31/2023 134.07 Description: INCISION OF WINDPIPE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3160F NOCOV DEF SYSMAN Description: DOC FE+ STORES B/4 EPO THX Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 31610 MEDSV DEF RBRVS 01/01/2024 900.70 Description: INCISION OF WINDPIPE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31610 MEDSV DEF RBRVS 09/01/2019 12/31/2023 516.34 Description: INCISION OF WINDPIPE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31611 MEDSV DEF RBRVS 01/01/2024 504.58 Description: SURGERY/SPEECH PROSTHESIS Category: Medical Services CMS Add: 01/01/1990 CMS Term: 31611 MEDSV DEF RBRVS 09/01/2019 12/31/2023 389.27 Description: SURGERY/SPEECH PROSTHESIS Category: Medical Services CMS Add: 01/01/1990 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 367 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 31612 MEDSV DEF RBRVS 01/01/2024 87.29 Description: PUNCTURE/CLEAR WINDPIPE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31612 MEDSV DEF RBRVS 09/01/2019 12/31/2023 59.71 Description: PUNCTURE/CLEAR WINDPIPE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31613 MEDSV DEF RBRVS 01/01/2024 398.29 Description: REPAIR WINDPIPE OPENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31613 MEDSV DEF RBRVS 09/01/2019 12/31/2023 326.46 Description: REPAIR WINDPIPE OPENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31614 MEDSV DEF RBRVS 01/01/2024 671.63 Description: REPAIR WINDPIPE OPENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31614 MEDSV DEF RBRVS 09/01/2019 12/31/2023 545.81 Description: REPAIR WINDPIPE OPENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31615 MEDSV DEF RBRVS 01/01/2024 161.77 Description: VISUALIZATION OF WINDPIPE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31615 MEDSV DEF RBRVS 09/15/2017 12/31/2023 120.45 Description: VISUALIZATION OF WINDPIPE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31622 MEDSV DEF RBRVS 01/01/2024 231.48 Description: DX BRONCHOSCOPE/WASH Category: Medical Services CMS Add: 01/01/1987 CMS Term: 31622 MEDSV DEF RBRVS 09/15/2017 12/31/2023 172.92 Description: DX BRONCHOSCOPE/WASH Category: Medical Services CMS Add: 01/01/1987 CMS Term: 31623 MEDSV DEF RBRVS 01/01/2024 257.21 Description: DX BRONCHOSCOPE/BRUSH Category: Medical Services CMS Add: 01/01/1999 CMS Term: 31623 MEDSV DEF RBRVS 09/15/2017 12/31/2023 194.44 Description: DX BRONCHOSCOPE/BRUSH Category: Medical Services CMS Add: 01/01/1999 CMS Term: 31624 MEDSV DEF RBRVS 01/01/2024 238.86 Description: DX BRONCHOSCOPE/LAVAGE Category: Medical Services CMS Add: 01/01/1999 CMS Term: 31624 MEDSV DEF RBRVS 09/15/2017 12/31/2023 181.97 Description: DX BRONCHOSCOPE/LAVAGE Category: Medical Services CMS Add: 01/01/1999 CMS Term: 31625 MEDSV DEF RBRVS 01/01/2024 326.46 Description: BRONCHOSCOPY W/BIOPSY(S) Category: Medical Services CMS Add: 01/01/1985 CMS Term: 31625 MEDSV DEF RBRVS 09/15/2017 12/31/2023 237.80 Description: BRONCHOSCOPY W/BIOPSY(S) Category: Medical Services CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 368 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 31626 MEDSV DEF RBRVS 01/01/2024 734.78 Description: BRONCHOSCOPY W/MARKERS Category: Medical Services CMS Add: 01/01/2010 CMS Term: 31626 MEDSV DEF RBRVS 09/15/2017 12/31/2023 597.10 Description: BRONCHOSCOPY W/MARKERS Category: Medical Services CMS Add: 01/01/2010 CMS Term: 31627 MEDSV DEF RBRVS 01/01/2024 1008.55 Description: NAVIGATIONAL BRONCHOSCOPY Category: Medical Services CMS Add: 01/01/2010 CMS Term: 31627 MEDSV DEF RBRVS 09/15/2017 12/31/2023 984.65 Description: NAVIGATIONAL BRONCHOSCOPY Category: Medical Services CMS Add: 01/01/2010 CMS Term: 31628 MEDSV DEF RBRVS 01/01/2024 348.94 Description: BRONCHOSCOPY/LUNG BX EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31628 MEDSV DEF RBRVS 09/15/2017 12/31/2023 252.84 Description: BRONCHOSCOPY/LUNG BX EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31629 MEDSV DEF RBRVS 01/01/2024 423.83 Description: BRONCHOSCOPY/NEEDLE BX EACH Category: Medical Services CMS Add: 01/01/1987 CMS Term: 31629 MEDSV DEF RBRVS 09/15/2017 12/31/2023 311.23 Description: BRONCHOSCOPY/NEEDLE BX EACH Category: Medical Services CMS Add: 01/01/1987 CMS Term: 31630 MEDSV DEF RBRVS 01/01/2024 183.75 Description: BRONCHOSCOPY DILATE/FX REPR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31630 MEDSV DEF RBRVS 02/01/2015 12/31/2023 147.78 Description: BRONCHOSCOPY DILATE/FX REPR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31631 MEDSV DEF RBRVS 01/01/2024 209.54 Description: BRONCHOSCOPY DILATE W/STENT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 31631 MEDSV DEF RBRVS 02/01/2015 12/31/2023 168.92 Description: BRONCHOSCOPY DILATE W/STENT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 31632 MEDSV DEF RBRVS 01/01/2024 60.90 0-4 Description: BRONCHOSCOPY/LUNG BX ADDL Category: Medical Services CMS Add: 01/01/2004 CMS Term: 31632 MEDSV DEF RBRVS 09/15/2017 12/31/2023 47.08 0-4 Description: BRONCHOSCOPY/LUNG BX ADDL Category: Medical Services CMS Add: 01/01/2004 CMS Term: 31633 MEDSV DEF RBRVS 01/01/2024 75.37 0-4 Description: BRONCHOSCOPY/NEEDLE BX ADDL Category: Medical Services CMS Add: 01/01/2004 CMS Term: 31633 MEDSV DEF RBRVS 09/15/2017 12/31/2023 58.59 0-4 Description: BRONCHOSCOPY/NEEDLE BX ADDL Category: Medical Services CMS Add: 01/01/2004 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 369 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 31634 MEDSV DEF MAXFEE 01/01/2024 1407.71 0.0 Description: BRONCH W/BALLOON OCCLUSION Category: Medical Services CMS Add: 01/01/2011 CMS Term: 31635 MEDSV DEF RBRVS 01/01/2024 273.58 Description: BRONCHOSCOPY W/FB REMOVAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31635 MEDSV DEF RBRVS 09/15/2017 12/31/2023 201.46 Description: BRONCHOSCOPY W/FB REMOVAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31636 MEDSV DEF RBRVS 01/01/2024 201.27 Description: BRONCHOSCOPY BRONCH STENTS Category: Medical Services CMS Add: 01/01/2005 CMS Term: 31636 MEDSV DEF RBRVS 02/01/2015 12/31/2023 163.34 Description: BRONCHOSCOPY BRONCH STENTS Category: Medical Services CMS Add: 01/01/2005 CMS Term: 31637 MEDSV DEF RBRVS 01/01/2024 71.71 Description: BRONCHOSCOPY STENT ADD-ON Category: Medical Services CMS Add: 01/01/2005 CMS Term: 31637 MEDSV DEF RBRVS 02/01/2015 12/31/2023 55.17 Description: BRONCHOSCOPY STENT ADD-ON Category: Medical Services CMS Add: 01/01/2005 CMS Term: 31638 MEDSV DEF RBRVS 01/01/2024 229.76 Description: BRONCHOSCOPY REVISE STENT Category: Medical Services CMS Add: 01/01/2005 CMS Term: 31638 MEDSV DEF RBRVS 02/01/2015 12/31/2023 187.43 Description: BRONCHOSCOPY REVISE STENT Category: Medical Services CMS Add: 01/01/2005 CMS Term: 31640 MEDSV DEF RBRVS 01/01/2024 231.15 Description: BRONCHOSCOPY W/TUMOR EXCISE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31640 MEDSV DEF RBRVS 02/01/2015 12/31/2023 187.87 Description: BRONCHOSCOPY W/TUMOR EXCISE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31641 MEDSV DEF RBRVS 01/01/2024 236.68 Description: BRONCHOSCOPY TREAT BLOCKAGE Category: Medical Services CMS Add: 01/01/1987 CMS Term: 31641 MEDSV DEF RBRVS 02/01/2015 12/31/2023 190.70 Description: BRONCHOSCOPY TREAT BLOCKAGE Category: Medical Services CMS Add: 01/01/1987 CMS Term: 31643 MEDSV DEF RBRVS 01/01/2024 159.04 Description: DIAG BRONCHOSCOPE/CATHETER Category: Medical Services CMS Add: 01/01/1999 CMS Term: 31643 MEDSV DEF RBRVS 02/01/2015 12/31/2023 130.84 Description: DIAG BRONCHOSCOPE/CATHETER Category: Medical Services CMS Add: 01/01/1999 CMS Term: 31645 MEDSV DEF RBRVS 01/01/2024 255.68 Description: BRNCHSC W/THER ASPIR 1ST Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 370 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 31645 MEDSV DEF RBRVS 09/15/2017 12/31/2023 183.55 Description: BRNCHSC W/THER ASPIR 1ST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31646 MEDSV DEF RBRVS 01/01/2024 132.04 Description: BRNCHSC W/THER ASPIR SBSQ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31646 MEDSV DEF RBRVS 09/15/2017 12/31/2023 165.12 Description: BRNCHSC W/THER ASPIR SBSQ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31647 MEDSV DEF RBRVS 01/01/2024 191.66 0-1 Description: BRONCHIAL VALVE INIT INSERT Category: Medical Services CMS Add: 01/01/2013 CMS Term: 31647 MEDSV DEF RBRVS 09/15/2017 12/31/2023 155.93 0-1 Description: BRONCHIAL VALVE INIT INSERT Category: Medical Services CMS Add: 01/01/2013 CMS Term: 31648 MEDSV DEF RBRVS 01/01/2024 183.34 0-1 Description: BRONCHIAL VALVE REMOV INIT Category: Medical Services CMS Add: 01/01/2013 CMS Term: 31648 MEDSV DEF RBRVS 09/15/2017 12/31/2023 143.53 0-1 Description: BRONCHIAL VALVE REMOV INIT Category: Medical Services CMS Add: 01/01/2013 CMS Term: 31649 MEDSV DEF RBRVS 01/01/2024 62.92 Description: BRONCHIAL VALVE REMOV ADDL Category: Medical Services CMS Add: 01/01/2013 CMS Term: 31649 MEDSV DEF RBRVS 09/15/2017 12/31/2023 51.65 Description: BRONCHIAL VALVE REMOV ADDL Category: Medical Services CMS Add: 01/01/2013 CMS Term: 31651 MEDSV DEF RBRVS 01/01/2024 71.41 Description: BRONCHIAL VALVE ADDL INSERT Category: Medical Services CMS Add: 01/01/2013 CMS Term: 31651 MEDSV DEF RBRVS 09/15/2017 12/31/2023 55.50 Description: BRONCHIAL VALVE ADDL INSERT Category: Medical Services CMS Add: 01/01/2013 CMS Term: 31652 MEDSV DEF RBRVS 01/01/2024 1171.71 0-1 Description: BRONCH EBUS SAMPLNG 1/2 NODE Category: Medical Services CMS Add: 01/01/2016 CMS Term: 31652 MEDSV DEF RBRVS 09/15/2017 12/31/2023 587.60 0-1 Description: BRONCH EBUS SAMPLNG 1/2 NODE Category: Medical Services CMS Add: 01/01/2016 CMS Term: 31653 MEDSV DEF RBRVS 01/01/2024 1218.48 0-1 Description: BRONCH EBUS SAMPLNG 3/> NODE Category: Medical Services CMS Add: 01/01/2016 CMS Term: 31653 MEDSV DEF RBRVS 09/15/2017 12/31/2023 622.17 0-1 Description: BRONCH EBUS SAMPLNG 3/> NODE Category: Medical Services CMS Add: 01/01/2016 CMS Term: 31654 MEDSV DEF RBRVS 01/01/2024 112.97 Description: BRONCH EBUS IVNTJ PERPH LES Category: Medical Services CMS Add: 01/01/2016 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 371 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 31654 MEDSV DEF RBRVS 09/15/2017 12/31/2023 90.79 Description: BRONCH EBUS IVNTJ PERPH LES Category: Medical Services CMS Add: 01/01/2016 CMS Term: 31660 NOCOV DEF SYSMAN Description: BRONCH THERMOPLSTY 1 LOBE Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 31661 NOCOV DEF SYSMAN Description: BRONCH THERMOPLSTY 2/> LOBES Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 3170F NOCOV DEF SYSMAN Description: BASELIN FLO CYTOMETRY B/4 TX Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 31717 MEDSV DEF RBRVS 01/01/2024 269.23 Description: BRONCHIAL BRUSH BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31717 MEDSV DEF RBRVS 09/01/2019 12/31/2023 187.01 Description: BRONCHIAL BRUSH BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31720 MEDSV DEF RBRVS 01/01/2024 46.16 Description: CLEARANCE OF AIRWAYS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31720 MEDSV DEF RBRVS 09/01/2019 12/31/2023 37.98 Description: CLEARANCE OF AIRWAYS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31725 MEDSV DEF RBRVS 01/01/2024 74.39 Description: CLEARANCE OF AIRWAYS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31725 MEDSV DEF RBRVS 09/15/2017 12/31/2023 58.00 Description: CLEARANCE OF AIRWAYS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31730 NOCOV DEF SYSMAN Description: INTRO WINDPIPE WIRE/TUBE Category: Non Covered Services CMS Add: 01/01/1993 CMS Term: 31750 MEDSV DEF RBRVS 01/01/2024 1272.33 Description: REPAIR OF WINDPIPE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31750 MEDSV DEF RBRVS 09/01/2019 12/31/2023 983.17 Description: REPAIR OF WINDPIPE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31755 MEDSV DEF RBRVS 01/01/2024 1628.35 Description: REPAIR OF WINDPIPE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31755 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1236.54 Description: REPAIR OF WINDPIPE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31760 MEDSV DEF RBRVS 01/01/2024 1239.02 Description: REPAIR OF WINDPIPE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 372 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 31760 MEDSV DEF RBRVS 09/01/2019 12/31/2023 987.43 Description: REPAIR OF WINDPIPE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31766 MEDSV DEF RBRVS 01/01/2024 1594.41 Description: RECONSTRUCTION OF WINDPIPE Category: Medical Services CMS Add: 01/01/1989 CMS Term: 31766 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1281.97 Description: RECONSTRUCTION OF WINDPIPE Category: Medical Services CMS Add: 01/01/1989 CMS Term: 31770 MEDSV DEF RBRVS 01/01/2024 1193.67 Description: REPAIR/GRAFT OF BRONCHUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31770 MEDSV DEF RBRVS 09/01/2019 12/31/2023 960.14 Description: REPAIR/GRAFT OF BRONCHUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31775 MEDSV DEF RBRVS 01/01/2024 1257.36 Description: RECONSTRUCT BRONCHUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31775 MEDSV DEF RBRVS 09/01/2019 12/31/2023 979.85 Description: RECONSTRUCT BRONCHUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31780 MEDSV DEF RBRVS 01/01/2024 1125.38 Description: RECONSTRUCT WINDPIPE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31780 MEDSV DEF RBRVS 09/01/2019 12/31/2023 857.08 Description: RECONSTRUCT WINDPIPE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31781 MEDSV DEF RBRVS 01/01/2024 1349.64 Description: RECONSTRUCT WINDPIPE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31781 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1103.84 Description: RECONSTRUCT WINDPIPE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31785 MEDSV DEF RBRVS 01/01/2024 1008.53 Description: REMOVE WINDPIPE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31785 MEDSV DEF RBRVS 09/01/2019 12/31/2023 789.22 Description: REMOVE WINDPIPE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31786 MEDSV DEF RBRVS 01/01/2024 1295.64 Description: REMOVE WINDPIPE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31786 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1039.72 Description: REMOVE WINDPIPE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31800 MEDSV DEF RBRVS 01/01/2024 667.72 Description: REPAIR OF WINDPIPE INJURY Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 373 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 31800 MEDSV DEF RBRVS 09/01/2019 12/31/2023 512.99 Description: REPAIR OF WINDPIPE INJURY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31805 MEDSV DEF RBRVS 01/01/2024 739.22 Description: REPAIR OF WINDPIPE INJURY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31805 MEDSV DEF RBRVS 09/01/2019 12/31/2023 586.58 Description: REPAIR OF WINDPIPE INJURY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31820 MEDSV DEF RBRVS 01/01/2024 418.10 Description: CLOSURE OF WINDPIPE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31820 MEDSV DEF RBRVS 09/01/2019 12/31/2023 313.10 Description: CLOSURE OF WINDPIPE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31825 MEDSV DEF RBRVS 01/01/2024 578.01 Description: REPAIR OF WINDPIPE DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31825 MEDSV DEF RBRVS 09/01/2019 12/31/2023 435.28 Description: REPAIR OF WINDPIPE DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31830 MEDSV DEF RBRVS 01/01/2024 467.56 Description: REVISE WINDPIPE SCAR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31830 MEDSV DEF RBRVS 09/01/2019 12/31/2023 317.68 Description: REVISE WINDPIPE SCAR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 31899 MEDSV DEF BILL20 Description: UNLISTED PX TRACHEA BRONCHI Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3200F NOCOV DEF SYSMAN Description: BARIUM SWALLOW TEST NOT REQ Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 32035 MEDSV DEF RBRVS 01/01/2024 665.77 Description: THORACOSTOMY W/RIB RESECTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32035 MEDSV DEF RBRVS 09/01/2019 12/31/2023 514.90 Description: THORACOSTOMY W/RIB RESECTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32036 MEDSV DEF RBRVS 01/01/2024 718.19 Description: THORACOSTOMY W/FLAP DRAINAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32036 MEDSV DEF RBRVS 09/01/2019 12/31/2023 558.80 Description: THORACOSTOMY W/FLAP DRAINAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32096 MEDSV DEF RBRVS 01/01/2024 720.93 Description: OPEN WEDGE/BX LUNG INFILTR Category: Medical Services CMS Add: 01/01/2012 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 374 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 32096 MEDSV DEF RBRVS 02/01/2015 12/31/2023 581.08 Description: OPEN WEDGE/BX LUNG INFILTR Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32097 MEDSV DEF RBRVS 01/01/2024 722.93 Description: OPEN WEDGE/BX LUNG NODULE Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32097 MEDSV DEF RBRVS 02/01/2015 12/31/2023 581.33 Description: OPEN WEDGE/BX LUNG NODULE Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32098 MEDSV DEF RBRVS 01/01/2024 685.86 Description: OPEN BIOPSY OF LUNG PLEURA Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32098 MEDSV DEF RBRVS 02/01/2015 12/31/2023 548.77 Description: OPEN BIOPSY OF LUNG PLEURA Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32100 MEDSV DEF RBRVS 01/01/2024 730.48 Description: EXPLORATION OF CHEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32100 MEDSV DEF RBRVS 09/01/2019 12/31/2023 585.79 Description: EXPLORATION OF CHEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3210F NOCOV DEF SYSMAN Description: GRP A STREP TEST PERFORMED Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 32110 MEDSV DEF RBRVS 01/01/2024 1329.68 Description: EXPLORE/REPAIR CHEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32110 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1049.83 Description: EXPLORE/REPAIR CHEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32120 MEDSV DEF RBRVS 01/01/2024 788.41 Description: RE-EXPLORATION OF CHEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32120 MEDSV DEF RBRVS 09/01/2019 12/31/2023 627.59 Description: RE-EXPLORATION OF CHEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32124 MEDSV DEF RBRVS 01/01/2024 834.02 Description: EXPLORE CHEST FREE ADHESIONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32124 MEDSV DEF RBRVS 09/01/2019 12/31/2023 668.54 Description: EXPLORE CHEST FREE ADHESIONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32140 MEDSV DEF RBRVS 01/01/2024 892.90 Description: REMOVAL OF LUNG LESION(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32140 MEDSV DEF RBRVS 09/01/2019 12/31/2023 714.68 Description: REMOVAL OF LUNG LESION(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 375 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 32141 MEDSV DEF RBRVS 01/01/2024 1370.15 Description: REMOVE/TREAT LUNG LESIONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32141 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1104.35 Description: REMOVE/TREAT LUNG LESIONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32150 MEDSV DEF RBRVS 01/01/2024 914.04 Description: REMOVAL OF LUNG LESION(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32150 MEDSV DEF RBRVS 09/01/2019 12/31/2023 723.60 Description: REMOVAL OF LUNG LESION(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32151 MEDSV DEF RBRVS 01/01/2024 905.98 Description: REMOVE LUNG FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32151 MEDSV DEF RBRVS 09/01/2019 12/31/2023 721.29 Description: REMOVE LUNG FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3215F NOCOV DEF SYSMAN Description: PT IMMUNITY TO HEP A DOCD Category: Non Covered Services CMS Add: 10/01/2007 CMS Term: 32160 MEDSV DEF RBRVS 01/01/2024 722.99 Description: OPEN CHEST HEART MASSAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32160 MEDSV DEF RBRVS 09/01/2019 12/31/2023 567.17 Description: OPEN CHEST HEART MASSAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3216F NOCOV DEF SYSMAN Description: PT IMMUNITY TO HEP B DOCD Category: Non Covered Services CMS Add: 10/01/2007 CMS Term: 3218F NOCOV DEF SYSMAN Description: RNA TSTNG HEP C DOCD DONE Category: Non Covered Services CMS Add: 10/01/2007 CMS Term: 32200 MEDSV DEF RBRVS 01/01/2024 1028.67 Description: DRAIN OPEN LUNG LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32200 MEDSV DEF RBRVS 09/01/2019 12/31/2023 817.09 Description: DRAIN OPEN LUNG LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3220F NOCOV DEF SYSMAN Description: HEP C QUANT RNA TSTNG DOCD Category: Non Covered Services CMS Add: 10/01/2007 CMS Term: 32215 MEDSV DEF RBRVS 01/01/2024 725.08 Description: TREAT CHEST LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32215 MEDSV DEF RBRVS 09/01/2019 12/31/2023 575.98 Description: TREAT CHEST LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 376 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 32220 MEDSV DEF RBRVS 01/01/2024 1441.65 Description: RELEASE OF LUNG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32220 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1142.71 Description: RELEASE OF LUNG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32225 MEDSV DEF RBRVS 01/01/2024 900.24 Description: PARTIAL RELEASE OF LUNG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32225 MEDSV DEF RBRVS 09/01/2019 12/31/2023 716.85 Description: PARTIAL RELEASE OF LUNG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3230F NOCOV DEF SYSMAN Description: NOTE HRING TST W/IN 6 MON Category: Non Covered Services CMS Add: 10/01/2007 CMS Term: 32310 MEDSV DEF RBRVS 01/01/2024 829.68 Description: REMOVAL OF CHEST LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32310 MEDSV DEF RBRVS 09/01/2019 12/31/2023 660.92 Description: REMOVAL OF CHEST LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32320 MEDSV DEF RBRVS 01/01/2024 1448.05 Description: FREE/REMOVE CHEST LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32320 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1151.65 Description: FREE/REMOVE CHEST LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32400 MEDSV DEF RBRVS 01/01/2024 157.93 Description: NEEDLE BIOPSY CHEST LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32400 MEDSV DEF RBRVS 09/01/2019 12/31/2023 108.56 Description: NEEDLE BIOPSY CHEST LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32408 MEDSV DEF RBRVS 01/01/2021 12/31/2023 704.89 Description: CORE NDL BX LNG/MED PERQ Category: Medical Services CMS Add: 01/01/2021 CMS Term: 32408 MEDSV DEF RBRVS 01/01/2024 805.65 Description: CORE NDL BX LNG/MED PERQ Category: Medical Services CMS Add: 01/01/2021 CMS Term: 32440 MEDSV DEF RBRVS 01/01/2024 1410.64 Description: REMOVE LUNG PNEUMONECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32440 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1129.91 Description: REMOVE LUNG PNEUMONECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32442 MEDSV DEF RBRVS 01/01/2024 2733.58 Description: SLEEVE PNEUMONECTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 377 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 32442 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2318.90 Description: SLEEVE PNEUMONECTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32445 MEDSV DEF RBRVS 01/01/2024 3163.08 Description: REMOVAL OF LUNG EXTRAPLEURAL Category: Medical Services CMS Add: 01/01/1985 CMS Term: 32445 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2551.77 Description: REMOVAL OF LUNG EXTRAPLEURAL Category: Medical Services CMS Add: 01/01/1985 CMS Term: 32480 MEDSV DEF RBRVS 01/01/2024 1331.88 Description: PARTIAL REMOVAL OF LUNG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32480 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1066.98 Description: PARTIAL REMOVAL OF LUNG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32482 MEDSV DEF RBRVS 01/01/2024 1423.16 Description: BILOBECTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32482 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1142.88 Description: BILOBECTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32484 MEDSV DEF RBRVS 01/01/2024 1288.53 Description: SEGMENTECTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32484 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1035.59 Description: SEGMENTECTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32486 MEDSV DEF RBRVS 01/01/2024 2097.25 Description: SLEEVE LOBECTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32486 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1695.30 Description: SLEEVE LOBECTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32488 MEDSV DEF RBRVS 01/01/2024 2144.21 Description: COMPLETION PNEUMONECTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32488 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1732.94 Description: COMPLETION PNEUMONECTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32491 NOCOV DEF SYSMAN Description: LUNG VOLUME REDUCTION Category: Non Covered Services CMS Add: 01/01/1997 CMS Term: 32501 MEDSV DEF RBRVS 01/01/2016 12/31/2023 177.35 Description: REPAIR BRONCHUS ADD-ON Category: Medical Services CMS Add: 01/01/1996 CMS Term: 32501 MEDSV DEF RBRVS 01/01/2024 216.91 Description: REPAIR BRONCHUS ADD-ON Category: Medical Services CMS Add: 01/01/1996 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 378 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 32503 MEDSV DEF RBRVS 01/01/2024 1611.92 Description: RESECT APICAL LUNG TUMOR Category: Medical Services CMS Add: 01/01/2006 CMS Term: 32503 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1309.36 Description: RESECT APICAL LUNG TUMOR Category: Medical Services CMS Add: 01/01/2006 CMS Term: 32504 MEDSV DEF RBRVS 01/01/2024 1834.46 Description: RESECT APICAL LUNG TUM/CHEST Category: Medical Services CMS Add: 01/01/2006 CMS Term: 32504 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1494.15 Description: RESECT APICAL LUNG TUM/CHEST Category: Medical Services CMS Add: 01/01/2006 CMS Term: 32505 MEDSV DEF RBRVS 01/01/2024 840.42 Description: WEDGE RESECT OF LUNG INITIAL Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32505 MEDSV DEF RBRVS 02/01/2015 12/31/2023 671.40 Description: WEDGE RESECT OF LUNG INITIAL Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32506 MEDSV DEF RBRVS 01/01/2024 139.80 Description: WEDGE RESECT OF LUNG ADD-ON Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32506 MEDSV DEF RBRVS 02/01/2015 12/31/2023 113.88 Description: WEDGE RESECT OF LUNG ADD-ON Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32507 MEDSV DEF RBRVS 01/01/2024 139.80 Description: WEDGE RESECT OF LUNG DIAG Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32507 MEDSV DEF RBRVS 02/01/2015 12/31/2023 113.88 Description: WEDGE RESECT OF LUNG DIAG Category: Medical Services CMS Add: 01/01/2012 CMS Term: 3250F NOCOV DEF SYSMAN Description: NONPRIM LOC ANAT BX SITE TUM Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 32540 MEDSV DEF RBRVS 01/01/2024 1554.72 Description: REMOVAL OF LUNG LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32540 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1252.36 Description: REMOVAL OF LUNG LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32550 MEDSV DEF RBRVS 01/01/2024 737.34 Description: INSERT PLEURAL CATH Category: Medical Services CMS Add: 01/01/2008 CMS Term: 32550 MEDSV DEF RBRVS 09/15/2017 12/31/2023 504.31 Description: INSERT PLEURAL CATH Category: Medical Services CMS Add: 01/01/2008 CMS Term: 32551 MEDSV DEF RBRVS 01/01/2024 142.73 Description: INSERTION OF CHEST TUBE Category: Medical Services CMS Add: 01/01/2008 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 379 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 32551 MEDSV DEF RBRVS 09/15/2017 12/31/2023 115.12 Description: INSERTION OF CHEST TUBE Category: Medical Services CMS Add: 01/01/2008 CMS Term: 32552 MEDSV DEF RBRVS 01/01/2024 170.25 Description: REMOVE LUNG CATHETER Category: Medical Services CMS Add: 01/01/2010 CMS Term: 32552 MEDSV DEF RBRVS 02/01/2015 12/31/2023 136.35 Description: REMOVE LUNG CATHETER Category: Medical Services CMS Add: 01/01/2010 CMS Term: 32553 MEDSV DEF RBRVS 01/01/2024 479.41 Description: INS MARK THOR FOR RT PERQ Category: Medical Services CMS Add: 01/01/2010 CMS Term: 32553 MEDSV DEF RBRVS 09/15/2017 12/31/2023 372.41 Description: INS MARK THOR FOR RT PERQ Category: Medical Services CMS Add: 01/01/2010 CMS Term: 32554 MEDSV DEF RBRVS 01/01/2024 219.56 0-3 Description: ASPIRATE PLEURA W/O IMAGING Category: Medical Services CMS Add: 01/01/2013 CMS Term: 32554 MEDSV DEF RBRVS 02/01/2015 12/31/2023 141.46 0-3 Description: ASPIRATE PLEURA W/O IMAGING Category: Medical Services CMS Add: 01/01/2013 CMS Term: 32555 MEDSV DEF RBRVS 01/01/2024 296.86 0-3 Description: ASPIRATE PLEURA W/ IMAGING Category: Medical Services CMS Add: 01/01/2013 CMS Term: 32555 MEDSV DEF RBRVS 02/01/2015 12/31/2023 210.28 0-3 Description: ASPIRATE PLEURA W/ IMAGING Category: Medical Services CMS Add: 01/01/2013 CMS Term: 32556 MEDSV DEF RBRVS 01/01/2024 691.72 0-3 Description: INSERT CATH PLEURA W/O IMAGE Category: Medical Services CMS Add: 01/01/2013 CMS Term: 32556 MEDSV DEF RBRVS 02/01/2015 12/31/2023 378.05 0-3 Description: INSERT CATH PLEURA W/O IMAGE Category: Medical Services CMS Add: 01/01/2013 CMS Term: 32557 MEDSV DEF RBRVS 01/01/2024 624.56 0-3 Description: INSERT CATH PLEURA W/ IMAGE Category: Medical Services CMS Add: 01/01/2013 CMS Term: 32557 MEDSV DEF RBRVS 02/01/2015 12/31/2023 400.66 0-3 Description: INSERT CATH PLEURA W/ IMAGE Category: Medical Services CMS Add: 01/01/2013 CMS Term: 32560 MEDSV DEF RBRVS 01/01/2024 237.41 Description: TREAT PLEURODESIS W/AGENT Category: Medical Services CMS Add: 01/01/2008 CMS Term: 32560 MEDSV DEF RBRVS 02/01/2015 12/31/2023 172.75 Description: TREAT PLEURODESIS W/AGENT Category: Medical Services CMS Add: 01/01/2008 CMS Term: 32561 MEDSV DEF RBRVS 01/01/2024 88.12 Description: LYSE CHEST FIBRIN INIT DAY Category: Medical Services CMS Add: 01/01/2010 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 380 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 32561 MEDSV DEF RBRVS 02/01/2015 12/31/2023 68.15 Description: LYSE CHEST FIBRIN INIT DAY Category: Medical Services CMS Add: 01/01/2010 CMS Term: 32562 MEDSV DEF RBRVS 01/01/2024 78.85 Description: LYSE CHEST FIBRIN SUBQ DAY Category: Medical Services CMS Add: 01/01/2010 CMS Term: 32562 MEDSV DEF RBRVS 02/01/2015 12/31/2023 61.23 Description: LYSE CHEST FIBRIN SUBQ DAY Category: Medical Services CMS Add: 01/01/2010 CMS Term: 32601 MEDSV DEF RBRVS 01/01/2024 276.60 Description: THORACOSCOPY DIAGNOSTIC Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32601 MEDSV DEF RBRVS 09/01/2019 12/31/2023 223.17 Description: THORACOSCOPY DIAGNOSTIC Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32604 MEDSV DEF RBRVS 01/01/2024 428.86 Description: THORACOSCOPY WBX SAC Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32604 MEDSV DEF RBRVS 09/01/2019 12/31/2023 347.61 Description: THORACOSCOPY WBX SAC Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32606 MEDSV DEF RBRVS 01/01/2024 413.44 Description: THORACOSCOPY W/BX MED SPACE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32606 MEDSV DEF RBRVS 09/01/2019 12/31/2023 334.01 Description: THORACOSCOPY W/BX MED SPACE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32607 MEDSV DEF RBRVS 01/01/2024 276.46 Description: THORACOSCOPY W/BX INFILTRATE Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32607 MEDSV DEF RBRVS 02/01/2015 12/31/2023 223.42 Description: THORACOSCOPY W/BX INFILTRATE Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32608 MEDSV DEF RBRVS 01/01/2024 339.36 Description: THORACOSCOPY W/BX NODULE Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32608 MEDSV DEF RBRVS 02/01/2015 12/31/2023 274.20 Description: THORACOSCOPY W/BX NODULE Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32609 MEDSV DEF RBRVS 01/01/2024 231.32 Description: THORACOSCOPY W/BX PLEURA Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32609 MEDSV DEF RBRVS 02/01/2015 12/31/2023 188.87 Description: THORACOSCOPY W/BX PLEURA Category: Medical Services CMS Add: 01/01/2012 CMS Term: 3260F NOCOV DEF SYSMAN Description: PT CAT/PN CAT/HIST GRD DOCD Category: Non Covered Services CMS Add: 10/01/2007 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 381 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 32650 MEDSV DEF RBRVS 01/01/2024 604.51 Description: THORACOSCOPY W/PLEURODESIS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32650 MEDSV DEF RBRVS 09/01/2019 12/31/2023 479.50 Description: THORACOSCOPY W/PLEURODESIS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32651 MEDSV DEF RBRVS 01/01/2024 986.19 Description: THORACOSCOPY REMOVE CORTEX Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32651 MEDSV DEF RBRVS 09/01/2019 12/31/2023 788.40 Description: THORACOSCOPY REMOVE CORTEX Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32652 MEDSV DEF RBRVS 01/01/2024 1495.23 Description: THORACOSCOPY REM TOTL CORTEX Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32652 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1197.54 Description: THORACOSCOPY REM TOTL CORTEX Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32653 MEDSV DEF RBRVS 01/01/2024 955.47 Description: THORACOSCOPY REMOV FB/FIBRIN Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32653 MEDSV DEF RBRVS 09/01/2019 12/31/2023 762.60 Description: THORACOSCOPY REMOV FB/FIBRIN Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32654 MEDSV DEF RBRVS 01/01/2024 1064.39 Description: THORACOSCOPY CONTRL BLEEDING Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32654 MEDSV DEF RBRVS 09/01/2019 12/31/2023 847.04 Description: THORACOSCOPY CONTRL BLEEDING Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32655 MEDSV DEF RBRVS 01/01/2024 863.08 Description: THORACOSCOPY RESECT BULLAE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32655 MEDSV DEF RBRVS 09/01/2019 12/31/2023 688.30 Description: THORACOSCOPY RESECT BULLAE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32656 MEDSV DEF RBRVS 01/01/2024 725.73 Description: THORACOSCOPY W/PLEURECTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32656 MEDSV DEF RBRVS 09/01/2019 12/31/2023 575.26 Description: THORACOSCOPY W/PLEURECTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32658 MEDSV DEF RBRVS 01/01/2024 645.50 Description: THORACOSCOPY W/SAC FB REMOVE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32658 MEDSV DEF RBRVS 09/01/2019 12/31/2023 513.88 Description: THORACOSCOPY W/SAC FB REMOVE Category: Medical Services CMS Add: 01/01/1994 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 382 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 32659 MEDSV DEF RBRVS 01/01/2024 663.03 Description: THORACOSCOPY W/SAC DRAINAGE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32659 MEDSV DEF RBRVS 09/01/2019 12/31/2023 526.34 Description: THORACOSCOPY W/SAC DRAINAGE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 3265F NOCOV DEF SYSMAN Description: RNA TSTNG HEPC VIR ORD/DOCD Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 32661 MEDSV DEF RBRVS 01/01/2024 720.26 Description: THORACOSCOPY W/PERICARD EXC Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32661 MEDSV DEF RBRVS 09/01/2019 12/31/2023 575.00 Description: THORACOSCOPY W/PERICARD EXC Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32662 MEDSV DEF RBRVS 01/01/2024 806.08 Description: THORACOSCOPY W/MEDIAST EXC Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32662 MEDSV DEF RBRVS 09/01/2019 12/31/2023 644.12 Description: THORACOSCOPY W/MEDIAST EXC Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32663 MEDSV DEF RBRVS 01/01/2024 1256.57 Description: THORACOSCOPY W/LOBECTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32663 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1010.59 Description: THORACOSCOPY W/LOBECTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32664 MEDSV DEF RBRVS 01/01/2024 764.33 Description: THORACOSCOPY W/ TH NRV EXC Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32664 MEDSV DEF RBRVS 09/01/2019 12/31/2023 611.09 Description: THORACOSCOPY W/ TH NRV EXC Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32665 MEDSV DEF RBRVS 01/01/2024 1107.03 Description: THORACOSCOP W/ESOPH MUSC EXC Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32665 MEDSV DEF RBRVS 09/01/2019 12/31/2023 882.27 Description: THORACOSCOP W/ESOPH MUSC EXC Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32666 MEDSV DEF RBRVS 01/01/2017 12/31/2023 627.16 Description: THORACOSCOPY W/WEDGE RESECT Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32666 MEDSV DEF RBRVS 01/01/2024 784.62 Description: THORACOSCOPY W/WEDGE RESECT Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32667 MEDSV DEF RBRVS 01/01/2024 139.80 Description: THORACOSCOPY W/W RESECT ADDL Category: Medical Services CMS Add: 01/01/2012 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 383 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 32667 MEDSV DEF RBRVS 02/01/2015 12/31/2023 114.13 Description: THORACOSCOPY W/W RESECT ADDL Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32668 MEDSV DEF RBRVS 01/01/2024 139.80 Description: THORACOSCOPY W/W RESECT DIAG Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32668 MEDSV DEF RBRVS 02/01/2015 12/31/2023 113.97 Description: THORACOSCOPY W/W RESECT DIAG Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32669 MEDSV DEF RBRVS 01/01/2024 1206.12 Description: THORACOSCOPY REMOVE SEGMENT Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32669 MEDSV DEF RBRVS 02/01/2015 12/31/2023 970.94 Description: THORACOSCOPY REMOVE SEGMENT Category: Medical Services CMS Add: 01/01/2012 CMS Term: 3266F NOCOV DEF SYSMAN Description: HEPC GN TSTNG DOCD B/4TXMNT Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 32670 MEDSV DEF RBRVS 01/01/2024 1441.58 Description: THORACOSCOPY BILOBECTOMY Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32670 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1154.06 Description: THORACOSCOPY BILOBECTOMY Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32671 MEDSV DEF RBRVS 01/01/2024 1589.97 Description: THORACOSCOPY PNEUMONECTOMY Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32671 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1284.89 Description: THORACOSCOPY PNEUMONECTOMY Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32672 MEDSV DEF RBRVS 01/01/2024 1359.30 Description: THORACOSCOPY FOR LVRS Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32672 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1101.58 Description: THORACOSCOPY FOR LVRS Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32673 MEDSV DEF RBRVS 01/01/2024 1092.47 Description: THORACOSCOPY W/THYMUS RESECT Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32673 MEDSV DEF RBRVS 02/01/2015 12/31/2023 873.75 Description: THORACOSCOPY W/THYMUS RESECT Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32674 MEDSV DEF RBRVS 01/01/2024 191.51 Description: THORACOSCOPY LYMPH NODE EXC Category: Medical Services CMS Add: 01/01/2012 CMS Term: 32674 MEDSV DEF RBRVS 02/01/2015 12/31/2023 156.12 Description: THORACOSCOPY LYMPH NODE EXC Category: Medical Services CMS Add: 01/01/2012 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 384 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 3267F NOCOV DEF SYSMAN Description: PATH RPRT W/ PT PN CAT ET AL Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: 3268F NOCOV DEF SYSMAN Description: PSA/T/GLSC DOCD B/4 TXMNT Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 3269F NOCOV DEF SYSMAN Description: BONE SCN B/4 TXMNT/AFTR DX Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 32701 MEDSV DEF RBRVS 01/01/2024 191.57 0-1 Description: THORAX STEREO RAD TARGETW/TX Category: Medical Services CMS Add: 01/01/2013 CMS Term: 32701 MEDSV DEF RBRVS 02/01/2015 12/31/2023 159.05 0-1 Description: THORAX STEREO RAD TARGETW/TX Category: Medical Services CMS Add: 01/01/2013 CMS Term: 3270F NOCOV DEF SYSMAN Description: NO BONE SCN B/4 TXMNT/AFTRDX Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 3271F NOCOV DEF SYSMAN Description: LOW RISK PROSTATE CANCER Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 3272F NOCOV DEF SYSMAN Description: MED RISK PROSTATE CANCER Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 3273F NOCOV DEF SYSMAN Description: HIGH RISK PROSTATE CANCER Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 3274F NOCOV DEF SYSMAN Description: PROST CNCR RSK NOT LW/MD/HGH Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 3278F NOCOV DEF SYSMAN Description: SERUM LVLS CA/IPTH/LPD ORD Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 3279F NOCOV DEF SYSMAN Description: HGB LVL >= 13 G/DL Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 32800 MEDSV DEF RBRVS 01/01/2024 856.50 Description: REPAIR LUNG HERNIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32800 MEDSV DEF RBRVS 09/01/2019 12/31/2023 679.32 Description: REPAIR LUNG HERNIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3280F NOCOV DEF SYSMAN Description: HGB LVL 11-12.9 G/DL Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 32810 MEDSV DEF RBRVS 01/01/2024 813.22 Description: CLOSE CHEST AFTER DRAINAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 385 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 32810 MEDSV DEF RBRVS 09/01/2019 12/31/2023 649.41 Description: CLOSE CHEST AFTER DRAINAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32815 MEDSV DEF RBRVS 01/01/2024 2521.05 Description: CLOSE BRONCHIAL FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32815 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2029.36 Description: CLOSE BRONCHIAL FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3281F NOCOV DEF SYSMAN Description: HGB LVL <11 G/DL Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 32820 MEDSV DEF RBRVS 01/01/2019 12/31/2023 958.73 Description: RECONSTRUCT INJURED CHEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32820 MEDSV DEF RBRVS 01/01/2024 1200.28 Description: RECONSTRUCT INJURED CHEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3284F NOCOV DEF SYSMAN Description: IOP RED >=15% PRE-NTRV LVL Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 32850 NOCOV DEF SYSMAN Description: DONOR PNEUMONECTOMY Category: Non Covered Services CMS Add: 01/01/1994 CMS Term: 32851 MEDSV DEF RBRVS 01/01/2019 12/31/2023 2378.07 Y Description: LUNG TRANSPLANT SINGLE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32851 MEDSV DEF RBRVS 01/01/2024 2933.27 Y Description: LUNG TRANSPLANT SINGLE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32852 MEDSV DEF RBRVS 01/01/2019 12/31/2023 2595.39 Y Description: LUNG TRANSPLANT WITH BYPASS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32852 MEDSV DEF RBRVS 01/01/2024 3178.66 Y Description: LUNG TRANSPLANT WITH BYPASS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32853 MEDSV DEF RBRVS 01/01/2019 12/31/2023 3317.57 Y Description: LUNG TRANSPLANT DOUBLE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32853 MEDSV DEF RBRVS 01/01/2024 4094.57 Y Description: LUNG TRANSPLANT DOUBLE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32854 MEDSV DEF RBRVS 01/01/2019 12/31/2023 3531.70 Y Description: LUNG TRANSPLANT WITH BYPASS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 32854 MEDSV DEF RBRVS 01/01/2024 4339.36 Y Description: LUNG TRANSPLANT WITH BYPASS Category: Medical Services CMS Add: 01/01/1994 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 386 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 32855 MEDSV DEF MAXFEE 01/01/2024 294.80 0.0 Y Description: PREPARE DONOR LUNG SINGLE Category: Medical Services CMS Add: 01/01/2005 CMS Term: 32856 MEDSV DEF MAXFEE 01/01/2024 346.40 0.0 Y Description: PREPARE DONOR LUNG DOUBLE Category: Medical Services CMS Add: 01/01/2005 CMS Term: 3285F NOCOV DEF SYSMAN Description: IOP DOWN <15% OF PRE-SVC LVL Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 3288F NOCOV DEF SYSMAN Description: FALL RISK ASSESSMENT DOCD Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 32900 MEDSV DEF RBRVS 01/01/2024 1292.12 Description: REMOVAL OF RIB(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32900 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1013.14 Description: REMOVAL OF RIB(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32905 MEDSV DEF RBRVS 01/01/2024 1199.82 Description: REVISE & REPAIR CHEST WALL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32905 MEDSV DEF RBRVS 09/01/2019 12/31/2023 963.83 Description: REVISE & REPAIR CHEST WALL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32906 MEDSV DEF RBRVS 01/01/2024 1478.84 Description: REVISE & REPAIR CHEST WALL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32906 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1191.54 Description: REVISE & REPAIR CHEST WALL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3290F NOCOV DEF SYSMAN Description: PT=D(RH)- AND UNSENSITIZED Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 3291F NOCOV DEF SYSMAN Description: PT=D(RH)+ OR SENSITIZED Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 3292F NOCOV DEF SYSMAN Description: HIV TSTNG ASKED/DOCD/REVWD Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 3293F NOCOV DEF SYSMAN Description: ABO RH BLOOD TYPING DOCD Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 32940 MEDSV DEF RBRVS 01/01/2024 1109.66 Description: REVISION OF LUNG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32940 MEDSV DEF RBRVS 09/01/2019 12/31/2023 890.54 Description: REVISION OF LUNG Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 387 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 3294F NOCOV DEF SYSMAN Description: GRP B STREP SCREENING DOCD Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 32960 MEDSV DEF RBRVS 01/01/2024 119.42 Description: THERAPEUTIC PNEUMOTHORAX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32960 MEDSV DEF RBRVS 09/01/2019 12/31/2023 106.58 Description: THERAPEUTIC PNEUMOTHORAX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 32994 MEDSV DEF MAXFEE 01/01/2024 4594.15 0.0 Description: ABLATE PULM TUMOR PERQ CRYBL Category: Medical Services CMS Add: 01/01/2018 CMS Term: 32997 MEDSV DEF RBRVS 01/01/2016 12/31/2023 261.06 0-2 Description: TOTAL LUNG LAVAGE Category: Medical Services CMS Add: 01/01/2000 CMS Term: 32997 MEDSV DEF RBRVS 01/01/2024 318.47 0-2 Description: TOTAL LUNG LAVAGE Category: Medical Services CMS Add: 01/01/2000 CMS Term: 32998 NOCOV DEF SYSMAN Description: ABLATE PULM TUMOR PERQ RF Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 32999 MEDSV DEF BILL20 Description: UNLISTED PX LUNGS & PLEURA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3300F NOCOV DEF SYSMAN Description: AJCC STAGE DOCD B/4 THXPY Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 33016 MEDSV DEF RBRVS 01/01/2020 12/31/2023 171.32 Description: PERICARDIOCENTESIS W/IMAGING Category: Medical Services CMS Add: 01/01/2020 CMS Term: 33016 MEDSV DEF RBRVS 01/01/2024 211.16 Description: PERICARDIOCENTESIS W/IMAGING Category: Medical Services CMS Add: 01/01/2020 CMS Term: 33017 MEDSV DEF RBRVS 01/01/2020 12/31/2023 178.14 Description: PRCRD DRG 6YR+ W/O CGEN CAR Category: Medical Services CMS Add: 01/01/2020 CMS Term: 33017 MEDSV DEF RBRVS 01/01/2024 221.73 Description: PRCRD DRG 6YR+ W/O CGEN CAR Category: Medical Services CMS Add: 01/01/2020 CMS Term: 33018 MEDSV DEF RBRVS 01/01/2020 12/31/2023 204.13 Description: PRCRD DRG 0-5YR OR W/ANOMLY Category: Medical Services CMS Add: 01/01/2020 CMS Term: 33018 MEDSV DEF RBRVS 01/01/2024 259.27 Description: PRCRD DRG 0-5YR OR W/ANOMLY Category: Medical Services CMS Add: 01/01/2020 CMS Term: 33019 MEDSV DEF RBRVS 01/01/2020 12/31/2023 165.06 Description: PERQ PRCRD DRG INSJ CATH CT Category: Medical Services CMS Add: 01/01/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 388 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33019 MEDSV DEF RBRVS 01/01/2024 196.82 Description: PERQ PRCRD DRG INSJ CATH CT Category: Medical Services CMS Add: 01/01/2020 CMS Term: 3301F NOCOV DEF SYSMAN Description: CANCER STAGE DOCD METAST Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 33020 MEDSV DEF RBRVS 01/01/2024 744.16 Description: INCISION OF HEART SAC Category: Medical Services CMS Add: 01/01/1985 CMS Term: 33020 MEDSV DEF RBRVS 09/01/2019 12/31/2023 632.56 Description: INCISION OF HEART SAC Category: Medical Services CMS Add: 01/01/1985 CMS Term: 33025 MEDSV DEF RBRVS 01/01/2024 694.32 Description: INCISION OF HEART SAC Category: Medical Services CMS Add: 01/01/1985 CMS Term: 33025 MEDSV DEF RBRVS 09/01/2019 12/31/2023 577.26 Description: INCISION OF HEART SAC Category: Medical Services CMS Add: 01/01/1985 CMS Term: 33030 MEDSV DEF RBRVS 01/01/2024 1794.00 Description: PARTIAL REMOVAL OF HEART SAC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33030 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1448.68 Description: PARTIAL REMOVAL OF HEART SAC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33031 MEDSV DEF RBRVS 01/01/2024 2218.16 Description: PARTIAL REMOVAL OF HEART SAC Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33031 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1796.36 Description: PARTIAL REMOVAL OF HEART SAC Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33050 MEDSV DEF RBRVS 01/01/2024 906.38 Description: RESECT HEART SAC LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33050 MEDSV DEF RBRVS 09/01/2019 12/31/2023 721.35 Description: RESECT HEART SAC LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33120 MEDSV DEF RBRVS 01/01/2024 1874.11 Description: REMOVAL OF HEART LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33120 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1523.02 Description: REMOVAL OF HEART LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33130 MEDSV DEF RBRVS 01/01/2024 1229.84 Description: REMOVAL OF HEART LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33130 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1003.50 Description: REMOVAL OF HEART LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 389 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33140 MEDSV DEF RBRVS 01/01/2024 1398.33 0-1 Description: HEART REVASCULARIZE (TMR) Category: Medical Services CMS Add: 01/01/2000 CMS Term: 33140 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1141.06 0-1 Description: HEART REVASCULARIZE (TMR) Category: Medical Services CMS Add: 01/01/2000 CMS Term: 33141 MEDSV DEF RBRVS 01/01/2016 12/31/2023 96.16 Description: HEART TMR W/OTHER PROCEDURE Category: Medical Services CMS Add: 01/01/2001 CMS Term: 33141 MEDSV DEF RBRVS 01/01/2024 117.65 Description: HEART TMR W/OTHER PROCEDURE Category: Medical Services CMS Add: 01/01/2001 CMS Term: 3315F NOCOV DEF SYSMAN Description: ER+ OR PR+ BREAST CANCER Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 3316F NOCOV DEF SYSMAN Description: ER- OR PR- BREAST CANCER Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 3317F NOCOV DEF SYSMAN Description: PATH RPT MALIG CANCER DOCD Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 3318F NOCOV DEF SYSMAN Description: PATH RPT MALIG CANCER DOCD Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 3319F NOCOV DEF SYSMAN Description: X-RAY/CT/ULTRSND ET AL ORD Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 33202 MEDSV DEF RBRVS 01/01/2024 695.55 Description: INSERT EPICARD ELTRD OPEN Category: Medical Services CMS Add: 01/01/2007 CMS Term: 33202 MEDSV DEF RBRVS 02/01/2015 12/31/2023 558.62 Description: INSERT EPICARD ELTRD OPEN Category: Medical Services CMS Add: 01/01/2007 CMS Term: 33203 MEDSV DEF RBRVS 01/01/2024 727.69 Description: INSERT EPICARD ELTRD ENDO Category: Medical Services CMS Add: 01/01/2007 CMS Term: 33203 MEDSV DEF RBRVS 02/01/2015 12/31/2023 581.29 Description: INSERT EPICARD ELTRD ENDO Category: Medical Services CMS Add: 01/01/2007 CMS Term: 33206 MEDSV DEF RBRVS 01/01/2024 414.17 Description: INSERT HEART PM ATRIAL Category: Medical Services CMS Add: 01/01/1982 CMS Term: 33206 MEDSV DEF RBRVS 09/15/2017 12/31/2023 325.53 Description: INSERT HEART PM ATRIAL Category: Medical Services CMS Add: 01/01/1982 CMS Term: 33207 MEDSV DEF RBRVS 01/01/2024 434.48 Description: INSERT HEART PM VENTRICULAR Category: Medical Services CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 390 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33207 MEDSV DEF RBRVS 09/15/2017 12/31/2023 347.06 Description: INSERT HEART PM VENTRICULAR Category: Medical Services CMS Add: 01/01/1982 CMS Term: 33208 MEDSV DEF RBRVS 01/01/2024 470.57 Description: INSRT HEART PM ATRIAL & VENT Category: Medical Services CMS Add: 01/01/1982 CMS Term: 33208 MEDSV DEF RBRVS 09/15/2017 12/31/2023 376.65 Description: INSRT HEART PM ATRIAL & VENT Category: Medical Services CMS Add: 01/01/1982 CMS Term: 3320F NOCOV DEF SYSMAN Description: NO XRAY/CT/ ET AL ORDD Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 33210 MEDSV DEF RBRVS 01/01/2024 146.07 Description: INSERT ELECTRD/PM CATH SNGL Category: Medical Services CMS Add: 01/01/1982 CMS Term: 33210 MEDSV DEF RBRVS 09/15/2017 12/31/2023 120.02 Description: INSERT ELECTRD/PM CATH SNGL Category: Medical Services CMS Add: 01/01/1982 CMS Term: 33211 MEDSV DEF RBRVS 01/01/2024 151.91 Description: INSERT CARD ELECTRODES DUAL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33211 MEDSV DEF RBRVS 09/15/2017 12/31/2023 122.76 Description: INSERT CARD ELECTRODES DUAL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33212 MEDSV DEF RBRVS 01/01/2024 292.00 Description: INSERT PULSE GEN SNGL LEAD Category: Medical Services CMS Add: 01/01/1982 CMS Term: 33212 MEDSV DEF RBRVS 09/15/2017 12/31/2023 230.98 Description: INSERT PULSE GEN SNGL LEAD Category: Medical Services CMS Add: 01/01/1982 CMS Term: 33213 MEDSV DEF RBRVS 01/01/2024 305.66 Description: INSERT PULSE GEN DUAL LEADS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33213 MEDSV DEF RBRVS 09/15/2017 12/31/2023 241.62 Description: INSERT PULSE GEN DUAL LEADS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33214 MEDSV DEF RBRVS 01/01/2024 436.43 Description: UPGRADE OF PACEMAKER SYSTEM Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33214 MEDSV DEF RBRVS 09/15/2017 12/31/2023 344.89 Description: UPGRADE OF PACEMAKER SYSTEM Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33215 MEDSV DEF RBRVS 01/01/2024 281.84 Description: REPOSITION PACING-DEFIB LEAD Category: Medical Services CMS Add: 01/01/2003 CMS Term: 33215 MEDSV DEF RBRVS 02/01/2015 12/31/2023 220.30 Description: REPOSITION PACING-DEFIB LEAD Category: Medical Services CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 391 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33216 MEDSV DEF RBRVS 01/01/2024 338.99 Description: INSERT 1 ELECTRODE PM-DEFIB Category: Medical Services CMS Add: 01/01/1982 CMS Term: 33216 MEDSV DEF RBRVS 09/15/2017 12/31/2023 266.94 Description: INSERT 1 ELECTRODE PM-DEFIB Category: Medical Services CMS Add: 01/01/1982 CMS Term: 33217 MEDSV DEF RBRVS 01/01/2024 335.65 Description: INSERT 2 ELECTRODE PM-DEFIB Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33217 MEDSV DEF RBRVS 09/15/2017 12/31/2023 261.84 Description: INSERT 2 ELECTRODE PM-DEFIB Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33218 MEDSV DEF RBRVS 01/01/2024 355.82 Description: REPAIR LEAD PACE-DEFIB ONE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 33218 MEDSV DEF RBRVS 09/15/2017 12/31/2023 280.48 Description: REPAIR LEAD PACE-DEFIB ONE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 3321F NOCOV DEF SYSMAN Description: AJCC CNCR 0/IA MELAN DOCD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 33220 MEDSV DEF RBRVS 01/01/2024 342.20 Description: REPAIR LEAD PACE-DEFIB DUAL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33220 MEDSV DEF RBRVS 09/15/2017 12/31/2023 280.90 Description: REPAIR LEAD PACE-DEFIB DUAL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33221 MEDSV DEF RBRVS 01/01/2024 327.33 Description: INSERT PULSE GEN MULT LEADS Category: Medical Services CMS Add: 01/01/2012 CMS Term: 33221 MEDSV DEF RBRVS 09/15/2017 12/31/2023 260.18 Description: INSERT PULSE GEN MULT LEADS Category: Medical Services CMS Add: 01/01/2012 CMS Term: 33222 MEDSV DEF RBRVS 01/01/2024 312.94 Description: RELOCATION POCKET PACEMAKER Category: Medical Services CMS Add: 01/01/1989 CMS Term: 33222 MEDSV DEF RBRVS 09/15/2017 12/31/2023 242.28 Description: RELOCATION POCKET PACEMAKER Category: Medical Services CMS Add: 01/01/1989 CMS Term: 33223 MEDSV DEF RBRVS 01/01/2024 372.93 Description: RELOCATE POCKET FOR DEFIB Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33223 MEDSV DEF RBRVS 09/15/2017 12/31/2023 294.04 Description: RELOCATE POCKET FOR DEFIB Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33224 MEDSV DEF RBRVS 01/01/2024 464.03 Description: INSERT PACING LEAD & CONNECT Category: Medical Services CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 392 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33224 MEDSV DEF RBRVS 02/01/2015 12/31/2023 367.66 Description: INSERT PACING LEAD & CONNECT Category: Medical Services CMS Add: 01/01/2003 CMS Term: 33225 MEDSV DEF RBRVS 01/01/2024 419.34 Description: L VENTRIC PACING LEAD ADD-ON Category: Medical Services CMS Add: 01/01/2003 CMS Term: 33225 MEDSV DEF RBRVS 02/01/2015 12/31/2023 333.56 Description: L VENTRIC PACING LEAD ADD-ON Category: Medical Services CMS Add: 01/01/2003 CMS Term: 33226 MEDSV DEF RBRVS 01/01/2024 441.74 Description: REPOSITION L VENTRIC LEAD Category: Medical Services CMS Add: 01/01/2003 CMS Term: 33226 MEDSV DEF RBRVS 02/01/2015 12/31/2023 352.87 Description: REPOSITION L VENTRIC LEAD Category: Medical Services CMS Add: 01/01/2003 CMS Term: 33227 MEDSV DEF RBRVS 01/01/2024 308.49 Description: REMOVE&REPLACE PM GEN SINGL Category: Medical Services CMS Add: 01/01/2012 CMS Term: 33227 MEDSV DEF RBRVS 09/15/2017 12/31/2023 243.53 Description: REMOVE&REPLACE PM GEN SINGL Category: Medical Services CMS Add: 01/01/2012 CMS Term: 33228 MEDSV DEF RBRVS 01/01/2024 322.30 Description: REMV&REPLC PM GEN DUAL LEAD Category: Medical Services CMS Add: 01/01/2012 CMS Term: 33228 MEDSV DEF RBRVS 09/15/2017 12/31/2023 254.75 Description: REMV&REPLC PM GEN DUAL LEAD Category: Medical Services CMS Add: 01/01/2012 CMS Term: 33229 MEDSV DEF RBRVS 01/01/2024 340.60 Description: REMV&REPLC PM GEN MULT LEADS Category: Medical Services CMS Add: 01/01/2012 CMS Term: 33229 MEDSV DEF RBRVS 09/15/2017 12/31/2023 269.85 Description: REMV&REPLC PM GEN MULT LEADS Category: Medical Services CMS Add: 01/01/2012 CMS Term: 3322F NOCOV DEF SYSMAN Description: MELANOMAAJCC STAGE 0 OR IA Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 33230 MEDSV DEF RBRVS 01/01/2024 348.88 Description: INSRT PULSE GEN W/DUAL LEADS Category: Medical Services CMS Add: 01/01/2012 CMS Term: 33230 MEDSV DEF RBRVS 09/15/2017 12/31/2023 276.14 Description: INSRT PULSE GEN W/DUAL LEADS Category: Medical Services CMS Add: 01/01/2012 CMS Term: 33231 MEDSV DEF RBRVS 01/01/2024 363.78 Description: INSRT PULSE GEN W/MULT LEADS Category: Medical Services CMS Add: 01/01/2012 CMS Term: 33231 MEDSV DEF RBRVS 09/15/2017 12/31/2023 290.33 Description: INSRT PULSE GEN W/MULT LEADS Category: Medical Services CMS Add: 01/01/2012 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 393 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33233 MEDSV DEF RBRVS 01/01/2024 213.23 Description: REMOVAL OF PM GENERATOR Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33233 MEDSV DEF RBRVS 09/15/2017 12/31/2023 165.37 Description: REMOVAL OF PM GENERATOR Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33234 MEDSV DEF RBRVS 01/01/2024 440.52 Description: REMOVAL OF PACEMAKER SYSTEM Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33234 MEDSV DEF RBRVS 09/15/2017 12/31/2023 350.07 Description: REMOVAL OF PACEMAKER SYSTEM Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33235 MEDSV DEF RBRVS 01/01/2024 579.14 Description: REMOVAL PACEMAKER ELECTRODE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33235 MEDSV DEF RBRVS 09/15/2017 12/31/2023 459.88 Description: REMOVAL PACEMAKER ELECTRODE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33236 MEDSV DEF RBRVS 01/01/2024 710.04 Description: REMOVE ELECTRODE/THORACOTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33236 MEDSV DEF RBRVS 09/01/2019 12/31/2023 566.64 Description: REMOVE ELECTRODE/THORACOTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33237 MEDSV DEF RBRVS 01/01/2024 761.09 Description: REMOVE ELECTRODE/THORACOTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33237 MEDSV DEF RBRVS 09/01/2019 12/31/2023 605.13 Description: REMOVE ELECTRODE/THORACOTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33238 MEDSV DEF RBRVS 01/01/2024 857.48 Description: REMOVE ELECTRODE/THORACOTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33238 MEDSV DEF RBRVS 09/01/2019 12/31/2023 677.19 Description: REMOVE ELECTRODE/THORACOTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 3323F NOCOV DEF SYSMAN Description: CLIN NODE STGNG DOCDB/4 SURG Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 33240 MEDSV DEF RBRVS 01/01/2024 332.62 Description: INSRT PULSE GEN W/SINGL LEAD Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33240 MEDSV DEF RBRVS 09/15/2017 12/31/2023 263.51 Description: INSRT PULSE GEN W/SINGL LEAD Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33241 MEDSV DEF RBRVS 01/01/2024 195.92 Description: REMOVE PULSE GENERATOR Category: Medical Services CMS Add: 01/01/1994 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 394 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33241 MEDSV DEF RBRVS 09/15/2017 12/31/2023 154.92 Description: REMOVE PULSE GENERATOR Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33243 MEDSV DEF RBRVS 01/01/2024 1238.28 Description: REMOVE ELTRD/THORACOTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33243 MEDSV DEF RBRVS 09/01/2019 12/31/2023 987.87 Description: REMOVE ELTRD/THORACOTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33244 MEDSV DEF RBRVS 01/01/2024 785.63 Description: REMOVE ELCTRD TRANSVENOUSLY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33244 MEDSV DEF RBRVS 09/15/2017 12/31/2023 620.78 Description: REMOVE ELCTRD TRANSVENOUSLY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33249 MEDSV DEF RBRVS 01/01/2024 829.62 Description: INSJ/RPLCMT DEFIB W/LEAD(S) Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33249 MEDSV DEF RBRVS 09/15/2017 12/31/2023 662.14 Description: INSJ/RPLCMT DEFIB W/LEAD(S) Category: Medical Services CMS Add: 01/01/1994 CMS Term: 3324F NOCOV DEF SYSMAN Description: MRI CT SCAN ORD RVWD RQSTD Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 33250 MEDSV DEF RBRVS 01/01/2024 1309.40 Description: ABLATE HEART DYSRHYTHM FOCUS Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33250 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1063.27 Description: ABLATE HEART DYSRHYTHM FOCUS Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33251 MEDSV DEF RBRVS 01/01/2024 1461.11 Description: ABLATE HEART DYSRHYTHM FOCUS Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33251 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1178.77 Description: ABLATE HEART DYSRHYTHM FOCUS Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33254 MEDSV DEF RBRVS 01/01/2024 1221.74 Description: ABLATE ATRIA LMTD Category: Medical Services CMS Add: 01/01/2007 CMS Term: 33254 MEDSV DEF RBRVS 02/01/2015 12/31/2023 987.42 Description: ABLATE ATRIA LMTD Category: Medical Services CMS Add: 01/01/2007 CMS Term: 33255 MEDSV DEF RBRVS 01/01/2024 1461.18 Description: ABLATE ATRIA W/O BYPASS EXT Category: Medical Services CMS Add: 01/01/2007 CMS Term: 33255 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1201.15 Description: ABLATE ATRIA W/O BYPASS EXT Category: Medical Services CMS Add: 01/01/2007 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 395 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33256 MEDSV DEF RBRVS 01/01/2024 1731.03 Description: ABLATE ATRIA W/BYPASS EXTEN Category: Medical Services CMS Add: 01/01/2007 CMS Term: 33256 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1419.05 Description: ABLATE ATRIA W/BYPASS EXTEN Category: Medical Services CMS Add: 01/01/2007 CMS Term: 33257 MEDSV DEF RBRVS 01/01/2024 525.40 Description: ABLATE ATRIA LMTD ADD-ON Category: Medical Services CMS Add: 01/01/2008 CMS Term: 33257 MEDSV DEF RBRVS 02/01/2015 12/31/2023 421.83 Description: ABLATE ATRIA LMTD ADD-ON Category: Medical Services CMS Add: 01/01/2008 CMS Term: 33258 MEDSV DEF RBRVS 01/01/2024 586.17 Description: ABLATE ATRIA X10SV ADD-ON Category: Medical Services CMS Add: 01/01/2008 CMS Term: 33258 MEDSV DEF RBRVS 02/01/2015 12/31/2023 474.16 Description: ABLATE ATRIA X10SV ADD-ON Category: Medical Services CMS Add: 01/01/2008 CMS Term: 33259 MEDSV DEF RBRVS 01/01/2024 763.01 Description: ABLATE ATRIA W/BYPASS ADD-ON Category: Medical Services CMS Add: 01/01/2008 CMS Term: 33259 MEDSV DEF RBRVS 02/01/2015 12/31/2023 612.70 Description: ABLATE ATRIA W/BYPASS ADD-ON Category: Medical Services CMS Add: 01/01/2008 CMS Term: 3325F NOCOV DEF SYSMAN Description: PREOP ASSES 4 CATARACT SURG Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 33261 MEDSV DEF RBRVS 01/01/2024 1448.31 Description: ABLATE HEART DYSRHYTHM FOCUS Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33261 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1191.90 Description: ABLATE HEART DYSRHYTHM FOCUS Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33262 MEDSV DEF RBRVS 01/01/2024 339.28 Description: RMVL& REPLC PULSE GEN 1 LEAD Category: Medical Services CMS Add: 01/01/2012 CMS Term: 33262 MEDSV DEF RBRVS 09/15/2017 12/31/2023 268.90 Description: RMVL& REPLC PULSE GEN 1 LEAD Category: Medical Services CMS Add: 01/01/2012 CMS Term: 33263 MEDSV DEF RBRVS 01/01/2024 352.32 Description: RMVL & RPLCMT DFB GEN 2 LEAD Category: Medical Services CMS Add: 01/01/2012 CMS Term: 33263 MEDSV DEF RBRVS 09/15/2017 12/31/2023 280.04 Description: RMVL & RPLCMT DFB GEN 2 LEAD Category: Medical Services CMS Add: 01/01/2012 CMS Term: 33264 MEDSV DEF RBRVS 01/01/2024 367.53 Description: RMVL & RPLCMT DFB GEN MLT LD Category: Medical Services CMS Add: 01/01/2012 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 396 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33264 MEDSV DEF RBRVS 09/15/2017 12/31/2023 292.00 Description: RMVL & RPLCMT DFB GEN MLT LD Category: Medical Services CMS Add: 01/01/2012 CMS Term: 33265 MEDSV DEF RBRVS 01/01/2024 1224.52 Description: ABLATE ATRIA LMTD ENDO Category: Medical Services CMS Add: 01/01/2007 CMS Term: 33265 MEDSV DEF RBRVS 02/01/2015 12/31/2023 988.08 Description: ABLATE ATRIA LMTD ENDO Category: Medical Services CMS Add: 01/01/2007 CMS Term: 33266 MEDSV DEF RBRVS 01/01/2024 1654.03 Description: ABLATE ATRIA X10SV ENDO Category: Medical Services CMS Add: 01/01/2007 CMS Term: 33266 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1340.74 Description: ABLATE ATRIA X10SV ENDO Category: Medical Services CMS Add: 01/01/2007 CMS Term: 33267 MEDSV DEF RBRVS 01/01/2022 12/31/2023 765.85 Description: EXCL LAA OPEN ANY METHOD Category: Medical Services CMS Add: 01/01/2022 CMS Term: 33267 MEDSV DEF RBRVS 01/01/2024 939.78 Description: EXCL LAA OPEN ANY METHOD Category: Medical Services CMS Add: 01/01/2022 CMS Term: 33268 MEDSV DEF RBRVS 01/01/2022 12/31/2023 95.66 Description: EXCL LAA OPN OTH PX ANY METH Category: Medical Services CMS Add: 01/01/2022 CMS Term: 33268 MEDSV DEF RBRVS 01/01/2024 117.19 Description: EXCL LAA OPN OTH PX ANY METH Category: Medical Services CMS Add: 01/01/2022 CMS Term: 33269 MEDSV DEF RBRVS 01/01/2022 12/31/2023 605.62 Description: EXCL LAA THRSCP ANY METHOD Category: Medical Services CMS Add: 01/01/2022 CMS Term: 33269 MEDSV DEF RBRVS 01/01/2024 743.30 Description: EXCL LAA THRSCP ANY METHOD Category: Medical Services CMS Add: 01/01/2022 CMS Term: 33270 MEDSV DEF RBRVS 01/01/2024 510.83 Description: INS/REP SUBQ DEFIBRILLATOR Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33270 MEDSV DEF RBRVS 07/01/2016 12/31/2023 425.84 Description: INS/REP SUBQ DEFIBRILLATOR Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33271 MEDSV DEF RBRVS 01/01/2024 409.47 Description: INSJ SUBQ IMPLTBL DFB ELCTRD Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33271 MEDSV DEF RBRVS 07/01/2016 12/31/2023 358.49 Description: INSJ SUBQ IMPLTBL DFB ELCTRD Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33272 MEDSV DEF RBRVS 01/01/2024 315.21 Description: RMVL OF SUBQ DEFIBRILLATOR Category: Medical Services CMS Add: 01/01/2015 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 397 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33272 MEDSV DEF RBRVS 07/01/2016 12/31/2023 252.89 Description: RMVL OF SUBQ DEFIBRILLATOR Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33273 MEDSV DEF RBRVS 01/01/2024 361.71 Description: REPOS PREV IMPLTBL SUBQ DFB Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33273 MEDSV DEF RBRVS 07/01/2016 12/31/2023 294.87 Description: REPOS PREV IMPLTBL SUBQ DFB Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33274 MEDSV DEF RBRVS 01/01/2019 12/31/2023 353.42 Description: TCAT INSJ/RPL PERM LDLS PM Category: Medical Services CMS Add: 01/01/2019 CMS Term: 33274 MEDSV DEF RBRVS 01/01/2024 435.72 Description: TCAT INSJ/RPL PERM LDLS PM Category: Medical Services CMS Add: 01/01/2019 CMS Term: 33275 MEDSV DEF RBRVS 01/01/2019 12/31/2023 375.31 Description: TCAT RMVL PERM LDLS PM W/IMG Category: Medical Services CMS Add: 01/01/2019 CMS Term: 33275 MEDSV DEF RBRVS 01/01/2024 453.83 Description: TCAT RMVL PERM LDLS PM W/IMG Category: Medical Services CMS Add: 01/01/2019 CMS Term: 33276 MEDSV DEF RBRVS 01/01/2024 523.09 Y Description: INSJ PHRNC NRV STIM SYS Category: Medical Services CMS Add: 01/01/2024 CMS Term: 33277 MEDSV DEF RBRVS 01/01/2024 273.28 Y Description: INSJ PHRNC NRV STIM TRANSVNS Category: Medical Services CMS Add: 01/01/2024 CMS Term: 33278 MEDSV DEF RBRVS 01/01/2024 520.04 Description: RMVL PHRNC NRV STIM SYS Category: Medical Services CMS Add: 01/01/2024 CMS Term: 33279 MEDSV DEF RBRVS 01/01/2024 314.62 Description: RMVL PHRNC NRV STIM TRANSVNS Category: Medical Services CMS Add: 01/01/2024 CMS Term: 33280 MEDSV DEF RBRVS 01/01/2024 195.06 Description: RMVL PHRNC NRV STIM PG ONLY Category: Medical Services CMS Add: 01/01/2024 CMS Term: 33281 MEDSV DEF RBRVS 01/01/2024 340.07 Description: REPOSG PHRNC NRV STIM TRNSVN Category: Medical Services CMS Add: 01/01/2024 CMS Term: 33285 MEDSV DEF RBRVS 01/01/2019 12/31/2023 3618.61 Description: INSJ SUBQ CAR RHYTHM MNTR Category: Medical Services CMS Add: 01/01/2019 CMS Term: 33285 MEDSV DEF RBRVS 01/01/2024 4026.60 Description: INSJ SUBQ CAR RHYTHM MNTR Category: Medical Services CMS Add: 01/01/2019 CMS Term: 33286 MEDSV DEF RBRVS 01/01/2019 12/31/2023 94.39 Description: RMVL SUBQ CAR RHYTHM MNTR Category: Medical Services CMS Add: 01/01/2019 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 398 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33286 MEDSV DEF RBRVS 01/01/2024 121.13 Description: RMVL SUBQ CAR RHYTHM MNTR Category: Medical Services CMS Add: 01/01/2019 CMS Term: 33287 MEDSV DEF RBRVS 01/01/2024 350.88 Description: RMV&RPLCMT PHRNC NRV STIM PG Category: Medical Services CMS Add: 01/01/2024 CMS Term: 33288 MEDSV DEF RBRVS 01/01/2024 462.25 Description: RMV&RPLCMT PHRNC NRV STIM LD Category: Medical Services CMS Add: 01/01/2024 CMS Term: 33289 NOCOV DEF SYSMAN Description: TCAT IMPL WRLS P-ART PRS SNR Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 3328F NOCOV DEF SYSMAN Description: PRFRMNC DOCD 2 WKS B/4 SURG Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 33300 MEDSV DEF RBRVS 01/01/2024 2182.98 Description: REPAIR OF HEART WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33300 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1772.76 Description: REPAIR OF HEART WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33305 MEDSV DEF RBRVS 01/01/2024 3658.27 Description: REPAIR OF HEART WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33305 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2975.74 Description: REPAIR OF HEART WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3330F NOCOV DEF SYSMAN Description: IMAGING STUDY ORDERED (BKP) Category: Non Covered Services CMS Add: 04/01/2008 CMS Term: 33310 MEDSV DEF RBRVS 01/01/2024 1053.96 Description: EXPLORATORY HEART SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33310 MEDSV DEF RBRVS 09/01/2019 12/31/2023 843.53 Description: EXPLORATORY HEART SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33315 MEDSV DEF RBRVS 01/01/2024 1718.75 Description: EXPLORATORY HEART SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33315 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1391.76 Description: EXPLORATORY HEART SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3331F NOCOV DEF SYSMAN Description: BK IMAGING TST NOT ORDERED Category: Non Covered Services CMS Add: 04/01/2008 CMS Term: 33320 MEDSV DEF RBRVS 01/01/2024 962.01 Description: REPAIR MAJOR BLOOD VESSEL(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 399 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33320 MEDSV DEF RBRVS 09/01/2019 12/31/2023 771.38 Description: REPAIR MAJOR BLOOD VESSEL(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33321 MEDSV DEF RBRVS 01/01/2019 12/31/2023 866.23 Description: REPAIR MAJOR VESSEL Category: Medical Services CMS Add: 01/01/1995 CMS Term: 33321 MEDSV DEF RBRVS 01/01/2024 1070.10 Description: REPAIR MAJOR VESSEL Category: Medical Services CMS Add: 01/01/1995 CMS Term: 33322 MEDSV DEF RBRVS 01/01/2024 1249.04 Description: REPAIR MAJOR BLOOD VESSEL(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33322 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1006.17 Description: REPAIR MAJOR BLOOD VESSEL(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33330 MEDSV DEF RBRVS 01/01/2024 1281.39 Description: INSERT MAJOR VESSEL GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33330 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1040.53 Description: INSERT MAJOR VESSEL GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33335 MEDSV DEF RBRVS 01/01/2024 1678.05 Description: INSERT MAJOR VESSEL GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33335 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1364.78 Description: INSERT MAJOR VESSEL GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33340 MEDSV DEF RBRVS 01/01/2017 12/31/2023 579.13 Description: PERQ CLSR TCAT L ATR APNDGE Category: Medical Services CMS Add: 01/01/2017 CMS Term: 33340 MEDSV DEF RBRVS 01/01/2024 705.08 Description: PERQ CLSR TCAT L ATR APNDGE Category: Medical Services CMS Add: 01/01/2017 CMS Term: 33361 MEDSV DEF RBRVS 01/01/2013 12/31/2023 991.06 Description: REPLACE AORTIC VALVE PERQ Category: Medical Services CMS Add: 01/01/2013 CMS Term: 33361 MEDSV DEF RBRVS 01/01/2024 1082.48 Description: REPLACE AORTIC VALVE PERQ Category: Medical Services CMS Add: 01/01/2013 CMS Term: 33362 MEDSV DEF RBRVS 01/01/2013 12/31/2023 1084.34 Description: REPLACE AORTIC VALVE OPEN Category: Medical Services CMS Add: 01/01/2013 CMS Term: 33362 MEDSV DEF RBRVS 01/01/2024 1180.43 Description: REPLACE AORTIC VALVE OPEN Category: Medical Services CMS Add: 01/01/2013 CMS Term: 33363 MEDSV DEF RBRVS 01/01/2013 12/31/2023 1122.73 Description: REPLACE AORTIC VALVE OPEN Category: Medical Services CMS Add: 01/01/2013 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 400 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33363 MEDSV DEF RBRVS 01/01/2024 1222.27 Description: REPLACE AORTIC VALVE OPEN Category: Medical Services CMS Add: 01/01/2013 CMS Term: 33364 MEDSV DEF RBRVS 01/01/2013 12/31/2023 1194.41 Description: REPLACE AORTIC VALVE OPEN Category: Medical Services CMS Add: 01/01/2013 CMS Term: 33364 MEDSV DEF RBRVS 01/01/2024 1223.04 Description: REPLACE AORTIC VALVE OPEN Category: Medical Services CMS Add: 01/01/2013 CMS Term: 33365 MEDSV DEF RBRVS 01/01/2013 12/31/2023 1305.49 Description: REPLACE AORTIC VALVE OPEN Category: Medical Services CMS Add: 01/01/2013 CMS Term: 33365 MEDSV DEF RBRVS 01/01/2024 1276.88 Description: REPLACE AORTIC VALVE OPEN Category: Medical Services CMS Add: 01/01/2013 CMS Term: 33366 MEDSV DEF RBRVS 01/01/2024 1407.13 Description: TRCATH REPLACE AORTIC VALVE Category: Medical Services CMS Add: 01/01/2014 CMS Term: 33366 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1387.00 Description: TRCATH REPLACE AORTIC VALVE Category: Medical Services CMS Add: 01/01/2014 CMS Term: 33367 MEDSV DEF RBRVS 01/01/2013 12/31/2023 458.50 Description: REPLACE AORTIC VALVE W/BYP Category: Medical Services CMS Add: 01/01/2013 CMS Term: 33367 MEDSV DEF RBRVS 01/01/2024 546.36 Description: REPLACE AORTIC VALVE W/BYP Category: Medical Services CMS Add: 01/01/2013 CMS Term: 33368 MEDSV DEF RBRVS 01/01/2013 12/31/2023 555.59 Description: REPLACE AORTIC VALVE W/BYP Category: Medical Services CMS Add: 01/01/2013 CMS Term: 33368 MEDSV DEF RBRVS 01/01/2024 661.73 Description: REPLACE AORTIC VALVE W/BYP Category: Medical Services CMS Add: 01/01/2013 CMS Term: 33369 MEDSV DEF RBRVS 01/01/2013 12/31/2023 733.54 Description: REPLACE AORTIC VALVE W/BYP Category: Medical Services CMS Add: 01/01/2013 CMS Term: 33369 MEDSV DEF RBRVS 01/01/2024 873.59 Description: REPLACE AORTIC VALVE W/BYP Category: Medical Services CMS Add: 01/01/2013 CMS Term: 33370 MEDSV DEF RBRVS 01/01/2022 12/31/2023 97.72 Description: TCAT PLMT&RMVL CEPD PERQ Category: Medical Services CMS Add: 01/01/2022 CMS Term: 33370 MEDSV DEF RBRVS 01/01/2024 120.28 Description: TCAT PLMT&RMVL CEPD PERQ Category: Medical Services CMS Add: 01/01/2022 CMS Term: 33390 MEDSV DEF RBRVS 01/01/2017 12/31/2023 1384.65 Description: VALVULOPLASTY AORTIC VALVE Category: Medical Services CMS Add: 01/01/2017 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 401 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33390 MEDSV DEF RBRVS 01/01/2024 1729.02 Description: VALVULOPLASTY AORTIC VALVE Category: Medical Services CMS Add: 01/01/2017 CMS Term: 33391 MEDSV DEF RBRVS 01/01/2017 12/31/2023 1640.80 Description: VALVULOPLASTY AORTIC VALVE Category: Medical Services CMS Add: 01/01/2017 CMS Term: 33391 MEDSV DEF RBRVS 01/01/2024 2049.20 Description: VALVULOPLASTY AORTIC VALVE Category: Medical Services CMS Add: 01/01/2017 CMS Term: 33404 MEDSV DEF RBRVS 01/01/2024 1571.22 Description: PREPARE HEART-AORTA CONDUIT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 33404 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1270.44 Description: PREPARE HEART-AORTA CONDUIT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 33405 MEDSV DEF RBRVS 01/01/2024 2036.35 Description: REPLACEMENT AORTIC VALVE OPN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33405 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1650.42 Description: REPLACEMENT AORTIC VALVE OPN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33406 MEDSV DEF RBRVS 01/01/2024 2579.69 Description: REPLACEMENT AORTIC VALVE OPN Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33406 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2090.74 Description: REPLACEMENT AORTIC VALVE OPN Category: Medical Services CMS Add: 01/01/1994 CMS Term: 3340F NOCOV DEF SYSMAN Description: MAMMO ASSESS INC XRAY DOCD Category: Non Covered Services CMS Add: 04/01/2008 CMS Term: 33410 MEDSV DEF RBRVS 01/01/2024 2278.65 0-1 Description: REPLACEMENT AORTIC VALVE OPN Category: Medical Services CMS Add: 01/01/2000 CMS Term: 33410 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1846.14 0-1 Description: REPLACEMENT AORTIC VALVE OPN Category: Medical Services CMS Add: 01/01/2000 CMS Term: 33411 MEDSV DEF RBRVS 01/01/2024 3004.25 Description: REPLACEMENT OF AORTIC VALVE Category: Medical Services CMS Add: 01/01/1987 CMS Term: 33411 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2441.13 Description: REPLACEMENT OF AORTIC VALVE Category: Medical Services CMS Add: 01/01/1987 CMS Term: 33412 MEDSV DEF RBRVS 01/01/2024 2818.34 Description: REPLACEMENT OF AORTIC VALVE Category: Medical Services CMS Add: 01/01/1987 CMS Term: 33412 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2309.69 Description: REPLACEMENT OF AORTIC VALVE Category: Medical Services CMS Add: 01/01/1987 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 402 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33413 MEDSV DEF RBRVS 01/01/2024 2888.08 Description: REPLACEMENT OF AORTIC VALVE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33413 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2346.84 Description: REPLACEMENT OF AORTIC VALVE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33414 MEDSV DEF RBRVS 01/01/2024 1922.31 Description: REPAIR OF AORTIC VALVE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33414 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1559.79 Description: REPAIR OF AORTIC VALVE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33415 MEDSV DEF RBRVS 01/01/2024 1818.64 Description: REVISION SUBVALVULAR TISSUE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 33415 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1475.37 Description: REVISION SUBVALVULAR TISSUE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 33416 MEDSV DEF RBRVS 01/01/2024 1816.13 Description: REVISE VENTRICLE MUSCLE Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33416 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1476.53 Description: REVISE VENTRICLE MUSCLE Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33417 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1205.14 Description: REPAIR OF AORTIC VALVE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 33417 MEDSV DEF RBRVS 01/01/2024 1498.69 Description: REPAIR OF AORTIC VALVE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 33418 MEDSV DEF RBRVS 01/01/2024 1612.85 Description: REPAIR TCAT MITRAL VALVE Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33418 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1346.93 Description: REPAIR TCAT MITRAL VALVE Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33419 MEDSV DEF RBRVS 01/01/2024 379.17 Description: REPAIR TCAT MITRAL VALVE Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33419 MEDSV DEF RBRVS 02/01/2015 12/31/2023 316.70 Description: REPAIR TCAT MITRAL VALVE Category: Medical Services CMS Add: 01/01/2015 CMS Term: 3341F NOCOV DEF SYSMAN Description: MAMMO ASSESS NEGATIVE DOCD Category: Non Covered Services CMS Add: 04/01/2008 CMS Term: 33420 MEDSV DEF RBRVS 01/01/2024 1304.89 Description: REVISION OF MITRAL VALVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 403 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33420 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1077.63 Description: REVISION OF MITRAL VALVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33422 MEDSV DEF RBRVS 01/01/2024 1495.95 Description: REVISION OF MITRAL VALVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33422 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1222.00 Description: REVISION OF MITRAL VALVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33425 MEDSV DEF RBRVS 01/01/2024 2446.26 Description: REPAIR OF MITRAL VALVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33425 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1986.85 Description: REPAIR OF MITRAL VALVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33426 MEDSV DEF RBRVS 01/01/2024 2136.25 Description: REPAIR OF MITRAL VALVE Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33426 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1732.15 Description: REPAIR OF MITRAL VALVE Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33427 MEDSV DEF RBRVS 01/01/2024 2189.11 Description: REPAIR OF MITRAL VALVE Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33427 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1778.33 Description: REPAIR OF MITRAL VALVE Category: Medical Services CMS Add: 01/01/1990 CMS Term: 3342F NOCOV DEF SYSMAN Description: MAMMO ASSESS BENGN DOCD Category: Non Covered Services CMS Add: 04/01/2008 CMS Term: 33430 MEDSV DEF RBRVS 01/01/2024 2512.73 Description: REPLACEMENT OF MITRAL VALVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33430 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2034.63 Description: REPLACEMENT OF MITRAL VALVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3343F NOCOV DEF SYSMAN Description: MAMMO PROBABLY BENGN DOCD Category: Non Covered Services CMS Add: 04/01/2008 CMS Term: 33440 MEDSV DEF RBRVS 01/01/2019 12/31/2023 2448.07 Description: RPLCMT A-VALVE TLCJ AUTOL PV Category: Medical Services CMS Add: 01/01/2019 CMS Term: 33440 MEDSV DEF RBRVS 01/01/2024 3048.10 Description: RPLCMT A-VALVE TLCJ AUTOL PV Category: Medical Services CMS Add: 01/01/2019 CMS Term: 3344F NOCOV DEF SYSMAN Description: MAMMO ASSESS SUSP DOCD Category: Non Covered Services CMS Add: 04/01/2008 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 404 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 3345F NOCOV DEF SYSMAN Description: MAMMO ASSESS HGHLYMALIG DOC Category: Non Covered Services CMS Add: 04/01/2008 CMS Term: 33460 MEDSV DEF RBRVS 01/01/2024 2150.25 Description: REVISION OF TRICUSPID VALVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33460 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1769.06 Description: REVISION OF TRICUSPID VALVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33463 MEDSV DEF RBRVS 01/01/2024 2765.87 Description: VALVULOPLASTY TRICUSPID Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33463 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2246.45 Description: VALVULOPLASTY TRICUSPID Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33464 MEDSV DEF RBRVS 01/01/2024 2187.58 Description: VALVULOPLASTY TRICUSPID Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33464 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1779.21 Description: VALVULOPLASTY TRICUSPID Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33465 MEDSV DEF RBRVS 01/01/2024 2468.65 Description: REPLACE TRICUSPID VALVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33465 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2004.22 Description: REPLACE TRICUSPID VALVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33468 MEDSV DEF RBRVS 01/01/2024 2192.99 Description: REVISION OF TRICUSPID VALVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33468 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1778.80 Description: REVISION OF TRICUSPID VALVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33471 MEDSV DEF RBRVS 01/01/2024 1191.68 Description: VLVT PV CLSD HRT VIA P-ART Category: Medical Services CMS Add: 01/01/1987 CMS Term: 33471 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1002.20 Description: VLVT PV CLSD HRT VIA P-ART Category: Medical Services CMS Add: 01/01/1987 CMS Term: 33474 MEDSV DEF RBRVS 01/01/2024 1953.30 Description: REVISION OF PULMONARY VALVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33474 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1577.27 Description: REVISION OF PULMONARY VALVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33475 MEDSV DEF RBRVS 01/01/2024 2086.20 Description: REPLACEMENT PULMONARY VALVE Category: Medical Services CMS Add: 01/01/1994 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 405 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33475 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1701.32 Description: REPLACEMENT PULMONARY VALVE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33476 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1107.86 Description: REVISION OF HEART CHAMBER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33476 MEDSV DEF RBRVS 01/01/2024 1369.84 Description: REVISION OF HEART CHAMBER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33477 MEDSV DEF RBRVS 01/01/2016 12/31/2023 952.04 Y Description: IMPLANT TCAT PULM VLV PERQ Category: Medical Services CMS Add: 01/01/2016 CMS Term: 33477 MEDSV DEF RBRVS 01/01/2024 1211.01 Y Description: IMPLANT TCAT PULM VLV PERQ Category: Medical Services CMS Add: 01/01/2016 CMS Term: 33478 MEDSV DEF RBRVS 01/01/2024 1415.06 Description: REVISION OF HEART CHAMBER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33478 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1138.63 Description: REVISION OF HEART CHAMBER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33496 MEDSV DEF RBRVS 01/01/2024 1496.76 Description: REPAIR PROSTH VALVE CLOT Category: Medical Services CMS Add: 01/01/1998 CMS Term: 33496 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1209.59 Description: REPAIR PROSTH VALVE CLOT Category: Medical Services CMS Add: 01/01/1998 CMS Term: 33500 MEDSV DEF RBRVS 01/01/2024 1403.40 Description: REPAIR HEART VESSEL FISTULA Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33500 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1146.66 Description: REPAIR HEART VESSEL FISTULA Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33501 MEDSV DEF RBRVS 01/01/2024 1005.00 Description: REPAIR HEART VESSEL FISTULA Category: Medical Services CMS Add: 01/01/1993 CMS Term: 33501 MEDSV DEF RBRVS 09/01/2019 12/31/2023 819.00 Description: REPAIR HEART VESSEL FISTULA Category: Medical Services CMS Add: 01/01/1993 CMS Term: 33502 MEDSV DEF RBRVS 01/01/2024 1150.79 Description: CORONARY ARTERY CORRECTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33502 MEDSV DEF RBRVS 09/01/2019 12/31/2023 924.23 Description: CORONARY ARTERY CORRECTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33503 MEDSV DEF RBRVS 01/01/2024 1196.27 Description: CORONARY ARTERY GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 406 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33503 MEDSV DEF RBRVS 09/01/2019 12/31/2023 953.60 Description: CORONARY ARTERY GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33504 MEDSV DEF RBRVS 01/01/2024 1319.08 Description: CORONARY ARTERY GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33504 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1066.64 Description: CORONARY ARTERY GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33505 MEDSV DEF RBRVS 01/01/2024 1842.23 Description: REPAIR ARTERY W/TUNNEL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33505 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1504.91 Description: REPAIR ARTERY W/TUNNEL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33506 MEDSV DEF RBRVS 01/01/2024 1835.99 Description: REPAIR ARTERY TRANSLOCATION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33506 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1488.73 Description: REPAIR ARTERY TRANSLOCATION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33507 MEDSV DEF RBRVS 01/01/2024 1541.38 Description: REPAIR ART INTRAMURAL Category: Medical Services CMS Add: 01/01/2006 CMS Term: 33507 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1242.43 Description: REPAIR ART INTRAMURAL Category: Medical Services CMS Add: 01/01/2006 CMS Term: 33508 MEDSV DEF RBRVS 01/01/2016 12/31/2023 11.71 Description: ENDOSCOPIC VEIN HARVEST Category: Medical Services CMS Add: 01/01/2003 CMS Term: 33508 MEDSV DEF RBRVS 01/01/2024 14.41 Description: ENDOSCOPIC VEIN HARVEST Category: Medical Services CMS Add: 01/01/2003 CMS Term: 33509 MEDSV DEF RBRVS 01/01/2022 12/31/2023 126.16 Description: NDSC HRV UXTR ART 1 SGM CAB Category: Medical Services CMS Add: 01/01/2022 CMS Term: 33509 MEDSV DEF RBRVS 01/01/2024 154.76 Description: NDSC HRV UXTR ART 1 SGM CAB Category: Medical Services CMS Add: 01/01/2022 CMS Term: 3350F NOCOV DEF SYSMAN Description: MAMMO BX PROVEN MALIG DOCD Category: Non Covered Services CMS Add: 04/01/2008 CMS Term: 33510 MEDSV DEF RBRVS 01/01/2024 1735.78 0-1 Description: CABG VEIN SINGLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33510 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1406.33 0-1 Description: CABG VEIN SINGLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 407 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33511 MEDSV DEF RBRVS 01/01/2024 1905.29 0-1 Description: CABG VEIN TWO Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33511 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1544.15 0-1 Description: CABG VEIN TWO Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33512 MEDSV DEF RBRVS 01/01/2024 2172.12 0-1 Description: CABG VEIN THREE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33512 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1755.66 0-1 Description: CABG VEIN THREE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33513 MEDSV DEF RBRVS 01/01/2024 2221.61 0-1 Description: CABG VEIN FOUR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33513 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1806.22 0-1 Description: CABG VEIN FOUR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33514 MEDSV DEF RBRVS 01/01/2024 2340.02 0-1 Description: CABG VEIN FIVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33514 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1906.20 0-1 Description: CABG VEIN FIVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33516 MEDSV DEF RBRVS 01/01/2024 2422.04 0-1 Description: CABG VEIN SIX OR MORE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33516 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1979.25 0-1 Description: CABG VEIN SIX OR MORE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33517 MEDSV DEF RBRVS 01/01/2024 166.87 0-1 Description: CABG ARTERY-VEIN SINGLE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 33517 MEDSV DEF RBRVS 02/01/2015 12/31/2023 136.55 0-1 Description: CABG ARTERY-VEIN SINGLE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 33518 MEDSV DEF RBRVS 01/01/2024 367.20 0-1 Description: CABG ARTERY-VEIN TWO Category: Medical Services CMS Add: 01/01/1993 CMS Term: 33518 MEDSV DEF RBRVS 02/01/2015 12/31/2023 300.27 0-1 Description: CABG ARTERY-VEIN TWO Category: Medical Services CMS Add: 01/01/1993 CMS Term: 33519 MEDSV DEF RBRVS 01/01/2024 485.37 0-1 Description: CABG ARTERY-VEIN THREE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 33519 MEDSV DEF RBRVS 02/01/2015 12/31/2023 396.96 0-1 Description: CABG ARTERY-VEIN THREE Category: Medical Services CMS Add: 01/01/1993 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 408 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 3351F NOCOV DEF SYSMAN Description: NEG SCRN DEP SYMP BY DEPTOOL Category: Non Covered Services CMS Add: 07/01/2008 CMS Term: 33521 MEDSV DEF RBRVS 01/01/2024 582.00 0-1 Description: CABG ARTERY-VEIN FOUR Category: Medical Services CMS Add: 01/01/1993 CMS Term: 33521 MEDSV DEF RBRVS 02/01/2015 12/31/2023 476.67 0-1 Description: CABG ARTERY-VEIN FOUR Category: Medical Services CMS Add: 01/01/1993 CMS Term: 33522 MEDSV DEF RBRVS 01/01/2024 653.61 0-1 Description: CABG ARTERY-VEIN FIVE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 33522 MEDSV DEF RBRVS 02/01/2015 12/31/2023 534.92 0-1 Description: CABG ARTERY-VEIN FIVE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 33523 MEDSV DEF RBRVS 01/01/2024 739.47 0-1 Description: CABG ART-VEIN SIX OR MORE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 33523 MEDSV DEF RBRVS 02/01/2015 12/31/2023 606.86 0-1 Description: CABG ART-VEIN SIX OR MORE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 3352F NOCOV DEF SYSMAN Description: NO SIG DEP SYMP BY DEP TOOL Category: Non Covered Services CMS Add: 07/01/2008 CMS Term: 33530 MEDSV DEF RBRVS 01/01/2019 12/31/2023 383.16 Description: CORONARY ARTERY BYPASS/REOP Category: Medical Services CMS Add: 01/01/1991 CMS Term: 33530 MEDSV DEF RBRVS 01/01/2024 468.63 Description: CORONARY ARTERY BYPASS/REOP Category: Medical Services CMS Add: 01/01/1991 CMS Term: 33533 MEDSV DEF RBRVS 01/01/2024 1680.05 0-1 Description: CABG ARTERIAL SINGLE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 33533 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1359.16 0-1 Description: CABG ARTERIAL SINGLE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 33534 MEDSV DEF RBRVS 01/01/2024 1972.66 0-1 Description: CABG ARTERIAL TWO Category: Medical Services CMS Add: 01/01/1993 CMS Term: 33534 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1598.10 0-1 Description: CABG ARTERIAL TWO Category: Medical Services CMS Add: 01/01/1993 CMS Term: 33535 MEDSV DEF RBRVS 01/01/2024 2194.26 0-1 Description: CABG ARTERIAL THREE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 33535 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1781.63 0-1 Description: CABG ARTERIAL THREE Category: Medical Services CMS Add: 01/01/1993 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 409 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33536 MEDSV DEF RBRVS 01/01/2024 2361.64 0-1 Description: CABG ARTERIAL FOUR OR MORE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 33536 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1912.63 0-1 Description: CABG ARTERIAL FOUR OR MORE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 3353F NOCOV DEF SYSMAN Description: MILD-MOD DEP SYMP BY DEPTOOL Category: Non Covered Services CMS Add: 07/01/2008 CMS Term: 33542 MEDSV DEF RBRVS 01/01/2024 2351.17 Description: REMOVAL OF HEART LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33542 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1909.69 Description: REMOVAL OF HEART LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33545 MEDSV DEF RBRVS 01/01/2024 2748.61 Description: REPAIR OF HEART DAMAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33545 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2247.81 Description: REPAIR OF HEART DAMAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33548 MEDSV DEF RBRVS 01/01/2024 2645.98 Description: RESTORE/REMODEL VENTRICLE Category: Medical Services CMS Add: 01/01/2006 CMS Term: 33548 MEDSV DEF RBRVS 02/01/2015 12/31/2023 2161.43 Description: RESTORE/REMODEL VENTRICLE Category: Medical Services CMS Add: 01/01/2006 CMS Term: 3354F NOCOV DEF SYSMAN Description: CLIN SIG DEP SYM BY DEP TOOL Category: Non Covered Services CMS Add: 07/01/2008 CMS Term: 33572 MEDSV DEF RBRVS 01/01/2019 12/31/2023 168.26 Description: OPEN CORONARY ENDARTERECTOMY Category: Medical Services CMS Add: 01/01/1995 CMS Term: 33572 MEDSV DEF RBRVS 01/01/2024 205.80 Description: OPEN CORONARY ENDARTERECTOMY Category: Medical Services CMS Add: 01/01/1995 CMS Term: 33600 MEDSV DEF RBRVS 01/01/2024 1543.94 Description: CLOSURE OF VALVE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33600 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1236.59 Description: CLOSURE OF VALVE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33602 MEDSV DEF RBRVS 01/01/2024 1499.03 Description: CLOSURE OF VALVE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33602 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1196.98 Description: CLOSURE OF VALVE Category: Medical Services CMS Add: 01/01/1994 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 410 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33606 MEDSV DEF RBRVS 01/01/2024 1596.59 Description: ANASTOMOSIS/ARTERY-AORTA Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33606 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1276.14 Description: ANASTOMOSIS/ARTERY-AORTA Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33608 MEDSV DEF RBRVS 01/01/2024 1616.68 Description: REPAIR ANOMALY W/CONDUIT Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33608 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1295.62 Description: REPAIR ANOMALY W/CONDUIT Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33610 MEDSV DEF RBRVS 01/01/2024 1594.79 Description: REPAIR BY ENLARGEMENT Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33610 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1277.85 Description: REPAIR BY ENLARGEMENT Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33611 MEDSV DEF RBRVS 01/01/2024 1746.02 Description: REPAIR DOUBLE VENTRICLE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33611 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1416.08 Description: REPAIR DOUBLE VENTRICLE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33612 MEDSV DEF RBRVS 01/01/2024 1792.42 Description: REPAIR DOUBLE VENTRICLE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33612 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1442.77 Description: REPAIR DOUBLE VENTRICLE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33615 MEDSV DEF RBRVS 01/01/2024 1791.17 Description: REPAIR MODIFIED FONTAN Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33615 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1460.75 Description: REPAIR MODIFIED FONTAN Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33617 MEDSV DEF RBRVS 01/01/2024 1939.50 Description: REPAIR SINGLE VENTRICLE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33617 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1558.62 Description: REPAIR SINGLE VENTRICLE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33619 MEDSV DEF RBRVS 01/01/2024 2463.68 Description: REPAIR SINGLE VENTRICLE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33619 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2065.17 Description: REPAIR SINGLE VENTRICLE Category: Medical Services CMS Add: 01/01/1994 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 411 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33620 MEDSV DEF RBRVS 01/01/2024 1476.43 Description: APPLY R&L PULM ART BANDS Category: Medical Services CMS Add: 01/01/2011 CMS Term: 33620 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1059.49 Description: APPLY R&L PULM ART BANDS Category: Medical Services CMS Add: 01/01/2011 CMS Term: 33621 MEDSV DEF RBRVS 01/01/2024 835.18 Description: TRANSTHOR CATH FOR STENT Category: Medical Services CMS Add: 01/01/2011 CMS Term: 33621 MEDSV DEF RBRVS 02/01/2015 12/31/2023 636.38 Description: TRANSTHOR CATH FOR STENT Category: Medical Services CMS Add: 01/01/2011 CMS Term: 33622 MEDSV DEF RBRVS 01/01/2024 3065.11 Description: REDO COMPL CARDIAC ANOMALY Category: Medical Services CMS Add: 01/01/2011 CMS Term: 33622 MEDSV DEF RBRVS 02/01/2015 12/31/2023 2503.47 Description: REDO COMPL CARDIAC ANOMALY Category: Medical Services CMS Add: 01/01/2011 CMS Term: 33641 MEDSV DEF RBRVS 01/01/2024 1468.14 Description: REPAIR HEART SEPTUM DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33641 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1188.41 Description: REPAIR HEART SEPTUM DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33645 MEDSV DEF RBRVS 01/01/2024 1551.26 Description: REVISION OF HEART VEINS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33645 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1255.10 Description: REVISION OF HEART VEINS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33647 MEDSV DEF RBRVS 01/01/2024 1626.89 Description: REPAIR HEART SEPTUM DEFECTS Category: Medical Services CMS Add: 01/01/1987 CMS Term: 33647 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1325.39 Description: REPAIR HEART SEPTUM DEFECTS Category: Medical Services CMS Add: 01/01/1987 CMS Term: 33660 MEDSV DEF RBRVS 01/01/2024 1572.53 Description: REPAIR OF HEART DEFECTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33660 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1274.46 Description: REPAIR OF HEART DEFECTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33665 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1396.23 Description: REPAIR OF HEART DEFECTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33665 MEDSV DEF RBRVS 01/01/2024 1712.55 Description: REPAIR OF HEART DEFECTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 412 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33670 MEDSV DEF RBRVS 01/01/2024 1762.51 Description: REPAIR OF HEART CHAMBERS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33670 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1439.93 Description: REPAIR OF HEART CHAMBERS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33675 MEDSV DEF RBRVS 01/01/2024 1764.20 Description: CLOSE MULT VSD Category: Medical Services CMS Add: 01/01/2007 CMS Term: 33675 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1431.07 Description: CLOSE MULT VSD Category: Medical Services CMS Add: 01/01/2007 CMS Term: 33676 MEDSV DEF RBRVS 01/01/2024 1811.08 Description: CLOSE MULT VSD W/RESECTION Category: Medical Services CMS Add: 01/01/2007 CMS Term: 33676 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1552.08 Description: CLOSE MULT VSD W/RESECTION Category: Medical Services CMS Add: 01/01/2007 CMS Term: 33677 MEDSV DEF RBRVS 01/01/2024 1880.35 Description: CL MULT VSD W/REM PUL BAND Category: Medical Services CMS Add: 01/01/2007 CMS Term: 33677 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1612.61 Description: CL MULT VSD W/REM PUL BAND Category: Medical Services CMS Add: 01/01/2007 CMS Term: 33681 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1331.02 Description: REPAIR HEART SEPTUM DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33681 MEDSV DEF RBRVS 01/01/2024 1656.74 Description: REPAIR HEART SEPTUM DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33684 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1370.37 Description: REPAIR HEART SEPTUM DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33684 MEDSV DEF RBRVS 01/01/2024 1690.66 Description: REPAIR HEART SEPTUM DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33688 MEDSV DEF RBRVS 01/01/2024 1684.14 Description: REPAIR HEART SEPTUM DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33688 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1368.12 Description: REPAIR HEART SEPTUM DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33690 MEDSV DEF RBRVS 01/01/2019 12/31/2023 862.48 Description: REINFORCE PULMONARY ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33690 MEDSV DEF RBRVS 01/01/2024 1082.94 Description: REINFORCE PULMONARY ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 413 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33692 MEDSV DEF RBRVS 01/01/2024 1748.63 Description: REPAIR OF HEART DEFECTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33692 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1503.33 Description: REPAIR OF HEART DEFECTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33694 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1423.26 Description: REPAIR OF HEART DEFECTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33694 MEDSV DEF RBRVS 01/01/2024 1746.02 Description: REPAIR OF HEART DEFECTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33697 MEDSV DEF RBRVS 01/01/2024 1839.12 Description: REPAIR OF HEART DEFECTS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33697 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1503.66 Description: REPAIR OF HEART DEFECTS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33702 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1119.84 Description: REPAIR OF HEART DEFECTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33702 MEDSV DEF RBRVS 01/01/2024 1390.18 Description: REPAIR OF HEART DEFECTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3370F NOCOV DEF SYSMAN Description: AJCC BRST CNCR STAGE 0 DOCD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 33710 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1533.99 Description: REPAIR OF HEART DEFECTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33710 MEDSV DEF RBRVS 01/01/2024 1836.13 Description: REPAIR OF HEART DEFECTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33720 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1119.79 Description: REPAIR OF HEART DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33720 MEDSV DEF RBRVS 01/01/2024 1390.86 Description: REPAIR OF HEART DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33724 MEDSV DEF RBRVS 01/01/2024 1378.14 Description: REPAIR VENOUS ANOMALY Category: Medical Services CMS Add: 01/01/2007 CMS Term: 33724 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1115.04 Description: REPAIR VENOUS ANOMALY Category: Medical Services CMS Add: 01/01/2007 CMS Term: 33726 MEDSV DEF RBRVS 01/01/2024 1818.23 Description: REPAIR PUL VENOUS STENOSIS Category: Medical Services CMS Add: 01/01/2007 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 414 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33726 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1505.53 Description: REPAIR PUL VENOUS STENOSIS Category: Medical Services CMS Add: 01/01/2007 CMS Term: 3372F NOCOV DEF SYSMAN Description: AJCC BRST CNCR STAGE 1 DOCD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 33730 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1453.77 Description: REPAIR HEART-VEIN DEFECT(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33730 MEDSV DEF RBRVS 01/01/2024 1798.61 Description: REPAIR HEART-VEIN DEFECT(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33732 MEDSV DEF RBRVS 01/01/2024 1481.31 Description: REPAIR HEART-VEIN DEFECT Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33732 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1259.53 Description: REPAIR HEART-VEIN DEFECT Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33735 MEDSV DEF RBRVS 01/01/2019 12/31/2023 937.93 Description: REVISION OF HEART CHAMBER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33735 MEDSV DEF RBRVS 01/01/2024 1167.96 Description: REVISION OF HEART CHAMBER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33736 MEDSV DEF RBRVS 01/01/2024 1266.38 Description: REVISION OF HEART CHAMBER Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33736 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1017.52 Description: REVISION OF HEART CHAMBER Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33737 MEDSV DEF RBRVS 01/01/2019 12/31/2023 976.81 Description: REVISION OF HEART CHAMBER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33737 MEDSV DEF RBRVS 01/01/2024 1168.81 Description: REVISION OF HEART CHAMBER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33741 MEDSV DEF RBRVS 01/01/2021 12/31/2023 557.17 Description: TAS CONGENITAL CAR ANOMAL Category: Medical Services CMS Add: 01/01/2021 CMS Term: 33741 MEDSV DEF RBRVS 01/01/2024 672.70 Description: TAS CONGENITAL CAR ANOMAL Category: Medical Services CMS Add: 01/01/2021 CMS Term: 33745 MEDSV DEF RBRVS 01/01/2021 12/31/2023 788.48 Description: TIS CGEN CAR ANOMAL 1ST SHNT Category: Medical Services CMS Add: 01/01/2021 CMS Term: 33745 MEDSV DEF RBRVS 01/01/2024 960.88 Description: TIS CGEN CAR ANOMAL 1ST SHNT Category: Medical Services CMS Add: 01/01/2021 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 415 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33746 MEDSV DEF RBRVS 01/01/2021 12/31/2023 311.64 Description: TIS CGEN CAR ANOMAL EA ADDL Category: Medical Services CMS Add: 01/01/2021 CMS Term: 33746 MEDSV DEF RBRVS 01/01/2024 384.19 Description: TIS CGEN CAR ANOMAL EA ADDL Category: Medical Services CMS Add: 01/01/2021 CMS Term: 3374F NOCOV DEF SYSMAN Description: AJCC BRST CNCR STAGE 1 DOCD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 33750 MEDSV DEF RBRVS 01/01/2024 1134.84 Description: MAJOR VESSEL SHUNT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 33750 MEDSV DEF RBRVS 02/01/2015 12/31/2023 952.20 Description: MAJOR VESSEL SHUNT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 33755 MEDSV DEF RBRVS 01/01/2019 12/31/2023 983.43 Description: MAJOR VESSEL SHUNT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 33755 MEDSV DEF RBRVS 01/01/2024 1186.52 Description: MAJOR VESSEL SHUNT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 33762 MEDSV DEF RBRVS 01/01/2019 12/31/2023 974.94 Description: MAJOR VESSEL SHUNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33762 MEDSV DEF RBRVS 01/01/2024 1152.25 Description: MAJOR VESSEL SHUNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33764 MEDSV DEF RBRVS 01/01/2019 12/31/2023 945.12 Description: MAJOR VESSEL SHUNT & GRAFT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 33764 MEDSV DEF RBRVS 01/01/2024 1186.52 Description: MAJOR VESSEL SHUNT & GRAFT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 33766 MEDSV DEF RBRVS 01/01/2024 1197.63 Description: MAJOR VESSEL SHUNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33766 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1000.99 Description: MAJOR VESSEL SHUNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33767 MEDSV DEF RBRVS 01/01/2024 1277.36 Description: MAJOR VESSEL SHUNT Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33767 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1036.09 Description: MAJOR VESSEL SHUNT Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33768 MEDSV DEF RBRVS 01/01/2024 371.01 Description: CAVOPULMONARY SHUNTING Category: Medical Services CMS Add: 01/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 416 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33768 MEDSV DEF RBRVS 02/01/2015 12/31/2023 322.38 Description: CAVOPULMONARY SHUNTING Category: Medical Services CMS Add: 01/01/2006 CMS Term: 3376F NOCOV DEF SYSMAN Description: AJCC BRSTCNCR STAGE 2 DOCD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 33770 MEDSV DEF RBRVS 01/01/2024 1892.66 Description: REPAIR GREAT VESSELS DEFECT Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33770 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1615.31 Description: REPAIR GREAT VESSELS DEFECT Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33771 MEDSV DEF RBRVS 01/01/2024 1945.63 Description: REPAIR GREAT VESSELS DEFECT Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33771 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1678.29 Description: REPAIR GREAT VESSELS DEFECT Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33774 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1310.17 Description: REPAIR GREAT VESSELS DEFECT Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33774 MEDSV DEF RBRVS 01/01/2024 1617.14 Description: REPAIR GREAT VESSELS DEFECT Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33775 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1411.49 Description: REPAIR GREAT VESSELS DEFECT Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33775 MEDSV DEF RBRVS 01/01/2024 1664.52 Description: REPAIR GREAT VESSELS DEFECT Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33776 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1420.22 Description: REPAIR GREAT VESSELS DEFECT Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33776 MEDSV DEF RBRVS 01/01/2024 1759.47 Description: REPAIR GREAT VESSELS DEFECT Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33777 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1445.42 Description: REPAIR GREAT VESSELS DEFECT Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33777 MEDSV DEF RBRVS 01/01/2024 1695.73 Description: REPAIR GREAT VESSELS DEFECT Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33778 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1799.66 Description: REPAIR GREAT VESSELS DEFECT Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33778 MEDSV DEF RBRVS 01/01/2024 2105.31 Description: REPAIR GREAT VESSELS DEFECT Category: Medical Services CMS Add: 01/01/1990 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 417 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33779 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1596.46 Description: REPAIR GREAT VESSELS DEFECT Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33779 MEDSV DEF RBRVS 01/01/2024 2077.20 Description: REPAIR GREAT VESSELS DEFECT Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33780 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1722.30 Description: REPAIR GREAT VESSELS DEFECT Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33780 MEDSV DEF RBRVS 01/01/2024 2116.68 Description: REPAIR GREAT VESSELS DEFECT Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33781 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1782.95 Description: REPAIR GREAT VESSELS DEFECT Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33781 MEDSV DEF RBRVS 01/01/2024 2065.41 Description: REPAIR GREAT VESSELS DEFECT Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33782 MEDSV DEF RBRVS 01/01/2024 2883.18 Description: NIKAIDOH PROC Category: Medical Services CMS Add: 01/01/2010 CMS Term: 33782 MEDSV DEF RBRVS 02/01/2015 12/31/2023 2392.70 Description: NIKAIDOH PROC Category: Medical Services CMS Add: 01/01/2010 CMS Term: 33783 MEDSV DEF RBRVS 01/01/2024 3115.32 Description: NIKAIDOH PROC W/OSTIA IMPLT Category: Medical Services CMS Add: 01/01/2010 CMS Term: 33783 MEDSV DEF RBRVS 02/01/2015 12/31/2023 2667.75 Description: NIKAIDOH PROC W/OSTIA IMPLT Category: Medical Services CMS Add: 01/01/2010 CMS Term: 33786 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1662.06 Description: REPAIR ARTERIAL TRUNK Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33786 MEDSV DEF RBRVS 01/01/2024 2037.69 Description: REPAIR ARTERIAL TRUNK Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33788 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1116.75 Description: REVISION OF PULMONARY ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33788 MEDSV DEF RBRVS 01/01/2024 1375.77 Description: REVISION OF PULMONARY ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3378F NOCOV DEF SYSMAN Description: AJCC BRSTCNCR STAGE 3 DOCD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 33800 MEDSV DEF RBRVS 01/01/2024 886.07 Description: AORTIC SUSPENSION Category: Medical Services CMS Add: 01/01/1993 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 418 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33800 MEDSV DEF RBRVS 09/01/2019 12/31/2023 662.88 Description: AORTIC SUSPENSION Category: Medical Services CMS Add: 01/01/1993 CMS Term: 33802 MEDSV DEF RBRVS 01/01/2019 12/31/2023 788.45 Description: REPAIR VESSEL DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33802 MEDSV DEF RBRVS 01/01/2024 978.43 Description: REPAIR VESSEL DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33803 MEDSV DEF RBRVS 01/01/2019 12/31/2023 874.18 Description: REPAIR VESSEL DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33803 MEDSV DEF RBRVS 01/01/2024 1034.61 Description: REPAIR VESSEL DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3380F NOCOV DEF SYSMAN Description: AJCC BRSTCNCR STAGE 4 DOCD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 33813 MEDSV DEF RBRVS 01/01/2019 12/31/2023 897.03 Description: REPAIR SEPTAL DEFECT Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33813 MEDSV DEF RBRVS 01/01/2024 1117.44 Description: REPAIR SEPTAL DEFECT Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33814 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1102.91 Description: REPAIR SEPTAL DEFECT Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33814 MEDSV DEF RBRVS 01/01/2024 1370.77 Description: REPAIR SEPTAL DEFECT Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33820 MEDSV DEF RBRVS 01/01/2019 12/31/2023 705.49 Description: REVISE MAJOR VESSEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33820 MEDSV DEF RBRVS 01/01/2024 870.77 Description: REVISE MAJOR VESSEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33822 MEDSV DEF RBRVS 01/01/2024 917.84 0-17years Description: REVISE MAJOR VESSEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33822 MEDSV DEF RBRVS 02/01/2015 12/31/2023 744.38 0-17years Description: REVISE MAJOR VESSEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33824 MEDSV DEF RBRVS 01/01/2019 12/31/2023 848.50 18-999years Description: REVISE MAJOR VESSEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33824 MEDSV DEF RBRVS 01/01/2024 1064.30 18-999years Description: REVISE MAJOR VESSEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 419 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 3382F NOCOV DEF SYSMAN Description: AJCC CLN CNCR STAGE 0 DOCD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 33840 MEDSV DEF RBRVS 01/01/2019 12/31/2023 936.70 Description: REMOVE AORTA CONSTRICTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33840 MEDSV DEF RBRVS 01/01/2024 1116.45 Description: REMOVE AORTA CONSTRICTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33845 MEDSV DEF RBRVS 01/01/2024 1201.76 Description: REMOVE AORTA CONSTRICTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33845 MEDSV DEF RBRVS 02/01/2015 12/31/2023 964.98 Description: REMOVE AORTA CONSTRICTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3384F NOCOV DEF SYSMAN Description: AJCC CLN CNCR STAGE 1 DOCD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 33851 MEDSV DEF RBRVS 01/01/2019 12/31/2023 962.24 Description: REMOVE AORTA CONSTRICTION Category: Medical Services CMS Add: 01/01/1987 CMS Term: 33851 MEDSV DEF RBRVS 01/01/2024 1146.11 Description: REMOVE AORTA CONSTRICTION Category: Medical Services CMS Add: 01/01/1987 CMS Term: 33852 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1018.20 Description: REPAIR SEPTAL DEFECT Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33852 MEDSV DEF RBRVS 01/01/2024 1258.95 Description: REPAIR SEPTAL DEFECT Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33853 MEDSV DEF RBRVS 01/01/2024 1646.00 Description: REPAIR SEPTAL DEFECT Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33853 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1334.93 Description: REPAIR SEPTAL DEFECT Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33858 MEDSV DEF RBRVS 01/01/2020 12/31/2023 2454.41 Description: AS-AORT GRF F/AORTIC DSJ Category: Medical Services CMS Add: 01/01/2020 CMS Term: 33858 MEDSV DEF RBRVS 01/01/2024 3037.88 Description: AS-AORT GRF F/AORTIC DSJ Category: Medical Services CMS Add: 01/01/2020 CMS Term: 33859 MEDSV DEF RBRVS 01/01/2020 12/31/2023 1762.28 Description: AS-AORT GRF F/DS OTH/THN DSJ Category: Medical Services CMS Add: 01/01/2020 CMS Term: 33859 MEDSV DEF RBRVS 01/01/2024 2182.85 Description: AS-AORT GRF F/DS OTH/THN DSJ Category: Medical Services CMS Add: 01/01/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 420 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33863 MEDSV DEF RBRVS 01/01/2024 2814.42 Description: ASCENDING AORTIC GRAFT Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33863 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2291.40 Description: ASCENDING AORTIC GRAFT Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33864 MEDSV DEF RBRVS 01/01/2024 2875.97 Description: ASCENDING AORTIC GRAFT Category: Medical Services CMS Add: 01/01/2008 CMS Term: 33864 MEDSV DEF RBRVS 02/01/2015 12/31/2023 2337.54 Description: ASCENDING AORTIC GRAFT Category: Medical Services CMS Add: 01/01/2008 CMS Term: 33866 MEDSV DEF RBRVS 01/01/2019 12/31/2023 747.31 Description: AORTIC HEMIARCH GRAFT Category: Medical Services CMS Add: 01/01/2019 CMS Term: 33866 MEDSV DEF RBRVS 01/01/2024 822.65 Description: AORTIC HEMIARCH GRAFT Category: Medical Services CMS Add: 01/01/2019 CMS Term: 3386F NOCOV DEF SYSMAN Description: AJCC CLN CNCR STAGE 2 DOCD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 33871 MEDSV DEF RBRVS 01/01/2020 12/31/2023 2358.54 Description: TRANSVRS A-ARCH GRF HYPTHRM Category: Medical Services CMS Add: 01/01/2020 CMS Term: 33871 MEDSV DEF RBRVS 01/01/2024 2913.50 Description: TRANSVRS A-ARCH GRF HYPTHRM Category: Medical Services CMS Add: 01/01/2020 CMS Term: 33875 MEDSV DEF RBRVS 01/01/2024 2454.22 Description: THORACIC AORTIC GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33875 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2002.07 Description: THORACIC AORTIC GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33877 MEDSV DEF RBRVS 01/01/2024 3216.93 Description: THORACOABDOMINAL GRAFT Category: Medical Services CMS Add: 01/01/1989 CMS Term: 33877 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2656.55 Description: THORACOABDOMINAL GRAFT Category: Medical Services CMS Add: 01/01/1989 CMS Term: 33880 MEDSV DEF RBRVS 01/01/2024 1597.03 Description: ENDOVASC TAA REPR INCL SUBCL Category: Medical Services CMS Add: 01/01/2006 CMS Term: 33880 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1322.75 Description: ENDOVASC TAA REPR INCL SUBCL Category: Medical Services CMS Add: 01/01/2006 CMS Term: 33881 MEDSV DEF RBRVS 01/01/2024 1368.91 Description: ENDOVASC TAA REPR W/O SUBCL Category: Medical Services CMS Add: 01/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 421 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33881 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1137.79 Description: ENDOVASC TAA REPR W/O SUBCL Category: Medical Services CMS Add: 01/01/2006 CMS Term: 33883 MEDSV DEF RBRVS 01/01/2024 993.73 Description: INSERT ENDOVASC PROSTH TAA Category: Medical Services CMS Add: 01/01/2006 CMS Term: 33883 MEDSV DEF RBRVS 02/01/2015 12/31/2023 824.13 Description: INSERT ENDOVASC PROSTH TAA Category: Medical Services CMS Add: 01/01/2006 CMS Term: 33884 MEDSV DEF RBRVS 01/01/2024 349.73 Description: ENDOVASC PROSTH TAA ADD-ON Category: Medical Services CMS Add: 01/01/2006 CMS Term: 33884 MEDSV DEF RBRVS 02/01/2015 12/31/2023 302.40 Description: ENDOVASC PROSTH TAA ADD-ON Category: Medical Services CMS Add: 01/01/2006 CMS Term: 33886 MEDSV DEF RBRVS 01/01/2024 858.20 Description: ENDOVASC PROSTH DELAYED Category: Medical Services CMS Add: 01/01/2006 CMS Term: 33886 MEDSV DEF RBRVS 02/01/2015 12/31/2023 714.46 Description: ENDOVASC PROSTH DELAYED Category: Medical Services CMS Add: 01/01/2006 CMS Term: 33889 MEDSV DEF RBRVS 01/01/2024 705.79 Description: ARTERY TRANSPOSE/ENDOVAS TAA Category: Medical Services CMS Add: 01/01/2006 CMS Term: 33889 MEDSV DEF RBRVS 02/01/2015 12/31/2023 586.46 Description: ARTERY TRANSPOSE/ENDOVAS TAA Category: Medical Services CMS Add: 01/01/2006 CMS Term: 3388F NOCOV DEF SYSMAN Description: AJCC CLN CNCR STAGE 3 DOCD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 33891 MEDSV DEF RBRVS 01/01/2024 853.06 Description: CAR-CAR BP GRFT/ENDOVAS TAA Category: Medical Services CMS Add: 01/01/2006 CMS Term: 33891 MEDSV DEF RBRVS 02/01/2015 12/31/2023 717.64 Description: CAR-CAR BP GRFT/ENDOVAS TAA Category: Medical Services CMS Add: 01/01/2006 CMS Term: 33894 MEDSV DEF RBRVS 01/01/2022 12/31/2023 713.84 Description: EVASC ST RPR THRC/AA ACRS BR Category: Medical Services CMS Add: 01/01/2022 CMS Term: 33894 MEDSV DEF RBRVS 01/01/2024 877.93 Description: EVASC ST RPR THRC/AA ACRS BR Category: Medical Services CMS Add: 01/01/2022 CMS Term: 33895 MEDSV DEF RBRVS 01/01/2022 12/31/2023 567.95 Description: EVASC ST RPR THRC/AA X CRSG Category: Medical Services CMS Add: 01/01/2022 CMS Term: 33895 MEDSV DEF RBRVS 01/01/2024 698.48 Description: EVASC ST RPR THRC/AA X CRSG Category: Medical Services CMS Add: 01/01/2022 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 422 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33897 MEDSV DEF RBRVS 01/01/2022 12/31/2023 422.65 Description: PERQ TRLUML ANGP NT/RECR COA Category: Medical Services CMS Add: 01/01/2022 CMS Term: 33897 MEDSV DEF RBRVS 01/01/2024 519.51 Description: PERQ TRLUML ANGP NT/RECR COA Category: Medical Services CMS Add: 01/01/2022 CMS Term: 33900 MEDSV DEF RBRVS 01/01/2023 529.42 Description: PERQ P-ART REVSC 1 NM NT UNI Category: Medical Services CMS Add: 01/01/2023 CMS Term: 33901 MEDSV DEF RBRVS 01/01/2023 695.93 Description: PERQ P-ART REVSC 1 NM NT BI Category: Medical Services CMS Add: 01/01/2023 CMS Term: 33902 MEDSV DEF RBRVS 01/01/2023 672.14 Description: PERQ P-ART REVSC 1 ABNOR UNI Category: Medical Services CMS Add: 01/01/2023 CMS Term: 33903 MEDSV DEF RBRVS 01/01/2023 792.22 Description: PERQ P-ART REVSC 1 ABNOR BI Category: Medical Services CMS Add: 01/01/2023 CMS Term: 33904 MEDSV DEF RBRVS 01/01/2023 265.77 Description: PERQ P-ART REVSC EACH ADDL Category: Medical Services CMS Add: 01/01/2023 CMS Term: 3390F NOCOV DEF SYSMAN Description: AJCC CLN CNCR STAGE 4 DOCD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 33910 MEDSV DEF RBRVS 01/01/2024 2364.50 Description: REMOVE LUNG ARTERY EMBOLI Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33910 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1924.64 Description: REMOVE LUNG ARTERY EMBOLI Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33915 MEDSV DEF RBRVS 01/01/2024 1236.78 Description: REMOVE LUNG ARTERY EMBOLI Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33915 MEDSV DEF RBRVS 09/01/2019 12/31/2023 928.17 Description: REMOVE LUNG ARTERY EMBOLI Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33916 MEDSV DEF RBRVS 01/01/2024 3733.77 Description: SURGERY OF GREAT VESSEL Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33916 MEDSV DEF RBRVS 09/01/2019 12/31/2023 3055.61 Description: SURGERY OF GREAT VESSEL Category: Medical Services CMS Add: 01/01/1990 CMS Term: 33917 MEDSV DEF RBRVS 01/01/2024 1311.94 Description: REPAIR PULMONARY ARTERY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33917 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1048.47 Description: REPAIR PULMONARY ARTERY Category: Medical Services CMS Add: 01/01/1994 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 423 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33920 MEDSV DEF RBRVS 01/01/2024 1622.67 Description: REPAIR PULMONARY ATRESIA Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33920 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1318.73 Description: REPAIR PULMONARY ATRESIA Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33922 MEDSV DEF RBRVS 01/01/2024 1249.69 Description: TRANSECT PULMONARY ARTERY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33922 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1011.12 Description: TRANSECT PULMONARY ARTERY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33924 MEDSV DEF RBRVS 01/01/2024 254.52 Description: REMOVE PULMONARY SHUNT Category: Medical Services CMS Add: 01/01/1996 CMS Term: 33924 MEDSV DEF RBRVS 02/01/2015 12/31/2023 206.30 Description: REMOVE PULMONARY SHUNT Category: Medical Services CMS Add: 01/01/1996 CMS Term: 33925 MEDSV DEF RBRVS 01/01/2024 1537.06 Description: RPR PUL ART UNIFOCAL W/O CPB Category: Medical Services CMS Add: 01/01/2006 CMS Term: 33925 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1238.50 Description: RPR PUL ART UNIFOCAL W/O CPB Category: Medical Services CMS Add: 01/01/2006 CMS Term: 33926 MEDSV DEF RBRVS 01/01/2024 2159.45 Description: REPR PUL ART UNIFOCAL W/CPB Category: Medical Services CMS Add: 01/01/2006 CMS Term: 33926 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1754.76 Description: REPR PUL ART UNIFOCAL W/CPB Category: Medical Services CMS Add: 01/01/2006 CMS Term: 33927 MEDSV DEF RBRVS 01/01/2018 12/31/2023 1837.70 Y Description: IMPLTJ TOT RPLCMT HRT SYS Category: Medical Services CMS Add: 01/01/2018 CMS Term: 33927 MEDSV DEF RBRVS 01/01/2024 2272.57 Y Description: IMPLTJ TOT RPLCMT HRT SYS Category: Medical Services CMS Add: 01/01/2018 CMS Term: 33928 MEDSV DEF MAXFEE 01/01/2024 1898.86 0.0 Y Description: RMVL & RPLCMT TOT HRT SYS Category: Medical Services CMS Add: 01/01/2018 CMS Term: 33929 MEDSV DEF MAXFEE 01/01/2024 1727.29 0.0 Y Description: RMVL RPLCMT HRT SYS F/TRNSPL Category: Medical Services CMS Add: 01/01/2018 CMS Term: 33930 MEDSV DEF BILL20 Description: REMOVAL OF DONOR HEART/LUNG Category: Medical Services CMS Add: 01/01/1986 CMS Term: 33933 MEDSV DEF MAXFEE 01/01/2024 359.56 0.0 Y Description: PREPARE DONOR HEART/LUNG Category: Medical Services CMS Add: 01/01/2005 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 424 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33935 MEDSV DEF RBRVS 01/01/2019 12/31/2023 3630.48 Y Description: TRANSPLANTATION HEART/LUNG Category: Medical Services CMS Add: 01/01/1986 CMS Term: 33935 MEDSV DEF RBRVS 01/01/2024 4416.87 Y Description: TRANSPLANTATION HEART/LUNG Category: Medical Services CMS Add: 01/01/1986 CMS Term: 33940 MEDSV PRF MAXFEE 01/01/2024 3566.59 0.0 Description: REMOVAL OF DONOR HEART Category: Medical Services CMS Add: 01/01/1986 CMS Term: 33944 MEDSV DEF MAXFEE 01/01/2024 498.75 0.0 Y Description: PREPARE DONOR HEART Category: Medical Services CMS Add: 01/01/2005 CMS Term: 33945 MEDSV DEF RBRVS 01/01/2019 12/31/2023 3525.61 Y Description: TRANSPLANTATION OF HEART Category: Medical Services CMS Add: 01/01/1986 CMS Term: 33945 MEDSV DEF RBRVS 01/01/2024 4359.16 Y Description: TRANSPLANTATION OF HEART Category: Medical Services CMS Add: 01/01/1986 CMS Term: 33946 MEDSV DEF RBRVS 01/01/2024 279.16 Description: ECMO/ECLS INITIATION VENOUS Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33946 MEDSV DEF RBRVS 02/01/2015 12/31/2023 225.95 Description: ECMO/ECLS INITIATION VENOUS Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33947 MEDSV DEF RBRVS 01/01/2024 308.48 Description: ECMO/ECLS INITIATION ARTERY Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33947 MEDSV DEF RBRVS 02/01/2015 12/31/2023 249.56 Description: ECMO/ECLS INITIATION ARTERY Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33948 MEDSV DEF RBRVS 01/01/2024 217.46 Description: ECMO/ECLS DAILY MGMT-VENOUS Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33948 MEDSV DEF RBRVS 02/01/2015 12/31/2023 178.86 Description: ECMO/ECLS DAILY MGMT-VENOUS Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33949 MEDSV DEF RBRVS 01/01/2024 211.17 Description: ECMO/ECLS DAILY MGMT ARTERY Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33949 MEDSV DEF RBRVS 02/01/2015 12/31/2023 174.05 Description: ECMO/ECLS DAILY MGMT ARTERY Category: Medical Services CMS Add: 01/01/2015 CMS Term: 3394F NOCOV DEF SYSMAN Description: QUANT HER2 IHC EVAL BRST CX Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: 33951 MEDSV DEF RBRVS 01/01/2024 378.51 0-5years Description: ECMO/ECLS INSJ PRPH CANNULA Category: Medical Services CMS Add: 01/01/2015 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 425 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33951 MEDSV DEF RBRVS 02/01/2015 12/31/2023 320.46 0-5years Description: ECMO/ECLS INSJ PRPH CANNULA Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33952 MEDSV DEF RBRVS 01/01/2024 383.41 6-999years Description: ECMO/ECLS INSJ PRPH CANNULA Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33952 MEDSV DEF RBRVS 02/01/2015 12/31/2023 312.12 6-999years Description: ECMO/ECLS INSJ PRPH CANNULA Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33953 MEDSV DEF RBRVS 01/01/2024 422.28 0-5years Description: ECMO/ECLS INSJ PRPH CANNULA Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33953 MEDSV DEF RBRVS 02/01/2015 12/31/2023 357.65 0-5years Description: ECMO/ECLS INSJ PRPH CANNULA Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33954 MEDSV DEF RBRVS 01/01/2024 425.24 6-999years Description: ECMO/ECLS INSJ PRPH CANNULA Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33954 MEDSV DEF RBRVS 02/01/2015 12/31/2023 348.65 6-999years Description: ECMO/ECLS INSJ PRPH CANNULA Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33955 MEDSV DEF RBRVS 01/01/2024 738.90 0-5years Description: ECMO/ECLS INSJ CTR CANNULA Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33955 MEDSV DEF RBRVS 02/01/2015 12/31/2023 645.75 0-5years Description: ECMO/ECLS INSJ CTR CANNULA Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33956 MEDSV DEF RBRVS 01/01/2024 746.11 6-999years Description: ECMO/ECLS INSJ CTR CANNULA Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33956 MEDSV DEF RBRVS 02/01/2015 12/31/2023 611.07 6-999years Description: ECMO/ECLS INSJ CTR CANNULA Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33957 MEDSV DEF RBRVS 01/01/2024 164.69 0-5years Description: ECMO/ECLS REPOS PERPH CNULA Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33957 MEDSV DEF RBRVS 02/01/2015 12/31/2023 143.44 0-5years Description: ECMO/ECLS REPOS PERPH CNULA Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33958 MEDSV DEF RBRVS 01/01/2024 164.69 6-999years Description: ECMO/ECLS REPOS PERPH CNULA Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33958 MEDSV DEF RBRVS 02/01/2015 12/31/2023 138.73 6-999years Description: ECMO/ECLS REPOS PERPH CNULA Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33959 MEDSV DEF RBRVS 01/01/2024 208.63 0-5years Description: ECMO/ECLS REPOS PERPH CNULA Category: Medical Services CMS Add: 01/01/2015 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 426 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33959 MEDSV DEF RBRVS 02/01/2015 12/31/2023 182.20 0-5years Description: ECMO/ECLS REPOS PERPH CNULA Category: Medical Services CMS Add: 01/01/2015 CMS Term: 3395F NOCOV DEF SYSMAN Description: QUANT NONHER2 IHC BRST CX Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: 33962 MEDSV DEF RBRVS 01/01/2024 208.63 6-999years Description: ECMO/ECLS REPOS PERPH CNULA Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33962 MEDSV DEF RBRVS 02/01/2015 12/31/2023 171.05 6-999years Description: ECMO/ECLS REPOS PERPH CNULA Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33963 MEDSV DEF RBRVS 01/01/2024 417.15 0-5years Description: ECMO/ECLS REPOS PERPH CNULA Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33963 MEDSV DEF RBRVS 02/01/2015 12/31/2023 363.95 0-5years Description: ECMO/ECLS REPOS PERPH CNULA Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33964 MEDSV DEF RBRVS 01/01/2024 440.34 6-999years Description: ECMO/ECLS REPOS PERPH CNULA Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33964 MEDSV DEF RBRVS 02/01/2015 12/31/2023 372.51 6-999years Description: ECMO/ECLS REPOS PERPH CNULA Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33965 MEDSV DEF RBRVS 01/01/2024 164.69 0-5years Description: ECMO/ECLS RMVL PERPH CANNULA Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33965 MEDSV DEF RBRVS 02/01/2015 12/31/2023 143.44 0-5years Description: ECMO/ECLS RMVL PERPH CANNULA Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33966 MEDSV DEF RBRVS 01/01/2024 211.94 6-999years Description: ECMO/ECLS RMVL PRPH CANNULA Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33966 MEDSV DEF RBRVS 02/01/2015 12/31/2023 172.27 6-999years Description: ECMO/ECLS RMVL PRPH CANNULA Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33967 MEDSV DEF RBRVS 01/01/2024 231.40 Description: INSERT I-AORT PERCUT DEVICE Category: Medical Services CMS Add: 01/01/2002 CMS Term: 33967 MEDSV DEF RBRVS 02/01/2015 12/31/2023 187.43 Description: INSERT I-AORT PERCUT DEVICE Category: Medical Services CMS Add: 01/01/2002 CMS Term: 33968 MEDSV DEF RBRVS 01/01/2024 30.42 0-1 Description: REMOVE AORTIC ASSIST DEVICE Category: Medical Services CMS Add: 01/01/2000 CMS Term: 33968 MEDSV DEF RBRVS 09/01/2019 12/31/2023 24.54 0-1 Description: REMOVE AORTIC ASSIST DEVICE Category: Medical Services CMS Add: 01/01/2000 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 427 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33969 MEDSV DEF RBRVS 01/01/2024 243.43 0-5years Description: ECMO/ECLS RMVL PERPH CANNULA Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33969 MEDSV DEF RBRVS 02/01/2015 12/31/2023 211.68 0-5years Description: ECMO/ECLS RMVL PERPH CANNULA Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33970 MEDSV DEF RBRVS 01/01/2024 317.08 Description: AORTIC CIRCULATION ASSIST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33970 MEDSV DEF RBRVS 09/01/2019 12/31/2023 257.64 Description: AORTIC CIRCULATION ASSIST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 33971 MEDSV DEF RBRVS 01/01/2024 637.96 Description: AORTIC CIRCULATION ASSIST Category: Medical Services CMS Add: 01/01/1987 CMS Term: 33971 MEDSV DEF RBRVS 09/01/2019 12/31/2023 514.06 Description: AORTIC CIRCULATION ASSIST Category: Medical Services CMS Add: 01/01/1987 CMS Term: 33973 MEDSV DEF RBRVS 01/01/2024 448.55 Description: INSERT BALLOON DEVICE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33973 MEDSV DEF RBRVS 09/01/2019 12/31/2023 373.69 Description: INSERT BALLOON DEVICE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33974 MEDSV DEF RBRVS 01/01/2024 804.38 Description: REMOVE INTRA-AORTIC BALLOON Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33974 MEDSV DEF RBRVS 09/01/2019 12/31/2023 644.05 Description: REMOVE INTRA-AORTIC BALLOON Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33975 MEDSV DEF RBRVS 01/01/2024 1161.03 Description: IMPLANT VENTRICULAR DEVICE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33975 MEDSV DEF RBRVS 09/01/2019 12/31/2023 965.11 Description: IMPLANT VENTRICULAR DEVICE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33976 MEDSV DEF RBRVS 01/01/2024 1413.97 Description: IMPLANT VENTRICULAR DEVICE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33976 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1172.62 Description: IMPLANT VENTRICULAR DEVICE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33977 MEDSV DEF RBRVS 01/01/2024 1005.46 Description: REMOVE VENTRICULAR DEVICE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33977 MEDSV DEF RBRVS 09/01/2019 12/31/2023 820.59 Description: REMOVE VENTRICULAR DEVICE Category: Medical Services CMS Add: 01/01/1994 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 428 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33978 MEDSV DEF RBRVS 01/01/2024 1190.02 Description: REMOVE VENTRICULAR DEVICE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33978 MEDSV DEF RBRVS 09/01/2019 12/31/2023 976.50 Description: REMOVE VENTRICULAR DEVICE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 33979 MEDSV DEF RBRVS 01/01/2024 1736.34 Description: INSERT INTRACORPOREAL DEVICE Category: Medical Services CMS Add: 01/01/2002 CMS Term: 33979 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1421.69 Description: INSERT INTRACORPOREAL DEVICE Category: Medical Services CMS Add: 01/01/2002 CMS Term: 33980 MEDSV DEF RBRVS 01/01/2024 1590.64 Description: REMOVE INTRACORPOREAL DEVICE Category: Medical Services CMS Add: 01/01/2002 CMS Term: 33980 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1298.52 Description: REMOVE INTRACORPOREAL DEVICE Category: Medical Services CMS Add: 01/01/2002 CMS Term: 33981 MEDSV DEF RBRVS 01/01/2024 740.80 Description: REPLACE VAD PUMP EXT Category: Medical Services CMS Add: 01/01/2010 CMS Term: 33981 MEDSV DEF RBRVS 02/01/2015 12/31/2023 609.73 Description: REPLACE VAD PUMP EXT Category: Medical Services CMS Add: 01/01/2010 CMS Term: 33982 MEDSV DEF RBRVS 01/01/2024 1740.72 Description: REPLACE VAD INTRA W/O BP Category: Medical Services CMS Add: 01/01/2010 CMS Term: 33982 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1426.99 Description: REPLACE VAD INTRA W/O BP Category: Medical Services CMS Add: 01/01/2010 CMS Term: 33983 MEDSV DEF RBRVS 01/01/2024 2065.41 Description: REPLACE VAD INTRA W/BP Category: Medical Services CMS Add: 01/01/2010 CMS Term: 33983 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1681.53 Description: REPLACE VAD INTRA W/BP Category: Medical Services CMS Add: 01/01/2010 CMS Term: 33984 MEDSV DEF RBRVS 01/01/2024 253.48 6-999years Description: ECMO/ECLS RMVL PRPH CANNULA Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33984 MEDSV DEF RBRVS 02/01/2015 12/31/2023 207.73 6-999years Description: ECMO/ECLS RMVL PRPH CANNULA Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33985 MEDSV DEF RBRVS 01/01/2024 458.57 0-5years Description: ECMO/ECLS RMVL CTR CANNULA Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33985 MEDSV DEF RBRVS 02/01/2015 12/31/2023 398.51 0-5years Description: ECMO/ECLS RMVL CTR CANNULA Category: Medical Services CMS Add: 01/01/2015 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 429 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33986 MEDSV DEF RBRVS 01/01/2024 467.90 6-999years Description: ECMO/ECLS RMVL CTR CANNULA Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33986 MEDSV DEF RBRVS 02/01/2015 12/31/2023 378.68 6-999years Description: ECMO/ECLS RMVL CTR CANNULA Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33987 MEDSV DEF RBRVS 01/01/2024 185.51 Description: ARTERY EXPOS/GRAFT ARTERY Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33987 MEDSV DEF RBRVS 02/01/2015 12/31/2023 151.90 Description: ARTERY EXPOS/GRAFT ARTERY Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33988 MEDSV DEF RBRVS 01/01/2024 693.14 Description: INSERTION OF LEFT HEART VENT Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33988 MEDSV DEF RBRVS 02/01/2015 12/31/2023 565.12 Description: INSERTION OF LEFT HEART VENT Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33989 MEDSV DEF RBRVS 01/01/2024 440.34 Description: REMOVAL OF LEFT HEART VENT Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33989 MEDSV DEF RBRVS 02/01/2015 12/31/2023 359.30 Description: REMOVAL OF LEFT HEART VENT Category: Medical Services CMS Add: 01/01/2015 CMS Term: 33990 MEDSV DEF RBRVS 01/01/2024 323.43 0-1 Description: INSJ PERQ VAD L HRT ARTERIAL Category: Medical Services CMS Add: 01/01/2013 CMS Term: 33990 MEDSV DEF RBRVS 09/15/2017 12/31/2023 309.04 0-1 Description: INSJ PERQ VAD L HRT ARTERIAL Category: Medical Services CMS Add: 01/01/2013 CMS Term: 33991 MEDSV DEF RBRVS 01/01/2024 406.77 0-1 Description: INSJ PERQ VAD L HRT ARTL&VEN Category: Medical Services CMS Add: 01/01/2013 CMS Term: 33991 MEDSV DEF RBRVS 09/15/2017 12/31/2023 452.78 0-1 Description: INSJ PERQ VAD L HRT ARTL&VEN Category: Medical Services CMS Add: 01/01/2013 CMS Term: 33992 MEDSV DEF RBRVS 01/01/2024 167.90 0-1 Description: RMVL PERQ LEFT HEART VAD Category: Medical Services CMS Add: 01/01/2013 CMS Term: 33992 MEDSV DEF RBRVS 09/15/2017 12/31/2023 145.51 0-1 Description: RMVL PERQ LEFT HEART VAD Category: Medical Services CMS Add: 01/01/2013 CMS Term: 33993 MEDSV DEF RBRVS 01/01/2024 149.47 0-1 Description: REPOSG PERQ R/L HRT VAD Category: Medical Services CMS Add: 01/01/2013 CMS Term: 33993 MEDSV DEF RBRVS 09/15/2017 12/31/2023 127.15 0-1 Description: REPOSG PERQ R/L HRT VAD Category: Medical Services CMS Add: 01/01/2013 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 430 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 33995 MEDSV DEF RBRVS 01/01/2021 12/31/2023 267.24 Description: INSJ PERQ VAD R HRT VENOUS Category: Medical Services CMS Add: 01/01/2021 CMS Term: 33995 MEDSV DEF RBRVS 01/01/2024 321.92 Description: INSJ PERQ VAD R HRT VENOUS Category: Medical Services CMS Add: 01/01/2021 CMS Term: 33997 MEDSV DEF RBRVS 01/01/2021 12/31/2023 118.84 Description: RMVL PERQ RIGHT HEART VAD Category: Medical Services CMS Add: 01/01/2021 CMS Term: 33997 MEDSV DEF RBRVS 01/01/2024 141.92 Description: RMVL PERQ RIGHT HEART VAD Category: Medical Services CMS Add: 01/01/2021 CMS Term: 33999 MEDSV DEF BILL20 Description: UNLISTED PX CARDIAC SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 34001 MEDSV DEF RBRVS 01/01/2024 814.52 Description: REMOVAL OF ARTERY CLOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 34001 MEDSV DEF RBRVS 09/01/2019 12/31/2023 706.42 Description: REMOVAL OF ARTERY CLOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 34051 MEDSV DEF RBRVS 01/01/2024 896.70 Description: REMOVAL OF ARTERY CLOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 34051 MEDSV DEF RBRVS 09/01/2019 12/31/2023 721.23 Description: REMOVAL OF ARTERY CLOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 34101 MEDSV DEF RBRVS 01/01/2024 533.75 Description: REMOVAL OF ARTERY CLOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 34101 MEDSV DEF RBRVS 09/01/2019 12/31/2023 442.97 Description: REMOVAL OF ARTERY CLOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 34111 MEDSV DEF RBRVS 01/01/2024 535.90 Description: REMOVAL OF ARM ARTERY CLOT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 34111 MEDSV DEF RBRVS 09/01/2019 12/31/2023 442.89 Description: REMOVAL OF ARM ARTERY CLOT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 34151 MEDSV DEF RBRVS 01/01/2024 1242.30 Description: REMOVAL OF ARTERY CLOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 34151 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1034.76 Description: REMOVAL OF ARTERY CLOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 34201 MEDSV DEF RBRVS 01/01/2024 910.05 Description: REMOVAL OF ARTERY CLOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 431 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 34201 MEDSV DEF RBRVS 09/01/2019 12/31/2023 761.55 Description: REMOVAL OF ARTERY CLOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 34203 MEDSV DEF RBRVS 01/01/2024 844.86 Description: REMOVAL OF LEG ARTERY CLOT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 34203 MEDSV DEF RBRVS 09/01/2019 12/31/2023 706.54 Description: REMOVAL OF LEG ARTERY CLOT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 34401 MEDSV DEF RBRVS 01/01/2024 1336.01 Description: REMOVAL OF VEIN CLOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 34401 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1070.43 Description: REMOVAL OF VEIN CLOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 34421 MEDSV DEF RBRVS 01/01/2024 619.14 Description: REMOVAL OF VEIN CLOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 34421 MEDSV DEF RBRVS 09/01/2019 12/31/2023 536.19 Description: REMOVAL OF VEIN CLOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 34451 MEDSV DEF RBRVS 01/01/2024 1276.81 Description: REMOVAL OF VEIN CLOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 34451 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1067.03 Description: REMOVAL OF VEIN CLOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 34471 MEDSV DEF RBRVS 01/01/2024 960.77 Description: REMOVAL OF VEIN CLOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 34471 MEDSV DEF RBRVS 09/01/2019 12/31/2023 792.79 Description: REMOVAL OF VEIN CLOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 34490 MEDSV DEF RBRVS 01/01/2024 583.40 Description: REMOVAL OF VEIN CLOT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 34490 MEDSV DEF RBRVS 09/01/2019 12/31/2023 445.98 Description: REMOVAL OF VEIN CLOT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 34501 MEDSV DEF RBRVS 01/01/2019 12/31/2023 724.08 Description: REPAIR VALVE FEMORAL VEIN Category: Medical Services CMS Add: 01/01/1986 CMS Term: 34501 MEDSV DEF RBRVS 01/01/2024 797.35 Description: REPAIR VALVE FEMORAL VEIN Category: Medical Services CMS Add: 01/01/1986 CMS Term: 34502 MEDSV DEF RBRVS 01/01/2024 1383.47 Description: RECONSTRUCT VENA CAVA Category: Medical Services CMS Add: 01/01/1994 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 432 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 34502 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1115.46 Description: RECONSTRUCT VENA CAVA Category: Medical Services CMS Add: 01/01/1994 CMS Term: 3450F NOCOV DEF SYSMAN Description: DYSPNEA SCRND NO-MILD DYSP Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 34510 MEDSV DEF RBRVS 01/01/2019 12/31/2023 854.76 Description: TRANSPOSITION OF VEIN VALVE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 34510 MEDSV DEF RBRVS 01/01/2024 909.41 Description: TRANSPOSITION OF VEIN VALVE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 3451F NOCOV DEF SYSMAN Description: DYSPNEA SCRND MOD-HIGH DYSP Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 34520 MEDSV DEF RBRVS 01/01/2019 12/31/2023 734.08 Description: CROSS-OVER VEIN GRAFT Category: Medical Services CMS Add: 01/01/1986 CMS Term: 34520 MEDSV DEF RBRVS 01/01/2024 881.64 Description: CROSS-OVER VEIN GRAFT Category: Medical Services CMS Add: 01/01/1986 CMS Term: 3452F NOCOV DEF SYSMAN Description: DYSPNEA NOT SCREENED Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 34530 MEDSV DEF RBRVS 01/01/2019 12/31/2023 793.72 Description: LEG VEIN FUSION Category: Medical Services CMS Add: 01/01/1986 CMS Term: 34530 MEDSV DEF RBRVS 01/01/2024 839.38 Description: LEG VEIN FUSION Category: Medical Services CMS Add: 01/01/1986 CMS Term: 3455F NOCOV DEF SYSMAN Description: TB SCR PFRMD&INTERPD 6 MO Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 34701 MEDSV DEF RBRVS 01/01/2018 12/31/2023 894.03 Description: EVASC RPR A-AO NDGFT Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34701 MEDSV DEF RBRVS 01/01/2024 1103.79 Description: EVASC RPR A-AO NDGFT Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34702 MEDSV DEF RBRVS 01/01/2018 12/31/2023 1337.45 Description: EVASC RPR A-AO NDGFT RPT Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34702 MEDSV DEF RBRVS 01/01/2024 1644.64 Description: EVASC RPR A-AO NDGFT RPT Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34703 MEDSV DEF RBRVS 01/01/2018 12/31/2023 1003.55 Description: EVASC RPR A-UNILAC NDGFT Category: Medical Services CMS Add: 01/01/2018 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 433 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 34703 MEDSV DEF RBRVS 01/01/2024 1225.46 Description: EVASC RPR A-UNILAC NDGFT Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34704 MEDSV DEF RBRVS 01/01/2018 12/31/2023 1672.58 Description: EVASC RPR A-UNILAC NDGFT RPT Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34704 MEDSV DEF RBRVS 01/01/2024 2039.76 Description: EVASC RPR A-UNILAC NDGFT RPT Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34705 MEDSV DEF RBRVS 01/01/2018 12/31/2023 1109.22 Description: EVAC RPR A-BIILIAC NDGFT Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34705 MEDSV DEF RBRVS 01/01/2024 1360.30 Description: EVAC RPR A-BIILIAC NDGFT Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34706 MEDSV DEF RBRVS 01/01/2018 12/31/2023 1670.02 Description: EVASC RPR A-BIILIAC RPT Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34706 MEDSV DEF RBRVS 01/01/2024 2024.39 Description: EVASC RPR A-BIILIAC RPT Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34707 MEDSV DEF RBRVS 01/01/2018 12/31/2023 833.80 Description: EVASC RPR ILIO-ILIAC NDGFT Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34707 MEDSV DEF RBRVS 01/01/2024 1040.46 Description: EVASC RPR ILIO-ILIAC NDGFT Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34708 MEDSV DEF RBRVS 01/01/2018 12/31/2023 1343.29 Description: EVASC RPR ILIO-ILIAC RPT Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34708 MEDSV DEF RBRVS 01/01/2024 1613.81 Description: EVASC RPR ILIO-ILIAC RPT Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34709 MEDSV DEF RBRVS 01/01/2018 12/31/2023 234.51 Description: PLMT XTN PROSTH EVASC RPR Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34709 MEDSV DEF RBRVS 01/01/2024 286.73 Description: PLMT XTN PROSTH EVASC RPR Category: Medical Services CMS Add: 01/01/2018 CMS Term: 3470F NOCOV DEF SYSMAN Description: RA DISEASE ACTIVITY LOW Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 34710 MEDSV DEF RBRVS 01/01/2018 12/31/2023 581.22 Description: DLYD PLMT XTN PROSTH 1ST VSL Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34710 MEDSV DEF RBRVS 01/01/2024 709.28 Description: DLYD PLMT XTN PROSTH 1ST VSL Category: Medical Services CMS Add: 01/01/2018 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 434 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 34711 MEDSV DEF RBRVS 01/01/2018 12/31/2023 216.45 Description: DLYD PLMT XTN PROSTH EA ADDL Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34711 MEDSV DEF RBRVS 01/01/2024 261.67 Description: DLYD PLMT XTN PROSTH EA ADDL Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34712 MEDSV DEF RBRVS 01/01/2018 12/31/2023 497.73 Description: TCAT DLVR ENHNCD FIXJ DEV Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34712 MEDSV DEF RBRVS 01/01/2024 586.62 Description: TCAT DLVR ENHNCD FIXJ DEV Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34713 MEDSV DEF RBRVS 01/01/2018 12/31/2023 93.68 Description: PERQ ACCESS & CLSR FEM ART Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34713 MEDSV DEF RBRVS 01/01/2024 109.65 Description: PERQ ACCESS & CLSR FEM ART Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34714 MEDSV DEF RBRVS 01/01/2018 12/31/2023 196.96 Description: OPN FEM ART EXPOS CNDT CRTJ Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34714 MEDSV DEF RBRVS 01/01/2024 239.85 Description: OPN FEM ART EXPOS CNDT CRTJ Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34715 MEDSV DEF RBRVS 01/01/2018 12/31/2023 220.58 Description: OPN AX/SUBCLA ART EXPOS Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34715 MEDSV DEF RBRVS 01/01/2024 265.87 Description: OPN AX/SUBCLA ART EXPOS Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34716 MEDSV DEF RBRVS 01/01/2018 12/31/2023 273.28 Description: OPN AX/SUBCLA ART EXPOS CNDT Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34716 MEDSV DEF RBRVS 01/01/2024 331.96 Description: OPN AX/SUBCLA ART EXPOS CNDT Category: Medical Services CMS Add: 01/01/2018 CMS Term: 34717 MEDSV DEF RBRVS 01/01/2020 12/31/2023 322.25 Description: EVASC RPR A-ILIAC NDGFT Category: Medical Services CMS Add: 01/01/2020 CMS Term: 34717 MEDSV DEF RBRVS 01/01/2024 393.74 Description: EVASC RPR A-ILIAC NDGFT Category: Medical Services CMS Add: 01/01/2020 CMS Term: 34718 MEDSV DEF RBRVS 01/01/2020 12/31/2023 898.11 Description: EVASC RPR N/A A-ILIAC NDGFT Category: Medical Services CMS Add: 01/01/2020 CMS Term: 34718 MEDSV DEF RBRVS 01/01/2024 1100.26 Description: EVASC RPR N/A A-ILIAC NDGFT Category: Medical Services CMS Add: 01/01/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 435 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 3471F NOCOV DEF SYSMAN Description: RA DISEASE ACTIVITY MOD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 3472F NOCOV DEF SYSMAN Description: RA DISEASE ACTIVITY HIGH Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 3475F NOCOV DEF SYSMAN Description: DISEASE PROGN RA POOR DOCD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 3476F NOCOV DEF SYSMAN Description: DISEASE PROGN RA GOOD DOCD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 34808 MEDSV DEF RBRVS 01/01/2019 12/31/2023 151.66 Description: ENDOVAS ILIAC A DEVICE ADDON Category: Medical Services CMS Add: 01/01/2001 CMS Term: 34808 MEDSV DEF RBRVS 01/01/2024 179.78 Description: ENDOVAS ILIAC A DEVICE ADDON Category: Medical Services CMS Add: 01/01/2001 CMS Term: 34812 MEDSV DEF RBRVS 01/01/2024 182.90 Description: OPN FEM ART EXPOS Category: Medical Services CMS Add: 01/01/2001 CMS Term: 34812 MEDSV DEF RBRVS 09/01/2019 12/31/2023 248.64 Description: OPN FEM ART EXPOS Category: Medical Services CMS Add: 01/01/2001 CMS Term: 34813 MEDSV DEF RBRVS 01/01/2019 12/31/2023 175.03 Description: FEMORAL ENDOVAS GRAFT ADD-ON Category: Medical Services CMS Add: 01/01/2001 CMS Term: 34813 MEDSV DEF RBRVS 01/01/2024 209.38 Description: FEMORAL ENDOVAS GRAFT ADD-ON Category: Medical Services CMS Add: 01/01/2001 CMS Term: 34820 MEDSV DEF RBRVS 01/01/2024 298.37 Description: OPN ILIAC ART EXPOS Category: Medical Services CMS Add: 01/01/2001 CMS Term: 34820 MEDSV DEF RBRVS 09/01/2019 12/31/2023 361.70 Description: OPN ILIAC ART EXPOS Category: Medical Services CMS Add: 01/01/2001 CMS Term: 34830 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1309.67 Description: OPEN AORTIC TUBE PROSTH REPR Category: Medical Services CMS Add: 01/01/2001 CMS Term: 34830 MEDSV DEF RBRVS 01/01/2024 1566.09 Description: OPEN AORTIC TUBE PROSTH REPR Category: Medical Services CMS Add: 01/01/2001 CMS Term: 34831 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1408.49 Description: OPEN AORTOILIAC PROSTH REPR Category: Medical Services CMS Add: 01/01/2001 CMS Term: 34831 MEDSV DEF RBRVS 01/01/2024 1712.82 Description: OPEN AORTOILIAC PROSTH REPR Category: Medical Services CMS Add: 01/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 436 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 34832 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1408.49 Description: OPEN AORTOFEMOR PROSTH REPR Category: Medical Services CMS Add: 01/01/2001 CMS Term: 34832 MEDSV DEF RBRVS 01/01/2024 1683.18 Description: OPEN AORTOFEMOR PROSTH REPR Category: Medical Services CMS Add: 01/01/2001 CMS Term: 34833 MEDSV DEF RBRVS 01/01/2024 347.74 Description: OPN ILAC ART EXPOS CNDT CRTJ Category: Medical Services CMS Add: 01/01/2003 CMS Term: 34833 MEDSV DEF RBRVS 09/01/2019 12/31/2023 449.96 Description: OPN ILAC ART EXPOS CNDT CRTJ Category: Medical Services CMS Add: 01/01/2003 CMS Term: 34834 MEDSV DEF RBRVS 01/01/2024 114.77 Description: OPN BRACH ART EXPOS Category: Medical Services CMS Add: 01/01/2003 CMS Term: 34834 MEDSV DEF RBRVS 09/01/2019 12/31/2023 201.78 Description: OPN BRACH ART EXPOS Category: Medical Services CMS Add: 01/01/2003 CMS Term: 34839 NOCOV DEF SYSMAN Description: PLNNING PT SPEC FENEST GRAFT Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 34841 MEDSV DEF MAXFEE 01/01/2024 1133.96 0.0 Y Description: ENDOVASC VISC AORTA 1 GRAFT Category: Medical Services CMS Add: 01/01/2014 CMS Term: 34842 MEDSV DEF MAXFEE 01/01/2024 1254.56 0.0 Y Description: ENDOVASC VISC AORTA 2 GRAFT Category: Medical Services CMS Add: 01/01/2014 CMS Term: 34843 MEDSV DEF MAXFEE 01/01/2024 1380.02 0.0 Y Description: ENDOVASC VISC AORTA 3 GRAFT Category: Medical Services CMS Add: 01/01/2014 CMS Term: 34844 MEDSV DEF MAXFEE 01/01/2024 1055.92 0.0 Y Description: ENDOVASC VISC AORTA 4 GRAFT Category: Medical Services CMS Add: 01/01/2014 CMS Term: 34845 MEDSV DEF MAXFEE 01/01/2024 2091.67 0.0 Y Description: VISC & INFRAREN ABD 1 PROSTH Category: Medical Services CMS Add: 01/01/2014 CMS Term: 34846 MEDSV DEF MAXFEE 01/01/2024 2300.84 0.0 Y Description: VISC & INFRAREN ABD 2 PROSTH Category: Medical Services CMS Add: 01/01/2014 CMS Term: 34847 MEDSV DEF MAXFEE 01/01/2024 2510.00 0.0 Y Description: VISC & INFRAREN ABD 3 PROSTH Category: Medical Services CMS Add: 01/01/2014 CMS Term: 34848 MEDSV DEF MAXFEE 01/01/2024 2719.17 0.0 Y Description: VISC & INFRAREN ABD 4+ PROST Category: Medical Services CMS Add: 01/01/2014 CMS Term: 3490F NOCOV DEF SYSMAN Description: HISTORY AIDS-DEFINING COND Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 437 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 3491F NOCOV DEF SYSMAN Description: HIV UNSURE BABY OF HIV+MOMS Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 3492F NOCOV DEF SYSMAN Description: HISTORY CD4+ CELL COUNT <350 Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 3493F NOCOV DEF SYSMAN Description: NO HIST CD4+ CELL COUNT <350 Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 3494F NOCOV DEF SYSMAN Description: CD4+CELL COUNT <200CELLS/MM3 Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 3495F NOCOV DEF SYSMAN Description: CD4+CELL CNT 200-499 CELLS Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 3496F NOCOV DEF SYSMAN Description: CD4+ CELL COUNT >= 500 CELLS Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 3497F NOCOV DEF SYSMAN Description: CD4+ CELL PERCENTAGE <15% Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 3498F NOCOV DEF SYSMAN Description: CD4+ CELL >=15% (HIV) Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 35001 MEDSV DEF RBRVS 01/01/2024 1003.96 Description: REPAIR DEFECT OF ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 35001 MEDSV DEF RBRVS 09/01/2019 12/31/2023 827.50 Description: REPAIR DEFECT OF ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 35002 MEDSV DEF RBRVS 01/01/2024 1013.10 Description: REPAIR ARTERY RUPTURE NECK Category: Medical Services CMS Add: 01/01/1984 CMS Term: 35002 MEDSV DEF RBRVS 09/01/2019 12/31/2023 834.77 Description: REPAIR ARTERY RUPTURE NECK Category: Medical Services CMS Add: 01/01/1984 CMS Term: 35005 MEDSV DEF RBRVS 01/01/2024 887.53 Description: REPAIR DEFECT OF ARTERY Category: Medical Services CMS Add: 01/01/1987 CMS Term: 35005 MEDSV DEF RBRVS 09/01/2019 12/31/2023 840.66 Description: REPAIR DEFECT OF ARTERY Category: Medical Services CMS Add: 01/01/1987 CMS Term: 3500F NOCOV DEF SYSMAN Description: CD4+CELL CNT/% DOCD AS DONE Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 35011 MEDSV DEF RBRVS 01/01/2024 901.82 Description: REPAIR DEFECT OF ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 438 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 35011 MEDSV DEF RBRVS 09/01/2019 12/31/2023 735.88 Description: REPAIR DEFECT OF ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 35013 MEDSV DEF RBRVS 01/01/2024 1134.05 Description: REPAIR ARTERY RUPTURE ARM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 35013 MEDSV DEF RBRVS 09/01/2019 12/31/2023 922.58 Description: REPAIR ARTERY RUPTURE ARM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 35021 MEDSV DEF RBRVS 01/01/2024 1135.06 Description: REPAIR DEFECT OF ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 35021 MEDSV DEF RBRVS 09/01/2019 12/31/2023 911.85 Description: REPAIR DEFECT OF ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 35022 MEDSV DEF RBRVS 01/01/2024 1297.04 Description: REPAIR ARTERY RUPTURE CHEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 35022 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1050.22 Description: REPAIR ARTERY RUPTURE CHEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3502F NOCOV DEF SYSMAN Description: HIV RNA VRL LD SEGMT Category: Medical Services CMS Add: 01/01/1999 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 455 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 35683 MEDSV DEF RBRVS 01/01/2024 362.39 Description: COMPOSITE BYP GRFT 3/> SEGMT Category: Medical Services CMS Add: 01/01/1999 CMS Term: 35685 MEDSV DEF RBRVS 01/01/2016 12/31/2023 148.02 Description: BYPASS GRAFT PATENCY/PATCH Category: Medical Services CMS Add: 01/01/2002 CMS Term: 35685 MEDSV DEF RBRVS 01/01/2024 175.52 Description: BYPASS GRAFT PATENCY/PATCH Category: Medical Services CMS Add: 01/01/2002 CMS Term: 35686 MEDSV DEF RBRVS 01/01/2016 12/31/2023 119.22 Description: BYPASS GRAFT/AV FIST PATENCY Category: Medical Services CMS Add: 01/01/2002 CMS Term: 35686 MEDSV DEF RBRVS 01/01/2024 142.42 Description: BYPASS GRAFT/AV FIST PATENCY Category: Medical Services CMS Add: 01/01/2002 CMS Term: 35691 MEDSV DEF RBRVS 01/01/2024 842.76 Description: ART TRNSPOSJ VERTBRL CAROTID Category: Medical Services CMS Add: 01/01/1994 CMS Term: 35691 MEDSV DEF RBRVS 09/01/2019 12/31/2023 701.92 Description: ART TRNSPOSJ VERTBRL CAROTID Category: Medical Services CMS Add: 01/01/1994 CMS Term: 35693 MEDSV DEF RBRVS 01/01/2024 745.63 Description: ART TRNSPOSJ SUBCLAVIAN Category: Medical Services CMS Add: 01/01/1994 CMS Term: 35693 MEDSV DEF RBRVS 09/01/2019 12/31/2023 619.50 Description: ART TRNSPOSJ SUBCLAVIAN Category: Medical Services CMS Add: 01/01/1994 CMS Term: 35694 MEDSV DEF RBRVS 01/01/2024 879.78 Description: ART TRNSPOSJ SUBCLAV CAROTID Category: Medical Services CMS Add: 01/01/1994 CMS Term: 35694 MEDSV DEF RBRVS 09/01/2019 12/31/2023 732.89 Description: ART TRNSPOSJ SUBCLAV CAROTID Category: Medical Services CMS Add: 01/01/1994 CMS Term: 35695 MEDSV DEF RBRVS 01/01/2024 913.14 Description: ART TRNSPOSJ CAROTID SUBCLAV Category: Medical Services CMS Add: 01/01/1994 CMS Term: 35695 MEDSV DEF RBRVS 09/01/2019 12/31/2023 761.03 Description: ART TRNSPOSJ CAROTID SUBCLAV Category: Medical Services CMS Add: 01/01/1994 CMS Term: 35697 MEDSV DEF RBRVS 01/01/2024 130.23 Description: REIMPLANT ARTERY EACH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 35697 MEDSV DEF RBRVS 02/01/2015 12/31/2023 109.59 Description: REIMPLANT ARTERY EACH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 35700 MEDSV DEF RBRVS 01/01/2016 12/31/2023 113.31 Description: REOPERATION BYPASS GRAFT Category: Medical Services CMS Add: 01/01/1994 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 456 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 35700 MEDSV DEF RBRVS 01/01/2024 134.50 Description: REOPERATION BYPASS GRAFT Category: Medical Services CMS Add: 01/01/1994 CMS Term: 35701 MEDSV DEF RBRVS 01/01/2024 406.89 Description: EXPL N/FLWD SURG NECK ART Category: Medical Services CMS Add: 01/01/1984 CMS Term: 35701 MEDSV DEF RBRVS 09/01/2019 12/31/2023 417.52 Description: EXPL N/FLWD SURG NECK ART Category: Medical Services CMS Add: 01/01/1984 CMS Term: 35702 MEDSV DEF RBRVS 01/01/2020 12/31/2023 296.92 Description: EXPL N/FLWD SURG UXTR ART Category: Medical Services CMS Add: 01/01/2020 CMS Term: 35702 MEDSV DEF RBRVS 01/01/2024 371.99 Description: EXPL N/FLWD SURG UXTR ART Category: Medical Services CMS Add: 01/01/2020 CMS Term: 35703 MEDSV DEF RBRVS 01/01/2020 12/31/2023 300.93 Description: EXPL N/FLWD SURG LXTR ART Category: Medical Services CMS Add: 01/01/2020 CMS Term: 35703 MEDSV DEF RBRVS 01/01/2024 374.78 Description: EXPL N/FLWD SURG LXTR ART Category: Medical Services CMS Add: 01/01/2020 CMS Term: 3570F NOCOV DEF SYSMAN Description: RPRT BONE SCINT XREF W XRAY Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 3572F NOCOV DEF SYSMAN Description: PT CONSID POSS RISK FX Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 3573F NOCOV DEF SYSMAN Description: PT NOT CONSID POSS RISK FX Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 35800 MEDSV DEF RBRVS 01/01/2024 673.05 Description: EXPLORE NECK VESSELS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 35800 MEDSV DEF RBRVS 09/01/2019 12/31/2023 524.64 Description: EXPLORE NECK VESSELS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 35820 MEDSV DEF RBRVS 01/01/2024 1806.50 Description: EXPLORE CHEST VESSELS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 35820 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1463.51 Description: EXPLORE CHEST VESSELS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 35840 MEDSV DEF RBRVS 01/01/2024 1100.77 Description: EXPLORE ABDOMINAL VESSELS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 35840 MEDSV DEF RBRVS 09/01/2019 12/31/2023 860.73 Description: EXPLORE ABDOMINAL VESSELS Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 457 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 35860 MEDSV DEF RBRVS 01/01/2024 752.73 Description: EXPLORE LIMB VESSELS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 35860 MEDSV DEF RBRVS 09/01/2019 12/31/2023 620.56 Description: EXPLORE LIMB VESSELS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 35870 MEDSV DEF RBRVS 01/01/2019 12/31/2023 924.50 Description: REPAIR VESSEL GRAFT DEFECT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 35870 MEDSV DEF RBRVS 01/01/2024 1110.47 Description: REPAIR VESSEL GRAFT DEFECT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 35875 MEDSV DEF RBRVS 01/01/2024 529.36 Description: REMOVAL OF CLOT IN GRAFT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 35875 MEDSV DEF RBRVS 09/01/2019 12/31/2023 438.48 Description: REMOVAL OF CLOT IN GRAFT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 35876 MEDSV DEF RBRVS 01/01/2024 840.53 Description: REMOVAL OF CLOT IN GRAFT Category: Medical Services CMS Add: 01/01/1994 CMS Term: 35876 MEDSV DEF RBRVS 09/01/2019 12/31/2023 699.52 Description: REMOVAL OF CLOT IN GRAFT Category: Medical Services CMS Add: 01/01/1994 CMS Term: 35879 MEDSV DEF RBRVS 01/01/2024 821.52 0-2 Description: REVISE GRAFT W/VEIN Category: Medical Services CMS Add: 01/01/2000 CMS Term: 35879 MEDSV DEF RBRVS 02/01/2015 12/31/2023 685.86 0-2 Description: REVISE GRAFT W/VEIN Category: Medical Services CMS Add: 01/01/2000 CMS Term: 35881 MEDSV DEF RBRVS 01/01/2024 912.10 0-2 Description: REVISE GRAFT W/VEIN Category: Medical Services CMS Add: 01/01/2000 CMS Term: 35881 MEDSV DEF RBRVS 02/01/2015 12/31/2023 756.48 0-2 Description: REVISE GRAFT W/VEIN Category: Medical Services CMS Add: 01/01/2000 CMS Term: 35883 MEDSV DEF RBRVS 01/01/2024 1065.72 Description: REVJ FEM ANAST NONAUTOG GRF Category: Medical Services CMS Add: 01/01/2007 CMS Term: 35883 MEDSV DEF RBRVS 02/01/2015 12/31/2023 896.16 Description: REVJ FEM ANAST NONAUTOG GRF Category: Medical Services CMS Add: 01/01/2007 CMS Term: 35884 MEDSV DEF RBRVS 01/01/2024 1101.37 Description: REVJ FEM ANAST AUTOG VN GRF Category: Medical Services CMS Add: 01/01/2007 CMS Term: 35884 MEDSV DEF RBRVS 02/01/2015 12/31/2023 921.93 Description: REVJ FEM ANAST AUTOG VN GRF Category: Medical Services CMS Add: 01/01/2007 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 458 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 35901 MEDSV DEF RBRVS 01/01/2024 426.24 Description: EXCISION GRAFT NECK Category: Medical Services CMS Add: 01/01/1994 CMS Term: 35901 MEDSV DEF RBRVS 09/01/2019 12/31/2023 348.28 Description: EXCISION GRAFT NECK Category: Medical Services CMS Add: 01/01/1994 CMS Term: 35903 MEDSV DEF RBRVS 01/01/2024 506.91 Description: EXCISION GRAFT EXTREMITY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 35903 MEDSV DEF RBRVS 09/01/2019 12/31/2023 416.17 Description: EXCISION GRAFT EXTREMITY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 35905 MEDSV DEF RBRVS 01/01/2024 1493.05 Description: EXCISION GRAFT THORAX Category: Medical Services CMS Add: 01/01/1994 CMS Term: 35905 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1248.28 Description: EXCISION GRAFT THORAX Category: Medical Services CMS Add: 01/01/1994 CMS Term: 35907 MEDSV DEF RBRVS 01/01/2024 1690.65 Description: EXCISION GRAFT ABDOMEN Category: Medical Services CMS Add: 01/01/1994 CMS Term: 35907 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1413.44 Description: EXCISION GRAFT ABDOMEN Category: Medical Services CMS Add: 01/01/1994 CMS Term: 36000 NOCOV DEF SYSMAN Description: PLACE NEEDLE IN VEIN Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: 36002 MEDSV DEF RBRVS 01/01/2016 12/31/2023 116.66 Description: PSEUDOANEURYSM INJECTION TRT Category: Medical Services CMS Add: 01/01/2002 CMS Term: 36002 MEDSV DEF RBRVS 01/01/2024 141.33 Description: PSEUDOANEURYSM INJECTION TRT Category: Medical Services CMS Add: 01/01/2002 CMS Term: 36005 MEDSV DEF RBRVS 01/01/2024 238.37 Description: INJECTION EXT VENOGRAPHY Category: Medical Services CMS Add: 01/01/1993 CMS Term: 36005 MEDSV DEF RBRVS 09/01/2019 12/31/2023 226.83 Description: INJECTION EXT VENOGRAPHY Category: Medical Services CMS Add: 01/01/1993 CMS Term: 36010 MEDSV DEF RBRVS 01/01/2024 503.85 Description: PLACE CATHETER IN VEIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36010 MEDSV DEF RBRVS 09/15/2017 12/31/2023 341.22 Description: PLACE CATHETER IN VEIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36011 MEDSV DEF RBRVS 01/01/2024 750.56 Description: PLACE CATHETER IN VEIN Category: Medical Services CMS Add: 01/01/1992 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 459 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 36011 MEDSV DEF RBRVS 09/01/2019 12/31/2023 590.20 Description: PLACE CATHETER IN VEIN Category: Medical Services CMS Add: 01/01/1992 CMS Term: 36012 MEDSV DEF RBRVS 01/01/2024 777.95 Description: PLACE CATHETER IN VEIN Category: Medical Services CMS Add: 01/01/1992 CMS Term: 36012 MEDSV DEF RBRVS 09/01/2019 12/31/2023 611.12 Description: PLACE CATHETER IN VEIN Category: Medical Services CMS Add: 01/01/1992 CMS Term: 36013 MEDSV DEF RBRVS 01/01/2024 733.92 Description: PLACE CATHETER IN ARTERY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 36013 MEDSV DEF RBRVS 09/01/2019 12/31/2023 554.14 Description: PLACE CATHETER IN ARTERY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 36014 MEDSV DEF RBRVS 01/01/2024 732.89 Description: PLACE CATHETER IN ARTERY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 36014 MEDSV DEF RBRVS 09/01/2019 12/31/2023 574.42 Description: PLACE CATHETER IN ARTERY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 36015 MEDSV DEF RBRVS 01/01/2024 795.46 Description: PLACE CATHETER IN ARTERY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 36015 MEDSV DEF RBRVS 09/01/2019 12/31/2023 615.83 Description: PLACE CATHETER IN ARTERY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 36100 MEDSV DEF RBRVS 01/01/2024 522.15 Description: ESTABLISH ACCESS TO ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36100 MEDSV DEF RBRVS 09/01/2019 12/31/2023 357.51 Description: ESTABLISH ACCESS TO ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36140 MEDSV DEF RBRVS 01/01/2024 473.70 Description: INTRO NDL ICATH UPR/LXTR ART Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36140 MEDSV DEF RBRVS 09/15/2017 12/31/2023 297.81 Description: INTRO NDL ICATH UPR/LXTR ART Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36160 MEDSV DEF RBRVS 01/01/2024 524.77 Description: ESTABLISH ACCESS TO AORTA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36160 MEDSV DEF RBRVS 09/01/2019 12/31/2023 361.75 Description: ESTABLISH ACCESS TO AORTA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36200 MEDSV DEF RBRVS 01/01/2024 549.76 Description: PLACE CATHETER IN AORTA Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 460 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 36200 MEDSV DEF RBRVS 09/15/2017 12/31/2023 395.55 Description: PLACE CATHETER IN AORTA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36215 MEDSV DEF RBRVS 01/01/2024 964.10 Description: PLACE CATHETER IN ARTERY Category: Medical Services CMS Add: 01/01/1987 CMS Term: 36215 MEDSV DEF RBRVS 09/01/2019 12/31/2023 778.20 Description: PLACE CATHETER IN ARTERY Category: Medical Services CMS Add: 01/01/1987 CMS Term: 36216 MEDSV DEF RBRVS 01/01/2024 987.93 Description: PLACE CATHETER IN ARTERY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 36216 MEDSV DEF RBRVS 09/01/2019 12/31/2023 877.64 Description: PLACE CATHETER IN ARTERY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 36217 MEDSV DEF RBRVS 01/01/2024 1652.19 Description: PLACE CATHETER IN ARTERY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 36217 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1506.99 Description: PLACE CATHETER IN ARTERY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 36218 MEDSV DEF RBRVS 01/01/2019 12/31/2023 141.83 Description: PLACE CATHETER IN ARTERY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 36218 MEDSV DEF RBRVS 01/01/2024 192.88 Description: PLACE CATHETER IN ARTERY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 36221 MEDSV DEF RBRVS 01/01/2024 917.21 0-1 Description: PLACE CATH THORACIC AORTA Category: Medical Services CMS Add: 01/01/2013 CMS Term: 36221 MEDSV DEF RBRVS 09/15/2017 12/31/2023 725.27 0-1 Description: PLACE CATH THORACIC AORTA Category: Medical Services CMS Add: 01/01/2013 CMS Term: 36222 MEDSV DEF RBRVS 01/01/2024 1126.58 0-1 Description: PLACE CATH CAROTID/INOM ART Category: Medical Services CMS Add: 01/01/2013 CMS Term: 36222 MEDSV DEF RBRVS 09/15/2017 12/31/2023 847.36 0-1 Description: PLACE CATH CAROTID/INOM ART Category: Medical Services CMS Add: 01/01/2013 CMS Term: 36223 MEDSV DEF RBRVS 01/01/2024 1517.48 0-1 Description: PLACE CATH CAROTID/INOM ART Category: Medical Services CMS Add: 01/01/2013 CMS Term: 36223 MEDSV DEF RBRVS 09/15/2017 12/31/2023 1039.50 0-1 Description: PLACE CATH CAROTID/INOM ART Category: Medical Services CMS Add: 01/01/2013 CMS Term: 36224 MEDSV DEF RBRVS 01/01/2024 1884.07 0-1 Description: PLACE CATH CAROTD ART Category: Medical Services CMS Add: 01/01/2013 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 461 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 36224 MEDSV DEF RBRVS 09/15/2017 12/31/2023 1322.12 0-1 Description: PLACE CATH CAROTD ART Category: Medical Services CMS Add: 01/01/2013 CMS Term: 36225 MEDSV DEF RBRVS 01/01/2024 1432.73 0-1 Description: PLACE CATH SUBCLAVIAN ART Category: Medical Services CMS Add: 01/01/2013 CMS Term: 36225 MEDSV DEF RBRVS 09/15/2017 12/31/2023 999.70 0-1 Description: PLACE CATH SUBCLAVIAN ART Category: Medical Services CMS Add: 01/01/2013 CMS Term: 36226 MEDSV DEF RBRVS 01/01/2024 1831.87 0-1 Description: PLACE CATH VERTEBRAL ART Category: Medical Services CMS Add: 01/01/2013 CMS Term: 36226 MEDSV DEF RBRVS 09/15/2017 12/31/2023 1254.33 0-1 Description: PLACE CATH VERTEBRAL ART Category: Medical Services CMS Add: 01/01/2013 CMS Term: 36227 MEDSV DEF RBRVS 01/01/2024 219.86 Description: PLACE CATH XTRNL CAROTID Category: Medical Services CMS Add: 01/01/2013 CMS Term: 36227 MEDSV DEF RBRVS 09/15/2017 12/31/2023 178.61 Description: PLACE CATH XTRNL CAROTID Category: Medical Services CMS Add: 01/01/2013 CMS Term: 36228 MEDSV DEF RBRVS 01/01/2024 1161.77 Description: PLACE CATH INTRACRANIAL ART Category: Medical Services CMS Add: 01/01/2013 CMS Term: 36228 MEDSV DEF RBRVS 09/15/2017 12/31/2023 898.05 Description: PLACE CATH INTRACRANIAL ART Category: Medical Services CMS Add: 01/01/2013 CMS Term: 36245 MEDSV DEF RBRVS 01/01/2024 1157.10 Description: INS CATH ABD/L-EXT ART 1ST Category: Medical Services CMS Add: 01/01/1987 CMS Term: 36245 MEDSV DEF RBRVS 09/15/2017 12/31/2023 917.30 Description: INS CATH ABD/L-EXT ART 1ST Category: Medical Services CMS Add: 01/01/1987 CMS Term: 36246 MEDSV DEF RBRVS 01/01/2024 773.99 Description: INS CATH ABD/L-EXT ART 2ND Category: Medical Services CMS Add: 01/01/1992 CMS Term: 36246 MEDSV DEF RBRVS 09/15/2017 12/31/2023 580.69 Description: INS CATH ABD/L-EXT ART 2ND Category: Medical Services CMS Add: 01/01/1992 CMS Term: 36247 MEDSV DEF RBRVS 01/01/2024 1323.51 Description: INS CATH ABD/L-EXT ART 3RD Category: Medical Services CMS Add: 01/01/1992 CMS Term: 36247 MEDSV DEF RBRVS 09/15/2017 12/31/2023 1055.55 Description: INS CATH ABD/L-EXT ART 3RD Category: Medical Services CMS Add: 01/01/1992 CMS Term: 36248 MEDSV DEF RBRVS 01/01/2024 109.63 Description: INS CATH ABD/L-EXT ART ADDL Category: Medical Services CMS Add: 01/01/1992 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 462 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 36248 MEDSV DEF RBRVS 09/15/2017 12/31/2023 108.47 Description: INS CATH ABD/L-EXT ART ADDL Category: Medical Services CMS Add: 01/01/1992 CMS Term: 36251 MEDSV DEF RBRVS 01/01/2024 1198.96 Description: INS CATH REN ART 1ST UNILAT Category: Medical Services CMS Add: 01/01/2012 CMS Term: 36251 MEDSV DEF RBRVS 09/15/2017 12/31/2023 966.87 Description: INS CATH REN ART 1ST UNILAT Category: Medical Services CMS Add: 01/01/2012 CMS Term: 36252 MEDSV DEF RBRVS 01/01/2024 1287.16 Description: INS CATH REN ART 1ST BILAT Category: Medical Services CMS Add: 01/01/2012 CMS Term: 36252 MEDSV DEF RBRVS 09/15/2017 12/31/2023 1046.28 Description: INS CATH REN ART 1ST BILAT Category: Medical Services CMS Add: 01/01/2012 CMS Term: 36253 MEDSV DEF RBRVS 01/01/2024 1880.72 Description: INS CATH REN ART 2ND+ UNILAT Category: Medical Services CMS Add: 01/01/2012 CMS Term: 36253 MEDSV DEF RBRVS 09/15/2017 12/31/2023 1555.27 Description: INS CATH REN ART 2ND+ UNILAT Category: Medical Services CMS Add: 01/01/2012 CMS Term: 36254 MEDSV DEF RBRVS 01/01/2024 1838.76 Description: INS CATH REN ART 2ND+ BILAT Category: Medical Services CMS Add: 01/01/2012 CMS Term: 36254 MEDSV DEF RBRVS 09/15/2017 12/31/2023 1504.84 Description: INS CATH REN ART 2ND+ BILAT Category: Medical Services CMS Add: 01/01/2012 CMS Term: 36260 MEDSV DEF RBRVS 01/01/2024 599.56 Description: INSERTION OF INFUSION PUMP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36260 MEDSV DEF RBRVS 09/01/2019 12/31/2023 445.45 Description: INSERTION OF INFUSION PUMP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36261 MEDSV DEF RBRVS 01/01/2024 376.78 Description: REVISION OF INFUSION PUMP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36261 MEDSV DEF RBRVS 09/01/2019 12/31/2023 258.20 Description: REVISION OF INFUSION PUMP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36262 MEDSV DEF RBRVS 01/01/2024 288.29 Description: REMOVAL OF INFUSION PUMP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36262 MEDSV DEF RBRVS 09/01/2019 12/31/2023 217.28 Description: REMOVAL OF INFUSION PUMP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36299 MEDSV DEF BILL20 Description: UNLISTED PX VASCULAR NJX Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 463 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 36400 MEDSV DEF RBRVS 01/01/2024 25.87 0-2years Description: BL DRAW < 3 YRS FEM/JUGULAR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36400 MEDSV DEF RBRVS 09/01/2019 12/31/2023 21.69 0-2years Description: BL DRAW < 3 YRS FEM/JUGULAR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36405 MEDSV DEF RBRVS 01/01/2024 22.25 0-2years Description: BL DRAW <3 YRS SCALP VEIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36405 MEDSV DEF RBRVS 09/01/2019 12/31/2023 19.06 0-2years Description: BL DRAW <3 YRS SCALP VEIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36406 MEDSV DEF RBRVS 01/01/2024 16.45 0-2years Description: BL DRAW <3 YRS OTHER VEIN Category: Medical Services CMS Add: 01/01/1987 CMS Term: 36406 MEDSV DEF RBRVS 09/01/2019 12/31/2023 13.51 0-2years Description: BL DRAW <3 YRS OTHER VEIN Category: Medical Services CMS Add: 01/01/1987 CMS Term: 36410 MEDSV DEF RBRVS 01/01/2024 16.30 3-999years Description: NON-ROUTINE BL DRAW 3/> YRS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36410 MEDSV DEF RBRVS 09/01/2019 12/31/2023 12.02 3-999years Description: NON-ROUTINE BL DRAW 3/> YRS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36415 MEDSV DEF MAXFEE 01/01/1986 12/31/2023 3.00 0.0 Description: ROUTINE VENIPUNCTURE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 36415 MEDSV DEF MAXFEE 01/01/2024 8.57 0.0 Description: ROUTINE VENIPUNCTURE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 36415 MRT DEF MAXFEE 01/01/1986 12/31/2023 3.00 0.0 Description: ROUTINE VENIPUNCTURE Category: Medical Review Team CMS Add: 01/01/1985 CMS Term: 36415 MRT DEF MAXFEE 01/01/2024 8.57 0.0 Description: ROUTINE VENIPUNCTURE Category: Medical Review Team CMS Add: 01/01/1985 CMS Term: 36416 MEDSV PRF MAXFEE 01/01/2024 3.89 0.0 Description: COLLJ CAPILLARY BLOOD SPEC Category: Medical Services CMS Add: 01/01/2003 CMS Term: 36420 MEDSV DEF RBRVS 01/01/2024 43.32 0-364days Description: VENIPUNCTURE CUTDOWN < 1 YR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36420 MEDSV DEF RBRVS 09/01/2019 12/31/2023 35.89 0-364days Description: VENIPUNCTURE CUTDOWN < 1 YR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36425 MEDSV DEF RBRVS 01/01/2024 36.93 1-999years Description: VENIPUNCTURE CUTDOWN 1 YR/> Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 464 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 36425 MEDSV DEF RBRVS 09/01/2019 12/31/2023 29.42 1-999years Description: VENIPUNCTURE CUTDOWN 1 YR/> Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36430 MEDSV DEF RBRVS 01/01/2024 35.82 Description: TRANSFUSION BLD/BLD COMPNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36430 MEDSV DEF RBRVS 02/01/2015 12/31/2023 23.45 Description: TRANSFUSION BLD/BLD COMPNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36440 MEDSV DEF RBRVS 01/01/2024 47.76 0-2years Description: BLD PUSH TFUJ 2 YR/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36440 MEDSV DEF RBRVS 09/01/2019 12/31/2023 41.38 0-2years Description: BLD PUSH TFUJ 2 YR/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36450 MEDSV DEF RBRVS 01/01/2024 161.51 0-28days Description: BLD EXCHANGE TRUJ NEWBORN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36450 MEDSV DEF RBRVS 09/01/2019 12/31/2023 80.56 0-28days Description: BLD EXCHANGE TRUJ NEWBORN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36455 MEDSV DEF RBRVS 01/01/2024 112.67 Description: BLD EXCHANGE TRUJ OTH THN NB Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36455 MEDSV DEF RBRVS 09/01/2019 12/31/2023 84.53 Description: BLD EXCHANGE TRUJ OTH THN NB Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36456 MEDSV DEF RBRVS 01/01/2017 12/31/2023 78.59 0-28days Description: PRTL EXCHANGE TRANSFUSE NB Category: Medical Services CMS Add: 01/01/2017 CMS Term: 36456 MEDSV DEF RBRVS 01/01/2024 92.56 0-28days Description: PRTL EXCHANGE TRANSFUSE NB Category: Medical Services CMS Add: 01/01/2017 CMS Term: 36460 MEDSV DEF RBRVS 01/01/2019 12/31/2023 263.58 Description: INTRAUTERINE TRANSFUSION FTL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36460 MEDSV DEF RBRVS 01/01/2024 319.41 Description: INTRAUTERINE TRANSFUSION FTL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36465 MEDSV DEF MAXFEE 01/01/2024 1219.69 0.0 Description: NJX NONCMPND SCLRSNT 1 VEIN Category: Medical Services CMS Add: 01/01/2018 CMS Term: 36468 NOCOV DEF SYSMAN Description: NJX SCLRSNT SPIDER VEINS Category: Non Covered Services CMS Add: 01/01/1990 CMS Term: 36469 NOCOV DEF SYSMAN Description: INJECTION(S) SPIDER VEINS Category: Non Covered Services CMS Add: 01/01/1990 CMS Term: 12/31/2014 *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 465 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 36470 MEDSV DEF RBRVS 01/01/2024 106.56 Description: NJX SCLRSNT 1 INCMPTNT VEIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36470 MEDSV DEF RBRVS 09/01/2019 12/31/2023 107.34 Description: NJX SCLRSNT 1 INCMPTNT VEIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36471 MEDSV DEF RBRVS 01/01/2024 184.85 Description: NJX SCLRSNT MLT INCMPTNT VN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36471 MEDSV DEF RBRVS 09/01/2019 12/31/2023 123.93 Description: NJX SCLRSNT MLT INCMPTNT VN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36474 MEDSV DEF RBRVS 01/01/2017 12/31/2023 193.83 Description: ENDOVENOUS MCHNCHEM ADD-ON Category: Medical Services CMS Add: 01/01/2017 CMS Term: 36474 MEDSV DEF RBRVS 01/01/2024 238.27 Description: ENDOVENOUS MCHNCHEM ADD-ON Category: Medical Services CMS Add: 01/01/2017 CMS Term: 36475 MEDSV DEF RBRVS 01/01/2024 1001.97 Description: ENDOVENOUS RF 1ST VEIN Category: Medical Services CMS Add: 01/01/2005 CMS Term: 36475 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1177.78 Description: ENDOVENOUS RF 1ST VEIN Category: Medical Services CMS Add: 01/01/2005 CMS Term: 36476 MEDSV DEF RBRVS 01/01/2024 262.43 Description: ENDOVENOUS RF VEIN ADD-ON Category: Medical Services CMS Add: 01/01/2005 CMS Term: 36476 MEDSV DEF RBRVS 09/01/2019 12/31/2023 268.92 Description: ENDOVENOUS RF VEIN ADD-ON Category: Medical Services CMS Add: 01/01/2005 CMS Term: 36478 MEDSV DEF RBRVS 01/01/2019 12/31/2023 940.30 Description: ENDOVENOUS LASER 1ST VEIN Category: Medical Services CMS Add: 01/01/2005 CMS Term: 36478 MEDSV DEF RBRVS 01/01/2024 910.10 Description: ENDOVENOUS LASER 1ST VEIN Category: Medical Services CMS Add: 01/01/2005 CMS Term: 36479 MEDSV DEF RBRVS 01/01/2024 277.24 Description: ENDOVENOUS LASER VEIN ADDON Category: Medical Services CMS Add: 01/01/2005 CMS Term: 36479 MEDSV DEF RBRVS 09/01/2019 12/31/2023 275.69 Description: ENDOVENOUS LASER VEIN ADDON Category: Medical Services CMS Add: 01/01/2005 CMS Term: 36481 MEDSV DEF RBRVS 01/01/2024 1630.09 Description: INSERTION OF CATHETER VEIN Category: Medical Services CMS Add: 01/01/1992 CMS Term: 36481 MEDSV DEF RBRVS 09/15/2017 12/31/2023 1385.87 Description: INSERTION OF CATHETER VEIN Category: Medical Services CMS Add: 01/01/1992 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 466 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 36482 MEDSV DEF RBRVS 01/01/2018 12/31/2023 1489.34 Description: ENDOVEN THER CHEM ADHES 1ST Category: Medical Services CMS Add: 01/01/2018 CMS Term: 36482 MEDSV DEF RBRVS 01/01/2024 1555.65 Description: ENDOVEN THER CHEM ADHES 1ST Category: Medical Services CMS Add: 01/01/2018 CMS Term: 36483 MEDSV DEF RBRVS 01/01/2018 12/31/2023 101.93 Description: ENDOVEN THER CHEM ADHES SBSQ Category: Medical Services CMS Add: 01/01/2018 CMS Term: 36483 MEDSV DEF RBRVS 01/01/2024 125.46 Description: ENDOVEN THER CHEM ADHES SBSQ Category: Medical Services CMS Add: 01/01/2018 CMS Term: 36500 MEDSV DEF RBRVS 01/01/2024 164.91 Description: INSERTION OF CATHETER VEIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36500 MEDSV DEF RBRVS 09/01/2019 12/31/2023 132.70 Description: INSERTION OF CATHETER VEIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3650F NOCOV DEF SYSMAN Description: EEG ORDERED RVWD REQSTD Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 36510 MEDSV DEF RBRVS 01/01/2024 80.83 0-28days Description: INSERTION OF CATHETER VEIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36510 MEDSV DEF RBRVS 09/01/2019 12/31/2023 70.24 0-28days Description: INSERTION OF CATHETER VEIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36511 MEDSV DEF RBRVS 01/01/2024 103.66 Description: APHERESIS WBC Category: Medical Services CMS Add: 01/01/2003 CMS Term: 36511 MEDSV DEF RBRVS 02/01/2015 12/31/2023 69.38 Description: APHERESIS WBC Category: Medical Services CMS Add: 01/01/2003 CMS Term: 36512 MEDSV DEF RBRVS 01/01/2024 100.89 Description: APHERESIS RBC Category: Medical Services CMS Add: 01/01/2003 CMS Term: 36512 MEDSV DEF RBRVS 02/01/2015 12/31/2023 69.29 Description: APHERESIS RBC Category: Medical Services CMS Add: 01/01/2003 CMS Term: 36513 MEDSV DEF RBRVS 01/01/2024 99.54 Description: APHERESIS PLATELETS Category: Medical Services CMS Add: 01/01/2003 CMS Term: 36513 MEDSV DEF RBRVS 02/01/2015 12/31/2023 71.77 Description: APHERESIS PLATELETS Category: Medical Services CMS Add: 01/01/2003 CMS Term: 36514 MEDSV DEF RBRVS 01/01/2019 12/31/2023 364.90 Description: APHERESIS PLASMA Category: Medical Services CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 467 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 36514 MEDSV DEF RBRVS 01/01/2024 523.88 Description: APHERESIS PLASMA Category: Medical Services CMS Add: 01/01/2003 CMS Term: 36516 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1412.30 Description: APHERESIS IMMUNOADS SLCTV Category: Medical Services CMS Add: 01/01/2003 CMS Term: 36516 MEDSV DEF RBRVS 01/01/2024 1630.58 Description: APHERESIS IMMUNOADS SLCTV Category: Medical Services CMS Add: 01/01/2003 CMS Term: 36522 MEDSV DEF RBRVS 01/01/2024 1259.35 Description: PHOTOPHERESIS Category: Medical Services CMS Add: 01/01/1990 CMS Term: 36522 MEDSV DEF RBRVS 09/01/2019 12/31/2023 941.60 Description: PHOTOPHERESIS Category: Medical Services CMS Add: 01/01/1990 CMS Term: 36555 MEDSV DEF RBRVS 01/01/2024 178.66 0-4years Description: INSERT NON-TUNNEL CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36555 MEDSV DEF RBRVS 09/15/2017 12/31/2023 147.94 0-4years Description: INSERT NON-TUNNEL CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36556 MEDSV DEF RBRVS 01/01/2024 199.91 5-999years Description: INSERT NON-TUNNEL CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36556 MEDSV DEF RBRVS 02/01/2015 12/31/2023 167.00 5-999years Description: INSERT NON-TUNNEL CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36557 MEDSV DEF RBRVS 01/01/2024 1077.98 0-4years Description: INSERT TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36557 MEDSV DEF RBRVS 09/15/2017 12/31/2023 648.04 0-4years Description: INSERT TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36558 MEDSV DEF RBRVS 01/01/2024 777.87 5-999years Description: INSERT TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36558 MEDSV DEF RBRVS 09/15/2017 12/31/2023 508.60 5-999years Description: INSERT TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36560 MEDSV DEF RBRVS 01/01/2024 1148.96 0-4years Description: INSERT TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36560 MEDSV DEF RBRVS 09/15/2017 12/31/2023 715.51 0-4years Description: INSERT TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36561 MEDSV DEF RBRVS 01/01/2024 919.22 5-999years Description: INSERT TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 468 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 36561 MEDSV DEF RBRVS 09/15/2017 12/31/2023 770.15 5-999years Description: INSERT TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36563 MEDSV DEF RBRVS 01/01/2024 1048.17 Description: INSERT TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36563 MEDSV DEF RBRVS 09/15/2017 12/31/2023 867.02 Description: INSERT TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36565 MEDSV DEF RBRVS 01/01/2024 763.98 Description: INSERT TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36565 MEDSV DEF RBRVS 09/15/2017 12/31/2023 625.73 Description: INSERT TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36566 MEDSV DEF RBRVS 01/01/2024 3966.29 Description: INSERT TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36566 MEDSV DEF RBRVS 09/15/2017 12/31/2023 3804.38 Description: INSERT TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36568 MEDSV DEF RBRVS 01/01/2024 86.33 0-4years Description: INSJ PICC <5 YR W/O IMAGING Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36568 MEDSV DEF RBRVS 09/15/2017 12/31/2023 176.32 0-4years Description: INSJ PICC <5 YR W/O IMAGING Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36569 MEDSV DEF RBRVS 01/01/2024 86.78 5-999years Description: INSJ PICC 5 YR+ W/O IMAGING Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36569 MEDSV DEF RBRVS 02/01/2015 12/31/2023 177.05 5-999years Description: INSJ PICC 5 YR+ W/O IMAGING Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36570 MEDSV DEF RBRVS 01/01/2024 1356.38 0-4years Description: INSERT PICVAD CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36570 MEDSV DEF RBRVS 09/15/2017 12/31/2023 871.77 0-4years Description: INSERT PICVAD CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36571 MEDSV DEF RBRVS 01/01/2024 1175.86 5-999years Description: INSERT PICVAD CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36571 MEDSV DEF RBRVS 09/15/2017 12/31/2023 857.03 5-999years Description: INSERT PICVAD CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36572 MEDSV DEF RBRVS 01/01/2019 12/31/2023 297.27 0-4years Description: INSJ PICC RS&I <5 YR Category: Medical Services CMS Add: 01/01/2019 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 469 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 36572 MEDSV DEF RBRVS 01/01/2024 351.08 0-4years Description: INSJ PICC RS&I <5 YR Category: Medical Services CMS Add: 01/01/2019 CMS Term: 36573 MEDSV DEF RBRVS 01/01/2019 12/31/2023 279.52 5-999years Description: INSJ PICC RS&I 5 YR+ Category: Medical Services CMS Add: 01/01/2019 CMS Term: 36573 MEDSV DEF RBRVS 01/01/2024 359.96 5-999years Description: INSJ PICC RS&I 5 YR+ Category: Medical Services CMS Add: 01/01/2019 CMS Term: 36575 MEDSV DEF RBRVS 01/01/2024 135.28 Description: REPAIR TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36575 MEDSV DEF RBRVS 02/01/2015 12/31/2023 117.50 Description: REPAIR TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36576 MEDSV DEF RBRVS 01/01/2024 321.34 Description: REPAIR TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36576 MEDSV DEF RBRVS 09/15/2017 12/31/2023 223.60 Description: REPAIR TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36578 MEDSV DEF RBRVS 01/01/2024 402.57 Description: REPLACE TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36578 MEDSV DEF RBRVS 09/15/2017 12/31/2023 318.44 Description: REPLACE TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36580 MEDSV DEF RBRVS 01/01/2024 177.87 Description: REPLACE CVAD CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36580 MEDSV DEF RBRVS 02/01/2015 12/31/2023 152.12 Description: REPLACE CVAD CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36581 MEDSV DEF RBRVS 01/01/2024 727.92 Description: REPLACE TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36581 MEDSV DEF RBRVS 09/15/2017 12/31/2023 498.73 Description: REPLACE TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36582 MEDSV DEF RBRVS 01/01/2024 821.65 Description: REPLACE TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36582 MEDSV DEF RBRVS 09/15/2017 12/31/2023 712.98 Description: REPLACE TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36583 MEDSV DEF RBRVS 01/01/2024 1069.36 Description: REPLACE TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 470 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 36583 MEDSV DEF RBRVS 09/15/2017 12/31/2023 878.90 Description: REPLACE TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36584 MEDSV DEF RBRVS 01/01/2024 305.62 Description: COMPL RPLCMT PICC RS&I Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36584 MEDSV DEF RBRVS 02/01/2015 12/31/2023 144.79 Description: COMPL RPLCMT PICC RS&I Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36585 MEDSV DEF RBRVS 01/01/2024 1079.89 Description: REPLACE PICVAD CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36585 MEDSV DEF RBRVS 09/15/2017 12/31/2023 759.95 Description: REPLACE PICVAD CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36589 MEDSV DEF RBRVS 01/01/2016 12/31/2023 119.06 Description: REMOVAL TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36589 MEDSV DEF RBRVS 01/01/2024 154.05 Description: REMOVAL TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36590 MEDSV DEF RBRVS 01/01/2024 207.28 Description: REMOVAL TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36590 MEDSV DEF RBRVS 09/15/2017 12/31/2023 159.18 Description: REMOVAL TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36591 MEDSV DEF RBRVS 01/01/2024 24.55 Description: DRAW BLOOD OFF VENOUS DEVICE Category: Medical Services CMS Add: 01/01/2008 CMS Term: 36591 MEDSV DEF RBRVS 02/01/2015 12/31/2023 16.02 Description: DRAW BLOOD OFF VENOUS DEVICE Category: Medical Services CMS Add: 01/01/2008 CMS Term: 36592 MEDSV DEF RBRVS 01/01/2024 26.71 Description: COLLECT BLOOD FROM PICC Category: Medical Services CMS Add: 01/01/2008 CMS Term: 36592 MEDSV DEF RBRVS 02/01/2015 12/31/2023 18.00 Description: COLLECT BLOOD FROM PICC Category: Medical Services CMS Add: 01/01/2008 CMS Term: 36593 MEDSV DEF RBRVS 01/01/2024 30.27 0-2 Description: DECLOT VASCULAR DEVICE Category: Medical Services CMS Add: 01/01/2008 CMS Term: 36593 MEDSV DEF RBRVS 02/01/2015 12/31/2023 21.22 0-2 Description: DECLOT VASCULAR DEVICE Category: Medical Services CMS Add: 01/01/2008 CMS Term: 36595 MEDSV DEF RBRVS 01/01/2024 555.06 Description: MECH REMOV TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 471 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 36595 MEDSV DEF RBRVS 02/01/2015 12/31/2023 413.45 Description: MECH REMOV TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36596 MEDSV DEF RBRVS 01/01/2024 106.36 Description: MECH REMOV TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36596 MEDSV DEF RBRVS 02/01/2015 12/31/2023 95.13 Description: MECH REMOV TUNNELED CV CATH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36597 MEDSV DEF RBRVS 01/01/2024 104.56 Description: REPOSITION VENOUS CATHETER Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36597 MEDSV DEF RBRVS 02/01/2015 12/31/2023 90.56 Description: REPOSITION VENOUS CATHETER Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36598 MEDSV DEF RBRVS 01/01/2024 113.26 Description: INJ W/FLUOR EVAL CV DEVICE Category: Medical Services CMS Add: 01/01/2006 CMS Term: 36598 MEDSV DEF RBRVS 02/01/2015 12/31/2023 78.51 Description: INJ W/FLUOR EVAL CV DEVICE Category: Medical Services CMS Add: 01/01/2006 CMS Term: 36600 MEDSV DEF RBRVS 01/01/2024 25.98 Description: WITHDRAWAL OF ARTERIAL BLOOD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36600 MEDSV DEF RBRVS 09/01/2019 12/31/2023 22.22 Description: WITHDRAWAL OF ARTERIAL BLOOD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36620 MEDSV DEF RBRVS 01/01/2024 41.98 Description: INSERTION CATHETER ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36620 MEDSV DEF RBRVS 02/01/2015 12/31/2023 38.00 Description: INSERTION CATHETER ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36625 MEDSV DEF RBRVS 01/01/2024 97.20 Description: INSERTION CATHETER ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36625 MEDSV DEF RBRVS 02/01/2015 12/31/2023 77.17 Description: INSERTION CATHETER ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36640 MEDSV DEF RBRVS 01/01/2024 110.02 Description: INSERTION CATHETER ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36640 MEDSV DEF RBRVS 09/01/2019 12/31/2023 93.99 Description: INSERTION CATHETER ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36660 MEDSV DEF RBRVS 01/01/2024 64.80 0-28days Description: INSERTION CATHETER ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 472 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 36660 MEDSV DEF RBRVS 09/01/2019 12/31/2023 49.01 0-28days Description: INSERTION CATHETER ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36680 MEDSV DEF RBRVS 01/01/2024 54.70 Description: INSERT NEEDLE BONE CAVITY Category: Medical Services CMS Add: 01/01/1989 CMS Term: 36680 MEDSV DEF RBRVS 09/01/2019 12/31/2023 43.64 Description: INSERT NEEDLE BONE CAVITY Category: Medical Services CMS Add: 01/01/1989 CMS Term: 36800 MEDSV DEF RBRVS 01/01/2024 112.64 Description: INSERTION OF CANNULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36800 MEDSV DEF RBRVS 09/01/2019 12/31/2023 91.71 Description: INSERTION OF CANNULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36810 MEDSV DEF RBRVS 01/01/2024 196.51 Description: INSERTION OF CANNULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36810 MEDSV DEF RBRVS 09/01/2019 12/31/2023 158.83 Description: INSERTION OF CANNULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36815 MEDSV DEF RBRVS 01/01/2024 120.86 Description: INSERTION OF CANNULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36815 MEDSV DEF RBRVS 09/01/2019 12/31/2023 106.56 Description: INSERTION OF CANNULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36818 MEDSV DEF RBRVS 01/01/2024 616.48 Description: AV FUSE UPPR ARM CEPHALIC Category: Medical Services CMS Add: 01/01/2005 CMS Term: 36818 MEDSV DEF RBRVS 02/01/2015 12/31/2023 490.56 Description: AV FUSE UPPR ARM CEPHALIC Category: Medical Services CMS Add: 01/01/2005 CMS Term: 36819 MEDSV DEF RBRVS 01/01/2024 652.23 Description: AV FUSE UPPR ARM BASILIC Category: Medical Services CMS Add: 01/01/2000 CMS Term: 36819 MEDSV DEF RBRVS 02/01/2015 12/31/2023 538.66 Description: AV FUSE UPPR ARM BASILIC Category: Medical Services CMS Add: 01/01/2000 CMS Term: 36820 MEDSV DEF RBRVS 01/01/2024 647.32 Description: AV FUSION/FOREARM VEIN Category: Medical Services CMS Add: 01/01/2002 CMS Term: 36820 MEDSV DEF RBRVS 02/01/2015 12/31/2023 588.87 Description: AV FUSION/FOREARM VEIN Category: Medical Services CMS Add: 01/01/2002 CMS Term: 36821 MEDSV DEF RBRVS 01/01/2024 591.15 Description: AV FUSION DIRECT ANY SITE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 473 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 36821 MEDSV DEF RBRVS 09/01/2019 12/31/2023 506.88 Description: AV FUSION DIRECT ANY SITE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36823 MEDSV DEF RBRVS 01/01/2024 1275.86 Description: INSERTION OF CANNULA(S) Category: Medical Services CMS Add: 01/01/1999 CMS Term: 36823 MEDSV DEF RBRVS 09/01/2019 12/31/2023 968.54 Description: INSERTION OF CANNULA(S) Category: Medical Services CMS Add: 01/01/1999 CMS Term: 36825 MEDSV DEF RBRVS 01/01/2024 709.36 Description: ARTERY-VEIN AUTOGRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36825 MEDSV DEF RBRVS 09/01/2019 12/31/2023 582.37 Description: ARTERY-VEIN AUTOGRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36830 MEDSV DEF RBRVS 01/01/2024 595.88 Description: ARTERY-VEIN NONAUTOGRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36830 MEDSV DEF RBRVS 09/01/2019 12/31/2023 480.70 Description: ARTERY-VEIN NONAUTOGRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36831 MEDSV DEF RBRVS 01/01/2024 550.95 Description: OPEN THROMBECT AV FISTULA Category: Medical Services CMS Add: 01/01/1999 CMS Term: 36831 MEDSV DEF RBRVS 02/01/2015 12/31/2023 332.12 Description: OPEN THROMBECT AV FISTULA Category: Medical Services CMS Add: 01/01/1999 CMS Term: 36832 MEDSV DEF RBRVS 01/01/2024 676.03 Description: AV FISTULA REVISION OPEN Category: Medical Services CMS Add: 01/01/1990 CMS Term: 36832 MEDSV DEF RBRVS 09/01/2019 12/31/2023 423.96 Description: AV FISTULA REVISION OPEN Category: Medical Services CMS Add: 01/01/1990 CMS Term: 36833 MEDSV DEF RBRVS 01/01/2024 721.67 Description: AV FISTULA REVISION Category: Medical Services CMS Add: 01/01/1999 CMS Term: 36833 MEDSV DEF RBRVS 02/01/2015 12/31/2023 480.51 Description: AV FISTULA REVISION Category: Medical Services CMS Add: 01/01/1999 CMS Term: 36835 MEDSV DEF RBRVS 01/01/2024 438.13 Description: ARTERY TO VEIN SHUNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36835 MEDSV DEF RBRVS 02/01/2015 12/31/2023 362.88 Description: ARTERY TO VEIN SHUNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 36836 MEDSV DEF RBRVS 01/01/2023 6495.28 Description: PRQ AV FSTL CRTJ UXTR 1 ACS Category: Medical Services CMS Add: 01/01/2023 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 474 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 36837 MEDSV DEF RBRVS 01/01/2023 12/31/2023 7416.51 Description: PRQ AV FSTL CRT UXTR SEP ACS Category: Medical Services CMS Add: 01/01/2023 CMS Term: 36837 MEDSV DEF RBRVS 01/01/2024 9240.36 Description: PRQ AV FSTL CRT UXTR SEP ACS Category: Medical Services CMS Add: 01/01/2023 CMS Term: 36838 MEDSV DEF RBRVS 01/01/2024 1017.11 Description: DIST REVAS LIGATION HEMO Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36838 MEDSV DEF RBRVS 02/01/2015 12/31/2023 844.54 Description: DIST REVAS LIGATION HEMO Category: Medical Services CMS Add: 01/01/2004 CMS Term: 36860 MEDSV DEF RBRVS 01/01/2024 214.01 Description: EXTERNAL CANNULA DECLOTTING Category: Medical Services CMS Add: 01/01/1985 CMS Term: 36860 MEDSV DEF RBRVS 09/01/2019 12/31/2023 151.03 Description: EXTERNAL CANNULA DECLOTTING Category: Medical Services CMS Add: 01/01/1985 CMS Term: 36861 MEDSV DEF RBRVS 01/01/2024 124.88 Description: CANNULA DECLOTTING Category: Medical Services CMS Add: 01/01/1985 CMS Term: 36861 MEDSV DEF RBRVS 09/01/2019 12/31/2023 95.62 Description: CANNULA DECLOTTING Category: Medical Services CMS Add: 01/01/1985 CMS Term: 36901 MEDSV DEF RBRVS 01/01/2017 12/31/2023 402.84 Description: INTRO CATH DIALYSIS CIRCUIT Category: Medical Services CMS Add: 01/01/2017 CMS Term: 36901 MEDSV DEF RBRVS 01/01/2024 657.69 Description: INTRO CATH DIALYSIS CIRCUIT Category: Medical Services CMS Add: 01/01/2017 CMS Term: 36902 MEDSV DEF RBRVS 01/01/2017 12/31/2023 855.50 Description: INTRO CATH DIALYSIS CIRCUIT Category: Medical Services CMS Add: 01/01/2017 CMS Term: 36902 MEDSV DEF RBRVS 01/01/2024 1125.62 Description: INTRO CATH DIALYSIS CIRCUIT Category: Medical Services CMS Add: 01/01/2017 CMS Term: 36903 MEDSV DEF MAXFEE 01/01/2024 3987.18 0.0 Description: INTRO CATH DIALYSIS CIRCUIT Category: Medical Services CMS Add: 01/01/2017 CMS Term: 36904 MEDSV DEF RBRVS 01/01/2017 12/31/2023 1247.73 Description: THRMBC/NFS DIALYSIS CIRCUIT Category: Medical Services CMS Add: 01/01/2017 CMS Term: 36904 MEDSV DEF RBRVS 01/01/2024 1689.15 Description: THRMBC/NFS DIALYSIS CIRCUIT Category: Medical Services CMS Add: 01/01/2017 CMS Term: 36905 MEDSV DEF RBRVS 01/01/2017 12/31/2023 1596.51 Description: THRMBC/NFS DIALYSIS CIRCUIT Category: Medical Services CMS Add: 01/01/2017 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 475 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 36905 MEDSV DEF RBRVS 01/01/2024 2127.96 Description: THRMBC/NFS DIALYSIS CIRCUIT Category: Medical Services CMS Add: 01/01/2017 CMS Term: 36906 MEDSV DEF MAXFEE 01/01/2024 5058.86 0.0 Description: THRMBC/NFS DIALYSIS CIRCUIT Category: Medical Services CMS Add: 01/01/2017 CMS Term: 36907 MEDSV DEF RBRVS 01/01/2017 12/31/2023 511.86 Description: BALO ANGIOP CTR DIALYSIS SEG Category: Medical Services CMS Add: 01/01/2017 CMS Term: 36907 MEDSV DEF RBRVS 01/01/2024 550.82 Description: BALO ANGIOP CTR DIALYSIS SEG Category: Medical Services CMS Add: 01/01/2017 CMS Term: 36908 MEDSV DEF MAXFEE 01/01/2024 1320.19 0.0 Description: STENT PLMT CTR DIALYSIS SEG Category: Medical Services CMS Add: 01/01/2017 CMS Term: 36909 MEDSV DEF MAXFEE 01/01/2024 1783.17 0.0 Description: DIALYSIS CIRCUIT EMBOLJ Category: Medical Services CMS Add: 01/01/2017 CMS Term: 3700F NOCOV DEF SYSMAN Description: PSYCH DISORDERS ASSESSED Category: Non Covered Services CMS Add: 10/01/2010 CMS Term: 37140 MEDSV DEF RBRVS 01/01/2024 2102.87 Description: REVISION OF CIRCULATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37140 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1649.70 Description: REVISION OF CIRCULATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37145 MEDSV DEF RBRVS 01/01/2024 1951.62 Description: REVISION OF CIRCULATION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 37145 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1532.60 Description: REVISION OF CIRCULATION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 37160 MEDSV DEF RBRVS 01/01/2024 2004.20 Description: REVISION OF CIRCULATION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 37160 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1571.69 Description: REVISION OF CIRCULATION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 37180 MEDSV DEF RBRVS 01/01/2024 1925.96 Description: REVISION OF CIRCULATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37180 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1511.90 Description: REVISION OF CIRCULATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37181 MEDSV DEF RBRVS 01/01/2024 2102.87 Description: SPLICE SPLEEN/KIDNEY VEINS Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 476 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 37181 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1649.54 Description: SPLICE SPLEEN/KIDNEY VEINS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37182 MEDSV DEF RBRVS 01/01/2019 12/31/2023 627.95 Description: INSERT HEPATIC SHUNT (TIPS) Category: Medical Services CMS Add: 01/01/2003 CMS Term: 37182 MEDSV DEF RBRVS 01/01/2024 759.11 Description: INSERT HEPATIC SHUNT (TIPS) Category: Medical Services CMS Add: 01/01/2003 CMS Term: 37183 MEDSV DEF RBRVS 01/01/2024 5476.50 Description: REVISION TIPS Category: Medical Services CMS Add: 01/01/2003 CMS Term: 37183 MEDSV DEF RBRVS 09/15/2017 12/31/2023 4088.74 Description: REVISION TIPS Category: Medical Services CMS Add: 01/01/2003 CMS Term: 37184 MEDSV DEF RBRVS 01/01/2024 1591.74 Description: PRIM ART M-THRMBC 1ST VSL Category: Medical Services CMS Add: 01/01/2006 CMS Term: 37184 MEDSV DEF RBRVS 09/15/2017 12/31/2023 1563.13 Description: PRIM ART M-THRMBC 1ST VSL Category: Medical Services CMS Add: 01/01/2006 CMS Term: 37185 MEDSV DEF RBRVS 01/01/2024 438.35 Description: PRIM ART M-THRMBC SBSQ VSL Category: Medical Services CMS Add: 01/01/2006 CMS Term: 37185 MEDSV DEF RBRVS 09/15/2017 12/31/2023 496.61 Description: PRIM ART M-THRMBC SBSQ VSL Category: Medical Services CMS Add: 01/01/2006 CMS Term: 37186 MEDSV DEF RBRVS 01/01/2024 1103.07 Description: SEC ART THROMBECTOMY ADD-ON Category: Medical Services CMS Add: 01/01/2006 CMS Term: 37186 MEDSV DEF RBRVS 09/15/2017 12/31/2023 940.41 Description: SEC ART THROMBECTOMY ADD-ON Category: Medical Services CMS Add: 01/01/2006 CMS Term: 37187 MEDSV DEF RBRVS 01/01/2024 1589.59 Description: VENOUS MECH THROMBECTOMY Category: Medical Services CMS Add: 01/01/2006 CMS Term: 37187 MEDSV DEF RBRVS 09/15/2017 12/31/2023 1389.31 Description: VENOUS MECH THROMBECTOMY Category: Medical Services CMS Add: 01/01/2006 CMS Term: 37188 MEDSV DEF RBRVS 01/01/2024 1370.93 Description: VEN MECHNL THRMBC REPEAT TX Category: Medical Services CMS Add: 01/01/2006 CMS Term: 37188 MEDSV DEF RBRVS 09/15/2017 12/31/2023 1185.62 Description: VEN MECHNL THRMBC REPEAT TX Category: Medical Services CMS Add: 01/01/2006 CMS Term: 37191 MEDSV DEF RBRVS 01/01/2024 1898.56 Description: INS ENDOVAS VENA CAVA FILTR Category: Medical Services CMS Add: 01/01/2012 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 477 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 37191 MEDSV DEF RBRVS 09/15/2017 12/31/2023 1804.71 Description: INS ENDOVAS VENA CAVA FILTR Category: Medical Services CMS Add: 01/01/2012 CMS Term: 37192 MEDSV DEF RBRVS 01/01/2024 1182.69 Description: REDO ENDOVAS VENA CAVA FILTR Category: Medical Services CMS Add: 01/01/2012 CMS Term: 37192 MEDSV DEF RBRVS 09/15/2017 12/31/2023 1132.57 Description: REDO ENDOVAS VENA CAVA FILTR Category: Medical Services CMS Add: 01/01/2012 CMS Term: 37193 MEDSV DEF RBRVS 01/01/2024 1400.78 Description: REM ENDOVAS VENA CAVA FILTER Category: Medical Services CMS Add: 01/01/2012 CMS Term: 37193 MEDSV DEF RBRVS 09/15/2017 12/31/2023 1080.06 Description: REM ENDOVAS VENA CAVA FILTER Category: Medical Services CMS Add: 01/01/2012 CMS Term: 37195 MEDSV DEF MAXFEE 01/01/2024 331.37 0.0 Description: THROMBOLYTIC THERAPY STROKE Category: Medical Services CMS Add: 01/01/1998 CMS Term: 37197 MEDSV DEF RBRVS 01/01/2024 1451.75 0-2 Description: REMOVE INTRVAS FOREIGN BODY Category: Medical Services CMS Add: 01/01/2013 CMS Term: 37197 MEDSV DEF RBRVS 09/15/2017 12/31/2023 1016.90 0-2 Description: REMOVE INTRVAS FOREIGN BODY Category: Medical Services CMS Add: 01/01/2013 CMS Term: 37200 MEDSV DEF RBRVS 01/01/2024 199.87 Description: TRANSCATHETER BIOPSY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 37200 MEDSV DEF RBRVS 09/01/2019 12/31/2023 166.01 Description: TRANSCATHETER BIOPSY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 3720F NOCOV DEF SYSMAN Description: COGNIT IMPAIRMENT ASSESSED Category: Non Covered Services CMS Add: 10/01/2010 CMS Term: 37211 MEDSV DEF RBRVS 01/01/2024 349.83 0-1 Description: THROMBOLYTIC ART THERAPY Category: Medical Services CMS Add: 01/01/2013 CMS Term: 37211 MEDSV DEF RBRVS 09/15/2017 12/31/2023 284.20 0-1 Description: THROMBOLYTIC ART THERAPY Category: Medical Services CMS Add: 01/01/2013 CMS Term: 37212 MEDSV DEF RBRVS 01/01/2024 307.31 0-1 Description: THROMBOLYTIC VENOUS THERAPY Category: Medical Services CMS Add: 01/01/2013 CMS Term: 37212 MEDSV DEF RBRVS 09/15/2017 12/31/2023 248.62 0-1 Description: THROMBOLYTIC VENOUS THERAPY Category: Medical Services CMS Add: 01/01/2013 CMS Term: 37213 MEDSV DEF RBRVS 01/01/2024 210.11 0-1 Description: THROMBLYTIC ART/VEN THERAPY Category: Medical Services CMS Add: 01/01/2013 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 478 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 37213 MEDSV DEF RBRVS 09/15/2017 12/31/2023 173.62 0-1 Description: THROMBLYTIC ART/VEN THERAPY Category: Medical Services CMS Add: 01/01/2013 CMS Term: 37214 MEDSV DEF RBRVS 01/01/2024 111.06 0-1 Description: CESSJ THERAPY CATH REMOVAL Category: Medical Services CMS Add: 01/01/2013 CMS Term: 37214 MEDSV DEF RBRVS 09/15/2017 12/31/2023 91.10 0-1 Description: CESSJ THERAPY CATH REMOVAL Category: Medical Services CMS Add: 01/01/2013 CMS Term: 37215 MEDSV DEF RBRVS 01/01/2024 883.66 Description: TRANSCATH STENT CCA W/EPS Category: Medical Services CMS Add: 01/01/2005 CMS Term: 37215 MEDSV DEF RBRVS 09/15/2017 12/31/2023 723.90 Description: TRANSCATH STENT CCA W/EPS Category: Medical Services CMS Add: 01/01/2005 CMS Term: 37216 NOCOV DEF SYSMAN Description: TRANSCATH STENT CCA W/O EPS Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: 37217 MEDSV DEF RBRVS 01/01/2024 964.48 Description: STENT PLACEMT RETRO CAROTID Category: Medical Services CMS Add: 01/01/2014 CMS Term: 37217 MEDSV DEF RBRVS 02/01/2015 12/31/2023 813.55 Description: STENT PLACEMT RETRO CAROTID Category: Medical Services CMS Add: 01/01/2014 CMS Term: 37218 MEDSV DEF RBRVS 01/01/2024 738.58 Description: STENT PLACEMT ANTE CAROTID Category: Medical Services CMS Add: 01/01/2015 CMS Term: 37218 MEDSV DEF RBRVS 09/15/2017 12/31/2023 593.50 Description: STENT PLACEMT ANTE CAROTID Category: Medical Services CMS Add: 01/01/2015 CMS Term: 37220 MEDSV DEF MAXFEE 01/01/2024 2330.43 0.0 Description: ILIAC REVASC Category: Medical Services CMS Add: 01/01/2011 CMS Term: 37221 MEDSV DEF MAXFEE 01/01/2024 2867.12 0.0 Description: ILIAC REVASC W/STENT Category: Medical Services CMS Add: 01/01/2011 CMS Term: 37222 MEDSV DEF MAXFEE 01/01/2024 569.93 0.0 Description: ILIAC REVASC ADD-ON Category: Medical Services CMS Add: 01/01/2011 CMS Term: 37223 MEDSV DEF MAXFEE 01/01/2024 1184.24 0.0 Description: ILIAC REVASC W/STENT ADD-ON Category: Medical Services CMS Add: 01/01/2011 CMS Term: 37224 MEDSV DEF MAXFEE 01/01/2024 2718.87 0.0 Description: FEM/POPL REVAS W/TLA Category: Medical Services CMS Add: 01/01/2011 CMS Term: 37225 MEDSV DEF MAXFEE 01/01/2024 8158.99 0.0 Description: FEM/POPL REVAS W/ATHER Category: Medical Services CMS Add: 01/01/2011 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 479 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 37226 MEDSV DEF MAXFEE 01/01/2024 7591.83 0.0 Description: FEM/POPL REVASC W/STENT Category: Medical Services CMS Add: 01/01/2011 CMS Term: 37227 MEDSV DEF MAXFEE 01/01/2024 10450.12 0.0 Description: FEM/POPL REVASC STNT & ATHER Category: Medical Services CMS Add: 01/01/2011 CMS Term: 37228 MEDSV DEF MAXFEE 01/01/2024 3861.53 0.0 Description: TIB/PER REVASC W/TLA Category: Medical Services CMS Add: 01/01/2011 CMS Term: 37229 MEDSV DEF MAXFEE 01/01/2024 8293.17 0.0 Description: TIB/PER REVASC W/ATHER Category: Medical Services CMS Add: 01/01/2011 CMS Term: 37230 MEDSV DEF MAXFEE 01/01/2024 8302.23 0.0 Description: TIB/PER REVASC W/STENT Category: Medical Services CMS Add: 01/01/2011 CMS Term: 37231 MEDSV DEF MAXFEE 01/01/2024 10974.34 0.0 Description: TIB/PER REVASC STENT & ATHER Category: Medical Services CMS Add: 01/01/2011 CMS Term: 37232 MEDSV DEF MAXFEE 01/01/2024 762.29 0.0 Description: TIB/PER REVASC ADD-ON Category: Medical Services CMS Add: 01/01/2011 CMS Term: 37233 MEDSV DEF MAXFEE 01/01/2024 968.79 0.0 Description: TIBPER REVASC W/ATHER ADD-ON Category: Medical Services CMS Add: 01/01/2011 CMS Term: 37234 MEDSV DEF MAXFEE 01/01/2024 3381.22 0.0 Description: REVSC OPN/PRQ TIB/PERO STENT Category: Medical Services CMS Add: 01/01/2011 CMS Term: 37235 MEDSV DEF MAXFEE 01/01/2024 3695.12 0.0 Description: TIB/PER REVASC STNT & ATHER Category: Medical Services CMS Add: 01/01/2011 CMS Term: 37236 MEDSV DEF RBRVS 01/01/2024 2555.99 Description: OPEN/PERQ PLACE STENT 1ST Category: Medical Services CMS Add: 01/01/2014 CMS Term: 37236 MEDSV DEF RBRVS 09/15/2017 12/31/2023 2778.22 Description: OPEN/PERQ PLACE STENT 1ST Category: Medical Services CMS Add: 01/01/2014 CMS Term: 37237 MEDSV DEF RBRVS 01/01/2024 1201.19 Description: OPEN/PERQ PLACE STENT EA ADD Category: Medical Services CMS Add: 01/01/2014 CMS Term: 37237 MEDSV DEF RBRVS 09/15/2017 12/31/2023 1695.93 Description: OPEN/PERQ PLACE STENT EA ADD Category: Medical Services CMS Add: 01/01/2014 CMS Term: 37238 MEDSV DEF RBRVS 01/01/2024 3213.53 Description: OPEN/PERQ PLACE STENT SAME Category: Medical Services CMS Add: 01/01/2014 CMS Term: 37238 MEDSV DEF RBRVS 09/15/2017 12/31/2023 2897.22 Description: OPEN/PERQ PLACE STENT SAME Category: Medical Services CMS Add: 01/01/2014 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 480 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 37239 MEDSV DEF RBRVS 01/01/2024 1595.50 Description: OPEN/PERQ PLACE STENT EA ADD Category: Medical Services CMS Add: 01/01/2014 CMS Term: 37239 MEDSV DEF RBRVS 09/15/2017 12/31/2023 1406.06 Description: OPEN/PERQ PLACE STENT EA ADD Category: Medical Services CMS Add: 01/01/2014 CMS Term: 37241 MEDSV DEF RBRVS 01/01/2024 4354.63 Description: VASC EMBOLIZE/OCCLUDE VENOUS Category: Medical Services CMS Add: 01/01/2014 CMS Term: 37241 MEDSV DEF RBRVS 09/15/2017 12/31/2023 3331.78 Description: VASC EMBOLIZE/OCCLUDE VENOUS Category: Medical Services CMS Add: 01/01/2014 CMS Term: 37242 MEDSV DEF RBRVS 01/01/2024 6644.87 Description: VASC EMBOLIZE/OCCLUDE ARTERY Category: Medical Services CMS Add: 01/01/2014 CMS Term: 37242 MEDSV DEF RBRVS 09/15/2017 12/31/2023 5223.88 Description: VASC EMBOLIZE/OCCLUDE ARTERY Category: Medical Services CMS Add: 01/01/2014 CMS Term: 37243 MEDSV DEF RBRVS 01/01/2024 8079.39 Description: VASC EMBOLIZE/OCCLUDE ORGAN Category: Medical Services CMS Add: 01/01/2014 CMS Term: 37243 MEDSV DEF RBRVS 09/15/2017 12/31/2023 6790.94 Description: VASC EMBOLIZE/OCCLUDE ORGAN Category: Medical Services CMS Add: 01/01/2014 CMS Term: 37244 MEDSV DEF RBRVS 01/01/2024 6171.45 Description: VASC EMBOLIZE/OCCLUDE BLEED Category: Medical Services CMS Add: 01/01/2014 CMS Term: 37244 MEDSV DEF RBRVS 09/15/2017 12/31/2023 4743.25 Description: VASC EMBOLIZE/OCCLUDE BLEED Category: Medical Services CMS Add: 01/01/2014 CMS Term: 37246 MEDSV DEF RBRVS 01/01/2017 12/31/2023 1505.92 Description: TRLUML BALO ANGIOP 1ST ART Category: Medical Services CMS Add: 01/01/2017 CMS Term: 37246 MEDSV DEF RBRVS 01/01/2024 1692.08 Description: TRLUML BALO ANGIOP 1ST ART Category: Medical Services CMS Add: 01/01/2017 CMS Term: 37247 MEDSV DEF RBRVS 01/01/2017 12/31/2023 609.78 Description: TRLUML BALO ANGIOP ADDL ART Category: Medical Services CMS Add: 01/01/2017 CMS Term: 37247 MEDSV DEF RBRVS 01/01/2024 523.64 Description: TRLUML BALO ANGIOP ADDL ART Category: Medical Services CMS Add: 01/01/2017 CMS Term: 37248 MEDSV DEF RBRVS 01/01/2017 12/31/2023 1043.98 Description: TRLUML BALO ANGIOP 1ST VEIN Category: Medical Services CMS Add: 01/01/2017 CMS Term: 37248 MEDSV DEF RBRVS 01/01/2024 1267.24 Description: TRLUML BALO ANGIOP 1ST VEIN Category: Medical Services CMS Add: 01/01/2017 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 481 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 37249 MEDSV DEF RBRVS 01/01/2017 12/31/2023 447.66 Description: TRLUML BALO ANGIOP ADDL VEIN Category: Medical Services CMS Add: 01/01/2017 CMS Term: 37249 MEDSV DEF RBRVS 01/01/2024 410.77 Description: TRLUML BALO ANGIOP ADDL VEIN Category: Medical Services CMS Add: 01/01/2017 CMS Term: 37252 MEDSV DEF RBRVS 01/01/2024 887.19 Description: INTRVASC US NONCORONARY 1ST Category: Medical Services CMS Add: 01/01/2016 CMS Term: 37252 MEDSV DEF RBRVS 09/15/2017 12/31/2023 967.80 Description: INTRVASC US NONCORONARY 1ST Category: Medical Services CMS Add: 01/01/2016 CMS Term: 37253 MEDSV DEF RBRVS 01/01/2024 158.56 Description: INTRVASC US NONCORONARY ADDL Category: Medical Services CMS Add: 01/01/2016 CMS Term: 37253 MEDSV DEF RBRVS 09/15/2017 12/31/2023 145.95 Description: INTRVASC US NONCORONARY ADDL Category: Medical Services CMS Add: 01/01/2016 CMS Term: 3725F NOCOV DEF SYSMAN Description: SCREEN DEPRESSION PERFORMED Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 37500 MEDSV DEF RBRVS 01/01/2024 563.58 Description: ENDOSCOPY LIGATE PERF VEINS Category: Medical Services CMS Add: 01/01/2003 CMS Term: 37500 MEDSV DEF RBRVS 02/01/2015 12/31/2023 552.11 Description: ENDOSCOPY LIGATE PERF VEINS Category: Medical Services CMS Add: 01/01/2003 CMS Term: 37501 MEDSV DEF BILL20 Description: UNLISTED VASC ENDOSCOPY PX Category: Medical Services CMS Add: 01/01/2003 CMS Term: 3750F NOCOV DEF SYSMAN Description: PTNOTRCVNGSTEROID>=10MG/DAY Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 3751F NOCOV DEF SYSMAN Description: ELECTRODIAG POLYNEURO 6 MN Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 3752F NOCOV DEF SYSMAN Description: NO ELECTRODIAG POLYNEURO 6MN Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 3753F NOCOV DEF SYSMAN Description: PT HAS SYMP&SIGNS NEUROPATHY Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 3754F NOCOV DEF SYSMAN Description: SCREENING TESTS DM DONE Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 3755F NOCOV DEF SYSMAN Description: COG&BEHAV IMPRMNT SCRNG DONE Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 482 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 37565 MEDSV DEF RBRVS 01/01/2024 667.59 Description: LIGATION OF NECK VEIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37565 MEDSV DEF RBRVS 09/01/2019 12/31/2023 531.36 Description: LIGATION OF NECK VEIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3756F NOCOV DEF SYSMAN Description: PT W/PSEUDOBULB AFFECT/ALS Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 3757F NOCOV DEF SYSMAN Description: PT W/O PSEUDOBULBAFFECT/ALS Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 3758F NOCOV DEF SYSMAN Description: PT REF PULM FX TEST/PEAKFLOW Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 3759F NOCOV DEF SYSMAN Description: PT SCRN DYSPHAG/WT LOSS/NUTR Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 37600 MEDSV DEF RBRVS 01/01/2024 690.22 Description: LIGATION OF NECK ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37600 MEDSV DEF RBRVS 09/01/2019 12/31/2023 519.66 Description: LIGATION OF NECK ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37605 MEDSV DEF RBRVS 01/01/2024 658.31 Description: LIGATION OF NECK ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37605 MEDSV DEF RBRVS 09/01/2019 12/31/2023 583.35 Description: LIGATION OF NECK ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37606 MEDSV DEF RBRVS 01/01/2024 656.24 Description: LIGATION OF NECK ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37606 MEDSV DEF RBRVS 09/01/2019 12/31/2023 413.58 Description: LIGATION OF NECK ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37607 MEDSV DEF RBRVS 01/01/2024 337.32 Description: LIGATION OF A-V FISTULA Category: Medical Services CMS Add: 01/01/1994 CMS Term: 37607 MEDSV DEF RBRVS 09/01/2019 12/31/2023 275.52 Description: LIGATION OF A-V FISTULA Category: Medical Services CMS Add: 01/01/1994 CMS Term: 37609 MEDSV DEF RBRVS 01/01/2024 289.48 Description: TEMPORAL ARTERY PROCEDURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37609 MEDSV DEF RBRVS 09/01/2019 12/31/2023 221.33 Description: TEMPORAL ARTERY PROCEDURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 483 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 3760F NOCOV DEF SYSMAN Description: PT W/DYSPHAG/WT LOSS/NUTR Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 37615 MEDSV DEF RBRVS 01/01/2024 474.66 Description: LIGATION OF NECK ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37615 MEDSV DEF RBRVS 09/01/2019 12/31/2023 383.31 Description: LIGATION OF NECK ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37616 MEDSV DEF RBRVS 01/01/2024 1001.12 Description: LIGATION OF CHEST ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37616 MEDSV DEF RBRVS 09/01/2019 12/31/2023 791.02 Description: LIGATION OF CHEST ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37617 MEDSV DEF RBRVS 01/01/2024 1194.39 Description: LIGATION OF ABDOMEN ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37617 MEDSV DEF RBRVS 09/01/2019 12/31/2023 968.42 Description: LIGATION OF ABDOMEN ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37618 MEDSV DEF RBRVS 01/01/2024 354.98 Description: LIGATION OF EXTREMITY ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37618 MEDSV DEF RBRVS 09/01/2019 12/31/2023 281.42 Description: LIGATION OF EXTREMITY ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37619 MEDSV DEF RBRVS 01/01/2024 1564.62 Description: LIGATION OF INF VENA CAVA Category: Medical Services CMS Add: 01/01/2012 CMS Term: 37619 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1192.34 Description: LIGATION OF INF VENA CAVA Category: Medical Services CMS Add: 01/01/2012 CMS Term: 3761F NOCOV DEF SYSMAN Description: PT W/O DYSPHAG/WT LOSS/NUTR Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 3762F NOCOV DEF SYSMAN Description: PATIENT IS DYSARTHRIC Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 3763F NOCOV DEF SYSMAN Description: PATIENT IS NOT DYSARTHRIC Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 37650 MEDSV DEF RBRVS 01/01/2024 411.17 Description: REVISION OF MAJOR VEIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37650 MEDSV DEF RBRVS 09/01/2019 12/31/2023 371.54 Description: REVISION OF MAJOR VEIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 484 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 37660 MEDSV DEF RBRVS 01/01/2024 1193.36 Description: REVISION OF MAJOR VEIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37660 MEDSV DEF RBRVS 09/01/2019 12/31/2023 827.20 Description: REVISION OF MAJOR VEIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37700 MEDSV DEF RBRVS 01/01/2024 221.58 Description: REVISE LEG VEIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37700 MEDSV DEF RBRVS 09/01/2019 12/31/2023 182.98 Description: REVISE LEG VEIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37718 MEDSV DEF RBRVS 01/01/2024 352.51 Description: LIGATE/STRIP SHORT LEG VEIN Category: Medical Services CMS Add: 01/01/2006 CMS Term: 37718 MEDSV DEF RBRVS 02/01/2015 12/31/2023 317.91 Description: LIGATE/STRIP SHORT LEG VEIN Category: Medical Services CMS Add: 01/01/2006 CMS Term: 37722 MEDSV DEF RBRVS 01/01/2024 417.84 Description: LIGATE/STRIP LONG LEG VEIN Category: Medical Services CMS Add: 01/01/2006 CMS Term: 37722 MEDSV DEF RBRVS 02/01/2015 12/31/2023 351.86 Description: LIGATE/STRIP LONG LEG VEIN Category: Medical Services CMS Add: 01/01/2006 CMS Term: 37735 MEDSV DEF RBRVS 01/01/2024 520.69 Description: REMOVAL OF LEG VEINS/LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37735 MEDSV DEF RBRVS 09/01/2019 12/31/2023 496.82 Description: REMOVAL OF LEG VEINS/LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 3775F NOCOV DEF SYSMAN Description: ADENOMA DETECTED SCREENING Category: Non Covered Services CMS Add: 04/01/2014 CMS Term: 37760 MEDSV DEF RBRVS 01/01/2024 515.69 Description: LIGATE LEG VEINS RADICAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37760 MEDSV DEF RBRVS 09/01/2019 12/31/2023 449.92 Description: LIGATE LEG VEINS RADICAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37761 MEDSV DEF RBRVS 01/01/2024 487.40 Description: LIGATE LEG VEINS OPEN Category: Medical Services CMS Add: 01/01/2010 CMS Term: 37761 MEDSV DEF RBRVS 02/01/2015 12/31/2023 402.53 Description: LIGATE LEG VEINS OPEN Category: Medical Services CMS Add: 01/01/2010 CMS Term: 37765 MEDSV DEF RBRVS 01/01/2024 389.65 Description: STAB PHLEB VEINS XTR 10-20 Category: Medical Services CMS Add: 01/01/2004 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 485 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 37765 MEDSV DEF RBRVS 02/01/2015 12/31/2023 471.22 Description: STAB PHLEB VEINS XTR 10-20 Category: Medical Services CMS Add: 01/01/2004 CMS Term: 37766 MEDSV DEF RBRVS 01/01/2024 457.47 Description: PHLEB VEINS - EXTREM 20+ Category: Medical Services CMS Add: 01/01/2004 CMS Term: 37766 MEDSV DEF RBRVS 02/01/2015 12/31/2023 564.74 Description: PHLEB VEINS - EXTREM 20+ Category: Medical Services CMS Add: 01/01/2004 CMS Term: 3776F NOCOV DEF SYSMAN Description: ADENOMA NOT DETECT SCREENING Category: Non Covered Services CMS Add: 04/01/2014 CMS Term: 37780 MEDSV DEF RBRVS 01/01/2024 212.06 Description: REVISION OF LEG VEIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37780 MEDSV DEF RBRVS 09/01/2019 12/31/2023 186.52 Description: REVISION OF LEG VEIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37785 MEDSV DEF RBRVS 01/01/2024 320.86 Description: LIGATE/DIVIDE/EXCISE VEIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37785 MEDSV DEF RBRVS 09/01/2019 12/31/2023 254.39 Description: LIGATE/DIVIDE/EXCISE VEIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 37788 MEDSV DEF RBRVS 01/01/2019 12/31/2023 961.84 Description: REVASCULARIZATION PENIS Category: Medical Services CMS Add: 01/01/1992 CMS Term: 37788 MEDSV DEF RBRVS 01/01/2024 1175.07 Description: REVASCULARIZATION PENIS Category: Medical Services CMS Add: 01/01/1992 CMS Term: 37790 MEDSV DEF RBRVS 01/01/2024 453.03 Description: PENILE VENOUS OCCLUSION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 37790 MEDSV DEF RBRVS 09/01/2019 12/31/2023 353.33 Description: PENILE VENOUS OCCLUSION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 37799 MEDSV DEF BILL20 Description: UNLISTED PX VASCULAR SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38100 MEDSV DEF RBRVS 01/01/2024 1050.35 Description: REMOVAL OF SPLEEN TOTAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38100 MEDSV DEF RBRVS 09/01/2019 12/31/2023 822.79 Description: REMOVAL OF SPLEEN TOTAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38101 MEDSV DEF RBRVS 01/01/2024 1058.88 Description: REMOVAL OF SPLEEN PARTIAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 486 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 38101 MEDSV DEF RBRVS 09/01/2019 12/31/2023 828.33 Description: REMOVAL OF SPLEEN PARTIAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38102 MEDSV DEF RBRVS 01/01/2024 238.06 Description: REMOVAL OF SPLEEN TOTAL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 38102 MEDSV DEF RBRVS 02/01/2015 12/31/2023 187.74 Description: REMOVAL OF SPLEEN TOTAL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 38115 MEDSV DEF RBRVS 01/01/2024 1173.89 Description: REPAIR OF RUPTURED SPLEEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38115 MEDSV DEF RBRVS 09/01/2019 12/31/2023 908.27 Description: REPAIR OF RUPTURED SPLEEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38120 MEDSV DEF RBRVS 01/01/2024 966.02 Description: LAPAROSCOPY SPLENECTOMY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 38120 MEDSV DEF RBRVS 09/01/2019 12/31/2023 749.96 Description: LAPAROSCOPY SPLENECTOMY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 38129 MEDSV DEF BILL20 0-1 Description: UNLISTED LAPS PX SPLEEN Category: Medical Services CMS Add: 01/01/2000 CMS Term: 38200 MEDSV DEF RBRVS 01/01/2024 122.80 Description: INJECTION FOR SPLEEN X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38200 MEDSV DEF RBRVS 09/01/2019 12/31/2023 94.96 Description: INJECTION FOR SPLEEN X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38204 NOCOV DEF SYSMAN Description: BL DONOR SEARCH MANAGEMENT Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: 38205 MEDSV DEF RBRVS 01/01/2024 79.61 Y Description: HARVEST ALLOGENEIC STEM CELL Category: Medical Services CMS Add: 01/01/2003 CMS Term: 38205 MEDSV DEF RBRVS 04/20/2018 12/31/2023 59.95 Y Description: HARVEST ALLOGENEIC STEM CELL Category: Medical Services CMS Add: 01/01/2003 CMS Term: 38206 MEDSV DEF RBRVS 01/01/2024 78.99 Y Description: HARVEST AUTO STEM CELLS Category: Medical Services CMS Add: 01/01/2003 CMS Term: 38206 MEDSV DEF RBRVS 02/01/2015 12/31/2023 60.70 Y Description: HARVEST AUTO STEM CELLS Category: Medical Services CMS Add: 01/01/2003 CMS Term: 38207 NOCOV DEF SYSMAN Description: CRYOPRESERVE STEM CELLS Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 487 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 38208 NOCOV DEF SYSMAN Description: THAW PRESERVED STEM CELLS Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: 38209 NOCOV DEF SYSMAN Description: WASH HARVEST STEM CELLS Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: 38210 NOCOV DEF SYSMAN Description: T-CELL DEPLETION OF HARVEST Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: 38211 NOCOV DEF SYSMAN Description: TUMOR CELL DEPLETE OF HARVST Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: 38212 NOCOV DEF SYSMAN Description: RBC DEPLETION OF HARVEST Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: 38213 NOCOV DEF SYSMAN Description: PLATELET DEPLETE OF HARVEST Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: 38214 NOCOV DEF SYSMAN Description: VOLUME DEPLETE OF HARVEST Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: 38215 NOCOV DEF SYSMAN Description: HARVEST STEM CELL CONCENTRTE Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: 38220 MEDSV DEF RBRVS 01/01/2016 12/31/2023 113.32 Description: DX BONE MARROW ASPIRATIONS Category: Medical Services CMS Add: 01/01/2002 CMS Term: 38220 MEDSV DEF RBRVS 01/01/2024 145.38 Description: DX BONE MARROW ASPIRATIONS Category: Medical Services CMS Add: 01/01/2002 CMS Term: 38221 MEDSV DEF RBRVS 01/01/2016 12/31/2023 118.14 Description: DX BONE MARROW BIOPSIES Category: Medical Services CMS Add: 01/01/2002 CMS Term: 38221 MEDSV DEF RBRVS 01/01/2024 151.18 Description: DX BONE MARROW BIOPSIES Category: Medical Services CMS Add: 01/01/2002 CMS Term: 38222 MEDSV DEF RBRVS 01/01/2018 12/31/2023 122.09 Description: DX BONE MARROW BX & ASPIR Category: Medical Services CMS Add: 01/01/2018 CMS Term: 38222 MEDSV DEF RBRVS 01/01/2024 164.03 Description: DX BONE MARROW BX & ASPIR Category: Medical Services CMS Add: 01/01/2018 CMS Term: 38230 MEDSV DEF RBRVS 01/01/2024 185.91 Y Description: BONE MARROW HARVEST ALLOGEN Category: Medical Services CMS Add: 01/01/1985 CMS Term: 38230 MEDSV DEF RBRVS 09/01/2019 12/31/2023 150.44 Y Description: BONE MARROW HARVEST ALLOGEN Category: Medical Services CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 488 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 38232 MEDSV DEF RBRVS 01/01/2024 178.99 Y Description: BONE MARROW HARVEST AUTOLOG Category: Medical Services CMS Add: 01/01/2012 CMS Term: 38232 MEDSV DEF RBRVS 02/01/2015 12/31/2023 149.20 Y Description: BONE MARROW HARVEST AUTOLOG Category: Medical Services CMS Add: 01/01/2012 CMS Term: 38240 MEDSV DEF RBRVS 01/01/2024 226.48 Y Description: TRANSPLT ALLO HCT/DONOR Category: Medical Services CMS Add: 01/01/1985 CMS Term: 38240 MEDSV DEF RBRVS 09/01/2019 12/31/2023 165.68 Y Description: TRANSPLT ALLO HCT/DONOR Category: Medical Services CMS Add: 01/01/1985 CMS Term: 38241 MEDSV DEF RBRVS 01/01/2024 167.39 Y Description: TRANSPLT AUTOL HCT/DONOR Category: Medical Services CMS Add: 01/01/1990 CMS Term: 38241 MEDSV DEF RBRVS 09/01/2019 12/31/2023 123.95 Y Description: TRANSPLT AUTOL HCT/DONOR Category: Medical Services CMS Add: 01/01/1990 CMS Term: 38242 MEDSV DEF RBRVS 01/01/2024 118.52 Y Description: TRANSPLT ALLO LYMPHOCYTES Category: Medical Services CMS Add: 01/01/2003 CMS Term: 38242 MEDSV DEF RBRVS 02/01/2015 12/31/2023 86.75 Y Description: TRANSPLT ALLO LYMPHOCYTES Category: Medical Services CMS Add: 01/01/2003 CMS Term: 38243 MEDSV DEF RBRVS 01/01/2024 116.11 Y 0-1 Description: TRANSPLJ HEMATOPOIETIC BOOST Category: Medical Services CMS Add: 01/01/2013 CMS Term: 38243 MEDSV DEF RBRVS 02/01/2015 12/31/2023 87.53 Y 0-1 Description: TRANSPLJ HEMATOPOIETIC BOOST Category: Medical Services CMS Add: 01/01/2013 CMS Term: 38300 MEDSV DEF RBRVS 01/01/2024 313.60 Description: DRAINAGE LYMPH NODE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38300 MEDSV DEF RBRVS 09/01/2019 12/31/2023 194.20 Description: DRAINAGE LYMPH NODE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38305 MEDSV DEF RBRVS 01/01/2024 453.60 Description: DRAINAGE LYMPH NODE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38305 MEDSV DEF RBRVS 09/01/2019 12/31/2023 339.92 Description: DRAINAGE LYMPH NODE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38308 MEDSV DEF RBRVS 01/01/2024 428.29 Description: INCISION OF LYMPH CHANNELS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38308 MEDSV DEF RBRVS 09/01/2019 12/31/2023 319.06 Description: INCISION OF LYMPH CHANNELS Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 489 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 38380 MEDSV DEF RBRVS 01/01/2024 533.37 Description: THORACIC DUCT PROCEDURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38380 MEDSV DEF RBRVS 09/01/2019 12/31/2023 416.64 Description: THORACIC DUCT PROCEDURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38381 MEDSV DEF RBRVS 01/01/2024 728.25 Description: THORACIC DUCT PROCEDURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38381 MEDSV DEF RBRVS 09/01/2019 12/31/2023 576.01 Description: THORACIC DUCT PROCEDURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38382 MEDSV DEF RBRVS 01/01/2024 621.13 Description: THORACIC DUCT PROCEDURE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 38382 MEDSV DEF RBRVS 09/01/2019 12/31/2023 430.82 Description: THORACIC DUCT PROCEDURE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 38500 MEDSV DEF RBRVS 01/01/2024 311.32 Description: BIOPSY/REMOVAL LYMPH NODES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38500 MEDSV DEF RBRVS 09/01/2019 12/31/2023 233.86 Description: BIOPSY/REMOVAL LYMPH NODES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38505 MEDSV DEF RBRVS 01/01/2024 165.90 Description: NEEDLE BIOPSY LYMPH NODES Category: Medical Services CMS Add: 01/01/1986 CMS Term: 38505 MEDSV DEF RBRVS 09/01/2019 12/31/2023 90.41 Description: NEEDLE BIOPSY LYMPH NODES Category: Medical Services CMS Add: 01/01/1986 CMS Term: 38510 MEDSV DEF RBRVS 01/01/2024 492.27 Description: BIOPSY/REMOVAL LYMPH NODES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38510 MEDSV DEF RBRVS 09/01/2019 12/31/2023 371.92 Description: BIOPSY/REMOVAL LYMPH NODES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38520 MEDSV DEF RBRVS 01/01/2024 432.90 Description: BIOPSY/REMOVAL LYMPH NODES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38520 MEDSV DEF RBRVS 09/01/2019 12/31/2023 333.47 Description: BIOPSY/REMOVAL LYMPH NODES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38525 MEDSV DEF RBRVS 01/01/2024 404.31 Description: BIOPSY/REMOVAL LYMPH NODES Category: Medical Services CMS Add: 01/01/1986 CMS Term: 38525 MEDSV DEF RBRVS 09/01/2019 12/31/2023 309.42 Description: BIOPSY/REMOVAL LYMPH NODES Category: Medical Services CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 490 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 38530 MEDSV DEF RBRVS 01/01/2024 521.60 Description: BIOPSY/REMOVAL LYMPH NODES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38530 MEDSV DEF RBRVS 09/01/2019 12/31/2023 393.28 Description: BIOPSY/REMOVAL LYMPH NODES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38531 MEDSV DEF RBRVS 01/01/2019 12/31/2023 315.85 Description: OPEN BX/EXC INGUINOFEM NODES Category: Medical Services CMS Add: 01/01/2019 CMS Term: 38531 MEDSV DEF RBRVS 01/01/2024 410.95 Description: OPEN BX/EXC INGUINOFEM NODES Category: Medical Services CMS Add: 01/01/2019 CMS Term: 38542 MEDSV DEF RBRVS 01/01/2024 488.70 Description: EXPLORE DEEP NODE(S) NECK Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38542 MEDSV DEF RBRVS 09/01/2019 12/31/2023 376.27 Description: EXPLORE DEEP NODE(S) NECK Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38550 MEDSV DEF RBRVS 01/01/2024 479.35 Description: REMOVAL NECK/ARMPIT LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38550 MEDSV DEF RBRVS 09/01/2019 12/31/2023 359.65 Description: REMOVAL NECK/ARMPIT LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38555 MEDSV DEF RBRVS 01/01/2024 937.63 Description: REMOVAL NECK/ARMPIT LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38555 MEDSV DEF RBRVS 09/01/2019 12/31/2023 714.00 Description: REMOVAL NECK/ARMPIT LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38562 MEDSV DEF RBRVS 01/01/2024 655.28 Description: REMOVAL PELVIC LYMPH NODES Category: Medical Services CMS Add: 01/01/1987 CMS Term: 38562 MEDSV DEF RBRVS 09/01/2019 12/31/2023 502.19 Description: REMOVAL PELVIC LYMPH NODES Category: Medical Services CMS Add: 01/01/1987 CMS Term: 38564 MEDSV DEF RBRVS 01/01/2024 645.33 Description: REMOVAL ABDOMEN LYMPH NODES Category: Medical Services CMS Add: 01/01/1987 CMS Term: 38564 MEDSV DEF RBRVS 09/01/2019 12/31/2023 501.05 Description: REMOVAL ABDOMEN LYMPH NODES Category: Medical Services CMS Add: 01/01/1987 CMS Term: 38570 MEDSV DEF RBRVS 01/01/2024 478.06 0-1 Description: LAPAROSCOPY LYMPH NODE BIOP Category: Medical Services CMS Add: 01/01/2000 CMS Term: 38570 MEDSV DEF RBRVS 02/01/2015 12/31/2023 385.79 0-1 Description: LAPAROSCOPY LYMPH NODE BIOP Category: Medical Services CMS Add: 01/01/2000 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 491 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 38571 MEDSV DEF RBRVS 01/01/2024 617.90 0-1 Description: LAPAROSCOPY LYMPHADENECTOMY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 38571 MEDSV DEF RBRVS 09/01/2019 12/31/2023 576.58 0-1 Description: LAPAROSCOPY LYMPHADENECTOMY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 38572 MEDSV DEF RBRVS 01/01/2024 842.21 0-1 Description: LAPAROSCOPY LYMPHADENECTOMY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 38572 MEDSV DEF RBRVS 09/01/2019 12/31/2023 695.27 0-1 Description: LAPAROSCOPY LYMPHADENECTOMY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 38573 MEDSV DEF RBRVS 01/01/2018 12/31/2023 845.36 Description: LAPS PELVIC LYMPHADEC Category: Medical Services CMS Add: 01/01/2018 CMS Term: 38573 MEDSV DEF RBRVS 01/01/2024 1090.70 Description: LAPS PELVIC LYMPHADEC Category: Medical Services CMS Add: 01/01/2018 CMS Term: 38589 MEDSV DEF BILL20 0-1 Description: UNLISTED LAPS PX LYMPHTC SYS Category: Medical Services CMS Add: 01/01/2000 CMS Term: 38700 MEDSV DEF RBRVS 01/01/2024 758.24 Description: REMOVAL OF LYMPH NODES NECK Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38700 MEDSV DEF RBRVS 09/01/2019 12/31/2023 589.09 Description: REMOVAL OF LYMPH NODES NECK Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38720 MEDSV DEF RBRVS 01/01/2024 1249.59 Description: REMOVAL OF LYMPH NODES NECK Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38720 MEDSV DEF RBRVS 09/01/2019 12/31/2023 981.89 Description: REMOVAL OF LYMPH NODES NECK Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38724 MEDSV DEF RBRVS 01/01/2024 1359.34 Description: REMOVAL OF LYMPH NODES NECK Category: Medical Services CMS Add: 01/01/1985 CMS Term: 38724 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1064.20 Description: REMOVAL OF LYMPH NODES NECK Category: Medical Services CMS Add: 01/01/1985 CMS Term: 38740 MEDSV DEF RBRVS 01/01/2024 642.62 Description: REMOVE ARMPIT LYMPH NODES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38740 MEDSV DEF RBRVS 09/01/2019 12/31/2023 492.85 Description: REMOVE ARMPIT LYMPH NODES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38745 MEDSV DEF RBRVS 01/01/2024 806.73 Description: REMOVE ARMPIT LYMPH NODES Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 492 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 38745 MEDSV DEF RBRVS 09/01/2019 12/31/2023 622.86 Description: REMOVE ARMPIT LYMPH NODES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38746 MEDSV DEF RBRVS 01/01/2024 191.35 Description: REMOVE THORACIC LYMPH NODES Category: Medical Services CMS Add: 01/01/1994 CMS Term: 38746 MEDSV DEF RBRVS 02/01/2015 12/31/2023 156.12 Description: REMOVE THORACIC LYMPH NODES Category: Medical Services CMS Add: 01/01/1994 CMS Term: 38747 MEDSV DEF RBRVS 01/01/2024 240.83 Description: REMOVE ABDOMINAL LYMPH NODES Category: Medical Services CMS Add: 01/01/1994 CMS Term: 38747 MEDSV DEF RBRVS 02/01/2015 12/31/2023 190.57 Description: REMOVE ABDOMINAL LYMPH NODES Category: Medical Services CMS Add: 01/01/1994 CMS Term: 38760 MEDSV DEF RBRVS 01/01/2024 771.05 Description: REMOVE GROIN LYMPH NODES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38760 MEDSV DEF RBRVS 09/01/2019 12/31/2023 601.28 Description: REMOVE GROIN LYMPH NODES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38765 MEDSV DEF RBRVS 01/01/2024 1205.01 Description: REMOVE GROIN LYMPH NODES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38765 MEDSV DEF RBRVS 09/01/2019 12/31/2023 923.36 Description: REMOVE GROIN LYMPH NODES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38770 MEDSV DEF RBRVS 01/01/2024 748.88 Description: REMOVE PELVIS LYMPH NODES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38770 MEDSV DEF RBRVS 09/01/2019 12/31/2023 581.31 Description: REMOVE PELVIS LYMPH NODES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38780 MEDSV DEF RBRVS 01/01/2024 963.66 Description: REMOVE ABDOMEN LYMPH NODES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38780 MEDSV DEF RBRVS 09/01/2019 12/31/2023 742.44 Description: REMOVE ABDOMEN LYMPH NODES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38790 MEDSV DEF RBRVS 01/01/2024 75.95 Description: INJECT FOR LYMPHATIC X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38790 MEDSV DEF RBRVS 09/01/2019 12/31/2023 60.51 Description: INJECT FOR LYMPHATIC X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38792 MEDSV DEF RBRVS 01/01/2019 12/31/2023 29.16 Description: RA TRACER ID OF SENTINL NODE Category: Medical Services CMS Add: 01/01/1999 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 493 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 38792 MEDSV DEF RBRVS 01/01/2024 77.03 Description: RA TRACER ID OF SENTINL NODE Category: Medical Services CMS Add: 01/01/1999 CMS Term: 38794 MEDSV DEF RBRVS 01/01/2024 262.32 Description: ACCESS THORACIC LYMPH DUCT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38794 MEDSV DEF RBRVS 09/01/2019 12/31/2023 218.67 Description: ACCESS THORACIC LYMPH DUCT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 38900 MEDSV DEF RBRVS 01/01/2024 124.31 Description: IO MAP OF SENT LYMPH NODE Category: Medical Services CMS Add: 01/01/2011 CMS Term: 38900 MEDSV DEF RBRVS 02/01/2015 12/31/2023 98.38 Description: IO MAP OF SENT LYMPH NODE Category: Medical Services CMS Add: 01/01/2011 CMS Term: 38999 MEDSV DEF BILL20 Y Description: UNLISTD PX HEMIC/LYMPHTC SYS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 39000 MEDSV DEF RBRVS 01/01/2024 442.02 Description: EXPLORATION OF CHEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 39000 MEDSV DEF RBRVS 09/01/2019 12/31/2023 358.14 Description: EXPLORATION OF CHEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 39010 MEDSV DEF RBRVS 01/01/2024 713.71 Description: EXPLORATION OF CHEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 39010 MEDSV DEF RBRVS 09/01/2019 12/31/2023 568.76 Description: EXPLORATION OF CHEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 39200 MEDSV DEF RBRVS 01/01/2024 784.03 Description: RESECT MEDIASTINAL CYST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 39200 MEDSV DEF RBRVS 09/01/2019 12/31/2023 631.12 Description: RESECT MEDIASTINAL CYST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 39220 MEDSV DEF RBRVS 01/01/2024 1030.56 Description: RESECT MEDIASTINAL TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 39220 MEDSV DEF RBRVS 09/01/2019 12/31/2023 826.10 Description: RESECT MEDIASTINAL TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 39401 MEDSV DEF RBRVS 01/01/2016 12/31/2023 226.02 Description: MEDIASTINOSCPY W/MEDSTNL BX Category: Medical Services CMS Add: 01/01/2016 CMS Term: 39401 MEDSV DEF RBRVS 01/01/2024 277.19 Description: MEDIASTINOSCPY W/MEDSTNL BX Category: Medical Services CMS Add: 01/01/2016 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 494 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 39402 MEDSV DEF RBRVS 01/01/2016 12/31/2023 294.88 Description: MEDIASTINOSCPY W/LMPH NOD BX Category: Medical Services CMS Add: 01/01/2016 CMS Term: 39402 MEDSV DEF RBRVS 01/01/2024 361.66 Description: MEDIASTINOSCPY W/LMPH NOD BX Category: Medical Services CMS Add: 01/01/2016 CMS Term: 39499 MEDSV DEF BILL20 Description: UNLISTED PX MEDIASTINUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 39501 MEDSV DEF RBRVS 01/01/2024 774.56 Description: REPAIR DIAPHRAGM LACERATION Category: Medical Services CMS Add: 01/01/1986 CMS Term: 39501 MEDSV DEF RBRVS 09/01/2019 12/31/2023 608.97 Description: REPAIR DIAPHRAGM LACERATION Category: Medical Services CMS Add: 01/01/1986 CMS Term: 39503 MEDSV DEF RBRVS 01/01/2024 5207.54 0-28days Description: REPAIR OF DIAPHRAGM HERNIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 39503 MEDSV DEF RBRVS 09/01/2019 12/31/2023 4380.46 0-28days Description: REPAIR OF DIAPHRAGM HERNIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 39540 MEDSV DEF RBRVS 01/01/2024 786.84 Description: REPAIR OF DIAPHRAGM HERNIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 39540 MEDSV DEF RBRVS 09/01/2019 12/31/2023 619.30 Description: REPAIR OF DIAPHRAGM HERNIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 39541 MEDSV DEF RBRVS 01/01/2024 848.79 Description: REPAIR OF DIAPHRAGM HERNIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 39541 MEDSV DEF RBRVS 09/01/2019 12/31/2023 674.29 Description: REPAIR OF DIAPHRAGM HERNIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 39545 MEDSV DEF RBRVS 01/01/2024 811.39 Description: REVISION OF DIAPHRAGM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 39545 MEDSV DEF RBRVS 09/01/2019 12/31/2023 643.12 Description: REVISION OF DIAPHRAGM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 39560 MEDSV DEF RBRVS 01/01/2024 733.88 0-1 Description: RESECT DIAPHRAGM SIMPLE Category: Medical Services CMS Add: 01/01/2000 CMS Term: 39560 MEDSV DEF RBRVS 02/01/2015 12/31/2023 571.87 0-1 Description: RESECT DIAPHRAGM SIMPLE Category: Medical Services CMS Add: 01/01/2000 CMS Term: 39561 MEDSV DEF RBRVS 01/01/2024 1138.06 0-1 Description: RESECT DIAPHRAGM COMPLEX Category: Medical Services CMS Add: 01/01/2000 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 495 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 39561 MEDSV DEF RBRVS 02/01/2015 12/31/2023 890.93 0-1 Description: RESECT DIAPHRAGM COMPLEX Category: Medical Services CMS Add: 01/01/2000 CMS Term: 39599 MEDSV DEF BILL20 Description: UNLISTED PX DIAPHRAGM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4000F NOCOV DEF SYSMAN Description: TOBACCO USE TXMNT COUNSELING Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: 4001F NOCOV DEF SYSMAN Description: TOBACCO USE TXMNT PHARMACOL Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: 4003F NOCOV DEF SYSMAN Description: PT ED WRITE/ORAL PTS W/ HF Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 4004F NOCOV DEF SYSMAN Description: PT TOBACCO SCREEN RCVD TLK Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 4005F NOCOV DEF SYSMAN Description: PHARM THX FOR OP RXD Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 4008F NOCOV DEF SYSMAN Description: BETA-BLOCKER THERAPY RXD/TKN Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 4010F NOCOV DEF SYSMAN Description: ACE/ARB THERAPY RXD/TAKEN Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 4011F NOCOV DEF SYSMAN Description: ORAL ANTIPLATELET THERAPY RX Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: 4012F NOCOV DEF SYSMAN Description: WARFARIN THERAPY RX Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 4013F NOCOV DEF SYSMAN Description: STATIN THERAPY/CURRENTLY TKN Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 4014F NOCOV DEF SYSMAN Description: WRITTEN DISCHARGE INSTR PRVD Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 4015F NOCOV DEF SYSMAN Description: PERSIST ASTHMA MEDICINE CTRL Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 4016F NOCOV DEF SYSMAN Description: ANTI-INFLM/ANLGSC AGENT RX Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 4017F NOCOV DEF SYSMAN Description: GI PROPHYLAXIS FOR NSAID RX Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 496 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 4018F NOCOV DEF SYSMAN Description: THERAPY EXERCISE JOINT RX Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 4019F NOCOV DEF SYSMAN Description: DOC RECPT COUNSL VIT D/CALC+ Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 4025F NOCOV DEF SYSMAN Description: INHALED BRONCHODILATOR RX Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 4030F NOCOV DEF SYSMAN Description: OXYGEN THERAPY RX Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 4033F NOCOV DEF SYSMAN Description: PULMONARY REHAB REC Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 4035F NOCOV DEF SYSMAN Description: INFLUENZA IMM REC Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 4037F NOCOV DEF SYSMAN Description: INFLUENZA IMM ORDER/ADMIN Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 4040F NOCOV DEF SYSMAN Description: PNEUMOC VAC/ADMIN/RCVD Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 4041F NOCOV DEF SYSMAN Description: DOC ORDER CEFAZOLIN/CEFUROX Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 4042F NOCOV DEF SYSMAN Description: DOC ANTIBIO NOT GIVEN Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 4043F NOCOV DEF SYSMAN Description: DOC ORDER GIVEN STOP ANTIBIO Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 4044F NOCOV DEF SYSMAN Description: DOC ORDER GIVEN VTE PROPHYLX Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 4045F NOCOV DEF SYSMAN Description: EMPIRIC ANTIBIOTIC RX Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 4046F NOCOV DEF SYSMAN Description: DOC ANTIBIO GIVEN B/4 SURG Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 4047F NOCOV DEF SYSMAN Description: DOC ANTIBIO GIVEN B/4 SURG Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 4048F NOCOV DEF SYSMAN Description: DOC ANTIBIO GIVEN B/4 SURG Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 497 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 40490 MEDSV DEF RBRVS 01/01/2024 115.51 Description: BIOPSY OF LIP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40490 MEDSV DEF RBRVS 09/01/2019 12/31/2023 90.83 Description: BIOPSY OF LIP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4049F NOCOV DEF SYSMAN Description: DOC ORDER GIVEN STOP ANTIBIO Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 40500 MEDSV DEF RBRVS 01/01/2024 495.46 Description: PARTIAL EXCISION OF LIP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40500 MEDSV DEF RBRVS 09/01/2019 12/31/2023 362.53 Description: PARTIAL EXCISION OF LIP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4050F NOCOV DEF SYSMAN Description: HT CARE PLAN DOC Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 40510 MEDSV DEF RBRVS 01/01/2024 459.67 Description: PARTIAL EXCISION OF LIP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40510 MEDSV DEF RBRVS 09/01/2019 12/31/2023 349.56 Description: PARTIAL EXCISION OF LIP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4051F NOCOV DEF SYSMAN Description: REFERRED FOR AN AV FISTULA Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 40520 MEDSV DEF RBRVS 01/01/2024 474.29 Description: PARTIAL EXCISION OF LIP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40520 MEDSV DEF RBRVS 09/01/2019 12/31/2023 352.39 Description: PARTIAL EXCISION OF LIP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40525 MEDSV DEF RBRVS 01/01/2024 516.47 Description: RECONSTRUCT LIP WITH FLAP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40525 MEDSV DEF RBRVS 09/01/2019 12/31/2023 402.79 Description: RECONSTRUCT LIP WITH FLAP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40527 MEDSV DEF RBRVS 01/01/2024 591.15 Description: RECONSTRUCT LIP WITH FLAP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40527 MEDSV DEF RBRVS 09/01/2019 12/31/2023 453.21 Description: RECONSTRUCT LIP WITH FLAP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4052F NOCOV DEF SYSMAN Description: HEMODIALYSIS VIA AV FISTULA Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 498 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 40530 MEDSV DEF RBRVS 01/01/2024 524.64 Description: PARTIAL REMOVAL OF LIP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40530 MEDSV DEF RBRVS 09/01/2019 12/31/2023 387.57 Description: PARTIAL REMOVAL OF LIP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4053F NOCOV DEF SYSMAN Description: HEMODIALYSIS VIA AV GRAFT Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 4054F NOCOV DEF SYSMAN Description: HEMODIALYSIS VIA CATHETER Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 4055F NOCOV DEF SYSMAN Description: PT RCVNG PERITON DIALYSIS Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 4056F NOCOV DEF SYSMAN Description: APPROP ORAL REHYD RECOMMD Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 4058F NOCOV DEF SYSMAN Description: PED GASTRO ED GIVEN CAREGVR Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 4060F NOCOV DEF SYSMAN Description: PSYCH SVCS PROVIDED Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 4062F NOCOV DEF SYSMAN Description: PT REFERRAL PSYCH DOCD Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 4063F NOCOV DEF SYSMAN Description: ANTIDEPRES RXTHXPY NOT RXD Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 4064F NOCOV DEF SYSMAN Description: ANTIDEPRESSANT RX Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 40650 MEDSV DEF RBRVS 01/01/2024 448.56 Description: RPR LIP FTH VERMILION ONLY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40650 MEDSV DEF RBRVS 09/01/2019 12/31/2023 314.43 Description: RPR LIP FTH VERMILION ONLY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40652 MEDSV DEF RBRVS 01/01/2024 485.72 Description: RPR LIP FTH1HALF VER HT/CPX Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 499 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 40654 MEDSV DEF RBRVS 09/01/2019 12/31/2023 406.68 Description: RPR LIP FTH>1HALF VER HT/CPX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4065F NOCOV DEF SYSMAN Description: ANTIPSYCHOTIC RX Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 4066F NOCOV DEF SYSMAN Description: ECT PROVIDED Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 4067F NOCOV DEF SYSMAN Description: PT REFERRAL FOR ECT DOCD Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 4069F NOCOV DEF SYSMAN Description: VTE PROPHYLAXIS RCVD Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 40700 MEDSV DEF RBRVS 01/01/2024 935.52 Description: REPAIR CLEFT LIP/NASAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40700 MEDSV DEF RBRVS 09/01/2019 12/31/2023 662.87 Description: REPAIR CLEFT LIP/NASAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40701 MEDSV DEF RBRVS 01/01/2024 1104.41 Description: REPAIR CLEFT LIP/NASAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40701 MEDSV DEF RBRVS 09/01/2019 12/31/2023 740.38 Description: REPAIR CLEFT LIP/NASAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40702 MEDSV DEF RBRVS 01/01/2024 927.65 Description: REPAIR CLEFT LIP/NASAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40702 MEDSV DEF RBRVS 09/01/2019 12/31/2023 657.70 Description: REPAIR CLEFT LIP/NASAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4070F NOCOV DEF SYSMAN Description: DVT PROPHYLX RECVD DAY 2 Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 40720 MEDSV DEF RBRVS 01/01/2024 952.69 Description: REPAIR CLEFT LIP/NASAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40720 MEDSV DEF RBRVS 09/01/2019 12/31/2023 749.82 Description: REPAIR CLEFT LIP/NASAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4073F NOCOV DEF SYSMAN Description: ORAL ANTIPLAT THX RX DISCHRG Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 4075F NOCOV DEF SYSMAN Description: ANTICOAG THX RX AT DISCHRG Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 500 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 40761 MEDSV DEF RBRVS 01/01/2024 1001.11 Description: REPAIR CLEFT LIP/NASAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40761 MEDSV DEF RBRVS 09/01/2019 12/31/2023 791.56 Description: REPAIR CLEFT LIP/NASAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4077F NOCOV DEF SYSMAN Description: DOC T-PA ADMIN CONSIDERED Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 40799 MEDSV DEF BILL20 Description: UNLISTED PROCEDURE LIPS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4079F NOCOV DEF SYSMAN Description: DOC REHAB SVCS CONSIDERED Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 40800 MEDSV DEF RBRVS 01/01/2024 189.63 Description: DRAINAGE OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40800 MEDSV DEF RBRVS 09/01/2019 12/31/2023 153.52 Description: DRAINAGE OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40801 MEDSV DEF RBRVS 01/01/2024 272.67 Description: DRAINAGE OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40801 MEDSV DEF RBRVS 09/01/2019 12/31/2023 228.54 Description: DRAINAGE OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40804 MEDSV DEF RBRVS 01/01/2024 175.21 Description: REMOVAL FOREIGN BODY MOUTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40804 MEDSV DEF RBRVS 09/01/2019 12/31/2023 158.54 Description: REMOVAL FOREIGN BODY MOUTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40805 MEDSV DEF RBRVS 01/01/2024 267.60 Description: REMOVAL FOREIGN BODY MOUTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40805 MEDSV DEF RBRVS 09/01/2019 12/31/2023 280.32 Description: REMOVAL FOREIGN BODY MOUTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40806 MEDSV DEF RBRVS 01/01/2024 92.65 Description: INCISION OF LIP FOLD Category: Medical Services CMS Add: 01/01/1985 CMS Term: 40806 MEDSV DEF RBRVS 09/01/2019 12/31/2023 94.70 Description: INCISION OF LIP FOLD Category: Medical Services CMS Add: 01/01/1985 CMS Term: 40808 MEDSV DEF RBRVS 01/01/2024 158.84 Description: BIOPSY OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 501 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 40808 MEDSV DEF RBRVS 09/01/2019 12/31/2023 134.73 Description: BIOPSY OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40810 MEDSV DEF RBRVS 01/01/2024 203.65 Description: EXCISION OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40810 MEDSV DEF RBRVS 09/01/2019 12/31/2023 149.83 Description: EXCISION OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40812 MEDSV DEF RBRVS 01/01/2024 264.79 Description: EXCISE/REPAIR MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40812 MEDSV DEF RBRVS 09/01/2019 12/31/2023 209.09 Description: EXCISE/REPAIR MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40814 MEDSV DEF RBRVS 01/01/2024 351.69 Description: EXCISE/REPAIR MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40814 MEDSV DEF RBRVS 09/01/2019 12/31/2023 280.03 Description: EXCISE/REPAIR MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40816 MEDSV DEF RBRVS 01/01/2024 378.10 Description: EXCISION OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40816 MEDSV DEF RBRVS 09/01/2019 12/31/2023 293.60 Description: EXCISION OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40818 MEDSV DEF RBRVS 01/01/2024 344.64 Description: EXCISE ORAL MUCOSA FOR GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40818 MEDSV DEF RBRVS 09/01/2019 12/31/2023 259.68 Description: EXCISE ORAL MUCOSA FOR GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40819 MEDSV DEF RBRVS 01/01/2024 253.30 Description: EXCISE LIP OR CHEEK FOLD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40819 MEDSV DEF RBRVS 09/01/2019 12/31/2023 225.81 Description: EXCISE LIP OR CHEEK FOLD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40820 MEDSV DEF RBRVS 01/01/2024 242.46 Description: TREATMENT OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40820 MEDSV DEF RBRVS 09/01/2019 12/31/2023 190.91 Description: TREATMENT OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40830 MEDSV DEF RBRVS 01/01/2024 212.47 Description: REPAIR MOUTH LACERATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 502 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 40830 MEDSV DEF RBRVS 09/01/2019 12/31/2023 192.58 Description: REPAIR MOUTH LACERATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40831 MEDSV DEF RBRVS 01/01/2024 279.15 Description: REPAIR MOUTH LACERATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40831 MEDSV DEF RBRVS 09/01/2019 12/31/2023 245.34 Description: REPAIR MOUTH LACERATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40840 MEDSV DEF RBRVS 01/01/2019 12/31/2023 585.79 Description: RECONSTRUCTION OF MOUTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40840 MEDSV DEF RBRVS 01/01/2024 811.87 Description: RECONSTRUCTION OF MOUTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40842 MEDSV DEF RBRVS 01/01/2019 12/31/2023 568.95 Description: RECONSTRUCTION OF MOUTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40842 MEDSV DEF RBRVS 01/01/2024 868.54 Description: RECONSTRUCTION OF MOUTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40843 MEDSV DEF RBRVS 01/01/2019 12/31/2023 800.36 Description: RECONSTRUCTION OF MOUTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40843 MEDSV DEF RBRVS 01/01/2024 1118.74 Description: RECONSTRUCTION OF MOUTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40844 MEDSV DEF RBRVS 01/01/2019 12/31/2023 959.79 Description: RECONSTRUCTION OF MOUTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40844 MEDSV DEF RBRVS 01/01/2024 1402.82 Description: RECONSTRUCTION OF MOUTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40845 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1062.66 Description: RECONSTRUCTION OF MOUTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 40845 MEDSV DEF RBRVS 01/01/2024 1391.19 Description: RECONSTRUCTION OF MOUTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4084F NOCOV DEF SYSMAN Description: ASPIRIN RECVD W/IN 24 HRS Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 4086F NOCOV DEF SYSMAN Description: ASPIRIN/CLOPIDOGREL RXD Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 40899 MEDSV DEF BILL20 Description: UNLISTED PX VESTIBULE MOUTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 503 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 4090F NOCOV DEF SYSMAN Description: PT RCVNG EPO THXPY Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 4095F NOCOV DEF SYSMAN Description: PT NOT RCVNG EPO THXPY Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 41000 MEDSV DEF RBRVS 01/01/2024 138.48 Description: DRAINAGE OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41000 MEDSV DEF RBRVS 09/01/2019 12/31/2023 118.10 Description: DRAINAGE OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41005 MEDSV DEF RBRVS 01/01/2024 224.64 Description: DRAINAGE OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41005 MEDSV DEF RBRVS 09/01/2019 12/31/2023 165.50 Description: DRAINAGE OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41006 MEDSV DEF RBRVS 01/01/2024 320.55 Description: DRAINAGE OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41006 MEDSV DEF RBRVS 09/01/2019 12/31/2023 260.33 Description: DRAINAGE OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41007 MEDSV DEF RBRVS 01/01/2024 308.99 Description: DRAINAGE OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41007 MEDSV DEF RBRVS 09/01/2019 12/31/2023 255.91 Description: DRAINAGE OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41008 MEDSV DEF RBRVS 01/01/2024 367.88 Description: DRAINAGE OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41008 MEDSV DEF RBRVS 09/01/2019 12/31/2023 274.04 Description: DRAINAGE OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41009 MEDSV DEF RBRVS 01/01/2024 397.81 Description: DRAINAGE OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41009 MEDSV DEF RBRVS 09/01/2019 12/31/2023 291.33 Description: DRAINAGE OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4100F NOCOV DEF SYSMAN Description: BIPHOS THXPY VEIN ORD/RECVD Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 41010 MEDSV DEF RBRVS 01/01/2024 204.28 Description: INCISION OF TONGUE FOLD Category: Medical Services CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 504 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 41010 MEDSV DEF RBRVS 09/01/2019 12/31/2023 147.41 Description: INCISION OF TONGUE FOLD Category: Medical Services CMS Add: 01/01/1985 CMS Term: 41015 MEDSV DEF RBRVS 01/01/2024 375.44 Description: DRAINAGE OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41015 MEDSV DEF RBRVS 09/01/2019 12/31/2023 325.22 Description: DRAINAGE OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41016 MEDSV DEF RBRVS 01/01/2024 439.57 Description: DRAINAGE OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 41016 MEDSV DEF RBRVS 09/01/2019 12/31/2023 319.17 Description: DRAINAGE OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 41017 MEDSV DEF RBRVS 01/01/2024 439.57 Description: DRAINAGE OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 41017 MEDSV DEF RBRVS 09/01/2019 12/31/2023 322.14 Description: DRAINAGE OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 41018 MEDSV DEF RBRVS 01/01/2024 494.93 Description: DRAINAGE OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41018 MEDSV DEF RBRVS 09/01/2019 12/31/2023 365.34 Description: DRAINAGE OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41019 MEDSV DEF RBRVS 01/01/2024 464.10 Description: PLACE NEEDLES H&N FOR RT Category: Medical Services CMS Add: 01/01/2008 CMS Term: 41019 MEDSV DEF RBRVS 02/01/2015 12/31/2023 344.28 Description: PLACE NEEDLES H&N FOR RT Category: Medical Services CMS Add: 01/01/2008 CMS Term: 41100 MEDSV DEF RBRVS 01/01/2024 176.21 Description: BIOPSY OF TONGUE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41100 MEDSV DEF RBRVS 09/01/2019 12/31/2023 122.05 Description: BIOPSY OF TONGUE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41105 MEDSV DEF RBRVS 01/01/2024 176.36 Description: BIOPSY OF TONGUE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41105 MEDSV DEF RBRVS 09/01/2019 12/31/2023 123.88 Description: BIOPSY OF TONGUE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41108 MEDSV DEF RBRVS 01/01/2024 158.25 Description: BIOPSY OF FLOOR OF MOUTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 505 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 41108 MEDSV DEF RBRVS 09/01/2019 12/31/2023 107.25 Description: BIOPSY OF FLOOR OF MOUTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4110F NOCOV DEF SYSMAN Description: INT MAM ART USED FOR CABG Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 41110 MEDSV DEF RBRVS 01/01/2024 216.32 Description: EXCISION OF TONGUE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41110 MEDSV DEF RBRVS 09/01/2019 12/31/2023 154.87 Description: EXCISION OF TONGUE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41112 MEDSV DEF RBRVS 01/01/2024 319.18 Description: EXCISION OF TONGUE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41112 MEDSV DEF RBRVS 09/01/2019 12/31/2023 243.08 Description: EXCISION OF TONGUE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41113 MEDSV DEF RBRVS 01/01/2024 342.66 Description: EXCISION OF TONGUE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41113 MEDSV DEF RBRVS 09/01/2019 12/31/2023 265.43 Description: EXCISION OF TONGUE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41114 MEDSV DEF RBRVS 01/01/2024 584.04 Description: EXCISION OF TONGUE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41114 MEDSV DEF RBRVS 09/01/2019 12/31/2023 466.03 Description: EXCISION OF TONGUE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41115 MEDSV DEF RBRVS 01/01/2024 246.21 Description: EXCISION OF TONGUE FOLD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41115 MEDSV DEF RBRVS 09/01/2019 12/31/2023 179.55 Description: EXCISION OF TONGUE FOLD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41116 MEDSV DEF RBRVS 01/01/2024 314.69 Description: EXCISION OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41116 MEDSV DEF RBRVS 09/01/2019 12/31/2023 241.60 Description: EXCISION OF MOUTH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41120 MEDSV DEF RBRVS 01/01/2024 993.97 Description: PARTIAL REMOVAL OF TONGUE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41120 MEDSV DEF RBRVS 09/01/2019 12/31/2023 760.23 Description: PARTIAL REMOVAL OF TONGUE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 506 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 41130 MEDSV DEF RBRVS 01/01/2024 1228.73 Description: PARTIAL REMOVAL OF TONGUE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41130 MEDSV DEF RBRVS 09/01/2019 12/31/2023 944.51 Description: PARTIAL REMOVAL OF TONGUE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41135 MEDSV DEF RBRVS 01/01/2024 2025.92 Description: TONGUE AND NECK SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41135 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1572.60 Description: TONGUE AND NECK SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41140 MEDSV DEF RBRVS 01/01/2024 2041.71 Description: REMOVAL OF TONGUE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41140 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1585.56 Description: REMOVAL OF TONGUE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41145 MEDSV DEF RBRVS 01/01/2024 2572.52 Description: TONGUE REMOVAL NECK SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41145 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2006.67 Description: TONGUE REMOVAL NECK SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41150 MEDSV DEF RBRVS 01/01/2024 2055.05 Description: TONGUE MOUTH JAW SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41150 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1593.40 Description: TONGUE MOUTH JAW SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41153 MEDSV DEF RBRVS 01/01/2024 2230.38 Description: TONGUE MOUTH NECK SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41153 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1733.92 Description: TONGUE MOUTH NECK SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41155 MEDSV DEF RBRVS 01/01/2024 2797.88 Description: TONGUE JAW & NECK SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41155 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2187.89 Description: TONGUE JAW & NECK SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4115F NOCOV DEF SYSMAN Description: BETA BLCKR ADMIN W/IN 24 HRS Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 4120F NOCOV DEF SYSMAN Description: ANTIBIOT RXD/GIVEN Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 507 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 4124F NOCOV DEF SYSMAN Description: ANTIBIOT NOT RXD/GIVEN Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 41250 MEDSV DEF RBRVS 01/01/2024 265.94 Description: REPAIR TONGUE LACERATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41250 MEDSV DEF RBRVS 09/01/2019 12/31/2023 192.46 Description: REPAIR TONGUE LACERATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41251 MEDSV DEF RBRVS 01/01/2024 294.58 Description: REPAIR TONGUE LACERATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41251 MEDSV DEF RBRVS 09/01/2019 12/31/2023 208.57 Description: REPAIR TONGUE LACERATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41252 MEDSV DEF RBRVS 01/01/2024 308.11 Description: REPAIR TONGUE LACERATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41252 MEDSV DEF RBRVS 09/01/2019 12/31/2023 228.70 Description: REPAIR TONGUE LACERATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4130F NOCOV DEF SYSMAN Description: TOPICAL PREP RX AOE Category: Non Covered Services CMS Add: 10/01/2007 CMS Term: 4131F NOCOV DEF SYSMAN Description: SYST ANTIMICROBIAL THX RX Category: Non Covered Services CMS Add: 10/01/2007 CMS Term: 4132F NOCOV DEF SYSMAN Description: NO SYST ANTIMICROBIAL THX RX Category: Non Covered Services CMS Add: 10/01/2007 CMS Term: 4133F NOCOV DEF SYSMAN Description: ANTIHIST/DECONG RX/RECOM Category: Non Covered Services CMS Add: 10/01/2007 CMS Term: 4134F NOCOV DEF SYSMAN Description: NO ANTIHIST/DECONG RX/RECOM Category: Non Covered Services CMS Add: 10/01/2007 CMS Term: 4135F NOCOV DEF SYSMAN Description: SYSTEMIC CORTICOSTEROIDS RX Category: Non Covered Services CMS Add: 10/01/2007 CMS Term: 4136F NOCOV DEF SYSMAN Description: SYST CORTICOSTEROIDS NOT RX Category: Non Covered Services CMS Add: 10/01/2007 CMS Term: 4140F NOCOV DEF SYSMAN Description: INHALED CORTICOSTEROIDS RXD Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 4142F NOCOV DEF SYSMAN Description: CORTICOSTER SPARNG THRPY RXD Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 508 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 4144F NOCOV DEF SYSMAN Description: ALT LONG-TERM CNTRL MED RXD Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 4145F NOCOV DEF SYSMAN Description: 2+ ANTI-HYPRTNSV AGENTS TKN Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 4148F NOCOV DEF SYSMAN Description: HEP A VAC INJXN ADMIN/RECVD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 4149F NOCOV DEF SYSMAN Description: HEP B VAC INJXN ADMIN/RECVD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 4150F NOCOV DEF SYSMAN Description: PT RECVNG ANTIVIR TXMNT HEPC Category: Non Covered Services CMS Add: 10/01/2007 CMS Term: 41510 MEDSV DEF RBRVS 01/01/2024 427.06 Description: TONGUE TO LIP SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41510 MEDSV DEF RBRVS 09/01/2019 12/31/2023 319.23 Description: TONGUE TO LIP SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41512 MEDSV DEF RBRVS 01/01/2024 626.56 Description: TONGUE SUSPENSION Category: Medical Services CMS Add: 01/01/2009 CMS Term: 41512 MEDSV DEF RBRVS 02/01/2015 12/31/2023 456.14 Description: TONGUE SUSPENSION Category: Medical Services CMS Add: 01/01/2009 CMS Term: 4151F NOCOV DEF SYSMAN Description: PT NOT RECVNG ANTIV HEP C Category: Non Covered Services CMS Add: 10/01/2007 CMS Term: 41520 MEDSV DEF RBRVS 01/01/2024 344.68 Description: RECONSTRUCTION TONGUE FOLD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41520 MEDSV DEF RBRVS 09/01/2019 12/31/2023 256.13 Description: RECONSTRUCTION TONGUE FOLD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41530 MEDSV DEF RBRVS 01/01/2024 861.52 Description: TONGUE BASE VOL REDUCTION Category: Medical Services CMS Add: 01/01/2009 CMS Term: 41530 MEDSV DEF RBRVS 02/01/2015 12/31/2023 2307.50 Description: TONGUE BASE VOL REDUCTION Category: Medical Services CMS Add: 01/01/2009 CMS Term: 4153F NOCOV DEF SYSMAN Description: COMBO PEGINTF/RIB RX Category: Non Covered Services CMS Add: 10/01/2007 CMS Term: 4155F NOCOV DEF SYSMAN Description: HEP A VAC SERIES PREV RECVD Category: Non Covered Services CMS Add: 10/01/2007 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 509 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 4157F NOCOV DEF SYSMAN Description: HEP B VAC SERIES PREV RECVD Category: Non Covered Services CMS Add: 10/01/2007 CMS Term: 4158F NOCOV DEF SYSMAN Description: PT EDU RE ALCOH DRNKNG DONE Category: Non Covered Services CMS Add: 10/01/2007 CMS Term: 41599 MEDSV DEF BILL20 Description: UNLISTED PX TONGUE FLR MOUTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4159F NOCOV DEF SYSMAN Description: CONTRCP TALK B/4 ANTIV TXMNT Category: Non Covered Services CMS Add: 10/01/2007 CMS Term: 4163F NOCOV DEF SYSMAN Description: PT COUNS 4 TXMNT OPT PROST Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 4164F NOCOV DEF SYSMAN Description: ADJV HRMNL THXPY RXD Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 4165F NOCOV DEF SYSMAN Description: 3D-CRT/IMRT RECEIVED Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 4167F NOCOV DEF SYSMAN Description: HD BED TILTED 1ST DAY VENT Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 4168F NOCOV DEF SYSMAN Description: PT CARE ICU&VENT W/IN 24HRS Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 4169F NOCOV DEF SYSMAN Description: NO PT CARE ICU/VENT IN 24HRS Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 4171F NOCOV DEF SYSMAN Description: PT RCVNG ESA THXPY Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 4172F NOCOV DEF SYSMAN Description: PT NOT RCVNG ESA THXPY Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 4174F NOCOV DEF SYSMAN Description: COUNS POTENT GLAUC IMPCT Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 4175F NOCOV DEF SYSMAN Description: VIS 20/40/> W/IN 90 DAYS Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 4176F NOCOV DEF SYSMAN Description: TALK RE UV LIGHT PT/CRGVR Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 4177F NOCOV DEF SYSMAN Description: TALK PT/CRGVR RE AREDS PREV Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 510 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 4178F NOCOV DEF SYSMAN Description: ANTID GLBLN RCVD W/IN 26WKS Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 4179F NOCOV DEF SYSMAN Description: TAMOXIFEN/AI PRESCRIBED Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 41800 MEDSV DEF RBRVS 01/01/2024 271.94 Description: DRAINAGE OF GUM LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41800 MEDSV DEF RBRVS 09/01/2019 12/31/2023 193.65 Description: DRAINAGE OF GUM LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41805 MEDSV DEF RBRVS 01/01/2024 291.55 Description: REMOVAL FOREIGN BODY GUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41805 MEDSV DEF RBRVS 09/01/2019 12/31/2023 187.69 Description: REMOVAL FOREIGN BODY GUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41806 MEDSV DEF RBRVS 01/01/2024 386.30 Description: REMOVAL FOREIGN BODY JAWBONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41806 MEDSV DEF RBRVS 09/01/2019 12/31/2023 260.17 Description: REMOVAL FOREIGN BODY JAWBONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4180F NOCOV DEF SYSMAN Description: ADJV THXPYRXD/RCVD COLON CA Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 4181F NOCOV DEF SYSMAN Description: CONFORMAL RADN THXPY RCVD Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 41820 MEDSV PRF MAXFEE 01/01/2024 10.65 0.0 Description: EXCISION GUM EACH QUADRANT Category: Medical Services CMS Add: 01/01/1982 CMS Term: 41821 MEDSV DEF BILL20 Description: EXCISION OF GUM FLAP Category: Medical Services CMS Add: 01/01/1982 CMS Term: 41822 MEDSV DEF RBRVS 01/01/2019 12/31/2023 211.65 Description: EXCISION OF GUM LESION Category: Medical Services CMS Add: 01/01/1982 CMS Term: 41822 MEDSV DEF RBRVS 01/01/2024 331.40 Description: EXCISION OF GUM LESION Category: Medical Services CMS Add: 01/01/1982 CMS Term: 41823 MEDSV DEF RBRVS 01/01/2019 12/31/2023 311.77 Description: EXCISION OF GUM LESION Category: Medical Services CMS Add: 01/01/1982 CMS Term: 41823 MEDSV DEF RBRVS 01/01/2024 493.56 Description: EXCISION OF GUM LESION Category: Medical Services CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 511 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 41825 MEDSV DEF RBRVS 01/01/2024 207.03 Description: EXCISION OF GUM LESION Category: Medical Services CMS Add: 01/01/1982 CMS Term: 41825 MEDSV DEF RBRVS 09/01/2019 12/31/2023 153.48 Description: EXCISION OF GUM LESION Category: Medical Services CMS Add: 01/01/1982 CMS Term: 41826 MEDSV DEF RBRVS 01/01/2024 284.81 Description: EXCISION OF GUM LESION Category: Medical Services CMS Add: 01/01/1982 CMS Term: 41826 MEDSV DEF RBRVS 09/01/2019 12/31/2023 228.00 Description: EXCISION OF GUM LESION Category: Medical Services CMS Add: 01/01/1982 CMS Term: 41827 MEDSV DEF RBRVS 01/01/2024 405.44 Description: EXCISION OF GUM LESION Category: Medical Services CMS Add: 01/01/1982 CMS Term: 41827 MEDSV DEF RBRVS 09/01/2019 12/31/2023 319.74 Description: EXCISION OF GUM LESION Category: Medical Services CMS Add: 01/01/1982 CMS Term: 41828 MEDSV DEF RBRVS 01/01/2019 12/31/2023 223.25 Description: EXCISION OF GUM LESION Category: Medical Services CMS Add: 01/01/1982 CMS Term: 41828 MEDSV DEF RBRVS 01/01/2024 329.05 Description: EXCISION OF GUM LESION Category: Medical Services CMS Add: 01/01/1982 CMS Term: 4182F NOCOV DEF SYSMAN Description: NO CONFORMAL RADN THXPY Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 41830 MEDSV DEF RBRVS 01/01/2019 12/31/2023 285.91 Description: REMOVAL OF GUM TISSUE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 41830 MEDSV DEF RBRVS 01/01/2024 438.39 Description: REMOVAL OF GUM TISSUE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 41850 MEDSV DEF BILL20 Description: TREATMENT OF GUM LESION Category: Medical Services CMS Add: 01/01/1982 CMS Term: 4185F NOCOV DEF SYSMAN Description: CONTINUOUS PPI OR H2RA RCVD Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 4186F NOCOV DEF SYSMAN Description: NO CONT PPI OR H2RA RCVD Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 41870 MEDSV DEF BILL20 Description: GUM GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41872 MEDSV DEF RBRVS 01/01/2019 12/31/2023 263.69 Description: REPAIR GUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 512 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 41872 MEDSV DEF RBRVS 01/01/2024 439.01 Description: REPAIR GUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41874 MEDSV DEF RBRVS 01/01/2019 12/31/2023 272.16 Description: REPAIR TOOTH SOCKET Category: Medical Services CMS Add: 01/01/1984 CMS Term: 41874 MEDSV DEF RBRVS 01/01/2024 357.76 Description: REPAIR TOOTH SOCKET Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4187F NOCOV DEF SYSMAN Description: ANTI RHEUM DRUGTHXPYRXD/GVN Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 4188F NOCOV DEF SYSMAN Description: APPROP ACE/ARB TSTNG DONE Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 41899 MEDSV DEF BILL20 Description: UNLISTED PX DENTALVLR STRUX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4189F NOCOV DEF SYSMAN Description: APPROP DIGOXIN TSTNG DONE Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 4190F NOCOV DEF SYSMAN Description: APPROP DIURETIC TSTNG DONE Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 4191F NOCOV DEF SYSMAN Description: APPROP ANTICONVULS TSTNG Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 4192F NOCOV DEF SYSMAN Description: PT NOT RCVNG GLUCOCO THXPY Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 4193F NOCOV DEF SYSMAN Description: PT RCV <10MG DAILY PREDNISO Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 4194F NOCOV DEF SYSMAN Description: PT RCV >=10MG DAILY PREDNISO Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 4195F NOCOV DEF SYSMAN Description: PT RCVNG ANTI-RHEUM THXPY RA Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 4196F NOCOV DEF SYSMAN Description: PTNOT RCVNG ANTI-RHM THXPYRA Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 42000 MEDSV DEF RBRVS 01/01/2024 151.40 Description: DRAINAGE MOUTH ROOF LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42000 MEDSV DEF RBRVS 09/01/2019 12/31/2023 114.40 Description: DRAINAGE MOUTH ROOF LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 513 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 4200F NOCOV DEF SYSMAN Description: EXTERNAL BEAM TO PROST ONLY Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 4201F NOCOV DEF SYSMAN Description: EXTRNL BEAM OTHER THAN PROST Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 42100 MEDSV DEF RBRVS 01/01/2024 137.89 Description: BIOPSY ROOF OF MOUTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42100 MEDSV DEF RBRVS 09/01/2019 12/31/2023 109.20 Description: BIOPSY ROOF OF MOUTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42104 MEDSV DEF RBRVS 01/01/2024 204.36 Description: EXCISION LESION MOUTH ROOF Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42104 MEDSV DEF RBRVS 09/01/2019 12/31/2023 157.29 Description: EXCISION LESION MOUTH ROOF Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42106 MEDSV DEF RBRVS 01/01/2024 239.26 Description: EXCISION LESION MOUTH ROOF Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42106 MEDSV DEF RBRVS 09/01/2019 12/31/2023 198.63 Description: EXCISION LESION MOUTH ROOF Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42107 MEDSV DEF RBRVS 01/01/2024 426.71 Description: EXCISION LESION MOUTH ROOF Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42107 MEDSV DEF RBRVS 09/01/2019 12/31/2023 335.64 Description: EXCISION LESION MOUTH ROOF Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4210F NOCOV DEF SYSMAN Description: ACE/ARB THXPY FOR MOS/> Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 42120 MEDSV DEF RBRVS 01/01/2024 942.48 Description: REMOVE PALATE/LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42120 MEDSV DEF RBRVS 09/01/2019 12/31/2023 723.42 Description: REMOVE PALATE/LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42140 MEDSV DEF RBRVS 01/01/2024 292.86 Description: EXCISION OF UVULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42140 MEDSV DEF RBRVS 09/01/2019 12/31/2023 183.82 Description: EXCISION OF UVULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42145 MEDSV DEF RBRVS 01/01/2024 647.83 Description: REPAIR PALATE PHARYNX/UVULA Category: Medical Services CMS Add: 01/01/1987 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 514 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 42145 MEDSV DEF RBRVS 09/01/2019 12/31/2023 516.43 Description: REPAIR PALATE PHARYNX/UVULA Category: Medical Services CMS Add: 01/01/1987 CMS Term: 42160 MEDSV DEF RBRVS 01/01/2024 218.29 Description: TREATMENT MOUTH ROOF LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42160 MEDSV DEF RBRVS 09/01/2019 12/31/2023 168.94 Description: TREATMENT MOUTH ROOF LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42180 MEDSV DEF RBRVS 01/01/2024 241.01 Description: REPAIR LAC PALATE<2 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42180 MEDSV DEF RBRVS 09/01/2019 12/31/2023 178.33 Description: REPAIR LAC PALATE<2 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42182 MEDSV DEF RBRVS 01/01/2024 311.64 Description: REPAIR PALATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42182 MEDSV DEF RBRVS 09/01/2019 12/31/2023 234.36 Description: REPAIR PALATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42200 MEDSV DEF RBRVS 01/01/2024 862.16 Description: RECONSTRUCT CLEFT PALATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42200 MEDSV DEF RBRVS 09/01/2019 12/31/2023 624.42 Description: RECONSTRUCT CLEFT PALATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42205 MEDSV DEF RBRVS 01/01/2024 896.72 Description: RECONSTRUCT CLEFT PALATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42205 MEDSV DEF RBRVS 09/01/2019 12/31/2023 652.55 Description: RECONSTRUCT CLEFT PALATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4220F NOCOV DEF SYSMAN Description: DIGOXIN THXPY FOR 6 MOS/> Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 42210 MEDSV DEF RBRVS 01/01/2024 1000.89 Description: RECONSTRUCT CLEFT PALATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42210 MEDSV DEF RBRVS 09/01/2019 12/31/2023 742.30 Description: RECONSTRUCT CLEFT PALATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42215 MEDSV DEF RBRVS 01/01/2024 654.09 Description: RECONSTRUCT CLEFT PALATE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 42215 MEDSV DEF RBRVS 09/01/2019 12/31/2023 482.91 Description: RECONSTRUCT CLEFT PALATE Category: Medical Services CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 515 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 4221F NOCOV DEF SYSMAN Description: DIURETIC THXPY FOR 6 MOS/> Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 42220 MEDSV DEF RBRVS 01/01/2024 538.77 Description: RECONSTRUCT CLEFT PALATE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 42220 MEDSV DEF RBRVS 09/01/2019 12/31/2023 382.87 Description: RECONSTRUCT CLEFT PALATE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 42225 MEDSV DEF RBRVS 01/01/2024 916.16 Description: RECONSTRUCT CLEFT PALATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42225 MEDSV DEF RBRVS 09/01/2019 12/31/2023 638.29 Description: RECONSTRUCT CLEFT PALATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42226 MEDSV DEF RBRVS 01/01/2024 851.82 Description: LENGTHENING OF PALATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42226 MEDSV DEF RBRVS 09/01/2019 12/31/2023 649.91 Description: LENGTHENING OF PALATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42227 MEDSV DEF RBRVS 01/01/2024 793.76 Description: LENGTHENING OF PALATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42227 MEDSV DEF RBRVS 09/01/2019 12/31/2023 609.99 Description: LENGTHENING OF PALATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42235 MEDSV DEF RBRVS 01/01/2024 697.74 Description: REPAIR PALATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42235 MEDSV DEF RBRVS 09/01/2019 12/31/2023 533.53 Description: REPAIR PALATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42260 MEDSV DEF RBRVS 01/01/2024 810.82 Description: REPAIR NOSE TO LIP FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42260 MEDSV DEF RBRVS 09/01/2019 12/31/2023 593.24 Description: REPAIR NOSE TO LIP FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42280 MEDSV DEF RBRVS 01/01/2024 167.44 Description: PREPARATION PALATE MOLD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42280 MEDSV DEF RBRVS 09/01/2019 12/31/2023 121.49 Description: PREPARATION PALATE MOLD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42281 MEDSV DEF RBRVS 01/01/2024 212.16 Description: INSERTION PALATE PROSTHESIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 516 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 42281 MEDSV DEF RBRVS 09/01/2019 12/31/2023 149.73 Description: INSERTION PALATE PROSTHESIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42299 MEDSV DEF BILL20 Description: UNLISTED PX PALATE UVULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42300 MEDSV DEF RBRVS 01/01/2024 203.28 Description: DRAINAGE OF SALIVARY GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42300 MEDSV DEF RBRVS 09/01/2019 12/31/2023 152.62 Description: DRAINAGE OF SALIVARY GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42305 MEDSV DEF RBRVS 01/01/2024 399.15 Description: DRAINAGE OF SALIVARY GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42305 MEDSV DEF RBRVS 09/01/2019 12/31/2023 315.61 Description: DRAINAGE OF SALIVARY GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4230F NOCOV DEF SYSMAN Description: ANTICONV THXPY FOR 6 MOS/> Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 42310 MEDSV DEF RBRVS 01/01/2024 161.80 Description: DRAINAGE OF SALIVARY GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42310 MEDSV DEF RBRVS 09/01/2019 12/31/2023 117.82 Description: DRAINAGE OF SALIVARY GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42320 MEDSV DEF RBRVS 01/01/2024 246.57 Description: DRAINAGE OF SALIVARY GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42320 MEDSV DEF RBRVS 09/01/2019 12/31/2023 182.40 Description: DRAINAGE OF SALIVARY GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42330 MEDSV DEF RBRVS 01/01/2024 220.33 Description: REMOVAL OF SALIVARY STONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42330 MEDSV DEF RBRVS 09/01/2019 12/31/2023 169.30 Description: REMOVAL OF SALIVARY STONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42335 MEDSV DEF RBRVS 01/01/2024 407.44 Description: REMOVAL OF SALIVARY STONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42335 MEDSV DEF RBRVS 09/01/2019 12/31/2023 273.11 Description: REMOVAL OF SALIVARY STONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42340 MEDSV DEF RBRVS 01/01/2024 502.60 Description: REMOVAL OF SALIVARY STONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 517 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 42340 MEDSV DEF RBRVS 09/01/2019 12/31/2023 338.78 Description: REMOVAL OF SALIVARY STONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42400 MEDSV DEF RBRVS 01/01/2024 91.31 Description: BIOPSY OF SALIVARY GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42400 MEDSV DEF RBRVS 09/01/2019 12/31/2023 76.78 Description: BIOPSY OF SALIVARY GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42405 MEDSV DEF RBRVS 01/01/2024 286.67 Description: BIOPSY OF SALIVARY GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42405 MEDSV DEF RBRVS 09/01/2019 12/31/2023 217.48 Description: BIOPSY OF SALIVARY GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42408 MEDSV DEF RBRVS 01/01/2024 513.55 Description: EXCISION OF SALIVARY CYST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42408 MEDSV DEF RBRVS 09/01/2019 12/31/2023 330.07 Description: EXCISION OF SALIVARY CYST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42409 MEDSV DEF RBRVS 01/01/2024 373.03 Description: DRAINAGE OF SALIVARY CYST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42409 MEDSV DEF RBRVS 09/01/2019 12/31/2023 242.75 Description: DRAINAGE OF SALIVARY CYST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4240F NOCOV DEF SYSMAN Description: INSTR XRCZ BACK PAIN 12 WKS Category: Non Covered Services CMS Add: 04/01/2008 CMS Term: 42410 MEDSV DEF RBRVS 01/01/2024 591.71 Description: EXCISE PAROTID GLAND/LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42410 MEDSV DEF RBRVS 09/01/2019 12/31/2023 455.30 Description: EXCISE PAROTID GLAND/LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42415 MEDSV DEF RBRVS 01/01/2024 994.67 Description: EXCISE PAROTID GLAND/LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42415 MEDSV DEF RBRVS 09/01/2019 12/31/2023 775.66 Description: EXCISE PAROTID GLAND/LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42420 MEDSV DEF RBRVS 01/01/2024 1114.41 Description: EXCISE PAROTID GLAND/LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42420 MEDSV DEF RBRVS 09/01/2019 12/31/2023 870.79 Description: EXCISE PAROTID GLAND/LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 518 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 42425 MEDSV DEF RBRVS 01/01/2024 789.81 Description: EXCISE PAROTID GLAND/LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42425 MEDSV DEF RBRVS 09/01/2019 12/31/2023 613.82 Description: EXCISE PAROTID GLAND/LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42426 MEDSV DEF RBRVS 01/01/2024 1265.61 Description: EXCISE PAROTID GLAND/LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42426 MEDSV DEF RBRVS 09/01/2019 12/31/2023 991.97 Description: EXCISE PAROTID GLAND/LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4242F NOCOV DEF SYSMAN Description: SPRVSD XRCZ BACK PN >12 WKS Category: Non Covered Services CMS Add: 04/01/2008 CMS Term: 42440 MEDSV DEF RBRVS 01/01/2024 391.73 Description: EXCISE SUBMAXILLARY GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42440 MEDSV DEF RBRVS 09/01/2019 12/31/2023 302.20 Description: EXCISE SUBMAXILLARY GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42450 MEDSV DEF RBRVS 01/01/2024 444.32 Description: EXCISE SUBLINGUAL GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42450 MEDSV DEF RBRVS 09/01/2019 12/31/2023 330.15 Description: EXCISE SUBLINGUAL GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4245F NOCOV DEF SYSMAN Description: PT INSTR NRML ACTIVITIES Category: Non Covered Services CMS Add: 04/01/2008 CMS Term: 4248F NOCOV DEF SYSMAN Description: PT INSTR NO BD REST 4 DAYS/> Category: Non Covered Services CMS Add: 04/01/2008 CMS Term: 42500 MEDSV DEF RBRVS 01/01/2024 424.46 Description: REPAIR SALIVARY DUCT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42500 MEDSV DEF RBRVS 09/01/2019 12/31/2023 316.93 Description: REPAIR SALIVARY DUCT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42505 MEDSV DEF RBRVS 01/01/2024 542.14 Description: REPAIR SALIVARY DUCT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42505 MEDSV DEF RBRVS 09/01/2019 12/31/2023 406.95 Description: REPAIR SALIVARY DUCT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42507 MEDSV DEF RBRVS 01/01/2024 466.61 Description: PAROTID DUCT DIVERSION Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 519 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 42507 MEDSV DEF RBRVS 09/01/2019 12/31/2023 375.84 Description: PAROTID DUCT DIVERSION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42509 MEDSV DEF RBRVS 01/01/2024 770.84 Description: PAROTID DUCT DIVERSION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42509 MEDSV DEF RBRVS 09/01/2019 12/31/2023 632.97 Description: PAROTID DUCT DIVERSION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4250F NOCOV DEF SYSMAN Description: WRMNG 4 SURG NORMOTHERMIA Category: Non Covered Services CMS Add: 04/01/2008 CMS Term: 42510 MEDSV DEF RBRVS 01/01/2024 572.85 Description: PAROTID DUCT DIVERSION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42510 MEDSV DEF RBRVS 09/01/2019 12/31/2023 460.59 Description: PAROTID DUCT DIVERSION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42550 MEDSV DEF RBRVS 01/01/2024 146.93 Description: INJECTION FOR SALIVARY X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42550 MEDSV DEF RBRVS 09/01/2019 12/31/2023 95.84 Description: INJECTION FOR SALIVARY X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4255F NOCOV DEF SYSMAN Description: ANESTH 60 MIN/> AS DOCD Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 4256F NOCOV DEF SYSMAN Description: ANESTHE <60 MIN AS DOCD Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 42600 MEDSV DEF RBRVS 01/01/2024 515.02 Description: CLOSURE OF SALIVARY FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42600 MEDSV DEF RBRVS 09/01/2019 12/31/2023 349.64 Description: CLOSURE OF SALIVARY FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4260F NOCOV DEF SYSMAN Description: WOUND SRFC CULTURETECH USED Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 4261F NOCOV DEF SYSMAN Description: TECH OTHER THAN SURFC CULTR Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 42650 MEDSV DEF RBRVS 01/01/2024 70.16 Description: DILATION OF SALIVARY DUCT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42650 MEDSV DEF RBRVS 09/01/2019 12/31/2023 61.23 Description: DILATION OF SALIVARY DUCT Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 520 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 4265F NOCOV DEF SYSMAN Description: WET-DRY DRESSINGS RX RECMD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 42660 MEDSV DEF RBRVS 01/01/2024 107.49 Description: DILATION OF SALIVARY DUCT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42660 MEDSV DEF RBRVS 09/01/2019 12/31/2023 88.49 Description: DILATION OF SALIVARY DUCT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42665 MEDSV DEF RBRVS 01/01/2024 354.71 Description: LIGATION OF SALIVARY DUCT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42665 MEDSV DEF RBRVS 09/01/2019 12/31/2023 228.71 Description: LIGATION OF SALIVARY DUCT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4266F NOCOV DEF SYSMAN Description: NO WET-DRY DRSSINGS RX RECMD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 4267F NOCOV DEF SYSMAN Description: COMPRSSION THXPY PRESCRIBED Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 4268F NOCOV DEF SYSMAN Description: PT ED RE COMP THXPY RCVD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 42699 MEDSV DEF BILL20 Y Description: UNLISTED PX SALIVRY GLND/DUX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4269F NOCOV DEF SYSMAN Description: APPROPOS MTHD OFFLOADING RXD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 42700 MEDSV DEF RBRVS 01/01/2024 181.32 Description: DRAINAGE OF TONSIL ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42700 MEDSV DEF RBRVS 09/01/2019 12/31/2023 138.18 Description: DRAINAGE OF TONSIL ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4270F NOCOV DEF SYSMAN Description: PT RCVNG ANTI R-VIRAL THXPY Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 4271F NOCOV DEF SYSMAN Description: PT RCVNG ANTI R-VIRAL THXPY Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 42720 MEDSV DEF RBRVS 01/01/2024 421.54 Description: DRAINAGE OF THROAT ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42720 MEDSV DEF RBRVS 09/01/2019 12/31/2023 332.20 Description: DRAINAGE OF THROAT ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 521 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 42725 MEDSV DEF RBRVS 01/01/2024 747.57 Description: DRAINAGE OF THROAT ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42725 MEDSV DEF RBRVS 09/01/2019 12/31/2023 596.09 Description: DRAINAGE OF THROAT ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4274F NOCOV DEF SYSMAN Description: FLU IMMUNO ADMIND RCVD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 4276F NOCOV DEF SYSMAN Description: POTENT ANTIVIR THXPY RXD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 4279F NOCOV DEF SYSMAN Description: PCP PROPHYLAXIS RXD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 42800 MEDSV DEF RBRVS 01/01/2024 148.95 Description: BIOPSY OF THROAT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42800 MEDSV DEF RBRVS 09/01/2019 12/31/2023 115.65 Description: BIOPSY OF THROAT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42804 MEDSV DEF RBRVS 01/01/2024 202.67 Description: BIOPSY OF UPPER NOSE/THROAT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42804 MEDSV DEF RBRVS 09/01/2019 12/31/2023 141.67 Description: BIOPSY OF UPPER NOSE/THROAT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42806 MEDSV DEF RBRVS 01/01/2024 226.26 Description: BIOPSY OF UPPER NOSE/THROAT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42806 MEDSV DEF RBRVS 09/01/2019 12/31/2023 159.48 Description: BIOPSY OF UPPER NOSE/THROAT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42808 MEDSV DEF RBRVS 01/01/2024 218.78 Description: EXCISE PHARYNX LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42808 MEDSV DEF RBRVS 09/01/2019 12/31/2023 165.53 Description: EXCISE PHARYNX LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42809 MEDSV DEF RBRVS 01/01/2024 191.18 Description: REMOVE PHARYNX FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42809 MEDSV DEF RBRVS 09/01/2019 12/31/2023 125.36 Description: REMOVE PHARYNX FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4280F NOCOV DEF SYSMAN Description: PCP PROPHYLAX RXD 3MON LOW % Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 522 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 42810 MEDSV DEF RBRVS 01/01/2024 366.91 Description: EXCISION OF NECK CYST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42810 MEDSV DEF RBRVS 09/01/2019 12/31/2023 282.71 Description: EXCISION OF NECK CYST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42815 MEDSV DEF RBRVS 01/01/2024 508.55 Description: EXCISION OF NECK CYST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42815 MEDSV DEF RBRVS 09/01/2019 12/31/2023 408.62 Description: EXCISION OF NECK CYST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42820 MEDSV DEF RBRVS 01/01/2024 274.44 0-11years Description: REMOVE TONSILS AND ADENOIDS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 42820 MEDSV DEF RBRVS 09/01/2019 12/31/2023 212.97 0-11years Description: REMOVE TONSILS AND ADENOIDS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 42821 MEDSV DEF RBRVS 01/01/2024 287.09 12-999years Description: REMOVE TONSILS AND ADENOIDS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 42821 MEDSV DEF RBRVS 09/01/2019 12/31/2023 221.19 12-999years Description: REMOVE TONSILS AND ADENOIDS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 42825 MEDSV DEF RBRVS 01/01/2024 253.26 0-11years Description: REMOVAL OF TONSILS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 42825 MEDSV DEF RBRVS 09/01/2019 12/31/2023 191.91 0-11years Description: REMOVAL OF TONSILS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 42826 MEDSV DEF RBRVS 01/01/2024 241.03 12-999years Description: REMOVAL OF TONSILS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 42826 MEDSV DEF RBRVS 09/01/2019 12/31/2023 184.35 12-999years Description: REMOVAL OF TONSILS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 42830 MEDSV DEF RBRVS 01/01/2024 200.10 0-11years Description: REMOVAL OF ADENOIDS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 42830 MEDSV DEF RBRVS 09/01/2019 12/31/2023 152.20 0-11years Description: REMOVAL OF ADENOIDS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 42831 MEDSV DEF RBRVS 01/01/2024 217.74 12-999years Description: REMOVAL OF ADENOIDS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 42831 MEDSV DEF RBRVS 09/01/2019 12/31/2023 163.69 12-999years Description: REMOVAL OF ADENOIDS Category: Medical Services CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 523 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 42835 MEDSV DEF RBRVS 01/01/2024 186.62 0-11years Description: REMOVAL OF ADENOIDS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 42835 MEDSV DEF RBRVS 09/01/2019 12/31/2023 130.66 0-11years Description: REMOVAL OF ADENOIDS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 42836 MEDSV DEF RBRVS 01/01/2024 231.17 12-999years Description: REMOVAL OF ADENOIDS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 42836 MEDSV DEF RBRVS 09/01/2019 12/31/2023 176.52 12-999years Description: REMOVAL OF ADENOIDS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 42842 MEDSV DEF RBRVS 01/01/2024 948.75 Description: EXTENSIVE SURGERY OF THROAT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42842 MEDSV DEF RBRVS 09/01/2019 12/31/2023 725.11 Description: EXTENSIVE SURGERY OF THROAT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42844 MEDSV DEF RBRVS 01/01/2024 1291.67 Description: EXTENSIVE SURGERY OF THROAT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42844 MEDSV DEF RBRVS 09/01/2019 12/31/2023 996.60 Description: EXTENSIVE SURGERY OF THROAT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42845 MEDSV DEF RBRVS 01/01/2024 2067.13 Description: EXTENSIVE SURGERY OF THROAT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42845 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1621.61 Description: EXTENSIVE SURGERY OF THROAT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42860 MEDSV DEF RBRVS 01/01/2024 182.82 Description: EXCISION OF TONSIL TAGS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42860 MEDSV DEF RBRVS 09/01/2019 12/31/2023 137.93 Description: EXCISION OF TONSIL TAGS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42870 MEDSV DEF RBRVS 01/01/2024 554.18 Description: EXCISION OF LINGUAL TONSIL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42870 MEDSV DEF RBRVS 09/01/2019 12/31/2023 419.89 Description: EXCISION OF LINGUAL TONSIL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42890 MEDSV DEF RBRVS 01/01/2024 1330.34 Description: PARTIAL REMOVAL OF PHARYNX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42890 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1032.62 Description: PARTIAL REMOVAL OF PHARYNX Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 524 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 42892 MEDSV DEF RBRVS 01/01/2024 1747.69 Description: REVISION OF PHARYNGEAL WALLS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42892 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1372.42 Description: REVISION OF PHARYNGEAL WALLS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42894 MEDSV DEF RBRVS 01/01/2024 2218.34 Description: REVISION OF PHARYNGEAL WALLS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42894 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1727.09 Description: REVISION OF PHARYNGEAL WALLS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42900 MEDSV DEF RBRVS 01/01/2024 311.73 Description: REPAIR THROAT WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42900 MEDSV DEF RBRVS 09/01/2019 12/31/2023 249.23 Description: REPAIR THROAT WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4290F NOCOV DEF SYSMAN Description: PT SCRNED FOR INJ DRUG USE Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 4293F NOCOV DEF SYSMAN Description: PT SCRND HGH-RISK SEX BEHAV Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 42950 MEDSV DEF RBRVS 01/01/2024 749.97 Description: RECONSTRUCTION OF THROAT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42950 MEDSV DEF RBRVS 09/01/2019 12/31/2023 576.10 Description: RECONSTRUCTION OF THROAT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42953 MEDSV DEF RBRVS 01/01/2024 896.29 Description: REPAIR THROAT ESOPHAGUS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 42953 MEDSV DEF RBRVS 09/01/2019 12/31/2023 688.48 Description: REPAIR THROAT ESOPHAGUS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 42955 MEDSV DEF RBRVS 01/01/2024 713.49 Description: SURGICAL OPENING OF THROAT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42955 MEDSV DEF RBRVS 09/01/2019 12/31/2023 546.90 Description: SURGICAL OPENING OF THROAT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42960 MEDSV DEF RBRVS 01/01/2024 151.54 Description: CONTROL THROAT BLEEDING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42960 MEDSV DEF RBRVS 09/01/2019 12/31/2023 124.88 Description: CONTROL THROAT BLEEDING Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 525 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 42961 MEDSV DEF RBRVS 01/01/2024 395.19 Description: CONTROL THROAT BLEEDING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42961 MEDSV DEF RBRVS 09/01/2019 12/31/2023 309.27 Description: CONTROL THROAT BLEEDING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42962 MEDSV DEF RBRVS 01/01/2024 488.87 Description: CONTROL THROAT BLEEDING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42962 MEDSV DEF RBRVS 09/01/2019 12/31/2023 379.82 Description: CONTROL THROAT BLEEDING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42970 MEDSV DEF RBRVS 01/01/2024 387.62 Description: CONTROL NOSE/THROAT BLEEDING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42970 MEDSV DEF RBRVS 09/01/2019 12/31/2023 300.87 Description: CONTROL NOSE/THROAT BLEEDING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42971 MEDSV DEF RBRVS 01/01/2024 427.09 Description: CONTROL NOSE/THROAT BLEEDING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42971 MEDSV DEF RBRVS 09/01/2019 12/31/2023 335.70 Description: CONTROL NOSE/THROAT BLEEDING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42972 MEDSV DEF RBRVS 01/01/2024 477.72 Description: CONTROL NOSE/THROAT BLEEDING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42972 MEDSV DEF RBRVS 09/01/2019 12/31/2023 376.01 Description: CONTROL NOSE/THROAT BLEEDING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 42975 MEDSV DEF RBRVS 01/01/2022 12/31/2023 84.16 Description: DISE EVAL SLP DO BRTH FLX DX Category: Medical Services CMS Add: 01/01/2022 CMS Term: 42975 MEDSV DEF RBRVS 01/01/2024 89.81 Description: DISE EVAL SLP DO BRTH FLX DX Category: Medical Services CMS Add: 01/01/2022 CMS Term: 42999 MEDSV DEF BILL20 Y Description: UNLISTED PX PHRNX ADND/TNSL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4300F NOCOV DEF SYSMAN Description: PT RCVNG WARF THXPY Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 4301F NOCOV DEF SYSMAN Description: PT NOT RCVNG WARF THXPY Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 43020 MEDSV DEF RBRVS 01/01/2024 518.12 Description: INCISION OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 526 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 43020 MEDSV DEF RBRVS 09/01/2019 12/31/2023 363.15 Description: INCISION OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43030 MEDSV DEF RBRVS 01/01/2024 491.97 Description: THROAT MUSCLE SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43030 MEDSV DEF RBRVS 09/01/2019 12/31/2023 379.82 Description: THROAT MUSCLE SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43045 MEDSV DEF RBRVS 01/01/2024 1178.21 Description: INCISION OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43045 MEDSV DEF RBRVS 09/01/2019 12/31/2023 938.08 Description: INCISION OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4305F NOCOV DEF SYSMAN Description: PT ED RE FT CARE INSPCT RCVD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 4306F NOCOV DEF SYSMAN Description: PT TLK PSYCH & RX OPD ADDIC Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 43100 MEDSV DEF RBRVS 01/01/2024 598.99 Description: EXCISION OF ESOPHAGUS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43100 MEDSV DEF RBRVS 09/01/2019 12/31/2023 460.53 Description: EXCISION OF ESOPHAGUS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43101 MEDSV DEF RBRVS 01/01/2024 909.65 Description: EXCISION OF ESOPHAGUS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43101 MEDSV DEF RBRVS 09/01/2019 12/31/2023 725.77 Description: EXCISION OF ESOPHAGUS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43107 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1830.22 Description: REMOVAL OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43107 MEDSV DEF RBRVS 01/01/2024 2684.72 Description: REMOVAL OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43108 MEDSV DEF RBRVS 01/01/2019 12/31/2023 3348.94 Description: REMOVAL OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43108 MEDSV DEF RBRVS 01/01/2024 3981.39 Description: REMOVAL OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43112 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1935.32 Description: ESPHG TOT W/THRCM Category: Medical Services CMS Add: 01/01/1995 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 527 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 43112 MEDSV DEF RBRVS 01/01/2024 3122.54 Description: ESPHG TOT W/THRCM Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43113 MEDSV DEF RBRVS 01/01/2019 12/31/2023 3273.19 Description: REMOVAL OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43113 MEDSV DEF RBRVS 01/01/2024 3894.37 Description: REMOVAL OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43116 MEDSV DEF RBRVS 01/01/2019 12/31/2023 3850.09 Description: PARTIAL REMOVAL OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43116 MEDSV DEF RBRVS 01/01/2024 4450.97 Description: PARTIAL REMOVAL OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43117 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1776.10 Description: PARTIAL REMOVAL OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43117 MEDSV DEF RBRVS 01/01/2024 2928.99 Description: PARTIAL REMOVAL OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43118 MEDSV DEF RBRVS 01/01/2019 12/31/2023 2605.44 Description: PARTIAL REMOVAL OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43118 MEDSV DEF RBRVS 01/01/2024 3248.82 Description: PARTIAL REMOVAL OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43121 MEDSV DEF RBRVS 01/01/2019 12/31/2023 2066.23 Description: PARTIAL REMOVAL OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43121 MEDSV DEF RBRVS 01/01/2024 2565.69 Description: PARTIAL REMOVAL OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43122 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1840.71 Description: PARTIAL REMOVAL OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43122 MEDSV DEF RBRVS 01/01/2024 2309.20 Description: PARTIAL REMOVAL OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43123 MEDSV DEF RBRVS 01/01/2019 12/31/2023 3392.73 Description: PARTIAL REMOVAL OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43123 MEDSV DEF RBRVS 01/01/2024 4036.69 Description: PARTIAL REMOVAL OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43124 MEDSV DEF RBRVS 01/01/2019 12/31/2023 2754.19 Description: REMOVAL OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1995 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 528 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 43124 MEDSV DEF RBRVS 01/01/2024 3415.92 Description: REMOVAL OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43130 MEDSV DEF RBRVS 01/01/2024 739.07 Description: REMOVAL OF ESOPHAGUS POUCH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43130 MEDSV DEF RBRVS 09/01/2019 12/31/2023 576.37 Description: REMOVAL OF ESOPHAGUS POUCH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43135 MEDSV DEF RBRVS 01/01/2024 1322.73 Description: REMOVAL OF ESOPHAGUS POUCH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43135 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1077.38 Description: REMOVAL OF ESOPHAGUS POUCH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43180 MEDSV DEF RBRVS 01/01/2024 513.09 Description: ESOPHAGOSCOPY RIGID TRNSO Category: Medical Services CMS Add: 01/01/2015 CMS Term: 43180 MEDSV DEF RBRVS 02/01/2015 12/31/2023 406.86 Description: ESOPHAGOSCOPY RIGID TRNSO Category: Medical Services CMS Add: 01/01/2015 CMS Term: 43191 MEDSV DEF RBRVS 01/01/2024 144.98 Description: ESOPHAGOSCOPY RIGID TRNSO DX Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43191 MEDSV DEF RBRVS 02/01/2015 12/31/2023 92.63 Description: ESOPHAGOSCOPY RIGID TRNSO DX Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43192 MEDSV DEF RBRVS 01/01/2024 158.57 Description: ESOPHAGOSCP RIG TRNSO INJECT Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43192 MEDSV DEF RBRVS 02/01/2015 12/31/2023 110.50 Description: ESOPHAGOSCP RIG TRNSO INJECT Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43193 MEDSV DEF RBRVS 01/01/2024 158.10 Description: ESOPHAGOSCP RIG TRNSO BIOPSY Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43193 MEDSV DEF RBRVS 02/01/2015 12/31/2023 131.72 Description: ESOPHAGOSCP RIG TRNSO BIOPSY Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43194 MEDSV DEF RBRVS 01/01/2024 178.60 Description: ESOPHAGOSCP RIG TRNSO REM FB Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43194 MEDSV DEF RBRVS 02/01/2015 12/31/2023 119.83 Description: ESOPHAGOSCP RIG TRNSO REM FB Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43195 MEDSV DEF RBRVS 01/01/2024 172.86 Description: ESOPHAGOSCOPY RIGID BALLOON Category: Medical Services CMS Add: 01/01/2014 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 529 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 43195 MEDSV DEF RBRVS 02/01/2015 12/31/2023 131.96 Description: ESOPHAGOSCOPY RIGID BALLOON Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43196 MEDSV DEF RBRVS 01/01/2024 182.84 Description: ESOPHAGOSCP GUIDE WIRE DILAT Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43196 MEDSV DEF RBRVS 02/01/2015 12/31/2023 144.15 Description: ESOPHAGOSCP GUIDE WIRE DILAT Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43197 MEDSV DEF RBRVS 01/01/2024 179.31 Description: ESOPHAGOSCOPY FLEX DX BRUSH Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43197 MEDSV DEF RBRVS 02/01/2015 12/31/2023 131.67 Description: ESOPHAGOSCOPY FLEX DX BRUSH Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43198 MEDSV DEF RBRVS 01/01/2024 199.37 Description: ESOPHAGOSC FLEX TRNSN BIOPSY Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43198 MEDSV DEF RBRVS 02/01/2015 12/31/2023 147.16 Description: ESOPHAGOSC FLEX TRNSN BIOPSY Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43200 MEDSV DEF RBRVS 01/01/2024 246.77 Description: ESOPHAGOSCOPY FLEXIBLE BRUSH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43200 MEDSV DEF RBRVS 09/15/2017 12/31/2023 153.51 Description: ESOPHAGOSCOPY FLEXIBLE BRUSH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43201 MEDSV DEF RBRVS 01/01/2024 243.52 Description: ESOPH SCOPE W/SUBMUCOUS INJ Category: Medical Services CMS Add: 01/01/2003 CMS Term: 43201 MEDSV DEF RBRVS 09/15/2017 12/31/2023 157.11 Description: ESOPH SCOPE W/SUBMUCOUS INJ Category: Medical Services CMS Add: 01/01/2003 CMS Term: 43202 MEDSV DEF RBRVS 01/01/2024 334.58 Description: ESOPHAGOSCOPY FLEX BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43202 MEDSV DEF RBRVS 09/15/2017 12/31/2023 217.47 Description: ESOPHAGOSCOPY FLEX BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43204 MEDSV DEF RBRVS 01/01/2024 125.60 Description: ESOPH SCOPE W/SCLEROSIS INJ Category: Medical Services CMS Add: 01/01/1982 CMS Term: 43204 MEDSV DEF RBRVS 09/15/2017 12/31/2023 101.25 Description: ESOPH SCOPE W/SCLEROSIS INJ Category: Medical Services CMS Add: 01/01/1982 CMS Term: 43205 MEDSV DEF RBRVS 01/01/2024 130.87 Description: ESOPHAGUS ENDOSCOPY/LIGATION Category: Medical Services CMS Add: 01/01/1994 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 530 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 43205 MEDSV DEF RBRVS 09/15/2017 12/31/2023 105.36 Description: ESOPHAGUS ENDOSCOPY/LIGATION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 43206 NOCOV DEF SYSMAN Description: ESOPH OPTICAL ENDOMICROSCOPY Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 4320F NOCOV DEF SYSMAN Description: PT TALK PSYCHSOC&RX OH DPND Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 43210 NOCOV DEF SYSMAN Description: EGD ESOPHAGOGASTRC FNDOPLSTY Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 43211 MEDSV DEF RBRVS 01/01/2024 218.13 Description: ESOPHAGOSCOP MUCOSAL RESECT Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43211 MEDSV DEF RBRVS 09/15/2017 12/31/2023 175.93 Description: ESOPHAGOSCOP MUCOSAL RESECT Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43212 MEDSV DEF RBRVS 01/01/2024 173.95 Description: ESOPHAGOSCOP STENT PLACEMENT Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43212 MEDSV DEF RBRVS 09/15/2017 12/31/2023 140.40 Description: ESOPHAGOSCOP STENT PLACEMENT Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43213 MEDSV DEF RBRVS 01/01/2024 1159.61 Description: ESOPHAGOSCOPY RETRO BALLOON Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43213 MEDSV DEF RBRVS 09/15/2017 12/31/2023 813.38 Description: ESOPHAGOSCOPY RETRO BALLOON Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43214 MEDSV DEF RBRVS 01/01/2024 179.76 Description: ESOPHAGOSC DILATE BALLOON 30 Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43214 MEDSV DEF RBRVS 09/15/2017 12/31/2023 143.12 Description: ESOPHAGOSC DILATE BALLOON 30 Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43215 MEDSV DEF RBRVS 01/01/2024 367.72 Description: ESOPHAGOSCOPY FLEX REMOVE FB Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43215 MEDSV DEF RBRVS 09/15/2017 12/31/2023 255.31 Description: ESOPHAGOSCOPY FLEX REMOVE FB Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43216 MEDSV DEF RBRVS 01/01/2024 384.21 Description: ESOPHAGOSCOPY LESION REMOVAL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 43216 MEDSV DEF RBRVS 09/15/2017 12/31/2023 253.03 Description: ESOPHAGOSCOPY LESION REMOVAL Category: Medical Services CMS Add: 01/01/1994 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 531 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 43217 MEDSV DEF RBRVS 01/01/2024 394.39 Description: ESOPHAGOSCOPY SNARE LES REMV Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43217 MEDSV DEF RBRVS 09/15/2017 12/31/2023 269.69 Description: ESOPHAGOSCOPY SNARE LES REMV Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43220 MEDSV DEF RBRVS 01/01/2024 844.21 Description: ESOPHAGOSCOPY BALLOON <30MM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43220 MEDSV DEF RBRVS 09/15/2017 12/31/2023 754.85 Description: ESOPHAGOSCOPY BALLOON <30MM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43226 MEDSV DEF RBRVS 01/01/2024 361.23 Description: ESOPH ENDOSCOPY DILATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43226 MEDSV DEF RBRVS 09/15/2017 12/31/2023 225.33 Description: ESOPH ENDOSCOPY DILATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43227 MEDSV DEF RBRVS 01/01/2024 556.92 Description: ESOPHAGOSCOPY CONTROL BLEED Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43227 MEDSV DEF RBRVS 09/15/2017 12/31/2023 444.27 Description: ESOPHAGOSCOPY CONTROL BLEED Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43229 MEDSV DEF RBRVS 01/01/2024 666.36 Description: ESOPHAGOSCOPY LESION ABLATE Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43229 MEDSV DEF RBRVS 09/15/2017 12/31/2023 457.42 Description: ESOPHAGOSCOPY LESION ABLATE Category: Medical Services CMS Add: 01/01/2014 CMS Term: 4322F NOCOV DEF SYSMAN Description: CRGVR PROV W/ ED ADDL RSRCS Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 43231 MEDSV DEF RBRVS 01/01/2024 146.95 Description: ESOPHAGOSCOP ULTRASOUND EXAM Category: Medical Services CMS Add: 01/01/2001 CMS Term: 43231 MEDSV DEF RBRVS 09/15/2017 12/31/2023 238.81 Description: ESOPHAGOSCOP ULTRASOUND EXAM Category: Medical Services CMS Add: 01/01/2001 CMS Term: 43232 MEDSV DEF RBRVS 01/01/2024 183.96 Description: ESOPHAGOSCOPY W/US NEEDLE BX Category: Medical Services CMS Add: 01/01/2001 CMS Term: 43232 MEDSV DEF RBRVS 09/15/2017 12/31/2023 287.20 Description: ESOPHAGOSCOPY W/US NEEDLE BX Category: Medical Services CMS Add: 01/01/2001 CMS Term: 43233 MEDSV DEF RBRVS 01/01/2024 210.70 Description: EGD BALLOON DIL ESOPH30 MM/> Category: Medical Services CMS Add: 01/01/2014 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 532 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 43233 MEDSV DEF RBRVS 09/15/2017 12/31/2023 169.47 Description: EGD BALLOON DIL ESOPH30 MM/> Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43235 MEDSV DEF RBRVS 01/01/2024 269.81 Description: EGD DIAGNOSTIC BRUSH WASH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43235 MEDSV DEF RBRVS 09/15/2017 12/31/2023 182.32 Description: EGD DIAGNOSTIC BRUSH WASH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43236 MEDSV DEF RBRVS 01/01/2024 376.14 Description: UPPR GI SCOPE W/SUBMUC INJ Category: Medical Services CMS Add: 01/01/2003 CMS Term: 43236 MEDSV DEF RBRVS 09/15/2017 12/31/2023 233.82 Description: UPPR GI SCOPE W/SUBMUC INJ Category: Medical Services CMS Add: 01/01/2003 CMS Term: 43237 MEDSV DEF RBRVS 01/01/2024 181.76 Description: ENDOSCOPIC US EXAM ESOPH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 43237 MEDSV DEF RBRVS 09/15/2017 12/31/2023 146.08 Description: ENDOSCOPIC US EXAM ESOPH Category: Medical Services CMS Add: 01/01/2004 CMS Term: 43238 MEDSV DEF RBRVS 01/01/2024 215.53 Description: EGD US FINE NEEDLE BX/ASPIR Category: Medical Services CMS Add: 01/01/2004 CMS Term: 43238 MEDSV DEF RBRVS 09/15/2017 12/31/2023 173.95 Description: EGD US FINE NEEDLE BX/ASPIR Category: Medical Services CMS Add: 01/01/2004 CMS Term: 43239 MEDSV DEF RBRVS 01/01/2024 353.00 Description: EGD BIOPSY SINGLE/MULTIPLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43239 MEDSV DEF RBRVS 09/15/2017 12/31/2023 243.40 Description: EGD BIOPSY SINGLE/MULTIPLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43240 MEDSV DEF RBRVS 01/01/2024 363.23 Description: EGD W/TRANSMURAL DRAIN CYST Category: Medical Services CMS Add: 01/01/2001 CMS Term: 43240 MEDSV DEF RBRVS 09/15/2017 12/31/2023 293.42 Description: EGD W/TRANSMURAL DRAIN CYST Category: Medical Services CMS Add: 01/01/2001 CMS Term: 43241 MEDSV DEF RBRVS 01/01/2024 131.50 Description: EGD TUBE/CATH INSERTION Category: Medical Services CMS Add: 01/01/1986 CMS Term: 43241 MEDSV DEF RBRVS 09/15/2017 12/31/2023 106.12 Description: EGD TUBE/CATH INSERTION Category: Medical Services CMS Add: 01/01/1986 CMS Term: 43242 MEDSV DEF RBRVS 01/01/2024 244.16 Description: EGD US FINE NEEDLE BX/ASPIR Category: Medical Services CMS Add: 01/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 533 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 43242 MEDSV DEF RBRVS 09/15/2017 12/31/2023 196.53 Description: EGD US FINE NEEDLE BX/ASPIR Category: Medical Services CMS Add: 01/01/2001 CMS Term: 43243 MEDSV DEF RBRVS 01/01/2024 219.76 Description: EGD INJECTION VARICES Category: Medical Services CMS Add: 01/01/1989 CMS Term: 43243 MEDSV DEF RBRVS 09/15/2017 12/31/2023 176.99 Description: EGD INJECTION VARICES Category: Medical Services CMS Add: 01/01/1989 CMS Term: 43244 MEDSV DEF RBRVS 01/01/2024 227.54 Description: EGD VARICES LIGATION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 43244 MEDSV DEF RBRVS 09/15/2017 12/31/2023 183.45 Description: EGD VARICES LIGATION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 43245 MEDSV DEF RBRVS 01/01/2024 556.77 Description: EGD DILATE STRICTURE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 43245 MEDSV DEF RBRVS 09/15/2017 12/31/2023 390.83 Description: EGD DILATE STRICTURE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 43246 MEDSV DEF RBRVS 01/01/2024 184.59 Description: EGD PLACE GASTROSTOMY TUBE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 43246 MEDSV DEF RBRVS 09/15/2017 12/31/2023 148.58 Description: EGD PLACE GASTROSTOMY TUBE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 43247 MEDSV DEF RBRVS 01/01/2024 359.42 Description: EGD REMOVE FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43247 MEDSV DEF RBRVS 09/15/2017 12/31/2023 249.20 Description: EGD REMOVE FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43248 MEDSV DEF RBRVS 01/01/2024 387.33 Description: EGD GUIDE WIRE INSERTION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 43248 MEDSV DEF RBRVS 09/15/2017 12/31/2023 249.44 Description: EGD GUIDE WIRE INSERTION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 43249 MEDSV DEF RBRVS 01/01/2024 1012.52 Description: ESOPH EGD DILATION <30 MM Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43249 MEDSV DEF RBRVS 09/15/2017 12/31/2023 716.54 Description: ESOPH EGD DILATION <30 MM Category: Medical Services CMS Add: 01/01/1995 CMS Term: 4324F NOCOV DEF SYSMAN Description: PT QUERIED PRKNS COMPLIC Category: Non Covered Services CMS Add: 10/01/2010 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 534 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 43250 MEDSV DEF RBRVS 01/01/2024 422.14 Description: EGD CAUTERY TUMOR POLYP Category: Medical Services CMS Add: 01/01/1994 CMS Term: 43250 MEDSV DEF RBRVS 09/15/2017 12/31/2023 281.85 Description: EGD CAUTERY TUMOR POLYP Category: Medical Services CMS Add: 01/01/1994 CMS Term: 43251 MEDSV DEF RBRVS 01/01/2024 464.86 Description: EGD REMOVE LESION SNARE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43251 MEDSV DEF RBRVS 09/15/2017 12/31/2023 313.12 Description: EGD REMOVE LESION SNARE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43252 NOCOV DEF SYSMAN Description: EGD OPTICAL ENDOMICROSCOPY Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 43253 MEDSV DEF RBRVS 01/01/2024 243.85 Description: EGD US TRANSMURAL INJXN/MARK Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43253 MEDSV DEF RBRVS 09/15/2017 12/31/2023 196.53 Description: EGD US TRANSMURAL INJXN/MARK Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43254 MEDSV DEF RBRVS 01/01/2024 250.61 Description: EGD ENDO MUCOSAL RESECTION Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43254 MEDSV DEF RBRVS 09/15/2017 12/31/2023 202.19 Description: EGD ENDO MUCOSAL RESECTION Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43255 MEDSV DEF RBRVS 01/01/2024 587.84 Description: EGD CONTROL BLEEDING ANY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43255 MEDSV DEF RBRVS 09/15/2017 12/31/2023 470.86 Description: EGD CONTROL BLEEDING ANY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43257 MEDSV DEF RBRVS 01/01/2024 214.62 0-1 Description: EGD W/THRML TXMNT GERD Category: Medical Services CMS Add: 01/01/2005 CMS Term: 43257 MEDSV DEF RBRVS 09/15/2017 12/31/2023 173.02 0-1 Description: EGD W/THRML TXMNT GERD Category: Medical Services CMS Add: 01/01/2005 CMS Term: 43259 MEDSV DEF RBRVS 01/01/2024 209.43 Description: EGD US EXAM DUODENUM/JEJUNUM Category: Medical Services CMS Add: 01/01/1994 CMS Term: 43259 MEDSV DEF RBRVS 09/15/2017 12/31/2023 168.99 Description: EGD US EXAM DUODENUM/JEJUNUM Category: Medical Services CMS Add: 01/01/1994 CMS Term: 4325F NOCOV DEF SYSMAN Description: MED TXMNT OPTIONS RVWD W/PT Category: Non Covered Services CMS Add: 10/01/2010 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 535 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 43260 MEDSV DEF RBRVS 01/01/2024 298.86 Description: ERCP W/SPECIMEN COLLECTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43260 MEDSV DEF RBRVS 09/15/2017 12/31/2023 241.07 Description: ERCP W/SPECIMEN COLLECTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43261 MEDSV DEF RBRVS 01/01/2024 313.84 Description: ENDO CHOLANGIOPANCREATOGRAPH Category: Medical Services CMS Add: 01/01/1994 CMS Term: 43261 MEDSV DEF RBRVS 09/15/2017 12/31/2023 253.26 Description: ENDO CHOLANGIOPANCREATOGRAPH Category: Medical Services CMS Add: 01/01/1994 CMS Term: 43262 MEDSV DEF RBRVS 01/01/2024 331.13 Description: ENDO CHOLANGIOPANCREATOGRAPH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43262 MEDSV DEF RBRVS 09/15/2017 12/31/2023 267.21 Description: ENDO CHOLANGIOPANCREATOGRAPH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43263 MEDSV DEF RBRVS 01/01/2024 331.44 Description: ERCP SPHINCTER PRESSURE MEAS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43263 MEDSV DEF RBRVS 09/15/2017 12/31/2023 267.54 Description: ERCP SPHINCTER PRESSURE MEAS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43264 MEDSV DEF RBRVS 01/01/2024 337.40 Description: ERCP REMOVE DUCT CALCULI Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43264 MEDSV DEF RBRVS 09/15/2017 12/31/2023 272.35 Description: ERCP REMOVE DUCT CALCULI Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43265 MEDSV DEF RBRVS 01/01/2024 401.30 Description: ERCP LITHOTRIPSY CALCULI Category: Medical Services CMS Add: 01/01/1989 CMS Term: 43265 MEDSV DEF RBRVS 09/15/2017 12/31/2023 324.21 Description: ERCP LITHOTRIPSY CALCULI Category: Medical Services CMS Add: 01/01/1989 CMS Term: 43266 MEDSV DEF RBRVS 01/01/2024 201.25 Description: EGD ENDOSCOPIC STENT PLACE Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43266 MEDSV DEF RBRVS 09/15/2017 12/31/2023 162.63 Description: EGD ENDOSCOPIC STENT PLACE Category: Medical Services CMS Add: 01/01/2014 CMS Term: 4326F NOCOV DEF SYSMAN Description: PT ASKED RE SYMP AUTO DYSFXN Category: Non Covered Services CMS Add: 10/01/2010 CMS Term: 43270 MEDSV DEF RBRVS 01/01/2024 685.08 Description: EGD LESION ABLATION Category: Medical Services CMS Add: 01/01/2014 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 536 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 43270 MEDSV DEF RBRVS 09/15/2017 12/31/2023 472.79 Description: EGD LESION ABLATION Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43273 MEDSV DEF RBRVS 01/01/2024 110.19 Description: ENDOSCOPIC PANCREATOSCOPY Category: Medical Services CMS Add: 01/01/2009 CMS Term: 43273 MEDSV DEF RBRVS 09/15/2017 12/31/2023 89.50 Description: ENDOSCOPIC PANCREATOSCOPY Category: Medical Services CMS Add: 01/01/2009 CMS Term: 43274 MEDSV DEF RBRVS 01/01/2024 428.78 Description: ERCP DUCT STENT PLACEMENT Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43274 MEDSV DEF RBRVS 09/15/2017 12/31/2023 346.33 Description: ERCP DUCT STENT PLACEMENT Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43275 MEDSV DEF RBRVS 01/01/2024 348.60 Description: ERCP REMOVE FORGN BODY DUCT Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43275 MEDSV DEF RBRVS 09/15/2017 12/31/2023 281.67 Description: ERCP REMOVE FORGN BODY DUCT Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43276 MEDSV DEF RBRVS 01/01/2024 446.57 Description: ERCP STENT EXCHANGE W/DILATE Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43276 MEDSV DEF RBRVS 09/15/2017 12/31/2023 360.63 Description: ERCP STENT EXCHANGE W/DILATE Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43277 MEDSV DEF RBRVS 01/01/2024 350.88 Description: ERCP EA DUCT/AMPULLA DILATE Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43277 MEDSV DEF RBRVS 09/15/2017 12/31/2023 283.24 Description: ERCP EA DUCT/AMPULLA DILATE Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43278 MEDSV DEF RBRVS 01/01/2024 400.96 Description: ERCP LESION ABLATE W/DILATE Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43278 MEDSV DEF RBRVS 09/15/2017 12/31/2023 323.94 Description: ERCP LESION ABLATE W/DILATE Category: Medical Services CMS Add: 01/01/2014 CMS Term: 43279 MEDSV DEF RBRVS 01/01/2024 1166.14 Description: LAP MYOTOMY HELLER Category: Medical Services CMS Add: 01/01/2009 CMS Term: 43279 MEDSV DEF RBRVS 02/01/2015 12/31/2023 921.53 Description: LAP MYOTOMY HELLER Category: Medical Services CMS Add: 01/01/2009 CMS Term: 43280 MEDSV DEF RBRVS 01/01/2024 981.96 0-1 Description: LAPAROSCOPY FUNDOPLASTY Category: Medical Services CMS Add: 01/01/2000 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 537 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 43280 MEDSV DEF RBRVS 02/01/2015 12/31/2023 771.53 0-1 Description: LAPAROSCOPY FUNDOPLASTY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 43281 MEDSV DEF RBRVS 01/01/2024 1397.20 0-1 Description: LAP PARAESOPHAG HERN REPAIR Category: Medical Services CMS Add: 01/01/2010 CMS Term: 43281 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1101.81 0-1 Description: LAP PARAESOPHAG HERN REPAIR Category: Medical Services CMS Add: 01/01/2010 CMS Term: 43282 MEDSV DEF RBRVS 01/01/2024 1571.48 0-1 Description: LAP PARAESOPH HER RPR W/MESH Category: Medical Services CMS Add: 01/01/2010 CMS Term: 43282 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1239.20 0-1 Description: LAP PARAESOPH HER RPR W/MESH Category: Medical Services CMS Add: 01/01/2010 CMS Term: 43283 MEDSV DEF RBRVS 01/01/2024 141.81 0-1 Description: LAP ESOPH LENGTHENING Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43283 MEDSV DEF RBRVS 02/01/2015 12/31/2023 112.70 0-1 Description: LAP ESOPH LENGTHENING Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43284 MEDSV DEF RBRVS 01/01/2017 12/31/2023 466.89 Description: LAPS ESOPHGL SPHNCTR AGMNTJ Category: Medical Services CMS Add: 01/01/2017 CMS Term: 43284 MEDSV DEF RBRVS 01/01/2024 596.09 Description: LAPS ESOPHGL SPHNCTR AGMNTJ Category: Medical Services CMS Add: 01/01/2017 CMS Term: 43285 MEDSV DEF RBRVS 01/01/2017 12/31/2023 472.39 Description: RMVL ESOPHGL SPHNCTR DEV Category: Medical Services CMS Add: 01/01/2017 CMS Term: 43285 MEDSV DEF RBRVS 01/01/2024 613.08 Description: RMVL ESOPHGL SPHNCTR DEV Category: Medical Services CMS Add: 01/01/2017 CMS Term: 43286 MEDSV DEF RBRVS 01/01/2018 12/31/2023 2282.36 Description: ESPHG TOT W/LAPS MOBLJ Category: Medical Services CMS Add: 01/01/2018 CMS Term: 43286 MEDSV DEF RBRVS 01/01/2024 2872.67 Description: ESPHG TOT W/LAPS MOBLJ Category: Medical Services CMS Add: 01/01/2018 CMS Term: 43287 MEDSV DEF RBRVS 01/01/2018 12/31/2023 2602.27 Description: ESPHG DSTL 2/3 W/LAPS MOBLJ Category: Medical Services CMS Add: 01/01/2018 CMS Term: 43287 MEDSV DEF RBRVS 01/01/2024 3193.63 Description: ESPHG DSTL 2/3 W/LAPS MOBLJ Category: Medical Services CMS Add: 01/01/2018 CMS Term: 43288 MEDSV DEF RBRVS 01/01/2018 12/31/2023 2722.14 Description: ESPHG THRSC MOBLJ Category: Medical Services CMS Add: 01/01/2018 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 538 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 43288 MEDSV DEF RBRVS 01/01/2024 3372.89 Description: ESPHG THRSC MOBLJ Category: Medical Services CMS Add: 01/01/2018 CMS Term: 43289 MEDSV DEF BILL20 0-1 Description: UNLISTED LAPS PX ESOPH Category: Medical Services CMS Add: 01/01/2000 CMS Term: 4328F NOCOV DEF SYSMAN Description: PT ASKED RE SLEEP DISTURB Category: Non Covered Services CMS Add: 10/01/2010 CMS Term: 43290 MEDSV DEF RBRVS 01/01/2023 2494.19 Y 18-999years Description: EGD FLX TRNSORL DPLMNT BALO Category: Medical Services CMS Add: 01/01/2023 CMS Term: 43291 MEDSV DEF RBRVS 01/01/2023 431.00 Y 18-999years Description: EGD FLX TRNSORL RMVL BALO Category: Medical Services CMS Add: 01/01/2023 CMS Term: 43300 MEDSV DEF RBRVS 01/01/2024 589.63 Description: REPAIR OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43300 MEDSV DEF RBRVS 09/01/2019 12/31/2023 451.99 Description: REPAIR OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43305 MEDSV DEF RBRVS 01/01/2024 1029.65 Description: REPAIR ESOPHAGUS AND FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43305 MEDSV DEF RBRVS 09/01/2019 12/31/2023 802.73 Description: REPAIR ESOPHAGUS AND FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4330F NOCOV DEF SYSMAN Description: CNSLNG EPI SPEC SFTY ISSUES Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 43310 MEDSV DEF RBRVS 01/01/2024 1334.75 Description: REPAIR OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43310 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1071.29 Description: REPAIR OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43312 MEDSV DEF RBRVS 01/01/2024 1425.27 Description: REPAIR ESOPHAGUS AND FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43312 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1154.85 Description: REPAIR ESOPHAGUS AND FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43313 MEDSV DEF RBRVS 01/01/2024 2634.05 Description: ESOPHAGOPLASTY CONGENITAL Category: Medical Services CMS Add: 01/01/2002 CMS Term: 43313 MEDSV DEF RBRVS 02/01/2015 12/31/2023 2072.04 Description: ESOPHAGOPLASTY CONGENITAL Category: Medical Services CMS Add: 01/01/2002 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 539 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 43314 MEDSV DEF RBRVS 01/01/2024 2821.84 Description: TRACHEO-ESOPHAGOPLASTY CONG Category: Medical Services CMS Add: 01/01/2002 CMS Term: 43314 MEDSV DEF RBRVS 02/01/2015 12/31/2023 2139.57 Description: TRACHEO-ESOPHAGOPLASTY CONG Category: Medical Services CMS Add: 01/01/2002 CMS Term: 43320 MEDSV DEF RBRVS 01/01/2024 1272.13 Description: FUSE ESOPHAGUS & STOMACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43320 MEDSV DEF RBRVS 09/01/2019 12/31/2023 993.26 Description: FUSE ESOPHAGUS & STOMACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43325 MEDSV DEF RBRVS 01/01/2024 1236.99 Description: REVISE ESOPHAGUS & STOMACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43325 MEDSV DEF RBRVS 09/01/2019 12/31/2023 958.50 Description: REVISE ESOPHAGUS & STOMACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43327 MEDSV DEF RBRVS 01/01/2024 748.15 Description: ESOPH FUNDOPLASTY LAP Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43327 MEDSV DEF RBRVS 02/01/2015 12/31/2023 585.19 Description: ESOPH FUNDOPLASTY LAP Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43328 MEDSV DEF RBRVS 01/01/2024 1011.42 Description: ESOPH FUNDOPLASTY THOR Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43328 MEDSV DEF RBRVS 02/01/2015 12/31/2023 827.35 Description: ESOPH FUNDOPLASTY THOR Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43330 MEDSV DEF RBRVS 01/01/2024 1216.85 Description: ESOPHAGOMYOTOMY ABDOMINAL Category: Medical Services CMS Add: 01/01/1985 CMS Term: 43330 MEDSV DEF RBRVS 09/01/2019 12/31/2023 950.12 Description: ESOPHAGOMYOTOMY ABDOMINAL Category: Medical Services CMS Add: 01/01/1985 CMS Term: 43331 MEDSV DEF RBRVS 01/01/2024 1208.97 Description: ESOPHAGOMYOTOMY THORACIC Category: Medical Services CMS Add: 01/01/1985 CMS Term: 43331 MEDSV DEF RBRVS 09/01/2019 12/31/2023 967.64 Description: ESOPHAGOMYOTOMY THORACIC Category: Medical Services CMS Add: 01/01/1985 CMS Term: 43332 MEDSV DEF RBRVS 01/01/2024 1042.78 Description: TRANSAB ESOPH HIAT HERN RPR Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43332 MEDSV DEF RBRVS 02/01/2015 12/31/2023 829.30 Description: TRANSAB ESOPH HIAT HERN RPR Category: Medical Services CMS Add: 01/01/2011 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 540 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 43333 MEDSV DEF RBRVS 01/01/2024 1141.43 Description: TRANSAB ESOPH HIAT HERN RPR Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43333 MEDSV DEF RBRVS 02/01/2015 12/31/2023 902.60 Description: TRANSAB ESOPH HIAT HERN RPR Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43334 MEDSV DEF RBRVS 01/01/2024 1119.21 Description: TRANSTHOR DIAPHRAG HERN RPR Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43334 MEDSV DEF RBRVS 02/01/2015 12/31/2023 895.81 Description: TRANSTHOR DIAPHRAG HERN RPR Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43335 MEDSV DEF RBRVS 01/01/2024 1199.50 Description: TRANSTHOR DIAPHRAG HERN RPR Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43335 MEDSV DEF RBRVS 02/01/2015 12/31/2023 960.13 Description: TRANSTHOR DIAPHRAG HERN RPR Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43336 MEDSV DEF RBRVS 01/01/2024 1303.51 Description: THORABD DIAPHR HERN REPAIR Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43336 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1084.80 Description: THORABD DIAPHR HERN REPAIR Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43337 MEDSV DEF RBRVS 01/01/2024 1389.00 Description: THORABD DIAPHR HERN REPAIR Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43337 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1170.98 Description: THORABD DIAPHR HERN REPAIR Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43338 MEDSV DEF RBRVS 01/01/2024 102.72 Description: ESOPH LENGTHENING Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43338 MEDSV DEF RBRVS 02/01/2015 12/31/2023 83.90 Description: ESOPH LENGTHENING Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43340 MEDSV DEF RBRVS 01/01/2024 1256.13 Description: FUSE ESOPHAGUS & INTESTINE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43340 MEDSV DEF RBRVS 09/01/2019 12/31/2023 980.78 Description: FUSE ESOPHAGUS & INTESTINE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43341 MEDSV DEF RBRVS 01/01/2024 1262.69 Description: FUSE ESOPHAGUS & INTESTINE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43341 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1006.51 Description: FUSE ESOPHAGUS & INTESTINE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 541 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 43351 MEDSV DEF RBRVS 01/01/2024 1192.01 Description: SURGICAL OPENING ESOPHAGUS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 43351 MEDSV DEF RBRVS 09/01/2019 12/31/2023 949.09 Description: SURGICAL OPENING ESOPHAGUS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 43352 MEDSV DEF RBRVS 01/01/2024 965.40 Description: SURGICAL OPENING ESOPHAGUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43352 MEDSV DEF RBRVS 09/01/2019 12/31/2023 769.19 Description: SURGICAL OPENING ESOPHAGUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43360 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1709.72 Description: GASTROINTESTINAL REPAIR Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43360 MEDSV DEF RBRVS 01/01/2024 2022.83 Description: GASTROINTESTINAL REPAIR Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43361 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1826.76 Description: GASTROINTESTINAL REPAIR Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43361 MEDSV DEF RBRVS 01/01/2024 2448.01 Description: GASTROINTESTINAL REPAIR Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43400 MEDSV DEF RBRVS 01/01/2024 1385.47 Description: LIGATE ESOPHAGUS VEINS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43400 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1114.56 Description: LIGATE ESOPHAGUS VEINS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43405 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1042.40 Description: LIGATE/STAPLE ESOPHAGUS Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43405 MEDSV DEF RBRVS 01/01/2024 1316.62 Description: LIGATE/STAPLE ESOPHAGUS Category: Medical Services CMS Add: 01/01/1995 CMS Term: 4340F NOCOV DEF SYSMAN Description: CNSLNG CHLDBRNG WOMEN EPI Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 43410 MEDSV DEF RBRVS 01/01/2024 971.00 Description: REPAIR ESOPHAGUS WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43410 MEDSV DEF RBRVS 09/01/2019 12/31/2023 754.20 Description: REPAIR ESOPHAGUS WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43415 MEDSV DEF RBRVS 01/01/2024 2323.67 Description: REPAIR ESOPHAGUS WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 542 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 43415 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1856.46 Description: REPAIR ESOPHAGUS WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43420 MEDSV DEF RBRVS 01/01/2024 957.03 Description: REPAIR ESOPHAGUS OPENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43420 MEDSV DEF RBRVS 09/01/2019 12/31/2023 748.68 Description: REPAIR ESOPHAGUS OPENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43425 MEDSV DEF RBRVS 01/01/2024 1300.62 Description: REPAIR ESOPHAGUS OPENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43425 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1034.54 Description: REPAIR ESOPHAGUS OPENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43450 MEDSV DEF RBRVS 01/01/2024 175.46 Description: DILATE ESOPHAGUS 1/MULT PASS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43450 MEDSV DEF RBRVS 09/01/2019 12/31/2023 151.03 Description: DILATE ESOPHAGUS 1/MULT PASS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43453 MEDSV DEF RBRVS 01/01/2024 751.31 Description: DILATE ESOPHAGUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43453 MEDSV DEF RBRVS 09/15/2017 12/31/2023 639.83 Description: DILATE ESOPHAGUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43460 MEDSV DEF RBRVS 01/01/2024 197.26 Description: PRESSURE TREATMENT ESOPHAGUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43460 MEDSV DEF RBRVS 09/01/2019 12/31/2023 161.45 Description: PRESSURE TREATMENT ESOPHAGUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43496 MEDSV DEF MAXFEE 01/01/2024 1014.88 0.0 Description: FREE JEJUNUM FLAP MICROVASC Category: Medical Services CMS Add: 01/01/1997 CMS Term: 43497 MEDSV DEF RBRVS 01/01/2022 12/31/2023 591.50 Description: TRANSORL LWR ESOPHGL MYOTOMY Category: Medical Services CMS Add: 01/01/2022 CMS Term: 43497 MEDSV DEF RBRVS 01/01/2024 737.22 Description: TRANSORL LWR ESOPHGL MYOTOMY Category: Medical Services CMS Add: 01/01/2022 CMS Term: 43499 MEDSV DEF BILL20 Description: UNLISTED PROCEDURE ESOPHAGUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43500 MEDSV DEF RBRVS 01/01/2024 717.71 Description: SURGICAL OPENING OF STOMACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 543 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 43500 MEDSV DEF RBRVS 09/01/2019 12/31/2023 561.31 Description: SURGICAL OPENING OF STOMACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43501 MEDSV DEF RBRVS 01/01/2024 1227.33 Description: SURGICAL REPAIR OF STOMACH Category: Medical Services CMS Add: 01/01/1987 CMS Term: 43501 MEDSV DEF RBRVS 09/01/2019 12/31/2023 960.40 Description: SURGICAL REPAIR OF STOMACH Category: Medical Services CMS Add: 01/01/1987 CMS Term: 43502 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1084.79 Description: SURGICAL REPAIR OF STOMACH Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43502 MEDSV DEF RBRVS 01/01/2024 1388.68 Description: SURGICAL REPAIR OF STOMACH Category: Medical Services CMS Add: 01/01/1995 CMS Term: 4350F NOCOV DEF SYSMAN Description: CNSLNG PROVIDED SYMP MNGMNT Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 43510 MEDSV DEF RBRVS 01/01/2024 867.79 Description: SURGICAL OPENING OF STOMACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43510 MEDSV DEF RBRVS 09/01/2019 12/31/2023 655.57 Description: SURGICAL OPENING OF STOMACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43520 MEDSV DEF RBRVS 01/01/2024 633.53 Description: INCISION OF PYLORIC MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43520 MEDSV DEF RBRVS 09/01/2019 12/31/2023 489.71 Description: INCISION OF PYLORIC MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43605 MEDSV DEF RBRVS 01/01/2024 761.17 Description: BIOPSY OF STOMACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43605 MEDSV DEF RBRVS 09/01/2019 12/31/2023 592.74 Description: BIOPSY OF STOMACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43610 MEDSV DEF RBRVS 01/01/2024 894.36 Description: EXCISION OF STOMACH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43610 MEDSV DEF RBRVS 09/01/2019 12/31/2023 699.30 Description: EXCISION OF STOMACH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43611 MEDSV DEF RBRVS 01/01/2024 1120.47 Description: EXCISION OF STOMACH LESION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 43611 MEDSV DEF RBRVS 09/01/2019 12/31/2023 870.86 Description: EXCISION OF STOMACH LESION Category: Medical Services CMS Add: 01/01/1994 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 544 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 43620 MEDSV DEF RBRVS 01/01/2024 1800.36 Description: REMOVAL OF STOMACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43620 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1400.63 Description: REMOVAL OF STOMACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43621 MEDSV DEF RBRVS 01/01/2024 2064.25 Description: REMOVAL OF STOMACH Category: Medical Services CMS Add: 01/01/1994 CMS Term: 43621 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1617.01 Description: REMOVAL OF STOMACH Category: Medical Services CMS Add: 01/01/1994 CMS Term: 43622 MEDSV DEF RBRVS 01/01/2024 2096.02 Description: REMOVAL OF STOMACH Category: Medical Services CMS Add: 01/01/1994 CMS Term: 43622 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1646.88 Description: REMOVAL OF STOMACH Category: Medical Services CMS Add: 01/01/1994 CMS Term: 43631 MEDSV DEF RBRVS 01/01/2024 1319.76 Description: REMOVAL OF STOMACH PARTIAL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 43631 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1033.68 Description: REMOVAL OF STOMACH PARTIAL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 43632 MEDSV DEF RBRVS 01/01/2024 1850.95 Description: REMOVAL OF STOMACH PARTIAL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 43632 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1448.11 Description: REMOVAL OF STOMACH PARTIAL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 43633 MEDSV DEF RBRVS 01/01/2024 1749.32 Description: REMOVAL OF STOMACH PARTIAL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 43633 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1368.52 Description: REMOVAL OF STOMACH PARTIAL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 43634 MEDSV DEF RBRVS 01/01/2024 1928.55 Description: REMOVAL OF STOMACH PARTIAL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 43634 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1513.84 Description: REMOVAL OF STOMACH PARTIAL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 43635 MEDSV DEF RBRVS 01/01/2024 101.79 Description: REMOVAL OF STOMACH PARTIAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43635 MEDSV DEF RBRVS 02/01/2015 12/31/2023 80.04 Description: REMOVAL OF STOMACH PARTIAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 545 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 43640 MEDSV DEF RBRVS 01/01/2024 1086.08 Description: VAGOTOMY & PYLORUS REPAIR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43640 MEDSV DEF RBRVS 09/01/2019 12/31/2023 841.56 Description: VAGOTOMY & PYLORUS REPAIR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43641 MEDSV DEF RBRVS 01/01/2024 1098.30 Description: VAGOTOMY & PYLORUS REPAIR Category: Medical Services CMS Add: 01/01/1987 CMS Term: 43641 MEDSV DEF RBRVS 09/01/2019 12/31/2023 854.63 Description: VAGOTOMY & PYLORUS REPAIR Category: Medical Services CMS Add: 01/01/1987 CMS Term: 43644 MEDSV DEF RBRVS 01/01/2024 1580.43 Y Description: LAP GASTRIC BYPASS/ROUX-EN-Y Category: Medical Services CMS Add: 01/01/2005 CMS Term: 43644 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1235.25 Y Description: LAP GASTRIC BYPASS/ROUX-EN-Y Category: Medical Services CMS Add: 01/01/2005 CMS Term: 43645 MEDSV DEF RBRVS 01/01/2024 1680.80 Y Description: LAP GASTR BYPASS INCL SMLL I Category: Medical Services CMS Add: 01/01/2005 CMS Term: 43645 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1320.06 Y Description: LAP GASTR BYPASS INCL SMLL I Category: Medical Services CMS Add: 01/01/2005 CMS Term: 43647 MEDSV DEF MAXFEE 01/01/2024 943.87 0.0 Description: LAP IMPL ELECTRODE ANTRUM Category: Medical Services CMS Add: 01/01/2007 CMS Term: 43648 MEDSV DEF MAXFEE 01/01/2024 943.87 0.0 Description: LAP REVISE/REMV ELTRD ANTRUM Category: Medical Services CMS Add: 01/01/2007 CMS Term: 43651 MEDSV DEF RBRVS 01/01/2024 601.03 0-1 Description: LAPAROSCOPY VAGUS NERVE Category: Medical Services CMS Add: 01/01/2000 CMS Term: 43651 MEDSV DEF RBRVS 02/01/2015 12/31/2023 464.90 0-1 Description: LAPAROSCOPY VAGUS NERVE Category: Medical Services CMS Add: 01/01/2000 CMS Term: 43652 MEDSV DEF RBRVS 01/01/2024 700.16 0-1 Description: LAPAROSCOPY VAGUS NERVE Category: Medical Services CMS Add: 01/01/2000 CMS Term: 43652 MEDSV DEF RBRVS 02/01/2015 12/31/2023 543.25 0-1 Description: LAPAROSCOPY VAGUS NERVE Category: Medical Services CMS Add: 01/01/2000 CMS Term: 43653 MEDSV DEF RBRVS 01/01/2024 530.46 0-1 Description: LAPAROSCOPY GASTROSTOMY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 43653 MEDSV DEF RBRVS 02/01/2015 12/31/2023 407.03 0-1 Description: LAPAROSCOPY GASTROSTOMY Category: Medical Services CMS Add: 01/01/2000 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 546 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 43659 MEDSV DEF BILL20 Y 0-1 Description: UNLISTED LAPS PX STOMACH Category: Medical Services CMS Add: 01/01/2000 CMS Term: 43752 MEDSV DEF RBRVS 01/01/2024 37.70 Description: NASAL/OROGASTRIC W/TUBE PLMT Category: Medical Services CMS Add: 01/01/2001 CMS Term: 43752 MEDSV DEF RBRVS 02/01/2015 12/31/2023 30.27 Description: NASAL/OROGASTRIC W/TUBE PLMT Category: Medical Services CMS Add: 01/01/2001 CMS Term: 43753 MEDSV DEF RBRVS 01/01/2024 19.93 Description: TX GASTRO INTUB W/ASP Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43753 MEDSV DEF RBRVS 02/01/2015 12/31/2023 15.56 Description: TX GASTRO INTUB W/ASP Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43754 MEDSV DEF RBRVS 01/01/2024 219.99 Description: DX GASTR INTUB W/ASP SPEC Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43754 MEDSV DEF RBRVS 02/01/2015 12/31/2023 64.03 Description: DX GASTR INTUB W/ASP SPEC Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43755 MEDSV DEF RBRVS 01/01/2024 189.52 Description: DX GASTR INTUB W/ASP SPECS Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43755 MEDSV DEF RBRVS 02/01/2015 12/31/2023 97.92 Description: DX GASTR INTUB W/ASP SPECS Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43756 MEDSV DEF RBRVS 01/01/2024 259.55 Description: DX DUOD INTUB W/ASP SPEC Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43756 MEDSV DEF RBRVS 02/01/2015 12/31/2023 149.33 Description: DX DUOD INTUB W/ASP SPEC Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43757 MEDSV DEF RBRVS 01/01/2024 348.59 Description: DX DUOD INTUB W/ASP SPECS Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43757 MEDSV DEF RBRVS 02/01/2015 12/31/2023 209.81 Description: DX DUOD INTUB W/ASP SPECS Category: Medical Services CMS Add: 01/01/2011 CMS Term: 43761 MEDSV DEF RBRVS 01/01/2024 115.42 Description: REPOSITION GASTROSTOMY TUBE Category: Medical Services CMS Add: 01/01/1992 CMS Term: 43761 MEDSV DEF RBRVS 09/01/2019 12/31/2023 85.79 Description: REPOSITION GASTROSTOMY TUBE Category: Medical Services CMS Add: 01/01/1992 CMS Term: 43762 MEDSV DEF RBRVS 01/01/2019 12/31/2023 156.97 Description: RPLC GTUBE NO REVJ TRC Category: Medical Services CMS Add: 01/01/2019 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 547 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 43762 MEDSV DEF RBRVS 01/01/2024 211.96 Description: RPLC GTUBE NO REVJ TRC Category: Medical Services CMS Add: 01/01/2019 CMS Term: 43763 MEDSV DEF RBRVS 01/01/2019 12/31/2023 233.41 Description: RPLC GTUBE REVJ GSTRST TRC Category: Medical Services CMS Add: 01/01/2019 CMS Term: 43763 MEDSV DEF RBRVS 01/01/2024 313.92 Description: RPLC GTUBE REVJ GSTRST TRC Category: Medical Services CMS Add: 01/01/2019 CMS Term: 43770 MEDSV DEF RBRVS 01/01/2024 1027.70 Y 18-999years Description: LAP PLACE GASTR ADJ DEVICE Category: Medical Services CMS Add: 01/01/2006 CMS Term: 43770 MEDSV DEF RBRVS 02/01/2015 12/31/2023 795.43 Y 18-999years Description: LAP PLACE GASTR ADJ DEVICE Category: Medical Services CMS Add: 01/01/2006 CMS Term: 43771 MEDSV DEF RBRVS 01/01/2024 1166.40 Y 18-999years Description: LAP REVISE GASTR ADJ DEVICE Category: Medical Services CMS Add: 01/01/2006 CMS Term: 43771 MEDSV DEF RBRVS 02/01/2015 12/31/2023 908.96 Y 18-999years Description: LAP REVISE GASTR ADJ DEVICE Category: Medical Services CMS Add: 01/01/2006 CMS Term: 43772 MEDSV DEF RBRVS 01/01/2024 866.27 Y 18-999years Description: LAP RMVL GASTR ADJ DEVICE Category: Medical Services CMS Add: 01/01/2006 CMS Term: 43772 MEDSV DEF RBRVS 02/01/2015 12/31/2023 679.47 Y 18-999years Description: LAP RMVL GASTR ADJ DEVICE Category: Medical Services CMS Add: 01/01/2006 CMS Term: 43773 MEDSV DEF RBRVS 01/01/2024 1166.40 Y 18-999years Description: LAP REPLACE GASTR ADJ DEVICE Category: Medical Services CMS Add: 01/01/2006 CMS Term: 43773 MEDSV DEF RBRVS 02/01/2015 12/31/2023 904.50 Y 18-999years Description: LAP REPLACE GASTR ADJ DEVICE Category: Medical Services CMS Add: 01/01/2006 CMS Term: 43774 MEDSV DEF RBRVS 01/01/2024 877.01 Y 18-999years Description: LAP RMVL GASTR ADJ ALL PARTS Category: Medical Services CMS Add: 01/01/2006 CMS Term: 43774 MEDSV DEF RBRVS 02/01/2015 12/31/2023 684.55 Y 18-999years Description: LAP RMVL GASTR ADJ ALL PARTS Category: Medical Services CMS Add: 01/01/2006 CMS Term: 43775 MEDSV DEF RBRVS 01/01/2024 1004.54 Y Description: LAP SLEEVE GASTRECTOMY Category: Medical Services CMS Add: 01/01/2010 CMS Term: 43775 MEDSV DEF RBRVS 02/01/2015 12/31/2023 905.52 Y Description: LAP SLEEVE GASTRECTOMY Category: Medical Services CMS Add: 01/01/2010 CMS Term: 43800 MEDSV DEF RBRVS 01/01/2024 848.13 Description: RECONSTRUCTION OF PYLORUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 548 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 43800 MEDSV DEF RBRVS 09/01/2019 12/31/2023 663.13 Description: RECONSTRUCTION OF PYLORUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43810 MEDSV DEF RBRVS 01/01/2024 926.74 Description: FUSION OF STOMACH AND BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43810 MEDSV DEF RBRVS 09/01/2019 12/31/2023 723.72 Description: FUSION OF STOMACH AND BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43820 MEDSV DEF RBRVS 01/01/2024 1226.59 Description: FUSION OF STOMACH AND BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43820 MEDSV DEF RBRVS 09/01/2019 12/31/2023 955.96 Description: FUSION OF STOMACH AND BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43825 MEDSV DEF RBRVS 01/01/2024 1194.80 Description: FUSION OF STOMACH AND BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43825 MEDSV DEF RBRVS 09/01/2019 12/31/2023 931.22 Description: FUSION OF STOMACH AND BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43830 MEDSV DEF RBRVS 01/01/2024 644.78 Description: PLACE GASTROSTOMY TUBE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43830 MEDSV DEF RBRVS 09/01/2019 12/31/2023 497.87 Description: PLACE GASTROSTOMY TUBE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43831 MEDSV DEF RBRVS 01/01/2024 560.00 0-28days Description: PLACE GASTROSTOMY TUBE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43831 MEDSV DEF RBRVS 09/01/2019 12/31/2023 421.91 0-28days Description: PLACE GASTROSTOMY TUBE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43832 MEDSV DEF RBRVS 01/01/2024 952.79 Description: PLACE GASTROSTOMY TUBE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43832 MEDSV DEF RBRVS 09/01/2019 12/31/2023 743.84 Description: PLACE GASTROSTOMY TUBE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43840 MEDSV DEF RBRVS 01/01/2024 1240.67 Description: REPAIR OF STOMACH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43840 MEDSV DEF RBRVS 09/01/2019 12/31/2023 968.47 Description: REPAIR OF STOMACH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43842 MEDSV DEF RBRVS 01/01/2024 1090.81 Y Description: V-BAND GASTROPLASTY Category: Medical Services CMS Add: 01/01/1993 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 549 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 43842 MEDSV DEF RBRVS 09/01/2019 12/31/2023 849.98 Y Description: V-BAND GASTROPLASTY Category: Medical Services CMS Add: 01/01/1993 CMS Term: 43843 MEDSV DEF RBRVS 01/01/2024 1170.35 Y Description: GASTROPLASTY W/O V-BAND Category: Medical Services CMS Add: 01/01/1993 CMS Term: 43843 MEDSV DEF RBRVS 09/01/2019 12/31/2023 910.50 Y Description: GASTROPLASTY W/O V-BAND Category: Medical Services CMS Add: 01/01/1993 CMS Term: 43845 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1396.36 Y Description: GASTROPLASTY DUODENAL SWITCH Category: Medical Services CMS Add: 01/01/2005 CMS Term: 43845 MEDSV DEF RBRVS 01/01/2024 1783.54 Y Description: GASTROPLASTY DUODENAL SWITCH Category: Medical Services CMS Add: 01/01/2005 CMS Term: 43846 MEDSV DEF RBRVS 01/01/2024 1504.51 Y Description: GASTRIC BYPASS FOR OBESITY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43846 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1149.17 Y Description: GASTRIC BYPASS FOR OBESITY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43847 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1282.35 Y Description: GASTRIC BYPASS INCL SMALL I Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43847 MEDSV DEF RBRVS 01/01/2024 1645.92 Y Description: GASTRIC BYPASS INCL SMALL I Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43848 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1372.83 Y Description: REVISION GASTROPLASTY Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43848 MEDSV DEF RBRVS 01/01/2024 1760.76 Y Description: REVISION GASTROPLASTY Category: Medical Services CMS Add: 01/01/1995 CMS Term: 43860 MEDSV DEF RBRVS 01/01/2024 1491.65 Description: REVISE STOMACH-BOWEL FUSION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43860 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1166.94 Description: REVISE STOMACH-BOWEL FUSION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43865 MEDSV DEF RBRVS 01/01/2024 1554.18 Description: REVISE STOMACH-BOWEL FUSION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43865 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1216.44 Description: REVISE STOMACH-BOWEL FUSION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43870 MEDSV DEF RBRVS 01/01/2024 651.38 Description: REPAIR STOMACH OPENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 550 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 43870 MEDSV DEF RBRVS 09/01/2019 12/31/2023 507.04 Description: REPAIR STOMACH OPENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43880 MEDSV DEF RBRVS 01/01/2024 1450.14 Description: REPAIR STOMACH-BOWEL FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43880 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1140.35 Description: REPAIR STOMACH-BOWEL FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 43881 MEDSV DEF MAXFEE 01/01/2024 839.03 0.0 Description: IMPL/REDO ELECTRD ANTRUM Category: Medical Services CMS Add: 01/01/2007 CMS Term: 43882 MEDSV DEF MAXFEE 01/01/2024 831.20 0.0 Description: REVISE/REMOVE ELECTRD ANTRUM Category: Medical Services CMS Add: 01/01/2007 CMS Term: 43886 MEDSV DEF RBRVS 01/01/2024 338.76 Description: REVISE GASTRIC PORT OPEN Category: Medical Services CMS Add: 01/01/2006 CMS Term: 43886 MEDSV DEF RBRVS 02/01/2015 12/31/2023 257.53 Description: REVISE GASTRIC PORT OPEN Category: Medical Services CMS Add: 01/01/2006 CMS Term: 43887 MEDSV DEF RBRVS 01/01/2024 305.48 Description: REMOVE GASTRIC PORT OPEN Category: Medical Services CMS Add: 01/01/2006 CMS Term: 43887 MEDSV DEF RBRVS 02/01/2015 12/31/2023 231.51 Description: REMOVE GASTRIC PORT OPEN Category: Medical Services CMS Add: 01/01/2006 CMS Term: 43888 MEDSV DEF RBRVS 01/01/2024 427.52 Description: CHANGE GASTRIC PORT OPEN Category: Medical Services CMS Add: 01/01/2006 CMS Term: 43888 MEDSV DEF RBRVS 02/01/2015 12/31/2023 326.70 Description: CHANGE GASTRIC PORT OPEN Category: Medical Services CMS Add: 01/01/2006 CMS Term: 43999 MEDSV DEF BILL20 Y Description: UNLISTED PROCEDURE STOMACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44005 MEDSV DEF RBRVS 01/01/2024 995.95 Description: FREEING OF BOWEL ADHESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44005 MEDSV DEF RBRVS 09/01/2019 12/31/2023 780.29 Description: FREEING OF BOWEL ADHESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4400F NOCOV DEF SYSMAN Description: REHAB THXPY OPTIONS W/PT Category: Non Covered Services CMS Add: 10/01/2010 CMS Term: 44010 MEDSV DEF RBRVS 01/01/2024 785.96 Description: INCISION OF SMALL BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 551 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 44010 MEDSV DEF RBRVS 09/01/2019 12/31/2023 621.95 Description: INCISION OF SMALL BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44015 MEDSV DEF RBRVS 01/01/2024 128.27 Description: INSERT NEEDLE CATH BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44015 MEDSV DEF RBRVS 02/01/2015 12/31/2023 102.10 Description: INSERT NEEDLE CATH BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44020 MEDSV DEF RBRVS 01/01/2024 888.86 Description: EXPLORE SMALL INTESTINE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 44020 MEDSV DEF RBRVS 09/01/2019 12/31/2023 692.86 Description: EXPLORE SMALL INTESTINE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 44021 MEDSV DEF RBRVS 01/01/2024 888.20 Description: DECOMPRESS SMALL BOWEL Category: Medical Services CMS Add: 01/01/1987 CMS Term: 44021 MEDSV DEF RBRVS 09/01/2019 12/31/2023 699.90 Description: DECOMPRESS SMALL BOWEL Category: Medical Services CMS Add: 01/01/1987 CMS Term: 44025 MEDSV DEF RBRVS 01/01/2024 896.45 Description: INCISION OF LARGE BOWEL Category: Medical Services CMS Add: 01/01/1985 CMS Term: 44025 MEDSV DEF RBRVS 09/01/2019 12/31/2023 706.60 Description: INCISION OF LARGE BOWEL Category: Medical Services CMS Add: 01/01/1985 CMS Term: 44050 MEDSV DEF RBRVS 01/01/2024 854.86 Description: REDUCE BOWEL OBSTRUCTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44050 MEDSV DEF RBRVS 09/01/2019 12/31/2023 667.11 Description: REDUCE BOWEL OBSTRUCTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44055 MEDSV DEF RBRVS 01/01/2024 1353.56 Description: CORRECT MALROTATION OF BOWEL Category: Medical Services CMS Add: 01/01/1987 CMS Term: 44055 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1067.24 Description: CORRECT MALROTATION OF BOWEL Category: Medical Services CMS Add: 01/01/1987 CMS Term: 44100 MEDSV DEF RBRVS 01/01/2024 99.29 Description: BIOPSY OF BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44100 MEDSV DEF RBRVS 09/01/2019 12/31/2023 81.75 Description: BIOPSY OF BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44110 MEDSV DEF RBRVS 01/01/2024 779.47 Description: EXCISE INTESTINE LESION(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 552 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 44110 MEDSV DEF RBRVS 09/01/2019 12/31/2023 608.52 Description: EXCISE INTESTINE LESION(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44111 MEDSV DEF RBRVS 01/01/2024 904.36 Description: EXCISION OF BOWEL LESION(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44111 MEDSV DEF RBRVS 09/01/2019 12/31/2023 704.06 Description: EXCISION OF BOWEL LESION(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44120 MEDSV DEF RBRVS 01/01/2024 1113.65 Description: REMOVAL OF SMALL INTESTINE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44120 MEDSV DEF RBRVS 09/01/2019 12/31/2023 873.51 Description: REMOVAL OF SMALL INTESTINE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44121 MEDSV DEF RBRVS 01/01/2019 12/31/2023 173.38 Description: REMOVAL OF SMALL INTESTINE Category: Medical Services CMS Add: 01/01/1995 CMS Term: 44121 MEDSV DEF RBRVS 01/01/2024 218.28 Description: REMOVAL OF SMALL INTESTINE Category: Medical Services CMS Add: 01/01/1995 CMS Term: 44125 MEDSV DEF RBRVS 01/01/2024 1074.52 Description: REMOVAL OF SMALL INTESTINE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44125 MEDSV DEF RBRVS 09/01/2019 12/31/2023 845.43 Description: REMOVAL OF SMALL INTESTINE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44126 MEDSV DEF RBRVS 01/01/2024 2241.48 Description: ENTERECTOMY W/O TAPER CONG Category: Medical Services CMS Add: 01/01/2002 CMS Term: 44126 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1755.94 Description: ENTERECTOMY W/O TAPER CONG Category: Medical Services CMS Add: 01/01/2002 CMS Term: 44127 MEDSV DEF RBRVS 01/01/2024 2587.20 Description: ENTERECTOMY W/TAPER CONG Category: Medical Services CMS Add: 01/01/2002 CMS Term: 44127 MEDSV DEF RBRVS 02/01/2015 12/31/2023 2030.62 Description: ENTERECTOMY W/TAPER CONG Category: Medical Services CMS Add: 01/01/2002 CMS Term: 44128 MEDSV DEF RBRVS 01/01/2024 219.12 Description: ENTERECTOMY CONG ADD-ON Category: Medical Services CMS Add: 01/01/2002 CMS Term: 44128 MEDSV DEF RBRVS 02/01/2015 12/31/2023 173.88 Description: ENTERECTOMY CONG ADD-ON Category: Medical Services CMS Add: 01/01/2002 CMS Term: 44130 MEDSV DEF RBRVS 01/01/2024 1201.05 Description: BOWEL TO BOWEL FUSION Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 553 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 44130 MEDSV DEF RBRVS 09/01/2019 12/31/2023 938.81 Description: BOWEL TO BOWEL FUSION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44132 MEDSV DEF BILL20 Y Description: ENTERECTOMY CADAVER DONOR Category: Medical Services CMS Add: 01/01/2001 CMS Term: 44133 MEDSV DEF BILL20 Y Description: ENTERECTOMY LIVE DONOR Category: Medical Services CMS Add: 01/01/2001 CMS Term: 44135 MEDSV DEF BILL20 Y Description: INTESTINE TRANSPLNT CADAVER Category: Medical Services CMS Add: 01/01/2001 CMS Term: 44136 MEDSV DEF BILL20 Y Description: INTESTINE TRANSPLANT LIVE Category: Medical Services CMS Add: 01/01/2001 CMS Term: 44137 MEDSV DEF MAXFEE 01/01/2024 1304.66 0.0 Y Description: REMOVE INTESTINAL ALLOGRAFT Category: Medical Services CMS Add: 01/01/2005 CMS Term: 44139 MEDSV DEF RBRVS 01/01/2019 12/31/2023 86.92 Y Description: MOBILIZATION OF COLON Category: Medical Services CMS Add: 01/01/1995 CMS Term: 44139 MEDSV DEF RBRVS 01/01/2024 109.39 Y Description: MOBILIZATION OF COLON Category: Medical Services CMS Add: 01/01/1995 CMS Term: 44140 MEDSV DEF RBRVS 01/01/2024 1224.62 Y Description: PARTIAL REMOVAL OF COLON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44140 MEDSV DEF RBRVS 09/01/2019 12/31/2023 958.47 Y Description: PARTIAL REMOVAL OF COLON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44141 MEDSV DEF RBRVS 01/01/2024 1653.91 Description: PARTIAL REMOVAL OF COLON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44141 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1305.27 Description: PARTIAL REMOVAL OF COLON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44143 MEDSV DEF RBRVS 01/01/2024 1508.43 Description: PARTIAL REMOVAL OF COLON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44143 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1190.10 Description: PARTIAL REMOVAL OF COLON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44144 MEDSV DEF RBRVS 01/01/2024 1610.04 Description: PARTIAL REMOVAL OF COLON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44144 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1266.87 Description: PARTIAL REMOVAL OF COLON Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 554 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 44145 MEDSV DEF RBRVS 01/01/2024 1510.24 Description: PARTIAL REMOVAL OF COLON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44145 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1191.17 Description: PARTIAL REMOVAL OF COLON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44146 MEDSV DEF RBRVS 01/01/2024 1919.35 Description: PARTIAL REMOVAL OF COLON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44146 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1521.68 Description: PARTIAL REMOVAL OF COLON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44147 MEDSV DEF RBRVS 01/01/2024 1760.78 Description: PARTIAL REMOVAL OF COLON Category: Medical Services CMS Add: 01/01/1987 CMS Term: 44147 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1394.94 Description: PARTIAL REMOVAL OF COLON Category: Medical Services CMS Add: 01/01/1987 CMS Term: 44150 MEDSV DEF RBRVS 01/01/2024 1695.12 Description: REMOVAL OF COLON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44150 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1340.76 Description: REMOVAL OF COLON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44151 MEDSV DEF RBRVS 01/01/2024 1954.27 Description: REMOVAL OF COLON/ILEOSTOMY Category: Medical Services CMS Add: 01/01/1987 CMS Term: 44151 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1533.69 Description: REMOVAL OF COLON/ILEOSTOMY Category: Medical Services CMS Add: 01/01/1987 CMS Term: 44155 MEDSV DEF RBRVS 01/01/2024 1894.26 Description: REMOVAL OF COLON/ILEOSTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44155 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1500.51 Description: REMOVAL OF COLON/ILEOSTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44156 MEDSV DEF RBRVS 01/01/2024 2089.88 Description: REMOVAL OF COLON/ILEOSTOMY Category: Medical Services CMS Add: 01/01/1987 CMS Term: 44156 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1646.36 Description: REMOVAL OF COLON/ILEOSTOMY Category: Medical Services CMS Add: 01/01/1987 CMS Term: 44157 MEDSV DEF RBRVS 01/01/2024 1985.46 Description: COLECTOMY W/ILEOANAL ANAST Category: Medical Services CMS Add: 01/01/2007 CMS Term: 44157 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1557.95 Description: COLECTOMY W/ILEOANAL ANAST Category: Medical Services CMS Add: 01/01/2007 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 555 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 44158 MEDSV DEF RBRVS 01/01/2024 2034.96 Description: COLECTOMY W/NEO-RECTUM POUCH Category: Medical Services CMS Add: 01/01/2007 CMS Term: 44158 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1605.95 Description: COLECTOMY W/NEO-RECTUM POUCH Category: Medical Services CMS Add: 01/01/2007 CMS Term: 44160 MEDSV DEF RBRVS 01/01/2024 1134.74 Description: REMOVAL OF COLON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44160 MEDSV DEF RBRVS 09/01/2019 12/31/2023 888.36 Description: REMOVAL OF COLON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44180 MEDSV DEF RBRVS 01/01/2024 839.85 Description: LAP ENTEROLYSIS Category: Medical Services CMS Add: 01/01/2006 CMS Term: 44180 MEDSV DEF RBRVS 02/01/2015 12/31/2023 656.02 Description: LAP ENTEROLYSIS Category: Medical Services CMS Add: 01/01/2006 CMS Term: 44186 MEDSV DEF RBRVS 01/01/2024 595.44 0-1 Description: LAP JEJUNOSTOMY Category: Medical Services CMS Add: 01/01/2006 CMS Term: 44186 MEDSV DEF RBRVS 02/01/2015 12/31/2023 464.27 0-1 Description: LAP JEJUNOSTOMY Category: Medical Services CMS Add: 01/01/2006 CMS Term: 44187 MEDSV DEF RBRVS 01/01/2024 1006.58 Description: LAP ILEO/JEJUNO-STOMY Category: Medical Services CMS Add: 01/01/2006 CMS Term: 44187 MEDSV DEF RBRVS 02/01/2015 12/31/2023 797.31 Description: LAP ILEO/JEJUNO-STOMY Category: Medical Services CMS Add: 01/01/2006 CMS Term: 44188 MEDSV DEF RBRVS 01/01/2024 1114.26 Description: LAP COLOSTOMY Category: Medical Services CMS Add: 01/01/2006 CMS Term: 44188 MEDSV DEF RBRVS 02/01/2015 12/31/2023 880.01 Description: LAP COLOSTOMY Category: Medical Services CMS Add: 01/01/2006 CMS Term: 44202 MEDSV DEF RBRVS 01/01/2024 1266.22 0-1 Description: LAP ENTERECTOMY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 44202 MEDSV DEF RBRVS 02/01/2015 12/31/2023 991.45 0-1 Description: LAP ENTERECTOMY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 44203 MEDSV DEF RBRVS 01/01/2024 218.77 Description: LAP RESECT S/INTESTINE ADDL Category: Medical Services CMS Add: 01/01/2002 CMS Term: 44203 MEDSV DEF RBRVS 02/01/2015 12/31/2023 173.38 Description: LAP RESECT S/INTESTINE ADDL Category: Medical Services CMS Add: 01/01/2002 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 556 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 44204 MEDSV DEF RBRVS 01/01/2024 1405.14 Description: LAPARO PARTIAL COLECTOMY Category: Medical Services CMS Add: 01/01/2002 CMS Term: 44204 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1106.30 Description: LAPARO PARTIAL COLECTOMY Category: Medical Services CMS Add: 01/01/2002 CMS Term: 44205 MEDSV DEF RBRVS 01/01/2024 1222.75 Description: LAP COLECTOMY PART W/ILEUM Category: Medical Services CMS Add: 01/01/2002 CMS Term: 44205 MEDSV DEF RBRVS 02/01/2015 12/31/2023 963.11 Description: LAP COLECTOMY PART W/ILEUM Category: Medical Services CMS Add: 01/01/2002 CMS Term: 44206 MEDSV DEF RBRVS 01/01/2024 1591.45 Description: LAP PART COLECTOMY W/STOMA Category: Medical Services CMS Add: 01/01/2003 CMS Term: 44206 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1260.35 Description: LAP PART COLECTOMY W/STOMA Category: Medical Services CMS Add: 01/01/2003 CMS Term: 44207 MEDSV DEF RBRVS 01/01/2024 1660.46 Description: L COLECTOMY/COLOPROCTOSTOMY Category: Medical Services CMS Add: 01/01/2003 CMS Term: 44207 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1317.16 Description: L COLECTOMY/COLOPROCTOSTOMY Category: Medical Services CMS Add: 01/01/2003 CMS Term: 44208 MEDSV DEF RBRVS 01/01/2024 1807.88 Description: L COLECTOMY/COLOPROCTOSTOMY Category: Medical Services CMS Add: 01/01/2003 CMS Term: 44208 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1434.71 Description: L COLECTOMY/COLOPROCTOSTOMY Category: Medical Services CMS Add: 01/01/2003 CMS Term: 44210 MEDSV DEF RBRVS 01/01/2024 1630.34 Description: LAPARO TOTAL PROCTOCOLECTOMY Category: Medical Services CMS Add: 01/01/2003 CMS Term: 44210 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1296.64 Description: LAPARO TOTAL PROCTOCOLECTOMY Category: Medical Services CMS Add: 01/01/2003 CMS Term: 44211 MEDSV DEF RBRVS 01/01/2024 1968.43 Description: LAP COLECTOMY W/PROCTECTOMY Category: Medical Services CMS Add: 01/01/2003 CMS Term: 44211 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1608.57 Description: LAP COLECTOMY W/PROCTECTOMY Category: Medical Services CMS Add: 01/01/2003 CMS Term: 44212 MEDSV DEF RBRVS 01/01/2024 1868.63 Description: LAPARO TOTAL PROCTOCOLECTOMY Category: Medical Services CMS Add: 01/01/2003 CMS Term: 44212 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1495.15 Description: LAPARO TOTAL PROCTOCOLECTOMY Category: Medical Services CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 557 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 44213 MEDSV DEF RBRVS 01/01/2024 169.84 Description: LAP MOBIL SPLENIC FL ADD-ON Category: Medical Services CMS Add: 01/01/2006 CMS Term: 44213 MEDSV DEF RBRVS 02/01/2015 12/31/2023 136.32 Description: LAP MOBIL SPLENIC FL ADD-ON Category: Medical Services CMS Add: 01/01/2006 CMS Term: 44227 MEDSV DEF RBRVS 01/01/2024 1515.08 Description: LAP CLOSE ENTEROSTOMY Category: Medical Services CMS Add: 01/01/2006 CMS Term: 44227 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1196.54 Description: LAP CLOSE ENTEROSTOMY Category: Medical Services CMS Add: 01/01/2006 CMS Term: 44238 MEDSV DEF BILL20 Description: UNLISTED LAPS PX INTESTINE Category: Medical Services CMS Add: 01/01/2003 CMS Term: 44300 MEDSV DEF RBRVS 01/01/2024 768.67 Description: OPEN BOWEL TO SKIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44300 MEDSV DEF RBRVS 09/01/2019 12/31/2023 600.65 Description: OPEN BOWEL TO SKIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44310 MEDSV DEF RBRVS 01/01/2024 953.55 Description: ILEOSTOMY/JEJUNOSTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44310 MEDSV DEF RBRVS 09/01/2019 12/31/2023 749.73 Description: ILEOSTOMY/JEJUNOSTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44312 MEDSV DEF RBRVS 01/01/2024 550.04 Description: REVISION OF ILEOSTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44312 MEDSV DEF RBRVS 09/01/2019 12/31/2023 423.39 Description: REVISION OF ILEOSTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44314 MEDSV DEF RBRVS 01/01/2024 925.84 Description: REVISION OF ILEOSTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44314 MEDSV DEF RBRVS 09/01/2019 12/31/2023 724.58 Description: REVISION OF ILEOSTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44316 MEDSV DEF RBRVS 01/01/2024 1287.99 Description: DEVISE BOWEL POUCH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44316 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1006.24 Description: DEVISE BOWEL POUCH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44320 MEDSV DEF RBRVS 01/01/2024 1098.20 Description: COLOSTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 558 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 44320 MEDSV DEF RBRVS 09/01/2019 12/31/2023 861.03 Description: COLOSTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44322 MEDSV DEF RBRVS 01/01/2024 920.51 Description: COLOSTOMY WITH BIOPSIES Category: Medical Services CMS Add: 01/01/1987 CMS Term: 44322 MEDSV DEF RBRVS 09/01/2019 12/31/2023 710.23 Description: COLOSTOMY WITH BIOPSIES Category: Medical Services CMS Add: 01/01/1987 CMS Term: 44340 MEDSV DEF RBRVS 01/01/2024 578.21 Description: REVISION OF COLOSTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44340 MEDSV DEF RBRVS 09/01/2019 12/31/2023 446.28 Description: REVISION OF COLOSTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44345 MEDSV DEF RBRVS 01/01/2024 964.75 Description: REVISION OF COLOSTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44345 MEDSV DEF RBRVS 09/01/2019 12/31/2023 755.07 Description: REVISION OF COLOSTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44346 MEDSV DEF RBRVS 01/01/2024 1084.13 Description: REVISION OF COLOSTOMY Category: Medical Services CMS Add: 01/01/1987 CMS Term: 44346 MEDSV DEF RBRVS 09/01/2019 12/31/2023 849.05 Description: REVISION OF COLOSTOMY Category: Medical Services CMS Add: 01/01/1987 CMS Term: 44360 MEDSV DEF RBRVS 01/01/2024 133.19 Description: SMALL BOWEL ENDOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44360 MEDSV DEF RBRVS 09/15/2017 12/31/2023 107.36 Description: SMALL BOWEL ENDOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44361 MEDSV DEF RBRVS 01/01/2024 147.02 Description: SMALL BOWEL ENDOSCOPY/BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44361 MEDSV DEF RBRVS 09/15/2017 12/31/2023 118.60 Description: SMALL BOWEL ENDOSCOPY/BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44363 MEDSV DEF RBRVS 01/01/2024 177.81 Description: SMALL BOWEL ENDOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44363 MEDSV DEF RBRVS 09/15/2017 12/31/2023 143.02 Description: SMALL BOWEL ENDOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44364 MEDSV DEF RBRVS 01/01/2024 189.66 Description: SMALL BOWEL ENDOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 559 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 44364 MEDSV DEF RBRVS 09/15/2017 12/31/2023 152.69 Description: SMALL BOWEL ENDOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44365 MEDSV DEF RBRVS 01/01/2024 168.76 Description: SMALL BOWEL ENDOSCOPY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 44365 MEDSV DEF RBRVS 09/15/2017 12/31/2023 135.05 Description: SMALL BOWEL ENDOSCOPY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 44366 MEDSV DEF RBRVS 01/01/2024 222.75 Description: SMALL BOWEL ENDOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44366 MEDSV DEF RBRVS 09/15/2017 12/31/2023 179.44 Description: SMALL BOWEL ENDOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44369 MEDSV DEF RBRVS 01/01/2024 227.88 Description: SMALL BOWEL ENDOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44369 MEDSV DEF RBRVS 09/15/2017 12/31/2023 183.97 Description: SMALL BOWEL ENDOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44370 MEDSV DEF RBRVS 01/01/2024 247.43 Description: SMALL BOWEL ENDOSCOPY/STENT Category: Medical Services CMS Add: 01/01/2001 CMS Term: 44370 MEDSV DEF RBRVS 09/15/2017 12/31/2023 198.76 Description: SMALL BOWEL ENDOSCOPY/STENT Category: Medical Services CMS Add: 01/01/2001 CMS Term: 44372 MEDSV DEF RBRVS 01/01/2024 221.41 Description: SMALL BOWEL ENDOSCOPY Category: Medical Services CMS Add: 01/01/1989 CMS Term: 44372 MEDSV DEF RBRVS 09/15/2017 12/31/2023 179.11 Description: SMALL BOWEL ENDOSCOPY Category: Medical Services CMS Add: 01/01/1989 CMS Term: 44373 MEDSV DEF RBRVS 01/01/2024 177.22 Description: SMALL BOWEL ENDOSCOPY Category: Medical Services CMS Add: 01/01/1989 CMS Term: 44373 MEDSV DEF RBRVS 09/15/2017 12/31/2023 143.02 Description: SMALL BOWEL ENDOSCOPY Category: Medical Services CMS Add: 01/01/1989 CMS Term: 44376 MEDSV DEF RBRVS 01/01/2024 263.81 Description: SMALL BOWEL ENDOSCOPY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 44376 MEDSV DEF RBRVS 09/15/2017 12/31/2023 212.27 Description: SMALL BOWEL ENDOSCOPY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 44377 MEDSV DEF RBRVS 01/01/2024 277.48 Description: SMALL BOWEL ENDOSCOPY/BIOPSY Category: Medical Services CMS Add: 01/01/1994 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 560 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 44377 MEDSV DEF RBRVS 09/15/2017 12/31/2023 223.74 Description: SMALL BOWEL ENDOSCOPY/BIOPSY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 44378 MEDSV DEF RBRVS 01/01/2024 356.65 Description: SMALL BOWEL ENDOSCOPY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 44378 MEDSV DEF RBRVS 09/15/2017 12/31/2023 287.87 Description: SMALL BOWEL ENDOSCOPY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 44379 MEDSV DEF RBRVS 01/01/2024 379.17 Description: S BOWEL ENDOSCOPE W/STENT Category: Medical Services CMS Add: 01/01/2001 CMS Term: 44379 MEDSV DEF RBRVS 09/15/2017 12/31/2023 306.33 Description: S BOWEL ENDOSCOPE W/STENT Category: Medical Services CMS Add: 01/01/2001 CMS Term: 44380 MEDSV DEF RBRVS 01/01/2024 182.83 Description: SMALL BOWEL ENDOSCOPY BR/WA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44380 MEDSV DEF RBRVS 09/15/2017 12/31/2023 119.08 Description: SMALL BOWEL ENDOSCOPY BR/WA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44381 MEDSV DEF RBRVS 01/01/2024 921.94 Description: SMALL BOWEL ENDOSCOPY BR/WA Category: Medical Services CMS Add: 01/01/2015 CMS Term: 44381 MEDSV DEF RBRVS 09/15/2017 12/31/2023 658.51 Description: SMALL BOWEL ENDOSCOPY BR/WA Category: Medical Services CMS Add: 01/01/2015 CMS Term: 44382 MEDSV DEF RBRVS 01/01/2024 279.48 Description: SMALL BOWEL ENDOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44382 MEDSV DEF RBRVS 09/15/2017 12/31/2023 185.27 Description: SMALL BOWEL ENDOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44384 MEDSV DEF RBRVS 01/01/2024 143.74 Description: SMALL BOWEL ENDOSCOPY Category: Medical Services CMS Add: 01/01/2015 CMS Term: 44384 MEDSV DEF RBRVS 09/15/2017 12/31/2023 114.23 Description: SMALL BOWEL ENDOSCOPY Category: Medical Services CMS Add: 01/01/2015 CMS Term: 44385 MEDSV DEF RBRVS 01/01/2024 201.62 Description: ENDOSCOPY OF BOWEL POUCH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44385 MEDSV DEF RBRVS 09/15/2017 12/31/2023 135.37 Description: ENDOSCOPY OF BOWEL POUCH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44386 MEDSV DEF RBRVS 01/01/2024 291.29 Description: ENDOSCOPY BOWEL POUCH/BIOP Category: Medical Services CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 561 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 44386 MEDSV DEF RBRVS 09/15/2017 12/31/2023 202.06 Description: ENDOSCOPY BOWEL POUCH/BIOP Category: Medical Services CMS Add: 01/01/1985 CMS Term: 44388 53 MEDSV DEF RBRVS 01/01/2023 147.64 Description: COLONOSCOPY THRU STOMA SPX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44388 MEDSV DEF RBRVS 01/01/2024 295.11 Description: COLONOSCOPY THRU STOMA SPX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44388 MEDSV DEF RBRVS 09/15/2017 12/31/2023 205.53 Description: COLONOSCOPY THRU STOMA SPX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44389 MEDSV DEF RBRVS 01/01/2024 385.85 Description: COLONOSCOPY WITH BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44389 MEDSV DEF RBRVS 09/15/2017 12/31/2023 269.24 Description: COLONOSCOPY WITH BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44390 MEDSV DEF RBRVS 01/01/2024 379.56 Description: COLONOSCOPY FOR FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44390 MEDSV DEF RBRVS 09/15/2017 12/31/2023 267.69 Description: COLONOSCOPY FOR FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44391 MEDSV DEF RBRVS 01/01/2024 599.78 Description: COLONOSCOPY FOR BLEEDING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44391 MEDSV DEF RBRVS 09/15/2017 12/31/2023 491.10 Description: COLONOSCOPY FOR BLEEDING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44392 MEDSV DEF RBRVS 01/01/2024 361.71 Description: COLONOSCOPY & POLYPECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44392 MEDSV DEF RBRVS 09/15/2017 12/31/2023 249.75 Description: COLONOSCOPY & POLYPECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44394 MEDSV DEF RBRVS 01/01/2024 410.75 Description: COLONOSCOPY W/SNARE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 44394 MEDSV DEF RBRVS 09/15/2017 12/31/2023 288.29 Description: COLONOSCOPY W/SNARE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 44401 MEDSV DEF RBRVS 01/01/2024 2223.04 Description: COLONOSCOPY WITH ABLATION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 44401 MEDSV DEF RBRVS 09/15/2017 12/31/2023 2235.56 Description: COLONOSCOPY WITH ABLATION Category: Medical Services CMS Add: 01/01/2015 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 562 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 44402 MEDSV DEF RBRVS 01/01/2024 242.83 Description: COLONOSCOPY W/STENT PLCMT Category: Medical Services CMS Add: 01/01/2015 CMS Term: 44402 MEDSV DEF RBRVS 09/15/2017 12/31/2023 194.15 Description: COLONOSCOPY W/STENT PLCMT Category: Medical Services CMS Add: 01/01/2015 CMS Term: 44403 MEDSV DEF RBRVS 01/01/2024 282.36 Description: COLONOSCOPY W/RESECTION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 44403 MEDSV DEF RBRVS 09/15/2017 12/31/2023 226.47 Description: COLONOSCOPY W/RESECTION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 44404 MEDSV DEF RBRVS 01/01/2024 394.81 Description: COLONOSCOPY W/INJECTION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 44404 MEDSV DEF RBRVS 09/15/2017 12/31/2023 256.36 Description: COLONOSCOPY W/INJECTION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 44405 MEDSV DEF RBRVS 01/01/2024 520.75 Description: COLONOSCOPY W/DILATION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 44405 MEDSV DEF RBRVS 09/15/2017 12/31/2023 382.14 Description: COLONOSCOPY W/DILATION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 44406 MEDSV DEF RBRVS 01/01/2024 212.88 Description: COLONOSCOPY W/ULTRASOUND Category: Medical Services CMS Add: 01/01/2015 CMS Term: 44406 MEDSV DEF RBRVS 09/15/2017 12/31/2023 171.18 Description: COLONOSCOPY W/ULTRASOUND Category: Medical Services CMS Add: 01/01/2015 CMS Term: 44407 MEDSV DEF RBRVS 01/01/2024 255.52 Description: COLONOSCOPY W/NDL ASPIR/BX Category: Medical Services CMS Add: 01/01/2015 CMS Term: 44407 MEDSV DEF RBRVS 09/15/2017 12/31/2023 205.27 Description: COLONOSCOPY W/NDL ASPIR/BX Category: Medical Services CMS Add: 01/01/2015 CMS Term: 44408 MEDSV DEF RBRVS 01/01/2024 214.85 Description: COLONOSCOPY W/DECOMPRESSION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 44408 MEDSV DEF RBRVS 09/15/2017 12/31/2023 172.75 Description: COLONOSCOPY W/DECOMPRESSION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 44500 MEDSV DEF RBRVS 01/01/2024 18.18 Description: INTRO GASTROINTESTINAL TUBE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 44500 MEDSV DEF RBRVS 09/15/2017 12/31/2023 14.44 Description: INTRO GASTROINTESTINAL TUBE Category: Medical Services CMS Add: 01/01/1994 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 563 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 4450F NOCOV DEF SYSMAN Description: SELF-CARE ED PROVIDED TO PT Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 44602 MEDSV DEF RBRVS 01/01/2024 1281.29 Description: SUTURE SMALL INTESTINE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 44602 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1009.35 Description: SUTURE SMALL INTESTINE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 44603 MEDSV DEF RBRVS 01/01/2024 1475.68 Description: SUTURE SMALL INTESTINE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 44603 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1157.51 Description: SUTURE SMALL INTESTINE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 44604 MEDSV DEF RBRVS 01/01/2024 963.42 Description: SUTURE LARGE INTESTINE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 44604 MEDSV DEF RBRVS 09/01/2019 12/31/2023 755.80 Description: SUTURE LARGE INTESTINE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 44605 MEDSV DEF RBRVS 01/01/2024 1184.47 Description: REPAIR OF BOWEL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44605 MEDSV DEF RBRVS 09/01/2019 12/31/2023 934.29 Description: REPAIR OF BOWEL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44615 MEDSV DEF RBRVS 01/01/2024 977.73 Description: INTESTINAL STRICTUROPLASTY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 44615 MEDSV DEF RBRVS 09/01/2019 12/31/2023 770.09 Description: INTESTINAL STRICTUROPLASTY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 44620 MEDSV DEF RBRVS 01/01/2024 794.00 Description: REPAIR BOWEL OPENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44620 MEDSV DEF RBRVS 09/01/2019 12/31/2023 623.21 Description: REPAIR BOWEL OPENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44625 MEDSV DEF RBRVS 01/01/2024 928.94 Description: REPAIR BOWEL OPENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44625 MEDSV DEF RBRVS 09/01/2019 12/31/2023 733.81 Description: REPAIR BOWEL OPENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44626 MEDSV DEF RBRVS 01/01/2024 1453.93 Description: REPAIR BOWEL OPENING Category: Medical Services CMS Add: 01/01/1998 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 564 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 44626 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1150.28 Description: REPAIR BOWEL OPENING Category: Medical Services CMS Add: 01/01/1998 CMS Term: 44640 MEDSV DEF RBRVS 01/01/2024 1274.45 Description: REPAIR BOWEL-SKIN FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44640 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1005.94 Description: REPAIR BOWEL-SKIN FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44650 MEDSV DEF RBRVS 01/01/2024 1316.47 Description: REPAIR BOWEL FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44650 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1040.24 Description: REPAIR BOWEL FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44660 MEDSV DEF RBRVS 01/01/2024 1231.07 Description: REPAIR BOWEL-BLADDER FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44660 MEDSV DEF RBRVS 09/01/2019 12/31/2023 963.79 Description: REPAIR BOWEL-BLADDER FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44661 MEDSV DEF RBRVS 01/01/2024 1414.12 Description: REPAIR BOWEL-BLADDER FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44661 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1117.91 Description: REPAIR BOWEL-BLADDER FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44680 MEDSV DEF RBRVS 01/01/2024 980.97 Description: SURGICAL REVISION INTESTINE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44680 MEDSV DEF RBRVS 09/01/2019 12/31/2023 763.39 Description: SURGICAL REVISION INTESTINE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44700 MEDSV DEF RBRVS 01/01/2024 923.70 Description: SUSPEND BOWEL W/PROSTHESIS Category: Medical Services CMS Add: 01/01/1998 CMS Term: 44700 MEDSV DEF RBRVS 02/01/2015 12/31/2023 737.44 Description: SUSPEND BOWEL W/PROSTHESIS Category: Medical Services CMS Add: 01/01/1998 CMS Term: 44701 MEDSV DEF RBRVS 01/01/2024 152.80 Description: INTRAOP COLON LAVAGE ADD-ON Category: Medical Services CMS Add: 01/01/2003 CMS Term: 44701 MEDSV DEF RBRVS 02/01/2015 12/31/2023 120.53 Description: INTRAOP COLON LAVAGE ADD-ON Category: Medical Services CMS Add: 01/01/2003 CMS Term: 44705 MEDSV DEF RBRVS 01/01/2024 105.19 Y Description: PREPARE FECAL MICROBIOTA Category: Medical Services CMS Add: 01/01/2013 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 565 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 44705 MEDSV DEF RBRVS 06/26/2020 12/31/2023 80.35 Y Description: PREPARE FECAL MICROBIOTA Category: Medical Services CMS Add: 01/01/2013 CMS Term: 4470F NOCOV DEF SYSMAN Description: ICD COUNSELING PROVIDED Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 44715 MEDSV DEF BILL20 Y Description: PREPARE DONOR INTESTINE Category: Medical Services CMS Add: 01/01/2005 CMS Term: 44720 MEDSV DEF RBRVS 01/01/2024 246.83 Y Description: PREP DONOR INTESTINE/VENOUS Category: Medical Services CMS Add: 01/01/2005 CMS Term: 44720 MEDSV DEF RBRVS 02/01/2015 12/31/2023 187.10 Y Description: PREP DONOR INTESTINE/VENOUS Category: Medical Services CMS Add: 01/01/2005 CMS Term: 44721 MEDSV DEF RBRVS 01/01/2024 345.17 Y Description: PREP DONOR INTESTINE/ARTERY Category: Medical Services CMS Add: 01/01/2005 CMS Term: 44721 MEDSV DEF RBRVS 02/01/2015 12/31/2023 278.09 Y Description: PREP DONOR INTESTINE/ARTERY Category: Medical Services CMS Add: 01/01/2005 CMS Term: 44799 MEDSV DEF BILL20 Y Y Description: UNLISTED PX SMALL INTESTINE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44800 MEDSV DEF RBRVS 01/01/2024 710.73 Description: EXCISION OF BOWEL POUCH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44800 MEDSV DEF RBRVS 09/01/2019 12/31/2023 544.57 Description: EXCISION OF BOWEL POUCH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4480F NOCOV DEF SYSMAN Description: PT RCVNG ACE/ARB B-BLOCKERTX Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 4481F NOCOV DEF SYSMAN Description: PT RCVNG ACE/ARB BLKER <3MOS Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 44820 MEDSV DEF RBRVS 01/01/2024 777.18 Description: EXCISION OF MESENTERY LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44820 MEDSV DEF RBRVS 09/01/2019 12/31/2023 600.69 Description: EXCISION OF MESENTERY LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44850 MEDSV DEF RBRVS 01/01/2024 683.90 Description: REPAIR OF MESENTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44850 MEDSV DEF RBRVS 09/01/2019 12/31/2023 535.11 Description: REPAIR OF MESENTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 566 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 44899 MEDSV DEF BILL20 Description: UNLISTED PX MECKEL'S DVRTCLM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44900 MEDSV DEF RBRVS 01/01/2024 716.86 Description: DRAIN APPENDIX ABSCESS OPEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44900 MEDSV DEF RBRVS 09/01/2019 12/31/2023 552.02 Description: DRAIN APPENDIX ABSCESS OPEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44950 MEDSV DEF RBRVS 01/01/2024 587.33 Description: APPENDECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44950 MEDSV DEF RBRVS 09/01/2019 12/31/2023 457.22 Description: APPENDECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44955 MEDSV DEF RBRVS 01/01/2024 76.15 Description: APPENDECTOMY ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44955 MEDSV DEF RBRVS 02/01/2015 12/31/2023 60.18 Description: APPENDECTOMY ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44960 MEDSV DEF RBRVS 01/01/2024 801.02 Description: APPENDECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44960 MEDSV DEF RBRVS 09/01/2019 12/31/2023 622.62 Description: APPENDECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 44970 MEDSV DEF RBRVS 01/01/2024 552.20 Description: LAPAROSCOPY APPENDECTOMY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 44970 MEDSV DEF RBRVS 02/01/2015 12/31/2023 426.90 Description: LAPAROSCOPY APPENDECTOMY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 44979 MEDSV DEF BILL20 0-1 Description: UNLISTED LAPS PX APPENDIX Category: Medical Services CMS Add: 01/01/2000 CMS Term: 45000 MEDSV DEF RBRVS 01/01/2024 397.95 Description: DRAINAGE OF PELVIC ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45000 MEDSV DEF RBRVS 09/01/2019 12/31/2023 306.09 Description: DRAINAGE OF PELVIC ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45005 MEDSV DEF RBRVS 01/01/2024 294.30 Description: DRAINAGE OF RECTAL ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45005 MEDSV DEF RBRVS 09/01/2019 12/31/2023 188.29 Description: DRAINAGE OF RECTAL ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 567 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 4500F NOCOV DEF SYSMAN Description: REF TO OUTPT CARD REHAB PROG Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 45020 MEDSV DEF RBRVS 01/01/2024 533.05 Description: DRAINAGE OF RECTAL ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45020 MEDSV DEF RBRVS 09/01/2019 12/31/2023 407.94 Description: DRAINAGE OF RECTAL ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45100 MEDSV DEF RBRVS 01/01/2024 281.56 Description: BIOPSY OF RECTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45100 MEDSV DEF RBRVS 09/01/2019 12/31/2023 215.07 Description: BIOPSY OF RECTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45108 MEDSV DEF RBRVS 01/01/2024 343.52 Description: REMOVAL OF ANORECTAL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45108 MEDSV DEF RBRVS 09/01/2019 12/31/2023 261.51 Description: REMOVAL OF ANORECTAL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4510F NOCOV DEF SYSMAN Description: PREV CARDREHAB QUALCARDEVENT Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 45110 MEDSV DEF RBRVS 01/01/2024 1678.88 Description: REMOVAL OF RECTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45110 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1335.29 Description: REMOVAL OF RECTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45111 MEDSV DEF RBRVS 01/01/2024 998.79 Description: PARTIAL REMOVAL OF RECTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45111 MEDSV DEF RBRVS 09/01/2019 12/31/2023 783.15 Description: PARTIAL REMOVAL OF RECTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45112 MEDSV DEF RBRVS 01/01/2024 1691.14 Description: REMOVAL OF RECTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45112 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1363.98 Description: REMOVAL OF RECTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45113 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1431.20 Description: PARTIAL PROCTECTOMY Category: Medical Services CMS Add: 01/01/1995 CMS Term: 45113 MEDSV DEF RBRVS 01/01/2024 1739.11 Description: PARTIAL PROCTECTOMY Category: Medical Services CMS Add: 01/01/1995 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 568 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 45114 MEDSV DEF RBRVS 01/01/2024 1650.95 Description: PARTIAL REMOVAL OF RECTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45114 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1293.41 Description: PARTIAL REMOVAL OF RECTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45116 MEDSV DEF RBRVS 01/01/2024 1440.34 Description: PARTIAL REMOVAL OF RECTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45116 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1142.04 Description: PARTIAL REMOVAL OF RECTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45119 MEDSV DEF RBRVS 01/01/2024 1751.65 Description: REMOVE RECTUM W/RESERVOIR Category: Medical Services CMS Add: 01/01/1998 CMS Term: 45119 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1415.30 Description: REMOVE RECTUM W/RESERVOIR Category: Medical Services CMS Add: 01/01/1998 CMS Term: 45120 MEDSV DEF RBRVS 01/01/2024 1456.84 Description: REMOVAL OF RECTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45120 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1137.06 Description: REMOVAL OF RECTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45121 MEDSV DEF RBRVS 01/01/2024 1589.31 Description: REMOVAL OF RECTUM AND COLON Category: Medical Services CMS Add: 01/01/1988 CMS Term: 45121 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1236.32 Description: REMOVAL OF RECTUM AND COLON Category: Medical Services CMS Add: 01/01/1988 CMS Term: 45123 MEDSV DEF RBRVS 01/01/2019 12/31/2023 812.17 Description: PARTIAL PROCTECTOMY Category: Medical Services CMS Add: 01/01/1995 CMS Term: 45123 MEDSV DEF RBRVS 01/01/2024 1032.30 Description: PARTIAL PROCTECTOMY Category: Medical Services CMS Add: 01/01/1995 CMS Term: 45126 MEDSV DEF RBRVS 01/01/2024 2528.80 Y Y Description: PELVIC EXENTERATION Category: Medical Services CMS Add: 01/01/1999 CMS Term: 45126 MEDSV DEF RBRVS 02/01/2015 12/31/2023 2060.01 Y Y Description: PELVIC EXENTERATION Category: Medical Services CMS Add: 01/01/1999 CMS Term: 45130 MEDSV DEF RBRVS 01/01/2024 1004.50 Description: EXCISION OF RECTAL PROLAPSE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45130 MEDSV DEF RBRVS 09/01/2019 12/31/2023 793.17 Description: EXCISION OF RECTAL PROLAPSE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 569 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 45135 MEDSV DEF RBRVS 01/01/2024 1210.39 Description: EXCISION OF RECTAL PROLAPSE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45135 MEDSV DEF RBRVS 09/01/2019 12/31/2023 978.88 Description: EXCISION OF RECTAL PROLAPSE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45136 MEDSV DEF RBRVS 01/01/2024 1664.05 Description: EXCISE ILEOANAL RESERVIOR Category: Medical Services CMS Add: 01/01/2002 CMS Term: 45136 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1331.03 Description: EXCISE ILEOANAL RESERVIOR Category: Medical Services CMS Add: 01/01/2002 CMS Term: 45150 MEDSV DEF RBRVS 01/01/2024 389.08 Description: EXCISION OF RECTAL STRICTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45150 MEDSV DEF RBRVS 09/01/2019 12/31/2023 285.91 Description: EXCISION OF RECTAL STRICTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45160 MEDSV DEF RBRVS 01/01/2024 936.88 Description: EXCISION OF RECTAL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45160 MEDSV DEF RBRVS 09/01/2019 12/31/2023 726.61 Description: EXCISION OF RECTAL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45171 MEDSV DEF RBRVS 01/01/2024 573.65 Description: EXC RECT TUM TRANSANAL PART Category: Medical Services CMS Add: 01/01/2010 CMS Term: 45171 MEDSV DEF RBRVS 02/01/2015 12/31/2023 430.49 Description: EXC RECT TUM TRANSANAL PART Category: Medical Services CMS Add: 01/01/2010 CMS Term: 45172 MEDSV DEF RBRVS 01/01/2024 765.90 Description: EXC RECT TUM TRANSANAL FULL Category: Medical Services CMS Add: 01/01/2010 CMS Term: 45172 MEDSV DEF RBRVS 02/01/2015 12/31/2023 585.27 Description: EXC RECT TUM TRANSANAL FULL Category: Medical Services CMS Add: 01/01/2010 CMS Term: 45190 MEDSV DEF RBRVS 01/01/2019 12/31/2023 500.35 Description: DESTRUCTION RECTAL TUMOR Category: Medical Services CMS Add: 01/01/1995 CMS Term: 45190 MEDSV DEF RBRVS 01/01/2024 651.73 Description: DESTRUCTION RECTAL TUMOR Category: Medical Services CMS Add: 01/01/1995 CMS Term: 4525F NOCOV DEF SYSMAN Description: NEUROPSYCHIA INTERVEN ORDER Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 4526F NOCOV DEF SYSMAN Description: NEUROPSYCHIA INTERVEN RCVD Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 570 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 45300 MEDSV DEF RBRVS 01/01/2024 120.11 Description: PROCTOSIGMOIDOSCOPY DX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45300 MEDSV DEF RBRVS 09/01/2019 12/31/2023 86.97 Description: PROCTOSIGMOIDOSCOPY DX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45303 MEDSV DEF RBRVS 01/01/2024 895.16 Description: PROCTOSIGMOIDOSCOPY DILATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45303 MEDSV DEF RBRVS 09/15/2017 12/31/2023 635.19 Description: PROCTOSIGMOIDOSCOPY DILATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45305 MEDSV DEF RBRVS 01/01/2024 169.84 Description: PROCTOSIGMOIDOSCOPY W/BX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45305 MEDSV DEF RBRVS 09/15/2017 12/31/2023 101.25 Description: PROCTOSIGMOIDOSCOPY W/BX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45307 MEDSV DEF RBRVS 01/01/2024 198.96 Description: PROCTOSIGMOIDOSCOPY FB Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45307 MEDSV DEF RBRVS 09/15/2017 12/31/2023 118.38 Description: PROCTOSIGMOIDOSCOPY FB Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45308 MEDSV DEF RBRVS 01/01/2024 190.30 Description: PROCTOSIGMOIDOSCOPY REMOVAL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 45308 MEDSV DEF RBRVS 09/15/2017 12/31/2023 112.88 Description: PROCTOSIGMOIDOSCOPY REMOVAL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 45309 MEDSV DEF RBRVS 01/01/2024 196.01 Description: PROCTOSIGMOIDOSCOPY REMOVAL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 45309 MEDSV DEF RBRVS 09/15/2017 12/31/2023 117.55 Description: PROCTOSIGMOIDOSCOPY REMOVAL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 45315 MEDSV DEF RBRVS 01/01/2024 211.48 Description: PROCTOSIGMOIDOSCOPY REMOVAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45315 MEDSV DEF RBRVS 09/15/2017 12/31/2023 128.00 Description: PROCTOSIGMOIDOSCOPY REMOVAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45317 MEDSV DEF RBRVS 01/01/2024 207.34 Description: PROCTOSIGMOIDOSCOPY BLEED Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45317 MEDSV DEF RBRVS 09/15/2017 12/31/2023 130.24 Description: PROCTOSIGMOIDOSCOPY BLEED Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 571 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 45320 MEDSV DEF RBRVS 01/01/2024 207.55 Description: PROCTOSIGMOIDOSCOPY ABLATE Category: Medical Services CMS Add: 01/01/1988 CMS Term: 45320 MEDSV DEF RBRVS 09/15/2017 12/31/2023 125.40 Description: PROCTOSIGMOIDOSCOPY ABLATE Category: Medical Services CMS Add: 01/01/1988 CMS Term: 45321 MEDSV DEF RBRVS 01/01/2024 93.55 Description: PROCTOSIGMOIDOSCOPY VOLVUL Category: Medical Services CMS Add: 01/01/1985 CMS Term: 45321 MEDSV DEF RBRVS 09/15/2017 12/31/2023 73.81 Description: PROCTOSIGMOIDOSCOPY VOLVUL Category: Medical Services CMS Add: 01/01/1985 CMS Term: 45327 MEDSV DEF RBRVS 01/01/2024 105.91 Description: PROCTOSIGMOIDOSCOPY W/STENT Category: Medical Services CMS Add: 01/01/2001 CMS Term: 45327 MEDSV DEF RBRVS 09/15/2017 12/31/2023 83.58 Description: PROCTOSIGMOIDOSCOPY W/STENT Category: Medical Services CMS Add: 01/01/2001 CMS Term: 45330 MEDSV DEF RBRVS 01/01/2024 173.64 Description: DIAGNOSTIC SIGMOIDOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45330 MEDSV DEF RBRVS 09/01/2019 12/31/2023 96.56 Description: DIAGNOSTIC SIGMOIDOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45331 MEDSV DEF RBRVS 01/01/2024 267.79 Description: SIGMOIDOSCOPY AND BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45331 MEDSV DEF RBRVS 02/01/2015 12/31/2023 115.45 Description: SIGMOIDOSCOPY AND BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45332 MEDSV DEF RBRVS 01/01/2024 259.07 Description: SIGMOIDOSCOPY W/FB REMOVAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45332 MEDSV DEF RBRVS 09/15/2017 12/31/2023 178.16 Description: SIGMOIDOSCOPY W/FB REMOVAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45333 MEDSV DEF RBRVS 01/01/2024 307.83 Description: SIGMOIDOSCOPY & POLYPECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45333 MEDSV DEF RBRVS 09/15/2017 12/31/2023 207.61 Description: SIGMOIDOSCOPY & POLYPECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45334 MEDSV DEF RBRVS 01/01/2024 461.70 Description: SIGMOIDOSCOPY FOR BLEEDING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45334 MEDSV DEF RBRVS 09/15/2017 12/31/2023 388.98 Description: SIGMOIDOSCOPY FOR BLEEDING Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 572 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 45335 MEDSV DEF RBRVS 01/01/2024 272.74 Description: SIGMOIDOSCOPY W/SUBMUC INJ Category: Medical Services CMS Add: 01/01/2003 CMS Term: 45335 MEDSV DEF RBRVS 09/15/2017 12/31/2023 165.18 Description: SIGMOIDOSCOPY W/SUBMUC INJ Category: Medical Services CMS Add: 01/01/2003 CMS Term: 45337 MEDSV DEF RBRVS 01/01/2024 106.07 Description: SIGMOIDOSCOPY & DECOMPRESS Category: Medical Services CMS Add: 01/01/1988 CMS Term: 45337 MEDSV DEF RBRVS 09/15/2017 12/31/2023 85.82 Description: SIGMOIDOSCOPY & DECOMPRESS Category: Medical Services CMS Add: 01/01/1988 CMS Term: 45338 MEDSV DEF RBRVS 01/01/2024 280.18 Description: SIGMOIDOSCOPY W/TUMR REMOVE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 45338 MEDSV DEF RBRVS 09/15/2017 12/31/2023 190.91 Description: SIGMOIDOSCOPY W/TUMR REMOVE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 45340 MEDSV DEF RBRVS 01/01/2024 427.75 Description: SIG W/TNDSC BALLOON DILATION Category: Medical Services CMS Add: 01/01/2003 CMS Term: 45340 MEDSV DEF RBRVS 09/15/2017 12/31/2023 304.09 Description: SIG W/TNDSC BALLOON DILATION Category: Medical Services CMS Add: 01/01/2003 CMS Term: 45341 MEDSV DEF RBRVS 01/01/2024 114.76 Description: SIGMOIDOSCOPY W/ULTRASOUND Category: Medical Services CMS Add: 01/01/2001 CMS Term: 45341 MEDSV DEF RBRVS 09/15/2017 12/31/2023 92.38 Description: SIGMOIDOSCOPY W/ULTRASOUND Category: Medical Services CMS Add: 01/01/2001 CMS Term: 45342 MEDSV DEF RBRVS 01/01/2024 158.05 Description: SIGMOIDOSCOPY W/US GUIDE BX Category: Medical Services CMS Add: 01/01/2001 CMS Term: 45342 MEDSV DEF RBRVS 09/15/2017 12/31/2023 126.72 Description: SIGMOIDOSCOPY W/US GUIDE BX Category: Medical Services CMS Add: 01/01/2001 CMS Term: 45346 MEDSV DEF MAXFEE 01/01/2024 2147.62 0.0 Description: SIGMOIDOSCOPY W/ABLATION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 45347 MEDSV DEF RBRVS 01/01/2024 142.85 Description: SIGMOIDOSCOPY W/PLCMT STENT Category: Medical Services CMS Add: 01/01/2015 CMS Term: 45347 MEDSV DEF RBRVS 09/15/2017 12/31/2023 115.19 Description: SIGMOIDOSCOPY W/PLCMT STENT Category: Medical Services CMS Add: 01/01/2015 CMS Term: 45349 MEDSV DEF RBRVS 01/01/2024 184.08 Description: SIGMOIDOSCOPY W/RESECTION Category: Medical Services CMS Add: 01/01/2015 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 573 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 45349 MEDSV DEF RBRVS 09/15/2017 12/31/2023 147.92 Description: SIGMOIDOSCOPY W/RESECTION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 45350 MEDSV DEF RBRVS 01/01/2024 627.89 Description: SGMDSC W/BAND LIGATION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 45350 MEDSV DEF RBRVS 09/15/2017 12/31/2023 369.98 Description: SGMDSC W/BAND LIGATION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 45378 53 MEDSV DEF RBRVS 01/01/2023 158.95 Description: DIAGNOSTIC COLONOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45378 MEDSV DEF RBRVS 01/01/2024 318.20 Description: DIAGNOSTIC COLONOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45378 MEDSV DEF RBRVS 09/15/2017 12/31/2023 225.65 Description: DIAGNOSTIC COLONOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45379 MEDSV DEF RBRVS 01/01/2024 407.95 Description: COLONOSCOPY W/FB REMOVAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45379 MEDSV DEF RBRVS 09/15/2017 12/31/2023 291.37 Description: COLONOSCOPY W/FB REMOVAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45380 MEDSV DEF RBRVS 01/01/2024 406.80 Description: COLONOSCOPY AND BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45380 MEDSV DEF RBRVS 09/15/2017 12/31/2023 288.37 Description: COLONOSCOPY AND BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45381 MEDSV DEF RBRVS 01/01/2024 415.28 Description: COLONOSCOPY SUBMUCOUS NJX Category: Medical Services CMS Add: 01/01/2003 CMS Term: 45381 MEDSV DEF RBRVS 09/15/2017 12/31/2023 275.82 Description: COLONOSCOPY SUBMUCOUS NJX Category: Medical Services CMS Add: 01/01/2003 CMS Term: 45382 MEDSV DEF RBRVS 01/01/2024 624.59 Description: COLONOSCOPY W/CONTROL BLEED Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45382 MEDSV DEF RBRVS 09/15/2017 12/31/2023 511.39 Description: COLONOSCOPY W/CONTROL BLEED Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45384 MEDSV DEF RBRVS 01/01/2024 457.06 Description: COLONOSCOPY W/LESION REMOVAL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 45384 MEDSV DEF RBRVS 09/15/2017 12/31/2023 319.50 Description: COLONOSCOPY W/LESION REMOVAL Category: Medical Services CMS Add: 01/01/1994 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 574 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 45385 MEDSV DEF RBRVS 01/01/2024 425.81 Description: COLONOSCOPY W/LESION REMOVAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45385 MEDSV DEF RBRVS 09/15/2017 12/31/2023 304.03 Description: COLONOSCOPY W/LESION REMOVAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45386 MEDSV DEF RBRVS 01/01/2024 572.15 Description: COLONOSCOPY W/BALLOON DILAT Category: Medical Services CMS Add: 01/01/2003 CMS Term: 45386 MEDSV DEF RBRVS 09/15/2017 12/31/2023 414.74 Description: COLONOSCOPY W/BALLOON DILAT Category: Medical Services CMS Add: 01/01/2003 CMS Term: 45388 MEDSV DEF RBRVS 01/01/2024 2297.14 Description: COLONOSCOPY W/ABLATION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 45388 MEDSV DEF RBRVS 09/15/2017 12/31/2023 2257.75 Description: COLONOSCOPY W/ABLATION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 45389 MEDSV DEF RBRVS 01/01/2024 268.91 Description: COLONOSCOPY W/STENT PLCMT Category: Medical Services CMS Add: 01/01/2015 CMS Term: 45389 MEDSV DEF RBRVS 09/15/2017 12/31/2023 216.43 Description: COLONOSCOPY W/STENT PLCMT Category: Medical Services CMS Add: 01/01/2015 CMS Term: 45390 MEDSV DEF RBRVS 01/01/2024 308.41 Description: COLONOSCOPY W/RESECTION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 45390 MEDSV DEF RBRVS 09/15/2017 12/31/2023 248.08 Description: COLONOSCOPY W/RESECTION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 45391 MEDSV DEF RBRVS 01/01/2024 239.40 Description: COLONOSCOPY W/ENDOSCOPE US Category: Medical Services CMS Add: 01/01/2005 CMS Term: 45391 MEDSV DEF RBRVS 09/15/2017 12/31/2023 192.63 Description: COLONOSCOPY W/ENDOSCOPE US Category: Medical Services CMS Add: 01/01/2005 CMS Term: 45392 MEDSV DEF RBRVS 01/01/2024 282.36 Description: COLONOSCOPY W/ENDOSCOPIC FNB Category: Medical Services CMS Add: 01/01/2005 CMS Term: 45392 MEDSV DEF RBRVS 09/15/2017 12/31/2023 227.13 Description: COLONOSCOPY W/ENDOSCOPIC FNB Category: Medical Services CMS Add: 01/01/2005 CMS Term: 45393 MEDSV DEF RBRVS 01/01/2024 233.23 Description: COLONOSCOPY W/DECOMPRESSION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 45393 MEDSV DEF RBRVS 09/15/2017 12/31/2023 188.33 Description: COLONOSCOPY W/DECOMPRESSION Category: Medical Services CMS Add: 01/01/2015 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 575 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 45395 MEDSV DEF RBRVS 01/01/2024 1804.67 Description: LAP REMOVAL OF RECTUM Category: Medical Services CMS Add: 01/01/2006 CMS Term: 45395 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1436.10 Description: LAP REMOVAL OF RECTUM Category: Medical Services CMS Add: 01/01/2006 CMS Term: 45397 MEDSV DEF RBRVS 01/01/2024 1963.52 Description: LAP REMOVE RECTUM W/POUCH Category: Medical Services CMS Add: 01/01/2006 CMS Term: 45397 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1563.57 Description: LAP REMOVE RECTUM W/POUCH Category: Medical Services CMS Add: 01/01/2006 CMS Term: 45398 MEDSV DEF RBRVS 01/01/2024 773.45 Description: COLONOSCOPY W/BAND LIGATION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 45398 MEDSV DEF RBRVS 09/15/2017 12/31/2023 476.99 Description: COLONOSCOPY W/BAND LIGATION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 45399 MEDSV DEF BILL20 Description: UNLISTED PROCEDURE COLON Category: Medical Services CMS Add: 01/01/2015 CMS Term: 45400 MEDSV DEF RBRVS 01/01/2024 1048.30 Description: LAPAROSCOPIC PROC Category: Medical Services CMS Add: 01/01/2006 CMS Term: 45400 MEDSV DEF RBRVS 02/01/2015 12/31/2023 833.79 Description: LAPAROSCOPIC PROC Category: Medical Services CMS Add: 01/01/2006 CMS Term: 45402 MEDSV DEF RBRVS 01/01/2024 1397.17 Description: LAP PROCTOPEXY W/SIG RESECT Category: Medical Services CMS Add: 01/01/2006 CMS Term: 45402 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1109.46 Description: LAP PROCTOPEXY W/SIG RESECT Category: Medical Services CMS Add: 01/01/2006 CMS Term: 4540F NOCOV DEF SYSMAN Description: DISEASE MODIF PHARMACOTHXPY Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 4541F NOCOV DEF SYSMAN Description: PT OFFERED TX FOR PSEUDOBULB Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 45499 MEDSV DEF BILL20 Description: LAPAROSCOPE PROC RECTUM Category: Medical Services CMS Add: 01/01/2006 CMS Term: 45500 MEDSV DEF RBRVS 01/01/2024 523.17 Description: REPAIR OF RECTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45500 MEDSV DEF RBRVS 09/01/2019 12/31/2023 382.66 Description: REPAIR OF RECTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 576 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 45505 MEDSV DEF RBRVS 01/01/2024 561.32 Description: REPAIR OF RECTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45505 MEDSV DEF RBRVS 09/01/2019 12/31/2023 425.27 Description: REPAIR OF RECTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4550F NOCOV DEF SYSMAN Description: NONINVAS RESP SUPPORT TALK Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 4551F NOCOV DEF SYSMAN Description: NUTRITIONAL SUPPORT OFFERED Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 45520 MEDSV DEF RBRVS 01/01/2024 152.51 Description: TREATMENT OF RECTAL PROLAPSE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45520 MEDSV DEF RBRVS 09/01/2019 12/31/2023 111.06 Description: TREATMENT OF RECTAL PROLAPSE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4552F NOCOV DEF SYSMAN Description: PT REF FOR SPEECH LANG PATH Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 4553F NOCOV DEF SYSMAN Description: PT ASST RE END LIFE ISSUES Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 45540 MEDSV DEF RBRVS 01/01/2024 975.82 Description: CORRECT RECTAL PROLAPSE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45540 MEDSV DEF RBRVS 09/01/2019 12/31/2023 767.19 Description: CORRECT RECTAL PROLAPSE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45541 MEDSV DEF RBRVS 01/01/2024 868.40 Description: CORRECT RECTAL PROLAPSE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45541 MEDSV DEF RBRVS 09/01/2019 12/31/2023 669.34 Description: CORRECT RECTAL PROLAPSE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4554F NOCOV DEF SYSMAN Description: PT RECVD INHAL ANESTHETIC Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 45550 MEDSV DEF RBRVS 01/01/2024 1346.97 Description: REPAIR RECTUM/REMOVE SIGMOID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45550 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1061.03 Description: REPAIR RECTUM/REMOVE SIGMOID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 4555F NOCOV DEF SYSMAN Description: PT RECVD NO INHAL ANESTHIC Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 577 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 45560 MEDSV DEF RBRVS 01/01/2024 645.43 Description: REPAIR OF RECTOCELE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45560 MEDSV DEF RBRVS 09/01/2019 12/31/2023 506.09 Description: REPAIR OF RECTOCELE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45562 MEDSV DEF RBRVS 01/01/2019 12/31/2023 802.49 Description: EXPLORATION/REPAIR OF RECTUM Category: Medical Services CMS Add: 01/01/1995 CMS Term: 45562 MEDSV DEF RBRVS 01/01/2024 1043.33 Description: EXPLORATION/REPAIR OF RECTUM Category: Medical Services CMS Add: 01/01/1995 CMS Term: 45563 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1170.46 Description: EXPLORATION/REPAIR OF RECTUM Category: Medical Services CMS Add: 01/01/1995 CMS Term: 45563 MEDSV DEF RBRVS 01/01/2024 1511.11 Description: EXPLORATION/REPAIR OF RECTUM Category: Medical Services CMS Add: 01/01/1995 CMS Term: 4556F NOCOV DEF SYSMAN Description: PT W/3+ POST-OP NAUSEA&VOM Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 4557F NOCOV DEF SYSMAN Description: PT W/O 3+ POST-OPNAUSEA&VOM Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 4558F NOCOV DEF SYSMAN Description: PT RECVD 2 RX ANTI-EMET AGT Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 4559F NOCOV DEF SYSMAN Description: 1 BODYTEMP >=35.5CW/IN 30MIN Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 4560F NOCOV DEF SYSMAN Description: ANESTH W/O GEN/NEURAX ANESTH Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 4561F NOCOV DEF SYSMAN Description: PT W/ CORONARY ARTERY STENT Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 4562F NOCOV DEF SYSMAN Description: PT W/O CORONARY ARTERY STENT Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 4563F NOCOV DEF SYSMAN Description: PT RECVD ASPIRIN W/IN 24 HRS Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 45800 MEDSV DEF RBRVS 01/01/2024 1159.32 Description: REPAIR RECT/BLADDER FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45800 MEDSV DEF RBRVS 09/01/2019 12/31/2023 866.49 Description: REPAIR RECT/BLADDER FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 578 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 45805 MEDSV DEF RBRVS 01/01/2024 1338.22 Description: REPAIR FISTULA W/COLOSTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45805 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1038.12 Description: REPAIR FISTULA W/COLOSTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45820 MEDSV DEF RBRVS 01/01/2024 1162.44 Description: REPAIR RECTOURETHRAL FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45820 MEDSV DEF RBRVS 09/01/2019 12/31/2023 861.81 Description: REPAIR RECTOURETHRAL FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45825 MEDSV DEF RBRVS 01/01/2024 1401.89 Description: REPAIR FISTULA W/COLOSTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45825 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1003.56 Description: REPAIR FISTULA W/COLOSTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45900 MEDSV DEF RBRVS 01/01/2024 194.90 Description: REDUCTION OF RECTAL PROLAPSE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45900 MEDSV DEF RBRVS 09/01/2019 12/31/2023 146.23 Description: REDUCTION OF RECTAL PROLAPSE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45905 MEDSV DEF RBRVS 01/01/2024 158.33 Description: DILATION OF ANAL SPHINCTER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45905 MEDSV DEF RBRVS 09/01/2019 12/31/2023 121.11 Description: DILATION OF ANAL SPHINCTER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45910 MEDSV DEF RBRVS 01/01/2024 179.48 Description: DILATION OF RECTAL NARROWING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45910 MEDSV DEF RBRVS 09/01/2019 12/31/2023 140.65 Description: DILATION OF RECTAL NARROWING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45915 MEDSV DEF RBRVS 01/01/2024 328.60 Description: REMOVE RECTAL OBSTRUCTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45915 MEDSV DEF RBRVS 09/01/2019 12/31/2023 233.93 Description: REMOVE RECTAL OBSTRUCTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 45990 MEDSV DEF RBRVS 01/01/2024 97.01 Description: SURG DX EXAM ANORECTAL Category: Medical Services CMS Add: 01/01/2006 CMS Term: 45990 MEDSV DEF RBRVS 02/01/2015 12/31/2023 77.59 Description: SURG DX EXAM ANORECTAL Category: Medical Services CMS Add: 01/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 579 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 45999 MEDSV DEF BILL20 Description: UNLISTED PROCEDURE RECTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46020 MEDSV DEF RBRVS 01/01/2024 107.56 Description: PLACEMENT OF SETON Category: Medical Services CMS Add: 01/01/2002 CMS Term: 46020 MEDSV DEF RBRVS 02/01/2015 12/31/2023 196.45 Description: PLACEMENT OF SETON Category: Medical Services CMS Add: 01/01/2002 CMS Term: 46030 MEDSV DEF RBRVS 01/01/2024 239.40 Description: REMOVAL OF RECTAL MARKER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46030 MEDSV DEF RBRVS 09/01/2019 12/31/2023 98.67 Description: REMOVAL OF RECTAL MARKER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46040 MEDSV DEF RBRVS 01/01/2024 515.36 Description: INCISION OF RECTAL ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46040 MEDSV DEF RBRVS 09/01/2019 12/31/2023 375.32 Description: INCISION OF RECTAL ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46045 MEDSV DEF RBRVS 01/01/2024 407.89 Description: INCISION OF RECTAL ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46045 MEDSV DEF RBRVS 09/01/2019 12/31/2023 308.00 Description: INCISION OF RECTAL ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46050 MEDSV DEF RBRVS 01/01/2024 220.78 Description: INCISION OF ANAL ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46050 MEDSV DEF RBRVS 09/01/2019 12/31/2023 141.90 Description: INCISION OF ANAL ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46060 MEDSV DEF RBRVS 01/01/2024 453.88 Description: INCISION OF RECTAL ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46060 MEDSV DEF RBRVS 09/01/2019 12/31/2023 339.68 Description: INCISION OF RECTAL ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46070 MEDSV DEF RBRVS 01/01/2024 250.76 0-364days Description: INCISION OF ANAL SEPTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46070 MEDSV DEF RBRVS 09/01/2019 12/31/2023 173.72 0-364days Description: INCISION OF ANAL SEPTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46080 MEDSV DEF RBRVS 01/01/2024 268.79 Description: INCISION OF ANAL SPHINCTER Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 580 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 46080 MEDSV DEF RBRVS 09/01/2019 12/31/2023 175.80 Description: INCISION OF ANAL SPHINCTER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46083 MEDSV DEF RBRVS 01/01/2024 193.95 Description: INCISE EXTERNAL HEMORRHOID Category: Medical Services CMS Add: 01/01/1985 CMS Term: 46083 MEDSV DEF RBRVS 09/01/2019 12/31/2023 124.26 Description: INCISE EXTERNAL HEMORRHOID Category: Medical Services CMS Add: 01/01/1985 CMS Term: 46200 MEDSV DEF RBRVS 01/01/2024 444.04 Description: REMOVAL OF ANAL FISSURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46200 MEDSV DEF RBRVS 09/01/2019 12/31/2023 312.47 Description: REMOVAL OF ANAL FISSURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46220 MEDSV DEF RBRVS 01/01/2024 234.57 Description: EXCISE ANAL EXT TAG/PAPILLA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46220 MEDSV DEF RBRVS 09/01/2019 12/31/2023 145.90 Description: EXCISE ANAL EXT TAG/PAPILLA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46221 MEDSV DEF RBRVS 01/01/2024 265.59 Description: LIGATION OF HEMORRHOID(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46221 MEDSV DEF RBRVS 09/01/2019 12/31/2023 189.99 Description: LIGATION OF HEMORRHOID(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46230 MEDSV DEF RBRVS 01/01/2024 291.90 Description: REMOVAL OF ANAL TAGS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46230 MEDSV DEF RBRVS 09/01/2019 12/31/2023 194.67 Description: REMOVAL OF ANAL TAGS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46250 MEDSV DEF RBRVS 01/01/2024 446.00 Description: REMOVE EXT HEM GROUPS 2+ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46250 MEDSV DEF RBRVS 09/01/2019 12/31/2023 325.25 Description: REMOVE EXT HEM GROUPS 2+ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46255 MEDSV DEF RBRVS 01/01/2024 485.88 Description: REMOVE INT/EXT HEM 1 GROUP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46255 MEDSV DEF RBRVS 09/01/2019 12/31/2023 356.13 Description: REMOVE INT/EXT HEM 1 GROUP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46257 MEDSV DEF RBRVS 01/01/2024 391.87 Description: REMOVE IN/EX HEM GRP & FISS Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 581 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 46257 MEDSV DEF RBRVS 09/01/2019 12/31/2023 308.64 Description: REMOVE IN/EX HEM GRP & FISS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46258 MEDSV DEF RBRVS 01/01/2024 442.71 Description: REMOVE IN/EX HEM GRP W/FISTU Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46258 MEDSV DEF RBRVS 09/01/2019 12/31/2023 329.61 Description: REMOVE IN/EX HEM GRP W/FISTU Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46260 MEDSV DEF RBRVS 01/01/2024 448.11 Description: REMOVE IN/EX HEM GROUPS 2+ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46260 MEDSV DEF RBRVS 09/01/2019 12/31/2023 338.79 Description: REMOVE IN/EX HEM GROUPS 2+ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46261 MEDSV DEF RBRVS 01/01/2024 493.56 Description: REMOVE IN/EX HEM GRPS & FISS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46261 MEDSV DEF RBRVS 09/01/2019 12/31/2023 376.37 Description: REMOVE IN/EX HEM GRPS & FISS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46262 MEDSV DEF RBRVS 01/01/2024 539.33 Description: REMOVE IN/EX HEM GRPS W/FIST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46262 MEDSV DEF RBRVS 09/01/2019 12/31/2023 395.84 Description: REMOVE IN/EX HEM GRPS W/FIST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46270 MEDSV DEF RBRVS 01/01/2024 498.45 Description: REMOVE ANAL FIST SUBQ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46270 MEDSV DEF RBRVS 09/01/2019 12/31/2023 357.28 Description: REMOVE ANAL FIST SUBQ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46275 MEDSV DEF RBRVS 01/01/2024 527.26 Description: REMOVE ANAL FIST INTER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46275 MEDSV DEF RBRVS 09/01/2019 12/31/2023 380.63 Description: REMOVE ANAL FIST INTER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46280 MEDSV DEF RBRVS 01/01/2024 448.96 Description: REMOVE ANAL FIST COMPLEX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46280 MEDSV DEF RBRVS 09/01/2019 12/31/2023 336.67 Description: REMOVE ANAL FIST COMPLEX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46285 MEDSV DEF RBRVS 01/01/2024 525.24 Description: REMOVE ANAL FIST 2 STAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 582 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 46285 MEDSV DEF RBRVS 09/01/2019 12/31/2023 379.72 Description: REMOVE ANAL FIST 2 STAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46288 MEDSV DEF RBRVS 01/01/2019 12/31/2023 394.80 Description: REPAIR ANAL FISTULA Category: Medical Services CMS Add: 01/01/1995 CMS Term: 46288 MEDSV DEF RBRVS 01/01/2024 521.29 Description: REPAIR ANAL FISTULA Category: Medical Services CMS Add: 01/01/1995 CMS Term: 46320 MEDSV DEF RBRVS 01/01/2024 199.46 Description: REMOVAL OF HEMORRHOID CLOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46320 MEDSV DEF RBRVS 09/01/2019 12/31/2023 130.10 Description: REMOVAL OF HEMORRHOID CLOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46500 MEDSV DEF RBRVS 01/01/2024 294.37 Description: INJECTION INTO HEMORRHOID(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46500 MEDSV DEF RBRVS 09/01/2019 12/31/2023 168.69 Description: INJECTION INTO HEMORRHOID(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46505 MEDSV DEF RBRVS 01/01/2024 294.43 Description: CHEMODENERVATION ANAL MUSC Category: Medical Services CMS Add: 01/01/2006 CMS Term: 46505 MEDSV DEF RBRVS 02/01/2015 12/31/2023 204.43 Description: CHEMODENERVATION ANAL MUSC Category: Medical Services CMS Add: 01/01/2006 CMS Term: 46600 MEDSV DEF RBRVS 01/01/2024 111.32 Description: DIAGNOSTIC ANOSCOPY SPX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46600 MEDSV DEF RBRVS 09/01/2019 12/31/2023 62.42 Description: DIAGNOSTIC ANOSCOPY SPX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46601 MEDSV DEF RBRVS 01/01/2024 139.88 Description: DIAGNOSTIC ANOSCOPY Category: Medical Services CMS Add: 01/01/2015 CMS Term: 46601 MEDSV DEF RBRVS 02/01/2015 12/31/2023 98.97 Description: DIAGNOSTIC ANOSCOPY Category: Medical Services CMS Add: 01/01/2015 CMS Term: 46604 MEDSV DEF RBRVS 01/01/2024 611.70 Description: ANOSCOPY AND DILATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46604 MEDSV DEF RBRVS 02/01/2015 12/31/2023 434.92 Description: ANOSCOPY AND DILATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46606 MEDSV DEF RBRVS 01/01/2024 262.45 Description: ANOSCOPY AND BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 583 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 46606 MEDSV DEF RBRVS 02/01/2015 12/31/2023 159.73 Description: ANOSCOPY AND BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46607 MEDSV DEF RBRVS 01/01/2024 193.60 Description: DIAGNOSTIC ANOSCOPY & BIOPSY Category: Medical Services CMS Add: 01/01/2015 CMS Term: 46607 MEDSV DEF RBRVS 02/01/2015 12/31/2023 138.13 Description: DIAGNOSTIC ANOSCOPY & BIOPSY Category: Medical Services CMS Add: 01/01/2015 CMS Term: 46608 MEDSV DEF RBRVS 01/01/2024 272.42 Description: ANOSCOPY REMOVE FOR BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46608 MEDSV DEF RBRVS 02/01/2015 12/31/2023 159.61 Description: ANOSCOPY REMOVE FOR BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46610 MEDSV DEF RBRVS 01/01/2024 259.18 Description: ANOSCOPY REMOVE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46610 MEDSV DEF RBRVS 02/01/2015 12/31/2023 159.57 Description: ANOSCOPY REMOVE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46611 MEDSV DEF RBRVS 01/01/2024 209.19 Description: ANOSCOPY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 46611 MEDSV DEF RBRVS 02/01/2015 12/31/2023 124.27 Description: ANOSCOPY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 46612 MEDSV DEF RBRVS 01/01/2024 311.47 Description: ANOSCOPY REMOVE LESIONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46612 MEDSV DEF RBRVS 02/01/2015 12/31/2023 192.40 Description: ANOSCOPY REMOVE LESIONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46614 MEDSV DEF RBRVS 01/01/2024 158.26 Description: ANOSCOPY CONTROL BLEEDING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46614 MEDSV DEF RBRVS 02/01/2015 12/31/2023 90.94 Description: ANOSCOPY CONTROL BLEEDING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46615 MEDSV DEF RBRVS 01/01/2024 166.88 Description: ANOSCOPY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 46615 MEDSV DEF RBRVS 02/01/2015 12/31/2023 102.64 Description: ANOSCOPY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 46700 MEDSV DEF RBRVS 01/01/2024 612.23 15-999years Description: REPAIR OF ANAL STRICTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 584 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 46700 MEDSV DEF RBRVS 09/01/2019 12/31/2023 471.91 15-999years Description: REPAIR OF ANAL STRICTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46705 MEDSV DEF RBRVS 01/01/2024 526.23 0-364days Description: REPAIR OF ANAL STRICTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46705 MEDSV DEF RBRVS 09/01/2019 12/31/2023 353.79 0-364days Description: REPAIR OF ANAL STRICTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46706 MEDSV DEF RBRVS 01/01/2024 164.58 Description: REPR OF ANAL FISTULA W/GLUE Category: Medical Services CMS Add: 01/01/2003 CMS Term: 46706 MEDSV DEF RBRVS 02/01/2015 12/31/2023 122.20 Description: REPR OF ANAL FISTULA W/GLUE Category: Medical Services CMS Add: 01/01/2003 CMS Term: 46707 MEDSV DEF RBRVS 01/01/2024 463.95 Description: REPAIR ANORECTAL FIST W/PLUG Category: Medical Services CMS Add: 01/01/2010 CMS Term: 46707 MEDSV DEF RBRVS 02/01/2015 12/31/2023 333.03 Description: REPAIR ANORECTAL FIST W/PLUG Category: Medical Services CMS Add: 01/01/2010 CMS Term: 46710 MEDSV DEF RBRVS 01/01/2024 1014.79 Description: REPR PER/VAG POUCH SNGL PROC Category: Medical Services CMS Add: 01/01/2006 CMS Term: 46710 MEDSV DEF RBRVS 02/01/2015 12/31/2023 784.79 Description: REPR PER/VAG POUCH SNGL PROC Category: Medical Services CMS Add: 01/01/2006 CMS Term: 46712 MEDSV DEF RBRVS 01/01/2024 2017.02 Description: REPR PER/VAG POUCH DBL PROC Category: Medical Services CMS Add: 01/01/2006 CMS Term: 46712 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1508.03 Description: REPR PER/VAG POUCH DBL PROC Category: Medical Services CMS Add: 01/01/2006 CMS Term: 46715 MEDSV DEF RBRVS 01/01/2024 510.47 Description: REP PERF ANOPER FISTU Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46715 MEDSV DEF RBRVS 09/01/2019 12/31/2023 364.26 Description: REP PERF ANOPER FISTU Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46716 MEDSV DEF RBRVS 01/01/2024 1129.97 Description: REP PERF ANOPER/VESTIB FISTU Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46716 MEDSV DEF RBRVS 09/01/2019 12/31/2023 786.68 Description: REP PERF ANOPER/VESTIB FISTU Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46730 MEDSV DEF RBRVS 01/01/2024 1813.97 Description: CONSTRUCTION OF ABSENT ANUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 585 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 46730 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1295.80 Description: CONSTRUCTION OF ABSENT ANUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46735 MEDSV DEF RBRVS 01/01/2024 2084.73 Description: CONSTRUCTION OF ABSENT ANUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46735 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1501.60 Description: CONSTRUCTION OF ABSENT ANUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46740 MEDSV DEF RBRVS 01/01/2024 1977.58 Description: CONSTRUCTION OF ABSENT ANUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46740 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1524.12 Description: CONSTRUCTION OF ABSENT ANUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46742 MEDSV DEF RBRVS 01/01/2024 2282.06 Description: REPAIR OF IMPERFORATED ANUS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 46742 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1741.90 Description: REPAIR OF IMPERFORATED ANUS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 46744 MEDSV DEF RBRVS 01/01/2024 3213.07 Description: REPAIR OF CLOACAL ANOMALY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 46744 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2435.92 Description: REPAIR OF CLOACAL ANOMALY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 46746 MEDSV DEF RBRVS 01/01/2024 3538.13 Description: REPAIR OF CLOACAL ANOMALY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 46746 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2603.18 Description: REPAIR OF CLOACAL ANOMALY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 46748 MEDSV DEF RBRVS 01/01/2024 3832.99 Description: REPAIR OF CLOACAL ANOMALY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 46748 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2827.51 Description: REPAIR OF CLOACAL ANOMALY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 46750 MEDSV DEF RBRVS 01/01/2024 699.03 15-999years Description: REPAIR OF ANAL SPHINCTER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46750 MEDSV DEF RBRVS 09/01/2019 12/31/2023 551.96 15-999years Description: REPAIR OF ANAL SPHINCTER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46751 MEDSV DEF RBRVS 01/01/2024 614.91 0-19years Description: REPAIR OF ANAL SPHINCTER Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 586 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 46751 MEDSV DEF RBRVS 09/01/2019 12/31/2023 436.65 0-19years Description: REPAIR OF ANAL SPHINCTER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46753 MEDSV DEF RBRVS 01/01/2024 569.16 Description: RECONSTRUCTION OF ANUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46753 MEDSV DEF RBRVS 09/01/2019 12/31/2023 424.40 Description: RECONSTRUCTION OF ANUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46754 MEDSV DEF RBRVS 01/01/2024 326.70 Description: REMOVAL OF SUTURE FROM ANUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46754 MEDSV DEF RBRVS 09/01/2019 12/31/2023 207.37 Description: REMOVAL OF SUTURE FROM ANUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46760 MEDSV DEF RBRVS 01/01/2024 1033.40 15-999years Description: REPAIR OF ANAL SPHINCTER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46760 MEDSV DEF RBRVS 09/01/2019 12/31/2023 798.31 15-999years Description: REPAIR OF ANAL SPHINCTER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46761 MEDSV DEF RBRVS 01/01/2024 852.87 15-999years Description: REPAIR OF ANAL SPHINCTER Category: Medical Services CMS Add: 01/01/1988 CMS Term: 46761 MEDSV DEF RBRVS 09/01/2019 12/31/2023 675.13 15-999years Description: REPAIR OF ANAL SPHINCTER Category: Medical Services CMS Add: 01/01/1988 CMS Term: 46900 MEDSV DEF RBRVS 01/01/2024 223.88 Description: DESTRUCTION ANAL LESION(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46900 MEDSV DEF RBRVS 09/01/2019 12/31/2023 170.80 Description: DESTRUCTION ANAL LESION(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46910 MEDSV DEF RBRVS 01/01/2024 245.83 Description: DESTRUCTION ANAL LESION(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46910 MEDSV DEF RBRVS 09/01/2019 12/31/2023 180.38 Description: DESTRUCTION ANAL LESION(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46916 MEDSV DEF RBRVS 01/01/2024 244.84 Description: CRYOSURGERY ANAL LESION(S) Category: Medical Services CMS Add: 01/01/1986 CMS Term: 46916 MEDSV DEF RBRVS 09/01/2019 12/31/2023 160.89 Description: CRYOSURGERY ANAL LESION(S) Category: Medical Services CMS Add: 01/01/1986 CMS Term: 46917 MEDSV DEF RBRVS 01/01/2024 418.24 Description: LASER SURGERY ANAL LESIONS Category: Medical Services CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 587 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 46917 MEDSV DEF RBRVS 09/01/2019 12/31/2023 313.48 Description: LASER SURGERY ANAL LESIONS Category: Medical Services CMS Add: 01/01/1986 CMS Term: 46922 MEDSV DEF RBRVS 01/01/2024 293.56 Description: EXCISION OF ANAL LESION(S) Category: Medical Services CMS Add: 01/01/1986 CMS Term: 46922 MEDSV DEF RBRVS 09/01/2019 12/31/2023 188.06 Description: EXCISION OF ANAL LESION(S) Category: Medical Services CMS Add: 01/01/1986 CMS Term: 46924 MEDSV DEF RBRVS 01/01/2024 513.35 Description: DESTRUCTION ANAL LESION(S) Category: Medical Services CMS Add: 01/01/1986 CMS Term: 46924 MEDSV DEF RBRVS 09/01/2019 12/31/2023 377.38 Description: DESTRUCTION ANAL LESION(S) Category: Medical Services CMS Add: 01/01/1986 CMS Term: 46930 MEDSV DEF RBRVS 01/01/2024 202.27 Description: DESTROY INTERNAL HEMORRHOIDS Category: Medical Services CMS Add: 01/01/2009 CMS Term: 46930 MEDSV DEF RBRVS 02/01/2015 12/31/2023 144.74 Description: DESTROY INTERNAL HEMORRHOIDS Category: Medical Services CMS Add: 01/01/2009 CMS Term: 46940 MEDSV DEF RBRVS 01/01/2024 250.12 Description: TREATMENT OF ANAL FISSURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46940 MEDSV DEF RBRVS 09/01/2019 12/31/2023 163.30 Description: TREATMENT OF ANAL FISSURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46942 MEDSV DEF RBRVS 01/01/2024 238.12 Description: TREATMENT OF ANAL FISSURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46942 MEDSV DEF RBRVS 09/01/2019 12/31/2023 155.03 Description: TREATMENT OF ANAL FISSURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46945 MEDSV DEF RBRVS 01/01/2024 316.99 Description: INT HRHC LIG 1 HROID W/O IMG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46945 MEDSV DEF RBRVS 09/01/2019 12/31/2023 214.45 Description: INT HRHC LIG 1 HROID W/O IMG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46946 MEDSV DEF RBRVS 01/01/2024 355.79 Description: INT HRHC LIG 2+HROID W/O IMG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46946 MEDSV DEF RBRVS 09/01/2019 12/31/2023 219.79 Description: INT HRHC LIG 2+HROID W/O IMG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 46947 MEDSV DEF RBRVS 01/01/2024 359.48 Description: HEMORRHOIDOPEXY BY STAPLING Category: Medical Services CMS Add: 01/01/2005 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 588 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 46947 MEDSV DEF RBRVS 02/01/2015 12/31/2023 273.10 Description: HEMORRHOIDOPEXY BY STAPLING Category: Medical Services CMS Add: 01/01/2005 CMS Term: 46948 MEDSV DEF RBRVS 01/01/2020 12/31/2023 317.53 Description: INT HRHC TRANAL DARTLZJ 2+ Category: Medical Services CMS Add: 01/01/2020 CMS Term: 46948 MEDSV DEF RBRVS 01/01/2024 413.28 Description: INT HRHC TRANAL DARTLZJ 2+ Category: Medical Services CMS Add: 01/01/2020 CMS Term: 46999 MEDSV DEF BILL20 Description: UNLISTED PROCEDURE ANUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47000 MEDSV DEF RBRVS 01/01/2024 283.39 Description: NEEDLE BIOPSY OF LIVER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47000 MEDSV DEF RBRVS 09/15/2017 12/31/2023 217.73 Description: NEEDLE BIOPSY OF LIVER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47001 MEDSV DEF RBRVS 01/01/2019 12/31/2023 73.84 Description: NEEDLE BIOPSY LIVER ADD-ON Category: Medical Services CMS Add: 01/01/1992 CMS Term: 47001 MEDSV DEF RBRVS 01/01/2024 93.71 Description: NEEDLE BIOPSY LIVER ADD-ON Category: Medical Services CMS Add: 01/01/1992 CMS Term: 47010 MEDSV DEF RBRVS 01/01/2024 1108.15 Description: OPEN DRAINAGE LIVER LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47010 MEDSV DEF RBRVS 09/01/2019 12/31/2023 858.31 Description: OPEN DRAINAGE LIVER LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47015 MEDSV DEF RBRVS 01/01/2019 12/31/2023 817.54 Description: INJECT/ASPIRATE LIVER CYST Category: Medical Services CMS Add: 01/01/1995 CMS Term: 47015 MEDSV DEF RBRVS 01/01/2024 1063.25 Description: INJECT/ASPIRATE LIVER CYST Category: Medical Services CMS Add: 01/01/1995 CMS Term: 47100 MEDSV DEF RBRVS 01/01/2024 777.42 Description: WEDGE BIOPSY OF LIVER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47100 MEDSV DEF RBRVS 09/01/2019 12/31/2023 599.88 Description: WEDGE BIOPSY OF LIVER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47120 MEDSV DEF RBRVS 01/01/2024 2127.43 Y Description: PARTIAL REMOVAL OF LIVER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47120 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1657.20 Y Description: PARTIAL REMOVAL OF LIVER Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 589 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 47122 MEDSV DEF RBRVS 01/01/2024 3110.65 Y Description: EXTENSIVE REMOVAL OF LIVER Category: Medical Services CMS Add: 01/01/1988 CMS Term: 47122 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2442.62 Y Description: EXTENSIVE REMOVAL OF LIVER Category: Medical Services CMS Add: 01/01/1988 CMS Term: 47125 MEDSV DEF RBRVS 01/01/2024 2793.69 Y Description: PARTIAL REMOVAL OF LIVER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47125 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2188.58 Y Description: PARTIAL REMOVAL OF LIVER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47130 MEDSV DEF RBRVS 01/01/2024 3000.59 Y Description: PARTIAL REMOVAL OF LIVER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47130 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2351.70 Y Description: PARTIAL REMOVAL OF LIVER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47133 MEDSV PRF MAXFEE 01/01/2024 3712.50 0.0 Description: REMOVAL OF DONOR LIVER Category: Medical Services CMS Add: 01/01/1986 CMS Term: 47135 MEDSV DEF RBRVS 01/01/2019 12/31/2023 3485.48 Y Description: TRANSPLANTATION OF LIVER Category: Medical Services CMS Add: 01/01/1982 CMS Term: 47135 MEDSV DEF RBRVS 01/01/2024 4895.83 Y Description: TRANSPLANTATION OF LIVER Category: Medical Services CMS Add: 01/01/1982 CMS Term: 47140 MEDSV DEF RBRVS 01/01/2024 3241.69 Description: PARTIAL REMOVAL DONOR LIVER Category: Medical Services CMS Add: 01/01/2004 CMS Term: 47140 MEDSV DEF RBRVS 02/01/2015 12/31/2023 2537.58 Description: PARTIAL REMOVAL DONOR LIVER Category: Medical Services CMS Add: 01/01/2004 CMS Term: 47141 MEDSV DEF RBRVS 01/01/2024 3873.54 Description: PARTIAL REMOVAL DONOR LIVER Category: Medical Services CMS Add: 01/01/2004 CMS Term: 47141 MEDSV DEF RBRVS 02/01/2015 12/31/2023 2872.51 Description: PARTIAL REMOVAL DONOR LIVER Category: Medical Services CMS Add: 01/01/2004 CMS Term: 47142 MEDSV DEF RBRVS 01/01/2024 4256.66 Description: PARTIAL REMOVAL DONOR LIVER Category: Medical Services CMS Add: 01/01/2004 CMS Term: 47142 MEDSV DEF RBRVS 02/01/2015 12/31/2023 3343.89 Description: PARTIAL REMOVAL DONOR LIVER Category: Medical Services CMS Add: 01/01/2004 CMS Term: 47143 MEDSV DEF MAXFEE 01/01/2024 482.09 0.0 Y Description: PREP DONOR LIVER WHOLE Category: Medical Services CMS Add: 01/01/2005 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 590 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 47144 MEDSV DEF MAXFEE 01/01/2024 392.87 0.0 Y Description: PREP DONOR LIVER 3-SEGMENT Category: Medical Services CMS Add: 01/01/2005 CMS Term: 47145 MEDSV DEF MAXFEE 01/01/2024 462.00 0.0 Y Description: PREP DONOR LIVER LOBE SPLIT Category: Medical Services CMS Add: 01/01/2005 CMS Term: 47146 MEDSV DEF RBRVS 01/01/2024 295.68 Y Description: PREP DONOR LIVER/VENOUS Category: Medical Services CMS Add: 01/01/2005 CMS Term: 47146 MEDSV DEF RBRVS 02/01/2015 12/31/2023 234.87 Y Description: PREP DONOR LIVER/VENOUS Category: Medical Services CMS Add: 01/01/2005 CMS Term: 47147 MEDSV DEF RBRVS 01/01/2024 344.69 Y Description: PREP DONOR LIVER/ARTERIAL Category: Medical Services CMS Add: 01/01/2005 CMS Term: 47147 MEDSV DEF RBRVS 02/01/2015 12/31/2023 273.96 Y Description: PREP DONOR LIVER/ARTERIAL Category: Medical Services CMS Add: 01/01/2005 CMS Term: 47300 MEDSV DEF RBRVS 01/01/2024 1038.87 Description: SURGERY FOR LIVER LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47300 MEDSV DEF RBRVS 09/01/2019 12/31/2023 802.41 Description: SURGERY FOR LIVER LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47350 MEDSV DEF RBRVS 01/01/2024 1249.54 Description: REPAIR LIVER WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47350 MEDSV DEF RBRVS 09/01/2019 12/31/2023 976.43 Description: REPAIR LIVER WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47360 MEDSV DEF RBRVS 01/01/2024 1704.61 Description: REPAIR LIVER WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47360 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1327.61 Description: REPAIR LIVER WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47361 MEDSV DEF RBRVS 01/01/2024 2744.39 Description: REPAIR LIVER WOUND Category: Medical Services CMS Add: 01/01/1996 CMS Term: 47361 MEDSV DEF RBRVS 02/01/2015 12/31/2023 2151.24 Description: REPAIR LIVER WOUND Category: Medical Services CMS Add: 01/01/1996 CMS Term: 47362 MEDSV DEF RBRVS 01/01/2024 1309.68 Description: REPAIR LIVER WOUND Category: Medical Services CMS Add: 01/01/1996 CMS Term: 47362 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1029.25 Description: REPAIR LIVER WOUND Category: Medical Services CMS Add: 01/01/1996 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 591 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 47370 MEDSV DEF RBRVS 01/01/2024 1144.13 Description: LAPARO ABLATE LIVER TUMOR RF Category: Medical Services CMS Add: 01/01/2002 CMS Term: 47370 MEDSV DEF RBRVS 02/01/2015 12/31/2023 883.96 Description: LAPARO ABLATE LIVER TUMOR RF Category: Medical Services CMS Add: 01/01/2002 CMS Term: 47371 MEDSV DEF RBRVS 01/01/2024 1147.29 Description: LAPARO ABLATE LIVER CRYOSURG Category: Medical Services CMS Add: 01/01/2002 CMS Term: 47371 MEDSV DEF RBRVS 02/01/2015 12/31/2023 874.05 Description: LAPARO ABLATE LIVER CRYOSURG Category: Medical Services CMS Add: 01/01/2002 CMS Term: 47379 MEDSV DEF BILL20 Description: UNLISTED LAPS PX LIVER Category: Medical Services CMS Add: 01/01/2001 CMS Term: 47380 MEDSV DEF RBRVS 01/01/2024 1319.56 Description: OPEN ABLATE LIVER TUMOR RF Category: Medical Services CMS Add: 01/01/2002 CMS Term: 47380 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1028.58 Description: OPEN ABLATE LIVER TUMOR RF Category: Medical Services CMS Add: 01/01/2002 CMS Term: 47381 MEDSV DEF RBRVS 01/01/2024 1348.12 Description: OPEN ABLATE LIVER TUMOR CRYO Category: Medical Services CMS Add: 01/01/2002 CMS Term: 47381 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1034.79 Description: OPEN ABLATE LIVER TUMOR CRYO Category: Medical Services CMS Add: 01/01/2002 CMS Term: 47382 MEDSV DEF RBRVS 01/01/2024 3449.88 Description: PERCUT ABLATE LIVER RF Category: Medical Services CMS Add: 01/01/2002 CMS Term: 47382 MEDSV DEF RBRVS 09/15/2017 12/31/2023 3418.30 Description: PERCUT ABLATE LIVER RF Category: Medical Services CMS Add: 01/01/2002 CMS Term: 47383 MEDSV PRF MAXFEE 01/01/2024 5586.52 0.0 Description: PERQ ABLTJ LVR CRYOABLATION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 47399 MEDSV DEF BILL20 Description: UNLISTED PROCEDURE LIVER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47400 MEDSV DEF RBRVS 01/01/2024 1953.60 Description: INCISION OF LIVER DUCT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47400 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1532.66 Description: INCISION OF LIVER DUCT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47420 MEDSV DEF RBRVS 01/01/2024 1216.19 Description: INCISION OF BILE DUCT Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 592 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 47420 MEDSV DEF RBRVS 09/01/2019 12/31/2023 955.57 Description: INCISION OF BILE DUCT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47425 MEDSV DEF RBRVS 01/01/2024 1246.25 Description: INCISION OF BILE DUCT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47425 MEDSV DEF RBRVS 09/01/2019 12/31/2023 971.84 Description: INCISION OF BILE DUCT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47460 MEDSV DEF RBRVS 01/01/2024 1157.67 Description: INCISE BILE DUCT SPHINCTER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47460 MEDSV DEF RBRVS 09/01/2019 12/31/2023 901.54 Description: INCISE BILE DUCT SPHINCTER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47480 MEDSV DEF RBRVS 01/01/2024 804.41 Description: INCISION OF GALLBLADDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47480 MEDSV DEF RBRVS 09/01/2019 12/31/2023 622.39 Description: INCISION OF GALLBLADDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47490 MEDSV DEF RBRVS 01/01/2024 311.02 Description: INCISION OF GALLBLADDER Category: Medical Services CMS Add: 01/01/1987 CMS Term: 47490 MEDSV DEF RBRVS 09/01/2019 12/31/2023 243.57 Description: INCISION OF GALLBLADDER Category: Medical Services CMS Add: 01/01/1987 CMS Term: 47531 MEDSV DEF RBRVS 01/01/2016 12/31/2023 263.96 Description: INJECTION FOR CHOLANGIOGRAM Category: Medical Services CMS Add: 01/01/2016 CMS Term: 47531 MEDSV DEF RBRVS 01/01/2024 399.15 Description: INJECTION FOR CHOLANGIOGRAM Category: Medical Services CMS Add: 01/01/2016 CMS Term: 47532 MEDSV DEF RBRVS 01/01/2024 788.29 Description: INJECTION FOR CHOLANGIOGRAM Category: Medical Services CMS Add: 01/01/2016 CMS Term: 47532 MEDSV DEF RBRVS 09/15/2017 12/31/2023 569.49 Description: INJECTION FOR CHOLANGIOGRAM Category: Medical Services CMS Add: 01/01/2016 CMS Term: 47533 MEDSV DEF RBRVS 01/01/2024 1096.93 Description: PLMT BILIARY DRAINAGE CATH Category: Medical Services CMS Add: 01/01/2016 CMS Term: 47533 MEDSV DEF RBRVS 09/15/2017 12/31/2023 877.04 Description: PLMT BILIARY DRAINAGE CATH Category: Medical Services CMS Add: 01/01/2016 CMS Term: 47534 MEDSV DEF RBRVS 01/01/2024 1204.40 Description: PLMT BILIARY DRAINAGE CATH Category: Medical Services CMS Add: 01/01/2016 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 593 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 47534 MEDSV DEF RBRVS 09/15/2017 12/31/2023 1046.34 Description: PLMT BILIARY DRAINAGE CATH Category: Medical Services CMS Add: 01/01/2016 CMS Term: 47535 MEDSV DEF RBRVS 01/01/2024 835.20 Description: CONVERSION EXT BIL DRG CATH Category: Medical Services CMS Add: 01/01/2016 CMS Term: 47535 MEDSV DEF RBRVS 09/15/2017 12/31/2023 720.05 Description: CONVERSION EXT BIL DRG CATH Category: Medical Services CMS Add: 01/01/2016 CMS Term: 47536 MEDSV DEF RBRVS 01/01/2024 598.61 Description: EXCHANGE BILIARY DRG CATH Category: Medical Services CMS Add: 01/01/2016 CMS Term: 47536 MEDSV DEF RBRVS 09/15/2017 12/31/2023 488.60 Description: EXCHANGE BILIARY DRG CATH Category: Medical Services CMS Add: 01/01/2016 CMS Term: 47537 MEDSV DEF RBRVS 01/01/2016 12/31/2023 285.24 Description: REMOVAL BILIARY DRG CATH Category: Medical Services CMS Add: 01/01/2016 CMS Term: 47537 MEDSV DEF RBRVS 01/01/2024 463.34 Description: REMOVAL BILIARY DRG CATH Category: Medical Services CMS Add: 01/01/2016 CMS Term: 47538 MEDSV DEF RBRVS 01/01/2024 3535.04 Description: PERQ PLMT BILE DUCT STENT Category: Medical Services CMS Add: 01/01/2016 CMS Term: 47538 MEDSV DEF RBRVS 09/15/2017 12/31/2023 3037.77 Description: PERQ PLMT BILE DUCT STENT Category: Medical Services CMS Add: 01/01/2016 CMS Term: 47539 MEDSV DEF RBRVS 01/01/2024 3944.88 Description: PERQ PLMT BILE DUCT STENT Category: Medical Services CMS Add: 01/01/2016 CMS Term: 47539 MEDSV DEF RBRVS 09/15/2017 12/31/2023 3366.79 Description: PERQ PLMT BILE DUCT STENT Category: Medical Services CMS Add: 01/01/2016 CMS Term: 47540 MEDSV DEF RBRVS 01/01/2024 3981.05 Description: PERQ PLMT BILE DUCT STENT Category: Medical Services CMS Add: 01/01/2016 CMS Term: 47540 MEDSV DEF RBRVS 09/15/2017 12/31/2023 3450.69 Description: PERQ PLMT BILE DUCT STENT Category: Medical Services CMS Add: 01/01/2016 CMS Term: 47541 MEDSV DEF RBRVS 01/01/2024 1092.99 Description: PLMT ACCESS BIL TREE SM BWL Category: Medical Services CMS Add: 01/01/2016 CMS Term: 47541 MEDSV DEF RBRVS 09/15/2017 12/31/2023 833.76 Description: PLMT ACCESS BIL TREE SM BWL Category: Medical Services CMS Add: 01/01/2016 CMS Term: 47542 MEDSV DEF RBRVS 01/01/2024 469.54 Description: DILATE BILIARY DUCT/AMPULLA Category: Medical Services CMS Add: 01/01/2016 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 594 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 47542 MEDSV DEF RBRVS 09/15/2017 12/31/2023 328.42 Description: DILATE BILIARY DUCT/AMPULLA Category: Medical Services CMS Add: 01/01/2016 CMS Term: 47543 MEDSV DEF RBRVS 01/01/2024 369.51 Description: ENDOLUMINAL BX BILIARY TREE Category: Medical Services CMS Add: 01/01/2016 CMS Term: 47543 MEDSV DEF RBRVS 09/15/2017 12/31/2023 407.01 Description: ENDOLUMINAL BX BILIARY TREE Category: Medical Services CMS Add: 01/01/2016 CMS Term: 47544 MEDSV DEF RBRVS 01/01/2024 786.22 Description: REMOVAL DUCT GLBLDR CALCULI Category: Medical Services CMS Add: 01/01/2016 CMS Term: 47544 MEDSV DEF RBRVS 09/15/2017 12/31/2023 768.27 Description: REMOVAL DUCT GLBLDR CALCULI Category: Medical Services CMS Add: 01/01/2016 CMS Term: 47550 MEDSV DEF RBRVS 01/01/2024 148.50 Description: BILE DUCT ENDOSCOPY ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47550 MEDSV DEF RBRVS 09/01/2019 12/31/2023 118.05 Description: BILE DUCT ENDOSCOPY ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47552 MEDSV DEF RBRVS 01/01/2024 258.38 Description: BILIARY ENDO PERQ DX W/SPECI Category: Medical Services CMS Add: 01/01/1985 CMS Term: 47552 MEDSV DEF RBRVS 09/01/2019 12/31/2023 233.36 Description: BILIARY ENDO PERQ DX W/SPECI Category: Medical Services CMS Add: 01/01/1985 CMS Term: 47553 MEDSV DEF RBRVS 01/01/2024 259.65 Description: BILIARY ENDOSCOPY THRU SKIN Category: Medical Services CMS Add: 01/01/1985 CMS Term: 47553 MEDSV DEF RBRVS 02/01/2015 12/31/2023 232.77 Description: BILIARY ENDOSCOPY THRU SKIN Category: Medical Services CMS Add: 01/01/1985 CMS Term: 47554 MEDSV DEF RBRVS 01/01/2019 12/31/2023 355.13 Description: BILIARY ENDOSCOPY THRU SKIN Category: Medical Services CMS Add: 01/01/1985 CMS Term: 47554 MEDSV DEF RBRVS 01/01/2024 415.52 Description: BILIARY ENDOSCOPY THRU SKIN Category: Medical Services CMS Add: 01/01/1985 CMS Term: 47555 MEDSV DEF RBRVS 01/01/2019 12/31/2023 276.51 Description: BILIARY ENDOSCOPY THRU SKIN Category: Medical Services CMS Add: 01/01/1985 CMS Term: 47555 MEDSV DEF RBRVS 01/01/2024 309.09 Description: BILIARY ENDOSCOPY THRU SKIN Category: Medical Services CMS Add: 01/01/1985 CMS Term: 47556 MEDSV DEF RBRVS 01/01/2019 12/31/2023 314.03 Description: BILIARY ENDOSCOPY THRU SKIN Category: Medical Services CMS Add: 01/01/1992 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 595 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 47556 MEDSV DEF RBRVS 01/01/2024 350.15 Description: BILIARY ENDOSCOPY THRU SKIN Category: Medical Services CMS Add: 01/01/1992 CMS Term: 47562 MEDSV DEF RBRVS 01/01/2024 603.77 Description: LAPAROSCOPIC CHOLECYSTECTOMY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 47562 MEDSV DEF RBRVS 02/01/2015 12/31/2023 467.52 Description: LAPAROSCOPIC CHOLECYSTECTOMY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 47563 MEDSV DEF RBRVS 01/01/2024 657.75 Description: LAPARO CHOLECYSTECTOMY/GRAPH Category: Medical Services CMS Add: 01/01/2000 CMS Term: 47563 MEDSV DEF RBRVS 02/01/2015 12/31/2023 508.01 Description: LAPARO CHOLECYSTECTOMY/GRAPH Category: Medical Services CMS Add: 01/01/2000 CMS Term: 47564 MEDSV DEF RBRVS 01/01/2024 1020.86 Description: LAPARO CHOLECYSTECTOMY/EXPLR Category: Medical Services CMS Add: 01/01/2000 CMS Term: 47564 MEDSV DEF RBRVS 02/01/2015 12/31/2023 791.96 Description: LAPARO CHOLECYSTECTOMY/EXPLR Category: Medical Services CMS Add: 01/01/2000 CMS Term: 47570 MEDSV DEF RBRVS 01/01/2024 709.11 0-1 Description: LAPARO CHOLECYSTOENTEROSTOMY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 47570 MEDSV DEF RBRVS 02/01/2015 12/31/2023 550.76 0-1 Description: LAPARO CHOLECYSTOENTEROSTOMY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 47579 MEDSV DEF BILL20 0-1 Description: UNLISTED LAPS PX BILIARY TRC Category: Medical Services CMS Add: 01/01/2000 CMS Term: 47600 MEDSV DEF RBRVS 01/01/2024 977.63 Description: REMOVAL OF GALLBLADDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47600 MEDSV DEF RBRVS 09/01/2019 12/31/2023 760.49 Description: REMOVAL OF GALLBLADDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47605 MEDSV DEF RBRVS 01/01/2024 1029.94 Description: REMOVAL OF GALLBLADDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47605 MEDSV DEF RBRVS 09/01/2019 12/31/2023 800.15 Description: REMOVAL OF GALLBLADDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47610 MEDSV DEF RBRVS 01/01/2024 1142.66 Description: REMOVAL OF GALLBLADDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47610 MEDSV DEF RBRVS 09/01/2019 12/31/2023 892.55 Description: REMOVAL OF GALLBLADDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 596 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 47612 MEDSV DEF RBRVS 01/01/2024 1159.86 Description: REMOVAL OF GALLBLADDER Category: Medical Services CMS Add: 01/01/1987 CMS Term: 47612 MEDSV DEF RBRVS 09/01/2019 12/31/2023 903.73 Description: REMOVAL OF GALLBLADDER Category: Medical Services CMS Add: 01/01/1987 CMS Term: 47620 MEDSV DEF RBRVS 01/01/2024 1252.06 Description: REMOVAL OF GALLBLADDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47620 MEDSV DEF RBRVS 09/01/2019 12/31/2023 980.95 Description: REMOVAL OF GALLBLADDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47700 MEDSV DEF RBRVS 01/01/2024 968.29 Description: EXPLORATION OF BILE DUCTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47700 MEDSV DEF RBRVS 09/01/2019 12/31/2023 747.45 Description: EXPLORATION OF BILE DUCTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47701 MEDSV DEF RBRVS 01/01/2024 1581.25 Description: BILE DUCT REVISION Category: Medical Services CMS Add: 01/01/1988 CMS Term: 47701 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1233.27 Description: BILE DUCT REVISION Category: Medical Services CMS Add: 01/01/1988 CMS Term: 47711 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1110.91 Description: EXCISION OF BILE DUCT TUMOR Category: Medical Services CMS Add: 01/01/1995 CMS Term: 47711 MEDSV DEF RBRVS 01/01/2024 1421.32 Description: EXCISION OF BILE DUCT TUMOR Category: Medical Services CMS Add: 01/01/1995 CMS Term: 47712 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1422.34 Description: EXCISION OF BILE DUCT TUMOR Category: Medical Services CMS Add: 01/01/1995 CMS Term: 47712 MEDSV DEF RBRVS 01/01/2024 1814.63 Description: EXCISION OF BILE DUCT TUMOR Category: Medical Services CMS Add: 01/01/1995 CMS Term: 47715 MEDSV DEF RBRVS 01/01/2024 1213.72 Description: EXCISION OF BILE DUCT CYST Category: Medical Services CMS Add: 01/01/1988 CMS Term: 47715 MEDSV DEF RBRVS 09/01/2019 12/31/2023 945.73 Description: EXCISION OF BILE DUCT CYST Category: Medical Services CMS Add: 01/01/1988 CMS Term: 47720 MEDSV DEF RBRVS 01/01/2024 1055.49 Description: FUSE GALLBLADDER & BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47720 MEDSV DEF RBRVS 09/01/2019 12/31/2023 819.35 Description: FUSE GALLBLADDER & BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 597 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 47721 MEDSV DEF RBRVS 01/01/2024 1235.67 Description: FUSE UPPER GI STRUCTURES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47721 MEDSV DEF RBRVS 09/01/2019 12/31/2023 963.00 Description: FUSE UPPER GI STRUCTURES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47740 MEDSV DEF RBRVS 01/01/2024 1197.89 Description: FUSE GALLBLADDER & BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47740 MEDSV DEF RBRVS 09/01/2019 12/31/2023 933.08 Description: FUSE GALLBLADDER & BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47741 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1049.48 Description: FUSE GALLBLADDER & BOWEL Category: Medical Services CMS Add: 01/01/1995 CMS Term: 47741 MEDSV DEF RBRVS 01/01/2024 1344.90 Description: FUSE GALLBLADDER & BOWEL Category: Medical Services CMS Add: 01/01/1995 CMS Term: 47760 MEDSV DEF RBRVS 01/01/2024 2050.06 Description: FUSE BILE DUCTS AND BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47760 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1606.63 Description: FUSE BILE DUCTS AND BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47765 MEDSV DEF RBRVS 01/01/2024 2702.42 Description: FUSE LIVER DUCTS & BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47765 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2163.35 Description: FUSE LIVER DUCTS & BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47780 MEDSV DEF RBRVS 01/01/2024 2248.11 Description: FUSE BILE DUCTS AND BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47780 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1762.49 Description: FUSE BILE DUCTS AND BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47785 MEDSV DEF RBRVS 01/01/2019 12/31/2023 2315.75 Description: FUSE BILE DUCTS AND BOWEL Category: Medical Services CMS Add: 01/01/1995 CMS Term: 47785 MEDSV DEF RBRVS 01/01/2024 2941.19 Description: FUSE BILE DUCTS AND BOWEL Category: Medical Services CMS Add: 01/01/1995 CMS Term: 47800 MEDSV DEF RBRVS 01/01/2024 1426.66 Description: RECONSTRUCTION OF BILE DUCTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 47800 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1125.68 Description: RECONSTRUCTION OF BILE DUCTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 598 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 47801 MEDSV DEF RBRVS 01/01/2024 1019.02 Description: PLACEMENT BILE DUCT SUPPORT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 47801 MEDSV DEF RBRVS 09/01/2019 12/31/2023 734.55 Description: PLACEMENT BILE DUCT SUPPORT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 47802 MEDSV DEF RBRVS 01/01/2024 1389.49 Description: FUSE LIVER DUCT & INTESTINE Category: Medical Services CMS Add: 01/01/1988 CMS Term: 47802 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1085.09 Description: FUSE LIVER DUCT & INTESTINE Category: Medical Services CMS Add: 01/01/1988 CMS Term: 47900 MEDSV DEF RBRVS 01/01/2019 12/31/2023 976.41 Description: SUTURE BILE DUCT INJURY Category: Medical Services CMS Add: 01/01/1995 CMS Term: 47900 MEDSV DEF RBRVS 01/01/2024 1257.93 Description: SUTURE BILE DUCT INJURY Category: Medical Services CMS Add: 01/01/1995 CMS Term: 47999 MEDSV DEF BILL20 Description: UNLISTED PX BILIARY TRACT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 48000 MEDSV DEF RBRVS 01/01/2024 1710.82 Description: DRAINAGE OF ABDOMEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 48000 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1326.64 Description: DRAINAGE OF ABDOMEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 48001 MEDSV DEF RBRVS 01/01/2024 2092.93 Description: PLACEMENT OF DRAIN PANCREAS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 48001 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1644.02 Description: PLACEMENT OF DRAIN PANCREAS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 48020 MEDSV DEF RBRVS 01/01/2024 1076.56 Description: REMOVAL OF PANCREATIC STONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 48020 MEDSV DEF RBRVS 09/01/2019 12/31/2023 836.94 Description: REMOVAL OF PANCREATIC STONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 48100 MEDSV DEF RBRVS 01/01/2024 812.11 Description: BIOPSY OF PANCREAS OPEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 48100 MEDSV DEF RBRVS 09/01/2019 12/31/2023 632.19 Description: BIOPSY OF PANCREAS OPEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 48102 MEDSV DEF RBRVS 01/01/2024 486.19 Description: NEEDLE BIOPSY PANCREAS Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 599 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 48102 MEDSV DEF RBRVS 09/01/2019 12/31/2023 379.69 Description: NEEDLE BIOPSY PANCREAS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 48105 MEDSV DEF RBRVS 01/01/2024 2584.46 Description: RESECT/DEBRIDE PANCREAS Category: Medical Services CMS Add: 01/01/2007 CMS Term: 48105 MEDSV DEF RBRVS 02/01/2015 12/31/2023 2030.95 Description: RESECT/DEBRIDE PANCREAS Category: Medical Services CMS Add: 01/01/2007 CMS Term: 48120 MEDSV DEF RBRVS 01/01/2024 1016.04 Description: REMOVAL OF PANCREAS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 48120 MEDSV DEF RBRVS 09/01/2019 12/31/2023 789.27 Description: REMOVAL OF PANCREAS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 48140 MEDSV DEF RBRVS 01/01/2024 1428.20 Description: PARTIAL REMOVAL OF PANCREAS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 48140 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1112.95 Description: PARTIAL REMOVAL OF PANCREAS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 48145 MEDSV DEF RBRVS 01/01/2024 1485.77 Description: PARTIAL REMOVAL OF PANCREAS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 48145 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1161.76 Description: PARTIAL REMOVAL OF PANCREAS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 48146 MEDSV DEF RBRVS 01/01/2024 1716.24 Description: PANCREATECTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 48146 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1336.20 Description: PANCREATECTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 48148 MEDSV DEF RBRVS 01/01/2024 1140.74 Description: REMOVAL OF PANCREATIC DUCT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 48148 MEDSV DEF RBRVS 09/01/2019 12/31/2023 887.64 Description: REMOVAL OF PANCREATIC DUCT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 48150 MEDSV DEF RBRVS 01/01/2024 2833.74 Y Description: PARTIAL REMOVAL OF PANCREAS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 48150 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2213.68 Y Description: PARTIAL REMOVAL OF PANCREAS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 48152 MEDSV DEF RBRVS 01/01/2024 2622.49 Y Description: PANCREATECTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 600 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 48152 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2054.03 Y Description: PANCREATECTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 48153 MEDSV DEF RBRVS 01/01/2024 2821.67 Y Description: PANCREATECTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 48153 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2206.06 Y Description: PANCREATECTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 48154 MEDSV DEF RBRVS 01/01/2024 2633.39 Y Description: PANCREATECTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 48154 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2062.86 Y Description: PANCREATECTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 48155 MEDSV DEF RBRVS 01/01/2024 1664.32 Y Description: REMOVAL OF PANCREAS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 48155 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1292.66 Y Description: REMOVAL OF PANCREAS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 48160 MEDSV PRF MAXFEE 01/01/2024 2595.24 0.0 Y Description: PANCREAS REMOVAL/TRANSPLANT Category: Medical Services CMS Add: 01/01/1982 CMS Term: 48400 MEDSV DEF RBRVS 01/01/2024 96.50 Description: INJECTION INTRAOP ADD-ON Category: Medical Services CMS Add: 01/01/1994 CMS Term: 48400 MEDSV DEF RBRVS 02/01/2015 12/31/2023 79.56 Description: INJECTION INTRAOP ADD-ON Category: Medical Services CMS Add: 01/01/1994 CMS Term: 48500 MEDSV DEF RBRVS 01/01/2024 1050.13 Description: SURGERY OF PANCREATIC CYST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 48500 MEDSV DEF RBRVS 09/01/2019 12/31/2023 817.81 Description: SURGERY OF PANCREATIC CYST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 48510 MEDSV DEF RBRVS 01/01/2024 1002.29 Description: DRAIN PANCREATIC PSEUDOCYST Category: Medical Services CMS Add: 01/01/1988 CMS Term: 48510 MEDSV DEF RBRVS 09/01/2019 12/31/2023 775.90 Description: DRAIN PANCREATIC PSEUDOCYST Category: Medical Services CMS Add: 01/01/1988 CMS Term: 48520 MEDSV DEF RBRVS 01/01/2024 1003.49 Description: FUSE PANCREAS CYST AND BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 48520 MEDSV DEF RBRVS 09/01/2019 12/31/2023 777.41 Description: FUSE PANCREAS CYST AND BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 601 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 48540 MEDSV DEF RBRVS 01/01/2024 1190.28 Description: FUSE PANCREAS CYST AND BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 48540 MEDSV DEF RBRVS 09/01/2019 12/31/2023 932.34 Description: FUSE PANCREAS CYST AND BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 48545 MEDSV DEF RBRVS 01/01/2024 1227.01 Description: PANCREATORRHAPHY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 48545 MEDSV DEF RBRVS 09/01/2019 12/31/2023 956.90 Description: PANCREATORRHAPHY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 48547 MEDSV DEF RBRVS 01/01/2024 1629.42 Description: DUODENAL EXCLUSION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 48547 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1275.79 Description: DUODENAL EXCLUSION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 48548 MEDSV DEF RBRVS 01/01/2024 1520.41 Description: FUSE PANCREAS AND BOWEL Category: Medical Services CMS Add: 01/01/2007 CMS Term: 48548 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1185.19 Description: FUSE PANCREAS AND BOWEL Category: Medical Services CMS Add: 01/01/2007 CMS Term: 48550 MEDSV DEF BILL20 Y Description: DONOR PANCREATECTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 48551 MEDSV DEF MAXFEE 01/01/2024 249.42 0.0 Y Description: PREP DONOR PANCREAS Category: Medical Services CMS Add: 01/01/2005 CMS Term: 48552 MEDSV DEF RBRVS 01/01/2024 212.18 Y Description: PREP DONOR PANCREAS/VENOUS Category: Medical Services CMS Add: 01/01/2005 CMS Term: 48552 MEDSV DEF RBRVS 02/01/2015 12/31/2023 168.13 Y Description: PREP DONOR PANCREAS/VENOUS Category: Medical Services CMS Add: 01/01/2005 CMS Term: 48554 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1822.53 Y Description: TRANSPL ALLOGRAFT PANCREAS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 48554 MEDSV DEF RBRVS 01/01/2024 2386.29 Y Description: TRANSPL ALLOGRAFT PANCREAS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 48556 MEDSV DEF RBRVS 01/01/2019 12/31/2023 904.78 Y Description: REMOVAL ALLOGRAFT PANCREAS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 48556 MEDSV DEF RBRVS 01/01/2024 1175.63 Y Description: REMOVAL ALLOGRAFT PANCREAS Category: Medical Services CMS Add: 01/01/1994 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 602 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 48999 MEDSV DEF BILL20 Y Description: UNLISTED PROCEDURE PANCREAS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49000 MEDSV DEF RBRVS 01/01/2024 703.92 Description: EXPLORATION OF ABDOMEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49000 MEDSV DEF RBRVS 09/01/2019 12/31/2023 550.22 Description: EXPLORATION OF ABDOMEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49002 MEDSV DEF RBRVS 01/01/2024 951.63 Description: REOPENING OF ABDOMEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49002 MEDSV DEF RBRVS 09/01/2019 12/31/2023 747.26 Description: REOPENING OF ABDOMEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49010 MEDSV DEF RBRVS 01/01/2024 840.72 Description: EXPLORATION BEHIND ABDOMEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49010 MEDSV DEF RBRVS 09/01/2019 12/31/2023 669.57 Description: EXPLORATION BEHIND ABDOMEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49013 MEDSV DEF RBRVS 01/01/2020 12/31/2023 320.55 Description: PRPERTL PEL PACK HEMRRG TRMA Category: Medical Services CMS Add: 01/01/2020 CMS Term: 49013 MEDSV DEF RBRVS 01/01/2024 411.52 Description: PRPERTL PEL PACK HEMRRG TRMA Category: Medical Services CMS Add: 01/01/2020 CMS Term: 49014 MEDSV DEF RBRVS 01/01/2020 12/31/2023 264.88 Description: REEXPLORATION PELVIC WOUND Category: Medical Services CMS Add: 01/01/2020 CMS Term: 49014 MEDSV DEF RBRVS 01/01/2024 342.62 Description: REEXPLORATION PELVIC WOUND Category: Medical Services CMS Add: 01/01/2020 CMS Term: 49020 MEDSV DEF RBRVS 01/01/2024 1456.08 Description: DRAINAGE ABDOM ABSCESS OPEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49020 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1135.56 Description: DRAINAGE ABDOM ABSCESS OPEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49040 MEDSV DEF RBRVS 01/01/2024 919.66 Description: DRAIN OPEN ABDOM ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49040 MEDSV DEF RBRVS 09/01/2019 12/31/2023 713.63 Description: DRAIN OPEN ABDOM ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49060 MEDSV DEF RBRVS 01/01/2024 1003.39 Description: DRAIN OPEN RETROPERI ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 603 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 49060 MEDSV DEF RBRVS 09/01/2019 12/31/2023 787.54 Description: DRAIN OPEN RETROPERI ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49062 MEDSV DEF RBRVS 01/01/2024 702.30 Description: DRAIN TO PERITONEAL CAVITY Category: Medical Services CMS Add: 01/01/1998 CMS Term: 49062 MEDSV DEF RBRVS 02/01/2015 12/31/2023 524.44 Description: DRAIN TO PERITONEAL CAVITY Category: Medical Services CMS Add: 01/01/1998 CMS Term: 49082 MEDSV DEF RBRVS 01/01/2024 197.89 Description: ABD PARACENTESIS Category: Medical Services CMS Add: 01/01/2012 CMS Term: 49082 MEDSV DEF RBRVS 02/01/2015 12/31/2023 135.21 Description: ABD PARACENTESIS Category: Medical Services CMS Add: 01/01/2012 CMS Term: 49083 MEDSV DEF RBRVS 01/01/2024 276.44 Description: ABD PARACENTESIS W/IMAGING Category: Medical Services CMS Add: 01/01/2012 CMS Term: 49083 MEDSV DEF RBRVS 02/01/2015 12/31/2023 210.13 Description: ABD PARACENTESIS W/IMAGING Category: Medical Services CMS Add: 01/01/2012 CMS Term: 49084 MEDSV DEF RBRVS 01/01/2024 97.70 Description: PERITONEAL LAVAGE Category: Medical Services CMS Add: 01/01/2012 CMS Term: 49084 MEDSV DEF RBRVS 02/01/2015 12/31/2023 74.63 Description: PERITONEAL LAVAGE Category: Medical Services CMS Add: 01/01/2012 CMS Term: 49180 MEDSV DEF RBRVS 01/01/2024 164.63 Description: BIOPSY ABDOMINAL MASS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49180 MEDSV DEF RBRVS 09/01/2019 12/31/2023 116.83 Description: BIOPSY ABDOMINAL MASS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49185 MEDSV DEF RBRVS 01/01/2016 12/31/2023 702.24 Description: SCLEROTX FLUID COLLECTION Category: Medical Services CMS Add: 01/01/2016 CMS Term: 49185 MEDSV DEF RBRVS 01/01/2024 1188.23 Description: SCLEROTX FLUID COLLECTION Category: Medical Services CMS Add: 01/01/2016 CMS Term: 49203 MEDSV DEF RBRVS 01/01/2024 1096.71 Description: EXC ABD TUM 5 CM OR LESS Category: Medical Services CMS Add: 01/01/2008 CMS Term: 49203 MEDSV DEF RBRVS 02/01/2015 12/31/2023 856.87 Description: EXC ABD TUM 5 CM OR LESS Category: Medical Services CMS Add: 01/01/2008 CMS Term: 49204 MEDSV DEF RBRVS 01/01/2024 1396.98 Description: EXC ABD TUM OVER 5 CM Category: Medical Services CMS Add: 01/01/2008 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 604 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 49204 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1094.96 Description: EXC ABD TUM OVER 5 CM Category: Medical Services CMS Add: 01/01/2008 CMS Term: 49205 MEDSV DEF RBRVS 01/01/2024 1602.74 Description: EXC ABD TUM OVER 10 CM Category: Medical Services CMS Add: 01/01/2008 CMS Term: 49205 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1257.10 Description: EXC ABD TUM OVER 10 CM Category: Medical Services CMS Add: 01/01/2008 CMS Term: 49215 MEDSV DEF RBRVS 01/01/2024 2020.87 Description: EXCISE SACRAL SPINE TUMOR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 49215 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1591.02 Description: EXCISE SACRAL SPINE TUMOR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 49250 MEDSV DEF RBRVS 01/01/2024 546.26 Description: EXCISION OF UMBILICUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49250 MEDSV DEF RBRVS 09/01/2019 12/31/2023 415.57 Description: EXCISION OF UMBILICUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49255 MEDSV DEF RBRVS 01/01/2024 729.62 Description: REMOVAL OF OMENTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49255 MEDSV DEF RBRVS 09/01/2019 12/31/2023 566.03 Description: REMOVAL OF OMENTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49320 MEDSV DEF RBRVS 01/01/2024 301.84 0-1 Description: DIAG LAPARO SEPARATE PROC Category: Medical Services CMS Add: 01/01/2000 CMS Term: 49320 MEDSV DEF RBRVS 02/01/2015 12/31/2023 234.22 0-1 Description: DIAG LAPARO SEPARATE PROC Category: Medical Services CMS Add: 01/01/2000 CMS Term: 49321 MEDSV DEF RBRVS 01/01/2024 316.96 0-1 Description: LAPAROSCOPY BIOPSY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 49321 MEDSV DEF RBRVS 02/01/2015 12/31/2023 247.73 0-1 Description: LAPAROSCOPY BIOPSY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 49322 MEDSV DEF RBRVS 01/01/2024 344.72 0-1 Description: LAPAROSCOPY ASPIRATION Category: Medical Services CMS Add: 01/01/2000 CMS Term: 49322 MEDSV DEF RBRVS 02/01/2015 12/31/2023 265.77 0-1 Description: LAPAROSCOPY ASPIRATION Category: Medical Services CMS Add: 01/01/2000 CMS Term: 49323 MEDSV DEF RBRVS 01/01/2024 585.26 0-1 Description: LAPARO DRAIN LYMPHOCELE Category: Medical Services CMS Add: 01/01/2000 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 605 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 49323 MEDSV DEF RBRVS 02/01/2015 12/31/2023 460.57 0-1 Description: LAPARO DRAIN LYMPHOCELE Category: Medical Services CMS Add: 01/01/2000 CMS Term: 49324 MEDSV DEF RBRVS 01/01/2024 353.50 Description: LAP INSERT TUNNEL IP CATH Category: Medical Services CMS Add: 01/01/2007 CMS Term: 49324 MEDSV DEF RBRVS 02/01/2015 12/31/2023 279.22 Description: LAP INSERT TUNNEL IP CATH Category: Medical Services CMS Add: 01/01/2007 CMS Term: 49325 MEDSV DEF RBRVS 01/01/2024 377.15 Description: LAP REVISION PERM IP CATH Category: Medical Services CMS Add: 01/01/2007 CMS Term: 49325 MEDSV DEF RBRVS 02/01/2015 12/31/2023 298.93 Description: LAP REVISION PERM IP CATH Category: Medical Services CMS Add: 01/01/2007 CMS Term: 49326 MEDSV DEF RBRVS 01/01/2024 169.80 Description: LAP W/OMENTOPEXY ADD-ON Category: Medical Services CMS Add: 01/01/2007 CMS Term: 49326 MEDSV DEF RBRVS 02/01/2015 12/31/2023 135.33 Description: LAP W/OMENTOPEXY ADD-ON Category: Medical Services CMS Add: 01/01/2007 CMS Term: 49327 MEDSV DEF RBRVS 01/01/2024 117.32 Description: LAP INS DEVICE FOR RT Category: Medical Services CMS Add: 01/01/2011 CMS Term: 49327 MEDSV DEF RBRVS 02/01/2015 12/31/2023 92.85 Description: LAP INS DEVICE FOR RT Category: Medical Services CMS Add: 01/01/2011 CMS Term: 49329 MEDSV DEF BILL20 0-1 Description: UNLSTD LAPS PX ABD PERTM&OMN Category: Medical Services CMS Add: 01/01/2000 CMS Term: 49400 MEDSV DEF RBRVS 01/01/2024 141.33 Description: AIR INJECTION INTO ABDOMEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49400 MEDSV DEF RBRVS 09/01/2019 12/31/2023 98.16 Description: AIR INJECTION INTO ABDOMEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49402 MEDSV DEF RBRVS 01/01/2024 781.13 Description: REMOVE FOREIGN BODY ADBOMEN Category: Medical Services CMS Add: 01/01/2007 CMS Term: 49402 MEDSV DEF RBRVS 02/01/2015 12/31/2023 609.62 Description: REMOVE FOREIGN BODY ADBOMEN Category: Medical Services CMS Add: 01/01/2007 CMS Term: 49405 MEDSV DEF RBRVS 01/01/2024 834.72 Description: IMAGE CATH FLUID COLXN VISC Category: Medical Services CMS Add: 01/01/2014 CMS Term: 49405 MEDSV DEF RBRVS 09/15/2017 12/31/2023 573.01 Description: IMAGE CATH FLUID COLXN VISC Category: Medical Services CMS Add: 01/01/2014 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 606 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 49406 MEDSV DEF RBRVS 01/01/2024 835.03 Description: IMAGE CATH FLUID PERI/RETRO Category: Medical Services CMS Add: 01/01/2014 CMS Term: 49406 MEDSV DEF RBRVS 09/15/2017 12/31/2023 573.26 Description: IMAGE CATH FLUID PERI/RETRO Category: Medical Services CMS Add: 01/01/2014 CMS Term: 49407 MEDSV DEF RBRVS 01/01/2024 706.17 Description: IMAGE CATH FLUID TRNS/VGNL Category: Medical Services CMS Add: 01/01/2014 CMS Term: 49407 MEDSV DEF RBRVS 09/15/2017 12/31/2023 466.60 Description: IMAGE CATH FLUID TRNS/VGNL Category: Medical Services CMS Add: 01/01/2014 CMS Term: 49411 MEDSV DEF RBRVS 01/01/2024 453.99 Description: INS MARK ABD/PEL FOR RT PERQ Category: Medical Services CMS Add: 01/01/2010 CMS Term: 49411 MEDSV DEF RBRVS 09/15/2017 12/31/2023 344.29 Description: INS MARK ABD/PEL FOR RT PERQ Category: Medical Services CMS Add: 01/01/2010 CMS Term: 49412 MEDSV DEF RBRVS 01/01/2024 74.07 Description: INS DEVICE FOR RT GUIDE OPEN Category: Medical Services CMS Add: 01/01/2011 CMS Term: 49412 MEDSV DEF RBRVS 02/01/2015 12/31/2023 58.47 Description: INS DEVICE FOR RT GUIDE OPEN Category: Medical Services CMS Add: 01/01/2011 CMS Term: 49418 MEDSV DEF MAXFEE 01/01/2024 924.94 0.0 Description: INSERT TUN IP CATH PERC Category: Medical Services CMS Add: 01/01/2011 CMS Term: 49419 MEDSV DEF RBRVS 01/01/2024 385.38 Description: INSERT TUN IP CATH W/PORT Category: Medical Services CMS Add: 01/01/2003 CMS Term: 49419 MEDSV DEF RBRVS 02/01/2015 12/31/2023 318.79 Description: INSERT TUN IP CATH W/PORT Category: Medical Services CMS Add: 01/01/2003 CMS Term: 49421 MEDSV DEF RBRVS 01/01/2024 205.06 Description: INS TUN IP CATH FOR DIAL OPN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49421 MEDSV DEF RBRVS 09/01/2019 12/31/2023 164.81 Description: INS TUN IP CATH FOR DIAL OPN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49422 MEDSV DEF RBRVS 01/01/2019 12/31/2023 272.05 Description: REMOVE TUNNELED IP CATH Category: Medical Services CMS Add: 01/01/1995 CMS Term: 49422 MEDSV DEF RBRVS 01/01/2024 200.83 Description: REMOVE TUNNELED IP CATH Category: Medical Services CMS Add: 01/01/1995 CMS Term: 49423 MEDSV DEF RBRVS 01/01/2024 554.80 Description: EXCHANGE DRAINAGE CATHETER Category: Medical Services CMS Add: 01/01/1998 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 607 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 49423 MEDSV DEF RBRVS 02/01/2015 12/31/2023 386.11 Description: EXCHANGE DRAINAGE CATHETER Category: Medical Services CMS Add: 01/01/1998 CMS Term: 49424 MEDSV DEF RBRVS 01/01/2024 171.52 Description: ASSESS CYST CONTRAST INJECT Category: Medical Services CMS Add: 01/01/1998 CMS Term: 49424 MEDSV DEF RBRVS 02/01/2015 12/31/2023 103.57 Description: ASSESS CYST CONTRAST INJECT Category: Medical Services CMS Add: 01/01/1998 CMS Term: 49425 MEDSV DEF RBRVS 01/01/2024 713.72 Description: INSERT ABDOMEN-VENOUS DRAIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49425 MEDSV DEF RBRVS 09/01/2019 12/31/2023 535.18 Description: INSERT ABDOMEN-VENOUS DRAIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49426 MEDSV DEF RBRVS 01/01/2024 613.51 Description: REVISE ABDOMEN-VENOUS SHUNT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 49426 MEDSV DEF RBRVS 09/01/2019 12/31/2023 442.21 Description: REVISE ABDOMEN-VENOUS SHUNT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 49427 NOCOV DEF SYSMAN Description: INJECTION ABDOMINAL SHUNT Category: Non Covered Services CMS Add: 01/01/1993 CMS Term: 49428 MEDSV DEF RBRVS 01/01/2019 12/31/2023 306.96 Description: LIGATION OF SHUNT Category: Medical Services CMS Add: 01/01/1995 CMS Term: 49428 MEDSV DEF RBRVS 01/01/2024 393.55 Description: LIGATION OF SHUNT Category: Medical Services CMS Add: 01/01/1995 CMS Term: 49429 MEDSV DEF RBRVS 01/01/2019 12/31/2023 326.32 Description: REMOVAL OF SHUNT Category: Medical Services CMS Add: 01/01/1995 CMS Term: 49429 MEDSV DEF RBRVS 01/01/2024 418.22 Description: REMOVAL OF SHUNT Category: Medical Services CMS Add: 01/01/1995 CMS Term: 49435 MEDSV DEF RBRVS 01/01/2024 106.71 Description: INSERT SUBQ EXTEN TO IP CATH Category: Medical Services CMS Add: 01/01/2007 CMS Term: 49435 MEDSV DEF RBRVS 02/01/2015 12/31/2023 85.89 Description: INSERT SUBQ EXTEN TO IP CATH Category: Medical Services CMS Add: 01/01/2007 CMS Term: 49436 MEDSV DEF RBRVS 01/01/2024 504.74 Description: EMBEDDED IP CATH EXIT-SITE Category: Medical Services CMS Add: 01/01/2007 CMS Term: 49436 MEDSV DEF RBRVS 02/01/2015 12/31/2023 132.62 Description: EMBEDDED IP CATH EXIT-SITE Category: Medical Services CMS Add: 01/01/2007 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 608 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 49440 MEDSV DEF RBRVS 01/01/2024 784.06 Description: PLACE GASTROSTOMY TUBE PERC Category: Medical Services CMS Add: 01/01/2008 CMS Term: 49440 MEDSV DEF RBRVS 09/15/2017 12/31/2023 686.89 Description: PLACE GASTROSTOMY TUBE PERC Category: Medical Services CMS Add: 01/01/2008 CMS Term: 49441 MEDSV DEF RBRVS 01/01/2024 889.07 Description: PLACE DUOD/JEJ TUBE PERC Category: Medical Services CMS Add: 01/01/2008 CMS Term: 49441 MEDSV DEF RBRVS 09/15/2017 12/31/2023 774.34 Description: PLACE DUOD/JEJ TUBE PERC Category: Medical Services CMS Add: 01/01/2008 CMS Term: 49442 MEDSV DEF RBRVS 01/01/2024 749.49 Description: PLACE CECOSTOMY TUBE PERC Category: Medical Services CMS Add: 01/01/2008 CMS Term: 49442 MEDSV DEF RBRVS 09/15/2017 12/31/2023 645.23 Description: PLACE CECOSTOMY TUBE PERC Category: Medical Services CMS Add: 01/01/2008 CMS Term: 49446 MEDSV DEF RBRVS 01/01/2024 751.42 Description: CHANGE G-TUBE TO G-J PERC Category: Medical Services CMS Add: 01/01/2008 CMS Term: 49446 MEDSV DEF RBRVS 09/15/2017 12/31/2023 659.06 Description: CHANGE G-TUBE TO G-J PERC Category: Medical Services CMS Add: 01/01/2008 CMS Term: 49450 MEDSV DEF RBRVS 01/01/2024 561.29 Description: REPLACE G/C TUBE PERC Category: Medical Services CMS Add: 01/01/2008 CMS Term: 49450 MEDSV DEF RBRVS 02/01/2015 12/31/2023 470.37 Description: REPLACE G/C TUBE PERC Category: Medical Services CMS Add: 01/01/2008 CMS Term: 49451 MEDSV DEF RBRVS 01/01/2024 600.41 Description: REPLACE DUOD/JEJ TUBE PERC Category: Medical Services CMS Add: 01/01/2008 CMS Term: 49451 MEDSV DEF RBRVS 02/01/2015 12/31/2023 515.80 Description: REPLACE DUOD/JEJ TUBE PERC Category: Medical Services CMS Add: 01/01/2008 CMS Term: 49452 MEDSV DEF RBRVS 01/01/2024 730.12 Description: REPLACE G-J TUBE PERC Category: Medical Services CMS Add: 01/01/2008 CMS Term: 49452 MEDSV DEF RBRVS 02/01/2015 12/31/2023 637.26 Description: REPLACE G-J TUBE PERC Category: Medical Services CMS Add: 01/01/2008 CMS Term: 49460 MEDSV DEF RBRVS 01/01/2024 658.37 Description: FIX G/COLON TUBE W/DEVICE Category: Medical Services CMS Add: 01/01/2008 CMS Term: 49460 MEDSV DEF RBRVS 02/01/2015 12/31/2023 518.91 Description: FIX G/COLON TUBE W/DEVICE Category: Medical Services CMS Add: 01/01/2008 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 609 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 49465 MEDSV DEF RBRVS 01/01/2024 127.86 Description: FLUORO EXAM OF G/COLON TUBE Category: Medical Services CMS Add: 01/01/2008 CMS Term: 49465 MEDSV DEF RBRVS 02/01/2015 12/31/2023 118.55 Description: FLUORO EXAM OF G/COLON TUBE Category: Medical Services CMS Add: 01/01/2008 CMS Term: 49491 MEDSV DEF RBRVS 01/01/2024 730.92 0-6months Description: RPR HERN PREEMIE REDUC Category: Medical Services CMS Add: 01/01/2002 CMS Term: 49491 MEDSV DEF RBRVS 02/01/2015 12/31/2023 563.08 0-6months Description: RPR HERN PREEMIE REDUC Category: Medical Services CMS Add: 01/01/2002 CMS Term: 49492 MEDSV DEF RBRVS 01/01/2024 876.91 0-6months Description: RPR ING HERN PREMIE BLOCKED Category: Medical Services CMS Add: 01/01/2002 CMS Term: 49492 MEDSV DEF RBRVS 02/01/2015 12/31/2023 670.97 0-6months Description: RPR ING HERN PREMIE BLOCKED Category: Medical Services CMS Add: 01/01/2002 CMS Term: 49495 MEDSV DEF RBRVS 01/01/2024 375.37 0-5months Description: RPR ING HERNIA BABY REDUC Category: Medical Services CMS Add: 01/01/1994 CMS Term: 49495 MEDSV DEF RBRVS 09/01/2019 12/31/2023 283.26 0-5months Description: RPR ING HERNIA BABY REDUC Category: Medical Services CMS Add: 01/01/1994 CMS Term: 49496 MEDSV DEF RBRVS 01/01/2024 564.04 0-5months Description: RPR ING HERNIA BABY BLOCKED Category: Medical Services CMS Add: 01/01/1994 CMS Term: 49496 MEDSV DEF RBRVS 09/01/2019 12/31/2023 431.96 0-5months Description: RPR ING HERNIA BABY BLOCKED Category: Medical Services CMS Add: 01/01/1994 CMS Term: 49500 MEDSV DEF RBRVS 01/01/2024 382.56 6-59months Description: RPR ING HERNIA INIT REDUCE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49500 MEDSV DEF RBRVS 09/01/2019 12/31/2023 269.95 6-59months Description: RPR ING HERNIA INIT REDUCE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49501 MEDSV DEF RBRVS 01/01/2024 556.29 6-59months Description: RPR ING HERNIA INIT BLOCKED Category: Medical Services CMS Add: 01/01/1994 CMS Term: 49501 MEDSV DEF RBRVS 09/01/2019 12/31/2023 429.02 6-59months Description: RPR ING HERNIA INIT BLOCKED Category: Medical Services CMS Add: 01/01/1994 CMS Term: 49505 MEDSV DEF RBRVS 01/01/2024 479.89 5-999years Description: PRP I/HERN INIT REDUC >5 YR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49505 MEDSV DEF RBRVS 09/01/2019 12/31/2023 369.44 5-999years Description: PRP I/HERN INIT REDUC >5 YR Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 610 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 49507 MEDSV DEF RBRVS 01/01/2024 539.51 5-999years Description: PRP I/HERN INIT BLOCK >5 YR Category: Medical Services CMS Add: 01/01/1994 CMS Term: 49507 MEDSV DEF RBRVS 09/01/2019 12/31/2023 415.82 5-999years Description: PRP I/HERN INIT BLOCK >5 YR Category: Medical Services CMS Add: 01/01/1994 CMS Term: 49520 MEDSV DEF RBRVS 01/01/2024 580.34 Description: REREPAIR ING HERNIA REDUCE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49520 MEDSV DEF RBRVS 09/01/2019 12/31/2023 448.51 Description: REREPAIR ING HERNIA REDUCE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49521 MEDSV DEF RBRVS 01/01/2024 656.69 Description: REREPAIR ING HERNIA BLOCKED Category: Medical Services CMS Add: 01/01/1994 CMS Term: 49521 MEDSV DEF RBRVS 09/01/2019 12/31/2023 508.44 Description: REREPAIR ING HERNIA BLOCKED Category: Medical Services CMS Add: 01/01/1994 CMS Term: 49525 MEDSV DEF RBRVS 01/01/2024 526.80 Description: REPAIR ING HERNIA SLIDING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49525 MEDSV DEF RBRVS 09/01/2019 12/31/2023 406.82 Description: REPAIR ING HERNIA SLIDING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49540 MEDSV DEF RBRVS 01/01/2024 623.29 Description: REPAIR LUMBAR HERNIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49540 MEDSV DEF RBRVS 09/01/2019 12/31/2023 478.07 Description: REPAIR LUMBAR HERNIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49550 MEDSV DEF RBRVS 01/01/2024 530.09 Description: RPR REM HERNIA INIT REDUCE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49550 MEDSV DEF RBRVS 09/01/2019 12/31/2023 408.18 Description: RPR REM HERNIA INIT REDUCE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49553 MEDSV DEF RBRVS 01/01/2024 580.42 Description: RPR FEM HERNIA INIT BLOCKED Category: Medical Services CMS Add: 01/01/1994 CMS Term: 49553 MEDSV DEF RBRVS 09/01/2019 12/31/2023 448.36 Description: RPR FEM HERNIA INIT BLOCKED Category: Medical Services CMS Add: 01/01/1994 CMS Term: 49555 MEDSV DEF RBRVS 01/01/2024 554.38 Description: REREPAIR FEM HERNIA REDUCE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49555 MEDSV DEF RBRVS 09/01/2019 12/31/2023 422.81 Description: REREPAIR FEM HERNIA REDUCE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 611 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 49557 MEDSV DEF RBRVS 01/01/2024 662.86 Description: REREPAIR FEM HERNIA BLOCKED Category: Medical Services CMS Add: 01/01/1994 CMS Term: 49557 MEDSV DEF RBRVS 09/01/2019 12/31/2023 513.86 Description: REREPAIR FEM HERNIA BLOCKED Category: Medical Services CMS Add: 01/01/1994 CMS Term: 49591 MEDSV DEF RBRVS 01/01/2023 311.44 Description: RPR AA HRN 1ST < 3 CM RDC Category: Medical Services CMS Add: 01/01/2023 CMS Term: 49592 MEDSV DEF RBRVS 01/01/2023 432.85 Description: RPR AA HRN 1ST < 3 NCR/STRN Category: Medical Services CMS Add: 01/01/2023 CMS Term: 49593 MEDSV DEF RBRVS 01/01/2023 12/31/2023 424.22 Description: RPR AA HRN 1ST 3-10 RDC Category: Medical Services CMS Add: 01/01/2023 CMS Term: 49593 MEDSV DEF RBRVS 01/01/2024 521.89 Description: RPR AA HRN 1ST 3-10 RDC Category: Medical Services CMS Add: 01/01/2023 CMS Term: 49594 MEDSV DEF RBRVS 01/01/2023 678.87 Description: RPR AA HRN 1ST 3-10 NCR/STRN Category: Medical Services CMS Add: 01/01/2023 CMS Term: 49595 MEDSV DEF RBRVS 01/01/2023 701.95 Description: RPR AA HRN 1ST > 10 RDC Category: Medical Services CMS Add: 01/01/2023 CMS Term: 49596 MEDSV DEF RBRVS 01/01/2023 932.72 Description: RPR AA HRN 1ST > 10 NCR/STRN Category: Medical Services CMS Add: 01/01/2023 CMS Term: 49600 MEDSV DEF RBRVS 01/01/2024 672.85 Description: REPAIR UMBILICAL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49600 MEDSV DEF RBRVS 09/01/2019 12/31/2023 518.17 Description: REPAIR UMBILICAL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49605 MEDSV DEF RBRVS 01/01/2024 4452.75 Description: REPAIR UMBILICAL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49605 MEDSV DEF RBRVS 09/01/2019 12/31/2023 3514.84 Description: REPAIR UMBILICAL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49606 MEDSV DEF RBRVS 01/01/2024 1035.05 Description: REPAIR UMBILICAL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49606 MEDSV DEF RBRVS 09/01/2019 12/31/2023 804.96 Description: REPAIR UMBILICAL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49610 MEDSV DEF RBRVS 01/01/2024 635.78 Description: REPAIR UMBILICAL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 612 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 49610 MEDSV DEF RBRVS 09/01/2019 12/31/2023 487.68 Description: REPAIR UMBILICAL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49611 MEDSV DEF RBRVS 01/01/2024 560.55 Description: REPAIR UMBILICAL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49611 MEDSV DEF RBRVS 09/01/2019 12/31/2023 408.08 Description: REPAIR UMBILICAL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49613 MEDSV DEF RBRVS 01/01/2023 384.28 Description: RPR AA HRN RCR < 3 RDC Category: Medical Services CMS Add: 01/01/2023 CMS Term: 49614 MEDSV DEF RBRVS 01/01/2023 12/31/2023 423.21 Description: RPR AA HRN RCR < 3 NCR/STRN Category: Medical Services CMS Add: 01/01/2023 CMS Term: 49614 MEDSV DEF RBRVS 01/01/2024 520.63 Description: RPR AA HRN RCR < 3 NCR/STRN Category: Medical Services CMS Add: 01/01/2023 CMS Term: 49615 MEDSV DEF RBRVS 01/01/2023 582.35 Description: RPR AA HRN RCR 3-10 RDC Category: Medical Services CMS Add: 01/01/2023 CMS Term: 49616 MEDSV DEF RBRVS 01/01/2023 781.66 Description: RPR AA HRN RCR 3-10 NCR/STRN Category: Medical Services CMS Add: 01/01/2023 CMS Term: 49617 MEDSV DEF RBRVS 01/01/2023 806.88 Description: RPR AA HRN RCR > 10 RDC Category: Medical Services CMS Add: 01/01/2023 CMS Term: 49618 MEDSV DEF RBRVS 01/01/2023 1129.74 Description: RPR AA HRN RCR > 10 NCR/STRN Category: Medical Services CMS Add: 01/01/2023 CMS Term: 49621 MEDSV DEF RBRVS 01/01/2023 680.59 Description: RPR PARASTOMAL HERNIA RDC Category: Medical Services CMS Add: 01/01/2023 CMS Term: 49622 MEDSV DEF RBRVS 01/01/2023 840.28 Description: RPR PARASTOMAL HRNA NCR/STRN Category: Medical Services CMS Add: 01/01/2023 CMS Term: 49623 MEDSV DEF RBRVS 01/01/2023 181.16 Description: RMVL NINFCT MESH HERNIA RPR Category: Medical Services CMS Add: 01/01/2023 CMS Term: 49650 MEDSV DEF RBRVS 01/01/2024 397.46 0-1 Description: LAP ING HERNIA REPAIR INIT Category: Medical Services CMS Add: 01/01/2000 CMS Term: 49650 MEDSV DEF RBRVS 02/01/2015 12/31/2023 304.07 0-1 Description: LAP ING HERNIA REPAIR INIT Category: Medical Services CMS Add: 01/01/2000 CMS Term: 49651 MEDSV DEF RBRVS 01/01/2024 518.74 0-1 Description: LAP ING HERNIA REPAIR RECUR Category: Medical Services CMS Add: 01/01/2000 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 613 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 49651 MEDSV DEF RBRVS 02/01/2015 12/31/2023 395.42 0-1 Description: LAP ING HERNIA REPAIR RECUR Category: Medical Services CMS Add: 01/01/2000 CMS Term: 49659 MEDSV DEF BILL20 0-1 Description: UNLSTD LAPS PX HRNAP HRNRPHY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 49900 MEDSV DEF RBRVS 01/01/2024 753.68 Description: REPAIR OF ABDOMINAL WALL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49900 MEDSV DEF RBRVS 09/01/2019 12/31/2023 580.58 Description: REPAIR OF ABDOMINAL WALL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 49904 MEDSV DEF RBRVS 01/01/2024 1276.41 Description: OMENTAL FLAP EXTRA-ABDOM Category: Medical Services CMS Add: 01/01/2003 CMS Term: 49904 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1032.45 Description: OMENTAL FLAP EXTRA-ABDOM Category: Medical Services CMS Add: 01/01/2003 CMS Term: 49905 MEDSV DEF RBRVS 01/01/2024 320.46 Description: OMENTAL FLAP INTRA-ABDOM Category: Medical Services CMS Add: 01/01/1993 CMS Term: 49905 MEDSV DEF RBRVS 02/01/2015 12/31/2023 253.83 Description: OMENTAL FLAP INTRA-ABDOM Category: Medical Services CMS Add: 01/01/1993 CMS Term: 49906 MEDSV DEF BILL20 Description: FREE OMENTAL FLAP MICROVASC Category: Medical Services CMS Add: 01/01/1997 CMS Term: 49999 MEDSV DEF BILL20 Description: UNLISTED PX ABD PERTM&OMN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50010 MEDSV DEF RBRVS 01/01/2024 687.90 Description: EXPLORATION OF KIDNEY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50010 MEDSV DEF RBRVS 09/01/2019 12/31/2023 533.73 Description: EXPLORATION OF KIDNEY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50020 MEDSV DEF RBRVS 01/01/2024 946.12 Description: RENAL ABSCESS OPEN DRAIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50020 MEDSV DEF RBRVS 09/01/2019 12/31/2023 744.97 Description: RENAL ABSCESS OPEN DRAIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50040 MEDSV DEF RBRVS 01/01/2024 862.45 Description: NFROS NFROT W/DRG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50040 MEDSV DEF RBRVS 09/01/2019 12/31/2023 672.59 Description: NFROS NFROT W/DRG Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 614 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 50045 MEDSV DEF RBRVS 01/01/2024 868.76 Description: NEPHROTOMY W/EXPLORATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50045 MEDSV DEF RBRVS 09/01/2019 12/31/2023 676.93 Description: NEPHROTOMY W/EXPLORATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 5005F NOCOV DEF SYSMAN Description: PT COUNSLD ON EXAM FOR MOLES Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 50060 MEDSV DEF RBRVS 01/01/2024 1060.42 Description: NL REMOVAL CALCULUS Category: Medical Services CMS Add: 01/01/1982 CMS Term: 50060 MEDSV DEF RBRVS 09/01/2019 12/31/2023 828.43 Description: NL REMOVAL CALCULUS Category: Medical Services CMS Add: 01/01/1982 CMS Term: 50065 MEDSV DEF RBRVS 01/01/2024 1124.11 Description: NL SEC SURG OPERJ CALCULUS Category: Medical Services CMS Add: 01/01/1982 CMS Term: 50065 MEDSV DEF RBRVS 09/01/2019 12/31/2023 879.36 Description: NL SEC SURG OPERJ CALCULUS Category: Medical Services CMS Add: 01/01/1982 CMS Term: 50070 MEDSV DEF RBRVS 01/01/2024 1102.58 Description: NL COMP CGEN KDN ABNORMALITY Category: Medical Services CMS Add: 01/01/1982 CMS Term: 50070 MEDSV DEF RBRVS 09/01/2019 12/31/2023 862.11 Description: NL COMP CGEN KDN ABNORMALITY Category: Medical Services CMS Add: 01/01/1982 CMS Term: 50075 MEDSV DEF RBRVS 01/01/2024 1354.80 Description: NL RMVL LG STAGHORN CALCULUS Category: Medical Services CMS Add: 01/01/1982 CMS Term: 50075 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1060.78 Description: NL RMVL LG STAGHORN CALCULUS Category: Medical Services CMS Add: 01/01/1982 CMS Term: 50080 MEDSV DEF RBRVS 01/01/2024 649.82 Description: PERQ NL/PL LITHOTRP SMPL<2CM Category: Medical Services CMS Add: 01/01/1985 CMS Term: 50080 MEDSV DEF RBRVS 09/01/2019 12/31/2023 632.14 Description: PERQ NL/PL LITHOTRP SMPL<2CM Category: Medical Services CMS Add: 01/01/1985 CMS Term: 50081 MEDSV DEF RBRVS 01/01/2024 1048.57 Description: PERQ NL/PL LITHOTRP CPLX>2CM Category: Medical Services CMS Add: 01/01/1985 CMS Term: 50081 MEDSV DEF RBRVS 09/01/2019 12/31/2023 928.49 Description: PERQ NL/PL LITHOTRP CPLX>2CM Category: Medical Services CMS Add: 01/01/1985 CMS Term: 50100 MEDSV DEF RBRVS 01/01/2024 986.75 Description: TRNSXJ/REPOS ABRRNT RNL VSLS Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 615 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 50100 MEDSV DEF RBRVS 09/01/2019 12/31/2023 766.12 Description: TRNSXJ/REPOS ABRRNT RNL VSLS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 5010F NOCOV DEF SYSMAN Description: MACUL RESULT PHY/QHP MNG DM Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 50120 MEDSV DEF RBRVS 01/01/2024 884.31 Description: PYELOTOMY W/EXPLORATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50120 MEDSV DEF RBRVS 09/01/2019 12/31/2023 689.55 Description: PYELOTOMY W/EXPLORATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50125 MEDSV DEF RBRVS 01/01/2024 914.90 Description: PYELOTOMY W/DRG PYELOSTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50125 MEDSV DEF RBRVS 09/01/2019 12/31/2023 713.70 Description: PYELOTOMY W/DRG PYELOSTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50130 MEDSV DEF RBRVS 01/01/2024 961.69 Description: PYELOTOMY W/REMOVAL CALCULUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50130 MEDSV DEF RBRVS 09/01/2019 12/31/2023 750.40 Description: PYELOTOMY W/REMOVAL CALCULUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50135 MEDSV DEF RBRVS 01/01/2024 1044.03 Description: PYELOTOMY COMPLICATED Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50135 MEDSV DEF RBRVS 09/01/2019 12/31/2023 815.46 Description: PYELOTOMY COMPLICATED Category: Medical Services CMS Add: 01/01/1984 CMS Term: 5015F NOCOV DEF SYSMAN Description: DOC FX & TEST/TXMNT FOR OP Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 50200 MEDSV DEF RBRVS 01/01/2024 484.14 Description: RENAL BIOPSY PERQ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50200 MEDSV DEF RBRVS 09/15/2017 12/31/2023 379.78 Description: RENAL BIOPSY PERQ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50205 MEDSV DEF RBRVS 01/01/2024 690.65 Description: RENAL BX SURG EXPOSURE KDN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50205 MEDSV DEF RBRVS 09/01/2019 12/31/2023 537.88 Description: RENAL BX SURG EXPOSURE KDN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 5020F NOCOV DEF SYSMAN Description: TXMNTS 2 PHYS/QHP BY 1 MON Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 616 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 50220 MEDSV DEF RBRVS 01/01/2024 975.10 Description: REMOVE KIDNEY OPEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50220 MEDSV DEF RBRVS 09/01/2019 12/31/2023 756.13 Description: REMOVE KIDNEY OPEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50225 MEDSV DEF RBRVS 01/01/2024 1115.67 Description: REMOVAL KIDNEY OPEN COMPLEX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50225 MEDSV DEF RBRVS 09/01/2019 12/31/2023 870.02 Description: REMOVAL KIDNEY OPEN COMPLEX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50230 MEDSV DEF RBRVS 01/01/2024 1188.16 Description: REMOVAL KIDNEY OPEN RADICAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50230 MEDSV DEF RBRVS 09/01/2019 12/31/2023 931.29 Description: REMOVAL KIDNEY OPEN RADICAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50234 MEDSV DEF RBRVS 01/01/2024 1210.79 Description: REMOVAL OF KIDNEY & URETER Category: Medical Services CMS Add: 01/01/1985 CMS Term: 50234 MEDSV DEF RBRVS 09/01/2019 12/31/2023 945.50 Description: REMOVAL OF KIDNEY & URETER Category: Medical Services CMS Add: 01/01/1985 CMS Term: 50236 MEDSV DEF RBRVS 01/01/2024 1362.08 Description: REMOVAL OF KIDNEY & URETER Category: Medical Services CMS Add: 01/01/1985 CMS Term: 50236 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1065.67 Description: REMOVAL OF KIDNEY & URETER Category: Medical Services CMS Add: 01/01/1985 CMS Term: 50240 MEDSV DEF RBRVS 01/01/2024 1233.58 Description: PARTIAL REMOVAL OF KIDNEY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50240 MEDSV DEF RBRVS 09/01/2019 12/31/2023 962.10 Description: PARTIAL REMOVAL OF KIDNEY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50250 MEDSV DEF RBRVS 01/01/2024 1132.43 Description: CRYOABLATE RENAL MASS OPEN Category: Medical Services CMS Add: 01/01/2006 CMS Term: 50250 MEDSV DEF RBRVS 02/01/2015 12/31/2023 884.27 Description: CRYOABLATE RENAL MASS OPEN Category: Medical Services CMS Add: 01/01/2006 CMS Term: 50280 MEDSV DEF RBRVS 01/01/2024 892.50 Description: REMOVAL OF KIDNEY LESION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 50280 MEDSV DEF RBRVS 09/01/2019 12/31/2023 692.19 Description: REMOVAL OF KIDNEY LESION Category: Medical Services CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 617 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 50290 MEDSV DEF RBRVS 01/01/2024 837.97 Description: REMOVAL OF KIDNEY LESION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 50290 MEDSV DEF RBRVS 09/01/2019 12/31/2023 652.40 Description: REMOVAL OF KIDNEY LESION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 50300 MEDSV DEF BILL35 Y Description: REMOVE CADAVER DONOR KIDNEY Category: Medical Services CMS Add: 01/01/1982 CMS Term: 50320 MEDSV DEF RBRVS 01/01/2024 1388.80 Y Description: REMOVE KIDNEY LIVING DONOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50320 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1020.14 Y Description: REMOVE KIDNEY LIVING DONOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50323 MEDSV DEF MAXFEE 01/01/2024 171.64 0.0 Y Description: PREP CADAVER RENAL ALLOGRAFT Category: Medical Services CMS Add: 01/01/2005 CMS Term: 50325 MEDSV DEF MAXFEE 01/01/2024 171.64 0.0 Y Description: PREP DONOR RENAL GRAFT Category: Medical Services CMS Add: 01/01/2005 CMS Term: 50327 MEDSV DEF RBRVS 01/01/2024 195.91 Y Description: PREP RENAL GRAFT/VENOUS Category: Medical Services CMS Add: 01/01/2005 CMS Term: 50327 MEDSV DEF RBRVS 02/01/2015 12/31/2023 154.54 Y Description: PREP RENAL GRAFT/VENOUS Category: Medical Services CMS Add: 01/01/2005 CMS Term: 50328 MEDSV DEF RBRVS 01/01/2024 171.32 Y Description: PREP RENAL GRAFT/ARTERIAL Category: Medical Services CMS Add: 01/01/2005 CMS Term: 50328 MEDSV DEF RBRVS 02/01/2015 12/31/2023 135.57 Y Description: PREP RENAL GRAFT/ARTERIAL Category: Medical Services CMS Add: 01/01/2005 CMS Term: 50329 MEDSV DEF RBRVS 01/01/2024 163.24 Y Description: PREP RENAL GRAFT/URETERAL Category: Medical Services CMS Add: 01/01/2005 CMS Term: 50329 MEDSV DEF RBRVS 02/01/2015 12/31/2023 126.57 Y Description: PREP RENAL GRAFT/URETERAL Category: Medical Services CMS Add: 01/01/2005 CMS Term: 50340 MEDSV DEF RBRVS 01/01/2024 876.96 Y Description: REMOVAL OF KIDNEY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50340 MEDSV DEF RBRVS 09/01/2019 12/31/2023 672.27 Y Description: REMOVAL OF KIDNEY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50360 MEDSV DEF RBRVS 01/01/2024 2217.52 Y Description: TRANSPLANTATION OF KIDNEY Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 618 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 50360 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1720.29 Y Description: TRANSPLANTATION OF KIDNEY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50365 MEDSV DEF RBRVS 01/01/2024 2644.62 Y Description: TRANSPLANTATION OF KIDNEY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50365 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2015.64 Y Description: TRANSPLANTATION OF KIDNEY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50370 MEDSV DEF RBRVS 01/01/2024 1112.10 Description: REMOVE TRANSPLANTED KIDNEY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50370 MEDSV DEF RBRVS 09/01/2019 12/31/2023 852.85 Description: REMOVE TRANSPLANTED KIDNEY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50380 MEDSV DEF RBRVS 01/01/2024 1860.86 Y Description: REIMPLANTATION OF KIDNEY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50380 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1419.56 Y Description: REIMPLANTATION OF KIDNEY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50382 MEDSV DEF RBRVS 01/01/2024 947.12 Description: CHANGE URETER STENT PERCUT Category: Medical Services CMS Add: 01/01/2006 CMS Term: 50382 MEDSV DEF RBRVS 09/15/2017 12/31/2023 787.59 Description: CHANGE URETER STENT PERCUT Category: Medical Services CMS Add: 01/01/2006 CMS Term: 50384 MEDSV DEF RBRVS 01/01/2024 809.44 Description: REMOVE URETER STENT PERCUT Category: Medical Services CMS Add: 01/01/2006 CMS Term: 50384 MEDSV DEF RBRVS 09/15/2017 12/31/2023 619.01 Description: REMOVE URETER STENT PERCUT Category: Medical Services CMS Add: 01/01/2006 CMS Term: 50385 MEDSV DEF RBRVS 01/01/2024 947.88 Description: CHANGE STENT VIA TRANSURETH Category: Medical Services CMS Add: 01/01/2008 CMS Term: 50385 MEDSV DEF RBRVS 09/15/2017 12/31/2023 765.31 Description: CHANGE STENT VIA TRANSURETH Category: Medical Services CMS Add: 01/01/2008 CMS Term: 50386 MEDSV DEF RBRVS 01/01/2024 700.95 Description: REMOVE STENT VIA TRANSURETH Category: Medical Services CMS Add: 01/01/2008 CMS Term: 50386 MEDSV DEF RBRVS 09/15/2017 12/31/2023 488.12 Description: REMOVE STENT VIA TRANSURETH Category: Medical Services CMS Add: 01/01/2008 CMS Term: 50387 MEDSV DEF RBRVS 01/01/2024 522.18 Description: CHANGE NEPHROURETERAL CATH Category: Medical Services CMS Add: 01/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 619 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 50387 MEDSV DEF RBRVS 09/15/2017 12/31/2023 347.25 Description: CHANGE NEPHROURETERAL CATH Category: Medical Services CMS Add: 01/01/2006 CMS Term: 50389 MEDSV DEF RBRVS 01/01/2024 390.36 Description: REMOVE RENAL TUBE W/FLUORO Category: Medical Services CMS Add: 01/01/2006 CMS Term: 50389 MEDSV DEF RBRVS 02/01/2015 12/31/2023 212.29 Description: REMOVE RENAL TUBE W/FLUORO Category: Medical Services CMS Add: 01/01/2006 CMS Term: 50390 MEDSV DEF RBRVS 01/01/2024 88.62 Description: DRAINAGE OF KIDNEY LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50390 MEDSV DEF RBRVS 09/01/2019 12/31/2023 72.07 Description: DRAINAGE OF KIDNEY LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50391 MEDSV DEF RBRVS 01/01/2016 12/31/2023 88.25 Description: INSTLL RX AGNT INTO RNAL TUB Category: Medical Services CMS Add: 01/01/2005 CMS Term: 50391 MEDSV DEF RBRVS 01/01/2024 116.74 Description: INSTLL RX AGNT INTO RNAL TUB Category: Medical Services CMS Add: 01/01/2005 CMS Term: 50396 MEDSV DEF RBRVS 01/01/2024 108.77 Description: MEASURE KIDNEY PRESSURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50396 MEDSV DEF RBRVS 09/01/2019 12/31/2023 87.04 Description: MEASURE KIDNEY PRESSURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50400 MEDSV DEF RBRVS 01/01/2024 1075.30 Description: REVISION OF KIDNEY/URETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50400 MEDSV DEF RBRVS 09/01/2019 12/31/2023 841.24 Description: REVISION OF KIDNEY/URETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50405 MEDSV DEF RBRVS 01/01/2024 1298.06 Description: REVISION OF KIDNEY/URETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50405 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1015.18 Description: REVISION OF KIDNEY/URETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50430 MEDSV DEF RBRVS 01/01/2024 592.72 Description: NJX PX NFROSGRM &/URTRGRM Category: Medical Services CMS Add: 01/01/2016 CMS Term: 50430 MEDSV DEF RBRVS 09/15/2017 12/31/2023 325.30 Description: NJX PX NFROSGRM &/URTRGRM Category: Medical Services CMS Add: 01/01/2016 CMS Term: 50431 MEDSV DEF RBRVS 01/01/2016 12/31/2023 115.18 Description: NJX PX NFROSGRM &/URTRGRM Category: Medical Services CMS Add: 01/01/2016 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 620 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 50431 MEDSV DEF RBRVS 01/01/2024 302.69 Description: NJX PX NFROSGRM &/URTRGRM Category: Medical Services CMS Add: 01/01/2016 CMS Term: 50432 MEDSV DEF RBRVS 01/01/2024 853.26 Description: PLMT NEPHROSTOMY CATHETER Category: Medical Services CMS Add: 01/01/2016 CMS Term: 50432 MEDSV DEF RBRVS 09/15/2017 12/31/2023 548.73 Description: PLMT NEPHROSTOMY CATHETER Category: Medical Services CMS Add: 01/01/2016 CMS Term: 50433 MEDSV DEF RBRVS 01/01/2024 1063.18 Description: PLMT NEPHROURETERAL CATHETER Category: Medical Services CMS Add: 01/01/2016 CMS Term: 50433 MEDSV DEF RBRVS 09/15/2017 12/31/2023 750.02 Description: PLMT NEPHROURETERAL CATHETER Category: Medical Services CMS Add: 01/01/2016 CMS Term: 50434 MEDSV DEF RBRVS 01/01/2024 853.26 Description: CONVERT NEPHROSTOMY CATHETER Category: Medical Services CMS Add: 01/01/2016 CMS Term: 50434 MEDSV DEF RBRVS 09/15/2017 12/31/2023 588.42 Description: CONVERT NEPHROSTOMY CATHETER Category: Medical Services CMS Add: 01/01/2016 CMS Term: 50435 MEDSV DEF RBRVS 01/01/2016 12/31/2023 334.18 Description: EXCHANGE NEPHROSTOMY CATH Category: Medical Services CMS Add: 01/01/2016 CMS Term: 50435 MEDSV DEF RBRVS 01/01/2024 564.23 Description: EXCHANGE NEPHROSTOMY CATH Category: Medical Services CMS Add: 01/01/2016 CMS Term: 50436 MEDSV DEF RBRVS 01/01/2019 12/31/2023 111.85 Description: DILAT XST TRC NDURLGC PX Category: Medical Services CMS Add: 01/01/2019 CMS Term: 50436 MEDSV DEF RBRVS 01/01/2024 138.70 Description: DILAT XST TRC NDURLGC PX Category: Medical Services CMS Add: 01/01/2019 CMS Term: 50437 MEDSV DEF RBRVS 01/01/2019 12/31/2023 187.04 Description: DILAT XST TRC NEW ACCESS RCS Category: Medical Services CMS Add: 01/01/2019 CMS Term: 50437 MEDSV DEF RBRVS 01/01/2024 232.12 Description: DILAT XST TRC NEW ACCESS RCS Category: Medical Services CMS Add: 01/01/2019 CMS Term: 50500 MEDSV DEF RBRVS 01/01/2024 1145.52 Description: REPAIR OF KIDNEY WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50500 MEDSV DEF RBRVS 09/01/2019 12/31/2023 913.49 Description: REPAIR OF KIDNEY WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 5050F NOCOV DEF SYSMAN Description: PLAN 2 MAIN DR BY 1 MONTH Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 621 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 50520 MEDSV DEF RBRVS 01/01/2024 1057.83 Description: CLOSE KIDNEY-SKIN FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50520 MEDSV DEF RBRVS 09/01/2019 12/31/2023 787.51 Description: CLOSE KIDNEY-SKIN FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50525 MEDSV DEF RBRVS 01/01/2024 1339.46 Description: CLOSE NEPHROVISCERAL FISTULA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 50525 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1048.54 Description: CLOSE NEPHROVISCERAL FISTULA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 50526 MEDSV DEF RBRVS 01/01/2024 1434.48 Description: CLOSE NEPHROVISCERAL FISTULA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 50526 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1054.10 Description: CLOSE NEPHROVISCERAL FISTULA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 50540 MEDSV DEF RBRVS 01/01/2024 1067.37 Description: REVISION OF HORSESHOE KIDNEY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50540 MEDSV DEF RBRVS 09/01/2019 12/31/2023 834.03 Description: REVISION OF HORSESHOE KIDNEY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50541 MEDSV DEF RBRVS 01/01/2016 12/31/2023 668.92 0-2 Description: LAPARO ABLATE RENAL CYST Category: Medical Services CMS Add: 01/01/2000 CMS Term: 50541 MEDSV DEF RBRVS 01/01/2024 854.10 0-2 Description: LAPARO ABLATE RENAL CYST Category: Medical Services CMS Add: 01/01/2000 CMS Term: 50542 MEDSV DEF RBRVS 01/01/2016 12/31/2023 847.87 Description: LAPARO ABLATE RENAL MASS Category: Medical Services CMS Add: 01/01/2003 CMS Term: 50542 MEDSV DEF RBRVS 01/01/2024 1086.29 Description: LAPARO ABLATE RENAL MASS Category: Medical Services CMS Add: 01/01/2003 CMS Term: 50543 MEDSV DEF RBRVS 01/01/2016 12/31/2023 1082.59 Description: LAPARO PARTIAL NEPHRECTOMY Category: Medical Services CMS Add: 01/01/2003 CMS Term: 50543 MEDSV DEF RBRVS 01/01/2024 1385.60 Description: LAPARO PARTIAL NEPHRECTOMY Category: Medical Services CMS Add: 01/01/2003 CMS Term: 50544 MEDSV DEF RBRVS 01/01/2016 12/31/2023 906.91 0-2 Description: LAPAROSCOPY PYELOPLASTY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 50544 MEDSV DEF RBRVS 01/01/2024 1154.99 0-2 Description: LAPAROSCOPY PYELOPLASTY Category: Medical Services CMS Add: 01/01/2000 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 622 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 50545 MEDSV DEF RBRVS 01/01/2024 1240.66 Description: LAPARO RADICAL NEPHRECTOMY Category: Medical Services CMS Add: 01/01/2001 CMS Term: 50545 MEDSV DEF RBRVS 02/01/2015 12/31/2023 976.18 Description: LAPARO RADICAL NEPHRECTOMY Category: Medical Services CMS Add: 01/01/2001 CMS Term: 50546 MEDSV DEF RBRVS 01/01/2016 12/31/2023 872.64 Description: LAPAROSCOPIC NEPHRECTOMY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 50546 MEDSV DEF RBRVS 01/01/2024 1117.78 Description: LAPAROSCOPIC NEPHRECTOMY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 50547 MEDSV DEF RBRVS 01/01/2024 1480.89 0-1 Description: LAPARO REMOVAL DONOR KIDNEY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 50547 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1147.17 0-1 Description: LAPARO REMOVAL DONOR KIDNEY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 50548 MEDSV DEF RBRVS 01/01/2016 12/31/2023 980.94 0-2 Description: LAPARO REMOVE W/URETER Category: Medical Services CMS Add: 01/01/2000 CMS Term: 50548 MEDSV DEF RBRVS 01/01/2024 1247.60 0-2 Description: LAPARO REMOVE W/URETER Category: Medical Services CMS Add: 01/01/2000 CMS Term: 50549 MEDSV DEF BILL35 Y 0-1 Description: UNLISTED LAPS PX RENAL Category: Medical Services CMS Add: 01/01/2000 CMS Term: 50551 MEDSV DEF RBRVS 01/01/2024 337.28 Description: KIDNEY ENDOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50551 MEDSV DEF RBRVS 09/01/2019 12/31/2023 257.87 Description: KIDNEY ENDOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50553 MEDSV DEF RBRVS 01/01/2024 361.49 Description: KIDNEY ENDOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50553 MEDSV DEF RBRVS 09/01/2019 12/31/2023 276.44 Description: KIDNEY ENDOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50555 MEDSV DEF RBRVS 01/01/2016 12/31/2023 295.82 Description: KIDNEY ENDOSCOPY & BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50555 MEDSV DEF RBRVS 01/01/2024 384.46 Description: KIDNEY ENDOSCOPY & BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50557 MEDSV DEF RBRVS 01/01/2016 12/31/2023 300.63 Description: KIDNEY ENDOSCOPY & TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 623 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 50557 MEDSV DEF RBRVS 01/01/2024 391.38 Description: KIDNEY ENDOSCOPY & TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50561 MEDSV DEF RBRVS 01/01/2019 12/31/2023 341.88 Description: KIDNEY ENDOSCOPY & TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50561 MEDSV DEF RBRVS 01/01/2024 443.77 Description: KIDNEY ENDOSCOPY & TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50562 MEDSV DEF RBRVS 01/01/2024 535.54 Description: RENAL SCOPE W/TUMOR RESECT Category: Medical Services CMS Add: 01/01/2003 CMS Term: 50562 MEDSV DEF RBRVS 02/01/2015 12/31/2023 423.74 Description: RENAL SCOPE W/TUMOR RESECT Category: Medical Services CMS Add: 01/01/2003 CMS Term: 50570 MEDSV DEF RBRVS 01/01/2024 453.81 Description: KIDNEY ENDOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50570 MEDSV DEF RBRVS 09/01/2019 12/31/2023 358.85 Description: KIDNEY ENDOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50572 MEDSV DEF RBRVS 01/01/2016 12/31/2023 388.69 Description: KIDNEY ENDOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50572 MEDSV DEF RBRVS 01/01/2024 490.86 Description: KIDNEY ENDOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50574 MEDSV DEF RBRVS 01/01/2016 12/31/2023 413.38 Description: KIDNEY ENDOSCOPY & BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50574 MEDSV DEF RBRVS 01/01/2024 522.11 Description: KIDNEY ENDOSCOPY & BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50575 MEDSV DEF RBRVS 01/01/2019 12/31/2023 522.38 Description: KIDNEY ENDOSCOPY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 50575 MEDSV DEF RBRVS 01/01/2024 659.55 Description: KIDNEY ENDOSCOPY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 50576 MEDSV DEF RBRVS 01/01/2016 12/31/2023 411.99 Description: KIDNEY ENDOSCOPY & TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50576 MEDSV DEF RBRVS 01/01/2024 520.78 Description: KIDNEY ENDOSCOPY & TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50580 MEDSV DEF RBRVS 01/01/2016 12/31/2023 444.70 Description: KIDNEY ENDOSCOPY & TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 624 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 50580 MEDSV DEF RBRVS 01/01/2024 560.98 Description: KIDNEY ENDOSCOPY & TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50590 MEDSV DEF RBRVS 01/01/2024 691.95 Description: FRAGMENTING OF KIDNEY STONE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 50590 MEDSV DEF RBRVS 09/01/2019 12/31/2023 514.10 Description: FRAGMENTING OF KIDNEY STONE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 50592 MEDSV DEF RBRVS 01/01/2024 2653.04 Description: PERC RF ABLATE RENAL TUMOR Category: Medical Services CMS Add: 01/01/2006 CMS Term: 50592 MEDSV DEF RBRVS 09/15/2017 12/31/2023 875.94 Description: PERC RF ABLATE RENAL TUMOR Category: Medical Services CMS Add: 01/01/2006 CMS Term: 50593 MEDSV DEF RBRVS 01/01/2024 3551.78 Description: PERC CRYO ABLATE RENAL TUM Category: Medical Services CMS Add: 01/01/2008 CMS Term: 50593 MEDSV DEF RBRVS 09/15/2017 12/31/2023 3191.59 Description: PERC CRYO ABLATE RENAL TUM Category: Medical Services CMS Add: 01/01/2008 CMS Term: 50600 MEDSV DEF RBRVS 01/01/2024 873.38 Description: EXPLORATION OF URETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50600 MEDSV DEF RBRVS 09/01/2019 12/31/2023 682.53 Description: EXPLORATION OF URETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50605 MEDSV DEF RBRVS 01/01/2024 920.44 Description: INSERT URETERAL SUPPORT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 50605 MEDSV DEF RBRVS 09/01/2019 12/31/2023 700.98 Description: INSERT URETERAL SUPPORT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 50606 MEDSV DEF RBRVS 01/01/2024 454.48 Description: ENDOLUMINAL BX URTR RNL PLVS Category: Medical Services CMS Add: 01/01/2016 CMS Term: 50606 MEDSV DEF RBRVS 09/15/2017 12/31/2023 498.92 Description: ENDOLUMINAL BX URTR RNL PLVS Category: Medical Services CMS Add: 01/01/2016 CMS Term: 5060F NOCOV DEF SYSMAN Description: FNDNGS MAMMO 2PT W/IN 3 DAYS Category: Non Covered Services CMS Add: 04/01/2008 CMS Term: 50610 MEDSV DEF RBRVS 01/01/2024 879.65 Description: REMOVAL OF URETER STONE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 50610 MEDSV DEF RBRVS 09/01/2019 12/31/2023 687.16 Description: REMOVAL OF URETER STONE Category: Medical Services CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 625 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 50620 MEDSV DEF RBRVS 01/01/2024 841.46 Description: REMOVAL OF URETER STONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50620 MEDSV DEF RBRVS 09/01/2019 12/31/2023 657.03 Description: REMOVAL OF URETER STONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 5062F NOCOV DEF SYSMAN Description: MAMMO RESULT COM TO PT 5 DAY Category: Non Covered Services CMS Add: 04/01/2008 CMS Term: 50630 MEDSV DEF RBRVS 01/01/2024 831.36 Description: REMOVAL OF URETER STONE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 50630 MEDSV DEF RBRVS 09/01/2019 12/31/2023 648.81 Description: REMOVAL OF URETER STONE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 50650 MEDSV DEF RBRVS 01/01/2024 964.67 Description: REMOVAL OF URETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50650 MEDSV DEF RBRVS 09/01/2019 12/31/2023 752.05 Description: REMOVAL OF URETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50660 MEDSV DEF RBRVS 01/01/2024 1063.41 Description: REMOVAL OF URETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50660 MEDSV DEF RBRVS 09/01/2019 12/31/2023 831.39 Description: REMOVAL OF URETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50684 MEDSV DEF RBRVS 01/01/2024 118.74 Description: INJECTION FOR URETER X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50684 MEDSV DEF RBRVS 09/01/2019 12/31/2023 74.59 Description: INJECTION FOR URETER X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50686 MEDSV DEF RBRVS 01/01/2024 133.10 Description: MEASURE URETER PRESSURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50686 MEDSV DEF RBRVS 09/01/2019 12/31/2023 108.45 Description: MEASURE URETER PRESSURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50688 MEDSV DEF RBRVS 01/01/2024 72.23 Description: CHANGE OF URETER TUBE/STENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50688 MEDSV DEF RBRVS 09/01/2019 12/31/2023 58.33 Description: CHANGE OF URETER TUBE/STENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50690 MEDSV DEF RBRVS 01/01/2024 111.94 Description: INJECTION FOR URETER X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 626 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 50690 MEDSV DEF RBRVS 09/01/2019 12/31/2023 70.47 Description: INJECTION FOR URETER X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50693 MEDSV DEF RBRVS 01/01/2024 934.32 Description: PLMT URETERAL STENT PRQ Category: Medical Services CMS Add: 01/01/2016 CMS Term: 50693 MEDSV DEF RBRVS 09/15/2017 12/31/2023 699.76 Description: PLMT URETERAL STENT PRQ Category: Medical Services CMS Add: 01/01/2016 CMS Term: 50694 MEDSV DEF RBRVS 01/01/2024 1049.28 Description: PLMT URETERAL STENT PRQ Category: Medical Services CMS Add: 01/01/2016 CMS Term: 50694 MEDSV DEF RBRVS 09/15/2017 12/31/2023 769.34 Description: PLMT URETERAL STENT PRQ Category: Medical Services CMS Add: 01/01/2016 CMS Term: 50695 MEDSV DEF RBRVS 01/01/2024 1259.65 Description: PLMT URETERAL STENT PRQ Category: Medical Services CMS Add: 01/01/2016 CMS Term: 50695 MEDSV DEF RBRVS 09/15/2017 12/31/2023 945.17 Description: PLMT URETERAL STENT PRQ Category: Medical Services CMS Add: 01/01/2016 CMS Term: 50700 MEDSV DEF RBRVS 01/01/2024 862.79 Description: REVISION OF URETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50700 MEDSV DEF RBRVS 09/01/2019 12/31/2023 674.67 Description: REVISION OF URETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50705 MEDSV DEF RBRVS 01/01/2024 1725.37 Description: URETERAL EMBOLIZATION/OCCL Category: Medical Services CMS Add: 01/01/2016 CMS Term: 50705 MEDSV DEF RBRVS 09/15/2017 12/31/2023 1366.01 Description: URETERAL EMBOLIZATION/OCCL Category: Medical Services CMS Add: 01/01/2016 CMS Term: 50706 MEDSV DEF RBRVS 01/01/2024 788.12 Description: BALLOON DILATE URTRL STRIX Category: Medical Services CMS Add: 01/01/2016 CMS Term: 50706 MEDSV DEF RBRVS 09/15/2017 12/31/2023 706.52 Description: BALLOON DILATE URTRL STRIX Category: Medical Services CMS Add: 01/01/2016 CMS Term: 50715 MEDSV DEF RBRVS 01/01/2024 1115.59 Description: RELEASE OF URETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50715 MEDSV DEF RBRVS 09/01/2019 12/31/2023 868.17 Description: RELEASE OF URETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50722 MEDSV DEF RBRVS 01/01/2024 951.36 Description: RELEASE OF URETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 627 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 50722 MEDSV DEF RBRVS 09/01/2019 12/31/2023 761.38 Description: RELEASE OF URETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50725 MEDSV DEF RBRVS 01/01/2024 1025.85 Description: RELEASE/REVISE URETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50725 MEDSV DEF RBRVS 09/01/2019 12/31/2023 801.10 Description: RELEASE/REVISE URETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50727 MEDSV DEF RBRVS 01/01/2024 476.39 Description: REVISE URETER Category: Medical Services CMS Add: 01/01/1993 CMS Term: 50727 MEDSV DEF RBRVS 09/01/2019 12/31/2023 365.48 Description: REVISE URETER Category: Medical Services CMS Add: 01/01/1993 CMS Term: 50728 MEDSV DEF RBRVS 01/01/2024 653.42 Description: REVISE URETER Category: Medical Services CMS Add: 01/01/1993 CMS Term: 50728 MEDSV DEF RBRVS 09/01/2019 12/31/2023 506.43 Description: REVISE URETER Category: Medical Services CMS Add: 01/01/1993 CMS Term: 50740 MEDSV DEF RBRVS 01/01/2024 1116.09 Description: FUSION OF URETER & KIDNEY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50740 MEDSV DEF RBRVS 09/01/2019 12/31/2023 868.80 Description: FUSION OF URETER & KIDNEY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50750 MEDSV DEF RBRVS 01/01/2024 1072.83 Description: FUSION OF URETER & KIDNEY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50750 MEDSV DEF RBRVS 09/01/2019 12/31/2023 838.66 Description: FUSION OF URETER & KIDNEY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50760 MEDSV DEF RBRVS 01/01/2024 1047.30 Description: FUSION OF URETERS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50760 MEDSV DEF RBRVS 09/01/2019 12/31/2023 815.70 Description: FUSION OF URETERS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50770 MEDSV DEF RBRVS 01/01/2024 1072.83 Description: SPLICING OF URETERS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50770 MEDSV DEF RBRVS 09/01/2019 12/31/2023 838.66 Description: SPLICING OF URETERS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50780 MEDSV DEF RBRVS 01/01/2024 1029.39 Description: REIMPLANT URETER IN BLADDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 628 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 50780 MEDSV DEF RBRVS 09/01/2019 12/31/2023 802.64 Description: REIMPLANT URETER IN BLADDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50782 MEDSV DEF RBRVS 01/01/2024 1000.56 Description: REIMPLANT URETER IN BLADDER Category: Medical Services CMS Add: 01/01/1993 CMS Term: 50782 MEDSV DEF RBRVS 09/01/2019 12/31/2023 746.07 Description: REIMPLANT URETER IN BLADDER Category: Medical Services CMS Add: 01/01/1993 CMS Term: 50783 MEDSV DEF RBRVS 01/01/2024 1048.85 Description: REIMPLANT URETER IN BLADDER Category: Medical Services CMS Add: 01/01/1993 CMS Term: 50783 MEDSV DEF RBRVS 09/01/2019 12/31/2023 819.57 Description: REIMPLANT URETER IN BLADDER Category: Medical Services CMS Add: 01/01/1993 CMS Term: 50785 MEDSV DEF RBRVS 01/01/2024 1128.60 Description: REIMPLANT URETER IN BLADDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50785 MEDSV DEF RBRVS 09/01/2019 12/31/2023 879.50 Description: REIMPLANT URETER IN BLADDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50800 MEDSV DEF RBRVS 01/01/2024 862.31 Description: IMPLANT URETER IN BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50800 MEDSV DEF RBRVS 09/01/2019 12/31/2023 671.20 Description: IMPLANT URETER IN BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50810 MEDSV DEF RBRVS 01/01/2024 1282.10 Description: FUSION OF URETER & BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50810 MEDSV DEF RBRVS 09/01/2019 12/31/2023 948.86 Description: FUSION OF URETER & BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50815 MEDSV DEF RBRVS 01/01/2024 1139.96 Description: URINE SHUNT TO INTESTINE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50815 MEDSV DEF RBRVS 09/01/2019 12/31/2023 888.65 Description: URINE SHUNT TO INTESTINE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50820 MEDSV DEF RBRVS 01/01/2024 1221.00 Description: CONSTRUCT BOWEL BLADDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50820 MEDSV DEF RBRVS 09/01/2019 12/31/2023 956.52 Description: CONSTRUCT BOWEL BLADDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50825 MEDSV DEF RBRVS 01/01/2024 1530.92 Description: CONSTRUCT BOWEL BLADDER Category: Medical Services CMS Add: 01/01/1988 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 629 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 50825 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1204.30 Description: CONSTRUCT BOWEL BLADDER Category: Medical Services CMS Add: 01/01/1988 CMS Term: 50830 MEDSV DEF RBRVS 01/01/2024 1674.31 Description: REVISE URINE FLOW Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50830 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1312.34 Description: REVISE URINE FLOW Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50840 MEDSV DEF RBRVS 01/01/2024 1146.23 Description: REPLACE URETER BY BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50840 MEDSV DEF RBRVS 09/01/2019 12/31/2023 893.30 Description: REPLACE URETER BY BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50845 MEDSV DEF RBRVS 01/01/2024 1168.06 Description: APPENDICO-VESICOSTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 50845 MEDSV DEF RBRVS 09/01/2019 12/31/2023 907.07 Description: APPENDICO-VESICOSTOMY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 50860 MEDSV DEF RBRVS 01/01/2024 880.67 Y Description: TRANSPLANT URETER TO SKIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50860 MEDSV DEF RBRVS 09/01/2019 12/31/2023 686.64 Y Description: TRANSPLANT URETER TO SKIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50900 MEDSV DEF RBRVS 01/01/2024 786.21 Description: REPAIR OF URETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50900 MEDSV DEF RBRVS 09/01/2019 12/31/2023 617.38 Description: REPAIR OF URETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50920 MEDSV DEF RBRVS 01/01/2024 821.94 Description: CLOSURE URETER/SKIN FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50920 MEDSV DEF RBRVS 09/01/2019 12/31/2023 640.05 Description: CLOSURE URETER/SKIN FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50930 MEDSV DEF RBRVS 01/01/2024 1025.51 Description: CLOSURE URETER/BOWEL FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50930 MEDSV DEF RBRVS 09/01/2019 12/31/2023 873.18 Description: CLOSURE URETER/BOWEL FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50940 MEDSV DEF RBRVS 01/01/2024 828.03 Description: RELEASE OF URETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 630 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 50940 MEDSV DEF RBRVS 09/01/2019 12/31/2023 644.43 Description: RELEASE OF URETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50945 MEDSV DEF RBRVS 01/01/2024 903.64 0-2 Description: LAPAROSCOPY URETEROLITHOTOMY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 50945 MEDSV DEF RBRVS 02/01/2015 12/31/2023 707.91 0-2 Description: LAPAROSCOPY URETEROLITHOTOMY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 50947 MEDSV DEF RBRVS 01/01/2024 1286.41 Description: LAPARO NEW URETER/BLADDER Category: Medical Services CMS Add: 01/01/2001 CMS Term: 50947 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1009.32 Description: LAPARO NEW URETER/BLADDER Category: Medical Services CMS Add: 01/01/2001 CMS Term: 50948 MEDSV DEF RBRVS 01/01/2024 1184.03 Description: LAPARO NEW URETER/BLADDER Category: Medical Services CMS Add: 01/01/2001 CMS Term: 50948 MEDSV DEF RBRVS 02/01/2015 12/31/2023 928.00 Description: LAPARO NEW URETER/BLADDER Category: Medical Services CMS Add: 01/01/2001 CMS Term: 50949 MEDSV DEF BILL35 Description: UNLISTED LAPS PX URETER Category: Medical Services CMS Add: 01/01/2001 CMS Term: 50951 MEDSV DEF RBRVS 01/01/2024 352.53 Description: ENDOSCOPY OF URETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50951 MEDSV DEF RBRVS 09/01/2019 12/31/2023 269.35 Description: ENDOSCOPY OF URETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50953 MEDSV DEF RBRVS 01/01/2019 12/31/2023 285.22 Description: ENDOSCOPY OF URETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50953 MEDSV DEF RBRVS 01/01/2024 373.37 Description: ENDOSCOPY OF URETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50955 MEDSV DEF RBRVS 01/01/2016 12/31/2023 305.28 Description: URETER ENDOSCOPY & BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50955 MEDSV DEF RBRVS 01/01/2024 397.94 Description: URETER ENDOSCOPY & BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50957 MEDSV DEF RBRVS 01/01/2016 12/31/2023 308.09 Description: URETER ENDOSCOPY & TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50957 MEDSV DEF RBRVS 01/01/2024 401.62 Description: URETER ENDOSCOPY & TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 631 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 50961 MEDSV DEF RBRVS 01/01/2019 12/31/2023 277.06 Description: URETER ENDOSCOPY & TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50961 MEDSV DEF RBRVS 01/01/2024 362.60 Description: URETER ENDOSCOPY & TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50970 MEDSV DEF RBRVS 01/01/2024 342.50 Description: URETER ENDOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50970 MEDSV DEF RBRVS 09/01/2019 12/31/2023 270.67 Description: URETER ENDOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50972 MEDSV DEF RBRVS 01/01/2024 331.24 Description: URETER ENDOSCOPY & CATHETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50972 MEDSV DEF RBRVS 09/01/2019 12/31/2023 261.56 Description: URETER ENDOSCOPY & CATHETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50974 MEDSV DEF RBRVS 01/01/2016 12/31/2023 345.44 Description: URETER ENDOSCOPY & BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50974 MEDSV DEF RBRVS 01/01/2024 436.78 Description: URETER ENDOSCOPY & BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50976 MEDSV DEF RBRVS 01/01/2016 12/31/2023 340.55 Description: URETER ENDOSCOPY & TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50976 MEDSV DEF RBRVS 01/01/2024 430.50 Description: URETER ENDOSCOPY & TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50980 MEDSV DEF RBRVS 01/01/2024 329.27 Description: URETER ENDOSCOPY & TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 50980 MEDSV DEF RBRVS 09/01/2019 12/31/2023 259.91 Description: URETER ENDOSCOPY & TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 5100F NOCOV DEF SYSMAN Description: RSK FX REF W/N 24 HRS XRAY Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 51020 MEDSV DEF RBRVS 01/01/2024 439.78 Description: INCISE & TREAT BLADDER Category: Medical Services CMS Add: 01/01/1985 CMS Term: 51020 MEDSV DEF RBRVS 09/01/2019 12/31/2023 339.64 Description: INCISE & TREAT BLADDER Category: Medical Services CMS Add: 01/01/1985 CMS Term: 51030 MEDSV DEF RBRVS 01/01/2024 442.62 Description: INCISE & TREAT BLADDER Category: Medical Services CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 632 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 51030 MEDSV DEF RBRVS 09/01/2019 12/31/2023 340.38 Description: INCISE & TREAT BLADDER Category: Medical Services CMS Add: 01/01/1985 CMS Term: 51040 MEDSV DEF RBRVS 01/01/2024 272.29 Description: INCISE & DRAIN BLADDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51040 MEDSV DEF RBRVS 09/01/2019 12/31/2023 208.33 Description: INCISE & DRAIN BLADDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51045 MEDSV DEF RBRVS 01/01/2024 464.03 Description: INCISE BLADDER/DRAIN URETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51045 MEDSV DEF RBRVS 09/01/2019 12/31/2023 353.10 Description: INCISE BLADDER/DRAIN URETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51050 MEDSV DEF RBRVS 01/01/2024 440.96 Description: REMOVAL OF BLADDER STONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51050 MEDSV DEF RBRVS 09/01/2019 12/31/2023 341.96 Description: REMOVAL OF BLADDER STONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51060 MEDSV DEF RBRVS 01/01/2024 544.96 Description: REMOVAL OF URETER STONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51060 MEDSV DEF RBRVS 09/01/2019 12/31/2023 421.08 Description: REMOVAL OF URETER STONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51065 MEDSV DEF RBRVS 01/01/2024 542.49 Description: REMOVE URETER CALCULUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51065 MEDSV DEF RBRVS 09/01/2019 12/31/2023 419.10 Description: REMOVE URETER CALCULUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51080 MEDSV DEF RBRVS 01/01/2024 382.72 Description: DRAINAGE OF BLADDER ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51080 MEDSV DEF RBRVS 09/01/2019 12/31/2023 295.31 Description: DRAINAGE OF BLADDER ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51100 MEDSV DEF RBRVS 01/01/2024 68.48 Description: DRAIN BLADDER BY NEEDLE Category: Medical Services CMS Add: 01/01/2008 CMS Term: 51100 MEDSV DEF RBRVS 02/01/2015 12/31/2023 43.58 Description: DRAIN BLADDER BY NEEDLE Category: Medical Services CMS Add: 01/01/2008 CMS Term: 51101 MEDSV DEF RBRVS 01/01/2024 144.24 Description: DRAIN BLADDER BY TROCAR/CATH Category: Medical Services CMS Add: 01/01/2008 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 633 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 51101 MEDSV DEF RBRVS 02/01/2015 12/31/2023 87.43 Description: DRAIN BLADDER BY TROCAR/CATH Category: Medical Services CMS Add: 01/01/2008 CMS Term: 51102 MEDSV DEF RBRVS 01/01/2024 225.98 Description: DRAIN BL W/CATH INSERTION Category: Medical Services CMS Add: 01/01/2008 CMS Term: 51102 MEDSV DEF RBRVS 02/01/2015 12/31/2023 162.13 Description: DRAIN BL W/CATH INSERTION Category: Medical Services CMS Add: 01/01/2008 CMS Term: 51500 MEDSV DEF RBRVS 01/01/2024 595.59 Description: REMOVAL OF BLADDER CYST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51500 MEDSV DEF RBRVS 09/01/2019 12/31/2023 461.29 Description: REMOVAL OF BLADDER CYST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51520 MEDSV DEF RBRVS 01/01/2024 556.87 Description: REMOVAL OF BLADDER LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51520 MEDSV DEF RBRVS 09/01/2019 12/31/2023 430.22 Description: REMOVAL OF BLADDER LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51525 MEDSV DEF RBRVS 01/01/2024 801.03 Description: REMOVAL OF BLADDER LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51525 MEDSV DEF RBRVS 09/01/2019 12/31/2023 624.37 Description: REMOVAL OF BLADDER LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51530 MEDSV DEF RBRVS 01/01/2024 718.66 Description: REMOVAL OF BLADDER LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51530 MEDSV DEF RBRVS 09/01/2019 12/31/2023 573.06 Description: REMOVAL OF BLADDER LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51535 MEDSV DEF RBRVS 01/01/2024 727.74 Description: REPAIR OF URETER LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51535 MEDSV DEF RBRVS 09/01/2019 12/31/2023 565.36 Description: REPAIR OF URETER LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51550 MEDSV DEF RBRVS 01/01/2024 894.28 Description: PARTIAL REMOVAL OF BLADDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51550 MEDSV DEF RBRVS 09/01/2019 12/31/2023 699.67 Description: PARTIAL REMOVAL OF BLADDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51555 MEDSV DEF RBRVS 01/01/2024 1171.30 Description: PARTIAL REMOVAL OF BLADDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 634 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 51555 MEDSV DEF RBRVS 09/01/2019 12/31/2023 921.05 Description: PARTIAL REMOVAL OF BLADDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51565 MEDSV DEF RBRVS 01/01/2024 1199.46 Description: REVISE BLADDER & URETER(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51565 MEDSV DEF RBRVS 09/01/2019 12/31/2023 939.68 Description: REVISE BLADDER & URETER(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51570 MEDSV DEF RBRVS 01/01/2024 1369.16 Description: REMOVAL OF BLADDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51570 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1075.35 Description: REMOVAL OF BLADDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51575 MEDSV DEF RBRVS 01/01/2024 1690.90 Description: REMOVAL OF BLADDER & NODES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51575 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1324.93 Description: REMOVAL OF BLADDER & NODES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51580 MEDSV DEF RBRVS 01/01/2024 1761.68 Description: REMOVE BLADDER/REVISE TRACT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51580 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1379.69 Description: REMOVE BLADDER/REVISE TRACT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51585 MEDSV DEF RBRVS 01/01/2024 1959.81 Description: REMOVAL OF BLADDER & NODES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51585 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1536.53 Description: REMOVAL OF BLADDER & NODES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51590 MEDSV DEF RBRVS 01/01/2024 1792.36 Description: REMOVE BLADDER/REVISE TRACT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51590 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1407.14 Description: REMOVE BLADDER/REVISE TRACT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51595 MEDSV DEF RBRVS 01/01/2024 2029.12 Description: REMOVE BLADDER/REVISE TRACT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51595 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1594.47 Description: REMOVE BLADDER/REVISE TRACT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51596 MEDSV DEF RBRVS 01/01/2024 2188.49 Description: REMOVE BLADDER/CREATE POUCH Category: Medical Services CMS Add: 01/01/1988 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 635 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 51596 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1712.27 Description: REMOVE BLADDER/CREATE POUCH Category: Medical Services CMS Add: 01/01/1988 CMS Term: 51597 MEDSV DEF RBRVS 01/01/2024 2132.08 Y Y Description: REMOVAL OF PELVIC STRUCTURES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51597 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1671.93 Y Y Description: REMOVAL OF PELVIC STRUCTURES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51600 MEDSV DEF RBRVS 01/01/2024 199.06 Description: INJECTION FOR BLADDER X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51600 MEDSV DEF RBRVS 09/01/2019 12/31/2023 127.77 Description: INJECTION FOR BLADDER X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51605 MEDSV DEF RBRVS 01/01/2024 35.63 Description: PREPARATION FOR BLADDER XRAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51605 MEDSV DEF RBRVS 09/01/2019 12/31/2023 27.68 Description: PREPARATION FOR BLADDER XRAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51610 MEDSV DEF RBRVS 01/01/2024 120.87 Description: INJECTION FOR BLADDER X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51610 MEDSV DEF RBRVS 09/01/2019 12/31/2023 75.44 Description: INJECTION FOR BLADDER X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51700 MEDSV DEF RBRVS 01/01/2024 71.01 Description: IRRIGATION OF BLADDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51700 MEDSV DEF RBRVS 09/01/2019 12/31/2023 58.65 Description: IRRIGATION OF BLADDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51701 MEDSV DEF RBRVS 01/01/2024 41.53 Description: INSERT BLADDER CATHETER Category: Medical Services CMS Add: 01/01/2003 CMS Term: 51701 MEDSV DEF RBRVS 02/01/2015 12/31/2023 38.54 Description: INSERT BLADDER CATHETER Category: Medical Services CMS Add: 01/01/2003 CMS Term: 51702 MEDSV DEF RBRVS 01/01/2024 57.42 Description: INSERT TEMP BLADDER CATH Category: Medical Services CMS Add: 01/01/2003 CMS Term: 51702 MEDSV DEF RBRVS 02/01/2015 12/31/2023 49.44 Description: INSERT TEMP BLADDER CATH Category: Medical Services CMS Add: 01/01/2003 CMS Term: 51703 MEDSV DEF RBRVS 01/01/2024 140.08 Description: INSERT BLADDER CATH COMPLEX Category: Medical Services CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 636 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 51703 MEDSV DEF RBRVS 02/01/2015 12/31/2023 91.68 Description: INSERT BLADDER CATH COMPLEX Category: Medical Services CMS Add: 01/01/2003 CMS Term: 51705 MEDSV DEF RBRVS 01/01/2024 90.62 Description: CHANGE OF BLADDER TUBE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51705 MEDSV DEF RBRVS 09/01/2019 12/31/2023 64.31 Description: CHANGE OF BLADDER TUBE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51710 MEDSV DEF RBRVS 01/01/2024 127.06 Description: CHANGE OF BLADDER TUBE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51710 MEDSV DEF RBRVS 09/01/2019 12/31/2023 90.60 Description: CHANGE OF BLADDER TUBE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51715 MEDSV DEF RBRVS 01/01/2024 347.62 Description: ENDOSCOPIC INJECTION/IMPLANT Category: Medical Services CMS Add: 01/01/1994 CMS Term: 51715 MEDSV DEF RBRVS 09/01/2019 12/31/2023 205.91 Description: ENDOSCOPIC INJECTION/IMPLANT Category: Medical Services CMS Add: 01/01/1994 CMS Term: 51720 MEDSV DEF RBRVS 01/01/2024 81.88 Description: TREATMENT OF BLADDER LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51720 MEDSV DEF RBRVS 09/01/2019 12/31/2023 77.62 Description: TREATMENT OF BLADDER LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51725 26 MEDSV DEF RBRVS 01/01/2024 71.19 Description: SIMPLE CYSTOMETROGRAM Category: Medical Services CMS Add: 01/01/1985 CMS Term: 51725 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 56.01 Description: SIMPLE CYSTOMETROGRAM Category: Medical Services CMS Add: 01/01/1985 CMS Term: 51725 MEDSV DEF RBRVS 01/01/2024 213.52 Description: SIMPLE CYSTOMETROGRAM Category: Medical Services CMS Add: 01/01/1985 CMS Term: 51725 MEDSV DEF RBRVS 09/01/2019 12/31/2023 131.48 Description: SIMPLE CYSTOMETROGRAM Category: Medical Services CMS Add: 01/01/1985 CMS Term: 51725 TC MEDSV DEF RBRVS 01/01/2024 142.33 Description: SIMPLE CYSTOMETROGRAM Category: Medical Services CMS Add: 01/01/1985 CMS Term: 51725 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 75.47 Description: SIMPLE CYSTOMETROGRAM Category: Medical Services CMS Add: 01/01/1985 CMS Term: 51726 26 MEDSV DEF RBRVS 01/01/2024 79.51 Description: COMPLEX CYSTOMETROGRAM Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 637 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 51726 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 62.95 Description: COMPLEX CYSTOMETROGRAM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51726 MEDSV DEF RBRVS 01/01/2024 281.43 Description: COMPLEX CYSTOMETROGRAM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51726 MEDSV DEF RBRVS 09/01/2019 12/31/2023 184.33 Description: COMPLEX CYSTOMETROGRAM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51726 TC MEDSV DEF RBRVS 01/01/2024 201.91 Description: COMPLEX CYSTOMETROGRAM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51726 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 121.38 Description: COMPLEX CYSTOMETROGRAM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51727 26 MEDSV DEF RBRVS 01/01/2024 99.12 Description: CYSTOMETROGRAM W/UP Category: Medical Services CMS Add: 01/01/2010 CMS Term: 51727 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 79.48 Description: CYSTOMETROGRAM W/UP Category: Medical Services CMS Add: 01/01/2010 CMS Term: 51727 MEDSV DEF RBRVS 01/01/2024 341.48 Description: CYSTOMETROGRAM W/UP Category: Medical Services CMS Add: 01/01/2010 CMS Term: 51727 MEDSV DEF RBRVS 02/01/2015 12/31/2023 219.61 Description: CYSTOMETROGRAM W/UP Category: Medical Services CMS Add: 01/01/2010 CMS Term: 51727 TC MEDSV DEF RBRVS 01/01/2024 242.35 Description: CYSTOMETROGRAM W/UP Category: Medical Services CMS Add: 01/01/2010 CMS Term: 51727 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 140.12 Description: CYSTOMETROGRAM W/UP Category: Medical Services CMS Add: 01/01/2010 CMS Term: 51728 26 MEDSV DEF RBRVS 01/01/2024 97.41 Description: CYSTOMETROGRAM W/VP Category: Medical Services CMS Add: 01/01/2010 CMS Term: 51728 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 77.58 Description: CYSTOMETROGRAM W/VP Category: Medical Services CMS Add: 01/01/2010 CMS Term: 51728 MEDSV DEF RBRVS 01/01/2024 340.99 Description: CYSTOMETROGRAM W/VP Category: Medical Services CMS Add: 01/01/2010 CMS Term: 51728 MEDSV DEF RBRVS 02/01/2015 12/31/2023 220.43 Description: CYSTOMETROGRAM W/VP Category: Medical Services CMS Add: 01/01/2010 CMS Term: 51728 TC MEDSV DEF RBRVS 01/01/2024 243.59 Description: CYSTOMETROGRAM W/VP Category: Medical Services CMS Add: 01/01/2010 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 638 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 51728 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 142.85 Description: CYSTOMETROGRAM W/VP Category: Medical Services CMS Add: 01/01/2010 CMS Term: 51729 26 MEDSV DEF RBRVS 01/01/2024 117.64 Description: CYSTOMETROGRAM W/VP&UP Category: Medical Services CMS Add: 01/01/2010 CMS Term: 51729 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 93.78 Description: CYSTOMETROGRAM W/VP&UP Category: Medical Services CMS Add: 01/01/2010 CMS Term: 51729 MEDSV DEF RBRVS 01/01/2024 360.92 Description: CYSTOMETROGRAM W/VP&UP Category: Medical Services CMS Add: 01/01/2010 CMS Term: 51729 MEDSV DEF RBRVS 02/01/2015 12/31/2023 239.35 Description: CYSTOMETROGRAM W/VP&UP Category: Medical Services CMS Add: 01/01/2010 CMS Term: 51729 TC MEDSV DEF RBRVS 01/01/2024 243.28 Description: CYSTOMETROGRAM W/VP&UP Category: Medical Services CMS Add: 01/01/2010 CMS Term: 51729 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 145.57 Description: CYSTOMETROGRAM W/VP&UP Category: Medical Services CMS Add: 01/01/2010 CMS Term: 51736 26 MEDSV DEF RBRVS 01/01/2024 7.77 Description: URINE FLOW MEASUREMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51736 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 6.22 Description: URINE FLOW MEASUREMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51736 MEDSV DEF RBRVS 01/01/2024 12.57 Description: URINE FLOW MEASUREMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51736 MEDSV DEF RBRVS 09/01/2019 12/31/2023 10.84 Description: URINE FLOW MEASUREMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51736 TC MEDSV DEF RBRVS 01/01/2024 4.79 Description: URINE FLOW MEASUREMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51736 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 4.62 Description: URINE FLOW MEASUREMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51741 26 MEDSV DEF RBRVS 01/01/2024 7.94 Description: ELECTRO-UROFLOWMETRY FIRST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51741 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 6.22 Description: ELECTRO-UROFLOWMETRY FIRST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51741 MEDSV DEF RBRVS 01/01/2024 13.04 Description: ELECTRO-UROFLOWMETRY FIRST Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 639 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 51741 MEDSV DEF RBRVS 09/01/2019 12/31/2023 11.09 Description: ELECTRO-UROFLOWMETRY FIRST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51741 TC MEDSV DEF RBRVS 01/01/2024 5.10 Description: ELECTRO-UROFLOWMETRY FIRST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51741 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 4.87 Description: ELECTRO-UROFLOWMETRY FIRST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51784 26 MEDSV DEF RBRVS 01/01/2019 12/31/2023 56.55 Description: ANAL/URINARY MUSCLE STUDY Category: Medical Services CMS Add: 01/01/1995 CMS Term: 51784 26 MEDSV DEF RBRVS 01/01/2024 34.88 Description: ANAL/URINARY MUSCLE STUDY Category: Medical Services CMS Add: 01/01/1995 CMS Term: 51784 MEDSV DEF RBRVS 01/01/2019 12/31/2023 134.99 Description: ANAL/URINARY MUSCLE STUDY Category: Medical Services CMS Add: 01/01/1995 CMS Term: 51784 MEDSV DEF RBRVS 01/01/2024 60.04 Description: ANAL/URINARY MUSCLE STUDY Category: Medical Services CMS Add: 01/01/1995 CMS Term: 51784 TC MEDSV DEF RBRVS 01/01/2019 12/31/2023 78.44 Description: ANAL/URINARY MUSCLE STUDY Category: Medical Services CMS Add: 01/01/1995 CMS Term: 51784 TC MEDSV DEF RBRVS 01/01/2024 25.17 Description: ANAL/URINARY MUSCLE STUDY Category: Medical Services CMS Add: 01/01/1995 CMS Term: 51785 26 MEDSV DEF RBRVS 01/01/2024 82.27 Description: ANAL/URINARY MUSCLE STUDY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51785 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 58.53 Description: ANAL/URINARY MUSCLE STUDY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51785 MEDSV DEF RBRVS 01/01/2024 401.81 Description: ANAL/URINARY MUSCLE STUDY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51785 MEDSV DEF RBRVS 09/01/2019 12/31/2023 179.83 Description: ANAL/URINARY MUSCLE STUDY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51785 TC MEDSV DEF RBRVS 01/01/2024 319.54 Description: ANAL/URINARY MUSCLE STUDY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51785 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 121.30 Description: ANAL/URINARY MUSCLE STUDY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51792 26 MEDSV DEF RBRVS 01/01/2024 50.93 Description: URINARY REFLEX STUDY Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 640 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 51792 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 40.87 Description: URINARY REFLEX STUDY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51792 MEDSV DEF RBRVS 01/01/2024 252.85 Description: URINARY REFLEX STUDY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51792 MEDSV DEF RBRVS 09/01/2019 12/31/2023 147.05 Description: URINARY REFLEX STUDY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51792 TC MEDSV DEF RBRVS 01/01/2024 201.92 Description: URINARY REFLEX STUDY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51792 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 106.19 Description: URINARY REFLEX STUDY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51797 26 MEDSV DEF RBRVS 01/01/2024 37.35 Description: INTRAABDOMINAL PRESSURE TEST Category: Medical Services CMS Add: 01/01/1985 CMS Term: 51797 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 29.26 Description: INTRAABDOMINAL PRESSURE TEST Category: Medical Services CMS Add: 01/01/1985 CMS Term: 51797 MEDSV DEF RBRVS 01/01/2024 179.67 Description: INTRAABDOMINAL PRESSURE TEST Category: Medical Services CMS Add: 01/01/1985 CMS Term: 51797 MEDSV DEF RBRVS 09/01/2019 12/31/2023 78.22 Description: INTRAABDOMINAL PRESSURE TEST Category: Medical Services CMS Add: 01/01/1985 CMS Term: 51797 TC MEDSV DEF RBRVS 01/01/2019 12/31/2023 48.97 Description: INTRAABDOMINAL PRESSURE TEST Category: Medical Services CMS Add: 01/01/1985 CMS Term: 51797 TC MEDSV DEF RBRVS 01/01/2024 142.32 Description: INTRAABDOMINAL PRESSURE TEST Category: Medical Services CMS Add: 01/01/1985 CMS Term: 51798 MEDSV DEF RBRVS 01/01/2024 9.73 Description: US URINE CAPACITY MEASURE Category: Medical Services CMS Add: 01/01/2003 CMS Term: 51798 MEDSV DEF RBRVS 02/01/2015 12/31/2023 13.05 Description: US URINE CAPACITY MEASURE Category: Medical Services CMS Add: 01/01/2003 CMS Term: 51800 MEDSV DEF RBRVS 01/01/2024 967.01 Description: REVISION OF BLADDER/URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51800 MEDSV DEF RBRVS 09/01/2019 12/31/2023 757.48 Description: REVISION OF BLADDER/URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51820 MEDSV DEF RBRVS 01/01/2024 1010.99 Description: REVISION OF URINARY TRACT Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 641 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 51820 MEDSV DEF RBRVS 09/01/2019 12/31/2023 786.61 Description: REVISION OF URINARY TRACT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51840 MEDSV DEF RBRVS 01/01/2024 650.52 Description: ATTACH BLADDER/URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51840 MEDSV DEF RBRVS 09/01/2019 12/31/2023 480.44 Description: ATTACH BLADDER/URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51841 MEDSV DEF RBRVS 01/01/2024 753.29 Description: ATTACH BLADDER/URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51841 MEDSV DEF RBRVS 09/01/2019 12/31/2023 570.52 Description: ATTACH BLADDER/URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51845 MEDSV DEF RBRVS 01/01/2024 544.48 Description: REPAIR BLADDER NECK Category: Medical Services CMS Add: 01/01/1985 CMS Term: 51845 MEDSV DEF RBRVS 09/01/2019 12/31/2023 428.69 Description: REPAIR BLADDER NECK Category: Medical Services CMS Add: 01/01/1985 CMS Term: 51860 MEDSV DEF RBRVS 01/01/2024 692.65 Description: REPAIR OF BLADDER WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51860 MEDSV DEF RBRVS 09/01/2019 12/31/2023 540.18 Description: REPAIR OF BLADDER WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51865 MEDSV DEF RBRVS 01/01/2024 833.81 Description: REPAIR OF BLADDER WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51865 MEDSV DEF RBRVS 09/01/2019 12/31/2023 649.11 Description: REPAIR OF BLADDER WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51880 MEDSV DEF RBRVS 01/01/2024 433.29 Description: REPAIR OF BLADDER OPENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51880 MEDSV DEF RBRVS 09/01/2019 12/31/2023 340.10 Description: REPAIR OF BLADDER OPENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51900 MEDSV DEF RBRVS 01/01/2024 768.90 Description: REPAIR BLADDER/VAGINA LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51900 MEDSV DEF RBRVS 09/01/2019 12/31/2023 602.81 Description: REPAIR BLADDER/VAGINA LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51920 MEDSV DEF RBRVS 01/01/2024 712.64 Description: CLOSE BLADDER-UTERUS FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 642 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 51920 MEDSV DEF RBRVS 09/01/2019 12/31/2023 585.47 Description: CLOSE BLADDER-UTERUS FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51925 MEDSV DEF RBRVS 01/01/2024 1008.69 Y Y Description: HYSTERECTOMY/BLADDER REPAIR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51925 MEDSV DEF RBRVS 09/01/2019 12/31/2023 756.21 Y Y Description: HYSTERECTOMY/BLADDER REPAIR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51940 MEDSV DEF RBRVS 01/01/2024 1525.30 Description: CORRECTION OF BLADDER DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51940 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1186.43 Description: CORRECTION OF BLADDER DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51960 MEDSV DEF RBRVS 01/01/2024 1288.14 Description: REVISION OF BLADDER & BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51960 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1011.82 Description: REVISION OF BLADDER & BOWEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51980 MEDSV DEF RBRVS 01/01/2024 666.37 Description: CONSTRUCT BLADDER OPENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51980 MEDSV DEF RBRVS 09/01/2019 12/31/2023 517.32 Description: CONSTRUCT BLADDER OPENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 51990 MEDSV DEF RBRVS 01/01/2024 694.45 0-1 Description: LAPARO URETHRAL SUSPENSION Category: Medical Services CMS Add: 01/01/2000 CMS Term: 51990 MEDSV DEF RBRVS 02/01/2015 12/31/2023 552.09 0-1 Description: LAPARO URETHRAL SUSPENSION Category: Medical Services CMS Add: 01/01/2000 CMS Term: 51992 MEDSV DEF RBRVS 01/01/2024 776.89 0-1 Description: LAPARO SLING OPERATION Category: Medical Services CMS Add: 01/01/2000 CMS Term: 51992 MEDSV DEF RBRVS 02/01/2015 12/31/2023 620.74 0-1 Description: LAPARO SLING OPERATION Category: Medical Services CMS Add: 01/01/2000 CMS Term: 51999 MEDSV DEF BILL35 Description: UNLISTED LAPS PX BLADDER Category: Medical Services CMS Add: 01/01/2006 CMS Term: 52000 MEDSV DEF RBRVS 01/01/2024 224.39 Description: CYSTOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52000 MEDSV DEF RBRVS 09/01/2019 12/31/2023 143.31 Description: CYSTOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 643 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 52001 MEDSV DEF RBRVS 01/01/2024 411.22 Description: CYSTOSCOPY REMOVAL OF CLOTS Category: Medical Services CMS Add: 01/01/2002 CMS Term: 52001 MEDSV DEF RBRVS 09/01/2019 12/31/2023 264.82 Description: CYSTOSCOPY REMOVAL OF CLOTS Category: Medical Services CMS Add: 01/01/2002 CMS Term: 52005 MEDSV DEF RBRVS 01/01/2024 284.09 Description: CYSTOSCOPY & URETER CATHETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52005 MEDSV DEF RBRVS 09/01/2019 12/31/2023 185.39 Description: CYSTOSCOPY & URETER CATHETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52007 MEDSV DEF RBRVS 01/01/2016 12/31/2023 308.63 Description: CYSTOSCOPY AND BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52007 MEDSV DEF RBRVS 01/01/2024 422.56 Description: CYSTOSCOPY AND BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 5200F NOCOV DEF SYSMAN Description: EVAL APPROS SURG THXPY EPI Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 52010 MEDSV DEF RBRVS 01/01/2024 357.57 Description: CYSTOSCOPY & DUCT CATHETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52010 MEDSV DEF RBRVS 02/01/2015 12/31/2023 256.11 Description: CYSTOSCOPY & DUCT CATHETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52204 MEDSV DEF RBRVS 01/01/2024 353.77 Description: CYSTOSCOPY W/BIOPSY(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52204 MEDSV DEF RBRVS 02/01/2015 12/31/2023 256.53 Description: CYSTOSCOPY W/BIOPSY(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52214 MEDSV DEF RBRVS 01/01/2024 699.57 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52214 MEDSV DEF RBRVS 02/01/2015 12/31/2023 457.27 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52224 MEDSV DEF RBRVS 01/01/2024 731.07 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52224 MEDSV DEF RBRVS 02/01/2015 12/31/2023 479.48 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52234 MEDSV DEF RBRVS 01/01/2024 227.46 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 644 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 52234 MEDSV DEF RBRVS 02/01/2015 12/31/2023 179.12 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52235 MEDSV DEF RBRVS 01/01/2024 266.74 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52235 MEDSV DEF RBRVS 09/01/2019 12/31/2023 210.32 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52240 MEDSV DEF RBRVS 01/01/2024 362.18 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52240 MEDSV DEF RBRVS 09/01/2019 12/31/2023 286.15 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52250 MEDSV DEF RBRVS 01/01/2024 221.35 Description: CYSTOSCOPY AND RADIOTRACER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52250 MEDSV DEF RBRVS 02/01/2015 12/31/2023 174.80 Description: CYSTOSCOPY AND RADIOTRACER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52260 MEDSV DEF RBRVS 01/01/2024 194.88 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52260 MEDSV DEF RBRVS 02/01/2015 12/31/2023 153.52 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52265 MEDSV DEF RBRVS 01/01/2024 350.25 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52265 MEDSV DEF RBRVS 02/01/2015 12/31/2023 256.11 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52270 MEDSV DEF RBRVS 01/01/2024 394.13 Description: CYSTOSCOPY & REVISE URETHRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 52270 MEDSV DEF RBRVS 02/01/2015 12/31/2023 248.90 Description: CYSTOSCOPY & REVISE URETHRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 52275 MEDSV DEF RBRVS 01/01/2024 505.52 Description: CYSTOSCOPY & REVISE URETHRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 52275 MEDSV DEF RBRVS 02/01/2015 12/31/2023 336.49 Description: CYSTOSCOPY & REVISE URETHRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 52276 MEDSV DEF RBRVS 01/01/2024 244.35 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 645 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 52276 MEDSV DEF RBRVS 02/01/2015 12/31/2023 193.11 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52277 MEDSV DEF RBRVS 01/01/2019 12/31/2023 235.86 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52277 MEDSV DEF RBRVS 01/01/2024 298.91 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52281 MEDSV DEF RBRVS 01/01/2024 305.50 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52281 MEDSV DEF RBRVS 02/01/2015 12/31/2023 190.97 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52282 MEDSV DEF RBRVS 01/01/2024 310.90 Description: CYSTOSCOPY IMPLANT STENT Category: Medical Services CMS Add: 01/01/1998 CMS Term: 52282 MEDSV DEF RBRVS 02/01/2015 12/31/2023 245.59 Description: CYSTOSCOPY IMPLANT STENT Category: Medical Services CMS Add: 01/01/1998 CMS Term: 52283 MEDSV DEF RBRVS 01/01/2024 331.68 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52283 MEDSV DEF RBRVS 02/01/2015 12/31/2023 196.17 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52284 MEDSV DEF RBRVS 01/01/2024 2482.08 Y Description: CYSTO RX BALO CATH URTL STRX Category: Medical Services CMS Add: 01/01/2024 CMS Term: 52285 MEDSV DEF RBRVS 01/01/2024 328.50 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52285 MEDSV DEF RBRVS 02/01/2015 12/31/2023 197.63 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52287 MEDSV DEF RBRVS 01/01/2024 363.86 Description: CYSTOSCOPY CHEMODENERVATION Category: Medical Services CMS Add: 01/01/2013 CMS Term: 52287 MEDSV DEF RBRVS 02/01/2015 12/31/2023 218.84 Description: CYSTOSCOPY CHEMODENERVATION Category: Medical Services CMS Add: 01/01/2013 CMS Term: 52290 MEDSV DEF RBRVS 01/01/2024 225.49 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52290 MEDSV DEF RBRVS 02/01/2015 12/31/2023 177.80 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 646 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 52300 MEDSV DEF RBRVS 01/01/2019 12/31/2023 205.82 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52300 MEDSV DEF RBRVS 01/01/2024 259.22 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52301 MEDSV DEF RBRVS 01/01/2019 12/31/2023 211.68 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1997 CMS Term: 52301 MEDSV DEF RBRVS 01/01/2024 268.15 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1997 CMS Term: 52305 MEDSV DEF RBRVS 01/01/2024 257.67 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52305 MEDSV DEF RBRVS 02/01/2015 12/31/2023 203.42 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52310 MEDSV DEF RBRVS 01/01/2024 298.12 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52310 MEDSV DEF RBRVS 02/01/2015 12/31/2023 171.28 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52315 MEDSV DEF RBRVS 01/01/2024 439.97 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52315 MEDSV DEF RBRVS 02/01/2015 12/31/2023 291.81 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52317 MEDSV DEF RBRVS 01/01/2024 828.81 Description: REMOVE BLADDER STONE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 52317 MEDSV DEF RBRVS 02/01/2015 12/31/2023 562.09 Description: REMOVE BLADDER STONE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 52318 MEDSV DEF RBRVS 01/01/2024 437.46 Description: REMOVE BLADDER STONE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 52318 MEDSV DEF RBRVS 02/01/2015 12/31/2023 345.73 Description: REMOVE BLADDER STONE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 52320 MEDSV DEF RBRVS 01/01/2016 12/31/2023 179.68 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1982 CMS Term: 52320 MEDSV DEF RBRVS 01/01/2024 227.67 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 647 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 52325 MEDSV DEF RBRVS 01/01/2016 12/31/2023 233.85 Description: CYSTOSCOPY STONE REMOVAL Category: Medical Services CMS Add: 01/01/1985 CMS Term: 52325 MEDSV DEF RBRVS 01/01/2024 296.10 Description: CYSTOSCOPY STONE REMOVAL Category: Medical Services CMS Add: 01/01/1985 CMS Term: 52327 MEDSV DEF RBRVS 01/01/2019 12/31/2023 191.53 Description: CYSTOSCOPY INJECT MATERIAL Category: Medical Services CMS Add: 01/01/1995 CMS Term: 52327 MEDSV DEF RBRVS 01/01/2024 240.14 Description: CYSTOSCOPY INJECT MATERIAL Category: Medical Services CMS Add: 01/01/1995 CMS Term: 52330 MEDSV DEF RBRVS 01/01/2016 12/31/2023 346.78 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52330 MEDSV DEF RBRVS 01/01/2024 564.91 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52332 MEDSV DEF RBRVS 01/01/2016 12/31/2023 340.08 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52332 MEDSV DEF RBRVS 01/01/2024 375.33 Description: CYSTOSCOPY AND TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52334 MEDSV DEF RBRVS 01/01/2019 12/31/2023 186.89 Description: CREATE PASSAGE TO KIDNEY Category: Medical Services CMS Add: 01/01/1985 CMS Term: 52334 MEDSV DEF RBRVS 01/01/2024 169.27 Description: CREATE PASSAGE TO KIDNEY Category: Medical Services CMS Add: 01/01/1985 CMS Term: 52341 MEDSV DEF RBRVS 01/01/2024 262.76 Description: CYSTO W/URETER STRICTURE TX Category: Medical Services CMS Add: 01/01/2001 CMS Term: 52341 MEDSV DEF RBRVS 02/01/2015 12/31/2023 206.99 Description: CYSTO W/URETER STRICTURE TX Category: Medical Services CMS Add: 01/01/2001 CMS Term: 52342 MEDSV DEF RBRVS 01/01/2024 285.60 Description: CYSTO W/UP STRICTURE TX Category: Medical Services CMS Add: 01/01/2001 CMS Term: 52342 MEDSV DEF RBRVS 02/01/2015 12/31/2023 225.30 Description: CYSTO W/UP STRICTURE TX Category: Medical Services CMS Add: 01/01/2001 CMS Term: 52343 MEDSV DEF RBRVS 01/01/2024 318.18 Description: CYSTO W/RENAL STRICTURE TX Category: Medical Services CMS Add: 01/01/2001 CMS Term: 52343 MEDSV DEF RBRVS 02/01/2015 12/31/2023 251.21 Description: CYSTO W/RENAL STRICTURE TX Category: Medical Services CMS Add: 01/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 648 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 52344 MEDSV DEF RBRVS 01/01/2024 340.87 Description: CYSTO/URETERO STRICTURE TX Category: Medical Services CMS Add: 01/01/2001 CMS Term: 52344 MEDSV DEF RBRVS 02/01/2015 12/31/2023 269.51 Description: CYSTO/URETERO STRICTURE TX Category: Medical Services CMS Add: 01/01/2001 CMS Term: 52345 MEDSV DEF RBRVS 01/01/2016 12/31/2023 287.82 Description: CYSTO/URETERO W/UP STRICTURE Category: Medical Services CMS Add: 01/01/2001 CMS Term: 52345 MEDSV DEF RBRVS 01/01/2024 364.18 Description: CYSTO/URETERO W/UP STRICTURE Category: Medical Services CMS Add: 01/01/2001 CMS Term: 52346 MEDSV DEF RBRVS 01/01/2016 12/31/2023 326.06 Description: CYSTOURETERO W/RENAL STRICT Category: Medical Services CMS Add: 01/01/2001 CMS Term: 52346 MEDSV DEF RBRVS 01/01/2024 412.13 Description: CYSTOURETERO W/RENAL STRICT Category: Medical Services CMS Add: 01/01/2001 CMS Term: 52351 MEDSV DEF RBRVS 01/01/2024 279.73 Description: CYSTOURETERO & OR PYELOSCOPE Category: Medical Services CMS Add: 01/01/2001 CMS Term: 52351 MEDSV DEF RBRVS 02/01/2015 12/31/2023 220.71 Description: CYSTOURETERO & OR PYELOSCOPE Category: Medical Services CMS Add: 01/01/2001 CMS Term: 52352 MEDSV DEF RBRVS 01/01/2016 12/31/2023 258.65 Description: CYSTOURETERO W/STONE REMOVE Category: Medical Services CMS Add: 01/01/2001 CMS Term: 52352 MEDSV DEF RBRVS 01/01/2024 327.44 Description: CYSTOURETERO W/STONE REMOVE Category: Medical Services CMS Add: 01/01/2001 CMS Term: 52353 MEDSV DEF RBRVS 01/01/2024 362.18 Description: CYSTOURETERO W/LITHOTRIPSY Category: Medical Services CMS Add: 01/01/2001 CMS Term: 52353 MEDSV DEF RBRVS 02/01/2015 12/31/2023 285.98 Description: CYSTOURETERO W/LITHOTRIPSY Category: Medical Services CMS Add: 01/01/2001 CMS Term: 52354 MEDSV DEF RBRVS 01/01/2024 385.18 Description: CYSTOURETERO W/BIOPSY Category: Medical Services CMS Add: 01/01/2001 CMS Term: 52354 MEDSV DEF RBRVS 02/01/2015 12/31/2023 304.45 Description: CYSTOURETERO W/BIOPSY Category: Medical Services CMS Add: 01/01/2001 CMS Term: 52355 MEDSV DEF RBRVS 01/01/2019 12/31/2023 341.39 Description: CYSTOURETERO W/EXCISE TUMOR Category: Medical Services CMS Add: 01/01/2001 CMS Term: 52355 MEDSV DEF RBRVS 01/01/2024 431.64 Description: CYSTOURETERO W/EXCISE TUMOR Category: Medical Services CMS Add: 01/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 649 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 52356 MEDSV DEF RBRVS 01/01/2024 383.94 Description: CYSTO/URETERO W/LITHOTRIPSY Category: Medical Services CMS Add: 01/01/2014 CMS Term: 52356 MEDSV DEF RBRVS 02/01/2015 12/31/2023 303.71 Description: CYSTO/URETERO W/LITHOTRIPSY Category: Medical Services CMS Add: 01/01/2014 CMS Term: 52400 MEDSV DEF RBRVS 01/01/2024 444.42 Description: CYSTOURETERO W/CONGEN REPR Category: Medical Services CMS Add: 01/01/2001 CMS Term: 52400 MEDSV DEF RBRVS 09/01/2019 12/31/2023 347.51 Description: CYSTOURETERO W/CONGEN REPR Category: Medical Services CMS Add: 01/01/2001 CMS Term: 52402 MEDSV DEF RBRVS 01/01/2019 12/31/2023 194.85 Description: CYSTOURETHRO CUT EJACUL DUCT Category: Medical Services CMS Add: 01/01/2005 CMS Term: 52402 MEDSV DEF RBRVS 01/01/2024 246.31 Description: CYSTOURETHRO CUT EJACUL DUCT Category: Medical Services CMS Add: 01/01/2005 CMS Term: 52441 MEDSV DEF RBRVS 01/01/2024 1184.40 Y Description: CYSTOURETHRO W/IMPLANT Category: Medical Services CMS Add: 01/01/2015 CMS Term: 52441 MEDSV DEF RBRVS 02/01/2015 12/31/2023 869.67 Y Description: CYSTOURETHRO W/IMPLANT Category: Medical Services CMS Add: 01/01/2015 CMS Term: 52442 MEDSV DEF RBRVS 01/01/2024 807.63 Y Description: CYSTOURETHRO W/ADDL IMPLANT Category: Medical Services CMS Add: 01/01/2015 CMS Term: 52442 MEDSV DEF RBRVS 02/01/2015 12/31/2023 662.51 Y Description: CYSTOURETHRO W/ADDL IMPLANT Category: Medical Services CMS Add: 01/01/2015 CMS Term: 52450 MEDSV DEF RBRVS 01/01/2024 443.14 Description: INCISION OF PROSTATE Category: Medical Services CMS Add: 01/01/1992 CMS Term: 52450 MEDSV DEF RBRVS 09/01/2019 12/31/2023 339.83 Description: INCISION OF PROSTATE Category: Medical Services CMS Add: 01/01/1992 CMS Term: 52500 MEDSV DEF RBRVS 01/01/2024 460.01 Description: REVISION OF BLADDER NECK Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52500 MEDSV DEF RBRVS 09/01/2019 12/31/2023 353.21 Description: REVISION OF BLADDER NECK Category: Medical Services CMS Add: 01/01/1984 CMS Term: 5250F NOCOV DEF SYSMAN Description: ASTHMA DISCHARGE PLAN PRESNT Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 52601 MEDSV DEF RBRVS 01/01/2024 679.14 Description: PROSTATECTOMY (TURP) Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 650 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 52601 MEDSV DEF RBRVS 09/01/2019 12/31/2023 614.20 Description: PROSTATECTOMY (TURP) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52630 MEDSV DEF RBRVS 01/01/2024 378.99 Description: REMOVE PROSTATE REGROWTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52630 MEDSV DEF RBRVS 09/01/2019 12/31/2023 289.36 Description: REMOVE PROSTATE REGROWTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52640 MEDSV DEF RBRVS 01/01/2024 301.01 Description: RELIEVE BLADDER CONTRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52640 MEDSV DEF RBRVS 09/01/2019 12/31/2023 226.96 Description: RELIEVE BLADDER CONTRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52647 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1239.47 Description: LASER SURGERY OF PROSTATE Category: Medical Services CMS Add: 01/01/1995 CMS Term: 52647 MEDSV DEF RBRVS 01/01/2024 1461.98 Description: LASER SURGERY OF PROSTATE Category: Medical Services CMS Add: 01/01/1995 CMS Term: 52648 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1277.34 Description: LASER SURGERY OF PROSTATE Category: Medical Services CMS Add: 01/01/1995 CMS Term: 52648 MEDSV DEF RBRVS 01/01/2024 1508.46 Description: LASER SURGERY OF PROSTATE Category: Medical Services CMS Add: 01/01/1995 CMS Term: 52649 MEDSV DEF RBRVS 01/01/2024 770.07 Description: PROSTATE LASER ENUCLEATION Category: Medical Services CMS Add: 01/01/2008 CMS Term: 52649 MEDSV DEF RBRVS 02/01/2015 12/31/2023 596.80 Description: PROSTATE LASER ENUCLEATION Category: Medical Services CMS Add: 01/01/2008 CMS Term: 52700 MEDSV DEF RBRVS 01/01/2024 413.71 Description: DRAINAGE OF PROSTATE ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 52700 MEDSV DEF RBRVS 09/01/2019 12/31/2023 319.15 Description: DRAINAGE OF PROSTATE ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53000 MEDSV DEF RBRVS 01/01/2024 138.56 Description: INCISION OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53000 MEDSV DEF RBRVS 09/01/2019 12/31/2023 107.03 Description: INCISION OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53010 MEDSV DEF RBRVS 01/01/2024 277.57 Description: INCISION OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 651 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 53010 MEDSV DEF RBRVS 09/01/2019 12/31/2023 211.88 Description: INCISION OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53020 MEDSV DEF RBRVS 01/01/2024 89.76 1-999years Description: INCISION OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53020 MEDSV DEF RBRVS 09/01/2019 12/31/2023 70.68 1-999years Description: INCISION OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53025 MEDSV DEF RBRVS 01/01/2024 63.70 0-364days Description: INCISION OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53025 MEDSV DEF RBRVS 09/01/2019 12/31/2023 49.10 0-364days Description: INCISION OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53040 MEDSV DEF RBRVS 01/01/2024 367.26 Description: DRAINAGE OF URETHRA ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53040 MEDSV DEF RBRVS 09/01/2019 12/31/2023 284.15 Description: DRAINAGE OF URETHRA ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53060 MEDSV DEF RBRVS 01/01/2024 176.93 Description: DRAINAGE OF URETHRA ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53060 MEDSV DEF RBRVS 09/01/2019 12/31/2023 134.18 Description: DRAINAGE OF URETHRA ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53080 MEDSV DEF RBRVS 01/01/2024 393.41 Description: DRAINAGE OF URINARY LEAKAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53080 MEDSV DEF RBRVS 09/01/2019 12/31/2023 303.76 Description: DRAINAGE OF URINARY LEAKAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53085 MEDSV DEF RBRVS 01/01/2024 605.71 Description: DRAINAGE OF URINARY LEAKAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53085 MEDSV DEF RBRVS 09/01/2019 12/31/2023 476.10 Description: DRAINAGE OF URINARY LEAKAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53200 MEDSV DEF RBRVS 01/01/2024 148.19 Description: BIOPSY OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53200 MEDSV DEF RBRVS 09/01/2019 12/31/2023 112.53 Description: BIOPSY OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53210 MEDSV DEF RBRVS 01/01/2024 723.98 Description: REMOVAL OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 652 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 53210 MEDSV DEF RBRVS 09/01/2019 12/31/2023 558.63 Description: REMOVAL OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53215 MEDSV DEF RBRVS 01/01/2024 864.68 Description: REMOVAL OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53215 MEDSV DEF RBRVS 09/01/2019 12/31/2023 674.43 Description: REMOVAL OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53220 MEDSV DEF RBRVS 01/01/2024 422.62 Description: TREATMENT OF URETHRA LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53220 MEDSV DEF RBRVS 09/01/2019 12/31/2023 328.03 Description: TREATMENT OF URETHRA LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53230 MEDSV DEF RBRVS 01/01/2024 568.62 Description: REMOVAL OF URETHRA LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53230 MEDSV DEF RBRVS 09/01/2019 12/31/2023 440.69 Description: REMOVAL OF URETHRA LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53235 MEDSV DEF RBRVS 01/01/2024 592.47 Description: REMOVAL OF URETHRA LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53235 MEDSV DEF RBRVS 09/01/2019 12/31/2023 458.36 Description: REMOVAL OF URETHRA LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53240 MEDSV DEF RBRVS 01/01/2024 397.61 Description: SURGERY FOR URETHRA POUCH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53240 MEDSV DEF RBRVS 09/01/2019 12/31/2023 307.23 Description: SURGERY FOR URETHRA POUCH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53250 MEDSV DEF RBRVS 01/01/2024 370.88 Description: REMOVAL OF URETHRA GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53250 MEDSV DEF RBRVS 09/01/2019 12/31/2023 298.47 Description: REMOVAL OF URETHRA GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53260 MEDSV DEF RBRVS 01/01/2024 193.86 Description: TREATMENT OF URETHRA LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53260 MEDSV DEF RBRVS 09/01/2019 12/31/2023 145.32 Description: TREATMENT OF URETHRA LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53265 MEDSV DEF RBRVS 01/01/2024 214.22 Description: TREATMENT OF URETHRA LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 653 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 53265 MEDSV DEF RBRVS 09/01/2019 12/31/2023 156.51 Description: TREATMENT OF URETHRA LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53270 MEDSV DEF RBRVS 01/01/2024 198.18 Description: REMOVAL OF URETHRA GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53270 MEDSV DEF RBRVS 09/01/2019 12/31/2023 151.25 Description: REMOVAL OF URETHRA GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53275 MEDSV DEF RBRVS 01/01/2024 245.55 Description: REPAIR OF URETHRA DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53275 MEDSV DEF RBRVS 09/01/2019 12/31/2023 190.33 Description: REPAIR OF URETHRA DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53400 MEDSV DEF RBRVS 01/01/2024 746.53 Description: REVISE URETHRA STAGE 1 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53400 MEDSV DEF RBRVS 09/01/2019 12/31/2023 581.45 Description: REVISE URETHRA STAGE 1 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53405 MEDSV DEF RBRVS 01/01/2024 814.54 Description: REVISE URETHRA STAGE 2 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53405 MEDSV DEF RBRVS 09/01/2019 12/31/2023 634.20 Description: REVISE URETHRA STAGE 2 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53410 MEDSV DEF RBRVS 01/01/2024 912.62 Description: RECONSTRUCTION OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53410 MEDSV DEF RBRVS 09/01/2019 12/31/2023 711.68 Description: RECONSTRUCTION OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53415 MEDSV DEF RBRVS 01/01/2024 1051.79 Description: RECONSTRUCTION OF URETHRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 53415 MEDSV DEF RBRVS 09/01/2019 12/31/2023 821.72 Description: RECONSTRUCTION OF URETHRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 53420 MEDSV DEF RBRVS 01/01/2024 784.29 Description: RECONSTRUCT URETHRA STAGE 1 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53420 MEDSV DEF RBRVS 09/01/2019 12/31/2023 610.88 Description: RECONSTRUCT URETHRA STAGE 1 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53425 MEDSV DEF RBRVS 01/01/2024 872.61 Description: RECONSTRUCT URETHRA STAGE 2 Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 654 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 53425 MEDSV DEF RBRVS 09/01/2019 12/31/2023 680.67 Description: RECONSTRUCT URETHRA STAGE 2 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53430 MEDSV DEF RBRVS 01/01/2024 905.88 Y Description: RECONSTRUCTION OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53430 MEDSV DEF RBRVS 09/01/2019 12/31/2023 704.47 Y Description: RECONSTRUCTION OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53431 MEDSV DEF RBRVS 01/01/2024 1073.02 Description: RECONSTRUCT URETHRA/BLADDER Category: Medical Services CMS Add: 01/01/2002 CMS Term: 53431 MEDSV DEF RBRVS 02/01/2015 12/31/2023 838.82 Description: RECONSTRUCT URETHRA/BLADDER Category: Medical Services CMS Add: 01/01/2002 CMS Term: 53440 MEDSV DEF RBRVS 01/01/2024 702.76 Description: MALE SLING PROCEDURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53440 MEDSV DEF RBRVS 09/01/2019 12/31/2023 546.31 Description: MALE SLING PROCEDURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53442 MEDSV DEF RBRVS 01/01/2024 733.57 Description: REMOVE/REVISE MALE SLING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53442 MEDSV DEF RBRVS 09/01/2019 12/31/2023 566.90 Description: REMOVE/REVISE MALE SLING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53444 MEDSV DEF RBRVS 01/01/2024 740.20 Description: INSERT TANDEM CUFF Category: Medical Services CMS Add: 01/01/2002 CMS Term: 53444 MEDSV DEF RBRVS 02/01/2015 12/31/2023 575.55 Description: INSERT TANDEM CUFF Category: Medical Services CMS Add: 01/01/2002 CMS Term: 53445 MEDSV DEF RBRVS 01/01/2024 706.59 Description: INSERT URO/VES NCK SPHINCTER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53445 MEDSV DEF RBRVS 09/01/2019 12/31/2023 545.80 Description: INSERT URO/VES NCK SPHINCTER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53446 MEDSV DEF RBRVS 01/01/2024 600.13 Description: REMOVE URO SPHINCTER Category: Medical Services CMS Add: 01/01/2002 CMS Term: 53446 MEDSV DEF RBRVS 02/01/2015 12/31/2023 465.11 Description: REMOVE URO SPHINCTER Category: Medical Services CMS Add: 01/01/2002 CMS Term: 53447 MEDSV DEF RBRVS 01/01/2024 752.53 Description: REMOVE/REPLACE UR SPHINCTER Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 655 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 53447 MEDSV DEF RBRVS 09/01/2019 12/31/2023 586.64 Description: REMOVE/REPLACE UR SPHINCTER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53448 MEDSV DEF RBRVS 01/01/2024 1188.07 Description: REMOV/REPLC UR SPHINCTR COMP Category: Medical Services CMS Add: 01/01/2002 CMS Term: 53448 MEDSV DEF RBRVS 02/01/2015 12/31/2023 930.51 Description: REMOV/REPLC UR SPHINCTR COMP Category: Medical Services CMS Add: 01/01/2002 CMS Term: 53449 MEDSV DEF RBRVS 01/01/2024 573.56 Description: REPAIR URO SPHINCTER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53449 MEDSV DEF RBRVS 09/01/2019 12/31/2023 443.17 Description: REPAIR URO SPHINCTER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53450 MEDSV DEF RBRVS 01/01/2024 382.76 Description: REVISION OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53450 MEDSV DEF RBRVS 09/01/2019 12/31/2023 295.43 Description: REVISION OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53451 MEDSV DEF BILL35 Description: TPRNL BALO CNTNC DEV BI Category: Medical Services CMS Add: 01/01/2022 CMS Term: 53452 MEDSV DEF BILL35 Description: TPRNL BALO CNTNC DEV UNI Category: Medical Services CMS Add: 01/01/2022 CMS Term: 53453 MEDSV DEF BILL35 Description: TPRNL BALO CNTNC DEV RMVL EA Category: Medical Services CMS Add: 01/01/2022 CMS Term: 53454 MEDSV DEF BILL35 Description: TPRNL BALO CNTNC DEV ADJMT Category: Medical Services CMS Add: 01/01/2022 CMS Term: 53460 MEDSV DEF RBRVS 01/01/2024 427.93 Description: REVISION OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53460 MEDSV DEF RBRVS 09/01/2019 12/31/2023 331.26 Description: REVISION OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53500 MEDSV DEF RBRVS 01/01/2024 698.14 Description: URETHRLYS TRANSVAG W/ SCOPE Category: Medical Services CMS Add: 01/01/2004 CMS Term: 53500 MEDSV DEF RBRVS 02/01/2015 12/31/2023 544.81 Description: URETHRLYS TRANSVAG W/ SCOPE Category: Medical Services CMS Add: 01/01/2004 CMS Term: 53502 MEDSV DEF RBRVS 01/01/2024 454.36 Description: REPAIR OF URETHRA INJURY Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 656 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 53502 MEDSV DEF RBRVS 09/01/2019 12/31/2023 352.56 Description: REPAIR OF URETHRA INJURY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53505 MEDSV DEF RBRVS 01/01/2024 454.05 Description: REPAIR OF URETHRA INJURY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53505 MEDSV DEF RBRVS 09/01/2019 12/31/2023 352.06 Description: REPAIR OF URETHRA INJURY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53510 MEDSV DEF RBRVS 01/01/2024 591.14 Description: REPAIR OF URETHRA INJURY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53510 MEDSV DEF RBRVS 09/01/2019 12/31/2023 457.30 Description: REPAIR OF URETHRA INJURY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53515 MEDSV DEF RBRVS 01/01/2024 742.16 Description: REPAIR OF URETHRA INJURY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53515 MEDSV DEF RBRVS 09/01/2019 12/31/2023 577.34 Description: REPAIR OF URETHRA INJURY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53520 MEDSV DEF RBRVS 01/01/2024 522.51 Description: REPAIR OF URETHRA DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53520 MEDSV DEF RBRVS 09/01/2019 12/31/2023 402.84 Description: REPAIR OF URETHRA DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53600 MEDSV DEF RBRVS 01/01/2024 82.95 Description: DILATE URETHRA STRICTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53600 MEDSV DEF RBRVS 09/01/2019 12/31/2023 59.59 Description: DILATE URETHRA STRICTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53601 MEDSV DEF RBRVS 01/01/2024 79.60 Description: DILATE URETHRA STRICTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53601 MEDSV DEF RBRVS 09/01/2019 12/31/2023 57.38 Description: DILATE URETHRA STRICTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53605 MEDSV DEF RBRVS 01/01/2024 59.70 Description: DILATE URETHRA STRICTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53605 MEDSV DEF RBRVS 09/01/2019 12/31/2023 47.11 Description: DILATE URETHRA STRICTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53620 MEDSV DEF RBRVS 01/01/2024 159.21 Description: DILATE URETHRA STRICTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 657 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 53620 MEDSV DEF RBRVS 09/01/2019 12/31/2023 82.91 Description: DILATE URETHRA STRICTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53621 MEDSV DEF RBRVS 01/01/2024 151.90 Description: DILATE URETHRA STRICTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53621 MEDSV DEF RBRVS 09/01/2019 12/31/2023 77.47 Description: DILATE URETHRA STRICTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53660 MEDSV DEF RBRVS 01/01/2024 70.43 Description: DILATION OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53660 MEDSV DEF RBRVS 09/01/2019 12/31/2023 49.71 Description: DILATION OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53661 MEDSV DEF RBRVS 01/01/2024 69.23 Description: DILATION OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53661 MEDSV DEF RBRVS 09/01/2019 12/31/2023 48.99 Description: DILATION OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53665 MEDSV DEF RBRVS 01/01/2024 35.39 Description: DILATION OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53665 MEDSV DEF RBRVS 09/01/2019 12/31/2023 28.43 Description: DILATION OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 53850 26 MEDSV DEF MAXFEE 01/01/2024 558.60 0.0 Description: PROSTATIC MICROWAVE THERMOTX Category: Medical Services CMS Add: 01/01/1998 CMS Term: 53850 26 MEDSV DEF RBRVS 02/01/2015 538.00 Description: PROSTATIC MICROWAVE THERMOTX Category: Medical Services CMS Add: 01/01/1998 CMS Term: 53850 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1439.88 Description: PROSTATIC MICROWAVE THERMOTX Category: Medical Services CMS Add: 01/01/1998 CMS Term: 53850 MEDSV DEF RBRVS 01/01/2024 1321.55 Description: PROSTATIC MICROWAVE THERMOTX Category: Medical Services CMS Add: 01/01/1998 CMS Term: 53850 TC MEDSV DEF MAXFEE 01/01/2024 1373.73 0.0 Description: PROSTATIC MICROWAVE THERMOTX Category: Medical Services CMS Add: 01/01/1998 CMS Term: 53850 TC MEDSV DEF RBRVS 02/01/2015 1318.83 Description: PROSTATIC MICROWAVE THERMOTX Category: Medical Services CMS Add: 01/01/1998 CMS Term: 53852 26 MEDSV DEF MAXFEE 01/01/2024 583.85 0.0 Description: PROSTATIC RF THERMOTX Category: Medical Services CMS Add: 01/01/1998 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 658 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 53852 26 MEDSV DEF RBRVS 02/01/2015 562.32 Description: PROSTATIC RF THERMOTX Category: Medical Services CMS Add: 01/01/1998 CMS Term: 53852 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1327.75 Description: PROSTATIC RF THERMOTX Category: Medical Services CMS Add: 01/01/1998 CMS Term: 53852 MEDSV DEF RBRVS 01/01/2024 1291.18 Description: PROSTATIC RF THERMOTX Category: Medical Services CMS Add: 01/01/1998 CMS Term: 53852 TC MEDSV DEF MAXFEE 01/01/2024 1374.27 0.0 Description: PROSTATIC RF THERMOTX Category: Medical Services CMS Add: 01/01/1998 CMS Term: 53852 TC MEDSV DEF RBRVS 02/01/2015 1318.62 Description: PROSTATIC RF THERMOTX Category: Medical Services CMS Add: 01/01/1998 CMS Term: 53854 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1296.09 Description: TRURL DSTRJ PRST8 TISS RF WV Category: Medical Services CMS Add: 01/01/2019 CMS Term: 53854 MEDSV DEF RBRVS 01/01/2024 1559.29 Description: TRURL DSTRJ PRST8 TISS RF WV Category: Medical Services CMS Add: 01/01/2019 CMS Term: 53855 NOCOV DEF SYSMAN Description: INSERT PROST URETHRAL STENT Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 53899 MEDSV DEF BILL35 Description: UNLISTED PX URINARY SYSTEM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54000 MEDSV DEF RBRVS 01/01/2024 152.02 0-28days Description: SLITTING OF PREPUCE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54000 MEDSV DEF RBRVS 09/01/2019 12/31/2023 104.32 0-28days Description: SLITTING OF PREPUCE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54001 MEDSV DEF RBRVS 01/01/2024 185.52 Description: SLITTING OF PREPUCE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54001 MEDSV DEF RBRVS 09/01/2019 12/31/2023 131.20 Description: SLITTING OF PREPUCE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54015 MEDSV DEF RBRVS 01/01/2024 284.40 Description: DRAIN PENIS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54015 MEDSV DEF RBRVS 09/01/2019 12/31/2023 224.02 Description: DRAIN PENIS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54050 MEDSV DEF RBRVS 01/01/2024 134.74 Description: DESTRUCTION PENIS LESION(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 659 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 54050 MEDSV DEF RBRVS 09/01/2019 12/31/2023 92.13 Description: DESTRUCTION PENIS LESION(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54055 MEDSV DEF RBRVS 01/01/2024 128.45 Description: DESTRUCTION PENIS LESION(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54055 MEDSV DEF RBRVS 09/01/2019 12/31/2023 82.80 Description: DESTRUCTION PENIS LESION(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54056 MEDSV DEF RBRVS 01/01/2024 134.88 Description: CRYOSURGERY PENIS LESION(S) Category: Medical Services CMS Add: 01/01/1986 CMS Term: 54056 MEDSV DEF RBRVS 09/01/2019 12/31/2023 99.40 Description: CRYOSURGERY PENIS LESION(S) Category: Medical Services CMS Add: 01/01/1986 CMS Term: 54057 MEDSV DEF RBRVS 01/01/2024 133.51 Description: LASER SURG PENIS LESION(S) Category: Medical Services CMS Add: 01/01/1986 CMS Term: 54057 MEDSV DEF RBRVS 09/01/2019 12/31/2023 95.18 Description: LASER SURG PENIS LESION(S) Category: Medical Services CMS Add: 01/01/1986 CMS Term: 54060 MEDSV DEF RBRVS 01/01/2024 182.24 Description: EXCISION OF PENIS LESION(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54060 MEDSV DEF RBRVS 09/01/2019 12/31/2023 126.52 Description: EXCISION OF PENIS LESION(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54065 MEDSV DEF RBRVS 01/01/2024 208.59 Description: DESTRUCTION PENIS LESION(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54065 MEDSV DEF RBRVS 09/01/2019 12/31/2023 155.29 Description: DESTRUCTION PENIS LESION(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54100 MEDSV DEF RBRVS 01/01/2024 189.86 Description: BIOPSY OF PENIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54100 MEDSV DEF RBRVS 09/01/2019 12/31/2023 138.33 Description: BIOPSY OF PENIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54105 MEDSV DEF RBRVS 01/01/2024 258.23 Description: BIOPSY OF PENIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54105 MEDSV DEF RBRVS 09/01/2019 12/31/2023 188.75 Description: BIOPSY OF PENIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54110 MEDSV DEF RBRVS 01/01/2024 583.14 Description: TREATMENT OF PENIS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 660 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 54110 MEDSV DEF RBRVS 09/01/2019 12/31/2023 452.51 Description: TREATMENT OF PENIS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54111 MEDSV DEF RBRVS 01/01/2024 745.55 Description: TREAT PENIS LESION GRAFT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54111 MEDSV DEF RBRVS 09/01/2019 12/31/2023 581.48 Description: TREAT PENIS LESION GRAFT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54112 MEDSV DEF RBRVS 01/01/2024 873.72 Description: TREAT PENIS LESION GRAFT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54112 MEDSV DEF RBRVS 09/01/2019 12/31/2023 681.14 Description: TREAT PENIS LESION GRAFT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54115 MEDSV DEF RBRVS 01/01/2024 427.77 Description: TREATMENT OF PENIS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54115 MEDSV DEF RBRVS 09/01/2019 12/31/2023 324.87 Description: TREATMENT OF PENIS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54120 MEDSV DEF RBRVS 01/01/2024 590.53 Description: PARTIAL REMOVAL OF PENIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54120 MEDSV DEF RBRVS 09/01/2019 12/31/2023 458.15 Description: PARTIAL REMOVAL OF PENIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54125 MEDSV DEF RBRVS 01/01/2024 768.75 Y Description: REMOVAL OF PENIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54125 MEDSV DEF RBRVS 09/01/2019 12/31/2023 589.78 Y Description: REMOVAL OF PENIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54130 MEDSV DEF RBRVS 01/01/2024 1111.20 Description: REMOVE PENIS & NODES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54130 MEDSV DEF RBRVS 09/01/2019 12/31/2023 867.54 Description: REMOVE PENIS & NODES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54135 MEDSV DEF RBRVS 01/01/2024 1404.91 Description: REMOVE PENIS & NODES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54135 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1100.12 Description: REMOVE PENIS & NODES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54150 MEDSV DEF RBRVS 01/01/2024 139.10 Description: CIRCUMCISION W/REGIONL BLOCK Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 661 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 54150 MEDSV DEF RBRVS 09/01/2019 12/31/2023 110.17 Description: CIRCUMCISION W/REGIONL BLOCK Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54160 MEDSV DEF RBRVS 01/01/2024 206.02 0-28days Description: CIRCUMCISION NEONATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54160 MEDSV DEF RBRVS 09/01/2019 12/31/2023 155.50 0-28days Description: CIRCUMCISION NEONATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54161 MEDSV DEF RBRVS 01/01/2024 184.39 Description: CIRCUM 28 DAYS OR OLDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54161 MEDSV DEF RBRVS 09/01/2019 12/31/2023 142.46 Description: CIRCUM 28 DAYS OR OLDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54162 MEDSV DEF RBRVS 01/01/2024 240.58 Description: LYSIS PENIL CIRCUMIC LESION Category: Medical Services CMS Add: 01/01/2002 CMS Term: 54162 MEDSV DEF RBRVS 02/01/2015 12/31/2023 183.42 Description: LYSIS PENIL CIRCUMIC LESION Category: Medical Services CMS Add: 01/01/2002 CMS Term: 54163 MEDSV DEF RBRVS 01/01/2024 204.46 Description: REPAIR OF CIRCUMCISION Category: Medical Services CMS Add: 01/01/2002 CMS Term: 54163 MEDSV DEF RBRVS 02/01/2015 12/31/2023 157.41 Description: REPAIR OF CIRCUMCISION Category: Medical Services CMS Add: 01/01/2002 CMS Term: 54164 MEDSV DEF RBRVS 01/01/2024 180.99 Description: FRENULOTOMY OF PENIS Category: Medical Services CMS Add: 01/01/2002 CMS Term: 54164 MEDSV DEF RBRVS 02/01/2015 12/31/2023 139.35 Description: FRENULOTOMY OF PENIS Category: Medical Services CMS Add: 01/01/2002 CMS Term: 54200 MEDSV DEF RBRVS 01/01/2024 108.09 Description: TREATMENT OF PENIS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54200 MEDSV DEF RBRVS 09/01/2019 12/31/2023 75.57 Description: TREATMENT OF PENIS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54205 MEDSV DEF RBRVS 01/01/2024 497.31 Description: TREATMENT OF PENIS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54205 MEDSV DEF RBRVS 09/01/2019 12/31/2023 385.09 Description: TREATMENT OF PENIS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54220 MEDSV DEF RBRVS 01/01/2024 204.96 Description: TREATMENT OF PENIS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 662 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 54220 MEDSV DEF RBRVS 09/01/2019 12/31/2023 144.45 Description: TREATMENT OF PENIS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54230 MEDSV DEF RBRVS 01/01/2024 99.08 Description: PREPARE PENIS STUDY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54230 MEDSV DEF RBRVS 09/01/2019 12/31/2023 69.03 Description: PREPARE PENIS STUDY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54231 MEDSV DEF RBRVS 01/01/2024 133.97 Description: DYNAMIC CAVERNOSOMETRY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 54231 MEDSV DEF RBRVS 09/01/2019 12/31/2023 100.56 Description: DYNAMIC CAVERNOSOMETRY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 54235 MEDSV DEF RBRVS 01/01/2024 83.81 Description: PENILE INJECTION Category: Medical Services CMS Add: 01/01/1988 CMS Term: 54235 MEDSV DEF RBRVS 09/01/2019 12/31/2023 64.51 Description: PENILE INJECTION Category: Medical Services CMS Add: 01/01/1988 CMS Term: 54240 26 MEDSV DEF RBRVS 01/01/2024 61.33 Description: PENIS STUDY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54240 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 47.42 Description: PENIS STUDY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54240 MEDSV DEF RBRVS 01/01/2024 99.62 Description: PENIS STUDY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54240 MEDSV DEF RBRVS 09/01/2019 12/31/2023 71.36 Description: PENIS STUDY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54240 TC MEDSV DEF RBRVS 01/01/2019 12/31/2023 23.95 Description: PENIS STUDY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54240 TC MEDSV DEF RBRVS 01/01/2024 38.29 Description: PENIS STUDY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54250 26 MEDSV DEF RBRVS 01/01/2024 102.06 Description: PENIS STUDY Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54250 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 80.37 Description: PENIS STUDY Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54250 MEDSV DEF RBRVS 01/01/2024 115.19 Description: PENIS STUDY Category: Medical Services CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 663 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 54250 MEDSV DEF RBRVS 09/01/2019 12/31/2023 87.72 Description: PENIS STUDY Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54250 TC MEDSV DEF RBRVS 01/01/2019 12/31/2023 7.35 Description: PENIS STUDY Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54250 TC MEDSV DEF RBRVS 01/01/2024 13.13 Description: PENIS STUDY Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54300 MEDSV DEF RBRVS 01/01/2024 602.39 Description: REVISION OF PENIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54300 MEDSV DEF RBRVS 09/01/2019 12/31/2023 464.74 Description: REVISION OF PENIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54304 MEDSV DEF RBRVS 01/01/2024 697.88 Description: REVISION OF PENIS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54304 MEDSV DEF RBRVS 09/01/2019 12/31/2023 543.91 Description: REVISION OF PENIS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54308 MEDSV DEF RBRVS 01/01/2024 668.99 Description: RECONSTRUCTION OF URETHRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54308 MEDSV DEF RBRVS 09/01/2019 12/31/2023 518.91 Description: RECONSTRUCTION OF URETHRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54312 MEDSV DEF RBRVS 01/01/2024 763.89 Description: RECONSTRUCTION OF URETHRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54312 MEDSV DEF RBRVS 09/01/2019 12/31/2023 593.81 Description: RECONSTRUCTION OF URETHRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54316 MEDSV DEF RBRVS 01/01/2024 926.58 Description: RECONSTRUCTION OF URETHRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54316 MEDSV DEF RBRVS 09/01/2019 12/31/2023 724.92 Description: RECONSTRUCTION OF URETHRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54318 MEDSV DEF RBRVS 01/01/2024 665.00 Description: RECONSTRUCTION OF URETHRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54318 MEDSV DEF RBRVS 09/01/2019 12/31/2023 510.17 Description: RECONSTRUCTION OF URETHRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54322 MEDSV DEF RBRVS 01/01/2024 729.07 Description: RECONSTRUCTION OF URETHRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 664 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 54322 MEDSV DEF RBRVS 09/01/2019 12/31/2023 567.01 Description: RECONSTRUCTION OF URETHRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54324 MEDSV DEF RBRVS 01/01/2024 902.34 Description: RECONSTRUCTION OF URETHRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54324 MEDSV DEF RBRVS 09/01/2019 12/31/2023 703.89 Description: RECONSTRUCTION OF URETHRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54326 MEDSV DEF RBRVS 01/01/2024 878.47 Description: RECONSTRUCTION OF URETHRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54326 MEDSV DEF RBRVS 09/01/2019 12/31/2023 687.01 Description: RECONSTRUCTION OF URETHRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54328 MEDSV DEF RBRVS 01/01/2024 872.67 Description: REVISE PENIS/URETHRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54328 MEDSV DEF RBRVS 09/01/2019 12/31/2023 682.44 Description: REVISE PENIS/URETHRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54332 MEDSV DEF RBRVS 01/01/2024 941.29 Description: REVISE PENIS/URETHRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54332 MEDSV DEF RBRVS 09/01/2019 12/31/2023 736.65 Description: REVISE PENIS/URETHRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54336 MEDSV DEF RBRVS 01/01/2024 1106.33 Description: REVISE PENIS/URETHRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54336 MEDSV DEF RBRVS 09/01/2019 12/31/2023 864.52 Description: REVISE PENIS/URETHRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54340 MEDSV DEF RBRVS 01/01/2024 532.17 Description: RPR HYPSPAD COMP SIMPLE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54340 MEDSV DEF RBRVS 09/01/2019 12/31/2023 412.57 Description: RPR HYPSPAD COMP SIMPLE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54344 MEDSV DEF RBRVS 01/01/2024 880.14 Description: RRP HYPSPAD COMP MOBLJ&URTP Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54344 MEDSV DEF RBRVS 09/01/2019 12/31/2023 723.01 Description: RRP HYPSPAD COMP MOBLJ&URTP Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54348 MEDSV DEF RBRVS 01/01/2024 941.14 Description: RPR HYPSPAD COMP DSJ & URTP Category: Medical Services CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 665 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 54348 MEDSV DEF RBRVS 09/01/2019 12/31/2023 728.78 Description: RPR HYPSPAD COMP DSJ & URTP Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54352 MEDSV DEF RBRVS 01/01/2024 1315.87 Description: REVJ PRIOR HYPSPAD REPAIR Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54352 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1030.69 Description: REVJ PRIOR HYPSPAD REPAIR Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54360 MEDSV DEF RBRVS 01/01/2024 673.50 Y Description: PENIS PLASTIC SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54360 MEDSV DEF RBRVS 09/01/2019 12/31/2023 523.30 Y Description: PENIS PLASTIC SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54380 MEDSV DEF RBRVS 01/01/2024 746.04 Description: REPAIR PENIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54380 MEDSV DEF RBRVS 09/01/2019 12/31/2023 579.98 Description: REPAIR PENIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54385 MEDSV DEF RBRVS 01/01/2024 867.94 Description: REPAIR PENIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54385 MEDSV DEF RBRVS 09/01/2019 12/31/2023 710.74 Description: REPAIR PENIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54390 MEDSV DEF RBRVS 01/01/2024 1156.36 Description: REPAIR PENIS AND BLADDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54390 MEDSV DEF RBRVS 09/01/2019 12/31/2023 933.32 Description: REPAIR PENIS AND BLADDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54400 NOCOV DEF SYSMAN Description: INSERT SEMI-RIGID PROSTHESIS Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 54401 NOCOV DEF SYSMAN Description: INSERT SELF-CONTD PROSTHESIS Category: Non Covered Services CMS Add: 01/01/1989 CMS Term: 54405 NOCOV DEF SYSMAN Description: INSERT MULTI-COMP PENIS PROS Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 54406 MEDSV DEF RBRVS 01/01/2024 682.94 Description: REMOVE MUTI-COMP PENIS PROS Category: Medical Services CMS Add: 01/01/2002 CMS Term: 54406 MEDSV DEF RBRVS 02/01/2015 12/31/2023 529.64 Description: REMOVE MUTI-COMP PENIS PROS Category: Medical Services CMS Add: 01/01/2002 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 666 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 54408 NOCOV DEF SYSMAN Description: REPAIR MULTI-COMP PENIS PROS Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: 54410 NOCOV DEF SYSMAN Description: REMOVE/REPLACE PENIS PROSTH Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: 54411 NOCOV DEF SYSMAN Description: REMOV/REPLC PENIS PROS COMP Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: 54415 MEDSV DEF RBRVS 01/01/2024 496.73 Description: REMOVE SELF-CONTD PENIS PROS Category: Medical Services CMS Add: 01/01/2002 CMS Term: 54415 MEDSV DEF RBRVS 02/01/2015 12/31/2023 382.43 Description: REMOVE SELF-CONTD PENIS PROS Category: Medical Services CMS Add: 01/01/2002 CMS Term: 54416 NOCOV DEF SYSMAN Description: REMV/REPL PENIS CONTAIN PROS Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: 54417 NOCOV DEF SYSMAN Description: REMV/REPLC PENIS PROS COMPL Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: 54420 MEDSV DEF RBRVS 01/01/2024 656.08 Description: REVISION OF PENIS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54420 MEDSV DEF RBRVS 09/01/2019 12/31/2023 511.33 Description: REVISION OF PENIS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54430 MEDSV DEF RBRVS 01/01/2024 596.85 Description: REVISION OF PENIS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54430 MEDSV DEF RBRVS 09/01/2019 12/31/2023 464.04 Description: REVISION OF PENIS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 54435 MEDSV DEF RBRVS 01/01/2024 387.82 Description: REVISION OF PENIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54435 MEDSV DEF RBRVS 09/01/2019 12/31/2023 301.21 Description: REVISION OF PENIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54437 MEDSV DEF RBRVS 01/01/2016 12/31/2023 497.41 Description: REPAIR CORPOREAL TEAR Category: Medical Services CMS Add: 01/01/2016 CMS Term: 54437 MEDSV DEF RBRVS 01/01/2024 633.56 Description: REPAIR CORPOREAL TEAR Category: Medical Services CMS Add: 01/01/2016 CMS Term: 54438 MEDSV DEF RBRVS 01/01/2016 12/31/2023 1002.35 Description: REPLANTATION OF PENIS Category: Medical Services CMS Add: 01/01/2016 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 667 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 54438 MEDSV DEF RBRVS 01/01/2024 1244.43 Description: REPLANTATION OF PENIS Category: Medical Services CMS Add: 01/01/2016 CMS Term: 54440 MEDSV DEF MAXFEE 01/01/1994 12/31/2023 453.35 0.0 Description: REPAIR OF PENIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54440 MEDSV DEF MAXFEE 01/01/2024 1090.48 0.0 Description: REPAIR OF PENIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54450 MEDSV DEF RBRVS 01/01/2024 63.98 Description: PREPUTIAL STRETCHING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54450 MEDSV DEF RBRVS 09/01/2019 12/31/2023 50.32 Description: PREPUTIAL STRETCHING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54500 MEDSV DEF RBRVS 01/01/2024 69.36 Description: BIOPSY OF TESTIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54500 MEDSV DEF RBRVS 09/01/2019 12/31/2023 54.11 Description: BIOPSY OF TESTIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54505 MEDSV DEF RBRVS 01/01/2024 196.06 Description: BIOPSY OF TESTIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54505 MEDSV DEF RBRVS 09/01/2019 12/31/2023 151.76 Description: BIOPSY OF TESTIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54512 MEDSV DEF RBRVS 01/01/2019 12/31/2023 391.21 Description: EXCISE LESION TESTIS Category: Medical Services CMS Add: 01/01/2001 CMS Term: 54512 MEDSV DEF RBRVS 01/01/2024 501.99 Description: EXCISE LESION TESTIS Category: Medical Services CMS Add: 01/01/2001 CMS Term: 54520 MEDSV DEF RBRVS 01/01/2024 306.17 Y Description: REMOVAL OF TESTIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54520 MEDSV DEF RBRVS 09/01/2019 12/31/2023 235.71 Y Description: REMOVAL OF TESTIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54522 MEDSV DEF RBRVS 01/01/2024 549.27 Description: ORCHIECTOMY PARTIAL Category: Medical Services CMS Add: 01/01/2001 CMS Term: 54522 MEDSV DEF RBRVS 02/01/2015 12/31/2023 436.58 Description: ORCHIECTOMY PARTIAL Category: Medical Services CMS Add: 01/01/2001 CMS Term: 54530 MEDSV DEF RBRVS 01/01/2024 475.39 Description: REMOVAL OF TESTIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 668 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 54530 MEDSV DEF RBRVS 09/01/2019 12/31/2023 366.11 Description: REMOVAL OF TESTIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54535 MEDSV DEF RBRVS 01/01/2024 694.97 Description: EXTENSIVE TESTIS SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54535 MEDSV DEF RBRVS 09/01/2019 12/31/2023 540.01 Description: EXTENSIVE TESTIS SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54550 MEDSV DEF RBRVS 01/01/2024 459.77 Description: EXPLORATION FOR TESTIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54550 MEDSV DEF RBRVS 09/01/2019 12/31/2023 356.50 Description: EXPLORATION FOR TESTIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54560 MEDSV DEF RBRVS 01/01/2024 642.37 Description: EXPLORATION FOR TESTIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54560 MEDSV DEF RBRVS 09/01/2019 12/31/2023 498.34 Description: EXPLORATION FOR TESTIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54600 MEDSV DEF RBRVS 01/01/2024 423.58 Description: REDUCE TESTIS TORSION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54600 MEDSV DEF RBRVS 09/01/2019 12/31/2023 328.05 Description: REDUCE TESTIS TORSION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54620 MEDSV DEF RBRVS 01/01/2024 278.85 Description: SUSPENSION OF TESTIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54620 MEDSV DEF RBRVS 09/01/2019 12/31/2023 217.27 Description: SUSPENSION OF TESTIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54640 MEDSV DEF RBRVS 01/01/2024 402.75 Description: ORCHIOPEXY INGUN/SCROT APPR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54640 MEDSV DEF RBRVS 09/01/2019 12/31/2023 345.25 Description: ORCHIOPEXY INGUN/SCROT APPR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54650 MEDSV DEF RBRVS 01/01/2024 665.34 Description: ORCHIOPEXY (FOWLER-STEPHENS) Category: Medical Services CMS Add: 01/01/1994 CMS Term: 54650 MEDSV DEF RBRVS 09/01/2019 12/31/2023 516.04 Description: ORCHIOPEXY (FOWLER-STEPHENS) Category: Medical Services CMS Add: 01/01/1994 CMS Term: 54660 MEDSV DEF RBRVS 01/01/2024 335.57 Y Description: REVISION OF TESTIS Category: Medical Services CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 669 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 54660 MEDSV DEF RBRVS 09/01/2019 12/31/2023 257.93 Y Description: REVISION OF TESTIS Category: Medical Services CMS Add: 01/01/1982 CMS Term: 54670 MEDSV DEF RBRVS 01/01/2019 12/31/2023 293.03 Description: REPAIR TESTIS INJURY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54670 MEDSV DEF RBRVS 01/01/2024 383.16 Description: REPAIR TESTIS INJURY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54680 MEDSV DEF RBRVS 01/01/2024 735.12 Description: RELOCATION OF TESTIS(ES) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54680 MEDSV DEF RBRVS 09/01/2019 12/31/2023 571.35 Description: RELOCATION OF TESTIS(ES) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54690 MEDSV DEF RBRVS 01/01/2024 611.95 Description: LAPAROSCOPY ORCHIECTOMY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 54690 MEDSV DEF RBRVS 02/01/2015 12/31/2023 524.18 Description: LAPAROSCOPY ORCHIECTOMY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 54692 MEDSV DEF RBRVS 01/01/2024 705.17 0-2 Description: LAPAROSCOPY ORCHIOPEXY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 54692 MEDSV DEF RBRVS 02/01/2015 12/31/2023 577.99 0-2 Description: LAPAROSCOPY ORCHIOPEXY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 54699 MEDSV DEF BILL35 0-1 Description: UNLISTED LAPS PX TESTIS Category: Medical Services CMS Add: 01/01/2000 CMS Term: 54700 MEDSV DEF RBRVS 01/01/2024 198.45 Description: DRAINAGE OF SCROTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54700 MEDSV DEF RBRVS 09/01/2019 12/31/2023 154.09 Description: DRAINAGE OF SCROTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54800 MEDSV DEF RBRVS 01/01/2024 116.03 Description: BIOPSY OF EPIDIDYMIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54800 MEDSV DEF RBRVS 09/01/2019 12/31/2023 93.40 Description: BIOPSY OF EPIDIDYMIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54830 MEDSV DEF RBRVS 01/01/2024 348.62 Description: REMOVE EPIDIDYMIS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54830 MEDSV DEF RBRVS 09/01/2019 12/31/2023 269.23 Description: REMOVE EPIDIDYMIS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 670 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 54840 MEDSV DEF RBRVS 01/01/2024 301.73 Description: REMOVE EPIDIDYMIS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54840 MEDSV DEF RBRVS 09/01/2019 12/31/2023 232.34 Description: REMOVE EPIDIDYMIS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54860 MEDSV DEF RBRVS 01/01/2024 392.27 Description: REMOVAL OF EPIDIDYMIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54860 MEDSV DEF RBRVS 09/01/2019 12/31/2023 302.99 Description: REMOVAL OF EPIDIDYMIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54861 MEDSV DEF RBRVS 01/01/2024 531.21 Description: REMOVAL OF EPIDIDYMIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54861 MEDSV DEF RBRVS 09/01/2019 12/31/2023 409.83 Description: REMOVAL OF EPIDIDYMIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54865 MEDSV DEF RBRVS 01/01/2024 337.22 Description: EXPLORE EPIDIDYMIS Category: Medical Services CMS Add: 01/01/2007 CMS Term: 54865 MEDSV DEF RBRVS 02/01/2015 12/31/2023 259.32 Description: EXPLORE EPIDIDYMIS Category: Medical Services CMS Add: 01/01/2007 CMS Term: 54900 MEDSV DEF RBRVS 01/01/2024 747.34 Description: FUSION OF SPERMATIC DUCTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54900 MEDSV DEF RBRVS 09/01/2019 12/31/2023 575.32 Description: FUSION OF SPERMATIC DUCTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54901 MEDSV DEF RBRVS 01/01/2024 986.79 Description: FUSION OF SPERMATIC DUCTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 54901 MEDSV DEF RBRVS 09/01/2019 12/31/2023 786.57 Description: FUSION OF SPERMATIC DUCTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55000 MEDSV DEF RBRVS 01/01/2024 112.48 Description: DRAINAGE OF HYDROCELE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55000 MEDSV DEF RBRVS 09/01/2019 12/31/2023 83.17 Description: DRAINAGE OF HYDROCELE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55040 MEDSV DEF RBRVS 01/01/2024 316.18 Description: REMOVAL OF HYDROCELE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55040 MEDSV DEF RBRVS 09/01/2019 12/31/2023 244.69 Description: REMOVAL OF HYDROCELE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 671 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 55041 MEDSV DEF RBRVS 01/01/2024 478.55 Description: REMOVAL OF HYDROCELES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55041 MEDSV DEF RBRVS 09/01/2019 12/31/2023 369.25 Description: REMOVAL OF HYDROCELES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55060 MEDSV DEF RBRVS 01/01/2024 355.69 Description: REPAIR OF HYDROCELE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55060 MEDSV DEF RBRVS 09/01/2019 12/31/2023 275.39 Description: REPAIR OF HYDROCELE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55100 MEDSV DEF RBRVS 01/01/2024 214.92 Description: DRAINAGE OF SCROTUM ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55100 MEDSV DEF RBRVS 09/01/2019 12/31/2023 153.85 Description: DRAINAGE OF SCROTUM ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55110 MEDSV DEF RBRVS 01/01/2024 363.06 Description: EXPLORE SCROTUM Category: Medical Services CMS Add: 01/01/1985 CMS Term: 55110 MEDSV DEF RBRVS 09/01/2019 12/31/2023 280.64 Description: EXPLORE SCROTUM Category: Medical Services CMS Add: 01/01/1985 CMS Term: 55120 MEDSV DEF RBRVS 01/01/2024 332.43 Description: REMOVAL OF SCROTUM LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55120 MEDSV DEF RBRVS 09/01/2019 12/31/2023 259.13 Description: REMOVAL OF SCROTUM LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55150 MEDSV DEF RBRVS 01/01/2024 461.29 Description: REMOVAL OF SCROTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55150 MEDSV DEF RBRVS 09/01/2019 12/31/2023 356.10 Description: REMOVAL OF SCROTUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55175 MEDSV DEF RBRVS 01/01/2024 341.87 Y Description: REVISION OF SCROTUM Category: Medical Services CMS Add: 01/01/1985 CMS Term: 55175 MEDSV DEF RBRVS 09/01/2019 12/31/2023 262.25 Y Description: REVISION OF SCROTUM Category: Medical Services CMS Add: 01/01/1985 CMS Term: 55180 MEDSV DEF RBRVS 01/01/2024 643.13 Y Description: REVISION OF SCROTUM Category: Medical Services CMS Add: 01/01/1985 CMS Term: 55180 MEDSV DEF RBRVS 09/01/2019 12/31/2023 503.28 Y Description: REVISION OF SCROTUM Category: Medical Services CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 672 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 55200 MEDSV DEF RBRVS 01/01/2024 359.07 Description: INCISION OF SPERM DUCT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55200 MEDSV DEF RBRVS 09/01/2019 12/31/2023 310.76 Description: INCISION OF SPERM DUCT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55250 MEDSV DEF RBRVS 01/01/2024 313.27 Y 21-999years Description: REMOVAL OF SPERM DUCT(S) Category: Medical Services CMS Add: 01/01/1982 CMS Term: 55250 MEDSV DEF RBRVS 09/01/2019 12/31/2023 270.22 Y 21-999years Description: REMOVAL OF SPERM DUCT(S) Category: Medical Services CMS Add: 01/01/1982 CMS Term: 55300 MEDSV DEF RBRVS 01/01/2024 172.91 Description: PREPARE SPERM DUCT X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55300 MEDSV DEF RBRVS 09/01/2019 12/31/2023 136.64 Description: PREPARE SPERM DUCT X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55400 NOCOV DEF SYSMAN Description: REPAIR OF SPERM DUCT Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: 55500 MEDSV DEF RBRVS 01/01/2024 365.89 Description: REMOVAL OF HYDROCELE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55500 MEDSV DEF RBRVS 09/01/2019 12/31/2023 285.78 Description: REMOVAL OF HYDROCELE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55520 MEDSV DEF RBRVS 01/01/2024 421.07 Description: REMOVAL OF SPERM CORD LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55520 MEDSV DEF RBRVS 09/01/2019 12/31/2023 322.29 Description: REMOVAL OF SPERM CORD LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55530 MEDSV DEF RBRVS 01/01/2024 329.46 Description: REVISE SPERMATIC CORD VEINS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55530 MEDSV DEF RBRVS 09/01/2019 12/31/2023 255.06 Description: REVISE SPERMATIC CORD VEINS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55535 MEDSV DEF RBRVS 01/01/2024 403.04 Description: REVISE SPERMATIC CORD VEINS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55535 MEDSV DEF RBRVS 09/01/2019 12/31/2023 311.34 Description: REVISE SPERMATIC CORD VEINS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55540 MEDSV DEF RBRVS 01/01/2024 508.62 Description: REVISE HERNIA & SPERM VEINS Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 673 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 55540 MEDSV DEF RBRVS 09/01/2019 12/31/2023 385.59 Description: REVISE HERNIA & SPERM VEINS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55550 MEDSV DEF RBRVS 01/01/2024 402.15 0-2 Description: LAPARO LIGATE SPERMATIC VEIN Category: Medical Services CMS Add: 01/01/2000 CMS Term: 55550 MEDSV DEF RBRVS 02/01/2015 12/31/2023 310.12 0-2 Description: LAPARO LIGATE SPERMATIC VEIN Category: Medical Services CMS Add: 01/01/2000 CMS Term: 55559 MEDSV DEF BILL35 0-1 Description: UNLSTD LAPS PX SPRMATIC CORD Category: Medical Services CMS Add: 01/01/2000 CMS Term: 55600 MEDSV DEF RBRVS 01/01/2024 395.08 Description: INCISE SPERM DUCT POUCH Category: Medical Services CMS Add: 01/01/1985 CMS Term: 55600 MEDSV DEF RBRVS 09/01/2019 12/31/2023 305.10 Description: INCISE SPERM DUCT POUCH Category: Medical Services CMS Add: 01/01/1985 CMS Term: 55605 MEDSV DEF RBRVS 01/01/2024 490.19 Description: INCISE SPERM DUCT POUCH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55605 MEDSV DEF RBRVS 09/01/2019 12/31/2023 391.75 Description: INCISE SPERM DUCT POUCH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55650 MEDSV DEF RBRVS 01/01/2024 670.78 Description: REMOVE SPERM DUCT POUCH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55650 MEDSV DEF RBRVS 09/01/2019 12/31/2023 520.71 Description: REMOVE SPERM DUCT POUCH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55680 MEDSV DEF RBRVS 01/01/2024 325.18 Description: REMOVE SPERM POUCH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55680 MEDSV DEF RBRVS 09/01/2019 12/31/2023 250.35 Description: REMOVE SPERM POUCH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55700 MEDSV DEF RBRVS 01/01/2024 225.69 Description: BIOPSY OF PROSTATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55700 MEDSV DEF RBRVS 09/01/2019 12/31/2023 154.45 Description: BIOPSY OF PROSTATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55705 MEDSV DEF RBRVS 01/01/2024 247.50 Description: BIOPSY OF PROSTATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55705 MEDSV DEF RBRVS 09/01/2019 12/31/2023 192.64 Description: BIOPSY OF PROSTATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 674 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 55706 MEDSV DEF RBRVS 01/01/2024 351.44 Description: PROSTATE SATURATION SAMPLING Category: Medical Services CMS Add: 01/01/2009 CMS Term: 55706 MEDSV DEF RBRVS 02/01/2015 12/31/2023 267.57 Description: PROSTATE SATURATION SAMPLING Category: Medical Services CMS Add: 01/01/2009 CMS Term: 55720 MEDSV DEF RBRVS 01/01/2024 422.62 Description: DRAINAGE OF PROSTATE ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55720 MEDSV DEF RBRVS 09/01/2019 12/31/2023 327.25 Description: DRAINAGE OF PROSTATE ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55725 MEDSV DEF RBRVS 01/01/2024 556.84 Description: DRAINAGE OF PROSTATE ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55725 MEDSV DEF RBRVS 09/01/2019 12/31/2023 429.72 Description: DRAINAGE OF PROSTATE ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55801 MEDSV DEF RBRVS 01/01/2024 1020.75 Description: REMOVAL OF PROSTATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55801 MEDSV DEF RBRVS 09/01/2019 12/31/2023 794.48 Description: REMOVAL OF PROSTATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55810 MEDSV DEF RBRVS 01/01/2024 1216.16 Description: EXTENSIVE PROSTATE SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55810 MEDSV DEF RBRVS 09/01/2019 12/31/2023 957.56 Description: EXTENSIVE PROSTATE SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55812 MEDSV DEF RBRVS 01/01/2024 1495.45 Description: EXTENSIVE PROSTATE SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55812 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1170.77 Description: EXTENSIVE PROSTATE SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55815 MEDSV DEF RBRVS 01/01/2024 1637.35 Description: EXTENSIVE PROSTATE SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55815 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1283.38 Description: EXTENSIVE PROSTATE SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55821 MEDSV DEF RBRVS 01/01/2024 782.47 Description: REMOVAL OF PROSTATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55821 MEDSV DEF RBRVS 09/01/2019 12/31/2023 634.90 Description: REMOVAL OF PROSTATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 675 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 55831 MEDSV DEF RBRVS 01/01/2024 802.78 Description: REMOVAL OF PROSTATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55831 MEDSV DEF RBRVS 09/01/2019 12/31/2023 687.03 Description: REMOVAL OF PROSTATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55840 MEDSV DEF RBRVS 01/01/2024 1088.41 Description: EXTENSIVE PROSTATE SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55840 MEDSV DEF RBRVS 09/01/2019 12/31/2023 972.72 Description: EXTENSIVE PROSTATE SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55842 MEDSV DEF RBRVS 01/01/2024 1088.73 Description: EXTENSIVE PROSTATE SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55842 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1041.94 Description: EXTENSIVE PROSTATE SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55845 MEDSV DEF RBRVS 01/01/2024 1266.17 Description: EXTENSIVE PROSTATE SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55845 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1190.16 Description: EXTENSIVE PROSTATE SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55860 MEDSV DEF RBRVS 01/01/2024 816.18 Description: SURGICAL EXPOSURE PROSTATE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 55860 MEDSV DEF RBRVS 09/01/2019 12/31/2023 635.57 Description: SURGICAL EXPOSURE PROSTATE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 55862 MEDSV DEF RBRVS 01/01/2024 1020.58 Description: EXTENSIVE PROSTATE SURGERY Category: Medical Services CMS Add: 01/01/1985 CMS Term: 55862 MEDSV DEF RBRVS 09/01/2019 12/31/2023 797.13 Description: EXTENSIVE PROSTATE SURGERY Category: Medical Services CMS Add: 01/01/1985 CMS Term: 55865 MEDSV DEF RBRVS 01/01/2024 1242.19 Description: EXTENSIVE PROSTATE SURGERY Category: Medical Services CMS Add: 01/01/1985 CMS Term: 55865 MEDSV DEF RBRVS 09/01/2019 12/31/2023 970.28 Description: EXTENSIVE PROSTATE SURGERY Category: Medical Services CMS Add: 01/01/1985 CMS Term: 55866 MEDSV DEF RBRVS 01/01/2024 1114.19 Description: LAPS SURG PRST8ECT RPBIC RAD Category: Medical Services CMS Add: 01/01/2003 CMS Term: 55866 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1262.85 Description: LAPS SURG PRST8ECT RPBIC RAD Category: Medical Services CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 676 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 55867 MEDSV DEF RBRVS 01/01/2023 978.09 Description: LAPS SURG PRST8ECT SMPL STOT Category: Medical Services CMS Add: 01/01/2023 CMS Term: 55870 NOCOV DEF SYSMAN Description: ELECTROEJACULATION Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: 55873 MEDSV DEF RBRVS 01/01/2024 5354.87 Description: CRYOABLATE PROSTATE Category: Medical Services CMS Add: 01/01/2001 CMS Term: 55873 MEDSV DEF RBRVS 02/01/2015 12/31/2023 4740.95 Description: CRYOABLATE PROSTATE Category: Medical Services CMS Add: 01/01/2001 CMS Term: 55874 MEDSV DEF MAXFEE 01/01/2024 2692.05 0.0 Description: TPRNL PLMT BIODEGRDABL MATRL Category: Medical Services CMS Add: 01/01/2018 CMS Term: 55875 MEDSV DEF RBRVS 01/01/2024 730.71 Description: TRANSPERI NEEDLE PLACE PROS Category: Medical Services CMS Add: 01/01/2007 CMS Term: 55875 MEDSV DEF RBRVS 02/01/2015 12/31/2023 553.87 Description: TRANSPERI NEEDLE PLACE PROS Category: Medical Services CMS Add: 01/01/2007 CMS Term: 55876 MEDSV DEF RBRVS 01/01/2024 141.95 Description: PLACE RT DEVICE/MARKER PROS Category: Medical Services CMS Add: 01/01/2007 CMS Term: 55876 MEDSV DEF RBRVS 02/01/2015 12/31/2023 96.27 Description: PLACE RT DEVICE/MARKER PROS Category: Medical Services CMS Add: 01/01/2007 CMS Term: 55880 MEDSV DEF RBRVS 01/01/2021 12/31/2023 739.69 Description: ABLTJ MAL PRST8 TISS HIFU Category: Medical Services CMS Add: 01/01/2021 CMS Term: 55880 MEDSV DEF RBRVS 01/01/2024 912.77 Description: ABLTJ MAL PRST8 TISS HIFU Category: Medical Services CMS Add: 01/01/2021 CMS Term: 55899 MEDSV DEF BILL35 Y Description: UNLISTED PX MALE GENITAL SYS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 55920 MEDSV DEF RBRVS 01/01/2024 437.17 Description: PLACE NEEDLES PELVIC FOR RT Category: Medical Services CMS Add: 01/01/2008 CMS Term: 55920 MEDSV DEF RBRVS 02/01/2015 12/31/2023 326.65 Description: PLACE NEEDLES PELVIC FOR RT Category: Medical Services CMS Add: 01/01/2008 CMS Term: 55970 MEDSV DEF MAXFEE 01/01/2024 3817.29 0.0 Y Description: SEX TRANSFORMATION M TO F Category: Medical Services CMS Add: 01/01/1982 CMS Term: 55980 MEDSV DEF MAXFEE 01/01/2024 4029.77 0.0 Y Description: SEX TRANSFORMATION F TO M Category: Medical Services CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 677 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 56405 MEDSV DEF RBRVS 01/01/2024 138.49 Description: I & D OF VULVA/PERINEUM Category: Medical Services CMS Add: 01/01/1993 CMS Term: 56405 MEDSV DEF RBRVS 09/01/2019 12/31/2023 79.09 Description: I & D OF VULVA/PERINEUM Category: Medical Services CMS Add: 01/01/1993 CMS Term: 56420 MEDSV DEF RBRVS 01/01/2024 174.45 Description: DRAINAGE OF GLAND ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 56420 MEDSV DEF RBRVS 09/01/2019 12/31/2023 87.08 Description: DRAINAGE OF GLAND ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 56440 MEDSV DEF RBRVS 01/01/2024 169.40 Description: SURGERY FOR VULVA LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 56440 MEDSV DEF RBRVS 09/01/2019 12/31/2023 132.97 Description: SURGERY FOR VULVA LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 56441 MEDSV DEF RBRVS 01/01/2024 172.38 Description: LYSIS OF LABIAL LESION(S) Category: Medical Services CMS Add: 01/01/1991 CMS Term: 56441 MEDSV DEF RBRVS 09/01/2019 12/31/2023 103.49 Description: LYSIS OF LABIAL LESION(S) Category: Medical Services CMS Add: 01/01/1991 CMS Term: 56442 MEDSV DEF RBRVS 01/01/2024 44.12 Description: HYMENOTOMY Category: Medical Services CMS Add: 01/01/2007 CMS Term: 56442 MEDSV DEF RBRVS 02/01/2015 12/31/2023 34.95 Description: HYMENOTOMY Category: Medical Services CMS Add: 01/01/2007 CMS Term: 56501 MEDSV DEF RBRVS 01/01/2024 181.36 Description: DESTROY VULVA LESIONS SIM Category: Medical Services CMS Add: 01/01/1987 CMS Term: 56501 MEDSV DEF RBRVS 09/01/2019 12/31/2023 93.81 Description: DESTROY VULVA LESIONS SIM Category: Medical Services CMS Add: 01/01/1987 CMS Term: 56515 MEDSV DEF RBRVS 01/01/2024 260.60 Description: DESTROY VULVA LESION/S COMPL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 56515 MEDSV DEF RBRVS 09/01/2019 12/31/2023 162.02 Description: DESTROY VULVA LESION/S COMPL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 56605 MEDSV DEF RBRVS 01/01/2024 90.49 0-1 Description: BIOPSY OF VULVA/PERINEUM Category: Medical Services CMS Add: 01/01/1993 CMS Term: 56605 MEDSV DEF RBRVS 09/01/2019 12/31/2023 59.36 0-1 Description: BIOPSY OF VULVA/PERINEUM Category: Medical Services CMS Add: 01/01/1993 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 678 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 56606 MEDSV DEF RBRVS 01/01/2019 12/31/2023 27.00 Description: BIOPSY OF VULVA/PERINEUM Category: Medical Services CMS Add: 01/01/1993 CMS Term: 56606 MEDSV DEF RBRVS 01/01/2024 35.99 Description: BIOPSY OF VULVA/PERINEUM Category: Medical Services CMS Add: 01/01/1993 CMS Term: 56620 MEDSV DEF RBRVS 01/01/2024 549.12 Description: PARTIAL REMOVAL OF VULVA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 56620 MEDSV DEF RBRVS 09/01/2019 12/31/2023 369.94 Description: PARTIAL REMOVAL OF VULVA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 56625 MEDSV DEF RBRVS 01/01/2024 625.11 Description: COMPLETE REMOVAL OF VULVA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 56625 MEDSV DEF RBRVS 09/01/2019 12/31/2023 444.97 Description: COMPLETE REMOVAL OF VULVA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 56630 MEDSV DEF RBRVS 01/01/2024 898.15 Description: EXTENSIVE VULVA SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 56630 MEDSV DEF RBRVS 09/01/2019 12/31/2023 656.35 Description: EXTENSIVE VULVA SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 56631 MEDSV DEF RBRVS 01/01/2024 1107.25 Description: EXTENSIVE VULVA SURGERY Category: Medical Services CMS Add: 01/01/1993 CMS Term: 56631 MEDSV DEF RBRVS 09/01/2019 12/31/2023 835.65 Description: EXTENSIVE VULVA SURGERY Category: Medical Services CMS Add: 01/01/1993 CMS Term: 56632 MEDSV DEF RBRVS 01/01/2024 1340.36 Description: EXTENSIVE VULVA SURGERY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 56632 MEDSV DEF RBRVS 09/01/2019 12/31/2023 969.57 Description: EXTENSIVE VULVA SURGERY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 56633 MEDSV DEF RBRVS 01/01/2024 1151.06 Description: EXTENSIVE VULVA SURGERY Category: Medical Services CMS Add: 01/01/1993 CMS Term: 56633 MEDSV DEF RBRVS 09/01/2019 12/31/2023 856.46 Description: EXTENSIVE VULVA SURGERY Category: Medical Services CMS Add: 01/01/1993 CMS Term: 56634 MEDSV DEF RBRVS 01/01/2024 1207.41 Description: EXTENSIVE VULVA SURGERY Category: Medical Services CMS Add: 01/01/1993 CMS Term: 56634 MEDSV DEF RBRVS 09/01/2019 12/31/2023 909.91 Description: EXTENSIVE VULVA SURGERY Category: Medical Services CMS Add: 01/01/1993 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 679 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 56637 MEDSV DEF RBRVS 01/01/2024 1414.21 Description: EXTENSIVE VULVA SURGERY Category: Medical Services CMS Add: 01/01/1993 CMS Term: 56637 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1062.74 Description: EXTENSIVE VULVA SURGERY Category: Medical Services CMS Add: 01/01/1993 CMS Term: 56640 MEDSV DEF RBRVS 01/01/2024 1422.95 Description: EXTENSIVE VULVA SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 56640 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1064.54 Description: EXTENSIVE VULVA SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 56700 MEDSV DEF RBRVS 01/01/2024 191.01 Description: PARTIAL REMOVAL OF HYMEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 56700 MEDSV DEF RBRVS 09/01/2019 12/31/2023 136.17 Description: PARTIAL REMOVAL OF HYMEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 56740 MEDSV DEF RBRVS 01/01/2024 295.26 Description: REMOVE VAGINA GLAND LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 56740 MEDSV DEF RBRVS 09/01/2019 12/31/2023 217.49 Description: REMOVE VAGINA GLAND LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 56800 MEDSV DEF RBRVS 01/01/2024 237.49 Description: REPAIR OF VAGINA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 56800 MEDSV DEF RBRVS 09/01/2019 12/31/2023 174.87 Description: REPAIR OF VAGINA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 56805 MEDSV DEF RBRVS 01/01/2024 1091.99 Y Description: REPAIR CLITORIS Category: Medical Services CMS Add: 01/01/1992 CMS Term: 56805 MEDSV DEF RBRVS 09/01/2019 12/31/2023 839.66 Y Description: REPAIR CLITORIS Category: Medical Services CMS Add: 01/01/1992 CMS Term: 56810 MEDSV DEF RBRVS 01/01/2024 254.96 Y Description: REPAIR OF PERINEUM Category: Medical Services CMS Add: 01/01/1993 CMS Term: 56810 MEDSV DEF RBRVS 09/01/2019 12/31/2023 189.33 Y Description: REPAIR OF PERINEUM Category: Medical Services CMS Add: 01/01/1993 CMS Term: 56820 MEDSV DEF RBRVS 01/01/2024 117.21 Description: EXAM OF VULVA W/SCOPE Category: Medical Services CMS Add: 01/01/2003 CMS Term: 56820 MEDSV DEF RBRVS 02/01/2015 12/31/2023 80.35 Description: EXAM OF VULVA W/SCOPE Category: Medical Services CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 680 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 56821 MEDSV DEF RBRVS 01/01/2024 156.91 Description: EXAM/BIOPSY OF VULVA W/SCOPE Category: Medical Services CMS Add: 01/01/2003 CMS Term: 56821 MEDSV DEF RBRVS 09/01/2019 12/31/2023 106.11 Description: EXAM/BIOPSY OF VULVA W/SCOPE Category: Medical Services CMS Add: 01/01/2003 CMS Term: 57000 MEDSV DEF RBRVS 01/01/2024 189.73 Description: EXPLORATION OF VAGINA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57000 MEDSV DEF RBRVS 09/01/2019 12/31/2023 137.87 Description: EXPLORATION OF VAGINA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57010 MEDSV DEF RBRVS 01/01/2024 429.65 Description: DRAINAGE OF PELVIC ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57010 MEDSV DEF RBRVS 09/01/2019 12/31/2023 316.80 Description: DRAINAGE OF PELVIC ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57020 MEDSV DEF RBRVS 01/01/2024 118.14 Description: DRAINAGE OF PELVIC FLUID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57020 MEDSV DEF RBRVS 09/01/2019 12/31/2023 68.21 Description: DRAINAGE OF PELVIC FLUID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57022 MEDSV DEF RBRVS 01/01/2024 170.29 Description: I & D VAGINAL HEMATOMA PP Category: Medical Services CMS Add: 01/01/2001 CMS Term: 57022 MEDSV DEF RBRVS 02/01/2015 12/31/2023 126.03 Description: I & D VAGINAL HEMATOMA PP Category: Medical Services CMS Add: 01/01/2001 CMS Term: 57023 MEDSV DEF RBRVS 01/01/2024 299.74 Description: I & D VAG HEMATOMA NON-OB Category: Medical Services CMS Add: 01/01/2001 CMS Term: 57023 MEDSV DEF RBRVS 02/01/2015 12/31/2023 226.95 Description: I & D VAG HEMATOMA NON-OB Category: Medical Services CMS Add: 01/01/2001 CMS Term: 57061 MEDSV DEF RBRVS 01/01/2024 157.19 Description: DESTROY VAG LESIONS SIMPLE Category: Medical Services CMS Add: 01/01/1987 CMS Term: 57061 MEDSV DEF RBRVS 09/01/2019 12/31/2023 81.25 Description: DESTROY VAG LESIONS SIMPLE Category: Medical Services CMS Add: 01/01/1987 CMS Term: 57065 MEDSV DEF RBRVS 01/01/2024 232.28 Description: DESTROY VAG LESIONS COMPLEX Category: Medical Services CMS Add: 01/01/1987 CMS Term: 57065 MEDSV DEF RBRVS 09/01/2019 12/31/2023 139.10 Description: DESTROY VAG LESIONS COMPLEX Category: Medical Services CMS Add: 01/01/1987 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 681 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 57100 MEDSV DEF RBRVS 01/01/2024 96.82 Description: BIOPSY OF VAGINA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57100 MEDSV DEF RBRVS 09/01/2019 12/31/2023 63.62 Description: BIOPSY OF VAGINA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57105 MEDSV DEF RBRVS 01/01/2024 166.11 Description: BIOPSY OF VAGINA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57105 MEDSV DEF RBRVS 09/01/2019 12/31/2023 97.20 Description: BIOPSY OF VAGINA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57106 MEDSV DEF RBRVS 01/01/2024 503.15 Y Description: REMOVE VAGINA WALL PARTIAL Category: Medical Services CMS Add: 01/01/1999 CMS Term: 57106 MEDSV DEF RBRVS 02/01/2015 12/31/2023 352.95 Y Description: REMOVE VAGINA WALL PARTIAL Category: Medical Services CMS Add: 01/01/1999 CMS Term: 57107 MEDSV DEF RBRVS 01/01/2024 1361.82 Description: REMOVE VAGINA TISSUE PART Category: Medical Services CMS Add: 01/01/1999 CMS Term: 57107 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1038.32 Description: REMOVE VAGINA TISSUE PART Category: Medical Services CMS Add: 01/01/1999 CMS Term: 57109 MEDSV DEF RBRVS 01/01/2024 1612.70 Description: VAGINECTOMY PARTIAL W/NODES Category: Medical Services CMS Add: 01/01/1999 CMS Term: 57109 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1217.62 Description: VAGINECTOMY PARTIAL W/NODES Category: Medical Services CMS Add: 01/01/1999 CMS Term: 57110 MEDSV DEF RBRVS 01/01/2024 847.27 Y Description: REMOVE VAGINA WALL COMPLETE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57110 MEDSV DEF RBRVS 09/01/2019 12/31/2023 656.54 Y Description: REMOVE VAGINA WALL COMPLETE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57111 MEDSV DEF RBRVS 01/01/2024 1612.70 Description: REMOVE VAGINA TISSUE COMPL Category: Medical Services CMS Add: 01/01/1999 CMS Term: 57111 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1177.25 Description: REMOVE VAGINA TISSUE COMPL Category: Medical Services CMS Add: 01/01/1999 CMS Term: 57120 MEDSV DEF RBRVS 01/01/2024 498.47 Description: CLOSURE OF VAGINA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57120 MEDSV DEF RBRVS 09/01/2019 12/31/2023 372.26 Description: CLOSURE OF VAGINA Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 682 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 57130 MEDSV DEF RBRVS 01/01/2024 217.46 Description: REMOVE VAGINA LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57130 MEDSV DEF RBRVS 09/01/2019 12/31/2023 128.03 Description: REMOVE VAGINA LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57135 MEDSV DEF RBRVS 01/01/2024 233.18 Description: REMOVE VAGINA LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57135 MEDSV DEF RBRVS 09/01/2019 12/31/2023 138.19 Description: REMOVE VAGINA LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57150 MEDSV DEF RBRVS 01/01/2024 54.35 Description: TREAT VAGINA INFECTION Category: Medical Services CMS Add: 01/01/1982 CMS Term: 57150 MEDSV DEF RBRVS 09/01/2019 12/31/2023 32.45 Description: TREAT VAGINA INFECTION Category: Medical Services CMS Add: 01/01/1982 CMS Term: 57155 MEDSV DEF RBRVS 01/01/2024 375.47 Description: INSERT UTERI TANDEM/OVOIDS Category: Medical Services CMS Add: 01/01/2002 CMS Term: 57155 MEDSV DEF RBRVS 09/15/2017 12/31/2023 264.13 Description: INSERT UTERI TANDEM/OVOIDS Category: Medical Services CMS Add: 01/01/2002 CMS Term: 57156 MEDSV DEF RBRVS 01/01/2024 216.64 Description: INS VAG BRACHYTX DEVICE Category: Medical Services CMS Add: 01/01/2011 CMS Term: 57156 MEDSV DEF RBRVS 02/01/2015 12/31/2023 141.06 Description: INS VAG BRACHYTX DEVICE Category: Medical Services CMS Add: 01/01/2011 CMS Term: 57160 MEDSV DEF RBRVS 01/01/2024 69.77 Description: INSERT PESSARY/OTHER DEVICE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57160 MEDSV DEF RBRVS 09/01/2019 12/31/2023 54.79 Description: INSERT PESSARY/OTHER DEVICE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57170 MEDSV DEF RBRVS 01/01/2024 73.09 Description: FITTING OF DIAPHRAGM/CAP Category: Medical Services CMS Add: 01/01/1982 CMS Term: 57170 MEDSV DEF RBRVS 09/01/2019 12/31/2023 43.94 Description: FITTING OF DIAPHRAGM/CAP Category: Medical Services CMS Add: 01/01/1982 CMS Term: 57180 MEDSV DEF RBRVS 01/01/2024 187.54 Description: TREAT VAGINAL BLEEDING Category: Medical Services CMS Add: 01/01/1987 CMS Term: 57180 MEDSV DEF RBRVS 09/01/2019 12/31/2023 100.60 Description: TREAT VAGINAL BLEEDING Category: Medical Services CMS Add: 01/01/1987 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 683 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 57200 MEDSV DEF RBRVS 01/01/2024 310.79 Description: REPAIR OF VAGINA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57200 MEDSV DEF RBRVS 09/01/2019 12/31/2023 217.18 Description: REPAIR OF VAGINA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57210 MEDSV DEF RBRVS 01/01/2024 368.98 Description: REPAIR VAGINA/PERINEUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57210 MEDSV DEF RBRVS 09/01/2019 12/31/2023 266.62 Description: REPAIR VAGINA/PERINEUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57220 MEDSV DEF RBRVS 01/01/2024 325.22 Description: REVISION OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57220 MEDSV DEF RBRVS 09/01/2019 12/31/2023 232.21 Description: REVISION OF URETHRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57230 MEDSV DEF RBRVS 01/01/2024 393.86 Description: REPAIR OF URETHRAL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57230 MEDSV DEF RBRVS 09/01/2019 12/31/2023 288.26 Description: REPAIR OF URETHRAL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57240 MEDSV DEF RBRVS 01/01/2024 575.99 Description: ANTERIOR COLPORRHAPHY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57240 MEDSV DEF RBRVS 09/01/2019 12/31/2023 488.33 Description: ANTERIOR COLPORRHAPHY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57250 MEDSV DEF RBRVS 01/01/2024 577.88 Description: REPAIR RECTUM & VAGINA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57250 MEDSV DEF RBRVS 09/01/2019 12/31/2023 494.69 Description: REPAIR RECTUM & VAGINA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57260 MEDSV DEF RBRVS 01/01/2024 730.23 Description: CMBN ANT PST COLPRHY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57260 MEDSV DEF RBRVS 09/01/2019 12/31/2023 610.02 Description: CMBN ANT PST COLPRHY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57265 MEDSV DEF RBRVS 01/01/2024 816.77 Description: CMBN AP COLPRHY W/NTRCL RPR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57265 MEDSV DEF RBRVS 09/01/2019 12/31/2023 668.32 Description: CMBN AP COLPRHY W/NTRCL RPR Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 684 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 57267 MEDSV DEF RBRVS 01/01/2016 12/31/2023 188.34 Description: INSERT MESH/PELVIC FLR ADDON Category: Medical Services CMS Add: 01/01/2005 CMS Term: 57267 MEDSV DEF RBRVS 01/01/2024 233.47 Description: INSERT MESH/PELVIC FLR ADDON Category: Medical Services CMS Add: 01/01/2005 CMS Term: 57268 MEDSV DEF RBRVS 01/01/2024 475.87 Description: REPAIR OF BOWEL BULGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57268 MEDSV DEF RBRVS 09/01/2019 12/31/2023 351.28 Description: REPAIR OF BOWEL BULGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57270 MEDSV DEF RBRVS 01/01/2024 762.91 Description: REPAIR OF BOWEL POUCH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57270 MEDSV DEF RBRVS 09/01/2019 12/31/2023 584.87 Description: REPAIR OF BOWEL POUCH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57280 MEDSV DEF RBRVS 01/01/2024 904.78 Description: SUSPENSION OF VAGINA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57280 MEDSV DEF RBRVS 09/01/2019 12/31/2023 697.95 Description: SUSPENSION OF VAGINA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57282 MEDSV DEF RBRVS 01/01/2024 651.37 Description: COLPOPEXY EXTRAPERITONEAL Category: Medical Services CMS Add: 01/01/1986 CMS Term: 57282 MEDSV DEF RBRVS 02/01/2015 12/31/2023 364.34 Description: COLPOPEXY EXTRAPERITONEAL Category: Medical Services CMS Add: 01/01/1986 CMS Term: 57283 MEDSV DEF RBRVS 01/01/2024 655.69 Description: COLPOPEXY INTRAPERITONEAL Category: Medical Services CMS Add: 01/01/2005 CMS Term: 57283 MEDSV DEF RBRVS 02/01/2015 12/31/2023 504.19 Description: COLPOPEXY INTRAPERITONEAL Category: Medical Services CMS Add: 01/01/2005 CMS Term: 57284 MEDSV DEF RBRVS 01/01/2024 779.53 Description: REPAIR PARAVAG DEFECT OPEN Category: Medical Services CMS Add: 01/01/1996 CMS Term: 57284 MEDSV DEF RBRVS 02/01/2015 12/31/2023 597.07 Description: REPAIR PARAVAG DEFECT OPEN Category: Medical Services CMS Add: 01/01/1996 CMS Term: 57285 MEDSV DEF RBRVS 01/01/2024 650.18 Description: REPAIR PARAVAG DEFECT VAG Category: Medical Services CMS Add: 01/01/2008 CMS Term: 57285 MEDSV DEF RBRVS 02/01/2015 12/31/2023 491.93 Description: REPAIR PARAVAG DEFECT VAG Category: Medical Services CMS Add: 01/01/2008 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 685 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 57287 MEDSV DEF RBRVS 01/01/2024 696.74 Description: REVISE/REMOVE SLING REPAIR Category: Medical Services CMS Add: 01/01/2001 CMS Term: 57287 MEDSV DEF RBRVS 02/01/2015 12/31/2023 493.05 Description: REVISE/REMOVE SLING REPAIR Category: Medical Services CMS Add: 01/01/2001 CMS Term: 57288 MEDSV DEF RBRVS 01/01/2024 697.02 Description: REPAIR BLADDER DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57288 MEDSV DEF RBRVS 09/01/2019 12/31/2023 519.21 Description: REPAIR BLADDER DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57289 MEDSV DEF RBRVS 01/01/2024 744.16 Description: REPAIR BLADDER & VAGINA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57289 MEDSV DEF RBRVS 09/01/2019 12/31/2023 528.54 Description: REPAIR BLADDER & VAGINA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57291 MEDSV DEF RBRVS 01/01/2024 515.67 Description: CONSTRUCTION OF VAGINA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57291 MEDSV DEF RBRVS 09/01/2019 12/31/2023 451.87 Description: CONSTRUCTION OF VAGINA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57292 MEDSV DEF RBRVS 01/01/2024 776.36 Description: CONSTRUCT VAGINA WITH GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57292 MEDSV DEF RBRVS 09/01/2019 12/31/2023 598.22 Description: CONSTRUCT VAGINA WITH GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57295 MEDSV DEF RBRVS 01/01/2024 471.38 Y Description: REVISE VAG GRAFT VIA VAGINA Category: Medical Services CMS Add: 01/01/2006 CMS Term: 57295 MEDSV DEF RBRVS 02/01/2015 12/31/2023 348.25 Y Description: REVISE VAG GRAFT VIA VAGINA Category: Medical Services CMS Add: 01/01/2006 CMS Term: 57296 MEDSV DEF RBRVS 01/01/2024 897.63 Description: REVISE VAG GRAFT OPEN ABD Category: Medical Services CMS Add: 01/01/2007 CMS Term: 57296 MEDSV DEF RBRVS 02/01/2015 12/31/2023 695.88 Description: REVISE VAG GRAFT OPEN ABD Category: Medical Services CMS Add: 01/01/2007 CMS Term: 57300 MEDSV DEF RBRVS 01/01/2024 572.12 Description: REPAIR RECTUM-VAGINA FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57300 MEDSV DEF RBRVS 09/01/2019 12/31/2023 405.11 Description: REPAIR RECTUM-VAGINA FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 686 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 57305 MEDSV DEF RBRVS 01/01/2024 915.84 Description: REPAIR RECTUM-VAGINA FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57305 MEDSV DEF RBRVS 09/01/2019 12/31/2023 671.88 Description: REPAIR RECTUM-VAGINA FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57307 MEDSV DEF RBRVS 01/01/2024 1018.02 Description: FISTULA REPAIR & COLOSTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57307 MEDSV DEF RBRVS 09/01/2019 12/31/2023 760.33 Description: FISTULA REPAIR & COLOSTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57308 MEDSV DEF RBRVS 01/01/2024 624.50 Description: FISTULA REPAIR TRANSPERINE Category: Medical Services CMS Add: 01/01/1998 CMS Term: 57308 MEDSV DEF RBRVS 02/01/2015 12/31/2023 484.36 Description: FISTULA REPAIR TRANSPERINE Category: Medical Services CMS Add: 01/01/1998 CMS Term: 57310 MEDSV DEF RBRVS 01/01/2024 463.13 Description: REPAIR URETHROVAGINAL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57310 MEDSV DEF RBRVS 09/01/2019 12/31/2023 332.78 Description: REPAIR URETHROVAGINAL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57311 MEDSV DEF RBRVS 01/01/2024 521.82 Description: REPAIR URETHROVAGINAL LESION Category: Medical Services CMS Add: 01/01/1987 CMS Term: 57311 MEDSV DEF RBRVS 09/01/2019 12/31/2023 379.27 Description: REPAIR URETHROVAGINAL LESION Category: Medical Services CMS Add: 01/01/1987 CMS Term: 57320 MEDSV DEF RBRVS 01/01/2024 530.34 Description: REPAIR BLADDER-VAGINA LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57320 MEDSV DEF RBRVS 09/01/2019 12/31/2023 385.90 Description: REPAIR BLADDER-VAGINA LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57330 MEDSV DEF RBRVS 01/01/2024 719.42 Description: REPAIR BLADDER-VAGINA LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57330 MEDSV DEF RBRVS 09/01/2019 12/31/2023 536.34 Description: REPAIR BLADDER-VAGINA LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57335 MEDSV DEF RBRVS 01/01/2024 1102.92 Description: REPAIR VAGINA Category: Medical Services CMS Add: 01/01/1992 CMS Term: 57335 MEDSV DEF RBRVS 09/01/2019 12/31/2023 822.78 Description: REPAIR VAGINA Category: Medical Services CMS Add: 01/01/1992 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 687 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 57400 MEDSV DEF RBRVS 01/01/2024 120.54 Description: DILATION OF VAGINA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57400 MEDSV DEF RBRVS 09/01/2019 12/31/2023 97.90 Description: DILATION OF VAGINA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57410 MEDSV DEF RBRVS 01/01/2024 98.22 Description: PELVIC EXAMINATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57410 MEDSV DEF RBRVS 09/01/2019 12/31/2023 78.40 Description: PELVIC EXAMINATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57415 MEDSV DEF RBRVS 01/01/2024 164.59 Description: REMOVE VAGINAL FOREIGN BODY Category: Medical Services CMS Add: 01/01/1993 CMS Term: 57415 MEDSV DEF RBRVS 09/01/2019 12/31/2023 116.03 Description: REMOVE VAGINAL FOREIGN BODY Category: Medical Services CMS Add: 01/01/1993 CMS Term: 57420 MEDSV DEF RBRVS 01/01/2024 124.00 Description: EXAM OF VAGINA W/SCOPE Category: Medical Services CMS Add: 01/01/2003 CMS Term: 57420 MEDSV DEF RBRVS 09/01/2019 12/31/2023 84.03 Description: EXAM OF VAGINA W/SCOPE Category: Medical Services CMS Add: 01/01/2003 CMS Term: 57421 MEDSV DEF RBRVS 01/01/2024 166.17 Description: EXAM/BIOPSY OF VAG W/SCOPE Category: Medical Services CMS Add: 01/01/2003 CMS Term: 57421 MEDSV DEF RBRVS 09/01/2019 12/31/2023 112.70 Description: EXAM/BIOPSY OF VAG W/SCOPE Category: Medical Services CMS Add: 01/01/2003 CMS Term: 57423 MEDSV DEF RBRVS 01/01/2024 869.79 Description: REPAIR PARAVAG DEFECT LAP Category: Medical Services CMS Add: 01/01/2008 CMS Term: 57423 MEDSV DEF RBRVS 02/01/2015 12/31/2023 671.67 Description: REPAIR PARAVAG DEFECT LAP Category: Medical Services CMS Add: 01/01/2008 CMS Term: 57425 MEDSV DEF RBRVS 01/01/2024 911.15 Description: LAPAROSCOPY SURG COLPOPEXY Category: Medical Services CMS Add: 01/01/2004 CMS Term: 57425 MEDSV DEF RBRVS 02/01/2015 12/31/2023 709.99 Description: LAPAROSCOPY SURG COLPOPEXY Category: Medical Services CMS Add: 01/01/2004 CMS Term: 57426 MEDSV DEF RBRVS 01/01/2024 817.10 Description: REVISE PROSTH VAG GRAFT LAP Category: Medical Services CMS Add: 01/01/2010 CMS Term: 57426 MEDSV DEF RBRVS 02/01/2015 12/31/2023 619.14 Description: REVISE PROSTH VAG GRAFT LAP Category: Medical Services CMS Add: 01/01/2010 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 688 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 57452 MEDSV DEF RBRVS 01/01/2024 118.76 Description: EXAM OF CERVIX W/SCOPE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57452 MEDSV DEF RBRVS 09/01/2019 12/31/2023 78.53 Description: EXAM OF CERVIX W/SCOPE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57454 MEDSV DEF RBRVS 01/01/2024 158.39 Description: BX/CURETT OF CERVIX W/SCOPE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57454 MEDSV DEF RBRVS 02/01/2015 12/31/2023 111.16 Description: BX/CURETT OF CERVIX W/SCOPE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57455 MEDSV DEF RBRVS 01/01/2024 151.15 Description: BIOPSY OF CERVIX W/SCOPE Category: Medical Services CMS Add: 01/01/2003 CMS Term: 57455 MEDSV DEF RBRVS 02/01/2015 12/31/2023 103.09 Description: BIOPSY OF CERVIX W/SCOPE Category: Medical Services CMS Add: 01/01/2003 CMS Term: 57456 MEDSV DEF RBRVS 01/01/2024 142.54 Description: ENDOCERV CURETTAGE W/SCOPE Category: Medical Services CMS Add: 01/01/2003 CMS Term: 57456 MEDSV DEF RBRVS 02/01/2015 12/31/2023 97.52 Description: ENDOCERV CURETTAGE W/SCOPE Category: Medical Services CMS Add: 01/01/2003 CMS Term: 57460 MEDSV DEF RBRVS 01/01/2019 12/31/2023 201.79 Description: BX OF CERVIX W/SCOPE LEEP Category: Medical Services CMS Add: 01/01/1993 CMS Term: 57460 MEDSV DEF RBRVS 01/01/2024 295.63 Description: BX OF CERVIX W/SCOPE LEEP Category: Medical Services CMS Add: 01/01/1993 CMS Term: 57461 MEDSV DEF RBRVS 01/01/2024 329.61 Description: CONZ OF CERVIX W/SCOPE LEEP Category: Medical Services CMS Add: 01/01/2003 CMS Term: 57461 MEDSV DEF RBRVS 02/01/2015 12/31/2023 228.73 Description: CONZ OF CERVIX W/SCOPE LEEP Category: Medical Services CMS Add: 01/01/2003 CMS Term: 57465 MEDSV DEF RBRVS 01/01/2021 12/31/2023 42.32 Description: CAM CERVIX UTERI DRG COLP Category: Medical Services CMS Add: 01/01/2021 CMS Term: 57465 MEDSV DEF RBRVS 01/01/2024 51.31 Description: CAM CERVIX UTERI DRG COLP Category: Medical Services CMS Add: 01/01/2021 CMS Term: 57500 MEDSV DEF RBRVS 01/01/2024 144.36 Description: BIOPSY OF CERVIX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57500 MEDSV DEF RBRVS 09/01/2019 12/31/2023 90.87 Description: BIOPSY OF CERVIX Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 689 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 57505 MEDSV DEF RBRVS 01/01/2024 145.57 Description: ENDOCERVICAL CURETTAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57505 MEDSV DEF RBRVS 09/01/2019 12/31/2023 73.01 Description: ENDOCERVICAL CURETTAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57510 MEDSV DEF RBRVS 01/01/2024 157.20 Description: CAUTERIZATION OF CERVIX Category: Medical Services CMS Add: 01/01/1985 CMS Term: 57510 MEDSV DEF RBRVS 09/01/2019 12/31/2023 95.14 Description: CAUTERIZATION OF CERVIX Category: Medical Services CMS Add: 01/01/1985 CMS Term: 57511 MEDSV DEF RBRVS 01/01/2024 187.45 Description: CRYOCAUTERY OF CERVIX Category: Medical Services CMS Add: 01/01/1985 CMS Term: 57511 MEDSV DEF RBRVS 09/01/2019 12/31/2023 104.74 Description: CRYOCAUTERY OF CERVIX Category: Medical Services CMS Add: 01/01/1985 CMS Term: 57513 MEDSV DEF RBRVS 01/01/2024 193.63 Description: LASER SURGERY OF CERVIX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57513 MEDSV DEF RBRVS 09/01/2019 12/31/2023 104.25 Description: LASER SURGERY OF CERVIX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57520 MEDSV DEF RBRVS 01/01/2024 331.58 Description: CONIZATION OF CERVIX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57520 MEDSV DEF RBRVS 09/01/2019 12/31/2023 220.00 Description: CONIZATION OF CERVIX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57522 MEDSV DEF RBRVS 01/01/2019 12/31/2023 190.26 Description: CONIZATION OF CERVIX Category: Medical Services CMS Add: 01/01/1995 CMS Term: 57522 MEDSV DEF RBRVS 01/01/2024 284.82 Description: CONIZATION OF CERVIX Category: Medical Services CMS Add: 01/01/1995 CMS Term: 57530 MEDSV DEF RBRVS 01/01/2024 350.95 Description: REMOVAL OF CERVIX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57530 MEDSV DEF RBRVS 09/01/2019 12/31/2023 250.67 Description: REMOVAL OF CERVIX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57531 MEDSV DEF RBRVS 01/01/2024 1654.15 Description: REMOVAL OF CERVIX RADICAL Category: Medical Services CMS Add: 01/01/1998 CMS Term: 57531 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1285.69 Description: REMOVAL OF CERVIX RADICAL Category: Medical Services CMS Add: 01/01/1998 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 690 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 57540 MEDSV DEF RBRVS 01/01/2024 742.15 Description: REMOVAL OF RESIDUAL CERVIX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57540 MEDSV DEF RBRVS 09/01/2019 12/31/2023 570.12 Description: REMOVAL OF RESIDUAL CERVIX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57545 MEDSV DEF RBRVS 01/01/2024 781.42 Description: REMOVE CERVIX/REPAIR PELVIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57545 MEDSV DEF RBRVS 09/01/2019 12/31/2023 601.79 Description: REMOVE CERVIX/REPAIR PELVIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57550 MEDSV DEF RBRVS 01/01/2024 405.40 Description: REMOVAL OF RESIDUAL CERVIX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57550 MEDSV DEF RBRVS 09/01/2019 12/31/2023 297.09 Description: REMOVAL OF RESIDUAL CERVIX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57555 MEDSV DEF RBRVS 01/01/2024 581.04 Description: REMOVE CERVIX/REPAIR VAGINA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 57555 MEDSV DEF RBRVS 09/01/2019 12/31/2023 438.99 Description: REMOVE CERVIX/REPAIR VAGINA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 57556 MEDSV DEF RBRVS 01/01/2024 551.75 Description: REMOVE CERVIX REPAIR BOWEL Category: Medical Services CMS Add: 01/01/1985 CMS Term: 57556 MEDSV DEF RBRVS 09/01/2019 12/31/2023 413.82 Description: REMOVE CERVIX REPAIR BOWEL Category: Medical Services CMS Add: 01/01/1985 CMS Term: 57558 MEDSV DEF RBRVS 01/01/2024 148.76 Description: D&C OF CERVICAL STUMP Category: Medical Services CMS Add: 01/01/2007 CMS Term: 57558 MEDSV DEF RBRVS 02/01/2015 12/31/2023 90.47 Description: D&C OF CERVICAL STUMP Category: Medical Services CMS Add: 01/01/2007 CMS Term: 57700 MEDSV DEF RBRVS 01/01/2024 335.27 Description: REVISION OF CERVIX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57700 MEDSV DEF RBRVS 09/01/2019 12/31/2023 225.13 Description: REVISION OF CERVIX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57720 MEDSV DEF RBRVS 01/01/2024 314.31 Description: REVISION OF CERVIX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57720 MEDSV DEF RBRVS 09/01/2019 12/31/2023 223.36 Description: REVISION OF CERVIX Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 691 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 57800 MEDSV DEF RBRVS 01/01/2024 72.79 Description: DILATION OF CERVICAL CANAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 57800 MEDSV DEF RBRVS 09/01/2019 12/31/2023 43.31 Description: DILATION OF CERVICAL CANAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58100 MEDSV DEF RBRVS 01/01/2024 95.31 Description: BIOPSY OF UTERUS LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58100 MEDSV DEF RBRVS 09/01/2019 12/31/2023 78.93 Description: BIOPSY OF UTERUS LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58110 MEDSV DEF RBRVS 01/01/2024 46.55 Description: BX DONE W/COLPOSCOPY ADD-ON Category: Medical Services CMS Add: 01/01/2006 CMS Term: 58110 MEDSV DEF RBRVS 02/01/2015 12/31/2023 34.89 Description: BX DONE W/COLPOSCOPY ADD-ON Category: Medical Services CMS Add: 01/01/2006 CMS Term: 58120 MEDSV DEF RBRVS 01/01/2024 279.33 Description: DILATION AND CURETTAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58120 MEDSV DEF RBRVS 09/01/2019 12/31/2023 186.05 Description: DILATION AND CURETTAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58140 MEDSV DEF RBRVS 01/01/2024 872.92 Description: MYOMECTOMY ABDOM METHOD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58140 MEDSV DEF RBRVS 09/01/2019 12/31/2023 672.14 Description: MYOMECTOMY ABDOM METHOD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58145 MEDSV DEF RBRVS 01/01/2024 532.29 Description: MYOMECTOMY VAG METHOD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58145 MEDSV DEF RBRVS 09/01/2019 12/31/2023 397.52 Description: MYOMECTOMY VAG METHOD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58146 MEDSV DEF RBRVS 01/01/2024 1081.08 Description: MYOMECTOMY ABDOM COMPLEX Category: Medical Services CMS Add: 01/01/2003 CMS Term: 58146 MEDSV DEF RBRVS 02/01/2015 12/31/2023 846.08 Description: MYOMECTOMY ABDOM COMPLEX Category: Medical Services CMS Add: 01/01/2003 CMS Term: 58150 MEDSV DEF RBRVS 01/01/2024 947.20 Y Y Description: TOTAL HYSTERECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58150 MEDSV DEF RBRVS 09/01/2019 12/31/2023 733.20 Y Y Description: TOTAL HYSTERECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 692 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 58152 MEDSV DEF RBRVS 01/01/2024 1158.06 Y Y Description: TOTAL HYSTERECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58152 MEDSV DEF RBRVS 09/01/2019 12/31/2023 912.51 Y Y Description: TOTAL HYSTERECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58180 MEDSV DEF RBRVS 01/01/2024 896.36 Y Y Description: PARTIAL HYSTERECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58180 MEDSV DEF RBRVS 09/01/2019 12/31/2023 702.32 Y Y Description: PARTIAL HYSTERECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58200 MEDSV DEF RBRVS 01/01/2024 1255.00 Y Y Description: EXTENSIVE HYSTERECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58200 MEDSV DEF RBRVS 09/01/2019 12/31/2023 972.91 Y Y Description: EXTENSIVE HYSTERECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58210 MEDSV DEF RBRVS 01/01/2024 1697.43 Y Y Description: EXTENSIVE HYSTERECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58210 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1305.13 Y Y Description: EXTENSIVE HYSTERECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58240 MEDSV DEF RBRVS 01/01/2024 2731.18 Y Y Description: REMOVAL OF PELVIS CONTENTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58240 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2074.10 Y Y Description: REMOVAL OF PELVIS CONTENTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58260 MEDSV DEF RBRVS 01/01/2024 786.35 Y Y Description: VAGINAL HYSTERECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58260 MEDSV DEF RBRVS 09/01/2019 12/31/2023 605.36 Y Y Description: VAGINAL HYSTERECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58262 MEDSV DEF RBRVS 01/01/2024 868.63 Y Y Description: VAG HYST INCLUDING T/O Category: Medical Services CMS Add: 01/01/1993 CMS Term: 58262 MEDSV DEF RBRVS 09/01/2019 12/31/2023 675.59 Y Y Description: VAG HYST INCLUDING T/O Category: Medical Services CMS Add: 01/01/1993 CMS Term: 58263 MEDSV DEF RBRVS 01/01/2024 931.48 Y Y Description: VAG HYST W/T/O & VAG REPAIR Category: Medical Services CMS Add: 01/01/1993 CMS Term: 58263 MEDSV DEF RBRVS 09/01/2019 12/31/2023 725.61 Y Y Description: VAG HYST W/T/O & VAG REPAIR Category: Medical Services CMS Add: 01/01/1993 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 693 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 58267 MEDSV DEF RBRVS 01/01/2024 1002.19 Y Y Description: VAG HYST W/URINARY REPAIR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58267 MEDSV DEF RBRVS 09/01/2019 12/31/2023 772.89 Y Y Description: VAG HYST W/URINARY REPAIR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58270 MEDSV DEF RBRVS 01/01/2024 839.03 Y Y Description: VAG HYST W/ENTEROCELE REPAIR Category: Medical Services CMS Add: 01/01/1985 CMS Term: 58270 MEDSV DEF RBRVS 09/01/2019 12/31/2023 645.92 Y Y Description: VAG HYST W/ENTEROCELE REPAIR Category: Medical Services CMS Add: 01/01/1985 CMS Term: 58275 MEDSV DEF RBRVS 01/01/2024 927.26 Y Y Description: HYSTERECTOMY/REVISE VAGINA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58275 MEDSV DEF RBRVS 09/01/2019 12/31/2023 720.56 Y Y Description: HYSTERECTOMY/REVISE VAGINA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58280 MEDSV DEF RBRVS 01/01/2024 992.84 Y Y Description: HYSTERECTOMY/REVISE VAGINA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58280 MEDSV DEF RBRVS 09/01/2019 12/31/2023 770.60 Y Y Description: HYSTERECTOMY/REVISE VAGINA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58285 MEDSV DEF RBRVS 01/01/2024 1325.36 Y Y Description: EXTENSIVE HYSTERECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58285 MEDSV DEF RBRVS 09/01/2019 12/31/2023 961.78 Y Y Description: EXTENSIVE HYSTERECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58290 MEDSV DEF RBRVS 01/01/2024 1077.62 Y Y Description: VAG HYST COMPLEX Category: Medical Services CMS Add: 01/01/2003 CMS Term: 58290 MEDSV DEF RBRVS 02/01/2015 12/31/2023 843.78 Y Y Description: VAG HYST COMPLEX Category: Medical Services CMS Add: 01/01/2003 CMS Term: 58291 MEDSV DEF RBRVS 01/01/2024 1164.41 Y Y Description: VAG HYST INCL T/O COMPLEX Category: Medical Services CMS Add: 01/01/2003 CMS Term: 58291 MEDSV DEF RBRVS 02/01/2015 12/31/2023 913.76 Y Y Description: VAG HYST INCL T/O COMPLEX Category: Medical Services CMS Add: 01/01/2003 CMS Term: 58292 MEDSV DEF RBRVS 01/01/2024 1227.10 Y Y Description: VAG HYST T/O & REPAIR COMPL Category: Medical Services CMS Add: 01/01/2003 CMS Term: 58292 MEDSV DEF RBRVS 02/01/2015 12/31/2023 964.19 Y Y Description: VAG HYST T/O & REPAIR COMPL Category: Medical Services CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 694 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 58294 MEDSV DEF RBRVS 01/01/2024 1139.67 Y Y Description: VAG HYST W/ENTEROCELE COMPL Category: Medical Services CMS Add: 01/01/2003 CMS Term: 58294 MEDSV DEF RBRVS 02/01/2015 12/31/2023 893.70 Y Y Description: VAG HYST W/ENTEROCELE COMPL Category: Medical Services CMS Add: 01/01/2003 CMS Term: 58300 MEDSV DEF RBRVS 01/01/2024 104.06 Description: INSERT INTRAUTERINE DEVICE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 58300 MEDSV DEF RBRVS 09/01/2019 12/31/2023 50.59 Description: INSERT INTRAUTERINE DEVICE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 58301 MEDSV DEF RBRVS 01/01/2024 103.37 Description: REMOVE INTRAUTERINE DEVICE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 58301 MEDSV DEF RBRVS 09/01/2019 12/31/2023 68.80 Description: REMOVE INTRAUTERINE DEVICE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 58321 NOCOV DEF SYSMAN Description: ARTIFICIAL INSEMINATION Category: Non Covered Services CMS Add: 01/01/1994 CMS Term: 58322 NOCOV DEF SYSMAN Description: ARTIFICIAL INSEMINATION Category: Non Covered Services CMS Add: 01/01/1994 CMS Term: 58323 NOCOV DEF SYSMAN Description: SPERM WASHING Category: Non Covered Services CMS Add: 01/01/1994 CMS Term: 58340 MEDSV DEF RBRVS 01/01/2024 229.65 Description: CATHETER FOR HYSTEROGRAPHY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58340 MEDSV DEF RBRVS 09/01/2019 12/31/2023 83.18 Description: CATHETER FOR HYSTEROGRAPHY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58345 MEDSV DEF RBRVS 01/01/2024 270.92 Description: REOPEN FALLOPIAN TUBE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 58345 MEDSV DEF RBRVS 09/01/2019 12/31/2023 203.82 Description: REOPEN FALLOPIAN TUBE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 58346 MEDSV DEF RBRVS 01/01/2024 472.36 Description: INSERT HEYMAN UTERI CAPSULE Category: Medical Services CMS Add: 01/01/2002 CMS Term: 58346 MEDSV DEF RBRVS 02/01/2015 12/31/2023 323.01 Description: INSERT HEYMAN UTERI CAPSULE Category: Medical Services CMS Add: 01/01/2002 CMS Term: 58350 MEDSV DEF RBRVS 01/01/2024 144.71 Description: REOPEN FALLOPIAN TUBE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 695 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 58350 MEDSV DEF RBRVS 09/01/2019 12/31/2023 68.94 Description: REOPEN FALLOPIAN TUBE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58353 MEDSV DEF RBRVS 01/01/2019 12/31/2023 700.57 Description: ENDOMETR ABLATE THERMAL Category: Medical Services CMS Add: 01/01/2001 CMS Term: 58353 MEDSV DEF RBRVS 01/01/2024 878.57 Description: ENDOMETR ABLATE THERMAL Category: Medical Services CMS Add: 01/01/2001 CMS Term: 58356 MEDSV DEF RBRVS 01/01/2016 12/31/2023 1311.38 Description: ENDOMETRIAL CRYOABLATION Category: Medical Services CMS Add: 01/01/2005 CMS Term: 58356 MEDSV DEF RBRVS 01/01/2024 1577.49 Description: ENDOMETRIAL CRYOABLATION Category: Medical Services CMS Add: 01/01/2005 CMS Term: 58400 MEDSV DEF RBRVS 01/01/2024 435.91 Description: SUSPENSION OF UTERUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58400 MEDSV DEF RBRVS 09/01/2019 12/31/2023 320.07 Description: SUSPENSION OF UTERUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58410 MEDSV DEF RBRVS 01/01/2024 764.90 Description: SUSPENSION OF UTERUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58410 MEDSV DEF RBRVS 09/01/2019 12/31/2023 588.61 Description: SUSPENSION OF UTERUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58520 MEDSV DEF RBRVS 01/01/2024 749.70 Description: REPAIR OF RUPTURED UTERUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58520 MEDSV DEF RBRVS 09/01/2019 12/31/2023 597.19 Description: REPAIR OF RUPTURED UTERUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58540 MEDSV DEF RBRVS 01/01/2024 858.99 Description: REVISION OF UTERUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58540 MEDSV DEF RBRVS 09/01/2019 12/31/2023 665.53 Description: REVISION OF UTERUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58541 MEDSV DEF RBRVS 01/01/2024 685.68 Y Y Description: LSH UTERUS 250 G OR LESS Category: Medical Services CMS Add: 01/01/2007 CMS Term: 58541 MEDSV DEF RBRVS 02/01/2015 12/31/2023 631.95 Y Y Description: LSH UTERUS 250 G OR LESS Category: Medical Services CMS Add: 01/01/2007 CMS Term: 58542 MEDSV DEF RBRVS 01/01/2024 778.64 Y Y Description: LSH W/T/O UT 250 G OR LESS Category: Medical Services CMS Add: 01/01/2007 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 696 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 58542 MEDSV DEF RBRVS 02/01/2015 12/31/2023 706.45 Y Y Description: LSH W/T/O UT 250 G OR LESS Category: Medical Services CMS Add: 01/01/2007 CMS Term: 58543 MEDSV DEF RBRVS 01/01/2024 789.90 Y Y Description: LSH UTERUS ABOVE 250 G Category: Medical Services CMS Add: 01/01/2007 CMS Term: 58543 MEDSV DEF RBRVS 02/01/2015 12/31/2023 717.25 Y Y Description: LSH UTERUS ABOVE 250 G Category: Medical Services CMS Add: 01/01/2007 CMS Term: 58544 MEDSV DEF RBRVS 01/01/2024 850.31 Y Y Description: LSH W/T/O UTERUS ABOVE 250 G Category: Medical Services CMS Add: 01/01/2007 CMS Term: 58544 MEDSV DEF RBRVS 02/01/2015 12/31/2023 779.36 Y Y Description: LSH W/T/O UTERUS ABOVE 250 G Category: Medical Services CMS Add: 01/01/2007 CMS Term: 58545 MEDSV DEF RBRVS 01/01/2024 842.18 Description: LAPAROSCOPIC MYOMECTOMY Category: Medical Services CMS Add: 01/01/2003 CMS Term: 58545 MEDSV DEF RBRVS 02/01/2015 12/31/2023 656.11 Description: LAPAROSCOPIC MYOMECTOMY Category: Medical Services CMS Add: 01/01/2003 CMS Term: 58546 MEDSV DEF RBRVS 01/01/2024 1042.01 Description: LAPARO-MYOMECTOMY COMPLEX Category: Medical Services CMS Add: 01/01/2003 CMS Term: 58546 MEDSV DEF RBRVS 02/01/2015 12/31/2023 825.83 Description: LAPARO-MYOMECTOMY COMPLEX Category: Medical Services CMS Add: 01/01/2003 CMS Term: 58548 MEDSV DEF RBRVS 01/01/2024 1754.15 Y Y Description: LAP RADICAL HYST Category: Medical Services CMS Add: 01/01/2007 CMS Term: 58548 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1342.89 Y Y Description: LAP RADICAL HYST Category: Medical Services CMS Add: 01/01/2007 CMS Term: 58550 MEDSV DEF RBRVS 01/01/2024 825.44 Y Y Description: LAPARO-ASST VAG HYSTERECTOMY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58550 MEDSV DEF RBRVS 02/01/2015 12/31/2023 646.33 Y Y Description: LAPARO-ASST VAG HYSTERECTOMY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58552 MEDSV DEF RBRVS 01/01/2024 918.01 Y Y Description: LAPARO-VAG HYST INCL T/O Category: Medical Services CMS Add: 01/01/2003 CMS Term: 58552 MEDSV DEF RBRVS 02/01/2015 12/31/2023 718.58 Y Y Description: LAPARO-VAG HYST INCL T/O Category: Medical Services CMS Add: 01/01/2003 CMS Term: 58553 MEDSV DEF RBRVS 01/01/2024 1047.63 Y Y Description: LAPARO-VAG HYST COMPLEX Category: Medical Services CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 697 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 58553 MEDSV DEF RBRVS 02/01/2015 12/31/2023 832.44 Y Y Description: LAPARO-VAG HYST COMPLEX Category: Medical Services CMS Add: 01/01/2003 CMS Term: 58554 MEDSV DEF RBRVS 01/01/2024 1218.45 Y Y Description: LAPARO-VAG HYST W/T/O COMPL Category: Medical Services CMS Add: 01/01/2003 CMS Term: 58554 MEDSV DEF RBRVS 02/01/2015 12/31/2023 966.16 Y Y Description: LAPARO-VAG HYST W/T/O COMPL Category: Medical Services CMS Add: 01/01/2003 CMS Term: 58555 MEDSV DEF RBRVS 01/01/2024 340.15 0-1 Description: HYSTEROSCOPY DX SEP PROC Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58555 MEDSV DEF RBRVS 02/01/2015 12/31/2023 216.30 0-1 Description: HYSTEROSCOPY DX SEP PROC Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58558 MEDSV DEF RBRVS 01/01/2024 1252.67 Description: HYSTEROSCOPY BIOPSY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58558 MEDSV DEF RBRVS 02/01/2015 12/31/2023 283.75 Description: HYSTEROSCOPY BIOPSY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58559 MEDSV DEF RBRVS 01/01/2024 264.13 0-1 Description: HYSTEROSCOPY LYSIS Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58559 MEDSV DEF RBRVS 02/01/2015 12/31/2023 251.14 0-1 Description: HYSTEROSCOPY LYSIS Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58560 MEDSV DEF RBRVS 01/01/2024 290.56 0-1 Description: HYSTEROSCOPY RESECT SEPTUM Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58560 MEDSV DEF RBRVS 02/01/2015 12/31/2023 284.01 0-1 Description: HYSTEROSCOPY RESECT SEPTUM Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58561 MEDSV DEF RBRVS 01/01/2024 332.43 0-1 Description: HYSTEROSCOPY REMOVE MYOMA Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58561 MEDSV DEF RBRVS 02/01/2015 12/31/2023 402.10 0-1 Description: HYSTEROSCOPY REMOVE MYOMA Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58562 MEDSV DEF RBRVS 01/01/2024 406.11 0-1 Description: HYSTEROSCOPY REMOVE FB Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58562 MEDSV DEF RBRVS 02/01/2015 12/31/2023 294.37 0-1 Description: HYSTEROSCOPY REMOVE FB Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58563 MEDSV DEF RBRVS 01/01/2024 1992.20 Description: HYSTEROSCOPY ABLATION Category: Medical Services CMS Add: 01/01/2000 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 698 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 58563 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1156.78 Description: HYSTEROSCOPY ABLATION Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58565 MEDSV DEF RBRVS 01/01/2024 1570.75 Y 21-999years 0-1 Description: HYSTEROSCOPY STERILIZATION Category: Medical Services CMS Add: 01/01/2005 CMS Term: 58565 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1301.73 Y 21-999years 0-1 Description: HYSTEROSCOPY STERILIZATION Category: Medical Services CMS Add: 01/01/2005 CMS Term: 58570 MEDSV DEF RBRVS 01/01/2024 755.36 Y Y Description: TLH UTERUS 250 G OR LESS Category: Medical Services CMS Add: 01/01/2008 CMS Term: 58570 MEDSV DEF RBRVS 02/01/2015 12/31/2023 680.17 Y Y Description: TLH UTERUS 250 G OR LESS Category: Medical Services CMS Add: 01/01/2008 CMS Term: 58571 MEDSV DEF RBRVS 01/01/2024 848.44 Y Y Description: TLH W/T/O 250 G OR LESS Category: Medical Services CMS Add: 01/01/2008 CMS Term: 58571 MEDSV DEF RBRVS 02/01/2015 12/31/2023 761.42 Y Y Description: TLH W/T/O 250 G OR LESS Category: Medical Services CMS Add: 01/01/2008 CMS Term: 58572 MEDSV DEF RBRVS 01/01/2024 970.07 Y Y Description: TLH UTERUS OVER 250 G Category: Medical Services CMS Add: 01/01/2008 CMS Term: 58572 MEDSV DEF RBRVS 02/01/2015 12/31/2023 848.11 Y Y Description: TLH UTERUS OVER 250 G Category: Medical Services CMS Add: 01/01/2008 CMS Term: 58573 MEDSV DEF RBRVS 01/01/2024 1136.34 Y Y Description: TLH W/T/O UTERUS OVER 250 G Category: Medical Services CMS Add: 01/01/2008 CMS Term: 58573 MEDSV DEF RBRVS 02/01/2015 12/31/2023 977.15 Y Y Description: TLH W/T/O UTERUS OVER 250 G Category: Medical Services CMS Add: 01/01/2008 CMS Term: 58575 MEDSV DEF RBRVS 01/01/2018 12/31/2023 1355.16 Description: LAPS TOT HYST RESJ MAL Category: Medical Services CMS Add: 01/01/2018 CMS Term: 58575 MEDSV DEF RBRVS 01/01/2024 1800.85 Description: LAPS TOT HYST RESJ MAL Category: Medical Services CMS Add: 01/01/2018 CMS Term: 58578 MEDSV DEF BILL35 0-1 Description: UNLISTED LAPS PX UTERUS Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58579 MEDSV DEF BILL35 0-1 Description: UNLISTED HYSTSC PX UTERUS Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58580 MEDSV DEF RBRVS 01/01/2024 2884.62 Description: TRANSCRV ABLTJ UTRN FIBRD RF Category: Medical Services CMS Add: 01/01/2024 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 699 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 58600 MEDSV DEF RBRVS 01/01/2024 348.02 Y 21-999years Description: DIVISION OF FALLOPIAN TUBE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 58600 MEDSV DEF RBRVS 09/01/2019 12/31/2023 266.22 Y 21-999years Description: DIVISION OF FALLOPIAN TUBE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 58605 MEDSV DEF RBRVS 01/01/2024 316.27 Y 21-999years Description: DIVISION OF FALLOPIAN TUBE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 58605 MEDSV DEF RBRVS 09/01/2019 12/31/2023 240.21 Y 21-999years Description: DIVISION OF FALLOPIAN TUBE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 58611 MEDSV DEF RBRVS 01/01/2024 70.45 Y 21-999years Description: LIGATE OVIDUCT(S) ADD-ON Category: Medical Services CMS Add: 01/01/1982 CMS Term: 58611 MEDSV DEF RBRVS 02/01/2015 12/31/2023 57.13 Y 21-999years Description: LIGATE OVIDUCT(S) ADD-ON Category: Medical Services CMS Add: 01/01/1982 CMS Term: 58615 MEDSV DEF RBRVS 01/01/2024 237.83 Y 21-999years Description: OCCLUDE FALLOPIAN TUBE(S) Category: Medical Services CMS Add: 01/01/1982 CMS Term: 58615 MEDSV DEF RBRVS 09/01/2019 12/31/2023 177.86 Y 21-999years Description: OCCLUDE FALLOPIAN TUBE(S) Category: Medical Services CMS Add: 01/01/1982 CMS Term: 58660 MEDSV DEF RBRVS 01/01/2024 634.36 Description: LAPAROSCOPY LYSIS Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58660 MEDSV DEF RBRVS 02/01/2015 12/31/2023 491.25 Description: LAPAROSCOPY LYSIS Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58661 MEDSV DEF RBRVS 01/01/2016 12/31/2023 472.00 Y Y Description: LAPAROSCOPY REMOVE ADNEXA Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58661 MEDSV DEF RBRVS 01/01/2024 610.00 Y Y Description: LAPAROSCOPY REMOVE ADNEXA Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58662 MEDSV DEF RBRVS 01/01/2024 665.75 Description: LAPAROSCOPY EXCISE LESIONS Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58662 MEDSV DEF RBRVS 02/01/2015 12/31/2023 516.20 Description: LAPAROSCOPY EXCISE LESIONS Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58670 MEDSV DEF RBRVS 01/01/2024 348.63 Y Description: LAPAROSCOPY TUBAL CAUTERY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58670 MEDSV DEF RBRVS 02/01/2015 12/31/2023 266.47 Y Description: LAPAROSCOPY TUBAL CAUTERY Category: Medical Services CMS Add: 01/01/2000 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 700 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 58671 MEDSV DEF RBRVS 01/01/2024 348.63 Y Description: LAPAROSCOPY TUBAL BLOCK Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58671 MEDSV DEF RBRVS 02/01/2015 12/31/2023 266.71 Y Description: LAPAROSCOPY TUBAL BLOCK Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58672 MEDSV DEF RBRVS 01/01/2024 684.16 Y Description: LAPAROSCOPY FIMBRIOPLASTY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58672 MEDSV DEF RBRVS 02/01/2015 12/31/2023 539.02 Y Description: LAPAROSCOPY FIMBRIOPLASTY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58673 MEDSV DEF RBRVS 01/01/2024 742.49 0-1 Description: LAPAROSCOPY SALPINGOSTOMY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58673 MEDSV DEF RBRVS 02/01/2015 12/31/2023 586.06 0-1 Description: LAPAROSCOPY SALPINGOSTOMY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58674 MEDSV DEF RBRVS 01/01/2017 12/31/2023 591.42 Description: LAPS ABLTJ UTERINE FIBROIDS Category: Medical Services CMS Add: 01/01/2017 CMS Term: 58674 MEDSV DEF RBRVS 01/01/2024 761.61 Description: LAPS ABLTJ UTERINE FIBROIDS Category: Medical Services CMS Add: 01/01/2017 CMS Term: 58679 MEDSV DEF BILL35 0-1 Description: UNLISTED LAPS PX OVIDCT OVRY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 58700 MEDSV DEF RBRVS 01/01/2024 746.02 Description: REMOVAL OF FALLOPIAN TUBE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 58700 MEDSV DEF RBRVS 09/01/2019 12/31/2023 564.29 Description: REMOVAL OF FALLOPIAN TUBE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 58720 MEDSV DEF RBRVS 01/01/2024 708.26 Y Description: REMOVAL OF OVARY/TUBE(S) Category: Medical Services CMS Add: 01/01/1982 CMS Term: 58720 MEDSV DEF RBRVS 09/01/2019 12/31/2023 529.68 Y Description: REMOVAL OF OVARY/TUBE(S) Category: Medical Services CMS Add: 01/01/1982 CMS Term: 58740 MEDSV DEF RBRVS 01/01/2024 841.48 Description: ADHESIOLYSIS TUBE OVARY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58740 MEDSV DEF RBRVS 09/01/2019 12/31/2023 638.89 Description: ADHESIOLYSIS TUBE OVARY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58750 NOCOV DEF SYSMAN Description: REPAIR OVIDUCT Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 701 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 58752 NOCOV DEF SYSMAN Description: REVISE OVARIAN TUBE(S) Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: 58760 NOCOV DEF SYSMAN Description: FIMBRIOPLASTY Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: 58770 MEDSV DEF RBRVS 01/01/2024 808.37 Description: CREATE NEW TUBAL OPENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58770 MEDSV DEF RBRVS 09/01/2019 12/31/2023 632.92 Description: CREATE NEW TUBAL OPENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58800 MEDSV DEF RBRVS 01/01/2024 340.89 Description: DRAINAGE OF OVARIAN CYST(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58800 MEDSV DEF RBRVS 09/01/2019 12/31/2023 230.32 Description: DRAINAGE OF OVARIAN CYST(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58805 MEDSV DEF RBRVS 01/01/2024 402.25 Description: DRAINAGE OF OVARIAN CYST(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58805 MEDSV DEF RBRVS 09/01/2019 12/31/2023 294.95 Description: DRAINAGE OF OVARIAN CYST(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58820 MEDSV DEF RBRVS 01/01/2024 318.77 Description: DRAIN OVARY ABSCESS OPEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58820 MEDSV DEF RBRVS 09/01/2019 12/31/2023 227.10 Description: DRAIN OVARY ABSCESS OPEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58822 MEDSV DEF RBRVS 01/01/2024 670.38 Description: DRAIN OVARY ABSCESS PERCUT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58822 MEDSV DEF RBRVS 09/01/2019 12/31/2023 533.99 Description: DRAIN OVARY ABSCESS PERCUT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58825 MEDSV DEF RBRVS 01/01/2024 665.35 Description: TRANSPOSITION OVARY(S) Category: Medical Services CMS Add: 01/01/1988 CMS Term: 58825 MEDSV DEF RBRVS 09/01/2019 12/31/2023 508.08 Description: TRANSPOSITION OVARY(S) Category: Medical Services CMS Add: 01/01/1988 CMS Term: 58900 MEDSV DEF RBRVS 01/01/2024 410.81 Description: BIOPSY OF OVARY(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58900 MEDSV DEF RBRVS 09/01/2019 12/31/2023 321.81 Description: BIOPSY OF OVARY(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 702 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 58920 MEDSV DEF RBRVS 01/01/2024 670.36 Description: PARTIAL REMOVAL OF OVARY(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58920 MEDSV DEF RBRVS 09/01/2019 12/31/2023 523.05 Description: PARTIAL REMOVAL OF OVARY(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58925 MEDSV DEF RBRVS 01/01/2024 715.84 Description: REMOVAL OF OVARIAN CYST(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58925 MEDSV DEF RBRVS 09/01/2019 12/31/2023 540.08 Description: REMOVAL OF OVARIAN CYST(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58940 MEDSV DEF RBRVS 01/01/2024 518.67 Description: REMOVAL OF OVARY(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58940 MEDSV DEF RBRVS 09/01/2019 12/31/2023 377.42 Description: REMOVAL OF OVARY(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 58943 MEDSV DEF RBRVS 01/01/2024 1092.62 Description: REMOVAL OF OVARY(S) Category: Medical Services CMS Add: 01/01/1988 CMS Term: 58943 MEDSV DEF RBRVS 09/01/2019 12/31/2023 836.27 Description: REMOVAL OF OVARY(S) Category: Medical Services CMS Add: 01/01/1988 CMS Term: 58950 MEDSV DEF RBRVS 01/01/2024 1075.28 Description: RESECT OVARIAN MALIGNANCY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 58950 MEDSV DEF RBRVS 09/01/2019 12/31/2023 800.58 Description: RESECT OVARIAN MALIGNANCY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 58951 MEDSV DEF RBRVS 01/01/2024 1344.79 Y Y Description: RESECT OVARIAN MALIGNANCY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 58951 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1029.27 Y Y Description: RESECT OVARIAN MALIGNANCY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 58952 MEDSV DEF RBRVS 01/01/2024 1535.34 Description: RESECT OVARIAN MALIGNANCY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 58952 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1161.79 Description: RESECT OVARIAN MALIGNANCY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 58953 MEDSV DEF RBRVS 01/01/2024 1864.95 Y Y Description: TAH RAD DISSECT FOR DEBULK Category: Medical Services CMS Add: 01/01/2002 CMS Term: 58953 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1437.64 Y Y Description: TAH RAD DISSECT FOR DEBULK Category: Medical Services CMS Add: 01/01/2002 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 703 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 58954 MEDSV DEF RBRVS 01/01/2024 2016.34 Y Y Description: TAH RAD DEBULK/LYMPH REMOVE Category: Medical Services CMS Add: 01/01/2002 CMS Term: 58954 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1559.53 Y Y Description: TAH RAD DEBULK/LYMPH REMOVE Category: Medical Services CMS Add: 01/01/2002 CMS Term: 58956 MEDSV DEF RBRVS 01/01/2024 1267.83 Y Y Description: BSO OMENTECTOMY W/TAH Category: Medical Services CMS Add: 01/01/2005 CMS Term: 58956 MEDSV DEF RBRVS 02/01/2015 12/31/2023 980.87 Y Y Description: BSO OMENTECTOMY W/TAH Category: Medical Services CMS Add: 01/01/2005 CMS Term: 58957 MEDSV DEF RBRVS 01/01/2024 1479.38 Description: RESECT RECURRENT GYN MAL Category: Medical Services CMS Add: 01/01/2007 CMS Term: 58957 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1123.88 Description: RESECT RECURRENT GYN MAL Category: Medical Services CMS Add: 01/01/2007 CMS Term: 58958 MEDSV DEF RBRVS 01/01/2024 1550.43 Description: RESECT RECUR GYN MAL W/LYM Category: Medical Services CMS Add: 01/01/2007 CMS Term: 58958 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1236.60 Description: RESECT RECUR GYN MAL W/LYM Category: Medical Services CMS Add: 01/01/2007 CMS Term: 58960 MEDSV DEF RBRVS 01/01/2024 928.87 Description: EXPLORATION OF ABDOMEN Category: Medical Services CMS Add: 01/01/1988 CMS Term: 58960 MEDSV DEF RBRVS 09/01/2019 12/31/2023 686.58 Description: EXPLORATION OF ABDOMEN Category: Medical Services CMS Add: 01/01/1988 CMS Term: 58970 NOCOV DEF SYSMAN Description: RETRIEVAL OF OOCYTE Category: Non Covered Services CMS Add: 01/01/1989 CMS Term: 58974 NOCOV DEF SYSMAN Description: TRANSFER OF EMBRYO Category: Non Covered Services CMS Add: 01/01/1989 CMS Term: 58976 NOCOV DEF SYSMAN Description: TRANSFER OF EMBRYO Category: Non Covered Services CMS Add: 01/01/1989 CMS Term: 58999 MEDSV DEF BILL35 Description: UNLISTED PX FML GENITAL SYS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59000 MEDSV DEF RBRVS 01/01/2024 106.97 Description: AMNIOCENTESIS DIAGNOSTIC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59000 MEDSV DEF RBRVS 09/01/2019 12/31/2023 118.69 Description: AMNIOCENTESIS DIAGNOSTIC Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 704 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 59001 MEDSV DEF RBRVS 01/01/2024 159.99 Description: AMNIOCENTESIS THERAPEUTIC Category: Medical Services CMS Add: 01/01/2002 CMS Term: 59001 MEDSV DEF RBRVS 02/01/2015 12/31/2023 173.10 Description: AMNIOCENTESIS THERAPEUTIC Category: Medical Services CMS Add: 01/01/2002 CMS Term: 59012 MEDSV DEF RBRVS 01/01/2024 180.69 Description: FETAL CORD PUNCTURE PRENATAL Category: Medical Services CMS Add: 01/01/1990 CMS Term: 59012 MEDSV DEF RBRVS 09/01/2019 12/31/2023 195.68 Description: FETAL CORD PUNCTURE PRENATAL Category: Medical Services CMS Add: 01/01/1990 CMS Term: 59015 MEDSV DEF RBRVS 01/01/2024 142.90 Description: CHORION BIOPSY Category: Medical Services CMS Add: 01/01/1987 CMS Term: 59015 MEDSV DEF RBRVS 09/01/2019 12/31/2023 148.84 Description: CHORION BIOPSY Category: Medical Services CMS Add: 01/01/1987 CMS Term: 59020 26 MEDSV DEF RBRVS 01/01/2024 33.29 Description: FETAL CONTRACT STRESS TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59020 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 35.54 Description: FETAL CONTRACT STRESS TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59020 MEDSV DEF RBRVS 01/01/2024 64.32 Description: FETAL CONTRACT STRESS TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59020 MEDSV DEF RBRVS 09/01/2019 12/31/2023 66.47 Description: FETAL CONTRACT STRESS TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59020 TC MEDSV DEF RBRVS 01/01/2024 31.03 Description: FETAL CONTRACT STRESS TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59020 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 30.94 Description: FETAL CONTRACT STRESS TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59025 26 MEDSV DEF RBRVS 01/01/2024 26.37 Description: FETAL NON-STRESS TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59025 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 28.35 Description: FETAL NON-STRESS TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59025 MEDSV DEF RBRVS 01/01/2024 44.75 Description: FETAL NON-STRESS TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59025 MEDSV DEF RBRVS 09/01/2019 12/31/2023 45.08 Description: FETAL NON-STRESS TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 705 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 59025 TC MEDSV DEF RBRVS 01/01/2024 18.37 Description: FETAL NON-STRESS TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59025 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 16.73 Description: FETAL NON-STRESS TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59030 MEDSV DEF RBRVS 01/01/2024 100.70 Description: FETAL SCALP BLOOD SAMPLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59030 MEDSV DEF RBRVS 09/01/2019 12/31/2023 99.14 Description: FETAL SCALP BLOOD SAMPLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59050 NOCOV DEF SYSMAN Description: FETAL MONITOR W/REPORT Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: 59051 MEDSV DEF RBRVS 01/01/2019 12/31/2023 40.71 Description: FETAL MONITOR/INTERPRET ONLY Category: Medical Services CMS Add: 01/01/1995 CMS Term: 59051 MEDSV DEF RBRVS 01/01/2024 37.57 Description: FETAL MONITOR/INTERPRET ONLY Category: Medical Services CMS Add: 01/01/1995 CMS Term: 59070 MEDSV DEF RBRVS 01/01/2024 362.28 Description: TRANSABDOM AMNIOINFUS W/US Category: Medical Services CMS Add: 01/01/2004 CMS Term: 59070 MEDSV DEF RBRVS 02/01/2015 12/31/2023 390.52 Description: TRANSABDOM AMNIOINFUS W/US Category: Medical Services CMS Add: 01/01/2004 CMS Term: 59072 NOCOV DEF SYSMAN Description: UMBILICAL CORD OCCLUD W/US Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: 59074 MEDSV DEF RBRVS 01/01/2024 347.77 Description: FETAL FLUID DRAINAGE W/US Category: Medical Services CMS Add: 01/01/2004 CMS Term: 59074 MEDSV DEF RBRVS 02/01/2015 12/31/2023 371.37 Description: FETAL FLUID DRAINAGE W/US Category: Medical Services CMS Add: 01/01/2004 CMS Term: 59076 MEDSV DEF RBRVS 01/01/2024 467.11 Description: FETAL SHUNT PLACEMENT W/US Category: Medical Services CMS Add: 01/01/2004 CMS Term: 59076 MEDSV DEF RBRVS 02/01/2015 12/31/2023 506.16 Description: FETAL SHUNT PLACEMENT W/US Category: Medical Services CMS Add: 01/01/2004 CMS Term: 59100 MEDSV DEF RBRVS 01/01/2024 777.69 Description: REMOVE UTERUS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59100 MEDSV DEF RBRVS 09/01/2019 12/31/2023 801.24 Description: REMOVE UTERUS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 706 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 59120 MEDSV DEF RBRVS 01/01/2024 742.41 Description: TREAT ECTOPIC PREGNANCY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59120 MEDSV DEF RBRVS 09/01/2019 12/31/2023 763.17 Description: TREAT ECTOPIC PREGNANCY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59121 MEDSV DEF RBRVS 01/01/2024 742.62 Description: TREAT ECTOPIC PREGNANCY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59121 MEDSV DEF RBRVS 09/01/2019 12/31/2023 763.59 Description: TREAT ECTOPIC PREGNANCY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59130 MEDSV DEF RBRVS 01/01/2024 861.45 Description: TREAT ECTOPIC PREGNANCY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59130 MEDSV DEF RBRVS 09/01/2019 12/31/2023 823.50 Description: TREAT ECTOPIC PREGNANCY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59136 MEDSV DEF RBRVS 01/01/2024 817.10 Description: TREAT ECTOPIC PREGNANCY Category: Medical Services CMS Add: 01/01/1990 CMS Term: 59136 MEDSV DEF RBRVS 09/01/2019 12/31/2023 848.18 Description: TREAT ECTOPIC PREGNANCY Category: Medical Services CMS Add: 01/01/1990 CMS Term: 59140 MEDSV DEF RBRVS 01/01/2024 381.20 Description: TREAT ECTOPIC PREGNANCY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59140 MEDSV DEF RBRVS 09/01/2019 12/31/2023 370.01 Description: TREAT ECTOPIC PREGNANCY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59150 MEDSV DEF RBRVS 01/01/2024 720.50 Description: TREAT ECTOPIC PREGNANCY Category: Medical Services CMS Add: 01/01/1990 CMS Term: 59150 MEDSV DEF RBRVS 09/01/2019 12/31/2023 739.21 Description: TREAT ECTOPIC PREGNANCY Category: Medical Services CMS Add: 01/01/1990 CMS Term: 59151 MEDSV DEF RBRVS 01/01/2024 705.09 Description: TREAT ECTOPIC PREGNANCY Category: Medical Services CMS Add: 01/01/1990 CMS Term: 59151 MEDSV DEF RBRVS 09/01/2019 12/31/2023 719.22 Description: TREAT ECTOPIC PREGNANCY Category: Medical Services CMS Add: 01/01/1990 CMS Term: 59160 MEDSV DEF RBRVS 01/01/2024 252.44 Description: D & C AFTER DELIVERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59160 MEDSV DEF RBRVS 09/01/2019 12/31/2023 194.00 Description: D & C AFTER DELIVERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 707 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 59200 MEDSV DEF RBRVS 01/01/2024 97.61 Description: INSERT CERVICAL DILATOR Category: Medical Services CMS Add: 01/01/1987 CMS Term: 59200 MEDSV DEF RBRVS 09/01/2019 12/31/2023 68.49 Description: INSERT CERVICAL DILATOR Category: Medical Services CMS Add: 01/01/1987 CMS Term: 59300 MEDSV DEF RBRVS 01/01/2024 211.80 Description: EPISIOTOMY OR VAGINAL REPAIR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59300 MEDSV DEF RBRVS 09/01/2019 12/31/2023 183.22 Description: EPISIOTOMY OR VAGINAL REPAIR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59320 MEDSV DEF RBRVS 01/01/2024 136.08 Description: REVISION OF CERVIX Category: Medical Services CMS Add: 01/01/1990 CMS Term: 59320 MEDSV DEF RBRVS 09/01/2019 12/31/2023 146.65 Description: REVISION OF CERVIX Category: Medical Services CMS Add: 01/01/1990 CMS Term: 59325 MEDSV DEF RBRVS 01/01/2024 216.33 Description: REVISION OF CERVIX Category: Medical Services CMS Add: 01/01/1990 CMS Term: 59325 MEDSV DEF RBRVS 09/01/2019 12/31/2023 215.35 Description: REVISION OF CERVIX Category: Medical Services CMS Add: 01/01/1990 CMS Term: 59350 MEDSV DEF RBRVS 01/01/2024 250.35 Description: REPAIR OF UTERUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59350 MEDSV DEF RBRVS 09/01/2019 12/31/2023 270.01 Description: REPAIR OF UTERUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59400* MEDSV DEF MAXFEE 12/31/2021 1759.06 0.0 Y 8-60years 0-1 Description: OBSTETRICAL CARE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59400* NOCOV DEF SYSMAN Y Description: OBSTETRICAL CARE Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: 59409 UA MEDSV DEF MAXFEE 01/01/2024 726.43 0.0 Description: OBSTETRICAL CARE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 59409 UA MEDSV DEF MAXFEE 02/01/2015 12/31/2023 818.87 0.0 Description: OBSTETRICAL CARE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 59409 UB MEDSV DEF MAXFEE 01/01/2024 726.43 0.0 Description: OBSTETRICAL CARE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 59409 UB MEDSV DEF MAXFEE 02/01/2015 12/31/2023 818.87 0.0 Description: OBSTETRICAL CARE Category: Medical Services CMS Add: 01/01/1994 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 708 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 59409 UC MEDSV DEF MAXFEE 01/01/2024 726.43 0.0 Description: OBSTETRICAL CARE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 59409 UC MEDSV DEF MAXFEE 02/01/2015 12/31/2023 818.87 0.0 Description: OBSTETRICAL CARE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 59410* MEDSV DEF MAXFEE 12/31/2021 776.58 0.0 Y 8-60years 0-1 Description: OBSTETRICAL CARE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59410* NOCOV DEF SYSMAN Y Description: OBSTETRICAL CARE Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: 59412 MEDSV DEF RBRVS 01/01/2024 92.40 10-60years Description: ANTEPARTUM MANIPULATION Category: Medical Services CMS Add: 01/01/1989 CMS Term: 59412 MEDSV DEF RBRVS 02/01/2015 12/31/2023 99.69 10-60years Description: ANTEPARTUM MANIPULATION Category: Medical Services CMS Add: 01/01/1989 CMS Term: 59414 MEDSV DEF RBRVS 01/01/2024 81.57 10-60years Description: DELIVER PLACENTA Category: Medical Services CMS Add: 01/01/1990 CMS Term: 59414 MEDSV DEF RBRVS 09/01/2019 12/31/2023 88.51 10-60years Description: DELIVER PLACENTA Category: Medical Services CMS Add: 01/01/1990 CMS Term: 59425 MEDSV DEF MAXFEE 01/01/2024 85.50 0.0 10-60years 0-6 Description: ANTEPARTUM CARE ONLY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 59425 MEDSV DEF MAXFEE 02/01/2015 12/31/2023 72.61 0.0 10-60years 0-6 Description: ANTEPARTUM CARE ONLY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 59426 MEDSV DEF MAXFEE 01/01/2024 93.86 0.0 10-60years Description: ANTEPARTUM CARE ONLY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 59426 MEDSV DEF MAXFEE 02/01/2015 12/31/2023 78.00 0.0 10-60years Description: ANTEPARTUM CARE ONLY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 59430 MEDSV DEF RBRVS 01/01/2024 242.91 10-60years Description: CARE AFTER DELIVERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59430 MEDSV DEF RBRVS 09/01/2019 12/31/2023 176.24 10-60years Description: CARE AFTER DELIVERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59510* MEDSV DEF MAXFEE 12/31/2021 1934.43 0.0 Y 8-60years 0-1 Description: CESAREAN DELIVERY Category: Medical Services CMS Add: 01/01/1990 CMS Term: 59510* NOCOV DEF SYSMAN Y Description: CESAREAN DELIVERY Category: Non Covered Services CMS Add: 01/01/1990 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 709 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 59514 UA MEDSV DEF MAXFEE 01/01/2024 817.19 0.0 0-1 Description: CESAREAN DELIVERY ONLY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 59514 UA MEDSV DEF MAXFEE 02/01/2015 12/31/2023 818.87 0.0 0-1 Description: CESAREAN DELIVERY ONLY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 59514 UB MEDSV DEF MAXFEE 01/01/2024 817.19 0.0 0-1 Description: CESAREAN DELIVERY ONLY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 59514 UB MEDSV DEF MAXFEE 02/01/2015 12/31/2023 818.87 0.0 0-1 Description: CESAREAN DELIVERY ONLY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 59514 UC MEDSV DEF MAXFEE 01/01/2024 817.19 0.0 0-1 Description: CESAREAN DELIVERY ONLY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 59514 UC MEDSV DEF MAXFEE 02/01/2015 12/31/2023 818.87 0.0 0-1 Description: CESAREAN DELIVERY ONLY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 59515* MEDSV DEF MAXFEE 12/31/2021 951.91 0.0 Y 8-60years 0-1 Description: CESAREAN DELIVERY Category: Medical Services CMS Add: 01/01/1990 CMS Term: 59515* NOCOV DEF SYSMAN Y Description: CESAREAN DELIVERY Category: Non Covered Services CMS Add: 01/01/1990 CMS Term: 59525 MEDSV DEF RBRVS 01/01/2024 431.67 Y Y Description: REMOVE UTERUS AFTER CESAREAN Category: Medical Services CMS Add: 01/01/1990 CMS Term: 59525 MEDSV DEF RBRVS 02/01/2015 12/31/2023 351.40 Y Y Description: REMOVE UTERUS AFTER CESAREAN Category: Medical Services CMS Add: 01/01/1990 CMS Term: 59610* MEDSV DEF MAXFEE 12/31/2021 1831.02 0.0 Y 8-60years 0-1 Description: VBAC DELIVERY Category: Medical Services CMS Add: 01/01/1996 CMS Term: 59610* NOCOV DEF SYSMAN Y Description: VBAC DELIVERY Category: Non Covered Services CMS Add: 01/01/1996 CMS Term: 59612 UA MEDSV DEF MAXFEE 01/01/2024 814.69 0.0 10-60years Description: VBAC DELIVERY ONLY Category: Medical Services CMS Add: 01/01/1996 CMS Term: 59612 UA MEDSV DEF MAXFEE 02/01/2015 12/31/2023 889.49 0.0 10-60years Description: VBAC DELIVERY ONLY Category: Medical Services CMS Add: 01/01/1996 CMS Term: 59612 UB MEDSV DEF MAXFEE 01/01/2024 814.69 0.0 10-60years Description: VBAC DELIVERY ONLY Category: Medical Services CMS Add: 01/01/1996 CMS Term: 59612 UB MEDSV DEF MAXFEE 02/01/2015 12/31/2023 889.49 0.0 10-60years Description: VBAC DELIVERY ONLY Category: Medical Services CMS Add: 01/01/1996 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 710 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 59612 UC MEDSV DEF MAXFEE 01/01/2024 814.69 0.0 10-60years Description: VBAC DELIVERY ONLY Category: Medical Services CMS Add: 01/01/1996 CMS Term: 59612 UC MEDSV DEF MAXFEE 02/01/2015 12/31/2023 889.49 0.0 10-60years Description: VBAC DELIVERY ONLY Category: Medical Services CMS Add: 01/01/1996 CMS Term: 59614* MEDSV DEF MAXFEE 12/31/2021 833.79 0.0 Y 8-60years 0-1 Description: VBAC CARE AFTER DELIVERY Category: Medical Services CMS Add: 01/01/1996 CMS Term: 59614* NOCOV DEF SYSMAN Y Description: VBAC CARE AFTER DELIVERY Category: Non Covered Services CMS Add: 01/01/1996 CMS Term: 59618* MEDSV DEF MAXFEE 12/31/2021 1954.43 0.0 Y 8-60years 0-1 Description: ATTEMPTED VBAC DELIVERY Category: Medical Services CMS Add: 01/01/1996 CMS Term: 59618* NOCOV DEF SYSMAN Y Description: ATTEMPTED VBAC DELIVERY Category: Non Covered Services CMS Add: 01/01/1996 CMS Term: 59620 UA MEDSV DEF MAXFEE 01/01/2024 843.37 0.0 10-60years 0-1 Description: ATTEMPTED VBAC DELIVERY ONLY Category: Medical Services CMS Add: 01/01/1996 CMS Term: 59620 UA MEDSV DEF MAXFEE 02/01/2015 12/31/2023 915.70 0.0 10-60years 0-1 Description: ATTEMPTED VBAC DELIVERY ONLY Category: Medical Services CMS Add: 01/01/1996 CMS Term: 59620 UB MEDSV DEF MAXFEE 01/01/2024 843.37 0.0 10-60years 0-1 Description: ATTEMPTED VBAC DELIVERY ONLY Category: Medical Services CMS Add: 01/01/1996 CMS Term: 59620 UB MEDSV DEF MAXFEE 02/01/2015 12/31/2023 915.70 0.0 10-60years 0-1 Description: ATTEMPTED VBAC DELIVERY ONLY Category: Medical Services CMS Add: 01/01/1996 CMS Term: 59620 UC MEDSV DEF MAXFEE 01/01/2024 843.37 0.0 10-60years 0-1 Description: ATTEMPTED VBAC DELIVERY ONLY Category: Medical Services CMS Add: 01/01/1996 CMS Term: 59620 UC MEDSV DEF MAXFEE 02/01/2015 12/31/2023 915.70 0.0 10-60years 0-1 Description: ATTEMPTED VBAC DELIVERY ONLY Category: Medical Services CMS Add: 01/01/1996 CMS Term: 59622* MEDSV DEF MAXFEE 12/31/2021 987.21 0.0 Y 8-60years 0-1 Description: ATTEMPTED VBAC AFTER CARE Category: Medical Services CMS Add: 01/01/1996 CMS Term: 59622* NOCOV DEF SYSMAN Y Description: ATTEMPTED VBAC AFTER CARE Category: Non Covered Services CMS Add: 01/01/1996 CMS Term: 59812 MEDSV DEF RBRVS 01/01/2024 333.15 Description: TREATMENT OF MISCARRIAGE Category: Medical Services CMS Add: 01/01/1990 CMS Term: 59812 MEDSV DEF RBRVS 09/01/2019 12/31/2023 303.40 Description: TREATMENT OF MISCARRIAGE Category: Medical Services CMS Add: 01/01/1990 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 711 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 59820 MEDSV DEF RBRVS 01/01/2024 404.22 Description: CARE OF MISCARRIAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59820 MEDSV DEF RBRVS 09/01/2019 12/31/2023 360.89 Description: CARE OF MISCARRIAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59821 MEDSV DEF RBRVS 01/01/2024 397.78 Description: TREATMENT OF MISCARRIAGE Category: Medical Services CMS Add: 01/01/1990 CMS Term: 59821 MEDSV DEF RBRVS 09/01/2019 12/31/2023 364.34 Description: TREATMENT OF MISCARRIAGE Category: Medical Services CMS Add: 01/01/1990 CMS Term: 59830 MEDSV DEF RBRVS 01/01/2024 423.89 Description: TREAT UTERUS INFECTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59830 MEDSV DEF RBRVS 09/01/2019 12/31/2023 417.97 Description: TREAT UTERUS INFECTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 59840 MEDSV DEF RBRVS 01/01/2024 229.17 Description: ABORTION Category: Medical Services CMS Add: 01/01/1982 CMS Term: 59840 MEDSV DEF RBRVS 09/01/2019 12/31/2023 205.71 Description: ABORTION Category: Medical Services CMS Add: 01/01/1982 CMS Term: 59841 MEDSV DEF RBRVS 01/01/2024 390.61 Description: ABORTION Category: Medical Services CMS Add: 01/01/1982 CMS Term: 59841 MEDSV DEF RBRVS 09/01/2019 12/31/2023 365.36 Description: ABORTION Category: Medical Services CMS Add: 01/01/1982 CMS Term: 59850 MEDSV DEF RBRVS 01/01/2024 356.53 Description: ABORTION Category: Medical Services CMS Add: 01/01/1982 CMS Term: 59850 MEDSV DEF RBRVS 09/01/2019 12/31/2023 337.20 Description: ABORTION Category: Medical Services CMS Add: 01/01/1982 CMS Term: 59851 MEDSV DEF RBRVS 01/01/2024 391.32 Description: ABORTION Category: Medical Services CMS Add: 01/01/1982 CMS Term: 59851 MEDSV DEF RBRVS 09/01/2019 12/31/2023 381.53 Description: ABORTION Category: Medical Services CMS Add: 01/01/1982 CMS Term: 59852 MEDSV DEF RBRVS 01/01/2024 538.60 Description: ABORTION Category: Medical Services CMS Add: 01/01/1982 CMS Term: 59852 MEDSV DEF RBRVS 09/01/2019 12/31/2023 492.45 Description: ABORTION Category: Medical Services CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 712 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 59855 MEDSV DEF RBRVS 01/01/2019 12/31/2023 398.15 Description: ABORTION Category: Medical Services CMS Add: 01/01/1995 CMS Term: 59855 MEDSV DEF RBRVS 01/01/2024 387.26 Description: ABORTION Category: Medical Services CMS Add: 01/01/1995 CMS Term: 59856 MEDSV DEF RBRVS 01/01/2019 12/31/2023 468.01 Description: ABORTION Category: Medical Services CMS Add: 01/01/1995 CMS Term: 59856 MEDSV DEF RBRVS 01/01/2024 452.45 Description: ABORTION Category: Medical Services CMS Add: 01/01/1995 CMS Term: 59857 MEDSV DEF RBRVS 01/01/2019 12/31/2023 506.75 Description: ABORTION Category: Medical Services CMS Add: 01/01/1995 CMS Term: 59857 MEDSV DEF RBRVS 01/01/2024 526.86 Description: ABORTION Category: Medical Services CMS Add: 01/01/1995 CMS Term: 59866 NOCOV DEF SYSMAN Description: ABORTION (MPR) Category: Non Covered Services CMS Add: 01/01/1997 CMS Term: 59870 MEDSV DEF RBRVS 01/01/2024 492.37 Description: EVACUATE MOLE OF UTERUS Category: Medical Services CMS Add: 01/01/1990 CMS Term: 59870 MEDSV DEF RBRVS 09/01/2019 12/31/2023 450.61 Description: EVACUATE MOLE OF UTERUS Category: Medical Services CMS Add: 01/01/1990 CMS Term: 59871 MEDSV DEF RBRVS 01/01/2024 119.69 Description: REMOVE CERCLAGE SUTURE Category: Medical Services CMS Add: 01/01/1998 CMS Term: 59871 MEDSV DEF RBRVS 02/01/2015 12/31/2023 128.71 Description: REMOVE CERCLAGE SUTURE Category: Medical Services CMS Add: 01/01/1998 CMS Term: 59897 MEDSV DEF BILL35 Y Description: UNLISTED FETAL INVAS PX W/US Category: Medical Services CMS Add: 01/01/2004 CMS Term: 59898 MEDSV DEF BILL35 Description: UNLSTD LAPS PX MAT CARE&DLVR Category: Medical Services CMS Add: 01/01/2000 CMS Term: 59899 MEDSV DEF BILL35 Description: UNLISTED PX MAT CARE&DLVR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60000 MEDSV DEF RBRVS 01/01/2024 174.34 Description: DRAIN THYROID/TONGUE CYST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60000 MEDSV DEF RBRVS 09/01/2019 12/31/2023 124.02 Description: DRAIN THYROID/TONGUE CYST Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 713 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 6005F NOCOV DEF SYSMAN Description: CARE LEVEL RATIONALE DOC Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 60100 MEDSV DEF RBRVS 01/01/2024 103.92 Description: BIOPSY OF THYROID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60100 MEDSV DEF RBRVS 09/01/2019 12/31/2023 81.55 Description: BIOPSY OF THYROID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 6010F NOCOV DEF SYSMAN Description: DYSPHAG TEST DONE B/4 EATING Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 6015F NOCOV DEF SYSMAN Description: DYSPHAG TEST DONE B/4 EATING Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 60200 MEDSV DEF RBRVS 01/01/2024 620.73 Description: REMOVE THYROID LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60200 MEDSV DEF RBRVS 09/01/2019 12/31/2023 475.98 Description: REMOVE THYROID LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 6020F NOCOV DEF SYSMAN Description: NPO (NOTHING-MOUTH) ORDERED Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 60210 MEDSV DEF RBRVS 01/01/2019 12/31/2023 508.33 Description: PARTIAL THYROID EXCISION Category: Medical Services CMS Add: 01/01/1995 CMS Term: 60210 MEDSV DEF RBRVS 01/01/2024 655.55 Description: PARTIAL THYROID EXCISION Category: Medical Services CMS Add: 01/01/1995 CMS Term: 60212 MEDSV DEF RBRVS 01/01/2019 12/31/2023 724.67 Description: PARTIAL THYROID EXCISION Category: Medical Services CMS Add: 01/01/1995 CMS Term: 60212 MEDSV DEF RBRVS 01/01/2024 937.21 Description: PARTIAL THYROID EXCISION Category: Medical Services CMS Add: 01/01/1995 CMS Term: 60220 MEDSV DEF RBRVS 01/01/2024 657.34 Description: PARTIAL REMOVAL OF THYROID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60220 MEDSV DEF RBRVS 09/01/2019 12/31/2023 511.71 Description: PARTIAL REMOVAL OF THYROID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60225 MEDSV DEF RBRVS 01/01/2024 868.53 Description: PARTIAL REMOVAL OF THYROID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60225 MEDSV DEF RBRVS 09/01/2019 12/31/2023 670.62 Description: PARTIAL REMOVAL OF THYROID Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 714 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 60240 MEDSV DEF RBRVS 01/01/2024 849.06 Description: REMOVAL OF THYROID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60240 MEDSV DEF RBRVS 09/01/2019 12/31/2023 662.88 Description: REMOVAL OF THYROID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60252 MEDSV DEF RBRVS 01/01/2024 1222.57 Description: REMOVAL OF THYROID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60252 MEDSV DEF RBRVS 09/01/2019 12/31/2023 951.64 Description: REMOVAL OF THYROID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60254 MEDSV DEF RBRVS 01/01/2024 1549.06 Description: EXTENSIVE THYROID SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60254 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1208.17 Description: EXTENSIVE THYROID SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60260 MEDSV DEF RBRVS 01/01/2024 1010.00 Description: REPEAT THYROID SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60260 MEDSV DEF RBRVS 09/01/2019 12/31/2023 790.93 Description: REPEAT THYROID SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60270 MEDSV DEF RBRVS 01/01/2024 1258.09 Description: REMOVAL OF THYROID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60270 MEDSV DEF RBRVS 09/01/2019 12/31/2023 984.85 Description: REMOVAL OF THYROID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60271 MEDSV DEF RBRVS 01/01/2019 12/31/2023 763.50 Description: REMOVAL OF THYROID Category: Medical Services CMS Add: 01/01/1995 CMS Term: 60271 MEDSV DEF RBRVS 01/01/2024 977.65 Description: REMOVAL OF THYROID Category: Medical Services CMS Add: 01/01/1995 CMS Term: 60280 MEDSV DEF RBRVS 01/01/2024 427.00 Description: REMOVE THYROID DUCT LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60280 MEDSV DEF RBRVS 09/01/2019 12/31/2023 321.40 Description: REMOVE THYROID DUCT LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60281 MEDSV DEF RBRVS 01/01/2024 561.81 Description: REMOVE THYROID DUCT LESION Category: Medical Services CMS Add: 01/01/1986 CMS Term: 60281 MEDSV DEF RBRVS 09/01/2019 12/31/2023 429.62 Description: REMOVE THYROID DUCT LESION Category: Medical Services CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 715 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 60300 MEDSV DEF RBRVS 01/01/2024 100.85 Description: ASPIR/INJ THYROID CYST Category: Medical Services CMS Add: 01/01/2008 CMS Term: 60300 MEDSV DEF RBRVS 02/01/2015 12/31/2023 83.61 Description: ASPIR/INJ THYROID CYST Category: Medical Services CMS Add: 01/01/2008 CMS Term: 6030F NOCOV DEF SYSMAN Description: MAX STERILE BARRIERS FLWD Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 6040F NOCOV DEF SYSMAN Description: APPRO RAD DS DVCS TECHS DOCD Category: Non Covered Services CMS Add: 04/01/2008 CMS Term: 6045F NOCOV DEF SYSMAN Description: RADXPS IN END RPRT4FLURO PXD Category: Non Covered Services CMS Add: 04/01/2008 CMS Term: 60500 MEDSV DEF RBRVS 01/01/2024 894.35 Description: EXPLORE PARATHYROID GLANDS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60500 MEDSV DEF RBRVS 09/01/2019 12/31/2023 693.12 Description: EXPLORE PARATHYROID GLANDS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60502 MEDSV DEF RBRVS 01/01/2024 1196.46 Description: RE-EXPLORE PARATHYROIDS Category: Medical Services CMS Add: 01/01/1986 CMS Term: 60502 MEDSV DEF RBRVS 09/01/2019 12/31/2023 923.17 Description: RE-EXPLORE PARATHYROIDS Category: Medical Services CMS Add: 01/01/1986 CMS Term: 60505 MEDSV DEF RBRVS 01/01/2024 1291.84 Description: EXPLORE PARATHYROID GLANDS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60505 MEDSV DEF RBRVS 09/01/2019 12/31/2023 997.36 Description: EXPLORE PARATHYROID GLANDS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60512 MEDSV DEF RBRVS 01/01/2019 12/31/2023 175.20 Y Description: AUTOTRANSPLANT PARATHYROID Category: Medical Services CMS Add: 01/01/1995 CMS Term: 60512 MEDSV DEF RBRVS 01/01/2024 221.60 Y Description: AUTOTRANSPLANT PARATHYROID Category: Medical Services CMS Add: 01/01/1995 CMS Term: 60520 MEDSV DEF RBRVS 01/01/2024 960.31 Description: REMOVAL OF THYMUS GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60520 MEDSV DEF RBRVS 09/01/2019 12/31/2023 745.78 Description: REMOVAL OF THYMUS GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60521 MEDSV DEF RBRVS 01/01/2019 12/31/2023 809.30 Description: REMOVAL OF THYMUS GLAND Category: Medical Services CMS Add: 01/01/1995 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 716 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 60521 MEDSV DEF RBRVS 01/01/2024 1017.55 Description: REMOVAL OF THYMUS GLAND Category: Medical Services CMS Add: 01/01/1995 CMS Term: 60522 MEDSV DEF RBRVS 01/01/2019 12/31/2023 981.15 Description: REMOVAL OF THYMUS GLAND Category: Medical Services CMS Add: 01/01/1995 CMS Term: 60522 MEDSV DEF RBRVS 01/01/2024 1232.32 Description: REMOVAL OF THYMUS GLAND Category: Medical Services CMS Add: 01/01/1995 CMS Term: 60540 MEDSV DEF RBRVS 01/01/2024 988.83 Description: EXPLORE ADRENAL GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60540 MEDSV DEF RBRVS 09/01/2019 12/31/2023 760.37 Description: EXPLORE ADRENAL GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60545 MEDSV DEF RBRVS 01/01/2024 1142.23 Description: EXPLORE ADRENAL GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60545 MEDSV DEF RBRVS 09/01/2019 12/31/2023 873.82 Description: EXPLORE ADRENAL GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60600 MEDSV DEF RBRVS 01/01/2024 1241.85 Description: REMOVE CAROTID BODY LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60600 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1025.81 Description: REMOVE CAROTID BODY LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60605 MEDSV DEF RBRVS 01/01/2024 1469.25 Description: REMOVE CAROTID BODY LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60605 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1161.66 Description: REMOVE CAROTID BODY LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 60650 MEDSV DEF RBRVS 01/01/2019 12/31/2023 855.15 0-2 Description: LAPAROSCOPY ADRENALECTOMY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 60650 MEDSV DEF RBRVS 01/01/2024 1091.37 0-2 Description: LAPAROSCOPY ADRENALECTOMY Category: Medical Services CMS Add: 01/01/2000 CMS Term: 60659 MEDSV DEF BILL20 0-1 Description: UNLISTED LAPS PX ENDOC SYS Category: Medical Services CMS Add: 01/01/2000 CMS Term: 60699 MEDSV DEF BILL20 Description: UNLISTED PX ENDOCRINE SYSTEM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 6070F NOCOV DEF SYSMAN Description: PT ASKED/CNSLD AED EFFECTS Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 717 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 6080F NOCOV DEF SYSMAN Description: PT/CAREGIVER QUERIED FALLS Category: Non Covered Services CMS Add: 10/01/2010 CMS Term: 6090F NOCOV DEF SYSMAN Description: PT/CAREGIVER COUNSEL SAFETY Category: Non Covered Services CMS Add: 10/01/2010 CMS Term: 61000 MEDSV DEF RBRVS 01/01/2024 100.43 Description: REMOVE CRANIAL CAVITY FLUID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61000 MEDSV DEF RBRVS 09/01/2019 12/31/2023 65.16 Description: REMOVE CRANIAL CAVITY FLUID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61001 MEDSV DEF RBRVS 01/01/2024 95.18 Description: REMOVE CRANIAL CAVITY FLUID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61001 MEDSV DEF RBRVS 09/01/2019 12/31/2023 75.46 Description: REMOVE CRANIAL CAVITY FLUID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 6100F NOCOV DEF SYSMAN Description: VERIFY PT SITE PXD DOCD Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: 6101F NOCOV DEF SYSMAN Description: SAFETY COUNSELING DEMENTIA Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 61020 MEDSV DEF RBRVS 01/01/2024 94.60 Description: REMOVE BRAIN CAVITY FLUID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61020 MEDSV DEF RBRVS 09/01/2019 12/31/2023 74.02 Description: REMOVE BRAIN CAVITY FLUID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61026 MEDSV DEF RBRVS 01/01/2024 97.67 Description: INJECTION INTO BRAIN CANAL Category: Medical Services CMS Add: 01/01/1985 CMS Term: 61026 MEDSV DEF RBRVS 09/01/2019 12/31/2023 76.62 Description: INJECTION INTO BRAIN CANAL Category: Medical Services CMS Add: 01/01/1985 CMS Term: 6102F NOCOV DEF SYSMAN Description: SAFETY COUNSELING DEM ORDER Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 61050 MEDSV DEF RBRVS 01/01/2024 75.95 Description: REMOVE BRAIN CANAL FLUID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61050 MEDSV DEF RBRVS 09/01/2019 12/31/2023 63.19 Description: REMOVE BRAIN CANAL FLUID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61055 MEDSV DEF RBRVS 01/01/2024 109.52 Description: INJECTION INTO BRAIN CANAL Category: Medical Services CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 718 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 61055 MEDSV DEF RBRVS 09/01/2019 12/31/2023 86.07 Description: INJECTION INTO BRAIN CANAL Category: Medical Services CMS Add: 01/01/1985 CMS Term: 61070 MEDSV DEF RBRVS 01/01/2024 52.04 Description: BRAIN CANAL SHUNT PROCEDURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61070 MEDSV DEF RBRVS 09/01/2019 12/31/2023 42.66 Description: BRAIN CANAL SHUNT PROCEDURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61105 MEDSV DEF RBRVS 01/01/2024 419.39 Description: TWIST DRILL HOLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61105 MEDSV DEF RBRVS 09/01/2019 12/31/2023 323.23 Description: TWIST DRILL HOLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61107 MEDSV DEF RBRVS 01/01/2024 274.59 Description: DRILL SKULL FOR IMPLANTATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61107 MEDSV DEF RBRVS 09/01/2019 12/31/2023 220.37 Description: DRILL SKULL FOR IMPLANTATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61108 MEDSV DEF RBRVS 01/01/2024 815.91 Description: DRILL SKULL FOR DRAINAGE Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61108 MEDSV DEF RBRVS 09/01/2019 12/31/2023 633.81 Description: DRILL SKULL FOR DRAINAGE Category: Medical Services CMS Add: 01/01/1988 CMS Term: 6110F NOCOV DEF SYSMAN Description: COUNSEL PROV DRIVING RISKS Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 61120 MEDSV DEF RBRVS 01/01/2024 674.26 Description: BURR HOLE FOR PUNCTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61120 MEDSV DEF RBRVS 09/01/2019 12/31/2023 521.69 Description: BURR HOLE FOR PUNCTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61140 MEDSV DEF RBRVS 01/01/2024 1135.80 Description: PIERCE SKULL FOR BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61140 MEDSV DEF RBRVS 09/01/2019 12/31/2023 880.95 Description: PIERCE SKULL FOR BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61150 MEDSV DEF RBRVS 01/01/2024 1204.76 Description: PIERCE SKULL FOR DRAINAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61150 MEDSV DEF RBRVS 09/01/2019 12/31/2023 944.57 Description: PIERCE SKULL FOR DRAINAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 719 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 61151 MEDSV DEF RBRVS 01/01/2024 889.55 Description: PIERCE SKULL FOR DRAINAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61151 MEDSV DEF RBRVS 09/01/2019 12/31/2023 693.51 Description: PIERCE SKULL FOR DRAINAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61154 MEDSV DEF RBRVS 01/01/2024 1143.77 Description: PIERCE SKULL & REMOVE CLOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61154 MEDSV DEF RBRVS 09/01/2019 12/31/2023 887.63 Description: PIERCE SKULL & REMOVE CLOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61156 MEDSV DEF RBRVS 01/01/2024 1100.93 Description: PIERCE SKULL FOR DRAINAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61156 MEDSV DEF RBRVS 09/01/2019 12/31/2023 867.04 Description: PIERCE SKULL FOR DRAINAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61210 MEDSV DEF RBRVS 01/01/2024 322.14 Description: PIERCE SKULL IMPLANT DEVICE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61210 MEDSV DEF RBRVS 09/01/2019 12/31/2023 257.39 Description: PIERCE SKULL IMPLANT DEVICE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61215 MEDSV DEF RBRVS 01/01/2024 467.14 Description: INSERT BRAIN-FLUID DEVICE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 61215 MEDSV DEF RBRVS 09/01/2019 12/31/2023 352.39 Description: INSERT BRAIN-FLUID DEVICE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 61250 MEDSV DEF RBRVS 01/01/2024 779.42 Description: PIERCE SKULL & EXPLORE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61250 MEDSV DEF RBRVS 09/01/2019 12/31/2023 604.92 Description: PIERCE SKULL & EXPLORE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61253 MEDSV DEF RBRVS 01/01/2024 889.55 Description: PIERCE SKULL & EXPLORE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61253 MEDSV DEF RBRVS 09/01/2019 12/31/2023 598.85 Description: PIERCE SKULL & EXPLORE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61304 MEDSV DEF RBRVS 01/01/2024 1460.04 Description: OPEN SKULL FOR EXPLORATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61304 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1146.09 Description: OPEN SKULL FOR EXPLORATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 720 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 61305 MEDSV DEF RBRVS 01/01/2024 1784.55 Description: OPEN SKULL FOR EXPLORATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61305 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1401.32 Description: OPEN SKULL FOR EXPLORATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61312 MEDSV DEF RBRVS 01/01/2024 1839.53 Description: OPEN SKULL FOR DRAINAGE Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61312 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1452.50 Description: OPEN SKULL FOR DRAINAGE Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61313 MEDSV DEF RBRVS 01/01/2024 1766.48 Description: OPEN SKULL FOR DRAINAGE Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61313 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1385.05 Description: OPEN SKULL FOR DRAINAGE Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61314 MEDSV DEF RBRVS 01/01/2024 1624.92 Description: OPEN SKULL FOR DRAINAGE Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61314 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1277.65 Description: OPEN SKULL FOR DRAINAGE Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61315 MEDSV DEF RBRVS 01/01/2024 1839.86 Description: OPEN SKULL FOR DRAINAGE Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61315 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1445.05 Description: OPEN SKULL FOR DRAINAGE Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61316 MEDSV DEF RBRVS 01/01/2024 76.80 Description: IMPLT CRAN BONE FLAP TO ABDO Category: Medical Services CMS Add: 01/01/2003 CMS Term: 61316 MEDSV DEF RBRVS 02/01/2015 12/31/2023 61.46 Description: IMPLT CRAN BONE FLAP TO ABDO Category: Medical Services CMS Add: 01/01/2003 CMS Term: 61320 MEDSV DEF RBRVS 01/01/2024 1683.96 Description: OPEN SKULL FOR DRAINAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61320 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1329.56 Description: OPEN SKULL FOR DRAINAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61321 MEDSV DEF RBRVS 01/01/2024 1889.23 Description: OPEN SKULL FOR DRAINAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61321 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1485.05 Description: OPEN SKULL FOR DRAINAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 721 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 61322 MEDSV DEF RBRVS 01/01/2024 2116.92 Description: DECOMPRESSIVE CRANIOTOMY Category: Medical Services CMS Add: 01/01/2003 CMS Term: 61322 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1657.44 Description: DECOMPRESSIVE CRANIOTOMY Category: Medical Services CMS Add: 01/01/2003 CMS Term: 61323 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1663.91 Description: DECOMPRESSIVE LOBECTOMY Category: Medical Services CMS Add: 01/01/2003 CMS Term: 61323 MEDSV DEF RBRVS 01/01/2024 2122.33 Description: DECOMPRESSIVE LOBECTOMY Category: Medical Services CMS Add: 01/01/2003 CMS Term: 61330 MEDSV DEF RBRVS 01/01/2024 1598.23 Description: DECOMPRESS EYE SOCKET Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61330 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1296.21 Description: DECOMPRESS EYE SOCKET Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61333 MEDSV DEF RBRVS 01/01/2024 1791.55 Description: EXPLORE ORBIT/REMOVE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61333 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1479.60 Description: EXPLORE ORBIT/REMOVE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61340 MEDSV DEF RBRVS 01/01/2024 1285.30 Description: SUBTEMPORAL DECOMPRESSION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61340 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1008.46 Description: SUBTEMPORAL DECOMPRESSION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61343 MEDSV DEF RBRVS 01/01/2024 1954.42 Description: INCISE SKULL (PRESS RELIEF) Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61343 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1535.40 Description: INCISE SKULL (PRESS RELIEF) Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61345 MEDSV DEF RBRVS 01/01/2024 1817.51 Description: RELIEVE CRANIAL PRESSURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61345 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1422.21 Description: RELIEVE CRANIAL PRESSURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61450 MEDSV DEF RBRVS 01/01/2024 1706.57 Description: INCISE SKULL FOR SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61450 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1340.78 Description: INCISE SKULL FOR SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 722 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 61458 MEDSV DEF RBRVS 01/01/2024 1794.60 Description: INCISE SKULL FOR BRAIN WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61458 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1401.49 Description: INCISE SKULL FOR BRAIN WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61460 MEDSV DEF RBRVS 01/01/2024 1873.46 Description: INCISE SKULL FOR SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61460 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1467.02 Description: INCISE SKULL FOR SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61500 MEDSV DEF RBRVS 01/01/2024 1184.70 Description: REMOVAL OF SKULL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61500 MEDSV DEF RBRVS 09/01/2019 12/31/2023 940.11 Description: REMOVAL OF SKULL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61501 MEDSV DEF RBRVS 01/01/2024 1034.15 Description: REMOVE INFECTED SKULL BONE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 61501 MEDSV DEF RBRVS 09/01/2019 12/31/2023 816.59 Description: REMOVE INFECTED SKULL BONE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 6150F NOCOV DEF SYSMAN Description: PT NOTRCVNG1ST ANTITNF TXMNT Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 61510 MEDSV DEF RBRVS 01/01/2024 1961.34 Description: REMOVAL OF BRAIN LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61510 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1527.21 Description: REMOVAL OF BRAIN LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61512 MEDSV DEF RBRVS 01/01/2024 2268.38 Description: REMOVE BRAIN LINING LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61512 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1780.41 Description: REMOVE BRAIN LINING LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61514 MEDSV DEF RBRVS 01/01/2024 1707.37 Description: REMOVAL OF BRAIN ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61514 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1331.89 Description: REMOVAL OF BRAIN ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61516 MEDSV DEF RBRVS 01/01/2024 1667.67 Description: REMOVAL OF BRAIN LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 723 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 61516 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1300.22 Description: REMOVAL OF BRAIN LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61517 MEDSV DEF RBRVS 01/01/2024 76.30 Description: IMPLT BRAIN CHEMOTX ADD-ON Category: Medical Services CMS Add: 01/01/2003 CMS Term: 61517 MEDSV DEF RBRVS 02/01/2015 12/31/2023 60.94 Description: IMPLT BRAIN CHEMOTX ADD-ON Category: Medical Services CMS Add: 01/01/2003 CMS Term: 61518 MEDSV DEF RBRVS 01/01/2024 2460.76 Description: REMOVAL OF BRAIN LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61518 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1927.46 Description: REMOVAL OF BRAIN LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61519 MEDSV DEF RBRVS 01/01/2024 2614.69 Description: REMOVE BRAIN LINING LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61519 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2059.82 Description: REMOVE BRAIN LINING LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61520 MEDSV DEF RBRVS 01/01/2024 3336.03 Description: REMOVAL OF BRAIN LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61520 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2632.86 Description: REMOVAL OF BRAIN LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61521 MEDSV DEF RBRVS 01/01/2024 2810.01 Description: REMOVAL OF BRAIN LESION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 61521 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2219.72 Description: REMOVAL OF BRAIN LESION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 61522 MEDSV DEF RBRVS 01/01/2024 1944.86 Description: REMOVAL OF BRAIN ABSCESS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 61522 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1524.74 Description: REMOVAL OF BRAIN ABSCESS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 61524 MEDSV DEF RBRVS 01/01/2024 1854.26 Description: REMOVAL OF BRAIN LESION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 61524 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1451.83 Description: REMOVAL OF BRAIN LESION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 61526 MEDSV DEF RBRVS 01/01/2024 3039.39 Description: REMOVAL OF BRAIN LESION Category: Medical Services CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 724 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 61526 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2544.65 Description: REMOVAL OF BRAIN LESION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 61530 MEDSV DEF RBRVS 01/01/2019 12/31/2023 2145.29 Description: REMOVAL OF BRAIN LESION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 61530 MEDSV DEF RBRVS 01/01/2024 2720.56 Description: REMOVAL OF BRAIN LESION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 61531 MEDSV DEF RBRVS 01/01/2024 1098.25 Description: IMPLANT BRAIN ELECTRODES Category: Medical Services CMS Add: 01/01/1993 CMS Term: 61531 MEDSV DEF RBRVS 09/01/2019 12/31/2023 852.48 Description: IMPLANT BRAIN ELECTRODES Category: Medical Services CMS Add: 01/01/1993 CMS Term: 61533 MEDSV DEF RBRVS 01/01/2024 1362.27 Description: IMPLANT BRAIN ELECTRODES Category: Medical Services CMS Add: 01/01/1985 CMS Term: 61533 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1062.15 Description: IMPLANT BRAIN ELECTRODES Category: Medical Services CMS Add: 01/01/1985 CMS Term: 61534 MEDSV DEF RBRVS 01/01/2024 1474.02 Description: REMOVAL OF BRAIN LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61534 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1147.07 Description: REMOVAL OF BRAIN LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61535 MEDSV DEF RBRVS 01/01/2024 902.78 Description: REMOVE BRAIN ELECTRODES Category: Medical Services CMS Add: 01/01/1985 CMS Term: 61535 MEDSV DEF RBRVS 09/01/2019 12/31/2023 697.34 Description: REMOVE BRAIN ELECTRODES Category: Medical Services CMS Add: 01/01/1985 CMS Term: 61536 MEDSV DEF RBRVS 01/01/2024 2286.85 Description: REMOVAL OF BRAIN LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61536 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1798.14 Description: REMOVAL OF BRAIN LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61537 MEDSV DEF RBRVS 01/01/2024 2177.72 Description: REMOVAL OF BRAIN TISSUE Category: Medical Services CMS Add: 01/01/2004 CMS Term: 61537 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1719.67 Description: REMOVAL OF BRAIN TISSUE Category: Medical Services CMS Add: 01/01/2004 CMS Term: 61538 MEDSV DEF RBRVS 01/01/2024 2356.74 Description: REMOVAL OF BRAIN TISSUE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 725 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 61538 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1861.39 Description: REMOVAL OF BRAIN TISSUE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61539 MEDSV DEF RBRVS 01/01/2024 2096.80 Description: REMOVAL OF BRAIN TISSUE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61539 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1645.92 Description: REMOVAL OF BRAIN TISSUE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61540 MEDSV DEF RBRVS 01/01/2024 1934.48 Description: REMOVAL OF BRAIN TISSUE Category: Medical Services CMS Add: 01/01/2004 CMS Term: 61540 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1521.86 Description: REMOVAL OF BRAIN TISSUE Category: Medical Services CMS Add: 01/01/2004 CMS Term: 61541 MEDSV DEF RBRVS 01/01/2024 1912.51 Description: INCISION OF BRAIN TISSUE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 61541 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1497.96 Description: INCISION OF BRAIN TISSUE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 61543 MEDSV DEF RBRVS 01/01/2024 1932.69 Description: REMOVAL OF BRAIN TISSUE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 61543 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1514.35 Description: REMOVAL OF BRAIN TISSUE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 61544 MEDSV DEF RBRVS 01/01/2024 1688.19 Description: REMOVE & TREAT BRAIN LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61544 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1326.38 Description: REMOVE & TREAT BRAIN LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61545 MEDSV DEF RBRVS 01/01/2024 2826.83 Description: EXCISION OF BRAIN TUMOR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61545 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2220.11 Description: EXCISION OF BRAIN TUMOR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61546 MEDSV DEF RBRVS 01/01/2024 2050.69 Description: REMOVAL OF PITUITARY GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61546 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1608.65 Description: REMOVAL OF PITUITARY GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61548 MEDSV DEF RBRVS 01/01/2024 1410.27 Description: REMOVAL OF PITUITARY GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 726 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 61548 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1099.67 Description: REMOVAL OF PITUITARY GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61550 MEDSV DEF RBRVS 01/01/2024 1074.58 Description: RELEASE OF SKULL SEAMS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61550 MEDSV DEF RBRVS 09/01/2019 12/31/2023 650.73 Description: RELEASE OF SKULL SEAMS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61552 MEDSV DEF RBRVS 01/01/2024 1329.47 Description: RELEASE OF SKULL SEAMS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61552 MEDSV DEF RBRVS 09/01/2019 12/31/2023 827.85 Description: RELEASE OF SKULL SEAMS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61556 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1188.06 Description: INCISE SKULL/SUTURES Category: Medical Services CMS Add: 01/01/1991 CMS Term: 61556 MEDSV DEF RBRVS 01/01/2024 1523.56 Description: INCISE SKULL/SUTURES Category: Medical Services CMS Add: 01/01/1991 CMS Term: 61557 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1171.89 Description: INCISE SKULL/SUTURES Category: Medical Services CMS Add: 01/01/1991 CMS Term: 61557 MEDSV DEF RBRVS 01/01/2024 1506.66 Description: INCISE SKULL/SUTURES Category: Medical Services CMS Add: 01/01/1991 CMS Term: 61558 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1180.49 Description: EXCISION OF SKULL/SUTURES Category: Medical Services CMS Add: 01/01/1991 CMS Term: 61558 MEDSV DEF RBRVS 01/01/2024 1677.98 Description: EXCISION OF SKULL/SUTURES Category: Medical Services CMS Add: 01/01/1991 CMS Term: 61559 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1300.80 Description: EXCISION OF SKULL/SUTURES Category: Medical Services CMS Add: 01/01/1991 CMS Term: 61559 MEDSV DEF RBRVS 01/01/2024 2135.47 Description: EXCISION OF SKULL/SUTURES Category: Medical Services CMS Add: 01/01/1991 CMS Term: 61563 MEDSV DEF RBRVS 01/01/2024 1763.51 Description: EXCISION OF SKULL TUMOR Category: Medical Services CMS Add: 01/01/1991 CMS Term: 61563 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1380.42 Description: EXCISION OF SKULL TUMOR Category: Medical Services CMS Add: 01/01/1991 CMS Term: 61564 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1677.60 Description: EXCISION OF SKULL TUMOR Category: Medical Services CMS Add: 01/01/1991 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 727 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 61564 MEDSV DEF RBRVS 01/01/2024 2138.45 Description: EXCISION OF SKULL TUMOR Category: Medical Services CMS Add: 01/01/1991 CMS Term: 61566 MEDSV DEF RBRVS 01/01/2024 1990.61 Description: REMOVAL OF BRAIN TISSUE Category: Medical Services CMS Add: 01/01/2004 CMS Term: 61566 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1567.02 Description: REMOVAL OF BRAIN TISSUE Category: Medical Services CMS Add: 01/01/2004 CMS Term: 61567 MEDSV DEF RBRVS 01/01/2024 2267.03 Description: INCISION OF BRAIN TISSUE Category: Medical Services CMS Add: 01/01/2004 CMS Term: 61567 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1786.88 Description: INCISION OF BRAIN TISSUE Category: Medical Services CMS Add: 01/01/2004 CMS Term: 61570 MEDSV DEF RBRVS 01/01/2024 1667.51 Description: REMOVE FOREIGN BODY BRAIN Category: Medical Services CMS Add: 01/01/1985 CMS Term: 61570 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1301.89 Description: REMOVE FOREIGN BODY BRAIN Category: Medical Services CMS Add: 01/01/1985 CMS Term: 61571 MEDSV DEF RBRVS 01/01/2024 1772.71 Description: INCISE SKULL FOR BRAIN WOUND Category: Medical Services CMS Add: 01/01/1985 CMS Term: 61571 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1386.49 Description: INCISE SKULL FOR BRAIN WOUND Category: Medical Services CMS Add: 01/01/1985 CMS Term: 61575 MEDSV DEF RBRVS 01/01/2024 2222.84 Description: SKULL BASE/BRAINSTEM SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61575 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1682.83 Description: SKULL BASE/BRAINSTEM SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61576 MEDSV DEF RBRVS 01/01/2024 3721.62 Description: SKULL BASE/BRAINSTEM SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61576 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2502.62 Description: SKULL BASE/BRAINSTEM SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61580 MEDSV DEF RBRVS 01/01/2024 2306.24 Description: CRANIOFACIAL APPROACH SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61580 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1789.61 Description: CRANIOFACIAL APPROACH SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61581 MEDSV DEF RBRVS 01/01/2024 2558.36 Description: CRANIOFACIAL APPROACH SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 728 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 61581 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1952.62 Description: CRANIOFACIAL APPROACH SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61582 MEDSV DEF RBRVS 01/01/2024 2835.60 Description: CRANIOFACIAL APPROACH SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61582 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2056.37 Description: CRANIOFACIAL APPROACH SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61583 MEDSV DEF RBRVS 01/01/2024 2631.96 Description: CRANIOFACIAL APPROACH SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61583 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2034.44 Description: CRANIOFACIAL APPROACH SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61584 MEDSV DEF RBRVS 01/01/2024 2603.57 Description: ORBITOCRANIAL APPROACH/SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61584 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1999.40 Description: ORBITOCRANIAL APPROACH/SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61585 MEDSV DEF RBRVS 01/01/2024 2934.39 Description: ORBITOCRANIAL APPROACH/SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61585 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2258.58 Description: ORBITOCRANIAL APPROACH/SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61586 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1708.03 Description: RESECT NASOPHARYNX SKULL Category: Medical Services CMS Add: 01/01/1997 CMS Term: 61586 MEDSV DEF RBRVS 01/01/2024 2287.65 Description: RESECT NASOPHARYNX SKULL Category: Medical Services CMS Add: 01/01/1997 CMS Term: 61590 MEDSV DEF RBRVS 01/01/2024 2810.62 Description: INFRATEMPORAL APPROACH/SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61590 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2203.40 Description: INFRATEMPORAL APPROACH/SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61591 MEDSV DEF RBRVS 01/01/2024 2840.37 Description: INFRATEMPORAL APPROACH/SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61591 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2228.72 Description: INFRATEMPORAL APPROACH/SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61592 MEDSV DEF RBRVS 01/01/2024 2840.66 Description: ORBITOCRANIAL APPROACH/SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 729 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 61592 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2225.29 Description: ORBITOCRANIAL APPROACH/SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61595 MEDSV DEF RBRVS 01/01/2024 2194.85 Description: TRANSTEMPORAL APPROACH/SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61595 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1697.76 Description: TRANSTEMPORAL APPROACH/SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61596 MEDSV DEF RBRVS 01/01/2024 2294.10 Description: TRANSCOCHLEAR APPROACH/SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61596 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1794.80 Description: TRANSCOCHLEAR APPROACH/SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61597 MEDSV DEF RBRVS 01/01/2024 2648.57 Description: TRANSCONDYLAR APPROACH/SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61597 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1988.53 Description: TRANSCONDYLAR APPROACH/SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61598 MEDSV DEF RBRVS 01/01/2024 2555.38 Description: TRANSPETROSAL APPROACH/SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61598 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1978.37 Description: TRANSPETROSAL APPROACH/SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61600 MEDSV DEF RBRVS 01/01/2024 1974.49 Description: RESECT/EXCISE CRANIAL LESION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61600 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1536.27 Description: RESECT/EXCISE CRANIAL LESION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61601 MEDSV DEF RBRVS 01/01/2024 2188.45 Description: RESECT/EXCISE CRANIAL LESION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61601 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1692.00 Description: RESECT/EXCISE CRANIAL LESION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61605 MEDSV DEF RBRVS 01/01/2024 2033.82 Description: RESECT/EXCISE CRANIAL LESION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61605 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1585.63 Description: RESECT/EXCISE CRANIAL LESION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61606 MEDSV DEF RBRVS 01/01/2024 2636.95 Description: RESECT/EXCISE CRANIAL LESION Category: Medical Services CMS Add: 01/01/1994 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 730 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 61606 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2107.61 Description: RESECT/EXCISE CRANIAL LESION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61607 MEDSV DEF RBRVS 01/01/2024 2444.39 Description: RESECT/EXCISE CRANIAL LESION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61607 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2016.26 Description: RESECT/EXCISE CRANIAL LESION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61608 MEDSV DEF RBRVS 01/01/2024 2930.47 Description: RESECT/EXCISE CRANIAL LESION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61608 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2270.67 Description: RESECT/EXCISE CRANIAL LESION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61611 MEDSV DEF RBRVS 01/01/2019 12/31/2023 292.81 Description: TRANSECT ARTERY SINUS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61611 MEDSV DEF RBRVS 01/01/2024 409.60 Description: TRANSECT ARTERY SINUS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61613 MEDSV DEF RBRVS 01/01/2024 2929.05 Description: REMOVE ANEURYSM SINUS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61613 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2289.42 Description: REMOVE ANEURYSM SINUS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61615 MEDSV DEF RBRVS 01/01/2024 2522.79 Description: RESECT/EXCISE LESION SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61615 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1650.80 Description: RESECT/EXCISE LESION SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61616 MEDSV DEF RBRVS 01/01/2024 3003.35 Description: RESECT/EXCISE LESION SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61616 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2341.54 Description: RESECT/EXCISE LESION SKULL Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61618 MEDSV DEF RBRVS 01/01/2024 1166.37 Description: REPAIR DURA Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61618 MEDSV DEF RBRVS 09/01/2019 12/31/2023 918.19 Description: REPAIR DURA Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61619 MEDSV DEF RBRVS 01/01/2024 1306.37 Description: REPAIR DURA Category: Medical Services CMS Add: 01/01/1994 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 731 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 61619 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1047.22 Description: REPAIR DURA Category: Medical Services CMS Add: 01/01/1994 CMS Term: 61623 MEDSV DEF RBRVS 01/01/2024 516.47 Description: ENDOVASC TEMPORY VESSEL OCCL Category: Medical Services CMS Add: 01/01/2003 CMS Term: 61623 MEDSV DEF RBRVS 02/01/2015 12/31/2023 400.61 Description: ENDOVASC TEMPORY VESSEL OCCL Category: Medical Services CMS Add: 01/01/2003 CMS Term: 61624 MEDSV DEF RBRVS 01/01/2024 1037.75 Description: TRANSCATH OCCLUSION CNS Category: Medical Services CMS Add: 01/01/1992 CMS Term: 61624 MEDSV DEF RBRVS 09/01/2019 12/31/2023 799.87 Description: TRANSCATH OCCLUSION CNS Category: Medical Services CMS Add: 01/01/1992 CMS Term: 61626 MEDSV DEF RBRVS 01/01/2024 816.32 Description: TRANSCATH OCCLUSION NON-CNS Category: Medical Services CMS Add: 01/01/1992 CMS Term: 61626 MEDSV DEF RBRVS 09/01/2019 12/31/2023 629.24 Description: TRANSCATH OCCLUSION NON-CNS Category: Medical Services CMS Add: 01/01/1992 CMS Term: 61630 NOCOV DEF SYSMAN Description: INTRACRANIAL ANGIOPLASTY Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 61635 MEDSV DEF RBRVS 01/01/2024 1332.56 Y Description: INTRACRAN ANGIOPLSTY W/STENT Category: Medical Services CMS Add: 01/01/2006 CMS Term: 61635 MEDSV DEF RBRVS 04/01/2017 12/31/2023 1037.83 Y Description: INTRACRAN ANGIOPLSTY W/STENT Category: Medical Services CMS Add: 01/01/2006 CMS Term: 61640 NOCOV DEF SYSMAN Description: DILATE IC VASOSPASM INIT Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 61641 NOCOV DEF SYSMAN Description: DILAT IC VSPSM EA VSL SM TER Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 61642 NOCOV DEF SYSMAN Description: DILAT IC VSPSM EA DIFF TER Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 61645 MEDSV DEF RBRVS 01/01/2024 758.23 Description: PERQ ART M-THROMBECT &/NFS Category: Medical Services CMS Add: 01/01/2016 CMS Term: 61645 MEDSV DEF RBRVS 04/13/2018 12/31/2023 598.32 Description: PERQ ART M-THROMBECT &/NFS Category: Medical Services CMS Add: 01/01/2016 CMS Term: 61650 MEDSV DEF RBRVS 01/01/2016 12/31/2023 385.78 Description: EVASC PRLNG ADMN RX AGNT 1ST Category: Medical Services CMS Add: 01/01/2016 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 732 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 61650 MEDSV DEF RBRVS 01/01/2024 512.61 Description: EVASC PRLNG ADMN RX AGNT 1ST Category: Medical Services CMS Add: 01/01/2016 CMS Term: 61651 MEDSV DEF RBRVS 01/01/2024 219.60 Description: EVASC PRLNG ADMN RX AGNT ADD Category: Medical Services CMS Add: 01/01/2016 CMS Term: 61651 MEDSV DEF RBRVS 09/01/2019 12/31/2023 164.23 Description: EVASC PRLNG ADMN RX AGNT ADD Category: Medical Services CMS Add: 01/01/2016 CMS Term: 61680 MEDSV DEF RBRVS 01/01/2024 1992.27 Description: INTRACRANIAL VESSEL SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61680 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1571.36 Description: INTRACRANIAL VESSEL SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61682 MEDSV DEF RBRVS 01/01/2024 3669.71 Description: INTRACRANIAL VESSEL SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61682 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2915.99 Description: INTRACRANIAL VESSEL SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61684 MEDSV DEF RBRVS 01/01/2024 2519.99 Description: INTRACRANIAL VESSEL SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61684 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1983.32 Description: INTRACRANIAL VESSEL SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61686 MEDSV DEF RBRVS 01/01/2024 3964.78 Description: INTRACRANIAL VESSEL SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61686 MEDSV DEF RBRVS 09/01/2019 12/31/2023 3138.60 Description: INTRACRANIAL VESSEL SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61690 MEDSV DEF RBRVS 01/01/2024 1938.34 Description: INTRACRANIAL VESSEL SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61690 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1524.32 Description: INTRACRANIAL VESSEL SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61692 MEDSV DEF RBRVS 01/01/2024 3224.54 Description: INTRACRANIAL VESSEL SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61692 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2553.15 Description: INTRACRANIAL VESSEL SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61697 MEDSV DEF RBRVS 01/01/2024 3734.36 Description: BRAIN ANEURYSM REPR COMPLX Category: Medical Services CMS Add: 01/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 733 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 61697 MEDSV DEF RBRVS 02/01/2015 12/31/2023 2947.34 Description: BRAIN ANEURYSM REPR COMPLX Category: Medical Services CMS Add: 01/01/2001 CMS Term: 61698 MEDSV DEF RBRVS 01/01/2024 4082.61 Description: BRAIN ANEURYSM REPR COMPLX Category: Medical Services CMS Add: 01/01/2001 CMS Term: 61698 MEDSV DEF RBRVS 02/01/2015 12/31/2023 3232.74 Description: BRAIN ANEURYSM REPR COMPLX Category: Medical Services CMS Add: 01/01/2001 CMS Term: 61700 MEDSV DEF RBRVS 01/01/2024 3007.92 Description: BRAIN ANEURYSM REPR SIMPLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61700 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2384.55 Description: BRAIN ANEURYSM REPR SIMPLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61702 MEDSV DEF RBRVS 01/01/2024 3552.54 Description: INNER SKULL VESSEL SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61702 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2808.34 Description: INNER SKULL VESSEL SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61703 MEDSV DEF RBRVS 01/01/2024 1214.92 Description: CLAMP NECK ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61703 MEDSV DEF RBRVS 09/01/2019 12/31/2023 947.50 Description: CLAMP NECK ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61705 MEDSV DEF RBRVS 01/01/2024 2308.00 Description: REVISE CIRCULATION TO HEAD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61705 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1814.95 Description: REVISE CIRCULATION TO HEAD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61708 MEDSV DEF RBRVS 01/01/2024 2257.97 Description: REVISE CIRCULATION TO HEAD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61708 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1445.04 Description: REVISE CIRCULATION TO HEAD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61710 MEDSV DEF RBRVS 01/01/2024 1905.47 Description: REVISE CIRCULATION TO HEAD Category: Medical Services CMS Add: 01/01/1982 CMS Term: 61710 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1425.58 Description: REVISE CIRCULATION TO HEAD Category: Medical Services CMS Add: 01/01/1982 CMS Term: 61711 MEDSV DEF RBRVS 01/01/2024 2288.42 Description: FUSION OF SKULL ARTERIES Category: Medical Services CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 734 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 61711 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1818.61 Description: FUSION OF SKULL ARTERIES Category: Medical Services CMS Add: 01/01/1982 CMS Term: 61720 MEDSV DEF RBRVS 01/01/2024 1136.65 Description: INCISE SKULL/BRAIN SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61720 MEDSV DEF RBRVS 09/01/2019 12/31/2023 885.48 Description: INCISE SKULL/BRAIN SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61735 MEDSV DEF RBRVS 01/01/2024 1424.16 Description: INCISE SKULL/BRAIN SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61735 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1108.45 Description: INCISE SKULL/BRAIN SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61736 MEDSV DEF RBRVS 01/01/2022 12/31/2023 683.94 Description: LITT ICR 1 TRAJ 1 SMPL LES Category: Medical Services CMS Add: 01/01/2022 CMS Term: 61736 MEDSV DEF RBRVS 01/01/2024 842.06 Description: LITT ICR 1 TRAJ 1 SMPL LES Category: Medical Services CMS Add: 01/01/2022 CMS Term: 61737 MEDSV DEF RBRVS 01/01/2022 12/31/2023 813.63 Description: LITT ICR MLT TRJ MLT/CPLX LS Category: Medical Services CMS Add: 01/01/2022 CMS Term: 61737 MEDSV DEF RBRVS 01/01/2024 1002.45 Description: LITT ICR MLT TRJ MLT/CPLX LS Category: Medical Services CMS Add: 01/01/2022 CMS Term: 61750 MEDSV DEF RBRVS 01/01/2024 1256.08 Description: INCISE SKULL/BRAIN BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61750 MEDSV DEF RBRVS 09/01/2019 12/31/2023 981.20 Description: INCISE SKULL/BRAIN BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61751 MEDSV DEF RBRVS 01/01/2024 1241.27 Description: BRAIN BIOPSY W/CT/MR GUIDE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61751 MEDSV DEF RBRVS 09/01/2019 12/31/2023 959.28 Description: BRAIN BIOPSY W/CT/MR GUIDE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61760 MEDSV DEF RBRVS 01/01/2024 1414.72 Description: IMPLANT BRAIN ELECTRODES Category: Medical Services CMS Add: 01/01/1993 CMS Term: 61760 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1101.76 Description: IMPLANT BRAIN ELECTRODES Category: Medical Services CMS Add: 01/01/1993 CMS Term: 61770 MEDSV DEF RBRVS 01/01/2024 1444.35 Description: INCISE SKULL FOR TREATMENT Category: Medical Services CMS Add: 01/01/1988 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 735 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 61770 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1129.94 Description: INCISE SKULL FOR TREATMENT Category: Medical Services CMS Add: 01/01/1988 CMS Term: 61781 MEDSV DEF RBRVS 01/01/2024 206.95 Description: SCAN PROC CRANIAL INTRA Category: Medical Services CMS Add: 01/01/2011 CMS Term: 61781 MEDSV DEF RBRVS 02/01/2015 12/31/2023 164.18 Description: SCAN PROC CRANIAL INTRA Category: Medical Services CMS Add: 01/01/2011 CMS Term: 61782 MEDSV DEF RBRVS 01/01/2024 161.47 Description: SCAN PROC CRANIAL EXTRA Category: Medical Services CMS Add: 01/01/2011 CMS Term: 61782 MEDSV DEF RBRVS 02/01/2015 12/31/2023 136.06 Description: SCAN PROC CRANIAL EXTRA Category: Medical Services CMS Add: 01/01/2011 CMS Term: 61783 MEDSV DEF RBRVS 01/01/2024 205.13 Description: SCAN PROC SPINAL Category: Medical Services CMS Add: 01/01/2011 CMS Term: 61783 MEDSV DEF RBRVS 02/01/2015 12/31/2023 164.67 Description: SCAN PROC SPINAL Category: Medical Services CMS Add: 01/01/2011 CMS Term: 61790 MEDSV DEF RBRVS 01/01/2024 793.93 Description: TREAT TRIGEMINAL NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61790 MEDSV DEF RBRVS 09/01/2019 12/31/2023 610.52 Description: TREAT TRIGEMINAL NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61791 MEDSV DEF RBRVS 01/01/2024 1008.99 Description: TREAT TRIGEMINAL TRACT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61791 MEDSV DEF RBRVS 09/01/2019 12/31/2023 778.79 Description: TREAT TRIGEMINAL TRACT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 61796 MEDSV DEF RBRVS 01/01/2024 911.03 Description: SRS CRANIAL LESION SIMPLE Category: Medical Services CMS Add: 01/01/2009 CMS Term: 61796 MEDSV DEF RBRVS 02/01/2015 12/31/2023 702.85 Description: SRS CRANIAL LESION SIMPLE Category: Medical Services CMS Add: 01/01/2009 CMS Term: 61797 MEDSV DEF RBRVS 01/01/2024 191.86 Description: SRS CRAN LES SIMPLE ADDL Category: Medical Services CMS Add: 01/01/2009 CMS Term: 61797 MEDSV DEF RBRVS 02/01/2015 12/31/2023 152.71 Description: SRS CRAN LES SIMPLE ADDL Category: Medical Services CMS Add: 01/01/2009 CMS Term: 61798 MEDSV DEF RBRVS 01/01/2024 1231.04 Description: SRS CRANIAL LESION COMPLEX Category: Medical Services CMS Add: 01/01/2009 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 736 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 61798 MEDSV DEF RBRVS 02/01/2015 12/31/2023 960.10 Description: SRS CRANIAL LESION COMPLEX Category: Medical Services CMS Add: 01/01/2009 CMS Term: 61799 MEDSV DEF RBRVS 01/01/2024 265.38 Description: SRS CRAN LES COMPLEX ADDL Category: Medical Services CMS Add: 01/01/2009 CMS Term: 61799 MEDSV DEF RBRVS 02/01/2015 12/31/2023 210.58 Description: SRS CRAN LES COMPLEX ADDL Category: Medical Services CMS Add: 01/01/2009 CMS Term: 61800 MEDSV DEF RBRVS 01/01/2024 132.88 Description: APPLY SRS HEADFRAME ADD-ON Category: Medical Services CMS Add: 01/01/2009 CMS Term: 61800 MEDSV DEF RBRVS 02/01/2015 12/31/2023 106.95 Description: APPLY SRS HEADFRAME ADD-ON Category: Medical Services CMS Add: 01/01/2009 CMS Term: 61850 MEDSV DEF RBRVS 01/01/2024 883.65 Y Description: IMPLANT NEUROELECTRODES Category: Medical Services CMS Add: 01/01/1982 CMS Term: 61850 MEDSV DEF RBRVS 09/01/2019 12/31/2023 684.69 Y Description: IMPLANT NEUROELECTRODES Category: Medical Services CMS Add: 01/01/1982 CMS Term: 61860 MEDSV DEF RBRVS 01/01/2024 1393.30 Y Description: IMPLANT NEUROELECTRODES Category: Medical Services CMS Add: 01/01/1982 CMS Term: 61860 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1090.92 Y Description: IMPLANT NEUROELECTRODES Category: Medical Services CMS Add: 01/01/1982 CMS Term: 61863 MEDSV DEF RBRVS 01/01/2024 1344.51 Y Description: IMPLANT NEUROELECTRODE Category: Medical Services CMS Add: 01/01/2004 CMS Term: 61863 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1048.94 Y Description: IMPLANT NEUROELECTRODE Category: Medical Services CMS Add: 01/01/2004 CMS Term: 61864 MEDSV DEF RBRVS 01/01/2016 12/31/2023 198.59 Y Description: IMPLANT NEUROELECTRDE ADDL Category: Medical Services CMS Add: 01/01/2004 CMS Term: 61864 MEDSV DEF RBRVS 01/01/2024 247.81 Y Description: IMPLANT NEUROELECTRDE ADDL Category: Medical Services CMS Add: 01/01/2004 CMS Term: 61867 MEDSV DEF RBRVS 01/01/2024 2026.18 Y Description: IMPLANT NEUROELECTRODE Category: Medical Services CMS Add: 01/01/2004 CMS Term: 61867 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1591.28 Y Description: IMPLANT NEUROELECTRODE Category: Medical Services CMS Add: 01/01/2004 CMS Term: 61868 MEDSV DEF RBRVS 01/01/2016 12/31/2023 349.61 Y Description: IMPLANT NEUROELECTRDE ADDL Category: Medical Services CMS Add: 01/01/2004 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 737 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 61868 MEDSV DEF RBRVS 01/01/2024 437.01 Y Description: IMPLANT NEUROELECTRDE ADDL Category: Medical Services CMS Add: 01/01/2004 CMS Term: 61880 MEDSV DEF RBRVS 01/01/2024 529.88 Description: REVISE/REMOVE NEUROELECTRODE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 61880 MEDSV DEF RBRVS 09/01/2019 12/31/2023 399.70 Description: REVISE/REMOVE NEUROELECTRODE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 61885 MEDSV DEF RBRVS 01/01/2024 477.16 Y Description: INSRT/REDO NEUROSTIM 1 ARRAY Category: Medical Services CMS Add: 01/01/1982 CMS Term: 61885 MEDSV DEF RBRVS 02/01/2015 12/31/2023 362.47 Y Description: INSRT/REDO NEUROSTIM 1 ARRAY Category: Medical Services CMS Add: 01/01/1982 CMS Term: 61886 MEDSV DEF RBRVS 01/01/2024 792.79 Y 0-1 Description: IMPLANT NEUROSTIM ARRAYS Category: Medical Services CMS Add: 01/01/2000 CMS Term: 61886 MEDSV DEF RBRVS 02/01/2015 12/31/2023 591.00 Y 0-1 Description: IMPLANT NEUROSTIM ARRAYS Category: Medical Services CMS Add: 01/01/2000 CMS Term: 61888 MEDSV DEF RBRVS 01/01/2024 358.25 Description: REVISE/REMOVE NEURORECEIVER Category: Medical Services CMS Add: 01/01/1982 CMS Term: 61888 MEDSV DEF RBRVS 09/01/2019 12/31/2023 274.38 Description: REVISE/REMOVE NEURORECEIVER Category: Medical Services CMS Add: 01/01/1982 CMS Term: 61889 MEDSV DEF RBRVS 01/01/2024 1204.42 Description: INS SK-MNT CRNL NSTM PG/RCVR Category: Medical Services CMS Add: 01/01/2024 CMS Term: 61891 MEDSV DEF RBRVS 01/01/2024 569.21 Description: REV/RPLCMT SK-MNT CRNL NSTM Category: Medical Services CMS Add: 01/01/2024 CMS Term: 61892 MEDSV DEF RBRVS 01/01/2024 788.71 Description: RMV SK-MNT CRNL NSTM PG/RCVR Category: Medical Services CMS Add: 01/01/2024 CMS Term: 62000 MEDSV DEF RBRVS 01/01/2024 927.42 Description: TREAT SKULL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62000 MEDSV DEF RBRVS 09/01/2019 12/31/2023 718.71 Description: TREAT SKULL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62005 MEDSV DEF RBRVS 01/01/2024 1137.46 Description: TREAT SKULL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62005 MEDSV DEF RBRVS 09/01/2019 12/31/2023 886.00 Description: TREAT SKULL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 738 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 62010 MEDSV DEF RBRVS 01/01/2024 1372.97 Description: TREATMENT OF HEAD INJURY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62010 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1067.79 Description: TREATMENT OF HEAD INJURY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62100 MEDSV DEF RBRVS 01/01/2024 1420.13 Description: REPAIR BRAIN FLUID LEAKAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62100 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1131.06 Description: REPAIR BRAIN FLUID LEAKAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62115 MEDSV DEF RBRVS 01/01/2019 12/31/2023 932.94 Description: REDUCTION OF SKULL DEFECT Category: Medical Services CMS Add: 01/01/1991 CMS Term: 62115 MEDSV DEF RBRVS 01/01/2024 1507.80 Description: REDUCTION OF SKULL DEFECT Category: Medical Services CMS Add: 01/01/1991 CMS Term: 62117 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1144.02 Description: REDUCTION OF SKULL DEFECT Category: Medical Services CMS Add: 01/01/1991 CMS Term: 62117 MEDSV DEF RBRVS 01/01/2024 1747.79 Description: REDUCTION OF SKULL DEFECT Category: Medical Services CMS Add: 01/01/1991 CMS Term: 62120 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1216.81 Description: REPAIR SKULL CAVITY LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62120 MEDSV DEF RBRVS 01/01/2024 1868.03 Description: REPAIR SKULL CAVITY LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62121 MEDSV DEF RBRVS 01/01/2024 1435.41 Description: INCISE SKULL REPAIR Category: Medical Services CMS Add: 01/01/1991 CMS Term: 62121 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1191.12 Description: INCISE SKULL REPAIR Category: Medical Services CMS Add: 01/01/1991 CMS Term: 62140 MEDSV DEF RBRVS 01/01/2024 924.02 Description: CRNOP SKULL DEFECT<5 CM DIAM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62140 MEDSV DEF RBRVS 09/01/2019 12/31/2023 728.76 Description: CRNOP SKULL DEFECT<5 CM DIAM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62141 MEDSV DEF RBRVS 01/01/2024 1027.70 Description: CRNOP SKULL DEFECT>5 CM DIAM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62141 MEDSV DEF RBRVS 09/01/2019 12/31/2023 801.31 Description: CRNOP SKULL DEFECT>5 CM DIAM Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 739 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 62142 MEDSV DEF RBRVS 01/01/2024 803.02 Description: RMVL B1 FLP/PROSTC PLATE SKL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62142 MEDSV DEF RBRVS 09/01/2019 12/31/2023 621.57 Description: RMVL B1 FLP/PROSTC PLATE SKL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62143 MEDSV DEF RBRVS 01/01/2024 938.07 Description: RPL B1 FLP/PROSTC PLATE SKL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62143 MEDSV DEF RBRVS 09/01/2019 12/31/2023 727.84 Description: RPL B1 FLP/PROSTC PLATE SKL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62145 MEDSV DEF RBRVS 01/01/2024 1264.88 Description: REPAIR OF SKULL & BRAIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62145 MEDSV DEF RBRVS 09/01/2019 12/31/2023 992.89 Description: REPAIR OF SKULL & BRAIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62146 MEDSV DEF RBRVS 01/01/2024 1117.93 Description: CRNOP W/AUTOGRAFT<5 CM DIAM Category: Medical Services CMS Add: 01/01/1991 CMS Term: 62146 MEDSV DEF RBRVS 09/01/2019 12/31/2023 870.57 Description: CRNOP W/AUTOGRAFT<5 CM DIAM Category: Medical Services CMS Add: 01/01/1991 CMS Term: 62147 MEDSV DEF RBRVS 01/01/2024 1273.50 Description: CRNOP W/AUTOGRAFT>5 CM DIAM Category: Medical Services CMS Add: 01/01/1991 CMS Term: 62147 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1015.66 Description: CRNOP W/AUTOGRAFT>5 CM DIAM Category: Medical Services CMS Add: 01/01/1991 CMS Term: 62148 MEDSV DEF RBRVS 01/01/2024 110.29 Description: RETR BONE FLAP TO FIX SKULL Category: Medical Services CMS Add: 01/01/2003 CMS Term: 62148 MEDSV DEF RBRVS 02/01/2015 12/31/2023 88.50 Description: RETR BONE FLAP TO FIX SKULL Category: Medical Services CMS Add: 01/01/2003 CMS Term: 62160 MEDSV DEF RBRVS 01/01/2024 165.12 Description: NEUROENDOSCOPY ADD-ON Category: Medical Services CMS Add: 01/01/2003 CMS Term: 62160 MEDSV DEF RBRVS 02/01/2015 12/31/2023 132.80 Description: NEUROENDOSCOPY ADD-ON Category: Medical Services CMS Add: 01/01/2003 CMS Term: 62161 MEDSV DEF RBRVS 01/01/2024 1358.22 Description: DISSECT BRAIN W/SCOPE Category: Medical Services CMS Add: 01/01/2003 CMS Term: 62161 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1058.45 Description: DISSECT BRAIN W/SCOPE Category: Medical Services CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 740 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 62162 MEDSV DEF RBRVS 01/01/2024 1682.96 Description: REMOVE COLLOID CYST W/SCOPE Category: Medical Services CMS Add: 01/01/2003 CMS Term: 62162 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1317.77 Description: REMOVE COLLOID CYST W/SCOPE Category: Medical Services CMS Add: 01/01/2003 CMS Term: 62164 MEDSV DEF RBRVS 01/01/2024 1866.48 Description: REMOVE BRAIN TUMOR W/SCOPE Category: Medical Services CMS Add: 01/01/2003 CMS Term: 62164 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1456.89 Description: REMOVE BRAIN TUMOR W/SCOPE Category: Medical Services CMS Add: 01/01/2003 CMS Term: 62165 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1097.56 Description: REMOVE PITUIT TUMOR W/SCOPE Category: Medical Services CMS Add: 01/01/2003 CMS Term: 62165 MEDSV DEF RBRVS 01/01/2024 1383.85 Description: REMOVE PITUIT TUMOR W/SCOPE Category: Medical Services CMS Add: 01/01/2003 CMS Term: 62180 MEDSV DEF RBRVS 01/01/2024 1425.99 Description: ESTABLISH BRAIN CAVITY SHUNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62180 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1116.36 Description: ESTABLISH BRAIN CAVITY SHUNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62190 MEDSV DEF RBRVS 01/01/2024 835.20 Description: ESTABLISH BRAIN CAVITY SHUNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62190 MEDSV DEF RBRVS 09/01/2019 12/31/2023 644.50 Description: ESTABLISH BRAIN CAVITY SHUNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62192 MEDSV DEF RBRVS 01/01/2024 877.29 Description: ESTABLISH BRAIN CAVITY SHUNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62192 MEDSV DEF RBRVS 09/01/2019 12/31/2023 681.57 Description: ESTABLISH BRAIN CAVITY SHUNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62194 MEDSV DEF RBRVS 01/01/2024 447.01 Description: REPLACE/IRRIGATE CATHETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62194 MEDSV DEF RBRVS 09/01/2019 12/31/2023 313.75 Description: REPLACE/IRRIGATE CATHETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62200 MEDSV DEF RBRVS 01/01/2024 1228.88 Description: ESTABLISH BRAIN CAVITY SHUNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62200 MEDSV DEF RBRVS 09/01/2019 12/31/2023 959.51 Description: ESTABLISH BRAIN CAVITY SHUNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 741 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 62201 MEDSV DEF RBRVS 01/01/2024 1091.33 Description: BRAIN CAVITY SHUNT W/SCOPE Category: Medical Services CMS Add: 01/01/1990 CMS Term: 62201 MEDSV DEF RBRVS 09/01/2019 12/31/2023 838.82 Description: BRAIN CAVITY SHUNT W/SCOPE Category: Medical Services CMS Add: 01/01/1990 CMS Term: 62220 MEDSV DEF RBRVS 01/01/2024 870.48 Description: ESTABLISH BRAIN CAVITY SHUNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62220 MEDSV DEF RBRVS 09/01/2019 12/31/2023 713.53 Description: ESTABLISH BRAIN CAVITY SHUNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62223 MEDSV DEF RBRVS 01/01/2024 934.85 Description: ESTABLISH BRAIN CAVITY SHUNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62223 MEDSV DEF RBRVS 09/01/2019 12/31/2023 737.04 Description: ESTABLISH BRAIN CAVITY SHUNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62225 MEDSV DEF RBRVS 01/01/2024 484.60 Description: REPLACE/IRRIGATE CATHETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62225 MEDSV DEF RBRVS 09/01/2019 12/31/2023 365.49 Description: REPLACE/IRRIGATE CATHETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62230 MEDSV DEF RBRVS 01/01/2024 756.49 Description: REPLACE/REVISE BRAIN SHUNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62230 MEDSV DEF RBRVS 09/01/2019 12/31/2023 589.35 Description: REPLACE/REVISE BRAIN SHUNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62252 26 MEDSV DEF RBRVS 01/01/2024 40.54 Description: CSF SHUNT REPROGRAM Category: Medical Services CMS Add: 01/01/2001 CMS Term: 62252 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 32.35 Description: CSF SHUNT REPROGRAM Category: Medical Services CMS Add: 01/01/2001 CMS Term: 62252 MEDSV DEF RBRVS 01/01/2024 75.89 Description: CSF SHUNT REPROGRAM Category: Medical Services CMS Add: 01/01/2001 CMS Term: 62252 MEDSV DEF RBRVS 02/01/2015 12/31/2023 59.27 Description: CSF SHUNT REPROGRAM Category: Medical Services CMS Add: 01/01/2001 CMS Term: 62252 TC MEDSV DEF RBRVS 01/01/2024 35.35 Description: CSF SHUNT REPROGRAM Category: Medical Services CMS Add: 01/01/2001 CMS Term: 62252 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 26.92 Description: CSF SHUNT REPROGRAM Category: Medical Services CMS Add: 01/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 742 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 62256 MEDSV DEF RBRVS 01/01/2024 550.86 Description: REMOVE BRAIN CAVITY SHUNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62256 MEDSV DEF RBRVS 09/01/2019 12/31/2023 419.02 Description: REMOVE BRAIN CAVITY SHUNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62258 MEDSV DEF RBRVS 01/01/2024 999.14 Description: REPLACE BRAIN CAVITY SHUNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62258 MEDSV DEF RBRVS 09/01/2019 12/31/2023 787.61 Description: REPLACE BRAIN CAVITY SHUNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62263 MEDSV DEF RBRVS 01/01/2024 598.09 0-1 Description: EPIDURAL LYSIS MULT SESSIONS Category: Medical Services CMS Add: 01/01/2000 CMS Term: 62263 MEDSV DEF RBRVS 02/01/2015 12/31/2023 492.12 0-1 Description: EPIDURAL LYSIS MULT SESSIONS Category: Medical Services CMS Add: 01/01/2000 CMS Term: 62264 MEDSV DEF RBRVS 01/01/2024 413.71 0-1 Description: EPIDURAL LYSIS ON SINGLE DAY Category: Medical Services CMS Add: 01/01/2003 CMS Term: 62264 MEDSV DEF RBRVS 02/01/2015 12/31/2023 303.30 0-1 Description: EPIDURAL LYSIS ON SINGLE DAY Category: Medical Services CMS Add: 01/01/2003 CMS Term: 62267 MEDSV DEF RBRVS 01/01/2024 252.04 Description: INTERDISCAL PERQ ASPIR DX Category: Medical Services CMS Add: 01/01/2009 CMS Term: 62267 MEDSV DEF RBRVS 02/01/2015 12/31/2023 179.03 Description: INTERDISCAL PERQ ASPIR DX Category: Medical Services CMS Add: 01/01/2009 CMS Term: 62268 MEDSV DEF RBRVS 01/01/2024 240.12 Description: DRAIN SPINAL CORD CYST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62268 MEDSV DEF RBRVS 09/01/2019 12/31/2023 192.89 Description: DRAIN SPINAL CORD CYST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62269 MEDSV DEF RBRVS 01/01/2024 246.01 Description: NEEDLE BIOPSY SPINAL CORD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62269 MEDSV DEF RBRVS 09/01/2019 12/31/2023 197.28 Description: NEEDLE BIOPSY SPINAL CORD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62270 MEDSV DEF RBRVS 01/01/2024 123.15 Description: DX LMBR SPI PNXR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62270 MEDSV DEF RBRVS 09/01/2019 12/31/2023 113.27 Description: DX LMBR SPI PNXR Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 743 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 62272 MEDSV DEF RBRVS 01/01/2024 163.57 Description: THER SPI PNXR DRG CSF Category: Medical Services CMS Add: 01/01/1985 CMS Term: 62272 MEDSV DEF RBRVS 09/01/2019 12/31/2023 142.38 Description: THER SPI PNXR DRG CSF Category: Medical Services CMS Add: 01/01/1985 CMS Term: 62273 MEDSV DEF RBRVS 01/01/2024 158.82 Description: INJECT EPIDURAL PATCH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62273 MEDSV DEF RBRVS 09/01/2019 12/31/2023 125.06 Description: INJECT EPIDURAL PATCH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62280 MEDSV DEF RBRVS 01/01/2024 306.17 Description: TREAT SPINAL CORD LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62280 MEDSV DEF RBRVS 09/01/2019 12/31/2023 226.23 Description: TREAT SPINAL CORD LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62281 MEDSV DEF RBRVS 01/01/2024 226.60 Description: TREAT SPINAL CORD LESION Category: Medical Services CMS Add: 01/01/1992 CMS Term: 62281 MEDSV DEF RBRVS 09/01/2019 12/31/2023 174.60 Description: TREAT SPINAL CORD LESION Category: Medical Services CMS Add: 01/01/1992 CMS Term: 62282 MEDSV DEF RBRVS 01/01/2024 294.57 Description: TREAT SPINAL CANAL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62282 MEDSV DEF RBRVS 09/01/2019 12/31/2023 204.46 Description: TREAT SPINAL CANAL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62284 MEDSV DEF RBRVS 01/01/2024 178.88 Description: INJECTION FOR MYELOGRAM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62284 MEDSV DEF RBRVS 09/01/2019 12/31/2023 137.57 Description: INJECTION FOR MYELOGRAM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62287 MEDSV DEF RBRVS 01/01/2024 532.26 Description: DCMPRN PX PERQ 1/MLT LUMBAR Category: Medical Services CMS Add: 01/01/1991 CMS Term: 62287 MEDSV DEF RBRVS 09/01/2019 12/31/2023 412.55 Description: DCMPRN PX PERQ 1/MLT LUMBAR Category: Medical Services CMS Add: 01/01/1991 CMS Term: 62290 ANEST DEF RBRVS 01/01/2024 329.52 Description: NJX PX DISCOGRAPHY LUMBAR Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 62290 ANEST DEF RBRVS 09/01/2019 12/31/2023 239.47 Description: NJX PX DISCOGRAPHY LUMBAR Category: Anesthesia CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 744 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 62291 ANEST DEF RBRVS 01/01/2024 303.92 Description: NJX PX DISCOGRAPHY CRV/THRC Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 62291 ANEST DEF RBRVS 09/01/2019 12/31/2023 230.86 Description: NJX PX DISCOGRAPHY CRV/THRC Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 62292 MEDSV DEF RBRVS 01/01/2024 542.66 Description: NJX CHEMONUCLEOLYSIS LMBR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62292 MEDSV DEF RBRVS 09/01/2019 12/31/2023 428.84 Description: NJX CHEMONUCLEOLYSIS LMBR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62294 MEDSV DEF RBRVS 01/01/2024 853.56 Description: INJECTION INTO SPINAL ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62294 MEDSV DEF RBRVS 09/01/2019 12/31/2023 529.18 Description: INJECTION INTO SPINAL ARTERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 62302 MEDSV DEF RBRVS 01/01/2024 242.60 Description: MYELOGRAPHY LUMBAR INJECTION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 62302 MEDSV DEF RBRVS 02/01/2015 12/31/2023 174.73 Description: MYELOGRAPHY LUMBAR INJECTION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 62303 MEDSV DEF RBRVS 01/01/2024 246.92 Description: MYELOGRAPHY LUMBAR INJECTION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 62303 MEDSV DEF RBRVS 02/01/2015 12/31/2023 181.42 Description: MYELOGRAPHY LUMBAR INJECTION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 62304 MEDSV DEF RBRVS 01/01/2024 240.94 Description: MYELOGRAPHY LUMBAR INJECTION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 62304 MEDSV DEF RBRVS 02/01/2015 12/31/2023 172.42 Description: MYELOGRAPHY LUMBAR INJECTION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 62305 MEDSV DEF RBRVS 01/01/2024 261.92 Description: MYELOGRAPHY LUMBAR INJECTION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 62305 MEDSV DEF RBRVS 02/01/2015 12/31/2023 188.15 Description: MYELOGRAPHY LUMBAR INJECTION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 62320 MEDSV DEF RBRVS 01/01/2017 12/31/2023 119.62 Description: NJX INTERLAMINAR CRV/THRC Category: Medical Services CMS Add: 01/01/2017 CMS Term: 62320 MEDSV DEF RBRVS 01/01/2024 154.40 Description: NJX INTERLAMINAR CRV/THRC Category: Medical Services CMS Add: 01/01/2017 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 745 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 62321 MEDSV DEF RBRVS 01/01/2017 12/31/2023 176.99 Description: NJX INTERLAMINAR CRV/THRC Category: Medical Services CMS Add: 01/01/2017 CMS Term: 62321 MEDSV DEF RBRVS 01/01/2024 245.41 Description: NJX INTERLAMINAR CRV/THRC Category: Medical Services CMS Add: 01/01/2017 CMS Term: 62322 MEDSV DEF RBRVS 01/01/2017 12/31/2023 111.50 Description: NJX INTERLAMINAR LMBR/SAC Category: Medical Services CMS Add: 01/01/2017 CMS Term: 62322 MEDSV DEF RBRVS 01/01/2024 129.82 Description: NJX INTERLAMINAR LMBR/SAC Category: Medical Services CMS Add: 01/01/2017 CMS Term: 62323 MEDSV DEF RBRVS 01/01/2017 12/31/2023 173.79 Description: NJX INTERLAMINAR LMBR/SAC Category: Medical Services CMS Add: 01/01/2017 CMS Term: 62323 MEDSV DEF RBRVS 01/01/2024 241.71 Description: NJX INTERLAMINAR LMBR/SAC Category: Medical Services CMS Add: 01/01/2017 CMS Term: 62324 MEDSV DEF RBRVS 01/01/2017 12/31/2023 104.78 Description: NJX INTERLAMINAR CRV/THRC Category: Medical Services CMS Add: 01/01/2017 CMS Term: 62324 MEDSV DEF RBRVS 01/01/2024 130.69 Description: NJX INTERLAMINAR CRV/THRC Category: Medical Services CMS Add: 01/01/2017 CMS Term: 62325 MEDSV DEF RBRVS 01/01/2017 12/31/2023 157.37 Description: NJX INTERLAMINAR CRV/THRC Category: Medical Services CMS Add: 01/01/2017 CMS Term: 62325 MEDSV DEF RBRVS 01/01/2024 238.30 Description: NJX INTERLAMINAR CRV/THRC Category: Medical Services CMS Add: 01/01/2017 CMS Term: 62326 MEDSV DEF RBRVS 01/01/2017 12/31/2023 110.00 Description: NJX INTERLAMINAR LMBR/SAC Category: Medical Services CMS Add: 01/01/2017 CMS Term: 62326 MEDSV DEF RBRVS 01/01/2024 131.28 Description: NJX INTERLAMINAR LMBR/SAC Category: Medical Services CMS Add: 01/01/2017 CMS Term: 62327 MEDSV DEF RBRVS 01/01/2017 12/31/2023 160.13 Description: NJX INTERLAMINAR LMBR/SAC Category: Medical Services CMS Add: 01/01/2017 CMS Term: 62327 MEDSV DEF RBRVS 01/01/2024 251.44 Description: NJX INTERLAMINAR LMBR/SAC Category: Medical Services CMS Add: 01/01/2017 CMS Term: 62328 MEDSV DEF RBRVS 01/01/2020 12/31/2023 184.95 Description: DX LMBR SPI PNXR W/FLUOR/CT Category: Medical Services CMS Add: 01/01/2020 CMS Term: 62328 MEDSV DEF RBRVS 01/01/2024 216.97 Description: DX LMBR SPI PNXR W/FLUOR/CT Category: Medical Services CMS Add: 01/01/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 746 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 62329 MEDSV DEF RBRVS 01/01/2020 12/31/2023 228.36 Description: THER SPI PNXR CSF FLUOR/CT Category: Medical Services CMS Add: 01/01/2020 CMS Term: 62329 MEDSV DEF RBRVS 01/01/2024 265.69 Description: THER SPI PNXR CSF FLUOR/CT Category: Medical Services CMS Add: 01/01/2020 CMS Term: 62350 MEDSV DEF RBRVS 01/01/2019 12/31/2023 290.29 Description: IMPLANT SPINAL CANAL CATH Category: Medical Services CMS Add: 01/01/1996 CMS Term: 62350 MEDSV DEF RBRVS 01/01/2024 368.33 Description: IMPLANT SPINAL CANAL CATH Category: Medical Services CMS Add: 01/01/1996 CMS Term: 62351 MEDSV DEF RBRVS 01/01/2024 817.24 Description: IMPLANT SPINAL CANAL CATH Category: Medical Services CMS Add: 01/01/1996 CMS Term: 62351 MEDSV DEF RBRVS 02/01/2015 12/31/2023 619.47 Description: IMPLANT SPINAL CANAL CATH Category: Medical Services CMS Add: 01/01/1996 CMS Term: 62355 MEDSV DEF RBRVS 01/01/2024 253.59 Description: REMOVE SPINAL CANAL CATHETER Category: Medical Services CMS Add: 01/01/1996 CMS Term: 62355 MEDSV DEF RBRVS 02/01/2015 12/31/2023 191.50 Description: REMOVE SPINAL CANAL CATHETER Category: Medical Services CMS Add: 01/01/1996 CMS Term: 62360 MEDSV DEF RBRVS 01/01/2024 293.12 Description: INSERT SPINE INFUSION DEVICE Category: Medical Services CMS Add: 01/01/1996 CMS Term: 62360 MEDSV DEF RBRVS 02/01/2015 12/31/2023 223.93 Description: INSERT SPINE INFUSION DEVICE Category: Medical Services CMS Add: 01/01/1996 CMS Term: 62361 MEDSV DEF RBRVS 01/01/2024 391.81 Description: IMPLANT SPINE INFUSION PUMP Category: Medical Services CMS Add: 01/01/1996 CMS Term: 62361 MEDSV DEF RBRVS 02/01/2015 12/31/2023 250.77 Description: IMPLANT SPINE INFUSION PUMP Category: Medical Services CMS Add: 01/01/1996 CMS Term: 62362 MEDSV DEF RBRVS 01/01/2024 354.54 Description: IMPLANT SPINE INFUSION PUMP Category: Medical Services CMS Add: 01/01/1996 CMS Term: 62362 MEDSV DEF RBRVS 02/01/2015 12/31/2023 277.38 Description: IMPLANT SPINE INFUSION PUMP Category: Medical Services CMS Add: 01/01/1996 CMS Term: 62365 MEDSV DEF RBRVS 01/01/2024 272.28 Description: REMOVE SPINE INFUSION DEVICE Category: Medical Services CMS Add: 01/01/1996 CMS Term: 62365 MEDSV DEF RBRVS 02/01/2015 12/31/2023 209.96 Description: REMOVE SPINE INFUSION DEVICE Category: Medical Services CMS Add: 01/01/1996 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 747 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 62367 26 MEDSV DEF MAXFEE 01/01/2024 29.45 0.0 Description: ANALYZE SPINE INFUS PUMP Category: Medical Services CMS Add: 01/01/1996 CMS Term: 62367 26 MEDSV DEF RBRVS 08/31/2011 28.20 Description: ANALYZE SPINE INFUS PUMP Category: Medical Services CMS Add: 01/01/1996 CMS Term: 62367 MEDSV DEF RBRVS 01/01/2019 12/31/2023 29.82 Description: ANALYZE SPINE INFUS PUMP Category: Medical Services CMS Add: 01/01/1996 CMS Term: 62367 MEDSV DEF RBRVS 01/01/2024 29.89 Description: ANALYZE SPINE INFUS PUMP Category: Medical Services CMS Add: 01/01/1996 CMS Term: 62368 MEDSV DEF RBRVS 01/01/2024 41.28 Description: ANALYZE SP INF PUMP W/REPROG Category: Medical Services CMS Add: 01/01/1996 CMS Term: 62368 MEDSV DEF RBRVS 09/01/2019 12/31/2023 40.46 Description: ANALYZE SP INF PUMP W/REPROG Category: Medical Services CMS Add: 01/01/1996 CMS Term: 62369 MEDSV DEF RBRVS 01/01/2024 85.73 Description: ANAL SP INF PMP W/REPRG&FILL Category: Medical Services CMS Add: 01/01/2012 CMS Term: 62369 MEDSV DEF RBRVS 02/01/2015 12/31/2023 85.05 Description: ANAL SP INF PMP W/REPRG&FILL Category: Medical Services CMS Add: 01/01/2012 CMS Term: 62370 MEDSV DEF RBRVS 01/01/2024 86.75 Description: ANL SP INF PMP W/MDREPRG&FIL Category: Medical Services CMS Add: 01/01/2012 CMS Term: 62370 MEDSV DEF RBRVS 02/01/2015 12/31/2023 89.83 Description: ANL SP INF PMP W/MDREPRG&FIL Category: Medical Services CMS Add: 01/01/2012 CMS Term: 62380 MEDSV DEF MAXFEE 01/01/2024 710.59 0.0 Description: NDSC DCMPRN 1 NTRSPC LUMBAR Category: Medical Services CMS Add: 01/01/2017 CMS Term: 63001 MEDSV DEF RBRVS 01/01/2024 1108.31 Description: REMOVE SPINE LAMINA 1/2 CRVL Category: Medical Services CMS Add: 01/01/1985 CMS Term: 63001 MEDSV DEF RBRVS 09/01/2019 12/31/2023 869.44 Description: REMOVE SPINE LAMINA 1/2 CRVL Category: Medical Services CMS Add: 01/01/1985 CMS Term: 63003 MEDSV DEF RBRVS 01/01/2024 1111.22 Description: REMOVE SPINE LAMINA 1/2 THRC Category: Medical Services CMS Add: 01/01/1985 CMS Term: 63003 MEDSV DEF RBRVS 09/01/2019 12/31/2023 869.46 Description: REMOVE SPINE LAMINA 1/2 THRC Category: Medical Services CMS Add: 01/01/1985 CMS Term: 63005 MEDSV DEF RBRVS 01/01/2024 1080.35 Description: REMOVE SPINE LAMINA 1/2 LMBR Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 748 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 63005 MEDSV DEF RBRVS 09/01/2019 12/31/2023 833.35 Description: REMOVE SPINE LAMINA 1/2 LMBR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63011 MEDSV DEF RBRVS 01/01/2024 1001.27 Description: REMOVE SPINE LAMINA 1/2 SCRL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63011 MEDSV DEF RBRVS 09/01/2019 12/31/2023 777.10 Description: REMOVE SPINE LAMINA 1/2 SCRL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63012 MEDSV DEF RBRVS 01/01/2024 1080.41 Description: REMOVE LAMINA/FACETS LUMBAR Category: Medical Services CMS Add: 01/01/1991 CMS Term: 63012 MEDSV DEF RBRVS 09/01/2019 12/31/2023 841.01 Description: REMOVE LAMINA/FACETS LUMBAR Category: Medical Services CMS Add: 01/01/1991 CMS Term: 63015 MEDSV DEF RBRVS 01/01/2024 1329.18 Description: REMOVE SPINE LAMINA >2 CRVCL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63015 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1040.48 Description: REMOVE SPINE LAMINA >2 CRVCL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63016 MEDSV DEF RBRVS 01/01/2024 1373.62 Description: REMOVE SPINE LAMINA >2 THRC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63016 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1068.79 Description: REMOVE SPINE LAMINA >2 THRC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63017 MEDSV DEF RBRVS 01/01/2024 1137.02 Description: REMOVE SPINE LAMINA >2 LMBR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63017 MEDSV DEF RBRVS 09/01/2019 12/31/2023 878.43 Description: REMOVE SPINE LAMINA >2 LMBR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63020 MEDSV DEF RBRVS 01/01/2024 995.23 Description: NECK SPINE DISK SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63020 MEDSV DEF RBRVS 09/01/2019 12/31/2023 824.37 Description: NECK SPINE DISK SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63030 MEDSV DEF RBRVS 01/01/2024 830.23 Description: LOW BACK DISK SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63030 MEDSV DEF RBRVS 09/01/2019 12/31/2023 685.75 Description: LOW BACK DISK SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63035 MEDSV DEF RBRVS 01/01/2016 12/31/2023 136.66 Description: SPINAL DISK SURGERY ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 749 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 63035 MEDSV DEF RBRVS 01/01/2024 209.23 Description: SPINAL DISK SURGERY ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63040 MEDSV DEF RBRVS 01/01/2024 1252.47 Description: LAMINOTOMY SINGLE CERVICAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63040 MEDSV DEF RBRVS 09/01/2019 12/31/2023 991.86 Description: LAMINOTOMY SINGLE CERVICAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63042 MEDSV DEF RBRVS 01/01/2024 1177.87 Description: LAMINOTOMY SINGLE LUMBAR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63042 MEDSV DEF RBRVS 09/01/2019 12/31/2023 922.05 Description: LAMINOTOMY SINGLE LUMBAR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63043 MEDSV DEF MAXFEE 01/01/2024 252.45 0.0 Description: LAMINOTOMY ADDL CERVICAL Category: Medical Services CMS Add: 01/01/2001 CMS Term: 63044 MEDSV DEF MAXFEE 01/01/2024 300.78 0.0 Description: LAMINOTOMY ADDL LUMBAR Category: Medical Services CMS Add: 01/01/2001 CMS Term: 63045 MEDSV DEF RBRVS 01/01/2024 1160.69 Description: LAM FACETEC & FORAMOT CRV Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63045 MEDSV DEF RBRVS 09/01/2019 12/31/2023 895.34 Description: LAM FACETEC & FORAMOT CRV Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63046 MEDSV DEF RBRVS 01/01/2024 1112.01 Description: LAM FACETEC & FORAMOT THRC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63046 MEDSV DEF RBRVS 09/01/2019 12/31/2023 855.39 Description: LAM FACETEC & FORAMOT THRC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63047 MEDSV DEF RBRVS 01/01/2024 1003.92 Description: LAM FACETEC & FORAMOT LUMBAR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63047 MEDSV DEF RBRVS 09/01/2019 12/31/2023 780.18 Description: LAM FACETEC & FORAMOT LUMBAR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63048 MEDSV DEF RBRVS 01/01/2016 12/31/2023 151.12 Description: LAM FACETEC &FORAMOT EA ADDL Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63048 MEDSV DEF RBRVS 01/01/2024 188.06 Description: LAM FACETEC &FORAMOT EA ADDL Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63050 MEDSV DEF RBRVS 01/01/2024 1343.25 Description: CERVICAL LAMINOPLSTY 2/> SEG Category: Medical Services CMS Add: 01/01/2005 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 750 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 63050 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1089.57 Description: CERVICAL LAMINOPLSTY 2/> SEG Category: Medical Services CMS Add: 01/01/2005 CMS Term: 63051 MEDSV DEF RBRVS 01/01/2024 1537.10 Description: C-LAMINOPLASTY W/GRAFT/PLATE Category: Medical Services CMS Add: 01/01/2005 CMS Term: 63051 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1214.64 Description: C-LAMINOPLASTY W/GRAFT/PLATE Category: Medical Services CMS Add: 01/01/2005 CMS Term: 63052 MEDSV DEF RBRVS 01/01/2022 12/31/2023 187.02 Description: LAM FACETC/FRMT ARTHRD LUM 1 Category: Medical Services CMS Add: 01/01/2022 CMS Term: 63052 MEDSV DEF RBRVS 01/01/2024 230.71 Description: LAM FACETC/FRMT ARTHRD LUM 1 Category: Medical Services CMS Add: 01/01/2022 CMS Term: 63053 MEDSV DEF RBRVS 01/01/2022 12/31/2023 140.05 Description: LAM FACTC/FRMT ARTHRD LUM EA Category: Medical Services CMS Add: 01/01/2022 CMS Term: 63053 MEDSV DEF RBRVS 01/01/2024 204.64 Description: LAM FACTC/FRMT ARTHRD LUM EA Category: Medical Services CMS Add: 01/01/2022 CMS Term: 63055 MEDSV DEF RBRVS 01/01/2024 1458.57 Description: DECOMPRESS SPINAL CORD THRC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63055 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1143.00 Description: DECOMPRESS SPINAL CORD THRC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63056 MEDSV DEF RBRVS 01/01/2024 1347.15 Description: DECOMPRESS SPINAL CORD LMBR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63056 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1048.78 Description: DECOMPRESS SPINAL CORD LMBR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63057 MEDSV DEF RBRVS 01/01/2024 285.87 Description: DECOMPRESS SPINE CORD ADD-ON Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63057 MEDSV DEF RBRVS 02/01/2015 12/31/2023 228.01 Description: DECOMPRESS SPINE CORD ADD-ON Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63064 MEDSV DEF RBRVS 01/01/2024 1598.98 Description: DECOMPRESS SPINAL CORD THRC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63064 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1250.65 Description: DECOMPRESS SPINAL CORD THRC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63066 MEDSV DEF RBRVS 01/01/2024 180.19 Description: DECOMPRESS SPINE CORD ADD-ON Category: Medical Services CMS Add: 01/01/1988 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 751 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 63066 MEDSV DEF RBRVS 02/01/2015 12/31/2023 144.49 Description: DECOMPRESS SPINE CORD ADD-ON Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63075 MEDSV DEF RBRVS 01/01/2024 1227.70 Description: NECK SPINE DISK SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63075 MEDSV DEF RBRVS 09/01/2019 12/31/2023 963.70 Description: NECK SPINE DISK SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63076 MEDSV DEF RBRVS 01/01/2024 218.10 Description: NECK SPINE DISK SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63076 MEDSV DEF RBRVS 02/01/2015 12/31/2023 175.93 Description: NECK SPINE DISK SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63077 MEDSV DEF RBRVS 01/01/2024 1377.24 Description: SPINE DISK SURGERY THORAX Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63077 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1064.62 Description: SPINE DISK SURGERY THORAX Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63078 MEDSV DEF RBRVS 01/01/2024 181.17 Description: SPINE DISK SURGERY THORAX Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63078 MEDSV DEF RBRVS 02/01/2015 12/31/2023 139.66 Description: SPINE DISK SURGERY THORAX Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63081 MEDSV DEF RBRVS 01/01/2024 1586.74 Description: REMOVE VERT BODY DCMPRN CRVL Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63081 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1250.07 Description: REMOVE VERT BODY DCMPRN CRVL Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63082 MEDSV DEF RBRVS 01/01/2024 236.63 Description: REMOVE VERTEBRAL BODY ADD-ON Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63082 MEDSV DEF RBRVS 02/01/2015 12/31/2023 189.81 Description: REMOVE VERTEBRAL BODY ADD-ON Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63085 MEDSV DEF RBRVS 01/01/2024 1736.73 Description: REMOVE VERT BODY DCMPRN THRC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63085 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1349.03 Description: REMOVE VERT BODY DCMPRN THRC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63086 MEDSV DEF RBRVS 01/01/2024 169.83 Description: REMOVE VERTEBRAL BODY ADD-ON Category: Medical Services CMS Add: 01/01/1988 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 752 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 63086 MEDSV DEF RBRVS 02/01/2015 12/31/2023 135.34 Description: REMOVE VERTEBRAL BODY ADD-ON Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63087 MEDSV DEF RBRVS 01/01/2024 2174.87 Description: REMOV VERTBR DCMPRN THRCLMBR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63087 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1701.18 Description: REMOV VERTBR DCMPRN THRCLMBR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63088 MEDSV DEF RBRVS 01/01/2024 230.34 Description: REMOVE VERTEBRAL BODY ADD-ON Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63088 MEDSV DEF RBRVS 02/01/2015 12/31/2023 183.78 Description: REMOVE VERTEBRAL BODY ADD-ON Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63090 MEDSV DEF RBRVS 01/01/2024 1769.17 Description: REMOVE VERT BODY DCMPRN LMBR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63090 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1406.34 Description: REMOVE VERT BODY DCMPRN LMBR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63091 MEDSV DEF RBRVS 01/01/2024 158.78 Description: REMOVE VERTEBRAL BODY ADD-ON Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63091 MEDSV DEF RBRVS 02/01/2015 12/31/2023 128.07 Description: REMOVE VERTEBRAL BODY ADD-ON Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63101 MEDSV DEF RBRVS 01/01/2024 2085.42 Description: REMOVE VERT BODY DCMPRN THRC Category: Medical Services CMS Add: 01/01/2004 CMS Term: 63101 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1633.89 Description: REMOVE VERT BODY DCMPRN THRC Category: Medical Services CMS Add: 01/01/2004 CMS Term: 63102 MEDSV DEF RBRVS 01/01/2024 2063.30 Description: REMOVE VERT BODY DCMPRN LMBR Category: Medical Services CMS Add: 01/01/2004 CMS Term: 63102 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1596.96 Description: REMOVE VERT BODY DCMPRN LMBR Category: Medical Services CMS Add: 01/01/2004 CMS Term: 63103 MEDSV DEF RBRVS 01/01/2024 262.39 Description: REMOVE VERTEBRAL BODY ADD-ON Category: Medical Services CMS Add: 01/01/2004 CMS Term: 63103 MEDSV DEF RBRVS 02/01/2015 12/31/2023 207.54 Description: REMOVE VERTEBRAL BODY ADD-ON Category: Medical Services CMS Add: 01/01/2004 CMS Term: 63170 MEDSV DEF RBRVS 01/01/2024 1422.92 Description: INCISE SPINAL CORD TRACT(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 753 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 63170 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1110.46 Description: INCISE SPINAL CORD TRACT(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63172 MEDSV DEF RBRVS 01/01/2024 1261.76 Description: DRAINAGE OF SPINAL CYST Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63172 MEDSV DEF RBRVS 09/01/2019 12/31/2023 984.11 Description: DRAINAGE OF SPINAL CYST Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63173 MEDSV DEF RBRVS 01/01/2024 1538.94 Description: DRAINAGE OF SPINAL CYST Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63173 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1203.88 Description: DRAINAGE OF SPINAL CYST Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63185 MEDSV DEF RBRVS 01/01/2024 1043.27 0-1 Description: INCISE SPINE NRV HALF SEGMNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63185 MEDSV DEF RBRVS 09/01/2019 12/31/2023 837.04 0-1 Description: INCISE SPINE NRV HALF SEGMNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63190 MEDSV DEF RBRVS 01/01/2024 1146.14 Description: INCISE SPINE NRV >2 SEGMNTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63190 MEDSV DEF RBRVS 09/01/2019 12/31/2023 904.97 Description: INCISE SPINE NRV >2 SEGMNTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63191 MEDSV DEF RBRVS 01/01/2024 1236.00 Description: INCISE SPINE ACCESSORY NERVE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 63191 MEDSV DEF RBRVS 09/01/2019 12/31/2023 913.04 Description: INCISE SPINE ACCESSORY NERVE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 63197 MEDSV DEF RBRVS 01/01/2024 1526.30 Description: LAM W/CORDOTOMY 1STG THRC Category: Medical Services CMS Add: 01/01/1982 CMS Term: 63197 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1074.84 Description: LAM W/CORDOTOMY 1STG THRC Category: Medical Services CMS Add: 01/01/1982 CMS Term: 63200 MEDSV DEF RBRVS 01/01/2024 1369.60 Description: RELEASE SPINAL CORD LUMBAR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63200 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1075.57 Description: RELEASE SPINAL CORD LUMBAR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63250 MEDSV DEF RBRVS 01/01/2024 2626.21 Description: REVISE SPINAL CORD VSLS CRVL Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 754 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 63250 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2069.80 Description: REVISE SPINAL CORD VSLS CRVL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63251 MEDSV DEF RBRVS 01/01/2024 2685.74 Description: REVISE SPINAL CORD VSLS THRC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63251 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2116.03 Description: REVISE SPINAL CORD VSLS THRC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63252 MEDSV DEF RBRVS 01/01/2024 2685.08 Description: REVISE SPINE CORD VSL THRLMB Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63252 MEDSV DEF RBRVS 09/01/2019 12/31/2023 2115.51 Description: REVISE SPINE CORD VSL THRLMB Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63265 MEDSV DEF RBRVS 01/01/2024 1497.15 Description: EXCISE INTRASPINL LESION CRV Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63265 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1170.73 Description: EXCISE INTRASPINL LESION CRV Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63266 MEDSV DEF RBRVS 01/01/2024 1540.63 Description: EXCISE INTRSPINL LESION THRC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63266 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1208.21 Description: EXCISE INTRSPINL LESION THRC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63267 MEDSV DEF RBRVS 01/01/2024 1239.04 Description: EXCISE INTRSPINL LESION LMBR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63267 MEDSV DEF RBRVS 09/01/2019 12/31/2023 968.34 Description: EXCISE INTRSPINL LESION LMBR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63268 MEDSV DEF RBRVS 01/01/2024 1265.67 Description: EXCISE INTRSPINL LESION SCRL Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63268 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1014.96 Description: EXCISE INTRSPINL LESION SCRL Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63270 MEDSV DEF RBRVS 01/01/2024 1849.33 Description: EXCISE INTRSPINL LESION CRVL Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63270 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1447.68 Description: EXCISE INTRSPINL LESION CRVL Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63271 MEDSV DEF RBRVS 01/01/2024 1850.81 Description: EXCISE INTRSPINL LESION THRC Category: Medical Services CMS Add: 01/01/1988 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 755 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 63271 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1447.76 Description: EXCISE INTRSPINL LESION THRC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63272 MEDSV DEF RBRVS 01/01/2024 1680.75 Description: EXCISE INTRSPINL LESION LMBR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63272 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1333.94 Description: EXCISE INTRSPINL LESION LMBR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63273 MEDSV DEF RBRVS 01/01/2024 1665.21 Description: EXCISE INTRSPINL LESION SCRL Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63273 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1300.32 Description: EXCISE INTRSPINL LESION SCRL Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63275 MEDSV DEF RBRVS 01/01/2024 1616.38 Description: BX/EXC XDRL SPINE LESN CRVL Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63275 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1262.87 Description: BX/EXC XDRL SPINE LESN CRVL Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63276 MEDSV DEF RBRVS 01/01/2024 1600.25 Description: BX/EXC XDRL SPINE LESN THRC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63276 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1251.20 Description: BX/EXC XDRL SPINE LESN THRC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63277 MEDSV DEF RBRVS 01/01/2024 1407.00 Description: BX/EXC XDRL SPINE LESN LMBR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63277 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1093.58 Description: BX/EXC XDRL SPINE LESN LMBR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63278 MEDSV DEF RBRVS 01/01/2024 1424.63 Description: BX/EXC XDRL SPINE LESN SCRL Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63278 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1107.80 Description: BX/EXC XDRL SPINE LESN SCRL Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63280 MEDSV DEF RBRVS 01/01/2024 1887.57 Description: BX/EXC IDRL SPINE LESN CRVL Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63280 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1478.19 Description: BX/EXC IDRL SPINE LESN CRVL Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63281 MEDSV DEF RBRVS 01/01/2024 1870.04 Description: BX/EXC IDRL SPINE LESN THRC Category: Medical Services CMS Add: 01/01/1988 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 756 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 63281 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1460.30 Description: BX/EXC IDRL SPINE LESN THRC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63282 MEDSV DEF RBRVS 01/01/2024 1767.51 Description: BX/EXC IDRL SPINE LESN LMBR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63282 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1380.80 Description: BX/EXC IDRL SPINE LESN LMBR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63283 MEDSV DEF RBRVS 01/01/2024 1697.35 Description: BX/EXC IDRL SPINE LESN SCRL Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63283 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1324.71 Description: BX/EXC IDRL SPINE LESN SCRL Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63285 MEDSV DEF RBRVS 01/01/2024 2321.26 Description: BX/EXC IDRL IMED LESN CERVL Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63285 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1824.18 Description: BX/EXC IDRL IMED LESN CERVL Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63286 MEDSV DEF RBRVS 01/01/2024 2298.10 Description: BX/EXC IDRL IMED LESN THRC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63286 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1798.92 Description: BX/EXC IDRL IMED LESN THRC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63287 MEDSV DEF RBRVS 01/01/2024 2433.36 Description: BX/EXC IDRL IMED LESN THRLMB Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63287 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1914.48 Description: BX/EXC IDRL IMED LESN THRLMB Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63290 MEDSV DEF RBRVS 01/01/2024 2474.38 Description: BX/EXC XDRL/IDRL LSN ANY LVL Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63290 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1943.69 Description: BX/EXC XDRL/IDRL LSN ANY LVL Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63295 MEDSV DEF RBRVS 01/01/2024 290.12 Description: REPAIR LAMINECTOMY DEFECT Category: Medical Services CMS Add: 01/01/2005 CMS Term: 63295 MEDSV DEF RBRVS 02/01/2015 12/31/2023 232.23 Description: REPAIR LAMINECTOMY DEFECT Category: Medical Services CMS Add: 01/01/2005 CMS Term: 63300 MEDSV DEF RBRVS 01/01/2024 1635.72 Description: REMOVE VERT XDRL BODY CRVCL Category: Medical Services CMS Add: 01/01/1988 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 757 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 63300 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1291.67 Description: REMOVE VERT XDRL BODY CRVCL Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63301 MEDSV DEF RBRVS 01/01/2024 1963.19 Description: REMOVE VERT XDRL BODY THRC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63301 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1537.60 Description: REMOVE VERT XDRL BODY THRC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63302 MEDSV DEF RBRVS 01/01/2024 1939.73 Description: REMOVE VERT XDRL BODY THRLMB Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63302 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1518.72 Description: REMOVE VERT XDRL BODY THRLMB Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63303 MEDSV DEF RBRVS 01/01/2024 2056.44 Description: REMOV VERT XDRL BDY LMBR/SAC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63303 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1613.34 Description: REMOV VERT XDRL BDY LMBR/SAC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63304 MEDSV DEF RBRVS 01/01/2024 2089.06 Description: REMOVE VERT IDRL BODY CRVCL Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63304 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1638.33 Description: REMOVE VERT IDRL BODY CRVCL Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63305 MEDSV DEF RBRVS 01/01/2024 2221.17 Description: REMOVE VERT IDRL BODY THRC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63305 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1744.25 Description: REMOVE VERT IDRL BODY THRC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63306 MEDSV DEF RBRVS 01/01/2024 2183.25 Description: REMOV VERT IDRL BDY THRCLMBR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63306 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1511.35 Description: REMOV VERT IDRL BDY THRCLMBR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63307 MEDSV DEF RBRVS 01/01/2024 2137.16 Description: REMOV VERT IDRL BDY LMBR/SAC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63307 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1678.23 Description: REMOV VERT IDRL BDY LMBR/SAC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63308 MEDSV DEF RBRVS 01/01/2019 12/31/2023 226.75 Description: REMOVE VERTEBRAL BODY ADD-ON Category: Medical Services CMS Add: 01/01/1988 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 758 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 63308 MEDSV DEF RBRVS 01/01/2024 283.86 Description: REMOVE VERTEBRAL BODY ADD-ON Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63600 MEDSV DEF RBRVS 01/01/2024 977.78 Description: REMOVE SPINAL CORD LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63600 MEDSV DEF RBRVS 09/01/2019 12/31/2023 668.24 Description: REMOVE SPINAL CORD LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63610 MEDSV DEF RBRVS 01/01/2024 510.99 Description: STIMULATION OF SPINAL CORD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63610 MEDSV DEF RBRVS 09/01/2019 12/31/2023 291.34 Description: STIMULATION OF SPINAL CORD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63620 MEDSV DEF RBRVS 01/01/2024 1005.76 Description: SRS SPINAL LESION Category: Medical Services CMS Add: 01/01/2009 CMS Term: 63620 MEDSV DEF RBRVS 02/01/2015 12/31/2023 775.05 Description: SRS SPINAL LESION Category: Medical Services CMS Add: 01/01/2009 CMS Term: 63621 MEDSV DEF RBRVS 01/01/2024 221.05 Description: SRS SPINAL LESION ADDL Category: Medical Services CMS Add: 01/01/2009 CMS Term: 63621 MEDSV DEF RBRVS 02/01/2015 12/31/2023 175.11 Description: SRS SPINAL LESION ADDL Category: Medical Services CMS Add: 01/01/2009 CMS Term: 63650 ANEST DEF RBRVS 01/01/2024 2142.48 Description: IMPLANT NEUROELECTRODES Category: Anesthesia CMS Add: 01/01/1982 CMS Term: 63650 ANEST DEF RBRVS 09/01/2019 12/31/2023 943.09 Description: IMPLANT NEUROELECTRODES Category: Anesthesia CMS Add: 01/01/1982 CMS Term: 63655 MEDSV DEF RBRVS 01/01/2024 759.48 Description: IMPLANT NEUROELECTRODES Category: Medical Services CMS Add: 01/01/1982 CMS Term: 63655 MEDSV DEF RBRVS 09/01/2019 12/31/2023 581.76 Description: IMPLANT NEUROELECTRODES Category: Medical Services CMS Add: 01/01/1982 CMS Term: 63661 ANEST DEF RBRVS 01/01/2024 634.78 Description: REMOVE SPINE ELTRD PERQ ARAY Category: Anesthesia CMS Add: 01/01/2010 CMS Term: 63661 ANEST DEF RBRVS 02/01/2015 12/31/2023 409.06 Description: REMOVE SPINE ELTRD PERQ ARAY Category: Anesthesia CMS Add: 01/01/2010 CMS Term: 63662 MEDSV DEF RBRVS 01/01/2024 768.25 Description: REMOVE SPINE ELTRD PLATE Category: Medical Services CMS Add: 01/01/2010 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 759 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 63662 MEDSV DEF RBRVS 02/01/2015 12/31/2023 558.29 Description: REMOVE SPINE ELTRD PLATE Category: Medical Services CMS Add: 01/01/2010 CMS Term: 63663 ANEST DEF RBRVS 01/01/2024 841.88 Description: REVISE SPINE ELTRD PERQ ARAY Category: Anesthesia CMS Add: 01/01/2010 CMS Term: 63663 ANEST DEF RBRVS 02/01/2015 12/31/2023 568.74 Description: REVISE SPINE ELTRD PERQ ARAY Category: Anesthesia CMS Add: 01/01/2010 CMS Term: 63664 MEDSV DEF RBRVS 01/01/2024 799.93 Description: REVISE SPINE ELTRD PLATE Category: Medical Services CMS Add: 01/01/2010 CMS Term: 63664 MEDSV DEF RBRVS 02/01/2015 12/31/2023 578.21 Description: REVISE SPINE ELTRD PLATE Category: Medical Services CMS Add: 01/01/2010 CMS Term: 63685 MEDSV DEF RBRVS 01/01/2024 333.90 Description: INS/RPLC SPI NPG/RCVR POCKET Category: Medical Services CMS Add: 01/01/1982 CMS Term: 63685 MEDSV DEF RBRVS 02/01/2015 12/31/2023 261.57 Description: INS/RPLC SPI NPG/RCVR POCKET Category: Medical Services CMS Add: 01/01/1982 CMS Term: 63688 MEDSV DEF RBRVS 01/01/2024 344.47 Description: REV/RMV IMP SP NPG/R DTCH CN Category: Medical Services CMS Add: 01/01/1982 CMS Term: 63688 MEDSV DEF RBRVS 09/01/2019 12/31/2023 263.95 Description: REV/RMV IMP SP NPG/R DTCH CN Category: Medical Services CMS Add: 01/01/1982 CMS Term: 63700 MEDSV DEF RBRVS 01/01/2024 1176.91 Description: REPAIR OF SPINAL HERNIATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63700 MEDSV DEF RBRVS 02/01/2015 12/31/2023 882.94 Description: REPAIR OF SPINAL HERNIATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63702 MEDSV DEF RBRVS 01/01/2024 1283.91 Description: REPAIR OF SPINAL HERNIATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63702 MEDSV DEF RBRVS 02/01/2015 12/31/2023 970.57 Description: REPAIR OF SPINAL HERNIATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63704 MEDSV DEF RBRVS 01/01/2019 12/31/2023 1149.82 Description: REPAIR OF SPINAL HERNIATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63704 MEDSV DEF RBRVS 01/01/2024 1493.11 Description: REPAIR OF SPINAL HERNIATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63706 MEDSV DEF RBRVS 01/01/2024 1654.74 Description: REPAIR OF SPINAL HERNIATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 760 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 63706 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1256.68 Description: REPAIR OF SPINAL HERNIATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63707 MEDSV DEF RBRVS 01/01/2024 852.40 Description: REPAIR SPINAL FLUID LEAKAGE Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63707 MEDSV DEF RBRVS 09/01/2019 12/31/2023 648.39 Description: REPAIR SPINAL FLUID LEAKAGE Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63709 MEDSV DEF RBRVS 01/01/2024 1011.82 Description: REPAIR SPINAL FLUID LEAKAGE Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63709 MEDSV DEF RBRVS 09/01/2019 12/31/2023 779.61 Description: REPAIR SPINAL FLUID LEAKAGE Category: Medical Services CMS Add: 01/01/1988 CMS Term: 63710 MEDSV DEF RBRVS 01/01/2024 985.96 Description: GRAFT REPAIR OF SPINE DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63710 MEDSV DEF RBRVS 09/01/2019 12/31/2023 777.94 Description: GRAFT REPAIR OF SPINE DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63740 MEDSV DEF RBRVS 01/01/2024 887.04 Description: INSTALL SPINAL SHUNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63740 MEDSV DEF RBRVS 09/01/2019 12/31/2023 661.73 Description: INSTALL SPINAL SHUNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63741 MEDSV DEF RBRVS 01/01/2024 622.24 Description: INSTALL SPINAL SHUNT Category: Medical Services CMS Add: 01/01/1991 CMS Term: 63741 MEDSV DEF RBRVS 09/01/2019 12/31/2023 463.86 Description: INSTALL SPINAL SHUNT Category: Medical Services CMS Add: 01/01/1991 CMS Term: 63744 MEDSV DEF RBRVS 01/01/2024 615.24 Description: REVISION OF SPINAL SHUNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63744 MEDSV DEF RBRVS 09/01/2019 12/31/2023 478.60 Description: REVISION OF SPINAL SHUNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63746 MEDSV DEF RBRVS 01/01/2024 551.65 Description: REMOVAL OF SPINAL SHUNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 63746 MEDSV DEF RBRVS 09/01/2019 12/31/2023 418.66 Description: REMOVAL OF SPINAL SHUNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64400 ANEST DEF RBRVS 01/01/2024 103.18 Description: NJX AA&/STRD TRIGEMINAL NRV Category: Anesthesia CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 761 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 64400 ANEST DEF RBRVS 09/01/2019 12/31/2023 88.12 Description: NJX AA&/STRD TRIGEMINAL NRV Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64405 ANEST DEF RBRVS 01/01/2024 68.74 Description: NJX AA&/STRD GR OCPL NRV Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64405 ANEST DEF RBRVS 09/01/2019 12/31/2023 71.08 Description: NJX AA&/STRD GR OCPL NRV Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64408 ANEST DEF RBRVS 01/01/2024 76.58 Description: NJX AA&/STRD VAGUS NRV Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64408 ANEST DEF RBRVS 09/01/2019 12/31/2023 71.57 Description: NJX AA&/STRD VAGUS NRV Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64415 ANEST DEF RBRVS 01/01/2024 127.16 Description: NJX AA&/STRD BRCH PLXS IMG Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64415 ANEST DEF RBRVS 09/01/2019 12/31/2023 85.18 Description: NJX AA&/STRD BRCH PLXS IMG Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64416 ANEST DEF RBRVS 01/01/2016 12/31/2023 58.70 Description: NJX AA&/STRD BRCH PL NFS IMG Category: Anesthesia CMS Add: 01/01/2003 CMS Term: 64416 ANEST DEF RBRVS 01/01/2024 74.23 Description: NJX AA&/STRD BRCH PL NFS IMG Category: Anesthesia CMS Add: 01/01/2003 CMS Term: 64417 ANEST DEF RBRVS 01/01/2024 150.05 Description: NJX AA&/STRD AX NERVE IMG Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64417 ANEST DEF RBRVS 09/01/2019 12/31/2023 92.77 Description: NJX AA&/STRD AX NERVE IMG Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64418 ANEST DEF RBRVS 01/01/2024 81.81 Description: NJX AA&/STRD SPRSCAP NRV Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64418 ANEST DEF RBRVS 09/01/2019 12/31/2023 101.69 Description: NJX AA&/STRD SPRSCAP NRV Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64420 ANEST DEF RBRVS 01/01/2020 12/31/2023 80.83 0-3 Description: NJX AA&/STRD NTRCOST NRV 1 Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64420 ANEST DEF RBRVS 01/01/2024 91.62 0-3 Description: NJX AA&/STRD NTRCOST NRV 1 Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64421 ANEST DEF RBRVS 01/01/2020 12/31/2023 109.46 Description: NJX AA&/STRD NTRCOST NRV EA Category: Anesthesia CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 762 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 64421 ANEST DEF RBRVS 01/01/2024 31.17 Description: NJX AA&/STRD NTRCOST NRV EA Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64425 ANEST DEF RBRVS 01/01/2024 103.72 Description: NJX AA&/STRD II IH NERVES Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64425 ANEST DEF RBRVS 09/01/2019 12/31/2023 95.98 Description: NJX AA&/STRD II IH NERVES Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64430 ANEST DEF RBRVS 01/01/2024 92.31 Description: NJX AA&/STRD PUDENDAL NERVE Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64430 ANEST DEF RBRVS 09/01/2019 12/31/2023 98.60 Description: NJX AA&/STRD PUDENDAL NERVE Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64435 ANEST DEF RBRVS 01/01/2024 75.51 Description: NJX AA&/STRD PARACRV NRV Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64435 ANEST DEF RBRVS 09/01/2019 12/31/2023 96.51 Description: NJX AA&/STRD PARACRV NRV Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64445 ANEST DEF RBRVS 01/01/2024 150.48 Description: NJX AA&/STRD SCIATIC NRV IMG Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64445 ANEST DEF RBRVS 09/01/2019 12/31/2023 96.49 Description: NJX AA&/STRD SCIATIC NRV IMG Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64446 ANEST DEF RBRVS 01/01/2016 12/31/2023 58.95 Description: NJX AA&/STRD SC NRV NFS IMG Category: Anesthesia CMS Add: 01/01/2003 CMS Term: 64446 ANEST DEF RBRVS 01/01/2024 72.54 Description: NJX AA&/STRD SC NRV NFS IMG Category: Anesthesia CMS Add: 01/01/2003 CMS Term: 64447 ANEST DEF RBRVS 01/01/2016 12/31/2023 85.22 Description: NJX AA&/STRD FEMORAL NRV IMG Category: Anesthesia CMS Add: 01/01/2003 CMS Term: 64447 ANEST DEF RBRVS 01/01/2024 109.85 Description: NJX AA&/STRD FEMORAL NRV IMG Category: Anesthesia CMS Add: 01/01/2003 CMS Term: 64448 ANEST DEF RBRVS 01/01/2016 12/31/2023 52.79 Description: NJX AA&/STRD FEM NRV NFS IMG Category: Anesthesia CMS Add: 01/01/2003 CMS Term: 64448 ANEST DEF RBRVS 01/01/2024 68.75 Description: NJX AA&/STRD FEM NRV NFS IMG Category: Anesthesia CMS Add: 01/01/2003 CMS Term: 64449 ANEST DEF RBRVS 01/01/2016 12/31/2023 61.43 Description: NJX AA&/STRD LMBR PLEX NFS Category: Anesthesia CMS Add: 01/01/2004 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 763 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 64449 ANEST DEF RBRVS 01/01/2024 58.55 Description: NJX AA&/STRD LMBR PLEX NFS Category: Anesthesia CMS Add: 01/01/2004 CMS Term: 64450 ANEST DEF RBRVS 01/01/2024 70.23 Description: NJX AA&/STRD OTHER PN/BRANCH Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64450 ANEST DEF RBRVS 09/01/2019 12/31/2023 57.06 Description: NJX AA&/STRD OTHER PN/BRANCH Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64451 MEDSV DEF RBRVS 01/01/2020 12/31/2023 150.33 Description: NJX AA&/STRD NRV NRVTG SI JT Category: Medical Services CMS Add: 01/01/2020 CMS Term: 64451 MEDSV DEF RBRVS 01/01/2024 213.06 Description: NJX AA&/STRD NRV NRVTG SI JT Category: Medical Services CMS Add: 01/01/2020 CMS Term: 64454 MEDSV DEF RBRVS 01/01/2020 12/31/2023 151.82 Y Description: NJX AA&/STRD GNCLR NRV BRNCH Category: Medical Services CMS Add: 01/01/2020 CMS Term: 64454 MEDSV DEF RBRVS 01/01/2024 206.88 Y Description: NJX AA&/STRD GNCLR NRV BRNCH Category: Medical Services CMS Add: 01/01/2020 CMS Term: 64455 ANEST DEF RBRVS 01/01/2024 47.06 Description: NJX AA&/STRD PLTR COM DG NRV Category: Anesthesia CMS Add: 01/01/2009 CMS Term: 64455 ANEST DEF RBRVS 02/01/2015 12/31/2023 34.85 Description: NJX AA&/STRD PLTR COM DG NRV Category: Anesthesia CMS Add: 01/01/2009 CMS Term: 64461 MEDSV DEF RBRVS 01/01/2016 12/31/2023 107.63 Description: PVB THORACIC SINGLE INJ SITE Category: Medical Services CMS Add: 01/01/2016 CMS Term: 64461 MEDSV DEF RBRVS 01/01/2024 127.49 Description: PVB THORACIC SINGLE INJ SITE Category: Medical Services CMS Add: 01/01/2016 CMS Term: 64462 MEDSV DEF RBRVS 01/01/2016 12/31/2023 60.93 Description: PVB THORACIC 2ND+ INJ SITE Category: Medical Services CMS Add: 01/01/2016 CMS Term: 64462 MEDSV DEF RBRVS 01/01/2024 68.21 Description: PVB THORACIC 2ND+ INJ SITE Category: Medical Services CMS Add: 01/01/2016 CMS Term: 64463 MEDSV DEF RBRVS 01/01/2016 12/31/2023 118.82 Description: PVB THORACIC CONT INFUSION Category: Medical Services CMS Add: 01/01/2016 CMS Term: 64463 MEDSV DEF RBRVS 01/01/2024 218.39 Description: PVB THORACIC CONT INFUSION Category: Medical Services CMS Add: 01/01/2016 CMS Term: 64479 ANEST DEF RBRVS 01/01/2016 12/31/2023 171.60 0-1 Description: NJX AA&/STRD TFRM EPI C/T 1 Category: Anesthesia CMS Add: 01/01/2000 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 764 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 64479 ANEST DEF RBRVS 01/01/2024 248.47 0-1 Description: NJX AA&/STRD TFRM EPI C/T 1 Category: Anesthesia CMS Add: 01/01/2000 CMS Term: 64480 ANEST DEF RBRVS 01/01/2016 12/31/2023 82.12 Description: NJX AA&/STRD TFRM EPI C/T EA Category: Anesthesia CMS Add: 01/01/2000 CMS Term: 64480 ANEST DEF RBRVS 01/01/2024 125.95 Description: NJX AA&/STRD TFRM EPI C/T EA Category: Anesthesia CMS Add: 01/01/2000 CMS Term: 64483 ANEST DEF RBRVS 01/01/2016 12/31/2023 158.56 0-1 Description: NJX AA&/STRD TFRM EPI L/S 1 Category: Anesthesia CMS Add: 01/01/2000 CMS Term: 64483 ANEST DEF RBRVS 01/01/2024 230.28 0-1 Description: NJX AA&/STRD TFRM EPI L/S 1 Category: Anesthesia CMS Add: 01/01/2000 CMS Term: 64484 ANEST DEF RBRVS 01/01/2016 12/31/2023 63.36 Description: NJX AA&/STRD TFRM EPI L/S EA Category: Anesthesia CMS Add: 01/01/2000 CMS Term: 64484 ANEST DEF RBRVS 01/01/2024 104.65 Description: NJX AA&/STRD TFRM EPI L/S EA Category: Anesthesia CMS Add: 01/01/2000 CMS Term: 64486 MEDSV DEF RBRVS 01/01/2024 105.93 0-1 Description: TAP BLOCK UNIL BY INJECTION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 64486 MEDSV DEF RBRVS 02/01/2015 12/31/2023 89.28 0-1 Description: TAP BLOCK UNIL BY INJECTION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 64487 MEDSV DEF RBRVS 01/01/2024 203.66 0-1 Description: TAP BLOCK UNI BY INFUSION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 64487 MEDSV DEF RBRVS 02/01/2015 12/31/2023 108.96 0-1 Description: TAP BLOCK UNI BY INFUSION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 64488 MEDSV DEF RBRVS 01/01/2024 131.17 0-2 Description: TAP BLOCK BI INJECTION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 64488 MEDSV DEF RBRVS 02/01/2015 12/31/2023 109.87 0-2 Description: TAP BLOCK BI INJECTION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 64489 MEDSV DEF RBRVS 01/01/2024 331.39 0-2 Description: TAP BLOCK BI BY INFUSION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 64489 MEDSV DEF RBRVS 02/01/2015 12/31/2023 151.91 0-2 Description: TAP BLOCK BI BY INFUSION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 64490 ANEST DEF RBRVS 01/01/2024 178.80 0-1 Description: INJ PARAVERT F JNT C/T 1 LEV Category: Anesthesia CMS Add: 01/01/2010 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 765 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 64490 ANEST DEF RBRVS 02/01/2015 12/31/2023 137.99 0-1 Description: INJ PARAVERT F JNT C/T 1 LEV Category: Anesthesia CMS Add: 01/01/2010 CMS Term: 64491 ANEST DEF RBRVS 01/01/2024 90.94 Description: INJ PARAVERT F JNT C/T 2 LEV Category: Anesthesia CMS Add: 01/01/2010 CMS Term: 64491 ANEST DEF RBRVS 02/01/2015 12/31/2023 68.16 Description: INJ PARAVERT F JNT C/T 2 LEV Category: Anesthesia CMS Add: 01/01/2010 CMS Term: 64492 ANEST DEF RBRVS 01/01/2024 91.56 Description: INJ PARAVERT F JNT C/T 3 LEV Category: Anesthesia CMS Add: 01/01/2010 CMS Term: 64492 ANEST DEF RBRVS 02/01/2015 12/31/2023 68.65 Description: INJ PARAVERT F JNT C/T 3 LEV Category: Anesthesia CMS Add: 01/01/2010 CMS Term: 64493 ANEST DEF RBRVS 01/01/2024 164.76 0-1 Description: INJ PARAVERT F JNT L/S 1 LEV Category: Anesthesia CMS Add: 01/01/2010 CMS Term: 64493 ANEST DEF RBRVS 02/01/2015 12/31/2023 124.73 0-1 Description: INJ PARAVERT F JNT L/S 1 LEV Category: Anesthesia CMS Add: 01/01/2010 CMS Term: 64494 ANEST DEF RBRVS 01/01/2024 84.89 Description: INJ PARAVERT F JNT L/S 2 LEV Category: Anesthesia CMS Add: 01/01/2010 CMS Term: 64494 ANEST DEF RBRVS 02/01/2015 12/31/2023 62.62 Description: INJ PARAVERT F JNT L/S 2 LEV Category: Anesthesia CMS Add: 01/01/2010 CMS Term: 64495 ANEST DEF RBRVS 01/01/2024 84.89 Description: INJ PARAVERT F JNT L/S 3 LEV Category: Anesthesia CMS Add: 01/01/2010 CMS Term: 64495 ANEST DEF RBRVS 02/01/2015 12/31/2023 62.87 Description: INJ PARAVERT F JNT L/S 3 LEV Category: Anesthesia CMS Add: 01/01/2010 CMS Term: 64505 ANEST DEF RBRVS 01/01/2024 131.53 Description: N BLOCK SPENOPALATINE GANGL Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64505 ANEST DEF RBRVS 09/01/2019 12/31/2023 74.85 Description: N BLOCK SPENOPALATINE GANGL Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64510 ANEST DEF RBRVS 01/01/2024 136.96 Description: N BLOCK STELLATE GANGLION Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64510 ANEST DEF RBRVS 09/01/2019 12/31/2023 90.91 Description: N BLOCK STELLATE GANGLION Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64517 ANEST DEF RBRVS 01/01/2024 182.57 Description: N BLOCK INJ HYPOGAS PLXS Category: Anesthesia CMS Add: 01/01/2004 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 766 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 64517 ANEST DEF RBRVS 02/01/2015 12/31/2023 126.57 Description: N BLOCK INJ HYPOGAS PLXS Category: Anesthesia CMS Add: 01/01/2004 CMS Term: 64520 ANEST DEF RBRVS 01/01/2024 214.38 Description: N BLOCK LUMBAR/THORACIC Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64520 ANEST DEF RBRVS 09/01/2019 12/31/2023 131.72 Description: N BLOCK LUMBAR/THORACIC Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64530 ANEST DEF RBRVS 01/01/2024 215.88 Description: N BLOCK INJ CELIAC PELUS Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64530 ANEST DEF RBRVS 09/01/2019 12/31/2023 136.50 Description: N BLOCK INJ CELIAC PELUS Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64553 MEDSV DEF RBRVS 01/01/2024 2351.65 Y Description: IMPLANT NEUROELECTRODES Category: Medical Services CMS Add: 01/01/1982 CMS Term: 64553 MEDSV DEF RBRVS 09/01/2019 12/31/2023 148.87 Y Description: IMPLANT NEUROELECTRODES Category: Medical Services CMS Add: 01/01/1982 CMS Term: 64555 ANEST DEF RBRVS 01/01/2024 2009.30 Y Description: IMPLANT NEUROELECTRODES Category: Anesthesia CMS Add: 01/01/1982 CMS Term: 64555 ANEST DEF RBRVS 09/01/2019 12/31/2023 144.99 Y Description: IMPLANT NEUROELECTRODES Category: Anesthesia CMS Add: 01/01/1982 CMS Term: 64561 MEDSV DEF RBRVS 01/01/2016 12/31/2023 567.64 Description: IMPLANT NEUROELECTRODES Category: Medical Services CMS Add: 01/01/2002 CMS Term: 64561 MEDSV DEF RBRVS 01/01/2024 691.11 Description: IMPLANT NEUROELECTRODES Category: Medical Services CMS Add: 01/01/2002 CMS Term: 64566 MEDSV DEF RBRVS 01/01/2024 108.99 Description: NEUROELTRD STIM POST TIBIAL Category: Medical Services CMS Add: 01/01/2011 CMS Term: 64566 MEDSV DEF RBRVS 02/01/2015 12/31/2023 84.32 Description: NEUROELTRD STIM POST TIBIAL Category: Medical Services CMS Add: 01/01/2011 CMS Term: 64568 MEDSV DEF RBRVS 01/01/2024 556.08 Description: OPN IMPLTJ CRNL NRV NEA&PG Category: Medical Services CMS Add: 01/01/2011 CMS Term: 64568 MEDSV DEF RBRVS 02/01/2015 12/31/2023 443.21 Description: OPN IMPLTJ CRNL NRV NEA&PG Category: Medical Services CMS Add: 01/01/2011 CMS Term: 64569 MEDSV DEF RBRVS 01/01/2024 696.90 Description: REVISE/REPL VAGUS N ELTRD Category: Medical Services CMS Add: 01/01/2011 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 767 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 64569 MEDSV DEF RBRVS 02/01/2015 12/31/2023 550.55 Description: REVISE/REPL VAGUS N ELTRD Category: Medical Services CMS Add: 01/01/2011 CMS Term: 64570 MEDSV DEF RBRVS 01/01/2024 662.28 Description: REMOVE VAGUS N ELTRD Category: Medical Services CMS Add: 01/01/2011 CMS Term: 64570 MEDSV DEF RBRVS 02/01/2015 12/31/2023 483.23 Description: REMOVE VAGUS N ELTRD Category: Medical Services CMS Add: 01/01/2011 CMS Term: 64575 MEDSV DEF RBRVS 01/01/2024 285.18 Y Description: OPN IMPLTJ NEA PERPH NERVE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 64575 MEDSV DEF RBRVS 09/01/2019 12/31/2023 223.54 Y Description: OPN IMPLTJ NEA PERPH NERVE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 64580 MEDSV DEF RBRVS 01/01/2024 289.02 Y Description: OPN IMPLTJ NEA NEUROMUSCULAR Category: Medical Services CMS Add: 01/01/1982 CMS Term: 64580 MEDSV DEF RBRVS 09/01/2019 12/31/2023 212.16 Y Description: OPN IMPLTJ NEA NEUROMUSCULAR Category: Medical Services CMS Add: 01/01/1982 CMS Term: 64581 MEDSV DEF RBRVS 01/01/2019 12/31/2023 486.25 Description: OPN IMPLTJ NEA SACRAL NERVE Category: Medical Services CMS Add: 01/01/2002 CMS Term: 64581 MEDSV DEF RBRVS 01/01/2024 613.16 Description: OPN IMPLTJ NEA SACRAL NERVE Category: Medical Services CMS Add: 01/01/2002 CMS Term: 64582 MEDSV DEF RBRVS 01/01/2022 12/31/2023 641.22 Description: OPN MPLTJ HPGLSL NSTM ARY PG Category: Medical Services CMS Add: 01/01/2022 CMS Term: 64582 MEDSV DEF RBRVS 01/01/2024 797.41 Description: OPN MPLTJ HPGLSL NSTM ARY PG Category: Medical Services CMS Add: 01/01/2022 CMS Term: 64583 MEDSV DEF RBRVS 01/01/2022 12/31/2023 598.41 Description: REV/RPLCT HPGLSL NSTM ARY PG Category: Medical Services CMS Add: 01/01/2022 CMS Term: 64583 MEDSV DEF RBRVS 01/01/2024 810.55 Description: REV/RPLCT HPGLSL NSTM ARY PG Category: Medical Services CMS Add: 01/01/2022 CMS Term: 64584 MEDSV DEF RBRVS 01/01/2022 12/31/2023 503.99 Description: RMVL HPGLSL NSTIM ARY PG Category: Medical Services CMS Add: 01/01/2022 CMS Term: 64584 MEDSV DEF RBRVS 01/01/2024 683.60 Description: RMVL HPGLSL NSTIM ARY PG Category: Medical Services CMS Add: 01/01/2022 CMS Term: 64585 MEDSV DEF RBRVS 01/01/2024 225.90 Description: REV/RMV PERPH NSTIM ELTRD RA Category: Medical Services CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 768 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 64585 MEDSV DEF RBRVS 09/01/2019 12/31/2023 173.70 Description: REV/RMV PERPH NSTIM ELTRD RA Category: Medical Services CMS Add: 01/01/1982 CMS Term: 64590 MEDSV DEF RBRVS 01/01/2019 12/31/2023 186.88 Y Description: INS/RPL PRPH SAC/GSTR NPG/R Category: Medical Services CMS Add: 01/01/1982 CMS Term: 64590 MEDSV DEF RBRVS 01/01/2024 245.17 Y Description: INS/RPL PRPH SAC/GSTR NPG/R Category: Medical Services CMS Add: 01/01/1982 CMS Term: 64595 MEDSV DEF RBRVS 01/01/2024 215.92 Description: REV/RMV PRPH SAC/GSTR NPG/R Category: Medical Services CMS Add: 01/01/1982 CMS Term: 64595 MEDSV DEF RBRVS 09/01/2019 12/31/2023 172.67 Description: REV/RMV PRPH SAC/GSTR NPG/R Category: Medical Services CMS Add: 01/01/1982 CMS Term: 64600 MEDSV DEF RBRVS 01/01/2024 431.16 Description: INJECTION TREATMENT OF NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64600 MEDSV DEF RBRVS 09/01/2019 12/31/2023 272.87 Description: INJECTION TREATMENT OF NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64605 MEDSV DEF RBRVS 01/01/2024 600.79 Description: INJECTION TREATMENT OF NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64605 MEDSV DEF RBRVS 09/01/2019 12/31/2023 526.60 Description: INJECTION TREATMENT OF NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64610 MEDSV DEF RBRVS 01/01/2024 713.89 Description: INJECTION TREATMENT OF NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64610 MEDSV DEF RBRVS 09/01/2019 12/31/2023 516.56 Description: INJECTION TREATMENT OF NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64611 MEDSV DEF RBRVS 01/01/2024 117.58 Description: CHEMODENERV SALIV GLANDS Category: Medical Services CMS Add: 01/01/2011 CMS Term: 64611 MEDSV DEF RBRVS 02/01/2015 12/31/2023 78.87 Description: CHEMODENERV SALIV GLANDS Category: Medical Services CMS Add: 01/01/2011 CMS Term: 64612 ANEST DEF RBRVS 01/01/2024 126.23 Description: DESTROY NERVE FACE MUSCLE Category: Anesthesia CMS Add: 01/01/1992 CMS Term: 64612 ANEST DEF RBRVS 09/01/2019 12/31/2023 95.93 Description: DESTROY NERVE FACE MUSCLE Category: Anesthesia CMS Add: 01/01/1992 CMS Term: 64615 MEDSV DEF RBRVS 01/01/2024 138.91 0-1 Description: CHEMODENERV MUSC MIGRAINE Category: Medical Services CMS Add: 01/01/2013 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 769 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 64615 MEDSV DEF RBRVS 02/01/2015 12/31/2023 100.00 0-1 Description: CHEMODENERV MUSC MIGRAINE Category: Medical Services CMS Add: 01/01/2013 CMS Term: 64616 MEDSV DEF RBRVS 01/01/2024 123.96 Description: CHEMODENERV MUSC NECK DYSTON Category: Medical Services CMS Add: 01/01/2014 CMS Term: 64616 MEDSV DEF RBRVS 02/01/2015 12/31/2023 85.86 Description: CHEMODENERV MUSC NECK DYSTON Category: Medical Services CMS Add: 01/01/2014 CMS Term: 64617 MEDSV DEF RBRVS 01/01/2024 152.70 Description: CHEMODENER MUSCLE LARYNX EMG Category: Medical Services CMS Add: 01/01/2014 CMS Term: 64617 MEDSV DEF RBRVS 02/01/2015 12/31/2023 135.85 Description: CHEMODENER MUSCLE LARYNX EMG Category: Medical Services CMS Add: 01/01/2014 CMS Term: 64620 ANEST DEF RBRVS 01/01/2024 196.02 Description: INJECTION TREATMENT OF NERVE Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64620 ANEST DEF RBRVS 09/01/2019 12/31/2023 148.91 Description: INJECTION TREATMENT OF NERVE Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64624 MEDSV DEF RBRVS 01/01/2020 12/31/2023 289.87 Description: DSTRJ NULYT AGT GNCLR NRV Category: Medical Services CMS Add: 01/01/2020 CMS Term: 64624 MEDSV DEF RBRVS 01/01/2024 363.48 Description: DSTRJ NULYT AGT GNCLR NRV Category: Medical Services CMS Add: 01/01/2020 CMS Term: 64625 MEDSV DEF RBRVS 01/01/2020 12/31/2023 354.73 Description: RF ABLTJ NRV NRVTG SI JT Category: Medical Services CMS Add: 01/01/2020 CMS Term: 64625 MEDSV DEF RBRVS 01/01/2024 442.00 Description: RF ABLTJ NRV NRVTG SI JT Category: Medical Services CMS Add: 01/01/2020 CMS Term: 64628 NOCOV DEF SYSMAN Description: TRML DSTRJ IOS BVN 1ST 2 L/S Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 64629 NOCOV DEF SYSMAN Description: TRML DSTRJ IOS BVN EA ADDL Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 64630 MEDSV DEF RBRVS 01/01/2024 237.83 Description: INJECTION TREATMENT OF NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64630 MEDSV DEF RBRVS 09/01/2019 12/31/2023 163.69 Description: INJECTION TREATMENT OF NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64632 MEDSV DEF RBRVS 01/01/2024 84.97 Description: N BLOCK INJ COMMON DIGIT Category: Medical Services CMS Add: 01/01/2009 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 770 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 64632 MEDSV DEF RBRVS 02/01/2015 12/31/2023 62.20 Description: N BLOCK INJ COMMON DIGIT Category: Medical Services CMS Add: 01/01/2009 CMS Term: 64633 MEDSV DEF RBRVS 01/01/2024 409.99 Description: DESTROY CERV/THOR FACET JNT Category: Medical Services CMS Add: 01/01/2012 CMS Term: 64633 MEDSV DEF RBRVS 02/01/2015 12/31/2023 310.10 Description: DESTROY CERV/THOR FACET JNT Category: Medical Services CMS Add: 01/01/2012 CMS Term: 64634 MEDSV DEF RBRVS 01/01/2024 240.23 Description: DESTROY C/TH FACET JNT ADDL Category: Medical Services CMS Add: 01/01/2012 CMS Term: 64634 MEDSV DEF RBRVS 02/01/2015 12/31/2023 140.08 Description: DESTROY C/TH FACET JNT ADDL Category: Medical Services CMS Add: 01/01/2012 CMS Term: 64635 MEDSV DEF RBRVS 01/01/2024 413.70 Description: DESTROY LUMB/SAC FACET JNT Category: Medical Services CMS Add: 01/01/2012 CMS Term: 64635 MEDSV DEF RBRVS 02/01/2015 12/31/2023 305.84 Description: DESTROY LUMB/SAC FACET JNT Category: Medical Services CMS Add: 01/01/2012 CMS Term: 64636 MEDSV DEF RBRVS 01/01/2024 225.69 Description: DESTROY L/S FACET JNT ADDL Category: Medical Services CMS Add: 01/01/2012 CMS Term: 64636 MEDSV DEF RBRVS 02/01/2015 12/31/2023 126.54 Description: DESTROY L/S FACET JNT ADDL Category: Medical Services CMS Add: 01/01/2012 CMS Term: 64640 ANEST DEF RBRVS 01/01/2024 230.69 Description: INJECTION TREATMENT OF NERVE Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64640 ANEST DEF RBRVS 09/01/2019 12/31/2023 95.31 Description: INJECTION TREATMENT OF NERVE Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 64642 MEDSV DEF RBRVS 01/01/2024 138.59 Description: CHEMODENERV 1 EXTREMITY 1-4 Category: Medical Services CMS Add: 01/01/2014 CMS Term: 64642 MEDSV DEF RBRVS 02/01/2015 12/31/2023 98.75 Description: CHEMODENERV 1 EXTREMITY 1-4 Category: Medical Services CMS Add: 01/01/2014 CMS Term: 64643 MEDSV DEF RBRVS 01/01/2024 85.50 Description: CHEMODENERV 1 EXTREM 1-4 EA Category: Medical Services CMS Add: 01/01/2014 CMS Term: 64643 MEDSV DEF RBRVS 02/01/2015 12/31/2023 65.15 Description: CHEMODENERV 1 EXTREM 1-4 EA Category: Medical Services CMS Add: 01/01/2014 CMS Term: 64644 MEDSV DEF RBRVS 01/01/2024 162.43 Description: CHEMODENERV 1 EXTREM 5/> MUS Category: Medical Services CMS Add: 01/01/2014 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 771 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 64644 MEDSV DEF RBRVS 02/01/2015 12/31/2023 112.81 Description: CHEMODENERV 1 EXTREM 5/> MUS Category: Medical Services CMS Add: 01/01/2014 CMS Term: 64645 MEDSV DEF RBRVS 01/01/2024 110.31 Description: CHEMODENERV 1 EXTREM 5/> EA Category: Medical Services CMS Add: 01/01/2014 CMS Term: 64645 MEDSV DEF RBRVS 02/01/2015 12/31/2023 79.54 Description: CHEMODENERV 1 EXTREM 5/> EA Category: Medical Services CMS Add: 01/01/2014 CMS Term: 64646 MEDSV DEF RBRVS 01/01/2024 145.75 Description: CHEMODENERV TRUNK MUSC 1-5 Category: Medical Services CMS Add: 01/01/2014 CMS Term: 64646 MEDSV DEF RBRVS 02/01/2015 12/31/2023 106.33 Description: CHEMODENERV TRUNK MUSC 1-5 Category: Medical Services CMS Add: 01/01/2014 CMS Term: 64647 MEDSV DEF RBRVS 01/01/2024 166.20 Description: CHEMODENERV TRUNK MUSC 6/> Category: Medical Services CMS Add: 01/01/2014 CMS Term: 64647 MEDSV DEF RBRVS 02/01/2015 12/31/2023 123.16 Description: CHEMODENERV TRUNK MUSC 6/> Category: Medical Services CMS Add: 01/01/2014 CMS Term: 64650 MEDSV DEF RBRVS 01/01/2024 82.46 Description: CHEMODENERV ECCRINE GLANDS Category: Medical Services CMS Add: 01/01/2006 CMS Term: 64650 MEDSV DEF RBRVS 02/01/2015 12/31/2023 53.82 Description: CHEMODENERV ECCRINE GLANDS Category: Medical Services CMS Add: 01/01/2006 CMS Term: 64653 MEDSV DEF RBRVS 01/01/2024 96.93 Description: CHEMODENERV ECCRINE GLANDS Category: Medical Services CMS Add: 01/01/2006 CMS Term: 64653 MEDSV DEF RBRVS 02/01/2015 12/31/2023 67.33 Description: CHEMODENERV ECCRINE GLANDS Category: Medical Services CMS Add: 01/01/2006 CMS Term: 64680 MEDSV DEF RBRVS 01/01/2024 325.58 Description: INJECTION TREATMENT OF NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64680 MEDSV DEF RBRVS 09/01/2019 12/31/2023 222.93 Description: INJECTION TREATMENT OF NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64681 MEDSV DEF RBRVS 01/01/2024 431.19 Description: INJECTION TREATMENT OF NERVE Category: Medical Services CMS Add: 01/01/2004 CMS Term: 64681 MEDSV DEF RBRVS 02/01/2015 12/31/2023 243.83 Description: INJECTION TREATMENT OF NERVE Category: Medical Services CMS Add: 01/01/2004 CMS Term: 64702 MEDSV DEF RBRVS 01/01/2024 480.82 Description: REVISE FINGER/TOE NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 772 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 64702 MEDSV DEF RBRVS 09/01/2019 12/31/2023 354.81 Description: REVISE FINGER/TOE NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64704 MEDSV DEF RBRVS 01/01/2024 305.93 Description: REVISE HAND/FOOT NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64704 MEDSV DEF RBRVS 09/01/2019 12/31/2023 230.96 Description: REVISE HAND/FOOT NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64708 MEDSV DEF RBRVS 01/01/2024 468.75 Description: REVISE ARM/LEG NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64708 MEDSV DEF RBRVS 09/01/2019 12/31/2023 353.70 Description: REVISE ARM/LEG NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64712 MEDSV DEF RBRVS 01/01/2024 552.23 Description: REVISION OF SCIATIC NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64712 MEDSV DEF RBRVS 09/01/2019 12/31/2023 404.02 Description: REVISION OF SCIATIC NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64713 MEDSV DEF RBRVS 01/01/2024 733.51 Description: REVISION OF ARM NERVE(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64713 MEDSV DEF RBRVS 09/01/2019 12/31/2023 519.17 Description: REVISION OF ARM NERVE(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64714 MEDSV DEF RBRVS 01/01/2024 702.77 Description: REVISE LOW BACK NERVE(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64714 MEDSV DEF RBRVS 09/01/2019 12/31/2023 457.94 Description: REVISE LOW BACK NERVE(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64716 MEDSV DEF RBRVS 01/01/2024 479.19 Description: REVISION OF CRANIAL NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64716 MEDSV DEF RBRVS 09/01/2019 12/31/2023 387.72 Description: REVISION OF CRANIAL NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64718 MEDSV DEF RBRVS 01/01/2024 562.33 Description: REVISE ULNAR NERVE AT ELBOW Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64718 MEDSV DEF RBRVS 09/01/2019 12/31/2023 421.40 Description: REVISE ULNAR NERVE AT ELBOW Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64719 MEDSV DEF RBRVS 01/01/2024 381.43 Description: REVISE ULNAR NERVE AT WRIST Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 773 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 64719 MEDSV DEF RBRVS 09/01/2019 12/31/2023 283.74 Description: REVISE ULNAR NERVE AT WRIST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64721 MEDSV DEF RBRVS 01/01/2024 415.57 Description: CARPAL TUNNEL SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64721 MEDSV DEF RBRVS 09/01/2019 12/31/2023 304.13 Description: CARPAL TUNNEL SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64722 MEDSV DEF RBRVS 01/01/2024 339.35 Description: RELIEVE PRESSURE ON NERVE(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64722 MEDSV DEF RBRVS 09/01/2019 12/31/2023 263.11 Description: RELIEVE PRESSURE ON NERVE(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64726 MEDSV DEF RBRVS 01/01/2024 256.09 Description: RELEASE FOOT/TOE NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64726 MEDSV DEF RBRVS 09/01/2019 12/31/2023 198.37 Description: RELEASE FOOT/TOE NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64727 MEDSV DEF RBRVS 01/01/2024 167.38 Description: INTERNAL NERVE REVISION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64727 MEDSV DEF RBRVS 02/01/2015 12/31/2023 132.09 Description: INTERNAL NERVE REVISION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64732 MEDSV DEF RBRVS 01/01/2024 411.36 Description: INCISION OF BROW NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64732 MEDSV DEF RBRVS 09/01/2019 12/31/2023 287.37 Description: INCISION OF BROW NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64734 MEDSV DEF RBRVS 01/01/2024 464.63 Description: INCISION OF CHEEK NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64734 MEDSV DEF RBRVS 09/01/2019 12/31/2023 280.99 Description: INCISION OF CHEEK NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64736 MEDSV DEF RBRVS 01/01/2024 313.70 Description: INCISION OF CHIN NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64736 MEDSV DEF RBRVS 09/01/2019 12/31/2023 304.52 Description: INCISION OF CHIN NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64738 MEDSV DEF RBRVS 01/01/2024 425.41 Description: INCISION OF JAW NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 774 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 64738 MEDSV DEF RBRVS 09/01/2019 12/31/2023 336.53 Description: INCISION OF JAW NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64740 MEDSV DEF RBRVS 01/01/2024 435.02 Description: INCISION OF TONGUE NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64740 MEDSV DEF RBRVS 09/01/2019 12/31/2023 332.18 Description: INCISION OF TONGUE NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64742 MEDSV DEF RBRVS 01/01/2024 465.09 Description: INCISION OF FACIAL NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64742 MEDSV DEF RBRVS 09/01/2019 12/31/2023 364.22 Description: INCISION OF FACIAL NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64744 MEDSV DEF RBRVS 01/01/2024 457.46 Description: INCISE NERVE BACK OF HEAD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64744 MEDSV DEF RBRVS 09/01/2019 12/31/2023 343.20 Description: INCISE NERVE BACK OF HEAD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64746 MEDSV DEF RBRVS 01/01/2024 393.90 Description: INCISE DIAPHRAGM NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64746 MEDSV DEF RBRVS 09/01/2019 12/31/2023 308.79 Description: INCISE DIAPHRAGM NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64755 MEDSV DEF RBRVS 01/01/2024 840.35 Description: INCISION OF STOMACH NERVES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64755 MEDSV DEF RBRVS 09/01/2019 12/31/2023 652.75 Description: INCISION OF STOMACH NERVES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64760 MEDSV DEF RBRVS 01/01/2024 477.97 Description: INCISION OF VAGUS NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64760 MEDSV DEF RBRVS 09/01/2019 12/31/2023 363.88 Description: INCISION OF VAGUS NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64763 MEDSV DEF RBRVS 01/01/2024 473.08 Description: INCISE HIP/THIGH NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64763 MEDSV DEF RBRVS 09/01/2019 12/31/2023 360.35 Description: INCISE HIP/THIGH NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64766 MEDSV DEF RBRVS 01/01/2024 583.35 Description: INCISE HIP/THIGH NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 775 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 64766 MEDSV DEF RBRVS 09/01/2019 12/31/2023 410.25 Description: INCISE HIP/THIGH NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64771 MEDSV DEF RBRVS 01/01/2024 540.59 Description: SEVER CRANIAL NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64771 MEDSV DEF RBRVS 09/01/2019 12/31/2023 422.76 Description: SEVER CRANIAL NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64772 MEDSV DEF RBRVS 01/01/2024 521.07 Description: INCISION OF SPINAL NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64772 MEDSV DEF RBRVS 09/01/2019 12/31/2023 397.27 Description: INCISION OF SPINAL NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64774 MEDSV DEF RBRVS 01/01/2024 397.48 Description: REMOVE SKIN NERVE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64774 MEDSV DEF RBRVS 09/01/2019 12/31/2023 298.44 Description: REMOVE SKIN NERVE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64776 MEDSV DEF RBRVS 01/01/2024 373.42 Description: REMOVE DIGIT NERVE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64776 MEDSV DEF RBRVS 09/01/2019 12/31/2023 282.08 Description: REMOVE DIGIT NERVE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64778 MEDSV DEF RBRVS 01/01/2019 12/31/2023 111.97 Description: DIGIT NERVE SURGERY ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64778 MEDSV DEF RBRVS 01/01/2024 165.39 Description: DIGIT NERVE SURGERY ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64782 MEDSV DEF RBRVS 01/01/2024 427.88 Description: REMOVE LIMB NERVE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64782 MEDSV DEF RBRVS 09/01/2019 12/31/2023 326.26 Description: REMOVE LIMB NERVE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64783 MEDSV DEF RBRVS 01/01/2019 12/31/2023 158.06 Description: LIMB NERVE SURGERY ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64783 MEDSV DEF RBRVS 01/01/2024 197.07 Description: LIMB NERVE SURGERY ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64784 MEDSV DEF RBRVS 01/01/2024 674.09 Description: REMOVE NERVE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 776 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 64784 MEDSV DEF RBRVS 09/01/2019 12/31/2023 527.94 Description: REMOVE NERVE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64786 MEDSV DEF RBRVS 01/01/2024 917.79 Description: REMOVE SCIATIC NERVE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64786 MEDSV DEF RBRVS 09/01/2019 12/31/2023 774.67 Description: REMOVE SCIATIC NERVE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64787 MEDSV DEF RBRVS 01/01/2019 12/31/2023 176.29 Description: IMPLANT NERVE END Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64787 MEDSV DEF RBRVS 01/01/2024 218.09 Description: IMPLANT NERVE END Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64788 MEDSV DEF RBRVS 01/01/2024 376.15 Description: REMOVE SKIN NERVE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64788 MEDSV DEF RBRVS 09/01/2019 12/31/2023 283.15 Description: REMOVE SKIN NERVE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64790 MEDSV DEF RBRVS 01/01/2024 776.36 Description: REMOVAL OF NERVE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64790 MEDSV DEF RBRVS 09/01/2019 12/31/2023 587.78 Description: REMOVAL OF NERVE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64792 MEDSV DEF RBRVS 01/01/2024 975.76 Description: REMOVAL OF NERVE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64792 MEDSV DEF RBRVS 09/01/2019 12/31/2023 828.86 Description: REMOVAL OF NERVE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64795 MEDSV DEF RBRVS 01/01/2024 175.69 Description: BIOPSY OF NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64795 MEDSV DEF RBRVS 09/01/2019 12/31/2023 137.60 Description: BIOPSY OF NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64802 MEDSV DEF RBRVS 01/01/2024 761.69 Description: SYMPATHECTOMY CERVICAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64802 MEDSV DEF RBRVS 09/01/2019 12/31/2023 494.87 Description: SYMPATHECTOMY CERVICAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64804 MEDSV DEF RBRVS 01/01/2024 1068.37 Description: REMOVE SYMPATHETIC NERVES Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 777 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 64804 MEDSV DEF RBRVS 09/01/2019 12/31/2023 753.13 Description: REMOVE SYMPATHETIC NERVES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64809 MEDSV DEF RBRVS 01/01/2024 975.84 Description: REMOVE SYMPATHETIC NERVES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64809 MEDSV DEF RBRVS 09/01/2019 12/31/2023 530.15 Description: REMOVE SYMPATHETIC NERVES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64818 MEDSV DEF RBRVS 01/01/2024 721.52 Description: REMOVE SYMPATHETIC NERVES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64818 MEDSV DEF RBRVS 09/01/2019 12/31/2023 465.21 Description: REMOVE SYMPATHETIC NERVES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64820 MEDSV DEF RBRVS 01/01/2019 12/31/2023 522.16 Description: SYMPATHECTOMY DIGITAL ARTERY Category: Medical Services CMS Add: 01/01/1995 CMS Term: 64820 MEDSV DEF RBRVS 01/01/2024 713.73 Description: SYMPATHECTOMY DIGITAL ARTERY Category: Medical Services CMS Add: 01/01/1995 CMS Term: 64821 MEDSV DEF RBRVS 01/01/2016 12/31/2023 498.98 Description: REMOVE SYMPATHETIC NERVES Category: Medical Services CMS Add: 01/01/2002 CMS Term: 64821 MEDSV DEF RBRVS 01/01/2024 648.07 Description: REMOVE SYMPATHETIC NERVES Category: Medical Services CMS Add: 01/01/2002 CMS Term: 64822 MEDSV DEF RBRVS 01/01/2016 12/31/2023 498.98 Description: REMOVE SYMPATHETIC NERVES Category: Medical Services CMS Add: 01/01/2002 CMS Term: 64822 MEDSV DEF RBRVS 01/01/2024 650.20 Description: REMOVE SYMPATHETIC NERVES Category: Medical Services CMS Add: 01/01/2002 CMS Term: 64823 MEDSV DEF RBRVS 01/01/2016 12/31/2023 569.49 Description: SYMPATHECTOMY SUPFC PALMAR Category: Medical Services CMS Add: 01/01/2002 CMS Term: 64823 MEDSV DEF RBRVS 01/01/2024 735.53 Description: SYMPATHECTOMY SUPFC PALMAR Category: Medical Services CMS Add: 01/01/2002 CMS Term: 64831 MEDSV DEF RBRVS 01/01/2024 647.24 Description: REPAIR OF DIGIT NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64831 MEDSV DEF RBRVS 09/01/2019 12/31/2023 489.87 Description: REPAIR OF DIGIT NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64832 MEDSV DEF RBRVS 01/01/2019 12/31/2023 244.37 Description: REPAIR NERVE ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 778 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 64832 MEDSV DEF RBRVS 01/01/2024 306.05 Description: REPAIR NERVE ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64834 MEDSV DEF RBRVS 01/01/2024 684.65 Description: REPAIR OF HAND OR FOOT NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64834 MEDSV DEF RBRVS 09/01/2019 12/31/2023 533.21 Description: REPAIR OF HAND OR FOOT NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64835 MEDSV DEF RBRVS 01/01/2024 756.85 Description: REPAIR OF HAND OR FOOT NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64835 MEDSV DEF RBRVS 09/01/2019 12/31/2023 582.12 Description: REPAIR OF HAND OR FOOT NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64836 MEDSV DEF RBRVS 01/01/2024 756.85 Description: REPAIR OF HAND OR FOOT NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64836 MEDSV DEF RBRVS 09/01/2019 12/31/2023 582.12 Description: REPAIR OF HAND OR FOOT NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64837 MEDSV DEF RBRVS 01/01/2024 332.10 Description: REPAIR NERVE ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64837 MEDSV DEF RBRVS 02/01/2015 12/31/2023 266.43 Description: REPAIR NERVE ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64840 MEDSV DEF RBRVS 01/01/2024 890.80 Description: REPAIR OF LEG NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64840 MEDSV DEF RBRVS 09/01/2019 12/31/2023 677.58 Description: REPAIR OF LEG NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64856 MEDSV DEF RBRVS 01/01/2024 933.70 Description: REPAIR/TRANSPOSE NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64856 MEDSV DEF RBRVS 09/01/2019 12/31/2023 724.55 Description: REPAIR/TRANSPOSE NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64857 MEDSV DEF RBRVS 01/01/2024 975.99 Description: REPAIR ARM/LEG NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64857 MEDSV DEF RBRVS 09/01/2019 12/31/2023 759.31 Description: REPAIR ARM/LEG NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64858 MEDSV DEF RBRVS 01/01/2024 1084.74 Description: REPAIR SCIATIC NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 779 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 64858 MEDSV DEF RBRVS 09/01/2019 12/31/2023 768.88 Description: REPAIR SCIATIC NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64859 MEDSV DEF RBRVS 01/01/2024 225.93 Description: NERVE SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64859 MEDSV DEF RBRVS 02/01/2015 12/31/2023 185.95 Description: NERVE SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64861 MEDSV DEF RBRVS 01/01/2024 1359.79 Description: REPAIR OF ARM NERVES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64861 MEDSV DEF RBRVS 09/01/2019 12/31/2023 982.82 Description: REPAIR OF ARM NERVES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64862 MEDSV DEF RBRVS 01/01/2024 1266.21 Description: REPAIR OF LOW BACK NERVES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64862 MEDSV DEF RBRVS 09/01/2019 12/31/2023 948.59 Description: REPAIR OF LOW BACK NERVES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64864 MEDSV DEF RBRVS 01/01/2024 805.16 Description: REPAIR OF FACIAL NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64864 MEDSV DEF RBRVS 09/01/2019 12/31/2023 635.43 Description: REPAIR OF FACIAL NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64865 MEDSV DEF RBRVS 01/01/2024 1020.48 Description: REPAIR OF FACIAL NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64865 MEDSV DEF RBRVS 09/01/2019 12/31/2023 809.83 Description: REPAIR OF FACIAL NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64866 MEDSV DEF RBRVS 01/01/2024 1156.87 Description: FUSION OF FACIAL/OTHER NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64866 MEDSV DEF RBRVS 09/01/2019 12/31/2023 840.11 Description: FUSION OF FACIAL/OTHER NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64868 MEDSV DEF RBRVS 01/01/2024 936.03 Description: FUSION OF FACIAL/OTHER NERVE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 64868 MEDSV DEF RBRVS 09/01/2019 12/31/2023 741.93 Description: FUSION OF FACIAL/OTHER NERVE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 64872 MEDSV DEF RBRVS 01/01/2019 12/31/2023 86.83 Description: SUBSEQUENT REPAIR OF NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 780 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 64872 MEDSV DEF RBRVS 01/01/2024 105.67 Description: SUBSEQUENT REPAIR OF NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64874 MEDSV DEF RBRVS 01/01/2019 12/31/2023 123.25 Description: REPAIR & REVISE NERVE ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64874 MEDSV DEF RBRVS 01/01/2024 158.02 Description: REPAIR & REVISE NERVE ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64876 MEDSV DEF RBRVS 01/01/2019 12/31/2023 132.99 Description: REPAIR NERVE/SHORTEN BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64876 MEDSV DEF RBRVS 01/01/2024 179.01 Description: REPAIR NERVE/SHORTEN BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64885 MEDSV DEF RBRVS 01/01/2024 1007.41 Description: NERVE GRAFT HEAD/NECK <4 CM Category: Medical Services CMS Add: 01/01/1992 CMS Term: 64885 MEDSV DEF RBRVS 09/01/2019 12/31/2023 830.66 Description: NERVE GRAFT HEAD/NECK <4 CM Category: Medical Services CMS Add: 01/01/1992 CMS Term: 64886 MEDSV DEF RBRVS 01/01/2024 1207.98 Description: NERVE GRAFT HEAD/NECK >4 CM Category: Medical Services CMS Add: 01/01/1992 CMS Term: 64886 MEDSV DEF RBRVS 09/01/2019 12/31/2023 947.07 Description: NERVE GRAFT HEAD/NECK >4 CM Category: Medical Services CMS Add: 01/01/1992 CMS Term: 64890 MEDSV DEF RBRVS 01/01/2024 996.88 Description: NRV GRF 1STRND HND/FOOT <4CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64890 MEDSV DEF RBRVS 09/01/2019 12/31/2023 796.28 Description: NRV GRF 1STRND HND/FOOT <4CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64891 MEDSV DEF RBRVS 01/01/2024 1059.65 Description: NRV GRF 1STRND HND/FOOT >4CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64891 MEDSV DEF RBRVS 09/01/2019 12/31/2023 848.56 Description: NRV GRF 1STRND HND/FOOT >4CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64892 MEDSV DEF RBRVS 01/01/2024 970.46 Description: NRV GRF 1STRND ARM/LEG <4CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64892 MEDSV DEF RBRVS 09/01/2019 12/31/2023 774.34 Description: NRV GRF 1STRND ARM/LEG <4CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64893 MEDSV DEF RBRVS 01/01/2024 1034.21 Description: NRV GRF 1STRND ARM/LEG >4 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 781 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 64893 MEDSV DEF RBRVS 09/01/2019 12/31/2023 827.16 Description: NRV GRF 1STRND ARM/LEG >4 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64895 MEDSV DEF RBRVS 01/01/2024 1221.58 Description: NRV GRF MLTST HND/FOOT <4 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64895 MEDSV DEF RBRVS 09/01/2019 12/31/2023 973.76 Description: NRV GRF MLTST HND/FOOT <4 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64896 MEDSV DEF RBRVS 01/01/2024 1316.19 Description: NRV GRF MLTST HND/FOOT >4 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64896 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1106.64 Description: NRV GRF MLTST HND/FOOT >4 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64897 MEDSV DEF RBRVS 01/01/2024 1167.45 Description: NRV GRF MLTST ARM/LEG <4 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64897 MEDSV DEF RBRVS 09/01/2019 12/31/2023 938.94 Description: NRV GRF MLTST ARM/LEG <4 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64898 MEDSV DEF RBRVS 01/01/2024 1263.84 Description: NRV GRF MLTST ARM/LEG >4 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64898 MEDSV DEF RBRVS 09/01/2019 12/31/2023 986.29 Description: NRV GRF MLTST ARM/LEG >4 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64901 MEDSV DEF RBRVS 01/01/2024 541.96 Description: NERVE GRAFT ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64901 MEDSV DEF RBRVS 02/01/2015 12/31/2023 423.27 Description: NERVE GRAFT ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64902 MEDSV DEF RBRVS 01/01/2019 12/31/2023 489.81 Description: NERVE GRAFT ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64902 MEDSV DEF RBRVS 01/01/2024 627.76 Description: NERVE GRAFT ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64905 MEDSV DEF RBRVS 01/01/2024 931.91 Description: NERVE PEDICLE TRANSFER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64905 MEDSV DEF RBRVS 09/01/2019 12/31/2023 746.10 Description: NERVE PEDICLE TRANSFER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64907 MEDSV DEF RBRVS 01/01/2024 1198.05 Description: NERVE PEDICLE TRANSFER Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 782 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 64907 MEDSV DEF RBRVS 09/01/2019 12/31/2023 895.03 Description: NERVE PEDICLE TRANSFER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 64910 MEDSV DEF RBRVS 01/01/2024 708.97 Description: NERVE REPAIR W/ALLOGRAFT Category: Medical Services CMS Add: 01/01/2007 CMS Term: 64910 MEDSV DEF RBRVS 02/01/2015 12/31/2023 591.48 Description: NERVE REPAIR W/ALLOGRAFT Category: Medical Services CMS Add: 01/01/2007 CMS Term: 64911 MEDSV DEF RBRVS 01/01/2024 946.92 Description: NEURORRAPHY W/VEIN AUTOGRAFT Category: Medical Services CMS Add: 01/01/2007 CMS Term: 64911 MEDSV DEF RBRVS 02/01/2015 12/31/2023 737.49 Description: NEURORRAPHY W/VEIN AUTOGRAFT Category: Medical Services CMS Add: 01/01/2007 CMS Term: 64912 MEDSV DEF RBRVS 01/01/2018 12/31/2023 565.26 Description: NRV RPR W/NRV ALGRFT 1ST Category: Medical Services CMS Add: 01/01/2018 CMS Term: 64912 MEDSV DEF RBRVS 01/01/2024 829.69 Description: NRV RPR W/NRV ALGRFT 1ST Category: Medical Services CMS Add: 01/01/2018 CMS Term: 64913 MEDSV DEF RBRVS 01/01/2018 12/31/2023 114.96 Y Description: NRV RPR W/NRV ALGRFT EA ADDL Category: Medical Services CMS Add: 01/01/2018 CMS Term: 64913 MEDSV DEF RBRVS 01/01/2024 159.59 Y Description: NRV RPR W/NRV ALGRFT EA ADDL Category: Medical Services CMS Add: 01/01/2018 CMS Term: 64999 MEDSV DEF BILL20 Description: UNLISTED PX NERVOUS SYSTEM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65091 MEDSV DEF RBRVS 01/01/2024 699.73 Description: REVISE EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65091 MEDSV DEF RBRVS 09/01/2019 12/31/2023 469.04 Description: REVISE EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65093 MEDSV DEF RBRVS 01/01/2024 693.82 Description: REVISE EYE WITH IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65093 MEDSV DEF RBRVS 09/01/2019 12/31/2023 462.80 Description: REVISE EYE WITH IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65101 MEDSV DEF RBRVS 01/01/2024 799.87 Description: REMOVAL OF EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65101 MEDSV DEF RBRVS 09/01/2019 12/31/2023 543.55 Description: REMOVAL OF EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 783 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 65103 MEDSV DEF RBRVS 01/01/2024 824.35 Description: REMOVE EYE/INSERT IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65103 MEDSV DEF RBRVS 09/01/2019 12/31/2023 567.89 Description: REMOVE EYE/INSERT IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65105 MEDSV DEF RBRVS 01/01/2024 898.40 Description: REMOVE EYE/ATTACH IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65105 MEDSV DEF RBRVS 09/01/2019 12/31/2023 627.48 Description: REMOVE EYE/ATTACH IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65110 MEDSV DEF RBRVS 01/01/2024 1240.39 Description: REMOVAL OF EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65110 MEDSV DEF RBRVS 09/01/2019 12/31/2023 892.08 Description: REMOVAL OF EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65112 MEDSV DEF RBRVS 01/01/2024 1420.33 Description: REMOVE EYE/REVISE SOCKET Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65112 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1035.61 Description: REMOVE EYE/REVISE SOCKET Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65114 MEDSV DEF RBRVS 01/01/2024 1483.12 Description: REMOVE EYE/REVISE SOCKET Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65114 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1086.72 Description: REMOVE EYE/REVISE SOCKET Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65125 MEDSV DEF RBRVS 01/01/2019 12/31/2023 328.80 Description: REVISE OCULAR IMPLANT Category: Medical Services CMS Add: 01/01/1992 CMS Term: 65125 MEDSV DEF RBRVS 01/01/2024 425.40 Description: REVISE OCULAR IMPLANT Category: Medical Services CMS Add: 01/01/1992 CMS Term: 65130 MEDSV DEF RBRVS 01/01/2024 802.70 Description: INSERT OCULAR IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65130 MEDSV DEF RBRVS 09/01/2019 12/31/2023 540.42 Description: INSERT OCULAR IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65135 MEDSV DEF RBRVS 01/01/2024 812.36 Description: INSERT OCULAR IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65135 MEDSV DEF RBRVS 09/01/2019 12/31/2023 548.56 Description: INSERT OCULAR IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 784 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 65140 MEDSV DEF RBRVS 01/01/2024 872.72 Description: ATTACH OCULAR IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65140 MEDSV DEF RBRVS 09/01/2019 12/31/2023 586.85 Description: ATTACH OCULAR IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65150 MEDSV DEF RBRVS 01/01/2024 660.61 Description: REVISE OCULAR IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65150 MEDSV DEF RBRVS 09/01/2019 12/31/2023 412.71 Description: REVISE OCULAR IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65152 MEDSV PRF MAXFEE 01/01/2024 161.74 0.0 Description: MODIFICATION OF OCULAR IM Category: Medical Services CMS Add: 01/01/1900 CMS Term: 06/30/2015 65155 MEDSV DEF RBRVS 01/01/2024 908.03 Description: REINSERT OCULAR IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65155 MEDSV DEF RBRVS 09/01/2019 12/31/2023 625.94 Description: REINSERT OCULAR IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65175 MEDSV DEF RBRVS 01/01/2024 733.67 Description: REMOVAL OF OCULAR IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65175 MEDSV DEF RBRVS 09/01/2019 12/31/2023 476.68 Description: REMOVAL OF OCULAR IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65205 MEDSV DEF RBRVS 01/01/2024 27.44 Description: REMOVE FOREIGN BODY FROM EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65205 MEDSV DEF RBRVS 09/01/2019 12/31/2023 41.29 Description: REMOVE FOREIGN BODY FROM EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65210 MEDSV DEF RBRVS 01/01/2024 36.44 Description: REMOVE FOREIGN BODY FROM EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65210 MEDSV DEF RBRVS 09/01/2019 12/31/2023 50.15 Description: REMOVE FOREIGN BODY FROM EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65220 MEDSV DEF RBRVS 01/01/2024 56.23 Description: REMOVE FOREIGN BODY FROM EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65220 MEDSV DEF RBRVS 09/01/2019 12/31/2023 41.70 Description: REMOVE FOREIGN BODY FROM EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65222 MEDSV DEF RBRVS 01/01/2024 63.68 Description: REMOVE FOREIGN BODY FROM EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 785 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 65222 MEDSV DEF RBRVS 09/01/2019 12/31/2023 49.32 Description: REMOVE FOREIGN BODY FROM EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65235 MEDSV DEF RBRVS 01/01/2024 682.87 Description: REMOVE FOREIGN BODY FROM EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65235 MEDSV DEF RBRVS 09/01/2019 12/31/2023 518.62 Description: REMOVE FOREIGN BODY FROM EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65260 MEDSV DEF RBRVS 01/01/2024 917.36 Description: REMOVE FOREIGN BODY FROM EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65260 MEDSV DEF RBRVS 09/01/2019 12/31/2023 689.67 Description: REMOVE FOREIGN BODY FROM EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65265 MEDSV DEF RBRVS 01/01/2024 1032.63 Description: REMOVE FOREIGN BODY FROM EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65265 MEDSV DEF RBRVS 09/01/2019 12/31/2023 810.54 Description: REMOVE FOREIGN BODY FROM EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65270 MEDSV DEF RBRVS 01/01/2024 266.70 Description: REPAIR OF EYE WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65270 MEDSV DEF RBRVS 09/01/2019 12/31/2023 190.21 Description: REPAIR OF EYE WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65272 MEDSV DEF RBRVS 01/01/2024 494.06 Description: REPAIR OF EYE WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65272 MEDSV DEF RBRVS 09/01/2019 12/31/2023 357.06 Description: REPAIR OF EYE WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65273 MEDSV DEF RBRVS 01/01/2024 354.79 Description: REPAIR OF EYE WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65273 MEDSV DEF RBRVS 09/01/2019 12/31/2023 274.72 Description: REPAIR OF EYE WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65275 MEDSV DEF RBRVS 01/01/2024 551.36 Description: REPAIR OF EYE WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65275 MEDSV DEF RBRVS 09/01/2019 12/31/2023 419.36 Description: REPAIR OF EYE WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65280 MEDSV DEF RBRVS 01/01/2024 626.04 Description: REPAIR OF EYE WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 786 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 65280 MEDSV DEF RBRVS 09/01/2019 12/31/2023 502.79 Description: REPAIR OF EYE WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65285 MEDSV DEF RBRVS 01/01/2024 1031.75 Description: REPAIR OF EYE WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65285 MEDSV DEF RBRVS 09/01/2019 12/31/2023 826.30 Description: REPAIR OF EYE WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65286 MEDSV DEF RBRVS 01/01/2024 652.73 Description: REPAIR OF EYE WOUND Category: Medical Services CMS Add: 01/01/1989 CMS Term: 65286 MEDSV DEF RBRVS 09/01/2019 12/31/2023 507.68 Description: REPAIR OF EYE WOUND Category: Medical Services CMS Add: 01/01/1989 CMS Term: 65290 MEDSV DEF RBRVS 01/01/2024 457.47 Description: REPAIR OF EYE SOCKET WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65290 MEDSV DEF RBRVS 09/01/2019 12/31/2023 366.28 Description: REPAIR OF EYE SOCKET WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65400 MEDSV DEF RBRVS 01/01/2024 647.53 Description: REMOVAL OF EYE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65400 MEDSV DEF RBRVS 09/01/2019 12/31/2023 494.06 Description: REMOVAL OF EYE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65410 MEDSV DEF RBRVS 01/01/2024 133.39 Description: BIOPSY OF CORNEA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65410 MEDSV DEF RBRVS 09/01/2019 12/31/2023 105.14 Description: BIOPSY OF CORNEA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65420 MEDSV DEF RBRVS 01/01/2024 503.61 Description: REMOVAL OF EYE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65420 MEDSV DEF RBRVS 09/01/2019 12/31/2023 365.85 Description: REMOVAL OF EYE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65426 MEDSV DEF RBRVS 01/01/2024 626.39 Description: REMOVAL OF EYE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65426 MEDSV DEF RBRVS 09/01/2019 12/31/2023 469.88 Description: REMOVAL OF EYE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65430 MEDSV DEF RBRVS 01/01/2024 107.77 Description: CORNEAL SMEAR Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 787 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 65430 MEDSV DEF RBRVS 09/01/2019 12/31/2023 84.33 Description: CORNEAL SMEAR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65435 MEDSV DEF RBRVS 01/01/2024 77.07 Description: CURETTE/TREAT CORNEA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65435 MEDSV DEF RBRVS 09/01/2019 12/31/2023 58.66 Description: CURETTE/TREAT CORNEA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65436 MEDSV DEF RBRVS 01/01/2024 362.24 Description: CURETTE/TREAT CORNEA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65436 MEDSV DEF RBRVS 09/01/2019 12/31/2023 286.14 Description: CURETTE/TREAT CORNEA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65450 MEDSV DEF RBRVS 01/01/2024 306.69 Description: TREATMENT OF CORNEAL LESION Category: Medical Services CMS Add: 01/01/1986 CMS Term: 65450 MEDSV DEF RBRVS 09/01/2019 12/31/2023 235.83 Description: TREATMENT OF CORNEAL LESION Category: Medical Services CMS Add: 01/01/1986 CMS Term: 65600 MEDSV DEF RBRVS 01/01/2024 409.25 Description: REVISION OF CORNEA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65600 MEDSV DEF RBRVS 09/01/2019 12/31/2023 286.25 Description: REVISION OF CORNEA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65710 MEDSV DEF RBRVS 01/01/2024 1066.00 Y Description: CORNEAL TRANSPLANT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 65710 MEDSV DEF RBRVS 09/01/2019 12/31/2023 811.43 Y Description: CORNEAL TRANSPLANT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 65730 MEDSV DEF RBRVS 01/01/2024 1169.84 Y Description: CORNEAL TRANSPLANT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 65730 MEDSV DEF RBRVS 09/01/2019 12/31/2023 901.28 Y Description: CORNEAL TRANSPLANT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 65750 MEDSV DEF RBRVS 01/01/2024 1178.31 Y Description: CORNEAL TRANSPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65750 MEDSV DEF RBRVS 09/01/2019 12/31/2023 905.90 Y Description: CORNEAL TRANSPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65755 MEDSV DEF RBRVS 01/01/2024 1173.96 Y Description: CORNEAL TRANSPLANT Category: Medical Services CMS Add: 01/01/1991 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 788 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 65755 MEDSV DEF RBRVS 09/01/2019 12/31/2023 902.95 Y Description: CORNEAL TRANSPLANT Category: Medical Services CMS Add: 01/01/1991 CMS Term: 65756 MEDSV DEF RBRVS 01/01/2024 1100.80 Description: CORNEAL TRNSPL ENDOTHELIAL Category: Medical Services CMS Add: 01/01/2009 CMS Term: 65756 MEDSV DEF RBRVS 02/01/2015 12/31/2023 856.39 Description: CORNEAL TRNSPL ENDOTHELIAL Category: Medical Services CMS Add: 01/01/2009 CMS Term: 65757 MEDSV DEF MAXFEE 01/01/2024 93.13 0.0 Description: PREP CORNEAL ENDO ALLOGRAFT Category: Medical Services CMS Add: 01/01/2009 CMS Term: 65760 NOCOV DEF SYSMAN Description: REVISION OF CORNEA Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 65765 NOCOV DEF SYSMAN Description: REVISION OF CORNEA Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 65767 NOCOV DEF SYSMAN Description: CORNEAL TISSUE TRANSPLANT Category: Non Covered Services CMS Add: 01/01/1987 CMS Term: 65770 MEDSV DEF RBRVS 01/01/2024 1314.23 Description: REVISE CORNEA WITH IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65770 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1105.69 Description: REVISE CORNEA WITH IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65771 NOCOV DEF SYSMAN Description: RADIAL KERATOTOMY Category: Non Covered Services CMS Add: 01/01/1991 CMS Term: 65772 MEDSV DEF RBRVS 01/01/2024 426.50 Description: CORRECTION OF ASTIGMATISM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 65772 MEDSV DEF RBRVS 09/01/2019 12/31/2023 327.33 Description: CORRECTION OF ASTIGMATISM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 65775 MEDSV DEF RBRVS 01/01/2024 535.97 Description: CORRECTION OF ASTIGMATISM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 65775 MEDSV DEF RBRVS 09/01/2019 12/31/2023 396.54 Description: CORRECTION OF ASTIGMATISM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 65778 MEDSV DEF MAXFEE 01/01/2024 1228.32 0.0 Description: COVER EYE W/MEMBRANE Category: Medical Services CMS Add: 01/01/2011 CMS Term: 65779 MEDSV DEF MAXFEE 01/01/2024 1059.60 0.0 Description: COVER EYE W/MEMBRANE SUTURE Category: Medical Services CMS Add: 01/01/2011 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 789 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 65780 MEDSV DEF RBRVS 01/01/2019 12/31/2023 648.64 Y Description: OCULAR RECONST TRANSPLANT Category: Medical Services CMS Add: 01/01/2004 CMS Term: 65780 MEDSV DEF RBRVS 01/01/2024 623.31 Y Description: OCULAR RECONST TRANSPLANT Category: Medical Services CMS Add: 01/01/2004 CMS Term: 65781 MEDSV DEF RBRVS 01/01/2024 1236.76 Y Description: OCULAR RECONST TRANSPLANT Category: Medical Services CMS Add: 01/01/2004 CMS Term: 65781 MEDSV DEF RBRVS 02/01/2015 12/31/2023 962.08 Y Description: OCULAR RECONST TRANSPLANT Category: Medical Services CMS Add: 01/01/2004 CMS Term: 65782 MEDSV DEF RBRVS 01/01/2019 12/31/2023 860.80 Y Description: OCULAR RECONST TRANSPLANT Category: Medical Services CMS Add: 01/01/2004 CMS Term: 65782 MEDSV DEF RBRVS 01/01/2024 1067.61 Y Description: OCULAR RECONST TRANSPLANT Category: Medical Services CMS Add: 01/01/2004 CMS Term: 65785 MEDSV DEF RBRVS 01/01/2024 2005.72 Y 21-999;0-20years Description: IMPLTJ NTRSTRML CRNL RNG SEG Category: Medical Services CMS Add: 01/01/2016 CMS Term: 65785 MEDSV DEF RBRVS 08/03/2018 12/31/2023 1778.50 Y 21-999;0-20years Description: IMPLTJ NTRSTRML CRNL RNG SEG Category: Medical Services CMS Add: 01/01/2016 CMS Term: 65800 MEDSV DEF RBRVS 01/01/2024 112.13 Description: DRAINAGE OF EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65800 MEDSV DEF RBRVS 09/01/2019 12/31/2023 87.43 Description: DRAINAGE OF EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65810 MEDSV DEF RBRVS 01/01/2024 432.44 Description: DRAINAGE OF EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65810 MEDSV DEF RBRVS 09/01/2019 12/31/2023 341.00 Description: DRAINAGE OF EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65815 MEDSV DEF RBRVS 01/01/2024 600.62 Description: DRAINAGE OF EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65815 MEDSV DEF RBRVS 09/01/2019 12/31/2023 463.75 Description: DRAINAGE OF EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65820 MEDSV DEF RBRVS 01/01/2024 770.54 Description: RELIEVE INNER EYE PRESSURE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 65820 MEDSV DEF RBRVS 09/01/2019 12/31/2023 537.64 Description: RELIEVE INNER EYE PRESSURE Category: Medical Services CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 790 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 65850 MEDSV DEF RBRVS 01/01/2024 788.19 Description: INCISION OF EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65850 MEDSV DEF RBRVS 09/01/2019 12/31/2023 624.76 Description: INCISION OF EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65855 MEDSV DEF RBRVS 01/01/2024 229.77 Description: TRABECULOPLASTY LASER SURG Category: Medical Services CMS Add: 01/01/1985 CMS Term: 65855 MEDSV DEF RBRVS 09/01/2019 12/31/2023 247.66 Description: TRABECULOPLASTY LASER SURG Category: Medical Services CMS Add: 01/01/1985 CMS Term: 65860 MEDSV DEF RBRVS 01/01/2024 287.46 Description: INCISE INNER EYE ADHESIONS Category: Medical Services CMS Add: 01/01/1993 CMS Term: 65860 MEDSV DEF RBRVS 09/01/2019 12/31/2023 238.16 Description: INCISE INNER EYE ADHESIONS Category: Medical Services CMS Add: 01/01/1993 CMS Term: 65865 MEDSV DEF RBRVS 01/01/2024 446.49 Description: INCISE INNER EYE ADHESIONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65865 MEDSV DEF RBRVS 09/01/2019 12/31/2023 339.24 Description: INCISE INNER EYE ADHESIONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65870 MEDSV DEF RBRVS 01/01/2024 555.19 Description: INCISE INNER EYE ADHESIONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65870 MEDSV DEF RBRVS 09/01/2019 12/31/2023 437.11 Description: INCISE INNER EYE ADHESIONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65875 MEDSV DEF RBRVS 01/01/2024 592.13 Description: INCISE INNER EYE ADHESIONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65875 MEDSV DEF RBRVS 09/01/2019 12/31/2023 460.94 Description: INCISE INNER EYE ADHESIONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65880 MEDSV DEF RBRVS 01/01/2024 622.23 Description: INCISE INNER EYE ADHESIONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65880 MEDSV DEF RBRVS 09/01/2019 12/31/2023 477.04 Description: INCISE INNER EYE ADHESIONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65900 MEDSV DEF RBRVS 01/01/2024 926.53 Description: REMOVE EYE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65900 MEDSV DEF RBRVS 09/01/2019 12/31/2023 693.57 Description: REMOVE EYE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 791 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 65920 MEDSV DEF RBRVS 01/01/2024 738.98 Description: REMOVE IMPLANT OF EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65920 MEDSV DEF RBRVS 09/01/2019 12/31/2023 576.32 Description: REMOVE IMPLANT OF EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65930 MEDSV DEF RBRVS 01/01/2024 600.09 Description: REMOVE BLOOD CLOT FROM EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 65930 MEDSV DEF RBRVS 09/01/2019 12/31/2023 473.06 Description: REMOVE BLOOD CLOT FROM EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66020 MEDSV DEF RBRVS 01/01/2024 184.39 Description: INJECTION TREATMENT OF EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66020 MEDSV DEF RBRVS 09/01/2019 12/31/2023 132.33 Description: INJECTION TREATMENT OF EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66030 MEDSV DEF RBRVS 01/01/2024 165.75 Description: INJECTION TREATMENT OF EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66030 MEDSV DEF RBRVS 09/01/2019 12/31/2023 118.49 Description: INJECTION TREATMENT OF EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66130 MEDSV DEF RBRVS 01/01/2024 661.03 Description: REMOVE EYE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66130 MEDSV DEF RBRVS 09/01/2019 12/31/2023 515.57 Description: REMOVE EYE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66150 MEDSV DEF RBRVS 01/01/2024 817.96 Description: GLAUCOMA SURGERY Category: Medical Services CMS Add: 01/01/1985 CMS Term: 66150 MEDSV DEF RBRVS 09/01/2019 12/31/2023 628.89 Description: GLAUCOMA SURGERY Category: Medical Services CMS Add: 01/01/1985 CMS Term: 66155 MEDSV DEF RBRVS 01/01/2024 817.31 Description: GLAUCOMA SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66155 MEDSV DEF RBRVS 09/01/2019 12/31/2023 628.38 Description: GLAUCOMA SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66160 MEDSV DEF RBRVS 01/01/2024 919.83 Description: GLAUCOMA SURGERY Category: Medical Services CMS Add: 01/01/1985 CMS Term: 66160 MEDSV DEF RBRVS 09/01/2019 12/31/2023 710.24 Description: GLAUCOMA SURGERY Category: Medical Services CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 792 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 66170 MEDSV DEF RBRVS 01/01/2024 1019.51 Description: GLAUCOMA SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66170 MEDSV DEF RBRVS 09/01/2019 12/31/2023 876.86 Description: GLAUCOMA SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66172 MEDSV DEF RBRVS 01/01/2024 1112.57 Description: INCISION OF EYE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 66172 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1105.54 Description: INCISION OF EYE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 66174 NOCOV DEF SYSMAN Description: TRLUML DIL AQ O/F CAN W/O ST Category: Non Covered Services CMS Add: 01/01/2011 CMS Term: 66175 NOCOV DEF SYSMAN Description: TRLUML DIL AQ O/F CAN W/ST Category: Non Covered Services CMS Add: 01/01/2011 CMS Term: 66179 MEDSV DEF RBRVS 01/01/2024 1007.34 Description: AQUEOUS SHUNT EYE W/O GRAFT Category: Medical Services CMS Add: 01/01/2015 CMS Term: 66179 MEDSV DEF RBRVS 02/01/2015 12/31/2023 775.96 Description: AQUEOUS SHUNT EYE W/O GRAFT Category: Medical Services CMS Add: 01/01/2015 CMS Term: 66180 MEDSV DEF RBRVS 01/01/2024 1062.27 Description: AQUEOUS SHUNT EYE W/GRAFT Category: Medical Services CMS Add: 01/01/1991 CMS Term: 66180 MEDSV DEF RBRVS 09/01/2019 12/31/2023 856.92 Description: AQUEOUS SHUNT EYE W/GRAFT Category: Medical Services CMS Add: 01/01/1991 CMS Term: 66183 MEDSV DEF RBRVS 01/01/2019 12/31/2023 762.98 Description: INSERT ANT DRAINAGE DEVICE Category: Medical Services CMS Add: 01/01/2014 CMS Term: 66183 MEDSV DEF RBRVS 01/01/2024 959.67 Description: INSERT ANT DRAINAGE DEVICE Category: Medical Services CMS Add: 01/01/2014 CMS Term: 66184 MEDSV DEF RBRVS 01/01/2024 738.02 Description: REVISION OF AQUEOUS SHUNT Category: Medical Services CMS Add: 01/01/2015 CMS Term: 66184 MEDSV DEF RBRVS 02/01/2015 12/31/2023 563.98 Description: REVISION OF AQUEOUS SHUNT Category: Medical Services CMS Add: 01/01/2015 CMS Term: 66185 MEDSV DEF RBRVS 01/01/2024 793.12 Description: REVISE AQUEOUS SHUNT EYE Category: Medical Services CMS Add: 01/01/1991 CMS Term: 66185 MEDSV DEF RBRVS 09/01/2019 12/31/2023 555.57 Description: REVISE AQUEOUS SHUNT EYE Category: Medical Services CMS Add: 01/01/1991 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 793 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 66225 MEDSV DEF RBRVS 01/01/2024 873.18 Description: REPAIR/GRAFT EYE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66225 MEDSV DEF RBRVS 09/01/2019 12/31/2023 697.30 Description: REPAIR/GRAFT EYE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66250 MEDSV DEF RBRVS 01/01/2024 703.26 Description: FOLLOW-UP SURGERY OF EYE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 66250 MEDSV DEF RBRVS 09/01/2019 12/31/2023 547.06 Description: FOLLOW-UP SURGERY OF EYE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 66500 MEDSV DEF RBRVS 01/01/2024 369.39 Description: INCISION OF IRIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66500 MEDSV DEF RBRVS 09/01/2019 12/31/2023 253.10 Description: INCISION OF IRIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66505 MEDSV DEF RBRVS 01/01/2024 401.14 Description: INCISION OF IRIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66505 MEDSV DEF RBRVS 09/01/2019 12/31/2023 277.45 Description: INCISION OF IRIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66600 MEDSV DEF RBRVS 01/01/2024 847.89 Description: REMOVE IRIS AND LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66600 MEDSV DEF RBRVS 09/01/2019 12/31/2023 598.55 Description: REMOVE IRIS AND LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66605 MEDSV DEF RBRVS 01/01/2024 1018.84 Description: REMOVAL OF IRIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66605 MEDSV DEF RBRVS 09/01/2019 12/31/2023 761.89 Description: REMOVAL OF IRIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66625 MEDSV DEF RBRVS 01/01/2024 399.83 Description: REMOVAL OF IRIS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 66625 MEDSV DEF RBRVS 09/01/2019 12/31/2023 314.07 Description: REMOVAL OF IRIS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 66630 MEDSV DEF RBRVS 01/01/2024 528.45 Description: REMOVAL OF IRIS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 66630 MEDSV DEF RBRVS 09/01/2019 12/31/2023 421.02 Description: REMOVAL OF IRIS Category: Medical Services CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 794 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 66635 MEDSV DEF RBRVS 01/01/2024 533.21 Description: REMOVAL OF IRIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66635 MEDSV DEF RBRVS 09/01/2019 12/31/2023 413.86 Description: REMOVAL OF IRIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66680 MEDSV DEF RBRVS 01/01/2024 486.52 Description: REPAIR IRIS & CILIARY BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66680 MEDSV DEF RBRVS 09/01/2019 12/31/2023 386.13 Description: REPAIR IRIS & CILIARY BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66682 MEDSV DEF RBRVS 01/01/2024 667.38 Description: REPAIR IRIS & CILIARY BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66682 MEDSV DEF RBRVS 09/01/2019 12/31/2023 471.75 Description: REPAIR IRIS & CILIARY BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66700 MEDSV DEF RBRVS 01/01/2024 422.64 Description: DESTRUCTION CILIARY BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66700 MEDSV DEF RBRVS 09/01/2019 12/31/2023 324.22 Description: DESTRUCTION CILIARY BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66710 MEDSV DEF RBRVS 01/01/2024 413.68 Description: CILIARY TRANSSLERAL THERAPY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 66710 MEDSV DEF RBRVS 02/01/2015 12/31/2023 325.71 Description: CILIARY TRANSSLERAL THERAPY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 66711 MEDSV DEF RBRVS 01/01/2024 470.89 Description: ECP CILIARY BODY DESTRUCTION Category: Medical Services CMS Add: 01/01/2005 CMS Term: 66711 MEDSV DEF RBRVS 02/01/2015 12/31/2023 461.77 Description: ECP CILIARY BODY DESTRUCTION Category: Medical Services CMS Add: 01/01/2005 CMS Term: 66720 MEDSV DEF RBRVS 01/01/2024 435.65 Description: DESTRUCTION CILIARY BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66720 MEDSV DEF RBRVS 09/15/2017 12/31/2023 329.59 Description: DESTRUCTION CILIARY BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66740 MEDSV DEF RBRVS 01/01/2024 410.91 Description: DESTRUCTION CILIARY BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66740 MEDSV DEF RBRVS 09/01/2019 12/31/2023 313.23 Description: DESTRUCTION CILIARY BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 795 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 66761 MEDSV DEF RBRVS 01/01/2024 279.48 Description: REVISION OF IRIS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 66761 MEDSV DEF RBRVS 09/01/2019 12/31/2023 215.03 Description: REVISION OF IRIS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 66762 MEDSV DEF RBRVS 01/01/2024 446.07 Description: REVISION OF IRIS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 66762 MEDSV DEF RBRVS 09/01/2019 12/31/2023 344.29 Description: REVISION OF IRIS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 66770 MEDSV DEF RBRVS 01/01/2024 494.52 Description: REMOVAL OF INNER EYE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66770 MEDSV DEF RBRVS 09/01/2019 12/31/2023 378.15 Description: REMOVAL OF INNER EYE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66820 MEDSV DEF RBRVS 01/01/2024 439.86 Description: INCISION SECONDARY CATARACT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66820 MEDSV DEF RBRVS 09/01/2019 12/31/2023 286.76 Description: INCISION SECONDARY CATARACT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66821 MEDSV DEF RBRVS 01/01/2024 311.94 Description: AFTER CATARACT LASER SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 66821 MEDSV DEF RBRVS 09/01/2019 12/31/2023 239.78 Description: AFTER CATARACT LASER SURGERY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 66825 MEDSV DEF RBRVS 01/01/2024 779.81 Description: REPOSITION INTRAOCULAR LENS Category: Medical Services CMS Add: 01/01/1993 CMS Term: 66825 MEDSV DEF RBRVS 09/01/2019 12/31/2023 553.63 Description: REPOSITION INTRAOCULAR LENS Category: Medical Services CMS Add: 01/01/1993 CMS Term: 66830 MEDSV DEF RBRVS 01/01/2024 660.97 Description: REMOVAL OF LENS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66830 MEDSV DEF RBRVS 09/01/2019 12/31/2023 513.71 Description: REMOVAL OF LENS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66840 MEDSV DEF RBRVS 01/01/2024 646.04 Description: REMOVAL OF LENS MATERIAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66840 MEDSV DEF RBRVS 09/01/2019 12/31/2023 520.46 Description: REMOVAL OF LENS MATERIAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 796 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 66850 MEDSV DEF RBRVS 01/01/2024 734.98 Description: REMOVAL OF LENS MATERIAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66850 MEDSV DEF RBRVS 09/01/2019 12/31/2023 582.78 Description: REMOVAL OF LENS MATERIAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66852 MEDSV DEF RBRVS 01/01/2024 782.08 Description: REMOVAL OF LENS MATERIAL Category: Medical Services CMS Add: 01/01/1991 CMS Term: 66852 MEDSV DEF RBRVS 09/01/2019 12/31/2023 628.19 Description: REMOVAL OF LENS MATERIAL Category: Medical Services CMS Add: 01/01/1991 CMS Term: 66920 MEDSV DEF RBRVS 01/01/2024 698.50 Description: EXTRACTION OF LENS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 66920 MEDSV DEF RBRVS 09/01/2019 12/31/2023 543.75 Description: EXTRACTION OF LENS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 66930 MEDSV DEF RBRVS 01/01/2024 799.51 Description: EXTRACTION OF LENS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66930 MEDSV DEF RBRVS 09/01/2019 12/31/2023 618.11 Description: EXTRACTION OF LENS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66940 MEDSV DEF RBRVS 01/01/2024 731.19 Description: EXTRACTION OF LENS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 66940 MEDSV DEF RBRVS 09/01/2019 12/31/2023 579.77 Description: EXTRACTION OF LENS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 66982 MEDSV DEF RBRVS 01/01/2019 12/31/2023 589.10 Description: XCAPSL CTRC RMVL CPLX WO ECP Category: Medical Services CMS Add: 01/01/2001 CMS Term: 66982 MEDSV DEF RBRVS 01/01/2024 695.31 Description: XCAPSL CTRC RMVL CPLX WO ECP Category: Medical Services CMS Add: 01/01/2001 CMS Term: 66983 MEDSV DEF MAXFEE 01/01/2024 700.49 0.0 Description: CATARACT SURG W/IOL 1 STAGE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 66983 MEDSV DEF RBRVS 09/01/2019 12/31/2023 540.50 Description: CATARACT SURG W/IOL 1 STAGE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 66984 MEDSV DEF RBRVS 01/01/2019 12/31/2023 472.75 Description: XCAPSL CTRC RMVL W/O ECP Category: Medical Services CMS Add: 01/01/1985 CMS Term: 66984 MEDSV DEF RBRVS 01/01/2024 507.67 Description: XCAPSL CTRC RMVL W/O ECP Category: Medical Services CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 797 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 66985 MEDSV DEF RBRVS 01/01/2024 717.02 Description: INSERT LENS PROSTHESIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66985 MEDSV DEF RBRVS 09/01/2019 12/31/2023 564.16 Description: INSERT LENS PROSTHESIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 66986 MEDSV DEF RBRVS 01/01/2024 842.09 Description: EXCHANGE LENS PROSTHESIS Category: Medical Services CMS Add: 01/01/1992 CMS Term: 66986 MEDSV DEF RBRVS 09/01/2019 12/31/2023 666.30 Description: EXCHANGE LENS PROSTHESIS Category: Medical Services CMS Add: 01/01/1992 CMS Term: 66987 MEDSV DEF MAXFEE 01/01/2024 748.57 0.0 Description: XCAPSL CTRC RMVL CPLX W/ECP Category: Medical Services CMS Add: 01/01/2020 CMS Term: 66988 MEDSV DEF MAXFEE 01/01/2024 610.48 0.0 Description: XCAPSL CTRC RMVL W/ECP Category: Medical Services CMS Add: 01/01/2020 CMS Term: 66989 MEDSV DEF RBRVS 01/01/2022 12/31/2023 630.84 Description: XCPSL CTRC RMVL CPLX INSJ 1+ Category: Medical Services CMS Add: 01/01/2022 CMS Term: 66989 MEDSV DEF RBRVS 01/01/2024 798.01 Description: XCPSL CTRC RMVL CPLX INSJ 1+ Category: Medical Services CMS Add: 01/01/2022 CMS Term: 66990 MEDSV DEF RBRVS 01/01/2016 12/31/2023 66.00 Description: OPHTHALMIC ENDOSCOPE ADD-ON Category: Medical Services CMS Add: 01/01/2003 CMS Term: 66990 MEDSV DEF RBRVS 01/01/2024 82.43 Description: OPHTHALMIC ENDOSCOPE ADD-ON Category: Medical Services CMS Add: 01/01/2003 CMS Term: 66991 MEDSV DEF RBRVS 01/01/2022 12/31/2023 502.97 Description: XCAPSL CTRC RMVL INSJ 1+ Category: Medical Services CMS Add: 01/01/2022 CMS Term: 66991 MEDSV DEF RBRVS 01/01/2024 637.22 Description: XCAPSL CTRC RMVL INSJ 1+ Category: Medical Services CMS Add: 01/01/2022 CMS Term: 66999 MEDSV DEF BILL20 Description: UNLISTED PX ANT SEGMENT EYE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67005 MEDSV DEF RBRVS 01/01/2024 443.46 Description: PARTIAL REMOVAL OF EYE FLUID Category: Medical Services CMS Add: 01/01/1986 CMS Term: 67005 MEDSV DEF RBRVS 09/01/2019 12/31/2023 352.96 Description: PARTIAL REMOVAL OF EYE FLUID Category: Medical Services CMS Add: 01/01/1986 CMS Term: 67010 MEDSV DEF RBRVS 01/01/2024 508.03 Description: PARTIAL REMOVAL OF EYE FLUID Category: Medical Services CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 798 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 67010 MEDSV DEF RBRVS 09/01/2019 12/31/2023 398.43 Description: PARTIAL REMOVAL OF EYE FLUID Category: Medical Services CMS Add: 01/01/1986 CMS Term: 67015 MEDSV DEF RBRVS 01/01/2024 565.08 Description: RELEASE OF EYE FLUID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67015 MEDSV DEF RBRVS 09/01/2019 12/31/2023 424.53 Description: RELEASE OF EYE FLUID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67025 MEDSV DEF RBRVS 01/01/2024 692.94 Description: REPLACE EYE FLUID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67025 MEDSV DEF RBRVS 09/01/2019 12/31/2023 533.49 Description: REPLACE EYE FLUID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67027 MEDSV DEF RBRVS 01/01/2024 790.13 Description: IMPLANT EYE DRUG SYSTEM Category: Medical Services CMS Add: 01/01/1998 CMS Term: 67027 MEDSV DEF RBRVS 02/01/2015 12/31/2023 634.08 Description: IMPLANT EYE DRUG SYSTEM Category: Medical Services CMS Add: 01/01/1998 CMS Term: 67028 MEDSV DEF RBRVS 01/01/2024 106.14 Description: INJECTION EYE DRUG Category: Medical Services CMS Add: 01/01/1991 CMS Term: 67028 MEDSV DEF RBRVS 09/01/2019 12/31/2023 75.02 Description: INJECTION EYE DRUG Category: Medical Services CMS Add: 01/01/1991 CMS Term: 67030 MEDSV DEF RBRVS 01/01/2024 520.39 Description: INCISE INNER EYE STRANDS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67030 MEDSV DEF RBRVS 09/01/2019 12/31/2023 381.32 Description: INCISE INNER EYE STRANDS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67031 MEDSV DEF RBRVS 01/01/2024 363.33 Description: LASER SURGERY EYE STRANDS Category: Medical Services CMS Add: 01/01/1986 CMS Term: 67031 MEDSV DEF RBRVS 09/01/2019 12/31/2023 282.44 Description: LASER SURGERY EYE STRANDS Category: Medical Services CMS Add: 01/01/1986 CMS Term: 67036 MEDSV DEF RBRVS 01/01/2024 835.05 Description: REMOVAL OF INNER EYE FLUID Category: Medical Services CMS Add: 01/01/1985 CMS Term: 67036 MEDSV DEF RBRVS 09/01/2019 12/31/2023 706.17 Description: REMOVAL OF INNER EYE FLUID Category: Medical Services CMS Add: 01/01/1985 CMS Term: 67039 MEDSV DEF RBRVS 01/01/2024 894.22 Description: LASER TREATMENT OF RETINA Category: Medical Services CMS Add: 01/01/1991 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 799 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 67039 MEDSV DEF RBRVS 09/01/2019 12/31/2023 918.04 Description: LASER TREATMENT OF RETINA Category: Medical Services CMS Add: 01/01/1991 CMS Term: 67040 MEDSV DEF RBRVS 01/01/2024 965.36 Description: LASER TREATMENT OF RETINA Category: Medical Services CMS Add: 01/01/1988 CMS Term: 67040 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1044.94 Description: LASER TREATMENT OF RETINA Category: Medical Services CMS Add: 01/01/1988 CMS Term: 67041 MEDSV DEF RBRVS 01/01/2024 1065.75 Description: VIT FOR MACULAR PUCKER Category: Medical Services CMS Add: 01/01/2008 CMS Term: 67041 MEDSV DEF RBRVS 02/01/2015 12/31/2023 978.46 Description: VIT FOR MACULAR PUCKER Category: Medical Services CMS Add: 01/01/2008 CMS Term: 67042 MEDSV DEF RBRVS 01/01/2024 1065.44 Description: VIT FOR MACULAR HOLE Category: Medical Services CMS Add: 01/01/2008 CMS Term: 67042 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1118.87 Description: VIT FOR MACULAR HOLE Category: Medical Services CMS Add: 01/01/2008 CMS Term: 67043 MEDSV DEF RBRVS 01/01/2024 1123.66 Description: VIT FOR MEMBRANE DISSECT Category: Medical Services CMS Add: 01/01/2008 CMS Term: 67043 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1190.04 Description: VIT FOR MEMBRANE DISSECT Category: Medical Services CMS Add: 01/01/2008 CMS Term: 67101 MEDSV DEF RBRVS 01/01/2024 312.19 Description: REPAIR DETACHED RETINA CRTX Category: Medical Services CMS Add: 01/01/1986 CMS Term: 67101 MEDSV DEF RBRVS 09/01/2019 12/31/2023 575.23 Description: REPAIR DETACHED RETINA CRTX Category: Medical Services CMS Add: 01/01/1986 CMS Term: 67105 MEDSV DEF RBRVS 01/01/2024 276.51 Description: REPAIR DETACHED RETINA PC Category: Medical Services CMS Add: 01/01/1986 CMS Term: 67105 MEDSV DEF RBRVS 09/01/2019 12/31/2023 524.88 Description: REPAIR DETACHED RETINA PC Category: Medical Services CMS Add: 01/01/1986 CMS Term: 67107 MEDSV DEF RBRVS 01/01/2024 1047.28 Description: REPAIR DETACHED RETINA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67107 MEDSV DEF RBRVS 09/01/2019 12/31/2023 905.02 Description: REPAIR DETACHED RETINA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67108 MEDSV DEF RBRVS 01/01/2024 1108.79 Description: REPAIR DETACHED RETINA Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 800 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 67108 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1184.02 Description: REPAIR DETACHED RETINA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67110 MEDSV DEF RBRVS 01/01/2024 831.46 Description: REPAIR DETACHED RETINA Category: Medical Services CMS Add: 01/01/1991 CMS Term: 67110 MEDSV DEF RBRVS 09/01/2019 12/31/2023 631.94 Description: REPAIR DETACHED RETINA Category: Medical Services CMS Add: 01/01/1991 CMS Term: 67113 MEDSV DEF RBRVS 01/01/2024 1239.41 Description: REPAIR RETINAL DETACH CPLX Category: Medical Services CMS Add: 01/01/2008 CMS Term: 67113 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1288.75 Description: REPAIR RETINAL DETACH CPLX Category: Medical Services CMS Add: 01/01/2008 CMS Term: 67115 MEDSV DEF RBRVS 01/01/2024 464.51 Description: RELEASE ENCIRCLING MATERIAL Category: Medical Services CMS Add: 01/01/1985 CMS Term: 67115 MEDSV DEF RBRVS 09/01/2019 12/31/2023 364.32 Description: RELEASE ENCIRCLING MATERIAL Category: Medical Services CMS Add: 01/01/1985 CMS Term: 67120 MEDSV DEF RBRVS 01/01/2024 626.70 Description: REMOVE EYE IMPLANT MATERIAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67120 MEDSV DEF RBRVS 09/01/2019 12/31/2023 484.15 Description: REMOVE EYE IMPLANT MATERIAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67121 MEDSV DEF RBRVS 01/01/2024 841.75 Description: REMOVE EYE IMPLANT MATERIAL Category: Medical Services CMS Add: 01/01/1985 CMS Term: 67121 MEDSV DEF RBRVS 09/01/2019 12/31/2023 675.69 Description: REMOVE EYE IMPLANT MATERIAL Category: Medical Services CMS Add: 01/01/1985 CMS Term: 67141 MEDSV DEF RBRVS 01/01/2024 251.18 Description: PROPH RTA DTCHMNT CRTX DTHRM Category: Medical Services CMS Add: 01/01/1986 CMS Term: 67141 MEDSV DEF RBRVS 09/01/2019 12/31/2023 385.79 Description: PROPH RTA DTCHMNT CRTX DTHRM Category: Medical Services CMS Add: 01/01/1986 CMS Term: 67145 MEDSV DEF RBRVS 01/01/2024 226.48 Description: PROPH RTA DTCHMNT PC Category: Medical Services CMS Add: 01/01/1986 CMS Term: 67145 MEDSV DEF RBRVS 09/01/2019 12/31/2023 384.49 Description: PROPH RTA DTCHMNT PC Category: Medical Services CMS Add: 01/01/1986 CMS Term: 67208 MEDSV DEF RBRVS 01/01/2024 562.47 Description: TREATMENT OF RETINAL LESION Category: Medical Services CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 801 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 67208 MEDSV DEF RBRVS 09/01/2019 12/31/2023 430.96 Description: TREATMENT OF RETINAL LESION Category: Medical Services CMS Add: 01/01/1986 CMS Term: 67210 MEDSV DEF RBRVS 01/01/2024 481.35 Description: TREATMENT OF RETINAL LESION Category: Medical Services CMS Add: 01/01/1986 CMS Term: 67210 MEDSV DEF RBRVS 09/01/2019 12/31/2023 379.95 Description: TREATMENT OF RETINAL LESION Category: Medical Services CMS Add: 01/01/1986 CMS Term: 67218 MEDSV DEF RBRVS 01/01/2024 1300.68 Description: TREATMENT OF RETINAL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67218 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1001.67 Description: TREATMENT OF RETINAL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67220 MEDSV DEF RBRVS 01/01/2024 495.08 Description: TREATMENT OF CHOROID LESION Category: Medical Services CMS Add: 01/01/1999 CMS Term: 67220 MEDSV DEF RBRVS 02/01/2015 12/31/2023 394.08 Description: TREATMENT OF CHOROID LESION Category: Medical Services CMS Add: 01/01/1999 CMS Term: 67221 MEDSV DEF RBRVS 01/01/2024 255.08 Description: OCULAR PHOTODYNAMIC THER Category: Medical Services CMS Add: 01/01/2001 CMS Term: 67221 MEDSV DEF RBRVS 02/01/2015 12/31/2023 209.53 Description: OCULAR PHOTODYNAMIC THER Category: Medical Services CMS Add: 01/01/2001 CMS Term: 67225 MEDSV DEF RBRVS 01/01/2024 27.38 Description: EYE PHOTODYNAMIC THER ADD-ON Category: Medical Services CMS Add: 01/01/2002 CMS Term: 67225 MEDSV DEF RBRVS 02/01/2015 12/31/2023 21.55 Description: EYE PHOTODYNAMIC THER ADD-ON Category: Medical Services CMS Add: 01/01/2002 CMS Term: 67227 MEDSV DEF RBRVS 01/01/2024 275.76 Description: DSTRJ EXTENSIVE RETINOPATHY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 67227 MEDSV DEF RBRVS 09/01/2019 12/31/2023 438.39 Description: DSTRJ EXTENSIVE RETINOPATHY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 67228 MEDSV DEF RBRVS 01/01/2024 317.40 Description: TREATMENT X10SV RETINOPATHY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 67228 MEDSV DEF RBRVS 09/01/2019 12/31/2023 739.43 Description: TREATMENT X10SV RETINOPATHY Category: Medical Services CMS Add: 01/01/1986 CMS Term: 67229 MEDSV DEF RBRVS 01/01/2024 1079.39 0-364days Description: TR RETINAL LES PRETERM INF Category: Medical Services CMS Add: 01/01/2008 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 802 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 67229 MEDSV DEF RBRVS 02/01/2015 12/31/2023 802.99 0-364days Description: TR RETINAL LES PRETERM INF Category: Medical Services CMS Add: 01/01/2008 CMS Term: 67250 MEDSV DEF RBRVS 01/01/2024 850.03 Description: REINFORCE EYE WALL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67250 MEDSV DEF RBRVS 09/01/2019 12/31/2023 575.86 Description: REINFORCE EYE WALL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67255 MEDSV DEF RBRVS 01/01/2024 641.74 Description: REINFORCE/GRAFT EYE WALL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67255 MEDSV DEF RBRVS 09/01/2019 12/31/2023 624.18 Description: REINFORCE/GRAFT EYE WALL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67299 MEDSV DEF BILL20 Description: UNLISTED PX POSTERIOR SEGMNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67311 MEDSV DEF RBRVS 01/01/2024 424.75 Description: REVISE EYE MUSCLE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 67311 MEDSV DEF RBRVS 09/01/2019 12/31/2023 442.94 Description: REVISE EYE MUSCLE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 67312 MEDSV DEF RBRVS 01/01/2024 620.47 Description: REVISE TWO EYE MUSCLES Category: Medical Services CMS Add: 01/01/1986 CMS Term: 67312 MEDSV DEF RBRVS 09/01/2019 12/31/2023 533.28 Description: REVISE TWO EYE MUSCLES Category: Medical Services CMS Add: 01/01/1986 CMS Term: 67314 MEDSV DEF RBRVS 01/01/2024 424.75 Description: REVISE EYE MUSCLE Category: Medical Services CMS Add: 01/01/1991 CMS Term: 67314 MEDSV DEF RBRVS 09/01/2019 12/31/2023 498.42 Description: REVISE EYE MUSCLE Category: Medical Services CMS Add: 01/01/1991 CMS Term: 67316 MEDSV DEF RBRVS 01/01/2024 665.56 Description: REVISE TWO EYE MUSCLES Category: Medical Services CMS Add: 01/01/1991 CMS Term: 67316 MEDSV DEF RBRVS 09/01/2019 12/31/2023 599.69 Description: REVISE TWO EYE MUSCLES Category: Medical Services CMS Add: 01/01/1991 CMS Term: 67318 MEDSV DEF RBRVS 01/01/2024 642.07 Description: REVISE EYE MUSCLE(S) Category: Medical Services CMS Add: 01/01/1991 CMS Term: 67318 MEDSV DEF RBRVS 09/01/2019 12/31/2023 507.78 Description: REVISE EYE MUSCLE(S) Category: Medical Services CMS Add: 01/01/1991 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 803 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 67320 MEDSV DEF RBRVS 01/01/2024 190.26 Description: REVISE EYE MUSCLE(S) ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67320 MEDSV DEF RBRVS 09/01/2019 12/31/2023 235.01 Description: REVISE EYE MUSCLE(S) ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67331 MEDSV DEF RBRVS 01/01/2024 179.18 Description: EYE SURGERY FOLLOW-UP ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67331 MEDSV DEF RBRVS 09/01/2019 12/31/2023 231.14 Description: EYE SURGERY FOLLOW-UP ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67332 MEDSV DEF RBRVS 01/01/2024 196.73 Description: REREVISE EYE MUSCLES ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67332 MEDSV DEF RBRVS 09/01/2019 12/31/2023 251.03 Description: REREVISE EYE MUSCLES ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67334 MEDSV DEF RBRVS 01/01/2024 176.89 Description: REVISE EYE MUSCLE W/SUTURE Category: Medical Services CMS Add: 01/01/1991 CMS Term: 67334 MEDSV DEF RBRVS 09/01/2019 12/31/2023 220.15 Description: REVISE EYE MUSCLE W/SUTURE Category: Medical Services CMS Add: 01/01/1991 CMS Term: 67335 MEDSV DEF RBRVS 01/01/2019 12/31/2023 112.48 Description: EYE SUTURE DURING SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 67335 MEDSV DEF RBRVS 01/01/2024 175.84 Description: EYE SUTURE DURING SURGERY Category: Medical Services CMS Add: 01/01/1988 CMS Term: 67340 MEDSV DEF RBRVS 01/01/2024 273.25 Description: REVISE EYE MUSCLE ADD-ON Category: Medical Services CMS Add: 01/01/1991 CMS Term: 67340 MEDSV DEF RBRVS 09/01/2019 12/31/2023 261.70 Description: REVISE EYE MUSCLE ADD-ON Category: Medical Services CMS Add: 01/01/1991 CMS Term: 67343 MEDSV DEF RBRVS 01/01/2024 625.37 Description: RELEASE EYE TISSUE Category: Medical Services CMS Add: 01/01/1991 CMS Term: 67343 MEDSV DEF RBRVS 09/01/2019 12/31/2023 487.18 Description: RELEASE EYE TISSUE Category: Medical Services CMS Add: 01/01/1991 CMS Term: 67345 MEDSV DEF RBRVS 01/01/2024 224.53 Description: DESTROY NERVE OF EYE MUSCLE Category: Medical Services CMS Add: 01/01/1990 CMS Term: 67345 MEDSV DEF RBRVS 09/01/2019 12/31/2023 179.30 Description: DESTROY NERVE OF EYE MUSCLE Category: Medical Services CMS Add: 01/01/1990 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 804 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 67346 MEDSV DEF RBRVS 01/01/2024 178.90 Description: BIOPSY EYE MUSCLE Category: Medical Services CMS Add: 01/01/2007 CMS Term: 67346 MEDSV DEF RBRVS 02/01/2015 12/31/2023 147.13 Description: BIOPSY EYE MUSCLE Category: Medical Services CMS Add: 01/01/2007 CMS Term: 67399 MEDSV DEF BILL20 Description: UNLISTED PX EXTRAOCULAR MUSC Category: Medical Services CMS Add: 01/01/1982 CMS Term: 67400 MEDSV DEF RBRVS 01/01/2024 973.93 Description: EXPLORE/BIOPSY EYE SOCKET Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67400 MEDSV DEF RBRVS 09/01/2019 12/31/2023 686.87 Description: EXPLORE/BIOPSY EYE SOCKET Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67405 MEDSV DEF RBRVS 01/01/2024 848.54 Description: EXPLORE/DRAIN EYE SOCKET Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67405 MEDSV DEF RBRVS 09/01/2019 12/31/2023 574.75 Description: EXPLORE/DRAIN EYE SOCKET Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67412 MEDSV DEF RBRVS 01/01/2024 931.36 Description: EXPLORE/TREAT EYE SOCKET Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67412 MEDSV DEF RBRVS 09/01/2019 12/31/2023 627.68 Description: EXPLORE/TREAT EYE SOCKET Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67413 MEDSV DEF RBRVS 01/01/2024 906.69 Description: EXPLORE/TREAT EYE SOCKET Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67413 MEDSV DEF RBRVS 09/01/2019 12/31/2023 630.94 Description: EXPLORE/TREAT EYE SOCKET Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67414 MEDSV DEF RBRVS 01/01/2024 1364.60 Description: EXPLR/DECOMPRESS EYE SOCKET Category: Medical Services CMS Add: 01/01/1992 CMS Term: 67414 MEDSV DEF RBRVS 09/01/2019 12/31/2023 970.51 Description: EXPLR/DECOMPRESS EYE SOCKET Category: Medical Services CMS Add: 01/01/1992 CMS Term: 67415 MEDSV DEF RBRVS 01/01/2024 96.16 Description: ASPIRATION ORBITAL CONTENTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67415 MEDSV DEF RBRVS 09/01/2019 12/31/2023 78.09 Description: ASPIRATION ORBITAL CONTENTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67420 MEDSV DEF RBRVS 01/01/2024 1639.24 Description: EXPLORE/TREAT EYE SOCKET Category: Medical Services CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 805 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 67420 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1202.61 Description: EXPLORE/TREAT EYE SOCKET Category: Medical Services CMS Add: 01/01/1985 CMS Term: 67430 MEDSV DEF RBRVS 01/01/2024 1301.65 Description: EXPLORE/TREAT EYE SOCKET Category: Medical Services CMS Add: 01/01/1985 CMS Term: 67430 MEDSV DEF RBRVS 09/01/2019 12/31/2023 895.42 Description: EXPLORE/TREAT EYE SOCKET Category: Medical Services CMS Add: 01/01/1985 CMS Term: 67440 MEDSV DEF RBRVS 01/01/2024 1262.91 Description: EXPLORE/DRAIN EYE SOCKET Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67440 MEDSV DEF RBRVS 09/01/2019 12/31/2023 879.54 Description: EXPLORE/DRAIN EYE SOCKET Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67445 MEDSV DEF RBRVS 01/01/2024 1435.69 Description: EXPLR/DECOMPRESS EYE SOCKET Category: Medical Services CMS Add: 01/01/1992 CMS Term: 67445 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1045.99 Description: EXPLR/DECOMPRESS EYE SOCKET Category: Medical Services CMS Add: 01/01/1992 CMS Term: 67450 MEDSV DEF RBRVS 01/01/2024 1308.35 Description: EXPLORE/BIOPSY EYE SOCKET Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67450 MEDSV DEF RBRVS 09/01/2019 12/31/2023 909.30 Description: EXPLORE/BIOPSY EYE SOCKET Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67500 MEDSV DEF RBRVS 01/01/2024 72.16 Description: INJECT/TREAT EYE SOCKET Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67500 MEDSV DEF RBRVS 09/01/2019 12/31/2023 57.35 Description: INJECT/TREAT EYE SOCKET Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67505 MEDSV DEF RBRVS 01/01/2024 81.11 Description: INJECT/TREAT EYE SOCKET Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67505 MEDSV DEF RBRVS 09/01/2019 12/31/2023 67.23 Description: INJECT/TREAT EYE SOCKET Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67515 MEDSV DEF RBRVS 01/01/2024 48.61 Description: INJECT/TREAT EYE SOCKET Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67515 MEDSV DEF RBRVS 09/01/2019 12/31/2023 72.71 Description: INJECT/TREAT EYE SOCKET Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67516 MEDSV DEF RBRVS 01/01/2024 113.36 Description: SPRCHOROIDAL SPC NJX RX AGT Category: Medical Services CMS Add: 01/01/2024 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 806 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 67550 MEDSV DEF RBRVS 01/01/2024 1019.54 Description: INSERT EYE SOCKET IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67550 MEDSV DEF RBRVS 09/01/2019 12/31/2023 711.52 Description: INSERT EYE SOCKET IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67560 MEDSV DEF RBRVS 01/01/2024 1040.39 Description: REVISE EYE SOCKET IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67560 MEDSV DEF RBRVS 09/01/2019 12/31/2023 719.63 Description: REVISE EYE SOCKET IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67570 MEDSV DEF RBRVS 01/01/2024 1196.74 Description: DECOMPRESS OPTIC NERVE Category: Medical Services CMS Add: 01/01/1992 CMS Term: 67570 MEDSV DEF RBRVS 09/01/2019 12/31/2023 884.01 Description: DECOMPRESS OPTIC NERVE Category: Medical Services CMS Add: 01/01/1992 CMS Term: 67599 MEDSV DEF BILL20 Description: UNLISTED PROCEDURE ORBIT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67700 MEDSV DEF RBRVS 01/01/2024 265.93 Description: DRAINAGE OF EYELID ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67700 MEDSV DEF RBRVS 09/01/2019 12/31/2023 189.38 Description: DRAINAGE OF EYELID ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67710 MEDSV DEF RBRVS 01/01/2024 227.11 Description: INCISION OF EYELID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67710 MEDSV DEF RBRVS 09/01/2019 12/31/2023 158.80 Description: INCISION OF EYELID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67715 MEDSV DEF RBRVS 01/01/2024 246.60 Description: INCISION OF EYELID FOLD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67715 MEDSV DEF RBRVS 09/01/2019 12/31/2023 168.55 Description: INCISION OF EYELID FOLD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67800 MEDSV DEF RBRVS 01/01/2024 120.86 Description: REMOVE EYELID LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67800 MEDSV DEF RBRVS 09/01/2019 12/31/2023 92.96 Description: REMOVE EYELID LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67801 MEDSV DEF RBRVS 01/01/2024 153.28 Description: REMOVE EYELID LESIONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 807 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 67801 MEDSV DEF RBRVS 09/01/2019 12/31/2023 119.52 Description: REMOVE EYELID LESIONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67805 MEDSV DEF RBRVS 01/01/2024 190.34 Description: REMOVE EYELID LESIONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67805 MEDSV DEF RBRVS 09/01/2019 12/31/2023 148.44 Description: REMOVE EYELID LESIONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67808 MEDSV DEF RBRVS 01/01/2024 342.89 Description: REMOVE EYELID LESION(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67808 MEDSV DEF RBRVS 09/01/2019 12/31/2023 273.55 Description: REMOVE EYELID LESION(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67810 MEDSV DEF RBRVS 01/01/2024 173.27 Description: BIOPSY EYELID & LID MARGIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67810 MEDSV DEF RBRVS 09/01/2019 12/31/2023 119.73 Description: BIOPSY EYELID & LID MARGIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67820 MEDSV DEF RBRVS 01/01/2024 18.27 Description: REVISE EYELASHES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67820 MEDSV DEF RBRVS 09/01/2019 12/31/2023 37.24 Description: REVISE EYELASHES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67825 MEDSV DEF RBRVS 01/01/2024 126.79 Description: REVISE EYELASHES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67825 MEDSV DEF RBRVS 09/01/2019 12/31/2023 94.49 Description: REVISE EYELASHES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67830 MEDSV DEF RBRVS 01/01/2024 252.65 Description: REVISE EYELASHES Category: Medical Services CMS Add: 01/01/1985 CMS Term: 67830 MEDSV DEF RBRVS 09/01/2019 12/31/2023 190.45 Description: REVISE EYELASHES Category: Medical Services CMS Add: 01/01/1985 CMS Term: 67835 MEDSV DEF RBRVS 01/01/2024 411.71 Description: REVISE EYELASHES Category: Medical Services CMS Add: 01/01/1985 CMS Term: 67835 MEDSV DEF RBRVS 09/01/2019 12/31/2023 327.54 Description: REVISE EYELASHES Category: Medical Services CMS Add: 01/01/1985 CMS Term: 67840 MEDSV DEF RBRVS 01/01/2024 262.96 Description: REMOVE EYELID LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 808 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 67840 MEDSV DEF RBRVS 09/01/2019 12/31/2023 196.86 Description: REMOVE EYELID LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67850 MEDSV DEF RBRVS 01/01/2024 203.71 Description: DSTRJ LESION LID MARGIN <1CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67850 MEDSV DEF RBRVS 09/01/2019 12/31/2023 151.37 Description: DSTRJ LESION LID MARGIN <1CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67875 MEDSV DEF RBRVS 01/01/2024 170.55 Description: CLOSURE OF EYELID BY SUTURE Category: Medical Services CMS Add: 01/01/1991 CMS Term: 67875 MEDSV DEF RBRVS 09/01/2019 12/31/2023 123.06 Description: CLOSURE OF EYELID BY SUTURE Category: Medical Services CMS Add: 01/01/1991 CMS Term: 67880 MEDSV DEF RBRVS 01/01/2024 437.52 Description: REVISION OF EYELID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67880 MEDSV DEF RBRVS 09/01/2019 12/31/2023 333.91 Description: REVISION OF EYELID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67882 MEDSV DEF RBRVS 01/01/2024 535.10 Description: REVISION OF EYELID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67882 MEDSV DEF RBRVS 09/01/2019 12/31/2023 414.01 Description: REVISION OF EYELID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67900 MEDSV DEF RBRVS 01/01/2024 608.45 Y Description: REPAIR BROW DEFECT Category: Medical Services CMS Add: 01/01/1992 CMS Term: 67900 MEDSV DEF RBRVS 09/01/2019 12/31/2023 466.13 Y Description: REPAIR BROW DEFECT Category: Medical Services CMS Add: 01/01/1992 CMS Term: 67901 MEDSV DEF RBRVS 01/01/2024 746.01 Y Description: REPAIR EYELID DEFECT Category: Medical Services CMS Add: 01/01/1982 CMS Term: 67901 MEDSV DEF RBRVS 09/01/2019 12/31/2023 552.30 Y Description: REPAIR EYELID DEFECT Category: Medical Services CMS Add: 01/01/1982 CMS Term: 67902 MEDSV DEF RBRVS 01/01/2024 677.33 Y Description: REPAIR EYELID DEFECT Category: Medical Services CMS Add: 01/01/1982 CMS Term: 67902 MEDSV DEF RBRVS 09/01/2019 12/31/2023 540.14 Y Description: REPAIR EYELID DEFECT Category: Medical Services CMS Add: 01/01/1982 CMS Term: 67903 MEDSV DEF RBRVS 01/01/2024 565.31 Y Description: REPAIR EYELID DEFECT Category: Medical Services CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 809 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 67903 MEDSV DEF RBRVS 09/01/2019 12/31/2023 435.43 Y Description: REPAIR EYELID DEFECT Category: Medical Services CMS Add: 01/01/1982 CMS Term: 67904 MEDSV DEF RBRVS 01/01/2024 693.45 Y Description: REPAIR EYELID DEFECT Category: Medical Services CMS Add: 01/01/1982 CMS Term: 67904 MEDSV DEF RBRVS 09/01/2019 12/31/2023 536.59 Y Description: REPAIR EYELID DEFECT Category: Medical Services CMS Add: 01/01/1982 CMS Term: 67906 MEDSV DEF RBRVS 01/01/2024 471.05 Y Description: REPAIR EYELID DEFECT Category: Medical Services CMS Add: 01/01/1982 CMS Term: 67906 MEDSV DEF RBRVS 09/01/2019 12/31/2023 366.86 Y Description: REPAIR EYELID DEFECT Category: Medical Services CMS Add: 01/01/1982 CMS Term: 67908 MEDSV DEF RBRVS 01/01/2024 507.57 Y Description: REPAIR EYELID DEFECT Category: Medical Services CMS Add: 01/01/1982 CMS Term: 67908 MEDSV DEF RBRVS 09/01/2019 12/31/2023 362.79 Y Description: REPAIR EYELID DEFECT Category: Medical Services CMS Add: 01/01/1982 CMS Term: 67909 MEDSV DEF RBRVS 01/01/2024 514.92 Description: REVISE EYELID DEFECT Category: Medical Services CMS Add: 01/01/1982 CMS Term: 67909 MEDSV DEF RBRVS 09/01/2019 12/31/2023 391.18 Description: REVISE EYELID DEFECT Category: Medical Services CMS Add: 01/01/1982 CMS Term: 67911 MEDSV DEF RBRVS 01/01/2024 521.12 Description: REVISE EYELID DEFECT Category: Medical Services CMS Add: 01/01/1982 CMS Term: 67911 MEDSV DEF RBRVS 09/01/2019 12/31/2023 418.60 Description: REVISE EYELID DEFECT Category: Medical Services CMS Add: 01/01/1982 CMS Term: 67912 MEDSV DEF RBRVS 01/01/2024 845.42 Y Description: CORRECTION EYELID W/IMPLANT Category: Medical Services CMS Add: 01/01/2004 CMS Term: 67912 MEDSV DEF RBRVS 02/01/2015 12/31/2023 628.00 Y Description: CORRECTION EYELID W/IMPLANT Category: Medical Services CMS Add: 01/01/2004 CMS Term: 67914 MEDSV DEF RBRVS 01/01/2024 456.83 Description: REPAIR EYELID DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67914 MEDSV DEF RBRVS 09/01/2019 12/31/2023 337.90 Description: REPAIR EYELID DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67915 MEDSV DEF RBRVS 01/01/2024 295.96 Description: REPAIR EYELID DEFECT Category: Medical Services CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 810 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 67915 MEDSV DEF RBRVS 09/01/2019 12/31/2023 208.13 Description: REPAIR EYELID DEFECT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 67916 MEDSV DEF RBRVS 01/01/2024 571.57 Description: REPAIR EYELID DEFECT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 67916 MEDSV DEF RBRVS 09/01/2019 12/31/2023 428.31 Description: REPAIR EYELID DEFECT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 67917 MEDSV DEF RBRVS 01/01/2024 584.85 Description: REPAIR EYELID DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67917 MEDSV DEF RBRVS 09/01/2019 12/31/2023 438.92 Description: REPAIR EYELID DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67921 MEDSV DEF RBRVS 01/01/2024 447.32 Description: REPAIR EYELID DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67921 MEDSV DEF RBRVS 09/01/2019 12/31/2023 331.62 Description: REPAIR EYELID DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67922 MEDSV DEF RBRVS 01/01/2024 287.32 Description: REPAIR EYELID DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67922 MEDSV DEF RBRVS 09/01/2019 12/31/2023 206.47 Description: REPAIR EYELID DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67923 MEDSV DEF RBRVS 01/01/2024 571.88 Description: REPAIR EYELID DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67923 MEDSV DEF RBRVS 09/01/2019 12/31/2023 429.72 Description: REPAIR EYELID DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67924 MEDSV DEF RBRVS 01/01/2024 608.61 Description: REPAIR EYELID DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67924 MEDSV DEF RBRVS 09/01/2019 12/31/2023 458.57 Description: REPAIR EYELID DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67930 MEDSV DEF RBRVS 01/01/2024 347.39 Description: REPAIR EYELID WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67930 MEDSV DEF RBRVS 09/01/2019 12/31/2023 264.62 Description: REPAIR EYELID WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67935 MEDSV DEF RBRVS 01/01/2024 560.72 Description: REPAIR EYELID WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 811 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 67935 MEDSV DEF RBRVS 09/01/2019 12/31/2023 434.21 Description: REPAIR EYELID WOUND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67938 MEDSV DEF RBRVS 01/01/2024 255.21 Description: REMOVE EYELID FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67938 MEDSV DEF RBRVS 09/01/2019 12/31/2023 171.59 Description: REMOVE EYELID FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67950 MEDSV DEF RBRVS 01/01/2024 547.70 Description: REVISION OF EYELID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67950 MEDSV DEF RBRVS 09/01/2019 12/31/2023 417.08 Description: REVISION OF EYELID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67961 MEDSV DEF RBRVS 01/01/2024 550.51 Description: REVISION OF EYELID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67961 MEDSV DEF RBRVS 09/01/2019 12/31/2023 419.53 Description: REVISION OF EYELID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67966 MEDSV DEF RBRVS 01/01/2024 728.47 Description: REVISION OF EYELID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67966 MEDSV DEF RBRVS 09/01/2019 12/31/2023 565.68 Description: REVISION OF EYELID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67971 MEDSV DEF RBRVS 01/01/2024 670.38 Description: RECONSTRUCTION OF EYELID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67971 MEDSV DEF RBRVS 09/01/2019 12/31/2023 541.36 Description: RECONSTRUCTION OF EYELID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67973 MEDSV DEF RBRVS 01/01/2024 861.78 Description: RECONSTRUCTION OF EYELID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67973 MEDSV DEF RBRVS 09/01/2019 12/31/2023 697.69 Description: RECONSTRUCTION OF EYELID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67974 MEDSV DEF RBRVS 01/01/2024 860.12 Description: RECONSTRUCTION OF EYELID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67974 MEDSV DEF RBRVS 09/01/2019 12/31/2023 696.88 Description: RECONSTRUCTION OF EYELID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67975 MEDSV DEF RBRVS 01/01/2024 634.86 Description: RECONSTRUCTION OF EYELID Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 812 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 67975 MEDSV DEF RBRVS 09/01/2019 12/31/2023 511.41 Description: RECONSTRUCTION OF EYELID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 67999 MEDSV DEF BILL20 Description: UNLISTED PROCEDURE EYELIDS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68020 MEDSV DEF RBRVS 01/01/2024 113.94 Description: INCISE/DRAIN EYELID LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68020 MEDSV DEF RBRVS 09/01/2019 12/31/2023 87.12 Description: INCISE/DRAIN EYELID LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68040 MEDSV DEF RBRVS 01/01/2024 58.47 Description: TREATMENT OF EYELID LESIONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68040 MEDSV DEF RBRVS 09/01/2019 12/31/2023 47.86 Description: TREATMENT OF EYELID LESIONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68100 MEDSV DEF RBRVS 01/01/2024 168.53 Description: BIOPSY OF EYELID LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68100 MEDSV DEF RBRVS 09/01/2019 12/31/2023 121.40 Description: BIOPSY OF EYELID LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68110 MEDSV DEF RBRVS 01/01/2024 221.37 Description: REMOVE EYELID LINING LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68110 MEDSV DEF RBRVS 09/01/2019 12/31/2023 162.85 Description: REMOVE EYELID LINING LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68115 MEDSV DEF RBRVS 01/01/2024 311.32 Description: REMOVE EYELID LINING LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68115 MEDSV DEF RBRVS 09/01/2019 12/31/2023 222.05 Description: REMOVE EYELID LINING LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68130 MEDSV DEF RBRVS 01/01/2024 516.36 Description: REMOVE EYELID LINING LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68130 MEDSV DEF RBRVS 09/01/2019 12/31/2023 382.51 Description: REMOVE EYELID LINING LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68135 MEDSV DEF RBRVS 01/01/2024 147.97 Description: REMOVE EYELID LINING LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68135 MEDSV DEF RBRVS 09/01/2019 12/31/2023 114.36 Description: REMOVE EYELID LINING LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 813 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 68200 MEDSV DEF RBRVS 01/01/2024 38.86 Description: TREAT EYELID BY INJECTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68200 MEDSV DEF RBRVS 09/01/2019 12/31/2023 30.34 Description: TREAT EYELID BY INJECTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68320 MEDSV DEF RBRVS 01/01/2024 695.07 Description: REVISE/GRAFT EYELID LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68320 MEDSV DEF RBRVS 09/01/2019 12/31/2023 526.70 Description: REVISE/GRAFT EYELID LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68325 MEDSV DEF RBRVS 01/01/2024 610.86 Description: REVISE/GRAFT EYELID LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68325 MEDSV DEF RBRVS 09/01/2019 12/31/2023 490.99 Description: REVISE/GRAFT EYELID LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68326 MEDSV DEF RBRVS 01/01/2024 599.73 Description: REVISE/GRAFT EYELID LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68326 MEDSV DEF RBRVS 09/01/2019 12/31/2023 481.46 Description: REVISE/GRAFT EYELID LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68328 MEDSV DEF RBRVS 01/01/2024 656.48 Description: REVISE/GRAFT EYELID LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68328 MEDSV DEF RBRVS 09/01/2019 12/31/2023 528.54 Description: REVISE/GRAFT EYELID LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68330 MEDSV DEF RBRVS 01/01/2024 582.98 Description: REVISE EYELID LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68330 MEDSV DEF RBRVS 09/01/2019 12/31/2023 440.59 Description: REVISE EYELID LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68335 MEDSV DEF RBRVS 01/01/2024 601.54 Description: REVISE/GRAFT EYELID LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68335 MEDSV DEF RBRVS 09/01/2019 12/31/2023 483.45 Description: REVISE/GRAFT EYELID LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68340 MEDSV DEF RBRVS 01/01/2024 564.63 Description: SEPARATE EYELID ADHESIONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68340 MEDSV DEF RBRVS 09/01/2019 12/31/2023 396.69 Description: SEPARATE EYELID ADHESIONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 814 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 68360 MEDSV DEF RBRVS 01/01/2024 507.94 Description: REVISE EYELID LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68360 MEDSV DEF RBRVS 09/01/2019 12/31/2023 388.20 Description: REVISE EYELID LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68362 MEDSV DEF RBRVS 01/01/2024 610.03 Description: REVISE EYELID LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68362 MEDSV DEF RBRVS 09/01/2019 12/31/2023 490.45 Description: REVISE EYELID LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68371 MEDSV DEF RBRVS 01/01/2016 12/31/2023 296.53 Y Description: HARVEST EYE TISSUE ALOGRAFT Category: Medical Services CMS Add: 01/01/2004 CMS Term: 68371 MEDSV DEF RBRVS 01/01/2024 383.59 Y Description: HARVEST EYE TISSUE ALOGRAFT Category: Medical Services CMS Add: 01/01/2004 CMS Term: 68399 MEDSV DEF BILL20 Description: UNLISTED PX CONJUNCTIVA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68400 MEDSV DEF RBRVS 01/01/2024 277.93 Description: INCISE/DRAIN TEAR GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68400 MEDSV DEF RBRVS 09/01/2019 12/31/2023 202.81 Description: INCISE/DRAIN TEAR GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68420 MEDSV DEF RBRVS 01/01/2024 310.83 Description: INCISE/DRAIN TEAR SAC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68420 MEDSV DEF RBRVS 09/01/2019 12/31/2023 228.20 Description: INCISE/DRAIN TEAR SAC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68440 MEDSV DEF RBRVS 01/01/2024 97.50 Description: INCISE TEAR DUCT OPENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68440 MEDSV DEF RBRVS 09/01/2019 12/31/2023 74.57 Description: INCISE TEAR DUCT OPENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68500 MEDSV DEF RBRVS 01/01/2024 995.24 Description: REMOVAL OF TEAR GLAND Category: Medical Services CMS Add: 01/01/1985 CMS Term: 68500 MEDSV DEF RBRVS 09/01/2019 12/31/2023 735.66 Description: REMOVAL OF TEAR GLAND Category: Medical Services CMS Add: 01/01/1985 CMS Term: 68505 MEDSV DEF RBRVS 01/01/2024 990.83 Description: PARTIAL REMOVAL TEAR GLAND Category: Medical Services CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 815 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 68505 MEDSV DEF RBRVS 09/01/2019 12/31/2023 724.18 Description: PARTIAL REMOVAL TEAR GLAND Category: Medical Services CMS Add: 01/01/1985 CMS Term: 68510 MEDSV DEF RBRVS 01/01/2024 423.92 Description: BIOPSY OF TEAR GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68510 MEDSV DEF RBRVS 09/01/2019 12/31/2023 327.55 Description: BIOPSY OF TEAR GLAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68520 MEDSV DEF RBRVS 01/01/2024 691.47 Description: REMOVAL OF TEAR SAC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68520 MEDSV DEF RBRVS 09/01/2019 12/31/2023 502.11 Description: REMOVAL OF TEAR SAC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68525 MEDSV DEF RBRVS 01/01/2024 241.25 Description: BIOPSY OF TEAR SAC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68525 MEDSV DEF RBRVS 09/01/2019 12/31/2023 200.92 Description: BIOPSY OF TEAR SAC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68530 MEDSV DEF RBRVS 01/01/2024 406.35 Description: CLEARANCE OF TEAR DUCT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68530 MEDSV DEF RBRVS 09/01/2019 12/31/2023 309.97 Description: CLEARANCE OF TEAR DUCT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68540 MEDSV DEF RBRVS 01/01/2024 920.88 Description: REMOVE TEAR GLAND LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68540 MEDSV DEF RBRVS 09/01/2019 12/31/2023 680.50 Description: REMOVE TEAR GLAND LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68550 MEDSV DEF RBRVS 01/01/2024 1146.58 Description: REMOVE TEAR GLAND LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68550 MEDSV DEF RBRVS 09/01/2019 12/31/2023 834.46 Description: REMOVE TEAR GLAND LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68700 MEDSV DEF RBRVS 01/01/2024 560.98 Description: REPAIR TEAR DUCTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68700 MEDSV DEF RBRVS 09/01/2019 12/31/2023 450.25 Description: REPAIR TEAR DUCTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68705 MEDSV DEF RBRVS 01/01/2024 245.73 Description: REVISE TEAR DUCT OPENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 816 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 68705 MEDSV DEF RBRVS 09/01/2019 12/31/2023 171.63 Description: REVISE TEAR DUCT OPENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68720 MEDSV DEF RBRVS 01/01/2024 759.13 Description: CREATE TEAR SAC DRAIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68720 MEDSV DEF RBRVS 09/01/2019 12/31/2023 559.67 Description: CREATE TEAR SAC DRAIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68745 MEDSV DEF RBRVS 01/01/2024 763.08 Description: CREATE TEAR DUCT DRAIN Category: Medical Services CMS Add: 01/01/1985 CMS Term: 68745 MEDSV DEF RBRVS 09/01/2019 12/31/2023 567.22 Description: CREATE TEAR DUCT DRAIN Category: Medical Services CMS Add: 01/01/1985 CMS Term: 68750 MEDSV DEF RBRVS 01/01/2024 804.18 Description: CREATE TEAR DUCT DRAIN Category: Medical Services CMS Add: 01/01/1985 CMS Term: 68750 MEDSV DEF RBRVS 09/01/2019 12/31/2023 584.82 Description: CREATE TEAR DUCT DRAIN Category: Medical Services CMS Add: 01/01/1985 CMS Term: 68760 MEDSV DEF RBRVS 01/01/2024 206.43 Description: CLOSE TEAR DUCT OPENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68760 MEDSV DEF RBRVS 09/01/2019 12/31/2023 146.17 Description: CLOSE TEAR DUCT OPENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68761 MEDSV DEF RBRVS 01/01/2024 137.36 Description: CLOSE TEAR DUCT OPENING Category: Medical Services CMS Add: 01/01/1993 CMS Term: 68761 MEDSV DEF RBRVS 09/01/2019 12/31/2023 107.00 Description: CLOSE TEAR DUCT OPENING Category: Medical Services CMS Add: 01/01/1993 CMS Term: 68770 MEDSV DEF RBRVS 01/01/2024 584.66 Description: CLOSE TEAR SYSTEM FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68770 MEDSV DEF RBRVS 09/01/2019 12/31/2023 469.55 Description: CLOSE TEAR SYSTEM FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68801 MEDSV DEF RBRVS 01/01/2019 12/31/2023 89.54 Description: DILATE TEAR DUCT OPENING Category: Medical Services CMS Add: 01/01/1997 CMS Term: 68801 MEDSV DEF RBRVS 01/01/2024 90.17 Description: DILATE TEAR DUCT OPENING Category: Medical Services CMS Add: 01/01/1997 CMS Term: 68810 MEDSV DEF RBRVS 01/01/2019 12/31/2023 175.35 Description: PROBE NASOLACRIMAL DUCT Category: Medical Services CMS Add: 01/01/1997 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 817 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 68810 MEDSV DEF RBRVS 01/01/2024 150.74 Description: PROBE NASOLACRIMAL DUCT Category: Medical Services CMS Add: 01/01/1997 CMS Term: 68811 MEDSV DEF RBRVS 01/01/2019 12/31/2023 152.69 Description: PROBE NASOLACRIMAL DUCT Category: Medical Services CMS Add: 01/01/1997 CMS Term: 68811 MEDSV DEF RBRVS 01/01/2024 125.74 Description: PROBE NASOLACRIMAL DUCT Category: Medical Services CMS Add: 01/01/1997 CMS Term: 68815 MEDSV DEF RBRVS 01/01/2019 12/31/2023 321.85 Description: PROBE NASOLACRIMAL DUCT Category: Medical Services CMS Add: 01/01/1997 CMS Term: 68815 MEDSV DEF RBRVS 01/01/2024 351.89 Description: PROBE NASOLACRIMAL DUCT Category: Medical Services CMS Add: 01/01/1997 CMS Term: 68816 MEDSV DEF RBRVS 01/01/2024 799.23 Description: PROBE NL DUCT W/BALLOON Category: Medical Services CMS Add: 01/01/2008 CMS Term: 68816 MEDSV DEF RBRVS 02/01/2015 12/31/2023 522.90 Description: PROBE NL DUCT W/BALLOON Category: Medical Services CMS Add: 01/01/2008 CMS Term: 68840 MEDSV DEF RBRVS 01/01/2024 124.69 Description: EXPLORE/IRRIGATE TEAR DUCTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68840 MEDSV DEF RBRVS 09/01/2019 12/31/2023 93.72 Description: EXPLORE/IRRIGATE TEAR DUCTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68841 MEDSV DEF RBRVS 01/01/2022 12/31/2023 28.19 Description: INSJ RX ELUT IMPLT LAC CANAL Category: Medical Services CMS Add: 01/01/2022 CMS Term: 68841 MEDSV DEF RBRVS 01/01/2024 35.77 Description: INSJ RX ELUT IMPLT LAC CANAL Category: Medical Services CMS Add: 01/01/2022 CMS Term: 68850 MEDSV DEF RBRVS 01/01/2024 55.09 Description: INJECTION FOR TEAR SAC X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68850 MEDSV DEF RBRVS 09/01/2019 12/31/2023 43.21 Description: INJECTION FOR TEAR SAC X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 68899 MEDSV DEF BILL20 Description: UNLISTED PX LACRIMAL SYSTEM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69000 MEDSV DEF RBRVS 01/01/2024 175.08 Description: DRAIN EXTERNAL EAR LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69000 MEDSV DEF RBRVS 09/01/2019 12/31/2023 134.19 Description: DRAIN EXTERNAL EAR LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 818 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 69005 MEDSV DEF RBRVS 01/01/2024 206.14 Description: DRAIN EXTERNAL EAR LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69005 MEDSV DEF RBRVS 09/01/2019 12/31/2023 154.56 Description: DRAIN EXTERNAL EAR LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69020 MEDSV DEF RBRVS 01/01/2024 220.55 Description: DRAIN OUTER EAR CANAL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69020 MEDSV DEF RBRVS 09/01/2019 12/31/2023 166.62 Description: DRAIN OUTER EAR CANAL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69090 NOCOV DEF SYSMAN Description: PIERCE EARLOBES Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 69100 MEDSV DEF RBRVS 01/01/2024 90.49 Description: BIOPSY OF EXTERNAL EAR Category: Medical Services CMS Add: 01/01/1985 CMS Term: 69100 MEDSV DEF RBRVS 09/01/2019 12/31/2023 69.90 Description: BIOPSY OF EXTERNAL EAR Category: Medical Services CMS Add: 01/01/1985 CMS Term: 69105 MEDSV DEF RBRVS 01/01/2024 136.32 Description: BIOPSY OF EXTERNAL EAR CANAL Category: Medical Services CMS Add: 01/01/1985 CMS Term: 69105 MEDSV DEF RBRVS 09/01/2019 12/31/2023 100.29 Description: BIOPSY OF EXTERNAL EAR CANAL Category: Medical Services CMS Add: 01/01/1985 CMS Term: 69110 MEDSV DEF RBRVS 01/01/2024 442.10 Description: REMOVE EXTERNAL EAR PARTIAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69110 MEDSV DEF RBRVS 09/01/2019 12/31/2023 324.97 Description: REMOVE EXTERNAL EAR PARTIAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69120 MEDSV DEF RBRVS 01/01/2024 366.20 Description: REMOVAL OF EXTERNAL EAR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69120 MEDSV DEF RBRVS 09/01/2019 12/31/2023 292.56 Description: REMOVAL OF EXTERNAL EAR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69140 MEDSV DEF RBRVS 01/01/2024 850.49 Description: REMOVE EAR CANAL LESION(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69140 MEDSV DEF RBRVS 09/01/2019 12/31/2023 630.82 Description: REMOVE EAR CANAL LESION(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69145 MEDSV DEF RBRVS 01/01/2024 387.49 Description: REMOVE EAR CANAL LESION(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 819 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 69145 MEDSV DEF RBRVS 09/01/2019 12/31/2023 285.08 Description: REMOVE EAR CANAL LESION(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69150 MEDSV DEF RBRVS 01/01/2024 950.14 Description: EXTENSIVE EAR CANAL SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69150 MEDSV DEF RBRVS 09/01/2019 12/31/2023 759.79 Description: EXTENSIVE EAR CANAL SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69155 MEDSV DEF RBRVS 01/01/2024 1532.67 Description: EXTENSIVE EAR/NECK SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69155 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1214.21 Description: EXTENSIVE EAR/NECK SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69200 MEDSV DEF RBRVS 01/01/2024 75.10 Description: CLEAR OUTER EAR CANAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69200 MEDSV DEF RBRVS 09/01/2019 12/31/2023 87.49 Description: CLEAR OUTER EAR CANAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69205 MEDSV DEF RBRVS 01/01/2024 89.90 Description: CLEAR OUTER EAR CANAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69205 MEDSV DEF RBRVS 09/01/2019 12/31/2023 73.63 Description: CLEAR OUTER EAR CANAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69209 MEDSV DEF RBRVS 01/01/2016 12/31/2023 8.84 Description: REMOVE IMPACTED EAR WAX UNI Category: Medical Services CMS Add: 01/01/2016 CMS Term: 69209 MEDSV DEF RBRVS 01/01/2024 14.05 Description: REMOVE IMPACTED EAR WAX UNI Category: Medical Services CMS Add: 01/01/2016 CMS Term: 69210 MEDSV DEF RBRVS 01/01/2024 44.49 0-1 Description: REMOVE IMPACTED EAR WAX UNI Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69210 MEDSV DEF RBRVS 09/01/2019 12/31/2023 35.38 0-1 Description: REMOVE IMPACTED EAR WAX UNI Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69220 MEDSV DEF RBRVS 01/01/2024 73.28 Description: CLEAN OUT MASTOID CAVITY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69220 MEDSV DEF RBRVS 09/01/2019 12/31/2023 98.27 Description: CLEAN OUT MASTOID CAVITY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69222 MEDSV DEF RBRVS 01/01/2024 203.32 Description: CLEAN OUT MASTOID CAVITY Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 820 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 69222 MEDSV DEF RBRVS 09/01/2019 12/31/2023 157.70 Description: CLEAN OUT MASTOID CAVITY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69300 MEDSV DEF RBRVS 01/01/2024 611.36 Y Description: REVISE EXTERNAL EAR Category: Medical Services CMS Add: 01/01/1982 CMS Term: 69300 MEDSV DEF RBRVS 09/15/2017 12/31/2023 423.88 Y Description: REVISE EXTERNAL EAR Category: Medical Services CMS Add: 01/01/1982 CMS Term: 69310 MEDSV DEF RBRVS 01/01/2024 1053.67 Description: REBUILD OUTER EAR CANAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69310 MEDSV DEF RBRVS 09/01/2019 12/31/2023 785.71 Description: REBUILD OUTER EAR CANAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69320 MEDSV DEF RBRVS 01/01/2024 1472.12 Description: REBUILD OUTER EAR CANAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69320 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1103.18 Description: REBUILD OUTER EAR CANAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69399 MEDSV DEF BILL20 Description: UNLISTED PX EXTERNAL EAR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69420 MEDSV DEF RBRVS 01/01/2024 179.79 Description: INCISION OF EARDRUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69420 MEDSV DEF RBRVS 09/01/2019 12/31/2023 137.49 Description: INCISION OF EARDRUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69421 MEDSV DEF RBRVS 01/01/2024 143.06 Description: INCISION OF EARDRUM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 69421 MEDSV DEF RBRVS 09/01/2019 12/31/2023 107.94 Description: INCISION OF EARDRUM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 69424 MEDSV DEF RBRVS 01/01/2024 120.25 Description: REMOVE VENTILATING TUBE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69424 MEDSV DEF RBRVS 09/01/2019 12/31/2023 91.37 Description: REMOVE VENTILATING TUBE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69433 MEDSV DEF RBRVS 01/01/2024 190.11 Description: CREATE EARDRUM OPENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69433 MEDSV DEF RBRVS 09/01/2019 12/31/2023 145.73 Description: CREATE EARDRUM OPENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 821 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 69436 MEDSV DEF RBRVS 01/01/2024 150.25 Description: CREATE EARDRUM OPENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69436 MEDSV DEF RBRVS 09/01/2019 12/31/2023 116.59 Description: CREATE EARDRUM OPENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69440 MEDSV DEF RBRVS 01/01/2024 653.91 Description: EXPLORATION OF MIDDLE EAR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69440 MEDSV DEF RBRVS 09/01/2019 12/31/2023 500.78 Description: EXPLORATION OF MIDDLE EAR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69450 MEDSV DEF RBRVS 01/01/2024 517.20 Description: EARDRUM REVISION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69450 MEDSV DEF RBRVS 09/01/2019 12/31/2023 394.65 Description: EARDRUM REVISION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69501 MEDSV DEF RBRVS 01/01/2024 671.54 Description: MASTOIDECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69501 MEDSV DEF RBRVS 09/01/2019 12/31/2023 532.66 Description: MASTOIDECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69502 MEDSV DEF RBRVS 01/01/2024 891.72 Description: MASTOIDECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69502 MEDSV DEF RBRVS 09/01/2019 12/31/2023 707.55 Description: MASTOIDECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69505 MEDSV DEF RBRVS 01/01/2024 1160.04 Description: REMOVE MASTOID STRUCTURES Category: Medical Services CMS Add: 01/01/1985 CMS Term: 69505 MEDSV DEF RBRVS 09/01/2019 12/31/2023 869.02 Description: REMOVE MASTOID STRUCTURES Category: Medical Services CMS Add: 01/01/1985 CMS Term: 69511 MEDSV DEF RBRVS 01/01/2024 1187.00 Description: EXTENSIVE MASTOID SURGERY Category: Medical Services CMS Add: 01/01/1985 CMS Term: 69511 MEDSV DEF RBRVS 09/01/2019 12/31/2023 890.44 Description: EXTENSIVE MASTOID SURGERY Category: Medical Services CMS Add: 01/01/1985 CMS Term: 69530 MEDSV DEF RBRVS 01/01/2024 1580.54 Description: EXTENSIVE MASTOID SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69530 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1196.75 Description: EXTENSIVE MASTOID SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 822 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 69535 MEDSV DEF RBRVS 01/01/2024 2511.04 Description: REMOVE PART OF TEMPORAL BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69535 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1947.55 Description: REMOVE PART OF TEMPORAL BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69540 MEDSV DEF RBRVS 01/01/2024 199.16 Description: REMOVE EAR LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69540 MEDSV DEF RBRVS 09/01/2019 12/31/2023 149.76 Description: REMOVE EAR LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69550 MEDSV DEF RBRVS 01/01/2024 1003.88 Description: REMOVE EAR LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69550 MEDSV DEF RBRVS 09/01/2019 12/31/2023 751.41 Description: REMOVE EAR LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69552 MEDSV DEF RBRVS 01/01/2024 1497.12 Description: REMOVE EAR LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69552 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1137.34 Description: REMOVE EAR LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69554 MEDSV DEF RBRVS 01/01/2024 2383.99 Description: REMOVE EAR LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69554 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1833.95 Description: REMOVE EAR LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69601 MEDSV DEF RBRVS 01/01/2024 961.65 Description: MASTOID SURGERY REVISION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69601 MEDSV DEF RBRVS 09/01/2019 12/31/2023 762.01 Description: MASTOID SURGERY REVISION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69602 MEDSV DEF RBRVS 01/01/2024 1028.20 Description: MASTOID SURGERY REVISION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 69602 MEDSV DEF RBRVS 09/01/2019 12/31/2023 792.23 Description: MASTOID SURGERY REVISION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 69603 MEDSV DEF RBRVS 01/01/2024 1212.33 Description: MASTOID SURGERY REVISION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 69603 MEDSV DEF RBRVS 09/01/2019 12/31/2023 910.40 Description: MASTOID SURGERY REVISION Category: Medical Services CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 823 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 69604 MEDSV DEF RBRVS 01/01/2024 1050.56 Description: MASTOID SURGERY REVISION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69604 MEDSV DEF RBRVS 09/01/2019 12/31/2023 809.83 Description: MASTOID SURGERY REVISION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69610 MEDSV DEF RBRVS 01/01/2024 361.06 Description: REPAIR OF EARDRUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69610 MEDSV DEF RBRVS 09/01/2019 12/31/2023 278.23 Description: REPAIR OF EARDRUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69620 MEDSV DEF RBRVS 01/01/2024 699.77 Description: REPAIR OF EARDRUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69620 MEDSV DEF RBRVS 09/01/2019 12/31/2023 496.84 Description: REPAIR OF EARDRUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69631 MEDSV DEF RBRVS 01/01/2024 840.87 Description: REPAIR EARDRUM STRUCTURES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69631 MEDSV DEF RBRVS 09/01/2019 12/31/2023 642.09 Description: REPAIR EARDRUM STRUCTURES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69632 MEDSV DEF RBRVS 01/01/2024 1022.96 Description: REBUILD EARDRUM STRUCTURES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69632 MEDSV DEF RBRVS 09/01/2019 12/31/2023 784.19 Description: REBUILD EARDRUM STRUCTURES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69633 MEDSV DEF RBRVS 01/01/2024 992.09 Description: REBUILD EARDRUM STRUCTURES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69633 MEDSV DEF RBRVS 09/01/2019 12/31/2023 758.14 Description: REBUILD EARDRUM STRUCTURES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69635 MEDSV DEF RBRVS 01/01/2024 1201.53 Description: REPAIR EARDRUM STRUCTURES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69635 MEDSV DEF RBRVS 09/01/2019 12/31/2023 890.04 Description: REPAIR EARDRUM STRUCTURES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69636 MEDSV DEF RBRVS 01/01/2024 1329.60 Description: REBUILD EARDRUM STRUCTURES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69636 MEDSV DEF RBRVS 09/01/2019 12/31/2023 996.54 Description: REBUILD EARDRUM STRUCTURES Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 824 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 69637 MEDSV DEF RBRVS 01/01/2024 1323.85 Description: REBUILD EARDRUM STRUCTURES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69637 MEDSV DEF RBRVS 09/01/2019 12/31/2023 992.84 Description: REBUILD EARDRUM STRUCTURES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69641 MEDSV DEF RBRVS 01/01/2024 985.22 Description: REVISE MIDDLE EAR & MASTOID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69641 MEDSV DEF RBRVS 09/01/2019 12/31/2023 757.70 Description: REVISE MIDDLE EAR & MASTOID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69642 MEDSV DEF RBRVS 01/01/2024 1263.82 Description: REVISE MIDDLE EAR & MASTOID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69642 MEDSV DEF RBRVS 09/01/2019 12/31/2023 973.45 Description: REVISE MIDDLE EAR & MASTOID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69643 MEDSV DEF RBRVS 01/01/2024 1156.32 Description: REVISE MIDDLE EAR & MASTOID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69643 MEDSV DEF RBRVS 09/01/2019 12/31/2023 891.10 Description: REVISE MIDDLE EAR & MASTOID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69644 MEDSV DEF RBRVS 01/01/2024 1421.82 Description: REVISE MIDDLE EAR & MASTOID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69644 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1068.68 Description: REVISE MIDDLE EAR & MASTOID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69645 MEDSV DEF RBRVS 01/01/2024 1395.18 Description: REVISE MIDDLE EAR & MASTOID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69645 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1050.58 Description: REVISE MIDDLE EAR & MASTOID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69646 MEDSV DEF RBRVS 01/01/2024 1481.10 Description: REVISE MIDDLE EAR & MASTOID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69646 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1115.83 Description: REVISE MIDDLE EAR & MASTOID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69650 MEDSV DEF RBRVS 01/01/2024 759.03 Description: RELEASE MIDDLE EAR BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69650 MEDSV DEF RBRVS 09/01/2019 12/31/2023 584.59 Description: RELEASE MIDDLE EAR BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 825 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 69660 MEDSV DEF RBRVS 01/01/2024 873.42 Description: REVISE MIDDLE EAR BONE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 69660 MEDSV DEF RBRVS 09/01/2019 12/31/2023 674.65 Description: REVISE MIDDLE EAR BONE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 69661 MEDSV DEF RBRVS 01/01/2024 1138.04 Description: REVISE MIDDLE EAR BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69661 MEDSV DEF RBRVS 09/01/2019 12/31/2023 879.41 Description: REVISE MIDDLE EAR BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69662 MEDSV DEF RBRVS 01/01/2024 1089.86 Description: REVISE MIDDLE EAR BONE Category: Medical Services CMS Add: 01/01/1990 CMS Term: 69662 MEDSV DEF RBRVS 09/01/2019 12/31/2023 842.08 Description: REVISE MIDDLE EAR BONE Category: Medical Services CMS Add: 01/01/1990 CMS Term: 69666 MEDSV DEF RBRVS 01/01/2024 763.48 Description: REPAIR MIDDLE EAR STRUCTURES Category: Medical Services CMS Add: 01/01/1985 CMS Term: 69666 MEDSV DEF RBRVS 09/01/2019 12/31/2023 588.09 Description: REPAIR MIDDLE EAR STRUCTURES Category: Medical Services CMS Add: 01/01/1985 CMS Term: 69667 MEDSV DEF RBRVS 01/01/2024 763.81 Description: REPAIR MIDDLE EAR STRUCTURES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69667 MEDSV DEF RBRVS 09/01/2019 12/31/2023 589.10 Description: REPAIR MIDDLE EAR STRUCTURES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69670 MEDSV DEF RBRVS 01/01/2024 891.46 Description: REMOVE MASTOID AIR CELLS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69670 MEDSV DEF RBRVS 09/01/2019 12/31/2023 686.74 Description: REMOVE MASTOID AIR CELLS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69676 MEDSV DEF RBRVS 01/01/2024 787.86 Description: REMOVE MIDDLE EAR NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69676 MEDSV DEF RBRVS 09/01/2019 12/31/2023 604.26 Description: REMOVE MIDDLE EAR NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69700 MEDSV DEF RBRVS 01/01/2024 628.79 Description: CLOSE MASTOID FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69700 MEDSV DEF RBRVS 09/01/2019 12/31/2023 498.78 Description: CLOSE MASTOID FISTULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 826 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 69705 MEDSV DEF MAXFEE 01/01/2024 2569.95 0.0 Description: NPS SURG DILAT EUST TUBE UNI Category: Medical Services CMS Add: 01/01/2021 CMS Term: 69706 MEDSV DEF MAXFEE 01/01/2024 2657.70 0.0 Description: NPS SURG DILAT EUST TUBE BI Category: Medical Services CMS Add: 01/01/2021 CMS Term: 69710 MEDSV DEF BILL20 Description: IMPLANT/REPLACE HEARING AID Category: Medical Services CMS Add: 01/01/1988 CMS Term: 69711 MEDSV DEF RBRVS 01/01/2024 792.16 Description: REMOVE/REPAIR HEARING AID Category: Medical Services CMS Add: 01/01/1988 CMS Term: 69711 MEDSV DEF RBRVS 09/01/2019 12/31/2023 627.35 Description: REMOVE/REPAIR HEARING AID Category: Medical Services CMS Add: 01/01/1988 CMS Term: 69714 MEDSV DEF RBRVS 01/01/2016 12/31/2023 784.01 Description: IMPL OI IMPLT SKULL PERQ ESP Category: Medical Services CMS Add: 01/01/2001 CMS Term: 69714 MEDSV DEF RBRVS 01/01/2024 464.24 Description: IMPL OI IMPLT SKULL PERQ ESP Category: Medical Services CMS Add: 01/01/2001 CMS Term: 69716 MEDSV DEF RBRVS 01/01/2022 12/31/2023 459.35 Description: IMPL OI IMPLT SK TC ESP<100 Category: Medical Services CMS Add: 01/01/2022 CMS Term: 69716 MEDSV DEF RBRVS 01/01/2024 583.45 Description: IMPL OI IMPLT SK TC ESP<100 Category: Medical Services CMS Add: 01/01/2022 CMS Term: 69717 MEDSV DEF RBRVS 01/01/2016 12/31/2023 823.39 Description: RPLCMT OI IMPLT SKL PRQ ESP Category: Medical Services CMS Add: 01/01/2001 CMS Term: 69717 MEDSV DEF RBRVS 01/01/2024 526.72 Description: RPLCMT OI IMPLT SKL PRQ ESP Category: Medical Services CMS Add: 01/01/2001 CMS Term: 69719 MEDSV DEF RBRVS 01/01/2022 12/31/2023 459.35 Description: RPLCM OI IMPLT SK TC ESP<100 Category: Medical Services CMS Add: 01/01/2022 CMS Term: 69719 MEDSV DEF RBRVS 01/01/2024 605.00 Description: RPLCM OI IMPLT SK TC ESP<100 Category: Medical Services CMS Add: 01/01/2022 CMS Term: 69720 MEDSV DEF RBRVS 01/01/2024 1121.55 Description: RELEASE FACIAL NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69720 MEDSV DEF RBRVS 09/01/2019 12/31/2023 868.28 Description: RELEASE FACIAL NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69725 MEDSV DEF RBRVS 01/01/2024 1759.80 Description: RELEASE FACIAL NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 827 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 69725 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1373.57 Description: RELEASE FACIAL NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69726 MEDSV DEF RBRVS 01/01/2022 12/31/2023 311.51 Description: RMV NTR OI IMPLT SKL PRQ ESP Category: Medical Services CMS Add: 01/01/2022 CMS Term: 69726 MEDSV DEF RBRVS 01/01/2024 448.12 Description: RMV NTR OI IMPLT SKL PRQ ESP Category: Medical Services CMS Add: 01/01/2022 CMS Term: 69727 MEDSV DEF RBRVS 01/01/2022 12/31/2023 356.79 Description: RMV NTR OI IMP SK TC ESP<100 Category: Medical Services CMS Add: 01/01/2022 CMS Term: 69727 MEDSV DEF RBRVS 01/01/2024 499.92 Description: RMV NTR OI IMP SK TC ESP<100 Category: Medical Services CMS Add: 01/01/2022 CMS Term: 69728 MEDSV DEF RBRVS 01/01/2023 12/31/2023 448.60 Description: RMV NTR OI IMP SK TC>=100 Category: Medical Services CMS Add: 01/01/2023 CMS Term: 69728 MEDSV DEF RBRVS 01/01/2024 557.13 Description: RMV NTR OI IMP SK TC>=100 Category: Medical Services CMS Add: 01/01/2023 CMS Term: 69729 MEDSV DEF RBRVS 01/01/2023 631.47 Description: IMPL OI IMPLT SK TC ESP>=100 Category: Medical Services CMS Add: 01/01/2023 CMS Term: 69730 MEDSV DEF RBRVS 01/01/2023 645.93 Description: RPLC OI IMPLT SK TC ESP>=100 Category: Medical Services CMS Add: 01/01/2023 CMS Term: 69740 MEDSV DEF RBRVS 01/01/2024 1094.67 Description: REPAIR FACIAL NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69740 MEDSV DEF RBRVS 09/01/2019 12/31/2023 851.74 Description: REPAIR FACIAL NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69745 MEDSV DEF RBRVS 01/01/2024 1167.07 Description: REPAIR FACIAL NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69745 MEDSV DEF RBRVS 09/01/2019 12/31/2023 905.58 Description: REPAIR FACIAL NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69799 MEDSV DEF BILL20 Description: UNLISTED PX MIDDLE EAR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69801 MEDSV DEF RBRVS 01/01/2024 214.63 Description: INCISE INNER EAR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69801 MEDSV DEF RBRVS 09/01/2019 12/31/2023 141.64 Description: INCISE INNER EAR Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 828 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 69805 MEDSV DEF RBRVS 01/01/2024 969.72 Description: EXPLORE INNER EAR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69805 MEDSV DEF RBRVS 09/01/2019 12/31/2023 769.20 Description: EXPLORE INNER EAR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69806 MEDSV DEF RBRVS 01/01/2024 869.56 Description: EXPLORE INNER EAR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69806 MEDSV DEF RBRVS 09/01/2019 12/31/2023 690.11 Description: EXPLORE INNER EAR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69905 MEDSV DEF RBRVS 01/01/2024 867.61 Description: REMOVE INNER EAR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69905 MEDSV DEF RBRVS 09/01/2019 12/31/2023 668.00 Description: REMOVE INNER EAR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69910 MEDSV DEF RBRVS 01/01/2024 934.66 Description: REMOVE INNER EAR & MASTOID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69910 MEDSV DEF RBRVS 09/01/2019 12/31/2023 742.01 Description: REMOVE INNER EAR & MASTOID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69915 MEDSV DEF RBRVS 01/01/2024 1415.57 Description: INCISE INNER EAR NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69915 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1124.89 Description: INCISE INNER EAR NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69930 MEDSV DEF RBRVS 01/01/2024 1146.13 Y Description: IMPLANT COCHLEAR DEVICE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 69930 MEDSV DEF RBRVS 09/01/2019 12/31/2023 894.19 Y Description: IMPLANT COCHLEAR DEVICE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 69949 MEDSV DEF BILL20 Description: UNLISTED PX INNER EAR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69950 MEDSV DEF RBRVS 01/01/2024 1641.85 Description: INCISE INNER EAR NERVE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 69950 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1303.69 Description: INCISE INNER EAR NERVE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 69955 MEDSV DEF RBRVS 01/01/2024 1851.00 Description: RELEASE FACIAL NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 829 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 69955 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1445.83 Description: RELEASE FACIAL NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69960 MEDSV DEF RBRVS 01/01/2024 1772.90 Description: RELEASE INNER EAR CANAL Category: Medical Services CMS Add: 01/01/1982 CMS Term: 69960 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1407.44 Description: RELEASE INNER EAR CANAL Category: Medical Services CMS Add: 01/01/1982 CMS Term: 69970 MEDSV DEF RBRVS 01/01/2024 2001.53 Description: REMOVE INNER EAR LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69970 MEDSV DEF RBRVS 09/01/2019 12/31/2023 1566.46 Description: REMOVE INNER EAR LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69979 MEDSV DEF BILL20 Description: UNLISTED PX TEMPORAL BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 69990 MEDSV DEF RBRVS 01/01/2019 12/31/2023 151.93 Description: MICROSURGERY ADD-ON Category: Medical Services CMS Add: 01/01/1999 CMS Term: 69990 MEDSV DEF RBRVS 01/01/2024 190.70 Description: MICROSURGERY ADD-ON Category: Medical Services CMS Add: 01/01/1999 CMS Term: 70010 26 RADIO DEF MAXFEE 01/01/2024 49.63 0.0 Description: CONTRAST X-RAY OF BRAIN Category: Radiology CMS Add: 01/01/1984 CMS Term: 70010 26 RADIO DEF RBRVS 02/01/2015 58.31 Description: CONTRAST X-RAY OF BRAIN Category: Radiology CMS Add: 01/01/1984 CMS Term: 70010 RADIO DEF RBRVS 01/01/2024 55.68 Description: CONTRAST X-RAY OF BRAIN Category: Radiology CMS Add: 01/01/1984 CMS Term: 70010 RADIO DEF RBRVS 02/01/2015 12/31/2023 46.34 Description: CONTRAST X-RAY OF BRAIN Category: Radiology CMS Add: 01/01/1984 CMS Term: 70010 TC RADIO DEF MAXFEE 01/01/2024 114.63 0.0 Description: CONTRAST X-RAY OF BRAIN Category: Radiology CMS Add: 01/01/1984 CMS Term: 70010 TC RADIO DEF RBRVS 02/01/2015 133.23 Description: CONTRAST X-RAY OF BRAIN Category: Radiology CMS Add: 01/01/1984 CMS Term: 70015 26 RADIO DEF RBRVS 01/01/2024 54.87 Description: CONTRAST X-RAY OF BRAIN Category: Radiology CMS Add: 01/01/1984 CMS Term: 70015 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 44.03 Description: CONTRAST X-RAY OF BRAIN Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 830 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 70015 RADIO DEF RBRVS 01/01/2024 158.76 Description: CONTRAST X-RAY OF BRAIN Category: Radiology CMS Add: 01/01/1984 CMS Term: 70015 RADIO DEF RBRVS 02/01/2015 12/31/2023 108.85 Description: CONTRAST X-RAY OF BRAIN Category: Radiology CMS Add: 01/01/1984 CMS Term: 70015 TC RADIO DEF RBRVS 01/01/2024 103.89 Description: CONTRAST X-RAY OF BRAIN Category: Radiology CMS Add: 01/01/1984 CMS Term: 70015 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 64.82 Description: CONTRAST X-RAY OF BRAIN Category: Radiology CMS Add: 01/01/1984 CMS Term: 70030 26 RADIO DEF RBRVS 01/01/2024 8.42 Description: X-RAY EYE FOR FOREIGN BODY Category: Radiology CMS Add: 01/01/1984 CMS Term: 70030 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 6.22 Description: X-RAY EYE FOR FOREIGN BODY Category: Radiology CMS Add: 01/01/1984 CMS Term: 70030 RADIO DEF RBRVS 01/01/2024 30.50 Description: X-RAY EYE FOR FOREIGN BODY Category: Radiology CMS Add: 01/01/1984 CMS Term: 70030 RADIO DEF RBRVS 02/01/2015 12/31/2023 21.00 Description: X-RAY EYE FOR FOREIGN BODY Category: Radiology CMS Add: 01/01/1984 CMS Term: 70030 TC RADIO DEF RBRVS 01/01/2024 22.08 Description: X-RAY EYE FOR FOREIGN BODY Category: Radiology CMS Add: 01/01/1984 CMS Term: 70030 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 14.78 Description: X-RAY EYE FOR FOREIGN BODY Category: Radiology CMS Add: 01/01/1984 CMS Term: 70100 26 RADIO DEF RBRVS 01/01/2024 8.42 Description: X-RAY EXAM OF JAW <4VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70100 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 6.74 Description: X-RAY EXAM OF JAW <4VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70100 RADIO DEF RBRVS 01/01/2024 36.06 Description: X-RAY EXAM OF JAW <4VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70100 RADIO DEF RBRVS 02/01/2015 12/31/2023 24.74 Description: X-RAY EXAM OF JAW <4VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70100 TC RADIO DEF RBRVS 01/01/2024 27.64 Description: X-RAY EXAM OF JAW <4VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70100 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 18.00 Description: X-RAY EXAM OF JAW <4VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 831 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 7010F NOCOV DEF SYSMAN Description: PT INFO INTO RECALL SYSTEM Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 70110 26 RADIO DEF RBRVS 01/01/2024 11.41 Description: X-RAY EXAM OF JAW 4/> VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70110 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 9.36 Description: X-RAY EXAM OF JAW 4/> VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70110 RADIO DEF RBRVS 01/01/2024 40.59 Description: X-RAY EXAM OF JAW 4/> VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70110 RADIO DEF RBRVS 02/01/2015 12/31/2023 28.60 Description: X-RAY EXAM OF JAW 4/> VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70110 TC RADIO DEF RBRVS 01/01/2024 29.18 Description: X-RAY EXAM OF JAW 4/> VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70110 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 19.24 Description: X-RAY EXAM OF JAW 4/> VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70120 26 RADIO DEF RBRVS 01/01/2024 8.42 Description: X-RAY EXAM OF MASTOIDS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70120 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 6.74 Description: X-RAY EXAM OF MASTOIDS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70120 RADIO DEF RBRVS 01/01/2024 36.06 Description: X-RAY EXAM OF MASTOIDS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70120 RADIO DEF RBRVS 02/01/2015 12/31/2023 25.73 Description: X-RAY EXAM OF MASTOIDS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70120 TC RADIO DEF RBRVS 01/01/2024 27.64 Description: X-RAY EXAM OF MASTOIDS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70120 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 18.99 Description: X-RAY EXAM OF MASTOIDS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70130 26 RADIO DEF RBRVS 01/01/2024 15.86 Description: X-RAY EXAM OF MASTOIDS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70130 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 12.52 Description: X-RAY EXAM OF MASTOIDS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70130 RADIO DEF RBRVS 01/01/2024 58.62 Description: X-RAY EXAM OF MASTOIDS Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 832 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 70130 RADIO DEF RBRVS 02/01/2015 12/31/2023 41.42 Description: X-RAY EXAM OF MASTOIDS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70130 TC RADIO DEF RBRVS 01/01/2024 42.76 Description: X-RAY EXAM OF MASTOIDS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70130 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 28.90 Description: X-RAY EXAM OF MASTOIDS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70134 26 RADIO DEF RBRVS 01/01/2024 16.62 Description: X-RAY EXAM OF MIDDLE EAR Category: Radiology CMS Add: 01/01/1984 CMS Term: 70134 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 13.26 Description: X-RAY EXAM OF MIDDLE EAR Category: Radiology CMS Add: 01/01/1984 CMS Term: 70134 RADIO DEF RBRVS 01/01/2024 57.84 Description: X-RAY EXAM OF MIDDLE EAR Category: Radiology CMS Add: 01/01/1984 CMS Term: 70134 RADIO DEF RBRVS 02/01/2015 12/31/2023 39.69 Description: X-RAY EXAM OF MIDDLE EAR Category: Radiology CMS Add: 01/01/1984 CMS Term: 70134 TC RADIO DEF RBRVS 01/01/2024 41.22 Description: X-RAY EXAM OF MIDDLE EAR Category: Radiology CMS Add: 01/01/1984 CMS Term: 70134 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 26.42 Description: X-RAY EXAM OF MIDDLE EAR Category: Radiology CMS Add: 01/01/1984 CMS Term: 70140 26 RADIO DEF RBRVS 01/01/2024 9.38 Description: X-RAY EXAM OF FACIAL BONES Category: Radiology CMS Add: 01/01/1984 CMS Term: 70140 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 7.50 Description: X-RAY EXAM OF FACIAL BONES Category: Radiology CMS Add: 01/01/1984 CMS Term: 70140 RADIO DEF RBRVS 01/01/2024 30.22 Description: X-RAY EXAM OF FACIAL BONES Category: Radiology CMS Add: 01/01/1984 CMS Term: 70140 RADIO DEF RBRVS 02/01/2015 12/31/2023 21.54 Description: X-RAY EXAM OF FACIAL BONES Category: Radiology CMS Add: 01/01/1984 CMS Term: 70140 TC RADIO DEF RBRVS 01/01/2024 20.84 Description: X-RAY EXAM OF FACIAL BONES Category: Radiology CMS Add: 01/01/1984 CMS Term: 70140 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 14.04 Description: X-RAY EXAM OF FACIAL BONES Category: Radiology CMS Add: 01/01/1984 CMS Term: 70150 26 RADIO DEF RBRVS 01/01/2024 12.06 Description: X-RAY EXAM OF FACIAL BONES Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 833 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 70150 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 9.63 Description: X-RAY EXAM OF FACIAL BONES Category: Radiology CMS Add: 01/01/1984 CMS Term: 70150 RADIO DEF RBRVS 01/01/2024 44.02 Description: X-RAY EXAM OF FACIAL BONES Category: Radiology CMS Add: 01/01/1984 CMS Term: 70150 RADIO DEF RBRVS 02/01/2015 12/31/2023 30.60 Description: X-RAY EXAM OF FACIAL BONES Category: Radiology CMS Add: 01/01/1984 CMS Term: 70150 TC RADIO DEF RBRVS 01/01/2024 31.96 Description: X-RAY EXAM OF FACIAL BONES Category: Radiology CMS Add: 01/01/1984 CMS Term: 70150 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 20.97 Description: X-RAY EXAM OF FACIAL BONES Category: Radiology CMS Add: 01/01/1984 CMS Term: 70160 26 RADIO DEF RBRVS 01/01/2024 8.08 Description: X-RAY EXAM OF NASAL BONES Category: Radiology CMS Add: 01/01/1984 CMS Term: 70160 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 6.47 Description: X-RAY EXAM OF NASAL BONES Category: Radiology CMS Add: 01/01/1984 CMS Term: 70160 RADIO DEF RBRVS 01/01/2024 35.72 Description: X-RAY EXAM OF NASAL BONES Category: Radiology CMS Add: 01/01/1984 CMS Term: 70160 RADIO DEF RBRVS 02/01/2015 12/31/2023 24.22 Description: X-RAY EXAM OF NASAL BONES Category: Radiology CMS Add: 01/01/1984 CMS Term: 70160 TC RADIO DEF RBRVS 01/01/2024 27.64 Description: X-RAY EXAM OF NASAL BONES Category: Radiology CMS Add: 01/01/1984 CMS Term: 70160 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 17.75 Description: X-RAY EXAM OF NASAL BONES Category: Radiology CMS Add: 01/01/1984 CMS Term: 70170 26 RADIO DEF RBRVS 01/01/2024 13.88 Description: X-RAY EXAM OF TEAR DUCT Category: Radiology CMS Add: 01/01/1984 CMS Term: 70170 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 11.28 Description: X-RAY EXAM OF TEAR DUCT Category: Radiology CMS Add: 01/01/1984 CMS Term: 70170 RADIO DEF MAXFEE 01/01/2024 52.50 0.0 Description: X-RAY EXAM OF TEAR DUCT Category: Radiology CMS Add: 01/01/1984 CMS Term: 70170 RADIO DEF RBRVS 02/01/2015 12/31/2023 35.39 Description: X-RAY EXAM OF TEAR DUCT Category: Radiology CMS Add: 01/01/1984 CMS Term: 70170 TC RADIO DEF MAXFEE 01/01/2024 37.19 0.0 Description: X-RAY EXAM OF TEAR DUCT Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 834 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 70170 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 23.53 Description: X-RAY EXAM OF TEAR DUCT Category: Radiology CMS Add: 01/01/1984 CMS Term: 70190 26 RADIO DEF RBRVS 01/01/2024 10.36 Description: X-RAY EXAM OF EYE SOCKETS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70190 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 8.04 Description: X-RAY EXAM OF EYE SOCKETS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70190 RADIO DEF RBRVS 01/01/2024 35.22 Description: X-RAY EXAM OF EYE SOCKETS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70190 RADIO DEF RBRVS 02/01/2015 12/31/2023 26.04 Description: X-RAY EXAM OF EYE SOCKETS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70190 TC RADIO DEF RBRVS 01/01/2024 24.86 Description: X-RAY EXAM OF EYE SOCKETS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70190 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 18.00 Description: X-RAY EXAM OF EYE SOCKETS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70200 26 RADIO DEF RBRVS 01/01/2024 13.05 Description: X-RAY EXAM OF EYE SOCKETS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70200 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 10.41 Description: X-RAY EXAM OF EYE SOCKETS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70200 RADIO DEF RBRVS 01/01/2024 45.00 Description: X-RAY EXAM OF EYE SOCKETS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70200 RADIO DEF RBRVS 02/01/2015 12/31/2023 31.39 Description: X-RAY EXAM OF EYE SOCKETS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70200 TC RADIO DEF RBRVS 01/01/2024 31.96 Description: X-RAY EXAM OF EYE SOCKETS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70200 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 20.97 Description: X-RAY EXAM OF EYE SOCKETS Category: Radiology CMS Add: 01/01/1984 CMS Term: 7020F NOCOV DEF SYSMAN Description: MAMMO ASSESS CAT IN DBASE Category: Non Covered Services CMS Add: 04/01/2008 CMS Term: 70210 26 RADIO DEF RBRVS 01/01/2024 8.08 Description: X-RAY EXAM OF SINUSES Category: Radiology CMS Add: 01/01/1984 CMS Term: 70210 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 6.47 Description: X-RAY EXAM OF SINUSES Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 835 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 70210 RADIO DEF RBRVS 01/01/2024 30.16 Description: X-RAY EXAM OF SINUSES Category: Radiology CMS Add: 01/01/1984 CMS Term: 70210 RADIO DEF RBRVS 02/01/2015 12/31/2023 21.99 Description: X-RAY EXAM OF SINUSES Category: Radiology CMS Add: 01/01/1984 CMS Term: 70210 TC RADIO DEF RBRVS 01/01/2024 22.08 Description: X-RAY EXAM OF SINUSES Category: Radiology CMS Add: 01/01/1984 CMS Term: 70210 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 15.52 Description: X-RAY EXAM OF SINUSES Category: Radiology CMS Add: 01/01/1984 CMS Term: 70220 26 RADIO DEF RBRVS 01/01/2024 10.09 Description: X-RAY EXAM OF SINUSES Category: Radiology CMS Add: 01/01/1984 CMS Term: 70220 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 9.36 Description: X-RAY EXAM OF SINUSES Category: Radiology CMS Add: 01/01/1984 CMS Term: 70220 RADIO DEF RBRVS 01/01/2024 35.25 Description: X-RAY EXAM OF SINUSES Category: Radiology CMS Add: 01/01/1984 CMS Term: 70220 RADIO DEF RBRVS 02/01/2015 12/31/2023 27.86 Description: X-RAY EXAM OF SINUSES Category: Radiology CMS Add: 01/01/1984 CMS Term: 70220 TC RADIO DEF RBRVS 01/01/2024 25.17 Description: X-RAY EXAM OF SINUSES Category: Radiology CMS Add: 01/01/1984 CMS Term: 70220 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 18.50 Description: X-RAY EXAM OF SINUSES Category: Radiology CMS Add: 01/01/1984 CMS Term: 70240 26 RADIO DEF RBRVS 01/01/2024 8.76 Description: X-RAY EXAM PITUITARY SADDLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70240 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 7.25 Description: X-RAY EXAM PITUITARY SADDLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70240 RADIO DEF RBRVS 01/01/2024 30.84 Description: X-RAY EXAM PITUITARY SADDLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70240 RADIO DEF RBRVS 02/01/2015 12/31/2023 22.03 Description: X-RAY EXAM PITUITARY SADDLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70240 TC RADIO DEF RBRVS 01/01/2024 22.08 Description: X-RAY EXAM PITUITARY SADDLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70240 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 14.78 Description: X-RAY EXAM PITUITARY SADDLE Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 836 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 70250 26 MRT DEF RBRVS 01/01/2024 8.42 Description: X-RAY EXAM OF SKULL Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 70250 26 MRT DEF RBRVS 02/01/2015 12/31/2023 9.34 Description: X-RAY EXAM OF SKULL Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 70250 26 RADIO DEF RBRVS 01/01/2024 8.42 Description: X-RAY EXAM OF SKULL Category: Radiology CMS Add: 01/01/1984 CMS Term: 70250 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 9.34 Description: X-RAY EXAM OF SKULL Category: Radiology CMS Add: 01/01/1984 CMS Term: 70250 MRT DEF RBRVS 01/01/2024 33.59 Description: X-RAY EXAM OF SKULL Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 70250 MRT DEF RBRVS 02/01/2015 12/31/2023 26.84 Description: X-RAY EXAM OF SKULL Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 70250 RADIO DEF RBRVS 01/01/2024 33.59 Description: X-RAY EXAM OF SKULL Category: Radiology CMS Add: 01/01/1984 CMS Term: 70250 RADIO DEF RBRVS 02/01/2015 12/31/2023 26.84 Description: X-RAY EXAM OF SKULL Category: Radiology CMS Add: 01/01/1984 CMS Term: 70250 TC MRT DEF RBRVS 01/01/2024 25.17 Description: X-RAY EXAM OF SKULL Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 70250 TC MRT DEF RBRVS 02/01/2015 12/31/2023 17.51 Description: X-RAY EXAM OF SKULL Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 70250 TC RADIO DEF RBRVS 01/01/2024 25.17 Description: X-RAY EXAM OF SKULL Category: Radiology CMS Add: 01/01/1984 CMS Term: 70250 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 17.51 Description: X-RAY EXAM OF SKULL Category: Radiology CMS Add: 01/01/1984 CMS Term: 7025F NOCOV DEF SYSMAN Description: PT INFOSYS ALARM 4 NXT MAMMO Category: Non Covered Services CMS Add: 04/01/2008 CMS Term: 70260 26 MRT DEF RBRVS 01/01/2024 13.05 Description: X-RAY EXAM OF SKULL Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 70260 26 MRT DEF RBRVS 02/01/2015 12/31/2023 12.77 Description: X-RAY EXAM OF SKULL Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 70260 26 RADIO DEF RBRVS 01/01/2024 13.05 Description: X-RAY EXAM OF SKULL Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 837 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 70260 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 12.77 Description: X-RAY EXAM OF SKULL Category: Radiology CMS Add: 01/01/1984 CMS Term: 70260 MRT DEF RBRVS 01/01/2024 41.92 Description: X-RAY EXAM OF SKULL Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 70260 MRT DEF RBRVS 02/01/2015 12/31/2023 34.24 Description: X-RAY EXAM OF SKULL Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 70260 RADIO DEF RBRVS 01/01/2024 41.92 Description: X-RAY EXAM OF SKULL Category: Radiology CMS Add: 01/01/1984 CMS Term: 70260 RADIO DEF RBRVS 02/01/2015 12/31/2023 34.24 Description: X-RAY EXAM OF SKULL Category: Radiology CMS Add: 01/01/1984 CMS Term: 70260 TC MRT DEF RBRVS 01/01/2024 28.87 Description: X-RAY EXAM OF SKULL Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 70260 TC MRT DEF RBRVS 02/01/2015 12/31/2023 21.47 Description: X-RAY EXAM OF SKULL Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 70260 TC RADIO DEF RBRVS 01/01/2024 28.87 Description: X-RAY EXAM OF SKULL Category: Radiology CMS Add: 01/01/1984 CMS Term: 70260 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 21.47 Description: X-RAY EXAM OF SKULL Category: Radiology CMS Add: 01/01/1984 CMS Term: 70300 26 RADIO DEF RBRVS 01/01/2024 4.78 Description: X-RAY EXAM OF TEETH Category: Radiology CMS Add: 01/01/1984 CMS Term: 70300 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 4.34 Description: X-RAY EXAM OF TEETH Category: Radiology CMS Add: 01/01/1984 CMS Term: 70300 RADIO DEF RBRVS 01/01/2024 12.05 Description: X-RAY EXAM OF TEETH Category: Radiology CMS Add: 01/01/1984 CMS Term: 70300 RADIO DEF RBRVS 02/01/2015 12/31/2023 10.70 Description: X-RAY EXAM OF TEETH Category: Radiology CMS Add: 01/01/1984 CMS Term: 70300 TC RADIO DEF RBRVS 01/01/2024 7.26 Description: X-RAY EXAM OF TEETH Category: Radiology CMS Add: 01/01/1984 CMS Term: 70300 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 6.36 Description: X-RAY EXAM OF TEETH Category: Radiology CMS Add: 01/01/1984 CMS Term: 70310 26 RADIO DEF RBRVS 01/01/2024 7.44 Description: X-RAY EXAM OF TEETH Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 838 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 70310 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 5.95 Description: X-RAY EXAM OF TEETH Category: Radiology CMS Add: 01/01/1984 CMS Term: 70310 RADIO DEF RBRVS 01/01/2024 36.62 Description: X-RAY EXAM OF TEETH Category: Radiology CMS Add: 01/01/1984 CMS Term: 70310 RADIO DEF RBRVS 02/01/2015 12/31/2023 27.17 Description: X-RAY EXAM OF TEETH Category: Radiology CMS Add: 01/01/1984 CMS Term: 70310 TC RADIO DEF RBRVS 01/01/2024 29.18 Description: X-RAY EXAM OF TEETH Category: Radiology CMS Add: 01/01/1984 CMS Term: 70310 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 21.22 Description: X-RAY EXAM OF TEETH Category: Radiology CMS Add: 01/01/1984 CMS Term: 70320 26 RADIO DEF RBRVS 01/01/2024 10.39 Description: FULL MOUTH X-RAY OF TEETH Category: Radiology CMS Add: 01/01/1984 CMS Term: 70320 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 8.80 Description: FULL MOUTH X-RAY OF TEETH Category: Radiology CMS Add: 01/01/1984 CMS Term: 70320 RADIO DEF RBRVS 01/01/2024 49.14 Description: FULL MOUTH X-RAY OF TEETH Category: Radiology CMS Add: 01/01/1984 CMS Term: 70320 RADIO DEF RBRVS 02/01/2015 12/31/2023 37.70 Description: FULL MOUTH X-RAY OF TEETH Category: Radiology CMS Add: 01/01/1984 CMS Term: 70320 TC RADIO DEF RBRVS 01/01/2024 38.75 Description: FULL MOUTH X-RAY OF TEETH Category: Radiology CMS Add: 01/01/1984 CMS Term: 70320 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 28.90 Description: FULL MOUTH X-RAY OF TEETH Category: Radiology CMS Add: 01/01/1984 CMS Term: 70328 26 RADIO DEF RBRVS 01/01/2024 8.42 Description: X-RAY EXAM OF JAW JOINT Category: Radiology CMS Add: 01/01/1984 CMS Term: 70328 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 6.98 Description: X-RAY EXAM OF JAW JOINT Category: Radiology CMS Add: 01/01/1984 CMS Term: 70328 RADIO DEF RBRVS 01/01/2024 32.35 Description: X-RAY EXAM OF JAW JOINT Category: Radiology CMS Add: 01/01/1984 CMS Term: 70328 RADIO DEF RBRVS 02/01/2015 12/31/2023 22.75 Description: X-RAY EXAM OF JAW JOINT Category: Radiology CMS Add: 01/01/1984 CMS Term: 70328 TC RADIO DEF RBRVS 01/01/2024 23.93 Description: X-RAY EXAM OF JAW JOINT Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 839 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 70328 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 15.77 Description: X-RAY EXAM OF JAW JOINT Category: Radiology CMS Add: 01/01/1984 CMS Term: 70330 26 RADIO DEF RBRVS 01/01/2024 11.07 Description: X-RAY EXAM OF JAW JOINTS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70330 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 9.34 Description: X-RAY EXAM OF JAW JOINTS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70330 RADIO DEF RBRVS 01/01/2024 49.51 Description: X-RAY EXAM OF JAW JOINTS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70330 RADIO DEF RBRVS 02/01/2015 12/31/2023 35.02 Description: X-RAY EXAM OF JAW JOINTS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70330 TC RADIO DEF RBRVS 01/01/2024 38.44 Description: X-RAY EXAM OF JAW JOINTS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70330 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 25.68 Description: X-RAY EXAM OF JAW JOINTS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70332 26 RADIO DEF RBRVS 01/01/2024 25.12 Description: X-RAY EXAM OF JAW JOINT Category: Radiology CMS Add: 01/01/1984 CMS Term: 70332 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 22.68 Description: X-RAY EXAM OF JAW JOINT Category: Radiology CMS Add: 01/01/1984 CMS Term: 70332 RADIO DEF RBRVS 01/01/2024 79.61 Description: X-RAY EXAM OF JAW JOINT Category: Radiology CMS Add: 01/01/1984 CMS Term: 70332 RADIO DEF RBRVS 02/01/2015 12/31/2023 59.51 Description: X-RAY EXAM OF JAW JOINT Category: Radiology CMS Add: 01/01/1984 CMS Term: 70332 TC RADIO DEF RBRVS 01/01/2024 54.49 Description: X-RAY EXAM OF JAW JOINT Category: Radiology CMS Add: 01/01/1984 CMS Term: 70332 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 36.83 Description: X-RAY EXAM OF JAW JOINT Category: Radiology CMS Add: 01/01/1984 CMS Term: 70336 26 RADIO DEF RBRVS 01/01/2023 12/31/2023 54.21 Description: MAGNETIC IMAGE JAW JOINT Category: Radiology CMS Add: 01/01/1989 CMS Term: 70336 26 RADIO DEF RBRVS 01/01/2024 67.49 Description: MAGNETIC IMAGE JAW JOINT Category: Radiology CMS Add: 01/01/1989 CMS Term: 70336 RADIO DEF RBRVS 01/01/2023 12/31/2023 228.77 Description: MAGNETIC IMAGE JAW JOINT Category: Radiology CMS Add: 01/01/1989 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 840 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 70336 RADIO DEF RBRVS 01/01/2024 259.53 Description: MAGNETIC IMAGE JAW JOINT Category: Radiology CMS Add: 01/01/1989 CMS Term: 70336 TC RADIO DEF RBRVS 01/01/2023 12/31/2023 174.56 Description: MAGNETIC IMAGE JAW JOINT Category: Radiology CMS Add: 01/01/1989 CMS Term: 70336 TC RADIO DEF RBRVS 01/01/2024 192.03 Description: MAGNETIC IMAGE JAW JOINT Category: Radiology CMS Add: 01/01/1989 CMS Term: 70350 26 RADIO DEF RBRVS 01/01/2024 8.08 Description: X-RAY HEAD FOR ORTHODONTIA Category: Radiology CMS Add: 01/01/1984 CMS Term: 70350 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 7.21 Description: X-RAY HEAD FOR ORTHODONTIA Category: Radiology CMS Add: 01/01/1984 CMS Term: 70350 RADIO DEF RBRVS 01/01/2024 15.34 Description: X-RAY HEAD FOR ORTHODONTIA Category: Radiology CMS Add: 01/01/1984 CMS Term: 70350 RADIO DEF RBRVS 02/01/2015 12/31/2023 15.30 Description: X-RAY HEAD FOR ORTHODONTIA Category: Radiology CMS Add: 01/01/1984 CMS Term: 70350 TC RADIO DEF RBRVS 01/01/2024 7.26 Description: X-RAY HEAD FOR ORTHODONTIA Category: Radiology CMS Add: 01/01/1984 CMS Term: 70350 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 8.09 Description: X-RAY HEAD FOR ORTHODONTIA Category: Radiology CMS Add: 01/01/1984 CMS Term: 70355 26 RADIO DEF RBRVS 01/01/2024 9.41 Description: PANORAMIC X-RAY OF JAWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70355 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 8.02 Description: PANORAMIC X-RAY OF JAWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70355 RADIO DEF RBRVS 01/01/2024 16.98 Description: PANORAMIC X-RAY OF JAWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70355 RADIO DEF RBRVS 02/01/2015 12/31/2023 14.87 Description: PANORAMIC X-RAY OF JAWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70355 TC RADIO DEF RBRVS 01/01/2024 7.57 Description: PANORAMIC X-RAY OF JAWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70355 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 6.85 Description: PANORAMIC X-RAY OF JAWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 70360 26 RADIO DEF RBRVS 01/01/2024 8.42 Description: X-RAY EXAM OF NECK Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 841 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 70360 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 6.22 Description: X-RAY EXAM OF NECK Category: Radiology CMS Add: 01/01/1984 CMS Term: 70360 RADIO DEF RBRVS 01/01/2024 29.58 Description: X-RAY EXAM OF NECK Category: Radiology CMS Add: 01/01/1984 CMS Term: 70360 RADIO DEF RBRVS 02/01/2015 12/31/2023 20.75 Description: X-RAY EXAM OF NECK Category: Radiology CMS Add: 01/01/1984 CMS Term: 70360 TC RADIO DEF RBRVS 01/01/2024 21.15 Description: X-RAY EXAM OF NECK Category: Radiology CMS Add: 01/01/1984 CMS Term: 70360 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 14.53 Description: X-RAY EXAM OF NECK Category: Radiology CMS Add: 01/01/1984 CMS Term: 70370 26 RADIO DEF RBRVS 01/01/2024 14.25 Description: THROAT X-RAY & FLUOROSCOPY Category: Radiology CMS Add: 01/01/1984 CMS Term: 70370 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 11.49 Description: THROAT X-RAY & FLUOROSCOPY Category: Radiology CMS Add: 01/01/1984 CMS Term: 70370 RADIO DEF RBRVS 01/01/2024 94.99 Description: THROAT X-RAY & FLUOROSCOPY Category: Radiology CMS Add: 01/01/1984 CMS Term: 70370 RADIO DEF RBRVS 02/01/2015 12/31/2023 57.23 Description: THROAT X-RAY & FLUOROSCOPY Category: Radiology CMS Add: 01/01/1984 CMS Term: 70370 TC RADIO DEF RBRVS 01/01/2024 80.73 Description: THROAT X-RAY & FLUOROSCOPY Category: Radiology CMS Add: 01/01/1984 CMS Term: 70370 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 45.74 Description: THROAT X-RAY & FLUOROSCOPY Category: Radiology CMS Add: 01/01/1984 CMS Term: 70371 26 RADIO DEF RBRVS 01/01/2024 39.61 Description: SPEECH EVALUATION COMPLEX Category: Radiology CMS Add: 01/01/1988 CMS Term: 70371 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 31.49 Description: SPEECH EVALUATION COMPLEX Category: Radiology CMS Add: 01/01/1988 CMS Term: 70371 RADIO DEF RBRVS 01/01/2024 102.13 Description: SPEECH EVALUATION COMPLEX Category: Radiology CMS Add: 01/01/1988 CMS Term: 70371 RADIO DEF RBRVS 02/01/2015 12/31/2023 66.58 Description: SPEECH EVALUATION COMPLEX Category: Radiology CMS Add: 01/01/1988 CMS Term: 70371 TC RADIO DEF RBRVS 01/01/2024 62.52 Description: SPEECH EVALUATION COMPLEX Category: Radiology CMS Add: 01/01/1988 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 842 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 70371 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 35.09 Description: SPEECH EVALUATION COMPLEX Category: Radiology CMS Add: 01/01/1988 CMS Term: 70380 26 RADIO DEF RBRVS 01/01/2024 7.77 Description: X-RAY EXAM OF SALIVARY GLAND Category: Radiology CMS Add: 01/01/1984 CMS Term: 70380 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 6.71 Description: X-RAY EXAM OF SALIVARY GLAND Category: Radiology CMS Add: 01/01/1984 CMS Term: 70380 RADIO DEF RBRVS 01/01/2024 35.10 Description: X-RAY EXAM OF SALIVARY GLAND Category: Radiology CMS Add: 01/01/1984 CMS Term: 70380 RADIO DEF RBRVS 02/01/2015 12/31/2023 27.19 Description: X-RAY EXAM OF SALIVARY GLAND Category: Radiology CMS Add: 01/01/1984 CMS Term: 70380 TC RADIO DEF RBRVS 01/01/2024 27.33 Description: X-RAY EXAM OF SALIVARY GLAND Category: Radiology CMS Add: 01/01/1984 CMS Term: 70380 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 20.48 Description: X-RAY EXAM OF SALIVARY GLAND Category: Radiology CMS Add: 01/01/1984 CMS Term: 70390 26 RADIO DEF RBRVS 01/01/2024 17.52 Description: X-RAY EXAM OF SALIVARY DUCT Category: Radiology CMS Add: 01/01/1984 CMS Term: 70390 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 14.17 Description: X-RAY EXAM OF SALIVARY DUCT Category: Radiology CMS Add: 01/01/1984 CMS Term: 70390 RADIO DEF RBRVS 01/01/2024 110.30 Description: X-RAY EXAM OF SALIVARY DUCT Category: Radiology CMS Add: 01/01/1984 CMS Term: 70390 RADIO DEF RBRVS 02/01/2015 12/31/2023 71.81 Description: X-RAY EXAM OF SALIVARY DUCT Category: Radiology CMS Add: 01/01/1984 CMS Term: 70390 TC RADIO DEF RBRVS 01/01/2024 92.77 Description: X-RAY EXAM OF SALIVARY DUCT Category: Radiology CMS Add: 01/01/1984 CMS Term: 70390 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 57.64 Description: X-RAY EXAM OF SALIVARY DUCT Category: Radiology CMS Add: 01/01/1984 CMS Term: 70450 26 RADIO DEF RBRVS 01/01/2024 39.02 Description: CT HEAD/BRAIN W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70450 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 31.18 Description: CT HEAD/BRAIN W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70450 RADIO DEF RBRVS 01/01/2024 103.39 Description: CT HEAD/BRAIN W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 843 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 70450 RADIO DEF RBRVS 09/01/2019 12/31/2023 87.82 Description: CT HEAD/BRAIN W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70450 TC RADIO DEF RBRVS 01/01/2024 64.37 Description: CT HEAD/BRAIN W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70450 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 56.64 Description: CT HEAD/BRAIN W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70460 26 RADIO DEF RBRVS 01/01/2024 51.92 Description: CT HEAD/BRAIN W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70460 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 41.59 Description: CT HEAD/BRAIN W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70460 RADIO DEF RBRVS 01/01/2024 144.07 Description: CT HEAD/BRAIN W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70460 RADIO DEF RBRVS 09/01/2019 12/31/2023 120.03 Description: CT HEAD/BRAIN W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70460 TC RADIO DEF RBRVS 01/01/2024 92.16 Description: CT HEAD/BRAIN W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70460 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 78.44 Description: CT HEAD/BRAIN W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70470 26 RADIO DEF RBRVS 01/01/2024 58.36 Description: CT HEAD/BRAIN W/O & W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70470 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 46.92 Description: CT HEAD/BRAIN W/O & W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70470 RADIO DEF RBRVS 01/01/2024 169.21 Description: CT HEAD/BRAIN W/O & W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70470 RADIO DEF RBRVS 09/01/2019 12/31/2023 143.94 Description: CT HEAD/BRAIN W/O & W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70470 TC RADIO DEF RBRVS 01/01/2024 110.84 Description: CT HEAD/BRAIN W/O & W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70470 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 97.02 Description: CT HEAD/BRAIN W/O & W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70480 26 RADIO DEF RBRVS 01/01/2024 59.01 Description: CT ORBIT/EAR/FOSSA W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 844 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 70480 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 47.19 Description: CT ORBIT/EAR/FOSSA W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70480 RADIO DEF RBRVS 01/01/2024 154.56 Description: CT ORBIT/EAR/FOSSA W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70480 RADIO DEF RBRVS 09/01/2019 12/31/2023 177.40 Description: CT ORBIT/EAR/FOSSA W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70480 TC RADIO DEF RBRVS 01/01/2024 95.55 Description: CT ORBIT/EAR/FOSSA W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70480 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 130.22 Description: CT ORBIT/EAR/FOSSA W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70481 26 RADIO DEF RBRVS 01/01/2024 51.92 Description: CT ORBIT/EAR/FOSSA W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70481 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 51.03 Description: CT ORBIT/EAR/FOSSA W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70481 RADIO DEF RBRVS 01/01/2024 175.72 Description: CT ORBIT/EAR/FOSSA W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70481 RADIO DEF RBRVS 09/01/2019 12/31/2023 206.51 Description: CT ORBIT/EAR/FOSSA W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70481 TC RADIO DEF RBRVS 01/01/2024 123.81 Description: CT ORBIT/EAR/FOSSA W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70481 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 155.48 Description: CT ORBIT/EAR/FOSSA W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70482 26 RADIO DEF RBRVS 01/01/2024 58.06 Description: CT ORBIT/EAR/FOSSA W/O&W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70482 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 53.41 Description: CT ORBIT/EAR/FOSSA W/O&W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70482 RADIO DEF RBRVS 01/01/2024 205.02 Description: CT ORBIT/EAR/FOSSA W/O&W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70482 RADIO DEF RBRVS 09/01/2019 12/31/2023 228.21 Description: CT ORBIT/EAR/FOSSA W/O&W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70482 TC RADIO DEF RBRVS 01/01/2024 146.96 Description: CT ORBIT/EAR/FOSSA W/O&W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 845 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 70482 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 174.80 Description: CT ORBIT/EAR/FOSSA W/O&W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70486 26 RADIO DEF RBRVS 01/01/2024 39.33 Description: CT MAXILLOFACIAL W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70486 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 42.11 Description: CT MAXILLOFACIAL W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70486 RADIO DEF RBRVS 01/01/2024 124.69 Description: CT MAXILLOFACIAL W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70486 RADIO DEF RBRVS 09/01/2019 12/31/2023 146.31 Description: CT MAXILLOFACIAL W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70486 TC RADIO DEF RBRVS 01/01/2024 85.37 Description: CT MAXILLOFACIAL W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70486 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 104.21 Description: CT MAXILLOFACIAL W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70487 26 RADIO DEF RBRVS 01/01/2024 51.92 Description: CT MAXILLOFACIAL W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70487 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 47.97 Description: CT MAXILLOFACIAL W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70487 RADIO DEF RBRVS 01/01/2024 148.09 Description: CT MAXILLOFACIAL W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70487 RADIO DEF RBRVS 09/01/2019 12/31/2023 176.95 Description: CT MAXILLOFACIAL W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70487 TC RADIO DEF RBRVS 01/01/2024 96.17 Description: CT MAXILLOFACIAL W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70487 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 128.98 Description: CT MAXILLOFACIAL W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70488 26 RADIO DEF RBRVS 01/01/2024 58.36 Description: CT MAXILLOFACIAL W/O & W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70488 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 52.35 Description: CT MAXILLOFACIAL W/O & W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70488 RADIO DEF RBRVS 01/01/2024 180.01 Description: CT MAXILLOFACIAL W/O & W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 846 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 70488 RADIO DEF RBRVS 09/01/2019 12/31/2023 211.55 Description: CT MAXILLOFACIAL W/O & W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70488 TC RADIO DEF RBRVS 01/01/2024 121.65 Description: CT MAXILLOFACIAL W/O & W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70488 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 159.20 Description: CT MAXILLOFACIAL W/O & W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70490 26 RADIO DEF RBRVS 01/01/2024 59.01 Description: CT SOFT TISSUE NECK W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70490 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 47.19 Description: CT SOFT TISSUE NECK W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70490 RADIO DEF RBRVS 01/01/2024 146.54 Description: CT SOFT TISSUE NECK W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70490 RADIO DEF RBRVS 09/01/2019 12/31/2023 144.95 Description: CT SOFT TISSUE NECK W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70490 TC RADIO DEF RBRVS 01/01/2024 87.53 Description: CT SOFT TISSUE NECK W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70490 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 97.76 Description: CT SOFT TISSUE NECK W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70491 26 RADIO DEF RBRVS 01/01/2024 63.64 Description: CT SOFT TISSUE NECK W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70491 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 50.87 Description: CT SOFT TISSUE NECK W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70491 RADIO DEF RBRVS 01/01/2024 180.03 Description: CT SOFT TISSUE NECK W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70491 RADIO DEF RBRVS 09/01/2019 12/31/2023 173.65 Description: CT SOFT TISSUE NECK W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70491 TC RADIO DEF RBRVS 01/01/2024 116.40 Description: CT SOFT TISSUE NECK W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70491 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 122.78 Description: CT SOFT TISSUE NECK W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70492 26 RADIO DEF RBRVS 01/01/2024 74.09 Description: CT SFT TSUE NCK W/O & W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 847 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 70492 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 53.41 Description: CT SFT TSUE NCK W/O & W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70492 RADIO DEF RBRVS 01/01/2024 216.42 Description: CT SFT TSUE NCK W/O & W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70492 RADIO DEF RBRVS 09/01/2019 12/31/2023 205.92 Description: CT SFT TSUE NCK W/O & W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70492 TC RADIO DEF RBRVS 01/01/2024 142.33 Description: CT SFT TSUE NCK W/O & W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70492 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 152.51 Description: CT SFT TSUE NCK W/O & W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 70496 26 RADIO DEF RBRVS 01/01/2024 80.36 Description: CT ANGIOGRAPHY HEAD Category: Radiology CMS Add: 01/01/2001 CMS Term: 70496 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 64.52 Description: CT ANGIOGRAPHY HEAD Category: Radiology CMS Add: 01/01/2001 CMS Term: 70496 RADIO DEF RBRVS 01/01/2024 268.39 Description: CT ANGIOGRAPHY HEAD Category: Radiology CMS Add: 01/01/2001 CMS Term: 70496 RADIO DEF RBRVS 09/01/2019 12/31/2023 314.63 Description: CT ANGIOGRAPHY HEAD Category: Radiology CMS Add: 01/01/2001 CMS Term: 70496 TC RADIO DEF RBRVS 01/01/2024 188.03 Description: CT ANGIOGRAPHY HEAD Category: Radiology CMS Add: 01/01/2001 CMS Term: 70496 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 250.11 Description: CT ANGIOGRAPHY HEAD Category: Radiology CMS Add: 01/01/2001 CMS Term: 70498 26 RADIO DEF RBRVS 01/01/2024 80.36 Description: CT ANGIOGRAPHY NECK Category: Radiology CMS Add: 01/01/2001 CMS Term: 70498 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 64.28 Description: CT ANGIOGRAPHY NECK Category: Radiology CMS Add: 01/01/2001 CMS Term: 70498 RADIO DEF RBRVS 01/01/2024 268.08 Description: CT ANGIOGRAPHY NECK Category: Radiology CMS Add: 01/01/2001 CMS Term: 70498 RADIO DEF RBRVS 09/01/2019 12/31/2023 326.52 Description: CT ANGIOGRAPHY NECK Category: Radiology CMS Add: 01/01/2001 CMS Term: 70498 TC RADIO DEF RBRVS 01/01/2024 187.72 Description: CT ANGIOGRAPHY NECK Category: Radiology CMS Add: 01/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 848 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 70498 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 262.25 Description: CT ANGIOGRAPHY NECK Category: Radiology CMS Add: 01/01/2001 CMS Term: 70540 26 RADIO DEF RBRVS 01/01/2024 61.69 Description: MRI ORBIT/FACE/NECK W/O DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 70540 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 49.73 Description: MRI ORBIT/FACE/NECK W/O DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 70540 RADIO DEF RBRVS 01/01/2024 221.31 Description: MRI ORBIT/FACE/NECK W/O DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 70540 RADIO DEF RBRVS 09/01/2019 12/31/2023 254.51 Description: MRI ORBIT/FACE/NECK W/O DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 70540 TC RADIO DEF RBRVS 01/01/2024 159.62 Description: MRI ORBIT/FACE/NECK W/O DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 70540 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 204.78 Description: MRI ORBIT/FACE/NECK W/O DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 70542 26 RADIO DEF RBRVS 01/01/2024 74.40 Description: MRI ORBIT/FACE/NECK W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70542 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 59.79 Description: MRI ORBIT/FACE/NECK W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70542 RADIO DEF RBRVS 01/01/2024 263.04 Description: MRI ORBIT/FACE/NECK W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70542 RADIO DEF RBRVS 09/01/2019 12/31/2023 290.83 Description: MRI ORBIT/FACE/NECK W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70542 TC RADIO DEF RBRVS 01/01/2024 188.64 Description: MRI ORBIT/FACE/NECK W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70542 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 231.04 Description: MRI ORBIT/FACE/NECK W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70543 26 RADIO DEF RBRVS 01/01/2024 98.40 Description: MRI ORBT/FAC/NCK W/O &W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70543 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 78.90 Description: MRI ORBT/FAC/NCK W/O &W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70543 RADIO DEF RBRVS 01/01/2024 332.12 Description: MRI ORBT/FAC/NCK W/O &W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 849 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 70543 RADIO DEF RBRVS 09/01/2019 12/31/2023 356.51 Description: MRI ORBT/FAC/NCK W/O &W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70543 TC RADIO DEF RBRVS 01/01/2024 233.72 Description: MRI ORBT/FAC/NCK W/O &W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70543 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 277.61 Description: MRI ORBT/FAC/NCK W/O &W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70544 26 RADIO DEF RBRVS 01/01/2024 55.21 Description: MR ANGIOGRAPHY HEAD W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70544 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 44.30 Description: MR ANGIOGRAPHY HEAD W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70544 RADIO DEF RBRVS 01/01/2024 209.89 Description: MR ANGIOGRAPHY HEAD W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70544 RADIO DEF RBRVS 09/01/2019 12/31/2023 284.75 Description: MR ANGIOGRAPHY HEAD W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70544 TC RADIO DEF RBRVS 01/01/2024 154.68 Description: MR ANGIOGRAPHY HEAD W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70544 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 240.45 Description: MR ANGIOGRAPHY HEAD W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70545 26 RADIO DEF RBRVS 01/01/2024 54.91 Description: MR ANGIOGRAPHY HEAD W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70545 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 44.30 Description: MR ANGIOGRAPHY HEAD W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70545 RADIO DEF RBRVS 01/01/2024 221.33 Description: MR ANGIOGRAPHY HEAD W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70545 RADIO DEF RBRVS 09/01/2019 12/31/2023 280.78 Description: MR ANGIOGRAPHY HEAD W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70545 TC RADIO DEF RBRVS 01/01/2024 166.42 Description: MR ANGIOGRAPHY HEAD W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70545 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 236.49 Description: MR ANGIOGRAPHY HEAD W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70546 26 RADIO DEF RBRVS 01/01/2024 67.80 Description: MR ANGIOGRAPH HEAD W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 850 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 70546 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 66.53 Description: MR ANGIOGRAPH HEAD W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70546 RADIO DEF RBRVS 01/01/2024 320.36 Description: MR ANGIOGRAPH HEAD W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70546 RADIO DEF RBRVS 09/01/2019 12/31/2023 428.11 Description: MR ANGIOGRAPH HEAD W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70546 TC RADIO DEF RBRVS 01/01/2024 252.55 Description: MR ANGIOGRAPH HEAD W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70546 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 361.58 Description: MR ANGIOGRAPH HEAD W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70547 26 RADIO DEF RBRVS 01/01/2024 55.21 Description: MR ANGIOGRAPHY NECK W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70547 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 44.30 Description: MR ANGIOGRAPHY NECK W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70547 RADIO DEF RBRVS 01/01/2024 210.20 Description: MR ANGIOGRAPHY NECK W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70547 RADIO DEF RBRVS 09/01/2019 12/31/2023 285.49 Description: MR ANGIOGRAPHY NECK W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70547 TC RADIO DEF RBRVS 01/01/2024 154.99 Description: MR ANGIOGRAPHY NECK W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70547 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 241.19 Description: MR ANGIOGRAPHY NECK W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70548 26 RADIO DEF RBRVS 01/01/2024 68.79 Description: MR ANGIOGRAPHY NECK W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70548 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 44.30 Description: MR ANGIOGRAPHY NECK W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70548 RADIO DEF RBRVS 01/01/2024 239.84 Description: MR ANGIOGRAPHY NECK W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70548 RADIO DEF RBRVS 09/01/2019 12/31/2023 299.61 Description: MR ANGIOGRAPHY NECK W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70548 TC RADIO DEF RBRVS 01/01/2024 171.05 Description: MR ANGIOGRAPHY NECK W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 851 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 70548 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 255.31 Description: MR ANGIOGRAPHY NECK W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70549 26 RADIO DEF RBRVS 01/01/2024 82.67 Description: MR ANGIOGRAPH NECK W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70549 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 66.36 Description: MR ANGIOGRAPH NECK W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70549 RADIO DEF RBRVS 01/01/2024 336.46 Description: MR ANGIOGRAPH NECK W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70549 RADIO DEF RBRVS 09/01/2019 12/31/2023 430.92 Description: MR ANGIOGRAPH NECK W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70549 TC RADIO DEF RBRVS 01/01/2024 253.79 Description: MR ANGIOGRAPH NECK W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70549 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 364.55 Description: MR ANGIOGRAPH NECK W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 70551 26 RADIO DEF RBRVS 01/01/2024 68.11 Description: MRI BRAIN STEM W/O DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 70551 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 54.46 Description: MRI BRAIN STEM W/O DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 70551 RADIO DEF RBRVS 01/01/2024 191.61 Description: MRI BRAIN STEM W/O DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 70551 RADIO DEF RBRVS 09/01/2019 12/31/2023 173.53 Description: MRI BRAIN STEM W/O DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 70551 TC RADIO DEF RBRVS 01/01/2024 123.50 Description: MRI BRAIN STEM W/O DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 70551 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 119.07 Description: MRI BRAIN STEM W/O DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 70552 26 RADIO DEF RBRVS 01/01/2024 82.00 Description: MRI BRAIN STEM W/DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 70552 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 65.99 Description: MRI BRAIN STEM W/DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 70552 RADIO DEF RBRVS 01/01/2024 264.47 Description: MRI BRAIN STEM W/DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 852 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 70552 RADIO DEF RBRVS 09/01/2019 12/31/2023 235.59 Description: MRI BRAIN STEM W/DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 70552 TC RADIO DEF RBRVS 01/01/2024 182.48 Description: MRI BRAIN STEM W/DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 70552 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 169.60 Description: MRI BRAIN STEM W/DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 70553 26 RADIO DEF RBRVS 01/01/2024 105.16 Description: MRI BRAIN STEM W/O & W/DYE Category: Radiology CMS Add: 01/01/1992 CMS Term: 70553 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 84.48 Description: MRI BRAIN STEM W/O & W/DYE Category: Radiology CMS Add: 01/01/1992 CMS Term: 70553 RADIO DEF RBRVS 01/01/2024 312.02 Description: MRI BRAIN STEM W/O & W/DYE Category: Radiology CMS Add: 01/01/1992 CMS Term: 70553 RADIO DEF RBRVS 09/01/2019 12/31/2023 278.36 Description: MRI BRAIN STEM W/O & W/DYE Category: Radiology CMS Add: 01/01/1992 CMS Term: 70553 TC RADIO DEF RBRVS 01/01/2024 206.86 Description: MRI BRAIN STEM W/O & W/DYE Category: Radiology CMS Add: 01/01/1992 CMS Term: 70553 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 193.88 Description: MRI BRAIN STEM W/O & W/DYE Category: Radiology CMS Add: 01/01/1992 CMS Term: 70554 26 RADIO DEF RBRVS 01/01/2024 96.90 Description: FMRI BRAIN BY TECH Category: Radiology CMS Add: 01/01/2007 CMS Term: 70554 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 77.83 Description: FMRI BRAIN BY TECH Category: Radiology CMS Add: 01/01/2007 CMS Term: 70554 RADIO DEF RBRVS 01/01/2024 370.13 Description: FMRI BRAIN BY TECH Category: Radiology CMS Add: 01/01/2007 CMS Term: 70554 RADIO DEF RBRVS 02/01/2015 12/31/2023 319.52 Description: FMRI BRAIN BY TECH Category: Radiology CMS Add: 01/01/2007 CMS Term: 70554 TC RADIO DEF RBRVS 01/01/2024 273.24 Description: FMRI BRAIN BY TECH Category: Radiology CMS Add: 01/01/2007 CMS Term: 70554 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 241.69 Description: FMRI BRAIN BY TECH Category: Radiology CMS Add: 01/01/2007 CMS Term: 70555 26 RADIO DEF RBRVS 01/01/2024 115.17 Description: FMRI BRAIN BY PHYS/PSYCH Category: Radiology CMS Add: 01/01/2007 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 853 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 70555 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 95.08 Description: FMRI BRAIN BY PHYS/PSYCH Category: Radiology CMS Add: 01/01/2007 CMS Term: 70555 RADIO DEF MAXFEE 01/01/2024 637.79 0.0 Description: FMRI BRAIN BY PHYS/PSYCH Category: Radiology CMS Add: 01/01/2007 CMS Term: 70555 TC RADIO DEF MAXFEE 01/01/2024 500.15 0.0 Description: FMRI BRAIN BY PHYS/PSYCH Category: Radiology CMS Add: 01/01/2007 CMS Term: 70557 26 RADIO DEF RBRVS 01/01/2024 145.62 Description: MRI BRAIN W/O DYE Category: Radiology CMS Add: 01/01/2004 CMS Term: 70557 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 120.94 Description: MRI BRAIN W/O DYE Category: Radiology CMS Add: 01/01/2004 CMS Term: 70558 26 RADIO DEF RBRVS 01/01/2024 159.78 Description: MRI BRAIN W/DYE Category: Radiology CMS Add: 01/01/2004 CMS Term: 70558 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 120.00 Description: MRI BRAIN W/DYE Category: Radiology CMS Add: 01/01/2004 CMS Term: 70559 26 RADIO DEF RBRVS 01/01/2024 151.24 Description: MRI BRAIN W/O & W/DYE Category: Radiology CMS Add: 01/01/2004 CMS Term: 70559 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 120.24 Description: MRI BRAIN W/O & W/DYE Category: Radiology CMS Add: 01/01/2004 CMS Term: 71045 26 MRT DEF RBRVS 01/01/2018 8.42 Description: X-RAY EXAM CHEST 1 VIEW Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 71045 26 RADIO DEF RBRVS 01/01/2018 8.42 Description: X-RAY EXAM CHEST 1 VIEW Category: Radiology CMS Add: 01/01/2018 CMS Term: 71045 MRT DEF RBRVS 01/01/2018 12/31/2023 14.08 Description: X-RAY EXAM CHEST 1 VIEW Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 71045 MRT DEF RBRVS 01/01/2024 24.33 Description: X-RAY EXAM CHEST 1 VIEW Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 71045 RADIO DEF RBRVS 01/01/2018 12/31/2023 14.08 Description: X-RAY EXAM CHEST 1 VIEW Category: Radiology CMS Add: 01/01/2018 CMS Term: 71045 RADIO DEF RBRVS 01/01/2024 24.33 Description: X-RAY EXAM CHEST 1 VIEW Category: Radiology CMS Add: 01/01/2018 CMS Term: 71045 TC MRT DEF RBRVS 01/01/2018 12/31/2023 7.35 Description: X-RAY EXAM CHEST 1 VIEW Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 854 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 71045 TC MRT DEF RBRVS 01/01/2024 15.91 Description: X-RAY EXAM CHEST 1 VIEW Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 71045 TC RADIO DEF RBRVS 01/01/2018 12/31/2023 7.35 Description: X-RAY EXAM CHEST 1 VIEW Category: Radiology CMS Add: 01/01/2018 CMS Term: 71045 TC RADIO DEF RBRVS 01/01/2024 15.91 Description: X-RAY EXAM CHEST 1 VIEW Category: Radiology CMS Add: 01/01/2018 CMS Term: 71046 26 MRT DEF RBRVS 01/01/2018 10.09 Description: X-RAY EXAM CHEST 2 VIEWS Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 71046 26 RADIO DEF RBRVS 01/01/2018 10.09 Description: X-RAY EXAM CHEST 2 VIEWS Category: Radiology CMS Add: 01/01/2018 CMS Term: 71046 MRT DEF RBRVS 01/01/2018 12/31/2023 21.60 Description: X-RAY EXAM CHEST 2 VIEWS Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 71046 MRT DEF RBRVS 01/01/2024 31.55 Description: X-RAY EXAM CHEST 2 VIEWS Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 71046 RADIO DEF RBRVS 01/01/2018 12/31/2023 21.60 Description: X-RAY EXAM CHEST 2 VIEWS Category: Radiology CMS Add: 01/01/2018 CMS Term: 71046 RADIO DEF RBRVS 01/01/2024 31.55 Description: X-RAY EXAM CHEST 2 VIEWS Category: Radiology CMS Add: 01/01/2018 CMS Term: 71046 TC MRT DEF RBRVS 01/01/2018 12/31/2023 13.54 Description: X-RAY EXAM CHEST 2 VIEWS Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 71046 TC MRT DEF RBRVS 01/01/2024 21.46 Description: X-RAY EXAM CHEST 2 VIEWS Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 71046 TC RADIO DEF RBRVS 01/01/2018 12/31/2023 13.54 Description: X-RAY EXAM CHEST 2 VIEWS Category: Radiology CMS Add: 01/01/2018 CMS Term: 71046 TC RADIO DEF RBRVS 01/01/2024 21.46 Description: X-RAY EXAM CHEST 2 VIEWS Category: Radiology CMS Add: 01/01/2018 CMS Term: 71047 26 MRT DEF RBRVS 01/01/2018 12/31/2023 10.39 Description: X-RAY EXAM CHEST 3 VIEWS Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 71047 26 MRT DEF RBRVS 01/01/2024 12.71 Description: X-RAY EXAM CHEST 3 VIEWS Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 71047 26 RADIO DEF RBRVS 01/01/2018 12/31/2023 10.39 Description: X-RAY EXAM CHEST 3 VIEWS Category: Radiology CMS Add: 01/01/2018 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 855 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 71047 26 RADIO DEF RBRVS 01/01/2024 12.71 Description: X-RAY EXAM CHEST 3 VIEWS Category: Radiology CMS Add: 01/01/2018 CMS Term: 71047 MRT DEF RBRVS 01/01/2018 12/31/2023 27.65 Description: X-RAY EXAM CHEST 3 VIEWS Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 71047 MRT DEF RBRVS 01/01/2024 39.73 Description: X-RAY EXAM CHEST 3 VIEWS Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 71047 RADIO DEF RBRVS 01/01/2018 12/31/2023 27.65 Description: X-RAY EXAM CHEST 3 VIEWS Category: Radiology CMS Add: 01/01/2018 CMS Term: 71047 RADIO DEF RBRVS 01/01/2024 39.73 Description: X-RAY EXAM CHEST 3 VIEWS Category: Radiology CMS Add: 01/01/2018 CMS Term: 71047 TC MRT DEF RBRVS 01/01/2018 12/31/2023 17.26 Description: X-RAY EXAM CHEST 3 VIEWS Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 71047 TC MRT DEF RBRVS 01/01/2024 27.02 Description: X-RAY EXAM CHEST 3 VIEWS Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 71047 TC RADIO DEF RBRVS 01/01/2018 12/31/2023 17.26 Description: X-RAY EXAM CHEST 3 VIEWS Category: Radiology CMS Add: 01/01/2018 CMS Term: 71047 TC RADIO DEF RBRVS 01/01/2024 27.02 Description: X-RAY EXAM CHEST 3 VIEWS Category: Radiology CMS Add: 01/01/2018 CMS Term: 71048 26 MRT DEF RBRVS 01/01/2018 12/31/2023 11.96 Description: X-RAY EXAM CHEST 4+ VIEWS Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 71048 26 MRT DEF RBRVS 01/01/2024 14.37 Description: X-RAY EXAM CHEST 4+ VIEWS Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 71048 26 RADIO DEF RBRVS 01/01/2018 12/31/2023 11.96 Description: X-RAY EXAM CHEST 4+ VIEWS Category: Radiology CMS Add: 01/01/2018 CMS Term: 71048 26 RADIO DEF RBRVS 01/01/2024 14.37 Description: X-RAY EXAM CHEST 4+ VIEWS Category: Radiology CMS Add: 01/01/2018 CMS Term: 71048 MRT DEF RBRVS 01/01/2018 12/31/2023 29.72 Description: X-RAY EXAM CHEST 4+ VIEWS Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 71048 MRT DEF RBRVS 01/01/2024 43.55 Description: X-RAY EXAM CHEST 4+ VIEWS Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 71048 RADIO DEF RBRVS 01/01/2018 12/31/2023 29.72 Description: X-RAY EXAM CHEST 4+ VIEWS Category: Radiology CMS Add: 01/01/2018 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 856 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 71048 RADIO DEF RBRVS 01/01/2024 43.55 Description: X-RAY EXAM CHEST 4+ VIEWS Category: Radiology CMS Add: 01/01/2018 CMS Term: 71048 TC MRT DEF RBRVS 01/01/2018 12/31/2023 17.75 Description: X-RAY EXAM CHEST 4+ VIEWS Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 71048 TC MRT DEF RBRVS 01/01/2024 29.18 Description: X-RAY EXAM CHEST 4+ VIEWS Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 71048 TC RADIO DEF RBRVS 01/01/2018 12/31/2023 17.75 Description: X-RAY EXAM CHEST 4+ VIEWS Category: Radiology CMS Add: 01/01/2018 CMS Term: 71048 TC RADIO DEF RBRVS 01/01/2024 29.18 Description: X-RAY EXAM CHEST 4+ VIEWS Category: Radiology CMS Add: 01/01/2018 CMS Term: 71100 26 MRT DEF RBRVS 01/01/2024 10.39 Description: X-RAY EXAM RIBS UNI 2 VIEWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 71100 26 MRT DEF RBRVS 02/01/2015 12/31/2023 8.31 Description: X-RAY EXAM RIBS UNI 2 VIEWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 71100 26 RADIO DEF RBRVS 01/01/2024 10.39 Description: X-RAY EXAM RIBS UNI 2 VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 71100 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 8.31 Description: X-RAY EXAM RIBS UNI 2 VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 71100 MRT DEF RBRVS 01/01/2024 34.64 Description: X-RAY EXAM RIBS UNI 2 VIEWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 71100 MRT DEF RBRVS 02/01/2015 12/31/2023 23.58 Description: X-RAY EXAM RIBS UNI 2 VIEWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 71100 RADIO DEF RBRVS 01/01/2024 34.64 Description: X-RAY EXAM RIBS UNI 2 VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 71100 RADIO DEF RBRVS 02/01/2015 12/31/2023 23.58 Description: X-RAY EXAM RIBS UNI 2 VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 71100 TC MRT DEF RBRVS 01/01/2024 24.24 Description: X-RAY EXAM RIBS UNI 2 VIEWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 71100 TC MRT DEF RBRVS 02/01/2015 12/31/2023 15.28 Description: X-RAY EXAM RIBS UNI 2 VIEWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 71100 TC RADIO DEF RBRVS 01/01/2024 24.24 Description: X-RAY EXAM RIBS UNI 2 VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 857 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 71100 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 15.28 Description: X-RAY EXAM RIBS UNI 2 VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 71101 26 RADIO DEF RBRVS 01/01/2024 12.40 Description: X-RAY EXAM UNILAT RIBS/CHEST Category: Radiology CMS Add: 01/01/1984 CMS Term: 71101 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 9.90 Description: X-RAY EXAM UNILAT RIBS/CHEST Category: Radiology CMS Add: 01/01/1984 CMS Term: 71101 RADIO DEF RBRVS 01/01/2024 39.73 Description: X-RAY EXAM UNILAT RIBS/CHEST Category: Radiology CMS Add: 01/01/1984 CMS Term: 71101 RADIO DEF RBRVS 02/01/2015 12/31/2023 28.64 Description: X-RAY EXAM UNILAT RIBS/CHEST Category: Radiology CMS Add: 01/01/1984 CMS Term: 71101 TC RADIO DEF RBRVS 01/01/2024 27.33 Description: X-RAY EXAM UNILAT RIBS/CHEST Category: Radiology CMS Add: 01/01/1984 CMS Term: 71101 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 18.74 Description: X-RAY EXAM UNILAT RIBS/CHEST Category: Radiology CMS Add: 01/01/1984 CMS Term: 71110 26 RADIO DEF RBRVS 01/01/2024 13.38 Description: X-RAY EXAM RIBS BIL 3 VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 71110 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 10.14 Description: X-RAY EXAM RIBS BIL 3 VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 71110 RADIO DEF RBRVS 01/01/2024 41.33 Description: X-RAY EXAM RIBS BIL 3 VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 71110 RADIO DEF RBRVS 02/01/2015 12/31/2023 29.38 Description: X-RAY EXAM RIBS BIL 3 VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 71110 TC RADIO DEF RBRVS 01/01/2024 27.95 Description: X-RAY EXAM RIBS BIL 3 VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 71110 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 19.24 Description: X-RAY EXAM RIBS BIL 3 VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 71111 26 RADIO DEF RBRVS 01/01/2024 14.87 Description: X-RAY EXAM RIBS/CHEST4/> VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 71111 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 11.98 Description: X-RAY EXAM RIBS/CHEST4/> VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 71111 RADIO DEF RBRVS 01/01/2024 49.30 Description: X-RAY EXAM RIBS/CHEST4/> VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 858 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 71111 RADIO DEF RBRVS 02/01/2015 12/31/2023 38.41 Description: X-RAY EXAM RIBS/CHEST4/> VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 71111 TC RADIO DEF RBRVS 01/01/2024 34.43 Description: X-RAY EXAM RIBS/CHEST4/> VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 71111 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 26.42 Description: X-RAY EXAM RIBS/CHEST4/> VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 71120 26 RADIO DEF RBRVS 01/01/2024 9.10 Description: X-RAY EXAM BREASTBONE 2/>VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 71120 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 7.52 Description: X-RAY EXAM BREASTBONE 2/>VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 71120 RADIO DEF RBRVS 01/01/2024 31.49 Description: X-RAY EXAM BREASTBONE 2/>VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 71120 RADIO DEF RBRVS 02/01/2015 12/31/2023 22.80 Description: X-RAY EXAM BREASTBONE 2/>VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 71120 TC RADIO DEF RBRVS 01/01/2024 22.39 Description: X-RAY EXAM BREASTBONE 2/>VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 71120 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 15.28 Description: X-RAY EXAM BREASTBONE 2/>VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 71130 26 RADIO DEF RBRVS 01/01/2024 10.09 Description: X-RAY STRENOCLAVIC JT 3/>VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 71130 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 8.31 Description: X-RAY STRENOCLAVIC JT 3/>VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 71130 RADIO DEF RBRVS 01/01/2024 38.65 Description: X-RAY STRENOCLAVIC JT 3/>VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 71130 RADIO DEF RBRVS 02/01/2015 12/31/2023 26.80 Description: X-RAY STRENOCLAVIC JT 3/>VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 71130 TC RADIO DEF RBRVS 01/01/2024 28.56 Description: X-RAY STRENOCLAVIC JT 3/>VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 71130 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 18.50 Description: X-RAY STRENOCLAVIC JT 3/>VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 71250 26 RADIO DEF RBRVS 01/01/2024 49.60 Description: CT THORAX DX C- Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 859 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 71250 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 37.40 Description: CT THORAX DX C- Category: Radiology CMS Add: 01/01/1984 CMS Term: 71250 RADIO DEF RBRVS 01/01/2024 129.72 Description: CT THORAX DX C- Category: Radiology CMS Add: 01/01/1984 CMS Term: 71250 RADIO DEF RBRVS 09/01/2019 12/31/2023 135.16 Description: CT THORAX DX C- Category: Radiology CMS Add: 01/01/1984 CMS Term: 71250 TC RADIO DEF RBRVS 01/01/2024 80.12 Description: CT THORAX DX C- Category: Radiology CMS Add: 01/01/1984 CMS Term: 71250 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 97.76 Description: CT THORAX DX C- Category: Radiology CMS Add: 01/01/1984 CMS Term: 71260 26 RADIO DEF RBRVS 01/01/2024 53.55 Description: CT THORAX DX C+ Category: Radiology CMS Add: 01/01/1984 CMS Term: 71260 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 45.87 Description: CT THORAX DX C+ Category: Radiology CMS Add: 01/01/1984 CMS Term: 71260 RADIO DEF RBRVS 01/01/2024 162.23 Description: CT THORAX DX C+ Category: Radiology CMS Add: 01/01/1984 CMS Term: 71260 RADIO DEF RBRVS 09/01/2019 12/31/2023 169.15 Description: CT THORAX DX C+ Category: Radiology CMS Add: 01/01/1984 CMS Term: 71260 TC RADIO DEF RBRVS 01/01/2024 108.68 Description: CT THORAX DX C+ Category: Radiology CMS Add: 01/01/1984 CMS Term: 71260 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 123.28 Description: CT THORAX DX C+ Category: Radiology CMS Add: 01/01/1984 CMS Term: 71270 26 RADIO DEF RBRVS 01/01/2024 57.22 Description: CT THORAX DX C-/C+ Category: Radiology CMS Add: 01/01/1984 CMS Term: 71270 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 50.62 Description: CT THORAX DX C-/C+ Category: Radiology CMS Add: 01/01/1984 CMS Term: 71270 RADIO DEF RBRVS 01/01/2024 191.21 Description: CT THORAX DX C-/C+ Category: Radiology CMS Add: 01/01/1984 CMS Term: 71270 RADIO DEF RBRVS 09/01/2019 12/31/2023 203.87 Description: CT THORAX DX C-/C+ Category: Radiology CMS Add: 01/01/1984 CMS Term: 71270 TC RADIO DEF RBRVS 01/01/2024 133.99 Description: CT THORAX DX C-/C+ Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 860 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 71270 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 153.25 Description: CT THORAX DX C-/C+ Category: Radiology CMS Add: 01/01/1984 CMS Term: 71271 26 RADIO DEF RBRVS 01/01/2021 12/31/2023 39.26 Description: CT THORAX LUNG CANCER SCR C- Category: Radiology CMS Add: 01/01/2021 CMS Term: 71271 26 RADIO DEF RBRVS 01/01/2024 49.60 Description: CT THORAX LUNG CANCER SCR C- Category: Radiology CMS Add: 01/01/2021 CMS Term: 71271 RADIO DEF RBRVS 01/01/2021 12/31/2023 110.27 Description: CT THORAX LUNG CANCER SCR C- Category: Radiology CMS Add: 01/01/2021 CMS Term: 71271 RADIO DEF RBRVS 01/01/2024 134.04 Description: CT THORAX LUNG CANCER SCR C- Category: Radiology CMS Add: 01/01/2021 CMS Term: 71271 TC RADIO DEF RBRVS 01/01/2021 12/31/2023 71.01 Description: CT THORAX LUNG CANCER SCR C- Category: Radiology CMS Add: 01/01/2021 CMS Term: 71271 TC RADIO DEF RBRVS 01/01/2024 84.44 Description: CT THORAX LUNG CANCER SCR C- Category: Radiology CMS Add: 01/01/2021 CMS Term: 71275 26 RADIO DEF RBRVS 01/01/2024 83.35 Description: CT ANGIOGRAPHY CHEST Category: Radiology CMS Add: 01/01/2001 CMS Term: 71275 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 70.74 Description: CT ANGIOGRAPHY CHEST Category: Radiology CMS Add: 01/01/2001 CMS Term: 71275 RADIO DEF RBRVS 01/01/2024 273.54 Description: CT ANGIOGRAPHY CHEST Category: Radiology CMS Add: 01/01/2001 CMS Term: 71275 RADIO DEF RBRVS 09/01/2019 12/31/2023 263.88 Description: CT ANGIOGRAPHY CHEST Category: Radiology CMS Add: 01/01/2001 CMS Term: 71275 TC RADIO DEF RBRVS 01/01/2024 190.19 Description: CT ANGIOGRAPHY CHEST Category: Radiology CMS Add: 01/01/2001 CMS Term: 71275 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 193.13 Description: CT ANGIOGRAPHY CHEST Category: Radiology CMS Add: 01/01/2001 CMS Term: 71550 26 RADIO DEF RBRVS 01/01/2024 67.12 Description: MRI CHEST W/O DYE Category: Radiology CMS Add: 01/01/1985 CMS Term: 71550 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 53.68 Description: MRI CHEST W/O DYE Category: Radiology CMS Add: 01/01/1985 CMS Term: 71550 RADIO DEF RBRVS 01/01/2024 330.79 Description: MRI CHEST W/O DYE Category: Radiology CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 861 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 71550 RADIO DEF RBRVS 09/01/2019 12/31/2023 292.89 Description: MRI CHEST W/O DYE Category: Radiology CMS Add: 01/01/1985 CMS Term: 71550 TC RADIO DEF RBRVS 01/01/2024 263.67 Description: MRI CHEST W/O DYE Category: Radiology CMS Add: 01/01/1985 CMS Term: 71550 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 239.21 Description: MRI CHEST W/O DYE Category: Radiology CMS Add: 01/01/1985 CMS Term: 71551 26 RADIO DEF RBRVS 01/01/2024 79.37 Description: MRI CHEST W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 71551 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 63.74 Description: MRI CHEST W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 71551 RADIO DEF RBRVS 01/01/2024 365.89 Description: MRI CHEST W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 71551 RADIO DEF RBRVS 09/01/2019 12/31/2023 331.44 Description: MRI CHEST W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 71551 TC RADIO DEF RBRVS 01/01/2024 286.51 Description: MRI CHEST W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 71551 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 267.70 Description: MRI CHEST W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 71552 26 RADIO DEF RBRVS 01/01/2024 103.83 Description: MRI CHEST W/O & W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 71552 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 83.10 Description: MRI CHEST W/O & W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 71552 RADIO DEF RBRVS 01/01/2024 462.58 Description: MRI CHEST W/O & W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 71552 RADIO DEF RBRVS 09/01/2019 12/31/2023 417.43 Description: MRI CHEST W/O & W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 71552 TC RADIO DEF RBRVS 01/01/2024 358.75 Description: MRI CHEST W/O & W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 71552 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 334.33 Description: MRI CHEST W/O & W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 71555 26 RADIO DEF RBRVS 01/01/2024 82.39 Description: MRI ANGIO CHEST W OR W/O DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 862 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 71555 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 66.38 Description: MRI ANGIO CHEST W OR W/O DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: 71555 RADIO DEF RBRVS 01/01/2024 325.69 Description: MRI ANGIO CHEST W OR W/O DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: 71555 RADIO DEF RBRVS 09/01/2019 12/31/2023 292.96 Description: MRI ANGIO CHEST W OR W/O DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: 71555 TC RADIO DEF RBRVS 01/01/2024 243.29 Description: MRI ANGIO CHEST W OR W/O DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: 71555 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 226.58 Description: MRI ANGIO CHEST W OR W/O DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: 72020 26 RADIO DEF RBRVS 01/01/2024 7.44 Description: X-RAY EXAM OF SPINE 1 VIEW Category: Radiology CMS Add: 01/01/1984 CMS Term: 72020 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 5.68 Description: X-RAY EXAM OF SPINE 1 VIEW Category: Radiology CMS Add: 01/01/1984 CMS Term: 72020 RADIO DEF RBRVS 01/01/2024 23.03 Description: X-RAY EXAM OF SPINE 1 VIEW Category: Radiology CMS Add: 01/01/1984 CMS Term: 72020 RADIO DEF RBRVS 02/01/2015 12/31/2023 16.50 Description: X-RAY EXAM OF SPINE 1 VIEW Category: Radiology CMS Add: 01/01/1984 CMS Term: 72020 TC RADIO DEF RBRVS 01/01/2024 15.60 Description: X-RAY EXAM OF SPINE 1 VIEW Category: Radiology CMS Add: 01/01/1984 CMS Term: 72020 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 10.82 Description: X-RAY EXAM OF SPINE 1 VIEW Category: Radiology CMS Add: 01/01/1984 CMS Term: 72040 26 MRT DEF RBRVS 01/01/2024 10.39 0-1 Description: X-RAY EXAM NECK SPINE 2-3 VW Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72040 26 MRT DEF RBRVS 02/01/2015 12/31/2023 8.64 0-1 Description: X-RAY EXAM NECK SPINE 2-3 VW Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72040 26 RADIO DEF RBRVS 01/01/2024 10.39 0-1 Description: X-RAY EXAM NECK SPINE 2-3 VW Category: Radiology CMS Add: 01/01/1984 CMS Term: 72040 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 8.64 0-1 Description: X-RAY EXAM NECK SPINE 2-3 VW Category: Radiology CMS Add: 01/01/1984 CMS Term: 72040 MRT DEF RBRVS 01/01/2024 37.10 0-1 Description: X-RAY EXAM NECK SPINE 2-3 VW Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 863 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 72040 MRT DEF RBRVS 02/01/2015 12/31/2023 25.65 0-1 Description: X-RAY EXAM NECK SPINE 2-3 VW Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72040 RADIO DEF RBRVS 01/01/2024 37.10 0-1 Description: X-RAY EXAM NECK SPINE 2-3 VW Category: Radiology CMS Add: 01/01/1984 CMS Term: 72040 RADIO DEF RBRVS 02/01/2015 12/31/2023 25.65 0-1 Description: X-RAY EXAM NECK SPINE 2-3 VW Category: Radiology CMS Add: 01/01/1984 CMS Term: 72040 TC MRT DEF RBRVS 01/01/2024 26.71 0-1 Description: X-RAY EXAM NECK SPINE 2-3 VW Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72040 TC MRT DEF RBRVS 02/01/2015 12/31/2023 17.01 0-1 Description: X-RAY EXAM NECK SPINE 2-3 VW Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72040 TC RADIO DEF RBRVS 01/01/2024 26.71 0-1 Description: X-RAY EXAM NECK SPINE 2-3 VW Category: Radiology CMS Add: 01/01/1984 CMS Term: 72040 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 17.01 0-1 Description: X-RAY EXAM NECK SPINE 2-3 VW Category: Radiology CMS Add: 01/01/1984 CMS Term: 72050 26 MRT DEF RBRVS 01/01/2024 12.71 Description: X-RAY EXAM NECK SPINE 4/5VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72050 26 MRT DEF RBRVS 02/01/2015 12/31/2023 11.80 Description: X-RAY EXAM NECK SPINE 4/5VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72050 26 RADIO DEF RBRVS 01/01/2024 12.71 Description: X-RAY EXAM NECK SPINE 4/5VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72050 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 11.80 Description: X-RAY EXAM NECK SPINE 4/5VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72050 MRT DEF RBRVS 01/01/2024 49.91 Description: X-RAY EXAM NECK SPINE 4/5VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72050 MRT DEF RBRVS 02/01/2015 12/31/2023 34.75 Description: X-RAY EXAM NECK SPINE 4/5VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72050 RADIO DEF RBRVS 01/01/2024 49.91 Description: X-RAY EXAM NECK SPINE 4/5VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72050 RADIO DEF RBRVS 02/01/2015 12/31/2023 34.75 Description: X-RAY EXAM NECK SPINE 4/5VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72050 TC MRT DEF RBRVS 01/01/2024 37.21 Description: X-RAY EXAM NECK SPINE 4/5VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 864 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 72050 TC MRT DEF RBRVS 02/01/2015 12/31/2023 22.95 Description: X-RAY EXAM NECK SPINE 4/5VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72050 TC RADIO DEF RBRVS 01/01/2024 37.21 Description: X-RAY EXAM NECK SPINE 4/5VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72050 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 22.95 Description: X-RAY EXAM NECK SPINE 4/5VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72052 26 MRT DEF RBRVS 01/01/2024 13.88 Description: X-RAY EXAM NECK SPINE 6/>VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72052 26 MRT DEF RBRVS 02/01/2015 12/31/2023 13.64 Description: X-RAY EXAM NECK SPINE 6/>VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72052 26 RADIO DEF RBRVS 01/01/2024 13.88 Description: X-RAY EXAM NECK SPINE 6/>VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72052 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 13.64 Description: X-RAY EXAM NECK SPINE 6/>VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72052 MRT DEF RBRVS 01/01/2024 58.19 Description: X-RAY EXAM NECK SPINE 6/>VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72052 MRT DEF RBRVS 02/01/2015 12/31/2023 44.52 Description: X-RAY EXAM NECK SPINE 6/>VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72052 RADIO DEF RBRVS 01/01/2024 58.19 Description: X-RAY EXAM NECK SPINE 6/>VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72052 RADIO DEF RBRVS 02/01/2015 12/31/2023 44.52 Description: X-RAY EXAM NECK SPINE 6/>VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72052 TC MRT DEF RBRVS 01/01/2024 44.31 Description: X-RAY EXAM NECK SPINE 6/>VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72052 TC MRT DEF RBRVS 02/01/2015 12/31/2023 30.88 Description: X-RAY EXAM NECK SPINE 6/>VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72052 TC RADIO DEF RBRVS 01/01/2024 44.31 Description: X-RAY EXAM NECK SPINE 6/>VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72052 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 30.88 Description: X-RAY EXAM NECK SPINE 6/>VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72070 26 MRT DEF RBRVS 01/01/2024 9.41 0-1 Description: X-RAY EXAM THORAC SPINE 2VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 865 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 72070 26 MRT DEF RBRVS 02/01/2015 12/31/2023 8.31 0-1 Description: X-RAY EXAM THORAC SPINE 2VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72070 26 RADIO DEF RBRVS 01/01/2024 9.41 0-1 Description: X-RAY EXAM THORAC SPINE 2VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72070 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 8.31 0-1 Description: X-RAY EXAM THORAC SPINE 2VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72070 MRT DEF RBRVS 01/01/2024 30.87 0-1 Description: X-RAY EXAM THORAC SPINE 2VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72070 MRT DEF RBRVS 02/01/2015 12/31/2023 24.08 0-1 Description: X-RAY EXAM THORAC SPINE 2VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72070 RADIO DEF RBRVS 01/01/2024 30.87 0-1 Description: X-RAY EXAM THORAC SPINE 2VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72070 RADIO DEF RBRVS 02/01/2015 12/31/2023 24.08 0-1 Description: X-RAY EXAM THORAC SPINE 2VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72070 TC MRT DEF RBRVS 01/01/2024 21.46 0-1 Description: X-RAY EXAM THORAC SPINE 2VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72070 TC MRT DEF RBRVS 02/01/2015 12/31/2023 15.77 0-1 Description: X-RAY EXAM THORAC SPINE 2VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72070 TC RADIO DEF RBRVS 01/01/2024 21.46 0-1 Description: X-RAY EXAM THORAC SPINE 2VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72070 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 15.77 0-1 Description: X-RAY EXAM THORAC SPINE 2VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72072 26 MRT DEF RBRVS 01/01/2024 10.42 Description: X-RAY EXAM THORAC SPINE 3VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72072 26 MRT DEF RBRVS 02/01/2015 12/31/2023 8.06 Description: X-RAY EXAM THORAC SPINE 3VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72072 26 RADIO DEF RBRVS 01/01/2024 10.42 Description: X-RAY EXAM THORAC SPINE 3VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72072 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 8.06 Description: X-RAY EXAM THORAC SPINE 3VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72072 MRT DEF RBRVS 01/01/2024 36.83 Description: X-RAY EXAM THORAC SPINE 3VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 866 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 72072 MRT DEF RBRVS 02/01/2015 12/31/2023 26.80 Description: X-RAY EXAM THORAC SPINE 3VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72072 RADIO DEF RBRVS 01/01/2024 36.83 Description: X-RAY EXAM THORAC SPINE 3VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72072 RADIO DEF RBRVS 02/01/2015 12/31/2023 26.80 Description: X-RAY EXAM THORAC SPINE 3VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72072 TC MRT DEF RBRVS 01/01/2024 26.40 Description: X-RAY EXAM THORAC SPINE 3VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72072 TC MRT DEF RBRVS 02/01/2015 12/31/2023 18.74 Description: X-RAY EXAM THORAC SPINE 3VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72072 TC RADIO DEF RBRVS 01/01/2024 26.40 Description: X-RAY EXAM THORAC SPINE 3VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72072 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 18.74 Description: X-RAY EXAM THORAC SPINE 3VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72074 26 MRT DEF RBRVS 01/01/2024 11.41 Description: X-RAY EXAM THORAC SPINE4/>VW Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72074 26 MRT DEF RBRVS 02/01/2015 12/31/2023 8.06 Description: X-RAY EXAM THORAC SPINE4/>VW Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72074 26 RADIO DEF RBRVS 01/01/2024 11.41 Description: X-RAY EXAM THORAC SPINE4/>VW Category: Radiology CMS Add: 01/01/1984 CMS Term: 72074 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 8.06 Description: X-RAY EXAM THORAC SPINE4/>VW Category: Radiology CMS Add: 01/01/1984 CMS Term: 72074 MRT DEF RBRVS 01/01/2024 41.52 Description: X-RAY EXAM THORAC SPINE4/>VW Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72074 MRT DEF RBRVS 02/01/2015 12/31/2023 31.76 Description: X-RAY EXAM THORAC SPINE4/>VW Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72074 RADIO DEF RBRVS 01/01/2024 41.52 Description: X-RAY EXAM THORAC SPINE4/>VW Category: Radiology CMS Add: 01/01/1984 CMS Term: 72074 RADIO DEF RBRVS 02/01/2015 12/31/2023 31.76 Description: X-RAY EXAM THORAC SPINE4/>VW Category: Radiology CMS Add: 01/01/1984 CMS Term: 72074 TC MRT DEF RBRVS 01/01/2024 30.11 Description: X-RAY EXAM THORAC SPINE4/>VW Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 867 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 72074 TC MRT DEF RBRVS 02/01/2015 12/31/2023 23.70 Description: X-RAY EXAM THORAC SPINE4/>VW Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72074 TC RADIO DEF RBRVS 01/01/2024 30.11 Description: X-RAY EXAM THORAC SPINE4/>VW Category: Radiology CMS Add: 01/01/1984 CMS Term: 72074 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 23.70 Description: X-RAY EXAM THORAC SPINE4/>VW Category: Radiology CMS Add: 01/01/1984 CMS Term: 72080 26 MRT DEF RBRVS 01/01/2016 12/31/2023 8.06 Description: X-RAY EXAM THORACOLMB 2/> VW Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72080 26 MRT DEF RBRVS 01/01/2024 9.75 Description: X-RAY EXAM THORACOLMB 2/> VW Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72080 26 RADIO DEF RBRVS 01/01/2016 12/31/2023 8.06 Description: X-RAY EXAM THORACOLMB 2/> VW Category: Radiology CMS Add: 01/01/1984 CMS Term: 72080 26 RADIO DEF RBRVS 01/01/2024 9.75 Description: X-RAY EXAM THORACOLMB 2/> VW Category: Radiology CMS Add: 01/01/1984 CMS Term: 72080 MRT DEF RBRVS 01/01/2016 12/31/2023 21.60 Description: X-RAY EXAM THORACOLMB 2/> VW Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72080 MRT DEF RBRVS 01/01/2024 32.44 Description: X-RAY EXAM THORACOLMB 2/> VW Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72080 RADIO DEF RBRVS 01/01/2016 12/31/2023 21.60 Description: X-RAY EXAM THORACOLMB 2/> VW Category: Radiology CMS Add: 01/01/1984 CMS Term: 72080 RADIO DEF RBRVS 01/01/2024 32.44 Description: X-RAY EXAM THORACOLMB 2/> VW Category: Radiology CMS Add: 01/01/1984 CMS Term: 72080 TC MRT DEF RBRVS 01/01/2016 12/31/2023 13.54 Description: X-RAY EXAM THORACOLMB 2/> VW Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72080 TC MRT DEF RBRVS 01/01/2024 22.70 Description: X-RAY EXAM THORACOLMB 2/> VW Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72080 TC RADIO DEF RBRVS 01/01/2016 12/31/2023 13.54 Description: X-RAY EXAM THORACOLMB 2/> VW Category: Radiology CMS Add: 01/01/1984 CMS Term: 72080 TC RADIO DEF RBRVS 01/01/2024 22.70 Description: X-RAY EXAM THORACOLMB 2/> VW Category: Radiology CMS Add: 01/01/1984 CMS Term: 72081 26 MRT DEF RBRVS 01/01/2016 12/31/2023 9.79 Description: X-RAY EXAM ENTIRE SPI 1 VW Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 868 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 72081 26 MRT DEF RBRVS 01/01/2024 12.06 Description: X-RAY EXAM ENTIRE SPI 1 VW Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 72081 26 RADIO DEF RBRVS 01/01/2016 12/31/2023 9.79 Description: X-RAY EXAM ENTIRE SPI 1 VW Category: Radiology CMS Add: 01/01/2016 CMS Term: 72081 26 RADIO DEF RBRVS 01/01/2024 12.06 Description: X-RAY EXAM ENTIRE SPI 1 VW Category: Radiology CMS Add: 01/01/2016 CMS Term: 72081 MRT DEF RBRVS 01/01/2016 12/31/2023 27.30 Description: X-RAY EXAM ENTIRE SPI 1 VW Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 72081 MRT DEF RBRVS 01/01/2024 40.00 Description: X-RAY EXAM ENTIRE SPI 1 VW Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 72081 RADIO DEF RBRVS 01/01/2016 12/31/2023 27.30 Description: X-RAY EXAM ENTIRE SPI 1 VW Category: Radiology CMS Add: 01/01/2016 CMS Term: 72081 RADIO DEF RBRVS 01/01/2024 40.00 Description: X-RAY EXAM ENTIRE SPI 1 VW Category: Radiology CMS Add: 01/01/2016 CMS Term: 72081 TC MRT DEF RBRVS 01/01/2016 12/31/2023 17.51 Description: X-RAY EXAM ENTIRE SPI 1 VW Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 72081 TC MRT DEF RBRVS 01/01/2024 27.95 Description: X-RAY EXAM ENTIRE SPI 1 VW Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 72081 TC RADIO DEF RBRVS 01/01/2016 12/31/2023 17.51 Description: X-RAY EXAM ENTIRE SPI 1 VW Category: Radiology CMS Add: 01/01/2016 CMS Term: 72081 TC RADIO DEF RBRVS 01/01/2024 27.95 Description: X-RAY EXAM ENTIRE SPI 1 VW Category: Radiology CMS Add: 01/01/2016 CMS Term: 72082 26 RADIO DEF RBRVS 01/01/2016 12/31/2023 11.88 Description: X-RAY EXAM ENTIRE SPI 2/3 VW Category: Radiology CMS Add: 01/01/2016 CMS Term: 72082 26 RADIO DEF RBRVS 01/01/2024 14.53 Description: X-RAY EXAM ENTIRE SPI 2/3 VW Category: Radiology CMS Add: 01/01/2016 CMS Term: 72082 RADIO DEF RBRVS 01/01/2016 12/31/2023 43.75 Description: X-RAY EXAM ENTIRE SPI 2/3 VW Category: Radiology CMS Add: 01/01/2016 CMS Term: 72082 RADIO DEF RBRVS 01/01/2024 65.63 Description: X-RAY EXAM ENTIRE SPI 2/3 VW Category: Radiology CMS Add: 01/01/2016 CMS Term: 72082 TC RADIO DEF RBRVS 01/01/2016 12/31/2023 31.87 Description: X-RAY EXAM ENTIRE SPI 2/3 VW Category: Radiology CMS Add: 01/01/2016 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 869 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 72082 TC RADIO DEF RBRVS 01/01/2024 51.10 Description: X-RAY EXAM ENTIRE SPI 2/3 VW Category: Radiology CMS Add: 01/01/2016 CMS Term: 72083 26 RADIO DEF RBRVS 01/01/2024 16.65 Description: X-RAY EXAM ENTIRE SPI 4/5 VW Category: Radiology CMS Add: 01/01/2016 CMS Term: 72083 26 RADIO DEF RBRVS 09/13/2019 12/31/2023 13.45 Description: X-RAY EXAM ENTIRE SPI 4/5 VW Category: Radiology CMS Add: 01/01/2016 CMS Term: 72083 RADIO DEF RBRVS 01/01/2024 73.92 Description: X-RAY EXAM ENTIRE SPI 4/5 VW Category: Radiology CMS Add: 01/01/2016 CMS Term: 72083 RADIO DEF RBRVS 09/13/2019 12/31/2023 53.99 Description: X-RAY EXAM ENTIRE SPI 4/5 VW Category: Radiology CMS Add: 01/01/2016 CMS Term: 72083 TC RADIO DEF RBRVS 01/01/2024 57.27 Description: X-RAY EXAM ENTIRE SPI 4/5 VW Category: Radiology CMS Add: 01/01/2016 CMS Term: 72083 TC RADIO DEF RBRVS 09/13/2019 12/31/2023 40.54 Description: X-RAY EXAM ENTIRE SPI 4/5 VW Category: Radiology CMS Add: 01/01/2016 CMS Term: 72084 26 RADIO DEF RBRVS 01/01/2024 19.46 Description: X-RAY EXAM ENTIRE SPI 6/> VW Category: Radiology CMS Add: 01/01/2016 CMS Term: 72084 26 RADIO DEF RBRVS 09/13/2019 12/31/2023 15.47 Description: X-RAY EXAM ENTIRE SPI 6/> VW Category: Radiology CMS Add: 01/01/2016 CMS Term: 72084 RADIO DEF RBRVS 01/01/2024 92.64 Description: X-RAY EXAM ENTIRE SPI 6/> VW Category: Radiology CMS Add: 01/01/2016 CMS Term: 72084 RADIO DEF RBRVS 09/13/2019 12/31/2023 62.95 Description: X-RAY EXAM ENTIRE SPI 6/> VW Category: Radiology CMS Add: 01/01/2016 CMS Term: 72084 TC RADIO DEF RBRVS 01/01/2024 73.18 Description: X-RAY EXAM ENTIRE SPI 6/> VW Category: Radiology CMS Add: 01/01/2016 CMS Term: 72084 TC RADIO DEF RBRVS 09/13/2019 12/31/2023 47.48 Description: X-RAY EXAM ENTIRE SPI 6/> VW Category: Radiology CMS Add: 01/01/2016 CMS Term: 72100 26 MRT DEF RBRVS 01/01/2024 10.39 0-1 Description: X-RAY EXAM L-S SPINE 2/3 VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72100 26 MRT DEF RBRVS 02/01/2015 12/31/2023 8.64 0-1 Description: X-RAY EXAM L-S SPINE 2/3 VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72100 26 RADIO DEF RBRVS 01/01/2024 10.39 0-1 Description: X-RAY EXAM L-S SPINE 2/3 VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 870 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 72100 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 8.64 0-1 Description: X-RAY EXAM L-S SPINE 2/3 VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72100 MRT DEF RBRVS 01/01/2024 37.41 0-1 Description: X-RAY EXAM L-S SPINE 2/3 VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72100 MRT DEF RBRVS 02/01/2015 12/31/2023 25.65 0-1 Description: X-RAY EXAM L-S SPINE 2/3 VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72100 RADIO DEF RBRVS 01/01/2024 37.41 0-1 Description: X-RAY EXAM L-S SPINE 2/3 VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72100 RADIO DEF RBRVS 02/01/2015 12/31/2023 25.65 0-1 Description: X-RAY EXAM L-S SPINE 2/3 VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72100 TC MRT DEF RBRVS 01/01/2024 27.02 0-1 Description: X-RAY EXAM L-S SPINE 2/3 VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72100 TC MRT DEF RBRVS 02/01/2015 12/31/2023 17.01 0-1 Description: X-RAY EXAM L-S SPINE 2/3 VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72100 TC RADIO DEF RBRVS 01/01/2024 27.02 0-1 Description: X-RAY EXAM L-S SPINE 2/3 VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72100 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 17.01 0-1 Description: X-RAY EXAM L-S SPINE 2/3 VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72110 26 MRT DEF RBRVS 01/01/2024 12.06 Description: X-RAY EXAM L-2 SPINE 4/>VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72110 26 MRT DEF RBRVS 02/01/2015 12/31/2023 11.80 Description: X-RAY EXAM L-2 SPINE 4/>VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72110 26 RADIO DEF RBRVS 01/01/2024 12.06 Description: X-RAY EXAM L-2 SPINE 4/>VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72110 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 11.80 Description: X-RAY EXAM L-2 SPINE 4/>VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72110 MRT DEF RBRVS 01/01/2024 48.03 Description: X-RAY EXAM L-2 SPINE 4/>VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72110 MRT DEF RBRVS 02/01/2015 12/31/2023 35.25 Description: X-RAY EXAM L-2 SPINE 4/>VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72110 RADIO DEF RBRVS 01/01/2024 48.03 Description: X-RAY EXAM L-2 SPINE 4/>VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 871 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 72110 RADIO DEF RBRVS 02/01/2015 12/31/2023 35.25 Description: X-RAY EXAM L-2 SPINE 4/>VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72110 TC MRT DEF RBRVS 01/01/2024 35.97 Description: X-RAY EXAM L-2 SPINE 4/>VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72110 TC MRT DEF RBRVS 02/01/2015 12/31/2023 23.45 Description: X-RAY EXAM L-2 SPINE 4/>VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72110 TC RADIO DEF RBRVS 01/01/2024 35.97 Description: X-RAY EXAM L-2 SPINE 4/>VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72110 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 23.45 Description: X-RAY EXAM L-2 SPINE 4/>VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72114 26 MRT DEF RBRVS 01/01/2024 14.19 Description: X-RAY EXAM L-S SPINE BENDING Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72114 26 MRT DEF RBRVS 02/01/2015 12/31/2023 12.48 Description: X-RAY EXAM L-S SPINE BENDING Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72114 26 RADIO DEF RBRVS 01/01/2024 14.19 Description: X-RAY EXAM L-S SPINE BENDING Category: Radiology CMS Add: 01/01/1984 CMS Term: 72114 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 12.48 Description: X-RAY EXAM L-S SPINE BENDING Category: Radiology CMS Add: 01/01/1984 CMS Term: 72114 MRT DEF RBRVS 01/01/2024 57.88 Description: X-RAY EXAM L-S SPINE BENDING Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72114 MRT DEF RBRVS 02/01/2015 12/31/2023 45.84 Description: X-RAY EXAM L-S SPINE BENDING Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72114 RADIO DEF RBRVS 01/01/2024 57.88 Description: X-RAY EXAM L-S SPINE BENDING Category: Radiology CMS Add: 01/01/1984 CMS Term: 72114 RADIO DEF RBRVS 02/01/2015 12/31/2023 45.84 Description: X-RAY EXAM L-S SPINE BENDING Category: Radiology CMS Add: 01/01/1984 CMS Term: 72114 TC MRT DEF RBRVS 01/01/2024 43.69 Description: X-RAY EXAM L-S SPINE BENDING Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72114 TC MRT DEF RBRVS 02/01/2015 12/31/2023 33.36 Description: X-RAY EXAM L-S SPINE BENDING Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72114 TC RADIO DEF RBRVS 01/01/2024 43.69 Description: X-RAY EXAM L-S SPINE BENDING Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 872 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 72114 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 33.36 Description: X-RAY EXAM L-S SPINE BENDING Category: Radiology CMS Add: 01/01/1984 CMS Term: 72120 26 RADIO DEF RBRVS 01/01/2024 10.39 Description: X-RAY BEND ONLY L-S SPINE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72120 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 8.64 Description: X-RAY BEND ONLY L-S SPINE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72120 RADIO DEF RBRVS 01/01/2024 38.03 Description: X-RAY BEND ONLY L-S SPINE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72120 RADIO DEF RBRVS 02/01/2015 12/31/2023 28.87 Description: X-RAY BEND ONLY L-S SPINE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72120 TC RADIO DEF RBRVS 01/01/2024 27.64 Description: X-RAY BEND ONLY L-S SPINE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72120 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 20.23 Description: X-RAY BEND ONLY L-S SPINE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72125 26 RADIO DEF RBRVS 01/01/2024 45.64 Description: CT NECK SPINE W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72125 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 39.23 Description: CT NECK SPINE W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72125 RADIO DEF RBRVS 01/01/2024 126.38 Description: CT NECK SPINE W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72125 RADIO DEF RBRVS 09/01/2019 12/31/2023 138.24 Description: CT NECK SPINE W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72125 TC RADIO DEF RBRVS 01/01/2024 80.73 Description: CT NECK SPINE W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72125 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 99.00 Description: CT NECK SPINE W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72126 26 RADIO DEF RBRVS 01/01/2024 55.89 Description: CT NECK SPINE W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72126 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 45.08 Description: CT NECK SPINE W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72126 RADIO DEF RBRVS 01/01/2024 164.26 Description: CT NECK SPINE W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 873 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 72126 RADIO DEF RBRVS 09/01/2019 12/31/2023 169.10 Description: CT NECK SPINE W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72126 TC RADIO DEF RBRVS 01/01/2024 108.37 Description: CT NECK SPINE W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72126 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 124.02 Description: CT NECK SPINE W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72127 26 RADIO DEF RBRVS 01/01/2024 58.06 Description: CT NECK SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 72127 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 46.67 Description: CT NECK SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 72127 RADIO DEF RBRVS 01/01/2024 192.05 Description: CT NECK SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 72127 RADIO DEF RBRVS 09/01/2019 12/31/2023 200.92 Description: CT NECK SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 72127 TC RADIO DEF RBRVS 01/01/2024 133.99 Description: CT NECK SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 72127 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 154.24 Description: CT NECK SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 72128 26 RADIO DEF RBRVS 01/01/2024 45.64 Description: CT CHEST SPINE W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72128 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 36.86 Description: CT CHEST SPINE W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72128 RADIO DEF RBRVS 01/01/2024 126.38 Description: CT CHEST SPINE W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72128 RADIO DEF RBRVS 09/01/2019 12/31/2023 135.37 Description: CT CHEST SPINE W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72128 TC RADIO DEF RBRVS 01/01/2024 80.73 Description: CT CHEST SPINE W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72128 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 98.51 Description: CT CHEST SPINE W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72129 26 RADIO DEF RBRVS 01/01/2024 56.05 Description: CT CHEST SPINE W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 874 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 72129 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 45.08 Description: CT CHEST SPINE W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72129 RADIO DEF RBRVS 01/01/2024 165.35 Description: CT CHEST SPINE W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72129 RADIO DEF RBRVS 09/01/2019 12/31/2023 169.10 Description: CT CHEST SPINE W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72129 TC RADIO DEF RBRVS 01/01/2024 109.30 Description: CT CHEST SPINE W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72129 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 124.02 Description: CT CHEST SPINE W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72130 26 RADIO DEF RBRVS 01/01/2024 58.36 Description: CT CHEST SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 72130 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 46.67 Description: CT CHEST SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 72130 RADIO DEF RBRVS 01/01/2024 193.90 Description: CT CHEST SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 72130 RADIO DEF RBRVS 09/01/2019 12/31/2023 203.15 Description: CT CHEST SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 72130 TC RADIO DEF RBRVS 01/01/2024 135.54 Description: CT CHEST SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 72130 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 156.47 Description: CT CHEST SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 72131 26 RADIO DEF RBRVS 01/01/2024 45.64 Description: CT LUMBAR SPINE W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72131 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 36.86 Description: CT LUMBAR SPINE W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72131 RADIO DEF RBRVS 01/01/2024 125.76 Description: CT LUMBAR SPINE W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72131 RADIO DEF RBRVS 09/01/2019 12/31/2023 134.87 Description: CT LUMBAR SPINE W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72131 TC RADIO DEF RBRVS 01/01/2024 80.12 Description: CT LUMBAR SPINE W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 875 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 72131 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 98.01 Description: CT LUMBAR SPINE W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72132 26 RADIO DEF RBRVS 01/01/2024 55.89 Description: CT LUMBAR SPINE W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72132 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 45.08 Description: CT LUMBAR SPINE W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72132 RADIO DEF RBRVS 01/01/2024 164.57 Description: CT LUMBAR SPINE W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72132 RADIO DEF RBRVS 09/01/2019 12/31/2023 168.61 Description: CT LUMBAR SPINE W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72132 TC RADIO DEF RBRVS 01/01/2024 108.68 Description: CT LUMBAR SPINE W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72132 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 123.53 Description: CT LUMBAR SPINE W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72133 26 RADIO DEF RBRVS 01/01/2024 58.36 Description: CT LUMBAR SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 72133 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 46.67 Description: CT LUMBAR SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 72133 RADIO DEF RBRVS 01/01/2024 192.67 Description: CT LUMBAR SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 72133 RADIO DEF RBRVS 09/01/2019 12/31/2023 201.16 Description: CT LUMBAR SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 72133 TC RADIO DEF RBRVS 01/01/2024 134.30 Description: CT LUMBAR SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 72133 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 154.49 Description: CT LUMBAR SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 72141 26 RADIO DEF RBRVS 01/01/2024 68.11 Description: MRI NECK SPINE W/O DYE Category: Radiology CMS Add: 01/01/1987 CMS Term: 72141 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 54.87 Description: MRI NECK SPINE W/O DYE Category: Radiology CMS Add: 01/01/1987 CMS Term: 72141 RADIO DEF RBRVS 01/01/2024 186.36 Description: MRI NECK SPINE W/O DYE Category: Radiology CMS Add: 01/01/1987 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 876 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 72141 RADIO DEF RBRVS 09/01/2019 12/31/2023 172.21 Description: MRI NECK SPINE W/O DYE Category: Radiology CMS Add: 01/01/1987 CMS Term: 72141 TC RADIO DEF RBRVS 01/01/2024 118.25 Description: MRI NECK SPINE W/O DYE Category: Radiology CMS Add: 01/01/1987 CMS Term: 72141 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 117.33 Description: MRI NECK SPINE W/O DYE Category: Radiology CMS Add: 01/01/1987 CMS Term: 72142 26 RADIO DEF RBRVS 01/01/2024 82.30 Description: MRI NECK SPINE W/DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 72142 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 65.82 Description: MRI NECK SPINE W/DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 72142 RADIO DEF RBRVS 01/01/2024 269.40 Description: MRI NECK SPINE W/DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 72142 RADIO DEF RBRVS 09/01/2019 12/31/2023 236.42 Description: MRI NECK SPINE W/DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 72142 TC RADIO DEF RBRVS 01/01/2024 187.09 Description: MRI NECK SPINE W/DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 72142 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 170.59 Description: MRI NECK SPINE W/DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 72146 26 RADIO DEF RBRVS 01/01/2024 68.11 Description: MRI CHEST SPINE W/O DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 72146 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 54.87 Description: MRI CHEST SPINE W/O DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 72146 RADIO DEF RBRVS 01/01/2024 186.36 Description: MRI CHEST SPINE W/O DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 72146 RADIO DEF RBRVS 09/01/2019 12/31/2023 172.21 Description: MRI CHEST SPINE W/O DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 72146 TC RADIO DEF RBRVS 01/01/2024 118.25 Description: MRI CHEST SPINE W/O DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 72146 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 117.33 Description: MRI CHEST SPINE W/O DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 72147 26 RADIO DEF RBRVS 01/01/2024 82.00 Description: MRI CHEST SPINE W/DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 877 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 72147 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 65.82 Description: MRI CHEST SPINE W/DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 72147 RADIO DEF RBRVS 01/01/2024 267.24 Description: MRI CHEST SPINE W/DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 72147 RADIO DEF RBRVS 09/01/2019 12/31/2023 234.19 Description: MRI CHEST SPINE W/DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 72147 TC RADIO DEF RBRVS 01/01/2024 185.24 Description: MRI CHEST SPINE W/DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 72147 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 168.36 Description: MRI CHEST SPINE W/DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 72148 26 RADIO DEF RBRVS 01/01/2024 68.11 Description: MRI LUMBAR SPINE W/O DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 72148 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 55.04 Description: MRI LUMBAR SPINE W/O DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 72148 RADIO DEF RBRVS 01/01/2024 186.98 Description: MRI LUMBAR SPINE W/O DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 72148 RADIO DEF RBRVS 09/01/2019 12/31/2023 172.37 Description: MRI LUMBAR SPINE W/O DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 72148 TC RADIO DEF RBRVS 01/01/2024 118.87 Description: MRI LUMBAR SPINE W/O DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 72148 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 117.33 Description: MRI LUMBAR SPINE W/O DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 72149 26 RADIO DEF RBRVS 01/01/2024 82.00 Description: MRI LUMBAR SPINE W/DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 72149 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 65.99 Description: MRI LUMBAR SPINE W/DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 72149 RADIO DEF RBRVS 01/01/2024 264.77 Description: MRI LUMBAR SPINE W/DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 72149 RADIO DEF RBRVS 09/01/2019 12/31/2023 233.36 Description: MRI LUMBAR SPINE W/DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 72149 TC RADIO DEF RBRVS 01/01/2024 182.77 Description: MRI LUMBAR SPINE W/DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 878 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 72149 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 167.37 Description: MRI LUMBAR SPINE W/DYE Category: Radiology CMS Add: 01/01/1990 CMS Term: 72156 26 RADIO DEF RBRVS 01/01/2024 105.16 Description: MRI NECK SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1992 CMS Term: 72156 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 84.48 Description: MRI NECK SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1992 CMS Term: 72156 RADIO DEF RBRVS 01/01/2024 313.56 Description: MRI NECK SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1992 CMS Term: 72156 RADIO DEF RBRVS 09/01/2019 12/31/2023 278.61 Description: MRI NECK SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1992 CMS Term: 72156 TC RADIO DEF RBRVS 01/01/2024 208.41 Description: MRI NECK SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1992 CMS Term: 72156 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 194.13 Description: MRI NECK SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1992 CMS Term: 72157 26 RADIO DEF RBRVS 01/01/2024 105.16 Description: MRI CHEST SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1992 CMS Term: 72157 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 84.48 Description: MRI CHEST SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1992 CMS Term: 72157 RADIO DEF RBRVS 01/01/2024 314.18 Description: MRI CHEST SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1992 CMS Term: 72157 RADIO DEF RBRVS 09/01/2019 12/31/2023 278.86 Description: MRI CHEST SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1992 CMS Term: 72157 TC RADIO DEF RBRVS 01/01/2024 209.02 Description: MRI CHEST SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1992 CMS Term: 72157 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 194.37 Description: MRI CHEST SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1992 CMS Term: 72158 26 RADIO DEF RBRVS 01/01/2024 105.16 Description: MRI LUMBAR SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1992 CMS Term: 72158 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 84.81 Description: MRI LUMBAR SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1992 CMS Term: 72158 RADIO DEF RBRVS 01/01/2024 312.95 Description: MRI LUMBAR SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1992 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 879 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 72158 RADIO DEF RBRVS 09/01/2019 12/31/2023 277.70 Description: MRI LUMBAR SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1992 CMS Term: 72158 TC RADIO DEF RBRVS 01/01/2024 207.79 Description: MRI LUMBAR SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1992 CMS Term: 72158 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 192.89 Description: MRI LUMBAR SPINE W/O & W/DYE Category: Radiology CMS Add: 01/01/1992 CMS Term: 72159 26 RADIO DEF RBRVS 01/01/2024 82.98 Description: MR ANGIO SPINE W/O&W/DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: 72159 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 66.11 Description: MR ANGIO SPINE W/O&W/DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: 72159 RADIO DEF RBRVS 01/01/2024 337.70 Description: MR ANGIO SPINE W/O&W/DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: 72159 RADIO DEF RBRVS 09/01/2019 12/31/2023 305.32 Description: MR ANGIO SPINE W/O&W/DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: 72159 TC RADIO DEF RBRVS 01/01/2024 254.71 Description: MR ANGIO SPINE W/O&W/DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: 72159 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 239.21 Description: MR ANGIO SPINE W/O&W/DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: 72170 26 MRT DEF RBRVS 01/01/2024 8.08 Description: X-RAY EXAM OF PELVIS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72170 26 MRT DEF RBRVS 02/01/2015 12/31/2023 6.80 Description: X-RAY EXAM OF PELVIS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72170 26 RADIO DEF RBRVS 01/01/2024 8.08 Description: X-RAY EXAM OF PELVIS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72170 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 6.80 Description: X-RAY EXAM OF PELVIS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72170 MRT DEF RBRVS 01/01/2024 26.15 Description: X-RAY EXAM OF PELVIS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72170 MRT DEF RBRVS 02/01/2015 12/31/2023 20.59 Description: X-RAY EXAM OF PELVIS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72170 RADIO DEF RBRVS 01/01/2024 26.15 Description: X-RAY EXAM OF PELVIS Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 880 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 72170 RADIO DEF RBRVS 02/01/2015 12/31/2023 20.59 Description: X-RAY EXAM OF PELVIS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72170 TC MRT DEF RBRVS 01/01/2024 18.07 Description: X-RAY EXAM OF PELVIS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72170 TC MRT DEF RBRVS 02/01/2015 12/31/2023 13.79 Description: X-RAY EXAM OF PELVIS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72170 TC RADIO DEF RBRVS 01/01/2024 18.07 Description: X-RAY EXAM OF PELVIS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72170 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 13.79 Description: X-RAY EXAM OF PELVIS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72190 26 RADIO DEF RBRVS 01/01/2024 11.72 Description: X-RAY EXAM OF PELVIS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72190 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 8.37 Description: X-RAY EXAM OF PELVIS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72190 RADIO DEF RBRVS 01/01/2024 39.66 Description: X-RAY EXAM OF PELVIS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72190 RADIO DEF RBRVS 02/01/2015 12/31/2023 30.58 Description: X-RAY EXAM OF PELVIS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72190 TC RADIO DEF RBRVS 01/01/2024 27.95 Description: X-RAY EXAM OF PELVIS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72190 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 22.21 Description: X-RAY EXAM OF PELVIS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72191 26 RADIO DEF RBRVS 01/01/2024 82.09 Description: CT ANGIOGRAPH PELV W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 72191 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 66.55 Description: CT ANGIOGRAPH PELV W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 72191 RADIO DEF RBRVS 01/01/2024 296.98 Description: CT ANGIOGRAPH PELV W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 72191 RADIO DEF RBRVS 09/01/2019 12/31/2023 274.05 Description: CT ANGIOGRAPH PELV W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 72191 TC RADIO DEF RBRVS 01/01/2024 214.89 Description: CT ANGIOGRAPH PELV W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 881 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 72191 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 207.50 Description: CT ANGIOGRAPH PELV W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 72192 26 RADIO DEF RBRVS 01/01/2024 49.94 Description: CT PELVIS W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72192 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 40.02 Description: CT PELVIS W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72192 RADIO DEF RBRVS 01/01/2024 129.75 Description: CT PELVIS W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72192 RADIO DEF RBRVS 09/01/2019 12/31/2023 107.32 Description: CT PELVIS W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72192 TC RADIO DEF RBRVS 01/01/2024 79.81 Description: CT PELVIS W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72192 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 67.30 Description: CT PELVIS W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72193 26 RADIO DEF RBRVS 01/01/2024 53.24 Description: CT PELVIS W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72193 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 42.97 Description: CT PELVIS W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72193 RADIO DEF RBRVS 01/01/2024 224.28 Description: CT PELVIS W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72193 RADIO DEF RBRVS 09/01/2019 12/31/2023 166.25 Description: CT PELVIS W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72193 TC RADIO DEF RBRVS 01/01/2024 171.04 Description: CT PELVIS W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72193 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 123.28 Description: CT PELVIS W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72194 26 RADIO DEF RBRVS 01/01/2024 55.89 Description: CT PELVIS W/O & W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72194 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 44.83 Description: CT PELVIS W/O & W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72194 RADIO DEF RBRVS 01/01/2024 247.31 Description: CT PELVIS W/O & W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 882 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 72194 RADIO DEF RBRVS 09/01/2019 12/31/2023 194.37 Description: CT PELVIS W/O & W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72194 TC RADIO DEF RBRVS 01/01/2024 191.41 Description: CT PELVIS W/O & W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72194 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 149.54 Description: CT PELVIS W/O & W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72195 26 RADIO DEF RBRVS 01/01/2024 67.12 Description: MRI PELVIS W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 72195 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 54.25 Description: MRI PELVIS W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 72195 RADIO DEF RBRVS 01/01/2024 224.27 Description: MRI PELVIS W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 72195 RADIO DEF RBRVS 09/01/2019 12/31/2023 266.22 Description: MRI PELVIS W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 72195 TC RADIO DEF RBRVS 01/01/2024 157.15 Description: MRI PELVIS W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 72195 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 211.96 Description: MRI PELVIS W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 72196 26 RADIO DEF RBRVS 01/01/2024 79.68 Description: MRI PELVIS W/DYE Category: Radiology CMS Add: 01/01/1988 CMS Term: 72196 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 63.99 Description: MRI PELVIS W/DYE Category: Radiology CMS Add: 01/01/1988 CMS Term: 72196 RADIO DEF RBRVS 01/01/2024 263.38 Description: MRI PELVIS W/DYE Category: Radiology CMS Add: 01/01/1988 CMS Term: 72196 RADIO DEF RBRVS 09/01/2019 12/31/2023 298.98 Description: MRI PELVIS W/DYE Category: Radiology CMS Add: 01/01/1988 CMS Term: 72196 TC RADIO DEF RBRVS 01/01/2024 183.70 Description: MRI PELVIS W/DYE Category: Radiology CMS Add: 01/01/1988 CMS Term: 72196 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 235.00 Description: MRI PELVIS W/DYE Category: Radiology CMS Add: 01/01/1988 CMS Term: 72197 26 RADIO DEF RBRVS 01/01/2024 100.71 Description: MRI PELVIS W/O & W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 883 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 72197 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 83.10 Description: MRI PELVIS W/O & W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 72197 RADIO DEF RBRVS 01/01/2024 330.73 Description: MRI PELVIS W/O & W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 72197 RADIO DEF RBRVS 09/01/2019 12/31/2023 365.41 Description: MRI PELVIS W/O & W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 72197 TC RADIO DEF RBRVS 01/01/2024 230.02 Description: MRI PELVIS W/O & W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 72197 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 282.31 Description: MRI PELVIS W/O & W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 72198 26 RADIO DEF RBRVS 01/01/2024 82.06 Description: MR ANGIO PELVIS W/O & W/DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: 72198 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 65.87 Description: MR ANGIO PELVIS W/O & W/DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: 72198 RADIO DEF RBRVS 01/01/2024 329.67 Description: MR ANGIO PELVIS W/O & W/DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: 72198 RADIO DEF RBRVS 09/01/2019 12/31/2023 296.41 Description: MR ANGIO PELVIS W/O & W/DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: 72198 TC RADIO DEF RBRVS 01/01/2024 247.61 Description: MR ANGIO PELVIS W/O & W/DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: 72198 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 230.54 Description: MR ANGIO PELVIS W/O & W/DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: 72200 26 MRT DEF RBRVS 01/01/2024 7.77 Description: X-RAY EXAM SI JOINTS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72200 26 MRT DEF RBRVS 02/01/2015 12/31/2023 6.47 Description: X-RAY EXAM SI JOINTS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72200 26 RADIO DEF RBRVS 01/01/2024 7.77 Description: X-RAY EXAM SI JOINTS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72200 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 6.47 Description: X-RAY EXAM SI JOINTS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72200 MRT DEF RBRVS 01/01/2024 30.78 Description: X-RAY EXAM SI JOINTS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 884 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 72200 MRT DEF RBRVS 02/01/2015 12/31/2023 21.25 Description: X-RAY EXAM SI JOINTS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72200 RADIO DEF RBRVS 01/01/2024 30.78 Description: X-RAY EXAM SI JOINTS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72200 RADIO DEF RBRVS 02/01/2015 12/31/2023 21.25 Description: X-RAY EXAM SI JOINTS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72200 TC MRT DEF RBRVS 01/01/2024 23.01 Description: X-RAY EXAM SI JOINTS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72200 TC MRT DEF RBRVS 02/01/2015 12/31/2023 14.78 Description: X-RAY EXAM SI JOINTS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72200 TC RADIO DEF RBRVS 01/01/2024 23.01 Description: X-RAY EXAM SI JOINTS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72200 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 14.78 Description: X-RAY EXAM SI JOINTS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72202 26 MRT DEF RBRVS 01/01/2024 10.42 Description: X-RAY EXAM SI JOINTS 3/> VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72202 26 MRT DEF RBRVS 02/01/2015 12/31/2023 7.00 Description: X-RAY EXAM SI JOINTS 3/> VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72202 26 RADIO DEF RBRVS 01/01/2024 10.42 Description: X-RAY EXAM SI JOINTS 3/> VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72202 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 7.00 Description: X-RAY EXAM SI JOINTS 3/> VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72202 MRT DEF RBRVS 01/01/2024 36.83 Description: X-RAY EXAM SI JOINTS 3/> VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72202 MRT DEF RBRVS 02/01/2015 12/31/2023 25.00 Description: X-RAY EXAM SI JOINTS 3/> VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72202 RADIO DEF RBRVS 01/01/2024 36.83 Description: X-RAY EXAM SI JOINTS 3/> VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72202 RADIO DEF RBRVS 02/01/2015 12/31/2023 25.00 Description: X-RAY EXAM SI JOINTS 3/> VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72202 TC MRT DEF RBRVS 01/01/2024 26.40 Description: X-RAY EXAM SI JOINTS 3/> VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 885 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 72202 TC MRT DEF RBRVS 02/01/2015 12/31/2023 18.00 Description: X-RAY EXAM SI JOINTS 3/> VWS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72202 TC RADIO DEF RBRVS 01/01/2024 26.40 Description: X-RAY EXAM SI JOINTS 3/> VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72202 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 18.00 Description: X-RAY EXAM SI JOINTS 3/> VWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72220 26 MRT DEF RBRVS 01/01/2024 8.08 Description: X-RAY EXAM SACRUM TAILBONE Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72220 26 MRT DEF RBRVS 02/01/2015 12/31/2023 6.47 Description: X-RAY EXAM SACRUM TAILBONE Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72220 26 RADIO DEF RBRVS 01/01/2024 8.08 Description: X-RAY EXAM SACRUM TAILBONE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72220 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 6.47 Description: X-RAY EXAM SACRUM TAILBONE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72220 MRT DEF RBRVS 01/01/2024 30.47 Description: X-RAY EXAM SACRUM TAILBONE Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72220 MRT DEF RBRVS 02/01/2015 12/31/2023 20.75 Description: X-RAY EXAM SACRUM TAILBONE Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72220 RADIO DEF RBRVS 01/01/2024 30.47 Description: X-RAY EXAM SACRUM TAILBONE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72220 RADIO DEF RBRVS 02/01/2015 12/31/2023 20.75 Description: X-RAY EXAM SACRUM TAILBONE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72220 TC MRT DEF RBRVS 01/01/2024 22.39 Description: X-RAY EXAM SACRUM TAILBONE Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72220 TC MRT DEF RBRVS 02/01/2015 12/31/2023 14.28 Description: X-RAY EXAM SACRUM TAILBONE Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 72220 TC RADIO DEF RBRVS 01/01/2024 22.39 Description: X-RAY EXAM SACRUM TAILBONE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72220 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 14.28 Description: X-RAY EXAM SACRUM TAILBONE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72240 26 RADIO DEF RBRVS 01/01/2024 42.46 Description: MYELOGRAPHY NECK SPINE Category: Radiology CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 886 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 72240 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 33.45 Description: MYELOGRAPHY NECK SPINE Category: Radiology CMS Add: 01/01/1985 CMS Term: 72240 RADIO DEF RBRVS 01/01/2024 108.07 Description: MYELOGRAPHY NECK SPINE Category: Radiology CMS Add: 01/01/1985 CMS Term: 72240 RADIO DEF RBRVS 02/01/2015 12/31/2023 92.57 Description: MYELOGRAPHY NECK SPINE Category: Radiology CMS Add: 01/01/1985 CMS Term: 72240 TC RADIO DEF RBRVS 01/01/2024 65.61 Description: MYELOGRAPHY NECK SPINE Category: Radiology CMS Add: 01/01/1985 CMS Term: 72240 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 59.12 Description: MYELOGRAPHY NECK SPINE Category: Radiology CMS Add: 01/01/1985 CMS Term: 72255 26 RADIO DEF RBRVS 01/01/2024 44.18 Description: MYELOGRAPHY THORACIC SPINE Category: Radiology CMS Add: 01/01/1985 CMS Term: 72255 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 33.78 Description: MYELOGRAPHY THORACIC SPINE Category: Radiology CMS Add: 01/01/1985 CMS Term: 72255 RADIO DEF RBRVS 01/01/2024 112.56 Description: MYELOGRAPHY THORACIC SPINE Category: Radiology CMS Add: 01/01/1985 CMS Term: 72255 RADIO DEF RBRVS 02/01/2015 12/31/2023 88.19 Description: MYELOGRAPHY THORACIC SPINE Category: Radiology CMS Add: 01/01/1985 CMS Term: 72255 TC RADIO DEF RBRVS 01/01/2024 68.39 Description: MYELOGRAPHY THORACIC SPINE Category: Radiology CMS Add: 01/01/1985 CMS Term: 72255 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 54.41 Description: MYELOGRAPHY THORACIC SPINE Category: Radiology CMS Add: 01/01/1985 CMS Term: 72265 26 RADIO DEF RBRVS 01/01/2024 38.34 Description: MYELOGRAPHY L-S SPINE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72265 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 30.64 Description: MYELOGRAPHY L-S SPINE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72265 RADIO DEF RBRVS 01/01/2024 103.33 Description: MYELOGRAPHY L-S SPINE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72265 RADIO DEF RBRVS 02/01/2015 12/31/2023 90.26 Description: MYELOGRAPHY L-S SPINE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72265 TC RADIO DEF RBRVS 01/01/2024 64.99 Description: MYELOGRAPHY L-S SPINE Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 887 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 72265 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 59.62 Description: MYELOGRAPHY L-S SPINE Category: Radiology CMS Add: 01/01/1984 CMS Term: 72270 26 RADIO DEF RBRVS 01/01/2024 63.48 Description: MYELOGPHY 2/> SPINE REGIONS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72270 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 49.03 Description: MYELOGPHY 2/> SPINE REGIONS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72270 RADIO DEF RBRVS 01/01/2024 155.33 Description: MYELOGPHY 2/> SPINE REGIONS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72270 RADIO DEF RBRVS 02/01/2015 12/31/2023 140.35 Description: MYELOGPHY 2/> SPINE REGIONS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72270 TC RADIO DEF RBRVS 01/01/2024 91.85 Description: MYELOGPHY 2/> SPINE REGIONS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72270 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 91.32 Description: MYELOGPHY 2/> SPINE REGIONS Category: Radiology CMS Add: 01/01/1984 CMS Term: 72285 26 ANEST DEF RBRVS 01/01/2024 53.85 Description: DISCOGRAPHY CERV/THOR SPINE Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 72285 26 ANEST DEF RBRVS 02/01/2015 12/31/2023 44.87 Description: DISCOGRAPHY CERV/THOR SPINE Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 72285 ANEST DEF RBRVS 01/01/2024 121.92 Description: DISCOGRAPHY CERV/THOR SPINE Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 72285 ANEST DEF RBRVS 02/01/2015 12/31/2023 82.69 Description: DISCOGRAPHY CERV/THOR SPINE Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 72285 TC ANEST DEF RBRVS 01/01/2024 68.08 Description: DISCOGRAPHY CERV/THOR SPINE Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 72285 TC ANEST DEF RBRVS 02/01/2015 12/31/2023 37.82 Description: DISCOGRAPHY CERV/THOR SPINE Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 72295 26 ANEST DEF RBRVS 01/01/2024 38.34 Description: X-RAY OF LOWER SPINE DISK Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 72295 26 ANEST DEF RBRVS 02/01/2015 12/31/2023 31.88 Description: X-RAY OF LOWER SPINE DISK Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 72295 ANEST DEF RBRVS 01/01/2024 104.57 Description: X-RAY OF LOWER SPINE DISK Category: Anesthesia CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 888 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 72295 ANEST DEF RBRVS 02/01/2015 12/31/2023 71.18 Description: X-RAY OF LOWER SPINE DISK Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 72295 TC ANEST DEF RBRVS 01/01/2024 66.23 Description: X-RAY OF LOWER SPINE DISK Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 72295 TC ANEST DEF RBRVS 02/01/2015 12/31/2023 39.30 Description: X-RAY OF LOWER SPINE DISK Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 73000 26 RADIO DEF RBRVS 01/01/2016 12/31/2023 6.20 Description: X-RAY EXAM OF COLLAR BONE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73000 26 RADIO DEF RBRVS 01/01/2024 7.74 Description: X-RAY EXAM OF COLLAR BONE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73000 RADIO DEF RBRVS 01/01/2016 12/31/2023 20.73 Description: X-RAY EXAM OF COLLAR BONE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73000 RADIO DEF RBRVS 01/01/2024 30.13 Description: X-RAY EXAM OF COLLAR BONE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73000 TC RADIO DEF RBRVS 01/01/2016 12/31/2023 14.53 Description: X-RAY EXAM OF COLLAR BONE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73000 TC RADIO DEF RBRVS 01/01/2024 22.39 Description: X-RAY EXAM OF COLLAR BONE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73010 26 RADIO DEF RBRVS 01/01/2016 12/31/2023 7.04 Description: X-RAY EXAM OF SHOULDER BLADE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73010 26 RADIO DEF RBRVS 01/01/2024 8.39 Description: X-RAY EXAM OF SHOULDER BLADE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73010 RADIO DEF RBRVS 01/01/2016 12/31/2023 22.82 Description: X-RAY EXAM OF SHOULDER BLADE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73010 RADIO DEF RBRVS 01/01/2024 22.14 Description: X-RAY EXAM OF SHOULDER BLADE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73010 TC RADIO DEF RBRVS 01/01/2016 12/31/2023 15.77 Description: X-RAY EXAM OF SHOULDER BLADE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73010 TC RADIO DEF RBRVS 01/01/2024 13.74 Description: X-RAY EXAM OF SHOULDER BLADE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73020 26 MRT DEF RBRVS 01/01/2024 7.10 Description: X-RAY EXAM OF SHOULDER Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 889 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73020 26 MRT DEF RBRVS 02/01/2015 12/31/2023 5.68 Description: X-RAY EXAM OF SHOULDER Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73020 26 RADIO DEF RBRVS 01/01/2024 7.10 Description: X-RAY EXAM OF SHOULDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 73020 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 5.68 Description: X-RAY EXAM OF SHOULDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 73020 MRT DEF RBRVS 01/01/2024 20.22 Description: X-RAY EXAM OF SHOULDER Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73020 MRT DEF RBRVS 02/01/2015 12/31/2023 16.99 Description: X-RAY EXAM OF SHOULDER Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73020 RADIO DEF RBRVS 01/01/2024 20.22 Description: X-RAY EXAM OF SHOULDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 73020 RADIO DEF RBRVS 02/01/2015 12/31/2023 16.99 Description: X-RAY EXAM OF SHOULDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 73020 TC MRT DEF RBRVS 01/01/2024 13.13 Description: X-RAY EXAM OF SHOULDER Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73020 TC MRT DEF RBRVS 02/01/2015 12/31/2023 11.31 Description: X-RAY EXAM OF SHOULDER Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73020 TC RADIO DEF RBRVS 01/01/2024 13.13 Description: X-RAY EXAM OF SHOULDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 73020 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 11.31 Description: X-RAY EXAM OF SHOULDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 73030 26 MRT DEF RBRVS 01/01/2024 8.73 Description: X-RAY EXAM OF SHOULDER Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73030 26 MRT DEF RBRVS 02/01/2015 12/31/2023 7.31 Description: X-RAY EXAM OF SHOULDER Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73030 26 RADIO DEF RBRVS 01/01/2024 8.73 Description: X-RAY EXAM OF SHOULDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 73030 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 7.31 Description: X-RAY EXAM OF SHOULDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 73030 MRT DEF RBRVS 01/01/2024 32.35 Description: X-RAY EXAM OF SHOULDER Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 890 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73030 MRT DEF RBRVS 02/01/2015 12/31/2023 22.09 Description: X-RAY EXAM OF SHOULDER Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73030 RADIO DEF RBRVS 01/01/2024 32.35 Description: X-RAY EXAM OF SHOULDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 73030 RADIO DEF RBRVS 02/01/2015 12/31/2023 22.09 Description: X-RAY EXAM OF SHOULDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 73030 TC MRT DEF RBRVS 01/01/2024 23.62 Description: X-RAY EXAM OF SHOULDER Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73030 TC MRT DEF RBRVS 02/01/2015 12/31/2023 14.78 Description: X-RAY EXAM OF SHOULDER Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73030 TC RADIO DEF RBRVS 01/01/2024 23.62 Description: X-RAY EXAM OF SHOULDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 73030 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 14.78 Description: X-RAY EXAM OF SHOULDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 73040 26 ANEST DEF RBRVS 01/01/2024 25.73 Description: CONTRAST X-RAY OF SHOULDER Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 73040 26 ANEST DEF RBRVS 02/01/2015 12/31/2023 20.37 Description: CONTRAST X-RAY OF SHOULDER Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 73040 ANEST DEF RBRVS 01/01/2024 123.14 Description: CONTRAST X-RAY OF SHOULDER Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 73040 ANEST DEF RBRVS 02/01/2015 12/31/2023 75.03 Description: CONTRAST X-RAY OF SHOULDER Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 73040 TC ANEST DEF RBRVS 01/01/2024 97.41 Description: CONTRAST X-RAY OF SHOULDER Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 73040 TC ANEST DEF RBRVS 02/01/2015 12/31/2023 54.66 Description: CONTRAST X-RAY OF SHOULDER Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 73050 26 RADIO DEF RBRVS 01/01/2024 8.73 Description: X-RAY EXAM OF SHOULDERS Category: Radiology CMS Add: 01/01/1984 CMS Term: 73050 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 8.10 Description: X-RAY EXAM OF SHOULDERS Category: Radiology CMS Add: 01/01/1984 CMS Term: 73050 RADIO DEF RBRVS 01/01/2024 26.80 Description: X-RAY EXAM OF SHOULDERS Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 891 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73050 RADIO DEF RBRVS 02/01/2015 12/31/2023 28.33 Description: X-RAY EXAM OF SHOULDERS Category: Radiology CMS Add: 01/01/1984 CMS Term: 73050 TC RADIO DEF RBRVS 01/01/2024 18.07 Description: X-RAY EXAM OF SHOULDERS Category: Radiology CMS Add: 01/01/1984 CMS Term: 73050 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 20.23 Description: X-RAY EXAM OF SHOULDERS Category: Radiology CMS Add: 01/01/1984 CMS Term: 73060 26 MRT DEF RBRVS 01/01/2017 12/31/2023 6.47 Description: X-RAY EXAM OF HUMERUS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73060 26 MRT DEF RBRVS 01/01/2024 7.74 Description: X-RAY EXAM OF HUMERUS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73060 26 RADIO DEF RBRVS 01/01/2017 12/31/2023 6.47 Description: X-RAY EXAM OF HUMERUS Category: Radiology CMS Add: 01/01/1984 CMS Term: 73060 26 RADIO DEF RBRVS 01/01/2024 7.74 Description: X-RAY EXAM OF HUMERUS Category: Radiology CMS Add: 01/01/1984 CMS Term: 73060 MRT DEF RBRVS 01/01/2017 12/31/2023 20.75 Description: X-RAY EXAM OF HUMERUS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73060 MRT DEF RBRVS 01/01/2024 30.13 Description: X-RAY EXAM OF HUMERUS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73060 RADIO DEF RBRVS 01/01/2017 12/31/2023 20.75 Description: X-RAY EXAM OF HUMERUS Category: Radiology CMS Add: 01/01/1984 CMS Term: 73060 RADIO DEF RBRVS 01/01/2024 30.13 Description: X-RAY EXAM OF HUMERUS Category: Radiology CMS Add: 01/01/1984 CMS Term: 73060 TC MRT DEF RBRVS 01/01/2017 12/31/2023 14.28 Description: X-RAY EXAM OF HUMERUS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73060 TC MRT DEF RBRVS 01/01/2024 22.39 Description: X-RAY EXAM OF HUMERUS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73060 TC RADIO DEF RBRVS 01/01/2017 12/31/2023 14.28 Description: X-RAY EXAM OF HUMERUS Category: Radiology CMS Add: 01/01/1984 CMS Term: 73060 TC RADIO DEF RBRVS 01/01/2024 22.39 Description: X-RAY EXAM OF HUMERUS Category: Radiology CMS Add: 01/01/1984 CMS Term: 73070 26 MRT DEF RBRVS 01/01/2016 12/31/2023 5.93 Description: X-RAY EXAM OF ELBOW Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 892 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73070 26 MRT DEF RBRVS 01/01/2024 7.74 Description: X-RAY EXAM OF ELBOW Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73070 26 RADIO DEF RBRVS 01/01/2016 12/31/2023 5.93 Description: X-RAY EXAM OF ELBOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 73070 26 RADIO DEF RBRVS 01/01/2024 7.74 Description: X-RAY EXAM OF ELBOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 73070 MRT DEF RBRVS 01/01/2016 12/31/2023 20.21 Description: X-RAY EXAM OF ELBOW Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73070 MRT DEF RBRVS 01/01/2024 27.35 Description: X-RAY EXAM OF ELBOW Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73070 RADIO DEF RBRVS 01/01/2016 12/31/2023 20.21 Description: X-RAY EXAM OF ELBOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 73070 RADIO DEF RBRVS 01/01/2024 27.35 Description: X-RAY EXAM OF ELBOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 73070 TC MRT DEF RBRVS 01/01/2016 12/31/2023 14.28 Description: X-RAY EXAM OF ELBOW Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73070 TC MRT DEF RBRVS 01/01/2024 19.61 Description: X-RAY EXAM OF ELBOW Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73070 TC RADIO DEF RBRVS 01/01/2016 12/31/2023 14.28 Description: X-RAY EXAM OF ELBOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 73070 TC RADIO DEF RBRVS 01/01/2024 19.61 Description: X-RAY EXAM OF ELBOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 73080 26 MRT DEF RBRVS 01/01/2016 12/31/2023 6.47 Description: X-RAY EXAM OF ELBOW Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73080 26 MRT DEF RBRVS 01/01/2024 8.08 Description: X-RAY EXAM OF ELBOW Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73080 26 RADIO DEF RBRVS 01/01/2016 12/31/2023 6.47 Description: X-RAY EXAM OF ELBOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 73080 26 RADIO DEF RBRVS 01/01/2024 8.08 Description: X-RAY EXAM OF ELBOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 73080 MRT DEF RBRVS 01/01/2016 12/31/2023 23.97 Description: X-RAY EXAM OF ELBOW Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 893 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73080 MRT DEF RBRVS 01/01/2024 30.47 Description: X-RAY EXAM OF ELBOW Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73080 RADIO DEF RBRVS 01/01/2016 12/31/2023 23.97 Description: X-RAY EXAM OF ELBOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 73080 RADIO DEF RBRVS 01/01/2024 30.47 Description: X-RAY EXAM OF ELBOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 73080 TC MRT DEF RBRVS 01/01/2016 12/31/2023 17.51 Description: X-RAY EXAM OF ELBOW Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73080 TC MRT DEF RBRVS 01/01/2024 22.39 Description: X-RAY EXAM OF ELBOW Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73080 TC RADIO DEF RBRVS 01/01/2016 12/31/2023 17.51 Description: X-RAY EXAM OF ELBOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 73080 TC RADIO DEF RBRVS 01/01/2024 22.39 Description: X-RAY EXAM OF ELBOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 73085 26 RADIO DEF RBRVS 01/01/2016 12/31/2023 21.20 Description: CONTRAST X-RAY OF ELBOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 73085 26 RADIO DEF RBRVS 01/01/2024 26.04 Description: CONTRAST X-RAY OF ELBOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 73085 RADIO DEF RBRVS 01/01/2016 12/31/2023 72.64 Description: CONTRAST X-RAY OF ELBOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 73085 RADIO DEF RBRVS 01/01/2024 104.62 Description: CONTRAST X-RAY OF ELBOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 73085 TC RADIO DEF RBRVS 01/01/2016 12/31/2023 51.44 Description: CONTRAST X-RAY OF ELBOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 73085 TC RADIO DEF RBRVS 01/01/2024 78.57 Description: CONTRAST X-RAY OF ELBOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 73090 26 MRT DEF RBRVS 01/01/2016 12/31/2023 6.20 Description: X-RAY EXAM OF FOREARM Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73090 26 MRT DEF RBRVS 01/01/2024 7.44 Description: X-RAY EXAM OF FOREARM Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73090 26 RADIO DEF RBRVS 01/01/2016 12/31/2023 6.20 Description: X-RAY EXAM OF FOREARM Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 894 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73090 26 RADIO DEF RBRVS 01/01/2024 7.44 Description: X-RAY EXAM OF FOREARM Category: Radiology CMS Add: 01/01/1984 CMS Term: 73090 MRT DEF RBRVS 01/01/2016 12/31/2023 19.99 Description: X-RAY EXAM OF FOREARM Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73090 MRT DEF RBRVS 01/01/2024 27.35 Description: X-RAY EXAM OF FOREARM Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73090 RADIO DEF RBRVS 01/01/2016 12/31/2023 19.99 Description: X-RAY EXAM OF FOREARM Category: Radiology CMS Add: 01/01/1984 CMS Term: 73090 RADIO DEF RBRVS 01/01/2024 27.35 Description: X-RAY EXAM OF FOREARM Category: Radiology CMS Add: 01/01/1984 CMS Term: 73090 TC MRT DEF RBRVS 01/01/2016 12/31/2023 13.79 Description: X-RAY EXAM OF FOREARM Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73090 TC MRT DEF RBRVS 01/01/2024 19.92 Description: X-RAY EXAM OF FOREARM Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73090 TC RADIO DEF RBRVS 01/01/2016 12/31/2023 13.79 Description: X-RAY EXAM OF FOREARM Category: Radiology CMS Add: 01/01/1984 CMS Term: 73090 TC RADIO DEF RBRVS 01/01/2024 19.92 Description: X-RAY EXAM OF FOREARM Category: Radiology CMS Add: 01/01/1984 CMS Term: 73092 26 RADIO DEF RBRVS 01/01/2016 12/31/2023 5.95 Description: X-RAY EXAM OF ARM INFANT Category: Radiology CMS Add: 01/01/1984 CMS Term: 73092 26 RADIO DEF RBRVS 01/01/2024 7.44 Description: X-RAY EXAM OF ARM INFANT Category: Radiology CMS Add: 01/01/1984 CMS Term: 73092 RADIO DEF RBRVS 01/01/2016 12/31/2023 20.24 Description: X-RAY EXAM OF ARM INFANT Category: Radiology CMS Add: 01/01/1984 CMS Term: 73092 RADIO DEF RBRVS 01/01/2024 29.51 Description: X-RAY EXAM OF ARM INFANT Category: Radiology CMS Add: 01/01/1984 CMS Term: 73092 TC RADIO DEF RBRVS 01/01/2016 12/31/2023 14.28 Description: X-RAY EXAM OF ARM INFANT Category: Radiology CMS Add: 01/01/1984 CMS Term: 73092 TC RADIO DEF RBRVS 01/01/2024 22.08 Description: X-RAY EXAM OF ARM INFANT Category: Radiology CMS Add: 01/01/1984 CMS Term: 73100 26 MRT DEF RBRVS 01/01/2016 12/31/2023 6.53 Description: X-RAY EXAM OF WRIST Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 895 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73100 26 MRT DEF RBRVS 01/01/2024 7.74 Description: X-RAY EXAM OF WRIST Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73100 26 RADIO DEF RBRVS 01/01/2016 12/31/2023 6.53 Description: X-RAY EXAM OF WRIST Category: Radiology CMS Add: 01/01/1984 CMS Term: 73100 26 RADIO DEF RBRVS 01/01/2024 7.74 Description: X-RAY EXAM OF WRIST Category: Radiology CMS Add: 01/01/1984 CMS Term: 73100 MRT DEF RBRVS 01/01/2016 12/31/2023 22.30 Description: X-RAY EXAM OF WRIST Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73100 MRT DEF RBRVS 01/01/2024 31.68 Description: X-RAY EXAM OF WRIST Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73100 RADIO DEF RBRVS 01/01/2016 12/31/2023 22.30 Description: X-RAY EXAM OF WRIST Category: Radiology CMS Add: 01/01/1984 CMS Term: 73100 RADIO DEF RBRVS 01/01/2024 31.68 Description: X-RAY EXAM OF WRIST Category: Radiology CMS Add: 01/01/1984 CMS Term: 73100 TC MRT DEF RBRVS 01/01/2016 12/31/2023 15.77 Description: X-RAY EXAM OF WRIST Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73100 TC MRT DEF RBRVS 01/01/2024 23.93 Description: X-RAY EXAM OF WRIST Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73100 TC RADIO DEF RBRVS 01/01/2016 12/31/2023 15.77 Description: X-RAY EXAM OF WRIST Category: Radiology CMS Add: 01/01/1984 CMS Term: 73100 TC RADIO DEF RBRVS 01/01/2024 23.93 Description: X-RAY EXAM OF WRIST Category: Radiology CMS Add: 01/01/1984 CMS Term: 73110 26 MRT DEF RBRVS 01/01/2016 12/31/2023 6.47 Description: X-RAY EXAM OF WRIST Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73110 26 MRT DEF RBRVS 01/01/2024 8.08 Description: X-RAY EXAM OF WRIST Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73110 26 RADIO DEF RBRVS 01/01/2016 12/31/2023 6.47 Description: X-RAY EXAM OF WRIST Category: Radiology CMS Add: 01/01/1984 CMS Term: 73110 26 RADIO DEF RBRVS 01/01/2024 8.08 Description: X-RAY EXAM OF WRIST Category: Radiology CMS Add: 01/01/1984 CMS Term: 73110 MRT DEF RBRVS 01/01/2016 12/31/2023 26.94 Description: X-RAY EXAM OF WRIST Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 896 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73110 MRT DEF RBRVS 01/01/2024 38.19 Description: X-RAY EXAM OF WRIST Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73110 RADIO DEF RBRVS 01/01/2016 12/31/2023 26.94 Description: X-RAY EXAM OF WRIST Category: Radiology CMS Add: 01/01/1984 CMS Term: 73110 RADIO DEF RBRVS 01/01/2024 38.19 Description: X-RAY EXAM OF WRIST Category: Radiology CMS Add: 01/01/1984 CMS Term: 73110 TC MRT DEF RBRVS 01/01/2016 12/31/2023 20.48 Description: X-RAY EXAM OF WRIST Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73110 TC MRT DEF RBRVS 01/01/2024 30.11 Description: X-RAY EXAM OF WRIST Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73110 TC RADIO DEF RBRVS 01/01/2016 12/31/2023 20.48 Description: X-RAY EXAM OF WRIST Category: Radiology CMS Add: 01/01/1984 CMS Term: 73110 TC RADIO DEF RBRVS 01/01/2024 30.11 Description: X-RAY EXAM OF WRIST Category: Radiology CMS Add: 01/01/1984 CMS Term: 73115 26 RADIO DEF RBRVS 01/01/2016 12/31/2023 20.87 Description: CONTRAST X-RAY OF WRIST Category: Radiology CMS Add: 01/01/1984 CMS Term: 73115 26 RADIO DEF RBRVS 01/01/2024 26.04 Description: CONTRAST X-RAY OF WRIST Category: Radiology CMS Add: 01/01/1984 CMS Term: 73115 RADIO DEF RBRVS 01/01/2016 12/31/2023 79.00 Description: CONTRAST X-RAY OF WRIST Category: Radiology CMS Add: 01/01/1984 CMS Term: 73115 RADIO DEF RBRVS 01/01/2024 126.84 Description: CONTRAST X-RAY OF WRIST Category: Radiology CMS Add: 01/01/1984 CMS Term: 73115 TC RADIO DEF RBRVS 01/01/2016 12/31/2023 58.13 Description: CONTRAST X-RAY OF WRIST Category: Radiology CMS Add: 01/01/1984 CMS Term: 73115 TC RADIO DEF RBRVS 01/01/2024 100.80 Description: CONTRAST X-RAY OF WRIST Category: Radiology CMS Add: 01/01/1984 CMS Term: 73120 26 MRT DEF RBRVS 01/01/2016 12/31/2023 6.20 Description: X-RAY EXAM OF HAND Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73120 26 MRT DEF RBRVS 01/01/2024 7.74 Description: X-RAY EXAM OF HAND Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73120 26 RADIO DEF RBRVS 01/01/2016 12/31/2023 6.20 Description: X-RAY EXAM OF HAND Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 897 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73120 26 RADIO DEF RBRVS 01/01/2024 7.74 Description: X-RAY EXAM OF HAND Category: Radiology CMS Add: 01/01/1984 CMS Term: 73120 MRT DEF RBRVS 01/01/2016 12/31/2023 19.74 Description: X-RAY EXAM OF HAND Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73120 MRT DEF RBRVS 01/01/2024 29.21 Description: X-RAY EXAM OF HAND Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73120 RADIO DEF RBRVS 01/01/2016 12/31/2023 19.74 Description: X-RAY EXAM OF HAND Category: Radiology CMS Add: 01/01/1984 CMS Term: 73120 RADIO DEF RBRVS 01/01/2024 29.21 Description: X-RAY EXAM OF HAND Category: Radiology CMS Add: 01/01/1984 CMS Term: 73120 TC MRT DEF RBRVS 01/01/2016 12/31/2023 13.54 Description: X-RAY EXAM OF HAND Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73120 TC MRT DEF RBRVS 01/01/2024 21.46 Description: X-RAY EXAM OF HAND Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73120 TC RADIO DEF RBRVS 01/01/2016 12/31/2023 13.54 Description: X-RAY EXAM OF HAND Category: Radiology CMS Add: 01/01/1984 CMS Term: 73120 TC RADIO DEF RBRVS 01/01/2024 21.46 Description: X-RAY EXAM OF HAND Category: Radiology CMS Add: 01/01/1984 CMS Term: 73130 26 MRT DEF RBRVS 01/01/2016 12/31/2023 6.47 Description: X-RAY EXAM OF HAND Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73130 26 MRT DEF RBRVS 01/01/2024 8.08 Description: X-RAY EXAM OF HAND Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73130 26 RADIO DEF RBRVS 01/01/2016 12/31/2023 6.47 Description: X-RAY EXAM OF HAND Category: Radiology CMS Add: 01/01/1984 CMS Term: 73130 26 RADIO DEF RBRVS 01/01/2024 8.08 Description: X-RAY EXAM OF HAND Category: Radiology CMS Add: 01/01/1984 CMS Term: 73130 MRT DEF RBRVS 01/01/2016 12/31/2023 23.48 Description: X-RAY EXAM OF HAND Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73130 MRT DEF RBRVS 01/01/2024 34.48 Description: X-RAY EXAM OF HAND Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73130 RADIO DEF RBRVS 01/01/2016 12/31/2023 23.48 Description: X-RAY EXAM OF HAND Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 898 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73130 RADIO DEF RBRVS 01/01/2024 34.48 Description: X-RAY EXAM OF HAND Category: Radiology CMS Add: 01/01/1984 CMS Term: 73130 TC MRT DEF RBRVS 01/01/2016 12/31/2023 17.01 Description: X-RAY EXAM OF HAND Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73130 TC MRT DEF RBRVS 01/01/2024 26.40 Description: X-RAY EXAM OF HAND Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73130 TC RADIO DEF RBRVS 01/01/2016 12/31/2023 17.01 Description: X-RAY EXAM OF HAND Category: Radiology CMS Add: 01/01/1984 CMS Term: 73130 TC RADIO DEF RBRVS 01/01/2024 26.40 Description: X-RAY EXAM OF HAND Category: Radiology CMS Add: 01/01/1984 CMS Term: 73140 26 RADIO DEF RBRVS 01/01/2016 12/31/2023 5.14 Description: X-RAY EXAM OF FINGER(S) Category: Radiology CMS Add: 01/01/1984 CMS Term: 73140 26 RADIO DEF RBRVS 01/01/2024 6.42 Description: X-RAY EXAM OF FINGER(S) Category: Radiology CMS Add: 01/01/1984 CMS Term: 73140 RADIO DEF RBRVS 01/01/2016 12/31/2023 23.64 Description: X-RAY EXAM OF FINGER(S) Category: Radiology CMS Add: 01/01/1984 CMS Term: 73140 RADIO DEF RBRVS 01/01/2024 35.29 Description: X-RAY EXAM OF FINGER(S) Category: Radiology CMS Add: 01/01/1984 CMS Term: 73140 TC RADIO DEF RBRVS 01/01/2016 12/31/2023 18.50 Description: X-RAY EXAM OF FINGER(S) Category: Radiology CMS Add: 01/01/1984 CMS Term: 73140 TC RADIO DEF RBRVS 01/01/2024 28.87 Description: X-RAY EXAM OF FINGER(S) Category: Radiology CMS Add: 01/01/1984 CMS Term: 73200 26 RADIO DEF RBRVS 01/01/2024 45.64 Description: CT UPPER EXTREMITY W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73200 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 37.19 Description: CT UPPER EXTREMITY W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73200 RADIO DEF RBRVS 01/01/2024 157.56 Description: CT UPPER EXTREMITY W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73200 RADIO DEF RBRVS 09/01/2019 12/31/2023 134.95 Description: CT UPPER EXTREMITY W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73200 TC RADIO DEF RBRVS 01/01/2024 111.91 Description: CT UPPER EXTREMITY W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 899 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73200 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 97.76 Description: CT UPPER EXTREMITY W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73201 26 RADIO DEF RBRVS 01/01/2024 53.24 Description: CT UPPER EXTREMITY W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73201 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 42.97 Description: CT UPPER EXTREMITY W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73201 RADIO DEF RBRVS 01/01/2024 196.19 Description: CT UPPER EXTREMITY W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73201 RADIO DEF RBRVS 09/01/2019 12/31/2023 165.02 Description: CT UPPER EXTREMITY W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73201 TC RADIO DEF RBRVS 01/01/2024 142.95 Description: CT UPPER EXTREMITY W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73201 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 122.04 Description: CT UPPER EXTREMITY W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73202 26 RADIO DEF RBRVS 01/01/2024 55.89 Description: CT UPPR EXTREMITY W/O&W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73202 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 44.83 Description: CT UPPR EXTREMITY W/O&W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73202 RADIO DEF RBRVS 01/01/2024 242.98 Description: CT UPPR EXTREMITY W/O&W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73202 RADIO DEF RBRVS 09/01/2019 12/31/2023 209.98 Description: CT UPPR EXTREMITY W/O&W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73202 TC RADIO DEF RBRVS 01/01/2024 187.09 Description: CT UPPR EXTREMITY W/O&W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73202 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 165.14 Description: CT UPPR EXTREMITY W/O&W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73206 26 RADIO DEF RBRVS 01/01/2024 82.09 Description: CT ANGIO UPR EXTRM W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73206 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 66.05 Description: CT ANGIO UPR EXTRM W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73206 RADIO DEF RBRVS 01/01/2024 289.57 Description: CT ANGIO UPR EXTRM W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 900 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73206 RADIO DEF RBRVS 09/01/2019 12/31/2023 237.14 Description: CT ANGIO UPR EXTRM W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73206 TC RADIO DEF RBRVS 01/01/2024 207.48 Description: CT ANGIO UPR EXTRM W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73206 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 171.09 Description: CT ANGIO UPR EXTRM W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73218 26 RADIO DEF RBRVS 01/01/2024 62.31 Description: MRI UPPER EXTREMITY W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73218 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 49.81 Description: MRI UPPER EXTREMITY W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73218 RADIO DEF RBRVS 01/01/2024 297.27 Description: MRI UPPER EXTREMITY W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73218 RADIO DEF RBRVS 09/01/2019 12/31/2023 258.80 Description: MRI UPPER EXTREMITY W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73218 TC RADIO DEF RBRVS 01/01/2024 234.96 Description: MRI UPPER EXTREMITY W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73218 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 208.99 Description: MRI UPPER EXTREMITY W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73219 26 RADIO DEF RBRVS 01/01/2024 74.40 Description: MRI UPPER EXTREMITY W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73219 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 60.04 Description: MRI UPPER EXTREMITY W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73219 RADIO DEF RBRVS 01/01/2024 325.10 Description: MRI UPPER EXTREMITY W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73219 RADIO DEF RBRVS 09/01/2019 12/31/2023 294.30 Description: MRI UPPER EXTREMITY W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73219 TC RADIO DEF RBRVS 01/01/2024 250.70 Description: MRI UPPER EXTREMITY W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73219 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 234.26 Description: MRI UPPER EXTREMITY W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73220 26 RADIO DEF RBRVS 01/01/2024 98.71 Description: MRI UPPR EXTREMITY W/O&W/DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 901 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73220 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 79.15 Description: MRI UPPR EXTREMITY W/O&W/DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 73220 RADIO DEF RBRVS 01/01/2024 402.20 Description: MRI UPPR EXTREMITY W/O&W/DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 73220 RADIO DEF RBRVS 09/01/2019 12/31/2023 361.46 Description: MRI UPPR EXTREMITY W/O&W/DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 73220 TC RADIO DEF RBRVS 01/01/2024 303.49 Description: MRI UPPR EXTREMITY W/O&W/DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 73220 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 282.31 Description: MRI UPPR EXTREMITY W/O&W/DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 73221 26 RADIO DEF RBRVS 01/01/2024 62.62 Description: MRI JOINT UPR EXTREM W/O DYE Category: Radiology CMS Add: 01/01/1989 CMS Term: 73221 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 50.56 Description: MRI JOINT UPR EXTREM W/O DYE Category: Radiology CMS Add: 01/01/1989 CMS Term: 73221 RADIO DEF RBRVS 01/01/2024 197.85 Description: MRI JOINT UPR EXTREM W/O DYE Category: Radiology CMS Add: 01/01/1989 CMS Term: 73221 RADIO DEF RBRVS 09/01/2019 12/31/2023 179.78 Description: MRI JOINT UPR EXTREM W/O DYE Category: Radiology CMS Add: 01/01/1989 CMS Term: 73221 TC RADIO DEF RBRVS 01/01/2024 135.23 Description: MRI JOINT UPR EXTREM W/O DYE Category: Radiology CMS Add: 01/01/1989 CMS Term: 73221 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 129.22 Description: MRI JOINT UPR EXTREM W/O DYE Category: Radiology CMS Add: 01/01/1989 CMS Term: 73222 26 RADIO DEF RBRVS 01/01/2024 74.71 Description: MRI JOINT UPR EXTREM W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73222 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 60.04 Description: MRI JOINT UPR EXTREM W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73222 RADIO DEF RBRVS 01/01/2024 306.87 Description: MRI JOINT UPR EXTREM W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73222 RADIO DEF RBRVS 09/01/2019 12/31/2023 274.97 Description: MRI JOINT UPR EXTREM W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73222 TC RADIO DEF RBRVS 01/01/2024 232.16 Description: MRI JOINT UPR EXTREM W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 902 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73222 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 214.93 Description: MRI JOINT UPR EXTREM W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73223 26 RADIO DEF RBRVS 01/01/2024 99.02 Description: MRI JOINT UPR EXTR W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73223 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 79.15 Description: MRI JOINT UPR EXTR W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73223 RADIO DEF RBRVS 01/01/2024 379.97 Description: MRI JOINT UPR EXTR W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73223 RADIO DEF RBRVS 09/01/2019 12/31/2023 341.15 Description: MRI JOINT UPR EXTR W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73223 TC RADIO DEF RBRVS 01/01/2024 280.95 Description: MRI JOINT UPR EXTR W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73223 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 262.00 Description: MRI JOINT UPR EXTR W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73225 26 RADIO DEF RBRVS 01/01/2024 79.68 Description: MR ANGIO UPR EXTR W/O&W/DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: 73225 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 63.24 Description: MR ANGIO UPR EXTR W/O&W/DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: 73225 RADIO DEF RBRVS 01/01/2024 334.40 Description: MR ANGIO UPR EXTR W/O&W/DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: 73225 RADIO DEF RBRVS 09/01/2019 12/31/2023 300.97 Description: MR ANGIO UPR EXTR W/O&W/DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: 73225 TC RADIO DEF RBRVS 01/01/2024 254.71 Description: MR ANGIO UPR EXTR W/O&W/DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: 73225 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 237.72 Description: MR ANGIO UPR EXTR W/O&W/DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: 73501 26 MRT DEF RBRVS 01/01/2016 12/31/2023 6.98 Description: X-RAY EXAM HIP UNI 1 VIEW Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 73501 26 MRT DEF RBRVS 01/01/2024 8.73 Description: X-RAY EXAM HIP UNI 1 VIEW Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 73501 26 RADIO DEF RBRVS 01/01/2016 12/31/2023 6.98 Description: X-RAY EXAM HIP UNI 1 VIEW Category: Radiology CMS Add: 01/01/2016 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 903 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73501 26 RADIO DEF RBRVS 01/01/2024 8.73 Description: X-RAY EXAM HIP UNI 1 VIEW Category: Radiology CMS Add: 01/01/2016 CMS Term: 73501 MRT DEF RBRVS 01/01/2016 12/31/2023 21.02 Description: X-RAY EXAM HIP UNI 1 VIEW Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 73501 MRT DEF RBRVS 01/01/2024 30.81 Description: X-RAY EXAM HIP UNI 1 VIEW Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 73501 RADIO DEF RBRVS 01/01/2016 12/31/2023 21.02 Description: X-RAY EXAM HIP UNI 1 VIEW Category: Radiology CMS Add: 01/01/2016 CMS Term: 73501 RADIO DEF RBRVS 01/01/2024 30.81 Description: X-RAY EXAM HIP UNI 1 VIEW Category: Radiology CMS Add: 01/01/2016 CMS Term: 73501 TC MRT DEF RBRVS 01/01/2016 12/31/2023 14.04 Description: X-RAY EXAM HIP UNI 1 VIEW Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 73501 TC MRT DEF RBRVS 01/01/2024 22.08 Description: X-RAY EXAM HIP UNI 1 VIEW Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 73501 TC RADIO DEF RBRVS 01/01/2016 12/31/2023 14.04 Description: X-RAY EXAM HIP UNI 1 VIEW Category: Radiology CMS Add: 01/01/2016 CMS Term: 73501 TC RADIO DEF RBRVS 01/01/2024 22.08 Description: X-RAY EXAM HIP UNI 1 VIEW Category: Radiology CMS Add: 01/01/2016 CMS Term: 73502 26 MRT DEF RBRVS 01/01/2016 12/31/2023 8.31 Description: X-RAY EXAM HIP UNI 2-3 VIEWS Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 73502 26 MRT DEF RBRVS 01/01/2024 10.39 Description: X-RAY EXAM HIP UNI 2-3 VIEWS Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 73502 26 RADIO DEF RBRVS 01/01/2016 12/31/2023 8.31 Description: X-RAY EXAM HIP UNI 2-3 VIEWS Category: Radiology CMS Add: 01/01/2016 CMS Term: 73502 26 RADIO DEF RBRVS 01/01/2024 10.39 Description: X-RAY EXAM HIP UNI 2-3 VIEWS Category: Radiology CMS Add: 01/01/2016 CMS Term: 73502 MRT DEF RBRVS 01/01/2016 12/31/2023 29.03 Description: X-RAY EXAM HIP UNI 2-3 VIEWS Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 73502 MRT DEF RBRVS 01/01/2024 43.90 Description: X-RAY EXAM HIP UNI 2-3 VIEWS Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 73502 RADIO DEF RBRVS 01/01/2016 12/31/2023 29.03 Description: X-RAY EXAM HIP UNI 2-3 VIEWS Category: Radiology CMS Add: 01/01/2016 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 904 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73502 RADIO DEF RBRVS 01/01/2024 43.90 Description: X-RAY EXAM HIP UNI 2-3 VIEWS Category: Radiology CMS Add: 01/01/2016 CMS Term: 73502 TC MRT DEF RBRVS 01/01/2016 12/31/2023 20.73 Description: X-RAY EXAM HIP UNI 2-3 VIEWS Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 73502 TC MRT DEF RBRVS 01/01/2024 33.50 Description: X-RAY EXAM HIP UNI 2-3 VIEWS Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 73502 TC RADIO DEF RBRVS 01/01/2016 12/31/2023 20.73 Description: X-RAY EXAM HIP UNI 2-3 VIEWS Category: Radiology CMS Add: 01/01/2016 CMS Term: 73502 TC RADIO DEF RBRVS 01/01/2024 33.50 Description: X-RAY EXAM HIP UNI 2-3 VIEWS Category: Radiology CMS Add: 01/01/2016 CMS Term: 73503 26 MRT DEF RBRVS 01/01/2016 12/31/2023 10.56 Description: X-RAY EXAM HIP UNI 4/> VIEWS Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 73503 26 MRT DEF RBRVS 01/01/2024 12.71 Description: X-RAY EXAM HIP UNI 4/> VIEWS Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 73503 26 RADIO DEF RBRVS 01/01/2016 12/31/2023 10.56 Description: X-RAY EXAM HIP UNI 4/> VIEWS Category: Radiology CMS Add: 01/01/2016 CMS Term: 73503 26 RADIO DEF RBRVS 01/01/2024 12.71 Description: X-RAY EXAM HIP UNI 4/> VIEWS Category: Radiology CMS Add: 01/01/2016 CMS Term: 73503 MRT DEF RBRVS 01/01/2016 12/31/2023 36.24 Description: X-RAY EXAM HIP UNI 4/> VIEWS Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 73503 MRT DEF RBRVS 01/01/2024 55.47 Description: X-RAY EXAM HIP UNI 4/> VIEWS Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 73503 RADIO DEF RBRVS 01/01/2016 12/31/2023 36.24 Description: X-RAY EXAM HIP UNI 4/> VIEWS Category: Radiology CMS Add: 01/01/2016 CMS Term: 73503 RADIO DEF RBRVS 01/01/2024 55.47 Description: X-RAY EXAM HIP UNI 4/> VIEWS Category: Radiology CMS Add: 01/01/2016 CMS Term: 73503 TC MRT DEF RBRVS 01/01/2016 12/31/2023 25.68 Description: X-RAY EXAM HIP UNI 4/> VIEWS Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 73503 TC MRT DEF RBRVS 01/01/2024 42.76 Description: X-RAY EXAM HIP UNI 4/> VIEWS Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 73503 TC RADIO DEF RBRVS 01/01/2016 12/31/2023 25.68 Description: X-RAY EXAM HIP UNI 4/> VIEWS Category: Radiology CMS Add: 01/01/2016 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 905 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73503 TC RADIO DEF RBRVS 01/01/2024 42.76 Description: X-RAY EXAM HIP UNI 4/> VIEWS Category: Radiology CMS Add: 01/01/2016 CMS Term: 73521 26 MRT DEF RBRVS 01/01/2016 12/31/2023 8.55 Description: X-RAY EXAM HIPS BI 2 VIEWS Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 73521 26 MRT DEF RBRVS 01/01/2024 10.39 Description: X-RAY EXAM HIPS BI 2 VIEWS Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 73521 26 RADIO DEF RBRVS 01/01/2016 12/31/2023 8.55 Description: X-RAY EXAM HIPS BI 2 VIEWS Category: Radiology CMS Add: 01/01/2016 CMS Term: 73521 26 RADIO DEF RBRVS 01/01/2024 10.39 Description: X-RAY EXAM HIPS BI 2 VIEWS Category: Radiology CMS Add: 01/01/2016 CMS Term: 73521 MRT DEF RBRVS 01/01/2016 12/31/2023 28.04 Description: X-RAY EXAM HIPS BI 2 VIEWS Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 73521 MRT DEF RBRVS 01/01/2024 38.65 Description: X-RAY EXAM HIPS BI 2 VIEWS Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 73521 RADIO DEF RBRVS 01/01/2016 12/31/2023 28.04 Description: X-RAY EXAM HIPS BI 2 VIEWS Category: Radiology CMS Add: 01/01/2016 CMS Term: 73521 RADIO DEF RBRVS 01/01/2024 38.65 Description: X-RAY EXAM HIPS BI 2 VIEWS Category: Radiology CMS Add: 01/01/2016 CMS Term: 73521 TC MRT DEF RBRVS 01/01/2016 12/31/2023 19.49 Description: X-RAY EXAM HIPS BI 2 VIEWS Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 73521 TC MRT DEF RBRVS 01/01/2024 28.25 Description: X-RAY EXAM HIPS BI 2 VIEWS Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 73521 TC RADIO DEF RBRVS 01/01/2016 12/31/2023 19.49 Description: X-RAY EXAM HIPS BI 2 VIEWS Category: Radiology CMS Add: 01/01/2016 CMS Term: 73521 TC RADIO DEF RBRVS 01/01/2024 28.25 Description: X-RAY EXAM HIPS BI 2 VIEWS Category: Radiology CMS Add: 01/01/2016 CMS Term: 73522 26 MRT DEF RBRVS 01/01/2016 12/31/2023 11.09 Description: X-RAY EXAM HIPS BI 3-4 VIEWS Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 73522 26 MRT DEF RBRVS 01/01/2024 13.69 Description: X-RAY EXAM HIPS BI 3-4 VIEWS Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 73522 26 RADIO DEF RBRVS 01/01/2016 12/31/2023 11.09 Description: X-RAY EXAM HIPS BI 3-4 VIEWS Category: Radiology CMS Add: 01/01/2016 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 906 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73522 26 RADIO DEF RBRVS 01/01/2024 13.69 Description: X-RAY EXAM HIPS BI 3-4 VIEWS Category: Radiology CMS Add: 01/01/2016 CMS Term: 73522 MRT DEF RBRVS 01/01/2016 12/31/2023 34.30 Description: X-RAY EXAM HIPS BI 3-4 VIEWS Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 73522 MRT DEF RBRVS 01/01/2024 50.28 Description: X-RAY EXAM HIPS BI 3-4 VIEWS Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 73522 RADIO DEF RBRVS 01/01/2016 12/31/2023 34.30 Description: X-RAY EXAM HIPS BI 3-4 VIEWS Category: Radiology CMS Add: 01/01/2016 CMS Term: 73522 RADIO DEF RBRVS 01/01/2024 50.28 Description: X-RAY EXAM HIPS BI 3-4 VIEWS Category: Radiology CMS Add: 01/01/2016 CMS Term: 73522 TC MRT DEF RBRVS 01/01/2016 12/31/2023 23.20 Description: X-RAY EXAM HIPS BI 3-4 VIEWS Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 73522 TC MRT DEF RBRVS 01/01/2024 36.59 Description: X-RAY EXAM HIPS BI 3-4 VIEWS Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 73522 TC RADIO DEF RBRVS 01/01/2016 12/31/2023 23.20 Description: X-RAY EXAM HIPS BI 3-4 VIEWS Category: Radiology CMS Add: 01/01/2016 CMS Term: 73522 TC RADIO DEF RBRVS 01/01/2024 36.59 Description: X-RAY EXAM HIPS BI 3-4 VIEWS Category: Radiology CMS Add: 01/01/2016 CMS Term: 73523 26 RADIO DEF RBRVS 01/01/2016 12/31/2023 11.88 Description: X-RAY EXAM HIPS BI 5/> VIEWS Category: Radiology CMS Add: 01/01/2016 CMS Term: 73523 26 RADIO DEF RBRVS 01/01/2024 14.53 Description: X-RAY EXAM HIPS BI 5/> VIEWS Category: Radiology CMS Add: 01/01/2016 CMS Term: 73523 RADIO DEF RBRVS 01/01/2016 12/31/2023 39.79 Description: X-RAY EXAM HIPS BI 5/> VIEWS Category: Radiology CMS Add: 01/01/2016 CMS Term: 73523 RADIO DEF RBRVS 01/01/2024 57.91 Description: X-RAY EXAM HIPS BI 5/> VIEWS Category: Radiology CMS Add: 01/01/2016 CMS Term: 73523 TC RADIO DEF RBRVS 01/01/2016 12/31/2023 27.91 Description: X-RAY EXAM HIPS BI 5/> VIEWS Category: Radiology CMS Add: 01/01/2016 CMS Term: 73523 TC RADIO DEF RBRVS 01/01/2024 43.38 Description: X-RAY EXAM HIPS BI 5/> VIEWS Category: Radiology CMS Add: 01/01/2016 CMS Term: 73525 26 ANEST DEF RBRVS 01/01/2024 26.66 Description: CONTRAST X-RAY OF HIP Category: Anesthesia CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 907 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73525 26 ANEST DEF RBRVS 02/01/2015 12/31/2023 21.11 Description: CONTRAST X-RAY OF HIP Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 73525 ANEST DEF RBRVS 01/01/2024 122.21 Description: CONTRAST X-RAY OF HIP Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 73525 ANEST DEF RBRVS 02/01/2015 12/31/2023 73.55 Description: CONTRAST X-RAY OF HIP Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 73525 TC ANEST DEF RBRVS 01/01/2024 95.55 Description: CONTRAST X-RAY OF HIP Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 73525 TC ANEST DEF RBRVS 02/01/2015 12/31/2023 52.43 Description: CONTRAST X-RAY OF HIP Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 73551 26 RADIO DEF RBRVS 01/01/2017 12/31/2023 6.20 Description: X-RAY EXAM OF FEMUR 1 Category: Radiology CMS Add: 01/01/2016 CMS Term: 73551 26 RADIO DEF RBRVS 01/01/2024 7.74 Description: X-RAY EXAM OF FEMUR 1 Category: Radiology CMS Add: 01/01/2016 CMS Term: 73551 RADIO DEF RBRVS 01/01/2017 12/31/2023 19.49 Description: X-RAY EXAM OF FEMUR 1 Category: Radiology CMS Add: 01/01/2016 CMS Term: 73551 RADIO DEF RBRVS 01/01/2024 27.35 Description: X-RAY EXAM OF FEMUR 1 Category: Radiology CMS Add: 01/01/2016 CMS Term: 73551 TC RADIO DEF RBRVS 01/01/2017 12/31/2023 13.29 Description: X-RAY EXAM OF FEMUR 1 Category: Radiology CMS Add: 01/01/2016 CMS Term: 73551 TC RADIO DEF RBRVS 01/01/2024 19.61 Description: X-RAY EXAM OF FEMUR 1 Category: Radiology CMS Add: 01/01/2016 CMS Term: 73552 26 MRT DEF RBRVS 01/01/2016 12/31/2023 6.98 Description: X-RAY EXAM OF FEMUR 2/> Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 73552 26 MRT DEF RBRVS 01/01/2024 8.42 Description: X-RAY EXAM OF FEMUR 2/> Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 73552 26 RADIO DEF RBRVS 01/01/2016 12/31/2023 6.98 Description: X-RAY EXAM OF FEMUR 2/> Category: Radiology CMS Add: 01/01/2016 CMS Term: 73552 26 RADIO DEF RBRVS 01/01/2024 8.42 Description: X-RAY EXAM OF FEMUR 2/> Category: Radiology CMS Add: 01/01/2016 CMS Term: 73552 MRT DEF RBRVS 01/01/2017 12/31/2023 22.75 Description: X-RAY EXAM OF FEMUR 2/> Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 908 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73552 MRT DEF RBRVS 01/01/2024 33.28 Description: X-RAY EXAM OF FEMUR 2/> Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 73552 RADIO DEF RBRVS 01/01/2017 12/31/2023 22.75 Description: X-RAY EXAM OF FEMUR 2/> Category: Radiology CMS Add: 01/01/2016 CMS Term: 73552 RADIO DEF RBRVS 01/01/2024 33.28 Description: X-RAY EXAM OF FEMUR 2/> Category: Radiology CMS Add: 01/01/2016 CMS Term: 73552 TC MRT DEF RBRVS 01/01/2017 12/31/2023 15.77 Description: X-RAY EXAM OF FEMUR 2/> Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 73552 TC MRT DEF RBRVS 01/01/2024 24.86 Description: X-RAY EXAM OF FEMUR 2/> Category: Medical Review Team CMS Add: 01/01/2016 CMS Term: 73552 TC RADIO DEF RBRVS 01/01/2017 12/31/2023 15.77 Description: X-RAY EXAM OF FEMUR 2/> Category: Radiology CMS Add: 01/01/2016 CMS Term: 73552 TC RADIO DEF RBRVS 01/01/2024 24.86 Description: X-RAY EXAM OF FEMUR 2/> Category: Radiology CMS Add: 01/01/2016 CMS Term: 73560 26 MRT DEF RBRVS 01/01/2024 7.74 Description: X-RAY EXAM OF KNEE 1 OR 2 Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73560 26 MRT DEF RBRVS 02/01/2015 12/31/2023 6.80 Description: X-RAY EXAM OF KNEE 1 OR 2 Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73560 26 RADIO DEF RBRVS 01/01/2024 7.74 Description: X-RAY EXAM OF KNEE 1 OR 2 Category: Radiology CMS Add: 01/01/1984 CMS Term: 73560 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 6.80 Description: X-RAY EXAM OF KNEE 1 OR 2 Category: Radiology CMS Add: 01/01/1984 CMS Term: 73560 MRT DEF RBRVS 01/01/2024 31.98 Description: X-RAY EXAM OF KNEE 1 OR 2 Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73560 MRT DEF RBRVS 02/01/2015 12/31/2023 21.83 Description: X-RAY EXAM OF KNEE 1 OR 2 Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73560 RADIO DEF RBRVS 01/01/2024 31.98 Description: X-RAY EXAM OF KNEE 1 OR 2 Category: Radiology CMS Add: 01/01/1984 CMS Term: 73560 RADIO DEF RBRVS 02/01/2015 12/31/2023 21.83 Description: X-RAY EXAM OF KNEE 1 OR 2 Category: Radiology CMS Add: 01/01/1984 CMS Term: 73560 TC MRT DEF RBRVS 01/01/2024 24.24 Description: X-RAY EXAM OF KNEE 1 OR 2 Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 909 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73560 TC MRT DEF RBRVS 02/01/2015 12/31/2023 15.03 Description: X-RAY EXAM OF KNEE 1 OR 2 Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73560 TC RADIO DEF RBRVS 01/01/2024 24.24 Description: X-RAY EXAM OF KNEE 1 OR 2 Category: Radiology CMS Add: 01/01/1984 CMS Term: 73560 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 15.03 Description: X-RAY EXAM OF KNEE 1 OR 2 Category: Radiology CMS Add: 01/01/1984 CMS Term: 73562 26 MRT DEF RBRVS 01/01/2024 8.73 Description: X-RAY EXAM OF KNEE 3 Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73562 26 MRT DEF RBRVS 02/01/2015 12/31/2023 7.31 Description: X-RAY EXAM OF KNEE 3 Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73562 26 RADIO DEF RBRVS 01/01/2024 8.73 Description: X-RAY EXAM OF KNEE 3 Category: Radiology CMS Add: 01/01/1984 CMS Term: 73562 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 7.31 Description: X-RAY EXAM OF KNEE 3 Category: Radiology CMS Add: 01/01/1984 CMS Term: 73562 MRT DEF RBRVS 01/01/2024 37.91 Description: X-RAY EXAM OF KNEE 3 Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73562 MRT DEF RBRVS 02/01/2015 12/31/2023 26.55 Description: X-RAY EXAM OF KNEE 3 Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73562 RADIO DEF RBRVS 01/01/2024 37.91 Description: X-RAY EXAM OF KNEE 3 Category: Radiology CMS Add: 01/01/1984 CMS Term: 73562 RADIO DEF RBRVS 02/01/2015 12/31/2023 26.55 Description: X-RAY EXAM OF KNEE 3 Category: Radiology CMS Add: 01/01/1984 CMS Term: 73562 TC MRT DEF RBRVS 01/01/2024 29.18 Description: X-RAY EXAM OF KNEE 3 Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73562 TC MRT DEF RBRVS 02/01/2015 12/31/2023 19.24 Description: X-RAY EXAM OF KNEE 3 Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73562 TC RADIO DEF RBRVS 01/01/2024 29.18 Description: X-RAY EXAM OF KNEE 3 Category: Radiology CMS Add: 01/01/1984 CMS Term: 73562 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 19.24 Description: X-RAY EXAM OF KNEE 3 Category: Radiology CMS Add: 01/01/1984 CMS Term: 73564 26 MRT DEF RBRVS 01/01/2024 10.70 Description: X-RAY EXAM KNEE 4 OR MORE Category: Medical Review Team CMS Add: 01/01/1983 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 910 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73564 26 MRT DEF RBRVS 02/01/2015 12/31/2023 8.64 Description: X-RAY EXAM KNEE 4 OR MORE Category: Medical Review Team CMS Add: 01/01/1983 CMS Term: 73564 26 RADIO DEF RBRVS 01/01/2024 10.70 Description: X-RAY EXAM KNEE 4 OR MORE Category: Radiology CMS Add: 01/01/1983 CMS Term: 73564 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 8.64 Description: X-RAY EXAM KNEE 4 OR MORE Category: Radiology CMS Add: 01/01/1983 CMS Term: 73564 MRT DEF RBRVS 01/01/2024 43.59 Description: X-RAY EXAM KNEE 4 OR MORE Category: Medical Review Team CMS Add: 01/01/1983 CMS Term: 73564 MRT DEF RBRVS 02/01/2015 12/31/2023 30.85 Description: X-RAY EXAM KNEE 4 OR MORE Category: Medical Review Team CMS Add: 01/01/1983 CMS Term: 73564 RADIO DEF RBRVS 01/01/2024 43.59 Description: X-RAY EXAM KNEE 4 OR MORE Category: Radiology CMS Add: 01/01/1983 CMS Term: 73564 RADIO DEF RBRVS 02/01/2015 12/31/2023 30.85 Description: X-RAY EXAM KNEE 4 OR MORE Category: Radiology CMS Add: 01/01/1983 CMS Term: 73564 TC MRT DEF RBRVS 01/01/2024 32.88 Description: X-RAY EXAM KNEE 4 OR MORE Category: Medical Review Team CMS Add: 01/01/1983 CMS Term: 73564 TC MRT DEF RBRVS 02/01/2015 12/31/2023 22.21 Description: X-RAY EXAM KNEE 4 OR MORE Category: Medical Review Team CMS Add: 01/01/1983 CMS Term: 73564 TC RADIO DEF RBRVS 01/01/2024 32.88 Description: X-RAY EXAM KNEE 4 OR MORE Category: Radiology CMS Add: 01/01/1983 CMS Term: 73564 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 22.21 Description: X-RAY EXAM KNEE 4 OR MORE Category: Radiology CMS Add: 01/01/1983 CMS Term: 73565 26 MRT DEF RBRVS 01/01/2024 8.05 Description: X-RAY EXAM OF KNEES Category: Medical Review Team CMS Add: 01/01/1991 CMS Term: 73565 26 MRT DEF RBRVS 02/01/2015 12/31/2023 7.04 Description: X-RAY EXAM OF KNEES Category: Medical Review Team CMS Add: 01/01/1991 CMS Term: 73565 26 RADIO DEF RBRVS 01/01/2024 8.05 Description: X-RAY EXAM OF KNEES Category: Radiology CMS Add: 01/01/1991 CMS Term: 73565 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 7.04 Description: X-RAY EXAM OF KNEES Category: Radiology CMS Add: 01/01/1991 CMS Term: 73565 MRT DEF RBRVS 01/01/2024 37.23 Description: X-RAY EXAM OF KNEES Category: Medical Review Team CMS Add: 01/01/1991 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 911 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73565 MRT DEF RBRVS 02/01/2015 12/31/2023 25.29 Description: X-RAY EXAM OF KNEES Category: Medical Review Team CMS Add: 01/01/1991 CMS Term: 73565 RADIO DEF RBRVS 01/01/2024 37.23 Description: X-RAY EXAM OF KNEES Category: Radiology CMS Add: 01/01/1991 CMS Term: 73565 RADIO DEF RBRVS 02/01/2015 12/31/2023 25.29 Description: X-RAY EXAM OF KNEES Category: Radiology CMS Add: 01/01/1991 CMS Term: 73565 TC MRT DEF RBRVS 01/01/2024 29.18 Description: X-RAY EXAM OF KNEES Category: Medical Review Team CMS Add: 01/01/1991 CMS Term: 73565 TC MRT DEF RBRVS 02/01/2015 12/31/2023 18.25 Description: X-RAY EXAM OF KNEES Category: Medical Review Team CMS Add: 01/01/1991 CMS Term: 73565 TC RADIO DEF RBRVS 01/01/2024 29.18 Description: X-RAY EXAM OF KNEES Category: Radiology CMS Add: 01/01/1991 CMS Term: 73565 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 18.25 Description: X-RAY EXAM OF KNEES Category: Radiology CMS Add: 01/01/1991 CMS Term: 73580 26 RADIO DEF RBRVS 01/01/2024 28.68 Description: CONTRAST X-RAY OF KNEE JOINT Category: Radiology CMS Add: 01/01/1984 CMS Term: 73580 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 21.28 Description: CONTRAST X-RAY OF KNEE JOINT Category: Radiology CMS Add: 01/01/1984 CMS Term: 73580 RADIO DEF RBRVS 01/01/2024 119.29 Description: CONTRAST X-RAY OF KNEE JOINT Category: Radiology CMS Add: 01/01/1984 CMS Term: 73580 RADIO DEF RBRVS 02/01/2015 12/31/2023 90.06 Description: CONTRAST X-RAY OF KNEE JOINT Category: Radiology CMS Add: 01/01/1984 CMS Term: 73580 TC RADIO DEF RBRVS 01/01/2024 90.61 Description: CONTRAST X-RAY OF KNEE JOINT Category: Radiology CMS Add: 01/01/1984 CMS Term: 73580 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 68.78 Description: CONTRAST X-RAY OF KNEE JOINT Category: Radiology CMS Add: 01/01/1984 CMS Term: 73590 26 MRT DEF RBRVS 01/01/2024 7.44 Description: X-RAY EXAM OF LOWER LEG Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73590 26 MRT DEF RBRVS 02/01/2015 12/31/2023 6.47 Description: X-RAY EXAM OF LOWER LEG Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73590 26 RADIO DEF RBRVS 01/01/2024 7.44 Description: X-RAY EXAM OF LOWER LEG Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 912 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73590 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 6.47 Description: X-RAY EXAM OF LOWER LEG Category: Radiology CMS Add: 01/01/1984 CMS Term: 73590 MRT DEF RBRVS 01/01/2024 29.51 Description: X-RAY EXAM OF LOWER LEG Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73590 MRT DEF RBRVS 02/01/2015 12/31/2023 19.76 Description: X-RAY EXAM OF LOWER LEG Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73590 RADIO DEF RBRVS 01/01/2024 29.51 Description: X-RAY EXAM OF LOWER LEG Category: Radiology CMS Add: 01/01/1984 CMS Term: 73590 RADIO DEF RBRVS 02/01/2015 12/31/2023 19.76 Description: X-RAY EXAM OF LOWER LEG Category: Radiology CMS Add: 01/01/1984 CMS Term: 73590 TC MRT DEF RBRVS 01/01/2024 22.08 Description: X-RAY EXAM OF LOWER LEG Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73590 TC MRT DEF RBRVS 02/01/2015 12/31/2023 13.29 Description: X-RAY EXAM OF LOWER LEG Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73590 TC RADIO DEF RBRVS 01/01/2024 22.08 Description: X-RAY EXAM OF LOWER LEG Category: Radiology CMS Add: 01/01/1984 CMS Term: 73590 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 13.29 Description: X-RAY EXAM OF LOWER LEG Category: Radiology CMS Add: 01/01/1984 CMS Term: 73592 26 RADIO DEF RBRVS 01/01/2024 7.44 0-364days Description: X-RAY EXAM OF LEG INFANT Category: Radiology CMS Add: 01/01/1984 CMS Term: 73592 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 5.95 0-364days Description: X-RAY EXAM OF LEG INFANT Category: Radiology CMS Add: 01/01/1984 CMS Term: 73592 RADIO DEF RBRVS 01/01/2024 29.51 0-364days Description: X-RAY EXAM OF LEG INFANT Category: Radiology CMS Add: 01/01/1984 CMS Term: 73592 RADIO DEF RBRVS 02/01/2015 12/31/2023 20.24 0-364days Description: X-RAY EXAM OF LEG INFANT Category: Radiology CMS Add: 01/01/1984 CMS Term: 73592 TC RADIO DEF RBRVS 01/01/2024 22.08 0-364days Description: X-RAY EXAM OF LEG INFANT Category: Radiology CMS Add: 01/01/1984 CMS Term: 73592 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 14.28 0-364days Description: X-RAY EXAM OF LEG INFANT Category: Radiology CMS Add: 01/01/1984 CMS Term: 73600 26 MRT DEF RBRVS 01/01/2024 7.74 Description: X-RAY EXAM OF ANKLE Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 913 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73600 26 MRT DEF RBRVS 02/01/2015 12/31/2023 6.20 Description: X-RAY EXAM OF ANKLE Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73600 26 RADIO DEF RBRVS 01/01/2024 7.74 Description: X-RAY EXAM OF ANKLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73600 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 6.20 Description: X-RAY EXAM OF ANKLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73600 MRT DEF RBRVS 01/01/2024 30.44 Description: X-RAY EXAM OF ANKLE Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73600 MRT DEF RBRVS 02/01/2015 12/31/2023 20.48 Description: X-RAY EXAM OF ANKLE Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73600 RADIO DEF RBRVS 01/01/2024 30.44 Description: X-RAY EXAM OF ANKLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73600 RADIO DEF RBRVS 02/01/2015 12/31/2023 20.48 Description: X-RAY EXAM OF ANKLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73600 TC MRT DEF RBRVS 01/01/2024 22.70 Description: X-RAY EXAM OF ANKLE Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73600 TC MRT DEF RBRVS 02/01/2015 12/31/2023 14.28 Description: X-RAY EXAM OF ANKLE Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73600 TC RADIO DEF RBRVS 01/01/2024 22.70 Description: X-RAY EXAM OF ANKLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73600 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 14.28 Description: X-RAY EXAM OF ANKLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73610 26 MRT DEF RBRVS 01/01/2024 8.08 Description: X-RAY EXAM OF ANKLE Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73610 26 MRT DEF RBRVS 02/01/2015 12/31/2023 6.47 Description: X-RAY EXAM OF ANKLE Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73610 26 RADIO DEF RBRVS 01/01/2024 8.08 Description: X-RAY EXAM OF ANKLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73610 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 6.47 Description: X-RAY EXAM OF ANKLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73610 MRT DEF RBRVS 01/01/2024 34.48 Description: X-RAY EXAM OF ANKLE Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 914 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73610 MRT DEF RBRVS 02/01/2015 12/31/2023 23.97 Description: X-RAY EXAM OF ANKLE Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73610 RADIO DEF RBRVS 01/01/2024 34.48 Description: X-RAY EXAM OF ANKLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73610 RADIO DEF RBRVS 02/01/2015 12/31/2023 23.97 Description: X-RAY EXAM OF ANKLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73610 TC MRT DEF RBRVS 01/01/2024 26.40 Description: X-RAY EXAM OF ANKLE Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73610 TC MRT DEF RBRVS 02/01/2015 12/31/2023 17.51 Description: X-RAY EXAM OF ANKLE Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73610 TC RADIO DEF RBRVS 01/01/2024 26.40 Description: X-RAY EXAM OF ANKLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73610 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 17.51 Description: X-RAY EXAM OF ANKLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73615 26 RADIO DEF RBRVS 01/01/2024 26.04 Description: CONTRAST X-RAY OF ANKLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73615 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 21.11 Description: CONTRAST X-RAY OF ANKLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73615 RADIO DEF RBRVS 01/01/2024 121.29 Description: CONTRAST X-RAY OF ANKLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73615 RADIO DEF RBRVS 02/01/2015 12/31/2023 73.55 Description: CONTRAST X-RAY OF ANKLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73615 TC RADIO DEF RBRVS 01/01/2024 95.24 Description: CONTRAST X-RAY OF ANKLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73615 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 52.43 Description: CONTRAST X-RAY OF ANKLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73620 26 MRT DEF RBRVS 01/01/2024 7.13 Description: X-RAY EXAM OF FOOT Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73620 26 MRT DEF RBRVS 02/01/2015 12/31/2023 5.70 Description: X-RAY EXAM OF FOOT Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73620 26 RADIO DEF RBRVS 01/01/2024 7.13 Description: X-RAY EXAM OF FOOT Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 915 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73620 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 5.70 Description: X-RAY EXAM OF FOOT Category: Radiology CMS Add: 01/01/1984 CMS Term: 73620 MRT DEF RBRVS 01/01/2024 26.43 Description: X-RAY EXAM OF FOOT Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73620 MRT DEF RBRVS 02/01/2015 12/31/2023 19.49 Description: X-RAY EXAM OF FOOT Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73620 RADIO DEF RBRVS 01/01/2024 26.43 Description: X-RAY EXAM OF FOOT Category: Radiology CMS Add: 01/01/1984 CMS Term: 73620 RADIO DEF RBRVS 02/01/2015 12/31/2023 19.49 Description: X-RAY EXAM OF FOOT Category: Radiology CMS Add: 01/01/1984 CMS Term: 73620 TC MRT DEF RBRVS 01/01/2024 19.30 Description: X-RAY EXAM OF FOOT Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73620 TC MRT DEF RBRVS 02/01/2015 12/31/2023 13.79 Description: X-RAY EXAM OF FOOT Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73620 TC RADIO DEF RBRVS 01/01/2024 19.30 Description: X-RAY EXAM OF FOOT Category: Radiology CMS Add: 01/01/1984 CMS Term: 73620 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 13.79 Description: X-RAY EXAM OF FOOT Category: Radiology CMS Add: 01/01/1984 CMS Term: 73630 26 MRT DEF RBRVS 01/01/2024 7.77 Description: X-RAY EXAM OF FOOT Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73630 26 MRT DEF RBRVS 02/01/2015 12/31/2023 6.22 Description: X-RAY EXAM OF FOOT Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73630 26 RADIO DEF RBRVS 01/01/2024 7.77 Description: X-RAY EXAM OF FOOT Category: Radiology CMS Add: 01/01/1984 CMS Term: 73630 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 6.22 Description: X-RAY EXAM OF FOOT Category: Radiology CMS Add: 01/01/1984 CMS Term: 73630 MRT DEF RBRVS 01/01/2024 32.01 Description: X-RAY EXAM OF FOOT Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73630 MRT DEF RBRVS 02/01/2015 12/31/2023 22.49 Description: X-RAY EXAM OF FOOT Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73630 RADIO DEF RBRVS 01/01/2024 32.01 Description: X-RAY EXAM OF FOOT Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 916 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73630 RADIO DEF RBRVS 02/01/2015 12/31/2023 22.49 Description: X-RAY EXAM OF FOOT Category: Radiology CMS Add: 01/01/1984 CMS Term: 73630 TC MRT DEF RBRVS 01/01/2024 24.24 Description: X-RAY EXAM OF FOOT Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73630 TC MRT DEF RBRVS 02/01/2015 12/31/2023 16.27 Description: X-RAY EXAM OF FOOT Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 73630 TC RADIO DEF RBRVS 01/01/2024 24.24 Description: X-RAY EXAM OF FOOT Category: Radiology CMS Add: 01/01/1984 CMS Term: 73630 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 16.27 Description: X-RAY EXAM OF FOOT Category: Radiology CMS Add: 01/01/1984 CMS Term: 73650 26 RADIO DEF RBRVS 01/01/2016 12/31/2023 5.95 Description: X-RAY EXAM OF HEEL Category: Radiology CMS Add: 01/01/1984 CMS Term: 73650 26 RADIO DEF RBRVS 01/01/2024 7.44 Description: X-RAY EXAM OF HEEL Category: Radiology CMS Add: 01/01/1984 CMS Term: 73650 RADIO DEF RBRVS 01/01/2016 12/31/2023 20.24 Description: X-RAY EXAM OF HEEL Category: Radiology CMS Add: 01/01/1984 CMS Term: 73650 RADIO DEF RBRVS 01/01/2024 26.74 Description: X-RAY EXAM OF HEEL Category: Radiology CMS Add: 01/01/1984 CMS Term: 73650 TC RADIO DEF RBRVS 01/01/2016 12/31/2023 14.28 Description: X-RAY EXAM OF HEEL Category: Radiology CMS Add: 01/01/1984 CMS Term: 73650 TC RADIO DEF RBRVS 01/01/2024 19.30 Description: X-RAY EXAM OF HEEL Category: Radiology CMS Add: 01/01/1984 CMS Term: 73660 26 RADIO DEF RBRVS 01/01/2016 12/31/2023 4.90 Description: X-RAY EXAM OF TOE(S) Category: Radiology CMS Add: 01/01/1984 CMS Term: 73660 26 RADIO DEF RBRVS 01/01/2024 6.11 Description: X-RAY EXAM OF TOE(S) Category: Radiology CMS Add: 01/01/1984 CMS Term: 73660 RADIO DEF RBRVS 01/01/2016 12/31/2023 21.66 Description: X-RAY EXAM OF TOE(S) Category: Radiology CMS Add: 01/01/1984 CMS Term: 73660 RADIO DEF RBRVS 01/01/2024 27.26 Description: X-RAY EXAM OF TOE(S) Category: Radiology CMS Add: 01/01/1984 CMS Term: 73660 TC RADIO DEF RBRVS 01/01/2016 12/31/2023 16.76 Description: X-RAY EXAM OF TOE(S) Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 917 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73660 TC RADIO DEF RBRVS 01/01/2024 21.15 Description: X-RAY EXAM OF TOE(S) Category: Radiology CMS Add: 01/01/1984 CMS Term: 73700 26 RADIO DEF RBRVS 01/01/2024 45.64 Description: CT LOWER EXTREMITY W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73700 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 37.19 Description: CT LOWER EXTREMITY W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73700 RADIO DEF RBRVS 01/01/2024 126.07 Description: CT LOWER EXTREMITY W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73700 RADIO DEF RBRVS 09/01/2019 12/31/2023 134.95 Description: CT LOWER EXTREMITY W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73700 TC RADIO DEF RBRVS 01/01/2024 80.43 Description: CT LOWER EXTREMITY W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73700 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 97.76 Description: CT LOWER EXTREMITY W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73701 26 RADIO DEF RBRVS 01/01/2024 53.24 Description: CT LOWER EXTREMITY W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73701 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 42.97 Description: CT LOWER EXTREMITY W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73701 RADIO DEF RBRVS 01/01/2024 162.23 Description: CT LOWER EXTREMITY W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73701 RADIO DEF RBRVS 09/01/2019 12/31/2023 167.00 Description: CT LOWER EXTREMITY W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73701 TC RADIO DEF RBRVS 01/01/2024 108.99 Description: CT LOWER EXTREMITY W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73701 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 124.02 Description: CT LOWER EXTREMITY W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73702 26 RADIO DEF RBRVS 01/01/2024 55.58 Description: CT LWR EXTREMITY W/O&W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73702 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 44.83 Description: CT LWR EXTREMITY W/O&W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73702 RADIO DEF RBRVS 01/01/2024 189.89 Description: CT LWR EXTREMITY W/O&W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 918 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73702 RADIO DEF RBRVS 09/01/2019 12/31/2023 208.24 Description: CT LWR EXTREMITY W/O&W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73702 TC RADIO DEF RBRVS 01/01/2024 134.30 Description: CT LWR EXTREMITY W/O&W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73702 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 163.41 Description: CT LWR EXTREMITY W/O&W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 73706 26 RADIO DEF RBRVS 01/01/2024 86.37 Description: CT ANGIO LWR EXTR W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73706 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 69.71 Description: CT ANGIO LWR EXTR W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73706 RADIO DEF RBRVS 01/01/2024 314.84 Description: CT ANGIO LWR EXTR W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73706 RADIO DEF RBRVS 09/01/2019 12/31/2023 263.34 Description: CT ANGIO LWR EXTR W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73706 TC RADIO DEF RBRVS 01/01/2024 228.47 Description: CT ANGIO LWR EXTR W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73706 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 193.63 Description: CT ANGIO LWR EXTR W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73718 26 RADIO DEF RBRVS 01/01/2024 62.00 Description: MRI LOWER EXTREMITY W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73718 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 49.73 Description: MRI LOWER EXTREMITY W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73718 RADIO DEF RBRVS 01/01/2024 218.84 Description: MRI LOWER EXTREMITY W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73718 RADIO DEF RBRVS 09/01/2019 12/31/2023 258.72 Description: MRI LOWER EXTREMITY W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73718 TC RADIO DEF RBRVS 01/01/2024 156.84 Description: MRI LOWER EXTREMITY W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73718 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 208.99 Description: MRI LOWER EXTREMITY W/O DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73719 26 RADIO DEF RBRVS 01/01/2024 74.40 Description: MRI LOWER EXTREMITY W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 919 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73719 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 60.04 Description: MRI LOWER EXTREMITY W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73719 RADIO DEF RBRVS 01/01/2024 257.17 Description: MRI LOWER EXTREMITY W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73719 RADIO DEF RBRVS 09/01/2019 12/31/2023 295.29 Description: MRI LOWER EXTREMITY W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73719 TC RADIO DEF RBRVS 01/01/2024 182.77 Description: MRI LOWER EXTREMITY W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73719 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 235.25 Description: MRI LOWER EXTREMITY W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73720 26 RADIO DEF RBRVS 01/01/2024 98.71 Description: MRI LWR EXTREMITY W/O&W/DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 73720 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 78.90 Description: MRI LWR EXTREMITY W/O&W/DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 73720 RADIO DEF RBRVS 01/01/2024 330.89 Description: MRI LWR EXTREMITY W/O&W/DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 73720 RADIO DEF RBRVS 09/01/2019 12/31/2023 363.45 Description: MRI LWR EXTREMITY W/O&W/DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 73720 TC RADIO DEF RBRVS 01/01/2024 232.18 Description: MRI LWR EXTREMITY W/O&W/DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 73720 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 284.54 Description: MRI LWR EXTREMITY W/O&W/DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 73721 26 RADIO DEF RBRVS 01/01/2024 62.31 Description: MRI JNT OF LWR EXTRE W/O DYE Category: Radiology CMS Add: 01/01/1989 CMS Term: 73721 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 50.56 Description: MRI JNT OF LWR EXTRE W/O DYE Category: Radiology CMS Add: 01/01/1989 CMS Term: 73721 RADIO DEF RBRVS 01/01/2024 197.54 Description: MRI JNT OF LWR EXTRE W/O DYE Category: Radiology CMS Add: 01/01/1989 CMS Term: 73721 RADIO DEF RBRVS 09/01/2019 12/31/2023 180.03 Description: MRI JNT OF LWR EXTRE W/O DYE Category: Radiology CMS Add: 01/01/1989 CMS Term: 73721 TC RADIO DEF RBRVS 01/01/2024 135.23 Description: MRI JNT OF LWR EXTRE W/O DYE Category: Radiology CMS Add: 01/01/1989 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 920 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73721 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 129.47 Description: MRI JNT OF LWR EXTRE W/O DYE Category: Radiology CMS Add: 01/01/1989 CMS Term: 73722 26 RADIO DEF RBRVS 01/01/2024 74.71 Description: MRI JOINT OF LWR EXTR W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73722 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 60.21 Description: MRI JOINT OF LWR EXTR W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73722 RADIO DEF RBRVS 01/01/2024 307.18 Description: MRI JOINT OF LWR EXTR W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73722 RADIO DEF RBRVS 09/01/2019 12/31/2023 278.61 Description: MRI JOINT OF LWR EXTR W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73722 TC RADIO DEF RBRVS 01/01/2024 232.47 Description: MRI JOINT OF LWR EXTR W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73722 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 218.40 Description: MRI JOINT OF LWR EXTR W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73723 26 RADIO DEF RBRVS 01/01/2024 98.71 Description: MRI JOINT LWR EXTR W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73723 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 79.15 Description: MRI JOINT LWR EXTR W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73723 RADIO DEF RBRVS 01/01/2024 378.74 Description: MRI JOINT LWR EXTR W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73723 RADIO DEF RBRVS 09/01/2019 12/31/2023 342.14 Description: MRI JOINT LWR EXTR W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73723 TC RADIO DEF RBRVS 01/01/2024 280.03 Description: MRI JOINT LWR EXTR W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73723 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 262.99 Description: MRI JOINT LWR EXTR W/O&W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 73725 26 RADIO DEF RBRVS 01/01/2024 82.42 Description: MR ANG LWR EXT W OR W/O DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: 73725 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 66.65 Description: MR ANG LWR EXT W OR W/O DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: 73725 RADIO DEF RBRVS 01/01/2024 327.26 Description: MR ANG LWR EXT W OR W/O DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 921 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 73725 RADIO DEF RBRVS 09/01/2019 12/31/2023 297.19 Description: MR ANG LWR EXT W OR W/O DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: 73725 TC RADIO DEF RBRVS 01/01/2024 244.84 Description: MR ANG LWR EXT W OR W/O DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: 73725 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 230.54 Description: MR ANG LWR EXT W OR W/O DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: 74018 26 MRT DEF RBRVS 01/01/2018 8.42 Description: X-RAY EXAM ABDOMEN 1 VIEW Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 74018 26 RADIO DEF RBRVS 01/01/2018 8.42 Description: X-RAY EXAM ABDOMEN 1 VIEW Category: Radiology CMS Add: 01/01/2018 CMS Term: 74018 MRT DEF RBRVS 01/01/2018 12/31/2023 19.29 Description: X-RAY EXAM ABDOMEN 1 VIEW Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 74018 MRT DEF RBRVS 01/01/2024 28.03 Description: X-RAY EXAM ABDOMEN 1 VIEW Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 74018 RADIO DEF RBRVS 01/01/2018 12/31/2023 19.29 Description: X-RAY EXAM ABDOMEN 1 VIEW Category: Radiology CMS Add: 01/01/2018 CMS Term: 74018 RADIO DEF RBRVS 01/01/2024 28.03 Description: X-RAY EXAM ABDOMEN 1 VIEW Category: Radiology CMS Add: 01/01/2018 CMS Term: 74018 TC MRT DEF RBRVS 01/01/2018 12/31/2023 12.55 Description: X-RAY EXAM ABDOMEN 1 VIEW Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 74018 TC MRT DEF RBRVS 01/01/2024 19.61 Description: X-RAY EXAM ABDOMEN 1 VIEW Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 74018 TC RADIO DEF RBRVS 01/01/2018 12/31/2023 12.55 Description: X-RAY EXAM ABDOMEN 1 VIEW Category: Radiology CMS Add: 01/01/2018 CMS Term: 74018 TC RADIO DEF RBRVS 01/01/2024 19.61 Description: X-RAY EXAM ABDOMEN 1 VIEW Category: Radiology CMS Add: 01/01/2018 CMS Term: 74019 26 MRT DEF RBRVS 01/01/2018 10.73 Description: X-RAY EXAM ABDOMEN 2 VIEWS Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 74019 26 RADIO DEF RBRVS 01/01/2018 10.73 Description: X-RAY EXAM ABDOMEN 2 VIEWS Category: Radiology CMS Add: 01/01/2018 CMS Term: 74019 MRT DEF RBRVS 01/01/2018 12/31/2023 23.60 Description: X-RAY EXAM ABDOMEN 2 VIEWS Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 922 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 74019 MRT DEF RBRVS 01/01/2024 34.67 Description: X-RAY EXAM ABDOMEN 2 VIEWS Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 74019 RADIO DEF RBRVS 01/01/2018 12/31/2023 23.60 Description: X-RAY EXAM ABDOMEN 2 VIEWS Category: Radiology CMS Add: 01/01/2018 CMS Term: 74019 RADIO DEF RBRVS 01/01/2024 34.67 Description: X-RAY EXAM ABDOMEN 2 VIEWS Category: Radiology CMS Add: 01/01/2018 CMS Term: 74019 TC MRT DEF RBRVS 01/01/2018 12/31/2023 15.03 Description: X-RAY EXAM ABDOMEN 2 VIEWS Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 74019 TC MRT DEF RBRVS 01/01/2024 23.93 Description: X-RAY EXAM ABDOMEN 2 VIEWS Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 74019 TC RADIO DEF RBRVS 01/01/2018 12/31/2023 15.03 Description: X-RAY EXAM ABDOMEN 2 VIEWS Category: Radiology CMS Add: 01/01/2018 CMS Term: 74019 TC RADIO DEF RBRVS 01/01/2024 23.93 Description: X-RAY EXAM ABDOMEN 2 VIEWS Category: Radiology CMS Add: 01/01/2018 CMS Term: 74021 26 MRT DEF RBRVS 01/01/2018 12/31/2023 10.06 Description: X-RAY EXAM ABDOMEN 3+ VIEWS Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 74021 26 MRT DEF RBRVS 01/01/2024 12.40 Description: X-RAY EXAM ABDOMEN 3+ VIEWS Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 74021 26 RADIO DEF RBRVS 01/01/2018 12/31/2023 10.06 Description: X-RAY EXAM ABDOMEN 3+ VIEWS Category: Radiology CMS Add: 01/01/2018 CMS Term: 74021 26 RADIO DEF RBRVS 01/01/2024 12.40 Description: X-RAY EXAM ABDOMEN 3+ VIEWS Category: Radiology CMS Add: 01/01/2018 CMS Term: 74021 MRT DEF RBRVS 01/01/2018 12/31/2023 27.57 Description: X-RAY EXAM ABDOMEN 3+ VIEWS Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 74021 MRT DEF RBRVS 01/01/2024 40.34 Description: X-RAY EXAM ABDOMEN 3+ VIEWS Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 74021 RADIO DEF RBRVS 01/01/2018 12/31/2023 27.57 Description: X-RAY EXAM ABDOMEN 3+ VIEWS Category: Radiology CMS Add: 01/01/2018 CMS Term: 74021 RADIO DEF RBRVS 01/01/2024 40.34 Description: X-RAY EXAM ABDOMEN 3+ VIEWS Category: Radiology CMS Add: 01/01/2018 CMS Term: 74021 TC MRT DEF RBRVS 01/01/2018 12/31/2023 17.51 Description: X-RAY EXAM ABDOMEN 3+ VIEWS Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 923 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 74021 TC MRT DEF RBRVS 01/01/2024 27.95 Description: X-RAY EXAM ABDOMEN 3+ VIEWS Category: Medical Review Team CMS Add: 01/01/2018 CMS Term: 74021 TC RADIO DEF RBRVS 01/01/2018 12/31/2023 17.51 Description: X-RAY EXAM ABDOMEN 3+ VIEWS Category: Radiology CMS Add: 01/01/2018 CMS Term: 74021 TC RADIO DEF RBRVS 01/01/2024 27.95 Description: X-RAY EXAM ABDOMEN 3+ VIEWS Category: Radiology CMS Add: 01/01/2018 CMS Term: 74022 26 MRT DEF RBRVS 01/01/2024 14.87 Description: X-RAY EXAM COMPLETE ABDOMEN Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 74022 26 MRT DEF RBRVS 02/01/2015 12/31/2023 11.74 Description: X-RAY EXAM COMPLETE ABDOMEN Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 74022 26 RADIO DEF RBRVS 01/01/2024 14.87 Description: X-RAY EXAM COMPLETE ABDOMEN Category: Radiology CMS Add: 01/01/1984 CMS Term: 74022 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 11.74 Description: X-RAY EXAM COMPLETE ABDOMEN Category: Radiology CMS Add: 01/01/1984 CMS Term: 74022 MRT DEF RBRVS 01/01/2024 46.83 Description: X-RAY EXAM COMPLETE ABDOMEN Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 74022 MRT DEF RBRVS 02/01/2015 12/31/2023 35.19 Description: X-RAY EXAM COMPLETE ABDOMEN Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 74022 RADIO DEF RBRVS 01/01/2024 46.83 Description: X-RAY EXAM COMPLETE ABDOMEN Category: Radiology CMS Add: 01/01/1984 CMS Term: 74022 RADIO DEF RBRVS 02/01/2015 12/31/2023 35.19 Description: X-RAY EXAM COMPLETE ABDOMEN Category: Radiology CMS Add: 01/01/1984 CMS Term: 74022 TC MRT DEF RBRVS 01/01/2024 31.96 Description: X-RAY EXAM COMPLETE ABDOMEN Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 74022 TC MRT DEF RBRVS 02/01/2015 12/31/2023 23.45 Description: X-RAY EXAM COMPLETE ABDOMEN Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 74022 TC RADIO DEF RBRVS 01/01/2024 31.96 Description: X-RAY EXAM COMPLETE ABDOMEN Category: Radiology CMS Add: 01/01/1984 CMS Term: 74022 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 23.45 Description: X-RAY EXAM COMPLETE ABDOMEN Category: Radiology CMS Add: 01/01/1984 CMS Term: 74150 26 RADIO DEF RBRVS 01/01/2024 54.57 Description: CT ABDOMEN W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 924 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 74150 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 44.03 Description: CT ABDOMEN W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 74150 RADIO DEF RBRVS 01/01/2024 133.45 Description: CT ABDOMEN W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 74150 RADIO DEF RBRVS 09/01/2019 12/31/2023 109.84 Description: CT ABDOMEN W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 74150 TC RADIO DEF RBRVS 01/01/2024 78.88 Description: CT ABDOMEN W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 74150 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 65.81 Description: CT ABDOMEN W/O DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 74160 26 RADIO DEF RBRVS 01/01/2024 58.36 Description: CT ABDOMEN W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 74160 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 46.92 Description: CT ABDOMEN W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 74160 RADIO DEF RBRVS 01/01/2024 228.48 Description: CT ABDOMEN W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 74160 RADIO DEF RBRVS 09/01/2019 12/31/2023 169.70 Description: CT ABDOMEN W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 74160 TC RADIO DEF RBRVS 01/01/2024 170.11 Description: CT ABDOMEN W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 74160 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 122.78 Description: CT ABDOMEN W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 74170 26 RADIO DEF RBRVS 01/01/2024 64.00 Description: CT ABDOMEN W/O & W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 74170 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 51.57 Description: CT ABDOMEN W/O & W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 74170 RADIO DEF RBRVS 01/01/2024 256.35 Description: CT ABDOMEN W/O & W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 74170 RADIO DEF RBRVS 09/01/2019 12/31/2023 195.90 Description: CT ABDOMEN W/O & W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 74170 TC RADIO DEF RBRVS 01/01/2024 192.34 Description: CT ABDOMEN W/O & W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 925 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 74170 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 144.34 Description: CT ABDOMEN W/O & W/DYE Category: Radiology CMS Add: 01/01/1984 CMS Term: 74174 26 RADIO DEF RBRVS 01/01/2024 100.25 Description: CT ANGIO ABD&PELV W/O&W/DYE Category: Radiology CMS Add: 01/01/2012 CMS Term: 74174 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 80.83 Description: CT ANGIO ABD&PELV W/O&W/DYE Category: Radiology CMS Add: 01/01/2012 CMS Term: 74174 RADIO DEF RBRVS 01/01/2024 370.40 Description: CT ANGIO ABD&PELV W/O&W/DYE Category: Radiology CMS Add: 01/01/2012 CMS Term: 74174 RADIO DEF RBRVS 02/01/2015 12/31/2023 382.71 Description: CT ANGIO ABD&PELV W/O&W/DYE Category: Radiology CMS Add: 01/01/2012 CMS Term: 74174 TC RADIO DEF RBRVS 01/01/2024 270.15 Description: CT ANGIO ABD&PELV W/O&W/DYE Category: Radiology CMS Add: 01/01/2012 CMS Term: 74174 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 301.88 Description: CT ANGIO ABD&PELV W/O&W/DYE Category: Radiology CMS Add: 01/01/2012 CMS Term: 74175 26 RADIO DEF RBRVS 01/01/2024 83.04 Description: CT ANGIO ABDOM W/O & W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 74175 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 69.96 Description: CT ANGIO ABDOM W/O & W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 74175 RADIO DEF RBRVS 01/01/2024 298.55 Description: CT ANGIO ABDOM W/O & W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 74175 RADIO DEF RBRVS 09/01/2019 12/31/2023 273.00 Description: CT ANGIO ABDOM W/O & W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 74175 TC RADIO DEF RBRVS 01/01/2024 215.51 Description: CT ANGIO ABDOM W/O & W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 74175 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 203.04 Description: CT ANGIO ABDOM W/O & W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 74176 26 RADIO DEF RBRVS 01/01/2024 80.02 Description: CT ABD & PELVIS W/O CONTRAST Category: Radiology CMS Add: 01/01/2011 CMS Term: 74176 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 64.25 Description: CT ABD & PELVIS W/O CONTRAST Category: Radiology CMS Add: 01/01/2011 CMS Term: 74176 RADIO DEF RBRVS 01/01/2024 178.82 Description: CT ABD & PELVIS W/O CONTRAST Category: Radiology CMS Add: 01/01/2011 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 926 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 74176 RADIO DEF RBRVS 02/01/2015 12/31/2023 154.09 Description: CT ABD & PELVIS W/O CONTRAST Category: Radiology CMS Add: 01/01/2011 CMS Term: 74176 TC RADIO DEF RBRVS 01/01/2024 98.80 Description: CT ABD & PELVIS W/O CONTRAST Category: Radiology CMS Add: 01/01/2011 CMS Term: 74176 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 89.84 Description: CT ABD & PELVIS W/O CONTRAST Category: Radiology CMS Add: 01/01/2011 CMS Term: 74177 26 RADIO DEF RBRVS 01/01/2024 83.66 Description: CT ABD & PELV W/CONTRAST Category: Radiology CMS Add: 01/01/2011 CMS Term: 74177 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 67.15 Description: CT ABD & PELV W/CONTRAST Category: Radiology CMS Add: 01/01/2011 CMS Term: 74177 RADIO DEF RBRVS 01/01/2024 297.61 Description: CT ABD & PELV W/CONTRAST Category: Radiology CMS Add: 01/01/2011 CMS Term: 74177 RADIO DEF RBRVS 02/01/2015 12/31/2023 229.32 Description: CT ABD & PELV W/CONTRAST Category: Radiology CMS Add: 01/01/2011 CMS Term: 74177 TC RADIO DEF RBRVS 01/01/2024 213.95 Description: CT ABD & PELV W/CONTRAST Category: Radiology CMS Add: 01/01/2011 CMS Term: 74177 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 162.17 Description: CT ABD & PELV W/CONTRAST Category: Radiology CMS Add: 01/01/2011 CMS Term: 74178 26 RADIO DEF RBRVS 01/01/2024 91.95 Description: CT ABD & PELV 1/> REGNS Category: Radiology CMS Add: 01/01/2011 CMS Term: 74178 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 74.15 Description: CT ABD & PELV 1/> REGNS Category: Radiology CMS Add: 01/01/2011 CMS Term: 74178 RADIO DEF RBRVS 01/01/2024 333.38 Description: CT ABD & PELV 1/> REGNS Category: Radiology CMS Add: 01/01/2011 CMS Term: 74178 RADIO DEF RBRVS 02/01/2015 12/31/2023 266.79 Description: CT ABD & PELV 1/> REGNS Category: Radiology CMS Add: 01/01/2011 CMS Term: 74178 TC RADIO DEF RBRVS 01/01/2024 241.43 Description: CT ABD & PELV 1/> REGNS Category: Radiology CMS Add: 01/01/2011 CMS Term: 74178 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 192.64 Description: CT ABD & PELV 1/> REGNS Category: Radiology CMS Add: 01/01/2011 CMS Term: 74181 26 RADIO DEF RBRVS 01/01/2024 67.12 Description: MRI ABDOMEN W/O DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 927 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 74181 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 53.68 Description: MRI ABDOMEN W/O DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 74181 RADIO DEF RBRVS 01/01/2024 192.17 Description: MRI ABDOMEN W/O DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 74181 RADIO DEF RBRVS 09/01/2019 12/31/2023 237.65 Description: MRI ABDOMEN W/O DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 74181 TC RADIO DEF RBRVS 01/01/2024 125.04 Description: MRI ABDOMEN W/O DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 74181 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 183.97 Description: MRI ABDOMEN W/O DYE Category: Radiology CMS Add: 01/01/1986 CMS Term: 74182 26 RADIO DEF RBRVS 01/01/2024 79.37 Description: MRI ABDOMEN W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 74182 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 63.74 Description: MRI ABDOMEN W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 74182 RADIO DEF RBRVS 01/01/2024 296.43 Description: MRI ABDOMEN W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 74182 RADIO DEF RBRVS 09/01/2019 12/31/2023 326.98 Description: MRI ABDOMEN W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 74182 TC RADIO DEF RBRVS 01/01/2024 217.05 Description: MRI ABDOMEN W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 74182 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 263.24 Description: MRI ABDOMEN W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 74183 26 RADIO DEF RBRVS 01/01/2024 100.71 Description: MRI ABDOMEN W/O & W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 74183 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 83.10 Description: MRI ABDOMEN W/O & W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 74183 RADIO DEF RBRVS 01/01/2024 331.96 Description: MRI ABDOMEN W/O & W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 74183 RADIO DEF RBRVS 09/01/2019 12/31/2023 366.65 Description: MRI ABDOMEN W/O & W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 74183 TC RADIO DEF RBRVS 01/01/2024 231.25 Description: MRI ABDOMEN W/O & W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 928 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 74183 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 283.55 Description: MRI ABDOMEN W/O & W/DYE Category: Radiology CMS Add: 01/01/2001 CMS Term: 74185 26 RADIO DEF RBRVS 01/01/2024 82.06 Description: MRI ANGIO ABDOM W ORW/O DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: 74185 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 66.11 Description: MRI ANGIO ABDOM W ORW/O DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: 74185 RADIO DEF RBRVS 01/01/2024 329.05 Description: MRI ANGIO ABDOM W ORW/O DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: 74185 RADIO DEF RBRVS 09/01/2019 12/31/2023 297.15 Description: MRI ANGIO ABDOM W ORW/O DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: 74185 TC RADIO DEF RBRVS 01/01/2024 247.00 Description: MRI ANGIO ABDOM W ORW/O DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: 74185 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 231.04 Description: MRI ANGIO ABDOM W ORW/O DYE Category: Radiology CMS Add: 01/01/1994 CMS Term: 74190 26 RADIO DEF RBRVS 01/01/2024 21.23 Description: X-RAY EXAM OF PERITONEUM Category: Radiology CMS Add: 01/01/1994 CMS Term: 74190 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 17.52 Description: X-RAY EXAM OF PERITONEUM Category: Radiology CMS Add: 01/01/1994 CMS Term: 74190 RADIO DEF MAXFEE 01/01/2024 75.51 0.0 Description: X-RAY EXAM OF PERITONEUM Category: Radiology CMS Add: 01/01/1994 CMS Term: 74190 RADIO DEF RBRVS 02/01/2015 12/31/2023 44.43 Description: X-RAY EXAM OF PERITONEUM Category: Radiology CMS Add: 01/01/1994 CMS Term: 74190 TC RADIO DEF MAXFEE 01/01/2024 51.03 0.0 Description: X-RAY EXAM OF PERITONEUM Category: Radiology CMS Add: 01/01/1994 CMS Term: 74190 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 32.29 Description: X-RAY EXAM OF PERITONEUM Category: Radiology CMS Add: 01/01/1994 CMS Term: 74210 26 RADIO DEF RBRVS 01/01/2024 27.12 Description: X-RAY XM PHRNX&/CRV ESOPH C+ Category: Radiology CMS Add: 01/01/1984 CMS Term: 74210 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 13.06 Description: X-RAY XM PHRNX&/CRV ESOPH C+ Category: Radiology CMS Add: 01/01/1984 CMS Term: 74210 RADIO DEF RBRVS 01/01/2024 91.18 Description: X-RAY XM PHRNX&/CRV ESOPH C+ Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 929 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 74210 RADIO DEF RBRVS 02/01/2015 12/31/2023 56.08 Description: X-RAY XM PHRNX&/CRV ESOPH C+ Category: Radiology CMS Add: 01/01/1984 CMS Term: 74210 TC RADIO DEF RBRVS 01/01/2024 64.06 Description: X-RAY XM PHRNX&/CRV ESOPH C+ Category: Radiology CMS Add: 01/01/1984 CMS Term: 74210 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 43.02 Description: X-RAY XM PHRNX&/CRV ESOPH C+ Category: Radiology CMS Add: 01/01/1984 CMS Term: 74220 26 RADIO DEF RBRVS 01/01/2024 27.77 Description: X-RAY XM ESOPHAGUS 1CNTRST Category: Radiology CMS Add: 01/01/1984 CMS Term: 74220 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 17.07 Description: X-RAY XM ESOPHAGUS 1CNTRST Category: Radiology CMS Add: 01/01/1984 CMS Term: 74220 RADIO DEF RBRVS 01/01/2024 93.38 Description: X-RAY XM ESOPHAGUS 1CNTRST Category: Radiology CMS Add: 01/01/1984 CMS Term: 74220 RADIO DEF RBRVS 02/01/2015 12/31/2023 65.54 Description: X-RAY XM ESOPHAGUS 1CNTRST Category: Radiology CMS Add: 01/01/1984 CMS Term: 74220 TC RADIO DEF RBRVS 01/01/2024 65.61 Description: X-RAY XM ESOPHAGUS 1CNTRST Category: Radiology CMS Add: 01/01/1984 CMS Term: 74220 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 48.47 Description: X-RAY XM ESOPHAGUS 1CNTRST Category: Radiology CMS Add: 01/01/1984 CMS Term: 74221 26 RADIO DEF RBRVS 01/01/2020 12/31/2023 25.74 Description: X-RAY XM ESOPHAGUS 2CNTRST Category: Radiology CMS Add: 01/01/2020 CMS Term: 74221 26 RADIO DEF RBRVS 01/01/2024 32.08 Description: X-RAY XM ESOPHAGUS 2CNTRST Category: Radiology CMS Add: 01/01/2020 CMS Term: 74221 RADIO DEF RBRVS 01/01/2020 12/31/2023 76.94 Description: X-RAY XM ESOPHAGUS 2CNTRST Category: Radiology CMS Add: 01/01/2020 CMS Term: 74221 RADIO DEF RBRVS 01/01/2024 105.10 Description: X-RAY XM ESOPHAGUS 2CNTRST Category: Radiology CMS Add: 01/01/2020 CMS Term: 74221 TC RADIO DEF RBRVS 01/01/2020 12/31/2023 51.19 Description: X-RAY XM ESOPHAGUS 2CNTRST Category: Radiology CMS Add: 01/01/2020 CMS Term: 74221 TC RADIO DEF RBRVS 01/01/2024 73.02 Description: X-RAY XM ESOPHAGUS 2CNTRST Category: Radiology CMS Add: 01/01/2020 CMS Term: 74230 26 RADIO DEF RBRVS 01/01/2024 24.47 Description: X-RAY XM SWLNG FUNCJ C+ Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 930 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 74230 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 19.69 Description: X-RAY XM SWLNG FUNCJ C+ Category: Radiology CMS Add: 01/01/1984 CMS Term: 74230 RADIO DEF RBRVS 01/01/2024 118.79 Description: X-RAY XM SWLNG FUNCJ C+ Category: Radiology CMS Add: 01/01/1984 CMS Term: 74230 RADIO DEF RBRVS 02/01/2015 12/31/2023 65.68 Description: X-RAY XM SWLNG FUNCJ C+ Category: Radiology CMS Add: 01/01/1984 CMS Term: 74230 TC RADIO DEF RBRVS 01/01/2024 94.32 Description: X-RAY XM SWLNG FUNCJ C+ Category: Radiology CMS Add: 01/01/1984 CMS Term: 74230 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 45.99 Description: X-RAY XM SWLNG FUNCJ C+ Category: Radiology CMS Add: 01/01/1984 CMS Term: 74235 26 RADIO DEF RBRVS 01/01/2024 54.87 Description: REMOVE ESOPHAGUS OBSTRUCTION Category: Radiology CMS Add: 01/01/1985 CMS Term: 74235 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 42.29 Description: REMOVE ESOPHAGUS OBSTRUCTION Category: Radiology CMS Add: 01/01/1985 CMS Term: 74235 RADIO DEF MAXFEE 01/01/2024 169.60 0.0 Description: REMOVE ESOPHAGUS OBSTRUCTION Category: Radiology CMS Add: 01/01/1985 CMS Term: 74235 RADIO DEF RBRVS 02/01/2015 12/31/2023 112.17 Description: REMOVE ESOPHAGUS OBSTRUCTION Category: Radiology CMS Add: 01/01/1985 CMS Term: 74235 TC RADIO DEF MAXFEE 01/01/2024 104.03 0.0 Description: REMOVE ESOPHAGUS OBSTRUCTION Category: Radiology CMS Add: 01/01/1985 CMS Term: 74235 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 65.48 Description: REMOVE ESOPHAGUS OBSTRUCTION Category: Radiology CMS Add: 01/01/1985 CMS Term: 74240 26 RADIO DEF RBRVS 01/01/2024 37.01 Description: X-RAY XM UPR GI TRC 1CNTRST Category: Radiology CMS Add: 01/01/1984 CMS Term: 74240 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 25.64 Description: X-RAY XM UPR GI TRC 1CNTRST Category: Radiology CMS Add: 01/01/1984 CMS Term: 74240 RADIO DEF RBRVS 01/01/2024 117.13 Description: X-RAY XM UPR GI TRC 1CNTRST Category: Radiology CMS Add: 01/01/1984 CMS Term: 74240 RADIO DEF RBRVS 02/01/2015 12/31/2023 82.28 Description: X-RAY XM UPR GI TRC 1CNTRST Category: Radiology CMS Add: 01/01/1984 CMS Term: 74240 TC RADIO DEF RBRVS 01/01/2024 80.12 Description: X-RAY XM UPR GI TRC 1CNTRST Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 931 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 74240 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 56.64 Description: X-RAY XM UPR GI TRC 1CNTRST Category: Radiology CMS Add: 01/01/1984 CMS Term: 74246 26 RADIO DEF RBRVS 01/01/2024 41.02 Description: X-RAY XM UPR GI TRC 2CNTRST Category: Radiology CMS Add: 01/01/1984 CMS Term: 74246 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 25.39 Description: X-RAY XM UPR GI TRC 2CNTRST Category: Radiology CMS Add: 01/01/1984 CMS Term: 74246 RADIO DEF RBRVS 01/01/2024 132.87 Description: X-RAY XM UPR GI TRC 2CNTRST Category: Radiology CMS Add: 01/01/1984 CMS Term: 74246 RADIO DEF RBRVS 02/01/2015 12/31/2023 92.44 Description: X-RAY XM UPR GI TRC 2CNTRST Category: Radiology CMS Add: 01/01/1984 CMS Term: 74246 TC RADIO DEF RBRVS 01/01/2024 91.85 Description: X-RAY XM UPR GI TRC 2CNTRST Category: Radiology CMS Add: 01/01/1984 CMS Term: 74246 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 67.05 Description: X-RAY XM UPR GI TRC 2CNTRST Category: Radiology CMS Add: 01/01/1984 CMS Term: 74248 26 RADIO DEF RBRVS 01/01/2020 12/31/2023 25.74 Description: X-RAY SM INT F-THRU STD Category: Radiology CMS Add: 01/01/2020 CMS Term: 74248 26 RADIO DEF RBRVS 01/01/2024 32.08 Description: X-RAY SM INT F-THRU STD Category: Radiology CMS Add: 01/01/2020 CMS Term: 74248 RADIO DEF RBRVS 01/01/2020 12/31/2023 58.69 Description: X-RAY SM INT F-THRU STD Category: Radiology CMS Add: 01/01/2020 CMS Term: 74248 RADIO DEF RBRVS 01/01/2024 78.86 Description: X-RAY SM INT F-THRU STD Category: Radiology CMS Add: 01/01/2020 CMS Term: 74248 TC RADIO DEF RBRVS 01/01/2020 12/31/2023 32.95 Description: X-RAY SM INT F-THRU STD Category: Radiology CMS Add: 01/01/2020 CMS Term: 74248 TC RADIO DEF RBRVS 01/01/2024 46.78 Description: X-RAY SM INT F-THRU STD Category: Radiology CMS Add: 01/01/2020 CMS Term: 74250 26 RADIO DEF RBRVS 01/01/2024 37.05 Description: X-RAY XM SM INT 1CNTRST STD Category: Radiology CMS Add: 01/01/1984 CMS Term: 74250 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 17.33 Description: X-RAY XM SM INT 1CNTRST STD Category: Radiology CMS Add: 01/01/1984 CMS Term: 74250 RADIO DEF RBRVS 01/01/2024 116.55 Description: X-RAY XM SM INT 1CNTRST STD Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 932 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 74250 RADIO DEF RBRVS 02/01/2015 12/31/2023 77.45 Description: X-RAY XM SM INT 1CNTRST STD Category: Radiology CMS Add: 01/01/1984 CMS Term: 74250 TC RADIO DEF RBRVS 01/01/2024 79.50 Description: X-RAY XM SM INT 1CNTRST STD Category: Radiology CMS Add: 01/01/1984 CMS Term: 74250 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 60.11 Description: X-RAY XM SM INT 1CNTRST STD Category: Radiology CMS Add: 01/01/1984 CMS Term: 74251 26 RADIO DEF RBRVS 01/01/2024 53.89 Description: X-RAY XM SM INT 2CNTRST STD Category: Radiology CMS Add: 01/01/1994 CMS Term: 74251 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 25.39 Description: X-RAY XM SM INT 2CNTRST STD Category: Radiology CMS Add: 01/01/1994 CMS Term: 74251 RADIO DEF RBRVS 01/01/2024 349.18 Description: X-RAY XM SM INT 2CNTRST STD Category: Radiology CMS Add: 01/01/1994 CMS Term: 74251 RADIO DEF RBRVS 02/01/2015 12/31/2023 294.08 Description: X-RAY XM SM INT 2CNTRST STD Category: Radiology CMS Add: 01/01/1994 CMS Term: 74251 TC RADIO DEF RBRVS 01/01/2024 295.29 Description: X-RAY XM SM INT 2CNTRST STD Category: Radiology CMS Add: 01/01/1994 CMS Term: 74251 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 268.69 Description: X-RAY XM SM INT 2CNTRST STD Category: Radiology CMS Add: 01/01/1994 CMS Term: 74261 NOCOV DEF SYSMAN Description: CT COLONOGRAPHY DX Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 74262 NOCOV DEF SYSMAN Description: CT COLONOGRAPHY DX W/DYE Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 74263 26 RADIO DEF RBRVS 01/01/2024 105.07 Description: CT COLONOGRAPHY SCREENING Category: Radiology CMS Add: 01/01/2010 CMS Term: 74263 26 RADIO DEF RBRVS 08/30/2022 12/31/2023 84.71 Description: CT COLONOGRAPHY SCREENING Category: Radiology CMS Add: 01/01/2010 CMS Term: 74263 RADIO DEF RBRVS 01/01/2024 640.41 Description: CT COLONOGRAPHY SCREENING Category: Radiology CMS Add: 01/01/2010 CMS Term: 74263 RADIO DEF RBRVS 08/30/2022 12/31/2023 528.70 Description: CT COLONOGRAPHY SCREENING Category: Radiology CMS Add: 01/01/2010 CMS Term: 74263 TC RADIO DEF RBRVS 01/01/2024 535.33 Description: CT COLONOGRAPHY SCREENING Category: Radiology CMS Add: 01/01/2010 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 933 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 74263 TC RADIO DEF RBRVS 08/30/2022 12/31/2023 443.99 Description: CT COLONOGRAPHY SCREENING Category: Radiology CMS Add: 01/01/2010 CMS Term: 74270 26 RADIO DEF RBRVS 01/01/2024 47.62 Description: X-RAY XM COLON 1CNTRST STD Category: Radiology CMS Add: 01/01/1984 CMS Term: 74270 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 25.39 Description: X-RAY XM COLON 1CNTRST STD Category: Radiology CMS Add: 01/01/1984 CMS Term: 74270 RADIO DEF RBRVS 01/01/2024 146.57 Description: X-RAY XM COLON 1CNTRST STD Category: Radiology CMS Add: 01/01/1984 CMS Term: 74270 RADIO DEF RBRVS 02/01/2015 12/31/2023 112.75 Description: X-RAY XM COLON 1CNTRST STD Category: Radiology CMS Add: 01/01/1984 CMS Term: 74270 TC RADIO DEF RBRVS 01/01/2024 98.95 Description: X-RAY XM COLON 1CNTRST STD Category: Radiology CMS Add: 01/01/1984 CMS Term: 74270 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 87.36 Description: X-RAY XM COLON 1CNTRST STD Category: Radiology CMS Add: 01/01/1984 CMS Term: 74280 26 RADIO DEF RBRVS 01/01/2024 57.72 Description: X-RAY XM COLON 2CNTRST STD Category: Radiology CMS Add: 01/01/1984 CMS Term: 74280 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 36.34 Description: X-RAY XM COLON 2CNTRST STD Category: Radiology CMS Add: 01/01/1984 CMS Term: 74280 RADIO DEF RBRVS 01/01/2024 210.23 Description: X-RAY XM COLON 2CNTRST STD Category: Radiology CMS Add: 01/01/1984 CMS Term: 74280 RADIO DEF RBRVS 02/01/2015 12/31/2023 157.64 Description: X-RAY XM COLON 2CNTRST STD Category: Radiology CMS Add: 01/01/1984 CMS Term: 74280 TC RADIO DEF RBRVS 01/01/2024 152.52 Description: X-RAY XM COLON 2CNTRST STD Category: Radiology CMS Add: 01/01/1984 CMS Term: 74280 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 121.30 Description: X-RAY XM COLON 2CNTRST STD Category: Radiology CMS Add: 01/01/1984 CMS Term: 74283 26 RADIO DEF RBRVS 01/01/2024 95.85 Description: THER NMA RDCTJ INTUS/OBSTRCJ Category: Radiology CMS Add: 01/01/1990 CMS Term: 74283 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 73.43 Description: THER NMA RDCTJ INTUS/OBSTRCJ Category: Radiology CMS Add: 01/01/1990 CMS Term: 74283 RADIO DEF RBRVS 01/01/2024 242.03 Description: THER NMA RDCTJ INTUS/OBSTRCJ Category: Radiology CMS Add: 01/01/1990 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 934 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 74283 RADIO DEF RBRVS 02/01/2015 12/31/2023 147.41 Description: THER NMA RDCTJ INTUS/OBSTRCJ Category: Radiology CMS Add: 01/01/1990 CMS Term: 74283 TC RADIO DEF RBRVS 01/01/2024 146.18 Description: THER NMA RDCTJ INTUS/OBSTRCJ Category: Radiology CMS Add: 01/01/1990 CMS Term: 74283 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 73.98 Description: THER NMA RDCTJ INTUS/OBSTRCJ Category: Radiology CMS Add: 01/01/1990 CMS Term: 74290 26 RADIO DEF RBRVS 01/01/2024 14.87 Description: CONTRAST X-RAY GALLBLADDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 74290 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 11.74 Description: CONTRAST X-RAY GALLBLADDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 74290 RADIO DEF RBRVS 01/01/2024 81.40 Description: CONTRAST X-RAY GALLBLADDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 74290 RADIO DEF RBRVS 02/01/2015 12/31/2023 50.05 Description: CONTRAST X-RAY GALLBLADDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 74290 TC RADIO DEF RBRVS 01/01/2024 66.53 Description: CONTRAST X-RAY GALLBLADDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 74290 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 38.31 Description: CONTRAST X-RAY GALLBLADDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 74300 26 RADIO DEF RBRVS 01/01/2024 12.56 Description: X-RAY BILE DUCTS/PANCREAS Category: Radiology CMS Add: 01/01/1984 CMS Term: 74300 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 13.39 Description: X-RAY BILE DUCTS/PANCREAS Category: Radiology CMS Add: 01/01/1984 CMS Term: 74301 26 RADIO DEF RBRVS 01/01/2024 9.75 Description: X-RAYS AT SURGERY ADD-ON Category: Radiology CMS Add: 01/01/1984 CMS Term: 74301 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 7.87 Description: X-RAYS AT SURGERY ADD-ON Category: Radiology CMS Add: 01/01/1984 CMS Term: 74328 26 RADIO DEF RBRVS 01/01/2024 22.11 Description: X-RAY BILE DUCT ENDOSCOPY Category: Radiology CMS Add: 01/01/1984 CMS Term: 74328 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 26.32 Description: X-RAY BILE DUCT ENDOSCOPY Category: Radiology CMS Add: 01/01/1984 CMS Term: 74328 RADIO DEF MAXFEE 01/01/2024 158.85 0.0 Description: X-RAY BILE DUCT ENDOSCOPY Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 935 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 74328 RADIO DEF RBRVS 02/01/2015 12/31/2023 106.03 Description: X-RAY BILE DUCT ENDOSCOPY Category: Radiology CMS Add: 01/01/1984 CMS Term: 74328 TC RADIO DEF MAXFEE 01/01/2024 123.15 0.0 Description: X-RAY BILE DUCT ENDOSCOPY Category: Radiology CMS Add: 01/01/1984 CMS Term: 74328 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 78.20 Description: X-RAY BILE DUCT ENDOSCOPY Category: Radiology CMS Add: 01/01/1984 CMS Term: 74329 26 RADIO DEF RBRVS 01/01/2024 22.42 Description: X-RAY FOR PANCREAS ENDOSCOPY Category: Radiology CMS Add: 01/01/1984 CMS Term: 74329 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 26.57 Description: X-RAY FOR PANCREAS ENDOSCOPY Category: Radiology CMS Add: 01/01/1984 CMS Term: 74329 RADIO DEF MAXFEE 01/01/2024 166.99 0.0 Description: X-RAY FOR PANCREAS ENDOSCOPY Category: Radiology CMS Add: 01/01/1984 CMS Term: 74329 RADIO DEF RBRVS 02/01/2015 12/31/2023 106.03 Description: X-RAY FOR PANCREAS ENDOSCOPY Category: Radiology CMS Add: 01/01/1984 CMS Term: 74329 TC RADIO DEF MAXFEE 01/01/2024 130.31 0.0 Description: X-RAY FOR PANCREAS ENDOSCOPY Category: Radiology CMS Add: 01/01/1984 CMS Term: 74329 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 78.20 Description: X-RAY FOR PANCREAS ENDOSCOPY Category: Radiology CMS Add: 01/01/1984 CMS Term: 74330 26 RADIO DEF RBRVS 01/01/2024 26.41 Description: X-RAY BILE/PANC ENDOSCOPY Category: Radiology CMS Add: 01/01/1984 CMS Term: 74330 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 34.01 Description: X-RAY BILE/PANC ENDOSCOPY Category: Radiology CMS Add: 01/01/1984 CMS Term: 74330 RADIO DEF MAXFEE 01/01/2024 168.85 0.0 Description: X-RAY BILE/PANC ENDOSCOPY Category: Radiology CMS Add: 01/01/1984 CMS Term: 74330 RADIO DEF RBRVS 02/01/2015 12/31/2023 106.03 Description: X-RAY BILE/PANC ENDOSCOPY Category: Radiology CMS Add: 01/01/1984 CMS Term: 74330 TC RADIO DEF MAXFEE 01/01/2024 123.15 0.0 Description: X-RAY BILE/PANC ENDOSCOPY Category: Radiology CMS Add: 01/01/1984 CMS Term: 74330 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 78.20 Description: X-RAY BILE/PANC ENDOSCOPY Category: Radiology CMS Add: 01/01/1984 CMS Term: 74340 26 RADIO DEF RBRVS 01/01/2024 24.81 Description: X-RAY GUIDE FOR GI TUBE Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 936 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 74340 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 20.12 Description: X-RAY GUIDE FOR GI TUBE Category: Radiology CMS Add: 01/01/1984 CMS Term: 74340 RADIO DEF MAXFEE 01/01/2024 130.19 0.0 Description: X-RAY GUIDE FOR GI TUBE Category: Radiology CMS Add: 01/01/1984 CMS Term: 74340 RADIO DEF RBRVS 02/01/2015 12/31/2023 87.11 Description: X-RAY GUIDE FOR GI TUBE Category: Radiology CMS Add: 01/01/1984 CMS Term: 74340 TC RADIO DEF MAXFEE 01/01/2024 102.45 0.0 Description: X-RAY GUIDE FOR GI TUBE Category: Radiology CMS Add: 01/01/1984 CMS Term: 74340 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 65.48 Description: X-RAY GUIDE FOR GI TUBE Category: Radiology CMS Add: 01/01/1984 CMS Term: 74355 26 RADIO DEF RBRVS 01/01/2024 35.04 Description: X-RAY GUIDE INTESTINAL TUBE Category: Radiology CMS Add: 01/01/1987 CMS Term: 74355 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 28.26 Description: X-RAY GUIDE INTESTINAL TUBE Category: Radiology CMS Add: 01/01/1987 CMS Term: 74355 RADIO DEF MAXFEE 01/01/2024 140.64 0.0 Description: X-RAY GUIDE INTESTINAL TUBE Category: Radiology CMS Add: 01/01/1987 CMS Term: 74355 RADIO DEF RBRVS 02/01/2015 12/31/2023 95.66 Description: X-RAY GUIDE INTESTINAL TUBE Category: Radiology CMS Add: 01/01/1987 CMS Term: 74355 TC RADIO DEF MAXFEE 01/01/2024 102.45 0.0 Description: X-RAY GUIDE INTESTINAL TUBE Category: Radiology CMS Add: 01/01/1987 CMS Term: 74355 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 65.48 Description: X-RAY GUIDE INTESTINAL TUBE Category: Radiology CMS Add: 01/01/1987 CMS Term: 74360 26 RADIO DEF RBRVS 01/01/2024 25.43 Description: X-RAY GUIDE GI DILATION Category: Radiology CMS Add: 01/01/1987 CMS Term: 74360 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 20.62 Description: X-RAY GUIDE GI DILATION Category: Radiology CMS Add: 01/01/1987 CMS Term: 74360 RADIO DEF MAXFEE 01/01/2024 151.66 0.0 Description: X-RAY GUIDE GI DILATION Category: Radiology CMS Add: 01/01/1987 CMS Term: 74360 RADIO DEF RBRVS 02/01/2015 12/31/2023 99.83 Description: X-RAY GUIDE GI DILATION Category: Radiology CMS Add: 01/01/1987 CMS Term: 74360 TC RADIO DEF MAXFEE 01/01/2024 123.15 0.0 Description: X-RAY GUIDE GI DILATION Category: Radiology CMS Add: 01/01/1987 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 937 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 74360 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 78.20 Description: X-RAY GUIDE GI DILATION Category: Radiology CMS Add: 01/01/1987 CMS Term: 74363 26 RADIO DEF RBRVS 01/01/2024 40.03 Description: X-RAY BILE DUCT DILATION Category: Radiology CMS Add: 01/01/1991 CMS Term: 74363 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 32.40 Description: X-RAY BILE DUCT DILATION Category: Radiology CMS Add: 01/01/1991 CMS Term: 74363 RADIO DEF MAXFEE 01/01/2024 288.88 0.0 Description: X-RAY BILE DUCT DILATION Category: Radiology CMS Add: 01/01/1991 CMS Term: 74363 RADIO DEF RBRVS 02/01/2015 12/31/2023 186.33 Description: X-RAY BILE DUCT DILATION Category: Radiology CMS Add: 01/01/1991 CMS Term: 74363 TC RADIO DEF MAXFEE 01/01/2024 240.89 0.0 Description: X-RAY BILE DUCT DILATION Category: Radiology CMS Add: 01/01/1991 CMS Term: 74363 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 151.52 Description: X-RAY BILE DUCT DILATION Category: Radiology CMS Add: 01/01/1991 CMS Term: 74400 26 RADIO DEF RBRVS 01/01/2024 22.50 Description: UROGRAPHY IV +-KUB TOMOG Category: Radiology CMS Add: 01/01/1986 CMS Term: 74400 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 18.12 Description: UROGRAPHY IV +-KUB TOMOG Category: Radiology CMS Add: 01/01/1986 CMS Term: 74400 RADIO DEF RBRVS 01/01/2024 127.16 Description: UROGRAPHY IV +-KUB TOMOG Category: Radiology CMS Add: 01/01/1986 CMS Term: 74400 RADIO DEF RBRVS 02/01/2015 12/31/2023 80.71 Description: UROGRAPHY IV +-KUB TOMOG Category: Radiology CMS Add: 01/01/1986 CMS Term: 74400 TC RADIO DEF RBRVS 01/01/2024 104.67 Description: UROGRAPHY IV +-KUB TOMOG Category: Radiology CMS Add: 01/01/1986 CMS Term: 74400 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 62.59 Description: UROGRAPHY IV +-KUB TOMOG Category: Radiology CMS Add: 01/01/1986 CMS Term: 74410 26 RADIO DEF RBRVS 01/01/2024 22.17 Description: UROGRAPHY NFS DRIP&/BOLUS Category: Radiology CMS Add: 01/01/1984 CMS Term: 74410 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 17.87 Description: UROGRAPHY NFS DRIP&/BOLUS Category: Radiology CMS Add: 01/01/1984 CMS Term: 74410 RADIO DEF RBRVS 01/01/2024 132.09 Description: UROGRAPHY NFS DRIP&/BOLUS Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 938 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 74410 RADIO DEF RBRVS 02/01/2015 12/31/2023 79.22 Description: UROGRAPHY NFS DRIP&/BOLUS Category: Radiology CMS Add: 01/01/1984 CMS Term: 74410 TC RADIO DEF RBRVS 01/01/2024 109.91 Description: UROGRAPHY NFS DRIP&/BOLUS Category: Radiology CMS Add: 01/01/1984 CMS Term: 74410 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 61.35 Description: UROGRAPHY NFS DRIP&/BOLUS Category: Radiology CMS Add: 01/01/1984 CMS Term: 74415 26 RADIO DEF RBRVS 01/01/2024 22.48 Description: UROGRAPHY NFS DRIP&/BLS W/NF Category: Radiology CMS Add: 01/01/1984 CMS Term: 74415 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 18.12 Description: UROGRAPHY NFS DRIP&/BLS W/NF Category: Radiology CMS Add: 01/01/1984 CMS Term: 74415 RADIO DEF RBRVS 01/01/2024 145.06 Description: UROGRAPHY NFS DRIP&/BLS W/NF Category: Radiology CMS Add: 01/01/1984 CMS Term: 74415 RADIO DEF RBRVS 02/01/2015 12/31/2023 98.30 Description: UROGRAPHY NFS DRIP&/BLS W/NF Category: Radiology CMS Add: 01/01/1984 CMS Term: 74415 TC RADIO DEF RBRVS 01/01/2024 122.57 Description: UROGRAPHY NFS DRIP&/BLS W/NF Category: Radiology CMS Add: 01/01/1984 CMS Term: 74415 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 80.18 Description: UROGRAPHY NFS DRIP&/BLS W/NF Category: Radiology CMS Add: 01/01/1984 CMS Term: 74420 26 RADIO DEF RBRVS 01/01/2024 23.50 Description: UROGRAPHY RTRGR +-KUB Category: Radiology CMS Add: 01/01/1984 CMS Term: 74420 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 13.39 Description: UROGRAPHY RTRGR +-KUB Category: Radiology CMS Add: 01/01/1984 CMS Term: 74420 RADIO DEF RBRVS 01/01/2024 72.44 Description: UROGRAPHY RTRGR +-KUB Category: Radiology CMS Add: 01/01/1984 CMS Term: 74420 RADIO DEF RBRVS 02/01/2015 12/31/2023 79.45 Description: UROGRAPHY RTRGR +-KUB Category: Radiology CMS Add: 01/01/1984 CMS Term: 74420 TC RADIO DEF RBRVS 01/01/2024 48.94 Description: UROGRAPHY RTRGR +-KUB Category: Radiology CMS Add: 01/01/1984 CMS Term: 74420 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 65.48 Description: UROGRAPHY RTRGR +-KUB Category: Radiology CMS Add: 01/01/1984 CMS Term: 74425 26 RADIO DEF RBRVS 01/01/2024 23.16 Description: UROGRAPHY ANTEGRADE RS&I Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 939 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 74425 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 13.14 Description: UROGRAPHY ANTEGRADE RS&I Category: Radiology CMS Add: 01/01/1984 CMS Term: 74425 RADIO DEF RBRVS 01/01/2024 128.28 Description: UROGRAPHY ANTEGRADE RS&I Category: Radiology CMS Add: 01/01/1984 CMS Term: 74425 RADIO DEF RBRVS 02/01/2015 12/31/2023 46.25 Description: UROGRAPHY ANTEGRADE RS&I Category: Radiology CMS Add: 01/01/1984 CMS Term: 74425 TC RADIO DEF RBRVS 01/01/2024 105.12 Description: UROGRAPHY ANTEGRADE RS&I Category: Radiology CMS Add: 01/01/1984 CMS Term: 74425 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 32.29 Description: UROGRAPHY ANTEGRADE RS&I Category: Radiology CMS Add: 01/01/1984 CMS Term: 74430 26 RADIO DEF RBRVS 01/01/2024 14.56 Description: CONTRAST X-RAY BLADDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 74430 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 11.49 Description: CONTRAST X-RAY BLADDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 74430 RADIO DEF RBRVS 01/01/2024 38.80 Description: CONTRAST X-RAY BLADDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 74430 RADIO DEF RBRVS 02/01/2015 12/31/2023 29.49 Description: CONTRAST X-RAY BLADDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 74430 TC RADIO DEF RBRVS 01/01/2024 24.24 Description: CONTRAST X-RAY BLADDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 74430 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 18.00 Description: CONTRAST X-RAY BLADDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 74440 26 RADIO DEF RBRVS 01/01/2024 17.05 Description: X-RAY MALE GENITAL TRACT Category: Radiology CMS Add: 01/01/1984 CMS Term: 74440 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 13.93 Description: X-RAY MALE GENITAL TRACT Category: Radiology CMS Add: 01/01/1984 CMS Term: 74440 RADIO DEF RBRVS 01/01/2024 90.99 Description: X-RAY MALE GENITAL TRACT Category: Radiology CMS Add: 01/01/1984 CMS Term: 74440 RADIO DEF RBRVS 02/01/2015 12/31/2023 58.43 Description: X-RAY MALE GENITAL TRACT Category: Radiology CMS Add: 01/01/1984 CMS Term: 74440 TC RADIO DEF RBRVS 01/01/2024 73.94 Description: X-RAY MALE GENITAL TRACT Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 940 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 74440 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 44.51 Description: X-RAY MALE GENITAL TRACT Category: Radiology CMS Add: 01/01/1984 CMS Term: 74445 26 RADIO DEF RBRVS 01/01/2024 51.32 Description: X-RAY EXAM OF PENIS Category: Radiology CMS Add: 01/01/1984 CMS Term: 74445 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 41.94 Description: X-RAY EXAM OF PENIS Category: Radiology CMS Add: 01/01/1984 CMS Term: 74445 RADIO DEF MAXFEE 01/01/2024 103.30 0.0 Description: X-RAY EXAM OF PENIS Category: Radiology CMS Add: 01/01/1984 CMS Term: 74445 RADIO DEF RBRVS 02/01/2015 12/31/2023 73.01 Description: X-RAY EXAM OF PENIS Category: Radiology CMS Add: 01/01/1984 CMS Term: 74445 TC RADIO DEF MAXFEE 01/01/2024 44.03 0.0 Description: X-RAY EXAM OF PENIS Category: Radiology CMS Add: 01/01/1984 CMS Term: 74445 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 28.16 Description: X-RAY EXAM OF PENIS Category: Radiology CMS Add: 01/01/1984 CMS Term: 74450 26 RADIO DEF RBRVS 01/01/2024 15.21 Description: X-RAY URETHRA/BLADDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 74450 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 12.33 Description: X-RAY URETHRA/BLADDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 74450 RADIO DEF MAXFEE 01/01/2024 74.04 0.0 Description: X-RAY URETHRA/BLADDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 74450 RADIO DEF RBRVS 02/01/2015 12/31/2023 49.33 Description: X-RAY URETHRA/BLADDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 74450 TC RADIO DEF MAXFEE 01/01/2024 56.92 0.0 Description: X-RAY URETHRA/BLADDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 74450 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 36.41 Description: X-RAY URETHRA/BLADDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 74455 26 RADIO DEF RBRVS 01/01/2024 15.05 Description: X-RAY URETHRA/BLADDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 74455 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 12.00 Description: X-RAY URETHRA/BLADDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 74455 RADIO DEF RBRVS 01/01/2024 97.94 Description: X-RAY URETHRA/BLADDER Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 941 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 74455 RADIO DEF RBRVS 02/01/2015 12/31/2023 59.48 Description: X-RAY URETHRA/BLADDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 74455 TC RADIO DEF RBRVS 01/01/2024 82.90 Description: X-RAY URETHRA/BLADDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 74455 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 47.48 Description: X-RAY URETHRA/BLADDER Category: Radiology CMS Add: 01/01/1984 CMS Term: 74470 26 RADIO DEF RBRVS 01/01/2024 24.19 Description: X-RAY EXAM OF KIDNEY LESION Category: Radiology CMS Add: 01/01/1984 CMS Term: 74470 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 19.63 Description: X-RAY EXAM OF KIDNEY LESION Category: Radiology CMS Add: 01/01/1984 CMS Term: 74470 RADIO DEF MAXFEE 01/01/2024 76.11 0.0 Description: X-RAY EXAM OF KIDNEY LESION Category: Radiology CMS Add: 01/01/1984 CMS Term: 74470 RADIO DEF RBRVS 02/01/2015 12/31/2023 52.68 Description: X-RAY EXAM OF KIDNEY LESION Category: Radiology CMS Add: 01/01/1984 CMS Term: 74470 TC RADIO DEF MAXFEE 01/01/2024 48.76 0.0 Description: X-RAY EXAM OF KIDNEY LESION Category: Radiology CMS Add: 01/01/1984 CMS Term: 74470 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 31.05 Description: X-RAY EXAM OF KIDNEY LESION Category: Radiology CMS Add: 01/01/1984 CMS Term: 74485 26 RADIO DEF RBRVS 01/01/2024 37.72 Description: DILATION URTR/URT RS&I Category: Radiology CMS Add: 01/01/1987 CMS Term: 74485 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 19.46 Description: DILATION URTR/URT RS&I Category: Radiology CMS Add: 01/01/1987 CMS Term: 74485 RADIO DEF RBRVS 01/01/2024 112.28 Description: DILATION URTR/URT RS&I Category: Radiology CMS Add: 01/01/1987 CMS Term: 74485 RADIO DEF RBRVS 02/01/2015 12/31/2023 68.68 Description: DILATION URTR/URT RS&I Category: Radiology CMS Add: 01/01/1987 CMS Term: 74485 TC RADIO DEF RBRVS 01/01/2024 74.56 Description: DILATION URTR/URT RS&I Category: Radiology CMS Add: 01/01/1987 CMS Term: 74485 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 49.21 Description: DILATION URTR/URT RS&I Category: Radiology CMS Add: 01/01/1987 CMS Term: 74710 26 RADIO DEF RBRVS 01/01/2024 15.55 Description: X-RAY MEASUREMENT OF PELVIS Category: Radiology CMS Add: 01/01/1984 CMS Term: 12/31/2023 *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 942 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 74710 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 12.52 Description: X-RAY MEASUREMENT OF PELVIS Category: Radiology CMS Add: 01/01/1984 CMS Term: 12/31/2023 74710 RADIO DEF RBRVS 01/01/2024 37.63 Description: X-RAY MEASUREMENT OF PELVIS Category: Radiology CMS Add: 01/01/1984 CMS Term: 12/31/2023 74710 RADIO DEF RBRVS 02/01/2015 12/31/2023 26.81 Description: X-RAY MEASUREMENT OF PELVIS Category: Radiology CMS Add: 01/01/1984 CMS Term: 12/31/2023 74710 TC RADIO DEF RBRVS 01/01/2024 22.08 Description: X-RAY MEASUREMENT OF PELVIS Category: Radiology CMS Add: 01/01/1984 CMS Term: 12/31/2023 74710 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 14.28 Description: X-RAY MEASUREMENT OF PELVIS Category: Radiology CMS Add: 01/01/1984 CMS Term: 12/31/2023 74712 26 RADIO DEF RBRVS 01/01/2016 12/31/2023 111.15 Description: MRI FETAL SNGL/1ST GESTATION Category: Radiology CMS Add: 01/01/2016 CMS Term: 74712 26 RADIO DEF RBRVS 01/01/2024 138.05 Description: MRI FETAL SNGL/1ST GESTATION Category: Radiology CMS Add: 01/01/2016 CMS Term: 74712 RADIO DEF RBRVS 01/01/2016 12/31/2023 339.88 Description: MRI FETAL SNGL/1ST GESTATION Category: Radiology CMS Add: 01/01/2016 CMS Term: 74712 RADIO DEF RBRVS 01/01/2024 401.71 Description: MRI FETAL SNGL/1ST GESTATION Category: Radiology CMS Add: 01/01/2016 CMS Term: 74712 TC RADIO DEF RBRVS 01/01/2016 12/31/2023 228.72 Description: MRI FETAL SNGL/1ST GESTATION Category: Radiology CMS Add: 01/01/2016 CMS Term: 74712 TC RADIO DEF RBRVS 01/01/2024 263.67 Description: MRI FETAL SNGL/1ST GESTATION Category: Radiology CMS Add: 01/01/2016 CMS Term: 74713 26 RADIO DEF RBRVS 01/01/2016 12/31/2023 65.82 Description: MRI FETAL EA ADDL GESTATION Category: Radiology CMS Add: 01/01/2016 CMS Term: 74713 26 RADIO DEF RBRVS 01/01/2024 85.29 Description: MRI FETAL EA ADDL GESTATION Category: Radiology CMS Add: 01/01/2016 CMS Term: 74713 RADIO DEF RBRVS 01/01/2016 12/31/2023 163.84 Description: MRI FETAL EA ADDL GESTATION Category: Radiology CMS Add: 01/01/2016 CMS Term: 74713 RADIO DEF RBRVS 01/01/2024 195.97 Description: MRI FETAL EA ADDL GESTATION Category: Radiology CMS Add: 01/01/2016 CMS Term: 74713 TC RADIO DEF RBRVS 01/01/2016 12/31/2023 98.01 Description: MRI FETAL EA ADDL GESTATION Category: Radiology CMS Add: 01/01/2016 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 943 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 74713 TC RADIO DEF RBRVS 01/01/2024 110.68 Description: MRI FETAL EA ADDL GESTATION Category: Radiology CMS Add: 01/01/2016 CMS Term: 74740 26 RADIO DEF RBRVS 01/01/2024 17.52 Description: X-RAY FEMALE GENITAL TRACT Category: Radiology CMS Add: 01/01/1984 CMS Term: 74740 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 13.84 Description: X-RAY FEMALE GENITAL TRACT Category: Radiology CMS Add: 01/01/1984 CMS Term: 74740 RADIO DEF RBRVS 01/01/2024 89.61 Description: X-RAY FEMALE GENITAL TRACT Category: Radiology CMS Add: 01/01/1984 CMS Term: 74740 RADIO DEF RBRVS 02/01/2015 12/31/2023 55.13 Description: X-RAY FEMALE GENITAL TRACT Category: Radiology CMS Add: 01/01/1984 CMS Term: 74740 TC RADIO DEF RBRVS 01/01/2024 72.09 Description: X-RAY FEMALE GENITAL TRACT Category: Radiology CMS Add: 01/01/1984 CMS Term: 74740 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 41.29 Description: X-RAY FEMALE GENITAL TRACT Category: Radiology CMS Add: 01/01/1984 CMS Term: 74742 26 RADIO DEF RBRVS 01/01/2024 28.11 Description: X-RAY FALLOPIAN TUBE Category: Radiology CMS Add: 01/01/1993 CMS Term: 74742 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 22.91 Description: X-RAY FALLOPIAN TUBE Category: Radiology CMS Add: 01/01/1993 CMS Term: 74742 RADIO DEF MAXFEE 01/01/2024 157.51 0.0 Description: X-RAY FALLOPIAN TUBE Category: Radiology CMS Add: 01/01/1993 CMS Term: 74742 RADIO DEF RBRVS 02/01/2015 12/31/2023 101.71 Description: X-RAY FALLOPIAN TUBE Category: Radiology CMS Add: 01/01/1993 CMS Term: 74742 TC RADIO DEF MAXFEE 01/01/2024 124.80 0.0 Description: X-RAY FALLOPIAN TUBE Category: Radiology CMS Add: 01/01/1993 CMS Term: 74742 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 78.20 Description: X-RAY FALLOPIAN TUBE Category: Radiology CMS Add: 01/01/1993 CMS Term: 74775 26 RADIO DEF RBRVS 01/01/2024 28.75 Description: X-RAY EXAM OF PERINEUM Category: Radiology CMS Add: 01/01/1985 CMS Term: 74775 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 22.93 Description: X-RAY EXAM OF PERINEUM Category: Radiology CMS Add: 01/01/1985 CMS Term: 74775 RADIO DEF MAXFEE 01/01/2024 88.53 0.0 Description: X-RAY EXAM OF PERINEUM Category: Radiology CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 944 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 74775 RADIO DEF RBRVS 02/01/2015 12/31/2023 61.19 Description: X-RAY EXAM OF PERINEUM Category: Radiology CMS Add: 01/01/1985 CMS Term: 74775 TC RADIO DEF MAXFEE 01/01/2024 56.92 0.0 Description: X-RAY EXAM OF PERINEUM Category: Radiology CMS Add: 01/01/1985 CMS Term: 74775 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 36.41 Description: X-RAY EXAM OF PERINEUM Category: Radiology CMS Add: 01/01/1985 CMS Term: 75557 26 RADIO DEF RBRVS 01/01/2024 106.87 Description: CARDIAC MRI FOR MORPH Category: Radiology CMS Add: 01/01/2008 CMS Term: 75557 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 85.60 Description: CARDIAC MRI FOR MORPH Category: Radiology CMS Add: 01/01/2008 CMS Term: 75557 RADIO DEF RBRVS 01/01/2024 273.59 Description: CARDIAC MRI FOR MORPH Category: Radiology CMS Add: 01/01/2008 CMS Term: 75557 RADIO DEF RBRVS 09/01/2019 12/31/2023 233.40 Description: CARDIAC MRI FOR MORPH Category: Radiology CMS Add: 01/01/2008 CMS Term: 75557 TC RADIO DEF RBRVS 01/01/2024 166.72 Description: CARDIAC MRI FOR MORPH Category: Radiology CMS Add: 01/01/2008 CMS Term: 75557 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 147.80 Description: CARDIAC MRI FOR MORPH Category: Radiology CMS Add: 01/01/2008 CMS Term: 75559 26 RADIO DEF RBRVS 01/01/2024 132.45 Description: CARDIAC MRI W/STRESS IMG Category: Radiology CMS Add: 01/01/2008 CMS Term: 75559 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 106.09 Description: CARDIAC MRI W/STRESS IMG Category: Radiology CMS Add: 01/01/2008 CMS Term: 75559 RADIO DEF RBRVS 01/01/2024 366.77 Description: CARDIAC MRI W/STRESS IMG Category: Radiology CMS Add: 01/01/2008 CMS Term: 75559 RADIO DEF RBRVS 09/01/2019 12/31/2023 315.33 Description: CARDIAC MRI W/STRESS IMG Category: Radiology CMS Add: 01/01/2008 CMS Term: 75559 TC RADIO DEF RBRVS 01/01/2024 234.33 Description: CARDIAC MRI W/STRESS IMG Category: Radiology CMS Add: 01/01/2008 CMS Term: 75559 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 209.24 Description: CARDIAC MRI W/STRESS IMG Category: Radiology CMS Add: 01/01/2008 CMS Term: 75561 26 RADIO DEF RBRVS 01/01/2024 118.28 Description: CARDIAC MRI FOR MORPH W/DYE Category: Radiology CMS Add: 01/01/2008 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 945 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 75561 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 94.46 Description: CARDIAC MRI FOR MORPH W/DYE Category: Radiology CMS Add: 01/01/2008 CMS Term: 75561 RADIO DEF RBRVS 01/01/2024 357.24 Description: CARDIAC MRI FOR MORPH W/DYE Category: Radiology CMS Add: 01/01/2008 CMS Term: 75561 RADIO DEF RBRVS 09/01/2019 12/31/2023 306.67 Description: CARDIAC MRI FOR MORPH W/DYE Category: Radiology CMS Add: 01/01/2008 CMS Term: 75561 TC RADIO DEF RBRVS 01/01/2024 238.96 Description: CARDIAC MRI FOR MORPH W/DYE Category: Radiology CMS Add: 01/01/2008 CMS Term: 75561 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 212.21 Description: CARDIAC MRI FOR MORPH W/DYE Category: Radiology CMS Add: 01/01/2008 CMS Term: 75563 26 RADIO DEF RBRVS 01/01/2024 134.76 Description: CARD MRI W/STRESS IMG & DYE Category: Radiology CMS Add: 01/01/2008 CMS Term: 75563 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 108.43 Description: CARD MRI W/STRESS IMG & DYE Category: Radiology CMS Add: 01/01/2008 CMS Term: 75563 RADIO DEF RBRVS 01/01/2024 415.41 Description: CARD MRI W/STRESS IMG & DYE Category: Radiology CMS Add: 01/01/2008 CMS Term: 75563 RADIO DEF RBRVS 09/01/2019 12/31/2023 361.76 Description: CARD MRI W/STRESS IMG & DYE Category: Radiology CMS Add: 01/01/2008 CMS Term: 75563 TC RADIO DEF RBRVS 01/01/2024 280.65 Description: CARD MRI W/STRESS IMG & DYE Category: Radiology CMS Add: 01/01/2008 CMS Term: 75563 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 253.33 Description: CARD MRI W/STRESS IMG & DYE Category: Radiology CMS Add: 01/01/2008 CMS Term: 75565 26 RADIO DEF RBRVS 01/01/2024 11.41 Description: CARD MRI VELOC FLOW MAPPING Category: Radiology CMS Add: 01/01/2010 CMS Term: 75565 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 9.11 Description: CARD MRI VELOC FLOW MAPPING Category: Radiology CMS Add: 01/01/2010 CMS Term: 75565 RADIO DEF RBRVS 01/01/2024 44.44 Description: CARD MRI VELOC FLOW MAPPING Category: Radiology CMS Add: 01/01/2010 CMS Term: 75565 RADIO DEF RBRVS 09/01/2019 12/31/2023 39.25 Description: CARD MRI VELOC FLOW MAPPING Category: Radiology CMS Add: 01/01/2010 CMS Term: 75565 TC RADIO DEF RBRVS 01/01/2024 33.03 Description: CARD MRI VELOC FLOW MAPPING Category: Radiology CMS Add: 01/01/2010 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 946 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 75565 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 30.14 Description: CARD MRI VELOC FLOW MAPPING Category: Radiology CMS Add: 01/01/2010 CMS Term: 75571 26 RADIO DEF RBRVS 01/01/2024 26.78 Description: CT HRT W/O DYE W/CA TEST Category: Radiology CMS Add: 01/01/2010 CMS Term: 75571 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 20.70 Description: CT HRT W/O DYE W/CA TEST Category: Radiology CMS Add: 01/01/2010 CMS Term: 75571 RADIO DEF RBRVS 01/01/2024 96.40 Description: CT HRT W/O DYE W/CA TEST Category: Radiology CMS Add: 01/01/2010 CMS Term: 75571 RADIO DEF RBRVS 09/01/2019 12/31/2023 74.62 Description: CT HRT W/O DYE W/CA TEST Category: Radiology CMS Add: 01/01/2010 CMS Term: 75571 TC RADIO DEF RBRVS 01/01/2024 69.62 Description: CT HRT W/O DYE W/CA TEST Category: Radiology CMS Add: 01/01/2010 CMS Term: 75571 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 53.92 Description: CT HRT W/O DYE W/CA TEST Category: Radiology CMS Add: 01/01/2010 CMS Term: 75572 26 RADIO DEF RBRVS 01/01/2024 79.73 Description: CT HRT W/3D IMAGE Category: Radiology CMS Add: 01/01/2010 CMS Term: 75572 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 63.20 Description: CT HRT W/3D IMAGE Category: Radiology CMS Add: 01/01/2010 CMS Term: 75572 RADIO DEF RBRVS 01/01/2024 220.53 Description: CT HRT W/3D IMAGE Category: Radiology CMS Add: 01/01/2010 CMS Term: 75572 RADIO DEF RBRVS 09/01/2019 12/31/2023 204.07 Description: CT HRT W/3D IMAGE Category: Radiology CMS Add: 01/01/2010 CMS Term: 75572 TC RADIO DEF RBRVS 01/01/2024 140.80 Description: CT HRT W/3D IMAGE Category: Radiology CMS Add: 01/01/2010 CMS Term: 75572 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 140.87 Description: CT HRT W/3D IMAGE Category: Radiology CMS Add: 01/01/2010 CMS Term: 75573 26 RADIO DEF RBRVS 01/01/2024 116.13 Description: CT HRT C+ STRUX CGEN HRT DS Category: Radiology CMS Add: 01/01/2010 CMS Term: 75573 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 92.13 Description: CT HRT C+ STRUX CGEN HRT DS Category: Radiology CMS Add: 01/01/2010 CMS Term: 75573 RADIO DEF RBRVS 01/01/2024 293.97 Description: CT HRT C+ STRUX CGEN HRT DS Category: Radiology CMS Add: 01/01/2010 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 947 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 75573 RADIO DEF RBRVS 09/01/2019 12/31/2023 280.56 Description: CT HRT C+ STRUX CGEN HRT DS Category: Radiology CMS Add: 01/01/2010 CMS Term: 75573 TC RADIO DEF RBRVS 01/01/2024 177.84 Description: CT HRT C+ STRUX CGEN HRT DS Category: Radiology CMS Add: 01/01/2010 CMS Term: 75573 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 188.43 Description: CT HRT C+ STRUX CGEN HRT DS Category: Radiology CMS Add: 01/01/2010 CMS Term: 75574 26 RADIO DEF RBRVS 01/01/2024 109.34 Description: CT ANGIO HRT W/3D IMAGE Category: Radiology CMS Add: 01/01/2010 CMS Term: 75574 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 86.86 Description: CT ANGIO HRT W/3D IMAGE Category: Radiology CMS Add: 01/01/2010 CMS Term: 75574 RADIO DEF RBRVS 01/01/2024 311.57 Description: CT ANGIO HRT W/3D IMAGE Category: Radiology CMS Add: 01/01/2010 CMS Term: 75574 RADIO DEF RBRVS 09/01/2019 12/31/2023 297.33 Description: CT ANGIO HRT W/3D IMAGE Category: Radiology CMS Add: 01/01/2010 CMS Term: 75574 TC RADIO DEF RBRVS 01/01/2024 202.23 Description: CT ANGIO HRT W/3D IMAGE Category: Radiology CMS Add: 01/01/2010 CMS Term: 75574 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 210.47 Description: CT ANGIO HRT W/3D IMAGE Category: Radiology CMS Add: 01/01/2010 CMS Term: 75580 26 RADIO DEF RBRVS 01/01/2024 33.92 Description: N-INVAS EST C FFR SW ALY CTA Category: Radiology CMS Add: 01/01/2024 CMS Term: 75580 RADIO DEF RBRVS 01/01/2024 838.16 Description: N-INVAS EST C FFR SW ALY CTA Category: Radiology CMS Add: 01/01/2024 CMS Term: 75580 TC RADIO DEF RBRVS 01/01/2024 804.24 Description: N-INVAS EST C FFR SW ALY CTA Category: Radiology CMS Add: 01/01/2024 CMS Term: 75600 26 RADIO DEF RBRVS 01/01/2024 21.91 Description: CONTRAST EXAM THORACIC AORTA Category: Radiology CMS Add: 01/01/1986 CMS Term: 75600 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 17.62 Description: CONTRAST EXAM THORACIC AORTA Category: Radiology CMS Add: 01/01/1986 CMS Term: 75600 RADIO DEF RBRVS 01/01/2024 171.03 Description: CONTRAST EXAM THORACIC AORTA Category: Radiology CMS Add: 01/01/1986 CMS Term: 75600 RADIO DEF RBRVS 09/01/2019 12/31/2023 147.34 Description: CONTRAST EXAM THORACIC AORTA Category: Radiology CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 948 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 75600 TC RADIO DEF RBRVS 01/01/2024 149.12 Description: CONTRAST EXAM THORACIC AORTA Category: Radiology CMS Add: 01/01/1986 CMS Term: 75600 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 129.72 Description: CONTRAST EXAM THORACIC AORTA Category: Radiology CMS Add: 01/01/1986 CMS Term: 75605 26 RADIO DEF RBRVS 01/01/2024 50.28 Description: CONTRAST EXAM THORACIC AORTA Category: Radiology CMS Add: 01/01/1984 CMS Term: 75605 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 40.70 Description: CONTRAST EXAM THORACIC AORTA Category: Radiology CMS Add: 01/01/1984 CMS Term: 75605 RADIO DEF RBRVS 01/01/2024 112.96 Description: CONTRAST EXAM THORACIC AORTA Category: Radiology CMS Add: 01/01/1984 CMS Term: 75605 RADIO DEF RBRVS 09/01/2019 12/31/2023 107.75 Description: CONTRAST EXAM THORACIC AORTA Category: Radiology CMS Add: 01/01/1984 CMS Term: 75605 TC RADIO DEF RBRVS 01/01/2024 62.68 Description: CONTRAST EXAM THORACIC AORTA Category: Radiology CMS Add: 01/01/1984 CMS Term: 75605 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 67.05 Description: CONTRAST EXAM THORACIC AORTA Category: Radiology CMS Add: 01/01/1984 CMS Term: 75625 26 RADIO DEF RBRVS 01/01/2024 62.66 Description: CONTRAST EXAM ABDOMINL AORTA Category: Radiology CMS Add: 01/01/1985 CMS Term: 75625 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 40.70 Description: CONTRAST EXAM ABDOMINL AORTA Category: Radiology CMS Add: 01/01/1985 CMS Term: 75625 RADIO DEF RBRVS 01/01/2024 118.08 Description: CONTRAST EXAM ABDOMINL AORTA Category: Radiology CMS Add: 01/01/1985 CMS Term: 75625 RADIO DEF RBRVS 09/01/2019 12/31/2023 107.26 Description: CONTRAST EXAM ABDOMINL AORTA Category: Radiology CMS Add: 01/01/1985 CMS Term: 75625 TC RADIO DEF RBRVS 01/01/2024 55.42 Description: CONTRAST EXAM ABDOMINL AORTA Category: Radiology CMS Add: 01/01/1985 CMS Term: 75625 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 66.55 Description: CONTRAST EXAM ABDOMINL AORTA Category: Radiology CMS Add: 01/01/1985 CMS Term: 75630 26 RADIO DEF RBRVS 01/01/2024 88.28 Description: X-RAY AORTA LEG ARTERIES Category: Radiology CMS Add: 01/01/1984 CMS Term: 75630 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 63.62 Description: X-RAY AORTA LEG ARTERIES Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 949 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 75630 RADIO DEF RBRVS 01/01/2024 147.72 Description: X-RAY AORTA LEG ARTERIES Category: Radiology CMS Add: 01/01/1984 CMS Term: 75630 RADIO DEF RBRVS 09/01/2019 12/31/2023 129.67 Description: X-RAY AORTA LEG ARTERIES Category: Radiology CMS Add: 01/01/1984 CMS Term: 75630 TC RADIO DEF RBRVS 01/01/2024 59.43 Description: X-RAY AORTA LEG ARTERIES Category: Radiology CMS Add: 01/01/1984 CMS Term: 75630 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 66.06 Description: X-RAY AORTA LEG ARTERIES Category: Radiology CMS Add: 01/01/1984 CMS Term: 75635 26 RADIO DEF RBRVS 01/01/2024 108.27 Description: CT ANGIO ABDOMINAL ARTERIES Category: Radiology CMS Add: 01/01/2001 CMS Term: 75635 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 87.35 Description: CT ANGIO ABDOMINAL ARTERIES Category: Radiology CMS Add: 01/01/2001 CMS Term: 75635 RADIO DEF RBRVS 01/01/2024 397.87 Description: CT ANGIO ABDOMINAL ARTERIES Category: Radiology CMS Add: 01/01/2001 CMS Term: 75635 RADIO DEF RBRVS 09/01/2019 12/31/2023 295.68 Description: CT ANGIO ABDOMINAL ARTERIES Category: Radiology CMS Add: 01/01/2001 CMS Term: 75635 TC RADIO DEF RBRVS 01/01/2024 289.60 Description: CT ANGIO ABDOMINAL ARTERIES Category: Radiology CMS Add: 01/01/2001 CMS Term: 75635 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 208.33 Description: CT ANGIO ABDOMINAL ARTERIES Category: Radiology CMS Add: 01/01/2001 CMS Term: 75705 26 RADIO DEF RBRVS 01/01/2024 106.42 Description: ARTERY X-RAYS SPINE Category: Radiology CMS Add: 01/01/1984 CMS Term: 75705 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 79.79 Description: ARTERY X-RAYS SPINE Category: Radiology CMS Add: 01/01/1984 CMS Term: 75705 RADIO DEF RBRVS 01/01/2024 229.31 Description: ARTERY X-RAYS SPINE Category: Radiology CMS Add: 01/01/1984 CMS Term: 75705 RADIO DEF RBRVS 09/01/2019 12/31/2023 176.57 Description: ARTERY X-RAYS SPINE Category: Radiology CMS Add: 01/01/1984 CMS Term: 75705 TC RADIO DEF RBRVS 01/01/2024 122.89 Description: ARTERY X-RAYS SPINE Category: Radiology CMS Add: 01/01/1984 CMS Term: 75705 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 96.77 Description: ARTERY X-RAYS SPINE Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 950 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 75710 26 RADIO DEF RBRVS 01/01/2024 77.04 Description: ARTERY X-RAYS ARM/LEG Category: Radiology CMS Add: 01/01/1985 CMS Term: 75710 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 40.12 Description: ARTERY X-RAYS ARM/LEG Category: Radiology CMS Add: 01/01/1985 CMS Term: 75710 RADIO DEF RBRVS 01/01/2024 140.65 Description: ARTERY X-RAYS ARM/LEG Category: Radiology CMS Add: 01/01/1985 CMS Term: 75710 RADIO DEF RBRVS 09/01/2019 12/31/2023 124.02 Description: ARTERY X-RAYS ARM/LEG Category: Radiology CMS Add: 01/01/1985 CMS Term: 75710 TC RADIO DEF RBRVS 01/01/2024 63.61 Description: ARTERY X-RAYS ARM/LEG Category: Radiology CMS Add: 01/01/1985 CMS Term: 75710 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 83.89 Description: ARTERY X-RAYS ARM/LEG Category: Radiology CMS Add: 01/01/1985 CMS Term: 75716 26 RADIO DEF RBRVS 01/01/2024 86.65 Description: ARTERY X-RAYS ARMS/LEGS Category: Radiology CMS Add: 01/01/1984 CMS Term: 75716 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 46.76 Description: ARTERY X-RAYS ARMS/LEGS Category: Radiology CMS Add: 01/01/1984 CMS Term: 75716 RADIO DEF RBRVS 01/01/2024 152.73 Description: ARTERY X-RAYS ARMS/LEGS Category: Radiology CMS Add: 01/01/1984 CMS Term: 75716 RADIO DEF RBRVS 09/01/2019 12/31/2023 147.82 Description: ARTERY X-RAYS ARMS/LEGS Category: Radiology CMS Add: 01/01/1984 CMS Term: 75716 TC RADIO DEF RBRVS 01/01/2024 66.08 Description: ARTERY X-RAYS ARMS/LEGS Category: Radiology CMS Add: 01/01/1984 CMS Term: 75716 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 101.07 Description: ARTERY X-RAYS ARMS/LEGS Category: Radiology CMS Add: 01/01/1984 CMS Term: 75726 26 RADIO DEF RBRVS 01/01/2024 90.11 Description: ARTERY X-RAYS ABDOMEN Category: Radiology CMS Add: 01/01/1984 CMS Term: 75726 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 41.12 Description: ARTERY X-RAYS ABDOMEN Category: Radiology CMS Add: 01/01/1984 CMS Term: 75726 RADIO DEF RBRVS 01/01/2024 161.74 Description: ARTERY X-RAYS ABDOMEN Category: Radiology CMS Add: 01/01/1984 CMS Term: 75726 RADIO DEF RBRVS 09/01/2019 12/31/2023 115.84 Description: ARTERY X-RAYS ABDOMEN Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 951 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 75726 TC RADIO DEF RBRVS 01/01/2024 71.63 Description: ARTERY X-RAYS ABDOMEN Category: Radiology CMS Add: 01/01/1984 CMS Term: 75726 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 74.73 Description: ARTERY X-RAYS ABDOMEN Category: Radiology CMS Add: 01/01/1984 CMS Term: 75731 26 RADIO DEF RBRVS 01/01/2024 52.56 Description: ARTERY X-RAYS ADRENAL GLAND Category: Radiology CMS Add: 01/01/1985 CMS Term: 75731 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 41.69 Description: ARTERY X-RAYS ADRENAL GLAND Category: Radiology CMS Add: 01/01/1985 CMS Term: 75731 RADIO DEF RBRVS 01/01/2024 143.66 Description: ARTERY X-RAYS ADRENAL GLAND Category: Radiology CMS Add: 01/01/1985 CMS Term: 75731 RADIO DEF RBRVS 09/01/2019 12/31/2023 128.56 Description: ARTERY X-RAYS ADRENAL GLAND Category: Radiology CMS Add: 01/01/1985 CMS Term: 75731 TC RADIO DEF RBRVS 01/01/2024 91.10 Description: ARTERY X-RAYS ADRENAL GLAND Category: Radiology CMS Add: 01/01/1985 CMS Term: 75731 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 86.87 Description: ARTERY X-RAYS ADRENAL GLAND Category: Radiology CMS Add: 01/01/1985 CMS Term: 75733 26 RADIO DEF RBRVS 01/01/2024 58.93 Description: ARTERY X-RAYS ADRENALS Category: Radiology CMS Add: 01/01/1985 CMS Term: 75733 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 47.00 Description: ARTERY X-RAYS ADRENALS Category: Radiology CMS Add: 01/01/1985 CMS Term: 75733 RADIO DEF RBRVS 01/01/2024 158.98 Description: ARTERY X-RAYS ADRENALS Category: Radiology CMS Add: 01/01/1985 CMS Term: 75733 RADIO DEF RBRVS 09/01/2019 12/31/2023 143.86 Description: ARTERY X-RAYS ADRENALS Category: Radiology CMS Add: 01/01/1985 CMS Term: 75733 TC RADIO DEF RBRVS 01/01/2024 100.05 Description: ARTERY X-RAYS ADRENALS Category: Radiology CMS Add: 01/01/1985 CMS Term: 75733 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 96.86 Description: ARTERY X-RAYS ADRENALS Category: Radiology CMS Add: 01/01/1985 CMS Term: 75736 26 RADIO DEF RBRVS 01/01/2024 49.81 Description: ARTERY X-RAYS PELVIS Category: Radiology CMS Add: 01/01/1984 CMS Term: 75736 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 40.12 Description: ARTERY X-RAYS PELVIS Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 952 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 75736 RADIO DEF RBRVS 01/01/2024 133.50 Description: ARTERY X-RAYS PELVIS Category: Radiology CMS Add: 01/01/1984 CMS Term: 75736 RADIO DEF RBRVS 09/01/2019 12/31/2023 122.04 Description: ARTERY X-RAYS PELVIS Category: Radiology CMS Add: 01/01/1984 CMS Term: 75736 TC RADIO DEF RBRVS 01/01/2024 83.69 Description: ARTERY X-RAYS PELVIS Category: Radiology CMS Add: 01/01/1984 CMS Term: 75736 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 81.91 Description: ARTERY X-RAYS PELVIS Category: Radiology CMS Add: 01/01/1984 CMS Term: 75741 26 RADIO DEF RBRVS 01/01/2024 57.73 Description: ARTERY X-RAYS LUNG Category: Radiology CMS Add: 01/01/1984 CMS Term: 75741 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 47.17 Description: ARTERY X-RAYS LUNG Category: Radiology CMS Add: 01/01/1984 CMS Term: 75741 RADIO DEF RBRVS 01/01/2024 123.19 Description: ARTERY X-RAYS LUNG Category: Radiology CMS Add: 01/01/1984 CMS Term: 75741 RADIO DEF RBRVS 09/01/2019 12/31/2023 115.21 Description: ARTERY X-RAYS LUNG Category: Radiology CMS Add: 01/01/1984 CMS Term: 75741 TC RADIO DEF RBRVS 01/01/2024 65.46 Description: ARTERY X-RAYS LUNG Category: Radiology CMS Add: 01/01/1984 CMS Term: 75741 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 68.04 Description: ARTERY X-RAYS LUNG Category: Radiology CMS Add: 01/01/1984 CMS Term: 75743 26 RADIO DEF RBRVS 01/01/2024 73.31 Description: ARTERY X-RAYS LUNGS Category: Radiology CMS Add: 01/01/1985 CMS Term: 75743 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 59.38 Description: ARTERY X-RAYS LUNGS Category: Radiology CMS Add: 01/01/1985 CMS Term: 75743 RADIO DEF RBRVS 01/01/2024 140.01 Description: ARTERY X-RAYS LUNGS Category: Radiology CMS Add: 01/01/1985 CMS Term: 75743 RADIO DEF RBRVS 09/01/2019 12/31/2023 133.61 Description: ARTERY X-RAYS LUNGS Category: Radiology CMS Add: 01/01/1985 CMS Term: 75743 TC RADIO DEF RBRVS 01/01/2024 66.70 Description: ARTERY X-RAYS LUNGS Category: Radiology CMS Add: 01/01/1985 CMS Term: 75743 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 74.23 Description: ARTERY X-RAYS LUNGS Category: Radiology CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 953 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 75746 26 RADIO DEF RBRVS 01/01/2024 50.72 Description: ARTERY X-RAYS LUNG Category: Radiology CMS Add: 01/01/1985 CMS Term: 75746 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 41.69 Description: ARTERY X-RAYS LUNG Category: Radiology CMS Add: 01/01/1985 CMS Term: 75746 RADIO DEF RBRVS 01/01/2024 126.68 Description: ARTERY X-RAYS LUNG Category: Radiology CMS Add: 01/01/1985 CMS Term: 75746 RADIO DEF RBRVS 09/01/2019 12/31/2023 119.15 Description: ARTERY X-RAYS LUNG Category: Radiology CMS Add: 01/01/1985 CMS Term: 75746 TC RADIO DEF RBRVS 01/01/2024 75.96 Description: ARTERY X-RAYS LUNG Category: Radiology CMS Add: 01/01/1985 CMS Term: 75746 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 77.45 Description: ARTERY X-RAYS LUNG Category: Radiology CMS Add: 01/01/1985 CMS Term: 75756 26 RADIO DEF RBRVS 01/01/2024 51.99 Description: ARTERY X-RAYS CHEST Category: Radiology CMS Add: 01/01/1984 CMS Term: 75756 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 42.27 Description: ARTERY X-RAYS CHEST Category: Radiology CMS Add: 01/01/1984 CMS Term: 75756 RADIO DEF RBRVS 01/01/2024 150.49 Description: ARTERY X-RAYS CHEST Category: Radiology CMS Add: 01/01/1984 CMS Term: 75756 RADIO DEF RBRVS 09/01/2019 12/31/2023 128.64 Description: ARTERY X-RAYS CHEST Category: Radiology CMS Add: 01/01/1984 CMS Term: 75756 TC RADIO DEF RBRVS 01/01/2024 98.51 Description: ARTERY X-RAYS CHEST Category: Radiology CMS Add: 01/01/1984 CMS Term: 75756 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 86.37 Description: ARTERY X-RAYS CHEST Category: Radiology CMS Add: 01/01/1984 CMS Term: 75774 26 RADIO DEF RBRVS 01/01/2024 44.16 Description: ARTERY X-RAY EACH VESSEL Category: Radiology CMS Add: 01/01/1987 CMS Term: 75774 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 12.89 Description: ARTERY X-RAY EACH VESSEL Category: Radiology CMS Add: 01/01/1987 CMS Term: 75774 RADIO DEF RBRVS 01/01/2024 91.55 Description: ARTERY X-RAY EACH VESSEL Category: Radiology CMS Add: 01/01/1987 CMS Term: 75774 RADIO DEF RBRVS 02/01/2015 12/31/2023 69.04 Description: ARTERY X-RAY EACH VESSEL Category: Radiology CMS Add: 01/01/1987 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 954 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 75774 TC RADIO DEF RBRVS 01/01/2024 47.39 Description: ARTERY X-RAY EACH VESSEL Category: Radiology CMS Add: 01/01/1987 CMS Term: 75774 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 56.15 Description: ARTERY X-RAY EACH VESSEL Category: Radiology CMS Add: 01/01/1987 CMS Term: 75801 26 RADIO DEF RBRVS 01/01/2024 39.26 Description: LYMPH VESSEL X-RAY ARM/LEG Category: Radiology CMS Add: 01/01/1986 CMS Term: 75801 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 31.76 Description: LYMPH VESSEL X-RAY ARM/LEG Category: Radiology CMS Add: 01/01/1986 CMS Term: 75801 RADIO DEF MAXFEE 01/01/2024 253.48 0.0 Description: LYMPH VESSEL X-RAY ARM/LEG Category: Radiology CMS Add: 01/01/1986 CMS Term: 75801 RADIO DEF RBRVS 02/01/2015 12/31/2023 166.78 Description: LYMPH VESSEL X-RAY ARM/LEG Category: Radiology CMS Add: 01/01/1986 CMS Term: 75801 TC RADIO DEF MAXFEE 01/01/2024 211.53 0.0 Description: LYMPH VESSEL X-RAY ARM/LEG Category: Radiology CMS Add: 01/01/1986 CMS Term: 75801 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 134.76 Description: LYMPH VESSEL X-RAY ARM/LEG Category: Radiology CMS Add: 01/01/1986 CMS Term: 75803 26 RADIO DEF RBRVS 01/01/2024 53.89 Description: LYMPH VESSEL X-RAY ARMS/LEGS Category: Radiology CMS Add: 01/01/1984 CMS Term: 75803 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 43.74 Description: LYMPH VESSEL X-RAY ARMS/LEGS Category: Radiology CMS Add: 01/01/1984 CMS Term: 75803 RADIO DEF MAXFEE 01/01/2024 270.15 0.0 Description: LYMPH VESSEL X-RAY ARMS/LEGS Category: Radiology CMS Add: 01/01/1984 CMS Term: 75803 RADIO DEF RBRVS 02/01/2015 12/31/2023 180.67 Description: LYMPH VESSEL X-RAY ARMS/LEGS Category: Radiology CMS Add: 01/01/1984 CMS Term: 75803 TC RADIO DEF MAXFEE 01/01/2024 211.53 0.0 Description: LYMPH VESSEL X-RAY ARMS/LEGS Category: Radiology CMS Add: 01/01/1984 CMS Term: 75803 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 134.76 Description: LYMPH VESSEL X-RAY ARMS/LEGS Category: Radiology CMS Add: 01/01/1984 CMS Term: 75805 26 RADIO DEF RBRVS 01/01/2024 37.35 Description: LYMPH VESSEL X-RAY TRUNK Category: Radiology CMS Add: 01/01/1984 CMS Term: 75805 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 30.35 Description: LYMPH VESSEL X-RAY TRUNK Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 955 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 75805 RADIO DEF MAXFEE 01/01/2024 279.88 0.0 Description: LYMPH VESSEL X-RAY TRUNK Category: Radiology CMS Add: 01/01/1984 CMS Term: 75805 RADIO DEF RBRVS 02/01/2015 12/31/2023 183.54 Description: LYMPH VESSEL X-RAY TRUNK Category: Radiology CMS Add: 01/01/1984 CMS Term: 75805 TC RADIO DEF MAXFEE 01/01/2024 238.47 0.0 Description: LYMPH VESSEL X-RAY TRUNK Category: Radiology CMS Add: 01/01/1984 CMS Term: 75805 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 151.52 Description: LYMPH VESSEL X-RAY TRUNK Category: Radiology CMS Add: 01/01/1984 CMS Term: 75807 26 RADIO DEF RBRVS 01/01/2024 50.51 Description: LYMPH VESSEL X-RAY TRUNK Category: Radiology CMS Add: 01/01/1984 CMS Term: 75807 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 43.74 Description: LYMPH VESSEL X-RAY TRUNK Category: Radiology CMS Add: 01/01/1984 CMS Term: 75807 RADIO DEF MAXFEE 01/01/2024 290.39 0.0 Description: LYMPH VESSEL X-RAY TRUNK Category: Radiology CMS Add: 01/01/1984 CMS Term: 75807 RADIO DEF RBRVS 02/01/2015 12/31/2023 197.43 Description: LYMPH VESSEL X-RAY TRUNK Category: Radiology CMS Add: 01/01/1984 CMS Term: 75807 TC RADIO DEF MAXFEE 01/01/2024 249.07 0.0 Description: LYMPH VESSEL X-RAY TRUNK Category: Radiology CMS Add: 01/01/1984 CMS Term: 75807 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 151.52 Description: LYMPH VESSEL X-RAY TRUNK Category: Radiology CMS Add: 01/01/1984 CMS Term: 75809 26 RADIO DEF RBRVS 01/01/2024 22.13 Description: NONVASCULAR SHUNT X-RAY Category: Radiology CMS Add: 01/01/1993 CMS Term: 75809 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 17.58 Description: NONVASCULAR SHUNT X-RAY Category: Radiology CMS Add: 01/01/1993 CMS Term: 75809 RADIO DEF RBRVS 01/01/2024 76.93 Description: NONVASCULAR SHUNT X-RAY Category: Radiology CMS Add: 01/01/1993 CMS Term: 75809 RADIO DEF RBRVS 09/01/2019 12/31/2023 72.99 Description: NONVASCULAR SHUNT X-RAY Category: Radiology CMS Add: 01/01/1993 CMS Term: 75809 TC RADIO DEF RBRVS 01/01/2024 54.80 Description: NONVASCULAR SHUNT X-RAY Category: Radiology CMS Add: 01/01/1993 CMS Term: 75809 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 55.41 Description: NONVASCULAR SHUNT X-RAY Category: Radiology CMS Add: 01/01/1993 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 956 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 75810 26 RADIO DEF RBRVS 01/01/2024 46.11 Description: VEIN X-RAY SPLEEN/LIVER Category: Radiology CMS Add: 01/01/1984 CMS Term: 75810 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 42.68 Description: VEIN X-RAY SPLEEN/LIVER Category: Radiology CMS Add: 01/01/1984 CMS Term: 75810 RADIO DEF MAXFEE 01/01/2024 549.75 0.0 Description: VEIN X-RAY SPLEEN/LIVER Category: Radiology CMS Add: 01/01/1984 CMS Term: 75810 RADIO DEF RBRVS 02/01/2015 12/31/2023 358.14 Description: VEIN X-RAY SPLEEN/LIVER Category: Radiology CMS Add: 01/01/1984 CMS Term: 75810 TC RADIO DEF MAXFEE 01/01/2024 491.97 0.0 Description: VEIN X-RAY SPLEEN/LIVER Category: Radiology CMS Add: 01/01/1984 CMS Term: 75810 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 313.28 Description: VEIN X-RAY SPLEEN/LIVER Category: Radiology CMS Add: 01/01/1984 CMS Term: 75820 26 RADIO DEF RBRVS 01/01/2024 47.06 Description: VEIN X-RAY ARM/LEG Category: Radiology CMS Add: 01/01/1984 CMS Term: 75820 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 25.41 Description: VEIN X-RAY ARM/LEG Category: Radiology CMS Add: 01/01/1984 CMS Term: 75820 RADIO DEF RBRVS 01/01/2024 102.79 Description: VEIN X-RAY ARM/LEG Category: Radiology CMS Add: 01/01/1984 CMS Term: 75820 RADIO DEF RBRVS 09/01/2019 12/31/2023 88.25 Description: VEIN X-RAY ARM/LEG Category: Radiology CMS Add: 01/01/1984 CMS Term: 75820 TC RADIO DEF RBRVS 01/01/2024 55.73 Description: VEIN X-RAY ARM/LEG Category: Radiology CMS Add: 01/01/1984 CMS Term: 75820 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 62.84 Description: VEIN X-RAY ARM/LEG Category: Radiology CMS Add: 01/01/1984 CMS Term: 75822 26 RADIO DEF RBRVS 01/01/2024 65.05 Description: VEIN X-RAY ARMS/LEGS Category: Radiology CMS Add: 01/01/1984 CMS Term: 75822 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 38.31 Description: VEIN X-RAY ARMS/LEGS Category: Radiology CMS Add: 01/01/1984 CMS Term: 75822 RADIO DEF RBRVS 01/01/2024 125.41 Description: VEIN X-RAY ARMS/LEGS Category: Radiology CMS Add: 01/01/1984 CMS Term: 75822 RADIO DEF RBRVS 09/01/2019 12/31/2023 110.31 Description: VEIN X-RAY ARMS/LEGS Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 957 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 75822 TC RADIO DEF RBRVS 01/01/2024 60.36 Description: VEIN X-RAY ARMS/LEGS Category: Radiology CMS Add: 01/01/1984 CMS Term: 75822 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 72.00 Description: VEIN X-RAY ARMS/LEGS Category: Radiology CMS Add: 01/01/1984 CMS Term: 75825 26 RADIO DEF RBRVS 01/01/2024 49.84 Description: VEIN X-RAY TRUNK Category: Radiology CMS Add: 01/01/1985 CMS Term: 75825 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 40.62 Description: VEIN X-RAY TRUNK Category: Radiology CMS Add: 01/01/1985 CMS Term: 75825 RADIO DEF RBRVS 01/01/2024 106.80 Description: VEIN X-RAY TRUNK Category: Radiology CMS Add: 01/01/1985 CMS Term: 75825 RADIO DEF RBRVS 09/01/2019 12/31/2023 103.71 Description: VEIN X-RAY TRUNK Category: Radiology CMS Add: 01/01/1985 CMS Term: 75825 TC RADIO DEF RBRVS 01/01/2024 56.96 Description: VEIN X-RAY TRUNK Category: Radiology CMS Add: 01/01/1985 CMS Term: 75825 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 63.08 Description: VEIN X-RAY TRUNK Category: Radiology CMS Add: 01/01/1985 CMS Term: 75827 26 RADIO DEF RBRVS 01/01/2024 50.45 Description: VEIN X-RAY CHEST Category: Radiology CMS Add: 01/01/1985 CMS Term: 75827 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 40.21 Description: VEIN X-RAY CHEST Category: Radiology CMS Add: 01/01/1985 CMS Term: 75827 RADIO DEF RBRVS 01/01/2024 111.74 Description: VEIN X-RAY CHEST Category: Radiology CMS Add: 01/01/1985 CMS Term: 75827 RADIO DEF RBRVS 09/01/2019 12/31/2023 105.03 Description: VEIN X-RAY CHEST Category: Radiology CMS Add: 01/01/1985 CMS Term: 75827 TC RADIO DEF RBRVS 01/01/2024 61.29 Description: VEIN X-RAY CHEST Category: Radiology CMS Add: 01/01/1985 CMS Term: 75827 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 64.82 Description: VEIN X-RAY CHEST Category: Radiology CMS Add: 01/01/1985 CMS Term: 75831 26 RADIO DEF RBRVS 01/01/2024 49.50 Description: VEIN X-RAY KIDNEY Category: Radiology CMS Add: 01/01/1985 CMS Term: 75831 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 43.10 Description: VEIN X-RAY KIDNEY Category: Radiology CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 958 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 75831 RADIO DEF RBRVS 01/01/2024 113.11 Description: VEIN X-RAY KIDNEY Category: Radiology CMS Add: 01/01/1985 CMS Term: 75831 RADIO DEF RBRVS 09/01/2019 12/31/2023 110.64 Description: VEIN X-RAY KIDNEY Category: Radiology CMS Add: 01/01/1985 CMS Term: 75831 TC RADIO DEF RBRVS 01/01/2024 63.61 Description: VEIN X-RAY KIDNEY Category: Radiology CMS Add: 01/01/1985 CMS Term: 75831 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 67.54 Description: VEIN X-RAY KIDNEY Category: Radiology CMS Add: 01/01/1985 CMS Term: 75833 26 RADIO DEF RBRVS 01/01/2024 65.43 Description: VEIN X-RAY KIDNEYS Category: Radiology CMS Add: 01/01/1985 CMS Term: 75833 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 51.51 Description: VEIN X-RAY KIDNEYS Category: Radiology CMS Add: 01/01/1985 CMS Term: 75833 RADIO DEF RBRVS 01/01/2024 137.37 Description: VEIN X-RAY KIDNEYS Category: Radiology CMS Add: 01/01/1985 CMS Term: 75833 RADIO DEF RBRVS 09/01/2019 12/31/2023 127.72 Description: VEIN X-RAY KIDNEYS Category: Radiology CMS Add: 01/01/1985 CMS Term: 75833 TC RADIO DEF RBRVS 01/01/2024 71.94 Description: VEIN X-RAY KIDNEYS Category: Radiology CMS Add: 01/01/1985 CMS Term: 75833 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 76.21 Description: VEIN X-RAY KIDNEYS Category: Radiology CMS Add: 01/01/1985 CMS Term: 75840 26 RADIO DEF RBRVS 01/01/2024 52.56 Description: VEIN X-RAY ADRENAL GLAND Category: Radiology CMS Add: 01/01/1985 CMS Term: 75840 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 44.83 Description: VEIN X-RAY ADRENAL GLAND Category: Radiology CMS Add: 01/01/1985 CMS Term: 75840 RADIO DEF RBRVS 01/01/2024 122.04 Description: VEIN X-RAY ADRENAL GLAND Category: Radiology CMS Add: 01/01/1985 CMS Term: 75840 RADIO DEF RBRVS 09/01/2019 12/31/2023 114.61 Description: VEIN X-RAY ADRENAL GLAND Category: Radiology CMS Add: 01/01/1985 CMS Term: 75840 TC RADIO DEF RBRVS 01/01/2024 69.47 Description: VEIN X-RAY ADRENAL GLAND Category: Radiology CMS Add: 01/01/1985 CMS Term: 75840 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 69.77 Description: VEIN X-RAY ADRENAL GLAND Category: Radiology CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 959 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 75842 26 RADIO DEF RBRVS 01/01/2024 68.76 Description: VEIN X-RAY ADRENAL GLANDS Category: Radiology CMS Add: 01/01/1985 CMS Term: 75842 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 54.98 Description: VEIN X-RAY ADRENAL GLANDS Category: Radiology CMS Add: 01/01/1985 CMS Term: 75842 RADIO DEF RBRVS 01/01/2024 150.27 Description: VEIN X-RAY ADRENAL GLANDS Category: Radiology CMS Add: 01/01/1985 CMS Term: 75842 RADIO DEF RBRVS 09/01/2019 12/31/2023 138.87 Description: VEIN X-RAY ADRENAL GLANDS Category: Radiology CMS Add: 01/01/1985 CMS Term: 75842 TC RADIO DEF RBRVS 01/01/2024 81.51 Description: VEIN X-RAY ADRENAL GLANDS Category: Radiology CMS Add: 01/01/1985 CMS Term: 75842 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 83.89 Description: VEIN X-RAY ADRENAL GLANDS Category: Radiology CMS Add: 01/01/1985 CMS Term: 75860 26 RADIO DEF RBRVS 01/01/2024 51.05 Description: VEIN X-RAY NECK Category: Radiology CMS Add: 01/01/1984 CMS Term: 75860 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 41.12 Description: VEIN X-RAY NECK Category: Radiology CMS Add: 01/01/1984 CMS Term: 75860 RADIO DEF RBRVS 01/01/2024 118.36 Description: VEIN X-RAY NECK Category: Radiology CMS Add: 01/01/1984 CMS Term: 75860 RADIO DEF RBRVS 09/01/2019 12/31/2023 108.91 Description: VEIN X-RAY NECK Category: Radiology CMS Add: 01/01/1984 CMS Term: 75860 TC RADIO DEF RBRVS 01/01/2024 67.31 Description: VEIN X-RAY NECK Category: Radiology CMS Add: 01/01/1984 CMS Term: 75860 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 67.79 Description: VEIN X-RAY NECK Category: Radiology CMS Add: 01/01/1984 CMS Term: 75870 26 RADIO DEF RBRVS 01/01/2024 54.80 Description: VEIN X-RAY SKULL Category: Radiology CMS Add: 01/01/1984 CMS Term: 75870 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 42.19 Description: VEIN X-RAY SKULL Category: Radiology CMS Add: 01/01/1984 CMS Term: 75870 RADIO DEF RBRVS 01/01/2024 145.58 Description: VEIN X-RAY SKULL Category: Radiology CMS Add: 01/01/1984 CMS Term: 75870 RADIO DEF RBRVS 09/01/2019 12/31/2023 111.47 Description: VEIN X-RAY SKULL Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 960 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 75870 TC RADIO DEF RBRVS 01/01/2024 90.77 Description: VEIN X-RAY SKULL Category: Radiology CMS Add: 01/01/1984 CMS Term: 75870 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 69.28 Description: VEIN X-RAY SKULL Category: Radiology CMS Add: 01/01/1984 CMS Term: 75872 26 RADIO DEF RBRVS 01/01/2024 52.56 Description: VEIN X-RAY SKULL EPIDURAL Category: Radiology CMS Add: 01/01/1984 CMS Term: 75872 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 37.98 Description: VEIN X-RAY SKULL EPIDURAL Category: Radiology CMS Add: 01/01/1984 CMS Term: 75872 RADIO DEF RBRVS 01/01/2024 122.04 Description: VEIN X-RAY SKULL EPIDURAL Category: Radiology CMS Add: 01/01/1984 CMS Term: 75872 RADIO DEF RBRVS 09/01/2019 12/31/2023 107.01 Description: VEIN X-RAY SKULL EPIDURAL Category: Radiology CMS Add: 01/01/1984 CMS Term: 75872 TC RADIO DEF RBRVS 01/01/2024 69.47 Description: VEIN X-RAY SKULL EPIDURAL Category: Radiology CMS Add: 01/01/1984 CMS Term: 75872 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 69.03 Description: VEIN X-RAY SKULL EPIDURAL Category: Radiology CMS Add: 01/01/1984 CMS Term: 75880 26 RADIO DEF RBRVS 01/01/2024 32.39 Description: VEIN X-RAY EYE SOCKET Category: Radiology CMS Add: 01/01/1984 CMS Term: 75880 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 25.91 Description: VEIN X-RAY EYE SOCKET Category: Radiology CMS Add: 01/01/1984 CMS Term: 75880 RADIO DEF RBRVS 01/01/2024 101.56 Description: VEIN X-RAY EYE SOCKET Category: Radiology CMS Add: 01/01/1984 CMS Term: 75880 RADIO DEF RBRVS 09/01/2019 12/31/2023 95.93 Description: VEIN X-RAY EYE SOCKET Category: Radiology CMS Add: 01/01/1984 CMS Term: 75880 TC RADIO DEF RBRVS 01/01/2024 69.16 Description: VEIN X-RAY EYE SOCKET Category: Radiology CMS Add: 01/01/1984 CMS Term: 75880 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 70.02 Description: VEIN X-RAY EYE SOCKET Category: Radiology CMS Add: 01/01/1984 CMS Term: 75885 26 RADIO DEF RBRVS 01/01/2024 62.14 Description: VEIN X-RAY LIVER W/HEMODYNAM Category: Radiology CMS Add: 01/01/1985 CMS Term: 75885 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 51.90 Description: VEIN X-RAY LIVER W/HEMODYNAM Category: Radiology CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 961 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 75885 RADIO DEF RBRVS 01/01/2024 128.83 Description: VEIN X-RAY LIVER W/HEMODYNAM Category: Radiology CMS Add: 01/01/1985 CMS Term: 75885 RADIO DEF RBRVS 09/01/2019 12/31/2023 120.44 Description: VEIN X-RAY LIVER W/HEMODYNAM Category: Radiology CMS Add: 01/01/1985 CMS Term: 75885 TC RADIO DEF RBRVS 01/01/2024 66.70 Description: VEIN X-RAY LIVER W/HEMODYNAM Category: Radiology CMS Add: 01/01/1985 CMS Term: 75885 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 68.53 Description: VEIN X-RAY LIVER W/HEMODYNAM Category: Radiology CMS Add: 01/01/1985 CMS Term: 75887 26 RADIO DEF RBRVS 01/01/2024 63.06 Description: VEIN X-RAY LIVER W/O HEMODYN Category: Radiology CMS Add: 01/01/1985 CMS Term: 75887 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 51.41 Description: VEIN X-RAY LIVER W/O HEMODYN Category: Radiology CMS Add: 01/01/1985 CMS Term: 75887 RADIO DEF RBRVS 01/01/2024 130.69 Description: VEIN X-RAY LIVER W/O HEMODYN Category: Radiology CMS Add: 01/01/1985 CMS Term: 75887 RADIO DEF RBRVS 09/01/2019 12/31/2023 119.94 Description: VEIN X-RAY LIVER W/O HEMODYN Category: Radiology CMS Add: 01/01/1985 CMS Term: 75887 TC RADIO DEF RBRVS 01/01/2024 67.62 Description: VEIN X-RAY LIVER W/O HEMODYN Category: Radiology CMS Add: 01/01/1985 CMS Term: 75887 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 68.53 Description: VEIN X-RAY LIVER W/O HEMODYN Category: Radiology CMS Add: 01/01/1985 CMS Term: 75889 26 RADIO DEF RBRVS 01/01/2024 49.49 Description: VEIN X-RAY LIVER W/HEMODYNAM Category: Radiology CMS Add: 01/01/1985 CMS Term: 75889 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 41.20 Description: VEIN X-RAY LIVER W/HEMODYNAM Category: Radiology CMS Add: 01/01/1985 CMS Term: 75889 RADIO DEF RBRVS 01/01/2024 116.49 Description: VEIN X-RAY LIVER W/HEMODYNAM Category: Radiology CMS Add: 01/01/1985 CMS Term: 75889 RADIO DEF RBRVS 09/01/2019 12/31/2023 110.23 Description: VEIN X-RAY LIVER W/HEMODYNAM Category: Radiology CMS Add: 01/01/1985 CMS Term: 75889 TC RADIO DEF RBRVS 01/01/2024 67.00 Description: VEIN X-RAY LIVER W/HEMODYNAM Category: Radiology CMS Add: 01/01/1985 CMS Term: 75889 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 69.03 Description: VEIN X-RAY LIVER W/HEMODYNAM Category: Radiology CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 962 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 75891 26 RADIO DEF RBRVS 01/01/2024 49.95 Description: VEIN X-RAY LIVER Category: Radiology CMS Add: 01/01/1985 CMS Term: 75891 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 41.69 Description: VEIN X-RAY LIVER Category: Radiology CMS Add: 01/01/1985 CMS Term: 75891 RADIO DEF RBRVS 01/01/2024 117.26 Description: VEIN X-RAY LIVER Category: Radiology CMS Add: 01/01/1985 CMS Term: 75891 RADIO DEF RBRVS 09/01/2019 12/31/2023 110.97 Description: VEIN X-RAY LIVER Category: Radiology CMS Add: 01/01/1985 CMS Term: 75891 TC RADIO DEF RBRVS 01/01/2024 67.31 Description: VEIN X-RAY LIVER Category: Radiology CMS Add: 01/01/1985 CMS Term: 75891 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 69.28 Description: VEIN X-RAY LIVER Category: Radiology CMS Add: 01/01/1985 CMS Term: 75893 26 RADIO DEF RBRVS 01/01/2024 23.88 Description: VENOUS SAMPLING BY CATHETER Category: Radiology CMS Add: 01/01/1984 CMS Term: 75893 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 19.63 Description: VENOUS SAMPLING BY CATHETER Category: Radiology CMS Add: 01/01/1984 CMS Term: 75893 RADIO DEF RBRVS 01/01/2024 96.75 Description: VENOUS SAMPLING BY CATHETER Category: Radiology CMS Add: 01/01/1984 CMS Term: 75893 RADIO DEF RBRVS 09/01/2019 12/31/2023 89.40 Description: VENOUS SAMPLING BY CATHETER Category: Radiology CMS Add: 01/01/1984 CMS Term: 75893 TC RADIO DEF RBRVS 01/01/2024 72.87 Description: VENOUS SAMPLING BY CATHETER Category: Radiology CMS Add: 01/01/1984 CMS Term: 75893 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 69.77 Description: VENOUS SAMPLING BY CATHETER Category: Radiology CMS Add: 01/01/1984 CMS Term: 75894 26 RADIO DEF RBRVS 01/01/2024 64.94 Description: X-RAYS TRANSCATH THERAPY Category: Radiology CMS Add: 01/01/1982 CMS Term: 75894 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 48.33 Description: X-RAYS TRANSCATH THERAPY Category: Radiology CMS Add: 01/01/1982 CMS Term: 75894 RADIO DEF MAXFEE 01/01/2024 1009.26 0.0 Description: X-RAYS TRANSCATH THERAPY Category: Radiology CMS Add: 01/01/1982 CMS Term: 75894 RADIO DEF RBRVS 02/01/2015 12/31/2023 651.88 Description: X-RAYS TRANSCATH THERAPY Category: Radiology CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 963 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 75894 TC RADIO DEF MAXFEE 01/01/2024 942.38 0.0 Description: X-RAYS TRANSCATH THERAPY Category: Radiology CMS Add: 01/01/1982 CMS Term: 75894 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 600.31 Description: X-RAYS TRANSCATH THERAPY Category: Radiology CMS Add: 01/01/1982 CMS Term: 75898 26 RADIO DEF RBRVS 01/01/2024 82.23 Description: FOLLOW-UP ANGIOGRAPHY Category: Radiology CMS Add: 01/01/1984 CMS Term: 75898 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 61.34 Description: FOLLOW-UP ANGIOGRAPHY Category: Radiology CMS Add: 01/01/1984 CMS Term: 75898 RADIO DEF MAXFEE 01/01/2024 125.21 0.0 Description: FOLLOW-UP ANGIOGRAPHY Category: Radiology CMS Add: 01/01/1984 CMS Term: 75898 RADIO DEF RBRVS 02/01/2015 12/31/2023 91.44 Description: FOLLOW-UP ANGIOGRAPHY Category: Radiology CMS Add: 01/01/1984 CMS Term: 75898 TC RADIO DEF MAXFEE 01/01/2024 40.98 0.0 Description: FOLLOW-UP ANGIOGRAPHY Category: Radiology CMS Add: 01/01/1984 CMS Term: 75898 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 26.18 Description: FOLLOW-UP ANGIOGRAPHY Category: Radiology CMS Add: 01/01/1984 CMS Term: 75901 26 RADIO DEF RBRVS 01/01/2024 21.57 Description: REMOVE CVA DEVICE OBSTRUCT Category: Radiology CMS Add: 01/01/2003 CMS Term: 75901 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 17.62 Description: REMOVE CVA DEVICE OBSTRUCT Category: Radiology CMS Add: 01/01/2003 CMS Term: 75901 RADIO DEF RBRVS 01/01/2024 214.84 Description: REMOVE CVA DEVICE OBSTRUCT Category: Radiology CMS Add: 01/01/2003 CMS Term: 75901 RADIO DEF RBRVS 02/01/2015 12/31/2023 124.55 Description: REMOVE CVA DEVICE OBSTRUCT Category: Radiology CMS Add: 01/01/2003 CMS Term: 75901 TC RADIO DEF RBRVS 01/01/2024 193.27 Description: REMOVE CVA DEVICE OBSTRUCT Category: Radiology CMS Add: 01/01/2003 CMS Term: 75901 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 106.93 Description: REMOVE CVA DEVICE OBSTRUCT Category: Radiology CMS Add: 01/01/2003 CMS Term: 75902 26 RADIO DEF RBRVS 01/01/2024 17.56 Description: REMOVE CVA LUMEN OBSTRUCT Category: Radiology CMS Add: 01/01/2003 CMS Term: 75902 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 14.11 Description: REMOVE CVA LUMEN OBSTRUCT Category: Radiology CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 964 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 75902 RADIO DEF RBRVS 01/01/2024 84.41 Description: REMOVE CVA LUMEN OBSTRUCT Category: Radiology CMS Add: 01/01/2003 CMS Term: 75902 RADIO DEF RBRVS 02/01/2015 12/31/2023 52.92 Description: REMOVE CVA LUMEN OBSTRUCT Category: Radiology CMS Add: 01/01/2003 CMS Term: 75902 TC RADIO DEF RBRVS 01/01/2024 66.84 Description: REMOVE CVA LUMEN OBSTRUCT Category: Radiology CMS Add: 01/01/2003 CMS Term: 75902 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 38.81 Description: REMOVE CVA LUMEN OBSTRUCT Category: Radiology CMS Add: 01/01/2003 CMS Term: 75956 26 RADIO DEF RBRVS 01/01/2024 303.68 Description: XRAY ENDOVASC THOR AO REPR Category: Radiology CMS Add: 01/01/2006 CMS Term: 75956 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 255.96 Description: XRAY ENDOVASC THOR AO REPR Category: Radiology CMS Add: 01/01/2006 CMS Term: 75957 26 RADIO DEF RBRVS 01/01/2024 260.10 Description: XRAY ENDOVASC THOR AO REPR Category: Radiology CMS Add: 01/01/2006 CMS Term: 75957 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 219.26 Description: XRAY ENDOVASC THOR AO REPR Category: Radiology CMS Add: 01/01/2006 CMS Term: 75958 26 RADIO DEF RBRVS 01/01/2024 172.63 Description: XRAY PLACE PROX EXT THOR AO Category: Radiology CMS Add: 01/01/2006 CMS Term: 75958 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 145.87 Description: XRAY PLACE PROX EXT THOR AO Category: Radiology CMS Add: 01/01/2006 CMS Term: 75959 26 RADIO DEF RBRVS 01/01/2024 151.30 Description: XRAY PLACE DIST EXT THOR AO Category: Radiology CMS Add: 01/01/2006 CMS Term: 75959 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 128.89 Description: XRAY PLACE DIST EXT THOR AO Category: Radiology CMS Add: 01/01/2006 CMS Term: 75970 26 RADIO DEF RBRVS 01/01/2024 36.19 Description: VASCULAR BIOPSY Category: Radiology CMS Add: 01/01/1984 CMS Term: 75970 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 30.14 Description: VASCULAR BIOPSY Category: Radiology CMS Add: 01/01/1984 CMS Term: 75970 RADIO DEF MAXFEE 01/01/2024 493.26 0.0 Description: VASCULAR BIOPSY Category: Radiology CMS Add: 01/01/1984 CMS Term: 75970 RADIO DEF RBRVS 02/01/2015 12/31/2023 320.00 Description: VASCULAR BIOPSY Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 965 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 75970 TC RADIO DEF MAXFEE 01/01/2024 450.42 0.0 Description: VASCULAR BIOPSY Category: Radiology CMS Add: 01/01/1984 CMS Term: 75970 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 287.02 Description: VASCULAR BIOPSY Category: Radiology CMS Add: 01/01/1984 CMS Term: 75984 26 RADIO DEF RBRVS 01/01/2024 36.18 Description: XRAY CONTROL CATHETER CHANGE Category: Radiology CMS Add: 01/01/1984 CMS Term: 75984 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 25.95 Description: XRAY CONTROL CATHETER CHANGE Category: Radiology CMS Add: 01/01/1984 CMS Term: 75984 RADIO DEF RBRVS 01/01/2024 90.67 Description: XRAY CONTROL CATHETER CHANGE Category: Radiology CMS Add: 01/01/1984 CMS Term: 75984 RADIO DEF RBRVS 02/01/2015 12/31/2023 78.88 Description: XRAY CONTROL CATHETER CHANGE Category: Radiology CMS Add: 01/01/1984 CMS Term: 75984 TC RADIO DEF RBRVS 01/01/2024 54.49 Description: XRAY CONTROL CATHETER CHANGE Category: Radiology CMS Add: 01/01/1984 CMS Term: 75984 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 52.93 Description: XRAY CONTROL CATHETER CHANGE Category: Radiology CMS Add: 01/01/1984 CMS Term: 75989 26 RADIO DEF RBRVS 01/01/2024 53.04 Description: ABSCESS DRAINAGE UNDER X-RAY Category: Radiology CMS Add: 01/01/1989 CMS Term: 75989 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 42.95 Description: ABSCESS DRAINAGE UNDER X-RAY Category: Radiology CMS Add: 01/01/1989 CMS Term: 75989 RADIO DEF RBRVS 01/01/2024 106.60 Description: ABSCESS DRAINAGE UNDER X-RAY Category: Radiology CMS Add: 01/01/1989 CMS Term: 75989 RADIO DEF RBRVS 02/01/2015 12/31/2023 89.69 Description: ABSCESS DRAINAGE UNDER X-RAY Category: Radiology CMS Add: 01/01/1989 CMS Term: 75989 TC RADIO DEF RBRVS 01/01/2024 53.57 Description: ABSCESS DRAINAGE UNDER X-RAY Category: Radiology CMS Add: 01/01/1989 CMS Term: 75989 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 46.74 Description: ABSCESS DRAINAGE UNDER X-RAY Category: Radiology CMS Add: 01/01/1989 CMS Term: 76000 26 RADIO DEF RBRVS 01/01/2024 14.51 Description: FLUOROSCOPY <1 HR PHYS/QHP Category: Radiology CMS Add: 01/01/1984 CMS Term: 76000 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 6.22 Description: FLUOROSCOPY <1 HR PHYS/QHP Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 966 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 76000 RADIO DEF RBRVS 01/01/2024 40.30 Description: FLUOROSCOPY <1 HR PHYS/QHP Category: Radiology CMS Add: 01/01/1984 CMS Term: 76000 RADIO DEF RBRVS 02/01/2015 12/31/2023 35.61 Description: FLUOROSCOPY <1 HR PHYS/QHP Category: Radiology CMS Add: 01/01/1984 CMS Term: 76000 TC RADIO DEF RBRVS 01/01/2024 25.78 Description: FLUOROSCOPY <1 HR PHYS/QHP Category: Radiology CMS Add: 01/01/1984 CMS Term: 76000 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 29.40 Description: FLUOROSCOPY <1 HR PHYS/QHP Category: Radiology CMS Add: 01/01/1984 CMS Term: 76010 26 RADIO DEF RBRVS 01/01/2024 8.42 0-19years Description: X-RAY NOSE TO RECTUM Category: Radiology CMS Add: 01/01/1985 CMS Term: 76010 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 6.74 0-19years Description: X-RAY NOSE TO RECTUM Category: Radiology CMS Add: 01/01/1985 CMS Term: 76010 RADIO DEF RBRVS 01/01/2024 28.03 0-19years Description: X-RAY NOSE TO RECTUM Category: Radiology CMS Add: 01/01/1985 CMS Term: 76010 RADIO DEF RBRVS 02/01/2015 12/31/2023 19.53 0-19years Description: X-RAY NOSE TO RECTUM Category: Radiology CMS Add: 01/01/1985 CMS Term: 76010 TC RADIO DEF RBRVS 01/01/2024 19.61 0-19years Description: X-RAY NOSE TO RECTUM Category: Radiology CMS Add: 01/01/1985 CMS Term: 76010 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 12.80 0-19years Description: X-RAY NOSE TO RECTUM Category: Radiology CMS Add: 01/01/1985 CMS Term: 76080 26 RADIO DEF RBRVS 01/01/2024 23.88 Description: X-RAY EXAM OF FISTULA Category: Radiology CMS Add: 01/01/1984 CMS Term: 76080 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 19.46 Description: X-RAY EXAM OF FISTULA Category: Radiology CMS Add: 01/01/1984 CMS Term: 76080 RADIO DEF RBRVS 01/01/2024 56.46 Description: X-RAY EXAM OF FISTULA Category: Radiology CMS Add: 01/01/1984 CMS Term: 76080 RADIO DEF RBRVS 02/01/2015 12/31/2023 43.41 Description: X-RAY EXAM OF FISTULA Category: Radiology CMS Add: 01/01/1984 CMS Term: 76080 TC RADIO DEF RBRVS 01/01/2024 32.58 Description: X-RAY EXAM OF FISTULA Category: Radiology CMS Add: 01/01/1984 CMS Term: 76080 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 23.95 Description: X-RAY EXAM OF FISTULA Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 967 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 76098 26 RADIO DEF RBRVS 01/01/2024 14.53 Description: X-RAY EXAM SURGICAL SPECIMEN Category: Radiology CMS Add: 01/01/1987 CMS Term: 76098 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 5.95 Description: X-RAY EXAM SURGICAL SPECIMEN Category: Radiology CMS Add: 01/01/1987 CMS Term: 76098 RADIO DEF RBRVS 01/01/2024 39.39 Description: X-RAY EXAM SURGICAL SPECIMEN Category: Radiology CMS Add: 01/01/1987 CMS Term: 76098 RADIO DEF RBRVS 02/01/2015 12/31/2023 13.55 Description: X-RAY EXAM SURGICAL SPECIMEN Category: Radiology CMS Add: 01/01/1987 CMS Term: 76098 TC RADIO DEF RBRVS 01/01/2024 24.86 Description: X-RAY EXAM SURGICAL SPECIMEN Category: Radiology CMS Add: 01/01/1987 CMS Term: 76098 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 7.60 Description: X-RAY EXAM SURGICAL SPECIMEN Category: Radiology CMS Add: 01/01/1987 CMS Term: 76100 26 RADIO DEF RBRVS 01/01/2024 27.09 Description: X-RAY EXAM OF BODY SECTION Category: Radiology CMS Add: 01/01/1984 CMS Term: 76100 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 23.10 Description: X-RAY EXAM OF BODY SECTION Category: Radiology CMS Add: 01/01/1984 CMS Term: 76100 RADIO DEF RBRVS 01/01/2024 84.36 Description: X-RAY EXAM OF BODY SECTION Category: Radiology CMS Add: 01/01/1984 CMS Term: 76100 RADIO DEF RBRVS 02/01/2015 12/31/2023 71.57 Description: X-RAY EXAM OF BODY SECTION Category: Radiology CMS Add: 01/01/1984 CMS Term: 76100 TC RADIO DEF RBRVS 01/01/2024 57.27 Description: X-RAY EXAM OF BODY SECTION Category: Radiology CMS Add: 01/01/1984 CMS Term: 76100 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 48.47 Description: X-RAY EXAM OF BODY SECTION Category: Radiology CMS Add: 01/01/1984 CMS Term: 76120 26 RADIO DEF RBRVS 01/01/2024 18.15 Description: CINE/VIDEO X-RAYS Category: Radiology CMS Add: 01/01/1984 CMS Term: 76120 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 14.42 Description: CINE/VIDEO X-RAYS Category: Radiology CMS Add: 01/01/1984 CMS Term: 76120 RADIO DEF RBRVS 01/01/2024 109.07 Description: CINE/VIDEO X-RAYS Category: Radiology CMS Add: 01/01/1984 CMS Term: 76120 RADIO DEF RBRVS 02/01/2015 12/31/2023 65.62 Description: CINE/VIDEO X-RAYS Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 968 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 76120 TC RADIO DEF RBRVS 01/01/2024 90.92 Description: CINE/VIDEO X-RAYS Category: Radiology CMS Add: 01/01/1984 CMS Term: 76120 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 51.19 Description: CINE/VIDEO X-RAYS Category: Radiology CMS Add: 01/01/1984 CMS Term: 76125 26 RADIO DEF RBRVS 01/01/2024 12.40 Description: CINE/VIDEO X-RAYS ADD-ON Category: Radiology CMS Add: 01/01/1984 CMS Term: 76125 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 10.47 Description: CINE/VIDEO X-RAYS ADD-ON Category: Radiology CMS Add: 01/01/1984 CMS Term: 76125 RADIO DEF MAXFEE 01/01/2024 44.21 0.0 Description: CINE/VIDEO X-RAYS ADD-ON Category: Radiology CMS Add: 01/01/1984 CMS Term: 76125 RADIO DEF RBRVS 02/01/2015 12/31/2023 30.21 Description: CINE/VIDEO X-RAYS ADD-ON Category: Radiology CMS Add: 01/01/1984 CMS Term: 76125 TC RADIO DEF MAXFEE 01/01/2024 30.55 0.0 Description: CINE/VIDEO X-RAYS ADD-ON Category: Radiology CMS Add: 01/01/1984 CMS Term: 76125 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 19.65 Description: CINE/VIDEO X-RAYS ADD-ON Category: Radiology CMS Add: 01/01/1984 CMS Term: 76140 RADIO DEF BILL25 Description: X-RAY CONSULTATION Category: Radiology CMS Add: 01/01/1984 CMS Term: 76145 NOCOV DEF SYSMAN Description: MED PHYSIC DOS EVAL RAD EXPS Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 76376 26 RADIO DEF RBRVS 01/01/2024 9.10 Description: 3D RENDER W/INTRP POSTPROCES Category: Radiology CMS Add: 01/01/2006 CMS Term: 76376 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 7.27 Description: 3D RENDER W/INTRP POSTPROCES Category: Radiology CMS Add: 01/01/2006 CMS Term: 76376 RADIO DEF RBRVS 01/01/2024 22.53 Description: 3D RENDER W/INTRP POSTPROCES Category: Radiology CMS Add: 01/01/2006 CMS Term: 76376 RADIO DEF RBRVS 02/01/2015 12/31/2023 20.32 Description: 3D RENDER W/INTRP POSTPROCES Category: Radiology CMS Add: 01/01/2006 CMS Term: 76376 TC RADIO DEF RBRVS 01/01/2024 13.44 Description: 3D RENDER W/INTRP POSTPROCES Category: Radiology CMS Add: 01/01/2006 CMS Term: 76376 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 13.05 Description: 3D RENDER W/INTRP POSTPROCES Category: Radiology CMS Add: 01/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 969 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 76377 26 RADIO DEF RBRVS 01/01/2024 36.37 Description: 3D RENDER W/INTRP POSTPROCES Category: Radiology CMS Add: 01/01/2006 CMS Term: 76377 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 29.07 Description: 3D RENDER W/INTRP POSTPROCES Category: Radiology CMS Add: 01/01/2006 CMS Term: 76377 RADIO DEF RBRVS 01/01/2024 71.72 Description: 3D RENDER W/INTRP POSTPROCES Category: Radiology CMS Add: 01/01/2006 CMS Term: 76377 RADIO DEF RBRVS 02/01/2015 12/31/2023 59.46 Description: 3D RENDER W/INTRP POSTPROCES Category: Radiology CMS Add: 01/01/2006 CMS Term: 76377 TC RADIO DEF RBRVS 01/01/2024 35.35 Description: 3D RENDER W/INTRP POSTPROCES Category: Radiology CMS Add: 01/01/2006 CMS Term: 76377 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 30.39 Description: 3D RENDER W/INTRP POSTPROCES Category: Radiology CMS Add: 01/01/2006 CMS Term: 76380 26 RADIO DEF RBRVS 01/01/2024 43.75 Description: CAT SCAN FOLLOW-UP STUDY Category: Radiology CMS Add: 01/01/1992 CMS Term: 76380 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 35.91 Description: CAT SCAN FOLLOW-UP STUDY Category: Radiology CMS Add: 01/01/1992 CMS Term: 76380 RADIO DEF RBRVS 01/01/2024 127.88 Description: CAT SCAN FOLLOW-UP STUDY Category: Radiology CMS Add: 01/01/1992 CMS Term: 76380 RADIO DEF RBRVS 02/01/2015 12/31/2023 107.42 Description: CAT SCAN FOLLOW-UP STUDY Category: Radiology CMS Add: 01/01/1992 CMS Term: 76380 TC RADIO DEF RBRVS 01/01/2024 84.13 Description: CAT SCAN FOLLOW-UP STUDY Category: Radiology CMS Add: 01/01/1992 CMS Term: 76380 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 71.51 Description: CAT SCAN FOLLOW-UP STUDY Category: Radiology CMS Add: 01/01/1992 CMS Term: 76390 26 RADIO DEF MAXFEE 01/01/2024 55.08 0.0 Description: MR SPECTROSCOPY Category: Radiology CMS Add: 01/01/1998 CMS Term: 76390 26 RADIO DEF RBRVS 01/01/2023 12/31/2023 51.82 Description: MR SPECTROSCOPY Category: Radiology CMS Add: 01/01/1998 CMS Term: 76390 RADIO DEF MAXFEE 01/01/2024 331.74 0.0 Description: MR SPECTROSCOPY Category: Radiology CMS Add: 01/01/1998 CMS Term: 76390 RADIO DEF RBRVS 01/01/2023 12/31/2023 312.08 Description: MR SPECTROSCOPY Category: Radiology CMS Add: 01/01/1998 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 970 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 76390 TC RADIO DEF MAXFEE 01/01/2024 276.67 0.0 Description: MR SPECTROSCOPY Category: Radiology CMS Add: 01/01/1998 CMS Term: 76390 TC RADIO DEF RBRVS 01/01/2023 12/31/2023 260.27 Description: MR SPECTROSCOPY Category: Radiology CMS Add: 01/01/1998 CMS Term: 76391 NOCOV DEF SYSMAN Description: MR ELASTOGRAPHY Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 76496 TC RADIO DEF MAXFEE 01/01/2024 44.09 0.0 Description: UNLISTED FLUOROSCOPIC PX Category: Radiology CMS Add: 01/01/2003 CMS Term: 76496 TC RADIO DEF MAXFEE 02/01/2015 12/31/2023 41.48 0.0 Description: UNLISTED FLUOROSCOPIC PX Category: Radiology CMS Add: 01/01/2003 CMS Term: 76497 TC RADIO DEF MAXFEE 01/01/2024 55.28 0.0 Description: UNLISTED CT PROCEDURE Category: Radiology CMS Add: 01/01/2003 CMS Term: 76497 TC RADIO DEF MAXFEE 02/01/2015 12/31/2023 52.00 0.0 Description: UNLISTED CT PROCEDURE Category: Radiology CMS Add: 01/01/2003 CMS Term: 76498 RADIO DEF BILL25 Description: UNLISTED MR PROCEDURE Category: Radiology CMS Add: 01/01/2003 CMS Term: 76499 RADIO DEF BILL25 Description: UNLISTED DX RADIOGRAPHIC PX Category: Radiology CMS Add: 01/01/1984 CMS Term: 76506 26 RADIO DEF RBRVS 01/01/2024 29.09 Description: ECHO EXAM OF HEAD Category: Radiology CMS Add: 01/01/1982 CMS Term: 76506 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 23.28 Description: ECHO EXAM OF HEAD Category: Radiology CMS Add: 01/01/1982 CMS Term: 76506 RADIO DEF RBRVS 01/01/2024 106.43 Description: ECHO EXAM OF HEAD Category: Radiology CMS Add: 01/01/1982 CMS Term: 76506 RADIO DEF RBRVS 02/01/2015 12/31/2023 87.36 Description: ECHO EXAM OF HEAD Category: Radiology CMS Add: 01/01/1982 CMS Term: 76506 TC RADIO DEF RBRVS 01/01/2024 77.34 Description: ECHO EXAM OF HEAD Category: Radiology CMS Add: 01/01/1982 CMS Term: 76506 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 64.08 Description: ECHO EXAM OF HEAD Category: Radiology CMS Add: 01/01/1982 CMS Term: 76510 26 MEDSV DEF RBRVS 01/01/2024 37.47 Description: OPH US DX B-SCAN&QUAN A-SCAN Category: Medical Services CMS Add: 01/01/2005 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 971 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 76510 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 69.80 Description: OPH US DX B-SCAN&QUAN A-SCAN Category: Medical Services CMS Add: 01/01/2005 CMS Term: 76510 MEDSV DEF RBRVS 01/01/2024 65.41 Description: OPH US DX B-SCAN&QUAN A-SCAN Category: Medical Services CMS Add: 01/01/2005 CMS Term: 76510 MEDSV DEF RBRVS 09/01/2019 12/31/2023 125.70 Description: OPH US DX B-SCAN&QUAN A-SCAN Category: Medical Services CMS Add: 01/01/2005 CMS Term: 76510 TC MEDSV DEF RBRVS 01/01/2024 27.95 Description: OPH US DX B-SCAN&QUAN A-SCAN Category: Medical Services CMS Add: 01/01/2005 CMS Term: 76510 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 55.90 Description: OPH US DX B-SCAN&QUAN A-SCAN Category: Medical Services CMS Add: 01/01/2005 CMS Term: 76511 26 MEDSV DEF RBRVS 01/01/2024 34.20 Description: OPH US DX QUAN A-SCAN ONLY Category: Medical Services CMS Add: 01/01/1982 CMS Term: 76511 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 39.54 Description: OPH US DX QUAN A-SCAN ONLY Category: Medical Services CMS Add: 01/01/1982 CMS Term: 76511 MEDSV DEF RBRVS 01/01/2024 54.12 Description: OPH US DX QUAN A-SCAN ONLY Category: Medical Services CMS Add: 01/01/1982 CMS Term: 76511 MEDSV DEF RBRVS 09/01/2019 12/31/2023 73.39 Description: OPH US DX QUAN A-SCAN ONLY Category: Medical Services CMS Add: 01/01/1982 CMS Term: 76511 TC MEDSV DEF RBRVS 01/01/2024 19.92 Description: OPH US DX QUAN A-SCAN ONLY Category: Medical Services CMS Add: 01/01/1982 CMS Term: 76511 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 33.85 Description: OPH US DX QUAN A-SCAN ONLY Category: Medical Services CMS Add: 01/01/1982 CMS Term: 76512 26 MEDSV DEF RBRVS 01/01/2024 29.33 Description: OPH US DX B-SCAN Category: Medical Services CMS Add: 01/01/1982 CMS Term: 76512 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 39.79 Description: OPH US DX B-SCAN Category: Medical Services CMS Add: 01/01/1982 CMS Term: 76512 MEDSV DEF RBRVS 01/01/2024 45.54 Description: OPH US DX B-SCAN Category: Medical Services CMS Add: 01/01/1982 CMS Term: 76512 MEDSV DEF RBRVS 09/01/2019 12/31/2023 67.20 Description: OPH US DX B-SCAN Category: Medical Services CMS Add: 01/01/1982 CMS Term: 76512 TC MEDSV DEF RBRVS 01/01/2024 16.21 Description: OPH US DX B-SCAN Category: Medical Services CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 972 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 76512 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 27.41 Description: OPH US DX B-SCAN Category: Medical Services CMS Add: 01/01/1982 CMS Term: 76513 26 MEDSV DEF RBRVS 01/01/2024 30.99 Description: OPH US DX ANT SGM US UNI/BI Category: Medical Services CMS Add: 01/01/1988 CMS Term: 76513 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 26.82 Description: OPH US DX ANT SGM US UNI/BI Category: Medical Services CMS Add: 01/01/1988 CMS Term: 76513 MEDSV DEF RBRVS 01/01/2024 70.67 Description: OPH US DX ANT SGM US UNI/BI Category: Medical Services CMS Add: 01/01/1988 CMS Term: 76513 MEDSV DEF RBRVS 09/01/2019 12/31/2023 68.35 Description: OPH US DX ANT SGM US UNI/BI Category: Medical Services CMS Add: 01/01/1988 CMS Term: 76513 TC MEDSV DEF RBRVS 01/01/2024 39.68 Description: OPH US DX ANT SGM US UNI/BI Category: Medical Services CMS Add: 01/01/1988 CMS Term: 76513 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 41.53 Description: OPH US DX ANT SGM US UNI/BI Category: Medical Services CMS Add: 01/01/1988 CMS Term: 76514 26 MEDSV DEF RBRVS 01/01/2024 7.37 Description: ECHO EXAM OF EYE THICKNESS Category: Medical Services CMS Add: 01/01/2004 CMS Term: 76514 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 7.21 Description: ECHO EXAM OF EYE THICKNESS Category: Medical Services CMS Add: 01/01/2004 CMS Term: 76514 MEDSV DEF RBRVS 01/01/2024 10.62 Description: ECHO EXAM OF EYE THICKNESS Category: Medical Services CMS Add: 01/01/2004 CMS Term: 76514 MEDSV DEF RBRVS 09/01/2019 12/31/2023 10.84 Description: ECHO EXAM OF EYE THICKNESS Category: Medical Services CMS Add: 01/01/2004 CMS Term: 76514 TC MEDSV DEF RBRVS 01/01/2024 3.25 Description: ECHO EXAM OF EYE THICKNESS Category: Medical Services CMS Add: 01/01/2004 CMS Term: 76514 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 3.63 Description: ECHO EXAM OF EYE THICKNESS Category: Medical Services CMS Add: 01/01/2004 CMS Term: 76516 26 MEDSV DEF RBRVS 01/01/2024 21.43 Description: ECHO EXAM OF EYE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 76516 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 22.85 Description: ECHO EXAM OF EYE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 76516 MEDSV DEF RBRVS 01/01/2024 43.82 Description: ECHO EXAM OF EYE Category: Medical Services CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 973 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 76516 MEDSV DEF RBRVS 09/01/2019 12/31/2023 55.71 Description: ECHO EXAM OF EYE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 76516 TC MEDSV DEF RBRVS 01/01/2024 22.39 Description: ECHO EXAM OF EYE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 76516 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 32.86 Description: ECHO EXAM OF EYE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 76519 26 MEDSV DEF RBRVS 01/01/2024 28.96 Description: ECHO EXAM OF EYE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 76519 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 23.43 Description: ECHO EXAM OF EYE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 76519 MEDSV DEF RBRVS 01/01/2024 63.38 Description: ECHO EXAM OF EYE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 76519 MEDSV DEF RBRVS 09/01/2019 12/31/2023 60.01 Description: ECHO EXAM OF EYE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 76519 TC MEDSV DEF RBRVS 01/01/2024 34.43 Description: ECHO EXAM OF EYE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 76519 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 36.58 Description: ECHO EXAM OF EYE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 76529 26 MEDSV DEF RBRVS 01/01/2024 30.59 Description: ECHO EXAM OF EYE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 76529 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 24.48 Description: ECHO EXAM OF EYE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 76529 MEDSV DEF RBRVS 01/01/2024 80.45 Description: ECHO EXAM OF EYE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 76529 MEDSV DEF RBRVS 02/01/2015 12/31/2023 56.85 Description: ECHO EXAM OF EYE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 76529 TC MEDSV DEF RBRVS 01/01/2024 49.86 Description: ECHO EXAM OF EYE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 76529 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 32.37 Description: ECHO EXAM OF EYE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 76536 26 RADIO DEF RBRVS 01/01/2024 26.10 Description: US EXAM OF HEAD AND NECK Category: Radiology CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 974 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 76536 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 20.74 Description: US EXAM OF HEAD AND NECK Category: Radiology CMS Add: 01/01/1986 CMS Term: 76536 RADIO DEF RBRVS 01/01/2024 104.37 Description: US EXAM OF HEAD AND NECK Category: Radiology CMS Add: 01/01/1986 CMS Term: 76536 RADIO DEF RBRVS 02/01/2015 12/31/2023 86.31 Description: US EXAM OF HEAD AND NECK Category: Radiology CMS Add: 01/01/1986 CMS Term: 76536 TC RADIO DEF RBRVS 01/01/2024 78.27 Description: US EXAM OF HEAD AND NECK Category: Radiology CMS Add: 01/01/1986 CMS Term: 76536 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 65.56 Description: US EXAM OF HEAD AND NECK Category: Radiology CMS Add: 01/01/1986 CMS Term: 76604 26 RADIO DEF RBRVS 01/01/2024 26.50 Description: US EXAM CHEST Category: Radiology CMS Add: 01/01/1982 CMS Term: 76604 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 19.98 Description: US EXAM CHEST Category: Radiology CMS Add: 01/01/1982 CMS Term: 76604 RADIO DEF RBRVS 01/01/2024 53.52 Description: US EXAM CHEST Category: Radiology CMS Add: 01/01/1982 CMS Term: 76604 RADIO DEF RBRVS 09/01/2019 12/31/2023 62.75 Description: US EXAM CHEST Category: Radiology CMS Add: 01/01/1982 CMS Term: 76604 TC RADIO DEF RBRVS 01/01/2024 27.02 Description: US EXAM CHEST Category: Radiology CMS Add: 01/01/1982 CMS Term: 76604 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 42.77 Description: US EXAM CHEST Category: Radiology CMS Add: 01/01/1982 CMS Term: 76641 26 RADIO DEF RBRVS 01/01/2024 33.72 Description: ULTRASOUND BREAST COMPLETE Category: Radiology CMS Add: 01/01/2015 CMS Term: 76641 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 27.13 Description: ULTRASOUND BREAST COMPLETE Category: Radiology CMS Add: 01/01/2015 CMS Term: 76641 RADIO DEF RBRVS 01/01/2024 97.47 Description: ULTRASOUND BREAST COMPLETE Category: Radiology CMS Add: 01/01/2015 CMS Term: 76641 RADIO DEF RBRVS 02/01/2015 12/31/2023 76.84 Description: ULTRASOUND BREAST COMPLETE Category: Radiology CMS Add: 01/01/2015 CMS Term: 76641 TC RADIO DEF RBRVS 01/01/2024 63.76 Description: ULTRASOUND BREAST COMPLETE Category: Radiology CMS Add: 01/01/2015 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 975 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 76641 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 49.71 Description: ULTRASOUND BREAST COMPLETE Category: Radiology CMS Add: 01/01/2015 CMS Term: 76642 26 RADIO DEF RBRVS 01/01/2024 31.40 Description: ULTRASOUND BREAST LIMITED Category: Radiology CMS Add: 01/01/2015 CMS Term: 76642 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 25.29 Description: ULTRASOUND BREAST LIMITED Category: Radiology CMS Add: 01/01/2015 CMS Term: 76642 RADIO DEF RBRVS 01/01/2024 80.34 Description: ULTRASOUND BREAST LIMITED Category: Radiology CMS Add: 01/01/2015 CMS Term: 76642 RADIO DEF RBRVS 02/01/2015 12/31/2023 63.35 Description: ULTRASOUND BREAST LIMITED Category: Radiology CMS Add: 01/01/2015 CMS Term: 76642 TC RADIO DEF RBRVS 01/01/2024 48.94 Description: ULTRASOUND BREAST LIMITED Category: Radiology CMS Add: 01/01/2015 CMS Term: 76642 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 38.07 Description: ULTRASOUND BREAST LIMITED Category: Radiology CMS Add: 01/01/2015 CMS Term: 76700 26 MRT DEF RBRVS 01/01/2024 37.05 Description: US EXAM ABDOM COMPLETE Category: Medical Review Team CMS Add: 01/01/1982 CMS Term: 76700 26 MRT DEF RBRVS 09/01/2019 12/31/2023 29.85 Description: US EXAM ABDOM COMPLETE Category: Medical Review Team CMS Add: 01/01/1982 CMS Term: 76700 26 RADIO DEF RBRVS 01/01/2024 37.05 Description: US EXAM ABDOM COMPLETE Category: Radiology CMS Add: 01/01/1982 CMS Term: 76700 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 29.85 Description: US EXAM ABDOM COMPLETE Category: Radiology CMS Add: 01/01/1982 CMS Term: 76700 MRT DEF RBRVS 01/01/2024 110.06 Description: US EXAM ABDOM COMPLETE Category: Medical Review Team CMS Add: 01/01/1982 CMS Term: 76700 MRT DEF RBRVS 09/01/2019 12/31/2023 100.12 Description: US EXAM ABDOM COMPLETE Category: Medical Review Team CMS Add: 01/01/1982 CMS Term: 76700 RADIO DEF RBRVS 01/01/2024 110.06 Description: US EXAM ABDOM COMPLETE Category: Radiology CMS Add: 01/01/1982 CMS Term: 76700 RADIO DEF RBRVS 09/01/2019 12/31/2023 100.12 Description: US EXAM ABDOM COMPLETE Category: Radiology CMS Add: 01/01/1982 CMS Term: 76700 TC MRT DEF RBRVS 01/01/2024 73.02 Description: US EXAM ABDOM COMPLETE Category: Medical Review Team CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 976 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 76700 TC MRT DEF RBRVS 09/01/2019 12/31/2023 70.27 Description: US EXAM ABDOM COMPLETE Category: Medical Review Team CMS Add: 01/01/1982 CMS Term: 76700 TC RADIO DEF RBRVS 01/01/2024 73.02 Description: US EXAM ABDOM COMPLETE Category: Radiology CMS Add: 01/01/1982 CMS Term: 76700 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 70.27 Description: US EXAM ABDOM COMPLETE Category: Radiology CMS Add: 01/01/1982 CMS Term: 76705 26 RADIO DEF RBRVS 01/01/2024 27.12 Description: ECHO EXAM OF ABDOMEN Category: Radiology CMS Add: 01/01/1982 CMS Term: 76705 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 21.55 Description: ECHO EXAM OF ABDOMEN Category: Radiology CMS Add: 01/01/1982 CMS Term: 76705 RADIO DEF RBRVS 01/01/2024 82.85 Description: ECHO EXAM OF ABDOMEN Category: Radiology CMS Add: 01/01/1982 CMS Term: 76705 RADIO DEF RBRVS 09/01/2019 12/31/2023 76.95 Description: ECHO EXAM OF ABDOMEN Category: Radiology CMS Add: 01/01/1982 CMS Term: 76705 TC RADIO DEF RBRVS 01/01/2024 55.73 Description: ECHO EXAM OF ABDOMEN Category: Radiology CMS Add: 01/01/1982 CMS Term: 76705 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 55.41 Description: ECHO EXAM OF ABDOMEN Category: Radiology CMS Add: 01/01/1982 CMS Term: 76706 26 RADIO DEF RBRVS 01/01/2017 12/31/2023 20.47 65-999years 0-1 Description: US ABDL AORTA SCREEN AAA Category: Radiology CMS Add: 01/01/2017 CMS Term: 76706 26 RADIO DEF RBRVS 01/01/2024 25.15 65-999years 0-1 Description: US ABDL AORTA SCREEN AAA Category: Radiology CMS Add: 01/01/2017 CMS Term: 76706 RADIO DEF RBRVS 01/01/2017 12/31/2023 66.71 65-999years 0-1 Description: US ABDL AORTA SCREEN AAA Category: Radiology CMS Add: 01/01/2017 CMS Term: 76706 RADIO DEF RBRVS 01/01/2024 100.02 65-999years 0-1 Description: US ABDL AORTA SCREEN AAA Category: Radiology CMS Add: 01/01/2017 CMS Term: 76706 TC RADIO DEF RBRVS 01/01/2017 12/31/2023 46.24 65-999years 0-1 Description: US ABDL AORTA SCREEN AAA Category: Radiology CMS Add: 01/01/2017 CMS Term: 76706 TC RADIO DEF RBRVS 01/01/2024 74.87 65-999years 0-1 Description: US ABDL AORTA SCREEN AAA Category: Radiology CMS Add: 01/01/2017 CMS Term: 76770 26 RADIO DEF RBRVS 01/01/2024 33.75 Description: US EXAM ABDO BACK WALL COMP Category: Radiology CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 977 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 76770 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 27.23 Description: US EXAM ABDO BACK WALL COMP Category: Radiology CMS Add: 01/01/1982 CMS Term: 76770 RADIO DEF RBRVS 01/01/2024 102.44 Description: US EXAM ABDO BACK WALL COMP Category: Radiology CMS Add: 01/01/1982 CMS Term: 76770 RADIO DEF RBRVS 09/01/2019 12/31/2023 94.28 Description: US EXAM ABDO BACK WALL COMP Category: Radiology CMS Add: 01/01/1982 CMS Term: 76770 TC RADIO DEF RBRVS 01/01/2024 68.70 Description: US EXAM ABDO BACK WALL COMP Category: Radiology CMS Add: 01/01/1982 CMS Term: 76770 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 67.05 Description: US EXAM ABDO BACK WALL COMP Category: Radiology CMS Add: 01/01/1982 CMS Term: 76775 26 RADIO DEF RBRVS 01/01/2024 26.47 Description: US EXAM ABDO BACK WALL LIM Category: Radiology CMS Add: 01/01/1982 CMS Term: 76775 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 21.28 Description: US EXAM ABDO BACK WALL LIM Category: Radiology CMS Add: 01/01/1982 CMS Term: 76775 RADIO DEF RBRVS 01/01/2024 55.65 Description: US EXAM ABDO BACK WALL LIM Category: Radiology CMS Add: 01/01/1982 CMS Term: 76775 RADIO DEF RBRVS 09/01/2019 12/31/2023 46.71 Description: US EXAM ABDO BACK WALL LIM Category: Radiology CMS Add: 01/01/1982 CMS Term: 76775 TC RADIO DEF RBRVS 01/01/2024 29.18 Description: US EXAM ABDO BACK WALL LIM Category: Radiology CMS Add: 01/01/1982 CMS Term: 76775 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 25.43 Description: US EXAM ABDO BACK WALL LIM Category: Radiology CMS Add: 01/01/1982 CMS Term: 76776 26 RADIO DEF RBRVS 01/01/2024 34.73 Description: US EXAM K TRANSPL W/DOPPLER Category: Radiology CMS Add: 01/01/2007 CMS Term: 76776 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 28.02 Description: US EXAM K TRANSPL W/DOPPLER Category: Radiology CMS Add: 01/01/2007 CMS Term: 76776 RADIO DEF RBRVS 01/01/2024 139.09 Description: US EXAM K TRANSPL W/DOPPLER Category: Radiology CMS Add: 01/01/2007 CMS Term: 76776 RADIO DEF RBRVS 02/01/2015 12/31/2023 109.43 Description: US EXAM K TRANSPL W/DOPPLER Category: Radiology CMS Add: 01/01/2007 CMS Term: 76776 TC RADIO DEF RBRVS 01/01/2024 104.36 Description: US EXAM K TRANSPL W/DOPPLER Category: Radiology CMS Add: 01/01/2007 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 978 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 76776 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 81.42 Description: US EXAM K TRANSPL W/DOPPLER Category: Radiology CMS Add: 01/01/2007 CMS Term: 76800 26 RADIO DEF RBRVS 01/01/2024 56.32 Description: US EXAM SPINAL CANAL Category: Radiology CMS Add: 01/01/1990 CMS Term: 76800 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 41.67 Description: US EXAM SPINAL CANAL Category: Radiology CMS Add: 01/01/1990 CMS Term: 76800 RADIO DEF RBRVS 01/01/2024 145.70 Description: US EXAM SPINAL CANAL Category: Radiology CMS Add: 01/01/1990 CMS Term: 76800 RADIO DEF RBRVS 02/01/2015 12/31/2023 99.06 Description: US EXAM SPINAL CANAL Category: Radiology CMS Add: 01/01/1990 CMS Term: 76800 TC RADIO DEF RBRVS 01/01/2024 89.38 Description: US EXAM SPINAL CANAL Category: Radiology CMS Add: 01/01/1990 CMS Term: 76800 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 57.39 Description: US EXAM SPINAL CANAL Category: Radiology CMS Add: 01/01/1990 CMS Term: 76801 26 RADIO DEF RBRVS 01/01/2024 45.61 Description: OB US < 14 WKS SINGLE FETUS Category: Radiology CMS Add: 01/01/2003 CMS Term: 76801 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 36.26 Description: OB US < 14 WKS SINGLE FETUS Category: Radiology CMS Add: 01/01/2003 CMS Term: 76801 RADIO DEF RBRVS 01/01/2024 111.53 Description: OB US < 14 WKS SINGLE FETUS Category: Radiology CMS Add: 01/01/2003 CMS Term: 76801 RADIO DEF RBRVS 02/01/2015 12/31/2023 90.18 Description: OB US < 14 WKS SINGLE FETUS Category: Radiology CMS Add: 01/01/2003 CMS Term: 76801 TC RADIO DEF RBRVS 01/01/2024 65.92 Description: OB US < 14 WKS SINGLE FETUS Category: Radiology CMS Add: 01/01/2003 CMS Term: 76801 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 53.92 Description: OB US < 14 WKS SINGLE FETUS Category: Radiology CMS Add: 01/01/2003 CMS Term: 76802 26 RADIO DEF RBRVS 01/01/2024 38.65 Description: OB US < 14 WKS ADDL FETUS Category: Radiology CMS Add: 01/01/2003 CMS Term: 76802 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 30.72 Description: OB US < 14 WKS ADDL FETUS Category: Radiology CMS Add: 01/01/2003 CMS Term: 76802 RADIO DEF RBRVS 01/01/2024 58.41 Description: OB US < 14 WKS ADDL FETUS Category: Radiology CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 979 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 76802 RADIO DEF RBRVS 02/01/2015 12/31/2023 48.48 Description: OB US < 14 WKS ADDL FETUS Category: Radiology CMS Add: 01/01/2003 CMS Term: 76802 TC RADIO DEF RBRVS 01/01/2024 19.76 Description: OB US < 14 WKS ADDL FETUS Category: Radiology CMS Add: 01/01/2003 CMS Term: 76802 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 17.75 Description: OB US < 14 WKS ADDL FETUS Category: Radiology CMS Add: 01/01/2003 CMS Term: 76805 26 RADIO DEF RBRVS 01/01/2024 45.92 Description: OB US >= 14 WKS SNGL FETUS Category: Radiology CMS Add: 01/01/1982 CMS Term: 76805 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 36.51 Description: OB US >= 14 WKS SNGL FETUS Category: Radiology CMS Add: 01/01/1982 CMS Term: 76805 RADIO DEF RBRVS 01/01/2024 128.05 Description: OB US >= 14 WKS SNGL FETUS Category: Radiology CMS Add: 01/01/1982 CMS Term: 76805 RADIO DEF RBRVS 02/01/2015 12/31/2023 104.05 Description: OB US >= 14 WKS SNGL FETUS Category: Radiology CMS Add: 01/01/1982 CMS Term: 76805 TC RADIO DEF RBRVS 01/01/2024 82.13 Description: OB US >= 14 WKS SNGL FETUS Category: Radiology CMS Add: 01/01/1982 CMS Term: 76805 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 67.54 Description: OB US >= 14 WKS SNGL FETUS Category: Radiology CMS Add: 01/01/1982 CMS Term: 76810 26 RADIO DEF RBRVS 01/01/2024 45.58 Description: OB US >= 14 WKS ADDL FETUS Category: Radiology CMS Add: 01/01/1992 CMS Term: 76810 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 36.24 Description: OB US >= 14 WKS ADDL FETUS Category: Radiology CMS Add: 01/01/1992 CMS Term: 76810 RADIO DEF RBRVS 01/01/2024 84.03 Description: OB US >= 14 WKS ADDL FETUS Category: Radiology CMS Add: 01/01/1992 CMS Term: 76810 RADIO DEF RBRVS 02/01/2015 12/31/2023 69.60 Description: OB US >= 14 WKS ADDL FETUS Category: Radiology CMS Add: 01/01/1992 CMS Term: 76810 TC RADIO DEF RBRVS 01/01/2024 38.44 Description: OB US >= 14 WKS ADDL FETUS Category: Radiology CMS Add: 01/01/1992 CMS Term: 76810 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 33.36 Description: OB US >= 14 WKS ADDL FETUS Category: Radiology CMS Add: 01/01/1992 CMS Term: 76811 26 RADIO DEF RBRVS 01/01/2024 87.87 Description: OB US DETAILED SNGL FETUS Category: Radiology CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 980 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 76811 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 70.45 Description: OB US DETAILED SNGL FETUS Category: Radiology CMS Add: 01/01/2003 CMS Term: 76811 RADIO DEF RBRVS 01/01/2024 167.24 Description: OB US DETAILED SNGL FETUS Category: Radiology CMS Add: 01/01/2003 CMS Term: 76811 RADIO DEF RBRVS 02/01/2015 12/31/2023 133.04 Description: OB US DETAILED SNGL FETUS Category: Radiology CMS Add: 01/01/2003 CMS Term: 76811 TC RADIO DEF RBRVS 01/01/2024 79.37 Description: OB US DETAILED SNGL FETUS Category: Radiology CMS Add: 01/01/2003 CMS Term: 76811 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 62.59 Description: OB US DETAILED SNGL FETUS Category: Radiology CMS Add: 01/01/2003 CMS Term: 76812 26 RADIO DEF RBRVS 01/01/2024 82.26 Description: OB US DETAILED ADDL FETUS Category: Radiology CMS Add: 01/01/2003 CMS Term: 76812 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 66.24 Description: OB US DETAILED ADDL FETUS Category: Radiology CMS Add: 01/01/2003 CMS Term: 76812 RADIO DEF RBRVS 01/01/2024 181.99 Description: OB US DETAILED ADDL FETUS Category: Radiology CMS Add: 01/01/2003 CMS Term: 76812 RADIO DEF RBRVS 02/01/2015 12/31/2023 150.13 Description: OB US DETAILED ADDL FETUS Category: Radiology CMS Add: 01/01/2003 CMS Term: 76812 TC RADIO DEF RBRVS 01/01/2024 99.73 Description: OB US DETAILED ADDL FETUS Category: Radiology CMS Add: 01/01/2003 CMS Term: 76812 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 83.89 Description: OB US DETAILED ADDL FETUS Category: Radiology CMS Add: 01/01/2003 CMS Term: 76813 26 RADIO DEF RBRVS 01/01/2024 54.83 Description: OB US NUCHAL MEAS 1 GEST Category: Radiology CMS Add: 01/01/2007 CMS Term: 76813 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 43.76 Description: OB US NUCHAL MEAS 1 GEST Category: Radiology CMS Add: 01/01/2007 CMS Term: 76813 RADIO DEF RBRVS 01/01/2024 111.49 Description: OB US NUCHAL MEAS 1 GEST Category: Radiology CMS Add: 01/01/2007 CMS Term: 76813 RADIO DEF RBRVS 02/01/2015 12/31/2023 86.78 Description: OB US NUCHAL MEAS 1 GEST Category: Radiology CMS Add: 01/01/2007 CMS Term: 76813 TC RADIO DEF RBRVS 01/01/2024 56.66 Description: OB US NUCHAL MEAS 1 GEST Category: Radiology CMS Add: 01/01/2007 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 981 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 76813 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 43.02 Description: OB US NUCHAL MEAS 1 GEST Category: Radiology CMS Add: 01/01/2007 CMS Term: 76814 26 RADIO DEF RBRVS 01/01/2024 45.60 Description: OB US NUCHAL MEAS ADD-ON Category: Radiology CMS Add: 01/01/2007 CMS Term: 76814 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 36.75 Description: OB US NUCHAL MEAS ADD-ON Category: Radiology CMS Add: 01/01/2007 CMS Term: 76814 RADIO DEF RBRVS 01/01/2024 71.69 Description: OB US NUCHAL MEAS ADD-ON Category: Radiology CMS Add: 01/01/2007 CMS Term: 76814 RADIO DEF RBRVS 02/01/2015 12/31/2023 57.48 Description: OB US NUCHAL MEAS ADD-ON Category: Radiology CMS Add: 01/01/2007 CMS Term: 76814 TC RADIO DEF RBRVS 01/01/2024 26.09 Description: OB US NUCHAL MEAS ADD-ON Category: Radiology CMS Add: 01/01/2007 CMS Term: 76814 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 20.73 Description: OB US NUCHAL MEAS ADD-ON Category: Radiology CMS Add: 01/01/2007 CMS Term: 76815 26 RADIO DEF RBRVS 01/01/2024 30.08 Description: OB US LIMITED FETUS(S) Category: Radiology CMS Add: 01/01/1982 CMS Term: 76815 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 23.82 Description: OB US LIMITED FETUS(S) Category: Radiology CMS Add: 01/01/1982 CMS Term: 76815 RADIO DEF RBRVS 01/01/2024 76.86 Description: OB US LIMITED FETUS(S) Category: Radiology CMS Add: 01/01/1982 CMS Term: 76815 RADIO DEF RBRVS 02/01/2015 12/31/2023 64.36 Description: OB US LIMITED FETUS(S) Category: Radiology CMS Add: 01/01/1982 CMS Term: 76815 TC RADIO DEF RBRVS 01/01/2024 46.78 Description: OB US LIMITED FETUS(S) Category: Radiology CMS Add: 01/01/1982 CMS Term: 76815 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 40.54 Description: OB US LIMITED FETUS(S) Category: Radiology CMS Add: 01/01/1982 CMS Term: 76816 26 RADIO DEF RBRVS 01/01/2024 39.31 Description: OB US FOLLOW-UP PER FETUS Category: Radiology CMS Add: 01/01/1986 CMS Term: 76816 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 31.51 Description: OB US FOLLOW-UP PER FETUS Category: Radiology CMS Add: 01/01/1986 CMS Term: 76816 RADIO DEF RBRVS 01/01/2024 103.69 Description: OB US FOLLOW-UP PER FETUS Category: Radiology CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 982 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 76816 RADIO DEF RBRVS 02/01/2015 12/31/2023 82.95 Description: OB US FOLLOW-UP PER FETUS Category: Radiology CMS Add: 01/01/1986 CMS Term: 76816 TC RADIO DEF RBRVS 01/01/2024 64.37 Description: OB US FOLLOW-UP PER FETUS Category: Radiology CMS Add: 01/01/1986 CMS Term: 76816 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 51.44 Description: OB US FOLLOW-UP PER FETUS Category: Radiology CMS Add: 01/01/1986 CMS Term: 76817 26 RADIO DEF RBRVS 01/01/2024 34.70 Description: TRANSVAGINAL US OBSTETRIC Category: Radiology CMS Add: 01/01/2003 CMS Term: 76817 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 27.83 Description: TRANSVAGINAL US OBSTETRIC Category: Radiology CMS Add: 01/01/2003 CMS Term: 76817 RADIO DEF RBRVS 01/01/2024 87.65 Description: TRANSVAGINAL US OBSTETRIC Category: Radiology CMS Add: 01/01/2003 CMS Term: 76817 RADIO DEF RBRVS 02/01/2015 12/31/2023 72.34 Description: TRANSVAGINAL US OBSTETRIC Category: Radiology CMS Add: 01/01/2003 CMS Term: 76817 TC RADIO DEF RBRVS 01/01/2024 52.95 Description: TRANSVAGINAL US OBSTETRIC Category: Radiology CMS Add: 01/01/2003 CMS Term: 76817 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 44.51 Description: TRANSVAGINAL US OBSTETRIC Category: Radiology CMS Add: 01/01/2003 CMS Term: 76818 26 RADIO DEF RBRVS 01/01/2024 48.88 Description: FETAL BIOPHYS PROFILE W/NST Category: Radiology CMS Add: 01/01/1986 CMS Term: 76818 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 39.11 Description: FETAL BIOPHYS PROFILE W/NST Category: Radiology CMS Add: 01/01/1986 CMS Term: 76818 RADIO DEF RBRVS 01/01/2024 110.33 Description: FETAL BIOPHYS PROFILE W/NST Category: Radiology CMS Add: 01/01/1986 CMS Term: 76818 RADIO DEF RBRVS 02/01/2015 12/31/2023 87.33 Description: FETAL BIOPHYS PROFILE W/NST Category: Radiology CMS Add: 01/01/1986 CMS Term: 76818 TC RADIO DEF RBRVS 01/01/2024 61.45 Description: FETAL BIOPHYS PROFILE W/NST Category: Radiology CMS Add: 01/01/1986 CMS Term: 76818 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 48.22 Description: FETAL BIOPHYS PROFILE W/NST Category: Radiology CMS Add: 01/01/1986 CMS Term: 76819 26 RADIO DEF RBRVS 01/01/2024 35.37 Description: FETAL BIOPHYS PROFIL W/O NST Category: Radiology CMS Add: 01/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 983 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 76819 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 28.61 Description: FETAL BIOPHYS PROFIL W/O NST Category: Radiology CMS Add: 01/01/2001 CMS Term: 76819 RADIO DEF RBRVS 01/01/2024 79.67 Description: FETAL BIOPHYS PROFIL W/O NST Category: Radiology CMS Add: 01/01/2001 CMS Term: 76819 RADIO DEF RBRVS 02/01/2015 12/31/2023 63.96 Description: FETAL BIOPHYS PROFIL W/O NST Category: Radiology CMS Add: 01/01/2001 CMS Term: 76819 TC RADIO DEF RBRVS 01/01/2024 44.31 Description: FETAL BIOPHYS PROFIL W/O NST Category: Radiology CMS Add: 01/01/2001 CMS Term: 76819 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 35.34 Description: FETAL BIOPHYS PROFIL W/O NST Category: Radiology CMS Add: 01/01/2001 CMS Term: 76820 26 RADIO DEF RBRVS 01/01/2024 22.97 Description: UMBILICAL ARTERY ECHO Category: Radiology CMS Add: 01/01/2005 CMS Term: 76820 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 18.55 Description: UMBILICAL ARTERY ECHO Category: Radiology CMS Add: 01/01/2005 CMS Term: 76820 RADIO DEF RBRVS 01/01/2024 42.58 Description: UMBILICAL ARTERY ECHO Category: Radiology CMS Add: 01/01/2005 CMS Term: 76820 RADIO DEF RBRVS 02/01/2015 12/31/2023 35.07 Description: UMBILICAL ARTERY ECHO Category: Radiology CMS Add: 01/01/2005 CMS Term: 76820 TC RADIO DEF RBRVS 01/01/2024 19.61 Description: UMBILICAL ARTERY ECHO Category: Radiology CMS Add: 01/01/2005 CMS Term: 76820 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 16.51 Description: UMBILICAL ARTERY ECHO Category: Radiology CMS Add: 01/01/2005 CMS Term: 76821 26 RADIO DEF RBRVS 01/01/2024 32.38 Description: MIDDLE CEREBRAL ARTERY ECHO Category: Radiology CMS Add: 01/01/2005 CMS Term: 76821 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 26.24 Description: MIDDLE CEREBRAL ARTERY ECHO Category: Radiology CMS Add: 01/01/2005 CMS Term: 76821 RADIO DEF RBRVS 01/01/2024 83.79 Description: MIDDLE CEREBRAL ARTERY ECHO Category: Radiology CMS Add: 01/01/2005 CMS Term: 76821 RADIO DEF RBRVS 02/01/2015 12/31/2023 67.03 Description: MIDDLE CEREBRAL ARTERY ECHO Category: Radiology CMS Add: 01/01/2005 CMS Term: 76821 TC RADIO DEF RBRVS 01/01/2024 51.41 Description: MIDDLE CEREBRAL ARTERY ECHO Category: Radiology CMS Add: 01/01/2005 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 984 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 76821 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 40.79 Description: MIDDLE CEREBRAL ARTERY ECHO Category: Radiology CMS Add: 01/01/2005 CMS Term: 76825 26 RADIO DEF RBRVS 01/01/2024 76.68 Description: ECHO EXAM OF FETAL HEART Category: Radiology CMS Add: 01/01/1986 CMS Term: 76825 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 61.14 Description: ECHO EXAM OF FETAL HEART Category: Radiology CMS Add: 01/01/1986 CMS Term: 76825 RADIO DEF RBRVS 01/01/2024 246.81 Description: ECHO EXAM OF FETAL HEART Category: Radiology CMS Add: 01/01/1986 CMS Term: 76825 RADIO DEF RBRVS 02/01/2015 12/31/2023 194.57 Description: ECHO EXAM OF FETAL HEART Category: Radiology CMS Add: 01/01/1986 CMS Term: 76825 TC RADIO DEF RBRVS 01/01/2024 170.13 Description: ECHO EXAM OF FETAL HEART Category: Radiology CMS Add: 01/01/1986 CMS Term: 76825 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 133.44 Description: ECHO EXAM OF FETAL HEART Category: Radiology CMS Add: 01/01/1986 CMS Term: 76826 26 RADIO DEF RBRVS 01/01/2024 38.02 Description: ECHO EXAM OF FETAL HEART Category: Radiology CMS Add: 01/01/1993 CMS Term: 76826 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 30.47 Description: ECHO EXAM OF FETAL HEART Category: Radiology CMS Add: 01/01/1993 CMS Term: 76826 RADIO DEF RBRVS 01/01/2024 147.32 Description: ECHO EXAM OF FETAL HEART Category: Radiology CMS Add: 01/01/1993 CMS Term: 76826 RADIO DEF RBRVS 02/01/2015 12/31/2023 116.10 Description: ECHO EXAM OF FETAL HEART Category: Radiology CMS Add: 01/01/1993 CMS Term: 76826 TC RADIO DEF RBRVS 01/01/2024 109.30 Description: ECHO EXAM OF FETAL HEART Category: Radiology CMS Add: 01/01/1993 CMS Term: 76826 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 85.63 Description: ECHO EXAM OF FETAL HEART Category: Radiology CMS Add: 01/01/1993 CMS Term: 76827 26 RADIO DEF RBRVS 01/01/2024 26.77 Description: ECHO EXAM OF FETAL HEART Category: Radiology CMS Add: 01/01/1993 CMS Term: 76827 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 21.20 Description: ECHO EXAM OF FETAL HEART Category: Radiology CMS Add: 01/01/1993 CMS Term: 76827 RADIO DEF RBRVS 01/01/2024 65.83 Description: ECHO EXAM OF FETAL HEART Category: Radiology CMS Add: 01/01/1993 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 985 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 76827 RADIO DEF RBRVS 02/01/2015 12/31/2023 53.81 Description: ECHO EXAM OF FETAL HEART Category: Radiology CMS Add: 01/01/1993 CMS Term: 76827 TC RADIO DEF RBRVS 01/01/2024 39.06 Description: ECHO EXAM OF FETAL HEART Category: Radiology CMS Add: 01/01/1993 CMS Term: 76827 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 32.62 Description: ECHO EXAM OF FETAL HEART Category: Radiology CMS Add: 01/01/1993 CMS Term: 76828 26 RADIO DEF RBRVS 01/01/2024 25.62 Description: ECHO EXAM OF FETAL HEART Category: Radiology CMS Add: 01/01/1993 CMS Term: 76828 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 20.66 Description: ECHO EXAM OF FETAL HEART Category: Radiology CMS Add: 01/01/1993 CMS Term: 76828 RADIO DEF RBRVS 01/01/2024 46.77 Description: ECHO EXAM OF FETAL HEART Category: Radiology CMS Add: 01/01/1993 CMS Term: 76828 RADIO DEF RBRVS 02/01/2015 12/31/2023 37.92 Description: ECHO EXAM OF FETAL HEART Category: Radiology CMS Add: 01/01/1993 CMS Term: 76828 TC RADIO DEF RBRVS 01/01/2024 21.15 Description: ECHO EXAM OF FETAL HEART Category: Radiology CMS Add: 01/01/1993 CMS Term: 76828 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 17.26 Description: ECHO EXAM OF FETAL HEART Category: Radiology CMS Add: 01/01/1993 CMS Term: 76830 26 RADIO DEF RBRVS 01/01/2024 32.05 Description: TRANSVAGINAL US NON-OB Category: Radiology CMS Add: 01/01/1990 CMS Term: 76830 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 25.47 Description: TRANSVAGINAL US NON-OB Category: Radiology CMS Add: 01/01/1990 CMS Term: 76830 RADIO DEF RBRVS 01/01/2024 112.79 Description: TRANSVAGINAL US NON-OB Category: Radiology CMS Add: 01/01/1990 CMS Term: 76830 RADIO DEF RBRVS 02/01/2015 12/31/2023 89.55 Description: TRANSVAGINAL US NON-OB Category: Radiology CMS Add: 01/01/1990 CMS Term: 76830 TC RADIO DEF RBRVS 01/01/2024 80.73 Description: TRANSVAGINAL US NON-OB Category: Radiology CMS Add: 01/01/1990 CMS Term: 76830 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 64.08 Description: TRANSVAGINAL US NON-OB Category: Radiology CMS Add: 01/01/1990 CMS Term: 76831 26 RADIO DEF RBRVS 01/01/2024 33.36 Description: ECHO EXAM UTERUS Category: Radiology CMS Add: 01/01/1998 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 986 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 76831 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 26.78 Description: ECHO EXAM UTERUS Category: Radiology CMS Add: 01/01/1998 CMS Term: 76831 RADIO DEF RBRVS 01/01/2024 109.78 Description: ECHO EXAM UTERUS Category: Radiology CMS Add: 01/01/1998 CMS Term: 76831 RADIO DEF RBRVS 09/01/2019 12/31/2023 87.88 Description: ECHO EXAM UTERUS Category: Radiology CMS Add: 01/01/1998 CMS Term: 76831 TC RADIO DEF RBRVS 01/01/2024 76.41 Description: ECHO EXAM UTERUS Category: Radiology CMS Add: 01/01/1998 CMS Term: 76831 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 61.10 Description: ECHO EXAM UTERUS Category: Radiology CMS Add: 01/01/1998 CMS Term: 76856 26 RADIO DEF RBRVS 01/01/2024 31.74 Description: US EXAM PELVIC COMPLETE Category: Radiology CMS Add: 01/01/1982 CMS Term: 76856 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 25.23 Description: US EXAM PELVIC COMPLETE Category: Radiology CMS Add: 01/01/1982 CMS Term: 76856 RADIO DEF RBRVS 01/01/2024 99.51 Description: US EXAM PELVIC COMPLETE Category: Radiology CMS Add: 01/01/1982 CMS Term: 76856 RADIO DEF RBRVS 09/01/2019 12/31/2023 88.06 Description: US EXAM PELVIC COMPLETE Category: Radiology CMS Add: 01/01/1982 CMS Term: 76856 TC RADIO DEF RBRVS 01/01/2024 67.77 Description: US EXAM PELVIC COMPLETE Category: Radiology CMS Add: 01/01/1982 CMS Term: 76856 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 62.84 Description: US EXAM PELVIC COMPLETE Category: Radiology CMS Add: 01/01/1982 CMS Term: 76857 26 RADIO DEF RBRVS 01/01/2024 22.82 Description: US EXAM PELVIC LIMITED Category: Radiology CMS Add: 01/01/1986 CMS Term: 76857 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 13.93 Description: US EXAM PELVIC LIMITED Category: Radiology CMS Add: 01/01/1986 CMS Term: 76857 RADIO DEF RBRVS 01/01/2024 46.14 Description: US EXAM PELVIC LIMITED Category: Radiology CMS Add: 01/01/1986 CMS Term: 76857 RADIO DEF RBRVS 09/01/2019 12/31/2023 38.12 Description: US EXAM PELVIC LIMITED Category: Radiology CMS Add: 01/01/1986 CMS Term: 76857 TC RADIO DEF RBRVS 01/01/2024 23.31 Description: US EXAM PELVIC LIMITED Category: Radiology CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 987 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 76857 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 24.19 Description: US EXAM PELVIC LIMITED Category: Radiology CMS Add: 01/01/1986 CMS Term: 76870 26 RADIO DEF RBRVS 01/01/2024 29.43 Description: US EXAM SCROTUM Category: Radiology CMS Add: 01/01/1983 CMS Term: 76870 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 23.55 Description: US EXAM SCROTUM Category: Radiology CMS Add: 01/01/1983 CMS Term: 76870 RADIO DEF RBRVS 01/01/2024 95.04 Description: US EXAM SCROTUM Category: Radiology CMS Add: 01/01/1983 CMS Term: 76870 RADIO DEF RBRVS 09/01/2019 12/31/2023 52.70 Description: US EXAM SCROTUM Category: Radiology CMS Add: 01/01/1983 CMS Term: 76870 TC RADIO DEF RBRVS 01/01/2024 65.61 Description: US EXAM SCROTUM Category: Radiology CMS Add: 01/01/1983 CMS Term: 76870 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 29.15 Description: US EXAM SCROTUM Category: Radiology CMS Add: 01/01/1983 CMS Term: 76872 26 RADIO DEF RBRVS 01/01/2024 31.11 Description: US TRANSRECTAL Category: Radiology CMS Add: 01/01/1990 CMS Term: 76872 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 25.14 Description: US TRANSRECTAL Category: Radiology CMS Add: 01/01/1990 CMS Term: 76872 RADIO DEF RBRVS 01/01/2024 187.64 Description: US TRANSRECTAL Category: Radiology CMS Add: 01/01/1990 CMS Term: 76872 RADIO DEF RBRVS 02/01/2015 12/31/2023 65.93 Description: US TRANSRECTAL Category: Radiology CMS Add: 01/01/1990 CMS Term: 76872 TC RADIO DEF RBRVS 01/01/2024 156.53 Description: US TRANSRECTAL Category: Radiology CMS Add: 01/01/1990 CMS Term: 76872 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 40.79 Description: US TRANSRECTAL Category: Radiology CMS Add: 01/01/1990 CMS Term: 76873 26 RADIO DEF RBRVS 01/01/2017 12/31/2023 57.58 0-1 Description: ECHOGRAP TRANS R PROS STUDY Category: Radiology CMS Add: 01/01/2000 CMS Term: 76873 26 RADIO DEF RBRVS 01/01/2024 73.56 0-1 Description: ECHOGRAP TRANS R PROS STUDY Category: Radiology CMS Add: 01/01/2000 CMS Term: 76873 RADIO DEF RBRVS 01/01/2017 12/31/2023 122.65 0-1 Description: ECHOGRAP TRANS R PROS STUDY Category: Radiology CMS Add: 01/01/2000 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 988 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 76873 RADIO DEF RBRVS 01/01/2024 164.95 0-1 Description: ECHOGRAP TRANS R PROS STUDY Category: Radiology CMS Add: 01/01/2000 CMS Term: 76873 TC RADIO DEF RBRVS 01/01/2017 12/31/2023 65.07 0-1 Description: ECHOGRAP TRANS R PROS STUDY Category: Radiology CMS Add: 01/01/2000 CMS Term: 76873 TC RADIO DEF RBRVS 01/01/2024 91.39 0-1 Description: ECHOGRAP TRANS R PROS STUDY Category: Radiology CMS Add: 01/01/2000 CMS Term: 76881 26 RADIO DEF RBRVS 01/01/2019 12/31/2023 23.28 Description: US COMPL JOINT R-T W/IMG Category: Radiology CMS Add: 01/01/2011 CMS Term: 76881 26 RADIO DEF RBRVS 01/01/2024 41.64 Description: US COMPL JOINT R-T W/IMG Category: Radiology CMS Add: 01/01/2011 CMS Term: 76881 RADIO DEF RBRVS 01/01/2019 12/31/2023 83.89 Description: US COMPL JOINT R-T W/IMG Category: Radiology CMS Add: 01/01/2011 CMS Term: 76881 RADIO DEF RBRVS 01/01/2024 51.68 Description: US COMPL JOINT R-T W/IMG Category: Radiology CMS Add: 01/01/2011 CMS Term: 76881 TC RADIO DEF RBRVS 01/01/2019 12/31/2023 60.61 Description: US COMPL JOINT R-T W/IMG Category: Radiology CMS Add: 01/01/2011 CMS Term: 76881 TC RADIO DEF RBRVS 01/01/2024 10.04 Description: US COMPL JOINT R-T W/IMG Category: Radiology CMS Add: 01/01/2011 CMS Term: 76882 26 RADIO DEF RBRVS 01/01/2019 12/31/2023 18.04 Description: US LMTD JT/FCL EVL NVASC XTR Category: Radiology CMS Add: 01/01/2011 CMS Term: 76882 26 RADIO DEF RBRVS 01/01/2024 31.74 Description: US LMTD JT/FCL EVL NVASC XTR Category: Radiology CMS Add: 01/01/2011 CMS Term: 76882 RADIO DEF RBRVS 01/01/2019 12/31/2023 25.63 Description: US LMTD JT/FCL EVL NVASC XTR Category: Radiology CMS Add: 01/01/2011 CMS Term: 76882 RADIO DEF RBRVS 01/01/2024 40.24 Description: US LMTD JT/FCL EVL NVASC XTR Category: Radiology CMS Add: 01/01/2011 CMS Term: 76882 TC RADIO DEF RBRVS 01/01/2019 12/31/2023 7.60 Description: US LMTD JT/FCL EVL NVASC XTR Category: Radiology CMS Add: 01/01/2011 CMS Term: 76882 TC RADIO DEF RBRVS 01/01/2024 8.50 Description: US LMTD JT/FCL EVL NVASC XTR Category: Radiology CMS Add: 01/01/2011 CMS Term: 76883 26 RADIO DEF RBRVS 01/01/2024 55.55 Description: US NRV&ACC STRUX 1XTR COMPRE Category: Radiology CMS Add: 01/01/2023 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 989 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 76883 RADIO DEF RBRVS 01/01/2023 12/31/2023 54.97 Description: US NRV&ACC STRUX 1XTR COMPRE Category: Radiology CMS Add: 01/01/2023 CMS Term: 76883 RADIO DEF RBRVS 01/01/2024 68.99 Description: US NRV&ACC STRUX 1XTR COMPRE Category: Radiology CMS Add: 01/01/2023 CMS Term: 76883 TC RADIO DEF RBRVS 01/01/2024 13.44 Description: US NRV&ACC STRUX 1XTR COMPRE Category: Radiology CMS Add: 01/01/2023 CMS Term: 76885 26 RADIO DEF RBRVS 01/01/2024 34.06 0-364days Description: US EXAM INFANT HIPS DYNAMIC Category: Radiology CMS Add: 01/01/1998 CMS Term: 76885 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 27.23 0-364days Description: US EXAM INFANT HIPS DYNAMIC Category: Radiology CMS Add: 01/01/1998 CMS Term: 76885 RADIO DEF RBRVS 01/01/2024 128.53 0-364days Description: US EXAM INFANT HIPS DYNAMIC Category: Radiology CMS Add: 01/01/1998 CMS Term: 76885 RADIO DEF RBRVS 02/01/2015 12/31/2023 105.18 0-364days Description: US EXAM INFANT HIPS DYNAMIC Category: Radiology CMS Add: 01/01/1998 CMS Term: 76885 TC RADIO DEF RBRVS 01/01/2024 94.48 0-364days Description: US EXAM INFANT HIPS DYNAMIC Category: Radiology CMS Add: 01/01/1998 CMS Term: 76885 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 77.95 0-364days Description: US EXAM INFANT HIPS DYNAMIC Category: Radiology CMS Add: 01/01/1998 CMS Term: 76886 26 RADIO DEF RBRVS 01/01/2024 28.75 0-364days Description: US EXAM INFANT HIPS STATIC Category: Radiology CMS Add: 01/01/1998 CMS Term: 76886 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 22.52 0-364days Description: US EXAM INFANT HIPS STATIC Category: Radiology CMS Add: 01/01/1998 CMS Term: 76886 RADIO DEF RBRVS 01/01/2024 94.98 0-364days Description: US EXAM INFANT HIPS STATIC Category: Radiology CMS Add: 01/01/1998 CMS Term: 76886 RADIO DEF RBRVS 02/01/2015 12/31/2023 75.94 0-364days Description: US EXAM INFANT HIPS STATIC Category: Radiology CMS Add: 01/01/1998 CMS Term: 76886 TC RADIO DEF RBRVS 01/01/2024 66.23 0-364days Description: US EXAM INFANT HIPS STATIC Category: Radiology CMS Add: 01/01/1998 CMS Term: 76886 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 53.42 0-364days Description: US EXAM INFANT HIPS STATIC Category: Radiology CMS Add: 01/01/1998 CMS Term: 76932 26 RADIO DEF RBRVS 01/01/2024 33.27 Description: ECHO GUIDE FOR HEART BIOPSY Category: Radiology CMS Add: 01/01/1990 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 990 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 76932 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 24.36 Description: ECHO GUIDE FOR HEART BIOPSY Category: Radiology CMS Add: 01/01/1990 CMS Term: 76932 RADIO DEF MAXFEE 01/01/2024 95.72 0.0 Description: ECHO GUIDE FOR HEART BIOPSY Category: Radiology CMS Add: 01/01/1990 CMS Term: 76932 RADIO DEF RBRVS 02/01/2015 12/31/2023 64.84 Description: ECHO GUIDE FOR HEART BIOPSY Category: Radiology CMS Add: 01/01/1990 CMS Term: 76932 TC RADIO DEF MAXFEE 01/01/2024 59.55 0.0 Description: ECHO GUIDE FOR HEART BIOPSY Category: Radiology CMS Add: 01/01/1990 CMS Term: 76932 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 38.07 Description: ECHO GUIDE FOR HEART BIOPSY Category: Radiology CMS Add: 01/01/1990 CMS Term: 76936 26 RADIO DEF RBRVS 01/01/2019 12/31/2023 70.72 Description: ECHO GUIDE FOR ARTERY REPAIR Category: Radiology CMS Add: 01/01/1995 CMS Term: 76936 26 RADIO DEF RBRVS 01/01/2024 87.96 Description: ECHO GUIDE FOR ARTERY REPAIR Category: Radiology CMS Add: 01/01/1995 CMS Term: 76936 RADIO DEF RBRVS 01/01/2019 12/31/2023 192.52 Description: ECHO GUIDE FOR ARTERY REPAIR Category: Radiology CMS Add: 01/01/1995 CMS Term: 76936 RADIO DEF RBRVS 01/01/2024 241.72 Description: ECHO GUIDE FOR ARTERY REPAIR Category: Radiology CMS Add: 01/01/1995 CMS Term: 76936 TC RADIO DEF RBRVS 01/01/2019 12/31/2023 121.79 Description: ECHO GUIDE FOR ARTERY REPAIR Category: Radiology CMS Add: 01/01/1995 CMS Term: 76936 TC RADIO DEF RBRVS 01/01/2024 153.77 Description: ECHO GUIDE FOR ARTERY REPAIR Category: Radiology CMS Add: 01/01/1995 CMS Term: 76937 26 RADIO DEF RBRVS 01/01/2024 13.28 Description: US GUIDE VASCULAR ACCESS Category: Radiology CMS Add: 01/01/2004 CMS Term: 76937 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 11.03 Description: US GUIDE VASCULAR ACCESS Category: Radiology CMS Add: 01/01/2004 CMS Term: 76937 RADIO DEF RBRVS 01/01/2024 36.74 Description: US GUIDE VASCULAR ACCESS Category: Radiology CMS Add: 01/01/2004 CMS Term: 76937 RADIO DEF RBRVS 02/01/2015 12/31/2023 25.57 Description: US GUIDE VASCULAR ACCESS Category: Radiology CMS Add: 01/01/2004 CMS Term: 76937 TC RADIO DEF RBRVS 01/01/2024 23.46 Description: US GUIDE VASCULAR ACCESS Category: Radiology CMS Add: 01/01/2004 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 991 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 76937 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 14.53 Description: US GUIDE VASCULAR ACCESS Category: Radiology CMS Add: 01/01/2004 CMS Term: 76940 26 RADIO DEF RBRVS 01/01/2024 93.11 Description: US GUIDE TISSUE ABLATION Category: Radiology CMS Add: 01/01/2004 CMS Term: 76940 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 75.45 Description: US GUIDE TISSUE ABLATION Category: Radiology CMS Add: 01/01/2004 CMS Term: 76940 RADIO DEF MAXFEE 01/01/2024 168.04 0.0 Description: US GUIDE TISSUE ABLATION Category: Radiology CMS Add: 01/01/2004 CMS Term: 76940 RADIO DEF RBRVS 02/01/2015 12/31/2023 113.91 Description: US GUIDE TISSUE ABLATION Category: Radiology CMS Add: 01/01/2004 CMS Term: 76940 TC RADIO DEF MAXFEE 01/01/2024 63.03 0.0 Description: US GUIDE TISSUE ABLATION Category: Radiology CMS Add: 01/01/2004 CMS Term: 76940 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 42.20 Description: US GUIDE TISSUE ABLATION Category: Radiology CMS Add: 01/01/2004 CMS Term: 76941 26 RADIO DEF RBRVS 01/01/2019 12/31/2023 50.95 Description: ECHO GUIDE FOR TRANSFUSION Category: Radiology CMS Add: 01/01/1995 CMS Term: 76941 26 RADIO DEF RBRVS 01/01/2024 62.11 Description: ECHO GUIDE FOR TRANSFUSION Category: Radiology CMS Add: 01/01/1995 CMS Term: 76941 RADIO DEF MAXFEE 01/01/2024 129.06 0.0 Description: ECHO GUIDE FOR TRANSFUSION Category: Radiology CMS Add: 01/01/1995 CMS Term: 76941 RADIO DEF RBRVS 01/01/2019 12/31/2023 90.42 Description: ECHO GUIDE FOR TRANSFUSION Category: Radiology CMS Add: 01/01/1995 CMS Term: 76941 TC RADIO DEF MAXFEE 01/01/2024 59.57 0.0 Description: ECHO GUIDE FOR TRANSFUSION Category: Radiology CMS Add: 01/01/1995 CMS Term: 76942 26 ANEST DEF RBRVS 01/01/2024 29.21 Description: ECHO GUIDE FOR BIOPSY Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 76942 26 ANEST DEF RBRVS 02/01/2015 12/31/2023 24.61 Description: ECHO GUIDE FOR BIOPSY Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 76942 ANEST DEF RBRVS 01/01/2024 55.00 Description: ECHO GUIDE FOR BIOPSY Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 76942 ANEST DEF RBRVS 02/01/2015 12/31/2023 52.27 Description: ECHO GUIDE FOR BIOPSY Category: Anesthesia CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 992 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 76942 TC ANEST DEF RBRVS 01/01/2024 25.78 Description: ECHO GUIDE FOR BIOPSY Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 76942 TC ANEST DEF RBRVS 02/01/2015 12/31/2023 27.66 Description: ECHO GUIDE FOR BIOPSY Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 76945 26 RADIO DEF RBRVS 01/01/2024 30.89 Description: ECHO GUIDE VILLUS SAMPLING Category: Radiology CMS Add: 01/01/1986 CMS Term: 76945 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 25.35 Description: ECHO GUIDE VILLUS SAMPLING Category: Radiology CMS Add: 01/01/1986 CMS Term: 76945 RADIO DEF MAXFEE 01/01/2024 93.65 0.0 Description: ECHO GUIDE VILLUS SAMPLING Category: Radiology CMS Add: 01/01/1986 CMS Term: 76945 TC RADIO DEF MAXFEE 01/01/2024 59.57 0.0 Description: ECHO GUIDE VILLUS SAMPLING Category: Radiology CMS Add: 01/01/1986 CMS Term: 76946 26 RADIO DEF RBRVS 01/01/2024 17.67 Description: ECHO GUIDE FOR AMNIOCENTESIS Category: Radiology CMS Add: 01/01/1984 CMS Term: 76946 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 14.09 Description: ECHO GUIDE FOR AMNIOCENTESIS Category: Radiology CMS Add: 01/01/1984 CMS Term: 76946 RADIO DEF RBRVS 01/01/2024 31.10 Description: ECHO GUIDE FOR AMNIOCENTESIS Category: Radiology CMS Add: 01/01/1984 CMS Term: 76946 RADIO DEF RBRVS 02/01/2015 12/31/2023 23.17 Description: ECHO GUIDE FOR AMNIOCENTESIS Category: Radiology CMS Add: 01/01/1984 CMS Term: 76946 TC RADIO DEF RBRVS 01/01/2024 13.44 Description: ECHO GUIDE FOR AMNIOCENTESIS Category: Radiology CMS Add: 01/01/1984 CMS Term: 76946 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 9.08 Description: ECHO GUIDE FOR AMNIOCENTESIS Category: Radiology CMS Add: 01/01/1984 CMS Term: 76948 26 RADIO DEF RBRVS 01/01/2024 30.89 Description: ECHO GUIDE OVA ASPIRATION Category: Radiology CMS Add: 01/01/1988 CMS Term: 76948 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 14.42 Description: ECHO GUIDE OVA ASPIRATION Category: Radiology CMS Add: 01/01/1988 CMS Term: 76948 RADIO DEF RBRVS 01/01/2024 76.12 Description: ECHO GUIDE OVA ASPIRATION Category: Radiology CMS Add: 01/01/1988 CMS Term: 76948 RADIO DEF RBRVS 02/01/2015 12/31/2023 23.50 Description: ECHO GUIDE OVA ASPIRATION Category: Radiology CMS Add: 01/01/1988 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 993 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 76948 TC RADIO DEF RBRVS 01/01/2024 45.23 Description: ECHO GUIDE OVA ASPIRATION Category: Radiology CMS Add: 01/01/1988 CMS Term: 76948 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 9.08 Description: ECHO GUIDE OVA ASPIRATION Category: Radiology CMS Add: 01/01/1988 CMS Term: 76965 26 RADIO DEF RBRVS 01/01/2024 64.58 Description: ECHO GUIDANCE RADIOTHERAPY Category: Radiology CMS Add: 01/01/1996 CMS Term: 76965 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 49.46 Description: ECHO GUIDANCE RADIOTHERAPY Category: Radiology CMS Add: 01/01/1996 CMS Term: 76965 RADIO DEF RBRVS 01/01/2024 89.43 Description: ECHO GUIDANCE RADIOTHERAPY Category: Radiology CMS Add: 01/01/1996 CMS Term: 76965 RADIO DEF RBRVS 02/01/2015 12/31/2023 65.73 Description: ECHO GUIDANCE RADIOTHERAPY Category: Radiology CMS Add: 01/01/1996 CMS Term: 76965 TC RADIO DEF RBRVS 01/01/2024 24.86 Description: ECHO GUIDANCE RADIOTHERAPY Category: Radiology CMS Add: 01/01/1996 CMS Term: 76965 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 16.27 Description: ECHO GUIDANCE RADIOTHERAPY Category: Radiology CMS Add: 01/01/1996 CMS Term: 76975 26 RADIO DEF RBRVS 01/01/2024 39.21 Description: GI ENDOSCOPIC ULTRASOUND Category: Radiology CMS Add: 01/01/1994 CMS Term: 76975 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 31.51 Description: GI ENDOSCOPIC ULTRASOUND Category: Radiology CMS Add: 01/01/1994 CMS Term: 76975 RADIO DEF MAXFEE 01/01/2024 101.53 0.0 Description: GI ENDOSCOPIC ULTRASOUND Category: Radiology CMS Add: 01/01/1994 CMS Term: 76975 RADIO DEF RBRVS 02/01/2015 12/31/2023 69.35 Description: GI ENDOSCOPIC ULTRASOUND Category: Radiology CMS Add: 01/01/1994 CMS Term: 76975 TC RADIO DEF MAXFEE 01/01/2024 59.55 0.0 Description: GI ENDOSCOPIC ULTRASOUND Category: Radiology CMS Add: 01/01/1994 CMS Term: 76975 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 38.07 Description: GI ENDOSCOPIC ULTRASOUND Category: Radiology CMS Add: 01/01/1994 CMS Term: 76977 26 RADIO DEF RBRVS 01/01/2024 2.47 Description: US BONE DENSITY MEASURE Category: Radiology CMS Add: 01/01/1999 CMS Term: 76977 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 2.00 Description: US BONE DENSITY MEASURE Category: Radiology CMS Add: 01/01/1999 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 994 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 76977 RADIO DEF RBRVS 01/01/2024 6.34 Description: US BONE DENSITY MEASURE Category: Radiology CMS Add: 01/01/1999 CMS Term: 76977 RADIO DEF RBRVS 02/01/2015 12/31/2023 4.89 Description: US BONE DENSITY MEASURE Category: Radiology CMS Add: 01/01/1999 CMS Term: 76977 TC RADIO DEF RBRVS 01/01/2024 3.87 Description: US BONE DENSITY MEASURE Category: Radiology CMS Add: 01/01/1999 CMS Term: 76977 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 2.89 Description: US BONE DENSITY MEASURE Category: Radiology CMS Add: 01/01/1999 CMS Term: 76978 26 RADIO DEF RBRVS 01/01/2019 12/31/2023 59.54 Description: US TRGT DYN MBUBB 1ST LES Category: Radiology CMS Add: 01/01/2019 CMS Term: 76978 26 RADIO DEF RBRVS 01/01/2024 74.40 Description: US TRGT DYN MBUBB 1ST LES Category: Radiology CMS Add: 01/01/2019 CMS Term: 76978 RADIO DEF RBRVS 01/01/2019 12/31/2023 229.89 Description: US TRGT DYN MBUBB 1ST LES Category: Radiology CMS Add: 01/01/2019 CMS Term: 76978 RADIO DEF RBRVS 01/01/2024 240.50 Description: US TRGT DYN MBUBB 1ST LES Category: Radiology CMS Add: 01/01/2019 CMS Term: 76978 TC RADIO DEF RBRVS 01/01/2019 12/31/2023 170.35 Description: US TRGT DYN MBUBB 1ST LES Category: Radiology CMS Add: 01/01/2019 CMS Term: 76978 TC RADIO DEF RBRVS 01/01/2024 166.10 Description: US TRGT DYN MBUBB 1ST LES Category: Radiology CMS Add: 01/01/2019 CMS Term: 76979 26 RADIO DEF RBRVS 01/01/2019 12/31/2023 31.34 Description: US TRGT DYN MBUBB EA ADDL Category: Radiology CMS Add: 01/01/2019 CMS Term: 76979 26 RADIO DEF RBRVS 01/01/2024 39.02 Description: US TRGT DYN MBUBB EA ADDL Category: Radiology CMS Add: 01/01/2019 CMS Term: 76979 RADIO DEF RBRVS 01/01/2019 12/31/2023 155.70 Description: US TRGT DYN MBUBB EA ADDL Category: Radiology CMS Add: 01/01/2019 CMS Term: 76979 RADIO DEF RBRVS 01/01/2024 156.80 Description: US TRGT DYN MBUBB EA ADDL Category: Radiology CMS Add: 01/01/2019 CMS Term: 76979 TC RADIO DEF RBRVS 01/01/2019 12/31/2023 124.35 Description: US TRGT DYN MBUBB EA ADDL Category: Radiology CMS Add: 01/01/2019 CMS Term: 76979 TC RADIO DEF RBRVS 01/01/2024 117.78 Description: US TRGT DYN MBUBB EA ADDL Category: Radiology CMS Add: 01/01/2019 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 995 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 76981 26 RADIO DEF RBRVS 01/01/2019 27.43 Description: USE PARENCHYMA Category: Radiology CMS Add: 01/01/2019 CMS Term: 76981 RADIO DEF RBRVS 01/01/2019 12/31/2023 76.13 Description: USE PARENCHYMA Category: Radiology CMS Add: 01/01/2019 CMS Term: 76981 RADIO DEF RBRVS 01/01/2024 97.67 Description: USE PARENCHYMA Category: Radiology CMS Add: 01/01/2019 CMS Term: 76981 TC RADIO DEF RBRVS 01/01/2019 12/31/2023 54.17 Description: USE PARENCHYMA Category: Radiology CMS Add: 01/01/2019 CMS Term: 76981 TC RADIO DEF RBRVS 01/01/2024 70.24 Description: USE PARENCHYMA Category: Radiology CMS Add: 01/01/2019 CMS Term: 76982 26 RADIO DEF RBRVS 01/01/2019 27.43 Description: USE 1ST TARGET LESION Category: Radiology CMS Add: 01/01/2019 CMS Term: 76982 RADIO DEF RBRVS 01/01/2019 12/31/2023 68.20 Description: USE 1ST TARGET LESION Category: Radiology CMS Add: 01/01/2019 CMS Term: 76982 RADIO DEF RBRVS 01/01/2024 87.79 Description: USE 1ST TARGET LESION Category: Radiology CMS Add: 01/01/2019 CMS Term: 76982 TC RADIO DEF RBRVS 01/01/2019 12/31/2023 46.24 Description: USE 1ST TARGET LESION Category: Radiology CMS Add: 01/01/2019 CMS Term: 76982 TC RADIO DEF RBRVS 01/01/2024 60.36 Description: USE 1ST TARGET LESION Category: Radiology CMS Add: 01/01/2019 CMS Term: 76983 26 RADIO DEF RBRVS 01/01/2019 12/31/2023 18.64 Description: USE EA ADDL TARGET LESION Category: Radiology CMS Add: 01/01/2019 CMS Term: 76983 26 RADIO DEF RBRVS 01/01/2024 23.76 Description: USE EA ADDL TARGET LESION Category: Radiology CMS Add: 01/01/2019 CMS Term: 76983 RADIO DEF RBRVS 01/01/2019 12/31/2023 42.17 Description: USE EA ADDL TARGET LESION Category: Radiology CMS Add: 01/01/2019 CMS Term: 76983 RADIO DEF RBRVS 01/01/2024 57.26 Description: USE EA ADDL TARGET LESION Category: Radiology CMS Add: 01/01/2019 CMS Term: 76983 TC RADIO DEF RBRVS 01/01/2019 12/31/2023 23.53 Description: USE EA ADDL TARGET LESION Category: Radiology CMS Add: 01/01/2019 CMS Term: 76983 TC RADIO DEF RBRVS 01/01/2024 33.50 Description: USE EA ADDL TARGET LESION Category: Radiology CMS Add: 01/01/2019 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 996 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 76984 26 RADIO DEF RBRVS 01/01/2024 28.59 Description: DX INTRAOP THORACIC AORTA US Category: Radiology CMS Add: 01/01/2024 CMS Term: 76987 26 RADIO DEF RBRVS 01/01/2024 88.64 Description: DX INTRAOP EPICAR CAR US CHD Category: Radiology CMS Add: 01/01/2024 CMS Term: 76988 26 RADIO DEF RBRVS 01/01/2024 56.22 Description: DX NTROP EPCR US CHD IMG ACQ Category: Radiology CMS Add: 01/01/2024 CMS Term: 76989 26 RADIO DEF RBRVS 01/01/2024 32.90 Description: DX INTRAOP EPCAR US CHD I&R Category: Radiology CMS Add: 01/01/2024 CMS Term: 76998 26 RADIO DEF RBRVS 01/01/2024 56.54 Description: US GUIDE INTRAOP Category: Radiology CMS Add: 01/01/2007 CMS Term: 76998 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 46.03 Description: US GUIDE INTRAOP Category: Radiology CMS Add: 01/01/2007 CMS Term: 76998 RADIO DEF MAXFEE 01/01/2024 164.91 0.0 Description: US GUIDE INTRAOP Category: Radiology CMS Add: 01/01/2007 CMS Term: 76998 TC RADIO DEF MAXFEE 01/01/2024 102.45 0.0 Description: US GUIDE INTRAOP Category: Radiology CMS Add: 01/01/2007 CMS Term: 76999 RADIO DEF BILL25 Description: ECHO EXAMINATION PROCEDURE Category: Radiology CMS Add: 01/01/1984 CMS Term: 77001 26 RADIO DEF RBRVS 01/01/2024 16.92 Description: FLUOROGUIDE FOR VEIN DEVICE Category: Radiology CMS Add: 01/01/2007 CMS Term: 77001 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 13.93 Description: FLUOROGUIDE FOR VEIN DEVICE Category: Radiology CMS Add: 01/01/2007 CMS Term: 77001 RADIO DEF RBRVS 01/01/2024 93.64 Description: FLUOROGUIDE FOR VEIN DEVICE Category: Radiology CMS Add: 01/01/2007 CMS Term: 77001 RADIO DEF RBRVS 02/01/2015 12/31/2023 55.71 Description: FLUOROGUIDE FOR VEIN DEVICE Category: Radiology CMS Add: 01/01/2007 CMS Term: 77001 TC RADIO DEF RBRVS 01/01/2024 76.72 Description: FLUOROGUIDE FOR VEIN DEVICE Category: Radiology CMS Add: 01/01/2007 CMS Term: 77001 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 41.78 Description: FLUOROGUIDE FOR VEIN DEVICE Category: Radiology CMS Add: 01/01/2007 CMS Term: 77002 26 ANEST DEF RBRVS 01/01/2024 25.73 Description: NEEDLE LOCALIZATION BY XRAY Category: Anesthesia CMS Add: 01/01/2007 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 997 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 77002 26 ANEST DEF RBRVS 02/01/2015 12/31/2023 20.45 Description: NEEDLE LOCALIZATION BY XRAY Category: Anesthesia CMS Add: 01/01/2007 CMS Term: 77002 ANEST DEF RBRVS 01/01/2024 108.94 Description: NEEDLE LOCALIZATION BY XRAY Category: Anesthesia CMS Add: 01/01/2007 CMS Term: 77002 ANEST DEF RBRVS 02/01/2015 12/31/2023 72.14 Description: NEEDLE LOCALIZATION BY XRAY Category: Anesthesia CMS Add: 01/01/2007 CMS Term: 77002 TC ANEST DEF RBRVS 01/01/2024 83.20 Description: NEEDLE LOCALIZATION BY XRAY Category: Anesthesia CMS Add: 01/01/2007 CMS Term: 77002 TC ANEST DEF RBRVS 02/01/2015 12/31/2023 51.69 Description: NEEDLE LOCALIZATION BY XRAY Category: Anesthesia CMS Add: 01/01/2007 CMS Term: 77003 26 ANEST DEF RBRVS 01/01/2024 27.46 Description: FLUOROGUIDE FOR SPINE INJECT Category: Anesthesia CMS Add: 01/01/2007 CMS Term: 77003 26 ANEST DEF RBRVS 09/01/2019 12/31/2023 22.31 Description: FLUOROGUIDE FOR SPINE INJECT Category: Anesthesia CMS Add: 01/01/2007 CMS Term: 77003 ANEST DEF RBRVS 01/01/2024 99.24 Description: FLUOROGUIDE FOR SPINE INJECT Category: Anesthesia CMS Add: 01/01/2007 CMS Term: 77003 ANEST DEF RBRVS 09/01/2019 12/31/2023 63.85 Description: FLUOROGUIDE FOR SPINE INJECT Category: Anesthesia CMS Add: 01/01/2007 CMS Term: 77003 TC ANEST DEF RBRVS 01/01/2024 71.78 Description: FLUOROGUIDE FOR SPINE INJECT Category: Anesthesia CMS Add: 01/01/2007 CMS Term: 77003 TC ANEST DEF RBRVS 09/01/2019 12/31/2023 41.53 Description: FLUOROGUIDE FOR SPINE INJECT Category: Anesthesia CMS Add: 01/01/2007 CMS Term: 77011 26 RADIO DEF RBRVS 01/01/2019 12/31/2023 45.31 Description: CT SCAN FOR LOCALIZATION Category: Radiology CMS Add: 01/01/2007 CMS Term: 77011 26 RADIO DEF RBRVS 01/01/2024 58.96 Description: CT SCAN FOR LOCALIZATION Category: Radiology CMS Add: 01/01/2007 CMS Term: 77011 RADIO DEF RBRVS 01/01/2019 12/31/2023 158.43 Description: CT SCAN FOR LOCALIZATION Category: Radiology CMS Add: 01/01/2007 CMS Term: 77011 RADIO DEF RBRVS 01/01/2024 209.77 Description: CT SCAN FOR LOCALIZATION Category: Radiology CMS Add: 01/01/2007 CMS Term: 77011 TC RADIO DEF RBRVS 01/01/2019 12/31/2023 113.12 Description: CT SCAN FOR LOCALIZATION Category: Radiology CMS Add: 01/01/2007 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 998 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 77011 TC RADIO DEF RBRVS 01/01/2024 150.81 Description: CT SCAN FOR LOCALIZATION Category: Radiology CMS Add: 01/01/2007 CMS Term: 77012 26 RADIO DEF RBRVS 01/01/2019 12/31/2023 41.98 Description: CT SCAN FOR NEEDLE BIOPSY Category: Radiology CMS Add: 01/01/2007 CMS Term: 77012 26 RADIO DEF RBRVS 01/01/2024 67.26 Description: CT SCAN FOR NEEDLE BIOPSY Category: Radiology CMS Add: 01/01/2007 CMS Term: 77012 RADIO DEF RBRVS 01/01/2019 12/31/2023 91.44 Description: CT SCAN FOR NEEDLE BIOPSY Category: Radiology CMS Add: 01/01/2007 CMS Term: 77012 RADIO DEF RBRVS 01/01/2024 133.79 Description: CT SCAN FOR NEEDLE BIOPSY Category: Radiology CMS Add: 01/01/2007 CMS Term: 77012 TC RADIO DEF RBRVS 01/01/2019 12/31/2023 49.46 Description: CT SCAN FOR NEEDLE BIOPSY Category: Radiology CMS Add: 01/01/2007 CMS Term: 77012 TC RADIO DEF RBRVS 01/01/2024 66.53 Description: CT SCAN FOR NEEDLE BIOPSY Category: Radiology CMS Add: 01/01/2007 CMS Term: 77013 26 RADIO DEF RBRVS 01/01/2024 175.04 Description: CT GUIDE FOR TISSUE ABLATION Category: Radiology CMS Add: 01/01/2007 CMS Term: 77013 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 146.67 Description: CT GUIDE FOR TISSUE ABLATION Category: Radiology CMS Add: 01/01/2007 CMS Term: 77013 RADIO DEF MAXFEE 01/01/2024 543.28 0.0 Description: CT GUIDE FOR TISSUE ABLATION Category: Radiology CMS Add: 01/01/2007 CMS Term: 77013 TC RADIO DEF MAXFEE 01/01/2024 341.17 0.0 Description: CT GUIDE FOR TISSUE ABLATION Category: Radiology CMS Add: 01/01/2007 CMS Term: 77014 26 RADIO DEF RBRVS 01/01/2019 12/31/2023 31.92 Description: CT SCAN FOR THERAPY GUIDE Category: Radiology CMS Add: 01/01/2007 CMS Term: 77014 26 RADIO DEF RBRVS 01/01/2024 43.03 Description: CT SCAN FOR THERAPY GUIDE Category: Radiology CMS Add: 01/01/2007 CMS Term: 77014 RADIO DEF RBRVS 01/01/2019 12/31/2023 87.08 Description: CT SCAN FOR THERAPY GUIDE Category: Radiology CMS Add: 01/01/2007 CMS Term: 77014 RADIO DEF RBRVS 01/01/2024 113.27 Description: CT SCAN FOR THERAPY GUIDE Category: Radiology CMS Add: 01/01/2007 CMS Term: 77014 TC RADIO DEF RBRVS 01/01/2019 12/31/2023 55.16 Description: CT SCAN FOR THERAPY GUIDE Category: Radiology CMS Add: 01/01/2007 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 999 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 77014 TC RADIO DEF RBRVS 01/01/2024 70.24 Description: CT SCAN FOR THERAPY GUIDE Category: Radiology CMS Add: 01/01/2007 CMS Term: 77021 26 RADIO DEF RBRVS 01/01/2019 12/31/2023 55.74 Description: MRI GUIDANCE NDL PLMT RS&I Category: Radiology CMS Add: 01/01/2007 CMS Term: 77021 26 RADIO DEF RBRVS 01/01/2024 68.01 Description: MRI GUIDANCE NDL PLMT RS&I Category: Radiology CMS Add: 01/01/2007 CMS Term: 77021 RADIO DEF RBRVS 01/01/2019 12/31/2023 278.36 Description: MRI GUIDANCE NDL PLMT RS&I Category: Radiology CMS Add: 01/01/2007 CMS Term: 77021 RADIO DEF RBRVS 01/01/2024 400.20 Description: MRI GUIDANCE NDL PLMT RS&I Category: Radiology CMS Add: 01/01/2007 CMS Term: 77021 TC RADIO DEF RBRVS 01/01/2019 12/31/2023 222.61 Description: MRI GUIDANCE NDL PLMT RS&I Category: Radiology CMS Add: 01/01/2007 CMS Term: 77021 TC RADIO DEF RBRVS 01/01/2024 332.19 Description: MRI GUIDANCE NDL PLMT RS&I Category: Radiology CMS Add: 01/01/2007 CMS Term: 77022 26 RADIO DEF RBRVS 01/01/2019 12/31/2023 156.03 Description: MRI GDN PARNCHYMA TISS ABLTJ Category: Radiology CMS Add: 01/01/2007 CMS Term: 77022 26 RADIO DEF RBRVS 01/01/2024 194.01 Description: MRI GDN PARNCHYMA TISS ABLTJ Category: Radiology CMS Add: 01/01/2007 CMS Term: 77022 RADIO DEF MAXFEE 01/01/2024 670.28 0.0 Description: MRI GDN PARNCHYMA TISS ABLTJ Category: Radiology CMS Add: 01/01/2007 CMS Term: 77022 TC RADIO DEF MAXFEE 01/01/2024 455.25 0.0 Description: MRI GDN PARNCHYMA TISS ABLTJ Category: Radiology CMS Add: 01/01/2007 CMS Term: 77046 26 RADIO DEF RBRVS 01/01/2019 12/31/2023 53.41 Description: MRI BREAST C- UNILATERAL Category: Radiology CMS Add: 01/01/2019 CMS Term: 77046 26 RADIO DEF RBRVS 01/01/2024 66.32 Description: MRI BREAST C- UNILATERAL Category: Radiology CMS Add: 01/01/2019 CMS Term: 77046 RADIO DEF RBRVS 01/01/2019 12/31/2023 176.19 Description: MRI BREAST C- UNILATERAL Category: Radiology CMS Add: 01/01/2019 CMS Term: 77046 RADIO DEF RBRVS 01/01/2024 207.72 Description: MRI BREAST C- UNILATERAL Category: Radiology CMS Add: 01/01/2019 CMS Term: 77046 TC RADIO DEF RBRVS 01/01/2019 12/31/2023 122.78 Description: MRI BREAST C- UNILATERAL Category: Radiology CMS Add: 01/01/2019 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,000 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 77046 TC RADIO DEF RBRVS 01/01/2024 141.40 Description: MRI BREAST C- UNILATERAL Category: Radiology CMS Add: 01/01/2019 CMS Term: 77047 26 RADIO DEF RBRVS 01/01/2019 12/31/2023 59.09 Description: MRI BREAST C- BILATERAL Category: Radiology CMS Add: 01/01/2019 CMS Term: 77047 26 RADIO DEF RBRVS 01/01/2024 73.41 Description: MRI BREAST C- BILATERAL Category: Radiology CMS Add: 01/01/2019 CMS Term: 77047 RADIO DEF RBRVS 01/01/2019 12/31/2023 181.13 Description: MRI BREAST C- BILATERAL Category: Radiology CMS Add: 01/01/2019 CMS Term: 77047 RADIO DEF RBRVS 01/01/2024 215.43 Description: MRI BREAST C- BILATERAL Category: Radiology CMS Add: 01/01/2019 CMS Term: 77047 TC RADIO DEF RBRVS 01/01/2019 12/31/2023 122.04 Description: MRI BREAST C- BILATERAL Category: Radiology CMS Add: 01/01/2019 CMS Term: 77047 TC RADIO DEF RBRVS 01/01/2024 142.02 Description: MRI BREAST C- BILATERAL Category: Radiology CMS Add: 01/01/2019 CMS Term: 77048 26 RADIO DEF RBRVS 01/01/2019 12/31/2023 77.23 Description: MRI BREAST C-+ W/CAD UNI Category: Radiology CMS Add: 01/01/2019 CMS Term: 77048 26 RADIO DEF RBRVS 01/01/2024 96.40 Description: MRI BREAST C-+ W/CAD UNI Category: Radiology CMS Add: 01/01/2019 CMS Term: 77048 RADIO DEF RBRVS 01/01/2019 12/31/2023 279.45 Description: MRI BREAST C-+ W/CAD UNI Category: Radiology CMS Add: 01/01/2019 CMS Term: 77048 RADIO DEF RBRVS 01/01/2024 329.50 Description: MRI BREAST C-+ W/CAD UNI Category: Radiology CMS Add: 01/01/2019 CMS Term: 77048 TC RADIO DEF RBRVS 01/01/2019 12/31/2023 202.22 Description: MRI BREAST C-+ W/CAD UNI Category: Radiology CMS Add: 01/01/2019 CMS Term: 77048 TC RADIO DEF RBRVS 01/01/2024 233.10 Description: MRI BREAST C-+ W/CAD UNI Category: Radiology CMS Add: 01/01/2019 CMS Term: 77049 26 RADIO DEF RBRVS 01/01/2019 12/31/2023 84.50 Description: MRI BREAST C-+ W/CAD BI Category: Radiology CMS Add: 01/01/2019 CMS Term: 77049 26 RADIO DEF RBRVS 01/01/2024 105.50 Description: MRI BREAST C-+ W/CAD BI Category: Radiology CMS Add: 01/01/2019 CMS Term: 77049 RADIO DEF RBRVS 01/01/2019 12/31/2023 285.73 Description: MRI BREAST C-+ W/CAD BI Category: Radiology CMS Add: 01/01/2019 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,001 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 77049 RADIO DEF RBRVS 01/01/2024 336.75 Description: MRI BREAST C-+ W/CAD BI Category: Radiology CMS Add: 01/01/2019 CMS Term: 77049 TC RADIO DEF RBRVS 01/01/2019 12/31/2023 201.23 Description: MRI BREAST C-+ W/CAD BI Category: Radiology CMS Add: 01/01/2019 CMS Term: 77049 TC RADIO DEF RBRVS 01/01/2024 231.25 Description: MRI BREAST C-+ W/CAD BI Category: Radiology CMS Add: 01/01/2019 CMS Term: 77053 26 RADIO DEF RBRVS 01/01/2019 12/31/2023 13.06 Description: X-RAY OF MAMMARY DUCT Category: Radiology CMS Add: 01/01/2007 CMS Term: 77053 26 RADIO DEF RBRVS 01/01/2024 16.53 Description: X-RAY OF MAMMARY DUCT Category: Radiology CMS Add: 01/01/2007 CMS Term: 77053 RADIO DEF RBRVS 01/01/2019 12/31/2023 42.21 Description: X-RAY OF MAMMARY DUCT Category: Radiology CMS Add: 01/01/2007 CMS Term: 77053 RADIO DEF RBRVS 01/01/2024 50.04 Description: X-RAY OF MAMMARY DUCT Category: Radiology CMS Add: 01/01/2007 CMS Term: 77053 TC RADIO DEF RBRVS 01/01/2019 12/31/2023 29.15 Description: X-RAY OF MAMMARY DUCT Category: Radiology CMS Add: 01/01/2007 CMS Term: 77053 TC RADIO DEF RBRVS 01/01/2024 33.50 Description: X-RAY OF MAMMARY DUCT Category: Radiology CMS Add: 01/01/2007 CMS Term: 77054 26 RADIO DEF RBRVS 01/01/2019 12/31/2023 16.80 Description: X-RAY OF MAMMARY DUCTS Category: Radiology CMS Add: 01/01/2007 CMS Term: 77054 26 RADIO DEF RBRVS 01/01/2024 20.51 Description: X-RAY OF MAMMARY DUCTS Category: Radiology CMS Add: 01/01/2007 CMS Term: 77054 RADIO DEF RBRVS 01/01/2019 12/31/2023 56.84 Description: X-RAY OF MAMMARY DUCTS Category: Radiology CMS Add: 01/01/2007 CMS Term: 77054 RADIO DEF RBRVS 01/01/2024 64.82 Description: X-RAY OF MAMMARY DUCTS Category: Radiology CMS Add: 01/01/2007 CMS Term: 77054 TC RADIO DEF RBRVS 01/01/2019 12/31/2023 40.05 Description: X-RAY OF MAMMARY DUCTS Category: Radiology CMS Add: 01/01/2007 CMS Term: 77054 TC RADIO DEF RBRVS 01/01/2024 44.31 Description: X-RAY OF MAMMARY DUCTS Category: Radiology CMS Add: 01/01/2007 CMS Term: 77061 RADIO DEF BILL25 Description: BREAST TOMOSYNTHESIS UNI Category: Radiology CMS Add: 01/01/2015 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,002 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 77062 RADIO DEF BILL25 Description: BREAST TOMOSYNTHESIS BI Category: Radiology CMS Add: 01/01/2015 CMS Term: 77063 26 RADIO DEF RBRVS 01/01/2024 27.77 Description: BREAST TOMOSYNTHESIS BI Category: Radiology CMS Add: 01/01/2015 CMS Term: 77063 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 22.07 Description: BREAST TOMOSYNTHESIS BI Category: Radiology CMS Add: 01/01/2015 CMS Term: 77063 RADIO DEF RBRVS 01/01/2024 50.00 Description: BREAST TOMOSYNTHESIS BI Category: Radiology CMS Add: 01/01/2015 CMS Term: 77063 RADIO DEF RBRVS 02/01/2015 12/31/2023 39.82 Description: BREAST TOMOSYNTHESIS BI Category: Radiology CMS Add: 01/01/2015 CMS Term: 77063 TC RADIO DEF RBRVS 01/01/2024 22.23 Description: BREAST TOMOSYNTHESIS BI Category: Radiology CMS Add: 01/01/2015 CMS Term: 77063 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 17.75 Description: BREAST TOMOSYNTHESIS BI Category: Radiology CMS Add: 01/01/2015 CMS Term: 77065 26 RADIO DEF RBRVS 01/01/2024 37.05 Description: DX MAMMO INCL CAD UNI Category: Radiology CMS Add: 01/01/2017 CMS Term: 77065 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 28.78 Description: DX MAMMO INCL CAD UNI Category: Radiology CMS Add: 01/01/2017 CMS Term: 77065 RADIO DEF RBRVS 01/01/2024 117.78 Description: DX MAMMO INCL CAD UNI Category: Radiology CMS Add: 01/01/2017 CMS Term: 77065 RADIO DEF RBRVS 09/01/2019 12/31/2023 94.34 Description: DX MAMMO INCL CAD UNI Category: Radiology CMS Add: 01/01/2017 CMS Term: 77065 TC RADIO DEF RBRVS 01/01/2024 80.73 Description: DX MAMMO INCL CAD UNI Category: Radiology CMS Add: 01/01/2017 CMS Term: 77065 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 65.56 Description: DX MAMMO INCL CAD UNI Category: Radiology CMS Add: 01/01/2017 CMS Term: 77066 26 RADIO DEF RBRVS 01/01/2024 45.64 Description: DX MAMMO INCL CAD BI Category: Radiology CMS Add: 01/01/2017 CMS Term: 77066 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 35.79 Description: DX MAMMO INCL CAD BI Category: Radiology CMS Add: 01/01/2017 CMS Term: 77066 RADIO DEF RBRVS 01/01/2024 148.61 Description: DX MAMMO INCL CAD BI Category: Radiology CMS Add: 01/01/2017 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,003 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 77066 RADIO DEF RBRVS 09/01/2019 12/31/2023 119.68 Description: DX MAMMO INCL CAD BI Category: Radiology CMS Add: 01/01/2017 CMS Term: 77066 TC RADIO DEF RBRVS 01/01/2024 102.96 Description: DX MAMMO INCL CAD BI Category: Radiology CMS Add: 01/01/2017 CMS Term: 77066 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 83.89 Description: DX MAMMO INCL CAD BI Category: Radiology CMS Add: 01/01/2017 CMS Term: 77067 26 RADIO DEF RBRVS 01/01/2024 35.04 Description: SCR MAMMO BI INCL CAD Category: Radiology CMS Add: 01/01/2017 CMS Term: 77067 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 27.27 Description: SCR MAMMO BI INCL CAD Category: Radiology CMS Add: 01/01/2017 CMS Term: 77067 RADIO DEF RBRVS 01/01/2024 120.41 Description: SCR MAMMO BI INCL CAD Category: Radiology CMS Add: 01/01/2017 CMS Term: 77067 RADIO DEF RBRVS 09/01/2019 12/31/2023 96.55 Description: SCR MAMMO BI INCL CAD Category: Radiology CMS Add: 01/01/2017 CMS Term: 77067 TC RADIO DEF RBRVS 01/01/2024 85.37 Description: SCR MAMMO BI INCL CAD Category: Radiology CMS Add: 01/01/2017 CMS Term: 77067 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 69.28 Description: SCR MAMMO BI INCL CAD Category: Radiology CMS Add: 01/01/2017 CMS Term: 77071 RADIO DEF RBRVS 01/01/2016 12/31/2023 35.95 Description: X-RAY STRESS VIEW Category: Radiology CMS Add: 01/01/2007 CMS Term: 77071 RADIO DEF RBRVS 01/01/2024 50.83 Description: X-RAY STRESS VIEW Category: Radiology CMS Add: 01/01/2007 CMS Term: 77072 26 RADIO DEF RBRVS 01/01/2024 8.76 Description: X-RAYS FOR BONE AGE Category: Radiology CMS Add: 01/01/2007 CMS Term: 77072 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 7.00 Description: X-RAYS FOR BONE AGE Category: Radiology CMS Add: 01/01/2007 CMS Term: 77072 RADIO DEF RBRVS 01/01/2024 24.36 Description: X-RAYS FOR BONE AGE Category: Radiology CMS Add: 01/01/2007 CMS Term: 77072 RADIO DEF RBRVS 02/01/2015 12/31/2023 16.83 Description: X-RAYS FOR BONE AGE Category: Radiology CMS Add: 01/01/2007 CMS Term: 77072 TC RADIO DEF RBRVS 01/01/2024 15.60 Description: X-RAYS FOR BONE AGE Category: Radiology CMS Add: 01/01/2007 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,004 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 77072 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 9.83 Description: X-RAYS FOR BONE AGE Category: Radiology CMS Add: 01/01/2007 CMS Term: 77073 26 RADIO DEF RBRVS 01/01/2024 12.53 Description: X-RAYS BONE LENGTH STUDIES Category: Radiology CMS Add: 01/01/2007 CMS Term: 77073 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 10.89 Description: X-RAYS BONE LENGTH STUDIES Category: Radiology CMS Add: 01/01/2007 CMS Term: 77073 RADIO DEF RBRVS 01/01/2024 42.02 Description: X-RAYS BONE LENGTH STUDIES Category: Radiology CMS Add: 01/01/2007 CMS Term: 77073 RADIO DEF RBRVS 02/01/2015 12/31/2023 26.91 Description: X-RAYS BONE LENGTH STUDIES Category: Radiology CMS Add: 01/01/2007 CMS Term: 77073 TC RADIO DEF RBRVS 01/01/2024 29.49 Description: X-RAYS BONE LENGTH STUDIES Category: Radiology CMS Add: 01/01/2007 CMS Term: 77073 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 16.02 Description: X-RAYS BONE LENGTH STUDIES Category: Radiology CMS Add: 01/01/2007 CMS Term: 77074 26 RADIO DEF RBRVS 01/01/2024 20.17 Description: X-RAYS BONE SURVEY LIMITED Category: Radiology CMS Add: 01/01/2007 CMS Term: 77074 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 16.80 Description: X-RAYS BONE SURVEY LIMITED Category: Radiology CMS Add: 01/01/2007 CMS Term: 77074 RADIO DEF RBRVS 01/01/2024 61.08 Description: X-RAYS BONE SURVEY LIMITED Category: Radiology CMS Add: 01/01/2007 CMS Term: 77074 RADIO DEF RBRVS 02/01/2015 12/31/2023 50.65 Description: X-RAYS BONE SURVEY LIMITED Category: Radiology CMS Add: 01/01/2007 CMS Term: 77074 TC RADIO DEF RBRVS 01/01/2024 40.91 Description: X-RAYS BONE SURVEY LIMITED Category: Radiology CMS Add: 01/01/2007 CMS Term: 77074 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 33.85 Description: X-RAYS BONE SURVEY LIMITED Category: Radiology CMS Add: 01/01/2007 CMS Term: 77075 26 RADIO DEF RBRVS 01/01/2024 25.46 Description: X-RAYS BONE SURVEY COMPLETE Category: Radiology CMS Add: 01/01/2007 CMS Term: 77075 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 19.96 Description: X-RAYS BONE SURVEY COMPLETE Category: Radiology CMS Add: 01/01/2007 CMS Term: 77075 RADIO DEF RBRVS 01/01/2024 93.39 Description: X-RAYS BONE SURVEY COMPLETE Category: Radiology CMS Add: 01/01/2007 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,005 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 77075 RADIO DEF RBRVS 02/01/2015 12/31/2023 75.61 Description: X-RAYS BONE SURVEY COMPLETE Category: Radiology CMS Add: 01/01/2007 CMS Term: 77075 TC RADIO DEF RBRVS 01/01/2024 67.93 Description: X-RAYS BONE SURVEY COMPLETE Category: Radiology CMS Add: 01/01/2007 CMS Term: 77075 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 55.65 Description: X-RAYS BONE SURVEY COMPLETE Category: Radiology CMS Add: 01/01/2007 CMS Term: 77076 26 RADIO DEF RBRVS 01/01/2024 32.39 Description: X-RAYS BONE SURVEY INFANT Category: Radiology CMS Add: 01/01/2007 CMS Term: 77076 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 25.91 Description: X-RAYS BONE SURVEY INFANT Category: Radiology CMS Add: 01/01/2007 CMS Term: 77076 RADIO DEF RBRVS 01/01/2024 100.94 Description: X-RAYS BONE SURVEY INFANT Category: Radiology CMS Add: 01/01/2007 CMS Term: 77076 RADIO DEF RBRVS 02/01/2015 12/31/2023 76.36 Description: X-RAYS BONE SURVEY INFANT Category: Radiology CMS Add: 01/01/2007 CMS Term: 77076 TC RADIO DEF RBRVS 01/01/2024 68.55 Description: X-RAYS BONE SURVEY INFANT Category: Radiology CMS Add: 01/01/2007 CMS Term: 77076 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 50.45 Description: X-RAYS BONE SURVEY INFANT Category: Radiology CMS Add: 01/01/2007 CMS Term: 77077 26 RADIO DEF RBRVS 01/01/2024 15.83 Description: JOINT SURVEY SINGLE VIEW Category: Radiology CMS Add: 01/01/2007 CMS Term: 77077 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 12.21 Description: JOINT SURVEY SINGLE VIEW Category: Radiology CMS Add: 01/01/2007 CMS Term: 77077 RADIO DEF RBRVS 01/01/2024 44.08 Description: JOINT SURVEY SINGLE VIEW Category: Radiology CMS Add: 01/01/2007 CMS Term: 77077 RADIO DEF RBRVS 02/01/2015 12/31/2023 28.48 Description: JOINT SURVEY SINGLE VIEW Category: Radiology CMS Add: 01/01/2007 CMS Term: 77077 TC RADIO DEF RBRVS 01/01/2024 28.25 Description: JOINT SURVEY SINGLE VIEW Category: Radiology CMS Add: 01/01/2007 CMS Term: 77077 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 16.27 Description: JOINT SURVEY SINGLE VIEW Category: Radiology CMS Add: 01/01/2007 CMS Term: 77078 26 RADIO DEF RBRVS 01/01/2024 11.41 Description: CT BONE DENSITY AXIAL Category: Radiology CMS Add: 01/01/2007 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,006 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 77078 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 9.11 Description: CT BONE DENSITY AXIAL Category: Radiology CMS Add: 01/01/2007 CMS Term: 77078 RADIO DEF RBRVS 01/01/2024 97.70 Description: CT BONE DENSITY AXIAL Category: Radiology CMS Add: 01/01/2007 CMS Term: 77078 RADIO DEF RBRVS 02/01/2015 12/31/2023 79.38 Description: CT BONE DENSITY AXIAL Category: Radiology CMS Add: 01/01/2007 CMS Term: 77078 TC RADIO DEF RBRVS 01/01/2024 86.29 Description: CT BONE DENSITY AXIAL Category: Radiology CMS Add: 01/01/2007 CMS Term: 77078 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 70.27 Description: CT BONE DENSITY AXIAL Category: Radiology CMS Add: 01/01/2007 CMS Term: 77080 26 RADIO DEF RBRVS 01/01/2024 9.10 Description: DXA BONE DENSITY AXIAL Category: Radiology CMS Add: 01/01/2007 CMS Term: 77080 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 7.52 Description: DXA BONE DENSITY AXIAL Category: Radiology CMS Add: 01/01/2007 CMS Term: 77080 RADIO DEF RBRVS 01/01/2024 35.50 Description: DXA BONE DENSITY AXIAL Category: Radiology CMS Add: 01/01/2007 CMS Term: 77080 RADIO DEF RBRVS 02/01/2015 12/31/2023 34.44 Description: DXA BONE DENSITY AXIAL Category: Radiology CMS Add: 01/01/2007 CMS Term: 77080 TC RADIO DEF RBRVS 01/01/2024 26.40 Description: DXA BONE DENSITY AXIAL Category: Radiology CMS Add: 01/01/2007 CMS Term: 77080 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 26.92 Description: DXA BONE DENSITY AXIAL Category: Radiology CMS Add: 01/01/2007 CMS Term: 77081 26 RADIO DEF RBRVS 01/01/2024 9.41 Description: DXA BONE DENSITY/PERIPHERAL Category: Radiology CMS Add: 01/01/2007 CMS Term: 77081 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 8.06 Description: DXA BONE DENSITY/PERIPHERAL Category: Radiology CMS Add: 01/01/2007 CMS Term: 77081 RADIO DEF RBRVS 01/01/2024 29.33 Description: DXA BONE DENSITY/PERIPHERAL Category: Radiology CMS Add: 01/01/2007 CMS Term: 77081 RADIO DEF RBRVS 02/01/2015 12/31/2023 19.62 Description: DXA BONE DENSITY/PERIPHERAL Category: Radiology CMS Add: 01/01/2007 CMS Term: 77081 TC RADIO DEF RBRVS 01/01/2024 19.92 Description: DXA BONE DENSITY/PERIPHERAL Category: Radiology CMS Add: 01/01/2007 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,007 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 77081 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 11.56 Description: DXA BONE DENSITY/PERIPHERAL Category: Radiology CMS Add: 01/01/2007 CMS Term: 77084 26 RADIO DEF RBRVS 01/01/2024 73.72 Description: MAGNETIC IMAGE BONE MARROW Category: Radiology CMS Add: 01/01/2007 CMS Term: 77084 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 59.25 Description: MAGNETIC IMAGE BONE MARROW Category: Radiology CMS Add: 01/01/2007 CMS Term: 77084 RADIO DEF RBRVS 01/01/2024 310.84 Description: MAGNETIC IMAGE BONE MARROW Category: Radiology CMS Add: 01/01/2007 CMS Term: 77084 RADIO DEF RBRVS 02/01/2015 12/31/2023 277.41 Description: MAGNETIC IMAGE BONE MARROW Category: Radiology CMS Add: 01/01/2007 CMS Term: 77084 TC RADIO DEF RBRVS 01/01/2024 237.12 Description: MAGNETIC IMAGE BONE MARROW Category: Radiology CMS Add: 01/01/2007 CMS Term: 77084 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 218.15 Description: MAGNETIC IMAGE BONE MARROW Category: Radiology CMS Add: 01/01/2007 CMS Term: 77085 26 RADIO DEF RBRVS 01/01/2024 14.03 Description: DXA BONE DENSITY STUDY Category: Radiology CMS Add: 01/01/2015 CMS Term: 77085 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 11.20 Description: DXA BONE DENSITY STUDY Category: Radiology CMS Add: 01/01/2015 CMS Term: 77085 RADIO DEF RBRVS 01/01/2024 48.46 Description: DXA BONE DENSITY STUDY Category: Radiology CMS Add: 01/01/2015 CMS Term: 77085 RADIO DEF RBRVS 02/01/2015 12/31/2023 39.60 Description: DXA BONE DENSITY STUDY Category: Radiology CMS Add: 01/01/2015 CMS Term: 77085 TC RADIO DEF RBRVS 01/01/2024 34.43 Description: DXA BONE DENSITY STUDY Category: Radiology CMS Add: 01/01/2015 CMS Term: 77085 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 28.40 Description: DXA BONE DENSITY STUDY Category: Radiology CMS Add: 01/01/2015 CMS Term: 77086 26 RADIO DEF RBRVS 01/01/2024 7.77 Description: FRACTURE ASSESSMENT VIA DXA Category: Radiology CMS Add: 01/01/2015 CMS Term: 77086 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 6.47 Description: FRACTURE ASSESSMENT VIA DXA Category: Radiology CMS Add: 01/01/2015 CMS Term: 77086 RADIO DEF RBRVS 01/01/2024 30.78 Description: FRACTURE ASSESSMENT VIA DXA Category: Radiology CMS Add: 01/01/2015 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,008 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 77086 RADIO DEF RBRVS 02/01/2015 12/31/2023 24.96 Description: FRACTURE ASSESSMENT VIA DXA Category: Radiology CMS Add: 01/01/2015 CMS Term: 77086 TC RADIO DEF RBRVS 01/01/2024 23.01 Description: FRACTURE ASSESSMENT VIA DXA Category: Radiology CMS Add: 01/01/2015 CMS Term: 77086 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 18.50 Description: FRACTURE ASSESSMENT VIA DXA Category: Radiology CMS Add: 01/01/2015 CMS Term: 77089 RADIO DEF RBRVS 01/01/2022 12/31/2023 29.90 Description: TBS DXA CAL W/I&R FX RISK Category: Radiology CMS Add: 01/01/2022 CMS Term: 77089 RADIO DEF RBRVS 01/01/2024 37.51 Description: TBS DXA CAL W/I&R FX RISK Category: Radiology CMS Add: 01/01/2022 CMS Term: 77090 RADIO DEF RBRVS 01/01/2022 12/31/2023 1.65 Description: TBS TECHL PREP&TRANSMIS DATA Category: Radiology CMS Add: 01/01/2022 CMS Term: 77090 RADIO DEF RBRVS 01/01/2024 2.32 Description: TBS TECHL PREP&TRANSMIS DATA Category: Radiology CMS Add: 01/01/2022 CMS Term: 77091 RADIO DEF RBRVS 01/01/2022 12/31/2023 20.48 Description: TBS TECHL CALCULATION ONLY Category: Radiology CMS Add: 01/01/2022 CMS Term: 77091 RADIO DEF RBRVS 01/01/2024 25.78 Description: TBS TECHL CALCULATION ONLY Category: Radiology CMS Add: 01/01/2022 CMS Term: 77092 RADIO DEF RBRVS 01/01/2022 12/31/2023 7.77 Description: TBS I&R FX RSK QHP Category: Radiology CMS Add: 01/01/2022 CMS Term: 77092 RADIO DEF RBRVS 01/01/2024 9.41 Description: TBS I&R FX RSK QHP Category: Radiology CMS Add: 01/01/2022 CMS Term: 77261 RADIO DEF RBRVS 01/01/2024 67.57 Description: RADIATION THERAPY PLANNING Category: Radiology CMS Add: 01/01/1984 CMS Term: 77261 RADIO DEF RBRVS 02/01/2015 12/31/2023 54.11 Description: RADIATION THERAPY PLANNING Category: Radiology CMS Add: 01/01/1984 CMS Term: 77262 RADIO DEF RBRVS 01/01/2024 103.06 Description: RADIATION THERAPY PLANNING Category: Radiology CMS Add: 01/01/1984 CMS Term: 77262 RADIO DEF RBRVS 02/01/2015 12/31/2023 81.05 Description: RADIATION THERAPY PLANNING Category: Radiology CMS Add: 01/01/1984 CMS Term: 77263 RADIO DEF RBRVS 01/01/2024 160.75 Description: RADIATION THERAPY PLANNING Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,009 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 77263 RADIO DEF RBRVS 02/01/2015 12/31/2023 119.71 Description: RADIATION THERAPY PLANNING Category: Radiology CMS Add: 01/01/1984 CMS Term: 77280 26 RADIO DEF RBRVS 01/01/2024 36.40 Description: SET RADIATION THERAPY FIELD Category: Radiology CMS Add: 01/01/1984 CMS Term: 77280 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 26.24 Description: SET RADIATION THERAPY FIELD Category: Radiology CMS Add: 01/01/1984 CMS Term: 77280 RADIO DEF RBRVS 01/01/2024 250.50 Description: SET RADIATION THERAPY FIELD Category: Radiology CMS Add: 01/01/1984 CMS Term: 77280 RADIO DEF RBRVS 02/01/2015 12/31/2023 188.90 Description: SET RADIATION THERAPY FIELD Category: Radiology CMS Add: 01/01/1984 CMS Term: 77280 TC RADIO DEF RBRVS 01/01/2024 214.10 Description: SET RADIATION THERAPY FIELD Category: Radiology CMS Add: 01/01/1984 CMS Term: 77280 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 162.67 Description: SET RADIATION THERAPY FIELD Category: Radiology CMS Add: 01/01/1984 CMS Term: 77285 26 RADIO DEF RBRVS 01/01/2024 54.75 Description: SET RADIATION THERAPY FIELD Category: Radiology CMS Add: 01/01/1984 CMS Term: 77285 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 39.44 Description: SET RADIATION THERAPY FIELD Category: Radiology CMS Add: 01/01/1984 CMS Term: 77285 RADIO DEF RBRVS 01/01/2024 410.09 Description: SET RADIATION THERAPY FIELD Category: Radiology CMS Add: 01/01/1984 CMS Term: 77285 RADIO DEF RBRVS 02/01/2015 12/31/2023 294.26 Description: SET RADIATION THERAPY FIELD Category: Radiology CMS Add: 01/01/1984 CMS Term: 77285 TC RADIO DEF RBRVS 01/01/2024 355.34 Description: SET RADIATION THERAPY FIELD Category: Radiology CMS Add: 01/01/1984 CMS Term: 77285 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 254.82 Description: SET RADIATION THERAPY FIELD Category: Radiology CMS Add: 01/01/1984 CMS Term: 77290 26 RADIO DEF RBRVS 01/01/2024 79.31 Description: SET RADIATION THERAPY FIELD Category: Radiology CMS Add: 01/01/1984 CMS Term: 77290 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 58.68 Description: SET RADIATION THERAPY FIELD Category: Radiology CMS Add: 01/01/1984 CMS Term: 77290 RADIO DEF RBRVS 01/01/2024 421.37 Description: SET RADIATION THERAPY FIELD Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,010 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 77290 RADIO DEF RBRVS 02/01/2015 12/31/2023 353.37 Description: SET RADIATION THERAPY FIELD Category: Radiology CMS Add: 01/01/1984 CMS Term: 77290 TC RADIO DEF RBRVS 01/01/2024 342.07 Description: SET RADIATION THERAPY FIELD Category: Radiology CMS Add: 01/01/1984 CMS Term: 77290 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 294.70 Description: SET RADIATION THERAPY FIELD Category: Radiology CMS Add: 01/01/1984 CMS Term: 77293 26 RADIO DEF RBRVS 01/01/2024 101.17 Description: RESPIRATOR MOTION MGMT SIMUL Category: Radiology CMS Add: 01/01/2014 CMS Term: 77293 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 75.20 Description: RESPIRATOR MOTION MGMT SIMUL Category: Radiology CMS Add: 01/01/2014 CMS Term: 77293 RADIO DEF RBRVS 01/01/2024 385.83 Description: RESPIRATOR MOTION MGMT SIMUL Category: Radiology CMS Add: 01/01/2014 CMS Term: 77293 RADIO DEF RBRVS 02/01/2015 12/31/2023 321.10 Description: RESPIRATOR MOTION MGMT SIMUL Category: Radiology CMS Add: 01/01/2014 CMS Term: 77293 TC RADIO DEF RBRVS 01/01/2024 284.66 Description: RESPIRATOR MOTION MGMT SIMUL Category: Radiology CMS Add: 01/01/2014 CMS Term: 77293 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 245.90 Description: RESPIRATOR MOTION MGMT SIMUL Category: Radiology CMS Add: 01/01/2014 CMS Term: 77295 26 RADIO DEF RBRVS 01/01/2024 217.12 Description: 3-D RADIOTHERAPY PLAN Category: Radiology CMS Add: 01/01/1994 CMS Term: 77295 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 161.34 Description: 3-D RADIOTHERAPY PLAN Category: Radiology CMS Add: 01/01/1994 CMS Term: 77295 RADIO DEF RBRVS 01/01/2024 450.39 Description: 3-D RADIOTHERAPY PLAN Category: Radiology CMS Add: 01/01/1994 CMS Term: 77295 RADIO DEF RBRVS 02/01/2015 12/31/2023 342.33 Description: 3-D RADIOTHERAPY PLAN Category: Radiology CMS Add: 01/01/1994 CMS Term: 77295 TC RADIO DEF RBRVS 01/01/2024 233.28 Description: 3-D RADIOTHERAPY PLAN Category: Radiology CMS Add: 01/01/1994 CMS Term: 77295 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 181.00 Description: 3-D RADIOTHERAPY PLAN Category: Radiology CMS Add: 01/01/1994 CMS Term: 77299 RADIO DEF BILL25 Description: UNLISTED PX THER RAD TX PLNG Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,011 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 77300 26 RADIO DEF RBRVS 01/01/2024 31.53 Description: RADIATION THERAPY DOSE PLAN Category: Radiology CMS Add: 01/01/1984 CMS Term: 77300 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 23.35 Description: RADIATION THERAPY DOSE PLAN Category: Radiology CMS Add: 01/01/1984 CMS Term: 77300 RADIO DEF RBRVS 01/01/2024 61.95 Description: RADIATION THERAPY DOSE PLAN Category: Radiology CMS Add: 01/01/1984 CMS Term: 77300 RADIO DEF RBRVS 02/01/2015 12/31/2023 47.54 Description: RADIATION THERAPY DOSE PLAN Category: Radiology CMS Add: 01/01/1984 CMS Term: 77300 TC RADIO DEF RBRVS 01/01/2024 30.41 Description: RADIATION THERAPY DOSE PLAN Category: Radiology CMS Add: 01/01/1984 CMS Term: 77300 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 24.19 Description: RADIATION THERAPY DOSE PLAN Category: Radiology CMS Add: 01/01/1984 CMS Term: 77301 26 RADIO DEF RBRVS 01/01/2024 404.66 Description: RADIOTHERAPY DOSE PLAN IMRT Category: Radiology CMS Add: 01/01/2002 CMS Term: 77301 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 300.38 Description: RADIOTHERAPY DOSE PLAN IMRT Category: Radiology CMS Add: 01/01/2002 CMS Term: 77301 RADIO DEF RBRVS 01/01/2024 1710.56 Description: RADIOTHERAPY DOSE PLAN IMRT Category: Radiology CMS Add: 01/01/2002 CMS Term: 77301 RADIO DEF RBRVS 02/01/2015 12/31/2023 1367.04 Description: RADIOTHERAPY DOSE PLAN IMRT Category: Radiology CMS Add: 01/01/2002 CMS Term: 77301 TC RADIO DEF RBRVS 01/01/2024 1305.90 Description: RADIOTHERAPY DOSE PLAN IMRT Category: Radiology CMS Add: 01/01/2002 CMS Term: 77301 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 1066.66 Description: RADIOTHERAPY DOSE PLAN IMRT Category: Radiology CMS Add: 01/01/2002 CMS Term: 77306 26 RADIO DEF RBRVS 01/01/2024 70.94 Description: TELETHX ISODOSE PLAN SIMPLE Category: Radiology CMS Add: 01/01/2015 CMS Term: 77306 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 52.48 Description: TELETHX ISODOSE PLAN SIMPLE Category: Radiology CMS Add: 01/01/2015 CMS Term: 77306 RADIO DEF RBRVS 01/01/2024 139.18 Description: TELETHX ISODOSE PLAN SIMPLE Category: Radiology CMS Add: 01/01/2015 CMS Term: 77306 RADIO DEF RBRVS 02/01/2015 12/31/2023 103.18 Description: TELETHX ISODOSE PLAN SIMPLE Category: Radiology CMS Add: 01/01/2015 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,012 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 77306 TC RADIO DEF RBRVS 01/01/2024 68.24 Description: TELETHX ISODOSE PLAN SIMPLE Category: Radiology CMS Add: 01/01/2015 CMS Term: 77306 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 50.70 Description: TELETHX ISODOSE PLAN SIMPLE Category: Radiology CMS Add: 01/01/2015 CMS Term: 77307 26 RADIO DEF RBRVS 01/01/2024 146.82 Description: TELETHX ISODOSE PLAN CPLX Category: Radiology CMS Add: 01/01/2015 CMS Term: 77307 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 109.21 Description: TELETHX ISODOSE PLAN CPLX Category: Radiology CMS Add: 01/01/2015 CMS Term: 77307 RADIO DEF RBRVS 01/01/2024 270.02 Description: TELETHX ISODOSE PLAN CPLX Category: Radiology CMS Add: 01/01/2015 CMS Term: 77307 RADIO DEF RBRVS 02/01/2015 12/31/2023 202.10 Description: TELETHX ISODOSE PLAN CPLX Category: Radiology CMS Add: 01/01/2015 CMS Term: 77307 TC RADIO DEF RBRVS 01/01/2024 123.20 Description: TELETHX ISODOSE PLAN CPLX Category: Radiology CMS Add: 01/01/2015 CMS Term: 77307 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 92.89 Description: TELETHX ISODOSE PLAN CPLX Category: Radiology CMS Add: 01/01/2015 CMS Term: 77316 26 RADIO DEF RBRVS 01/01/2024 70.94 Description: BRACHYTX ISODOSE PLAN SIMPLE Category: Radiology CMS Add: 01/01/2015 CMS Term: 77316 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 52.48 Description: BRACHYTX ISODOSE PLAN SIMPLE Category: Radiology CMS Add: 01/01/2015 CMS Term: 77316 RADIO DEF RBRVS 01/01/2024 228.10 Description: BRACHYTX ISODOSE PLAN SIMPLE Category: Radiology CMS Add: 01/01/2015 CMS Term: 77316 RADIO DEF RBRVS 02/01/2015 12/31/2023 131.50 Description: BRACHYTX ISODOSE PLAN SIMPLE Category: Radiology CMS Add: 01/01/2015 CMS Term: 77316 TC RADIO DEF RBRVS 01/01/2024 157.16 Description: BRACHYTX ISODOSE PLAN SIMPLE Category: Radiology CMS Add: 01/01/2015 CMS Term: 77316 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 79.02 Description: BRACHYTX ISODOSE PLAN SIMPLE Category: Radiology CMS Add: 01/01/2015 CMS Term: 77317 26 RADIO DEF RBRVS 01/01/2024 92.63 Description: BRACHYTX ISODOSE INTERMED Category: Radiology CMS Add: 01/01/2015 CMS Term: 77317 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 68.98 Description: BRACHYTX ISODOSE INTERMED Category: Radiology CMS Add: 01/01/2015 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,013 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 77317 RADIO DEF RBRVS 01/01/2024 299.81 Description: BRACHYTX ISODOSE INTERMED Category: Radiology CMS Add: 01/01/2015 CMS Term: 77317 RADIO DEF RBRVS 02/01/2015 12/31/2023 171.95 Description: BRACHYTX ISODOSE INTERMED Category: Radiology CMS Add: 01/01/2015 CMS Term: 77317 TC RADIO DEF RBRVS 01/01/2024 207.19 Description: BRACHYTX ISODOSE INTERMED Category: Radiology CMS Add: 01/01/2015 CMS Term: 77317 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 102.97 Description: BRACHYTX ISODOSE INTERMED Category: Radiology CMS Add: 01/01/2015 CMS Term: 77318 26 RADIO DEF RBRVS 01/01/2024 146.51 Description: BRACHYTX ISODOSE COMPLEX Category: Radiology CMS Add: 01/01/2015 CMS Term: 77318 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 109.21 Description: BRACHYTX ISODOSE COMPLEX Category: Radiology CMS Add: 01/01/2015 CMS Term: 77318 RADIO DEF RBRVS 01/01/2024 426.57 Description: BRACHYTX ISODOSE COMPLEX Category: Radiology CMS Add: 01/01/2015 CMS Term: 77318 RADIO DEF RBRVS 02/01/2015 12/31/2023 249.00 Description: BRACHYTX ISODOSE COMPLEX Category: Radiology CMS Add: 01/01/2015 CMS Term: 77318 TC RADIO DEF RBRVS 01/01/2024 280.06 Description: BRACHYTX ISODOSE COMPLEX Category: Radiology CMS Add: 01/01/2015 CMS Term: 77318 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 139.79 Description: BRACHYTX ISODOSE COMPLEX Category: Radiology CMS Add: 01/01/2015 CMS Term: 77321 26 RADIO DEF RBRVS 01/01/2024 48.27 Description: SPECIAL TELETX PORT PLAN Category: Radiology CMS Add: 01/01/1984 CMS Term: 77321 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 35.60 Description: SPECIAL TELETX PORT PLAN Category: Radiology CMS Add: 01/01/1984 CMS Term: 77321 RADIO DEF RBRVS 01/01/2024 88.57 Description: SPECIAL TELETX PORT PLAN Category: Radiology CMS Add: 01/01/1984 CMS Term: 77321 RADIO DEF RBRVS 02/01/2015 12/31/2023 64.99 Description: SPECIAL TELETX PORT PLAN Category: Radiology CMS Add: 01/01/1984 CMS Term: 77321 TC RADIO DEF RBRVS 01/01/2024 40.29 Description: SPECIAL TELETX PORT PLAN Category: Radiology CMS Add: 01/01/1984 CMS Term: 77321 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 29.40 Description: SPECIAL TELETX PORT PLAN Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,014 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 77331 26 RADIO DEF RBRVS 01/01/2024 44.02 Description: SPECIAL RADIATION DOSIMETRY Category: Radiology CMS Add: 01/01/1984 CMS Term: 77331 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 32.71 Description: SPECIAL RADIATION DOSIMETRY Category: Radiology CMS Add: 01/01/1984 CMS Term: 77331 RADIO DEF RBRVS 01/01/2024 61.47 Description: SPECIAL RADIATION DOSIMETRY Category: Radiology CMS Add: 01/01/1984 CMS Term: 77331 RADIO DEF RBRVS 02/01/2015 12/31/2023 45.50 Description: SPECIAL RADIATION DOSIMETRY Category: Radiology CMS Add: 01/01/1984 CMS Term: 77331 TC RADIO DEF RBRVS 01/01/2024 17.45 Description: SPECIAL RADIATION DOSIMETRY Category: Radiology CMS Add: 01/01/1984 CMS Term: 77331 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 12.80 Description: SPECIAL RADIATION DOSIMETRY Category: Radiology CMS Add: 01/01/1984 CMS Term: 77332 26 RADIO DEF RBRVS 01/01/2024 22.98 Description: RADIATION TREATMENT AID(S) Category: Radiology CMS Add: 01/01/1984 CMS Term: 77332 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 20.45 Description: RADIATION TREATMENT AID(S) Category: Radiology CMS Add: 01/01/1984 CMS Term: 77332 RADIO DEF RBRVS 01/01/2024 36.11 Description: RADIATION TREATMENT AID(S) Category: Radiology CMS Add: 01/01/1984 CMS Term: 77332 RADIO DEF RBRVS 02/01/2015 12/31/2023 56.54 Description: RADIATION TREATMENT AID(S) Category: Radiology CMS Add: 01/01/1984 CMS Term: 77332 TC RADIO DEF RBRVS 01/01/2024 13.13 Description: RADIATION TREATMENT AID(S) Category: Radiology CMS Add: 01/01/1984 CMS Term: 77332 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 36.08 Description: RADIATION TREATMENT AID(S) Category: Radiology CMS Add: 01/01/1984 CMS Term: 77333 26 RADIO DEF RBRVS 01/01/2024 38.10 Description: RADIATION TREATMENT AID(S) Category: Radiology CMS Add: 01/01/1984 CMS Term: 77333 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 31.65 Description: RADIATION TREATMENT AID(S) Category: Radiology CMS Add: 01/01/1984 CMS Term: 77333 RADIO DEF RBRVS 01/01/2024 128.71 Description: RADIATION TREATMENT AID(S) Category: Radiology CMS Add: 01/01/1984 CMS Term: 77333 RADIO DEF RBRVS 02/01/2015 12/31/2023 38.01 Description: RADIATION TREATMENT AID(S) Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,015 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 77333 TC RADIO DEF RBRVS 01/01/2024 90.61 Description: RADIATION TREATMENT AID(S) Category: Radiology CMS Add: 01/01/1984 CMS Term: 77333 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 6.36 Description: RADIATION TREATMENT AID(S) Category: Radiology CMS Add: 01/01/1984 CMS Term: 77334 26 RADIO DEF RBRVS 01/01/2024 58.14 Description: RADIATION TREATMENT AID(S) Category: Radiology CMS Add: 01/01/1984 CMS Term: 77334 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 46.53 Description: RADIATION TREATMENT AID(S) Category: Radiology CMS Add: 01/01/1984 CMS Term: 77334 RADIO DEF RBRVS 01/01/2024 117.88 Description: RADIATION TREATMENT AID(S) Category: Radiology CMS Add: 01/01/1984 CMS Term: 77334 RADIO DEF RBRVS 02/01/2015 12/31/2023 106.14 Description: RADIATION TREATMENT AID(S) Category: Radiology CMS Add: 01/01/1984 CMS Term: 77334 TC RADIO DEF RBRVS 01/01/2024 59.74 Description: RADIATION TREATMENT AID(S) Category: Radiology CMS Add: 01/01/1984 CMS Term: 77334 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 59.62 Description: RADIATION TREATMENT AID(S) Category: Radiology CMS Add: 01/01/1984 CMS Term: 77336 RADIO DEF RBRVS 01/01/2024 78.47 Description: RADIATION PHYSICS CONSULT Category: Radiology CMS Add: 01/01/1984 CMS Term: 77336 RADIO DEF RBRVS 02/01/2015 12/31/2023 51.69 Description: RADIATION PHYSICS CONSULT Category: Radiology CMS Add: 01/01/1984 CMS Term: 77338 26 RADIO DEF RBRVS 01/01/2024 217.12 Description: DESIGN MLC DEVICE FOR IMRT Category: Radiology CMS Add: 01/01/2010 CMS Term: 77338 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 161.50 Description: DESIGN MLC DEVICE FOR IMRT Category: Radiology CMS Add: 01/01/2010 CMS Term: 77338 RADIO DEF RBRVS 01/01/2024 436.97 Description: DESIGN MLC DEVICE FOR IMRT Category: Radiology CMS Add: 01/01/2010 CMS Term: 77338 RADIO DEF RBRVS 02/01/2015 12/31/2023 353.89 Description: DESIGN MLC DEVICE FOR IMRT Category: Radiology CMS Add: 01/01/2010 CMS Term: 77338 TC RADIO DEF RBRVS 01/01/2024 219.86 Description: DESIGN MLC DEVICE FOR IMRT Category: Radiology CMS Add: 01/01/2010 CMS Term: 77338 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 192.39 Description: DESIGN MLC DEVICE FOR IMRT Category: Radiology CMS Add: 01/01/2010 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,016 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 77370 RADIO DEF RBRVS 01/01/2024 126.05 Description: RADIATION PHYSICS CONSULT Category: Radiology CMS Add: 01/01/1984 CMS Term: 77370 RADIO DEF RBRVS 02/01/2015 12/31/2023 78.94 Description: RADIATION PHYSICS CONSULT Category: Radiology CMS Add: 01/01/1984 CMS Term: 77371 RADIO DEF BILL25 Description: SRS MULTISOURCE Category: Radiology CMS Add: 01/01/2007 CMS Term: 77372 RADIO DEF RBRVS 01/01/2024 890.61 Description: SRS LINEAR BASED Category: Radiology CMS Add: 01/01/2007 CMS Term: 77372 RADIO DEF RBRVS 02/01/2015 12/31/2023 722.42 Description: SRS LINEAR BASED Category: Radiology CMS Add: 01/01/2007 CMS Term: 77373 RADIO DEF RBRVS 01/01/2024 924.90 0-1 Description: SBRT DELIVERY Category: Radiology CMS Add: 01/01/2007 CMS Term: 77373 RADIO DEF RBRVS 09/01/2019 12/31/2023 864.94 0-1 Description: SBRT DELIVERY Category: Radiology CMS Add: 01/01/2007 CMS Term: 77387 NOCOV DEF SYSMAN Description: GUIDANCE FOR RADJ TX DLVR Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 77399 RADIO DEF BILL25 Description: UNLISTED PX MED RADJ PHYSICS Category: Radiology CMS Add: 01/01/1984 CMS Term: 77401 RADIO DEF RBRVS 01/01/2024 37.82 Description: RADIATION TREATMENT DELIVERY Category: Radiology CMS Add: 01/01/1991 CMS Term: 77401 RADIO DEF RBRVS 02/01/2015 12/31/2023 13.79 Description: RADIATION TREATMENT DELIVERY Category: Radiology CMS Add: 01/01/1991 CMS Term: 77402 TC RADIO DEF MAXFEE 01/01/2015 12/31/2023 100.09 0.0 Description: RADIATION TREATMENT DELIVERY Category: Radiology CMS Add: 01/01/1991 CMS Term: 77402 TC RADIO DEF MAXFEE 01/01/2024 106.40 0.0 Description: RADIATION TREATMENT DELIVERY Category: Radiology CMS Add: 01/01/1991 CMS Term: 77407 TC RADIO DEF MAXFEE 01/01/2015 12/31/2023 100.09 0.0 Description: RADIATION TREATMENT DELIVERY Category: Radiology CMS Add: 01/01/1991 CMS Term: 77407 TC RADIO DEF MAXFEE 01/01/2024 106.40 0.0 Description: RADIATION TREATMENT DELIVERY Category: Radiology CMS Add: 01/01/1991 CMS Term: 77417 RADIO DEF RBRVS 01/01/2024 12.51 Description: RADIOLOGY PORT IMAGES(S) Category: Radiology CMS Add: 01/01/1991 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,017 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 77417 RADIO DEF RBRVS 02/01/2015 12/31/2023 9.58 Description: RADIOLOGY PORT IMAGES(S) Category: Radiology CMS Add: 01/01/1991 CMS Term: 77423 RADIO DEF MAXFEE 01/01/2024 74.93 0.0 Description: NEUTRON BEAM TX COMPLEX Category: Radiology CMS Add: 01/01/2006 CMS Term: 77423 RADIO DEF RBRVS 02/01/2015 12/31/2023 34.35 Description: NEUTRON BEAM TX COMPLEX Category: Radiology CMS Add: 01/01/2006 CMS Term: 77424 NOCOV DEF SYSMAN Description: IO RAD TX DELIVERY BY X-RAY Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 77427 RADIO DEF RBRVS 01/01/2024 181.98 0-1 Description: RADIATION TX MANAGEMENT X5 Category: Radiology CMS Add: 01/01/2000 CMS Term: 77427 RADIO DEF RBRVS 09/01/2019 12/31/2023 133.73 0-1 Description: RADIATION TX MANAGEMENT X5 Category: Radiology CMS Add: 01/01/2000 CMS Term: 77431 RADIO DEF RBRVS 01/01/2024 101.87 Description: RADIATION THERAPY MANAGEMENT Category: Radiology CMS Add: 01/01/1991 CMS Term: 77431 RADIO DEF RBRVS 02/01/2015 12/31/2023 73.32 Description: RADIATION THERAPY MANAGEMENT Category: Radiology CMS Add: 01/01/1991 CMS Term: 77432 RADIO DEF RBRVS 01/01/2024 405.23 Description: STEREOTACTIC RADIATION TRMT Category: Radiology CMS Add: 01/01/1994 CMS Term: 77432 RADIO DEF RBRVS 02/01/2015 12/31/2023 301.56 Description: STEREOTACTIC RADIATION TRMT Category: Radiology CMS Add: 01/01/1994 CMS Term: 77435 26 RADIO DEF MAXFEE 01/01/2024 504.96 0.0 0-1 Description: SBRT MANAGEMENT Category: Radiology CMS Add: 01/01/2007 CMS Term: 77435 26 RADIO DEF RBRVS 02/01/2015 594.25 0-1 Description: SBRT MANAGEMENT Category: Radiology CMS Add: 01/01/2007 CMS Term: 77435 RADIO DEF RBRVS 01/01/2024 611.69 0-1 Description: SBRT MANAGEMENT Category: Radiology CMS Add: 01/01/2007 CMS Term: 77435 RADIO DEF RBRVS 02/01/2015 12/31/2023 455.25 0-1 Description: SBRT MANAGEMENT Category: Radiology CMS Add: 01/01/2007 CMS Term: 77469 RADIO DEF RBRVS 01/01/2024 303.81 0-1 Description: IO RADIATION TX MANAGEMENT Category: Radiology CMS Add: 01/01/2012 CMS Term: 77469 RADIO DEF RBRVS 02/01/2015 12/31/2023 225.09 0-1 Description: IO RADIATION TX MANAGEMENT Category: Radiology CMS Add: 01/01/2012 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,018 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 77470 26 RADIO DEF RBRVS 01/01/2024 102.82 Description: SPECIAL RADIATION TREATMENT Category: Radiology CMS Add: 01/01/1984 CMS Term: 77470 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 78.61 Description: SPECIAL RADIATION TREATMENT Category: Radiology CMS Add: 01/01/1984 CMS Term: 77470 RADIO DEF RBRVS 01/01/2024 132.47 Description: SPECIAL RADIATION TREATMENT Category: Radiology CMS Add: 01/01/1984 CMS Term: 77470 RADIO DEF RBRVS 02/01/2015 12/31/2023 110.73 Description: SPECIAL RADIATION TREATMENT Category: Radiology CMS Add: 01/01/1984 CMS Term: 77470 TC RADIO DEF RBRVS 01/01/2024 29.65 Description: SPECIAL RADIATION TREATMENT Category: Radiology CMS Add: 01/01/1984 CMS Term: 77470 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 32.12 Description: SPECIAL RADIATION TREATMENT Category: Radiology CMS Add: 01/01/1984 CMS Term: 77499 RADIO DEF BILL25 Description: UNLISTED PX THER RAD TX MGMT Category: Radiology CMS Add: 01/01/1984 CMS Term: 77520 RADIO DEF MAXFEE 01/01/2024 571.19 0.0 0-1 Description: PROTON TRMT SIMPLE W/O COMP Category: Radiology CMS Add: 01/01/2000 CMS Term: 77520 RADIO DEF MAXFEE 02/13/2017 12/31/2023 322.29 0.0 0-1 Description: PROTON TRMT SIMPLE W/O COMP Category: Radiology CMS Add: 01/01/2000 CMS Term: 77520 TC RADIO DEF MAXFEE 02/01/2015 09/30/2023 322.29 0.0 0-1 Description: PROTON TRMT SIMPLE W/O COMP Category: Radiology CMS Add: 01/01/2000 CMS Term: 77522 RADIO DEF MAXFEE 01/01/2024 571.19 0.0 Description: PROTON TRMT SIMPLE W/COMP Category: Radiology CMS Add: 01/01/2001 CMS Term: 77522 RADIO DEF MAXFEE 02/13/2017 12/31/2023 322.29 0.0 Description: PROTON TRMT SIMPLE W/COMP Category: Radiology CMS Add: 01/01/2001 CMS Term: 77523 RADIO DEF MAXFEE 01/01/2024 865.50 0.0 Description: PROTON TRMT INTERMEDIATE Category: Radiology CMS Add: 01/01/2000 CMS Term: 77523 RADIO DEF MAXFEE 02/13/2017 12/31/2023 487.78 0.0 Description: PROTON TRMT INTERMEDIATE Category: Radiology CMS Add: 01/01/2000 CMS Term: 77525 RADIO DEF MAXFEE 01/01/2024 865.50 0.0 Description: PROTON TREATMENT COMPLEX Category: Radiology CMS Add: 01/01/2001 CMS Term: 77525 RADIO DEF MAXFEE 02/13/2017 12/31/2023 487.78 0.0 Description: PROTON TREATMENT COMPLEX Category: Radiology CMS Add: 01/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,019 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 77600 NOCOV DEF SYSMAN Description: HYPERTHERMIA TREATMENT Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: 77605 NOCOV DEF SYSMAN Description: HYPERTHERMIA TREATMENT Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: 77610 NOCOV DEF SYSMAN Description: HYPERTHERMIA TREATMENT Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: 77615 NOCOV DEF SYSMAN Description: HYPERTHERMIA TREATMENT Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: 77620 NOCOV DEF SYSMAN Description: HYPERTHERMIA TREATMENT Category: Non Covered Services CMS Add: 01/01/1988 CMS Term: 77750 26 RADIO DEF RBRVS 01/01/2024 253.23 Description: INFUSE RADIOACTIVE MATERIALS Category: Radiology CMS Add: 01/01/1984 CMS Term: 77750 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 187.76 Description: INFUSE RADIOACTIVE MATERIALS Category: Radiology CMS Add: 01/01/1984 CMS Term: 77750 RADIO DEF RBRVS 01/01/2024 372.42 Description: INFUSE RADIOACTIVE MATERIALS Category: Radiology CMS Add: 01/01/1984 CMS Term: 77750 RADIO DEF RBRVS 02/01/2015 12/31/2023 263.31 Description: INFUSE RADIOACTIVE MATERIALS Category: Radiology CMS Add: 01/01/1984 CMS Term: 77750 TC RADIO DEF RBRVS 01/01/2024 119.19 Description: INFUSE RADIOACTIVE MATERIALS Category: Radiology CMS Add: 01/01/1984 CMS Term: 77750 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 75.55 Description: INFUSE RADIOACTIVE MATERIALS Category: Radiology CMS Add: 01/01/1984 CMS Term: 77761 26 RADIO DEF RBRVS 01/01/2024 195.25 Description: APPLY INTRCAV RADIAT SIMPLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 77761 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 143.49 Description: APPLY INTRCAV RADIAT SIMPLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 77761 RADIO DEF RBRVS 01/01/2024 393.65 Description: APPLY INTRCAV RADIAT SIMPLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 77761 RADIO DEF RBRVS 02/01/2015 12/31/2023 273.95 Description: APPLY INTRCAV RADIAT SIMPLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 77761 TC RADIO DEF RBRVS 01/01/2024 198.39 Description: APPLY INTRCAV RADIAT SIMPLE Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,020 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 77761 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 130.46 Description: APPLY INTRCAV RADIAT SIMPLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 77762 26 RADIO DEF RBRVS 01/01/2024 291.51 Description: APPLY INTRCAV RADIAT INTERM Category: Radiology CMS Add: 01/01/1984 CMS Term: 77762 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 215.78 Description: APPLY INTRCAV RADIAT INTERM Category: Radiology CMS Add: 01/01/1984 CMS Term: 77762 RADIO DEF RBRVS 01/01/2024 518.78 Description: APPLY INTRCAV RADIAT INTERM Category: Radiology CMS Add: 01/01/1984 CMS Term: 77762 RADIO DEF RBRVS 02/01/2015 12/31/2023 363.75 Description: APPLY INTRCAV RADIAT INTERM Category: Radiology CMS Add: 01/01/1984 CMS Term: 77762 TC RADIO DEF RBRVS 01/01/2024 227.28 Description: APPLY INTRCAV RADIAT INTERM Category: Radiology CMS Add: 01/01/1984 CMS Term: 77762 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 147.97 Description: APPLY INTRCAV RADIAT INTERM Category: Radiology CMS Add: 01/01/1984 CMS Term: 77763 26 RADIO DEF RBRVS 01/01/2024 438.63 Description: APPLY INTRCAV RADIAT COMPL Category: Radiology CMS Add: 01/01/1984 CMS Term: 77763 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 325.57 Description: APPLY INTRCAV RADIAT COMPL Category: Radiology CMS Add: 01/01/1984 CMS Term: 77763 RADIO DEF RBRVS 01/01/2024 733.23 Description: APPLY INTRCAV RADIAT COMPL Category: Radiology CMS Add: 01/01/1984 CMS Term: 77763 RADIO DEF RBRVS 02/01/2015 12/31/2023 516.97 Description: APPLY INTRCAV RADIAT COMPL Category: Radiology CMS Add: 01/01/1984 CMS Term: 77763 TC RADIO DEF RBRVS 01/01/2024 294.59 Description: APPLY INTRCAV RADIAT COMPL Category: Radiology CMS Add: 01/01/1984 CMS Term: 77763 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 191.40 Description: APPLY INTRCAV RADIAT COMPL Category: Radiology CMS Add: 01/01/1984 CMS Term: 77767 26 RADIO DEF RBRVS 01/01/2016 12/31/2023 39.94 Description: HDR RDNCL SKN SURF BRACHYTX Category: Radiology CMS Add: 01/01/2016 CMS Term: 77767 26 RADIO DEF RBRVS 01/01/2024 53.20 Description: HDR RDNCL SKN SURF BRACHYTX Category: Radiology CMS Add: 01/01/2016 CMS Term: 77767 RADIO DEF RBRVS 01/01/2016 12/31/2023 158.59 Description: HDR RDNCL SKN SURF BRACHYTX Category: Radiology CMS Add: 01/01/2016 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,021 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 77767 RADIO DEF RBRVS 01/01/2024 231.67 Description: HDR RDNCL SKN SURF BRACHYTX Category: Radiology CMS Add: 01/01/2016 CMS Term: 77767 TC RADIO DEF RBRVS 01/01/2016 12/31/2023 118.66 Description: HDR RDNCL SKN SURF BRACHYTX Category: Radiology CMS Add: 01/01/2016 CMS Term: 77767 TC RADIO DEF RBRVS 01/01/2024 178.46 Description: HDR RDNCL SKN SURF BRACHYTX Category: Radiology CMS Add: 01/01/2016 CMS Term: 77768 26 RADIO DEF RBRVS 01/01/2016 12/31/2023 52.97 Description: HDR RDNCL SKN SURF BRACHYTX Category: Radiology CMS Add: 01/01/2016 CMS Term: 77768 26 RADIO DEF RBRVS 01/01/2024 70.94 Description: HDR RDNCL SKN SURF BRACHYTX Category: Radiology CMS Add: 01/01/2016 CMS Term: 77768 RADIO DEF RBRVS 01/01/2016 12/31/2023 248.01 Description: HDR RDNCL SKN SURF BRACHYTX Category: Radiology CMS Add: 01/01/2016 CMS Term: 77768 RADIO DEF RBRVS 01/01/2024 337.87 Description: HDR RDNCL SKN SURF BRACHYTX Category: Radiology CMS Add: 01/01/2016 CMS Term: 77768 TC RADIO DEF RBRVS 01/01/2016 12/31/2023 195.03 Description: HDR RDNCL SKN SURF BRACHYTX Category: Radiology CMS Add: 01/01/2016 CMS Term: 77768 TC RADIO DEF RBRVS 01/01/2024 266.93 Description: HDR RDNCL SKN SURF BRACHYTX Category: Radiology CMS Add: 01/01/2016 CMS Term: 77770 26 RADIO DEF RBRVS 01/01/2016 12/31/2023 73.78 Description: HDR RDNCL NTRSTL/ICAV BRCHTX Category: Radiology CMS Add: 01/01/2016 CMS Term: 77770 26 RADIO DEF RBRVS 01/01/2024 98.55 Description: HDR RDNCL NTRSTL/ICAV BRCHTX Category: Radiology CMS Add: 01/01/2016 CMS Term: 77770 RADIO DEF RBRVS 01/01/2016 12/31/2023 227.28 Description: HDR RDNCL NTRSTL/ICAV BRCHTX Category: Radiology CMS Add: 01/01/2016 CMS Term: 77770 RADIO DEF RBRVS 01/01/2024 323.32 Description: HDR RDNCL NTRSTL/ICAV BRCHTX Category: Radiology CMS Add: 01/01/2016 CMS Term: 77770 TC RADIO DEF RBRVS 01/01/2016 12/31/2023 153.50 Description: HDR RDNCL NTRSTL/ICAV BRCHTX Category: Radiology CMS Add: 01/01/2016 CMS Term: 77770 TC RADIO DEF RBRVS 01/01/2024 224.77 Description: HDR RDNCL NTRSTL/ICAV BRCHTX Category: Radiology CMS Add: 01/01/2016 CMS Term: 77771 26 RADIO DEF RBRVS 01/01/2016 12/31/2023 144.13 Description: HDR RDNCL NTRSTL/ICAV BRCHTX Category: Radiology CMS Add: 01/01/2016 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,022 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 77771 26 RADIO DEF RBRVS 01/01/2024 192.63 Description: HDR RDNCL NTRSTL/ICAV BRCHTX Category: Radiology CMS Add: 01/01/2016 CMS Term: 77771 RADIO DEF RBRVS 01/01/2016 12/31/2023 423.71 Description: HDR RDNCL NTRSTL/ICAV BRCHTX Category: Radiology CMS Add: 01/01/2016 CMS Term: 77771 RADIO DEF RBRVS 01/01/2024 562.23 Description: HDR RDNCL NTRSTL/ICAV BRCHTX Category: Radiology CMS Add: 01/01/2016 CMS Term: 77771 TC RADIO DEF RBRVS 01/01/2016 12/31/2023 279.59 Description: HDR RDNCL NTRSTL/ICAV BRCHTX Category: Radiology CMS Add: 01/01/2016 CMS Term: 77771 TC RADIO DEF RBRVS 01/01/2024 369.59 Description: HDR RDNCL NTRSTL/ICAV BRCHTX Category: Radiology CMS Add: 01/01/2016 CMS Term: 77772 26 RADIO DEF RBRVS 01/01/2016 12/31/2023 204.37 Description: HDR RDNCL NTRSTL/ICAV BRCHTX Category: Radiology CMS Add: 01/01/2016 CMS Term: 77772 26 RADIO DEF RBRVS 01/01/2024 271.43 Description: HDR RDNCL NTRSTL/ICAV BRCHTX Category: Radiology CMS Add: 01/01/2016 CMS Term: 77772 RADIO DEF RBRVS 01/01/2016 12/31/2023 645.55 Description: HDR RDNCL NTRSTL/ICAV BRCHTX Category: Radiology CMS Add: 01/01/2016 CMS Term: 77772 RADIO DEF RBRVS 01/01/2024 836.33 Description: HDR RDNCL NTRSTL/ICAV BRCHTX Category: Radiology CMS Add: 01/01/2016 CMS Term: 77772 TC RADIO DEF RBRVS 01/01/2016 12/31/2023 441.18 Description: HDR RDNCL NTRSTL/ICAV BRCHTX Category: Radiology CMS Add: 01/01/2016 CMS Term: 77772 TC RADIO DEF RBRVS 01/01/2024 564.90 Description: HDR RDNCL NTRSTL/ICAV BRCHTX Category: Radiology CMS Add: 01/01/2016 CMS Term: 77778 26 RADIO DEF RBRVS 01/01/2019 12/31/2023 424.78 Description: APPLY INTERSTIT RADIAT COMPL Category: Radiology CMS Add: 01/01/1984 CMS Term: 77778 26 RADIO DEF RBRVS 01/01/2024 443.48 Description: APPLY INTERSTIT RADIAT COMPL Category: Radiology CMS Add: 01/01/1984 CMS Term: 77778 RADIO DEF RBRVS 01/01/2024 859.89 Description: APPLY INTERSTIT RADIAT COMPL Category: Radiology CMS Add: 01/01/1984 CMS Term: 77778 RADIO DEF RBRVS 02/01/2015 12/31/2023 621.05 Description: APPLY INTERSTIT RADIAT COMPL Category: Radiology CMS Add: 01/01/1984 CMS Term: 77778 TC RADIO DEF RBRVS 01/01/2024 416.41 Description: APPLY INTERSTIT RADIAT COMPL Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,023 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 77778 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 196.27 Description: APPLY INTERSTIT RADIAT COMPL Category: Radiology CMS Add: 01/01/1984 CMS Term: 77789 26 RADIO DEF RBRVS 01/01/2024 57.80 Description: APPLY SURF LDR RADIONUCLIDE Category: Radiology CMS Add: 01/01/1984 CMS Term: 77789 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 42.85 Description: APPLY SURF LDR RADIONUCLIDE Category: Radiology CMS Add: 01/01/1984 CMS Term: 77789 RADIO DEF RBRVS 01/01/2024 123.88 Description: APPLY SURF LDR RADIONUCLIDE Category: Radiology CMS Add: 01/01/1984 CMS Term: 77789 RADIO DEF RBRVS 02/01/2015 12/31/2023 83.64 Description: APPLY SURF LDR RADIONUCLIDE Category: Radiology CMS Add: 01/01/1984 CMS Term: 77789 TC RADIO DEF RBRVS 01/01/2024 66.08 Description: APPLY SURF LDR RADIONUCLIDE Category: Radiology CMS Add: 01/01/1984 CMS Term: 77789 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 40.79 Description: APPLY SURF LDR RADIONUCLIDE Category: Radiology CMS Add: 01/01/1984 CMS Term: 77790 26 RADIO DEF MAXFEE 01/01/2024 41.49 0.0 Description: RADIATION HANDLING Category: Radiology CMS Add: 01/01/1984 CMS Term: 77790 26 RADIO DEF RBRVS 02/01/2015 48.88 Description: RADIATION HANDLING Category: Radiology CMS Add: 01/01/1984 CMS Term: 77790 RADIO DEF RBRVS 01/01/2024 15.76 Description: RADIATION HANDLING Category: Radiology CMS Add: 01/01/1984 CMS Term: 77790 RADIO DEF RBRVS 02/01/2015 12/31/2023 68.18 Description: RADIATION HANDLING Category: Radiology CMS Add: 01/01/1984 CMS Term: 77790 TC RADIO DEF MAXFEE 01/01/2024 30.99 0.0 Description: RADIATION HANDLING Category: Radiology CMS Add: 01/01/1984 CMS Term: 77790 TC RADIO DEF RBRVS 02/01/2015 36.28 Description: RADIATION HANDLING Category: Radiology CMS Add: 01/01/1984 CMS Term: 77799 RADIO DEF BILL25 Description: UNLISTED PX CLIN BRACHYTX Category: Radiology CMS Add: 01/01/1984 CMS Term: 78012 26 RADIO DEF RBRVS 01/01/2024 8.45 0-1 Description: THYROID UPTAKE MEASUREMENT Category: Radiology CMS Add: 01/01/2013 CMS Term: 78012 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 6.76 0-1 Description: THYROID UPTAKE MEASUREMENT Category: Radiology CMS Add: 01/01/2013 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,024 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 78012 RADIO DEF RBRVS 01/01/2024 74.54 0-1 Description: THYROID UPTAKE MEASUREMENT Category: Radiology CMS Add: 01/01/2013 CMS Term: 78012 RADIO DEF RBRVS 02/01/2015 12/31/2023 54.48 0-1 Description: THYROID UPTAKE MEASUREMENT Category: Radiology CMS Add: 01/01/2013 CMS Term: 78012 TC RADIO DEF RBRVS 01/01/2024 66.09 0-1 Description: THYROID UPTAKE MEASUREMENT Category: Radiology CMS Add: 01/01/2013 CMS Term: 78012 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 47.73 0-1 Description: THYROID UPTAKE MEASUREMENT Category: Radiology CMS Add: 01/01/2013 CMS Term: 78013 26 RADIO DEF RBRVS 01/01/2024 16.87 0-1 Description: THYROID IMAGING W/BLOOD FLOW Category: Radiology CMS Add: 01/01/2013 CMS Term: 78013 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 13.33 0-1 Description: THYROID IMAGING W/BLOOD FLOW Category: Radiology CMS Add: 01/01/2013 CMS Term: 78013 RADIO DEF RBRVS 01/01/2024 165.08 0-1 Description: THYROID IMAGING W/BLOOD FLOW Category: Radiology CMS Add: 01/01/2013 CMS Term: 78013 RADIO DEF RBRVS 02/01/2015 12/31/2023 137.18 0-1 Description: THYROID IMAGING W/BLOOD FLOW Category: Radiology CMS Add: 01/01/2013 CMS Term: 78013 TC RADIO DEF RBRVS 01/01/2024 148.21 0-1 Description: THYROID IMAGING W/BLOOD FLOW Category: Radiology CMS Add: 01/01/2013 CMS Term: 78013 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 123.86 0-1 Description: THYROID IMAGING W/BLOOD FLOW Category: Radiology CMS Add: 01/01/2013 CMS Term: 78014 26 RADIO DEF RBRVS 01/01/2024 22.51 0-1 Description: THYROID IMAGING W/BLOOD FLOW Category: Radiology CMS Add: 01/01/2013 CMS Term: 78014 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 18.14 0-1 Description: THYROID IMAGING W/BLOOD FLOW Category: Radiology CMS Add: 01/01/2013 CMS Term: 78014 RADIO DEF RBRVS 01/01/2024 206.22 0-1 Description: THYROID IMAGING W/BLOOD FLOW Category: Radiology CMS Add: 01/01/2013 CMS Term: 78014 RADIO DEF RBRVS 02/01/2015 12/31/2023 166.27 0-1 Description: THYROID IMAGING W/BLOOD FLOW Category: Radiology CMS Add: 01/01/2013 CMS Term: 78014 TC RADIO DEF RBRVS 01/01/2024 183.71 0-1 Description: THYROID IMAGING W/BLOOD FLOW Category: Radiology CMS Add: 01/01/2013 CMS Term: 78014 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 148.13 0-1 Description: THYROID IMAGING W/BLOOD FLOW Category: Radiology CMS Add: 01/01/2013 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,025 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 78015 26 RADIO DEF RBRVS 01/01/2024 31.07 Description: THYROID MET IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78015 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 24.36 Description: THYROID MET IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78015 RADIO DEF RBRVS 01/01/2024 200.58 Description: THYROID MET IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78015 RADIO DEF RBRVS 02/01/2015 12/31/2023 154.66 Description: THYROID MET IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78015 TC RADIO DEF RBRVS 01/01/2024 169.51 Description: THYROID MET IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78015 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 130.30 Description: THYROID MET IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78016 26 RADIO DEF RBRVS 01/01/2024 32.27 Description: THYROID MET IMAGING/STUDIES Category: Radiology CMS Add: 01/01/1984 CMS Term: 78016 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 25.99 Description: THYROID MET IMAGING/STUDIES Category: Radiology CMS Add: 01/01/1984 CMS Term: 78016 RADIO DEF RBRVS 01/01/2024 240.07 Description: THYROID MET IMAGING/STUDIES Category: Radiology CMS Add: 01/01/1984 CMS Term: 78016 RADIO DEF RBRVS 02/01/2015 12/31/2023 199.40 Description: THYROID MET IMAGING/STUDIES Category: Radiology CMS Add: 01/01/1984 CMS Term: 78016 TC RADIO DEF RBRVS 01/01/2024 207.80 Description: THYROID MET IMAGING/STUDIES Category: Radiology CMS Add: 01/01/1984 CMS Term: 78016 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 173.40 Description: THYROID MET IMAGING/STUDIES Category: Radiology CMS Add: 01/01/1984 CMS Term: 78018 26 RADIO DEF RBRVS 01/01/2024 37.81 Description: THYROID MET IMAGING BODY Category: Radiology CMS Add: 01/01/1984 CMS Term: 78018 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 30.45 Description: THYROID MET IMAGING BODY Category: Radiology CMS Add: 01/01/1984 CMS Term: 78018 RADIO DEF RBRVS 01/01/2024 269.99 Description: THYROID MET IMAGING BODY Category: Radiology CMS Add: 01/01/1984 CMS Term: 78018 RADIO DEF RBRVS 02/01/2015 12/31/2023 222.19 Description: THYROID MET IMAGING BODY Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,026 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 78018 TC RADIO DEF RBRVS 01/01/2024 232.18 Description: THYROID MET IMAGING BODY Category: Radiology CMS Add: 01/01/1984 CMS Term: 78018 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 191.73 Description: THYROID MET IMAGING BODY Category: Radiology CMS Add: 01/01/1984 CMS Term: 78020 26 RADIO DEF RBRVS 01/01/2024 25.59 Description: THYROID MET UPTAKE Category: Radiology CMS Add: 01/01/1999 CMS Term: 78020 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 20.58 Description: THYROID MET UPTAKE Category: Radiology CMS Add: 01/01/1999 CMS Term: 78020 RADIO DEF RBRVS 01/01/2024 73.77 Description: THYROID MET UPTAKE Category: Radiology CMS Add: 01/01/1999 CMS Term: 78020 RADIO DEF RBRVS 02/01/2015 12/31/2023 59.39 Description: THYROID MET UPTAKE Category: Radiology CMS Add: 01/01/1999 CMS Term: 78020 TC RADIO DEF RBRVS 01/01/2024 48.17 Description: THYROID MET UPTAKE Category: Radiology CMS Add: 01/01/1999 CMS Term: 78020 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 38.81 Description: THYROID MET UPTAKE Category: Radiology CMS Add: 01/01/1999 CMS Term: 78070 26 RADIO DEF RBRVS 01/01/2024 36.09 Description: PARATHYROID PLANAR IMAGING Category: Radiology CMS Add: 01/01/1989 CMS Term: 78070 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 28.84 Description: PARATHYROID PLANAR IMAGING Category: Radiology CMS Add: 01/01/1989 CMS Term: 78070 RADIO DEF RBRVS 01/01/2024 254.07 Description: PARATHYROID PLANAR IMAGING Category: Radiology CMS Add: 01/01/1989 CMS Term: 78070 RADIO DEF RBRVS 02/01/2015 12/31/2023 211.41 Description: PARATHYROID PLANAR IMAGING Category: Radiology CMS Add: 01/01/1989 CMS Term: 78070 TC RADIO DEF RBRVS 01/01/2024 217.98 Description: PARATHYROID PLANAR IMAGING Category: Radiology CMS Add: 01/01/1989 CMS Term: 78070 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 182.57 Description: PARATHYROID PLANAR IMAGING Category: Radiology CMS Add: 01/01/1989 CMS Term: 78071 26 RADIO DEF RBRVS 01/01/2024 53.98 0-1 Description: PARATHYRD PLANAR W/WO SUBTRJ Category: Radiology CMS Add: 01/01/2013 CMS Term: 78071 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 43.14 0-1 Description: PARATHYRD PLANAR W/WO SUBTRJ Category: Radiology CMS Add: 01/01/2013 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,027 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 78071 RADIO DEF RBRVS 01/01/2024 304.06 0-1 Description: PARATHYRD PLANAR W/WO SUBTRJ Category: Radiology CMS Add: 01/01/2013 CMS Term: 78071 RADIO DEF RBRVS 02/01/2015 12/31/2023 248.74 0-1 Description: PARATHYRD PLANAR W/WO SUBTRJ Category: Radiology CMS Add: 01/01/2013 CMS Term: 78071 TC RADIO DEF RBRVS 01/01/2024 250.08 0-1 Description: PARATHYRD PLANAR W/WO SUBTRJ Category: Radiology CMS Add: 01/01/2013 CMS Term: 78071 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 205.60 0-1 Description: PARATHYRD PLANAR W/WO SUBTRJ Category: Radiology CMS Add: 01/01/2013 CMS Term: 78072 26 RADIO DEF RBRVS 01/01/2024 70.93 0-1 Description: PARATHYRD PLANAR W/SPECT&CT Category: Radiology CMS Add: 01/01/2013 CMS Term: 78072 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 58.51 0-1 Description: PARATHYRD PLANAR W/SPECT&CT Category: Radiology CMS Add: 01/01/2013 CMS Term: 78072 RADIO DEF RBRVS 01/01/2024 379.67 0-1 Description: PARATHYRD PLANAR W/SPECT&CT Category: Radiology CMS Add: 01/01/2013 CMS Term: 78072 RADIO DEF RBRVS 02/01/2015 12/31/2023 311.43 0-1 Description: PARATHYRD PLANAR W/SPECT&CT Category: Radiology CMS Add: 01/01/2013 CMS Term: 78072 TC RADIO DEF RBRVS 01/01/2024 308.74 0-1 Description: PARATHYRD PLANAR W/SPECT&CT Category: Radiology CMS Add: 01/01/2013 CMS Term: 78072 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 252.92 0-1 Description: PARATHYRD PLANAR W/SPECT&CT Category: Radiology CMS Add: 01/01/2013 CMS Term: 78075 26 RADIO DEF RBRVS 01/01/2024 34.06 Description: ADRENAL CORTEX & MEDULLA IMG Category: Radiology CMS Add: 01/01/1984 CMS Term: 78075 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 25.99 Description: ADRENAL CORTEX & MEDULLA IMG Category: Radiology CMS Add: 01/01/1984 CMS Term: 78075 RADIO DEF RBRVS 01/01/2024 384.34 Description: ADRENAL CORTEX & MEDULLA IMG Category: Radiology CMS Add: 01/01/1984 CMS Term: 78075 RADIO DEF RBRVS 02/01/2015 12/31/2023 301.12 Description: ADRENAL CORTEX & MEDULLA IMG Category: Radiology CMS Add: 01/01/1984 CMS Term: 78075 TC RADIO DEF RBRVS 01/01/2024 350.28 Description: ADRENAL CORTEX & MEDULLA IMG Category: Radiology CMS Add: 01/01/1984 CMS Term: 78075 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 275.13 Description: ADRENAL CORTEX & MEDULLA IMG Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,028 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 78099 RADIO DEF BILL25 Description: UNLISTED ENDOCRINE PX DX NUC Category: Radiology CMS Add: 01/01/1984 CMS Term: 78102 26 RADIO DEF RBRVS 01/01/2024 24.21 Description: BONE MARROW IMAGING LTD Category: Radiology CMS Add: 01/01/1984 CMS Term: 78102 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 19.48 Description: BONE MARROW IMAGING LTD Category: Radiology CMS Add: 01/01/1984 CMS Term: 78102 RADIO DEF RBRVS 01/01/2024 150.81 Description: BONE MARROW IMAGING LTD Category: Radiology CMS Add: 01/01/1984 CMS Term: 78102 RADIO DEF RBRVS 02/01/2015 12/31/2023 120.06 Description: BONE MARROW IMAGING LTD Category: Radiology CMS Add: 01/01/1984 CMS Term: 78102 TC RADIO DEF RBRVS 01/01/2024 126.60 Description: BONE MARROW IMAGING LTD Category: Radiology CMS Add: 01/01/1984 CMS Term: 78102 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 100.57 Description: BONE MARROW IMAGING LTD Category: Radiology CMS Add: 01/01/1984 CMS Term: 78103 26 RADIO DEF RBRVS 01/01/2024 29.28 Description: BONE MARROW IMAGING MULT Category: Radiology CMS Add: 01/01/1984 CMS Term: 78103 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 27.00 Description: BONE MARROW IMAGING MULT Category: Radiology CMS Add: 01/01/1984 CMS Term: 78103 RADIO DEF RBRVS 01/01/2024 162.67 Description: BONE MARROW IMAGING MULT Category: Radiology CMS Add: 01/01/1984 CMS Term: 78103 RADIO DEF RBRVS 02/01/2015 12/31/2023 159.53 Description: BONE MARROW IMAGING MULT Category: Radiology CMS Add: 01/01/1984 CMS Term: 78103 TC RADIO DEF RBRVS 01/01/2024 133.39 Description: BONE MARROW IMAGING MULT Category: Radiology CMS Add: 01/01/1984 CMS Term: 78103 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 132.53 Description: BONE MARROW IMAGING MULT Category: Radiology CMS Add: 01/01/1984 CMS Term: 78104 26 RADIO DEF RBRVS 01/01/2024 35.78 Description: BONE MARROW IMAGING BODY Category: Radiology CMS Add: 01/01/1984 CMS Term: 78104 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 28.10 Description: BONE MARROW IMAGING BODY Category: Radiology CMS Add: 01/01/1984 CMS Term: 78104 RADIO DEF RBRVS 01/01/2024 217.95 Description: BONE MARROW IMAGING BODY Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,029 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 78104 RADIO DEF RBRVS 02/01/2015 12/31/2023 172.52 Description: BONE MARROW IMAGING BODY Category: Radiology CMS Add: 01/01/1984 CMS Term: 78104 TC RADIO DEF RBRVS 01/01/2024 182.17 Description: BONE MARROW IMAGING BODY Category: Radiology CMS Add: 01/01/1984 CMS Term: 78104 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 144.42 Description: BONE MARROW IMAGING BODY Category: Radiology CMS Add: 01/01/1984 CMS Term: 78110 26 RADIO DEF RBRVS 01/01/2024 7.53 Description: PLASMA VOLUME SINGLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 78110 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 7.00 Description: PLASMA VOLUME SINGLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 78110 RADIO DEF RBRVS 01/01/2024 63.43 Description: PLASMA VOLUME SINGLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 78110 RADIO DEF RBRVS 02/01/2015 12/31/2023 66.46 Description: PLASMA VOLUME SINGLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 78110 TC RADIO DEF RBRVS 01/01/2024 55.90 Description: PLASMA VOLUME SINGLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 78110 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 59.45 Description: PLASMA VOLUME SINGLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 78111 26 RADIO DEF RBRVS 01/01/2024 8.85 Description: PLASMA VOLUME MULTIPLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 78111 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 8.06 Description: PLASMA VOLUME MULTIPLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 78111 RADIO DEF RBRVS 01/01/2024 67.53 Description: PLASMA VOLUME MULTIPLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 78111 RADIO DEF RBRVS 02/01/2015 12/31/2023 69.74 Description: PLASMA VOLUME MULTIPLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 78111 TC RADIO DEF RBRVS 01/01/2024 58.68 Description: PLASMA VOLUME MULTIPLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 78111 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 61.68 Description: PLASMA VOLUME MULTIPLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 78120 26 RADIO DEF RBRVS 01/01/2024 9.19 Description: RED CELL MASS SINGLE Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,030 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 78120 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 8.57 Description: RED CELL MASS SINGLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 78120 RADIO DEF RBRVS 01/01/2024 65.09 Description: RED CELL MASS SINGLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 78120 RADIO DEF RBRVS 02/01/2015 12/31/2023 67.28 Description: RED CELL MASS SINGLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 78120 TC RADIO DEF RBRVS 01/01/2024 55.90 Description: RED CELL MASS SINGLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 78120 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 58.71 Description: RED CELL MASS SINGLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 78121 26 RADIO DEF RBRVS 01/01/2024 12.55 Description: RED CELL MASS MULTIPLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 78121 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 11.74 Description: RED CELL MASS MULTIPLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 78121 RADIO DEF RBRVS 01/01/2024 71.23 Description: RED CELL MASS MULTIPLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 78121 RADIO DEF RBRVS 02/01/2015 12/31/2023 71.19 Description: RED CELL MASS MULTIPLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 78121 TC RADIO DEF RBRVS 01/01/2024 58.68 Description: RED CELL MASS MULTIPLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 78121 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 59.45 Description: RED CELL MASS MULTIPLE Category: Radiology CMS Add: 01/01/1984 CMS Term: 78122 26 RADIO DEF RBRVS 01/01/2024 19.89 Description: BLOOD VOLUME Category: Radiology CMS Add: 01/01/1987 CMS Term: 78122 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 15.72 Description: BLOOD VOLUME Category: Radiology CMS Add: 01/01/1987 CMS Term: 78122 RADIO DEF RBRVS 01/01/2024 91.85 Description: BLOOD VOLUME Category: Radiology CMS Add: 01/01/1987 CMS Term: 78122 RADIO DEF RBRVS 02/01/2015 12/31/2023 69.97 Description: BLOOD VOLUME Category: Radiology CMS Add: 01/01/1987 CMS Term: 78122 TC RADIO DEF RBRVS 01/01/2024 71.96 Description: BLOOD VOLUME Category: Radiology CMS Add: 01/01/1987 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,031 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 78122 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 54.25 Description: BLOOD VOLUME Category: Radiology CMS Add: 01/01/1987 CMS Term: 78130 26 RADIO DEF RBRVS 01/01/2024 23.92 Description: RED CELL SURVIVAL STUDY Category: Radiology CMS Add: 01/01/1984 CMS Term: 78130 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 22.75 Description: RED CELL SURVIVAL STUDY Category: Radiology CMS Add: 01/01/1984 CMS Term: 78130 RADIO DEF RBRVS 01/01/2024 114.72 Description: RED CELL SURVIVAL STUDY Category: Radiology CMS Add: 01/01/1984 CMS Term: 78130 RADIO DEF RBRVS 02/01/2015 12/31/2023 120.76 Description: RED CELL SURVIVAL STUDY Category: Radiology CMS Add: 01/01/1984 CMS Term: 78130 TC RADIO DEF RBRVS 01/01/2024 90.80 Description: RED CELL SURVIVAL STUDY Category: Radiology CMS Add: 01/01/1984 CMS Term: 78130 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 98.01 Description: RED CELL SURVIVAL STUDY Category: Radiology CMS Add: 01/01/1984 CMS Term: 78140 26 RADIO DEF RBRVS 01/01/2024 23.92 Description: RED CELL SEQUESTRATION Category: Radiology CMS Add: 01/01/1984 CMS Term: 78140 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 22.75 Description: RED CELL SEQUESTRATION Category: Radiology CMS Add: 01/01/1984 CMS Term: 78140 RADIO DEF RBRVS 01/01/2024 101.74 Description: RED CELL SEQUESTRATION Category: Radiology CMS Add: 01/01/1984 CMS Term: 78140 RADIO DEF RBRVS 02/01/2015 12/31/2023 96.57 Description: RED CELL SEQUESTRATION Category: Radiology CMS Add: 01/01/1984 CMS Term: 78140 TC RADIO DEF RBRVS 01/01/2024 77.82 Description: RED CELL SEQUESTRATION Category: Radiology CMS Add: 01/01/1984 CMS Term: 78140 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 73.82 Description: RED CELL SEQUESTRATION Category: Radiology CMS Add: 01/01/1984 CMS Term: 78185 26 RADIO DEF RBRVS 01/01/2024 15.88 Description: SPLEEN IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78185 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 14.63 Description: SPLEEN IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78185 RADIO DEF RBRVS 01/01/2024 146.80 Description: SPLEEN IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,032 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 78185 RADIO DEF RBRVS 02/01/2015 12/31/2023 149.14 Description: SPLEEN IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78185 TC RADIO DEF RBRVS 01/01/2024 130.92 Description: SPLEEN IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78185 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 134.51 Description: SPLEEN IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78191 26 RADIO DEF RBRVS 01/01/2024 23.92 Description: PLATELET SURVIVAL Category: Radiology CMS Add: 01/01/1984 CMS Term: 78191 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 22.75 Description: PLATELET SURVIVAL Category: Radiology CMS Add: 01/01/1984 CMS Term: 78191 RADIO DEF RBRVS 01/01/2024 114.72 Description: PLATELET SURVIVAL Category: Radiology CMS Add: 01/01/1984 CMS Term: 78191 RADIO DEF RBRVS 02/01/2015 12/31/2023 120.76 Description: PLATELET SURVIVAL Category: Radiology CMS Add: 01/01/1984 CMS Term: 78191 TC RADIO DEF RBRVS 01/01/2024 90.80 Description: PLATELET SURVIVAL Category: Radiology CMS Add: 01/01/1984 CMS Term: 78191 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 98.01 Description: PLATELET SURVIVAL Category: Radiology CMS Add: 01/01/1984 CMS Term: 78195 26 RADIO DEF RBRVS 01/01/2024 53.67 Description: LYMPH SYSTEM IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78195 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 43.31 Description: LYMPH SYSTEM IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78195 RADIO DEF RBRVS 01/01/2024 306.84 Description: LYMPH SYSTEM IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78195 RADIO DEF RBRVS 02/01/2015 12/31/2023 253.62 Description: LYMPH SYSTEM IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78195 TC RADIO DEF RBRVS 01/01/2024 253.17 Description: LYMPH SYSTEM IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78195 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 210.31 Description: LYMPH SYSTEM IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78199 RADIO DEF BILL25 Description: UNLSTD HEMATOP RET/ENDO LYMP Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,033 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 78201 26 RADIO DEF RBRVS 01/01/2024 19.55 Description: LIVER IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78201 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 15.70 Description: LIVER IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78201 RADIO DEF RBRVS 01/01/2024 165.91 Description: LIVER IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78201 RADIO DEF RBRVS 02/01/2015 12/31/2023 132.38 Description: LIVER IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78201 TC RADIO DEF RBRVS 01/01/2024 146.36 Description: LIVER IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78201 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 116.67 Description: LIVER IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78202 26 RADIO DEF RBRVS 01/01/2024 22.54 Description: LIVER IMAGING WITH FLOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 78202 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 17.58 Description: LIVER IMAGING WITH FLOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 78202 RADIO DEF RBRVS 01/01/2024 181.25 Description: LIVER IMAGING WITH FLOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 78202 RADIO DEF RBRVS 02/01/2015 12/31/2023 143.92 Description: LIVER IMAGING WITH FLOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 78202 TC RADIO DEF RBRVS 01/01/2024 158.70 Description: LIVER IMAGING WITH FLOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 78202 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 126.33 Description: LIVER IMAGING WITH FLOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 78215 26 RADIO DEF RBRVS 01/01/2024 22.17 Description: LIVER AND SPLEEN IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78215 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 17.87 Description: LIVER AND SPLEEN IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78215 RADIO DEF RBRVS 01/01/2024 171.00 Description: LIVER AND SPLEEN IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78215 RADIO DEF RBRVS 02/01/2015 12/31/2023 138.01 Description: LIVER AND SPLEEN IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,034 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 78215 TC RADIO DEF RBRVS 01/01/2024 148.83 Description: LIVER AND SPLEEN IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78215 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 120.14 Description: LIVER AND SPLEEN IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78216 26 RADIO DEF RBRVS 01/01/2024 25.52 Description: LIVER & SPLEEN IMAGE/FLOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 78216 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 20.02 Description: LIVER & SPLEEN IMAGE/FLOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 78216 RADIO DEF RBRVS 01/01/2024 119.39 Description: LIVER & SPLEEN IMAGE/FLOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 78216 RADIO DEF RBRVS 02/01/2015 12/31/2023 87.40 Description: LIVER & SPLEEN IMAGE/FLOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 78216 TC RADIO DEF RBRVS 01/01/2024 93.87 Description: LIVER & SPLEEN IMAGE/FLOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 78216 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 67.38 Description: LIVER & SPLEEN IMAGE/FLOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 78226 26 RADIO DEF RBRVS 01/01/2024 33.44 Description: HEPATOBILIARY SYSTEM IMAGING Category: Radiology CMS Add: 01/01/2012 CMS Term: 78226 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 26.98 Description: HEPATOBILIARY SYSTEM IMAGING Category: Radiology CMS Add: 01/01/2012 CMS Term: 78226 RADIO DEF RBRVS 01/01/2024 281.05 Description: HEPATOBILIARY SYSTEM IMAGING Category: Radiology CMS Add: 01/01/2012 CMS Term: 78226 RADIO DEF RBRVS 02/01/2015 12/31/2023 235.06 Description: HEPATOBILIARY SYSTEM IMAGING Category: Radiology CMS Add: 01/01/2012 CMS Term: 78226 TC RADIO DEF RBRVS 01/01/2024 247.61 Description: HEPATOBILIARY SYSTEM IMAGING Category: Radiology CMS Add: 01/01/2012 CMS Term: 78226 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 208.08 Description: HEPATOBILIARY SYSTEM IMAGING Category: Radiology CMS Add: 01/01/2012 CMS Term: 78227 26 RADIO DEF RBRVS 01/01/2024 40.71 Description: HEPATOBIL SYST IMAGE W/DRUG Category: Radiology CMS Add: 01/01/2012 CMS Term: 78227 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 32.77 Description: HEPATOBIL SYST IMAGE W/DRUG Category: Radiology CMS Add: 01/01/2012 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,035 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 78227 RADIO DEF RBRVS 01/01/2024 377.41 Description: HEPATOBIL SYST IMAGE W/DRUG Category: Radiology CMS Add: 01/01/2012 CMS Term: 78227 RADIO DEF RBRVS 02/01/2015 12/31/2023 318.30 Description: HEPATOBIL SYST IMAGE W/DRUG Category: Radiology CMS Add: 01/01/2012 CMS Term: 78227 TC RADIO DEF RBRVS 01/01/2024 336.70 Description: HEPATOBIL SYST IMAGE W/DRUG Category: Radiology CMS Add: 01/01/2012 CMS Term: 78227 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 285.53 Description: HEPATOBIL SYST IMAGE W/DRUG Category: Radiology CMS Add: 01/01/2012 CMS Term: 78230 26 RADIO DEF RBRVS 01/01/2024 20.51 Description: SALIVARY GLAND IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78230 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 14.32 Description: SALIVARY GLAND IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78230 RADIO DEF RBRVS 01/01/2024 154.21 Description: SALIVARY GLAND IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78230 RADIO DEF RBRVS 02/01/2015 12/31/2023 97.06 Description: SALIVARY GLAND IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78230 TC RADIO DEF RBRVS 01/01/2024 133.70 Description: SALIVARY GLAND IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78230 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 82.74 Description: SALIVARY GLAND IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78231 26 RADIO DEF RBRVS 01/01/2024 20.56 Description: SERIAL SALIVARY IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78231 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 18.84 Description: SERIAL SALIVARY IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78231 RADIO DEF RBRVS 01/01/2024 96.53 Description: SERIAL SALIVARY IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78231 RADIO DEF RBRVS 02/01/2015 12/31/2023 91.92 Description: SERIAL SALIVARY IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78231 TC RADIO DEF RBRVS 01/01/2024 75.97 Description: SERIAL SALIVARY IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78231 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 73.08 Description: SERIAL SALIVARY IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,036 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 78232 26 RADIO DEF RBRVS 01/01/2024 18.56 Description: SALIVARY GLAND FUNCTION EXAM Category: Radiology CMS Add: 01/01/1984 CMS Term: 78232 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 15.10 Description: SALIVARY GLAND FUNCTION EXAM Category: Radiology CMS Add: 01/01/1984 CMS Term: 78232 RADIO DEF RBRVS 01/01/2024 94.84 Description: SALIVARY GLAND FUNCTION EXAM Category: Radiology CMS Add: 01/01/1984 CMS Term: 78232 RADIO DEF RBRVS 02/01/2015 12/31/2023 70.59 Description: SALIVARY GLAND FUNCTION EXAM Category: Radiology CMS Add: 01/01/1984 CMS Term: 78232 TC RADIO DEF RBRVS 01/01/2024 76.28 Description: SALIVARY GLAND FUNCTION EXAM Category: Radiology CMS Add: 01/01/1984 CMS Term: 78232 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 55.49 Description: SALIVARY GLAND FUNCTION EXAM Category: Radiology CMS Add: 01/01/1984 CMS Term: 78258 26 RADIO DEF RBRVS 01/01/2024 32.51 Description: ESOPHAGEAL MOTILITY STUDY Category: Radiology CMS Add: 01/01/1987 CMS Term: 78258 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 26.57 Description: ESOPHAGEAL MOTILITY STUDY Category: Radiology CMS Add: 01/01/1987 CMS Term: 78258 RADIO DEF RBRVS 01/01/2024 186.59 Description: ESOPHAGEAL MOTILITY STUDY Category: Radiology CMS Add: 01/01/1987 CMS Term: 78258 RADIO DEF RBRVS 02/01/2015 12/31/2023 157.12 Description: ESOPHAGEAL MOTILITY STUDY Category: Radiology CMS Add: 01/01/1987 CMS Term: 78258 TC RADIO DEF RBRVS 01/01/2024 154.07 Description: ESOPHAGEAL MOTILITY STUDY Category: Radiology CMS Add: 01/01/1987 CMS Term: 78258 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 130.55 Description: ESOPHAGEAL MOTILITY STUDY Category: Radiology CMS Add: 01/01/1987 CMS Term: 78261 26 RADIO DEF RBRVS 01/01/2024 26.94 Description: GASTRIC MUCOSA IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78261 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 25.64 Description: GASTRIC MUCOSA IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78261 RADIO DEF RBRVS 01/01/2024 175.15 Description: GASTRIC MUCOSA IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78261 RADIO DEF RBRVS 02/01/2015 12/31/2023 179.47 Description: GASTRIC MUCOSA IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,037 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 78261 TC RADIO DEF RBRVS 01/01/2024 148.21 Description: GASTRIC MUCOSA IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78261 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 153.83 Description: GASTRIC MUCOSA IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78262 26 RADIO DEF RBRVS 01/01/2024 31.40 Description: GASTROESOPHAGEAL REFLUX EXAM Category: Radiology CMS Add: 01/01/1984 CMS Term: 78262 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 24.13 Description: GASTROESOPHAGEAL REFLUX EXAM Category: Radiology CMS Add: 01/01/1984 CMS Term: 78262 RADIO DEF RBRVS 01/01/2024 213.88 Description: GASTROESOPHAGEAL REFLUX EXAM Category: Radiology CMS Add: 01/01/1984 CMS Term: 78262 RADIO DEF RBRVS 02/01/2015 12/31/2023 173.26 Description: GASTROESOPHAGEAL REFLUX EXAM Category: Radiology CMS Add: 01/01/1984 CMS Term: 78262 TC RADIO DEF RBRVS 01/01/2024 182.48 Description: GASTROESOPHAGEAL REFLUX EXAM Category: Radiology CMS Add: 01/01/1984 CMS Term: 78262 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 149.12 Description: GASTROESOPHAGEAL REFLUX EXAM Category: Radiology CMS Add: 01/01/1984 CMS Term: 78264 26 RADIO DEF RBRVS 01/01/2024 35.75 Description: GASTRIC EMPTYING IMAG STUDY Category: Radiology CMS Add: 01/01/1984 CMS Term: 78264 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 29.09 Description: GASTRIC EMPTYING IMAG STUDY Category: Radiology CMS Add: 01/01/1984 CMS Term: 78264 RADIO DEF RBRVS 01/01/2024 285.83 Description: GASTRIC EMPTYING IMAG STUDY Category: Radiology CMS Add: 01/01/1984 CMS Term: 78264 RADIO DEF RBRVS 02/01/2015 12/31/2023 204.47 Description: GASTRIC EMPTYING IMAG STUDY Category: Radiology CMS Add: 01/01/1984 CMS Term: 78264 TC RADIO DEF RBRVS 01/01/2024 250.08 Description: GASTRIC EMPTYING IMAG STUDY Category: Radiology CMS Add: 01/01/1984 CMS Term: 78264 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 175.38 Description: GASTRIC EMPTYING IMAG STUDY Category: Radiology CMS Add: 01/01/1984 CMS Term: 78265 26 RADIO DEF RBRVS 01/01/2016 12/31/2023 35.58 Description: GASTRIC EMPTYING IMAG STUDY Category: Radiology CMS Add: 01/01/2016 CMS Term: 78265 26 RADIO DEF RBRVS 01/01/2024 44.04 Description: GASTRIC EMPTYING IMAG STUDY Category: Radiology CMS Add: 01/01/2016 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,038 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 78265 RADIO DEF RBRVS 01/01/2019 12/31/2023 288.58 Description: GASTRIC EMPTYING IMAG STUDY Category: Radiology CMS Add: 01/01/2016 CMS Term: 78265 RADIO DEF RBRVS 01/01/2024 338.28 Description: GASTRIC EMPTYING IMAG STUDY Category: Radiology CMS Add: 01/01/2016 CMS Term: 78265 TC RADIO DEF RBRVS 01/01/2019 12/31/2023 253.00 Description: GASTRIC EMPTYING IMAG STUDY Category: Radiology CMS Add: 01/01/2016 CMS Term: 78265 TC RADIO DEF RBRVS 01/01/2024 294.24 Description: GASTRIC EMPTYING IMAG STUDY Category: Radiology CMS Add: 01/01/2016 CMS Term: 78266 26 RADIO DEF RBRVS 01/01/2016 12/31/2023 39.42 Description: GASTRIC EMPTYING IMAG STUDY Category: Radiology CMS Add: 01/01/2016 CMS Term: 78266 26 RADIO DEF RBRVS 01/01/2024 47.12 Description: GASTRIC EMPTYING IMAG STUDY Category: Radiology CMS Add: 01/01/2016 CMS Term: 78266 RADIO DEF RBRVS 01/01/2019 12/31/2023 342.21 Description: GASTRIC EMPTYING IMAG STUDY Category: Radiology CMS Add: 01/01/2016 CMS Term: 78266 RADIO DEF RBRVS 01/01/2024 384.44 Description: GASTRIC EMPTYING IMAG STUDY Category: Radiology CMS Add: 01/01/2016 CMS Term: 78266 TC RADIO DEF RBRVS 01/01/2016 12/31/2023 302.79 Description: GASTRIC EMPTYING IMAG STUDY Category: Radiology CMS Add: 01/01/2016 CMS Term: 78266 TC RADIO DEF RBRVS 01/01/2024 337.31 Description: GASTRIC EMPTYING IMAG STUDY Category: Radiology CMS Add: 01/01/2016 CMS Term: 78267 RADIO L60 MAXFEE 01/01/2024 11.06 0.0 0-1 Description: BREATH TST ATTAIN/ANAL C-14 Category: Radiology CMS Add: 01/01/2000 CMS Term: 78267 RADIO L60 MAXFEE 07/01/2015 12/31/2023 10.70 0.0 0-1 Description: BREATH TST ATTAIN/ANAL C-14 Category: Radiology CMS Add: 01/01/2000 CMS Term: 78268 RADIO L60 MAXFEE 01/01/2024 94.41 0.0 0-1 Description: BREATH TEST ANALYSIS C-14 Category: Radiology CMS Add: 01/01/2000 CMS Term: 78268 RADIO L60 MAXFEE 07/01/2015 12/31/2023 91.66 0.0 0-1 Description: BREATH TEST ANALYSIS C-14 Category: Radiology CMS Add: 01/01/2000 CMS Term: 78278 26 RADIO DEF RBRVS 01/01/2024 44.69 Description: ACUTE GI BLOOD LOSS IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78278 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 35.85 Description: ACUTE GI BLOOD LOSS IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,039 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 78278 RADIO DEF RBRVS 01/01/2024 301.87 Description: ACUTE GI BLOOD LOSS IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78278 RADIO DEF RBRVS 02/01/2015 12/31/2023 247.89 Description: ACUTE GI BLOOD LOSS IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78278 TC RADIO DEF RBRVS 01/01/2024 257.18 Description: ACUTE GI BLOOD LOSS IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78278 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 212.04 Description: ACUTE GI BLOOD LOSS IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78282 26 RADIO DEF RBRVS 01/01/2024 14.89 Description: GI PROTEIN LOSS EXAM Category: Radiology CMS Add: 01/01/1985 CMS Term: 78282 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 14.17 Description: GI PROTEIN LOSS EXAM Category: Radiology CMS Add: 01/01/1985 CMS Term: 78290 26 RADIO DEF RBRVS 01/01/2024 30.79 Description: MECKELS DIVERT EXAM Category: Radiology CMS Add: 01/01/1984 CMS Term: 78290 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 24.88 Description: MECKELS DIVERT EXAM Category: Radiology CMS Add: 01/01/1984 CMS Term: 78290 RADIO DEF RBRVS 01/01/2024 285.19 Description: MECKELS DIVERT EXAM Category: Radiology CMS Add: 01/01/1984 CMS Term: 78290 RADIO DEF RBRVS 02/01/2015 12/31/2023 236.92 Description: MECKELS DIVERT EXAM Category: Radiology CMS Add: 01/01/1984 CMS Term: 78290 TC RADIO DEF RBRVS 01/01/2024 254.41 Description: MECKELS DIVERT EXAM Category: Radiology CMS Add: 01/01/1984 CMS Term: 78290 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 212.04 Description: MECKELS DIVERT EXAM Category: Radiology CMS Add: 01/01/1984 CMS Term: 78291 26 RADIO DEF RBRVS 01/01/2024 40.34 Description: LEVEEN/SHUNT PATENCY EXAM Category: Radiology CMS Add: 01/01/1985 CMS Term: 78291 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 31.41 Description: LEVEEN/SHUNT PATENCY EXAM Category: Radiology CMS Add: 01/01/1985 CMS Term: 78291 RADIO DEF RBRVS 01/01/2024 228.68 Description: LEVEEN/SHUNT PATENCY EXAM Category: Radiology CMS Add: 01/01/1985 CMS Term: 78291 RADIO DEF RBRVS 02/01/2015 12/31/2023 178.55 Description: LEVEEN/SHUNT PATENCY EXAM Category: Radiology CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,040 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 78291 TC RADIO DEF RBRVS 01/01/2024 188.34 Description: LEVEEN/SHUNT PATENCY EXAM Category: Radiology CMS Add: 01/01/1985 CMS Term: 78291 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 147.14 Description: LEVEEN/SHUNT PATENCY EXAM Category: Radiology CMS Add: 01/01/1985 CMS Term: 78299 RADIO DEF BILL25 Description: UNLISTED GI PX DX NUC MED Category: Radiology CMS Add: 01/01/1984 CMS Term: 78300 26 RADIO DEF RBRVS 01/01/2024 28.45 Description: BONE IMAGING LIMITED AREA Category: Radiology CMS Add: 01/01/1984 CMS Term: 78300 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 22.85 Description: BONE IMAGING LIMITED AREA Category: Radiology CMS Add: 01/01/1984 CMS Term: 78300 RADIO DEF RBRVS 01/01/2024 196.72 Description: BONE IMAGING LIMITED AREA Category: Radiology CMS Add: 01/01/1984 CMS Term: 78300 RADIO DEF RBRVS 02/01/2015 12/31/2023 128.63 Description: BONE IMAGING LIMITED AREA Category: Radiology CMS Add: 01/01/1984 CMS Term: 78300 TC RADIO DEF RBRVS 01/01/2024 168.27 Description: BONE IMAGING LIMITED AREA Category: Radiology CMS Add: 01/01/1984 CMS Term: 78300 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 105.77 Description: BONE IMAGING LIMITED AREA Category: Radiology CMS Add: 01/01/1984 CMS Term: 78305 26 RADIO DEF RBRVS 01/01/2024 37.72 Description: BONE IMAGING MULTIPLE AREAS Category: Radiology CMS Add: 01/01/1984 CMS Term: 78305 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 30.14 Description: BONE IMAGING MULTIPLE AREAS Category: Radiology CMS Add: 01/01/1984 CMS Term: 78305 RADIO DEF RBRVS 01/01/2024 239.65 Description: BONE IMAGING MULTIPLE AREAS Category: Radiology CMS Add: 01/01/1984 CMS Term: 78305 RADIO DEF RBRVS 02/01/2015 12/31/2023 164.16 Description: BONE IMAGING MULTIPLE AREAS Category: Radiology CMS Add: 01/01/1984 CMS Term: 78305 TC RADIO DEF RBRVS 01/01/2024 201.92 Description: BONE IMAGING MULTIPLE AREAS Category: Radiology CMS Add: 01/01/1984 CMS Term: 78305 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 134.01 Description: BONE IMAGING MULTIPLE AREAS Category: Radiology CMS Add: 01/01/1984 CMS Term: 78306 26 RADIO DEF RBRVS 01/01/2024 38.74 Description: BONE IMAGING WHOLE BODY Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,041 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 78306 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 31.20 Description: BONE IMAGING WHOLE BODY Category: Radiology CMS Add: 01/01/1984 CMS Term: 78306 RADIO DEF RBRVS 01/01/2024 256.10 Description: BONE IMAGING WHOLE BODY Category: Radiology CMS Add: 01/01/1984 CMS Term: 78306 RADIO DEF RBRVS 09/01/2019 12/31/2023 178.59 Description: BONE IMAGING WHOLE BODY Category: Radiology CMS Add: 01/01/1984 CMS Term: 78306 TC RADIO DEF RBRVS 01/01/2024 217.36 Description: BONE IMAGING WHOLE BODY Category: Radiology CMS Add: 01/01/1984 CMS Term: 78306 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 147.39 Description: BONE IMAGING WHOLE BODY Category: Radiology CMS Add: 01/01/1984 CMS Term: 78315 26 RADIO DEF RBRVS 01/01/2024 46.01 Description: BONE IMAGING 3 PHASE Category: Radiology CMS Add: 01/01/1987 CMS Term: 78315 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 36.90 Description: BONE IMAGING 3 PHASE Category: Radiology CMS Add: 01/01/1987 CMS Term: 78315 RADIO DEF RBRVS 01/01/2024 300.11 Description: BONE IMAGING 3 PHASE Category: Radiology CMS Add: 01/01/1987 CMS Term: 78315 RADIO DEF RBRVS 02/01/2015 12/31/2023 247.46 Description: BONE IMAGING 3 PHASE Category: Radiology CMS Add: 01/01/1987 CMS Term: 78315 TC RADIO DEF RBRVS 01/01/2024 254.10 Description: BONE IMAGING 3 PHASE Category: Radiology CMS Add: 01/01/1987 CMS Term: 78315 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 210.56 Description: BONE IMAGING 3 PHASE Category: Radiology CMS Add: 01/01/1987 CMS Term: 78350 26 RADIO DEF RBRVS 01/01/2024 10.39 Description: BONE MINERAL SINGLE PHOTON Category: Radiology CMS Add: 01/01/1986 CMS Term: 78350 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 8.06 Description: BONE MINERAL SINGLE PHOTON Category: Radiology CMS Add: 01/01/1986 CMS Term: 78350 RADIO DEF RBRVS 01/01/2024 29.70 Description: BONE MINERAL SINGLE PHOTON Category: Radiology CMS Add: 01/01/1986 CMS Term: 78350 RADIO DEF RBRVS 09/01/2019 12/31/2023 23.09 Description: BONE MINERAL SINGLE PHOTON Category: Radiology CMS Add: 01/01/1986 CMS Term: 78350 TC RADIO DEF RBRVS 01/01/2024 19.30 Description: BONE MINERAL SINGLE PHOTON Category: Radiology CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,042 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 78350 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 15.03 Description: BONE MINERAL SINGLE PHOTON Category: Radiology CMS Add: 01/01/1986 CMS Term: 78351 RADIO DEF RBRVS 01/01/2024 14.19 Description: BONE MINERAL DUAL PHOTON Category: Radiology CMS Add: 01/01/1986 CMS Term: 78351 RADIO DEF RBRVS 02/01/2015 12/31/2023 11.20 Description: BONE MINERAL DUAL PHOTON Category: Radiology CMS Add: 01/01/1986 CMS Term: 78399 RADIO DEF BILL25 Description: UNLISTED MUSCSKEL PX DX NUC Category: Radiology CMS Add: 01/01/1984 CMS Term: 78414 26 RADIO DEF RBRVS 01/01/2024 20.35 Description: NON-IMAGING HEART FUNCTION Category: Radiology CMS Add: 01/01/1984 CMS Term: 78414 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 16.55 Description: NON-IMAGING HEART FUNCTION Category: Radiology CMS Add: 01/01/1984 CMS Term: 78414 RADIO DEF MAXFEE 01/01/2024 125.52 0.0 Description: NON-IMAGING HEART FUNCTION Category: Radiology CMS Add: 01/01/1984 CMS Term: 78414 TC RADIO DEF MAXFEE 01/01/2024 101.50 0.0 Description: NON-IMAGING HEART FUNCTION Category: Radiology CMS Add: 01/01/1984 CMS Term: 78428 26 RADIO DEF RBRVS 01/01/2024 34.79 Description: CARDIAC SHUNT IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78428 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 27.89 Description: CARDIAC SHUNT IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78428 RADIO DEF RBRVS 01/01/2024 163.55 Description: CARDIAC SHUNT IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78428 RADIO DEF RBRVS 09/01/2019 12/31/2023 130.20 Description: CARDIAC SHUNT IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78428 TC RADIO DEF RBRVS 01/01/2024 128.76 Description: CARDIAC SHUNT IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78428 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 102.31 Description: CARDIAC SHUNT IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78429 26 RADIO DEF RBRVS 01/01/2020 12/31/2023 61.90 Y Description: MYOCRD IMG PET 1 STD W/CT Category: Radiology CMS Add: 01/01/2020 CMS Term: 78429 26 RADIO DEF RBRVS 01/01/2024 76.66 Y Description: MYOCRD IMG PET 1 STD W/CT Category: Radiology CMS Add: 01/01/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,043 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 78430 26 RADIO DEF RBRVS 01/01/2020 12/31/2023 58.74 Y Description: MYOCRD IMG PET RST/STRS W/CT Category: Radiology CMS Add: 01/01/2020 CMS Term: 78430 26 RADIO DEF RBRVS 01/01/2024 72.67 Y Description: MYOCRD IMG PET RST/STRS W/CT Category: Radiology CMS Add: 01/01/2020 CMS Term: 78431 26 RADIO DEF RBRVS 01/01/2020 12/31/2023 68.22 Y Description: MYOCRD IMG PET RST&STRS CT Category: Radiology CMS Add: 01/01/2020 CMS Term: 78431 26 RADIO DEF RBRVS 01/01/2024 84.80 Y Description: MYOCRD IMG PET RST&STRS CT Category: Radiology CMS Add: 01/01/2020 CMS Term: 78432 NOCOV DEF SYSMAN Description: MYOCRD IMG PET 2RTRACER Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 78433 NOCOV DEF SYSMAN Description: MYOCRD IMG PET 2RTRACER CT Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 78434 NOCOV DEF SYSMAN Description: AQMBF PET REST & RX STRESS Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 78445 26 RADIO DEF RBRVS 01/01/2024 23.11 Description: VASCULAR FLOW IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78445 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 16.80 Description: VASCULAR FLOW IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78445 RADIO DEF RBRVS 01/01/2024 182.13 Description: VASCULAR FLOW IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78445 RADIO DEF RBRVS 09/01/2019 12/31/2023 121.83 Description: VASCULAR FLOW IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78445 TC RADIO DEF RBRVS 01/01/2024 159.01 Description: VASCULAR FLOW IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78445 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 105.03 Description: VASCULAR FLOW IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78451 26 RADIO DEF RBRVS 01/01/2024 61.92 Description: HT MUSCLE IMAGE SPECT SING Category: Radiology CMS Add: 01/01/2010 CMS Term: 78451 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 49.55 Description: HT MUSCLE IMAGE SPECT SING Category: Radiology CMS Add: 01/01/2010 CMS Term: 78451 RADIO DEF RBRVS 01/01/2024 294.71 Description: HT MUSCLE IMAGE SPECT SING Category: Radiology CMS Add: 01/01/2010 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,044 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 78451 RADIO DEF RBRVS 09/01/2019 12/31/2023 244.74 Description: HT MUSCLE IMAGE SPECT SING Category: Radiology CMS Add: 01/01/2010 CMS Term: 78451 TC RADIO DEF RBRVS 01/01/2024 232.80 Description: HT MUSCLE IMAGE SPECT SING Category: Radiology CMS Add: 01/01/2010 CMS Term: 78451 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 195.20 Description: HT MUSCLE IMAGE SPECT SING Category: Radiology CMS Add: 01/01/2010 CMS Term: 78452 26 RADIO DEF RBRVS 01/01/2024 73.15 Description: HT MUSCLE IMAGE SPECT MULT Category: Radiology CMS Add: 01/01/2010 CMS Term: 78452 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 58.22 Description: HT MUSCLE IMAGE SPECT MULT Category: Radiology CMS Add: 01/01/2010 CMS Term: 78452 RADIO DEF RBRVS 01/01/2024 407.69 Description: HT MUSCLE IMAGE SPECT MULT Category: Radiology CMS Add: 01/01/2010 CMS Term: 78452 RADIO DEF RBRVS 09/01/2019 12/31/2023 339.05 Description: HT MUSCLE IMAGE SPECT MULT Category: Radiology CMS Add: 01/01/2010 CMS Term: 78452 TC RADIO DEF RBRVS 01/01/2024 334.54 Description: HT MUSCLE IMAGE SPECT MULT Category: Radiology CMS Add: 01/01/2010 CMS Term: 78452 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 280.83 Description: HT MUSCLE IMAGE SPECT MULT Category: Radiology CMS Add: 01/01/2010 CMS Term: 78453 26 RADIO DEF RBRVS 01/01/2024 44.72 Description: HT MUSCLE IMAGE PLANAR SING Category: Radiology CMS Add: 01/01/2010 CMS Term: 78453 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 36.61 Description: HT MUSCLE IMAGE PLANAR SING Category: Radiology CMS Add: 01/01/2010 CMS Term: 78453 RADIO DEF RBRVS 01/01/2024 253.74 Description: HT MUSCLE IMAGE PLANAR SING Category: Radiology CMS Add: 01/01/2010 CMS Term: 78453 RADIO DEF RBRVS 09/01/2019 12/31/2023 217.94 Description: HT MUSCLE IMAGE PLANAR SING Category: Radiology CMS Add: 01/01/2010 CMS Term: 78453 TC RADIO DEF RBRVS 01/01/2024 209.02 Description: HT MUSCLE IMAGE PLANAR SING Category: Radiology CMS Add: 01/01/2010 CMS Term: 78453 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 181.33 Description: HT MUSCLE IMAGE PLANAR SING Category: Radiology CMS Add: 01/01/2010 CMS Term: 78454 26 RADIO DEF RBRVS 01/01/2024 61.35 Description: HT MUSC IMAGE PLANAR MULT Category: Radiology CMS Add: 01/01/2010 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,045 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 78454 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 48.72 Description: HT MUSC IMAGE PLANAR MULT Category: Radiology CMS Add: 01/01/2010 CMS Term: 78454 RADIO DEF RBRVS 01/01/2024 377.68 Description: HT MUSC IMAGE PLANAR MULT Category: Radiology CMS Add: 01/01/2010 CMS Term: 78454 RADIO DEF RBRVS 09/01/2019 12/31/2023 310.22 Description: HT MUSC IMAGE PLANAR MULT Category: Radiology CMS Add: 01/01/2010 CMS Term: 78454 TC RADIO DEF RBRVS 01/01/2024 316.32 Description: HT MUSC IMAGE PLANAR MULT Category: Radiology CMS Add: 01/01/2010 CMS Term: 78454 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 261.50 Description: HT MUSC IMAGE PLANAR MULT Category: Radiology CMS Add: 01/01/2010 CMS Term: 78456 26 RADIO DEF RBRVS 01/01/2024 45.03 0-1 Description: ACUTE VENOUS THROMBUS IMAGE Category: Radiology CMS Add: 01/01/2000 CMS Term: 78456 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 36.03 0-1 Description: ACUTE VENOUS THROMBUS IMAGE Category: Radiology CMS Add: 01/01/2000 CMS Term: 78456 RADIO DEF RBRVS 01/01/2024 270.41 0-1 Description: ACUTE VENOUS THROMBUS IMAGE Category: Radiology CMS Add: 01/01/2000 CMS Term: 78456 RADIO DEF RBRVS 09/01/2019 12/31/2023 227.76 0-1 Description: ACUTE VENOUS THROMBUS IMAGE Category: Radiology CMS Add: 01/01/2000 CMS Term: 78456 TC RADIO DEF RBRVS 01/01/2024 225.39 0-1 Description: ACUTE VENOUS THROMBUS IMAGE Category: Radiology CMS Add: 01/01/2000 CMS Term: 78456 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 191.73 0-1 Description: ACUTE VENOUS THROMBUS IMAGE Category: Radiology CMS Add: 01/01/2000 CMS Term: 78457 26 RADIO DEF RBRVS 01/01/2024 33.29 Description: VENOUS THROMBOSIS IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78457 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 27.79 Description: VENOUS THROMBOSIS IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78457 RADIO DEF RBRVS 01/01/2024 144.76 Description: VENOUS THROMBOSIS IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78457 RADIO DEF RBRVS 09/01/2019 12/31/2023 138.52 Description: VENOUS THROMBOSIS IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78457 TC RADIO DEF RBRVS 01/01/2024 111.47 Description: VENOUS THROMBOSIS IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,046 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 78457 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 110.73 Description: VENOUS THROMBOSIS IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78458 26 RADIO DEF RBRVS 01/01/2024 41.33 Description: VEN THROMBOSIS IMAGES BILAT Category: Radiology CMS Add: 01/01/1984 CMS Term: 78458 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 28.47 Description: VEN THROMBOSIS IMAGES BILAT Category: Radiology CMS Add: 01/01/1984 CMS Term: 78458 RADIO DEF RBRVS 01/01/2024 182.13 Description: VEN THROMBOSIS IMAGES BILAT Category: Radiology CMS Add: 01/01/1984 CMS Term: 78458 RADIO DEF RBRVS 09/01/2019 12/31/2023 115.92 Description: VEN THROMBOSIS IMAGES BILAT Category: Radiology CMS Add: 01/01/1984 CMS Term: 78458 TC RADIO DEF RBRVS 01/01/2024 140.80 Description: VEN THROMBOSIS IMAGES BILAT Category: Radiology CMS Add: 01/01/1984 CMS Term: 78458 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 87.44 Description: VEN THROMBOSIS IMAGES BILAT Category: Radiology CMS Add: 01/01/1984 CMS Term: 78459 26 RADIO DEF RBRVS 01/01/2024 70.33 Y Description: MYOCRD IMG PET SINGLE STUDY Category: Radiology CMS Add: 01/01/1996 CMS Term: 78459 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 53.35 Y Description: MYOCRD IMG PET SINGLE STUDY Category: Radiology CMS Add: 01/01/1996 CMS Term: 78459 RADIO DEF MAXFEE 01/01/2024 897.79 0.0 Y Description: MYOCRD IMG PET SINGLE STUDY Category: Radiology CMS Add: 01/01/1996 CMS Term: 78459 RADIO DEF RBRVS 09/01/2019 12/31/2023 833.33 Y Description: MYOCRD IMG PET SINGLE STUDY Category: Radiology CMS Add: 01/01/1996 CMS Term: 78459 TC RADIO DEF MAXFEE 01/01/2024 818.97 0.0 Y Description: MYOCRD IMG PET SINGLE STUDY Category: Radiology CMS Add: 01/01/1996 CMS Term: 78459 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 777.75 Y Description: MYOCRD IMG PET SINGLE STUDY Category: Radiology CMS Add: 01/01/1996 CMS Term: 78466 26 RADIO DEF RBRVS 01/01/2024 31.74 Description: HEART INFARCT IMAGE Category: Radiology CMS Add: 01/01/1988 CMS Term: 78466 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 25.47 Description: HEART INFARCT IMAGE Category: Radiology CMS Add: 01/01/1988 CMS Term: 78466 RADIO DEF RBRVS 01/01/2024 161.74 Description: HEART INFARCT IMAGE Category: Radiology CMS Add: 01/01/1988 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,047 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 78466 RADIO DEF RBRVS 09/01/2019 12/31/2023 130.01 Description: HEART INFARCT IMAGE Category: Radiology CMS Add: 01/01/1988 CMS Term: 78466 TC RADIO DEF RBRVS 01/01/2024 129.99 Description: HEART INFARCT IMAGE Category: Radiology CMS Add: 01/01/1988 CMS Term: 78466 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 104.54 Description: HEART INFARCT IMAGE Category: Radiology CMS Add: 01/01/1988 CMS Term: 78468 26 RADIO DEF RBRVS 01/01/2024 35.77 Description: HEART INFARCT IMAGE (EF) Category: Radiology CMS Add: 01/01/1988 CMS Term: 78468 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 28.93 Description: HEART INFARCT IMAGE (EF) Category: Radiology CMS Add: 01/01/1988 CMS Term: 78468 RADIO DEF RBRVS 01/01/2024 170.70 Description: HEART INFARCT IMAGE (EF) Category: Radiology CMS Add: 01/01/1988 CMS Term: 78468 RADIO DEF RBRVS 09/01/2019 12/31/2023 140.15 Description: HEART INFARCT IMAGE (EF) Category: Radiology CMS Add: 01/01/1988 CMS Term: 78468 TC RADIO DEF RBRVS 01/01/2024 134.93 Description: HEART INFARCT IMAGE (EF) Category: Radiology CMS Add: 01/01/1988 CMS Term: 78468 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 111.22 Description: HEART INFARCT IMAGE (EF) Category: Radiology CMS Add: 01/01/1988 CMS Term: 78469 26 RADIO DEF RBRVS 01/01/2024 41.39 Description: HEART INFARCT IMAGE (3D) Category: Radiology CMS Add: 01/01/1988 CMS Term: 78469 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 33.64 Description: HEART INFARCT IMAGE (3D) Category: Radiology CMS Add: 01/01/1988 CMS Term: 78469 RADIO DEF RBRVS 01/01/2024 193.92 Description: HEART INFARCT IMAGE (3D) Category: Radiology CMS Add: 01/01/1988 CMS Term: 78469 RADIO DEF RBRVS 09/01/2019 12/31/2023 160.71 Description: HEART INFARCT IMAGE (3D) Category: Radiology CMS Add: 01/01/1988 CMS Term: 78469 TC RADIO DEF RBRVS 01/01/2024 152.53 Description: HEART INFARCT IMAGE (3D) Category: Radiology CMS Add: 01/01/1988 CMS Term: 78469 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 127.08 Description: HEART INFARCT IMAGE (3D) Category: Radiology CMS Add: 01/01/1988 CMS Term: 78472 26 RADIO DEF RBRVS 01/01/2024 44.04 Description: GATED HEART PLANAR SINGLE Category: Radiology CMS Add: 01/01/1988 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,048 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 78472 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 35.17 Description: GATED HEART PLANAR SINGLE Category: Radiology CMS Add: 01/01/1988 CMS Term: 78472 RADIO DEF RBRVS 01/01/2024 198.42 Description: GATED HEART PLANAR SINGLE Category: Radiology CMS Add: 01/01/1988 CMS Term: 78472 RADIO DEF RBRVS 09/01/2019 12/31/2023 163.73 Description: GATED HEART PLANAR SINGLE Category: Radiology CMS Add: 01/01/1988 CMS Term: 78472 TC RADIO DEF RBRVS 01/01/2024 154.38 Description: GATED HEART PLANAR SINGLE Category: Radiology CMS Add: 01/01/1988 CMS Term: 78472 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 128.56 Description: GATED HEART PLANAR SINGLE Category: Radiology CMS Add: 01/01/1988 CMS Term: 78473 26 RADIO DEF RBRVS 01/01/2024 65.89 Description: GATED HEART MULTIPLE Category: Radiology CMS Add: 01/01/1992 CMS Term: 78473 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 52.71 Description: GATED HEART MULTIPLE Category: Radiology CMS Add: 01/01/1992 CMS Term: 78473 RADIO DEF RBRVS 01/01/2024 252.69 Description: GATED HEART MULTIPLE Category: Radiology CMS Add: 01/01/1992 CMS Term: 78473 RADIO DEF RBRVS 09/01/2019 12/31/2023 207.53 Description: GATED HEART MULTIPLE Category: Radiology CMS Add: 01/01/1992 CMS Term: 78473 TC RADIO DEF RBRVS 01/01/2024 186.80 Description: GATED HEART MULTIPLE Category: Radiology CMS Add: 01/01/1992 CMS Term: 78473 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 154.82 Description: GATED HEART MULTIPLE Category: Radiology CMS Add: 01/01/1992 CMS Term: 78481 26 RADIO DEF RBRVS 01/01/2024 44.35 Description: HEART FIRST PASS SINGLE Category: Radiology CMS Add: 01/01/1988 CMS Term: 78481 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 35.00 Description: HEART FIRST PASS SINGLE Category: Radiology CMS Add: 01/01/1988 CMS Term: 78481 RADIO DEF RBRVS 01/01/2024 155.82 Description: HEART FIRST PASS SINGLE Category: Radiology CMS Add: 01/01/1988 CMS Term: 78481 RADIO DEF RBRVS 09/01/2019 12/31/2023 126.32 Description: HEART FIRST PASS SINGLE Category: Radiology CMS Add: 01/01/1988 CMS Term: 78481 TC RADIO DEF RBRVS 01/01/2024 111.47 Description: HEART FIRST PASS SINGLE Category: Radiology CMS Add: 01/01/1988 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,049 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 78481 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 91.32 Description: HEART FIRST PASS SINGLE Category: Radiology CMS Add: 01/01/1988 CMS Term: 78483 26 RADIO DEF RBRVS 01/01/2024 66.20 Description: HEART FIRST PASS MULTIPLE Category: Radiology CMS Add: 01/01/1992 CMS Term: 78483 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 52.95 Description: HEART FIRST PASS MULTIPLE Category: Radiology CMS Add: 01/01/1992 CMS Term: 78483 RADIO DEF RBRVS 01/01/2024 210.71 Description: HEART FIRST PASS MULTIPLE Category: Radiology CMS Add: 01/01/1992 CMS Term: 78483 RADIO DEF RBRVS 09/01/2019 12/31/2023 172.35 Description: HEART FIRST PASS MULTIPLE Category: Radiology CMS Add: 01/01/1992 CMS Term: 78483 TC RADIO DEF RBRVS 01/01/2024 144.50 Description: HEART FIRST PASS MULTIPLE Category: Radiology CMS Add: 01/01/1992 CMS Term: 78483 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 119.40 Description: HEART FIRST PASS MULTIPLE Category: Radiology CMS Add: 01/01/1992 CMS Term: 78491 26 RADIO DEF RBRVS 01/01/2024 68.33 Y Description: MYOCRD IMG PET 1STD RST/STRS Category: Radiology CMS Add: 01/01/1998 CMS Term: 78491 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 53.84 Y Description: MYOCRD IMG PET 1STD RST/STRS Category: Radiology CMS Add: 01/01/1998 CMS Term: 78491 RADIO DEF MAXFEE 01/01/2024 899.12 0.0 Y Description: MYOCRD IMG PET 1STD RST/STRS Category: Radiology CMS Add: 01/01/1998 CMS Term: 78491 RADIO DEF RBRVS 09/01/2019 12/31/2023 833.33 Y Description: MYOCRD IMG PET 1STD RST/STRS Category: Radiology CMS Add: 01/01/1998 CMS Term: 78491 TC RADIO DEF MAXFEE 01/01/2024 818.97 0.0 Y Description: MYOCRD IMG PET 1STD RST/STRS Category: Radiology CMS Add: 01/01/1998 CMS Term: 78491 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 777.75 Y Description: MYOCRD IMG PET 1STD RST/STRS Category: Radiology CMS Add: 01/01/1998 CMS Term: 78492 26 RADIO DEF RBRVS 01/01/2024 81.10 Y Description: MYOCRD IMG PET MLT RST&STRS Category: Radiology CMS Add: 01/01/1998 CMS Term: 78492 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 66.92 Y Description: MYOCRD IMG PET MLT RST&STRS Category: Radiology CMS Add: 01/01/1998 CMS Term: 78492 RADIO DEF MAXFEE 01/01/2024 920.37 0.0 Y Description: MYOCRD IMG PET MLT RST&STRS Category: Radiology CMS Add: 01/01/1998 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,050 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 78492 RADIO DEF RBRVS 09/01/2019 12/31/2023 833.33 Y Description: MYOCRD IMG PET MLT RST&STRS Category: Radiology CMS Add: 01/01/1998 CMS Term: 78492 TC RADIO DEF MAXFEE 01/01/2024 818.97 0.0 Y Description: MYOCRD IMG PET MLT RST&STRS Category: Radiology CMS Add: 01/01/1998 CMS Term: 78492 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 777.75 Y Description: MYOCRD IMG PET MLT RST&STRS Category: Radiology CMS Add: 01/01/1998 CMS Term: 78494 26 RADIO DEF RBRVS 01/01/2024 53.63 Description: HEART IMAGE SPECT Category: Radiology CMS Add: 01/01/1999 CMS Term: 78494 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 42.79 Description: HEART IMAGE SPECT Category: Radiology CMS Add: 01/01/1999 CMS Term: 78494 RADIO DEF RBRVS 01/01/2024 200.29 Description: HEART IMAGE SPECT Category: Radiology CMS Add: 01/01/1999 CMS Term: 78494 RADIO DEF RBRVS 09/01/2019 12/31/2023 162.19 Description: HEART IMAGE SPECT Category: Radiology CMS Add: 01/01/1999 CMS Term: 78494 TC RADIO DEF RBRVS 01/01/2024 146.66 Description: HEART IMAGE SPECT Category: Radiology CMS Add: 01/01/1999 CMS Term: 78494 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 119.40 Description: HEART IMAGE SPECT Category: Radiology CMS Add: 01/01/1999 CMS Term: 78496 26 RADIO DEF RBRVS 01/01/2024 22.51 Description: HEART FIRST PASS ADD-ON Category: Radiology CMS Add: 01/01/1999 CMS Term: 78496 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 18.06 Description: HEART FIRST PASS ADD-ON Category: Radiology CMS Add: 01/01/1999 CMS Term: 78496 RADIO DEF RBRVS 01/01/2024 39.65 Description: HEART FIRST PASS ADD-ON Category: Radiology CMS Add: 01/01/1999 CMS Term: 78496 RADIO DEF RBRVS 02/01/2015 12/31/2023 32.34 Description: HEART FIRST PASS ADD-ON Category: Radiology CMS Add: 01/01/1999 CMS Term: 78496 TC RADIO DEF RBRVS 01/01/2024 17.14 Description: HEART FIRST PASS ADD-ON Category: Radiology CMS Add: 01/01/1999 CMS Term: 78496 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 14.28 Description: HEART FIRST PASS ADD-ON Category: Radiology CMS Add: 01/01/1999 CMS Term: 78499 RADIO DEF BILL25 Description: UNLISTED CV PX DX NUC MED Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,051 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 78579 26 RADIO DEF RBRVS 01/01/2024 22.17 Description: LUNG VENTILATION IMAGING Category: Radiology CMS Add: 01/01/2012 CMS Term: 78579 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 17.62 Description: LUNG VENTILATION IMAGING Category: Radiology CMS Add: 01/01/2012 CMS Term: 78579 RADIO DEF RBRVS 01/01/2024 163.59 Description: LUNG VENTILATION IMAGING Category: Radiology CMS Add: 01/01/2012 CMS Term: 78579 RADIO DEF RBRVS 02/01/2015 12/31/2023 132.40 Description: LUNG VENTILATION IMAGING Category: Radiology CMS Add: 01/01/2012 CMS Term: 78579 TC RADIO DEF RBRVS 01/01/2024 141.42 Description: LUNG VENTILATION IMAGING Category: Radiology CMS Add: 01/01/2012 CMS Term: 78579 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 114.77 Description: LUNG VENTILATION IMAGING Category: Radiology CMS Add: 01/01/2012 CMS Term: 78580 26 RADIO DEF RBRVS 01/01/2024 33.44 Description: LUNG PERFUSION IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78580 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 26.82 Description: LUNG PERFUSION IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78580 RADIO DEF RBRVS 01/01/2024 205.42 Description: LUNG PERFUSION IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78580 RADIO DEF RBRVS 02/01/2015 12/31/2023 170.00 Description: LUNG PERFUSION IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78580 TC RADIO DEF RBRVS 01/01/2024 171.98 Description: LUNG PERFUSION IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78580 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 143.18 Description: LUNG PERFUSION IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78582 26 RADIO DEF RBRVS 01/01/2024 48.02 Description: LUNG VENTILAT&PERFUS IMAGING Category: Radiology CMS Add: 01/01/2012 CMS Term: 78582 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 38.74 Description: LUNG VENTILAT&PERFUS IMAGING Category: Radiology CMS Add: 01/01/2012 CMS Term: 78582 RADIO DEF RBRVS 01/01/2024 287.91 Description: LUNG VENTILAT&PERFUS IMAGING Category: Radiology CMS Add: 01/01/2012 CMS Term: 78582 RADIO DEF RBRVS 02/01/2015 12/31/2023 238.65 Description: LUNG VENTILAT&PERFUS IMAGING Category: Radiology CMS Add: 01/01/2012 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,052 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 78582 TC RADIO DEF RBRVS 01/01/2024 239.90 Description: LUNG VENTILAT&PERFUS IMAGING Category: Radiology CMS Add: 01/01/2012 CMS Term: 78582 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 199.91 Description: LUNG VENTILAT&PERFUS IMAGING Category: Radiology CMS Add: 01/01/2012 CMS Term: 78597 26 RADIO DEF RBRVS 01/01/2024 32.85 Description: LUNG PERFUSION DIFFERENTIAL Category: Radiology CMS Add: 01/01/2012 CMS Term: 78597 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 26.18 Description: LUNG PERFUSION DIFFERENTIAL Category: Radiology CMS Add: 01/01/2012 CMS Term: 78597 RADIO DEF RBRVS 01/01/2024 174.89 Description: LUNG PERFUSION DIFFERENTIAL Category: Radiology CMS Add: 01/01/2012 CMS Term: 78597 RADIO DEF RBRVS 02/01/2015 12/31/2023 143.93 Description: LUNG PERFUSION DIFFERENTIAL Category: Radiology CMS Add: 01/01/2012 CMS Term: 78597 TC RADIO DEF RBRVS 01/01/2024 142.03 Description: LUNG PERFUSION DIFFERENTIAL Category: Radiology CMS Add: 01/01/2012 CMS Term: 78597 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 117.75 Description: LUNG PERFUSION DIFFERENTIAL Category: Radiology CMS Add: 01/01/2012 CMS Term: 78598 26 RADIO DEF RBRVS 01/01/2024 37.78 Description: LUNG PERF&VENTILAT DIFERENTL Category: Radiology CMS Add: 01/01/2012 CMS Term: 78598 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 30.27 Description: LUNG PERF&VENTILAT DIFERENTL Category: Radiology CMS Add: 01/01/2012 CMS Term: 78598 RADIO DEF RBRVS 01/01/2024 261.93 Description: LUNG PERF&VENTILAT DIFERENTL Category: Radiology CMS Add: 01/01/2012 CMS Term: 78598 RADIO DEF RBRVS 02/01/2015 12/31/2023 218.28 Description: LUNG PERF&VENTILAT DIFERENTL Category: Radiology CMS Add: 01/01/2012 CMS Term: 78598 TC RADIO DEF RBRVS 01/01/2024 224.15 Description: LUNG PERF&VENTILAT DIFERENTL Category: Radiology CMS Add: 01/01/2012 CMS Term: 78598 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 188.02 Description: LUNG PERF&VENTILAT DIFERENTL Category: Radiology CMS Add: 01/01/2012 CMS Term: 78599 RADIO DEF BILL25 Description: UNLISTED RESP PX DX NUC MED Category: Radiology CMS Add: 01/01/1984 CMS Term: 78600 26 RADIO DEF RBRVS 01/01/2024 19.86 Description: BRAIN IMAGE < 4 VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,053 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 78600 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 15.95 Description: BRAIN IMAGE < 4 VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 78600 RADIO DEF RBRVS 01/01/2024 157.88 Description: BRAIN IMAGE < 4 VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 78600 RADIO DEF RBRVS 02/01/2015 12/31/2023 129.90 Description: BRAIN IMAGE < 4 VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 78600 TC RADIO DEF RBRVS 01/01/2024 138.02 Description: BRAIN IMAGE < 4 VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 78600 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 113.95 Description: BRAIN IMAGE < 4 VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 78601 26 RADIO DEF RBRVS 01/01/2024 22.85 Description: BRAIN IMAGE W/FLOW < 4 VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 78601 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 18.66 Description: BRAIN IMAGE W/FLOW < 4 VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 78601 RADIO DEF RBRVS 01/01/2024 188.04 Description: BRAIN IMAGE W/FLOW < 4 VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 78601 RADIO DEF RBRVS 02/01/2015 12/31/2023 153.41 Description: BRAIN IMAGE W/FLOW < 4 VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 78601 TC RADIO DEF RBRVS 01/01/2024 165.19 Description: BRAIN IMAGE W/FLOW < 4 VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 78601 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 134.76 Description: BRAIN IMAGE W/FLOW < 4 VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 78605 26 RADIO DEF RBRVS 01/01/2024 24.47 Description: BRAIN IMAGE 4+ VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 78605 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 19.69 Description: BRAIN IMAGE 4+ VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 78605 RADIO DEF RBRVS 01/01/2024 175.15 Description: BRAIN IMAGE 4+ VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 78605 RADIO DEF RBRVS 02/01/2015 12/31/2023 140.57 Description: BRAIN IMAGE 4+ VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 78605 TC RADIO DEF RBRVS 01/01/2024 150.68 Description: BRAIN IMAGE 4+ VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,054 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 78605 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 120.89 Description: BRAIN IMAGE 4+ VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 78606 26 RADIO DEF RBRVS 01/01/2024 28.81 Description: BRAIN IMAGE W/FLOW 4 + VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 78606 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 22.81 Description: BRAIN IMAGE W/FLOW 4 + VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 78606 RADIO DEF RBRVS 01/01/2024 282.29 Description: BRAIN IMAGE W/FLOW 4 + VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 78606 RADIO DEF RBRVS 02/01/2015 12/31/2023 233.62 Description: BRAIN IMAGE W/FLOW 4 + VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 78606 TC RADIO DEF RBRVS 01/01/2024 253.48 Description: BRAIN IMAGE W/FLOW 4 + VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 78606 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 210.81 Description: BRAIN IMAGE W/FLOW 4 + VIEWS Category: Radiology CMS Add: 01/01/1984 CMS Term: 78608 26 RADIO DEF RBRVS 01/01/2024 66.61 Y Description: BRAIN IMAGING (PET) Category: Radiology CMS Add: 01/01/1994 CMS Term: 78608 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 53.76 Y Description: BRAIN IMAGING (PET) Category: Radiology CMS Add: 01/01/1994 CMS Term: 78608 RADIO DEF MAXFEE 01/01/2024 1088.04 0.0 Y Description: BRAIN IMAGING (PET) Category: Radiology CMS Add: 01/01/1994 CMS Term: 78608 RADIO DEF RBRVS 02/01/2015 12/31/2023 833.33 Y Description: BRAIN IMAGING (PET) Category: Radiology CMS Add: 01/01/1994 CMS Term: 78608 TC RADIO DEF MAXFEE 01/01/2024 1007.53 0.0 Y Description: BRAIN IMAGING (PET) Category: Radiology CMS Add: 01/01/1994 CMS Term: 78608 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 777.75 Y Description: BRAIN IMAGING (PET) Category: Radiology CMS Add: 01/01/1994 CMS Term: 78609 26 RADIO DEF RBRVS 01/01/2024 69.38 Y Description: BRAIN IMAGING (PET) Category: Radiology CMS Add: 01/01/1994 CMS Term: 78609 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 56.32 Y Description: BRAIN IMAGING (PET) Category: Radiology CMS Add: 01/01/1994 CMS Term: 78609 RADIO DEF RBRVS 01/01/2024 69.38 Y Description: BRAIN IMAGING (PET) Category: Radiology CMS Add: 01/01/1994 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,055 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 78609 RADIO DEF RBRVS 09/01/2019 12/31/2023 56.32 Y Description: BRAIN IMAGING (PET) Category: Radiology CMS Add: 01/01/1994 CMS Term: 78609 TC RADIO DEF MAXFEE 01/01/2024 826.75 0.0 Y Description: BRAIN IMAGING (PET) Category: Radiology CMS Add: 01/01/1994 CMS Term: 78609 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 777.75 Y Description: BRAIN IMAGING (PET) Category: Radiology CMS Add: 01/01/1994 CMS Term: 78610 26 RADIO DEF RBRVS 01/01/2024 13.72 Description: BRAIN FLOW IMAGING ONLY Category: Radiology CMS Add: 01/01/1984 CMS Term: 78610 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 10.95 Description: BRAIN FLOW IMAGING ONLY Category: Radiology CMS Add: 01/01/1984 CMS Term: 78610 RADIO DEF RBRVS 01/01/2024 152.67 Description: BRAIN FLOW IMAGING ONLY Category: Radiology CMS Add: 01/01/1984 CMS Term: 78610 RADIO DEF RBRVS 02/01/2015 12/31/2023 123.41 Description: BRAIN FLOW IMAGING ONLY Category: Radiology CMS Add: 01/01/1984 CMS Term: 78610 TC RADIO DEF RBRVS 01/01/2024 138.95 Description: BRAIN FLOW IMAGING ONLY Category: Radiology CMS Add: 01/01/1984 CMS Term: 78610 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 112.46 Description: BRAIN FLOW IMAGING ONLY Category: Radiology CMS Add: 01/01/1984 CMS Term: 78630 26 RADIO DEF RBRVS 01/01/2024 30.79 Description: CEREBROSPINAL FLUID SCAN Category: Radiology CMS Add: 01/01/1984 CMS Term: 78630 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 24.71 Description: CEREBROSPINAL FLUID SCAN Category: Radiology CMS Add: 01/01/1984 CMS Term: 78630 RADIO DEF RBRVS 01/01/2024 291.06 Description: CEREBROSPINAL FLUID SCAN Category: Radiology CMS Add: 01/01/1984 CMS Term: 78630 RADIO DEF RBRVS 02/01/2015 12/31/2023 239.48 Description: CEREBROSPINAL FLUID SCAN Category: Radiology CMS Add: 01/01/1984 CMS Term: 78630 TC RADIO DEF RBRVS 01/01/2024 260.27 Description: CEREBROSPINAL FLUID SCAN Category: Radiology CMS Add: 01/01/1984 CMS Term: 78630 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 214.77 Description: CEREBROSPINAL FLUID SCAN Category: Radiology CMS Add: 01/01/1984 CMS Term: 78635 26 RADIO DEF RBRVS 01/01/2024 28.11 Description: CSF VENTRICULOGRAPHY Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,056 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 78635 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 22.25 Description: CSF VENTRICULOGRAPHY Category: Radiology CMS Add: 01/01/1984 CMS Term: 78635 RADIO DEF RBRVS 01/01/2024 291.46 Description: CSF VENTRICULOGRAPHY Category: Radiology CMS Add: 01/01/1984 CMS Term: 78635 RADIO DEF RBRVS 02/01/2015 12/31/2023 240.24 Description: CSF VENTRICULOGRAPHY Category: Radiology CMS Add: 01/01/1984 CMS Term: 78635 TC RADIO DEF RBRVS 01/01/2024 263.36 Description: CSF VENTRICULOGRAPHY Category: Radiology CMS Add: 01/01/1984 CMS Term: 78635 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 217.99 Description: CSF VENTRICULOGRAPHY Category: Radiology CMS Add: 01/01/1984 CMS Term: 78645 26 RADIO DEF RBRVS 01/01/2024 25.19 Description: CSF SHUNT EVALUATION Category: Radiology CMS Add: 01/01/1984 CMS Term: 78645 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 20.27 Description: CSF SHUNT EVALUATION Category: Radiology CMS Add: 01/01/1984 CMS Term: 78645 RADIO DEF RBRVS 01/01/2024 278.37 Description: CSF SHUNT EVALUATION Category: Radiology CMS Add: 01/01/1984 CMS Term: 78645 RADIO DEF RBRVS 02/01/2015 12/31/2023 228.84 Description: CSF SHUNT EVALUATION Category: Radiology CMS Add: 01/01/1984 CMS Term: 78645 TC RADIO DEF RBRVS 01/01/2024 253.17 Description: CSF SHUNT EVALUATION Category: Radiology CMS Add: 01/01/1984 CMS Term: 78645 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 208.58 Description: CSF SHUNT EVALUATION Category: Radiology CMS Add: 01/01/1984 CMS Term: 78650 26 RADIO DEF RBRVS 01/01/2024 23.92 Description: CSF LEAKAGE IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78650 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 22.25 Description: CSF LEAKAGE IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78650 RADIO DEF RBRVS 01/01/2024 234.49 Description: CSF LEAKAGE IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78650 RADIO DEF RBRVS 02/01/2015 12/31/2023 238.01 Description: CSF LEAKAGE IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78650 TC RADIO DEF RBRVS 01/01/2024 210.57 Description: CSF LEAKAGE IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,057 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 78650 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 215.76 Description: CSF LEAKAGE IMAGING Category: Radiology CMS Add: 01/01/1984 CMS Term: 78660 26 RADIO DEF RBRVS 01/01/2024 20.90 Description: NUCLEAR EXAM OF TEAR FLOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 78660 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 19.94 Description: NUCLEAR EXAM OF TEAR FLOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 78660 RADIO DEF RBRVS 01/01/2024 133.91 Description: NUCLEAR EXAM OF TEAR FLOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 78660 RADIO DEF RBRVS 02/01/2015 12/31/2023 132.15 Description: NUCLEAR EXAM OF TEAR FLOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 78660 TC RADIO DEF RBRVS 01/01/2024 113.02 Description: NUCLEAR EXAM OF TEAR FLOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 78660 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 112.22 Description: NUCLEAR EXAM OF TEAR FLOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 78699 TC RADIO DEF MAXFEE 01/01/2024 181.18 0.0 Description: UNLISTED NRVS SYS PX DX NUC Category: Radiology CMS Add: 01/01/1984 CMS Term: 78699 TC RADIO DEF MAXFEE 02/01/2015 12/31/2023 170.44 0.0 Description: UNLISTED NRVS SYS PX DX NUC Category: Radiology CMS Add: 01/01/1984 CMS Term: 78700 26 RADIO DEF RBRVS 01/01/2024 20.20 Description: KIDNEY IMAGING MORPHOL Category: Radiology CMS Add: 01/01/1984 CMS Term: 78700 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 16.30 Description: KIDNEY IMAGING MORPHOL Category: Radiology CMS Add: 01/01/1984 CMS Term: 78700 RADIO DEF RBRVS 01/01/2024 148.96 Description: KIDNEY IMAGING MORPHOL Category: Radiology CMS Add: 01/01/1984 CMS Term: 78700 RADIO DEF RBRVS 02/01/2015 12/31/2023 123.31 Description: KIDNEY IMAGING MORPHOL Category: Radiology CMS Add: 01/01/1984 CMS Term: 78700 TC RADIO DEF RBRVS 01/01/2024 128.76 Description: KIDNEY IMAGING MORPHOL Category: Radiology CMS Add: 01/01/1984 CMS Term: 78700 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 107.01 Description: KIDNEY IMAGING MORPHOL Category: Radiology CMS Add: 01/01/1984 CMS Term: 78701 26 RADIO DEF RBRVS 01/01/2024 22.48 Description: KIDNEY IMAGING WITH FLOW Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,058 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 78701 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 17.87 Description: KIDNEY IMAGING WITH FLOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 78701 RADIO DEF RBRVS 01/01/2024 195.70 Description: KIDNEY IMAGING WITH FLOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 78701 RADIO DEF RBRVS 02/01/2015 12/31/2023 151.64 Description: KIDNEY IMAGING WITH FLOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 78701 TC RADIO DEF RBRVS 01/01/2024 173.21 Description: KIDNEY IMAGING WITH FLOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 78701 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 133.77 Description: KIDNEY IMAGING WITH FLOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 78707 26 RADIO DEF RBRVS 01/01/2024 42.75 Description: K FLOW/FUNCT IMAGE W/O DRUG Category: Radiology CMS Add: 01/01/1984 CMS Term: 78707 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 34.38 Description: K FLOW/FUNCT IMAGE W/O DRUG Category: Radiology CMS Add: 01/01/1984 CMS Term: 78707 RADIO DEF RBRVS 01/01/2024 203.61 Description: K FLOW/FUNCT IMAGE W/O DRUG Category: Radiology CMS Add: 01/01/1984 CMS Term: 78707 RADIO DEF RBRVS 02/01/2015 12/31/2023 164.93 Description: K FLOW/FUNCT IMAGE W/O DRUG Category: Radiology CMS Add: 01/01/1984 CMS Term: 78707 TC RADIO DEF RBRVS 01/01/2024 160.87 Description: K FLOW/FUNCT IMAGE W/O DRUG Category: Radiology CMS Add: 01/01/1984 CMS Term: 78707 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 130.55 Description: K FLOW/FUNCT IMAGE W/O DRUG Category: Radiology CMS Add: 01/01/1984 CMS Term: 78708 26 RADIO DEF RBRVS 01/01/2024 54.00 Description: K FLOW/FUNCT IMAGE W/DRUG Category: Radiology CMS Add: 01/01/1998 CMS Term: 78708 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 43.49 Description: K FLOW/FUNCT IMAGE W/DRUG Category: Radiology CMS Add: 01/01/1998 CMS Term: 78708 RADIO DEF RBRVS 01/01/2024 163.00 Description: K FLOW/FUNCT IMAGE W/DRUG Category: Radiology CMS Add: 01/01/1998 CMS Term: 78708 RADIO DEF RBRVS 02/01/2015 12/31/2023 124.00 Description: K FLOW/FUNCT IMAGE W/DRUG Category: Radiology CMS Add: 01/01/1998 CMS Term: 78708 TC RADIO DEF RBRVS 01/01/2024 109.00 Description: K FLOW/FUNCT IMAGE W/DRUG Category: Radiology CMS Add: 01/01/1998 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,059 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 78708 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 80.51 Description: K FLOW/FUNCT IMAGE W/DRUG Category: Radiology CMS Add: 01/01/1998 CMS Term: 78709 26 RADIO DEF RBRVS 01/01/2024 63.26 Description: K FLOW/FUNCT IMAGE MULTIPLE Category: Radiology CMS Add: 01/01/1998 CMS Term: 78709 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 50.43 Description: K FLOW/FUNCT IMAGE MULTIPLE Category: Radiology CMS Add: 01/01/1998 CMS Term: 78709 RADIO DEF RBRVS 01/01/2024 321.69 Description: K FLOW/FUNCT IMAGE MULTIPLE Category: Radiology CMS Add: 01/01/1998 CMS Term: 78709 RADIO DEF RBRVS 02/01/2015 12/31/2023 260.50 Description: K FLOW/FUNCT IMAGE MULTIPLE Category: Radiology CMS Add: 01/01/1998 CMS Term: 78709 TC RADIO DEF RBRVS 01/01/2024 258.43 Description: K FLOW/FUNCT IMAGE MULTIPLE Category: Radiology CMS Add: 01/01/1998 CMS Term: 78709 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 210.06 Description: K FLOW/FUNCT IMAGE MULTIPLE Category: Radiology CMS Add: 01/01/1998 CMS Term: 78725 26 RADIO DEF RBRVS 01/01/2024 17.05 Description: KIDNEY FUNCTION STUDY Category: Radiology CMS Add: 01/01/1984 CMS Term: 78725 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 13.35 Description: KIDNEY FUNCTION STUDY Category: Radiology CMS Add: 01/01/1984 CMS Term: 78725 RADIO DEF RBRVS 01/01/2024 104.75 Description: KIDNEY FUNCTION STUDY Category: Radiology CMS Add: 01/01/1984 CMS Term: 78725 RADIO DEF RBRVS 02/01/2015 12/31/2023 77.26 Description: KIDNEY FUNCTION STUDY Category: Radiology CMS Add: 01/01/1984 CMS Term: 78725 TC RADIO DEF RBRVS 01/01/2024 87.70 Description: KIDNEY FUNCTION STUDY Category: Radiology CMS Add: 01/01/1984 CMS Term: 78725 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 63.91 Description: KIDNEY FUNCTION STUDY Category: Radiology CMS Add: 01/01/1984 CMS Term: 78730 26 RADIO DEF RBRVS 01/01/2024 6.94 Description: URINARY BLADDER RETENTION Category: Radiology CMS Add: 01/01/1984 CMS Term: 78730 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 5.68 Description: URINARY BLADDER RETENTION Category: Radiology CMS Add: 01/01/1984 CMS Term: 78730 RADIO DEF RBRVS 01/01/2024 63.28 Description: URINARY BLADDER RETENTION Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,060 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 78730 RADIO DEF RBRVS 02/01/2015 12/31/2023 53.66 Description: URINARY BLADDER RETENTION Category: Radiology CMS Add: 01/01/1984 CMS Term: 78730 TC RADIO DEF RBRVS 01/01/2024 56.35 Description: URINARY BLADDER RETENTION Category: Radiology CMS Add: 01/01/1984 CMS Term: 78730 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 47.97 Description: URINARY BLADDER RETENTION Category: Radiology CMS Add: 01/01/1984 CMS Term: 78740 26 RADIO DEF RBRVS 01/01/2024 25.19 Description: URETERAL REFLUX STUDY Category: Radiology CMS Add: 01/01/1984 CMS Term: 78740 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 20.52 Description: URETERAL REFLUX STUDY Category: Radiology CMS Add: 01/01/1984 CMS Term: 78740 RADIO DEF RBRVS 01/01/2024 189.15 Description: URETERAL REFLUX STUDY Category: Radiology CMS Add: 01/01/1984 CMS Term: 78740 RADIO DEF RBRVS 02/01/2015 12/31/2023 156.02 Description: URETERAL REFLUX STUDY Category: Radiology CMS Add: 01/01/1984 CMS Term: 78740 TC RADIO DEF RBRVS 01/01/2024 163.95 Description: URETERAL REFLUX STUDY Category: Radiology CMS Add: 01/01/1984 CMS Term: 78740 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 135.50 Description: URETERAL REFLUX STUDY Category: Radiology CMS Add: 01/01/1984 CMS Term: 78761 26 RADIO DEF RBRVS 01/01/2024 32.73 Description: TESTICULAR IMAGING W/FLOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 78761 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 26.18 Description: TESTICULAR IMAGING W/FLOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 78761 RADIO DEF RBRVS 01/01/2024 185.88 Description: TESTICULAR IMAGING W/FLOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 78761 RADIO DEF RBRVS 02/01/2015 12/31/2023 149.54 Description: TESTICULAR IMAGING W/FLOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 78761 TC RADIO DEF RBRVS 01/01/2024 153.15 Description: TESTICULAR IMAGING W/FLOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 78761 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 123.36 Description: TESTICULAR IMAGING W/FLOW Category: Radiology CMS Add: 01/01/1984 CMS Term: 78799 RADIO DEF BILL25 Description: UNLISTED GU PX DX NUC MED Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,061 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 78800 26 RADIO DEF RBRVS 01/01/2024 29.12 Description: RP LOCLZJ TUM 1 AREA 1 D IMG Category: Radiology CMS Add: 01/01/1984 CMS Term: 78800 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 24.34 Description: RP LOCLZJ TUM 1 AREA 1 D IMG Category: Radiology CMS Add: 01/01/1984 CMS Term: 78800 RADIO DEF RBRVS 01/01/2024 218.39 Description: RP LOCLZJ TUM 1 AREA 1 D IMG Category: Radiology CMS Add: 01/01/1984 CMS Term: 78800 RADIO DEF RBRVS 02/01/2015 12/31/2023 135.31 Description: RP LOCLZJ TUM 1 AREA 1 D IMG Category: Radiology CMS Add: 01/01/1984 CMS Term: 78800 TC RADIO DEF RBRVS 01/01/2024 189.27 Description: RP LOCLZJ TUM 1 AREA 1 D IMG Category: Radiology CMS Add: 01/01/1984 CMS Term: 78800 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 110.98 Description: RP LOCLZJ TUM 1 AREA 1 D IMG Category: Radiology CMS Add: 01/01/1984 CMS Term: 78801 26 RADIO DEF RBRVS 01/01/2024 32.79 Description: RP LOCLZJ TUM 2+AREA 1+D IMG Category: Radiology CMS Add: 01/01/1984 CMS Term: 78801 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 28.82 Description: RP LOCLZJ TUM 2+AREA 1+D IMG Category: Radiology CMS Add: 01/01/1984 CMS Term: 78801 RADIO DEF RBRVS 01/01/2024 237.18 Description: RP LOCLZJ TUM 2+AREA 1+D IMG Category: Radiology CMS Add: 01/01/1984 CMS Term: 78801 RADIO DEF RBRVS 02/01/2015 12/31/2023 177.95 Description: RP LOCLZJ TUM 2+AREA 1+D IMG Category: Radiology CMS Add: 01/01/1984 CMS Term: 78801 TC RADIO DEF RBRVS 01/01/2024 204.39 Description: RP LOCLZJ TUM 2+AREA 1+D IMG Category: Radiology CMS Add: 01/01/1984 CMS Term: 78801 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 149.12 Description: RP LOCLZJ TUM 2+AREA 1+D IMG Category: Radiology CMS Add: 01/01/1984 CMS Term: 78802 26 RADIO DEF RBRVS 01/01/2024 35.78 Description: RP LOCLZJ TUM WHBDY 1 D IMG Category: Radiology CMS Add: 01/01/1984 CMS Term: 78802 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 30.70 Description: RP LOCLZJ TUM WHBDY 1 D IMG Category: Radiology CMS Add: 01/01/1984 CMS Term: 78802 RADIO DEF RBRVS 01/01/2024 267.96 Description: RP LOCLZJ TUM WHBDY 1 D IMG Category: Radiology CMS Add: 01/01/1984 CMS Term: 78802 RADIO DEF RBRVS 09/01/2019 12/31/2023 228.63 Description: RP LOCLZJ TUM WHBDY 1 D IMG Category: Radiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,062 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 78802 TC RADIO DEF RBRVS 01/01/2024 232.18 Description: RP LOCLZJ TUM WHBDY 1 D IMG Category: Radiology CMS Add: 01/01/1984 CMS Term: 78802 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 197.92 Description: RP LOCLZJ TUM WHBDY 1 D IMG Category: Radiology CMS Add: 01/01/1984 CMS Term: 78803 26 RADIO DEF RBRVS 01/01/2024 48.39 Description: RP LOCLZJ TUM SPECT 1 AREA Category: Radiology CMS Add: 01/01/1988 CMS Term: 78803 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 38.29 Description: RP LOCLZJ TUM SPECT 1 AREA Category: Radiology CMS Add: 01/01/1988 CMS Term: 78803 RADIO DEF RBRVS 01/01/2024 330.27 Description: RP LOCLZJ TUM SPECT 1 AREA Category: Radiology CMS Add: 01/01/1988 CMS Term: 78803 RADIO DEF RBRVS 09/01/2019 12/31/2023 241.41 Description: RP LOCLZJ TUM SPECT 1 AREA Category: Radiology CMS Add: 01/01/1988 CMS Term: 78803 TC RADIO DEF RBRVS 01/01/2024 281.88 Description: RP LOCLZJ TUM SPECT 1 AREA Category: Radiology CMS Add: 01/01/1988 CMS Term: 78803 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 203.13 Description: RP LOCLZJ TUM SPECT 1 AREA Category: Radiology CMS Add: 01/01/1988 CMS Term: 78804 26 RADIO DEF RBRVS 01/01/2024 45.06 0-1 Description: RP LOCLZJ TUM WHBDY 2+D IMG Category: Radiology CMS Add: 01/01/2004 CMS Term: 78804 26 RADIO DEF RBRVS 09/01/2019 12/31/2023 38.24 0-1 Description: RP LOCLZJ TUM WHBDY 2+D IMG Category: Radiology CMS Add: 01/01/2004 CMS Term: 78804 RADIO DEF RBRVS 01/01/2024 557.88 0-1 Description: RP LOCLZJ TUM WHBDY 2+D IMG Category: Radiology CMS Add: 01/01/2004 CMS Term: 78804 RADIO DEF RBRVS 09/01/2019 12/31/2023 401.97 0-1 Description: RP LOCLZJ TUM WHBDY 2+D IMG Category: Radiology CMS Add: 01/01/2004 CMS Term: 78804 TC RADIO DEF RBRVS 01/01/2024 512.82 0-1 Description: RP LOCLZJ TUM WHBDY 2+D IMG Category: Radiology CMS Add: 01/01/2004 CMS Term: 78804 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 363.73 0-1 Description: RP LOCLZJ TUM WHBDY 2+D IMG Category: Radiology CMS Add: 01/01/2004 CMS Term: 78808 NOCOV DEF SYSMAN Description: IV INJ RA DRUG DX STUDY Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 78811 26 RADIO DEF RBRVS 01/01/2024 67.97 Y Description: PET IMAGE LTD AREA Category: Radiology CMS Add: 01/01/2005 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,063 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 78811 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 57.81 Y Description: PET IMAGE LTD AREA Category: Radiology CMS Add: 01/01/2005 CMS Term: 78811 RADIO DEF MAXFEE 01/01/2024 1277.05 0.0 Y Description: PET IMAGE LTD AREA Category: Radiology CMS Add: 01/01/2005 CMS Term: 78811 RADIO DEF RBRVS 09/01/2019 12/31/2023 833.33 Y Description: PET IMAGE LTD AREA Category: Radiology CMS Add: 01/01/2005 CMS Term: 78811 TC RADIO DEF MAXFEE 01/01/2024 1209.08 0.0 Y Description: PET IMAGE LTD AREA Category: Radiology CMS Add: 01/01/2005 CMS Term: 78811 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 777.75 Y Description: PET IMAGE LTD AREA Category: Radiology CMS Add: 01/01/2005 CMS Term: 78812 26 RADIO DEF RBRVS 01/01/2024 86.77 Y Description: PET IMAGE SKULL-THIGH Category: Radiology CMS Add: 01/01/2005 CMS Term: 78812 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 70.19 Y Description: PET IMAGE SKULL-THIGH Category: Radiology CMS Add: 01/01/2005 CMS Term: 78812 RADIO DEF MAXFEE 01/01/2024 1443.41 0.0 Y Description: PET IMAGE SKULL-THIGH Category: Radiology CMS Add: 01/01/2005 CMS Term: 78812 RADIO DEF RBRVS 09/01/2019 12/31/2023 833.33 Y Description: PET IMAGE SKULL-THIGH Category: Radiology CMS Add: 01/01/2005 CMS Term: 78812 TC RADIO DEF MAXFEE 01/01/2024 1356.64 0.0 Y Description: PET IMAGE SKULL-THIGH Category: Radiology CMS Add: 01/01/2005 CMS Term: 78812 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 777.75 Y Description: PET IMAGE SKULL-THIGH Category: Radiology CMS Add: 01/01/2005 CMS Term: 78813 26 RADIO DEF RBRVS 01/01/2024 87.89 Y Description: PET IMAGE FULL BODY Category: Radiology CMS Add: 01/01/2005 CMS Term: 78813 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 73.64 Y Description: PET IMAGE FULL BODY Category: Radiology CMS Add: 01/01/2005 CMS Term: 78813 RADIO DEF MAXFEE 01/01/2024 1444.54 0.0 Y Description: PET IMAGE FULL BODY Category: Radiology CMS Add: 01/01/2005 CMS Term: 78813 RADIO DEF RBRVS 09/01/2019 12/31/2023 833.33 Y Description: PET IMAGE FULL BODY Category: Radiology CMS Add: 01/01/2005 CMS Term: 78813 TC RADIO DEF MAXFEE 01/01/2024 1356.64 0.0 Y Description: PET IMAGE FULL BODY Category: Radiology CMS Add: 01/01/2005 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,064 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 78813 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 777.75 Y Description: PET IMAGE FULL BODY Category: Radiology CMS Add: 01/01/2005 CMS Term: 78814 26 RADIO DEF RBRVS 01/01/2024 98.70 Y Description: PET IMAGE W/CT LMTD Category: Radiology CMS Add: 01/01/2005 CMS Term: 78814 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 81.07 Y Description: PET IMAGE W/CT LMTD Category: Radiology CMS Add: 01/01/2005 CMS Term: 78814 RADIO DEF MAXFEE 01/01/2024 1455.34 0.0 Y Description: PET IMAGE W/CT LMTD Category: Radiology CMS Add: 01/01/2005 CMS Term: 78814 RADIO DEF RBRVS 09/01/2019 12/31/2023 833.33 Y Description: PET IMAGE W/CT LMTD Category: Radiology CMS Add: 01/01/2005 CMS Term: 78814 TC RADIO DEF MAXFEE 01/01/2024 1356.64 0.0 Y Description: PET IMAGE W/CT LMTD Category: Radiology CMS Add: 01/01/2005 CMS Term: 78814 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 777.75 Y Description: PET IMAGE W/CT LMTD Category: Radiology CMS Add: 01/01/2005 CMS Term: 78815 26 RADIO DEF RBRVS 01/01/2024 109.46 Y Description: PET IMAGE W/CT SKULL-THIGH Category: Radiology CMS Add: 01/01/2005 CMS Term: 78815 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 89.34 Y Description: PET IMAGE W/CT SKULL-THIGH Category: Radiology CMS Add: 01/01/2005 CMS Term: 78815 RADIO DEF MAXFEE 01/01/2024 1466.10 0.0 Y Description: PET IMAGE W/CT SKULL-THIGH Category: Radiology CMS Add: 01/01/2005 CMS Term: 78815 RADIO DEF RBRVS 09/01/2019 12/31/2023 833.33 Y Description: PET IMAGE W/CT SKULL-THIGH Category: Radiology CMS Add: 01/01/2005 CMS Term: 78815 TC RADIO DEF MAXFEE 01/01/2024 1356.64 0.0 Y Description: PET IMAGE W/CT SKULL-THIGH Category: Radiology CMS Add: 01/01/2005 CMS Term: 78815 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 777.75 Y Description: PET IMAGE W/CT SKULL-THIGH Category: Radiology CMS Add: 01/01/2005 CMS Term: 78816 26 RADIO DEF RBRVS 01/01/2024 110.41 Y Description: PET IMAGE W/CT FULL BODY Category: Radiology CMS Add: 01/01/2005 CMS Term: 78816 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 90.21 Y Description: PET IMAGE W/CT FULL BODY Category: Radiology CMS Add: 01/01/2005 CMS Term: 78816 RADIO DEF MAXFEE 01/01/2024 1467.05 0.0 Y Description: PET IMAGE W/CT FULL BODY Category: Radiology CMS Add: 01/01/2005 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,065 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 78816 RADIO DEF RBRVS 09/01/2019 12/31/2023 833.33 Y Description: PET IMAGE W/CT FULL BODY Category: Radiology CMS Add: 01/01/2005 CMS Term: 78816 TC RADIO DEF MAXFEE 01/01/2024 1356.64 0.0 Y Description: PET IMAGE W/CT FULL BODY Category: Radiology CMS Add: 01/01/2005 CMS Term: 78816 TC RADIO DEF RBRVS 09/01/2019 12/31/2023 777.75 Y Description: PET IMAGE W/CT FULL BODY Category: Radiology CMS Add: 01/01/2005 CMS Term: 78830 26 RADIO DEF RBRVS 01/01/2020 12/31/2023 53.16 Y Description: RP LOCLZJ TUM SPECT W/CT 1 Category: Radiology CMS Add: 01/01/2020 CMS Term: 78830 26 RADIO DEF RBRVS 01/01/2024 65.35 Y Description: RP LOCLZJ TUM SPECT W/CT 1 Category: Radiology CMS Add: 01/01/2020 CMS Term: 78830 RADIO DEF RBRVS 01/01/2020 12/31/2023 350.75 Y Description: RP LOCLZJ TUM SPECT W/CT 1 Category: Radiology CMS Add: 01/01/2020 CMS Term: 78830 RADIO DEF RBRVS 01/01/2024 416.09 Y Description: RP LOCLZJ TUM SPECT W/CT 1 Category: Radiology CMS Add: 01/01/2020 CMS Term: 78830 TC RADIO DEF RBRVS 01/01/2020 12/31/2023 297.59 Y Description: RP LOCLZJ TUM SPECT W/CT 1 Category: Radiology CMS Add: 01/01/2020 CMS Term: 78830 TC RADIO DEF RBRVS 01/01/2024 350.74 Y Description: RP LOCLZJ TUM SPECT W/CT 1 Category: Radiology CMS Add: 01/01/2020 CMS Term: 78831 26 RADIO DEF RBRVS 01/01/2020 81.18 Y Description: RP LOCLZJ TUM SPECT 2 AREAS Category: Radiology CMS Add: 01/01/2020 CMS Term: 78831 RADIO DEF RBRVS 01/01/2020 12/31/2023 506.51 Y Description: RP LOCLZJ TUM SPECT 2 AREAS Category: Radiology CMS Add: 01/01/2020 CMS Term: 78831 RADIO DEF RBRVS 01/01/2024 613.46 Y Description: RP LOCLZJ TUM SPECT 2 AREAS Category: Radiology CMS Add: 01/01/2020 CMS Term: 78831 TC RADIO DEF RBRVS 01/01/2020 12/31/2023 441.68 Y Description: RP LOCLZJ TUM SPECT 2 AREAS Category: Radiology CMS Add: 01/01/2020 CMS Term: 78831 TC RADIO DEF RBRVS 01/01/2024 532.29 Y Description: RP LOCLZJ TUM SPECT 2 AREAS Category: Radiology CMS Add: 01/01/2020 CMS Term: 78832 26 RADIO DEF RBRVS 01/01/2020 12/31/2023 75.54 Y Description: RP LOCLZJ TUM SPECT W/CT 2 Category: Radiology CMS Add: 01/01/2020 CMS Term: 78832 26 RADIO DEF RBRVS 01/01/2024 93.83 Y Description: RP LOCLZJ TUM SPECT W/CT 2 Category: Radiology CMS Add: 01/01/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,066 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 78832 RADIO DEF RBRVS 01/01/2020 12/31/2023 658.91 Y Description: RP LOCLZJ TUM SPECT W/CT 2 Category: Radiology CMS Add: 01/01/2020 CMS Term: 78832 RADIO DEF RBRVS 01/01/2024 785.72 Y Description: RP LOCLZJ TUM SPECT W/CT 2 Category: Radiology CMS Add: 01/01/2020 CMS Term: 78832 TC RADIO DEF RBRVS 01/01/2020 12/31/2023 583.37 Y Description: RP LOCLZJ TUM SPECT W/CT 2 Category: Radiology CMS Add: 01/01/2020 CMS Term: 78832 TC RADIO DEF RBRVS 01/01/2024 691.89 Y Description: RP LOCLZJ TUM SPECT W/CT 2 Category: Radiology CMS Add: 01/01/2020 CMS Term: 78835 NOCOV DEF SYSMAN Description: RP QUAN MEAS SINGLE AREA Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 78999 RADIO DEF BILL25 Description: UNLISTED MISC PX DX NUC MED Category: Radiology CMS Add: 01/01/1984 CMS Term: 79005 26 RADIO DEF RBRVS 01/01/2024 81.26 Description: NUCLEAR RX ORAL ADMIN Category: Radiology CMS Add: 01/01/2005 CMS Term: 79005 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 64.63 Description: NUCLEAR RX ORAL ADMIN Category: Radiology CMS Add: 01/01/2005 CMS Term: 79005 RADIO DEF RBRVS 01/01/2024 128.20 Description: NUCLEAR RX ORAL ADMIN Category: Radiology CMS Add: 01/01/2005 CMS Term: 79005 RADIO DEF RBRVS 02/01/2015 12/31/2023 98.23 Description: NUCLEAR RX ORAL ADMIN Category: Radiology CMS Add: 01/01/2005 CMS Term: 79005 TC RADIO DEF RBRVS 01/01/2024 46.94 Description: NUCLEAR RX ORAL ADMIN Category: Radiology CMS Add: 01/01/2005 CMS Term: 79005 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 33.61 Description: NUCLEAR RX ORAL ADMIN Category: Radiology CMS Add: 01/01/2005 CMS Term: 79101 26 RADIO DEF RBRVS 01/01/2024 90.70 Description: NUCLEAR RX IV ADMIN Category: Radiology CMS Add: 01/01/2005 CMS Term: 79101 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 69.92 Description: NUCLEAR RX IV ADMIN Category: Radiology CMS Add: 01/01/2005 CMS Term: 79101 RADIO DEF RBRVS 01/01/2024 139.80 Description: NUCLEAR RX IV ADMIN Category: Radiology CMS Add: 01/01/2005 CMS Term: 79101 RADIO DEF RBRVS 02/01/2015 12/31/2023 104.02 Description: NUCLEAR RX IV ADMIN Category: Radiology CMS Add: 01/01/2005 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,067 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 79101 TC RADIO DEF RBRVS 01/01/2024 49.10 Description: NUCLEAR RX IV ADMIN Category: Radiology CMS Add: 01/01/2005 CMS Term: 79101 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 34.10 Description: NUCLEAR RX IV ADMIN Category: Radiology CMS Add: 01/01/2005 CMS Term: 79200 26 RADIO DEF RBRVS 01/01/2024 77.94 Description: NUCLEAR RX INTRACAV ADMIN Category: Radiology CMS Add: 01/01/1984 CMS Term: 79200 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 75.10 Description: NUCLEAR RX INTRACAV ADMIN Category: Radiology CMS Add: 01/01/1984 CMS Term: 79200 RADIO DEF RBRVS 01/01/2024 126.43 Description: NUCLEAR RX INTRACAV ADMIN Category: Radiology CMS Add: 01/01/1984 CMS Term: 79200 RADIO DEF RBRVS 02/01/2015 12/31/2023 113.66 Description: NUCLEAR RX INTRACAV ADMIN Category: Radiology CMS Add: 01/01/1984 CMS Term: 79200 TC RADIO DEF RBRVS 01/01/2024 48.48 Description: NUCLEAR RX INTRACAV ADMIN Category: Radiology CMS Add: 01/01/1984 CMS Term: 79200 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 38.56 Description: NUCLEAR RX INTRACAV ADMIN Category: Radiology CMS Add: 01/01/1984 CMS Term: 79300 26 RADIO DEF RBRVS 01/01/2024 62.57 Description: NUCLR RX INTERSTIT COLLOID Category: Radiology CMS Add: 01/01/1984 CMS Term: 79300 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 59.75 Description: NUCLR RX INTERSTIT COLLOID Category: Radiology CMS Add: 01/01/1984 CMS Term: 79403 26 RADIO DEF RBRVS 01/01/2024 102.85 0-1 Description: HEMATOPOIETIC NUCLEAR TX Category: Radiology CMS Add: 01/01/2004 CMS Term: 79403 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 82.83 0-1 Description: HEMATOPOIETIC NUCLEAR TX Category: Radiology CMS Add: 01/01/2004 CMS Term: 79403 RADIO DEF RBRVS 01/01/2024 188.70 0-1 Description: HEMATOPOIETIC NUCLEAR TX Category: Radiology CMS Add: 01/01/2004 CMS Term: 79403 RADIO DEF RBRVS 02/01/2015 12/31/2023 138.81 0-1 Description: HEMATOPOIETIC NUCLEAR TX Category: Radiology CMS Add: 01/01/2004 CMS Term: 79403 TC RADIO DEF RBRVS 01/01/2024 85.85 0-1 Description: HEMATOPOIETIC NUCLEAR TX Category: Radiology CMS Add: 01/01/2004 CMS Term: 79403 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 55.98 0-1 Description: HEMATOPOIETIC NUCLEAR TX Category: Radiology CMS Add: 01/01/2004 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,068 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 79440 26 RADIO DEF RBRVS 01/01/2024 77.94 Description: NUCLEAR RX INTRA-ARTICULAR Category: Radiology CMS Add: 01/01/1984 CMS Term: 79440 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 72.62 Description: NUCLEAR RX INTRA-ARTICULAR Category: Radiology CMS Add: 01/01/1984 CMS Term: 79440 RADIO DEF RBRVS 01/01/2024 114.39 Description: NUCLEAR RX INTRA-ARTICULAR Category: Radiology CMS Add: 01/01/1984 CMS Term: 79440 RADIO DEF RBRVS 02/01/2015 12/31/2023 105.49 Description: NUCLEAR RX INTRA-ARTICULAR Category: Radiology CMS Add: 01/01/1984 CMS Term: 79440 TC RADIO DEF RBRVS 01/01/2024 36.44 Description: NUCLEAR RX INTRA-ARTICULAR Category: Radiology CMS Add: 01/01/1984 CMS Term: 79440 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 32.86 Description: NUCLEAR RX INTRA-ARTICULAR Category: Radiology CMS Add: 01/01/1984 CMS Term: 79445 26 RADIO DEF RBRVS 01/01/2024 105.19 Description: NUCLEAR RX INTRA-ARTERIAL Category: Radiology CMS Add: 01/01/2005 CMS Term: 79445 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 85.70 Description: NUCLEAR RX INTRA-ARTERIAL Category: Radiology CMS Add: 01/01/2005 CMS Term: 79445 RADIO DEF MAXFEE 01/01/2024 239.76 0.0 Description: NUCLEAR RX INTRA-ARTERIAL Category: Radiology CMS Add: 01/01/2005 CMS Term: 79445 RADIO DEF RBRVS 02/01/2015 12/31/2023 154.32 Description: NUCLEAR RX INTRA-ARTERIAL Category: Radiology CMS Add: 01/01/2005 CMS Term: 79445 TC RADIO DEF MAXFEE 01/01/2024 109.30 0.0 Description: NUCLEAR RX INTRA-ARTERIAL Category: Radiology CMS Add: 01/01/2005 CMS Term: 79445 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 67.54 Description: NUCLEAR RX INTRA-ARTERIAL Category: Radiology CMS Add: 01/01/2005 CMS Term: 79999 RADIO DEF BILL25 Description: RP THERAPY UNLISTED PX Category: Radiology CMS Add: 01/01/1982 CMS Term: 80047 LAB L60 MAXFEE 01/01/2015 12/31/2023 8.69 0.0 0-2 Description: METABOLIC PANEL IONIZED CA Category: Laboratory CMS Add: 01/01/2008 CMS Term: 80047 LAB L60 MAXFEE 01/01/2024 13.73 0.0 0-2 Description: METABOLIC PANEL IONIZED CA Category: Laboratory CMS Add: 01/01/2008 CMS Term: 80048 LAB L60 MAXFEE 01/01/2020 8.46 0.0 0-2 Description: METABOLIC PANEL TOTAL CA Category: Laboratory CMS Add: 01/01/2000 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,069 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 80048 MRT L60 MAXFEE 01/01/2020 8.46 0.0 0-2 Description: METABOLIC PANEL TOTAL CA Category: Medical Review Team CMS Add: 01/01/2000 CMS Term: 80050 LAB L60 MAXFEE 01/01/1997 12/31/2023 50.04 0.0 Description: GENERAL HEALTH PANEL Category: Laboratory CMS Add: 01/01/1984 CMS Term: 80050 LAB L60 MAXFEE 01/01/2024 65.05 0.0 Description: GENERAL HEALTH PANEL Category: Laboratory CMS Add: 01/01/1984 CMS Term: 80051 LAB L60 MAXFEE 01/01/2020 7.01 0.0 Description: ELECTROLYTE PANEL Category: Laboratory CMS Add: 01/01/1998 CMS Term: 80053 LAB L60 MAXFEE 01/01/2020 10.56 0.0 0-1 Description: COMPREHEN METABOLIC PANEL Category: Laboratory CMS Add: 01/01/2000 CMS Term: 80053 MRT L60 MAXFEE 01/01/2020 10.56 0.0 0-1 Description: COMPREHEN METABOLIC PANEL Category: Medical Review Team CMS Add: 01/01/2000 CMS Term: 80055 LAB L60 MAXFEE 01/01/2024 47.81 0.0 Description: OBSTETRIC PANEL Category: Laboratory CMS Add: 01/01/1984 CMS Term: 80055 LAB L60 MAXFEE 12/17/2001 12/31/2023 37.99 0.0 Description: OBSTETRIC PANEL Category: Laboratory CMS Add: 01/01/1984 CMS Term: 80061 LAB L60 MAXFEE 01/01/2020 13.39 0.0 Description: LIPID PANEL Category: Laboratory CMS Add: 01/01/1984 CMS Term: 80061 MRT L60 MAXFEE 01/01/2020 13.39 0.0 Description: LIPID PANEL Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 80069 LAB L60 MAXFEE 01/01/2020 8.68 0.0 0-1 Description: RENAL FUNCTION PANEL Category: Laboratory CMS Add: 01/01/2000 CMS Term: 80074 LAB L60 MAXFEE 01/01/2020 47.63 0.0 0-1 Description: ACUTE HEPATITIS PANEL Category: Laboratory CMS Add: 01/01/2000 CMS Term: 80076 LAB L60 MAXFEE 01/01/2020 8.17 0.0 0-1 Description: HEPATIC FUNCTION PANEL Category: Laboratory CMS Add: 01/01/2000 CMS Term: 80076 MRT L60 MAXFEE 01/01/2020 8.17 0.0 0-1 Description: HEPATIC FUNCTION PANEL Category: Medical Review Team CMS Add: 01/01/2000 CMS Term: 80081 LAB L60 MAXFEE 01/01/2020 74.86 0.0 10-60years Description: OBSTETRIC PANEL Category: Laboratory CMS Add: 01/01/2016 CMS Term: 80143 LAB L60 MAXFEE 01/01/2021 18.64 0.0 Description: DRUG ASSAY ACETAMINOPHEN Category: Laboratory CMS Add: 01/01/2021 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,070 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 80145 LAB L60 MAXFEE 01/01/2020 38.57 0.0 Description: DRUG ASSAY ADALIMUMAB Category: Laboratory CMS Add: 01/01/2020 CMS Term: 80150 LAB L60 MAXFEE 01/01/2020 15.08 0.0 Description: ASSAY OF AMIKACIN Category: Laboratory CMS Add: 01/01/1993 CMS Term: 80151 LAB L60 MAXFEE 01/01/2021 18.64 0.0 Description: DRUG ASSAY AMIODARONE Category: Laboratory CMS Add: 01/01/2021 CMS Term: 80155 LAB L60 MAXFEE 01/01/2015 12/31/2023 19.25 0.0 Description: DRUG ASSAY CAFFEINE Category: Laboratory CMS Add: 01/01/2014 CMS Term: 80155 LAB L60 MAXFEE 01/01/2024 38.57 0.0 Description: DRUG ASSAY CAFFEINE Category: Laboratory CMS Add: 01/01/2014 CMS Term: 80156 LAB L60 MAXFEE 01/01/2020 14.57 0.0 Description: ASSAY CARBAMAZEPINE TOTAL Category: Laboratory CMS Add: 01/01/1993 CMS Term: 80157 LAB L60 MAXFEE 01/01/2020 13.25 0.0 Description: ASSAY CARBAMAZEPINE FREE Category: Laboratory CMS Add: 01/01/2001 CMS Term: 80158 LAB L60 MAXFEE 01/01/2020 18.05 0.0 Description: DRUG ASSAY CYCLOSPORINE Category: Laboratory CMS Add: 01/01/1993 CMS Term: 80159 LAB L60 MAXFEE 01/01/2020 20.15 0.0 Description: DRUG ASSAY CLOZAPINE Category: Laboratory CMS Add: 01/01/2014 CMS Term: 80161 LAB L60 MAXFEE 01/01/2021 18.64 0.0 Description: ASY CARBAMAZEPIN 10,11-EPXID Category: Laboratory CMS Add: 01/01/2021 CMS Term: 80162 LAB L60 MAXFEE 01/01/2020 13.28 0.0 Description: ASSAY OF DIGOXIN TOTAL Category: Laboratory CMS Add: 01/01/1993 CMS Term: 80163 LAB L60 MAXFEE 01/01/2020 13.28 0.0 Description: ASSAY OF DIGOXIN FREE Category: Laboratory CMS Add: 01/01/2015 CMS Term: 80164 LAB L60 MAXFEE 01/01/2020 13.54 0.0 Description: ASSAY DIPROPYLACETIC ACD TOT Category: Laboratory CMS Add: 01/01/1993 CMS Term: 80164 MRT L60 MAXFEE 01/01/2020 13.54 0.0 Description: ASSAY DIPROPYLACETIC ACD TOT Category: Medical Review Team CMS Add: 01/01/1993 CMS Term: 80165 LAB L60 MAXFEE 01/01/2020 13.54 0.0 Description: DIPROPYLACETIC ACID FREE Category: Laboratory CMS Add: 01/01/2015 CMS Term: 80167 LAB L60 MAXFEE 01/01/2021 18.64 0.0 Description: DRUG ASSAY FELBAMATE Category: Laboratory CMS Add: 01/01/2021 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,071 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 80168 LAB L60 MAXFEE 01/01/2020 16.34 0.0 Description: ASSAY OF ETHOSUXIMIDE Category: Laboratory CMS Add: 01/01/1993 CMS Term: 80169 LAB L60 MAXFEE 01/01/2020 13.73 0.0 Description: DRUG ASSAY EVEROLIMUS Category: Laboratory CMS Add: 01/01/2014 CMS Term: 80170 LAB L60 MAXFEE 01/01/2020 16.38 0.0 Description: ASSAY OF GENTAMICIN Category: Laboratory CMS Add: 01/01/1993 CMS Term: 80171 LAB L60 MAXFEE 01/01/2015 12/31/2023 18.04 0.0 Description: DRUG SCREEN QUANT GABAPENTIN Category: Laboratory CMS Add: 01/01/2014 CMS Term: 80171 LAB L60 MAXFEE 01/01/2024 21.67 0.0 Description: DRUG SCREEN QUANT GABAPENTIN Category: Laboratory CMS Add: 01/01/2014 CMS Term: 80173 LAB L60 MAXFEE 01/01/2020 15.78 0.0 Description: ASSAY OF HALOPERIDOL Category: Laboratory CMS Add: 01/01/2001 CMS Term: 80175 LAB L60 MAXFEE 01/01/2020 13.25 0.0 Description: DRUG SCREEN QUAN LAMOTRIGINE Category: Laboratory CMS Add: 01/01/2014 CMS Term: 80176 LAB L60 MAXFEE 01/01/2020 14.69 0.0 Description: ASSAY OF LIDOCAINE Category: Laboratory CMS Add: 01/01/1993 CMS Term: 80177 LAB L60 MAXFEE 01/01/2020 13.25 0.0 Description: DRUG SCRN QUAN LEVETIRACETAM Category: Laboratory CMS Add: 01/01/2014 CMS Term: 80178 LAB L60 MAXFEE 01/01/2020 6.61 0.0 Description: ASSAY OF LITHIUM Category: Laboratory CMS Add: 01/01/1993 CMS Term: 80179 LAB L60 MAXFEE 01/01/2021 18.64 0.0 Description: DRUG ASSAY SALICYLATE Category: Laboratory CMS Add: 01/01/2021 CMS Term: 80180 LAB L60 MAXFEE 01/01/2020 18.05 0.0 Description: DRUG SCRN QUAN MYCOPHENOLATE Category: Laboratory CMS Add: 01/01/2014 CMS Term: 80181 LAB L60 MAXFEE 01/01/2021 18.64 0.0 Description: DRUG ASSAY FLECAINIDE Category: Laboratory CMS Add: 01/01/2021 CMS Term: 80183 LAB L60 MAXFEE 01/01/2020 13.25 0.0 Description: DRUG SCRN QUANT OXCARBAZEPIN Category: Laboratory CMS Add: 01/01/2014 CMS Term: 80184 LAB L60 MAXFEE 01/01/2018 15.30 0.0 Description: ASSAY OF PHENOBARBITAL Category: Laboratory CMS Add: 01/01/1993 CMS Term: 80185 LAB L60 MAXFEE 01/01/2020 13.25 0.0 Description: ASSAY OF PHENYTOIN TOTAL Category: Laboratory CMS Add: 01/01/1993 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,072 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 80186 LAB L60 MAXFEE 01/01/2020 13.76 0.0 Description: ASSAY OF PHENYTOIN FREE Category: Laboratory CMS Add: 01/01/1993 CMS Term: 80187 LAB L60 MAXFEE 01/01/2020 27.11 0.0 Description: DRUG ASSAY POSACONAZOLE Category: Laboratory CMS Add: 01/01/2020 CMS Term: 80188 LAB L60 MAXFEE 01/01/2020 16.59 0.0 Description: ASSAY OF PRIMIDONE Category: Laboratory CMS Add: 01/01/1993 CMS Term: 80189 LAB L60 MAXFEE 01/01/2021 27.11 0.0 Description: DRUG ASSAY ITRACONAZOLE Category: Laboratory CMS Add: 01/01/2021 CMS Term: 80190 LAB L60 MAXFEE 01/01/2015 12/31/2023 22.80 0.0 Description: ASSAY OF PROCAINAMIDE Category: Laboratory CMS Add: 01/01/1993 CMS Term: 80190 LAB L60 MAXFEE 01/01/2024 60.00 0.0 Description: ASSAY OF PROCAINAMIDE Category: Laboratory CMS Add: 01/01/1993 CMS Term: 80192 LAB L60 MAXFEE 01/01/2020 16.75 0.0 Description: ASSAY OF PROCAINAMIDE Category: Laboratory CMS Add: 01/01/1993 CMS Term: 80193 LAB L60 MAXFEE 01/01/2021 38.57 0.0 Description: DRUG ASSAY LEFLUNOMIDE Category: Laboratory CMS Add: 01/01/2021 CMS Term: 80194 LAB L60 MAXFEE 01/01/2020 14.60 0.0 Description: ASSAY OF QUINIDINE Category: Laboratory CMS Add: 01/01/1993 CMS Term: 80195 LAB L60 MAXFEE 01/01/2020 13.73 0.0 Description: ASSAY OF SIROLIMUS Category: Laboratory CMS Add: 01/01/2006 CMS Term: 80197 LAB L60 MAXFEE 01/01/2020 13.73 0.0 Description: ASSAY OF TACROLIMUS Category: Laboratory CMS Add: 01/01/1997 CMS Term: 80198 LAB L60 MAXFEE 01/01/2020 14.14 0.0 Description: ASSAY OF THEOPHYLLINE Category: Laboratory CMS Add: 01/01/1993 CMS Term: 80199 LAB L60 MAXFEE 01/01/2015 12/31/2023 23.71 0.0 Description: DRUG SCREEN QUANT TIAGABINE Category: Laboratory CMS Add: 01/01/2014 CMS Term: 80199 LAB L60 MAXFEE 01/01/2024 27.11 0.0 Description: DRUG SCREEN QUANT TIAGABINE Category: Laboratory CMS Add: 01/01/2014 CMS Term: 80200 LAB L60 MAXFEE 01/01/2020 16.13 0.0 Description: ASSAY OF TOBRAMYCIN Category: Laboratory CMS Add: 01/01/1993 CMS Term: 80201 LAB L60 MAXFEE 01/01/2020 11.92 0.0 Description: ASSAY OF TOPIRAMATE Category: Laboratory CMS Add: 01/01/1998 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,073 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 80202 LAB L60 MAXFEE 01/01/2020 13.54 0.0 Description: ASSAY OF VANCOMYCIN Category: Laboratory CMS Add: 01/01/1993 CMS Term: 80203 LAB L60 MAXFEE 01/01/2020 13.25 0.0 Description: DRUG SCREEN QUANT ZONISAMIDE Category: Laboratory CMS Add: 01/01/2014 CMS Term: 80204 LAB L60 MAXFEE 01/01/2021 38.57 0.0 Description: DRUG ASSAY METHOTREXATE Category: Laboratory CMS Add: 01/01/2021 CMS Term: 80210 LAB L60 MAXFEE 01/01/2021 27.11 0.0 Description: DRUG ASSAY RUFINAMIDE Category: Laboratory CMS Add: 01/01/2021 CMS Term: 80220 LAB L60 MAXFEE 01/01/2022 18.64 0.0 Description: DRUG ASY HYDROXYCHLOROQUINE Category: Laboratory CMS Add: 01/01/2022 CMS Term: 80230 LAB L60 MAXFEE 01/01/2020 38.57 0.0 Description: DRUG ASSAY INFLIXIMAB Category: Laboratory CMS Add: 01/01/2020 CMS Term: 80235 LAB L60 MAXFEE 01/01/2020 27.11 0.0 Description: DRUG ASSAY LACOSAMIDE Category: Laboratory CMS Add: 01/01/2020 CMS Term: 80280 LAB L60 MAXFEE 01/01/2020 38.57 0.0 Description: DRUG ASSAY VEDOLIZUMAB Category: Laboratory CMS Add: 01/01/2020 CMS Term: 80285 LAB L60 MAXFEE 01/01/2020 27.11 0.0 Description: DRUG ASSAY VORICONAZOLE Category: Laboratory CMS Add: 01/01/2020 CMS Term: 80299 LAB L60 MAXFEE 01/01/2015 18.64 0.0 Description: QUANTITATIVE ASSAY DRUG Category: Laboratory CMS Add: 01/01/1993 CMS Term: 80305 LAB L60 MAXFEE 01/01/2019 12.60 0.0 Description: DRUG TEST PRSMV DIR OPT OBS Category: Laboratory CMS Add: 01/01/2017 CMS Term: 80306 LAB L60 MAXFEE 01/01/2019 17.14 0.0 Description: DRUG TEST PRSMV INSTRMNT Category: Laboratory CMS Add: 01/01/2017 CMS Term: 80307 LAB L60 MAXFEE 01/01/2020 62.14 0.0 Description: DRUG TEST PRSMV CHEM ANLYZR Category: Laboratory CMS Add: 01/01/2017 CMS Term: 80320 NOCOV DEF SYSMAN Description: DRUG SCREEN QUANTALCOHOLS Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 80321 NOCOV DEF SYSMAN Description: ALCOHOLS BIOMARKERS 1OR 2 Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 80322 NOCOV DEF SYSMAN Description: ALCOHOLS BIOMARKERS 3/MORE Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,074 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 80323 NOCOV DEF SYSMAN Description: ALKALOIDS NOS Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 80324 NOCOV DEF SYSMAN Description: DRUG SCREEN AMPHETAMINES 1/2 Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 80325 NOCOV DEF SYSMAN Description: AMPHETAMINES 3OR 4 Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 80326 NOCOV DEF SYSMAN Description: AMPHETAMINES 5 OR MORE Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 80327 NOCOV DEF SYSMAN Description: ANABOLIC STEROID 1 OR 2 Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 80328 NOCOV DEF SYSMAN Description: ANABOLIC STEROID 3 OR MORE Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 80329 NOCOV DEF SYSMAN Description: ANALGESICS NON-OPIOID 1 OR 2 Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 80330 NOCOV DEF SYSMAN Description: ANALGESICS NON-OPIOID 3-5 Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 80331 NOCOV DEF SYSMAN Description: ANALGESICS NON-OPIOID 6/MORE Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 80332 NOCOV DEF SYSMAN Description: ANTIDEPRESSANTS CLASS 1 OR 2 Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 80333 NOCOV DEF SYSMAN Description: ANTIDEPRESSANTS CLASS 3-5 Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 80334 NOCOV DEF SYSMAN Description: ANTIDEPRESSANTS CLASS 6/MORE Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 80335 NOCOV DEF SYSMAN Description: ANTIDEPRESSANT TRICYCLIC 1/2 Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 80336 NOCOV DEF SYSMAN Description: ANTIDEPRESSANT TRICYCLIC 3-5 Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 80337 NOCOV DEF SYSMAN Description: TRICYCLIC & CYCLICALS 6/MORE Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 80338 NOCOV DEF SYSMAN Description: ANTIDEPRESSANT NOT SPECIFIED Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,075 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 80339 NOCOV DEF SYSMAN Description: ANTIEPILEPTICS NOS 1-3 Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 80340 NOCOV DEF SYSMAN Description: ANTIEPILEPTICS NOS 4-6 Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 80341 NOCOV DEF SYSMAN Description: ANTIEPILEPTICS NOS 7/MORE Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 80342 NOCOV DEF SYSMAN Description: ANTIPSYCHOTICS NOS 1-3 Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 80343 NOCOV DEF SYSMAN Description: ANTIPSYCHOTICS NOS 4-6 Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 80344 NOCOV DEF SYSMAN Description: ANTIPSYCHOTICS NOS 7/MORE Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 80345 NOCOV DEF SYSMAN Description: DRUG SCREENING BARBITURATES Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 80346 NOCOV DEF SYSMAN Description: BENZODIAZEPINES1-12 Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 80347 NOCOV DEF SYSMAN Description: BENZODIAZEPINES 13 OR MORE Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 80348 NOCOV DEF SYSMAN Description: DRUG SCREENING BUPRENORPHINE Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 80349 NOCOV DEF SYSMAN Description: CANNABINOIDS NATURAL Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 80350 NOCOV DEF SYSMAN Description: CANNABINOIDS SYNTHETIC 1-3 Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 80351 NOCOV DEF SYSMAN Description: CANNABINOIDS SYNTHETIC 4-6 Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 80352 NOCOV DEF SYSMAN Description: CANNABINOID SYNTHETIC 7/MORE Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 80353 NOCOV DEF SYSMAN Description: DRUG SCREENING COCAINE Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 80354 NOCOV DEF SYSMAN Description: DRUG SCREENING FENTANYL Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,076 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 80355 NOCOV DEF SYSMAN Description: GABAPENTIN NON-BLOOD Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 80356 NOCOV DEF SYSMAN Description: HEROIN METABOLITE Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 80357 NOCOV DEF SYSMAN Description: KETAMINE AND NORKETAMINE Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 80358 NOCOV DEF SYSMAN Description: DRUG SCREENING METHADONE Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 80359 NOCOV DEF SYSMAN Description: METHYLENEDIOXYAMPHETAMINES Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 80360 NOCOV DEF SYSMAN Description: METHYLPHENIDATE Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 80361 NOCOV DEF SYSMAN Description: OPIATES 1 OR MORE Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 80362 NOCOV DEF SYSMAN Description: OPIOIDS & OPIATE ANALOGS 1/2 Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 80363 NOCOV DEF SYSMAN Description: OPIOIDS & OPIATE ANALOGS 3/4 Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 80364 NOCOV DEF SYSMAN Description: OPIOID &OPIATE ANALOG 5/MORE Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 80365 NOCOV DEF SYSMAN Description: DRUG SCREENING OXYCODONE Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 80366 NOCOV DEF SYSMAN Description: DRUG SCREENING PREGABALIN Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 80367 NOCOV DEF SYSMAN Description: DRUG SCREENING PROPOXYPHENE Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 80368 NOCOV DEF SYSMAN Description: SEDATIVE HYPNOTICS Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 80369 NOCOV DEF SYSMAN Description: SKELETAL MUSCLE RELAXANT 1/2 Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 80370 NOCOV DEF SYSMAN Description: SKEL MUSC RELAXANT 3 OR MORE Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,077 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 80371 NOCOV DEF SYSMAN Description: STIMULANTS SYNTHETIC Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 80372 NOCOV DEF SYSMAN Description: DRUG SCREENING TAPENTADOL Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 80373 NOCOV DEF SYSMAN Description: DRUG SCREENING TRAMADOL Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 80374 NOCOV DEF SYSMAN Description: STEREOISOMER ANALYSIS Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 80375 NOCOV DEF SYSMAN Description: DRUG/SUBSTANCE NOS 1-3 Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 80376 NOCOV DEF SYSMAN Description: DRUG/SUBSTANCE NOS 4-6 Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 80377 NOCOV DEF SYSMAN Description: DRUG/SUBSTANCE NOS 7/MORE Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 80400 LAB L60 MAXFEE 01/01/2020 32.62 0.0 Description: ACTH STIMULATION PANEL Category: Laboratory CMS Add: 01/01/1994 CMS Term: 80402 LAB L60 MAXFEE 01/01/2020 86.96 0.0 Description: ACTH STIMULATION PANEL Category: Laboratory CMS Add: 01/01/1994 CMS Term: 80406 LAB L60 MAXFEE 01/01/2020 78.26 0.0 Description: ACTH STIMULATION PANEL Category: Laboratory CMS Add: 01/01/1994 CMS Term: 80408 LAB L60 MAXFEE 01/01/2020 125.50 0.0 Description: ALDOSTERONE SUPPRESSION EVAL Category: Laboratory CMS Add: 01/01/1994 CMS Term: 80410 LAB L60 MAXFEE 01/01/2020 80.37 0.0 Description: CALCITONIN STIMUL PANEL Category: Laboratory CMS Add: 01/01/1994 CMS Term: 80412 LAB L60 MAXFEE 01/01/2015 12/31/2023 432.03 0.0 Description: CRH STIMULATION PANEL Category: Laboratory CMS Add: 01/01/1994 CMS Term: 80412 LAB L60 MAXFEE 01/01/2024 801.62 0.0 Description: CRH STIMULATION PANEL Category: Laboratory CMS Add: 01/01/1994 CMS Term: 80414 LAB L60 MAXFEE 01/01/2020 51.64 0.0 Description: TESTOSTERONE RESPONSE PANEL Category: Laboratory CMS Add: 01/01/1994 CMS Term: 80415 LAB L60 MAXFEE 01/01/2020 55.89 0.0 Description: TOT ESTRADIOL RESPONSE PANEL Category: Laboratory CMS Add: 01/01/1994 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,078 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 80416 LAB L60 MAXFEE 01/01/2015 12/31/2023 179.58 0.0 Description: RENIN STIMULATION PANEL Category: Laboratory CMS Add: 01/01/1996 CMS Term: 80416 LAB L60 MAXFEE 01/01/2024 209.32 0.0 Description: RENIN STIMULATION PANEL Category: Laboratory CMS Add: 01/01/1996 CMS Term: 80417 LAB L60 MAXFEE 01/01/2020 43.99 0.0 Description: RENIN STIMULATION PANEL Category: Laboratory CMS Add: 01/01/1996 CMS Term: 80418 LAB L60 MAXFEE 01/01/2020 579.48 0.0 Description: PITUITARY EVALUATION PANEL Category: Laboratory CMS Add: 01/01/1994 CMS Term: 80420 LAB L60 MAXFEE 01/01/2015 12/31/2023 92.53 0.0 Description: DEXAMETHASONE PANEL Category: Laboratory CMS Add: 01/01/1994 CMS Term: 80420 LAB L60 MAXFEE 01/01/2024 161.88 0.0 Description: DEXAMETHASONE PANEL Category: Laboratory CMS Add: 01/01/1994 CMS Term: 80422 LAB L60 MAXFEE 01/01/2020 46.07 0.0 Description: GLUCAGON TOLERANCE PANEL Category: Laboratory CMS Add: 01/01/1994 CMS Term: 80424 LAB L60 MAXFEE 01/01/2020 50.50 0.0 Description: GLUCAGON TOLERANCE PANEL Category: Laboratory CMS Add: 01/01/1994 CMS Term: 80426 LAB L60 MAXFEE 01/01/2020 148.41 0.0 Description: GONADOTROPIN HORMONE PANEL Category: Laboratory CMS Add: 01/01/1994 CMS Term: 80428 LAB L60 MAXFEE 01/01/2020 66.70 0.0 Description: GROWTH HORMONE PANEL Category: Laboratory CMS Add: 01/01/1994 CMS Term: 80430 LAB L60 MAXFEE 01/01/2015 12/31/2023 106.80 0.0 Description: GROWTH HORMONE PANEL Category: Laboratory CMS Add: 01/01/1994 CMS Term: 80430 LAB L60 MAXFEE 01/01/2024 129.33 0.0 Description: GROWTH HORMONE PANEL Category: Laboratory CMS Add: 01/01/1994 CMS Term: 80432 LAB L60 MAXFEE 01/01/2019 165.61 0.0 Description: INSULIN SUPPRESSION PANEL Category: Laboratory CMS Add: 01/01/1994 CMS Term: 80434 LAB L60 MAXFEE 01/01/2015 12/31/2023 123.90 0.0 Description: INSULIN TOLERANCE PANEL Category: Laboratory CMS Add: 01/01/1994 CMS Term: 80434 LAB L60 MAXFEE 01/01/2024 285.03 0.0 Description: INSULIN TOLERANCE PANEL Category: Laboratory CMS Add: 01/01/1994 CMS Term: 80435 LAB L60 MAXFEE 01/01/2020 103.00 0.0 Description: INSULIN TOLERANCE PANEL Category: Laboratory CMS Add: 01/01/1994 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,079 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 80436 LAB L60 MAXFEE 01/01/2020 91.16 0.0 Description: METYRAPONE PANEL Category: Laboratory CMS Add: 01/01/1994 CMS Term: 80438 LAB L60 MAXFEE 01/01/2020 50.41 0.0 Description: TRH STIMULATION PANEL Category: Laboratory CMS Add: 01/01/1994 CMS Term: 80439 LAB L60 MAXFEE 01/01/2020 67.21 0.0 Description: TRH STIMULATION PANEL Category: Laboratory CMS Add: 01/01/1994 CMS Term: 80503 LAB DEF RBRVS 01/01/2022 12/31/2023 19.81 Description: PATH CLIN CONSLTJ SF 5-20 Category: Laboratory CMS Add: 01/01/2022 CMS Term: 80503 LAB DEF RBRVS 01/01/2024 25.70 Description: PATH CLIN CONSLTJ SF 5-20 Category: Laboratory CMS Add: 01/01/2022 CMS Term: 80504 LAB DEF RBRVS 01/01/2022 12/31/2023 39.64 Description: PATH CLIN CONSLTJ MOD 21-40 Category: Laboratory CMS Add: 01/01/2022 CMS Term: 80504 LAB DEF RBRVS 01/01/2024 50.62 Description: PATH CLIN CONSLTJ MOD 21-40 Category: Laboratory CMS Add: 01/01/2022 CMS Term: 80505 LAB DEF RBRVS 01/01/2022 12/31/2023 71.87 Description: PATH CLIN CONSLTJ HIGH 41-60 Category: Laboratory CMS Add: 01/01/2022 CMS Term: 80505 LAB DEF RBRVS 01/01/2024 91.35 Description: PATH CLIN CONSLTJ HIGH 41-60 Category: Laboratory CMS Add: 01/01/2022 CMS Term: 80506 LAB DEF RBRVS 01/01/2022 12/31/2023 32.31 Description: PATH CLIN CONSLTJ PROLNG SVC Category: Laboratory CMS Add: 01/01/2022 CMS Term: 80506 LAB DEF RBRVS 01/01/2024 41.03 Description: PATH CLIN CONSLTJ PROLNG SVC Category: Laboratory CMS Add: 01/01/2022 CMS Term: 81000 LAB L60 MAXFEE 01/01/2018 4.02 0.0 Description: URINALYSIS NONAUTO W/SCOPE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 81001 LAB L60 MAXFEE 01/01/2020 3.17 0.0 Description: URINALYSIS AUTO W/SCOPE Category: Laboratory CMS Add: 01/01/1996 CMS Term: 81002 LAB L60 MAXFEE 01/01/2015 3.48 0.0 Description: URINALYSIS NONAUTO W/O SCOPE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 81003 LAB L60 MAXFEE 01/01/2020 2.25 0.0 Description: URINALYSIS AUTO W/O SCOPE Category: Laboratory CMS Add: 01/01/1993 CMS Term: 81005 LAB L60 MAXFEE 01/01/2020 2.17 0.0 Description: URINALYSIS Category: Laboratory CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,080 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 81007 LAB L60 MAXFEE 01/01/2015 12/31/2023 3.49 0.0 Description: URINE SCREEN FOR BACTERIA Category: Laboratory CMS Add: 01/01/1990 CMS Term: 81007 LAB L60 MAXFEE 01/01/2024 29.98 0.0 Description: URINE SCREEN FOR BACTERIA Category: Laboratory CMS Add: 01/01/1990 CMS Term: 81015 LAB L60 MAXFEE 01/01/2020 3.05 0.0 Description: MICROSCOPIC EXAM OF URINE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 81020 LAB L60 MAXFEE 01/01/2018 4.70 0.0 Description: URINALYSIS GLASS TEST Category: Laboratory CMS Add: 01/01/1984 CMS Term: 81025 LAB L60 MAXFEE 01/01/2015 8.61 0.0 Description: URINE PREGNANCY TEST Category: Laboratory CMS Add: 01/01/1993 CMS Term: 81050 LAB L60 MAXFEE 01/01/2019 3.64 0.0 Description: URINALYSIS VOLUME MEASURE Category: Laboratory CMS Add: 01/01/1993 CMS Term: 81099 LAB L60 MAXFEE 01/01/2024 40.56 0.0 Description: UNLISTED URINALYSIS PX Category: Laboratory CMS Add: 01/01/1984 CMS Term: 81099 LAB L60 MAXFEE 07/01/1985 12/31/2023 31.20 0.0 Description: UNLISTED URINALYSIS PX Category: Laboratory CMS Add: 01/01/1984 CMS Term: 81105 NOCOV DEF SYSMAN Description: HPA-1 GENOTYPING Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 81106 NOCOV DEF SYSMAN Description: HPA-2 GENOTYPING Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 81107 NOCOV DEF SYSMAN Description: HPA-3 GENOTYPING Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 81108 NOCOV DEF SYSMAN Description: HPA-4 GENOTYPING Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 81109 NOCOV DEF SYSMAN Description: HPA-5 GENOTYPING Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 81110 NOCOV DEF SYSMAN Description: HPA-6 GENOTYPING Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 81111 NOCOV DEF SYSMAN Description: HPA-9 GENOTYPING Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 81112 NOCOV DEF SYSMAN Description: HPA-15 GENOTYPING Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,081 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 81120 NOCOV DEF SYSMAN Description: IDH1 COMMON VARIANTS Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 81121 NOCOV DEF SYSMAN Description: IDH2 COMMON VARIANTS Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 81161 LAB L60 MAXFEE 01/01/2024 279.00 0.0 Y Description: DMD DUP/DELET ANALYSIS Category: Laboratory CMS Add: 01/01/2013 CMS Term: 81161 LAB L60 MAXFEE 03/16/2016 12/31/2023 140.14 0.0 Y Description: DMD DUP/DELET ANALYSIS Category: Laboratory CMS Add: 01/01/2013 CMS Term: 81162 LAB L60 MAXFEE 01/01/2020 1824.88 0.0 Y 0-1 Description: BRCA1&2 GEN FULL SEQ DUP/DEL Category: Laboratory CMS Add: 01/01/2016 CMS Term: 81163 LAB L60 MAXFEE 01/01/2019 468.00 0.0 Y 0-1 Description: BRCA1&2 GENE FULL SEQ ALYS Category: Laboratory CMS Add: 01/01/2019 CMS Term: 81164 LAB L60 MAXFEE 01/01/2019 584.23 0.0 Y 0-1 Description: BRCA1&2 GEN FUL DUP/DEL ALYS Category: Laboratory CMS Add: 01/01/2019 CMS Term: 81165 LAB L60 MAXFEE 01/01/2019 282.88 0.0 Y 0-1 Description: BRCA1 GENE FULL SEQ ALYS Category: Laboratory CMS Add: 01/01/2019 CMS Term: 81166 LAB L60 MAXFEE 01/01/2019 301.35 0.0 Y 0-1 Description: BRCA1 GENE FULL DUP/DEL ALYS Category: Laboratory CMS Add: 01/01/2019 CMS Term: 81167 LAB L60 MAXFEE 01/01/2019 282.88 0.0 Y 0-1 Description: BRCA2 GENE FULL DUP/DEL ALYS Category: Laboratory CMS Add: 01/01/2019 CMS Term: 81168 LAB L60 MAXFEE 01/01/2021 207.31 0.0 Y Description: CCND1/IGH TRANSLOCATION ALYS Category: Laboratory CMS Add: 01/01/2021 CMS Term: 81170 NOCOV DEF SYSMAN Description: ABL1 GENE Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 81171 NOCOV DEF SYSMAN Description: AFF2 GEN ALY DETC ABNL ALLEL Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 81172 NOCOV DEF SYSMAN Description: AFF2 GEN ALYS CHARAC ALLELES Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 81173 NOCOV DEF SYSMAN Description: AR GENE FULL GENE SEQUENCE Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 81174 NOCOV DEF SYSMAN Description: AR GENE KNOWN FAMIL VARIANT Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,082 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 81175 NOCOV DEF SYSMAN Description: ASXL1 FULL GENE SEQUENCE Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 81176 NOCOV DEF SYSMAN Description: ASXL1 GENE TARGET SEQ ALYS Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 81177 NOCOV DEF SYSMAN Description: ATN1 GENE DETC ABNOR ALLELES Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 81178 NOCOV DEF SYSMAN Description: ATXN1 GENE DETC ABNOR ALLELE Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 81179 NOCOV DEF SYSMAN Description: ATXN2 GENE DETC ABNOR ALLELE Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 81180 NOCOV DEF SYSMAN Description: ATXN3 GENE DETC ABNOR ALLELE Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 81181 NOCOV DEF SYSMAN Description: ATXN7 GENE DETC ABNOR ALLELE Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 81182 NOCOV DEF SYSMAN Description: ATXN8OS GEN DETC ABNOR ALLEL Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 81183 NOCOV DEF SYSMAN Description: ATXN10 GENE DETC ABNOR ALLEL Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 81184 NOCOV DEF SYSMAN Description: CACNA1A GEN DETC ABNOR ALLEL Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 81185 NOCOV DEF SYSMAN Description: CACNA1A GENE FULL GENE SEQ Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 81186 NOCOV DEF SYSMAN Description: CACNA1A GEN KNOWN FAMIL VRNT Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 81187 NOCOV DEF SYSMAN Description: CNBP GENE DETC ABNOR ALLELE Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 81188 NOCOV DEF SYSMAN Description: CSTB GENE DETC ABNOR ALLELE Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 81189 NOCOV DEF SYSMAN Description: CSTB GENE FULL GENE SEQUENCE Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 81190 NOCOV DEF SYSMAN Description: CSTB GENE KNOWN FAMIL VRNT Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,083 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 81191 NOCOV DEF SYSMAN Description: NTRK1 TRANSLOCATION ANALYSIS Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 81192 NOCOV DEF SYSMAN Description: NTRK2 TRANSLOCATION ANALYSIS Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 81193 NOCOV DEF SYSMAN Description: NTRK3 TRANSLOCATION ANALYSIS Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 81194 NOCOV DEF SYSMAN Description: NTRK TRANSLOCATION ANALYSIS Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 81200 LAB L60 MAXFEE 01/01/2018 47.25 0.0 Y 0-1 Description: ASPA GENE Category: Laboratory CMS Add: 01/01/2012 CMS Term: 81201 LAB L60 MAXFEE 01/01/2018 780.00 0.0 Y 0-1 Description: APC GENE FULL SEQUENCE Category: Laboratory CMS Add: 01/01/2013 CMS Term: 81202 LAB L60 MAXFEE 01/01/2018 280.00 0.0 Y 0-1 Description: APC GENE KNOWN FAM VARIANTS Category: Laboratory CMS Add: 01/01/2013 CMS Term: 81203 LAB L60 MAXFEE 01/01/2018 200.00 0.0 Y 0-1 Description: APC GENE DUP/DELET VARIANTS Category: Laboratory CMS Add: 01/01/2013 CMS Term: 81204 NOCOV DEF SYSMAN Description: AR GENE CHARAC ALLELES Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 81205 NOCOV DEF SYSMAN Description: BCKDHB GENE Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 81206 LAB L60 MAXFEE 01/01/2020 163.96 0.0 Y Description: BCR/ABL1 GENE MAJOR BP Category: Laboratory CMS Add: 01/01/2012 CMS Term: 81207 LAB L60 MAXFEE 01/01/2020 144.84 0.0 Y Description: BCR/ABL1 GENE MINOR BP Category: Laboratory CMS Add: 01/01/2012 CMS Term: 81208 LAB L60 MAXFEE 01/01/2018 214.62 0.0 Y Description: BCR/ABL1 GENE OTHER BP Category: Laboratory CMS Add: 01/01/2012 CMS Term: 81209 NOCOV DEF SYSMAN Description: BLM GENE Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 81210 NOCOV DEF SYSMAN Description: BRAF GENE Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 81212 LAB L60 MAXFEE 01/01/2015 12/31/2023 176.26 0.0 Y 0-1 Description: BRCA1&2 185&5385&6174 VRNT Category: Laboratory CMS Add: 01/01/2012 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,084 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 81212 LAB L60 MAXFEE 01/01/2024 440.00 0.0 Y 0-1 Description: BRCA1&2 185&5385&6174 VRNT Category: Laboratory CMS Add: 01/01/2012 CMS Term: 81215 LAB L60 MAXFEE 01/01/2015 12/31/2023 93.01 0.0 Y 0-1 Description: BRCA1 GENE KNOWN FAMIL VRNT Category: Laboratory CMS Add: 01/01/2012 CMS Term: 81215 LAB L60 MAXFEE 01/01/2024 375.25 0.0 Y 0-1 Description: BRCA1 GENE KNOWN FAMIL VRNT Category: Laboratory CMS Add: 01/01/2012 CMS Term: 81216 LAB L60 MAXFEE 01/01/2018 185.12 0.0 Y 0-1 Description: BRCA2 GENE FULL SEQ ALYS Category: Laboratory CMS Add: 01/01/2012 CMS Term: 81217 LAB L60 MAXFEE 01/01/2024 375.25 0.0 Y 0-1 Description: BRCA2 GENE KNOWN FAMIL VRNT Category: Laboratory CMS Add: 01/01/2012 CMS Term: 81217 LAB L60 MAXFEE 07/01/2015 12/31/2023 93.01 0.0 Y 0-1 Description: BRCA2 GENE KNOWN FAMIL VRNT Category: Laboratory CMS Add: 01/01/2012 CMS Term: 81218 LAB L60 MAXFEE 01/01/2020 241.90 0.0 Y 0-1 Description: CEBPA GENE FULL SEQUENCE Category: Laboratory CMS Add: 01/01/2016 CMS Term: 81219 LAB L60 MAXFEE 01/01/2020 121.63 0.0 Y 0-1 Description: CALR GENE COM VARIANTS Category: Laboratory CMS Add: 01/01/2016 CMS Term: 81220 LAB L60 MAXFEE 01/01/2018 556.60 0.0 0-1 Description: CFTR GENE COM VARIANTS Category: Laboratory CMS Add: 01/01/2012 CMS Term: 81221 NOCOV DEF SYSMAN Description: CFTR GENE KNOWN FAM VARIANTS Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 81222 NOCOV DEF SYSMAN Description: CFTR GENE DUP/DELET VARIANTS Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 81223 NOCOV DEF SYSMAN Description: CFTR GENE FULL SEQUENCE Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 81224 NOCOV DEF SYSMAN Description: CFTR GENE INTRON POLY T Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 81225 NOCOV DEF SYSMAN Description: CYP2C19 GENE COM VARIANTS Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 81226 NOCOV DEF SYSMAN Description: CYP2D6 GENE COM VARIANTS Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 81227 NOCOV DEF SYSMAN Description: CYP2C9 GENE COM VARIANTS Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,085 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 81228 LAB L60 MAXFEE 01/01/2018 900.00 0.0 Y 0-1 Description: CYTOG ALYS CHRML ABNR CGH Category: Laboratory CMS Add: 01/01/2012 CMS Term: 81229 LAB L60 MAXFEE 01/01/2018 1160.00 0.0 Y 0-1 Description: CYTOG ALYS CHRML ABNR SNPCGH Category: Laboratory CMS Add: 01/01/2012 CMS Term: 81230 LAB L60 MAXFEE 01/01/2018 174.81 0.0 Y 0-1 Description: CYP3A4 GENE COMMON VARIANTS Category: Laboratory CMS Add: 01/01/2018 CMS Term: 81231 LAB L60 MAXFEE 01/01/2018 174.81 0.0 Y 0-1 Description: CYP3A5 GENE COMMON VARIANTS Category: Laboratory CMS Add: 01/01/2018 CMS Term: 81232 LAB L60 MAXFEE 01/01/2018 174.81 0.0 Y 0-1 Description: DPYD GENE COMMON VARIANTS Category: Laboratory CMS Add: 01/01/2018 CMS Term: 81233 NOCOV DEF SYSMAN Description: BTK GENE COMMON VARIANTS Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 81234 NOCOV DEF SYSMAN Description: DMPK GENE DETC ABNOR ALLELE Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 81235 LAB L60 MAXFEE 01/01/2018 324.58 0.0 Y 0-1 Description: EGFR GENE COM VARIANTS Category: Laboratory CMS Add: 01/01/2013 CMS Term: 81236 NOCOV DEF SYSMAN Description: EZH2 GENE FULL GENE SEQUENCE Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 81237 NOCOV DEF SYSMAN Description: EZH2 GENE COMMON VARIANTS Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 81238 LAB L60 MAXFEE 01/01/2018 600.00 0.0 Y 0-1 Description: F9 FULL GENE SEQUENCE Category: Laboratory CMS Add: 01/01/2018 CMS Term: 81239 NOCOV DEF SYSMAN Description: DMPK GENE CHARAC ALLELES Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 81240 NOCOV DEF SYSMAN Description: F2 GENE Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 81241 NOCOV DEF SYSMAN Description: F5 GENE Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 81242 NOCOV DEF SYSMAN Description: FANCC GENE Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 81243 LAB L60 MAXFEE 01/01/2018 57.04 0.0 Y 0-1 Description: FMR1 GEN ALY DETC ABNL ALLEL Category: Laboratory CMS Add: 01/01/2012 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,086 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 81244 LAB L60 MAXFEE 01/01/2018 44.89 0.0 Y 0-1 Description: FMR1 GEN ALYS CHARAC ALLELES Category: Laboratory CMS Add: 01/01/2012 CMS Term: 81245 NOCOV DEF SYSMAN Description: FLT3 GENE Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 81246 LAB L60 MAXFEE 01/01/2018 83.00 0.0 Description: FLT3 GENE ANALYSIS Category: Laboratory CMS Add: 01/01/2015 CMS Term: 81247 NOCOV DEF SYSMAN Description: G6PD GENE ALYS CMN VARIANT Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 81248 NOCOV DEF SYSMAN Description: G6PD KNOWN FAMILIAL VARIANT Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 81249 NOCOV DEF SYSMAN Description: G6PD FULL GENE SEQUENCE Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 81250 NOCOV DEF SYSMAN Description: G6PC GENE Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 81251 LAB L60 MAXFEE 01/01/2018 47.25 0.0 Y 0-1 Description: GBA GENE Category: Laboratory CMS Add: 01/01/2012 CMS Term: 81252 LAB L60 MAXFEE 01/01/2018 101.12 0.0 Y Description: GJB2 GENE FULL SEQUENCE Category: Laboratory CMS Add: 01/01/2013 CMS Term: 81253 LAB L60 MAXFEE 01/01/2018 61.52 0.0 Y 0-1 Description: GJB2 GENE KNOWN FAM VARIANTS Category: Laboratory CMS Add: 01/01/2013 CMS Term: 81254 LAB L60 MAXFEE 01/01/2018 35.00 0.0 Y 0-1 Description: GJB6 GENE COM VARIANTS Category: Laboratory CMS Add: 01/01/2013 CMS Term: 81255 LAB L60 MAXFEE 01/01/2018 51.45 0.0 0-1 Description: HEXA GENE Category: Laboratory CMS Add: 01/01/2012 CMS Term: 81256 NOCOV DEF SYSMAN Description: HFE GENE Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 81257 LAB L60 MAXFEE 01/01/2018 102.26 0.0 Y Description: HBA1/HBA2 GENE Category: Laboratory CMS Add: 01/01/2012 CMS Term: 81258 LAB L60 MAXFEE 01/01/2018 375.25 0.0 Y 0-1 Description: HBA1/HBA2 GENE FAM VRNT Category: Laboratory CMS Add: 01/01/2018 CMS Term: 81259 LAB L60 MAXFEE 01/01/2018 600.00 0.0 Y 0-1 Description: HBA1/HBA2 FULL GENE SEQUENCE Category: Laboratory CMS Add: 01/01/2018 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,087 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 81260 NOCOV DEF SYSMAN Description: IKBKAP GENE Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 81261 NOCOV DEF SYSMAN Description: IGH GENE REARRANGE AMP METH Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 81262 NOCOV DEF SYSMAN Description: IGH GENE REARRANG DIR PROBE Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 81263 NOCOV DEF SYSMAN Description: IGH VARI REGIONAL MUTATION Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 81264 NOCOV DEF SYSMAN Description: IGK REARRANGEABN CLONAL POP Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 81265 NOCOV DEF SYSMAN Description: STR MARKERS SPECIMEN ANAL Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 81266 NOCOV DEF SYSMAN Description: STR MARKERS SPEC ANAL ADDL Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 81267 NOCOV DEF SYSMAN Description: CHIMERISM ANAL NO CELL SELEC Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 81268 NOCOV DEF SYSMAN Description: CHIMERISM ANAL W/CELL SELECT Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 81269 LAB L60 MAXFEE 01/01/2018 202.40 0.0 Y 0-1 Description: HBA1/HBA2 GENE DUP/DEL VRNTS Category: Laboratory CMS Add: 01/01/2018 CMS Term: 81270 LAB L60 MAXFEE 01/01/2020 91.66 0.0 Y Description: JAK2 GENE Category: Laboratory CMS Add: 01/01/2012 CMS Term: 81271 NOCOV DEF SYSMAN Description: HTT GENE DETC ABNOR ALLELES Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 81272 NOCOV DEF SYSMAN Description: KIT GENE TARGETED SEQ ANALYS Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 81273 NOCOV DEF SYSMAN Description: KIT GENE ANALYS D816 VARIANT Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 81274 NOCOV DEF SYSMAN Description: HTT GENE CHARAC ALLELES Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 81275 NOCOV DEF SYSMAN Description: KRAS GENE VARIANTS EXON 2 Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,088 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 81276 LAB L60 MAXFEE 01/01/2018 193.25 0.0 Y 0-1 Description: KRAS GENE ADDL VARIANTS Category: Laboratory CMS Add: 01/01/2016 CMS Term: 81277 LAB L60 MAXFEE 01/01/2020 1160.00 0.0 Y Description: CYTOGENOMIC NEO MICRORA ALYS Category: Laboratory CMS Add: 01/01/2020 CMS Term: 81278 LAB L60 MAXFEE 01/01/2021 207.31 0.0 Y Description: IGH@/BCL2 TRANSLOCATION ALYS Category: Laboratory CMS Add: 01/01/2021 CMS Term: 81279 LAB L60 MAXFEE 01/01/2021 185.20 0.0 Y Description: JAK2 GENE TRGT SEQUENCE ALYS Category: Laboratory CMS Add: 01/01/2021 CMS Term: 81283 NOCOV DEF SYSMAN Description: IFNL3 GENE Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 81284 NOCOV DEF SYSMAN Description: FXN GENE DETC ABNOR ALLELES Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 81285 NOCOV DEF SYSMAN Description: FXN GENE CHARAC ALLELES Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 81286 NOCOV DEF SYSMAN Description: FXN GENE FULL GENE SEQUENCE Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 81287 NOCOV DEF SYSMAN Description: MGMT GENE PRMTR MTHYLTN ALYS Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: 81288 LAB L60 MAXFEE 01/01/2024 192.32 0.0 Description: MLH1 GENE Category: Laboratory CMS Add: 01/01/2015 CMS Term: 81288 LAB L60 MAXFEE 03/16/2016 12/31/2023 159.64 0.0 Description: MLH1 GENE Category: Laboratory CMS Add: 01/01/2015 CMS Term: 81289 NOCOV DEF SYSMAN Description: FXN GENE KNOWN FAMIL VARIANT Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 81290 NOCOV DEF SYSMAN Description: MCOLN1 GENE Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 81291 NOCOV DEF SYSMAN Description: MTHFR GENE Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 81292 LAB L60 MAXFEE 01/01/2015 12/31/2023 644.62 0.0 Y 0-1 Description: MLH1 GENE FULL SEQ Category: Laboratory CMS Add: 01/01/2012 CMS Term: 81292 LAB L60 MAXFEE 01/01/2024 675.40 0.0 Y 0-1 Description: MLH1 GENE FULL SEQ Category: Laboratory CMS Add: 01/01/2012 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,089 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 81293 LAB L60 MAXFEE 01/01/2015 12/31/2023 258.41 0.0 Y 0-1 Description: MLH1 GENE KNOWN VARIANTS Category: Laboratory CMS Add: 01/01/2012 CMS Term: 81293 LAB L60 MAXFEE 01/01/2024 331.00 0.0 Y 0-1 Description: MLH1 GENE KNOWN VARIANTS Category: Laboratory CMS Add: 01/01/2012 CMS Term: 81294 LAB L60 MAXFEE 01/01/2015 12/31/2023 190.20 0.0 Y 0-1 Description: MLH1 GENE DUP/DELETE VARIANT Category: Laboratory CMS Add: 01/01/2012 CMS Term: 81294 LAB L60 MAXFEE 01/01/2024 202.40 0.0 Y 0-1 Description: MLH1 GENE DUP/DELETE VARIANT Category: Laboratory CMS Add: 01/01/2012 CMS Term: 81295 LAB L60 MAXFEE 01/01/2015 12/31/2023 151.33 0.0 Y 0-1 Description: MSH2 GENE FULL SEQ Category: Laboratory CMS Add: 01/01/2012 CMS Term: 81295 LAB L60 MAXFEE 01/01/2024 381.70 0.0 Y 0-1 Description: MSH2 GENE FULL SEQ Category: Laboratory CMS Add: 01/01/2012 CMS Term: 81296 LAB L60 MAXFEE 01/01/2015 12/31/2023 129.21 0.0 Y 0-1 Description: MSH2 GENE KNOWN VARIANTS Category: Laboratory CMS Add: 01/01/2012 CMS Term: 81296 LAB L60 MAXFEE 01/01/2024 337.73 0.0 Y 0-1 Description: MSH2 GENE KNOWN VARIANTS Category: Laboratory CMS Add: 01/01/2012 CMS Term: 81297 LAB L60 MAXFEE 01/01/2015 12/31/2023 151.33 0.0 Y 0-1 Description: MSH2 GENE DUP/DELETE VARIANT Category: Laboratory CMS Add: 01/01/2012 CMS Term: 81297 LAB L60 MAXFEE 01/01/2024 213.30 0.0 Y 0-1 Description: MSH2 GENE DUP/DELETE VARIANT Category: Laboratory CMS Add: 01/01/2012 CMS Term: 81298 LAB L60 MAXFEE 01/01/2015 12/31/2023 287.11 0.0 Y 0-1 Description: MSH6 GENE FULL SEQ Category: Laboratory CMS Add: 01/01/2012 CMS Term: 81298 LAB L60 MAXFEE 01/01/2024 641.85 0.0 Y 0-1 Description: MSH6 GENE FULL SEQ Category: Laboratory CMS Add: 01/01/2012 CMS Term: 81299 LAB L60 MAXFEE 01/01/2015 12/31/2023 160.84 0.0 Y 0-1 Description: MSH6 GENE KNOWN VARIANTS Category: Laboratory CMS Add: 01/01/2012 CMS Term: 81299 LAB L60 MAXFEE 01/01/2024 308.00 0.0 Y 0-1 Description: MSH6 GENE KNOWN VARIANTS Category: Laboratory CMS Add: 01/01/2012 CMS Term: 81300 LAB L60 MAXFEE 01/01/2015 12/31/2023 161.28 0.0 Y 0-1 Description: MSH6 GENE DUP/DELETE VARIANT Category: Laboratory CMS Add: 01/01/2012 CMS Term: 81300 LAB L60 MAXFEE 01/01/2024 238.00 0.0 Y 0-1 Description: MSH6 GENE DUP/DELETE VARIANT Category: Laboratory CMS Add: 01/01/2012 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,090 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 81301 LAB L60 MAXFEE 01/01/2019 348.56 0.0 Y 0-1 Description: MICROSATELLITE INSTABILITY Category: Laboratory CMS Add: 01/01/2012 CMS Term: 81302 LAB L60 MAXFEE 01/01/2018 527.87 0.0 Y 0-1 Description: MECP2 GENE FULL SEQ Category: Laboratory CMS Add: 01/01/2012 CMS Term: 81303 LAB L60 MAXFEE 01/01/2018 120.00 0.0 Y 0-1 Description: MECP2 GENE KNOWN VARIANT Category: Laboratory CMS Add: 01/01/2012 CMS Term: 81304 LAB L60 MAXFEE 01/01/2018 150.00 0.0 Y 0-1 Description: MECP2 GENE DUP/DELET VARIANT Category: Laboratory CMS Add: 01/01/2012 CMS Term: 81305 NOCOV DEF SYSMAN Description: MYD88 GENE P.LEU265PRO VRNT Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 81306 NOCOV DEF SYSMAN Description: NUDT15 GENE COMMON VARIANTS Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 81307 LAB L60 MAXFEE 01/01/2020 12/31/2023 282.88 0.0 Y Description: PALB2 GENE FULL GENE SEQ Category: Laboratory CMS Add: 01/01/2020 CMS Term: 81307 LAB L60 MAXFEE 01/01/2024 676.50 0.0 Y Description: PALB2 GENE FULL GENE SEQ Category: Laboratory CMS Add: 01/01/2020 CMS Term: 81308 LAB L60 MAXFEE 01/01/2020 301.35 0.0 Y Description: PALB2 GENE KNOWN FAMIL VRNT Category: Laboratory CMS Add: 01/01/2020 CMS Term: 81309 LAB L60 MAXFEE 01/01/2020 274.83 0.0 Y Description: PIK3CA GENE TRGT SEQ ALYS Category: Laboratory CMS Add: 01/01/2020 CMS Term: 81310 LAB L60 MAXFEE 01/01/2015 246.52 0.0 Y 0-1 Description: NPM1 GENE Category: Laboratory CMS Add: 01/01/2012 CMS Term: 81311 LAB L60 MAXFEE 01/01/2016 295.79 0.0 Y 0-1 Description: NRAS GENE VARIANTS EXON 2&3 Category: Laboratory CMS Add: 01/01/2016 CMS Term: 81312 NOCOV DEF SYSMAN Description: PABPN1 GENE DETC ABNOR ALLEL Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 81313 NOCOV DEF SYSMAN Description: PCA3/KLK3 ANTIGEN Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 81314 NOCOV DEF SYSMAN Description: PDGFRA GENE Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 81315 LAB L60 MAXFEE 01/01/2020 207.31 0.0 Y 0-1 Description: PML/RARALPHA COM BREAKPOINTS Category: Laboratory CMS Add: 01/01/2012 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,091 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 81316 LAB L60 MAXFEE 01/01/2020 207.31 0.0 Y 0-1 Description: PML/RARALPHA 1 BREAKPOINT Category: Laboratory CMS Add: 01/01/2012 CMS Term: 81317 LAB L60 MAXFEE 01/01/2019 676.50 0.0 Y 0-1 Description: PMS2 GENE FULL SEQ ANALYSIS Category: Laboratory CMS Add: 01/01/2012 CMS Term: 81318 LAB L60 MAXFEE 01/01/2015 12/31/2023 184.15 0.0 Y 0-1 Description: PMS2 KNOWN FAMILIAL VARIANTS Category: Laboratory CMS Add: 01/01/2012 CMS Term: 81318 LAB L60 MAXFEE 01/01/2024 331.00 0.0 Y 0-1 Description: PMS2 KNOWN FAMILIAL VARIANTS Category: Laboratory CMS Add: 01/01/2012 CMS Term: 81319 LAB L60 MAXFEE 01/01/2018 203.50 0.0 Y 0-1 Description: PMS2 GENE DUP/DELET VARIANTS Category: Laboratory CMS Add: 01/01/2012 CMS Term: 81320 NOCOV DEF SYSMAN Description: PLCG2 GENE COMMON VARIANTS Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 81321 LAB L60 MAXFEE 01/01/2015 12/31/2023 599.20 0.0 Y 0-1 Description: PTEN GENE FULL SEQUENCE Category: Laboratory CMS Add: 01/01/2013 CMS Term: 81321 LAB L60 MAXFEE 01/01/2024 600.00 0.0 Y 0-1 Description: PTEN GENE FULL SEQUENCE Category: Laboratory CMS Add: 01/01/2013 CMS Term: 81322 LAB L60 MAXFEE 01/01/2020 46.60 0.0 Y 0-1 Description: PTEN GENE KNOWN FAM VARIANT Category: Laboratory CMS Add: 01/01/2013 CMS Term: 81323 LAB L60 MAXFEE 01/01/2015 12/31/2023 87.38 0.0 Y 0-1 Description: PTEN GENE DUP/DELET VARIANT Category: Laboratory CMS Add: 01/01/2013 CMS Term: 81323 LAB L60 MAXFEE 01/01/2024 300.00 0.0 Y 0-1 Description: PTEN GENE DUP/DELET VARIANT Category: Laboratory CMS Add: 01/01/2013 CMS Term: 81324 NOCOV DEF SYSMAN Description: PMP22 GENE DUP/DELET Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 81325 NOCOV DEF SYSMAN Description: PMP22 GENE FULL SEQUENCE Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 81326 NOCOV DEF SYSMAN Description: PMP22 GENE KNOWN FAM VARIANT Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 81327 NOCOV DEF SYSMAN Description: SEPT9 GEN PRMTR MTHYLTN ALYS Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: 81328 LAB L60 MAXFEE 01/01/2018 174.81 0.0 Y 0-1 Description: SLCO1B1 GENE COM VARIANTS Category: Laboratory CMS Add: 01/01/2018 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,092 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 81329 LAB L60 MAXFEE 12/01/2022 137.00 0.0 Description: SMN1 GENE DOS/DELETION ALYS Category: Laboratory CMS Add: 01/01/2019 CMS Term: 81330 LAB L60 MAXFEE 01/01/2018 47.00 0.0 Y Description: SMPD1 GENE COMMON VARIANTS Category: Laboratory CMS Add: 01/01/2012 CMS Term: 81331 NOCOV DEF SYSMAN Description: SNRPN/UBE3A GENE Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 81332 NOCOV DEF SYSMAN Description: SERPINA1 GENE Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 81333 NOCOV DEF SYSMAN Description: TGFBI GENE COMMON VARIANTS Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 81334 NOCOV DEF SYSMAN Description: RUNX1 GENE TARGETED SEQ ALYS Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 81335 LAB L60 MAXFEE 01/01/2018 174.81 0.0 Y 0-1 Description: TPMT GENE COM VARIANTS Category: Laboratory CMS Add: 01/01/2018 CMS Term: 81336 NOCOV DEF SYSMAN Description: SMN1 GENE FULL GENE SEQUENCE Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 81337 NOCOV DEF SYSMAN Description: SMN1 GEN NOWN FAMIL SEQ VRNT Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 81338 LAB L60 MAXFEE 06/30/2023 150.33 0.0 Y Description: MPL GENE COMMON VARIANTS Category: Laboratory CMS Add: 01/01/2021 CMS Term: 81339 NOCOV DEF SYSMAN Description: MPL GENE SEQ ALYS EXON 10 Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 81340 NOCOV DEF SYSMAN Description: TRB@ GENE REARRANGE AMPLIFY Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 81341 NOCOV DEF SYSMAN Description: TRB@ GENE REARRANGE DIRPROBE Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 81342 NOCOV DEF SYSMAN Description: TRG GENE REARRANGEMENT ANAL Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 81343 NOCOV DEF SYSMAN Description: PPP2R2B GEN DETC ABNOR ALLEL Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 81344 NOCOV DEF SYSMAN Description: TBP GENE DETC ABNOR ALLELES Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,093 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 81345 NOCOV DEF SYSMAN Description: TERT GENE TARGETED SEQ ALYS Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 81346 LAB L60 MAXFEE 01/01/2018 174.81 0.0 Y 0-1 Description: TYMS GENE COM VARIANTS Category: Laboratory CMS Add: 01/01/2018 CMS Term: 81347 NOCOV DEF SYSMAN Description: SF3B1 GENE COMMON VARIANTS Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 81348 NOCOV DEF SYSMAN Description: SRSF2 GENE COMMON VARIANTS Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 81349 NOCOV DEF SYSMAN Description: CYTOG ALYS CHRML ABNR LW-PS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 81350 NOCOV DEF SYSMAN Description: UGT1A1 GENE COMMON VARIANTS Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 81351 NOCOV DEF SYSMAN Description: TP53 GENE FULL GENE SEQUENCE Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 81352 NOCOV DEF SYSMAN Description: TP53 GENE TRGT SEQUENCE ALYS Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 81353 NOCOV DEF SYSMAN Description: TP53 GENE KNOWN FAMIL VRNT Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 81355 NOCOV DEF SYSMAN Description: VKORC1 GENE Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 81357 NOCOV DEF SYSMAN Description: U2AF1 GENE COMMON VARIANTS Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 81360 NOCOV DEF SYSMAN Description: ZRSR2 GENE COMMON VARIANTS Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 81361 LAB L60 MAXFEE 12/01/2022 174.81 0.0 Description: HBB GENE COM VARIANTS Category: Laboratory CMS Add: 01/01/2018 CMS Term: 81362 NOCOV DEF SYSMAN Description: HBB GENE KNOWN FAM VARIANT Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 81363 NOCOV DEF SYSMAN Description: HBB GENE DUP/DEL VARIANTS Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 81364 LAB L60 MAXFEE 01/01/2018 324.58 0.0 Y Description: HBB FULL GENE SEQUENCE Category: Laboratory CMS Add: 01/01/2018 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,094 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 81370 NOCOV DEF SYSMAN Description: HLA I & II TYPING LR Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 81371 NOCOV DEF SYSMAN Description: HLA I & II TYPE VERIFY LR Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 81372 NOCOV DEF SYSMAN Description: HLA I TYPING COMPLETE LR Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 81373 NOCOV DEF SYSMAN Description: HLA I TYPING 1 LOCUS LR Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 81374 NOCOV DEF SYSMAN Description: HLA I TYPING 1 ANTIGEN LR Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 81375 NOCOV DEF SYSMAN Description: HLA II TYPING AG EQUIV LR Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 81376 NOCOV DEF SYSMAN Description: HLA II TYPING 1 LOCUS LR Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 81377 NOCOV DEF SYSMAN Description: HLA II TYPE 1 AG EQUIV LR Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 81378 NOCOV DEF SYSMAN Description: HLA I & II TYPING HR Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 81379 NOCOV DEF SYSMAN Description: HLA I TYPING COMPLETE HR Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 81380 NOCOV DEF SYSMAN Description: HLA I TYPING 1 LOCUS HR Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 81381 NOCOV DEF SYSMAN Description: HLA I TYPING 1 ALLELE HR Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 81382 NOCOV DEF SYSMAN Description: HLA II TYPING 1 LOC HR Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 81383 NOCOV DEF SYSMAN Description: HLA II TYPING 1 ALLELE HR Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 81400 NOCOV DEF SYSMAN Description: MOPATH PROCEDURE LEVEL 1 Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 81401 NOCOV DEF SYSMAN Description: MOPATH PROCEDURE LEVEL 2 Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,095 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 81402 NOCOV DEF SYSMAN Description: MOPATH PROCEDURE LEVEL 3 Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 81403 LAB L60 MAXFEE 01/01/2018 185.20 0.0 Y Description: MOPATH PROCEDURE LEVEL 4 Category: Laboratory CMS Add: 01/01/2012 CMS Term: 81404 LAB L60 MAXFEE 01/01/2018 274.83 0.0 Y Description: MOPATH PROCEDURE LEVEL 5 Category: Laboratory CMS Add: 01/01/2012 CMS Term: 81405 LAB L60 MAXFEE 01/01/2018 301.35 0.0 Y Description: MOPATH PROCEDURE LEVEL 6 Category: Laboratory CMS Add: 01/01/2012 CMS Term: 81406 NOCOV DEF SYSMAN Description: MOPATH PROCEDURE LEVEL 7 Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 81407 LAB L60 MAXFEE 01/01/2018 846.27 0.0 Y Description: MOPATH PROCEDURE LEVEL 8 Category: Laboratory CMS Add: 01/01/2012 CMS Term: 81408 NOCOV DEF SYSMAN Description: MOPATH PROCEDURE LEVEL 9 Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 81410 NOCOV DEF SYSMAN Description: AORTIC DYSFUNCTION/DILATION Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 81411 NOCOV DEF SYSMAN Description: AORTIC DYSFUNCTION/DILATION Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 81412 NOCOV DEF SYSMAN Description: ASHKENAZI JEWISH ASSOC DIS Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 81413 NOCOV DEF SYSMAN Description: CAR ION CHNNLPATH INC 10 GNS Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: 81414 NOCOV DEF SYSMAN Description: CAR ION CHNNLPATH INC 2 GNS Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: 81415 NOCOV DEF SYSMAN Description: EXOME SEQUENCE ANALYSIS Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 81416 NOCOV DEF SYSMAN Description: EXOME SEQUENCE ANALYSIS Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 81417 NOCOV DEF SYSMAN Description: EXOME RE-EVALUATION Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 81418 NOCOV DEF SYSMAN Description: RX METAB GEN SEQ ALYS PNL 6 Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,096 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 81419 NOCOV DEF SYSMAN Description: EPILEPSY GEN SEQ ALYS PANEL Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 81420 LAB L60 MAXFEE 01/01/2018 759.05 0.0 Description: FETAL CHRMOML ANEUPLOIDY Category: Laboratory CMS Add: 01/01/2015 CMS Term: 81422 NOCOV DEF SYSMAN Description: FETAL CHRMOML MICRODELTJ Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: 81425 NOCOV DEF SYSMAN Description: GENOME SEQUENCE ANALYSIS Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 81426 NOCOV DEF SYSMAN Description: GENOME SEQUENCE ANALYSIS Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 81427 NOCOV DEF SYSMAN Description: GENOME RE-EVALUATION Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 81430 NOCOV DEF SYSMAN Description: HEARING LOSS SEQUENCE ANALYS Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 81431 NOCOV DEF SYSMAN Description: HEARING LOSS DUP/DEL ANALYS Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 81432 NOCOV DEF SYSMAN Description: HRDTRY BRST CA-RLATD DSORDRS Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 81433 NOCOV DEF SYSMAN Description: HRDTRY BRST CA-RLATD DSORDRS Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 81434 NOCOV DEF SYSMAN Description: HEREDITARY RETINAL DISORDERS Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 81435 NOCOV DEF SYSMAN Description: HEREDITARY COLON CA DSORDRS Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 81436 NOCOV DEF SYSMAN Description: HEREDITARY COLON CA DSORDRS Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 81437 NOCOV DEF SYSMAN Description: HEREDTRY NURONDCRN TUM DSRDR Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 81438 NOCOV DEF SYSMAN Description: HEREDTRY NURONDCRN TUM DSRDR Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 81439 LAB L60 MAXFEE 01/01/2020 584.90 0.0 Y 0-1 Description: HRDTRY CARDMYPY GENE PANEL Category: Laboratory CMS Add: 01/01/2017 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,097 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 81440 NOCOV DEF SYSMAN Description: MITOCHONDRIAL GENE Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 81441 NOCOV DEF SYSMAN Description: IBMFS SEQ ALYS PNL 30 GENES Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 81442 NOCOV DEF SYSMAN Description: NOONAN SPECTRUM DISORDERS Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 81443 NOCOV DEF SYSMAN Description: GENETIC TSTG SEVERE INH COND Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 81445 NOCOV DEF SYSMAN Description: SO NEO GSAP 5-50DNA/DNA&RNA Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 81448 NOCOV DEF SYSMAN Description: HRDTRY PERPH NEURPHY PANEL Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 81449 NOCOV DEF SYSMAN Description: SO NEO GSAP 5-50 RNA ALYS Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 81450 NOCOV DEF SYSMAN Description: HL NEO GSAP 5-50DNA/DNA&RNA Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 81451 NOCOV DEF SYSMAN Description: HL NEO GSAP 5-50 RNA ALYS Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 81455 NOCOV DEF SYSMAN Description: SO/HL 51/>GSAP DNA/DNA&RNA Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 81456 NOCOV DEF SYSMAN Description: SO/HL 51/>GSAP RNA ALYS Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 81457 NOCOV DEF SYSMAN Description: SO NEO GSAP DNA MCRSTL INS Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 81458 NOCOV DEF SYSMAN Description: SO GSAP DNA CPY NMBR&MCRSTL Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 81459 NOCOV DEF SYSMAN Description: SO NEO GSAP DNA/DNA&RNA Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 81460 NOCOV DEF SYSMAN Description: WHOLE MITOCHONDRIAL GENOME Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 81462 NOCOV DEF SYSMAN Description: SO GSAP CLL FR DNA/DNA&RNA Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,098 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 81463 NOCOV DEF SYSMAN Description: SO GSAP CL FR CPY NMBR&MCRST Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 81464 NOCOV DEF SYSMAN Description: SO GSAP CLL FR MCRSTL INS Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 81465 NOCOV DEF SYSMAN Description: WHOLE MITOCHONDRIAL GENOME Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 81470 NOCOV DEF SYSMAN Description: X-LINKED INTELLECTUAL DBLT Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 81471 NOCOV DEF SYSMAN Description: X-LINKED INTELLECTUAL DBLT Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 81479 LAB DEF BILL90 Y Description: UNLISTED MOLECULAR PATHOLOGY Category: Laboratory CMS Add: 01/01/2013 CMS Term: 81490 NOCOV DEF SYSMAN Description: AUTOIMMUNE RA ALYS 12 BMRK Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 81493 NOCOV DEF SYSMAN Description: COR ARTERY DISEASE MRNA Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 81500 NOCOV DEF SYSMAN Description: ONCO (OVAR) TWO PROTEINS Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 81503 NOCOV DEF SYSMAN Description: ONCO (OVAR) FIVE PROTEINS Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 81504 LAB L60 MAXFEE 01/01/2018 520.00 0.0 Y Description: ONCOLOGY TISSUE OF ORIGIN Category: Laboratory CMS Add: 01/01/2014 CMS Term: 81506 NOCOV DEF SYSMAN Description: ENDO ASSAY SEVEN ANAL Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 81507 LAB L60 MAXFEE 01/01/2018 795.00 0.0 Description: FETAL ANEUPLOIDY TRISOM RISK Category: Laboratory CMS Add: 01/01/2014 CMS Term: 81508 NOCOV DEF SYSMAN Description: FTL CGEN ABNOR TWO PROTEINS Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 81509 NOCOV DEF SYSMAN Description: FTL CGEN ABNOR 3 PROTEINS Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 81510 NOCOV DEF SYSMAN Description: FTL CGEN ABNOR THREE ANAL Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,099 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 81511 NOCOV DEF SYSMAN Description: FTL CGEN ABNOR FOUR ANAL Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 81512 NOCOV DEF SYSMAN Description: FTL CGEN ABNOR FIVE ANAL Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 81513 LAB L60 MAXFEE 01/16/2023 142.63 0.0 Description: NFCT DS BV RNA VAG FLU ALG Category: Laboratory CMS Add: 01/01/2021 CMS Term: 81514 NOCOV DEF SYSMAN Description: NFCT DS BV&VAGINITIS DNA ALG Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 81517 NOCOV DEF SYSMAN Description: LIVER DS ALYS 3 BMRK SRM ALG Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 81518 NOCOV DEF SYSMAN Description: ONC BRST MRNA 11 GENES Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 81519 LAB L60 MAXFEE 01/01/2024 3873.00 0.0 Y Description: ONCOLOGY BREAST MRNA Category: Laboratory CMS Add: 01/01/2015 CMS Term: 81519 LAB L60 MAXFEE 03/16/2016 12/31/2023 3419.42 0.0 Y Description: ONCOLOGY BREAST MRNA Category: Laboratory CMS Add: 01/01/2015 CMS Term: 81520 NOCOV DEF SYSMAN Description: ONC BREAST MRNA 58 GENES Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 81521 NOCOV DEF SYSMAN Description: ONC BREAST MRNA 70 GENES Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 81522 LAB L60 MAXFEE 01/01/2020 3873.00 0.0 Y Description: ONC BREAST MRNA 12 GENES Category: Laboratory CMS Add: 01/01/2020 CMS Term: 81523 NOCOV DEF SYSMAN Description: ONC BRST MRNA 70 CNT 31 GENE Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 81525 NOCOV DEF SYSMAN Description: ONCOLOGY COLON MRNA Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 81528 LAB L60 MAXFEE 01/01/2018 508.87 0.0 45-75years Description: ONCOLOGY COLORECTAL SCR Category: Laboratory CMS Add: 01/01/2016 CMS Term: 81529 NOCOV DEF SYSMAN Description: ONC CUTAN MLNMA MRNA 31 GENE Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 81535 NOCOV DEF SYSMAN Description: ONCOLOGY GYNECOLOGIC Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,100 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 81536 NOCOV DEF SYSMAN Description: ONCOLOGY GYNECOLOGIC Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 81538 NOCOV DEF SYSMAN Description: ONCOLOGY LUNG Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 81539 NOCOV DEF SYSMAN Description: ONCOLOGY PROSTATE PROB SCORE Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: 81540 NOCOV DEF SYSMAN Description: ONCOLOGY TUM UNKNOWN ORIGIN Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 81541 NOCOV DEF SYSMAN Description: ONC PROSTATE MRNA 46 GENES Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 81542 NOCOV DEF SYSMAN Description: ONC PROSTATE MRNA 22 CNT GEN Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 81546 LAB L60 MAXFEE 01/20/2023 3600.00 0.0 Y Description: ONC THYR MRNA 10,196 GEN ALG Category: Laboratory CMS Add: 01/01/2021 CMS Term: 81551 NOCOV DEF SYSMAN Description: ONC PROSTATE 3 GENES Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 81552 NOCOV DEF SYSMAN Description: ONC UVEAL MLNMA MRNA 15 GENE Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 81554 NOCOV DEF SYSMAN Description: PULM DS IPF MRNA 190 GEN ALG Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 81560 NOCOV DEF SYSMAN Description: TRNSPLJ PD LVR&BWL CD154+CLL Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 81595 NOCOV DEF SYSMAN Description: CARDIOLOGY HRT TRNSPL MRNA Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 81596 NOCOV DEF SYSMAN Description: NFCT DS CHRNC HCV 6 ASSAYS Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 81599 NOCOV DEF SYSMAN Description: UNLISTED MAAA Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 82009 LAB L60 MAXFEE 01/01/2020 4.52 0.0 Description: TEST FOR ACETONE/KETONES Category: Laboratory CMS Add: 01/01/1982 CMS Term: 82010 LAB L60 MAXFEE 01/01/2020 8.17 0.0 Description: ACETONE ASSAY Category: Laboratory CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,101 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 82013 LAB L60 MAXFEE 01/01/2020 12.29 0.0 Description: ACETYLCHOLINESTERASE ASSAY Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82016 LAB L60 MAXFEE 01/01/2019 16.49 0.0 Description: ACYLCARNITINES QUAL Category: Laboratory CMS Add: 01/01/1999 CMS Term: 82017 LAB L60 MAXFEE 01/01/2020 16.87 0.0 Description: ACYLCARNITINES QUANT Category: Laboratory CMS Add: 01/01/1999 CMS Term: 82024 LAB L60 MAXFEE 01/01/2020 38.62 0.0 Description: ASSAY OF ACTH Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82030 LAB L60 MAXFEE 01/01/2020 25.80 0.0 Description: ASSAY OF ADP & AMP Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82040 LAB L60 MAXFEE 01/01/2020 4.95 0.0 Description: ASSAY OF SERUM ALBUMIN Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82042 LAB L60 MAXFEE 01/01/2015 12/31/2023 7.04 0.0 Description: OTHER SOURCE ALBUMIN QUAN EA Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82042 LAB L60 MAXFEE 01/01/2024 7.78 0.0 Description: OTHER SOURCE ALBUMIN QUAN EA Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82043 LAB L60 MAXFEE 01/01/2020 5.78 0.0 Description: UR ALBUMIN QUANTITATIVE Category: Laboratory CMS Add: 01/01/1993 CMS Term: 82044 LAB L60 MAXFEE 01/01/2015 12/31/2023 3.95 0.0 Description: UR ALBUMIN SEMIQUANTITATIVE Category: Laboratory CMS Add: 01/01/1993 CMS Term: 82044 LAB L60 MAXFEE 01/01/2024 6.23 0.0 Description: UR ALBUMIN SEMIQUANTITATIVE Category: Laboratory CMS Add: 01/01/1993 CMS Term: 82045 LAB L60 MAXFEE 01/01/2020 33.94 0.0 Description: ALBUMIN ISCHEMIA MODIFIED Category: Laboratory CMS Add: 01/01/2005 CMS Term: 82075 LAB L60 MAXFEE 01/01/2015 12/31/2023 16.40 0.0 Description: ASSAY OF BREATH ETHANOL Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82075 LAB L60 MAXFEE 01/01/2024 30.00 0.0 Description: ASSAY OF BREATH ETHANOL Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82077 LAB L60 MAXFEE 01/01/2021 17.27 0.0 Description: ASSAY SPEC XCP UR&BREATH IA Category: Laboratory CMS Add: 01/01/2021 CMS Term: 82085 LAB L60 MAXFEE 01/01/2020 9.71 0.0 Description: ASSAY OF ALDOLASE Category: Laboratory CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,102 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 82088 LAB L60 MAXFEE 01/01/2020 40.75 0.0 Description: ASSAY OF ALDOSTERONE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82103 LAB L60 MAXFEE 01/01/2020 13.44 0.0 Description: ALPHA-1-ANTITRYPSIN TOTAL Category: Laboratory CMS Add: 01/01/1993 CMS Term: 82104 LAB L60 MAXFEE 01/01/2020 14.46 0.0 Description: ALPHA-1-ANTITRYPSIN PHENO Category: Laboratory CMS Add: 01/01/1993 CMS Term: 82105 LAB L60 MAXFEE 01/01/2020 16.77 0.0 Description: ALPHA-FETOPROTEIN SERUM Category: Laboratory CMS Add: 01/01/1993 CMS Term: 82106 LAB L60 MAXFEE 01/01/2020 17.00 0.0 Description: ALPHA-FETOPROTEIN AMNIOTIC Category: Laboratory CMS Add: 01/01/1993 CMS Term: 82107 LAB L60 MAXFEE 01/01/2020 64.41 0.0 Description: ALPHA-FETOPROTEIN L3 Category: Laboratory CMS Add: 01/01/2007 CMS Term: 82108 LAB L60 MAXFEE 01/01/2020 25.48 0.0 Description: ASSAY OF ALUMINUM Category: Laboratory CMS Add: 01/01/1988 CMS Term: 82120 LAB L60 MAXFEE 01/01/2015 12/31/2023 5.12 0.0 Description: AMINES VAGINAL FLUID QUAL Category: Laboratory CMS Add: 01/01/2000 CMS Term: 82120 LAB L60 MAXFEE 01/01/2024 5.99 0.0 Description: AMINES VAGINAL FLUID QUAL Category: Laboratory CMS Add: 01/01/2000 CMS Term: 82127 LAB L60 MAXFEE 01/01/2020 14.18 0.0 Description: AMINO ACID SINGLE QUAL Category: Laboratory CMS Add: 01/01/1999 CMS Term: 82128 LAB L60 MAXFEE 01/01/2020 13.87 0.0 Description: AMINO ACIDS MULT QUAL Category: Laboratory CMS Add: 01/01/1985 CMS Term: 82131 LAB L60 MAXFEE 01/01/2018 22.98 0.0 Description: AMINO ACIDS SINGLE QUANT Category: Laboratory CMS Add: 01/01/1993 CMS Term: 82135 LAB L60 MAXFEE 01/01/2020 16.45 0.0 Description: ASSAY AMINOLEVULINIC ACID Category: Laboratory CMS Add: 01/01/1985 CMS Term: 82136 LAB L60 MAXFEE 01/01/2019 19.61 0.0 Description: AMINO ACIDS QUANT 2-5 Category: Laboratory CMS Add: 01/01/1999 CMS Term: 82139 LAB L60 MAXFEE 01/01/2020 16.87 0.0 Description: AMINO ACIDS QUAN 6 OR MORE Category: Laboratory CMS Add: 01/01/1999 CMS Term: 82140 LAB L60 MAXFEE 01/01/2020 14.57 0.0 Description: ASSAY OF AMMONIA Category: Laboratory CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,103 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 82143 LAB L60 MAXFEE 01/01/2015 12/31/2023 8.60 0.0 Description: AMNIOTIC FLUID SCAN Category: Laboratory CMS Add: 01/01/1982 CMS Term: 82143 LAB L60 MAXFEE 01/01/2024 9.35 0.0 Description: AMNIOTIC FLUID SCAN Category: Laboratory CMS Add: 01/01/1982 CMS Term: 82150 LAB L60 MAXFEE 01/01/2020 6.48 0.0 Description: ASSAY OF AMYLASE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82150 MRT L60 MAXFEE 01/01/2020 6.48 0.0 Description: ASSAY OF AMYLASE Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 82154 LAB L60 MAXFEE 01/01/2020 28.83 0.0 Description: ANDROSTANEDIOL GLUCURONIDE Category: Laboratory CMS Add: 01/01/1994 CMS Term: 82157 LAB L60 MAXFEE 01/01/2020 29.28 0.0 Description: ASSAY OF ANDROSTENEDIONE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82160 LAB L60 MAXFEE 01/01/2020 25.55 0.0 Description: ASSAY OF ANDROSTERONE Category: Laboratory CMS Add: 01/01/1985 CMS Term: 82163 LAB L60 MAXFEE 01/01/2020 20.52 0.0 Description: ASSAY OF ANGIOTENSIN II Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82164 LAB L60 MAXFEE 01/01/2020 14.60 0.0 Description: ANGIOTENSIN I ENZYME TEST Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82166 NOCOV DEF SYSMAN Description: ASSAY ANTI-MULLERIAN HORM Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 82172 LAB L60 MAXFEE 01/01/2015 12/31/2023 6.40 0.0 Description: ASSAY OF APOLIPOPROTEIN Category: Laboratory CMS Add: 01/01/1987 CMS Term: 82172 LAB L60 MAXFEE 01/01/2024 21.09 0.0 Description: ASSAY OF APOLIPOPROTEIN Category: Laboratory CMS Add: 01/01/1987 CMS Term: 82175 LAB L60 MAXFEE 01/01/2020 18.97 0.0 Description: ASSAY OF ARSENIC Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82180 LAB L60 MAXFEE 01/01/2020 9.89 0.0 Description: ASSAY OF ASCORBIC ACID Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82190 LAB L60 MAXFEE 01/01/2020 15.90 0.0 Description: ATOMIC ABSORPTION Category: Laboratory CMS Add: 01/01/1993 CMS Term: 82232 LAB L60 MAXFEE 01/01/2020 16.18 0.0 Description: ASSAY OF BETA-2 PROTEIN Category: Laboratory CMS Add: 01/01/1983 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,104 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 82239 LAB L60 MAXFEE 01/01/2020 17.12 0.0 Description: BILE ACIDS TOTAL Category: Laboratory CMS Add: 01/01/1993 CMS Term: 82240 LAB L60 MAXFEE 01/01/2015 12/31/2023 4.70 0.0 Description: BILE ACIDS CHOLYLGLYCINE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82240 LAB L60 MAXFEE 01/01/2024 26.58 0.0 Description: BILE ACIDS CHOLYLGLYCINE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82247 LAB L60 MAXFEE 01/01/2020 5.02 0.0 Description: BILIRUBIN TOTAL Category: Laboratory CMS Add: 01/01/1999 CMS Term: 82248 LAB L60 MAXFEE 01/01/2020 5.02 0.0 Description: BILIRUBIN DIRECT Category: Laboratory CMS Add: 01/01/1999 CMS Term: 82252 LAB L60 MAXFEE 01/01/2020 4.56 0.0 Description: FECAL BILIRUBIN TEST Category: Laboratory CMS Add: 01/01/1985 CMS Term: 82261 LAB L60 MAXFEE 01/01/2020 16.87 0.0 Description: ASSAY OF BIOTINIDASE Category: Laboratory CMS Add: 01/01/1999 CMS Term: 82270 LAB L60 MAXFEE 01/01/2018 4.38 0.0 Description: OCCULT BLOOD FECES Category: Laboratory CMS Add: 01/01/1985 CMS Term: 82271 LAB L60 MAXFEE 01/01/2015 12/31/2023 4.43 0.0 Description: OCCULT BLOOD OTHER SOURCES Category: Laboratory CMS Add: 01/01/2006 CMS Term: 82271 LAB L60 MAXFEE 01/01/2024 5.32 0.0 Description: OCCULT BLOOD OTHER SOURCES Category: Laboratory CMS Add: 01/01/2006 CMS Term: 82272 LAB L60 MAXFEE 01/01/2018 4.23 0.0 Description: OCCULT BLD FECES 1-3 TESTS Category: Laboratory CMS Add: 01/01/2006 CMS Term: 82274 LAB L60 MAXFEE 01/01/2020 15.92 0.0 Description: ASSAY TEST FOR BLOOD FECAL Category: Laboratory CMS Add: 01/01/2002 CMS Term: 82286 LAB L60 MAXFEE 01/01/2020 5.16 0.0 Description: ASSAY OF BRADYKININ Category: Laboratory CMS Add: 01/01/1982 CMS Term: 82300 LAB L60 MAXFEE 01/01/2020 23.64 0.0 Description: ASSAY OF CADMIUM Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82306 LAB L60 MAXFEE 01/01/2020 29.60 0.0 Description: VITAMIN D 25 HYDROXY Category: Laboratory CMS Add: 01/01/1985 CMS Term: 82308 LAB L60 MAXFEE 01/01/2020 26.79 0.0 Description: ASSAY OF CALCITONIN Category: Laboratory CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,105 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 82310 LAB L60 MAXFEE 01/01/2020 5.16 0.0 Description: ASSAY OF CALCIUM Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82330 LAB L60 MAXFEE 01/01/2015 12/31/2023 9.62 0.0 Description: ASSAY OF CALCIUM Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82330 LAB L60 MAXFEE 01/01/2024 13.68 0.0 Description: ASSAY OF CALCIUM Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82331 LAB L60 MAXFEE 01/01/2015 12/31/2023 7.04 0.0 Description: CALCIUM INFUSION TEST Category: Laboratory CMS Add: 01/01/1985 CMS Term: 82331 LAB L60 MAXFEE 01/01/2024 13.34 0.0 Description: CALCIUM INFUSION TEST Category: Laboratory CMS Add: 01/01/1985 CMS Term: 82340 LAB L60 MAXFEE 01/01/2015 12/31/2023 5.60 0.0 Description: ASSAY OF CALCIUM IN URINE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82340 LAB L60 MAXFEE 01/01/2024 6.03 0.0 Description: ASSAY OF CALCIUM IN URINE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82355 LAB L60 MAXFEE 01/01/2020 11.58 0.0 Description: CALCULUS ANALYSIS QUAL Category: Laboratory CMS Add: 01/01/1982 CMS Term: 82360 LAB L60 MAXFEE 01/01/2015 12/31/2023 10.11 0.0 Description: CALCULUS ASSAY QUANT Category: Laboratory CMS Add: 01/01/1982 CMS Term: 82360 LAB L60 MAXFEE 01/01/2024 12.87 0.0 Description: CALCULUS ASSAY QUANT Category: Laboratory CMS Add: 01/01/1982 CMS Term: 82365 LAB L60 MAXFEE 01/01/2020 12.90 0.0 Description: CALCULUS SPECTROSCOPY Category: Laboratory CMS Add: 01/01/1985 CMS Term: 82370 LAB L60 MAXFEE 01/01/2020 12.52 0.0 Description: X-RAY ASSAY CALCULUS Category: Laboratory CMS Add: 01/01/1985 CMS Term: 82373 LAB L60 MAXFEE 01/01/2001 12/31/2023 9.95 0.0 Description: ASSAY C-D TRANSFER MEASURE Category: Laboratory CMS Add: 01/01/2001 CMS Term: 82373 LAB L60 MAXFEE 01/01/2024 18.06 0.0 Description: ASSAY C-D TRANSFER MEASURE Category: Laboratory CMS Add: 01/01/2001 CMS Term: 82374 LAB L60 MAXFEE 01/01/2015 12/31/2023 4.70 0.0 Description: ASSAY BLOOD CARBON DIOXIDE Category: Laboratory CMS Add: 01/01/1985 CMS Term: 82374 LAB L60 MAXFEE 01/01/2024 4.88 0.0 Description: ASSAY BLOOD CARBON DIOXIDE Category: Laboratory CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,106 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 82375 LAB L60 MAXFEE 01/01/2020 12.32 0.0 Description: ASSAY CARBOXYHB QUANT Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82376 LAB L60 MAXFEE 01/01/2015 12/31/2023 8.15 0.0 Description: ASSAY CARBOXYHB QUAL Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82376 LAB L60 MAXFEE 01/01/2024 14.07 0.0 Description: ASSAY CARBOXYHB QUAL Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82378 LAB L60 MAXFEE 01/01/2020 18.96 0.0 Description: CARCINOEMBRYONIC ANTIGEN Category: Laboratory CMS Add: 01/01/1993 CMS Term: 82379 LAB L60 MAXFEE 01/01/2020 16.87 0.0 Description: ASSAY OF CARNITINE Category: Laboratory CMS Add: 01/01/1999 CMS Term: 82380 LAB L60 MAXFEE 01/01/2020 9.22 0.0 Description: ASSAY OF CAROTENE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82382 LAB L60 MAXFEE 01/01/2015 12/31/2023 23.40 0.0 Description: ASSAY URINE CATECHOLAMINES Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82382 LAB L60 MAXFEE 01/01/2024 27.30 0.0 Description: ASSAY URINE CATECHOLAMINES Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82383 LAB L60 MAXFEE 01/01/2019 29.08 0.0 Description: ASSAY BLOOD CATECHOLAMINES Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82384 LAB L60 MAXFEE 01/01/2020 25.25 0.0 Description: ASSAY THREE CATECHOLAMINES Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82387 LAB L60 MAXFEE 01/01/2020 18.06 0.0 Description: ASSAY OF CATHEPSIN-D Category: Laboratory CMS Add: 01/01/1993 CMS Term: 82390 LAB L60 MAXFEE 01/01/2020 10.74 0.0 Description: ASSAY OF CERULOPLASMIN Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82397 LAB L60 MAXFEE 01/01/2015 12/31/2023 12.16 0.0 Description: CHEMILUMINESCENT ASSAY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 82397 LAB L60 MAXFEE 01/01/2024 14.12 0.0 Description: CHEMILUMINESCENT ASSAY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 82415 LAB L60 MAXFEE 01/01/2020 12.67 0.0 Description: ASSAY OF CHLORAMPHENICOL Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82435 LAB L60 MAXFEE 01/01/2020 4.60 0.0 Description: ASSAY OF BLOOD CHLORIDE Category: Laboratory CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,107 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 82436 LAB L60 MAXFEE 01/01/2015 12/31/2023 4.70 0.0 Description: ASSAY OF URINE CHLORIDE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82436 LAB L60 MAXFEE 01/01/2024 5.75 0.0 Description: ASSAY OF URINE CHLORIDE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82438 LAB L60 MAXFEE 01/01/2020 5.00 0.0 Description: ASSAY OTHER FLUID CHLORIDES Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82441 LAB L60 MAXFEE 01/01/2020 6.01 0.0 Description: TEST FOR CHLOROHYDROCARBONS Category: Laboratory CMS Add: 01/01/1982 CMS Term: 82465 LAB L60 MAXFEE 01/01/2020 4.35 0.0 Description: ASSAY BLD/SERUM CHOLESTEROL Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82465 MRT L60 MAXFEE 01/01/2020 4.35 0.0 Description: ASSAY BLD/SERUM CHOLESTEROL Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 82480 LAB L60 MAXFEE 01/01/2020 7.87 0.0 Description: ASSAY SERUM CHOLINESTERASE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82482 LAB L60 MAXFEE 01/01/2018 9.81 0.0 Description: ASSAY RBC CHOLINESTERASE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82485 LAB L60 MAXFEE 01/01/2020 20.65 0.0 Description: ASSAY CHONDROITIN SULFATE Category: Laboratory CMS Add: 01/01/1985 CMS Term: 82495 LAB L60 MAXFEE 01/01/2020 20.28 0.0 Description: ASSAY OF CHROMIUM Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82507 LAB L60 MAXFEE 01/01/2020 27.80 0.0 Description: ASSAY OF CITRATE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82523 LAB L60 MAXFEE 01/01/2020 18.68 0.0 Description: COLLAGEN CROSSLINKS Category: Laboratory CMS Add: 01/01/1997 CMS Term: 82525 LAB L60 MAXFEE 01/01/2020 12.41 0.0 Description: ASSAY OF COPPER Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82528 LAB L60 MAXFEE 01/01/2020 22.52 0.0 Description: ASSAY OF CORTICOSTERONE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82530 LAB L60 MAXFEE 01/01/2020 16.71 0.0 Description: CORTISOL FREE Category: Laboratory CMS Add: 01/01/1993 CMS Term: 82533 LAB L60 MAXFEE 01/01/2020 16.30 0.0 Description: TOTAL CORTISOL Category: Laboratory CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,108 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 82540 LAB L60 MAXFEE 01/01/2020 4.64 0.0 Description: ASSAY OF CREATINE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82542 LAB L60 MAXFEE 01/01/2015 12/31/2023 23.71 0.0 Description: COL CHROMOTOGRAPHY QUAL/QUAN Category: Laboratory CMS Add: 01/01/1999 CMS Term: 82542 LAB L60 MAXFEE 01/01/2024 24.09 0.0 Description: COL CHROMOTOGRAPHY QUAL/QUAN Category: Laboratory CMS Add: 01/01/1999 CMS Term: 82550 LAB L60 MAXFEE 01/01/2020 6.51 0.0 Description: ASSAY OF CK (CPK) Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82552 LAB L60 MAXFEE 01/01/2020 13.39 0.0 Description: ASSAY OF CPK IN BLOOD Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82553 LAB L60 MAXFEE 01/01/2015 12/31/2023 8.38 0.0 Description: CREATINE MB FRACTION Category: Laboratory CMS Add: 01/01/1993 CMS Term: 82553 LAB L60 MAXFEE 01/01/2024 11.55 0.0 Description: CREATINE MB FRACTION Category: Laboratory CMS Add: 01/01/1993 CMS Term: 82554 LAB L60 MAXFEE 01/01/2020 11.87 0.0 Description: CREATINE ISOFORMS Category: Laboratory CMS Add: 01/01/1993 CMS Term: 82565 LAB L60 MAXFEE 01/01/2020 5.12 0.0 Description: ASSAY OF CREATININE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82565 MRT L60 MAXFEE 01/01/2020 5.12 0.0 Description: ASSAY OF CREATININE Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 82570 LAB L60 MAXFEE 01/01/2020 5.18 0.0 Description: ASSAY OF URINE CREATININE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82575 LAB L60 MAXFEE 01/01/2020 9.46 0.0 Description: CREATININE CLEARANCE TEST Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82575 MRT L60 MAXFEE 01/01/2020 9.46 0.0 Description: CREATININE CLEARANCE TEST Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 82585 LAB L60 MAXFEE 01/01/2015 12/31/2023 11.68 0.0 Description: ASSAY OF CRYOFIBRINOGEN Category: Laboratory CMS Add: 01/01/1982 CMS Term: 82585 LAB L60 MAXFEE 01/01/2024 14.14 0.0 Description: ASSAY OF CRYOFIBRINOGEN Category: Laboratory CMS Add: 01/01/1982 CMS Term: 82595 LAB L60 MAXFEE 01/01/2020 6.47 0.0 Description: ASSAY OF CRYOGLOBULIN Category: Laboratory CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,109 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 82600 LAB L60 MAXFEE 01/01/2020 19.40 0.0 Description: ASSAY OF CYANIDE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82607 LAB L60 MAXFEE 01/01/2020 15.08 0.0 Description: VITAMIN B-12 Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82608 LAB L60 MAXFEE 01/01/2020 14.32 0.0 Description: B-12 BINDING CAPACITY Category: Laboratory CMS Add: 01/01/1982 CMS Term: 82610 LAB L60 MAXFEE 01/01/2015 12/31/2023 16.45 0.0 Description: CYSTATIN C Category: Laboratory CMS Add: 01/01/2008 CMS Term: 82610 LAB L60 MAXFEE 01/01/2024 18.52 0.0 Description: CYSTATIN C Category: Laboratory CMS Add: 01/01/2008 CMS Term: 82615 LAB L60 MAXFEE 01/01/2019 9.55 0.0 Description: TEST FOR URINE CYSTINES Category: Laboratory CMS Add: 01/01/1985 CMS Term: 82626 LAB L60 MAXFEE 01/01/2020 25.27 0.0 Description: DEHYDROEPIANDROSTERONE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82627 LAB L60 MAXFEE 01/01/2020 22.23 0.0 Description: DEHYDROEPIANDROSTERONE Category: Laboratory CMS Add: 01/01/1993 CMS Term: 82633 LAB L60 MAXFEE 01/01/2020 30.98 0.0 Description: DESOXYCORTICOSTERONE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82634 LAB L60 MAXFEE 01/01/2020 29.28 0.0 Description: DEOXYCORTISOL Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82638 LAB L60 MAXFEE 01/01/2020 12.25 0.0 Description: ASSAY OF DIBUCAINE NUMBER Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82642 NOCOV DEF SYSMAN Description: DIHYDROTESTOSTERONE Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 82652 LAB L60 MAXFEE 01/01/2020 38.50 0.0 Description: VIT D 1 25-DIHYDROXY Category: Laboratory CMS Add: 01/01/1986 CMS Term: 82653 LAB L60 MAXFEE 01/01/2022 22.97 0.0 Description: EL-1 FECAL QUANTITATIVE Category: Laboratory CMS Add: 01/01/2022 CMS Term: 82656 LAB L60 MAXFEE 01/01/2020 11.53 0.0 Description: EL-1 FECAL QUAL/SEMIQ Category: Laboratory CMS Add: 01/01/2005 CMS Term: 82657 LAB L60 MAXFEE 01/01/2019 22.17 0.0 Description: ENZYME CELL ACTIVITY Category: Laboratory CMS Add: 01/01/1999 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,110 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 82658 LAB L60 MAXFEE 01/01/2015 12/31/2023 23.71 0.0 Description: ENZYME CELL ACTIVITY RA Category: Laboratory CMS Add: 01/01/1999 CMS Term: 82658 LAB L60 MAXFEE 01/01/2024 44.03 0.0 Description: ENZYME CELL ACTIVITY RA Category: Laboratory CMS Add: 01/01/1999 CMS Term: 82664 LAB L60 MAXFEE 01/01/2015 12/31/2023 39.51 0.0 Description: ELECTROPHORETIC TEST Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82664 LAB L60 MAXFEE 01/01/2024 61.50 0.0 Description: ELECTROPHORETIC TEST Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82668 LAB L60 MAXFEE 01/01/2020 18.79 0.0 Description: ASSAY OF ERYTHROPOIETIN Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82670 LAB L60 MAXFEE 01/01/2020 27.94 0.0 Description: ASSAY OF TOTAL ESTRADIOL Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82671 LAB L60 MAXFEE 01/01/2020 32.30 0.0 Description: ASSAY OF ESTROGENS Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82672 LAB L60 MAXFEE 01/01/2020 21.70 0.0 Description: ASSAY OF ESTROGEN Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82677 LAB L60 MAXFEE 01/01/2020 24.18 0.0 Description: ASSAY OF ESTRIOL Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82679 LAB L60 MAXFEE 01/01/2020 24.95 0.0 Description: ASSAY OF ESTRONE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82681 LAB L60 MAXFEE 01/01/2021 27.94 0.0 Description: ASSAY DIR MEAS FR ESTRADIOL Category: Laboratory CMS Add: 01/01/2021 CMS Term: 82693 LAB L60 MAXFEE 01/01/2020 14.90 0.0 Description: ASSAY OF ETHYLENE GLYCOL Category: Laboratory CMS Add: 01/01/1993 CMS Term: 82696 LAB L60 MAXFEE 01/01/2019 26.24 0.0 Description: ASSAY OF ETIOCHOLANOLONE Category: Laboratory CMS Add: 01/01/1985 CMS Term: 82705 LAB L60 MAXFEE 01/01/2015 12/31/2023 2.40 0.0 Description: FATS/LIPIDS FECES QUAL Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82705 LAB L60 MAXFEE 01/01/2024 5.10 0.0 Description: FATS/LIPIDS FECES QUAL Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82710 LAB L60 MAXFEE 01/01/2015 12/31/2023 15.84 0.0 Description: FATS/LIPIDS FECES QUANT Category: Laboratory CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,111 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 82710 LAB L60 MAXFEE 01/01/2024 16.80 0.0 Description: FATS/LIPIDS FECES QUANT Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82715 LAB L60 MAXFEE 01/01/2015 12/31/2023 16.08 0.0 Description: ASSAY OF FECAL FAT Category: Laboratory CMS Add: 01/01/1982 CMS Term: 82715 LAB L60 MAXFEE 01/01/2024 22.97 0.0 Description: ASSAY OF FECAL FAT Category: Laboratory CMS Add: 01/01/1982 CMS Term: 82725 LAB L60 MAXFEE 01/01/2015 12/31/2023 10.25 0.0 Description: ASSAY OF BLOOD FATTY ACIDS Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82725 LAB L60 MAXFEE 01/01/2024 18.77 0.0 Description: ASSAY OF BLOOD FATTY ACIDS Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82726 LAB L60 MAXFEE 01/01/2020 19.75 0.0 Description: LONG CHAIN FATTY ACIDS Category: Laboratory CMS Add: 01/01/1999 CMS Term: 82728 LAB L60 MAXFEE 01/01/2020 13.63 0.0 Description: ASSAY OF FERRITIN Category: Laboratory CMS Add: 01/01/1982 CMS Term: 82731 LAB L60 MAXFEE 01/01/2020 64.41 0.0 Description: ASSAY OF FETAL FIBRONECTIN Category: Laboratory CMS Add: 01/01/1999 CMS Term: 82735 LAB L60 MAXFEE 01/01/2020 18.54 0.0 Description: ASSAY OF FLUORIDE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82746 LAB L60 MAXFEE 01/01/2020 14.70 0.0 Description: ASSAY OF FOLIC ACID SERUM Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82747 LAB L60 MAXFEE 01/01/2020 17.65 0.0 Description: ASSAY OF FOLIC ACID RBC Category: Laboratory CMS Add: 01/01/1993 CMS Term: 82757 LAB L60 MAXFEE 01/01/2020 17.34 0.0 Description: ASSAY OF SEMEN FRUCTOSE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82759 LAB L60 MAXFEE 01/01/2020 21.48 0.0 Description: ASSAY OF RBC GALACTOKINASE Category: Laboratory CMS Add: 01/01/1985 CMS Term: 82760 LAB L60 MAXFEE 01/01/2020 11.20 0.0 Description: ASSAY OF GALACTOSE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82775 LAB L60 MAXFEE 01/01/2020 21.07 0.0 Description: ASSAY GALACTOSE TRANSFERASE Category: Laboratory CMS Add: 01/01/1985 CMS Term: 82776 LAB L60 MAXFEE 01/01/2015 12/31/2023 11.41 0.0 Description: GALACTOSE TRANSFERASE TEST Category: Laboratory CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,112 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 82776 LAB L60 MAXFEE 01/01/2024 11.74 0.0 Description: GALACTOSE TRANSFERASE TEST Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82777 NOCOV DEF SYSMAN Description: GALECTIN-3 Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 82784 LAB L60 MAXFEE 01/01/2020 9.30 0.0 Description: ASSAY IGA/IGD/IGG/IGM EACH Category: Laboratory CMS Add: 01/01/1985 CMS Term: 82785 LAB L60 MAXFEE 01/01/2020 16.46 0.0 Description: ASSAY OF IGE Category: Laboratory CMS Add: 01/01/1985 CMS Term: 82787 LAB L60 MAXFEE 01/01/2015 12/31/2023 6.07 0.0 Description: IGG 1 2 3 OR 4 EACH Category: Laboratory CMS Add: 01/01/1993 CMS Term: 82787 LAB L60 MAXFEE 01/01/2024 8.02 0.0 Description: IGG 1 2 3 OR 4 EACH Category: Laboratory CMS Add: 01/01/1993 CMS Term: 82800 LAB L60 MAXFEE 01/01/2018 11.00 0.0 Description: BLOOD PH Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82803 LAB L60 MAXFEE 01/01/2015 12/31/2023 23.55 0.0 Description: BLOOD GASES ANY COMBINATION Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82803 LAB L60 MAXFEE 01/01/2024 26.07 0.0 Description: BLOOD GASES ANY COMBINATION Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82803 MRT L60 MAXFEE 01/01/2015 12/31/2023 23.55 0.0 Description: BLOOD GASES ANY COMBINATION Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 82803 MRT L60 MAXFEE 01/01/2024 26.07 0.0 Description: BLOOD GASES ANY COMBINATION Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 82805 LAB L60 MAXFEE 01/01/2015 12/31/2023 38.62 0.0 Description: BLOOD GASES W/O2 SATURATION Category: Laboratory CMS Add: 01/01/1994 CMS Term: 82805 LAB L60 MAXFEE 01/01/2024 78.77 0.0 Description: BLOOD GASES W/O2 SATURATION Category: Laboratory CMS Add: 01/01/1994 CMS Term: 82810 LAB L60 MAXFEE 01/01/2019 9.77 0.0 Description: BLOOD GASES O2 SAT ONLY Category: Laboratory CMS Add: 01/01/1994 CMS Term: 82820 LAB L60 MAXFEE 01/01/2018 13.34 0.0 Description: HEMOGLOBIN-OXYGEN AFFINITY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 82930 LAB L60 MAXFEE 01/01/2019 6.71 0.0 Description: GASTRIC ANALY W/PH EA SPEC Category: Laboratory CMS Add: 01/01/2011 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,113 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 82938 LAB L60 MAXFEE 01/01/2020 17.69 0.0 Description: GASTRIN TEST Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82941 LAB L60 MAXFEE 01/01/2020 17.63 0.0 Description: ASSAY OF GASTRIN Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82943 LAB L60 MAXFEE 01/01/2020 14.29 0.0 Description: ASSAY OF GLUCAGON Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82945 LAB L60 MAXFEE 01/01/2020 3.93 0.0 Description: GLUCOSE OTHER FLUID Category: Laboratory CMS Add: 01/01/2001 CMS Term: 82946 LAB L60 MAXFEE 01/01/2019 17.77 0.0 Description: GLUCAGON TOLERANCE TEST Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82947 LAB L60 MAXFEE 01/01/2020 3.93 0.0 Description: ASSAY GLUCOSE BLOOD QUANT Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82947 MRT L60 MAXFEE 01/01/2020 3.93 0.0 Description: ASSAY GLUCOSE BLOOD QUANT Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 82948 LAB L60 MAXFEE 01/01/2015 12/31/2023 4.31 0.0 Description: REAGENT STRIP/BLOOD GLUCOSE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82948 LAB L60 MAXFEE 01/01/2024 5.04 0.0 Description: REAGENT STRIP/BLOOD GLUCOSE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82950 LAB L60 MAXFEE 01/01/2020 4.75 0.0 Description: GLUCOSE TEST Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82951 LAB L60 MAXFEE 01/01/2020 12.87 0.0 Description: GLUCOSE TOLERANCE TEST (GTT) Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82952 LAB L60 MAXFEE 01/01/2020 3.92 0.0 Description: GTT-ADDED SAMPLES Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82955 LAB L60 MAXFEE 01/01/2020 9.70 0.0 Description: ASSAY OF G6PD ENZYME Category: Laboratory CMS Add: 01/01/1982 CMS Term: 82960 LAB L60 MAXFEE 01/01/2020 6.05 0.0 Description: TEST FOR G6PD ENZYME Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82962 LAB L60 MAXFEE 01/01/2015 12/31/2023 3.19 0.0 Description: GLUCOSE BLOOD TEST Category: Laboratory CMS Add: 01/01/1993 CMS Term: 82962 LAB L60 MAXFEE 01/01/2024 3.28 0.0 Description: GLUCOSE BLOOD TEST Category: Laboratory CMS Add: 01/01/1993 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,114 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 82963 LAB L60 MAXFEE 01/01/2020 21.48 0.0 Description: ASSAY OF GLUCOSIDASE Category: Laboratory CMS Add: 01/01/1983 CMS Term: 82965 LAB L60 MAXFEE 01/01/2015 12/31/2023 10.52 0.0 Description: ASSAY OF GDH ENZYME Category: Laboratory CMS Add: 01/01/1982 CMS Term: 82965 LAB L60 MAXFEE 01/01/2024 13.15 0.0 Description: ASSAY OF GDH ENZYME Category: Laboratory CMS Add: 01/01/1982 CMS Term: 82977 LAB L60 MAXFEE 01/01/2020 7.20 0.0 Description: ASSAY OF GGT Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82978 LAB L60 MAXFEE 01/01/2020 15.45 0.0 Description: ASSAY OF GLUTATHIONE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82979 LAB L60 MAXFEE 01/01/2015 12/31/2023 9.38 0.0 Description: ASSAY RBC GLUTATHIONE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82979 LAB L60 MAXFEE 01/01/2024 9.44 0.0 Description: ASSAY RBC GLUTATHIONE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 82985 LAB L60 MAXFEE 01/01/2019 16.76 0.0 Description: ASSAY OF GLYCATED PROTEIN Category: Laboratory CMS Add: 01/01/1984 CMS Term: 83001 LAB L60 MAXFEE 01/01/2020 18.58 0.0 Description: ASSAY OF GONADOTROPIN (FSH) Category: Laboratory CMS Add: 01/01/1984 CMS Term: 83002 LAB L60 MAXFEE 01/01/2020 18.52 0.0 Description: ASSAY OF GONADOTROPIN (LH) Category: Laboratory CMS Add: 01/01/1984 CMS Term: 83003 LAB L60 MAXFEE 01/01/2020 16.67 0.0 Description: ASSAY GROWTH HORMONE (HGH) Category: Laboratory CMS Add: 01/01/1984 CMS Term: 83006 LAB L60 MAXFEE 01/01/2015 12/31/2023 29.93 0.0 Description: GROWTH STIMULATION GENE 2 Category: Laboratory CMS Add: 01/01/2015 CMS Term: 83006 LAB L60 MAXFEE 01/01/2024 75.60 0.0 Description: GROWTH STIMULATION GENE 2 Category: Laboratory CMS Add: 01/01/2015 CMS Term: 83009 LAB L60 MAXFEE 01/01/2020 67.36 0.0 Description: H PYLORI (C-13) BLOOD Category: Laboratory CMS Add: 01/01/2005 CMS Term: 83010 LAB L60 MAXFEE 01/01/2020 12.58 0.0 Description: ASSAY OF HAPTOGLOBIN QUANT Category: Laboratory CMS Add: 01/01/1982 CMS Term: 83012 LAB L60 MAXFEE 01/01/2015 12/31/2023 23.40 0.0 Description: ASSAY OF HAPTOGLOBINS Category: Laboratory CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,115 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 83012 LAB L60 MAXFEE 01/01/2024 26.89 0.0 Description: ASSAY OF HAPTOGLOBINS Category: Laboratory CMS Add: 01/01/1982 CMS Term: 83013 LAB L60 MAXFEE 01/01/2020 67.36 0.0 Description: H PYLORI (C-13) BREATH Category: Laboratory CMS Add: 01/01/1999 CMS Term: 83014 LAB L60 MAXFEE 01/01/2020 7.86 0.0 Description: H PYLORI DRUG ADMIN Category: Laboratory CMS Add: 01/01/1999 CMS Term: 83015 LAB L60 MAXFEE 01/01/2019 20.94 0.0 Description: HEAVY METAL QUAL ANY ANAL Category: Laboratory CMS Add: 01/01/1984 CMS Term: 83018 LAB L60 MAXFEE 01/01/2015 12/31/2023 12.48 0.0 Description: HEAVY METAL QUANT EACH NES Category: Laboratory CMS Add: 01/01/1984 CMS Term: 83018 LAB L60 MAXFEE 01/01/2024 21.96 0.0 Description: HEAVY METAL QUANT EACH NES Category: Laboratory CMS Add: 01/01/1984 CMS Term: 83020* 26 LAB DEF RBRVS 01/01/2024 17.02 Description: HEMOGLOBIN ELECTROPHORESIS Category: Laboratory CMS Add: 01/01/1984 CMS Term: 83020* 26 LAB DEF RBRVS 02/01/2015 12/31/2023 13.90 Description: HEMOGLOBIN ELECTROPHORESIS Category: Laboratory CMS Add: 01/01/1984 CMS Term: 83020* LAB L60 MAXFEE 01/01/2020 12.87 0.0 Description: HEMOGLOBIN ELECTROPHORESIS Category: Laboratory CMS Add: 01/01/1984 CMS Term: 83021 LAB L60 MAXFEE 01/01/2020 18.06 0.0 Description: HEMOGLOBIN CHROMOTOGRAPHY Category: Laboratory CMS Add: 01/01/1999 CMS Term: 83026 LAB L60 MAXFEE 01/01/2015 12/31/2023 3.22 0.0 Description: HEMOGLOBIN COPPER SULFATE Category: Laboratory CMS Add: 01/01/1993 CMS Term: 83026 LAB L60 MAXFEE 01/01/2024 4.01 0.0 Description: HEMOGLOBIN COPPER SULFATE Category: Laboratory CMS Add: 01/01/1993 CMS Term: 83030 LAB L60 MAXFEE 01/01/2018 10.74 0.0 Description: HEMOGLOBIN F FETAL CHEMICAL Category: Laboratory CMS Add: 01/01/1984 CMS Term: 83033 LAB L60 MAXFEE 01/01/2018 8.00 0.0 Description: HEMOGLOBIN FTL F ASSAY QUAL Category: Laboratory CMS Add: 01/01/1984 CMS Term: 83036 LAB L60 MAXFEE 01/01/2020 9.71 0.0 Description: HEMOGLOBIN GLYCOSYLATED A1C Category: Laboratory CMS Add: 01/01/1985 CMS Term: 83036 MRT L60 MAXFEE 01/01/2020 9.71 0.0 Description: HEMOGLOBIN GLYCOSYLATED A1C Category: Medical Review Team CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,116 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 83037 LAB L60 MAXFEE 01/01/2020 9.71 0.0 Description: HB GLYCOSYLATED A1C HOME DEV Category: Laboratory CMS Add: 01/01/2006 CMS Term: 83045 LAB L60 MAXFEE 01/01/2018 6.49 0.0 Description: HGB METHEMOGLOBIN QUAL Category: Laboratory CMS Add: 01/01/1984 CMS Term: 83050 LAB L60 MAXFEE 01/01/2019 8.20 0.0 Description: HGB METHEMOGLOBIN QUAN Category: Laboratory CMS Add: 01/01/1984 CMS Term: 83051 LAB L60 MAXFEE 01/01/2015 12/31/2023 7.10 0.0 Description: HEMOGLOBIN PLASMA Category: Laboratory CMS Add: 01/01/1984 CMS Term: 83051 LAB L60 MAXFEE 01/01/2024 7.31 0.0 Description: HEMOGLOBIN PLASMA Category: Laboratory CMS Add: 01/01/1984 CMS Term: 83060 LAB L60 MAXFEE 01/01/2020 8.80 0.0 Description: HGB SULFHEMOGLOBIN QUAN Category: Laboratory CMS Add: 01/01/1984 CMS Term: 83065 LAB L60 MAXFEE 01/01/2018 9.00 0.0 Description: HEMOGLOBIN THERMOLABILE Category: Laboratory CMS Add: 01/01/1985 CMS Term: 83068 LAB L60 MAXFEE 01/01/2019 9.47 0.0 Description: HEMOGLOBIN UNSTABLE SCREEN Category: Laboratory CMS Add: 01/01/1985 CMS Term: 83069 LAB L60 MAXFEE 01/01/2015 12/31/2023 3.92 0.0 Description: HEMOGLOBIN URINE Category: Laboratory CMS Add: 01/01/1982 CMS Term: 83069 LAB L60 MAXFEE 01/01/2024 3.95 0.0 Description: HEMOGLOBIN URINE Category: Laboratory CMS Add: 01/01/1982 CMS Term: 83070 LAB L60 MAXFEE 01/01/2020 4.75 0.0 Description: ASSAY OF HEMOSIDERIN QUAL Category: Laboratory CMS Add: 01/01/1985 CMS Term: 83080 LAB L60 MAXFEE 01/01/2020 16.87 0.0 Description: ASSAY OF B HEXOSAMINIDASE EA Category: Laboratory CMS Add: 01/01/1999 CMS Term: 83088 LAB L60 MAXFEE 01/01/2020 29.53 0.0 Description: ASSAY OF HISTAMINE Category: Laboratory CMS Add: 01/01/1982 CMS Term: 83090 LAB L60 MAXFEE 01/01/2020 17.92 0.0 Description: ASSAY OF HOMOCYSTEINE Category: Laboratory CMS Add: 01/01/2001 CMS Term: 83150 LAB L60 MAXFEE 01/01/2019 22.41 0.0 Description: ASSAY OF HOMOVANILLIC ACID Category: Laboratory CMS Add: 01/01/1984 CMS Term: 83491 LAB L60 MAXFEE 01/01/2020 17.90 0.0 Description: ASY HYDROXYCORTICOSTEROIDS17 Category: Laboratory CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,117 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 83497 LAB L60 MAXFEE 01/01/2020 12.90 0.0 Description: ASSAY OF 5-HIAA Category: Laboratory CMS Add: 01/01/1982 CMS Term: 83498 LAB L60 MAXFEE 01/01/2020 27.17 0.0 Description: ASY HYDROXYPROGESTERONE 17-D Category: Laboratory CMS Add: 01/01/1984 CMS Term: 83500 LAB L60 MAXFEE 01/01/2020 22.65 0.0 Description: ASSAY FREE HYDROXYPROLINE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 83505 LAB L60 MAXFEE 01/01/2020 24.30 0.0 Description: ASSAY TOTAL HYDROXYPROLINE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 83516 LAB L60 MAXFEE 01/01/2020 11.53 0.0 Description: IMMUNOASSAY NONANTIBODY Category: Laboratory CMS Add: 01/01/1995 CMS Term: 83518 LAB L60 MAXFEE 01/01/2019 9.64 0.0 Description: IMMUNOASSAY DIPSTICK Category: Laboratory CMS Add: 01/01/1993 CMS Term: 83519 LAB L60 MAXFEE 01/01/2015 12/31/2023 18.39 0.0 Description: RIA NONANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 83519 LAB L60 MAXFEE 01/01/2024 18.40 0.0 Description: RIA NONANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 83520 LAB L60 MAXFEE 01/01/2018 17.27 0.0 Description: IMMUNOASSAY QUANT NOS NONAB Category: Laboratory CMS Add: 01/01/1993 CMS Term: 83521 LAB L60 MAXFEE 01/01/2022 17.27 0.0 Description: IG LIGHT CHAINS FREE EACH Category: Laboratory CMS Add: 01/01/2022 CMS Term: 83525 LAB L60 MAXFEE 01/01/2020 11.43 0.0 Description: ASSAY OF INSULIN Category: Laboratory CMS Add: 01/01/1984 CMS Term: 83527 LAB L60 MAXFEE 01/01/2020 12.95 0.0 Description: ASSAY OF INSULIN Category: Laboratory CMS Add: 01/01/1994 CMS Term: 83528 LAB L60 MAXFEE 01/01/2015 12/31/2023 19.75 0.0 Description: ASSAY OF INTRINSIC FACTOR Category: Laboratory CMS Add: 01/01/1982 CMS Term: 83528 LAB L60 MAXFEE 01/01/2024 19.82 0.0 Description: ASSAY OF INTRINSIC FACTOR Category: Laboratory CMS Add: 01/01/1982 CMS Term: 83529 LAB L60 MAXFEE 01/01/2022 17.27 0.0 Description: ASAY OF INTERLEUKIN-6 (IL-6) Category: Laboratory CMS Add: 01/01/2022 CMS Term: 83540 LAB L60 MAXFEE 01/01/2020 6.47 0.0 Description: ASSAY OF IRON Category: Laboratory CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,118 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 83550 LAB L60 MAXFEE 01/01/2020 8.74 0.0 Description: IRON BINDING TEST Category: Laboratory CMS Add: 01/01/1984 CMS Term: 83570 LAB L60 MAXFEE 01/01/2020 8.85 0.0 Description: ASSAY OF IDH ENZYME Category: Laboratory CMS Add: 01/01/1984 CMS Term: 83582 LAB L60 MAXFEE 01/01/2020 15.47 0.0 Description: ASSAY OF KETOGENIC STEROIDS Category: Laboratory CMS Add: 01/01/1984 CMS Term: 83586 LAB L60 MAXFEE 01/01/2020 12.80 0.0 Description: ASSAY 17- KETOSTEROIDS Category: Laboratory CMS Add: 01/01/1984 CMS Term: 83593 LAB L60 MAXFEE 01/01/2015 12/31/2023 11.41 0.0 Description: FRACTIONATION KETOSTEROIDS Category: Laboratory CMS Add: 01/01/1984 CMS Term: 83593 LAB L60 MAXFEE 01/01/2024 28.50 0.0 Description: FRACTIONATION KETOSTEROIDS Category: Laboratory CMS Add: 01/01/1984 CMS Term: 83605 LAB L60 MAXFEE 01/01/2020 11.57 0.0 Description: ASSAY OF LACTIC ACID Category: Laboratory CMS Add: 01/01/1984 CMS Term: 83615 LAB L60 MAXFEE 01/01/2020 6.04 0.0 Description: LACTATE (LD) (LDH) ENZYME Category: Laboratory CMS Add: 01/01/1984 CMS Term: 83625 LAB L60 MAXFEE 01/01/2020 12.79 0.0 Description: ASSAY OF LDH ENZYMES Category: Laboratory CMS Add: 01/01/1984 CMS Term: 83630 LAB L60 MAXFEE 01/01/2013 12/31/2023 16.00 0.0 Description: LACTOFERRIN FECAL (QUAL) Category: Laboratory CMS Add: 01/01/2005 CMS Term: 83630 LAB L60 MAXFEE 01/01/2024 19.70 0.0 Description: LACTOFERRIN FECAL (QUAL) Category: Laboratory CMS Add: 01/01/2005 CMS Term: 83631 NOCOV DEF SYSMAN Description: LACTOFERRIN FECAL (QUANT) Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 83632 LAB L60 MAXFEE 01/01/2020 20.22 0.0 Description: PLACENTAL LACTOGEN Category: Laboratory CMS Add: 01/01/1984 CMS Term: 83633 LAB L60 MAXFEE 01/01/2015 12/31/2023 3.19 0.0 Description: TEST URINE FOR LACTOSE Category: Laboratory CMS Add: 01/01/1982 CMS Term: 83633 LAB L60 MAXFEE 01/01/2024 11.25 0.0 Description: TEST URINE FOR LACTOSE Category: Laboratory CMS Add: 01/01/1982 CMS Term: 83655 LAB L60 MAXFEE 01/01/2020 12.11 0.0 Description: ASSAY OF LEAD Category: Laboratory CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,119 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 83655 U1 LAB L60 MAXFEE 01/01/2024 13.00 0.0 Description: ASSAY OF LEAD Category: Laboratory CMS Add: 01/01/1984 CMS Term: 83655 U1 LAB L60 MAXFEE 12/01/2007 12/31/2023 10.00 0.0 Description: ASSAY OF LEAD Category: Laboratory CMS Add: 01/01/1984 CMS Term: 83655 U2 LAB L60 MAXFEE 01/01/2024 6.50 0.0 Description: ASSAY OF LEAD Category: Laboratory CMS Add: 01/01/1984 CMS Term: 83655 U2 LAB L60 MAXFEE 12/01/2007 12/31/2023 5.00 0.0 Description: ASSAY OF LEAD Category: Laboratory CMS Add: 01/01/1984 CMS Term: 83661 LAB L60 MAXFEE 01/01/2020 21.99 0.0 Description: L/S RATIO FETAL LUNG Category: Laboratory CMS Add: 01/01/1982 CMS Term: 83662 LAB L60 MAXFEE 01/01/2015 12/31/2023 18.34 0.0 Description: FOAM STABILITY FETAL LUNG Category: Laboratory CMS Add: 01/01/1993 CMS Term: 83662 LAB L60 MAXFEE 01/01/2024 18.91 0.0 Description: FOAM STABILITY FETAL LUNG Category: Laboratory CMS Add: 01/01/1993 CMS Term: 83663 LAB L60 MAXFEE 01/01/2001 12/31/2023 9.32 0.0 Description: FLUORO POLARIZE FETAL LUNG Category: Laboratory CMS Add: 01/01/2001 CMS Term: 83663 LAB L60 MAXFEE 01/01/2024 18.91 0.0 Description: FLUORO POLARIZE FETAL LUNG Category: Laboratory CMS Add: 01/01/2001 CMS Term: 83664 LAB L60 MAXFEE 01/01/2001 12/31/2023 4.66 0.0 10-60years Description: LAMELLAR BDY FETAL LUNG Category: Laboratory CMS Add: 01/01/2001 CMS Term: 83664 LAB L60 MAXFEE 01/01/2024 19.32 0.0 10-60years Description: LAMELLAR BDY FETAL LUNG Category: Laboratory CMS Add: 01/01/2001 CMS Term: 83670 LAB L60 MAXFEE 01/01/2020 9.81 0.0 Description: ASSAY OF LAP ENZYME Category: Laboratory CMS Add: 01/01/1982 CMS Term: 83690 LAB L60 MAXFEE 01/01/2015 12/31/2023 5.18 0.0 Description: ASSAY OF LIPASE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 83690 LAB L60 MAXFEE 01/01/2024 6.89 0.0 Description: ASSAY OF LIPASE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 83690 MRT L60 MAXFEE 01/01/2015 12/31/2023 5.18 0.0 Description: ASSAY OF LIPASE Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 83690 MRT L60 MAXFEE 01/01/2024 6.89 0.0 Description: ASSAY OF LIPASE Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,120 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 83695 LAB L60 MAXFEE 01/01/2020 14.32 0.0 Description: ASSAY OF LIPOPROTEIN(A) Category: Laboratory CMS Add: 01/01/2006 CMS Term: 83698 LAB L60 MAXFEE 01/01/2015 12/31/2023 39.51 0.0 Description: ASSAY LIPOPROTEIN PLA2 Category: Laboratory CMS Add: 01/01/2007 CMS Term: 83698 LAB L60 MAXFEE 01/01/2024 46.31 0.0 Description: ASSAY LIPOPROTEIN PLA2 Category: Laboratory CMS Add: 01/01/2007 CMS Term: 83700 LAB L60 MAXFEE 01/01/2020 11.26 0.0 Description: LIPOPRO BLD ELECTROPHORETIC Category: Laboratory CMS Add: 01/01/2006 CMS Term: 83701 LAB L60 MAXFEE 01/01/2015 12/31/2023 22.03 0.0 Description: LIPOPROTEIN BLD HR FRACTION Category: Laboratory CMS Add: 01/01/2006 CMS Term: 83701 LAB L60 MAXFEE 01/01/2024 33.86 0.0 Description: LIPOPROTEIN BLD HR FRACTION Category: Laboratory CMS Add: 01/01/2006 CMS Term: 83704 LAB L60 MAXFEE 01/01/2020 34.19 0.0 Description: LIPOPROTEIN BLD QUAN PART Category: Laboratory CMS Add: 01/01/2006 CMS Term: 83718 LAB L60 MAXFEE 01/01/2020 8.19 0.0 Description: ASSAY OF LIPOPROTEIN Category: Laboratory CMS Add: 01/01/1984 CMS Term: 83718 MRT L60 MAXFEE 01/01/2020 8.19 0.0 Description: ASSAY OF LIPOPROTEIN Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 83719 LAB L60 MAXFEE 01/01/2020 12.75 0.0 Description: ASSAY OF BLOOD LIPOPROTEIN Category: Laboratory CMS Add: 01/01/1984 CMS Term: 83721 LAB L60 MAXFEE 01/01/2020 10.50 0.0 Description: ASSAY OF BLOOD LIPOPROTEIN Category: Laboratory CMS Add: 01/01/1993 CMS Term: 83722 LAB L60 MAXFEE 01/01/2020 34.19 0.0 Description: LIPOPRTN DIR MEAS SD LDL CHL Category: Laboratory CMS Add: 01/01/2019 CMS Term: 83727 LAB L60 MAXFEE 01/01/2020 17.19 0.0 Description: ASSAY OF LRH HORMONE Category: Laboratory CMS Add: 01/01/1985 CMS Term: 83735 LAB L60 MAXFEE 01/01/2020 6.70 0.0 Description: ASSAY OF MAGNESIUM Category: Laboratory CMS Add: 01/01/1984 CMS Term: 83775 LAB L60 MAXFEE 01/01/2020 7.37 0.0 Description: ASSAY MALATE DEHYDROGENASE Category: Laboratory CMS Add: 01/01/1985 CMS Term: 83785 LAB L60 MAXFEE 01/01/2020 26.65 0.0 Description: ASSAY OF MANGANESE Category: Laboratory CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,121 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 83789 LAB L60 MAXFEE 01/01/2015 12/31/2023 23.71 0.0 Description: MASS SPECTROMETRY QUAL/QUAN Category: Laboratory CMS Add: 01/01/1999 CMS Term: 83789 LAB L60 MAXFEE 01/01/2024 24.11 0.0 Description: MASS SPECTROMETRY QUAL/QUAN Category: Laboratory CMS Add: 01/01/1999 CMS Term: 83825 LAB L60 MAXFEE 01/01/2020 16.26 0.0 Description: ASSAY OF MERCURY Category: Laboratory CMS Add: 01/01/1984 CMS Term: 83835 LAB L60 MAXFEE 01/01/2020 16.94 0.0 Description: ASSAY OF METANEPHRINES Category: Laboratory CMS Add: 01/01/1984 CMS Term: 83857 LAB L60 MAXFEE 01/01/2020 10.74 0.0 Description: ASSAY OF METHEMALBUMIN Category: Laboratory CMS Add: 01/01/1982 CMS Term: 83861 LAB L60 MAXFEE 01/01/2015 22.48 0.0 Description: MICROFLUID ANALY TEARS Category: Laboratory CMS Add: 01/01/2011 CMS Term: 83864 LAB L60 MAXFEE 01/01/2015 12/31/2023 27.10 0.0 Description: MUCOPOLYSACCHARIDES Category: Laboratory CMS Add: 01/01/1984 CMS Term: 83864 LAB L60 MAXFEE 01/01/2024 28.50 0.0 Description: MUCOPOLYSACCHARIDES Category: Laboratory CMS Add: 01/01/1984 CMS Term: 83872 LAB L60 MAXFEE 01/01/2020 5.86 0.0 Description: ASSAY SYNOVIAL FLUID MUCIN Category: Laboratory CMS Add: 01/01/1984 CMS Term: 83873 LAB L60 MAXFEE 01/01/2020 17.20 0.0 Description: ASSAY OF CSF PROTEIN Category: Laboratory CMS Add: 01/01/1983 CMS Term: 83874 LAB L60 MAXFEE 01/01/2020 12.92 0.0 Description: ASSAY OF MYOGLOBIN Category: Laboratory CMS Add: 01/01/1984 CMS Term: 83876 LAB L60 MAXFEE 01/01/2009 12/31/2023 18.91 0.0 Description: ASSAY MYELOPEROXIDASE Category: Laboratory CMS Add: 01/01/2009 CMS Term: 83876 LAB L60 MAXFEE 01/01/2024 50.86 0.0 Description: ASSAY MYELOPEROXIDASE Category: Laboratory CMS Add: 01/01/2009 CMS Term: 83880 LAB L60 MAXFEE 01/01/2019 39.26 0.0 Description: ASSAY OF NATRIURETIC PEPTIDE Category: Laboratory CMS Add: 01/01/2003 CMS Term: 83883 LAB L60 MAXFEE 01/01/2020 13.60 0.0 Description: ASSAY NEPHELOMETRY NOT SPEC Category: Laboratory CMS Add: 01/01/1993 CMS Term: 83885 LAB L60 MAXFEE 01/01/2020 24.51 0.0 Description: ASSAY OF NICKEL Category: Laboratory CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,122 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 83915 LAB L60 MAXFEE 01/01/2020 11.15 0.0 Description: ASSAY OF NUCLEOTIDASE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 83916 LAB L60 MAXFEE 01/01/2015 12/31/2023 27.37 0.0 Description: OLIGOCLONAL BANDS Category: Laboratory CMS Add: 01/01/1983 CMS Term: 83916 LAB L60 MAXFEE 01/01/2024 27.39 0.0 Description: OLIGOCLONAL BANDS Category: Laboratory CMS Add: 01/01/1983 CMS Term: 83918 LAB L60 MAXFEE 01/01/2015 12/31/2023 22.39 0.0 Description: ORGANIC ACIDS TOTAL QUANT Category: Laboratory CMS Add: 01/01/1984 CMS Term: 83918 LAB L60 MAXFEE 01/01/2024 23.60 0.0 Description: ORGANIC ACIDS TOTAL QUANT Category: Laboratory CMS Add: 01/01/1984 CMS Term: 83919 LAB L60 MAXFEE 01/01/2020 16.45 0.0 Description: ORGANIC ACIDS QUAL EACH Category: Laboratory CMS Add: 01/01/1999 CMS Term: 83921 LAB L60 MAXFEE 01/01/2018 21.21 0.0 Description: ORGANIC ACID SINGLE QUANT Category: Laboratory CMS Add: 01/01/2001 CMS Term: 83930 LAB L60 MAXFEE 01/01/2020 6.61 0.0 Description: ASSAY OF BLOOD OSMOLALITY Category: Laboratory CMS Add: 01/01/1984 CMS Term: 83935 LAB L60 MAXFEE 01/01/2020 6.82 0.0 Description: ASSAY OF URINE OSMOLALITY Category: Laboratory CMS Add: 01/01/1984 CMS Term: 83937 LAB L60 MAXFEE 01/01/2020 29.85 0.0 Description: ASSAY OF OSTEOCALCIN Category: Laboratory CMS Add: 01/01/1994 CMS Term: 83945 LAB L60 MAXFEE 01/01/2019 14.45 0.0 Description: ASSAY OF OXALATE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 83950 LAB L60 MAXFEE 01/01/2020 64.41 0.0 Description: ONCOPROTEIN HER-2/NEU Category: Laboratory CMS Add: 01/01/2002 CMS Term: 83951 LAB L60 MAXFEE 01/01/2020 64.41 0.0 Description: ONCOPROTEIN DCP Category: Laboratory CMS Add: 01/01/2009 CMS Term: 83970 LAB L60 MAXFEE 01/01/2020 41.28 0.0 Description: ASSAY OF PARATHORMONE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 83986 LAB L60 MAXFEE 01/01/2020 3.58 0.0 Description: ASSAY PH BODY FLUID NOS Category: Laboratory CMS Add: 01/01/1984 CMS Term: 83987 LAB L60 MAXFEE 01/01/2020 3.58 0.0 Description: EXHALED BREATH CONDENSATE Category: Laboratory CMS Add: 01/01/2010 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,123 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 83992 LAB L60 MAXFEE 01/01/2015 12/31/2023 20.00 0.0 Description: ASSAY FOR PHENCYCLIDINE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 83992 LAB L60 MAXFEE 01/01/2024 26.00 0.0 Description: ASSAY FOR PHENCYCLIDINE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 83993 LAB L60 MAXFEE 01/01/2020 19.63 0.0 Description: ASSAY FOR CALPROTECTIN FECAL Category: Laboratory CMS Add: 01/01/2008 CMS Term: 84030 LAB L60 MAXFEE 01/01/2020 5.50 0.0 Description: ASSAY OF BLOOD PKU Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84035 LAB L60 MAXFEE 01/01/2020 3.98 0.0 Description: ASSAY OF PHENYLKETONES Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84060 LAB L60 MAXFEE 01/01/2020 7.64 0.0 Description: ASSAY ACID PHOSPHATASE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84066 LAB L60 MAXFEE 01/01/2020 9.66 0.0 Description: ASSAY PROSTATE PHOSPHATASE Category: Laboratory CMS Add: 01/01/1985 CMS Term: 84075 LAB L60 MAXFEE 01/01/2020 5.18 0.0 Description: ASSAY ALKALINE PHOSPHATASE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84078 LAB L60 MAXFEE 01/01/2019 8.26 0.0 Description: ASSAY ALKALINE PHOSPHATASE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84080 LAB L60 MAXFEE 01/01/2020 14.78 0.0 Description: ASSAY ALKALINE PHOSPHATASES Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84081 LAB L60 MAXFEE 01/01/2020 16.52 0.0 Description: ASSAY PHOSPHATIDYLGLYCEROL Category: Laboratory CMS Add: 01/01/1985 CMS Term: 84085 LAB L60 MAXFEE 01/01/2015 12/31/2023 9.18 0.0 Description: ASSAY OF RBC PG6D ENZYME Category: Laboratory CMS Add: 01/01/1985 CMS Term: 84085 LAB L60 MAXFEE 01/01/2024 9.44 0.0 Description: ASSAY OF RBC PG6D ENZYME Category: Laboratory CMS Add: 01/01/1985 CMS Term: 84087 LAB L60 MAXFEE 01/01/2020 10.73 0.0 Description: ASSAY PHOSPHOHEXOSE ENZYMES Category: Laboratory CMS Add: 01/01/1985 CMS Term: 84100 LAB L60 MAXFEE 01/01/2020 4.74 0.0 Description: ASSAY OF PHOSPHORUS Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84105 LAB L60 MAXFEE 01/01/2019 5.78 0.0 Description: ASSAY OF URINE PHOSPHORUS Category: Laboratory CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,124 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 84106 LAB L60 MAXFEE 01/01/2015 5.82 0.0 Description: TEST FOR PORPHOBILINOGEN Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84110 LAB L60 MAXFEE 01/01/2020 8.44 0.0 Description: ASSAY OF PORPHOBILINOGEN Category: Laboratory CMS Add: 01/01/1985 CMS Term: 84112 LAB L60 MAXFEE 01/01/2024 98.11 0.0 Description: EVAL AMNIOTIC FLUID PROTEIN Category: Laboratory CMS Add: 01/01/2011 CMS Term: 84112 LAB L60 MAXFEE 07/01/2015 12/31/2023 87.65 0.0 Description: EVAL AMNIOTIC FLUID PROTEIN Category: Laboratory CMS Add: 01/01/2011 CMS Term: 84119 LAB L60 MAXFEE 01/01/2015 12/31/2023 11.72 0.0 Description: TEST URINE FOR PORPHYRINS Category: Laboratory CMS Add: 01/01/1985 CMS Term: 84119 LAB L60 MAXFEE 01/01/2024 13.36 0.0 Description: TEST URINE FOR PORPHYRINS Category: Laboratory CMS Add: 01/01/1985 CMS Term: 84120 LAB L60 MAXFEE 01/01/2020 14.71 0.0 Description: ASSAY OF URINE PORPHYRINS Category: Laboratory CMS Add: 01/01/1985 CMS Term: 84126 LAB L60 MAXFEE 01/01/2015 12/31/2023 20.14 0.0 Description: ASSAY OF FECES PORPHYRINS Category: Laboratory CMS Add: 01/01/1985 CMS Term: 84126 LAB L60 MAXFEE 01/01/2024 39.11 0.0 Description: ASSAY OF FECES PORPHYRINS Category: Laboratory CMS Add: 01/01/1985 CMS Term: 84132 LAB L60 MAXFEE 01/01/2020 4.76 0.0 Description: ASSAY OF SERUM POTASSIUM Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84133 LAB L60 MAXFEE 01/01/2015 12/31/2023 4.70 0.0 Description: ASSAY OF URINE POTASSIUM Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84133 LAB L60 MAXFEE 01/01/2024 4.73 0.0 Description: ASSAY OF URINE POTASSIUM Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84134 LAB L60 MAXFEE 01/01/2015 12/31/2023 7.82 0.0 Description: ASSAY OF PREALBUMIN Category: Laboratory CMS Add: 01/01/1993 CMS Term: 84134 LAB L60 MAXFEE 01/01/2024 14.59 0.0 Description: ASSAY OF PREALBUMIN Category: Laboratory CMS Add: 01/01/1993 CMS Term: 84135 LAB L60 MAXFEE 01/01/2019 21.27 0.0 Description: ASSAY OF PREGNANEDIOL Category: Laboratory CMS Add: 01/01/1985 CMS Term: 84138 LAB L60 MAXFEE 01/01/2019 21.05 0.0 Description: ASSAY OF PREGNANETRIOL Category: Laboratory CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,125 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 84140 LAB L60 MAXFEE 01/01/2020 20.67 0.0 Description: ASSAY OF PREGNENOLONE Category: Laboratory CMS Add: 01/01/1994 CMS Term: 84143 LAB L60 MAXFEE 01/01/2020 22.81 0.0 Description: ASSAY OF 17-HYDROXYPREGNENO Category: Laboratory CMS Add: 01/01/1994 CMS Term: 84144 LAB L60 MAXFEE 01/01/2020 20.86 0.0 Description: ASSAY OF PROGESTERONE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84145 LAB L60 MAXFEE 01/01/2020 27.22 0.0 Description: PROCALCITONIN (PCT) Category: Laboratory CMS Add: 01/01/2010 CMS Term: 84146 LAB L60 MAXFEE 01/01/2020 19.38 0.0 Description: ASSAY OF PROLACTIN Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84150 LAB L60 MAXFEE 01/01/2015 12/31/2023 33.96 0.0 Description: ASSAY OF PROSTAGLANDIN Category: Laboratory CMS Add: 01/01/1982 CMS Term: 84150 LAB L60 MAXFEE 01/01/2024 41.77 0.0 Description: ASSAY OF PROSTAGLANDIN Category: Laboratory CMS Add: 01/01/1982 CMS Term: 84152 LAB L60 MAXFEE 01/01/2020 18.39 0.0 Description: ASSAY OF PSA COMPLEXED Category: Laboratory CMS Add: 01/01/2001 CMS Term: 84153 LAB L60 MAXFEE 01/01/2020 18.39 0.0 Description: ASSAY OF PSA TOTAL Category: Laboratory CMS Add: 01/01/1993 CMS Term: 84154 LAB L60 MAXFEE 01/01/2020 18.39 0.0 Description: ASSAY OF PSA FREE Category: Laboratory CMS Add: 01/01/1999 CMS Term: 84155 LAB L60 MAXFEE 01/01/2020 3.67 0.0 Description: ASSAY OF PROTEIN SERUM Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84156 LAB L60 MAXFEE 01/01/2020 3.67 0.0 Description: ASSAY OF PROTEIN URINE Category: Laboratory CMS Add: 01/01/2004 CMS Term: 84157 LAB L60 MAXFEE 01/01/2020 4.00 0.0 Description: ASSAY OF PROTEIN OTHER Category: Laboratory CMS Add: 01/01/2004 CMS Term: 84160 LAB L60 MAXFEE 01/01/2020 5.61 0.0 Description: ASSAY OF PROTEIN ANY SOURCE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84163 LAB L60 MAXFEE 01/01/2015 12/31/2023 9.51 0.0 Description: PAPPA SERUM Category: Laboratory CMS Add: 01/01/2005 CMS Term: 84163 LAB L60 MAXFEE 01/01/2024 15.05 0.0 Description: PAPPA SERUM Category: Laboratory CMS Add: 01/01/2005 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,126 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 84165* 26 LAB DEF RBRVS 01/01/2024 17.02 Description: PROTEIN E-PHORESIS SERUM Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84165* 26 LAB DEF RBRVS 02/01/2015 12/31/2023 13.90 Description: PROTEIN E-PHORESIS SERUM Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84165* LAB L60 MAXFEE 01/01/2004 12/31/2023 5.12 0.0 Description: PROTEIN E-PHORESIS SERUM Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84165* LAB L60 MAXFEE 01/01/2024 10.74 0.0 Description: PROTEIN E-PHORESIS SERUM Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84166* 26 LAB DEF RBRVS 01/01/2024 17.02 Description: PROTEIN E-PHORESIS/URINE/CSF Category: Laboratory CMS Add: 01/01/2005 CMS Term: 84166* 26 LAB DEF RBRVS 02/01/2015 12/31/2023 13.90 Description: PROTEIN E-PHORESIS/URINE/CSF Category: Laboratory CMS Add: 01/01/2005 CMS Term: 84166* LAB L60 MAXFEE 01/01/2020 17.83 0.0 Description: PROTEIN E-PHORESIS/URINE/CSF Category: Laboratory CMS Add: 01/01/2005 CMS Term: 84181* 26 LAB DEF RBRVS 01/01/2024 17.02 Description: WESTERN BLOT TEST Category: Laboratory CMS Add: 01/01/1993 CMS Term: 84181* 26 LAB DEF RBRVS 02/01/2015 12/31/2023 13.90 Description: WESTERN BLOT TEST Category: Laboratory CMS Add: 01/01/1993 CMS Term: 84181* LAB L60 MAXFEE 01/01/2020 17.03 0.0 Description: WESTERN BLOT TEST Category: Laboratory CMS Add: 01/01/1993 CMS Term: 84182* 26 LAB DEF RBRVS 01/01/2024 17.02 Description: PROTEIN WESTERN BLOT TEST Category: Laboratory CMS Add: 01/01/1993 CMS Term: 84182* 26 LAB DEF RBRVS 02/01/2015 12/31/2023 13.90 Description: PROTEIN WESTERN BLOT TEST Category: Laboratory CMS Add: 01/01/1993 CMS Term: 84182* LAB L60 MAXFEE 01/01/2015 12/31/2023 24.49 0.0 Description: PROTEIN WESTERN BLOT TEST Category: Laboratory CMS Add: 01/01/1993 CMS Term: 84182* LAB L60 MAXFEE 01/01/2024 29.21 0.0 Description: PROTEIN WESTERN BLOT TEST Category: Laboratory CMS Add: 01/01/1993 CMS Term: 84202 LAB L60 MAXFEE 01/01/2020 14.35 0.0 Description: ASSAY RBC PROTOPORPHYRIN Category: Laboratory CMS Add: 01/01/1985 CMS Term: 84203 LAB L60 MAXFEE 01/01/2019 9.74 0.0 Description: TEST RBC PROTOPORPHYRIN Category: Laboratory CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,127 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 84206 LAB L60 MAXFEE 01/01/2015 12/31/2023 24.24 0.0 Description: ASSAY OF PROINSULIN Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84206 LAB L60 MAXFEE 01/01/2024 26.69 0.0 Description: ASSAY OF PROINSULIN Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84207 LAB L60 MAXFEE 01/01/2020 28.10 0.0 Description: ASSAY OF VITAMIN B-6 Category: Laboratory CMS Add: 01/01/1985 CMS Term: 84210 LAB L60 MAXFEE 01/01/2015 12/31/2023 12.15 0.0 Description: ASSAY OF PYRUVATE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84210 LAB L60 MAXFEE 01/01/2024 14.48 0.0 Description: ASSAY OF PYRUVATE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84220 LAB L60 MAXFEE 01/01/2020 9.44 0.0 Description: ASSAY OF PYRUVATE KINASE Category: Laboratory CMS Add: 01/01/1985 CMS Term: 84228 LAB L60 MAXFEE 01/01/2020 11.63 0.0 Description: ASSAY OF QUININE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84233 LAB L60 MAXFEE 01/01/2015 12/31/2023 87.65 0.0 Description: ASSAY OF ESTROGEN Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84233 LAB L60 MAXFEE 01/01/2024 87.88 0.0 Description: ASSAY OF ESTROGEN Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84234 LAB L60 MAXFEE 01/01/2020 64.88 0.0 Description: ASSAY OF PROGESTERONE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84235 LAB L60 MAXFEE 01/01/2015 12/31/2023 16.45 0.0 Description: ASSAY OF ENDOCRINE HORMONE Category: Laboratory CMS Add: 01/01/1985 CMS Term: 84235 LAB L60 MAXFEE 01/01/2024 71.23 0.0 Description: ASSAY OF ENDOCRINE HORMONE Category: Laboratory CMS Add: 01/01/1985 CMS Term: 84238 LAB L60 MAXFEE 01/01/2020 36.57 0.0 Description: ASSAY NONENDOCRINE RECEPTOR Category: Laboratory CMS Add: 01/01/1985 CMS Term: 84244 LAB L60 MAXFEE 01/01/2020 21.99 0.0 Description: ASSAY OF RENIN Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84252 LAB L60 MAXFEE 01/01/2020 20.24 0.0 Description: ASSAY OF VITAMIN B-2 Category: Laboratory CMS Add: 01/01/1985 CMS Term: 84255 LAB L60 MAXFEE 01/01/2020 25.53 0.0 Description: ASSAY OF SELENIUM Category: Laboratory CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,128 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 84260 LAB L60 MAXFEE 01/01/2020 30.98 0.0 Description: ASSAY OF SEROTONIN Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84270 LAB L60 MAXFEE 01/01/2020 21.73 0.0 Description: ASSAY OF SEX HORMONE GLOBUL Category: Laboratory CMS Add: 01/01/1993 CMS Term: 84275 LAB L60 MAXFEE 01/01/2020 13.44 0.0 Description: ASSAY OF SIALIC ACID Category: Laboratory CMS Add: 01/01/1982 CMS Term: 84285 LAB L60 MAXFEE 01/01/2020 25.21 0.0 Description: ASSAY OF SILICA Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84295 LAB L60 MAXFEE 01/01/2020 4.81 0.0 Description: ASSAY OF SERUM SODIUM Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84300 LAB L60 MAXFEE 01/01/2015 12/31/2023 4.70 0.0 Description: ASSAY OF URINE SODIUM Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84300 LAB L60 MAXFEE 01/01/2024 5.06 0.0 Description: ASSAY OF URINE SODIUM Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84302 LAB L60 MAXFEE 01/01/2015 12/31/2023 4.70 0.0 Description: ASSAY OF SWEAT SODIUM Category: Laboratory CMS Add: 01/01/2003 CMS Term: 84302 LAB L60 MAXFEE 01/01/2024 4.86 0.0 Description: ASSAY OF SWEAT SODIUM Category: Laboratory CMS Add: 01/01/2003 CMS Term: 84305 LAB L60 MAXFEE 01/01/2020 21.26 0.0 Description: ASSAY OF SOMATOMEDIN Category: Laboratory CMS Add: 01/01/1993 CMS Term: 84307 LAB L60 MAXFEE 01/01/2020 18.28 0.0 Description: ASSAY OF SOMATOSTATIN Category: Laboratory CMS Add: 01/01/1993 CMS Term: 84311 LAB L60 MAXFEE 01/01/2019 8.10 0.0 Description: SPECTROPHOTOMETRY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 84315 LAB L60 MAXFEE 01/01/2014 12/31/2023 1.52 0.0 Description: BODY FLUID SPECIFIC GRAVITY Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84315 LAB L60 MAXFEE 01/01/2024 3.28 0.0 Description: BODY FLUID SPECIFIC GRAVITY Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84375 LAB L60 MAXFEE 01/01/2015 12/31/2023 26.68 0.0 Description: CHROMATOGRAM ASSAY SUGARS Category: Laboratory CMS Add: 01/01/1982 CMS Term: 84375 LAB L60 MAXFEE 01/01/2024 39.00 0.0 Description: CHROMATOGRAM ASSAY SUGARS Category: Laboratory CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,129 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 84376 LAB L60 MAXFEE 01/01/2015 12/31/2023 3.19 0.0 Description: SUGARS SINGLE QUAL Category: Laboratory CMS Add: 01/01/1999 CMS Term: 84376 LAB L60 MAXFEE 01/01/2024 5.50 0.0 Description: SUGARS SINGLE QUAL Category: Laboratory CMS Add: 01/01/1999 CMS Term: 84377 LAB L60 MAXFEE 01/01/2015 12/31/2023 3.19 0.0 Description: SUGARS MULTIPLE QUAL Category: Laboratory CMS Add: 01/01/1999 CMS Term: 84377 LAB L60 MAXFEE 01/01/2024 5.50 0.0 Description: SUGARS MULTIPLE QUAL Category: Laboratory CMS Add: 01/01/1999 CMS Term: 84378 LAB L60 MAXFEE 01/01/2015 12/31/2023 8.10 0.0 Description: SUGARS SINGLE QUANT Category: Laboratory CMS Add: 01/01/1999 CMS Term: 84378 LAB L60 MAXFEE 01/01/2024 11.53 0.0 Description: SUGARS SINGLE QUANT Category: Laboratory CMS Add: 01/01/1999 CMS Term: 84379 LAB L60 MAXFEE 01/01/2015 12/31/2023 8.10 0.0 Description: SUGARS MULTIPLE QUANT Category: Laboratory CMS Add: 01/01/1999 CMS Term: 84379 LAB L60 MAXFEE 01/01/2024 11.53 0.0 Description: SUGARS MULTIPLE QUANT Category: Laboratory CMS Add: 01/01/1999 CMS Term: 84392 LAB L60 MAXFEE 01/01/2019 5.49 0.0 Description: ASSAY OF URINE SULFATE Category: Laboratory CMS Add: 01/01/1992 CMS Term: 84402 LAB L60 MAXFEE 01/01/2020 25.47 0.0 Description: ASSAY OF FREE TESTOSTERONE Category: Laboratory CMS Add: 01/01/1993 CMS Term: 84403 LAB L60 MAXFEE 01/01/2020 25.81 0.0 Description: ASSAY OF TOTAL TESTOSTERONE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84410 LAB L60 MAXFEE 01/01/2020 51.28 0.0 Description: TESTOSTERONE BIOAVAILABLE Category: Laboratory CMS Add: 01/01/2017 CMS Term: 84425 LAB L60 MAXFEE 01/01/2020 21.23 0.0 Description: ASSAY OF VITAMIN B-1 Category: Laboratory CMS Add: 01/01/1985 CMS Term: 84430 LAB L60 MAXFEE 01/01/2020 11.63 0.0 Description: ASSAY OF THIOCYANATE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84431 LAB L60 MAXFEE 01/01/2010 12/31/2023 18.54 0.0 Description: THROMBOXANE URINE Category: Laboratory CMS Add: 01/01/2010 CMS Term: 84431 LAB L60 MAXFEE 01/01/2024 35.11 0.0 Description: THROMBOXANE URINE Category: Laboratory CMS Add: 01/01/2010 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,130 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 84432 LAB L60 MAXFEE 01/01/2020 16.06 0.0 Description: ASSAY OF THYROGLOBULIN Category: Laboratory CMS Add: 01/01/1993 CMS Term: 84433 NOCOV DEF SYSMAN Description: ASY THIOPURIN S-MTHYLTRNSFRS Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 84436 LAB L60 MAXFEE 01/01/2020 6.87 0.0 Description: ASSAY OF TOTAL THYROXINE Category: Laboratory CMS Add: 01/01/1985 CMS Term: 84436 MRT L60 MAXFEE 01/01/2020 6.87 0.0 Description: ASSAY OF TOTAL THYROXINE Category: Medical Review Team CMS Add: 01/01/1985 CMS Term: 84437 LAB L60 MAXFEE 01/01/2020 6.47 0.0 Description: ASSAY OF NEONATAL THYROXINE Category: Laboratory CMS Add: 01/01/1985 CMS Term: 84439 LAB L60 MAXFEE 01/01/2020 9.02 0.0 Description: ASSAY OF FREE THYROXINE Category: Laboratory CMS Add: 01/01/1985 CMS Term: 84442 LAB L60 MAXFEE 01/01/2020 14.78 0.0 Description: ASSAY OF THYROID ACTIVITY Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84443 LAB L60 MAXFEE 01/01/2020 16.80 0.0 Description: ASSAY THYROID STIM HORMONE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84443 MRT L60 MAXFEE 01/01/2020 16.80 0.0 Description: ASSAY THYROID STIM HORMONE Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 84445 LAB L60 MAXFEE 01/01/2020 50.86 0.0 Description: ASSAY OF TSI GLOBULIN Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84446 LAB L60 MAXFEE 01/01/2020 14.18 0.0 Description: ASSAY OF VITAMIN E Category: Laboratory CMS Add: 01/01/1985 CMS Term: 84449 LAB L60 MAXFEE 01/01/2020 18.00 0.0 Description: ASSAY OF TRANSCORTIN Category: Laboratory CMS Add: 01/01/1994 CMS Term: 84450 LAB L60 MAXFEE 01/01/2020 5.18 0.0 Description: TRANSFERASE (AST) (SGOT) Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84450 MRT L60 MAXFEE 01/01/2020 5.18 0.0 Description: TRANSFERASE (AST) (SGOT) Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 84460 LAB L60 MAXFEE 01/01/2020 5.30 0.0 Description: ALANINE AMINO (ALT) (SGPT) Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84460 MRT L60 MAXFEE 01/01/2020 5.30 0.0 Description: ALANINE AMINO (ALT) (SGPT) Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,131 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 84466 LAB L60 MAXFEE 01/01/2020 12.76 0.0 Description: ASSAY OF TRANSFERRIN Category: Laboratory CMS Add: 01/01/1993 CMS Term: 84478 LAB L60 MAXFEE 01/01/2020 5.74 0.0 Description: ASSAY OF TRIGLYCERIDES Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84478 MRT L60 MAXFEE 01/01/2020 5.74 0.0 Description: ASSAY OF TRIGLYCERIDES Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 84479 LAB L60 MAXFEE 01/01/2020 6.47 0.0 Description: ASSAY OF THYROID (T3 OR T4) Category: Laboratory CMS Add: 01/01/1985 CMS Term: 84479 MRT L60 MAXFEE 01/01/2020 6.47 0.0 Description: ASSAY OF THYROID (T3 OR T4) Category: Medical Review Team CMS Add: 01/01/1985 CMS Term: 84480 LAB L60 MAXFEE 01/01/2015 12/31/2023 13.43 0.0 Description: ASSAY TRIIODOTHYRONINE (T3) Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84480 LAB L60 MAXFEE 01/01/2024 14.18 0.0 Description: ASSAY TRIIODOTHYRONINE (T3) Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84481 LAB L60 MAXFEE 01/01/2020 16.94 0.0 Description: FREE ASSAY (FT-3) Category: Laboratory CMS Add: 01/01/1982 CMS Term: 84482 LAB L60 MAXFEE 01/01/2020 15.76 0.0 Description: T3 REVERSE Category: Laboratory CMS Add: 01/01/1993 CMS Term: 84484 LAB L60 MAXFEE 01/01/2018 12.47 0.0 Description: ASSAY OF TROPONIN QUANT Category: Laboratory CMS Add: 01/01/1997 CMS Term: 84485 LAB L60 MAXFEE 01/01/2020 7.20 0.0 Description: ASSAY DUODENAL FLUID TRYPSIN Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84488 LAB L60 MAXFEE 01/01/2020 7.30 0.0 Description: TEST FECES FOR TRYPSIN Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84490 LAB L60 MAXFEE 01/01/2015 12/31/2023 4.93 0.0 Description: ASSAY OF FECES FOR TRYPSIN Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84490 LAB L60 MAXFEE 01/01/2024 9.93 0.0 Description: ASSAY OF FECES FOR TRYPSIN Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84510 LAB L60 MAXFEE 01/01/2020 10.63 0.0 Description: ASSAY OF TYROSINE Category: Laboratory CMS Add: 01/01/1982 CMS Term: 84512 LAB L60 MAXFEE 01/01/2018 10.09 0.0 Description: ASSAY OF TROPONIN QUAL Category: Laboratory CMS Add: 01/01/1998 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,132 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 84520 LAB L60 MAXFEE 01/01/2020 3.95 0.0 Description: ASSAY OF UREA NITROGEN Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84525 LAB L60 MAXFEE 01/01/2015 12/31/2023 5.12 0.0 Description: UREA NITROGEN SEMI-QUANT Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84525 LAB L60 MAXFEE 01/01/2024 5.13 0.0 Description: UREA NITROGEN SEMI-QUANT Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84540 LAB L60 MAXFEE 01/01/2015 12/31/2023 3.92 0.0 Description: ASSAY OF URINE/UREA-N Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84540 LAB L60 MAXFEE 01/01/2024 5.56 0.0 Description: ASSAY OF URINE/UREA-N Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84545 LAB L60 MAXFEE 01/01/2020 7.20 0.0 Description: UREA-N CLEARANCE TEST Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84550 LAB L60 MAXFEE 01/01/2020 4.52 0.0 Description: ASSAY OF BLOOD/URIC ACID Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84550 MRT L60 MAXFEE 01/01/2020 4.52 0.0 Description: ASSAY OF BLOOD/URIC ACID Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 84560 LAB L60 MAXFEE 01/01/2020 5.08 0.0 Description: ASSAY OF URINE/URIC ACID Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84577 LAB L60 MAXFEE 01/01/2015 12/31/2023 16.08 0.0 Description: ASSAY OF FECES/UROBILINOGEN Category: Laboratory CMS Add: 01/01/1982 CMS Term: 84577 LAB L60 MAXFEE 01/01/2024 16.80 0.0 Description: ASSAY OF FECES/UROBILINOGEN Category: Laboratory CMS Add: 01/01/1982 CMS Term: 84578 LAB L60 MAXFEE 01/01/2014 12/31/2023 4.43 0.0 Description: TEST URINE UROBILINOGEN Category: Laboratory CMS Add: 01/01/1982 CMS Term: 84578 LAB L60 MAXFEE 01/01/2024 4.47 0.0 Description: TEST URINE UROBILINOGEN Category: Laboratory CMS Add: 01/01/1982 CMS Term: 84580 LAB L60 MAXFEE 01/01/2019 9.55 0.0 Description: ASSAY OF URINE UROBILINOGEN Category: Laboratory CMS Add: 01/01/1982 CMS Term: 84583 LAB L60 MAXFEE 01/01/2019 6.05 0.0 Description: ASSAY OF URINE UROBILINOGEN Category: Laboratory CMS Add: 01/01/1982 CMS Term: 84585 LAB L60 MAXFEE 01/01/2015 12/31/2023 14.18 0.0 Description: ASSAY OF URINE VMA Category: Laboratory CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,133 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 84585 LAB L60 MAXFEE 01/01/2024 15.50 0.0 Description: ASSAY OF URINE VMA Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84586 LAB L60 MAXFEE 01/01/2020 35.33 0.0 Description: ASSAY OF VIP Category: Laboratory CMS Add: 01/01/1994 CMS Term: 84588 LAB L60 MAXFEE 01/01/2020 33.94 0.0 Description: ASSAY OF VASOPRESSIN Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84590 LAB L60 MAXFEE 01/01/2020 11.61 0.0 Description: ASSAY OF VITAMIN A Category: Laboratory CMS Add: 01/01/1985 CMS Term: 84591 LAB L60 MAXFEE 01/01/2015 12/31/2023 15.79 0.0 Description: ASSAY OF NOS VITAMIN Category: Laboratory CMS Add: 01/01/2001 CMS Term: 84591 LAB L60 MAXFEE 01/01/2024 17.06 0.0 Description: ASSAY OF NOS VITAMIN Category: Laboratory CMS Add: 01/01/2001 CMS Term: 84597 LAB L60 MAXFEE 01/01/2020 13.72 0.0 Description: ASSAY OF VITAMIN K Category: Laboratory CMS Add: 01/01/1985 CMS Term: 84600 LAB L60 MAXFEE 01/01/2020 17.11 0.0 Description: ASSAY OF VOLATILES Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84620 LAB L60 MAXFEE 01/01/2020 12.91 0.0 Description: XYLOSE TOLERANCE TEST Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84630 LAB L60 MAXFEE 01/01/2015 12/31/2023 6.45 0.0 Description: ASSAY OF ZINC Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84630 LAB L60 MAXFEE 01/01/2024 11.39 0.0 Description: ASSAY OF ZINC Category: Laboratory CMS Add: 01/01/1984 CMS Term: 84681 LAB L60 MAXFEE 01/01/2020 20.81 0.0 Description: ASSAY OF C-PEPTIDE Category: Laboratory CMS Add: 01/01/1987 CMS Term: 84702 LAB L60 MAXFEE 01/01/2015 12/31/2023 9.51 0.0 Description: CHORIONIC GONADOTROPIN TEST Category: Laboratory CMS Add: 01/01/1987 CMS Term: 84702 LAB L60 MAXFEE 01/01/2024 15.05 0.0 Description: CHORIONIC GONADOTROPIN TEST Category: Laboratory CMS Add: 01/01/1987 CMS Term: 84703 LAB L60 MAXFEE 01/01/2020 7.52 0.0 Description: CHORIONIC GONADOTROPIN ASSAY Category: Laboratory CMS Add: 01/01/1987 CMS Term: 84704 LAB L60 MAXFEE 01/01/2015 12/31/2023 9.51 0.0 Description: HCG FREE BETACHAIN TEST Category: Laboratory CMS Add: 01/01/2008 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,134 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 84704 LAB L60 MAXFEE 01/01/2024 15.29 0.0 Description: HCG FREE BETACHAIN TEST Category: Laboratory CMS Add: 01/01/2008 CMS Term: 84830 LAB L60 MAXFEE 01/01/2018 12.70 0.0 Description: OVULATION TESTS Category: Laboratory CMS Add: 01/01/1993 CMS Term: 84999 LAB DEF BILL30 Description: UNLISTED CHEMISTRY PROCEDURE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85002 LAB L60 MAXFEE 01/01/2020 4.82 0.0 Description: BLEEDING TIME TEST Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85004 LAB L60 MAXFEE 01/01/2020 6.47 0.0 Description: AUTOMATED DIFF WBC COUNT Category: Laboratory CMS Add: 01/01/2003 CMS Term: 85007 LAB L60 MAXFEE 01/01/2020 3.80 0.0 Description: BL SMEAR W/DIFF WBC COUNT Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85008 LAB L60 MAXFEE 01/01/2020 3.43 0.0 Description: BL SMEAR W/O DIFF WBC COUNT Category: Laboratory CMS Add: 01/01/1993 CMS Term: 85009 LAB L60 MAXFEE 01/01/2015 12/31/2023 5.06 0.0 Description: MANUAL DIFF WBC COUNT B-COAT Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85009 LAB L60 MAXFEE 01/01/2024 5.07 0.0 Description: MANUAL DIFF WBC COUNT B-COAT Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85013 LAB L60 MAXFEE 01/01/2014 12/31/2023 3.23 0.0 Description: SPUN MICROHEMATOCRIT Category: Laboratory CMS Add: 01/01/1993 CMS Term: 85013 LAB L60 MAXFEE 01/01/2024 7.00 0.0 Description: SPUN MICROHEMATOCRIT Category: Laboratory CMS Add: 01/01/1993 CMS Term: 85014 LAB L60 MAXFEE 01/01/2020 2.37 0.0 Description: HEMATOCRIT Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85018 LAB L60 MAXFEE 01/01/2020 2.37 0.0 Description: HEMOGLOBIN Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85018 MRT L60 MAXFEE 01/01/2020 2.37 0.0 Description: HEMOGLOBIN Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 85025 LAB L60 MAXFEE 01/01/2020 7.77 0.0 Description: COMPLETE CBC W/AUTO DIFF WBC Category: Laboratory CMS Add: 01/01/1987 CMS Term: 85025 MRT L60 MAXFEE 01/01/2020 7.77 0.0 Description: COMPLETE CBC W/AUTO DIFF WBC Category: Medical Review Team CMS Add: 01/01/1987 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,135 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 85027 LAB L60 MAXFEE 01/01/2020 6.47 0.0 Description: COMPLETE CBC AUTOMATED Category: Laboratory CMS Add: 01/01/1985 CMS Term: 85027 MRT L60 MAXFEE 01/01/2020 6.47 0.0 Description: COMPLETE CBC AUTOMATED Category: Medical Review Team CMS Add: 01/01/1985 CMS Term: 85032 LAB L60 MAXFEE 01/01/2020 4.31 0.0 Description: MANUAL CELL COUNT EACH Category: Laboratory CMS Add: 01/01/2003 CMS Term: 85041 LAB L60 MAXFEE 01/01/2020 3.02 0.0 Description: AUTOMATED RBC COUNT Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85044 LAB L60 MAXFEE 01/01/2020 4.31 0.0 Description: MANUAL RETICULOCYTE COUNT Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85045 LAB L60 MAXFEE 01/01/2020 3.99 0.0 Description: AUTOMATED RETICULOCYTE COUNT Category: Laboratory CMS Add: 01/01/1990 CMS Term: 85046 LAB L60 MAXFEE 01/01/2020 5.57 0.0 Description: RETICYTE/HGB CONCENTRATE Category: Laboratory CMS Add: 01/01/1999 CMS Term: 85048 LAB L60 MAXFEE 01/01/2020 2.54 0.0 Description: AUTOMATED LEUKOCYTE COUNT Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85049 LAB L60 MAXFEE 01/01/2020 4.48 0.0 Description: AUTOMATED PLATELET COUNT Category: Laboratory CMS Add: 01/01/2003 CMS Term: 85055 LAB L60 MAXFEE 01/01/2018 35.74 0.0 Description: RETICULATED PLATELET ASSAY Category: Laboratory CMS Add: 01/01/2004 CMS Term: 85060 LAB DEF RBRVS 01/01/2024 22.68 Description: BLOOD SMEAR INTERPRETATION Category: Laboratory CMS Add: 01/01/1985 CMS Term: 85060 LAB DEF RBRVS 02/01/2015 12/31/2023 17.79 Description: BLOOD SMEAR INTERPRETATION Category: Laboratory CMS Add: 01/01/1985 CMS Term: 85097 LAB DEF RBRVS 01/01/2024 65.22 Description: BONE MARROW INTERPRETATION Category: Laboratory CMS Add: 01/01/1985 CMS Term: 85097 LAB DEF RBRVS 02/01/2015 12/31/2023 61.26 Description: BONE MARROW INTERPRETATION Category: Laboratory CMS Add: 01/01/1985 CMS Term: 85130 LAB L60 MAXFEE 01/01/2015 12/31/2023 11.71 0.0 Description: CHROMOGENIC SUBSTRATE ASSAY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 85130 LAB L60 MAXFEE 01/01/2024 11.89 0.0 Description: CHROMOGENIC SUBSTRATE ASSAY Category: Laboratory CMS Add: 01/01/1993 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,136 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 85170 LAB L60 MAXFEE 01/01/2015 12/31/2023 3.19 0.0 Description: BLOOD CLOT RETRACTION Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85170 LAB L60 MAXFEE 01/01/2024 16.30 0.0 Description: BLOOD CLOT RETRACTION Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85175 LAB L60 MAXFEE 01/01/2015 12/31/2023 3.19 0.0 Description: BLOOD CLOT LYSIS TIME Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85175 LAB L60 MAXFEE 01/01/2024 20.37 0.0 Description: BLOOD CLOT LYSIS TIME Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85210 LAB L60 MAXFEE 01/01/2020 12.98 0.0 Description: CLOT FACTOR II PROTHROM SPEC Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85220 LAB L60 MAXFEE 01/01/2020 17.65 0.0 Description: BLOOC CLOT FACTOR V TEST Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85230 LAB L60 MAXFEE 01/01/2020 17.90 0.0 Description: CLOT FACTOR VII PROCONVERTIN Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85240 LAB L60 MAXFEE 01/01/2020 17.90 0.0 Description: CLOT FACTOR VIII AHG 1 STAGE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85244 LAB L60 MAXFEE 01/01/2020 20.42 0.0 Description: CLOT FACTOR VIII RELTD ANTGN Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85245 LAB L60 MAXFEE 01/01/2020 22.94 0.0 Description: CLOT FACTOR VIII VW RISTOCTN Category: Laboratory CMS Add: 01/01/1993 CMS Term: 85246 LAB L60 MAXFEE 01/01/2020 22.94 0.0 Description: CLOT FACTOR VIII VW ANTIGEN Category: Laboratory CMS Add: 01/01/1993 CMS Term: 85247 LAB L60 MAXFEE 01/01/2020 22.94 0.0 Description: CLOT FACTOR VIII MULTIMETRIC Category: Laboratory CMS Add: 01/01/1993 CMS Term: 85250 LAB L60 MAXFEE 01/01/2020 19.04 0.0 Description: CLOT FACTOR IX PTC/CHRSTMAS Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85260 LAB L60 MAXFEE 01/01/2020 17.90 0.0 Description: CLOT FACTOR X STUART-POWER Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85270 LAB L60 MAXFEE 01/01/2020 17.90 0.0 Description: CLOT FACTOR XI PTA Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85280 LAB L60 MAXFEE 01/01/2020 19.35 0.0 Description: CLOT FACTOR XII HAGEMAN Category: Laboratory CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,137 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 85290 LAB L60 MAXFEE 01/01/2020 16.34 0.0 Description: CLOT FACTOR XIII FIBRIN STAB Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85291 LAB L60 MAXFEE 01/01/2020 9.11 0.0 Description: CLOT FACTOR XIII FIBRIN SCRN Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85292 LAB L60 MAXFEE 01/01/2020 18.93 0.0 Description: CLOT FACTOR FLETCHER FACT Category: Laboratory CMS Add: 01/01/1985 CMS Term: 85293 LAB L60 MAXFEE 01/01/2020 18.93 0.0 Description: CLOT FACTOR WGHT KININOGEN Category: Laboratory CMS Add: 01/01/1985 CMS Term: 85300 LAB L60 MAXFEE 01/01/2020 11.85 0.0 Description: ANTITHROMBIN III ACTIVITY Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85301 LAB L60 MAXFEE 01/01/2020 10.81 0.0 Description: ANTITHROMBIN III ANTIGEN Category: Laboratory CMS Add: 01/01/1985 CMS Term: 85302 LAB L60 MAXFEE 01/01/2020 12.01 0.0 Description: CLOT INHIBIT PROT C ANTIGEN Category: Laboratory CMS Add: 01/01/1985 CMS Term: 85303 LAB L60 MAXFEE 01/01/2020 13.84 0.0 Description: CLOT INHIBIT PROT C ACTIVITY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 85305 LAB L60 MAXFEE 01/01/2020 11.61 0.0 Description: CLOT INHIBIT PROT S TOTAL Category: Laboratory CMS Add: 01/01/1992 CMS Term: 85306 LAB L60 MAXFEE 01/01/2020 15.32 0.0 Description: CLOT INHIBIT PROT S FREE Category: Laboratory CMS Add: 01/01/1993 CMS Term: 85307 LAB L60 MAXFEE 01/01/2020 15.32 0.0 Description: ASSAY ACTIVATED PROTEIN C Category: Laboratory CMS Add: 01/01/2001 CMS Term: 85335 LAB L60 MAXFEE 01/01/2020 12.87 0.0 Description: FACTOR INHIBITOR TEST Category: Laboratory CMS Add: 01/01/1993 CMS Term: 85337 LAB L60 MAXFEE 01/01/2015 12/31/2023 14.19 0.0 Description: THROMBOMODULIN Category: Laboratory CMS Add: 01/01/1993 CMS Term: 85337 LAB L60 MAXFEE 01/01/2024 17.27 0.0 Description: THROMBOMODULIN Category: Laboratory CMS Add: 01/01/1993 CMS Term: 85345 LAB L60 MAXFEE 01/01/2020 4.69 0.0 Description: COAGULATION TIME LEE & WHITE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85347 LAB L60 MAXFEE 01/01/2015 12/31/2023 3.19 0.0 Description: COAGULATION TIME ACTIVATED Category: Laboratory CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,138 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 85347 LAB L60 MAXFEE 01/01/2024 4.28 0.0 Description: COAGULATION TIME ACTIVATED Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85348 LAB L60 MAXFEE 01/01/2019 4.49 0.0 Description: COAGULATION TIME OTR METHOD Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85360 LAB L60 MAXFEE 01/01/2020 8.41 0.0 Description: EUGLOBULIN LYSIS Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85362 LAB L60 MAXFEE 01/01/2020 6.89 0.0 Description: FIBRIN DEGRADATION PRODUCTS Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85366 LAB L60 MAXFEE 01/01/2015 12/31/2023 11.72 0.0 Description: FIBRINOGEN TEST Category: Laboratory CMS Add: 01/01/1993 CMS Term: 85366 LAB L60 MAXFEE 01/01/2024 80.46 0.0 Description: FIBRINOGEN TEST Category: Laboratory CMS Add: 01/01/1993 CMS Term: 85370 LAB L60 MAXFEE 01/01/2020 12.43 0.0 Description: FIBRINOGEN TEST Category: Laboratory CMS Add: 01/01/1993 CMS Term: 85378 LAB L60 MAXFEE 01/01/2015 12/31/2023 9.71 0.0 Description: FIBRIN DEGRADE SEMIQUANT Category: Laboratory CMS Add: 01/01/1993 CMS Term: 85378 LAB L60 MAXFEE 01/01/2024 9.72 0.0 Description: FIBRIN DEGRADE SEMIQUANT Category: Laboratory CMS Add: 01/01/1993 CMS Term: 85379 LAB L60 MAXFEE 01/01/2020 10.18 0.0 Description: FIBRIN DEGRADATION QUANT Category: Laboratory CMS Add: 01/01/1993 CMS Term: 85380 LAB L60 MAXFEE 01/01/2020 10.18 0.0 Description: FIBRIN DEGRADJ D-DIMER Category: Laboratory CMS Add: 01/01/2003 CMS Term: 85384 LAB L60 MAXFEE 01/01/2019 9.72 0.0 Description: FIBRINOGEN ACTIVITY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 85385 LAB L60 MAXFEE 01/01/2015 12/31/2023 11.19 0.0 Description: FIBRINOGEN ANTIGEN Category: Laboratory CMS Add: 01/01/1993 CMS Term: 85385 LAB L60 MAXFEE 01/01/2024 14.46 0.0 Description: FIBRINOGEN ANTIGEN Category: Laboratory CMS Add: 01/01/1993 CMS Term: 85390* 26 LAB DEF RBRVS 01/01/2024 34.69 Description: FIBRINOLYSINS SCREEN I&R Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85390* 26 LAB DEF RBRVS 02/01/2015 12/31/2023 13.90 Description: FIBRINOLYSINS SCREEN I&R Category: Laboratory CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,139 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 85390* LAB L60 MAXFEE 01/01/2015 12/31/2023 3.19 0.0 Description: FIBRINOLYSINS SCREEN I&R Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85390* LAB L60 MAXFEE 01/01/2024 15.48 0.0 Description: FIBRINOLYSINS SCREEN I&R Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85396 LAB DEF RBRVS 01/01/2024 18.42 Description: CLOTTING ASSAY WHOLE BLOOD Category: Laboratory CMS Add: 01/01/2004 CMS Term: 85396 LAB DEF RBRVS 09/01/2019 12/31/2023 14.65 Description: CLOTTING ASSAY WHOLE BLOOD Category: Laboratory CMS Add: 01/01/2004 CMS Term: 85397 LAB L60 MAXFEE 01/01/2018 30.86 0.0 Description: CLOTTING FUNCT ACTIVITY Category: Laboratory CMS Add: 01/01/2009 CMS Term: 85400 LAB L60 MAXFEE 01/01/2015 12/31/2023 3.19 0.0 Description: FIBRINOLYTIC PLASMIN Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85400 LAB L60 MAXFEE 01/01/2024 7.71 0.0 Description: FIBRINOLYTIC PLASMIN Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85410 LAB L60 MAXFEE 01/01/2015 12/31/2023 3.19 0.0 Description: FIBRINOLYTIC ANTIPLASMIN Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85410 LAB L60 MAXFEE 01/01/2024 7.71 0.0 Description: FIBRINOLYTIC ANTIPLASMIN Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85415 LAB L60 MAXFEE 01/01/2020 17.19 0.0 Description: FIBRINOLYTIC PLASMINOGEN Category: Laboratory CMS Add: 01/01/1993 CMS Term: 85420 LAB L60 MAXFEE 01/01/2020 6.53 0.0 Description: FIBRINOLYTIC PLASMINOGEN Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85421 LAB L60 MAXFEE 01/01/2020 10.18 0.0 Description: FIBRINOLYTIC PLASMINOGEN Category: Laboratory CMS Add: 01/01/1985 CMS Term: 85441 LAB L60 MAXFEE 01/01/2020 4.20 0.0 Description: HEINZ BODIES DIRECT Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85445 LAB L60 MAXFEE 01/01/2020 6.82 0.0 Description: HEINZ BODIES INDUCED Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85460 LAB L60 MAXFEE 01/01/2015 12/31/2023 4.06 0.0 Description: HEMOGLOBIN FETAL Category: Laboratory CMS Add: 01/01/1982 CMS Term: 85460 LAB L60 MAXFEE 01/01/2024 7.73 0.0 Description: HEMOGLOBIN FETAL Category: Laboratory CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,140 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 85461 LAB L60 MAXFEE 01/01/2015 12/31/2023 9.03 0.0 Description: HEMOGLOBIN FETAL Category: Laboratory CMS Add: 01/01/1995 CMS Term: 85461 LAB L60 MAXFEE 01/01/2024 9.36 0.0 Description: HEMOGLOBIN FETAL Category: Laboratory CMS Add: 01/01/1995 CMS Term: 85475 LAB L60 MAXFEE 01/01/2020 8.87 0.0 Description: HEMOLYSIN ACID Category: Laboratory CMS Add: 01/01/1993 CMS Term: 85520 LAB L60 MAXFEE 01/01/2020 13.09 0.0 Description: HEPARIN ASSAY Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85525 LAB L60 MAXFEE 01/01/2020 11.84 0.0 Description: HEPARIN NEUTRALIZATION Category: Laboratory CMS Add: 01/01/1993 CMS Term: 85530 LAB L60 MAXFEE 01/01/2020 13.09 0.0 Description: HEPARIN-PROTAMINE TOLERANCE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85536 LAB L60 MAXFEE 01/01/2020 6.88 0.0 Description: IRON STAIN PERIPHERAL BLOOD Category: Laboratory CMS Add: 01/01/2001 CMS Term: 85540 LAB L60 MAXFEE 01/01/2020 8.60 0.0 Description: WBC ALKALINE PHOSPHATASE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85547 LAB L60 MAXFEE 01/01/2015 12/31/2023 8.10 0.0 Description: RBC MECHANICAL FRAGILITY Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85547 LAB L60 MAXFEE 01/01/2024 8.60 0.0 Description: RBC MECHANICAL FRAGILITY Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85549 LAB L60 MAXFEE 01/01/2020 18.75 0.0 Description: MURAMIDASE Category: Laboratory CMS Add: 01/01/1982 CMS Term: 85555 LAB L60 MAXFEE 01/01/2019 7.47 0.0 Description: RBC OSMOTIC FRAGILITY Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85557 LAB L60 MAXFEE 01/01/2015 12/31/2023 8.10 0.0 Description: RBC OSMOTIC FRAGILITY Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85557 LAB L60 MAXFEE 01/01/2024 13.36 0.0 Description: RBC OSMOTIC FRAGILITY Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85576* 26 LAB DEF RBRVS 01/01/2024 17.02 Description: BLOOD PLATELET AGGREGATION Category: Laboratory CMS Add: 01/01/1985 CMS Term: 85576* 26 LAB DEF RBRVS 02/01/2015 12/31/2023 13.90 Description: BLOOD PLATELET AGGREGATION Category: Laboratory CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,141 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 85576* LAB L60 MAXFEE 01/01/2019 24.91 0.0 Description: BLOOD PLATELET AGGREGATION Category: Laboratory CMS Add: 01/01/1985 CMS Term: 85597 LAB L60 MAXFEE 01/01/2015 12/31/2023 8.02 0.0 Description: PHOSPHOLIPID PLTLT NEUTRALIZ Category: Laboratory CMS Add: 01/01/1993 CMS Term: 85597 LAB L60 MAXFEE 01/01/2024 17.98 0.0 Description: PHOSPHOLIPID PLTLT NEUTRALIZ Category: Laboratory CMS Add: 01/01/1993 CMS Term: 85598 LAB L60 MAXFEE 01/01/2015 12/31/2023 8.02 0.0 Description: HEXAGNAL PHOSPH PLTLT NEUTRL Category: Laboratory CMS Add: 01/01/2011 CMS Term: 85598 LAB L60 MAXFEE 01/01/2024 17.98 0.0 Description: HEXAGNAL PHOSPH PLTLT NEUTRL Category: Laboratory CMS Add: 01/01/2011 CMS Term: 85610 LAB L60 MAXFEE 01/01/2020 4.29 0.0 Description: PROTHROMBIN TIME Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85611 LAB L60 MAXFEE 01/01/2020 3.94 0.0 Description: PROTHROMBIN TEST Category: Laboratory CMS Add: 01/01/1993 CMS Term: 85612 LAB L60 MAXFEE 01/01/2015 12/31/2023 8.10 0.0 Description: VIPER VENOM PROTHROMBIN TIME Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85612 LAB L60 MAXFEE 01/01/2024 17.49 0.0 Description: VIPER VENOM PROTHROMBIN TIME Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85613 LAB L60 MAXFEE 01/01/2015 12/31/2023 8.10 0.0 Description: RUSSELL VIPER VENOM DILUTED Category: Laboratory CMS Add: 01/01/1993 CMS Term: 85613 LAB L60 MAXFEE 01/01/2024 9.58 0.0 Description: RUSSELL VIPER VENOM DILUTED Category: Laboratory CMS Add: 01/01/1993 CMS Term: 85635 LAB L60 MAXFEE 01/01/2020 9.85 0.0 Description: REPTILASE TEST Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85651 LAB L60 MAXFEE 01/01/2019 4.27 0.0 Description: RBC SED RATE NONAUTOMATED Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85651 MRT L60 MAXFEE 01/01/2019 4.27 0.0 Description: RBC SED RATE NONAUTOMATED Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 85652 LAB L60 MAXFEE 01/01/2020 2.70 0.0 Description: RBC SED RATE AUTOMATED Category: Laboratory CMS Add: 01/01/1996 CMS Term: 85652 MRT L60 MAXFEE 01/01/2020 2.70 0.0 Description: RBC SED RATE AUTOMATED Category: Medical Review Team CMS Add: 01/01/1996 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,142 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 85660 LAB L60 MAXFEE 01/01/2020 5.51 0.0 Description: RBC SICKLE CELL TEST Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85670 LAB L60 MAXFEE 01/01/2020 5.77 0.0 Description: THROMBIN TIME PLASMA Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85675 LAB L60 MAXFEE 01/01/2020 6.85 0.0 Description: THROMBIN TIME TITER Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85705 LAB L60 MAXFEE 01/01/2020 9.63 0.0 Description: THROMBOPLASTIN INHIBITION Category: Laboratory CMS Add: 01/01/1993 CMS Term: 85730 LAB L60 MAXFEE 01/01/2020 6.01 0.0 Description: THROMBOPLASTIN TIME PARTIAL Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85732 LAB L60 MAXFEE 01/01/2020 6.47 0.0 Description: THROMBOPLASTIN TIME PARTIAL Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85810 LAB L60 MAXFEE 01/01/2020 11.67 0.0 Description: BLOOD VISCOSITY EXAMINATION Category: Laboratory CMS Add: 01/01/1982 CMS Term: 85999 LAB L60 MAXFEE 01/01/2024 40.56 0.0 Description: UNLISTED HEMATOLOGY&COAGJ PX Category: Laboratory CMS Add: 01/01/1984 CMS Term: 85999 LAB L60 MAXFEE 07/01/1985 12/31/2023 31.20 0.0 Description: UNLISTED HEMATOLOGY&COAGJ PX Category: Laboratory CMS Add: 01/01/1984 CMS Term: 86000 LAB L60 MAXFEE 01/01/2020 6.98 0.0 Description: AGGLUTININS FEBRILE ANTIGEN Category: Laboratory CMS Add: 01/01/1984 CMS Term: 86001 LAB L60 MAXFEE 01/01/2015 12/31/2023 7.10 0.0 Description: ALLERGEN SPECIFIC IGG Category: Laboratory CMS Add: 01/01/2001 CMS Term: 86001 LAB L60 MAXFEE 01/01/2024 7.82 0.0 Description: ALLERGEN SPECIFIC IGG Category: Laboratory CMS Add: 01/01/2001 CMS Term: 86003 LAB L60 MAXFEE 01/01/2020 5.22 0.0 Description: ALLG SPEC IGE CRUDE XTRC EA Category: Laboratory CMS Add: 01/01/1994 CMS Term: 86005 LAB L60 MAXFEE 01/01/2020 7.97 0.0 Description: ALLG SPEC IGE MULTIALLG SCR Category: Laboratory CMS Add: 01/01/1994 CMS Term: 86008 NOCOV DEF SYSMAN Description: ALLG SPEC IGE RECOMB EA Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 86015 LAB L60 MAXFEE 01/01/2022 12/31/2023 11.53 0.0 Description: ACTIN ANTIBODY EACH Category: Laboratory CMS Add: 01/01/2022 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,143 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 86015 LAB L60 MAXFEE 01/01/2024 12.05 0.0 Description: ACTIN ANTIBODY EACH Category: Laboratory CMS Add: 01/01/2022 CMS Term: 86021 LAB L60 MAXFEE 01/01/2015 12/31/2023 12.54 0.0 Description: WBC ANTIBODY IDENTIFICATION Category: Laboratory CMS Add: 01/01/1984 CMS Term: 86021 LAB L60 MAXFEE 01/01/2024 15.05 0.0 Description: WBC ANTIBODY IDENTIFICATION Category: Laboratory CMS Add: 01/01/1984 CMS Term: 86022 LAB L60 MAXFEE 01/01/2015 12/31/2023 7.23 0.0 Description: PLATELET ANTIBODIES Category: Laboratory CMS Add: 01/01/1982 CMS Term: 86022 LAB L60 MAXFEE 01/01/2024 18.37 0.0 Description: PLATELET ANTIBODIES Category: Laboratory CMS Add: 01/01/1982 CMS Term: 86023 LAB L60 MAXFEE 01/01/2020 12.46 0.0 Description: IMMUNOGLOBULIN ASSAY Category: Laboratory CMS Add: 01/01/1984 CMS Term: 86036 LAB L60 MAXFEE 01/01/2022 12.05 0.0 Description: ANCA SCREEN EACH ANTIBODY Category: Laboratory CMS Add: 01/01/2022 CMS Term: 86037 LAB L60 MAXFEE 01/01/2022 12.05 0.0 Description: ANCA TITER EACH ANTIBODY Category: Laboratory CMS Add: 01/01/2022 CMS Term: 86038 LAB L60 MAXFEE 01/01/2020 12.09 0.0 Description: ANTINUCLEAR ANTIBODIES Category: Laboratory CMS Add: 01/01/1985 CMS Term: 86039 LAB L60 MAXFEE 01/01/2020 11.16 0.0 Description: ANTINUCLEAR ANTIBODIES (ANA) Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86041 NOCOV DEF SYSMAN Description: ACETYLCHOLN RCPTR BNDNG ANTB Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 86042 NOCOV DEF SYSMAN Description: ACETYLCHOLN RCPTR BLCKG ANTB Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 86043 NOCOV DEF SYSMAN Description: ACETYLCHOLN RCPTR MODLG ANTB Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 86051 LAB L60 MAXFEE 01/01/2022 11.53 0.0 Description: AQUAPORIN-4 ANTB ELISA Category: Laboratory CMS Add: 01/01/2022 CMS Term: 86052 LAB L60 MAXFEE 01/01/2022 12.05 0.0 Description: AQUAPORIN-4 ANTB CBA EACH Category: Laboratory CMS Add: 01/01/2022 CMS Term: 86053 LAB L60 MAXFEE 01/01/2022 12/31/2023 12.05 0.0 Description: AQAPRN-4 ANTB FLO CYTMTRY EA Category: Laboratory CMS Add: 01/01/2022 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,144 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 86053 LAB L60 MAXFEE 01/01/2024 37.73 0.0 Description: AQAPRN-4 ANTB FLO CYTMTRY EA Category: Laboratory CMS Add: 01/01/2022 CMS Term: 86060 LAB L60 MAXFEE 01/01/2020 7.30 0.0 Description: ANTISTREPTOLYSIN O TITER Category: Laboratory CMS Add: 01/01/1984 CMS Term: 86063 LAB L60 MAXFEE 01/01/2015 12/31/2023 5.18 0.0 Description: ANTISTREPTOLYSIN O SCREEN Category: Laboratory CMS Add: 01/01/1984 CMS Term: 86063 LAB L60 MAXFEE 01/01/2024 5.77 0.0 Description: ANTISTREPTOLYSIN O SCREEN Category: Laboratory CMS Add: 01/01/1984 CMS Term: 86077 LAB DEF RBRVS 01/01/2024 50.71 Description: PHYS BLOOD BANK SERV XMATCH Category: Laboratory CMS Add: 01/01/1985 CMS Term: 86077 LAB DEF RBRVS 02/01/2015 12/31/2023 39.46 Description: PHYS BLOOD BANK SERV XMATCH Category: Laboratory CMS Add: 01/01/1985 CMS Term: 86078 LAB DEF RBRVS 01/01/2024 50.71 Description: PHYS BLOOD BANK SERV REACTJ Category: Laboratory CMS Add: 01/01/1985 CMS Term: 86078 LAB DEF RBRVS 02/01/2015 12/31/2023 39.46 Description: PHYS BLOOD BANK SERV REACTJ Category: Laboratory CMS Add: 01/01/1985 CMS Term: 86079 LAB DEF RBRVS 01/01/2024 51.02 Description: PHYS BLOOD BANK SERV AUTHRJ Category: Laboratory CMS Add: 01/01/1985 CMS Term: 86079 LAB DEF RBRVS 02/01/2015 12/31/2023 39.21 Description: PHYS BLOOD BANK SERV AUTHRJ Category: Laboratory CMS Add: 01/01/1985 CMS Term: 86140 LAB L60 MAXFEE 01/01/2020 5.18 0.0 Description: C-REACTIVE PROTEIN Category: Laboratory CMS Add: 01/01/1982 CMS Term: 86141 LAB L60 MAXFEE 01/01/2020 12.95 0.0 Description: C-REACTIVE PROTEIN HS Category: Laboratory CMS Add: 01/01/2002 CMS Term: 86146 LAB L60 MAXFEE 01/01/2015 12/31/2023 8.88 0.0 Description: BETA-2 GLYCOPROTEIN ANTIBODY Category: Laboratory CMS Add: 01/01/2001 CMS Term: 86146 LAB L60 MAXFEE 01/01/2024 25.45 0.0 Description: BETA-2 GLYCOPROTEIN ANTIBODY Category: Laboratory CMS Add: 01/01/2001 CMS Term: 86147 LAB L60 MAXFEE 01/01/2015 12/31/2023 8.88 0.0 Description: CARDIOLIPIN ANTIBODY EA IG Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86147 LAB L60 MAXFEE 01/01/2024 25.45 0.0 Description: CARDIOLIPIN ANTIBODY EA IG Category: Laboratory CMS Add: 01/01/1993 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,145 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 86148 LAB L60 MAXFEE 01/01/2020 16.07 0.0 Description: ANTI-PHOSPHOLIPID ANTIBODY Category: Laboratory CMS Add: 01/01/1998 CMS Term: 86152 NOCOV DEF SYSMAN Description: CELL ENUMERATION & ID Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 86153 NOCOV DEF SYSMAN Description: CELL ENUMERATION PHYS INTERP Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 86155 LAB L60 MAXFEE 01/01/2020 15.99 0.0 Description: CHEMOTAXIS ASSAY Category: Laboratory CMS Add: 01/01/1984 CMS Term: 86156 LAB L60 MAXFEE 01/01/2015 12/31/2023 7.73 0.0 Description: COLD AGGLUTININ SCREEN Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86156 LAB L60 MAXFEE 01/01/2024 8.07 0.0 Description: COLD AGGLUTININ SCREEN Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86157 LAB L60 MAXFEE 01/01/2020 8.06 0.0 Description: COLD AGGLUTININ TITER Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86160 LAB L60 MAXFEE 01/01/2020 12.00 0.0 Description: COMPLEMENT ANTIGEN Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86161 LAB L60 MAXFEE 01/01/2020 12.00 0.0 Description: COMPLEMENT/FUNCTION ACTIVITY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86162 LAB L60 MAXFEE 01/01/2020 20.32 0.0 Description: COMPLEMENT TOTAL (CH50) Category: Laboratory CMS Add: 01/01/1984 CMS Term: 86171 LAB L60 MAXFEE 01/01/2020 10.01 0.0 Description: COMPLEMENT FIXATION EACH Category: Laboratory CMS Add: 01/01/1984 CMS Term: 86200 LAB L60 MAXFEE 01/01/2020 12.95 0.0 Description: CCP ANTIBODY Category: Laboratory CMS Add: 01/01/2006 CMS Term: 86215 LAB L60 MAXFEE 01/01/2020 13.25 0.0 Description: DEOXYRIBONUCLEASE ANTIBODY Category: Laboratory CMS Add: 01/01/1985 CMS Term: 86225 LAB L60 MAXFEE 01/01/2020 13.74 0.0 Description: DNA ANTIBODY NATIVE Category: Laboratory CMS Add: 01/01/1985 CMS Term: 86226 LAB L60 MAXFEE 01/01/2020 12.11 0.0 Description: DNA ANTIBODY SINGLE STRAND Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86231 LAB L60 MAXFEE 01/01/2022 12.09 0.0 Description: EMA EACH IG CLASS Category: Laboratory CMS Add: 01/01/2022 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,146 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 86235 LAB L60 MAXFEE 01/01/2020 17.93 0.0 Description: NUCLEAR ANTIGEN ANTIBODY Category: Laboratory CMS Add: 01/01/1985 CMS Term: 86255* 26 LAB DEF RBRVS 01/01/2024 17.02 Description: FLUORESCENT ANTIBODY SCREEN Category: Laboratory CMS Add: 01/01/1984 CMS Term: 86255* 26 LAB DEF RBRVS 02/01/2015 12/31/2023 13.90 Description: FLUORESCENT ANTIBODY SCREEN Category: Laboratory CMS Add: 01/01/1984 CMS Term: 86255* LAB L60 MAXFEE 01/01/2020 12.05 0.0 Description: FLUORESCENT ANTIBODY SCREEN Category: Laboratory CMS Add: 01/01/1984 CMS Term: 86256* 26 LAB DEF RBRVS 01/01/2024 17.02 Description: FLUORESCENT ANTIBODY TITER Category: Laboratory CMS Add: 01/01/1982 CMS Term: 86256* 26 LAB DEF RBRVS 02/01/2015 12/31/2023 13.57 Description: FLUORESCENT ANTIBODY TITER Category: Laboratory CMS Add: 01/01/1982 CMS Term: 86256* LAB L60 MAXFEE 01/01/2020 12.05 0.0 Description: FLUORESCENT ANTIBODY TITER Category: Laboratory CMS Add: 01/01/1982 CMS Term: 86258 LAB L60 MAXFEE 01/01/2022 12/31/2023 11.53 0.0 Description: DGP ANTIBODY EACH IG CLASS Category: Laboratory CMS Add: 01/01/2022 CMS Term: 86258 LAB L60 MAXFEE 01/01/2024 12.05 0.0 Description: DGP ANTIBODY EACH IG CLASS Category: Laboratory CMS Add: 01/01/2022 CMS Term: 86277 LAB L60 MAXFEE 01/01/2020 15.74 0.0 Description: GROWTH HORMONE ANTIBODY Category: Laboratory CMS Add: 01/01/1985 CMS Term: 86280 LAB L60 MAXFEE 01/01/2020 8.19 0.0 Description: HEMAGGLUTINATION INHIBITION Category: Laboratory CMS Add: 01/01/1982 CMS Term: 86294 LAB L60 MAXFEE 01/01/2015 12/31/2023 25.22 0.0 Description: IMMUNOASSAY TUMOR QUAL Category: Laboratory CMS Add: 01/01/2001 CMS Term: 86294 LAB L60 MAXFEE 01/01/2024 25.57 0.0 Description: IMMUNOASSAY TUMOR QUAL Category: Laboratory CMS Add: 01/01/2001 CMS Term: 86300 LAB L60 MAXFEE 01/01/2020 20.81 0.0 Description: IMMUNOASSAY TUMOR CA 15-3 Category: Laboratory CMS Add: 01/01/2001 CMS Term: 86301 LAB L60 MAXFEE 01/01/2020 20.81 0.0 Description: IMMUNOASSAY TUMOR CA 19-9 Category: Laboratory CMS Add: 01/01/2001 CMS Term: 86304 LAB L60 MAXFEE 01/01/2020 20.81 0.0 Description: IMMUNOASSAY TUMOR CA 125 Category: Laboratory CMS Add: 01/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,147 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 86305 LAB L60 MAXFEE 01/01/2020 20.81 0.0 Description: HUMAN EPIDIDYMIS PROTEIN 4 Category: Laboratory CMS Add: 01/01/2010 CMS Term: 86308 LAB L60 MAXFEE 01/01/2020 5.18 0.0 Description: HETEROPHILE ANTIBODY SCREEN Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86309 LAB L60 MAXFEE 01/01/2020 6.47 0.0 Description: HETEROPHILE ANTIBODY TITER Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86310 LAB L60 MAXFEE 01/01/2020 7.37 0.0 Description: HETEROPHILE ANTIBODY ABSRBJ Category: Laboratory CMS Add: 01/01/1984 CMS Term: 86316 LAB L60 MAXFEE 01/01/2020 20.81 0.0 Description: IMMUNOASSAY TUMOR OTHER Category: Laboratory CMS Add: 01/01/1988 CMS Term: 86317 LAB L60 MAXFEE 01/01/2020 14.99 0.0 Description: IMMUNOASSAY INFECTIOUS AGENT Category: Laboratory CMS Add: 01/01/1988 CMS Term: 86318 LAB L60 MAXFEE 01/01/2015 12/31/2023 17.62 0.0 Description: IA INFECTIOUS AGENT ANTIBODY Category: Laboratory CMS Add: 01/01/1989 CMS Term: 86318 LAB L60 MAXFEE 01/01/2024 18.09 0.0 Description: IA INFECTIOUS AGENT ANTIBODY Category: Laboratory CMS Add: 01/01/1989 CMS Term: 86320* 26 LAB DEF RBRVS 01/01/2024 17.02 Description: SERUM IMMUNOELECTROPHORESIS Category: Laboratory CMS Add: 01/01/1985 CMS Term: 86320* 26 LAB DEF RBRVS 02/01/2015 12/31/2023 13.57 Description: SERUM IMMUNOELECTROPHORESIS Category: Laboratory CMS Add: 01/01/1985 CMS Term: 86320* LAB L60 MAXFEE 01/01/2018 29.92 0.0 Description: SERUM IMMUNOELECTROPHORESIS Category: Laboratory CMS Add: 01/01/1985 CMS Term: 86325* 26 LAB DEF RBRVS 01/01/2024 17.02 Description: OTHER IMMUNOELECTROPHORESIS Category: Laboratory CMS Add: 01/01/1985 CMS Term: 86325* 26 LAB DEF RBRVS 02/01/2015 12/31/2023 13.57 Description: OTHER IMMUNOELECTROPHORESIS Category: Laboratory CMS Add: 01/01/1985 CMS Term: 86325* LAB L60 MAXFEE 01/01/2020 23.13 0.0 Description: OTHER IMMUNOELECTROPHORESIS Category: Laboratory CMS Add: 01/01/1985 CMS Term: 86327* 26 LAB DEF RBRVS 01/01/2024 20.88 Description: IMMUNOELECTROPHORESIS ASSAY Category: Laboratory CMS Add: 01/01/1984 CMS Term: 86327* 26 LAB DEF RBRVS 02/01/2015 12/31/2023 15.74 Description: IMMUNOELECTROPHORESIS ASSAY Category: Laboratory CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,148 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 86327* LAB L60 MAXFEE 01/01/2018 29.92 0.0 Description: IMMUNOELECTROPHORESIS ASSAY Category: Laboratory CMS Add: 01/01/1984 CMS Term: 86328 LAB L60 MAXFEE 01/01/2024 45.28 0.0 Description: IA NFCT AB SARSCOV2 COVID19 Category: Laboratory CMS Add: 04/10/2020 CMS Term: 86328 LAB L60 MAXFEE 05/19/2020 12/31/2023 45.23 0.0 Description: IA NFCT AB SARSCOV2 COVID19 Category: Laboratory CMS Add: 04/10/2020 CMS Term: 86329 LAB L60 MAXFEE 01/01/2020 14.05 0.0 Description: IMMUNODIFFUSION NES Category: Laboratory CMS Add: 01/01/1984 CMS Term: 86331 LAB L60 MAXFEE 01/01/2020 11.98 0.0 Description: IMMUNODIFFUSION OUCHTERLONY Category: Laboratory CMS Add: 01/01/1984 CMS Term: 86332 LAB L60 MAXFEE 01/01/2020 24.37 0.0 Description: IMMUNE COMPLEX ASSAY Category: Laboratory CMS Add: 01/01/1989 CMS Term: 86334* 26 LAB DEF RBRVS 01/01/2024 17.02 Description: IMMUNOFIX E-PHORESIS SERUM Category: Laboratory CMS Add: 01/01/1989 CMS Term: 86334* 26 LAB DEF RBRVS 02/01/2015 12/31/2023 13.90 Description: IMMUNOFIX E-PHORESIS SERUM Category: Laboratory CMS Add: 01/01/1989 CMS Term: 86334* LAB L60 MAXFEE 01/01/2020 22.34 0.0 Description: IMMUNOFIX E-PHORESIS SERUM Category: Laboratory CMS Add: 01/01/1989 CMS Term: 86335* 26 LAB DEF RBRVS 01/01/2024 17.02 Description: IMMUNFIX E-PHORSIS/URINE/CSF Category: Laboratory CMS Add: 01/01/2005 CMS Term: 86335* 26 LAB DEF RBRVS 02/01/2015 12/31/2023 13.90 Description: IMMUNFIX E-PHORSIS/URINE/CSF Category: Laboratory CMS Add: 01/01/2005 CMS Term: 86335* LAB L60 MAXFEE 01/01/2020 29.35 0.0 Description: IMMUNFIX E-PHORSIS/URINE/CSF Category: Laboratory CMS Add: 01/01/2005 CMS Term: 86336 LAB L60 MAXFEE 01/01/2020 15.59 0.0 Description: INHIBIN A Category: Laboratory CMS Add: 01/01/2002 CMS Term: 86337 LAB L60 MAXFEE 01/01/2020 21.41 0.0 Description: INSULIN ANTIBODIES Category: Laboratory CMS Add: 01/01/1982 CMS Term: 86340 LAB L60 MAXFEE 01/01/2020 15.08 0.0 Description: INTRINSIC FACTOR ANTIBODY Category: Laboratory CMS Add: 01/01/1982 CMS Term: 86341 LAB L60 MAXFEE 01/01/2019 23.57 0.0 Description: ISLET CELL ANTIBODY Category: Laboratory CMS Add: 01/01/1994 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,149 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 86343 LAB L60 MAXFEE 01/01/2020 12.46 0.0 Description: LEUKOCYTE HISTAMINE RELEASE Category: Laboratory CMS Add: 01/01/1982 CMS Term: 86344 LAB L60 MAXFEE 01/01/2018 10.39 0.0 Description: LEUKOCYTE PHAGOCYTOSIS Category: Laboratory CMS Add: 01/01/1982 CMS Term: 86352 LAB L60 MAXFEE 01/01/2010 12/31/2023 54.37 0.0 Description: CELL FUNCTION ASSAY W/STIM Category: Laboratory CMS Add: 01/01/2010 CMS Term: 86352 LAB L60 MAXFEE 01/01/2024 135.86 0.0 Description: CELL FUNCTION ASSAY W/STIM Category: Laboratory CMS Add: 01/01/2010 CMS Term: 86353 LAB L60 MAXFEE 01/01/2015 12/31/2023 39.51 0.0 Description: LYMPHOCYTE TRANSFORMATION Category: Laboratory CMS Add: 01/01/1982 CMS Term: 86353 LAB L60 MAXFEE 01/01/2024 49.03 0.0 Description: LYMPHOCYTE TRANSFORMATION Category: Laboratory CMS Add: 01/01/1982 CMS Term: 86355 LAB L60 MAXFEE 01/01/2020 37.73 0.0 Description: B CELLS TOTAL COUNT Category: Laboratory CMS Add: 01/01/2006 CMS Term: 86356 LAB L60 MAXFEE 01/01/2020 26.78 0.0 Description: MONONUCLEAR CELL ANTIGEN Category: Laboratory CMS Add: 01/01/2008 CMS Term: 86357 LAB L60 MAXFEE 01/01/2020 37.73 0.0 Description: NK CELLS TOTAL COUNT Category: Laboratory CMS Add: 01/01/2006 CMS Term: 86359 LAB L60 MAXFEE 01/01/2020 37.73 0.0 Description: T CELLS TOTAL COUNT Category: Laboratory CMS Add: 01/01/1994 CMS Term: 86360 LAB L60 MAXFEE 01/01/2020 46.98 0.0 Description: T CELL ABSOLUTE COUNT/RATIO Category: Laboratory CMS Add: 01/01/1994 CMS Term: 86361 LAB L60 MAXFEE 01/01/2020 26.78 0.0 Description: T CELL ABSOLUTE COUNT Category: Laboratory CMS Add: 01/01/1998 CMS Term: 86361 MRT L60 MAXFEE 01/01/2020 26.78 0.0 Description: T CELL ABSOLUTE COUNT Category: Medical Review Team CMS Add: 01/01/1998 CMS Term: 86362 LAB L60 MAXFEE 01/01/2022 12.05 0.0 Description: MOG-IGG1 ANTB CBA EACH Category: Laboratory CMS Add: 01/01/2022 CMS Term: 86363 LAB L60 MAXFEE 01/01/2022 12/31/2023 12.05 0.0 Description: MOG-IGG1 ANTB FLO CYTMTRY EA Category: Laboratory CMS Add: 01/01/2022 CMS Term: 86363 LAB L60 MAXFEE 01/01/2024 37.73 0.0 Description: MOG-IGG1 ANTB FLO CYTMTRY EA Category: Laboratory CMS Add: 01/01/2022 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,150 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 86364 LAB L60 MAXFEE 01/01/2022 11.53 0.0 Description: TISS TRNSGLTMNASE EA IG CLAS Category: Laboratory CMS Add: 01/01/2022 CMS Term: 86366 NOCOV DEF SYSMAN Description: MUSCLE-SPECIFIC KINASE ANTB Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 86367 LAB L60 MAXFEE 01/01/2015 12/31/2023 51.34 0.0 Description: STEM CELLS TOTAL COUNT Category: Laboratory CMS Add: 01/01/2006 CMS Term: 86367 LAB L60 MAXFEE 01/01/2024 77.78 0.0 Description: STEM CELLS TOTAL COUNT Category: Laboratory CMS Add: 01/01/2006 CMS Term: 86376 LAB L60 MAXFEE 01/01/2020 14.55 0.0 Description: MICROSOMAL ANTIBODY EACH Category: Laboratory CMS Add: 01/01/1982 CMS Term: 86381 LAB L60 MAXFEE 01/01/2022 25.45 0.0 Description: MITOCHONDRIAL ANTIBODY EACH Category: Laboratory CMS Add: 01/01/2022 CMS Term: 86382 LAB L60 MAXFEE 01/01/2020 16.91 0.0 Description: NEUTRALIZATION TEST VIRAL Category: Laboratory CMS Add: 01/01/1985 CMS Term: 86384 LAB L60 MAXFEE 01/01/2019 13.61 0.0 Description: NITROBLUE TETRAZOLIUM DYE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 86386 LAB L60 MAXFEE 01/01/2015 12/31/2023 21.73 0.0 Description: NUCLEAR MATRIX PROTEIN 22 Category: Laboratory CMS Add: 01/01/2012 CMS Term: 86386 LAB L60 MAXFEE 01/01/2024 21.78 0.0 Description: NUCLEAR MATRIX PROTEIN 22 Category: Laboratory CMS Add: 01/01/2012 CMS Term: 86403 LAB L60 MAXFEE 01/01/2019 11.54 0.0 Description: PARTICLE AGGLUT ANTBDY SCRN Category: Laboratory CMS Add: 01/01/1986 CMS Term: 86406 LAB L60 MAXFEE 01/01/2020 10.64 0.0 Description: PARTICLE AGGLUT ANTBDY TITR Category: Laboratory CMS Add: 01/01/1995 CMS Term: 86408 LAB L60 MAXFEE 04/09/2021 42.13 0.0 Description: NEUTRLZG ANTB SARSCOV2 SCR Category: Laboratory CMS Add: 08/10/2020 CMS Term: 86409 LAB L60 MAXFEE 01/01/2024 103.49 0.0 Description: NEUTRLZG ANTB SARSCOV2 TITER Category: Laboratory CMS Add: 08/10/2020 CMS Term: 86409 LAB L60 MAXFEE 04/09/2021 12/31/2023 79.61 0.0 Description: NEUTRLZG ANTB SARSCOV2 TITER Category: Laboratory CMS Add: 08/10/2020 CMS Term: 86413 NOCOV DEF SYSMAN Description: SARS-COV-2 ANTB QUANTITATIVE Category: Non Covered Services CMS Add: 09/08/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,151 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 86430 LAB L60 MAXFEE 01/01/2020 6.14 0.0 Description: RHEUMATOID FACTOR TEST QUAL Category: Laboratory CMS Add: 01/01/1984 CMS Term: 86430 MRT L60 MAXFEE 01/01/2020 6.14 0.0 Description: RHEUMATOID FACTOR TEST QUAL Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 86431 LAB L60 MAXFEE 01/01/2020 5.67 0.0 Description: RHEUMATOID FACTOR QUANT Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86480 LAB L60 MAXFEE 01/01/2020 61.98 0.0 Description: TB TEST CELL IMMUN MEASURE Category: Laboratory CMS Add: 01/01/2006 CMS Term: 86481 LAB L60 MAXFEE 01/01/2011 12/31/2023 65.48 0.0 Description: TB AG RESPONSE T-CELL SUSP Category: Laboratory CMS Add: 01/01/2011 CMS Term: 86481 LAB L60 MAXFEE 01/01/2024 100.00 0.0 Description: TB AG RESPONSE T-CELL SUSP Category: Laboratory CMS Add: 01/01/2011 CMS Term: 86485 LAB DEF BILL30 Description: SKIN TEST CANDIDA Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86486 LAB DEF RBRVS 01/01/2024 5.72 Description: SKIN TEST UNLISTED ANTIGN EA Category: Laboratory CMS Add: 01/01/2008 CMS Term: 86486 LAB DEF RBRVS 09/01/2019 12/31/2023 3.39 Description: SKIN TEST UNLISTED ANTIGN EA Category: Laboratory CMS Add: 01/01/2008 CMS Term: 86490 LAB DEF RBRVS 01/01/2024 71.78 Description: COCCIDIOIDOMYCOSIS SKIN TEST Category: Laboratory CMS Add: 01/01/1982 CMS Term: 86490 LAB DEF RBRVS 02/01/2015 12/31/2023 3.39 Description: COCCIDIOIDOMYCOSIS SKIN TEST Category: Laboratory CMS Add: 01/01/1982 CMS Term: 86510 LAB DEF RBRVS 01/01/2024 6.64 Description: HISTOPLASMOSIS SKIN TEST Category: Laboratory CMS Add: 01/01/1982 CMS Term: 86510 LAB DEF RBRVS 02/01/2015 12/31/2023 4.38 Description: HISTOPLASMOSIS SKIN TEST Category: Laboratory CMS Add: 01/01/1982 CMS Term: 86580 LAB DEF RBRVS 01/01/2024 9.11 Description: TB INTRADERMAL TEST Category: Laboratory CMS Add: 01/01/1982 CMS Term: 86580 LAB DEF RBRVS 02/01/2015 12/31/2023 5.37 Description: TB INTRADERMAL TEST Category: Laboratory CMS Add: 01/01/1982 CMS Term: 86590 LAB L60 MAXFEE 01/01/2019 12.66 0.0 Description: STREPTOKINASE ANTIBODY Category: Laboratory CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,152 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 86592 LAB L60 MAXFEE 01/01/2020 4.27 0.0 Description: SYPHILIS TEST NON-TREP QUAL Category: Laboratory CMS Add: 01/01/1984 CMS Term: 86593 LAB L60 MAXFEE 01/01/2020 4.40 0.0 Description: SYPHILIS TEST NON-TREP QUANT Category: Laboratory CMS Add: 01/01/1984 CMS Term: 86596 LAB L60 MAXFEE 01/01/2022 12/31/2023 18.40 0.0 Description: VOLTAGE-GTD CA CHNL ANTB EA Category: Laboratory CMS Add: 01/01/2022 CMS Term: 86596 LAB L60 MAXFEE 01/01/2024 12.05 0.0 Description: VOLTAGE-GTD CA CHNL ANTB EA Category: Laboratory CMS Add: 01/01/2022 CMS Term: 86602 LAB L60 MAXFEE 01/01/2020 10.18 0.0 Description: ANTINOMYCES ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86603 LAB L60 MAXFEE 01/01/2020 12.87 0.0 Description: ADENOVIRUS ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86606 LAB L60 MAXFEE 01/01/2015 12/31/2023 13.91 0.0 Description: ASPERGILLUS ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86606 LAB L60 MAXFEE 01/01/2024 15.05 0.0 Description: ASPERGILLUS ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86609 LAB L60 MAXFEE 01/01/2020 12.88 0.0 Description: BACTERIUM ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86611 LAB L60 MAXFEE 01/01/2020 10.18 0.0 Description: BARTONELLA ANTIBODY Category: Laboratory CMS Add: 01/01/2001 CMS Term: 86612 LAB L60 MAXFEE 01/01/2020 12.90 0.0 Description: BLASTOMYCES ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86615 LAB L60 MAXFEE 01/01/2020 13.19 0.0 Description: BORDETELLA ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86617 LAB L60 MAXFEE 01/01/2020 15.49 0.0 Description: LYME DISEASE ANTIBODY Category: Laboratory CMS Add: 01/01/1995 CMS Term: 86618 LAB L60 MAXFEE 01/01/2015 12/31/2023 13.91 0.0 Description: LYME DISEASE ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86618 LAB L60 MAXFEE 01/01/2024 17.03 0.0 Description: LYME DISEASE ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86619 LAB L60 MAXFEE 01/01/2020 13.38 0.0 Description: BORRELIA ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,153 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 86622 LAB L60 MAXFEE 01/01/2020 8.93 0.0 Description: BRUCELLA ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86625 LAB L60 MAXFEE 01/01/2020 13.12 0.0 Description: CAMPYLOBACTER ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86628 LAB L60 MAXFEE 01/01/2020 12.01 0.0 Description: CANDIDA ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86631 LAB L60 MAXFEE 01/01/2020 11.82 0.0 Description: CHLAMYDIA ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86632 LAB L60 MAXFEE 01/01/2020 12.68 0.0 Description: CHLAMYDIA IGM ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86635 LAB L60 MAXFEE 01/01/2020 11.47 0.0 Description: COCCIDIOIDES ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86638 LAB L60 MAXFEE 01/01/2020 12.12 0.0 Description: Q FEVER ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86641 LAB L60 MAXFEE 01/01/2015 12/31/2023 13.91 0.0 Description: CRYPTOCOCCUS ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86641 LAB L60 MAXFEE 01/01/2024 14.41 0.0 Description: CRYPTOCOCCUS ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86644 LAB L60 MAXFEE 01/01/2020 14.39 0.0 Description: CMV ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86645 LAB L60 MAXFEE 01/01/2015 12/31/2023 13.91 0.0 Description: CMV ANTIBODY IGM Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86645 LAB L60 MAXFEE 01/01/2024 16.85 0.0 Description: CMV ANTIBODY IGM Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86648 LAB L60 MAXFEE 01/01/2015 12/31/2023 13.91 0.0 Description: DIPHTHERIA ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86648 LAB L60 MAXFEE 01/01/2024 15.21 0.0 Description: DIPHTHERIA ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86651 LAB L60 MAXFEE 01/01/2020 13.19 0.0 Description: ENCEPHALITIS CALIFORN ANTBDY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86652 LAB L60 MAXFEE 01/01/2020 13.19 0.0 Description: ENCEPHALTIS EAST EQNE ANBDY Category: Laboratory CMS Add: 01/01/1993 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,154 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 86653 LAB L60 MAXFEE 01/01/2020 13.19 0.0 Description: ENCEPHALTIS ST LOUIS ANTBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86654 LAB L60 MAXFEE 01/01/2020 13.19 0.0 Description: ENCEPHALTIS WEST EQNE ANTBDY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86658 LAB L60 MAXFEE 01/01/2020 13.03 0.0 Description: ENTEROVIRUS ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86663 LAB L60 MAXFEE 01/01/2020 13.12 0.0 Description: EPSTEIN-BARR ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86664 LAB L60 MAXFEE 01/01/2020 15.29 0.0 Description: EPSTEIN-BARR NUCLEAR ANTIGEN Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86665 LAB L60 MAXFEE 01/01/2020 18.14 0.0 Description: EPSTEIN-BARR CAPSID VCA Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86666 LAB L60 MAXFEE 01/01/2020 10.18 0.0 Description: EHRLICHIA ANTIBODY Category: Laboratory CMS Add: 01/01/2001 CMS Term: 86668 LAB L60 MAXFEE 01/01/2015 12/31/2023 13.91 0.0 Description: FRANCISELLA TULARENSIS Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86668 LAB L60 MAXFEE 01/01/2024 14.16 0.0 Description: FRANCISELLA TULARENSIS Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86671 LAB L60 MAXFEE 01/01/2020 12.25 0.0 Description: FUNGUS NES ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86674 LAB L60 MAXFEE 01/01/2020 14.72 0.0 Description: GIARDIA LAMBLIA ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86677 LAB L60 MAXFEE 01/01/2015 12/31/2023 13.91 0.0 Description: HELICOBACTER PYLORI ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86677 LAB L60 MAXFEE 01/01/2024 16.85 0.0 Description: HELICOBACTER PYLORI ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86682 LAB L60 MAXFEE 01/01/2020 13.01 0.0 Description: HELMINTH ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86684 LAB L60 MAXFEE 01/01/2015 12/31/2023 13.91 0.0 Description: HEMOPHILUS INFLUENZA ANTIBDY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86684 LAB L60 MAXFEE 01/01/2024 15.84 0.0 Description: HEMOPHILUS INFLUENZA ANTIBDY Category: Laboratory CMS Add: 01/01/1993 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,155 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 86687 LAB L60 MAXFEE 01/01/2020 9.09 0.0 Description: HTLV-I ANTIBODY Category: Laboratory CMS Add: 01/01/1990 CMS Term: 86688 LAB L60 MAXFEE 01/01/2020 14.00 0.0 Description: HTLV-II ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86689 LAB L60 MAXFEE 01/01/2020 19.35 0.0 Description: HTLV/HIV CONFIRMJ ANTIBODY Category: Laboratory CMS Add: 01/01/1990 CMS Term: 86692 LAB L60 MAXFEE 01/01/2020 17.16 0.0 Description: HEPATITIS DELTA AGENT ANTBDY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86694 LAB L60 MAXFEE 01/01/2020 14.39 0.0 Description: HERPES SIMPLEX NES ANTBDY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86695 LAB L60 MAXFEE 01/01/2020 13.19 0.0 Description: HERPES SIMPLEX TYPE 1 TEST Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86696 LAB L60 MAXFEE 01/01/2020 19.35 0.0 Description: HERPES SIMPLEX TYPE 2 TEST Category: Laboratory CMS Add: 01/01/2001 CMS Term: 86698 LAB L60 MAXFEE 01/01/2020 13.79 0.0 Description: HISTOPLASMA ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86701 LAB L60 MAXFEE 01/01/2020 8.89 0.0 Description: HIV-1ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86702 LAB L60 MAXFEE 01/01/2020 13.52 0.0 Description: HIV-2 ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86703 LAB L60 MAXFEE 01/01/2020 13.71 0.0 Description: HIV-1/HIV-2 1 RESULT ANTBDY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86704 LAB L60 MAXFEE 01/01/2020 12.05 0.0 Description: HEP B CORE ANTIBODY TOTAL Category: Laboratory CMS Add: 01/01/1998 CMS Term: 86705 LAB L60 MAXFEE 01/01/2020 11.77 0.0 Description: HEP B CORE ANTIBODY IGM Category: Laboratory CMS Add: 01/01/1998 CMS Term: 86706 LAB L60 MAXFEE 01/01/2020 10.74 0.0 Description: HEP B SURFACE ANTIBODY Category: Laboratory CMS Add: 01/01/1998 CMS Term: 86707 LAB L60 MAXFEE 01/01/2015 12/31/2023 6.32 0.0 Description: HEPATITIS BE ANTIBODY Category: Laboratory CMS Add: 01/01/1998 CMS Term: 86707 LAB L60 MAXFEE 01/01/2024 11.57 0.0 Description: HEPATITIS BE ANTIBODY Category: Laboratory CMS Add: 01/01/1998 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,156 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 86707 MRT L60 MAXFEE 01/01/2015 12/31/2023 6.32 0.0 Description: HEPATITIS BE ANTIBODY Category: Medical Review Team CMS Add: 01/01/1998 CMS Term: 86707 MRT L60 MAXFEE 01/01/2024 11.57 0.0 Description: HEPATITIS BE ANTIBODY Category: Medical Review Team CMS Add: 01/01/1998 CMS Term: 86708 LAB L60 MAXFEE 01/01/2020 12.39 0.0 Description: HEPATITIS A ANTIBODY Category: Laboratory CMS Add: 01/01/1998 CMS Term: 86708 MRT L60 MAXFEE 01/01/2020 12.39 0.0 Description: HEPATITIS A ANTIBODY Category: Medical Review Team CMS Add: 01/01/1998 CMS Term: 86709 LAB L60 MAXFEE 01/01/2020 11.26 0.0 Description: HEPATITIS A IGM ANTIBODY Category: Laboratory CMS Add: 01/01/1998 CMS Term: 86710 LAB L60 MAXFEE 01/01/2020 13.55 0.0 Description: INFLUENZA VIRUS ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86711 LAB L60 MAXFEE 01/01/2019 16.89 0.0 0-2 Description: JOHN CUNNINGHAM ANTIBODY Category: Laboratory CMS Add: 01/01/2013 CMS Term: 86713 LAB L60 MAXFEE 01/01/2015 12/31/2023 13.91 0.0 Description: LEGIONELLA ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86713 LAB L60 MAXFEE 01/01/2024 15.30 0.0 Description: LEGIONELLA ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86717 LAB L60 MAXFEE 01/01/2020 12.25 0.0 Description: LEISHMANIA ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86720 LAB L60 MAXFEE 01/01/2015 12/31/2023 13.91 0.0 Description: LEPTOSPIRA ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86720 LAB L60 MAXFEE 01/01/2024 16.20 0.0 Description: LEPTOSPIRA ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86723 LAB L60 MAXFEE 01/01/2020 13.19 0.0 Description: LISTERIA MONOCYTOGENES Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86727 LAB L60 MAXFEE 01/01/2020 12.87 0.0 Description: LYMPH CHORIOMENINGITIS AB Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86732 LAB L60 MAXFEE 01/01/2015 12/31/2023 13.91 0.0 Description: MUCORMYCOSIS ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86732 LAB L60 MAXFEE 01/01/2024 15.00 0.0 Description: MUCORMYCOSIS ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,157 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 86735 LAB L60 MAXFEE 01/01/2020 13.05 0.0 Description: MUMPS ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86738 LAB L60 MAXFEE 01/01/2020 13.24 0.0 Description: MYCOPLASMA ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86741 LAB L60 MAXFEE 01/01/2015 12/31/2023 7.91 0.0 Description: NEISSERIA MENINGITIDIS Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86741 LAB L60 MAXFEE 01/01/2024 13.19 0.0 Description: NEISSERIA MENINGITIDIS Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86744 LAB L60 MAXFEE 01/01/2015 12/31/2023 7.91 0.0 Description: NOCARDIA ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86744 LAB L60 MAXFEE 01/01/2024 15.99 0.0 Description: NOCARDIA ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86747 LAB L60 MAXFEE 01/01/2020 15.03 0.0 Description: PARVOVIRUS ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86750 LAB L60 MAXFEE 01/01/2020 13.19 0.0 Description: MALARIA ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86753 LAB L60 MAXFEE 01/01/2015 12/31/2023 7.91 0.0 Description: PROTOZOA ANTIBODY NOS Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86753 LAB L60 MAXFEE 01/01/2024 12.39 0.0 Description: PROTOZOA ANTIBODY NOS Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86756 LAB L60 MAXFEE 01/01/2015 12/31/2023 7.91 0.0 Description: RESPIRATORY VIRUS ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86756 LAB L60 MAXFEE 01/01/2024 15.89 0.0 Description: RESPIRATORY VIRUS ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86757 LAB L60 MAXFEE 01/01/2020 19.35 0.0 Description: RICKETTSIA ANTIBODY Category: Laboratory CMS Add: 01/01/2001 CMS Term: 86759 LAB L60 MAXFEE 01/01/2015 12/31/2023 11.81 0.0 Description: ROTAVIRUS ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86759 LAB L60 MAXFEE 01/01/2024 18.23 0.0 Description: ROTAVIRUS ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86762 LAB L60 MAXFEE 01/01/2020 14.39 0.0 Description: RUBELLA ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,158 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 86765 LAB L60 MAXFEE 01/01/2020 12.88 0.0 Description: RUBEOLA ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86768 LAB L60 MAXFEE 01/01/2020 13.19 0.0 Description: SALMONELLA ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86769 LAB L60 MAXFEE 05/19/2020 42.13 0.0 Description: SARS-COV-2 COVID-19 ANTIBODY Category: Laboratory CMS Add: 04/10/2020 CMS Term: 86771 LAB L60 MAXFEE 01/01/2015 12/31/2023 13.91 0.0 Description: SHIGELLA ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86771 LAB L60 MAXFEE 01/01/2024 24.48 0.0 Description: SHIGELLA ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86774 LAB L60 MAXFEE 01/01/2015 12/31/2023 13.91 0.0 Description: TETANUS ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86774 LAB L60 MAXFEE 01/01/2024 14.80 0.0 Description: TETANUS ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86777 LAB L60 MAXFEE 01/01/2020 14.39 0.0 Description: TOXOPLASMA ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86778 LAB L60 MAXFEE 01/01/2015 12/31/2023 13.91 0.0 Description: TOXOPLASMA ANTIBODY IGM Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86778 LAB L60 MAXFEE 01/01/2024 14.41 0.0 Description: TOXOPLASMA ANTIBODY IGM Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86780 LAB L60 MAXFEE 01/01/2020 13.24 0.0 Description: TREPONEMA PALLIDUM Category: Laboratory CMS Add: 01/01/2010 CMS Term: 86784 LAB L60 MAXFEE 01/01/2020 12.56 0.0 Description: TRICHINELLA ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86787 LAB L60 MAXFEE 01/01/2020 12.88 0.0 Description: VARICELLA-ZOSTER ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86788 LAB L60 MAXFEE 01/01/2015 12/31/2023 13.91 0.0 Description: WEST NILE VIRUS AB IGM Category: Laboratory CMS Add: 01/01/2007 CMS Term: 86788 LAB L60 MAXFEE 01/01/2024 16.85 0.0 Description: WEST NILE VIRUS AB IGM Category: Laboratory CMS Add: 01/01/2007 CMS Term: 86789 LAB L60 MAXFEE 01/01/2020 14.39 0.0 Description: WEST NILE VIRUS ANTIBODY Category: Laboratory CMS Add: 01/01/2007 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,159 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 86790 LAB L60 MAXFEE 01/01/2020 12.88 0.0 Description: VIRUS ANTIBODY NOS Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86793 LAB L60 MAXFEE 01/01/2020 13.19 0.0 Description: YERSINIA ANTIBODY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86794 LAB L60 MAXFEE 01/01/2020 16.85 0.0 Description: ZIKA VIRUS IGM ANTIBODY Category: Laboratory CMS Add: 01/01/2018 CMS Term: 86800 LAB L60 MAXFEE 01/01/2020 15.91 0.0 Description: THYROGLOBULIN ANTIBODY Category: Laboratory CMS Add: 01/01/1982 CMS Term: 86803 LAB L60 MAXFEE 01/01/2020 14.27 0.0 Description: HEPATITIS C AB TEST Category: Laboratory CMS Add: 01/01/1998 CMS Term: 86803 MRT L60 MAXFEE 01/01/2020 14.27 0.0 Description: HEPATITIS C AB TEST Category: Medical Review Team CMS Add: 01/01/1998 CMS Term: 86804 LAB L60 MAXFEE 01/01/2020 15.49 0.0 Description: HEP C AB TEST CONFIRM Category: Laboratory CMS Add: 01/01/1998 CMS Term: 86805 LAB L60 MAXFEE 01/01/2015 12/31/2023 71.16 0.0 Description: LYMPHOCYTOTOXICITY ASSAY Category: Laboratory CMS Add: 01/01/1989 CMS Term: 86805 LAB L60 MAXFEE 01/01/2024 189.51 0.0 Description: LYMPHOCYTOTOXICITY ASSAY Category: Laboratory CMS Add: 01/01/1989 CMS Term: 86806 LAB L60 MAXFEE 01/01/2020 47.59 0.0 Description: LYMPHOCYTOTOXICITY ASSAY Category: Laboratory CMS Add: 01/01/1989 CMS Term: 86807 LAB L60 MAXFEE 01/01/2015 12/31/2023 53.86 0.0 Description: CYTOTOXIC ANTIBODY SCREENING Category: Laboratory CMS Add: 01/01/1989 CMS Term: 86807 LAB L60 MAXFEE 01/01/2024 78.65 0.0 Description: CYTOTOXIC ANTIBODY SCREENING Category: Laboratory CMS Add: 01/01/1989 CMS Term: 86808 LAB L60 MAXFEE 01/01/2020 29.68 0.0 Description: CYTOTOXIC ANTIBODY SCREENING Category: Laboratory CMS Add: 01/01/1989 CMS Term: 86812 LAB L60 MAXFEE 01/01/2020 25.81 0.0 Description: HLA TYPING A B OR C Category: Laboratory CMS Add: 01/01/1984 CMS Term: 86813 LAB L60 MAXFEE 01/01/2020 58.00 0.0 Description: HLA TYPING A B OR C Category: Laboratory CMS Add: 01/01/1984 CMS Term: 86816 LAB L60 MAXFEE 01/01/2020 30.17 0.0 Description: HLA TYPING DR/DQ Category: Laboratory CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,160 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 86817 LAB L60 MAXFEE 01/01/2015 12/31/2023 87.62 0.0 Description: HLA TYPING DR/DQ Category: Laboratory CMS Add: 01/01/1984 CMS Term: 86817 LAB L60 MAXFEE 01/01/2024 106.14 0.0 Description: HLA TYPING DR/DQ Category: Laboratory CMS Add: 01/01/1984 CMS Term: 86821 LAB L60 MAXFEE 01/01/2020 36.56 0.0 Description: LYMPHOCYTE CULTURE MIXED Category: Laboratory CMS Add: 01/01/1984 CMS Term: 86825 LAB L60 MAXFEE 01/01/2015 12/31/2023 109.30 0.0 Description: HLA X-MATH NON-CYTOTOXIC Category: Laboratory CMS Add: 01/01/2010 CMS Term: 86825 LAB L60 MAXFEE 01/01/2024 109.49 0.0 Description: HLA X-MATH NON-CYTOTOXIC Category: Laboratory CMS Add: 01/01/2010 CMS Term: 86826 LAB L60 MAXFEE 01/01/2015 12/31/2023 36.44 0.0 Description: HLA X-MATCH NONCYTOTOXC ADDL Category: Laboratory CMS Add: 01/01/2010 CMS Term: 86826 LAB L60 MAXFEE 01/01/2024 36.53 0.0 Description: HLA X-MATCH NONCYTOTOXC ADDL Category: Laboratory CMS Add: 01/01/2010 CMS Term: 86828 LAB L60 MAXFEE 01/01/2015 12/31/2023 53.86 0.0 0-2 Description: HLA CLASS I&II ANTIBODY QUAL Category: Laboratory CMS Add: 01/01/2013 CMS Term: 86828 LAB L60 MAXFEE 01/01/2024 64.19 0.0 0-2 Description: HLA CLASS I&II ANTIBODY QUAL Category: Laboratory CMS Add: 01/01/2013 CMS Term: 86829 LAB L60 MAXFEE 01/01/2015 12/31/2023 40.39 0.0 0-2 Description: HLA CLASS I/II ANTIBODY QUAL Category: Laboratory CMS Add: 01/01/2013 CMS Term: 86829 LAB L60 MAXFEE 01/01/2024 64.19 0.0 0-2 Description: HLA CLASS I/II ANTIBODY QUAL Category: Laboratory CMS Add: 01/01/2013 CMS Term: 86830 LAB L60 MAXFEE 01/01/2019 95.52 0.0 0-2 Description: HLA CLASS I PHENOTYPE QUAL Category: Laboratory CMS Add: 01/01/2013 CMS Term: 86831 LAB L60 MAXFEE 01/01/2019 81.88 0.0 0-2 Description: HLA CLASS II PHENOTYPE QUAL Category: Laboratory CMS Add: 01/01/2013 CMS Term: 86832 LAB L60 MAXFEE 01/01/2015 12/31/2023 172.66 0.0 0-2 Description: HLA CLASS I HIGH DEFIN QUAL Category: Laboratory CMS Add: 01/01/2013 CMS Term: 86832 LAB L60 MAXFEE 01/01/2024 323.75 0.0 0-2 Description: HLA CLASS I HIGH DEFIN QUAL Category: Laboratory CMS Add: 01/01/2013 CMS Term: 86833 LAB L60 MAXFEE 01/01/2015 12/31/2023 156.97 0.0 0-2 Description: HLA CLASS II HIGH DEFIN QUAL Category: Laboratory CMS Add: 01/01/2013 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,161 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 86833 LAB L60 MAXFEE 01/01/2024 325.80 0.0 0-2 Description: HLA CLASS II HIGH DEFIN QUAL Category: Laboratory CMS Add: 01/01/2013 CMS Term: 86834 LAB L60 MAXFEE 01/01/2020 357.56 0.0 0-1 Description: HLA CLASS I SEMIQUANT PANEL Category: Laboratory CMS Add: 01/01/2013 CMS Term: 86835 LAB L60 MAXFEE 01/01/2020 322.96 0.0 0-1 Description: HLA CLASS II SEMIQUANT PANEL Category: Laboratory CMS Add: 01/01/2013 CMS Term: 86849 LAB DEF MAXFEE 01/01/2024 65.00 0.0 Description: IMMUNOLOGY PROCEDURE Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86849 LAB DEF MAXFEE 08/01/1993 12/31/2023 50.00 0.0 Description: IMMUNOLOGY PROCEDURE Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86850 LAB L60 MAXFEE 01/01/2016 12/31/2023 5.21 0.0 Description: RBC ANTIBODY SCREEN Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86850 LAB L60 MAXFEE 01/01/2024 9.77 0.0 Description: RBC ANTIBODY SCREEN Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86860 LAB DEF MAXFEE 01/01/2024 65.01 0.0 Description: RBC ANTIBODY ELUTION Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86860 LAB DEF MAXFEE 09/18/2000 12/31/2023 50.01 0.0 Description: RBC ANTIBODY ELUTION Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86870 LAB DEF MAXFEE 01/01/2024 65.00 0.0 Description: RBC ANTIBODY IDENTIFICATION Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86870 LAB DEF MAXFEE 08/01/1993 12/31/2023 50.00 0.0 Description: RBC ANTIBODY IDENTIFICATION Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86880 LAB L60 MAXFEE 01/01/2020 5.39 0.0 Description: COOMBS TEST DIRECT Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86885 LAB L60 MAXFEE 01/01/2020 5.72 0.0 Description: COOMBS TEST INDIRECT QUAL Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86886 LAB L60 MAXFEE 01/01/2020 5.18 0.0 Description: COOMBS TEST INDIRECT TITER Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86890 LAB DEF MAXFEE 01/01/2024 65.00 0.0 Description: AUTOLOGOUS BLOOD PROCESS Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86890 LAB DEF MAXFEE 08/01/1993 12/31/2023 50.00 0.0 Description: AUTOLOGOUS BLOOD PROCESS Category: Laboratory CMS Add: 01/01/1993 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,162 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 86891 LAB DEF BILL30 Description: AUTOLOGOUS BLOOD OP SALVAGE Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86900 LAB L60 MAXFEE 01/01/2020 2.99 0.0 Description: BLOOD TYPING SEROLOGIC ABO Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86901 LAB L60 MAXFEE 01/01/2020 2.99 0.0 Description: BLOOD TYPING SEROLOGIC RH(D) Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86902 LAB L60 MAXFEE 01/01/2015 12/31/2023 5.20 0.0 Description: BLOOD TYPE ANTIGEN DONOR EA Category: Laboratory CMS Add: 01/01/2011 CMS Term: 86902 LAB L60 MAXFEE 01/01/2024 6.35 0.0 Description: BLOOD TYPE ANTIGEN DONOR EA Category: Laboratory CMS Add: 01/01/2011 CMS Term: 86904 LAB L60 MAXFEE 01/01/2015 12/31/2023 12.94 0.0 Description: BLOOD TYPING PATIENT SERUM Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86904 LAB L60 MAXFEE 01/01/2024 16.34 0.0 Description: BLOOD TYPING PATIENT SERUM Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86905 LAB L60 MAXFEE 01/01/2020 3.83 0.0 Description: BLOOD TYPING RBC ANTIGENS Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86906 LAB L60 MAXFEE 01/01/2020 7.75 0.0 Description: BLD TYPING SEROLOGIC RH PHNT Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86910 LAB L60 MAXFEE 01/01/1994 12/31/2023 27.38 0.0 Description: BLOOD TYPING PATERNITY TEST Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86910 LAB L60 MAXFEE 01/01/2024 35.59 0.0 Description: BLOOD TYPING PATERNITY TEST Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86911 LAB L60 MAXFEE 01/01/1994 12/31/2023 7.77 0.0 Description: BLOOD TYPING ANTIGEN SYSTEM Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86911 LAB L60 MAXFEE 01/01/2024 10.10 0.0 Description: BLOOD TYPING ANTIGEN SYSTEM Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86920 LAB DEF MAXFEE 01/01/2024 41.38 0.0 Description: COMPATIBILITY TEST SPIN Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86920 LAB DEF MAXFEE 09/18/2000 12/31/2023 31.83 0.0 Description: COMPATIBILITY TEST SPIN Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86921 LAB DEF MAXFEE 01/01/2024 26.00 0.0 Description: COMPATIBILITY TEST INCUBATE Category: Laboratory CMS Add: 01/01/1993 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,163 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 86921 LAB DEF MAXFEE 08/01/1993 12/31/2023 20.00 0.0 Description: COMPATIBILITY TEST INCUBATE Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86922 LAB DEF MAXFEE 01/01/2024 26.00 0.0 Description: COMPATIBILITY TEST ANTIGLOB Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86922 LAB DEF MAXFEE 08/01/1993 12/31/2023 20.00 0.0 Description: COMPATIBILITY TEST ANTIGLOB Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86923 LAB DEF BILL30 Description: COMPATIBILITY TEST ELECTRIC Category: Laboratory CMS Add: 01/01/2006 CMS Term: 86927 LAB DEF MAXFEE 01/01/2024 65.00 0.0 Description: PLASMA FRESH FROZEN Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86927 LAB DEF MAXFEE 08/01/1993 12/31/2023 50.00 0.0 Description: PLASMA FRESH FROZEN Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86930 LAB DEF MAXFEE 01/01/2024 65.00 0.0 Description: FROZEN BLOOD PREP Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86930 LAB DEF MAXFEE 08/01/1993 12/31/2023 50.00 0.0 Description: FROZEN BLOOD PREP Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86931 LAB DEF MAXFEE 01/01/2024 65.00 0.0 Description: FROZEN BLOOD THAW Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86931 LAB DEF MAXFEE 08/01/1993 12/31/2023 50.00 0.0 Description: FROZEN BLOOD THAW Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86932 LAB DEF MAXFEE 01/01/2024 65.00 0.0 Description: FROZEN BLOOD FREEZE/THAW Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86932 LAB DEF MAXFEE 08/01/1993 12/31/2023 50.00 0.0 Description: FROZEN BLOOD FREEZE/THAW Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86940 LAB L60 MAXFEE 01/01/2020 8.77 0.0 Description: HEMOLYSINS/AGGLUTININS AUTO Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86941 LAB L60 MAXFEE 01/01/2020 12.11 0.0 Description: HEMOLYSINS/AGGLUTININS Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86945 LAB L60 MAXFEE 01/01/2024 79.44 0.0 Description: BLOOD PRODUCT/IRRADIATION Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86945 LAB L60 MAXFEE 08/01/1993 12/31/2023 61.11 0.0 Description: BLOOD PRODUCT/IRRADIATION Category: Laboratory CMS Add: 01/01/1993 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,164 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 86950 LAB DEF MAXFEE 01/01/2024 83.11 0.0 Description: LEUKACYTE TRANSFUSION Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86950 LAB DEF MAXFEE 08/01/1993 12/31/2023 63.93 0.0 Description: LEUKACYTE TRANSFUSION Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86960 LAB DEF BILL30 Description: VOL REDUCTION OF BLOOD/PROD Category: Laboratory CMS Add: 01/01/2006 CMS Term: 86965 LAB DEF MAXFEE 01/01/2024 26.00 0.0 Description: POOLING BLOOD PLATELETS Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86965 LAB DEF MAXFEE 08/01/1993 12/31/2023 20.00 0.0 Description: POOLING BLOOD PLATELETS Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86970 LAB DEF BILL30 Description: RBC PRETX INCUBATJ W/CHEMICL Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86971 LAB DEF BILL30 Description: RBC PRETX INCUBATJ W/ENZYMES Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86972 LAB DEF MAXFEE 01/01/2024 39.00 0.0 Description: RBC PRETX INCUBATJ W/DENSITY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86972 LAB DEF MAXFEE 08/01/1993 12/31/2023 30.00 0.0 Description: RBC PRETX INCUBATJ W/DENSITY Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86975 LAB DEF MAXFEE 01/01/2024 39.00 0.0 Description: RBC SERUM PRETX INCUBJ DRUGS Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86975 LAB DEF MAXFEE 08/01/1993 12/31/2023 30.00 0.0 Description: RBC SERUM PRETX INCUBJ DRUGS Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86976 LAB DEF MAXFEE 01/01/2024 26.00 0.0 Description: RBC SERUM PRETX ID DILUTION Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86976 LAB DEF MAXFEE 08/01/1993 12/31/2023 20.00 0.0 Description: RBC SERUM PRETX ID DILUTION Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86977 LAB DEF MAXFEE 01/01/2024 19.50 0.0 Description: RBC SERUM PRETX INCUBJ/INHIB Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86977 LAB DEF MAXFEE 08/01/1993 12/31/2023 15.00 0.0 Description: RBC SERUM PRETX INCUBJ/INHIB Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86978 LAB DEF MAXFEE 01/01/2024 26.00 0.0 Description: RBC PRETREATMENT SERUM Category: Laboratory CMS Add: 01/01/1993 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,165 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 86978 LAB DEF MAXFEE 08/01/1993 12/31/2023 20.00 0.0 Description: RBC PRETREATMENT SERUM Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86985 LAB DEF MAXFEE 01/01/2024 19.50 0.0 Description: SPLIT BLOOD OR PRODUCTS Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86985 LAB DEF MAXFEE 08/01/1993 12/31/2023 15.00 0.0 Description: SPLIT BLOOD OR PRODUCTS Category: Laboratory CMS Add: 01/01/1993 CMS Term: 86999 LAB L60 MAXFEE 01/01/2024 40.56 0.0 Description: UNLISTED TRANSFUSION MED PX Category: Laboratory CMS Add: 01/01/1984 CMS Term: 86999 LAB L60 MAXFEE 07/01/1985 12/31/2023 31.20 0.0 Description: UNLISTED TRANSFUSION MED PX Category: Laboratory CMS Add: 01/01/1984 CMS Term: 87003 LAB L60 MAXFEE 01/01/2020 16.84 0.0 Description: SMALL ANIMAL INOCULATION Category: Laboratory CMS Add: 01/01/1982 CMS Term: 87015 LAB L60 MAXFEE 01/01/2020 6.68 0.0 Description: SPECIMEN INFECT AGNT CONCNTJ Category: Laboratory CMS Add: 01/01/1982 CMS Term: 87040 LAB L60 MAXFEE 01/01/2020 10.32 0.0 Description: BLOOD CULTURE FOR BACTERIA Category: Laboratory CMS Add: 01/01/1984 CMS Term: 87045 LAB L60 MAXFEE 01/01/2020 9.44 0.0 Description: FECES CULTURE AEROBIC BACT Category: Laboratory CMS Add: 01/01/1985 CMS Term: 87046 LAB L60 MAXFEE 01/01/2001 12/31/2023 3.22 0.0 Description: STOOL CULTR AEROBIC BACT EA Category: Laboratory CMS Add: 01/01/2001 CMS Term: 87046 LAB L60 MAXFEE 01/01/2024 9.44 0.0 Description: STOOL CULTR AEROBIC BACT EA Category: Laboratory CMS Add: 01/01/2001 CMS Term: 87070 LAB L60 MAXFEE 01/01/2020 8.62 0.0 Description: CULTURE OTHR SPECIMN AEROBIC Category: Laboratory CMS Add: 01/01/1985 CMS Term: 87071 LAB L60 MAXFEE 01/01/2001 12/31/2023 6.43 0.0 Description: CULTURE AEROBIC QUANT OTHER Category: Laboratory CMS Add: 01/01/2001 CMS Term: 87071 LAB L60 MAXFEE 01/01/2024 9.89 0.0 Description: CULTURE AEROBIC QUANT OTHER Category: Laboratory CMS Add: 01/01/2001 CMS Term: 87073 LAB L60 MAXFEE 01/01/2001 12/31/2023 6.43 0.0 Description: CULTURE BACTERIA ANAEROBIC Category: Laboratory CMS Add: 01/01/2001 CMS Term: 87073 LAB L60 MAXFEE 01/01/2024 9.66 0.0 Description: CULTURE BACTERIA ANAEROBIC Category: Laboratory CMS Add: 01/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,166 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 87075 LAB L60 MAXFEE 01/01/2015 12/31/2023 8.48 0.0 Description: CULTR BACTERIA EXCEPT BLOOD Category: Laboratory CMS Add: 01/01/1984 CMS Term: 87075 LAB L60 MAXFEE 01/01/2024 9.47 0.0 Description: CULTR BACTERIA EXCEPT BLOOD Category: Laboratory CMS Add: 01/01/1984 CMS Term: 87076 LAB L60 MAXFEE 01/01/2020 8.08 0.0 Description: CULTURE ANAEROBE IDENT EACH Category: Laboratory CMS Add: 01/01/1984 CMS Term: 87077 LAB L60 MAXFEE 01/01/2020 8.08 0.0 Description: CULTURE AEROBIC IDENTIFY Category: Laboratory CMS Add: 01/01/2001 CMS Term: 87081 LAB L60 MAXFEE 01/01/2020 6.63 0.0 Description: CULTURE SCREEN ONLY Category: Laboratory CMS Add: 01/01/1984 CMS Term: 87084 LAB L60 MAXFEE 01/01/2015 12/31/2023 11.72 0.0 Description: CULTURE OF SPECIMEN BY KIT Category: Laboratory CMS Add: 01/01/1982 CMS Term: 87084 LAB L60 MAXFEE 01/01/2024 27.07 0.0 Description: CULTURE OF SPECIMEN BY KIT Category: Laboratory CMS Add: 01/01/1982 CMS Term: 87086 LAB L60 MAXFEE 01/01/2020 8.07 0.0 Description: URINE CULTURE/COLONY COUNT Category: Laboratory CMS Add: 01/01/1984 CMS Term: 87088 LAB L60 MAXFEE 01/01/2020 8.09 0.0 Description: URINE BACTERIA CULTURE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 87101 LAB L60 MAXFEE 01/01/2020 7.71 0.0 Description: SKIN FUNGI CULTURE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 87102 LAB L60 MAXFEE 01/01/2020 8.41 0.0 Description: FUNGUS ISOLATION CULTURE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 87103 LAB L60 MAXFEE 01/01/2015 12/31/2023 12.27 0.0 Description: BLOOD FUNGUS CULTURE Category: Laboratory CMS Add: 01/01/1988 CMS Term: 87103 LAB L60 MAXFEE 01/01/2024 20.46 0.0 Description: BLOOD FUNGUS CULTURE Category: Laboratory CMS Add: 01/01/1988 CMS Term: 87106 LAB L60 MAXFEE 01/01/2020 10.32 0.0 Description: FUNGI IDENTIFICATION YEAST Category: Laboratory CMS Add: 01/01/1984 CMS Term: 87107 LAB L60 MAXFEE 01/01/2020 10.32 0.0 Description: FUNGI IDENTIFICATION MOLD Category: Laboratory CMS Add: 01/01/2001 CMS Term: 87109 LAB L60 MAXFEE 01/01/2020 15.39 0.0 Description: MYCOPLASMA Category: Laboratory CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,167 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 87110 LAB L60 MAXFEE 01/01/2015 12/31/2023 15.84 0.0 Description: CHLAMYDIA CULTURE Category: Laboratory CMS Add: 01/01/1988 CMS Term: 87110 LAB L60 MAXFEE 01/01/2024 19.60 0.0 Description: CHLAMYDIA CULTURE Category: Laboratory CMS Add: 01/01/1988 CMS Term: 87116 LAB L60 MAXFEE 01/01/2020 10.80 0.0 Description: MYCOBACTERIA CULTURE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 87118 LAB L60 MAXFEE 01/01/2018 14.61 0.0 Description: MYCOBACTERIC IDENTIFICATION Category: Laboratory CMS Add: 01/01/1984 CMS Term: 87140 LAB L60 MAXFEE 01/01/2020 5.57 0.0 Description: CULTURE TYPE IMMUNOFLUORESC Category: Laboratory CMS Add: 01/01/1982 CMS Term: 87143 LAB L60 MAXFEE 01/01/2015 12/31/2023 8.10 0.0 Description: CULTURE TYPING GLC/HPLC Category: Laboratory CMS Add: 01/01/1982 CMS Term: 87143 LAB L60 MAXFEE 01/01/2024 12.52 0.0 Description: CULTURE TYPING GLC/HPLC Category: Laboratory CMS Add: 01/01/1982 CMS Term: 87147 LAB L60 MAXFEE 01/01/2015 5.18 0.0 Description: CULTURE TYPE IMMUNOLOGIC Category: Laboratory CMS Add: 01/01/1982 CMS Term: 87149 LAB L60 MAXFEE 01/01/2020 20.05 0.0 Description: DNA/RNA DIRECT PROBE Category: Laboratory CMS Add: 01/01/2001 CMS Term: 87150 LAB L60 MAXFEE 01/01/2020 35.09 0.0 Description: DNA/RNA AMPLIFIED PROBE Category: Laboratory CMS Add: 01/01/2010 CMS Term: 87152 LAB L60 MAXFEE 01/01/2015 12/31/2023 7.12 0.0 Description: CULTURE TYPE PULSE FIELD GEL Category: Laboratory CMS Add: 01/01/2001 CMS Term: 87152 LAB L60 MAXFEE 01/01/2024 7.74 0.0 Description: CULTURE TYPE PULSE FIELD GEL Category: Laboratory CMS Add: 01/01/2001 CMS Term: 87153 LAB L60 MAXFEE 01/01/2020 115.36 0.0 Description: DNA/RNA SEQUENCING Category: Laboratory CMS Add: 01/01/2010 CMS Term: 87154 LAB L60 MAXFEE 01/01/2022 218.06 0.0 Description: CUL TYP ID BLD PTHGN 6+ TRGT Category: Laboratory CMS Add: 01/01/2022 CMS Term: 87158 LAB L60 MAXFEE 01/01/2015 12/31/2023 7.12 0.0 Description: CULTURE TYPING ADDED METHOD Category: Laboratory CMS Add: 01/01/1982 CMS Term: 87158 LAB L60 MAXFEE 01/01/2024 7.74 0.0 Description: CULTURE TYPING ADDED METHOD Category: Laboratory CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,168 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 87164* 26 LAB DEF RBRVS 01/01/2024 18.26 Description: DARK FIELD EXAMINATION Category: Laboratory CMS Add: 01/01/1984 CMS Term: 87164* 26 LAB DEF RBRVS 02/01/2015 12/31/2023 13.90 Description: DARK FIELD EXAMINATION Category: Laboratory CMS Add: 01/01/1984 CMS Term: 87164* LAB L60 MAXFEE 01/01/2020 10.74 0.0 Description: DARK FIELD EXAMINATION Category: Laboratory CMS Add: 01/01/1984 CMS Term: 87166 LAB L60 MAXFEE 01/01/2020 11.30 0.0 Description: DARK FIELD EXAMINATION Category: Laboratory CMS Add: 01/01/1984 CMS Term: 87168 LAB L60 MAXFEE 01/01/2020 4.27 0.0 Description: MACROSCOPIC EXAM ARTHROPOD Category: Laboratory CMS Add: 01/01/2001 CMS Term: 87169 LAB L60 MAXFEE 01/01/2020 4.31 0.0 Description: MACROSCOPIC EXAM PARASITE Category: Laboratory CMS Add: 01/01/2001 CMS Term: 87172 LAB L60 MAXFEE 01/01/2020 4.27 0.0 Description: PINWORM EXAM Category: Laboratory CMS Add: 01/01/2001 CMS Term: 87176 LAB L60 MAXFEE 01/01/2020 5.88 0.0 Description: TISSUE HOMOGENIZATION CULTR Category: Laboratory CMS Add: 01/01/1985 CMS Term: 87177 LAB L60 MAXFEE 01/01/2020 8.90 0.0 Description: OVA AND PARASITES SMEARS Category: Laboratory CMS Add: 01/01/1984 CMS Term: 87181 LAB L60 MAXFEE 01/01/2020 4.75 0.0 Description: MICROBE SUSCEPTIBLE DIFFUSE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 87184 LAB L60 MAXFEE 01/01/2020 7.48 0.0 Description: MICROBE SUSCEPTIBLE DISK Category: Laboratory CMS Add: 01/01/1984 CMS Term: 87185 LAB L60 MAXFEE 01/01/2020 4.75 0.0 Description: MICROBE SUSCEPTIBLE ENZYME Category: Laboratory CMS Add: 01/01/2001 CMS Term: 87186 LAB L60 MAXFEE 01/01/2020 8.65 0.0 Description: MICROBE SUSCEPTIBLE MIC Category: Laboratory CMS Add: 01/01/1984 CMS Term: 87187 LAB L60 MAXFEE 01/01/2015 12/31/2023 11.89 0.0 Description: MICROBE SUSCEPTIBLE MLC Category: Laboratory CMS Add: 01/01/1988 CMS Term: 87187 LAB L60 MAXFEE 01/01/2024 40.17 0.0 Description: MICROBE SUSCEPTIBLE MLC Category: Laboratory CMS Add: 01/01/1988 CMS Term: 87188 LAB L60 MAXFEE 01/01/2020 6.64 0.0 Description: MICROBE SUSCEPT MACROBROTH Category: Laboratory CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,169 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 87190 LAB L60 MAXFEE 01/01/2018 7.31 0.0 Description: MICROBE SUSCEPT MYCOBACTERI Category: Laboratory CMS Add: 01/01/1984 CMS Term: 87197 LAB L60 MAXFEE 01/01/2015 12/31/2023 11.22 0.0 Description: BACTERICIDAL LEVEL SERUM Category: Laboratory CMS Add: 01/01/1988 CMS Term: 87197 LAB L60 MAXFEE 01/01/2024 15.02 0.0 Description: BACTERICIDAL LEVEL SERUM Category: Laboratory CMS Add: 01/01/1988 CMS Term: 87205 LAB L60 MAXFEE 01/01/2020 4.27 0.0 Description: SMEAR GRAM STAIN Category: Laboratory CMS Add: 01/01/1985 CMS Term: 87206 LAB L60 MAXFEE 01/01/2020 5.39 0.0 Description: SMEAR FLUORESCENT/ACID STAI Category: Laboratory CMS Add: 01/01/1985 CMS Term: 87207* 26 LAB DEF RBRVS 01/01/2024 17.02 Description: SMEAR SPECIAL STAIN Category: Laboratory CMS Add: 01/01/1984 CMS Term: 87207* 26 LAB DEF RBRVS 02/01/2015 12/31/2023 13.90 Description: SMEAR SPECIAL STAIN Category: Laboratory CMS Add: 01/01/1984 CMS Term: 87207* LAB L60 MAXFEE 01/01/2020 5.99 0.0 Description: SMEAR SPECIAL STAIN Category: Laboratory CMS Add: 01/01/1984 CMS Term: 87209 LAB L60 MAXFEE 01/01/2020 17.98 0.0 Description: SMEAR COMPLEX STAIN Category: Laboratory CMS Add: 01/01/2006 CMS Term: 87210 LAB L60 MAXFEE 01/01/2015 12/31/2023 5.81 0.0 Description: SMEAR WET MOUNT SALINE/INK Category: Laboratory CMS Add: 01/01/1985 CMS Term: 87210 LAB L60 MAXFEE 01/01/2024 5.82 0.0 Description: SMEAR WET MOUNT SALINE/INK Category: Laboratory CMS Add: 01/01/1985 CMS Term: 87220 LAB L60 MAXFEE 01/01/2020 4.27 0.0 Description: TISSUE EXAM FOR FUNGI Category: Laboratory CMS Add: 01/01/1984 CMS Term: 87230 LAB L60 MAXFEE 01/01/2015 12/31/2023 13.70 0.0 Description: ASSAY TOXIN OR ANTITOXIN Category: Laboratory CMS Add: 01/01/1988 CMS Term: 87230 LAB L60 MAXFEE 01/01/2024 19.74 0.0 Description: ASSAY TOXIN OR ANTITOXIN Category: Laboratory CMS Add: 01/01/1988 CMS Term: 87250 LAB L60 MAXFEE 01/01/2020 19.56 0.0 Description: VIRUS INOCULATE EGGS/ANIMAL Category: Laboratory CMS Add: 01/01/1984 CMS Term: 87252 LAB L60 MAXFEE 01/01/2015 12/31/2023 24.29 0.0 Description: VIRUS INOCULATION TISSUE Category: Laboratory CMS Add: 01/01/1988 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,170 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 87252 LAB L60 MAXFEE 01/01/2024 26.07 0.0 Description: VIRUS INOCULATION TISSUE Category: Laboratory CMS Add: 01/01/1988 CMS Term: 87253 LAB L60 MAXFEE 01/01/2020 20.20 0.0 Description: VIRUS INOCULATE TISSUE ADDL Category: Laboratory CMS Add: 01/01/1988 CMS Term: 87254 LAB L60 MAXFEE 01/01/2001 12/31/2023 6.76 0.0 Description: VIRUS INOCULATION SHELL VIA Category: Laboratory CMS Add: 01/01/2001 CMS Term: 87254 LAB L60 MAXFEE 01/01/2024 19.56 0.0 Description: VIRUS INOCULATION SHELL VIA Category: Laboratory CMS Add: 01/01/2001 CMS Term: 87255 LAB L60 MAXFEE 01/01/2020 33.86 0.0 Description: GENET VIRUS ISOLATE HSV Category: Laboratory CMS Add: 01/01/2003 CMS Term: 87260 LAB L60 MAXFEE 01/01/2019 14.43 0.0 Description: ADENOVIRUS AG IF Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87265 LAB L60 MAXFEE 01/01/2020 11.98 0.0 Description: PERTUSSIS AG IF Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87267 LAB L60 MAXFEE 01/01/2019 13.42 0.0 Description: ENTEROVIRUS ANTIBODY DFA Category: Laboratory CMS Add: 01/01/2003 CMS Term: 87269 LAB L60 MAXFEE 01/01/2019 13.61 0.0 Description: GIARDIA AG IF Category: Laboratory CMS Add: 01/01/2004 CMS Term: 87270 LAB L60 MAXFEE 01/01/2020 11.98 0.0 Description: CHLAMYDIA TRACHOMATIS AG IF Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87271 LAB L60 MAXFEE 01/01/2019 13.42 0.0 Description: CYTOMEGALOVIRUS DFA Category: Laboratory CMS Add: 01/01/2003 CMS Term: 87272 LAB L60 MAXFEE 01/01/2020 11.98 0.0 Description: CRYPTOSPORIDIUM AG IF Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87273 LAB L60 MAXFEE 01/01/2020 11.98 0.0 Description: HERPES SIMPLEX 2 AG IF Category: Laboratory CMS Add: 01/01/2001 CMS Term: 87274 LAB L60 MAXFEE 01/01/2020 11.98 0.0 Description: HERPES SIMPLEX 1 AG IF Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87275 LAB L60 MAXFEE 01/01/2020 12.25 0.0 Description: INFLUENZA B AG IF Category: Laboratory CMS Add: 01/01/2001 CMS Term: 87276 LAB L60 MAXFEE 01/01/2018 16.07 0.0 Description: INFLUENZA A AG IF Category: Laboratory CMS Add: 01/01/1998 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,171 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 87278 LAB L60 MAXFEE 01/01/2018 15.60 0.0 Description: LEGION PNEUMOPHILIA AG IF Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87279 LAB L60 MAXFEE 01/01/2015 12/31/2023 16.32 0.0 Description: PARAINFLUENZA AG IF Category: Laboratory CMS Add: 01/01/2001 CMS Term: 87279 LAB L60 MAXFEE 01/01/2024 16.43 0.0 Description: PARAINFLUENZA AG IF Category: Laboratory CMS Add: 01/01/2001 CMS Term: 87280 LAB L60 MAXFEE 01/01/2019 13.42 0.0 Description: RESPIRATORY SYNCYTIAL AG IF Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87281 LAB L60 MAXFEE 01/01/2020 11.98 0.0 Description: PNEUMOCYSTIS CARINII AG IF Category: Laboratory CMS Add: 01/01/2001 CMS Term: 87283 LAB L60 MAXFEE 01/01/2015 12/31/2023 16.32 0.0 Description: RUBEOLA AG IF Category: Laboratory CMS Add: 01/01/2001 CMS Term: 87283 LAB L60 MAXFEE 01/01/2024 60.80 0.0 Description: RUBEOLA AG IF Category: Laboratory CMS Add: 01/01/2001 CMS Term: 87285 LAB L60 MAXFEE 01/01/2020 12.18 0.0 Description: TREPONEMA PALLIDUM AG IF Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87290 LAB L60 MAXFEE 01/01/2019 13.42 0.0 Description: VARICELLA ZOSTER AG IF Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87299 LAB L60 MAXFEE 01/01/2018 16.10 0.0 Description: ANTIBODY DETECTION NOS IF Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87300 LAB L60 MAXFEE 01/01/2013 12/31/2023 8.29 0.0 Description: AG DETECTION POLYVAL IF Category: Laboratory CMS Add: 01/01/2001 CMS Term: 87300 LAB L60 MAXFEE 01/01/2024 11.98 0.0 Description: AG DETECTION POLYVAL IF Category: Laboratory CMS Add: 01/01/2001 CMS Term: 87301 LAB L60 MAXFEE 01/01/2020 11.98 0.0 Description: ADENOVIRUS AG IA Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87305 LAB L60 MAXFEE 01/01/2020 11.98 0.0 Description: ASPERGILLUS AG IA Category: Laboratory CMS Add: 01/01/2007 CMS Term: 87320 LAB L60 MAXFEE 01/01/2018 15.00 0.0 Description: CHLMYD TRACH AG IA Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87324 LAB L60 MAXFEE 01/01/2020 11.98 0.0 Description: CLOSTRIDIUM AG IA Category: Laboratory CMS Add: 01/01/1998 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,172 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 87327 LAB L60 MAXFEE 01/01/2019 13.42 0.0 Description: CRYPTOCOCCUS NEOFORM AG IA Category: Laboratory CMS Add: 01/01/2001 CMS Term: 87328 LAB L60 MAXFEE 01/01/2019 13.82 0.0 Description: CRYPTOSPORIDIUM AG IA Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87329 LAB L60 MAXFEE 01/01/2020 11.98 0.0 Description: GIARDIA AG IA Category: Laboratory CMS Add: 01/01/2004 CMS Term: 87332 LAB L60 MAXFEE 01/01/2020 11.98 0.0 Description: CYTOMEGALOVIRUS AG IA Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87335 LAB L60 MAXFEE 01/01/2020 12.66 0.0 Description: E COLI 0157 AG IA Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87336 LAB L60 MAXFEE 01/01/2018 16.00 0.0 Description: ENTAMOEB HIST DISPR AG IA Category: Laboratory CMS Add: 01/01/2001 CMS Term: 87337 LAB L60 MAXFEE 01/01/2020 11.98 0.0 Description: ENTAMOEB HIST GROUP AG IA Category: Laboratory CMS Add: 01/01/2001 CMS Term: 87338 LAB L60 MAXFEE 01/01/2020 14.38 0.0 Description: HPYLORI STOOL AG IA Category: Laboratory CMS Add: 01/01/2000 CMS Term: 87339 LAB L60 MAXFEE 01/01/2018 16.00 0.0 Description: H PYLORI AG IA Category: Laboratory CMS Add: 01/01/2001 CMS Term: 87340 LAB L60 MAXFEE 01/01/2015 12/31/2023 8.73 0.0 Description: HEPATITIS B SURFACE AG IA Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87340 LAB L60 MAXFEE 01/01/2024 10.33 0.0 Description: HEPATITIS B SURFACE AG IA Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87341 LAB L60 MAXFEE 01/01/2015 12/31/2023 8.73 0.0 Description: HEP B SURFACE AG NEUTRLZJ IA Category: Laboratory CMS Add: 01/01/2001 CMS Term: 87341 LAB L60 MAXFEE 01/01/2024 10.33 0.0 Description: HEP B SURFACE AG NEUTRLZJ IA Category: Laboratory CMS Add: 01/01/2001 CMS Term: 87350 LAB L60 MAXFEE 01/01/2020 11.53 0.0 Description: HEPATITIS BE AG IA Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87380 LAB L60 MAXFEE 01/01/2019 18.36 0.0 Description: HEPATITIS DELTA AGENT AG IA Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87385 LAB L60 MAXFEE 01/01/2020 13.25 0.0 Description: HISTOPLASMA CAPSUL AG IA Category: Laboratory CMS Add: 01/01/1998 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,173 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 87389 LAB L60 MAXFEE 01/01/2020 24.08 0.0 Description: HIV-1 AG W/HIV-1&-2 AB AG IA Category: Laboratory CMS Add: 01/01/2012 CMS Term: 87390 LAB L60 MAXFEE 01/01/2015 12/31/2023 24.01 0.0 Description: HIV-1 AG IA Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87390 LAB L60 MAXFEE 01/01/2024 24.06 0.0 Description: HIV-1 AG IA Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87391 LAB L60 MAXFEE 01/01/2018 21.90 0.0 Description: HIV-2 AG IA Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87400 LAB L60 MAXFEE 01/01/2001 12/31/2023 8.29 0.0 Description: INFLUENZA A/B EACH AG IA Category: Laboratory CMS Add: 01/01/2001 CMS Term: 87400 LAB L60 MAXFEE 01/01/2024 14.13 0.0 Description: INFLUENZA A/B EACH AG IA Category: Laboratory CMS Add: 01/01/2001 CMS Term: 87420 LAB L60 MAXFEE 01/01/2019 13.91 0.0 Description: RESP SYNCYTIAL VIRUS AG IA Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87425 LAB L60 MAXFEE 01/01/2020 11.98 0.0 Description: ROTAVIRUS AG IA Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87426 LAB L60 MAXFEE 04/09/2021 35.33 0.0 Description: SARSCOV CORONAVIRUS AG IA Category: Laboratory CMS Add: 06/25/2020 CMS Term: 87427 LAB L60 MAXFEE 01/01/2020 11.98 0.0 Description: SHIGA-LIKE TOXIN AG IA Category: Laboratory CMS Add: 01/01/2001 CMS Term: 87428 LAB L60 MAXFEE 01/01/2022 12/31/2023 30.94 0.0 Description: SARSCOV & INF VIR A&B AG IA Category: Laboratory CMS Add: 11/10/2020 CMS Term: 87428 LAB L60 MAXFEE 01/01/2024 40.22 0.0 Description: SARSCOV & INF VIR A&B AG IA Category: Laboratory CMS Add: 11/10/2020 CMS Term: 87430 LAB L60 MAXFEE 01/01/2015 12/31/2023 16.32 0.0 Description: STREP A AG IA Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87430 LAB L60 MAXFEE 01/01/2024 16.81 0.0 Description: STREP A AG IA Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87449 LAB L60 MAXFEE 01/01/2020 11.98 0.0 Description: NOS EACH ORGANISM AG IA Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87451 LAB L60 MAXFEE 01/01/2020 10.51 0.0 Description: POLYVALENT MULT ORG EA AG IA Category: Laboratory CMS Add: 01/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,174 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 87467 LAB L60 MAXFEE 01/01/2023 15.05 0.0 Description: HEPATITIS B SURFACE AG QUAN Category: Laboratory CMS Add: 01/01/2023 CMS Term: 87468 LAB L60 MAXFEE 01/01/2023 35.09 0.0 Description: ANAPLSMA PHGCYTOPHLM AMP PRB Category: Laboratory CMS Add: 01/01/2023 CMS Term: 87469 LAB L60 MAXFEE 01/01/2023 35.09 0.0 Description: BABESIA MICROTI AMP PRB Category: Laboratory CMS Add: 01/01/2023 CMS Term: 87471 LAB L60 MAXFEE 01/01/2020 35.09 0.0 Description: BARTONELLA DNA AMP PROBE Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87472 LAB L60 MAXFEE 01/01/2020 42.84 0.0 Description: BARTONELLA DNA QUANT Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87475 LAB L60 MAXFEE 01/01/2020 20.05 0.0 Description: LYME DIS DNA DIR PROBE Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87476 LAB L60 MAXFEE 01/01/2020 35.09 0.0 Description: LYME DIS DNA AMP PROBE Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87478 LAB L60 MAXFEE 01/01/2023 35.09 0.0 Description: BORRELIA MIYAMOTOI AMP PRB Category: Laboratory CMS Add: 01/01/2023 CMS Term: 87480 LAB L60 MAXFEE 01/01/2020 20.05 0.0 Description: CANDIDA DNA DIR PROBE Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87481 LAB L60 MAXFEE 01/01/2020 35.09 0.0 Description: CANDIDA DNA AMP PROBE Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87482 LAB L60 MAXFEE 01/01/2018 55.74 0.0 Description: CANDIDA DNA QUANT Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87483 LAB L60 MAXFEE 01/01/2020 416.78 0.0 Description: CNS DNA AMP PROBE TYPE 12-25 Category: Laboratory CMS Add: 01/01/2017 CMS Term: 87484 LAB L60 MAXFEE 01/01/2023 35.09 0.0 Description: EHRLICHA CHAFFEENSIS AMP PRB Category: Laboratory CMS Add: 01/01/2023 CMS Term: 87485 LAB L60 MAXFEE 01/01/2020 20.05 0.0 Description: CHLMYD PNEUM DNA DIR PROBE Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87486 LAB L60 MAXFEE 01/01/2020 35.09 0.0 Description: CHLMYD PNEUM DNA AMP PROBE Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87487 LAB L60 MAXFEE 01/01/2020 42.84 0.0 Description: CHLMYD PNEUM DNA QUANT Category: Laboratory CMS Add: 01/01/1998 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,175 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 87490 LAB L60 MAXFEE 01/01/2019 22.75 0.0 Description: CHLMYD TRACH DNA DIR PROBE Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87491 LAB L60 MAXFEE 01/01/2020 35.09 0.0 Description: CHLMYD TRACH DNA AMP PROBE Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87492 LAB L60 MAXFEE 01/01/2015 12/31/2023 47.57 0.0 Description: CHLMYD TRACH DNA QUANT Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87492 LAB L60 MAXFEE 01/01/2024 53.47 0.0 Description: CHLMYD TRACH DNA QUANT Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87493 LAB L60 MAXFEE 01/01/2020 37.27 0.0 Description: C DIFF AMPLIFIED PROBE Category: Laboratory CMS Add: 01/01/2010 CMS Term: 87495 LAB L60 MAXFEE 01/01/2015 12/31/2023 27.29 0.0 Description: CYTOMEG DNA DIR PROBE Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87495 LAB L60 MAXFEE 01/01/2024 30.03 0.0 Description: CYTOMEG DNA DIR PROBE Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87496 LAB L60 MAXFEE 01/01/2020 35.09 0.0 Description: CYTOMEG DNA AMP PROBE Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87497 LAB L60 MAXFEE 01/01/2020 42.84 0.0 Description: CYTOMEG DNA QUANT Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87498 LAB L60 MAXFEE 01/01/2020 35.09 0.0 Description: ENTEROVIRUS PROBE&REVRS TRNS Category: Laboratory CMS Add: 01/01/2007 CMS Term: 87500 LAB L60 MAXFEE 01/01/2020 35.09 0.0 Description: VANOMYCIN DNA AMP PROBE Category: Laboratory CMS Add: 01/01/2008 CMS Term: 87501 LAB L60 MAXFEE 01/01/2020 51.31 0.0 Description: INFLUENZA DNA AMP PROB 1+ Category: Laboratory CMS Add: 01/01/2011 CMS Term: 87502 LAB L60 MAXFEE 01/01/2019 95.80 0.0 Description: INFLUENZA DNA AMP PROBE Category: Laboratory CMS Add: 01/01/2011 CMS Term: 87503 LAB L60 MAXFEE 01/01/2015 12/31/2023 28.26 0.0 Description: INFLUENZA DNA AMP PROB ADDL Category: Laboratory CMS Add: 01/01/2011 CMS Term: 87503 LAB L60 MAXFEE 01/01/2024 29.22 0.0 Description: INFLUENZA DNA AMP PROB ADDL Category: Laboratory CMS Add: 01/01/2011 CMS Term: 87505 LAB L60 MAXFEE 01/01/2020 128.29 0.0 Description: NFCT AGENT DETECTION GI Category: Laboratory CMS Add: 01/01/2015 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,176 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 87506 LAB L60 MAXFEE 01/01/2019 262.99 0.0 Description: IADNA-DNA/RNA PROBE TQ 6-11 Category: Laboratory CMS Add: 01/01/2015 CMS Term: 87507 LAB L60 MAXFEE 01/01/2020 416.78 0.0 Description: IADNA-DNA/RNA PROBE TQ 12-25 Category: Laboratory CMS Add: 01/01/2015 CMS Term: 87510 LAB L60 MAXFEE 01/01/2020 20.05 0.0 Description: GARDNER VAG DNA DIR PROBE Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87511 LAB L60 MAXFEE 01/01/2020 35.09 0.0 Description: GARDNER VAG DNA AMP PROBE Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87512 LAB L60 MAXFEE 01/01/2020 41.76 0.0 Description: GARDNER VAG DNA QUANT Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87516 LAB L60 MAXFEE 01/01/2020 35.09 0.0 Description: HEPATITIS B DNA AMP PROBE Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87517 LAB L60 MAXFEE 01/01/2020 42.84 0.0 Description: HEPATITIS B DNA QUANT Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87520 LAB L60 MAXFEE 01/01/2015 12/31/2023 27.29 0.0 Description: HEPATITIS C RNA DIR PROBE Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87520 LAB L60 MAXFEE 01/01/2024 31.22 0.0 Description: HEPATITIS C RNA DIR PROBE Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87521 LAB L60 MAXFEE 01/01/2020 35.09 0.0 Description: HEPATITIS C PROBE&RVRS TRNSC Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87522 LAB L60 MAXFEE 01/01/2020 42.84 0.0 Description: HEPATITIS C REVRS TRNSCRPJ Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87523 NOCOV DEF SYSMAN Description: HEPATITIS D QUANTIFICATION Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 87525 LAB L60 MAXFEE 01/01/2015 12/31/2023 27.29 0.0 Description: HEPATITIS G DNA DIR PROBE Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87525 LAB L60 MAXFEE 01/01/2024 29.80 0.0 Description: HEPATITIS G DNA DIR PROBE Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87526 LAB L60 MAXFEE 01/01/2019 39.26 0.0 Description: HEPATITIS G DNA AMP PROBE Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87527 LAB L60 MAXFEE 01/01/2020 41.76 0.0 Description: HEPATITIS G DNA QUANT Category: Laboratory CMS Add: 01/01/1998 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,177 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 87528 LAB L60 MAXFEE 01/01/2020 20.05 0.0 Description: HSV DNA DIR PROBE Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87529 LAB L60 MAXFEE 01/01/2020 35.09 0.0 Description: HSV DNA AMP PROBE Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87530 LAB L60 MAXFEE 01/01/2020 42.84 0.0 Description: HSV DNA QUANT Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87531 LAB L60 MAXFEE 01/01/2015 12/31/2023 27.29 0.0 Description: HHV-6 DNA DIR PROBE Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87531 LAB L60 MAXFEE 01/01/2024 58.00 0.0 Description: HHV-6 DNA DIR PROBE Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87532 LAB L60 MAXFEE 01/01/2020 35.09 0.0 Description: HHV-6 DNA AMP PROBE Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87533 LAB L60 MAXFEE 01/01/2020 41.76 0.0 Description: HHV-6 DNA QUANT Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87534 LAB L60 MAXFEE 01/01/2020 21.92 0.0 Description: HIV-1 DNA DIR PROBE Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87535 LAB L60 MAXFEE 01/01/2020 35.09 0.0 Description: HIV-1 PROBE&REVERSE TRNSCRPJ Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87536 LAB L60 MAXFEE 01/01/2020 85.10 0.0 Description: HIV-1 QUANT&REVRSE TRNSCRPJ Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87537 LAB L60 MAXFEE 01/01/2020 21.92 0.0 Description: HIV-2 DNA DIR PROBE Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87538 LAB L60 MAXFEE 01/01/2020 35.09 0.0 Description: HIV-2 PROBE&REVRSE TRNSCRIPJ Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87539 LAB L60 MAXFEE 01/01/2015 12/31/2023 58.29 0.0 Description: HIV-2 QUANT&REVRSE TRNSCRIPJ Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87539 LAB L60 MAXFEE 01/01/2024 58.62 0.0 Description: HIV-2 QUANT&REVRSE TRNSCRIPJ Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87540 LAB L60 MAXFEE 01/01/2020 20.05 0.0 Description: LEGION PNEUMO DNA DIR PROB Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87541 LAB L60 MAXFEE 01/01/2020 35.09 0.0 Description: LEGION PNEUMO DNA AMP PROB Category: Laboratory CMS Add: 01/01/1998 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,178 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 87542 LAB L60 MAXFEE 01/01/2020 41.76 0.0 Description: LEGION PNEUMO DNA QUANT Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87550 LAB L60 MAXFEE 01/01/2020 20.05 0.0 Description: MYCOBACTERIA DNA DIR PROBE Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87551 LAB L60 MAXFEE 01/01/2015 12/31/2023 47.76 0.0 Description: MYCOBACTERIA DNA AMP PROBE Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87551 LAB L60 MAXFEE 01/01/2024 48.24 0.0 Description: MYCOBACTERIA DNA AMP PROBE Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87552 LAB L60 MAXFEE 01/01/2020 42.84 0.0 Description: MYCOBACTERIA DNA QUANT Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87555 LAB L60 MAXFEE 01/01/2018 26.88 0.0 Description: M.TUBERCULO DNA DIR PROBE Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87556 LAB L60 MAXFEE 01/01/2019 41.68 0.0 Description: M.TUBERCULO DNA AMP PROBE Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87557 LAB L60 MAXFEE 01/01/2020 42.84 0.0 Description: M.TUBERCULO DNA QUANT Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87560 LAB L60 MAXFEE 01/01/2015 27.29 0.0 Description: M.AVIUM-INTRA DNA DIR PROB Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87561 LAB L60 MAXFEE 01/01/2020 35.09 0.0 Description: M.AVIUM-INTRA DNA AMP PROB Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87562 LAB L60 MAXFEE 01/01/2020 42.84 0.0 Description: M.AVIUM-INTRA DNA QUANT Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87563 LAB L60 MAXFEE 01/01/2020 35.09 0.0 Description: M. GENITALIUM AMP PROBE Category: Laboratory CMS Add: 01/01/2020 CMS Term: 87580 LAB L60 MAXFEE 01/01/2020 20.05 0.0 Description: M.PNEUMON DNA DIR PROBE Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87581 LAB L60 MAXFEE 01/01/2020 35.09 0.0 Description: M.PNEUMON DNA AMP PROBE Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87582 LAB L60 MAXFEE 01/01/2015 12/31/2023 56.82 0.0 Description: M.PNEUMON DNA QUANT Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87582 LAB L60 MAXFEE 01/01/2024 302.62 0.0 Description: M.PNEUMON DNA QUANT Category: Laboratory CMS Add: 01/01/1998 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,179 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 87590 LAB L60 MAXFEE 01/01/2018 26.88 0.0 Description: N.GONORRHOEAE DNA DIR PROB Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87591 LAB L60 MAXFEE 01/01/2020 35.09 0.0 Description: N.GONORRHOEAE DNA AMP PROB Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87592 LAB L60 MAXFEE 01/01/2020 42.84 0.0 Description: N.GONORRHOEAE DNA QUANT Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87593 LAB DEF BILL30 0-999years Description: ORTHOPOXVIRUS AMP PRB EACH Category: Laboratory CMS Add: 07/26/2022 CMS Term: 87623 NOCOV DEF SYSMAN Description: HPV LOW-RISK TYPES Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 87624 LAB L60 MAXFEE 01/01/2020 35.09 0.0 Description: HPV HIGH-RISK TYPES Category: Laboratory CMS Add: 01/01/2015 CMS Term: 87625 LAB L60 MAXFEE 01/01/2019 40.55 0.0 Description: HPV TYPES 16 & 18 ONLY Category: Laboratory CMS Add: 01/01/2015 CMS Term: 87631 LAB L60 MAXFEE 01/01/2019 142.63 0.0 0-1 Description: RESP VIRUS 3-5 TARGETS Category: Laboratory CMS Add: 01/01/2013 CMS Term: 87632 LAB L60 MAXFEE 01/01/2020 218.06 0.0 0-1 Description: RESP VIRUS 6-11 TARGETS Category: Laboratory CMS Add: 01/01/2013 CMS Term: 87633 LAB L60 MAXFEE 01/01/2020 416.78 0.0 0-1 Description: RESP VIRUS 12-25 TARGETS Category: Laboratory CMS Add: 01/01/2013 CMS Term: 87634 LAB L60 MAXFEE 01/01/2020 70.20 0.0 Description: RSV DNA/RNA AMP PROBE Category: Laboratory CMS Add: 01/01/2018 CMS Term: 87635 LAB L60 MAXFEE 04/30/2020 51.31 0.0 Description: SARS-COV-2 COVID-19 AMP PRB Category: Laboratory CMS Add: 03/13/2020 CMS Term: 87636 LAB L60 MAXFEE 04/09/2021 142.63 0.0 Description: SARSCOV2 & INF A&B AMP PRB Category: Laboratory CMS Add: 10/06/2020 CMS Term: 87637 LAB L60 MAXFEE 04/09/2021 142.63 0.0 Description: SARSCOV2&INF A&B&RSV AMP PRB Category: Laboratory CMS Add: 10/06/2020 CMS Term: 87640 LAB L60 MAXFEE 01/01/2020 35.09 0.0 Description: STAPH A DNA AMP PROBE Category: Laboratory CMS Add: 01/01/2007 CMS Term: 87641 LAB L60 MAXFEE 01/01/2020 35.09 0.0 Description: MR-STAPH DNA AMP PROBE Category: Laboratory CMS Add: 01/01/2007 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,180 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 87650 LAB L60 MAXFEE 01/01/2020 20.05 0.0 Description: STREP A DNA DIR PROBE Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87651 LAB L60 MAXFEE 01/01/2020 35.09 0.0 Description: STREP A DNA AMP PROBE Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87652 LAB L60 MAXFEE 01/01/2020 41.76 0.0 Description: STREP A DNA QUANT Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87653 LAB L60 MAXFEE 01/01/2020 35.09 0.0 Description: STREP B DNA AMP PROBE Category: Laboratory CMS Add: 01/01/2007 CMS Term: 87660 LAB L60 MAXFEE 01/01/2020 20.05 0.0 Description: TRICHOMONAS VAGIN DIR PROBE Category: Laboratory CMS Add: 01/01/2004 CMS Term: 87661 LAB L60 MAXFEE 01/01/2020 35.09 0.0 Description: TRICHOMONAS VAGINALIS AMPLIF Category: Laboratory CMS Add: 01/01/2014 CMS Term: 87662 LAB L60 MAXFEE 01/01/2020 51.31 0.0 Description: ZIKA VIRUS DNA/RNA AMP PROBE Category: Laboratory CMS Add: 01/01/2018 CMS Term: 87797 LAB L60 MAXFEE 01/01/2015 12/31/2023 27.29 0.0 Description: DETECT AGENT NOS DNA DIR Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87797 LAB L60 MAXFEE 01/01/2024 30.03 0.0 Description: DETECT AGENT NOS DNA DIR Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87798 LAB L60 MAXFEE 01/01/2020 35.09 0.0 Description: DETECT AGENT NOS DNA AMP Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87799 LAB L60 MAXFEE 01/01/2020 42.84 0.0 Description: DETECT AGENT NOS DNA QUANT Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87800 LAB L60 MAXFEE 01/01/2001 12/31/2023 27.71 0.0 Description: DETECT AGNT MULT DNA DIREC Category: Laboratory CMS Add: 01/01/2001 CMS Term: 87800 LAB L60 MAXFEE 01/01/2024 43.67 0.0 Description: DETECT AGNT MULT DNA DIREC Category: Laboratory CMS Add: 01/01/2001 CMS Term: 87801 LAB L60 MAXFEE 01/01/2001 12/31/2023 48.50 0.0 Description: DETECT AGNT MULT DNA AMPLI Category: Laboratory CMS Add: 01/01/2001 CMS Term: 87801 LAB L60 MAXFEE 01/01/2024 70.20 0.0 Description: DETECT AGNT MULT DNA AMPLI Category: Laboratory CMS Add: 01/01/2001 CMS Term: 87802 LAB L60 MAXFEE 01/01/2020 12.73 0.0 Description: STREP B ASSAY W/OPTIC Category: Laboratory CMS Add: 01/01/2002 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,181 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 87803 LAB L60 MAXFEE 01/01/2018 16.00 0.0 Description: CLOSTRIDIUM TOXIN A W/OPTIC Category: Laboratory CMS Add: 01/01/2002 CMS Term: 87804 LAB L60 MAXFEE 01/01/2015 12/31/2023 16.32 0.0 Description: INFLUENZA ASSAY W/OPTIC Category: Laboratory CMS Add: 01/01/2002 CMS Term: 87804 LAB L60 MAXFEE 01/01/2024 16.55 0.0 Description: INFLUENZA ASSAY W/OPTIC Category: Laboratory CMS Add: 01/01/2002 CMS Term: 87806 LAB L60 MAXFEE 01/01/2015 12/31/2023 16.32 0.0 Description: HIV AG W/HIV1&2 ANTB W/OPTIC Category: Laboratory CMS Add: 01/01/2015 CMS Term: 87806 LAB L60 MAXFEE 01/01/2024 32.77 0.0 Description: HIV AG W/HIV1&2 ANTB W/OPTIC Category: Laboratory CMS Add: 01/01/2015 CMS Term: 87807 LAB L60 MAXFEE 01/01/2020 13.10 0.0 Description: RSV ASSAY W/OPTIC Category: Laboratory CMS Add: 01/01/2005 CMS Term: 87808 LAB L60 MAXFEE 01/01/2018 15.29 0.0 Description: TRICHOMONAS ASSAY W/OPTIC Category: Laboratory CMS Add: 01/01/2007 CMS Term: 87809 LAB L60 MAXFEE 01/01/2015 12/31/2023 16.32 0.0 Description: ADENOVIRUS ASSAY W/OPTIC Category: Laboratory CMS Add: 01/01/2008 CMS Term: 87809 LAB L60 MAXFEE 01/01/2024 21.76 0.0 Description: ADENOVIRUS ASSAY W/OPTIC Category: Laboratory CMS Add: 01/01/2008 CMS Term: 87810 LAB L60 MAXFEE 01/01/2015 12/31/2023 16.32 0.0 Description: CHLMYD TRACH ASSAY W/OPTIC Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87810 LAB L60 MAXFEE 01/01/2024 35.29 0.0 Description: CHLMYD TRACH ASSAY W/OPTIC Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87811 LAB L60 MAXFEE 04/09/2021 41.38 0.0 Description: SARS-COV-2 COVID19 W/OPTIC Category: Laboratory CMS Add: 10/06/2020 CMS Term: 87850 LAB L60 MAXFEE 01/01/2015 12/31/2023 16.32 0.0 Description: N. GONORRHOEAE ASSAY W/OPTIC Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87850 LAB L60 MAXFEE 01/01/2024 24.56 0.0 Description: N. GONORRHOEAE ASSAY W/OPTIC Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87880 LAB L60 MAXFEE 01/01/2015 12/31/2023 16.32 0.0 Description: STREP A ASSAY W/OPTIC Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87880 LAB L60 MAXFEE 01/01/2024 16.53 0.0 Description: STREP A ASSAY W/OPTIC Category: Laboratory CMS Add: 01/01/1998 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,182 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 87899 LAB L60 MAXFEE 01/01/2018 16.07 0.0 Description: AGENT NOS ASSAY W/OPTIC Category: Laboratory CMS Add: 01/01/1998 CMS Term: 87900 LAB L60 MAXFEE 01/01/2015 12/31/2023 121.51 0.0 Description: PHENOTYPE INFECT AGENT DRUG Category: Laboratory CMS Add: 01/01/2006 CMS Term: 87900 LAB L60 MAXFEE 01/01/2024 130.35 0.0 Description: PHENOTYPE INFECT AGENT DRUG Category: Laboratory CMS Add: 01/01/2006 CMS Term: 87901 LAB L60 MAXFEE 01/01/2020 257.45 0.0 Description: NFCT AGT GNTYP ALYS HIV1 REV Category: Laboratory CMS Add: 01/01/2001 CMS Term: 87902 LAB L60 MAXFEE 01/01/2020 257.45 0.0 Description: NFCT AGT GNTYP ALYS HEP C Category: Laboratory CMS Add: 01/01/2002 CMS Term: 87903 LAB L60 MAXFEE 01/01/2020 488.66 0.0 Description: PHENOTYPE DNA HIV W/CULTURE Category: Laboratory CMS Add: 01/01/2001 CMS Term: 87904 LAB L60 MAXFEE 01/01/2015 12/31/2023 24.29 0.0 Description: PHENOTYPE DNA HIV W/CLT ADD Category: Laboratory CMS Add: 01/01/2001 CMS Term: 87904 LAB L60 MAXFEE 01/01/2024 26.07 0.0 Description: PHENOTYPE DNA HIV W/CLT ADD Category: Laboratory CMS Add: 01/01/2001 CMS Term: 87905 LAB L60 MAXFEE 01/01/2020 12.22 0.0 Description: SIALIDASE ENZYME ASSAY Category: Laboratory CMS Add: 01/01/2009 CMS Term: 87906 LAB L60 MAXFEE 01/01/2020 128.73 0.0 Description: NFCT AGT GNTYP ALYS HIV1 Category: Laboratory CMS Add: 01/01/2011 CMS Term: 87910 LAB L60 MAXFEE 01/01/2020 257.45 0.0 0-1 Description: NFCT AGT GNTYP ALYS CMV Category: Laboratory CMS Add: 01/01/2013 CMS Term: 87912 LAB L60 MAXFEE 01/01/2020 257.45 0.0 0-1 Description: NFCT AGT GNTYP ALYS HEP B Category: Laboratory CMS Add: 01/01/2013 CMS Term: 87913 LAB L60 MAXFEE 02/21/2022 257.45 0.0 Description: NFCT AGT GNTYP ALYS SARSCOV2 Category: Laboratory CMS Add: 02/21/2022 CMS Term: 87999 LAB L60 MAXFEE 01/01/2024 40.56 0.0 Description: UNLISTED MICROBIOLOGY PX Category: Laboratory CMS Add: 01/01/1982 CMS Term: 87999 LAB L60 MAXFEE 07/01/1985 12/31/2023 31.20 0.0 Description: UNLISTED MICROBIOLOGY PX Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88000 NOCOV DEF SYSMAN Description: AUTOPSY (NECROPSY) GROSS Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,183 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 88005 NOCOV DEF SYSMAN Description: AUTOPSY (NECROPSY) GROSS Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 88007 NOCOV DEF SYSMAN Description: AUTOPSY (NECROPSY) GROSS Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 88012 NOCOV DEF SYSMAN Description: AUTOPSY (NECROPSY) GROSS Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 88014 NOCOV DEF SYSMAN Description: AUTOPSY (NECROPSY) GROSS Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 88016 NOCOV DEF SYSMAN Description: AUTOPSY (NECROPSY) GROSS Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 88020 NOCOV DEF SYSMAN Description: AUTOPSY (NECROPSY) COMPLETE Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 88025 NOCOV DEF SYSMAN Description: AUTOPSY (NECROPSY) COMPLETE Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 88027 NOCOV DEF SYSMAN Description: AUTOPSY (NECROPSY) COMPLETE Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 88028 NOCOV DEF SYSMAN Description: AUTOPSY (NECROPSY) COMPLETE Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 88029 NOCOV DEF SYSMAN Description: AUTOPSY (NECROPSY) COMPLETE Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 88036 NOCOV DEF SYSMAN Description: LIMITED AUTOPSY Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 88037 NOCOV DEF SYSMAN Description: LIMITED AUTOPSY Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 88040 NOCOV DEF SYSMAN Description: FORENSIC AUTOPSY (NECROPSY) Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 88045 NOCOV DEF SYSMAN Description: CORONERS AUTOPSY (NECROPSY) Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 88099 NOCOV DEF SYSMAN Description: UNLISTED NECROPSY (AUTOPSY) Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 88104 26 LAB DEF RBRVS 01/01/2024 25.93 Description: CYTOPATH FL NONGYN SMEARS Category: Laboratory CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,184 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 88104 26 LAB DEF RBRVS 02/01/2015 12/31/2023 21.40 Description: CYTOPATH FL NONGYN SMEARS Category: Laboratory CMS Add: 01/01/1984 CMS Term: 88104 LAB DEF RBRVS 01/01/2024 64.84 Description: CYTOPATH FL NONGYN SMEARS Category: Laboratory CMS Add: 01/01/1984 CMS Term: 88104 LAB DEF RBRVS 02/01/2015 12/31/2023 52.29 Description: CYTOPATH FL NONGYN SMEARS Category: Laboratory CMS Add: 01/01/1984 CMS Term: 88104 TC LAB DEF RBRVS 01/01/2024 38.91 Description: CYTOPATH FL NONGYN SMEARS Category: Laboratory CMS Add: 01/01/1984 CMS Term: 88104 TC LAB DEF RBRVS 02/01/2015 12/31/2023 30.88 Description: CYTOPATH FL NONGYN SMEARS Category: Laboratory CMS Add: 01/01/1984 CMS Term: 88106 26 LAB DEF RBRVS 01/01/2024 18.26 Description: CYTOPATH FL NONGYN FILTER Category: Laboratory CMS Add: 01/01/1984 CMS Term: 88106 26 LAB DEF RBRVS 02/01/2015 12/31/2023 14.32 Description: CYTOPATH FL NONGYN FILTER Category: Laboratory CMS Add: 01/01/1984 CMS Term: 88106 LAB DEF RBRVS 01/01/2024 65.03 Description: CYTOPATH FL NONGYN FILTER Category: Laboratory CMS Add: 01/01/1984 CMS Term: 88106 LAB DEF RBRVS 02/01/2015 12/31/2023 59.07 Description: CYTOPATH FL NONGYN FILTER Category: Laboratory CMS Add: 01/01/1984 CMS Term: 88106 TC LAB DEF RBRVS 01/01/2024 46.78 Description: CYTOPATH FL NONGYN FILTER Category: Laboratory CMS Add: 01/01/1984 CMS Term: 88106 TC LAB DEF RBRVS 02/01/2015 12/31/2023 44.75 Description: CYTOPATH FL NONGYN FILTER Category: Laboratory CMS Add: 01/01/1984 CMS Term: 88108 26 LAB DEF RBRVS 01/01/2024 21.25 Description: CYTOPATH CONCENTRATE TECH Category: Laboratory CMS Add: 01/01/1984 CMS Term: 88108 26 LAB DEF RBRVS 02/01/2015 12/31/2023 16.69 Description: CYTOPATH CONCENTRATE TECH Category: Laboratory CMS Add: 01/01/1984 CMS Term: 88108 LAB DEF RBRVS 01/01/2024 61.85 Description: CYTOPATH CONCENTRATE TECH Category: Laboratory CMS Add: 01/01/1984 CMS Term: 88108 LAB DEF RBRVS 02/01/2015 12/31/2023 55.25 Description: CYTOPATH CONCENTRATE TECH Category: Laboratory CMS Add: 01/01/1984 CMS Term: 88108 TC LAB DEF RBRVS 01/01/2024 40.60 Description: CYTOPATH CONCENTRATE TECH Category: Laboratory CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,185 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 88108 TC LAB DEF RBRVS 02/01/2015 12/31/2023 38.56 Description: CYTOPATH CONCENTRATE TECH Category: Laboratory CMS Add: 01/01/1984 CMS Term: 88112 26 LAB DEF RBRVS 01/01/2024 26.24 Description: CYTOPATH CELL ENHANCE TECH Category: Laboratory CMS Add: 01/01/2004 CMS Term: 88112 26 LAB DEF RBRVS 02/01/2015 12/31/2023 20.66 Description: CYTOPATH CELL ENHANCE TECH Category: Laboratory CMS Add: 01/01/2004 CMS Term: 88112 LAB DEF RBRVS 01/01/2024 62.83 Description: CYTOPATH CELL ENHANCE TECH Category: Laboratory CMS Add: 01/01/2004 CMS Term: 88112 LAB DEF RBRVS 02/01/2015 12/31/2023 44.61 Description: CYTOPATH CELL ENHANCE TECH Category: Laboratory CMS Add: 01/01/2004 CMS Term: 88112 TC LAB DEF RBRVS 01/01/2024 36.59 Description: CYTOPATH CELL ENHANCE TECH Category: Laboratory CMS Add: 01/01/2004 CMS Term: 88112 TC LAB DEF RBRVS 02/01/2015 12/31/2023 23.95 Description: CYTOPATH CELL ENHANCE TECH Category: Laboratory CMS Add: 01/01/2004 CMS Term: 88120 26 LAB DEF RBRVS 01/01/2024 55.50 Description: CYTP URNE 3-5 PROBES EA SPEC Category: Laboratory CMS Add: 01/01/2011 CMS Term: 88120 26 LAB DEF RBRVS 02/01/2015 12/31/2023 43.14 Description: CYTP URNE 3-5 PROBES EA SPEC Category: Laboratory CMS Add: 01/01/2011 CMS Term: 88120 LAB DEF RBRVS 01/01/2024 552.86 Description: CYTP URNE 3-5 PROBES EA SPEC Category: Laboratory CMS Add: 01/01/2011 CMS Term: 88120 LAB DEF RBRVS 02/01/2015 12/31/2023 429.82 Description: CYTP URNE 3-5 PROBES EA SPEC Category: Laboratory CMS Add: 01/01/2011 CMS Term: 88120 TC LAB DEF RBRVS 01/01/2024 497.36 Description: CYTP URNE 3-5 PROBES EA SPEC Category: Laboratory CMS Add: 01/01/2011 CMS Term: 88120 TC LAB DEF RBRVS 02/01/2015 12/31/2023 386.68 Description: CYTP URNE 3-5 PROBES EA SPEC Category: Laboratory CMS Add: 01/01/2011 CMS Term: 88121 26 LAB DEF RBRVS 01/01/2024 45.94 Description: CYTP URINE 3-5 PROBES CMPTR Category: Laboratory CMS Add: 01/01/2011 CMS Term: 88121 26 LAB DEF RBRVS 02/01/2015 12/31/2023 37.02 Description: CYTP URINE 3-5 PROBES CMPTR Category: Laboratory CMS Add: 01/01/2011 CMS Term: 88121 LAB DEF RBRVS 01/01/2024 389.08 Description: CYTP URINE 3-5 PROBES CMPTR Category: Laboratory CMS Add: 01/01/2011 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,186 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 88121 LAB DEF RBRVS 02/01/2015 12/31/2023 371.85 Description: CYTP URINE 3-5 PROBES CMPTR Category: Laboratory CMS Add: 01/01/2011 CMS Term: 88121 TC LAB DEF RBRVS 01/01/2024 343.14 Description: CYTP URINE 3-5 PROBES CMPTR Category: Laboratory CMS Add: 01/01/2011 CMS Term: 88121 TC LAB DEF RBRVS 02/01/2015 12/31/2023 334.83 Description: CYTP URINE 3-5 PROBES CMPTR Category: Laboratory CMS Add: 01/01/2011 CMS Term: 88125 26 LAB DEF RBRVS 01/01/2024 12.98 Description: FORENSIC CYTOPATHOLOGY Category: Laboratory CMS Add: 01/01/1984 CMS Term: 88125 26 LAB DEF RBRVS 02/01/2015 12/31/2023 9.63 Description: FORENSIC CYTOPATHOLOGY Category: Laboratory CMS Add: 01/01/1984 CMS Term: 88125 LAB DEF RBRVS 01/01/2024 26.42 Description: FORENSIC CYTOPATHOLOGY Category: Laboratory CMS Add: 01/01/1984 CMS Term: 88125 LAB DEF RBRVS 02/01/2015 12/31/2023 15.74 Description: FORENSIC CYTOPATHOLOGY Category: Laboratory CMS Add: 01/01/1984 CMS Term: 88125 TC LAB DEF RBRVS 01/01/2024 13.44 Description: FORENSIC CYTOPATHOLOGY Category: Laboratory CMS Add: 01/01/1984 CMS Term: 88125 TC LAB DEF RBRVS 02/01/2015 12/31/2023 6.11 Description: FORENSIC CYTOPATHOLOGY Category: Laboratory CMS Add: 01/01/1984 CMS Term: 88130 LAB L60 MAXFEE 01/01/2020 17.98 0.0 Description: SEX CHROMATIN IDENTIFICATION Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88140 LAB L60 MAXFEE 01/01/2020 7.99 0.0 Description: SEX CHROMATIN IDENTIFICATION Category: Laboratory CMS Add: 01/01/1985 CMS Term: 88141 LAB DEF RBRVS 01/01/2024 21.63 Description: CYTOPATH C/V INTERPRET Category: Laboratory CMS Add: 01/01/1998 CMS Term: 88141 LAB DEF RBRVS 02/01/2015 12/31/2023 22.68 Description: CYTOPATH C/V INTERPRET Category: Laboratory CMS Add: 01/01/1998 CMS Term: 88142 LAB L60 MAXFEE 01/01/2013 12/31/2023 14.60 0.0 Description: CYTOPATH C/V THIN LAYER Category: Laboratory CMS Add: 01/01/1998 CMS Term: 88142 LAB L60 MAXFEE 01/01/2024 20.26 0.0 Description: CYTOPATH C/V THIN LAYER Category: Laboratory CMS Add: 01/01/1998 CMS Term: 88143 LAB L60 MAXFEE 01/01/2019 23.04 0.0 Description: CYTOPATH C/V THIN LAYER REDO Category: Laboratory CMS Add: 01/01/1999 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,187 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 88147 LAB L60 MAXFEE 01/01/2017 12/31/2023 14.49 0.0 Description: CYTOPATH C/V AUTOMATED Category: Laboratory CMS Add: 01/01/1999 CMS Term: 88147 LAB L60 MAXFEE 01/01/2024 50.56 0.0 Description: CYTOPATH C/V AUTOMATED Category: Laboratory CMS Add: 01/01/1999 CMS Term: 88148 LAB L60 MAXFEE 01/01/2017 12/31/2023 14.49 0.0 Description: CYTOPATH C/V AUTO RESCREEN Category: Laboratory CMS Add: 01/01/1999 CMS Term: 88148 LAB L60 MAXFEE 01/01/2024 17.31 0.0 Description: CYTOPATH C/V AUTO RESCREEN Category: Laboratory CMS Add: 01/01/1999 CMS Term: 88150 LAB L60 MAXFEE 01/01/2017 12/31/2023 14.49 0.0 Description: CYTOPATH C/V MANUAL Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88150 LAB L60 MAXFEE 01/01/2024 17.31 0.0 Description: CYTOPATH C/V MANUAL Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88152 LAB L60 MAXFEE 01/01/2017 12/31/2023 14.49 0.0 Description: CYTOPATH C/V AUTO REDO Category: Laboratory CMS Add: 01/01/1998 CMS Term: 88152 LAB L60 MAXFEE 01/01/2024 27.64 0.0 Description: CYTOPATH C/V AUTO REDO Category: Laboratory CMS Add: 01/01/1998 CMS Term: 88153 LAB L60 MAXFEE 01/01/2017 12/31/2023 14.49 0.0 Description: CYTOPATH C/V REDO Category: Laboratory CMS Add: 01/01/1999 CMS Term: 88153 LAB L60 MAXFEE 01/01/2024 24.03 0.0 Description: CYTOPATH C/V REDO Category: Laboratory CMS Add: 01/01/1999 CMS Term: 88155 LAB L60 MAXFEE 01/01/2015 12/31/2023 8.15 0.0 Description: CYTOPATH C/V INDEX ADD-ON Category: Laboratory CMS Add: 01/01/1984 CMS Term: 88155 LAB L60 MAXFEE 01/01/2024 14.65 0.0 Description: CYTOPATH C/V INDEX ADD-ON Category: Laboratory CMS Add: 01/01/1984 CMS Term: 88160 26 LAB DEF RBRVS 01/01/2024 24.51 Description: CYTOPATH SMEAR OTHER SOURCE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 88160 26 LAB DEF RBRVS 02/01/2015 12/31/2023 19.30 Description: CYTOPATH SMEAR OTHER SOURCE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 88160 LAB DEF RBRVS 01/01/2024 70.22 Description: CYTOPATH SMEAR OTHER SOURCE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 88160 LAB DEF RBRVS 02/01/2015 12/31/2023 45.47 Description: CYTOPATH SMEAR OTHER SOURCE Category: Laboratory CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,188 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 88160 TC LAB DEF RBRVS 01/01/2024 45.70 Description: CYTOPATH SMEAR OTHER SOURCE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 88160 TC LAB DEF RBRVS 02/01/2015 12/31/2023 26.18 Description: CYTOPATH SMEAR OTHER SOURCE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 88161 26 LAB DEF RBRVS 01/01/2024 24.20 Description: CYTOPATH SMEAR OTHER SOURCE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 88161 26 LAB DEF RBRVS 02/01/2015 12/31/2023 18.55 Description: CYTOPATH SMEAR OTHER SOURCE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 88161 LAB DEF RBRVS 01/01/2024 71.76 Description: CYTOPATH SMEAR OTHER SOURCE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 88161 LAB DEF RBRVS 02/01/2015 12/31/2023 41.51 Description: CYTOPATH SMEAR OTHER SOURCE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 88161 TC LAB DEF RBRVS 01/01/2024 47.55 Description: CYTOPATH SMEAR OTHER SOURCE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 88161 TC LAB DEF RBRVS 02/01/2015 12/31/2023 22.95 Description: CYTOPATH SMEAR OTHER SOURCE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 88162 26 LAB DEF RBRVS 01/01/2024 37.34 Description: CYTOPATH SMEAR OTHER SOURCE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 88162 26 LAB DEF RBRVS 02/01/2015 12/31/2023 29.34 Description: CYTOPATH SMEAR OTHER SOURCE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 88162 LAB DEF RBRVS 01/01/2024 111.13 Description: CYTOPATH SMEAR OTHER SOURCE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 88162 LAB DEF RBRVS 02/01/2015 12/31/2023 67.90 Description: CYTOPATH SMEAR OTHER SOURCE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 88162 TC LAB DEF RBRVS 01/01/2024 73.80 Description: CYTOPATH SMEAR OTHER SOURCE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 88162 TC LAB DEF RBRVS 02/01/2015 12/31/2023 38.56 Description: CYTOPATH SMEAR OTHER SOURCE Category: Laboratory CMS Add: 01/01/1984 CMS Term: 88164 LAB L60 MAXFEE 01/01/2017 12/31/2023 14.49 0.0 Description: CYTOPATH TBS C/V MANUAL Category: Laboratory CMS Add: 01/01/1999 CMS Term: 88164 LAB L60 MAXFEE 01/01/2024 17.31 0.0 Description: CYTOPATH TBS C/V MANUAL Category: Laboratory CMS Add: 01/01/1999 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,189 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 88165 LAB L60 MAXFEE 01/01/2017 12/31/2023 14.49 0.0 Description: CYTOPATH TBS C/V REDO Category: Laboratory CMS Add: 01/01/1999 CMS Term: 88165 LAB L60 MAXFEE 01/01/2024 42.22 0.0 Description: CYTOPATH TBS C/V REDO Category: Laboratory CMS Add: 01/01/1999 CMS Term: 88166 LAB L60 MAXFEE 01/01/2017 12/31/2023 14.49 0.0 Description: CYTOPATH TBS C/V AUTO REDO Category: Laboratory CMS Add: 01/01/1999 CMS Term: 88166 LAB L60 MAXFEE 01/01/2024 17.31 0.0 Description: CYTOPATH TBS C/V AUTO REDO Category: Laboratory CMS Add: 01/01/1999 CMS Term: 88167 LAB L60 MAXFEE 01/01/2017 12/31/2023 14.49 0.0 Description: CYTOPATH TBS C/V SELECT Category: Laboratory CMS Add: 01/01/1999 CMS Term: 88167 LAB L60 MAXFEE 01/01/2024 17.31 0.0 Description: CYTOPATH TBS C/V SELECT Category: Laboratory CMS Add: 01/01/1999 CMS Term: 88172 26 LAB DEF RBRVS 01/01/2024 33.73 Description: CYTP DX EVAL FNA 1ST EA SITE Category: Laboratory CMS Add: 01/01/1985 CMS Term: 88172 26 LAB DEF RBRVS 02/01/2015 12/31/2023 26.38 Description: CYTP DX EVAL FNA 1ST EA SITE Category: Laboratory CMS Add: 01/01/1985 CMS Term: 88172 LAB DEF RBRVS 01/01/2024 52.72 Description: CYTP DX EVAL FNA 1ST EA SITE Category: Laboratory CMS Add: 01/01/1985 CMS Term: 88172 LAB DEF RBRVS 02/01/2015 12/31/2023 38.93 Description: CYTP DX EVAL FNA 1ST EA SITE Category: Laboratory CMS Add: 01/01/1985 CMS Term: 88172 TC LAB DEF RBRVS 01/01/2024 18.99 Description: CYTP DX EVAL FNA 1ST EA SITE Category: Laboratory CMS Add: 01/01/1985 CMS Term: 88172 TC LAB DEF RBRVS 02/01/2015 12/31/2023 12.55 Description: CYTP DX EVAL FNA 1ST EA SITE Category: Laboratory CMS Add: 01/01/1985 CMS Term: 88173 26 LAB DEF RBRVS 01/01/2024 66.57 Description: CYTOPATH EVAL FNA REPORT Category: Laboratory CMS Add: 01/01/1985 CMS Term: 88173 26 LAB DEF RBRVS 02/01/2015 12/31/2023 52.37 Description: CYTOPATH EVAL FNA REPORT Category: Laboratory CMS Add: 01/01/1985 CMS Term: 88173 LAB DEF RBRVS 01/01/2024 151.80 Description: CYTOPATH EVAL FNA REPORT Category: Laboratory CMS Add: 01/01/1985 CMS Term: 88173 LAB DEF RBRVS 02/01/2015 12/31/2023 104.06 Description: CYTOPATH EVAL FNA REPORT Category: Laboratory CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,190 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 88173 TC LAB DEF RBRVS 01/01/2024 85.23 Description: CYTOPATH EVAL FNA REPORT Category: Laboratory CMS Add: 01/01/1985 CMS Term: 88173 TC LAB DEF RBRVS 02/01/2015 12/31/2023 51.69 Description: CYTOPATH EVAL FNA REPORT Category: Laboratory CMS Add: 01/01/1985 CMS Term: 88174 LAB L60 MAXFEE 01/01/2019 25.37 0.0 Description: CYTOPATH C/V AUTO IN FLUID Category: Laboratory CMS Add: 01/01/2003 CMS Term: 88175 LAB L60 MAXFEE 01/01/2003 12/31/2023 14.76 0.0 Description: CYTOPATH C/V AUTO FLUID REDO Category: Laboratory CMS Add: 01/01/2003 CMS Term: 88175 LAB L60 MAXFEE 01/01/2024 26.61 0.0 Description: CYTOPATH C/V AUTO FLUID REDO Category: Laboratory CMS Add: 01/01/2003 CMS Term: 88177 26 LAB DEF RBRVS 01/01/2024 20.57 Description: CYTP FNA EVAL EA ADDL Category: Laboratory CMS Add: 01/01/2011 CMS Term: 88177 26 LAB DEF RBRVS 02/01/2015 12/31/2023 16.16 Description: CYTP FNA EVAL EA ADDL Category: Laboratory CMS Add: 01/01/2011 CMS Term: 88177 LAB DEF RBRVS 01/01/2024 27.98 Description: CYTP FNA EVAL EA ADDL Category: Laboratory CMS Add: 01/01/2011 CMS Term: 88177 LAB DEF RBRVS 02/01/2015 12/31/2023 21.28 Description: CYTP FNA EVAL EA ADDL Category: Laboratory CMS Add: 01/01/2011 CMS Term: 88177 TC LAB DEF RBRVS 01/01/2024 7.41 Description: CYTP FNA EVAL EA ADDL Category: Laboratory CMS Add: 01/01/2011 CMS Term: 88177 TC LAB DEF RBRVS 02/01/2015 12/31/2023 5.12 Description: CYTP FNA EVAL EA ADDL Category: Laboratory CMS Add: 01/01/2011 CMS Term: 88182 26 LAB DEF RBRVS 01/01/2024 37.06 Description: CELL MARKER STUDY Category: Laboratory CMS Add: 01/01/1986 CMS Term: 88182 26 LAB DEF RBRVS 02/01/2015 12/31/2023 26.88 Description: CELL MARKER STUDY Category: Laboratory CMS Add: 01/01/1986 CMS Term: 88182 LAB DEF RBRVS 01/01/2024 149.15 Description: CELL MARKER STUDY Category: Laboratory CMS Add: 01/01/1986 CMS Term: 88182 LAB DEF RBRVS 02/01/2015 12/31/2023 77.17 Description: CELL MARKER STUDY Category: Laboratory CMS Add: 01/01/1986 CMS Term: 88182 TC LAB DEF RBRVS 01/01/2024 112.09 Description: CELL MARKER STUDY Category: Laboratory CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,191 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 88182 TC LAB DEF RBRVS 02/01/2015 12/31/2023 50.29 Description: CELL MARKER STUDY Category: Laboratory CMS Add: 01/01/1986 CMS Term: 88184 LAB DEF RBRVS 01/01/2024 68.24 Description: FLOWCYTOMETRY/ TC 1 MARKER Category: Laboratory CMS Add: 01/01/2005 CMS Term: 88184 LAB DEF RBRVS 02/01/2015 12/31/2023 60.61 Description: FLOWCYTOMETRY/ TC 1 MARKER Category: Laboratory CMS Add: 01/01/2005 CMS Term: 88185 LAB DEF RBRVS 01/01/2024 21.92 Description: FLOWCYTOMETRY/TC ADD-ON Category: Laboratory CMS Add: 01/01/2005 CMS Term: 88185 LAB DEF RBRVS 02/01/2015 12/31/2023 37.07 Description: FLOWCYTOMETRY/TC ADD-ON Category: Laboratory CMS Add: 01/01/2005 CMS Term: 88187 LAB DEF RBRVS 01/01/2024 33.75 Description: FLOWCYTOMETRY/READ 2-8 Category: Laboratory CMS Add: 01/01/2005 CMS Term: 88187 LAB DEF RBRVS 02/01/2015 12/31/2023 51.73 Description: FLOWCYTOMETRY/READ 2-8 Category: Laboratory CMS Add: 01/01/2005 CMS Term: 88188 LAB DEF RBRVS 01/01/2024 58.92 Description: FLOWCYTOMETRY/READ 9-15 Category: Laboratory CMS Add: 01/01/2005 CMS Term: 88188 LAB DEF RBRVS 02/01/2015 12/31/2023 65.14 Description: FLOWCYTOMETRY/READ 9-15 Category: Laboratory CMS Add: 01/01/2005 CMS Term: 88189 LAB DEF RBRVS 01/01/2024 79.89 Description: FLOWCYTOMETRY/READ 16 & > Category: Laboratory CMS Add: 01/01/2005 CMS Term: 88189 LAB DEF RBRVS 02/01/2015 12/31/2023 80.31 Description: FLOWCYTOMETRY/READ 16 & > Category: Laboratory CMS Add: 01/01/2005 CMS Term: 88199 LAB DEF MAXFEE 01/01/2024 14.03 0.0 Description: UNLISTED CYTOPATHOLOGY PX Category: Laboratory CMS Add: 01/01/1984 CMS Term: 88199 LAB DEF MAXFEE 02/01/2015 12/31/2023 10.79 0.0 Description: UNLISTED CYTOPATHOLOGY PX Category: Laboratory CMS Add: 01/01/1984 CMS Term: 88230 LAB L60 MAXFEE 01/01/2015 12/31/2023 75.71 0.0 Description: TISSUE CULTURE LYMPHOCYTE Category: Laboratory CMS Add: 01/01/1988 CMS Term: 88230 LAB L60 MAXFEE 01/01/2024 116.49 0.0 Description: TISSUE CULTURE LYMPHOCYTE Category: Laboratory CMS Add: 01/01/1988 CMS Term: 88233 LAB L60 MAXFEE 01/01/2020 140.73 0.0 Description: TISSUE CULTURE SKIN/BIOPSY Category: Laboratory CMS Add: 01/01/1988 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,192 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 88235 LAB L60 MAXFEE 01/01/2015 12/31/2023 99.71 0.0 Description: TISSUE CULTURE PLACENTA Category: Laboratory CMS Add: 01/01/1988 CMS Term: 88235 LAB L60 MAXFEE 01/01/2024 150.30 0.0 Description: TISSUE CULTURE PLACENTA Category: Laboratory CMS Add: 01/01/1988 CMS Term: 88237 LAB L60 MAXFEE 01/01/2015 12/31/2023 86.50 0.0 Description: TISSUE CULTURE BONE MARROW Category: Laboratory CMS Add: 01/01/1988 CMS Term: 88237 LAB L60 MAXFEE 01/01/2024 143.75 0.0 Description: TISSUE CULTURE BONE MARROW Category: Laboratory CMS Add: 01/01/1988 CMS Term: 88239 LAB L60 MAXFEE 01/01/2020 147.52 0.0 Description: TISSUE CULTURE TUMOR Category: Laboratory CMS Add: 01/01/1988 CMS Term: 88240 LAB L60 MAXFEE 01/01/2018 13.07 0.0 Description: CELL CRYOPRESERVE/STORAGE Category: Laboratory CMS Add: 01/01/1999 CMS Term: 88241 LAB L60 MAXFEE 01/01/2019 12.09 0.0 Description: FROZEN CELL PREPARATION Category: Laboratory CMS Add: 01/01/1999 CMS Term: 88245 LAB L60 MAXFEE 01/01/2020 173.17 0.0 Description: CHROMOSOME ANALYSIS 20-25 Category: Laboratory CMS Add: 01/01/1988 CMS Term: 88248 LAB L60 MAXFEE 01/01/2020 173.17 0.0 Description: CHROMOSOME ANALYSIS 50-100 Category: Laboratory CMS Add: 01/01/1988 CMS Term: 88249 LAB L60 MAXFEE 01/01/2020 173.17 0.0 Description: CHROMOSOME ANALYSIS 100 Category: Laboratory CMS Add: 01/01/1999 CMS Term: 88261 LAB L60 MAXFEE 01/01/2015 12/31/2023 240.51 0.0 Description: CHROMOSOME ANALYSIS 5 Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88261 LAB L60 MAXFEE 01/01/2024 264.34 0.0 Description: CHROMOSOME ANALYSIS 5 Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88262 LAB L60 MAXFEE 01/01/2020 125.49 0.0 Description: CHROMOSOME ANALYSIS 15-20 Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88263 LAB L60 MAXFEE 01/01/2020 150.29 0.0 Description: CHROMOSOME ANALYSIS 45 Category: Laboratory CMS Add: 01/01/1988 CMS Term: 88264 LAB L60 MAXFEE 01/01/2019 144.61 0.0 Description: CHROMOSOME ANALYSIS 20-25 Category: Laboratory CMS Add: 01/01/1999 CMS Term: 88267 LAB L60 MAXFEE 01/01/2020 188.57 0.0 Description: CHROMOSOME ANALYS PLACENTA Category: Laboratory CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,193 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 88269 LAB L60 MAXFEE 01/01/2020 173.66 0.0 Description: CHROMOSOME ANALYS AMNIOTIC Category: Laboratory CMS Add: 01/01/1988 CMS Term: 88271 LAB L60 MAXFEE 01/01/2015 12/31/2023 19.70 0.0 Description: CYTOGENETICS DNA PROBE Category: Laboratory CMS Add: 01/01/1999 CMS Term: 88271 LAB L60 MAXFEE 01/01/2024 21.42 0.0 Description: CYTOGENETICS DNA PROBE Category: Laboratory CMS Add: 01/01/1999 CMS Term: 88272 LAB L60 MAXFEE 01/01/2015 12/31/2023 36.44 0.0 Description: CYTOGENETICS 3-5 Category: Laboratory CMS Add: 01/01/1999 CMS Term: 88272 LAB L60 MAXFEE 01/01/2024 40.70 0.0 Description: CYTOGENETICS 3-5 Category: Laboratory CMS Add: 01/01/1999 CMS Term: 88273 LAB L60 MAXFEE 01/01/2020 34.81 0.0 Description: CYTOGENETICS 10-30 Category: Laboratory CMS Add: 01/01/1999 CMS Term: 88274 LAB L60 MAXFEE 01/01/2019 42.38 0.0 Description: CYTOGENETICS 25-99 Category: Laboratory CMS Add: 01/01/1999 CMS Term: 88275 LAB L60 MAXFEE 01/01/2018 51.19 0.0 Description: CYTOGENETICS 100-300 Category: Laboratory CMS Add: 01/01/1999 CMS Term: 88280 LAB L60 MAXFEE 01/01/2018 33.47 0.0 Description: CHROMOSOME KARYOTYPE STUDY Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88283 LAB L60 MAXFEE 01/01/2020 68.60 0.0 Description: CHROMOSOME BANDING STUDY Category: Laboratory CMS Add: 01/01/1988 CMS Term: 88285 LAB L60 MAXFEE 01/01/2015 12/31/2023 25.86 0.0 Description: CHROMOSOME COUNT ADDITIONAL Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88285 LAB L60 MAXFEE 01/01/2024 26.91 0.0 Description: CHROMOSOME COUNT ADDITIONAL Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88289 LAB L60 MAXFEE 01/01/2020 34.43 0.0 Description: CHROMOSOME STUDY ADDITIONAL Category: Laboratory CMS Add: 01/01/1988 CMS Term: 88291 LAB DEF RBRVS 01/01/2024 30.91 Description: CYTO/MOLECULAR REPORT Category: Laboratory CMS Add: 01/01/1999 CMS Term: 88291 LAB DEF RBRVS 02/01/2015 12/31/2023 22.39 Description: CYTO/MOLECULAR REPORT Category: Laboratory CMS Add: 01/01/1999 CMS Term: 88299 LAB DEF BILL30 Description: UNLISTED CYTOGENETIC STUDY Category: Laboratory CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,194 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 88300 26 LAB DEF RBRVS 01/01/2024 4.11 Description: SURGICAL PATH GROSS Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88300 26 LAB DEF RBRVS 02/01/2015 12/31/2023 3.31 Description: SURGICAL PATH GROSS Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88300 LAB DEF RBRVS 01/01/2024 14.76 Description: SURGICAL PATH GROSS Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88300 LAB DEF RBRVS 02/01/2015 12/31/2023 10.16 Description: SURGICAL PATH GROSS Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88300 TC LAB DEF RBRVS 01/01/2024 10.66 Description: SURGICAL PATH GROSS Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88300 TC LAB DEF RBRVS 02/01/2015 12/31/2023 6.85 Description: SURGICAL PATH GROSS Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88302 26 LAB DEF RBRVS 01/01/2024 6.42 Description: TISSUE EXAM BY PATHOLOGIST Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88302 26 LAB DEF RBRVS 02/01/2015 12/31/2023 5.14 Description: TISSUE EXAM BY PATHOLOGIST Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88302 LAB DEF RBRVS 01/01/2024 30.35 Description: TISSUE EXAM BY PATHOLOGIST Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88302 LAB DEF RBRVS 02/01/2015 12/31/2023 20.92 Description: TISSUE EXAM BY PATHOLOGIST Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88302 TC LAB DEF RBRVS 01/01/2024 23.93 Description: TISSUE EXAM BY PATHOLOGIST Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88302 TC LAB DEF RBRVS 02/01/2015 12/31/2023 15.77 Description: TISSUE EXAM BY PATHOLOGIST Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88304 26 LAB DEF RBRVS 01/01/2024 10.70 Description: TISSUE EXAM BY PATHOLOGIST Category: Laboratory CMS Add: 01/01/1985 CMS Term: 88304 26 LAB DEF RBRVS 02/01/2015 12/31/2023 8.31 Description: TISSUE EXAM BY PATHOLOGIST Category: Laboratory CMS Add: 01/01/1985 CMS Term: 88304 LAB DEF RBRVS 01/01/2024 39.57 Description: TISSUE EXAM BY PATHOLOGIST Category: Laboratory CMS Add: 01/01/1985 CMS Term: 88304 LAB DEF RBRVS 02/01/2015 12/31/2023 30.27 Description: TISSUE EXAM BY PATHOLOGIST Category: Laboratory CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,195 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 88304 TC LAB DEF RBRVS 01/01/2024 28.87 Description: TISSUE EXAM BY PATHOLOGIST Category: Laboratory CMS Add: 01/01/1985 CMS Term: 88304 TC LAB DEF RBRVS 02/01/2015 12/31/2023 21.96 Description: TISSUE EXAM BY PATHOLOGIST Category: Laboratory CMS Add: 01/01/1985 CMS Term: 88305 26 LAB DEF RBRVS 01/01/2024 35.46 Description: TISSUE EXAM BY PATHOLOGIST Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88305 26 LAB DEF RBRVS 02/01/2015 12/31/2023 27.99 Description: TISSUE EXAM BY PATHOLOGIST Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88305 LAB DEF RBRVS 01/01/2024 67.41 Description: TISSUE EXAM BY PATHOLOGIST Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88305 LAB DEF RBRVS 02/01/2015 12/31/2023 50.21 Description: TISSUE EXAM BY PATHOLOGIST Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88305 TC LAB DEF RBRVS 01/01/2024 31.96 Description: TISSUE EXAM BY PATHOLOGIST Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88305 TC LAB DEF RBRVS 02/01/2015 12/31/2023 22.21 Description: TISSUE EXAM BY PATHOLOGIST Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88307 26 LAB DEF RBRVS 01/01/2024 77.99 Description: TISSUE EXAM BY PATHOLOGIST Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88307 26 LAB DEF RBRVS 02/01/2015 12/31/2023 61.22 Description: TISSUE EXAM BY PATHOLOGIST Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88307 LAB DEF RBRVS 01/01/2024 270.34 Description: TISSUE EXAM BY PATHOLOGIST Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88307 LAB DEF RBRVS 02/01/2015 12/31/2023 202.33 Description: TISSUE EXAM BY PATHOLOGIST Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88307 TC LAB DEF RBRVS 01/01/2024 192.35 Description: TISSUE EXAM BY PATHOLOGIST Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88307 TC LAB DEF RBRVS 02/01/2015 12/31/2023 141.11 Description: TISSUE EXAM BY PATHOLOGIST Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88309 26 LAB DEF RBRVS 01/01/2024 137.51 Description: TISSUE EXAM BY PATHOLOGIST Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88309 26 LAB DEF RBRVS 02/01/2015 12/31/2023 108.26 Description: TISSUE EXAM BY PATHOLOGIST Category: Laboratory CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,196 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 88309 LAB DEF RBRVS 01/01/2024 409.51 Description: TISSUE EXAM BY PATHOLOGIST Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88309 LAB DEF RBRVS 02/01/2015 12/31/2023 308.41 Description: TISSUE EXAM BY PATHOLOGIST Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88309 TC LAB DEF RBRVS 01/01/2024 272.00 Description: TISSUE EXAM BY PATHOLOGIST Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88309 TC LAB DEF RBRVS 02/01/2015 12/31/2023 200.15 Description: TISSUE EXAM BY PATHOLOGIST Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88311 26 LAB DEF RBRVS 01/01/2024 11.69 Description: DECALCIFY TISSUE Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88311 26 LAB DEF RBRVS 02/01/2015 12/31/2023 9.09 Description: DECALCIFY TISSUE Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88311 LAB DEF RBRVS 01/01/2024 19.26 Description: DECALCIFY TISSUE Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88311 LAB DEF RBRVS 02/01/2015 12/31/2023 14.46 Description: DECALCIFY TISSUE Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88311 TC LAB DEF RBRVS 01/01/2024 7.57 Description: DECALCIFY TISSUE Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88311 TC LAB DEF RBRVS 02/01/2015 12/31/2023 5.37 Description: DECALCIFY TISSUE Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88312 26 LAB DEF RBRVS 01/01/2024 25.25 Description: SPECIAL STAINS GROUP 1 Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88312 26 LAB DEF RBRVS 02/01/2015 12/31/2023 20.12 Description: SPECIAL STAINS GROUP 1 Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88312 LAB DEF RBRVS 01/01/2024 104.75 Description: SPECIAL STAINS GROUP 1 Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88312 LAB DEF RBRVS 02/01/2015 12/31/2023 66.36 Description: SPECIAL STAINS GROUP 1 Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88312 TC LAB DEF RBRVS 01/01/2024 79.50 Description: SPECIAL STAINS GROUP 1 Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88312 TC LAB DEF RBRVS 02/01/2015 12/31/2023 46.24 Description: SPECIAL STAINS GROUP 1 Category: Laboratory CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,197 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 88313 26 LAB DEF RBRVS 01/01/2024 11.38 Description: SPECIAL STAINS GROUP 2 Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88313 26 LAB DEF RBRVS 02/01/2015 12/31/2023 8.84 Description: SPECIAL STAINS GROUP 2 Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88313 LAB DEF RBRVS 01/01/2024 75.75 Description: SPECIAL STAINS GROUP 2 Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88313 LAB DEF RBRVS 02/01/2015 12/31/2023 45.92 Description: SPECIAL STAINS GROUP 2 Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88313 TC LAB DEF RBRVS 01/01/2024 64.37 Description: SPECIAL STAINS GROUP 2 Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88313 TC LAB DEF RBRVS 02/01/2015 12/31/2023 37.07 Description: SPECIAL STAINS GROUP 2 Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88314 26 LAB DEF RBRVS 01/01/2024 19.73 Description: HISTOCHEMICAL STAINS ADD-ON Category: Laboratory CMS Add: 01/01/1985 CMS Term: 88314 26 LAB DEF RBRVS 02/01/2015 12/31/2023 16.71 Description: HISTOCHEMICAL STAINS ADD-ON Category: Laboratory CMS Add: 01/01/1985 CMS Term: 88314 LAB DEF RBRVS 01/01/2024 84.41 Description: HISTOCHEMICAL STAINS ADD-ON Category: Laboratory CMS Add: 01/01/1985 CMS Term: 88314 LAB DEF RBRVS 02/01/2015 12/31/2023 54.78 Description: HISTOCHEMICAL STAINS ADD-ON Category: Laboratory CMS Add: 01/01/1985 CMS Term: 88314 TC LAB DEF RBRVS 01/01/2024 64.68 Description: HISTOCHEMICAL STAINS ADD-ON Category: Laboratory CMS Add: 01/01/1985 CMS Term: 88314 TC LAB DEF RBRVS 02/01/2015 12/31/2023 38.07 Description: HISTOCHEMICAL STAINS ADD-ON Category: Laboratory CMS Add: 01/01/1985 CMS Term: 88319 26 LAB DEF RBRVS 01/01/2024 25.53 Description: ENZYME HISTOCHEMISTRY Category: Laboratory CMS Add: 01/01/1985 CMS Term: 88319 26 LAB DEF RBRVS 02/01/2015 12/31/2023 20.43 Description: ENZYME HISTOCHEMISTRY Category: Laboratory CMS Add: 01/01/1985 CMS Term: 88319 LAB DEF RBRVS 01/01/2024 125.88 Description: ENZYME HISTOCHEMISTRY Category: Laboratory CMS Add: 01/01/1985 CMS Term: 88319 LAB DEF RBRVS 02/01/2015 12/31/2023 60.23 Description: ENZYME HISTOCHEMISTRY Category: Laboratory CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,198 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 88319 TC LAB DEF RBRVS 01/01/2024 100.34 Description: ENZYME HISTOCHEMISTRY Category: Laboratory CMS Add: 01/01/1985 CMS Term: 88319 TC LAB DEF RBRVS 02/01/2015 12/31/2023 39.80 Description: ENZYME HISTOCHEMISTRY Category: Laboratory CMS Add: 01/01/1985 CMS Term: 88321 LAB DEF RBRVS 01/01/2024 92.33 Description: CONSLTJ&REPRT SLD PREP ELSWR Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88321 LAB DEF RBRVS 02/01/2015 12/31/2023 68.48 Description: CONSLTJ&REPRT SLD PREP ELSWR Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88323 26 LAB DEF RBRVS 01/01/2024 83.78 Description: CONSLTJ&REPRT MATRL PREP SLD Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88323 26 LAB DEF RBRVS 02/01/2015 12/31/2023 64.44 Description: CONSLTJ&REPRT MATRL PREP SLD Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88323 LAB DEF RBRVS 01/01/2024 109.57 Description: CONSLTJ&REPRT MATRL PREP SLD Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88323 LAB DEF RBRVS 02/01/2015 12/31/2023 105.48 Description: CONSLTJ&REPRT MATRL PREP SLD Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88323 TC LAB DEF RBRVS 01/01/2024 25.78 Description: CONSLTJ&REPRT MATRL PREP SLD Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88323 TC LAB DEF RBRVS 02/01/2015 12/31/2023 41.04 Description: CONSLTJ&REPRT MATRL PREP SLD Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88325 LAB DEF RBRVS 01/01/2024 149.14 Description: CONSLTJ COMPRE RVW REC REPRT Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88325 LAB DEF RBRVS 02/01/2015 12/31/2023 151.47 Description: CONSLTJ COMPRE RVW REC REPRT Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88329 LAB DEF RBRVS 01/01/2024 52.98 Description: PATH CONSLTJ DRG SURG Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88329 LAB DEF RBRVS 02/01/2015 12/31/2023 40.71 Description: PATH CONSLTJ DRG SURG Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88331 26 LAB DEF RBRVS 01/01/2024 58.86 Description: PATH CONSLTJ SURG 1 BLK 1SPC Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88331 26 LAB DEF RBRVS 02/01/2015 12/31/2023 45.76 Description: PATH CONSLTJ SURG 1 BLK 1SPC Category: Laboratory CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,199 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 88331 LAB DEF RBRVS 01/01/2024 96.69 Description: PATH CONSLTJ SURG 1 BLK 1SPC Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88331 LAB DEF RBRVS 02/01/2015 12/31/2023 70.70 Description: PATH CONSLTJ SURG 1 BLK 1SPC Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88331 TC LAB DEF RBRVS 01/01/2024 37.82 Description: PATH CONSLTJ SURG 1 BLK 1SPC Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88331 TC LAB DEF RBRVS 02/01/2015 12/31/2023 24.94 Description: PATH CONSLTJ SURG 1 BLK 1SPC Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88332 26 LAB DEF RBRVS 01/01/2024 29.11 Description: PATH CONSLTJ SURG EA ADD BLK Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88332 26 LAB DEF RBRVS 02/01/2015 12/31/2023 22.71 Description: PATH CONSLTJ SURG EA ADD BLK Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88332 LAB DEF RBRVS 01/01/2024 51.80 Description: PATH CONSLTJ SURG EA ADD BLK Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88332 LAB DEF RBRVS 02/01/2015 12/31/2023 31.29 Description: PATH CONSLTJ SURG EA ADD BLK Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88332 TC LAB DEF RBRVS 01/01/2024 22.70 Description: PATH CONSLTJ SURG EA ADD BLK Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88332 TC LAB DEF RBRVS 02/01/2015 12/31/2023 8.59 Description: PATH CONSLTJ SURG EA ADD BLK Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88333 26 LAB DEF RBRVS 01/01/2024 58.89 Description: PATH CONSLTJ SURG CYTO XM 1 Category: Laboratory CMS Add: 01/01/2006 CMS Term: 88333 26 LAB DEF RBRVS 02/01/2015 12/31/2023 46.28 Description: PATH CONSLTJ SURG CYTO XM 1 Category: Laboratory CMS Add: 01/01/2006 CMS Term: 88333 LAB DEF RBRVS 01/01/2024 88.38 Description: PATH CONSLTJ SURG CYTO XM 1 Category: Laboratory CMS Add: 01/01/2006 CMS Term: 88333 LAB DEF RBRVS 02/01/2015 12/31/2023 74.44 Description: PATH CONSLTJ SURG CYTO XM 1 Category: Laboratory CMS Add: 01/01/2006 CMS Term: 88333 TC LAB DEF RBRVS 01/01/2024 29.49 Description: PATH CONSLTJ SURG CYTO XM 1 Category: Laboratory CMS Add: 01/01/2006 CMS Term: 88333 TC LAB DEF RBRVS 02/01/2015 12/31/2023 28.16 Description: PATH CONSLTJ SURG CYTO XM 1 Category: Laboratory CMS Add: 01/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,200 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 88334 26 LAB DEF RBRVS 01/01/2024 35.70 Description: PATH CONSLTJ SURG CYTO XM EA Category: Laboratory CMS Add: 01/01/2006 CMS Term: 88334 26 LAB DEF RBRVS 02/01/2015 12/31/2023 28.53 Description: PATH CONSLTJ SURG CYTO XM EA Category: Laboratory CMS Add: 01/01/2006 CMS Term: 88334 LAB DEF RBRVS 01/01/2024 53.61 Description: PATH CONSLTJ SURG CYTO XM EA Category: Laboratory CMS Add: 01/01/2006 CMS Term: 88334 LAB DEF RBRVS 02/01/2015 12/31/2023 46.28 Description: PATH CONSLTJ SURG CYTO XM EA Category: Laboratory CMS Add: 01/01/2006 CMS Term: 88334 TC LAB DEF RBRVS 01/01/2024 17.91 Description: PATH CONSLTJ SURG CYTO XM EA Category: Laboratory CMS Add: 01/01/2006 CMS Term: 88334 TC LAB DEF RBRVS 02/01/2015 12/31/2023 17.75 Description: PATH CONSLTJ SURG CYTO XM EA Category: Laboratory CMS Add: 01/01/2006 CMS Term: 88341 26 LAB DEF RBRVS 01/01/2024 26.86 Description: IMHCHEM/IMCYTCHM EA ADD ANTB Category: Laboratory CMS Add: 01/01/2015 CMS Term: 88341 26 LAB DEF RBRVS 02/01/2015 12/31/2023 15.91 Description: IMHCHEM/IMCYTCHM EA ADD ANTB Category: Laboratory CMS Add: 01/01/2015 CMS Term: 88341 LAB DEF RBRVS 01/01/2024 80.88 Description: IMHCHEM/IMCYTCHM EA ADD ANTB Category: Laboratory CMS Add: 01/01/2015 CMS Term: 88341 LAB DEF RBRVS 02/01/2015 12/31/2023 47.53 Description: IMHCHEM/IMCYTCHM EA ADD ANTB Category: Laboratory CMS Add: 01/01/2015 CMS Term: 88341 TC LAB DEF RBRVS 01/01/2024 54.02 Description: IMHCHEM/IMCYTCHM EA ADD ANTB Category: Laboratory CMS Add: 01/01/2015 CMS Term: 88341 TC LAB DEF RBRVS 02/01/2015 12/31/2023 31.62 Description: IMHCHEM/IMCYTCHM EA ADD ANTB Category: Laboratory CMS Add: 01/01/2015 CMS Term: 88342 26 LAB DEF RBRVS 01/01/2024 33.14 Description: IMHCHEM/IMCYTCHM 1ST ANTB Category: Laboratory CMS Add: 01/01/1985 CMS Term: 88342 26 LAB DEF RBRVS 02/01/2015 12/31/2023 31.61 Description: IMHCHEM/IMCYTCHM 1ST ANTB Category: Laboratory CMS Add: 01/01/1985 CMS Term: 88342 LAB DEF RBRVS 01/01/2024 93.81 Description: IMHCHEM/IMCYTCHM 1ST ANTB Category: Laboratory CMS Add: 01/01/1985 CMS Term: 88342 LAB DEF RBRVS 02/01/2015 12/31/2023 39.62 Description: IMHCHEM/IMCYTCHM 1ST ANTB Category: Laboratory CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,201 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 88342 TC LAB DEF RBRVS 01/01/2024 60.67 Description: IMHCHEM/IMCYTCHM 1ST ANTB Category: Laboratory CMS Add: 01/01/1985 CMS Term: 88342 TC LAB DEF RBRVS 02/01/2015 12/31/2023 8.01 Description: IMHCHEM/IMCYTCHM 1ST ANTB Category: Laboratory CMS Add: 01/01/1985 CMS Term: 88344 26 LAB DEF RBRVS 01/01/2024 36.44 Description: IMHCHEM/IMCYTCHM EA MLT ANTB Category: Laboratory CMS Add: 01/01/2015 CMS Term: 88344 26 LAB DEF RBRVS 02/01/2015 12/31/2023 29.28 Description: IMHCHEM/IMCYTCHM EA MLT ANTB Category: Laboratory CMS Add: 01/01/2015 CMS Term: 88344 LAB DEF RBRVS 01/01/2024 156.69 Description: IMHCHEM/IMCYTCHM EA MLT ANTB Category: Laboratory CMS Add: 01/01/2015 CMS Term: 88344 LAB DEF RBRVS 02/01/2015 12/31/2023 82.45 Description: IMHCHEM/IMCYTCHM EA MLT ANTB Category: Laboratory CMS Add: 01/01/2015 CMS Term: 88344 TC LAB DEF RBRVS 01/01/2024 120.25 Description: IMHCHEM/IMCYTCHM EA MLT ANTB Category: Laboratory CMS Add: 01/01/2015 CMS Term: 88344 TC LAB DEF RBRVS 02/01/2015 12/31/2023 53.18 Description: IMHCHEM/IMCYTCHM EA MLT ANTB Category: Laboratory CMS Add: 01/01/2015 CMS Term: 88346 26 LAB DEF RBRVS 01/01/2024 34.19 Description: IMFLUOR 1ST 1ANTB STAIN PX Category: Laboratory CMS Add: 01/01/1985 CMS Term: 88346 26 LAB DEF RBRVS 02/01/2015 12/31/2023 31.45 Description: IMFLUOR 1ST 1ANTB STAIN PX Category: Laboratory CMS Add: 01/01/1985 CMS Term: 88346 LAB DEF RBRVS 01/01/2024 141.78 Description: IMFLUOR 1ST 1ANTB STAIN PX Category: Laboratory CMS Add: 01/01/1985 CMS Term: 88346 LAB DEF RBRVS 02/01/2015 12/31/2023 75.21 Description: IMFLUOR 1ST 1ANTB STAIN PX Category: Laboratory CMS Add: 01/01/1985 CMS Term: 88346 TC LAB DEF RBRVS 01/01/2024 107.59 Description: IMFLUOR 1ST 1ANTB STAIN PX Category: Laboratory CMS Add: 01/01/1985 CMS Term: 88346 TC LAB DEF RBRVS 02/01/2015 12/31/2023 43.76 Description: IMFLUOR 1ST 1ANTB STAIN PX Category: Laboratory CMS Add: 01/01/1985 CMS Term: 88348 26 LAB DEF RBRVS 01/01/2024 73.41 Description: ELECTRON MICROSCOPY DX Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88348 26 LAB DEF RBRVS 02/01/2015 12/31/2023 55.85 Description: ELECTRON MICROSCOPY DX Category: Laboratory CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,202 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 88348 LAB DEF RBRVS 01/01/2024 438.36 Description: ELECTRON MICROSCOPY DX Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88348 LAB DEF RBRVS 02/01/2015 12/31/2023 487.94 Description: ELECTRON MICROSCOPY DX Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88348 TC LAB DEF RBRVS 01/01/2024 364.95 Description: ELECTRON MICROSCOPY DX Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88348 TC LAB DEF RBRVS 02/01/2015 12/31/2023 432.10 Description: ELECTRON MICROSCOPY DX Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88350 26 LAB DEF RBRVS 01/01/2016 12/31/2023 20.91 Description: IMFLUOR EA ADDL 1ANTB STN PX Category: Laboratory CMS Add: 01/01/2016 CMS Term: 88350 26 LAB DEF RBRVS 01/01/2024 27.56 Description: IMFLUOR EA ADDL 1ANTB STN PX Category: Laboratory CMS Add: 01/01/2016 CMS Term: 88350 LAB DEF RBRVS 01/01/2016 12/31/2023 51.13 Description: IMFLUOR EA ADDL 1ANTB STN PX Category: Laboratory CMS Add: 01/01/2016 CMS Term: 88350 LAB DEF RBRVS 01/01/2024 108.61 Description: IMFLUOR EA ADDL 1ANTB STN PX Category: Laboratory CMS Add: 01/01/2016 CMS Term: 88350 TC LAB DEF RBRVS 01/01/2016 12/31/2023 30.22 Description: IMFLUOR EA ADDL 1ANTB STN PX Category: Laboratory CMS Add: 01/01/2016 CMS Term: 88350 TC LAB DEF RBRVS 01/01/2024 81.04 Description: IMFLUOR EA ADDL 1ANTB STN PX Category: Laboratory CMS Add: 01/01/2016 CMS Term: 88355 26 LAB DEF RBRVS 01/01/2024 78.91 Description: M/PHMTRC ALYS SKELETAL MUSC Category: Laboratory CMS Add: 01/01/1987 CMS Term: 88355 26 LAB DEF RBRVS 02/01/2015 12/31/2023 61.93 Description: M/PHMTRC ALYS SKELETAL MUSC Category: Laboratory CMS Add: 01/01/1987 CMS Term: 88355 LAB DEF RBRVS 01/01/2024 134.49 Description: M/PHMTRC ALYS SKELETAL MUSC Category: Laboratory CMS Add: 01/01/1987 CMS Term: 88355 LAB DEF RBRVS 02/01/2015 12/31/2023 125.26 Description: M/PHMTRC ALYS SKELETAL MUSC Category: Laboratory CMS Add: 01/01/1987 CMS Term: 88355 TC LAB DEF RBRVS 01/01/2024 55.58 Description: M/PHMTRC ALYS SKELETAL MUSC Category: Laboratory CMS Add: 01/01/1987 CMS Term: 88355 TC LAB DEF RBRVS 02/01/2015 12/31/2023 63.33 Description: M/PHMTRC ALYS SKELETAL MUSC Category: Laboratory CMS Add: 01/01/1987 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,203 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 88356 26 LAB DEF RBRVS 01/01/2024 118.98 Description: ANALYSIS NERVE Category: Laboratory CMS Add: 01/01/1987 CMS Term: 88356 26 LAB DEF RBRVS 02/01/2015 12/31/2023 97.90 Description: ANALYSIS NERVE Category: Laboratory CMS Add: 01/01/1987 CMS Term: 88356 LAB DEF RBRVS 01/01/2024 221.80 Description: ANALYSIS NERVE Category: Laboratory CMS Add: 01/01/1987 CMS Term: 88356 LAB DEF RBRVS 02/01/2015 12/31/2023 198.39 Description: ANALYSIS NERVE Category: Laboratory CMS Add: 01/01/1987 CMS Term: 88356 TC LAB DEF RBRVS 01/01/2024 102.83 Description: ANALYSIS NERVE Category: Laboratory CMS Add: 01/01/1987 CMS Term: 88356 TC LAB DEF RBRVS 02/01/2015 12/31/2023 100.49 Description: ANALYSIS NERVE Category: Laboratory CMS Add: 01/01/1987 CMS Term: 88358 26 LAB DEF RBRVS 01/01/2024 47.02 Description: ANALYSIS TUMOR Category: Laboratory CMS Add: 01/01/1988 CMS Term: 88358 26 LAB DEF RBRVS 02/01/2015 12/31/2023 33.20 Description: ANALYSIS TUMOR Category: Laboratory CMS Add: 01/01/1988 CMS Term: 88358 LAB DEF RBRVS 01/01/2024 130.54 Description: ANALYSIS TUMOR Category: Laboratory CMS Add: 01/01/1988 CMS Term: 88358 LAB DEF RBRVS 02/01/2015 12/31/2023 59.38 Description: ANALYSIS TUMOR Category: Laboratory CMS Add: 01/01/1988 CMS Term: 88358 TC LAB DEF RBRVS 01/01/2024 83.51 Description: ANALYSIS TUMOR Category: Laboratory CMS Add: 01/01/1988 CMS Term: 88358 TC LAB DEF RBRVS 02/01/2015 12/31/2023 26.18 Description: ANALYSIS TUMOR Category: Laboratory CMS Add: 01/01/1988 CMS Term: 88360 26 LAB DEF RBRVS 01/01/2024 39.77 Description: TUMOR IMMUNOHISTOCHEM/MANUAL Category: Laboratory CMS Add: 01/01/2005 CMS Term: 88360 26 LAB DEF RBRVS 02/01/2015 12/31/2023 39.96 Description: TUMOR IMMUNOHISTOCHEM/MANUAL Category: Laboratory CMS Add: 01/01/2005 CMS Term: 88360 LAB DEF RBRVS 01/01/2024 110.93 Description: TUMOR IMMUNOHISTOCHEM/MANUAL Category: Laboratory CMS Add: 01/01/2005 CMS Term: 88360 LAB DEF RBRVS 02/01/2015 12/31/2023 91.90 Description: TUMOR IMMUNOHISTOCHEM/MANUAL Category: Laboratory CMS Add: 01/01/2005 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,204 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 88360 TC LAB DEF RBRVS 01/01/2024 71.16 Description: TUMOR IMMUNOHISTOCHEM/MANUAL Category: Laboratory CMS Add: 01/01/2005 CMS Term: 88360 TC LAB DEF RBRVS 02/01/2015 12/31/2023 51.94 Description: TUMOR IMMUNOHISTOCHEM/MANUAL Category: Laboratory CMS Add: 01/01/2005 CMS Term: 88361 26 LAB DEF RBRVS 01/01/2024 41.92 Description: TUMOR IMMUNOHISTOCHEM/COMPUT Category: Laboratory CMS Add: 01/01/2004 CMS Term: 88361 26 LAB DEF RBRVS 02/01/2015 12/31/2023 43.26 Description: TUMOR IMMUNOHISTOCHEM/COMPUT Category: Laboratory CMS Add: 01/01/2004 CMS Term: 88361 LAB DEF RBRVS 01/01/2024 111.24 Description: TUMOR IMMUNOHISTOCHEM/COMPUT Category: Laboratory CMS Add: 01/01/2004 CMS Term: 88361 LAB DEF RBRVS 02/01/2015 12/31/2023 111.30 Description: TUMOR IMMUNOHISTOCHEM/COMPUT Category: Laboratory CMS Add: 01/01/2004 CMS Term: 88361 TC LAB DEF RBRVS 01/01/2024 69.31 Description: TUMOR IMMUNOHISTOCHEM/COMPUT Category: Laboratory CMS Add: 01/01/2004 CMS Term: 88361 TC LAB DEF RBRVS 02/01/2015 12/31/2023 68.04 Description: TUMOR IMMUNOHISTOCHEM/COMPUT Category: Laboratory CMS Add: 01/01/2004 CMS Term: 88362 26 LAB DEF RBRVS 01/01/2024 105.05 Description: NERVE TEASING PREPARATIONS Category: Laboratory CMS Add: 01/01/1988 CMS Term: 88362 26 LAB DEF RBRVS 02/01/2015 12/31/2023 82.25 Description: NERVE TEASING PREPARATIONS Category: Laboratory CMS Add: 01/01/1988 CMS Term: 88362 LAB DEF RBRVS 01/01/2024 215.29 Description: NERVE TEASING PREPARATIONS Category: Laboratory CMS Add: 01/01/1988 CMS Term: 88362 LAB DEF RBRVS 02/01/2015 12/31/2023 216.43 Description: NERVE TEASING PREPARATIONS Category: Laboratory CMS Add: 01/01/1988 CMS Term: 88362 TC LAB DEF RBRVS 01/01/2024 110.24 Description: NERVE TEASING PREPARATIONS Category: Laboratory CMS Add: 01/01/1988 CMS Term: 88362 TC LAB DEF RBRVS 02/01/2015 12/31/2023 134.18 Description: NERVE TEASING PREPARATIONS Category: Laboratory CMS Add: 01/01/1988 CMS Term: 88363 LAB DEF RBRVS 01/01/2024 21.81 Description: XM ARCHIVE TISSUE MOLEC ANAL Category: Laboratory CMS Add: 01/01/2011 CMS Term: 88363 LAB DEF RBRVS 02/01/2015 12/31/2023 15.89 Description: XM ARCHIVE TISSUE MOLEC ANAL Category: Laboratory CMS Add: 01/01/2011 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,205 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 88364 26 LAB DEF RBRVS 01/01/2024 32.53 Description: INSITU HYBRIDIZATION (FISH) Category: Laboratory CMS Add: 01/01/2015 CMS Term: 88364 26 LAB DEF RBRVS 02/01/2015 12/31/2023 19.85 Description: INSITU HYBRIDIZATION (FISH) Category: Laboratory CMS Add: 01/01/2015 CMS Term: 88364 LAB DEF RBRVS 01/01/2024 127.46 Description: INSITU HYBRIDIZATION (FISH) Category: Laboratory CMS Add: 01/01/2015 CMS Term: 88364 LAB DEF RBRVS 02/01/2015 12/31/2023 68.32 Description: INSITU HYBRIDIZATION (FISH) Category: Laboratory CMS Add: 01/01/2015 CMS Term: 88364 TC LAB DEF RBRVS 01/01/2024 94.94 Description: INSITU HYBRIDIZATION (FISH) Category: Laboratory CMS Add: 01/01/2015 CMS Term: 88364 TC LAB DEF RBRVS 02/01/2015 12/31/2023 48.47 Description: INSITU HYBRIDIZATION (FISH) Category: Laboratory CMS Add: 01/01/2015 CMS Term: 88365 26 LAB DEF RBRVS 01/01/2024 41.10 Description: INSITU HYBRIDIZATION (FISH) Category: Laboratory CMS Add: 01/01/1989 CMS Term: 88365 26 LAB DEF RBRVS 02/01/2015 12/31/2023 43.88 Description: INSITU HYBRIDIZATION (FISH) Category: Laboratory CMS Add: 01/01/1989 CMS Term: 88365 LAB DEF RBRVS 01/01/2024 168.30 Description: INSITU HYBRIDIZATION (FISH) Category: Laboratory CMS Add: 01/01/1989 CMS Term: 88365 LAB DEF RBRVS 02/01/2015 12/31/2023 124.80 Description: INSITU HYBRIDIZATION (FISH) Category: Laboratory CMS Add: 01/01/1989 CMS Term: 88365 TC LAB DEF RBRVS 01/01/2024 127.20 Description: INSITU HYBRIDIZATION (FISH) Category: Laboratory CMS Add: 01/01/1989 CMS Term: 88365 TC LAB DEF RBRVS 02/01/2015 12/31/2023 80.92 Description: INSITU HYBRIDIZATION (FISH) Category: Laboratory CMS Add: 01/01/1989 CMS Term: 88366 26 LAB DEF RBRVS 01/01/2024 59.01 Description: INSITU HYBRIDIZATION (FISH) Category: Laboratory CMS Add: 01/01/2015 CMS Term: 88366 26 LAB DEF RBRVS 02/01/2015 12/31/2023 46.11 Description: INSITU HYBRIDIZATION (FISH) Category: Laboratory CMS Add: 01/01/2015 CMS Term: 88366 LAB DEF RBRVS 01/01/2024 259.69 Description: INSITU HYBRIDIZATION (FISH) Category: Laboratory CMS Add: 01/01/2015 CMS Term: 88366 LAB DEF RBRVS 02/01/2015 12/31/2023 105.98 Description: INSITU HYBRIDIZATION (FISH) Category: Laboratory CMS Add: 01/01/2015 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,206 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 88366 TC LAB DEF RBRVS 01/01/2024 200.68 Description: INSITU HYBRIDIZATION (FISH) Category: Laboratory CMS Add: 01/01/2015 CMS Term: 88366 TC LAB DEF RBRVS 02/01/2015 12/31/2023 59.86 Description: INSITU HYBRIDIZATION (FISH) Category: Laboratory CMS Add: 01/01/2015 CMS Term: 88367 26 LAB DEF RBRVS 01/01/2024 32.00 Description: INSITU HYBRIDIZATION AUTO Category: Laboratory CMS Add: 01/01/2005 CMS Term: 88367 26 LAB DEF RBRVS 02/01/2015 12/31/2023 45.66 Description: INSITU HYBRIDIZATION AUTO Category: Laboratory CMS Add: 01/01/2005 CMS Term: 88367 LAB DEF RBRVS 01/01/2024 106.56 Description: INSITU HYBRIDIZATION AUTO Category: Laboratory CMS Add: 01/01/2005 CMS Term: 88367 LAB DEF RBRVS 02/01/2015 12/31/2023 179.10 Description: INSITU HYBRIDIZATION AUTO Category: Laboratory CMS Add: 01/01/2005 CMS Term: 88367 TC LAB DEF RBRVS 01/01/2024 74.56 Description: INSITU HYBRIDIZATION AUTO Category: Laboratory CMS Add: 01/01/2005 CMS Term: 88367 TC LAB DEF RBRVS 02/01/2015 12/31/2023 133.44 Description: INSITU HYBRIDIZATION AUTO Category: Laboratory CMS Add: 01/01/2005 CMS Term: 88368 26 LAB DEF RBRVS 01/01/2024 39.86 Description: INSITU HYBRIDIZATION MANUAL Category: Laboratory CMS Add: 01/01/2005 CMS Term: 88368 26 LAB DEF RBRVS 02/01/2015 12/31/2023 47.44 Description: INSITU HYBRIDIZATION MANUAL Category: Laboratory CMS Add: 01/01/2005 CMS Term: 88368 LAB DEF RBRVS 01/01/2024 133.10 Description: INSITU HYBRIDIZATION MANUAL Category: Laboratory CMS Add: 01/01/2005 CMS Term: 88368 LAB DEF RBRVS 02/01/2015 12/31/2023 163.29 Description: INSITU HYBRIDIZATION MANUAL Category: Laboratory CMS Add: 01/01/2005 CMS Term: 88368 TC LAB DEF RBRVS 01/01/2024 93.24 Description: INSITU HYBRIDIZATION MANUAL Category: Laboratory CMS Add: 01/01/2005 CMS Term: 88368 TC LAB DEF RBRVS 02/01/2015 12/31/2023 115.85 Description: INSITU HYBRIDIZATION MANUAL Category: Laboratory CMS Add: 01/01/2005 CMS Term: 88369 26 LAB DEF RBRVS 01/01/2024 31.60 Description: M/PHMTRC ALYSISHQUANT/SEMIQ Category: Laboratory CMS Add: 01/01/2015 CMS Term: 88369 26 LAB DEF RBRVS 02/01/2015 12/31/2023 18.37 Description: M/PHMTRC ALYSISHQUANT/SEMIQ Category: Laboratory CMS Add: 01/01/2015 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,207 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 88369 LAB DEF RBRVS 01/01/2024 114.19 Description: M/PHMTRC ALYSISHQUANT/SEMIQ Category: Laboratory CMS Add: 01/01/2015 CMS Term: 88369 LAB DEF RBRVS 02/01/2015 12/31/2023 51.97 Description: M/PHMTRC ALYSISHQUANT/SEMIQ Category: Laboratory CMS Add: 01/01/2015 CMS Term: 88369 TC LAB DEF RBRVS 01/01/2024 82.59 Description: M/PHMTRC ALYSISHQUANT/SEMIQ Category: Laboratory CMS Add: 01/01/2015 CMS Term: 88369 TC LAB DEF RBRVS 02/01/2015 12/31/2023 33.61 Description: M/PHMTRC ALYSISHQUANT/SEMIQ Category: Laboratory CMS Add: 01/01/2015 CMS Term: 88371* 26 LAB DEF RBRVS 01/01/2024 18.26 Description: PROTEIN WESTERN BLOT TISSUE Category: Laboratory CMS Add: 01/01/1993 CMS Term: 88371* 26 LAB DEF RBRVS 02/01/2015 12/31/2023 13.90 Description: PROTEIN WESTERN BLOT TISSUE Category: Laboratory CMS Add: 01/01/1993 CMS Term: 88371* LAB L60 MAXFEE 01/01/2020 22.23 0.0 Description: PROTEIN WESTERN BLOT TISSUE Category: Laboratory CMS Add: 01/01/1993 CMS Term: 88372* 26 LAB DEF RBRVS 01/01/2024 17.02 Description: PROTEIN ANALYSIS W/PROBE Category: Laboratory CMS Add: 01/01/1993 CMS Term: 88372* 26 LAB DEF RBRVS 02/01/2015 12/31/2023 13.90 Description: PROTEIN ANALYSIS W/PROBE Category: Laboratory CMS Add: 01/01/1993 CMS Term: 88372* LAB L60 MAXFEE 01/01/2015 12/31/2023 24.45 0.0 Description: PROTEIN ANALYSIS W/PROBE Category: Laboratory CMS Add: 01/01/1993 CMS Term: 88372* LAB L60 MAXFEE 01/01/2024 26.22 0.0 Description: PROTEIN ANALYSIS W/PROBE Category: Laboratory CMS Add: 01/01/1993 CMS Term: 88373 26 LAB DEF RBRVS 01/01/2024 24.29 Description: M/PHMTRC ALYS ISHQUANT/SEMIQ Category: Laboratory CMS Add: 01/01/2015 CMS Term: 88373 26 LAB DEF RBRVS 02/01/2015 12/31/2023 15.43 Description: M/PHMTRC ALYS ISHQUANT/SEMIQ Category: Laboratory CMS Add: 01/01/2015 CMS Term: 88373 LAB DEF RBRVS 01/01/2024 64.73 Description: M/PHMTRC ALYS ISHQUANT/SEMIQ Category: Laboratory CMS Add: 01/01/2015 CMS Term: 88373 LAB DEF RBRVS 02/01/2015 12/31/2023 42.60 Description: M/PHMTRC ALYS ISHQUANT/SEMIQ Category: Laboratory CMS Add: 01/01/2015 CMS Term: 88373 TC LAB DEF RBRVS 01/01/2024 40.44 Description: M/PHMTRC ALYS ISHQUANT/SEMIQ Category: Laboratory CMS Add: 01/01/2015 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,208 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 88373 TC LAB DEF RBRVS 02/01/2015 12/31/2023 27.17 Description: M/PHMTRC ALYS ISHQUANT/SEMIQ Category: Laboratory CMS Add: 01/01/2015 CMS Term: 88374 26 LAB DEF RBRVS 01/01/2024 40.94 Description: M/PHMTRC ALYS ISHQUANT/SEMIQ Category: Laboratory CMS Add: 01/01/2015 CMS Term: 88374 26 LAB DEF RBRVS 02/01/2015 12/31/2023 33.08 Description: M/PHMTRC ALYS ISHQUANT/SEMIQ Category: Laboratory CMS Add: 01/01/2015 CMS Term: 88374 LAB DEF RBRVS 01/01/2024 281.59 Description: M/PHMTRC ALYS ISHQUANT/SEMIQ Category: Laboratory CMS Add: 01/01/2015 CMS Term: 88374 LAB DEF RBRVS 02/01/2015 12/31/2023 143.48 Description: M/PHMTRC ALYS ISHQUANT/SEMIQ Category: Laboratory CMS Add: 01/01/2015 CMS Term: 88374 TC LAB DEF RBRVS 01/01/2024 240.65 Description: M/PHMTRC ALYS ISHQUANT/SEMIQ Category: Laboratory CMS Add: 01/01/2015 CMS Term: 88374 TC LAB DEF RBRVS 02/01/2015 12/31/2023 110.40 Description: M/PHMTRC ALYS ISHQUANT/SEMIQ Category: Laboratory CMS Add: 01/01/2015 CMS Term: 88375 NOCOV DEF SYSMAN Description: OPTICAL ENDOMICROSCPY INTERP Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 88377 26 LAB DEF RBRVS 01/01/2024 61.19 Description: M/PHMTRC ALYS ISHQUANT/SEMIQ Category: Laboratory CMS Add: 01/01/2015 CMS Term: 88377 26 LAB DEF RBRVS 02/10/2015 12/31/2023 48.18 Description: M/PHMTRC ALYS ISHQUANT/SEMIQ Category: Laboratory CMS Add: 01/01/2015 CMS Term: 88377 LAB DEF RBRVS 01/01/2024 368.37 Description: M/PHMTRC ALYS ISHQUANT/SEMIQ Category: Laboratory CMS Add: 01/01/2015 CMS Term: 88377 LAB DEF RBRVS 02/01/2015 12/31/2023 150.90 Description: M/PHMTRC ALYS ISHQUANT/SEMIQ Category: Laboratory CMS Add: 01/01/2015 CMS Term: 88377 TC LAB DEF RBRVS 01/01/2024 307.18 Description: M/PHMTRC ALYS ISHQUANT/SEMIQ Category: Laboratory CMS Add: 01/01/2015 CMS Term: 88377 TC LAB DEF RBRVS 02/01/2015 12/31/2023 102.72 Description: M/PHMTRC ALYS ISHQUANT/SEMIQ Category: Laboratory CMS Add: 01/01/2015 CMS Term: 88380 26 LAB DEF RBRVS 01/01/2024 50.83 Description: MICRODISSECTION LASER Category: Laboratory CMS Add: 01/01/2002 CMS Term: 88380 26 LAB DEF RBRVS 09/01/2019 12/31/2023 58.43 Description: MICRODISSECTION LASER Category: Laboratory CMS Add: 01/01/2002 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,209 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 88380 LAB DEF RBRVS 01/01/2024 115.98 Description: MICRODISSECTION LASER Category: Laboratory CMS Add: 01/01/2002 CMS Term: 88380 LAB DEF RBRVS 09/01/2019 12/31/2023 134.64 Description: MICRODISSECTION LASER Category: Laboratory CMS Add: 01/01/2002 CMS Term: 88380 TC LAB DEF RBRVS 01/01/2024 65.15 Description: MICRODISSECTION LASER Category: Laboratory CMS Add: 01/01/2002 CMS Term: 88380 TC LAB DEF RBRVS 09/01/2019 12/31/2023 76.21 Description: MICRODISSECTION LASER Category: Laboratory CMS Add: 01/01/2002 CMS Term: 88381 26 LAB DEF RBRVS 01/01/2024 22.75 Description: MICRODISSECTION MANUAL Category: Laboratory CMS Add: 01/01/2008 CMS Term: 88381 26 LAB DEF RBRVS 02/01/2015 12/31/2023 40.37 Description: MICRODISSECTION MANUAL Category: Laboratory CMS Add: 01/01/2008 CMS Term: 88381 LAB DEF RBRVS 01/01/2024 186.70 Description: MICRODISSECTION MANUAL Category: Laboratory CMS Add: 01/01/2008 CMS Term: 88381 LAB DEF RBRVS 02/01/2015 12/31/2023 113.37 Description: MICRODISSECTION MANUAL Category: Laboratory CMS Add: 01/01/2008 CMS Term: 88381 TC LAB DEF RBRVS 01/01/2024 163.95 Description: MICRODISSECTION MANUAL Category: Laboratory CMS Add: 01/01/2008 CMS Term: 88381 TC LAB DEF RBRVS 02/01/2015 12/31/2023 72.99 Description: MICRODISSECTION MANUAL Category: Laboratory CMS Add: 01/01/2008 CMS Term: 88387 26 LAB DEF RBRVS 01/01/2024 25.80 Description: TISS EXAM MOLECULAR STUDY Category: Laboratory CMS Add: 01/01/2010 CMS Term: 88387 26 LAB DEF RBRVS 02/01/2015 12/31/2023 21.53 Description: TISS EXAM MOLECULAR STUDY Category: Laboratory CMS Add: 01/01/2010 CMS Term: 88387 LAB DEF RBRVS 01/01/2024 32.75 Description: TISS EXAM MOLECULAR STUDY Category: Laboratory CMS Add: 01/01/2010 CMS Term: 88387 LAB DEF RBRVS 02/01/2015 12/31/2023 25.91 Description: TISS EXAM MOLECULAR STUDY Category: Laboratory CMS Add: 01/01/2010 CMS Term: 88387 TC LAB DEF RBRVS 01/01/2024 6.95 Description: TISS EXAM MOLECULAR STUDY Category: Laboratory CMS Add: 01/01/2010 CMS Term: 88387 TC LAB DEF RBRVS 02/01/2015 12/31/2023 4.38 Description: TISS EXAM MOLECULAR STUDY Category: Laboratory CMS Add: 01/01/2010 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,210 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 88388 26 LAB DEF RBRVS 01/01/2024 22.20 Description: TISS EX MOLECUL STUDY ADD-ON Category: Laboratory CMS Add: 01/01/2010 CMS Term: 88388 26 LAB DEF RBRVS 02/01/2015 12/31/2023 17.46 Description: TISS EX MOLECUL STUDY ADD-ON Category: Laboratory CMS Add: 01/01/2010 CMS Term: 88388 LAB DEF RBRVS 01/01/2024 34.71 Description: TISS EX MOLECUL STUDY ADD-ON Category: Laboratory CMS Add: 01/01/2010 CMS Term: 88388 LAB DEF RBRVS 02/01/2015 12/31/2023 23.57 Description: TISS EX MOLECUL STUDY ADD-ON Category: Laboratory CMS Add: 01/01/2010 CMS Term: 88388 TC LAB DEF RBRVS 01/01/2024 12.51 Description: TISS EX MOLECUL STUDY ADD-ON Category: Laboratory CMS Add: 01/01/2010 CMS Term: 88388 TC LAB DEF RBRVS 02/01/2015 12/31/2023 6.11 Description: TISS EX MOLECUL STUDY ADD-ON Category: Laboratory CMS Add: 01/01/2010 CMS Term: 88399 LAB DEF MAXFEE 01/01/2024 57.71 0.0 Y Description: UNLISTED SURGICAL PATH PX Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88399 LAB DEF MAXFEE 02/01/2015 12/31/2023 44.39 0.0 Y Description: UNLISTED SURGICAL PATH PX Category: Laboratory CMS Add: 01/01/1982 CMS Term: 88720 LAB L60 MAXFEE 01/01/2009 12/31/2023 3.47 0.0 Description: BILIRUBIN TOTAL TRANSCUT Category: Laboratory CMS Add: 01/01/2009 CMS Term: 88720 LAB L60 MAXFEE 01/01/2024 5.02 0.0 Description: BILIRUBIN TOTAL TRANSCUT Category: Laboratory CMS Add: 01/01/2009 CMS Term: 88738 LAB L60 MAXFEE 01/01/2020 5.02 0.0 Description: HGB QUANT TRANSCUTANEOUS Category: Laboratory CMS Add: 01/01/2010 CMS Term: 88740 LAB L60 MAXFEE 01/01/2015 12/31/2023 6.83 0.0 Description: TRANSCUTANEOUS CARBOXYHB Category: Laboratory CMS Add: 01/01/2009 CMS Term: 88740 LAB L60 MAXFEE 01/01/2024 9.37 0.0 Description: TRANSCUTANEOUS CARBOXYHB Category: Laboratory CMS Add: 01/01/2009 CMS Term: 88741 LAB L60 MAXFEE 01/01/2015 12/31/2023 6.83 0.0 Description: TRANSCUTANEOUS METHB Category: Laboratory CMS Add: 01/01/2009 CMS Term: 88741 LAB L60 MAXFEE 01/01/2024 9.37 0.0 Description: TRANSCUTANEOUS METHB Category: Laboratory CMS Add: 01/01/2009 CMS Term: 88749 LAB DEF BILL30 Description: UNLISTED IN VIVO LAB SERVICE Category: Laboratory CMS Add: 01/01/2011 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,211 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 89049 LAB DEF RBRVS 01/01/2024 259.49 Description: CHCT FOR MAL HYPERTHERMIA Category: Laboratory CMS Add: 01/01/2006 CMS Term: 89049 LAB DEF RBRVS 02/01/2015 12/31/2023 181.21 Description: CHCT FOR MAL HYPERTHERMIA Category: Laboratory CMS Add: 01/01/2006 CMS Term: 89050 LAB L60 MAXFEE 01/01/2020 4.72 0.0 Description: BODY FLUID CELL COUNT Category: Laboratory CMS Add: 01/01/1984 CMS Term: 89051 LAB L60 MAXFEE 01/01/2020 5.60 0.0 Description: BODY FLUID CELL COUNT Category: Laboratory CMS Add: 01/01/1984 CMS Term: 89055 LAB L60 MAXFEE 01/01/2020 4.27 0.0 Description: LEUKOCYTE ASSESSMENT FECAL Category: Laboratory CMS Add: 01/01/2003 CMS Term: 89060* 26 LAB DEF RBRVS 01/01/2024 17.02 Description: EXAM SYNOVIAL FLUID CRYSTALS Category: Laboratory CMS Add: 01/01/1986 CMS Term: 89060* 26 LAB DEF RBRVS 02/01/2015 12/31/2023 13.90 Description: EXAM SYNOVIAL FLUID CRYSTALS Category: Laboratory CMS Add: 01/01/1986 CMS Term: 89060* LAB L60 MAXFEE 01/01/2020 7.33 0.0 Description: EXAM SYNOVIAL FLUID CRYSTALS Category: Laboratory CMS Add: 01/01/1986 CMS Term: 89125 LAB L60 MAXFEE 01/01/2015 12/31/2023 5.70 0.0 Description: SPECIMEN FAT STAIN Category: Laboratory CMS Add: 01/01/1984 CMS Term: 89125 LAB L60 MAXFEE 01/01/2024 5.88 0.0 Description: SPECIMEN FAT STAIN Category: Laboratory CMS Add: 01/01/1984 CMS Term: 89160 LAB L60 MAXFEE 01/01/2018 4.85 0.0 Description: EXAM FECES FOR MEAT FIBERS Category: Laboratory CMS Add: 01/01/1982 CMS Term: 89190 LAB L60 MAXFEE 01/01/2019 5.79 0.0 Description: NASAL SMEAR FOR EOSINOPHILS Category: Laboratory CMS Add: 01/01/1985 CMS Term: 89220 LAB DEF RBRVS 01/01/2024 16.52 Description: SPUTUM SPECIMEN COLLECTION Category: Laboratory CMS Add: 01/01/2004 CMS Term: 89220 LAB DEF RBRVS 09/01/2019 12/31/2023 10.24 Description: SPUTUM SPECIMEN COLLECTION Category: Laboratory CMS Add: 01/01/2004 CMS Term: 89230 LAB DEF RBRVS 01/01/2024 2.32 Description: COLLECT SWEAT FOR TEST Category: Laboratory CMS Add: 01/01/2004 CMS Term: 89230 LAB DEF RBRVS 09/01/2019 12/31/2023 3.39 Description: COLLECT SWEAT FOR TEST Category: Laboratory CMS Add: 01/01/2004 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,212 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 89240 LAB DEF BILL30 Description: UNLISTED MISC PATH TEST Category: Laboratory CMS Add: 01/01/2004 CMS Term: 89250 NOCOV DEF SYSMAN Description: CULTR OOCYTE/EMBRYO <4 DAYS Category: Non Covered Services CMS Add: 01/01/1996 CMS Term: 89251 NOCOV DEF SYSMAN Description: CULTR OOCYTE/EMBRYO <4 DAYS Category: Non Covered Services CMS Add: 01/01/1998 CMS Term: 89253 NOCOV DEF SYSMAN Description: EMBRYO HATCHING Category: Non Covered Services CMS Add: 01/01/1998 CMS Term: 89254 NOCOV DEF SYSMAN Description: OOCYTE IDENTIFICATION Category: Non Covered Services CMS Add: 01/01/1998 CMS Term: 89255 NOCOV DEF SYSMAN Description: PREPARE EMBRYO FOR TRANSFER Category: Non Covered Services CMS Add: 01/01/1998 CMS Term: 89257 NOCOV DEF SYSMAN Description: SPERM IDENTIFICATION Category: Non Covered Services CMS Add: 01/01/1998 CMS Term: 89258 NOCOV DEF SYSMAN Description: CRYOPRESERVATION EMBRYO(S) Category: Non Covered Services CMS Add: 01/01/1998 CMS Term: 89259 NOCOV DEF SYSMAN Description: CRYOPRESERVATION SPERM Category: Non Covered Services CMS Add: 01/01/1998 CMS Term: 89260 NOCOV DEF SYSMAN Description: SPERM ISOLATION SIMPLE Category: Non Covered Services CMS Add: 01/01/1998 CMS Term: 89261 NOCOV DEF SYSMAN Description: SPERM ISOLATION COMPLEX Category: Non Covered Services CMS Add: 01/01/1998 CMS Term: 89264 NOCOV DEF SYSMAN Description: IDENTIFY SPERM TISSUE Category: Non Covered Services CMS Add: 01/01/1999 CMS Term: 89268 NOCOV DEF SYSMAN Description: INSEMINATION OF OOCYTES Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: 89272 NOCOV DEF SYSMAN Description: EXTENDED CULTURE OF OOCYTES Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: 89280 NOCOV DEF SYSMAN Description: ASSIST OOCYTE FERTILIZATION Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: 89281 NOCOV DEF SYSMAN Description: ASSIST OOCYTE FERTILIZATION Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,213 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 89290 NOCOV DEF SYSMAN Description: BIOPSY OOCYTE POLAR BODY <=5 Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: 89291 NOCOV DEF SYSMAN Description: BIOPSY OOCYTE POLAR BODY Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: 89300 NOCOV DEF SYSMAN Description: SEMEN ANALYSIS W/HUHNER Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: 89310 NOCOV DEF SYSMAN Description: SEMEN ANALYSIS W/COUNT Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: 89320 NOCOV DEF SYSMAN Description: SEMEN ANAL VOL/COUNT/MOT Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: 89321 LAB L60 MAXFEE 01/01/2015 12/31/2023 11.90 0.0 Description: SEMEN ANAL SPERM DETECTION Category: Laboratory CMS Add: 01/01/2001 CMS Term: 89321 LAB L60 MAXFEE 01/01/2024 12.05 0.0 Description: SEMEN ANAL SPERM DETECTION Category: Laboratory CMS Add: 01/01/2001 CMS Term: 89322 NOCOV DEF SYSMAN Description: SEMEN ANAL STRICT CRITERIA Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 89325 NOCOV DEF SYSMAN Description: SPERM ANTIBODY TEST Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: 89329 NOCOV DEF SYSMAN Description: SPERM EVALUATION TEST Category: Non Covered Services CMS Add: 01/01/1987 CMS Term: 89330 NOCOV DEF SYSMAN Description: EVALUATION CERVICAL MUCUS Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: 89331 NOCOV DEF SYSMAN Description: RETROGRADE EJACULATION ANAL Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 89335 NOCOV DEF SYSMAN Description: CRYOPRESERVE TESTICULAR TISS Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: 89337 NOCOV DEF SYSMAN Description: CRYOPRESERVATION OOCYTE(S) Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 89342 NOCOV DEF SYSMAN Description: STORAGE/YEAR EMBRYO(S) Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: 89343 NOCOV DEF SYSMAN Description: STORAGE/YEAR SPERM/SEMEN Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,214 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 89344 NOCOV DEF SYSMAN Description: STORAGE/YEAR REPROD TISSUE Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: 89346 NOCOV DEF SYSMAN Description: STORAGE/YEAR OOCYTE(S) Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: 89352 NOCOV DEF SYSMAN Description: THAWING CRYOPRESRVED EMBRYO Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: 89353 NOCOV DEF SYSMAN Description: THAWING CRYOPRESRVED SPERM Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: 89354 NOCOV DEF SYSMAN Description: THAW CRYOPRSVRD REPROD TISS Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: 89356 NOCOV DEF SYSMAN Description: THAWING CRYOPRESRVED OOCYTE Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: 89398 NOCOV DEF SYSMAN Description: UNLISTED REPROD MED LAB PROC Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 9001F NOCOV DEF SYSMAN Description: AORTIC ANEURYSM<5CM DIAM CT Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: 9002F NOCOV DEF SYSMAN Description: AORTIC ANEURYSM 5-5.4CM DIAM Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: 9003F NOCOV DEF SYSMAN Description: AORTIC ANRYSM5.5-5.9CM DIAM Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: 9004F NOCOV DEF SYSMAN Description: AORTIC ANRYSM 6/> CM DIAM Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: 9005F NOCOV DEF SYSMAN Description: ASYMPT CAROT/VRTBRBAS STEN Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: 9006F NOCOV DEF SYSMAN Description: SYMPT STEN-TIA/STRK<120DAYS Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: 9007F NOCOV DEF SYSMAN Description: OTHER CAROT STEN 120 DAYS/> Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: 90281 DRUG L60 MAXFEE 07/01/2023 49.92 0.0 Description: HUMAN IG IM Category: Drugs CMS Add: 01/01/1999 CMS Term: 90281 DRUG L60 MAXFEE 10/01/2022 06/30/2023 48.46 0.0 Description: HUMAN IG IM Category: Drugs CMS Add: 01/01/1999 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,215 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 90283 DRUG DEF BILL40 Description: HUMAN IG IV Category: Drugs CMS Add: 01/01/1999 CMS Term: 90284 DRUG DEF MAXFEE 01/01/2008 15.00 0.0 Description: HUMAN IG SC Category: Drugs CMS Add: 01/01/2008 CMS Term: 90287 DRUG L60 MAXFEE 01/01/1999 2.90 0.0 Description: BOTULINUM ANTITOXIN Category: Drugs CMS Add: 01/01/1999 CMS Term: 90288 DRUG DEF BILL40 Description: BOTULISM IG IV Category: Drugs CMS Add: 01/01/1999 CMS Term: 90291 DRUG DEF MAXFEE 10/01/2022 36.89 0.0 Description: CMV IG IV Category: Drugs CMS Add: 01/01/1999 CMS Term: 90296 NOCOV DEF SYSMAN Description: DIPHTHERIA ANTITOXIN Category: Non Covered Services CMS Add: 01/01/1999 CMS Term: 90371 DRUG DEF MAXFEE 01/01/2024 153.47 0.0 Description: HEP B IG IM Category: Drugs CMS Add: 01/01/1999 CMS Term: 90371 DRUG DEF MAXFEE 10/01/2021 12/31/2023 149.00 0.0 Description: HEP B IG IM Category: Drugs CMS Add: 01/01/1999 CMS Term: 90375 DRUG DEF MAXFEE 04/01/2023 714.52 0.0 Description: RABIES IG IM/SC Category: Drugs CMS Add: 01/01/1999 CMS Term: 90376 DRUG DEF MAXFEE 04/01/2023 475.19 0.0 Description: RABIES IG HEAT TREATED Category: Drugs CMS Add: 01/01/1999 CMS Term: 90377 DRUG DEF MAXFEE 01/01/2021 357.34 0.0 Description: RABIES IG HT&SOL HUMAN IM/SC Category: Drugs CMS Add: 01/01/2021 CMS Term: 90378 NOCOV DEF SYSMAN Description: RSV MAB IM 50MG Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: 90380 MEDSV DEF MAXFEE 07/17/2023 0.00 0.0 0-2years Description: RSV MONOC ANTB SEASN .5ML IM Category: Medical Services CMS Add: 07/17/2023 CMS Term: 90381 MEDSV DEF MAXFEE 07/17/2023 0.00 0.0 0-2years Description: RSV MONOC ANTB SEASN 1 ML IM Category: Medical Services CMS Add: 07/17/2023 CMS Term: 90384 DRUG DEF MAXFEE 04/01/2024 86.97 0.0 Description: RH IG FULL-DOSE IM Category: Drugs CMS Add: 01/01/1999 CMS Term: 90384 DRUG DEF MAXFEE 07/01/2022 03/31/2024 80.40 0.0 Description: RH IG FULL-DOSE IM Category: Drugs CMS Add: 01/01/1999 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,216 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 90385 DRUG DEF MAXFEE 07/01/2018 30.40 0.0 Description: RH IG MINIDOSE IM Category: Drugs CMS Add: 01/01/1999 CMS Term: 90386 DRUG DEF MAXFEE 04/01/2022 113.36 0.0 Description: RH IG IV Category: Drugs CMS Add: 01/01/1999 CMS Term: 90389 DRUG DEF MAXFEE 04/01/2024 681.63 0.0 Description: TETANUS IG IM Category: Drugs CMS Add: 01/01/1999 CMS Term: 90389 DRUG DEF MAXFEE 07/01/2023 03/31/2024 661.77 0.0 Description: TETANUS IG IM Category: Drugs CMS Add: 01/01/1999 CMS Term: 90389 DRUG DEF MAXFEE 10/01/2022 06/30/2023 642.50 0.0 Description: TETANUS IG IM Category: Drugs CMS Add: 01/01/1999 CMS Term: 90393 DRUG DEF MAXFEE 01/01/1999 2.90 0.0 Description: VACCINA IG IM Category: Drugs CMS Add: 01/01/1999 CMS Term: 90396 DRUG DEF MAXFEE 10/01/2022 2291.70 0.0 Description: VARICELLA-ZOSTER IG IM Category: Drugs CMS Add: 01/01/1999 CMS Term: 90399 DRUG DEF BILL40 Description: UNLISTED IMMUNE GLOBULIN Category: Drugs CMS Add: 01/01/1999 CMS Term: 90460 DDWA DEF RBRVS 01/01/2024 21.11 0-18years Description: IM ADMIN 1ST/ONLY COMPONENT Category: CIH Waiver CMS Add: 01/01/2011 CMS Term: 90460 DDWA DEF RBRVS 07/26/2022 12/31/2023 17.61 0-18years Description: IM ADMIN 1ST/ONLY COMPONENT Category: CIH Waiver CMS Add: 01/01/2011 CMS Term: 90460 MEDSV DEF RBRVS 01/01/2024 21.11 0-18years Description: IM ADMIN 1ST/ONLY COMPONENT Category: Medical Services CMS Add: 01/01/2011 CMS Term: 90460 MEDSV DEF RBRVS 07/26/2022 12/31/2023 17.61 0-18years Description: IM ADMIN 1ST/ONLY COMPONENT Category: Medical Services CMS Add: 01/01/2011 CMS Term: 90460 SSFS DEF RBRVS 01/01/2024 21.11 0-18years Description: IM ADMIN 1ST/ONLY COMPONENT Category: Family Support Waivr CMS Add: 01/01/2011 CMS Term: 90460 SSFS DEF RBRVS 07/26/2022 12/31/2023 17.61 0-18years Description: IM ADMIN 1ST/ONLY COMPONENT Category: Family Support Waivr CMS Add: 01/01/2011 CMS Term: 90460 TRANS DEF RBRVS 01/01/2024 21.11 0-18years Description: IM ADMIN 1ST/ONLY COMPONENT Category: Transportation CMS Add: 01/01/2011 CMS Term: 90460 TRANS DEF RBRVS 07/26/2022 12/31/2023 17.61 0-18years Description: IM ADMIN 1ST/ONLY COMPONENT Category: Transportation CMS Add: 01/01/2011 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,217 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 90461 DDWA DEF RBRVS 01/01/2024 9.66 0-18years Description: IM ADMIN EACH ADDL COMPONENT Category: CIH Waiver CMS Add: 01/01/2011 CMS Term: 90461 DDWA DEF RBRVS 07/26/2022 12/31/2023 8.90 0-18years Description: IM ADMIN EACH ADDL COMPONENT Category: CIH Waiver CMS Add: 01/01/2011 CMS Term: 90461 MEDSV DEF RBRVS 01/01/2024 9.66 0-18years Description: IM ADMIN EACH ADDL COMPONENT Category: Medical Services CMS Add: 01/01/2011 CMS Term: 90461 MEDSV DEF RBRVS 07/26/2022 12/31/2023 8.90 0-18years Description: IM ADMIN EACH ADDL COMPONENT Category: Medical Services CMS Add: 01/01/2011 CMS Term: 90461 SSFS DEF RBRVS 01/01/2024 9.66 0-18years Description: IM ADMIN EACH ADDL COMPONENT Category: Family Support Waivr CMS Add: 01/01/2011 CMS Term: 90461 SSFS DEF RBRVS 07/26/2022 12/31/2023 8.90 0-18years Description: IM ADMIN EACH ADDL COMPONENT Category: Family Support Waivr CMS Add: 01/01/2011 CMS Term: 90461 TRANS DEF RBRVS 01/01/2024 9.66 0-18years Description: IM ADMIN EACH ADDL COMPONENT Category: Transportation CMS Add: 01/01/2011 CMS Term: 90461 TRANS DEF RBRVS 07/26/2022 12/31/2023 8.90 0-18years Description: IM ADMIN EACH ADDL COMPONENT Category: Transportation CMS Add: 01/01/2011 CMS Term: 90471* MEDSV DEF RBRVS 01/01/2024 18.89 0-18years 0-1 Description: IMMUNIZATION ADMIN Category: Medical Services CMS Add: 01/01/1999 CMS Term: 90471* MEDSV DEF RBRVS 02/01/2015 12/31/2023 17.61 0-18years 0-1 Description: IMMUNIZATION ADMIN Category: Medical Services CMS Add: 01/01/1999 CMS Term: 90471* SL MEDSV MSL MAXFEE 01/01/2020 15.00 0.0 0-18years 0-1 Description: IMMUNIZATION ADMIN Category: Medical Services CMS Add: 01/01/1999 CMS Term: 90471* SL TRANS MSL MAXFEE 01/01/2020 15.00 0.0 0-18years Description: IMMUNIZATION ADMIN Category: Transportation CMS Add: 01/01/1999 CMS Term: 90471* TRANS DEF RBRVS 01/01/2024 18.89 0-18years Description: IMMUNIZATION ADMIN Category: Transportation CMS Add: 01/01/1999 CMS Term: 90471* TRANS DEF RBRVS 02/01/2015 12/31/2023 17.61 0-18years Description: IMMUNIZATION ADMIN Category: Transportation CMS Add: 01/01/1999 CMS Term: 90472* MEDSV DEF RBRVS 01/01/2024 13.58 0-18years Description: IMMUNIZATION ADMIN EACH ADD Category: Medical Services CMS Add: 01/01/1999 CMS Term: 90472* MEDSV DEF RBRVS 02/01/2015 12/31/2023 8.90 0-18years Description: IMMUNIZATION ADMIN EACH ADD Category: Medical Services CMS Add: 01/01/1999 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,218 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 90472* SL MEDSV MSL MAXFEE 01/01/2020 15.00 0.0 0-18years Description: IMMUNIZATION ADMIN EACH ADD Category: Medical Services CMS Add: 01/01/1999 CMS Term: 90472* SL TRANS MSL MAXFEE 01/01/2020 15.00 0.0 0-18years Description: IMMUNIZATION ADMIN EACH ADD Category: Transportation CMS Add: 01/01/1999 CMS Term: 90472* TRANS DEF RBRVS 01/01/2024 13.58 0-18years Description: IMMUNIZATION ADMIN EACH ADD Category: Transportation CMS Add: 01/01/1999 CMS Term: 90472* TRANS DEF RBRVS 02/01/2015 12/31/2023 8.90 0-18years Description: IMMUNIZATION ADMIN EACH ADD Category: Transportation CMS Add: 01/01/1999 CMS Term: 90473* MEDSV DEF RBRVS 01/01/2024 15.49 0-18years 0-1 Description: IMMUNE ADMIN ORAL/NASAL Category: Medical Services CMS Add: 01/01/2002 CMS Term: 90473* MEDSV DEF RBRVS 02/01/2015 12/31/2023 17.61 0-18years 0-1 Description: IMMUNE ADMIN ORAL/NASAL Category: Medical Services CMS Add: 01/01/2002 CMS Term: 90473* SL MEDSV MSL MAXFEE 01/01/2020 15.00 0.0 0-18years 0-1 Description: IMMUNE ADMIN ORAL/NASAL Category: Medical Services CMS Add: 01/01/2002 CMS Term: 90473* SL TRANS MSL MAXFEE 01/01/2020 15.00 0.0 0-18years Description: IMMUNE ADMIN ORAL/NASAL Category: Transportation CMS Add: 01/01/2002 CMS Term: 90473* TRANS DEF RBRVS 01/01/2024 15.49 0-18years Description: IMMUNE ADMIN ORAL/NASAL Category: Transportation CMS Add: 01/01/2002 CMS Term: 90473* TRANS DEF RBRVS 02/01/2015 12/31/2023 17.61 0-18years Description: IMMUNE ADMIN ORAL/NASAL Category: Transportation CMS Add: 01/01/2002 CMS Term: 90474* MEDSV DEF RBRVS 01/01/2024 11.11 0-18years Description: IMMUNE ADMIN ORAL/NASAL ADDL Category: Medical Services CMS Add: 01/01/2002 CMS Term: 90474* MEDSV DEF RBRVS 02/01/2015 12/31/2023 8.90 0-18years Description: IMMUNE ADMIN ORAL/NASAL ADDL Category: Medical Services CMS Add: 01/01/2002 CMS Term: 90474* SL MEDSV MSL MAXFEE 01/01/2020 15.00 0.0 0-18years Description: IMMUNE ADMIN ORAL/NASAL ADDL Category: Medical Services CMS Add: 01/01/2002 CMS Term: 90474* SL TRANS MSL MAXFEE 01/01/2020 15.00 0.0 0-18years Description: IMMUNE ADMIN ORAL/NASAL ADDL Category: Transportation CMS Add: 01/01/2002 CMS Term: 90474* TRANS DEF RBRVS 01/01/2024 11.11 0-18years Description: IMMUNE ADMIN ORAL/NASAL ADDL Category: Transportation CMS Add: 01/01/2002 CMS Term: 90474* TRANS DEF RBRVS 02/01/2015 12/31/2023 8.90 0-18years Description: IMMUNE ADMIN ORAL/NASAL ADDL Category: Transportation CMS Add: 01/01/2002 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,219 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 90476 NOCOV DEF SYSMAN Description: ADENOVIRUS VACCINE TYPE 4 Category: Non Covered Services CMS Add: 01/01/1999 CMS Term: 90477 NOCOV DEF SYSMAN Description: ADENOVIRUS VACCINE TYPE 7 Category: Non Covered Services CMS Add: 01/01/1999 CMS Term: 90480* DDWA DEF MAXFEE 09/11/2023 38.95 0.0 Description: ADMN SARSCOV2 VACC 1 DOSE Category: CIH Waiver CMS Add: 09/11/2023 CMS Term: 90480* MEDSV DEF MAXFEE 09/11/2023 38.95 0.0 0-18years Description: ADMN SARSCOV2 VACC 1 DOSE Category: Medical Services CMS Add: 09/11/2023 CMS Term: 90480* SL DDWA MSL MAXFEE 09/11/2023 15.00 0.0 Description: ADMN SARSCOV2 VACC 1 DOSE Category: CIH Waiver CMS Add: 09/11/2023 CMS Term: 90480* SL MEDSV MSL MAXFEE 09/11/2023 15.00 0.0 0-18years Description: ADMN SARSCOV2 VACC 1 DOSE Category: Medical Services CMS Add: 09/11/2023 CMS Term: 90480* SL SSFS MSL MAXFEE 09/11/2023 15.00 0.0 0-999years Description: ADMN SARSCOV2 VACC 1 DOSE Category: Family Support Waivr CMS Add: 09/11/2023 CMS Term: 90480* SL TRANS MSL MAXFEE 09/11/2023 15.00 0.0 Description: ADMN SARSCOV2 VACC 1 DOSE Category: Transportation CMS Add: 09/11/2023 CMS Term: 90480* SSFS DEF MAXFEE 09/11/2023 38.95 0.0 0-999years Description: ADMN SARSCOV2 VACC 1 DOSE Category: Family Support Waivr CMS Add: 09/11/2023 CMS Term: 90480* TRANS DEF MAXFEE 09/11/2023 38.95 0.0 Description: ADMN SARSCOV2 VACC 1 DOSE Category: Transportation CMS Add: 09/11/2023 CMS Term: 90581 NOCOV DEF SYSMAN 18-999years Description: ANTHRAX VACCINE SC OR IM Category: Non Covered Services CMS Add: 01/01/1999 CMS Term: 90584 NOCOV DEF SYSMAN Description: DENGUE VACC QUAD 2 DOSE SUBQ Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 90585 DRUG DEF MAXFEE 07/01/2018 164.92 0.0 Description: BCG VACCINE PERCUT Category: Drugs CMS Add: 01/01/1999 CMS Term: 90586 DRUG DEF MAXFEE 07/01/2018 164.92 0.0 Description: BCG VACCINE INTRAVESICAL Category: Drugs CMS Add: 01/01/1999 CMS Term: 90587 NOCOV DEF SYSMAN Description: DENGUE VACC QUAD 3 DOSE SUBQ Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 90589 NOCOV DEF SYSMAN Description: CHIKUNGUNYA VACCINE LIVE IM Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,220 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 90611 DDWA DEF MAXFEE 07/26/2022 0.00 0.0 18-999years Description: SMALLPOX&MONKEYPOX VAC 0.5ML Category: CIH Waiver CMS Add: 07/26/2022 CMS Term: 90611 DRUG DEF MAXFEE 07/26/2022 0.00 0.0 18-999years Description: SMALLPOX&MONKEYPOX VAC 0.5ML Category: Drugs CMS Add: 07/26/2022 CMS Term: 90611 SSFS DEF MAXFEE 07/26/2022 0.00 0.0 18-999years Description: SMALLPOX&MONKEYPOX VAC 0.5ML Category: Family Support Waivr CMS Add: 07/26/2022 CMS Term: 90619* DRUG DEF MAXFEE 04/01/2023 03/31/2024 163.13 0.0 2-999years Description: MENACWY-TT VACCINE IM Category: Drugs CMS Add: 07/01/2019 CMS Term: 90619* DRUG DEF MAXFEE 04/01/2024 174.54 0.0 2-999years Description: MENACWY-TT VACCINE IM Category: Drugs CMS Add: 07/01/2019 CMS Term: 90619* DRUG I01 MAXFEE 10/27/2021 0.00 0.0 2-999years Description: MENACWY-TT VACCINE IM Category: Drugs CMS Add: 07/01/2019 CMS Term: 90620* DRUG DEF MAXFEE 04/01/2023 03/31/2024 221.10 0.0 Description: MENB-4C VACC 2 DOSE IM Category: Drugs CMS Add: 02/01/2015 CMS Term: 90620* DRUG DEF MAXFEE 04/01/2024 234.15 0.0 Description: MENB-4C VACC 2 DOSE IM Category: Drugs CMS Add: 02/01/2015 CMS Term: 90620* DRUG I01 MAXFEE 01/01/2020 0.00 0.0 Description: MENB-4C VACC 2 DOSE IM Category: Drugs CMS Add: 02/01/2015 CMS Term: 90621* DRUG DEF MAXFEE 04/01/2023 03/31/2024 187.90 0.0 Description: MENB-FHBP VACC 2/3 DOSE IM Category: Drugs CMS Add: 01/01/2015 CMS Term: 90621* DRUG DEF MAXFEE 04/01/2024 198.99 0.0 Description: MENB-FHBP VACC 2/3 DOSE IM Category: Drugs CMS Add: 01/01/2015 CMS Term: 90621* DRUG I01 MAXFEE 01/01/2020 0.00 0.0 Description: MENB-FHBP VACC 2/3 DOSE IM Category: Drugs CMS Add: 01/01/2015 CMS Term: 90622 DDWA DEF MAXFEE 07/26/2022 0.00 0.0 1-999years Description: VACCINIA VRS VAC 0.3 ML PERQ Category: CIH Waiver CMS Add: 07/26/2022 CMS Term: 90622 DRUG DEF MAXFEE 07/26/2022 0.00 0.0 1-999years Description: VACCINIA VRS VAC 0.3 ML PERQ Category: Drugs CMS Add: 07/26/2022 CMS Term: 90622 SSFS DEF MAXFEE 07/26/2022 0.00 0.0 1-999years Description: VACCINIA VRS VAC 0.3 ML PERQ Category: Family Support Waivr CMS Add: 07/26/2022 CMS Term: 90623 DRUG DEF MAXFEE 01/01/2024 241.50 0.0 Description: MENACWY-TT MENB-FHBP VACC IM Category: Drugs CMS Add: 01/01/2024 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,221 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 90625 NOCOV DEF SYSMAN Description: CHOLERA VACCINE LIVE ORAL Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 90626 NOCOV DEF SYSMAN Description: TIC-BRN ENCEPH VAC 0.25ML IM Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 90627 NOCOV DEF SYSMAN Description: TIC-BRN ENCEPH VAC 0.5ML IM Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 90630 DRUG DEF MAXFEE 10/01/2016 18.08 0.0 Description: FLU VACC IIV4 NO PRESERV ID Category: Drugs CMS Add: 01/01/2015 CMS Term: 90632* DRUG DEF MAXFEE 10/01/2022 09/30/2023 79.74 0.0 Description: HEPA VACCINE ADULT IM Category: Drugs CMS Add: 01/01/1999 CMS Term: 90632* DRUG DEF MAXFEE 10/01/2023 82.13 0.0 Description: HEPA VACCINE ADULT IM Category: Drugs CMS Add: 01/01/1999 CMS Term: 90632* DRUG I01 MAXFEE 01/01/2020 0.00 0.0 Description: HEPA VACCINE ADULT IM Category: Drugs CMS Add: 01/01/1999 CMS Term: 90633 DRUG I01 MAXFEE 01/01/2020 0.00 0.0 0-18years Description: HEPA VACC PED/ADOL 2 DOSE IM Category: Drugs CMS Add: 01/01/1999 CMS Term: 90634 DRUG DEF SYSMAN 0-18years Description: HEPA VACC PED/ADOL 3 DOSE Category: Drugs CMS Add: 01/01/1999 CMS Term: 90636 DRUG DEF MAXFEE 04/01/2023 03/31/2024 125.90 0.0 19-999years Description: HEP A/HEP B VACC ADULT IM Category: Drugs CMS Add: 01/01/1999 CMS Term: 90636 DRUG DEF MAXFEE 04/01/2024 130.93 0.0 19-999years Description: HEP A/HEP B VACC ADULT IM Category: Drugs CMS Add: 01/01/1999 CMS Term: 90644 DRUG DEF SYSMAN 1-18months Description: HIB-MENCY VACC 6WK-18M0 IM Category: Drugs CMS Add: 01/01/2010 CMS Term: 90647* DRUG DEF MAXFEE 10/01/2022 09/30/2023 29.52 0.0 Description: HIB PRP-OMP VACC 3 DOSE IM Category: Drugs CMS Add: 01/01/1999 CMS Term: 90647* DRUG DEF MAXFEE 10/01/2023 30.41 0.0 Description: HIB PRP-OMP VACC 3 DOSE IM Category: Drugs CMS Add: 01/01/1999 CMS Term: 90647* DRUG I01 MAXFEE 01/01/2020 0.00 0.0 Description: HIB PRP-OMP VACC 3 DOSE IM Category: Drugs CMS Add: 01/01/1999 CMS Term: 90648* DRUG DEF MAXFEE 04/01/2023 03/31/2024 12.29 0.0 Description: HIB PRP-T VACCINE 4 DOSE IM Category: Drugs CMS Add: 01/01/1999 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,222 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 90648* DRUG DEF MAXFEE 04/01/2024 12.66 0.0 Description: HIB PRP-T VACCINE 4 DOSE IM Category: Drugs CMS Add: 01/01/1999 CMS Term: 90648* DRUG I01 MAXFEE 01/01/2020 0.00 0.0 Description: HIB PRP-T VACCINE 4 DOSE IM Category: Drugs CMS Add: 01/01/1999 CMS Term: 90649 DRUG DEF SYSMAN 9-26years Description: 4VHPV VACCINE 3 DOSE IM Category: Drugs CMS Add: 01/01/2006 CMS Term: 90650 DRUG DEF MAXFEE 10/01/2009 134.40 0.0 9-25years Description: 2VHPV VACCINE 3 DOSE IM Category: Drugs CMS Add: 01/01/2009 CMS Term: 90651* DRUG DEF MAXFEE 10/01/2022 09/30/2023 281.42 0.0 9-45years Description: 9VHPV VACCINE 2/3 DOSE IM Category: Drugs CMS Add: 01/01/2015 CMS Term: 90651* DRUG DEF MAXFEE 10/01/2023 301.12 0.0 9-45years Description: 9VHPV VACCINE 2/3 DOSE IM Category: Drugs CMS Add: 01/01/2015 CMS Term: 90651* DRUG I01 MAXFEE 01/01/2020 0.00 0.0 9-45years Description: 9VHPV VACCINE 2/3 DOSE IM Category: Drugs CMS Add: 01/01/2015 CMS Term: 90653 NOCOV DEF SYSMAN Description: IIV ADJUVANT VACCINE IM Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 90654 DRUG DEF SYSMAN 18-64years Description: FLU VACC IIV3 NO PRESERV ID Category: Drugs CMS Add: 01/01/2011 CMS Term: 90655 DRUG DEF SYSMAN 0-1 Description: IIV3 VACC NO PRSV 0.25 ML IM Category: Drugs CMS Add: 01/01/2004 CMS Term: 90656 DRUG DEF MAXFEE 10/01/2018 17.56 0.0 0-1 Description: IIV3 VACC NO PRSV 0.5 ML IM Category: Drugs CMS Add: 01/01/2005 CMS Term: 90657 DRUG DEF SYSMAN Description: IIV3 VACCINE SPLT 0.25 ML IM Category: Drugs CMS Add: 01/01/1999 CMS Term: 90658 DRUG DEF MAXFEE 10/01/2018 16.14 0.0 Description: IIV3 VACCINE SPLT 0.5 ML IM Category: Drugs CMS Add: 01/01/1999 CMS Term: 90660 DRUG DEF SYSMAN 2-49years 0-1 Description: LAIV3 VACCINE INTRANASAL Category: Drugs CMS Add: 01/01/1999 CMS Term: 90661 DRUG DEF MAXFEE 10/01/2015 19.87 0.0 Description: CCIIV3 VAC NO PRSV 0.5 ML IM Category: Drugs CMS Add: 01/01/2008 CMS Term: 90662 DRUG DEF MAXFEE 10/01/2022 09/30/2023 63.77 0.0 65-999years Description: IIV NO PRSV INCREASED AG IM Category: Drugs CMS Add: 01/01/2008 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,223 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 90662 DRUG DEF MAXFEE 10/01/2023 66.95 0.0 65-999years Description: IIV NO PRSV INCREASED AG IM Category: Drugs CMS Add: 01/01/2008 CMS Term: 90664 NOCOV DEF SYSMAN Description: LAIV VACC PANDEMIC INTRANASL Category: Non Covered Services CMS Add: 07/01/2010 CMS Term: 90666 NOCOV DEF SYSMAN Description: FLU VAC PANDEM PRSRV FREE IM Category: Non Covered Services CMS Add: 07/01/2010 CMS Term: 90667 NOCOV DEF SYSMAN Description: IIV VACC PANDEMIC ADJUVT IM Category: Non Covered Services CMS Add: 07/01/2010 CMS Term: 90668 NOCOV DEF SYSMAN Description: IIV VACCINE PANDEMIC IM Category: Non Covered Services CMS Add: 07/01/2010 CMS Term: 90670* DRUG DEF MAXFEE 04/01/2022 236.97 0.0 Description: PCV13 VACCINE IM Category: Drugs CMS Add: 07/01/2009 CMS Term: 90670* DRUG I01 MAXFEE 01/01/2020 0.00 0.0 Description: PCV13 VACCINE IM Category: Drugs CMS Add: 07/01/2009 CMS Term: 90671 DRUG DEF MAXFEE 05/20/2022 09/30/2023 226.10 0.0 0-999years Description: PCV15 VACCINE IM Category: Drugs CMS Add: 07/01/2021 CMS Term: 90671 DRUG DEF MAXFEE 10/01/2023 232.89 0.0 0-999years Description: PCV15 VACCINE IM Category: Drugs CMS Add: 07/01/2021 CMS Term: 90672* DRUG DEF MAXFEE 10/01/2018 09/30/2023 24.10 0.0 0-1 Description: LAIV4 VACCINE INTRANASAL Category: Drugs CMS Add: 01/01/2013 CMS Term: 90672* DRUG DEF MAXFEE 10/01/2023 24.94 0.0 0-1 Description: LAIV4 VACCINE INTRANASAL Category: Drugs CMS Add: 01/01/2013 CMS Term: 90672* DRUG I01 MAXFEE 01/01/2020 0.00 0.0 0-1 Description: LAIV4 VACCINE INTRANASAL Category: Drugs CMS Add: 01/01/2013 CMS Term: 90673 DRUG DEF SYSMAN 18-49years Description: RIV3 VACCINE NO PRESERV IM Category: Drugs CMS Add: 01/01/2014 CMS Term: 90674* DRUG DEF MAXFEE 10/01/2022 09/30/2023 29.07 0.0 Description: CCIIV4 VAC NO PRSV 0.5 ML IM Category: Drugs CMS Add: 08/01/2016 CMS Term: 90674* DRUG DEF MAXFEE 10/01/2023 30.82 0.0 Description: CCIIV4 VAC NO PRSV 0.5 ML IM Category: Drugs CMS Add: 08/01/2016 CMS Term: 90674* DRUG I01 MAXFEE 01/01/2020 0.00 0.0 Description: CCIIV4 VAC NO PRSV 0.5 ML IM Category: Drugs CMS Add: 08/01/2016 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,224 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 90675 DRUG L60 MAXFEE 04/01/2022 397.99 0.0 Description: RABIES VACCINE IM Category: Drugs CMS Add: 01/01/1999 CMS Term: 90676 NOCOV DEF SYSMAN Description: RABIES VACCINE ID Category: Non Covered Services CMS Add: 01/01/1999 CMS Term: 90677 DRUG DEF MAXFEE 04/01/2023 03/31/2024 265.87 0.0 0-999years Description: PCV20 VACCINE IM Category: Drugs CMS Add: 07/01/2021 CMS Term: 90677 DRUG DEF MAXFEE 04/01/2024 273.85 0.0 0-999years Description: PCV20 VACCINE IM Category: Drugs CMS Add: 07/01/2021 CMS Term: 90678 DRUG DEF MAXFEE 05/31/2023 309.75 0.0 10-999years Description: RSV VACC PREF BIVALENT IM Category: Drugs CMS Add: 01/01/2023 CMS Term: 90678 NOCOV DEF SYSMAN Description: RSV VACC PREF BIVALENT IM Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 90679 DRUG DEF MAXFEE 05/03/2023 294.00 0.0 60-999years Description: RSV VACC PREF RECOMB ADJT IM Category: Drugs CMS Add: 05/03/2023 CMS Term: 90680* DRUG I01 MAXFEE 01/01/2020 0.00 0.0 Description: RV5 VACC 3 DOSE LIVE ORAL Category: Drugs CMS Add: 01/01/1999 CMS Term: 90680* DRUG L60 MAXFEE 10/01/2022 09/30/2023 97.06 0.0 Description: RV5 VACC 3 DOSE LIVE ORAL Category: Drugs CMS Add: 01/01/1999 CMS Term: 90680* DRUG L60 MAXFEE 10/01/2023 99.97 0.0 Description: RV5 VACC 3 DOSE LIVE ORAL Category: Drugs CMS Add: 01/01/1999 CMS Term: 90681 DRUG I01 MAXFEE 01/01/2020 0.00 0.0 0-2years Description: RV1 VACC 2 DOSE LIVE ORAL Category: Drugs CMS Add: 01/01/2009 CMS Term: 90682 DRUG DEF MAXFEE 10/01/2022 09/30/2023 63.76 0.0 19-999years Description: RIV4 VACC RECOMBINANT DNA IM Category: Drugs CMS Add: 01/01/2017 CMS Term: 90682 DRUG DEF MAXFEE 10/01/2023 66.95 0.0 19-999years Description: RIV4 VACC RECOMBINANT DNA IM Category: Drugs CMS Add: 01/01/2017 CMS Term: 90683 NOCOV DEF SYSMAN Description: RSV VACC MRNA LIPID NANO IM Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 90685* DRUG DEF MAXFEE 10/01/2021 19.27 0.0 Description: IIV4 VACC NO PRSV 0.25 ML IM Category: Drugs CMS Add: 01/01/2013 CMS Term: 90685* DRUG I01 MAXFEE 01/01/2020 0.00 0.0 Description: IIV4 VACC NO PRSV 0.25 ML IM Category: Drugs CMS Add: 01/01/2013 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,225 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 90686* DRUG DEF MAXFEE 10/01/2022 09/30/2023 19.16 0.0 Description: IIV4 VACC NO PRSV 0.5 ML IM Category: Drugs CMS Add: 01/01/2013 CMS Term: 90686* DRUG DEF MAXFEE 10/01/2023 19.93 0.0 Description: IIV4 VACC NO PRSV 0.5 ML IM Category: Drugs CMS Add: 01/01/2013 CMS Term: 90686* DRUG I01 MAXFEE 01/01/2020 0.00 0.0 Description: IIV4 VACC NO PRSV 0.5 ML IM Category: Drugs CMS Add: 01/01/2013 CMS Term: 90687* DRUG DEF MAXFEE 10/01/2022 09/30/2023 9.10 0.0 Description: IIV4 VACCINE SPLT 0.25 ML IM Category: Drugs CMS Add: 01/01/2013 CMS Term: 90687* DRUG DEF MAXFEE 10/01/2023 9.29 0.0 Description: IIV4 VACCINE SPLT 0.25 ML IM Category: Drugs CMS Add: 01/01/2013 CMS Term: 90687* DRUG I01 MAXFEE 01/01/2020 0.00 0.0 Description: IIV4 VACCINE SPLT 0.25 ML IM Category: Drugs CMS Add: 01/01/2013 CMS Term: 90688* DRUG DEF MAXFEE 10/01/2022 09/30/2023 18.21 0.0 Description: IIV4 VACCINE SPLT 0.5 ML IM Category: Drugs CMS Add: 01/01/2013 CMS Term: 90688* DRUG DEF MAXFEE 10/01/2023 18.57 0.0 Description: IIV4 VACCINE SPLT 0.5 ML IM Category: Drugs CMS Add: 01/01/2013 CMS Term: 90688* DRUG I01 MAXFEE 01/01/2020 0.00 0.0 Description: IIV4 VACCINE SPLT 0.5 ML IM Category: Drugs CMS Add: 01/01/2013 CMS Term: 90689 NOCOV DEF SYSMAN Description: VACC IIV4 NO PRSRV 0.25ML IM Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 90690 DRUG L60 MAXFEE 04/01/2023 09/30/2023 26.05 0.0 Description: TYPHOID VACCINE ORAL Category: Drugs CMS Add: 01/01/1999 CMS Term: 90690 DRUG L60 MAXFEE 10/01/2023 28.00 0.0 Description: TYPHOID VACCINE ORAL Category: Drugs CMS Add: 01/01/1999 CMS Term: 90691 DRUG DEF MAXFEE 04/01/2023 03/31/2024 88.53 0.0 Description: TYPHOID VACCINE IM Category: Drugs CMS Add: 01/01/1999 CMS Term: 90691 DRUG DEF MAXFEE 04/01/2024 96.49 0.0 Description: TYPHOID VACCINE IM Category: Drugs CMS Add: 01/01/1999 CMS Term: 90694 DRUG DEF MAXFEE 10/01/2022 09/30/2023 65.37 0.0 Description: VACC AIIV4 NO PRSRV 0.5ML IM Category: Drugs CMS Add: 01/01/2020 CMS Term: 90694 DRUG DEF MAXFEE 10/01/2023 70.60 0.0 Description: VACC AIIV4 NO PRSRV 0.5ML IM Category: Drugs CMS Add: 01/01/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,226 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 90696 DRUG I01 MAXFEE 01/01/2020 0.00 0.0 4-6years Description: DTAP-IPV VACCINE 4-6 YRS IM Category: Drugs CMS Add: 01/01/2009 CMS Term: 90697 DRUG I01 MAXFEE 10/27/2021 0.00 0.0 0-4years Description: DTAP-IPV-HIB-HEPB VACCINE IM Category: Drugs CMS Add: 01/01/2015 CMS Term: 90698* DRUG DEF MAXFEE 04/01/2022 107.55 0.0 Description: DTAP-IPV/HIB VACCINE IM Category: Drugs CMS Add: 01/01/2004 CMS Term: 90698* DRUG I01 MAXFEE 01/01/2020 0.00 0.0 Description: DTAP-IPV/HIB VACCINE IM Category: Drugs CMS Add: 01/01/2004 CMS Term: 90700 DRUG I01 MAXFEE 01/01/2020 0.00 0.0 0-6years Description: DTAP VACCINE < 7 YRS IM Category: Drugs CMS Add: 01/01/1994 CMS Term: 90702 DRUG I01 MAXFEE 01/01/2020 0.00 0.0 0-6years Description: DT VACCINE UNDER 7 YRS IM Category: Drugs CMS Add: 01/01/1984 CMS Term: 90707* DRUG DEF MAXFEE 04/01/2024 94.75 0.0 Description: MMR VACCINE SC Category: Drugs CMS Add: 01/01/1984 CMS Term: 90707* DRUG DEF MAXFEE 10/01/2022 03/31/2024 92.00 0.0 Description: MMR VACCINE SC Category: Drugs CMS Add: 01/01/1984 CMS Term: 90707* DRUG I01 MAXFEE 01/01/2020 0.00 0.0 Description: MMR VACCINE SC Category: Drugs CMS Add: 01/01/1984 CMS Term: 90710* DRUG DEF MAXFEE 10/01/2022 09/30/2023 272.34 0.0 Description: MMRV VACCINE SC Category: Drugs CMS Add: 01/01/1994 CMS Term: 90710* DRUG DEF MAXFEE 10/01/2023 280.51 0.0 Description: MMRV VACCINE SC Category: Drugs CMS Add: 01/01/1994 CMS Term: 90710* DRUG I01 MAXFEE 01/01/2020 0.00 0.0 Description: MMRV VACCINE SC Category: Drugs CMS Add: 01/01/1994 CMS Term: 90713* DRUG DEF MAXFEE 04/01/2023 03/31/2024 41.90 0.0 Description: POLIOVIRUS IPV SC/IM Category: Drugs CMS Add: 01/01/1984 CMS Term: 90713* DRUG DEF MAXFEE 04/01/2024 43.98 0.0 Description: POLIOVIRUS IPV SC/IM Category: Drugs CMS Add: 01/01/1984 CMS Term: 90713* DRUG I01 MAXFEE 01/01/2020 0.00 0.0 Description: POLIOVIRUS IPV SC/IM Category: Drugs CMS Add: 01/01/1984 CMS Term: 90714* DRUG DEF MAXFEE 07/01/2018 18.89 0.0 7-999years Description: TD VACC NO PRESV 7 YRS+ IM Category: Drugs CMS Add: 07/01/2005 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,227 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 90714* DRUG I01 MAXFEE 01/01/2020 0.00 0.0 7-999years Description: TD VACC NO PRESV 7 YRS+ IM Category: Drugs CMS Add: 07/01/2005 CMS Term: 90715* DRUG DEF MAXFEE 04/01/2022 44.68 0.0 7-999years Description: TDAP VACCINE 7 YRS/> IM Category: Drugs CMS Add: 01/01/2004 CMS Term: 90715* DRUG I01 MAXFEE 01/01/2020 0.00 0.0 7-999years Description: TDAP VACCINE 7 YRS/> IM Category: Drugs CMS Add: 01/01/2004 CMS Term: 90716* DRUG DEF MAXFEE 10/01/2022 09/30/2023 167.20 0.0 Description: VAR VACCINE LIVE SUBQ Category: Drugs CMS Add: 01/01/1994 CMS Term: 90716* DRUG DEF MAXFEE 10/01/2023 182.25 0.0 Description: VAR VACCINE LIVE SUBQ Category: Drugs CMS Add: 01/01/1994 CMS Term: 90716* DRUG I01 MAXFEE 01/01/2020 0.00 0.0 Description: VAR VACCINE LIVE SUBQ Category: Drugs CMS Add: 01/01/1994 CMS Term: 90717 DRUG DEF MAXFEE 01/01/2024 03/31/2024 188.51 0.0 Description: YELLOW FEVER VACCINE SUBQ Category: Drugs CMS Add: 01/01/1984 CMS Term: 90717 DRUG DEF MAXFEE 04/01/2023 12/31/2023 188.61 0.0 Description: YELLOW FEVER VACCINE SUBQ Category: Drugs CMS Add: 01/01/1984 CMS Term: 90717 DRUG DEF MAXFEE 04/01/2024 205.47 0.0 Description: YELLOW FEVER VACCINE SUBQ Category: Drugs CMS Add: 01/01/1984 CMS Term: 90723* DRUG DEF MAXFEE 04/01/2023 03/31/2024 93.33 0.0 Description: DTAP-HEP B-IPV VACCINE IM Category: Drugs CMS Add: 01/01/2001 CMS Term: 90723* DRUG DEF MAXFEE 04/01/2024 98.93 0.0 Description: DTAP-HEP B-IPV VACCINE IM Category: Drugs CMS Add: 01/01/2001 CMS Term: 90723* DRUG I01 MAXFEE 01/01/2020 0.00 0.0 Description: DTAP-HEP B-IPV VACCINE IM Category: Drugs CMS Add: 01/01/2001 CMS Term: 90732* DRUG DEF MAXFEE 01/01/2022 122.94 0.0 2-999years Description: PPSV23 VACC 2 YRS+ SUBQ/IM Category: Drugs CMS Add: 01/01/1984 CMS Term: 90732* DRUG I01 MAXFEE 01/01/2020 0.00 0.0 2-999years Description: PPSV23 VACC 2 YRS+ SUBQ/IM Category: Drugs CMS Add: 01/01/1984 CMS Term: 90733* DRUG DEF SYSMAN Description: MPSV4 VACCINE SUBQ Category: Drugs CMS Add: 01/01/1984 CMS Term: 90733* DRUG I01 MAXFEE 01/01/2020 0.00 0.0 Description: MPSV4 VACCINE SUBQ Category: Drugs CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,228 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 90734* DRUG I01 MAXFEE 01/01/2020 0.00 0.0 Description: MENACWYD/MENACWYCRM VACC IM Category: Drugs CMS Add: 01/01/2004 CMS Term: 90734* DRUG L60 MAXFEE 01/14/2005 102.50 0.0 Description: MENACWYD/MENACWYCRM VACC IM Category: Drugs CMS Add: 01/01/2004 CMS Term: 90736 DRUG DEF MAXFEE 05/01/2006 161.63 0.0 60-999years Description: HZV VACCINE LIVE SUBQ Category: Drugs CMS Add: 01/01/2006 CMS Term: 90738 NOCOV DEF SYSMAN Description: INACTIVATED JE VACC IM Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 90739* DRUG DEF MAXFEE 04/01/2023 03/31/2024 147.63 0.0 Description: HEPB VACC 2/4 DOSE ADULT IM Category: Drugs CMS Add: 01/01/2013 CMS Term: 90739* DRUG DEF MAXFEE 04/01/2024 155.01 0.0 Description: HEPB VACC 2/4 DOSE ADULT IM Category: Drugs CMS Add: 01/01/2013 CMS Term: 90739* DRUG I01 MAXFEE 01/01/2020 0.00 0.0 Description: HEPB VACC 2/4 DOSE ADULT IM Category: Drugs CMS Add: 01/01/2013 CMS Term: 90740 DRUG L60 MAXFEE 04/01/2023 09/30/2023 184.13 0.0 Description: HEPB VACC 3 DOSE IMMUNSUP IM Category: Drugs CMS Add: 01/01/2001 CMS Term: 90740 DRUG L60 MAXFEE 10/01/2023 189.65 0.0 Description: HEPB VACC 3 DOSE IMMUNSUP IM Category: Drugs CMS Add: 01/01/2001 CMS Term: 90743 DRUG L60 MAXFEE 10/01/2022 09/30/2023 33.68 0.0 Description: HEPB VACC 2 DOSE ADOLESC IM Category: Drugs CMS Add: 01/01/2001 CMS Term: 90743 DRUG L60 MAXFEE 10/01/2023 34.28 0.0 Description: HEPB VACC 2 DOSE ADOLESC IM Category: Drugs CMS Add: 01/01/2001 CMS Term: 90744* DRUG I01 MAXFEE 01/01/2020 0.00 0.0 Description: HEPB VACC 3 DOSE PED/ADOL IM Category: Drugs CMS Add: 01/01/1996 CMS Term: 90744* DRUG L60 MAXFEE 10/01/2022 09/30/2023 26.88 0.0 Description: HEPB VACC 3 DOSE PED/ADOL IM Category: Drugs CMS Add: 01/01/1996 CMS Term: 90744* DRUG L60 MAXFEE 10/01/2023 27.68 0.0 Description: HEPB VACC 3 DOSE PED/ADOL IM Category: Drugs CMS Add: 01/01/1996 CMS Term: 90746* DRUG I01 MAXFEE 01/01/2020 0.00 0.0 Description: HEPB VACCINE 3 DOSE ADULT IM Category: Drugs CMS Add: 01/01/1996 CMS Term: 90746* DRUG L60 MAXFEE 10/01/2022 09/30/2023 67.36 0.0 Description: HEPB VACCINE 3 DOSE ADULT IM Category: Drugs CMS Add: 01/01/1996 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,229 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 90746* DRUG L60 MAXFEE 10/01/2023 69.38 0.0 Description: HEPB VACCINE 3 DOSE ADULT IM Category: Drugs CMS Add: 01/01/1996 CMS Term: 90747 DRUG DEF MAXFEE 04/01/2023 03/31/2024 138.80 0.0 Description: HEPB VACC 4 DOSE IMMUNSUP IM Category: Drugs CMS Add: 01/01/1996 CMS Term: 90747 DRUG DEF MAXFEE 04/01/2024 144.35 0.0 Description: HEPB VACC 4 DOSE IMMUNSUP IM Category: Drugs CMS Add: 01/01/1996 CMS Term: 90748 DRUG DEF SYSMAN Description: HIB-HEPB VACCINE IM Category: Drugs CMS Add: 01/01/1998 CMS Term: 90749 DRUG DEF BILL40 Description: UNLISTED VACCINE/TOXOID Category: Drugs CMS Add: 01/01/1984 CMS Term: 90750 MEDSV DEF MAXFEE 01/01/2024 03/31/2024 233.47 0.0 50-999years Description: HZV VACC RECOMBINANT IM Category: Medical Services CMS Add: 01/01/2017 CMS Term: 90750 MEDSV DEF MAXFEE 04/01/2023 12/31/2023 192.58 0.0 50-999years Description: HZV VACC RECOMBINANT IM Category: Medical Services CMS Add: 01/01/2017 CMS Term: 90750 MEDSV DEF MAXFEE 04/01/2024 207.79 0.0 50-999years Description: HZV VACC RECOMBINANT IM Category: Medical Services CMS Add: 01/01/2017 CMS Term: 90756* MEDSV DEF MAXFEE 10/01/2022 09/30/2023 27.51 0.0 Description: CCIIV4 VACC ABX FREE IM Category: Medical Services CMS Add: 01/01/2018 CMS Term: 90756* MEDSV DEF MAXFEE 10/01/2023 29.16 0.0 Description: CCIIV4 VACC ABX FREE IM Category: Medical Services CMS Add: 01/01/2018 CMS Term: 90756* MEDSV I01 MAXFEE 01/01/2020 0.00 0.0 Description: CCIIV4 VACC ABX FREE IM Category: Medical Services CMS Add: 01/01/2018 CMS Term: 90758 NOCOV DEF SYSMAN Description: ZAIRE EBOLAVIRUS VAC LIVE IM Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 90785 MEDSV DEF RBRVS 01/01/2024 14.43 0-1 Description: PSYTX COMPLEX INTERACTIVE Category: Medical Services CMS Add: 01/01/2013 CMS Term: 90785 MEDSV DEF RBRVS 02/01/2015 12/31/2023 11.22 0-1 Description: PSYTX COMPLEX INTERACTIVE Category: Medical Services CMS Add: 01/01/2013 CMS Term: 90791 MENTL DEF RBRVS 01/01/2019 12/31/2023 104.56 0-1 Description: PSYCH DIAGNOSTIC EVALUATION Category: Mental Health CMS Add: 01/01/2013 CMS Term: 90791 MENTL DEF RBRVS 01/01/2024 169.40 0-1 Description: PSYCH DIAGNOSTIC EVALUATION Category: Mental Health CMS Add: 01/01/2013 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,230 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 90791 SE MRT DEF MAXFEE 06/01/2014 119.49 0.0 Description: PSYCH DIAGNOSTIC EVALUATION Category: Medical Review Team CMS Add: 01/01/2013 CMS Term: 90792 MENTL DEF RBRVS 01/01/2024 188.94 0-1 Description: PSYCH DIAG EVAL W/MED SRVCS Category: Mental Health CMS Add: 01/01/2013 CMS Term: 90792 MENTL DEF RBRVS 02/01/2015 12/31/2023 112.78 0-1 Description: PSYCH DIAG EVAL W/MED SRVCS Category: Mental Health CMS Add: 01/01/2013 CMS Term: 90832 MENTL DEF RBRVS 01/01/2024 73.38 0-1 Description: PSYTX W PT 30 MINUTES Category: Mental Health CMS Add: 01/01/2013 CMS Term: 90832 MENTL DEF RBRVS 02/01/2015 12/31/2023 50.65 0-1 Description: PSYTX W PT 30 MINUTES Category: Mental Health CMS Add: 01/01/2013 CMS Term: 90833 MENTL DEF RBRVS 01/01/2024 66.92 0-1 Description: PSYTX W PT W E/M 30 MIN Category: Mental Health CMS Add: 01/01/2013 CMS Term: 90833 MENTL DEF RBRVS 02/01/2015 12/31/2023 51.71 0-1 Description: PSYTX W PT W E/M 30 MIN Category: Mental Health CMS Add: 01/01/2013 CMS Term: 90834 MENTL DEF RBRVS 01/01/2024 96.94 0-1 Description: PSYTX W PT 45 MINUTES Category: Mental Health CMS Add: 01/01/2013 CMS Term: 90834 MENTL DEF RBRVS 02/01/2015 12/31/2023 67.18 0-1 Description: PSYTX W PT 45 MINUTES Category: Mental Health CMS Add: 01/01/2013 CMS Term: 90836 MENTL DEF RBRVS 01/01/2024 84.81 0-1 Description: PSYTX W PT W E/M 45 MIN Category: Mental Health CMS Add: 01/01/2013 CMS Term: 90836 MENTL DEF RBRVS 02/01/2015 12/31/2023 65.46 0-1 Description: PSYTX W PT W E/M 45 MIN Category: Mental Health CMS Add: 01/01/2013 CMS Term: 90837 MENTL DEF RBRVS 01/01/2024 142.78 0-1 Description: PSYTX W PT 60 MINUTES Category: Mental Health CMS Add: 01/01/2013 CMS Term: 90837 MENTL DEF RBRVS 02/01/2015 12/31/2023 100.60 0-1 Description: PSYTX W PT 60 MINUTES Category: Mental Health CMS Add: 01/01/2013 CMS Term: 90838 MENTL DEF RBRVS 01/01/2024 112.11 0-1 Description: PSYTX W PT W E/M 60 MIN Category: Mental Health CMS Add: 01/01/2013 CMS Term: 90838 MENTL DEF RBRVS 02/01/2015 12/31/2023 86.36 0-1 Description: PSYTX W PT W E/M 60 MIN Category: Mental Health CMS Add: 01/01/2013 CMS Term: 90839 MENTL DEF RBRVS 01/01/2024 136.70 0-1 Description: PSYTX CRISIS INITIAL 60 MIN Category: Mental Health CMS Add: 01/01/2013 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,231 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 90839 MENTL DEF RBRVS 09/01/2019 12/31/2023 105.11 0-1 Description: PSYTX CRISIS INITIAL 60 MIN Category: Mental Health CMS Add: 01/01/2013 CMS Term: 90840 MENTL DEF RBRVS 01/01/2024 67.25 Description: PSYTX CRISIS EA ADDL 30 MIN Category: Mental Health CMS Add: 01/01/2013 CMS Term: 90840 MENTL DEF RBRVS 09/01/2019 12/31/2023 50.39 Description: PSYTX CRISIS EA ADDL 30 MIN Category: Mental Health CMS Add: 01/01/2013 CMS Term: 90845 MENTL DEF RBRVS 01/01/2024 91.58 Description: PSYCHOANALYSIS Category: Mental Health CMS Add: 01/01/1990 CMS Term: 90845 MENTL DEF RBRVS 02/01/2015 12/31/2023 72.43 Description: PSYCHOANALYSIS Category: Mental Health CMS Add: 01/01/1990 CMS Term: 90846 MENTL DEF RBRVS 01/01/2024 93.26 0-1 Description: FAMILY PSYTX W/O PT 50 MIN Category: Mental Health CMS Add: 01/01/1990 CMS Term: 90846 MENTL DEF RBRVS 02/01/2015 12/31/2023 81.46 0-1 Description: FAMILY PSYTX W/O PT 50 MIN Category: Mental Health CMS Add: 01/01/1990 CMS Term: 90846 U5 U7 DDWA WDD MAXFEE 01/01/2008 17.27 0.0 Y Description: FAMILY PSYTX W/O PT 50 MIN Category: CIH Waiver CMS Add: 01/01/1990 CMS Term: 90846 U5 U7 MFPCI W3M MAXFEE 01/01/2014 17.27 0.0 Y Description: FAMILY PSYTX W/O PT 50 MIN Category: MFP CIH Waiver CMS Add: 01/01/1990 CMS Term: 90846 U5 U7 MFPTS W5M MAXFEE 01/01/2008 17.27 0.0 Y Description: FAMILY PSYTX W/O PT 50 MIN Category: MFP SOF Waiver CMS Add: 01/01/1990 CMS Term: 90846 U5 U7 SSFS WSS MAXFEE 01/01/2008 17.27 0.0 Y Description: FAMILY PSYTX W/O PT 50 MIN Category: Family Support Waivr CMS Add: 01/01/1990 CMS Term: 90847 MENTL DEF RBRVS 01/01/2024 97.27 Description: FAMILY PSYTX W/PT 50 MIN Category: Mental Health CMS Add: 01/01/1984 CMS Term: 90847 MENTL DEF RBRVS 02/01/2015 12/31/2023 84.07 Description: FAMILY PSYTX W/PT 50 MIN Category: Mental Health CMS Add: 01/01/1984 CMS Term: 90849 MENTL DEF RBRVS 01/01/2024 35.44 Description: MULTIPLE FAMILY GROUP PSYTX Category: Mental Health CMS Add: 01/01/1983 CMS Term: 90849 MENTL DEF RBRVS 02/01/2015 12/31/2023 26.42 Description: MULTIPLE FAMILY GROUP PSYTX Category: Mental Health CMS Add: 01/01/1983 CMS Term: 90853 MENTL DEF RBRVS 01/01/2024 25.87 0-1 Description: GROUP PSYCHOTHERAPY Category: Mental Health CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,232 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 90853 MENTL DEF RBRVS 02/01/2015 12/31/2023 20.61 0-1 Description: GROUP PSYCHOTHERAPY Category: Mental Health CMS Add: 01/01/1984 CMS Term: 90853 U5 U7 DDWA WDD MAXFEE 01/01/2008 4.81 0.0 Y Description: GROUP PSYCHOTHERAPY Category: CIH Waiver CMS Add: 01/01/1984 CMS Term: 90853 U5 U7 MFPCI W3M MAXFEE 01/01/2014 4.81 0.0 Y Description: GROUP PSYCHOTHERAPY Category: MFP CIH Waiver CMS Add: 01/01/1984 CMS Term: 90853 U5 U7 MFPTS W5M MAXFEE 01/01/2008 4.81 0.0 Y Description: GROUP PSYCHOTHERAPY Category: MFP SOF Waiver CMS Add: 01/01/1984 CMS Term: 90853 U5 U7 SSFS WSS MAXFEE 01/01/2008 4.81 0.0 Y Description: GROUP PSYCHOTHERAPY Category: Family Support Waivr CMS Add: 01/01/1984 CMS Term: 90863 NOCOV DEF SYSMAN Description: PHARMACOLOGIC MGMT W/PSYTX Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 90865 NOCOV DEF SYSMAN Description: NARCOSYNTHESIS Category: Non Covered Services CMS Add: 01/01/1998 CMS Term: 90867 MEDSV PRF MAXFEE 01/01/2024 180.63 0.0 Y 18-999years Description: TCRANIAL MAGN STIM TX PLAN Category: Medical Services CMS Add: 01/01/2011 CMS Term: 90868 MEDSV PRF MAXFEE 01/01/2024 142.09 0.0 Y 18-999years Description: TCRANIAL MAGN STIM TX DELI Category: Medical Services CMS Add: 01/01/2011 CMS Term: 90869 MEDSV PRF MAXFEE 01/01/2024 144.52 0.0 Y 18-999years Description: TCRAN MAGN STIM REDETEMINE Category: Medical Services CMS Add: 01/01/2012 CMS Term: 90870 MENTL DEF RBRVS 01/01/2024 163.81 Description: ELECTROCONVULSIVE THERAPY Category: Mental Health CMS Add: 01/01/1984 CMS Term: 90870 MENTL DEF RBRVS 02/01/2015 12/31/2023 136.21 Description: ELECTROCONVULSIVE THERAPY Category: Mental Health CMS Add: 01/01/1984 CMS Term: 90875 NOCOV DEF SYSMAN Description: PSYCHOPHYSIOLOGICAL THERAPY Category: Non Covered Services CMS Add: 01/01/1997 CMS Term: 90876 NOCOV DEF SYSMAN Description: PSYCHOPHYSIOLOGICAL THERAPY Category: Non Covered Services CMS Add: 01/01/1997 CMS Term: 90880 NOCOV DEF SYSMAN Description: HYPNOTHERAPY Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: 90882 NOCOV DEF SYSMAN Description: ENVIRONMENTAL MANIPULATION Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,233 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 90885 NOCOV DEF SYSMAN Description: PSY EVALUATION OF RECORDS Category: Non Covered Services CMS Add: 01/01/1998 CMS Term: 90887 NOCOV DEF SYSMAN Description: CONSULTATION WITH FAMILY Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: 90889 NOCOV DEF SYSMAN Description: PREPARATION OF REPORT Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: 90899 MENTL PRF MAXFEE 01/01/2024 179.82 0.0 Description: UNLISTED PSYC SVC/THERAPY Category: Mental Health CMS Add: 01/01/1984 CMS Term: 90901 NOCOV DEF SYSMAN Description: BIOFEEDBACK TRAIN ANY METH Category: Non Covered Services CMS Add: 01/01/1997 CMS Term: 90912 NOCOV DEF SYSMAN Description: BFB TRAINING 1ST 15 MIN Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 90913 NOCOV DEF SYSMAN Description: BFB TRAINING EA ADDL 15 MIN Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 90935 MEDSV DEF RBRVS 01/01/2024 68.12 Description: HEMODIALYSIS ONE EVALUATION Category: Medical Services CMS Add: 01/01/1989 CMS Term: 90935 MEDSV DEF RBRVS 02/01/2015 12/31/2023 53.22 Description: HEMODIALYSIS ONE EVALUATION Category: Medical Services CMS Add: 01/01/1989 CMS Term: 90937 MEDSV DEF RBRVS 01/01/2024 97.20 Description: HEMODIALYSIS REPEATED EVAL Category: Medical Services CMS Add: 01/01/1989 CMS Term: 90937 MEDSV DEF RBRVS 02/01/2015 12/31/2023 76.34 Description: HEMODIALYSIS REPEATED EVAL Category: Medical Services CMS Add: 01/01/1989 CMS Term: 90940 MEDSV DEF BILL40 Description: HEMODIALYSIS ACCESS STUDY Category: Medical Services CMS Add: 01/01/2001 CMS Term: 90945 MEDSV DEF RBRVS 01/01/2024 81.02 Description: DIALYSIS ONE EVALUATION Category: Medical Services CMS Add: 01/01/1989 CMS Term: 90945 MEDSV DEF RBRVS 02/01/2015 12/31/2023 62.56 Description: DIALYSIS ONE EVALUATION Category: Medical Services CMS Add: 01/01/1989 CMS Term: 90947 MEDSV DEF RBRVS 01/01/2024 116.39 Description: DIALYSIS REPEATED EVAL Category: Medical Services CMS Add: 01/01/1989 CMS Term: 90947 MEDSV DEF RBRVS 02/01/2015 12/31/2023 91.07 Description: DIALYSIS REPEATED EVAL Category: Medical Services CMS Add: 01/01/1989 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,234 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 90951 MEDSV DEF RBRVS 01/01/2024 1117.26 0-1years Description: ESRD SERV 4 VISITS P MO <2YR Category: Medical Services CMS Add: 01/01/2009 CMS Term: 90951 MEDSV DEF RBRVS 02/01/2015 12/31/2023 682.59 0-1years Description: ESRD SERV 4 VISITS P MO <2YR Category: Medical Services CMS Add: 01/01/2009 CMS Term: 90952 MEDSV DEF MAXFEE 01/01/2024 760.33 0.0 0-1years Description: ESRD SERV 2-3 VSTS P MO <2YR Category: Medical Services CMS Add: 01/01/2009 CMS Term: 90953 MEDSV DEF MAXFEE 01/01/2024 503.53 0.0 0-1years Description: ESRD SERV 1 VISIT P MO <2YRS Category: Medical Services CMS Add: 01/01/2009 CMS Term: 90954 MEDSV DEF RBRVS 01/01/2024 959.98 2-11years Description: ESRD SERV 4 VSTS P MO 2-11 Category: Medical Services CMS Add: 01/01/2009 CMS Term: 90954 MEDSV DEF RBRVS 02/01/2015 12/31/2023 592.18 2-11years Description: ESRD SERV 4 VSTS P MO 2-11 Category: Medical Services CMS Add: 01/01/2009 CMS Term: 90955 MEDSV DEF RBRVS 01/01/2024 495.97 2-11years Description: ESRD SRV 2-3 VSTS P MO 2-11 Category: Medical Services CMS Add: 01/01/2009 CMS Term: 90955 MEDSV DEF RBRVS 02/01/2015 12/31/2023 333.60 2-11years Description: ESRD SRV 2-3 VSTS P MO 2-11 Category: Medical Services CMS Add: 01/01/2009 CMS Term: 90956 MEDSV DEF RBRVS 01/01/2024 330.22 2-11years Description: ESRD SRV 1 VISIT P MO 2-11 Category: Medical Services CMS Add: 01/01/2009 CMS Term: 90956 MEDSV DEF RBRVS 02/01/2015 12/31/2023 231.95 2-11years Description: ESRD SRV 1 VISIT P MO 2-11 Category: Medical Services CMS Add: 01/01/2009 CMS Term: 90957 MEDSV DEF RBRVS 01/01/2024 732.91 12-19years Description: ESRD SRV 4 VSTS P MO 12-19 Category: Medical Services CMS Add: 01/01/2009 CMS Term: 90957 MEDSV DEF RBRVS 02/01/2015 12/31/2023 470.64 12-19years Description: ESRD SRV 4 VSTS P MO 12-19 Category: Medical Services CMS Add: 01/01/2009 CMS Term: 90958 MEDSV DEF RBRVS 01/01/2024 476.25 12-19years Description: ESRD SRV 2-3 VSTS P MO 12-19 Category: Medical Services CMS Add: 01/01/2009 CMS Term: 90958 MEDSV DEF RBRVS 02/01/2015 12/31/2023 318.12 12-19years Description: ESRD SRV 2-3 VSTS P MO 12-19 Category: Medical Services CMS Add: 01/01/2009 CMS Term: 90959 MEDSV DEF RBRVS 01/01/2024 308.80 12-19years Description: ESRD SERV 1 VST P MO 12-19 Category: Medical Services CMS Add: 01/01/2009 CMS Term: 90959 MEDSV DEF RBRVS 02/01/2015 12/31/2023 215.15 12-19years Description: ESRD SERV 1 VST P MO 12-19 Category: Medical Services CMS Add: 01/01/2009 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,235 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 90960 MEDSV DEF RBRVS 01/01/2024 335.88 20-999years Description: ESRD SRV 4 VISITS P MO 20+ Category: Medical Services CMS Add: 01/01/2009 CMS Term: 90960 MEDSV DEF RBRVS 02/01/2015 12/31/2023 206.80 20-999years Description: ESRD SRV 4 VISITS P MO 20+ Category: Medical Services CMS Add: 01/01/2009 CMS Term: 90961 MEDSV DEF RBRVS 01/01/2024 278.97 20-999years Description: ESRD SRV 2-3 VSTS P MO 20+ Category: Medical Services CMS Add: 01/01/2009 CMS Term: 90961 MEDSV DEF RBRVS 02/01/2015 12/31/2023 173.83 20-999years Description: ESRD SRV 2-3 VSTS P MO 20+ Category: Medical Services CMS Add: 01/01/2009 CMS Term: 90962 MEDSV DEF RBRVS 01/01/2024 191.51 20-999years Description: ESRD SERV 1 VISIT P MO 20+ Category: Medical Services CMS Add: 01/01/2009 CMS Term: 90962 MEDSV DEF RBRVS 02/01/2015 12/31/2023 133.85 20-999years Description: ESRD SERV 1 VISIT P MO 20+ Category: Medical Services CMS Add: 01/01/2009 CMS Term: 90963 MEDSV DEF RBRVS 01/01/2024 577.98 0-1years Description: ESRD HOME PT SERV P MO <2YRS Category: Medical Services CMS Add: 01/01/2009 CMS Term: 90963 MEDSV DEF RBRVS 02/01/2015 12/31/2023 398.91 0-1years Description: ESRD HOME PT SERV P MO <2YRS Category: Medical Services CMS Add: 01/01/2009 CMS Term: 90964 MEDSV DEF RBRVS 01/01/2024 495.49 2-11years Description: ESRD HOME PT SERV P MO 2-11 Category: Medical Services CMS Add: 01/01/2009 CMS Term: 90964 MEDSV DEF RBRVS 02/01/2015 12/31/2023 347.46 2-11years Description: ESRD HOME PT SERV P MO 2-11 Category: Medical Services CMS Add: 01/01/2009 CMS Term: 90965 MEDSV DEF RBRVS 01/01/2024 474.96 12-19years Description: ESRD HOME PT SERV P MO 12-19 Category: Medical Services CMS Add: 01/01/2009 CMS Term: 90965 MEDSV DEF RBRVS 02/01/2015 12/31/2023 329.68 12-19years Description: ESRD HOME PT SERV P MO 12-19 Category: Medical Services CMS Add: 01/01/2009 CMS Term: 90966 MEDSV DEF RBRVS 01/01/2024 278.66 20-999years Description: ESRD HOME PT SERV P MO 20+ Category: Medical Services CMS Add: 01/01/2009 CMS Term: 90966 MEDSV DEF RBRVS 02/01/2015 12/31/2023 173.58 20-999years Description: ESRD HOME PT SERV P MO 20+ Category: Medical Services CMS Add: 01/01/2009 CMS Term: 90967 MEDSV DEF RBRVS 01/01/2024 16.81 0-1years Description: ESRD SVC PR DAY PT <2 Category: Medical Services CMS Add: 01/01/2009 CMS Term: 90967 MEDSV DEF RBRVS 02/01/2015 12/31/2023 13.04 0-1years Description: ESRD SVC PR DAY PT <2 Category: Medical Services CMS Add: 01/01/2009 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,236 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 90968 MEDSV DEF RBRVS 01/01/2024 16.47 2-11years Description: ESRD SVC PR DAY PT 2-11 Category: Medical Services CMS Add: 01/01/2009 CMS Term: 90968 MEDSV DEF RBRVS 02/01/2015 12/31/2023 11.20 2-11years Description: ESRD SVC PR DAY PT 2-11 Category: Medical Services CMS Add: 01/01/2009 CMS Term: 90969 MEDSV DEF RBRVS 01/01/2024 16.14 12-19years Description: ESRD SVC PR DAY PT 12-19 Category: Medical Services CMS Add: 01/01/2009 CMS Term: 90969 MEDSV DEF RBRVS 02/01/2015 12/31/2023 10.93 12-19years Description: ESRD SVC PR DAY PT 12-19 Category: Medical Services CMS Add: 01/01/2009 CMS Term: 90970 MEDSV DEF RBRVS 01/01/2024 9.04 20-999years Description: ESRD SVC PR DAY PT 20+ Category: Medical Services CMS Add: 01/01/2009 CMS Term: 90970 MEDSV DEF RBRVS 02/01/2015 12/31/2023 5.66 20-999years Description: ESRD SVC PR DAY PT 20+ Category: Medical Services CMS Add: 01/01/2009 CMS Term: 90989 MEDSV DEF MAXFEE 01/01/1994 12/31/2023 278.57 0.0 Description: DIALYSIS TRAINING COMPLETE Category: Medical Services CMS Add: 01/01/1991 CMS Term: 90989 MEDSV DEF MAXFEE 01/01/2024 361.03 0.0 Description: DIALYSIS TRAINING COMPLETE Category: Medical Services CMS Add: 01/01/1991 CMS Term: 90993 MEDSV DEF MAXFEE 01/01/1994 12/31/2023 16.06 0.0 Description: DIALYSIS TRAINING INCOMPL Category: Medical Services CMS Add: 01/01/1991 CMS Term: 90993 MEDSV DEF MAXFEE 01/01/2024 20.81 0.0 Description: DIALYSIS TRAINING INCOMPL Category: Medical Services CMS Add: 01/01/1991 CMS Term: 90997 MEDSV DEF RBRVS 01/01/2024 83.88 Description: HEMOPERFUSION Category: Medical Services CMS Add: 01/01/1982 CMS Term: 90997 MEDSV DEF RBRVS 02/01/2015 12/31/2023 67.68 Description: HEMOPERFUSION Category: Medical Services CMS Add: 01/01/1982 CMS Term: 90999 MEDSV DEF MAXFEE 01/01/2024 90.45 0.0 Description: UNLISTED DIALYSIS PROCEDURE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 90999 MEDSV DEF RBRVS 02/01/2015 12/31/2023 69.79 Description: UNLISTED DIALYSIS PROCEDURE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 91010 26 MEDSV DEF RBRVS 01/01/2024 61.32 Description: ESOPHAGUS MOTILITY STUDY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 91010 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 49.91 Description: ESOPHAGUS MOTILITY STUDY Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,237 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 91010 MEDSV DEF RBRVS 01/01/2024 207.35 Description: ESOPHAGUS MOTILITY STUDY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 91010 MEDSV DEF RBRVS 02/01/2015 12/31/2023 125.14 Description: ESOPHAGUS MOTILITY STUDY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 91010 TC MEDSV DEF RBRVS 01/01/2024 146.03 Description: ESOPHAGUS MOTILITY STUDY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 91010 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 75.22 Description: ESOPHAGUS MOTILITY STUDY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 91013 26 MEDSV DEF RBRVS 01/01/2024 8.73 Description: ESOPHGL MOTIL W/STIM/PERFUS Category: Medical Services CMS Add: 01/01/2011 CMS Term: 91013 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 6.98 Description: ESOPHGL MOTIL W/STIM/PERFUS Category: Medical Services CMS Add: 01/01/2011 CMS Term: 91013 MEDSV DEF RBRVS 01/01/2024 24.17 Description: ESOPHGL MOTIL W/STIM/PERFUS Category: Medical Services CMS Add: 01/01/2011 CMS Term: 91013 MEDSV DEF RBRVS 02/01/2015 12/31/2023 16.81 Description: ESOPHGL MOTIL W/STIM/PERFUS Category: Medical Services CMS Add: 01/01/2011 CMS Term: 91013 TC MEDSV DEF RBRVS 01/01/2024 15.44 Description: ESOPHGL MOTIL W/STIM/PERFUS Category: Medical Services CMS Add: 01/01/2011 CMS Term: 91013 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 9.83 Description: ESOPHGL MOTIL W/STIM/PERFUS Category: Medical Services CMS Add: 01/01/2011 CMS Term: 91020 26 MEDSV DEF RBRVS 01/01/2024 69.20 Description: GASTRIC MOTILITY STUDIES Category: Medical Services CMS Add: 01/01/1986 CMS Term: 91020 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 56.19 Description: GASTRIC MOTILITY STUDIES Category: Medical Services CMS Add: 01/01/1986 CMS Term: 91020 MEDSV DEF RBRVS 01/01/2024 257.53 Description: GASTRIC MOTILITY STUDIES Category: Medical Services CMS Add: 01/01/1986 CMS Term: 91020 MEDSV DEF RBRVS 02/01/2015 12/31/2023 165.85 Description: GASTRIC MOTILITY STUDIES Category: Medical Services CMS Add: 01/01/1986 CMS Term: 91020 TC MEDSV DEF RBRVS 01/01/2024 188.33 Description: GASTRIC MOTILITY STUDIES Category: Medical Services CMS Add: 01/01/1986 CMS Term: 91020 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 109.66 Description: GASTRIC MOTILITY STUDIES Category: Medical Services CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,238 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 91022 26 MEDSV DEF RBRVS 01/01/2024 69.20 Description: DUODENAL MOTILITY STUDY Category: Medical Services CMS Add: 01/01/2006 CMS Term: 91022 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 55.86 Description: DUODENAL MOTILITY STUDY Category: Medical Services CMS Add: 01/01/2006 CMS Term: 91022 MEDSV DEF RBRVS 01/01/2024 161.83 Description: DUODENAL MOTILITY STUDY Category: Medical Services CMS Add: 01/01/2006 CMS Term: 91022 MEDSV DEF RBRVS 02/01/2015 12/31/2023 120.43 Description: DUODENAL MOTILITY STUDY Category: Medical Services CMS Add: 01/01/2006 CMS Term: 91022 TC MEDSV DEF RBRVS 01/01/2024 92.63 Description: DUODENAL MOTILITY STUDY Category: Medical Services CMS Add: 01/01/2006 CMS Term: 91022 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 64.57 Description: DUODENAL MOTILITY STUDY Category: Medical Services CMS Add: 01/01/2006 CMS Term: 91030 26 MEDSV DEF RBRVS 01/01/2024 43.83 Description: ACID PERFUSION OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 91030 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 35.51 Description: ACID PERFUSION OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 91030 MEDSV DEF RBRVS 01/01/2024 135.22 Description: ACID PERFUSION OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 91030 MEDSV DEF RBRVS 02/01/2015 12/31/2023 97.61 Description: ACID PERFUSION OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 91030 TC MEDSV DEF RBRVS 01/01/2024 91.39 Description: ACID PERFUSION OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 91030 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 62.09 Description: ACID PERFUSION OF ESOPHAGUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 91034 26 MEDSV DEF RBRVS 01/01/2024 47.11 Description: GASTROESOPHAGEAL REFLUX TEST Category: Medical Services CMS Add: 01/01/2005 CMS Term: 91034 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 37.62 Description: GASTROESOPHAGEAL REFLUX TEST Category: Medical Services CMS Add: 01/01/2005 CMS Term: 91034 MEDSV DEF RBRVS 01/01/2024 179.87 Description: GASTROESOPHAGEAL REFLUX TEST Category: Medical Services CMS Add: 01/01/2005 CMS Term: 91034 MEDSV DEF RBRVS 02/01/2015 12/31/2023 133.90 Description: GASTROESOPHAGEAL REFLUX TEST Category: Medical Services CMS Add: 01/01/2005 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,239 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 91034 TC MEDSV DEF RBRVS 01/01/2024 132.76 Description: GASTROESOPHAGEAL REFLUX TEST Category: Medical Services CMS Add: 01/01/2005 CMS Term: 91034 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 96.28 Description: GASTROESOPHAGEAL REFLUX TEST Category: Medical Services CMS Add: 01/01/2005 CMS Term: 91035 26 MEDSV DEF RBRVS 01/01/2024 76.80 Description: G-ESOPH REFLX TST W/ELECTROD Category: Medical Services CMS Add: 01/01/2005 CMS Term: 91035 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 61.46 Description: G-ESOPH REFLX TST W/ELECTROD Category: Medical Services CMS Add: 01/01/2005 CMS Term: 91035 MEDSV DEF RBRVS 01/01/2024 430.75 Description: G-ESOPH REFLX TST W/ELECTROD Category: Medical Services CMS Add: 01/01/2005 CMS Term: 91035 MEDSV DEF RBRVS 02/01/2015 12/31/2023 339.07 Description: G-ESOPH REFLX TST W/ELECTROD Category: Medical Services CMS Add: 01/01/2005 CMS Term: 91035 TC MEDSV DEF RBRVS 01/01/2024 353.95 Description: G-ESOPH REFLX TST W/ELECTROD Category: Medical Services CMS Add: 01/01/2005 CMS Term: 91035 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 277.61 Description: G-ESOPH REFLX TST W/ELECTROD Category: Medical Services CMS Add: 01/01/2005 CMS Term: 91037 26 MEDSV DEF RBRVS 01/01/2024 46.48 Description: ESOPH IMPED FUNCTION TEST Category: Medical Services CMS Add: 01/01/2005 CMS Term: 91037 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 38.12 Description: ESOPH IMPED FUNCTION TEST Category: Medical Services CMS Add: 01/01/2005 CMS Term: 91037 MEDSV DEF RBRVS 01/01/2024 157.94 Description: ESOPH IMPED FUNCTION TEST Category: Medical Services CMS Add: 01/01/2005 CMS Term: 91037 MEDSV DEF RBRVS 02/01/2015 12/31/2023 114.33 Description: ESOPH IMPED FUNCTION TEST Category: Medical Services CMS Add: 01/01/2005 CMS Term: 91037 TC MEDSV DEF RBRVS 01/01/2024 111.46 Description: ESOPH IMPED FUNCTION TEST Category: Medical Services CMS Add: 01/01/2005 CMS Term: 91037 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 76.21 Description: ESOPH IMPED FUNCTION TEST Category: Medical Services CMS Add: 01/01/2005 CMS Term: 91038 26 MEDSV DEF RBRVS 01/01/2024 52.74 Description: ESOPH IMPED FUNCT TEST > 1HR Category: Medical Services CMS Add: 01/01/2005 CMS Term: 91038 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 42.77 Description: ESOPH IMPED FUNCT TEST > 1HR Category: Medical Services CMS Add: 01/01/2005 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,240 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 91038 MEDSV DEF RBRVS 01/01/2024 380.91 Description: ESOPH IMPED FUNCT TEST > 1HR Category: Medical Services CMS Add: 01/01/2005 CMS Term: 91038 MEDSV DEF RBRVS 02/01/2015 12/31/2023 317.15 Description: ESOPH IMPED FUNCT TEST > 1HR Category: Medical Services CMS Add: 01/01/2005 CMS Term: 91038 TC MEDSV DEF RBRVS 01/01/2024 328.17 Description: ESOPH IMPED FUNCT TEST > 1HR Category: Medical Services CMS Add: 01/01/2005 CMS Term: 91038 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 274.39 Description: ESOPH IMPED FUNCT TEST > 1HR Category: Medical Services CMS Add: 01/01/2005 CMS Term: 91040 26 MEDSV DEF RBRVS 01/01/2024 46.65 Description: ESOPH BALLOON DISTENSION TST Category: Medical Services CMS Add: 01/01/2005 CMS Term: 91040 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 36.71 Description: ESOPH BALLOON DISTENSION TST Category: Medical Services CMS Add: 01/01/2005 CMS Term: 91040 MEDSV DEF RBRVS 01/01/2024 489.51 Description: ESOPH BALLOON DISTENSION TST Category: Medical Services CMS Add: 01/01/2005 CMS Term: 91040 MEDSV DEF RBRVS 02/01/2015 12/31/2023 280.63 Description: ESOPH BALLOON DISTENSION TST Category: Medical Services CMS Add: 01/01/2005 CMS Term: 91040 TC MEDSV DEF RBRVS 01/01/2024 442.85 Description: ESOPH BALLOON DISTENSION TST Category: Medical Services CMS Add: 01/01/2005 CMS Term: 91040 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 243.92 Description: ESOPH BALLOON DISTENSION TST Category: Medical Services CMS Add: 01/01/2005 CMS Term: 91065 26 MEDSV DEF RBRVS 01/01/2024 9.41 Description: BREATH HYDROGEN/METHANE TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 91065 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 7.77 Description: BREATH HYDROGEN/METHANE TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 91065 MEDSV DEF RBRVS 01/01/2024 78.10 Description: BREATH HYDROGEN/METHANE TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 91065 MEDSV DEF RBRVS 02/01/2015 12/31/2023 57.72 Description: BREATH HYDROGEN/METHANE TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 91065 TC MEDSV DEF RBRVS 01/01/2024 68.70 Description: BREATH HYDROGEN/METHANE TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 91065 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 49.96 Description: BREATH HYDROGEN/METHANE TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,241 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 91110 26 MEDSV DEF RBRVS 01/01/2024 107.29 Description: GI TRC IMG INTRAL ESOPH-ILE Category: Medical Services CMS Add: 01/01/2004 CMS Term: 91110 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 141.89 Description: GI TRC IMG INTRAL ESOPH-ILE Category: Medical Services CMS Add: 01/01/2004 CMS Term: 91110 MEDSV DEF RBRVS 01/01/2024 694.93 Description: GI TRC IMG INTRAL ESOPH-ILE Category: Medical Services CMS Add: 01/01/2004 CMS Term: 91110 MEDSV DEF RBRVS 02/01/2015 12/31/2023 628.57 Description: GI TRC IMG INTRAL ESOPH-ILE Category: Medical Services CMS Add: 01/01/2004 CMS Term: 91110 TC MEDSV DEF RBRVS 01/01/2024 587.64 Description: GI TRC IMG INTRAL ESOPH-ILE Category: Medical Services CMS Add: 01/01/2004 CMS Term: 91110 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 486.68 Description: GI TRC IMG INTRAL ESOPH-ILE Category: Medical Services CMS Add: 01/01/2004 CMS Term: 91111 NOCOV DEF SYSMAN Description: GI TRC IMG INTRAL ESOPHAGUS Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 91112 NOCOV DEF SYSMAN Description: GI WIRELESS CAPSULE MEASURE Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 91113 26 RADIO DEF RBRVS 01/01/2022 115.68 Description: GI TRC IMG INTRAL COLON I&R Category: Radiology CMS Add: 01/01/2022 CMS Term: 91113 RADIO DEF RBRVS 01/01/2022 12/31/2023 699.89 Description: GI TRC IMG INTRAL COLON I&R Category: Radiology CMS Add: 01/01/2022 CMS Term: 91113 RADIO DEF RBRVS 01/01/2024 850.43 Description: GI TRC IMG INTRAL COLON I&R Category: Radiology CMS Add: 01/01/2022 CMS Term: 91113 TC RADIO DEF RBRVS 01/01/2022 12/31/2023 607.56 Description: GI TRC IMG INTRAL COLON I&R Category: Radiology CMS Add: 01/01/2022 CMS Term: 91113 TC RADIO DEF RBRVS 01/01/2024 734.75 Description: GI TRC IMG INTRAL COLON I&R Category: Radiology CMS Add: 01/01/2022 CMS Term: 91117 MEDSV DEF RBRVS 01/01/2024 128.21 Description: COLON MOTILITY 6 HR STUDY Category: Medical Services CMS Add: 01/01/2011 CMS Term: 91117 MEDSV DEF RBRVS 02/01/2015 12/31/2023 106.95 Description: COLON MOTILITY 6 HR STUDY Category: Medical Services CMS Add: 01/01/2011 CMS Term: 91120 26 MEDSV DEF RBRVS 01/01/2024 45.86 Description: RECTAL SENSATION TEST Category: Medical Services CMS Add: 01/01/2005 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,242 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 91120 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 37.29 Description: RECTAL SENSATION TEST Category: Medical Services CMS Add: 01/01/2005 CMS Term: 91120 MEDSV DEF RBRVS 01/01/2024 475.13 Description: RECTAL SENSATION TEST Category: Medical Services CMS Add: 01/01/2005 CMS Term: 91120 MEDSV DEF RBRVS 02/01/2015 12/31/2023 279.97 Description: RECTAL SENSATION TEST Category: Medical Services CMS Add: 01/01/2005 CMS Term: 91120 TC MEDSV DEF RBRVS 01/01/2024 429.27 Description: RECTAL SENSATION TEST Category: Medical Services CMS Add: 01/01/2005 CMS Term: 91120 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 242.68 Description: RECTAL SENSATION TEST Category: Medical Services CMS Add: 01/01/2005 CMS Term: 91122 26 MEDSV DEF RBRVS 01/01/2024 83.51 Description: ANAL PRESSURE RECORD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 91122 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 66.05 Description: ANAL PRESSURE RECORD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 91122 MEDSV DEF RBRVS 01/01/2024 257.33 Description: ANAL PRESSURE RECORD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 91122 MEDSV DEF RBRVS 02/01/2015 12/31/2023 157.62 Description: ANAL PRESSURE RECORD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 91122 TC MEDSV DEF RBRVS 01/01/2024 173.82 Description: ANAL PRESSURE RECORD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 91122 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 91.57 Description: ANAL PRESSURE RECORD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 91132 26 MEDSV DEF RBRVS 01/01/2024 25.04 Description: ELECTROGASTROGRAPHY Category: Medical Services CMS Add: 01/01/2001 CMS Term: 91132 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 20.41 Description: ELECTROGASTROGRAPHY Category: Medical Services CMS Add: 01/01/2001 CMS Term: 91132 MEDSV DEF RBRVS 01/01/2024 413.56 Description: ELECTROGASTROGRAPHY Category: Medical Services CMS Add: 01/01/2001 CMS Term: 91132 MEDSV DEF RBRVS 02/01/2015 12/31/2023 107.52 Description: ELECTROGASTROGRAPHY Category: Medical Services CMS Add: 01/01/2001 CMS Term: 91132 TC MEDSV DEF RBRVS 01/01/2024 388.52 Description: ELECTROGASTROGRAPHY Category: Medical Services CMS Add: 01/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,243 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 91132 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 87.11 Description: ELECTROGASTROGRAPHY Category: Medical Services CMS Add: 01/01/2001 CMS Term: 91133 26 MEDSV DEF RBRVS 01/01/2024 31.64 Description: ELECTROGASTROGRAPHY W/TEST Category: Medical Services CMS Add: 01/01/2001 CMS Term: 91133 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 26.07 Description: ELECTROGASTROGRAPHY W/TEST Category: Medical Services CMS Add: 01/01/2001 CMS Term: 91133 MEDSV DEF RBRVS 01/01/2024 435.60 Description: ELECTROGASTROGRAPHY W/TEST Category: Medical Services CMS Add: 01/01/2001 CMS Term: 91133 MEDSV DEF RBRVS 02/01/2015 12/31/2023 125.82 Description: ELECTROGASTROGRAPHY W/TEST Category: Medical Services CMS Add: 01/01/2001 CMS Term: 91133 TC MEDSV DEF RBRVS 01/01/2024 403.96 Description: ELECTROGASTROGRAPHY W/TEST Category: Medical Services CMS Add: 01/01/2001 CMS Term: 91133 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 99.75 Description: ELECTROGASTROGRAPHY W/TEST Category: Medical Services CMS Add: 01/01/2001 CMS Term: 91200 26 MEDSV DEF RBRVS 01/01/2024 10.06 Y Description: LIVER ELASTOGRAPHY Category: Medical Services CMS Add: 01/01/2015 CMS Term: 91200 26 MEDSV DEF RBRVS 11/25/2017 12/31/2023 10.14 Y Description: LIVER ELASTOGRAPHY Category: Medical Services CMS Add: 01/01/2015 CMS Term: 91200 MEDSV DEF RBRVS 01/01/2024 28.43 Y Description: LIVER ELASTOGRAPHY Category: Medical Services CMS Add: 01/01/2015 CMS Term: 91200 MEDSV DEF RBRVS 11/25/2017 12/31/2023 27.40 Y Description: LIVER ELASTOGRAPHY Category: Medical Services CMS Add: 01/01/2015 CMS Term: 91200 TC MEDSV DEF RBRVS 01/01/2024 18.37 Y Description: LIVER ELASTOGRAPHY Category: Medical Services CMS Add: 01/01/2015 CMS Term: 91200 TC MEDSV DEF RBRVS 11/25/2017 12/31/2023 17.26 Y Description: LIVER ELASTOGRAPHY Category: Medical Services CMS Add: 01/01/2015 CMS Term: 91299 MEDSV DEF BILL40 Description: UNLISTED DX GI PROCEDURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 91300 NOCOV DEF SYSMAN Description: SARSCOV2 VAC 30MCG/0.3ML IM Category: Non Covered Services CMS Add: 12/11/2020 CMS Term: 10/31/2023 91301 NOCOV DEF SYSMAN Description: SARSCOV2 VAC 100MCG/0.5ML IM Category: Non Covered Services CMS Add: 12/18/2020 CMS Term: 10/31/2023 *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,244 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 91302 NOCOV DEF SYSMAN Description: CORONAVIRUS VACCINE 3 Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 01/01/2021 91303 NOCOV DEF SYSMAN Description: SARSCOV2 VAC AD26 .5ML IM Category: Non Covered Services CMS Add: 02/27/2021 CMS Term: 10/31/2023 91304 DDWA DEF MAXFEE 07/13/2022 10/02/2023 0.00 0.0 12-999years Description: SARSCOV2 VAC 5MCG/0.5ML IM Category: CIH Waiver CMS Add: 07/13/2022 CMS Term: 91304 DDWA DEF MAXFEE 10/03/2023 136.50 0.0 12-999years Description: SARSCOV2 VAC 5MCG/0.5ML IM Category: CIH Waiver CMS Add: 07/13/2022 CMS Term: 91304 DRUG DEF MAXFEE 07/13/2022 10/02/2023 0.00 0.0 12-999years Description: SARSCOV2 VAC 5MCG/0.5ML IM Category: Drugs CMS Add: 07/13/2022 CMS Term: 91304 DRUG DEF MAXFEE 10/03/2023 136.50 0.0 12-999years Description: SARSCOV2 VAC 5MCG/0.5ML IM Category: Drugs CMS Add: 07/13/2022 CMS Term: 91304 SSFS DEF MAXFEE 07/13/2022 10/02/2023 0.00 0.0 12-999years Description: SARSCOV2 VAC 5MCG/0.5ML IM Category: Family Support Waivr CMS Add: 07/13/2022 CMS Term: 91304 SSFS DEF MAXFEE 10/03/2023 136.50 0.0 12-999years Description: SARSCOV2 VAC 5MCG/0.5ML IM Category: Family Support Waivr CMS Add: 07/13/2022 CMS Term: 91304 TRANS DEF MAXFEE 07/13/2022 10/02/2023 0.00 0.0 12-999years Description: SARSCOV2 VAC 5MCG/0.5ML IM Category: Transportation CMS Add: 07/13/2022 CMS Term: 91304 TRANS DEF MAXFEE 10/03/2023 136.50 0.0 12-999years Description: SARSCOV2 VAC 5MCG/0.5ML IM Category: Transportation CMS Add: 07/13/2022 CMS Term: 91305 NOCOV DEF SYSMAN Description: SARSCOV2 VAC 30 MCG TRS-SUCR Category: Non Covered Services CMS Add: 01/03/2022 CMS Term: 10/31/2023 91306 NOCOV DEF SYSMAN Description: SARSCOV2 VAC 50MCG/0.25ML IM Category: Non Covered Services CMS Add: 10/20/2021 CMS Term: 10/31/2023 91307 NOCOV DEF SYSMAN Description: SARSCOV2 VAC 10 MCG TRS-SUCR Category: Non Covered Services CMS Add: 10/29/2021 CMS Term: 10/31/2023 91308 NOCOV DEF SYSMAN Description: SARSCOV2 VAC 3 MCG TRS-SUCR Category: Non Covered Services CMS Add: 06/17/2022 CMS Term: 10/31/2023 91309 NOCOV DEF SYSMAN Description: SARSCOV2 VAC 50MCG/0.5ML IM Category: Non Covered Services CMS Add: 03/29/2022 CMS Term: 10/31/2023 91310 NOCOV DEF SYSMAN Description: CORONAVIRUS VACCINE 11 Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 01/01/2021 *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,245 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 91311 NOCOV DEF SYSMAN Description: SARSCOV2 VAC 25MCG/0.25ML IM Category: Non Covered Services CMS Add: 06/17/2022 CMS Term: 10/31/2023 91312 NOCOV DEF SYSMAN Description: SARSCOV2 VAC BVL 30MCG/0.3ML Category: Non Covered Services CMS Add: 08/31/2022 CMS Term: 10/31/2023 91313 NOCOV DEF SYSMAN Description: SARSCOV2 VAC BVL 50MCG/0.5ML Category: Non Covered Services CMS Add: 08/31/2022 CMS Term: 10/31/2023 91314 NOCOV DEF SYSMAN Description: SARSCOV2 VAC BVL 25MCG/.25ML Category: Non Covered Services CMS Add: 10/12/2022 CMS Term: 10/31/2023 91315 NOCOV DEF SYSMAN Description: SARSCOV2 VAC BVL 10MCG/0.2ML Category: Non Covered Services CMS Add: 10/12/2022 CMS Term: 10/31/2023 91316 NOCOV DEF SYSMAN Description: SARSCOV2 VAC BVL 10MCG/0.2ML Category: Non Covered Services CMS Add: 12/08/2022 CMS Term: 10/31/2023 91317 NOCOV DEF SYSMAN Description: SARSCOV2 VAC BVL 3MCG/0.2ML Category: Non Covered Services CMS Add: 12/08/2022 CMS Term: 10/31/2023 91318 DDWA DEF MAXFEE 09/11/2023 60.37 0.0 0-4years Description: SARSCOV2 VAC 3MCG TRS-SUC IM Category: CIH Waiver CMS Add: 09/11/2023 CMS Term: 91318 DRUG DEF MAXFEE 09/11/2023 60.37 0.0 0-4years Description: SARSCOV2 VAC 3MCG TRS-SUC IM Category: Drugs CMS Add: 09/11/2023 CMS Term: 91318 DRUG PRF MAXFEE 09/11/2023 0.00 0.0 0-4years Description: SARSCOV2 VAC 3MCG TRS-SUC IM Category: Drugs CMS Add: 09/11/2023 CMS Term: 91318 SSFS DEF MAXFEE 09/11/2023 60.37 0.0 0-4years Description: SARSCOV2 VAC 3MCG TRS-SUC IM Category: Family Support Waivr CMS Add: 09/11/2023 CMS Term: 91319 DDWA DEF MAXFEE 09/11/2023 80.85 0.0 5-11years Description: SARSCV2 VAC 10MCG TRS-SUC IM Category: CIH Waiver CMS Add: 09/11/2023 CMS Term: 91319 DRUG DEF MAXFEE 09/11/2023 80.85 0.0 5-11years Description: SARSCV2 VAC 10MCG TRS-SUC IM Category: Drugs CMS Add: 09/11/2023 CMS Term: 91319 DRUG PRF MAXFEE 09/11/2023 0.00 0.0 5-11years Description: SARSCV2 VAC 10MCG TRS-SUC IM Category: Drugs CMS Add: 09/11/2023 CMS Term: 91319 SSFS DEF MAXFEE 09/11/2023 80.85 0.0 5-11years Description: SARSCV2 VAC 10MCG TRS-SUC IM Category: Family Support Waivr CMS Add: 09/11/2023 CMS Term: 91320 DDWA DEF MAXFEE 09/11/2023 120.75 0.0 12-999years Description: SARSCV2 VAC 30MCG TRS-SUC IM Category: CIH Waiver CMS Add: 09/11/2023 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,246 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 91320 DRUG DEF MAXFEE 09/11/2023 120.75 0.0 12-999years Description: SARSCV2 VAC 30MCG TRS-SUC IM Category: Drugs CMS Add: 09/11/2023 CMS Term: 91320 DRUG PRF MAXFEE 09/11/2023 0.00 0.0 12-999years Description: SARSCV2 VAC 30MCG TRS-SUC IM Category: Drugs CMS Add: 09/11/2023 CMS Term: 91320 SSFS DEF MAXFEE 09/11/2023 120.75 0.0 12-999years Description: SARSCV2 VAC 30MCG TRS-SUC IM Category: Family Support Waivr CMS Add: 09/11/2023 CMS Term: 91321 DDWA DEF MAXFEE 09/11/2023 134.40 0.0 0-11years Description: SARSCOV2 VAC 25 MCG/.25ML IM Category: CIH Waiver CMS Add: 09/11/2023 CMS Term: 91321 DRUG DEF MAXFEE 09/11/2023 134.40 0.0 0-11years Description: SARSCOV2 VAC 25 MCG/.25ML IM Category: Drugs CMS Add: 09/11/2023 CMS Term: 91321 DRUG PRF MAXFEE 09/11/2023 0.00 0.0 0-11years Description: SARSCOV2 VAC 25 MCG/.25ML IM Category: Drugs CMS Add: 09/11/2023 CMS Term: 91321 SSFS DEF MAXFEE 09/11/2023 134.40 0.0 0-11years Description: SARSCOV2 VAC 25 MCG/.25ML IM Category: Family Support Waivr CMS Add: 09/11/2023 CMS Term: 91322 DDWA DEF MAXFEE 09/11/2023 134.40 0.0 12-999years Description: SARSCOV2 VAC 50 MCG/0.5ML IM Category: CIH Waiver CMS Add: 09/11/2023 CMS Term: 91322 DRUG DEF MAXFEE 09/11/2023 134.40 0.0 12-999years Description: SARSCOV2 VAC 50 MCG/0.5ML IM Category: Drugs CMS Add: 09/11/2023 CMS Term: 91322 DRUG PRF MAXFEE 09/11/2023 0.00 0.0 12-999years Description: SARSCOV2 VAC 50 MCG/0.5ML IM Category: Drugs CMS Add: 09/11/2023 CMS Term: 91322 SSFS DEF MAXFEE 09/11/2023 134.40 0.0 12-999years Description: SARSCOV2 VAC 50 MCG/0.5ML IM Category: Family Support Waivr CMS Add: 09/11/2023 CMS Term: 92002 SE MRT DEF MAXFEE 07/01/2002 29.00 0.0 Description: INTRM OPH EXAM NEW PATIENT Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 92002 VISIO DEF RBRVS 01/01/2024 80.77 Description: INTRM OPH EXAM NEW PATIENT Category: Vision CMS Add: 01/01/1984 CMS Term: 92002 VISIO DEF RBRVS 02/01/2015 12/31/2023 58.74 Description: INTRM OPH EXAM NEW PATIENT Category: Vision CMS Add: 01/01/1984 CMS Term: 92004 VISIO DEF RBRVS 01/01/2024 141.97 Description: COMPRE OPH EXAM NEW PT 1/> Category: Vision CMS Add: 01/01/1984 CMS Term: 92004 VISIO DEF RBRVS 02/01/2015 12/31/2023 107.44 Description: COMPRE OPH EXAM NEW PT 1/> Category: Vision CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,247 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 92012 SE MRT DEF MAXFEE 07/01/2002 29.00 0.0 Description: INTRM OPH EXAM EST PATIENT Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 92012 VISIO DEF RBRVS 01/01/2024 84.61 Description: INTRM OPH EXAM EST PATIENT Category: Vision CMS Add: 01/01/1984 CMS Term: 92012 VISIO DEF RBRVS 02/01/2015 12/31/2023 61.55 Description: INTRM OPH EXAM EST PATIENT Category: Vision CMS Add: 01/01/1984 CMS Term: 92014 VISIO DEF RBRVS 01/01/2024 119.46 Description: COMPRE OPH EXAM EST PT 1/> Category: Vision CMS Add: 01/01/1984 CMS Term: 92014 VISIO DEF RBRVS 02/01/2015 12/31/2023 89.35 Description: COMPRE OPH EXAM EST PT 1/> Category: Vision CMS Add: 01/01/1984 CMS Term: 92015 MRT DEF RBRVS 01/01/2024 18.45 Description: DETERMINE REFRACTIVE STATE Category: Medical Review Team CMS Add: 01/01/1992 CMS Term: 92015 MRT DEF RBRVS 02/01/2015 12/31/2023 14.67 Description: DETERMINE REFRACTIVE STATE Category: Medical Review Team CMS Add: 01/01/1992 CMS Term: 92015 VISIO DEF RBRVS 01/01/2024 18.45 Description: DETERMINE REFRACTIVE STATE Category: Vision CMS Add: 01/01/1992 CMS Term: 92015 VISIO DEF RBRVS 02/01/2015 12/31/2023 14.67 Description: DETERMINE REFRACTIVE STATE Category: Vision CMS Add: 01/01/1992 CMS Term: 92018 VISIO DEF RBRVS 01/01/2024 132.02 Description: COMPL OPH EXAM GENERAL ANES Category: Vision CMS Add: 01/01/1985 CMS Term: 92018 VISIO DEF RBRVS 02/01/2015 12/31/2023 108.04 Description: COMPL OPH EXAM GENERAL ANES Category: Vision CMS Add: 01/01/1985 CMS Term: 92019 VISIO DEF RBRVS 01/01/2024 68.50 Description: LMTD OPH EXAM GENERAL ANES Category: Vision CMS Add: 01/01/1985 CMS Term: 92019 VISIO DEF RBRVS 02/01/2015 12/31/2023 52.70 Description: LMTD OPH EXAM GENERAL ANES Category: Vision CMS Add: 01/01/1985 CMS Term: 92020 VISIO DEF RBRVS 01/01/2024 26.28 Description: GONIOSCOPY Category: Vision CMS Add: 01/01/1984 CMS Term: 92020 VISIO DEF RBRVS 02/01/2015 12/31/2023 19.85 Description: GONIOSCOPY Category: Vision CMS Add: 01/01/1984 CMS Term: 92025 26 VISIO DEF RBRVS 01/01/2024 18.50 Description: CPTRIZED CORNEAL TOPOGRAPHY Category: Vision CMS Add: 01/01/2007 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,248 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 92025 26 VISIO DEF RBRVS 09/01/2019 12/31/2023 14.77 Description: CPTRIZED CORNEAL TOPOGRAPHY Category: Vision CMS Add: 01/01/2007 CMS Term: 92025 TC VISIO DEF RBRVS 01/01/2024 15.60 Description: CPTRIZED CORNEAL TOPOGRAPHY Category: Vision CMS Add: 01/01/2007 CMS Term: 92025 TC VISIO DEF RBRVS 09/01/2019 12/31/2023 12.30 Description: CPTRIZED CORNEAL TOPOGRAPHY Category: Vision CMS Add: 01/01/2007 CMS Term: 92025 VISIO DEF RBRVS 01/01/2024 34.10 Description: CPTRIZED CORNEAL TOPOGRAPHY Category: Vision CMS Add: 01/01/2007 CMS Term: 92025 VISIO DEF RBRVS 09/01/2019 12/31/2023 27.07 Description: CPTRIZED CORNEAL TOPOGRAPHY Category: Vision CMS Add: 01/01/2007 CMS Term: 92060 26 VISIO DEF RBRVS 01/01/2024 35.27 Description: SENSORIMOTOR EXAMINATION Category: Vision CMS Add: 01/01/1984 CMS Term: 92060 26 VISIO DEF RBRVS 09/01/2019 12/31/2023 28.69 Description: SENSORIMOTOR EXAMINATION Category: Vision CMS Add: 01/01/1984 CMS Term: 92060 TC VISIO DEF RBRVS 01/01/2024 24.55 Description: SENSORIMOTOR EXAMINATION Category: Vision CMS Add: 01/01/1984 CMS Term: 92060 TC VISIO DEF RBRVS 09/01/2019 12/31/2023 18.25 Description: SENSORIMOTOR EXAMINATION Category: Vision CMS Add: 01/01/1984 CMS Term: 92060 VISIO DEF RBRVS 01/01/2024 59.82 Description: SENSORIMOTOR EXAMINATION Category: Vision CMS Add: 01/01/1984 CMS Term: 92060 VISIO DEF RBRVS 09/01/2019 12/31/2023 46.94 Description: SENSORIMOTOR EXAMINATION Category: Vision CMS Add: 01/01/1984 CMS Term: 92065 26 VISIO DEF RBRVS 01/01/2024 31.94 Description: ORTHOP TRAING PFRMD PHYS/QHP Category: Vision CMS Add: 01/01/1984 CMS Term: 92065 26 VISIO DEF RBRVS 02/01/2015 12/31/2023 13.33 Description: ORTHOP TRAING PFRMD PHYS/QHP Category: Vision CMS Add: 01/01/1984 CMS Term: 92065 TC VISIO DEF RBRVS 01/01/2024 7.57 Description: ORTHOP TRAING PFRMD PHYS/QHP Category: Vision CMS Add: 01/01/1984 CMS Term: 92065 TC VISIO DEF RBRVS 02/01/2015 12/31/2023 24.44 Description: ORTHOP TRAING PFRMD PHYS/QHP Category: Vision CMS Add: 01/01/1984 CMS Term: 92065 VISIO DEF RBRVS 01/01/2024 39.51 Description: ORTHOP TRAING PFRMD PHYS/QHP Category: Vision CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,249 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 92065 VISIO DEF RBRVS 02/01/2015 12/31/2023 37.77 Description: ORTHOP TRAING PFRMD PHYS/QHP Category: Vision CMS Add: 01/01/1984 CMS Term: 92066 VISIO DEF RBRVS 01/01/2023 23.62 Description: ORTHOP TRAING SUPVJ PHYS/QHP Category: Vision CMS Add: 01/01/2023 CMS Term: 92071 VISIO DEF RBRVS 01/01/2016 12/31/2023 27.78 Description: CONTACT LENS FITTING FOR TX Category: Vision CMS Add: 01/01/2012 CMS Term: 92071 VISIO DEF RBRVS 01/01/2024 34.89 Description: CONTACT LENS FITTING FOR TX Category: Vision CMS Add: 01/01/2012 CMS Term: 92072 VISIO DEF RBRVS 01/01/2016 12/31/2023 99.83 Description: FITG C-LENS KERATOCONUS 1ST Category: Vision CMS Add: 01/01/2012 CMS Term: 92072 VISIO DEF RBRVS 01/01/2024 121.41 Description: FITG C-LENS KERATOCONUS 1ST Category: Vision CMS Add: 01/01/2012 CMS Term: 92081 26 VISIO DEF RBRVS 01/01/2024 15.27 Description: LIMITED VISUAL FIELD XM Category: Vision CMS Add: 01/01/1984 CMS Term: 92081 26 VISIO DEF RBRVS 09/01/2019 12/31/2023 12.27 Description: LIMITED VISUAL FIELD XM Category: Vision CMS Add: 01/01/1984 CMS Term: 92081 TC VISIO DEF RBRVS 01/01/2024 15.91 Description: LIMITED VISUAL FIELD XM Category: Vision CMS Add: 01/01/1984 CMS Term: 92081 TC VISIO DEF RBRVS 09/01/2019 12/31/2023 12.06 Description: LIMITED VISUAL FIELD XM Category: Vision CMS Add: 01/01/1984 CMS Term: 92081 VISIO DEF RBRVS 01/01/2024 31.17 Description: LIMITED VISUAL FIELD XM Category: Vision CMS Add: 01/01/1984 CMS Term: 92081 VISIO DEF RBRVS 09/01/2019 12/31/2023 24.33 Description: LIMITED VISUAL FIELD XM Category: Vision CMS Add: 01/01/1984 CMS Term: 92082 26 VISIO DEF RBRVS 01/01/2024 19.89 Description: INTERMEDIATE VISUAL FIELD XM Category: Vision CMS Add: 01/01/1984 CMS Term: 92082 26 VISIO DEF RBRVS 09/01/2019 12/31/2023 16.61 Description: INTERMEDIATE VISUAL FIELD XM Category: Vision CMS Add: 01/01/1984 CMS Term: 92082 TC VISIO DEF RBRVS 01/01/2024 23.93 Description: INTERMEDIATE VISUAL FIELD XM Category: Vision CMS Add: 01/01/1984 CMS Term: 92082 TC VISIO DEF RBRVS 09/01/2019 12/31/2023 18.25 Description: INTERMEDIATE VISUAL FIELD XM Category: Vision CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,250 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 92082 VISIO DEF RBRVS 01/01/2024 43.82 Description: INTERMEDIATE VISUAL FIELD XM Category: Vision CMS Add: 01/01/1984 CMS Term: 92082 VISIO DEF RBRVS 09/01/2019 12/31/2023 34.86 Description: INTERMEDIATE VISUAL FIELD XM Category: Vision CMS Add: 01/01/1984 CMS Term: 92083 26 MRT DEF RBRVS 01/01/2024 25.75 Description: EXTENDED VISUAL FIELD XM Category: Medical Review Team CMS Add: 01/01/1982 CMS Term: 92083 26 MRT DEF RBRVS 09/01/2019 12/31/2023 20.87 Description: EXTENDED VISUAL FIELD XM Category: Medical Review Team CMS Add: 01/01/1982 CMS Term: 92083 26 VISIO DEF RBRVS 01/01/2024 25.75 Description: EXTENDED VISUAL FIELD XM Category: Vision CMS Add: 01/01/1982 CMS Term: 92083 26 VISIO DEF RBRVS 09/01/2019 12/31/2023 20.87 Description: EXTENDED VISUAL FIELD XM Category: Vision CMS Add: 01/01/1982 CMS Term: 92083 MRT DEF RBRVS 01/01/2024 58.63 Description: EXTENDED VISUAL FIELD XM Category: Medical Review Team CMS Add: 01/01/1982 CMS Term: 92083 MRT DEF RBRVS 09/01/2019 12/31/2023 45.80 Description: EXTENDED VISUAL FIELD XM Category: Medical Review Team CMS Add: 01/01/1982 CMS Term: 92083 TC MRT DEF RBRVS 01/01/2024 32.88 Description: EXTENDED VISUAL FIELD XM Category: Medical Review Team CMS Add: 01/01/1982 CMS Term: 92083 TC MRT DEF RBRVS 09/01/2019 12/31/2023 24.94 Description: EXTENDED VISUAL FIELD XM Category: Medical Review Team CMS Add: 01/01/1982 CMS Term: 92083 TC VISIO DEF RBRVS 01/01/2024 32.88 Description: EXTENDED VISUAL FIELD XM Category: Vision CMS Add: 01/01/1982 CMS Term: 92083 TC VISIO DEF RBRVS 09/01/2019 12/31/2023 24.94 Description: EXTENDED VISUAL FIELD XM Category: Vision CMS Add: 01/01/1982 CMS Term: 92083 VISIO DEF RBRVS 01/01/2024 58.63 Description: EXTENDED VISUAL FIELD XM Category: Vision CMS Add: 01/01/1982 CMS Term: 92083 VISIO DEF RBRVS 09/01/2019 12/31/2023 45.80 Description: EXTENDED VISUAL FIELD XM Category: Vision CMS Add: 01/01/1982 CMS Term: 92100 VISIO DEF RBRVS 01/01/2024 79.96 Description: SERIAL TONOMETRY Category: Vision CMS Add: 01/01/1984 CMS Term: 92100 VISIO DEF RBRVS 02/01/2015 12/31/2023 57.01 Description: SERIAL TONOMETRY Category: Vision CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,251 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 92132 26 VISIO DEF RBRVS 01/01/2024 15.58 Description: CMPTR OPHTH DX IMG ANT SEGMT Category: Vision CMS Add: 01/01/2011 CMS Term: 92132 26 VISIO DEF RBRVS 09/01/2019 12/31/2023 14.61 Description: CMPTR OPHTH DX IMG ANT SEGMT Category: Vision CMS Add: 01/01/2011 CMS Term: 92132 TC VISIO DEF RBRVS 01/01/2024 14.05 Description: CMPTR OPHTH DX IMG ANT SEGMT Category: Vision CMS Add: 01/01/2011 CMS Term: 92132 TC VISIO DEF RBRVS 09/01/2019 12/31/2023 10.82 Description: CMPTR OPHTH DX IMG ANT SEGMT Category: Vision CMS Add: 01/01/2011 CMS Term: 92132 VISIO DEF RBRVS 01/01/2024 29.63 Description: CMPTR OPHTH DX IMG ANT SEGMT Category: Vision CMS Add: 01/01/2011 CMS Term: 92132 VISIO DEF RBRVS 09/01/2019 12/31/2023 25.42 Description: CMPTR OPHTH DX IMG ANT SEGMT Category: Vision CMS Add: 01/01/2011 CMS Term: 92133 26 VISIO DEF RBRVS 01/01/2024 20.51 Description: CMPTR OPHTH IMG OPTIC NERVE Category: Vision CMS Add: 01/01/2011 CMS Term: 92133 26 VISIO DEF RBRVS 09/01/2019 12/31/2023 20.87 Description: CMPTR OPHTH IMG OPTIC NERVE Category: Vision CMS Add: 01/01/2011 CMS Term: 92133 TC VISIO DEF RBRVS 01/01/2024 14.05 Description: CMPTR OPHTH IMG OPTIC NERVE Category: Vision CMS Add: 01/01/2011 CMS Term: 92133 TC VISIO DEF RBRVS 09/01/2019 12/31/2023 11.06 Description: CMPTR OPHTH IMG OPTIC NERVE Category: Vision CMS Add: 01/01/2011 CMS Term: 92133 VISIO DEF RBRVS 01/01/2024 34.56 Description: CMPTR OPHTH IMG OPTIC NERVE Category: Vision CMS Add: 01/01/2011 CMS Term: 92133 VISIO DEF RBRVS 09/01/2019 12/31/2023 31.93 Description: CMPTR OPHTH IMG OPTIC NERVE Category: Vision CMS Add: 01/01/2011 CMS Term: 92134 26 VISIO DEF RBRVS 01/01/2024 23.75 Description: CPTR OPHTH DX IMG POST SEGMT Category: Vision CMS Add: 01/01/2011 CMS Term: 92134 26 VISIO DEF RBRVS 09/01/2019 12/31/2023 21.61 Description: CPTR OPHTH DX IMG POST SEGMT Category: Vision CMS Add: 01/01/2011 CMS Term: 92134 TC VISIO DEF RBRVS 01/01/2024 14.36 Description: CPTR OPHTH DX IMG POST SEGMT Category: Vision CMS Add: 01/01/2011 CMS Term: 92134 TC VISIO DEF RBRVS 09/01/2019 12/31/2023 11.06 Description: CPTR OPHTH DX IMG POST SEGMT Category: Vision CMS Add: 01/01/2011 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,252 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 92134 VISIO DEF RBRVS 01/01/2024 38.11 Description: CPTR OPHTH DX IMG POST SEGMT Category: Vision CMS Add: 01/01/2011 CMS Term: 92134 VISIO DEF RBRVS 09/01/2019 12/31/2023 32.67 Description: CPTR OPHTH DX IMG POST SEGMT Category: Vision CMS Add: 01/01/2011 CMS Term: 92136 26 VISIO DEF RBRVS 01/01/2024 28.96 Description: OPHTHALMIC BIOMETRY Category: Vision CMS Add: 01/01/2002 CMS Term: 92136 26 VISIO DEF RBRVS 09/01/2019 12/31/2023 23.10 Description: OPHTHALMIC BIOMETRY Category: Vision CMS Add: 01/01/2002 CMS Term: 92136 TC VISIO DEF RBRVS 01/01/2024 15.60 Description: OPHTHALMIC BIOMETRY Category: Vision CMS Add: 01/01/2002 CMS Term: 92136 TC VISIO DEF RBRVS 09/01/2019 12/31/2023 40.54 Description: OPHTHALMIC BIOMETRY Category: Vision CMS Add: 01/01/2002 CMS Term: 92136 VISIO DEF RBRVS 01/01/2024 44.55 Description: OPHTHALMIC BIOMETRY Category: Vision CMS Add: 01/01/2002 CMS Term: 92136 VISIO DEF RBRVS 09/01/2019 12/31/2023 63.64 Description: OPHTHALMIC BIOMETRY Category: Vision CMS Add: 01/01/2002 CMS Term: 92145 NOCOV DEF SYSMAN Description: CORNEAL HYSTERESIS DETER Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 92201 VISIO DEF RBRVS 01/01/2020 12/31/2023 18.26 Description: OPSCPY EXTND RTA DRAW UNI/BI Category: Vision CMS Add: 01/01/2020 CMS Term: 92201 VISIO DEF RBRVS 01/01/2024 23.45 Description: OPSCPY EXTND RTA DRAW UNI/BI Category: Vision CMS Add: 01/01/2020 CMS Term: 92202 VISIO DEF RBRVS 01/01/2020 12/31/2023 11.61 Description: OPSCPY EXTND ON/MAC DRAW Category: Vision CMS Add: 01/01/2020 CMS Term: 92202 VISIO DEF RBRVS 01/01/2024 14.84 Description: OPSCPY EXTND ON/MAC DRAW Category: Vision CMS Add: 01/01/2020 CMS Term: 92227 MEDSV DEF RBRVS 01/01/2024 15.29 0-1 Description: IMG RTA DETCJ/MNTR DS STAFF Category: Medical Services CMS Add: 01/01/2011 CMS Term: 92227 MEDSV DEF RBRVS 02/01/2015 12/31/2023 9.83 0-1 Description: IMG RTA DETCJ/MNTR DS STAFF Category: Medical Services CMS Add: 01/01/2011 CMS Term: 92228 26 VISIO DEF RBRVS 01/01/2024 15.94 0-1 Description: IMG RTA DETC/MNTR DS PHY/QHP Category: Vision CMS Add: 01/01/2011 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,253 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 92228 26 VISIO DEF RBRVS 09/01/2019 12/31/2023 15.80 0-1 Description: IMG RTA DETC/MNTR DS PHY/QHP Category: Vision CMS Add: 01/01/2011 CMS Term: 92228 TC VISIO DEF RBRVS 01/01/2024 11.58 0-1 Description: IMG RTA DETC/MNTR DS PHY/QHP Category: Vision CMS Add: 01/01/2011 CMS Term: 92228 TC VISIO DEF RBRVS 09/01/2019 12/31/2023 9.33 0-1 Description: IMG RTA DETC/MNTR DS PHY/QHP Category: Vision CMS Add: 01/01/2011 CMS Term: 92228 VISIO DEF RBRVS 01/01/2024 27.53 0-1 Description: IMG RTA DETC/MNTR DS PHY/QHP Category: Vision CMS Add: 01/01/2011 CMS Term: 92228 VISIO DEF RBRVS 09/01/2019 12/31/2023 25.13 0-1 Description: IMG RTA DETC/MNTR DS PHY/QHP Category: Vision CMS Add: 01/01/2011 CMS Term: 92229 MEDSV PRF MAXFEE 01/01/2024 41.53 0.0 0-1 Description: IMG RTA DETC/MNTR DS POC ALY Category: Medical Services CMS Add: 01/01/2021 CMS Term: 92230 VISIO DEF RBRVS 01/01/2024 104.64 Description: FLUORESCEIN ANGIOSCOPY I&R Category: Vision CMS Add: 01/01/1984 CMS Term: 92230 VISIO DEF RBRVS 02/01/2015 12/31/2023 42.30 Description: FLUORESCEIN ANGIOSCOPY I&R Category: Vision CMS Add: 01/01/1984 CMS Term: 92235 26 VISIO DEF RBRVS 01/01/2024 40.39 Description: FLUORESCEIN ANGRPH MLTIFRAME Category: Vision CMS Add: 01/01/1984 CMS Term: 92235 26 VISIO DEF RBRVS 09/01/2019 12/31/2023 34.89 Description: FLUORESCEIN ANGRPH MLTIFRAME Category: Vision CMS Add: 01/01/1984 CMS Term: 92235 TC VISIO DEF RBRVS 01/01/2024 87.84 Description: FLUORESCEIN ANGRPH MLTIFRAME Category: Vision CMS Add: 01/01/1984 CMS Term: 92235 TC VISIO DEF RBRVS 09/01/2019 12/31/2023 43.02 Description: FLUORESCEIN ANGRPH MLTIFRAME Category: Vision CMS Add: 01/01/1984 CMS Term: 92235 VISIO DEF RBRVS 01/01/2024 128.23 Description: FLUORESCEIN ANGRPH MLTIFRAME Category: Vision CMS Add: 01/01/1984 CMS Term: 92235 VISIO DEF RBRVS 09/01/2019 12/31/2023 77.91 Description: FLUORESCEIN ANGRPH MLTIFRAME Category: Vision CMS Add: 01/01/1984 CMS Term: 92240 26 VISIO DEF RBRVS 01/01/2024 44.14 Description: ICG ANGIOGRAPHY I&R UNI/BI Category: Vision CMS Add: 01/01/1997 CMS Term: 92240 26 VISIO DEF RBRVS 09/01/2019 12/31/2023 47.39 Description: ICG ANGIOGRAPHY I&R UNI/BI Category: Vision CMS Add: 01/01/1997 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,254 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 92240 TC VISIO DEF RBRVS 01/01/2024 132.60 Description: ICG ANGIOGRAPHY I&R UNI/BI Category: Vision CMS Add: 01/01/1997 CMS Term: 92240 TC VISIO DEF RBRVS 09/01/2019 12/31/2023 131.45 Description: ICG ANGIOGRAPHY I&R UNI/BI Category: Vision CMS Add: 01/01/1997 CMS Term: 92240 VISIO DEF RBRVS 01/01/2024 176.74 Description: ICG ANGIOGRAPHY I&R UNI/BI Category: Vision CMS Add: 01/01/1997 CMS Term: 92240 VISIO DEF RBRVS 09/01/2019 12/31/2023 178.84 Description: ICG ANGIOGRAPHY I&R UNI/BI Category: Vision CMS Add: 01/01/1997 CMS Term: 92242 26 RADIO DEF RBRVS 01/01/2017 12/31/2023 40.72 Description: FLUORESCEIN&ICG ANGIOGRAPHY Category: Radiology CMS Add: 01/01/2017 CMS Term: 92242 26 RADIO DEF RBRVS 01/01/2024 51.67 Description: FLUORESCEIN&ICG ANGIOGRAPHY Category: Radiology CMS Add: 01/01/2017 CMS Term: 92242 RADIO DEF RBRVS 01/01/2017 12/31/2023 160.28 Description: FLUORESCEIN&ICG ANGIOGRAPHY Category: Radiology CMS Add: 01/01/2017 CMS Term: 92242 RADIO DEF RBRVS 01/01/2024 240.45 Description: FLUORESCEIN&ICG ANGIOGRAPHY Category: Radiology CMS Add: 01/01/2017 CMS Term: 92242 TC RADIO DEF RBRVS 01/01/2017 12/31/2023 119.56 Description: FLUORESCEIN&ICG ANGIOGRAPHY Category: Radiology CMS Add: 01/01/2017 CMS Term: 92242 TC RADIO DEF RBRVS 01/01/2024 188.78 Description: FLUORESCEIN&ICG ANGIOGRAPHY Category: Radiology CMS Add: 01/01/2017 CMS Term: 92250 26 VISIO DEF RBRVS 01/01/2024 20.20 Description: FUNDUS PHOTOGRAPHY W/I&R Category: Vision CMS Add: 01/01/1984 CMS Term: 92250 26 VISIO DEF RBRVS 09/01/2019 12/31/2023 17.68 Description: FUNDUS PHOTOGRAPHY W/I&R Category: Vision CMS Add: 01/01/1984 CMS Term: 92250 TC VISIO DEF RBRVS 01/01/2024 14.98 Description: FUNDUS PHOTOGRAPHY W/I&R Category: Vision CMS Add: 01/01/1984 CMS Term: 92250 TC VISIO DEF RBRVS 09/01/2019 12/31/2023 37.82 Description: FUNDUS PHOTOGRAPHY W/I&R Category: Vision CMS Add: 01/01/1984 CMS Term: 92250 VISIO DEF RBRVS 01/01/2024 35.18 Description: FUNDUS PHOTOGRAPHY W/I&R Category: Vision CMS Add: 01/01/1984 CMS Term: 92250 VISIO DEF RBRVS 09/01/2019 12/31/2023 55.50 Description: FUNDUS PHOTOGRAPHY W/I&R Category: Vision CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,255 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 92260 VISIO DEF RBRVS 01/01/2024 18.67 Description: OPHTHALMODYNAMOMETRY Category: Vision CMS Add: 01/01/1984 CMS Term: 92260 VISIO DEF RBRVS 02/01/2015 12/31/2023 13.47 Description: OPHTHALMODYNAMOMETRY Category: Vision CMS Add: 01/01/1984 CMS Term: 92265 26 VISIO DEF RBRVS 01/01/2024 43.66 Description: NDL OCULOELECTROMYOGRAPHY 1+ Category: Vision CMS Add: 01/01/1984 CMS Term: 92265 26 VISIO DEF RBRVS 09/01/2019 12/31/2023 30.85 Description: NDL OCULOELECTROMYOGRAPHY 1+ Category: Vision CMS Add: 01/01/1984 CMS Term: 92265 TC VISIO DEF RBRVS 01/01/2024 38.13 Description: NDL OCULOELECTROMYOGRAPHY 1+ Category: Vision CMS Add: 01/01/1984 CMS Term: 92265 TC VISIO DEF RBRVS 09/01/2019 12/31/2023 24.19 Description: NDL OCULOELECTROMYOGRAPHY 1+ Category: Vision CMS Add: 01/01/1984 CMS Term: 92265 VISIO DEF RBRVS 01/01/2024 81.80 Description: NDL OCULOELECTROMYOGRAPHY 1+ Category: Vision CMS Add: 01/01/1984 CMS Term: 92265 VISIO DEF RBRVS 09/01/2019 12/31/2023 55.04 Description: NDL OCULOELECTROMYOGRAPHY 1+ Category: Vision CMS Add: 01/01/1984 CMS Term: 92270 26 VISIO DEF RBRVS 01/01/2024 40.27 Description: ELECTRO-OCULOGRAPHY W/I&R Category: Vision CMS Add: 01/01/1984 CMS Term: 92270 26 VISIO DEF RBRVS 09/01/2019 12/31/2023 30.43 Description: ELECTRO-OCULOGRAPHY W/I&R Category: Vision CMS Add: 01/01/1984 CMS Term: 92270 TC VISIO DEF RBRVS 01/01/2024 62.06 Description: ELECTRO-OCULOGRAPHY W/I&R Category: Vision CMS Add: 01/01/1984 CMS Term: 92270 TC VISIO DEF RBRVS 09/01/2019 12/31/2023 33.85 Description: ELECTRO-OCULOGRAPHY W/I&R Category: Vision CMS Add: 01/01/1984 CMS Term: 92270 VISIO DEF RBRVS 01/01/2024 102.33 Description: ELECTRO-OCULOGRAPHY W/I&R Category: Vision CMS Add: 01/01/1984 CMS Term: 92270 VISIO DEF RBRVS 09/01/2019 12/31/2023 64.29 Description: ELECTRO-OCULOGRAPHY W/I&R Category: Vision CMS Add: 01/01/1984 CMS Term: 92273 26 VISIO DEF RBRVS 01/01/2019 12/31/2023 27.62 Description: FULL FIELD ERG W/I&R Category: Vision CMS Add: 01/01/2019 CMS Term: 92273 26 VISIO DEF RBRVS 01/01/2024 34.97 Description: FULL FIELD ERG W/I&R Category: Vision CMS Add: 01/01/2019 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,256 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 92273 TC VISIO DEF RBRVS 01/01/2019 12/31/2023 67.30 Description: FULL FIELD ERG W/I&R Category: Vision CMS Add: 01/01/2019 CMS Term: 92273 TC VISIO DEF RBRVS 01/01/2024 83.37 Description: FULL FIELD ERG W/I&R Category: Vision CMS Add: 01/01/2019 CMS Term: 92273 VISIO DEF RBRVS 01/01/2019 12/31/2023 94.92 Description: FULL FIELD ERG W/I&R Category: Vision CMS Add: 01/01/2019 CMS Term: 92273 VISIO DEF RBRVS 01/01/2024 118.33 Description: FULL FIELD ERG W/I&R Category: Vision CMS Add: 01/01/2019 CMS Term: 92274 26 VISIO DEF RBRVS 01/01/2019 12/31/2023 24.48 Description: MULTIFOCAL ERG W/I&R Category: Vision CMS Add: 01/01/2019 CMS Term: 92274 26 VISIO DEF RBRVS 01/01/2024 31.64 Description: MULTIFOCAL ERG W/I&R Category: Vision CMS Add: 01/01/2019 CMS Term: 92274 TC VISIO DEF RBRVS 01/01/2019 12/31/2023 40.05 Description: MULTIFOCAL ERG W/I&R Category: Vision CMS Add: 01/01/2019 CMS Term: 92274 TC VISIO DEF RBRVS 01/01/2024 51.72 Description: MULTIFOCAL ERG W/I&R Category: Vision CMS Add: 01/01/2019 CMS Term: 92274 VISIO DEF RBRVS 01/01/2019 12/31/2023 64.53 Description: MULTIFOCAL ERG W/I&R Category: Vision CMS Add: 01/01/2019 CMS Term: 92274 VISIO DEF RBRVS 01/01/2024 83.35 Description: MULTIFOCAL ERG W/I&R Category: Vision CMS Add: 01/01/2019 CMS Term: 92283 NOCOV DEF SYSMAN Description: EXTND COLOR VISION XM Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: 92284 26 VISIO DEF MAXFEE 01/01/2024 11.14 0.0 Description: DX DARK ADAPTATION EXAM I&R Category: Vision CMS Add: 01/01/1984 CMS Term: 92284 26 VISIO DEF RBRVS 09/01/2019 11.38 Description: DX DARK ADAPTATION EXAM I&R Category: Vision CMS Add: 01/01/1984 CMS Term: 92284 TC VISIO DEF MAXFEE 01/01/2024 40.87 0.0 Description: DX DARK ADAPTATION EXAM I&R Category: Vision CMS Add: 01/01/1984 CMS Term: 92284 TC VISIO DEF RBRVS 09/01/2019 41.53 Description: DX DARK ADAPTATION EXAM I&R Category: Vision CMS Add: 01/01/1984 CMS Term: 92284 VISIO DEF MAXFEE 03/01/1994 4.72 0.0 Description: DX DARK ADAPTATION EXAM I&R Category: Vision CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,257 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 92284 VISIO DEF RBRVS 01/01/2024 42.45 Description: DX DARK ADAPTATION EXAM I&R Category: Vision CMS Add: 01/01/1984 CMS Term: 92284 VISIO DEF RBRVS 09/01/2019 12/31/2023 42.45 Description: DX DARK ADAPTATION EXAM I&R Category: Vision CMS Add: 01/01/1984 CMS Term: 92285 26 VISIO DEF RBRVS 01/01/2024 2.78 Description: EXTERNAL OCULAR PHOTOGRAPHY Category: Vision CMS Add: 01/01/1984 CMS Term: 92285 26 VISIO DEF RBRVS 09/01/2019 12/31/2023 2.25 Description: EXTERNAL OCULAR PHOTOGRAPHY Category: Vision CMS Add: 01/01/1984 CMS Term: 92285 TC VISIO DEF RBRVS 01/01/2024 18.37 Description: EXTERNAL OCULAR PHOTOGRAPHY Category: Vision CMS Add: 01/01/1984 CMS Term: 92285 TC VISIO DEF RBRVS 09/01/2019 12/31/2023 12.06 Description: EXTERNAL OCULAR PHOTOGRAPHY Category: Vision CMS Add: 01/01/1984 CMS Term: 92285 VISIO DEF RBRVS 01/01/2024 21.16 Description: EXTERNAL OCULAR PHOTOGRAPHY Category: Vision CMS Add: 01/01/1984 CMS Term: 92285 VISIO DEF RBRVS 09/01/2019 12/31/2023 14.31 Description: EXTERNAL OCULAR PHOTOGRAPHY Category: Vision CMS Add: 01/01/1984 CMS Term: 92286 26 VISIO DEF RBRVS 01/01/2024 20.51 Description: ANT SGM IMG I&R SPECLR MIC Category: Vision CMS Add: 01/01/1982 CMS Term: 92286 26 VISIO DEF RBRVS 09/01/2019 12/31/2023 16.36 Description: ANT SGM IMG I&R SPECLR MIC Category: Vision CMS Add: 01/01/1982 CMS Term: 92286 TC VISIO DEF RBRVS 01/01/2024 16.21 Description: ANT SGM IMG I&R SPECLR MIC Category: Vision CMS Add: 01/01/1982 CMS Term: 92286 TC VISIO DEF RBRVS 09/01/2019 12/31/2023 11.06 Description: ANT SGM IMG I&R SPECLR MIC Category: Vision CMS Add: 01/01/1982 CMS Term: 92286 VISIO DEF RBRVS 01/01/2024 36.72 Description: ANT SGM IMG I&R SPECLR MIC Category: Vision CMS Add: 01/01/1982 CMS Term: 92286 VISIO DEF RBRVS 09/01/2019 12/31/2023 27.43 Description: ANT SGM IMG I&R SPECLR MIC Category: Vision CMS Add: 01/01/1982 CMS Term: 92287 26 VISIO DEF RBRVS 01/01/2016 12/31/2023 34.89 Description: ANT SGM IMG IR FLRSCN ANGRPH Category: Vision CMS Add: 01/01/1985 CMS Term: 92287 26 VISIO DEF RBRVS 01/01/2024 34.09 Description: ANT SGM IMG IR FLRSCN ANGRPH Category: Vision CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,258 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 92287 TC VISIO DEF RBRVS 01/01/2016 12/31/2023 62.34 Description: ANT SGM IMG IR FLRSCN ANGRPH Category: Vision CMS Add: 01/01/1985 CMS Term: 92287 TC VISIO DEF RBRVS 01/01/2024 99.88 Description: ANT SGM IMG IR FLRSCN ANGRPH Category: Vision CMS Add: 01/01/1985 CMS Term: 92287 VISIO DEF RBRVS 01/01/2024 133.97 Description: ANT SGM IMG IR FLRSCN ANGRPH Category: Vision CMS Add: 01/01/1985 CMS Term: 92287 VISIO DEF RBRVS 02/01/2015 12/31/2023 97.23 Description: ANT SGM IMG IR FLRSCN ANGRPH Category: Vision CMS Add: 01/01/1985 CMS Term: 92310 VISIO DEF RBRVS 01/01/2024 94.49 Description: CONTACT LENS FITTING OU Category: Vision CMS Add: 01/01/1982 CMS Term: 92310 VISIO DEF RBRVS 02/01/2015 12/31/2023 68.67 Description: CONTACT LENS FITTING OU Category: Vision CMS Add: 01/01/1982 CMS Term: 92311 VISIO DEF RBRVS 01/01/2024 99.74 Description: CONTACT LENS FITG APHAKIA 1 Category: Vision CMS Add: 01/01/1982 CMS Term: 92311 VISIO DEF RBRVS 02/01/2015 12/31/2023 73.19 Description: CONTACT LENS FITG APHAKIA 1 Category: Vision CMS Add: 01/01/1982 CMS Term: 92312 VISIO DEF RBRVS 01/01/2024 115.71 Description: CONTACT LENS FITG APHAKIA OU Category: Vision CMS Add: 01/01/1982 CMS Term: 92312 VISIO DEF RBRVS 02/01/2015 12/31/2023 82.98 Description: CONTACT LENS FITG APHAKIA OU Category: Vision CMS Add: 01/01/1982 CMS Term: 92313 VISIO DEF RBRVS 01/01/2024 94.31 Description: C-LENS FITG CORNEOSCLRL LENS Category: Vision CMS Add: 01/01/1982 CMS Term: 92313 VISIO DEF RBRVS 02/01/2015 12/31/2023 70.13 Description: C-LENS FITG CORNEOSCLRL LENS Category: Vision CMS Add: 01/01/1982 CMS Term: 92314 VISIO DEF RBRVS 01/01/2024 81.45 Description: C-LENS FITG TECH OU Category: Vision CMS Add: 01/01/1982 CMS Term: 92314 VISIO DEF RBRVS 02/01/2015 12/31/2023 56.36 Description: C-LENS FITG TECH OU Category: Vision CMS Add: 01/01/1982 CMS Term: 92315 VISIO DEF RBRVS 01/01/2024 77.15 Description: C-LENS FITG TECH APHAKIA 1 Category: Vision CMS Add: 01/01/1982 CMS Term: 92315 VISIO DEF RBRVS 09/01/2019 12/31/2023 51.89 Description: C-LENS FITG TECH APHAKIA 1 Category: Vision CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,259 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 92316 VISIO DEF RBRVS 01/01/2024 95.75 Description: C-LENS FITG TECH APHAKIA OU Category: Vision CMS Add: 01/01/1982 CMS Term: 92316 VISIO DEF RBRVS 02/01/2015 12/31/2023 65.01 Description: C-LENS FITG TECH APHAKIA OU Category: Vision CMS Add: 01/01/1982 CMS Term: 92317 VISIO DEF RBRVS 01/01/2024 81.17 Description: C-LENS FITG TECH CORNEOSCLRL Category: Vision CMS Add: 01/01/1982 CMS Term: 92317 VISIO DEF RBRVS 02/01/2015 12/31/2023 53.62 Description: C-LENS FITG TECH CORNEOSCLRL Category: Vision CMS Add: 01/01/1982 CMS Term: 92325 VISIO DEF RBRVS 01/01/2024 41.53 Description: MODIFICATION OF CONTACT LENS Category: Vision CMS Add: 01/01/1982 CMS Term: 92325 VISIO DEF RBRVS 02/01/2015 12/31/2023 28.65 Description: MODIFICATION OF CONTACT LENS Category: Vision CMS Add: 01/01/1982 CMS Term: 92326 VISIO DEF RBRVS 01/01/2024 35.66 Description: REPLACEMENT OF CONTACT LENS Category: Vision CMS Add: 01/01/1982 CMS Term: 92326 VISIO DEF RBRVS 02/01/2015 12/31/2023 24.69 Description: REPLACEMENT OF CONTACT LENS Category: Vision CMS Add: 01/01/1982 CMS Term: 92340 NOCOV DEF SYSMAN Description: FIT SPECTACLES MONOFOCAL Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 92341 NOCOV DEF SYSMAN Description: FIT SPECTACLES BIFOCAL Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 92342 NOCOV DEF SYSMAN Description: FIT SPECTACLES MULTIFOCAL Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 92352 NOCOV DEF SYSMAN Description: FIT APHAKIA SPECTCL MONOFOCL Category: Non Covered Services CMS Add: 01/01/1985 CMS Term: 92353 NOCOV DEF SYSMAN Description: FIT APHAKIA SPECTCL MULTIFOC Category: Non Covered Services CMS Add: 01/01/1985 CMS Term: 92354 NOCOV DEF SYSMAN Description: FITG SPECT LOW VIS 1SYSTEM Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 92355 NOCOV DEF SYSMAN Description: FITG SPECT LW VIS CMPND LENS Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 92358 NOCOV DEF SYSMAN Description: APHAKIA PROSTH SERVICE TEMP Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,260 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 92370 VISIO DEF RBRVS 01/01/2024 28.45 Description: RPR&REFITG SPECT XCP APHAKIA Category: Vision CMS Add: 01/01/1982 CMS Term: 92370 VISIO DEF RBRVS 02/01/2015 12/31/2023 21.97 Description: RPR&REFITG SPECT XCP APHAKIA Category: Vision CMS Add: 01/01/1982 CMS Term: 92371 NOCOV DEF SYSMAN Description: RPR&REFIT SPCT PRSTH APHAKIA Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: 92499 VISIO PRF MAXFEE 01/01/2024 18.35 0.0 Description: UNLISTED OPH SVC/PROCEDURE Category: Vision CMS Add: 01/01/1984 CMS Term: 92502 MEDSV DEF RBRVS 01/01/2024 89.82 Description: EAR AND THROAT EXAMINATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 92502 MEDSV DEF RBRVS 02/01/2015 12/31/2023 70.71 Description: EAR AND THROAT EXAMINATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 92504 MEDSV DEF RBRVS 01/01/2024 27.25 Description: EAR MICROSCOPY EXAMINATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 92504 MEDSV DEF RBRVS 02/01/2015 12/31/2023 21.35 Description: EAR MICROSCOPY EXAMINATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 92507 THEPY DEF RBRVS 01/01/2024 73.72 Y 0-1 Description: SPEECH/HEARING THERAPY Category: Therapy Services CMS Add: 01/01/1984 CMS Term: 92507 THEPY DEF RBRVS 09/01/2019 12/31/2023 57.88 Y 0-1 Description: SPEECH/HEARING THERAPY Category: Therapy Services CMS Add: 01/01/1984 CMS Term: 92507 U5 U7 UA DDWA WDD MAXFEE 01/01/2008 18.12 0.0 Y Description: SPEECH/HEARING THERAPY Category: CIH Waiver CMS Add: 01/01/1984 CMS Term: 92507 U5 U7 UA MFPCI W3M MAXFEE 01/01/2014 18.12 0.0 Y Description: SPEECH/HEARING THERAPY Category: MFP CIH Waiver CMS Add: 01/01/1984 CMS Term: 92507 U5 U7 UA MFPTS W5M MAXFEE 07/01/2023 18.12 0.0 Y Description: SPEECH/HEARING THERAPY Category: MFP SOF Waiver CMS Add: 01/01/1984 CMS Term: 92507 U5 U7 UA SSFS WSS MAXFEE 01/01/2008 18.12 0.0 Y Description: SPEECH/HEARING THERAPY Category: Family Support Waivr CMS Add: 01/01/1984 CMS Term: 92508 THEPY DEF RBRVS 01/01/2024 22.77 Y Description: SPEECH/HEARING THERAPY Category: Therapy Services CMS Add: 01/01/1984 CMS Term: 92508 THEPY DEF RBRVS 09/01/2019 12/31/2023 16.96 Y Description: SPEECH/HEARING THERAPY Category: Therapy Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,261 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 92511 MEDSV DEF RBRVS 01/01/2024 110.53 Description: NASOPHARYNGOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 92511 MEDSV DEF RBRVS 02/01/2015 12/31/2023 96.65 Description: NASOPHARYNGOSCOPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 92512 MEDSV DEF RBRVS 01/01/2024 59.41 Description: NASAL FUNCTION STUDIES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 92512 MEDSV DEF RBRVS 02/01/2015 12/31/2023 43.51 Description: NASAL FUNCTION STUDIES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 92516 THEPY DEF RBRVS 01/01/2024 66.15 Description: FACIAL NERVE FUNCTION TEST Category: Therapy Services CMS Add: 01/01/1984 CMS Term: 92516 THEPY DEF RBRVS 02/01/2015 12/31/2023 49.45 Description: FACIAL NERVE FUNCTION TEST Category: Therapy Services CMS Add: 01/01/1984 CMS Term: 92517 NOCOV DEF SYSMAN Description: VEMP TEST I&R CERVICAL Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 92518 NOCOV DEF SYSMAN Description: VEMP TEST I&R OCULAR Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 92519 NOCOV DEF SYSMAN Description: VEMP TST I&R CERVICAL&OCULAR Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 92520 MEDSV DEF RBRVS 01/01/2024 80.08 Y Description: LARYNGEAL FUNCTION STUDIES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 92520 MEDSV DEF RBRVS 02/01/2015 12/31/2023 53.26 Y Description: LARYNGEAL FUNCTION STUDIES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 92521 AUDIO DEF RBRVS 01/01/2024 128.12 Description: EVALUATION OF SPEECH FLUENCY Category: Audiology CMS Add: 01/01/2014 CMS Term: 92521 AUDIO DEF RBRVS 02/01/2015 12/31/2023 82.36 Description: EVALUATION OF SPEECH FLUENCY Category: Audiology CMS Add: 01/01/2014 CMS Term: 92522 AUDIO DEF RBRVS 01/01/2024 106.94 Description: EVALUATE SPEECH PRODUCTION Category: Audiology CMS Add: 01/01/2014 CMS Term: 92522 AUDIO DEF RBRVS 02/01/2015 12/31/2023 67.05 Description: EVALUATE SPEECH PRODUCTION Category: Audiology CMS Add: 01/01/2014 CMS Term: 92523 AUDIO DEF RBRVS 01/01/2024 219.72 Description: SPEECH SOUND LANG COMPREHEN Category: Audiology CMS Add: 01/01/2014 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,262 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 92523 AUDIO DEF RBRVS 02/01/2015 12/31/2023 138.98 Description: SPEECH SOUND LANG COMPREHEN Category: Audiology CMS Add: 01/01/2014 CMS Term: 92524 AUDIO DEF RBRVS 01/01/2024 105.71 Description: BEHAVRAL QUALIT ANALYS VOICE Category: Audiology CMS Add: 01/01/2014 CMS Term: 92524 AUDIO DEF RBRVS 02/01/2015 12/31/2023 69.37 Description: BEHAVRAL QUALIT ANALYS VOICE Category: Audiology CMS Add: 01/01/2014 CMS Term: 92526 MEDSV DEF RBRVS 01/01/2024 81.55 Y Description: ORAL FUNCTION THERAPY Category: Medical Services CMS Add: 01/01/1996 CMS Term: 92526 MEDSV DEF RBRVS 09/01/2019 12/31/2023 62.92 Y Description: ORAL FUNCTION THERAPY Category: Medical Services CMS Add: 01/01/1996 CMS Term: 92531 NOCOV DEF SYSMAN Description: SPONTANEOUS NYSTAGMUS STUDY Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: 92532 NOCOV DEF SYSMAN Description: POSITIONAL NYSTAGMUS TEST Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: 92533 NOCOV DEF SYSMAN Description: CALORIC VESTIBULAR TEST Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: 92534 NOCOV DEF SYSMAN Description: OPTOKINETIC NYSTAGMUS TEST Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: 92537 26 AUDIO DEF RBRVS 01/01/2017 12/31/2023 23.39 Description: CALORIC VSTBLR TEST W/REC Category: Audiology CMS Add: 01/01/2016 CMS Term: 92537 26 AUDIO DEF RBRVS 01/01/2024 29.75 Description: CALORIC VSTBLR TEST W/REC Category: Audiology CMS Add: 01/01/2016 CMS Term: 92537 AUDIO DEF RBRVS 01/01/2017 12/31/2023 29.25 Description: CALORIC VSTBLR TEST W/REC Category: Audiology CMS Add: 01/01/2016 CMS Term: 92537 AUDIO DEF RBRVS 01/01/2024 38.56 Description: CALORIC VSTBLR TEST W/REC Category: Audiology CMS Add: 01/01/2016 CMS Term: 92537 TC AUDIO DEF RBRVS 01/01/2017 12/31/2023 5.86 Description: CALORIC VSTBLR TEST W/REC Category: Audiology CMS Add: 01/01/2016 CMS Term: 92537 TC AUDIO DEF RBRVS 01/01/2024 8.80 Description: CALORIC VSTBLR TEST W/REC Category: Audiology CMS Add: 01/01/2016 CMS Term: 92538 26 AUDIO DEF RBRVS 01/01/2017 12/31/2023 11.69 Description: CALORIC VSTBLR TEST W/REC Category: Audiology CMS Add: 01/01/2016 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,263 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 92538 26 AUDIO DEF RBRVS 01/01/2024 15.27 Description: CALORIC VSTBLR TEST W/REC Category: Audiology CMS Add: 01/01/2016 CMS Term: 92538 AUDIO DEF RBRVS 01/01/2017 12/31/2023 14.83 Description: CALORIC VSTBLR TEST W/REC Category: Audiology CMS Add: 01/01/2016 CMS Term: 92538 AUDIO DEF RBRVS 01/01/2024 21.29 Description: CALORIC VSTBLR TEST W/REC Category: Audiology CMS Add: 01/01/2016 CMS Term: 92538 TC AUDIO DEF RBRVS 01/01/2017 12/31/2023 3.14 Description: CALORIC VSTBLR TEST W/REC Category: Audiology CMS Add: 01/01/2016 CMS Term: 92538 TC AUDIO DEF RBRVS 01/01/2024 6.03 Description: CALORIC VSTBLR TEST W/REC Category: Audiology CMS Add: 01/01/2016 CMS Term: 92540 26 AUDIO DEF RBRVS 01/01/2024 74.63 Description: BASIC VESTIBULAR EVALUATION Category: Audiology CMS Add: 01/01/2010 CMS Term: 92540 26 AUDIO DEF RBRVS 02/01/2015 12/31/2023 58.55 Description: BASIC VESTIBULAR EVALUATION Category: Audiology CMS Add: 01/01/2010 CMS Term: 92540 AUDIO DEF RBRVS 01/01/2024 103.81 Description: BASIC VESTIBULAR EVALUATION Category: Audiology CMS Add: 01/01/2010 CMS Term: 92540 AUDIO DEF RBRVS 02/01/2015 12/31/2023 73.58 Description: BASIC VESTIBULAR EVALUATION Category: Audiology CMS Add: 01/01/2010 CMS Term: 92540 TC AUDIO DEF RBRVS 01/01/2024 29.18 Description: BASIC VESTIBULAR EVALUATION Category: Audiology CMS Add: 01/01/2010 CMS Term: 92540 TC AUDIO DEF RBRVS 02/01/2015 12/31/2023 15.03 Description: BASIC VESTIBULAR EVALUATION Category: Audiology CMS Add: 01/01/2010 CMS Term: 92541 26 AUDIO DEF RBRVS 01/01/2024 20.20 Description: SPONTANEOUS NYSTAGMUS TEST Category: Audiology CMS Add: 01/01/1984 CMS Term: 92541 26 AUDIO DEF RBRVS 02/01/2015 12/31/2023 15.37 Description: SPONTANEOUS NYSTAGMUS TEST Category: Audiology CMS Add: 01/01/1984 CMS Term: 92541 AUDIO DEF RBRVS 01/01/2024 24.06 Description: SPONTANEOUS NYSTAGMUS TEST Category: Audiology CMS Add: 01/01/1984 CMS Term: 92541 AUDIO DEF RBRVS 02/01/2015 12/31/2023 21.98 Description: SPONTANEOUS NYSTAGMUS TEST Category: Audiology CMS Add: 01/01/1984 CMS Term: 92541 TC AUDIO DEF RBRVS 01/01/2024 3.87 Description: SPONTANEOUS NYSTAGMUS TEST Category: Audiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,264 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 92541 TC AUDIO DEF RBRVS 02/01/2015 12/31/2023 6.61 Description: SPONTANEOUS NYSTAGMUS TEST Category: Audiology CMS Add: 01/01/1984 CMS Term: 92542 26 AUDIO DEF RBRVS 01/01/2024 23.84 Description: POSITIONAL NYSTAGMUS TEST Category: Audiology CMS Add: 01/01/1984 CMS Term: 92542 26 AUDIO DEF RBRVS 02/01/2015 12/31/2023 12.75 Description: POSITIONAL NYSTAGMUS TEST Category: Audiology CMS Add: 01/01/1984 CMS Term: 92542 AUDIO DEF RBRVS 01/01/2024 27.70 Description: POSITIONAL NYSTAGMUS TEST Category: Audiology CMS Add: 01/01/1984 CMS Term: 92542 AUDIO DEF RBRVS 02/01/2015 12/31/2023 18.86 Description: POSITIONAL NYSTAGMUS TEST Category: Audiology CMS Add: 01/01/1984 CMS Term: 92542 TC AUDIO DEF RBRVS 01/01/2024 3.87 Description: POSITIONAL NYSTAGMUS TEST Category: Audiology CMS Add: 01/01/1984 CMS Term: 92542 TC AUDIO DEF RBRVS 02/01/2015 12/31/2023 6.11 Description: POSITIONAL NYSTAGMUS TEST Category: Audiology CMS Add: 01/01/1984 CMS Term: 92544 26 AUDIO DEF RBRVS 01/01/2024 13.63 Description: OPTOKINETIC NYSTAGMUS TEST Category: Audiology CMS Add: 01/01/1984 CMS Term: 92544 26 AUDIO DEF RBRVS 02/01/2015 12/31/2023 10.12 Description: OPTOKINETIC NYSTAGMUS TEST Category: Audiology CMS Add: 01/01/1984 CMS Term: 92544 AUDIO DEF RBRVS 01/01/2024 16.88 Description: OPTOKINETIC NYSTAGMUS TEST Category: Audiology CMS Add: 01/01/1984 CMS Term: 92544 AUDIO DEF RBRVS 02/01/2015 12/31/2023 16.98 Description: OPTOKINETIC NYSTAGMUS TEST Category: Audiology CMS Add: 01/01/1984 CMS Term: 92544 TC AUDIO DEF RBRVS 01/01/2024 3.25 Description: OPTOKINETIC NYSTAGMUS TEST Category: Audiology CMS Add: 01/01/1984 CMS Term: 92544 TC AUDIO DEF RBRVS 02/01/2015 12/31/2023 6.85 Description: OPTOKINETIC NYSTAGMUS TEST Category: Audiology CMS Add: 01/01/1984 CMS Term: 92545 26 AUDIO DEF RBRVS 01/01/2024 12.65 Description: OSCILLATING TRACKING TEST Category: Audiology CMS Add: 01/01/1984 CMS Term: 92545 26 AUDIO DEF RBRVS 02/01/2015 12/31/2023 8.82 Description: OSCILLATING TRACKING TEST Category: Audiology CMS Add: 01/01/1984 CMS Term: 92545 AUDIO DEF RBRVS 01/01/2024 15.89 Description: OSCILLATING TRACKING TEST Category: Audiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,265 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 92545 AUDIO DEF RBRVS 02/01/2015 12/31/2023 14.68 Description: OSCILLATING TRACKING TEST Category: Audiology CMS Add: 01/01/1984 CMS Term: 92545 TC AUDIO DEF RBRVS 01/01/2024 3.25 Description: OSCILLATING TRACKING TEST Category: Audiology CMS Add: 01/01/1984 CMS Term: 92545 TC AUDIO DEF RBRVS 02/01/2015 12/31/2023 5.86 Description: OSCILLATING TRACKING TEST Category: Audiology CMS Add: 01/01/1984 CMS Term: 92546 26 AUDIO DEF RBRVS 01/01/2024 14.31 Description: SINUSOIDAL ROTATIONAL TEST Category: Audiology CMS Add: 01/01/1984 CMS Term: 92546 26 AUDIO DEF RBRVS 02/01/2015 12/31/2023 11.18 Description: SINUSOIDAL ROTATIONAL TEST Category: Audiology CMS Add: 01/01/1984 CMS Term: 92546 AUDIO DEF RBRVS 01/01/2024 117.43 Description: SINUSOIDAL ROTATIONAL TEST Category: Audiology CMS Add: 01/01/1984 CMS Term: 92546 AUDIO DEF RBRVS 02/01/2015 12/31/2023 72.03 Description: SINUSOIDAL ROTATIONAL TEST Category: Audiology CMS Add: 01/01/1984 CMS Term: 92546 TC AUDIO DEF RBRVS 01/01/2024 103.12 Description: SINUSOIDAL ROTATIONAL TEST Category: Audiology CMS Add: 01/01/1984 CMS Term: 92546 TC AUDIO DEF RBRVS 02/01/2015 12/31/2023 60.86 Description: SINUSOIDAL ROTATIONAL TEST Category: Audiology CMS Add: 01/01/1984 CMS Term: 92547 AUDIO DEF RBRVS 01/01/2024 9.88 Description: SUPPLEMENTAL ELECTRICAL TEST Category: Audiology CMS Add: 01/01/1984 CMS Term: 92547 AUDIO DEF RBRVS 02/01/2015 12/31/2023 4.13 Description: SUPPLEMENTAL ELECTRICAL TEST Category: Audiology CMS Add: 01/01/1984 CMS Term: 92548 26 AUDIO DEF RBRVS 01/01/2024 32.29 Description: CDP-SOT 6 COND W/I&R Category: Audiology CMS Add: 01/01/1997 CMS Term: 92548 26 AUDIO DEF RBRVS 02/01/2015 12/31/2023 19.05 Description: CDP-SOT 6 COND W/I&R Category: Audiology CMS Add: 01/01/1997 CMS Term: 92548 AUDIO DEF RBRVS 01/01/2019 12/31/2023 73.22 Description: CDP-SOT 6 COND W/I&R Category: Audiology CMS Add: 01/01/1997 CMS Term: 92548 AUDIO DEF RBRVS 01/01/2024 45.11 Description: CDP-SOT 6 COND W/I&R Category: Audiology CMS Add: 01/01/1997 CMS Term: 92548 TC AUDIO DEF RBRVS 01/01/2019 12/31/2023 54.17 Description: CDP-SOT 6 COND W/I&R Category: Audiology CMS Add: 01/01/1997 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,266 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 92548 TC AUDIO DEF RBRVS 01/01/2024 12.82 Description: CDP-SOT 6 COND W/I&R Category: Audiology CMS Add: 01/01/1997 CMS Term: 92549 26 AUDIO DEF RBRVS 01/01/2020 12/31/2023 33.37 Description: CDP-SOT 6 COND W/I&R MCT&ADT Category: Audiology CMS Add: 01/01/2020 CMS Term: 92549 26 AUDIO DEF RBRVS 01/01/2024 43.23 Description: CDP-SOT 6 COND W/I&R MCT&ADT Category: Audiology CMS Add: 01/01/2020 CMS Term: 92549 AUDIO DEF RBRVS 01/01/2020 12/31/2023 46.16 Description: CDP-SOT 6 COND W/I&R MCT&ADT Category: Audiology CMS Add: 01/01/2020 CMS Term: 92549 AUDIO DEF RBRVS 01/01/2024 61.91 Description: CDP-SOT 6 COND W/I&R MCT&ADT Category: Audiology CMS Add: 01/01/2020 CMS Term: 92549 TC AUDIO DEF RBRVS 01/01/2020 12/31/2023 12.80 Description: CDP-SOT 6 COND W/I&R MCT&ADT Category: Audiology CMS Add: 01/01/2020 CMS Term: 92549 TC AUDIO DEF RBRVS 01/01/2024 18.68 Description: CDP-SOT 6 COND W/I&R MCT&ADT Category: Audiology CMS Add: 01/01/2020 CMS Term: 92550 AUDIO DEF RBRVS 01/01/2024 21.28 Description: TYMPANOMETRY & REFLEX THRESH Category: Audiology CMS Add: 01/01/2010 CMS Term: 92550 AUDIO DEF RBRVS 02/01/2015 12/31/2023 15.27 Description: TYMPANOMETRY & REFLEX THRESH Category: Audiology CMS Add: 01/01/2010 CMS Term: 92551 AUDIO DEF RBRVS 01/01/2024 10.97 Description: PURE TONE HEARING TEST AIR Category: Audiology CMS Add: 01/01/1982 CMS Term: 92551 AUDIO DEF RBRVS 02/01/2015 12/31/2023 8.09 Description: PURE TONE HEARING TEST AIR Category: Audiology CMS Add: 01/01/1982 CMS Term: 92551 MRT DEF RBRVS 01/01/2024 10.97 Description: PURE TONE HEARING TEST AIR Category: Medical Review Team CMS Add: 01/01/1982 CMS Term: 92551 MRT DEF RBRVS 02/01/2015 12/31/2023 8.09 Description: PURE TONE HEARING TEST AIR Category: Medical Review Team CMS Add: 01/01/1982 CMS Term: 92552 AUDIO DEF RBRVS 01/01/2024 32.58 Description: PURE TONE AUDIOMETRY AIR Category: Audiology CMS Add: 01/01/1984 CMS Term: 92552 AUDIO DEF RBRVS 02/01/2015 12/31/2023 21.22 Description: PURE TONE AUDIOMETRY AIR Category: Audiology CMS Add: 01/01/1984 CMS Term: 92552 MRT DEF RBRVS 01/01/2024 32.58 Description: PURE TONE AUDIOMETRY AIR Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,267 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 92552 MRT DEF RBRVS 02/01/2015 12/31/2023 21.22 Description: PURE TONE AUDIOMETRY AIR Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 92553 AUDIO DEF RBRVS 01/01/2024 39.98 Description: AUDIOMETRY AIR & BONE Category: Audiology CMS Add: 01/01/1984 CMS Term: 92553 AUDIO DEF RBRVS 02/01/2015 12/31/2023 25.43 Description: AUDIOMETRY AIR & BONE Category: Audiology CMS Add: 01/01/1984 CMS Term: 92553 MRT DEF RBRVS 01/01/2024 39.98 Description: AUDIOMETRY AIR & BONE Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 92553 MRT DEF RBRVS 02/01/2015 12/31/2023 25.43 Description: AUDIOMETRY AIR & BONE Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 92555 AUDIO DEF RBRVS 01/01/2024 25.17 Description: SPEECH THRESHOLD AUDIOMETRY Category: Audiology CMS Add: 01/01/1984 CMS Term: 92555 AUDIO DEF RBRVS 02/01/2015 12/31/2023 15.77 Description: SPEECH THRESHOLD AUDIOMETRY Category: Audiology CMS Add: 01/01/1984 CMS Term: 92556 AUDIO DEF RBRVS 01/01/2024 39.06 Description: SPEECH AUDIOMETRY COMPLETE Category: Audiology CMS Add: 01/01/1984 CMS Term: 92556 AUDIO DEF RBRVS 02/01/2015 12/31/2023 25.18 Description: SPEECH AUDIOMETRY COMPLETE Category: Audiology CMS Add: 01/01/1984 CMS Term: 92557 AUDIO DEF RBRVS 01/01/2024 35.47 Description: COMPREHENSIVE HEARING TEST Category: Audiology CMS Add: 01/01/1984 CMS Term: 92557 AUDIO DEF RBRVS 02/01/2015 12/31/2023 27.27 Description: COMPREHENSIVE HEARING TEST Category: Audiology CMS Add: 01/01/1984 CMS Term: 92557 MRT DEF RBRVS 01/01/2024 35.47 Description: COMPREHENSIVE HEARING TEST Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 92557 MRT DEF RBRVS 02/01/2015 12/31/2023 27.27 Description: COMPREHENSIVE HEARING TEST Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 92558 NOCOV DEF SYSMAN Description: EVOKED AUDITORY TEST QUAL Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 92562 AUDIO DEF RBRVS 01/01/2024 44.00 Description: LOUDNESS BALANCE TEST Category: Audiology CMS Add: 01/01/1984 CMS Term: 92562 AUDIO DEF RBRVS 02/01/2015 12/31/2023 31.87 Description: LOUDNESS BALANCE TEST Category: Audiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,268 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 92563 AUDIO DEF RBRVS 01/01/2024 30.41 Description: TONE DECAY HEARING TEST Category: Audiology CMS Add: 01/01/1984 CMS Term: 92563 AUDIO DEF RBRVS 02/01/2015 12/31/2023 20.97 Description: TONE DECAY HEARING TEST Category: Audiology CMS Add: 01/01/1984 CMS Term: 92565 AUDIO DEF RBRVS 01/01/2024 18.37 Description: STENGER TEST PURE TONE Category: Audiology CMS Add: 01/01/1984 CMS Term: 92565 AUDIO DEF RBRVS 02/01/2015 12/31/2023 11.31 Description: STENGER TEST PURE TONE Category: Audiology CMS Add: 01/01/1984 CMS Term: 92567 AUDIO DEF RBRVS 01/01/2024 15.58 Description: TYMPANOMETRY Category: Audiology CMS Add: 01/01/1984 CMS Term: 92567 AUDIO DEF RBRVS 02/01/2015 12/31/2023 10.49 Description: TYMPANOMETRY Category: Audiology CMS Add: 01/01/1984 CMS Term: 92568 AUDIO DEF RBRVS 01/01/2024 14.78 Description: ACOUSTIC REFL THRESHOLD TST Category: Audiology CMS Add: 01/01/1984 CMS Term: 92568 AUDIO DEF RBRVS 02/01/2015 12/31/2023 11.42 Description: ACOUSTIC REFL THRESHOLD TST Category: Audiology CMS Add: 01/01/1984 CMS Term: 92570 AUDIO DEF RBRVS 01/01/2024 31.00 Description: ACOUSTIC IMMITANCE TESTING Category: Audiology CMS Add: 01/01/2010 CMS Term: 92570 AUDIO DEF RBRVS 02/01/2015 12/31/2023 23.45 Description: ACOUSTIC IMMITANCE TESTING Category: Audiology CMS Add: 01/01/2010 CMS Term: 92571 AUDIO DEF RBRVS 01/01/2024 27.64 Description: FILTERED SPEECH HEARING TEST Category: Audiology CMS Add: 01/01/1984 CMS Term: 92571 AUDIO DEF RBRVS 02/01/2015 12/31/2023 18.50 Description: FILTERED SPEECH HEARING TEST Category: Audiology CMS Add: 01/01/1984 CMS Term: 92572 AUDIO DEF RBRVS 01/01/2024 43.38 Description: STAGGERED SPONDAIC WORD TEST Category: Audiology CMS Add: 01/01/1984 CMS Term: 92572 AUDIO DEF RBRVS 02/01/2015 12/31/2023 35.34 Description: STAGGERED SPONDAIC WORD TEST Category: Audiology CMS Add: 01/01/1984 CMS Term: 92575 AUDIO DEF RBRVS 01/01/2024 68.55 Description: SENSORINEURAL ACUITY TEST Category: Audiology CMS Add: 01/01/1984 CMS Term: 92575 AUDIO DEF RBRVS 02/01/2015 12/31/2023 51.69 Description: SENSORINEURAL ACUITY TEST Category: Audiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,269 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 92576 AUDIO DEF RBRVS 01/01/2024 36.59 Description: SYNTHETIC SENTENCE TEST Category: Audiology CMS Add: 01/01/1984 CMS Term: 92576 AUDIO DEF RBRVS 02/01/2015 12/31/2023 23.95 Description: SYNTHETIC SENTENCE TEST Category: Audiology CMS Add: 01/01/1984 CMS Term: 92577 AUDIO DEF RBRVS 01/01/2024 18.68 Description: STENGER TEST SPEECH Category: Audiology CMS Add: 01/01/1984 CMS Term: 92577 AUDIO DEF RBRVS 02/01/2015 12/31/2023 13.29 Description: STENGER TEST SPEECH Category: Audiology CMS Add: 01/01/1984 CMS Term: 92579 AUDIO DEF RBRVS 01/01/2024 43.18 Description: VISUAL AUDIOMETRY (VRA) Category: Audiology CMS Add: 01/01/1996 CMS Term: 92579 AUDIO DEF RBRVS 02/01/2015 12/31/2023 30.70 Description: VISUAL AUDIOMETRY (VRA) Category: Audiology CMS Add: 01/01/1996 CMS Term: 92582 AUDIO DEF RBRVS 01/01/2024 75.49 Description: CONDITIONING PLAY AUDIOMETRY Category: Audiology CMS Add: 01/01/1984 CMS Term: 92582 AUDIO DEF RBRVS 02/01/2015 12/31/2023 47.23 Description: CONDITIONING PLAY AUDIOMETRY Category: Audiology CMS Add: 01/01/1984 CMS Term: 92583 AUDIO DEF RBRVS 01/01/2024 49.86 Description: SELECT PICTURE AUDIOMETRY Category: Audiology CMS Add: 01/01/1984 CMS Term: 92583 AUDIO DEF RBRVS 02/01/2015 12/31/2023 35.84 Description: SELECT PICTURE AUDIOMETRY Category: Audiology CMS Add: 01/01/1984 CMS Term: 92584 AUDIO DEF RBRVS 01/01/2024 106.77 Description: ELECTROCOCHLEOGRAPHY Category: Audiology CMS Add: 01/01/1984 CMS Term: 92584 AUDIO DEF RBRVS 02/01/2015 12/31/2023 48.72 Description: ELECTROCOCHLEOGRAPHY Category: Audiology CMS Add: 01/01/1984 CMS Term: 92587 26 AUDIO DEF RBRVS 01/01/2016 12/31/2023 13.86 Description: EVOKED AUDITORY TEST LIMITED Category: Audiology CMS Add: 01/01/1995 CMS Term: 92587 26 AUDIO DEF RBRVS 01/01/2024 17.27 Description: EVOKED AUDITORY TEST LIMITED Category: Audiology CMS Add: 01/01/1995 CMS Term: 92587 AUDIO DEF RBRVS 01/01/2019 12/31/2023 15.76 Description: EVOKED AUDITORY TEST LIMITED Category: Audiology CMS Add: 01/01/1995 CMS Term: 92587 AUDIO DEF RBRVS 01/01/2024 20.83 Description: EVOKED AUDITORY TEST LIMITED Category: Audiology CMS Add: 01/01/1995 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,270 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 92587 TC AUDIO DEF RBRVS 01/01/2016 12/31/2023 1.90 Description: EVOKED AUDITORY TEST LIMITED Category: Audiology CMS Add: 01/01/1995 CMS Term: 92587 TC AUDIO DEF RBRVS 01/01/2024 3.56 Description: EVOKED AUDITORY TEST LIMITED Category: Audiology CMS Add: 01/01/1995 CMS Term: 92588 26 AUDIO DEF RBRVS 01/01/2016 12/31/2023 21.55 Description: EVOKED AUDITORY TST COMPLETE Category: Audiology CMS Add: 01/01/1995 CMS Term: 92588 26 AUDIO DEF RBRVS 01/01/2024 27.75 Description: EVOKED AUDITORY TST COMPLETE Category: Audiology CMS Add: 01/01/1995 CMS Term: 92588 AUDIO DEF RBRVS 01/01/2019 12/31/2023 24.19 Description: EVOKED AUDITORY TST COMPLETE Category: Audiology CMS Add: 01/01/1995 CMS Term: 92588 AUDIO DEF RBRVS 01/01/2024 32.54 Description: EVOKED AUDITORY TST COMPLETE Category: Audiology CMS Add: 01/01/1995 CMS Term: 92588 TC AUDIO DEF RBRVS 01/01/2016 12/31/2023 2.64 Description: EVOKED AUDITORY TST COMPLETE Category: Audiology CMS Add: 01/01/1995 CMS Term: 92588 TC AUDIO DEF RBRVS 01/01/2024 4.79 Description: EVOKED AUDITORY TST COMPLETE Category: Audiology CMS Add: 01/01/1995 CMS Term: 92590 AUDIO PRF MAXFEE 01/01/2024 54.95 0.0 Description: HEARING AID EXAM ONE EAR Category: Audiology CMS Add: 01/01/1982 CMS Term: 92591 AUDIO PRF MAXFEE 01/01/2024 64.38 0.0 Description: HEARING AID EXAM BOTH EARS Category: Audiology CMS Add: 01/01/1982 CMS Term: 92592 AUDIO PRF MAXFEE 01/01/2024 49.92 0.0 Description: HEARING AID CHECK ONE EAR Category: Audiology CMS Add: 01/01/1982 CMS Term: 92593 AUDIO PRF MAXFEE 01/01/2024 56.52 0.0 Description: HEARING AID CHECK BOTH EARS Category: Audiology CMS Add: 01/01/1982 CMS Term: 92594 AUDIO DEF BILL40 Description: ELECTRO HEARNG AID TEST ONE Category: Audiology CMS Add: 01/01/1985 CMS Term: 92595 AUDIO DEF BILL40 Description: ELECTRO HEARNG AID TST BOTH Category: Audiology CMS Add: 01/01/1984 CMS Term: 92596 AUDIO DEF RBRVS 01/01/2024 67.46 Description: EAR PROTECTOR EVALUATION Category: Audiology CMS Add: 01/01/1984 CMS Term: 92596 AUDIO DEF RBRVS 02/01/2015 12/31/2023 29.40 Description: EAR PROTECTOR EVALUATION Category: Audiology CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,271 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 92597 AUDIO DEF RBRVS 01/01/2024 69.27 Y Description: ORAL SPEECH DEVICE EVAL Category: Audiology CMS Add: 01/01/1996 CMS Term: 92597 AUDIO DEF RBRVS 09/01/2019 12/31/2023 52.84 Y Description: ORAL SPEECH DEVICE EVAL Category: Audiology CMS Add: 01/01/1996 CMS Term: 92601 AUDIO DEF RBRVS 01/01/2024 154.23 0-6years Description: COCHLEAR IMPLT F/UP EXAM <7 Category: Audiology CMS Add: 01/01/2003 CMS Term: 92601 AUDIO DEF RBRVS 02/01/2015 12/31/2023 101.26 0-6years Description: COCHLEAR IMPLT F/UP EXAM <7 Category: Audiology CMS Add: 01/01/2003 CMS Term: 92602 AUDIO DEF RBRVS 01/01/2024 97.18 0-6years Description: REPROGRAM COCHLEAR IMPLT <7 Category: Audiology CMS Add: 01/01/2003 CMS Term: 92602 AUDIO DEF RBRVS 02/01/2015 12/31/2023 59.62 0-6years Description: REPROGRAM COCHLEAR IMPLT <7 Category: Audiology CMS Add: 01/01/2003 CMS Term: 92603 AUDIO DEF RBRVS 01/01/2024 144.82 7-999years Description: COCHLEAR IMPLT F/UP EXAM 7/> Category: Audiology CMS Add: 01/01/2003 CMS Term: 92603 AUDIO DEF RBRVS 02/01/2015 12/31/2023 106.61 7-999years Description: COCHLEAR IMPLT F/UP EXAM 7/> Category: Audiology CMS Add: 01/01/2003 CMS Term: 92604 AUDIO DEF RBRVS 01/01/2024 87.15 7-999years Description: REPROGRAM COCHLEAR IMPLT 7/> Category: Audiology CMS Add: 01/01/2003 CMS Term: 92604 AUDIO DEF RBRVS 02/01/2015 12/31/2023 64.14 7-999years Description: REPROGRAM COCHLEAR IMPLT 7/> Category: Audiology CMS Add: 01/01/2003 CMS Term: 92605 NOCOV DEF SYSMAN Description: EX FOR NONSPEECH DEVICE RX Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: 92606 NOCOV DEF SYSMAN Description: NON-SPEECH DEVICE SERVICE Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: 92607 AUDIO DEF RBRVS 01/01/2024 118.90 Y Description: EX FOR SPEECH DEVICE RX 1HR Category: Audiology CMS Add: 01/01/2003 CMS Term: 92607 AUDIO DEF RBRVS 09/01/2019 12/31/2023 92.97 Y Description: EX FOR SPEECH DEVICE RX 1HR Category: Audiology CMS Add: 01/01/2003 CMS Term: 92608 AUDIO DEF RBRVS 01/01/2024 46.58 Y Description: EX FOR SPEECH DEVICE RX ADDL Category: Audiology CMS Add: 01/01/2003 CMS Term: 92608 AUDIO DEF RBRVS 02/01/2015 12/31/2023 38.29 Y Description: EX FOR SPEECH DEVICE RX ADDL Category: Audiology CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,272 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 92609 AUDIO DEF RBRVS 01/01/2024 99.02 Y Description: USE OF SPEECH DEVICE SERVICE Category: Audiology CMS Add: 01/01/2003 CMS Term: 92609 AUDIO DEF RBRVS 09/01/2019 12/31/2023 80.35 Y Description: USE OF SPEECH DEVICE SERVICE Category: Audiology CMS Add: 01/01/2003 CMS Term: 92610 THEPY DEF RBRVS 01/01/2024 81.43 Description: EVALUATE SWALLOWING FUNCTION Category: Therapy Services CMS Add: 01/01/2003 CMS Term: 92610 THEPY DEF RBRVS 02/01/2015 12/31/2023 61.60 Description: EVALUATE SWALLOWING FUNCTION Category: Therapy Services CMS Add: 01/01/2003 CMS Term: 92611 AUDIO DEF RBRVS 01/01/2024 87.14 Description: MOTION FLUOROSCOPY/SWALLOW Category: Audiology CMS Add: 01/01/2003 CMS Term: 92611 AUDIO DEF RBRVS 02/01/2015 12/31/2023 65.81 Description: MOTION FLUOROSCOPY/SWALLOW Category: Audiology CMS Add: 01/01/2003 CMS Term: 92612 AUDIO DEF RBRVS 01/01/2024 184.47 Description: ENDOSCOPY SWALLOW (FEES) VID Category: Audiology CMS Add: 01/01/2003 CMS Term: 92612 AUDIO DEF RBRVS 02/01/2015 12/31/2023 125.94 Description: ENDOSCOPY SWALLOW (FEES) VID Category: Audiology CMS Add: 01/01/2003 CMS Term: 92613 AUDIO DEF RBRVS 01/01/2024 35.20 Description: ENDOSCOPY SWALLOW (FEES) I&R Category: Audiology CMS Add: 01/01/2003 CMS Term: 92613 AUDIO DEF RBRVS 02/01/2015 12/31/2023 27.66 Description: ENDOSCOPY SWALLOW (FEES) I&R Category: Audiology CMS Add: 01/01/2003 CMS Term: 92614 AUDIO DEF RBRVS 01/01/2024 138.32 Description: LARYNGOSCOPIC SENSORY VID Category: Audiology CMS Add: 01/01/2003 CMS Term: 92614 AUDIO DEF RBRVS 02/01/2015 12/31/2023 106.87 Description: LARYNGOSCOPIC SENSORY VID Category: Audiology CMS Add: 01/01/2003 CMS Term: 92615 AUDIO DEF RBRVS 01/01/2024 31.25 Description: LARYNGOSCOPIC SENSORY I&R Category: Audiology CMS Add: 01/01/2003 CMS Term: 92615 AUDIO DEF RBRVS 02/01/2015 12/31/2023 24.85 Description: LARYNGOSCOPIC SENSORY I&R Category: Audiology CMS Add: 01/01/2003 CMS Term: 92616 AUDIO DEF RBRVS 01/01/2024 211.03 Description: FEES W/LARYNGEAL SENSE TEST Category: Audiology CMS Add: 01/01/2003 CMS Term: 92616 AUDIO DEF RBRVS 02/01/2015 12/31/2023 150.75 Description: FEES W/LARYNGEAL SENSE TEST Category: Audiology CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,273 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 92617 AUDIO DEF RBRVS 01/01/2024 39.15 Description: FEES W/LARYNGEAL SENSE I&R Category: Audiology CMS Add: 01/01/2003 CMS Term: 92617 AUDIO DEF RBRVS 02/01/2015 12/31/2023 30.80 Description: FEES W/LARYNGEAL SENSE I&R Category: Audiology CMS Add: 01/01/2003 CMS Term: 92618 NOCOV DEF SYSMAN Description: EX FOR NONSPEECH DEV RX ADD Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 92620 AUDIO DEF RBRVS 01/01/2024 85.14 Description: AUDITORY FUNCTION 60 MIN Category: Audiology CMS Add: 01/01/2005 CMS Term: 92620 AUDIO DEF RBRVS 02/01/2015 12/31/2023 68.21 Description: AUDITORY FUNCTION 60 MIN Category: Audiology CMS Add: 01/01/2005 CMS Term: 92621 AUDIO DEF RBRVS 01/01/2016 12/31/2023 16.26 Description: AUDITORY FUNCTION + 15 MIN Category: Audiology CMS Add: 01/01/2005 CMS Term: 92621 AUDIO DEF RBRVS 01/01/2024 20.97 Description: AUDITORY FUNCTION + 15 MIN Category: Audiology CMS Add: 01/01/2005 CMS Term: 92622 NOCOV DEF SYSMAN Description: DX ALY AUD OI SND PRCSR 1ST Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 92623 NOCOV DEF SYSMAN Description: DX ALY AUD OI SND PRCSR EACH Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 92625 AUDIO DEF RBRVS 01/01/2024 65.55 Description: TINNITUS ASSESSMENT Category: Audiology CMS Add: 01/01/2005 CMS Term: 92625 AUDIO DEF RBRVS 02/01/2015 12/31/2023 50.80 Description: TINNITUS ASSESSMENT Category: Audiology CMS Add: 01/01/2005 CMS Term: 92626 AUDIO DEF RBRVS 01/01/2024 83.59 Description: EVAL AUD FUNCJ 1ST HOUR Category: Audiology CMS Add: 01/01/2006 CMS Term: 92626 AUDIO DEF RBRVS 02/01/2015 12/31/2023 65.28 Description: EVAL AUD FUNCJ 1ST HOUR Category: Audiology CMS Add: 01/01/2006 CMS Term: 92627 AUDIO DEF RBRVS 01/01/2016 12/31/2023 15.72 Description: EVAL AUD FUNCJ EA ADDL 15 Category: Audiology CMS Add: 01/01/2006 CMS Term: 92627 AUDIO DEF RBRVS 01/01/2024 19.68 Description: EVAL AUD FUNCJ EA ADDL 15 Category: Audiology CMS Add: 01/01/2006 CMS Term: 92630 AUDIO DEF MAXFEE 01/01/2024 108.05 0.0 Description: AUD REHAB PRE-LING HEAR LOSS Category: Audiology CMS Add: 01/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,274 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 92633 AUDIO DEF MAXFEE 01/01/2024 108.05 0.0 Description: AUD REHAB POSTLING HEAR LOSS Category: Audiology CMS Add: 01/01/2006 CMS Term: 92640 AUDIO DEF RBRVS 01/01/2024 105.67 Y Description: AUD BRAINSTEM IMPLT PROGRAMG Category: Audiology CMS Add: 01/01/2007 CMS Term: 92640 AUDIO DEF RBRVS 02/01/2015 12/31/2023 87.25 Y Description: AUD BRAINSTEM IMPLT PROGRAMG Category: Audiology CMS Add: 01/01/2007 CMS Term: 92650 AUDIO DEF RBRVS 01/01/2021 12/31/2023 21.41 Description: AEP SCR AUDITORY POTENTIAL Category: Audiology CMS Add: 01/01/2021 CMS Term: 92650 AUDIO DEF RBRVS 01/01/2024 26.08 Description: AEP SCR AUDITORY POTENTIAL Category: Audiology CMS Add: 01/01/2021 CMS Term: 92651 AUDIO DEF RBRVS 01/01/2021 12/31/2023 67.08 Description: AEP HEARING STATUS DETER I&R Category: Audiology CMS Add: 01/01/2021 CMS Term: 92651 AUDIO DEF RBRVS 01/01/2024 80.53 Description: AEP HEARING STATUS DETER I&R Category: Audiology CMS Add: 01/01/2021 CMS Term: 92652 AUDIO DEF RBRVS 01/01/2021 12/31/2023 88.85 Description: AEP THRSHLD EST MLT FREQ I&R Category: Audiology CMS Add: 01/01/2021 CMS Term: 92652 AUDIO DEF RBRVS 01/01/2024 107.69 Description: AEP THRSHLD EST MLT FREQ I&R Category: Audiology CMS Add: 01/01/2021 CMS Term: 92653 AUDIO DEF RBRVS 01/01/2021 12/31/2023 65.29 Description: AEP NEURODIAGNOSTIC I&R Category: Audiology CMS Add: 01/01/2021 CMS Term: 92653 AUDIO DEF RBRVS 01/01/2024 80.08 Description: AEP NEURODIAGNOSTIC I&R Category: Audiology CMS Add: 01/01/2021 CMS Term: 92700 AUDIO DEF BILL40 Description: UNLISTED ORL SERVICE/PX Category: Audiology CMS Add: 01/01/2003 CMS Term: 92920 MEDSV DEF RBRVS 01/01/2024 472.90 0-1 Description: PRQ CARDIAC ANGIOPLAST 1 ART Category: Medical Services CMS Add: 01/01/2013 CMS Term: 92920 MEDSV DEF RBRVS 09/15/2017 12/31/2023 385.88 0-1 Description: PRQ CARDIAC ANGIOPLAST 1 ART Category: Medical Services CMS Add: 01/01/2013 CMS Term: 92924 MEDSV DEF RBRVS 01/01/2024 564.42 0-1 Description: PRQ CARD ANGIO/ATHRECT 1 ART Category: Medical Services CMS Add: 01/01/2013 CMS Term: 92924 MEDSV DEF RBRVS 09/15/2017 12/31/2023 460.36 0-1 Description: PRQ CARD ANGIO/ATHRECT 1 ART Category: Medical Services CMS Add: 01/01/2013 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,275 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 92928 MEDSV DEF RBRVS 01/01/2024 526.75 0-1 Description: PRQ CARD STENT W/ANGIO 1 VSL Category: Medical Services CMS Add: 01/01/2013 CMS Term: 92928 MEDSV DEF RBRVS 09/15/2017 12/31/2023 429.33 0-1 Description: PRQ CARD STENT W/ANGIO 1 VSL Category: Medical Services CMS Add: 01/01/2013 CMS Term: 92933 MEDSV DEF RBRVS 01/01/2024 590.38 0-1 Description: PRQ CARD STENT/ATH/ANGIO Category: Medical Services CMS Add: 01/01/2013 CMS Term: 92933 MEDSV DEF RBRVS 09/15/2017 12/31/2023 481.58 0-1 Description: PRQ CARD STENT/ATH/ANGIO Category: Medical Services CMS Add: 01/01/2013 CMS Term: 92937 MEDSV DEF RBRVS 01/01/2024 526.11 0-1 Description: PRQ REVASC BYP GRAFT 1 VSL Category: Medical Services CMS Add: 01/01/2013 CMS Term: 92937 MEDSV DEF RBRVS 09/15/2017 12/31/2023 429.06 0-1 Description: PRQ REVASC BYP GRAFT 1 VSL Category: Medical Services CMS Add: 01/01/2013 CMS Term: 92941 MEDSV DEF RBRVS 01/01/2024 591.36 0-1 Description: PRQ CARD REVASC MI 1 VSL Category: Medical Services CMS Add: 01/01/2013 CMS Term: 92941 MEDSV DEF RBRVS 09/15/2017 12/31/2023 482.53 0-1 Description: PRQ CARD REVASC MI 1 VSL Category: Medical Services CMS Add: 01/01/2013 CMS Term: 92943 MEDSV DEF RBRVS 01/01/2024 591.53 0-1 Description: PRQ CARD REVASC CHRONIC 1VSL Category: Medical Services CMS Add: 01/01/2013 CMS Term: 92943 MEDSV DEF RBRVS 09/15/2017 12/31/2023 482.20 0-1 Description: PRQ CARD REVASC CHRONIC 1VSL Category: Medical Services CMS Add: 01/01/2013 CMS Term: 92950 MEDSV DEF RBRVS 01/01/2024 307.14 Description: HEART/LUNG RESUSCITATION CPR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 92950 MEDSV DEF RBRVS 02/01/2015 12/31/2023 216.88 Description: HEART/LUNG RESUSCITATION CPR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 92953 MEDSV DEF RBRVS 09/15/2017 0.81 Description: TEMPORARY EXTERNAL PACING Category: Medical Services CMS Add: 01/01/1988 CMS Term: 92960 MEDSV DEF RBRVS 01/01/2024 146.15 Description: CARDIOVERSION ELECTRIC EXT Category: Medical Services CMS Add: 01/01/1982 CMS Term: 92960 MEDSV DEF RBRVS 09/15/2017 12/31/2023 114.26 Description: CARDIOVERSION ELECTRIC EXT Category: Medical Services CMS Add: 01/01/1982 CMS Term: 92961 MEDSV DEF RBRVS 01/01/2024 220.68 0-1 Description: CARDIOVERSION ELECTRIC INT Category: Medical Services CMS Add: 01/01/2000 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,276 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 92961 MEDSV DEF RBRVS 09/15/2017 12/31/2023 180.36 0-1 Description: CARDIOVERSION ELECTRIC INT Category: Medical Services CMS Add: 01/01/2000 CMS Term: 92970 MEDSV DEF RBRVS 01/01/2024 168.40 Description: CARDIOASSIST INTERNAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 92970 MEDSV DEF RBRVS 02/01/2015 12/31/2023 129.07 Description: CARDIOASSIST INTERNAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 92971 MEDSV DEF RBRVS 01/01/2024 89.88 Description: CARDIOASSIST EXTERNAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 92971 MEDSV DEF RBRVS 02/01/2015 12/31/2023 67.95 Description: CARDIOASSIST EXTERNAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 92972 NOCOV DEF SYSMAN Description: PERQ TRLUML CORONRY LITHOTRP Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 92973 MEDSV DEF RBRVS 01/01/2024 157.32 Description: PRQ CORONARY MECH THROMBECT Category: Medical Services CMS Add: 01/01/2002 CMS Term: 92973 MEDSV DEF RBRVS 09/15/2017 12/31/2023 128.34 Description: PRQ CORONARY MECH THROMBECT Category: Medical Services CMS Add: 01/01/2002 CMS Term: 92974 MEDSV DEF RBRVS 01/01/2024 144.08 Description: CATH PLACE CARDIO BRACHYTX Category: Medical Services CMS Add: 01/01/2002 CMS Term: 92974 MEDSV DEF RBRVS 09/15/2017 12/31/2023 117.43 Description: CATH PLACE CARDIO BRACHYTX Category: Medical Services CMS Add: 01/01/2002 CMS Term: 92975 MEDSV DEF RBRVS 01/01/2024 335.93 Description: DISSOLVE CLOT HEART VESSEL Category: Medical Services CMS Add: 01/01/1986 CMS Term: 92975 MEDSV DEF RBRVS 09/15/2017 12/31/2023 273.61 Description: DISSOLVE CLOT HEART VESSEL Category: Medical Services CMS Add: 01/01/1986 CMS Term: 92977 MEDSV DEF RBRVS 01/01/2024 47.00 Description: DISSOLVE CLOT HEART VESSEL Category: Medical Services CMS Add: 01/01/1986 CMS Term: 92977 MEDSV DEF RBRVS 02/01/2015 12/31/2023 87.44 Description: DISSOLVE CLOT HEART VESSEL Category: Medical Services CMS Add: 01/01/1986 CMS Term: 92978 26 MEDSV DEF RBRVS 01/01/2024 85.61 Description: ENDOLUMINL IVUS OCT C 1ST Category: Medical Services CMS Add: 01/01/1997 CMS Term: 92978 26 MEDSV DEF RBRVS 09/15/2017 12/31/2023 69.67 Description: ENDOLUMINL IVUS OCT C 1ST Category: Medical Services CMS Add: 01/01/1997 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,277 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 92978 MEDSV PRF MAXFEE 01/01/2024 276.64 0.0 Description: ENDOLUMINL IVUS OCT C 1ST Category: Medical Services CMS Add: 01/01/1997 CMS Term: 92978 TC MEDSV PRF MAXFEE 01/01/2024 177.97 0.0 Description: ENDOLUMINL IVUS OCT C 1ST Category: Medical Services CMS Add: 01/01/1997 CMS Term: 92979 26 MEDSV DEF RBRVS 01/01/2024 68.42 Description: ENDOLUMINL IVUS OCT C EA Category: Medical Services CMS Add: 01/01/1997 CMS Term: 92979 26 MEDSV DEF RBRVS 09/15/2017 12/31/2023 55.87 Description: ENDOLUMINL IVUS OCT C EA Category: Medical Services CMS Add: 01/01/1997 CMS Term: 92979 MEDSV PRF MAXFEE 01/01/2024 168.91 0.0 Description: ENDOLUMINL IVUS OCT C EA Category: Medical Services CMS Add: 01/01/1997 CMS Term: 92979 TC MEDSV PRF MAXFEE 01/01/2024 89.75 0.0 Description: ENDOLUMINL IVUS OCT C EA Category: Medical Services CMS Add: 01/01/1997 CMS Term: 92986 MEDSV DEF RBRVS 01/01/2024 1187.92 Description: REVISION OF AORTIC VALVE Category: Medical Services CMS Add: 01/01/1992 CMS Term: 92986 MEDSV DEF RBRVS 09/15/2017 12/31/2023 955.36 Description: REVISION OF AORTIC VALVE Category: Medical Services CMS Add: 01/01/1992 CMS Term: 92987 MEDSV DEF RBRVS 01/01/2024 1228.37 Description: REVISION OF MITRAL VALVE Category: Medical Services CMS Add: 01/01/1996 CMS Term: 92987 MEDSV DEF RBRVS 09/15/2017 12/31/2023 986.31 Description: REVISION OF MITRAL VALVE Category: Medical Services CMS Add: 01/01/1996 CMS Term: 92990 MEDSV DEF RBRVS 01/01/2024 979.80 Description: REVISION OF PULMONARY VALVE Category: Medical Services CMS Add: 01/01/1992 CMS Term: 92990 MEDSV DEF RBRVS 09/01/2019 12/31/2023 776.43 Description: REVISION OF PULMONARY VALVE Category: Medical Services CMS Add: 01/01/1992 CMS Term: 92997 MEDSV DEF RBRVS 01/01/2024 575.16 Description: PUL ART BALLOON REPR PERCUT Category: Medical Services CMS Add: 01/01/1998 CMS Term: 92997 MEDSV DEF RBRVS 02/01/2015 12/31/2023 469.20 Description: PUL ART BALLOON REPR PERCUT Category: Medical Services CMS Add: 01/01/1998 CMS Term: 92998 MEDSV DEF RBRVS 01/01/2024 285.63 Description: PUL ART BALLOON REPR PERCUT Category: Medical Services CMS Add: 01/01/1998 CMS Term: 92998 MEDSV DEF RBRVS 02/01/2015 12/31/2023 232.12 Description: PUL ART BALLOON REPR PERCUT Category: Medical Services CMS Add: 01/01/1998 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,278 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 93000 MEDSV DEF RBRVS 01/01/2024 13.49 Description: ELECTROCARDIOGRAM COMPLETE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93000 MEDSV DEF RBRVS 09/01/2019 12/31/2023 11.83 Description: ELECTROCARDIOGRAM COMPLETE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93000 MRT DEF RBRVS 01/01/2024 13.49 Description: ELECTROCARDIOGRAM COMPLETE Category: Medical Review Team CMS Add: 01/01/1982 CMS Term: 93000 MRT DEF RBRVS 09/01/2019 12/31/2023 11.83 Description: ELECTROCARDIOGRAM COMPLETE Category: Medical Review Team CMS Add: 01/01/1982 CMS Term: 93005 MEDSV DEF RBRVS 01/01/2024 5.72 Description: ELECTROCARDIOGRAM TRACING Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93005 MEDSV DEF RBRVS 09/01/2019 12/31/2023 5.61 Description: ELECTROCARDIOGRAM TRACING Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93010 MEDSV DEF RBRVS 01/01/2024 7.77 Description: ELECTROCARDIOGRAM REPORT Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93010 MEDSV DEF RBRVS 02/01/2015 12/31/2023 6.22 Description: ELECTROCARDIOGRAM REPORT Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93010 MRT DEF RBRVS 01/01/2024 7.77 Description: ELECTROCARDIOGRAM REPORT Category: Medical Review Team CMS Add: 01/01/1982 CMS Term: 93010 MRT DEF RBRVS 02/01/2015 12/31/2023 6.22 Description: ELECTROCARDIOGRAM REPORT Category: Medical Review Team CMS Add: 01/01/1982 CMS Term: 93015 MEDSV DEF RBRVS 01/01/2024 66.50 Description: CARDIOVASCULAR STRESS TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 93015 MEDSV DEF RBRVS 09/01/2019 12/31/2023 53.84 Description: CARDIOVASCULAR STRESS TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 93016 MEDSV DEF RBRVS 01/01/2024 20.35 Description: CARDIOVASCULAR STRESS TEST Category: Medical Services CMS Add: 01/01/1994 CMS Term: 93016 MEDSV DEF RBRVS 02/01/2015 12/31/2023 16.22 Description: CARDIOVASCULAR STRESS TEST Category: Medical Services CMS Add: 01/01/1994 CMS Term: 93017 MEDSV DEF RBRVS 01/01/2024 32.74 Description: CARDIOVASCULAR STRESS TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 93017 MEDSV DEF RBRVS 09/01/2019 12/31/2023 26.92 Description: CARDIOVASCULAR STRESS TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,279 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 93018 MEDSV DEF RBRVS 01/01/2024 13.41 Description: CARDIOVASCULAR STRESS TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 93018 MEDSV DEF RBRVS 02/01/2015 12/31/2023 10.70 Description: CARDIOVASCULAR STRESS TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 93024 26 MEDSV DEF RBRVS 01/01/2024 52.64 Description: CARDIAC DRUG STRESS TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 93024 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 42.25 Description: CARDIAC DRUG STRESS TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 93024 MEDSV DEF RBRVS 01/01/2024 103.30 Description: CARDIAC DRUG STRESS TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 93024 MEDSV DEF RBRVS 09/01/2019 12/31/2023 79.57 Description: CARDIAC DRUG STRESS TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 93024 TC MEDSV DEF RBRVS 01/01/2024 50.66 Description: CARDIAC DRUG STRESS TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 93024 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 37.32 Description: CARDIAC DRUG STRESS TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 93025 26 MEDSV DEF RBRVS 01/01/2024 35.31 Description: MICROVOLT T-WAVE ASSESS Category: Medical Services CMS Add: 01/01/2002 CMS Term: 93025 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 27.33 Description: MICROVOLT T-WAVE ASSESS Category: Medical Services CMS Add: 01/01/2002 CMS Term: 93025 MEDSV DEF RBRVS 01/01/2024 113.42 Description: MICROVOLT T-WAVE ASSESS Category: Medical Services CMS Add: 01/01/2002 CMS Term: 93025 MEDSV DEF RBRVS 09/01/2019 12/31/2023 114.94 Description: MICROVOLT T-WAVE ASSESS Category: Medical Services CMS Add: 01/01/2002 CMS Term: 93025 TC MEDSV DEF RBRVS 01/01/2024 78.12 Description: MICROVOLT T-WAVE ASSESS Category: Medical Services CMS Add: 01/01/2002 CMS Term: 93025 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 87.61 Description: MICROVOLT T-WAVE ASSESS Category: Medical Services CMS Add: 01/01/2002 CMS Term: 93040 MEDSV DEF RBRVS 01/01/2024 11.89 Description: RHYTHM ECG WITH REPORT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 93040 MEDSV DEF RBRVS 09/01/2019 12/31/2023 9.07 Description: RHYTHM ECG WITH REPORT Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,280 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 93041 MEDSV DEF RBRVS 01/01/2024 5.41 Description: RHYTHM ECG TRACING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 93041 MEDSV DEF RBRVS 09/01/2019 12/31/2023 3.88 Description: RHYTHM ECG TRACING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 93042 MEDSV DEF RBRVS 01/01/2024 6.48 Description: RHYTHM ECG REPORT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 93042 MEDSV DEF RBRVS 02/01/2015 12/31/2023 5.19 Description: RHYTHM ECG REPORT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 93050 26 MEDSV DEF RBRVS 01/01/2024 7.77 Description: ART PRESSURE WAVEFORM ANALYS Category: Medical Services CMS Add: 01/01/2016 CMS Term: 93050 26 MEDSV DEF RBRVS 08/03/2018 12/31/2023 10.18 Description: ART PRESSURE WAVEFORM ANALYS Category: Medical Services CMS Add: 01/01/2016 CMS Term: 93050 MEDSV DEF RBRVS 08/03/2018 14.73 Description: ART PRESSURE WAVEFORM ANALYS Category: Medical Services CMS Add: 01/01/2016 CMS Term: 93050 TC MEDSV DEF RBRVS 08/03/2018 6.95 Description: ART PRESSURE WAVEFORM ANALYS Category: Medical Services CMS Add: 01/01/2016 CMS Term: 93150 NOCOV DEF SYSMAN Description: THERAPY ACTIVATION IPNSS Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 93151 NOCOV DEF SYSMAN Description: INTERROG&PRGRMG IPNSS Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 93152 NOCOV DEF SYSMAN Description: INTERROG&PRGRMG IPNSS POLYSM Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 93153 NOCOV DEF SYSMAN Description: INTERROG W/O PRGRMG IPNSS Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 93224 MEDSV DEF RBRVS 01/01/2024 67.72 Description: ECG MONIT/REPRT UP TO 48 HRS Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93224 MEDSV DEF RBRVS 09/01/2019 12/31/2023 64.26 Description: ECG MONIT/REPRT UP TO 48 HRS Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93225 MEDSV DEF RBRVS 01/01/2024 16.83 Description: ECG MONIT/REPRT UP TO 48 HRS Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93225 MEDSV DEF RBRVS 09/01/2019 12/31/2023 18.50 Description: ECG MONIT/REPRT UP TO 48 HRS Category: Medical Services CMS Add: 01/01/1990 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,281 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 93226 MEDSV DEF RBRVS 01/01/2024 33.19 Description: ECG MONIT/REPRT UP TO 48 HRS Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93226 MEDSV DEF RBRVS 09/01/2019 12/31/2023 26.18 Description: ECG MONIT/REPRT UP TO 48 HRS Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93227 MEDSV DEF RBRVS 01/01/2024 17.70 Description: ECG MONIT/REPRT UP TO 48 HRS Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93227 MEDSV DEF RBRVS 02/01/2015 12/31/2023 19.59 Description: ECG MONIT/REPRT UP TO 48 HRS Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93228 MEDSV DEF RBRVS 01/01/2024 24.01 Description: REMOTE 30 DAY ECG REV/REPORT Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93228 MEDSV DEF RBRVS 02/01/2015 12/31/2023 19.17 Description: REMOTE 30 DAY ECG REV/REPORT Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93229 MEDSV DEF RBRVS 01/01/2024 772.46 Description: REMOTE 30 DAY ECG TECH SUPP Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93229 MEDSV DEF RBRVS 09/01/2019 12/31/2023 462.65 Description: REMOTE 30 DAY ECG TECH SUPP Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93241 RADIO DEF MAXFEE 01/01/2024 244.49 0.0 Description: EXT ECG>48HR<7D REC SCAN A/R Category: Radiology CMS Add: 01/01/2021 CMS Term: 93242 RADIO DEF RBRVS 01/01/2021 12/31/2023 11.06 Description: EXT ECG>48HR<7D RECORDING Category: Radiology CMS Add: 01/01/2021 CMS Term: 93242 RADIO DEF RBRVS 01/01/2024 10.97 Description: EXT ECG>48HR<7D RECORDING Category: Radiology CMS Add: 01/01/2021 CMS Term: 93243 RADIO DEF MAXFEE 01/01/2024 211.01 0.0 Description: EXT ECG>48HR<7D SCAN A/R Category: Radiology CMS Add: 01/01/2021 CMS Term: 93244 RADIO DEF RBRVS 01/01/2021 12/31/2023 18.72 Description: EXT ECG>48HR<7D REV&INTERPJ Category: Radiology CMS Add: 01/01/2021 CMS Term: 93244 RADIO DEF RBRVS 01/01/2024 22.51 Description: EXT ECG>48HR<7D REV&INTERPJ Category: Radiology CMS Add: 01/01/2021 CMS Term: 93245 RADIO DEF MAXFEE 01/01/2024 257.61 0.0 Description: EXT ECG>7D<15D REC SCAN A/R Category: Radiology CMS Add: 01/01/2021 CMS Term: 93246 RADIO DEF RBRVS 01/01/2021 12/31/2023 11.06 Description: EXT ECG>7D<15D RECORDING Category: Radiology CMS Add: 01/01/2021 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,282 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 93246 RADIO DEF RBRVS 01/01/2024 10.97 Description: EXT ECG>7D<15D RECORDING Category: Radiology CMS Add: 01/01/2021 CMS Term: 93247 RADIO DEF MAXFEE 01/01/2024 221.82 0.0 Description: EXT ECG>7D<15D SCAN A/R Category: Radiology CMS Add: 01/01/2021 CMS Term: 93248 RADIO DEF RBRVS 01/01/2021 12/31/2023 20.56 Description: EXT ECG>7D<15D REV&INTERPJ Category: Radiology CMS Add: 01/01/2021 CMS Term: 93248 RADIO DEF RBRVS 01/01/2024 24.83 Description: EXT ECG>7D<15D REV&INTERPJ Category: Radiology CMS Add: 01/01/2021 CMS Term: 93260 26 MEDSV DEF RBRVS 01/01/2024 40.25 Description: PRGRMG DEV EVAL IMPLTBL SYS Category: Medical Services CMS Add: 01/01/2015 CMS Term: 93260 26 MEDSV DEF RBRVS 07/01/2016 12/31/2023 32.99 Description: PRGRMG DEV EVAL IMPLTBL SYS Category: Medical Services CMS Add: 01/01/2015 CMS Term: 93260 MEDSV DEF RBRVS 01/01/2024 72.52 Description: PRGRMG DEV EVAL IMPLTBL SYS Category: Medical Services CMS Add: 01/01/2015 CMS Term: 93260 MEDSV DEF RBRVS 07/01/2016 12/31/2023 48.27 Description: PRGRMG DEV EVAL IMPLTBL SYS Category: Medical Services CMS Add: 01/01/2015 CMS Term: 93260 TC MEDSV DEF RBRVS 01/01/2024 32.27 Description: PRGRMG DEV EVAL IMPLTBL SYS Category: Medical Services CMS Add: 01/01/2015 CMS Term: 93260 TC MEDSV DEF RBRVS 07/01/2016 12/31/2023 15.28 Description: PRGRMG DEV EVAL IMPLTBL SYS Category: Medical Services CMS Add: 01/01/2015 CMS Term: 93261 26 MEDSV DEF RBRVS 01/01/2024 34.66 Description: INTERROGATE SUBQ DEFIB Category: Medical Services CMS Add: 01/01/2015 CMS Term: 93261 26 MEDSV DEF RBRVS 07/01/2016 12/31/2023 28.39 Description: INTERROGATE SUBQ DEFIB Category: Medical Services CMS Add: 01/01/2015 CMS Term: 93261 MEDSV DEF RBRVS 01/01/2024 66.62 Description: INTERROGATE SUBQ DEFIB Category: Medical Services CMS Add: 01/01/2015 CMS Term: 93261 MEDSV DEF RBRVS 07/01/2016 12/31/2023 43.66 Description: INTERROGATE SUBQ DEFIB Category: Medical Services CMS Add: 01/01/2015 CMS Term: 93261 TC MEDSV DEF RBRVS 01/01/2024 31.96 Description: INTERROGATE SUBQ DEFIB Category: Medical Services CMS Add: 01/01/2015 CMS Term: 93261 TC MEDSV DEF RBRVS 07/01/2016 12/31/2023 15.28 Description: INTERROGATE SUBQ DEFIB Category: Medical Services CMS Add: 01/01/2015 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,283 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 93264 NOCOV DEF SYSMAN Description: REM MNTR WRLS P-ART PRS SNR Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 93268 26 MEDSV DEF RBRVS 02/01/2015 31.11 Description: ECG RECORD/REVIEW Category: Medical Services CMS Add: 01/01/1987 CMS Term: 93268 26 MEDSV PRF MAXFEE 01/01/2024 32.36 0.0 Description: ECG RECORD/REVIEW Category: Medical Services CMS Add: 01/01/1987 CMS Term: 93268 MEDSV DEF RBRVS 01/01/2024 165.52 Description: ECG RECORD/REVIEW Category: Medical Services CMS Add: 01/01/1987 CMS Term: 93268 MEDSV DEF RBRVS 09/01/2019 12/31/2023 142.78 Description: ECG RECORD/REVIEW Category: Medical Services CMS Add: 01/01/1987 CMS Term: 93268 TC MEDSV DEF RBRVS 02/01/2015 112.11 Description: ECG RECORD/REVIEW Category: Medical Services CMS Add: 01/01/1987 CMS Term: 93268 TC MEDSV PRF MAXFEE 01/01/2024 118.04 0.0 Description: ECG RECORD/REVIEW Category: Medical Services CMS Add: 01/01/1987 CMS Term: 93270 MEDSV DEF RBRVS 01/01/2024 7.57 Description: REMOTE 30 DAY ECG REV/REPORT Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93270 MEDSV DEF RBRVS 02/01/2015 12/31/2023 6.36 Description: REMOTE 30 DAY ECG REV/REPORT Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93271 MEDSV DEF RBRVS 01/01/2024 134.76 Description: ECG/MONITORING AND ANALYSIS Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93271 MEDSV DEF RBRVS 02/01/2015 12/31/2023 117.83 Description: ECG/MONITORING AND ANALYSIS Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93272 MEDSV DEF RBRVS 01/01/2019 12/31/2023 18.59 Description: ECG/REVIEW INTERPRET ONLY Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93272 MEDSV DEF RBRVS 01/01/2024 23.19 Description: ECG/REVIEW INTERPRET ONLY Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93278 26 MEDSV DEF RBRVS 01/01/2024 11.72 Description: ECG/SIGNAL-AVERAGED Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93278 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 9.11 Description: ECG/SIGNAL-AVERAGED Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93278 MEDSV DEF RBRVS 01/01/2024 27.01 Description: ECG/SIGNAL-AVERAGED Category: Medical Services CMS Add: 01/01/1992 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,284 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 93278 MEDSV DEF RBRVS 09/01/2019 12/31/2023 21.41 Description: ECG/SIGNAL-AVERAGED Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93278 TC MEDSV DEF RBRVS 01/01/2024 15.29 Description: ECG/SIGNAL-AVERAGED Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93278 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 12.30 Description: ECG/SIGNAL-AVERAGED Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93279 26 MEDSV DEF RBRVS 01/01/2024 30.07 Description: PRGRMG DEV EVAL PM/LDLS PM Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93279 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 23.90 Description: PRGRMG DEV EVAL PM/LDLS PM Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93279 MEDSV DEF RBRVS 01/01/2024 64.19 Description: PRGRMG DEV EVAL PM/LDLS PM Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93279 MEDSV DEF RBRVS 09/01/2019 12/31/2023 35.71 Description: PRGRMG DEV EVAL PM/LDLS PM Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93279 TC MEDSV DEF RBRVS 01/01/2024 34.12 Description: PRGRMG DEV EVAL PM/LDLS PM Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93279 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 11.81 Description: PRGRMG DEV EVAL PM/LDLS PM Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93280 26 MEDSV DEF RBRVS 01/01/2024 35.68 Description: PM DEVICE PROGR EVAL DUAL Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93280 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 28.37 Description: PM DEVICE PROGR EVAL DUAL Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93280 MEDSV DEF RBRVS 01/01/2024 75.35 Description: PM DEVICE PROGR EVAL DUAL Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93280 MEDSV DEF RBRVS 09/01/2019 12/31/2023 41.91 Description: PM DEVICE PROGR EVAL DUAL Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93280 TC MEDSV DEF RBRVS 01/01/2024 39.68 Description: PM DEVICE PROGR EVAL DUAL Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93280 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 13.54 Description: PM DEVICE PROGR EVAL DUAL Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93281 26 MEDSV DEF RBRVS 01/01/2024 39.94 Description: PM DEVICE PROGR EVAL MULTI Category: Medical Services CMS Add: 01/01/2009 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,285 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 93281 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 33.10 Description: PM DEVICE PROGR EVAL MULTI Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93281 MEDSV DEF RBRVS 01/01/2024 80.24 Description: PM DEVICE PROGR EVAL MULTI Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93281 MEDSV DEF RBRVS 09/01/2019 12/31/2023 48.87 Description: PM DEVICE PROGR EVAL MULTI Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93281 TC MEDSV DEF RBRVS 01/01/2024 40.29 Description: PM DEVICE PROGR EVAL MULTI Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93281 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 15.77 Description: PM DEVICE PROGR EVAL MULTI Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93282 26 MEDSV DEF RBRVS 01/01/2024 39.94 Description: PRGRMG EVAL IMPLANTABLE DFB Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93282 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 31.26 Description: PRGRMG EVAL IMPLANTABLE DFB Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93282 MEDSV DEF RBRVS 01/01/2024 76.53 Description: PRGRMG EVAL IMPLANTABLE DFB Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93282 MEDSV DEF RBRVS 09/01/2019 12/31/2023 45.05 Description: PRGRMG EVAL IMPLANTABLE DFB Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93282 TC MEDSV DEF RBRVS 01/01/2024 36.59 Description: PRGRMG EVAL IMPLANTABLE DFB Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93282 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 13.79 Description: PRGRMG EVAL IMPLANTABLE DFB Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93283 26 MEDSV DEF RBRVS 01/01/2024 53.81 Description: PRGRMG EVAL IMPLANTABLE DFB Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93283 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 42.46 Description: PRGRMG EVAL IMPLANTABLE DFB Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93283 MEDSV DEF RBRVS 01/01/2024 93.80 Description: PRGRMG EVAL IMPLANTABLE DFB Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93283 MEDSV DEF RBRVS 09/01/2019 12/31/2023 58.72 Description: PRGRMG EVAL IMPLANTABLE DFB Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93283 TC MEDSV DEF RBRVS 01/01/2024 39.98 Description: PRGRMG EVAL IMPLANTABLE DFB Category: Medical Services CMS Add: 01/01/2009 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,286 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 93283 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 16.27 Description: PRGRMG EVAL IMPLANTABLE DFB Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93284 26 MEDSV DEF RBRVS 01/01/2024 58.44 Description: PRGRMG EVAL IMPLANTABLE DFB Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93284 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 46.14 Description: PRGRMG EVAL IMPLANTABLE DFB Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93284 MEDSV DEF RBRVS 01/01/2024 101.20 Description: PRGRMG EVAL IMPLANTABLE DFB Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93284 MEDSV DEF RBRVS 09/01/2019 12/31/2023 64.63 Description: PRGRMG EVAL IMPLANTABLE DFB Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93284 TC MEDSV DEF RBRVS 01/01/2024 42.76 Description: PRGRMG EVAL IMPLANTABLE DFB Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93284 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 18.50 Description: PRGRMG EVAL IMPLANTABLE DFB Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93285 26 MEDSV DEF RBRVS 01/01/2024 24.43 Description: PRGRMG DEV EVAL SCRMS IP Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93285 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 19.09 Description: PRGRMG DEV EVAL SCRMS IP Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93285 MEDSV DEF RBRVS 01/01/2024 57.31 Description: PRGRMG DEV EVAL SCRMS IP Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93285 MEDSV DEF RBRVS 09/01/2019 12/31/2023 29.91 Description: PRGRMG DEV EVAL SCRMS IP Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93285 TC MEDSV DEF RBRVS 01/01/2024 32.88 Description: PRGRMG DEV EVAL SCRMS IP Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93285 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 10.82 Description: PRGRMG DEV EVAL SCRMS IP Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93286 26 MEDSV DEF RBRVS 01/01/2024 14.03 Description: PERI-PX EVAL PM/LDLS PM IP Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93286 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 11.20 Description: PERI-PX EVAL PM/LDLS PM IP Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93286 MEDSV DEF RBRVS 01/01/2024 43.21 Description: PERI-PX EVAL PM/LDLS PM IP Category: Medical Services CMS Add: 01/01/2009 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,287 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 93286 MEDSV DEF RBRVS 09/01/2019 12/31/2023 19.29 Description: PERI-PX EVAL PM/LDLS PM IP Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93286 TC MEDSV DEF RBRVS 01/01/2024 29.18 Description: PERI-PX EVAL PM/LDLS PM IP Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93286 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 8.09 Description: PERI-PX EVAL PM/LDLS PM IP Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93287 26 MEDSV DEF RBRVS 01/01/2024 21.28 Description: PERI-PX DEVICE EVAL & PRGR Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93287 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 16.71 Description: PERI-PX DEVICE EVAL & PRGR Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93287 MEDSV DEF RBRVS 01/01/2024 50.46 Description: PERI-PX DEVICE EVAL & PRGR Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93287 MEDSV DEF RBRVS 09/01/2019 12/31/2023 25.55 Description: PERI-PX DEVICE EVAL & PRGR Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93287 TC MEDSV DEF RBRVS 01/01/2024 29.18 Description: PERI-PX DEVICE EVAL & PRGR Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93287 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 8.84 Description: PERI-PX DEVICE EVAL & PRGR Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93288 26 MEDSV DEF RBRVS 01/01/2024 19.67 Description: INTERROG EVL PM/LDLS PM IP Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93288 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 15.43 Description: INTERROG EVL PM/LDLS PM IP Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93288 MEDSV DEF RBRVS 01/01/2024 53.17 Description: INTERROG EVL PM/LDLS PM IP Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93288 MEDSV DEF RBRVS 09/01/2019 12/31/2023 26.25 Description: INTERROG EVL PM/LDLS PM IP Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93288 TC MEDSV DEF RBRVS 01/01/2024 33.50 Description: INTERROG EVL PM/LDLS PM IP Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93288 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 10.82 Description: INTERROG EVL PM/LDLS PM IP Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93289 26 MEDSV DEF RBRVS 01/01/2024 35.01 Description: INTERROG DEVICE EVAL HEART Category: Medical Services CMS Add: 01/01/2009 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,288 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 93289 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 33.64 Description: INTERROG DEVICE EVAL HEART Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93289 MEDSV DEF RBRVS 01/01/2024 68.82 Description: INTERROG DEVICE EVAL HEART Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93289 MEDSV DEF RBRVS 09/01/2019 12/31/2023 46.93 Description: INTERROG DEVICE EVAL HEART Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93289 TC MEDSV DEF RBRVS 01/01/2024 33.81 Description: INTERROG DEVICE EVAL HEART Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93289 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 13.29 Description: INTERROG DEVICE EVAL HEART Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93290 26 MEDSV DEF RBRVS 01/01/2024 20.14 Description: INTERROG DEV EVAL ICPMS IP Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93290 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 15.68 Description: INTERROG DEV EVAL ICPMS IP Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93290 MEDSV DEF RBRVS 01/01/2024 50.56 Description: INTERROG DEV EVAL ICPMS IP Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93290 MEDSV DEF RBRVS 09/01/2019 12/31/2023 22.04 Description: INTERROG DEV EVAL ICPMS IP Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93290 TC MEDSV DEF RBRVS 01/01/2024 30.41 Description: INTERROG DEV EVAL ICPMS IP Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93290 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 6.36 Description: INTERROG DEV EVAL ICPMS IP Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93291 26 MEDSV DEF RBRVS 01/01/2024 17.33 Description: INTERROG DEV EVAL SCRMS IP Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93291 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 15.68 Description: INTERROG DEV EVAL SCRMS IP Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93291 MEDSV DEF RBRVS 01/01/2024 46.82 Description: INTERROG DEV EVAL SCRMS IP Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93291 MEDSV DEF RBRVS 09/01/2019 12/31/2023 25.76 Description: INTERROG DEV EVAL SCRMS IP Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93291 TC MEDSV DEF RBRVS 01/01/2024 29.49 Description: INTERROG DEV EVAL SCRMS IP Category: Medical Services CMS Add: 01/01/2009 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,289 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 93291 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 10.07 Description: INTERROG DEV EVAL SCRMS IP Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93292 26 MEDSV DEF RBRVS 01/01/2024 19.83 Description: WCD DEVICE INTERROGATE Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93292 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 15.43 Description: WCD DEVICE INTERROGATE Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93292 MEDSV DEF RBRVS 01/01/2024 48.09 Description: WCD DEVICE INTERROGATE Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93292 MEDSV DEF RBRVS 09/01/2019 12/31/2023 22.78 Description: WCD DEVICE INTERROGATE Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93292 TC MEDSV DEF RBRVS 01/01/2024 28.25 Description: WCD DEVICE INTERROGATE Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93292 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 7.35 Description: WCD DEVICE INTERROGATE Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93293 26 MEDSV DEF RBRVS 01/01/2024 13.75 Description: PM PHONE R-STRIP DEVICE EVAL Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93293 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 11.74 Description: PM PHONE R-STRIP DEVICE EVAL Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93293 MEDSV DEF RBRVS 01/01/2024 42.62 Description: PM PHONE R-STRIP DEVICE EVAL Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93293 MEDSV DEF RBRVS 02/01/2015 12/31/2023 37.66 Description: PM PHONE R-STRIP DEVICE EVAL Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93293 TC MEDSV DEF RBRVS 01/01/2024 28.87 Description: PM PHONE R-STRIP DEVICE EVAL Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93293 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 25.93 Description: PM PHONE R-STRIP DEVICE EVAL Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93294 MEDSV DEF RBRVS 01/01/2024 28.39 Description: REM INTERROG EVL PM/LDLS PM Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93294 MEDSV DEF RBRVS 02/01/2015 12/31/2023 24.57 Description: REM INTERROG EVL PM/LDLS PM Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93295 MEDSV DEF RBRVS 01/01/2024 34.98 Description: DEV INTERROG REMOTE 1/2/MLT Category: Medical Services CMS Add: 01/01/2009 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,290 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 93295 MEDSV DEF RBRVS 02/01/2015 12/31/2023 48.86 Description: DEV INTERROG REMOTE 1/2/MLT Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93296 MEDSV DEF RBRVS 01/01/2024 20.54 Description: REM INTERROG EVL PM/IDS Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93296 MEDSV DEF RBRVS 02/01/2015 12/31/2023 17.75 Description: REM INTERROG EVL PM/IDS Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93297 26 MEDSV DEF RBRVS 01/01/2024 23.81 Description: REM INTERROG DEV EVAL ICPMS Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93297 MEDSV DEF RBRVS 01/01/2024 24.44 Description: REM INTERROG DEV EVAL ICPMS Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93297 MEDSV DEF RBRVS 02/01/2015 12/31/2023 19.17 Description: REM INTERROG DEV EVAL ICPMS Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93297 TC MEDSV DEF RBRVS 01/01/2024 33.19 Description: REM INTERROG DEV EVAL ICPMS Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93298 26 MEDSV DEF RBRVS 01/01/2024 23.81 Description: REM INTERROG DEV EVAL SCRMS Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93298 MEDSV DEF RBRVS 01/01/2024 24.75 Description: REM INTERROG DEV EVAL SCRMS Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93298 MEDSV DEF RBRVS 02/01/2015 12/31/2023 19.42 Description: REM INTERROG DEV EVAL SCRMS Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93298 TC MEDSV DEF RBRVS 01/01/2024 71.33 Description: REM INTERROG DEV EVAL SCRMS Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93303 26 MEDSV DEF RBRVS 01/01/2024 58.90 Description: ECHO TRANSTHORACIC Category: Medical Services CMS Add: 01/01/1997 CMS Term: 93303 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 46.98 Description: ECHO TRANSTHORACIC Category: Medical Services CMS Add: 01/01/1997 CMS Term: 93303 MEDSV DEF RBRVS 01/01/2024 206.18 Description: ECHO TRANSTHORACIC Category: Medical Services CMS Add: 01/01/1997 CMS Term: 93303 MEDSV DEF RBRVS 09/01/2019 12/31/2023 167.79 Description: ECHO TRANSTHORACIC Category: Medical Services CMS Add: 01/01/1997 CMS Term: 93303 TC MEDSV DEF RBRVS 01/01/2024 147.28 Description: ECHO TRANSTHORACIC Category: Medical Services CMS Add: 01/01/1997 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,291 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 93303 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 120.80 Description: ECHO TRANSTHORACIC Category: Medical Services CMS Add: 01/01/1997 CMS Term: 93304 26 MEDSV DEF RBRVS 01/01/2024 34.39 Description: ECHO TRANSTHORACIC Category: Medical Services CMS Add: 01/01/1997 CMS Term: 93304 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 27.09 Description: ECHO TRANSTHORACIC Category: Medical Services CMS Add: 01/01/1997 CMS Term: 93304 MEDSV DEF RBRVS 01/01/2024 144.93 Description: ECHO TRANSTHORACIC Category: Medical Services CMS Add: 01/01/1997 CMS Term: 93304 MEDSV DEF RBRVS 09/01/2019 12/31/2023 110.98 Description: ECHO TRANSTHORACIC Category: Medical Services CMS Add: 01/01/1997 CMS Term: 93304 TC MEDSV DEF RBRVS 01/01/2024 110.53 Description: ECHO TRANSTHORACIC Category: Medical Services CMS Add: 01/01/1997 CMS Term: 93304 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 83.89 Description: ECHO TRANSTHORACIC Category: Medical Services CMS Add: 01/01/1997 CMS Term: 93306 26 MEDSV DEF RBRVS 01/01/2024 65.86 Description: TTE W/DOPPLER COMPLETE Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93306 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 46.98 Description: TTE W/DOPPLER COMPLETE Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93306 MEDSV DEF RBRVS 01/01/2024 184.13 Description: TTE W/DOPPLER COMPLETE Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93306 MEDSV DEF RBRVS 09/01/2019 12/31/2023 160.85 Description: TTE W/DOPPLER COMPLETE Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93306 TC MEDSV DEF RBRVS 01/01/2024 118.26 Description: TTE W/DOPPLER COMPLETE Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93306 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 113.87 Description: TTE W/DOPPLER COMPLETE Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93307 26 MEDSV DEF RBRVS 01/01/2024 41.70 Description: TTE W/O DOPPLER COMPLETE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93307 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 33.39 Description: TTE W/O DOPPLER COMPLETE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93307 MEDSV DEF RBRVS 01/01/2024 128.15 Description: TTE W/O DOPPLER COMPLETE Category: Medical Services CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,292 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 93307 MEDSV DEF RBRVS 09/01/2019 12/31/2023 93.25 Description: TTE W/O DOPPLER COMPLETE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93307 TC MEDSV DEF RBRVS 01/01/2024 86.45 Description: TTE W/O DOPPLER COMPLETE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93307 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 59.86 Description: TTE W/O DOPPLER COMPLETE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93308 26 MEDSV DEF RBRVS 01/01/2024 23.84 Description: TTE F-UP OR LMTD Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93308 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 18.86 Description: TTE F-UP OR LMTD Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93308 MEDSV DEF RBRVS 01/01/2024 91.77 Description: TTE F-UP OR LMTD Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93308 MEDSV DEF RBRVS 09/01/2019 12/31/2023 86.41 Description: TTE F-UP OR LMTD Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93308 TC MEDSV DEF RBRVS 01/01/2024 67.93 Description: TTE F-UP OR LMTD Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93308 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 67.54 Description: TTE F-UP OR LMTD Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93312 26 MEDSV DEF RBRVS 01/01/2024 102.07 Description: ECHO TRANSESOPHAGEAL Category: Medical Services CMS Add: 01/01/1989 CMS Term: 93312 26 MEDSV DEF RBRVS 09/15/2017 12/31/2023 81.12 Description: ECHO TRANSESOPHAGEAL Category: Medical Services CMS Add: 01/01/1989 CMS Term: 93312 MEDSV DEF RBRVS 01/01/2024 223.41 Description: ECHO TRANSESOPHAGEAL Category: Medical Services CMS Add: 01/01/1989 CMS Term: 93312 MEDSV DEF RBRVS 09/15/2017 12/31/2023 176.32 Description: ECHO TRANSESOPHAGEAL Category: Medical Services CMS Add: 01/01/1989 CMS Term: 93312 TC MEDSV DEF RBRVS 01/01/2024 121.34 Description: ECHO TRANSESOPHAGEAL Category: Medical Services CMS Add: 01/01/1989 CMS Term: 93312 TC MEDSV DEF RBRVS 09/15/2017 12/31/2023 95.21 Description: ECHO TRANSESOPHAGEAL Category: Medical Services CMS Add: 01/01/1989 CMS Term: 93313 ANEST DEF RBRVS 09/15/2017 10.68 Description: ECHO TRANSESOPHAGEAL Category: Anesthesia CMS Add: 01/01/1993 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,293 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 93314 26 MEDSV DEF RBRVS 01/01/2024 84.11 Description: ECHO TRANSESOPHAGEAL Category: Medical Services CMS Add: 01/01/1993 CMS Term: 93314 26 MEDSV DEF RBRVS 09/15/2017 12/31/2023 66.96 Description: ECHO TRANSESOPHAGEAL Category: Medical Services CMS Add: 01/01/1993 CMS Term: 93314 MEDSV DEF RBRVS 01/01/2024 212.86 Description: ECHO TRANSESOPHAGEAL Category: Medical Services CMS Add: 01/01/1993 CMS Term: 93314 MEDSV DEF RBRVS 09/15/2017 12/31/2023 168.11 Description: ECHO TRANSESOPHAGEAL Category: Medical Services CMS Add: 01/01/1993 CMS Term: 93314 TC MEDSV DEF RBRVS 01/01/2024 128.75 Description: ECHO TRANSESOPHAGEAL Category: Medical Services CMS Add: 01/01/1993 CMS Term: 93314 TC MEDSV DEF RBRVS 09/15/2017 12/31/2023 101.15 Description: ECHO TRANSESOPHAGEAL Category: Medical Services CMS Add: 01/01/1993 CMS Term: 93315 26 MEDSV DEF RBRVS 01/01/2024 120.86 Description: ECHO TRANSESOPHAGEAL Category: Medical Services CMS Add: 01/01/1997 CMS Term: 93315 26 MEDSV DEF RBRVS 09/15/2017 12/31/2023 95.72 Description: ECHO TRANSESOPHAGEAL Category: Medical Services CMS Add: 01/01/1997 CMS Term: 93315 MEDSV DEF MAXFEE 01/01/2024 315.90 0.0 Description: ECHO TRANSESOPHAGEAL Category: Medical Services CMS Add: 01/01/1997 CMS Term: 93315 TC MEDSV DEF MAXFEE 01/01/2024 165.38 0.0 Description: ECHO TRANSESOPHAGEAL Category: Medical Services CMS Add: 01/01/1997 CMS Term: 93316 MEDSV DEF RBRVS 01/01/2024 24.37 Description: ECHO TRANSESOPHAGEAL Category: Medical Services CMS Add: 01/01/1997 CMS Term: 93316 MEDSV DEF RBRVS 09/15/2017 12/31/2023 19.92 Description: ECHO TRANSESOPHAGEAL Category: Medical Services CMS Add: 01/01/1997 CMS Term: 93317 26 MEDSV DEF RBRVS 01/01/2024 83.72 Description: ECHO TRANSESOPHAGEAL Category: Medical Services CMS Add: 01/01/1997 CMS Term: 93317 26 MEDSV DEF RBRVS 09/15/2017 12/31/2023 68.26 Description: ECHO TRANSESOPHAGEAL Category: Medical Services CMS Add: 01/01/1997 CMS Term: 93317 MEDSV DEF MAXFEE 01/01/2024 247.91 0.0 Description: ECHO TRANSESOPHAGEAL Category: Medical Services CMS Add: 01/01/1997 CMS Term: 93317 TC MEDSV DEF MAXFEE 01/01/2024 143.62 0.0 Description: ECHO TRANSESOPHAGEAL Category: Medical Services CMS Add: 01/01/1997 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,294 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 93318 26 MEDSV DEF RBRVS 01/01/2024 97.02 Description: ECHO TRANSESOPHAGEAL INTRAOP Category: Medical Services CMS Add: 01/01/2001 CMS Term: 93318 26 MEDSV DEF RBRVS 09/15/2017 12/31/2023 77.25 Description: ECHO TRANSESOPHAGEAL INTRAOP Category: Medical Services CMS Add: 01/01/2001 CMS Term: 93318 MEDSV DEF MAXFEE 01/01/2024 479.88 0.0 Description: ECHO TRANSESOPHAGEAL INTRAOP Category: Medical Services CMS Add: 01/01/2001 CMS Term: 93318 TC MEDSV DEF MAXFEE 01/01/2024 298.81 0.0 Description: ECHO TRANSESOPHAGEAL INTRAOP Category: Medical Services CMS Add: 01/01/2001 CMS Term: 93319 RADIO DEF RBRVS 01/01/2022 12/31/2023 44.98 Description: 3D ECHO IMG CGEN CAR ANOMAL Category: Radiology CMS Add: 01/01/2022 CMS Term: 93319 RADIO DEF RBRVS 01/01/2024 51.85 Description: 3D ECHO IMG CGEN CAR ANOMAL Category: Radiology CMS Add: 01/01/2022 CMS Term: 93320 26 MEDSV DEF RBRVS 01/01/2024 17.05 Description: DOPPLER ECHO EXAM HEART Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93320 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 13.60 Description: DOPPLER ECHO EXAM HEART Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93320 MEDSV DEF RBRVS 01/01/2024 47.47 Description: DOPPLER ECHO EXAM HEART Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93320 MEDSV DEF RBRVS 02/01/2015 12/31/2023 38.53 Description: DOPPLER ECHO EXAM HEART Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93320 TC MEDSV DEF RBRVS 01/01/2024 30.41 Description: DOPPLER ECHO EXAM HEART Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93320 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 24.94 Description: DOPPLER ECHO EXAM HEART Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93321 26 MEDSV DEF RBRVS 01/01/2024 6.79 Description: DOPPLER ECHO EXAM HEART Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93321 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 5.43 Description: DOPPLER ECHO EXAM HEART Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93321 MEDSV DEF RBRVS 01/01/2024 23.46 Description: DOPPLER ECHO EXAM HEART Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93321 MEDSV DEF RBRVS 02/01/2015 12/31/2023 21.70 Description: DOPPLER ECHO EXAM HEART Category: Medical Services CMS Add: 01/01/1990 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,295 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 93321 TC MEDSV DEF RBRVS 01/01/2024 16.67 Description: DOPPLER ECHO EXAM HEART Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93321 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 16.27 Description: DOPPLER ECHO EXAM HEART Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93325 26 MEDSV DEF RBRVS 01/01/2024 2.99 Description: DOPPLER COLOR FLOW ADD-ON Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93325 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 2.54 Description: DOPPLER COLOR FLOW ADD-ON Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93325 MEDSV DEF RBRVS 01/01/2024 21.82 Description: DOPPLER COLOR FLOW ADD-ON Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93325 MEDSV DEF RBRVS 02/01/2015 12/31/2023 18.06 Description: DOPPLER COLOR FLOW ADD-ON Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93325 TC MEDSV DEF RBRVS 01/01/2024 18.83 Description: DOPPLER COLOR FLOW ADD-ON Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93325 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 15.52 Description: DOPPLER COLOR FLOW ADD-ON Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93350 26 MEDSV DEF RBRVS 01/01/2024 65.86 Description: STRESS TTE ONLY Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93350 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 52.69 Description: STRESS TTE ONLY Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93350 MEDSV DEF RBRVS 01/01/2024 174.54 Description: STRESS TTE ONLY Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93350 MEDSV DEF RBRVS 09/01/2019 12/31/2023 170.02 Description: STRESS TTE ONLY Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93350 TC MEDSV DEF RBRVS 01/01/2024 108.68 Description: STRESS TTE ONLY Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93350 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 117.33 Description: STRESS TTE ONLY Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93351 26 MEDSV DEF RBRVS 01/01/2024 79.10 Description: STRESS TTE COMPLETE Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93351 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 62.95 Description: STRESS TTE COMPLETE Category: Medical Services CMS Add: 01/01/2009 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,296 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 93351 MEDSV DEF RBRVS 01/01/2024 217.74 Description: STRESS TTE COMPLETE Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93351 MEDSV DEF RBRVS 09/01/2019 12/31/2023 197.71 Description: STRESS TTE COMPLETE Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93351 TC MEDSV DEF RBRVS 01/01/2024 138.64 Description: STRESS TTE COMPLETE Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93351 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 134.76 Description: STRESS TTE COMPLETE Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93352 MEDSV DEF RBRVS 01/01/2024 31.46 Description: ADMIN ECG CONTRAST AGENT Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93352 MEDSV DEF RBRVS 02/01/2015 12/31/2023 23.60 Description: ADMIN ECG CONTRAST AGENT Category: Medical Services CMS Add: 01/01/2009 CMS Term: 93355 RADIO DEF RBRVS 01/01/2024 212.30 Description: ECHO TRANSESOPHAGEAL (TEE) Category: Radiology CMS Add: 01/01/2015 CMS Term: 93355 RADIO DEF RBRVS 09/01/2019 12/31/2023 166.41 Description: ECHO TRANSESOPHAGEAL (TEE) Category: Radiology CMS Add: 01/01/2015 CMS Term: 93356 RADIO DEF RBRVS 01/01/2020 12/31/2023 28.33 Y Description: MYOCRD STRAIN IMG SPCKL TRCK Category: Radiology CMS Add: 01/01/2020 CMS Term: 93356 RADIO DEF RBRVS 01/01/2024 34.70 Y Description: MYOCRD STRAIN IMG SPCKL TRCK Category: Radiology CMS Add: 01/01/2020 CMS Term: 93451 26 MEDSV DEF RBRVS 01/01/2024 118.72 Description: RIGHT HEART CATH Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93451 26 MEDSV DEF RBRVS 09/15/2017 12/31/2023 95.35 Description: RIGHT HEART CATH Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93451 MEDSV DEF RBRVS 01/01/2024 803.16 Description: RIGHT HEART CATH Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93451 MEDSV DEF RBRVS 09/15/2017 12/31/2023 509.61 Description: RIGHT HEART CATH Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93451 TC MEDSV DEF RBRVS 01/01/2024 684.44 Description: RIGHT HEART CATH Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93451 TC MEDSV DEF RBRVS 09/15/2017 12/31/2023 414.26 Description: RIGHT HEART CATH Category: Medical Services CMS Add: 01/01/2011 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,297 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 93452 26 MEDSV DEF RBRVS 01/01/2024 213.53 Description: LEFT HRT CATH W/VENTRCLGRPHY Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93452 26 MEDSV DEF RBRVS 09/15/2017 12/31/2023 173.92 Description: LEFT HRT CATH W/VENTRCLGRPHY Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93452 MEDSV DEF RBRVS 01/01/2024 834.68 Description: LEFT HRT CATH W/VENTRCLGRPHY Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93452 MEDSV DEF RBRVS 09/15/2017 12/31/2023 581.16 Description: LEFT HRT CATH W/VENTRCLGRPHY Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93452 TC MEDSV DEF RBRVS 01/01/2024 621.16 Description: LEFT HRT CATH W/VENTRCLGRPHY Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93452 TC MEDSV DEF RBRVS 09/15/2017 12/31/2023 407.24 Description: LEFT HRT CATH W/VENTRCLGRPHY Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93453 26 MEDSV DEF RBRVS 01/01/2024 285.06 Description: R&L HRT CATH W/VENTRICLGRPHY Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93453 26 MEDSV DEF RBRVS 09/15/2017 12/31/2023 232.12 Description: R&L HRT CATH W/VENTRICLGRPHY Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93453 MEDSV DEF RBRVS 01/01/2024 1061.19 Description: R&L HRT CATH W/VENTRICLGRPHY Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93453 MEDSV DEF RBRVS 09/15/2017 12/31/2023 753.97 Description: R&L HRT CATH W/VENTRICLGRPHY Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93453 TC MEDSV DEF RBRVS 01/01/2024 776.13 Description: R&L HRT CATH W/VENTRICLGRPHY Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93453 TC MEDSV DEF RBRVS 09/15/2017 12/31/2023 521.85 Description: R&L HRT CATH W/VENTRICLGRPHY Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93454 26 MEDSV DEF RBRVS 01/01/2024 215.37 Description: CORONARY ARTERY ANGIO S&I Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93454 26 MEDSV DEF RBRVS 09/15/2017 12/31/2023 175.74 Description: CORONARY ARTERY ANGIO S&I Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93454 MEDSV DEF RBRVS 01/01/2024 837.76 Description: CORONARY ARTERY ANGIO S&I Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93454 MEDSV DEF RBRVS 09/15/2017 12/31/2023 589.42 Description: CORONARY ARTERY ANGIO S&I Category: Medical Services CMS Add: 01/01/2011 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,298 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 93454 TC MEDSV DEF RBRVS 01/01/2024 622.39 Description: CORONARY ARTERY ANGIO S&I Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93454 TC MEDSV DEF RBRVS 09/15/2017 12/31/2023 413.68 Description: CORONARY ARTERY ANGIO S&I Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93455 26 MEDSV DEF RBRVS 01/01/2024 251.06 Description: CORONARY ART/GRFT ANGIO S&I Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93455 26 MEDSV DEF RBRVS 09/15/2017 12/31/2023 204.56 Description: CORONARY ART/GRFT ANGIO S&I Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93455 MEDSV DEF RBRVS 01/01/2024 933.34 Description: CORONARY ART/GRFT ANGIO S&I Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93455 MEDSV DEF RBRVS 09/15/2017 12/31/2023 689.09 Description: CORONARY ART/GRFT ANGIO S&I Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93455 TC MEDSV DEF RBRVS 01/01/2024 682.28 Description: CORONARY ART/GRFT ANGIO S&I Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93455 TC MEDSV DEF RBRVS 09/15/2017 12/31/2023 484.53 Description: CORONARY ART/GRFT ANGIO S&I Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93456 26 MEDSV DEF RBRVS 01/01/2024 280.60 Description: R HRT CORONARY ARTERY ANGIO Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93456 26 MEDSV DEF RBRVS 09/15/2017 12/31/2023 228.38 Description: R HRT CORONARY ARTERY ANGIO Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93456 MEDSV DEF RBRVS 01/01/2024 1042.53 Description: R HRT CORONARY ARTERY ANGIO Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93456 MEDSV DEF RBRVS 09/15/2017 12/31/2023 745.36 Description: R HRT CORONARY ARTERY ANGIO Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93456 TC MEDSV DEF RBRVS 01/01/2024 761.93 Description: R HRT CORONARY ARTERY ANGIO Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93456 TC MEDSV DEF RBRVS 09/15/2017 12/31/2023 516.98 Description: R HRT CORONARY ARTERY ANGIO Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93457 26 MEDSV DEF RBRVS 01/01/2024 315.18 Description: R HRT ART/GRFT ANGIO Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93457 26 MEDSV DEF RBRVS 09/15/2017 12/31/2023 257.10 Description: R HRT ART/GRFT ANGIO Category: Medical Services CMS Add: 01/01/2011 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,299 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 93457 MEDSV DEF RBRVS 01/01/2024 1136.08 Description: R HRT ART/GRFT ANGIO Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93457 MEDSV DEF RBRVS 09/15/2017 12/31/2023 844.35 Description: R HRT ART/GRFT ANGIO Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93457 TC MEDSV DEF RBRVS 01/01/2024 820.89 Description: R HRT ART/GRFT ANGIO Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93457 TC MEDSV DEF RBRVS 09/15/2017 12/31/2023 587.25 Description: R HRT ART/GRFT ANGIO Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93458 26 MEDSV DEF RBRVS 01/01/2024 265.62 Description: L HRT ARTERY/VENTRICLE ANGIO Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93458 26 MEDSV DEF RBRVS 09/15/2017 12/31/2023 216.77 Description: L HRT ARTERY/VENTRICLE ANGIO Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93458 MEDSV DEF RBRVS 01/01/2024 962.72 Description: L HRT ARTERY/VENTRICLE ANGIO Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93458 MEDSV DEF RBRVS 09/15/2017 12/31/2023 709.89 Description: L HRT ARTERY/VENTRICLE ANGIO Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93458 TC MEDSV DEF RBRVS 01/01/2024 697.10 Description: L HRT ARTERY/VENTRICLE ANGIO Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93458 TC MEDSV DEF RBRVS 09/15/2017 12/31/2023 493.12 Description: L HRT ARTERY/VENTRICLE ANGIO Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93459 26 MEDSV DEF RBRVS 01/01/2024 301.32 Description: L HRT ART/GRFT ANGIO Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93459 26 MEDSV DEF RBRVS 09/15/2017 12/31/2023 245.59 Description: L HRT ART/GRFT ANGIO Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93459 MEDSV DEF RBRVS 01/01/2024 1035.77 Description: L HRT ART/GRFT ANGIO Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93459 MEDSV DEF RBRVS 09/15/2017 12/31/2023 787.01 Description: L HRT ART/GRFT ANGIO Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93459 TC MEDSV DEF RBRVS 01/01/2024 734.45 Description: L HRT ART/GRFT ANGIO Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93459 TC MEDSV DEF RBRVS 09/15/2017 12/31/2023 541.42 Description: L HRT ART/GRFT ANGIO Category: Medical Services CMS Add: 01/01/2011 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,300 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 93460 26 MEDSV DEF RBRVS 01/01/2024 337.32 Description: R&L HRT ART/VENTRICLE ANGIO Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93460 26 MEDSV DEF RBRVS 09/15/2017 12/31/2023 274.91 Description: R&L HRT ART/VENTRICLE ANGIO Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93460 MEDSV DEF RBRVS 01/01/2024 1150.49 Description: R&L HRT ART/VENTRICLE ANGIO Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93460 MEDSV DEF RBRVS 09/15/2017 12/31/2023 848.29 Description: R&L HRT ART/VENTRICLE ANGIO Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93460 TC MEDSV DEF RBRVS 01/01/2024 813.17 Description: R&L HRT ART/VENTRICLE ANGIO Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93460 TC MEDSV DEF RBRVS 09/15/2017 12/31/2023 573.38 Description: R&L HRT ART/VENTRICLE ANGIO Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93461 26 MEDSV DEF RBRVS 01/01/2024 372.71 Description: R&L HRT ART/VENTRICLE ANGIO Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93461 26 MEDSV DEF RBRVS 09/15/2017 12/31/2023 303.98 Description: R&L HRT ART/VENTRICLE ANGIO Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93461 MEDSV DEF RBRVS 01/01/2024 1268.63 Description: R&L HRT ART/VENTRICLE ANGIO Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93461 MEDSV DEF RBRVS 09/15/2017 12/31/2023 970.74 Description: R&L HRT ART/VENTRICLE ANGIO Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93461 TC MEDSV DEF RBRVS 01/01/2024 895.92 Description: R&L HRT ART/VENTRICLE ANGIO Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93461 TC MEDSV DEF RBRVS 09/15/2017 12/31/2023 666.77 Description: R&L HRT ART/VENTRICLE ANGIO Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93462 MEDSV DEF RBRVS 01/01/2024 187.76 Description: L HRT CATH TRNSPTL PUNCTURE Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93462 MEDSV DEF RBRVS 09/15/2017 12/31/2023 151.66 Description: L HRT CATH TRNSPTL PUNCTURE Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93463 MEDSV DEF RBRVS 01/01/2024 92.12 Description: DRUG ADMIN & HEMODYNMIC MEAS Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93463 MEDSV DEF RBRVS 09/15/2017 12/31/2023 72.97 Description: DRUG ADMIN & HEMODYNMIC MEAS Category: Medical Services CMS Add: 01/01/2011 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,301 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 93464 26 MEDSV DEF RBRVS 01/01/2024 83.45 Description: EXERCISE W/HEMODYNAMIC MEAS Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93464 26 MEDSV DEF RBRVS 09/15/2017 12/31/2023 64.88 Description: EXERCISE W/HEMODYNAMIC MEAS Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93464 MEDSV DEF RBRVS 01/01/2024 205.55 Description: EXERCISE W/HEMODYNAMIC MEAS Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93464 MEDSV DEF RBRVS 09/15/2017 12/31/2023 181.96 Description: EXERCISE W/HEMODYNAMIC MEAS Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93464 TC MEDSV DEF RBRVS 01/01/2024 122.10 Description: EXERCISE W/HEMODYNAMIC MEAS Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93464 TC MEDSV DEF RBRVS 09/15/2017 12/31/2023 117.09 Description: EXERCISE W/HEMODYNAMIC MEAS Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93503 MEDSV DEF RBRVS 01/01/2024 83.02 Description: INSERT/PLACE HEART CATHETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 93503 MEDSV DEF RBRVS 02/01/2015 12/31/2023 96.10 Description: INSERT/PLACE HEART CATHETER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 93505 26 MEDSV DEF RBRVS 01/01/2024 205.09 Description: BIOPSY OF HEART LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 93505 26 MEDSV DEF RBRVS 09/15/2017 12/31/2023 159.50 Description: BIOPSY OF HEART LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 93505 MEDSV DEF RBRVS 01/01/2024 597.79 Description: BIOPSY OF HEART LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 93505 MEDSV DEF RBRVS 09/15/2017 12/31/2023 493.25 Description: BIOPSY OF HEART LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 93505 TC MEDSV DEF RBRVS 01/01/2024 392.70 Description: BIOPSY OF HEART LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 93505 TC MEDSV DEF RBRVS 09/15/2017 12/31/2023 333.75 Description: BIOPSY OF HEART LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 93563 MEDSV DEF RBRVS 01/01/2024 47.43 Description: NJX CGEN CAR CTH SLCTV C ANG Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93563 MEDSV DEF RBRVS 09/15/2017 12/31/2023 42.71 Description: NJX CGEN CAR CTH SLCTV C ANG Category: Medical Services CMS Add: 01/01/2011 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,302 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 93564 MEDSV DEF RBRVS 01/01/2024 49.41 Description: NJX CGEN CAR CATH SLCTV OPAC Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93564 MEDSV DEF RBRVS 09/15/2017 12/31/2023 44.56 Description: NJX CGEN CAR CATH SLCTV OPAC Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93565 MEDSV DEF RBRVS 01/01/2024 24.12 Description: NJX CAR CTH SLCTV LV/LA ANG Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93565 MEDSV DEF RBRVS 09/15/2017 12/31/2023 33.18 Description: NJX CAR CTH SLCTV LV/LA ANG Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93566 MEDSV DEF RBRVS 01/01/2024 24.11 Description: NJX CAR CTH SLCTV RV/RA ANG Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93566 MEDSV DEF RBRVS 09/15/2017 12/31/2023 113.69 Description: NJX CAR CTH SLCTV RV/RA ANG Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93567 MEDSV DEF RBRVS 01/01/2024 33.87 Description: NJX CAR CTH SPRVLV AORTGRPHY Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93567 MEDSV DEF RBRVS 09/15/2017 12/31/2023 96.08 Description: NJX CAR CTH SPRVLV AORTGRPHY Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93568 MEDSV DEF RBRVS 01/01/2024 42.45 Description: NJX CAR CTH NSLC P-ART ANGRP Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93568 MEDSV DEF RBRVS 09/15/2017 12/31/2023 101.84 Description: NJX CAR CTH NSLC P-ART ANGRP Category: Medical Services CMS Add: 01/01/2011 CMS Term: 93569 MEDSV DEF RBRVS 01/01/2023 35.73 Description: NJX CTH SLCT P-ART ANGRP UNI Category: Medical Services CMS Add: 01/01/2023 CMS Term: 93571 26 MEDSV DEF RBRVS 01/01/2024 65.61 Description: HEART FLOW RESERVE MEASURE Category: Medical Services CMS Add: 01/01/1999 CMS Term: 93571 26 MEDSV DEF RBRVS 09/15/2017 12/31/2023 69.67 Description: HEART FLOW RESERVE MEASURE Category: Medical Services CMS Add: 01/01/1999 CMS Term: 93571 MEDSV DEF MAXFEE 01/01/2024 275.88 0.0 Description: HEART FLOW RESERVE MEASURE Category: Medical Services CMS Add: 01/01/1999 CMS Term: 93571 TC MEDSV DEF MAXFEE 01/01/2024 177.97 0.0 Description: HEART FLOW RESERVE MEASURE Category: Medical Services CMS Add: 01/01/1999 CMS Term: 93572 26 MEDSV DEF RBRVS 01/01/2024 47.44 Description: HEART FLOW RESERVE MEASURE Category: Medical Services CMS Add: 01/01/1999 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,303 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 93572 26 MEDSV DEF RBRVS 09/15/2017 12/31/2023 55.87 Description: HEART FLOW RESERVE MEASURE Category: Medical Services CMS Add: 01/01/1999 CMS Term: 93572 MEDSV DEF MAXFEE 01/01/2024 142.90 0.0 Description: HEART FLOW RESERVE MEASURE Category: Medical Services CMS Add: 01/01/1999 CMS Term: 93572 TC MEDSV DEF MAXFEE 01/01/2024 93.10 0.0 Description: HEART FLOW RESERVE MEASURE Category: Medical Services CMS Add: 01/01/1999 CMS Term: 93573 MEDSV DEF RBRVS 01/01/2023 59.56 Description: NJX CATH SLCT P-ART ANGRP BI Category: Medical Services CMS Add: 01/01/2023 CMS Term: 93574 MEDSV DEF RBRVS 01/01/2023 65.84 Description: NJX CATH SLCT PULM VN ANGRPH Category: Medical Services CMS Add: 01/01/2023 CMS Term: 93575 MEDSV DEF RBRVS 01/01/2023 88.00 Description: NJX CATH SLCT P ANGRPH MAPCA Category: Medical Services CMS Add: 01/01/2023 CMS Term: 93580 MEDSV DEF RBRVS 01/01/2024 873.32 Description: TRANSCATH CLOSURE OF ASD Category: Medical Services CMS Add: 01/01/2003 CMS Term: 93580 MEDSV DEF RBRVS 02/01/2015 12/31/2023 706.27 Description: TRANSCATH CLOSURE OF ASD Category: Medical Services CMS Add: 01/01/2003 CMS Term: 93581 MEDSV DEF RBRVS 01/01/2024 1182.69 Description: TRANSCATH CLOSURE OF VSD Category: Medical Services CMS Add: 01/01/2003 CMS Term: 93581 MEDSV DEF RBRVS 02/01/2015 12/31/2023 953.67 Description: TRANSCATH CLOSURE OF VSD Category: Medical Services CMS Add: 01/01/2003 CMS Term: 93582 MEDSV DEF RBRVS 01/01/2024 591.40 Description: PERQ TRANSCATH CLOSURE PDA Category: Medical Services CMS Add: 01/01/2014 CMS Term: 93582 MEDSV DEF RBRVS 09/15/2017 12/31/2023 477.32 Description: PERQ TRANSCATH CLOSURE PDA Category: Medical Services CMS Add: 01/01/2014 CMS Term: 93583 MEDSV DEF RBRVS 01/01/2024 663.21 Description: PERQ TRANSCATH SEPTAL REDUXN Category: Medical Services CMS Add: 01/01/2014 CMS Term: 93583 MEDSV DEF RBRVS 09/15/2017 12/31/2023 538.56 Description: PERQ TRANSCATH SEPTAL REDUXN Category: Medical Services CMS Add: 01/01/2014 CMS Term: 93584 MEDSV DEF RBRVS 01/01/2024 55.55 Description: VNGRPH CHD ANOM/PERSIST SVC Category: Medical Services CMS Add: 01/01/2024 CMS Term: 93585 MEDSV DEF RBRVS 01/01/2024 52.25 Description: VNGRPH CHD AZYGS/HEMIAZYGS Category: Medical Services CMS Add: 01/01/2024 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,304 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 93586 MEDSV DEF RBRVS 01/01/2024 66.13 Description: VNGRPH CHD CORONARY SINUS Category: Medical Services CMS Add: 01/01/2024 CMS Term: 93587 MEDSV DEF RBRVS 01/01/2024 97.55 Description: VNGRPH CHD VNVN CLTRL AT/ABV Category: Medical Services CMS Add: 01/01/2024 CMS Term: 93588 MEDSV DEF RBRVS 01/01/2024 98.54 Description: VNGRPH CHD VNVN CLTRL BELOW Category: Medical Services CMS Add: 01/01/2024 CMS Term: 93590 MEDSV DEF RBRVS 01/01/2017 12/31/2023 863.39 Description: PERQ TRANSCATH CLS MITRAL Category: Medical Services CMS Add: 01/01/2017 CMS Term: 93590 MEDSV DEF RBRVS 01/01/2024 1004.93 Description: PERQ TRANSCATH CLS MITRAL Category: Medical Services CMS Add: 01/01/2017 CMS Term: 93591 MEDSV DEF RBRVS 01/01/2017 12/31/2023 716.52 Description: PERQ TRANSCATH CLS AORTIC Category: Medical Services CMS Add: 01/01/2017 CMS Term: 93591 MEDSV DEF RBRVS 01/01/2024 829.95 Description: PERQ TRANSCATH CLS AORTIC Category: Medical Services CMS Add: 01/01/2017 CMS Term: 93592 MEDSV DEF RBRVS 01/01/2017 12/31/2023 315.69 Description: PERQ TRANSCATH CLOSURE EACH Category: Medical Services CMS Add: 01/01/2017 CMS Term: 93592 MEDSV DEF RBRVS 01/01/2024 365.84 Description: PERQ TRANSCATH CLOSURE EACH Category: Medical Services CMS Add: 01/01/2017 CMS Term: 93593 26 MEDSV DEF RBRVS 01/01/2022 12/31/2023 144.36 Description: R HRT CATH CHD NML NT CNJ Category: Medical Services CMS Add: 01/01/2022 CMS Term: 93593 26 MEDSV DEF RBRVS 01/01/2024 180.37 Description: R HRT CATH CHD NML NT CNJ Category: Medical Services CMS Add: 01/01/2022 CMS Term: 93594 26 MEDSV DEF RBRVS 01/01/2022 12/31/2023 226.56 Description: R HRT CATH CHD ABNL NT CNJ Category: Medical Services CMS Add: 01/01/2022 CMS Term: 93594 26 MEDSV DEF RBRVS 01/01/2024 281.51 Description: R HRT CATH CHD ABNL NT CNJ Category: Medical Services CMS Add: 01/01/2022 CMS Term: 93595 26 MEDSV DEF RBRVS 01/01/2022 12/31/2023 204.42 Description: L HRT CATH CHD NM/ABN NT CNJ Category: Medical Services CMS Add: 01/01/2022 CMS Term: 93595 26 MEDSV DEF RBRVS 01/01/2024 253.76 Description: L HRT CATH CHD NM/ABN NT CNJ Category: Medical Services CMS Add: 01/01/2022 CMS Term: 93596 26 MEDSV DEF RBRVS 01/01/2022 12/31/2023 248.10 Description: R&L HRT CATH CHD NML NT CNJ Category: Medical Services CMS Add: 01/01/2022 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,305 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 93596 26 MEDSV DEF RBRVS 01/01/2024 309.41 Description: R&L HRT CATH CHD NML NT CNJ Category: Medical Services CMS Add: 01/01/2022 CMS Term: 93597 26 MEDSV DEF RBRVS 01/01/2022 12/31/2023 329.91 Description: R&L HRT CATH CHD ABNL NT CNJ Category: Medical Services CMS Add: 01/01/2022 CMS Term: 93597 26 MEDSV DEF RBRVS 01/01/2024 409.56 Description: R&L HRT CATH CHD ABNL NT CNJ Category: Medical Services CMS Add: 01/01/2022 CMS Term: 93598 26 MEDSV DEF RBRVS 01/01/2022 12/31/2023 53.88 Description: CAR OUTP MEAS DRG CATH CHD Category: Medical Services CMS Add: 01/01/2022 CMS Term: 93598 26 MEDSV DEF RBRVS 01/01/2024 66.73 Description: CAR OUTP MEAS DRG CATH CHD Category: Medical Services CMS Add: 01/01/2022 CMS Term: 93600 26 MEDSV DEF RBRVS 01/01/2024 106.68 Description: BUNDLE OF HIS RECORDING Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93600 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 85.61 Description: BUNDLE OF HIS RECORDING Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93600 MEDSV DEF RBRVS 02/01/2015 12/31/2023 184.66 Description: BUNDLE OF HIS RECORDING Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93600 MEDSV PRF MAXFEE 01/01/2024 194.04 0.0 Description: BUNDLE OF HIS RECORDING Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93600 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 48.88 Description: BUNDLE OF HIS RECORDING Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93600 TC MEDSV PRF MAXFEE 01/01/2024 76.81 0.0 Description: BUNDLE OF HIS RECORDING Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93602 26 MEDSV DEF RBRVS 01/01/2024 104.35 Description: INTRA-ATRIAL RECORDING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 93602 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 84.62 Description: INTRA-ATRIAL RECORDING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 93602 MEDSV DEF RBRVS 02/01/2015 12/31/2023 131.98 Description: INTRA-ATRIAL RECORDING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 93602 MEDSV PRF MAXFEE 01/01/2024 160.45 0.0 Description: INTRA-ATRIAL RECORDING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 93602 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 27.83 Description: INTRA-ATRIAL RECORDING Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,306 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 93602 TC MEDSV PRF MAXFEE 01/01/2024 43.44 0.0 Description: INTRA-ATRIAL RECORDING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 93603 26 MEDSV DEF RBRVS 01/01/2024 104.35 Description: RIGHT VENTRICULAR RECORDING Category: Medical Services CMS Add: 01/01/1987 CMS Term: 93603 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 84.13 Description: RIGHT VENTRICULAR RECORDING Category: Medical Services CMS Add: 01/01/1987 CMS Term: 93603 MEDSV DEF RBRVS 02/01/2015 12/31/2023 157.00 Description: RIGHT VENTRICULAR RECORDING Category: Medical Services CMS Add: 01/01/1987 CMS Term: 93603 MEDSV PRF MAXFEE 01/01/2024 182.64 0.0 Description: RIGHT VENTRICULAR RECORDING Category: Medical Services CMS Add: 01/01/1987 CMS Term: 93603 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 42.11 Description: RIGHT VENTRICULAR RECORDING Category: Medical Services CMS Add: 01/01/1987 CMS Term: 93603 TC MEDSV PRF MAXFEE 01/01/2024 65.82 0.0 Description: RIGHT VENTRICULAR RECORDING Category: Medical Services CMS Add: 01/01/1987 CMS Term: 93609 26 MEDSV DEF RBRVS 01/01/2024 249.50 Description: MAP TACHYCARDIA ADD-ON Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93609 26 MEDSV DEF RBRVS 09/15/2017 12/31/2023 202.28 Description: MAP TACHYCARDIA ADD-ON Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93609 MEDSV DEF MAXFEE 01/01/2024 383.16 0.0 Description: MAP TACHYCARDIA ADD-ON Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93609 TC MEDSV DEF MAXFEE 01/01/2024 106.79 0.0 Description: MAP TACHYCARDIA ADD-ON Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93610 26 MEDSV DEF RBRVS 01/01/2024 147.46 Description: INTRA-ATRIAL PACING Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93610 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 119.87 Description: INTRA-ATRIAL PACING Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93610 MEDSV DEF RBRVS 02/01/2015 12/31/2023 176.57 Description: INTRA-ATRIAL PACING Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93610 MEDSV PRF MAXFEE 01/01/2024 219.03 0.0 Description: INTRA-ATRIAL PACING Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93610 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 33.86 Description: INTRA-ATRIAL PACING Category: Medical Services CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,307 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 93610 TC MEDSV PRF MAXFEE 01/01/2024 53.09 0.0 Description: INTRA-ATRIAL PACING Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93612 26 MEDSV DEF RBRVS 01/01/2024 145.43 Description: INTRAVENTRICULAR PACING Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93612 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 118.88 Description: INTRAVENTRICULAR PACING Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93612 MEDSV DEF RBRVS 02/01/2015 12/31/2023 184.09 Description: INTRAVENTRICULAR PACING Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93612 MEDSV PRF MAXFEE 01/01/2024 228.90 0.0 Description: INTRAVENTRICULAR PACING Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93612 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 40.63 Description: INTRAVENTRICULAR PACING Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93612 TC MEDSV PRF MAXFEE 01/01/2024 63.18 0.0 Description: INTRAVENTRICULAR PACING Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93613 MEDSV DEF RBRVS 01/01/2024 264.28 Description: ELECTROPHYS MAP 3D ADD-ON Category: Medical Services CMS Add: 01/01/2002 CMS Term: 93613 MEDSV DEF RBRVS 09/15/2017 12/31/2023 288.22 Description: ELECTROPHYS MAP 3D ADD-ON Category: Medical Services CMS Add: 01/01/2002 CMS Term: 93615 26 MEDSV DEF RBRVS 01/01/2024 35.28 Description: ESOPHAGEAL RECORDING Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93615 26 MEDSV DEF RBRVS 09/15/2017 12/31/2023 28.55 Description: ESOPHAGEAL RECORDING Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93615 MEDSV PRF MAXFEE 01/01/2024 62.94 0.0 Description: ESOPHAGEAL RECORDING Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93615 TC MEDSV PRF MAXFEE 01/01/2024 12.53 0.0 Description: ESOPHAGEAL RECORDING Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93616 26 MEDSV DEF RBRVS 01/01/2024 55.94 Description: ESOPHAGEAL RECORDING Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93616 26 MEDSV DEF RBRVS 09/15/2017 12/31/2023 39.76 Description: ESOPHAGEAL RECORDING Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93616 MEDSV PRF MAXFEE 01/01/2024 93.45 0.0 Description: ESOPHAGEAL RECORDING Category: Medical Services CMS Add: 01/01/1990 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,308 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 93616 TC MEDSV PRF MAXFEE 01/01/2024 20.07 0.0 Description: ESOPHAGEAL RECORDING Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93618 26 MEDSV DEF RBRVS 01/01/2024 198.08 Description: HEART RHYTHM PACING Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93618 26 MEDSV DEF RBRVS 09/15/2017 12/31/2023 161.23 Description: HEART RHYTHM PACING Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93618 MEDSV DEF MAXFEE 01/01/2024 390.76 0.0 Description: HEART RHYTHM PACING Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93618 TC MEDSV DEF MAXFEE 01/01/2024 155.17 0.0 Description: HEART RHYTHM PACING Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93619 26 MEDSV DEF RBRVS 01/01/2024 350.92 Description: ELECTROPHYSIOLOGY EVALUATION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 93619 26 MEDSV DEF RBRVS 09/15/2017 12/31/2023 284.49 Description: ELECTROPHYSIOLOGY EVALUATION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 93619 MEDSV DEF MAXFEE 01/01/2024 714.67 0.0 Description: ELECTROPHYSIOLOGY EVALUATION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 93619 TC MEDSV DEF MAXFEE 01/01/2024 301.82 0.0 Description: ELECTROPHYSIOLOGY EVALUATION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 93620 26 MEDSV DEF RBRVS 01/01/2024 564.19 Description: ELECTROPHYSIOLOGY EVALUATION Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93620 26 MEDSV DEF RBRVS 09/15/2017 12/31/2023 457.57 Description: ELECTROPHYSIOLOGY EVALUATION Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93620 MEDSV DEF MAXFEE 01/01/2024 1012.87 0.0 Description: ELECTROPHYSIOLOGY EVALUATION Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93620 TC MEDSV DEF MAXFEE 01/01/2024 337.82 0.0 Description: ELECTROPHYSIOLOGY EVALUATION Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93621 26 MEDSV DEF RBRVS 01/01/2024 74.93 Description: ELECTROPHYSIOLOGY EVALUATION Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93621 26 MEDSV DEF RBRVS 09/15/2017 12/31/2023 85.57 Description: ELECTROPHYSIOLOGY EVALUATION Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93622 26 MEDSV DEF RBRVS 01/01/2024 154.52 Description: ELECTROPHYSIOLOGY EVALUATION Category: Medical Services CMS Add: 01/01/1990 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,309 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 93622 26 MEDSV DEF RBRVS 09/15/2017 12/31/2023 125.41 Description: ELECTROPHYSIOLOGY EVALUATION Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93623 26 MEDSV DEF RBRVS 01/01/2024 75.47 Description: STIMULATION PACING HEART Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93623 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 114.72 Description: STIMULATION PACING HEART Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93624 26 MEDSV DEF RBRVS 01/01/2024 224.98 Description: ELECTROPHYSIOLOGIC STUDY Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93624 26 MEDSV DEF RBRVS 09/15/2017 12/31/2023 176.01 Description: ELECTROPHYSIOLOGIC STUDY Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93631 26 MEDSV DEF RBRVS 01/01/2024 357.90 Description: HEART PACING MAPPING Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93631 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 291.46 Description: HEART PACING MAPPING Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93631 MEDSV DEF RBRVS 02/01/2015 12/31/2023 520.37 Description: HEART PACING MAPPING Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93631 MEDSV PRF MAXFEE 01/01/2024 674.40 0.0 Description: HEART PACING MAPPING Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93631 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 158.63 Description: HEART PACING MAPPING Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93631 TC MEDSV PRF MAXFEE 01/01/2024 205.58 0.0 Description: HEART PACING MAPPING Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93640 26 MEDSV DEF RBRVS 01/01/2024 160.41 Description: EVALUATION HEART DEVICE Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93640 26 MEDSV DEF RBRVS 09/15/2017 12/31/2023 130.45 Description: EVALUATION HEART DEVICE Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93640 MEDSV DEF MAXFEE 01/01/2024 254.27 0.0 Description: EVALUATION HEART DEVICE Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93640 TC MEDSV DEF MAXFEE 01/01/2024 78.26 0.0 Description: EVALUATION HEART DEVICE Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93641 26 MEDSV DEF RBRVS 01/01/2024 280.82 Description: ELECTROPHYSIOLOGY EVALUATION Category: Medical Services CMS Add: 01/01/1994 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,310 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 93641 26 MEDSV DEF RBRVS 09/15/2017 12/31/2023 227.65 Description: ELECTROPHYSIOLOGY EVALUATION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 93641 MEDSV DEF MAXFEE 01/01/2024 607.84 0.0 Description: ELECTROPHYSIOLOGY EVALUATION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 93641 TC MEDSV DEF MAXFEE 01/01/2024 280.77 0.0 Description: ELECTROPHYSIOLOGY EVALUATION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 93642 26 MEDSV DEF RBRVS 01/01/2024 229.24 Description: ELECTROPHYSIOLOGY EVALUATION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 93642 26 MEDSV DEF RBRVS 09/15/2017 12/31/2023 187.24 Description: ELECTROPHYSIOLOGY EVALUATION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 93642 MEDSV DEF RBRVS 01/01/2024 304.90 Description: ELECTROPHYSIOLOGY EVALUATION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 93642 MEDSV DEF RBRVS 09/15/2017 12/31/2023 244.30 Description: ELECTROPHYSIOLOGY EVALUATION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 93642 TC MEDSV DEF RBRVS 01/01/2024 75.66 Description: ELECTROPHYSIOLOGY EVALUATION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 93642 TC MEDSV DEF RBRVS 09/15/2017 12/31/2023 57.06 Description: ELECTROPHYSIOLOGY EVALUATION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 93644 26 MEDSV DEF RBRVS 01/01/2024 136.42 Description: ELECTROPHYSIOLOGY EVALUATION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 93644 26 MEDSV DEF RBRVS 09/15/2017 12/31/2023 117.93 Description: ELECTROPHYSIOLOGY EVALUATION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 93644 MEDSV DEF RBRVS 01/01/2024 182.89 Description: ELECTROPHYSIOLOGY EVALUATION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 93644 MEDSV DEF RBRVS 09/15/2017 12/31/2023 158.47 Description: ELECTROPHYSIOLOGY EVALUATION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 93644 TC MEDSV DEF RBRVS 01/01/2024 46.47 Description: ELECTROPHYSIOLOGY EVALUATION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 93644 TC MEDSV DEF RBRVS 09/15/2017 12/31/2023 40.54 Description: ELECTROPHYSIOLOGY EVALUATION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 93650 MEDSV DEF RBRVS 01/01/2024 528.18 Description: ABLATE HEART DYSRHYTHM FOCUS Category: Medical Services CMS Add: 01/01/1990 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,311 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 93650 MEDSV DEF RBRVS 09/15/2017 12/31/2023 428.31 Description: ABLATE HEART DYSRHYTHM FOCUS Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93653 MEDSV DEF RBRVS 01/01/2024 758.56 0-1 Description: COMPRE EP EVAL TX SVT Category: Medical Services CMS Add: 01/01/2013 CMS Term: 93653 MEDSV DEF RBRVS 09/15/2017 12/31/2023 606.05 0-1 Description: COMPRE EP EVAL TX SVT Category: Medical Services CMS Add: 01/01/2013 CMS Term: 93654 MEDSV DEF RBRVS 01/01/2024 914.23 0-1 Description: COMPRE EP EVAL TX VT Category: Medical Services CMS Add: 01/01/2013 CMS Term: 93654 MEDSV DEF RBRVS 09/15/2017 12/31/2023 811.57 0-1 Description: COMPRE EP EVAL TX VT Category: Medical Services CMS Add: 01/01/2013 CMS Term: 93655 MEDSV DEF RBRVS 01/01/2024 278.40 0-1 Description: ICAR CATH ABLTJ DSCRT ARRHYT Category: Medical Services CMS Add: 01/01/2013 CMS Term: 93655 MEDSV DEF RBRVS 09/15/2017 12/31/2023 308.78 0-1 Description: ICAR CATH ABLTJ DSCRT ARRHYT Category: Medical Services CMS Add: 01/01/2013 CMS Term: 93656 MEDSV DEF RBRVS 01/01/2024 860.13 0-1 Description: COMPRE EP EVAL ABLTJ ATR FIB Category: Medical Services CMS Add: 01/01/2013 CMS Term: 93656 MEDSV DEF RBRVS 09/15/2017 12/31/2023 814.34 0-1 Description: COMPRE EP EVAL ABLTJ ATR FIB Category: Medical Services CMS Add: 01/01/2013 CMS Term: 93657 MEDSV DEF RBRVS 01/01/2024 278.40 Description: TX L/R ATRIAL FIB ADDL Category: Medical Services CMS Add: 01/01/2013 CMS Term: 93657 MEDSV DEF RBRVS 09/15/2017 12/31/2023 308.04 Description: TX L/R ATRIAL FIB ADDL Category: Medical Services CMS Add: 01/01/2013 CMS Term: 93660 26 MEDSV DEF RBRVS 01/01/2024 87.55 Description: TILT TABLE EVALUATION Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93660 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 69.52 Description: TILT TABLE EVALUATION Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93660 MEDSV DEF RBRVS 01/01/2024 151.79 Description: TILT TABLE EVALUATION Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93660 MEDSV DEF RBRVS 09/01/2019 12/31/2023 112.54 Description: TILT TABLE EVALUATION Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93660 TC MEDSV DEF RBRVS 01/01/2024 64.24 Description: TILT TABLE EVALUATION Category: Medical Services CMS Add: 01/01/1992 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,312 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 93660 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 43.02 Description: TILT TABLE EVALUATION Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93662 26 MEDSV DEF RBRVS 01/01/2024 70.43 Description: INTRACARDIAC ECG (ICE) Category: Medical Services CMS Add: 01/01/2001 CMS Term: 93662 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 106.11 Description: INTRACARDIAC ECG (ICE) Category: Medical Services CMS Add: 01/01/2001 CMS Term: 93662 MEDSV DEF MAXFEE 01/01/2024 317.32 0.0 Description: INTRACARDIAC ECG (ICE) Category: Medical Services CMS Add: 01/01/2001 CMS Term: 93662 MEDSV DEF RBRVS 02/01/2015 12/31/2023 205.36 Description: INTRACARDIAC ECG (ICE) Category: Medical Services CMS Add: 01/01/2001 CMS Term: 93662 TC MEDSV DEF MAXFEE 01/01/2024 151.76 0.0 Description: INTRACARDIAC ECG (ICE) Category: Medical Services CMS Add: 01/01/2001 CMS Term: 93662 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 98.10 Description: INTRACARDIAC ECG (ICE) Category: Medical Services CMS Add: 01/01/2001 CMS Term: 93668 MEDSV DEF RBRVS 01/01/2024 13.13 Description: PERIPHERAL VASCULAR REHAB Category: Medical Services CMS Add: 01/01/2001 CMS Term: 93668 MEDSV DEF RBRVS 09/01/2019 12/31/2023 13.05 Description: PERIPHERAL VASCULAR REHAB Category: Medical Services CMS Add: 01/01/2001 CMS Term: 93701 26 MEDSV DEF MAXFEE 01/01/2024 8.39 0.0 Description: BIOIMPEDANCE CV ANALYSIS Category: Medical Services CMS Add: 01/01/2002 CMS Term: 93701 26 MEDSV DEF RBRVS 02/01/2015 8.08 Description: BIOIMPEDANCE CV ANALYSIS Category: Medical Services CMS Add: 01/01/2002 CMS Term: 93701 MEDSV DEF RBRVS 01/01/2024 24.24 Description: BIOIMPEDANCE CV ANALYSIS Category: Medical Services CMS Add: 01/01/2002 CMS Term: 93701 MEDSV DEF RBRVS 09/01/2019 12/31/2023 16.51 Description: BIOIMPEDANCE CV ANALYSIS Category: Medical Services CMS Add: 01/01/2002 CMS Term: 93701 TC MEDSV DEF MAXFEE 01/01/2024 23.00 0.0 Description: BIOIMPEDANCE CV ANALYSIS Category: Medical Services CMS Add: 01/01/2002 CMS Term: 93701 TC MEDSV DEF RBRVS 02/01/2015 22.08 Description: BIOIMPEDANCE CV ANALYSIS Category: Medical Services CMS Add: 01/01/2002 CMS Term: 93702 NOCOV DEF SYSMAN Description: BIS XTRACELL FLUID ANALYSIS Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,313 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 93724 26 MEDSV DEF RBRVS 01/01/2024 228.00 Description: ANALYZE PACEMAKER SYSTEM Category: Medical Services CMS Add: 01/01/1994 CMS Term: 93724 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 178.76 Description: ANALYZE PACEMAKER SYSTEM Category: Medical Services CMS Add: 01/01/1994 CMS Term: 93724 MEDSV DEF RBRVS 01/01/2024 270.76 Description: ANALYZE PACEMAKER SYSTEM Category: Medical Services CMS Add: 01/01/1994 CMS Term: 93724 MEDSV DEF RBRVS 09/01/2019 12/31/2023 198.00 Description: ANALYZE PACEMAKER SYSTEM Category: Medical Services CMS Add: 01/01/1994 CMS Term: 93724 TC MEDSV DEF RBRVS 01/01/2024 42.76 Description: ANALYZE PACEMAKER SYSTEM Category: Medical Services CMS Add: 01/01/1994 CMS Term: 93724 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 19.24 Description: ANALYZE PACEMAKER SYSTEM Category: Medical Services CMS Add: 01/01/1994 CMS Term: 93740 MEDSV DEF RBRVS 01/01/2024 7.44 Description: TEMPERATURE GRADIENT STUDIES Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93745 MEDSV DEF MAXFEE 01/01/2024 84.88 0.0 Description: SET-UP CARDIOVERT-DEFIBRILL Category: Medical Services CMS Add: 01/01/2005 CMS Term: 93750 MEDSV DEF RBRVS 01/01/2024 46.80 Description: INTERROGATION VAD IN PERSON Category: Medical Services CMS Add: 01/01/2010 CMS Term: 93750 MEDSV DEF RBRVS 02/01/2015 12/31/2023 39.42 Description: INTERROGATION VAD IN PERSON Category: Medical Services CMS Add: 01/01/2010 CMS Term: 93770 NOCOV DEF SYSMAN Description: MEASURE VENOUS PRESSURE Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: 93784 MEDSV DEF RBRVS 01/01/2024 42.69 Description: AMBL BP MNTR W/SOFTWARE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93784 MEDSV DEF RBRVS 02/01/2015 12/31/2023 37.95 Description: AMBL BP MNTR W/SOFTWARE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93786 MEDSV DEF RBRVS 01/01/2024 20.54 Description: AMBL BP MNTR W/SW REC ONLY Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93786 MEDSV DEF RBRVS 02/01/2015 12/31/2023 20.48 Description: AMBL BP MNTR W/SW REC ONLY Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93788 MEDSV DEF RBRVS 01/01/2024 4.79 Description: AMBL BP MNTR W/SW A/R Category: Medical Services CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,314 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 93788 MEDSV DEF RBRVS 09/01/2019 12/31/2023 3.63 Description: AMBL BP MNTR W/SW A/R Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93790 MEDSV DEF RBRVS 01/01/2024 17.36 Description: AMBL BP MNTR W/SW I&R Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93790 MEDSV DEF RBRVS 02/01/2015 12/31/2023 13.84 Description: AMBL BP MNTR W/SW I&R Category: Medical Services CMS Add: 01/01/1982 CMS Term: 93792 MEDSV DEF RBRVS 01/01/2024 64.24 Y Description: PT/CAREGIVER TRAING HOME INR Category: Medical Services CMS Add: 01/01/2018 CMS Term: 93792 MEDSV DEF RBRVS 07/19/2018 12/31/2023 37.74 Y Description: PT/CAREGIVER TRAING HOME INR Category: Medical Services CMS Add: 01/01/2018 CMS Term: 93793 MEDSV DEF RBRVS 07/19/2018 10.89 Y Description: ANTICOAG MGMT PT WARFARIN Category: Medical Services CMS Add: 01/01/2018 CMS Term: 93797 MEDSV DEF RBRVS 01/01/2024 15.83 Description: CARDIAC REHAB Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93797 MEDSV DEF RBRVS 02/01/2015 12/31/2023 11.69 Description: CARDIAC REHAB Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93798 MEDSV DEF RBRVS 01/01/2024 24.01 Description: CARDIAC REHAB/MONITOR Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93798 MEDSV DEF RBRVS 02/01/2015 12/31/2023 17.60 Description: CARDIAC REHAB/MONITOR Category: Medical Services CMS Add: 01/01/1990 CMS Term: 93799 MEDSV DEF MAXFEE 01/01/2024 645.45 0.0 Description: UNLISTED CV SVC/PROCEDURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 93799 MEDSV DEF MAXFEE 02/01/2015 12/31/2023 498.03 0.0 Description: UNLISTED CV SVC/PROCEDURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 93880 26 MEDSV DEF RBRVS 01/01/2024 36.26 Description: EXTRACRANIAL BILAT STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93880 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 21.98 Description: EXTRACRANIAL BILAT STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93880 MEDSV DEF RBRVS 01/01/2024 177.68 Description: EXTRACRANIAL BILAT STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93880 MEDSV DEF RBRVS 09/01/2019 12/31/2023 133.62 Description: EXTRACRANIAL BILAT STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,315 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 93880 TC MEDSV DEF RBRVS 01/01/2024 141.42 Description: EXTRACRANIAL BILAT STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93880 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 111.64 Description: EXTRACRANIAL BILAT STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93882 26 MEDSV DEF RBRVS 01/01/2024 22.39 Description: EXTRACRANIAL UNI/LTD STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93882 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 14.79 Description: EXTRACRANIAL UNI/LTD STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93882 MEDSV DEF RBRVS 01/01/2024 115.02 Description: EXTRACRANIAL UNI/LTD STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93882 MEDSV DEF RBRVS 09/01/2019 12/31/2023 86.30 Description: EXTRACRANIAL UNI/LTD STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93882 TC MEDSV DEF RBRVS 01/01/2024 92.63 Description: EXTRACRANIAL UNI/LTD STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93882 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 71.51 Description: EXTRACRANIAL UNI/LTD STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93886 26 MEDSV DEF RBRVS 01/01/2024 43.52 Description: INTRACRANIAL COMPLETE STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93886 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 35.58 Description: INTRACRANIAL COMPLETE STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93886 MEDSV DEF RBRVS 01/01/2024 251.31 Description: INTRACRANIAL COMPLETE STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93886 MEDSV DEF RBRVS 09/01/2019 12/31/2023 251.50 Description: INTRACRANIAL COMPLETE STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93886 TC MEDSV DEF RBRVS 01/01/2024 207.79 Description: INTRACRANIAL COMPLETE STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93886 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 215.92 Description: INTRACRANIAL COMPLETE STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93888 26 MEDSV DEF RBRVS 01/01/2024 23.76 Description: INTRACRANIAL LIMITED STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93888 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 23.02 Description: INTRACRANIAL LIMITED STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,316 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 93888 MEDSV DEF RBRVS 01/01/2024 147.88 Description: INTRACRANIAL LIMITED STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93888 MEDSV DEF RBRVS 09/01/2019 12/31/2023 147.04 Description: INTRACRANIAL LIMITED STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93888 TC MEDSV DEF RBRVS 01/01/2024 124.12 Description: INTRACRANIAL LIMITED STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93888 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 124.02 Description: INTRACRANIAL LIMITED STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93890 26 MEDSV DEF RBRVS 01/01/2024 48.11 Description: TCD VASOREACTIVITY STUDY Category: Medical Services CMS Add: 01/01/2005 CMS Term: 93890 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 37.44 Description: TCD VASOREACTIVITY STUDY Category: Medical Services CMS Add: 01/01/2005 CMS Term: 93890 MEDSV DEF RBRVS 01/01/2024 258.68 Description: TCD VASOREACTIVITY STUDY Category: Medical Services CMS Add: 01/01/2005 CMS Term: 93890 MEDSV DEF RBRVS 09/01/2019 12/31/2023 203.08 Description: TCD VASOREACTIVITY STUDY Category: Medical Services CMS Add: 01/01/2005 CMS Term: 93890 TC MEDSV DEF RBRVS 01/01/2024 210.57 Description: TCD VASOREACTIVITY STUDY Category: Medical Services CMS Add: 01/01/2005 CMS Term: 93890 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 165.64 Description: TCD VASOREACTIVITY STUDY Category: Medical Services CMS Add: 01/01/2005 CMS Term: 93892 26 MEDSV DEF RBRVS 01/01/2024 55.99 Description: TCD EMBOLI DETECT W/O INJ Category: Medical Services CMS Add: 01/01/2005 CMS Term: 93892 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 43.37 Description: TCD EMBOLI DETECT W/O INJ Category: Medical Services CMS Add: 01/01/2005 CMS Term: 93892 MEDSV DEF RBRVS 01/01/2024 296.50 Description: TCD EMBOLI DETECT W/O INJ Category: Medical Services CMS Add: 01/01/2005 CMS Term: 93892 MEDSV DEF RBRVS 09/01/2019 12/31/2023 236.50 Description: TCD EMBOLI DETECT W/O INJ Category: Medical Services CMS Add: 01/01/2005 CMS Term: 93892 TC MEDSV DEF RBRVS 01/01/2024 240.51 Description: TCD EMBOLI DETECT W/O INJ Category: Medical Services CMS Add: 01/01/2005 CMS Term: 93892 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 193.13 Description: TCD EMBOLI DETECT W/O INJ Category: Medical Services CMS Add: 01/01/2005 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,317 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 93893 26 MEDSV DEF RBRVS 01/01/2024 56.62 Description: TCD EMBOLI DETECT W/INJ Category: Medical Services CMS Add: 01/01/2005 CMS Term: 93893 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 43.61 Description: TCD EMBOLI DETECT W/INJ Category: Medical Services CMS Add: 01/01/2005 CMS Term: 93893 MEDSV DEF RBRVS 01/01/2024 366.90 Description: TCD EMBOLI DETECT W/INJ Category: Medical Services CMS Add: 01/01/2005 CMS Term: 93893 MEDSV DEF RBRVS 09/01/2019 12/31/2023 244.18 Description: TCD EMBOLI DETECT W/INJ Category: Medical Services CMS Add: 01/01/2005 CMS Term: 93893 TC MEDSV DEF RBRVS 01/01/2024 310.28 Description: TCD EMBOLI DETECT W/INJ Category: Medical Services CMS Add: 01/01/2005 CMS Term: 93893 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 200.57 Description: TCD EMBOLI DETECT W/INJ Category: Medical Services CMS Add: 01/01/2005 CMS Term: 93895 NOCOV DEF SYSMAN Description: CAROTID INTIMA ATHEROMA EVAL Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 93922 26 MEDSV DEF RBRVS 01/01/2024 11.28 Description: UPR/L XTREMITY ART 2 LEVELS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 93922 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 8.86 Description: UPR/L XTREMITY ART 2 LEVELS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 93922 MEDSV DEF RBRVS 01/01/2024 75.81 Description: UPR/L XTREMITY ART 2 LEVELS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 93922 MEDSV DEF RBRVS 09/01/2019 12/31/2023 62.04 Description: UPR/L XTREMITY ART 2 LEVELS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 93922 TC MEDSV DEF RBRVS 01/01/2024 64.53 Description: UPR/L XTREMITY ART 2 LEVELS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 93922 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 53.18 Description: UPR/L XTREMITY ART 2 LEVELS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 93923 26 MEDSV DEF RBRVS 01/01/2024 20.23 Description: UPR/LXTR ART STDY 3+ LVLS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 93923 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 16.22 Description: UPR/LXTR ART STDY 3+ LVLS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 93923 MEDSV DEF RBRVS 01/01/2024 118.72 Description: UPR/LXTR ART STDY 3+ LVLS Category: Medical Services CMS Add: 01/01/1994 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,318 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 93923 MEDSV DEF RBRVS 09/01/2019 12/31/2023 97.39 Description: UPR/LXTR ART STDY 3+ LVLS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 93923 TC MEDSV DEF RBRVS 01/01/2024 98.49 Description: UPR/LXTR ART STDY 3+ LVLS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 93923 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 81.17 Description: UPR/LXTR ART STDY 3+ LVLS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 93924 26 MEDSV DEF RBRVS 01/01/2024 22.54 Description: LWR XTR VASC STDY BILAT Category: Medical Services CMS Add: 01/01/1994 CMS Term: 93924 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 18.06 Description: LWR XTR VASC STDY BILAT Category: Medical Services CMS Add: 01/01/1994 CMS Term: 93924 MEDSV DEF RBRVS 01/01/2024 145.74 Description: LWR XTR VASC STDY BILAT Category: Medical Services CMS Add: 01/01/1994 CMS Term: 93924 MEDSV DEF RBRVS 09/01/2019 12/31/2023 122.26 Description: LWR XTR VASC STDY BILAT Category: Medical Services CMS Add: 01/01/1994 CMS Term: 93924 TC MEDSV DEF RBRVS 01/01/2024 123.20 Description: LWR XTR VASC STDY BILAT Category: Medical Services CMS Add: 01/01/1994 CMS Term: 93924 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 104.21 Description: LWR XTR VASC STDY BILAT Category: Medical Services CMS Add: 01/01/1994 CMS Term: 93925 26 MEDSV DEF RBRVS 01/01/2024 35.48 Description: LOWER EXTREMITY STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93925 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 29.17 Description: LOWER EXTREMITY STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93925 MEDSV DEF RBRVS 01/01/2024 223.21 Description: LOWER EXTREMITY STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93925 MEDSV DEF RBRVS 09/01/2019 12/31/2023 172.35 Description: LOWER EXTREMITY STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93925 TC MEDSV DEF RBRVS 01/01/2024 187.72 Description: LOWER EXTREMITY STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93925 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 143.18 Description: LOWER EXTREMITY STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93926 26 MEDSV DEF RBRVS 01/01/2024 21.60 Description: LOWER EXTREMITY STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,319 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 93926 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 18.14 Description: LOWER EXTREMITY STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93926 MEDSV DEF RBRVS 01/01/2024 132.75 Description: LOWER EXTREMITY STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93926 MEDSV DEF RBRVS 09/01/2019 12/31/2023 98.81 Description: LOWER EXTREMITY STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93926 TC MEDSV DEF RBRVS 01/01/2024 111.15 Description: LOWER EXTREMITY STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93926 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 80.67 Description: LOWER EXTREMITY STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93930 26 MEDSV DEF RBRVS 01/01/2024 35.81 Description: UPPER EXTREMITY STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93930 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 16.74 Description: UPPER EXTREMITY STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93930 MEDSV DEF RBRVS 01/01/2024 181.85 Description: UPPER EXTREMITY STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93930 MEDSV DEF RBRVS 09/01/2019 12/31/2023 160.58 Description: UPPER EXTREMITY STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93930 TC MEDSV DEF RBRVS 01/01/2024 146.05 Description: UPPER EXTREMITY STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93930 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 143.84 Description: UPPER EXTREMITY STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93931 26 MEDSV DEF RBRVS 01/01/2024 21.91 Description: UPPER EXTREMITY STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93931 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 11.30 Description: UPPER EXTREMITY STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93931 MEDSV DEF RBRVS 01/01/2024 114.85 Description: UPPER EXTREMITY STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93931 MEDSV DEF RBRVS 09/01/2019 12/31/2023 109.81 Description: UPPER EXTREMITY STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93931 TC MEDSV DEF RBRVS 01/01/2024 92.94 Description: UPPER EXTREMITY STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,320 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 93931 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 98.51 Description: UPPER EXTREMITY STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93970 26 MEDSV DEF RBRVS 01/01/2024 31.48 Description: EXTREMITY STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93970 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 25.66 Description: EXTREMITY STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93970 MEDSV DEF RBRVS 01/01/2024 175.06 Description: EXTREMITY STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93970 MEDSV DEF RBRVS 09/01/2019 12/31/2023 131.35 Description: EXTREMITY STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93970 TC MEDSV DEF RBRVS 01/01/2024 143.58 Description: EXTREMITY STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93970 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 105.69 Description: EXTREMITY STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93971 26 MEDSV DEF RBRVS 01/01/2024 20.22 Description: EXTREMITY STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93971 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 16.47 Description: EXTREMITY STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93971 MEDSV DEF RBRVS 01/01/2024 110.99 Description: EXTREMITY STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93971 MEDSV DEF RBRVS 09/01/2019 12/31/2023 79.80 Description: EXTREMITY STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93971 TC MEDSV DEF RBRVS 01/01/2024 90.77 Description: EXTREMITY STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93971 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 63.33 Description: EXTREMITY STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93975 26 MEDSV DEF RBRVS 01/01/2024 52.65 Description: VASCULAR STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93975 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 65.62 Description: VASCULAR STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93975 MEDSV DEF RBRVS 01/01/2024 247.78 Description: VASCULAR STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,321 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 93975 MEDSV DEF RBRVS 09/01/2019 12/31/2023 252.64 Description: VASCULAR STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93975 TC MEDSV DEF RBRVS 01/01/2024 195.13 Description: VASCULAR STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93975 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 187.02 Description: VASCULAR STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93976 26 MEDSV DEF RBRVS 01/01/2024 36.40 Description: VASCULAR STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93976 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 44.48 Description: VASCULAR STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93976 MEDSV DEF RBRVS 01/01/2024 148.16 Description: VASCULAR STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93976 MEDSV DEF RBRVS 09/01/2019 12/31/2023 149.43 Description: VASCULAR STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93976 TC MEDSV DEF RBRVS 01/01/2024 111.77 Description: VASCULAR STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93976 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 104.95 Description: VASCULAR STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93978 26 MEDSV DEF RBRVS 01/01/2024 35.51 Description: VASCULAR STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93978 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 23.57 Description: VASCULAR STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93978 MEDSV DEF RBRVS 01/01/2024 167.36 Description: VASCULAR STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93978 MEDSV DEF RBRVS 09/01/2019 12/31/2023 157.51 Description: VASCULAR STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93978 TC MEDSV DEF RBRVS 01/01/2024 131.85 Description: VASCULAR STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93978 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 133.93 Description: VASCULAR STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93979 26 MEDSV DEF RBRVS 01/01/2024 21.91 Description: VASCULAR STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,322 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 93979 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 15.70 Description: VASCULAR STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93979 MEDSV DEF RBRVS 01/01/2024 108.98 Description: VASCULAR STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93979 MEDSV DEF RBRVS 09/01/2019 12/31/2023 109.01 Description: VASCULAR STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93979 TC MEDSV DEF RBRVS 01/01/2024 87.07 Description: VASCULAR STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93979 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 93.31 Description: VASCULAR STUDY Category: Medical Services CMS Add: 01/01/1992 CMS Term: 93980 26 MEDSV DEF RBRVS 01/01/2024 56.89 Description: PENILE VASCULAR STUDY Category: Medical Services CMS Add: 01/01/1993 CMS Term: 93980 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 45.64 Description: PENILE VASCULAR STUDY Category: Medical Services CMS Add: 01/01/1993 CMS Term: 93980 MEDSV DEF RBRVS 01/01/2024 109.85 Description: PENILE VASCULAR STUDY Category: Medical Services CMS Add: 01/01/1993 CMS Term: 93980 MEDSV DEF RBRVS 09/01/2019 12/31/2023 87.42 Description: PENILE VASCULAR STUDY Category: Medical Services CMS Add: 01/01/1993 CMS Term: 93980 TC MEDSV DEF RBRVS 01/01/2024 52.95 Description: PENILE VASCULAR STUDY Category: Medical Services CMS Add: 01/01/1993 CMS Term: 93980 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 41.78 Description: PENILE VASCULAR STUDY Category: Medical Services CMS Add: 01/01/1993 CMS Term: 93981 26 MEDSV DEF RBRVS 01/01/2024 20.18 Description: PENILE VASCULAR STUDY Category: Medical Services CMS Add: 01/01/1993 CMS Term: 93981 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 16.03 Description: PENILE VASCULAR STUDY Category: Medical Services CMS Add: 01/01/1993 CMS Term: 93981 MEDSV DEF RBRVS 01/01/2024 65.42 Description: PENILE VASCULAR STUDY Category: Medical Services CMS Add: 01/01/1993 CMS Term: 93981 MEDSV DEF RBRVS 09/01/2019 12/31/2023 52.36 Description: PENILE VASCULAR STUDY Category: Medical Services CMS Add: 01/01/1993 CMS Term: 93981 TC MEDSV DEF RBRVS 01/01/2024 45.23 Description: PENILE VASCULAR STUDY Category: Medical Services CMS Add: 01/01/1993 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,323 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 93981 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 36.33 Description: PENILE VASCULAR STUDY Category: Medical Services CMS Add: 01/01/1993 CMS Term: 93985 26 RADIO DEF RBRVS 01/01/2020 12/31/2023 28.51 Description: DUP-SCAN HEMO COMPL BI STD Category: Radiology CMS Add: 01/01/2020 CMS Term: 93985 26 RADIO DEF RBRVS 01/01/2024 35.22 Description: DUP-SCAN HEMO COMPL BI STD Category: Radiology CMS Add: 01/01/2020 CMS Term: 93985 RADIO DEF RBRVS 01/01/2020 12/31/2023 194.65 Description: DUP-SCAN HEMO COMPL BI STD Category: Radiology CMS Add: 01/01/2020 CMS Term: 93985 RADIO DEF RBRVS 01/01/2024 229.73 Description: DUP-SCAN HEMO COMPL BI STD Category: Radiology CMS Add: 01/01/2020 CMS Term: 93985 TC RADIO DEF RBRVS 01/01/2020 12/31/2023 166.13 Description: DUP-SCAN HEMO COMPL BI STD Category: Radiology CMS Add: 01/01/2020 CMS Term: 93985 TC RADIO DEF RBRVS 01/01/2024 194.52 Description: DUP-SCAN HEMO COMPL BI STD Category: Radiology CMS Add: 01/01/2020 CMS Term: 93986 26 RADIO DEF RBRVS 01/01/2020 12/31/2023 17.65 Description: DUP-SCAN HEMO COMPL UNI STD Category: Radiology CMS Add: 01/01/2020 CMS Term: 93986 26 RADIO DEF RBRVS 01/01/2024 22.08 Description: DUP-SCAN HEMO COMPL UNI STD Category: Radiology CMS Add: 01/01/2020 CMS Term: 93986 RADIO DEF RBRVS 01/01/2020 12/31/2023 112.60 Description: DUP-SCAN HEMO COMPL UNI STD Category: Radiology CMS Add: 01/01/2020 CMS Term: 93986 RADIO DEF RBRVS 01/01/2024 136.94 Description: DUP-SCAN HEMO COMPL UNI STD Category: Radiology CMS Add: 01/01/2020 CMS Term: 93986 TC RADIO DEF RBRVS 01/01/2020 12/31/2023 94.96 Description: DUP-SCAN HEMO COMPL UNI STD Category: Radiology CMS Add: 01/01/2020 CMS Term: 93986 TC RADIO DEF RBRVS 01/01/2024 114.85 Description: DUP-SCAN HEMO COMPL UNI STD Category: Radiology CMS Add: 01/01/2020 CMS Term: 93990 26 MEDSV DEF RBRVS 01/01/2024 21.63 Description: DOPPLER FLOW TESTING Category: Medical Services CMS Add: 01/01/1995 CMS Term: 93990 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 9.11 Description: DOPPLER FLOW TESTING Category: Medical Services CMS Add: 01/01/1995 CMS Term: 93990 MEDSV DEF RBRVS 01/01/2024 135.56 Description: DOPPLER FLOW TESTING Category: Medical Services CMS Add: 01/01/1995 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,324 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 93990 MEDSV DEF RBRVS 02/01/2015 12/31/2023 135.61 Description: DOPPLER FLOW TESTING Category: Medical Services CMS Add: 01/01/1995 CMS Term: 93990 TC MEDSV DEF RBRVS 01/01/2024 113.93 Description: DOPPLER FLOW TESTING Category: Medical Services CMS Add: 01/01/1995 CMS Term: 93990 TC MEDSV DEF RBRVS 09/01/2019 12/31/2023 126.50 Description: DOPPLER FLOW TESTING Category: Medical Services CMS Add: 01/01/1995 CMS Term: 93998 MEDSV DEF BILL40 Description: UNLISTD NONINVAS VASC DX STD Category: Medical Services CMS Add: 01/01/2012 CMS Term: 94002 MEDSV DEF RBRVS 01/01/2024 86.84 Description: VENT MGMT INPAT INIT DAY Category: Medical Services CMS Add: 01/01/2007 CMS Term: 94002 MEDSV DEF RBRVS 02/01/2015 12/31/2023 68.33 Description: VENT MGMT INPAT INIT DAY Category: Medical Services CMS Add: 01/01/2007 CMS Term: 94003 MEDSV DEF RBRVS 01/01/2024 60.85 Description: VENT MGMT INPAT SUBQ DAY Category: Medical Services CMS Add: 01/01/2007 CMS Term: 94003 MEDSV DEF RBRVS 02/01/2015 12/31/2023 49.11 Description: VENT MGMT INPAT SUBQ DAY Category: Medical Services CMS Add: 01/01/2007 CMS Term: 94004 MEDSV DEF RBRVS 01/01/2024 45.05 Description: VENT MGMT NF PER DAY Category: Medical Services CMS Add: 01/01/2007 CMS Term: 94004 MEDSV DEF RBRVS 02/01/2015 12/31/2023 36.20 Description: VENT MGMT NF PER DAY Category: Medical Services CMS Add: 01/01/2007 CMS Term: 94005 NOCOV DEF SYSMAN Description: HOME VENT MGMT SUPERVISION Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 94010 26 MEDSV DEF RBRVS 01/01/2024 7.77 Description: BREATHING CAPACITY TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94010 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 6.22 Description: BREATHING CAPACITY TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94010 26 MRT DEF RBRVS 01/01/2024 7.77 Description: BREATHING CAPACITY TEST Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 94010 26 MRT DEF RBRVS 02/01/2015 12/31/2023 6.22 Description: BREATHING CAPACITY TEST Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 94010 MEDSV DEF RBRVS 01/01/2024 24.91 Description: BREATHING CAPACITY TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,325 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 94010 MEDSV DEF RBRVS 02/01/2015 12/31/2023 25.21 Description: BREATHING CAPACITY TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94010 MRT DEF RBRVS 01/01/2024 24.91 Description: BREATHING CAPACITY TEST Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 94010 MRT DEF RBRVS 02/01/2015 12/31/2023 25.21 Description: BREATHING CAPACITY TEST Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 94010 TC MEDSV DEF RBRVS 01/01/2024 17.14 Description: BREATHING CAPACITY TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94010 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 18.99 Description: BREATHING CAPACITY TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94010 TC MRT DEF RBRVS 01/01/2024 17.14 Description: BREATHING CAPACITY TEST Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 94010 TC MRT DEF RBRVS 02/01/2015 12/31/2023 18.99 Description: BREATHING CAPACITY TEST Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 94011 MEDSV DEF RBRVS 01/01/2024 80.99 0-2years Description: SPIROMETRY UP TO 2 YRS OLD Category: Medical Services CMS Add: 01/01/2010 CMS Term: 94011 MEDSV DEF RBRVS 09/15/2017 12/31/2023 67.41 0-2years Description: SPIROMETRY UP TO 2 YRS OLD Category: Medical Services CMS Add: 01/01/2010 CMS Term: 94012 MEDSV DEF RBRVS 01/01/2024 131.43 0-2years Description: SPIRMTRY W/BRNCHDIL INF-2 YR Category: Medical Services CMS Add: 01/01/2010 CMS Term: 94012 MEDSV DEF RBRVS 09/15/2017 12/31/2023 108.61 0-2years Description: SPIRMTRY W/BRNCHDIL INF-2 YR Category: Medical Services CMS Add: 01/01/2010 CMS Term: 94013 MEDSV DEF RBRVS 01/01/2024 17.93 0-2years Description: MEAS LUNG VOL THRU 2 YRS Category: Medical Services CMS Add: 01/01/2010 CMS Term: 94013 MEDSV DEF RBRVS 09/15/2017 12/31/2023 14.73 0-2years Description: MEAS LUNG VOL THRU 2 YRS Category: Medical Services CMS Add: 01/01/2010 CMS Term: 94014 26 MEDSV DEF RBRVS 02/01/2015 24.12 Description: PATIENT RECORDED SPIROMETRY Category: Medical Services CMS Add: 01/01/1999 CMS Term: 94014 26 MEDSV PRF MAXFEE 01/01/2024 24.96 0.0 Description: PATIENT RECORDED SPIROMETRY Category: Medical Services CMS Add: 01/01/1999 CMS Term: 94014 MEDSV DEF RBRVS 01/01/2024 51.75 Description: PATIENT RECORDED SPIROMETRY Category: Medical Services CMS Add: 01/01/1999 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,326 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 94014 MEDSV DEF RBRVS 02/01/2015 12/31/2023 37.09 Description: PATIENT RECORDED SPIROMETRY Category: Medical Services CMS Add: 01/01/1999 CMS Term: 94014 TC MEDSV DEF RBRVS 02/01/2015 13.60 Description: PATIENT RECORDED SPIROMETRY Category: Medical Services CMS Add: 01/01/1999 CMS Term: 94014 TC MEDSV PRF MAXFEE 01/01/2024 14.23 0.0 Description: PATIENT RECORDED SPIROMETRY Category: Medical Services CMS Add: 01/01/1999 CMS Term: 94015 MEDSV DEF RBRVS 01/01/2024 28.25 Description: PATIENT RECORDED SPIROMETRY Category: Medical Services CMS Add: 01/01/1999 CMS Term: 94015 MEDSV DEF RBRVS 02/01/2015 12/31/2023 18.50 Description: PATIENT RECORDED SPIROMETRY Category: Medical Services CMS Add: 01/01/1999 CMS Term: 94016 MEDSV DEF RBRVS 01/01/2024 23.50 Description: REVIEW PATIENT SPIROMETRY Category: Medical Services CMS Add: 01/01/1999 CMS Term: 94016 MEDSV DEF RBRVS 02/01/2015 12/31/2023 18.59 Description: REVIEW PATIENT SPIROMETRY Category: Medical Services CMS Add: 01/01/1999 CMS Term: 94060 26 MEDSV DEF RBRVS 01/01/2024 9.78 Description: EVALUATION OF WHEEZING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94060 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 9.65 Description: EVALUATION OF WHEEZING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94060 26 MRT DEF RBRVS 01/01/2024 9.78 Description: EVALUATION OF WHEEZING Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 94060 26 MRT DEF RBRVS 02/01/2015 12/31/2023 9.65 Description: EVALUATION OF WHEEZING Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 94060 MEDSV DEF RBRVS 01/01/2024 35.87 Description: EVALUATION OF WHEEZING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94060 MEDSV DEF RBRVS 02/01/2015 12/31/2023 42.51 Description: EVALUATION OF WHEEZING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94060 MRT DEF RBRVS 01/01/2024 35.87 Description: EVALUATION OF WHEEZING Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 94060 MRT DEF RBRVS 02/01/2015 12/31/2023 42.51 Description: EVALUATION OF WHEEZING Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 94060 TC MEDSV DEF RBRVS 01/01/2024 26.09 Description: EVALUATION OF WHEEZING Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,327 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 94060 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 32.86 Description: EVALUATION OF WHEEZING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94060 TC MRT DEF RBRVS 01/01/2024 26.09 Description: EVALUATION OF WHEEZING Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 94060 TC MRT DEF RBRVS 02/01/2015 12/31/2023 32.86 Description: EVALUATION OF WHEEZING Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 94070 26 MEDSV DEF RBRVS 01/01/2024 26.52 Description: EVALUATION OF WHEEZING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94070 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 21.32 Description: EVALUATION OF WHEEZING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94070 MEDSV DEF RBRVS 01/01/2024 57.55 Description: EVALUATION OF WHEEZING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94070 MEDSV DEF RBRVS 02/01/2015 12/31/2023 42.54 Description: EVALUATION OF WHEEZING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94070 TC MEDSV DEF RBRVS 01/01/2024 31.03 Description: EVALUATION OF WHEEZING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94070 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 21.22 Description: EVALUATION OF WHEEZING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94150 MEDSV DEF MAXFEE 01/01/2024 22.76 0.0 Description: VITAL CAPACITY TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94150 MEDSV DEF MAXFEE 02/01/2015 12/31/2023 0.00 0.0 Description: VITAL CAPACITY TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94200 26 MEDSV DEF RBRVS 01/01/2024 2.47 Description: LUNG FUNCTION TEST (MBC/MVV) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94200 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 4.11 Description: LUNG FUNCTION TEST (MBC/MVV) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94200 MEDSV DEF RBRVS 01/01/2024 13.44 Description: LUNG FUNCTION TEST (MBC/MVV) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94200 MEDSV DEF RBRVS 02/01/2015 12/31/2023 17.16 Description: LUNG FUNCTION TEST (MBC/MVV) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94200 TC MEDSV DEF RBRVS 01/01/2024 10.97 Description: LUNG FUNCTION TEST (MBC/MVV) Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,328 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 94200 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 13.05 Description: LUNG FUNCTION TEST (MBC/MVV) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94375 26 MEDSV DEF RBRVS 01/01/2024 13.75 Description: RESPIRATORY FLOW VOLUME LOOP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94375 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 10.97 Description: RESPIRATORY FLOW VOLUME LOOP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94375 MEDSV DEF RBRVS 01/01/2024 35.83 Description: RESPIRATORY FLOW VOLUME LOOP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94375 MEDSV DEF RBRVS 02/01/2015 12/31/2023 27.73 Description: RESPIRATORY FLOW VOLUME LOOP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94375 TC MEDSV DEF RBRVS 01/01/2024 22.08 Description: RESPIRATORY FLOW VOLUME LOOP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94375 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 16.76 Description: RESPIRATORY FLOW VOLUME LOOP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94450 26 MEDSV DEF RBRVS 01/01/2024 18.82 Description: HYPOXIA RESPONSE CURVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94450 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 14.63 Description: HYPOXIA RESPONSE CURVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94450 MEDSV DEF RBRVS 01/01/2024 76.25 Description: HYPOXIA RESPONSE CURVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94450 MEDSV DEF RBRVS 02/01/2015 12/31/2023 47.99 Description: HYPOXIA RESPONSE CURVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94450 TC MEDSV DEF RBRVS 01/01/2024 57.43 Description: HYPOXIA RESPONSE CURVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94450 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 33.36 Description: HYPOXIA RESPONSE CURVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94452 26 MEDSV DEF RBRVS 01/01/2024 13.44 Description: HAST W/REPORT Category: Medical Services CMS Add: 01/01/2005 CMS Term: 94452 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 10.72 Description: HAST W/REPORT Category: Medical Services CMS Add: 01/01/2005 CMS Term: 94452 MEDSV DEF RBRVS 01/01/2024 45.40 Description: HAST W/REPORT Category: Medical Services CMS Add: 01/01/2005 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,329 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 94452 MEDSV DEF RBRVS 02/01/2015 12/31/2023 40.61 Description: HAST W/REPORT Category: Medical Services CMS Add: 01/01/2005 CMS Term: 94452 TC MEDSV DEF RBRVS 01/01/2024 31.96 Description: HAST W/REPORT Category: Medical Services CMS Add: 01/01/2005 CMS Term: 94452 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 29.89 Description: HAST W/REPORT Category: Medical Services CMS Add: 01/01/2005 CMS Term: 94453 26 MEDSV DEF RBRVS 01/01/2024 17.58 Description: HAST W/OXYGEN TITRATE Category: Medical Services CMS Add: 01/01/2005 CMS Term: 94453 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 13.88 Description: HAST W/OXYGEN TITRATE Category: Medical Services CMS Add: 01/01/2005 CMS Term: 94453 MEDSV DEF RBRVS 01/01/2024 61.74 Description: HAST W/OXYGEN TITRATE Category: Medical Services CMS Add: 01/01/2005 CMS Term: 94453 MEDSV DEF RBRVS 02/01/2015 12/31/2023 56.41 Description: HAST W/OXYGEN TITRATE Category: Medical Services CMS Add: 01/01/2005 CMS Term: 94453 TC MEDSV DEF RBRVS 01/01/2024 44.16 Description: HAST W/OXYGEN TITRATE Category: Medical Services CMS Add: 01/01/2005 CMS Term: 94453 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 42.52 Description: HAST W/OXYGEN TITRATE Category: Medical Services CMS Add: 01/01/2005 CMS Term: 94610 NOCOV DEF SYSMAN Description: SURFACTANT ADMIN THRU TUBE Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 94617 26 MEDSV DEF RBRVS 01/01/2018 12/31/2023 24.75 Description: EXERCISE TST BRNCSPSM W/ECG Category: Medical Services CMS Add: 01/01/2018 CMS Term: 94617 26 MEDSV DEF RBRVS 01/01/2024 30.67 Description: EXERCISE TST BRNCSPSM W/ECG Category: Medical Services CMS Add: 01/01/2018 CMS Term: 94617 MEDSV DEF RBRVS 01/01/2018 12/31/2023 67.94 Description: EXERCISE TST BRNCSPSM W/ECG Category: Medical Services CMS Add: 01/01/2018 CMS Term: 94617 MEDSV DEF RBRVS 01/01/2024 81.93 Description: EXERCISE TST BRNCSPSM W/ECG Category: Medical Services CMS Add: 01/01/2018 CMS Term: 94617 TC MEDSV DEF RBRVS 01/01/2018 12/31/2023 43.19 Description: EXERCISE TST BRNCSPSM W/ECG Category: Medical Services CMS Add: 01/01/2018 CMS Term: 94617 TC MEDSV DEF RBRVS 01/01/2024 51.26 Description: EXERCISE TST BRNCSPSM W/ECG Category: Medical Services CMS Add: 01/01/2018 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,330 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 94618 26 MEDSV DEF RBRVS 01/01/2018 21.22 Description: PULMONARY STRESS TESTING Category: Medical Services CMS Add: 01/01/2018 CMS Term: 94618 MEDSV DEF RBRVS 01/01/2018 12/31/2023 24.79 Description: PULMONARY STRESS TESTING Category: Medical Services CMS Add: 01/01/2018 CMS Term: 94618 MEDSV DEF RBRVS 01/01/2024 31.88 Description: PULMONARY STRESS TESTING Category: Medical Services CMS Add: 01/01/2018 CMS Term: 94618 TC MEDSV DEF RBRVS 01/01/2018 12/31/2023 7.84 Description: PULMONARY STRESS TESTING Category: Medical Services CMS Add: 01/01/2018 CMS Term: 94618 TC MEDSV DEF RBRVS 01/01/2024 10.66 Description: PULMONARY STRESS TESTING Category: Medical Services CMS Add: 01/01/2018 CMS Term: 94619 26 MEDSV DEF RBRVS 01/01/2021 12/31/2023 17.46 Description: EXERCISE TST BRNCSPSM WO ECG Category: Medical Services CMS Add: 01/01/2021 CMS Term: 94619 26 MEDSV DEF RBRVS 01/01/2024 21.56 Description: EXERCISE TST BRNCSPSM WO ECG Category: Medical Services CMS Add: 01/01/2021 CMS Term: 94619 MEDSV DEF RBRVS 01/01/2021 12/31/2023 54.20 Description: EXERCISE TST BRNCSPSM WO ECG Category: Medical Services CMS Add: 01/01/2021 CMS Term: 94619 MEDSV DEF RBRVS 01/01/2024 71.27 Description: EXERCISE TST BRNCSPSM WO ECG Category: Medical Services CMS Add: 01/01/2021 CMS Term: 94619 TC MEDSV DEF RBRVS 01/01/2021 12/31/2023 36.74 Description: EXERCISE TST BRNCSPSM WO ECG Category: Medical Services CMS Add: 01/01/2021 CMS Term: 94619 TC MEDSV DEF RBRVS 01/01/2024 49.72 Description: EXERCISE TST BRNCSPSM WO ECG Category: Medical Services CMS Add: 01/01/2021 CMS Term: 94621 26 MEDSV DEF RBRVS 01/01/2024 64.53 Description: CARDIOPULM EXERCISE TESTING Category: Medical Services CMS Add: 01/01/1999 CMS Term: 94621 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 51.12 Description: CARDIOPULM EXERCISE TESTING Category: Medical Services CMS Add: 01/01/1999 CMS Term: 94621 MEDSV DEF RBRVS 01/01/2024 143.28 Description: CARDIOPULM EXERCISE TESTING Category: Medical Services CMS Add: 01/01/1999 CMS Term: 94621 MEDSV DEF RBRVS 02/01/2015 12/31/2023 116.43 Description: CARDIOPULM EXERCISE TESTING Category: Medical Services CMS Add: 01/01/1999 CMS Term: 94621 TC MEDSV DEF RBRVS 01/01/2024 78.75 Description: CARDIOPULM EXERCISE TESTING Category: Medical Services CMS Add: 01/01/1999 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,331 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 94621 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 65.31 Description: CARDIOPULM EXERCISE TESTING Category: Medical Services CMS Add: 01/01/1999 CMS Term: 94625 MEDSV DEF RBRVS 01/01/2022 12/31/2023 47.66 Y Description: PHY/QHP OP PULM RHB W/O MNTR Category: Medical Services CMS Add: 01/01/2022 CMS Term: 94625 MEDSV DEF RBRVS 01/01/2024 53.90 Y Description: PHY/QHP OP PULM RHB W/O MNTR Category: Medical Services CMS Add: 01/01/2022 CMS Term: 94626 MEDSV DEF RBRVS 01/01/2022 12/31/2023 54.60 Y Description: PHY/QHP OP PULM RHB W/MNTR Category: Medical Services CMS Add: 01/01/2022 CMS Term: 94626 MEDSV DEF RBRVS 01/01/2024 72.10 Y Description: PHY/QHP OP PULM RHB W/MNTR Category: Medical Services CMS Add: 01/01/2022 CMS Term: 94640 MEDSV DEF RBRVS 01/01/2016 12/31/2023 12.80 Description: AIRWAY INHALATION TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94640 MEDSV DEF RBRVS 01/01/2024 8.19 Description: AIRWAY INHALATION TREATMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94642 MEDSV DEF MAXFEE 01/01/2024 41.00 0.0 Description: AEROSOL INHALATION TREATMENT Category: Medical Services CMS Add: 01/01/1991 CMS Term: 94642 MEDSV DEF MAXFEE 02/01/2015 12/31/2023 14.45 0.0 Description: AEROSOL INHALATION TREATMENT Category: Medical Services CMS Add: 01/01/1991 CMS Term: 94644 MEDSV DEF RBRVS 01/01/2024 54.80 Description: CBT 1ST HOUR Category: Medical Services CMS Add: 01/01/2007 CMS Term: 94644 MEDSV DEF RBRVS 02/01/2015 12/31/2023 30.39 Description: CBT 1ST HOUR Category: Medical Services CMS Add: 01/01/2007 CMS Term: 94645 MEDSV DEF RBRVS 01/01/2024 14.36 Description: CBT EACH ADDL HOUR Category: Medical Services CMS Add: 01/01/2007 CMS Term: 94645 MEDSV DEF RBRVS 02/01/2015 12/31/2023 9.83 Description: CBT EACH ADDL HOUR Category: Medical Services CMS Add: 01/01/2007 CMS Term: 94660 MEDSV DEF RBRVS 01/01/2024 59.44 Description: POS AIRWAY PRESSURE CPAP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94660 MEDSV DEF RBRVS 02/01/2015 12/31/2023 45.03 Description: POS AIRWAY PRESSURE CPAP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94662 MEDSV DEF RBRVS 01/01/2024 33.20 Description: NEG PRESS VENTILATION CNP Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,332 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 94662 MEDSV DEF RBRVS 02/01/2015 12/31/2023 29.42 Description: NEG PRESS VENTILATION CNP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94664 MEDSV DEF RBRVS 01/01/2024 15.60 Description: EVALUATE PT USE OF INHALER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94664 MEDSV DEF RBRVS 02/01/2015 12/31/2023 11.81 Description: EVALUATE PT USE OF INHALER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94667 MEDSV DEF RBRVS 01/01/2024 21.31 Description: CHEST WALL MANIPULATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94667 MEDSV DEF RBRVS 02/01/2015 12/31/2023 17.51 Description: CHEST WALL MANIPULATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94668 MEDSV DEF RBRVS 01/01/2024 33.35 Description: CHEST WALL MANIPULATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94668 MEDSV DEF RBRVS 02/01/2015 12/31/2023 20.23 Description: CHEST WALL MANIPULATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94669 MEDSV DEF RBRVS 01/01/2024 17.61 Description: MECHANICAL CHEST WALL OSCILL Category: Medical Services CMS Add: 01/01/2014 CMS Term: 94669 MEDSV DEF RBRVS 02/01/2015 12/31/2023 24.44 Description: MECHANICAL CHEST WALL OSCILL Category: Medical Services CMS Add: 01/01/2014 CMS Term: 94680 26 MEDSV DEF RBRVS 01/01/2024 11.91 Description: EXHALED AIR ANALYSIS O2 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94680 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 9.38 Description: EXHALED AIR ANALYSIS O2 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94680 MEDSV DEF RBRVS 01/01/2024 48.66 Description: EXHALED AIR ANALYSIS O2 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94680 MEDSV DEF RBRVS 02/01/2015 12/31/2023 40.51 Description: EXHALED AIR ANALYSIS O2 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94680 TC MEDSV DEF RBRVS 01/01/2024 36.75 Description: EXHALED AIR ANALYSIS O2 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94680 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 31.13 Description: EXHALED AIR ANALYSIS O2 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94681 26 MEDSV DEF RBRVS 01/01/2024 9.10 Description: EXHALED AIR ANALYSIS O2/CO2 Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,333 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 94681 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 7.27 Description: EXHALED AIR ANALYSIS O2/CO2 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94681 MEDSV DEF RBRVS 01/01/2024 43.38 Description: EXHALED AIR ANALYSIS O2/CO2 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94681 MEDSV DEF RBRVS 02/01/2015 12/31/2023 35.68 Description: EXHALED AIR ANALYSIS O2/CO2 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94681 TC MEDSV DEF RBRVS 01/01/2024 34.28 Description: EXHALED AIR ANALYSIS O2/CO2 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94681 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 28.40 Description: EXHALED AIR ANALYSIS O2/CO2 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94690 26 MEDSV DEF RBRVS 01/01/2024 3.46 Description: EXHALED AIR ANALYSIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94690 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 2.79 Description: EXHALED AIR ANALYSIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94690 MEDSV DEF RBRVS 01/01/2024 43.75 Description: EXHALED AIR ANALYSIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94690 MEDSV DEF RBRVS 02/01/2015 12/31/2023 33.92 Description: EXHALED AIR ANALYSIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94690 TC MEDSV DEF RBRVS 01/01/2024 40.29 Description: EXHALED AIR ANALYSIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94690 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 31.13 Description: EXHALED AIR ANALYSIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94726 26 MEDSV DEF RBRVS 01/01/2024 11.44 Description: PULM FUNCT TST PLETHYSMOGRAP Category: Medical Services CMS Add: 01/01/2012 CMS Term: 94726 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 9.13 Description: PULM FUNCT TST PLETHYSMOGRAP Category: Medical Services CMS Add: 01/01/2012 CMS Term: 94726 MEDSV DEF RBRVS 01/01/2024 50.35 Description: PULM FUNCT TST PLETHYSMOGRAP Category: Medical Services CMS Add: 01/01/2012 CMS Term: 94726 MEDSV DEF RBRVS 02/01/2015 12/31/2023 37.21 Description: PULM FUNCT TST PLETHYSMOGRAP Category: Medical Services CMS Add: 01/01/2012 CMS Term: 94726 TC MEDSV DEF RBRVS 01/01/2024 38.91 Description: PULM FUNCT TST PLETHYSMOGRAP Category: Medical Services CMS Add: 01/01/2012 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,334 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 94726 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 28.07 Description: PULM FUNCT TST PLETHYSMOGRAP Category: Medical Services CMS Add: 01/01/2012 CMS Term: 94727 26 MEDSV DEF RBRVS 01/01/2024 11.44 Description: PULM FUNCTION TEST BY GAS Category: Medical Services CMS Add: 01/01/2012 CMS Term: 94727 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 9.13 Description: PULM FUNCTION TEST BY GAS Category: Medical Services CMS Add: 01/01/2012 CMS Term: 94727 MEDSV DEF RBRVS 01/01/2024 40.62 Description: PULM FUNCTION TEST BY GAS Category: Medical Services CMS Add: 01/01/2012 CMS Term: 94727 MEDSV DEF RBRVS 02/01/2015 12/31/2023 29.61 Description: PULM FUNCTION TEST BY GAS Category: Medical Services CMS Add: 01/01/2012 CMS Term: 94727 TC MEDSV DEF RBRVS 01/01/2024 29.18 Description: PULM FUNCTION TEST BY GAS Category: Medical Services CMS Add: 01/01/2012 CMS Term: 94727 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 20.48 Description: PULM FUNCTION TEST BY GAS Category: Medical Services CMS Add: 01/01/2012 CMS Term: 94728 26 MEDSV DEF RBRVS 01/01/2024 11.75 Description: AIRWY RESIST BY OSCILLOMETRY Category: Medical Services CMS Add: 01/01/2012 CMS Term: 94728 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 9.38 Description: AIRWY RESIST BY OSCILLOMETRY Category: Medical Services CMS Add: 01/01/2012 CMS Term: 94728 MEDSV DEF RBRVS 01/01/2024 36.92 Description: AIRWY RESIST BY OSCILLOMETRY Category: Medical Services CMS Add: 01/01/2012 CMS Term: 94728 MEDSV DEF RBRVS 02/01/2015 12/31/2023 28.37 Description: AIRWY RESIST BY OSCILLOMETRY Category: Medical Services CMS Add: 01/01/2012 CMS Term: 94728 TC MEDSV DEF RBRVS 01/01/2024 25.17 Description: AIRWY RESIST BY OSCILLOMETRY Category: Medical Services CMS Add: 01/01/2012 CMS Term: 94728 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 18.99 Description: AIRWY RESIST BY OSCILLOMETRY Category: Medical Services CMS Add: 01/01/2012 CMS Term: 94729 26 MEDSV DEF RBRVS 01/01/2024 8.45 Description: CO/MEMBANE DIFFUSE CAPACITY Category: Medical Services CMS Add: 01/01/2012 CMS Term: 94729 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 6.76 Description: CO/MEMBANE DIFFUSE CAPACITY Category: Medical Services CMS Add: 01/01/2012 CMS Term: 94729 MEDSV DEF RBRVS 01/01/2024 52.45 Description: CO/MEMBANE DIFFUSE CAPACITY Category: Medical Services CMS Add: 01/01/2012 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,335 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 94729 MEDSV DEF RBRVS 02/01/2015 12/31/2023 37.89 Description: CO/MEMBANE DIFFUSE CAPACITY Category: Medical Services CMS Add: 01/01/2012 CMS Term: 94729 TC MEDSV DEF RBRVS 01/01/2024 44.00 Description: CO/MEMBANE DIFFUSE CAPACITY Category: Medical Services CMS Add: 01/01/2012 CMS Term: 94729 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 31.13 Description: CO/MEMBANE DIFFUSE CAPACITY Category: Medical Services CMS Add: 01/01/2012 CMS Term: 94760 MEDSV DEF RBRVS 01/01/2024 2.01 Description: MEASURE BLOOD OXYGEN LEVEL Category: Medical Services CMS Add: 01/01/1989 CMS Term: 94760 MEDSV DEF RBRVS 02/01/2015 12/31/2023 2.15 Description: MEASURE BLOOD OXYGEN LEVEL Category: Medical Services CMS Add: 01/01/1989 CMS Term: 94761 MEDSV DEF RBRVS 01/01/2024 3.25 Description: MEASURE BLOOD OXYGEN LEVEL Category: Medical Services CMS Add: 01/01/1989 CMS Term: 94761 MEDSV DEF RBRVS 02/01/2015 12/31/2023 3.39 Description: MEASURE BLOOD OXYGEN LEVEL Category: Medical Services CMS Add: 01/01/1989 CMS Term: 94762 MEDSV DEF RBRVS 01/01/2024 23.31 Description: MEASURE BLOOD OXYGEN LEVEL Category: Medical Services CMS Add: 01/01/1989 CMS Term: 94762 MEDSV DEF RBRVS 02/01/2015 12/31/2023 17.01 Description: MEASURE BLOOD OXYGEN LEVEL Category: Medical Services CMS Add: 01/01/1989 CMS Term: 94772 26 MEDSV DEF MAXFEE 01/01/2024 156.79 0.0 0-364days Description: BREATH RECORDING INFANT Category: Medical Services CMS Add: 01/01/1992 CMS Term: 94772 26 MEDSV DEF MAXFEE 02/01/2015 12/31/2023 120.98 0.0 0-364days Description: BREATH RECORDING INFANT Category: Medical Services CMS Add: 01/01/1992 CMS Term: 94772 MEDSV DEF MAXFEE 01/01/2024 489.97 0.0 0-364days Description: BREATH RECORDING INFANT Category: Medical Services CMS Add: 01/01/1992 CMS Term: 94772 MEDSV DEF MAXFEE 02/01/2015 12/31/2023 378.06 0.0 0-364days Description: BREATH RECORDING INFANT Category: Medical Services CMS Add: 01/01/1992 CMS Term: 94772 TC MEDSV DEF MAXFEE 01/01/2024 333.18 0.0 0-364days Description: BREATH RECORDING INFANT Category: Medical Services CMS Add: 01/01/1992 CMS Term: 94772 TC MEDSV DEF MAXFEE 02/01/2015 12/31/2023 257.08 0.0 0-364days Description: BREATH RECORDING INFANT Category: Medical Services CMS Add: 01/01/1992 CMS Term: 94774 NOCOV DEF SYSMAN Description: PED HOME APNEA REC COMPL Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,336 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 94775 NOCOV DEF SYSMAN Description: PED HOME APNEA REC HK-UP Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 94776 NOCOV DEF SYSMAN Description: PED HOME APNEA REC DOWNLD Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 94777 NOCOV DEF SYSMAN Description: PED HOME APNEA REC REPORT Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 94780 MEDSV DEF RBRVS 01/01/2024 48.40 0-1 Description: CARS/BD TST INFT-12MO 60 MIN Category: Medical Services CMS Add: 01/01/2012 CMS Term: 94780 MEDSV DEF RBRVS 02/01/2015 12/31/2023 36.68 0-1 Description: CARS/BD TST INFT-12MO 60 MIN Category: Medical Services CMS Add: 01/01/2012 CMS Term: 94781 MEDSV DEF RBRVS 01/01/2024 19.20 0-2 Description: CARS/BD TST INFT-12MO +30MIN Category: Medical Services CMS Add: 01/01/2012 CMS Term: 94781 MEDSV DEF RBRVS 02/01/2015 12/31/2023 14.39 0-2 Description: CARS/BD TST INFT-12MO +30MIN Category: Medical Services CMS Add: 01/01/2012 CMS Term: 94799 MEDSV DEF MAXFEE 01/01/2024 23.59 0.0 Description: UNLISTED PULMONARY SVC/PX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 94799 MEDSV DEF MAXFEE 02/01/2015 12/31/2023 18.20 0.0 Description: UNLISTED PULMONARY SVC/PX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95004 MEDSV DEF RBRVS 01/01/2024 3.59 Description: PERCUT ALLERGY SKIN TESTS Category: Medical Services CMS Add: 01/01/1993 CMS Term: 95004 MEDSV DEF RBRVS 02/01/2015 12/31/2023 4.40 Description: PERCUT ALLERGY SKIN TESTS Category: Medical Services CMS Add: 01/01/1993 CMS Term: 95012 MEDSV DEF RBRVS 01/01/2024 17.14 Description: EXHALED NITRIC OXIDE MEAS Category: Medical Services CMS Add: 01/01/2007 CMS Term: 95012 MEDSV DEF RBRVS 02/01/2015 12/31/2023 13.29 Description: EXHALED NITRIC OXIDE MEAS Category: Medical Services CMS Add: 01/01/2007 CMS Term: 95017 MEDSV DEF RBRVS 01/01/2024 8.09 Description: PERQ & ICUT ALLG TEST VENOMS Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95017 MEDSV DEF RBRVS 02/01/2015 12/31/2023 5.76 Description: PERQ & ICUT ALLG TEST VENOMS Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95018 MEDSV DEF RBRVS 01/01/2024 18.80 0-19 Description: PERQ&IC ALLG TEST DRUGS/BIOL Category: Medical Services CMS Add: 01/01/2013 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,337 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 95018 MEDSV DEF RBRVS 02/01/2015 12/31/2023 14.08 0-19 Description: PERQ&IC ALLG TEST DRUGS/BIOL Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95024 MEDSV DEF RBRVS 01/01/2024 7.29 Description: ICUT ALLERGY TEST DRUG/BUG Category: Medical Services CMS Add: 01/01/1993 CMS Term: 95024 MEDSV DEF RBRVS 02/01/2015 12/31/2023 5.39 Description: ICUT ALLERGY TEST DRUG/BUG Category: Medical Services CMS Add: 01/01/1993 CMS Term: 95027 MEDSV DEF RBRVS 01/01/2024 4.51 Description: ICUT ALLERGY TITRATE-AIRBORN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95027 MEDSV DEF RBRVS 02/01/2015 12/31/2023 3.16 Description: ICUT ALLERGY TITRATE-AIRBORN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95028 MEDSV DEF RBRVS 01/01/2024 11.58 Description: ICUT ALLERGY TEST-DELAYED Category: Medical Services CMS Add: 01/01/1993 CMS Term: 95028 MEDSV DEF RBRVS 02/01/2015 12/31/2023 9.33 Description: ICUT ALLERGY TEST-DELAYED Category: Medical Services CMS Add: 01/01/1993 CMS Term: 95044 MEDSV DEF RBRVS 01/01/2024 4.48 Description: ALLERGY PATCH TESTS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 95044 MEDSV DEF RBRVS 02/01/2015 12/31/2023 3.63 Description: ALLERGY PATCH TESTS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 95052 MEDSV DEF RBRVS 01/01/2024 5.72 Description: PHOTO PATCH TEST Category: Medical Services CMS Add: 01/01/1994 CMS Term: 95052 MEDSV DEF RBRVS 02/01/2015 12/31/2023 4.38 Description: PHOTO PATCH TEST Category: Medical Services CMS Add: 01/01/1994 CMS Term: 95056 MEDSV DEF RBRVS 01/01/2024 46.63 Description: PHOTOSENSITIVITY TESTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95056 MEDSV DEF RBRVS 02/01/2015 12/31/2023 29.89 Description: PHOTOSENSITIVITY TESTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95060 MEDSV DEF RBRVS 01/01/2024 34.43 Description: EYE ALLERGY TESTS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 95060 MEDSV DEF RBRVS 02/01/2015 12/31/2023 23.20 Description: EYE ALLERGY TESTS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 95065 MEDSV DEF RBRVS 01/01/2024 25.48 Description: NOSE ALLERGY TEST Category: Medical Services CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,338 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 95065 MEDSV DEF RBRVS 02/01/2015 12/31/2023 18.25 Description: NOSE ALLERGY TEST Category: Medical Services CMS Add: 01/01/1985 CMS Term: 95070 MEDSV DEF RBRVS 01/01/2024 31.50 Description: BRONCHIAL ALLERGY TESTS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 95070 MEDSV DEF RBRVS 02/01/2015 12/31/2023 20.23 Description: BRONCHIAL ALLERGY TESTS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 95076 MEDSV DEF RBRVS 01/01/2024 114.77 0-1 Description: INGEST CHALLENGE INI 120 MIN Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95076 MEDSV DEF RBRVS 02/01/2015 12/31/2023 83.98 0-1 Description: INGEST CHALLENGE INI 120 MIN Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95079 MEDSV DEF RBRVS 01/01/2024 80.76 Description: INGEST CHALLENGE ADDL 60 MIN Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95079 MEDSV DEF RBRVS 02/01/2015 12/31/2023 60.69 Description: INGEST CHALLENGE ADDL 60 MIN Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95115 MEDSV DEF RBRVS 01/01/2024 9.11 Description: IMMUNOTHERAPY ONE INJECTION Category: Medical Services CMS Add: 01/01/1988 CMS Term: 95115 MEDSV DEF RBRVS 02/01/2015 12/31/2023 6.11 Description: IMMUNOTHERAPY ONE INJECTION Category: Medical Services CMS Add: 01/01/1988 CMS Term: 95117 MEDSV DEF RBRVS 01/01/2024 10.66 Description: IMMUNOTHERAPY INJECTIONS Category: Medical Services CMS Add: 01/01/1988 CMS Term: 95117 MEDSV DEF RBRVS 02/01/2015 12/31/2023 7.10 Description: IMMUNOTHERAPY INJECTIONS Category: Medical Services CMS Add: 01/01/1988 CMS Term: 95120 MEDSV DEF MAXFEE 01/01/1994 12/31/2023 3.00 0.0 Description: IMMUNOTHERAPY ONE INJECTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95120 MEDSV DEF MAXFEE 01/01/2024 3.89 0.0 Description: IMMUNOTHERAPY ONE INJECTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95125 MEDSV DEF MAXFEE 01/01/1994 12/31/2023 2.98 0.0 Description: IMMUNOTHERAPY 2/> INJECTIONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95125 MEDSV DEF MAXFEE 01/01/2024 3.86 0.0 Description: IMMUNOTHERAPY 2/> INJECTIONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95130 MEDSV DEF MAXFEE 01/01/1994 12/31/2023 3.00 0.0 Description: IMMNTX 1 STING INSECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,339 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 95130 MEDSV DEF MAXFEE 01/01/2024 3.89 0.0 Description: IMMNTX 1 STING INSECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95131 MEDSV DEF MAXFEE 01/01/1994 12/31/2023 7.65 0.0 Description: IMMNTX 2 STING INSECTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95131 MEDSV DEF MAXFEE 01/01/2024 9.91 0.0 Description: IMMNTX 2 STING INSECTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95132 MEDSV DEF MAXFEE 01/01/1994 12/31/2023 5.86 0.0 Description: IMMNTX 3 STING INSECTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95132 MEDSV DEF MAXFEE 01/01/2024 7.59 0.0 Description: IMMNTX 3 STING INSECTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95133 MEDSV DEF MAXFEE 01/01/1994 12/31/2023 12.00 0.0 Description: IMMNTX 4 STING INSECTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95133 MEDSV DEF MAXFEE 01/01/2024 15.55 0.0 Description: IMMNTX 4 STING INSECTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95134 MEDSV DEF MAXFEE 01/01/1994 12/31/2023 207.99 0.0 Description: IMMNTX 5 STING INSECTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95134 MEDSV DEF MAXFEE 01/01/2024 269.56 0.0 Description: IMMNTX 5 STING INSECTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95144 MEDSV DEF RBRVS 01/01/2024 15.47 Description: ANTIGEN THERAPY SERVICES Category: Medical Services CMS Add: 01/01/1994 CMS Term: 95144 MEDSV DEF RBRVS 02/01/2015 12/31/2023 8.71 Description: ANTIGEN THERAPY SERVICES Category: Medical Services CMS Add: 01/01/1994 CMS Term: 95145 MEDSV DEF RBRVS 01/01/2024 30.60 Description: ANTIGEN THERAPY SERVICES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95145 MEDSV DEF RBRVS 02/01/2015 12/31/2023 15.15 Description: ANTIGEN THERAPY SERVICES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95146 MEDSV DEF RBRVS 01/01/2024 56.22 Description: ANTIGEN THERAPY SERVICES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95146 MEDSV DEF RBRVS 02/01/2015 12/31/2023 27.04 Description: ANTIGEN THERAPY SERVICES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95147 MEDSV DEF RBRVS 01/01/2024 54.37 Description: ANTIGEN THERAPY SERVICES Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,340 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 95147 MEDSV DEF RBRVS 02/01/2015 12/31/2023 24.32 Description: ANTIGEN THERAPY SERVICES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95148 MEDSV DEF RBRVS 01/01/2024 80.30 Description: ANTIGEN THERAPY SERVICES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95148 MEDSV DEF RBRVS 02/01/2015 12/31/2023 36.46 Description: ANTIGEN THERAPY SERVICES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95149 MEDSV DEF RBRVS 01/01/2024 106.23 Description: ANTIGEN THERAPY SERVICES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95149 MEDSV DEF RBRVS 02/01/2015 12/31/2023 48.60 Description: ANTIGEN THERAPY SERVICES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95165 MEDSV DEF RBRVS 01/01/2019 12/31/2023 8.96 Description: ANTIGEN THERAPY SERVICES Category: Medical Services CMS Add: 01/01/1994 CMS Term: 95165 MEDSV DEF RBRVS 01/01/2024 13.93 Description: ANTIGEN THERAPY SERVICES Category: Medical Services CMS Add: 01/01/1994 CMS Term: 95170 MEDSV DEF RBRVS 01/01/2024 10.53 Description: ANTIGEN THERAPY SERVICES Category: Medical Services CMS Add: 01/01/1988 CMS Term: 95170 MEDSV DEF RBRVS 02/01/2015 12/31/2023 6.73 Description: ANTIGEN THERAPY SERVICES Category: Medical Services CMS Add: 01/01/1988 CMS Term: 95180 MEDSV DEF RBRVS 01/01/2024 130.53 Description: RAPID DESENSITIZATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95180 MEDSV DEF RBRVS 02/01/2015 12/31/2023 97.27 Description: RAPID DESENSITIZATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95199 MEDSV DEF MAXFEE 01/01/2024 14.83 0.0 Description: UNLISTED ALL/IMMLG SVC/PX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95199 MEDSV DEF MAXFEE 02/01/2015 12/31/2023 11.44 0.0 Description: UNLISTED ALL/IMMLG SVC/PX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95249 MEDSV DEF RBRVS 01/01/2018 12/31/2023 38.40 Y Description: CONT GLUC MNTR PT PROV EQP Category: Medical Services CMS Add: 01/01/2018 CMS Term: 95249 MEDSV DEF RBRVS 01/01/2024 55.59 Y Description: CONT GLUC MNTR PT PROV EQP Category: Medical Services CMS Add: 01/01/2018 CMS Term: 95250 MEDSV DEF RBRVS 01/01/2024 133.39 Y Description: CONT GLUC MNTR PHYS/QHP EQP Category: Medical Services CMS Add: 01/01/2002 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,341 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 95250 MEDSV DEF RBRVS 02/01/2015 12/31/2023 108.66 Y Description: CONT GLUC MNTR PHYS/QHP EQP Category: Medical Services CMS Add: 01/01/2002 CMS Term: 95251 MEDSV DEF RBRVS 01/01/2024 33.01 Description: CONT GLUC MNTR ANALYSIS I&R Category: Medical Services CMS Add: 01/01/2006 CMS Term: 95251 MEDSV DEF RBRVS 02/01/2015 12/31/2023 31.92 Description: CONT GLUC MNTR ANALYSIS I&R Category: Medical Services CMS Add: 01/01/2006 CMS Term: 95700 MEDSV PRF MAXFEE 01/01/2024 259.12 0.0 Description: EEG CONT REC W/VID EEG TECH Category: Medical Services CMS Add: 01/01/2020 CMS Term: 95705 MEDSV PRF MAXFEE 01/01/2024 103.65 0.0 Description: EEG W/O VID 2-12 HR UNMNTR Category: Medical Services CMS Add: 01/01/2020 CMS Term: 95706 MEDSV PRF MAXFEE 01/01/2024 409.40 0.0 Description: EEG WO VID 2-12HR INTMT MNTR Category: Medical Services CMS Add: 01/01/2020 CMS Term: 95707 MEDSV PRF MAXFEE 01/01/2024 538.96 0.0 Description: EEG W/O VID 2-12HR CONT MNTR Category: Medical Services CMS Add: 01/01/2020 CMS Term: 95708 MEDSV PRF MAXFEE 01/01/2024 145.10 0.0 Description: EEG WO VID EA 12-26HR UNMNTR Category: Medical Services CMS Add: 01/01/2020 CMS Term: 95709 MEDSV PRF MAXFEE 01/01/2024 766.98 0.0 Description: EEG W/O VID EA 12-26HR INTMT Category: Medical Services CMS Add: 01/01/2020 CMS Term: 95710 MEDSV PRF MAXFEE 01/01/2024 881.00 0.0 Description: EEG W/O VID EA 12-26HR CONT Category: Medical Services CMS Add: 01/01/2020 CMS Term: 95711 MEDSV PRF MAXFEE 01/01/2024 129.56 0.0 Description: VEEG 2-12 HR UNMONITORED Category: Medical Services CMS Add: 01/01/2020 CMS Term: 95712 MEDSV PRF MAXFEE 01/01/2024 456.04 0.0 Description: VEEG 2-12 HR INTMT MNTR Category: Medical Services CMS Add: 01/01/2020 CMS Term: 95713 MEDSV PRF MAXFEE 01/01/2024 647.79 0.0 Description: VEEG 2-12 HR CONT MNTR Category: Medical Services CMS Add: 01/01/2020 CMS Term: 95714 MEDSV PRF MAXFEE 01/01/2024 181.38 0.0 Description: VEEG EA 12-26 HR UNMNTR Category: Medical Services CMS Add: 01/01/2020 CMS Term: 95715 MEDSV PRF MAXFEE 01/01/2024 715.16 0.0 Description: VEEG EA 12-26HR INTMT MNTR Category: Medical Services CMS Add: 01/01/2020 CMS Term: 95716 MEDSV PRF MAXFEE 01/01/2024 989.82 0.0 Description: VEEG EA 12-26HR CONT MNTR Category: Medical Services CMS Add: 01/01/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,342 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 95717 MEDSV DEF RBRVS 01/01/2020 12/31/2023 76.03 Description: EEG PHYS/QHP 2-12 HR W/O VID Category: Medical Services CMS Add: 01/01/2020 CMS Term: 95717 MEDSV DEF RBRVS 01/01/2024 96.87 Description: EEG PHYS/QHP 2-12 HR W/O VID Category: Medical Services CMS Add: 01/01/2020 CMS Term: 95718 MEDSV DEF RBRVS 01/01/2020 12/31/2023 99.62 Description: EEG PHYS/QHP 2-12 HR W/VEEG Category: Medical Services CMS Add: 01/01/2020 CMS Term: 95718 MEDSV DEF RBRVS 01/01/2024 127.29 Description: EEG PHYS/QHP 2-12 HR W/VEEG Category: Medical Services CMS Add: 01/01/2020 CMS Term: 95719 MEDSV DEF RBRVS 01/01/2020 12/31/2023 117.26 Description: EEG PHYS/QHP EA INCR W/O VID Category: Medical Services CMS Add: 01/01/2020 CMS Term: 95719 MEDSV DEF RBRVS 01/01/2024 149.66 Description: EEG PHYS/QHP EA INCR W/O VID Category: Medical Services CMS Add: 01/01/2020 CMS Term: 95720 MEDSV DEF RBRVS 01/01/2020 12/31/2023 154.16 Description: EEG PHY/QHP EA INCR W/VEEG Category: Medical Services CMS Add: 01/01/2020 CMS Term: 95720 MEDSV DEF RBRVS 01/01/2024 196.76 Description: EEG PHY/QHP EA INCR W/VEEG Category: Medical Services CMS Add: 01/01/2020 CMS Term: 95721 MEDSV DEF RBRVS 01/01/2020 12/31/2023 155.40 Description: EEG PHY/QHP>36<60 HR W/O VID Category: Medical Services CMS Add: 01/01/2020 CMS Term: 95721 MEDSV DEF RBRVS 01/01/2024 196.29 Description: EEG PHY/QHP>36<60 HR W/O VID Category: Medical Services CMS Add: 01/01/2020 CMS Term: 95722 MEDSV DEF RBRVS 01/01/2020 12/31/2023 188.54 Description: EEG PHY/QHP>36<60 HR W/VEEG Category: Medical Services CMS Add: 01/01/2020 CMS Term: 95722 MEDSV DEF RBRVS 01/01/2024 238.70 Description: EEG PHY/QHP>36<60 HR W/VEEG Category: Medical Services CMS Add: 01/01/2020 CMS Term: 95723 MEDSV DEF RBRVS 01/01/2020 12/31/2023 192.44 Description: EEG PHY/QHP>60<84 HR W/O VID Category: Medical Services CMS Add: 01/01/2020 CMS Term: 95723 MEDSV DEF RBRVS 01/01/2024 240.07 Description: EEG PHY/QHP>60<84 HR W/O VID Category: Medical Services CMS Add: 01/01/2020 CMS Term: 95724 MEDSV DEF RBRVS 01/01/2020 12/31/2023 240.81 Description: EEG PHY/QHP>60<84 HR W/VEEG Category: Medical Services CMS Add: 01/01/2020 CMS Term: 95724 MEDSV DEF RBRVS 01/01/2024 302.40 Description: EEG PHY/QHP>60<84 HR W/VEEG Category: Medical Services CMS Add: 01/01/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,343 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 95725 MEDSV DEF RBRVS 01/01/2020 12/31/2023 219.65 Description: EEG PHY/QHP>84 HR W/O VID Category: Medical Services CMS Add: 01/01/2020 CMS Term: 95725 MEDSV DEF RBRVS 01/01/2024 274.49 Description: EEG PHY/QHP>84 HR W/O VID Category: Medical Services CMS Add: 01/01/2020 CMS Term: 95726 MEDSV DEF RBRVS 01/01/2020 12/31/2023 304.31 Description: EEG PHY/QHP>84 HR W/VEEG Category: Medical Services CMS Add: 01/01/2020 CMS Term: 95726 MEDSV DEF RBRVS 01/01/2024 384.13 Description: EEG PHY/QHP>84 HR W/VEEG Category: Medical Services CMS Add: 01/01/2020 CMS Term: 95782 26 MEDSV DEF RBRVS 01/01/2024 118.41 0-5years Description: POLYSOM <6 YRS 4/> PARAMTRS Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95782 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 96.28 0-5years Description: POLYSOM <6 YRS 4/> PARAMTRS Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95782 MEDSV DEF RBRVS 01/01/2024 879.71 0-5years Description: POLYSOM <6 YRS 4/> PARAMTRS Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95782 MEDSV DEF RBRVS 02/01/2015 12/31/2023 712.84 0-5years Description: POLYSOM <6 YRS 4/> PARAMTRS Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95782 TC MEDSV DEF RBRVS 01/01/2024 761.30 0-5years Description: POLYSOM <6 YRS 4/> PARAMTRS Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95782 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 616.56 0-5years Description: POLYSOM <6 YRS 4/> PARAMTRS Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95783 26 MEDSV DEF RBRVS 01/01/2024 129.00 0-5years Description: POLYSOM <6 YRS CPAP/BILVL Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95783 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 104.85 0-5years Description: POLYSOM <6 YRS CPAP/BILVL Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95783 MEDSV DEF RBRVS 01/01/2024 932.13 0-5years Description: POLYSOM <6 YRS CPAP/BILVL Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95783 MEDSV DEF RBRVS 02/01/2015 12/31/2023 759.89 0-5years Description: POLYSOM <6 YRS CPAP/BILVL Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95783 TC MEDSV DEF RBRVS 01/01/2024 803.13 0-5years Description: POLYSOM <6 YRS CPAP/BILVL Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95783 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 655.04 0-5years Description: POLYSOM <6 YRS CPAP/BILVL Category: Medical Services CMS Add: 01/01/2013 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,344 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 95800 26 MEDSV DEF RBRVS 01/01/2024 38.71 Description: SLP STDY UNATTENDED Category: Medical Services CMS Add: 01/01/2011 CMS Term: 95800 26 MEDSV DEF RBRVS 12/22/2022 12/31/2023 31.18 Description: SLP STDY UNATTENDED Category: Medical Services CMS Add: 01/01/2011 CMS Term: 95800 MEDSV DEF RBRVS 01/01/2024 139.05 Description: SLP STDY UNATTENDED Category: Medical Services CMS Add: 01/01/2011 CMS Term: 95800 MEDSV DEF RBRVS 12/22/2022 12/31/2023 118.79 Description: SLP STDY UNATTENDED Category: Medical Services CMS Add: 01/01/2011 CMS Term: 95800 TC MEDSV DEF RBRVS 01/01/2024 100.34 Description: SLP STDY UNATTENDED Category: Medical Services CMS Add: 01/01/2011 CMS Term: 95800 TC MEDSV DEF RBRVS 12/22/2022 12/31/2023 87.61 Description: SLP STDY UNATTENDED Category: Medical Services CMS Add: 01/01/2011 CMS Term: 95801 NOCOV DEF SYSMAN Description: SLP STDY UNATND W/ANAL Category: Non Covered Services CMS Add: 01/01/2011 CMS Term: 95803 NOCOV DEF SYSMAN Description: ACTIGRAPHY TESTING Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 95805 26 MEDSV DEF RBRVS 01/01/2024 54.58 Description: MULTIPLE SLEEP LATENCY TEST Category: Medical Services CMS Add: 01/01/1991 CMS Term: 95805 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 43.80 Description: MULTIPLE SLEEP LATENCY TEST Category: Medical Services CMS Add: 01/01/1991 CMS Term: 95805 MEDSV DEF RBRVS 01/01/2024 386.98 Description: MULTIPLE SLEEP LATENCY TEST Category: Medical Services CMS Add: 01/01/1991 CMS Term: 95805 MEDSV DEF RBRVS 02/01/2015 12/31/2023 294.41 Description: MULTIPLE SLEEP LATENCY TEST Category: Medical Services CMS Add: 01/01/1991 CMS Term: 95805 TC MEDSV DEF RBRVS 01/01/2024 332.40 Description: MULTIPLE SLEEP LATENCY TEST Category: Medical Services CMS Add: 01/01/1991 CMS Term: 95805 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 250.61 Description: MULTIPLE SLEEP LATENCY TEST Category: Medical Services CMS Add: 01/01/1991 CMS Term: 95806 26 MEDSV DEF RBRVS 01/01/2024 42.04 Description: SLEEP STUDY UNATT&RESP EFFT Category: Medical Services CMS Add: 01/01/1998 CMS Term: 95806 26 MEDSV DEF RBRVS 09/01/2019 12/31/2023 45.31 Description: SLEEP STUDY UNATT&RESP EFFT Category: Medical Services CMS Add: 01/01/1998 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,345 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 95806 MEDSV DEF RBRVS 01/01/2024 86.51 Description: SLEEP STUDY UNATT&RESP EFFT Category: Medical Services CMS Add: 01/01/1998 CMS Term: 95806 MEDSV DEF RBRVS 09/01/2019 12/31/2023 121.61 Description: SLEEP STUDY UNATT&RESP EFFT Category: Medical Services CMS Add: 01/01/1998 CMS Term: 95806 TC MEDSV DEF RBRVS 01/01/2024 44.47 Description: SLEEP STUDY UNATT&RESP EFFT Category: Medical Services CMS Add: 01/01/1998 CMS Term: 95806 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 76.30 Description: SLEEP STUDY UNATT&RESP EFFT Category: Medical Services CMS Add: 01/01/1998 CMS Term: 95807 26 MEDSV DEF RBRVS 01/01/2024 56.68 Description: SLEEP STUDY ATTENDED Category: Medical Services CMS Add: 01/01/1994 CMS Term: 95807 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 45.87 Description: SLEEP STUDY ATTENDED Category: Medical Services CMS Add: 01/01/1994 CMS Term: 95807 MEDSV DEF RBRVS 01/01/2024 358.35 Description: SLEEP STUDY ATTENDED Category: Medical Services CMS Add: 01/01/1994 CMS Term: 95807 MEDSV DEF RBRVS 02/01/2015 12/31/2023 330.91 Description: SLEEP STUDY ATTENDED Category: Medical Services CMS Add: 01/01/1994 CMS Term: 95807 TC MEDSV DEF RBRVS 01/01/2024 301.68 Description: SLEEP STUDY ATTENDED Category: Medical Services CMS Add: 01/01/1994 CMS Term: 95807 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 285.04 Description: SLEEP STUDY ATTENDED Category: Medical Services CMS Add: 01/01/1994 CMS Term: 95808 26 MEDSV DEF RBRVS 01/01/2024 79.38 Description: POLYSOM ANY AGE 1-3> PARAM Category: Medical Services CMS Add: 01/01/1994 CMS Term: 95808 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 64.25 Description: POLYSOM ANY AGE 1-3> PARAM Category: Medical Services CMS Add: 01/01/1994 CMS Term: 95808 MEDSV DEF RBRVS 01/01/2024 509.19 Description: POLYSOM ANY AGE 1-3> PARAM Category: Medical Services CMS Add: 01/01/1994 CMS Term: 95808 MEDSV DEF RBRVS 02/01/2015 12/31/2023 443.92 Description: POLYSOM ANY AGE 1-3> PARAM Category: Medical Services CMS Add: 01/01/1994 CMS Term: 95808 TC MEDSV DEF RBRVS 01/01/2024 429.81 Description: POLYSOM ANY AGE 1-3> PARAM Category: Medical Services CMS Add: 01/01/1994 CMS Term: 95808 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 379.66 Description: POLYSOM ANY AGE 1-3> PARAM Category: Medical Services CMS Add: 01/01/1994 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,346 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 95810 26 MEDSV DEF RBRVS 01/01/2024 113.19 Description: POLYSOM 6/> YRS 4/> PARAM Category: Medical Services CMS Add: 01/01/1994 CMS Term: 95810 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 90.12 Description: POLYSOM 6/> YRS 4/> PARAM Category: Medical Services CMS Add: 01/01/1994 CMS Term: 95810 MEDSV DEF RBRVS 01/01/2024 564.31 Description: POLYSOM 6/> YRS 4/> PARAM Category: Medical Services CMS Add: 01/01/1994 CMS Term: 95810 MEDSV DEF RBRVS 02/01/2015 12/31/2023 433.04 Description: POLYSOM 6/> YRS 4/> PARAM Category: Medical Services CMS Add: 01/01/1994 CMS Term: 95810 TC MEDSV DEF RBRVS 01/01/2024 451.12 Description: POLYSOM 6/> YRS 4/> PARAM Category: Medical Services CMS Add: 01/01/1994 CMS Term: 95810 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 342.92 Description: POLYSOM 6/> YRS 4/> PARAM Category: Medical Services CMS Add: 01/01/1994 CMS Term: 95811 26 MEDSV DEF RBRVS 01/01/2024 117.50 Description: POLYSOM 6/>YRS CPAP 4/> PARM Category: Medical Services CMS Add: 01/01/1998 CMS Term: 95811 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 93.72 Description: POLYSOM 6/>YRS CPAP 4/> PARM Category: Medical Services CMS Add: 01/01/1998 CMS Term: 95811 MEDSV DEF RBRVS 01/01/2024 590.10 Description: POLYSOM 6/>YRS CPAP 4/> PARM Category: Medical Services CMS Add: 01/01/1998 CMS Term: 95811 MEDSV DEF RBRVS 02/01/2015 12/31/2023 454.23 Description: POLYSOM 6/>YRS CPAP 4/> PARM Category: Medical Services CMS Add: 01/01/1998 CMS Term: 95811 TC MEDSV DEF RBRVS 01/01/2024 472.60 Description: POLYSOM 6/>YRS CPAP 4/> PARM Category: Medical Services CMS Add: 01/01/1998 CMS Term: 95811 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 360.51 Description: POLYSOM 6/>YRS CPAP 4/> PARM Category: Medical Services CMS Add: 01/01/1998 CMS Term: 95812 26 MEDSV DEF RBRVS 01/01/2024 53.60 Description: EEG 41-60 MINUTES Category: Medical Services CMS Add: 01/01/1995 CMS Term: 95812 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 42.06 Description: EEG 41-60 MINUTES Category: Medical Services CMS Add: 01/01/1995 CMS Term: 95812 MEDSV DEF RBRVS 01/01/2019 12/31/2023 301.67 Description: EEG 41-60 MINUTES Category: Medical Services CMS Add: 01/01/1995 CMS Term: 95812 MEDSV DEF RBRVS 01/01/2024 320.67 Description: EEG 41-60 MINUTES Category: Medical Services CMS Add: 01/01/1995 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,347 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 95812 TC MEDSV DEF RBRVS 01/01/2024 267.06 Description: EEG 41-60 MINUTES Category: Medical Services CMS Add: 01/01/1995 CMS Term: 95812 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 259.61 Description: EEG 41-60 MINUTES Category: Medical Services CMS Add: 01/01/1995 CMS Term: 95813 26 MEDSV DEF RBRVS 01/01/2024 81.06 Description: EEG EXTND MNTR 61-119 MIN Category: Medical Services CMS Add: 01/01/1995 CMS Term: 95813 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 67.45 Description: EEG EXTND MNTR 61-119 MIN Category: Medical Services CMS Add: 01/01/1995 CMS Term: 95813 MEDSV DEF RBRVS 01/01/2019 12/31/2023 353.73 Description: EEG EXTND MNTR 61-119 MIN Category: Medical Services CMS Add: 01/01/1995 CMS Term: 95813 MEDSV DEF RBRVS 01/01/2024 399.06 Description: EEG EXTND MNTR 61-119 MIN Category: Medical Services CMS Add: 01/01/1995 CMS Term: 95813 TC MEDSV DEF RBRVS 01/01/2024 318.00 Description: EEG EXTND MNTR 61-119 MIN Category: Medical Services CMS Add: 01/01/1995 CMS Term: 95813 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 286.28 Description: EEG EXTND MNTR 61-119 MIN Category: Medical Services CMS Add: 01/01/1995 CMS Term: 95816 26 MEDSV DEF RBRVS 01/01/2024 53.60 Description: EEG AWAKE AND DROWSY Category: Medical Services CMS Add: 01/01/1991 CMS Term: 95816 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 42.23 Description: EEG AWAKE AND DROWSY Category: Medical Services CMS Add: 01/01/1991 CMS Term: 95816 26 MRT DEF RBRVS 01/01/2024 53.60 Description: EEG AWAKE AND DROWSY Category: Medical Review Team CMS Add: 01/01/1991 CMS Term: 95816 26 MRT DEF RBRVS 02/01/2015 12/31/2023 42.23 Description: EEG AWAKE AND DROWSY Category: Medical Review Team CMS Add: 01/01/1991 CMS Term: 95816 MEDSV DEF RBRVS 01/01/2024 355.24 Description: EEG AWAKE AND DROWSY Category: Medical Services CMS Add: 01/01/1991 CMS Term: 95816 MEDSV DEF RBRVS 02/01/2015 12/31/2023 246.84 Description: EEG AWAKE AND DROWSY Category: Medical Services CMS Add: 01/01/1991 CMS Term: 95816 MRT DEF RBRVS 01/01/2024 355.24 Description: EEG AWAKE AND DROWSY Category: Medical Review Team CMS Add: 01/01/1991 CMS Term: 95816 MRT DEF RBRVS 02/01/2015 12/31/2023 246.84 Description: EEG AWAKE AND DROWSY Category: Medical Review Team CMS Add: 01/01/1991 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,348 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 95816 TC MEDSV DEF RBRVS 01/01/2024 301.64 Description: EEG AWAKE AND DROWSY Category: Medical Services CMS Add: 01/01/1991 CMS Term: 95816 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 204.61 Description: EEG AWAKE AND DROWSY Category: Medical Services CMS Add: 01/01/1991 CMS Term: 95816 TC MRT DEF RBRVS 01/01/2024 301.64 Description: EEG AWAKE AND DROWSY Category: Medical Review Team CMS Add: 01/01/1991 CMS Term: 95816 TC MRT DEF RBRVS 02/01/2015 12/31/2023 204.61 Description: EEG AWAKE AND DROWSY Category: Medical Review Team CMS Add: 01/01/1991 CMS Term: 95819 26 MEDSV DEF RBRVS 01/01/2024 53.60 Description: EEG AWAKE AND ASLEEP Category: Medical Services CMS Add: 01/01/1985 CMS Term: 95819 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 42.06 Description: EEG AWAKE AND ASLEEP Category: Medical Services CMS Add: 01/01/1985 CMS Term: 95819 26 MRT DEF RBRVS 01/01/2024 53.60 Description: EEG AWAKE AND ASLEEP Category: Medical Review Team CMS Add: 01/01/1985 CMS Term: 95819 26 MRT DEF RBRVS 02/01/2015 12/31/2023 42.06 Description: EEG AWAKE AND ASLEEP Category: Medical Review Team CMS Add: 01/01/1985 CMS Term: 95819 MEDSV DEF RBRVS 01/01/2024 411.74 Description: EEG AWAKE AND ASLEEP Category: Medical Services CMS Add: 01/01/1985 CMS Term: 95819 MEDSV DEF RBRVS 02/01/2015 12/31/2023 281.60 Description: EEG AWAKE AND ASLEEP Category: Medical Services CMS Add: 01/01/1985 CMS Term: 95819 MRT DEF RBRVS 01/01/2024 411.74 Description: EEG AWAKE AND ASLEEP Category: Medical Review Team CMS Add: 01/01/1985 CMS Term: 95819 MRT DEF RBRVS 02/01/2015 12/31/2023 281.60 Description: EEG AWAKE AND ASLEEP Category: Medical Review Team CMS Add: 01/01/1985 CMS Term: 95819 TC MEDSV DEF RBRVS 01/01/2024 358.13 Description: EEG AWAKE AND ASLEEP Category: Medical Services CMS Add: 01/01/1985 CMS Term: 95819 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 239.54 Description: EEG AWAKE AND ASLEEP Category: Medical Services CMS Add: 01/01/1985 CMS Term: 95819 TC MRT DEF RBRVS 01/01/2024 358.13 Description: EEG AWAKE AND ASLEEP Category: Medical Review Team CMS Add: 01/01/1985 CMS Term: 95819 TC MRT DEF RBRVS 02/01/2015 12/31/2023 239.54 Description: EEG AWAKE AND ASLEEP Category: Medical Review Team CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,349 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 95822 26 MEDSV DEF RBRVS 01/01/2024 53.91 Description: EEG COMA OR SLEEP ONLY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95822 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 42.06 Description: EEG COMA OR SLEEP ONLY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95822 MEDSV DEF RBRVS 01/01/2024 385.80 Description: EEG COMA OR SLEEP ONLY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95822 MEDSV DEF RBRVS 02/01/2015 12/31/2023 251.13 Description: EEG COMA OR SLEEP ONLY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95822 TC MEDSV DEF RBRVS 01/01/2024 331.89 Description: EEG COMA OR SLEEP ONLY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95822 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 209.07 Description: EEG COMA OR SLEEP ONLY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95824 26 MEDSV DEF RBRVS 01/01/2024 36.83 Description: EEG CEREBRAL DEATH ONLY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95824 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 29.38 Description: EEG CEREBRAL DEATH ONLY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95824 MEDSV DEF RBRVS 02/01/2015 12/31/2023 45.83 Description: EEG CEREBRAL DEATH ONLY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95824 MEDSV PRF MAXFEE 01/01/2024 62.73 0.0 Description: EEG CEREBRAL DEATH ONLY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95824 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 10.40 Description: EEG CEREBRAL DEATH ONLY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95824 TC MEDSV PRF MAXFEE 01/01/2024 16.70 0.0 Description: EEG CEREBRAL DEATH ONLY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95829 26 MEDSV DEF RBRVS 01/01/2024 311.31 Description: SURGERY ELECTROCORTICOGRAM Category: Medical Services CMS Add: 01/01/1982 CMS Term: 95829 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 239.65 Description: SURGERY ELECTROCORTICOGRAM Category: Medical Services CMS Add: 01/01/1982 CMS Term: 95829 MEDSV DEF RBRVS 01/01/2024 1645.33 Description: SURGERY ELECTROCORTICOGRAM Category: Medical Services CMS Add: 01/01/1982 CMS Term: 95829 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1295.99 Description: SURGERY ELECTROCORTICOGRAM Category: Medical Services CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,350 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 95829 TC MEDSV DEF RBRVS 01/01/2024 1334.01 Description: SURGERY ELECTROCORTICOGRAM Category: Medical Services CMS Add: 01/01/1982 CMS Term: 95829 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 1056.34 Description: SURGERY ELECTROCORTICOGRAM Category: Medical Services CMS Add: 01/01/1982 CMS Term: 95830 MEDSV DEF RBRVS 01/01/2024 643.02 Description: INSERT ELECTRODES FOR EEG Category: Medical Services CMS Add: 01/01/1985 CMS Term: 95830 MEDSV DEF RBRVS 02/01/2015 12/31/2023 177.87 Description: INSERT ELECTRODES FOR EEG Category: Medical Services CMS Add: 01/01/1985 CMS Term: 95836 NOCOV DEF SYSMAN Description: ECOG IMPLTD BRN NPGT <30 D Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 95851 MEDSV DEF RBRVS 01/01/2024 19.78 Y Description: RANGE OF MOTION MEASUREMENTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95851 MEDSV DEF RBRVS 02/01/2015 12/31/2023 12.64 Y Description: RANGE OF MOTION MEASUREMENTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95852 MEDSV DEF RBRVS 01/01/2024 16.24 Y Description: RANGE OF MOTION MEASUREMENTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95852 MEDSV DEF RBRVS 02/01/2015 12/31/2023 11.79 Y Description: RANGE OF MOTION MEASUREMENTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95857 MEDSV DEF RBRVS 01/01/2024 58.43 Description: CHOLINESTERASE CHALLENGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95857 MEDSV DEF RBRVS 02/01/2015 12/31/2023 39.18 Description: CHOLINESTERASE CHALLENGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95860 26 MEDSV DEF RBRVS 01/01/2024 47.99 Description: MUSCLE TEST ONE LIMB Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95860 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 37.93 Description: MUSCLE TEST ONE LIMB Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95860 26 MRT DEF RBRVS 01/01/2024 47.99 Description: MUSCLE TEST ONE LIMB Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 95860 26 MRT DEF RBRVS 02/01/2015 12/31/2023 37.93 Description: MUSCLE TEST ONE LIMB Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 95860 MEDSV DEF RBRVS 01/01/2024 105.58 Description: MUSCLE TEST ONE LIMB Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,351 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 95860 MEDSV DEF RBRVS 02/01/2015 12/31/2023 85.90 Description: MUSCLE TEST ONE LIMB Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95860 MRT DEF RBRVS 01/01/2024 105.58 Description: MUSCLE TEST ONE LIMB Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 95860 MRT DEF RBRVS 02/01/2015 12/31/2023 85.90 Description: MUSCLE TEST ONE LIMB Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 95860 TC MEDSV DEF RBRVS 01/01/2024 57.58 Description: MUSCLE TEST ONE LIMB Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95860 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 47.97 Description: MUSCLE TEST ONE LIMB Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95860 TC MRT DEF RBRVS 01/01/2024 57.58 Description: MUSCLE TEST ONE LIMB Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 95860 TC MRT DEF RBRVS 02/01/2015 12/31/2023 47.97 Description: MUSCLE TEST ONE LIMB Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 95861 26 MEDSV DEF RBRVS 01/01/2024 76.78 Description: MUSCLE TEST 2 LIMBS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95861 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 60.53 Description: MUSCLE TEST 2 LIMBS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95861 26 MRT DEF RBRVS 01/01/2024 76.78 Description: MUSCLE TEST 2 LIMBS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 95861 26 MRT DEF RBRVS 02/01/2015 12/31/2023 60.53 Description: MUSCLE TEST 2 LIMBS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 95861 MEDSV DEF RBRVS 01/01/2024 151.34 Description: MUSCLE TEST 2 LIMBS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95861 MEDSV DEF RBRVS 02/01/2015 12/31/2023 119.41 Description: MUSCLE TEST 2 LIMBS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95861 MRT DEF RBRVS 01/01/2024 151.34 Description: MUSCLE TEST 2 LIMBS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 95861 MRT DEF RBRVS 02/01/2015 12/31/2023 119.41 Description: MUSCLE TEST 2 LIMBS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 95861 TC MEDSV DEF RBRVS 01/01/2024 74.56 Description: MUSCLE TEST 2 LIMBS Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,352 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 95861 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 58.87 Description: MUSCLE TEST 2 LIMBS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95861 TC MRT DEF RBRVS 01/01/2024 74.56 Description: MUSCLE TEST 2 LIMBS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 95861 TC MRT DEF RBRVS 02/01/2015 12/31/2023 58.87 Description: MUSCLE TEST 2 LIMBS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 95863 26 MEDSV DEF RBRVS 01/01/2024 93.68 Description: MUSCLE TEST 3 LIMBS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95863 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 73.20 Description: MUSCLE TEST 3 LIMBS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95863 26 MRT DEF RBRVS 01/01/2024 93.68 Description: MUSCLE TEST 3 LIMBS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 95863 26 MRT DEF RBRVS 02/01/2015 12/31/2023 73.20 Description: MUSCLE TEST 3 LIMBS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 95863 MEDSV DEF RBRVS 01/01/2024 196.33 Description: MUSCLE TEST 3 LIMBS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95863 MEDSV DEF RBRVS 02/01/2015 12/31/2023 145.20 Description: MUSCLE TEST 3 LIMBS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95863 MRT DEF RBRVS 01/01/2024 196.33 Description: MUSCLE TEST 3 LIMBS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 95863 MRT DEF RBRVS 02/01/2015 12/31/2023 145.20 Description: MUSCLE TEST 3 LIMBS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 95863 TC MEDSV DEF RBRVS 01/01/2024 102.65 Description: MUSCLE TEST 3 LIMBS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95863 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 72.00 Description: MUSCLE TEST 3 LIMBS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95863 TC MRT DEF RBRVS 01/01/2024 102.65 Description: MUSCLE TEST 3 LIMBS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 95863 TC MRT DEF RBRVS 02/01/2015 12/31/2023 72.00 Description: MUSCLE TEST 3 LIMBS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 95864 26 MEDSV DEF RBRVS 01/01/2024 99.61 Description: MUSCLE TEST 4 LIMBS Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,353 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 95864 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 77.91 Description: MUSCLE TEST 4 LIMBS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95864 26 MRT DEF RBRVS 01/01/2024 99.61 Description: MUSCLE TEST 4 LIMBS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 95864 26 MRT DEF RBRVS 02/01/2015 12/31/2023 77.91 Description: MUSCLE TEST 4 LIMBS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 95864 MEDSV DEF RBRVS 01/01/2024 219.55 Description: MUSCLE TEST 4 LIMBS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95864 MEDSV DEF RBRVS 02/01/2015 12/31/2023 167.00 Description: MUSCLE TEST 4 LIMBS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95864 MRT DEF RBRVS 01/01/2024 219.55 Description: MUSCLE TEST 4 LIMBS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 95864 MRT DEF RBRVS 02/01/2015 12/31/2023 167.00 Description: MUSCLE TEST 4 LIMBS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 95864 TC MEDSV DEF RBRVS 01/01/2024 119.94 Description: MUSCLE TEST 4 LIMBS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95864 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 89.09 Description: MUSCLE TEST 4 LIMBS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95864 TC MRT DEF RBRVS 01/01/2024 119.94 Description: MUSCLE TEST 4 LIMBS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 95864 TC MRT DEF RBRVS 02/01/2015 12/31/2023 89.09 Description: MUSCLE TEST 4 LIMBS Category: Medical Review Team CMS Add: 01/01/1984 CMS Term: 95865 26 MEDSV DEF RBRVS 01/01/2024 77.94 Description: MUSCLE TEST LARYNX Category: Medical Services CMS Add: 01/01/2006 CMS Term: 95865 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 60.68 Description: MUSCLE TEST LARYNX Category: Medical Services CMS Add: 01/01/2006 CMS Term: 95865 MEDSV DEF RBRVS 01/01/2024 141.39 Description: MUSCLE TEST LARYNX Category: Medical Services CMS Add: 01/01/2006 CMS Term: 95865 MEDSV DEF RBRVS 02/01/2015 12/31/2023 97.75 Description: MUSCLE TEST LARYNX Category: Medical Services CMS Add: 01/01/2006 CMS Term: 95865 TC MEDSV DEF RBRVS 01/01/2024 63.45 Description: MUSCLE TEST LARYNX Category: Medical Services CMS Add: 01/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,354 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 95865 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 37.07 Description: MUSCLE TEST LARYNX Category: Medical Services CMS Add: 01/01/2006 CMS Term: 95866 26 MEDSV DEF RBRVS 01/01/2017 12/31/2023 49.52 Description: MUSCLE TEST HEMIDIAPHRAGM Category: Medical Services CMS Add: 01/01/2006 CMS Term: 95866 26 MEDSV DEF RBRVS 01/01/2024 60.91 Description: MUSCLE TEST HEMIDIAPHRAGM Category: Medical Services CMS Add: 01/01/2006 CMS Term: 95866 MEDSV DEF RBRVS 01/01/2017 12/31/2023 93.78 Description: MUSCLE TEST HEMIDIAPHRAGM Category: Medical Services CMS Add: 01/01/2006 CMS Term: 95866 MEDSV DEF RBRVS 01/01/2024 119.72 Description: MUSCLE TEST HEMIDIAPHRAGM Category: Medical Services CMS Add: 01/01/2006 CMS Term: 95866 TC MEDSV DEF RBRVS 01/01/2017 12/31/2023 44.26 Description: MUSCLE TEST HEMIDIAPHRAGM Category: Medical Services CMS Add: 01/01/2006 CMS Term: 95866 TC MEDSV DEF RBRVS 01/01/2024 58.82 Description: MUSCLE TEST HEMIDIAPHRAGM Category: Medical Services CMS Add: 01/01/2006 CMS Term: 95867 26 MEDSV DEF RBRVS 01/01/2024 39.45 Description: MUSCLE TEST CRAN NERV UNILAT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95867 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 30.89 Description: MUSCLE TEST CRAN NERV UNILAT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95867 MEDSV DEF RBRVS 01/01/2024 100.43 Description: MUSCLE TEST CRAN NERV UNILAT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95867 MEDSV DEF RBRVS 02/01/2015 12/31/2023 66.23 Description: MUSCLE TEST CRAN NERV UNILAT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95867 TC MEDSV DEF RBRVS 01/01/2024 60.98 Description: MUSCLE TEST CRAN NERV UNILAT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95867 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 35.34 Description: MUSCLE TEST CRAN NERV UNILAT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95868 26 MEDSV DEF RBRVS 01/01/2024 58.84 Description: MUSCLE TEST CRAN NERVE BILAT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95868 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 45.99 Description: MUSCLE TEST CRAN NERVE BILAT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95868 MEDSV DEF RBRVS 01/01/2024 131.24 Description: MUSCLE TEST CRAN NERVE BILAT Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,355 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 95868 MEDSV DEF RBRVS 02/01/2015 12/31/2023 92.48 Description: MUSCLE TEST CRAN NERVE BILAT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95868 TC MEDSV DEF RBRVS 01/01/2024 72.40 Description: MUSCLE TEST CRAN NERVE BILAT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95868 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 46.49 Description: MUSCLE TEST CRAN NERVE BILAT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95869 26 MEDSV DEF RBRVS 01/01/2024 18.73 Description: MUSCLE TEST THOR PARASPINAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95869 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 14.32 Description: MUSCLE TEST THOR PARASPINAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95869 MEDSV DEF RBRVS 01/01/2024 89.27 Description: MUSCLE TEST THOR PARASPINAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95869 MEDSV DEF RBRVS 02/01/2015 12/31/2023 52.88 Description: MUSCLE TEST THOR PARASPINAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95869 TC MEDSV DEF RBRVS 01/01/2024 70.55 Description: MUSCLE TEST THOR PARASPINAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95869 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 38.56 Description: MUSCLE TEST THOR PARASPINAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95870 26 MEDSV DEF RBRVS 01/01/2024 18.42 Description: MUSCLE TEST NONPARASPINAL Category: Medical Services CMS Add: 01/01/1998 CMS Term: 95870 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 14.56 Description: MUSCLE TEST NONPARASPINAL Category: Medical Services CMS Add: 01/01/1998 CMS Term: 95870 MEDSV DEF RBRVS 01/01/2024 77.54 Description: MUSCLE TEST NONPARASPINAL Category: Medical Services CMS Add: 01/01/1998 CMS Term: 95870 MEDSV DEF RBRVS 02/01/2015 12/31/2023 61.55 Description: MUSCLE TEST NONPARASPINAL Category: Medical Services CMS Add: 01/01/1998 CMS Term: 95870 TC MEDSV DEF RBRVS 01/01/2024 59.13 Description: MUSCLE TEST NONPARASPINAL Category: Medical Services CMS Add: 01/01/1998 CMS Term: 95870 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 46.98 Description: MUSCLE TEST NONPARASPINAL Category: Medical Services CMS Add: 01/01/1998 CMS Term: 95872 26 MEDSV DEF RBRVS 01/01/2024 141.70 Description: MUSCLE TEST ONE FIBER Category: Medical Services CMS Add: 01/01/1988 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,356 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 95872 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 113.38 Description: MUSCLE TEST ONE FIBER Category: Medical Services CMS Add: 01/01/1988 CMS Term: 95872 MEDSV DEF RBRVS 01/01/2024 187.55 Description: MUSCLE TEST ONE FIBER Category: Medical Services CMS Add: 01/01/1988 CMS Term: 95872 MEDSV DEF RBRVS 02/01/2015 12/31/2023 146.99 Description: MUSCLE TEST ONE FIBER Category: Medical Services CMS Add: 01/01/1988 CMS Term: 95872 TC MEDSV DEF RBRVS 01/01/2024 45.85 Description: MUSCLE TEST ONE FIBER Category: Medical Services CMS Add: 01/01/1988 CMS Term: 95872 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 33.61 Description: MUSCLE TEST ONE FIBER Category: Medical Services CMS Add: 01/01/1988 CMS Term: 95873 26 MEDSV DEF RBRVS 01/01/2024 18.56 Description: GUIDE NERV DESTR ELEC STIM Category: Medical Services CMS Add: 01/01/2006 CMS Term: 95873 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 15.06 Description: GUIDE NERV DESTR ELEC STIM Category: Medical Services CMS Add: 01/01/2006 CMS Term: 95873 MEDSV DEF RBRVS 01/01/2024 67.34 Description: GUIDE NERV DESTR ELEC STIM Category: Medical Services CMS Add: 01/01/2006 CMS Term: 95873 MEDSV DEF RBRVS 02/01/2015 12/31/2023 52.38 Description: GUIDE NERV DESTR ELEC STIM Category: Medical Services CMS Add: 01/01/2006 CMS Term: 95873 TC MEDSV DEF RBRVS 01/01/2024 48.78 Description: GUIDE NERV DESTR ELEC STIM Category: Medical Services CMS Add: 01/01/2006 CMS Term: 95873 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 37.32 Description: GUIDE NERV DESTR ELEC STIM Category: Medical Services CMS Add: 01/01/2006 CMS Term: 95874 26 MEDSV DEF RBRVS 01/01/2024 18.56 Description: GUIDE NERV DESTR NEEDLE EMG Category: Medical Services CMS Add: 01/01/2006 CMS Term: 95874 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 14.56 Description: GUIDE NERV DESTR NEEDLE EMG Category: Medical Services CMS Add: 01/01/2006 CMS Term: 95874 MEDSV DEF RBRVS 01/01/2024 72.28 Description: GUIDE NERV DESTR NEEDLE EMG Category: Medical Services CMS Add: 01/01/2006 CMS Term: 95874 MEDSV DEF RBRVS 02/01/2015 12/31/2023 50.65 Description: GUIDE NERV DESTR NEEDLE EMG Category: Medical Services CMS Add: 01/01/2006 CMS Term: 95874 TC MEDSV DEF RBRVS 01/01/2024 53.72 Description: GUIDE NERV DESTR NEEDLE EMG Category: Medical Services CMS Add: 01/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,357 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 95874 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 36.08 Description: GUIDE NERV DESTR NEEDLE EMG Category: Medical Services CMS Add: 01/01/2006 CMS Term: 95875 26 MEDSV DEF RBRVS 01/01/2024 54.90 Description: LIMB EXERCISE TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95875 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 43.01 Description: LIMB EXERCISE TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95875 MEDSV DEF RBRVS 01/01/2024 128.53 Description: LIMB EXERCISE TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95875 MEDSV DEF RBRVS 02/01/2015 12/31/2023 90.00 Description: LIMB EXERCISE TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95875 TC MEDSV DEF RBRVS 01/01/2024 73.63 Description: LIMB EXERCISE TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95875 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 46.98 Description: LIMB EXERCISE TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95885 26 MEDSV DEF RBRVS 01/01/2024 17.27 Description: MUSC TST DONE W/NERV TST LIM Category: Medical Services CMS Add: 01/01/2012 CMS Term: 95885 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 13.78 Description: MUSC TST DONE W/NERV TST LIM Category: Medical Services CMS Add: 01/01/2012 CMS Term: 95885 MEDSV DEF RBRVS 01/01/2024 58.02 Description: MUSC TST DONE W/NERV TST LIM Category: Medical Services CMS Add: 01/01/2012 CMS Term: 95885 MEDSV DEF RBRVS 02/01/2015 12/31/2023 41.19 Description: MUSC TST DONE W/NERV TST LIM Category: Medical Services CMS Add: 01/01/2012 CMS Term: 95885 TC MEDSV DEF RBRVS 01/01/2024 40.75 Description: MUSC TST DONE W/NERV TST LIM Category: Medical Services CMS Add: 01/01/2012 CMS Term: 95885 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 27.41 Description: MUSC TST DONE W/NERV TST LIM Category: Medical Services CMS Add: 01/01/2012 CMS Term: 95886 26 MEDSV DEF RBRVS 01/01/2024 43.06 Description: MUSC TEST DONE W/N TEST COMP Category: Medical Services CMS Add: 01/01/2012 CMS Term: 95886 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 34.01 Description: MUSC TEST DONE W/N TEST COMP Category: Medical Services CMS Add: 01/01/2012 CMS Term: 95886 MEDSV DEF RBRVS 01/01/2024 91.84 Description: MUSC TEST DONE W/N TEST COMP Category: Medical Services CMS Add: 01/01/2012 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,358 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 95886 MEDSV DEF RBRVS 02/01/2015 12/31/2023 65.13 Description: MUSC TEST DONE W/N TEST COMP Category: Medical Services CMS Add: 01/01/2012 CMS Term: 95886 TC MEDSV DEF RBRVS 01/01/2024 48.78 Description: MUSC TEST DONE W/N TEST COMP Category: Medical Services CMS Add: 01/01/2012 CMS Term: 95886 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 31.13 Description: MUSC TEST DONE W/N TEST COMP Category: Medical Services CMS Add: 01/01/2012 CMS Term: 95887 26 MEDSV DEF RBRVS 01/01/2024 35.20 Description: MUSC TST DONE W/N TST NONEXT Category: Medical Services CMS Add: 01/01/2012 CMS Term: 95887 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 27.83 Description: MUSC TST DONE W/N TST NONEXT Category: Medical Services CMS Add: 01/01/2012 CMS Term: 95887 MEDSV DEF RBRVS 01/01/2024 78.73 Description: MUSC TST DONE W/N TST NONEXT Category: Medical Services CMS Add: 01/01/2012 CMS Term: 95887 MEDSV DEF RBRVS 02/01/2015 12/31/2023 61.19 Description: MUSC TST DONE W/N TST NONEXT Category: Medical Services CMS Add: 01/01/2012 CMS Term: 95887 TC MEDSV DEF RBRVS 01/01/2024 43.53 Description: MUSC TST DONE W/N TST NONEXT Category: Medical Services CMS Add: 01/01/2012 CMS Term: 95887 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 33.36 Description: MUSC TST DONE W/N TST NONEXT Category: Medical Services CMS Add: 01/01/2012 CMS Term: 95905 26 MEDSV DEF RBRVS 01/01/2024 2.47 Description: MOTOR &/ SENS NRVE CNDJ TEST Category: Medical Services CMS Add: 01/01/2010 CMS Term: 95905 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 2.00 Description: MOTOR &/ SENS NRVE CNDJ TEST Category: Medical Services CMS Add: 01/01/2010 CMS Term: 95905 MEDSV DEF RBRVS 01/01/2024 31.65 Description: MOTOR &/ SENS NRVE CNDJ TEST Category: Medical Services CMS Add: 01/01/2010 CMS Term: 95905 MEDSV DEF RBRVS 02/01/2015 12/31/2023 47.25 Description: MOTOR &/ SENS NRVE CNDJ TEST Category: Medical Services CMS Add: 01/01/2010 CMS Term: 95905 TC MEDSV DEF RBRVS 01/01/2024 29.18 Description: MOTOR &/ SENS NRVE CNDJ TEST Category: Medical Services CMS Add: 01/01/2010 CMS Term: 95905 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 45.25 Description: MOTOR &/ SENS NRVE CNDJ TEST Category: Medical Services CMS Add: 01/01/2010 CMS Term: 95907 26 MEDSV DEF RBRVS 01/01/2024 49.97 0-1 Description: NVR CNDJ TST 1-2 STUDIES Category: Medical Services CMS Add: 01/01/2013 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,359 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 95907 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 39.01 0-1 Description: NVR CNDJ TST 1-2 STUDIES Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95907 MEDSV DEF RBRVS 01/01/2024 84.70 0-1 Description: NVR CNDJ TST 1-2 STUDIES Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95907 MEDSV DEF RBRVS 02/01/2015 12/31/2023 67.49 0-1 Description: NVR CNDJ TST 1-2 STUDIES Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95907 TC MEDSV DEF RBRVS 01/01/2024 34.74 0-1 Description: NVR CNDJ TST 1-2 STUDIES Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95907 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 28.49 0-1 Description: NVR CNDJ TST 1-2 STUDIES Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95908 26 MEDSV DEF RBRVS 01/01/2024 62.45 0-1 Description: NRV CNDJ TST 3-4 STUDIES Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95908 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 48.61 0-1 Description: NRV CNDJ TST 3-4 STUDIES Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95908 MEDSV DEF RBRVS 01/01/2024 105.52 0-1 Description: NRV CNDJ TST 3-4 STUDIES Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95908 MEDSV DEF RBRVS 02/01/2015 12/31/2023 83.29 0-1 Description: NRV CNDJ TST 3-4 STUDIES Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95908 TC MEDSV DEF RBRVS 01/01/2024 43.07 0-1 Description: NRV CNDJ TST 3-4 STUDIES Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95908 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 34.68 0-1 Description: NRV CNDJ TST 3-4 STUDIES Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95909 26 MEDSV DEF RBRVS 01/01/2024 74.95 0-1 Description: NRV CNDJ TST 5-6 STUDIES Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95909 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 58.30 0-1 Description: NRV CNDJ TST 5-6 STUDIES Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95909 MEDSV DEF RBRVS 01/01/2024 126.67 0-1 Description: NRV CNDJ TST 5-6 STUDIES Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95909 MEDSV DEF RBRVS 02/01/2015 12/31/2023 100.25 0-1 Description: NRV CNDJ TST 5-6 STUDIES Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95909 TC MEDSV DEF RBRVS 01/01/2024 51.72 0-1 Description: NRV CNDJ TST 5-6 STUDIES Category: Medical Services CMS Add: 01/01/2013 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,360 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 95909 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 41.95 0-1 Description: NRV CNDJ TST 5-6 STUDIES Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95910 26 MEDSV DEF RBRVS 01/01/2024 99.62 0-1 Description: NRV CNDJ TEST 7-8 STUDIES Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95910 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 77.76 0-1 Description: NRV CNDJ TEST 7-8 STUDIES Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95910 MEDSV DEF RBRVS 01/01/2024 165.85 0-1 Description: NRV CNDJ TEST 7-8 STUDIES Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95910 MEDSV DEF RBRVS 02/01/2015 12/31/2023 131.77 0-1 Description: NRV CNDJ TEST 7-8 STUDIES Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95910 TC MEDSV DEF RBRVS 01/01/2024 66.23 0-1 Description: NRV CNDJ TEST 7-8 STUDIES Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95910 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 54.00 0-1 Description: NRV CNDJ TEST 7-8 STUDIES Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95911 26 MEDSV DEF RBRVS 01/01/2024 124.30 0-1 Description: NRV CNDJ TEST 9-10 STUDIES Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95911 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 97.31 0-1 Description: NRV CNDJ TEST 9-10 STUDIES Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95911 MEDSV DEF RBRVS 01/01/2024 200.40 0-1 Description: NRV CNDJ TEST 9-10 STUDIES Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95911 MEDSV DEF RBRVS 02/01/2015 12/31/2023 160.31 0-1 Description: NRV CNDJ TEST 9-10 STUDIES Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95911 TC MEDSV DEF RBRVS 01/01/2024 76.10 0-1 Description: NRV CNDJ TEST 9-10 STUDIES Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95911 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 63.00 0-1 Description: NRV CNDJ TEST 9-10 STUDIES Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95912 26 MEDSV DEF RBRVS 01/01/2024 148.97 0-1 Description: NRV CNDJ TEST 11-12 STUDIES Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95912 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 116.77 0-1 Description: NRV CNDJ TEST 11-12 STUDIES Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95912 MEDSV DEF RBRVS 01/01/2024 234.50 0-1 Description: NRV CNDJ TEST 11-12 STUDIES Category: Medical Services CMS Add: 01/01/2013 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,361 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 95912 MEDSV DEF RBRVS 02/01/2015 12/31/2023 188.61 0-1 Description: NRV CNDJ TEST 11-12 STUDIES Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95912 TC MEDSV DEF RBRVS 01/01/2024 85.53 0-1 Description: NRV CNDJ TEST 11-12 STUDIES Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95912 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 71.84 0-1 Description: NRV CNDJ TEST 11-12 STUDIES Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95913 26 MEDSV DEF RBRVS 01/01/2024 176.61 0-1 Description: NRV CNDJ TEST 13/> STUDIES Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95913 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 138.42 0-1 Description: NRV CNDJ TEST 13/> STUDIES Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95913 MEDSV DEF RBRVS 01/01/2024 271.09 0-1 Description: NRV CNDJ TEST 13/> STUDIES Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95913 MEDSV DEF RBRVS 02/01/2015 12/31/2023 218.52 0-1 Description: NRV CNDJ TEST 13/> STUDIES Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95913 TC MEDSV DEF RBRVS 01/01/2024 94.48 0-1 Description: NRV CNDJ TEST 13/> STUDIES Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95913 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 80.10 0-1 Description: NRV CNDJ TEST 13/> STUDIES Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95919 NOCOV DEF SYSMAN Description: QUAN PUPLMTRY PHY/QHP UNI/BI Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 95921 26 MEDSV DEF RBRVS 01/01/2024 42.56 Description: AUTONOMIC NRV PARASYM INERVJ Category: Medical Services CMS Add: 01/01/1997 CMS Term: 95921 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 33.76 Description: AUTONOMIC NRV PARASYM INERVJ Category: Medical Services CMS Add: 01/01/1997 CMS Term: 95921 MEDSV DEF RBRVS 01/01/2019 12/31/2023 63.65 Description: AUTONOMIC NRV PARASYM INERVJ Category: Medical Services CMS Add: 01/01/1997 CMS Term: 95921 MEDSV DEF RBRVS 01/01/2024 82.55 Description: AUTONOMIC NRV PARASYM INERVJ Category: Medical Services CMS Add: 01/01/1997 CMS Term: 95921 TC MEDSV DEF RBRVS 01/01/2024 39.98 Description: AUTONOMIC NRV PARASYM INERVJ Category: Medical Services CMS Add: 01/01/1997 CMS Term: 95921 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 29.89 Description: AUTONOMIC NRV PARASYM INERVJ Category: Medical Services CMS Add: 01/01/1997 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,362 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 95922 26 MEDSV DEF RBRVS 01/01/2024 43.98 Description: AUTONOMIC NRV ADRENRG INERVJ Category: Medical Services CMS Add: 01/01/1997 CMS Term: 95922 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 36.36 Description: AUTONOMIC NRV ADRENRG INERVJ Category: Medical Services CMS Add: 01/01/1997 CMS Term: 95922 MEDSV DEF RBRVS 01/01/2019 12/31/2023 76.16 Description: AUTONOMIC NRV ADRENRG INERVJ Category: Medical Services CMS Add: 01/01/1997 CMS Term: 95922 MEDSV DEF RBRVS 01/01/2024 91.23 Description: AUTONOMIC NRV ADRENRG INERVJ Category: Medical Services CMS Add: 01/01/1997 CMS Term: 95922 TC MEDSV DEF RBRVS 01/01/2024 47.25 Description: AUTONOMIC NRV ADRENRG INERVJ Category: Medical Services CMS Add: 01/01/1997 CMS Term: 95922 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 39.80 Description: AUTONOMIC NRV ADRENRG INERVJ Category: Medical Services CMS Add: 01/01/1997 CMS Term: 95923 26 MEDSV DEF RBRVS 01/01/2024 42.56 Description: AUTONOMIC NRV SYST FUNJ TEST Category: Medical Services CMS Add: 01/01/1997 CMS Term: 95923 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 34.25 Description: AUTONOMIC NRV SYST FUNJ TEST Category: Medical Services CMS Add: 01/01/1997 CMS Term: 95923 MEDSV DEF RBRVS 01/01/2019 12/31/2023 144.90 Description: AUTONOMIC NRV SYST FUNJ TEST Category: Medical Services CMS Add: 01/01/1997 CMS Term: 95923 MEDSV DEF RBRVS 01/01/2024 115.58 Description: AUTONOMIC NRV SYST FUNJ TEST Category: Medical Services CMS Add: 01/01/1997 CMS Term: 95923 TC MEDSV DEF RBRVS 01/01/2024 73.02 Description: AUTONOMIC NRV SYST FUNJ TEST Category: Medical Services CMS Add: 01/01/1997 CMS Term: 95923 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 110.65 Description: AUTONOMIC NRV SYST FUNJ TEST Category: Medical Services CMS Add: 01/01/1997 CMS Term: 95924 26 MEDSV DEF RBRVS 01/01/2024 82.77 Description: ANS PARASYMP & SYMP W/TILT Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95924 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 64.89 Description: ANS PARASYMP & SYMP W/TILT Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95924 MEDSV DEF RBRVS 01/01/2024 143.29 Description: ANS PARASYMP & SYMP W/TILT Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95924 MEDSV DEF RBRVS 02/01/2015 12/31/2023 104.20 Description: ANS PARASYMP & SYMP W/TILT Category: Medical Services CMS Add: 01/01/2013 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,363 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 95924 TC MEDSV DEF RBRVS 01/01/2024 60.52 Description: ANS PARASYMP & SYMP W/TILT Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95924 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 39.30 Description: ANS PARASYMP & SYMP W/TILT Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95925 26 MEDSV DEF RBRVS 01/01/2016 12/31/2023 20.62 Description: SOMATOSENSORY TESTING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95925 26 MEDSV DEF RBRVS 01/01/2024 26.66 Description: SOMATOSENSORY TESTING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95925 MEDSV DEF RBRVS 01/01/2016 12/31/2023 121.60 Description: SOMATOSENSORY TESTING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95925 MEDSV DEF RBRVS 01/01/2024 164.68 Description: SOMATOSENSORY TESTING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95925 TC MEDSV DEF RBRVS 01/01/2016 12/31/2023 100.99 Description: SOMATOSENSORY TESTING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95925 TC MEDSV DEF RBRVS 01/01/2024 138.02 Description: SOMATOSENSORY TESTING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95926 26 MEDSV DEF RBRVS 01/01/2024 26.03 Description: SOMATOSENSORY TESTING Category: Medical Services CMS Add: 01/01/1996 CMS Term: 95926 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 20.45 Description: SOMATOSENSORY TESTING Category: Medical Services CMS Add: 01/01/1996 CMS Term: 95926 MEDSV DEF RBRVS 01/01/2024 143.98 Description: SOMATOSENSORY TESTING Category: Medical Services CMS Add: 01/01/1996 CMS Term: 95926 MEDSV DEF RBRVS 09/01/2019 12/31/2023 101.62 Description: SOMATOSENSORY TESTING Category: Medical Services CMS Add: 01/01/1996 CMS Term: 95926 TC MEDSV DEF RBRVS 01/01/2024 117.95 Description: SOMATOSENSORY TESTING Category: Medical Services CMS Add: 01/01/1996 CMS Term: 95926 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 81.17 Description: SOMATOSENSORY TESTING Category: Medical Services CMS Add: 01/01/1996 CMS Term: 95927 26 MEDSV DEF RBRVS 01/01/2024 25.72 Description: SOMATOSENSORY TESTING Category: Medical Services CMS Add: 01/01/1996 CMS Term: 95927 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 20.37 Description: SOMATOSENSORY TESTING Category: Medical Services CMS Add: 01/01/1996 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,364 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 95927 MEDSV DEF RBRVS 01/01/2024 153.86 Description: SOMATOSENSORY TESTING Category: Medical Services CMS Add: 01/01/1996 CMS Term: 95927 MEDSV DEF RBRVS 09/01/2019 12/31/2023 113.43 Description: SOMATOSENSORY TESTING Category: Medical Services CMS Add: 01/01/1996 CMS Term: 95927 TC MEDSV DEF RBRVS 01/01/2024 128.14 Description: SOMATOSENSORY TESTING Category: Medical Services CMS Add: 01/01/1996 CMS Term: 95927 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 93.06 Description: SOMATOSENSORY TESTING Category: Medical Services CMS Add: 01/01/1996 CMS Term: 95928 26 MEDSV DEF RBRVS 01/01/2016 12/31/2023 58.80 Description: C MOTOR EVOKED UPPR LIMBS Category: Medical Services CMS Add: 01/01/2005 CMS Term: 95928 26 MEDSV DEF RBRVS 01/01/2024 74.80 Description: C MOTOR EVOKED UPPR LIMBS Category: Medical Services CMS Add: 01/01/2005 CMS Term: 95928 MEDSV DEF RBRVS 01/01/2016 12/31/2023 177.95 Description: C MOTOR EVOKED UPPR LIMBS Category: Medical Services CMS Add: 01/01/2005 CMS Term: 95928 MEDSV DEF RBRVS 01/01/2024 220.53 Description: C MOTOR EVOKED UPPR LIMBS Category: Medical Services CMS Add: 01/01/2005 CMS Term: 95928 TC MEDSV DEF RBRVS 01/01/2016 12/31/2023 119.15 Description: C MOTOR EVOKED UPPR LIMBS Category: Medical Services CMS Add: 01/01/2005 CMS Term: 95928 TC MEDSV DEF RBRVS 01/01/2024 145.73 Description: C MOTOR EVOKED UPPR LIMBS Category: Medical Services CMS Add: 01/01/2005 CMS Term: 95929 26 MEDSV DEF RBRVS 01/01/2016 12/31/2023 58.30 Description: C MOTOR EVOKED LWR LIMBS Category: Medical Services CMS Add: 01/01/2005 CMS Term: 95929 26 MEDSV DEF RBRVS 01/01/2024 74.64 Description: C MOTOR EVOKED LWR LIMBS Category: Medical Services CMS Add: 01/01/2005 CMS Term: 95929 MEDSV DEF RBRVS 01/01/2016 12/31/2023 173.49 Description: C MOTOR EVOKED LWR LIMBS Category: Medical Services CMS Add: 01/01/2005 CMS Term: 95929 MEDSV DEF RBRVS 01/01/2024 224.07 Description: C MOTOR EVOKED LWR LIMBS Category: Medical Services CMS Add: 01/01/2005 CMS Term: 95929 TC MEDSV DEF RBRVS 01/01/2016 12/31/2023 115.19 Description: C MOTOR EVOKED LWR LIMBS Category: Medical Services CMS Add: 01/01/2005 CMS Term: 95929 TC MEDSV DEF RBRVS 01/01/2024 149.43 Description: C MOTOR EVOKED LWR LIMBS Category: Medical Services CMS Add: 01/01/2005 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,365 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 95930 26 MEDSV DEF RBRVS 01/01/2024 17.58 Description: VISUAL EP TEST CNS W/I&R Category: Medical Services CMS Add: 01/01/1996 CMS Term: 95930 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 13.53 Description: VISUAL EP TEST CNS W/I&R Category: Medical Services CMS Add: 01/01/1996 CMS Term: 95930 MEDSV DEF RBRVS 01/01/2024 61.89 Description: VISUAL EP TEST CNS W/I&R Category: Medical Services CMS Add: 01/01/1996 CMS Term: 95930 MEDSV DEF RBRVS 02/01/2015 12/31/2023 93.21 Description: VISUAL EP TEST CNS W/I&R Category: Medical Services CMS Add: 01/01/1996 CMS Term: 95930 TC MEDSV DEF RBRVS 01/01/2024 44.31 Description: VISUAL EP TEST CNS W/I&R Category: Medical Services CMS Add: 01/01/1996 CMS Term: 95930 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 79.68 Description: VISUAL EP TEST CNS W/I&R Category: Medical Services CMS Add: 01/01/1996 CMS Term: 95933 26 MEDSV DEF RBRVS 01/01/2024 29.59 Description: BLINK REFLEX TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95933 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 23.04 Description: BLINK REFLEX TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95933 MEDSV DEF RBRVS 01/01/2024 76.98 Description: BLINK REFLEX TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95933 MEDSV DEF RBRVS 02/01/2015 12/31/2023 58.62 Description: BLINK REFLEX TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95933 TC MEDSV DEF RBRVS 01/01/2024 47.39 Description: BLINK REFLEX TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95933 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 35.59 Description: BLINK REFLEX TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95937 26 MEDSV DEF RBRVS 01/01/2024 32.55 Description: NEUROMUSCULAR JUNCTION TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95937 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 25.56 Description: NEUROMUSCULAR JUNCTION TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95937 MEDSV DEF RBRVS 01/01/2024 98.47 Description: NEUROMUSCULAR JUNCTION TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95937 MEDSV DEF RBRVS 02/01/2015 12/31/2023 57.43 Description: NEUROMUSCULAR JUNCTION TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,366 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 95937 TC MEDSV DEF RBRVS 01/01/2024 65.92 Description: NEUROMUSCULAR JUNCTION TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95937 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 31.87 Description: NEUROMUSCULAR JUNCTION TEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95938 26 MEDSV DEF RBRVS 01/01/2024 42.75 Description: SOMATOSENSORY TESTING Category: Medical Services CMS Add: 01/01/2012 CMS Term: 95938 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 33.68 Description: SOMATOSENSORY TESTING Category: Medical Services CMS Add: 01/01/2012 CMS Term: 95938 MEDSV DEF RBRVS 01/01/2024 337.29 Description: SOMATOSENSORY TESTING Category: Medical Services CMS Add: 01/01/2012 CMS Term: 95938 MEDSV DEF RBRVS 02/01/2015 12/31/2023 235.32 Description: SOMATOSENSORY TESTING Category: Medical Services CMS Add: 01/01/2012 CMS Term: 95938 TC MEDSV DEF RBRVS 01/01/2024 294.54 Description: SOMATOSENSORY TESTING Category: Medical Services CMS Add: 01/01/2012 CMS Term: 95938 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 201.64 Description: SOMATOSENSORY TESTING Category: Medical Services CMS Add: 01/01/2012 CMS Term: 95939 26 MEDSV DEF RBRVS 01/01/2024 111.81 Description: C MOTOR EVOKED UPR&LWR LIMBS Category: Medical Services CMS Add: 01/01/2012 CMS Term: 95939 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 88.03 Description: C MOTOR EVOKED UPR&LWR LIMBS Category: Medical Services CMS Add: 01/01/2012 CMS Term: 95939 MEDSV DEF RBRVS 01/01/2024 508.23 Description: C MOTOR EVOKED UPR&LWR LIMBS Category: Medical Services CMS Add: 01/01/2012 CMS Term: 95939 MEDSV DEF RBRVS 02/01/2015 12/31/2023 345.57 Description: C MOTOR EVOKED UPR&LWR LIMBS Category: Medical Services CMS Add: 01/01/2012 CMS Term: 95939 TC MEDSV DEF RBRVS 01/01/2024 396.41 Description: C MOTOR EVOKED UPR&LWR LIMBS Category: Medical Services CMS Add: 01/01/2012 CMS Term: 95939 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 257.54 Description: C MOTOR EVOKED UPR&LWR LIMBS Category: Medical Services CMS Add: 01/01/2012 CMS Term: 95940 MEDSV DEF RBRVS 01/01/2024 30.55 Description: IONM IN OPERATNG ROOM 15 MIN Category: Medical Services CMS Add: 01/01/2013 CMS Term: 95940 MEDSV DEF RBRVS 02/01/2015 12/31/2023 23.55 Description: IONM IN OPERATNG ROOM 15 MIN Category: Medical Services CMS Add: 01/01/2013 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,367 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 95941 NOCOV DEF SYSMAN Description: IONM REMOTE/>1 PT OR PER HR Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 95954 26 MEDSV DEF RBRVS 01/01/2024 103.93 Description: EEG MONITORING/GIVING DRUGS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 95954 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 90.18 Description: EEG MONITORING/GIVING DRUGS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 95954 MEDSV DEF RBRVS 01/01/2024 377.04 Description: EEG MONITORING/GIVING DRUGS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 95954 MEDSV DEF RBRVS 02/01/2015 12/31/2023 308.59 Description: EEG MONITORING/GIVING DRUGS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 95954 TC MEDSV DEF RBRVS 01/01/2024 273.10 Description: EEG MONITORING/GIVING DRUGS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 95954 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 218.40 Description: EEG MONITORING/GIVING DRUGS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 95955 26 MEDSV DEF RBRVS 01/01/2024 50.31 Description: EEG DURING SURGERY Category: Medical Services CMS Add: 01/01/1985 CMS Term: 95955 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 39.44 Description: EEG DURING SURGERY Category: Medical Services CMS Add: 01/01/1985 CMS Term: 95955 MEDSV DEF RBRVS 01/01/2024 179.82 Description: EEG DURING SURGERY Category: Medical Services CMS Add: 01/01/1985 CMS Term: 95955 MEDSV DEF RBRVS 02/01/2015 12/31/2023 160.49 Description: EEG DURING SURGERY Category: Medical Services CMS Add: 01/01/1985 CMS Term: 95955 TC MEDSV DEF RBRVS 01/01/2024 129.51 Description: EEG DURING SURGERY Category: Medical Services CMS Add: 01/01/1985 CMS Term: 95955 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 121.05 Description: EEG DURING SURGERY Category: Medical Services CMS Add: 01/01/1985 CMS Term: 95957 26 MEDSV DEF RBRVS 01/01/2019 12/31/2023 77.39 Description: EEG DIGITAL ANALYSIS Category: Medical Services CMS Add: 01/01/1995 CMS Term: 95957 26 MEDSV DEF RBRVS 01/01/2024 96.48 Description: EEG DIGITAL ANALYSIS Category: Medical Services CMS Add: 01/01/1995 CMS Term: 95957 MEDSV DEF RBRVS 01/01/2019 12/31/2023 309.42 Description: EEG DIGITAL ANALYSIS Category: Medical Services CMS Add: 01/01/1995 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,368 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 95957 MEDSV DEF RBRVS 01/01/2024 257.96 Description: EEG DIGITAL ANALYSIS Category: Medical Services CMS Add: 01/01/1995 CMS Term: 95957 TC MEDSV DEF RBRVS 01/01/2019 12/31/2023 232.03 Description: EEG DIGITAL ANALYSIS Category: Medical Services CMS Add: 01/01/1995 CMS Term: 95957 TC MEDSV DEF RBRVS 01/01/2024 161.48 Description: EEG DIGITAL ANALYSIS Category: Medical Services CMS Add: 01/01/1995 CMS Term: 95958 26 MEDSV DEF RBRVS 01/01/2024 212.19 Description: EEG MONITORING/FUNCTION TEST Category: Medical Services CMS Add: 01/01/1985 CMS Term: 95958 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 164.45 Description: EEG MONITORING/FUNCTION TEST Category: Medical Services CMS Add: 01/01/1985 CMS Term: 95958 MEDSV DEF RBRVS 01/01/2024 626.84 Description: EEG MONITORING/FUNCTION TEST Category: Medical Services CMS Add: 01/01/1985 CMS Term: 95958 MEDSV DEF RBRVS 02/01/2015 12/31/2023 399.45 Description: EEG MONITORING/FUNCTION TEST Category: Medical Services CMS Add: 01/01/1985 CMS Term: 95958 TC MEDSV DEF RBRVS 01/01/2024 414.65 Description: EEG MONITORING/FUNCTION TEST Category: Medical Services CMS Add: 01/01/1985 CMS Term: 95958 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 235.00 Description: EEG MONITORING/FUNCTION TEST Category: Medical Services CMS Add: 01/01/1985 CMS Term: 95961 26 MEDSV DEF RBRVS 01/01/2024 149.77 Description: ELECTRODE STIMULATION BRAIN Category: Medical Services CMS Add: 01/01/1991 CMS Term: 95961 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 115.14 Description: ELECTRODE STIMULATION BRAIN Category: Medical Services CMS Add: 01/01/1991 CMS Term: 95961 MEDSV DEF RBRVS 01/01/2024 292.10 Description: ELECTRODE STIMULATION BRAIN Category: Medical Services CMS Add: 01/01/1991 CMS Term: 95961 MEDSV DEF RBRVS 02/01/2015 12/31/2023 203.74 Description: ELECTRODE STIMULATION BRAIN Category: Medical Services CMS Add: 01/01/1991 CMS Term: 95961 TC MEDSV DEF RBRVS 01/01/2024 142.33 Description: ELECTRODE STIMULATION BRAIN Category: Medical Services CMS Add: 01/01/1991 CMS Term: 95961 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 88.60 Description: ELECTRODE STIMULATION BRAIN Category: Medical Services CMS Add: 01/01/1991 CMS Term: 95962 26 MEDSV DEF RBRVS 01/01/2024 161.57 Description: ELECTRODE STIM BRAIN ADD-ON Category: Medical Services CMS Add: 01/01/1991 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,369 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 95962 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 124.31 Description: ELECTRODE STIM BRAIN ADD-ON Category: Medical Services CMS Add: 01/01/1991 CMS Term: 95962 MEDSV DEF RBRVS 01/01/2024 255.12 Description: ELECTRODE STIM BRAIN ADD-ON Category: Medical Services CMS Add: 01/01/1991 CMS Term: 95962 MEDSV DEF RBRVS 02/01/2015 12/31/2023 180.71 Description: ELECTRODE STIM BRAIN ADD-ON Category: Medical Services CMS Add: 01/01/1991 CMS Term: 95962 TC MEDSV DEF RBRVS 01/01/2024 93.55 Description: ELECTRODE STIM BRAIN ADD-ON Category: Medical Services CMS Add: 01/01/1991 CMS Term: 95962 TC MEDSV DEF RBRVS 02/01/2015 12/31/2023 56.40 Description: ELECTRODE STIM BRAIN ADD-ON Category: Medical Services CMS Add: 01/01/1991 CMS Term: 95965 26 MEDSV DEF RBRVS 01/01/2024 391.54 0-1 Description: MEG SPONTANEOUS Category: Medical Services CMS Add: 01/01/2002 CMS Term: 95965 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 311.70 0-1 Description: MEG SPONTANEOUS Category: Medical Services CMS Add: 01/01/2002 CMS Term: 95966 26 MEDSV DEF RBRVS 01/01/2024 199.54 0-1 Description: MEG EVOKED SINGLE Category: Medical Services CMS Add: 01/01/2002 CMS Term: 95966 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 158.23 0-1 Description: MEG EVOKED SINGLE Category: Medical Services CMS Add: 01/01/2002 CMS Term: 95967 26 MEDSV DEF RBRVS 01/01/2024 174.72 0-3 Description: MEG EVOKED EACH ADDL Category: Medical Services CMS Add: 01/01/2002 CMS Term: 95967 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 138.77 0-3 Description: MEG EVOKED EACH ADDL Category: Medical Services CMS Add: 01/01/2002 CMS Term: 95970 MEDSV DEF RBRVS 01/01/2024 17.75 Description: ALYS NPGT W/O PRGRMG Category: Medical Services CMS Add: 01/01/1999 CMS Term: 95970 MEDSV DEF RBRVS 02/01/2015 12/31/2023 48.42 Description: ALYS NPGT W/O PRGRMG Category: Medical Services CMS Add: 01/01/1999 CMS Term: 95971 MEDSV DEF RBRVS 01/01/2024 45.16 Description: ALYS SMPL SP/PN NPGT W/PRGRM Category: Medical Services CMS Add: 01/01/1999 CMS Term: 95971 MEDSV DEF RBRVS 02/01/2015 12/31/2023 43.17 Description: ALYS SMPL SP/PN NPGT W/PRGRM Category: Medical Services CMS Add: 01/01/1999 CMS Term: 95972 MEDSV DEF RBRVS 01/01/2024 52.80 Description: ALYS CPLX SP/PN NPGT W/PRGRM Category: Medical Services CMS Add: 01/01/1999 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,370 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 95972 MEDSV DEF RBRVS 02/01/2015 12/31/2023 78.12 Description: ALYS CPLX SP/PN NPGT W/PRGRM Category: Medical Services CMS Add: 01/01/1999 CMS Term: 95976 RADIO DEF RBRVS 01/01/2019 12/31/2023 29.69 Description: ALYS SMPL CN NPGT PRGRMG Category: Radiology CMS Add: 01/01/2019 CMS Term: 95976 RADIO DEF RBRVS 01/01/2024 37.60 Description: ALYS SMPL CN NPGT PRGRMG Category: Radiology CMS Add: 01/01/2019 CMS Term: 95977 RADIO DEF RBRVS 01/01/2019 12/31/2023 39.44 Description: ALYS CPLX CN NPGT PRGRMG Category: Radiology CMS Add: 01/01/2019 CMS Term: 95977 RADIO DEF RBRVS 01/01/2024 49.61 Description: ALYS CPLX CN NPGT PRGRMG Category: Radiology CMS Add: 01/01/2019 CMS Term: 95980 MEDSV DEF RBRVS 01/01/2024 41.28 Description: IO ANAL GAST N-STIM INIT Category: Medical Services CMS Add: 01/01/2008 CMS Term: 95980 MEDSV DEF RBRVS 02/01/2015 12/31/2023 31.90 Description: IO ANAL GAST N-STIM INIT Category: Medical Services CMS Add: 01/01/2008 CMS Term: 95981 MEDSV DEF RBRVS 01/01/2024 35.52 Description: IO ANAL GAST N-STIM SUBSQ Category: Medical Services CMS Add: 01/01/2008 CMS Term: 95981 MEDSV DEF RBRVS 02/01/2015 12/31/2023 22.68 Description: IO ANAL GAST N-STIM SUBSQ Category: Medical Services CMS Add: 01/01/2008 CMS Term: 95982 MEDSV DEF RBRVS 01/01/2024 54.21 Description: IO GA N-STIM SUBSQ W/REPROG Category: Medical Services CMS Add: 01/01/2008 CMS Term: 95982 MEDSV DEF RBRVS 02/01/2015 12/31/2023 36.87 Description: IO GA N-STIM SUBSQ W/REPROG Category: Medical Services CMS Add: 01/01/2008 CMS Term: 95983 RADIO DEF RBRVS 01/01/2019 12/31/2023 37.25 Description: ALYS BRN NPGT PRGRMG 15 MIN Category: Radiology CMS Add: 01/01/2019 CMS Term: 95983 RADIO DEF RBRVS 01/01/2024 47.27 Description: ALYS BRN NPGT PRGRMG 15 MIN Category: Radiology CMS Add: 01/01/2019 CMS Term: 95984 RADIO DEF RBRVS 01/01/2019 12/31/2023 32.48 Description: ALYS BRN NPGT PRGRMG ADDL 15 Category: Radiology CMS Add: 01/01/2019 CMS Term: 95984 RADIO DEF RBRVS 01/01/2024 41.05 Description: ALYS BRN NPGT PRGRMG ADDL 15 Category: Radiology CMS Add: 01/01/2019 CMS Term: 95990 MEDSV DEF RBRVS 01/01/2024 82.14 Description: SPIN/BRAIN PUMP REFIL & MAIN Category: Medical Services CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,371 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 95990 MEDSV DEF RBRVS 02/01/2015 12/31/2023 63.91 Description: SPIN/BRAIN PUMP REFIL & MAIN Category: Medical Services CMS Add: 01/01/2003 CMS Term: 95991 MEDSV DEF RBRVS 01/01/2024 102.72 Description: SPIN/BRAIN PUMP REFIL & MAIN Category: Medical Services CMS Add: 01/01/2004 CMS Term: 95991 MEDSV DEF RBRVS 02/01/2015 12/31/2023 85.67 Description: SPIN/BRAIN PUMP REFIL & MAIN Category: Medical Services CMS Add: 01/01/2004 CMS Term: 95992 MEDSV DEF RBRVS 01/01/2024 41.49 Description: CANALITH REPOSITIONING PROC Category: Medical Services CMS Add: 01/01/2009 CMS Term: 95992 MEDSV DEF RBRVS 06/24/2022 12/31/2023 32.95 Description: CANALITH REPOSITIONING PROC Category: Medical Services CMS Add: 01/01/2009 CMS Term: 95999 MEDSV DEF MAXFEE 01/01/2024 53.91 0.0 Y Description: UNLISTED NEUROLOGICAL DX PX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 95999 MEDSV DEF MAXFEE 02/01/2015 12/31/2023 41.60 0.0 Y Description: UNLISTED NEUROLOGICAL DX PX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 96000 MEDSV DEF RBRVS 01/01/2016 12/31/2023 69.25 Y Description: MOTION ANALYSIS VIDEO/3D Category: Medical Services CMS Add: 01/01/2002 CMS Term: 96000 MEDSV DEF RBRVS 01/01/2024 80.49 Y Description: MOTION ANALYSIS VIDEO/3D Category: Medical Services CMS Add: 01/01/2002 CMS Term: 96001 MEDSV DEF RBRVS 01/01/2016 12/31/2023 72.71 Y Description: MOTION TEST W/FT PRESS MEAS Category: Medical Services CMS Add: 01/01/2002 CMS Term: 96001 MEDSV DEF RBRVS 01/01/2024 104.61 Y Description: MOTION TEST W/FT PRESS MEAS Category: Medical Services CMS Add: 01/01/2002 CMS Term: 96002 MEDSV DEF RBRVS 01/01/2016 12/31/2023 15.47 Y Description: DYNAMIC SURFACE EMG Category: Medical Services CMS Add: 01/01/2002 CMS Term: 96002 MEDSV DEF RBRVS 01/01/2024 20.40 Y Description: DYNAMIC SURFACE EMG Category: Medical Services CMS Add: 01/01/2002 CMS Term: 96003 MEDSV DEF RBRVS 01/01/2016 12/31/2023 14.40 Y Description: DYNAMIC FINE WIRE EMG Category: Medical Services CMS Add: 01/01/2002 CMS Term: 96003 MEDSV DEF RBRVS 01/01/2024 16.10 Y Description: DYNAMIC FINE WIRE EMG Category: Medical Services CMS Add: 01/01/2002 CMS Term: 96004 MEDSV DEF RBRVS 01/01/2016 12/31/2023 85.41 Y Description: PHYS REVIEW OF MOTION TESTS Category: Medical Services CMS Add: 01/01/2002 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,372 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 96004 MEDSV DEF RBRVS 01/01/2024 103.04 Y Description: PHYS REVIEW OF MOTION TESTS Category: Medical Services CMS Add: 01/01/2002 CMS Term: 96020 26 MEDSV DEF RBRVS 01/01/2024 152.44 Description: FUNCTIONAL BRAIN MAPPING Category: Medical Services CMS Add: 01/01/2007 CMS Term: 96020 26 MEDSV DEF RBRVS 02/01/2015 12/31/2023 124.36 Description: FUNCTIONAL BRAIN MAPPING Category: Medical Services CMS Add: 01/01/2007 CMS Term: 96040 MEDSV DEF RBRVS 01/01/2024 44.48 Description: GENETIC COUNSELING 30 MIN Category: Medical Services CMS Add: 01/01/2007 CMS Term: 96040 MEDSV DEF RBRVS 02/01/2015 12/31/2023 32.70 Description: GENETIC COUNSELING 30 MIN Category: Medical Services CMS Add: 01/01/2007 CMS Term: 96105 MEDSV DEF RBRVS 01/01/2024 93.33 Description: ASSESSMENT OF APHASIA Category: Medical Services CMS Add: 01/01/1996 CMS Term: 96105 MEDSV DEF RBRVS 02/01/2015 12/31/2023 73.69 Description: ASSESSMENT OF APHASIA Category: Medical Services CMS Add: 01/01/1996 CMS Term: 96110 MEDSV DEF RBRVS 01/01/2024 9.73 Description: DEVELOPMENTAL SCREEN W/SCORE Category: Medical Services CMS Add: 01/01/1996 CMS Term: 96110 MEDSV DEF RBRVS 09/01/2019 12/31/2023 5.61 Description: DEVELOPMENTAL SCREEN W/SCORE Category: Medical Services CMS Add: 01/01/1996 CMS Term: 96112 MEDSV DEF RBRVS 01/01/2019 12/31/2023 99.08 Description: DEVEL TST PHYS/QHP 1ST HR Category: Medical Services CMS Add: 01/01/2019 CMS Term: 96112 MEDSV DEF RBRVS 01/01/2024 121.11 Description: DEVEL TST PHYS/QHP 1ST HR Category: Medical Services CMS Add: 01/01/2019 CMS Term: 96113 MEDSV DEF RBRVS 01/01/2019 12/31/2023 44.21 Description: DEVEL TST PHYS/QHP EA ADDL Category: Medical Services CMS Add: 01/01/2019 CMS Term: 96113 MEDSV DEF RBRVS 01/01/2024 57.25 Description: DEVEL TST PHYS/QHP EA ADDL Category: Medical Services CMS Add: 01/01/2019 CMS Term: 96116 MEDSV DEF RBRVS 01/01/2024 89.32 Y Description: NUBHVL XM PHYS/QHP 1ST HR Category: Medical Services CMS Add: 01/01/2006 CMS Term: 96116 MEDSV DEF RBRVS 02/01/2015 12/31/2023 68.72 Y Description: NUBHVL XM PHYS/QHP 1ST HR Category: Medical Services CMS Add: 01/01/2006 CMS Term: 96121 MEDSV DEF RBRVS 01/01/2019 12/31/2023 60.39 Y Description: NUBHVL XM PHY/QHP EA ADDL HR Category: Medical Services CMS Add: 01/01/2019 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,373 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 96121 MEDSV DEF RBRVS 01/01/2024 73.72 Y Description: NUBHVL XM PHY/QHP EA ADDL HR Category: Medical Services CMS Add: 01/01/2019 CMS Term: 96125 NOCOV DEF SYSMAN Description: COGNITIVE TEST BY HC PRO Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 96127 MEDSV DEF RBRVS 01/01/2024 4.17 Description: BRIEF EMOTIONAL/BEHAV ASSMT Category: Medical Services CMS Add: 01/01/2015 CMS Term: 96127 MEDSV DEF RBRVS 02/01/2015 12/31/2023 3.88 Description: BRIEF EMOTIONAL/BEHAV ASSMT Category: Medical Services CMS Add: 01/01/2015 CMS Term: 96130 MENTL DEF RBRVS 01/01/2019 12/31/2023 86.29 Y Description: PSYCL TST EVAL PHYS/QHP 1ST Category: Mental Health CMS Add: 01/01/2019 CMS Term: 96130 MENTL DEF RBRVS 01/01/2024 115.84 Y Description: PSYCL TST EVAL PHYS/QHP 1ST Category: Mental Health CMS Add: 01/01/2019 CMS Term: 96130 MRT DEF RBRVS 01/01/2019 12/31/2023 86.29 Description: PSYCL TST EVAL PHYS/QHP 1ST Category: Medical Review Team CMS Add: 01/01/2019 CMS Term: 96130 MRT DEF RBRVS 01/01/2024 115.84 Description: PSYCL TST EVAL PHYS/QHP 1ST Category: Medical Review Team CMS Add: 01/01/2019 CMS Term: 96131 MENTL DEF RBRVS 01/01/2019 12/31/2023 65.71 Y Description: PSYCL TST EVAL PHYS/QHP EA Category: Mental Health CMS Add: 01/01/2019 CMS Term: 96131 MENTL DEF RBRVS 01/01/2024 84.35 Y Description: PSYCL TST EVAL PHYS/QHP EA Category: Mental Health CMS Add: 01/01/2019 CMS Term: 96131 MRT DEF RBRVS 01/01/2019 12/31/2023 65.71 Description: PSYCL TST EVAL PHYS/QHP EA Category: Medical Review Team CMS Add: 01/01/2019 CMS Term: 96131 MRT DEF RBRVS 01/01/2024 84.35 Description: PSYCL TST EVAL PHYS/QHP EA Category: Medical Review Team CMS Add: 01/01/2019 CMS Term: 96132 MENTL DEF RBRVS 01/01/2019 12/31/2023 96.52 Y Description: NRPSYC TST EVAL PHYS/QHP 1ST Category: Mental Health CMS Add: 01/01/2019 CMS Term: 96132 MENTL DEF RBRVS 01/01/2024 124.79 Y Description: NRPSYC TST EVAL PHYS/QHP 1ST Category: Mental Health CMS Add: 01/01/2019 CMS Term: 96133 MENTL DEF RBRVS 01/01/2019 12/31/2023 73.63 Y Description: NRPSYC TST EVAL PHYS/QHP EA Category: Mental Health CMS Add: 01/01/2019 CMS Term: 96133 MENTL DEF RBRVS 01/01/2024 95.46 Y Description: NRPSYC TST EVAL PHYS/QHP EA Category: Mental Health CMS Add: 01/01/2019 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,374 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 96136 MENTL DEF RBRVS 01/01/2019 12/31/2023 33.85 Y Description: PSYCL/NRPSYC TST PHY/QHP 1ST Category: Mental Health CMS Add: 01/01/2019 CMS Term: 96136 MENTL DEF RBRVS 01/01/2024 40.26 Y Description: PSYCL/NRPSYC TST PHY/QHP 1ST Category: Mental Health CMS Add: 01/01/2019 CMS Term: 96136 MRT DEF RBRVS 01/01/2019 12/31/2023 33.85 Description: PSYCL/NRPSYC TST PHY/QHP 1ST Category: Medical Review Team CMS Add: 01/01/2019 CMS Term: 96136 MRT DEF RBRVS 01/01/2024 40.26 Description: PSYCL/NRPSYC TST PHY/QHP 1ST Category: Medical Review Team CMS Add: 01/01/2019 CMS Term: 96137 MENTL DEF RBRVS 01/01/2019 12/31/2023 31.27 Y Description: PSYCL/NRPSYC TST PHY/QHP EA Category: Mental Health CMS Add: 01/01/2019 CMS Term: 96137 MENTL DEF RBRVS 01/01/2024 37.05 Y Description: PSYCL/NRPSYC TST PHY/QHP EA Category: Mental Health CMS Add: 01/01/2019 CMS Term: 96137 MRT DEF RBRVS 01/01/2019 12/31/2023 31.27 Description: PSYCL/NRPSYC TST PHY/QHP EA Category: Medical Review Team CMS Add: 01/01/2019 CMS Term: 96137 MRT DEF RBRVS 01/01/2024 37.05 Description: PSYCL/NRPSYC TST PHY/QHP EA Category: Medical Review Team CMS Add: 01/01/2019 CMS Term: 96138 MENTL DEF RBRVS 01/01/2019 12/31/2023 26.67 Y Description: PSYCL/NRPSYC TECH 1ST Category: Mental Health CMS Add: 01/01/2019 CMS Term: 96138 MENTL DEF RBRVS 01/01/2024 31.03 Y Description: PSYCL/NRPSYC TECH 1ST Category: Mental Health CMS Add: 01/01/2019 CMS Term: 96139 MENTL DEF RBRVS 01/01/2019 12/31/2023 26.67 Y Description: PSYCL/NRPSYC TST TECH EA Category: Mental Health CMS Add: 01/01/2019 CMS Term: 96139 MENTL DEF RBRVS 01/01/2024 31.96 Y Description: PSYCL/NRPSYC TST TECH EA Category: Mental Health CMS Add: 01/01/2019 CMS Term: 96146 MENTL DEF RBRVS 01/01/2019 12/31/2023 1.40 Y Description: PSYCL/NRPSYC TST AUTO RESULT Category: Mental Health CMS Add: 01/01/2019 CMS Term: 96146 MENTL DEF RBRVS 01/01/2024 2.01 Y Description: PSYCL/NRPSYC TST AUTO RESULT Category: Mental Health CMS Add: 01/01/2019 CMS Term: 96156 MENTL DEF RBRVS 01/01/2020 12/31/2023 72.28 Description: HLTH BHV ASSMT/REASSESSMENT Category: Mental Health CMS Add: 01/01/2020 CMS Term: 96156 MENTL DEF RBRVS 01/01/2024 92.20 Description: HLTH BHV ASSMT/REASSESSMENT Category: Mental Health CMS Add: 01/01/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,375 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 96158 MENTL DEF RBRVS 01/01/2020 12/31/2023 49.44 Description: HLTH BHV IVNTJ INDIV 1ST 30 Category: Mental Health CMS Add: 01/01/2020 CMS Term: 96158 MENTL DEF RBRVS 01/01/2024 63.05 Description: HLTH BHV IVNTJ INDIV 1ST 30 Category: Mental Health CMS Add: 01/01/2020 CMS Term: 96159 MENTL DEF RBRVS 01/01/2020 12/31/2023 17.23 Description: HLTH BHV IVNTJ INDIV EA ADDL Category: Mental Health CMS Add: 01/01/2020 CMS Term: 96159 MENTL DEF RBRVS 01/01/2024 21.74 Description: HLTH BHV IVNTJ INDIV EA ADDL Category: Mental Health CMS Add: 01/01/2020 CMS Term: 96160 THEPY DEF RBRVS 01/01/2017 12/31/2023 3.22 Description: PT-FOCUSED HLTH RISK ASSMT Category: Therapy Services CMS Add: 01/01/2017 CMS Term: 96160 THEPY DEF RBRVS 01/01/2024 2.47 Description: PT-FOCUSED HLTH RISK ASSMT Category: Therapy Services CMS Add: 01/01/2017 CMS Term: 96161 THEPY DEF RBRVS 01/01/2017 12/31/2023 3.22 Description: CAREGIVER HEALTH RISK ASSMT Category: Therapy Services CMS Add: 01/01/2017 CMS Term: 96161 THEPY DEF RBRVS 01/01/2024 2.47 Description: CAREGIVER HEALTH RISK ASSMT Category: Therapy Services CMS Add: 01/01/2017 CMS Term: 96164 MENTL DEF RBRVS 01/01/2020 12/31/2023 7.29 Description: HLTH BHV IVNTJ GRP 1ST 30 Category: Mental Health CMS Add: 01/01/2020 CMS Term: 96164 MENTL DEF RBRVS 01/01/2024 9.44 Description: HLTH BHV IVNTJ GRP 1ST 30 Category: Mental Health CMS Add: 01/01/2020 CMS Term: 96165 MENTL DEF RBRVS 01/01/2020 12/31/2023 3.43 Description: HLTH BHV IVNTJ GRP EA ADDL Category: Mental Health CMS Add: 01/01/2020 CMS Term: 96165 MENTL DEF RBRVS 01/01/2024 4.31 Description: HLTH BHV IVNTJ GRP EA ADDL Category: Mental Health CMS Add: 01/01/2020 CMS Term: 96167 MENTL DEF RBRVS 01/01/2020 12/31/2023 53.04 Description: HLTH BHV IVNTJ FAM 1ST 30 Category: Mental Health CMS Add: 01/01/2020 CMS Term: 96167 MENTL DEF RBRVS 01/01/2024 67.06 Description: HLTH BHV IVNTJ FAM 1ST 30 Category: Mental Health CMS Add: 01/01/2020 CMS Term: 96168 MENTL DEF RBRVS 01/01/2020 12/31/2023 18.82 Description: HLTH BHV IVNTJ FAM EA ADDL Category: Mental Health CMS Add: 01/01/2020 CMS Term: 96168 MENTL DEF RBRVS 01/01/2024 23.74 Description: HLTH BHV IVNTJ FAM EA ADDL Category: Mental Health CMS Add: 01/01/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,376 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 96170 MENTL DEF RBRVS 01/01/2020 12/31/2023 59.21 Description: HLTH BHV IVNTJ FAM WO PT 1ST Category: Mental Health CMS Add: 01/01/2020 CMS Term: 96170 MENTL DEF RBRVS 01/01/2024 74.67 Description: HLTH BHV IVNTJ FAM WO PT 1ST Category: Mental Health CMS Add: 01/01/2020 CMS Term: 96171 MENTL DEF RBRVS 01/01/2020 12/31/2023 21.53 Description: HLTH BHV IVNTJ FAM W/O PT EA Category: Mental Health CMS Add: 01/01/2020 CMS Term: 96171 MENTL DEF RBRVS 01/01/2024 26.97 Description: HLTH BHV IVNTJ FAM W/O PT EA Category: Mental Health CMS Add: 01/01/2020 CMS Term: 96202 NOCOV DEF SYSMAN Description: MLT FAM GRP BHV TRAIN 1ST 60 Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 96203 NOCOV DEF SYSMAN Description: MLT FAM GRP BHV TRAIN EA ADD Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 96360 MEDSV DEF RBRVS 01/01/2024 30.31 Description: HYDRATION IV INFUSION INIT Category: Medical Services CMS Add: 01/01/2009 CMS Term: 96360 MEDSV DEF RBRVS 02/01/2015 12/31/2023 39.50 Description: HYDRATION IV INFUSION INIT Category: Medical Services CMS Add: 01/01/2009 CMS Term: 96361 MEDSV DEF RBRVS 01/01/2024 11.85 Description: HYDRATE IV INFUSION ADD-ON Category: Medical Services CMS Add: 01/01/2009 CMS Term: 96361 MEDSV DEF RBRVS 02/01/2015 12/31/2023 10.51 Description: HYDRATE IV INFUSION ADD-ON Category: Medical Services CMS Add: 01/01/2009 CMS Term: 96365 MEDSV DEF RBRVS 01/01/2024 59.01 Description: THER/PROPH/DIAG IV INF INIT Category: Medical Services CMS Add: 01/01/2009 CMS Term: 96365 MEDSV DEF RBRVS 02/01/2015 12/31/2023 47.75 Description: THER/PROPH/DIAG IV INF INIT Category: Medical Services CMS Add: 01/01/2009 CMS Term: 96366 MEDSV DEF RBRVS 01/01/2024 19.23 Description: THER/PROPH/DIAG IV INF ADDON Category: Medical Services CMS Add: 01/01/2009 CMS Term: 96366 MEDSV DEF RBRVS 02/01/2015 12/31/2023 13.18 Description: THER/PROPH/DIAG IV INF ADDON Category: Medical Services CMS Add: 01/01/2009 CMS Term: 96367 MEDSV DEF RBRVS 01/01/2024 26.97 Description: TX/PROPH/DG ADDL SEQ IV INF Category: Medical Services CMS Add: 01/01/2009 CMS Term: 96367 MEDSV DEF RBRVS 02/01/2015 12/31/2023 21.12 Description: TX/PROPH/DG ADDL SEQ IV INF Category: Medical Services CMS Add: 01/01/2009 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,377 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 96368 MEDSV DEF RBRVS 01/01/2024 18.58 Description: THER/DIAG CONCURRENT INF Category: Medical Services CMS Add: 01/01/2009 CMS Term: 96368 MEDSV DEF RBRVS 02/01/2015 12/31/2023 14.39 Description: THER/DIAG CONCURRENT INF Category: Medical Services CMS Add: 01/01/2009 CMS Term: 96369 MEDSV DEF RBRVS 01/01/2024 129.08 Description: SC THER INFUSION UP TO 1 HR Category: Medical Services CMS Add: 01/01/2009 CMS Term: 96369 MEDSV DEF RBRVS 02/01/2015 12/31/2023 134.95 Description: SC THER INFUSION UP TO 1 HR Category: Medical Services CMS Add: 01/01/2009 CMS Term: 96370 MEDSV DEF RBRVS 01/01/2024 14.60 Description: SC THER INFUSION ADDL HR Category: Medical Services CMS Add: 01/01/2009 CMS Term: 96370 MEDSV DEF RBRVS 02/01/2015 12/31/2023 10.95 Description: SC THER INFUSION ADDL HR Category: Medical Services CMS Add: 01/01/2009 CMS Term: 96371 MEDSV DEF RBRVS 01/01/2024 51.86 Description: SC THER INFUSION RESET PUMP Category: Medical Services CMS Add: 01/01/2009 CMS Term: 96371 MEDSV DEF RBRVS 02/01/2015 12/31/2023 62.84 Description: SC THER INFUSION RESET PUMP Category: Medical Services CMS Add: 01/01/2009 CMS Term: 96372 MEDSV DEF RBRVS 01/01/2024 13.33 Description: THER/PROPH/DIAG INJ SC/IM Category: Medical Services CMS Add: 01/01/2009 CMS Term: 96372 MEDSV DEF RBRVS 02/01/2015 12/31/2023 17.61 Description: THER/PROPH/DIAG INJ SC/IM Category: Medical Services CMS Add: 01/01/2009 CMS Term: 96372 TRANS DEF RBRVS 01/01/2024 13.33 Description: THER/PROPH/DIAG INJ SC/IM Category: Transportation CMS Add: 01/01/2009 CMS Term: 96372 TRANS DEF RBRVS 02/01/2015 12/31/2023 17.61 Description: THER/PROPH/DIAG INJ SC/IM Category: Transportation CMS Add: 01/01/2009 CMS Term: 96373 MEDSV DEF RBRVS 01/01/2024 17.04 Description: THER/PROPH/DIAG INJ IA Category: Medical Services CMS Add: 01/01/2009 CMS Term: 96373 MEDSV DEF RBRVS 02/01/2015 12/31/2023 13.65 Description: THER/PROPH/DIAG INJ IA Category: Medical Services CMS Add: 01/01/2009 CMS Term: 96374 MEDSV DEF RBRVS 01/01/2024 34.51 Description: THER/PROPH/DIAG INJ IV PUSH Category: Medical Services CMS Add: 01/01/2009 CMS Term: 96374 MEDSV DEF RBRVS 02/01/2015 12/31/2023 39.02 Description: THER/PROPH/DIAG INJ IV PUSH Category: Medical Services CMS Add: 01/01/2009 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,378 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 96375 MEDSV DEF RBRVS 01/01/2024 14.35 Description: TX/PRO/DX INJ NEW DRUG ADDON Category: Medical Services CMS Add: 01/01/2009 CMS Term: 96375 MEDSV DEF RBRVS 02/01/2015 12/31/2023 15.49 Description: TX/PRO/DX INJ NEW DRUG ADDON Category: Medical Services CMS Add: 01/01/2009 CMS Term: 96376 NOCOV DEF SYSMAN Description: TX/PRO/DX INJ SAME DRUG ADON Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 96377 MEDSV DEF RBRVS 01/01/2024 17.34 Description: APPLICATON ON-BODY INJECTOR Category: Medical Services CMS Add: 01/01/2017 CMS Term: 96377 MEDSV DEF RBRVS 04/13/2018 12/31/2023 14.64 Description: APPLICATON ON-BODY INJECTOR Category: Medical Services CMS Add: 01/01/2017 CMS Term: 96379 MEDSV DEF BILL40 Description: UNL THER/PROP/DIAG INJ/INF Category: Medical Services CMS Add: 01/01/2009 CMS Term: 96380 SL MEDSV MSL MAXFEE 10/06/2023 15.00 0.0 0-2years Description: ADMN RSV MONOC ANTB IM CNSL Category: Medical Services CMS Add: 10/06/2023 CMS Term: 96381 SL MEDSV MSL MAXFEE 10/06/2023 15.00 0.0 0-2years Description: ADMN RSV MONOC ANTB IM NJX Category: Medical Services CMS Add: 10/06/2023 CMS Term: 96401 MEDSV DEF RBRVS 01/01/2024 67.03 Description: CHEMO ANTI-NEOPL SQ/IM Category: Medical Services CMS Add: 01/01/2006 CMS Term: 96401 MEDSV DEF RBRVS 02/01/2015 12/31/2023 51.14 Description: CHEMO ANTI-NEOPL SQ/IM Category: Medical Services CMS Add: 01/01/2006 CMS Term: 96402 MEDSV DEF RBRVS 01/01/2024 31.46 Description: CHEMO HORMON ANTINEOPL SQ/IM Category: Medical Services CMS Add: 01/01/2006 CMS Term: 96402 MEDSV DEF RBRVS 02/01/2015 12/31/2023 22.36 Description: CHEMO HORMON ANTINEOPL SQ/IM Category: Medical Services CMS Add: 01/01/2006 CMS Term: 96405 MEDSV DEF RBRVS 01/01/2024 78.46 Description: CHEMO INTRALESIONAL UP TO 7 Category: Medical Services CMS Add: 01/01/1994 CMS Term: 96405 MEDSV DEF RBRVS 09/01/2019 12/31/2023 57.07 Description: CHEMO INTRALESIONAL UP TO 7 Category: Medical Services CMS Add: 01/01/1994 CMS Term: 96406 MEDSV DEF RBRVS 01/01/2024 122.54 Description: CHEMO INTRALESIONAL OVER 7 Category: Medical Services CMS Add: 01/01/1994 CMS Term: 96406 MEDSV DEF RBRVS 09/01/2019 12/31/2023 79.87 Description: CHEMO INTRALESIONAL OVER 7 Category: Medical Services CMS Add: 01/01/1994 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,379 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 96409 MEDSV DEF RBRVS 01/01/2024 92.76 Description: CHEMO IV PUSH SNGL DRUG Category: Medical Services CMS Add: 01/01/2006 CMS Term: 96409 MEDSV DEF RBRVS 02/01/2015 12/31/2023 75.40 Description: CHEMO IV PUSH SNGL DRUG Category: Medical Services CMS Add: 01/01/2006 CMS Term: 96411 MEDSV DEF RBRVS 01/01/2024 50.95 Description: CHEMO IV PUSH ADDL DRUG Category: Medical Services CMS Add: 01/01/2006 CMS Term: 96411 MEDSV DEF RBRVS 02/01/2015 12/31/2023 42.53 Description: CHEMO IV PUSH ADDL DRUG Category: Medical Services CMS Add: 01/01/2006 CMS Term: 96413 MEDSV DEF RBRVS 01/01/2024 120.21 Description: CHEMO IV INFUSION 1 HR Category: Medical Services CMS Add: 01/01/2006 CMS Term: 96413 MEDSV DEF RBRVS 02/01/2015 12/31/2023 92.32 Description: CHEMO IV INFUSION 1 HR Category: Medical Services CMS Add: 01/01/2006 CMS Term: 96415 MEDSV DEF RBRVS 01/01/2024 26.21 Description: CHEMO IV INFUSION ADDL HR Category: Medical Services CMS Add: 01/01/2006 CMS Term: 96415 MEDSV DEF RBRVS 02/01/2015 12/31/2023 19.64 Description: CHEMO IV INFUSION ADDL HR Category: Medical Services CMS Add: 01/01/2006 CMS Term: 96416 MEDSV DEF RBRVS 01/01/2024 117.84 Description: CHEMO PROLONG INFUSE W/PUMP Category: Medical Services CMS Add: 01/01/2006 CMS Term: 96416 MEDSV DEF RBRVS 02/01/2015 12/31/2023 95.98 Description: CHEMO PROLONG INFUSE W/PUMP Category: Medical Services CMS Add: 01/01/2006 CMS Term: 96417 MEDSV DEF RBRVS 01/01/2024 59.32 Description: CHEMO IV INFUS EACH ADDL SEQ Category: Medical Services CMS Add: 01/01/2006 CMS Term: 96417 MEDSV DEF RBRVS 02/01/2015 12/31/2023 43.05 Description: CHEMO IV INFUS EACH ADDL SEQ Category: Medical Services CMS Add: 01/01/2006 CMS Term: 96420 MEDSV DEF RBRVS 01/01/2024 94.40 Description: CHEMO IA PUSH TECNIQUE Category: Medical Services CMS Add: 01/01/1990 CMS Term: 96420 MEDSV DEF RBRVS 02/01/2015 12/31/2023 71.78 Description: CHEMO IA PUSH TECNIQUE Category: Medical Services CMS Add: 01/01/1990 CMS Term: 96422 MEDSV DEF RBRVS 01/01/2024 144.75 Description: CHEMO IA INFUSION UP TO 1 HR Category: Medical Services CMS Add: 01/01/1990 CMS Term: 96422 MEDSV DEF RBRVS 02/01/2015 12/31/2023 115.63 Description: CHEMO IA INFUSION UP TO 1 HR Category: Medical Services CMS Add: 01/01/1990 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,380 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 96423 MEDSV DEF RBRVS 01/01/2024 67.22 Description: CHEMO IA INFUSE EACH ADDL HR Category: Medical Services CMS Add: 01/01/1990 CMS Term: 96423 MEDSV DEF RBRVS 02/01/2015 12/31/2023 53.53 Description: CHEMO IA INFUSE EACH ADDL HR Category: Medical Services CMS Add: 01/01/1990 CMS Term: 96425 MEDSV DEF RBRVS 01/01/2024 155.10 Description: CHEMOTHERAPY INFUSION METHOD Category: Medical Services CMS Add: 01/01/1990 CMS Term: 96425 MEDSV DEF RBRVS 02/01/2015 12/31/2023 124.38 Description: CHEMOTHERAPY INFUSION METHOD Category: Medical Services CMS Add: 01/01/1990 CMS Term: 96440 MEDSV DEF RBRVS 01/01/2024 700.16 Description: CHMOTX ADMN PLRL CAV THRCNTS Category: Medical Services CMS Add: 01/01/1990 CMS Term: 96440 MEDSV DEF RBRVS 02/01/2015 12/31/2023 591.72 Description: CHMOTX ADMN PLRL CAV THRCNTS Category: Medical Services CMS Add: 01/01/1990 CMS Term: 96446 MEDSV DEF RBRVS 01/01/2024 174.26 Description: CHEMOTX ADMN PERTL CAV IMPL Category: Medical Services CMS Add: 01/01/2011 CMS Term: 96446 MEDSV DEF RBRVS 02/01/2015 12/31/2023 133.96 Description: CHEMOTX ADMN PERTL CAV IMPL Category: Medical Services CMS Add: 01/01/2011 CMS Term: 96450 MEDSV DEF RBRVS 01/01/2024 154.74 Description: CHEMOTHERAPY INTO CNS Category: Medical Services CMS Add: 01/01/1990 CMS Term: 96450 MEDSV DEF RBRVS 02/01/2015 12/31/2023 128.14 Description: CHEMOTHERAPY INTO CNS Category: Medical Services CMS Add: 01/01/1990 CMS Term: 96521 MEDSV DEF RBRVS 01/01/2024 115.98 Description: REFILL/MAINT PORTABLE PUMP Category: Medical Services CMS Add: 01/01/2006 CMS Term: 96521 MEDSV DEF RBRVS 02/01/2015 12/31/2023 93.42 Description: REFILL/MAINT PORTABLE PUMP Category: Medical Services CMS Add: 01/01/2006 CMS Term: 96522 MEDSV DEF RBRVS 01/01/2024 107.03 Description: REFILL/MAINT PUMP/RESVR SYST Category: Medical Services CMS Add: 01/01/2006 CMS Term: 96522 MEDSV DEF RBRVS 02/01/2015 12/31/2023 76.82 Description: REFILL/MAINT PUMP/RESVR SYST Category: Medical Services CMS Add: 01/01/2006 CMS Term: 96523 MEDSV DEF RBRVS 01/01/2024 23.44 0-1 Description: IRRIG DRUG DELIVERY DEVICE Category: Medical Services CMS Add: 01/01/2006 CMS Term: 96523 MEDSV DEF RBRVS 02/01/2015 12/31/2023 17.09 0-1 Description: IRRIG DRUG DELIVERY DEVICE Category: Medical Services CMS Add: 01/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,381 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 96542 MEDSV DEF RBRVS 01/01/2024 120.85 Description: CHEMOTHERAPY INJECTION Category: Medical Services CMS Add: 01/01/1993 CMS Term: 96542 MEDSV DEF RBRVS 02/01/2015 12/31/2023 83.24 Description: CHEMOTHERAPY INJECTION Category: Medical Services CMS Add: 01/01/1993 CMS Term: 96547 NOCOV DEF SYSMAN Description: INTRAOP HIPEC PX 1ST 60 MIN Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 96548 NOCOV DEF SYSMAN Description: NTRAOP HIPEC PX EA ADD 30MIN Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 96549 MEDSV PRF MAXFEE 01/01/2024 137.10 0.0 Description: UNLISTED CHEMOTHERAPY PX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 96567 MEDSV DEF RBRVS 01/01/2024 129.82 Description: PDT DSTR PRMLG LES SKN Category: Medical Services CMS Add: 01/01/2002 CMS Term: 96567 MEDSV DEF RBRVS 02/01/2015 12/31/2023 91.32 Description: PDT DSTR PRMLG LES SKN Category: Medical Services CMS Add: 01/01/2002 CMS Term: 96570 MEDSV DEF RBRVS 01/01/2024 50.52 Description: PHOTODYNMC TX 30 MIN ADD-ON Category: Medical Services CMS Add: 01/01/2000 CMS Term: 96570 MEDSV DEF RBRVS 09/01/2019 12/31/2023 41.03 Description: PHOTODYNMC TX 30 MIN ADD-ON Category: Medical Services CMS Add: 01/01/2000 CMS Term: 96571 MEDSV DEF RBRVS 01/01/2024 23.91 Description: PHOTODYNAMIC TX ADDL 15 MIN Category: Medical Services CMS Add: 01/01/2000 CMS Term: 96571 MEDSV DEF RBRVS 09/01/2019 12/31/2023 19.40 Description: PHOTODYNAMIC TX ADDL 15 MIN Category: Medical Services CMS Add: 01/01/2000 CMS Term: 96573 MEDSV DEF RBRVS 01/01/2018 12/31/2023 133.78 Description: PDT DSTR PRMLG LES PHYS/QHP Category: Medical Services CMS Add: 01/01/2018 CMS Term: 96573 MEDSV DEF RBRVS 01/01/2024 214.16 Description: PDT DSTR PRMLG LES PHYS/QHP Category: Medical Services CMS Add: 01/01/2018 CMS Term: 96574 MEDSV DEF RBRVS 01/01/2018 12/31/2023 173.12 Description: DBRDMT PRMLG LES W/PDT Category: Medical Services CMS Add: 01/01/2018 CMS Term: 96574 MEDSV DEF RBRVS 01/01/2024 262.70 Description: DBRDMT PRMLG LES W/PDT Category: Medical Services CMS Add: 01/01/2018 CMS Term: 96900 MEDSV DEF RBRVS 01/01/2024 22.39 Description: ULTRAVIOLET LIGHT THERAPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,382 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 96900 MEDSV DEF RBRVS 02/01/2015 12/31/2023 14.04 Description: ULTRAVIOLET LIGHT THERAPY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 96902 NOCOV DEF SYSMAN Description: TRICHOGRAM Category: Non Covered Services CMS Add: 01/01/1998 CMS Term: 96904 MEDSV DEF RBRVS 01/01/2024 64.68 Description: WHOLE BODY PHOTOGRAPHY Category: Medical Services CMS Add: 01/01/2007 CMS Term: 96904 MEDSV DEF RBRVS 02/01/2015 12/31/2023 46.24 Description: WHOLE BODY PHOTOGRAPHY Category: Medical Services CMS Add: 01/01/2007 CMS Term: 96910 MEDSV DEF RBRVS 01/01/2024 108.68 Description: PHOTOCHEMOTHERAPY WITH UV-B Category: Medical Services CMS Add: 01/01/1982 CMS Term: 96910 MEDSV DEF RBRVS 02/01/2015 12/31/2023 47.97 Description: PHOTOCHEMOTHERAPY WITH UV-B Category: Medical Services CMS Add: 01/01/1982 CMS Term: 96912 MEDSV DEF RBRVS 01/01/2024 92.77 Description: PHOTOCHEMOTHERAPY WITH UV-A Category: Medical Services CMS Add: 01/01/1982 CMS Term: 96912 MEDSV DEF RBRVS 02/01/2015 12/31/2023 61.85 Description: PHOTOCHEMOTHERAPY WITH UV-A Category: Medical Services CMS Add: 01/01/1982 CMS Term: 96913 MEDSV DEF RBRVS 01/01/2024 140.48 Description: PHOTOCHEMOTHERAPY UV-A OR B Category: Medical Services CMS Add: 01/01/1991 CMS Term: 96913 MEDSV DEF RBRVS 02/01/2015 12/31/2023 87.11 Description: PHOTOCHEMOTHERAPY UV-A OR B Category: Medical Services CMS Add: 01/01/1991 CMS Term: 96920 MEDSV DEF RBRVS 01/01/2024 147.05 Y Description: EXCIMER LSR PSRIASIS<250SQCM Category: Medical Services CMS Add: 01/01/2003 CMS Term: 96920 MEDSV DEF RBRVS 02/01/2015 12/31/2023 108.10 Y Description: EXCIMER LSR PSRIASIS<250SQCM Category: Medical Services CMS Add: 01/01/2003 CMS Term: 96921 MEDSV DEF RBRVS 01/01/2024 161.40 Y Description: EXCIMER LSR PSRIASIS 250-500 Category: Medical Services CMS Add: 01/01/2003 CMS Term: 96921 MEDSV DEF RBRVS 02/01/2015 12/31/2023 119.32 Y Description: EXCIMER LSR PSRIASIS 250-500 Category: Medical Services CMS Add: 01/01/2003 CMS Term: 96922 MEDSV DEF RBRVS 01/01/2024 220.65 Y Description: EXCIMER LSR PSRIASIS>500SQCM Category: Medical Services CMS Add: 01/01/2003 CMS Term: 96922 MEDSV DEF RBRVS 02/01/2015 12/31/2023 165.99 Y Description: EXCIMER LSR PSRIASIS>500SQCM Category: Medical Services CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,383 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 96931 NOCOV DEF SYSMAN Description: RCM CELULR SUBCELULR IMG SKN Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 96932 NOCOV DEF SYSMAN Description: RCM CELULR SUBCELULR IMG SKN Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 96933 NOCOV DEF SYSMAN Description: RCM CELULR SUBCELULR IMG SKN Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 96934 NOCOV DEF SYSMAN Description: RCM CELULR SUBCELULR IMG SKN Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 96935 NOCOV DEF SYSMAN Description: RCM CELULR SUBCELULR IMG SKN Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 96936 NOCOV DEF SYSMAN Description: RCM CELULR SUBCELULR IMG SKN Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 96999 MEDSV PRF MAXFEE 01/01/2024 15.32 0.0 Description: UNLISTED SPEC DERM SVC/PX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 97010 NOCOV DEF SYSMAN Description: HOT OR COLD PACKS THERAPY Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: 97012* CHIRO DEF RBRVS 01/01/2024 13.88 Y Description: MECHANICAL TRACTION THERAPY Category: Chiropractor CMS Add: 01/01/1984 CMS Term: 97012* CHIRO DEF RBRVS 09/01/2019 12/31/2023 11.59 Y Description: MECHANICAL TRACTION THERAPY Category: Chiropractor CMS Add: 01/01/1984 CMS Term: 97014* CHIRO DEF RBRVS 01/01/2024 11.82 Y Description: ELECTRIC STIMULATION THERAPY Category: Chiropractor CMS Add: 01/01/1983 CMS Term: 97014* CHIRO DEF RBRVS 09/01/2019 12/31/2023 11.44 Y Description: ELECTRIC STIMULATION THERAPY Category: Chiropractor CMS Add: 01/01/1983 CMS Term: 97016* CHIRO DEF RBRVS 01/01/2024 11.20 Y Description: VASOPNEUMATIC DEVICE THERAPY Category: Chiropractor CMS Add: 01/01/1984 CMS Term: 97016* CHIRO DEF RBRVS 09/01/2019 12/31/2023 13.67 Y Description: VASOPNEUMATIC DEVICE THERAPY Category: Chiropractor CMS Add: 01/01/1984 CMS Term: 97018* CHIRO DEF RBRVS 01/01/2024 5.28 Y Description: PARAFFIN BATH THERAPY Category: Chiropractor CMS Add: 01/01/1984 CMS Term: 97018* CHIRO DEF RBRVS 09/01/2019 12/31/2023 7.72 Y Description: PARAFFIN BATH THERAPY Category: Chiropractor CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,384 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 97022* CHIRO DEF RBRVS 01/01/2024 16.11 Y Description: WHIRLPOOL THERAPY Category: Chiropractor CMS Add: 01/01/1984 CMS Term: 97022* CHIRO DEF RBRVS 09/01/2019 12/31/2023 16.62 Y Description: WHIRLPOOL THERAPY Category: Chiropractor CMS Add: 01/01/1984 CMS Term: 97024* CHIRO DEF RBRVS 01/01/2024 6.82 Y Description: DIATHERMY EG MICROWAVE Category: Chiropractor CMS Add: 01/01/1983 CMS Term: 97024* CHIRO DEF RBRVS 09/01/2019 12/31/2023 4.50 Y Description: DIATHERMY EG MICROWAVE Category: Chiropractor CMS Add: 01/01/1983 CMS Term: 97026* CHIRO DEF RBRVS 01/01/2024 6.21 Y Description: INFRARED THERAPY Category: Chiropractor CMS Add: 01/01/1984 CMS Term: 97026* CHIRO DEF RBRVS 09/01/2019 12/31/2023 4.25 Y Description: INFRARED THERAPY Category: Chiropractor CMS Add: 01/01/1984 CMS Term: 97028* CHIRO DEF RBRVS 01/01/2024 7.81 Y Description: ULTRAVIOLET THERAPY Category: Chiropractor CMS Add: 01/01/1984 CMS Term: 97028* CHIRO DEF RBRVS 09/01/2019 12/31/2023 5.29 Y Description: ULTRAVIOLET THERAPY Category: Chiropractor CMS Add: 01/01/1984 CMS Term: 97032* CHIRO DEF RBRVS 01/01/2024 13.88 Y Description: APPL MODALITY 1+ESTIM EA 15 Category: Chiropractor CMS Add: 01/01/1995 CMS Term: 97032* CHIRO DEF RBRVS 09/01/2019 12/31/2023 13.82 Y Description: APPL MODALITY 1+ESTIM EA 15 Category: Chiropractor CMS Add: 01/01/1995 CMS Term: 97033* CHIRO DEF RBRVS 01/01/2024 18.85 Y Description: APP MDLTY 1+IONTPHRSIS EA 15 Category: Chiropractor CMS Add: 01/01/1995 CMS Term: 97033* CHIRO DEF RBRVS 09/01/2019 12/31/2023 23.00 Y Description: APP MDLTY 1+IONTPHRSIS EA 15 Category: Chiropractor CMS Add: 01/01/1995 CMS Term: 97034* CHIRO DEF RBRVS 01/01/2024 13.76 Y Description: APP MDLTY 1+CNTRST BTH EA 15 Category: Chiropractor CMS Add: 01/01/1995 CMS Term: 97034* CHIRO DEF RBRVS 09/01/2019 12/31/2023 12.99 Y Description: APP MDLTY 1+CNTRST BTH EA 15 Category: Chiropractor CMS Add: 01/01/1995 CMS Term: 97035* CHIRO DEF RBRVS 01/01/2024 13.76 Y Description: APP MDLTY 1+ULTRASOUND EA 15 Category: Chiropractor CMS Add: 01/01/1995 CMS Term: 97035* CHIRO DEF RBRVS 09/01/2019 12/31/2023 9.28 Y Description: APP MDLTY 1+ULTRASOUND EA 15 Category: Chiropractor CMS Add: 01/01/1995 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,385 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 97036* CHIRO DEF RBRVS 01/01/2024 32.80 Y Description: APP MDLTY 1+HUBBRD TNK EA 15 Category: Chiropractor CMS Add: 01/01/1995 CMS Term: 97036* CHIRO DEF RBRVS 09/01/2019 12/31/2023 23.29 Y Description: APP MDLTY 1+HUBBRD TNK EA 15 Category: Chiropractor CMS Add: 01/01/1995 CMS Term: 97037 NOCOV DEF SYSMAN Description: APPL MODALITY 1+LLLT PO PAIN Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 97039* CHIRO PRF MAXFEE 01/01/2024 18.44 0.0 Y Description: UNLISTED MODALITY Category: Chiropractor CMS Add: 01/01/1984 CMS Term: 97110* CHIRO DEF RBRVS 01/01/2024 28.38 Y Description: THERAPEUTIC EXERCISES Category: Chiropractor CMS Add: 01/01/1984 CMS Term: 97110* CHIRO DEF RBRVS 09/01/2019 12/31/2023 23.15 Y Description: THERAPEUTIC EXERCISES Category: Chiropractor CMS Add: 01/01/1984 CMS Term: 97112 THEPY DEF RBRVS 01/01/2024 32.54 Y Description: NEUROMUSCULAR REEDUCATION Category: Therapy Services CMS Add: 01/01/1984 CMS Term: 97112 THEPY DEF RBRVS 09/01/2019 12/31/2023 24.15 Y Description: NEUROMUSCULAR REEDUCATION Category: Therapy Services CMS Add: 01/01/1984 CMS Term: 97113* CHIRO DEF RBRVS 01/01/2024 35.26 Y Description: AQUATIC THERAPY/EXERCISES Category: Chiropractor CMS Add: 01/01/1995 CMS Term: 97113* CHIRO DEF RBRVS 09/01/2019 12/31/2023 30.81 Y Description: AQUATIC THERAPY/EXERCISES Category: Chiropractor CMS Add: 01/01/1995 CMS Term: 97116 THEPY DEF RBRVS 01/01/2024 28.38 Y Description: GAIT TRAINING THERAPY Category: Therapy Services CMS Add: 01/01/1984 CMS Term: 97116 THEPY DEF RBRVS 09/01/2019 12/31/2023 20.57 Y Description: GAIT TRAINING THERAPY Category: Therapy Services CMS Add: 01/01/1984 CMS Term: 97124* CHIRO DEF RBRVS 01/01/2024 28.69 Y Description: MASSAGE THERAPY Category: Chiropractor CMS Add: 01/01/1984 CMS Term: 97124* CHIRO DEF RBRVS 09/01/2019 12/31/2023 18.98 Y Description: MASSAGE THERAPY Category: Chiropractor CMS Add: 01/01/1984 CMS Term: 97129 MEDSV DEF RBRVS 01/01/2020 12/31/2023 17.73 Y Description: THER IVNTJ 1ST 15 MIN Category: Medical Services CMS Add: 01/01/2020 CMS Term: 97129 MEDSV DEF RBRVS 01/01/2024 22.04 Y Description: THER IVNTJ 1ST 15 MIN Category: Medical Services CMS Add: 01/01/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,386 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 97130 MEDSV DEF RBRVS 01/01/2020 12/31/2023 16.94 Y Description: THER IVNTJ EA ADDL 15 MIN Category: Medical Services CMS Add: 01/01/2020 CMS Term: 97130 MEDSV DEF RBRVS 01/01/2024 21.06 Y Description: THER IVNTJ EA ADDL 15 MIN Category: Medical Services CMS Add: 01/01/2020 CMS Term: 97139* CHIRO PRF MAXFEE 01/01/2024 21.82 0.0 Y Description: UNLISTED THERAPEUTIC PX Category: Chiropractor CMS Add: 01/01/1984 CMS Term: 97140* CHIRO DEF RBRVS 01/01/2024 26.15 Y Description: MANUAL THERAPY 1/> REGIONS Category: Chiropractor CMS Add: 01/01/1999 CMS Term: 97140* CHIRO DEF RBRVS 09/01/2019 12/31/2023 21.63 Y Description: MANUAL THERAPY 1/> REGIONS Category: Chiropractor CMS Add: 01/01/1999 CMS Term: 97150 THEPY DEF RBRVS 01/01/2024 17.09 Y Description: GROUP THERAPEUTIC PROCEDURES Category: Therapy Services CMS Add: 01/01/1995 CMS Term: 97150 THEPY DEF RBRVS 09/01/2019 12/31/2023 12.66 Y Description: GROUP THERAPEUTIC PROCEDURES Category: Therapy Services CMS Add: 01/01/1995 CMS Term: 97151 MENTL DEF MAXFEE 01/01/2019 33.38 0.0 Y 0-999years Description: BHV ID ASSMT BY PHYS/QHP Category: Mental Health CMS Add: 01/01/2019 CMS Term: 97151 U2 MENTL DEF MAXFEE 01/01/2024 21.87 0.0 Y 0-999years Description: BHV ID ASSMT BY PHYS/QHP Category: Mental Health CMS Add: 01/01/2019 CMS Term: 97151 U3 MENTL DEF MAXFEE 01/01/2024 27.63 0.0 Y 0-999years Description: BHV ID ASSMT BY PHYS/QHP Category: Mental Health CMS Add: 01/01/2019 CMS Term: 97152 MENTL DEF MAXFEE 01/01/2019 33.38 0.0 Y 0-999years Description: BHV ID SUPRT ASSMT BY 1 TECH Category: Mental Health CMS Add: 01/01/2019 CMS Term: 97152 U1 MENTL DEF MAXFEE 01/01/2024 17.06 0.0 Y 0-999years Description: BHV ID SUPRT ASSMT BY 1 TECH Category: Mental Health CMS Add: 01/01/2019 CMS Term: 97153 MENTL DEF MAXFEE 01/01/2019 33.38 0.0 Y 0-999years Description: ADAPTIVE BEHAVIOR TX BY TECH Category: Mental Health CMS Add: 01/01/2019 CMS Term: 97153 U1 MENTL DEF MAXFEE 01/01/2024 17.06 0.0 Y 0-999years Description: ADAPTIVE BEHAVIOR TX BY TECH Category: Mental Health CMS Add: 01/01/2019 CMS Term: 97154 MENTL DEF MAXFEE 01/01/2019 33.38 0.0 Y 0-999years Description: GRP ADAPT BHV TX BY TECH Category: Mental Health CMS Add: 01/01/2019 CMS Term: 97154 U1 MENTL DEF MAXFEE 01/01/2024 4.87 0.0 Y 0-999years Description: GRP ADAPT BHV TX BY TECH Category: Mental Health CMS Add: 01/01/2019 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,387 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 97155 MENTL DEF MAXFEE 01/01/2019 33.38 0.0 Y 0-999years Description: ADAPT BEHAVIOR TX PHYS/QHP Category: Mental Health CMS Add: 01/01/2019 CMS Term: 97155 U2 MENTL DEF MAXFEE 01/01/2024 21.85 0.0 Y 0-999years Description: ADAPT BEHAVIOR TX PHYS/QHP Category: Mental Health CMS Add: 01/01/2019 CMS Term: 97155 U3 MENTL DEF MAXFEE 01/01/2024 27.63 0.0 Y 0-999years Description: ADAPT BEHAVIOR TX PHYS/QHP Category: Mental Health CMS Add: 01/01/2019 CMS Term: 97156 MENTL DEF MAXFEE 01/01/2019 33.38 0.0 Y 0-999years Description: FAM ADAPT BHV TX GDN PHY/QHP Category: Mental Health CMS Add: 01/01/2019 CMS Term: 97156 U2 MENTL DEF MAXFEE 01/01/2024 21.87 0.0 Y 0-999years Description: FAM ADAPT BHV TX GDN PHY/QHP Category: Mental Health CMS Add: 01/01/2019 CMS Term: 97156 U3 MENTL DEF MAXFEE 01/01/2024 28.23 0.0 Y 0-999years Description: FAM ADAPT BHV TX GDN PHY/QHP Category: Mental Health CMS Add: 01/01/2019 CMS Term: 97157 MENTL DEF MAXFEE 01/01/2019 33.38 0.0 Y 0-999years Description: MULT FAM ADAPT BHV TX GDN Category: Mental Health CMS Add: 01/01/2019 CMS Term: 97157 U2 MENTL DEF MAXFEE 01/01/2024 6.25 0.0 Y 0-999years Description: MULT FAM ADAPT BHV TX GDN Category: Mental Health CMS Add: 01/01/2019 CMS Term: 97157 U3 MENTL DEF MAXFEE 01/01/2024 7.89 0.0 Y 0-999years Description: MULT FAM ADAPT BHV TX GDN Category: Mental Health CMS Add: 01/01/2019 CMS Term: 97158 MENTL DEF MAXFEE 01/01/2019 33.38 0.0 Y 0-999years Description: GRP ADAPT BHV TX BY PHY/QHP Category: Mental Health CMS Add: 01/01/2019 CMS Term: 97158 U2 MENTL DEF MAXFEE 01/01/2024 6.25 0.0 Y 0-999years Description: GRP ADAPT BHV TX BY PHY/QHP Category: Mental Health CMS Add: 01/01/2019 CMS Term: 97158 U3 MENTL DEF MAXFEE 01/01/2024 7.89 0.0 Y 0-999years Description: GRP ADAPT BHV TX BY PHY/QHP Category: Mental Health CMS Add: 01/01/2019 CMS Term: 97161 THEPY DEF RBRVS 01/01/2017 12/31/2023 58.17 Description: PT EVAL LOW COMPLEX 20 MIN Category: Therapy Services CMS Add: 01/01/2017 CMS Term: 97161 THEPY DEF RBRVS 01/01/2024 96.67 Description: PT EVAL LOW COMPLEX 20 MIN Category: Therapy Services CMS Add: 01/01/2017 CMS Term: 97162 THEPY DEF RBRVS 01/01/2017 12/31/2023 58.17 Description: PT EVAL MOD COMPLEX 30 MIN Category: Therapy Services CMS Add: 01/01/2017 CMS Term: 97162 THEPY DEF RBRVS 01/01/2024 96.67 Description: PT EVAL MOD COMPLEX 30 MIN Category: Therapy Services CMS Add: 01/01/2017 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,388 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 97163 THEPY DEF RBRVS 01/01/2017 12/31/2023 58.17 Description: PT EVAL HIGH COMPLEX 45 MIN Category: Therapy Services CMS Add: 01/01/2017 CMS Term: 97163 THEPY DEF RBRVS 01/01/2024 96.67 Description: PT EVAL HIGH COMPLEX 45 MIN Category: Therapy Services CMS Add: 01/01/2017 CMS Term: 97164 THEPY DEF RBRVS 01/01/2017 12/31/2023 39.39 Y Description: PT RE-EVAL EST PLAN CARE Category: Therapy Services CMS Add: 01/01/2017 CMS Term: 97164 THEPY DEF RBRVS 01/01/2024 66.52 Y Description: PT RE-EVAL EST PLAN CARE Category: Therapy Services CMS Add: 01/01/2017 CMS Term: 97165 THEPY DEF RBRVS 01/01/2017 12/31/2023 56.43 Description: OT EVAL LOW COMPLEX 30 MIN Category: Therapy Services CMS Add: 01/01/2017 CMS Term: 97165 THEPY DEF RBRVS 01/01/2024 96.67 Description: OT EVAL LOW COMPLEX 30 MIN Category: Therapy Services CMS Add: 01/01/2017 CMS Term: 97166 THEPY DEF RBRVS 01/01/2017 12/31/2023 56.43 Description: OT EVAL MOD COMPLEX 45 MIN Category: Therapy Services CMS Add: 01/01/2017 CMS Term: 97166 THEPY DEF RBRVS 01/01/2024 96.67 Description: OT EVAL MOD COMPLEX 45 MIN Category: Therapy Services CMS Add: 01/01/2017 CMS Term: 97167 THEPY DEF RBRVS 01/01/2017 12/31/2023 56.43 Description: OT EVAL HIGH COMPLEX 60 MIN Category: Therapy Services CMS Add: 01/01/2017 CMS Term: 97167 THEPY DEF RBRVS 01/01/2024 96.67 Description: OT EVAL HIGH COMPLEX 60 MIN Category: Therapy Services CMS Add: 01/01/2017 CMS Term: 97168 THEPY DEF RBRVS 01/01/2017 12/31/2023 37.24 Y Description: OT RE-EVAL EST PLAN CARE Category: Therapy Services CMS Add: 01/01/2017 CMS Term: 97168 THEPY DEF RBRVS 01/01/2024 66.21 Y Description: OT RE-EVAL EST PLAN CARE Category: Therapy Services CMS Add: 01/01/2017 CMS Term: 97169 NOCOV DEF SYSMAN Description: ATHLETIC TRN EVAL LOW CMPLX Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: 97170 NOCOV DEF SYSMAN Description: ATHLETIC TRN EVAL MOD CMPLX Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: 97171 NOCOV DEF SYSMAN Description: ATHLETIC TRN EVAL HIGH CMPLX Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: 97172 NOCOV DEF SYSMAN Description: ATHLETIC TRN RE-EVAL PLAN CR Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,389 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 97530 THEPY DEF RBRVS 01/01/2024 35.45 Y Description: THERAPEUTIC ACTIVITIES Category: Therapy Services CMS Add: 01/01/1985 CMS Term: 97530 THEPY DEF RBRVS 09/01/2019 12/31/2023 25.12 Y Description: THERAPEUTIC ACTIVITIES Category: Therapy Services CMS Add: 01/01/1985 CMS Term: 97533 THEPY DEF RBRVS 01/01/2024 59.96 Y Description: SENSORY INTEGRATION Category: Therapy Services CMS Add: 01/01/2001 CMS Term: 97533 THEPY DEF RBRVS 09/01/2019 12/31/2023 21.15 Y Description: SENSORY INTEGRATION Category: Therapy Services CMS Add: 01/01/2001 CMS Term: 97535 THEPY DEF RBRVS 01/01/2024 31.46 Y Description: SELF CARE MNGMENT TRAINING Category: Therapy Services CMS Add: 01/01/1996 CMS Term: 97535 THEPY DEF RBRVS 09/01/2019 12/31/2023 25.14 Y Description: SELF CARE MNGMENT TRAINING Category: Therapy Services CMS Add: 01/01/1996 CMS Term: 97535 U7 MFPTB W2M MAXFEE 06/02/2008 06/30/2023 6.99 0.0 Y Description: SELF CARE MNGMENT TRAINING Category: MFP TBI CMS Add: 01/01/1996 CMS Term: 97535 U7 MFPTB W2M MAXFEE 07/01/2023 9.45 0.0 Y Description: SELF CARE MNGMENT TRAINING Category: MFP TBI CMS Add: 01/01/1996 CMS Term: 97535 U7 TBIWA WTB MAXFEE 01/01/2004 06/30/2023 6.99 0.0 Y Description: SELF CARE MNGMENT TRAINING Category: TBI Waiver CMS Add: 01/01/1996 CMS Term: 97535 U7 TBIWA WTB MAXFEE 07/01/2023 9.45 0.0 Y Description: SELF CARE MNGMENT TRAINING Category: TBI Waiver CMS Add: 01/01/1996 CMS Term: 97537 THEPY DEF RBRVS 01/01/2024 30.63 Y Description: COMMUNITY/WORK REINTEGRATION Category: Therapy Services CMS Add: 01/01/1996 CMS Term: 97537 THEPY DEF RBRVS 09/01/2019 12/31/2023 21.92 Y Description: COMMUNITY/WORK REINTEGRATION Category: Therapy Services CMS Add: 01/01/1996 CMS Term: 97537 UB AMHH WUB MAXFEE 10/01/2013 26.14 0.0 Y 19-999years Description: COMMUNITY/WORK REINTEGRATION Category: Adult MNTL HLTH CMS Add: 01/01/1996 CMS Term: 97542 THEPY DEF RBRVS 01/01/2024 30.63 Y Description: WHEELCHAIR MNGMENT TRAINING Category: Therapy Services CMS Add: 01/01/1996 CMS Term: 97542 THEPY DEF RBRVS 09/01/2019 12/31/2023 22.16 Y Description: WHEELCHAIR MNGMENT TRAINING Category: Therapy Services CMS Add: 01/01/1996 CMS Term: 97545 NOCOV DEF SYSMAN Description: WORK HARDENING Category: Non Covered Services CMS Add: 01/01/1993 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,390 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 97546 NOCOV DEF SYSMAN Description: WORK HARDENING ADD-ON Category: Non Covered Services CMS Add: 01/01/1993 CMS Term: 97550 NOCOV DEF SYSMAN Description: CAREGIVER TRAING 1ST 30 MIN Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 97551 NOCOV DEF SYSMAN Description: CAREGIVER TRAING EA ADDL 15 Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 97552 NOCOV DEF SYSMAN Description: GROUP CAREGIVER TRAINING Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 97597 MEDSV DEF RBRVS 01/01/2024 94.36 Description: DBRDMT OPN WND 1ST 20 CM/< Category: Medical Services CMS Add: 01/01/2005 CMS Term: 97597 MEDSV DEF RBRVS 02/01/2015 12/31/2023 53.92 Description: DBRDMT OPN WND 1ST 20 CM/< Category: Medical Services CMS Add: 01/01/2005 CMS Term: 97598 MEDSV DEF RBRVS 01/01/2024 41.99 Description: DBRDMT OPN WND ADDL 20CM/< Category: Medical Services CMS Add: 01/01/2005 CMS Term: 97598 MEDSV DEF RBRVS 02/01/2015 12/31/2023 17.84 Description: DBRDMT OPN WND ADDL 20CM/< Category: Medical Services CMS Add: 01/01/2005 CMS Term: 97605 MEDSV DEF RBRVS 01/01/2024 40.72 Description: NEG PRS WND THER DME<=50SQCM Category: Medical Services CMS Add: 01/01/2005 CMS Term: 97605 MEDSV DEF RBRVS 02/01/2015 12/31/2023 30.22 Description: NEG PRS WND THER DME<=50SQCM Category: Medical Services CMS Add: 01/01/2005 CMS Term: 97606 MEDSV DEF RBRVS 01/01/2024 48.59 Description: NEG PRS WND THER DME>50 SQCM Category: Medical Services CMS Add: 01/01/2005 CMS Term: 97606 MEDSV DEF RBRVS 02/01/2015 12/31/2023 32.14 Description: NEG PRS WND THER DME>50 SQCM Category: Medical Services CMS Add: 01/01/2005 CMS Term: 97607 MEDSV DEF MAXFEE 01/01/2024 409.40 0.0 Description: NEG PRS WND THR NDME<=50SQCM Category: Medical Services CMS Add: 01/01/2015 CMS Term: 97608 MEDSV DEF MAXFEE 01/01/2024 409.40 0.0 Description: NEG PRS WND THER NDME>50SQCM Category: Medical Services CMS Add: 01/01/2015 CMS Term: 97610 MEDSV PRF MAXFEE 01/01/2024 409.40 0.0 Description: LOW FREQUENCY NON-THERMAL US Category: Medical Services CMS Add: 01/01/2014 CMS Term: 97750 THEPY DEF RBRVS 01/01/2024 32.39 Y Description: PHYSICAL PERFORMANCE TEST Category: Therapy Services CMS Add: 01/01/1995 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,391 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 97750 THEPY DEF RBRVS 09/01/2019 12/31/2023 23.98 Y Description: PHYSICAL PERFORMANCE TEST Category: Therapy Services CMS Add: 01/01/1995 CMS Term: 97755 NOCOV DEF SYSMAN Description: ASSISTIVE TECHNOLOGY ASSESS Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: 97760 MEDSV DEF RBRVS 01/01/2024 46.12 Y Description: ORTHOTIC MGMT&TRAING 1ST ENC Category: Medical Services CMS Add: 01/01/2006 CMS Term: 97760 MEDSV DEF RBRVS 09/01/2019 12/31/2023 33.83 Y Description: ORTHOTIC MGMT&TRAING 1ST ENC Category: Medical Services CMS Add: 01/01/2006 CMS Term: 97761 MEDSV DEF RBRVS 01/01/2024 39.95 Y Description: PROSTHETIC TRAING 1ST ENC Category: Medical Services CMS Add: 01/01/2006 CMS Term: 97761 MEDSV DEF RBRVS 09/01/2019 12/31/2023 29.37 Y Description: PROSTHETIC TRAING 1ST ENC Category: Medical Services CMS Add: 01/01/2006 CMS Term: 97763 MEDSV DEF RBRVS 01/01/2018 12/31/2023 34.78 Y Description: ORTHC/PROSTC MGMT SBSQ ENC Category: Medical Services CMS Add: 01/01/2018 CMS Term: 97763 MEDSV DEF RBRVS 01/01/2024 50.39 Y Description: ORTHC/PROSTC MGMT SBSQ ENC Category: Medical Services CMS Add: 01/01/2018 CMS Term: 97799 THEPY DEF MAXFEE 01/01/2024 29.82 0.0 Y Description: UNLISTED PHYSCL MED/REHAB PX Category: Therapy Services CMS Add: 01/01/1984 CMS Term: 97799 THEPY DEF MAXFEE 02/01/2015 12/31/2023 23.01 0.0 Y Description: UNLISTED PHYSCL MED/REHAB PX Category: Therapy Services CMS Add: 01/01/1984 CMS Term: 97802 MEDSV DEF RBRVS 01/01/2024 35.10 Description: MEDICAL NUTRITION INDIV IN Category: Medical Services CMS Add: 01/01/2001 CMS Term: 97802 MEDSV DEF RBRVS 09/01/2019 12/31/2023 25.63 Description: MEDICAL NUTRITION INDIV IN Category: Medical Services CMS Add: 01/01/2001 CMS Term: 97803 MEDSV DEF RBRVS 01/01/2024 30.54 Description: MED NUTRITION INDIV SUBSEQ Category: Medical Services CMS Add: 01/01/2001 CMS Term: 97803 MEDSV DEF RBRVS 09/01/2019 12/31/2023 22.00 Description: MED NUTRITION INDIV SUBSEQ Category: Medical Services CMS Add: 01/01/2001 CMS Term: 97804 MEDSV DEF RBRVS 01/01/2024 16.04 Description: MEDICAL NUTRITION GROUP Category: Medical Services CMS Add: 01/01/2001 CMS Term: 97804 MEDSV DEF RBRVS 09/01/2019 12/31/2023 11.59 Description: MEDICAL NUTRITION GROUP Category: Medical Services CMS Add: 01/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,392 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 97810 NOCOV DEF SYSMAN Description: ACUPUNCT W/O STIMUL 15 MIN Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: 97811 NOCOV DEF SYSMAN Description: ACUPUNCT W/O STIMUL ADDL 15M Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: 97813 NOCOV DEF SYSMAN Description: ACUPUNCT W/STIMUL 15 MIN Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: 97814 NOCOV DEF SYSMAN Description: ACUPUNCT W/STIMUL ADDL 15M Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: 98925 MEDSV DEF RBRVS 01/01/2024 29.51 Y Description: OSTEOPATH MANJ 1-2 REGIONS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 98925 MEDSV DEF RBRVS 02/01/2015 12/31/2023 22.52 Y Description: OSTEOPATH MANJ 1-2 REGIONS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 98926 MEDSV DEF RBRVS 01/01/2024 42.61 Description: OSTEOPATH MANJ 3-4 REGIONS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 98926 MEDSV DEF RBRVS 02/01/2015 12/31/2023 32.70 Description: OSTEOPATH MANJ 3-4 REGIONS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 98927 MEDSV DEF RBRVS 01/01/2024 55.40 Description: OSTEOPATH MANJ 5-6 REGIONS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 98927 MEDSV DEF RBRVS 02/01/2015 12/31/2023 42.80 Description: OSTEOPATH MANJ 5-6 REGIONS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 98928 MEDSV DEF RBRVS 01/01/2024 68.06 Description: OSTEOPATH MANJ 7-8 REGIONS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 98928 MEDSV DEF RBRVS 02/01/2015 12/31/2023 52.82 Description: OSTEOPATH MANJ 7-8 REGIONS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 98929 MEDSV DEF RBRVS 01/01/2024 80.09 Description: OSTEOPATH MANJ 9-10 REGIONS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 98929 MEDSV DEF RBRVS 02/01/2015 12/31/2023 63.26 Description: OSTEOPATH MANJ 9-10 REGIONS Category: Medical Services CMS Add: 01/01/1994 CMS Term: 98940* CHIRO DEF RBRVS 01/01/2019 12/31/2023 20.45 Description: CHIROPRACT MANJ 1-2 REGIONS Category: Chiropractor CMS Add: 01/01/1997 CMS Term: 98940* CHIRO DEF RBRVS 01/01/2024 26.55 Description: CHIROPRACT MANJ 1-2 REGIONS Category: Chiropractor CMS Add: 01/01/1997 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,393 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 98941* CHIRO DEF RBRVS 01/01/2019 12/31/2023 29.98 Description: CHIROPRACT MANJ 3-4 REGIONS Category: Chiropractor CMS Add: 01/01/1997 CMS Term: 98941* CHIRO DEF RBRVS 01/01/2024 38.42 Description: CHIROPRACT MANJ 3-4 REGIONS Category: Chiropractor CMS Add: 01/01/1997 CMS Term: 98942* CHIRO DEF RBRVS 01/01/2019 12/31/2023 38.92 Description: CHIROPRACTIC MANJ 5 REGIONS Category: Chiropractor CMS Add: 01/01/1997 CMS Term: 98942* CHIRO DEF RBRVS 01/01/2024 49.98 Description: CHIROPRACTIC MANJ 5 REGIONS Category: Chiropractor CMS Add: 01/01/1997 CMS Term: 98943* CHIRO DEF RBRVS 01/01/2019 12/31/2023 19.79 Description: CHIROPRACT MANJ XTRSPINL 1/> Category: Chiropractor CMS Add: 01/01/1997 CMS Term: 98943* CHIRO DEF RBRVS 01/01/2024 24.88 Description: CHIROPRACT MANJ XTRSPINL 1/> Category: Chiropractor CMS Add: 01/01/1997 CMS Term: 98960 MEDSV DEF RBRVS 01/01/2017 12/31/2023 19.40 Y 0-4 Description: SELF-MGMT EDUC & TRAIN 1 PT Category: Medical Services CMS Add: 01/01/2006 CMS Term: 98960 MEDSV DEF RBRVS 01/01/2024 26.56 Y 0-4 Description: SELF-MGMT EDUC & TRAIN 1 PT Category: Medical Services CMS Add: 01/01/2006 CMS Term: 98961 MEDSV DEF RBRVS 01/01/2017 12/31/2023 9.33 Y 0-4 Description: SELF-MGMT EDUC/TRAIN 2-4 PT Category: Medical Services CMS Add: 01/01/2006 CMS Term: 98961 MEDSV DEF RBRVS 01/01/2024 12.82 Y 0-4 Description: SELF-MGMT EDUC/TRAIN 2-4 PT Category: Medical Services CMS Add: 01/01/2006 CMS Term: 98962 MEDSV DEF RBRVS 01/01/2017 12/31/2023 6.85 Y 0-4 Description: SELF-MGMT EDUC/TRAIN 5-8 PT Category: Medical Services CMS Add: 01/01/2006 CMS Term: 98962 MEDSV DEF RBRVS 01/01/2024 9.42 Y 0-4 Description: SELF-MGMT EDUC/TRAIN 5-8 PT Category: Medical Services CMS Add: 01/01/2006 CMS Term: 98966* NOCOV DEF SYSMAN Description: HC PRO PHONE CALL 5-10 MIN Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 98967* NOCOV DEF SYSMAN Description: HC PRO PHONE CALL 11-20 MIN Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 98968* NOCOV DEF SYSMAN Description: HC PRO PHONE CALL 21-30 MIN Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 98970 NOCOV DEF SYSMAN Description: QNHP OL DIG ASSMT&MGMT 5-10 Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,394 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 98971 NOCOV DEF SYSMAN Description: QNHP OL DIG ASSMT&MGMT 11-20 Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 98972 NOCOV DEF SYSMAN Description: QNHP OL DIG ASSMT&MGMT 21+ Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 98975 MEDSV DEF RBRVS 01/01/2022 12/31/2023 13.71 Y Description: REM THER MNTR 1ST SETUP&EDU Category: Medical Services CMS Add: 01/01/2022 CMS Term: 98975 MEDSV DEF RBRVS 01/01/2024 17.30 Y Description: REM THER MNTR 1ST SETUP&EDU Category: Medical Services CMS Add: 01/01/2022 CMS Term: 98976 MEDSV DEF RBRVS 01/01/2022 12/31/2023 39.80 Y Description: REM THER MNTR DEV SPLY RESP Category: Medical Services CMS Add: 01/01/2022 CMS Term: 98976 MEDSV DEF RBRVS 01/01/2024 45.54 Y Description: REM THER MNTR DEV SPLY RESP Category: Medical Services CMS Add: 01/01/2022 CMS Term: 98977 MEDSV DEF RBRVS 01/01/2022 12/31/2023 39.80 Y Description: REM THER MNTR DV SPLY MSCSKL Category: Medical Services CMS Add: 01/01/2022 CMS Term: 98977 MEDSV DEF RBRVS 01/01/2024 45.54 Y Description: REM THER MNTR DV SPLY MSCSKL Category: Medical Services CMS Add: 01/01/2022 CMS Term: 98978 NOCOV DEF SYSMAN Description: REM THER MNTR DEV SPLY CBT Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 98980 MEDSV DEF RBRVS 01/01/2022 12/31/2023 36.89 Y Description: REM THER MNTR 1ST 20 MIN Category: Medical Services CMS Add: 01/01/2022 CMS Term: 98980 MEDSV DEF RBRVS 01/01/2024 46.35 Y Description: REM THER MNTR 1ST 20 MIN Category: Medical Services CMS Add: 01/01/2022 CMS Term: 98981 MEDSV DEF RBRVS 01/01/2022 12/31/2023 30.10 Y Description: REM THER MNTR EA ADDL 20 MIN Category: Medical Services CMS Add: 01/01/2022 CMS Term: 98981 MEDSV DEF RBRVS 01/01/2024 37.37 Y Description: REM THER MNTR EA ADDL 20 MIN Category: Medical Services CMS Add: 01/01/2022 CMS Term: 99000 LAB DEF MAXFEE 01/01/1994 12/31/2023 2.97 0.0 0-2 Description: SPECIMEN HANDLING OFFICE-LAB Category: Laboratory CMS Add: 01/01/1984 CMS Term: 99000 LAB DEF MAXFEE 01/01/2024 3.86 0.0 0-2 Description: SPECIMEN HANDLING OFFICE-LAB Category: Laboratory CMS Add: 01/01/1984 CMS Term: 99001 LAB DEF MAXFEE 01/01/1994 12/31/2023 3.00 0.0 0-2 Description: SPECIMEN HANDLING PT-LAB Category: Laboratory CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,395 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 99001 LAB DEF MAXFEE 01/01/2024 3.90 0.0 0-2 Description: SPECIMEN HANDLING PT-LAB Category: Laboratory CMS Add: 01/01/1984 CMS Term: 99002 NOCOV DEF SYSMAN Description: DEVICE HANDLING PHYS/QHP Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: 99024 NOCOV DEF SYSMAN Description: POSTOP FOLLOW-UP VISIT Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 99026 NOCOV DEF SYSMAN Description: IN-HOSPITAL ON CALL SERVICE Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: 99027 NOCOV DEF SYSMAN Description: OUT-OF-HOSP ON CALL SERVICE Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: 99050 NOCOV DEF SYSMAN Description: MEDICAL SERVICES AFTER HRS Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 99051 NOCOV DEF SYSMAN Description: MED SERV EVE/WKEND/HOLIDAY Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 99053 NOCOV DEF SYSMAN Description: MED SERV 10PM-8AM 24 HR FAC Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 99056 NOCOV DEF SYSMAN Description: MED SERVICE OUT OF OFFICE Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 99058 NOCOV DEF SYSMAN Description: OFFICE EMERGENCY CARE Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 99060 NOCOV DEF SYSMAN Description: OUT OF OFFICE EMERG MED SERV Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 99070 NOCOV DEF SYSMAN Description: SPECIAL SUPPLIES PHYS/QHP Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 99071 NOCOV DEF SYSMAN Description: PATIENT EDUCATION MATERIALS Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 99072 NOCOV DEF SYSMAN Description: ADDL SUPL MATRL&STAF TM PHE Category: Non Covered Services CMS Add: 09/08/2020 CMS Term: 99075 NOCOV DEF SYSMAN Description: MEDICAL TESTIMONY Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 99078 NOCOV DEF SYSMAN Description: GROUP HEALTH EDUCATION Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,396 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 99080 MRT DEF MAXFEE 07/01/2002 10.00 0.0 Description: SPECIAL REPORTS OR FORMS Category: Medical Review Team CMS Add: 01/01/1982 CMS Term: 99082 NOCOV DEF SYSMAN Description: UNUSUAL PHYSICIAN TRAVEL Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 99091 MEDSV DEF RBRVS 01/01/2024 51.53 Y Description: COLLJ & INTERPJ DATA EA 30 D Category: Medical Services CMS Add: 01/01/2002 CMS Term: 99091 MEDSV DEF RBRVS 07/21/2022 12/31/2023 41.94 Y Description: COLLJ & INTERPJ DATA EA 30 D Category: Medical Services CMS Add: 01/01/2002 CMS Term: 99100 NOCOV DEF SYSMAN Description: ANES PT EXTEME AGE<1 YR&>70 Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: 99116 NOCOV DEF SYSMAN Description: ANES COMP TOT BDY HYPTHRM Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: 99135 NOCOV DEF SYSMAN Description: ANES COMP CTRLD HYPOTENSION Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: 99140 ANEST PRF MAXFEE 01/01/2024 49.82 0.0 0-1 Description: ANES COMP EMERGENCY COND Category: Anesthesia CMS Add: 01/01/1986 CMS Term: 99151 ANEST DEF RBRVS 01/01/2017 12/31/2023 54.64 0-4years Description: MOD SED SAME PHYS/QHP <5 YRS Category: Anesthesia CMS Add: 01/01/2017 CMS Term: 99151 ANEST DEF RBRVS 01/01/2024 56.49 0-4years Description: MOD SED SAME PHYS/QHP <5 YRS Category: Anesthesia CMS Add: 01/01/2017 CMS Term: 99152 ANEST DEF RBRVS 01/01/2017 12/31/2023 36.28 5-999years Description: MOD SED SAME PHYS/QHP 5/>YRS Category: Anesthesia CMS Add: 01/01/2017 CMS Term: 99152 ANEST DEF RBRVS 01/01/2024 46.47 5-999years Description: MOD SED SAME PHYS/QHP 5/>YRS Category: Anesthesia CMS Add: 01/01/2017 CMS Term: 99153 ANEST DEF RBRVS 01/01/2017 12/31/2023 7.60 Description: MOD SED SAME PHYS/QHP EA Category: Anesthesia CMS Add: 01/01/2017 CMS Term: 99153 ANEST DEF RBRVS 01/01/2024 9.89 Description: MOD SED SAME PHYS/QHP EA Category: Anesthesia CMS Add: 01/01/2017 CMS Term: 99155 ANEST DEF RBRVS 01/01/2017 12/31/2023 67.73 0-4years Description: MOD SED OTH PHYS/QHP <5 YRS Category: Anesthesia CMS Add: 01/01/2017 CMS Term: 99155 ANEST DEF RBRVS 01/01/2024 78.10 0-4years Description: MOD SED OTH PHYS/QHP <5 YRS Category: Anesthesia CMS Add: 01/01/2017 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,397 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 99156 ANEST DEF RBRVS 01/01/2017 12/31/2023 55.48 5-999years Description: MOD SED OTH PHYS/QHP 5/>YRS Category: Anesthesia CMS Add: 01/01/2017 CMS Term: 99156 ANEST DEF RBRVS 01/01/2024 71.47 5-999years Description: MOD SED OTH PHYS/QHP 5/>YRS Category: Anesthesia CMS Add: 01/01/2017 CMS Term: 99157 ANEST DEF RBRVS 01/01/2017 12/31/2023 42.09 Description: MOD SED OTHER PHYS/QHP EA Category: Anesthesia CMS Add: 01/01/2017 CMS Term: 99157 ANEST DEF RBRVS 01/01/2024 58.64 Description: MOD SED OTHER PHYS/QHP EA Category: Anesthesia CMS Add: 01/01/2017 CMS Term: 99170 MEDSV DEF RBRVS 01/01/2024 152.92 0-19years Description: ANOGENITAL EXAM CHILD W IMAG Category: Medical Services CMS Add: 01/01/2000 CMS Term: 99170 MEDSV DEF RBRVS 02/01/2015 12/31/2023 123.40 0-19years Description: ANOGENITAL EXAM CHILD W IMAG Category: Medical Services CMS Add: 01/01/2000 CMS Term: 99172 MEDSV DEF MAXFEE 01/01/2001 12/31/2023 9.98 0.0 0-1 Description: OCULAR FUNCTION SCREEN Category: Medical Services CMS Add: 01/01/2001 CMS Term: 99172 MEDSV DEF MAXFEE 01/01/2024 12.93 0.0 0-1 Description: OCULAR FUNCTION SCREEN Category: Medical Services CMS Add: 01/01/2001 CMS Term: 99173 MEDSV DEF RBRVS 01/01/2024 2.63 0-1 Description: VISUAL ACUITY SCREEN Category: Medical Services CMS Add: 01/01/2000 CMS Term: 99173 MEDSV DEF RBRVS 02/01/2015 12/31/2023 1.90 0-1 Description: VISUAL ACUITY SCREEN Category: Medical Services CMS Add: 01/01/2000 CMS Term: 99174 MEDSV DEF RBRVS 01/01/2024 5.41 Description: OCULAR INSTRUMNT SCREEN BIL Category: Medical Services CMS Add: 01/01/2008 CMS Term: 99174 MEDSV DEF RBRVS 02/01/2015 12/31/2023 5.12 Description: OCULAR INSTRUMNT SCREEN BIL Category: Medical Services CMS Add: 01/01/2008 CMS Term: 99175 MEDSV DEF RBRVS 01/01/2024 27.64 Description: INDUCTION OF VOMITING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 99175 MEDSV DEF RBRVS 02/01/2015 12/31/2023 11.56 Description: INDUCTION OF VOMITING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 99177 MEDSV DEF RBRVS 04/13/2018 4.17 Description: OCULAR INSTRUMNT SCREEN BIL Category: Medical Services CMS Add: 01/01/2016 CMS Term: 99183 MEDSV DEF RBRVS 01/01/2024 99.46 0-1 Description: HYPERBARIC OXYGEN THERAPY Category: Medical Services CMS Add: 01/01/1994 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,398 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 99183 MEDSV DEF RBRVS 02/01/2015 12/31/2023 151.47 0-1 Description: HYPERBARIC OXYGEN THERAPY Category: Medical Services CMS Add: 01/01/1994 CMS Term: 99184 MEDSV DEF RBRVS 01/01/2024 204.55 Description: HYPOTHERMIA ILL NEONATE Category: Medical Services CMS Add: 01/01/2015 CMS Term: 99184 MEDSV DEF RBRVS 02/01/2015 12/31/2023 170.12 Description: HYPOTHERMIA ILL NEONATE Category: Medical Services CMS Add: 01/01/2015 CMS Term: 99188 MEDSV DEF RBRVS 04/13/2018 11.26 0-3years Description: APP TOPICAL FLUORIDE VARNISH Category: Medical Services CMS Add: 01/01/2015 CMS Term: 99190 NOCOV DEF SYSMAN Description: SPECIAL PUMP SERVICES Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: 99191 NOCOV DEF SYSMAN 0-1 Description: SPECIAL PUMP SERVICES Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: 99192 NOCOV DEF SYSMAN 0-1 Description: SPECIAL PUMP SERVICES Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: 99195 MEDSV DEF RBRVS 01/01/2024 88.64 Description: PHLEBOTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 99195 MEDSV DEF RBRVS 02/01/2015 12/31/2023 67.96 Description: PHLEBOTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 99199 MEDSV DEF MAXFEE 01/01/2024 38.18 0.0 Description: UNLISTED SPECIAL SVC PX/RPRT Category: Medical Services CMS Add: 01/01/1986 CMS Term: 99199 MEDSV DEF MAXFEE 02/01/2015 12/31/2023 29.46 0.0 Description: UNLISTED SPECIAL SVC PX/RPRT Category: Medical Services CMS Add: 01/01/1986 CMS Term: 99202 MEDSV DEF RBRVS 01/01/2021 12/31/2023 53.72 Description: OFFICE O/P NEW SF 15 MIN Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99202 MEDSV DEF RBRVS 01/01/2024 68.00 Description: OFFICE O/P NEW SF 15 MIN Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99203 MEDSV DEF RBRVS 01/01/2021 12/31/2023 82.87 Description: OFFICE O/P NEW LOW 30 MIN Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99203 MEDSV DEF RBRVS 01/01/2024 105.12 Description: OFFICE O/P NEW LOW 30 MIN Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99203 MRT DEF RBRVS 01/01/2021 12/31/2023 82.87 Description: OFFICE O/P NEW LOW 30 MIN Category: Medical Review Team CMS Add: 01/01/1992 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,399 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 99203 MRT DEF RBRVS 01/01/2024 105.12 Description: OFFICE O/P NEW LOW 30 MIN Category: Medical Review Team CMS Add: 01/01/1992 CMS Term: 99204 MEDSV DEF RBRVS 01/01/2021 12/31/2023 124.19 Description: OFFICE O/P NEW MOD 45 MIN Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99204 MEDSV DEF RBRVS 01/01/2024 156.95 Description: OFFICE O/P NEW MOD 45 MIN Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99204 MRT DEF RBRVS 01/01/2021 12/31/2023 124.19 Description: OFFICE O/P NEW MOD 45 MIN Category: Medical Review Team CMS Add: 01/01/1992 CMS Term: 99204 MRT DEF RBRVS 01/01/2024 156.95 Description: OFFICE O/P NEW MOD 45 MIN Category: Medical Review Team CMS Add: 01/01/1992 CMS Term: 99205 MEDSV DEF RBRVS 01/01/2021 12/31/2023 164.06 Description: OFFICE O/P NEW HI 60 MIN Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99205 MEDSV DEF RBRVS 01/01/2024 207.26 Description: OFFICE O/P NEW HI 60 MIN Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99205 MRT DEF RBRVS 01/01/2021 12/31/2023 164.06 Description: OFFICE O/P NEW HI 60 MIN Category: Medical Review Team CMS Add: 01/01/1992 CMS Term: 99205 MRT DEF RBRVS 01/01/2024 207.26 Description: OFFICE O/P NEW HI 60 MIN Category: Medical Review Team CMS Add: 01/01/1992 CMS Term: 99211* MEDSV DEF RBRVS 01/01/2021 12/31/2023 16.64 Description: OFF/OP EST MAY X REQ PHY/QHP Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99211* MEDSV DEF RBRVS 01/01/2024 21.70 Description: OFF/OP EST MAY X REQ PHY/QHP Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99212 MEDSV DEF RBRVS 01/01/2021 12/31/2023 41.43 Description: OFFICE O/P EST SF 10 MIN Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99212 MEDSV DEF RBRVS 01/01/2024 53.09 Description: OFFICE O/P EST SF 10 MIN Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99213 MEDSV DEF RBRVS 01/01/2021 12/31/2023 67.54 Description: OFFICE O/P EST LOW 20 MIN Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99213 MEDSV DEF RBRVS 01/01/2024 85.18 Description: OFFICE O/P EST LOW 20 MIN Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99213 MRT DEF RBRVS 01/01/2021 12/31/2023 67.54 Description: OFFICE O/P EST LOW 20 MIN Category: Medical Review Team CMS Add: 01/01/1992 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,400 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 99213 MRT DEF RBRVS 01/01/2024 85.18 Description: OFFICE O/P EST LOW 20 MIN Category: Medical Review Team CMS Add: 01/01/1992 CMS Term: 99214 MEDSV DEF RBRVS 01/01/2021 12/31/2023 96.01 Description: OFFICE O/P EST MOD 30 MIN Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99214 MEDSV DEF RBRVS 01/01/2024 120.72 Description: OFFICE O/P EST MOD 30 MIN Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99214 MRT DEF RBRVS 01/01/2021 12/31/2023 96.01 Description: OFFICE O/P EST MOD 30 MIN Category: Medical Review Team CMS Add: 01/01/1992 CMS Term: 99214 MRT DEF RBRVS 01/01/2024 120.72 Description: OFFICE O/P EST MOD 30 MIN Category: Medical Review Team CMS Add: 01/01/1992 CMS Term: 99215 MEDSV DEF RBRVS 01/01/2021 12/31/2023 134.19 Description: OFFICE O/P EST HI 40 MIN Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99215 MEDSV DEF RBRVS 01/01/2024 169.42 Description: OFFICE O/P EST HI 40 MIN Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99215 MRT DEF RBRVS 01/01/2021 12/31/2023 134.19 Description: OFFICE O/P EST HI 40 MIN Category: Medical Review Team CMS Add: 01/01/1992 CMS Term: 99215 MRT DEF RBRVS 01/01/2024 169.42 Description: OFFICE O/P EST HI 40 MIN Category: Medical Review Team CMS Add: 01/01/1992 CMS Term: 99221 MEDSV DEF RBRVS 01/01/2024 78.20 Description: 1ST HOSP IP/OBS SF/LOW 40 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99221 MEDSV DEF RBRVS 02/01/2015 12/31/2023 73.22 Description: 1ST HOSP IP/OBS SF/LOW 40 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99222 MEDSV DEF RBRVS 01/01/2024 123.45 Description: 1ST HOSP IP/OBS MODERATE 55 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99222 MEDSV DEF RBRVS 02/01/2015 12/31/2023 99.60 Description: 1ST HOSP IP/OBS MODERATE 55 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99223 MEDSV DEF RBRVS 01/01/2024 165.08 Description: 1ST HOSP IP/OBS HIGH 75 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99223 MEDSV DEF RBRVS 02/01/2015 12/31/2023 146.98 Description: 1ST HOSP IP/OBS HIGH 75 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99231 MEDSV DEF RBRVS 01/01/2024 46.92 Description: SBSQ HOSP IP/OBS SF/LOW 25 Category: Medical Services CMS Add: 01/01/1992 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,401 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 99231 MEDSV DEF RBRVS 02/01/2015 12/31/2023 28.43 Description: SBSQ HOSP IP/OBS SF/LOW 25 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99232 MEDSV DEF RBRVS 01/01/2024 75.26 Description: SBSQ HOSP IP/OBS MODERATE 35 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99232 MEDSV DEF RBRVS 02/01/2015 12/31/2023 52.29 Description: SBSQ HOSP IP/OBS MODERATE 35 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99233 MEDSV DEF RBRVS 01/01/2024 113.25 Description: SBSQ HOSP IP/OBS HIGH 50 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99233 MEDSV DEF RBRVS 02/01/2015 12/31/2023 75.37 Description: SBSQ HOSP IP/OBS HIGH 50 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99234 MEDSV DEF RBRVS 01/01/2024 93.52 Description: HOSP IP/OBS SM DT SF/LOW 45 Category: Medical Services CMS Add: 01/01/1998 CMS Term: 99234 MEDSV DEF RBRVS 02/01/2015 12/31/2023 97.52 Description: HOSP IP/OBS SM DT SF/LOW 45 Category: Medical Services CMS Add: 01/01/1998 CMS Term: 99235 MEDSV DEF RBRVS 01/01/2024 151.78 Description: HOSP IP/OBS SAME DATE MOD 70 Category: Medical Services CMS Add: 01/01/1998 CMS Term: 99235 MEDSV DEF RBRVS 02/01/2015 12/31/2023 122.47 Description: HOSP IP/OBS SAME DATE MOD 70 Category: Medical Services CMS Add: 01/01/1998 CMS Term: 99236 MEDSV DEF RBRVS 01/01/2024 199.01 Description: HOSP IP/OBS SAME DATE HI 85 Category: Medical Services CMS Add: 01/01/1998 CMS Term: 99236 MEDSV DEF RBRVS 02/01/2015 12/31/2023 158.09 Description: HOSP IP/OBS SAME DATE HI 85 Category: Medical Services CMS Add: 01/01/1998 CMS Term: 99238 MEDSV DEF RBRVS 01/01/2024 76.68 Description: HOSP IP/OBS DSCHRG MGMT 30/< Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99238 MEDSV DEF RBRVS 02/01/2015 12/31/2023 52.39 Description: HOSP IP/OBS DSCHRG MGMT 30/< Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99239 MEDSV DEF RBRVS 01/01/2024 108.63 Description: HOSP IP/OBS DSCHRG MGMT >30 Category: Medical Services CMS Add: 01/01/1996 CMS Term: 99239 MEDSV DEF RBRVS 02/01/2015 12/31/2023 77.39 Description: HOSP IP/OBS DSCHRG MGMT >30 Category: Medical Services CMS Add: 01/01/1996 CMS Term: 99242 NOCOV DEF SYSMAN Description: OFF/OP CONSLTJ NEW/EST SF 20 Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,402 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 99243 NOCOV DEF SYSMAN Description: OFF/OP CNSLTJ NEW/EST LOW 30 Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: 99244 NOCOV DEF SYSMAN Description: OFF/OP CNSLTJ NEW/EST MOD 40 Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: 99245 NOCOV DEF SYSMAN Description: OFF/OP CONSLTJ NEW/EST HI 55 Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: 99252 NOCOV DEF SYSMAN Description: IP/OBS CONSLTJ NEW/EST SF 35 Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: 99253 NOCOV DEF SYSMAN Description: IP/OBS CNSLTJ NEW/EST LOW 45 Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: 99254 NOCOV DEF SYSMAN Description: IP/OBS CNSLTJ NEW/EST MOD 60 Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: 99255 NOCOV DEF SYSMAN Description: IP/OBS CONSLTJ NEW/EST HI 80 Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: 99281 MEDSV DEF RBRVS 01/01/2024 10.97 Description: EMR DPT VST MAYX REQ PHY/QHP Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99281 MEDSV DEF RBRVS 02/01/2015 12/31/2023 15.31 Description: EMR DPT VST MAYX REQ PHY/QHP Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99282 MEDSV DEF RBRVS 01/01/2024 39.61 Description: EMERGENCY DEPT VISIT SF MDM Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99282 MEDSV DEF RBRVS 02/01/2015 12/31/2023 30.00 Description: EMERGENCY DEPT VISIT SF MDM Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99283 MEDSV DEF RBRVS 01/01/2024 67.92 Description: EMERGENCY DEPT VISIT LOW MDM Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99283 MEDSV DEF RBRVS 02/01/2015 12/31/2023 44.84 Description: EMERGENCY DEPT VISIT LOW MDM Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99284 MEDSV DEF RBRVS 01/01/2024 114.79 Description: EMERGENCY DEPT VISIT MOD MDM Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99284 MEDSV DEF RBRVS 02/01/2015 12/31/2023 85.38 Description: EMERGENCY DEPT VISIT MOD MDM Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99285 MEDSV DEF RBRVS 01/01/2024 166.70 Description: EMERGENCY DEPT VISIT HI MDM Category: Medical Services CMS Add: 01/01/1992 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,403 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 99285 MEDSV DEF RBRVS 02/01/2015 12/31/2023 125.71 Description: EMERGENCY DEPT VISIT HI MDM Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99288 NOCOV DEF SYSMAN Description: DIRECT ADVANCED LIFE SUPPORT Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: 99291 MEDSV DEF RBRVS 01/01/2024 258.35 0-1 Description: CRITICAL CARE FIRST HOUR Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99291 MEDSV DEF RBRVS 02/01/2015 12/31/2023 196.71 0-1 Description: CRITICAL CARE FIRST HOUR Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99292 MEDSV DEF RBRVS 01/01/2024 113.13 Description: CRITICAL CARE ADDL 30 MIN Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99292 MEDSV DEF RBRVS 02/01/2015 12/31/2023 88.53 Description: CRITICAL CARE ADDL 30 MIN Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99304 MEDSV DEF RBRVS 01/01/2024 76.37 Description: 1ST NF CARE SF/LOW MDM 25 Category: Medical Services CMS Add: 01/01/2006 CMS Term: 99304 MEDSV DEF RBRVS 02/01/2015 12/31/2023 67.02 Description: 1ST NF CARE SF/LOW MDM 25 Category: Medical Services CMS Add: 01/01/2006 CMS Term: 99305 MEDSV DEF RBRVS 01/01/2024 126.51 Description: 1ST NF CARE MODERATE MDM 35 Category: Medical Services CMS Add: 01/01/2006 CMS Term: 99305 MEDSV DEF RBRVS 02/01/2015 12/31/2023 95.51 Description: 1ST NF CARE MODERATE MDM 35 Category: Medical Services CMS Add: 01/01/2006 CMS Term: 99306 MEDSV DEF RBRVS 01/01/2024 173.39 Description: 1ST NF CARE HIGH MDM 50 Category: Medical Services CMS Add: 01/01/2006 CMS Term: 99306 MEDSV DEF RBRVS 02/01/2015 12/31/2023 121.27 Description: 1ST NF CARE HIGH MDM 50 Category: Medical Services CMS Add: 01/01/2006 CMS Term: 99307 MEDSV DEF RBRVS 01/01/2024 37.64 Description: SBSQ NF CARE SF MDM 10 Category: Medical Services CMS Add: 01/01/2006 CMS Term: 99307 MEDSV DEF RBRVS 02/01/2015 12/31/2023 32.23 Description: SBSQ NF CARE SF MDM 10 Category: Medical Services CMS Add: 01/01/2006 CMS Term: 99308 MEDSV DEF RBRVS 01/01/2024 70.36 Description: SBSQ NF CARE LOW MDM 20 Category: Medical Services CMS Add: 01/01/2006 CMS Term: 99308 MEDSV DEF RBRVS 02/01/2015 12/31/2023 49.66 Description: SBSQ NF CARE LOW MDM 20 Category: Medical Services CMS Add: 01/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,404 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 99309 MEDSV DEF RBRVS 01/01/2024 101.26 Description: SBSQ NF CARE MODERATE MDM 30 Category: Medical Services CMS Add: 01/01/2006 CMS Term: 99309 MEDSV DEF RBRVS 02/01/2015 12/31/2023 65.51 Description: SBSQ NF CARE MODERATE MDM 30 Category: Medical Services CMS Add: 01/01/2006 CMS Term: 99310 MEDSV DEF RBRVS 01/01/2024 145.48 Description: SBSQ NF CARE HIGH MDM 45 Category: Medical Services CMS Add: 01/01/2006 CMS Term: 99310 MEDSV DEF RBRVS 02/01/2015 12/31/2023 97.49 Description: SBSQ NF CARE HIGH MDM 45 Category: Medical Services CMS Add: 01/01/2006 CMS Term: 99315 MEDSV DEF RBRVS 01/01/2024 77.45 Description: NF DSCHRG MGMT 30 MIN/LESS Category: Medical Services CMS Add: 01/01/1998 CMS Term: 99315 MEDSV DEF RBRVS 02/01/2015 12/31/2023 52.80 Description: NF DSCHRG MGMT 30 MIN/LESS Category: Medical Services CMS Add: 01/01/1998 CMS Term: 99316 MEDSV DEF RBRVS 01/01/2024 124.66 Description: NF DSCHRG MGMT 30 MIN+ Category: Medical Services CMS Add: 01/01/1998 CMS Term: 99316 MEDSV DEF RBRVS 02/01/2015 12/31/2023 75.98 Description: NF DSCHRG MGMT 30 MIN+ Category: Medical Services CMS Add: 01/01/1998 CMS Term: 99341 MEDSV DEF RBRVS 01/01/2024 46.88 Description: HOME/RES VST NEW SF MDM 15 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99341 MEDSV DEF RBRVS 02/01/2015 12/31/2023 39.93 Description: HOME/RES VST NEW SF MDM 15 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99342 MEDSV DEF RBRVS 01/01/2024 74.80 Description: HOME/RES VST NEW LOW MDM 30 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99342 MEDSV DEF RBRVS 02/01/2015 12/31/2023 57.77 Description: HOME/RES VST NEW LOW MDM 30 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99344 MEDSV DEF RBRVS 01/01/2024 137.20 Description: HOME/RES VST NEW MOD MDM 60 Category: Medical Services CMS Add: 01/01/1998 CMS Term: 99344 MEDSV DEF RBRVS 02/01/2015 12/31/2023 131.93 Description: HOME/RES VST NEW MOD MDM 60 Category: Medical Services CMS Add: 01/01/1998 CMS Term: 99345 MEDSV DEF RBRVS 01/01/2024 192.62 Description: HOME/RES VST NEW HIGH MDM 75 Category: Medical Services CMS Add: 01/01/1998 CMS Term: 99345 MEDSV DEF RBRVS 02/01/2015 12/31/2023 159.10 Description: HOME/RES VST NEW HIGH MDM 75 Category: Medical Services CMS Add: 01/01/1998 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,405 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 99347 MEDSV DEF RBRVS 01/01/2024 42.87 Description: HOME/RES VST EST SF MDM 20 Category: Medical Services CMS Add: 01/01/1998 CMS Term: 99347 MEDSV DEF RBRVS 02/01/2015 12/31/2023 40.16 Description: HOME/RES VST EST SF MDM 20 Category: Medical Services CMS Add: 01/01/1998 CMS Term: 99348 MEDSV DEF RBRVS 01/01/2024 72.80 Description: HOME/RES VST EST LOW MDM 30 Category: Medical Services CMS Add: 01/01/1998 CMS Term: 99348 MEDSV DEF RBRVS 02/01/2015 12/31/2023 60.91 Description: HOME/RES VST EST LOW MDM 30 Category: Medical Services CMS Add: 01/01/1998 CMS Term: 99349 MEDSV DEF RBRVS 01/01/2024 121.23 Description: HOME/RES VST EST MOD MDM 40 Category: Medical Services CMS Add: 01/01/1998 CMS Term: 99349 MEDSV DEF RBRVS 02/01/2015 12/31/2023 92.24 Description: HOME/RES VST EST MOD MDM 40 Category: Medical Services CMS Add: 01/01/1998 CMS Term: 99350 MEDSV DEF RBRVS 01/01/2024 176.96 Description: HOME/RES VST EST HIGH MDM 60 Category: Medical Services CMS Add: 01/01/1998 CMS Term: 99350 MEDSV DEF RBRVS 02/01/2015 12/31/2023 128.50 Description: HOME/RES VST EST HIGH MDM 60 Category: Medical Services CMS Add: 01/01/1998 CMS Term: 99358 NOCOV DEF SYSMAN 0-1 Description: PROLONG SERVICE W/O CONTACT Category: Non Covered Services CMS Add: 01/01/1994 CMS Term: 99359 NOCOV DEF SYSMAN Description: PROLONG SERV W/O CONTACT ADD Category: Non Covered Services CMS Add: 01/01/1994 CMS Term: 99360 NOCOV DEF SYSMAN Description: PHYSICIAN STANDBY SERVICES Category: Non Covered Services CMS Add: 01/01/1994 CMS Term: 99366 NOCOV DEF SYSMAN Description: TEAM CONF W/PAT BY HC PROF Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 99367 NOCOV DEF SYSMAN Description: TEAM CONF W/O PAT BY PHYS Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 99368 NOCOV DEF SYSMAN Description: TEAM CONF W/O PAT BY HC PRO Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 99374 NOCOV DEF SYSMAN Description: HOME HEALTH CARE SUPERVISION Category: Non Covered Services CMS Add: 01/01/1998 CMS Term: 99375 NOCOV DEF SYSMAN Description: HOME HEALTH CARE SUPERVISION Category: Non Covered Services CMS Add: 01/01/1994 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,406 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 99377 NOCOV DEF SYSMAN Description: HOSPICE CARE SUPERVISION Category: Non Covered Services CMS Add: 01/01/1998 CMS Term: 99378 NOCOV DEF SYSMAN Description: HOSPICE CARE SUPERVISION Category: Non Covered Services CMS Add: 01/01/1998 CMS Term: 99379 NOCOV DEF SYSMAN Description: NURSING FAC CARE SUPERVISION Category: Non Covered Services CMS Add: 01/01/1998 CMS Term: 99380 NOCOV DEF SYSMAN Description: NURSING FAC CARE SUPERVISION Category: Non Covered Services CMS Add: 01/01/1998 CMS Term: 99381 MEDSV DEF MAXFEE 01/01/2024 102.76 0.0 0-364days 0-1 Description: INIT PM E/M NEW PAT INFANT Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99381 MEDSV DEF MAXFEE 02/01/2015 12/31/2023 79.11 0.0 0-364days 0-1 Description: INIT PM E/M NEW PAT INFANT Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99381 MEDSV E01 MAXFEE 01/01/2024 102.76 0.0 0-364days 0-1 Description: INIT PM E/M NEW PAT INFANT Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99381 MEDSV E01 MAXFEE 12/01/2014 12/31/2023 100.00 0.0 0-364days 0-1 Description: INIT PM E/M NEW PAT INFANT Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99382 MEDSV DEF MAXFEE 01/01/2024 107.38 0.0 1-4years Description: INIT PM E/M NEW PAT 1-4 YRS Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99382 MEDSV DEF MAXFEE 02/01/2015 12/31/2023 82.62 0.0 1-4years Description: INIT PM E/M NEW PAT 1-4 YRS Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99382 MEDSV E01 MAXFEE 01/01/2024 107.38 0.0 1-4years Description: INIT PM E/M NEW PAT 1-4 YRS Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99382 MEDSV E01 MAXFEE 12/01/2014 12/31/2023 100.00 0.0 1-4years Description: INIT PM E/M NEW PAT 1-4 YRS Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99383 MEDSV DEF MAXFEE 01/01/2024 111.70 0.0 5-11years 0-1 Description: PREV VISIT NEW AGE 5-11 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99383 MEDSV DEF MAXFEE 02/01/2015 12/31/2023 86.22 0.0 5-11years 0-1 Description: PREV VISIT NEW AGE 5-11 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99383 MEDSV E01 MAXFEE 01/01/2024 111.70 0.0 5-11years 0-1 Description: PREV VISIT NEW AGE 5-11 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99383 MEDSV E01 MAXFEE 12/01/2014 12/31/2023 100.00 0.0 5-11years 0-1 Description: PREV VISIT NEW AGE 5-11 Category: Medical Services CMS Add: 01/01/1992 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,407 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 99384 MEDSV DEF MAXFEE 01/01/2024 125.89 0.0 12-17years 0-1 Description: PREV VISIT NEW AGE 12-17 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99384 MEDSV DEF MAXFEE 02/01/2015 12/31/2023 97.58 0.0 12-17years 0-1 Description: PREV VISIT NEW AGE 12-17 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99384 MEDSV E01 MAXFEE 01/01/2024 125.89 0.0 12-17years 0-1 Description: PREV VISIT NEW AGE 12-17 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99384 MEDSV E01 MAXFEE 12/01/2014 12/31/2023 100.00 0.0 12-17years 0-1 Description: PREV VISIT NEW AGE 12-17 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99385 MEDSV DEF MAXFEE 01/01/2024 122.25 0.0 18-39years 0-1 Description: PREV VISIT NEW AGE 18-39 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99385 MEDSV DEF MAXFEE 02/01/2015 12/31/2023 94.69 0.0 18-39years 0-1 Description: PREV VISIT NEW AGE 18-39 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99385 MEDSV E01 MAXFEE 01/01/2024 122.25 0.0 18-39years 0-1 Description: PREV VISIT NEW AGE 18-39 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99385 MEDSV E01 MAXFEE 12/01/2014 12/31/2023 100.00 0.0 18-39years 0-1 Description: PREV VISIT NEW AGE 18-39 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99386 MEDSV DEF RBRVS 01/01/2024 141.10 40-64years Description: PREV VISIT NEW AGE 40-64 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99386 MEDSV DEF RBRVS 02/01/2015 12/31/2023 109.50 40-64years Description: PREV VISIT NEW AGE 40-64 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99387 MEDSV DEF RBRVS 01/01/2024 153.21 65-999years Description: INIT PM E/M NEW PAT 65+ YRS Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99387 MEDSV DEF RBRVS 02/01/2015 12/31/2023 118.86 65-999years Description: INIT PM E/M NEW PAT 65+ YRS Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99391 MEDSV DEF MAXFEE 01/01/2024 92.48 0.0 0-364days 0-1 Description: PER PM REEVAL EST PAT INFANT Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99391 MEDSV DEF MAXFEE 02/01/2015 12/31/2023 71.24 0.0 0-364days 0-1 Description: PER PM REEVAL EST PAT INFANT Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99391 MEDSV E01 MAXFEE 01/01/2024 92.48 0.0 0-364days 0-1 Description: PER PM REEVAL EST PAT INFANT Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99391 MEDSV E01 MAXFEE 12/01/2014 12/31/2023 87.00 0.0 0-364days 0-1 Description: PER PM REEVAL EST PAT INFANT Category: Medical Services CMS Add: 01/01/1992 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,408 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 99392 MEDSV DEF MAXFEE 01/01/2024 98.75 0.0 1-4years 0-1 Description: PREV VISIT EST AGE 1-4 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99392 MEDSV DEF MAXFEE 02/01/2015 12/31/2023 76.14 0.0 1-4years 0-1 Description: PREV VISIT EST AGE 1-4 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99392 MEDSV E01 MAXFEE 01/01/2024 98.75 0.0 1-4years 0-1 Description: PREV VISIT EST AGE 1-4 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99392 MEDSV E01 MAXFEE 12/01/2014 12/31/2023 87.00 0.0 1-4years 0-1 Description: PREV VISIT EST AGE 1-4 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99393 MEDSV DEF MAXFEE 01/01/2024 98.44 0.0 5-11years 0-1 Description: PREV VISIT EST AGE 5-11 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99393 MEDSV DEF MAXFEE 02/01/2015 12/31/2023 75.89 0.0 5-11years 0-1 Description: PREV VISIT EST AGE 5-11 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99393 MEDSV E01 MAXFEE 01/01/2024 98.44 0.0 5-11years 0-1 Description: PREV VISIT EST AGE 5-11 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99393 MEDSV E01 MAXFEE 12/01/2014 12/31/2023 87.00 0.0 5-11years 0-1 Description: PREV VISIT EST AGE 5-11 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99394 MEDSV DEF MAXFEE 01/01/2024 107.69 0.0 12-17years 0-1 Description: PREV VISIT EST AGE 12-17 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99394 MEDSV DEF MAXFEE 02/01/2015 12/31/2023 83.25 0.0 12-17years 0-1 Description: PREV VISIT EST AGE 12-17 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99394 MEDSV E01 MAXFEE 01/01/2024 107.69 0.0 12-17years 0-1 Description: PREV VISIT EST AGE 12-17 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99394 MEDSV E01 MAXFEE 12/01/2014 12/31/2023 87.00 0.0 12-17years 0-1 Description: PREV VISIT EST AGE 12-17 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99395 MEDSV DEF MAXFEE 01/01/2024 110.16 0.0 18-39years 0-1 Description: PREV VISIT EST AGE 18-39 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99395 MEDSV DEF MAXFEE 02/01/2015 12/31/2023 85.08 0.0 18-39years 0-1 Description: PREV VISIT EST AGE 18-39 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99395 MEDSV E01 MAXFEE 01/01/2024 110.16 0.0 18-39years 0-1 Description: PREV VISIT EST AGE 18-39 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99395 MEDSV E01 MAXFEE 12/01/2014 12/31/2023 87.00 0.0 18-39years 0-1 Description: PREV VISIT EST AGE 18-39 Category: Medical Services CMS Add: 01/01/1992 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,409 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 99396 MEDSV DEF RBRVS 01/01/2024 117.09 40-64years Description: PREV VISIT EST AGE 40-64 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99396 MEDSV DEF RBRVS 02/01/2015 12/31/2023 90.77 40-64years Description: PREV VISIT EST AGE 40-64 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99397 MEDSV DEF RBRVS 01/01/2024 126.20 65-999years Description: PER PM REEVAL EST PAT 65+ YR Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99397 MEDSV DEF RBRVS 02/01/2015 12/31/2023 97.58 65-999years Description: PER PM REEVAL EST PAT 65+ YR Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99401* 25 MEDSV DEF MAXFEE 01/01/2024 37.48 0.0 0-1 Description: PREV MED CNSL INDIV APPRX 15 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99401* HK MEDSV DEF MAXFEE 01/01/2024 25.92 0.0 0-1 Description: PREV MED CNSL INDIV APPRX 15 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99401* HK MEDSV DEF MAXFEE 12/01/2011 12/31/2023 20.00 0.0 0-1 Description: PREV MED CNSL INDIV APPRX 15 Category: Medical Services CMS Add: 01/01/1992 CMS Term: 99402 NOCOV DEF SYSMAN Description: PREV MED CNSL INDIV APPRX 30 Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: 99403 NOCOV DEF SYSMAN Description: PREV MED CNSL INDIV APPRX 45 Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: 99404 NOCOV DEF SYSMAN Description: PREV MED CNSL INDIV APPRX 60 Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: 99406 MEDSV DEF RBRVS 01/01/2024 14.01 Description: BEHAV CHNG SMOKING 3-10 MIN Category: Medical Services CMS Add: 01/01/2008 CMS Term: 99406 MEDSV DEF RBRVS 07/01/2021 12/31/2023 11.49 Description: BEHAV CHNG SMOKING 3-10 MIN Category: Medical Services CMS Add: 01/01/2008 CMS Term: 99407 MEDSV DEF RBRVS 01/01/2024 26.23 Description: BEHAV CHNG SMOKING > 10 MIN Category: Medical Services CMS Add: 01/01/2008 CMS Term: 99407 MEDSV DEF RBRVS 07/01/2021 12/31/2023 22.70 Description: BEHAV CHNG SMOKING > 10 MIN Category: Medical Services CMS Add: 01/01/2008 CMS Term: 99408 MEDSV DEF RBRVS 01/01/2024 33.17 Description: AUDIT/DAST 15-30 MIN Category: Medical Services CMS Add: 01/01/2008 CMS Term: 99408 MEDSV DEF RBRVS 02/01/2015 12/31/2023 27.26 Description: AUDIT/DAST 15-30 MIN Category: Medical Services CMS Add: 01/01/2008 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,410 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 99409 MEDSV DEF RBRVS 01/01/2024 63.56 Description: AUDIT/DAST OVER 30 MIN Category: Medical Services CMS Add: 01/01/2008 CMS Term: 99409 MEDSV DEF RBRVS 02/01/2015 12/31/2023 53.20 Description: AUDIT/DAST OVER 30 MIN Category: Medical Services CMS Add: 01/01/2008 CMS Term: 99411 NOCOV DEF SYSMAN Description: PREVENTIVE COUNSELING GROUP Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: 99412 NOCOV DEF SYSMAN Description: PREVENTIVE COUNSELING GROUP Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: 99415 NOCOV DEF SYSMAN Description: PROLNG CLIN STAFF SVC 1ST HR Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 99416 NOCOV DEF SYSMAN Description: PROLNG CLIN STAFF SVC EA ADD Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 99417 MEDSV DEF MAXFEE 01/01/2021 12/31/2023 24.89 0.0 Description: PROLNG OP E/M EACH 15 MIN Category: Medical Services CMS Add: 01/01/2021 CMS Term: 99417 MEDSV DEF MAXFEE 01/01/2024 29.65 0.0 Description: PROLNG OP E/M EACH 15 MIN Category: Medical Services CMS Add: 01/01/2021 CMS Term: 99418 MEDSV DEF RBRVS 01/01/2023 37.66 Description: PROLNG IP/OBS E/M EA 15 MIN Category: Medical Services CMS Add: 01/01/2023 CMS Term: 99421 NOCOV DEF SYSMAN Description: OL DIG E/M SVC 5-10 MIN Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 99422 NOCOV DEF SYSMAN Description: OL DIG E/M SVC 11-20 MIN Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 99423 NOCOV DEF SYSMAN Description: OL DIG E/M SVC 21+ MIN Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 99424 NOCOV DEF SYSMAN Description: PRIN CARE MGMT PHYS 1ST 30 Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 99425 NOCOV DEF SYSMAN Description: PRIN CARE MGMT PHYS EA ADDL Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 99426 NOCOV DEF SYSMAN Description: PRIN CARE MGMT STAFF 1ST 30 Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 99427 NOCOV DEF SYSMAN Description: PRIN CARE MGMT STAFF EA ADDL Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,411 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 99429 NOCOV DEF SYSMAN Description: UNLISTED PREVENTIVE SERVICE Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: 99437 NOCOV DEF SYSMAN Description: CHRNC CARE MGMT PHYS EA ADDL Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 99439 NOCOV DEF SYSMAN Description: CHRNC CARE MGMT STAF EA ADDL Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 99441* NOCOV DEF SYSMAN Description: PHONE E/M PHYS/QHP 5-10 MIN Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 99442* NOCOV DEF SYSMAN Description: PHONE E/M PHYS/QHP 11-20 MIN Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 99443* NOCOV DEF SYSMAN Description: PHONE E/M PHYS/QHP 21-30 MIN Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 99446 NOCOV DEF SYSMAN Description: NTRPROF PH1/NTRNET/EHR 5-10 Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: 99447 NOCOV DEF SYSMAN Description: NTRPROF PH1/NTRNET/EHR 11-20 Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: 99448 NOCOV DEF SYSMAN Description: NTRPROF PH1/NTRNET/EHR 21-30 Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: 99449 NOCOV DEF SYSMAN Description: NTRPROF PH1/NTRNET/EHR 31/> Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: 99450 MRT DEF MAXFEE 07/01/2002 65.00 0.0 Description: BASIC LIFE DISABILITY EXAM Category: Medical Review Team CMS Add: 01/01/1995 CMS Term: 99451 NOCOV DEF SYSMAN Description: NTRPROF PH1/NTRNET/EHR 5/> Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 99452 NOCOV DEF SYSMAN Description: NTRPROF PH1/NTRNET/EHR RFRL Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 99453 MEDSV DEF RBRVS 01/01/2024 17.30 Y Description: REM MNTR PHYSIOL PARAM SETUP Category: Medical Services CMS Add: 01/01/2019 CMS Term: 99453 MEDSV DEF RBRVS 07/21/2022 12/31/2023 13.54 Y Description: REM MNTR PHYSIOL PARAM SETUP Category: Medical Services CMS Add: 01/01/2019 CMS Term: 99454 MEDSV DEF RBRVS 01/01/2024 45.54 Y Description: REM MNTR PHYSIOL PARAM DEV Category: Medical Services CMS Add: 01/01/2019 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,412 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 99454 MEDSV DEF RBRVS 07/21/2022 12/31/2023 39.80 Y Description: REM MNTR PHYSIOL PARAM DEV Category: Medical Services CMS Add: 01/01/2019 CMS Term: 99455 NOCOV DEF SYSMAN Description: WORK RELATED DISABILITY EXAM Category: Non Covered Services CMS Add: 01/01/1995 CMS Term: 99456 NOCOV DEF SYSMAN Description: DISABILITY EXAMINATION Category: Non Covered Services CMS Add: 01/01/1995 CMS Term: 99457 MEDSV DEF RBRVS 01/01/2024 45.70 Y Description: REM PHYSIOL MNTR 1ST 20 MIN Category: Medical Services CMS Add: 01/01/2019 CMS Term: 99457 MEDSV DEF RBRVS 07/21/2022 12/31/2023 36.87 Y Description: REM PHYSIOL MNTR 1ST 20 MIN Category: Medical Services CMS Add: 01/01/2019 CMS Term: 99458 MEDSV DEF RBRVS 01/01/2024 37.37 Y Description: REM PHYSIOL MNTR EA ADDL 20 Category: Medical Services CMS Add: 01/01/2020 CMS Term: 99458 MEDSV DEF RBRVS 07/21/2022 12/31/2023 30.18 Y Description: REM PHYSIOL MNTR EA ADDL 20 Category: Medical Services CMS Add: 01/01/2020 CMS Term: 99459 MEDSV DEF RBRVS 01/01/2024 20.99 Description: PELVIC EXAMINATION Category: Medical Services CMS Add: 01/01/2024 CMS Term: 99460 MEDSV DEF RBRVS 01/01/2024 88.60 0-28days Description: INIT NB EM PER DAY HOSP Category: Medical Services CMS Add: 01/01/2009 CMS Term: 99460 MEDSV DEF RBRVS 02/01/2015 12/31/2023 69.01 0-28days Description: INIT NB EM PER DAY HOSP Category: Medical Services CMS Add: 01/01/2009 CMS Term: 99461 MEDSV DEF RBRVS 01/01/2024 86.29 0-28days Description: INIT NB EM PER DAY NON-FAC Category: Medical Services CMS Add: 01/01/2009 CMS Term: 99461 MEDSV DEF RBRVS 02/01/2015 12/31/2023 70.10 0-28days Description: INIT NB EM PER DAY NON-FAC Category: Medical Services CMS Add: 01/01/2009 CMS Term: 99462 MEDSV DEF RBRVS 01/01/2024 39.00 0-28days Description: SBSQ NB EM PER DAY HOSP Category: Medical Services CMS Add: 01/01/2009 CMS Term: 99462 MEDSV DEF RBRVS 02/01/2015 12/31/2023 30.58 0-28days Description: SBSQ NB EM PER DAY HOSP Category: Medical Services CMS Add: 01/01/2009 CMS Term: 99463 MEDSV DEF RBRVS 01/01/2024 103.32 0-28days Description: SAME DAY NB DISCHARGE Category: Medical Services CMS Add: 01/01/2009 CMS Term: 99463 MEDSV DEF RBRVS 02/01/2015 12/31/2023 83.07 0-28days Description: SAME DAY NB DISCHARGE Category: Medical Services CMS Add: 01/01/2009 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,413 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 99464 MEDSV DEF RBRVS 01/01/2024 69.42 0-28days Description: ATTENDANCE AT DELIVERY Category: Medical Services CMS Add: 01/01/2009 CMS Term: 99464 MEDSV DEF RBRVS 02/01/2015 12/31/2023 51.86 0-28days Description: ATTENDANCE AT DELIVERY Category: Medical Services CMS Add: 01/01/2009 CMS Term: 99465 MEDSV DEF RBRVS 01/01/2024 135.07 Description: NB RESUSCITATION Category: Medical Services CMS Add: 01/01/2009 CMS Term: 99465 MEDSV DEF RBRVS 02/01/2015 12/31/2023 106.96 Description: NB RESUSCITATION Category: Medical Services CMS Add: 01/01/2009 CMS Term: 99466 MEDSV DEF RBRVS 01/01/2024 221.03 0-24months 0-1 Description: PED CRIT CARE TRANSPORT Category: Medical Services CMS Add: 01/01/2009 CMS Term: 99466 MEDSV DEF RBRVS 02/01/2015 12/31/2023 184.77 0-24months 0-1 Description: PED CRIT CARE TRANSPORT Category: Medical Services CMS Add: 01/01/2009 CMS Term: 99467 MEDSV DEF RBRVS 01/01/2024 111.39 0-24months 0-1 Description: PED CRIT CARE TRANSPORT ADDL Category: Medical Services CMS Add: 01/01/2009 CMS Term: 99467 MEDSV DEF RBRVS 02/01/2015 12/31/2023 89.42 0-24months 0-1 Description: PED CRIT CARE TRANSPORT ADDL Category: Medical Services CMS Add: 01/01/2009 CMS Term: 99468 MEDSV DEF RBRVS 01/01/2024 852.66 0-28days 0-1 Description: NEONATE CRIT CARE INITIAL Category: Medical Services CMS Add: 01/01/2009 CMS Term: 99468 MEDSV DEF RBRVS 02/01/2015 12/31/2023 674.75 0-28days 0-1 Description: NEONATE CRIT CARE INITIAL Category: Medical Services CMS Add: 01/01/2009 CMS Term: 99469 MEDSV DEF RBRVS 01/01/2024 368.98 0-28days 0-1 Description: NEONATE CRIT CARE SUBSQ Category: Medical Services CMS Add: 01/01/2009 CMS Term: 99469 MEDSV DEF RBRVS 02/01/2015 12/31/2023 288.16 0-28days 0-1 Description: NEONATE CRIT CARE SUBSQ Category: Medical Services CMS Add: 01/01/2009 CMS Term: 99471 MEDSV DEF RBRVS 01/01/2024 737.94 29-730days 0-1 Description: PED CRITICAL CARE INITIAL Category: Medical Services CMS Add: 01/01/2009 CMS Term: 99471 MEDSV DEF RBRVS 02/01/2015 12/31/2023 619.67 29-730days 0-1 Description: PED CRITICAL CARE INITIAL Category: Medical Services CMS Add: 01/01/2009 CMS Term: 99472 MEDSV DEF RBRVS 01/01/2024 373.03 29-730days 0-1 Description: PED CRITICAL CARE SUBSQ Category: Medical Services CMS Add: 01/01/2009 CMS Term: 99472 MEDSV DEF RBRVS 02/01/2015 12/31/2023 292.12 29-730days 0-1 Description: PED CRITICAL CARE SUBSQ Category: Medical Services CMS Add: 01/01/2009 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,414 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 99473 MEDSV DEF RBRVS 01/01/2020 12/31/2023 7.60 Description: SELF-MEAS BP PT EDUCAJ/TRAIN Category: Medical Services CMS Add: 01/01/2020 CMS Term: 99473 MEDSV DEF RBRVS 01/01/2024 11.58 Description: SELF-MEAS BP PT EDUCAJ/TRAIN Category: Medical Services CMS Add: 01/01/2020 CMS Term: 99474 MEDSV DEF RBRVS 01/01/2020 12/31/2023 10.70 Description: SELF-MEAS BP 2 READG BID 30D Category: Medical Services CMS Add: 01/01/2020 CMS Term: 99474 MEDSV DEF RBRVS 01/01/2024 14.29 Description: SELF-MEAS BP 2 READG BID 30D Category: Medical Services CMS Add: 01/01/2020 CMS Term: 99475 MEDSV DEF RBRVS 01/01/2024 529.08 2-5years 0-1 Description: PED CRIT CARE AGE 2-5 INIT Category: Medical Services CMS Add: 01/01/2009 CMS Term: 99475 MEDSV DEF RBRVS 02/01/2015 12/31/2023 417.12 2-5years 0-1 Description: PED CRIT CARE AGE 2-5 INIT Category: Medical Services CMS Add: 01/01/2009 CMS Term: 99476 MEDSV DEF RBRVS 01/01/2024 318.78 2-5years 0-1 Description: PED CRIT CARE AGE 2-5 SUBSQ Category: Medical Services CMS Add: 01/01/2009 CMS Term: 99476 MEDSV DEF RBRVS 02/01/2015 12/31/2023 252.04 2-5years 0-1 Description: PED CRIT CARE AGE 2-5 SUBSQ Category: Medical Services CMS Add: 01/01/2009 CMS Term: 99477 MEDSV DEF RBRVS 01/01/2024 323.34 0-28days 0-1 Description: INIT DAY HOSP NEONATE CARE Category: Medical Services CMS Add: 01/01/2008 CMS Term: 99477 MEDSV DEF RBRVS 02/01/2015 12/31/2023 252.73 0-28days 0-1 Description: INIT DAY HOSP NEONATE CARE Category: Medical Services CMS Add: 01/01/2008 CMS Term: 99478 MEDSV DEF RBRVS 01/01/2024 127.12 0-364days 0-1 Description: IC LBW INF < 1500 GM SUBSQ Category: Medical Services CMS Add: 01/01/2009 CMS Term: 99478 MEDSV DEF RBRVS 02/01/2015 12/31/2023 99.98 0-364days 0-1 Description: IC LBW INF < 1500 GM SUBSQ Category: Medical Services CMS Add: 01/01/2009 CMS Term: 99479 MEDSV DEF RBRVS 01/01/2024 115.71 0-364days 0-1 Description: IC LBW INF 1500-2500 G SUBSQ Category: Medical Services CMS Add: 01/01/2009 CMS Term: 99479 MEDSV DEF RBRVS 02/01/2015 12/31/2023 90.70 0-364days 0-1 Description: IC LBW INF 1500-2500 G SUBSQ Category: Medical Services CMS Add: 01/01/2009 CMS Term: 99480 MEDSV DEF RBRVS 01/01/2024 111.39 0-364days 0-1 Description: IC INF PBW 2501-5000 G SUBSQ Category: Medical Services CMS Add: 01/01/2009 CMS Term: 99480 MEDSV DEF RBRVS 02/01/2015 12/31/2023 87.27 0-364days 0-1 Description: IC INF PBW 2501-5000 G SUBSQ Category: Medical Services CMS Add: 01/01/2009 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,415 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 99483 NOCOV DEF SYSMAN Description: ASSMT & CARE PLN PT COG IMP Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 99484 NOCOV DEF SYSMAN Description: CARE MGMT SVC BHVL HLTH COND Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 99485 NOCOV DEF SYSMAN Description: SUPRV INTERFACILTY TRANSPORT Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 99486 NOCOV DEF SYSMAN Description: SUPRV INTERFAC TRNSPORT ADDL Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 99487 NOCOV DEF SYSMAN Description: CPLX CHRNC CARE 1ST 60 MIN Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 99489 NOCOV DEF SYSMAN Description: CPLX CHRNC CARE EA ADDL 30 Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 99490 NOCOV DEF SYSMAN Description: CHRNC CARE MGMT STAFF 1ST 20 Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 99491 NOCOV DEF SYSMAN Description: CHRNC CARE MGMT PHYS 1ST 30 Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 99492 NOCOV DEF SYSMAN Description: 1ST PSYC COLLAB CARE MGMT Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 99493 NOCOV DEF SYSMAN Description: SBSQ PSYC COLLAB CARE MGMT Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 99494 NOCOV DEF SYSMAN Description: 1ST/SBSQ PSYC COLLAB CARE Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 99495 NOCOV DEF SYSMAN Description: TRANSJ CARE MGMT MOD F2F 14D Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 99496 NOCOV DEF SYSMAN Description: TRANSJ CARE MGMT HIGH F2F 7D Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 99497 NOCOV DEF SYSMAN Description: ADVNCD CARE PLAN 30 MIN Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 99498 NOCOV DEF SYSMAN Description: ADVNCD CARE PLAN ADDL 30 MIN Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 99499 MEDSV PRF MAXFEE 01/01/2024 44.03 0.0 Description: UNLISTED E&M SERVICE Category: Medical Services CMS Add: 01/01/1992 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,416 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 99500 NOCOV DEF SYSMAN Description: HOME VISIT PRENATAL Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: 99501 NOCOV DEF SYSMAN Description: HOME VISIT POSTNATAL Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: 99502 NOCOV DEF SYSMAN Description: HOME VISIT NB CARE Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: 99503 NOCOV DEF SYSMAN Description: HOME VISIT RESP THERAPY Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: 99504 NOCOV DEF SYSMAN Description: HOME VISIT MECH VENTILATOR Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: 99505 NOCOV DEF SYSMAN Description: HOME VISIT STOMA CARE Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: 99506 NOCOV DEF SYSMAN Description: HOME VISIT IM INJECTION Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: 99507 NOCOV DEF SYSMAN Description: HOME VISIT CATH MAINTAIN Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: 99509 NOCOV DEF SYSMAN Description: HOME VISIT DAY LIFE ACTIVITY Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: 99510 NOCOV DEF SYSMAN Description: HOME VISIT SING/M/FAM COUNS Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: 99511 NOCOV DEF SYSMAN Description: HOME VISIT FECAL/ENEMA MGMT Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: 99512 NOCOV DEF SYSMAN Description: HOME VISIT FOR HEMODIALYSIS Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: 99600 MEDSV DEF MAXFEE 07/01/2021 06/30/2023 19.82 0.0 Y Description: UNLISTED HOME VISIT SVC/PX Category: Medical Services CMS Add: 01/01/2003 CMS Term: 99600 MEDSV DEF MAXFEE 07/01/2023 28.52 0.0 Y Description: UNLISTED HOME VISIT SVC/PX Category: Medical Services CMS Add: 01/01/2003 CMS Term: 99600 MEDSV PRF MAXFEE 01/01/2024 28.51 0.0 Y Description: UNLISTED HOME VISIT SVC/PX Category: Medical Services CMS Add: 01/01/2003 CMS Term: 99600 TD MEDSV DEF MAXFEE 01/01/2024 63.80 0.0 Y Description: UNLISTED HOME VISIT SVC/PX Category: Medical Services CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,417 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 99600 TD MEDSV DEF MAXFEE 07/01/2021 06/30/2023 48.97 0.0 Y Description: UNLISTED HOME VISIT SVC/PX Category: Medical Services CMS Add: 01/01/2003 CMS Term: 99600 TD MEDSV DEF MAXFEE 07/01/2023 12/31/2023 63.79 0.0 Y Description: UNLISTED HOME VISIT SVC/PX Category: Medical Services CMS Add: 01/01/2003 CMS Term: 99600 TD TM MEDSV DEF MAXFEE 01/01/2022 06/30/2023 10.87 0.0 Y Description: UNLISTED HOME VISIT SVC/PX Category: Medical Services CMS Add: 01/01/2003 CMS Term: 99600 TD TM MEDSV DEF MAXFEE 07/01/2023 15.95 0.0 Y Description: UNLISTED HOME VISIT SVC/PX Category: Medical Services CMS Add: 01/01/2003 CMS Term: 99600 TD U2 MEDSV DEF MAXFEE 01/01/2024 12.75 0.0 Y Description: UNLISTED HOME VISIT SVC/PX Category: Medical Services CMS Add: 01/01/2003 CMS Term: 99600 TD U2 MEDSV DEF MAXFEE 12/01/2014 12/31/2023 9.84 0.0 Y Description: UNLISTED HOME VISIT SVC/PX Category: Medical Services CMS Add: 01/01/2003 CMS Term: 99600 TE MEDSV DEF MAXFEE 07/01/2021 06/30/2023 34.78 0.0 Y Description: UNLISTED HOME VISIT SVC/PX Category: Medical Services CMS Add: 01/01/2003 CMS Term: 99600 TE MEDSV DEF MAXFEE 07/01/2023 50.29 0.0 Y Description: UNLISTED HOME VISIT SVC/PX Category: Medical Services CMS Add: 01/01/2003 CMS Term: 99600 TE TM MEDSV DEF MAXFEE 07/01/2023 12.57 0.0 Y Description: UNLISTED HOME VISIT SVC/PX Category: Medical Services CMS Add: 01/01/2003 CMS Term: 99600 U1 MEDSV DEF MAXFEE 01/01/2024 18.73 0.0 Y Description: UNLISTED HOME VISIT SVC/PX Category: Medical Services CMS Add: 01/01/2003 CMS Term: 99600 U1 MEDSV DEF MAXFEE 12/01/2014 12/31/2023 14.45 0.0 Y Description: UNLISTED HOME VISIT SVC/PX Category: Medical Services CMS Add: 01/01/2003 CMS Term: 99601 MEDSV DEF BILL40 0-1 Description: HOME NFS VISIT <2 HRS Category: Medical Services CMS Add: 01/01/2004 CMS Term: 99602 MEDSV DEF BILL40 0-22 Description: HOME NFS VISIT EACH ADDL HR Category: Medical Services CMS Add: 01/01/2004 CMS Term: 99605 NOCOV DEF SYSMAN Description: MTMS BY PHARM NP 15 MIN Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 99606 NOCOV DEF SYSMAN Description: MTMS BY PHARM EST 15 MIN Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 99607 NOCOV DEF SYSMAN Description: MTMS BY PHARM ADDL 15 MIN Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,418 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A0021 NOCOV DEF SYSMAN Description: OUTSIDE STATE AMBULANCE SERV Category: Non Covered Services CMS Add: 01/01/1985 CMS Term: A0080 NOCOV DEF SYSMAN Description: NONINTEREST ESCORT IN NON ER Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: A0090 TRANS DEF MAXFEE 01/01/2024 0.50 0.0 Description: INTEREST ESCORT IN NON ER Category: Transportation CMS Add: 01/01/1982 CMS Term: A0090 TRANS DEF MAXFEE 06/15/2022 12/31/2023 0.49 0.0 Description: INTEREST ESCORT IN NON ER Category: Transportation CMS Add: 01/01/1982 CMS Term: A0100 TK UA TRANS DEF MAXFEE 01/01/2014 12/31/2023 3.00 0.0 Description: NONEMERGENCY TRANSPORT TAXI Category: Transportation CMS Add: 01/01/1982 CMS Term: A0100 TK UA TRANS DEF MAXFEE 01/01/2024 3.60 0.0 Description: NONEMERGENCY TRANSPORT TAXI Category: Transportation CMS Add: 01/01/1982 CMS Term: A0100 TK UB TRANS DEF MAXFEE 01/01/2014 12/31/2023 5.00 0.0 Description: NONEMERGENCY TRANSPORT TAXI Category: Transportation CMS Add: 01/01/1982 CMS Term: A0100 TK UB TRANS DEF MAXFEE 01/01/2024 6.00 0.0 Description: NONEMERGENCY TRANSPORT TAXI Category: Transportation CMS Add: 01/01/1982 CMS Term: A0100 TK UC TRANS DEF MAXFEE 01/01/2014 12/31/2023 7.50 0.0 Description: NONEMERGENCY TRANSPORT TAXI Category: Transportation CMS Add: 01/01/1982 CMS Term: A0100 TK UC TRANS DEF MAXFEE 01/01/2024 9.00 0.0 Description: NONEMERGENCY TRANSPORT TAXI Category: Transportation CMS Add: 01/01/1982 CMS Term: A0100 TRANS DEF MAXFEE 01/01/2024 1.20 0.0 Description: NONEMERGENCY TRANSPORT TAXI Category: Transportation CMS Add: 01/01/1982 CMS Term: A0100 TRANS DEF MAXFEE 06/01/2018 12/31/2023 1.00 0.0 Description: NONEMERGENCY TRANSPORT TAXI Category: Transportation CMS Add: 01/01/1982 CMS Term: A0100 TT UA TRANS DEF MAXFEE 01/01/2014 12/31/2023 3.00 0.0 Description: NONEMERGENCY TRANSPORT TAXI Category: Transportation CMS Add: 01/01/1982 CMS Term: A0100 TT UA TRANS DEF MAXFEE 01/01/2024 3.60 0.0 Description: NONEMERGENCY TRANSPORT TAXI Category: Transportation CMS Add: 01/01/1982 CMS Term: A0100 TT UB TRANS DEF MAXFEE 01/01/2014 12/31/2023 5.00 0.0 Description: NONEMERGENCY TRANSPORT TAXI Category: Transportation CMS Add: 01/01/1982 CMS Term: A0100 TT UB TRANS DEF MAXFEE 01/01/2024 6.00 0.0 Description: NONEMERGENCY TRANSPORT TAXI Category: Transportation CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,419 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A0100 TT UC TRANS DEF MAXFEE 01/01/2014 12/31/2023 7.50 0.0 Description: NONEMERGENCY TRANSPORT TAXI Category: Transportation CMS Add: 01/01/1982 CMS Term: A0100 TT UC TRANS DEF MAXFEE 01/01/2024 9.00 0.0 Description: NONEMERGENCY TRANSPORT TAXI Category: Transportation CMS Add: 01/01/1982 CMS Term: A0100 U4 TRANS DEF MAXFEE 01/01/2014 12/31/2023 15.00 0.0 Description: NONEMERGENCY TRANSPORT TAXI Category: Transportation CMS Add: 01/01/1982 CMS Term: A0100 U4 TRANS DEF MAXFEE 01/01/2024 18.00 0.0 Description: NONEMERGENCY TRANSPORT TAXI Category: Transportation CMS Add: 01/01/1982 CMS Term: A0100 UA TRANS DEF MAXFEE 01/01/2014 12/31/2023 6.00 0.0 Description: NONEMERGENCY TRANSPORT TAXI Category: Transportation CMS Add: 01/01/1982 CMS Term: A0100 UA TRANS DEF MAXFEE 01/01/2024 7.20 0.0 Description: NONEMERGENCY TRANSPORT TAXI Category: Transportation CMS Add: 01/01/1982 CMS Term: A0100 UB TRANS DEF MAXFEE 01/01/2014 12/31/2023 10.00 0.0 Description: NONEMERGENCY TRANSPORT TAXI Category: Transportation CMS Add: 01/01/1982 CMS Term: A0100 UB TRANS DEF MAXFEE 01/01/2024 12.00 0.0 Description: NONEMERGENCY TRANSPORT TAXI Category: Transportation CMS Add: 01/01/1982 CMS Term: A0100 UC TRANS DEF MAXFEE 01/01/2014 12/31/2023 15.00 0.0 Description: NONEMERGENCY TRANSPORT TAXI Category: Transportation CMS Add: 01/01/1982 CMS Term: A0100 UC TRANS DEF MAXFEE 01/01/2024 18.00 0.0 Description: NONEMERGENCY TRANSPORT TAXI Category: Transportation CMS Add: 01/01/1982 CMS Term: A0110 TRANS DEF SYSMAN Y Description: NONEMERGENCY TRANSPORT BUS Category: Transportation CMS Add: 01/01/1984 CMS Term: A0120 NOCOV DEF SYSMAN Description: NONER TRANSPORT MINI-BUS Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: A0130 CR TRANS DEF MAXFEE 01/01/2024 115.01 0.0 Description: NONER TRANSPORT WHEELCH VAN Category: Transportation CMS Add: 01/01/1982 CMS Term: A0130 CR TRANS DEF MAXFEE 03/01/2020 12/31/2023 95.84 0.0 Description: NONER TRANSPORT WHEELCH VAN Category: Transportation CMS Add: 01/01/1982 CMS Term: A0130 TK TRANS DEF MAXFEE 01/01/2024 15.00 0.0 Description: NONER TRANSPORT WHEELCH VAN Category: Transportation CMS Add: 01/01/1982 CMS Term: A0130 TK TRANS DEF MAXFEE 10/01/2019 12/31/2023 12.50 0.0 Description: NONER TRANSPORT WHEELCH VAN Category: Transportation CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,420 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A0130 TRANS DEF MAXFEE 01/01/2024 30.00 0.0 Description: NONER TRANSPORT WHEELCH VAN Category: Transportation CMS Add: 01/01/1982 CMS Term: A0130 TRANS DEF MAXFEE 10/01/2019 12/31/2023 25.00 0.0 Description: NONER TRANSPORT WHEELCH VAN Category: Transportation CMS Add: 01/01/1982 CMS Term: A0130 TT TRANS DEF MAXFEE 01/01/2024 15.00 0.0 Description: NONER TRANSPORT WHEELCH VAN Category: Transportation CMS Add: 01/01/1982 CMS Term: A0130 TT TRANS DEF MAXFEE 10/01/2019 12/31/2023 12.50 0.0 Description: NONER TRANSPORT WHEELCH VAN Category: Transportation CMS Add: 01/01/1982 CMS Term: A0130 U6 TRANS DEF MAXFEE 01/01/2024 7.50 0.0 Description: NONER TRANSPORT WHEELCH VAN Category: Transportation CMS Add: 01/01/1982 CMS Term: A0130 U6 TRANS DEF MAXFEE 10/01/2019 12/31/2023 6.25 0.0 Description: NONER TRANSPORT WHEELCH VAN Category: Transportation CMS Add: 01/01/1982 CMS Term: A0140 TRANS DEF SYSMAN Y Y Description: NONEMERGENCY TRANSPORT AIR Category: Transportation CMS Add: 01/01/1985 CMS Term: A0160 NOCOV DEF SYSMAN Description: NONER TRANSPORT CASE WORKER Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: A0170 NOCOV DEF SYSMAN Description: TRANSPORT PARKING FEES/TOLLS Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: A0180 NOCOV DEF SYSMAN Description: NONER TRANSPORT LODGNG RECIP Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: A0190 NOCOV DEF SYSMAN Description: NONER TRANSPORT MEALS RECIP Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: A0200 NOCOV DEF SYSMAN Description: NONER TRANSPORT LODGNG ESCRT Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: A0210 NOCOV DEF SYSMAN Description: NONER TRANSPORT MEALS ESCORT Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: A0225 TRANS DEF MAXFEE 01/01/2014 06/30/2023 160.84 0.0 0-28days Description: NEONATAL EMERGENCY TRANSPORT Category: Transportation CMS Add: 01/01/1985 CMS Term: A0225 TRANS DEF MAXFEE 07/01/2023 482.56 0.0 0-28days Description: NEONATAL EMERGENCY TRANSPORT Category: Transportation CMS Add: 01/01/1985 CMS Term: A0380 NOCOV DEF SYSMAN Description: BASIC LIFE SUPPORT MILEAGE Category: Non Covered Services CMS Add: 01/01/1995 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,421 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A0382 NOCOV DEF SYSMAN Description: BASIC SUPPORT ROUTINE SUPPLS Category: Non Covered Services CMS Add: 01/01/1995 CMS Term: A0384 NOCOV DEF SYSMAN Description: BLS DEFIBRILLATION SUPPLIES Category: Non Covered Services CMS Add: 01/01/1995 CMS Term: A0390 NOCOV DEF SYSMAN Description: ADVANCED LIFE SUPPORT MILEAG Category: Non Covered Services CMS Add: 01/01/1995 CMS Term: A0392 NOCOV DEF SYSMAN Description: ALS DEFIBRILLATION SUPPLIES Category: Non Covered Services CMS Add: 01/01/1995 CMS Term: A0394 NOCOV DEF SYSMAN Description: ALS IV DRUG THERAPY SUPPLIES Category: Non Covered Services CMS Add: 01/01/1995 CMS Term: A0396 NOCOV DEF SYSMAN Description: ALS ESOPHAGEAL INTUB SUPPLS Category: Non Covered Services CMS Add: 01/01/1995 CMS Term: A0398 NOCOV DEF SYSMAN Description: ALS ROUTINE DISPOSBLE SUPPLS Category: Non Covered Services CMS Add: 01/01/1995 CMS Term: A0420 U1 TRANS DEF MAXFEE 01/01/2014 06/30/2023 20.00 0.0 Description: AMBULANCE WAITING 1/2 HR Category: Transportation CMS Add: 01/01/1995 CMS Term: A0420 U1 TRANS DEF MAXFEE 07/01/2023 25.16 0.0 Description: AMBULANCE WAITING 1/2 HR Category: Transportation CMS Add: 01/01/1995 CMS Term: A0420 U2 TRANS DEF MAXFEE 01/01/2014 06/30/2023 20.00 0.0 Description: AMBULANCE WAITING 1/2 HR Category: Transportation CMS Add: 01/01/1995 CMS Term: A0420 U2 TRANS DEF MAXFEE 07/01/2023 25.16 0.0 Description: AMBULANCE WAITING 1/2 HR Category: Transportation CMS Add: 01/01/1995 CMS Term: A0422 TRANS DEF MAXFEE 01/01/2014 15.00 0.0 Description: AMBULANCE 02 LIFE SUSTAINING Category: Transportation CMS Add: 01/01/1995 CMS Term: A0424 TRANS DEF MAXFEE 01/01/2014 06/30/2023 5.00 0.0 Description: EXTRA AMBULANCE ATTENDANT Category: Transportation CMS Add: 01/01/1995 CMS Term: A0424 TRANS DEF MAXFEE 07/01/2023 6.29 0.0 Description: EXTRA AMBULANCE ATTENDANT Category: Transportation CMS Add: 01/01/1995 CMS Term: A0425 MRT DEF MAXFEE 07/01/2023 8.71 0.0 Description: GROUND MILEAGE Category: Medical Review Team CMS Add: 01/01/2001 CMS Term: A0425 SE MRT DEF MAXFEE 07/01/2002 06/30/2023 1.25 0.0 Description: GROUND MILEAGE Category: Medical Review Team CMS Add: 01/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,422 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A0425 SE MRT DEF MAXFEE 07/01/2023 1.57 0.0 Description: GROUND MILEAGE Category: Medical Review Team CMS Add: 01/01/2001 CMS Term: A0425 SE TRANS DEF MAXFEE 07/01/2002 06/30/2023 1.25 0.0 Description: GROUND MILEAGE Category: Transportation CMS Add: 01/01/2001 CMS Term: A0425 SE TRANS DEF MAXFEE 07/01/2023 1.57 0.0 Description: GROUND MILEAGE Category: Transportation CMS Add: 01/01/2001 CMS Term: A0425 TRANS DEF MAXFEE 07/01/2023 8.71 0.0 Description: GROUND MILEAGE Category: Transportation CMS Add: 01/01/2001 CMS Term: A0425 U1 MRT DEF MAXFEE 01/01/2014 06/30/2023 4.41 0.0 Description: GROUND MILEAGE Category: Medical Review Team CMS Add: 01/01/2001 CMS Term: A0425 U1 MRT DEF MAXFEE 07/01/2023 8.71 0.0 Description: GROUND MILEAGE Category: Medical Review Team CMS Add: 01/01/2001 CMS Term: A0425 U1 TRANS DEF MAXFEE 01/01/2014 06/30/2023 4.41 0.0 Description: GROUND MILEAGE Category: Transportation CMS Add: 01/01/2001 CMS Term: A0425 U1 TRANS DEF MAXFEE 07/01/2023 8.71 0.0 Description: GROUND MILEAGE Category: Transportation CMS Add: 01/01/2001 CMS Term: A0425 U2 MRT DEF MAXFEE 01/01/2014 06/30/2023 3.31 0.0 Description: GROUND MILEAGE Category: Medical Review Team CMS Add: 01/01/2001 CMS Term: A0425 U2 MRT DEF MAXFEE 07/01/2023 8.71 0.0 Description: GROUND MILEAGE Category: Medical Review Team CMS Add: 01/01/2001 CMS Term: A0425 U2 TRANS DEF MAXFEE 01/01/2014 06/30/2023 3.31 0.0 Description: GROUND MILEAGE Category: Transportation CMS Add: 01/01/2001 CMS Term: A0425 U2 TRANS DEF MAXFEE 07/01/2023 8.71 0.0 Description: GROUND MILEAGE Category: Transportation CMS Add: 01/01/2001 CMS Term: A0425 U3 MRT DEF MAXFEE 01/01/2014 06/30/2023 1.25 0.0 Description: GROUND MILEAGE Category: Medical Review Team CMS Add: 01/01/2001 CMS Term: A0425 U3 MRT DEF MAXFEE 07/01/2023 1.57 0.0 Description: GROUND MILEAGE Category: Medical Review Team CMS Add: 01/01/2001 CMS Term: A0425 U3 TRANS DEF MAXFEE 01/01/2014 06/30/2023 1.25 0.0 Description: GROUND MILEAGE Category: Transportation CMS Add: 01/01/2001 CMS Term: A0425 U3 TRANS DEF MAXFEE 07/01/2023 1.57 0.0 Description: GROUND MILEAGE Category: Transportation CMS Add: 01/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,423 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A0425 U5 MRT DEF MAXFEE 01/01/2014 06/30/2023 1.25 0.0 Description: GROUND MILEAGE Category: Medical Review Team CMS Add: 01/01/2001 CMS Term: A0425 U5 MRT DEF MAXFEE 07/01/2023 1.57 0.0 Description: GROUND MILEAGE Category: Medical Review Team CMS Add: 01/01/2001 CMS Term: A0425 U5 TRANS DEF MAXFEE 01/01/2014 06/30/2023 1.25 0.0 Description: GROUND MILEAGE Category: Transportation CMS Add: 01/01/2001 CMS Term: A0425 U5 TRANS DEF MAXFEE 07/01/2023 1.57 0.0 Description: GROUND MILEAGE Category: Transportation CMS Add: 01/01/2001 CMS Term: A0426 TRANS DEF MAXFEE 01/01/2014 06/30/2023 95.84 0.0 Description: ALS 1 Category: Transportation CMS Add: 01/01/2001 CMS Term: A0426 TRANS DEF MAXFEE 07/01/2023 304.77 0.0 Description: ALS 1 Category: Transportation CMS Add: 01/01/2001 CMS Term: A0427 TRANS DEF MAXFEE 01/01/2014 06/30/2023 160.84 0.0 Description: ALS1-EMERGENCY Category: Transportation CMS Add: 01/01/2001 CMS Term: A0427 TRANS DEF MAXFEE 07/01/2023 482.56 0.0 Description: ALS1-EMERGENCY Category: Transportation CMS Add: 01/01/2001 CMS Term: A0428 TRANS DEF MAXFEE 01/01/2014 06/30/2023 95.84 0.0 Description: BLS Category: Transportation CMS Add: 01/01/2001 CMS Term: A0428 TRANS DEF MAXFEE 07/01/2023 253.98 0.0 Description: BLS Category: Transportation CMS Add: 01/01/2001 CMS Term: A0429 TRANS DEF MAXFEE 01/01/2014 06/30/2023 110.84 0.0 Description: BLS-EMERGENCY Category: Transportation CMS Add: 01/01/2001 CMS Term: A0429 TRANS DEF MAXFEE 07/01/2023 406.36 0.0 Description: BLS-EMERGENCY Category: Transportation CMS Add: 01/01/2001 CMS Term: A0430 TRANS DEF MAXFEE 01/01/2014 06/30/2023 2788.24 0.0 Y Description: FIXED WING AIR TRANSPORT Category: Transportation CMS Add: 01/01/2001 CMS Term: A0430 TRANS DEF MAXFEE 07/01/2023 3443.13 0.0 Y Description: FIXED WING AIR TRANSPORT Category: Transportation CMS Add: 01/01/2001 CMS Term: A0431 QL TRANS DEF MAXFEE 01/01/2014 06/30/2023 3172.27 0.0 Y 0-1 Description: ROTARY WING AIR TRANSPORT Category: Transportation CMS Add: 01/01/2001 CMS Term: A0431 QL TRANS DEF MAXFEE 07/01/2023 4003.15 0.0 Y 0-1 Description: ROTARY WING AIR TRANSPORT Category: Transportation CMS Add: 01/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,424 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A0431 TRANS DEF MAXFEE 01/01/2014 06/30/2023 3172.27 0.0 Y 0-1 Description: ROTARY WING AIR TRANSPORT Category: Transportation CMS Add: 01/01/2001 CMS Term: A0431 TRANS DEF MAXFEE 07/01/2023 4003.15 0.0 Y 0-1 Description: ROTARY WING AIR TRANSPORT Category: Transportation CMS Add: 01/01/2001 CMS Term: A0432 NOCOV DEF SYSMAN Description: PI VOLUNTEER AMBULANCE CO Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: A0433 TRANS DEF MAXFEE 01/01/2014 06/30/2023 160.84 0.0 Description: ALS 2 Category: Transportation CMS Add: 01/01/2001 CMS Term: A0433 TRANS DEF MAXFEE 07/01/2023 698.44 0.0 Description: ALS 2 Category: Transportation CMS Add: 01/01/2001 CMS Term: A0434 NOCOV DEF SYSMAN Description: SPECIALTY CARE TRANSPORT Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: A0435 TRANS DEF MAXFEE 01/01/2014 06/30/2023 8.07 0.0 Y Description: FIXED WING AIR MILEAGE Category: Transportation CMS Add: 01/01/2001 CMS Term: A0435 TRANS DEF MAXFEE 07/01/2023 10.23 0.0 Y Description: FIXED WING AIR MILEAGE Category: Transportation CMS Add: 01/01/2001 CMS Term: A0436 TRANS DEF MAXFEE 01/01/2014 06/30/2023 21.53 0.0 Y Description: ROTARY WING AIR MILEAGE Category: Transportation CMS Add: 01/01/2001 CMS Term: A0436 TRANS DEF MAXFEE 07/01/2023 27.28 0.0 Y Description: ROTARY WING AIR MILEAGE Category: Transportation CMS Add: 01/01/2001 CMS Term: A0888 NOCOV DEF SYSMAN Description: NONCOVERED AMBULANCE MILEAGE Category: Non Covered Services CMS Add: 01/01/1995 CMS Term: A0998 TRANS DEF MAXFEE 03/01/2020 76.71 0.0 Description: AMBULANCE RESPONSE/TREATMENT Category: Transportation CMS Add: 01/01/2006 CMS Term: A0999 TRANS DEF SYSMAN Y Y Description: UNLISTED AMBULANCE SERVICE Category: Transportation CMS Add: 01/01/1987 CMS Term: A2001 MDSPY DEF MAXFEE 01/01/2022 12/31/2023 37.56 0.0 Description: INNOVAMATRIX AC, PER SQ CM Category: Medical Supplies CMS Add: 01/01/2022 CMS Term: A2001 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: INNOVAMATRIX AC, PER SQ CM Category: Medical Supplies CMS Add: 01/01/2022 CMS Term: A2002 MDSPY DEF MAXFEE 01/01/2022 12/31/2023 37.56 0.0 Description: MIRRAGEN ADV WND MAT PER SQ Category: Medical Supplies CMS Add: 01/01/2022 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,425 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A2002 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: MIRRAGEN ADV WND MAT PER SQ Category: Medical Supplies CMS Add: 01/01/2022 CMS Term: A2004 MDSPY DEF MAXFEE 01/01/2022 12/31/2023 37.56 0.0 Description: XCELLISTEM, 1 MG Category: Medical Supplies CMS Add: 01/01/2022 CMS Term: A2004 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: XCELLISTEM, 1 MG Category: Medical Supplies CMS Add: 01/01/2022 CMS Term: A2005 MDSPY DEF MAXFEE 01/01/2022 12/31/2023 37.56 0.0 Description: MICROLYTE MATRIX, PER SQ CM Category: Medical Supplies CMS Add: 01/01/2022 CMS Term: A2005 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: MICROLYTE MATRIX, PER SQ CM Category: Medical Supplies CMS Add: 01/01/2022 CMS Term: A2006 MDSPY DEF MAXFEE 01/01/2022 12/31/2023 37.56 0.0 Description: NOVOSORB SYNPATH PER SQ CM Category: Medical Supplies CMS Add: 01/01/2022 CMS Term: A2006 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: NOVOSORB SYNPATH PER SQ CM Category: Medical Supplies CMS Add: 01/01/2022 CMS Term: A2007 MDSPY DEF MAXFEE 01/01/2022 12/31/2023 37.56 0.0 Description: RESTRATA, PER SQ CM Category: Medical Supplies CMS Add: 01/01/2022 CMS Term: A2007 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: RESTRATA, PER SQ CM Category: Medical Supplies CMS Add: 01/01/2022 CMS Term: A2008 MDSPY DEF MAXFEE 01/01/2022 12/31/2023 37.56 0.0 Description: THERAGENESIS, PER SQ CM Category: Medical Supplies CMS Add: 01/01/2022 CMS Term: A2008 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: THERAGENESIS, PER SQ CM Category: Medical Supplies CMS Add: 01/01/2022 CMS Term: A2009 MDSPY DEF MAXFEE 01/01/2022 12/31/2023 37.56 0.0 Description: SYMPHONY, PER SQ CM Category: Medical Supplies CMS Add: 01/01/2022 CMS Term: A2009 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: SYMPHONY, PER SQ CM Category: Medical Supplies CMS Add: 01/01/2022 CMS Term: A2010 MDSPY DEF MAXFEE 01/01/2022 12/31/2023 37.56 0.0 Description: APIS, PER SQUARE CENTIMETER Category: Medical Supplies CMS Add: 01/01/2022 CMS Term: A2010 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: APIS, PER SQUARE CENTIMETER Category: Medical Supplies CMS Add: 01/01/2022 CMS Term: A2011 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: SUPRA SDRM, PER SQ CM Category: Medical Supplies CMS Add: 04/01/2022 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,426 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A2011 MDSPY DEF MAXFEE 04/01/2022 12/31/2023 37.56 0.0 Description: SUPRA SDRM, PER SQ CM Category: Medical Supplies CMS Add: 04/01/2022 CMS Term: A2012 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: SUPRATHEL, PER SQ CM Category: Medical Supplies CMS Add: 04/01/2022 CMS Term: A2012 MDSPY DEF MAXFEE 04/01/2022 12/31/2023 37.56 0.0 Description: SUPRATHEL, PER SQ CM Category: Medical Supplies CMS Add: 04/01/2022 CMS Term: A2013 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: INNOVAMATRIX FS, PER SQ CM Category: Medical Supplies CMS Add: 04/01/2022 CMS Term: A2013 MDSPY DEF MAXFEE 04/01/2022 12/31/2023 37.56 0.0 Description: INNOVAMATRIX FS, PER SQ CM Category: Medical Supplies CMS Add: 04/01/2022 CMS Term: A2014 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: OMEZA COLLAG PER 100 MG Category: Medical Supplies CMS Add: 10/01/2022 CMS Term: A2014 MDSPY DEF MAXFEE 10/01/2022 12/31/2023 37.56 0.0 Description: OMEZA COLLAG PER 100 MG Category: Medical Supplies CMS Add: 10/01/2022 CMS Term: A2015 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: PHOENIX WND MTRX, PER SQ CM Category: Medical Supplies CMS Add: 10/01/2022 CMS Term: A2015 MDSPY DEF MAXFEE 10/01/2022 12/31/2023 37.56 0.0 Description: PHOENIX WND MTRX, PER SQ CM Category: Medical Supplies CMS Add: 10/01/2022 CMS Term: A2016 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: PERMEADERM B, PER SQ CM Category: Medical Supplies CMS Add: 10/01/2022 CMS Term: A2016 MDSPY DEF MAXFEE 10/01/2022 12/31/2023 37.56 0.0 Description: PERMEADERM B, PER SQ CM Category: Medical Supplies CMS Add: 10/01/2022 CMS Term: A2017 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: PERMEADERM GLOVE, EACH Category: Medical Supplies CMS Add: 10/01/2022 CMS Term: A2017 MDSPY DEF MAXFEE 10/01/2022 12/31/2023 37.56 0.0 Description: PERMEADERM GLOVE, EACH Category: Medical Supplies CMS Add: 10/01/2022 CMS Term: A2018 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: PERMEADERM C, PER SQ CM Category: Medical Supplies CMS Add: 10/01/2022 CMS Term: A2018 MDSPY DEF MAXFEE 10/01/2022 12/31/2023 37.56 0.0 Description: PERMEADERM C, PER SQ CM Category: Medical Supplies CMS Add: 10/01/2022 CMS Term: A2019 MDSPY DEF MAXFEE 01/01/2024 48.68 0.0 Description: KERECIS MARIGEN SHLD SQ CM Category: Medical Supplies CMS Add: 04/01/2023 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,427 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A2019 MDSPY DEF MAXFEE 04/01/2023 12/31/2023 37.56 0.0 Description: KERECIS MARIGEN SHLD SQ CM Category: Medical Supplies CMS Add: 04/01/2023 CMS Term: A2020 MDSPY DEF MAXFEE 01/01/2024 48.68 0.0 Y Description: AC5 WOUND SYSTEM Category: Medical Supplies CMS Add: 04/01/2023 CMS Term: A2020 MDSPY DEF MAXFEE 04/01/2023 12/31/2023 37.56 0.0 Y Description: AC5 WOUND SYSTEM Category: Medical Supplies CMS Add: 04/01/2023 CMS Term: A2021 MDSPY DEF MAXFEE 01/01/2024 48.68 0.0 Description: NEOMATRIX PER SQ CM Category: Medical Supplies CMS Add: 04/01/2023 CMS Term: A2021 MDSPY DEF MAXFEE 04/01/2023 12/31/2023 37.56 0.0 Description: NEOMATRIX PER SQ CM Category: Medical Supplies CMS Add: 04/01/2023 CMS Term: A2022 MDSPY DEF MAXFEE 01/01/2024 48.68 0.0 Description: INNOVABRN/INNOVAMATX XL SQCM Category: Medical Supplies CMS Add: 10/01/2023 CMS Term: A2022 MDSPY DEF MAXFEE 10/01/2023 12/31/2023 37.56 0.0 Description: INNOVABRN/INNOVAMATX XL SQCM Category: Medical Supplies CMS Add: 10/01/2023 CMS Term: A2023 MDSPY DEF MAXFEE 01/01/2024 48.68 0.0 Description: INNOVAMATRIX PD, 1 MG Category: Medical Supplies CMS Add: 10/01/2023 CMS Term: A2023 MDSPY DEF MAXFEE 10/01/2023 12/31/2023 37.56 0.0 Description: INNOVAMATRIX PD, 1 MG Category: Medical Supplies CMS Add: 10/01/2023 CMS Term: A2024 MDSPY DEF MAXFEE 01/01/2024 48.68 0.0 Description: RESOLVE MATRIX PER SQ CM Category: Medical Supplies CMS Add: 10/01/2023 CMS Term: A2024 MDSPY DEF MAXFEE 10/01/2023 12/31/2023 37.56 0.0 Description: RESOLVE MATRIX PER SQ CM Category: Medical Supplies CMS Add: 10/01/2023 CMS Term: A2025 MDSPY DEF MAXFEE 01/01/2024 48.68 0.0 Description: MIRO3D PER CUBIC CM Category: Medical Supplies CMS Add: 10/01/2023 CMS Term: A2025 MDSPY DEF MAXFEE 10/01/2023 12/31/2023 37.56 0.0 Description: MIRO3D PER CUBIC CM Category: Medical Supplies CMS Add: 10/01/2023 CMS Term: A4100 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: SKIN SUB FDA CLRD AS DEV NOS Category: Medical Supplies CMS Add: 04/01/2022 CMS Term: A4100 MDSPY DEF MAXFEE 04/01/2022 12/31/2023 37.56 0.0 Description: SKIN SUB FDA CLRD AS DEV NOS Category: Medical Supplies CMS Add: 04/01/2022 CMS Term: A4206 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 0.31 0.0 Description: 1 CC STERILE SYRINGE&NEEDLE Category: Medical Supplies CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,428 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A4206 MDSPY DEF MAXFEE 01/01/2024 0.40 0.0 Description: 1 CC STERILE SYRINGE&NEEDLE Category: Medical Supplies CMS Add: 01/01/1985 CMS Term: A4207 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 0.17 0.0 Description: 2 CC STERILE SYRINGE&NEEDLE Category: Medical Supplies CMS Add: 01/01/1985 CMS Term: A4207 MDSPY DEF MAXFEE 01/01/2024 0.22 0.0 Description: 2 CC STERILE SYRINGE&NEEDLE Category: Medical Supplies CMS Add: 01/01/1985 CMS Term: A4208 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 0.17 0.0 Description: 3 CC STERILE SYRINGE&NEEDLE Category: Medical Supplies CMS Add: 01/01/1985 CMS Term: A4208 MDSPY DEF MAXFEE 01/01/2024 0.22 0.0 Description: 3 CC STERILE SYRINGE&NEEDLE Category: Medical Supplies CMS Add: 01/01/1985 CMS Term: A4209 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 0.34 0.0 Description: 5+ CC STERILE SYRINGE&NEEDLE Category: Medical Supplies CMS Add: 01/01/1985 CMS Term: A4209 MDSPY DEF MAXFEE 01/01/2024 0.44 0.0 Description: 5+ CC STERILE SYRINGE&NEEDLE Category: Medical Supplies CMS Add: 01/01/1985 CMS Term: A4210 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 0.29 0.0 Description: NONNEEDLE INJECTION DEVICE Category: Medical Supplies CMS Add: 01/01/1989 CMS Term: A4210 MDSPY DEF MAXFEE 01/01/2024 0.38 0.0 Description: NONNEEDLE INJECTION DEVICE Category: Medical Supplies CMS Add: 01/01/1989 CMS Term: A4211 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 0.28 0.0 Description: SUPP FOR SELF-ADM INJECTIONS Category: Medical Supplies CMS Add: 01/01/1993 CMS Term: A4211 MDSPY DEF MAXFEE 01/01/2024 0.36 0.0 Description: SUPP FOR SELF-ADM INJECTIONS Category: Medical Supplies CMS Add: 01/01/1993 CMS Term: A4212 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 2.27 0.0 Description: NON CORING NEEDLE OR STYLET Category: Medical Supplies CMS Add: 01/01/1993 CMS Term: A4212 MDSPY DEF MAXFEE 01/01/2024 2.95 0.0 Description: NON CORING NEEDLE OR STYLET Category: Medical Supplies CMS Add: 01/01/1993 CMS Term: A4213 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 1.08 0.0 Description: 20+ CC SYRINGE ONLY Category: Medical Supplies CMS Add: 01/01/1985 CMS Term: A4213 MDSPY DEF MAXFEE 01/01/2024 1.40 0.0 Description: 20+ CC SYRINGE ONLY Category: Medical Supplies CMS Add: 01/01/1985 CMS Term: A4215 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 0.24 0.0 Description: STERILE NEEDLE Category: Medical Supplies CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,429 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A4215 MDSPY DEF MAXFEE 01/01/2024 0.31 0.0 Description: STERILE NEEDLE Category: Medical Supplies CMS Add: 01/01/1985 CMS Term: A4216 NOCOV DEF SYSMAN Description: STERILE WATER/SALINE, 10 ML Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: A4217 NOCOV DEF SYSMAN Description: STERILE WATER/SALINE, 500 ML Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: A4218 NOCOV DEF SYSMAN Description: STERILE SALINE OR WATER Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: A4220 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 128.00 0.0 Description: INFUSION PUMP REFILL KIT Category: Medical Supplies CMS Add: 01/01/1994 CMS Term: A4220 MDSPY DEF MAXFEE 01/01/2024 166.40 0.0 Description: INFUSION PUMP REFILL KIT Category: Medical Supplies CMS Add: 01/01/1994 CMS Term: A4221 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 18.02 0.0 Description: SUPP NON-INSULIN INF CATH/WK Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A4221 MDSPY DEF MAXFEE 01/01/2024 25.41 0.0 Description: SUPP NON-INSULIN INF CATH/WK Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A4222 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 37.20 0.0 Description: INFUSION SUPPLIES WITH PUMP Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A4222 MDSPY DEF MAXFEE 01/01/2024 49.45 0.0 Description: INFUSION SUPPLIES WITH PUMP Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A4223 MDSPY DEF SYSMAN Y Description: INFUSION SUPPLIES W/O PUMP Category: Medical Supplies CMS Add: 01/01/2005 CMS Term: A4224 MDSPY DEF MAXFEE 01/01/2017 12/31/2023 15.52 0.0 Description: SUPPLY INSULIN INF CATH/WK Category: Medical Supplies CMS Add: 01/01/2017 CMS Term: A4224 MDSPY DEF MAXFEE 01/01/2024 25.41 0.0 Description: SUPPLY INSULIN INF CATH/WK Category: Medical Supplies CMS Add: 01/01/2017 CMS Term: A4225 MDSPY DEF MAXFEE 01/01/2017 12/31/2023 2.08 0.0 Description: SUP/EXT INSULIN INF PUMP SYR Category: Medical Supplies CMS Add: 01/01/2017 CMS Term: A4225 MDSPY DEF MAXFEE 01/01/2024 3.28 0.0 Description: SUP/EXT INSULIN INF PUMP SYR Category: Medical Supplies CMS Add: 01/01/2017 CMS Term: A4226 MDSPY DEF SYSMAN Y Description: WEEKLY SUPPLY MAINT CGS PUMP Category: Medical Supplies CMS Add: 01/01/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,430 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A4230 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 8.66 0.0 Description: INFUS INSULIN PUMP NON NEEDL Category: Medical Supplies CMS Add: 01/01/1996 CMS Term: A4230 MDSPY DEF MAXFEE 01/01/2024 11.26 0.0 Description: INFUS INSULIN PUMP NON NEEDL Category: Medical Supplies CMS Add: 01/01/1996 CMS Term: A4231 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 5.50 0.0 Description: INFUSION INSULIN PUMP NEEDLE Category: Medical Supplies CMS Add: 01/01/1996 CMS Term: A4231 MDSPY DEF MAXFEE 01/01/2024 7.15 0.0 Description: INFUSION INSULIN PUMP NEEDLE Category: Medical Supplies CMS Add: 01/01/1996 CMS Term: A4232 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 2.11 0.0 Description: SYRINGE W/NEEDLE INSULIN 3CC Category: Medical Supplies CMS Add: 01/01/1996 CMS Term: A4232 MDSPY DEF MAXFEE 01/01/2024 2.74 0.0 Description: SYRINGE W/NEEDLE INSULIN 3CC Category: Medical Supplies CMS Add: 01/01/1996 CMS Term: A4233 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 0.80 0.0 Description: ALKALIN BATT FOR GLUCOSE MON Category: Medical Supplies CMS Add: 01/01/2006 CMS Term: A4233 MDSPY DEF MAXFEE 01/01/2024 0.51 0.0 Description: ALKALIN BATT FOR GLUCOSE MON Category: Medical Supplies CMS Add: 01/01/2006 CMS Term: A4234 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 3.63 0.0 Description: J-CELL BATT FOR GLUCOSE MON Category: Medical Supplies CMS Add: 01/01/2006 CMS Term: A4234 MDSPY DEF MAXFEE 01/01/2024 2.36 0.0 Description: J-CELL BATT FOR GLUCOSE MON Category: Medical Supplies CMS Add: 01/01/2006 CMS Term: A4235 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 2.34 0.0 Description: LITHIUM BATT FOR GLUCOSE MON Category: Medical Supplies CMS Add: 01/01/2006 CMS Term: A4235 MDSPY DEF MAXFEE 01/01/2024 1.00 0.0 Description: LITHIUM BATT FOR GLUCOSE MON Category: Medical Supplies CMS Add: 01/01/2006 CMS Term: A4236 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 1.68 0.0 Description: SILVR OXIDE BATT GLUCOSE MON Category: Medical Supplies CMS Add: 01/01/2006 CMS Term: A4236 MDSPY DEF MAXFEE 01/01/2024 1.16 0.0 Description: SILVR OXIDE BATT GLUCOSE MON Category: Medical Supplies CMS Add: 01/01/2006 CMS Term: A4238 MDSPY DEF MAXFEE 01/01/2024 261.95 0.0 Y Y Description: ADJU CGM SUPPLY ALLOWANCE Category: Medical Supplies CMS Add: 04/01/2022 CMS Term: A4238 MDSPY DEF SYSMAN Y Y Description: ADJU CGM SUPPLY ALLOWANCE Category: Medical Supplies CMS Add: 04/01/2022 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,431 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A4239 MDSPY DEF MAXFEE 01/01/2023 255.01 0.0 Description: NON-ADJU CGM SUPPLY ALLOW Category: Medical Supplies CMS Add: 01/01/2023 CMS Term: A4244 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 1.28 0.0 Description: ALCOHOL OR PEROXIDE PER PINT Category: Medical Supplies CMS Add: 01/01/1985 CMS Term: A4244 MDSPY DEF MAXFEE 01/01/2024 1.66 0.0 Description: ALCOHOL OR PEROXIDE PER PINT Category: Medical Supplies CMS Add: 01/01/1985 CMS Term: A4245 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 1.60 0.0 Description: ALCOHOL WIPES PER BOX Category: Medical Supplies CMS Add: 01/01/1985 CMS Term: A4245 MDSPY DEF MAXFEE 01/01/2024 2.08 0.0 Description: ALCOHOL WIPES PER BOX Category: Medical Supplies CMS Add: 01/01/1985 CMS Term: A4246 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 7.12 0.0 Description: BETADINE/PHISOHEX SOLUTION Category: Medical Supplies CMS Add: 01/01/1985 CMS Term: A4246 MDSPY DEF MAXFEE 01/01/2024 9.26 0.0 Description: BETADINE/PHISOHEX SOLUTION Category: Medical Supplies CMS Add: 01/01/1985 CMS Term: A4247 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 9.60 0.0 Description: BETADINE/IODINE SWABS/WIPES Category: Medical Supplies CMS Add: 01/01/1985 CMS Term: A4247 MDSPY DEF MAXFEE 01/01/2024 12.48 0.0 Description: BETADINE/IODINE SWABS/WIPES Category: Medical Supplies CMS Add: 01/01/1985 CMS Term: A4248 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 0.17 0.0 Description: CHLORHEXIDINE ANTISEPT Category: Medical Supplies CMS Add: 01/01/2004 CMS Term: A4248 MDSPY DEF MAXFEE 01/01/2024 0.22 0.0 Description: CHLORHEXIDINE ANTISEPT Category: Medical Supplies CMS Add: 01/01/2004 CMS Term: A4250 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 17.54 0.0 Description: URINE REAGENT STRIPS/TABLETS Category: Medical Supplies CMS Add: 01/01/1990 CMS Term: A4250 MDSPY DEF MAXFEE 01/01/2024 22.80 0.0 Description: URINE REAGENT STRIPS/TABLETS Category: Medical Supplies CMS Add: 01/01/1990 CMS Term: A4252 NOCOV DEF SYSMAN Description: BLOOD KETONE TEST OR STRIP Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: A4253 MDSPY DEF MAXFEE 01/01/2024 8.32 0.0 Description: BLOOD GLUCOSE/REAGENT STRIPS Category: Medical Supplies CMS Add: 01/01/1986 CMS Term: A4253 MDSPY DEF MAXFEE 04/29/2003 12/31/2023 36.72 0.0 Description: BLOOD GLUCOSE/REAGENT STRIPS Category: Medical Supplies CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,432 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A4253 U1 MDSPY DEF MAXFEE 01/01/2011 12/31/2023 36.72 0.0 Description: BLOOD GLUCOSE/REAGENT STRIPS Category: Medical Supplies CMS Add: 01/01/1986 CMS Term: A4253 U1 MDSPY DEF MAXFEE 01/01/2024 8.32 0.0 Description: BLOOD GLUCOSE/REAGENT STRIPS Category: Medical Supplies CMS Add: 01/01/1986 CMS Term: A4255 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 3.27 0.0 Description: GLUCOSE MONITOR PLATFORMS Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A4255 MDSPY DEF MAXFEE 01/01/2024 5.47 0.0 Description: GLUCOSE MONITOR PLATFORMS Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A4256 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 8.74 0.0 Description: CALIBRATOR SOLUTION/CHIPS Category: Medical Supplies CMS Add: 01/01/1985 CMS Term: A4256 MDSPY DEF MAXFEE 01/01/2024 3.38 0.0 Description: CALIBRATOR SOLUTION/CHIPS Category: Medical Supplies CMS Add: 01/01/1985 CMS Term: A4257 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 10.15 0.0 0-99 Description: REPLACE LENSSHIELD CARTRIDGE Category: Medical Supplies CMS Add: 01/01/2002 CMS Term: A4257 MDSPY DEF MAXFEE 01/01/2024 16.97 0.0 0-99 Description: REPLACE LENSSHIELD CARTRIDGE Category: Medical Supplies CMS Add: 01/01/2002 CMS Term: A4258 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 14.44 0.0 Description: LANCET DEVICE EACH Category: Medical Supplies CMS Add: 01/01/1996 CMS Term: A4258 MDSPY DEF MAXFEE 01/01/2024 2.12 0.0 Description: LANCET DEVICE EACH Category: Medical Supplies CMS Add: 01/01/1996 CMS Term: A4259 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 8.84 0.0 Description: LANCETS PER BOX Category: Medical Supplies CMS Add: 01/01/1985 CMS Term: A4259 MDSPY DEF MAXFEE 01/01/2024 1.42 0.0 Description: LANCETS PER BOX Category: Medical Supplies CMS Add: 01/01/1985 CMS Term: A4261 MDSPY DEF SYSMAN Y Description: CERVICAL CAP CONTRACEPTIVE Category: Medical Supplies CMS Add: 01/01/1999 CMS Term: A4262 NOCOV DEF SYSMAN Description: TEMPORARY TEAR DUCT PLUG Category: Non Covered Services CMS Add: 01/01/1994 CMS Term: A4263 NOCOV DEF SYSMAN Description: PERMANENT TEAR DUCT PLUG Category: Non Covered Services CMS Add: 01/01/1994 CMS Term: A4264 MDSPY DEF SYSMAN Y 21-999years 0-1 Description: INTRATUBAL OCCLUSION DEVICE Category: Medical Supplies CMS Add: 01/01/2010 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,433 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A4265 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 2.71 0.0 Description: PARAFFIN Category: Medical Supplies CMS Add: 01/01/1986 CMS Term: A4265 MDSPY DEF MAXFEE 01/01/2024 4.53 0.0 Description: PARAFFIN Category: Medical Supplies CMS Add: 01/01/1986 CMS Term: A4266 MDSPY DEF SYSMAN Y Description: DIAPHRAGM Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A4267 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 0.43 0.0 Description: MALE CONDOM Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A4267 MDSPY DEF MAXFEE 01/01/2024 0.56 0.0 Description: MALE CONDOM Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A4268 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 2.36 0.0 Description: FEMALE CONDOM Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A4268 MDSPY DEF MAXFEE 01/01/2024 3.07 0.0 Description: FEMALE CONDOM Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A4269 MDSPY DEF SYSMAN Y Description: SPERMICIDE Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A4270 NOCOV DEF SYSMAN Description: DISPOSABLE ENDOSCOPE SHEATH Category: Non Covered Services CMS Add: 01/01/1994 CMS Term: A4280 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 3.93 0.0 Description: BRST PRSTHS ADHSV ATTCHMNT Category: Medical Supplies CMS Add: 01/01/2000 CMS Term: A4280 MDSPY DEF MAXFEE 01/01/2024 7.09 0.0 Description: BRST PRSTHS ADHSV ATTCHMNT Category: Medical Supplies CMS Add: 01/01/2000 CMS Term: A4281 MDSPY DEF SYSMAN Y Description: REPLACEMENT BREASTPUMP TUBE Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A4282 MDSPY DEF SYSMAN Y Description: REPLACEMENT BREASTPUMP ADPT Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A4283 MDSPY DEF SYSMAN Y Description: REPLACEMENT BREASTPUMP CAP Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A4284 MDSPY DEF SYSMAN Y Description: REPLCMNT BREAST PUMP SHIELD Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A4285 MDSPY DEF SYSMAN Y Description: REPLCMNT BREAST PUMP BOTTLE Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,434 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A4286 MDSPY DEF SYSMAN Y Description: REPLCMNT BREASTPUMP LOK RING Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A4290 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 103.72 0.0 Description: SACRAL NERVE STIM TEST LEAD Category: Medical Supplies CMS Add: 01/01/2001 CMS Term: A4290 MDSPY DEF MAXFEE 01/01/2024 134.84 0.0 Description: SACRAL NERVE STIM TEST LEAD Category: Medical Supplies CMS Add: 01/01/2001 CMS Term: A4300 NOCOV DEF SYSMAN Description: CATH IMPL VASC ACCESS PORTAL Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: A4301 MDSPY DEF SYSMAN Y Description: IMPLANTABLE ACCESS SYST PERC Category: Medical Supplies CMS Add: 01/01/1996 CMS Term: A4305 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 24.80 0.0 Description: DRUG DELIVERY SYSTEM >=50 ML Category: Medical Supplies CMS Add: 01/01/1993 CMS Term: A4305 MDSPY DEF MAXFEE 01/01/2024 32.24 0.0 Description: DRUG DELIVERY SYSTEM >=50 ML Category: Medical Supplies CMS Add: 01/01/1993 CMS Term: A4306 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 24.00 0.0 Description: DRUG DELIVERY SYSTEM <=50 ML Category: Medical Supplies CMS Add: 01/01/1993 CMS Term: A4306 MDSPY DEF MAXFEE 01/01/2024 31.20 0.0 Description: DRUG DELIVERY SYSTEM <=50 ML Category: Medical Supplies CMS Add: 01/01/1993 CMS Term: A4310 INCON DEF MAXFEE 01/01/2014 6.11 0.0 Description: INSERT TRAY W/O BAG/CATH Category: Incontinence CMS Add: 01/01/1990 CMS Term: A4311 INCON DEF MAXFEE 01/01/2014 11.74 0.0 Description: CATHETER W/O BAG 2-WAY LATEX Category: Incontinence CMS Add: 01/01/1990 CMS Term: A4312 INCON DEF MAXFEE 01/01/2014 14.27 0.0 Description: CATH W/O BAG 2-WAY SILICONE Category: Incontinence CMS Add: 01/01/1990 CMS Term: A4313 INCON DEF MAXFEE 01/01/2014 14.66 0.0 Description: CATHETER W/BAG 3-WAY Category: Incontinence CMS Add: 01/01/1990 CMS Term: A4314 INCON DEF MAXFEE 01/01/2014 20.01 0.0 Description: CATH W/DRAINAGE 2-WAY LATEX Category: Incontinence CMS Add: 01/01/1990 CMS Term: A4315 INCON DEF MAXFEE 01/01/2014 20.88 0.0 Description: CATH W/DRAINAGE 2-WAY SILCNE Category: Incontinence CMS Add: 01/01/1990 CMS Term: A4316 INCON DEF MAXFEE 01/01/2014 22.47 0.0 Description: CATH W/DRAINAGE 3-WAY Category: Incontinence CMS Add: 01/01/1990 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,435 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A4320 INCON DEF MAXFEE 01/01/2014 4.13 0.0 Description: IRRIGATION TRAY Category: Incontinence CMS Add: 01/01/1990 CMS Term: A4321 INCON DEF SYSMAN Description: CATH THERAPEUTIC IRRIG AGENT Category: Incontinence CMS Add: 01/01/1997 CMS Term: A4322 INCON DEF MAXFEE 01/01/2014 2.37 0.0 Description: IRRIGATION SYRINGE Category: Incontinence CMS Add: 01/01/1990 CMS Term: A4326 INCON DEF MAXFEE 01/01/2014 8.54 0.0 Description: MALE EXTERNAL CATHETER Category: Incontinence CMS Add: 01/01/1990 CMS Term: A4327 INCON DEF MAXFEE 01/01/2014 35.30 0.0 Description: FEM URINARY COLLECT DEV CUP Category: Incontinence CMS Add: 01/01/1990 CMS Term: A4328 INCON DEF MAXFEE 01/01/2014 8.27 0.0 Description: FEM URINARY COLLECT POUCH Category: Incontinence CMS Add: 01/01/1990 CMS Term: A4330 NOCOV DEF SYSMAN Description: STOOL COLLECTION POUCH Category: Non Covered Services CMS Add: 01/01/1990 CMS Term: A4331 INCON DEF MAXFEE 01/01/2014 2.52 0.0 Description: EXTENSION DRAINAGE TUBING Category: Incontinence CMS Add: 01/01/2001 CMS Term: A4332 INCON DEF MAXFEE 01/01/2014 0.10 0.0 Description: LUBE STERILE PACKET Category: Incontinence CMS Add: 01/01/2001 CMS Term: A4333 INCON DEF MAXFEE 01/01/2014 1.74 0.0 Description: URINARY CATH ANCHOR DEVICE Category: Incontinence CMS Add: 01/01/2001 CMS Term: A4334 INCON DEF MAXFEE 01/01/2014 3.90 0.0 Description: URINARY CATH LEG STRAP Category: Incontinence CMS Add: 01/01/2001 CMS Term: A4335 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 1.40 0.0 3-999years Description: INCONTINENCE SUPPLY Category: Medical Supplies CMS Add: 01/01/1990 CMS Term: A4335 MDSPY DEF MAXFEE 01/01/2024 1.82 0.0 3-999years Description: INCONTINENCE SUPPLY Category: Medical Supplies CMS Add: 01/01/1990 CMS Term: A4336 NOCOV DEF SYSMAN Description: URETHRAL INSERT Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: A4337 NOCOV DEF SYSMAN Description: INCONTINENT RECTAL INSERT Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: A4338 INCON DEF MAXFEE 01/01/2014 9.70 0.0 Description: INDWELLING CATHETER LATEX Category: Incontinence CMS Add: 01/01/1990 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,436 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A4340 INCON DEF MAXFEE 01/01/2014 20.12 0.0 Description: INDWELLING CATHETER SPECIAL Category: Incontinence CMS Add: 01/01/1990 CMS Term: A4341 INCON DEF MAXFEE 04/01/2023 259.60 0.0 Description: IDUC VALVE PAT INST REPL Category: Incontinence CMS Add: 04/01/2023 CMS Term: A4342 INCON DEF MAXFEE 04/01/2023 655.49 0.0 Description: IDUC VALVE SPLY REPL Category: Incontinence CMS Add: 04/01/2023 CMS Term: A4344 INCON DEF MAXFEE 01/01/2014 12.68 0.0 Description: CATH INDW FOLEY 2 WAY SILICN Category: Incontinence CMS Add: 01/01/1983 CMS Term: A4346 INCON DEF MAXFEE 01/01/2014 15.50 0.0 Description: CATH INDW FOLEY 3 WAY Category: Incontinence CMS Add: 01/01/1983 CMS Term: A4349 INCON DEF MAXFEE 01/01/2014 2.02 0.0 Description: DISPOSABLE MALE EXTERNAL CAT Category: Incontinence CMS Add: 01/01/2005 CMS Term: A4351 INCON DEF MAXFEE 01/01/2014 0.94 0.0 Description: STRAIGHT TIP URINE CATHETER Category: Incontinence CMS Add: 01/01/1990 CMS Term: A4352 INCON DEF MAXFEE 01/01/2014 5.71 0.0 Description: COUDE TIP URINARY CATHETER Category: Incontinence CMS Add: 01/01/1990 CMS Term: A4353 INCON DEF MAXFEE 01/01/2014 9.82 0.0 Description: INTERMITTENT URINARY CATH Category: Incontinence CMS Add: 01/01/1997 CMS Term: A4354 INCON DEF MAXFEE 01/01/2014 9.21 0.0 Description: CATH INSERTION TRAY W/BAG Category: Incontinence CMS Add: 01/01/1986 CMS Term: A4355 INCON DEF MAXFEE 01/01/2014 7.05 0.0 Description: BLADDER IRRIGATION TUBING Category: Incontinence CMS Add: 01/01/1984 CMS Term: A4356 INCON DEF MAXFEE 01/01/2014 36.10 0.0 Description: EXT URETH CLMP OR COMPR DVC Category: Incontinence CMS Add: 01/01/1985 CMS Term: A4357 INCON DEF MAXFEE 01/01/2014 7.67 0.0 Description: BEDSIDE DRAINAGE BAG Category: Incontinence CMS Add: 01/01/1985 CMS Term: A4358 INCON DEF MAXFEE 01/01/2014 4.46 0.0 Description: URINARY LEG OR ABDOMEN BAG Category: Incontinence CMS Add: 01/01/1985 CMS Term: A4360 INCON DEF MAXFEE 01/01/2014 12/31/2023 0.41 0.0 Description: DISPOSABLE EXT URETHRAL DEV Category: Incontinence CMS Add: 01/01/2010 CMS Term: A4360 INCON DEF MAXFEE 01/01/2024 0.65 0.0 Description: DISPOSABLE EXT URETHRAL DEV Category: Incontinence CMS Add: 01/01/2010 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,437 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A4361 INCON DEF MAXFEE 01/01/2014 14.54 0.0 Description: OSTOMY FACE PLATE Category: Incontinence CMS Add: 01/01/1985 CMS Term: A4362 INCON DEF MAXFEE 01/01/2014 2.95 0.0 Description: SOLID SKIN BARRIER Category: Incontinence CMS Add: 01/01/1985 CMS Term: A4363 INCON DEF MAXFEE 01/01/2014 2.36 0.0 Description: OSTOMY CLAMP, REPLACEMENT Category: Incontinence CMS Add: 01/01/2006 CMS Term: A4364 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 1.98 0.0 Description: ADHESIVE, LIQUID OR EQUAL Category: Medical Supplies CMS Add: 01/01/1985 CMS Term: A4364 MDSPY DEF MAXFEE 01/01/2024 3.32 0.0 Description: ADHESIVE, LIQUID OR EQUAL Category: Medical Supplies CMS Add: 01/01/1985 CMS Term: A4366 INCON DEF MAXFEE 01/01/2014 1.10 0.0 Description: OSTOMY VENT Category: Incontinence CMS Add: 01/01/2004 CMS Term: A4367 INCON DEF MAXFEE 01/01/2014 8.34 0.0 Description: OSTOMY BELT Category: Incontinence CMS Add: 01/01/1985 CMS Term: A4368 INCON DEF MAXFEE 01/01/2014 0.21 0.0 Description: OSTOMY FILTER Category: Incontinence CMS Add: 01/01/1997 CMS Term: A4369 INCON DEF MAXFEE 01/01/2014 1.91 0.0 Description: SKIN BARRIER LIQUID PER OZ Category: Incontinence CMS Add: 01/01/2000 CMS Term: A4371 INCON DEF MAXFEE 01/01/2014 2.89 0.0 Description: SKIN BARRIER POWDER PER OZ Category: Incontinence CMS Add: 01/01/2000 CMS Term: A4372 INCON DEF MAXFEE 01/01/2014 3.30 0.0 Description: SKIN BARRIER SOLID 4X4 EQUIV Category: Incontinence CMS Add: 01/01/2000 CMS Term: A4373 INCON DEF MAXFEE 01/01/2014 5.99 0.0 Description: SKIN BARRIER WITH FLANGE Category: Incontinence CMS Add: 01/01/2000 CMS Term: A4375 INCON DEF MAXFEE 01/01/2014 13.59 0.0 Description: DRAINABLE PLASTIC PCH W FCPL Category: Incontinence CMS Add: 01/01/2000 CMS Term: A4376 INCON DEF MAXFEE 01/01/2014 37.65 0.0 Description: DRAINABLE RUBBER PCH W FCPLT Category: Incontinence CMS Add: 01/01/2000 CMS Term: A4377 INCON DEF MAXFEE 01/01/2014 3.39 0.0 Description: DRAINABLE PLSTIC PCH W/O FP Category: Incontinence CMS Add: 01/01/2000 CMS Term: A4378 INCON DEF MAXFEE 01/01/2014 24.34 0.0 Description: DRAINABLE RUBBER PCH W/O FP Category: Incontinence CMS Add: 01/01/2000 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,438 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A4379 INCON DEF MAXFEE 01/01/2014 11.89 0.0 Description: URINARY PLASTIC POUCH W FCPL Category: Incontinence CMS Add: 01/01/2000 CMS Term: A4380 INCON DEF MAXFEE 01/01/2014 29.54 0.0 Description: URINARY RUBBER POUCH W FCPLT Category: Incontinence CMS Add: 01/01/2000 CMS Term: A4381 INCON DEF MAXFEE 01/01/2014 3.65 0.0 Description: URINARY PLASTIC POUCH W/O FP Category: Incontinence CMS Add: 01/01/2000 CMS Term: A4382 INCON DEF MAXFEE 01/01/2014 19.48 0.0 Description: URINARY HVY PLSTC PCH W/O FP Category: Incontinence CMS Add: 01/01/2000 CMS Term: A4383 INCON DEF MAXFEE 01/01/2014 22.30 0.0 Description: URINARY RUBBER POUCH W/O FP Category: Incontinence CMS Add: 01/01/2000 CMS Term: A4384 INCON DEF MAXFEE 01/01/2014 7.62 0.0 Description: OSTOMY FACEPLT/SILICONE RING Category: Incontinence CMS Add: 01/01/2000 CMS Term: A4385 INCON DEF MAXFEE 01/01/2014 4.03 0.0 Description: OST SKN BARRIER SLD EXT WEAR Category: Incontinence CMS Add: 01/01/2000 CMS Term: A4387 INCON DEF MAXFEE 01/01/2014 3.18 0.0 Description: OST CLSD POUCH W ATT ST BARR Category: Incontinence CMS Add: 01/01/2000 CMS Term: A4388 INCON DEF MAXFEE 01/01/2014 3.45 0.0 Description: DRAINABLE PCH W EX WEAR BARR Category: Incontinence CMS Add: 01/01/2000 CMS Term: A4389 INCON DEF MAXFEE 01/01/2014 4.92 0.0 Description: DRAINABLE PCH W ST WEAR BARR Category: Incontinence CMS Add: 01/01/2000 CMS Term: A4390 INCON DEF MAXFEE 01/01/2014 7.61 0.0 Description: DRAINABLE PCH EX WEAR CONVEX Category: Incontinence CMS Add: 01/01/2000 CMS Term: A4391 INCON DEF MAXFEE 01/01/2014 6.33 0.0 Description: URINARY POUCH W EX WEAR BARR Category: Incontinence CMS Add: 01/01/2000 CMS Term: A4392 INCON DEF MAXFEE 01/01/2014 5.26 0.0 Description: URINARY POUCH W ST WEAR BARR Category: Incontinence CMS Add: 01/01/2000 CMS Term: A4393 INCON DEF MAXFEE 01/01/2014 7.26 0.0 Description: URINE PCH W EX WEAR BAR CONV Category: Incontinence CMS Add: 01/01/2000 CMS Term: A4394 INCON DEF MAXFEE 01/01/2014 2.04 0.0 Description: OSTOMY POUCH LIQ DEODORANT Category: Incontinence CMS Add: 01/01/2000 CMS Term: A4395 INCON DEF MAXFEE 01/01/2014 0.04 0.0 Description: OSTOMY POUCH SOLID DEODORANT Category: Incontinence CMS Add: 01/01/2000 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,439 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A4396 INCON DEF MAXFEE 01/01/2014 32.03 0.0 Description: PERISTOMAL HERNIA SUPPRT BLT Category: Incontinence CMS Add: 01/01/2001 CMS Term: A4398 INCON DEF MAXFEE 01/01/2014 10.93 0.0 Description: OSTOMY IRRIGATION BAG Category: Incontinence CMS Add: 01/01/1989 CMS Term: A4399 INCON DEF MAXFEE 01/01/2014 9.70 0.0 Description: OSTOMY IRRIG CONE/CATH W BRS Category: Incontinence CMS Add: 01/01/1989 CMS Term: A4400 INCON DEF MAXFEE 01/01/2014 34.15 0.0 Description: OSTOMY IRRIGATION SET Category: Incontinence CMS Add: 01/01/1982 CMS Term: A4402 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 1.07 0.0 Description: LUBRICANT PER OUNCE Category: Medical Supplies CMS Add: 01/01/1985 CMS Term: A4402 MDSPY DEF MAXFEE 01/01/2024 1.80 0.0 Description: LUBRICANT PER OUNCE Category: Medical Supplies CMS Add: 01/01/1985 CMS Term: A4404 INCON DEF MAXFEE 01/01/2014 1.32 0.0 Description: OSTOMY RING EACH Category: Incontinence CMS Add: 01/01/1985 CMS Term: A4405 INCON DEF MAXFEE 01/01/2014 4.73 0.0 Description: NONPECTIN BASED OSTOMY PASTE Category: Incontinence CMS Add: 01/01/2003 CMS Term: A4406 INCON DEF MAXFEE 01/01/2014 4.42 0.0 Description: PECTIN BASED OSTOMY PASTE Category: Incontinence CMS Add: 01/01/2003 CMS Term: A4407 INCON DEF MAXFEE 01/01/2014 7.45 0.0 Description: EXT WEAR OST SKN BARR <=4SQ" Category: Incontinence CMS Add: 01/01/2003 CMS Term: A4408 INCON DEF MAXFEE 01/01/2014 8.39 0.0 Description: EXT WEAR OST SKN BARR >4SQ" Category: Incontinence CMS Add: 01/01/2003 CMS Term: A4409 INCON DEF MAXFEE 01/01/2014 5.29 0.0 Description: OST SKN BARR CONVEX <=4 SQ I Category: Incontinence CMS Add: 01/01/2003 CMS Term: A4410 INCON DEF MAXFEE 01/01/2014 7.68 0.0 Description: OST SKN BARR EXTND >4 SQ Category: Incontinence CMS Add: 01/01/2003 CMS Term: A4411 INCON DEF MAXFEE 01/01/2014 5.10 0.0 Description: OST SKN BARR EXTND =4SQ Category: Incontinence CMS Add: 01/01/2006 CMS Term: A4412 INCON DEF MAXFEE 01/01/2014 2.70 0.0 Description: OST POUCH DRAIN HIGH OUTPUT Category: Incontinence CMS Add: 01/01/2006 CMS Term: A4413 INCON DEF MAXFEE 01/01/2014 4.68 0.0 Description: 2 PC DRAINABLE OST POUCH Category: Incontinence CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,440 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A4414 INCON DEF MAXFEE 01/01/2014 4.26 0.0 Description: OST SKNBAR W/O CONV<=4 SQ IN Category: Incontinence CMS Add: 01/01/2003 CMS Term: A4415 INCON DEF MAXFEE 01/01/2014 5.10 0.0 Description: OST SKN BARR W/O CONV >4 SQI Category: Incontinence CMS Add: 01/01/2003 CMS Term: A4416 INCON DEF MAXFEE 01/01/2014 2.75 0.0 Description: OST PCH CLSD W BARRIER/FILTR Category: Incontinence CMS Add: 01/01/2004 CMS Term: A4417 INCON DEF MAXFEE 01/01/2014 3.72 0.0 Description: OST PCH W BAR/BLTINCONV/FLTR Category: Incontinence CMS Add: 01/01/2004 CMS Term: A4418 INCON DEF MAXFEE 01/01/2014 1.81 0.0 Description: OST PCH CLSD W/O BAR W FILTR Category: Incontinence CMS Add: 01/01/2004 CMS Term: A4419 INCON DEF MAXFEE 01/01/2014 1.74 0.0 Description: OST PCH FOR BAR W FLANGE/FLT Category: Incontinence CMS Add: 01/01/2004 CMS Term: A4420 INCON DEF SYSMAN Description: OST PCH CLSD FOR BAR W LK FL Category: Incontinence CMS Add: 01/01/2004 CMS Term: A4421 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 0.15 0.0 Description: OSTOMY SUPPLY MISC Category: Medical Supplies CMS Add: 01/01/1985 CMS Term: A4421 MDSPY DEF MAXFEE 01/01/2024 0.20 0.0 Description: OSTOMY SUPPLY MISC Category: Medical Supplies CMS Add: 01/01/1985 CMS Term: A4422 INCON DEF MAXFEE 01/01/2014 0.10 0.0 Description: OST POUCH ABSORBENT MATERIAL Category: Incontinence CMS Add: 01/01/2003 CMS Term: A4423 INCON DEF MAXFEE 01/01/2014 1.86 0.0 Description: OST PCH FOR BAR W LK FL/FLTR Category: Incontinence CMS Add: 01/01/2004 CMS Term: A4424 INCON DEF MAXFEE 01/01/2014 4.75 0.0 Description: OST PCH DRAIN W BAR & FILTER Category: Incontinence CMS Add: 01/01/2004 CMS Term: A4425 INCON DEF MAXFEE 01/01/2014 3.58 0.0 Description: OST PCH DRAIN FOR BARRIER FL Category: Incontinence CMS Add: 01/01/2004 CMS Term: A4426 INCON DEF MAXFEE 01/01/2014 2.73 0.0 Description: OST PCH DRAIN 2 PIECE SYSTEM Category: Incontinence CMS Add: 01/01/2004 CMS Term: A4427 INCON DEF MAXFEE 01/01/2014 2.78 0.0 Description: OST PCH DRAIN/BARR LK FLNG/F Category: Incontinence CMS Add: 01/01/2004 CMS Term: A4428 INCON DEF MAXFEE 01/01/2014 6.51 0.0 Description: URINE OST POUCH W FAUCET/TAP Category: Incontinence CMS Add: 01/01/2004 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,441 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A4429 INCON DEF MAXFEE 01/01/2014 8.25 0.0 Description: URINE OST POUCH W BLTINCONV Category: Incontinence CMS Add: 01/01/2004 CMS Term: A4430 INCON DEF MAXFEE 01/01/2014 7.16 0.0 Description: OST URINE PCH W B/BLTIN CONV Category: Incontinence CMS Add: 01/01/2004 CMS Term: A4431 INCON DEF MAXFEE 01/01/2014 6.22 0.0 Description: OST PCH URINE W BARRIER/TAPV Category: Incontinence CMS Add: 01/01/2004 CMS Term: A4432 INCON DEF MAXFEE 01/01/2014 3.59 0.0 Description: OS PCH URINE W BAR/FANGE/TAP Category: Incontinence CMS Add: 01/01/2004 CMS Term: A4433 INCON DEF MAXFEE 01/01/2014 3.34 0.0 Description: URINE OST PCH BAR W LOCK FLN Category: Incontinence CMS Add: 01/01/2004 CMS Term: A4434 INCON DEF MAXFEE 01/01/2014 3.75 0.0 Description: OST PCH URINE W LOCK FLNG/FT Category: Incontinence CMS Add: 01/01/2004 CMS Term: A4435 INCON DEF MAXFEE 01/01/2013 12/31/2023 5.01 0.0 Description: 1PC OST PCH DRAIN HGH OUTPUT Category: Incontinence CMS Add: 01/01/2013 CMS Term: A4435 INCON DEF MAXFEE 01/01/2024 7.66 0.0 Description: 1PC OST PCH DRAIN HGH OUTPUT Category: Incontinence CMS Add: 01/01/2013 CMS Term: A4436 INCON DEF MAXFEE 01/01/2022 12/31/2023 16.48 0.0 Description: IRR SUPPLY SLEEV REUS PER MO Category: Incontinence CMS Add: 01/01/2022 CMS Term: A4436 INCON DEF MAXFEE 01/01/2024 22.39 0.0 Description: IRR SUPPLY SLEEV REUS PER MO Category: Incontinence CMS Add: 01/01/2022 CMS Term: A4437 INCON DEF MAXFEE 01/01/2022 12/31/2023 16.48 0.0 Description: IRR SUPPLY SLEEV DISP PER MO Category: Incontinence CMS Add: 01/01/2022 CMS Term: A4437 INCON DEF MAXFEE 01/01/2024 22.39 0.0 Description: IRR SUPPLY SLEEV DISP PER MO Category: Incontinence CMS Add: 01/01/2022 CMS Term: A4450 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 0.08 0.0 Description: NON-WATERPROOF TAPE Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A4450 MDSPY DEF MAXFEE 01/01/2024 0.10 0.0 Description: NON-WATERPROOF TAPE Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A4452 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 0.31 0.0 Description: WATERPROOF TAPE Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A4452 MDSPY DEF MAXFEE 01/01/2024 0.47 0.0 Description: WATERPROOF TAPE Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,442 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A4453 MDSPY DEF SYSMAN Description: REC CATH MAN PUMP ENEMA REPL Category: Medical Supplies CMS Add: 10/01/2021 CMS Term: A4455 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 2.43 0.0 Description: ADHESIVE REMOVER PER OUNCE Category: Medical Supplies CMS Add: 01/01/1989 CMS Term: A4455 MDSPY DEF MAXFEE 01/01/2024 1.61 0.0 Description: ADHESIVE REMOVER PER OUNCE Category: Medical Supplies CMS Add: 01/01/1989 CMS Term: A4456 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 0.21 0.0 Description: ADHESIVE REMOVER, WIPES Category: Medical Supplies CMS Add: 01/01/2010 CMS Term: A4456 MDSPY DEF MAXFEE 01/01/2024 0.32 0.0 Description: ADHESIVE REMOVER, WIPES Category: Medical Supplies CMS Add: 01/01/2010 CMS Term: A4458 INCON DEF SYSMAN Description: REUSABLE ENEMA BAG Category: Incontinence CMS Add: 01/01/2003 CMS Term: A4459 MDSPY DEF SYSMAN Y Description: MANUAL PUMP ENEMA, REUSABLE Category: Medical Supplies CMS Add: 01/01/2015 CMS Term: A4461 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 3.29 0.0 Description: SURGICL DRESS HOLD NON-REUSE Category: Medical Supplies CMS Add: 01/01/2007 CMS Term: A4461 MDSPY DEF MAXFEE 01/01/2024 4.39 0.0 Description: SURGICL DRESS HOLD NON-REUSE Category: Medical Supplies CMS Add: 01/01/2007 CMS Term: A4463 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 13.31 0.0 Description: SURGICAL DRESS HOLDER REUSE Category: Medical Supplies CMS Add: 01/01/2007 CMS Term: A4463 MDSPY DEF MAXFEE 01/01/2024 17.70 0.0 Description: SURGICAL DRESS HOLDER REUSE Category: Medical Supplies CMS Add: 01/01/2007 CMS Term: A4465 NOCOV DEF SYSMAN Description: NON-ELASTIC EXTREMITY BINDER Category: Non Covered Services CMS Add: 01/01/1994 CMS Term: A4467 MDSPY DEF SYSMAN Y Description: BELT STRAP SLEEV GRMNT COVER Category: Medical Supplies CMS Add: 01/01/2017 CMS Term: A4468 NOCOV DEF SYSMAN Description: EXSUFF BELT INCL ALL SUP ACC Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: A4470 NOCOV DEF SYSMAN Description: GRAVLEE JET WASHER Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: A4480 NOCOV DEF SYSMAN Description: VABRA ASPIRATOR Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,443 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A4481 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 0.30 0.0 Description: TRACHEOSTOMA FILTER Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A4481 MDSPY DEF MAXFEE 01/01/2024 0.49 0.0 Description: TRACHEOSTOMA FILTER Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A4483 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 3.76 0.0 Description: MOISTURE EXCHANGER Category: Medical Supplies CMS Add: 01/01/1999 CMS Term: A4483 MDSPY DEF MAXFEE 01/01/2024 4.89 0.0 Description: MOISTURE EXCHANGER Category: Medical Supplies CMS Add: 01/01/1999 CMS Term: A4490 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 43.20 0.0 Description: ABOVE KNEE SURGICAL STOCKING Category: Medical Supplies CMS Add: 01/01/1986 CMS Term: A4490 MDSPY DEF MAXFEE 01/01/2024 56.16 0.0 Description: ABOVE KNEE SURGICAL STOCKING Category: Medical Supplies CMS Add: 01/01/1986 CMS Term: A4495 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 15.20 0.0 Description: THIGH LENGTH SURG STOCKING Category: Medical Supplies CMS Add: 01/01/1986 CMS Term: A4495 MDSPY DEF MAXFEE 01/01/2024 19.76 0.0 Description: THIGH LENGTH SURG STOCKING Category: Medical Supplies CMS Add: 01/01/1986 CMS Term: A4500 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 12.00 0.0 Description: BELOW KNEE SURGICAL STOCKING Category: Medical Supplies CMS Add: 01/01/1986 CMS Term: A4500 MDSPY DEF MAXFEE 01/01/2024 15.60 0.0 Description: BELOW KNEE SURGICAL STOCKING Category: Medical Supplies CMS Add: 01/01/1986 CMS Term: A4510 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 12.44 0.0 Description: FULL LENGTH SURG STOCKING Category: Medical Supplies CMS Add: 01/01/1986 CMS Term: A4510 MDSPY DEF MAXFEE 01/01/2024 16.17 0.0 Description: FULL LENGTH SURG STOCKING Category: Medical Supplies CMS Add: 01/01/1986 CMS Term: A4520 NOCOV DEF SYSMAN Description: INCONTINENCE GARMENT ANYTYPE Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: A4540 NOCOV DEF SYSMAN Description: TRANS ELEC NERV PERIPH NERV Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: A4541 NOCOV DEF SYSMAN Description: MONTHLY SUPP USE WITH E0733 Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: A4550 NOCOV DEF SYSMAN Description: SURGICAL TRAYS Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,444 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A4553 NOCOV DEF SYSMAN Description: NONDISP UNDERPADS, ALL SIZES Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: A4554 NOCOV DEF SYSMAN 3-999years Description: DISPOSABLE UNDERPADS Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: A4555 MDSPY DEF SYSMAN Y Y Description: CA TX E-STIM ELECTR/TRANSDUC Category: Medical Supplies CMS Add: 01/01/2014 CMS Term: A4556 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 4.80 0.0 Description: ELECTRODES, PAIR Category: Medical Supplies CMS Add: 01/01/1984 CMS Term: A4556 MDSPY DEF MAXFEE 01/01/2024 16.15 0.0 Description: ELECTRODES, PAIR Category: Medical Supplies CMS Add: 01/01/1984 CMS Term: A4557 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 9.60 0.0 Description: LEAD WIRES, PAIR Category: Medical Supplies CMS Add: 01/01/1984 CMS Term: A4557 MDSPY DEF MAXFEE 01/01/2024 9.44 0.0 Description: LEAD WIRES, PAIR Category: Medical Supplies CMS Add: 01/01/1984 CMS Term: A4558 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 3.70 0.0 Description: CONDUCTIVE GEL OR PASTE Category: Medical Supplies CMS Add: 01/01/1985 CMS Term: A4558 MDSPY DEF MAXFEE 01/01/2024 7.25 0.0 Description: CONDUCTIVE GEL OR PASTE Category: Medical Supplies CMS Add: 01/01/1985 CMS Term: A4559 NOCOV DEF SYSMAN Description: COUPLING GEL OR PASTE Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: A4560 NOCOV DEF SYSMAN Description: NMES DISPOSABLE Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: A4561 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 15.14 0.0 Description: PESSARY REUSABLE RUB ANYTYPE Category: Medical Supplies CMS Add: 01/01/2001 CMS Term: A4561 MDSPY DEF MAXFEE 01/01/2024 27.26 0.0 Description: PESSARY REUSABLE RUB ANYTYPE Category: Medical Supplies CMS Add: 01/01/2001 CMS Term: A4562 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 37.62 0.0 Description: PESSARY REUSABLE NONRUBBER Category: Medical Supplies CMS Add: 01/01/2001 CMS Term: A4562 MDSPY DEF MAXFEE 01/01/2024 67.72 0.0 Description: PESSARY REUSABLE NONRUBBER Category: Medical Supplies CMS Add: 01/01/2001 CMS Term: A4563 NOCOV DEF SYSMAN Description: VAG INSER RECTAL CONTROL SYS Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,445 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A4565 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 5.00 0.0 Description: SLINGS Category: Medical Supplies CMS Add: 01/01/1983 CMS Term: A4565 MDSPY DEF MAXFEE 01/01/2024 10.24 0.0 Description: SLINGS Category: Medical Supplies CMS Add: 01/01/1983 CMS Term: A4566 MDSPY DEF SYSMAN Y Description: SHOULD SLING/VEST/ABRESTRAIN Category: Medical Supplies CMS Add: 01/01/2011 CMS Term: A4570 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 14.40 0.0 Description: SPLINT Category: Medical Supplies CMS Add: 01/01/1982 CMS Term: A4570 MDSPY DEF MAXFEE 01/01/2024 18.72 0.0 Description: SPLINT Category: Medical Supplies CMS Add: 01/01/1982 CMS Term: A4575 NOCOV DEF SYSMAN Description: HYPERBARIC O2 CHAMBER DISPS Category: Non Covered Services CMS Add: 01/01/1996 CMS Term: A4580 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 7.96 0.0 Description: CAST SUPPLIES (PLASTER) Category: Medical Supplies CMS Add: 01/01/1982 CMS Term: A4580 MDSPY DEF MAXFEE 01/01/2024 10.35 0.0 Description: CAST SUPPLIES (PLASTER) Category: Medical Supplies CMS Add: 01/01/1982 CMS Term: A4590 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 14.32 0.0 Description: SPECIAL CASTING MATERIAL Category: Medical Supplies CMS Add: 01/01/1984 CMS Term: A4590 MDSPY DEF MAXFEE 01/01/2024 18.62 0.0 Description: SPECIAL CASTING MATERIAL Category: Medical Supplies CMS Add: 01/01/1984 CMS Term: A4595 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 22.94 0.0 Description: TENS SUPPL 2 LEAD PER MONTH Category: Medical Supplies CMS Add: 01/01/1996 CMS Term: A4595 MDSPY DEF MAXFEE 01/01/2024 10.29 0.0 Description: TENS SUPPL 2 LEAD PER MONTH Category: Medical Supplies CMS Add: 01/01/1996 CMS Term: A4596 NOCOV DEF SYSMAN Description: CES SYSTEM MONTHLY SUPP Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: A4600 NOCOV DEF SYSMAN Description: SLEEVE, INTER LIMB COMP DEV Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: A4601 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 280.54 0.0 Description: LITH ION NON PROSTH RECHARGE Category: Medical Supplies CMS Add: 01/01/2007 CMS Term: A4601 MDSPY DEF MAXFEE 01/01/2024 364.70 0.0 Description: LITH ION NON PROSTH RECHARGE Category: Medical Supplies CMS Add: 01/01/2007 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,446 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A4602 NU MDSPY PUR MAXFEE 01/01/2024 4.96 0.0 Description: REPLACE LITHIUM BATTERY 1.5V Category: Medical Supplies CMS Add: 01/01/2015 CMS Term: A4602 NU MDSPY PUR MAXFEE 02/12/2016 12/31/2023 3.30 0.0 Description: REPLACE LITHIUM BATTERY 1.5V Category: Medical Supplies CMS Add: 01/01/2015 CMS Term: A4604 NU MDSPY PUR MAXFEE 01/01/2014 12/31/2023 66.81 0.0 Description: TUBING WITH HEATING ELEMENT Category: Medical Supplies CMS Add: 01/01/2006 CMS Term: A4604 NU MDSPY PUR MAXFEE 01/01/2024 43.25 0.0 Description: TUBING WITH HEATING ELEMENT Category: Medical Supplies CMS Add: 01/01/2006 CMS Term: A4605 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 16.40 0.0 Description: TRACH SUCTION CATH CLOSE SYS Category: Medical Supplies CMS Add: 01/01/2005 CMS Term: A4605 MDSPY DEF MAXFEE 01/01/2024 21.81 0.0 Description: TRACH SUCTION CATH CLOSE SYS Category: Medical Supplies CMS Add: 01/01/2005 CMS Term: A4606 MDSPY DEF SYSMAN Y Y Description: OXYGEN PROBE USED W OXIMETER Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A4608 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 46.80 0.0 Y Description: TRANSTRACHEAL OXYGEN CATH Category: Medical Supplies CMS Add: 01/01/2001 CMS Term: A4608 MDSPY DEF MAXFEE 01/01/2024 66.67 0.0 Y Description: TRANSTRACHEAL OXYGEN CATH Category: Medical Supplies CMS Add: 01/01/2001 CMS Term: A4611 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 153.14 0.0 Description: HEAVY DUTY BATTERY Category: Medical Supplies CMS Add: 01/01/1990 CMS Term: A4611 MDSPY DEF MAXFEE 01/01/2024 199.08 0.0 Description: HEAVY DUTY BATTERY Category: Medical Supplies CMS Add: 01/01/1990 CMS Term: A4612 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 54.08 0.0 Description: BATTERY CABLES Category: Medical Supplies CMS Add: 01/01/1990 CMS Term: A4612 MDSPY DEF MAXFEE 01/01/2024 70.30 0.0 Description: BATTERY CABLES Category: Medical Supplies CMS Add: 01/01/1990 CMS Term: A4613 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 114.80 0.0 Description: BATTERY CHARGER Category: Medical Supplies CMS Add: 01/01/1990 CMS Term: A4613 MDSPY DEF MAXFEE 01/01/2024 149.24 0.0 Description: BATTERY CHARGER Category: Medical Supplies CMS Add: 01/01/1990 CMS Term: A4614 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 18.93 0.0 Description: HAND-HELD PEFR METER Category: Medical Supplies CMS Add: 01/01/1999 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,447 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A4614 MDSPY DEF MAXFEE 01/01/2024 31.63 0.0 Description: HAND-HELD PEFR METER Category: Medical Supplies CMS Add: 01/01/1999 CMS Term: A4615 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 1.56 0.0 Y Description: CANNULA NASAL Category: Medical Supplies CMS Add: 01/01/1990 CMS Term: A4615 MDSPY DEF MAXFEE 01/01/2024 0.97 0.0 Y Description: CANNULA NASAL Category: Medical Supplies CMS Add: 01/01/1990 CMS Term: A4616 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 3.08 0.0 Y Description: TUBING (OXYGEN) PER FOOT Category: Medical Supplies CMS Add: 01/01/1990 CMS Term: A4616 MDSPY DEF MAXFEE 01/01/2024 0.08 0.0 Y Description: TUBING (OXYGEN) PER FOOT Category: Medical Supplies CMS Add: 01/01/1990 CMS Term: A4617 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 3.58 0.0 Y Description: MOUTH PIECE Category: Medical Supplies CMS Add: 01/01/1990 CMS Term: A4617 MDSPY DEF MAXFEE 01/01/2024 4.12 0.0 Y Description: MOUTH PIECE Category: Medical Supplies CMS Add: 01/01/1990 CMS Term: A4618 NU MDSPY PUR MAXFEE 01/01/2014 12/31/2023 6.01 0.0 Y Description: BREATHING CIRCUITS Category: Medical Supplies CMS Add: 01/01/1990 CMS Term: A4618 NU MDSPY PUR MAXFEE 01/01/2024 10.06 0.0 Y Description: BREATHING CIRCUITS Category: Medical Supplies CMS Add: 01/01/1990 CMS Term: A4619 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 0.98 0.0 Y Description: FACE TENT Category: Medical Supplies CMS Add: 01/01/1990 CMS Term: A4619 MDSPY DEF MAXFEE 01/01/2024 2.38 0.0 Y Description: FACE TENT Category: Medical Supplies CMS Add: 01/01/1990 CMS Term: A4620 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 2.32 0.0 Y Description: VARIABLE CONCENTRATION MASK Category: Medical Supplies CMS Add: 01/01/1990 CMS Term: A4620 MDSPY DEF MAXFEE 01/01/2024 0.85 0.0 Y Description: VARIABLE CONCENTRATION MASK Category: Medical Supplies CMS Add: 01/01/1990 CMS Term: A4623 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 5.18 0.0 Description: TRACHEOSTOMY INNER CANNULA Category: Medical Supplies CMS Add: 01/01/1990 CMS Term: A4623 MDSPY DEF MAXFEE 01/01/2024 8.72 0.0 Description: TRACHEOSTOMY INNER CANNULA Category: Medical Supplies CMS Add: 01/01/1990 CMS Term: A4624 NU MDSPY PUR MAXFEE 01/01/2014 12/31/2023 1.78 0.0 Description: TRACHEAL SUCTION TUBE Category: Medical Supplies CMS Add: 01/01/1990 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,448 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A4624 NU MDSPY PUR MAXFEE 01/01/2024 2.98 0.0 Description: TRACHEAL SUCTION TUBE Category: Medical Supplies CMS Add: 01/01/1990 CMS Term: A4625 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 4.66 0.0 Description: TRACH CARE KIT FOR NEW TRACH Category: Medical Supplies CMS Add: 01/01/1990 CMS Term: A4625 MDSPY DEF MAXFEE 01/01/2024 7.83 0.0 Description: TRACH CARE KIT FOR NEW TRACH Category: Medical Supplies CMS Add: 01/01/1990 CMS Term: A4626 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 2.53 0.0 Description: TRACHEOSTOMY CLEANING BRUSH Category: Medical Supplies CMS Add: 01/01/1990 CMS Term: A4626 MDSPY DEF MAXFEE 01/01/2024 4.24 0.0 Description: TRACHEOSTOMY CLEANING BRUSH Category: Medical Supplies CMS Add: 01/01/1990 CMS Term: A4627 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 25.80 0.0 Description: SPACER BAG/RESERVOIR Category: Medical Supplies CMS Add: 01/01/1991 CMS Term: A4627 MDSPY DEF MAXFEE 01/01/2024 33.54 0.0 Description: SPACER BAG/RESERVOIR Category: Medical Supplies CMS Add: 01/01/1991 CMS Term: A4628 NU MDSPY PUR MAXFEE 01/01/2014 12/31/2023 2.98 0.0 Description: OROPHARYNGEAL SUCTION CATH Category: Medical Supplies CMS Add: 01/01/1996 CMS Term: A4628 NU MDSPY PUR MAXFEE 01/01/2024 4.98 0.0 Description: OROPHARYNGEAL SUCTION CATH Category: Medical Supplies CMS Add: 01/01/1996 CMS Term: A4629 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 3.66 0.0 Description: TRACHEOSTOMY CARE KIT Category: Medical Supplies CMS Add: 01/01/1996 CMS Term: A4629 MDSPY DEF MAXFEE 01/01/2024 6.19 0.0 Description: TRACHEOSTOMY CARE KIT Category: Medical Supplies CMS Add: 01/01/1996 CMS Term: A4630 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 4.23 0.0 Description: REPL BAT T.E.N.S. OWN BY PT Category: Medical Supplies CMS Add: 01/01/1991 CMS Term: A4630 MDSPY DEF MAXFEE 01/01/2024 7.05 0.0 Description: REPL BAT T.E.N.S. OWN BY PT Category: Medical Supplies CMS Add: 01/01/1991 CMS Term: A4633 NU MDSPY PUR MAXFEE 01/01/2014 12/31/2023 34.88 0.0 Description: UVL REPLACEMENT BULB Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A4633 NU MDSPY PUR MAXFEE 01/01/2024 54.58 0.0 Description: UVL REPLACEMENT BULB Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A4634 MDSPY DEF SYSMAN Y Description: REPLACEMENT BULB TH LIGHTBOX Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,449 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A4635 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 4.07 0.0 Description: UNDERARM CRUTCH PAD Category: Medical Supplies CMS Add: 01/01/1991 CMS Term: A4635 MDSPY DEF MAXFEE 01/01/2024 6.79 0.0 Description: UNDERARM CRUTCH PAD Category: Medical Supplies CMS Add: 01/01/1991 CMS Term: A4636 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 3.34 0.0 Description: HANDGRIP FOR CANE ETC Category: Medical Supplies CMS Add: 01/01/1991 CMS Term: A4636 MDSPY DEF MAXFEE 01/01/2024 3.94 0.0 Description: HANDGRIP FOR CANE ETC Category: Medical Supplies CMS Add: 01/01/1991 CMS Term: A4637 NU MDSPY PUR MAXFEE 01/01/2014 12/31/2023 1.63 0.0 Description: REPL TIP CANE/CRUTCH/WALKER Category: Medical Supplies CMS Add: 01/01/1991 CMS Term: A4637 NU MDSPY PUR MAXFEE 01/01/2024 2.11 0.0 Description: REPL TIP CANE/CRUTCH/WALKER Category: Medical Supplies CMS Add: 01/01/1991 CMS Term: A4638 MDSPY DEF SYSMAN Y Description: REPL BATT PULSE GEN SYS Category: Medical Supplies CMS Add: 01/01/2004 CMS Term: A4639 NU MDSPY PUR MAXFEE 01/01/2014 12/31/2023 244.13 0.0 Description: INFRARED HT SYS REPLCMNT PAD Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A4639 NU MDSPY PUR MAXFEE 01/01/2024 382.10 0.0 Description: INFRARED HT SYS REPLCMNT PAD Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A4640 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 50.41 0.0 Description: ALTERNATING PRESSURE PAD Category: Medical Supplies CMS Add: 01/01/1991 CMS Term: A4640 MDSPY DEF MAXFEE 01/01/2024 59.30 0.0 Description: ALTERNATING PRESSURE PAD Category: Medical Supplies CMS Add: 01/01/1991 CMS Term: A4641 NOCOV DEF SYSMAN Description: RADIOPHARM DX AGENT NOC Category: Non Covered Services CMS Add: 01/01/1994 CMS Term: A4642 MDSPY DEF BILL90 Description: IN111 SATUMOMAB Category: Medical Supplies CMS Add: 01/01/1995 CMS Term: A4648 MDSPY DEF BILL90 Description: IMPLANTABLE TISSUE MARKER Category: Medical Supplies CMS Add: 01/01/2008 CMS Term: A4649 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 0.22 0.0 Description: SURGICAL SUPPLIES Category: Medical Supplies CMS Add: 01/01/1982 CMS Term: A4649 MDSPY DEF MAXFEE 01/01/2024 0.29 0.0 Description: SURGICAL SUPPLIES Category: Medical Supplies CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,450 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A4650 MDSPY DEF BILL90 Description: IMPLANT RADIATION DOSIMETER Category: Medical Supplies CMS Add: 01/01/2008 CMS Term: A4651 NOCOV DEF SYSMAN Description: CALIBRATED MICROCAP TUBE Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: A4652 NOCOV DEF SYSMAN Description: MICROCAPILLARY TUBE SEALANT Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: A4653 MDSPY DEF MAXFEE 04/06/2018 0.00 0.0 Description: PD CATHETER ANCHOR BELT Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A4657 NOCOV DEF SYSMAN Description: SYRINGE W/WO NEEDLE Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: A4660 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 27.78 0.0 Description: SPHYG/BP APP W CUFF AND STET Category: Medical Supplies CMS Add: 01/01/1986 CMS Term: A4660 MDSPY DEF MAXFEE 01/01/2024 36.11 0.0 Description: SPHYG/BP APP W CUFF AND STET Category: Medical Supplies CMS Add: 01/01/1986 CMS Term: A4663 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 27.80 0.0 Description: DIALYSIS BLOOD PRESSURE CUFF Category: Medical Supplies CMS Add: 01/01/1986 CMS Term: A4663 MDSPY DEF MAXFEE 01/01/2024 36.14 0.0 Description: DIALYSIS BLOOD PRESSURE CUFF Category: Medical Supplies CMS Add: 01/01/1986 CMS Term: A4670 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 40.00 0.0 Y Description: AUTOMATIC BP MONITOR, DIAL Category: Medical Supplies CMS Add: 01/01/1986 CMS Term: A4670 MDSPY DEF MAXFEE 01/01/2024 52.00 0.0 Y Description: AUTOMATIC BP MONITOR, DIAL Category: Medical Supplies CMS Add: 01/01/1986 CMS Term: A4671 NOCOV DEF SYSMAN Description: DISPOSABLE CYCLER SET Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: A4672 NOCOV DEF SYSMAN Description: DRAINAGE EXT LINE, DIALYSIS Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: A4673 NOCOV DEF SYSMAN Description: EXT LINE W EASY LOCK CONNECT Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: A4674 NOCOV DEF SYSMAN Description: CHEM/ANTISEPT SOLUTION, 8OZ Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: A4680 MDSPY DEF MAXFEE 04/06/2018 0.00 0.0 Description: ACTIVATED CARBON FILTER, EA Category: Medical Supplies CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,451 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A4690 MDSPY DEF MAXFEE 04/06/2018 0.00 0.0 Description: DIALYZER, EACH Category: Medical Supplies CMS Add: 01/01/1986 CMS Term: A4706 NOCOV DEF SYSMAN Description: BICARBONATE CONC SOL PER GAL Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: A4707 NOCOV DEF SYSMAN Description: BICARBONATE CONC POW PER PAC Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: A4708 NOCOV DEF SYSMAN Description: ACETATE CONC SOL PER GALLON Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: A4709 NOCOV DEF SYSMAN Description: ACID CONC SOL PER GALLON Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: A4714 MDSPY DEF MAXFEE 04/06/2018 0.00 0.0 Description: TREATED WATER PER GALLON Category: Medical Supplies CMS Add: 01/01/1986 CMS Term: A4719 NOCOV DEF SYSMAN Description: "Y SET" TUBING Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: A4720 NOCOV DEF SYSMAN Description: DIALYSAT SOL FLD VOL > 249CC Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: A4721 NOCOV DEF SYSMAN Description: DIALYSAT SOL FLD VOL > 999CC Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: A4722 NOCOV DEF SYSMAN Description: DIALYS SOL FLD VOL > 1999CC Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: A4723 NOCOV DEF SYSMAN Description: DIALYS SOL FLD VOL > 2999CC Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: A4724 NOCOV DEF SYSMAN Description: DIALYS SOL FLD VOL > 3999CC Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: A4725 NOCOV DEF SYSMAN Description: DIALYS SOL FLD VOL > 4999CC Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: A4726 NOCOV DEF SYSMAN Description: DIALYS SOL FLD VOL > 5999CC Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: A4728 NOCOV DEF SYSMAN Description: DIALYSATE SOLUTION, NON-DEX Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: A4730 MDSPY DEF MAXFEE 04/06/2018 0.00 0.0 Description: FISTULA CANNULATION SET, EA Category: Medical Supplies CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,452 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A4736 NOCOV DEF SYSMAN Description: TOPICAL ANESTHETIC, PER GRAM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: A4737 NOCOV DEF SYSMAN Description: INJ ANESTHETIC PER 10 ML Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: A4740 MDSPY DEF MAXFEE 04/06/2018 0.00 0.0 Description: SHUNT ACCESSORY Category: Medical Supplies CMS Add: 01/01/1986 CMS Term: A4750 NOCOV DEF SYSMAN Description: ART OR VENOUS BLOOD TUBING Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: A4755 NOCOV DEF SYSMAN Description: COMB ART/VENOUS BLOOD TUBING Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: A4760 MDSPY DEF MAXFEE 04/06/2018 0.00 0.0 Description: DIALYSATE SOL TEST KIT, EACH Category: Medical Supplies CMS Add: 01/01/1986 CMS Term: A4765 MDSPY DEF MAXFEE 04/06/2018 0.00 0.0 Description: DIALYSATE CONC POW PER PACK Category: Medical Supplies CMS Add: 01/01/1986 CMS Term: A4766 NOCOV DEF SYSMAN Description: DIALYSATE CONC SOL ADD 10 ML Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: A4770 MDSPY DEF MAXFEE 04/06/2018 0.00 0.0 Description: BLOOD COLLECTION TUBE/VACUUM Category: Medical Supplies CMS Add: 01/01/1986 CMS Term: A4771 MDSPY DEF MAXFEE 04/06/2018 0.00 0.0 Description: SERUM CLOTTING TIME TUBE Category: Medical Supplies CMS Add: 01/01/1986 CMS Term: A4772 MDSPY DEF MAXFEE 04/06/2018 0.00 0.0 Description: BLOOD GLUCOSE TEST STRIPS Category: Medical Supplies CMS Add: 01/01/1986 CMS Term: A4773 MDSPY DEF MAXFEE 04/06/2018 0.00 0.0 Description: OCCULT BLOOD TEST STRIPS Category: Medical Supplies CMS Add: 01/01/1986 CMS Term: A4774 MDSPY DEF MAXFEE 04/06/2018 0.00 0.0 Description: AMMONIA TEST STRIPS Category: Medical Supplies CMS Add: 01/01/1986 CMS Term: A4802 NOCOV DEF SYSMAN Description: PROTAMINE SULFATE PER 50 MG Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: A4860 MDSPY DEF MAXFEE 04/06/2018 0.00 0.0 Description: DISPOSABLE CATHETER TIPS Category: Medical Supplies CMS Add: 01/01/1986 CMS Term: A4870 MDSPY DEF MAXFEE 04/06/2018 0.00 0.0 Y Description: PLUMB/ELEC WK HM HEMO EQUIP Category: Medical Supplies CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,453 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A4890 NOCOV DEF SYSMAN Description: REPAIR/MAINT CONT HEMO EQUIP Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: A4911 NOCOV DEF SYSMAN Description: DRAIN BAG/BOTTLE Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: A4913 MDSPY DEF MAXFEE 04/06/2018 0.00 0.0 Description: MISC DIALYSIS SUPPLIES NOC Category: Medical Supplies CMS Add: 01/01/1986 CMS Term: A4918 MDSPY DEF MAXFEE 04/06/2018 0.00 0.0 Description: VENOUS PRESSURE CLAMP Category: Medical Supplies CMS Add: 01/01/1986 CMS Term: A4927 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 10.00 0.0 0-5 Description: NON-STERILE GLOVES Category: Medical Supplies CMS Add: 01/01/1986 CMS Term: A4927 MDSPY DEF MAXFEE 01/01/2024 13.00 0.0 0-5 Description: NON-STERILE GLOVES Category: Medical Supplies CMS Add: 01/01/1986 CMS Term: A4928 NOCOV DEF SYSMAN Description: SURGICAL MASK Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: A4929 NOCOV DEF SYSMAN Description: TOURNIQUET FOR DIALYSIS, EA Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: A4930 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 0.65 0.0 0-99 Description: STERILE, GLOVES PER PAIR Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A4930 MDSPY DEF MAXFEE 01/01/2024 0.85 0.0 0-99 Description: STERILE, GLOVES PER PAIR Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A4931 NOCOV DEF SYSMAN Description: REUSABLE ORAL THERMOMETER Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: A4932 NOCOV DEF SYSMAN Description: REUSABLE RECTAL THERMOMETER Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: A5051 INCON DEF MAXFEE 01/01/2014 2.46 0.0 Description: POUCH CLSD W BARR ATTACHED Category: Incontinence CMS Add: 01/01/1990 CMS Term: A5052 INCON DEF MAXFEE 01/01/2014 1.44 0.0 Description: CLSD OSTOMY POUCH W/O BARR Category: Incontinence CMS Add: 01/01/1990 CMS Term: A5053 INCON DEF MAXFEE 01/01/2014 1.38 0.0 Description: CLSD OSTOMY POUCH FACEPLATE Category: Incontinence CMS Add: 01/01/1990 CMS Term: A5054 INCON DEF MAXFEE 01/01/2014 1.34 0.0 Description: CLSD OSTOMY POUCH W/FLANGE Category: Incontinence CMS Add: 01/01/1990 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,454 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A5055 INCON DEF MAXFEE 01/01/2014 1.50 0.0 Description: STOMA CAP Category: Incontinence CMS Add: 01/01/1990 CMS Term: A5056 INCON DEF MAXFEE 01/01/2012 12/31/2023 4.01 0.0 Description: 1 PC OST POUCH W FILTER Category: Incontinence CMS Add: 01/01/2012 CMS Term: A5056 INCON DEF MAXFEE 01/01/2024 6.22 0.0 Description: 1 PC OST POUCH W FILTER Category: Incontinence CMS Add: 01/01/2012 CMS Term: A5057 INCON DEF MAXFEE 01/01/2012 12/31/2023 8.26 0.0 Description: 1 PC OST POU W BUILT-IN CONV Category: Incontinence CMS Add: 01/01/2012 CMS Term: A5057 INCON DEF MAXFEE 01/01/2024 12.77 0.0 Description: 1 PC OST POU W BUILT-IN CONV Category: Incontinence CMS Add: 01/01/2012 CMS Term: A5061 INCON DEF MAXFEE 01/01/2014 3.28 0.0 Description: POUCH DRAINABLE W BARRIER AT Category: Incontinence CMS Add: 01/01/1990 CMS Term: A5062 INCON DEF MAXFEE 01/01/2014 1.76 0.0 Description: DRNBLE OSTOMY POUCH W/O BARR Category: Incontinence CMS Add: 01/01/1990 CMS Term: A5063 INCON DEF MAXFEE 01/01/2014 2.67 0.0 Description: DRAIN OSTOMY POUCH W/FLANGE Category: Incontinence CMS Add: 01/01/1990 CMS Term: A5071 INCON DEF MAXFEE 01/01/2014 3.44 0.0 Description: URINARY POUCH W/BARRIER Category: Incontinence CMS Add: 01/01/1990 CMS Term: A5072 INCON DEF MAXFEE 01/01/2014 2.37 0.0 Description: URINARY POUCH W/O BARRIER Category: Incontinence CMS Add: 01/01/1990 CMS Term: A5073 INCON DEF MAXFEE 01/01/2014 3.17 0.0 Description: URINARY POUCH ON BARR W/FLNG Category: Incontinence CMS Add: 01/01/1990 CMS Term: A5081 INCON DEF MAXFEE 01/01/2014 2.22 0.0 Description: STOMA PLUG OR SEAL, ANY TYPE Category: Incontinence CMS Add: 01/01/1990 CMS Term: A5082 INCON DEF MAXFEE 01/01/2014 8.00 0.0 Description: CONTINENT STOMA CATHETER Category: Incontinence CMS Add: 01/01/1990 CMS Term: A5083 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 0.50 0.0 Description: STOMA ABSORPTIVE COVER Category: Medical Supplies CMS Add: 01/01/2008 CMS Term: A5083 MDSPY DEF MAXFEE 01/01/2024 0.86 0.0 Description: STOMA ABSORPTIVE COVER Category: Medical Supplies CMS Add: 01/01/2008 CMS Term: A5093 INCON DEF MAXFEE 01/01/2014 1.38 0.0 Description: OSTOMY ACCESSORY CONVEX INSE Category: Incontinence CMS Add: 01/01/1990 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,455 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A5102 INCON DEF MAXFEE 01/01/2014 28.25 0.0 Description: BEDSIDE DRAIN BTL W/WO TUBE Category: Incontinence CMS Add: 01/01/1990 CMS Term: A5105 INCON DEF MAXFEE 01/01/2014 32.26 0.0 Description: URINARY SUSPENSORY Category: Incontinence CMS Add: 01/01/1990 CMS Term: A5112 INCON DEF MAXFEE 01/01/2014 32.75 0.0 Description: URINARY LEG BAG Category: Incontinence CMS Add: 01/01/1990 CMS Term: A5113 INCON DEF MAXFEE 01/01/2014 3.16 0.0 Description: LATEX LEG STRAP Category: Incontinence CMS Add: 01/01/1990 CMS Term: A5114 INCON DEF MAXFEE 01/01/2014 7.07 0.0 Description: FOAM/FABRIC LEG STRAP Category: Incontinence CMS Add: 01/01/1990 CMS Term: A5120 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 0.22 0.0 Description: SKIN BARRIER, WIPE OR SWAB Category: Medical Supplies CMS Add: 01/01/2006 CMS Term: A5120 MDSPY DEF MAXFEE 01/01/2024 0.28 0.0 Description: SKIN BARRIER, WIPE OR SWAB Category: Medical Supplies CMS Add: 01/01/2006 CMS Term: A5121 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 5.55 0.0 Description: SOLID SKIN BARRIER 6X6 Category: Medical Supplies CMS Add: 01/01/1990 CMS Term: A5121 MDSPY DEF MAXFEE 01/01/2024 9.35 0.0 Description: SOLID SKIN BARRIER 6X6 Category: Medical Supplies CMS Add: 01/01/1990 CMS Term: A5122 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 9.67 0.0 Description: SOLID SKIN BARRIER 8X8 Category: Medical Supplies CMS Add: 01/01/1990 CMS Term: A5122 MDSPY DEF MAXFEE 01/01/2024 16.27 0.0 Description: SOLID SKIN BARRIER 8X8 Category: Medical Supplies CMS Add: 01/01/1990 CMS Term: A5126 INCON DEF MAXFEE 01/01/2014 0.96 0.0 Description: DISK/FOAM PAD +OR- ADHESIVE Category: Incontinence CMS Add: 01/01/1990 CMS Term: A5131 INCON DEF MAXFEE 01/01/2014 11.09 0.0 Description: APPLIANCE CLEANER Category: Incontinence CMS Add: 01/01/1990 CMS Term: A5200 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 8.94 0.0 Description: PERCUTANEOUS CATHETER ANCHOR Category: Medical Supplies CMS Add: 01/01/1999 CMS Term: A5200 MDSPY DEF MAXFEE 01/01/2024 15.04 0.0 Description: PERCUTANEOUS CATHETER ANCHOR Category: Medical Supplies CMS Add: 01/01/1999 CMS Term: A5500 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 62.40 0.0 Description: DIAB SHOE FOR DENSITY INSERT Category: Medical Supplies CMS Add: 01/01/1995 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,456 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A5500 MDSPY DEF MAXFEE 01/01/2024 84.57 0.0 Description: DIAB SHOE FOR DENSITY INSERT Category: Medical Supplies CMS Add: 01/01/1995 CMS Term: A5501 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 178.50 0.0 Y Description: DIABETIC CUSTOM MOLDED SHOE Category: Medical Supplies CMS Add: 01/01/1995 CMS Term: A5501 MDSPY DEF MAXFEE 01/01/2024 253.63 0.0 Y Description: DIABETIC CUSTOM MOLDED SHOE Category: Medical Supplies CMS Add: 01/01/1995 CMS Term: A5503 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 29.69 0.0 Description: DIABETIC SHOE W/ROLLER/ROCKR Category: Medical Supplies CMS Add: 01/01/1995 CMS Term: A5503 MDSPY DEF MAXFEE 01/01/2024 43.06 0.0 Description: DIABETIC SHOE W/ROLLER/ROCKR Category: Medical Supplies CMS Add: 01/01/1995 CMS Term: A5504 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 29.69 0.0 Description: DIABETIC SHOE WITH WEDGE Category: Medical Supplies CMS Add: 01/01/1995 CMS Term: A5504 MDSPY DEF MAXFEE 01/01/2024 43.06 0.0 Description: DIABETIC SHOE WITH WEDGE Category: Medical Supplies CMS Add: 01/01/1995 CMS Term: A5505 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 29.69 0.0 Description: DIAB SHOE W/METATARSAL BAR Category: Medical Supplies CMS Add: 01/01/1995 CMS Term: A5505 MDSPY DEF MAXFEE 01/01/2024 43.06 0.0 Description: DIAB SHOE W/METATARSAL BAR Category: Medical Supplies CMS Add: 01/01/1995 CMS Term: A5506 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 29.69 0.0 Description: DIABETIC SHOE W/OFF SET HEEL Category: Medical Supplies CMS Add: 01/01/1995 CMS Term: A5506 MDSPY DEF MAXFEE 01/01/2024 43.06 0.0 Description: DIABETIC SHOE W/OFF SET HEEL Category: Medical Supplies CMS Add: 01/01/1995 CMS Term: A5507 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 29.69 0.0 Description: MODIFICATION DIABETIC SHOE Category: Medical Supplies CMS Add: 01/01/1995 CMS Term: A5507 MDSPY DEF MAXFEE 01/01/2024 43.06 0.0 Description: MODIFICATION DIABETIC SHOE Category: Medical Supplies CMS Add: 01/01/1995 CMS Term: A5508 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 38.13 0.0 Description: DIABETIC DELUXE SHOE Category: Medical Supplies CMS Add: 01/01/2000 CMS Term: A5508 MDSPY DEF MAXFEE 01/01/2024 49.57 0.0 Description: DIABETIC DELUXE SHOE Category: Medical Supplies CMS Add: 01/01/2000 CMS Term: A5510 MDSPY DEF SYSMAN Y Description: COMPRESSION FORM SHOE INSERT Category: Medical Supplies CMS Add: 01/01/2002 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,457 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A5512 NU MDSPY PUR MAXFEE 01/01/2014 12/31/2023 24.22 0.0 0-6 Description: MULTI DEN INSERT DIRECT FORM Category: Medical Supplies CMS Add: 01/01/2006 CMS Term: A5512 NU MDSPY PUR MAXFEE 01/01/2024 34.49 0.0 0-6 Description: MULTI DEN INSERT DIRECT FORM Category: Medical Supplies CMS Add: 01/01/2006 CMS Term: A5513 NU MDSPY PUR MAXFEE 01/01/2014 12/31/2023 36.14 0.0 0-2 Description: MULTI DEN INSERT CUSTOM MOLD Category: Medical Supplies CMS Add: 01/01/2006 CMS Term: A5513 NU MDSPY PUR MAXFEE 01/01/2024 51.47 0.0 0-2 Description: MULTI DEN INSERT CUSTOM MOLD Category: Medical Supplies CMS Add: 01/01/2006 CMS Term: A5514 MDSPY DEF MAXFEE 01/01/2023 12/31/2023 54.17 0.0 Description: MULT DEN INSERT DIR CARV/CAM Category: Medical Supplies CMS Add: 01/01/2019 CMS Term: A5514 MDSPY DEF MAXFEE 01/01/2024 52.81 0.0 Description: MULT DEN INSERT DIR CARV/CAM Category: Medical Supplies CMS Add: 01/01/2019 CMS Term: A6000 MDSPY DEF SYSMAN Y Description: WOUND WARMING WOUND COVER Category: Medical Supplies CMS Add: 01/01/2002 CMS Term: A6010 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 24.50 0.0 Description: COLLAGEN BASED WOUND FILLER Category: Medical Supplies CMS Add: 01/01/2002 CMS Term: A6010 MDSPY DEF MAXFEE 01/01/2024 41.19 0.0 Description: COLLAGEN BASED WOUND FILLER Category: Medical Supplies CMS Add: 01/01/2002 CMS Term: A6011 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 1.94 0.0 Description: COLLAGEN GEL/PASTE WOUND FIL Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A6011 MDSPY DEF MAXFEE 01/01/2024 3.04 0.0 Description: COLLAGEN GEL/PASTE WOUND FIL Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A6021 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 16.63 0.0 Description: COLLAGEN DRESSING <=16 SQ IN Category: Medical Supplies CMS Add: 01/01/2001 CMS Term: A6021 MDSPY DEF MAXFEE 01/01/2024 27.96 0.0 Description: COLLAGEN DRESSING <=16 SQ IN Category: Medical Supplies CMS Add: 01/01/2001 CMS Term: A6022 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 16.63 0.0 Description: COLLAGEN DRSG>16<=48 SQ IN Category: Medical Supplies CMS Add: 01/01/2001 CMS Term: A6022 MDSPY DEF MAXFEE 01/01/2024 27.96 0.0 Description: COLLAGEN DRSG>16<=48 SQ IN Category: Medical Supplies CMS Add: 01/01/2001 CMS Term: A6023 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 150.58 0.0 Description: COLLAGEN DRESSING >48 SQ IN Category: Medical Supplies CMS Add: 01/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,458 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A6023 MDSPY DEF MAXFEE 01/01/2024 253.09 0.0 Description: COLLAGEN DRESSING >48 SQ IN Category: Medical Supplies CMS Add: 01/01/2001 CMS Term: A6024 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 4.90 0.0 Description: COLLAGEN DSG WOUND FILLER Category: Medical Supplies CMS Add: 01/01/2001 CMS Term: A6024 MDSPY DEF MAXFEE 01/01/2024 8.23 0.0 Description: COLLAGEN DSG WOUND FILLER Category: Medical Supplies CMS Add: 01/01/2001 CMS Term: A6025 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 25.20 0.0 Description: SILICONE GEL SHEET, EACH Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6025 MDSPY DEF MAXFEE 01/01/2024 32.76 0.0 Description: SILICONE GEL SHEET, EACH Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6154 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 11.38 0.0 Description: WOUND POUCH EACH Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6154 MDSPY DEF MAXFEE 01/01/2024 19.12 0.0 Description: WOUND POUCH EACH Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6196 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 5.82 0.0 Description: ALGINATE DRESSING <=16 SQ IN Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6196 MDSPY DEF MAXFEE 01/01/2024 9.79 0.0 Description: ALGINATE DRESSING <=16 SQ IN Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6197 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 13.01 0.0 Description: ALGINATE DRSG >16 <=48 SQ IN Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6197 MDSPY DEF MAXFEE 01/01/2024 21.87 0.0 Description: ALGINATE DRSG >16 <=48 SQ IN Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6198 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 8.55 0.0 Description: ALGINATE DRESSING > 48 SQ IN Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6198 MDSPY DEF MAXFEE 01/01/2024 11.12 0.0 Description: ALGINATE DRESSING > 48 SQ IN Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6199 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 4.18 0.0 Description: ALGINATE DRSG WOUND FILLER Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6199 MDSPY DEF MAXFEE 01/01/2024 7.02 0.0 Description: ALGINATE DRSG WOUND FILLER Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6203 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 2.65 0.0 Description: COMPOSITE DRSG <= 16 SQ IN Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,459 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A6203 MDSPY DEF MAXFEE 01/01/2024 4.48 0.0 Description: COMPOSITE DRSG <= 16 SQ IN Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6204 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 4.93 0.0 Description: COMPOSITE DRSG >16<=48 SQ IN Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6204 MDSPY DEF MAXFEE 01/01/2024 8.27 0.0 Description: COMPOSITE DRSG >16<=48 SQ IN Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6205 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 3.84 0.0 Description: COMPOSITE DRSG > 48 SQ IN Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6205 MDSPY DEF MAXFEE 01/01/2024 4.99 0.0 Description: COMPOSITE DRSG > 48 SQ IN Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6206 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 4.64 0.0 Description: CONTACT LAYER <= 16 SQ IN Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6206 MDSPY DEF MAXFEE 01/01/2024 6.03 0.0 Description: CONTACT LAYER <= 16 SQ IN Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6207 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 5.81 0.0 Description: CONTACT LAYER >16<= 48 SQ IN Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6207 MDSPY DEF MAXFEE 01/01/2024 9.77 0.0 Description: CONTACT LAYER >16<= 48 SQ IN Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6208 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 3.93 0.0 Description: CONTACT LAYER > 48 SQ IN Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6208 MDSPY DEF MAXFEE 01/01/2024 5.11 0.0 Description: CONTACT LAYER > 48 SQ IN Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6209 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 5.92 0.0 Description: FOAM DRSG <=16 SQ IN W/O BDR Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6209 MDSPY DEF MAXFEE 01/01/2024 9.94 0.0 Description: FOAM DRSG <=16 SQ IN W/O BDR Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6210 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 15.76 0.0 Description: FOAM DRG >16<=48 SQ IN W/O B Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6210 MDSPY DEF MAXFEE 01/01/2024 26.50 0.0 Description: FOAM DRG >16<=48 SQ IN W/O B Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6211 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 23.24 0.0 Description: FOAM DRG > 48 SQ IN W/O BRDR Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,460 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A6211 MDSPY DEF MAXFEE 01/01/2024 39.06 0.0 Description: FOAM DRG > 48 SQ IN W/O BRDR Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6212 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 7.67 0.0 Description: FOAM DRG <=16 SQ IN W/BORDER Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6212 MDSPY DEF MAXFEE 01/01/2024 12.91 0.0 Description: FOAM DRG <=16 SQ IN W/BORDER Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6213 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 10.63 0.0 Description: FOAM DRG >16<=48 SQ IN W/BDR Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6213 MDSPY DEF MAXFEE 01/01/2024 13.82 0.0 Description: FOAM DRG >16<=48 SQ IN W/BDR Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6214 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 8.14 0.0 Description: FOAM DRG > 48 SQ IN W/BORDER Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6214 MDSPY DEF MAXFEE 01/01/2024 13.69 0.0 Description: FOAM DRG > 48 SQ IN W/BORDER Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6215 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 0.16 0.0 Description: FOAM DRESSING WOUND FILLER Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6215 MDSPY DEF MAXFEE 01/01/2024 0.21 0.0 Description: FOAM DRESSING WOUND FILLER Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6216 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 0.04 0.0 Description: NON-STERILE GAUZE<=16 SQ IN Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6216 MDSPY DEF MAXFEE 01/01/2024 0.05 0.0 Description: NON-STERILE GAUZE<=16 SQ IN Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6217 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 0.28 0.0 Description: NON-STERILE GAUZE>16<=48 SQ Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6217 MDSPY DEF MAXFEE 01/01/2024 0.36 0.0 Description: NON-STERILE GAUZE>16<=48 SQ Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6218 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 0.40 0.0 Description: NON-STERILE GAUZE > 48 SQ IN Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6218 MDSPY DEF MAXFEE 01/01/2024 0.52 0.0 Description: NON-STERILE GAUZE > 48 SQ IN Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6219 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 0.75 0.0 Description: GAUZE <= 16 SQ IN W/BORDER Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,461 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A6219 MDSPY DEF MAXFEE 01/01/2024 1.27 0.0 Description: GAUZE <= 16 SQ IN W/BORDER Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6220 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 2.04 0.0 Description: GAUZE >16 <=48 SQ IN W/BORDR Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6220 MDSPY DEF MAXFEE 01/01/2024 3.45 0.0 Description: GAUZE >16 <=48 SQ IN W/BORDR Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6221 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 0.60 0.0 Description: GAUZE > 48 SQ IN W/BORDER Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6221 MDSPY DEF MAXFEE 01/01/2024 0.78 0.0 Description: GAUZE > 48 SQ IN W/BORDER Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6222 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 1.69 0.0 Description: GAUZE <=16 IN NO W/SAL W/O B Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6222 MDSPY DEF MAXFEE 01/01/2024 2.84 0.0 Description: GAUZE <=16 IN NO W/SAL W/O B Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6223 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 1.91 0.0 Description: GAUZE >16<=48 NO W/SAL W/O B Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6223 MDSPY DEF MAXFEE 01/01/2024 3.23 0.0 Description: GAUZE >16<=48 NO W/SAL W/O B Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6224 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 2.86 0.0 Description: GAUZE > 48 IN NO W/SAL W/O B Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6224 MDSPY DEF MAXFEE 01/01/2024 4.79 0.0 Description: GAUZE > 48 IN NO W/SAL W/O B Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6228 MDSPY DEF SYSMAN Y Description: GAUZE <= 16 SQ IN WATER/SAL Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6229 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 2.86 0.0 Description: GAUZE >16<=48 SQ IN WATR/SAL Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6229 MDSPY DEF MAXFEE 01/01/2024 4.79 0.0 Description: GAUZE >16<=48 SQ IN WATR/SAL Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6230 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 11.11 0.0 Description: GAUZE > 48 SQ IN WATER/SALNE Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6230 MDSPY DEF MAXFEE 01/01/2024 14.44 0.0 Description: GAUZE > 48 SQ IN WATER/SALNE Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,462 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A6231 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 3.70 0.0 Description: HYDROGEL DSG<=16 SQ IN Category: Medical Supplies CMS Add: 01/01/2001 CMS Term: A6231 MDSPY DEF MAXFEE 01/01/2024 6.24 0.0 Description: HYDROGEL DSG<=16 SQ IN Category: Medical Supplies CMS Add: 01/01/2001 CMS Term: A6232 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 5.45 0.0 Description: HYDROGEL DSG>16<=48 SQ IN Category: Medical Supplies CMS Add: 01/01/2001 CMS Term: A6232 MDSPY DEF MAXFEE 01/01/2024 9.13 0.0 Description: HYDROGEL DSG>16<=48 SQ IN Category: Medical Supplies CMS Add: 01/01/2001 CMS Term: A6233 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 15.18 0.0 Description: HYDROGEL DRESSING >48 SQ IN Category: Medical Supplies CMS Add: 01/01/2001 CMS Term: A6233 MDSPY DEF MAXFEE 01/01/2024 25.50 0.0 Description: HYDROGEL DRESSING >48 SQ IN Category: Medical Supplies CMS Add: 01/01/2001 CMS Term: A6234 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 5.18 0.0 Description: HYDROCOLLD DRG <=16 W/O BDR Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6234 MDSPY DEF MAXFEE 01/01/2024 8.71 0.0 Description: HYDROCOLLD DRG <=16 W/O BDR Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6235 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 13.31 0.0 Description: HYDROCOLLD DRG >16<=48 W/O B Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6235 MDSPY DEF MAXFEE 01/01/2024 22.37 0.0 Description: HYDROCOLLD DRG >16<=48 W/O B Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6236 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 21.56 0.0 Description: HYDROCOLLD DRG > 48 IN W/O B Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6236 MDSPY DEF MAXFEE 01/01/2024 36.24 0.0 Description: HYDROCOLLD DRG > 48 IN W/O B Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6237 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 6.26 0.0 Description: HYDROCOLLD DRG <=16 IN W/BDR Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6237 MDSPY DEF MAXFEE 01/01/2024 10.52 0.0 Description: HYDROCOLLD DRG <=16 IN W/BDR Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6238 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 18.03 0.0 Description: HYDROCOLLD DRG >16<=48 W/BDR Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6238 MDSPY DEF MAXFEE 01/01/2024 30.32 0.0 Description: HYDROCOLLD DRG >16<=48 W/BDR Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,463 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A6239 MDSPY DEF SYSMAN Y Description: HYDROCOLLD DRG > 48 IN W/BDR Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6240 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 9.69 0.0 Description: HYDROCOLLD DRG FILLER PASTE Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6240 MDSPY DEF MAXFEE 01/01/2024 16.29 0.0 Description: HYDROCOLLD DRG FILLER PASTE Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6241 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 2.03 0.0 Description: HYDROCOLLOID DRG FILLER DRY Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6241 MDSPY DEF MAXFEE 01/01/2024 3.42 0.0 Description: HYDROCOLLOID DRG FILLER DRY Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6242 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 4.80 0.0 Description: HYDROGEL DRG <=16 IN W/O BDR Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6242 MDSPY DEF MAXFEE 01/01/2024 8.05 0.0 Description: HYDROGEL DRG <=16 IN W/O BDR Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6243 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 9.74 0.0 Description: HYDROGEL DRG >16<=48 W/O BDR Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6243 MDSPY DEF MAXFEE 01/01/2024 16.39 0.0 Description: HYDROGEL DRG >16<=48 W/O BDR Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6244 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 31.08 0.0 Description: HYDROGEL DRG >48 IN W/O BDR Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6244 MDSPY DEF MAXFEE 01/01/2024 52.24 0.0 Description: HYDROGEL DRG >48 IN W/O BDR Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6245 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 5.75 0.0 Description: HYDROGEL DRG <= 16 IN W/BDR Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6245 MDSPY DEF MAXFEE 01/01/2024 9.67 0.0 Description: HYDROGEL DRG <= 16 IN W/BDR Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6246 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 7.85 0.0 Description: HYDROGEL DRG >16<=48 IN W/B Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6246 MDSPY DEF MAXFEE 01/01/2024 13.21 0.0 Description: HYDROGEL DRG >16<=48 IN W/B Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6247 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 18.82 0.0 Description: HYDROGEL DRG > 48 SQ IN W/B Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,464 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A6247 MDSPY DEF MAXFEE 01/01/2024 31.63 0.0 Description: HYDROGEL DRG > 48 SQ IN W/B Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6248 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 12.85 0.0 Description: HYDROGEL DRSG GEL FILLER Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6248 MDSPY DEF MAXFEE 01/01/2024 21.61 0.0 Description: HYDROGEL DRSG GEL FILLER Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6250 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 10.80 0.0 Description: SKIN SEAL PROTECT MOISTURIZR Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6250 MDSPY DEF MAXFEE 01/01/2024 14.04 0.0 Description: SKIN SEAL PROTECT MOISTURIZR Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6251 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 1.58 0.0 Description: ABSORPT DRG <=16 SQ IN W/O B Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6251 MDSPY DEF MAXFEE 01/01/2024 2.64 0.0 Description: ABSORPT DRG <=16 SQ IN W/O B Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6252 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 2.57 0.0 Description: ABSORPT DRG >16 <=48 W/O BDR Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6252 MDSPY DEF MAXFEE 01/01/2024 4.33 0.0 Description: ABSORPT DRG >16 <=48 W/O BDR Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6253 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 5.02 0.0 Description: ABSORPT DRG > 48 SQ IN W/O B Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6253 MDSPY DEF MAXFEE 01/01/2024 8.42 0.0 Description: ABSORPT DRG > 48 SQ IN W/O B Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6254 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 0.96 0.0 Description: ABSORPT DRG <=16 SQ IN W/BDR Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6254 MDSPY DEF MAXFEE 01/01/2024 1.59 0.0 Description: ABSORPT DRG <=16 SQ IN W/BDR Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6255 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 2.40 0.0 Description: ABSORPT DRG >16<=48 IN W/BDR Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6255 MDSPY DEF MAXFEE 01/01/2024 4.04 0.0 Description: ABSORPT DRG >16<=48 IN W/BDR Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6256 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 1.18 0.0 Description: ABSORPT DRG > 48 SQ IN W/BDR Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,465 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A6256 MDSPY DEF MAXFEE 01/01/2024 1.53 0.0 Description: ABSORPT DRG > 48 SQ IN W/BDR Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6257 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 1.21 0.0 Description: TRANSPARENT FILM <= 16 SQ IN Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6257 MDSPY DEF MAXFEE 01/01/2024 2.04 0.0 Description: TRANSPARENT FILM <= 16 SQ IN Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6258 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 3.40 0.0 Description: TRANSPARENT FILM >16<=48 IN Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6258 MDSPY DEF MAXFEE 01/01/2024 5.73 0.0 Description: TRANSPARENT FILM >16<=48 IN Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6259 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 8.66 0.0 Description: TRANSPARENT FILM > 48 SQ IN Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6259 MDSPY DEF MAXFEE 01/01/2024 14.54 0.0 Description: TRANSPARENT FILM > 48 SQ IN Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6260 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 2.33 0.0 Description: WOUND CLEANSER ANY TYPE/SIZE Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6260 MDSPY DEF MAXFEE 01/01/2024 3.03 0.0 Description: WOUND CLEANSER ANY TYPE/SIZE Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6261 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 0.98 0.0 Description: WOUND FILLER GEL/PASTE /OZ Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6261 MDSPY DEF MAXFEE 01/01/2024 1.27 0.0 Description: WOUND FILLER GEL/PASTE /OZ Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6262 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 1.20 0.0 Description: WOUND FILLER DRY FORM / GRAM Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6262 MDSPY DEF MAXFEE 01/01/2024 1.56 0.0 Description: WOUND FILLER DRY FORM / GRAM Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6266 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 1.52 0.0 Description: IMPREG GAUZE NO H20/SAL/YARD Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6266 MDSPY DEF MAXFEE 01/01/2024 2.54 0.0 Description: IMPREG GAUZE NO H20/SAL/YARD Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6402 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 0.27 0.0 Description: STERILE GAUZE <= 16 SQ IN Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,466 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A6402 MDSPY DEF MAXFEE 01/01/2024 0.15 0.0 Description: STERILE GAUZE <= 16 SQ IN Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6403 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 0.34 0.0 Description: STERILE GAUZE>16 <= 48 SQ IN Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6403 MDSPY DEF MAXFEE 01/01/2024 0.55 0.0 Description: STERILE GAUZE>16 <= 48 SQ IN Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6404 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 1.14 0.0 Description: STERILE GAUZE > 48 SQ IN Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6404 MDSPY DEF MAXFEE 01/01/2024 1.48 0.0 Description: STERILE GAUZE > 48 SQ IN Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A6407 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 1.88 0.0 Description: PACKING STRIPS, NON-IMPREG Category: Medical Supplies CMS Add: 01/01/2004 CMS Term: A6407 MDSPY DEF MAXFEE 01/01/2024 2.49 0.0 Description: PACKING STRIPS, NON-IMPREG Category: Medical Supplies CMS Add: 01/01/2004 CMS Term: A6410 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 0.33 0.0 Description: STERILE EYE PAD Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A6410 MDSPY DEF MAXFEE 01/01/2024 0.50 0.0 Description: STERILE EYE PAD Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A6411 MDSPY DEF SYSMAN Y Description: NON-STERILE EYE PAD Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A6412 MDSPY DEF SYSMAN Y Description: OCCLUSIVE EYE PATCH Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A6413 NOCOV DEF SYSMAN Description: ADHESIVE BANDAGE, FIRST-AID Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: A6441 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 0.67 0.0 Description: PAD BAND W>=3" <5"/YD Category: Medical Supplies CMS Add: 01/01/2004 CMS Term: A6441 MDSPY DEF MAXFEE 01/01/2024 0.91 0.0 Description: PAD BAND W>=3" <5"/YD Category: Medical Supplies CMS Add: 01/01/2004 CMS Term: A6442 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 0.17 0.0 Description: CONFORM BAND N/S W<3"/YD Category: Medical Supplies CMS Add: 01/01/2004 CMS Term: A6442 MDSPY DEF MAXFEE 01/01/2024 0.21 0.0 Description: CONFORM BAND N/S W<3"/YD Category: Medical Supplies CMS Add: 01/01/2004 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,467 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A6443 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 0.29 0.0 Description: CONFORM BAND N/S W>=3"<5"/YD Category: Medical Supplies CMS Add: 01/01/2004 CMS Term: A6443 MDSPY DEF MAXFEE 01/01/2024 0.37 0.0 Description: CONFORM BAND N/S W>=3"<5"/YD Category: Medical Supplies CMS Add: 01/01/2004 CMS Term: A6444 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 0.56 0.0 Description: CONFORM BAND N/S W>=5"/YD Category: Medical Supplies CMS Add: 01/01/2004 CMS Term: A6444 MDSPY DEF MAXFEE 01/01/2024 0.74 0.0 Description: CONFORM BAND N/S W>=5"/YD Category: Medical Supplies CMS Add: 01/01/2004 CMS Term: A6445 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 0.32 0.0 Description: CONFORM BAND S W <3"/YD Category: Medical Supplies CMS Add: 01/01/2004 CMS Term: A6445 MDSPY DEF MAXFEE 01/01/2024 0.42 0.0 Description: CONFORM BAND S W <3"/YD Category: Medical Supplies CMS Add: 01/01/2004 CMS Term: A6446 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 0.41 0.0 Description: CONFORM BAND S W>=3" <5"/YD Category: Medical Supplies CMS Add: 01/01/2004 CMS Term: A6446 MDSPY DEF MAXFEE 01/01/2024 0.52 0.0 Description: CONFORM BAND S W>=3" <5"/YD Category: Medical Supplies CMS Add: 01/01/2004 CMS Term: A6447 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 0.67 0.0 Description: CONFORM BAND S W >=5"/YD Category: Medical Supplies CMS Add: 01/01/2004 CMS Term: A6447 MDSPY DEF MAXFEE 01/01/2024 0.91 0.0 Description: CONFORM BAND S W >=5"/YD Category: Medical Supplies CMS Add: 01/01/2004 CMS Term: A6448 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 1.16 0.0 Description: LT COMPRES BAND <3"/YD Category: Medical Supplies CMS Add: 01/01/2004 CMS Term: A6448 MDSPY DEF MAXFEE 01/01/2024 1.53 0.0 Description: LT COMPRES BAND <3"/YD Category: Medical Supplies CMS Add: 01/01/2004 CMS Term: A6449 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 1.75 0.0 Description: LT COMPRES BAND >=3" <5"/YD Category: Medical Supplies CMS Add: 01/01/2004 CMS Term: A6449 MDSPY DEF MAXFEE 01/01/2024 2.33 0.0 Description: LT COMPRES BAND >=3" <5"/YD Category: Medical Supplies CMS Add: 01/01/2004 CMS Term: A6450 MDSPY DEF MAXFEE 01/01/2024 2.33 0.0 Description: LT COMPRES BAND >=5"/YD Category: Medical Supplies CMS Add: 01/01/2004 CMS Term: A6450 MDSPY DEF MAXFEE 04/28/2017 12/31/2023 1.56 0.0 Description: LT COMPRES BAND >=5"/YD Category: Medical Supplies CMS Add: 01/01/2004 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,468 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A6451 MDSPY DEF MAXFEE 01/01/2024 2.33 0.0 Description: MOD COMPRES BAND W>=3"<5"/YD Category: Medical Supplies CMS Add: 01/01/2004 CMS Term: A6451 MDSPY DEF MAXFEE 04/28/2017 12/31/2023 1.56 0.0 Description: MOD COMPRES BAND W>=3"<5"/YD Category: Medical Supplies CMS Add: 01/01/2004 CMS Term: A6452 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 5.91 0.0 Description: HIGH COMPRES BAND W>=3"<5"YD Category: Medical Supplies CMS Add: 01/01/2004 CMS Term: A6452 MDSPY DEF MAXFEE 01/01/2024 7.85 0.0 Description: HIGH COMPRES BAND W>=3"<5"YD Category: Medical Supplies CMS Add: 01/01/2004 CMS Term: A6453 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 0.61 0.0 Description: SELF-ADHER BAND W <3"/YD Category: Medical Supplies CMS Add: 01/01/2004 CMS Term: A6453 MDSPY DEF MAXFEE 01/01/2024 0.84 0.0 Description: SELF-ADHER BAND W <3"/YD Category: Medical Supplies CMS Add: 01/01/2004 CMS Term: A6454 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 0.77 0.0 Description: SELF-ADHER BAND W>=3" <5"/YD Category: Medical Supplies CMS Add: 01/01/2004 CMS Term: A6454 MDSPY DEF MAXFEE 01/01/2024 1.04 0.0 Description: SELF-ADHER BAND W>=3" <5"/YD Category: Medical Supplies CMS Add: 01/01/2004 CMS Term: A6455 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 1.39 0.0 Description: SELF-ADHER BAND >=5"/YD Category: Medical Supplies CMS Add: 01/01/2004 CMS Term: A6455 MDSPY DEF MAXFEE 01/01/2024 1.85 0.0 Description: SELF-ADHER BAND >=5"/YD Category: Medical Supplies CMS Add: 01/01/2004 CMS Term: A6456 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 1.28 0.0 Description: ZINC PASTE BAND W >=3"<5"/YD Category: Medical Supplies CMS Add: 01/01/2004 CMS Term: A6456 MDSPY DEF MAXFEE 01/01/2024 1.67 0.0 Description: ZINC PASTE BAND W >=3"<5"/YD Category: Medical Supplies CMS Add: 01/01/2004 CMS Term: A6457 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 1.14 0.0 Description: TUBULAR DRESSING Category: Medical Supplies CMS Add: 01/01/2006 CMS Term: A6457 MDSPY DEF MAXFEE 01/01/2024 1.51 0.0 Description: TUBULAR DRESSING Category: Medical Supplies CMS Add: 01/01/2006 CMS Term: A6460 MDSPY DEF SYSMAN Y Description: SYNTHETIC DRSG <= 16 SQ IN Category: Medical Supplies CMS Add: 01/01/2019 CMS Term: A6461 MDSPY DEF SYSMAN Y Description: SYNTHETIC DRSG >16<=48 SQ IN Category: Medical Supplies CMS Add: 01/01/2019 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,469 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A6501 MDSPY DEF SYSMAN Y Description: COMPRES BURNGARMENT BODYSUIT Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A6502 MDSPY DEF SYSMAN Y Description: COMPRES BURNGARMENT CHINSTRP Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A6503 MDSPY DEF SYSMAN Y Description: COMPRES BURNGARMENT FACEHOOD Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A6504 MDSPY DEF SYSMAN Y Description: CMPRSBURNGARMENT GLOVE-WRIST Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A6505 MDSPY DEF SYSMAN Y Description: CMPRSBURNGARMENT GLOVE-ELBOW Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A6506 MDSPY DEF SYSMAN Y Description: CMPRSBURNGRMNT GLOVE-AXILLA Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A6507 MDSPY DEF SYSMAN Y Description: CMPRS BURNGARMENT FOOT-KNEE Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A6508 MDSPY DEF SYSMAN Y Description: CMPRS BURNGARMENT FOOT-THIGH Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A6509 MDSPY DEF MAXFEE 01/01/2024 231.09 0.0 Description: COMPRES BURN GARMENT JACKET Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A6509 MDSPY DEF MAXFEE 12/15/2012 12/31/2023 177.76 0.0 Description: COMPRES BURN GARMENT JACKET Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A6510 MDSPY DEF SYSMAN Y Description: COMPRES BURN GARMENT LEOTARD Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A6511 MDSPY DEF SYSMAN Y Description: COMPRES BURN GARMENT PANTY Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A6512 MDSPY DEF SYSMAN Y Description: COMPRES BURN GARMENT, NOC Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A6513 MDSPY DEF SYSMAN Y Description: COMPRESS BURN MASK FACE/NECK Category: Medical Supplies CMS Add: 01/01/2006 CMS Term: A6530 MDSPY DEF SYSMAN Y Description: COMPRESSION STOCKING BK18-30 Category: Medical Supplies CMS Add: 01/01/2006 CMS Term: A6531 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 43.27 0.0 Description: COMPRESS STKING BK30-40 SURG Category: Medical Supplies CMS Add: 01/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,470 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A6531 MDSPY DEF MAXFEE 01/01/2024 57.53 0.0 Description: COMPRESS STKING BK30-40 SURG Category: Medical Supplies CMS Add: 01/01/2006 CMS Term: A6532 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 60.96 0.0 Description: COMPRESS STKING BK40-50 SURG Category: Medical Supplies CMS Add: 01/01/2006 CMS Term: A6532 MDSPY DEF MAXFEE 01/01/2024 81.07 0.0 Description: COMPRESS STKING BK40-50 SURG Category: Medical Supplies CMS Add: 01/01/2006 CMS Term: A6533 MDSPY DEF SYSMAN Y Description: GC STOCKING THIGHLNGTH 18-30 Category: Medical Supplies CMS Add: 01/01/2006 CMS Term: A6534 MDSPY DEF SYSMAN Y Description: GC STOCKING THIGHLNGTH 30-40 Category: Medical Supplies CMS Add: 01/01/2006 CMS Term: A6535 MDSPY DEF SYSMAN Y Description: GC STOCKING THIGHLNGTH 40+ Category: Medical Supplies CMS Add: 01/01/2006 CMS Term: A6536 MDSPY DEF SYSMAN Y Description: GC STOCKING FULL LNGTH 18-30 Category: Medical Supplies CMS Add: 01/01/2006 CMS Term: A6537 MDSPY DEF SYSMAN Y Description: GC STOCKING FULL LNGTH 30-40 Category: Medical Supplies CMS Add: 01/01/2006 CMS Term: A6538 MDSPY DEF SYSMAN Y Description: GC STOCKING FULL LNGTH 40+ Category: Medical Supplies CMS Add: 01/01/2006 CMS Term: A6539 MDSPY DEF SYSMAN Y Description: GC STOCKING WAISTLNGTH 18-30 Category: Medical Supplies CMS Add: 01/01/2006 CMS Term: A6540 NU MDSPY PUR MAXFEE 01/01/2024 78.57 0.0 Description: GC STOCKING WAISTLNGTH 30-40 Category: Medical Supplies CMS Add: 01/01/2006 CMS Term: A6540 NU MDSPY PUR MAXFEE 09/01/2012 12/31/2023 60.44 0.0 Description: GC STOCKING WAISTLNGTH 30-40 Category: Medical Supplies CMS Add: 01/01/2006 CMS Term: A6541 MDSPY DEF SYSMAN Y Description: GC STOCKING WAISTLNGTH 40+ Category: Medical Supplies CMS Add: 01/01/2006 CMS Term: A6544 MDSPY DEF SYSMAN Y Description: GC STOCKING GARTER BELT Category: Medical Supplies CMS Add: 01/01/2006 CMS Term: A6545 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 71.56 0.0 Description: GRAD COM NON-ELASTIC BK SURG Category: Medical Supplies CMS Add: 01/01/2009 CMS Term: A6545 MDSPY DEF MAXFEE 01/01/2024 113.29 0.0 Description: GRAD COM NON-ELASTIC BK SURG Category: Medical Supplies CMS Add: 01/01/2009 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,471 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A6549 MDSPY DEF SYSMAN Y Description: G COMPRESSION GARMENT Category: Medical Supplies CMS Add: 01/01/2006 CMS Term: A6550 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 27.42 0.0 Y Description: NEG PRES WOUND THER DRSG SET Category: Medical Supplies CMS Add: 01/01/2004 CMS Term: A6550 MDSPY DEF MAXFEE 01/01/2024 29.49 0.0 Y Description: NEG PRES WOUND THER DRSG SET Category: Medical Supplies CMS Add: 01/01/2004 CMS Term: A6590 INCON DEF MAXFEE 04/01/2023 333.12 0.0 Description: URINARY CATH DISP SUC PUMP Category: Incontinence CMS Add: 04/01/2023 CMS Term: A6591 INCON DEF MAXFEE 04/01/2023 67.66 0.0 Description: URINARY CATH SUC PUMP Category: Incontinence CMS Add: 04/01/2023 CMS Term: A7000 NU MDSPY PUR MAXFEE 01/01/2014 12/31/2023 7.11 0.0 Description: DISPOSABLE CANISTER FOR PUMP Category: Medical Supplies CMS Add: 01/01/2000 CMS Term: A7000 NU MDSPY PUR MAXFEE 01/01/2024 9.63 0.0 Description: DISPOSABLE CANISTER FOR PUMP Category: Medical Supplies CMS Add: 01/01/2000 CMS Term: A7001 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 26.34 0.0 Description: NONDISPOSABLE PUMP CANISTER Category: Medical Supplies CMS Add: 01/01/2000 CMS Term: A7001 MDSPY DEF MAXFEE 01/01/2024 43.99 0.0 Description: NONDISPOSABLE PUMP CANISTER Category: Medical Supplies CMS Add: 01/01/2000 CMS Term: A7002 NU MDSPY PUR MAXFEE 01/01/2014 12/31/2023 3.05 0.0 Description: TUBING USED W SUCTION PUMP Category: Medical Supplies CMS Add: 01/01/2000 CMS Term: A7002 NU MDSPY PUR MAXFEE 01/01/2024 5.10 0.0 Description: TUBING USED W SUCTION PUMP Category: Medical Supplies CMS Add: 01/01/2000 CMS Term: A7003 NU MDSPY PUR MAXFEE 01/01/2014 12/31/2023 1.89 0.0 Description: NEBULIZER ADMINISTRATION SET Category: Medical Supplies CMS Add: 01/01/2000 CMS Term: A7003 NU MDSPY PUR MAXFEE 01/01/2024 1.63 0.0 Description: NEBULIZER ADMINISTRATION SET Category: Medical Supplies CMS Add: 01/01/2000 CMS Term: A7004 NU MDSPY PUR MAXFEE 01/01/2014 12/31/2023 1.43 0.0 Description: DISPOSABLE NEBULIZER SML VOL Category: Medical Supplies CMS Add: 01/01/2000 CMS Term: A7004 NU MDSPY PUR MAXFEE 01/01/2024 1.42 0.0 Description: DISPOSABLE NEBULIZER SML VOL Category: Medical Supplies CMS Add: 01/01/2000 CMS Term: A7005 NU MDSPY PUR MAXFEE 01/01/2014 12/31/2023 24.54 0.0 Description: NONDISPOSABLE NEBULIZER SET Category: Medical Supplies CMS Add: 01/01/2000 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,472 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A7005 NU MDSPY PUR MAXFEE 01/01/2024 15.79 0.0 Description: NONDISPOSABLE NEBULIZER SET Category: Medical Supplies CMS Add: 01/01/2000 CMS Term: A7006 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 7.60 0.0 Description: FILTERED NEBULIZER ADMIN SET Category: Medical Supplies CMS Add: 01/01/2000 CMS Term: A7006 MDSPY DEF MAXFEE 01/01/2024 9.11 0.0 Description: FILTERED NEBULIZER ADMIN SET Category: Medical Supplies CMS Add: 01/01/2000 CMS Term: A7007 NU MDSPY PUR MAXFEE 01/01/2023 12/31/2023 4.55 0.0 Description: LG VOL NEBULIZER DISPOSABLE Category: Medical Supplies CMS Add: 01/01/2000 CMS Term: A7007 NU MDSPY PUR MAXFEE 01/01/2024 4.14 0.0 Description: LG VOL NEBULIZER DISPOSABLE Category: Medical Supplies CMS Add: 01/01/2000 CMS Term: A7008 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 8.76 0.0 Description: DISPOSABLE NEBULIZER PREFILL Category: Medical Supplies CMS Add: 01/01/2000 CMS Term: A7008 MDSPY DEF MAXFEE 01/01/2024 14.62 0.0 Description: DISPOSABLE NEBULIZER PREFILL Category: Medical Supplies CMS Add: 01/01/2000 CMS Term: A7009 NU MDSPY PUR MAXFEE 01/01/2024 55.93 0.0 Description: NEBULIZER RESERVOIR BOTTLE Category: Medical Supplies CMS Add: 01/01/2000 CMS Term: A7009 NU MDSPY PUR MAXFEE 02/01/2021 12/31/2023 48.95 0.0 Description: NEBULIZER RESERVOIR BOTTLE Category: Medical Supplies CMS Add: 01/01/2000 CMS Term: A7010 NU MDSPY PUR MAXFEE 01/01/2014 12/31/2023 18.78 0.0 Description: DISPOSABLE CORRUGATED TUBING Category: Medical Supplies CMS Add: 01/01/2000 CMS Term: A7010 NU MDSPY PUR MAXFEE 01/01/2024 18.95 0.0 Description: DISPOSABLE CORRUGATED TUBING Category: Medical Supplies CMS Add: 01/01/2000 CMS Term: A7012 NU MDSPY PUR MAXFEE 01/01/2014 12/31/2023 2.57 0.0 Description: NEBULIZER WATER COLLEC DEVIC Category: Medical Supplies CMS Add: 01/01/2000 CMS Term: A7012 NU MDSPY PUR MAXFEE 01/01/2024 3.39 0.0 Description: NEBULIZER WATER COLLEC DEVIC Category: Medical Supplies CMS Add: 01/01/2000 CMS Term: A7013 NU MDSPY PUR MAXFEE 01/01/2014 12/31/2023 0.66 0.0 Description: DISPOSABLE COMPRESSOR FILTER Category: Medical Supplies CMS Add: 01/01/2000 CMS Term: A7013 NU MDSPY PUR MAXFEE 01/01/2024 0.78 0.0 Description: DISPOSABLE COMPRESSOR FILTER Category: Medical Supplies CMS Add: 01/01/2000 CMS Term: A7014 NU MDSPY PUR MAXFEE 01/01/2014 12/31/2023 3.58 0.0 Description: COMPRESSOR NONDISPOS FILTER Category: Medical Supplies CMS Add: 01/01/2000 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,473 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A7014 NU MDSPY PUR MAXFEE 01/01/2024 4.10 0.0 Description: COMPRESSOR NONDISPOS FILTER Category: Medical Supplies CMS Add: 01/01/2000 CMS Term: A7015 NU MDSPY PUR MAXFEE 01/01/2014 12/31/2023 1.36 0.0 Description: AEROSOL MASK USED W NEBULIZE Category: Medical Supplies CMS Add: 01/01/2000 CMS Term: A7015 NU MDSPY PUR MAXFEE 01/01/2024 1.51 0.0 Description: AEROSOL MASK USED W NEBULIZE Category: Medical Supplies CMS Add: 01/01/2000 CMS Term: A7016 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 5.77 0.0 Description: NEBULIZER DOME & MOUTHPIECE Category: Medical Supplies CMS Add: 01/01/2000 CMS Term: A7016 MDSPY DEF MAXFEE 01/01/2024 9.65 0.0 Description: NEBULIZER DOME & MOUTHPIECE Category: Medical Supplies CMS Add: 01/01/2000 CMS Term: A7017 NU MDSPY PUR MAXFEE 01/01/2023 12/31/2023 151.11 0.0 Description: NEBULIZER NOT USED W OXYGEN Category: Medical Supplies CMS Add: 01/01/2000 CMS Term: A7017 NU MDSPY PUR MAXFEE 01/01/2024 146.33 0.0 Description: NEBULIZER NOT USED W OXYGEN Category: Medical Supplies CMS Add: 01/01/2000 CMS Term: A7017 RR MDSPY RTL MAXFEE 01/01/2023 12/31/2023 15.12 0.0 Description: NEBULIZER NOT USED W OXYGEN Category: Medical Supplies CMS Add: 01/01/2000 CMS Term: A7017 RR MDSPY RTL MAXFEE 01/01/2024 14.63 0.0 Description: NEBULIZER NOT USED W OXYGEN Category: Medical Supplies CMS Add: 01/01/2000 CMS Term: A7018 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 0.30 0.0 Description: WATER DISTILLED W/NEBULIZER Category: Medical Supplies CMS Add: 01/01/2001 CMS Term: A7018 MDSPY DEF MAXFEE 01/01/2024 0.38 0.0 Description: WATER DISTILLED W/NEBULIZER Category: Medical Supplies CMS Add: 01/01/2001 CMS Term: A7020 NU MDSPY PUR MAXFEE 01/01/2024 19.25 0.0 Description: INTERFACE, COUGH STIM DEVICE Category: Medical Supplies CMS Add: 01/01/2011 CMS Term: A7020 NU MDSPY PUR MAXFEE 12/15/2012 12/31/2023 15.55 0.0 Description: INTERFACE, COUGH STIM DEVICE Category: Medical Supplies CMS Add: 01/01/2011 CMS Term: A7023 NOCOV DEF SYSMAN Description: MECH ALLERGEN PARTI BARRIER Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: A7025 NU MDSPY PUR MAXFEE 01/01/2014 12/31/2023 369.70 0.0 Y Description: REPLACE CHEST COMPRESS VEST Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A7025 NU MDSPY PUR MAXFEE 01/01/2024 578.50 0.0 Y Description: REPLACE CHEST COMPRESS VEST Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,474 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A7026 NU MDSPY PUR MAXFEE 01/01/2014 12/31/2023 24.44 0.0 Y Description: REPLACE CHST CMPRSS SYS HOSE Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A7026 NU MDSPY PUR MAXFEE 01/01/2024 38.23 0.0 Y Description: REPLACE CHST CMPRSS SYS HOSE Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A7027 NOCOV DEF SYSMAN Description: COMBINATION ORAL/NASAL MASK Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: A7028 NOCOV DEF SYSMAN Description: REPL ORAL CUSHION COMBO MASK Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: A7029 NOCOV DEF SYSMAN Description: REPL NASAL PILLOW COMB MASK Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: A7030 NU MDSPY PUR MAXFEE 01/01/2014 12/31/2023 160.34 0.0 Description: CPAP FULL FACE MASK Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A7030 NU MDSPY PUR MAXFEE 01/01/2024 100.69 0.0 Description: CPAP FULL FACE MASK Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A7031 NU MDSPY PUR MAXFEE 01/01/2014 12/31/2023 59.30 0.0 Description: REPLACEMENT FACEMASK INTERFA Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A7031 NU MDSPY PUR MAXFEE 01/01/2024 39.92 0.0 Description: REPLACEMENT FACEMASK INTERFA Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A7032 NU MDSPY PUR MAXFEE 01/01/2014 12/31/2023 34.45 0.0 Description: REPLACEMENT NASAL CUSHION Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A7032 NU MDSPY PUR MAXFEE 01/01/2024 21.85 0.0 Description: REPLACEMENT NASAL CUSHION Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A7033 NU MDSPY PUR MAXFEE 01/01/2014 12/31/2023 24.15 0.0 Description: REPLACEMENT NASAL PILLOWS Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A7033 NU MDSPY PUR MAXFEE 01/01/2024 18.16 0.0 Description: REPLACEMENT NASAL PILLOWS Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A7034 NU MDSPY PUR MAXFEE 01/01/2014 12/31/2023 99.99 0.0 Description: NASAL APPLICATION DEVICE Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A7034 NU MDSPY PUR MAXFEE 01/01/2024 64.49 0.0 Description: NASAL APPLICATION DEVICE Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A7035 NU MDSPY PUR MAXFEE 01/01/2014 12/31/2023 33.79 0.0 Description: POS AIRWAY PRESS HEADGEAR Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,475 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A7035 NU MDSPY PUR MAXFEE 01/01/2024 20.38 0.0 Description: POS AIRWAY PRESS HEADGEAR Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A7036 NU MDSPY PUR MAXFEE 01/01/2014 12/31/2023 15.47 0.0 Description: POS AIRWAY PRESS CHINSTRAP Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A7036 NU MDSPY PUR MAXFEE 01/01/2024 12.52 0.0 Description: POS AIRWAY PRESS CHINSTRAP Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A7037 NU MDSPY PUR MAXFEE 01/01/2014 12/31/2023 34.87 0.0 Description: POS AIRWAY PRESSURE TUBING Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A7037 NU MDSPY PUR MAXFEE 01/01/2024 14.15 0.0 Description: POS AIRWAY PRESSURE TUBING Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A7038 NU MDSPY PUR MAXFEE 01/01/2014 12/31/2023 4.58 0.0 Description: POS AIRWAY PRESSURE FILTER Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A7038 NU MDSPY PUR MAXFEE 01/01/2024 2.36 0.0 Description: POS AIRWAY PRESSURE FILTER Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A7039 NU MDSPY PUR MAXFEE 01/01/2014 12/31/2023 13.03 0.0 Description: FILTER, NON DISPOSABLE W PAP Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A7039 NU MDSPY PUR MAXFEE 01/01/2024 7.22 0.0 Description: FILTER, NON DISPOSABLE W PAP Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A7040 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 37.76 0.0 Description: ONE WAY CHEST DRAIN VALVE Category: Medical Supplies CMS Add: 01/01/2005 CMS Term: A7040 MDSPY DEF MAXFEE 01/01/2024 53.78 0.0 Description: ONE WAY CHEST DRAIN VALVE Category: Medical Supplies CMS Add: 01/01/2005 CMS Term: A7041 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 70.97 0.0 Description: WATER SEAL DRAIN CONTAINER Category: Medical Supplies CMS Add: 01/01/2005 CMS Term: A7041 MDSPY DEF MAXFEE 01/01/2024 101.09 0.0 Description: WATER SEAL DRAIN CONTAINER Category: Medical Supplies CMS Add: 01/01/2005 CMS Term: A7044 NU MDSPY PUR MAXFEE 01/01/2014 12/31/2023 102.77 0.0 Description: PAP ORAL INTERFACE Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A7044 NU MDSPY PUR MAXFEE 01/01/2024 106.38 0.0 Description: PAP ORAL INTERFACE Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A7045 NU MDSPY PUR MAXFEE 01/01/2014 12/31/2023 17.62 0.0 Description: REPL EXHALATION PORT FOR PAP Category: Medical Supplies CMS Add: 01/01/2005 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,476 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A7045 NU MDSPY PUR MAXFEE 01/01/2024 15.07 0.0 Description: REPL EXHALATION PORT FOR PAP Category: Medical Supplies CMS Add: 01/01/2005 CMS Term: A7045 RR MDSPY RTL MAXFEE 01/01/2014 12/31/2023 1.76 0.0 Description: REPL EXHALATION PORT FOR PAP Category: Medical Supplies CMS Add: 01/01/2005 CMS Term: A7045 RR MDSPY RTL MAXFEE 01/01/2024 1.67 0.0 Description: REPL EXHALATION PORT FOR PAP Category: Medical Supplies CMS Add: 01/01/2005 CMS Term: A7046 NU MDSPY PUR MAXFEE 01/01/2014 12/31/2023 19.51 0.0 Description: REPL WATER CHAMBER, PAP DEV Category: Medical Supplies CMS Add: 01/01/2004 CMS Term: A7046 NU MDSPY PUR MAXFEE 01/01/2024 15.49 0.0 Description: REPL WATER CHAMBER, PAP DEV Category: Medical Supplies CMS Add: 01/01/2004 CMS Term: A7047 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 312.22 0.0 Description: RESP SUCTION ORAL INTERFACE Category: Medical Supplies CMS Add: 01/01/2014 CMS Term: A7047 MDSPY DEF MAXFEE 01/01/2024 160.79 0.0 Description: RESP SUCTION ORAL INTERFACE Category: Medical Supplies CMS Add: 01/01/2014 CMS Term: A7048 MDSPY DEF MAXFEE 01/01/2015 12/31/2023 37.58 0.0 Description: VACUUM DRAIN BOTTLE/TUBE KIT Category: Medical Supplies CMS Add: 01/01/2015 CMS Term: A7048 MDSPY DEF MAXFEE 01/01/2024 56.30 0.0 Description: VACUUM DRAIN BOTTLE/TUBE KIT Category: Medical Supplies CMS Add: 01/01/2015 CMS Term: A7049 NOCOV DEF SYSMAN Description: EPAP NASAL VALVE Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: A7501 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 83.11 0.0 Description: TRACHEOSTOMA VALVE W DIAPHRA Category: Medical Supplies CMS Add: 01/01/2001 CMS Term: A7501 MDSPY DEF MAXFEE 01/01/2024 139.66 0.0 Description: TRACHEOSTOMA VALVE W DIAPHRA Category: Medical Supplies CMS Add: 01/01/2001 CMS Term: A7502 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 39.50 0.0 Description: REPLACEMENT DIAPHRAGM/FPLATE Category: Medical Supplies CMS Add: 01/01/2001 CMS Term: A7502 MDSPY DEF MAXFEE 01/01/2024 66.39 0.0 Description: REPLACEMENT DIAPHRAGM/FPLATE Category: Medical Supplies CMS Add: 01/01/2001 CMS Term: A7503 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 8.97 0.0 Description: HMES FILTER HOLDER OR CAP Category: Medical Supplies CMS Add: 01/01/2001 CMS Term: A7503 MDSPY DEF MAXFEE 01/01/2024 15.09 0.0 Description: HMES FILTER HOLDER OR CAP Category: Medical Supplies CMS Add: 01/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,477 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A7504 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 0.53 0.0 Description: TRACHEOSTOMA HMES FILTER Category: Medical Supplies CMS Add: 01/01/2001 CMS Term: A7504 MDSPY DEF MAXFEE 01/01/2024 0.91 0.0 Description: TRACHEOSTOMA HMES FILTER Category: Medical Supplies CMS Add: 01/01/2001 CMS Term: A7505 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 3.70 0.0 Description: HMES OR TRACH VALVE HOUSING Category: Medical Supplies CMS Add: 01/01/2001 CMS Term: A7505 MDSPY DEF MAXFEE 01/01/2024 6.24 0.0 Description: HMES OR TRACH VALVE HOUSING Category: Medical Supplies CMS Add: 01/01/2001 CMS Term: A7506 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 0.26 0.0 Description: HMES/TRACHVALVE ADHESIVEDISK Category: Medical Supplies CMS Add: 01/01/2001 CMS Term: A7506 MDSPY DEF MAXFEE 01/01/2024 0.43 0.0 Description: HMES/TRACHVALVE ADHESIVEDISK Category: Medical Supplies CMS Add: 01/01/2001 CMS Term: A7507 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 2.39 0.0 Description: INTEGRATED FILTER & HOLDER Category: Medical Supplies CMS Add: 01/01/2001 CMS Term: A7507 MDSPY DEF MAXFEE 01/01/2024 3.32 0.0 Description: INTEGRATED FILTER & HOLDER Category: Medical Supplies CMS Add: 01/01/2001 CMS Term: A7508 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 2.27 0.0 Description: HOUSING & INTEGRATED ADHESIV Category: Medical Supplies CMS Add: 01/01/2001 CMS Term: A7508 MDSPY DEF MAXFEE 01/01/2024 3.82 0.0 Description: HOUSING & INTEGRATED ADHESIV Category: Medical Supplies CMS Add: 01/01/2001 CMS Term: A7509 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 1.11 0.0 Description: HEAT & MOISTURE EXCHANGE SYS Category: Medical Supplies CMS Add: 01/01/2001 CMS Term: A7509 MDSPY DEF MAXFEE 01/01/2024 1.87 0.0 Description: HEAT & MOISTURE EXCHANGE SYS Category: Medical Supplies CMS Add: 01/01/2001 CMS Term: A7520 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 47.48 0.0 Description: TRACH/LARYN TUBE NON-CUFFED Category: Medical Supplies CMS Add: 01/01/2004 CMS Term: A7520 MDSPY DEF MAXFEE 01/01/2024 63.14 0.0 Description: TRACH/LARYN TUBE NON-CUFFED Category: Medical Supplies CMS Add: 01/01/2004 CMS Term: A7521 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 47.05 0.0 Description: TRACH/LARYN TUBE CUFFED Category: Medical Supplies CMS Add: 01/01/2004 CMS Term: A7521 MDSPY DEF MAXFEE 01/01/2024 62.56 0.0 Description: TRACH/LARYN TUBE CUFFED Category: Medical Supplies CMS Add: 01/01/2004 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,478 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A7522 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 45.16 0.0 Description: TRACH/LARYN TUBE STAINLESS Category: Medical Supplies CMS Add: 01/01/2004 CMS Term: A7522 MDSPY DEF MAXFEE 01/01/2024 60.06 0.0 Description: TRACH/LARYN TUBE STAINLESS Category: Medical Supplies CMS Add: 01/01/2004 CMS Term: A7523 MDSPY DEF SYSMAN Y Description: TRACHEOSTOMY SHOWER PROTECT Category: Medical Supplies CMS Add: 01/01/2004 CMS Term: A7524 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 77.40 0.0 Description: TRACHEOSTOMA STENT/STUD/BTTN Category: Medical Supplies CMS Add: 01/01/2004 CMS Term: A7524 MDSPY DEF MAXFEE 01/01/2024 102.95 0.0 Description: TRACHEOSTOMA STENT/STUD/BTTN Category: Medical Supplies CMS Add: 01/01/2004 CMS Term: A7525 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 1.56 0.0 Description: TRACHEOSTOMY MASK Category: Medical Supplies CMS Add: 01/01/2004 CMS Term: A7525 MDSPY DEF MAXFEE 01/01/2024 2.74 0.0 Description: TRACHEOSTOMY MASK Category: Medical Supplies CMS Add: 01/01/2004 CMS Term: A7526 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 3.26 0.0 Description: TRACHEOSTOMY TUBE COLLAR Category: Medical Supplies CMS Add: 01/01/2004 CMS Term: A7526 MDSPY DEF MAXFEE 01/01/2024 4.51 0.0 Description: TRACHEOSTOMY TUBE COLLAR Category: Medical Supplies CMS Add: 01/01/2004 CMS Term: A7527 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 3.04 0.0 Description: TRACH/LARYN TUBE PLUG/STOP Category: Medical Supplies CMS Add: 01/01/2005 CMS Term: A7527 MDSPY DEF MAXFEE 01/01/2024 4.76 0.0 Description: TRACH/LARYN TUBE PLUG/STOP Category: Medical Supplies CMS Add: 01/01/2005 CMS Term: A8000 NU MDSPY PUR MAXFEE 01/01/2014 12/31/2023 153.35 0.0 Description: SOFT PROTECT HELMET PREFAB Category: Medical Supplies CMS Add: 01/01/2007 CMS Term: A8000 NU MDSPY PUR MAXFEE 01/01/2024 203.96 0.0 Description: SOFT PROTECT HELMET PREFAB Category: Medical Supplies CMS Add: 01/01/2007 CMS Term: A8000 RR MDSPY RTL MAXFEE 01/01/2014 12/31/2023 15.33 0.0 Description: SOFT PROTECT HELMET PREFAB Category: Medical Supplies CMS Add: 01/01/2007 CMS Term: A8000 RR MDSPY RTL MAXFEE 01/01/2024 20.40 0.0 Description: SOFT PROTECT HELMET PREFAB Category: Medical Supplies CMS Add: 01/01/2007 CMS Term: A8001 NU MDSPY PUR MAXFEE 01/01/2014 12/31/2023 153.35 0.0 Description: HARD PROTECT HELMET PREFAB Category: Medical Supplies CMS Add: 01/01/2007 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,479 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A8001 NU MDSPY PUR MAXFEE 01/01/2024 203.96 0.0 Description: HARD PROTECT HELMET PREFAB Category: Medical Supplies CMS Add: 01/01/2007 CMS Term: A8001 RR MDSPY RTL MAXFEE 01/01/2014 12/31/2023 15.33 0.0 Description: HARD PROTECT HELMET PREFAB Category: Medical Supplies CMS Add: 01/01/2007 CMS Term: A8001 RR MDSPY RTL MAXFEE 01/01/2024 20.40 0.0 Description: HARD PROTECT HELMET PREFAB Category: Medical Supplies CMS Add: 01/01/2007 CMS Term: A8002 MDSPY DEF SYSMAN Y Y Description: SOFT PROTECT HELMET CUSTOM Category: Medical Supplies CMS Add: 01/01/2007 CMS Term: A8003 MDSPY DEF SYSMAN Y Y Description: HARD PROTECT HELMET CUSTOM Category: Medical Supplies CMS Add: 01/01/2007 CMS Term: A8004 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 70.00 0.0 Y Description: REPL SOFT INTERFACE, HELMET Category: Medical Supplies CMS Add: 01/01/2007 CMS Term: A8004 MDSPY DEF MAXFEE 01/01/2024 91.00 0.0 Y Description: REPL SOFT INTERFACE, HELMET Category: Medical Supplies CMS Add: 01/01/2007 CMS Term: A9150 NOCOV DEF SYSMAN Description: MISC/EXPER NON-PRESCRIPT DRU Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: A9152 NOCOV DEF SYSMAN Description: SINGLE VITAMIN NOS Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: A9153 NOCOV DEF SYSMAN Description: MULTI-VITAMIN NOS Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: A9155 MDSPY DEF SYSMAN Y Description: ARTIFICIAL SALIVA Category: Medical Supplies CMS Add: 01/01/2008 CMS Term: A9156 NOCOV DEF SYSMAN Description: ORAL MUCOADHESIVE PER 1 ML Category: Non Covered Services CMS Add: 10/01/2023 CMS Term: A9180 NOCOV DEF SYSMAN Description: LICE TREATMENT, TOPICAL Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: A9190 NOCOV DEF SYSMAN Description: MISC/EXPE PERSONAL COMFORT I Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: 12/31/2001 A9268 NOCOV DEF SYSMAN Description: PROGRAMMER ORALLY INGEST CAP Category: Non Covered Services CMS Add: 10/01/2023 CMS Term: A9269 NOCOV DEF SYSMAN Description: PROGRAMABLE INGEST CAPSULE Category: Non Covered Services CMS Add: 10/01/2023 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,480 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A9270 NOCOV DEF SYSMAN Description: NON-COVERED ITEM OR SERVICE Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: A9272 NOCOV DEF SYSMAN Description: DISP WOUND SUCT, DRSG/ACCESS Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: A9273 MDSPY DEF SYSMAN Y Description: HOT/COLD BOTLE/CAP/COL/WRAP Category: Medical Supplies CMS Add: 01/01/2011 CMS Term: A9274 NU MDSPY PUR MAXFEE 01/01/2014 12/31/2023 5297.70 0.0 Y Description: EXT AMB INSULIN DELIVERY SYS Category: Medical Supplies CMS Add: 01/01/2008 CMS Term: A9274 NU MDSPY PUR MAXFEE 01/01/2024 6887.01 0.0 Y Description: EXT AMB INSULIN DELIVERY SYS Category: Medical Supplies CMS Add: 01/01/2008 CMS Term: A9274 RR MDSPY RTL MAXFEE 01/01/2014 12/31/2023 353.18 0.0 Y Description: EXT AMB INSULIN DELIVERY SYS Category: Medical Supplies CMS Add: 01/01/2008 CMS Term: A9274 RR MDSPY RTL MAXFEE 01/01/2024 459.13 0.0 Y Description: EXT AMB INSULIN DELIVERY SYS Category: Medical Supplies CMS Add: 01/01/2008 CMS Term: A9275 NOCOV DEF SYSMAN Description: DISP HOME GLUCOSE MONITOR Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: A9276 NOCOV DEF SYSMAN Description: DISPOSABLE SENSOR, CGM SYS Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: A9277 NOCOV DEF SYSMAN Description: EXTERNAL TRANSMITTER, CGM Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: A9278 NOCOV DEF SYSMAN Description: EXTERNAL RECEIVER, CGM SYS Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: A9279 NU U5 U7 MFPTS W5M MAXFEE 07/16/2020 500.00 0.0 Y Description: MONITORING FEATURE/DEVICENOC Category: MFP SOF Waiver CMS Add: 01/01/2007 CMS Term: A9279 NU U5 U7 SSFS WSS MAXFEE 07/16/2020 500.00 0.0 Y Description: MONITORING FEATURE/DEVICENOC Category: Family Support Waivr CMS Add: 01/01/2007 CMS Term: A9279 U2 U5 U7 DDWA WDD MAXFEE 07/01/2023 12.13 0.0 Y Description: MONITORING FEATURE/DEVICENOC Category: CIH Waiver CMS Add: 01/01/2007 CMS Term: A9279 U2 U5 U7 DDWA WDD MAXFEE 10/01/2009 06/30/2023 6.81 0.0 Y Description: MONITORING FEATURE/DEVICENOC Category: CIH Waiver CMS Add: 01/01/2007 CMS Term: A9279 U2 U5 U7 MFPCI W3M MAXFEE 01/01/2014 06/30/2023 6.81 0.0 Y Description: MONITORING FEATURE/DEVICENOC Category: MFP CIH Waiver CMS Add: 01/01/2007 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,481 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A9279 U2 U5 U7 MFPCI W3M MAXFEE 07/01/2023 12.13 0.0 Y Description: MONITORING FEATURE/DEVICENOC Category: MFP CIH Waiver CMS Add: 01/01/2007 CMS Term: A9279 U2 U5 U7 MFPTS W5M MAXFEE 07/01/2023 12.13 0.0 Y Description: MONITORING FEATURE/DEVICENOC Category: MFP SOF Waiver CMS Add: 01/01/2007 CMS Term: A9279 U2 U5 U7 MFPTS W5M MAXFEE 07/16/2020 06/30/2023 6.81 0.0 Y Description: MONITORING FEATURE/DEVICENOC Category: MFP SOF Waiver CMS Add: 01/01/2007 CMS Term: A9279 U2 U5 U7 SSFS WSS MAXFEE 07/01/2023 12.13 0.0 Y Description: MONITORING FEATURE/DEVICENOC Category: Family Support Waivr CMS Add: 01/01/2007 CMS Term: A9279 U2 U5 U7 SSFS WSS MAXFEE 07/16/2020 06/30/2023 6.81 0.0 Y Description: MONITORING FEATURE/DEVICENOC Category: Family Support Waivr CMS Add: 01/01/2007 CMS Term: A9279 U3 U5 U7 DDWA WDD MAXFEE 07/01/2023 8.09 0.0 Y Description: MONITORING FEATURE/DEVICENOC Category: CIH Waiver CMS Add: 01/01/2007 CMS Term: A9279 U3 U5 U7 DDWA WDD MAXFEE 10/01/2009 06/30/2023 4.54 0.0 Y Description: MONITORING FEATURE/DEVICENOC Category: CIH Waiver CMS Add: 01/01/2007 CMS Term: A9279 U3 U5 U7 MFPCI W3M MAXFEE 01/01/2014 06/30/2023 4.54 0.0 Y Description: MONITORING FEATURE/DEVICENOC Category: MFP CIH Waiver CMS Add: 01/01/2007 CMS Term: A9279 U3 U5 U7 MFPCI W3M MAXFEE 07/01/2023 8.09 0.0 Y Description: MONITORING FEATURE/DEVICENOC Category: MFP CIH Waiver CMS Add: 01/01/2007 CMS Term: A9279 U3 U5 U7 MFPTS W5M MAXFEE 07/01/2023 8.09 0.0 Y Description: MONITORING FEATURE/DEVICENOC Category: MFP SOF Waiver CMS Add: 01/01/2007 CMS Term: A9279 U3 U5 U7 MFPTS W5M MAXFEE 07/16/2020 06/30/2023 4.54 0.0 Y Description: MONITORING FEATURE/DEVICENOC Category: MFP SOF Waiver CMS Add: 01/01/2007 CMS Term: A9279 U3 U5 U7 SSFS WSS MAXFEE 07/01/2023 8.09 0.0 Y Description: MONITORING FEATURE/DEVICENOC Category: Family Support Waivr CMS Add: 01/01/2007 CMS Term: A9279 U3 U5 U7 SSFS WSS MAXFEE 07/16/2020 06/30/2023 4.54 0.0 Y Description: MONITORING FEATURE/DEVICENOC Category: Family Support Waivr CMS Add: 01/01/2007 CMS Term: A9279 U4 U5 U7 DDWA WDD MAXFEE 07/01/2023 6.06 0.0 Y Description: MONITORING FEATURE/DEVICENOC Category: CIH Waiver CMS Add: 01/01/2007 CMS Term: A9279 U4 U5 U7 DDWA WDD MAXFEE 10/01/2009 06/30/2023 3.41 0.0 Y Description: MONITORING FEATURE/DEVICENOC Category: CIH Waiver CMS Add: 01/01/2007 CMS Term: A9279 U4 U5 U7 MFPCI W3M MAXFEE 01/01/2014 06/30/2023 3.41 0.0 Y Description: MONITORING FEATURE/DEVICENOC Category: MFP CIH Waiver CMS Add: 01/01/2007 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,482 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A9279 U4 U5 U7 MFPCI W3M MAXFEE 07/01/2023 6.06 0.0 Y Description: MONITORING FEATURE/DEVICENOC Category: MFP CIH Waiver CMS Add: 01/01/2007 CMS Term: A9279 U4 U5 U7 MFPTS W5M MAXFEE 07/01/2023 6.06 0.0 Y Description: MONITORING FEATURE/DEVICENOC Category: MFP SOF Waiver CMS Add: 01/01/2007 CMS Term: A9279 U4 U5 U7 MFPTS W5M MAXFEE 07/16/2020 06/30/2023 3.41 0.0 Y Description: MONITORING FEATURE/DEVICENOC Category: MFP SOF Waiver CMS Add: 01/01/2007 CMS Term: A9279 U4 U5 U7 SSFS WSS MAXFEE 07/01/2023 6.06 0.0 Y Description: MONITORING FEATURE/DEVICENOC Category: Family Support Waivr CMS Add: 01/01/2007 CMS Term: A9279 U4 U5 U7 SSFS WSS MAXFEE 07/16/2020 06/30/2023 3.41 0.0 Y Description: MONITORING FEATURE/DEVICENOC Category: Family Support Waivr CMS Add: 01/01/2007 CMS Term: A9279 U5 U7 UA DDWA WDD MAXFEE 07/01/2023 24.26 0.0 Y Description: MONITORING FEATURE/DEVICENOC Category: CIH Waiver CMS Add: 01/01/2007 CMS Term: A9279 U5 U7 UA DDWA WDD MAXFEE 10/01/2009 06/30/2023 13.62 0.0 Y Description: MONITORING FEATURE/DEVICENOC Category: CIH Waiver CMS Add: 01/01/2007 CMS Term: A9279 U5 U7 UA MFPCI W3M MAXFEE 01/01/2014 06/30/2023 13.62 0.0 Y Description: MONITORING FEATURE/DEVICENOC Category: MFP CIH Waiver CMS Add: 01/01/2007 CMS Term: A9279 U5 U7 UA MFPCI W3M MAXFEE 07/01/2023 24.26 0.0 Y Description: MONITORING FEATURE/DEVICENOC Category: MFP CIH Waiver CMS Add: 01/01/2007 CMS Term: A9279 U5 U7 UA MFPTS W5M MAXFEE 07/01/2023 24.26 0.0 Y Description: MONITORING FEATURE/DEVICENOC Category: MFP SOF Waiver CMS Add: 01/01/2007 CMS Term: A9279 U5 U7 UA MFPTS W5M MAXFEE 07/16/2020 06/30/2023 13.62 0.0 Y Description: MONITORING FEATURE/DEVICENOC Category: MFP SOF Waiver CMS Add: 01/01/2007 CMS Term: A9279 U5 U7 UA SSFS WSS MAXFEE 07/01/2023 24.26 0.0 Y Description: MONITORING FEATURE/DEVICENOC Category: Family Support Waivr CMS Add: 01/01/2007 CMS Term: A9279 U5 U7 UA SSFS WSS MAXFEE 07/16/2020 06/30/2023 13.62 0.0 Y Description: MONITORING FEATURE/DEVICENOC Category: Family Support Waivr CMS Add: 01/01/2007 CMS Term: A9280 NOCOV DEF SYSMAN Description: ALERT DEVICE, NOC Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: A9281 NOCOV DEF SYSMAN Description: REACHING/GRABBING DEVICE Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: A9282 NOCOV DEF SYSMAN Description: WIG ANY TYPE Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,483 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A9283 NOCOV DEF SYSMAN Description: FOOT PRESS OFF LOAD SUPP DEV Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: A9284 NOCOV DEF SYSMAN Description: NON-ELECTRONIC SPIROMETER Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: A9285 NOCOV DEF SYSMAN Description: INVERSION EVERSION COR DEVIC Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: A9286 MDSPY DEF SYSMAN Y Y Description: ANY HYGIENIC ITEM, DEVICE Category: Medical Supplies CMS Add: 01/01/2017 CMS Term: A9290 NOCOV DEF SYSMAN Description: DESCRIPTION OF SERVICE DO Category: Non Covered Services CMS Add: 01/01/1900 CMS Term: 06/30/2015 A9291 NOCOV DEF SYSMAN Description: PRES DIG COG BEHAV THERA FDA Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: A9292 NOCOV DEF SYSMAN Description: PRES DIG VISUAL THERAPY FDA Category: Non Covered Services CMS Add: 10/01/2023 CMS Term: A9300 NOCOV DEF SYSMAN Description: EXERCISE EQUIPMENT Category: Non Covered Services CMS Add: 01/01/1993 CMS Term: A9500 MDSPY DEF BILL90 Description: TC99M SESTAMIBI Category: Medical Supplies CMS Add: 01/01/1996 CMS Term: A9501 NOCOV DEF SYSMAN Description: TECHNETIUM TC-99M TEBOROXIME Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: A9502 MDSPY DEF BILL90 Description: TC99M TETROFOSMIN Category: Medical Supplies CMS Add: 01/01/1998 CMS Term: A9503 MDSPY DEF BILL90 Description: TC99M MEDRONATE Category: Medical Supplies CMS Add: 01/01/1997 CMS Term: A9504 MDSPY DEF BILL90 Description: TC99M APCITIDE Category: Medical Supplies CMS Add: 01/01/2000 CMS Term: A9505 MDSPY DEF BILL90 Description: TL201 THALLIUM Category: Medical Supplies CMS Add: 01/01/1996 CMS Term: A9507 MDSPY DEF BILL90 Description: IN111 CAPROMAB Category: Medical Supplies CMS Add: 01/01/1999 CMS Term: A9508 MDSPY DEF BILL90 Description: I131 IODOBENGUATE, DX Category: Medical Supplies CMS Add: 01/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,484 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A9509 NOCOV DEF SYSMAN Description: IODINE I-123 SOD IODIDE MIL Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: A9510 MDSPY DEF BILL90 Description: TC99M DISOFENIN Category: Medical Supplies CMS Add: 01/01/2001 CMS Term: A9512 NOCOV DEF SYSMAN Description: TC99M PERTECHNETATE Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: A9513 DRUG DEF MAXFEE 01/01/2024 293.45 0.0 Y Description: LUTETIUM LU 177 DOTATAT THER Category: Drugs CMS Add: 01/01/2019 CMS Term: A9513 DRUG DEF MAXFEE 04/01/2023 12/31/2023 287.70 0.0 Y Description: LUTETIUM LU 177 DOTATAT THER Category: Drugs CMS Add: 01/01/2019 CMS Term: A9515 NOCOV DEF SYSMAN Description: CHOLINE C-11 Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: A9516 NOCOV DEF SYSMAN Description: IODINE I-123 SOD IODIDE MIC Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: A9517 MDSPY DEF BILL90 Description: I131 IODIDE CAP, RX Category: Medical Supplies CMS Add: 01/01/2003 CMS Term: A9520 MDSPY DEF BILL90 Description: TC99 TILMANOCEPT DIAG 0.5MCI Category: Medical Supplies CMS Add: 01/01/2014 CMS Term: A9521 NOCOV DEF SYSMAN Description: TC99M EXAMETAZIME Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: A9524 NOCOV DEF SYSMAN Description: I131 SERUM ALBUMIN, DX Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: A9526 MDSPY DEF BILL90 Description: NITROGEN N-13 AMMONIA Category: Medical Supplies CMS Add: 01/01/2004 CMS Term: A9527 MEDSV L60 MAXFEE 09/21/2018 0.00 0.0 Description: IODINE I-125 SODIUM IODIDE Category: Medical Services CMS Add: 01/01/2007 CMS Term: A9528 NOCOV DEF SYSMAN Description: IODINE I-131 IODIDE CAP, DX Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: A9529 NOCOV DEF SYSMAN Description: I131 IODIDE SOL, DX Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: A9530 NOCOV DEF SYSMAN Description: I131 IODIDE SOL, RX Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,485 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A9531 NOCOV DEF SYSMAN Description: I131 MAX 100UCI Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: A9532 NOCOV DEF SYSMAN Description: I125 SERUM ALBUMIN, DX Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: A9536 NOCOV DEF SYSMAN Description: TC99M DEPREOTIDE Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: A9537 NOCOV DEF SYSMAN Description: TC99M MEBROFENIN Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: A9538 NOCOV DEF SYSMAN Description: TC99M PYROPHOSPHATE Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: A9539 NOCOV DEF SYSMAN Description: TC99M PENTETATE Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: A9540 NOCOV DEF SYSMAN Description: TC99M MAA Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: A9541 NOCOV DEF SYSMAN Description: TC99M SULFUR COLLOID Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: A9542 MDSPY DEF MAXFEE 01/01/2006 12/31/2023 1719.48 0.0 0-1 Description: IN111 IBRITUMOMAB, DX Category: Medical Supplies CMS Add: 01/01/2006 CMS Term: A9542 MDSPY DEF MAXFEE 01/01/2024 2235.32 0.0 0-1 Description: IN111 IBRITUMOMAB, DX Category: Medical Supplies CMS Add: 01/01/2006 CMS Term: A9543 MDSPY DEF MAXFEE 01/01/2006 12/31/2023 12505.30 0.0 0-1 Description: Y90 IBRITUMOMAB, RX Category: Medical Supplies CMS Add: 01/01/2006 CMS Term: A9543 MDSPY DEF MAXFEE 01/01/2024 16256.89 0.0 0-1 Description: Y90 IBRITUMOMAB, RX Category: Medical Supplies CMS Add: 01/01/2006 CMS Term: A9546 MDSPY DEF BILL90 Description: CO57/58 Category: Medical Supplies CMS Add: 01/01/2006 CMS Term: A9547 NOCOV DEF SYSMAN Description: IN111 OXYQUINOLINE Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: A9548 NOCOV DEF SYSMAN Description: IN111 PENTETATE Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: A9550 MDSPY DEF BILL90 Description: TC99M GLUCEPTATE Category: Medical Supplies CMS Add: 01/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,486 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A9551 NOCOV DEF SYSMAN Description: TC99M SUCCIMER Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: A9552 NOCOV DEF SYSMAN Description: F18 FDG Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: A9553 NOCOV DEF SYSMAN Description: CR51 CHROMATE Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: A9554 NOCOV DEF SYSMAN Description: I125 IOTHALAMATE, DX Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: A9555 MDSPY DEF BILL90 Description: RB82 RUBIDIUM Category: Medical Supplies CMS Add: 01/01/2006 CMS Term: A9556 MDSPY DEF BILL90 Description: GA67 GALLIUM Category: Medical Supplies CMS Add: 01/01/2006 CMS Term: A9557 MDSPY DEF BILL90 Description: TC99M BICISATE Category: Medical Supplies CMS Add: 01/01/2006 CMS Term: A9558 MDSPY DEF BILL90 Description: XE133 XENON 10MCI Category: Medical Supplies CMS Add: 01/01/2006 CMS Term: A9559 NOCOV DEF SYSMAN Description: CO57 CYANO Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: A9560 MDSPY DEF BILL90 Description: TC99M LABELED RBC Category: Medical Supplies CMS Add: 01/01/2006 CMS Term: A9561 MDSPY DEF BILL90 Description: TC99M OXIDRONATE Category: Medical Supplies CMS Add: 01/01/2006 CMS Term: A9562 MDSPY DEF BILL90 Description: TC99M MERTIATIDE Category: Medical Supplies CMS Add: 01/01/2006 CMS Term: A9563 MDSPY DEF BILL90 Description: P32 NA PHOSPHATE Category: Medical Supplies CMS Add: 01/01/2006 CMS Term: A9564 MDSPY DEF MAXFEE 01/01/2024 410.89 0.0 Description: P32 CHROMIC PHOSPHATE Category: Medical Supplies CMS Add: 01/01/2006 CMS Term: A9564 MDSPY DEF MAXFEE 02/01/2014 12/31/2023 316.07 0.0 Description: P32 CHROMIC PHOSPHATE Category: Medical Supplies CMS Add: 01/01/2006 CMS Term: A9566 NOCOV DEF SYSMAN Description: TC99M FANOLESOMAB Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,487 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A9567 NOCOV DEF SYSMAN Description: TECHNETIUM TC-99M AEROSOL Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: A9568 NOCOV DEF SYSMAN Description: TECHNETIUM TC99M ARCITUMOMAB Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: A9569 NOCOV DEF SYSMAN Description: TECHNETIUM TC-99M AUTO WBC Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: A9570 NOCOV DEF SYSMAN Description: INDIUM IN-111 AUTO WBC Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: A9571 NOCOV DEF SYSMAN Description: INDIUM IN-111 AUTO PLATELET Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: A9572 NOCOV DEF SYSMAN Description: INDIUM IN-111 PENTETREOTIDE Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: A9573 NOCOV DEF SYSMAN Description: INJ, GADOPICLENOL, 1 ML Category: Non Covered Services CMS Add: 10/01/2023 CMS Term: A9574 NOCOV DEF SYSMAN Description: AIR POLY INTRAUTERINE FOAM Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: A9575 NOCOV DEF SYSMAN Description: INJ GADOTERATE MEGLUMI 0.1ML Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: A9576 NOCOV DEF SYSMAN Description: INJ PROHANCE MULTIPACK Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: A9577 NOCOV DEF SYSMAN Description: INJ MULTIHANCE Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: A9578 NOCOV DEF SYSMAN Description: INJ MULTIHANCE MULTIPACK Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: A9579 NOCOV DEF SYSMAN Description: GAD-BASE MR CONTRAST NOS,1ML Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: A9580 MDSPY DEF BILL90 Description: SODIUM FLUORIDE F-18 Category: Medical Supplies CMS Add: 01/01/2009 CMS Term: A9581 NOCOV DEF SYSMAN Description: GADOXETATE DISODIUM INJ Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: A9582 NOCOV DEF SYSMAN Description: IODINE I-123 IOBENGUANE Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,488 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A9583 NOCOV DEF SYSMAN Description: GADOFOSVESET TRISODIUM INJ Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: A9584 NOCOV DEF SYSMAN Description: IODINE I-123 IOFLUPANE Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: A9585 NOCOV DEF SYSMAN Description: GADOBUTROL INJECTION Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: A9586 MDSPY DEF MAXFEE 01/01/2013 12/31/2023 1680.00 0.0 Description: FLORBETAPIR F18 Category: Medical Supplies CMS Add: 01/01/2013 CMS Term: A9586 MDSPY DEF MAXFEE 01/01/2024 2184.00 0.0 Description: FLORBETAPIR F18 Category: Medical Supplies CMS Add: 01/01/2013 CMS Term: A9587 NOCOV DEF SYSMAN Description: GALLIUM GA-68 Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: A9588 NOCOV DEF SYSMAN Description: FLUCICLOVINE F-18 Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: A9589 NOCOV DEF SYSMAN Description: INSTI HEXAMINOLEVULINATE HCL Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: A9590 NOCOV DEF SYSMAN Description: IODINE I-131 IOBENGUANE 1MCI Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: A9591 NOCOV DEF SYSMAN Description: FLUOROESTRADIOL F 18 Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: A9592 NOCOV DEF SYSMAN Description: COPPER CU 64 DOTATATE DIAG Category: Non Covered Services CMS Add: 04/01/2021 CMS Term: A9593 NOCOV DEF SYSMAN Description: GALLIUM GA-68 PSMA-11 UCSF Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: A9594 NOCOV DEF SYSMAN Description: GALLIUM GA-68 PSMA-11, UCLA Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: A9595 DRUG DEF MAXFEE 04/01/2024 609.31 0.0 Description: PIFLU F-18, DIA 1 MILLICURIE Category: Drugs CMS Add: 01/01/2022 CMS Term: A9595 DRUG DEF MAXFEE 04/28/2023 03/31/2024 574.88 0.0 Description: PIFLU F-18, DIA 1 MILLICURIE Category: Drugs CMS Add: 01/01/2022 CMS Term: A9596 DRUG DEF MAXFEE 01/01/2024 1033.20 0.0 Description: GALLIUM ILLUCCIX 1 MILLICURE Category: Drugs CMS Add: 07/01/2022 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,489 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A9596 DRUG DEF MAXFEE 12/11/2023 12/31/2023 987.00 0.0 Description: GALLIUM ILLUCCIX 1 MILLICURE Category: Drugs CMS Add: 07/01/2022 CMS Term: A9597 NOCOV DEF SYSMAN Description: PET, DX, FOR TUMOR ID, NOC Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: A9598 NOCOV DEF SYSMAN Description: PET DX FOR NON-TUMOR ID, NOC Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: A9600 MDSPY DEF BILL90 Description: SR89 STRONTIUM Category: Medical Supplies CMS Add: 01/01/1998 CMS Term: A9601 NOCOV DEF SYSMAN Description: FLORTAUCIPIR INJ 1 MILLICURI Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: A9602 NOCOV DEF SYSMAN Description: FLUORODOPA F-18 DIAG PER MCI Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: A9603 NOCOV DEF SYSMAN Description: INJ, PAFOLACIANINE, 0.1 MG Category: Non Covered Services CMS Add: 10/01/2023 CMS Term: A9604 MDSPY DEF MAXFEE 01/01/2024 22226.13 0.0 Description: SM 153 LEXIDRONAM Category: Medical Supplies CMS Add: 01/01/2010 CMS Term: A9604 MDSPY DEF MAXFEE 04/01/2020 12/31/2023 17097.02 0.0 Description: SM 153 LEXIDRONAM Category: Medical Supplies CMS Add: 01/01/2010 CMS Term: A9606 DRUG DEF MAXFEE 04/01/2023 09/30/2023 159.01 0.0 Description: RADIUM RA223 DICHLORIDE THER Category: Drugs CMS Add: 01/01/2015 CMS Term: A9606 DRUG DEF MAXFEE 04/01/2024 165.43 0.0 Description: RADIUM RA223 DICHLORIDE THER Category: Drugs CMS Add: 01/01/2015 CMS Term: A9606 DRUG DEF MAXFEE 10/01/2023 03/31/2024 162.19 0.0 Description: RADIUM RA223 DICHLORIDE THER Category: Drugs CMS Add: 01/01/2015 CMS Term: A9607 DRUG DEF MAXFEE 01/01/2024 238.97 0.0 Description: LUTETIUM LU 177 VIPIVOTIDE Category: Drugs CMS Add: 10/01/2022 CMS Term: A9607 DRUG DEF MAXFEE 04/01/2023 12/31/2023 227.59 0.0 Description: LUTETIUM LU 177 VIPIVOTIDE Category: Drugs CMS Add: 10/01/2022 CMS Term: A9608 DRUG DEF MAXFEE 01/01/2024 03/31/2024 5013.75 0.0 Description: FLOTUFOLASTAT F18 DIAG 1 MCI Category: Drugs CMS Add: 01/01/2024 CMS Term: A9608 DRUG DEF MAXFEE 04/01/2024 5164.16 0.0 Description: FLOTUFOLASTAT F18 DIAG 1 MCI Category: Drugs CMS Add: 01/01/2024 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,490 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- A9609 NOCOV DEF SYSMAN Description: F18 FDG, 15 MILLICURIES Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: A9697 NOCOV DEF SYSMAN Description: INJ, MAGTRACE PER STUDY DOSE Category: Non Covered Services CMS Add: 10/01/2023 CMS Term: A9698 NOCOV DEF SYSMAN Description: NON-RAD CONTRAST MATERIALNOC Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: A9699 NOCOV DEF SYSMAN Description: RADIOPHARM RX AGENT NOC Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: A9700 MDSPY DEF BILL90 Description: ECHOCARDIOGRAPHY CONTRAST Category: Medical Supplies CMS Add: 01/01/2001 CMS Term: A9800 DRUG DEF MAXFEE 12/11/2023 865.20 0.0 Description: GALLIUM LOCAMETZ 1 MILLICURI Category: Drugs CMS Add: 10/01/2022 CMS Term: A9900 NOCOV DEF SYSMAN Description: SUPPLY/ACCESSORY/SERVICE Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: A9901 NOCOV DEF SYSMAN Description: DELIVERY/SET UP/DISPENSING Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: A9999 MDSPY DEF SYSMAN Y Y Description: DME SUPPLY OR ACCESSORY, NOS Category: Medical Supplies CMS Add: 01/01/2004 CMS Term: B4034 DME DEF MAXFEE 01/01/2014 12/31/2023 5.60 0.0 Description: ENTER FEED SUPKIT SYR BY DAY Category: Durable Medical CMS Add: 01/01/1986 CMS Term: B4034 DME DEF MAXFEE 01/01/2024 3.39 0.0 Description: ENTER FEED SUPKIT SYR BY DAY Category: Durable Medical CMS Add: 01/01/1986 CMS Term: B4035 DME DEF MAXFEE 01/01/2014 12/31/2023 10.67 0.0 Description: ENTERAL FEED SUPP PUMP PER D Category: Durable Medical CMS Add: 01/01/1986 CMS Term: B4035 DME DEF MAXFEE 01/01/2024 5.49 0.0 Description: ENTERAL FEED SUPP PUMP PER D Category: Durable Medical CMS Add: 01/01/1986 CMS Term: B4036 DME DEF MAXFEE 01/01/2014 12/31/2023 7.31 0.0 Description: ENTERAL FEED SUP KIT GRAV BY Category: Durable Medical CMS Add: 01/01/1986 CMS Term: B4036 DME DEF MAXFEE 01/01/2024 4.73 0.0 Description: ENTERAL FEED SUP KIT GRAV BY Category: Durable Medical CMS Add: 01/01/1986 CMS Term: B4081 DME DEF MAXFEE 01/01/2014 12/31/2023 19.78 0.0 Description: ENTERAL NG TUBING W/ STYLET Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,491 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- B4081 DME DEF MAXFEE 01/01/2024 17.50 0.0 Description: ENTERAL NG TUBING W/ STYLET Category: Durable Medical CMS Add: 01/01/1986 CMS Term: B4082 DME DEF MAXFEE 01/01/2014 12/31/2023 14.73 0.0 Description: ENTERAL NG TUBING W/O STYLET Category: Durable Medical CMS Add: 01/01/1986 CMS Term: B4082 DME DEF MAXFEE 01/01/2024 12.27 0.0 Description: ENTERAL NG TUBING W/O STYLET Category: Durable Medical CMS Add: 01/01/1986 CMS Term: B4083 DME DEF MAXFEE 01/01/2014 12/31/2023 2.25 0.0 Description: ENTERAL STOMACH TUBE LEVINE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: B4083 DME DEF MAXFEE 01/01/2024 1.83 0.0 Description: ENTERAL STOMACH TUBE LEVINE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: B4087 DME DEF MAXFEE 01/01/2014 12/31/2023 17.03 0.0 Description: GASTRO/JEJUNO TUBE, STD Category: Durable Medical CMS Add: 01/01/2008 CMS Term: B4087 DME DEF MAXFEE 01/01/2024 29.50 0.0 Description: GASTRO/JEJUNO TUBE, STD Category: Durable Medical CMS Add: 01/01/2008 CMS Term: B4088 DME DEF MAXFEE 01/01/2014 12/31/2023 17.03 0.0 Description: GASTRO/JEJUNO TUBE, LOW-PRO Category: Durable Medical CMS Add: 01/01/2008 CMS Term: B4088 DME DEF MAXFEE 01/01/2024 35.06 0.0 Description: GASTRO/JEJUNO TUBE, LOW-PRO Category: Durable Medical CMS Add: 01/01/2008 CMS Term: B4100 DME DEF SYSMAN Y Y Description: FOOD THICKENER ORAL Category: Durable Medical CMS Add: 01/01/2003 CMS Term: B4102 DME DEF MAXFEE 01/01/2014 12/31/2023 4.41 0.0 Y Description: EF ADULT FLUIDS AND ELECTRO Category: Durable Medical CMS Add: 01/01/2005 CMS Term: B4102 DME DEF MAXFEE 01/01/2024 5.73 0.0 Y Description: EF ADULT FLUIDS AND ELECTRO Category: Durable Medical CMS Add: 01/01/2005 CMS Term: B4103 DME DEF MAXFEE 01/01/2014 12/31/2023 4.41 0.0 Y Description: EF PED FLUID AND ELECTROLYTE Category: Durable Medical CMS Add: 01/01/2005 CMS Term: B4103 DME DEF MAXFEE 01/01/2024 5.73 0.0 Y Description: EF PED FLUID AND ELECTROLYTE Category: Durable Medical CMS Add: 01/01/2005 CMS Term: B4104 NOCOV DEF SYSMAN Description: ADDITIVE FOR ENTERAL FORMULA Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: B4105 DME DEF SYSMAN Y Description: ENZYME CARTRIDGE ENTERAL NUT Category: Durable Medical CMS Add: 01/01/2019 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,492 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- B4149 DME DEF MAXFEE 01/01/2014 12/31/2023 1.70 0.0 Y Description: EF BLENDERIZED FOODS Category: Durable Medical CMS Add: 01/01/2005 CMS Term: B4149 DME DEF MAXFEE 01/01/2024 1.15 0.0 Y Description: EF BLENDERIZED FOODS Category: Durable Medical CMS Add: 01/01/2005 CMS Term: B4150 DME DEF MAXFEE 01/01/2014 12/31/2023 0.61 0.0 Y Description: EF COMPLET W/INTACT NUTRIENT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: B4150 DME DEF MAXFEE 01/01/2024 0.43 0.0 Y Description: EF COMPLET W/INTACT NUTRIENT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: B4150 U7 ADWA WAD MAXFEE 07/01/2008 1200.00 0.0 Y Description: EF COMPLET W/INTACT NUTRIENT Category: A&D Waiver CMS Add: 01/01/1986 CMS Term: B4150 U7 MFPAD W1M MAXFEE 06/02/2008 1200.00 0.0 Y Description: EF COMPLET W/INTACT NUTRIENT Category: MFP Demo Grant CMS Add: 01/01/1986 CMS Term: B4150 U7 MFPTB W2M MAXFEE 01/01/2010 1200.00 0.0 Y Description: EF COMPLET W/INTACT NUTRIENT Category: MFP TBI CMS Add: 01/01/1986 CMS Term: B4150 U7 TBIWA WTB MAXFEE 01/01/2010 1200.00 0.0 Y Description: EF COMPLET W/INTACT NUTRIENT Category: TBI Waiver CMS Add: 01/01/1986 CMS Term: B4152 DME DEF MAXFEE 01/01/2014 12/31/2023 0.51 0.0 Y Description: EF CALORIE DENSE>/=1.5KCAL Category: Durable Medical CMS Add: 01/01/1984 CMS Term: B4152 DME DEF MAXFEE 01/01/2024 0.36 0.0 Y Description: EF CALORIE DENSE>/=1.5KCAL Category: Durable Medical CMS Add: 01/01/1984 CMS Term: B4153 DME DEF MAXFEE 01/01/2014 12/31/2023 2.30 0.0 Y Description: EF HYDROLYZED/AMINO ACIDS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: B4153 DME DEF MAXFEE 01/01/2024 1.42 0.0 Y Description: EF HYDROLYZED/AMINO ACIDS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: B4154 DME DEF MAXFEE 01/01/2014 12/31/2023 2.92 0.0 Y Description: EF SPEC METABOLIC NONINHERIT Category: Durable Medical CMS Add: 01/01/1984 CMS Term: B4154 DME DEF MAXFEE 01/01/2024 0.74 0.0 Y Description: EF SPEC METABOLIC NONINHERIT Category: Durable Medical CMS Add: 01/01/1984 CMS Term: B4155 DME DEF MAXFEE 01/01/2014 12/31/2023 0.87 0.0 Y Description: EF INCOMPLETE/MODULAR Category: Durable Medical CMS Add: 01/01/1986 CMS Term: B4155 DME DEF MAXFEE 01/01/2024 0.83 0.0 Y Description: EF INCOMPLETE/MODULAR Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,493 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- B4157 DME DEF SYSMAN Y Y Description: EF SPECIAL METABOLIC INHERIT Category: Durable Medical CMS Add: 01/01/2005 CMS Term: B4158 DME DEF MAXFEE 01/01/2014 12/31/2023 1.01 0.0 Y Description: EF PED COMPLETE INTACT NUT Category: Durable Medical CMS Add: 01/01/2005 CMS Term: B4158 DME DEF MAXFEE 01/01/2024 1.31 0.0 Y Description: EF PED COMPLETE INTACT NUT Category: Durable Medical CMS Add: 01/01/2005 CMS Term: B4159 DME DEF MAXFEE 01/01/2014 12/31/2023 1.58 0.0 Y Description: EF PED COMPLETE SOY BASED Category: Durable Medical CMS Add: 01/01/2005 CMS Term: B4159 DME DEF MAXFEE 01/01/2024 2.05 0.0 Y Description: EF PED COMPLETE SOY BASED Category: Durable Medical CMS Add: 01/01/2005 CMS Term: B4160 DME DEF MAXFEE 01/01/2014 12/31/2023 1.07 0.0 Y Description: EF PED CALORIC DENSE>/=0.7KC Category: Durable Medical CMS Add: 01/01/2005 CMS Term: B4160 DME DEF MAXFEE 01/01/2024 1.39 0.0 Y Description: EF PED CALORIC DENSE>/=0.7KC Category: Durable Medical CMS Add: 01/01/2005 CMS Term: B4161 DME DEF MAXFEE 01/01/2014 12/31/2023 3.69 0.0 Y Description: EF PED HYDROLYZED/AMINO ACID Category: Durable Medical CMS Add: 01/01/2005 CMS Term: B4161 DME DEF MAXFEE 01/01/2024 4.80 0.0 Y Description: EF PED HYDROLYZED/AMINO ACID Category: Durable Medical CMS Add: 01/01/2005 CMS Term: B4162 DME DEF MAXFEE 01/01/2014 12/31/2023 3.51 0.0 Y Description: EF PED SPECMETABOLIC INHERIT Category: Durable Medical CMS Add: 01/01/2005 CMS Term: B4162 DME DEF MAXFEE 01/01/2024 4.56 0.0 Y Description: EF PED SPECMETABOLIC INHERIT Category: Durable Medical CMS Add: 01/01/2005 CMS Term: B4164 DME DEF MAXFEE 01/01/2014 12/31/2023 15.08 0.0 Description: PARENTERAL 50% DEXTROSE SOLU Category: Durable Medical CMS Add: 01/01/1986 CMS Term: B4164 DME DEF MAXFEE 01/01/2024 23.47 0.0 Description: PARENTERAL 50% DEXTROSE SOLU Category: Durable Medical CMS Add: 01/01/1986 CMS Term: B4168 DME DEF MAXFEE 01/01/2014 12/31/2023 21.96 0.0 Description: PARENTERAL SOL AMINO ACID 3. Category: Durable Medical CMS Add: 01/01/1984 CMS Term: B4168 DME DEF MAXFEE 01/01/2024 34.23 0.0 Description: PARENTERAL SOL AMINO ACID 3. Category: Durable Medical CMS Add: 01/01/1984 CMS Term: B4172 DME DEF SYSMAN Y Description: PARENTERAL SOL AMINO ACID 5. Category: Durable Medical CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,494 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- B4176 DME DEF MAXFEE 01/01/2014 12/31/2023 51.04 0.0 Description: PARENTERAL SOL AMINO ACID 7- Category: Durable Medical CMS Add: 01/01/1986 CMS Term: B4176 DME DEF MAXFEE 01/01/2024 66.22 0.0 Description: PARENTERAL SOL AMINO ACID 7- Category: Durable Medical CMS Add: 01/01/1986 CMS Term: B4178 DME DEF MAXFEE 01/01/2014 12/31/2023 51.04 0.0 Description: PARENTERAL SOL AMINO ACID > Category: Durable Medical CMS Add: 01/01/1988 CMS Term: B4178 DME DEF MAXFEE 01/01/2024 79.46 0.0 Description: PARENTERAL SOL AMINO ACID > Category: Durable Medical CMS Add: 01/01/1988 CMS Term: B4180 DME DEF MAXFEE 01/01/2014 12/31/2023 21.61 0.0 Description: PARENTERAL SOL CARB > 50% Category: Durable Medical CMS Add: 01/01/1986 CMS Term: B4180 DME DEF MAXFEE 01/01/2024 33.69 0.0 Description: PARENTERAL SOL CARB > 50% Category: Durable Medical CMS Add: 01/01/1986 CMS Term: B4185 DME DEF MAXFEE 01/01/2014 12/31/2023 2.37 0.0 Description: PN SOLN NOS 10 GRAMS LIPIDS Category: Durable Medical CMS Add: 01/01/2006 CMS Term: B4185 DME DEF MAXFEE 01/01/2024 15.51 0.0 Description: PN SOLN NOS 10 GRAMS LIPIDS Category: Durable Medical CMS Add: 01/01/2006 CMS Term: B4187 DME DEF MAXFEE 01/01/2024 15.51 0.0 Y Description: OMEGAVEN, 10 GRAMS LIPIDS Category: Durable Medical CMS Add: 01/01/2020 CMS Term: B4187 DME DEF MAXFEE 04/30/2021 12/31/2023 13.58 0.0 Y Description: OMEGAVEN, 10 GRAMS LIPIDS Category: Durable Medical CMS Add: 01/01/2020 CMS Term: B4189 DME DEF MAXFEE 01/01/2014 12/31/2023 157.66 0.0 Description: PARENTERAL SOL AMINO ACID & Category: Durable Medical CMS Add: 01/01/1988 CMS Term: B4189 DME DEF MAXFEE 01/01/2024 245.48 0.0 Description: PARENTERAL SOL AMINO ACID & Category: Durable Medical CMS Add: 01/01/1988 CMS Term: B4193 DME DEF MAXFEE 01/01/2014 12/31/2023 203.73 0.0 Description: PARENTERAL SOL 52-73 GM PROT Category: Durable Medical CMS Add: 01/01/1988 CMS Term: B4193 DME DEF MAXFEE 01/01/2024 317.18 0.0 Description: PARENTERAL SOL 52-73 GM PROT Category: Durable Medical CMS Add: 01/01/1988 CMS Term: B4197 DME DEF MAXFEE 01/01/2014 12/31/2023 248.02 0.0 Description: PARENTERAL SOL 74-100 GM PRO Category: Durable Medical CMS Add: 01/01/1988 CMS Term: B4197 DME DEF MAXFEE 01/01/2024 386.17 0.0 Description: PARENTERAL SOL 74-100 GM PRO Category: Durable Medical CMS Add: 01/01/1988 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,495 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- B4199 DME DEF MAXFEE 01/01/2014 12/31/2023 298.43 0.0 Description: PARENTERAL SOL > 100GM PROTE Category: Durable Medical CMS Add: 01/01/1988 CMS Term: B4199 DME DEF MAXFEE 01/01/2024 441.26 0.0 Description: PARENTERAL SOL > 100GM PROTE Category: Durable Medical CMS Add: 01/01/1988 CMS Term: B4216 DME DEF MAXFEE 01/01/2014 12/31/2023 6.85 0.0 Description: PARENTERAL NUTRITION ADDITIV Category: Durable Medical CMS Add: 01/01/1984 CMS Term: B4216 DME DEF MAXFEE 01/01/2024 10.66 0.0 Description: PARENTERAL NUTRITION ADDITIV Category: Durable Medical CMS Add: 01/01/1984 CMS Term: B4220 DME DEF MAXFEE 01/01/2014 12/31/2023 7.10 0.0 Description: PARENTERAL SUPPLY KIT PREMIX Category: Durable Medical CMS Add: 01/01/1984 CMS Term: B4220 DME DEF MAXFEE 01/01/2024 11.05 0.0 Description: PARENTERAL SUPPLY KIT PREMIX Category: Durable Medical CMS Add: 01/01/1984 CMS Term: B4222 DME DEF MAXFEE 01/01/2014 12/31/2023 10.41 0.0 Description: PARENTERAL SUPPLY KIT HOMEMI Category: Durable Medical CMS Add: 01/01/1986 CMS Term: B4222 DME DEF MAXFEE 01/01/2024 13.64 0.0 Description: PARENTERAL SUPPLY KIT HOMEMI Category: Durable Medical CMS Add: 01/01/1986 CMS Term: B4224 DME DEF MAXFEE 01/01/2014 12/31/2023 22.19 0.0 Description: PARENTERAL ADMINISTRATION KI Category: Durable Medical CMS Add: 01/01/1986 CMS Term: B4224 DME DEF MAXFEE 01/01/2024 34.52 0.0 Description: PARENTERAL ADMINISTRATION KI Category: Durable Medical CMS Add: 01/01/1986 CMS Term: B5000 DME DEF MAXFEE 01/01/2014 12/31/2023 10.54 0.0 Description: PARENTERAL SOL RENAL-AMIROSY Category: Durable Medical CMS Add: 01/01/1988 CMS Term: B5000 DME DEF MAXFEE 01/01/2024 16.42 0.0 Description: PARENTERAL SOL RENAL-AMIROSY Category: Durable Medical CMS Add: 01/01/1988 CMS Term: B5100 DME DEF MAXFEE 01/01/2014 12/31/2023 4.12 0.0 Description: PARENTERAL SOLUTION HEPATIC Category: Durable Medical CMS Add: 01/01/1988 CMS Term: B5100 DME DEF MAXFEE 01/01/2024 6.41 0.0 Description: PARENTERAL SOLUTION HEPATIC Category: Durable Medical CMS Add: 01/01/1988 CMS Term: B5200 DME DEF MAXFEE 01/01/2014 12/31/2023 5.68 0.0 Description: PARENTERAL SOL HEPATIC FREAM Category: Durable Medical CMS Add: 01/01/1988 CMS Term: B5200 DME DEF MAXFEE 01/01/2024 7.38 0.0 Description: PARENTERAL SOL HEPATIC FREAM Category: Durable Medical CMS Add: 01/01/1988 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,496 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- B9002 RR DME RTL MAXFEE 01/01/2014 12/31/2023 108.66 0.0 Description: ENTER NUTR INF PUMP ANY TYPE Category: Durable Medical CMS Add: 01/01/1988 CMS Term: B9002 RR DME RTL MAXFEE 01/01/2024 35.28 0.0 Description: ENTER NUTR INF PUMP ANY TYPE Category: Durable Medical CMS Add: 01/01/1988 CMS Term: B9004 RR DME RTL MAXFEE 01/01/2014 12/31/2023 354.00 0.0 Description: PARENTERAL INFUS PUMP PORTAB Category: Durable Medical CMS Add: 01/01/1988 CMS Term: B9004 RR DME RTL MAXFEE 01/01/2024 551.59 0.0 Description: PARENTERAL INFUS PUMP PORTAB Category: Durable Medical CMS Add: 01/01/1988 CMS Term: B9006 RR DME RTL MAXFEE 01/01/2014 12/31/2023 354.30 0.0 Description: PARENTERAL INFUS PUMP STATIO Category: Durable Medical CMS Add: 01/01/1988 CMS Term: B9006 RR DME RTL MAXFEE 01/01/2024 551.59 0.0 Description: PARENTERAL INFUS PUMP STATIO Category: Durable Medical CMS Add: 01/01/1988 CMS Term: B9998 DME DEF SYSMAN Y Description: ENTERAL SUPP NOT OTHERWISE C Category: Durable Medical CMS Add: 01/01/1985 CMS Term: B9999 DME DEF SYSMAN Y Description: PARENTERAL SUPP NOT OTHRWS C Category: Durable Medical CMS Add: 01/01/1985 CMS Term: C1031 NOCOV DEF SYSMAN Description: MR COMP/MOD LEVEEN NED ELECT Category: Non Covered Services CMS Add: 08/01/2000 CMS Term: 12/31/2000 C1052 DRUG DEF MAXFEE 01/01/2021 0.00 0.0 Description: HEMOSTATIC AGENT, GI, TOPIC Category: Drugs CMS Add: 01/01/2021 CMS Term: C1062 NOCOV DEF SYSMAN Description: INTRAVERTEBRAL FX AUG IMPL Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: C1088 NOCOV DEF SYSMAN Description: LASER OPTIC TR SYS Category: Non Covered Services CMS Add: 08/01/2000 CMS Term: 12/31/2003 C1146 NOCOV DEF SYSMAN Description: VETT TUBE Category: Non Covered Services CMS Add: 08/01/2000 CMS Term: 12/31/2000 C1170 NOCOV DEF SYSMAN Description: ABBI DISP BIOPSY DEVICE Category: Non Covered Services CMS Add: 08/01/2000 CMS Term: 12/31/2000 C1175 NOCOV DEF SYSMAN Description: MIBB DISP BIOPSY DEVICE Category: Non Covered Services CMS Add: 10/01/2000 CMS Term: 12/31/2000 C1176 NOCOV DEF SYSMAN Description: MAMMOTOME HH PROBE W/VAC SYS Category: Non Covered Services CMS Add: 10/01/2000 CMS Term: 12/31/2000 *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,497 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- C1177 NOCOV DEF SYSMAN Description: 11-G MAMMOTOME PROBE Category: Non Covered Services CMS Add: 10/01/2000 CMS Term: 12/31/2000 C1179 NOCOV DEF SYSMAN Description: 14-G MAMMOTOME PROBE Category: Non Covered Services CMS Add: 10/01/2000 CMS Term: 12/31/2000 C1321 NOCOV DEF SYSMAN Description: PALATE/BASE OF TONGUE ELECTR Category: Non Covered Services CMS Add: 10/01/2000 CMS Term: 12/31/2000 C1322 NOCOV DEF SYSMAN Description: TURBINATE SOMNOPLASTY ELECTR Category: Non Covered Services CMS Add: 10/01/2000 CMS Term: 12/31/2000 C1323 NOCOV DEF SYSMAN Description: VAPR/T DISP ELECTRODE Category: Non Covered Services CMS Add: 10/01/2000 CMS Term: 12/31/2000 C1324 NOCOV DEF SYSMAN Description: LIGASURE DISPOSABLE ELECTROD Category: Non Covered Services CMS Add: 08/01/2000 CMS Term: 12/31/2000 C1329 NOCOV DEF SYSMAN Description: VERSAPOINT DISP ELECTRODE Category: Non Covered Services CMS Add: 10/01/2000 CMS Term: 12/31/2000 C1368 NOCOV DEF SYSMAN Description: ON-Q PAIN MGT SYS Category: Non Covered Services CMS Add: 08/01/2000 CMS Term: 12/31/2000 C1600 MEDSV DEF BILL90 Description: CATH, BLADED, VASC PREP Category: Medical Services CMS Add: 01/01/2024 CMS Term: C1601 MEDSV DEF BILL90 Description: ENDO, SINGLE, PULMONARY Category: Medical Services CMS Add: 01/01/2024 CMS Term: C1602 MEDSV DEF BILL90 Description: ORTH/MATRX/BN FILL DRUG-ELUT Category: Medical Services CMS Add: 01/01/2024 CMS Term: C1603 MEDSV DEF BILL90 Description: RET DEV, LASER, IVC FILTER Category: Medical Services CMS Add: 01/01/2024 CMS Term: C1604 MEDSV DEF BILL90 Description: GRFT, TRNSMURL/TRNSVENS BYPS Category: Medical Services CMS Add: 01/01/2024 CMS Term: C1713 NOCOV DEF SYSMAN Description: ANCHOR/SCREW BN/BN,TIS/BN Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1714 NOCOV DEF SYSMAN Description: CATH, TRANS ATHERECTOMY, DIR Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1715 NOCOV DEF SYSMAN Description: BRACHYTHERAPY NEEDLE Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,498 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- C1716 MEDSV L60 MAXFEE 09/21/2018 0.00 0.0 Description: BRACHYTX, NON-STR, GOLD-198 Category: Medical Services CMS Add: 04/01/2001 CMS Term: C1717 MEDSV L60 MAXFEE 09/21/2018 0.00 0.0 Description: BRACHYTX, NON-STR,HDR IR-192 Category: Medical Services CMS Add: 04/01/2001 CMS Term: C1719 MEDSV L60 MAXFEE 09/21/2018 0.00 0.0 Description: BRACHYTX, NS, NON-HDRIR-192 Category: Medical Services CMS Add: 04/01/2001 CMS Term: C1721 MEDSV DEF SYSMAN Y Y Description: AICD, DUAL CHAMBER Category: Medical Services CMS Add: 04/01/2001 CMS Term: C1722 MEDSV DEF SYSMAN Y Y Description: AICD, SINGLE CHAMBER Category: Medical Services CMS Add: 04/01/2001 CMS Term: C1724 NOCOV DEF SYSMAN Description: CATH, TRANS ATHEREC,ROTATION Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1725 NOCOV DEF SYSMAN Description: CATH, TRANSLUMIN NON-LASER Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1726 NOCOV DEF SYSMAN Description: CATH, BAL DIL, NON-VASCULAR Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1727 NOCOV DEF SYSMAN Description: CATH, BAL TIS DIS, NON-VAS Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1728 NOCOV DEF SYSMAN Description: CATH, BRACHYTX SEED ADM Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1729 NOCOV DEF SYSMAN Description: CATH, DRAINAGE Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1730 NOCOV DEF SYSMAN Description: CATH, EP, 19 OR FEW ELECT Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1731 NOCOV DEF SYSMAN Description: CATH, EP, 20 OR MORE ELEC Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1732 NOCOV DEF SYSMAN Description: CATH, EP, DIAG/ABL, 3D/VECT Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1733 NOCOV DEF SYSMAN Description: CATH, EP, OTHR THAN COOL-TIP Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1734 NOCOV DEF SYSMAN Description: ORTH/DEVIC/DRUG BN/BN,TIS/BN Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,499 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- C1747 MDSPY DEF BILL90 Description: ENDO, SINGLE, URINARY TRACT Category: Medical Supplies CMS Add: 01/01/2023 CMS Term: C1748 MDSPY DEF BILL90 Description: ENDOSCOPE, SINGLE, UGI Category: Medical Supplies CMS Add: 07/01/2020 CMS Term: C1749 MEDSV DEF SYSMAN Description: ENDO, COLON, RETRO IMAGING Category: Medical Services CMS Add: 10/01/2010 CMS Term: C1750 NOCOV DEF SYSMAN Description: CATH, HEMODIALYSIS,LONG-TERM Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1751 NOCOV DEF SYSMAN Description: CATH, INF, PER/CENT/MIDLINE Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1752 NOCOV DEF SYSMAN Description: CATH,HEMODIALYSIS,SHORT-TERM Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1753 NOCOV DEF SYSMAN Description: CATH, INTRAVAS ULTRASOUND Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1754 NOCOV DEF SYSMAN Description: CATHETER, INTRADISCAL Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1755 NOCOV DEF SYSMAN Description: CATHETER, INTRASPINAL Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1756 NOCOV DEF SYSMAN Description: CATH, PACING, TRANSESOPH Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1757 NOCOV DEF SYSMAN Description: CATH, THROMBECTOMY/EMBOLECT Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1758 NOCOV DEF SYSMAN Description: CATHETER, URETERAL Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1759 NOCOV DEF SYSMAN Description: CATH, INTRA ECHOCARDIOGRAPHY Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1760 NOCOV DEF SYSMAN Description: CLOSURE DEV, VASC Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1761 NOCOV DEF SYSMAN Description: CATH, TRANS INTRA LITHO/CORO Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: C1762 NOCOV DEF SYSMAN Description: CONN TISS, HUMAN(INC FASCIA) Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,500 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- C1763 NOCOV DEF SYSMAN Description: CONN TISS, NON-HUMAN Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1764 NOCOV DEF SYSMAN Description: EVENT RECORDER, CARDIAC Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1765 NOCOV DEF SYSMAN Description: ADHESION BARRIER Category: Non Covered Services CMS Add: 07/01/2001 CMS Term: C1766 NOCOV DEF SYSMAN Description: INTRO/SHEATH,STRBLE,NON-PEEL Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1767 NOCOV DEF SYSMAN Description: GENERATOR, NEURO NON-RECHARG Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1768 NOCOV DEF SYSMAN Description: GRAFT, VASCULAR Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1769 NOCOV DEF SYSMAN Description: GUIDE WIRE Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1770 NOCOV DEF SYSMAN Description: IMAGING COIL, MR, INSERTABLE Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1771 NOCOV DEF SYSMAN Description: REP DEV, URINARY, W/SLING Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1772 NOCOV DEF SYSMAN Description: INFUSION PUMP, PROGRAMMABLE Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1773 NOCOV DEF SYSMAN Description: RET DEV, INSERTABLE Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1776 NOCOV DEF SYSMAN Description: JOINT DEVICE (IMPLANTABLE) Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1777 MEDSV DEF SYSMAN Y Y Description: LEAD, AICD, ENDO SINGLE COIL Category: Medical Services CMS Add: 04/01/2001 CMS Term: C1778 NOCOV DEF SYSMAN Description: LEAD, NEUROSTIMULATOR Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1779 MEDSV DEF SYSMAN Y Y Description: LEAD, PMKR, TRANSVENOUS VDD Category: Medical Services CMS Add: 04/01/2001 CMS Term: C1780 MEDSV DEF SYSMAN Y Description: LENS, INTRAOCULAR (NEW TECH) Category: Medical Services CMS Add: 04/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,501 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- C1781 NOCOV DEF SYSMAN Description: MESH (IMPLANTABLE) Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1782 NOCOV DEF SYSMAN Description: MORCELLATOR Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1783 NOCOV DEF SYSMAN Description: OCULAR IMP, AQUEOUS DRAIN DE Category: Non Covered Services CMS Add: 07/01/2002 CMS Term: C1784 NOCOV DEF SYSMAN Description: OCULAR DEV, INTRAOP, DET RET Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1785 MEDSV DEF SYSMAN Y Description: PMKR, DUAL, RATE-RESP Category: Medical Services CMS Add: 04/01/2001 CMS Term: C1786 MEDSV DEF SYSMAN Y Description: PMKR, SINGLE, RATE-RESP Category: Medical Services CMS Add: 04/01/2001 CMS Term: C1787 NOCOV DEF SYSMAN Description: PATIENT PROGR, NEUROSTIM Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1788 NOCOV DEF SYSMAN Description: PORT, INDWELLING, IMP Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1789 NOCOV DEF SYSMAN Description: PROSTHESIS, BREAST, IMP Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1813 NOCOV DEF SYSMAN Description: PROSTHESIS, PENILE, INFLATAB Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1814 NOCOV DEF SYSMAN Description: RETINAL TAMP, SILICONE OIL Category: Non Covered Services CMS Add: 04/01/2003 CMS Term: C1815 NOCOV DEF SYSMAN Description: PROS, URINARY SPH, IMP Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1816 NOCOV DEF SYSMAN Description: RECEIVER/TRANSMITTER, NEURO Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1817 NOCOV DEF SYSMAN Description: SEPTAL DEFECT IMP SYS Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1818 NOCOV DEF SYSMAN Description: INTEGRATED KERATOPROSTHESIS Category: Non Covered Services CMS Add: 07/01/2003 CMS Term: C1819 NOCOV DEF SYSMAN Description: TISSUE LOCALIZATION-EXCISION Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,502 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- C1820 NOCOV DEF SYSMAN Description: GENERATOR NEURO RECHG BAT SY Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: C1821 NOCOV DEF SYSMAN Description: INTERSPINOUS IMPLANT Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: C1822 NOCOV DEF SYSMAN Description: GEN, NEURO, HF, RECHG BAT Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: C1823 NOCOV DEF SYSMAN Description: GEN, NEURO, TRANS SEN/STIM Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: C1824 NOCOV DEF SYSMAN Description: GENERATOR, CCM, IMPLANT Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: C1825 DME DEF MAXFEE 01/01/2021 0.00 0.0 Y Description: GEN, NEURO, CAROT SINUS BARO Category: Durable Medical CMS Add: 01/01/2021 CMS Term: C1826 NOCOV DEF SYSMAN Description: GEN, NEURO, CLO LOOP, RECHG Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: C1827 NOCOV DEF SYSMAN Description: GEN, NEURO, IMP LED, EX CNTR Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: C1830 NOCOV DEF SYSMAN Description: POWER BONE MARROW BX NEEDLE Category: Non Covered Services CMS Add: 10/01/2011 CMS Term: C1831 NOCOV DEF SYSMAN Description: PERSONALIZED INTERBODY CAGE Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: C1832 MEDSV DEF MAXFEE 01/01/2022 0.00 0.0 Description: AUTO CELL PROCESS SYS Category: Medical Services CMS Add: 01/01/2022 CMS Term: C1833 NOCOV DEF SYSMAN Description: CARDIAC MONITOR SYS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: C1839 NOCOV DEF SYSMAN Description: IRIS PROSTHESIS Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: C1840 NOCOV DEF SYSMAN Description: TELESCOPIC INTRAOCULAR LENS Category: Non Covered Services CMS Add: 10/01/2011 CMS Term: C1874 NOCOV DEF SYSMAN Description: STENT, COATED/COV W/DEL SYS Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1875 NOCOV DEF SYSMAN Description: STENT, COATED/COV W/O DEL SY Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,503 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- C1876 NOCOV DEF SYSMAN Description: STENT, NON-COA/NON-COV W/DEL Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1877 NOCOV DEF SYSMAN Description: STENT, NON-COAT/COV W/O DEL Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1878 NOCOV DEF SYSMAN Description: MATRL FOR VOCAL CORD Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1879 NOCOV DEF SYSMAN Description: TISSUE MARKER, IMPLANTABLE Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: 06/30/2013 C1880 NOCOV DEF SYSMAN Description: VENA CAVA FILTER Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1881 NOCOV DEF SYSMAN Description: DIALYSIS ACCESS SYSTEM Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1882 MEDSV DEF SYSMAN Y Y Description: AICD, OTHER THAN SING/DUAL Category: Medical Services CMS Add: 04/01/2001 CMS Term: C1883 NOCOV DEF SYSMAN Description: ADAPT/EXT, PACING/NEURO LEAD Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1884 NOCOV DEF SYSMAN Description: EMBOLIZATION PROTECT SYST Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: C1885 NOCOV DEF SYSMAN Description: CATH, TRANSLUMIN ANGIO LASER Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1886 NOCOV DEF SYSMAN Description: CATHETER, ABLATION Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: C1887 NOCOV DEF SYSMAN Description: CATHETER, GUIDING Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1888 NOCOV DEF SYSMAN Description: ENDOVAS NON-CARDIAC ABL CATH Category: Non Covered Services CMS Add: 07/01/2002 CMS Term: C1889 NOCOV DEF SYSMAN Description: IMPLANT/INSERT DEVICE, NOC Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: C1890 NOCOV DEF SYSMAN Description: NO DEVICE W/DEV-INTENSIVE PX Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: C1891 NOCOV DEF SYSMAN Description: INFUSION PUMP,NON-PROG, PERM Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,504 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- C1892 NOCOV DEF SYSMAN Description: INTRO/SHEATH,FIXED,PEEL-AWAY Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1893 NOCOV DEF SYSMAN Description: INTRO/SHEATH, FIXED,NON-PEEL Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1894 NOCOV DEF SYSMAN Description: INTRO/SHEATH, NON-LASER Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1895 MEDSV DEF SYSMAN Y Y Description: LEAD, AICD, ENDO DUAL COIL Category: Medical Services CMS Add: 04/01/2001 CMS Term: C1896 MEDSV DEF SYSMAN Y Y Description: LEAD, AICD, NON SING/DUAL Category: Medical Services CMS Add: 04/01/2001 CMS Term: C1897 NOCOV DEF SYSMAN Description: LEAD, NEUROSTIM TEST KIT Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C1898 MEDSV DEF SYSMAN Y Y Description: LEAD, PMKR, OTHER THAN TRANS Category: Medical Services CMS Add: 04/01/2001 CMS Term: C1899 MEDSV DEF SYSMAN Y Y Description: LEAD, PMKR/AICD COMBINATION Category: Medical Services CMS Add: 04/01/2001 CMS Term: C1900 MEDSV DEF SYSMAN Y Y Description: LEAD, CORONARY VENOUS Category: Medical Services CMS Add: 07/01/2002 CMS Term: C1982 MEDSV DEF BILL90 Description: CATH, PRESSURE,VALVE-OCCLU Category: Medical Services CMS Add: 01/01/2020 CMS Term: C2596 MEDSV DEF BILL90 Description: PROBE, ROBOTIC, WATER-JET Category: Medical Services CMS Add: 01/01/2020 CMS Term: C2600 NOCOV DEF SYSMAN Description: GOLD PROBE CATHETER Category: Non Covered Services CMS Add: 10/01/2000 CMS Term: 12/31/2000 C2613 MEDSV DEF BILL90 Description: LUNG BX PLUG W/DEL SYS Category: Medical Services CMS Add: 07/01/2015 CMS Term: C2614 NOCOV DEF SYSMAN Description: PROBE, PERC LUMB DISC Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: C2615 NOCOV DEF SYSMAN Description: SEALANT, PULMONARY, LIQUID Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C2616 MEDSV L60 MAXFEE 09/21/2018 0.00 0.0 Description: BRACHYTX, NON-STR,YTTRIUM-90 Category: Medical Services CMS Add: 04/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,505 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- C2617 NOCOV DEF SYSMAN Description: STENT, NON-COR, TEM W/O DEL Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C2618 NOCOV DEF SYSMAN Description: PROBE/NEEDLE, CRYO Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C2619 NOCOV DEF SYSMAN Description: PMKR, DUAL, NON RATE-RESP Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C2620 NOCOV DEF SYSMAN Description: PMKR, SINGLE, NON RATE-RESP Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C2621 MEDSV DEF SYSMAN Y Description: PMKR, OTHER THAN SING/DUAL Category: Medical Services CMS Add: 04/01/2001 CMS Term: C2622 NOCOV DEF SYSMAN Description: PROSTHESIS, PENILE, NON-INF Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C2623 NOCOV DEF SYSMAN Description: CATH, TRANSLUMIN, DRUG-COAT Category: Non Covered Services CMS Add: 04/01/2015 CMS Term: C2624 NOCOV DEF SYSMAN Description: WIRELESS PRESSURE SENSOR Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: C2625 NOCOV DEF SYSMAN Description: STENT, NON-COR, TEM W/DEL SY Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C2626 NOCOV DEF SYSMAN Description: INFUSION PUMP, NON-PROG,TEMP Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C2627 NOCOV DEF SYSMAN Description: CATH, SUPRAPUBIC/CYSTOSCOPIC Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C2628 NOCOV DEF SYSMAN Description: CATHETER, OCCLUSION Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C2629 NOCOV DEF SYSMAN Description: INTRO/SHEATH, LASER Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C2630 NOCOV DEF SYSMAN Description: CATH, EP, COOL-TIP Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C2631 NOCOV DEF SYSMAN Description: REP DEV, URINARY, W/O SLING Category: Non Covered Services CMS Add: 04/01/2001 CMS Term: C2634 MEDSV L60 MAXFEE 09/21/2018 0.00 0.0 Description: BRACHYTX, NON-STR, HA, I-125 Category: Medical Services CMS Add: 01/01/2005 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,506 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- C2635 MEDSV L60 MAXFEE 09/21/2018 0.00 0.0 Description: BRACHYTX, NON-STR, HA, P-103 Category: Medical Services CMS Add: 01/01/2005 CMS Term: C2636 MEDSV L60 MAXFEE 09/21/2018 0.00 0.0 Description: BRACHY LINEAR, NON-STR,P-103 Category: Medical Services CMS Add: 01/01/2005 CMS Term: C2637 MEDSV L60 MAXFEE 09/21/2018 0.00 0.0 Description: BRACHY,NON-STR,YTTERBIUM-169 Category: Medical Services CMS Add: 10/01/2005 CMS Term: C2638 MEDSV L60 MAXFEE 09/21/2018 0.00 0.0 Description: BRACHYTX, STRANDED, I-125 Category: Medical Services CMS Add: 07/01/2007 CMS Term: C2639 MEDSV L60 MAXFEE 09/21/2018 0.00 0.0 Description: BRACHYTX, NON-STRANDED,I-125 Category: Medical Services CMS Add: 07/01/2007 CMS Term: C2640 MEDSV L60 MAXFEE 09/21/2018 0.00 0.0 Description: BRACHYTX, STRANDED, P-103 Category: Medical Services CMS Add: 07/01/2007 CMS Term: C2641 MEDSV L60 MAXFEE 09/21/2018 0.00 0.0 Description: BRACHYTX, NON-STRANDED,P-103 Category: Medical Services CMS Add: 07/01/2007 CMS Term: C2642 MEDSV L60 MAXFEE 09/21/2018 0.00 0.0 Description: BRACHYTX, STRANDED, C-131 Category: Medical Services CMS Add: 07/01/2007 CMS Term: C2643 MEDSV L60 MAXFEE 09/21/2018 0.00 0.0 Description: BRACHYTX, NON-STRANDED,C-131 Category: Medical Services CMS Add: 07/01/2007 CMS Term: C2644 DRUG L60 MAXFEE 09/21/2018 0.00 0.0 Description: BRACHYTX CESIUM-131 CHLORIDE Category: Drugs CMS Add: 07/01/2014 CMS Term: C2645 MEDSV L60 MAXFEE 09/21/2018 0.00 0.0 Description: BRACHYTX PLANAR, P-103 Category: Medical Services CMS Add: 01/01/2016 CMS Term: C2698 MEDSV L60 MAXFEE 09/21/2018 0.00 0.0 Description: BRACHYTX, STRANDED, NOS Category: Medical Services CMS Add: 07/01/2007 CMS Term: C2699 MEDSV L60 MAXFEE 09/21/2018 0.00 0.0 Description: BRACHYTX, NON-STRANDED, NOS Category: Medical Services CMS Add: 07/01/2007 CMS Term: C5271 NOCOV DEF SYSMAN Description: LOW COST SKIN SUBSTITUTE APP Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: C5272 NOCOV DEF SYSMAN Description: LOW COST SKIN SUBSTITUTE APP Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: C5273 NOCOV DEF SYSMAN Description: LOW COST SKIN SUBSTITUTE APP Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,507 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- C5274 NOCOV DEF SYSMAN Description: LOW COST SKIN SUBSTITUTE APP Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: C5275 NOCOV DEF SYSMAN Description: LOW COST SKIN SUBSTITUTE APP Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: C5276 NOCOV DEF SYSMAN Description: LOW COST SKIN SUBSTITUTE APP Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: C5277 NOCOV DEF SYSMAN Description: LOW COST SKIN SUBSTITUTE APP Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: C5278 NOCOV DEF SYSMAN Description: LOW COST SKIN SUBSTITUTE APP Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: C7500 MEDSV DEF BILL90 Description: DEB BONE 20 CM2 W/DRUG DEV Category: Medical Services CMS Add: 01/01/2023 CMS Term: C7501 MEDSV DEF BILL90 Description: PERC BX BREAST LESIONS STERO Category: Medical Services CMS Add: 01/01/2023 CMS Term: C7502 MEDSV DEF BILL90 Description: PERC BX BREAST LESIONS MR Category: Medical Services CMS Add: 01/01/2023 CMS Term: C7503 MEDSV DEF BILL90 Description: OPEN EXC CERV NODE(S) W/ ID Category: Medical Services CMS Add: 01/01/2023 CMS Term: C7504 MEDSV DEF BILL90 Description: PERQ CVT&LS INJ VERT BODIES Category: Medical Services CMS Add: 01/01/2023 CMS Term: C7505 MEDSV DEF BILL90 Description: PERQ LS&CVT INJ VERT BODIES Category: Medical Services CMS Add: 01/01/2023 CMS Term: C7506 MEDSV DEF BILL90 Description: FUSION OF FINGER JOINTS Category: Medical Services CMS Add: 01/01/2023 CMS Term: C7507 NOCOV DEF SYSMAN Description: PERQ THOR&LUMB VERT AUG Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: C7508 NOCOV DEF SYSMAN Description: PERQ LUMB&THOR VERT AUG Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: C7509 MEDSV DEF BILL90 Description: DX BRONCH W/ NAVIGATION Category: Medical Services CMS Add: 01/01/2023 CMS Term: C7510 MEDSV DEF BILL90 Description: BRONCH/LAVAG W/ NAVIGATION Category: Medical Services CMS Add: 01/01/2023 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,508 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- C7511 MEDSV DEF BILL90 Description: BRONCH/BPSY(S) W/ NAVIGATION Category: Medical Services CMS Add: 01/01/2023 CMS Term: C7512 MEDSV DEF BILL90 Description: BRONCH/BPSY(S) W/ EBUS Category: Medical Services CMS Add: 01/01/2023 CMS Term: C7513 MEDSV DEF BILL90 Description: CATH/ANGIO DIALCIR W/APLASTY Category: Medical Services CMS Add: 01/01/2023 CMS Term: C7514 MEDSV DEF BILL90 Description: CATH/ANGIO DIAL CIR W/STENTS Category: Medical Services CMS Add: 01/01/2023 CMS Term: C7515 MEDSV DEF BILL90 Description: CATH/ANGIO DIAL CIR W/EMBOL Category: Medical Services CMS Add: 01/01/2023 CMS Term: C7516 MEDSV DEF BILL90 Description: COR ANGIO W/ IVUS OR OCT Category: Medical Services CMS Add: 01/01/2023 CMS Term: C7517 NOCOV DEF SYSMAN Description: COR ANGIO W/ILIC/FEM ANGIO Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: C7518 MEDSV DEF BILL90 Description: COR/GFT ANGIO W/ IVUS OR OCT Category: Medical Services CMS Add: 01/01/2023 CMS Term: C7519 MEDSV DEF BILL90 Description: COR/GFT ANGIO W/ FLOW RESRV Category: Medical Services CMS Add: 01/01/2023 CMS Term: C7520 NOCOV DEF SYSMAN Description: COR/GFT ANGIO W/ILIC/FEM ANG Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: C7521 MEDSV DEF BILL90 Description: R HRT ANGIO W/ IVUS OR OCT Category: Medical Services CMS Add: 01/01/2023 CMS Term: C7522 MEDSV DEF BILL90 Description: R HRT ANGIO W/FLOW RESRV Category: Medical Services CMS Add: 01/01/2023 CMS Term: C7523 MEDSV DEF BILL90 Description: L HRT ANGIO W/ IVUS OR OCT Category: Medical Services CMS Add: 01/01/2023 CMS Term: C7524 MEDSV DEF BILL90 Description: L HRT ANGIO W/FLOW RESRV Category: Medical Services CMS Add: 01/01/2023 CMS Term: C7525 MEDSV DEF BILL90 Description: L HRT GFT ANG W/ IVUS OR OCT Category: Medical Services CMS Add: 01/01/2023 CMS Term: C7526 MEDSV DEF BILL90 Description: L HRT GFT ANG W/FLOW RESRV Category: Medical Services CMS Add: 01/01/2023 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,509 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- C7527 MEDSV DEF BILL90 Description: R&L HRT ANGIO W/ IVUS OR OCT Category: Medical Services CMS Add: 01/01/2023 CMS Term: C7528 MEDSV DEF BILL90 Description: R&L HRT ANGIO W/FLOW RESRV Category: Medical Services CMS Add: 01/01/2023 CMS Term: C7529 MEDSV DEF BILL90 Description: R&L HRT GFT ANG W/FLOW RESRV Category: Medical Services CMS Add: 01/01/2023 CMS Term: C7530 MEDSV DEF BILL90 Description: CATH/APLASTY DIAL CIR W/STNT Category: Medical Services CMS Add: 01/01/2023 CMS Term: C7531 MEDSV DEF BILL90 Description: ANGIO FEM/POP W/ US Category: Medical Services CMS Add: 01/01/2023 CMS Term: C7532 MEDSV DEF BILL90 Description: ANGIO W/ US NON-CORONARY Category: Medical Services CMS Add: 01/01/2023 CMS Term: C7533 MEDSV DEF BILL90 Description: PTCA W/ PLCMT BRACHYTX DEV Category: Medical Services CMS Add: 01/01/2023 CMS Term: C7534 MEDSV DEF BILL90 Description: FEM/POP REVASC W/ARTHR & US Category: Medical Services CMS Add: 01/01/2023 CMS Term: C7535 MEDSV DEF BILL90 Description: FEM/POP REVASC W/STENT & US Category: Medical Services CMS Add: 01/01/2023 CMS Term: C7537 MEDSV DEF BILL90 Description: INSRT ATRIL PM W/L VENT LEAD Category: Medical Services CMS Add: 01/01/2023 CMS Term: C7538 MEDSV DEF BILL90 Description: INSRT VENT PM W/L VENT LEAD Category: Medical Services CMS Add: 01/01/2023 CMS Term: C7539 MEDSV DEF BILL90 Description: INSRT A & V PM W/L VENT LEAD Category: Medical Services CMS Add: 01/01/2023 CMS Term: C7540 MEDSV DEF BILL90 Description: RMV&RPLC PM DUL W/L VNT LEAD Category: Medical Services CMS Add: 01/01/2023 CMS Term: C7541 MEDSV DEF BILL90 Description: ERCP W/ PANCREATOSCOPY Category: Medical Services CMS Add: 01/01/2023 CMS Term: C7542 MEDSV DEF BILL90 Description: ERCP W/BX & PANCREATOSCOPY Category: Medical Services CMS Add: 01/01/2023 CMS Term: C7543 MEDSV DEF BILL90 Description: ERCP W/OTOMY, PANCREATOSCOPY Category: Medical Services CMS Add: 01/01/2023 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,510 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- C7544 MEDSV DEF BILL90 Description: ERCP RMV CALC PANCREATOSCOPY Category: Medical Services CMS Add: 01/01/2023 CMS Term: C7545 MEDSV DEF BILL90 Description: EXCH BIL CATH W/ RMV CALCULI Category: Medical Services CMS Add: 01/01/2023 CMS Term: C7546 MEDSV DEF BILL90 Description: REP NPH/URT CATH W/DIL STRIC Category: Medical Services CMS Add: 01/01/2023 CMS Term: C7547 MEDSV DEF BILL90 Description: CNVRT NEPH CATH W/ DIL STRIC Category: Medical Services CMS Add: 01/01/2023 CMS Term: C7548 MEDSV DEF BILL90 Description: EXCH NEPH CATH W/ DIL STRIC Category: Medical Services CMS Add: 01/01/2023 CMS Term: C7549 MEDSV DEF BILL90 Description: CHGE URTR STENT W/ DIL STRIC Category: Medical Services CMS Add: 01/01/2023 CMS Term: C7550 MEDSV DEF BILL90 Description: CYSTO W/ BX(S) W/ BLUE LIGHT Category: Medical Services CMS Add: 01/01/2023 CMS Term: C7551 MEDSV DEF BILL90 Description: EXC NEUROMA W/ IMPLNT NV END Category: Medical Services CMS Add: 01/01/2023 CMS Term: C7552 MEDSV DEF BILL90 Description: R HRT ART/GRFT ANG HRT FLOW Category: Medical Services CMS Add: 01/01/2023 CMS Term: C7553 MEDSV DEF BILL90 Description: R&I HRT ART/VENT ANG DRG AD Category: Medical Services CMS Add: 01/01/2023 CMS Term: C7554 MEDSV DEF BILL90 Description: CYSTURETH BLU LI CYST FL IMG Category: Medical Services CMS Add: 01/01/2023 CMS Term: C7555 MEDSV DEF BILL90 Description: RMVL THYRD W/AUTOTRAN PARATH Category: Medical Services CMS Add: 01/01/2023 CMS Term: C7556 MEDSV DEF BILL90 Description: BRONCH LAVAGE W/EBUS Category: Medical Services CMS Add: 01/01/2024 CMS Term: C7557 MEDSV DEF BILL90 Description: COR ANGIO/VENT W/FFR Category: Medical Services CMS Add: 01/01/2024 CMS Term: C7558 MEDSV DEF BILL90 Description: COR ANGIO/VENT W/DRUG ADMIN Category: Medical Services CMS Add: 01/01/2024 CMS Term: C7560 MEDSV DEF BILL90 Description: ERCP REMOVE FORGN BODY&ENDO Category: Medical Services CMS Add: 01/01/2024 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,511 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- C7900 NOCOV DEF SYSMAN Description: HOPD MNTL HLT, 15-29 MIN Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: C7901 NOCOV DEF SYSMAN Description: HOPD MNTL HLT, 30-60 MIN Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: C7902 NOCOV DEF SYSMAN Description: HOPD MNTL HLT, EA ADDL Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: C7903 MENTL DEF BILL90 0-1 Description: HOPD MNTL HLT, GRP Category: Mental Health CMS Add: 01/01/2024 CMS Term: C8900 NOCOV DEF SYSMAN Description: MRA W/CONT, ABD Category: Non Covered Services CMS Add: 10/01/2001 CMS Term: C8901 NOCOV DEF SYSMAN Description: MRA W/O CONT, ABD Category: Non Covered Services CMS Add: 10/01/2001 CMS Term: C8902 NOCOV DEF SYSMAN Description: MRA W/O FOL W/CONT, ABD Category: Non Covered Services CMS Add: 10/01/2001 CMS Term: C8903 NOCOV DEF SYSMAN Description: MRI W/CONT, BREAST, UNI Category: Non Covered Services CMS Add: 10/01/2001 CMS Term: C8905 NOCOV DEF SYSMAN Description: MRI W/O FOL W/CONT, BRST, UN Category: Non Covered Services CMS Add: 10/01/2001 CMS Term: C8906 NOCOV DEF SYSMAN Description: MRI W/CONT, BREAST, BI Category: Non Covered Services CMS Add: 10/01/2001 CMS Term: C8908 NOCOV DEF SYSMAN Description: MRI W/O FOL W/CONT, BREAST, Category: Non Covered Services CMS Add: 10/01/2001 CMS Term: C8909 NOCOV DEF SYSMAN Description: MRA W/CONT, CHEST Category: Non Covered Services CMS Add: 10/01/2001 CMS Term: C8910 NOCOV DEF SYSMAN Description: MRA W/O CONT, CHEST Category: Non Covered Services CMS Add: 10/01/2001 CMS Term: C8911 NOCOV DEF SYSMAN Description: MRA W/O FOL W/CONT, CHEST Category: Non Covered Services CMS Add: 10/01/2001 CMS Term: C8912 NOCOV DEF SYSMAN Description: MRA W/CONT, LWR EXT Category: Non Covered Services CMS Add: 10/01/2001 CMS Term: C8913 NOCOV DEF SYSMAN Description: MRA W/O CONT, LWR EXT Category: Non Covered Services CMS Add: 10/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,512 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- C8914 NOCOV DEF SYSMAN Description: MRA W/O FOL W/CONT, LWR EXT Category: Non Covered Services CMS Add: 10/01/2001 CMS Term: C8918 NOCOV DEF SYSMAN Description: MRA W/CONT, PELVIS Category: Non Covered Services CMS Add: 07/01/2003 CMS Term: C8919 NOCOV DEF SYSMAN Description: MRA W/O CONT, PELVIS Category: Non Covered Services CMS Add: 07/01/2003 CMS Term: C8920 NOCOV DEF SYSMAN Description: MRA W/O FOL W/CONT, PELVIS Category: Non Covered Services CMS Add: 07/01/2003 CMS Term: C8921 NOCOV DEF SYSMAN Description: TTE W OR W/O FOL W/CONT, COM Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: C8922 NOCOV DEF SYSMAN Description: TTE W OR W/O FOL W/CONT, F/U Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: C8923 NOCOV DEF SYSMAN Description: 2D TTE W OR W/O FOL W/CON,CO Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: C8924 NOCOV DEF SYSMAN Description: 2D TTE W OR W/O FOL W/CON,FU Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: C8925 NOCOV DEF SYSMAN Description: 2D TEE W OR W/O FOL W/CON,IN Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: C8926 NOCOV DEF SYSMAN Description: TEE W OR W/O FOL W/CONT,CONG Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: C8927 NOCOV DEF SYSMAN Description: TEE W OR W/O FOL W/CONT, MON Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: C8928 NOCOV DEF SYSMAN Description: TTE W OR W/O FOL W/CON,STRES Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: C8929 MEDSV DEF BILL90 Description: TTE W OR WO FOL WCON,DOPPLER Category: Medical Services CMS Add: 01/01/2009 CMS Term: C8930 MEDSV DEF BILL90 Description: TTE W OR W/O CONTR, CONT ECG Category: Medical Services CMS Add: 01/01/2009 CMS Term: C8931 NOCOV DEF SYSMAN Description: MRA, W/DYE, SPINAL CANAL Category: Non Covered Services CMS Add: 10/01/2010 CMS Term: C8932 NOCOV DEF SYSMAN Description: MRA, W/O DYE, SPINAL CANAL Category: Non Covered Services CMS Add: 10/01/2010 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,513 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- C8933 NOCOV DEF SYSMAN Description: MRA, W/O&W/DYE, SPINAL CANAL Category: Non Covered Services CMS Add: 10/01/2010 CMS Term: C8934 NOCOV DEF SYSMAN Description: MRA, W/DYE, UPPER EXTREMITY Category: Non Covered Services CMS Add: 10/01/2010 CMS Term: C8935 NOCOV DEF SYSMAN Description: MRA, W/O DYE, UPPER EXTR Category: Non Covered Services CMS Add: 10/01/2010 CMS Term: C8936 NOCOV DEF SYSMAN Description: MRA, W/O&W/DYE, UPPER EXTR Category: Non Covered Services CMS Add: 10/01/2010 CMS Term: C8937 RADIO DEF BILL90 Y Description: CAD BREAST MRI Category: Radiology CMS Add: 01/01/2019 CMS Term: C8957 NOCOV DEF SYSMAN Description: PROLONGED IV INF, REQ PUMP Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: C9034 NOCOV DEF SYSMAN Description: INJECTION, DEXAMETHASONE 9% Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: 12/31/2018 C9046 DRUG DEF MAXFEE 04/01/2023 1.61 0.0 Description: COCAINE HCL NASAL (GOPRELTO) Category: Drugs CMS Add: 04/01/2019 CMS Term: C9047 DRUG DEF MAXFEE 04/01/2023 03/31/2024 756.48 0.0 Description: INJECTION, CAPLACIZUMAB-YHDP Category: Drugs CMS Add: 07/01/2019 CMS Term: C9047 DRUG DEF MAXFEE 04/01/2024 786.74 0.0 Description: INJECTION, CAPLACIZUMAB-YHDP Category: Drugs CMS Add: 07/01/2019 CMS Term: C9067 NOCOV DEF SYSMAN Description: GALLIUM GA-68 DOTATOC Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: C9088 DRUG DEF MAXFEE 04/01/2023 03/31/2024 0.72 0.0 Description: INSTILL, BUPIVAC AND MELOXIC Category: Drugs CMS Add: 01/01/2022 CMS Term: C9088 DRUG DEF MAXFEE 04/01/2024 0.76 0.0 Description: INSTILL, BUPIVAC AND MELOXIC Category: Drugs CMS Add: 01/01/2022 CMS Term: C9089 NOCOV DEF SYSMAN Description: BUPIVACAINE IMPLANT, 1 MG Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: C9101 DRUG DEF SYSMAN Description: INJ, OLICERIDINE 0.1 MG Category: Drugs CMS Add: 10/01/2022 CMS Term: C9113 NOCOV DEF SYSMAN Description: INJ PANTOPRAZOLE SODIUM, VIA Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,514 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- C9143 DRUG DEF BILL90 Description: COCAINE HCL NASAL (NUMBRINO) Category: Drugs CMS Add: 01/01/2023 CMS Term: C9144 NOCOV DEF SYSMAN Description: INJ, BUPIVACAINE (POSIMIR) Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: C9145 DRUG DEF MAXFEE 04/15/2023 1.90 0.0 Description: INJ, APONVIE, 1 MG Category: Drugs CMS Add: 04/01/2023 CMS Term: C9150 NOCOV DEF SYSMAN Description: XE129 XENON, DIAGNOSTIC Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: C9159 NOCOV DEF SYSMAN Description: INJ, BALFAXAR, PER I.U Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 03/31/2024 C9160 NOCOV DEF SYSMAN Description: INJ DAXIBOTULINUMTOXINA-LANM Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: 03/31/2024 C9161 DRUG DEF MAXFEE 01/01/2024 344.53 0.0 Description: INJ, AFLIBERCEPT HD, 1 MG Category: Drugs CMS Add: 01/01/2024 CMS Term: 03/31/2024 C9162 DRUG DEF MAXFEE 01/01/2024 110.25 0.0 Description: INJ, AVACINCAPTAD PEG 0.1 MG Category: Drugs CMS Add: 01/01/2024 CMS Term: 03/31/2024 C9163 DRUG DEF MAXFEE 01/01/2024 67.99 0.0 Description: INJ TALQUETAMAB-TGVS 0.25 MG Category: Drugs CMS Add: 01/01/2024 CMS Term: 03/31/2024 C9164 DRUG DEF MAXFEE 01/01/2024 719.25 0.0 Description: CANTHARIDIN TOP, APPLICATOR Category: Drugs CMS Add: 01/01/2024 CMS Term: 03/31/2024 C9165 DRUG DEF MAXFEE 01/01/2024 180.31 0.0 Description: INJ, ELRANATAMAB-BCMM, 1 MG Category: Drugs CMS Add: 01/01/2024 CMS Term: 03/31/2024 C9226 NOCOV DEF SYSMAN Description: ZICONOTIDE INTRATHECAL INF Category: Non Covered Services CMS Add: 10/01/2005 CMS Term: 12/31/2005 C9248 DRUG DEF MAXFEE 04/01/2023 03/31/2024 3.49 0.0 Description: INJ, CLEVIDIPINE BUTYRATE Category: Drugs CMS Add: 01/01/2009 CMS Term: C9248 DRUG DEF MAXFEE 04/01/2024 3.59 0.0 Description: INJ, CLEVIDIPINE BUTYRATE Category: Drugs CMS Add: 01/01/2009 CMS Term: C9250 MEDSV DEF MAXFEE 01/01/2024 231.25 0.0 Description: ARTISS FIBRIN SEALANT Category: Medical Services CMS Add: 07/01/2009 CMS Term: C9250 MEDSV DEF MAXFEE 04/01/2022 09/30/2023 178.43 0.0 Description: ARTISS FIBRIN SEALANT Category: Medical Services CMS Add: 07/01/2009 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,515 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- C9250 MEDSV DEF MAXFEE 10/01/2023 12/31/2023 182.00 0.0 Description: ARTISS FIBRIN SEALANT Category: Medical Services CMS Add: 07/01/2009 CMS Term: C9254 DRUG DEF MAXFEE 01/01/2023 06/30/2023 0.21 0.0 Description: INJECTION, LACOSAMIDE Category: Drugs CMS Add: 01/01/2010 CMS Term: C9254 DRUG DEF MAXFEE 07/01/2023 0.20 0.0 Description: INJECTION, LACOSAMIDE Category: Drugs CMS Add: 01/01/2010 CMS Term: C9257 DRUG DEF MAXFEE 10/01/2018 2.09 0.0 Description: BEVACIZUMAB INJECTION Category: Drugs CMS Add: 01/01/2010 CMS Term: C9285 NOCOV DEF SYSMAN Description: PATCH, LIDOCAINE/TETRACAINE Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: C9290 NOCOV DEF SYSMAN Description: INJ, BUPIVACAINE LIPOSOME Category: Non Covered Services CMS Add: 04/01/2012 CMS Term: C9293 NOCOV DEF SYSMAN Description: INJECTION, GLUCARPIDASE Category: Non Covered Services CMS Add: 10/01/2012 CMS Term: C9352 MEDSV M26 MAXFEE 01/01/2021 0.00 0.0 Description: NEURAGEN NERVE GUIDE, PER CM Category: Medical Services CMS Add: 01/01/2008 CMS Term: C9353 MEDSV M26 MAXFEE 01/01/2021 0.00 0.0 Description: NEURAWRAP NERVE PROTECTOR,CM Category: Medical Services CMS Add: 01/01/2008 CMS Term: C9354 NOCOV DEF SYSMAN Description: VERITAS COLLAGEN MATRIX, CM2 Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: C9355 NOCOV DEF SYSMAN Description: NEUROMATRIX NERVE CUFF, CM Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: C9356 MEDSV DEF MAXFEE 01/01/2024 35.99 0.0 Description: TENOGLIDE TENDON PROT, CM2 Category: Medical Services CMS Add: 07/01/2008 CMS Term: C9356 MEDSV DEF MAXFEE 02/01/2011 12/31/2023 27.77 0.0 Description: TENOGLIDE TENDON PROT, CM2 Category: Medical Services CMS Add: 07/01/2008 CMS Term: C9358 MEDSV DEF MAXFEE 01/01/2024 13.87 0.0 Description: SURGIMEND, FETAL Category: Medical Services CMS Add: 07/01/2008 CMS Term: C9358 MEDSV DEF MAXFEE 02/01/2011 12/31/2023 10.70 0.0 Description: SURGIMEND, FETAL Category: Medical Services CMS Add: 07/01/2008 CMS Term: C9359 MEDSV DEF MAXFEE 01/01/2024 82.00 0.0 Description: IMPLNT,BON VOID FILLER-PUTTY Category: Medical Services CMS Add: 10/01/2008 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,516 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- C9359 MEDSV DEF MAXFEE 02/01/2011 12/31/2023 63.27 0.0 Description: IMPLNT,BON VOID FILLER-PUTTY Category: Medical Services CMS Add: 10/01/2008 CMS Term: C9360 MEDSV DEF MAXFEE 01/01/2024 14.66 0.0 Description: SURGIMEND, NEONATAL Category: Medical Services CMS Add: 07/01/2009 CMS Term: C9361 MEDSV DEF MAXFEE 01/01/2010 12/31/2023 252.18 0.0 Description: NEUROMEND NERVE WRAP Category: Medical Services CMS Add: 07/01/2009 CMS Term: C9361 MEDSV DEF MAXFEE 01/01/2024 326.83 0.0 Description: NEUROMEND NERVE WRAP Category: Medical Services CMS Add: 07/01/2009 CMS Term: C9362 MEDSV DEF MAXFEE 01/01/2010 12/31/2023 50.33 0.0 Description: IMPLNT,BON VOID FILLER-STRIP Category: Medical Services CMS Add: 07/01/2009 CMS Term: C9362 MEDSV DEF MAXFEE 01/01/2024 65.23 0.0 Description: IMPLNT,BON VOID FILLER-STRIP Category: Medical Services CMS Add: 07/01/2009 CMS Term: C9363 NOCOV DEF SYSMAN Description: INTEGRA MESHED BIL WOUND MAT Category: Non Covered Services CMS Add: 07/01/2009 CMS Term: C9364 MEDSV DEF MAXFEE 01/01/2010 12/31/2023 17.48 0.0 Description: PORCINE IMPLANT, PERMACOL Category: Medical Services CMS Add: 07/01/2009 CMS Term: C9364 MEDSV DEF MAXFEE 01/01/2024 22.65 0.0 Description: PORCINE IMPLANT, PERMACOL Category: Medical Services CMS Add: 07/01/2009 CMS Term: C9399 NOCOV DEF SYSMAN Description: UNCLASSIFIED DRUGS OR BIOLOG Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: C9460 DRUG DEF MAXFEE 04/01/2023 03/31/2024 18.73 0.0 Description: INJECTION, CANGRELOR Category: Drugs CMS Add: 01/01/2016 CMS Term: C9460 DRUG DEF MAXFEE 04/01/2024 20.04 0.0 Description: INJECTION, CANGRELOR Category: Drugs CMS Add: 01/01/2016 CMS Term: C9462 DRUG DEF MAXFEE 04/01/2022 0.50 0.0 Description: INJECTION, DELAFLOXACIN Category: Drugs CMS Add: 04/01/2018 CMS Term: C9482 NOCOV DEF SYSMAN Description: SOTALOL HYDROCHLORIDE IV Category: Non Covered Services CMS Add: 10/01/2016 CMS Term: C9488 DRUG DEF MAXFEE 04/01/2021 46.79 0.0 Description: CONIVAPTAN HCL Category: Drugs CMS Add: 04/01/2017 CMS Term: C9507 DRUG DEF MAXFEE 04/01/2022 750.50 0.0 Description: COVID-19 CONVALESCENT PLASMA Category: Drugs CMS Add: 12/28/2021 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,517 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- C9600 MEDSV M26 MAXFEE 01/01/2021 0.00 0.0 Description: PERC DRUG-EL COR STENT SING Category: Medical Services CMS Add: 01/01/2013 CMS Term: C9601 MEDSV M26 MAXFEE 01/01/2021 0.00 0.0 Description: PERC DRUG-EL COR STENT BRAN Category: Medical Services CMS Add: 01/01/2013 CMS Term: C9602 MEDSV M26 MAXFEE 01/01/2021 0.00 0.0 Description: PERC D-E COR STENT ATHER S Category: Medical Services CMS Add: 01/01/2013 CMS Term: C9603 MEDSV M26 MAXFEE 01/01/2021 0.00 0.0 Description: PERC D-E COR STENT ATHER BR Category: Medical Services CMS Add: 01/01/2013 CMS Term: C9604 MEDSV M26 MAXFEE 01/01/2021 0.00 0.0 Description: PERC D-E COR REVASC T CABG S Category: Medical Services CMS Add: 01/01/2013 CMS Term: C9605 MEDSV M26 MAXFEE 01/01/2021 0.00 0.0 Description: PERC D-E COR REVASC T CABG B Category: Medical Services CMS Add: 01/01/2013 CMS Term: C9606 MEDSV M26 MAXFEE 01/01/2021 0.00 0.0 Description: PERC D-E COR REVASC W AMI S Category: Medical Services CMS Add: 01/01/2013 CMS Term: C9607 MEDSV M26 MAXFEE 01/01/2021 0.00 0.0 Description: PERC D-E COR REVASC CHRO SIN Category: Medical Services CMS Add: 01/01/2013 CMS Term: C9608 MEDSV M26 MAXFEE 01/01/2021 0.00 0.0 Description: PERC D-E COR REVASC CHRO ADD Category: Medical Services CMS Add: 01/01/2013 CMS Term: C9725 MEDSV L60 MAXFEE 09/21/2018 0.00 0.0 Description: PLACE ENDORECTAL APP Category: Medical Services CMS Add: 10/01/2005 CMS Term: C9726 MEDSV L60 MAXFEE 09/21/2018 0.00 0.0 Description: RXT BREAST APPL PLACE/REMOV Category: Medical Services CMS Add: 01/01/2006 CMS Term: C9727 NOCOV DEF SYSMAN Description: INSERT PALATE IMPLANTS Category: Non Covered Services CMS Add: 10/01/2006 CMS Term: C9728 MEDSV L60 MAXFEE 09/21/2018 0.00 0.0 Description: PLACE DEVICE/MARKER, NON PRO Category: Medical Services CMS Add: 07/01/2007 CMS Term: C9733 MEDSV DEF MAXFEE 01/01/2024 200.71 0.0 Description: NON-OPHTHALMIC FVA Category: Medical Services CMS Add: 04/01/2012 CMS Term: C9733 MEDSV DEF MAXFEE 11/25/2017 12/31/2023 154.87 0.0 Description: NON-OPHTHALMIC FVA Category: Medical Services CMS Add: 04/01/2012 CMS Term: C9734 NOCOV DEF SYSMAN Description: U/S TRTMT, NOT LEIOMYOMATA Category: Non Covered Services CMS Add: 04/01/2013 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,518 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- C9736 NOCOV DEF SYSMAN Description: LAP ABLATE UTERI FIBROID RF Category: Non Covered Services CMS Add: 07/01/2013 CMS Term: 12/31/2013 C9738 NOCOV DEF SYSMAN Description: BLUE LIGHT CYSTO IMAG AGENT Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: C9739 MEDSV M26 MAXFEE 01/01/2021 0.00 0.0 Y 0-1 Description: CYSTOSCOPY PROSTATIC IMP 1-3 Category: Medical Services CMS Add: 04/01/2014 CMS Term: C9740 MEDSV M26 MAXFEE 01/01/2021 0.00 0.0 Y 0-1 Description: CYSTO IMPL 4 OR MORE Category: Medical Services CMS Add: 04/01/2014 CMS Term: C9751 NOCOV DEF SYSMAN Description: MICROWAVE BRONCH, 3D, EBUS Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: C9756 DRUG DEF BILL90 Description: FLUORESCENCE LYMPH MAP W/ICG Category: Drugs CMS Add: 07/01/2019 CMS Term: C9757 MEDSV DEF BILL90 Y Description: SPINE DEVICE IMPLANT SURGERY Category: Medical Services CMS Add: 01/01/2020 CMS Term: C9758 NOCOV DEF SYSMAN Description: BLIND INTERATRIAL SHUNT IDE Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: C9759 NOCOV DEF SYSMAN Description: TRANSCATH INTRAOP MICROINF Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: C9760 NOCOV DEF SYSMAN Description: NON-BLIND INTERATRIAL SHUNT Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: C9761 MEDSV DEF MAXFEE 10/01/2020 0.00 0.0 Description: CYSTO, LITHO, VACUUM KIDNEY Category: Medical Services CMS Add: 10/01/2020 CMS Term: C9762 RADIO DEF BILL90 Description: CARDIAC MRI SEG DYS STRAIN Category: Radiology CMS Add: 07/01/2020 CMS Term: C9763 RADIO DEF BILL90 Description: CARDIAC MRI SEG DYS STRESS Category: Radiology CMS Add: 07/01/2020 CMS Term: C9764 NOCOV DEF SYSMAN Description: REVASC INTRAVASC LITHOTRIPSY Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: C9765 NOCOV DEF SYSMAN Description: REVASC INTRA LITHOTRIP-STENT Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: C9766 NOCOV DEF SYSMAN Description: REVASC INTRA LITHOTRIP-ATHER Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,519 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- C9767 NOCOV DEF SYSMAN Description: REVASC LITHOTRIP-STENT-ATHER Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: C9768 MEDSV DEF MAXFEE 10/01/2020 0.00 0.0 Description: ENDO US-GUIDE HEP PORTO GRAD Category: Medical Services CMS Add: 10/01/2020 CMS Term: C9769 MEDSV DEF MAXFEE 10/01/2020 0.00 0.0 Description: CYSTO W/TEMP PROS IMPLANT Category: Medical Services CMS Add: 10/01/2020 CMS Term: C9772 NOCOV DEF SYSMAN Description: REVASC LITHOTRIP TIBI/PERONE Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: C9773 NOCOV DEF SYSMAN Description: REVASC LITHOTR-STENT TIB/PER Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: C9774 NOCOV DEF SYSMAN Description: REVASC LITHOTR-ATHER TIB/PER Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: C9775 NOCOV DEF SYSMAN Description: REVASC LITH-STEN-ATH TIB/PER Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: C9776 NOCOV DEF SYSMAN Description: FLUO BILE DUCT IMAGING W/ICG Category: Non Covered Services CMS Add: 04/01/2021 CMS Term: C9777 NOCOV DEF SYSMAN Description: ESOPHAG MUC INTEG W/ESO EGD Category: Non Covered Services CMS Add: 04/01/2021 CMS Term: C9778 MEDSV DEF MAXFEE 07/01/2021 0.00 0.0 Description: COLPOPEXY, MIN/INV, EX-PERIT Category: Medical Services CMS Add: 07/01/2021 CMS Term: C9779 MEDSV DEF MAXFEE 10/01/2021 0.00 0.0 Description: ESD ENDOSCOPY OR COLONOSCOPY Category: Medical Services CMS Add: 10/01/2021 CMS Term: C9780 NOCOV DEF SYSMAN Description: INSERT CV CATH INF & SUP APP Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: C9781 NOCOV DEF SYSMAN Description: ARTHRO/SHOUL SURG; W/SPACER Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: C9782 NOCOV DEF SYSMAN Description: BLIND MYOCAR TRPL BON MARROW Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: C9783 NOCOV DEF SYSMAN Description: BLIND COR SINUS REDUCER IMPL Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: C9784 NOCOV DEF SYSMAN Description: ENDO SLEEVE GASTRO W/TUBE Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,520 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- C9785 NOCOV DEF SYSMAN Description: ENDO OUTLET RESTRICT W/TUBE Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: C9786 NOCOV DEF SYSMAN Description: ECHO CAD FOR HF PRESERVED EF Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: C9787 NOCOV DEF SYSMAN Description: GASTRIC EP MAPG SIMULT PT SX Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: C9789 MEDSV DEF BILL90 Description: INSTILL PHARM RENAL PELVIS Category: Medical Services CMS Add: 10/01/2023 CMS Term: C9790 NOCOV DEF SYSMAN Description: KIDNEY HISTOTRIPSY W/IMAGE Category: Non Covered Services CMS Add: 10/01/2023 CMS Term: C9791 MEDSV DEF BILL90 Y Description: MRI HYPERPOLARIZED XENON129 Category: Medical Services CMS Add: 10/01/2023 CMS Term: C9792 NOCOV DEF SYSMAN Description: BLIND/NONBLIND TRANS ATRIAL Category: Non Covered Services CMS Add: 10/01/2023 CMS Term: C9793 RADIO DEF BILL90 Y Description: PRE-PLAN 3D MODEL W/CCTA Category: Radiology CMS Add: 01/01/2024 CMS Term: C9794 RADIO DEF BILL90 Y Description: COMPLEX SIMULATION W/PET-CT Category: Radiology CMS Add: 01/01/2024 CMS Term: C9795 RADIO DEF BILL90 Y Description: SBRT W/POSITRON EMISSION DEL Category: Radiology CMS Add: 01/01/2024 CMS Term: C9801 NOCOV DEF SYSMAN Description: TOBACCO-USE COUNSEL 3-10 MIN Category: Non Covered Services CMS Add: 08/25/2010 CMS Term: 12/31/2010 C9802 NOCOV DEF SYSMAN Description: TOBACCO-USE COUNSEL >10MIN Category: Non Covered Services CMS Add: 08/25/2010 CMS Term: 12/31/2010 C9898 NOCOV DEF SYSMAN Description: INPNT STAY RADIOLABELED ITEM Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: C9899 NOCOV DEF SYSMAN Description: INPT IMPLANT PROS DEV,NO COV Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: D0120 DENTL DEF MAXFEE 01/01/2014 12/31/2023 22.58 0.0 0-1 Description: PERIODIC ORAL EVALUATION Category: Dental CMS Add: 01/01/1982 CMS Term: D0120 DENTL DEF MAXFEE 01/01/2024 29.40 0.0 0-1 Description: PERIODIC ORAL EVALUATION Category: Dental CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,521 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D0140 DENTL DEF MAXFEE 01/01/2014 12/31/2023 37.08 0.0 0-1 Description: LIMIT ORAL EVAL PROBLM FOCUS Category: Dental CMS Add: 01/01/1996 CMS Term: D0140 DENTL DEF MAXFEE 01/01/2024 43.05 0.0 0-1 Description: LIMIT ORAL EVAL PROBLM FOCUS Category: Dental CMS Add: 01/01/1996 CMS Term: D0145 DENTL DEF MAXFEE 01/01/2014 12/31/2023 35.50 0.0 0-2years 0-1 Description: ORAL EVALUATION, PT < 3YRS Category: Dental CMS Add: 01/01/2007 CMS Term: D0145 DENTL DEF MAXFEE 01/01/2024 38.64 0.0 0-2years 0-1 Description: ORAL EVALUATION, PT < 3YRS Category: Dental CMS Add: 01/01/2007 CMS Term: D0150 DENTL DEF MAXFEE 01/01/2014 12/31/2023 35.50 0.0 0-1 Description: COMPREHENSVE ORAL EVALUATION Category: Dental CMS Add: 01/01/1996 CMS Term: D0150 DENTL DEF MAXFEE 01/01/2024 51.44 0.0 0-1 Description: COMPREHENSVE ORAL EVALUATION Category: Dental CMS Add: 01/01/1996 CMS Term: D0160 DENTL DEF MAXFEE 01/01/2014 12/31/2023 50.00 0.0 0-1 Description: EXTENSV ORAL EVAL PROB FOCUS Category: Dental CMS Add: 01/01/1996 CMS Term: D0160 DENTL DEF MAXFEE 01/01/2024 83.15 0.0 0-1 Description: EXTENSV ORAL EVAL PROB FOCUS Category: Dental CMS Add: 01/01/1996 CMS Term: D0170 DENTL DEF MAXFEE 01/01/2014 12/31/2023 20.00 0.0 0-1 Description: RE-EVAL,EST PT,PROBLEM FOCUS Category: Dental CMS Add: 01/01/2000 CMS Term: D0170 DENTL DEF MAXFEE 01/01/2024 39.69 0.0 0-1 Description: RE-EVAL,EST PT,PROBLEM FOCUS Category: Dental CMS Add: 01/01/2000 CMS Term: D0171 NOCOV DEF SYSMAN Description: RE-EVAL POST-OP VISIT Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: D0180 NOCOV DEF SYSMAN 0-1 Description: COMP PERIODONTAL EVALUATION Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: D0190 NOCOV DEF SYSMAN Description: SCREENING OF A PATIENT Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: D0191 NOCOV DEF SYSMAN Description: ASSESSMENT OF A PATIENT Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: D0210 DENTL DEF MAXFEE 01/01/2014 12/31/2023 72.25 0.0 0-1 Description: INTRAOR COMPREHENSIVE SERIES Category: Dental CMS Add: 01/01/1982 CMS Term: D0210 DENTL DEF MAXFEE 01/01/2024 74.81 0.0 0-1 Description: INTRAOR COMPREHENSIVE SERIES Category: Dental CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,522 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D0220 DENTL DEF MAXFEE 01/01/2014 12/31/2023 13.25 0.0 0-1 Description: INTRAORAL PERIAPICAL FIRST Category: Dental CMS Add: 01/01/1984 CMS Term: D0220 DENTL DEF MAXFEE 01/01/2024 16.98 0.0 0-1 Description: INTRAORAL PERIAPICAL FIRST Category: Dental CMS Add: 01/01/1984 CMS Term: D0230 DENTL DEF MAXFEE 01/01/2014 12/31/2023 10.00 0.0 0-1 Description: INTRAORAL PERIAPICAL EA ADD Category: Dental CMS Add: 01/01/1984 CMS Term: D0230 DENTL DEF MAXFEE 01/01/2024 14.62 0.0 0-1 Description: INTRAORAL PERIAPICAL EA ADD Category: Dental CMS Add: 01/01/1984 CMS Term: D0240 DENTL DEF MAXFEE 01/01/2014 12/31/2023 18.50 0.0 0-2 Description: INTRAORAL OCCLUSAL FILM Category: Dental CMS Add: 01/01/1984 CMS Term: D0240 DENTL DEF MAXFEE 01/01/2024 22.14 0.0 0-2 Description: INTRAORAL OCCLUSAL FILM Category: Dental CMS Add: 01/01/1984 CMS Term: D0250 DENTL DEF MAXFEE 01/01/2014 12/31/2023 17.75 0.0 0-1 Description: EXTRAORAL 2D PROJECT IMAGE Category: Dental CMS Add: 01/01/1984 CMS Term: D0250 DENTL DEF MAXFEE 01/01/2024 34.61 0.0 0-1 Description: EXTRAORAL 2D PROJECT IMAGE Category: Dental CMS Add: 01/01/1984 CMS Term: D0251 DENTL DEF MAXFEE 01/01/2024 39.56 0.0 0-1 Description: EXTRAORAL POSTERIOR IMAGE Category: Dental CMS Add: 01/01/2016 CMS Term: D0251 DENTL DEF MAXFEE 04/28/2017 12/31/2023 70.00 0.0 0-1 Description: EXTRAORAL POSTERIOR IMAGE Category: Dental CMS Add: 01/01/2016 CMS Term: D0270 DENTL DEF MAXFEE 01/01/2014 12/31/2023 17.29 0.0 0-1 Description: DENTAL BITEWING SINGLE IMAGE Category: Dental CMS Add: 01/01/1982 CMS Term: D0270 DENTL DEF MAXFEE 01/01/2024 16.34 0.0 0-1 Description: DENTAL BITEWING SINGLE IMAGE Category: Dental CMS Add: 01/01/1982 CMS Term: D0272 DENTL DEF MAXFEE 01/01/2014 12/31/2023 24.81 0.0 0-1 Description: DENTAL BITEWINGS TWO IMAGES Category: Dental CMS Add: 01/01/1982 CMS Term: D0272 DENTL DEF MAXFEE 01/01/2024 26.23 0.0 0-1 Description: DENTAL BITEWINGS TWO IMAGES Category: Dental CMS Add: 01/01/1982 CMS Term: D0273 DENTL DEF MAXFEE 01/01/2014 12/31/2023 27.75 0.0 0-1 Description: BITEWINGS - THREE IMAGES Category: Dental CMS Add: 01/01/2007 CMS Term: D0273 DENTL DEF MAXFEE 01/01/2024 30.95 0.0 0-1 Description: BITEWINGS - THREE IMAGES Category: Dental CMS Add: 01/01/2007 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,523 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D0274 DENTL DEF MAXFEE 01/01/2014 12/31/2023 35.17 0.0 0-1 Description: BITEWINGS FOUR IMAGES Category: Dental CMS Add: 01/01/1982 CMS Term: D0274 DENTL DEF MAXFEE 01/01/2024 36.76 0.0 0-1 Description: BITEWINGS FOUR IMAGES Category: Dental CMS Add: 01/01/1982 CMS Term: D0277 DENTL DEF MAXFEE 01/01/2024 54.39 0.0 0-1 Description: VERT BITEWINGS 7 TO 8 IMAGES Category: Dental CMS Add: 01/01/2000 CMS Term: D0277 DENTL DEF MAXFEE 04/01/2010 12/31/2023 50.59 0.0 0-1 Description: VERT BITEWINGS 7 TO 8 IMAGES Category: Dental CMS Add: 01/01/2000 CMS Term: D0310 DENTL DEF MAXFEE 01/01/2014 61.75 0.0 0-1 Description: DENTAL SALIOGRAPHY Category: Dental CMS Add: 01/01/1986 CMS Term: D0320 NOCOV DEF SYSMAN Description: DENTAL TMJ ARTHROGRAM INCL I Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: D0321 NOCOV DEF SYSMAN Description: OTHER TMJ IMAGES BY REPORT Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D0322 NOCOV DEF SYSMAN Description: DENTAL TOMOGRAPHIC SURVEY Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: D0330 DENTL DEF MAXFEE 01/01/2014 12/31/2023 64.52 0.0 0-1 Description: PANORAMIC IMAGE Category: Dental CMS Add: 01/01/1984 CMS Term: D0330 DENTL DEF MAXFEE 01/01/2024 64.28 0.0 0-1 Description: PANORAMIC IMAGE Category: Dental CMS Add: 01/01/1984 CMS Term: D0340 DENTL DEF MAXFEE 01/01/2014 12/31/2023 34.25 0.0 0-1 Description: 2D CEPHALOMETRIC IMAGE Category: Dental CMS Add: 01/01/1982 CMS Term: D0340 DENTL DEF MAXFEE 01/01/2024 66.00 0.0 0-1 Description: 2D CEPHALOMETRIC IMAGE Category: Dental CMS Add: 01/01/1982 CMS Term: D0350 NOCOV DEF SYSMAN 0-1 Description: ORAL/FACIAL PHOTO IMAGES Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: D0363 NOCOV DEF SYSMAN Description: CONE BEAM, THREE DIMENSIONAL Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 12/31/2013 D0364 NOCOV DEF SYSMAN Description: CONE BEAM CT CAPT & INTERP Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: D0365 NOCOV DEF SYSMAN Description: CONE BEAM CT INTERPRETE MAN Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,524 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D0366 NOCOV DEF SYSMAN Description: CONE BEAM CT INTERPRETE MAX Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: D0367 NOCOV DEF SYSMAN Description: CONE BEAM CT INTERP BOTH JAW Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: D0368 NOCOV DEF SYSMAN Description: CONE BEAM CT INTERPRETE TMJ Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: D0369 NOCOV DEF SYSMAN Description: MAX MRI CAPTURE & INTERPRETE Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: D0370 NOCOV DEF SYSMAN Description: MAX ULTRASOUND CAPT & INTERP Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: D0371 NOCOV DEF SYSMAN Description: SIALOENDOSCOPY CAPT & INTERP Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: D0372 NOCOV DEF SYSMAN Description: TOMO COMP SERIES IMAGES Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: D0373 NOCOV DEF SYSMAN Description: TOMO BITEWING IMAGE Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: D0374 NOCOV DEF SYSMAN Description: TOMO PERIAPICAL IMAGE Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: D0380 NOCOV DEF SYSMAN Description: CONE BEAM CT CAPTURE LIMITED Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: D0381 NOCOV DEF SYSMAN Description: CONE BEAM CT CAPT MANDIBLE Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: D0382 NOCOV DEF SYSMAN Description: CONE BEAM CT CAPT MAXILLA Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: D0383 NOCOV DEF SYSMAN Description: CONE BEAM CT BOTH JAWS Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: D0384 NOCOV DEF SYSMAN Description: CONE BEAM CT CAPTURE TMJ Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: D0385 NOCOV DEF SYSMAN Description: MAX MRI IMAGE CAPTURE Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: D0386 NOCOV DEF SYSMAN Description: MAX ULTRASOUND IMAGE CAPTURE Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,525 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D0387 NOCOV DEF SYSMAN Description: COMP IMAGE CAPTURE ONLY Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: D0388 NOCOV DEF SYSMAN Description: BITEWING IMAGE CAPTURE ONLY Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: D0389 NOCOV DEF SYSMAN Description: PERIOPIC IMAGE CAPTURE ONLY Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: D0391 NOCOV DEF SYSMAN Description: IMTERPRETE DIAGNOSTIC IMAGE Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: D0393 NOCOV DEF SYSMAN Description: TRTMNT SIMULATION 3D IMAGE Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: D0394 NOCOV DEF SYSMAN Description: DIGITAL SUB 2 OR MORE IMAGES Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: D0395 NOCOV DEF SYSMAN Description: FUSION 2 OR MORE 3D IMAGES Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: D0396 NOCOV DEF SYSMAN Description: 3D PRINT OF 3D SURFACE SCAN Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: D0411 DENTL DEF BILL90 0-1 Description: HBA1C IN OFFICE TESTING Category: Dental CMS Add: 01/01/2018 CMS Term: D0412 NOCOV DEF SYSMAN Description: BLOOD GLUCOSE LEVEL TEST Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: D0414 NOCOV DEF SYSMAN Description: LAB PROCESS MICROBIAL SPEC Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: D0415 NOCOV DEF SYSMAN 0-1 Description: COLLECTION OF MICROORGANISMS Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: D0416 NOCOV DEF SYSMAN Description: VIRAL CULTURE Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: D0417 NOCOV DEF SYSMAN Description: COLLECT & PREP SALIVA SAMPLE Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: D0418 NOCOV DEF SYSMAN Description: ANALYSIS OF SALIVA SAMPLE Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: D0419 NOCOV DEF SYSMAN Description: ASSESS OF SALIVARY FLOW Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,526 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D0422 NOCOV DEF SYSMAN Description: COLLECT & PREP GENETIC SAMP Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: D0423 NOCOV DEF SYSMAN Description: GENETIC TEST SPEC ANALYSIS Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: D0425 NOCOV DEF SYSMAN 0-1 Description: CARIES SUSCEPTIBILITY TEST Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: D0431 NOCOV DEF SYSMAN Description: DIAG TST DETECT MUCOS ABNORM Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: D0460 NOCOV DEF SYSMAN Description: PULP VITALITY TEST Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: D0470 NOCOV DEF SYSMAN 0-1 Description: DIAGNOSTIC CASTS Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: D0472 NOCOV DEF SYSMAN Description: GROSS EXAM, PREP & REPORT Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: D0473 NOCOV DEF SYSMAN Description: MICRO EXAM, PREP & REPORT Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: D0474 NOCOV DEF SYSMAN Description: MICRO W EXAM OF SURG MARGINS Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: D0475 NOCOV DEF SYSMAN Description: DECALCIFICATION PROCEDURE Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: D0476 NOCOV DEF SYSMAN Description: SPEC STAINS FOR MICROORGANIS Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: D0477 NOCOV DEF SYSMAN Description: SPEC STAINS NOT FOR MICROORG Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: D0478 NOCOV DEF SYSMAN Description: IMMUNOHISTOCHEMICAL STAINS Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: D0479 NOCOV DEF SYSMAN Description: TISSUE IN-SITU HYBRIDIZATION Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: D0480 NOCOV DEF SYSMAN 0-1 Description: CYTOPATH SMEAR PREP & REPORT Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: D0481 NOCOV DEF SYSMAN Description: ELECTRON MICROSCOPY Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,527 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D0482 NOCOV DEF SYSMAN Description: DIRECT IMMUNOFLUORESCENCE Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: D0483 NOCOV DEF SYSMAN Description: INDIRECT IMMUNOFLUORESCENCE Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: D0484 NOCOV DEF SYSMAN Description: CONSULT SLIDES PREP ELSEWHER Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: D0485 NOCOV DEF SYSMAN Description: CONSULT INC PREP OF SLIDES Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: D0486 DENTL DEF MAXFEE 01/01/2014 68.71 0.0 0-1 Description: ACCESS OF TRANSEP CYTOL SAMP Category: Dental CMS Add: 01/01/2007 CMS Term: D0502 NOCOV DEF SYSMAN 0-1 Description: OTHER ORAL PATHOLOGY PROCEDU Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: D0600 NOCOV DEF SYSMAN Description: NON-IONIZING DIAG PROC Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: D0601 NOCOV DEF SYSMAN Description: CARIES RISK ASSESS LOW RISK Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: D0602 NOCOV DEF SYSMAN Description: CARIES RISK ASSESS MOD RISK Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: D0603 NOCOV DEF SYSMAN Description: CARIES RISK ASSESS HIGH RISK Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: D0604 NOCOV DEF SYSMAN Description: ANTIGEN TEST PUB HLTH PATHOG Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: D0605 NOCOV DEF SYSMAN Description: ANTIBODY TEST PUB HLTH PATH Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: D0606 DENTL DEF BILL90 Description: MOLECULAR TEST PUB HLTH PATH Category: Dental CMS Add: 01/01/2021 CMS Term: D0701 NOCOV DEF SYSMAN Description: PANO RADIO IMAGE Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: D0702 NOCOV DEF SYSMAN Description: 2D CEPHAL RADIO IMAGE Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: D0703 NOCOV DEF SYSMAN Description: 2D ORAL/FACIAL PHOTO IMAGE Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,528 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D0705 NOCOV DEF SYSMAN Description: EXTRA ORAL POST RADIO IMAGE Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: D0706 NOCOV DEF SYSMAN Description: INTRAORAL OCCLUS RADIO IMAGE Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: D0707 NOCOV DEF SYSMAN Description: INTRAORAL PERIAP RADIO IMAGE Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: D0708 NOCOV DEF SYSMAN Description: INTRAORAL BITE RADIO IMAGE Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: D0709 NOCOV DEF SYSMAN Description: INTRAORAL COMP IMAGE CAPTURE Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: D0801 NOCOV DEF SYSMAN Description: 3D DENTAL SCAN DIRECT Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: D0802 NOCOV DEF SYSMAN Description: 3D DENTAL SCAN INDIRECT Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: D0803 NOCOV DEF SYSMAN Description: 3D FACIAL SCAN DIRECT Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: D0804 NOCOV DEF SYSMAN Description: 3D FACIAL SCAN INDIRECT Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: D0999 NOCOV DEF SYSMAN 0-1 Description: UNSPECIFIED DIAGNOSTIC PROCE Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D1110 DENTL DEF MAXFEE 01/01/2014 12/31/2023 47.75 0.0 12-999years Description: DENTAL PROPHYLAXIS ADULT Category: Dental CMS Add: 01/01/1984 CMS Term: D1110 DENTL DEF MAXFEE 01/01/2024 62.05 0.0 12-999years Description: DENTAL PROPHYLAXIS ADULT Category: Dental CMS Add: 01/01/1984 CMS Term: D1120 DENTL DEF MAXFEE 01/01/2014 12/31/2023 34.50 0.0 1-11years Description: DENTAL PROPHYLAXIS CHILD Category: Dental CMS Add: 01/01/1984 CMS Term: D1120 DENTL DEF MAXFEE 01/01/2024 46.34 0.0 1-11years Description: DENTAL PROPHYLAXIS CHILD Category: Dental CMS Add: 01/01/1984 CMS Term: D1206 DENTL DEF MAXFEE 01/01/2014 12/31/2023 22.25 0.0 1-20years Description: TOPICAL FLUORIDE VARNISH Category: Dental CMS Add: 01/01/2007 CMS Term: D1206 DENTL DEF MAXFEE 01/01/2024 26.48 0.0 1-20years Description: TOPICAL FLUORIDE VARNISH Category: Dental CMS Add: 01/01/2007 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,529 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D1208 DENTL DEF MAXFEE 01/01/2014 12/31/2023 22.39 0.0 0-20years Description: TOPICAL APP FLUORID EX VRNSH Category: Dental CMS Add: 01/01/2013 CMS Term: D1208 DENTL DEF MAXFEE 01/01/2024 25.49 0.0 0-20years Description: TOPICAL APP FLUORID EX VRNSH Category: Dental CMS Add: 01/01/2013 CMS Term: D1310 NOCOV DEF SYSMAN 0-1 Description: NUTRI COUNSEL-CONTROL CARIES Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: D1320 DENTL DEF MAXFEE 01/01/2024 43.42 0.0 Description: TOBACCO COUNSELING Category: Dental CMS Add: 01/01/1996 CMS Term: D1320 DENTL DEF MAXFEE 07/01/2021 12/31/2023 64.00 0.0 Description: TOBACCO COUNSELING Category: Dental CMS Add: 01/01/1996 CMS Term: D1321 NOCOV DEF SYSMAN Description: COUNS FOR HIGH RISK SUB USE Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: D1330 NOCOV DEF SYSMAN 0-1 Description: ORAL HYGIENE INSTRUCTION Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: D1351 DENTL DEF MAXFEE 01/01/2014 12/31/2023 29.35 0.0 0-20years 0-1 Description: DENTAL SEALANT PER TOOTH Category: Dental CMS Add: 01/01/1985 CMS Term: D1351 DENTL DEF MAXFEE 01/01/2024 32.62 0.0 0-20years 0-1 Description: DENTAL SEALANT PER TOOTH Category: Dental CMS Add: 01/01/1985 CMS Term: D1352 DENTL DEF MAXFEE 01/01/2014 12/31/2023 35.45 0.0 0-20years Description: PREV RESIN REST, PERM TOOTH Category: Dental CMS Add: 01/01/2011 CMS Term: D1352 DENTL DEF MAXFEE 01/01/2024 46.80 0.0 0-20years Description: PREV RESIN REST, PERM TOOTH Category: Dental CMS Add: 01/01/2011 CMS Term: D1353 NOCOV DEF SYSMAN Description: SEALANT REPAIR PER TOOTH Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: D1354 DENTL DEF MAXFEE 01/01/2024 34.45 0.0 Y 0-20;21-999years 0-1 Description: INT CARIES MED APP PER TOOTH Category: Dental CMS Add: 01/01/2016 CMS Term: D1354 DENTL DEF MAXFEE 04/28/2017 12/31/2023 98.50 0.0 Y 0-20;21-999years 0-1 Description: INT CARIES MED APP PER TOOTH Category: Dental CMS Add: 01/01/2016 CMS Term: D1355 DENTL DEF BILL90 Y 1-20;21-999years Description: CARIES MED APP PER TOOTH Category: Dental CMS Add: 01/01/2021 CMS Term: D1510 DENTL DEF MAXFEE 01/01/2014 12/31/2023 194.34 0.0 1-20years 0-1 Description: SPACE MAINTAINER FXD UNILAT Category: Dental CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,530 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D1510 DENTL DEF MAXFEE 01/01/2024 190.69 0.0 1-20years 0-1 Description: SPACE MAINTAINER FXD UNILAT Category: Dental CMS Add: 01/01/1984 CMS Term: D1516* DENTL DEF MAXFEE 01/01/2024 257.66 0.0 Y 1-3;4-20years 0-1 Description: FIXED BILAT SPACE MAINT, MAX Category: Dental CMS Add: 01/01/2019 CMS Term: D1517* DENTL DEF MAXFEE 01/01/2024 260.99 0.0 Y 1-3;4-20years 0-1 Description: FIXED BILAT SPACE MAINT, MAN Category: Dental CMS Add: 01/01/2019 CMS Term: D1520 DENTL DEF MAXFEE 01/01/2014 12/31/2023 154.75 0.0 1-20years 0-1 Description: REMOVE UNILAT SPACE MAINTAIN Category: Dental CMS Add: 01/01/1984 CMS Term: D1520 DENTL DEF MAXFEE 01/01/2024 227.50 0.0 1-20years 0-1 Description: REMOVE UNILAT SPACE MAINTAIN Category: Dental CMS Add: 01/01/1984 CMS Term: D1526* DENTL DEF MAXFEE 01/01/2024 277.14 0.0 Y 1-3;4-20years 0-1 Description: REMOVE BILAT SPACE MAIN, MAX Category: Dental CMS Add: 01/01/2019 CMS Term: D1527* DENTL DEF MAXFEE 01/01/2024 279.99 0.0 Y 1-3;4-20years 0-1 Description: REMOVE BILAT SPACE MAIN, MAN Category: Dental CMS Add: 01/01/2019 CMS Term: D1551 DENTL DEF MAXFEE 01/01/2024 59.61 0.0 1-20years 0-1 Description: RECEMENT SPACE MAINT - MAX Category: Dental CMS Add: 01/01/2020 CMS Term: D1552 DENTL DEF MAXFEE 01/01/2024 61.04 0.0 1-20years 0-1 Description: RECEMENT SPACE MAINT - MAN Category: Dental CMS Add: 01/01/2020 CMS Term: D1553 DENTL DEF MAXFEE 01/01/2024 57.46 0.0 1-20years 0-1 Description: RECEMENT UNILAT SPACE MAINT Category: Dental CMS Add: 01/01/2020 CMS Term: D1556 DENTL DEF MAXFEE 01/01/2024 55.81 0.0 0-1 Description: REM FIXED UNILAT SPACE MAINT Category: Dental CMS Add: 01/01/2020 CMS Term: D1557 DENTL DEF MAXFEE 01/01/2024 60.79 0.0 0-1 Description: REMOVE FIXED BILAT MAINT MAX Category: Dental CMS Add: 01/01/2020 CMS Term: D1558 DENTL DEF MAXFEE 01/01/2024 61.98 0.0 0-1 Description: REMOVE FIXED BILAT MAN Category: Dental CMS Add: 01/01/2020 CMS Term: D1575 DENTL DEF MAXFEE 01/01/2024 225.37 0.0 0-20years 0-1 Description: DIST SPACE MAINT, FIXED UNIL Category: Dental CMS Add: 01/01/2017 CMS Term: D1575 DENTL DEF MAXFEE 03/20/2018 12/31/2023 444.00 0.0 0-20years 0-1 Description: DIST SPACE MAINT, FIXED UNIL Category: Dental CMS Add: 01/01/2017 CMS Term: D1701 DENTL DEF BILL90 Description: PFIZER VACC ADMIN 1ST DOSE Category: Dental CMS Add: 01/01/2021 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,531 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D1702 DENTL DEF BILL90 Description: PFIZER VACC ADMIN 2ND DOSE Category: Dental CMS Add: 01/01/2021 CMS Term: D1703 DENTL DEF BILL90 Description: MODERNA VACC ADMIN 1ST DOSE Category: Dental CMS Add: 01/01/2021 CMS Term: D1704 DENTL DEF BILL90 Description: MODERNA VACC ADMIN 2ND DOSE Category: Dental CMS Add: 01/01/2021 CMS Term: D1705 NOCOV DEF SYSMAN Description: ASTRAZENECA VACC ADM 1ST DOS Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: D1706 NOCOV DEF SYSMAN Description: ASTRAZENECA VACC ADM 2ND DOS Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: D1707 NOCOV DEF SYSMAN Description: JANSSEN VACCINE ADMIN Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: D1708 DENTL DEF BILL90 12-999years Description: PFIZER VACC ADMIN 3RD DOSE Category: Dental CMS Add: 01/01/2022 CMS Term: D1709 DENTL DEF BILL90 12-999years Description: PFIZER VACCINE ADMIN BOOSTER Category: Dental CMS Add: 01/01/2022 CMS Term: D1710 DENTL DEF BILL90 12-999years Description: MODERNA VACC ADMIN 3RD DOSE Category: Dental CMS Add: 01/01/2022 CMS Term: D1711 DENTL DEF BILL90 12-999years Description: MODERNA VACC ADMIN BOOSTER Category: Dental CMS Add: 01/01/2022 CMS Term: D1712 NOCOV DEF SYSMAN Description: JANSSEN VACC ADMIN BOOSTER Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: D1713 DENTL DEF BILL90 5-11years Description: PFIZER VACC ADM PED 1ST DOSE Category: Dental CMS Add: 01/01/2022 CMS Term: D1714 DENTL DEF BILL90 5-11years Description: PFIZER VACC ADM PED 2ND DOSE Category: Dental CMS Add: 01/01/2022 CMS Term: D1781 DENTL DEF BILL90 9-45years Description: VAC ADMIN HUMAN PAP DOSE 1 Category: Dental CMS Add: 01/01/2023 CMS Term: D1782 DENTL DEF BILL90 9-45years Description: VAC ADMIN HUMAN PAP DOSE 2 Category: Dental CMS Add: 01/01/2023 CMS Term: D1783 DENTL DEF BILL90 15-26years Description: VAC ADMIN HUMAN PAP DOSE 3 Category: Dental CMS Add: 01/01/2023 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,532 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D1999 DENTL DEF MAXFEE 01/01/2024 58.49 0.0 Y 0-1 Description: UNSPECIFIED PREVENTIVE PROC Category: Dental CMS Add: 01/01/2014 CMS Term: D2140 DENTL DEF MAXFEE 01/01/2024 63.47 0.0 0-1 Description: AMALGAM ONE SURFACE PERMANEN Category: Dental CMS Add: 01/01/1982 CMS Term: D2150 DENTL DEF MAXFEE 01/01/2024 80.56 0.0 0-1 Description: AMALGAM TWO SURFACES PERMANE Category: Dental CMS Add: 01/01/1982 CMS Term: D2160 DENTL DEF MAXFEE 01/01/2024 98.14 0.0 0-1 Description: AMALGAM THREE SURFACES PERMA Category: Dental CMS Add: 01/01/1982 CMS Term: D2161 DENTL DEF MAXFEE 01/01/2024 115.90 0.0 0-1 Description: AMALGAM 4 OR > SURFACES PERM Category: Dental CMS Add: 01/01/1982 CMS Term: D2330 DENTL DEF MAXFEE 01/01/2014 12/31/2023 79.18 0.0 0-1 Description: RESIN ONE SURFACE-ANTERIOR Category: Dental CMS Add: 01/01/1984 CMS Term: D2330 DENTL DEF MAXFEE 01/01/2024 76.06 0.0 0-1 Description: RESIN ONE SURFACE-ANTERIOR Category: Dental CMS Add: 01/01/1984 CMS Term: D2331 DENTL DEF MAXFEE 01/01/2014 12/31/2023 96.47 0.0 0-1 Description: RESIN TWO SURFACES-ANTERIOR Category: Dental CMS Add: 01/01/1984 CMS Term: D2331 DENTL DEF MAXFEE 01/01/2024 91.42 0.0 0-1 Description: RESIN TWO SURFACES-ANTERIOR Category: Dental CMS Add: 01/01/1984 CMS Term: D2332 DENTL DEF MAXFEE 01/01/2014 12/31/2023 111.58 0.0 0-1 Description: RESIN THREE SURFACES-ANTERIO Category: Dental CMS Add: 01/01/1984 CMS Term: D2332 DENTL DEF MAXFEE 01/01/2024 112.80 0.0 0-1 Description: RESIN THREE SURFACES-ANTERIO Category: Dental CMS Add: 01/01/1984 CMS Term: D2335 DENTL DEF MAXFEE 01/01/2014 12/31/2023 154.74 0.0 0-1 Description: RESIN 4/> SURF OR W INCIS AN Category: Dental CMS Add: 01/01/1984 CMS Term: D2335 DENTL DEF MAXFEE 01/01/2024 142.30 0.0 0-1 Description: RESIN 4/> SURF OR W INCIS AN Category: Dental CMS Add: 01/01/1984 CMS Term: D2390 DENTL DEF MAXFEE 01/01/2024 170.50 0.0 0-1 Description: ANT RESIN-BASED CMPST CROWN Category: Dental CMS Add: 01/01/2003 CMS Term: D2391 DENTL DEF MAXFEE 01/01/2024 82.45 0.0 0-1 Description: POST 1 SRFC RESINBASED CMPST Category: Dental CMS Add: 01/01/2003 CMS Term: D2392 DENTL DEF MAXFEE 01/01/2024 104.53 0.0 0-1 Description: POST 2 SRFC RESINBASED CMPST Category: Dental CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,533 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D2393 DENTL DEF MAXFEE 01/01/2024 130.40 0.0 0-1 Description: POST 3 SRFC RESINBASED CMPST Category: Dental CMS Add: 01/01/2003 CMS Term: D2394 DENTL DEF MAXFEE 01/01/2024 152.65 0.0 0-1 Description: POST >=4SRFC RESINBASE CMPST Category: Dental CMS Add: 01/01/2003 CMS Term: D2410 NOCOV DEF SYSMAN 0-1 Description: DENTAL GOLD FOIL ONE SURFACE Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: D2420 NOCOV DEF SYSMAN 0-1 Description: DENTAL GOLD FOIL TWO SURFACE Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: D2430 NOCOV DEF SYSMAN 0-1 Description: DENTAL GOLD FOIL THREE SURFA Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: D2510 NOCOV DEF SYSMAN 0-1 Description: DENTAL INLAY METALIC 1 SURF Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D2520 NOCOV DEF SYSMAN 0-1 Description: DENTAL INLAY METALLIC 2 SURF Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D2530 NOCOV DEF SYSMAN 0-1 Description: DENTAL INLAY METL 3/MORE SUR Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D2542 NOCOV DEF SYSMAN 0-1 Description: DENTAL ONLAY METALLIC 2 SURF Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: D2543 NOCOV DEF SYSMAN 0-1 Description: DENTAL ONLAY METALLIC 3 SURF Category: Non Covered Services CMS Add: 01/01/1996 CMS Term: D2544 NOCOV DEF SYSMAN 0-1 Description: DENTAL ONLAY METL 4/MORE SUR Category: Non Covered Services CMS Add: 01/01/1996 CMS Term: D2610 NOCOV DEF SYSMAN 0-1 Description: INLAY PORCELAIN/CERAMIC 1 SU Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D2620 NOCOV DEF SYSMAN 0-1 Description: INLAY PORCELAIN/CERAMIC 2 SU Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: D2630 NOCOV DEF SYSMAN 0-1 Description: DENTAL ONLAY PORC 3/MORE SUR Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: D2642 NOCOV DEF SYSMAN 0-1 Description: DENTAL ONLAY PORCELIN 2 SURF Category: Non Covered Services CMS Add: 01/01/1996 CMS Term: D2643 NOCOV DEF SYSMAN 0-1 Description: DENTAL ONLAY PORCELIN 3 SURF Category: Non Covered Services CMS Add: 01/01/1996 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,534 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D2644 NOCOV DEF SYSMAN 0-1 Description: DENTAL ONLAY PORC 4/MORE SUR Category: Non Covered Services CMS Add: 01/01/1996 CMS Term: D2650 NOCOV DEF SYSMAN 0-1 Description: INLAY COMPOSITE/RESIN ONE SU Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: D2651 NOCOV DEF SYSMAN 0-1 Description: INLAY COMPOSITE/RESIN TWO SU Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: D2652 NOCOV DEF SYSMAN 0-1 Description: DENTAL INLAY RESIN 3/MRE SUR Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: D2662 NOCOV DEF SYSMAN Description: DENTAL ONLAY RESIN 2 SURFACE Category: Non Covered Services CMS Add: 01/01/1996 CMS Term: D2663 NOCOV DEF SYSMAN Description: DENTAL ONLAY RESIN 3 SURFACE Category: Non Covered Services CMS Add: 01/01/1996 CMS Term: D2664 NOCOV DEF SYSMAN Description: DENTAL ONLAY RESIN 4/MRE SUR Category: Non Covered Services CMS Add: 01/01/1996 CMS Term: D2710 NOCOV DEF SYSMAN 0-1 Description: CROWN RESIN-BASED INDIRECT Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D2712 NOCOV DEF SYSMAN Description: CROWN 3/4 RESIN-BASED COMPOS Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: D2720 NOCOV DEF SYSMAN 0-1 Description: CROWN RESIN W/ HIGH NOBLE ME Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D2721 NOCOV DEF SYSMAN 0-1 Description: CROWN RESIN W/ BASE METAL Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D2722 NOCOV DEF SYSMAN 0-1 Description: CROWN RESIN W/ NOBLE METAL Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D2740 NOCOV DEF SYSMAN 0-1 Description: CROWN PORCELAIN/CERAMIC Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D2750 NOCOV DEF SYSMAN 0-1 Description: CROWN PORCELAIN W/ H NOBLE M Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D2751 NOCOV DEF SYSMAN 0-1 Description: CROWN PORCELAIN FUSED BASE M Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: D2752 NOCOV DEF SYSMAN 0-1 Description: CROWN PORCELAIN W/ NOBLE MET Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,535 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D2753 NOCOV DEF SYSMAN Description: CROWN PORC FUSED TO TITANIUM Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: D2780 NOCOV DEF SYSMAN 0-1 Description: CROWN 3/4 CAST HI NOBLE MET Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: D2781 NOCOV DEF SYSMAN 0-1 Description: CROWN 3/4 CAST BASE METAL Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: D2782 NOCOV DEF SYSMAN 0-1 Description: CROWN 3/4 CAST NOBLE METAL Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: D2783 NOCOV DEF SYSMAN 0-1 Description: CROWN 3/4 PORCELAIN/CERAMIC Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: D2790 NOCOV DEF SYSMAN 0-1 Description: CROWN FULL CAST HIGH NOBLE M Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D2791 NOCOV DEF SYSMAN 0-1 Description: CROWN FULL CAST BASE METAL Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D2792 NOCOV DEF SYSMAN 0-1 Description: CROWN FULL CAST NOBLE METAL Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D2794 NOCOV DEF SYSMAN Description: CROWN-TITANIUM Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: D2799 NOCOV DEF SYSMAN 0-1 Description: INTERIM CROWN Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: D2910 DENTL DEF MAXFEE 01/01/2014 12/31/2023 56.00 0.0 0-1 Description: RECEMENT INLAY ONLAY OR PART Category: Dental CMS Add: 01/01/1984 CMS Term: D2910 DENTL DEF MAXFEE 01/01/2024 50.82 0.0 0-1 Description: RECEMENT INLAY ONLAY OR PART Category: Dental CMS Add: 01/01/1984 CMS Term: D2915 NOCOV DEF SYSMAN Description: RECEMENT CAST OR PREFAB POST Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: D2920 DENTL DEF MAXFEE 01/01/2014 12/31/2023 58.27 0.0 0-1 Description: RE-CEMENT OR RE-BOND CROWN Category: Dental CMS Add: 01/01/1984 CMS Term: D2920 DENTL DEF MAXFEE 01/01/2024 50.82 0.0 0-1 Description: RE-CEMENT OR RE-BOND CROWN Category: Dental CMS Add: 01/01/1984 CMS Term: D2921 DENTL DEF MAXFEE 01/01/2014 12/31/2023 170.82 0.0 0-1 Description: REATTACH TOOTH FRAGMENT Category: Dental CMS Add: 01/01/2014 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,536 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D2921 DENTL DEF MAXFEE 01/01/2024 112.85 0.0 0-1 Description: REATTACH TOOTH FRAGMENT Category: Dental CMS Add: 01/01/2014 CMS Term: D2928 NOCOV DEF SYSMAN Description: PREFAB PORC/CER CROWN PERM Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: D2929 NOCOV DEF SYSMAN Description: PREFAB PORC/CERAM CROWN PRI Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: D2930 DENTL DEF MAXFEE 01/01/2014 12/31/2023 155.86 0.0 0-1 Description: PREFAB STNLSS STEEL CRWN PRI Category: Dental CMS Add: 01/01/1986 CMS Term: D2930 DENTL DEF MAXFEE 01/01/2024 159.83 0.0 0-1 Description: PREFAB STNLSS STEEL CRWN PRI Category: Dental CMS Add: 01/01/1986 CMS Term: D2931 DENTL DEF MAXFEE 01/01/2014 12/31/2023 185.69 0.0 0-1 Description: PREFAB STNLSS STEEL CROWN PE Category: Dental CMS Add: 01/01/1986 CMS Term: D2931 DENTL DEF MAXFEE 01/01/2024 193.87 0.0 0-1 Description: PREFAB STNLSS STEEL CROWN PE Category: Dental CMS Add: 01/01/1986 CMS Term: D2932 DENTL DEF MAXFEE 01/01/2014 12/31/2023 138.75 0.0 1-20years 0-1 Description: PREFABRICATED RESIN CROWN Category: Dental CMS Add: 01/01/1986 CMS Term: D2932 DENTL DEF MAXFEE 01/01/2024 163.28 0.0 1-20years 0-1 Description: PREFABRICATED RESIN CROWN Category: Dental CMS Add: 01/01/1986 CMS Term: D2933 DENTL DEF MAXFEE 01/01/2014 12/31/2023 161.75 0.0 1-20years 0-1 Description: PREFAB STAINLESS STEEL CROWN Category: Dental CMS Add: 01/01/1992 CMS Term: D2933 DENTL DEF MAXFEE 01/01/2024 168.25 0.0 1-20years 0-1 Description: PREFAB STAINLESS STEEL CROWN Category: Dental CMS Add: 01/01/1992 CMS Term: D2934 DENTL DEF MAXFEE 01/01/2014 12/31/2023 155.86 0.0 Description: PREFAB STEEL CROWN PRIMARY Category: Dental CMS Add: 01/01/2005 CMS Term: D2934 DENTL DEF MAXFEE 01/01/2024 166.31 0.0 Description: PREFAB STEEL CROWN PRIMARY Category: Dental CMS Add: 01/01/2005 CMS Term: D2940 DENTL DEF MAXFEE 01/01/2014 12/31/2023 60.78 0.0 0-1 Description: PROTECTIVE RESTORATION Category: Dental CMS Add: 01/01/1984 CMS Term: D2940 DENTL DEF MAXFEE 01/01/2024 60.34 0.0 0-1 Description: PROTECTIVE RESTORATION Category: Dental CMS Add: 01/01/1984 CMS Term: D2941 DENTL DEF MAXFEE 01/01/2014 12/31/2023 170.82 0.0 0-1 Description: INT THERAPEUTIC RESTORATION Category: Dental CMS Add: 01/01/2014 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,537 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D2941 DENTL DEF MAXFEE 01/01/2024 90.69 0.0 0-1 Description: INT THERAPEUTIC RESTORATION Category: Dental CMS Add: 01/01/2014 CMS Term: D2949 DENTL DEF MAXFEE 01/01/2014 12/31/2023 170.82 0.0 0-1 Description: RESTORATIVE FOUNDATION Category: Dental CMS Add: 01/01/2014 CMS Term: D2949 DENTL DEF MAXFEE 01/01/2024 100.46 0.0 0-1 Description: RESTORATIVE FOUNDATION Category: Dental CMS Add: 01/01/2014 CMS Term: D2950 NOCOV DEF SYSMAN 0-1 Description: CORE BUILD-UP INCL ANY PINS Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: D2951 NOCOV DEF SYSMAN 0-1 Description: TOOTH PIN RETENTION Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: D2952 NOCOV DEF SYSMAN 0-1 Description: POST AND CORE CAST + CROWN Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: D2953 NOCOV DEF SYSMAN 0-1 Description: EACH ADDTNL CAST POST Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: D2954 NOCOV DEF SYSMAN 0-1 Description: PREFAB POST/CORE + CROWN Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: D2955 NOCOV DEF SYSMAN 0-1 Description: POST REMOVAL Category: Non Covered Services CMS Add: 01/01/1996 CMS Term: D2957 NOCOV DEF SYSMAN 0-1 Description: EACH ADDTNL PREFAB POST Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: D2960 NOCOV DEF SYSMAN 0-1 Description: LABIAL VENEER RESIN DIRECT Category: Non Covered Services CMS Add: 01/01/1985 CMS Term: D2961 NOCOV DEF SYSMAN 0-1 Description: LABIAL VENEER RESIN INDIRECT Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: D2962 NOCOV DEF SYSMAN 0-1 Description: LABIAL VENEER PORC INDIRECT Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: D2971 NOCOV DEF SYSMAN Description: ADD PROC CONSTRUCT NEW CROWN Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: D2975 NOCOV DEF SYSMAN Description: COPING Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: D2980 DENTL DEF MAXFEE 01/01/2014 12/31/2023 160.25 0.0 0-1 Description: CROWN REPAIR Category: Dental CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,538 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D2980 DENTL DEF MAXFEE 01/01/2024 123.74 0.0 0-1 Description: CROWN REPAIR Category: Dental CMS Add: 01/01/1986 CMS Term: D2981 NOCOV DEF SYSMAN Description: INLAY REPAIR Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: D2982 NOCOV DEF SYSMAN Description: ONLAY REPAIR Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: D2983 NOCOV DEF SYSMAN Description: VENEER REPAIR Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: D2989 NOCOV DEF SYSMAN Description: EXCAVATE TOOTH NON-RESTORABL Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: D2990 DENTL DEF MAXFEE 01/01/2014 12/31/2023 177.03 0.0 0-1 Description: RESIN INFILTRATION OF LESION Category: Dental CMS Add: 01/01/2013 CMS Term: D2990 DENTL DEF MAXFEE 01/01/2024 84.66 0.0 0-1 Description: RESIN INFILTRATION OF LESION Category: Dental CMS Add: 01/01/2013 CMS Term: D2991 NOCOV DEF SYSMAN Description: APP OF HYDROXYAPATITE Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: D2999 NOCOV DEF SYSMAN 0-1 Description: DENTAL UNSPEC RESTORATIVE PR Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: D3110 NOCOV DEF SYSMAN 0-1 Description: PULP CAP DIRECT Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: D3120 NOCOV DEF SYSMAN 0-1 Description: PULP CAP INDIRECT Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D3220 DENTL DEF MAXFEE 01/01/2014 12/31/2023 105.11 0.0 0-1 Description: THERAPEUTIC PULPOTOMY Category: Dental CMS Add: 01/01/1984 CMS Term: D3220 DENTL DEF MAXFEE 01/01/2024 126.48 0.0 0-1 Description: THERAPEUTIC PULPOTOMY Category: Dental CMS Add: 01/01/1984 CMS Term: D3221 NOCOV DEF SYSMAN 0-1 Description: GROSS PULPAL DEBRIDEMENT Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: D3222 DENTL DEF MAXFEE 01/01/2014 12/31/2023 105.11 0.0 Description: PART PULP FOR APEXOGENESIS Category: Dental CMS Add: 01/01/2009 CMS Term: D3222 DENTL DEF MAXFEE 01/01/2024 173.34 0.0 Description: PART PULP FOR APEXOGENESIS Category: Dental CMS Add: 01/01/2009 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,539 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D3230 DENTL DEF MAXFEE 01/01/2014 12/31/2023 136.06 0.0 0-1 Description: PULPAL THERAPY ANTERIOR PRIM Category: Dental CMS Add: 01/01/1996 CMS Term: D3230 DENTL DEF MAXFEE 01/01/2024 170.19 0.0 0-1 Description: PULPAL THERAPY ANTERIOR PRIM Category: Dental CMS Add: 01/01/1996 CMS Term: D3240 DENTL DEF MAXFEE 01/01/2014 12/31/2023 115.50 0.0 0-1 Description: PULPAL THERAPY POSTERIOR PRI Category: Dental CMS Add: 01/01/1996 CMS Term: D3240 DENTL DEF MAXFEE 01/01/2024 182.60 0.0 0-1 Description: PULPAL THERAPY POSTERIOR PRI Category: Dental CMS Add: 01/01/1996 CMS Term: D3310 DENTL DEF MAXFEE 01/01/2014 12/31/2023 377.52 0.0 1-20years 0-1 Description: END THXPY, ANTERIOR TOOTH Category: Dental CMS Add: 01/01/1984 CMS Term: D3310 DENTL DEF MAXFEE 01/01/2024 517.30 0.0 1-20years 0-1 Description: END THXPY, ANTERIOR TOOTH Category: Dental CMS Add: 01/01/1984 CMS Term: D3320 DENTL DEF MAXFEE 01/01/2014 12/31/2023 464.23 0.0 1-20years 0-1 Description: END THXPY, PREMOLAR TOOTH Category: Dental CMS Add: 01/01/1984 CMS Term: D3320 DENTL DEF MAXFEE 01/01/2024 594.87 0.0 1-20years 0-1 Description: END THXPY, PREMOLAR TOOTH Category: Dental CMS Add: 01/01/1984 CMS Term: D3330 DENTL DEF MAXFEE 01/01/2014 12/31/2023 569.32 0.0 1-20years 0-1 Description: END THXPY, MOLAR TOOTH Category: Dental CMS Add: 01/01/1984 CMS Term: D3330 DENTL DEF MAXFEE 01/01/2024 719.77 0.0 1-20years 0-1 Description: END THXPY, MOLAR TOOTH Category: Dental CMS Add: 01/01/1984 CMS Term: D3331 NOCOV DEF SYSMAN 0-1 Description: NON-SURG TX ROOT CANAL OBS Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: D3332 NOCOV DEF SYSMAN 0-1 Description: INCOMPLETE ENDODONTIC TX Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: D3333 NOCOV DEF SYSMAN 0-1 Description: INTERNAL ROOT REPAIR Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: D3346 DENTL DEF MAXFEE 01/01/2024 562.03 0.0 1-20years 0-1 Description: RETREAT ROOT CANAL ANTERIOR Category: Dental CMS Add: 01/01/1992 CMS Term: D3346 DENTL DEF MAXFEE 08/01/2015 12/31/2023 564.50 0.0 1-20years 0-1 Description: RETREAT ROOT CANAL ANTERIOR Category: Dental CMS Add: 01/01/1992 CMS Term: D3347 DENTL DEF MAXFEE 01/01/2024 638.74 0.0 1-20years 0-1 Description: RETREAT ROOT CANAL PREMOLAR Category: Dental CMS Add: 01/01/1992 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,540 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D3347 DENTL DEF MAXFEE 08/01/2015 12/31/2023 639.00 0.0 1-20years 0-1 Description: RETREAT ROOT CANAL PREMOLAR Category: Dental CMS Add: 01/01/1992 CMS Term: D3348 DENTL DEF MAXFEE 01/01/2024 759.51 0.0 1-20years 0-1 Description: RETREAT ROOT CANAL MOLAR Category: Dental CMS Add: 01/01/1992 CMS Term: D3348 DENTL DEF MAXFEE 08/01/2015 12/31/2023 792.00 0.0 1-20years 0-1 Description: RETREAT ROOT CANAL MOLAR Category: Dental CMS Add: 01/01/1992 CMS Term: D3351 DENTL DEF MAXFEE 01/01/2014 12/31/2023 240.50 0.0 1-20years 0-1 Description: APEXIFICATION/RECALC INITIAL Category: Dental CMS Add: 01/01/1992 CMS Term: D3351 DENTL DEF MAXFEE 01/01/2024 220.78 0.0 1-20years 0-1 Description: APEXIFICATION/RECALC INITIAL Category: Dental CMS Add: 01/01/1992 CMS Term: D3352 DENTL DEF MAXFEE 01/01/2014 12/31/2023 49.50 0.0 1-20years 0-1 Description: APEXIFICATION/RECALC INTERIM Category: Dental CMS Add: 01/01/1992 CMS Term: D3352 DENTL DEF MAXFEE 01/01/2024 163.52 0.0 1-20years 0-1 Description: APEXIFICATION/RECALC INTERIM Category: Dental CMS Add: 01/01/1992 CMS Term: D3353 DENTL DEF MAXFEE 01/01/2014 12/31/2023 49.50 0.0 1-20years 0-1 Description: APEXIFICATION/RECALC FINAL Category: Dental CMS Add: 01/01/1992 CMS Term: D3353 DENTL DEF MAXFEE 01/01/2024 319.21 0.0 1-20years 0-1 Description: APEXIFICATION/RECALC FINAL Category: Dental CMS Add: 01/01/1992 CMS Term: D3355 NOCOV DEF SYSMAN Description: PULPAL REGENERATION INITIAL Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: D3356 NOCOV DEF SYSMAN Description: PULPAL REGENERATION INTERIM Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: D3357 NOCOV DEF SYSMAN Description: PULPAL REGENERATION COMPLETE Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: D3410 DENTL DEF MAXFEE 01/01/2014 12/31/2023 352.00 0.0 1-20years 0-1 Description: APICOECTOMY - ANTERIOR Category: Dental CMS Add: 01/01/1984 CMS Term: D3410 DENTL DEF MAXFEE 01/01/2024 439.95 0.0 1-20years 0-1 Description: APICOECTOMY - ANTERIOR Category: Dental CMS Add: 01/01/1984 CMS Term: D3421 DENTL DEF MAXFEE 01/01/2024 492.61 0.0 1-20years 0-1 Description: ROOT SURGERY PREMOLAR Category: Dental CMS Add: 01/01/1992 CMS Term: D3421 DENTL DEF MAXFEE 08/01/2015 12/31/2023 528.50 0.0 1-20years 0-1 Description: ROOT SURGERY PREMOLAR Category: Dental CMS Add: 01/01/1992 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,541 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D3425 DENTL DEF MAXFEE 01/01/2024 565.29 0.0 1-20years 0-1 Description: ROOT SURGERY MOLAR Category: Dental CMS Add: 01/01/1992 CMS Term: D3425 DENTL DEF MAXFEE 08/01/2015 12/31/2023 620.00 0.0 1-20years 0-1 Description: ROOT SURGERY MOLAR Category: Dental CMS Add: 01/01/1992 CMS Term: D3426 DENTL DEF MAXFEE 01/01/2024 265.17 0.0 1-20years 0-1 Description: ROOT SURGERY EA ADD ROOT Category: Dental CMS Add: 01/01/1992 CMS Term: D3426 DENTL DEF MAXFEE 08/01/2015 12/31/2023 258.00 0.0 1-20years 0-1 Description: ROOT SURGERY EA ADD ROOT Category: Dental CMS Add: 01/01/1992 CMS Term: D3428 NOCOV DEF SYSMAN Description: BONE GRAFT PERI PER TOOTH Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: D3429 NOCOV DEF SYSMAN Description: BONE GRAFT PERI EACH ADDL Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: D3430 DENTL DEF MAXFEE 01/01/2014 12/31/2023 108.25 0.0 1-20years 0-3 Description: RETROGRADE FILLING Category: Dental CMS Add: 01/01/1984 CMS Term: D3430 DENTL DEF MAXFEE 01/01/2024 177.08 0.0 1-20years 0-3 Description: RETROGRADE FILLING Category: Dental CMS Add: 01/01/1984 CMS Term: D3431 NOCOV DEF SYSMAN Description: BIOLOGICAL MATERIALS Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: D3432 NOCOV DEF SYSMAN Description: GUIDED TISSUE REGENERATION Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: D3450 NOCOV DEF SYSMAN 0-1 Description: ROOT AMPUTATION Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D3460 NOCOV DEF SYSMAN 0-1 Description: ENDODONTIC ENDOSSEOUS IMPLAN Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D3470 NOCOV DEF SYSMAN 0-1 Description: INTENTIONAL REPLANTATION Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: D3471 DENTL DEF BILL90 1-20years 0-1 Description: SURG REP ROOT RES ANTERIOR Category: Dental CMS Add: 01/01/2021 CMS Term: D3472 DENTL DEF BILL90 1-20years 0-1 Description: SURG REP ROOT RES PREMOLAR Category: Dental CMS Add: 01/01/2021 CMS Term: D3473 DENTL DEF BILL90 1-20years 0-1 Description: SURG REP ROOT RES MOLAR Category: Dental CMS Add: 01/01/2021 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,542 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D3501 DENTL DEF BILL90 1-20years 0-1 Description: SURG EXP ROOT SURF ANTERIOR Category: Dental CMS Add: 01/01/2021 CMS Term: D3502 DENTL DEF BILL90 1-20years 0-1 Description: SURG EXP ROOT SURF PREMOLAR Category: Dental CMS Add: 01/01/2021 CMS Term: D3503 DENTL DEF BILL90 1-20years 0-1 Description: SURG EXP ROOT SURF MOLAR Category: Dental CMS Add: 01/01/2021 CMS Term: D3910 NOCOV DEF SYSMAN 0-1 Description: ISOLATION- TOOTH W RUBB DAM Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: D3911 DENTL DEF BILL90 Description: INTRAORIFICE BARRIER Category: Dental CMS Add: 01/01/2022 CMS Term: D3920 NOCOV DEF SYSMAN 0-1 Description: TOOTH SPLITTING Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D3921 DENTL DEF BILL90 Description: DECOR OR SUBMERG ERUPT TOOTH Category: Dental CMS Add: 01/01/2022 CMS Term: D3950 NOCOV DEF SYSMAN 0-1 Description: CANAL PREP/FITTING OF DOWEL Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: D3999 NOCOV DEF SYSMAN 0-20years 0-1 Description: ENDODONTIC PROCEDURE Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D4210 DENTL DEF MAXFEE 01/01/2014 12/31/2023 371.38 0.0 0-1 Description: GINGIVECTOMY/PLASTY 4 OR MOR Category: Dental CMS Add: 01/01/1985 CMS Term: D4210 DENTL DEF MAXFEE 01/01/2024 557.06 0.0 0-1 Description: GINGIVECTOMY/PLASTY 4 OR MOR Category: Dental CMS Add: 01/01/1985 CMS Term: D4211 DENTL DEF MAXFEE 01/01/2014 12/31/2023 127.42 0.0 0-1 Description: GINGIVECTOMY/PLASTY 1 TO 3 Category: Dental CMS Add: 01/01/1986 CMS Term: D4211 DENTL DEF MAXFEE 01/01/2024 299.13 0.0 0-1 Description: GINGIVECTOMY/PLASTY 1 TO 3 Category: Dental CMS Add: 01/01/1986 CMS Term: D4212 DENTL DEF MAXFEE 01/01/2014 12/31/2023 399.06 0.0 0-1 Description: GINGIVECTOMY/PLASTY REST Category: Dental CMS Add: 01/01/2013 CMS Term: D4212 DENTL DEF MAXFEE 01/01/2024 259.27 0.0 0-1 Description: GINGIVECTOMY/PLASTY REST Category: Dental CMS Add: 01/01/2013 CMS Term: D4230 NOCOV DEF SYSMAN Description: ANA CROWN EXP 4 OR> PER QUAD Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,543 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D4231 NOCOV DEF SYSMAN Description: ANA CROWN EXP 1-3 PER QUAD Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: D4240 DENTL DEF MAXFEE 01/01/2024 671.61 0.0 0-1 Description: GINGIVAL FLAP PROC W/ PLANIN Category: Dental CMS Add: 01/01/1984 CMS Term: D4240 DENTL DEF MAXFEE 08/01/2015 12/31/2023 533.50 0.0 0-1 Description: GINGIVAL FLAP PROC W/ PLANIN Category: Dental CMS Add: 01/01/1984 CMS Term: D4241 DENTL DEF MAXFEE 01/01/2024 565.09 0.0 0-1 Description: GNGVL FLAP W ROOTPLAN 1-3 TH Category: Dental CMS Add: 01/01/2003 CMS Term: D4241 DENTL DEF MAXFEE 08/01/2015 12/31/2023 491.50 0.0 0-1 Description: GNGVL FLAP W ROOTPLAN 1-3 TH Category: Dental CMS Add: 01/01/2003 CMS Term: D4245 NOCOV DEF SYSMAN 0-1 Description: APICALLY POSITIONED FLAP Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: D4249 NOCOV DEF SYSMAN 0-1 Description: CROWN LENGTHEN HARD TISSUE Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: D4260 DENTL DEF MAXFEE 01/01/2024 992.17 0.0 0-1 Description: OSSEOUS SURGERY 4 OR MORE Category: Dental CMS Add: 01/01/1985 CMS Term: D4260 DENTL DEF MAXFEE 08/01/2015 12/31/2023 480.00 0.0 0-1 Description: OSSEOUS SURGERY 4 OR MORE Category: Dental CMS Add: 01/01/1985 CMS Term: D4261 DENTL DEF MAXFEE 01/01/2017 12/31/2023 920.00 0.0 0-1 Description: OSSEOUS SURG 1 TO 3 TEETH Category: Dental CMS Add: 01/01/2003 CMS Term: D4261 DENTL DEF MAXFEE 01/01/2024 797.22 0.0 0-1 Description: OSSEOUS SURG 1 TO 3 TEETH Category: Dental CMS Add: 01/01/2003 CMS Term: D4263 NOCOV DEF SYSMAN 0-1 Description: BONE REPLCE GRAFT FIRST SITE Category: Non Covered Services CMS Add: 01/01/1996 CMS Term: D4264 NOCOV DEF SYSMAN 0-1 Description: BONE REPLCE GRAFT EACH ADD Category: Non Covered Services CMS Add: 01/01/1996 CMS Term: D4265 NOCOV DEF SYSMAN 0-1 Description: BIO MTRLS TO AID SOFT/OS REG Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: D4266 NOCOV DEF SYSMAN 0-1 Description: GUIDED TISS REGEN RESORBLE Category: Non Covered Services CMS Add: 01/01/1996 CMS Term: D4267 NOCOV DEF SYSMAN 0-1 Description: GUIDED TISS REGEN NONRESORB Category: Non Covered Services CMS Add: 01/01/1996 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,544 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D4268 NOCOV DEF SYSMAN 0-1 Description: SURGICAL REVISION PROCEDURE Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: D4270 NOCOV DEF SYSMAN 0-1 Description: PEDICLE SOFT TISSUE GRAFT PR Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D4273 NOCOV DEF SYSMAN 0-1 Description: AUTO TISSUE GRAFT 1ST TOOTH Category: Non Covered Services CMS Add: 01/01/1996 CMS Term: D4274 NOCOV DEF SYSMAN 0-1 Description: MESIAL/DISTAL WEDGE PROC Category: Non Covered Services CMS Add: 01/01/1996 CMS Term: D4275 NOCOV DEF SYSMAN 0-1 Description: NON-AUTO GRAFT 1ST TOOTH Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: D4276 NOCOV DEF SYSMAN 0-1 Description: CON TISSUE W PEDICLE GRAFT Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: D4277 NOCOV DEF SYSMAN Description: SOFT TISSUE GRAFT FIRSTTOOTH Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: D4278 NOCOV DEF SYSMAN Description: SOFT TISSUE GRAFT ADDL TOOTH Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: D4283 NOCOV DEF SYSMAN Description: AUTO TISSUE GRAFT ADDL TOOTH Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: D4285 NOCOV DEF SYSMAN Description: NON-AUTO GRAFT ADDL TOOTH Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: D4286 NOCOV DEF SYSMAN Description: REMOVE NON-RESORB BARRIER Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: D4322 DENTL DEF BILL90 Description: SPLINT INTRA-CORONAL Category: Dental CMS Add: 01/01/2022 CMS Term: D4323 DENTL DEF BILL90 Description: SPLINT EXTRA-CORONAL Category: Dental CMS Add: 01/01/2022 CMS Term: D4341 DENTL DEF MAXFEE 01/01/2014 12/31/2023 154.74 0.0 Y 0-4 Description: PERIODONTAL SCALING & ROOT Category: Dental CMS Add: 01/01/1985 CMS Term: D4341 DENTL DEF MAXFEE 01/01/2024 192.65 0.0 Y 0-4 Description: PERIODONTAL SCALING & ROOT Category: Dental CMS Add: 01/01/1985 CMS Term: D4342 DENTL DEF MAXFEE 01/01/2014 12/31/2023 52.03 0.0 Y 0-4 Description: PERIODONTAL SCALING 1-3TEETH Category: Dental CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,545 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D4342 DENTL DEF MAXFEE 01/01/2024 145.34 0.0 Y 0-4 Description: PERIODONTAL SCALING 1-3TEETH Category: Dental CMS Add: 01/01/2003 CMS Term: D4346 DENTL DEF MAXFEE 01/01/2024 130.23 0.0 0-1 Description: SCALING GINGIV INFLAMMATION Category: Dental CMS Add: 01/01/2017 CMS Term: D4346 DENTL DEF MAXFEE 03/20/2018 12/31/2023 204.00 0.0 0-1 Description: SCALING GINGIV INFLAMMATION Category: Dental CMS Add: 01/01/2017 CMS Term: D4355 DENTL DEF MAXFEE 01/01/2014 12/31/2023 98.14 0.0 0-4 Description: FULL MOUTH DEBRIDEMENT Category: Dental CMS Add: 01/01/1996 CMS Term: D4355 DENTL DEF MAXFEE 01/01/2024 138.50 0.0 0-4 Description: FULL MOUTH DEBRIDEMENT Category: Dental CMS Add: 01/01/1996 CMS Term: D4381 NOCOV DEF SYSMAN 0-1 Description: LOCALIZED DELIVERY ANTIMICRO Category: Non Covered Services CMS Add: 01/01/1996 CMS Term: D4910 DENTL DEF MAXFEE 01/01/2024 102.03 0.0 3-999years 0-1 Description: PERIODONTAL MAINT PROCEDURES Category: Dental CMS Add: 01/01/1984 CMS Term: D4910 DENTL DEF MAXFEE 08/01/2015 12/31/2023 153.00 0.0 3-999years 0-1 Description: PERIODONTAL MAINT PROCEDURES Category: Dental CMS Add: 01/01/1984 CMS Term: D4920 NOCOV DEF SYSMAN Description: UNSCHEDULED DRESSING CHANGE Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D4921 NOCOV DEF SYSMAN Description: GINGIVAL IRRIGATION PER QUAD Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: D4999 NOCOV DEF SYSMAN 0-1 Description: UNSPECIFIED PERIODONTAL PROC Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D5110* DENTL DEF MAXFEE 01/01/2024 559.03 0.0 Y 21-999;0-20years 0-1 Description: DENTURES COMPLETE MAXILLARY Category: Dental CMS Add: 01/01/1982 CMS Term: D5120* DENTL DEF MAXFEE 01/01/2024 562.39 0.0 Y 21-999;0-20years 0-1 Description: DENTURES COMPLETE MANDIBLE Category: Dental CMS Add: 01/01/1982 CMS Term: D5130 DENTL DEF MAXFEE 01/01/2014 12/31/2023 391.25 0.0 Y 21-999years 0-1 Description: DENTURES IMMEDIAT MAXILLARY Category: Dental CMS Add: 01/01/1982 CMS Term: D5130 DENTL DEF MAXFEE 01/01/2024 583.98 0.0 Y 21-999years 0-1 Description: DENTURES IMMEDIAT MAXILLARY Category: Dental CMS Add: 01/01/1982 CMS Term: D5140 DENTL DEF MAXFEE 01/01/2014 12/31/2023 394.13 0.0 Y 21-999years 0-1 Description: DENTURES IMMEDIAT MANDIBLE Category: Dental CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,546 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D5140 DENTL DEF MAXFEE 01/01/2024 588.19 0.0 Y 21-999years 0-1 Description: DENTURES IMMEDIAT MANDIBLE Category: Dental CMS Add: 01/01/1982 CMS Term: D5211* DENTL DEF MAXFEE 01/01/2024 443.96 0.0 Y 21-999;0-20years 0-1 Description: DENTURES MAXILL PART RESIN Category: Dental CMS Add: 01/01/1984 CMS Term: D5212* DENTL DEF MAXFEE 01/01/2024 441.56 0.0 Y 21-999;0-20years 0-1 Description: DENTURES MAND PART RESIN Category: Dental CMS Add: 01/01/1984 CMS Term: D5213* DENTL DEF MAXFEE 01/01/2024 574.15 0.0 Y 21-999;0-20years 0-1 Description: DENTURES MAXILL PART METAL Category: Dental CMS Add: 01/01/1984 CMS Term: D5214* DENTL DEF MAXFEE 01/01/2024 574.51 0.0 Y 21-999;0-20years 0-1 Description: DENTURES MANDIBL PART METAL Category: Dental CMS Add: 01/01/1984 CMS Term: D5221 NOCOV DEF SYSMAN Description: IMMED MAX PART DENTURE RESIN Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: D5222 NOCOV DEF SYSMAN Description: IMMED MAN PART DENTURE RESIN Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: D5223 NOCOV DEF SYSMAN Description: IMMED MAX PART DENT METAL Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: D5224 NOCOV DEF SYSMAN Description: IMMED MAND PART DENT METAL Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: D5225 DENTL DEF MAXFEE 01/01/2024 488.47 0.0 Y 0-1 Description: MAXILLARY PART DENTURE FLEX Category: Dental CMS Add: 01/01/2005 CMS Term: D5226 DENTL DEF MAXFEE 01/01/2024 489.07 0.0 Y 0-1 Description: MANDIBULAR PART DENTURE FLEX Category: Dental CMS Add: 01/01/2005 CMS Term: D5227 DENTL DEF BILL90 Y 21-999years Description: IMMED MAX PART DENTURE Category: Dental CMS Add: 01/01/2022 CMS Term: D5228 DENTL DEF BILL90 Y 21-999years Description: IMMED MAND PART DENTURE Category: Dental CMS Add: 01/01/2022 CMS Term: D5282* DENTL DEF MAXFEE 01/01/2024 346.29 0.0 Y 0-20;21-999years 0-1 Description: REMOVE UNIL PART DENTURE,MAX Category: Dental CMS Add: 01/01/2019 CMS Term: D5283* DENTL DEF BILL90 Y 0-20;21-999years 0-1 Description: REMOVE UNIL PART DENTURE,MAN Category: Dental CMS Add: 01/01/2019 CMS Term: D5284* DENTL DEF BILL90 Y 1-20;21-999years 0-1 Description: REM UNILAT DENT FLEX BASE Category: Dental CMS Add: 01/01/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,547 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D5286* DENTL DEF MAXFEE 01/01/2024 352.41 0.0 Y 1-20;21-999years 0-1 Description: REM UNILAT DENT 1 PC RESIN Category: Dental CMS Add: 01/01/2020 CMS Term: D5410 NOCOV DEF SYSMAN Description: DENTURES ADJUST CMPLT MAXIL Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D5411 NOCOV DEF SYSMAN Description: DENTURES ADJUST CMPLT MAND Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: D5421 NOCOV DEF SYSMAN Description: DENTURES ADJUST PART MAXILL Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D5422 NOCOV DEF SYSMAN Description: DENTURES ADJUST PART MANDBL Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D5511* DENTL DEF MAXFEE 01/01/2024 82.61 0.0 Y 21-999;0-20years 0-1 Description: REP BROKE COMP DENT BASE MAN Category: Dental CMS Add: 01/01/2018 CMS Term: D5512* DENTL DEF MAXFEE 01/01/2024 82.34 0.0 Y 21-999;0-20years 0-1 Description: REP BROKE COMP DENT BASE MAX Category: Dental CMS Add: 01/01/2018 CMS Term: D5520* DENTL DEF MAXFEE 01/01/2014 12/31/2023 83.25 0.0 Y 0-999years 0-1 Description: REPLACE DENTURE TEETH COMPLT Category: Dental CMS Add: 01/01/1986 CMS Term: D5520* DENTL DEF MAXFEE 01/01/2024 69.52 0.0 Y 0-999years 0-1 Description: REPLACE DENTURE TEETH COMPLT Category: Dental CMS Add: 01/01/1986 CMS Term: D5611* DENTL DEF MAXFEE 01/01/2024 77.89 0.0 Y 21-999;0-20years 0-1 Description: REP RESIN PART DENT BASE MAN Category: Dental CMS Add: 01/01/2018 CMS Term: D5612* DENTL DEF MAXFEE 01/01/2024 78.16 0.0 Y 21-999;0-20years 0-1 Description: REP RESIN PART DENT BASE MAX Category: Dental CMS Add: 01/01/2018 CMS Term: D5621* DENTL DEF MAXFEE 01/01/2024 101.24 0.0 Y 21-999;0-20years 0-1 Description: REP CAST PART FRAME MAN Category: Dental CMS Add: 01/01/2018 CMS Term: D5622* DENTL DEF BILL90 Y 21-999;0-20years 0-1 Description: REP CAST PART FRAME MAX Category: Dental CMS Add: 01/01/2018 CMS Term: D5630* DENTL DEF MAXFEE 01/01/2014 12/31/2023 144.25 0.0 Y 0-999years 0-1 Description: REP PARTIAL DENTURE CLASP Category: Dental CMS Add: 01/01/1984 CMS Term: D5630* DENTL DEF MAXFEE 01/01/2024 93.41 0.0 Y 0-999years 0-1 Description: REP PARTIAL DENTURE CLASP Category: Dental CMS Add: 01/01/1984 CMS Term: D5640* DENTL DEF MAXFEE 01/01/2014 12/31/2023 83.25 0.0 Y 0-999years 0-1 Description: REPLACE PART DENTURE TEETH Category: Dental CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,548 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D5640* DENTL DEF MAXFEE 01/01/2024 69.79 0.0 Y 0-999years 0-1 Description: REPLACE PART DENTURE TEETH Category: Dental CMS Add: 01/01/1984 CMS Term: D5650* DENTL DEF MAXFEE 01/01/2014 12/31/2023 111.00 0.0 Y 0-999years 0-1 Description: ADD TOOTH TO PARTIAL DENTURE Category: Dental CMS Add: 01/01/1984 CMS Term: D5650* DENTL DEF MAXFEE 01/01/2024 79.64 0.0 Y 0-999years 0-1 Description: ADD TOOTH TO PARTIAL DENTURE Category: Dental CMS Add: 01/01/1984 CMS Term: D5660* DENTL DEF MAXFEE 01/01/2014 12/31/2023 155.50 0.0 Y 0-999years 0-1 Description: ADD CLASP TO PARTIAL DENTURE Category: Dental CMS Add: 01/01/1984 CMS Term: D5660* DENTL DEF MAXFEE 01/01/2024 93.55 0.0 Y 0-999years 0-1 Description: ADD CLASP TO PARTIAL DENTURE Category: Dental CMS Add: 01/01/1984 CMS Term: D5670 NOCOV DEF SYSMAN 21-999years 0-1 Description: REPLC TTH&ACRLC ON MTL FRMWK Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: D5671 NOCOV DEF SYSMAN 21-999years 0-1 Description: REPLC TTH&ACRLC MANDIBULAR Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: D5710 NOCOV DEF SYSMAN Description: DENTURES REBASE CMPLT MAXIL Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D5711 NOCOV DEF SYSMAN 1-20years 0-1 Description: DENTURES REBASE CMPLT MAND Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: D5720 NOCOV DEF SYSMAN Description: DENTURES REBASE PART MAXILL Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D5721 NOCOV DEF SYSMAN 1-20years 0-1 Description: DENTURES REBASE PART MANDBL Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: D5725 NOCOV DEF SYSMAN Description: REBASE HYBRID PROSTHESIS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: D5730 DENTL DEF MAXFEE 01/01/2014 12/31/2023 194.25 0.0 Y 1-999years 0-1 Description: DENTURE RELN CMPLT MAX DIR Category: Dental CMS Add: 01/01/1984 CMS Term: D5730 DENTL DEF MAXFEE 01/01/2024 131.61 0.0 Y 1-999years 0-1 Description: DENTURE RELN CMPLT MAX DIR Category: Dental CMS Add: 01/01/1984 CMS Term: D5731 DENTL DEF MAXFEE 01/01/2014 12/31/2023 194.25 0.0 Y 1-999years 0-1 Description: DENTURE RELN CMPLT MAND DIR Category: Dental CMS Add: 01/01/1986 CMS Term: D5731 DENTL DEF MAXFEE 01/01/2024 131.61 0.0 Y 1-999years 0-1 Description: DENTURE RELN CMPLT MAND DIR Category: Dental CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,549 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D5740 DENTL DEF MAXFEE 01/01/2014 12/31/2023 126.25 0.0 Y 1-999years 0-1 Description: DENTURE RELN PART MAX DIR Category: Dental CMS Add: 01/01/1984 CMS Term: D5740 DENTL DEF MAXFEE 01/01/2024 128.37 0.0 Y 1-999years 0-1 Description: DENTURE RELN PART MAX DIR Category: Dental CMS Add: 01/01/1984 CMS Term: D5741 DENTL DEF MAXFEE 01/01/2014 12/31/2023 69.50 0.0 Y 1-999years 0-1 Description: DENTURE RELN PART MAND DIR Category: Dental CMS Add: 01/01/1986 CMS Term: D5741 DENTL DEF MAXFEE 01/01/2024 130.67 0.0 Y 1-999years 0-1 Description: DENTURE RELN PART MAND DIR Category: Dental CMS Add: 01/01/1986 CMS Term: D5750* DENTL DEF MAXFEE 01/01/2014 12/31/2023 249.75 0.0 Y 0-999years 0-1 Description: DENTURE RELN CMPLT MAX INDIR Category: Dental CMS Add: 01/01/1984 CMS Term: D5750* DENTL DEF MAXFEE 01/01/2024 165.36 0.0 Y 0-999years 0-1 Description: DENTURE RELN CMPLT MAX INDIR Category: Dental CMS Add: 01/01/1984 CMS Term: D5751* DENTL DEF MAXFEE 01/01/2014 12/31/2023 249.75 0.0 Y 0-999years 0-1 Description: DENTURE RELN CMPLT MAND IND Category: Dental CMS Add: 01/01/1986 CMS Term: D5751* DENTL DEF MAXFEE 01/01/2024 165.50 0.0 Y 0-999years 0-1 Description: DENTURE RELN CMPLT MAND IND Category: Dental CMS Add: 01/01/1986 CMS Term: D5760* DENTL DEF MAXFEE 01/01/2014 12/31/2023 200.00 0.0 Y 0-999years 0-1 Description: DENTURE RELN PART MAX INDIR Category: Dental CMS Add: 01/01/1984 CMS Term: D5760* DENTL DEF MAXFEE 01/01/2024 162.66 0.0 Y 0-999years 0-1 Description: DENTURE RELN PART MAX INDIR Category: Dental CMS Add: 01/01/1984 CMS Term: D5761* DENTL DEF MAXFEE 01/01/2014 12/31/2023 144.50 0.0 Y 0-999years 0-1 Description: DENTURE RELN PART MAND INDIR Category: Dental CMS Add: 01/01/1986 CMS Term: D5761* DENTL DEF MAXFEE 01/01/2024 162.66 0.0 Y 0-999years 0-1 Description: DENTURE RELN PART MAND INDIR Category: Dental CMS Add: 01/01/1986 CMS Term: D5765 DENTL DEF BILL90 0-1 Description: LINER COMPL/PARTIAL REM DENT Category: Dental CMS Add: 01/01/2022 CMS Term: D5810 NOCOV DEF SYSMAN 0-1 Description: DENTURE INTERM CMPLT MAXILL Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D5811 NOCOV DEF SYSMAN 0-1 Description: DENTURE INTERM CMPLT MANDBL Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D5820 NOCOV DEF SYSMAN 0-1 Description: DENTURE INTERM PART MAXILL Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,550 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D5821 NOCOV DEF SYSMAN 0-1 Description: DENTURE INTERM PART MANDBL Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D5850 NOCOV DEF SYSMAN 0-1 Description: DENTURE TISS CONDITN MAXILL Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D5851 NOCOV DEF SYSMAN 0-1 Description: DENTURE TISS CONDTIN MANDBL Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: D5860 NOCOV DEF SYSMAN 0-1 Description: OVERDENTURE COMPLETE Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: 12/31/2013 D5861 NOCOV DEF SYSMAN 0-1 Description: OVERDENTURE PARTIAL Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: 12/31/2013 D5862 NOCOV DEF SYSMAN 0-1 Description: PRECISION ATTACHMENT Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: D5863 NOCOV DEF SYSMAN Description: OVERDENTURE COMPLETE MAX Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: D5864 NOCOV DEF SYSMAN Description: OVERDENTURE PARTIAL MAX Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: D5865 NOCOV DEF SYSMAN Description: OVERDENTURE COMPLETE MANDIB Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: D5866 NOCOV DEF SYSMAN Description: OVERDENTURE PARTIAL MANDIB Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: D5867 NOCOV DEF SYSMAN 0-1 Description: REPLACEMENT OF PRECISION ATT Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: D5875 NOCOV DEF SYSMAN 0-1 Description: PROSTHESIS MODIFICATION Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: D5876 DENTL DEF MAXFEE 01/01/2024 166.03 0.0 Y 0-1 Description: ADD METAL SUB TO ACRYLC DENT Category: Dental CMS Add: 01/01/2019 CMS Term: D5899 NOCOV DEF SYSMAN 0-1 Description: REMOVABLE PROSTHODONTIC PROC Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: D5911 NOCOV DEF SYSMAN 0-1 Description: FACIAL MOULAGE SECTIONAL Category: Non Covered Services CMS Add: 01/01/1985 CMS Term: D5912 NOCOV DEF SYSMAN 0-1 Description: FACIAL MOULAGE COMPLETE Category: Non Covered Services CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,551 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D5913 NOCOV DEF SYSMAN 0-1 Description: NASAL PROSTHESIS Category: Non Covered Services CMS Add: 01/01/1985 CMS Term: D5914 NOCOV DEF SYSMAN Description: AURICULAR PROSTHESIS Category: Non Covered Services CMS Add: 01/01/1985 CMS Term: D5915 NOCOV DEF SYSMAN Description: ORBITAL PROSTHESIS Category: Non Covered Services CMS Add: 01/01/1985 CMS Term: D5916 NOCOV DEF SYSMAN Description: OCULAR PROSTHESIS Category: Non Covered Services CMS Add: 01/01/1985 CMS Term: D5919 NOCOV DEF SYSMAN 0-1 Description: FACIAL PROSTHESIS Category: Non Covered Services CMS Add: 01/01/1985 CMS Term: D5922 NOCOV DEF SYSMAN 0-1 Description: NASAL SEPTAL PROSTHESIS Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: D5923 NOCOV DEF SYSMAN Description: OCULAR PROSTHESIS INTERIM Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: D5924 NOCOV DEF SYSMAN 0-1 Description: CRANIAL PROSTHESIS Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: D5925 NOCOV DEF SYSMAN 0-1 Description: FACIAL AUGMENTATION IMPLANT Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: D5926 NOCOV DEF SYSMAN Description: REPLACEMENT NASAL PROSTHESIS Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: D5927 NOCOV DEF SYSMAN Description: AURICULAR REPLACEMENT Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: D5928 NOCOV DEF SYSMAN Description: ORBITAL REPLACEMENT Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: D5929 NOCOV DEF SYSMAN Description: FACIAL REPLACEMENT Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: D5931 NOCOV DEF SYSMAN Description: SURGICAL OBTURATOR Category: Non Covered Services CMS Add: 01/01/1985 CMS Term: D5932 NOCOV DEF SYSMAN Description: POSTSURGICAL OBTURATOR Category: Non Covered Services CMS Add: 01/01/1985 CMS Term: D5933 NOCOV DEF SYSMAN Description: REFITTING OF OBTURATOR Category: Non Covered Services CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,552 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D5934 NOCOV DEF SYSMAN Description: MANDIBULAR FLANGE PROSTHESIS Category: Non Covered Services CMS Add: 01/01/1985 CMS Term: D5935 NOCOV DEF SYSMAN Description: MANDIBULAR DENTURE PROSTH Category: Non Covered Services CMS Add: 01/01/1985 CMS Term: D5936 NOCOV DEF SYSMAN Description: TEMP OBTURATOR PROSTHESIS Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: D5937 NOCOV DEF SYSMAN 0-1 Description: TRISMUS APPLIANCE Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: D5951 DENTL DEF MAXFEE 08/01/2015 791.50 0.0 0-20years 0-1 Description: FEEDING AID Category: Dental CMS Add: 01/01/1985 CMS Term: D5952 DENTL DEF MAXFEE 01/01/2014 12/31/2023 1352.25 0.0 0-19years 0-1 Description: PEDIATRIC SPEECH AID Category: Dental CMS Add: 01/01/1985 CMS Term: D5952 DENTL DEF MAXFEE 01/01/2024 1071.62 0.0 0-19years 0-1 Description: PEDIATRIC SPEECH AID Category: Dental CMS Add: 01/01/1985 CMS Term: D5953 NOCOV DEF SYSMAN Description: ADULT SPEECH AID Category: Non Covered Services CMS Add: 01/01/1985 CMS Term: D5954 NOCOV DEF SYSMAN Description: SUPERIMPOSED PROSTHESIS Category: Non Covered Services CMS Add: 01/01/1985 CMS Term: D5955 NOCOV DEF SYSMAN Description: PALATAL LIFT PROSTHESIS Category: Non Covered Services CMS Add: 01/01/1985 CMS Term: D5958 NOCOV DEF SYSMAN Description: INTRAORAL CON DEF INTER PLT Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: D5959 NOCOV DEF SYSMAN 0-1 Description: INTRAORAL CON DEF MOD PALAT Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: D5960 NOCOV DEF SYSMAN Description: MODIFY SPEECH AID PROSTHESIS Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: D5982 NOCOV DEF SYSMAN Description: SURGICAL STENT Category: Non Covered Services CMS Add: 01/01/1985 CMS Term: D5983 NOCOV DEF SYSMAN Description: RADIATION APPLICATOR Category: Non Covered Services CMS Add: 01/01/1985 CMS Term: D5984 NOCOV DEF SYSMAN Description: RADIATION SHIELD Category: Non Covered Services CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,553 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D5985 NOCOV DEF SYSMAN Description: RADIATION CONE LOCATOR Category: Non Covered Services CMS Add: 01/01/1985 CMS Term: D5986 NOCOV DEF SYSMAN Description: FLUORIDE APPLICATOR Category: Non Covered Services CMS Add: 01/01/1985 CMS Term: D5987 NOCOV DEF SYSMAN Description: COMMISSURE SPLINT Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: D5988 NOCOV DEF SYSMAN Description: SURGICAL SPLINT Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: D5991 NOCOV DEF SYSMAN Description: VESICULOBULLOUS DISEASE CARR Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: D5992 NOCOV DEF SYSMAN Description: ADJUST MAX PROST APPLIANCE Category: Non Covered Services CMS Add: 01/01/2011 CMS Term: D5993 DENTL DEF MAXFEE 01/01/2024 70.73 0.0 0-20years Description: MAIN/CLEAN MAX PROSTHESIS Category: Dental CMS Add: 01/01/2011 CMS Term: D5995 NOCOV DEF SYSMAN Description: PERI MEDICAMENT W/SEAL, MAX Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: D5996 NOCOV DEF SYSMAN Description: PERI MEDICAMENT W/SEAL, MAND Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: D5999 DENTL DEF MAXFEE 01/01/2024 656.04 0.0 Y Y 0-1 Description: MAXILLOFACIAL PROSTHESIS Category: Dental CMS Add: 01/01/1986 CMS Term: D6010 NOCOV DEF SYSMAN 0-1 Description: ODONTICS ENDOSTEAL IMPLANT Category: Non Covered Services CMS Add: 01/01/1996 CMS Term: D6011 NOCOV DEF SYSMAN Description: SECOND STAGE IMPLANT SURGERY Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: D6012 NOCOV DEF SYSMAN Description: ENDOSTEAL IMPLANT Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: D6013 NOCOV DEF SYSMAN Description: SURGICAL PLACE MINI IMPLANT Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: D6040 NOCOV DEF SYSMAN 0-1 Description: ODONTICS EPOSTEAL IMPLANT Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: D6050 NOCOV DEF SYSMAN 0-1 Description: ODONTICS TRANSOSTEAL IMPLNT Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,554 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D6051 NOCOV DEF SYSMAN Description: INTERIM IMPLANT ABUTMENT Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: D6055 NOCOV DEF SYSMAN 0-1 Description: IMPLANT CONNECTING BAR Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: D6056 NOCOV DEF SYSMAN 0-1 Description: PREFABRICATED ABUTMENT Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: D6057 NOCOV DEF SYSMAN 0-1 Description: CUSTOM ABUTMENT Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: D6058 NOCOV DEF SYSMAN 0-1 Description: ABUTMENT SUPPORTED CROWN Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: D6059 NOCOV DEF SYSMAN 0-1 Description: ABUTMENT SUPPORTED MTL CROWN Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: D6060 NOCOV DEF SYSMAN 0-1 Description: ABUTMENT SUPPORTED MTL CROWN Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: D6061 NOCOV DEF SYSMAN 0-1 Description: ABUTMENT SUPPORTED MTL CROWN Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: D6062 NOCOV DEF SYSMAN 0-1 Description: ABUTMENT SUPPORTED MTL CROWN Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: D6063 NOCOV DEF SYSMAN 0-1 Description: ABUTMENT SUPPORTED MTL CROWN Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: D6064 NOCOV DEF SYSMAN 0-1 Description: ABUTMENT SUPPORTED MTL CROWN Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: D6065 NOCOV DEF SYSMAN 0-1 Description: IMPLANT SUPPORTED CROWN Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: D6066 NOCOV DEF SYSMAN 0-1 Description: IMPLANT SUPPORTED MTL CROWN Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: D6067 NOCOV DEF SYSMAN 0-1 Description: IMPLANT SUPPORTED MTL CROWN Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: D6068 NOCOV DEF SYSMAN 0-1 Description: ABUTMENT SUPPORTED RETAINER Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: D6069 NOCOV DEF SYSMAN 0-1 Description: ABUTMENT SUPPORTED RETAINER Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,555 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D6070 NOCOV DEF SYSMAN 0-1 Description: ABUTMENT SUPPORTED RETAINER Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: D6071 NOCOV DEF SYSMAN 0-1 Description: ABUTMENT SUPPORTED RETAINER Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: D6072 NOCOV DEF SYSMAN 0-1 Description: ABUTMENT SUPPORTED RETAINER Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: D6073 NOCOV DEF SYSMAN 0-1 Description: ABUTMENT SUPPORTED RETAINER Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: D6074 NOCOV DEF SYSMAN 0-1 Description: ABUTMENT SUPPORTED RETAINER Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: D6075 NOCOV DEF SYSMAN 0-1 Description: IMPLANT SUPPORTED RETAINER Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: D6076 NOCOV DEF SYSMAN 0-1 Description: IMPLANT SUPPORTED RETAINER Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: D6077 NOCOV DEF SYSMAN 0-1 Description: IMPLANT SUPPORTED RETAINER Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: D6080 NOCOV DEF SYSMAN 0-1 Description: IMPLANT MAINTENANCE Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: D6081 DENTL DEF MAXFEE 03/20/2018 230.50 0.0 Y 0-1 Description: SCALE & DEBRIDE, SINGLE IMP Category: Dental CMS Add: 01/01/2017 CMS Term: D6082 NOCOV DEF SYSMAN Description: IMP CROWN PORC TO BASE ALLOY Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: D6083 NOCOV DEF SYSMAN Description: IMP CROWN PORC TO NOBLE ALLO Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: D6084 NOCOV DEF SYSMAN Description: IMP CROWN PORC TO TITANIUM Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: D6085 NOCOV DEF SYSMAN Description: INTERIM IMPLANT CROWN Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: D6086 NOCOV DEF SYSMAN Description: IMP CROWN BASE ALLOYS Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: D6087 NOCOV DEF SYSMAN Description: IMPLANT CROWN NOBLE ALLOYS Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,556 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D6088 NOCOV DEF SYSMAN Description: IMP CROWN TITANIUM ALLOYS Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: D6090 NOCOV DEF SYSMAN 0-1 Description: REPAIR IMPLANT Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: D6091 NOCOV DEF SYSMAN Description: REPL SEMI/PRECISION ATTACH Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: D6092 NOCOV DEF SYSMAN Description: RECEMENT SUPP CROWN Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: D6093 NOCOV DEF SYSMAN Description: RECEMENT SUPP PART DENTURE Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: D6094 NOCOV DEF SYSMAN Description: ABUT SUPPORT CROWN TITANIUM Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: D6095 NOCOV DEF SYSMAN 0-1 Description: ODONTICS REPR ABUTMENT Category: Non Covered Services CMS Add: 01/01/1996 CMS Term: D6096 DENTL DEF BILL90 0-1 Description: REMOVE BROKEN IMP RET SCREW Category: Dental CMS Add: 01/01/2018 CMS Term: D6097 NOCOV DEF SYSMAN Description: ABUT CROWN PORC TO TITANIUM Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: D6098 NOCOV DEF SYSMAN Description: IMP RETAIN PORC TO BASE ALLO Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: D6099 NOCOV DEF SYSMAN Description: IMP RETAINER FOR FPD Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: D6100 NOCOV DEF SYSMAN Description: SURG REMOVAL OF IMPLANT BODY Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: D6101 NOCOV DEF SYSMAN Description: DEBRIDEMENT OF A PERIIMPLANT Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: D6102 NOCOV DEF SYSMAN Description: DEBRIDEMENT & CONTOURING Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: D6103 NOCOV DEF SYSMAN Description: BONE GRAFT REPAIR PERIMPLANT Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: D6104 NOCOV DEF SYSMAN Description: BONE GRAFT TIME OF IMPLANT Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,557 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D6105 NOCOV DEF SYSMAN Description: REMOVE IMPLANT BODY Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: D6106 NOCOV DEF SYSMAN Description: TISSUE REGEN RESORBABLE Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: D6107 NOCOV DEF SYSMAN Description: TISSUE REGEN NON-RESORBABLE Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: D6110 NOCOV DEF SYSMAN Description: IMPLNT/ABUT REMOV DENT MAX Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: D6111 NOCOV DEF SYSMAN Description: IMPLNT/ABUT REMOV DENT MAND Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: D6112 NOCOV DEF SYSMAN Description: IMP/ABUT REM DENT PART MAX Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: D6113 NOCOV DEF SYSMAN Description: IMP/ABUT REM DENT PART MAND Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: D6114 NOCOV DEF SYSMAN Description: IMPLNT/ABUT FIXED DENT MAX Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: D6115 NOCOV DEF SYSMAN Description: IMPLNT/ABUT FIXED DENT MAND Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: D6116 NOCOV DEF SYSMAN Description: IMP/ABUT FIXED DENT PART MAX Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: D6117 NOCOV DEF SYSMAN Description: IMP/ABUT FIXED DENT PART MAN Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: D6118 NOCOV DEF SYSMAN Description: IMP/ABUT INT FIXED DENT MAN Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: D6119 NOCOV DEF SYSMAN Description: INT/ABUT INT FIXED DENT MAX Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: D6120 NOCOV DEF SYSMAN Description: IMP RETAIN PORC TO TITANIUM Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: D6121 NOCOV DEF SYSMAN Description: RETAIN METAL FPD BASE ALLOYS Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: D6122 NOCOV DEF SYSMAN Description: RETAIN METAL FPD NOBLE ALLOY Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,558 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D6123 NOCOV DEF SYSMAN Description: RETAIN METAL FPD TITANIUM Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: D6190 NOCOV DEF SYSMAN Description: RADIO/SURGICAL IMPLANT INDEX Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: D6191 NOCOV DEF SYSMAN Description: SEMI PRECISION ABUTMENT Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: D6192 NOCOV DEF SYSMAN Description: SEMI PRECISION ATTACHMENT Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: D6194 NOCOV DEF SYSMAN Description: ABUT SUPPORT RETAINER TITANI Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: D6195 NOCOV DEF SYSMAN Description: ABUT RETAIN PORC TO TITANIUM Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: D6197 NOCOV DEF SYSMAN Description: REPLACE MATERIAL PROSTHESIS Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: D6198 NOCOV DEF SYSMAN Description: REMOVE INTERIM IMPLANT Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: D6199 NOCOV DEF SYSMAN 0-1 Description: IMPLANT PROCEDURE Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: D6205 NOCOV DEF SYSMAN Description: PONTIC-INDIRECT RESIN BASED Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: D6210 NOCOV DEF SYSMAN 0-1 Description: PROSTHODONT HIGH NOBLE METAL Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D6211 NOCOV DEF SYSMAN Description: BRIDGE BASE METAL CAST Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D6212 NOCOV DEF SYSMAN 0-1 Description: BRIDGE NOBLE METAL CAST Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D6214 NOCOV DEF SYSMAN Description: PONTIC TITANIUM Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: D6240 NOCOV DEF SYSMAN 0-1 Description: BRIDGE PORCELAIN HIGH NOBLE Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D6241 NOCOV DEF SYSMAN 0-1 Description: BRIDGE PORCELAIN BASE METAL Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,559 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D6242 NOCOV DEF SYSMAN 0-1 Description: BRIDGE PORCELAIN NOBEL METAL Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D6243 NOCOV DEF SYSMAN Description: PONTIC PORCELAIN TO TITANIUM Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: D6245 NOCOV DEF SYSMAN 0-1 Description: BRIDGE PORCELAIN/CERAMIC Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: D6250 NOCOV DEF SYSMAN 0-1 Description: BRIDGE RESIN W/HIGH NOBLE Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D6251 NOCOV DEF SYSMAN 0-1 Description: BRIDGE RESIN BASE METAL Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D6252 NOCOV DEF SYSMAN 0-1 Description: BRIDGE RESIN W/NOBLE METAL Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D6253 NOCOV DEF SYSMAN 0-1 Description: INTERIM PONTIC Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: D6545 NOCOV DEF SYSMAN 0-1 Description: DENTAL RETAINR CAST METL Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D6548 NOCOV DEF SYSMAN 0-1 Description: PORCELAIN/CERAMIC RETAINER Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: D6549 NOCOV DEF SYSMAN Description: RESIN RETAINER Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: D6600 NOCOV DEF SYSMAN 0-1 Description: PORCELAIN/CERAMIC INLAY 2SRF Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: D6601 NOCOV DEF SYSMAN 0-1 Description: PORC/CERAM INLAY >= 3 SURFAC Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: D6602 NOCOV DEF SYSMAN 0-1 Description: CST HGH NBLE MTL INLAY 2 SRF Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: D6603 NOCOV DEF SYSMAN 0-1 Description: CST HGH NBLE MTL INLAY >=3SR Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: D6604 NOCOV DEF SYSMAN 0-1 Description: CST BSE MTL INLAY 2 SURFACES Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: D6605 NOCOV DEF SYSMAN 0-1 Description: CST BSE MTL INLAY >= 3 SURFA Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,560 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D6606 NOCOV DEF SYSMAN 0-1 Description: CAST NOBLE METAL INLAY 2 SUR Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: D6607 NOCOV DEF SYSMAN 0-1 Description: CST NOBLE MTL INLAY >=3 SURF Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: D6608 NOCOV DEF SYSMAN 0-1 Description: ONLAY PORC/CRMC 2 SURFACES Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: D6609 NOCOV DEF SYSMAN 0-1 Description: ONLAY PORC/CRMC >=3 SURFACES Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: D6610 NOCOV DEF SYSMAN 0-1 Description: ONLAY CST HGH NBL MTL 2 SRFC Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: D6611 NOCOV DEF SYSMAN 0-1 Description: ONLAY CST HGH NBL MTL >=3SRF Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: D6612 NOCOV DEF SYSMAN 0-1 Description: ONLAY CST BASE MTL 2 SURFACE Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: D6613 NOCOV DEF SYSMAN 0-1 Description: ONLAY CST BASE MTL >=3 SURFA Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: D6614 NOCOV DEF SYSMAN 0-1 Description: ONLAY CST NBL MTL 2 SURFACES Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: D6615 NOCOV DEF SYSMAN 0-1 Description: ONLAY CST NBL MTL >=3 SURFAC Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: D6624 NOCOV DEF SYSMAN Description: INLAY TITANIUM Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: D6634 NOCOV DEF SYSMAN Description: ONLAY TITANIUM Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: D6710 NOCOV DEF SYSMAN Description: CROWN-INDIRECT RESIN BASED Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: D6720 NOCOV DEF SYSMAN 0-1 Description: RETAIN CROWN RESIN W HI NBLE Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D6721 NOCOV DEF SYSMAN 0-1 Description: CROWN RESIN W/BASE METAL Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: D6722 NOCOV DEF SYSMAN 0-1 Description: CROWN RESIN W/NOBLE METAL Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,561 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D6740 NOCOV DEF SYSMAN 0-1 Description: CROWN PORCELAIN/CERAMIC Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: D6750 NOCOV DEF SYSMAN 0-1 Description: CROWN PORCELAIN HIGH NOBLE Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D6751 NOCOV DEF SYSMAN 0-1 Description: CROWN PORCELAIN BASE METAL Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D6752 NOCOV DEF SYSMAN 0-1 Description: CROWN PORCELAIN NOBLE METAL Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D6753 NOCOV DEF SYSMAN Description: RETAIN CROWN PORC TO TITANIU Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: D6780 NOCOV DEF SYSMAN 0-1 Description: CROWN 3/4 HIGH NOBLE METAL Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D6781 NOCOV DEF SYSMAN 0-1 Description: CROWN 3/4 CAST BASED METAL Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: D6782 NOCOV DEF SYSMAN 0-1 Description: CROWN 3/4 CAST NOBLE METAL Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: D6783 NOCOV DEF SYSMAN 0-1 Description: CROWN 3/4 PORCELAIN/CERAMIC Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: D6784 NOCOV DEF SYSMAN Description: RETAINER CROWN 3/4 TITANIUM Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: D6790 NOCOV DEF SYSMAN 0-1 Description: CROWN FULL HIGH NOBLE METAL Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D6791 NOCOV DEF SYSMAN 0-1 Description: CROWN FULL BASE METAL CAST Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D6792 NOCOV DEF SYSMAN 0-1 Description: CROWN FULL NOBLE METAL CAST Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D6793 NOCOV DEF SYSMAN 0-1 Description: INTERIM RETAINER CROWN Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: D6794 NOCOV DEF SYSMAN Description: CROWN TITANIUM Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: D6920 NOCOV DEF SYSMAN 0-1 Description: DENTAL CONNECTOR BAR Category: Non Covered Services CMS Add: 01/01/1996 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,562 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D6930 DENTL DEF MAXFEE 01/01/2024 88.53 0.0 1-20years 0-1 Description: RECEMENT/BOND PART DENTURE Category: Dental CMS Add: 01/01/1982 CMS Term: D6930 DENTL DEF MAXFEE 08/01/2015 12/31/2023 75.00 0.0 1-20years 0-1 Description: RECEMENT/BOND PART DENTURE Category: Dental CMS Add: 01/01/1982 CMS Term: D6940 NOCOV DEF SYSMAN 0-1 Description: STRESS BREAKER Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: D6950 NOCOV DEF SYSMAN 0-1 Description: PRECISION ATTACHMENT Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: D6980 DENTL DEF MAXFEE 08/01/2015 282.00 0.0 1-20years 0-1 Description: FIXED PARTIAL REPAIR Category: Dental CMS Add: 01/01/1986 CMS Term: D6985 NOCOV DEF SYSMAN 0-1 Description: PEDIATRIC PARTIAL DENTURE FX Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: D6999 NOCOV DEF SYSMAN 0-1 Description: FIXED PROSTHODONTIC PROC Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D7111 DENTL DEF MAXFEE 01/01/2014 12/31/2023 72.25 0.0 0-1 Description: EXTRACTION CORONAL REMNANTS Category: Dental CMS Add: 01/01/2003 CMS Term: D7111 DENTL DEF MAXFEE 01/01/2024 95.57 0.0 0-1 Description: EXTRACTION CORONAL REMNANTS Category: Dental CMS Add: 01/01/2003 CMS Term: D7140 DENTL DEF MAXFEE 01/01/2014 12/31/2023 77.24 0.0 0-1 Description: EXTRACTION ERUPTED TOOTH/EXR Category: Dental CMS Add: 01/01/2003 CMS Term: D7140 DENTL DEF MAXFEE 01/01/2024 137.15 0.0 0-1 Description: EXTRACTION ERUPTED TOOTH/EXR Category: Dental CMS Add: 01/01/2003 CMS Term: D7210 DENTL DEF MAXFEE 01/01/2014 12/31/2023 154.20 0.0 0-1 Description: REM IMP TOOTH W MUCOPER FLP Category: Dental CMS Add: 01/01/1984 CMS Term: D7210 DENTL DEF MAXFEE 01/01/2024 200.86 0.0 0-1 Description: REM IMP TOOTH W MUCOPER FLP Category: Dental CMS Add: 01/01/1984 CMS Term: D7220 DENTL DEF MAXFEE 01/01/2014 12/31/2023 185.69 0.0 0-1 Description: IMPACT TOOTH REMOV SOFT TISS Category: Dental CMS Add: 01/01/1984 CMS Term: D7220 DENTL DEF MAXFEE 01/01/2024 226.50 0.0 0-1 Description: IMPACT TOOTH REMOV SOFT TISS Category: Dental CMS Add: 01/01/1984 CMS Term: D7230 DENTL DEF MAXFEE 01/01/2014 12/31/2023 247.59 0.0 0-1 Description: IMPACT TOOTH REMOV PART BONY Category: Dental CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,563 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D7230 DENTL DEF MAXFEE 01/01/2024 279.43 0.0 0-1 Description: IMPACT TOOTH REMOV PART BONY Category: Dental CMS Add: 01/01/1984 CMS Term: D7240 DENTL DEF MAXFEE 01/01/2014 12/31/2023 321.76 0.0 0-1 Description: IMPACT TOOTH REMOV COMP BONY Category: Dental CMS Add: 01/01/1984 CMS Term: D7240 DENTL DEF MAXFEE 01/01/2024 344.48 0.0 0-1 Description: IMPACT TOOTH REMOV COMP BONY Category: Dental CMS Add: 01/01/1984 CMS Term: D7241 DENTL DEF MAXFEE 01/01/2014 12/31/2023 333.00 0.0 0-1 Description: IMPACT TOOTH REM BONY W/COMP Category: Dental CMS Add: 01/01/1984 CMS Term: D7241 DENTL DEF MAXFEE 01/01/2024 403.08 0.0 0-1 Description: IMPACT TOOTH REM BONY W/COMP Category: Dental CMS Add: 01/01/1984 CMS Term: D7250 DENTL DEF MAXFEE 01/01/2014 12/31/2023 185.69 0.0 0-1 Description: TOOTH ROOT REMOVAL Category: Dental CMS Add: 01/01/1984 CMS Term: D7250 DENTL DEF MAXFEE 01/01/2024 222.73 0.0 0-1 Description: TOOTH ROOT REMOVAL Category: Dental CMS Add: 01/01/1984 CMS Term: D7251 DENTL DEF MAXFEE 01/01/2014 12/31/2023 236.94 0.0 Description: CORONECTOMY Category: Dental CMS Add: 01/01/2011 CMS Term: D7251 DENTL DEF MAXFEE 01/01/2024 329.37 0.0 Description: CORONECTOMY Category: Dental CMS Add: 01/01/2011 CMS Term: D7260 DENTL DEF MAXFEE 01/01/2014 12/31/2023 355.75 0.0 0-1 Description: ORAL ANTRAL FISTULA CLOSURE Category: Dental CMS Add: 01/01/1984 CMS Term: D7260 DENTL DEF MAXFEE 01/01/2024 601.33 0.0 0-1 Description: ORAL ANTRAL FISTULA CLOSURE Category: Dental CMS Add: 01/01/1984 CMS Term: D7261 DENTL DEF MAXFEE 01/01/2024 387.86 0.0 0-1 Description: PRIMARY CLOSURE SINUS PERF Category: Dental CMS Add: 01/01/2003 CMS Term: D7261 DENTL DEF MAXFEE 08/01/2015 12/31/2023 590.50 0.0 0-1 Description: PRIMARY CLOSURE SINUS PERF Category: Dental CMS Add: 01/01/2003 CMS Term: D7270 DENTL DEF MAXFEE 01/01/2014 12/31/2023 216.25 0.0 0-1 Description: TOOTH REIMPLANTATION Category: Dental CMS Add: 01/01/1984 CMS Term: D7270 DENTL DEF MAXFEE 01/01/2024 334.85 0.0 0-1 Description: TOOTH REIMPLANTATION Category: Dental CMS Add: 01/01/1984 CMS Term: D7272 NOCOV DEF SYSMAN 0-1 Description: TOOTH TRANSPLANTATION Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,564 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D7280 DENTL DEF MAXFEE 01/01/2014 12/31/2023 158.50 0.0 0-1 Description: EXPOSURE OF UNERUPTED TOOTH Category: Dental CMS Add: 01/01/1984 CMS Term: D7280 DENTL DEF MAXFEE 01/01/2024 301.96 0.0 0-1 Description: EXPOSURE OF UNERUPTED TOOTH Category: Dental CMS Add: 01/01/1984 CMS Term: D7282 DENTL DEF MAXFEE 01/01/2024 293.92 0.0 0-1 Description: MOBILIZE ERUPTED/MALPOS TOOT Category: Dental CMS Add: 01/01/2003 CMS Term: D7282 DENTL DEF MAXFEE 08/01/2015 12/31/2023 429.00 0.0 0-1 Description: MOBILIZE ERUPTED/MALPOS TOOT Category: Dental CMS Add: 01/01/2003 CMS Term: D7283 NOCOV DEF SYSMAN Description: PLACE DEVICE IMPACTED TOOTH Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: D7285 DENTL DEF MAXFEE 01/01/2014 12/31/2023 210.50 0.0 0-1 Description: BIOPSY OF ORAL TISSUE HARD Category: Dental CMS Add: 01/01/1984 CMS Term: D7285 DENTL DEF MAXFEE 01/01/2024 359.95 0.0 0-1 Description: BIOPSY OF ORAL TISSUE HARD Category: Dental CMS Add: 01/01/1984 CMS Term: D7286 DENTL DEF MAXFEE 01/01/2014 12/31/2023 172.59 0.0 0-1 Description: BIOPSY OF ORAL TISSUE SOFT Category: Dental CMS Add: 01/01/1984 CMS Term: D7286 DENTL DEF MAXFEE 01/01/2024 239.45 0.0 0-1 Description: BIOPSY OF ORAL TISSUE SOFT Category: Dental CMS Add: 01/01/1984 CMS Term: D7287 NOCOV DEF SYSMAN 0-1 Description: EXFOLIATIVE CYTOLOG COLLECT Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: D7288 DENTL DEF MAXFEE 01/01/2014 12/31/2023 35.00 0.0 0-1 Description: BRUSH BIOPSY Category: Dental CMS Add: 01/01/2005 CMS Term: D7288 DENTL DEF MAXFEE 01/01/2024 147.79 0.0 0-1 Description: BRUSH BIOPSY Category: Dental CMS Add: 01/01/2005 CMS Term: D7290 NOCOV DEF SYSMAN 0-1 Description: REPOSITIONING OF TEETH Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: D7291 NOCOV DEF SYSMAN 0-1 Description: TRANSSEPTAL FIBEROTOMY Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: D7292 NOCOV DEF SYSMAN Description: SCREW RETAINED PLATE Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: D7293 NOCOV DEF SYSMAN Description: TEMP ANCHORAGE DEV W FLAP Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,565 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D7294 NOCOV DEF SYSMAN Description: TEMP ANCHORAGE DEV W/O FLAP Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: D7295 DENTL DEF MAXFEE 01/01/2011 12/31/2023 308.51 0.0 Description: BONE HARVEST,AUTO GRAFT PROC Category: Dental CMS Add: 01/01/2011 CMS Term: D7295 DENTL DEF MAXFEE 01/01/2024 612.20 0.0 Description: BONE HARVEST,AUTO GRAFT PROC Category: Dental CMS Add: 01/01/2011 CMS Term: D7296 DENTL DEF BILL90 Y 0-20years 0-4 Description: CORTICOTOMY, 1-3 TEETH Category: Dental CMS Add: 01/01/2018 CMS Term: D7297 DENTL DEF BILL90 Y 0-20years 0-4 Description: CORTICOTOMY, 4 OR MORE TEETH Category: Dental CMS Add: 01/01/2018 CMS Term: D7298 NOCOV DEF SYSMAN Description: REMOVE SCREW RETAINED PLATE Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: D7299 NOCOV DEF SYSMAN Description: REM ANCHORAGE DEVICE W/FLAP Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: D7300 NOCOV DEF SYSMAN Description: REM ANCHORAGE DEV W/O FLAP Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: D7310 DENTL DEF MAXFEE 01/01/2014 12/31/2023 185.69 0.0 0-1 Description: ALVEOPLASTY W/ EXTRACTION Category: Dental CMS Add: 01/01/1984 CMS Term: D7310 DENTL DEF MAXFEE 01/01/2024 231.63 0.0 0-1 Description: ALVEOPLASTY W/ EXTRACTION Category: Dental CMS Add: 01/01/1984 CMS Term: D7311 DENTL DEF MAXFEE 01/01/2014 12/31/2023 157.89 0.0 0-1 Description: ALVEOLOPLASTY W/EXTRACT 1-3 Category: Dental CMS Add: 01/01/2005 CMS Term: D7311 DENTL DEF MAXFEE 01/01/2024 229.66 0.0 0-1 Description: ALVEOLOPLASTY W/EXTRACT 1-3 Category: Dental CMS Add: 01/01/2005 CMS Term: D7320 DENTL DEF MAXFEE 01/01/2014 12/31/2023 247.59 0.0 0-1 Description: ALVEOPLASTY W/O EXTRACTION Category: Dental CMS Add: 01/01/1984 CMS Term: D7320 DENTL DEF MAXFEE 01/01/2024 338.12 0.0 0-1 Description: ALVEOPLASTY W/O EXTRACTION Category: Dental CMS Add: 01/01/1984 CMS Term: D7321 DENTL DEF MAXFEE 01/01/2014 12/31/2023 198.94 0.0 0-1 Description: ALVEOLOPLASTY NOT W/EXTRACTS Category: Dental CMS Add: 01/01/2005 CMS Term: D7321 DENTL DEF MAXFEE 01/01/2024 310.15 0.0 0-1 Description: ALVEOLOPLASTY NOT W/EXTRACTS Category: Dental CMS Add: 01/01/2005 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,566 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D7340 NOCOV DEF SYSMAN Description: VESTIBULOPLASTY RIDGE EXTENS Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D7350 NOCOV DEF SYSMAN Description: VESTIBULOPLASTY EXTEN GRAFT Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D7410 DENTL DEF MAXFEE 01/01/2014 12/31/2023 111.48 0.0 0-1 Description: RAD EXC LESION UP TO 1.25 CM Category: Dental CMS Add: 01/01/1982 CMS Term: D7410 DENTL DEF MAXFEE 01/01/2024 276.22 0.0 0-1 Description: RAD EXC LESION UP TO 1.25 CM Category: Dental CMS Add: 01/01/1982 CMS Term: D7411 DENTL DEF MAXFEE 01/01/2014 12/31/2023 477.75 0.0 0-1 Description: EXCISION BENIGN LESION>1.25C Category: Dental CMS Add: 01/01/2003 CMS Term: D7411 DENTL DEF MAXFEE 01/01/2024 414.20 0.0 0-1 Description: EXCISION BENIGN LESION>1.25C Category: Dental CMS Add: 01/01/2003 CMS Term: D7412 DENTL DEF MAXFEE 01/01/2024 630.90 0.0 0-1 Description: EXCISION BENIGN LESION COMPL Category: Dental CMS Add: 01/01/2003 CMS Term: D7412 DENTL DEF MAXFEE 08/01/2015 12/31/2023 584.50 0.0 0-1 Description: EXCISION BENIGN LESION COMPL Category: Dental CMS Add: 01/01/2003 CMS Term: D7413 DENTL DEF MAXFEE 01/01/2024 483.56 0.0 0-1 Description: EXCISION MALIG LESION<=1.25C Category: Dental CMS Add: 01/01/2003 CMS Term: D7413 DENTL DEF MAXFEE 08/01/2015 12/31/2023 504.50 0.0 0-1 Description: EXCISION MALIG LESION<=1.25C Category: Dental CMS Add: 01/01/2003 CMS Term: D7414 DENTL DEF MAXFEE 01/01/2024 714.41 0.0 0-1 Description: EXCISION MALIG LESION>1.25CM Category: Dental CMS Add: 01/01/2003 CMS Term: D7414 DENTL DEF MAXFEE 08/01/2015 12/31/2023 750.50 0.0 0-1 Description: EXCISION MALIG LESION>1.25CM Category: Dental CMS Add: 01/01/2003 CMS Term: D7415 DENTL DEF MAXFEE 01/01/2024 766.50 0.0 0-1 Description: EXCISION MALIG LES COMPLICAT Category: Dental CMS Add: 01/01/2003 CMS Term: D7415 DENTL DEF MAXFEE 08/01/2015 12/31/2023 907.50 0.0 0-1 Description: EXCISION MALIG LES COMPLICAT Category: Dental CMS Add: 01/01/2003 CMS Term: D7440 DENTL DEF MAXFEE 01/01/2014 12/31/2023 152.00 0.0 0-1 Description: MALIG TUMOR EXC TO 1.25 CM Category: Dental CMS Add: 01/01/1984 CMS Term: D7440 DENTL DEF MAXFEE 01/01/2024 567.46 0.0 0-1 Description: MALIG TUMOR EXC TO 1.25 CM Category: Dental CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,567 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D7441 DENTL DEF MAXFEE 01/01/2014 171.00 0.0 0-1 Description: MALIG TUMOR > 1.25 CM Category: Dental CMS Add: 01/01/1984 CMS Term: D7450 DENTL DEF MAXFEE 01/01/2014 12/31/2023 233.00 0.0 0-1 Description: REM ODONTOGEN CYST TO 1.25CM Category: Dental CMS Add: 01/01/1984 CMS Term: D7450 DENTL DEF MAXFEE 01/01/2024 398.93 0.0 0-1 Description: REM ODONTOGEN CYST TO 1.25CM Category: Dental CMS Add: 01/01/1984 CMS Term: D7451 DENTL DEF MAXFEE 01/01/2014 12/31/2023 347.75 0.0 0-1 Description: REM ODONTOGEN CYST > 1.25 CM Category: Dental CMS Add: 01/01/1984 CMS Term: D7451 DENTL DEF MAXFEE 01/01/2024 607.55 0.0 0-1 Description: REM ODONTOGEN CYST > 1.25 CM Category: Dental CMS Add: 01/01/1984 CMS Term: D7460 DENTL DEF MAXFEE 01/01/2014 12/31/2023 162.25 0.0 0-1 Description: REM NONODONTO CYST TO 1.25CM Category: Dental CMS Add: 01/01/1984 CMS Term: D7460 DENTL DEF MAXFEE 01/01/2024 394.23 0.0 0-1 Description: REM NONODONTO CYST TO 1.25CM Category: Dental CMS Add: 01/01/1984 CMS Term: D7461 DENTL DEF MAXFEE 01/01/2014 12/31/2023 360.50 0.0 0-1 Description: REM NONODONTO CYST > 1.25 CM Category: Dental CMS Add: 01/01/1984 CMS Term: D7461 DENTL DEF MAXFEE 01/01/2024 633.54 0.0 0-1 Description: REM NONODONTO CYST > 1.25 CM Category: Dental CMS Add: 01/01/1984 CMS Term: D7465 NOCOV DEF SYSMAN Description: LESION DESTRUCTION Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D7471 DENTL DEF MAXFEE 01/01/2014 12/31/2023 270.50 0.0 0-1 Description: REM EXOSTOSIS ANY SITE Category: Dental CMS Add: 01/01/2000 CMS Term: D7471 DENTL DEF MAXFEE 01/01/2024 550.75 0.0 0-1 Description: REM EXOSTOSIS ANY SITE Category: Dental CMS Add: 01/01/2000 CMS Term: D7472 DENTL DEF MAXFEE 01/01/2024 653.62 0.0 0-1 Description: REMOVAL OF TORUS PALATINUS Category: Dental CMS Add: 01/01/2003 CMS Term: D7472 DENTL DEF MAXFEE 08/01/2015 12/31/2023 606.50 0.0 0-1 Description: REMOVAL OF TORUS PALATINUS Category: Dental CMS Add: 01/01/2003 CMS Term: D7473 DENTL DEF MAXFEE 01/01/2024 628.77 0.0 0-1 Description: REMOVE TORUS MANDIBULARIS Category: Dental CMS Add: 01/01/2003 CMS Term: D7473 DENTL DEF MAXFEE 08/01/2015 12/31/2023 587.50 0.0 0-1 Description: REMOVE TORUS MANDIBULARIS Category: Dental CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,568 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D7485 DENTL DEF MAXFEE 01/01/2024 623.64 0.0 0-1 Description: SURG REDUCT OSSEOUSTUBEROSIT Category: Dental CMS Add: 01/01/2003 CMS Term: D7485 DENTL DEF MAXFEE 08/01/2015 12/31/2023 526.00 0.0 0-1 Description: SURG REDUCT OSSEOUSTUBEROSIT Category: Dental CMS Add: 01/01/2003 CMS Term: D7490 NOCOV DEF SYSMAN 0-1 Description: MAXILLA OR MANDIBLE RESECTIO Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: D7509 DENTL DEF BILL90 Description: MARSUPIALIZATION ODON CYST Category: Dental CMS Add: 01/01/2023 CMS Term: D7510 DENTL DEF MAXFEE 01/01/2014 12/31/2023 87.50 0.0 0-1 Description: I&D ABSC INTRAORAL SOFT TISS Category: Dental CMS Add: 01/01/1984 CMS Term: D7510 DENTL DEF MAXFEE 01/01/2024 147.42 0.0 0-1 Description: I&D ABSC INTRAORAL SOFT TISS Category: Dental CMS Add: 01/01/1984 CMS Term: D7511 DENTL DEF MAXFEE 01/01/2024 224.23 0.0 0-1 Description: INCISION/DRAIN ABSCESS INTRA Category: Dental CMS Add: 01/01/2005 CMS Term: D7511 DENTL DEF MAXFEE 08/01/2015 12/31/2023 213.00 0.0 0-1 Description: INCISION/DRAIN ABSCESS INTRA Category: Dental CMS Add: 01/01/2005 CMS Term: D7520 DENTL DEF MAXFEE 01/01/2014 12/31/2023 96.25 0.0 0-1 Description: I&D ABSCESS EXTRAORAL Category: Dental CMS Add: 01/01/1984 CMS Term: D7520 DENTL DEF MAXFEE 01/01/2024 311.17 0.0 0-1 Description: I&D ABSCESS EXTRAORAL Category: Dental CMS Add: 01/01/1984 CMS Term: D7521 DENTL DEF MAXFEE 01/01/2024 390.74 0.0 0-1 Description: INCISION/DRAIN ABSCESS EXTRA Category: Dental CMS Add: 01/01/2005 CMS Term: D7521 DENTL DEF MAXFEE 08/01/2015 12/31/2023 345.50 0.0 0-1 Description: INCISION/DRAIN ABSCESS EXTRA Category: Dental CMS Add: 01/01/2005 CMS Term: D7530 NOCOV DEF SYSMAN 0-1 Description: REMOVAL FB SKIN/AREOLAR TISS Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D7540 NOCOV DEF SYSMAN 0-1 Description: REMOVAL OF FB REACTION Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D7550 NOCOV DEF SYSMAN 0-1 Description: REMOVAL OF SLOUGHED OFF BONE Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: D7560 DENTL DEF MAXFEE 01/01/2014 12/31/2023 153.50 0.0 0-1 Description: MAXILLARY SINUSOTOMY Category: Dental CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,569 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D7560 DENTL DEF MAXFEE 01/01/2024 820.01 0.0 0-1 Description: MAXILLARY SINUSOTOMY Category: Dental CMS Add: 01/01/1982 CMS Term: D7610 DENTL DEF MAXFEE 08/01/2015 3280.50 0.0 0-1 Description: MAXILLA OPEN REDUCT SIMPLE Category: Dental CMS Add: 01/01/1984 CMS Term: D7620 DENTL DEF MAXFEE 01/01/2014 12/31/2023 486.00 0.0 0-1 Description: CLSD REDUCT SIMPL MAXILLA FX Category: Dental CMS Add: 01/01/1984 CMS Term: D7620 DENTL DEF MAXFEE 01/01/2024 1729.44 0.0 0-1 Description: CLSD REDUCT SIMPL MAXILLA FX Category: Dental CMS Add: 01/01/1984 CMS Term: D7630 DENTL DEF MAXFEE 08/01/2015 700.00 0.0 0-1 Description: OPEN RED SIMPL MANDIBLE FX Category: Dental CMS Add: 01/01/1984 CMS Term: D7640 DENTL DEF MAXFEE 01/01/2014 12/31/2023 1313.25 0.0 0-1 Description: CLSD RED SIMPL MANDIBLE FX Category: Dental CMS Add: 01/01/1984 CMS Term: D7640 DENTL DEF MAXFEE 01/01/2024 1701.44 0.0 0-1 Description: CLSD RED SIMPL MANDIBLE FX Category: Dental CMS Add: 01/01/1984 CMS Term: D7650 DENTL DEF MAXFEE 08/01/2015 2954.50 0.0 0-1 Description: OPEN RED SIMP MALAR/ZYGOM FX Category: Dental CMS Add: 01/01/1984 CMS Term: D7660 DENTL DEF MAXFEE 01/01/2014 143.25 0.0 0-1 Description: CLSD RED SIMP MALAR/ZYGOM FX Category: Dental CMS Add: 01/01/1984 CMS Term: D7670 DENTL DEF MAXFEE 01/01/2014 12/31/2023 311.25 0.0 0-1 Description: CLOSD RDUCTN SPLINT ALVEOLUS Category: Dental CMS Add: 01/01/1984 CMS Term: D7670 DENTL DEF MAXFEE 01/01/2024 840.52 0.0 0-1 Description: CLOSD RDUCTN SPLINT ALVEOLUS Category: Dental CMS Add: 01/01/1984 CMS Term: D7671 DENTL DEF MAXFEE 08/01/2015 705.00 0.0 0-1 Description: ALVEOLUS OPEN REDUCTION Category: Dental CMS Add: 01/01/2003 CMS Term: D7680 DENTL DEF MAXFEE 08/01/2015 5088.00 0.0 0-1 Description: REDUCT SIMPLE FACIAL BONE FX Category: Dental CMS Add: 01/01/1982 CMS Term: D7710 DENTL DEF MAXFEE 01/01/2014 542.75 0.0 0-1 Description: MAXILLA OPEN REDUCT COMPOUND Category: Dental CMS Add: 01/01/1984 CMS Term: D7720 DENTL DEF MAXFEE 01/01/2014 435.25 0.0 0-1 Description: CLSD REDUCT COMPD MAXILLA FX Category: Dental CMS Add: 01/01/1984 CMS Term: D7730 DENTL DEF MAXFEE 01/01/2014 12/31/2023 2522.25 0.0 0-1 Description: OPEN REDUCT COMPD MANDBLE FX Category: Dental CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,570 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D7730 DENTL DEF MAXFEE 01/01/2024 2507.37 0.0 0-1 Description: OPEN REDUCT COMPD MANDBLE FX Category: Dental CMS Add: 01/01/1984 CMS Term: D7740 DENTL DEF MAXFEE 01/01/2024 1717.84 0.0 0-1 Description: CLSD REDUCT COMPD MANDBLE FX Category: Dental CMS Add: 01/01/1984 CMS Term: D7740 DENTL DEF MAXFEE 08/01/2015 12/31/2023 400.00 0.0 0-1 Description: CLSD REDUCT COMPD MANDBLE FX Category: Dental CMS Add: 01/01/1984 CMS Term: D7750 DENTL DEF MAXFEE 01/01/2014 744.00 0.0 0-1 Description: OPEN RED COMP MALAR/ZYGMA FX Category: Dental CMS Add: 01/01/1984 CMS Term: D7760 DENTL DEF MAXFEE 01/01/2014 143.25 0.0 0-1 Description: CLSD RED COMP MALAR/ZYGMA FX Category: Dental CMS Add: 01/01/1984 CMS Term: D7770 DENTL DEF MAXFEE 01/01/2014 495.00 0.0 0-1 Description: OPEN REDUC COMPD ALVEOLUS FX Category: Dental CMS Add: 01/01/1984 CMS Term: D7771 DENTL DEF MAXFEE 01/01/2024 992.11 0.0 0-1 Description: ALVEOLUS CLSD REDUC STBLZ TE Category: Dental CMS Add: 01/01/2003 CMS Term: D7771 DENTL DEF MAXFEE 08/01/2015 12/31/2023 1217.00 0.0 0-1 Description: ALVEOLUS CLSD REDUC STBLZ TE Category: Dental CMS Add: 01/01/2003 CMS Term: D7780 DENTL DEF MAXFEE 01/01/2014 1173.00 0.0 0-1 Description: REDUCT COMPND FACIAL BONE FX Category: Dental CMS Add: 01/01/1982 CMS Term: D7810 DENTL DEF MAXFEE 01/01/2014 487.00 0.0 0-1 Description: TMJ OPEN REDUCT-DISLOCATION Category: Dental CMS Add: 01/01/1982 CMS Term: D7820 DENTL DEF MAXFEE 01/01/2014 12/31/2023 335.25 0.0 0-1 Description: CLOSED TMP MANIPULATION Category: Dental CMS Add: 01/01/1982 CMS Term: D7820 DENTL DEF MAXFEE 01/01/2024 388.20 0.0 0-1 Description: CLOSED TMP MANIPULATION Category: Dental CMS Add: 01/01/1982 CMS Term: D7830 NOCOV DEF SYSMAN Description: TMJ MANIPULATION UNDER ANEST Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: D7840 NOCOV DEF SYSMAN 0-1 Description: REMOVAL OF TMJ CONDYLE Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: D7850 NOCOV DEF SYSMAN 0-1 Description: TMJ MENISCECTOMY Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D7852 NOCOV DEF SYSMAN Description: TMJ REPAIR OF JOINT DISC Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,571 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D7854 NOCOV DEF SYSMAN Description: TMJ EXCISN OF JOINT MEMBRANE Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: D7856 NOCOV DEF SYSMAN Description: TMJ CUTTING OF A MUSCLE Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: D7858 NOCOV DEF SYSMAN Description: TMJ RECONSTRUCTION Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: D7860 NOCOV DEF SYSMAN Description: TMJ CUTTING INTO JOINT Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: D7865 NOCOV DEF SYSMAN Description: TMJ RESHAPING COMPONENTS Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: D7870 NOCOV DEF SYSMAN Description: TMJ ASPIRATION JOINT FLUID Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: D7871 NOCOV DEF SYSMAN Description: LYSIS + LAVAGE W CATHETERS Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: D7872 NOCOV DEF SYSMAN Description: TMJ DIAGNOSTIC ARTHROSCOPY Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: D7873 NOCOV DEF SYSMAN Description: TMJ ARTHROSCOPY LYSIS ADHESN Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: D7874 NOCOV DEF SYSMAN Description: TMJ ARTHROSCOPY DISC REPOSIT Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: D7875 NOCOV DEF SYSMAN Description: TMJ ARTHROSCOPY SYNOVECTOMY Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: D7876 NOCOV DEF SYSMAN Description: TMJ ARTHROSCOPY DISCECTOMY Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: D7877 NOCOV DEF SYSMAN Description: TMJ ARTHROSCOPY DEBRIDEMENT Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: D7880 NOCOV DEF SYSMAN Description: OCCLUSAL ORTHOTIC APPLIANCE Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: D7881 NOCOV DEF SYSMAN Description: OCC ORTHOTIC DEVICE ADJUST Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: D7899 NOCOV DEF SYSMAN Description: TMJ UNSPECIFIED THERAPY Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,572 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D7910 DENTL DEF MAXFEE 01/01/2014 12/31/2023 117.66 0.0 0-1 Description: DENT SUTUR RECENT WND TO 5CM Category: Dental CMS Add: 01/01/1984 CMS Term: D7910 DENTL DEF MAXFEE 01/01/2024 166.40 0.0 0-1 Description: DENT SUTUR RECENT WND TO 5CM Category: Dental CMS Add: 01/01/1984 CMS Term: D7911 DENTL DEF MAXFEE 01/01/2014 12/31/2023 117.75 0.0 0-1 Description: DENTAL SUTURE WOUND TO 5 CM Category: Dental CMS Add: 01/01/1984 CMS Term: D7911 DENTL DEF MAXFEE 01/01/2024 314.30 0.0 0-1 Description: DENTAL SUTURE WOUND TO 5 CM Category: Dental CMS Add: 01/01/1984 CMS Term: D7912 DENTL DEF MAXFEE 01/01/2014 12/31/2023 245.50 0.0 0-1 Description: SUTURE COMPLICATE WND > 5 CM Category: Dental CMS Add: 01/01/1984 CMS Term: D7912 DENTL DEF MAXFEE 01/01/2024 560.46 0.0 0-1 Description: SUTURE COMPLICATE WND > 5 CM Category: Dental CMS Add: 01/01/1984 CMS Term: D7920 NOCOV DEF SYSMAN Description: DENTAL SKIN GRAFT Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D7921 NOCOV DEF SYSMAN Description: COLLECT & APPL BLOOD PRODUCT Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: D7922 NOCOV DEF SYSMAN Description: PLACE INTRA-SOCKET BIO DRESS Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: D7939 NOCOV DEF SYSMAN Description: INDEXING FOR OSTEOTOMY Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: D7940 NOCOV DEF SYSMAN Description: RESHAPING BONE ORTHOGNATHIC Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: D7941 NOCOV DEF SYSMAN 0-1 Description: BONE CUTTING RAMUS CLOSED Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D7943 NOCOV DEF SYSMAN 0-1 Description: CUTTING RAMUS OPEN W/GRAFT Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D7944 NOCOV DEF SYSMAN 0-1 Description: BONE CUTTING SEGMENTED Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D7945 NOCOV DEF SYSMAN 0-1 Description: BONE CUTTING BODY MANDIBLE Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D7946 NOCOV DEF SYSMAN 0-1 Description: RECONSTRUCTION MAXILLA TOTAL Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,573 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D7947 NOCOV DEF SYSMAN 0-1 Description: RECONSTRUCT MAXILLA SEGMENT Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D7948 NOCOV DEF SYSMAN 0-1 Description: RECONSTRUCT MIDFACE NO GRAFT Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D7949 NOCOV DEF SYSMAN 0-1 Description: RECONSTRUCT MIDFACE W/GRAFT Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D7950 NOCOV DEF SYSMAN 0-1 Description: MANDIBLE GRAFT Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D7951 NOCOV DEF SYSMAN Description: SINUS AUG W BONE OR BONE SUB Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: D7952 NOCOV DEF SYSMAN Description: SINUS AUGMENTATION VERTICAL Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: D7953 NOCOV DEF SYSMAN Description: BONE REPLACEMENT GRAFT Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: D7955 NOCOV DEF SYSMAN 0-1 Description: REPAIR MAXILLOFACIAL DEFECTS Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: D7956 NOCOV DEF SYSMAN Description: TISS REGEN EDENT RESORB Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: D7957 NOCOV DEF SYSMAN Description: TISS REGEN EDENT NONRESORB Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: D7961 DENTL DEF MAXFEE 01/01/2024 273.90 0.0 Y 0-1;2-999years 0-2 Description: BUCCAL/LABIAL FRENECTOMY Category: Dental CMS Add: 01/01/2021 CMS Term: D7962 DENTL DEF MAXFEE 01/01/2024 285.17 0.0 Y 0-1;2-999years 0-2 Description: LINGUAL FRENECTOMY Category: Dental CMS Add: 01/01/2021 CMS Term: D7963 NOCOV DEF SYSMAN Description: FRENULOPLASTY Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: D7970 NOCOV DEF SYSMAN Description: EXCISION HYPERPLASTIC TISSUE Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D7971 NOCOV DEF SYSMAN Description: EXCISION PERICORONAL GINGIVA Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: D7972 DENTL DEF MAXFEE 01/01/2024 430.98 0.0 0-1 Description: SURG REDCT FIBROUS TUBEROSIT Category: Dental CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,574 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D7972 DENTL DEF MAXFEE 08/01/2015 12/31/2023 648.00 0.0 0-1 Description: SURG REDCT FIBROUS TUBEROSIT Category: Dental CMS Add: 01/01/2003 CMS Term: D7979 DENTL DEF MAXFEE 01/01/2024 379.47 0.0 0-1 Description: NON-SURGICAL SIALOLITHOTOMY Category: Dental CMS Add: 01/01/2018 CMS Term: D7980 DENTL DEF MAXFEE 01/01/2014 244.75 0.0 0-1 Description: SURGICAL SIALOLITHOTOMY Category: Dental CMS Add: 01/01/1982 CMS Term: D7981 NOCOV DEF SYSMAN 0-1 Description: EXCISION OF SALIVARY GLAND Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: D7982 DENTL DEF MAXFEE 01/01/2014 243.50 0.0 0-1 Description: SIALODOCHOPLASTY Category: Dental CMS Add: 01/01/1984 CMS Term: D7983 DENTL DEF MAXFEE 01/01/2014 238.50 0.0 0-1 Description: CLOSURE OF SALIVARY FISTULA Category: Dental CMS Add: 01/01/1982 CMS Term: D7990 NOCOV DEF SYSMAN Description: EMERGENCY TRACHEOTOMY Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: D7991 NOCOV DEF SYSMAN 0-1 Description: DENTAL CORONOIDECTOMY Category: Non Covered Services CMS Add: 01/01/1985 CMS Term: D7993 NOCOV DEF SYSMAN Description: SURG PLACE CRANIOFACIAL IMPL Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: D7994 NOCOV DEF SYSMAN Description: SURG PLACE ZYGOMATIC IMPL Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: D7995 NOCOV DEF SYSMAN 0-1 Description: SYNTHETIC GRAFT FACIAL BONES Category: Non Covered Services CMS Add: 01/01/1996 CMS Term: D7996 NOCOV DEF SYSMAN 0-1 Description: IMPLANT MANDIBLE FOR AUGMENT Category: Non Covered Services CMS Add: 01/01/1996 CMS Term: D7997 NOCOV DEF SYSMAN 0-1 Description: APPLIANCE REMOVAL Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: D7998 NOCOV DEF SYSMAN Description: INTRAORAL PLACE OF FIX DEV Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: D7999 DENTL DEF MAXFEE 01/01/2024 317.37 0.0 Y 0-1 Description: ORAL SURGERY PROCEDURE Category: Dental CMS Add: 01/01/1984 CMS Term: D8010 DENTL DEF MAXFEE 01/01/2022 1490.00 0.0 Y 1-20years 0-1 Description: LIMITED DENTAL TX PRIMARY Category: Dental CMS Add: 01/01/1996 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,575 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D8020 DENTL DEF MAXFEE 01/01/2022 12/31/2023 1625.59 0.0 Y 1-20years 0-1 Description: LIMITED DENTAL TX TRANSITION Category: Dental CMS Add: 01/01/1996 CMS Term: D8020 DENTL DEF MAXFEE 01/01/2024 2165.81 0.0 Y 1-20years 0-1 Description: LIMITED DENTAL TX TRANSITION Category: Dental CMS Add: 01/01/1996 CMS Term: D8030 DENTL DEF MAXFEE 01/01/2022 1415.50 0.0 Y 1-20years 0-1 Description: LIMITED DENTAL TX ADOLESCENT Category: Dental CMS Add: 01/01/1996 CMS Term: D8040 DENTL DEF MAXFEE 01/01/2022 12/31/2023 2235.00 0.0 Y 1-20years 0-1 Description: LIMITED DENTAL TX ADULT Category: Dental CMS Add: 01/01/1996 CMS Term: D8040 DENTL DEF MAXFEE 01/01/2024 2550.02 0.0 Y 1-20years 0-1 Description: LIMITED DENTAL TX ADULT Category: Dental CMS Add: 01/01/1996 CMS Term: D8070 DENTL DEF MAXFEE 01/01/2024 3768.40 0.0 Y 1-20years 0-1 Description: COMPRE DENTAL TX TRANSITION Category: Dental CMS Add: 01/01/1996 CMS Term: D8070 DENTL DEF MAXFEE 05/15/2010 12/31/2023 3474.17 0.0 Y 1-20years 0-1 Description: COMPRE DENTAL TX TRANSITION Category: Dental CMS Add: 01/01/1996 CMS Term: D8080 DENTL DEF MAXFEE 01/01/2024 3875.59 0.0 Y 1-20years 0-1 Description: COMPRE DENTAL TX ADOLESCENT Category: Dental CMS Add: 01/01/1996 CMS Term: D8080 DENTL DEF MAXFEE 05/15/2010 12/31/2023 3548.43 0.0 Y 1-20years 0-1 Description: COMPRE DENTAL TX ADOLESCENT Category: Dental CMS Add: 01/01/1996 CMS Term: D8090 DENTL DEF MAXFEE 01/01/2024 3826.84 0.0 Y 1-20years 0-1 Description: COMPRE DENTAL TX ADULT Category: Dental CMS Add: 01/01/1996 CMS Term: D8090 DENTL DEF MAXFEE 05/15/2010 12/31/2023 3676.96 0.0 Y 1-20years 0-1 Description: COMPRE DENTAL TX ADULT Category: Dental CMS Add: 01/01/1996 CMS Term: D8210 DENTL DEF MAXFEE 01/01/2014 12/31/2023 455.00 0.0 Y 1-20years 0-1 Description: ORTHODONTIC REM APPLIANCE TX Category: Dental CMS Add: 01/01/1982 CMS Term: D8210 DENTL DEF MAXFEE 01/01/2024 623.16 0.0 Y 1-20years 0-1 Description: ORTHODONTIC REM APPLIANCE TX Category: Dental CMS Add: 01/01/1982 CMS Term: D8220 DENTL DEF MAXFEE 01/01/2024 715.37 0.0 Y 0-1 Description: FIXED APPLIANCE THERAPY HABT Category: Dental CMS Add: 01/01/1984 CMS Term: D8220 DENTL DEF MAXFEE 08/01/2015 12/31/2023 725.00 0.0 Y 0-1 Description: FIXED APPLIANCE THERAPY HABT Category: Dental CMS Add: 01/01/1984 CMS Term: D8660 NOCOV DEF SYSMAN 1-20years 0-1 Description: PREORTHODONTIC TX VISIT Category: Non Covered Services CMS Add: 01/01/1996 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,576 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D8670 NOCOV DEF SYSMAN 1-20years 0-1 Description: PERIODIC ORTHODONTC TX VISIT Category: Non Covered Services CMS Add: 01/01/1996 CMS Term: D8680 NOCOV DEF SYSMAN Description: ORTHODONTIC RETENTION Category: Non Covered Services CMS Add: 01/01/1996 CMS Term: D8681 NOCOV DEF SYSMAN Description: REMOVABLE RETAINER ADJUST Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: D8695 NOCOV DEF SYSMAN Description: REMOVE FIXED ORTHO APPLIANCE Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: D8696 NOCOV DEF SYSMAN Description: REP OF ORTHO APPLIANCE MAX Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: D8697 NOCOV DEF SYSMAN Description: REP OF ORTHO APPLIANCE MAN Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: D8698 NOCOV DEF SYSMAN Description: RECEMENT FIXED RETAINER MAX Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: D8699 NOCOV DEF SYSMAN Description: RECEMENT FIXED RETAINER MAN Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: D8701 NOCOV DEF SYSMAN Description: REPAIR FIXED RETAINER MAX Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: D8702 NOCOV DEF SYSMAN Description: REPAIR OF FIXED RETAINER MAN Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: D8703 NOCOV DEF SYSMAN Description: REPLACE BROKEN RETAINER MAX Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: D8704 NOCOV DEF SYSMAN Description: REPLACE BROKEN RETAINER MAN Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: D8750 NOCOV DEF SYSMAN 0-1 Description: POST TREATMENT STABILIZAT Category: Non Covered Services CMS Add: 01/01/1900 CMS Term: 06/30/2015 D8999 NOCOV DEF SYSMAN 0-1 Description: ORTHODONTIC PROCEDURE Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D9110 NOCOV DEF SYSMAN Description: PALLIATIVE TX DENTAL PAIN Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D9120 DENTL DEF MAXFEE 01/01/2024 75.40 0.0 Y Description: FIX PARTIAL DENTURE SECTION Category: Dental CMS Add: 01/01/2007 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,577 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D9120 DENTL DEF MAXFEE 08/01/2015 12/31/2023 242.50 0.0 Y Description: FIX PARTIAL DENTURE SECTION Category: Dental CMS Add: 01/01/2007 CMS Term: D9130 NOCOV DEF SYSMAN Description: TEMPOROMANDIBULAR JOINT DYSF Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: D9210 NOCOV DEF SYSMAN 1-20years 0-1 Description: DENT ANESTHESIA W/O SURGERY Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D9211 NOCOV DEF SYSMAN 0-1 Description: REGIONAL BLOCK ANESTHESIA Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: D9212 NOCOV DEF SYSMAN 0-1 Description: TRIGEMINAL BLOCK ANESTHESIA Category: Non Covered Services CMS Add: 01/01/1985 CMS Term: D9215 NOCOV DEF SYSMAN 0-1 Description: LOCAL ANESTHESIA Category: Non Covered Services CMS Add: 01/01/1985 CMS Term: D9219 NOCOV DEF SYSMAN Description: EVAL MOD/DEEP SED/GEN ANEST Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: D9222 DENTL DEF MAXFEE 01/01/2018 12/31/2023 76.64 0.0 0-20years 0-1 Description: DEEP ANEST, 1ST 15 MIN Category: Dental CMS Add: 01/01/2018 CMS Term: D9222 DENTL DEF MAXFEE 01/01/2024 95.78 0.0 0-20years 0-1 Description: DEEP ANEST, 1ST 15 MIN Category: Dental CMS Add: 01/01/2018 CMS Term: D9223 DENTL DEF MAXFEE 01/01/2017 12/31/2023 76.64 0.0 0-20years Description: GENERAL ANESTH EA ADDL 15 MI Category: Dental CMS Add: 01/01/2016 CMS Term: D9223 DENTL DEF MAXFEE 01/01/2024 96.40 0.0 0-20years Description: GENERAL ANESTH EA ADDL 15 MI Category: Dental CMS Add: 01/01/2016 CMS Term: D9230 DENTL DEF MAXFEE 01/01/2014 12/31/2023 30.95 0.0 0-20years 0-1 Description: ANALGESIA Category: Dental CMS Add: 01/01/1982 CMS Term: D9230 DENTL DEF MAXFEE 01/01/2024 33.17 0.0 0-20years 0-1 Description: ANALGESIA Category: Dental CMS Add: 01/01/1982 CMS Term: D9239 DENTL DEF MAXFEE 01/01/2018 12/31/2023 71.08 0.0 0-999years 0-1 Description: IV MOD SEDATION, 1ST 15 MIN Category: Dental CMS Add: 01/01/2018 CMS Term: D9239 DENTL DEF MAXFEE 01/01/2024 94.54 0.0 0-999years 0-1 Description: IV MOD SEDATION, 1ST 15 MIN Category: Dental CMS Add: 01/01/2018 CMS Term: D9243 DENTL DEF MAXFEE 01/01/2017 12/31/2023 71.08 0.0 0-999years Description: IV SEDATION EA ADDL 15M Category: Dental CMS Add: 01/01/2016 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,578 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D9243 DENTL DEF MAXFEE 01/01/2024 91.91 0.0 0-999years Description: IV SEDATION EA ADDL 15M Category: Dental CMS Add: 01/01/2016 CMS Term: D9248 DENTL DEF MAXFEE 01/01/2014 12/31/2023 38.50 0.0 0-20years 0-1 Description: SEDATION (NON-IV) Category: Dental CMS Add: 01/01/2000 CMS Term: D9248 DENTL DEF MAXFEE 01/01/2024 124.14 0.0 0-20years 0-1 Description: SEDATION (NON-IV) Category: Dental CMS Add: 01/01/2000 CMS Term: D9310 NOCOV DEF SYSMAN 0-1 Description: DENTAL CONSULTATION Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: D9311 NOCOV DEF SYSMAN Description: CONSULT W/MED HLTH CARE PROF Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: D9410 NOCOV DEF SYSMAN 0-1 Description: DENTAL HOUSE CALL Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D9420 NOCOV DEF SYSMAN Description: HOSPITAL/ASC CALL Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D9430 NOCOV DEF SYSMAN 0-1 Description: OFFICE VISIT DURING HOURS Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D9440 NOCOV DEF SYSMAN Description: OFFICE VISIT AFTER HOURS Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D9450 NOCOV DEF SYSMAN 0-1 Description: CASE PRESENTATION TX PLAN Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: D9610 NOCOV DEF SYSMAN 0-1 Description: DENT THERAPEUTIC DRUG INJECT Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D9612 NOCOV DEF SYSMAN Description: THERA PAR DRUGS 2 OR > ADMIN Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: D9613 NOCOV DEF SYSMAN Description: INFILTRATION THERA DRUG Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: D9630 NOCOV DEF SYSMAN Description: DRUGS/MEDS DISP FOR HOME USE Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D9910 NOCOV DEF SYSMAN 0-1 Description: DENT APPL DESENSITIZING MED Category: Non Covered Services CMS Add: 01/01/1985 CMS Term: D9911 NOCOV DEF SYSMAN Description: APPL DESENSITIZING RESIN Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,579 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D9912 NOCOV DEF SYSMAN Description: PRE-VISIT PATIENT SCREENING Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: D9920 DENTL DEF MAXFEE 01/01/2014 12/31/2023 46.75 0.0 0-999years 0-1 Description: BEHAVIOR MANAGEMENT Category: Dental CMS Add: 01/01/1986 CMS Term: D9920 DENTL DEF MAXFEE 01/01/2024 62.46 0.0 0-999years 0-1 Description: BEHAVIOR MANAGEMENT Category: Dental CMS Add: 01/01/1986 CMS Term: D9930 NOCOV DEF SYSMAN Description: TREATMENT OF COMPLICATIONS Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D9932 NOCOV DEF SYSMAN Description: CLEAN & INSPECT REM DENT MAX Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: D9933 NOCOV DEF SYSMAN Description: CLEAN & INSPECT REM DENT MAN Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: D9934 NOCOV DEF SYSMAN Description: CLEAN REM PART DENTURE MAX Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: D9935 NOCOV DEF SYSMAN Description: CLEAN REM PART DENTURE MAND Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: D9938 NOCOV DEF SYSMAN Description: FAB REMOVABLE APPLIANCE Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: D9939 NOCOV DEF SYSMAN Description: PLACEMNT REMOVABLE APPLIANCE Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: D9941 NOCOV DEF SYSMAN 0-1 Description: FABRICATION ATHLETIC GUARD Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: D9942 NOCOV DEF SYSMAN Description: REPAIR/RELINE OCCLUSAL GUARD Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: D9943 NOCOV DEF SYSMAN Description: OCCLUSAL GUARD ADJUSTMENT Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: D9944 NOCOV DEF SYSMAN Description: OCC GUARD, HARD, FULL ARCH Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: D9945 NOCOV DEF SYSMAN Description: OCC GUARD, SOFT, FULL ARCH Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: D9946 NOCOV DEF SYSMAN Description: OCC GUARD, HARD, PART ARCH Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,580 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D9947 DENTL DEF BILL90 Y Description: SLEEP APNEA APPLIANCE Category: Dental CMS Add: 01/01/2022 CMS Term: D9948 DENTL DEF BILL90 Description: ADJUST SLEEP APNEA APPLIANCE Category: Dental CMS Add: 01/01/2022 CMS Term: D9949 DENTL DEF BILL90 Description: REPAIR SLEEP APNEA APPLIANCE Category: Dental CMS Add: 01/01/2022 CMS Term: D9950 NOCOV DEF SYSMAN 0-1 Description: OCCLUSION ANALYSIS Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: D9951 NOCOV DEF SYSMAN Description: LIMITED OCCLUSAL ADJUSTMENT Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: D9952 NOCOV DEF SYSMAN Description: COMPLETE OCCLUSAL ADJUSTMENT Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: D9953 DENTL DEF BILL90 Description: RELINE SLEEP APNEA APPLIANCE Category: Dental CMS Add: 01/01/2023 CMS Term: D9955 NOCOV DEF SYSMAN Description: ORAL APP THXPY TITRATION VIS Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: D9956 NOCOV DEF SYSMAN Description: ADMIN HOME SLEEP APNEA TEST Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: D9957 NOCOV DEF SYSMAN Description: SCREENING SLEEP DISORDERS Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: D9961 NOCOV DEF SYSMAN Description: DUP/COPY PATIENT'S RECORDS Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: D9970 NOCOV DEF SYSMAN Description: ENAMEL MICROABRASION Category: Non Covered Services CMS Add: 01/01/1996 CMS Term: D9971 NOCOV DEF SYSMAN 0-1 Description: ODONTOPLASTY PER TOOTH Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: D9972 NOCOV DEF SYSMAN 0-1 Description: EXTRNL BLEACHING PER ARCH Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: D9973 NOCOV DEF SYSMAN 0-1 Description: EXTRNL BLEACHING PER TOOTH Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: D9974 NOCOV DEF SYSMAN 0-1 Description: INTRNL BLEACHING PER TOOTH Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,581 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- D9975 NOCOV DEF SYSMAN Description: EXTERNAL BLEACHING HOME APP Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: D9985 NOCOV DEF SYSMAN Description: SALES TAX Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: D9986 NOCOV DEF SYSMAN Description: MISSED APPOINTMENT Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: D9987 NOCOV DEF SYSMAN Description: CANCELLED APPOINTMENT Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: D9990 NOCOV DEF SYSMAN Description: TRANS OR SIGN LANGUAGE SVCS Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: D9991 NOCOV DEF SYSMAN Description: CASE MGMT, APPT BARRIERS Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: D9992 NOCOV DEF SYSMAN Description: CASE MGMT, CARE COORDINATION Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: D9993 NOCOV DEF SYSMAN Description: CASE MGMT, INTERVIEWING Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: D9994 NOCOV DEF SYSMAN Description: CASE MGMT, PT EDUCATION Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: D9995 NOCOV DEF SYSMAN Description: TELEDENTISTRY REAL-TIME Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: D9996 NOCOV DEF SYSMAN Description: TELEDENTISTRY DENT REVIEW Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: D9997 NOCOV DEF SYSMAN Description: DENT CASE MGMT SPECIAL NEEDS Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: E0100 NU DME PUR MAXFEE 01/01/2023 12/31/2023 27.57 0.0 Description: CANE ADJUST/FIXED WITH TIP Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0100 NU DME PUR MAXFEE 01/01/2024 28.29 0.0 Description: CANE ADJUST/FIXED WITH TIP Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0100 RR DME RTL MAXFEE 01/01/2023 12/31/2023 7.88 0.0 Description: CANE ADJUST/FIXED WITH TIP Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0100 RR DME RTL MAXFEE 01/01/2024 8.08 0.0 Description: CANE ADJUST/FIXED WITH TIP Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,582 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0105 NU DME PUR MAXFEE 01/01/2023 12/31/2023 61.37 0.0 Description: CANE ADJUST/FIXED QUAD/3 PRO Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0105 NU DME PUR MAXFEE 01/01/2024 62.97 0.0 Description: CANE ADJUST/FIXED QUAD/3 PRO Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0105 RR DME RTL MAXFEE 01/01/2023 12/31/2023 11.79 0.0 Description: CANE ADJUST/FIXED QUAD/3 PRO Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0105 RR DME RTL MAXFEE 01/01/2024 12.10 0.0 Description: CANE ADJUST/FIXED QUAD/3 PRO Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0110 NU DME PUR MAXFEE 01/01/2023 12/31/2023 103.19 0.0 Description: CRUTCH FOREARM PAIR Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0110 NU DME PUR MAXFEE 01/01/2024 105.87 0.0 Description: CRUTCH FOREARM PAIR Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0110 RR DME RTL MAXFEE 01/01/2023 12/31/2023 18.07 0.0 Description: CRUTCH FOREARM PAIR Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0110 RR DME RTL MAXFEE 01/01/2024 18.54 0.0 Description: CRUTCH FOREARM PAIR Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0111 NU DME PUR MAXFEE 01/01/2023 12/31/2023 70.81 0.0 Description: CRUTCH FOREARM EACH Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0111 NU DME PUR MAXFEE 01/01/2024 72.65 0.0 Description: CRUTCH FOREARM EACH Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0111 RR DME RTL MAXFEE 01/01/2023 12/31/2023 9.53 0.0 Description: CRUTCH FOREARM EACH Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0111 RR DME RTL MAXFEE 01/01/2024 9.78 0.0 Description: CRUTCH FOREARM EACH Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0112 NU DME PUR MAXFEE 01/01/2023 12/31/2023 44.64 0.0 Description: CRUTCH UNDERARM PAIR WOOD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0112 NU DME PUR MAXFEE 01/01/2024 45.80 0.0 Description: CRUTCH UNDERARM PAIR WOOD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0112 RR DME RTL MAXFEE 01/01/2023 12/31/2023 11.24 0.0 Description: CRUTCH UNDERARM PAIR WOOD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0112 RR DME RTL MAXFEE 01/01/2024 11.53 0.0 Description: CRUTCH UNDERARM PAIR WOOD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,583 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0113 NU DME PUR MAXFEE 01/01/2023 12/31/2023 23.90 0.0 Description: CRUTCH UNDERARM EACH WOOD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0113 NU DME PUR MAXFEE 01/01/2024 24.52 0.0 Description: CRUTCH UNDERARM EACH WOOD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0113 RR DME RTL MAXFEE 01/01/2023 12/31/2023 5.81 0.0 Description: CRUTCH UNDERARM EACH WOOD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0113 RR DME RTL MAXFEE 01/01/2024 5.96 0.0 Description: CRUTCH UNDERARM EACH WOOD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0114 NU DME PUR MAXFEE 01/01/2023 12/31/2023 62.76 0.0 Description: CRUTCH UNDERARM PAIR NO WOOD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0114 NU DME PUR MAXFEE 01/01/2024 64.39 0.0 Description: CRUTCH UNDERARM PAIR NO WOOD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0114 RR DME RTL MAXFEE 01/01/2023 12/31/2023 9.68 0.0 Description: CRUTCH UNDERARM PAIR NO WOOD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0114 RR DME RTL MAXFEE 01/01/2024 9.94 0.0 Description: CRUTCH UNDERARM PAIR NO WOOD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0116 NU DME PUR MAXFEE 01/01/2023 12/31/2023 31.89 0.0 Description: CRUTCH UNDERARM EACH NO WOOD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0116 NU DME PUR MAXFEE 01/01/2024 32.72 0.0 Description: CRUTCH UNDERARM EACH NO WOOD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0116 RR DME RTL MAXFEE 01/01/2023 12/31/2023 6.12 0.0 Description: CRUTCH UNDERARM EACH NO WOOD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0116 RR DME RTL MAXFEE 01/01/2024 6.28 0.0 Description: CRUTCH UNDERARM EACH NO WOOD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0117 NU DME PUR MAXFEE 01/01/2014 12/31/2023 163.80 0.0 Description: UNDERARM SPRINGASSIST CRUTCH Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E0117 NU DME PUR MAXFEE 01/01/2024 256.10 0.0 Description: UNDERARM SPRINGASSIST CRUTCH Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E0117 RR DME RTL MAXFEE 01/01/2014 12/31/2023 16.37 0.0 Description: UNDERARM SPRINGASSIST CRUTCH Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E0117 RR DME RTL MAXFEE 01/01/2024 25.61 0.0 Description: UNDERARM SPRINGASSIST CRUTCH Category: Durable Medical CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,584 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0118 NOCOV DEF SYSMAN Description: CRUTCH SUBSTITUTE Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: E0130 NU DME PUR MAXFEE 01/01/2023 12/31/2023 57.64 0.0 Description: WALKER RIGID ADJUST/FIXED HT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0130 NU DME PUR MAXFEE 01/01/2024 55.27 0.0 Description: WALKER RIGID ADJUST/FIXED HT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0130 RR DME RTL MAXFEE 01/01/2023 12/31/2023 8.59 0.0 Description: WALKER RIGID ADJUST/FIXED HT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0130 RR DME RTL MAXFEE 01/01/2024 5.53 0.0 Description: WALKER RIGID ADJUST/FIXED HT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0135 NU DME PUR MAXFEE 01/01/2023 12/31/2023 63.76 0.0 Description: WALKER FOLDING ADJUST/FIXED Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0135 NU DME PUR MAXFEE 01/01/2024 55.48 0.0 Description: WALKER FOLDING ADJUST/FIXED Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0135 RR DME RTL MAXFEE 01/01/2023 12/31/2023 8.83 0.0 Description: WALKER FOLDING ADJUST/FIXED Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0135 RR DME RTL MAXFEE 01/01/2024 5.55 0.0 Description: WALKER FOLDING ADJUST/FIXED Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0140 NU DME PUR MAXFEE 01/01/2023 12/31/2023 365.30 0.0 Description: WALKER W TRUNK SUPPORT Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0140 NU DME PUR MAXFEE 01/01/2024 359.70 0.0 Description: WALKER W TRUNK SUPPORT Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0140 RR DME RTL MAXFEE 01/01/2023 12/31/2023 36.53 0.0 Description: WALKER W TRUNK SUPPORT Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0140 RR DME RTL MAXFEE 01/01/2024 35.97 0.0 Description: WALKER W TRUNK SUPPORT Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0141 NU DME PUR MAXFEE 01/01/2023 12/31/2023 73.08 0.0 Description: RIGID WHEELED WALKER ADJ/FIX Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0141 NU DME PUR MAXFEE 01/01/2024 56.96 0.0 Description: RIGID WHEELED WALKER ADJ/FIX Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0141 RR DME RTL MAXFEE 01/01/2023 12/31/2023 9.60 0.0 Description: RIGID WHEELED WALKER ADJ/FIX Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,585 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0141 RR DME RTL MAXFEE 01/01/2024 5.70 0.0 Description: RIGID WHEELED WALKER ADJ/FIX Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0143 NU DME PUR MAXFEE 01/01/2023 12/31/2023 75.73 0.0 Description: WALKER FOLDING WHEELED W/O S Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0143 NU DME PUR MAXFEE 01/01/2024 56.96 0.0 Description: WALKER FOLDING WHEELED W/O S Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0143 RR DME RTL MAXFEE 01/01/2023 12/31/2023 9.70 0.0 Description: WALKER FOLDING WHEELED W/O S Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0143 RR DME RTL MAXFEE 01/01/2024 5.70 0.0 Description: WALKER FOLDING WHEELED W/O S Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0144 NU DME PUR MAXFEE 01/01/2023 12/31/2023 327.80 0.0 Y Description: ENCLOSED WALKER W REAR SEAT Category: Durable Medical CMS Add: 01/01/2000 CMS Term: E0144 NU DME PUR MAXFEE 01/01/2024 324.80 0.0 Y Description: ENCLOSED WALKER W REAR SEAT Category: Durable Medical CMS Add: 01/01/2000 CMS Term: E0144 RR DME RTL MAXFEE 01/01/2023 12/31/2023 32.78 0.0 Y Description: ENCLOSED WALKER W REAR SEAT Category: Durable Medical CMS Add: 01/01/2000 CMS Term: E0144 RR DME RTL MAXFEE 01/01/2024 32.48 0.0 Y Description: ENCLOSED WALKER W REAR SEAT Category: Durable Medical CMS Add: 01/01/2000 CMS Term: E0147 NU DME PUR MAXFEE 01/01/2023 12/31/2023 517.48 0.0 Description: WALKER VARIABLE WHEEL RESIST Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0147 NU DME PUR MAXFEE 01/01/2024 484.46 0.0 Description: WALKER VARIABLE WHEEL RESIST Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0147 RR DME RTL MAXFEE 01/01/2023 12/31/2023 51.75 0.0 Description: WALKER VARIABLE WHEEL RESIST Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0147 RR DME RTL MAXFEE 01/01/2024 48.45 0.0 Description: WALKER VARIABLE WHEEL RESIST Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0148 NU DME PUR MAXFEE 01/01/2023 12/31/2023 108.97 0.0 0-1 Description: HEAVYDUTY WALKER NO WHEELS Category: Durable Medical CMS Add: 01/01/2001 CMS Term: E0148 NU DME PUR MAXFEE 01/01/2024 99.65 0.0 0-1 Description: HEAVYDUTY WALKER NO WHEELS Category: Durable Medical CMS Add: 01/01/2001 CMS Term: E0148 RR DME RTL MAXFEE 01/01/2023 12/31/2023 10.90 0.0 0-1 Description: HEAVYDUTY WALKER NO WHEELS Category: Durable Medical CMS Add: 01/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,586 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0148 RR DME RTL MAXFEE 01/01/2024 9.96 0.0 0-1 Description: HEAVYDUTY WALKER NO WHEELS Category: Durable Medical CMS Add: 01/01/2001 CMS Term: E0149 NU DME PUR MAXFEE 01/01/2023 12/31/2023 167.20 0.0 0-1 Description: HEAVY DUTY WHEELED WALKER Category: Durable Medical CMS Add: 01/01/2001 CMS Term: E0149 NU DME PUR MAXFEE 01/01/2024 141.70 0.0 0-1 Description: HEAVY DUTY WHEELED WALKER Category: Durable Medical CMS Add: 01/01/2001 CMS Term: E0149 RR DME RTL MAXFEE 01/01/2023 12/31/2023 16.72 0.0 0-1 Description: HEAVY DUTY WHEELED WALKER Category: Durable Medical CMS Add: 01/01/2001 CMS Term: E0149 RR DME RTL MAXFEE 01/01/2024 14.17 0.0 0-1 Description: HEAVY DUTY WHEELED WALKER Category: Durable Medical CMS Add: 01/01/2001 CMS Term: E0153 DME DEF MAXFEE 01/01/2014 12/31/2023 57.57 0.0 Description: FOREARM CRUTCH PLATFORM ATTA Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0153 DME DEF MAXFEE 01/01/2024 92.29 0.0 Description: FOREARM CRUTCH PLATFORM ATTA Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0154 DME DEF MAXFEE 01/01/2014 12/31/2023 50.88 0.0 Description: WALKER PLATFORM ATTACHMENT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0154 DME DEF MAXFEE 01/01/2024 53.33 0.0 Description: WALKER PLATFORM ATTACHMENT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0155 NU DME PUR MAXFEE 01/01/2014 12/31/2023 25.35 0.0 Description: WALKER WHEEL ATTACHMENT,PAIR Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0155 NU DME PUR MAXFEE 01/01/2024 21.65 0.0 Description: WALKER WHEEL ATTACHMENT,PAIR Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0156 NU DME PUR MAXFEE 01/01/2014 12/31/2023 26.15 0.0 Description: WALKER SEAT ATTACHMENT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0156 NU DME PUR MAXFEE 01/01/2024 18.86 0.0 Description: WALKER SEAT ATTACHMENT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0157 DME DEF MAXFEE 01/01/2014 12/31/2023 59.27 0.0 Description: WALKER CRUTCH ATTACHMENT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0157 DME DEF MAXFEE 01/01/2024 68.42 0.0 Description: WALKER CRUTCH ATTACHMENT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0158 NU DME PUR MAXFEE 01/01/2014 12/31/2023 23.08 0.0 Description: WALKER LEG EXTENDERS SET OF4 Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,587 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0158 NU DME PUR MAXFEE 01/01/2024 22.77 0.0 Description: WALKER LEG EXTENDERS SET OF4 Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0159 NU DME PUR MAXFEE 01/01/2014 12/31/2023 17.05 0.0 Description: BRAKE FOR WHEELED WALKER Category: Durable Medical CMS Add: 01/01/1997 CMS Term: E0159 NU DME PUR MAXFEE 01/01/2024 16.28 0.0 Description: BRAKE FOR WHEELED WALKER Category: Durable Medical CMS Add: 01/01/1997 CMS Term: E0159 RR DME RTL MAXFEE 01/01/2014 12/31/2023 1.72 0.0 Description: BRAKE FOR WHEELED WALKER Category: Durable Medical CMS Add: 01/01/1997 CMS Term: E0159 RR DME RTL MAXFEE 01/01/2024 1.88 0.0 Description: BRAKE FOR WHEELED WALKER Category: Durable Medical CMS Add: 01/01/1997 CMS Term: E0160 NU DME PUR MAXFEE 01/01/2023 12/31/2023 37.05 0.0 Y Description: SITZ TYPE BATH OR EQUIPMENT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0160 NU DME PUR MAXFEE 01/01/2024 35.79 0.0 Y Description: SITZ TYPE BATH OR EQUIPMENT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0160 RR DME RTL MAXFEE 01/01/2023 12/31/2023 4.05 0.0 Y Description: SITZ TYPE BATH OR EQUIPMENT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0160 RR DME RTL MAXFEE 01/01/2024 3.58 0.0 Y Description: SITZ TYPE BATH OR EQUIPMENT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0161 NU DME PUR MAXFEE 01/01/2023 12/31/2023 30.86 0.0 Y Description: SITZ BATH/EQUIPMENT W/FAUCET Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0161 NU DME PUR MAXFEE 01/01/2024 26.55 0.0 Y Description: SITZ BATH/EQUIPMENT W/FAUCET Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0161 RR DME RTL MAXFEE 01/01/2023 3.40 0.0 Y Description: SITZ BATH/EQUIPMENT W/FAUCET Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0162 NU DME PUR MAXFEE 01/01/2014 12/31/2023 123.22 0.0 Y Description: SITZ BATH CHAIR Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0162 NU DME PUR MAXFEE 01/01/2024 164.70 0.0 Y Description: SITZ BATH CHAIR Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0162 RR DME RTL MAXFEE 01/01/2014 12/31/2023 12.93 0.0 Y Description: SITZ BATH CHAIR Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0162 RR DME RTL MAXFEE 01/01/2024 17.29 0.0 Y Description: SITZ BATH CHAIR Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,588 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0163 NU DME PUR MAXFEE 01/01/2023 12/31/2023 82.53 0.0 Description: COMMODE CHAIR WITH FIXED ARM Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0163 NU DME PUR MAXFEE 01/01/2024 62.99 0.0 Description: COMMODE CHAIR WITH FIXED ARM Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0163 RR DME RTL MAXFEE 01/01/2023 12/31/2023 12.70 0.0 Description: COMMODE CHAIR WITH FIXED ARM Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0163 RR DME RTL MAXFEE 01/01/2024 6.30 0.0 Description: COMMODE CHAIR WITH FIXED ARM Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0165 NU DME PUR MAXFEE 01/01/2023 12/31/2023 159.80 0.0 Description: COMMODE CHAIR WITH DETACHARM Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0165 NU DME PUR MAXFEE 01/01/2024 147.40 0.0 Description: COMMODE CHAIR WITH DETACHARM Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0165 RR DME RTL MAXFEE 01/01/2023 12/31/2023 15.98 0.0 Description: COMMODE CHAIR WITH DETACHARM Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0165 RR DME RTL MAXFEE 01/01/2024 14.74 0.0 Description: COMMODE CHAIR WITH DETACHARM Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0167 NU DME PUR MAXFEE 01/01/2023 12/31/2023 13.94 0.0 Description: COMMODE CHAIR PAIL OR PAN Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0167 NU DME PUR MAXFEE 01/01/2024 13.66 0.0 Description: COMMODE CHAIR PAIL OR PAN Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0167 RR DME RTL MAXFEE 01/01/2023 12/31/2023 1.40 0.0 Description: COMMODE CHAIR PAIL OR PAN Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0167 RR DME RTL MAXFEE 01/01/2024 1.37 0.0 Description: COMMODE CHAIR PAIL OR PAN Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0168 NU DME PUR MAXFEE 01/01/2023 12/31/2023 152.09 0.0 0-1 Description: HEAVYDUTY/WIDE COMMODE CHAIR Category: Durable Medical CMS Add: 01/01/2001 CMS Term: E0168 NU DME PUR MAXFEE 01/01/2024 139.96 0.0 0-1 Description: HEAVYDUTY/WIDE COMMODE CHAIR Category: Durable Medical CMS Add: 01/01/2001 CMS Term: E0168 RR DME RTL MAXFEE 01/01/2023 12/31/2023 15.23 0.0 0-1 Description: HEAVYDUTY/WIDE COMMODE CHAIR Category: Durable Medical CMS Add: 01/01/2001 CMS Term: E0168 RR DME RTL MAXFEE 01/01/2024 14.00 0.0 0-1 Description: HEAVYDUTY/WIDE COMMODE CHAIR Category: Durable Medical CMS Add: 01/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,589 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0170 NU DME PUR MAXFEE 01/01/2024 1972.80 0.0 Y Description: COMMODE CHAIR ELECTRIC Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E0170 NU DME PUR MAXFEE 02/01/2021 12/31/2023 1717.00 0.0 Y Description: COMMODE CHAIR ELECTRIC Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E0170 RR DME RTL MAXFEE 01/01/2024 197.28 0.0 Y Description: COMMODE CHAIR ELECTRIC Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E0170 RR DME RTL MAXFEE 02/01/2021 12/31/2023 171.70 0.0 Y Description: COMMODE CHAIR ELECTRIC Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E0171 NU DME PUR MAXFEE 01/01/2024 369.90 0.0 Y Description: COMMODE CHAIR NON-ELECTRIC Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E0171 RR DME RTL MAXFEE 01/01/2014 12/31/2023 28.92 0.0 Y Description: COMMODE CHAIR NON-ELECTRIC Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E0171 RR DME RTL MAXFEE 01/01/2024 36.99 0.0 Y Description: COMMODE CHAIR NON-ELECTRIC Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E0172 RR DME RTL MAXFEE 01/01/2014 12/31/2023 42.72 0.0 Y Description: SEAT LIFT MECHANISM TOILET Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E0172 RR DME RTL MAXFEE 01/01/2024 55.54 0.0 Y Description: SEAT LIFT MECHANISM TOILET Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E0175 DME DEF MAXFEE 01/01/2014 12/31/2023 53.78 0.0 Description: COMMODE CHAIR FOOT REST Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0175 DME DEF MAXFEE 01/01/2024 83.80 0.0 Description: COMMODE CHAIR FOOT REST Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0181 NU DME PUR MAXFEE 01/01/2023 12/31/2023 219.40 0.0 Description: PRESS PAD ALTERNATING W/ PUM Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0181 NU DME PUR MAXFEE 01/01/2024 182.40 0.0 Description: PRESS PAD ALTERNATING W/ PUM Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0181 RR DME RTL MAXFEE 01/01/2023 12/31/2023 21.94 0.0 Description: PRESS PAD ALTERNATING W/ PUM Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0181 RR DME RTL MAXFEE 01/01/2024 18.24 0.0 Description: PRESS PAD ALTERNATING W/ PUM Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0182 NU DME PUR MAXFEE 01/01/2014 12/31/2023 300.00 0.0 Description: REPLACE PUMP, ALT PRESS PAD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,590 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0182 NU DME PUR MAXFEE 01/01/2024 238.90 0.0 Description: REPLACE PUMP, ALT PRESS PAD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0182 RR DME RTL MAXFEE 01/01/2014 12/31/2023 21.08 0.0 Description: REPLACE PUMP, ALT PRESS PAD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0182 RR DME RTL MAXFEE 01/01/2024 23.89 0.0 Description: REPLACE PUMP, ALT PRESS PAD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0183 NU DME PUR MAXFEE 01/01/2024 219.40 0.0 50-999years Description: PRESS UNDERLAY ALTER W/PUMP Category: Durable Medical CMS Add: 10/01/2022 CMS Term: E0183 NU DME PUR MAXFEE 10/01/2022 12/31/2023 201.40 0.0 50-999years Description: PRESS UNDERLAY ALTER W/PUMP Category: Durable Medical CMS Add: 10/01/2022 CMS Term: E0183 RR DME RTL MAXFEE 01/01/2024 21.94 0.0 50-999years Description: PRESS UNDERLAY ALTER W/PUMP Category: Durable Medical CMS Add: 10/01/2022 CMS Term: E0183 RR DME RTL MAXFEE 10/01/2022 12/31/2023 20.14 0.0 50-999years Description: PRESS UNDERLAY ALTER W/PUMP Category: Durable Medical CMS Add: 10/01/2022 CMS Term: E0184 NU DME PUR MAXFEE 01/01/2023 12/31/2023 198.69 0.0 Description: DRY PRESSURE MATTRESS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0184 NU DME PUR MAXFEE 01/01/2024 183.96 0.0 Description: DRY PRESSURE MATTRESS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0184 RR DME RTL MAXFEE 01/01/2023 12/31/2023 21.56 0.0 Description: DRY PRESSURE MATTRESS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0184 RR DME RTL MAXFEE 01/01/2024 18.40 0.0 Description: DRY PRESSURE MATTRESS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0185 NU DME PUR MAXFEE 01/01/2023 12/31/2023 233.68 0.0 Description: GEL PRESSURE MATTRESS PAD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0185 NU DME PUR MAXFEE 01/01/2024 196.79 0.0 Description: GEL PRESSURE MATTRESS PAD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0185 RR DME RTL MAXFEE 01/01/2023 12/31/2023 27.03 0.0 Description: GEL PRESSURE MATTRESS PAD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0185 RR DME RTL MAXFEE 01/01/2024 19.68 0.0 Description: GEL PRESSURE MATTRESS PAD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0186 NU DME PUR MAXFEE 01/01/2023 12/31/2023 260.80 0.0 Description: AIR PRESSURE MATTRESS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,591 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0186 NU DME PUR MAXFEE 01/01/2024 227.30 0.0 Description: AIR PRESSURE MATTRESS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0186 RR DME RTL MAXFEE 01/01/2023 12/31/2023 26.08 0.0 Description: AIR PRESSURE MATTRESS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0186 RR DME RTL MAXFEE 01/01/2024 22.73 0.0 Description: AIR PRESSURE MATTRESS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0187 NU DME PUR MAXFEE 01/01/2014 12/31/2023 158.19 0.0 Description: WATER PRESSURE MATTRESS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0187 NU DME PUR MAXFEE 01/01/2024 245.50 0.0 Description: WATER PRESSURE MATTRESS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0187 RR DME RTL MAXFEE 01/01/2014 12/31/2023 21.19 0.0 Description: WATER PRESSURE MATTRESS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0187 RR DME RTL MAXFEE 01/01/2024 24.55 0.0 Description: WATER PRESSURE MATTRESS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0188 NU DME PUR MAXFEE 01/01/2023 12/31/2023 31.17 0.0 Description: SYNTHETIC SHEEPSKIN PAD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0188 NU DME PUR MAXFEE 01/01/2024 30.74 0.0 Description: SYNTHETIC SHEEPSKIN PAD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0188 RR DME RTL MAXFEE 01/01/2023 12/31/2023 3.27 0.0 Description: SYNTHETIC SHEEPSKIN PAD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0188 RR DME RTL MAXFEE 01/01/2024 3.07 0.0 Description: SYNTHETIC SHEEPSKIN PAD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0189 NU DME PUR MAXFEE 01/01/2023 12/31/2023 59.40 0.0 Description: LAMBSWOOL SHEEPSKIN PAD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0189 NU DME PUR MAXFEE 01/01/2024 57.85 0.0 Description: LAMBSWOOL SHEEPSKIN PAD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0189 RR DME RTL MAXFEE 01/01/2023 12/31/2023 6.08 0.0 Description: LAMBSWOOL SHEEPSKIN PAD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0189 RR DME RTL MAXFEE 01/01/2024 5.78 0.0 Description: LAMBSWOOL SHEEPSKIN PAD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0190 DME DEF SYSMAN Y Description: POSITIONING CUSHION Category: Durable Medical CMS Add: 01/01/2004 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,592 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0191 NU DME PUR MAXFEE 01/01/2014 12/31/2023 7.88 0.0 Description: PROTECTOR HEEL OR ELBOW Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0191 NU DME PUR MAXFEE 01/01/2024 12.28 0.0 Description: PROTECTOR HEEL OR ELBOW Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0193 NOCOV DEF SYSMAN Description: POWERED AIR FLOTATION BED Category: Non Covered Services CMS Add: 01/01/1990 CMS Term: E0194 NOCOV DEF SYSMAN Description: AIR FLUIDIZED BED Category: Non Covered Services CMS Add: 01/01/1991 CMS Term: E0196 NU DME PUR MAXFEE 01/01/2023 12/31/2023 398.30 0.0 Y Description: GEL PRESSURE MATTRESS Category: Durable Medical CMS Add: 01/01/1991 CMS Term: E0196 NU DME PUR MAXFEE 01/01/2024 398.70 0.0 Y Description: GEL PRESSURE MATTRESS Category: Durable Medical CMS Add: 01/01/1991 CMS Term: E0196 RR DME RTL MAXFEE 01/01/2023 12/31/2023 39.83 0.0 Y Description: GEL PRESSURE MATTRESS Category: Durable Medical CMS Add: 01/01/1991 CMS Term: E0196 RR DME RTL MAXFEE 01/01/2024 39.87 0.0 Y Description: GEL PRESSURE MATTRESS Category: Durable Medical CMS Add: 01/01/1991 CMS Term: E0197 NU DME PUR MAXFEE 01/01/2023 12/31/2023 248.10 0.0 Y Description: AIR PRESSURE PAD FOR MATTRES Category: Durable Medical CMS Add: 01/01/1991 CMS Term: E0197 NU DME PUR MAXFEE 01/01/2024 222.10 0.0 Y Description: AIR PRESSURE PAD FOR MATTRES Category: Durable Medical CMS Add: 01/01/1991 CMS Term: E0197 RR DME RTL MAXFEE 01/01/2023 12/31/2023 24.81 0.0 Y Description: AIR PRESSURE PAD FOR MATTRES Category: Durable Medical CMS Add: 01/01/1991 CMS Term: E0197 RR DME RTL MAXFEE 01/01/2024 22.21 0.0 Y Description: AIR PRESSURE PAD FOR MATTRES Category: Durable Medical CMS Add: 01/01/1991 CMS Term: E0198 NU DME PUR MAXFEE 01/01/2014 12/31/2023 161.77 0.0 Y Description: WATER PRESSURE PAD FOR MATTR Category: Durable Medical CMS Add: 01/01/1991 CMS Term: E0198 NU DME PUR MAXFEE 01/01/2024 250.50 0.0 Y Description: WATER PRESSURE PAD FOR MATTR Category: Durable Medical CMS Add: 01/01/1991 CMS Term: E0198 RR DME RTL MAXFEE 01/01/2014 12/31/2023 25.09 0.0 Y Description: WATER PRESSURE PAD FOR MATTR Category: Durable Medical CMS Add: 01/01/1991 CMS Term: E0198 RR DME RTL MAXFEE 01/01/2024 25.05 0.0 Y Description: WATER PRESSURE PAD FOR MATTR Category: Durable Medical CMS Add: 01/01/1991 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,593 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0199 NU DME PUR MAXFEE 01/01/2023 12/31/2023 34.14 0.0 Description: DRY PRESSURE PAD FOR MATTRES Category: Durable Medical CMS Add: 01/01/1991 CMS Term: E0199 NU DME PUR MAXFEE 01/01/2024 34.44 0.0 Description: DRY PRESSURE PAD FOR MATTRES Category: Durable Medical CMS Add: 01/01/1991 CMS Term: E0199 RR DME RTL MAXFEE 01/01/2023 12/31/2023 3.41 0.0 Description: DRY PRESSURE PAD FOR MATTRES Category: Durable Medical CMS Add: 01/01/1991 CMS Term: E0199 RR DME RTL MAXFEE 01/01/2024 3.44 0.0 Description: DRY PRESSURE PAD FOR MATTRES Category: Durable Medical CMS Add: 01/01/1991 CMS Term: E0200 NU DME PUR MAXFEE 01/01/2014 12/31/2023 92.29 0.0 Description: HEAT LAMP WITHOUT STAND Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0200 NU DME PUR MAXFEE 01/01/2024 89.62 0.0 Description: HEAT LAMP WITHOUT STAND Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0200 RR DME RTL MAXFEE 01/01/2014 12/31/2023 11.80 0.0 Description: HEAT LAMP WITHOUT STAND Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0200 RR DME RTL MAXFEE 01/01/2024 12.17 0.0 Description: HEAT LAMP WITHOUT STAND Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0202 NU DME PUR MAXFEE 02/01/2021 679.40 0.0 Description: PHOTOTHERAPY LIGHT W/ PHOTOM Category: Durable Medical CMS Add: 01/01/1985 CMS Term: E0202 RR DME RTL MAXFEE 02/01/2021 67.94 0.0 Description: PHOTOTHERAPY LIGHT W/ PHOTOM Category: Durable Medical CMS Add: 01/01/1985 CMS Term: E0203 RR DME RTL MAXFEE 01/01/2014 12/31/2023 90.44 0.0 Description: THERAPEUTIC LIGHTBOX TABLETP Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E0203 RR DME RTL MAXFEE 01/01/2024 117.57 0.0 Description: THERAPEUTIC LIGHTBOX TABLETP Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E0205 NU DME PUR MAXFEE 01/01/2014 12/31/2023 155.53 0.0 Description: HEAT LAMP WITH STAND Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0205 NU DME PUR MAXFEE 01/01/2024 258.08 0.0 Description: HEAT LAMP WITH STAND Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0205 RR DME RTL MAXFEE 01/01/2014 12/31/2023 19.69 0.0 Description: HEAT LAMP WITH STAND Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0205 RR DME RTL MAXFEE 01/01/2024 28.39 0.0 Description: HEAT LAMP WITH STAND Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,594 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0210 NU DME PUR MAXFEE 01/01/2023 12/31/2023 36.92 0.0 Description: ELECTRIC HEAT PAD STANDARD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0210 NU DME PUR MAXFEE 01/01/2024 37.88 0.0 Description: ELECTRIC HEAT PAD STANDARD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0210 RR DME RTL MAXFEE 01/01/2023 12/31/2023 3.48 0.0 Description: ELECTRIC HEAT PAD STANDARD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0210 RR DME RTL MAXFEE 01/01/2024 3.57 0.0 Description: ELECTRIC HEAT PAD STANDARD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0215 NU DME PUR MAXFEE 01/01/2014 12/31/2023 47.11 0.0 Description: ELECTRIC HEAT PAD MOIST Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0215 NU DME PUR MAXFEE 01/01/2024 80.08 0.0 Description: ELECTRIC HEAT PAD MOIST Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0215 RR DME RTL MAXFEE 01/01/2014 12/31/2023 8.83 0.0 Description: ELECTRIC HEAT PAD MOIST Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0215 RR DME RTL MAXFEE 01/01/2024 8.38 0.0 Description: ELECTRIC HEAT PAD MOIST Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0217 NU DME PUR MAXFEE 01/01/2014 12/31/2023 402.52 0.0 Description: WATER CIRC HEAT PAD W PUMP Category: Durable Medical CMS Add: 01/01/1997 CMS Term: E0217 NU DME PUR MAXFEE 01/01/2024 561.20 0.0 Description: WATER CIRC HEAT PAD W PUMP Category: Durable Medical CMS Add: 01/01/1997 CMS Term: E0217 RR DME RTL MAXFEE 01/01/2014 12/31/2023 44.82 0.0 Description: WATER CIRC HEAT PAD W PUMP Category: Durable Medical CMS Add: 01/01/1997 CMS Term: E0217 RR DME RTL MAXFEE 01/01/2024 62.48 0.0 Description: WATER CIRC HEAT PAD W PUMP Category: Durable Medical CMS Add: 01/01/1997 CMS Term: E0218 DME DEF SYSMAN Y Description: FLUID CIRC COLD PAD W PUMP Category: Durable Medical CMS Add: 01/01/1997 CMS Term: E0221 NU DME PUR MAXFEE 01/01/2014 12/31/2023 1787.55 0.0 Description: INFRARED HEATING PAD SYSTEM Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E0221 NU DME PUR MAXFEE 01/01/2024 2323.82 0.0 Description: INFRARED HEATING PAD SYSTEM Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E0221 RR DME RTL MAXFEE 01/01/2014 12/31/2023 178.75 0.0 Description: INFRARED HEATING PAD SYSTEM Category: Durable Medical CMS Add: 01/01/2002 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,595 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0221 RR DME RTL MAXFEE 01/01/2024 232.38 0.0 Description: INFRARED HEATING PAD SYSTEM Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E0225 NU DME PUR MAXFEE 01/01/2014 12/31/2023 334.51 0.0 Description: HYDROCOLLATOR UNIT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0225 NU DME PUR MAXFEE 01/01/2024 439.32 0.0 Description: HYDROCOLLATOR UNIT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0231 DME DEF SYSMAN Y Description: WOUND WARMING DEVICE Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E0232 DME DEF SYSMAN Y Description: WARMING CARD FOR NWT Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E0235 NU DME PUR MAXFEE 01/01/2023 12/31/2023 229.40 0.0 Description: PARAFFIN BATH UNIT PORTABLE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0235 NU DME PUR MAXFEE 01/01/2024 235.40 0.0 Description: PARAFFIN BATH UNIT PORTABLE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0235 RR DME RTL MAXFEE 01/01/2023 12/31/2023 22.94 0.0 Description: PARAFFIN BATH UNIT PORTABLE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0235 RR DME RTL MAXFEE 01/01/2024 23.54 0.0 Description: PARAFFIN BATH UNIT PORTABLE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0236 NU DME PUR MAXFEE 01/01/2014 12/31/2023 554.27 0.0 Description: PUMP FOR WATER CIRCULATING P Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0236 NU DME PUR MAXFEE 01/01/2024 588.40 0.0 Description: PUMP FOR WATER CIRCULATING P Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0236 RR DME RTL MAXFEE 01/01/2014 12/31/2023 55.43 0.0 Description: PUMP FOR WATER CIRCULATING P Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0236 RR DME RTL MAXFEE 01/01/2024 58.84 0.0 Description: PUMP FOR WATER CIRCULATING P Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0239 NU DME PUR MAXFEE 01/01/2014 12/31/2023 380.47 0.0 Description: HYDROCOLLATOR UNIT PORTABLE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0239 NU DME PUR MAXFEE 01/01/2024 508.49 0.0 Description: HYDROCOLLATOR UNIT PORTABLE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0239 RR DME RTL MAXFEE 01/01/2014 12/31/2023 38.05 0.0 Description: HYDROCOLLATOR UNIT PORTABLE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,596 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0239 RR DME RTL MAXFEE 01/01/2024 50.86 0.0 Description: HYDROCOLLATOR UNIT PORTABLE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0240 DME DEF SYSMAN Y Y Description: BATH/SHOWER CHAIR Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0241 DME DEF MAXFEE 01/01/2014 12/31/2023 18.60 0.0 Description: BATH TUB WALL RAIL Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0241 DME DEF MAXFEE 01/01/2024 24.18 0.0 Description: BATH TUB WALL RAIL Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0242 NU DME PUR MAXFEE 01/01/2014 12/31/2023 85.70 0.0 Description: BATH TUB RAIL FLOOR Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0242 NU DME PUR MAXFEE 01/01/2024 111.41 0.0 Description: BATH TUB RAIL FLOOR Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0243 NU DME PUR MAXFEE 01/01/2014 12/31/2023 40.00 0.0 Description: TOILET RAIL Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0243 NU DME PUR MAXFEE 01/01/2024 52.00 0.0 Description: TOILET RAIL Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0244 NU DME PUR MAXFEE 01/01/2014 12/31/2023 66.00 0.0 Description: TOILET SEAT RAISED Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0244 NU DME PUR MAXFEE 01/01/2024 85.80 0.0 Description: TOILET SEAT RAISED Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0245 NU DME PUR MAXFEE 01/01/2014 12/31/2023 33.60 0.0 Description: TUB STOOL OR BENCH Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0245 NU DME PUR MAXFEE 01/01/2024 43.68 0.0 Description: TUB STOOL OR BENCH Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0246 NU DME PUR MAXFEE 01/01/2014 12/31/2023 86.50 0.0 Description: TRANSFER TUB RAIL ATTACHMENT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0246 NU DME PUR MAXFEE 01/01/2024 112.45 0.0 Description: TRANSFER TUB RAIL ATTACHMENT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0247 NU DME PUR MAXFEE 01/01/2024 110.98 0.0 Y Description: TRANS BENCH W/WO COMM OPEN Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0247 NU DME PUR MAXFEE 09/01/2012 12/31/2023 85.37 0.0 Y Description: TRANS BENCH W/WO COMM OPEN Category: Durable Medical CMS Add: 01/01/2004 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,597 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0248 NU DME PUR MAXFEE 01/01/2024 157.66 0.0 Y Description: HDTRANS BENCH W/WO COMM OPEN Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0248 NU DME PUR MAXFEE 09/01/2012 12/31/2023 121.28 0.0 Y Description: HDTRANS BENCH W/WO COMM OPEN Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0249 NU DME PUR MAXFEE 01/01/2014 12/31/2023 74.67 0.0 Y Description: PAD WATER CIRCULATING HEAT U Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0249 NU DME PUR MAXFEE 01/01/2024 112.59 0.0 Y Description: PAD WATER CIRCULATING HEAT U Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0250 NU DME PUR MAXFEE 01/01/2023 12/31/2023 796.40 0.0 Y Description: HOSP BED FIXED HT W/ MATTRES Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0250 NU DME PUR MAXFEE 01/01/2024 709.00 0.0 Y Description: HOSP BED FIXED HT W/ MATTRES Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0250 RR DME RTL MAXFEE 01/01/2023 12/31/2023 79.64 0.0 Y Description: HOSP BED FIXED HT W/ MATTRES Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0250 RR DME RTL MAXFEE 01/01/2024 70.90 0.0 Y Description: HOSP BED FIXED HT W/ MATTRES Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0251 NU DME PUR MAXFEE 01/01/2023 12/31/2023 713.40 0.0 Y Description: HOSP BED FIXD HT W/O MATTRES Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0251 NU DME PUR MAXFEE 01/01/2024 688.20 0.0 Y Description: HOSP BED FIXD HT W/O MATTRES Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0251 RR DME RTL MAXFEE 01/01/2023 12/31/2023 71.34 0.0 Y Description: HOSP BED FIXD HT W/O MATTRES Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0251 RR DME RTL MAXFEE 01/01/2024 68.82 0.0 Y Description: HOSP BED FIXD HT W/O MATTRES Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0255 NU DME PUR MAXFEE 01/01/2023 12/31/2023 822.40 0.0 Y Description: HOSPITAL BED VAR HT W/ MATTR Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0255 NU DME PUR MAXFEE 01/01/2024 717.50 0.0 Y Description: HOSPITAL BED VAR HT W/ MATTR Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0255 RR DME RTL MAXFEE 01/01/2023 12/31/2023 82.24 0.0 Y Description: HOSPITAL BED VAR HT W/ MATTR Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0255 RR DME RTL MAXFEE 01/01/2024 71.75 0.0 Y Description: HOSPITAL BED VAR HT W/ MATTR Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,598 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0256 NU DME PUR MAXFEE 01/01/2023 12/31/2023 740.50 0.0 Y Description: HOSPITAL BED VAR HT W/O MATT Category: Durable Medical CMS Add: 01/01/1991 CMS Term: E0256 NU DME PUR MAXFEE 01/01/2024 693.90 0.0 Y Description: HOSPITAL BED VAR HT W/O MATT Category: Durable Medical CMS Add: 01/01/1991 CMS Term: E0256 RR DME RTL MAXFEE 01/01/2023 12/31/2023 74.05 0.0 Y Description: HOSPITAL BED VAR HT W/O MATT Category: Durable Medical CMS Add: 01/01/1991 CMS Term: E0256 RR DME RTL MAXFEE 01/01/2024 69.39 0.0 Y Description: HOSPITAL BED VAR HT W/O MATT Category: Durable Medical CMS Add: 01/01/1991 CMS Term: E0260 NU DME PUR MAXFEE 01/01/2023 12/31/2023 924.90 0.0 Y Description: HOSP BED SEMI-ELECTR W/ MATT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0260 NU DME PUR MAXFEE 01/01/2024 717.50 0.0 Y Description: HOSP BED SEMI-ELECTR W/ MATT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0260 RR DME RTL MAXFEE 01/01/2023 12/31/2023 92.49 0.0 Y Description: HOSP BED SEMI-ELECTR W/ MATT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0260 RR DME RTL MAXFEE 01/01/2024 71.75 0.0 Y Description: HOSP BED SEMI-ELECTR W/ MATT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0261 NU DME PUR MAXFEE 01/01/2023 12/31/2023 885.70 0.0 Y Description: HOSP BED SEMI-ELECTR W/O MAT Category: Durable Medical CMS Add: 01/01/1991 CMS Term: E0261 NU DME PUR MAXFEE 01/01/2024 717.50 0.0 Y Description: HOSP BED SEMI-ELECTR W/O MAT Category: Durable Medical CMS Add: 01/01/1991 CMS Term: E0261 RR DME RTL MAXFEE 01/01/2023 12/31/2023 88.57 0.0 Y Description: HOSP BED SEMI-ELECTR W/O MAT Category: Durable Medical CMS Add: 01/01/1991 CMS Term: E0261 RR DME RTL MAXFEE 01/01/2024 71.75 0.0 Y Description: HOSP BED SEMI-ELECTR W/O MAT Category: Durable Medical CMS Add: 01/01/1991 CMS Term: E0265 NU DME PUR MAXFEE 01/01/2023 12/31/2023 1823.90 0.0 Y Description: HOSP BED TOTAL ELECTR W/ MAT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0265 NU DME PUR MAXFEE 01/01/2024 1739.50 0.0 Y Description: HOSP BED TOTAL ELECTR W/ MAT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0265 RR DME RTL MAXFEE 01/01/2023 12/31/2023 182.39 0.0 Y Description: HOSP BED TOTAL ELECTR W/ MAT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0265 RR DME RTL MAXFEE 01/01/2024 173.95 0.0 Y Description: HOSP BED TOTAL ELECTR W/ MAT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,599 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0266 NU DME PUR MAXFEE 01/01/2024 1513.60 0.0 Y Description: HOSP BED TOTAL ELEC W/O MATT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0266 NU DME PUR MAXFEE 02/01/2021 12/31/2023 1403.90 0.0 Y Description: HOSP BED TOTAL ELEC W/O MATT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0266 RR DME RTL MAXFEE 01/01/2024 151.36 0.0 Y Description: HOSP BED TOTAL ELEC W/O MATT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0266 RR DME RTL MAXFEE 02/01/2021 12/31/2023 140.39 0.0 Y Description: HOSP BED TOTAL ELEC W/O MATT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0270 DME DEF SYSMAN Y Y Description: HOSPITAL BED INSTITUTIONAL T Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0271 NU DME PUR MAXFEE 01/01/2014 12/31/2023 175.86 0.0 Y Description: MATTRESS INNERSPRING Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0271 NU DME PUR MAXFEE 01/01/2024 155.58 0.0 Y Description: MATTRESS INNERSPRING Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0271 RR DME RTL MAXFEE 01/01/2014 12/31/2023 21.58 0.0 Y Description: MATTRESS INNERSPRING Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0271 RR DME RTL MAXFEE 01/01/2024 17.39 0.0 Y Description: MATTRESS INNERSPRING Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0272 NU DME PUR MAXFEE 01/01/2014 12/31/2023 160.90 0.0 Y Description: MATTRESS FOAM RUBBER Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0272 NU DME PUR MAXFEE 01/01/2024 161.85 0.0 Y Description: MATTRESS FOAM RUBBER Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0272 RR DME RTL MAXFEE 01/01/2014 12/31/2023 17.78 0.0 Y Description: MATTRESS FOAM RUBBER Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0272 RR DME RTL MAXFEE 01/01/2024 17.56 0.0 Y Description: MATTRESS FOAM RUBBER Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0273 DME DEF SYSMAN Y Y Description: BED BOARD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0274 NU DME PUR MAXFEE 01/01/2014 12/31/2023 154.30 0.0 Y Description: OVER-BED TABLE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0274 NU DME PUR MAXFEE 01/01/2024 200.59 0.0 Y Description: OVER-BED TABLE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,600 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0274 RR DME RTL MAXFEE 01/01/2014 12/31/2023 19.00 0.0 Y Description: OVER-BED TABLE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0274 RR DME RTL MAXFEE 01/01/2024 24.70 0.0 Y Description: OVER-BED TABLE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0275 DME DEF MAXFEE 01/01/2014 12/31/2023 14.19 0.0 Description: BED PAN STANDARD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0275 DME DEF MAXFEE 01/01/2024 16.23 0.0 Description: BED PAN STANDARD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0276 DME DEF MAXFEE 01/01/2014 12/31/2023 11.99 0.0 Description: BED PAN FRACTURE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0276 DME DEF MAXFEE 01/01/2024 14.48 0.0 Description: BED PAN FRACTURE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0277 NU DME PUR MAXFEE 01/01/2023 12/31/2023 3599.20 0.0 Y Description: POWERED PRES-REDU AIR MATTRS Category: Durable Medical CMS Add: 01/01/1992 CMS Term: E0277 NU DME PUR MAXFEE 01/01/2024 2174.50 0.0 Y Description: POWERED PRES-REDU AIR MATTRS Category: Durable Medical CMS Add: 01/01/1992 CMS Term: E0277 RR DME RTL MAXFEE 01/01/2023 12/31/2023 359.92 0.0 Y Description: POWERED PRES-REDU AIR MATTRS Category: Durable Medical CMS Add: 01/01/1992 CMS Term: E0277 RR DME RTL MAXFEE 01/01/2024 217.45 0.0 Y Description: POWERED PRES-REDU AIR MATTRS Category: Durable Medical CMS Add: 01/01/1992 CMS Term: E0280 NU DME PUR MAXFEE 01/01/2014 12/31/2023 34.79 0.0 Description: BED CRADLE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0280 NU DME PUR MAXFEE 01/01/2024 35.27 0.0 Description: BED CRADLE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0290 NU DME PUR MAXFEE 01/01/2023 12/31/2023 709.60 0.0 Y Description: HOSP BED FX HT W/O RAILS W/M Category: Durable Medical CMS Add: 01/01/1991 CMS Term: E0290 NU DME PUR MAXFEE 01/01/2024 680.40 0.0 Y Description: HOSP BED FX HT W/O RAILS W/M Category: Durable Medical CMS Add: 01/01/1991 CMS Term: E0290 RR DME RTL MAXFEE 01/01/2023 12/31/2023 70.96 0.0 Y Description: HOSP BED FX HT W/O RAILS W/M Category: Durable Medical CMS Add: 01/01/1991 CMS Term: E0290 RR DME RTL MAXFEE 01/01/2024 68.04 0.0 Y Description: HOSP BED FX HT W/O RAILS W/M Category: Durable Medical CMS Add: 01/01/1991 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,601 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0291 NU DME PUR MAXFEE 01/01/2023 12/31/2023 534.90 0.0 Y Description: HOSP BED FX HT W/O RAIL W/O Category: Durable Medical CMS Add: 01/01/1991 CMS Term: E0291 NU DME PUR MAXFEE 01/01/2024 520.90 0.0 Y Description: HOSP BED FX HT W/O RAIL W/O Category: Durable Medical CMS Add: 01/01/1991 CMS Term: E0291 RR DME RTL MAXFEE 01/01/2023 12/31/2023 53.49 0.0 Y Description: HOSP BED FX HT W/O RAIL W/O Category: Durable Medical CMS Add: 01/01/1991 CMS Term: E0291 RR DME RTL MAXFEE 01/01/2024 52.09 0.0 Y Description: HOSP BED FX HT W/O RAIL W/O Category: Durable Medical CMS Add: 01/01/1991 CMS Term: E0292 NU DME PUR MAXFEE 01/01/2023 12/31/2023 753.80 0.0 Y Description: HOSP BED VAR HT NO SR W/MATT Category: Durable Medical CMS Add: 01/01/1991 CMS Term: E0292 NU DME PUR MAXFEE 01/01/2024 704.50 0.0 Y Description: HOSP BED VAR HT NO SR W/MATT Category: Durable Medical CMS Add: 01/01/1991 CMS Term: E0292 RR DME RTL MAXFEE 01/01/2023 12/31/2023 75.38 0.0 Y Description: HOSP BED VAR HT NO SR W/MATT Category: Durable Medical CMS Add: 01/01/1991 CMS Term: E0292 RR DME RTL MAXFEE 01/01/2024 70.45 0.0 Y Description: HOSP BED VAR HT NO SR W/MATT Category: Durable Medical CMS Add: 01/01/1991 CMS Term: E0293 NU DME PUR MAXFEE 01/01/2023 12/31/2023 668.30 0.0 Y Description: HOSP BED VAR HT NO SR NO MAT Category: Durable Medical CMS Add: 01/01/1991 CMS Term: E0293 NU DME PUR MAXFEE 01/01/2024 664.60 0.0 Y Description: HOSP BED VAR HT NO SR NO MAT Category: Durable Medical CMS Add: 01/01/1991 CMS Term: E0293 RR DME RTL MAXFEE 01/01/2023 12/31/2023 66.83 0.0 Y Description: HOSP BED VAR HT NO SR NO MAT Category: Durable Medical CMS Add: 01/01/1991 CMS Term: E0293 RR DME RTL MAXFEE 01/01/2024 66.46 0.0 Y Description: HOSP BED VAR HT NO SR NO MAT Category: Durable Medical CMS Add: 01/01/1991 CMS Term: E0294 NU DME PUR MAXFEE 01/01/2023 12/31/2023 891.00 0.0 Y Description: HOSP BED SEMI-ELECT W/ MATTR Category: Durable Medical CMS Add: 01/01/1991 CMS Term: E0294 NU DME PUR MAXFEE 01/01/2024 717.50 0.0 Y Description: HOSP BED SEMI-ELECT W/ MATTR Category: Durable Medical CMS Add: 01/01/1991 CMS Term: E0294 RR DME RTL MAXFEE 01/01/2023 12/31/2023 89.10 0.0 Y Description: HOSP BED SEMI-ELECT W/ MATTR Category: Durable Medical CMS Add: 01/01/1991 CMS Term: E0294 RR DME RTL MAXFEE 01/01/2024 71.75 0.0 Y Description: HOSP BED SEMI-ELECT W/ MATTR Category: Durable Medical CMS Add: 01/01/1991 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,602 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0295 NU DME PUR MAXFEE 01/01/2023 12/31/2023 834.50 0.0 Y Description: HOSP BED SEMI-ELECT W/O MATT Category: Durable Medical CMS Add: 01/01/1991 CMS Term: E0295 NU DME PUR MAXFEE 01/01/2024 717.50 0.0 Y Description: HOSP BED SEMI-ELECT W/O MATT Category: Durable Medical CMS Add: 01/01/1991 CMS Term: E0295 RR DME RTL MAXFEE 01/01/2023 12/31/2023 83.45 0.0 Y Description: HOSP BED SEMI-ELECT W/O MATT Category: Durable Medical CMS Add: 01/01/1991 CMS Term: E0295 RR DME RTL MAXFEE 01/01/2024 71.75 0.0 Y Description: HOSP BED SEMI-ELECT W/O MATT Category: Durable Medical CMS Add: 01/01/1991 CMS Term: E0296 NU DME PUR MAXFEE 01/01/2014 12/31/2023 1787.71 0.0 Y Description: HOSP BED TOTAL ELECT W/ MATT Category: Durable Medical CMS Add: 01/01/1991 CMS Term: E0296 NU DME PUR MAXFEE 01/01/2024 1429.20 0.0 Y Description: HOSP BED TOTAL ELECT W/ MATT Category: Durable Medical CMS Add: 01/01/1991 CMS Term: E0296 RR DME RTL MAXFEE 01/01/2014 12/31/2023 112.96 0.0 Y Description: HOSP BED TOTAL ELECT W/ MATT Category: Durable Medical CMS Add: 01/01/1991 CMS Term: E0296 RR DME RTL MAXFEE 01/01/2024 142.92 0.0 Y Description: HOSP BED TOTAL ELECT W/ MATT Category: Durable Medical CMS Add: 01/01/1991 CMS Term: E0297 NU DME PUR MAXFEE 01/01/2023 12/31/2023 1256.50 0.0 Y Description: HOSP BED TOTAL ELECT W/O MAT Category: Durable Medical CMS Add: 01/01/1991 CMS Term: E0297 NU DME PUR MAXFEE 01/01/2024 1197.70 0.0 Y Description: HOSP BED TOTAL ELECT W/O MAT Category: Durable Medical CMS Add: 01/01/1991 CMS Term: E0297 RR DME RTL MAXFEE 01/01/2023 12/31/2023 125.65 0.0 Y Description: HOSP BED TOTAL ELECT W/O MAT Category: Durable Medical CMS Add: 01/01/1991 CMS Term: E0297 RR DME RTL MAXFEE 01/01/2024 119.77 0.0 Y Description: HOSP BED TOTAL ELECT W/O MAT Category: Durable Medical CMS Add: 01/01/1991 CMS Term: E0300 NU DME PUR MAXFEE 01/01/2023 12/31/2023 3015.50 0.0 Y Description: ENCLOSED PED CRIB HOSP GRADE Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0300 NU DME PUR MAXFEE 01/01/2024 3024.30 0.0 Y Description: ENCLOSED PED CRIB HOSP GRADE Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0300 RR DME RTL MAXFEE 01/01/2023 12/31/2023 301.55 0.0 Y Description: ENCLOSED PED CRIB HOSP GRADE Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0300 RR DME RTL MAXFEE 01/01/2024 302.43 0.0 Y Description: ENCLOSED PED CRIB HOSP GRADE Category: Durable Medical CMS Add: 01/01/2004 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,603 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0301 NU DME PUR MAXFEE 01/01/2023 12/31/2023 2162.20 0.0 Y Description: HD HOSP BED, 350-600 LBS Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0301 NU DME PUR MAXFEE 01/01/2024 1904.10 0.0 Y Description: HD HOSP BED, 350-600 LBS Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0301 RR DME RTL MAXFEE 01/01/2023 12/31/2023 216.22 0.0 Y Description: HD HOSP BED, 350-600 LBS Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0301 RR DME RTL MAXFEE 01/01/2024 190.41 0.0 Y Description: HD HOSP BED, 350-600 LBS Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0302 NU DME PUR MAXFEE 01/01/2023 12/31/2023 6019.10 0.0 Y Description: EX HD HOSP BED > 600 LBS Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0302 NU DME PUR MAXFEE 01/01/2024 5450.70 0.0 Y Description: EX HD HOSP BED > 600 LBS Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0302 RR DME RTL MAXFEE 01/01/2023 12/31/2023 601.91 0.0 Y Description: EX HD HOSP BED > 600 LBS Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0302 RR DME RTL MAXFEE 01/01/2024 545.07 0.0 Y Description: EX HD HOSP BED > 600 LBS Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0303 NU DME PUR MAXFEE 01/01/2023 12/31/2023 2282.30 0.0 Y Description: HOSP BED HVY DTY XTRA WIDE Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0303 NU DME PUR MAXFEE 01/01/2024 1938.00 0.0 Y Description: HOSP BED HVY DTY XTRA WIDE Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0303 RR DME RTL MAXFEE 01/01/2023 12/31/2023 228.23 0.0 Y Description: HOSP BED HVY DTY XTRA WIDE Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0303 RR DME RTL MAXFEE 01/01/2024 193.80 0.0 Y Description: HOSP BED HVY DTY XTRA WIDE Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0304 NU DME PUR MAXFEE 01/01/2023 12/31/2023 6397.60 0.0 Y Description: HOSP BED XTRA HVY DTY X WIDE Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0304 NU DME PUR MAXFEE 01/01/2024 5753.20 0.0 Y Description: HOSP BED XTRA HVY DTY X WIDE Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0304 RR DME RTL MAXFEE 01/01/2023 12/31/2023 639.76 0.0 Y Description: HOSP BED XTRA HVY DTY X WIDE Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0304 RR DME RTL MAXFEE 01/01/2024 575.32 0.0 Y Description: HOSP BED XTRA HVY DTY X WIDE Category: Durable Medical CMS Add: 01/01/2004 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,604 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0305 NU DME PUR MAXFEE 01/01/2014 12/31/2023 175.43 0.0 Y Description: RAILS BED SIDE HALF LENGTH Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0305 NU DME PUR MAXFEE 01/01/2024 119.80 0.0 Y Description: RAILS BED SIDE HALF LENGTH Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0305 RR DME RTL MAXFEE 01/01/2014 12/31/2023 14.30 0.0 Y Description: RAILS BED SIDE HALF LENGTH Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0305 RR DME RTL MAXFEE 01/01/2024 11.98 0.0 Y Description: RAILS BED SIDE HALF LENGTH Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0310 NU DME PUR MAXFEE 01/01/2014 12/31/2023 158.17 0.0 Y Description: RAILS BED SIDE FULL LENGTH Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0310 NU DME PUR MAXFEE 01/01/2024 121.89 0.0 Y Description: RAILS BED SIDE FULL LENGTH Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0310 RR DME RTL MAXFEE 01/01/2014 12/31/2023 19.42 0.0 Y Description: RAILS BED SIDE FULL LENGTH Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0310 RR DME RTL MAXFEE 01/01/2024 15.97 0.0 Y Description: RAILS BED SIDE FULL LENGTH Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0315 NU DME PUR MAXFEE 01/01/2014 12/31/2023 399.00 0.0 Y Description: BED ACCESSORY BRD/TBL/SUPPRT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0315 NU DME PUR MAXFEE 01/01/2024 518.70 0.0 Y Description: BED ACCESSORY BRD/TBL/SUPPRT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0316 NU DME PUR MAXFEE 01/01/2014 12/31/2023 4164.00 0.0 Y Description: BED SAFETY ENCLOSURE Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E0316 NU DME PUR MAXFEE 01/01/2024 2379.60 0.0 Y Description: BED SAFETY ENCLOSURE Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E0316 RR DME RTL MAXFEE 01/01/2014 12/31/2023 277.60 0.0 Y Description: BED SAFETY ENCLOSURE Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E0316 RR DME RTL MAXFEE 01/01/2024 237.96 0.0 Y Description: BED SAFETY ENCLOSURE Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E0325 DME DEF MAXFEE 01/01/2014 12/31/2023 9.32 0.0 Description: URINAL MALE JUG-TYPE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0325 DME DEF MAXFEE 01/01/2024 10.67 0.0 Description: URINAL MALE JUG-TYPE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,605 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0326 DME DEF MAXFEE 01/01/2014 12/31/2023 8.60 0.0 Description: URINAL FEMALE JUG-TYPE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0326 DME DEF MAXFEE 01/01/2024 10.85 0.0 Description: URINAL FEMALE JUG-TYPE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0328 NU DME PUR MAXFEE 09/01/2012 5407.41 0.0 Y Description: PED HOSPITAL BED, MANUAL Category: Durable Medical CMS Add: 01/01/2008 CMS Term: E0328 RR DME RTL MAXFEE 09/01/2012 540.74 0.0 Y Description: PED HOSPITAL BED, MANUAL Category: Durable Medical CMS Add: 01/01/2008 CMS Term: E0329 NU DME PUR MAXFEE 09/01/2012 5907.41 0.0 Y Description: PED HOSPITAL BED SEMI/ELECT Category: Durable Medical CMS Add: 01/01/2008 CMS Term: E0329 RR DME RTL MAXFEE 09/01/2012 590.74 0.0 Y Description: PED HOSPITAL BED SEMI/ELECT Category: Durable Medical CMS Add: 01/01/2008 CMS Term: E0350 DME DEF SYSMAN Y Description: CONTROL UNIT BOWEL SYSTEM Category: Durable Medical CMS Add: 01/01/1995 CMS Term: E0352 DME DEF SYSMAN Y Description: DISPOSABLE PACK W/BOWEL SYST Category: Durable Medical CMS Add: 01/01/1995 CMS Term: E0370 NU DME PUR MAXFEE 01/01/2014 12/31/2023 21.16 0.0 Description: AIR ELEVATOR FOR HEEL Category: Durable Medical CMS Add: 01/01/1997 CMS Term: E0370 NU DME PUR MAXFEE 01/01/2024 27.51 0.0 Description: AIR ELEVATOR FOR HEEL Category: Durable Medical CMS Add: 01/01/1997 CMS Term: E0370 RR DME RTL MAXFEE 01/01/2014 12/31/2023 2.13 0.0 Description: AIR ELEVATOR FOR HEEL Category: Durable Medical CMS Add: 01/01/1997 CMS Term: E0370 RR DME RTL MAXFEE 01/01/2024 2.77 0.0 Description: AIR ELEVATOR FOR HEEL Category: Durable Medical CMS Add: 01/01/1997 CMS Term: E0371 NU DME PUR MAXFEE 01/01/2023 12/31/2023 2857.00 0.0 Y Description: NONPOWER MATTRESS OVERLAY Category: Durable Medical CMS Add: 01/01/1998 CMS Term: E0371 NU DME PUR MAXFEE 01/01/2024 2174.50 0.0 Y Description: NONPOWER MATTRESS OVERLAY Category: Durable Medical CMS Add: 01/01/1998 CMS Term: E0371 RR DME RTL MAXFEE 01/01/2023 12/31/2023 285.70 0.0 Y Description: NONPOWER MATTRESS OVERLAY Category: Durable Medical CMS Add: 01/01/1998 CMS Term: E0371 RR DME RTL MAXFEE 01/01/2024 217.45 0.0 Y Description: NONPOWER MATTRESS OVERLAY Category: Durable Medical CMS Add: 01/01/1998 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,606 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0372 NU DME PUR MAXFEE 01/01/2023 12/31/2023 3128.80 0.0 Y Description: POWERED AIR MATTRESS OVERLAY Category: Durable Medical CMS Add: 01/01/1998 CMS Term: E0372 NU DME PUR MAXFEE 01/01/2024 2174.50 0.0 Y Description: POWERED AIR MATTRESS OVERLAY Category: Durable Medical CMS Add: 01/01/1998 CMS Term: E0372 RR DME RTL MAXFEE 01/01/2023 12/31/2023 312.88 0.0 Y Description: POWERED AIR MATTRESS OVERLAY Category: Durable Medical CMS Add: 01/01/1998 CMS Term: E0372 RR DME RTL MAXFEE 01/01/2024 217.45 0.0 Y Description: POWERED AIR MATTRESS OVERLAY Category: Durable Medical CMS Add: 01/01/1998 CMS Term: E0373 NU DME PUR MAXFEE 01/01/2023 12/31/2023 3344.20 0.0 Y Description: NONPOWERED PRESSURE MATTRESS Category: Durable Medical CMS Add: 01/01/1998 CMS Term: E0373 NU DME PUR MAXFEE 01/01/2024 2174.50 0.0 Y Description: NONPOWERED PRESSURE MATTRESS Category: Durable Medical CMS Add: 01/01/1998 CMS Term: E0373 RR DME RTL MAXFEE 01/01/2023 12/31/2023 334.42 0.0 Y Description: NONPOWERED PRESSURE MATTRESS Category: Durable Medical CMS Add: 01/01/1998 CMS Term: E0373 RR DME RTL MAXFEE 01/01/2024 217.45 0.0 Y Description: NONPOWERED PRESSURE MATTRESS Category: Durable Medical CMS Add: 01/01/1998 CMS Term: E0424 RR DME RTL MAXFEE 01/01/2023 12/31/2023 125.61 0.0 Y Description: STATIONARY COMPRESSED GAS 02 Category: Durable Medical CMS Add: 01/01/1993 CMS Term: E0424 RR DME RTL MAXFEE 01/01/2024 93.89 0.0 Y Description: STATIONARY COMPRESSED GAS 02 Category: Durable Medical CMS Add: 01/01/1993 CMS Term: E0424 RR QB DME RTL MAXFEE 01/01/2024 93.89 0.0 Y Description: STATIONARY COMPRESSED GAS 02 Category: Durable Medical CMS Add: 01/01/1993 CMS Term: E0424 RR QF DME RTL MAXFEE 01/01/2024 93.89 0.0 Y Description: STATIONARY COMPRESSED GAS 02 Category: Durable Medical CMS Add: 01/01/1993 CMS Term: E0425 NOCOV DEF SYSMAN Description: GAS SYSTEM STATIONARY COMPRE Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: E0430 NOCOV DEF SYSMAN Description: OXYGEN SYSTEM GAS PORTABLE Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: E0431 RR DME RTL MAXFEE 01/01/2023 12/31/2023 24.31 0.0 Y Description: PORTABLE GASEOUS 02 Category: Durable Medical CMS Add: 01/01/1993 CMS Term: E0431 RR DME RTL MAXFEE 01/01/2024 20.91 0.0 Y Description: PORTABLE GASEOUS 02 Category: Durable Medical CMS Add: 01/01/1993 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,607 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0431 RR QB DME RTL MAXFEE 01/01/2023 12/31/2023 62.81 0.0 Y Description: PORTABLE GASEOUS 02 Category: Durable Medical CMS Add: 01/01/1993 CMS Term: E0431 RR QB DME RTL MAXFEE 01/01/2024 46.95 0.0 Y Description: PORTABLE GASEOUS 02 Category: Durable Medical CMS Add: 01/01/1993 CMS Term: E0431 RR QF DME RTL MAXFEE 01/01/2023 12/31/2023 62.81 0.0 Y Description: PORTABLE GASEOUS 02 Category: Durable Medical CMS Add: 01/01/1993 CMS Term: E0431 RR QF DME RTL MAXFEE 01/01/2024 46.95 0.0 Y Description: PORTABLE GASEOUS 02 Category: Durable Medical CMS Add: 01/01/1993 CMS Term: E0433 RR DME RTL MAXFEE 01/01/2023 12/31/2023 44.76 0.0 Y Description: PORTABLE LIQUID OXYGEN SYS Category: Durable Medical CMS Add: 01/01/2010 CMS Term: E0433 RR DME RTL MAXFEE 01/01/2024 43.75 0.0 Y Description: PORTABLE LIQUID OXYGEN SYS Category: Durable Medical CMS Add: 01/01/2010 CMS Term: E0433 RR QB DME RTL MAXFEE 01/01/2023 12/31/2023 62.81 0.0 Y Description: PORTABLE LIQUID OXYGEN SYS Category: Durable Medical CMS Add: 01/01/2010 CMS Term: E0433 RR QB DME RTL MAXFEE 01/01/2024 46.95 0.0 Y Description: PORTABLE LIQUID OXYGEN SYS Category: Durable Medical CMS Add: 01/01/2010 CMS Term: E0433 RR QF DME RTL MAXFEE 01/01/2023 12/31/2023 62.81 0.0 Y Description: PORTABLE LIQUID OXYGEN SYS Category: Durable Medical CMS Add: 01/01/2010 CMS Term: E0433 RR QF DME RTL MAXFEE 01/01/2024 46.95 0.0 Y Description: PORTABLE LIQUID OXYGEN SYS Category: Durable Medical CMS Add: 01/01/2010 CMS Term: E0434 RR DME RTL MAXFEE 01/01/2023 12/31/2023 44.76 0.0 Y Description: PORTABLE LIQUID 02 Category: Durable Medical CMS Add: 01/01/1993 CMS Term: E0434 RR DME RTL MAXFEE 01/01/2024 43.75 0.0 Y Description: PORTABLE LIQUID 02 Category: Durable Medical CMS Add: 01/01/1993 CMS Term: E0434 RR QB DME RTL MAXFEE 01/01/2023 12/31/2023 62.81 0.0 Y Description: PORTABLE LIQUID 02 Category: Durable Medical CMS Add: 01/01/1993 CMS Term: E0434 RR QB DME RTL MAXFEE 01/01/2024 46.95 0.0 Y Description: PORTABLE LIQUID 02 Category: Durable Medical CMS Add: 01/01/1993 CMS Term: E0434 RR QF DME RTL MAXFEE 01/01/2023 12/31/2023 62.81 0.0 Y Description: PORTABLE LIQUID 02 Category: Durable Medical CMS Add: 01/01/1993 CMS Term: E0434 RR QF DME RTL MAXFEE 01/01/2024 46.95 0.0 Y Description: PORTABLE LIQUID 02 Category: Durable Medical CMS Add: 01/01/1993 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,608 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0435 NOCOV DEF SYSMAN Description: OXYGEN SYSTEM LIQUID PORTABL Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: E0439 RR DME RTL MAXFEE 01/01/2023 12/31/2023 125.61 0.0 Y Description: STATIONARY LIQUID 02 Category: Durable Medical CMS Add: 01/01/1993 CMS Term: E0439 RR DME RTL MAXFEE 01/01/2024 93.89 0.0 Y Description: STATIONARY LIQUID 02 Category: Durable Medical CMS Add: 01/01/1993 CMS Term: E0439 RR QB DME RTL MAXFEE 01/01/2024 93.89 0.0 Y Description: STATIONARY LIQUID 02 Category: Durable Medical CMS Add: 01/01/1993 CMS Term: E0439 RR QF DME RTL MAXFEE 01/01/2024 93.89 0.0 Y Description: STATIONARY LIQUID 02 Category: Durable Medical CMS Add: 01/01/1993 CMS Term: E0440 NOCOV DEF SYSMAN Description: OXYGEN SYSTEM LIQUID STATION Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: E0441 DME DEF MAXFEE 01/01/2023 12/31/2023 65.87 0.0 Y Description: STATIONARY O2 CONTENTS, GAS Category: Durable Medical CMS Add: 01/01/1993 CMS Term: E0441 DME DEF MAXFEE 01/01/2024 63.87 0.0 Y Description: STATIONARY O2 CONTENTS, GAS Category: Durable Medical CMS Add: 01/01/1993 CMS Term: E0442 DME DEF MAXFEE 01/01/2023 12/31/2023 65.87 0.0 Y Description: STATIONARY O2 CONTENTS, LIQ Category: Durable Medical CMS Add: 01/01/1993 CMS Term: E0442 DME DEF MAXFEE 01/01/2024 63.87 0.0 Y Description: STATIONARY O2 CONTENTS, LIQ Category: Durable Medical CMS Add: 01/01/1993 CMS Term: E0443 DME DEF MAXFEE 01/01/2023 12/31/2023 61.11 0.0 Y Description: PORTABLE 02 CONTENTS, GAS Category: Durable Medical CMS Add: 01/01/1993 CMS Term: E0443 DME DEF MAXFEE 01/01/2024 57.34 0.0 Y Description: PORTABLE 02 CONTENTS, GAS Category: Durable Medical CMS Add: 01/01/1993 CMS Term: E0444 DME DEF MAXFEE 01/01/2023 12/31/2023 61.11 0.0 Y Description: PORTABLE 02 CONTENTS, LIQUID Category: Durable Medical CMS Add: 01/01/1993 CMS Term: E0444 DME DEF MAXFEE 01/01/2024 57.34 0.0 Y Description: PORTABLE 02 CONTENTS, LIQUID Category: Durable Medical CMS Add: 01/01/1993 CMS Term: E0445 NU DME PUR MAXFEE 01/01/2014 12/31/2023 2399.99 0.0 Y Description: OXIMETER NON-INVASIVE Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E0445 NU DME PUR MAXFEE 01/01/2024 3119.99 0.0 Y Description: OXIMETER NON-INVASIVE Category: Durable Medical CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,609 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0445 RR DME RTL MAXFEE 01/01/2014 12/31/2023 160.00 0.0 Y Description: OXIMETER NON-INVASIVE Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E0445 RR DME RTL MAXFEE 01/01/2024 208.00 0.0 Y Description: OXIMETER NON-INVASIVE Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E0446 NOCOV DEF SYSMAN Description: TOPICAL OX DELIVER SYS, NOS Category: Non Covered Services CMS Add: 01/01/2011 CMS Term: E0447 DME DEF MAXFEE 01/01/2019 12/31/2023 66.54 0.0 Y Description: PORT O2 CONT, LIQ OVER 4 LPM Category: Durable Medical CMS Add: 01/01/2019 CMS Term: E0447 DME DEF MAXFEE 01/01/2024 84.18 0.0 Y Description: PORT O2 CONT, LIQ OVER 4 LPM Category: Durable Medical CMS Add: 01/01/2019 CMS Term: E0455 NU DME PUR MAXFEE 01/01/2014 12/31/2023 2128.00 0.0 Y Description: OXYGEN TENT EXCL CROUP/PED T Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0455 NU DME PUR MAXFEE 01/01/2024 2766.40 0.0 Y Description: OXYGEN TENT EXCL CROUP/PED T Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0455 RR DME RTL MAXFEE 01/01/2014 12/31/2023 215.00 0.0 Y Description: OXYGEN TENT EXCL CROUP/PED T Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0455 RR DME RTL MAXFEE 01/01/2024 279.50 0.0 Y Description: OXYGEN TENT EXCL CROUP/PED T Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0457 RR DME RTL MAXFEE 01/01/2014 12/31/2023 64.12 0.0 Y Description: CHEST SHELL Category: Durable Medical CMS Add: 01/01/1990 CMS Term: E0457 RR DME RTL MAXFEE 01/01/2024 83.36 0.0 Y Description: CHEST SHELL Category: Durable Medical CMS Add: 01/01/1990 CMS Term: E0459 RR DME RTL MAXFEE 01/01/2014 12/31/2023 43.04 0.0 Y Description: CHEST WRAP Category: Durable Medical CMS Add: 01/01/1990 CMS Term: E0459 RR DME RTL MAXFEE 01/01/2024 55.95 0.0 Y Description: CHEST WRAP Category: Durable Medical CMS Add: 01/01/1990 CMS Term: E0462 RR DME RTL MAXFEE 01/01/2014 12/31/2023 235.26 0.0 Y Description: ROCKING BED W/ OR W/O SIDE R Category: Durable Medical CMS Add: 01/01/1990 CMS Term: E0462 RR DME RTL MAXFEE 01/01/2024 366.30 0.0 Y Description: ROCKING BED W/ OR W/O SIDE R Category: Durable Medical CMS Add: 01/01/1990 CMS Term: E0465 DME DEF MAXFEE 01/01/2024 1107.04 0.0 Y Description: HOME VENT INVASIVE INTERFACE Category: Durable Medical CMS Add: 01/01/2016 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,610 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0465 RR DME RTL MAXFEE 01/01/2023 1078.99 0.0 Y Description: HOME VENT INVASIVE INTERFACE Category: Durable Medical CMS Add: 01/01/2016 CMS Term: E0466 DME DEF MAXFEE 01/01/2024 1107.04 0.0 Y Description: HOME VENT NON-INVASIVE INTER Category: Durable Medical CMS Add: 01/01/2016 CMS Term: E0466 RR DME RTL MAXFEE 01/01/2023 1078.99 0.0 Y Description: HOME VENT NON-INVASIVE INTER Category: Durable Medical CMS Add: 01/01/2016 CMS Term: E0467 DME DEF MAXFEE 01/01/2024 1310.05 0.0 Y Description: HOME VENT MULTI-FUNCTION Category: Durable Medical CMS Add: 01/01/2019 CMS Term: E0467 RR DME RTL MAXFEE 01/01/2023 1276.86 0.0 Y Description: HOME VENT MULTI-FUNCTION Category: Durable Medical CMS Add: 01/01/2019 CMS Term: E0470 NU DME PUR MAXFEE 01/01/2023 12/31/2023 1679.00 0.0 Description: RAD W/O BACKUP NON-INV INTFC Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0470 NU DME PUR MAXFEE 01/01/2024 1292.00 0.0 Description: RAD W/O BACKUP NON-INV INTFC Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0470 RR DME RTL MAXFEE 01/01/2023 12/31/2023 167.90 0.0 Description: RAD W/O BACKUP NON-INV INTFC Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0470 RR DME RTL MAXFEE 01/01/2024 129.20 0.0 Description: RAD W/O BACKUP NON-INV INTFC Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0471 NU DME PUR MAXFEE 01/01/2023 12/31/2023 3938.50 0.0 Description: RAD W/BACKUP NON INV INTRFC Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0471 NU DME PUR MAXFEE 01/01/2024 3252.20 0.0 Description: RAD W/BACKUP NON INV INTRFC Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0471 RR DME RTL MAXFEE 01/01/2023 12/31/2023 393.85 0.0 Description: RAD W/BACKUP NON INV INTRFC Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0471 RR DME RTL MAXFEE 01/01/2024 325.22 0.0 Description: RAD W/BACKUP NON INV INTRFC Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0472 NU DME PUR MAXFEE 01/01/2023 12/31/2023 5246.00 0.0 Description: RAD W BACKUP INVASIVE INTRFC Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0472 NU DME PUR MAXFEE 01/01/2024 5047.80 0.0 Description: RAD W BACKUP INVASIVE INTRFC Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0472 RR DME RTL MAXFEE 01/01/2023 12/31/2023 524.60 0.0 Description: RAD W BACKUP INVASIVE INTRFC Category: Durable Medical CMS Add: 01/01/2004 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,611 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0472 RR DME RTL MAXFEE 01/01/2024 504.78 0.0 Description: RAD W BACKUP INVASIVE INTRFC Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0480 NOCOV DEF SYSMAN Description: PERCUSSOR ELECT/PNEUM HOME M Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: E0481 DME DEF SYSMAN Y Y Description: INTRPULMNRY PERCUSS VENT SYS Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E0482 NU DME PUR MAXFEE 01/01/2023 12/31/2023 5718.90 0.0 Y Description: COUGH STIMULATING DEVICE Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E0482 NU DME PUR MAXFEE 01/01/2024 5867.60 0.0 Y Description: COUGH STIMULATING DEVICE Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E0482 RR DME RTL MAXFEE 01/01/2023 12/31/2023 571.89 0.0 Y Description: COUGH STIMULATING DEVICE Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E0482 RR DME RTL MAXFEE 01/01/2024 586.76 0.0 Y Description: COUGH STIMULATING DEVICE Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E0483 NU DME PUR MAXFEE 01/01/2023 12/31/2023 14138.40 0.0 Y Description: HI FREQ CHEST WALL OSCIL SYS Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E0483 NU DME PUR MAXFEE 01/01/2024 14506.00 0.0 Y Description: HI FREQ CHEST WALL OSCIL SYS Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E0483 RR DME RTL MAXFEE 01/01/2023 12/31/2023 1413.84 0.0 Y Description: HI FREQ CHEST WALL OSCIL SYS Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E0483 RR DME RTL MAXFEE 01/01/2024 1450.60 0.0 Y Description: HI FREQ CHEST WALL OSCIL SYS Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E0484 NU DME PUR MAXFEE 01/01/2014 12/31/2023 31.38 0.0 Y Description: NON-ELEC OSCILLATORY PEP DVC Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E0484 NU DME PUR MAXFEE 01/01/2024 49.12 0.0 Y Description: NON-ELEC OSCILLATORY PEP DVC Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E0484 RR DME RTL MAXFEE 01/01/2014 12/31/2023 3.14 0.0 Y Description: NON-ELEC OSCILLATORY PEP DVC Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E0484 RR DME RTL MAXFEE 01/01/2024 4.91 0.0 Y Description: NON-ELEC OSCILLATORY PEP DVC Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E0485 DME DEF SYSMAN Y Y Description: ORAL DEVICE/APPLIANCE PREFAB Category: Durable Medical CMS Add: 01/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,612 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0486 DME DEF SYSMAN Y Y Description: ORAL DEVICE/APPLIANCE CUSFAB Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E0487 NOCOV DEF SYSMAN Description: ELECTRONIC SPIROMETER Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: E0490 NOCOV DEF SYSMAN Description: CONTROL UNIT NM HW REMOTE Category: Non Covered Services CMS Add: 10/01/2023 CMS Term: E0491 NOCOV DEF SYSMAN Description: ORAL DV NM MOUTHPC HW REMOTE Category: Non Covered Services CMS Add: 10/01/2023 CMS Term: E0492 NOCOV DEF SYSMAN Description: CONTROL UNIT NM STIM W PHONE Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: E0493 NOCOV DEF SYSMAN Description: ORAL DV/APP NEUROMUS MOUTHPI Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: E0500 RR DME RTL MAXFEE 01/01/2023 12/31/2023 139.07 0.0 Description: IPPB ALL TYPES Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0500 RR DME RTL MAXFEE 01/01/2024 142.69 0.0 Description: IPPB ALL TYPES Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0530 NOCOV DEF SYSMAN Description: ELECTRONIC POSA TREATMENT Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: E0550 NU DME PUR MAXFEE 01/01/2014 12/31/2023 1022.24 0.0 Description: HUMIDIF EXTENS SUPPLE W IPPB Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0550 NU DME PUR MAXFEE 01/01/2024 666.80 0.0 Description: HUMIDIF EXTENS SUPPLE W IPPB Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0550 RR DME RTL MAXFEE 01/01/2014 12/31/2023 41.04 0.0 Description: HUMIDIF EXTENS SUPPLE W IPPB Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0550 RR DME RTL MAXFEE 01/01/2024 66.68 0.0 Description: HUMIDIF EXTENS SUPPLE W IPPB Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0555 NU DME PUR MAXFEE 01/01/2014 12/31/2023 100.00 0.0 Description: HUMIDIFIER FOR USE W/ REGULA Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0555 NU DME PUR MAXFEE 01/01/2024 130.00 0.0 Description: HUMIDIFIER FOR USE W/ REGULA Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0555 RR DME RTL MAXFEE 01/01/2014 12/31/2023 15.00 0.0 Description: HUMIDIFIER FOR USE W/ REGULA Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,613 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0555 RR DME RTL MAXFEE 01/01/2024 19.50 0.0 Description: HUMIDIFIER FOR USE W/ REGULA Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0560 NU DME PUR MAXFEE 01/01/2014 12/31/2023 168.14 0.0 Description: HUMIDIFIER SUPPLEMENTAL W/ I Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0560 NU DME PUR MAXFEE 01/01/2024 196.58 0.0 Description: HUMIDIFIER SUPPLEMENTAL W/ I Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0560 RR DME RTL MAXFEE 01/01/2014 12/31/2023 19.94 0.0 Description: HUMIDIFIER SUPPLEMENTAL W/ I Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0560 RR DME RTL MAXFEE 01/01/2024 23.03 0.0 Description: HUMIDIFIER SUPPLEMENTAL W/ I Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0561 NU DME PUR MAXFEE 01/01/2014 12/31/2023 107.00 0.0 Description: HUMIDIFIER NONHEATED W PAP Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0561 NU DME PUR MAXFEE 01/01/2024 91.60 0.0 Description: HUMIDIFIER NONHEATED W PAP Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0561 RR DME RTL MAXFEE 01/01/2014 12/31/2023 7.13 0.0 Description: HUMIDIFIER NONHEATED W PAP Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0561 RR DME RTL MAXFEE 01/01/2024 9.69 0.0 Description: HUMIDIFIER NONHEATED W PAP Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0562 NU DME PUR MAXFEE 01/01/2014 12/31/2023 301.22 0.0 Description: HUMIDIFIER HEATED USED W PAP Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0562 NU DME PUR MAXFEE 01/01/2024 155.56 0.0 Description: HUMIDIFIER HEATED USED W PAP Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0562 RR DME RTL MAXFEE 01/01/2014 12/31/2023 20.08 0.0 Description: HUMIDIFIER HEATED USED W PAP Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0562 RR DME RTL MAXFEE 01/01/2024 20.39 0.0 Description: HUMIDIFIER HEATED USED W PAP Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0565 NU DME PUR MAXFEE 01/01/2014 12/31/2023 900.00 0.0 Description: COMPRESSOR AIR POWER SOURCE Category: Durable Medical CMS Add: 01/01/1982 CMS Term: E0565 NU DME PUR MAXFEE 01/01/2024 489.50 0.0 Description: COMPRESSOR AIR POWER SOURCE Category: Durable Medical CMS Add: 01/01/1982 CMS Term: E0565 RR DME RTL MAXFEE 01/01/2014 12/31/2023 45.78 0.0 Description: COMPRESSOR AIR POWER SOURCE Category: Durable Medical CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,614 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0565 RR DME RTL MAXFEE 01/01/2024 48.95 0.0 Description: COMPRESSOR AIR POWER SOURCE Category: Durable Medical CMS Add: 01/01/1982 CMS Term: E0570 NU DME PUR MAXFEE 01/01/2023 12/31/2023 106.60 0.0 Description: NEBULIZER WITH COMPRESSION Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0570 NU DME PUR MAXFEE 01/01/2024 72.90 0.0 Description: NEBULIZER WITH COMPRESSION Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0570 RR DME RTL MAXFEE 01/01/2023 12/31/2023 10.66 0.0 Description: NEBULIZER WITH COMPRESSION Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0570 RR DME RTL MAXFEE 01/01/2024 7.29 0.0 Description: NEBULIZER WITH COMPRESSION Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0572 NU DME PUR MAXFEE 01/01/2023 12/31/2023 398.10 0.0 0-1 Description: AEROSOL COMPRESSOR ADJUST PR Category: Durable Medical CMS Add: 01/01/2001 CMS Term: E0572 NU DME PUR MAXFEE 01/01/2024 372.90 0.0 0-1 Description: AEROSOL COMPRESSOR ADJUST PR Category: Durable Medical CMS Add: 01/01/2001 CMS Term: E0572 RR DME RTL MAXFEE 01/01/2023 12/31/2023 39.81 0.0 0-1 Description: AEROSOL COMPRESSOR ADJUST PR Category: Durable Medical CMS Add: 01/01/2001 CMS Term: E0572 RR DME RTL MAXFEE 01/01/2024 37.29 0.0 0-1 Description: AEROSOL COMPRESSOR ADJUST PR Category: Durable Medical CMS Add: 01/01/2001 CMS Term: E0574 NU DME PUR MAXFEE 01/01/2023 12/31/2023 535.30 0.0 0-1 Description: ULTRASONIC GENERATOR W SVNEB Category: Durable Medical CMS Add: 01/01/2001 CMS Term: E0574 NU DME PUR MAXFEE 01/01/2024 549.20 0.0 0-1 Description: ULTRASONIC GENERATOR W SVNEB Category: Durable Medical CMS Add: 01/01/2001 CMS Term: E0574 RR DME RTL MAXFEE 01/01/2023 12/31/2023 53.53 0.0 0-1 Description: ULTRASONIC GENERATOR W SVNEB Category: Durable Medical CMS Add: 01/01/2001 CMS Term: E0574 RR DME RTL MAXFEE 01/01/2024 54.92 0.0 0-1 Description: ULTRASONIC GENERATOR W SVNEB Category: Durable Medical CMS Add: 01/01/2001 CMS Term: E0575 NU DME PUR MAXFEE 01/01/2023 1366.90 0.0 Description: NEBULIZER ULTRASONIC Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0575 RR DME RTL MAXFEE 01/01/2023 136.69 0.0 Description: NEBULIZER ULTRASONIC Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0580 NU DME PUR MAXFEE 01/01/2014 147.26 0.0 Description: NEBULIZER FOR USE W/ REGULAT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,615 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0580 RR DME RTL MAXFEE 01/01/2014 34.00 0.0 Description: NEBULIZER FOR USE W/ REGULAT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0585 NU DME PUR MAXFEE 01/01/2023 12/31/2023 381.60 0.0 Description: NEBULIZER W/ COMPRESSOR & HE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0585 NU DME PUR MAXFEE 01/01/2024 363.90 0.0 Description: NEBULIZER W/ COMPRESSOR & HE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0585 RR DME RTL MAXFEE 01/01/2023 12/31/2023 38.16 0.0 Description: NEBULIZER W/ COMPRESSOR & HE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0585 RR DME RTL MAXFEE 01/01/2024 36.39 0.0 Description: NEBULIZER W/ COMPRESSOR & HE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0600 NU DME PUR MAXFEE 01/01/2023 12/31/2023 517.60 0.0 Description: SUCTION PUMP PORTAB HOM MODL Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0600 NU DME PUR MAXFEE 01/01/2024 531.00 0.0 Description: SUCTION PUMP PORTAB HOM MODL Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0600 RR DME RTL MAXFEE 01/01/2023 12/31/2023 51.76 0.0 Description: SUCTION PUMP PORTAB HOM MODL Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0600 RR DME RTL MAXFEE 01/01/2024 53.10 0.0 Description: SUCTION PUMP PORTAB HOM MODL Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0601 NU DME PUR MAXFEE 01/01/2023 12/31/2023 683.80 0.0 Description: CONT AIRWAY PRESSURE DEVICE Category: Durable Medical CMS Add: 01/01/1988 CMS Term: E0601 NU DME PUR MAXFEE 01/01/2024 497.70 0.0 Description: CONT AIRWAY PRESSURE DEVICE Category: Durable Medical CMS Add: 01/01/1988 CMS Term: E0601 RR DME RTL MAXFEE 01/01/2023 12/31/2023 68.38 0.0 Description: CONT AIRWAY PRESSURE DEVICE Category: Durable Medical CMS Add: 01/01/1988 CMS Term: E0601 RR DME RTL MAXFEE 01/01/2024 49.77 0.0 Description: CONT AIRWAY PRESSURE DEVICE Category: Durable Medical CMS Add: 01/01/1988 CMS Term: E0602 NU DME PUR MAXFEE 01/01/2014 12/31/2023 24.97 0.0 Description: MANUAL BREAST PUMP Category: Durable Medical CMS Add: 01/01/2000 CMS Term: E0602 NU DME PUR MAXFEE 01/01/2024 39.25 0.0 Description: MANUAL BREAST PUMP Category: Durable Medical CMS Add: 01/01/2000 CMS Term: E0602 RR DME RTL MAXFEE 01/01/2014 12/31/2023 2.51 0.0 Description: MANUAL BREAST PUMP Category: Durable Medical CMS Add: 01/01/2000 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,616 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0602 RR DME RTL MAXFEE 01/01/2024 3.96 0.0 Description: MANUAL BREAST PUMP Category: Durable Medical CMS Add: 01/01/2000 CMS Term: E0603 NU DME PUR MAXFEE 01/01/2014 12/31/2023 329.00 0.0 Description: ELECTRIC BREAST PUMP Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E0603 NU DME PUR MAXFEE 01/01/2024 427.70 0.0 Description: ELECTRIC BREAST PUMP Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E0603 RR DME RTL MAXFEE 01/01/2014 12/31/2023 21.93 0.0 Description: ELECTRIC BREAST PUMP Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E0603 RR DME RTL MAXFEE 01/01/2024 28.51 0.0 Description: ELECTRIC BREAST PUMP Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E0604 NOCOV DEF SYSMAN Description: HOSP GRADE ELEC BREAST PUMP Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: E0605 NU DME PUR MAXFEE 01/01/2014 12/31/2023 27.06 0.0 Description: VAPORIZER ROOM TYPE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0605 NU DME PUR MAXFEE 01/01/2024 35.13 0.0 Description: VAPORIZER ROOM TYPE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0605 RR DME RTL MAXFEE 01/01/2014 12/31/2023 5.42 0.0 Description: VAPORIZER ROOM TYPE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0605 RR DME RTL MAXFEE 01/01/2024 4.09 0.0 Description: VAPORIZER ROOM TYPE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0606 NU DME PUR MAXFEE 01/01/2014 12/31/2023 180.75 0.0 Y Description: DRAINAGE BOARD POSTURAL Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0606 NU DME PUR MAXFEE 01/01/2024 305.20 0.0 Y Description: DRAINAGE BOARD POSTURAL Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0606 RR DME RTL MAXFEE 01/01/2014 12/31/2023 16.80 0.0 Y Description: DRAINAGE BOARD POSTURAL Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0606 RR DME RTL MAXFEE 01/01/2024 30.52 0.0 Y Description: DRAINAGE BOARD POSTURAL Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0607 DME DEF MAXFEE 01/01/2023 88.86 0.0 Description: BLOOD GLUCOSE MONITOR HOME Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0607 NU DME PUR MAXFEE 01/01/2024 91.17 0.0 Description: BLOOD GLUCOSE MONITOR HOME Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,617 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0607 RR DME RTL MAXFEE 01/01/2023 12/31/2023 8.88 0.0 Description: BLOOD GLUCOSE MONITOR HOME Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0607 RR DME RTL MAXFEE 01/01/2024 9.11 0.0 Description: BLOOD GLUCOSE MONITOR HOME Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0607 RR U1 DME RTL MAXFEE 01/01/2023 8.88 0.0 Description: BLOOD GLUCOSE MONITOR HOME Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0607 U1 DME DEF MAXFEE 01/01/2023 88.86 0.0 Description: BLOOD GLUCOSE MONITOR HOME Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0610 NU DME PUR MAXFEE 01/01/2014 12/31/2023 318.77 0.0 Description: PACEMAKER MONITR AUDIBLE/VIS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0610 NU DME PUR MAXFEE 01/01/2024 316.31 0.0 Description: PACEMAKER MONITR AUDIBLE/VIS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0610 RR DME RTL MAXFEE 01/01/2014 12/31/2023 32.04 0.0 Description: PACEMAKER MONITR AUDIBLE/VIS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0610 RR DME RTL MAXFEE 01/01/2024 33.36 0.0 Description: PACEMAKER MONITR AUDIBLE/VIS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0615 NU DME PUR MAXFEE 01/01/2014 12/31/2023 384.52 0.0 Description: PACEMAKER MONITR DIGITAL/VIS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0615 NU DME PUR MAXFEE 01/01/2024 599.32 0.0 Description: PACEMAKER MONITR DIGITAL/VIS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0615 RR DME RTL MAXFEE 01/01/2014 12/31/2023 48.45 0.0 Description: PACEMAKER MONITR DIGITAL/VIS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0615 RR DME RTL MAXFEE 01/01/2024 77.80 0.0 Description: PACEMAKER MONITR DIGITAL/VIS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0616 NU DME PUR MAXFEE 01/01/2014 12/31/2023 3100.00 0.0 0-1 Description: CARDIAC EVENT RECORDER Category: Durable Medical CMS Add: 01/01/2000 CMS Term: E0616 NU DME PUR MAXFEE 01/01/2024 4030.00 0.0 0-1 Description: CARDIAC EVENT RECORDER Category: Durable Medical CMS Add: 01/01/2000 CMS Term: E0617 NU DME PUR MAXFEE 01/01/2014 12/31/2023 4656.60 0.0 Y Description: AUTOMATIC EXT DEFIBRILLATOR Category: Durable Medical CMS Add: 01/01/2001 CMS Term: E0617 NU DME PUR MAXFEE 01/01/2024 4148.40 0.0 Y Description: AUTOMATIC EXT DEFIBRILLATOR Category: Durable Medical CMS Add: 01/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,618 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0617 NU KF DME PUR MAXFEE 01/01/2024 4606.00 0.0 Y Description: AUTOMATIC EXT DEFIBRILLATOR Category: Durable Medical CMS Add: 01/01/2001 CMS Term: E0617 RR DME RTL MAXFEE 01/01/2014 12/31/2023 310.44 0.0 Y Description: AUTOMATIC EXT DEFIBRILLATOR Category: Durable Medical CMS Add: 01/01/2001 CMS Term: E0617 RR DME RTL MAXFEE 01/01/2024 414.84 0.0 Y Description: AUTOMATIC EXT DEFIBRILLATOR Category: Durable Medical CMS Add: 01/01/2001 CMS Term: E0617 RR KF DME RTL MAXFEE 01/01/2024 460.60 0.0 Y Description: AUTOMATIC EXT DEFIBRILLATOR Category: Durable Medical CMS Add: 01/01/2001 CMS Term: E0618 NU DME PUR MAXFEE 01/01/2014 12/31/2023 2626.50 0.0 Description: APNEA MONITOR Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E0618 NU DME PUR MAXFEE 01/01/2024 3492.70 0.0 Description: APNEA MONITOR Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E0618 RR DME RTL MAXFEE 01/01/2014 12/31/2023 175.10 0.0 Description: APNEA MONITOR Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E0618 RR DME RTL MAXFEE 01/01/2024 349.27 0.0 Description: APNEA MONITOR Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E0619 NU DME PUR MAXFEE 01/01/2014 12/31/2023 2833.65 0.0 Description: APNEA MONITOR W RECORDER Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E0619 NU DME PUR MAXFEE 01/01/2024 3683.75 0.0 Description: APNEA MONITOR W RECORDER Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E0619 RR DME RTL MAXFEE 01/01/2014 12/31/2023 188.91 0.0 Description: APNEA MONITOR W RECORDER Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E0619 RR DME RTL MAXFEE 01/01/2024 245.58 0.0 Description: APNEA MONITOR W RECORDER Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E0620 NU DME PUR MAXFEE 01/01/2023 1162.70 0.0 Description: CAP BLD SKIN PIERCING LASER Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E0620 RR DME RTL MAXFEE 01/01/2023 116.27 0.0 Description: CAP BLD SKIN PIERCING LASER Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E0621 DME DEF MAXFEE 01/01/2014 12/31/2023 75.76 0.0 Description: PATIENT LIFT SLING OR SEAT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0621 DME DEF MAXFEE 01/01/2024 92.29 0.0 Description: PATIENT LIFT SLING OR SEAT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,619 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0625 DME DEF SYSMAN Y Y Description: PATIENT LIFT BATHROOM OR TOI Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0627 NU DME PUR MAXFEE 01/01/2023 12/31/2023 338.71 0.0 Y Description: SEAT LIFT MECH, ELECTRIC ANY Category: Durable Medical CMS Add: 01/01/1992 CMS Term: E0627 NU DME PUR MAXFEE 01/01/2024 319.76 0.0 Y Description: SEAT LIFT MECH, ELECTRIC ANY Category: Durable Medical CMS Add: 01/01/1992 CMS Term: E0627 RR DME RTL MAXFEE 01/01/2023 12/31/2023 33.87 0.0 Y Description: SEAT LIFT MECH, ELECTRIC ANY Category: Durable Medical CMS Add: 01/01/1992 CMS Term: E0627 RR DME RTL MAXFEE 01/01/2024 31.98 0.0 Y Description: SEAT LIFT MECH, ELECTRIC ANY Category: Durable Medical CMS Add: 01/01/1992 CMS Term: E0629 NU DME PUR MAXFEE 01/01/2023 12/31/2023 335.97 0.0 Y Description: SEAT LIFT MECH, NON-ELECTRIC Category: Durable Medical CMS Add: 01/01/1992 CMS Term: E0629 NU DME PUR MAXFEE 01/01/2024 315.99 0.0 Y Description: SEAT LIFT MECH, NON-ELECTRIC Category: Durable Medical CMS Add: 01/01/1992 CMS Term: E0629 RR DME RTL MAXFEE 01/01/2023 12/31/2023 33.59 0.0 Y Description: SEAT LIFT MECH, NON-ELECTRIC Category: Durable Medical CMS Add: 01/01/1992 CMS Term: E0629 RR DME RTL MAXFEE 01/01/2024 31.60 0.0 Y Description: SEAT LIFT MECH, NON-ELECTRIC Category: Durable Medical CMS Add: 01/01/1992 CMS Term: E0630 NU DME PUR MAXFEE 01/01/2023 12/31/2023 847.00 0.0 Y Description: PATIENT LIFT HYDRAULIC Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0630 NU DME PUR MAXFEE 01/01/2024 701.30 0.0 Y Description: PATIENT LIFT HYDRAULIC Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0630 RR DME RTL MAXFEE 01/01/2023 12/31/2023 84.70 0.0 Y Description: PATIENT LIFT HYDRAULIC Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0630 RR DME RTL MAXFEE 01/01/2024 70.13 0.0 Y Description: PATIENT LIFT HYDRAULIC Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0635 NU DME PUR MAXFEE 01/01/2023 12/31/2023 1400.70 0.0 Y Description: PATIENT LIFT ELECTRIC Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0635 NU DME PUR MAXFEE 01/01/2024 1364.90 0.0 Y Description: PATIENT LIFT ELECTRIC Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0635 RR DME RTL MAXFEE 01/01/2023 12/31/2023 140.07 0.0 Y Description: PATIENT LIFT ELECTRIC Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,620 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0635 RR DME RTL MAXFEE 01/01/2024 136.49 0.0 Y Description: PATIENT LIFT ELECTRIC Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0636 NU DME PUR MAXFEE 01/01/2023 12/31/2023 12089.80 0.0 Y Description: PT SUPPORT & POSITIONING SYS Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E0636 NU DME PUR MAXFEE 01/01/2024 11788.30 0.0 Y Description: PT SUPPORT & POSITIONING SYS Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E0636 RR DME RTL MAXFEE 01/01/2023 12/31/2023 1208.98 0.0 Y Description: PT SUPPORT & POSITIONING SYS Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E0636 RR DME RTL MAXFEE 01/01/2024 1178.83 0.0 Y Description: PT SUPPORT & POSITIONING SYS Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E0637 NU DME PUR MAXFEE 01/01/2014 12/31/2023 2104.97 0.0 Y Description: COMBINATION SIT TO STAND SYS Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0637 NU DME PUR MAXFEE 01/01/2024 2736.46 0.0 Y Description: COMBINATION SIT TO STAND SYS Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0637 RR DME RTL MAXFEE 01/01/2014 12/31/2023 210.51 0.0 Y Description: COMBINATION SIT TO STAND SYS Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0637 RR DME RTL MAXFEE 01/01/2024 273.66 0.0 Y Description: COMBINATION SIT TO STAND SYS Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0638 NU DME PUR MAXFEE 01/01/2014 12/31/2023 853.57 0.0 Y Description: STANDING FRAME SYS Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0638 NU DME PUR MAXFEE 01/01/2024 1109.64 0.0 Y Description: STANDING FRAME SYS Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0638 RR DME RTL MAXFEE 01/01/2014 12/31/2023 85.36 0.0 Y Description: STANDING FRAME SYS Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0638 RR DME RTL MAXFEE 01/01/2024 110.97 0.0 Y Description: STANDING FRAME SYS Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0639 NU DME PUR MAXFEE 01/01/2023 12/31/2023 1483.50 0.0 Y Description: MOVEABLE PATIENT LIFT SYSTEM Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E0639 NU DME PUR MAXFEE 01/01/2024 1522.10 0.0 Y Description: MOVEABLE PATIENT LIFT SYSTEM Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E0639 RR DME RTL MAXFEE 01/01/2023 12/31/2023 148.35 0.0 Y Description: MOVEABLE PATIENT LIFT SYSTEM Category: Durable Medical CMS Add: 01/01/2005 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,621 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0639 RR DME RTL MAXFEE 01/01/2024 152.21 0.0 Y Description: MOVEABLE PATIENT LIFT SYSTEM Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E0640 NU DME PUR MAXFEE 01/01/2023 12/31/2023 1483.50 0.0 Y Description: FIXED PATIENT LIFT SYSTEM Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E0640 NU DME PUR MAXFEE 01/01/2024 1522.10 0.0 Y Description: FIXED PATIENT LIFT SYSTEM Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E0640 RR DME RTL MAXFEE 01/01/2023 12/31/2023 148.35 0.0 Y Description: FIXED PATIENT LIFT SYSTEM Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E0640 RR DME RTL MAXFEE 01/01/2024 152.21 0.0 Y Description: FIXED PATIENT LIFT SYSTEM Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E0641 NU DME PUR MAXFEE 01/01/2014 12/31/2023 2102.00 0.0 Y Description: MULTI-POSITION STND FRAM SYS Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E0641 NU DME PUR MAXFEE 01/01/2024 2732.60 0.0 Y Description: MULTI-POSITION STND FRAM SYS Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E0641 RR DME RTL MAXFEE 01/01/2014 12/31/2023 140.00 0.0 Y Description: MULTI-POSITION STND FRAM SYS Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E0641 RR DME RTL MAXFEE 01/01/2024 182.00 0.0 Y Description: MULTI-POSITION STND FRAM SYS Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E0642 NOCOV DEF SYSMAN Description: DYNAMIC STANDING FRAME Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: E0650 NU DME PUR MAXFEE 01/01/2023 12/31/2023 957.78 0.0 Description: PNEUMA COMPRESOR NON-SEGMENT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0650 NU DME PUR MAXFEE 01/01/2024 982.68 0.0 Description: PNEUMA COMPRESOR NON-SEGMENT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0650 RR DME RTL MAXFEE 01/01/2023 12/31/2023 118.20 0.0 Description: PNEUMA COMPRESOR NON-SEGMENT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0650 RR DME RTL MAXFEE 01/01/2024 121.27 0.0 Description: PNEUMA COMPRESOR NON-SEGMENT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0651 NU DME PUR MAXFEE 01/01/2023 12/31/2023 1070.15 0.0 Description: PNEUM COMPRESSOR SEGMENTAL Category: Durable Medical CMS Add: 01/01/1988 CMS Term: E0651 NU DME PUR MAXFEE 01/01/2024 1097.97 0.0 Description: PNEUM COMPRESSOR SEGMENTAL Category: Durable Medical CMS Add: 01/01/1988 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,622 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0651 RR DME RTL MAXFEE 01/01/2023 12/31/2023 124.78 0.0 Description: PNEUM COMPRESSOR SEGMENTAL Category: Durable Medical CMS Add: 01/01/1988 CMS Term: E0651 RR DME RTL MAXFEE 01/01/2024 128.02 0.0 Description: PNEUM COMPRESSOR SEGMENTAL Category: Durable Medical CMS Add: 01/01/1988 CMS Term: E0652 NU DME PUR MAXFEE 01/01/2023 12/31/2023 7037.51 0.0 Description: PNEUM COMPRES W/CAL PRESSURE Category: Durable Medical CMS Add: 01/01/1988 CMS Term: E0652 NU DME PUR MAXFEE 01/01/2024 7220.49 0.0 Description: PNEUM COMPRES W/CAL PRESSURE Category: Durable Medical CMS Add: 01/01/1988 CMS Term: E0652 RR DME RTL MAXFEE 01/01/2023 12/31/2023 696.77 0.0 Description: PNEUM COMPRES W/CAL PRESSURE Category: Durable Medical CMS Add: 01/01/1988 CMS Term: E0652 RR DME RTL MAXFEE 01/01/2024 714.89 0.0 Description: PNEUM COMPRES W/CAL PRESSURE Category: Durable Medical CMS Add: 01/01/1988 CMS Term: E0655 NU DME PUR MAXFEE 01/01/2014 12/31/2023 85.69 0.0 Description: PNEUMATIC APPLIANCE HALF ARM Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0655 NU DME PUR MAXFEE 01/01/2024 133.55 0.0 Description: PNEUMATIC APPLIANCE HALF ARM Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0655 RR DME RTL MAXFEE 01/01/2014 12/31/2023 11.66 0.0 Description: PNEUMATIC APPLIANCE HALF ARM Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0655 RR DME RTL MAXFEE 01/01/2024 14.34 0.0 Description: PNEUMATIC APPLIANCE HALF ARM Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0656 NU DME PUR MAXFEE 01/01/2014 12/31/2023 606.60 0.0 Description: SEGMENTAL PNEUMATIC TRUNK Category: Durable Medical CMS Add: 01/01/2009 CMS Term: E0656 NU DME PUR MAXFEE 01/01/2024 768.50 0.0 Description: SEGMENTAL PNEUMATIC TRUNK Category: Durable Medical CMS Add: 01/01/2009 CMS Term: E0656 RR DME RTL MAXFEE 01/01/2014 12/31/2023 60.59 0.0 Description: SEGMENTAL PNEUMATIC TRUNK Category: Durable Medical CMS Add: 01/01/2009 CMS Term: E0656 RR DME RTL MAXFEE 01/01/2024 76.85 0.0 Description: SEGMENTAL PNEUMATIC TRUNK Category: Durable Medical CMS Add: 01/01/2009 CMS Term: E0657 NU DME PUR MAXFEE 01/01/2014 12/31/2023 569.88 0.0 Description: SEGMENTAL PNEUMATIC CHEST Category: Durable Medical CMS Add: 01/01/2009 CMS Term: E0657 NU DME PUR MAXFEE 01/01/2024 721.90 0.0 Description: SEGMENTAL PNEUMATIC CHEST Category: Durable Medical CMS Add: 01/01/2009 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,623 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0657 RR DME RTL MAXFEE 01/01/2014 12/31/2023 56.89 0.0 Description: SEGMENTAL PNEUMATIC CHEST Category: Durable Medical CMS Add: 01/01/2009 CMS Term: E0657 RR DME RTL MAXFEE 01/01/2024 72.19 0.0 Description: SEGMENTAL PNEUMATIC CHEST Category: Durable Medical CMS Add: 01/01/2009 CMS Term: E0660 NU DME PUR MAXFEE 01/01/2014 12/31/2023 134.18 0.0 Description: PNEUMATIC APPLIANCE FULL LEG Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0660 NU DME PUR MAXFEE 01/01/2024 209.14 0.0 Description: PNEUMATIC APPLIANCE FULL LEG Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0660 RR DME RTL MAXFEE 01/01/2014 12/31/2023 14.69 0.0 Description: PNEUMATIC APPLIANCE FULL LEG Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0660 RR DME RTL MAXFEE 01/01/2024 20.90 0.0 Description: PNEUMATIC APPLIANCE FULL LEG Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0665 NU DME PUR MAXFEE 01/01/2014 12/31/2023 113.57 0.0 Description: PNEUMATIC APPLIANCE FULL ARM Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0665 NU DME PUR MAXFEE 01/01/2024 182.19 0.0 Description: PNEUMATIC APPLIANCE FULL ARM Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0665 RR DME RTL MAXFEE 01/01/2014 12/31/2023 15.60 0.0 Description: PNEUMATIC APPLIANCE FULL ARM Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0665 RR DME RTL MAXFEE 01/01/2024 18.37 0.0 Description: PNEUMATIC APPLIANCE FULL ARM Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0666 NU DME PUR MAXFEE 01/01/2014 12/31/2023 115.00 0.0 Description: PNEUMATIC APPLIANCE HALF LEG Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0666 NU DME PUR MAXFEE 01/01/2024 183.65 0.0 Description: PNEUMATIC APPLIANCE HALF LEG Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0666 RR DME RTL MAXFEE 01/01/2014 12/31/2023 14.02 0.0 Description: PNEUMATIC APPLIANCE HALF LEG Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0666 RR DME RTL MAXFEE 01/01/2024 18.37 0.0 Description: PNEUMATIC APPLIANCE HALF LEG Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0667 NU DME PUR MAXFEE 01/01/2014 12/31/2023 319.97 0.0 Description: SEG PNEUMATIC APPL FULL LEG Category: Durable Medical CMS Add: 01/01/1988 CMS Term: E0667 NU DME PUR MAXFEE 01/01/2024 365.98 0.0 Description: SEG PNEUMATIC APPL FULL LEG Category: Durable Medical CMS Add: 01/01/1988 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,624 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0667 RR DME RTL MAXFEE 01/01/2014 12/31/2023 34.74 0.0 Description: SEG PNEUMATIC APPL FULL LEG Category: Durable Medical CMS Add: 01/01/1988 CMS Term: E0667 RR DME RTL MAXFEE 01/01/2024 41.33 0.0 Description: SEG PNEUMATIC APPL FULL LEG Category: Durable Medical CMS Add: 01/01/1988 CMS Term: E0668 NU DME PUR MAXFEE 01/01/2014 12/31/2023 309.75 0.0 Description: SEG PNEUMATIC APPL FULL ARM Category: Durable Medical CMS Add: 01/01/1988 CMS Term: E0668 NU DME PUR MAXFEE 01/01/2024 499.49 0.0 Description: SEG PNEUMATIC APPL FULL ARM Category: Durable Medical CMS Add: 01/01/1988 CMS Term: E0668 RR DME RTL MAXFEE 01/01/2014 12/31/2023 31.08 0.0 Description: SEG PNEUMATIC APPL FULL ARM Category: Durable Medical CMS Add: 01/01/1988 CMS Term: E0668 RR DME RTL MAXFEE 01/01/2024 49.29 0.0 Description: SEG PNEUMATIC APPL FULL ARM Category: Durable Medical CMS Add: 01/01/1988 CMS Term: E0669 NU DME PUR MAXFEE 01/01/2014 12/31/2023 155.05 0.0 Description: SEG PNEUMATIC APPLI HALF LEG Category: Durable Medical CMS Add: 01/01/1994 CMS Term: E0669 NU DME PUR MAXFEE 01/01/2024 243.05 0.0 Description: SEG PNEUMATIC APPLI HALF LEG Category: Durable Medical CMS Add: 01/01/1994 CMS Term: E0669 RR DME RTL MAXFEE 01/01/2014 12/31/2023 15.51 0.0 Description: SEG PNEUMATIC APPLI HALF LEG Category: Durable Medical CMS Add: 01/01/1994 CMS Term: E0669 RR DME RTL MAXFEE 01/01/2024 24.28 0.0 Description: SEG PNEUMATIC APPLI HALF LEG Category: Durable Medical CMS Add: 01/01/1994 CMS Term: E0670 NU DME PUR MAXFEE 01/01/2013 12/31/2023 1156.88 0.0 Description: SEG PNEUM INT LEGS/TRUNK Category: Durable Medical CMS Add: 01/01/2013 CMS Term: E0670 NU DME PUR MAXFEE 01/01/2024 1420.96 0.0 Description: SEG PNEUM INT LEGS/TRUNK Category: Durable Medical CMS Add: 01/01/2013 CMS Term: E0670 RR DME RTL MAXFEE 01/01/2013 12/31/2023 123.85 0.0 Description: SEG PNEUM INT LEGS/TRUNK Category: Durable Medical CMS Add: 01/01/2013 CMS Term: E0670 RR DME RTL MAXFEE 01/01/2024 152.11 0.0 Description: SEG PNEUM INT LEGS/TRUNK Category: Durable Medical CMS Add: 01/01/2013 CMS Term: E0671 NU DME PUR MAXFEE 01/01/2014 12/31/2023 396.17 0.0 Description: PRESSURE PNEUM APPL FULL LEG Category: Durable Medical CMS Add: 01/01/1995 CMS Term: E0671 NU DME PUR MAXFEE 01/01/2024 552.37 0.0 Description: PRESSURE PNEUM APPL FULL LEG Category: Durable Medical CMS Add: 01/01/1995 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,625 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0671 RR DME RTL MAXFEE 01/01/2014 12/31/2023 39.62 0.0 Description: PRESSURE PNEUM APPL FULL LEG Category: Durable Medical CMS Add: 01/01/1995 CMS Term: E0671 RR DME RTL MAXFEE 01/01/2024 55.27 0.0 Description: PRESSURE PNEUM APPL FULL LEG Category: Durable Medical CMS Add: 01/01/1995 CMS Term: E0672 NU DME PUR MAXFEE 01/01/2014 12/31/2023 307.83 0.0 Description: PRESSURE PNEUM APPL FULL ARM Category: Durable Medical CMS Add: 01/01/1995 CMS Term: E0672 NU DME PUR MAXFEE 01/01/2024 429.17 0.0 Description: PRESSURE PNEUM APPL FULL ARM Category: Durable Medical CMS Add: 01/01/1995 CMS Term: E0672 RR DME RTL MAXFEE 01/01/2014 12/31/2023 30.79 0.0 Description: PRESSURE PNEUM APPL FULL ARM Category: Durable Medical CMS Add: 01/01/1995 CMS Term: E0672 RR DME RTL MAXFEE 01/01/2024 42.95 0.0 Description: PRESSURE PNEUM APPL FULL ARM Category: Durable Medical CMS Add: 01/01/1995 CMS Term: E0673 NU DME PUR MAXFEE 01/01/2014 12/31/2023 241.57 0.0 Description: PRESSURE PNEUM APPL HALF LEG Category: Durable Medical CMS Add: 01/01/1995 CMS Term: E0673 NU DME PUR MAXFEE 01/01/2024 356.62 0.0 Description: PRESSURE PNEUM APPL HALF LEG Category: Durable Medical CMS Add: 01/01/1995 CMS Term: E0673 RR DME RTL MAXFEE 01/01/2014 12/31/2023 24.16 0.0 Description: PRESSURE PNEUM APPL HALF LEG Category: Durable Medical CMS Add: 01/01/1995 CMS Term: E0673 RR DME RTL MAXFEE 01/01/2024 35.66 0.0 Description: PRESSURE PNEUM APPL HALF LEG Category: Durable Medical CMS Add: 01/01/1995 CMS Term: E0675 NOCOV DEF SYSMAN Description: PNEUMATIC COMPRESSION DEVICE Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: E0676 NOCOV DEF SYSMAN Description: INTER LIMB COMPRESS DEV NOS Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: E0691 NU DME PUR MAXFEE 01/01/2023 12/31/2023 1195.00 0.0 Y Description: UVL PNL 2 SQ FT OR LESS Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E0691 NU DME PUR MAXFEE 01/01/2024 1226.07 0.0 Y Description: UVL PNL 2 SQ FT OR LESS Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E0691 RR DME RTL MAXFEE 01/01/2023 12/31/2023 119.49 0.0 Y Description: UVL PNL 2 SQ FT OR LESS Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E0691 RR DME RTL MAXFEE 01/01/2024 122.60 0.0 Y Description: UVL PNL 2 SQ FT OR LESS Category: Durable Medical CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,626 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0692 NU DME PUR MAXFEE 01/01/2023 12/31/2023 1500.60 0.0 Y Description: UVL SYS PANEL 4 FT Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E0692 NU DME PUR MAXFEE 01/01/2024 1539.62 0.0 Y Description: UVL SYS PANEL 4 FT Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E0692 RR DME RTL MAXFEE 01/01/2023 12/31/2023 150.04 0.0 Y Description: UVL SYS PANEL 4 FT Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E0692 RR DME RTL MAXFEE 01/01/2024 153.94 0.0 Y Description: UVL SYS PANEL 4 FT Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E0693 NU DME PUR MAXFEE 01/01/2023 12/31/2023 1849.81 0.0 Y Description: UVL SYS PANEL 6 FT Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E0693 NU DME PUR MAXFEE 01/01/2024 1897.91 0.0 Y Description: UVL SYS PANEL 6 FT Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E0693 RR DME RTL MAXFEE 01/01/2023 12/31/2023 184.99 0.0 Y Description: UVL SYS PANEL 6 FT Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E0693 RR DME RTL MAXFEE 01/01/2024 189.80 0.0 Y Description: UVL SYS PANEL 6 FT Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E0694 NU DME PUR MAXFEE 01/01/2023 12/31/2023 5887.80 0.0 Y Description: UVL MD CABINET SYS 6 FT Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E0694 NU DME PUR MAXFEE 01/01/2024 6040.88 0.0 Y Description: UVL MD CABINET SYS 6 FT Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E0694 RR DME RTL MAXFEE 01/01/2023 12/31/2023 588.77 0.0 Y Description: UVL MD CABINET SYS 6 FT Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E0694 RR DME RTL MAXFEE 01/01/2024 604.08 0.0 Y Description: UVL MD CABINET SYS 6 FT Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E0700 DME DEF MAXFEE 01/01/1988 12/31/2023 37.00 0.0 Description: SAFETY EQUIPMENT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0700 DME DEF MAXFEE 01/01/2024 48.10 0.0 Description: SAFETY EQUIPMENT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0705 NU DME PUR MAXFEE 01/01/2014 12/31/2023 57.25 0.0 Description: TRANSFER DEVICE Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E0705 NU DME PUR MAXFEE 01/01/2024 50.43 0.0 Description: TRANSFER DEVICE Category: Durable Medical CMS Add: 01/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,627 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0710 DME DEF MAXFEE 01/01/2014 12/31/2023 13.00 0.0 Description: RESTRAINTS ANY TYPE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0710 DME DEF MAXFEE 01/01/2024 16.90 0.0 Description: RESTRAINTS ANY TYPE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0711 NOCOV DEF SYSMAN Description: UE ENCLOSURE RESTR ROM Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: E0720 NU DME PUR MAXFEE 01/01/2023 12/31/2023 171.38 0.0 Y Description: TENS TWO LEAD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0720 NU DME PUR MAXFEE 01/01/2024 86.39 0.0 Y Description: TENS TWO LEAD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0730 NU DME PUR MAXFEE 01/01/2023 12/31/2023 183.32 0.0 Y Description: TENS FOUR LEAD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0730 NU DME PUR MAXFEE 01/01/2024 87.29 0.0 Y Description: TENS FOUR LEAD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0731 NU DME PUR MAXFEE 01/01/2014 12/31/2023 190.83 0.0 Description: CONDUCTIVE GARMENT FOR TENS/ Category: Durable Medical CMS Add: 01/01/1989 CMS Term: E0731 NU DME PUR MAXFEE 01/01/2024 78.51 0.0 Description: CONDUCTIVE GARMENT FOR TENS/ Category: Durable Medical CMS Add: 01/01/1989 CMS Term: E0731 RR DME RTL MAXFEE 01/01/2014 12/31/2023 12.78 0.0 Description: CONDUCTIVE GARMENT FOR TENS/ Category: Durable Medical CMS Add: 01/01/1989 CMS Term: E0731 RR DME RTL MAXFEE 01/01/2024 7.85 0.0 Description: CONDUCTIVE GARMENT FOR TENS/ Category: Durable Medical CMS Add: 01/01/1989 CMS Term: E0732 NOCOV DEF SYSMAN Description: CES SYSTEM Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: E0733 NOCOV DEF SYSMAN Description: TRANS ELEC NERV FOR TRIGEMIN Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: E0734 NOCOV DEF SYSMAN Description: EXT UP LIMB TREMOR STIM WRIS Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: E0735 NOCOV DEF SYSMAN Description: NON-INVASIVE VAGUS NERV STIM Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: E0740 NU DME PUR MAXFEE 01/01/2023 12/31/2023 695.40 0.0 Y Description: NON-IMPLANT PELV FLR E-STIM Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,628 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0740 NU DME PUR MAXFEE 01/01/2024 713.50 0.0 Y Description: NON-IMPLANT PELV FLR E-STIM Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0740 RR DME RTL MAXFEE 01/01/2023 12/31/2023 69.54 0.0 Y Description: NON-IMPLANT PELV FLR E-STIM Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0740 RR DME RTL MAXFEE 01/01/2024 71.35 0.0 Y Description: NON-IMPLANT PELV FLR E-STIM Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0744 NU DME PUR MAXFEE 01/01/2014 12/31/2023 905.13 0.0 Y Description: NEUROMUSCULAR STIM FOR SCOLI Category: Durable Medical CMS Add: 01/01/1989 CMS Term: E0744 NU DME PUR MAXFEE 01/01/2024 1164.40 0.0 Y Description: NEUROMUSCULAR STIM FOR SCOLI Category: Durable Medical CMS Add: 01/01/1989 CMS Term: E0744 RR DME RTL MAXFEE 01/01/2014 12/31/2023 68.68 0.0 Y Description: NEUROMUSCULAR STIM FOR SCOLI Category: Durable Medical CMS Add: 01/01/1989 CMS Term: E0744 RR DME RTL MAXFEE 01/01/2024 116.44 0.0 Y Description: NEUROMUSCULAR STIM FOR SCOLI Category: Durable Medical CMS Add: 01/01/1989 CMS Term: E0745 NU DME PUR MAXFEE 01/01/2023 12/31/2023 1190.50 0.0 Y Description: NEUROMUSCULAR STIM FOR SHOCK Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0745 NU DME PUR MAXFEE 01/01/2024 1221.50 0.0 Y Description: NEUROMUSCULAR STIM FOR SHOCK Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0745 RR DME RTL MAXFEE 01/01/2023 12/31/2023 119.05 0.0 Y Description: NEUROMUSCULAR STIM FOR SHOCK Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0745 RR DME RTL MAXFEE 01/01/2024 122.15 0.0 Y Description: NEUROMUSCULAR STIM FOR SHOCK Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0746 NOCOV DEF SYSMAN Description: ELECTROMYOGRAPH BIOFEEDBACK Category: Non Covered Services CMS Add: 01/01/1989 CMS Term: E0747 NU DME PUR MAXFEE 01/01/2023 12/31/2023 5054.23 0.0 Y Description: ELEC OSTEOGEN STIM NOT SPINE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0747 NU DME PUR MAXFEE 01/01/2024 5185.64 0.0 Y Description: ELEC OSTEOGEN STIM NOT SPINE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0747 RR DME RTL MAXFEE 01/01/2023 12/31/2023 505.39 0.0 Y Description: ELEC OSTEOGEN STIM NOT SPINE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0747 RR DME RTL MAXFEE 01/01/2024 518.53 0.0 Y Description: ELEC OSTEOGEN STIM NOT SPINE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,629 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0748 NU DME PUR MAXFEE 01/01/2023 5174.14 0.0 Y Description: ELEC OSTEOGEN STIM SPINAL Category: Durable Medical CMS Add: 01/01/1996 CMS Term: E0748 NU KF DME PUR MAXFEE 01/01/2024 5308.67 0.0 Y Description: ELEC OSTEOGEN STIM SPINAL Category: Durable Medical CMS Add: 01/01/1996 CMS Term: E0748 RR DME RTL MAXFEE 01/01/2023 517.38 0.0 Y Description: ELEC OSTEOGEN STIM SPINAL Category: Durable Medical CMS Add: 01/01/1996 CMS Term: E0748 RR KF DME RTL MAXFEE 01/01/2024 530.83 0.0 Y Description: ELEC OSTEOGEN STIM SPINAL Category: Durable Medical CMS Add: 01/01/1996 CMS Term: E0749 DME DEF MAXFEE 01/01/2014 12/31/2023 1968.90 0.0 Y Description: ELEC OSTEOGEN STIM IMPLANTED Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0749 DME DEF MAXFEE 01/01/2024 3781.70 0.0 Y Description: ELEC OSTEOGEN STIM IMPLANTED Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0755 DME DEF SYSMAN Y Y Description: ELECTRONIC SALIVARY REFLEX S Category: Durable Medical CMS Add: 01/01/1990 CMS Term: E0760 NU DME PUR MAXFEE 01/01/2023 4299.61 0.0 Y Description: OSTEOGEN ULTRASOUND STIMLTOR Category: Durable Medical CMS Add: 01/01/1997 CMS Term: E0760 NU KF DME PUR MAXFEE 01/01/2024 4411.40 0.0 Y Description: OSTEOGEN ULTRASOUND STIMLTOR Category: Durable Medical CMS Add: 01/01/1997 CMS Term: E0760 RR DME RTL MAXFEE 01/01/2023 429.96 0.0 Y Description: OSTEOGEN ULTRASOUND STIMLTOR Category: Durable Medical CMS Add: 01/01/1997 CMS Term: E0760 RR KF DME RTL MAXFEE 01/01/2024 441.14 0.0 Y Description: OSTEOGEN ULTRASOUND STIMLTOR Category: Durable Medical CMS Add: 01/01/1997 CMS Term: E0761 NOCOV DEF SYSMAN Description: NONTHERM ELECTROMGNTC DEVICE Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: E0762 NOCOV DEF SYSMAN Description: TRANS ELEC JT STIM DEV SYS Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: E0764 NOCOV DEF SYSMAN Description: FUNCTIONAL NEUROMUSCULARSTIM Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: E0765 NU DME PUR MAXFEE 01/01/2014 12/31/2023 71.15 0.0 Y Description: NERVE STIMULATOR FOR TX N&V Category: Durable Medical CMS Add: 01/01/2001 CMS Term: E0765 NU DME PUR MAXFEE 01/01/2024 111.88 0.0 Y Description: NERVE STIMULATOR FOR TX N&V Category: Durable Medical CMS Add: 01/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,630 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0765 RR DME RTL MAXFEE 01/01/2014 12/31/2023 7.13 0.0 Y Description: NERVE STIMULATOR FOR TX N&V Category: Durable Medical CMS Add: 01/01/2001 CMS Term: E0765 RR DME RTL MAXFEE 01/01/2024 11.21 0.0 Y Description: NERVE STIMULATOR FOR TX N&V Category: Durable Medical CMS Add: 01/01/2001 CMS Term: E0766 RR DME RTL MAXFEE 01/01/2024 15289.44 0.0 Y Description: ELEC STIM CANCER TREATMENT Category: Durable Medical CMS Add: 01/01/2014 CMS Term: E0766 RR DME RTL MAXFEE 10/29/2020 12/31/2023 13356.47 0.0 Y Description: ELEC STIM CANCER TREATMENT Category: Durable Medical CMS Add: 01/01/2014 CMS Term: E0769 DME DEF SYSMAN Y Y Description: ELECTRIC WOUND TREATMENT DEV Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E0770 DME DEF SYSMAN Y Y Description: FUNCTIONAL ELECTRIC STIM NOS Category: Durable Medical CMS Add: 01/01/2009 CMS Term: E0776 NU DME PUR MAXFEE 01/01/2014 12/31/2023 135.04 0.0 Description: IV POLE Category: Durable Medical CMS Add: 01/01/1985 CMS Term: E0776 NU DME PUR MAXFEE 01/01/2024 57.87 0.0 Description: IV POLE Category: Durable Medical CMS Add: 01/01/1985 CMS Term: E0776 RR DME RTL MAXFEE 01/01/2014 12/31/2023 18.22 0.0 Description: IV POLE Category: Durable Medical CMS Add: 01/01/1985 CMS Term: E0776 RR DME RTL MAXFEE 01/01/2024 18.90 0.0 Description: IV POLE Category: Durable Medical CMS Add: 01/01/1985 CMS Term: E0779 NU DME PUR MAXFEE 01/01/2023 12/31/2023 220.30 0.0 0-1 Description: AMB INFUSION PUMP MECHANICAL Category: Durable Medical CMS Add: 01/01/2000 CMS Term: E0779 NU DME PUR MAXFEE 01/01/2024 225.30 0.0 0-1 Description: AMB INFUSION PUMP MECHANICAL Category: Durable Medical CMS Add: 01/01/2000 CMS Term: E0779 RR DME RTL MAXFEE 01/01/2023 12/31/2023 22.03 0.0 0-1 Description: AMB INFUSION PUMP MECHANICAL Category: Durable Medical CMS Add: 01/01/2000 CMS Term: E0779 RR DME RTL MAXFEE 01/01/2024 22.53 0.0 0-1 Description: AMB INFUSION PUMP MECHANICAL Category: Durable Medical CMS Add: 01/01/2000 CMS Term: E0780 NU DME PUR MAXFEE 01/01/2023 12/31/2023 13.79 0.0 0-1 Description: MECH AMB INFUSION PUMP <8HRS Category: Durable Medical CMS Add: 01/01/2000 CMS Term: E0780 NU DME PUR MAXFEE 01/01/2024 14.15 0.0 0-1 Description: MECH AMB INFUSION PUMP <8HRS Category: Durable Medical CMS Add: 01/01/2000 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,631 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0781 NU DME PUR MAXFEE 01/01/2023 12/31/2023 3018.20 0.0 Description: EXTERNAL AMBULATORY INFUS PU Category: Durable Medical CMS Add: 01/01/1987 CMS Term: E0781 NU DME PUR MAXFEE 01/01/2024 2924.20 0.0 Description: EXTERNAL AMBULATORY INFUS PU Category: Durable Medical CMS Add: 01/01/1987 CMS Term: E0781 RR DME RTL MAXFEE 01/01/2023 12/31/2023 301.82 0.0 Description: EXTERNAL AMBULATORY INFUS PU Category: Durable Medical CMS Add: 01/01/1987 CMS Term: E0781 RR DME RTL MAXFEE 01/01/2024 292.42 0.0 Description: EXTERNAL AMBULATORY INFUS PU Category: Durable Medical CMS Add: 01/01/1987 CMS Term: E0782 DME DEF MAXFEE 01/01/2014 12/31/2023 3345.94 0.0 Description: NON-PROGRAMBLE INFUSION PUMP Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0782 DME DEF MAXFEE 01/01/2024 4853.25 0.0 Description: NON-PROGRAMBLE INFUSION PUMP Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0783 NU DME PUR MAXFEE 01/01/2014 12/31/2023 6236.85 0.0 Description: PROGRAMMABLE INFUSION PUMP Category: Durable Medical CMS Add: 01/01/1995 CMS Term: E0783 NU DME PUR MAXFEE 01/01/2024 10887.51 0.0 Description: PROGRAMMABLE INFUSION PUMP Category: Durable Medical CMS Add: 01/01/1995 CMS Term: E0783 RR DME RTL MAXFEE 01/01/2014 12/31/2023 623.70 0.0 Description: PROGRAMMABLE INFUSION PUMP Category: Durable Medical CMS Add: 01/01/1995 CMS Term: E0783 RR DME RTL MAXFEE 01/01/2024 1088.77 0.0 Description: PROGRAMMABLE INFUSION PUMP Category: Durable Medical CMS Add: 01/01/1995 CMS Term: E0784 NU DME PUR MAXFEE 01/01/2023 12/31/2023 5242.60 0.0 Y Description: EXT AMB INFUSN PUMP INSULIN Category: Durable Medical CMS Add: 01/01/1996 CMS Term: E0784 NU DME PUR MAXFEE 01/01/2024 5272.70 0.0 Y Description: EXT AMB INFUSN PUMP INSULIN Category: Durable Medical CMS Add: 01/01/1996 CMS Term: E0784 RR DME RTL MAXFEE 01/01/2023 12/31/2023 524.26 0.0 Y Description: EXT AMB INFUSN PUMP INSULIN Category: Durable Medical CMS Add: 01/01/1996 CMS Term: E0784 RR DME RTL MAXFEE 01/01/2024 527.27 0.0 Y Description: EXT AMB INFUSN PUMP INSULIN Category: Durable Medical CMS Add: 01/01/1996 CMS Term: E0785 DME DEF MAXFEE 01/01/2014 12/31/2023 359.96 0.0 Description: REPLACEMENT IMPL PUMP CATHET Category: Durable Medical CMS Add: 01/01/1999 CMS Term: E0785 DME DEF MAXFEE 01/01/2024 534.12 0.0 Description: REPLACEMENT IMPL PUMP CATHET Category: Durable Medical CMS Add: 01/01/1999 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,632 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0786 NU DME PUR MAXFEE 01/01/2014 12/31/2023 6831.93 0.0 0-1 Description: IMPLANTABLE PUMP REPLACEMENT Category: Durable Medical CMS Add: 01/01/2001 CMS Term: E0786 NU DME PUR MAXFEE 01/01/2024 10620.10 0.0 0-1 Description: IMPLANTABLE PUMP REPLACEMENT Category: Durable Medical CMS Add: 01/01/2001 CMS Term: E0787 DME DEF SYSMAN Y Y Description: CGS DOSE ADJ INSULIN INF PMP Category: Durable Medical CMS Add: 01/01/2020 CMS Term: E0791 NU DME PUR MAXFEE 01/01/2023 12/31/2023 3590.70 0.0 Description: PARENTERAL INFUSION PUMP STA Category: Durable Medical CMS Add: 01/01/1989 CMS Term: E0791 NU DME PUR MAXFEE 01/01/2024 3473.90 0.0 Description: PARENTERAL INFUSION PUMP STA Category: Durable Medical CMS Add: 01/01/1989 CMS Term: E0791 RR DME RTL MAXFEE 01/01/2023 12/31/2023 359.07 0.0 Description: PARENTERAL INFUSION PUMP STA Category: Durable Medical CMS Add: 01/01/1989 CMS Term: E0791 RR DME RTL MAXFEE 01/01/2024 347.39 0.0 Description: PARENTERAL INFUSION PUMP STA Category: Durable Medical CMS Add: 01/01/1989 CMS Term: E0830 NOCOV DEF SYSMAN 0-1 Description: AMBULATORY TRACTION DEVICE Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: E0840 NU DME PUR MAXFEE 01/01/2014 12/31/2023 65.16 0.0 Description: TRACT FRAME ATTACH HEADBOARD Category: Durable Medical CMS Add: 01/01/1984 CMS Term: E0840 NU DME PUR MAXFEE 01/01/2024 82.82 0.0 Description: TRACT FRAME ATTACH HEADBOARD Category: Durable Medical CMS Add: 01/01/1984 CMS Term: E0840 RR DME RTL MAXFEE 01/01/2014 12/31/2023 22.81 0.0 Description: TRACT FRAME ATTACH HEADBOARD Category: Durable Medical CMS Add: 01/01/1984 CMS Term: E0840 RR DME RTL MAXFEE 01/01/2024 21.72 0.0 Description: TRACT FRAME ATTACH HEADBOARD Category: Durable Medical CMS Add: 01/01/1984 CMS Term: E0849 NU DME PUR MAXFEE 01/01/2023 12/31/2023 685.40 0.0 Description: CERVICAL PNEUM TRAC EQUIP Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E0849 NU DME PUR MAXFEE 01/01/2024 703.20 0.0 Description: CERVICAL PNEUM TRAC EQUIP Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E0849 RR DME RTL MAXFEE 01/01/2023 12/31/2023 68.54 0.0 Description: CERVICAL PNEUM TRAC EQUIP Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E0849 RR DME RTL MAXFEE 01/01/2024 70.32 0.0 Description: CERVICAL PNEUM TRAC EQUIP Category: Durable Medical CMS Add: 01/01/2005 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,633 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0850 NU DME PUR MAXFEE 01/01/2014 12/31/2023 74.27 0.0 Description: TRACTION STAND FREE STANDING Category: Durable Medical CMS Add: 01/01/1982 CMS Term: E0850 NU DME PUR MAXFEE 01/01/2024 118.75 0.0 Description: TRACTION STAND FREE STANDING Category: Durable Medical CMS Add: 01/01/1982 CMS Term: E0850 RR DME RTL MAXFEE 01/01/2014 12/31/2023 17.25 0.0 Description: TRACTION STAND FREE STANDING Category: Durable Medical CMS Add: 01/01/1982 CMS Term: E0850 RR DME RTL MAXFEE 01/01/2024 16.31 0.0 Description: TRACTION STAND FREE STANDING Category: Durable Medical CMS Add: 01/01/1982 CMS Term: E0855 NU DME PUR MAXFEE 01/01/2023 12/31/2023 668.40 0.0 Description: CERVICAL TRACTION EQUIPMENT Category: Durable Medical CMS Add: 01/01/1998 CMS Term: E0855 NU DME PUR MAXFEE 01/01/2024 685.80 0.0 Description: CERVICAL TRACTION EQUIPMENT Category: Durable Medical CMS Add: 01/01/1998 CMS Term: E0855 RR DME RTL MAXFEE 01/01/2023 12/31/2023 66.84 0.0 Description: CERVICAL TRACTION EQUIPMENT Category: Durable Medical CMS Add: 01/01/1998 CMS Term: E0855 RR DME RTL MAXFEE 01/01/2024 68.58 0.0 Description: CERVICAL TRACTION EQUIPMENT Category: Durable Medical CMS Add: 01/01/1998 CMS Term: E0856 NU DME PUR MAXFEE 01/01/2014 12/31/2023 154.03 0.0 Y Description: CERVIC COLLAR W AIR BLADDERS Category: Durable Medical CMS Add: 01/01/2008 CMS Term: E0856 NU DME PUR MAXFEE 01/01/2024 204.70 0.0 Y Description: CERVIC COLLAR W AIR BLADDERS Category: Durable Medical CMS Add: 01/01/2008 CMS Term: E0856 RR DME RTL MAXFEE 01/01/2014 12/31/2023 15.42 0.0 Y Description: CERVIC COLLAR W AIR BLADDERS Category: Durable Medical CMS Add: 01/01/2008 CMS Term: E0856 RR DME RTL MAXFEE 01/01/2024 20.47 0.0 Y Description: CERVIC COLLAR W AIR BLADDERS Category: Durable Medical CMS Add: 01/01/2008 CMS Term: E0860 NU DME PUR MAXFEE 01/01/2023 12/31/2023 51.25 0.0 Description: TRACT EQUIP CERVICAL TRACT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0860 NU DME PUR MAXFEE 01/01/2024 52.58 0.0 Description: TRACT EQUIP CERVICAL TRACT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0860 RR DME RTL MAXFEE 01/01/2023 12/31/2023 8.67 0.0 Description: TRACT EQUIP CERVICAL TRACT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0860 RR DME RTL MAXFEE 01/01/2024 8.90 0.0 Description: TRACT EQUIP CERVICAL TRACT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,634 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0870 NU DME PUR MAXFEE 01/01/2023 12/31/2023 154.69 0.0 Description: TRACT FRAME ATTACH FOOTBOARD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0870 NU DME PUR MAXFEE 01/01/2024 158.71 0.0 Description: TRACT FRAME ATTACH FOOTBOARD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0870 RR DME RTL MAXFEE 01/01/2023 12/31/2023 17.84 0.0 Description: TRACT FRAME ATTACH FOOTBOARD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0870 RR DME RTL MAXFEE 01/01/2024 18.30 0.0 Description: TRACT FRAME ATTACH FOOTBOARD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0880 NU DME PUR MAXFEE 01/01/2023 166.95 0.0 Description: TRAC STAND FREE STAND EXTREM Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0880 RR DME RTL MAXFEE 01/01/2023 26.21 0.0 Description: TRAC STAND FREE STAND EXTREM Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0890 NU DME PUR MAXFEE 01/01/2023 160.12 0.0 Description: TRACTION FRAME ATTACH PELVIC Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0890 RR DME RTL MAXFEE 01/01/2023 43.66 0.0 Description: TRACTION FRAME ATTACH PELVIC Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0900 NU DME PUR MAXFEE 01/01/2023 12/31/2023 158.73 0.0 Description: TRAC STAND FREE STAND PELVIC Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0900 NU DME PUR MAXFEE 01/01/2024 162.86 0.0 Description: TRAC STAND FREE STAND PELVIC Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0900 RR DME RTL MAXFEE 01/01/2023 12/31/2023 36.74 0.0 Description: TRAC STAND FREE STAND PELVIC Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0900 RR DME RTL MAXFEE 01/01/2024 37.70 0.0 Description: TRAC STAND FREE STAND PELVIC Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0910 NU DME PUR MAXFEE 01/01/2023 12/31/2023 156.40 0.0 Description: TRAPEZE BAR ATTACHED TO BED Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0910 NU DME PUR MAXFEE 01/01/2024 136.10 0.0 Description: TRAPEZE BAR ATTACHED TO BED Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0910 RR DME RTL MAXFEE 01/01/2023 12/31/2023 15.64 0.0 Description: TRAPEZE BAR ATTACHED TO BED Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0910 RR DME RTL MAXFEE 01/01/2024 13.61 0.0 Description: TRAPEZE BAR ATTACHED TO BED Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,635 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0911 NU DME PUR MAXFEE 01/01/2023 12/31/2023 503.00 0.0 Description: HD TRAPEZE BAR ATTACH TO BED Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E0911 NU DME PUR MAXFEE 01/01/2024 494.70 0.0 Description: HD TRAPEZE BAR ATTACH TO BED Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E0911 RR DME RTL MAXFEE 01/01/2023 12/31/2023 50.30 0.0 Description: HD TRAPEZE BAR ATTACH TO BED Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E0911 RR DME RTL MAXFEE 01/01/2024 49.47 0.0 Description: HD TRAPEZE BAR ATTACH TO BED Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E0912 NU DME PUR MAXFEE 01/01/2023 12/31/2023 1036.90 0.0 Description: HD TRAPEZE BAR FREE STANDING Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E0912 NU DME PUR MAXFEE 01/01/2024 973.50 0.0 Description: HD TRAPEZE BAR FREE STANDING Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E0912 RR DME RTL MAXFEE 01/01/2023 12/31/2023 103.69 0.0 Description: HD TRAPEZE BAR FREE STANDING Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E0912 RR DME RTL MAXFEE 01/01/2024 97.35 0.0 Description: HD TRAPEZE BAR FREE STANDING Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E0920 NU DME PUR MAXFEE 01/01/2023 12/31/2023 570.90 0.0 Description: FRACTURE FRAME ATTACHED TO B Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0920 NU DME PUR MAXFEE 01/01/2024 585.70 0.0 Description: FRACTURE FRAME ATTACHED TO B Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0920 RR DME RTL MAXFEE 01/01/2023 12/31/2023 57.09 0.0 Description: FRACTURE FRAME ATTACHED TO B Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0920 RR DME RTL MAXFEE 01/01/2024 58.57 0.0 Description: FRACTURE FRAME ATTACHED TO B Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0930 NU DME PUR MAXFEE 01/01/2014 12/31/2023 344.05 0.0 Description: FRACTURE FRAME FREE STANDING Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0930 NU DME PUR MAXFEE 01/01/2024 525.00 0.0 Description: FRACTURE FRAME FREE STANDING Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0930 RR DME RTL MAXFEE 01/01/2014 12/31/2023 34.07 0.0 Description: FRACTURE FRAME FREE STANDING Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0930 RR DME RTL MAXFEE 01/01/2024 52.50 0.0 Description: FRACTURE FRAME FREE STANDING Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,636 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0935 RR DME RTL MAXFEE 01/01/2023 12/31/2023 30.25 0.0 Description: CONT PAS MOTION EXERCISE DEV Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0935 RR DME RTL MAXFEE 01/01/2024 31.04 0.0 Description: CONT PAS MOTION EXERCISE DEV Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0936 RR DME RTL MAXFEE 01/01/2014 12/31/2023 21.10 0.0 Description: CPM DEVICE, OTHER THAN KNEE Category: Durable Medical CMS Add: 01/01/2007 CMS Term: E0936 RR DME RTL MAXFEE 01/01/2024 27.43 0.0 Description: CPM DEVICE, OTHER THAN KNEE Category: Durable Medical CMS Add: 01/01/2007 CMS Term: E0940 NU DME PUR MAXFEE 01/01/2023 12/31/2023 272.00 0.0 Description: TRAPEZE BAR FREE STANDING Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0940 NU DME PUR MAXFEE 01/01/2024 253.30 0.0 Description: TRAPEZE BAR FREE STANDING Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0940 RR DME RTL MAXFEE 01/01/2023 12/31/2023 27.20 0.0 Description: TRAPEZE BAR FREE STANDING Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0940 RR DME RTL MAXFEE 01/01/2024 25.33 0.0 Description: TRAPEZE BAR FREE STANDING Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0941 NU DME PUR MAXFEE 01/01/2023 12/31/2023 566.50 0.0 Description: GRAVITY ASSISTED TRACTION DE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0941 NU DME PUR MAXFEE 01/01/2024 581.20 0.0 Description: GRAVITY ASSISTED TRACTION DE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0941 RR DME RTL MAXFEE 01/01/2023 12/31/2023 56.65 0.0 Description: GRAVITY ASSISTED TRACTION DE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0941 RR DME RTL MAXFEE 01/01/2024 58.12 0.0 Description: GRAVITY ASSISTED TRACTION DE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0942 DME DEF MAXFEE 01/01/2014 12/31/2023 15.84 0.0 Description: CERVICAL HEAD HARNESS/HALTER Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0942 DME DEF MAXFEE 01/01/2024 24.42 0.0 Description: CERVICAL HEAD HARNESS/HALTER Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0944 DME DEF MAXFEE 01/01/2014 12/31/2023 37.64 0.0 Description: PELVIC BELT/HARNESS/BOOT Category: Durable Medical CMS Add: 01/01/1985 CMS Term: E0944 DME DEF MAXFEE 01/01/2024 61.00 0.0 Description: PELVIC BELT/HARNESS/BOOT Category: Durable Medical CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,637 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0945 DME DEF MAXFEE 01/01/2014 12/31/2023 35.45 0.0 Description: BELT/HARNESS EXTREMITY Category: Durable Medical CMS Add: 01/01/1985 CMS Term: E0945 DME DEF MAXFEE 01/01/2024 58.94 0.0 Description: BELT/HARNESS EXTREMITY Category: Durable Medical CMS Add: 01/01/1985 CMS Term: E0946 NU DME PUR MAXFEE 01/01/2023 668.80 0.0 Description: FRACTURE FRAME DUAL W CROSS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0946 RR DME RTL MAXFEE 01/01/2023 66.88 0.0 Description: FRACTURE FRAME DUAL W CROSS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0947 NU DME PUR MAXFEE 01/01/2023 12/31/2023 685.53 0.0 Description: FRACTURE FRAME ATTACHMNTS PE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0947 NU DME PUR MAXFEE 01/01/2024 703.36 0.0 Description: FRACTURE FRAME ATTACHMNTS PE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0947 RR DME RTL MAXFEE 01/01/2023 12/31/2023 71.08 0.0 Description: FRACTURE FRAME ATTACHMNTS PE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0947 RR DME RTL MAXFEE 01/01/2024 72.92 0.0 Description: FRACTURE FRAME ATTACHMNTS PE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0948 NU DME PUR MAXFEE 01/01/2023 663.06 0.0 Description: FRACTURE FRAME ATTACHMNTS CE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0948 RR DME RTL MAXFEE 01/01/2023 66.28 0.0 Description: FRACTURE FRAME ATTACHMNTS CE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0950 NU DME PUR MAXFEE 01/01/2014 12/31/2023 81.76 0.0 Description: TRAY Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0950 NU DME PUR MAXFEE 01/01/2024 82.13 0.0 Description: TRAY Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0951 NU DME PUR MAXFEE 01/01/2014 12/31/2023 16.38 0.0 Description: LOOP HEEL Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0951 NU DME PUR MAXFEE 01/01/2024 15.34 0.0 Description: LOOP HEEL Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0952 NU DME PUR MAXFEE 01/01/2014 12/31/2023 14.77 0.0 Description: TOE LOOP/HOLDER, EACH Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0952 NU DME PUR MAXFEE 01/01/2024 19.23 0.0 Description: TOE LOOP/HOLDER, EACH Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,638 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0953 NU DME PUR MAXFEE 01/01/2018 12/31/2023 75.94 0.0 Y Description: W/C LATERAL THIGH/KNEE SUP Category: Durable Medical CMS Add: 01/01/2018 CMS Term: E0953 NU DME PUR MAXFEE 01/01/2024 95.18 0.0 Y Description: W/C LATERAL THIGH/KNEE SUP Category: Durable Medical CMS Add: 01/01/2018 CMS Term: E0953 RR DME RTL MAXFEE 01/01/2018 12/31/2023 7.59 0.0 Y Description: W/C LATERAL THIGH/KNEE SUP Category: Durable Medical CMS Add: 01/01/2018 CMS Term: E0953 RR DME RTL MAXFEE 01/01/2024 9.52 0.0 Y Description: W/C LATERAL THIGH/KNEE SUP Category: Durable Medical CMS Add: 01/01/2018 CMS Term: E0954 NU DME PUR MAXFEE 01/01/2018 12/31/2023 51.19 0.0 Y Description: FOOT BOX, ANY TYPE EACH FOOT Category: Durable Medical CMS Add: 01/01/2018 CMS Term: E0954 NU DME PUR MAXFEE 01/01/2024 63.44 0.0 Y Description: FOOT BOX, ANY TYPE EACH FOOT Category: Durable Medical CMS Add: 01/01/2018 CMS Term: E0954 RR DME RTL MAXFEE 01/01/2018 12/31/2023 5.12 0.0 Y Description: FOOT BOX, ANY TYPE EACH FOOT Category: Durable Medical CMS Add: 01/01/2018 CMS Term: E0954 RR DME RTL MAXFEE 01/01/2024 6.36 0.0 Y Description: FOOT BOX, ANY TYPE EACH FOOT Category: Durable Medical CMS Add: 01/01/2018 CMS Term: E0955 NU DME PUR MAXFEE 01/01/2014 12/31/2023 202.18 0.0 Y Description: CUSHIONED HEADREST Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0955 NU DME PUR MAXFEE 01/01/2024 162.80 0.0 Y Description: CUSHIONED HEADREST Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0955 RR DME RTL MAXFEE 01/01/2014 12/31/2023 20.23 0.0 Y Description: CUSHIONED HEADREST Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0955 RR DME RTL MAXFEE 01/01/2024 16.28 0.0 Y Description: CUSHIONED HEADREST Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0956 NU DME PUR MAXFEE 01/01/2014 12/31/2023 98.58 0.0 Y Description: W/C LATERAL TRUNK/HIP SUPPOR Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0956 NU DME PUR MAXFEE 01/01/2024 80.51 0.0 Y Description: W/C LATERAL TRUNK/HIP SUPPOR Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0956 RR DME RTL MAXFEE 01/01/2014 12/31/2023 9.87 0.0 Y Description: W/C LATERAL TRUNK/HIP SUPPOR Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0956 RR DME RTL MAXFEE 01/01/2024 9.52 0.0 Y Description: W/C LATERAL TRUNK/HIP SUPPOR Category: Durable Medical CMS Add: 01/01/2004 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,639 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0957 NU DME PUR MAXFEE 01/01/2014 12/31/2023 137.93 0.0 Y Description: W/C MEDIAL THIGH SUPPORT Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0957 NU DME PUR MAXFEE 01/01/2024 132.48 0.0 Y Description: W/C MEDIAL THIGH SUPPORT Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0957 RR DME RTL MAXFEE 01/01/2014 12/31/2023 13.79 0.0 Y Description: W/C MEDIAL THIGH SUPPORT Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0957 RR DME RTL MAXFEE 01/01/2024 14.16 0.0 Y Description: W/C MEDIAL THIGH SUPPORT Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0958 NU DME PUR MAXFEE 01/01/2014 12/31/2023 336.00 0.0 Description: WHLCHR ATT- CONV 1 ARM DRIVE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0958 NU DME PUR MAXFEE 01/01/2024 437.00 0.0 Description: WHLCHR ATT- CONV 1 ARM DRIVE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0959 NU DME PUR MAXFEE 01/01/2014 12/31/2023 71.74 0.0 Description: AMPUTEE ADAPTER Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0959 NU DME PUR MAXFEE 01/01/2024 46.89 0.0 Description: AMPUTEE ADAPTER Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0960 NU DME PUR MAXFEE 01/01/2014 12/31/2023 90.98 0.0 Description: W/C SHOULDER HARNESS/STRAPS Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0960 NU DME PUR MAXFEE 01/01/2024 79.75 0.0 Description: W/C SHOULDER HARNESS/STRAPS Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0961 NU DME PUR MAXFEE 01/01/2014 12/31/2023 19.56 0.0 Description: WHEELCHAIR BRAKE EXTENSION Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0961 NU DME PUR MAXFEE 01/01/2024 22.72 0.0 Description: WHEELCHAIR BRAKE EXTENSION Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0966 NU DME PUR MAXFEE 01/01/2014 12/31/2023 69.38 0.0 Description: WHEELCHAIR HEAD REST EXTENSI Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0966 NU DME PUR MAXFEE 01/01/2024 85.52 0.0 Description: WHEELCHAIR HEAD REST EXTENSI Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0967 NU DME PUR MAXFEE 01/01/2014 12/31/2023 97.21 0.0 Y Description: MAN WC RIM/PROJECTION REP EA Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0967 NU DME PUR MAXFEE 01/01/2024 83.97 0.0 Y Description: MAN WC RIM/PROJECTION REP EA Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,640 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0968 NU DME PUR MAXFEE 01/01/2014 12/31/2023 144.44 0.0 Y Description: WHEELCHAIR COMMODE SEAT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0968 NU DME PUR MAXFEE 01/01/2024 238.30 0.0 Y Description: WHEELCHAIR COMMODE SEAT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0968 RR DME RTL MAXFEE 01/01/2014 12/31/2023 66.00 0.0 Y Description: WHEELCHAIR COMMODE SEAT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0968 RR DME RTL MAXFEE 01/01/2024 23.83 0.0 Y Description: WHEELCHAIR COMMODE SEAT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0969 NU DME PUR MAXFEE 01/01/2014 12/31/2023 131.39 0.0 Y Description: WHEELCHAIR NARROWING DEVICE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0969 NU DME PUR MAXFEE 01/01/2024 208.29 0.0 Y Description: WHEELCHAIR NARROWING DEVICE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0969 RR DME RTL MAXFEE 01/01/2014 12/31/2023 10.00 0.0 Y Description: WHEELCHAIR NARROWING DEVICE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0969 RR DME RTL MAXFEE 01/01/2024 20.62 0.0 Y Description: WHEELCHAIR NARROWING DEVICE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0970 NU DME PUR MAXFEE 01/01/2014 12/31/2023 45.72 0.0 Description: WHEELCHAIR NO. 2 FOOTPLATES Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0970 NU DME PUR MAXFEE 01/01/2024 59.44 0.0 Description: WHEELCHAIR NO. 2 FOOTPLATES Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0971 NU DME PUR MAXFEE 01/01/2014 12/31/2023 54.42 0.0 Description: WHEELCHAIR ANTI-TIPPING DEVI Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0971 NU DME PUR MAXFEE 01/01/2024 34.45 0.0 Description: WHEELCHAIR ANTI-TIPPING DEVI Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0973 NU DME PUR MAXFEE 01/01/2014 12/31/2023 103.78 0.0 Y Description: W/CH ACCESS DET ADJ ARMREST Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0973 NU DME PUR MAXFEE 01/01/2024 60.50 0.0 Y Description: W/CH ACCESS DET ADJ ARMREST Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0974 NU DME PUR MAXFEE 01/01/2014 12/31/2023 67.21 0.0 Y Description: W/CH ACCESS ANTI-ROLLBACK Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0974 NU DME PUR MAXFEE 01/01/2024 84.09 0.0 Y Description: W/CH ACCESS ANTI-ROLLBACK Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,641 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0978 NU DME PUR MAXFEE 01/01/2014 12/31/2023 36.09 0.0 Description: W/C ACC,SAF BELT PELV STRAP Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0978 NU DME PUR MAXFEE 01/01/2024 28.32 0.0 Description: W/C ACC,SAF BELT PELV STRAP Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0980 NU DME PUR MAXFEE 01/01/2014 12/31/2023 27.43 0.0 Description: WHEELCHAIR SAFETY VEST Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0980 NU DME PUR MAXFEE 01/01/2024 43.96 0.0 Description: WHEELCHAIR SAFETY VEST Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0981 NU DME PUR MAXFEE 01/01/2014 12/31/2023 47.15 0.0 Y Description: SEAT UPHOLSTERY, REPLACEMENT Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0981 NU DME PUR MAXFEE 01/01/2024 49.29 0.0 Y Description: SEAT UPHOLSTERY, REPLACEMENT Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0982 NU DME PUR MAXFEE 01/01/2014 12/31/2023 51.53 0.0 Y Description: BACK UPHOLSTERY, REPLACEMENT Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0982 NU DME PUR MAXFEE 01/01/2024 54.38 0.0 Y Description: BACK UPHOLSTERY, REPLACEMENT Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0983 NU DME PUR MAXFEE 01/01/2014 12/31/2023 3748.95 0.0 Y Description: ADD PWR JOYSTICK Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0983 NU DME PUR MAXFEE 01/01/2024 3323.80 0.0 Y Description: ADD PWR JOYSTICK Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0983 RR DME RTL MAXFEE 01/01/2014 12/31/2023 249.93 0.0 Y Description: ADD PWR JOYSTICK Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0983 RR DME RTL MAXFEE 01/01/2024 332.38 0.0 Y Description: ADD PWR JOYSTICK Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0984 NU DME PUR MAXFEE 01/01/2014 12/31/2023 1623.99 0.0 Y Description: ADD PWR TILLER Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0984 NU DME PUR MAXFEE 01/01/2024 2159.50 0.0 Y Description: ADD PWR TILLER Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0984 RR DME RTL MAXFEE 01/01/2014 12/31/2023 150.95 0.0 Y Description: ADD PWR TILLER Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0984 RR DME RTL MAXFEE 01/01/2024 215.95 0.0 Y Description: ADD PWR TILLER Category: Durable Medical CMS Add: 01/01/2004 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,642 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0985 NU DME PUR MAXFEE 01/01/2014 12/31/2023 202.85 0.0 Y Description: W/C SEAT LIFT MECHANISM Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0985 NU DME PUR MAXFEE 01/01/2024 251.50 0.0 Y Description: W/C SEAT LIFT MECHANISM Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0985 RR DME RTL MAXFEE 01/01/2014 12/31/2023 20.30 0.0 Y Description: W/C SEAT LIFT MECHANISM Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0985 RR DME RTL MAXFEE 01/01/2024 25.15 0.0 Y Description: W/C SEAT LIFT MECHANISM Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0986 NU DME PUR MAXFEE 01/01/2024 6469.00 0.0 Y Description: MAN W/C PUSH-RIM POWR SYSTEM Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0986 NU DME PUR MAXFEE 05/13/2022 12/31/2023 5951.20 0.0 Y Description: MAN W/C PUSH-RIM POWR SYSTEM Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0986 RR DME RTL MAXFEE 01/01/2024 646.90 0.0 Y Description: MAN W/C PUSH-RIM POWR SYSTEM Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0986 RR DME RTL MAXFEE 05/13/2022 12/31/2023 595.12 0.0 Y Description: MAN W/C PUSH-RIM POWR SYSTEM Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E0988 RR DME RTL MAXFEE 01/01/2012 12/31/2023 321.54 0.0 Y Description: LEVER-ACTIVATED WHEEL DRIVE Category: Durable Medical CMS Add: 01/01/2012 CMS Term: E0988 RR DME RTL MAXFEE 01/01/2024 398.10 0.0 Y Description: LEVER-ACTIVATED WHEEL DRIVE Category: Durable Medical CMS Add: 01/01/2012 CMS Term: E0990 NU DME PUR MAXFEE 01/01/2014 12/31/2023 83.89 0.0 Y Description: WHEELCHAIR ELEVATING LEG RES Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0990 NU DME PUR MAXFEE 01/01/2024 85.17 0.0 Y Description: WHEELCHAIR ELEVATING LEG RES Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0992 NU DME PUR MAXFEE 01/01/2014 12/31/2023 68.30 0.0 Y Description: WHEELCHAIR SOLID SEAT INSERT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0992 NU DME PUR MAXFEE 01/01/2024 84.05 0.0 Y Description: WHEELCHAIR SOLID SEAT INSERT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0994 NU DME PUR MAXFEE 01/01/2014 12/31/2023 15.22 0.0 Description: WHEELCHAIR ARM REST Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0994 NU DME PUR MAXFEE 01/01/2024 20.65 0.0 Description: WHEELCHAIR ARM REST Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,643 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E0995 NU DME PUR MAXFEE 01/01/2014 12/31/2023 29.85 0.0 Description: WC CALF REST, PAD REPLACEMNT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E0995 NU DME PUR MAXFEE 01/01/2024 29.62 0.0 Description: WC CALF REST, PAD REPLACEMNT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1002 NU DME PUR MAXFEE 01/01/2014 12/31/2023 4113.02 0.0 Y Description: PWR SEAT TILT Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E1002 NU DME PUR MAXFEE 01/01/2024 4351.50 0.0 Y Description: PWR SEAT TILT Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E1002 RR DME RTL MAXFEE 01/01/2014 12/31/2023 411.33 0.0 Y Description: PWR SEAT TILT Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E1002 RR DME RTL MAXFEE 01/01/2024 435.15 0.0 Y Description: PWR SEAT TILT Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E1003 NU DME PUR MAXFEE 01/01/2014 12/31/2023 4391.30 0.0 Y Description: PWR SEAT RECLINE Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E1003 NU DME PUR MAXFEE 01/01/2024 4992.30 0.0 Y Description: PWR SEAT RECLINE Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E1003 RR DME RTL MAXFEE 01/01/2014 12/31/2023 439.14 0.0 Y Description: PWR SEAT RECLINE Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E1003 RR DME RTL MAXFEE 01/01/2024 499.23 0.0 Y Description: PWR SEAT RECLINE Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E1004 NU DME PUR MAXFEE 01/01/2014 12/31/2023 4869.05 0.0 Y Description: PWR SEAT RECLINE MECH Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E1004 NU DME PUR MAXFEE 01/01/2024 5499.30 0.0 Y Description: PWR SEAT RECLINE MECH Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E1004 RR DME RTL MAXFEE 01/01/2014 12/31/2023 486.90 0.0 Y Description: PWR SEAT RECLINE MECH Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E1004 RR DME RTL MAXFEE 01/01/2024 549.93 0.0 Y Description: PWR SEAT RECLINE MECH Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E1005 NU DME PUR MAXFEE 01/01/2014 12/31/2023 5270.36 0.0 Y Description: PWR SEAT RECLINE PWR Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E1005 NU DME PUR MAXFEE 01/01/2024 5999.80 0.0 Y Description: PWR SEAT RECLINE PWR Category: Durable Medical CMS Add: 01/01/2004 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,644 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E1005 RR DME RTL MAXFEE 01/01/2014 12/31/2023 527.03 0.0 Y Description: PWR SEAT RECLINE PWR Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E1005 RR DME RTL MAXFEE 01/01/2024 599.98 0.0 Y Description: PWR SEAT RECLINE PWR Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E1006 NU DME PUR MAXFEE 01/01/2014 12/31/2023 6445.70 0.0 Y Description: PWR SEAT COMBO W/O SHEAR Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E1006 NU DME PUR MAXFEE 01/01/2024 7385.40 0.0 Y Description: PWR SEAT COMBO W/O SHEAR Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E1006 RR DME RTL MAXFEE 01/01/2014 12/31/2023 644.55 0.0 Y Description: PWR SEAT COMBO W/O SHEAR Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E1006 RR DME RTL MAXFEE 01/01/2024 738.54 0.0 Y Description: PWR SEAT COMBO W/O SHEAR Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E1007 NU DME PUR MAXFEE 01/01/2014 12/31/2023 8741.27 0.0 Y Description: PWR SEAT COMBO W/SHEAR Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E1007 NU DME PUR MAXFEE 01/01/2024 9376.10 0.0 Y Description: PWR SEAT COMBO W/SHEAR Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E1007 RR DME RTL MAXFEE 01/01/2014 12/31/2023 874.13 0.0 Y Description: PWR SEAT COMBO W/SHEAR Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E1007 RR DME RTL MAXFEE 01/01/2024 937.61 0.0 Y Description: PWR SEAT COMBO W/SHEAR Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E1008 NU DME PUR MAXFEE 01/01/2014 12/31/2023 8742.05 0.0 Y Description: PWR SEAT COMBO PWR SHEAR Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E1008 NU DME PUR MAXFEE 01/01/2024 9553.10 0.0 Y Description: PWR SEAT COMBO PWR SHEAR Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E1008 RR DME RTL MAXFEE 01/01/2014 12/31/2023 874.20 0.0 Y Description: PWR SEAT COMBO PWR SHEAR Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E1008 RR DME RTL MAXFEE 01/01/2024 955.31 0.0 Y Description: PWR SEAT COMBO PWR SHEAR Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E1009 NOCOV DEF SYSMAN Description: ADD MECH LEG ELEVATION Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: E1010 NU DME PUR MAXFEE 01/01/2014 12/31/2023 2302.72 0.0 Y Description: ADD PWR LEG ELEVATION Category: Durable Medical CMS Add: 01/01/2004 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,645 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E1010 NU DME PUR MAXFEE 01/01/2024 1285.60 0.0 Y Description: ADD PWR LEG ELEVATION Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E1010 RR DME RTL MAXFEE 01/01/2014 12/31/2023 230.26 0.0 Y Description: ADD PWR LEG ELEVATION Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E1010 RR DME RTL MAXFEE 01/01/2024 128.56 0.0 Y Description: ADD PWR LEG ELEVATION Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E1011 DME DEF SYSMAN Y Y Description: PED WC MODIFY WIDTH ADJUSTM Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1012 RR DME RTL MAXFEE 01/01/2016 12/31/2023 94.99 0.0 Y Description: CTR MOUNT PWR ELEV LEG REST Category: Durable Medical CMS Add: 01/01/2016 CMS Term: E1012 RR DME RTL MAXFEE 01/01/2024 128.56 0.0 Y Description: CTR MOUNT PWR ELEV LEG REST Category: Durable Medical CMS Add: 01/01/2016 CMS Term: E1014 NU DME PUR MAXFEE 01/01/2014 12/31/2023 365.14 0.0 Y Description: RECLINING BACK ADD PED W/C Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1014 NU DME PUR MAXFEE 01/01/2024 485.80 0.0 Y Description: RECLINING BACK ADD PED W/C Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1014 RR DME RTL MAXFEE 01/01/2014 12/31/2023 24.34 0.0 Y Description: RECLINING BACK ADD PED W/C Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1014 RR DME RTL MAXFEE 01/01/2024 48.58 0.0 Y Description: RECLINING BACK ADD PED W/C Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1015 NU DME PUR MAXFEE 01/01/2014 12/31/2023 97.50 0.0 Y Description: SHOCK ABSORBER FOR MAN W/C Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1015 NU DME PUR MAXFEE 01/01/2024 142.68 0.0 Y Description: SHOCK ABSORBER FOR MAN W/C Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1015 RR DME RTL MAXFEE 01/01/2014 12/31/2023 9.74 0.0 Y Description: SHOCK ABSORBER FOR MAN W/C Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1015 RR DME RTL MAXFEE 01/01/2024 14.50 0.0 Y Description: SHOCK ABSORBER FOR MAN W/C Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1016 NU DME PUR MAXFEE 01/01/2014 12/31/2023 111.61 0.0 Y Description: SHOCK ABSORBER FOR POWER W/C Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1016 NU DME PUR MAXFEE 01/01/2024 133.31 0.0 Y Description: SHOCK ABSORBER FOR POWER W/C Category: Durable Medical CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,646 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E1016 RR DME RTL MAXFEE 01/01/2014 12/31/2023 11.17 0.0 Y Description: SHOCK ABSORBER FOR POWER W/C Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1016 RR DME RTL MAXFEE 01/01/2024 13.98 0.0 Y Description: SHOCK ABSORBER FOR POWER W/C Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1017 DME DEF SYSMAN Y Y Description: HD SHCK ABSRBR FOR HD MAN WC Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1018 DME DEF SYSMAN Y Y Description: HD SHCK ABSRBER FOR HD POWWC Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1020 NU DME PUR MAXFEE 01/01/2014 12/31/2023 206.90 0.0 Y Description: RESIDUAL LIMB SUPPORT SYSTEM Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1020 NU DME PUR MAXFEE 01/01/2024 192.30 0.0 Y Description: RESIDUAL LIMB SUPPORT SYSTEM Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1020 RR DME RTL MAXFEE 01/01/2014 12/31/2023 20.67 0.0 Y Description: RESIDUAL LIMB SUPPORT SYSTEM Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1020 RR DME RTL MAXFEE 01/01/2024 19.23 0.0 Y Description: RESIDUAL LIMB SUPPORT SYSTEM Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1028 NU DME PUR MAXFEE 01/01/2014 12/31/2023 206.54 0.0 Y Description: W/C MANUAL SWINGAWAY Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E1028 NU DME PUR MAXFEE 01/01/2024 157.60 0.0 Y Description: W/C MANUAL SWINGAWAY Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E1028 RR DME RTL MAXFEE 01/01/2014 12/31/2023 20.65 0.0 Y Description: W/C MANUAL SWINGAWAY Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E1028 RR DME RTL MAXFEE 01/01/2024 15.76 0.0 Y Description: W/C MANUAL SWINGAWAY Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E1029 NU DME PUR MAXFEE 01/01/2014 12/31/2023 369.54 0.0 Description: W/C VENT TRAY FIXED Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E1029 NU DME PUR MAXFEE 01/01/2024 423.40 0.0 Description: W/C VENT TRAY FIXED Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E1030 NU DME PUR MAXFEE 01/01/2014 12/31/2023 1054.57 0.0 Description: W/C VENT TRAY GIMBALED Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E1030 NU DME PUR MAXFEE 01/01/2024 1335.70 0.0 Description: W/C VENT TRAY GIMBALED Category: Durable Medical CMS Add: 01/01/2004 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,647 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E1030 RR DME RTL MAXFEE 01/01/2014 12/31/2023 105.46 0.0 Description: W/C VENT TRAY GIMBALED Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E1030 RR DME RTL MAXFEE 01/01/2024 133.57 0.0 Description: W/C VENT TRAY GIMBALED Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E1031 NU DME PUR MAXFEE 01/01/2023 12/31/2023 530.80 0.0 Description: ROLLABOUT CHAIR WITH CASTERS Category: Durable Medical CMS Add: 01/01/1990 CMS Term: E1031 NU DME PUR MAXFEE 01/01/2024 508.20 0.0 Description: ROLLABOUT CHAIR WITH CASTERS Category: Durable Medical CMS Add: 01/01/1990 CMS Term: E1031 RR DME RTL MAXFEE 01/01/2023 12/31/2023 53.08 0.0 Description: ROLLABOUT CHAIR WITH CASTERS Category: Durable Medical CMS Add: 01/01/1990 CMS Term: E1031 RR DME RTL MAXFEE 01/01/2024 50.82 0.0 Description: ROLLABOUT CHAIR WITH CASTERS Category: Durable Medical CMS Add: 01/01/1990 CMS Term: E1035 NU DME PUR MAXFEE 01/01/2023 12/31/2023 7076.60 0.0 Y 0-1 Description: PATIENT TRANSFER SYSTEM <300 Category: Durable Medical CMS Add: 01/01/2001 CMS Term: E1035 NU DME PUR MAXFEE 01/01/2024 6918.70 0.0 Y 0-1 Description: PATIENT TRANSFER SYSTEM <300 Category: Durable Medical CMS Add: 01/01/2001 CMS Term: E1035 RR DME RTL MAXFEE 01/01/2023 12/31/2023 707.66 0.0 Y 0-1 Description: PATIENT TRANSFER SYSTEM <300 Category: Durable Medical CMS Add: 01/01/2001 CMS Term: E1035 RR DME RTL MAXFEE 01/01/2024 691.87 0.0 Y 0-1 Description: PATIENT TRANSFER SYSTEM <300 Category: Durable Medical CMS Add: 01/01/2001 CMS Term: E1036 NU DME PUR MAXFEE 01/01/2023 12/31/2023 10262.20 0.0 Y 0-1 Description: PATIENT TRANSFER SYSTEM >300 Category: Durable Medical CMS Add: 01/01/2010 CMS Term: E1036 NU DME PUR MAXFEE 01/01/2024 10168.40 0.0 Y 0-1 Description: PATIENT TRANSFER SYSTEM >300 Category: Durable Medical CMS Add: 01/01/2010 CMS Term: E1036 RR DME RTL MAXFEE 01/01/2023 12/31/2023 1026.22 0.0 Y 0-1 Description: PATIENT TRANSFER SYSTEM >300 Category: Durable Medical CMS Add: 01/01/2010 CMS Term: E1036 RR DME RTL MAXFEE 01/01/2024 1016.84 0.0 Y 0-1 Description: PATIENT TRANSFER SYSTEM >300 Category: Durable Medical CMS Add: 01/01/2010 CMS Term: E1037 NU DME PUR MAXFEE 01/01/2023 12/31/2023 1311.70 0.0 Y Description: TRANSPORT CHAIR, PED SIZE Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1037 NU DME PUR MAXFEE 01/01/2024 1306.10 0.0 Y Description: TRANSPORT CHAIR, PED SIZE Category: Durable Medical CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,648 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E1037 RR DME RTL MAXFEE 01/01/2023 12/31/2023 131.17 0.0 Y Description: TRANSPORT CHAIR, PED SIZE Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1037 RR DME RTL MAXFEE 01/01/2024 130.61 0.0 Y Description: TRANSPORT CHAIR, PED SIZE Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1038 NU DME PUR MAXFEE 01/01/2023 12/31/2023 183.10 0.0 Y Description: TRANSPORT CHAIR PT WT<=300LB Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1038 NU DME PUR MAXFEE 01/01/2024 169.10 0.0 Y Description: TRANSPORT CHAIR PT WT<=300LB Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1038 RR DME RTL MAXFEE 01/01/2023 12/31/2023 18.31 0.0 Y Description: TRANSPORT CHAIR PT WT<=300LB Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1038 RR DME RTL MAXFEE 01/01/2024 16.91 0.0 Y Description: TRANSPORT CHAIR PT WT<=300LB Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1039 NU DME PUR MAXFEE 01/01/2023 12/31/2023 396.80 0.0 Y Description: TRANSPORT CHAIR PT WT >300LB Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E1039 NU DME PUR MAXFEE 01/01/2024 388.80 0.0 Y Description: TRANSPORT CHAIR PT WT >300LB Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E1039 RR DME RTL MAXFEE 01/01/2023 12/31/2023 39.68 0.0 Y Description: TRANSPORT CHAIR PT WT >300LB Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E1039 RR DME RTL MAXFEE 01/01/2024 38.88 0.0 Y Description: TRANSPORT CHAIR PT WT >300LB Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E1050 NU DME PUR MAXFEE 01/01/2014 12/31/2023 953.61 0.0 Y Description: WHELCHR FXD FULL LENGTH ARMS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1050 NU DME PUR MAXFEE 01/01/2024 1354.50 0.0 Y Description: WHELCHR FXD FULL LENGTH ARMS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1050 RR DME RTL MAXFEE 01/01/2014 12/31/2023 78.73 0.0 Y Description: WHELCHR FXD FULL LENGTH ARMS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1050 RR DME RTL MAXFEE 01/01/2024 135.45 0.0 Y Description: WHELCHR FXD FULL LENGTH ARMS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1060 NU DME PUR MAXFEE 01/01/2014 12/31/2023 1483.00 0.0 Y Description: WHEELCHAIR DETACHABLE ARMS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1060 NU DME PUR MAXFEE 01/01/2024 1676.40 0.0 Y Description: WHEELCHAIR DETACHABLE ARMS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,649 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E1060 RR DME RTL MAXFEE 01/01/2014 12/31/2023 99.88 0.0 Y Description: WHEELCHAIR DETACHABLE ARMS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1060 RR DME RTL MAXFEE 01/01/2024 167.64 0.0 Y Description: WHEELCHAIR DETACHABLE ARMS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1070 NU DME PUR MAXFEE 01/01/2014 12/31/2023 1067.85 0.0 Y Description: WHEELCHAIR DETACHABLE FOOT R Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1070 NU DME PUR MAXFEE 01/01/2024 1456.70 0.0 Y Description: WHEELCHAIR DETACHABLE FOOT R Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1070 RR DME RTL MAXFEE 01/01/2014 12/31/2023 88.16 0.0 Y Description: WHEELCHAIR DETACHABLE FOOT R Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1070 RR DME RTL MAXFEE 01/01/2024 145.67 0.0 Y Description: WHEELCHAIR DETACHABLE FOOT R Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1083 NU DME PUR MAXFEE 01/01/2014 12/31/2023 762.30 0.0 Y Description: HEMI-WHEELCHAIR FIXED ARMS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1083 NU DME PUR MAXFEE 01/01/2024 1047.10 0.0 Y Description: HEMI-WHEELCHAIR FIXED ARMS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1083 RR DME RTL MAXFEE 01/01/2014 12/31/2023 56.63 0.0 Y Description: HEMI-WHEELCHAIR FIXED ARMS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1083 RR DME RTL MAXFEE 01/01/2024 104.71 0.0 Y Description: HEMI-WHEELCHAIR FIXED ARMS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1084 NU DME PUR MAXFEE 01/01/2014 12/31/2023 1139.04 0.0 Y Description: HEMI-WHEELCHAIR DETACHABLE A Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1084 NU DME PUR MAXFEE 01/01/2024 1304.60 0.0 Y Description: HEMI-WHEELCHAIR DETACHABLE A Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1084 RR DME RTL MAXFEE 01/01/2014 12/31/2023 82.61 0.0 Y Description: HEMI-WHEELCHAIR DETACHABLE A Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1084 RR DME RTL MAXFEE 01/01/2024 130.46 0.0 Y Description: HEMI-WHEELCHAIR DETACHABLE A Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1085 NU DME PUR MAXFEE 01/01/2014 12/31/2023 745.00 0.0 Y Description: HEMI-WHEELCHAIR FIXED ARMS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1085 NU DME PUR MAXFEE 01/01/2024 968.50 0.0 Y Description: HEMI-WHEELCHAIR FIXED ARMS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,650 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E1085 RR DME RTL MAXFEE 01/01/2014 12/31/2023 58.10 0.0 Y Description: HEMI-WHEELCHAIR FIXED ARMS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1085 RR DME RTL MAXFEE 01/01/2024 75.53 0.0 Y Description: HEMI-WHEELCHAIR FIXED ARMS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1086 NU DME PUR MAXFEE 01/01/2014 12/31/2023 860.00 0.0 Y Description: HEMI-WHEELCHAIR DETACHABLE A Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1086 NU DME PUR MAXFEE 01/01/2024 1118.00 0.0 Y Description: HEMI-WHEELCHAIR DETACHABLE A Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1086 RR DME RTL MAXFEE 01/01/2014 12/31/2023 71.01 0.0 Y Description: HEMI-WHEELCHAIR DETACHABLE A Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1086 RR DME RTL MAXFEE 01/01/2024 92.31 0.0 Y Description: HEMI-WHEELCHAIR DETACHABLE A Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1087 NU DME PUR MAXFEE 01/01/2014 12/31/2023 1661.78 0.0 Y Description: WHEELCHAIR LIGHTWT FIXED ARM Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1087 NU DME PUR MAXFEE 01/01/2024 1682.70 0.0 Y Description: WHEELCHAIR LIGHTWT FIXED ARM Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1087 RR DME RTL MAXFEE 01/01/2014 12/31/2023 104.02 0.0 Y Description: WHEELCHAIR LIGHTWT FIXED ARM Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1087 RR DME RTL MAXFEE 01/01/2024 168.27 0.0 Y Description: WHEELCHAIR LIGHTWT FIXED ARM Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1088 NU DME PUR MAXFEE 01/01/2024 1748.60 0.0 Y Description: WHEELCHAIR LIGHTWEIGHT DET A Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1088 NU DME PUR MAXFEE 02/01/2021 12/31/2023 1491.80 0.0 Y Description: WHEELCHAIR LIGHTWEIGHT DET A Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1088 RR DME RTL MAXFEE 01/01/2024 174.86 0.0 Y Description: WHEELCHAIR LIGHTWEIGHT DET A Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1088 RR DME RTL MAXFEE 02/01/2021 12/31/2023 149.18 0.0 Y Description: WHEELCHAIR LIGHTWEIGHT DET A Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1089 NU DME PUR MAXFEE 01/01/2014 12/31/2023 1610.93 0.0 Y Description: WHEELCHAIR LIGHTWT FIXED ARM Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1089 NU DME PUR MAXFEE 01/01/2024 2094.21 0.0 Y Description: WHEELCHAIR LIGHTWT FIXED ARM Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,651 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E1089 RR DME RTL MAXFEE 01/01/2014 12/31/2023 91.06 0.0 Y Description: WHEELCHAIR LIGHTWT FIXED ARM Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1089 RR DME RTL MAXFEE 01/01/2024 118.38 0.0 Y Description: WHEELCHAIR LIGHTWT FIXED ARM Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1090 NU DME PUR MAXFEE 01/01/2014 12/31/2023 1626.70 0.0 Y Description: WHEELCHAIR LIGHTWEIGHT DET A Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1090 NU DME PUR MAXFEE 01/01/2024 2114.71 0.0 Y Description: WHEELCHAIR LIGHTWEIGHT DET A Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1090 RR DME RTL MAXFEE 01/01/2014 12/31/2023 103.36 0.0 Y Description: WHEELCHAIR LIGHTWEIGHT DET A Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1090 RR DME RTL MAXFEE 01/01/2024 134.37 0.0 Y Description: WHEELCHAIR LIGHTWEIGHT DET A Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1092 NU DME PUR MAXFEE 01/01/2014 12/31/2023 1675.00 0.0 Y Description: WHEELCHAIR WIDE W/ LEG RESTS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1092 NU DME PUR MAXFEE 01/01/2024 1709.10 0.0 Y Description: WHEELCHAIR WIDE W/ LEG RESTS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1092 RR DME RTL MAXFEE 01/01/2014 12/31/2023 107.27 0.0 Y Description: WHEELCHAIR WIDE W/ LEG RESTS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1092 RR DME RTL MAXFEE 01/01/2024 170.91 0.0 Y Description: WHEELCHAIR WIDE W/ LEG RESTS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1093 NU DME PUR MAXFEE 01/01/2024 1508.00 0.0 Y Description: WHEELCHAIR WIDE W/ FOOT REST Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1093 NU DME PUR MAXFEE 02/01/2021 12/31/2023 1286.60 0.0 Y Description: WHEELCHAIR WIDE W/ FOOT REST Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1093 RR DME RTL MAXFEE 01/01/2024 150.80 0.0 Y Description: WHEELCHAIR WIDE W/ FOOT REST Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1093 RR DME RTL MAXFEE 02/01/2021 12/31/2023 128.66 0.0 Y Description: WHEELCHAIR WIDE W/ FOOT REST Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1100 NU DME PUR MAXFEE 01/01/2014 12/31/2023 1105.00 0.0 Y Description: WHCHR S-RECL FXD ARM LEG RES Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1100 NU DME PUR MAXFEE 01/01/2024 1380.40 0.0 Y Description: WHCHR S-RECL FXD ARM LEG RES Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,652 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E1100 RR DME RTL MAXFEE 01/01/2014 12/31/2023 80.51 0.0 Y Description: WHCHR S-RECL FXD ARM LEG RES Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1100 RR DME RTL MAXFEE 01/01/2024 138.04 0.0 Y Description: WHCHR S-RECL FXD ARM LEG RES Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1110 NU DME PUR MAXFEE 01/01/2014 12/31/2023 1371.25 0.0 Y Description: WHEELCHAIR SEMI-RECL DETACH Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1110 NU DME PUR MAXFEE 01/01/2024 1351.80 0.0 Y Description: WHEELCHAIR SEMI-RECL DETACH Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1110 RR DME RTL MAXFEE 01/01/2014 12/31/2023 89.44 0.0 Y Description: WHEELCHAIR SEMI-RECL DETACH Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1110 RR DME RTL MAXFEE 01/01/2024 135.18 0.0 Y Description: WHEELCHAIR SEMI-RECL DETACH Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1130 NU DME PUR MAXFEE 01/01/2014 12/31/2023 625.00 0.0 Y Description: WHLCHR STAND FXD ARM FT REST Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1130 NU DME PUR MAXFEE 01/01/2024 812.50 0.0 Y Description: WHLCHR STAND FXD ARM FT REST Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1130 RR DME RTL MAXFEE 01/01/2014 12/31/2023 35.69 0.0 Y Description: WHLCHR STAND FXD ARM FT REST Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1130 RR DME RTL MAXFEE 01/01/2024 46.40 0.0 Y Description: WHLCHR STAND FXD ARM FT REST Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1140 NU DME PUR MAXFEE 01/01/2014 12/31/2023 685.00 0.0 Y Description: WHEELCHAIR STANDARD DETACH A Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1140 NU DME PUR MAXFEE 01/01/2024 890.50 0.0 Y Description: WHEELCHAIR STANDARD DETACH A Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1140 RR DME RTL MAXFEE 01/01/2014 12/31/2023 51.80 0.0 Y Description: WHEELCHAIR STANDARD DETACH A Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1140 RR DME RTL MAXFEE 01/01/2024 67.34 0.0 Y Description: WHEELCHAIR STANDARD DETACH A Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1150 NU DME PUR MAXFEE 01/01/2023 975.30 0.0 Y Description: WHEELCHAIR STANDARD W/ LEG R Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1150 RR DME RTL MAXFEE 01/01/2023 97.53 0.0 Y Description: WHEELCHAIR STANDARD W/ LEG R Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,653 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E1160 NU DME PUR MAXFEE 01/01/2023 806.80 0.0 Y Description: WHEELCHAIR FIXED ARMS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1160 RR DME RTL MAXFEE 01/01/2023 80.68 0.0 Y Description: WHEELCHAIR FIXED ARMS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1161 NU DME PUR MAXFEE 01/01/2023 12/31/2023 3146.50 0.0 Y Description: MANUAL ADULT WC W TILTINSPAC Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1161 NU DME PUR MAXFEE 01/01/2024 3228.30 0.0 Y Description: MANUAL ADULT WC W TILTINSPAC Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1161 RR DME RTL MAXFEE 01/01/2023 12/31/2023 314.65 0.0 Y Description: MANUAL ADULT WC W TILTINSPAC Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1161 RR DME RTL MAXFEE 01/01/2024 322.83 0.0 Y Description: MANUAL ADULT WC W TILTINSPAC Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1170 NU DME PUR MAXFEE 01/01/2014 12/31/2023 1215.00 0.0 Y Description: WHLCHR AMPU FXD ARM LEG REST Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1170 NU DME PUR MAXFEE 01/01/2024 1187.90 0.0 Y Description: WHLCHR AMPU FXD ARM LEG REST Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1170 RR DME RTL MAXFEE 01/01/2014 12/31/2023 61.60 0.0 Y Description: WHLCHR AMPU FXD ARM LEG REST Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1170 RR DME RTL MAXFEE 01/01/2024 118.79 0.0 Y Description: WHLCHR AMPU FXD ARM LEG REST Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1171 NU DME PUR MAXFEE 01/01/2014 12/31/2023 985.00 0.0 Y Description: WHEELCHAIR AMPUTEE W/O LEG R Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1171 NU DME PUR MAXFEE 01/01/2024 1065.90 0.0 Y Description: WHEELCHAIR AMPUTEE W/O LEG R Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1171 RR DME RTL MAXFEE 01/01/2014 12/31/2023 67.52 0.0 Y Description: WHEELCHAIR AMPUTEE W/O LEG R Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1171 RR DME RTL MAXFEE 01/01/2024 106.59 0.0 Y Description: WHEELCHAIR AMPUTEE W/O LEG R Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1172 NU DME PUR MAXFEE 01/01/2014 12/31/2023 1250.00 0.0 Y Description: WHEELCHAIR AMPUTEE DETACH AR Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1172 NU DME PUR MAXFEE 01/01/2024 1303.00 0.0 Y Description: WHEELCHAIR AMPUTEE DETACH AR Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,654 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E1172 RR DME RTL MAXFEE 01/01/2014 12/31/2023 80.73 0.0 Y Description: WHEELCHAIR AMPUTEE DETACH AR Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1172 RR DME RTL MAXFEE 01/01/2024 130.30 0.0 Y Description: WHEELCHAIR AMPUTEE DETACH AR Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1180 NU DME PUR MAXFEE 01/01/2014 12/31/2023 1270.00 0.0 Y Description: WHEELCHAIR AMPUTEE W/ FOOT R Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1180 NU DME PUR MAXFEE 01/01/2024 1347.70 0.0 Y Description: WHEELCHAIR AMPUTEE W/ FOOT R Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1180 RR DME RTL MAXFEE 01/01/2014 12/31/2023 82.16 0.0 Y Description: WHEELCHAIR AMPUTEE W/ FOOT R Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1180 RR DME RTL MAXFEE 01/01/2024 134.77 0.0 Y Description: WHEELCHAIR AMPUTEE W/ FOOT R Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1190 NU DME PUR MAXFEE 01/01/2014 12/31/2023 1362.50 0.0 Y Description: WHEELCHAIR AMPUTEE W/ LEG RE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1190 NU DME PUR MAXFEE 01/01/2024 1556.90 0.0 Y Description: WHEELCHAIR AMPUTEE W/ LEG RE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1190 RR DME RTL MAXFEE 01/01/2014 12/31/2023 92.45 0.0 Y Description: WHEELCHAIR AMPUTEE W/ LEG RE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1190 RR DME RTL MAXFEE 01/01/2024 155.69 0.0 Y Description: WHEELCHAIR AMPUTEE W/ LEG RE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1195 NU DME PUR MAXFEE 01/01/2014 12/31/2023 1050.00 0.0 Y Description: WHEELCHAIR AMPUTEE HEAVY DUT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1195 NU DME PUR MAXFEE 01/01/2024 1499.60 0.0 Y Description: WHEELCHAIR AMPUTEE HEAVY DUT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1195 RR DME RTL MAXFEE 01/01/2014 12/31/2023 90.08 0.0 Y Description: WHEELCHAIR AMPUTEE HEAVY DUT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1195 RR DME RTL MAXFEE 01/01/2024 149.96 0.0 Y Description: WHEELCHAIR AMPUTEE HEAVY DUT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1200 NU DME PUR MAXFEE 01/01/2014 12/31/2023 1072.50 0.0 Y Description: WHEELCHAIR AMPUTEE FIXED ARM Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1200 NU DME PUR MAXFEE 01/01/2024 1157.10 0.0 Y Description: WHEELCHAIR AMPUTEE FIXED ARM Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,655 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E1200 RR DME RTL MAXFEE 01/01/2014 12/31/2023 71.59 0.0 Y Description: WHEELCHAIR AMPUTEE FIXED ARM Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1200 RR DME RTL MAXFEE 01/01/2024 115.71 0.0 Y Description: WHEELCHAIR AMPUTEE FIXED ARM Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1220 DME DEF SYSMAN Y Y Description: WHLCHR SPECIAL SIZE/CONSTRC Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1221 NU DME PUR MAXFEE 01/01/2014 12/31/2023 650.00 0.0 Y Description: WHEELCHAIR SPEC SIZE W FOOT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1221 NU DME PUR MAXFEE 01/01/2024 537.10 0.0 Y Description: WHEELCHAIR SPEC SIZE W FOOT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1221 RR DME RTL MAXFEE 01/01/2014 12/31/2023 34.19 0.0 Y Description: WHEELCHAIR SPEC SIZE W FOOT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1221 RR DME RTL MAXFEE 01/01/2024 53.71 0.0 Y Description: WHEELCHAIR SPEC SIZE W FOOT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1222 NU DME PUR MAXFEE 01/01/2014 12/31/2023 1154.96 0.0 Y Description: WHEELCHAIR SPEC SIZE W/ LEG Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1222 NU DME PUR MAXFEE 01/01/2024 766.10 0.0 Y Description: WHEELCHAIR SPEC SIZE W/ LEG Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1222 RR DME RTL MAXFEE 01/01/2014 12/31/2023 53.79 0.0 Y Description: WHEELCHAIR SPEC SIZE W/ LEG Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1222 RR DME RTL MAXFEE 01/01/2024 76.61 0.0 Y Description: WHEELCHAIR SPEC SIZE W/ LEG Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1223 NU DME PUR MAXFEE 01/01/2014 12/31/2023 3101.37 0.0 Y Description: WHEELCHAIR SPEC SIZE W FOOT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1223 NU DME PUR MAXFEE 01/01/2024 934.30 0.0 Y Description: WHEELCHAIR SPEC SIZE W FOOT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1223 RR DME RTL MAXFEE 01/01/2014 12/31/2023 52.23 0.0 Y Description: WHEELCHAIR SPEC SIZE W FOOT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1223 RR DME RTL MAXFEE 01/01/2024 93.43 0.0 Y Description: WHEELCHAIR SPEC SIZE W FOOT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1224 NU DME PUR MAXFEE 01/01/2014 12/31/2023 875.00 0.0 Y Description: WHEELCHAIR SPEC SIZE W/ LEG Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,656 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E1224 NU DME PUR MAXFEE 01/01/2024 1079.20 0.0 Y Description: WHEELCHAIR SPEC SIZE W/ LEG Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1224 RR DME RTL MAXFEE 01/01/2014 12/31/2023 60.04 0.0 Y Description: WHEELCHAIR SPEC SIZE W/ LEG Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1224 RR DME RTL MAXFEE 01/01/2024 107.92 0.0 Y Description: WHEELCHAIR SPEC SIZE W/ LEG Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1225 DME DEF MAXFEE 01/01/2014 12/31/2023 338.70 0.0 Y Description: MANUAL SEMI-RECLINING BACK Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1225 DME DEF MAXFEE 01/01/2024 427.50 0.0 Y Description: MANUAL SEMI-RECLINING BACK Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1226 DME DEF MAXFEE 01/01/2014 12/31/2023 401.70 0.0 Y Description: MANUAL FULLY RECLINING BACK Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1226 DME DEF MAXFEE 01/01/2024 431.45 0.0 Y Description: MANUAL FULLY RECLINING BACK Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1227 DME DEF MAXFEE 01/01/2014 12/31/2023 239.65 0.0 Y Description: WHEELCHAIR SPEC SZ SPEC HT A Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1227 DME DEF MAXFEE 01/01/2024 369.04 0.0 Y Description: WHEELCHAIR SPEC SZ SPEC HT A Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1228 DME DEF MAXFEE 01/01/2014 12/31/2023 171.60 0.0 Y Description: WHEELCHAIR SPEC SZ SPEC HT B Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1228 DME DEF MAXFEE 01/01/2024 316.80 0.0 Y Description: WHEELCHAIR SPEC SZ SPEC HT B Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1229 DME DEF SYSMAN Y Y Description: PEDIATRIC WHEELCHAIR NOS Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E1230 NOCOV DEF SYSMAN Description: POWER OPERATED VEHICLE Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: E1231 DME DEF SYSMAN Y Y Description: RIGID PED W/C TILT-IN-SPACE Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1232 NU DME PUR MAXFEE 01/01/2023 12/31/2023 2844.10 0.0 Y Description: FOLDING PED WC TILT-IN-SPACE Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1232 NU DME PUR MAXFEE 01/01/2024 2918.00 0.0 Y Description: FOLDING PED WC TILT-IN-SPACE Category: Durable Medical CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,657 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E1232 RR DME RTL MAXFEE 01/01/2023 12/31/2023 284.41 0.0 Y Description: FOLDING PED WC TILT-IN-SPACE Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1232 RR DME RTL MAXFEE 01/01/2024 291.80 0.0 Y Description: FOLDING PED WC TILT-IN-SPACE Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1233 NU DME PUR MAXFEE 01/01/2023 12/31/2023 2946.50 0.0 Y Description: RIG PED WC TLTNSPC W/O SEAT Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1233 NU DME PUR MAXFEE 01/01/2024 3023.10 0.0 Y Description: RIG PED WC TLTNSPC W/O SEAT Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1233 RR DME RTL MAXFEE 01/01/2023 12/31/2023 294.65 0.0 Y Description: RIG PED WC TLTNSPC W/O SEAT Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1233 RR DME RTL MAXFEE 01/01/2024 302.31 0.0 Y Description: RIG PED WC TLTNSPC W/O SEAT Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1234 NU DME PUR MAXFEE 01/01/2023 12/31/2023 2565.30 0.0 Y Description: FLD PED WC TLTNSPC W/O SEAT Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1234 NU DME PUR MAXFEE 01/01/2024 2632.00 0.0 Y Description: FLD PED WC TLTNSPC W/O SEAT Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1234 RR DME RTL MAXFEE 01/01/2023 12/31/2023 256.53 0.0 Y Description: FLD PED WC TLTNSPC W/O SEAT Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1234 RR DME RTL MAXFEE 01/01/2024 263.20 0.0 Y Description: FLD PED WC TLTNSPC W/O SEAT Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1235 NU DME PUR MAXFEE 01/01/2023 12/31/2023 2470.30 0.0 Y Description: RIGID PED WC ADJUSTABLE Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1235 NU DME PUR MAXFEE 01/01/2024 2534.50 0.0 Y Description: RIGID PED WC ADJUSTABLE Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1235 RR DME RTL MAXFEE 01/01/2023 12/31/2023 247.03 0.0 Y Description: RIGID PED WC ADJUSTABLE Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1235 RR DME RTL MAXFEE 01/01/2024 253.45 0.0 Y Description: RIGID PED WC ADJUSTABLE Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1236 NU DME PUR MAXFEE 01/01/2023 12/31/2023 2179.30 0.0 Y Description: FOLDING PED WC ADJUSTABLE Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1236 NU DME PUR MAXFEE 01/01/2024 2236.00 0.0 Y Description: FOLDING PED WC ADJUSTABLE Category: Durable Medical CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,658 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E1236 RR DME RTL MAXFEE 01/01/2023 12/31/2023 217.93 0.0 Y Description: FOLDING PED WC ADJUSTABLE Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1236 RR DME RTL MAXFEE 01/01/2024 223.60 0.0 Y Description: FOLDING PED WC ADJUSTABLE Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1237 NU DME PUR MAXFEE 01/01/2023 12/31/2023 2198.20 0.0 Y Description: RGD PED WC ADJSTABL W/O SEAT Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1237 NU DME PUR MAXFEE 01/01/2024 2255.40 0.0 Y Description: RGD PED WC ADJSTABL W/O SEAT Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1237 RR DME RTL MAXFEE 01/01/2023 12/31/2023 219.82 0.0 Y Description: RGD PED WC ADJSTABL W/O SEAT Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1237 RR DME RTL MAXFEE 01/01/2024 225.54 0.0 Y Description: RGD PED WC ADJSTABL W/O SEAT Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1238 NU DME PUR MAXFEE 01/01/2023 12/31/2023 2179.30 0.0 Y Description: FLD PED WC ADJSTABL W/O SEAT Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1238 NU DME PUR MAXFEE 01/01/2024 2236.00 0.0 Y Description: FLD PED WC ADJSTABL W/O SEAT Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1238 RR DME RTL MAXFEE 01/01/2023 12/31/2023 217.93 0.0 Y Description: FLD PED WC ADJSTABL W/O SEAT Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1238 RR DME RTL MAXFEE 01/01/2024 223.60 0.0 Y Description: FLD PED WC ADJSTABL W/O SEAT Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1239 NOCOV DEF SYSMAN Description: PED POWER WHEELCHAIR NOS Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: E1240 NU DME PUR MAXFEE 01/01/2014 12/31/2023 1065.00 0.0 Y Description: WHCHR LITWT DET ARM LEG REST Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1240 NU DME PUR MAXFEE 01/01/2024 1270.60 0.0 Y Description: WHCHR LITWT DET ARM LEG REST Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1240 RR DME RTL MAXFEE 01/01/2014 12/31/2023 70.46 0.0 Y Description: WHCHR LITWT DET ARM LEG REST Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1240 RR DME RTL MAXFEE 01/01/2024 127.06 0.0 Y Description: WHCHR LITWT DET ARM LEG REST Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1250 NU DME PUR MAXFEE 01/01/2014 12/31/2023 664.31 0.0 Y Description: WHEELCHAIR LIGHTWT FIXED ARM Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,659 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E1250 NU DME PUR MAXFEE 01/01/2024 863.60 0.0 Y Description: WHEELCHAIR LIGHTWT FIXED ARM Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1250 RR DME RTL MAXFEE 01/01/2014 12/31/2023 60.74 0.0 Y Description: WHEELCHAIR LIGHTWT FIXED ARM Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1250 RR DME RTL MAXFEE 01/01/2024 78.96 0.0 Y Description: WHEELCHAIR LIGHTWT FIXED ARM Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1260 NU DME PUR MAXFEE 01/01/2014 12/31/2023 795.00 0.0 Y Description: WHEELCHAIR LIGHTWT FOOT REST Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1260 NU DME PUR MAXFEE 01/01/2024 1033.50 0.0 Y Description: WHEELCHAIR LIGHTWT FOOT REST Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1260 RR DME RTL MAXFEE 01/01/2014 12/31/2023 79.82 0.0 Y Description: WHEELCHAIR LIGHTWT FOOT REST Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1260 RR DME RTL MAXFEE 01/01/2024 103.77 0.0 Y Description: WHEELCHAIR LIGHTWT FOOT REST Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1270 NU DME PUR MAXFEE 01/01/2014 12/31/2023 700.00 0.0 Y Description: WHEELCHAIR LIGHTWEIGHT LEG R Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1270 NU DME PUR MAXFEE 01/01/2024 893.00 0.0 Y Description: WHEELCHAIR LIGHTWEIGHT LEG R Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1270 RR DME RTL MAXFEE 01/01/2014 12/31/2023 56.40 0.0 Y Description: WHEELCHAIR LIGHTWEIGHT LEG R Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1270 RR DME RTL MAXFEE 01/01/2024 89.30 0.0 Y Description: WHEELCHAIR LIGHTWEIGHT LEG R Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1280 NU DME PUR MAXFEE 01/01/2014 12/31/2023 1612.50 0.0 Y Description: WHCHR H-DUTY DET ARM LEG RES Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1280 NU DME PUR MAXFEE 01/01/2024 1732.20 0.0 Y Description: WHCHR H-DUTY DET ARM LEG RES Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1280 RR DME RTL MAXFEE 01/01/2014 12/31/2023 93.70 0.0 Y Description: WHCHR H-DUTY DET ARM LEG RES Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1280 RR DME RTL MAXFEE 01/01/2024 173.22 0.0 Y Description: WHCHR H-DUTY DET ARM LEG RES Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1285 NU DME PUR MAXFEE 01/01/2014 12/31/2023 850.00 0.0 Y Description: WHEELCHAIR HEAVY DUTY FIXED Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,660 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E1285 NU DME PUR MAXFEE 01/01/2024 1105.00 0.0 Y Description: WHEELCHAIR HEAVY DUTY FIXED Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1285 RR DME RTL MAXFEE 01/01/2014 12/31/2023 78.27 0.0 Y Description: WHEELCHAIR HEAVY DUTY FIXED Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1285 RR DME RTL MAXFEE 01/01/2024 101.75 0.0 Y Description: WHEELCHAIR HEAVY DUTY FIXED Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1290 NU DME PUR MAXFEE 01/01/2014 12/31/2023 1520.00 0.0 Y Description: WHEELCHAIR HVY DUTY DETACH A Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1290 NU DME PUR MAXFEE 01/01/2024 1976.00 0.0 Y Description: WHEELCHAIR HVY DUTY DETACH A Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1290 RR DME RTL MAXFEE 01/01/2014 12/31/2023 92.70 0.0 Y Description: WHEELCHAIR HVY DUTY DETACH A Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1290 RR DME RTL MAXFEE 01/01/2024 120.51 0.0 Y Description: WHEELCHAIR HVY DUTY DETACH A Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1295 NU DME PUR MAXFEE 01/01/2014 12/31/2023 982.42 0.0 Y Description: WHEELCHAIR HEAVY DUTY FIXED Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1295 NU DME PUR MAXFEE 01/01/2024 1499.60 0.0 Y Description: WHEELCHAIR HEAVY DUTY FIXED Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1295 RR DME RTL MAXFEE 01/01/2014 12/31/2023 97.49 0.0 Y Description: WHEELCHAIR HEAVY DUTY FIXED Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1295 RR DME RTL MAXFEE 01/01/2024 149.96 0.0 Y Description: WHEELCHAIR HEAVY DUTY FIXED Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1296 DME DEF MAXFEE 01/01/2014 12/31/2023 407.05 0.0 Y Description: WHEELCHAIR SPECIAL SEAT HEIG Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1296 DME DEF MAXFEE 01/01/2024 634.42 0.0 Y Description: WHEELCHAIR SPECIAL SEAT HEIG Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1297 NU DME PUR MAXFEE 01/01/2014 12/31/2023 110.81 0.0 Y Description: WHEELCHAIR SPECIAL SEAT DEPT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1297 NU DME PUR MAXFEE 01/01/2024 138.11 0.0 Y Description: WHEELCHAIR SPECIAL SEAT DEPT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1297 RR DME RTL MAXFEE 01/01/2014 12/31/2023 54.00 0.0 Y Description: WHEELCHAIR SPECIAL SEAT DEPT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,661 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E1297 RR DME RTL MAXFEE 01/01/2024 13.83 0.0 Y Description: WHEELCHAIR SPECIAL SEAT DEPT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1298 DME DEF MAXFEE 01/01/2014 12/31/2023 359.49 0.0 Y Description: WHEELCHAIR SPEC SEAT DEPTH/W Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1298 DME DEF MAXFEE 01/01/2024 563.41 0.0 Y Description: WHEELCHAIR SPEC SEAT DEPTH/W Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1300 NOCOV DEF SYSMAN Description: WHIRLPOOL PORTABLE Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: E1301 NOCOV DEF SYSMAN Description: WHIRLPOOL TUB WALKIN PORTABL Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: E1310 NU DME PUR MAXFEE 01/01/2014 12/31/2023 1649.95 0.0 Y Description: WHIRLPOOL NON-PORTABLE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1310 NU DME PUR MAXFEE 01/01/2024 2427.41 0.0 Y Description: WHIRLPOOL NON-PORTABLE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1310 RR DME RTL MAXFEE 01/01/2014 12/31/2023 147.47 0.0 Y Description: WHIRLPOOL NON-PORTABLE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1310 RR DME RTL MAXFEE 01/01/2024 207.60 0.0 Y Description: WHIRLPOOL NON-PORTABLE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1352 DME DEF SYSMAN Y Y Description: O2 FLOW REG POS INSPIR PRESS Category: Durable Medical CMS Add: 01/01/2014 CMS Term: E1353 NU DME PUR MAXFEE 01/01/2014 12/31/2023 132.50 0.0 Y Description: OXYGEN SUPPLIES REGULATOR Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1353 NU DME PUR MAXFEE 01/01/2024 376.60 0.0 Y Description: OXYGEN SUPPLIES REGULATOR Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1353 RR DME RTL MAXFEE 01/01/2014 12/31/2023 42.00 0.0 Y Description: OXYGEN SUPPLIES REGULATOR Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1353 RR DME RTL MAXFEE 01/01/2024 37.66 0.0 Y Description: OXYGEN SUPPLIES REGULATOR Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1354 NOCOV DEF SYSMAN Description: WHEELED CART, PORT CYL/CONC Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: E1355 DME DEF MAXFEE 01/01/2014 12/31/2023 22.40 0.0 Y Description: OXYGEN SUPPLIES STAND/RACK Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,662 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E1355 DME DEF MAXFEE 01/01/2024 28.38 0.0 Y Description: OXYGEN SUPPLIES STAND/RACK Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1356 DME DEF SYSMAN Y Y Description: BATT PACK/CART, PORT CONC Category: Durable Medical CMS Add: 01/01/2009 CMS Term: E1357 DME DEF SYSMAN Y Y Description: BATTERY CHARGER, PORT CONC Category: Durable Medical CMS Add: 01/01/2009 CMS Term: E1358 DME DEF SYSMAN Y Y Description: DC POWER ADAPTER, PORT CONC Category: Durable Medical CMS Add: 01/01/2009 CMS Term: E1372 NU DME PUR MAXFEE 01/01/2014 12/31/2023 133.30 0.0 Y Description: OXY SUPPL HEATER FOR NEBULIZ Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1372 NU DME PUR MAXFEE 01/01/2024 152.77 0.0 Y Description: OXY SUPPL HEATER FOR NEBULIZ Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1372 RR DME RTL MAXFEE 01/01/2014 12/31/2023 20.00 0.0 Y Description: OXY SUPPL HEATER FOR NEBULIZ Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1372 RR DME RTL MAXFEE 01/01/2024 19.51 0.0 Y Description: OXY SUPPL HEATER FOR NEBULIZ Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1390 RR DME RTL MAXFEE 01/01/2023 12/31/2023 125.61 0.0 Y 0-1 Description: OXYGEN CONCENTRATOR Category: Durable Medical CMS Add: 01/01/2000 CMS Term: E1390 RR DME RTL MAXFEE 01/01/2024 93.89 0.0 Y 0-1 Description: OXYGEN CONCENTRATOR Category: Durable Medical CMS Add: 01/01/2000 CMS Term: E1390 RR QB DME RTL MAXFEE 01/01/2024 93.89 0.0 Y 0-1 Description: OXYGEN CONCENTRATOR Category: Durable Medical CMS Add: 01/01/2000 CMS Term: E1390 RR QF DME RTL MAXFEE 01/01/2024 93.89 0.0 Y 0-1 Description: OXYGEN CONCENTRATOR Category: Durable Medical CMS Add: 01/01/2000 CMS Term: E1391 RR DME RTL MAXFEE 01/01/2023 12/31/2023 125.61 0.0 Y Description: OXYGEN CONCENTRATOR, DUAL Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E1391 RR DME RTL MAXFEE 01/01/2024 93.89 0.0 Y Description: OXYGEN CONCENTRATOR, DUAL Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E1391 RR QB DME RTL MAXFEE 01/01/2024 93.89 0.0 Y Description: OXYGEN CONCENTRATOR, DUAL Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E1391 RR QF DME RTL MAXFEE 01/01/2024 93.89 0.0 Y Description: OXYGEN CONCENTRATOR, DUAL Category: Durable Medical CMS Add: 01/01/2004 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,663 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E1392 RR DME RTL MAXFEE 01/01/2023 12/31/2023 44.76 0.0 Y Description: PORTABLE OXYGEN CONCENTRATOR Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E1392 RR DME RTL MAXFEE 01/01/2024 43.75 0.0 Y Description: PORTABLE OXYGEN CONCENTRATOR Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E1392 RR QB DME RTL MAXFEE 01/01/2023 12/31/2023 62.81 0.0 Y Description: PORTABLE OXYGEN CONCENTRATOR Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E1392 RR QB DME RTL MAXFEE 01/01/2024 46.95 0.0 Y Description: PORTABLE OXYGEN CONCENTRATOR Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E1392 RR QF DME RTL MAXFEE 01/01/2023 12/31/2023 62.81 0.0 Y Description: PORTABLE OXYGEN CONCENTRATOR Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E1392 RR QF DME RTL MAXFEE 01/01/2024 46.95 0.0 Y Description: PORTABLE OXYGEN CONCENTRATOR Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E1399* DME DEF SYSMAN Y Y 0-1 Description: DURABLE MEDICAL EQUIPMENT MI Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1399* NU U1 DME DU1 MAXFEE 01/01/2014 12/31/2023 1736.01 0.0 Y Y 0-1 Description: DURABLE MEDICAL EQUIPMENT MI Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1399* NU U1 DME DU1 MAXFEE 01/01/2024 2256.81 0.0 Y Y 0-1 Description: DURABLE MEDICAL EQUIPMENT MI Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1399* NU U2 DME DU2 MAXFEE 01/01/2014 12/31/2023 950.00 0.0 Y Y 0-1 Description: DURABLE MEDICAL EQUIPMENT MI Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1399* NU U2 DME DU2 MAXFEE 01/01/2024 1235.00 0.0 Y Y 0-1 Description: DURABLE MEDICAL EQUIPMENT MI Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1405 RR DME RTL MAXFEE 01/01/2014 12/31/2023 353.84 0.0 Y Description: O2/WATER VAPOR ENRICH W/HEAT Category: Durable Medical CMS Add: 01/01/1988 CMS Term: E1405 RR DME RTL MAXFEE 01/01/2024 130.28 0.0 Y Description: O2/WATER VAPOR ENRICH W/HEAT Category: Durable Medical CMS Add: 01/01/1988 CMS Term: E1406 RR DME RTL MAXFEE 01/01/2014 12/31/2023 342.35 0.0 Y Description: O2/WATER VAPOR ENRICH W/O HE Category: Durable Medical CMS Add: 01/01/1988 CMS Term: E1406 RR DME RTL MAXFEE 01/01/2024 136.27 0.0 Y Description: O2/WATER VAPOR ENRICH W/O HE Category: Durable Medical CMS Add: 01/01/1988 CMS Term: E1500 NOCOV DEF SYSMAN Description: CENTRIFUGE Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,664 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E1510 DME DEF MAXFEE 04/06/2018 0.00 0.0 Description: KIDNEY DIALYSATE DELIVRY SYS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1520 DME DEF MAXFEE 04/06/2018 0.00 0.0 Description: HEPARIN INFUSION PUMP Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1530 DME DEF MAXFEE 04/06/2018 0.00 0.0 Description: REPLACEMENT AIR BUBBLE DETEC Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1540 DME DEF MAXFEE 04/06/2018 0.00 0.0 Description: REPLACEMENT PRESSURE ALARM Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1550 DME DEF MAXFEE 04/06/2018 0.00 0.0 Description: BATH CONDUCTIVITY METER Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1560 DME DEF MAXFEE 04/06/2018 0.00 0.0 Description: REPLACE BLOOD LEAK DETECTOR Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1570 NU DME PUR MAXFEE 04/06/2018 0.00 0.0 Description: ADJUSTABLE CHAIR FOR ESRD PT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1570 RR DME RTL MAXFEE 04/06/2018 0.00 0.0 Description: ADJUSTABLE CHAIR FOR ESRD PT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1575 DME DEF MAXFEE 04/06/2018 0.00 0.0 Description: TRANSDUCER PROTECT/FLD BAR Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1580 DME DEF MAXFEE 04/06/2018 0.00 0.0 Description: UNIPUNCTURE CONTROL SYSTEM Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1590 DME DEF MAXFEE 04/06/2018 0.00 0.0 Description: HEMODIALYSIS MACHINE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1592 DME DEF MAXFEE 04/06/2018 0.00 0.0 Description: AUTO INTERM PERITONEAL DIALY Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1594 DME DEF MAXFEE 04/06/2018 0.00 0.0 Description: CYCLER DIALYSIS MACHINE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1600 DME DEF MAXFEE 04/06/2018 0.00 0.0 Description: DELI/INSTALL CHRG HEMO EQUIP Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1610 NU DME PUR MAXFEE 04/06/2018 0.00 0.0 Description: REVERSE OSMOSIS H2O PURI SYS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1610 RR DME RTL MAXFEE 04/06/2018 0.00 0.0 Description: REVERSE OSMOSIS H2O PURI SYS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,665 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E1615 NU DME PUR MAXFEE 04/06/2018 0.00 0.0 Description: DEIONIZER H2O PURI SYSTEM Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1615 RR DME RTL MAXFEE 04/06/2018 0.00 0.0 Description: DEIONIZER H2O PURI SYSTEM Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1620 DME DEF MAXFEE 04/06/2018 0.00 0.0 Description: REPLACEMENT BLOOD PUMP Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1625 DME DEF MAXFEE 04/06/2018 0.00 0.0 Description: WATER SOFTENING SYSTEM Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1629 DME DEF MAXFEE 01/01/2022 0.00 0.0 Description: TABLO FOR DIALYSIS SERVICE Category: Durable Medical CMS Add: 01/01/2022 CMS Term: E1630 DME DEF MAXFEE 04/06/2018 0.00 0.0 Description: RECIPROCATING PERITONEAL DIA Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1632 DME DEF MAXFEE 04/06/2018 0.00 0.0 Description: WEARABLE ARTIFICIAL KIDNEY Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1634 DME DEF MAXFEE 04/06/2018 0.00 0.0 Description: PERITONEAL DIALYSIS CLAMP Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E1635 DME DEF MAXFEE 04/06/2018 0.00 0.0 Description: COMPACT TRAVEL HEMODIALYZER Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1636 DME DEF MAXFEE 04/06/2018 0.00 0.0 Description: SORBENT CARTRIDGES PER 10 Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1637 NOCOV DEF SYSMAN Description: HEMOSTATS FOR DIALYSIS, EACH Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: E1639 NOCOV DEF SYSMAN Description: SCALE, EACH Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: E1699 DME DEF MAXFEE 04/06/2018 0.00 0.0 Description: DIALYSIS EQUIPMENT NOC Category: Durable Medical CMS Add: 01/01/1986 CMS Term: E1700 DME DEF MAXFEE 01/01/2014 12/31/2023 156.24 0.0 Description: JAW MOTION REHAB SYSTEM Category: Durable Medical CMS Add: 01/01/1993 CMS Term: E1700 DME DEF MAXFEE 01/01/2024 389.90 0.0 Description: JAW MOTION REHAB SYSTEM Category: Durable Medical CMS Add: 01/01/1993 CMS Term: E1701 DME DEF MAXFEE 01/01/2014 12/31/2023 8.97 0.0 Description: REPL CUSHIONS FOR JAW MOTION Category: Durable Medical CMS Add: 01/01/1993 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,666 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E1701 DME DEF MAXFEE 01/01/2024 14.09 0.0 Description: REPL CUSHIONS FOR JAW MOTION Category: Durable Medical CMS Add: 01/01/1993 CMS Term: E1702 DME DEF MAXFEE 01/01/2014 12/31/2023 19.08 0.0 Description: REPL MEASR SCALES JAW MOTION Category: Durable Medical CMS Add: 01/01/1993 CMS Term: E1702 DME DEF MAXFEE 01/01/2024 30.00 0.0 Description: REPL MEASR SCALES JAW MOTION Category: Durable Medical CMS Add: 01/01/1993 CMS Term: E1800 NU DME PUR MAXFEE 01/01/2023 12/31/2023 1629.10 0.0 Y Description: ADJUST ELBOW EXT/FLEX DEVICE Category: Durable Medical CMS Add: 01/01/1996 CMS Term: E1800 NU DME PUR MAXFEE 01/01/2024 1671.50 0.0 Y Description: ADJUST ELBOW EXT/FLEX DEVICE Category: Durable Medical CMS Add: 01/01/1996 CMS Term: E1800 RR DME RTL MAXFEE 01/01/2023 12/31/2023 162.91 0.0 Y Description: ADJUST ELBOW EXT/FLEX DEVICE Category: Durable Medical CMS Add: 01/01/1996 CMS Term: E1800 RR DME RTL MAXFEE 01/01/2024 167.15 0.0 Y Description: ADJUST ELBOW EXT/FLEX DEVICE Category: Durable Medical CMS Add: 01/01/1996 CMS Term: E1801 NU DME PUR MAXFEE 01/01/2023 12/31/2023 1715.70 0.0 Y Description: SPS ELBOW DEVICE Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E1801 NU DME PUR MAXFEE 01/01/2024 1760.30 0.0 Y Description: SPS ELBOW DEVICE Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E1801 RR DME RTL MAXFEE 01/01/2023 12/31/2023 171.57 0.0 Y Description: SPS ELBOW DEVICE Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E1801 RR DME RTL MAXFEE 01/01/2024 176.03 0.0 Y Description: SPS ELBOW DEVICE Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E1802 NU DME PUR MAXFEE 01/01/2023 12/31/2023 4346.20 0.0 Y Description: ADJST FOREARM PRO/SUP DEVICE Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1802 NU DME PUR MAXFEE 01/01/2024 4459.20 0.0 Y Description: ADJST FOREARM PRO/SUP DEVICE Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1802 RR DME RTL MAXFEE 01/01/2023 12/31/2023 434.62 0.0 Y Description: ADJST FOREARM PRO/SUP DEVICE Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1802 RR DME RTL MAXFEE 01/01/2024 445.92 0.0 Y Description: ADJST FOREARM PRO/SUP DEVICE Category: Durable Medical CMS Add: 01/01/2003 CMS Term: E1805 NU DME PUR MAXFEE 01/01/2023 12/31/2023 1680.30 0.0 Y Description: ADJUST WRIST EXT/FLEX DEVICE Category: Durable Medical CMS Add: 01/01/1996 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,667 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E1805 NU DME PUR MAXFEE 01/01/2024 1724.00 0.0 Y Description: ADJUST WRIST EXT/FLEX DEVICE Category: Durable Medical CMS Add: 01/01/1996 CMS Term: E1805 RR DME RTL MAXFEE 01/01/2023 12/31/2023 168.03 0.0 Y Description: ADJUST WRIST EXT/FLEX DEVICE Category: Durable Medical CMS Add: 01/01/1996 CMS Term: E1805 RR DME RTL MAXFEE 01/01/2024 172.40 0.0 Y Description: ADJUST WRIST EXT/FLEX DEVICE Category: Durable Medical CMS Add: 01/01/1996 CMS Term: E1806 NU DME PUR MAXFEE 01/01/2023 12/31/2023 1408.80 0.0 Y Description: SPS WRIST DEVICE Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E1806 NU DME PUR MAXFEE 01/01/2024 1445.40 0.0 Y Description: SPS WRIST DEVICE Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E1806 RR DME RTL MAXFEE 01/01/2023 12/31/2023 140.88 0.0 Y Description: SPS WRIST DEVICE Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E1806 RR DME RTL MAXFEE 01/01/2024 144.54 0.0 Y Description: SPS WRIST DEVICE Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E1810 NU DME PUR MAXFEE 01/01/2023 12/31/2023 1656.90 0.0 Y Description: ADJUST KNEE EXT/FLEX DEVICE Category: Durable Medical CMS Add: 01/01/1996 CMS Term: E1810 NU DME PUR MAXFEE 01/01/2024 1700.00 0.0 Y Description: ADJUST KNEE EXT/FLEX DEVICE Category: Durable Medical CMS Add: 01/01/1996 CMS Term: E1810 RR DME RTL MAXFEE 01/01/2023 12/31/2023 165.69 0.0 Y Description: ADJUST KNEE EXT/FLEX DEVICE Category: Durable Medical CMS Add: 01/01/1996 CMS Term: E1810 RR DME RTL MAXFEE 01/01/2024 170.00 0.0 Y Description: ADJUST KNEE EXT/FLEX DEVICE Category: Durable Medical CMS Add: 01/01/1996 CMS Term: E1811 NU DME PUR MAXFEE 01/01/2023 12/31/2023 1783.50 0.0 Y Description: SPS KNEE DEVICE Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E1811 NU DME PUR MAXFEE 01/01/2024 1829.90 0.0 Y Description: SPS KNEE DEVICE Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E1811 RR DME RTL MAXFEE 01/01/2023 12/31/2023 178.35 0.0 Y Description: SPS KNEE DEVICE Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E1811 RR DME RTL MAXFEE 01/01/2024 182.99 0.0 Y Description: SPS KNEE DEVICE Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E1812 NU DME PUR MAXFEE 01/01/2023 1143.60 0.0 Y Description: KNEE EXT/FLEX W ACT RES CTRL Category: Durable Medical CMS Add: 01/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,668 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E1812 RR DME RTL MAXFEE 01/01/2023 114.36 0.0 Y Description: KNEE EXT/FLEX W ACT RES CTRL Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E1815 NU DME PUR MAXFEE 01/01/2023 12/31/2023 1680.30 0.0 Y Description: ADJUST ANKLE EXT/FLEX DEVICE Category: Durable Medical CMS Add: 01/01/1996 CMS Term: E1815 NU DME PUR MAXFEE 01/01/2024 1724.00 0.0 Y Description: ADJUST ANKLE EXT/FLEX DEVICE Category: Durable Medical CMS Add: 01/01/1996 CMS Term: E1815 RR DME RTL MAXFEE 01/01/2023 12/31/2023 168.03 0.0 Y Description: ADJUST ANKLE EXT/FLEX DEVICE Category: Durable Medical CMS Add: 01/01/1996 CMS Term: E1815 RR DME RTL MAXFEE 01/01/2024 172.40 0.0 Y Description: ADJUST ANKLE EXT/FLEX DEVICE Category: Durable Medical CMS Add: 01/01/1996 CMS Term: E1816 NU DME PUR MAXFEE 01/01/2023 12/31/2023 1811.90 0.0 Y Description: SPS ANKLE DEVICE Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E1816 NU DME PUR MAXFEE 01/01/2024 1859.00 0.0 Y Description: SPS ANKLE DEVICE Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E1816 RR DME RTL MAXFEE 01/01/2023 12/31/2023 181.19 0.0 Y Description: SPS ANKLE DEVICE Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E1816 RR DME RTL MAXFEE 01/01/2024 185.90 0.0 Y Description: SPS ANKLE DEVICE Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E1818 NU DME PUR MAXFEE 01/01/2023 12/31/2023 1849.60 0.0 Y Description: SPS FOREARM DEVICE Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E1818 NU DME PUR MAXFEE 01/01/2024 1897.70 0.0 Y Description: SPS FOREARM DEVICE Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E1818 RR DME RTL MAXFEE 01/01/2023 12/31/2023 184.96 0.0 Y Description: SPS FOREARM DEVICE Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E1818 RR DME RTL MAXFEE 01/01/2024 189.77 0.0 Y Description: SPS FOREARM DEVICE Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E1820 NU DME PUR MAXFEE 01/01/2023 12/31/2023 107.71 0.0 Y Description: SOFT INTERFACE MATERIAL Category: Durable Medical CMS Add: 01/01/1996 CMS Term: E1820 NU DME PUR MAXFEE 01/01/2024 110.51 0.0 Y Description: SOFT INTERFACE MATERIAL Category: Durable Medical CMS Add: 01/01/1996 CMS Term: E1820 RR DME RTL MAXFEE 01/01/2023 12/31/2023 10.77 0.0 Y Description: SOFT INTERFACE MATERIAL Category: Durable Medical CMS Add: 01/01/1996 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,669 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E1820 RR DME RTL MAXFEE 01/01/2024 11.05 0.0 Y Description: SOFT INTERFACE MATERIAL Category: Durable Medical CMS Add: 01/01/1996 CMS Term: E1821 NU DME PUR MAXFEE 01/01/2024 139.95 0.0 Y Description: REPLACEMENT INTERFACE SPSD Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E1821 NU DME PUR MAXFEE 02/01/2021 12/31/2023 122.50 0.0 Y Description: REPLACEMENT INTERFACE SPSD Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E1821 RR DME RTL MAXFEE 01/01/2024 13.96 0.0 Y Description: REPLACEMENT INTERFACE SPSD Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E1821 RR DME RTL MAXFEE 02/01/2021 12/31/2023 12.22 0.0 Y Description: REPLACEMENT INTERFACE SPSD Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E1825 NU DME PUR MAXFEE 01/01/2023 12/31/2023 1680.30 0.0 Y Description: ADJUST FINGER EXT/FLEX DEVC Category: Durable Medical CMS Add: 01/01/1996 CMS Term: E1825 NU DME PUR MAXFEE 01/01/2024 1724.00 0.0 Y Description: ADJUST FINGER EXT/FLEX DEVC Category: Durable Medical CMS Add: 01/01/1996 CMS Term: E1825 RR DME RTL MAXFEE 01/01/2023 12/31/2023 168.03 0.0 Y Description: ADJUST FINGER EXT/FLEX DEVC Category: Durable Medical CMS Add: 01/01/1996 CMS Term: E1825 RR DME RTL MAXFEE 01/01/2024 172.40 0.0 Y Description: ADJUST FINGER EXT/FLEX DEVC Category: Durable Medical CMS Add: 01/01/1996 CMS Term: E1830 NU DME PUR MAXFEE 01/01/2023 12/31/2023 1680.30 0.0 Y Description: ADJUST TOE EXT/FLEX DEVICE Category: Durable Medical CMS Add: 01/01/1996 CMS Term: E1830 NU DME PUR MAXFEE 01/01/2024 1724.00 0.0 Y Description: ADJUST TOE EXT/FLEX DEVICE Category: Durable Medical CMS Add: 01/01/1996 CMS Term: E1830 RR DME RTL MAXFEE 01/01/2023 12/31/2023 168.03 0.0 Y Description: ADJUST TOE EXT/FLEX DEVICE Category: Durable Medical CMS Add: 01/01/1996 CMS Term: E1830 RR DME RTL MAXFEE 01/01/2024 172.40 0.0 Y Description: ADJUST TOE EXT/FLEX DEVICE Category: Durable Medical CMS Add: 01/01/1996 CMS Term: E1831 NU DME PUR MAXFEE 01/01/2023 12/31/2023 878.60 0.0 Y Description: STATIC STR TOE DEV EXT/FLEX Category: Durable Medical CMS Add: 01/01/2011 CMS Term: E1831 NU DME PUR MAXFEE 01/01/2024 901.40 0.0 Y Description: STATIC STR TOE DEV EXT/FLEX Category: Durable Medical CMS Add: 01/01/2011 CMS Term: E1831 RR DME RTL MAXFEE 01/01/2023 12/31/2023 87.86 0.0 Y Description: STATIC STR TOE DEV EXT/FLEX Category: Durable Medical CMS Add: 01/01/2011 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,670 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E1831 RR DME RTL MAXFEE 01/01/2024 90.14 0.0 Y Description: STATIC STR TOE DEV EXT/FLEX Category: Durable Medical CMS Add: 01/01/2011 CMS Term: E1840 NU DME PUR MAXFEE 01/01/2023 12/31/2023 5089.70 0.0 Y Description: ADJ SHOULDER EXT/FLEX DEVICE Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E1840 NU DME PUR MAXFEE 01/01/2024 5222.00 0.0 Y Description: ADJ SHOULDER EXT/FLEX DEVICE Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E1840 RR DME RTL MAXFEE 01/01/2023 12/31/2023 508.97 0.0 Y Description: ADJ SHOULDER EXT/FLEX DEVICE Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E1840 RR DME RTL MAXFEE 01/01/2024 522.20 0.0 Y Description: ADJ SHOULDER EXT/FLEX DEVICE Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E1841 NU DME PUR MAXFEE 01/01/2023 12/31/2023 6024.20 0.0 Y Description: STATIC STR SHLDR DEV ROM ADJ Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E1841 NU DME PUR MAXFEE 01/01/2024 6180.80 0.0 Y Description: STATIC STR SHLDR DEV ROM ADJ Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E1841 RR DME RTL MAXFEE 01/01/2023 12/31/2023 602.42 0.0 Y Description: STATIC STR SHLDR DEV ROM ADJ Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E1841 RR DME RTL MAXFEE 01/01/2024 618.08 0.0 Y Description: STATIC STR SHLDR DEV ROM ADJ Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E1902 DME DEF SYSMAN Y Y Description: AAC NON-ELECTRONIC BOARD Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E1905 NOCOV DEF SYSMAN Description: VR CBT THERAPY Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: E2000 NU DME PUR MAXFEE 01/01/2023 12/31/2023 689.30 0.0 Description: GASTRIC SUCTION PUMP HME MDL Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E2000 NU DME PUR MAXFEE 01/01/2024 707.20 0.0 Description: GASTRIC SUCTION PUMP HME MDL Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E2000 RR DME RTL MAXFEE 01/01/2023 12/31/2023 68.93 0.0 Description: GASTRIC SUCTION PUMP HME MDL Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E2000 RR DME RTL MAXFEE 01/01/2024 70.72 0.0 Description: GASTRIC SUCTION PUMP HME MDL Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E2001 NOCOV DEF SYSMAN Description: SUCT PUM EXT MGMT SYS Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,671 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E2100 NU DME PUR MAXFEE 01/01/2023 12/31/2023 727.04 0.0 Y Description: BLD GLUCOSE MONITOR W VOICE Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E2100 NU DME PUR MAXFEE 01/01/2024 745.94 0.0 Y Description: BLD GLUCOSE MONITOR W VOICE Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E2100 RR DME RTL MAXFEE 01/01/2023 12/31/2023 72.73 0.0 Y Description: BLD GLUCOSE MONITOR W VOICE Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E2100 RR DME RTL MAXFEE 01/01/2024 74.61 0.0 Y Description: BLD GLUCOSE MONITOR W VOICE Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E2101 NU DME PUR MAXFEE 01/01/2023 12/31/2023 250.75 0.0 Y Description: BLD GLUCOSE MONITOR W LANCE Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E2101 NU DME PUR MAXFEE 01/01/2024 257.27 0.0 Y Description: BLD GLUCOSE MONITOR W LANCE Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E2101 RR DME RTL MAXFEE 01/01/2023 12/31/2023 25.08 0.0 Y Description: BLD GLUCOSE MONITOR W LANCE Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E2101 RR DME RTL MAXFEE 01/01/2024 25.73 0.0 Y Description: BLD GLUCOSE MONITOR W LANCE Category: Durable Medical CMS Add: 01/01/2002 CMS Term: E2102 NU KF DME PUR MAXFEE 01/01/2024 181.03 0.0 Y Y Description: ADJU CGM RECEIVER/MONITOR Category: Durable Medical CMS Add: 04/01/2022 CMS Term: E2102 RR KF DME RTL MAXFEE 01/01/2024 18.11 0.0 Y Y Description: ADJU CGM RECEIVER/MONITOR Category: Durable Medical CMS Add: 04/01/2022 CMS Term: E2103 NU DME PUR MAXFEE 01/01/2023 12/31/2023 281.13 0.0 Y Description: NON-ADJU CGM RECEIVER/MON Category: Durable Medical CMS Add: 01/01/2023 CMS Term: E2103 NU DME PUR MAXFEE 01/01/2024 245.19 0.0 Y Description: NON-ADJU CGM RECEIVER/MON Category: Durable Medical CMS Add: 01/01/2023 CMS Term: E2103 NU KF DME PUR MAXFEE 01/01/2024 272.20 0.0 Y Description: NON-ADJU CGM RECEIVER/MON Category: Durable Medical CMS Add: 01/01/2023 CMS Term: E2103 RR DME RTL MAXFEE 01/01/2023 12/31/2023 23.90 0.0 Y Description: NON-ADJU CGM RECEIVER/MON Category: Durable Medical CMS Add: 01/01/2023 CMS Term: E2103 RR DME RTL MAXFEE 01/01/2024 24.52 0.0 Y Description: NON-ADJU CGM RECEIVER/MON Category: Durable Medical CMS Add: 01/01/2023 CMS Term: E2103 RR KF DME RTL MAXFEE 01/01/2024 27.22 0.0 Y Description: NON-ADJU CGM RECEIVER/MON Category: Durable Medical CMS Add: 01/01/2023 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,672 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E2120 NOCOV DEF SYSMAN Description: PULSE GEN SYS TX ENDOLYMP FL Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: E2201 NU DME PUR MAXFEE 01/01/2014 12/31/2023 373.10 0.0 Y Description: MAN W/CH ACC SEAT W>=20"<24" Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2201 NU DME PUR MAXFEE 01/01/2024 366.40 0.0 Y Description: MAN W/CH ACC SEAT W>=20"<24" Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2201 RR DME RTL MAXFEE 01/01/2014 12/31/2023 37.31 0.0 Y Description: MAN W/CH ACC SEAT W>=20"<24" Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2201 RR DME RTL MAXFEE 01/01/2024 38.55 0.0 Y Description: MAN W/CH ACC SEAT W>=20"<24" Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2202 NU DME PUR MAXFEE 01/01/2014 12/31/2023 473.98 0.0 Y Description: SEAT WIDTH 24-27 IN Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2202 NU DME PUR MAXFEE 01/01/2024 527.51 0.0 Y Description: SEAT WIDTH 24-27 IN Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2202 RR DME RTL MAXFEE 01/01/2014 12/31/2023 47.40 0.0 Y Description: SEAT WIDTH 24-27 IN Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2202 RR DME RTL MAXFEE 01/01/2024 54.50 0.0 Y Description: SEAT WIDTH 24-27 IN Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2203 NU DME PUR MAXFEE 01/01/2014 12/31/2023 479.05 0.0 Y Description: FRAME DEPTH LESS THAN 22 IN Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2203 NU DME PUR MAXFEE 01/01/2024 471.03 0.0 Y Description: FRAME DEPTH LESS THAN 22 IN Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2203 RR DME RTL MAXFEE 01/01/2014 12/31/2023 47.89 0.0 Y Description: FRAME DEPTH LESS THAN 22 IN Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2203 RR DME RTL MAXFEE 01/01/2024 52.13 0.0 Y Description: FRAME DEPTH LESS THAN 22 IN Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2204 NU DME PUR MAXFEE 01/01/2014 12/31/2023 813.40 0.0 Y Description: FRAME DEPTH 22 TO 25 IN Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2204 NU DME PUR MAXFEE 01/01/2024 905.28 0.0 Y Description: FRAME DEPTH 22 TO 25 IN Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2204 RR DME RTL MAXFEE 01/01/2014 12/31/2023 81.35 0.0 Y Description: FRAME DEPTH 22 TO 25 IN Category: Durable Medical CMS Add: 01/01/2004 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,673 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E2204 RR DME RTL MAXFEE 01/01/2024 91.67 0.0 Y Description: FRAME DEPTH 22 TO 25 IN Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2205 NU DME PUR MAXFEE 01/01/2014 12/31/2023 32.67 0.0 Y Description: MANUAL WC ACCESSORY, HANDRIM Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E2205 NU DME PUR MAXFEE 01/01/2024 39.00 0.0 Y Description: MANUAL WC ACCESSORY, HANDRIM Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E2206 NU DME PUR MAXFEE 01/01/2014 12/31/2023 40.68 0.0 Y Description: MAN WC WHL LOCK COMP REPL EA Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E2206 NU DME PUR MAXFEE 01/01/2024 39.99 0.0 Y Description: MAN WC WHL LOCK COMP REPL EA Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E2207 NOCOV DEF SYSMAN Description: CRUTCH AND CANE HOLDER Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: E2208 NOCOV DEF SYSMAN Description: CYLINDER TANK CARRIER Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: E2209 NU DME PUR MAXFEE 01/01/2014 12/31/2023 107.16 0.0 Y Description: ARM TROUGH EACH Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2209 NU DME PUR MAXFEE 01/01/2024 84.93 0.0 Y Description: ARM TROUGH EACH Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2209 RR DME RTL MAXFEE 01/01/2014 12/31/2023 10.74 0.0 Y Description: ARM TROUGH EACH Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2209 RR DME RTL MAXFEE 01/01/2024 10.38 0.0 Y Description: ARM TROUGH EACH Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2210 NU DME PUR MAXFEE 01/01/2014 12/31/2023 6.55 0.0 Y Description: WHEELCHAIR BEARINGS Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2210 NU DME PUR MAXFEE 01/01/2024 5.78 0.0 Y Description: WHEELCHAIR BEARINGS Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2210 RR DME RTL MAXFEE 01/01/2014 12/31/2023 0.66 0.0 Y Description: WHEELCHAIR BEARINGS Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2210 RR DME RTL MAXFEE 01/01/2024 0.68 0.0 Y Description: WHEELCHAIR BEARINGS Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2211 NU DME PUR MAXFEE 01/01/2014 12/31/2023 34.77 0.0 Y Description: PNEUMATIC PROPULSION TIRE Category: Durable Medical CMS Add: 01/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,674 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E2211 NU DME PUR MAXFEE 01/01/2024 34.84 0.0 Y Description: PNEUMATIC PROPULSION TIRE Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2211 RR DME RTL MAXFEE 01/01/2014 12/31/2023 3.41 0.0 Y Description: PNEUMATIC PROPULSION TIRE Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2211 RR DME RTL MAXFEE 01/01/2024 3.99 0.0 Y Description: PNEUMATIC PROPULSION TIRE Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2212 NU DME PUR MAXFEE 01/01/2014 12/31/2023 5.88 0.0 Y Description: PNEUMATIC PROP TIRE TUBE Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2212 NU DME PUR MAXFEE 01/01/2024 7.31 0.0 Y Description: PNEUMATIC PROP TIRE TUBE Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2212 RR DME RTL MAXFEE 01/01/2014 12/31/2023 0.61 0.0 Y Description: PNEUMATIC PROP TIRE TUBE Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2212 RR DME RTL MAXFEE 01/01/2024 0.76 0.0 Y Description: PNEUMATIC PROP TIRE TUBE Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2213 NU DME PUR MAXFEE 01/01/2014 12/31/2023 30.41 0.0 Y Description: PNEUMATIC PROP TIRE INSERT Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2213 NU DME PUR MAXFEE 01/01/2024 30.20 0.0 Y Description: PNEUMATIC PROP TIRE INSERT Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2213 RR DME RTL MAXFEE 01/01/2014 12/31/2023 3.05 0.0 Y Description: PNEUMATIC PROP TIRE INSERT Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2213 RR DME RTL MAXFEE 01/01/2024 3.58 0.0 Y Description: PNEUMATIC PROP TIRE INSERT Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2214 NU DME PUR MAXFEE 01/01/2014 12/31/2023 36.00 0.0 Y Description: PNEUMATIC CASTER TIRE EACH Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2214 NU DME PUR MAXFEE 01/01/2024 33.25 0.0 Y Description: PNEUMATIC CASTER TIRE EACH Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2214 RR DME RTL MAXFEE 01/01/2014 12/31/2023 3.96 0.0 Y Description: PNEUMATIC CASTER TIRE EACH Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2214 RR DME RTL MAXFEE 01/01/2024 4.12 0.0 Y Description: PNEUMATIC CASTER TIRE EACH Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2215 NU DME PUR MAXFEE 01/01/2014 12/31/2023 9.60 0.0 Y Description: PNEUMATIC CASTER TIRE TUBE Category: Durable Medical CMS Add: 01/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,675 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E2215 NU DME PUR MAXFEE 01/01/2024 11.80 0.0 Y Description: PNEUMATIC CASTER TIRE TUBE Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2215 RR DME RTL MAXFEE 01/01/2014 12/31/2023 0.95 0.0 Y Description: PNEUMATIC CASTER TIRE TUBE Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2215 RR DME RTL MAXFEE 01/01/2024 1.20 0.0 Y Description: PNEUMATIC CASTER TIRE TUBE Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2216 NU DME PUR MAXFEE 01/01/2024 55.47 0.0 Y Description: FOAM FILLED PROPULSION TIRE Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2216 NU DME PUR MAXFEE 10/15/2020 12/31/2023 47.22 0.0 Y Description: FOAM FILLED PROPULSION TIRE Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2216 RR DME RTL MAXFEE 01/01/2024 5.60 0.0 Y Description: FOAM FILLED PROPULSION TIRE Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2216 RR DME RTL MAXFEE 10/15/2020 12/31/2023 4.72 0.0 Y Description: FOAM FILLED PROPULSION TIRE Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2217 NU DME PUR MAXFEE 01/01/2024 49.09 0.0 Y Description: FOAM FILLED CASTER TIRE EACH Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2217 NU DME PUR MAXFEE 10/15/2020 12/31/2023 41.79 0.0 Y Description: FOAM FILLED CASTER TIRE EACH Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2217 RR DME RTL MAXFEE 01/01/2024 4.96 0.0 Y Description: FOAM FILLED CASTER TIRE EACH Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2217 RR DME RTL MAXFEE 10/15/2020 12/31/2023 4.18 0.0 Y Description: FOAM FILLED CASTER TIRE EACH Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2218 NU DME PUR MAXFEE 01/01/2024 55.47 0.0 Y Description: FOAM PROPULSION TIRE EACH Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2218 NU DME PUR MAXFEE 10/15/2020 12/31/2023 47.22 0.0 Y Description: FOAM PROPULSION TIRE EACH Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2218 RR DME RTL MAXFEE 01/01/2024 5.60 0.0 Y Description: FOAM PROPULSION TIRE EACH Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2218 RR DME RTL MAXFEE 10/15/2020 12/31/2023 4.72 0.0 Y Description: FOAM PROPULSION TIRE EACH Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2219 NU DME PUR MAXFEE 01/01/2014 12/31/2023 38.62 0.0 Y Description: FOAM CASTER TIRE ANY SIZE EA Category: Durable Medical CMS Add: 01/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,676 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E2219 NU DME PUR MAXFEE 01/01/2024 45.41 0.0 Y Description: FOAM CASTER TIRE ANY SIZE EA Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2219 RR DME RTL MAXFEE 01/01/2014 12/31/2023 4.01 0.0 Y Description: FOAM CASTER TIRE ANY SIZE EA Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2219 RR DME RTL MAXFEE 01/01/2024 4.96 0.0 Y Description: FOAM CASTER TIRE ANY SIZE EA Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2220 NU DME PUR MAXFEE 01/01/2014 12/31/2023 25.31 0.0 Y Description: SOLID PROPULS TIRE, REPL, EA Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2220 NU DME PUR MAXFEE 01/01/2024 29.63 0.0 Y Description: SOLID PROPULS TIRE, REPL, EA Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2220 RR DME RTL MAXFEE 01/01/2014 12/31/2023 2.53 0.0 Y Description: SOLID PROPULS TIRE, REPL, EA Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2220 RR DME RTL MAXFEE 01/01/2024 3.22 0.0 Y Description: SOLID PROPULS TIRE, REPL, EA Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2221 NU DME PUR MAXFEE 01/01/2014 12/31/2023 25.55 0.0 Y Description: SOLID CASTER TIRE REPL, EACH Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2221 NU DME PUR MAXFEE 01/01/2024 30.11 0.0 Y Description: SOLID CASTER TIRE REPL, EACH Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2221 RR DME RTL MAXFEE 01/01/2014 12/31/2023 2.58 0.0 Y Description: SOLID CASTER TIRE REPL, EACH Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2221 RR DME RTL MAXFEE 01/01/2024 3.20 0.0 Y Description: SOLID CASTER TIRE REPL, EACH Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2222 NU DME PUR MAXFEE 01/01/2014 12/31/2023 21.06 0.0 Y Description: SOLID CASTER INTEG WHL, REPL Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2222 NU DME PUR MAXFEE 01/01/2024 24.82 0.0 Y Description: SOLID CASTER INTEG WHL, REPL Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2222 RR DME RTL MAXFEE 01/01/2014 12/31/2023 2.09 0.0 Y Description: SOLID CASTER INTEG WHL, REPL Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2222 RR DME RTL MAXFEE 01/01/2024 2.62 0.0 Y Description: SOLID CASTER INTEG WHL, REPL Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2224 NU DME PUR MAXFEE 01/01/2014 12/31/2023 98.06 0.0 Y Description: PROPULSION WHL EXCL TIRE REP Category: Durable Medical CMS Add: 01/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,677 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E2224 NU DME PUR MAXFEE 01/01/2024 100.57 0.0 Y Description: PROPULSION WHL EXCL TIRE REP Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2224 RR DME RTL MAXFEE 01/01/2014 12/31/2023 10.29 0.0 Y Description: PROPULSION WHL EXCL TIRE REP Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2224 RR DME RTL MAXFEE 01/01/2024 11.15 0.0 Y Description: PROPULSION WHL EXCL TIRE REP Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2225 NU DME PUR MAXFEE 01/01/2014 12/31/2023 17.40 0.0 Y Description: CASTER WHEEL EXCLUDES TIRE Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2225 NU DME PUR MAXFEE 01/01/2024 20.64 0.0 Y Description: CASTER WHEEL EXCLUDES TIRE Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2225 RR DME RTL MAXFEE 01/01/2014 12/31/2023 1.74 0.0 Y Description: CASTER WHEEL EXCLUDES TIRE Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2225 RR DME RTL MAXFEE 01/01/2024 2.20 0.0 Y Description: CASTER WHEEL EXCLUDES TIRE Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2226 NU DME PUR MAXFEE 01/01/2014 12/31/2023 37.94 0.0 Y Description: CASTER FORK REPLACEMENT ONLY Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2226 NU DME PUR MAXFEE 01/01/2024 39.55 0.0 Y Description: CASTER FORK REPLACEMENT ONLY Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2226 RR DME RTL MAXFEE 01/01/2014 12/31/2023 3.79 0.0 Y Description: CASTER FORK REPLACEMENT ONLY Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2226 RR DME RTL MAXFEE 01/01/2024 4.71 0.0 Y Description: CASTER FORK REPLACEMENT ONLY Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2227 NU DME PUR MAXFEE 01/01/2014 12/31/2023 1569.13 0.0 Y Description: GEAR REDUCTION DRIVE WHEEL Category: Durable Medical CMS Add: 01/01/2008 CMS Term: E2227 NU DME PUR MAXFEE 01/01/2024 2487.90 0.0 Y Description: GEAR REDUCTION DRIVE WHEEL Category: Durable Medical CMS Add: 01/01/2008 CMS Term: E2227 RR DME RTL MAXFEE 01/01/2014 12/31/2023 156.93 0.0 Y Description: GEAR REDUCTION DRIVE WHEEL Category: Durable Medical CMS Add: 01/01/2008 CMS Term: E2227 RR DME RTL MAXFEE 01/01/2024 248.79 0.0 Y Description: GEAR REDUCTION DRIVE WHEEL Category: Durable Medical CMS Add: 01/01/2008 CMS Term: E2228 NU DME PUR MAXFEE 01/01/2014 12/31/2023 936.26 0.0 Y Description: MWC ACC, WHEELCHAIR BRAKE Category: Durable Medical CMS Add: 01/01/2008 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,678 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E2228 NU DME PUR MAXFEE 01/01/2024 1103.40 0.0 Y Description: MWC ACC, WHEELCHAIR BRAKE Category: Durable Medical CMS Add: 01/01/2008 CMS Term: E2228 RR DME RTL MAXFEE 01/01/2014 12/31/2023 93.62 0.0 Y Description: MWC ACC, WHEELCHAIR BRAKE Category: Durable Medical CMS Add: 01/01/2008 CMS Term: E2228 RR DME RTL MAXFEE 01/01/2024 110.34 0.0 Y Description: MWC ACC, WHEELCHAIR BRAKE Category: Durable Medical CMS Add: 01/01/2008 CMS Term: E2230 DME DEF SYSMAN Y Y Description: MANUAL STANDING SYSTEM Category: Durable Medical CMS Add: 01/01/2009 CMS Term: E2231 NU DME PUR MAXFEE 01/01/2014 12/31/2023 161.36 0.0 Y Description: SOLID SEAT SUPPORT BASE Category: Durable Medical CMS Add: 01/01/2009 CMS Term: E2231 NU DME PUR MAXFEE 01/01/2024 163.85 0.0 Y Description: SOLID SEAT SUPPORT BASE Category: Durable Medical CMS Add: 01/01/2009 CMS Term: E2231 RR DME RTL MAXFEE 01/01/2014 12/31/2023 16.14 0.0 Y Description: SOLID SEAT SUPPORT BASE Category: Durable Medical CMS Add: 01/01/2009 CMS Term: E2231 RR DME RTL MAXFEE 01/01/2024 17.24 0.0 Y Description: SOLID SEAT SUPPORT BASE Category: Durable Medical CMS Add: 01/01/2009 CMS Term: E2291 DME DEF SYSMAN Y Y Description: PLANAR BACK FOR PED SIZE WC Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E2292 DME DEF SYSMAN Y Y Description: PLANAR SEAT FOR PED SIZE WC Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E2293 DME DEF SYSMAN Y Y Description: CONTOUR BACK FOR PED SIZE WC Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E2294 DME DEF SYSMAN Y Y Description: CONTOUR SEAT FOR PED SIZE WC Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E2295 DME DEF SYSMAN Y Y Description: PED DYNAMIC SEATING FRAME Category: Durable Medical CMS Add: 01/01/2009 CMS Term: E2300 NOCOV DEF SYSMAN Description: PWR SEAT ELEVATION SYS Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: 03/31/2024 E2301 NOCOV DEF SYSMAN Description: PWR STANDING Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: E2310 NU DME PUR MAXFEE 01/01/2014 12/31/2023 1170.24 0.0 Y Description: ELECTRO CONNECT BTW CONTROL Category: Durable Medical CMS Add: 01/01/2004 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,679 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E2310 NU DME PUR MAXFEE 01/01/2024 1269.40 0.0 Y Description: ELECTRO CONNECT BTW CONTROL Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2310 RR DME RTL MAXFEE 01/01/2014 12/31/2023 117.02 0.0 Y Description: ELECTRO CONNECT BTW CONTROL Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2310 RR DME RTL MAXFEE 01/01/2024 126.94 0.0 Y Description: ELECTRO CONNECT BTW CONTROL Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2311 NU DME PUR MAXFEE 01/01/2014 12/31/2023 2369.20 0.0 Y Description: ELECTRO CONNECT BTW 2 SYS Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2311 NU DME PUR MAXFEE 01/01/2024 2563.90 0.0 Y Description: ELECTRO CONNECT BTW 2 SYS Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2311 RR DME RTL MAXFEE 01/01/2014 12/31/2023 236.93 0.0 Y Description: ELECTRO CONNECT BTW 2 SYS Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2311 RR DME RTL MAXFEE 01/01/2024 256.39 0.0 Y Description: ELECTRO CONNECT BTW 2 SYS Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2312 RR DME RTL MAXFEE 11/01/2023 268.18 0.0 Y Description: MINI-PROP REMOTE JOYSTICK Category: Durable Medical CMS Add: 01/01/2008 CMS Term: E2312 RR KC DME RTL MAXFEE 11/01/2023 342.05 0.0 Y Description: MINI-PROP REMOTE JOYSTICK Category: Durable Medical CMS Add: 01/01/2008 CMS Term: E2312 RR KU DME RTL MAXFEE 11/01/2023 271.57 0.0 Y Description: MINI-PROP REMOTE JOYSTICK Category: Durable Medical CMS Add: 01/01/2008 CMS Term: E2313 NU DME PUR MAXFEE 01/01/2024 426.10 0.0 Y Description: PWC HARNESS, EXPAND CONTROL Category: Durable Medical CMS Add: 01/01/2008 CMS Term: E2313 NU DME PUR MAXFEE 05/13/2022 12/31/2023 392.00 0.0 Y Description: PWC HARNESS, EXPAND CONTROL Category: Durable Medical CMS Add: 01/01/2008 CMS Term: E2313 RR DME RTL MAXFEE 01/01/2024 42.61 0.0 Y Description: PWC HARNESS, EXPAND CONTROL Category: Durable Medical CMS Add: 01/01/2008 CMS Term: E2313 RR DME RTL MAXFEE 05/13/2022 12/31/2023 39.20 0.0 Y Description: PWC HARNESS, EXPAND CONTROL Category: Durable Medical CMS Add: 01/01/2008 CMS Term: E2321 NU DME PUR MAXFEE 01/01/2014 12/31/2023 1532.90 0.0 Y Description: HAND INTERFACE JOYSTICK Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2321 NU DME PUR MAXFEE 01/01/2024 1724.60 0.0 Y Description: HAND INTERFACE JOYSTICK Category: Durable Medical CMS Add: 01/01/2004 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,680 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E2321 RR DME RTL MAXFEE 01/01/2024 172.46 0.0 Y Description: HAND INTERFACE JOYSTICK Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2321 RR DME RTL MAXFEE 07/01/2014 12/31/2023 152.04 0.0 Y Description: HAND INTERFACE JOYSTICK Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2322 NU DME PUR MAXFEE 01/01/2014 12/31/2023 1410.36 0.0 Y Description: MULT MECH SWITCHES Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2322 NU DME PUR MAXFEE 01/01/2024 1603.20 0.0 Y Description: MULT MECH SWITCHES Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2323 NU DME PUR MAXFEE 01/01/2014 12/31/2023 64.64 0.0 Y Description: SPECIAL JOYSTICK HANDLE Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2323 NU DME PUR MAXFEE 01/01/2024 78.27 0.0 Y Description: SPECIAL JOYSTICK HANDLE Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2324 NU DME PUR MAXFEE 01/01/2014 12/31/2023 44.49 0.0 Y Description: CHIN CUP INTERFACE Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2324 NU DME PUR MAXFEE 01/01/2024 50.23 0.0 Y Description: CHIN CUP INTERFACE Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2325 NU DME PUR MAXFEE 01/01/2014 12/31/2023 1346.83 0.0 Description: SIP AND PUFF INTERFACE Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2325 NU DME PUR MAXFEE 01/01/2024 1532.00 0.0 Description: SIP AND PUFF INTERFACE Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2326 NU DME PUR MAXFEE 01/01/2014 12/31/2023 319.60 0.0 Description: BREATH TUBE KIT Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2326 NU DME PUR MAXFEE 01/01/2024 398.00 0.0 Description: BREATH TUBE KIT Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2327 NU DME PUR MAXFEE 01/01/2014 12/31/2023 2306.14 0.0 Y Description: HEAD CONTROL INTERFACE MECH Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2327 NU DME PUR MAXFEE 01/01/2024 2990.40 0.0 Y Description: HEAD CONTROL INTERFACE MECH Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2328 NU DME PUR MAXFEE 01/01/2014 12/31/2023 3877.32 0.0 Y Description: HEAD/EXTREMITY CONTROL INTER Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2328 NU DME PUR MAXFEE 01/01/2024 5651.30 0.0 Y Description: HEAD/EXTREMITY CONTROL INTER Category: Durable Medical CMS Add: 01/01/2004 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,681 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E2329 NU DME PUR MAXFEE 01/01/2014 12/31/2023 1730.31 0.0 Y Description: HEAD CONTROL NONPROPORTIONAL Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2329 NU DME PUR MAXFEE 01/01/2024 2024.40 0.0 Y Description: HEAD CONTROL NONPROPORTIONAL Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2330 NU DME PUR MAXFEE 01/01/2014 12/31/2023 3333.27 0.0 Description: HEAD CONTROL PROXIMITY SWITC Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2330 NU DME PUR MAXFEE 01/01/2024 3914.30 0.0 Description: HEAD CONTROL PROXIMITY SWITC Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2331 DME DEF SYSMAN Y Y Description: ATTENDANT CONTROL Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2340 NU DME PUR MAXFEE 01/01/2014 12/31/2023 314.22 0.0 Y Description: W/C WDTH 20-23 IN SEAT FRAME Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2340 NU DME PUR MAXFEE 01/01/2024 476.56 0.0 Y Description: W/C WDTH 20-23 IN SEAT FRAME Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2340 RR DME RTL MAXFEE 01/01/2014 12/31/2023 31.42 0.0 Y Description: W/C WDTH 20-23 IN SEAT FRAME Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2340 RR DME RTL MAXFEE 01/01/2024 47.68 0.0 Y Description: W/C WDTH 20-23 IN SEAT FRAME Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2341 NU DME PUR MAXFEE 01/01/2014 12/31/2023 462.97 0.0 Y Description: W/C WDTH 24-27 IN SEAT FRAME Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2341 NU DME PUR MAXFEE 01/01/2024 714.91 0.0 Y Description: W/C WDTH 24-27 IN SEAT FRAME Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2341 RR DME RTL MAXFEE 01/01/2014 12/31/2023 46.30 0.0 Y Description: W/C WDTH 24-27 IN SEAT FRAME Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2341 RR DME RTL MAXFEE 01/01/2024 71.48 0.0 Y Description: W/C WDTH 24-27 IN SEAT FRAME Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2342 NU DME PUR MAXFEE 01/01/2014 12/31/2023 448.03 0.0 Y Description: W/C DPTH 20-21 IN SEAT FRAME Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2342 NU DME PUR MAXFEE 01/01/2024 595.77 0.0 Y Description: W/C DPTH 20-21 IN SEAT FRAME Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2342 RR DME RTL MAXFEE 01/01/2014 12/31/2023 44.80 0.0 Y Description: W/C DPTH 20-21 IN SEAT FRAME Category: Durable Medical CMS Add: 01/01/2004 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,682 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E2342 RR DME RTL MAXFEE 01/01/2024 59.57 0.0 Y Description: W/C DPTH 20-21 IN SEAT FRAME Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2343 NU DME PUR MAXFEE 01/01/2014 12/31/2023 259.27 0.0 Y Description: W/C DPTH 22-25 IN SEAT FRAME Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2343 NU DME PUR MAXFEE 01/01/2024 953.24 0.0 Y Description: W/C DPTH 22-25 IN SEAT FRAME Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2343 RR DME RTL MAXFEE 01/01/2014 12/31/2023 25.93 0.0 Y Description: W/C DPTH 22-25 IN SEAT FRAME Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2343 RR DME RTL MAXFEE 01/01/2024 95.31 0.0 Y Description: W/C DPTH 22-25 IN SEAT FRAME Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2351 NOCOV DEF SYSMAN Description: ELECTRONIC SGD INTERFACE Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: E2358 DME DEF SYSMAN Y Y Description: GR 34 NONSEALED LEADACID Category: Durable Medical CMS Add: 01/01/2012 CMS Term: E2359 NU DME PUR MAXFEE 01/01/2012 12/31/2023 187.04 0.0 Y Description: GR34 SEALED LEADACID BATTERY Category: Durable Medical CMS Add: 01/01/2012 CMS Term: E2359 NU DME PUR MAXFEE 01/01/2024 195.12 0.0 Y Description: GR34 SEALED LEADACID BATTERY Category: Durable Medical CMS Add: 01/01/2012 CMS Term: E2359 RR DME RTL MAXFEE 01/01/2012 12/31/2023 18.71 0.0 Y Description: GR34 SEALED LEADACID BATTERY Category: Durable Medical CMS Add: 01/01/2012 CMS Term: E2359 RR DME RTL MAXFEE 01/01/2024 20.55 0.0 Y Description: GR34 SEALED LEADACID BATTERY Category: Durable Medical CMS Add: 01/01/2012 CMS Term: E2360 NU DME PUR MAXFEE 01/01/2014 12/31/2023 95.49 0.0 Y Description: 22NF NONSEALED LEADACID Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2360 NU DME PUR MAXFEE 01/01/2024 127.00 0.0 Y Description: 22NF NONSEALED LEADACID Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2360 RR DME RTL MAXFEE 01/01/2014 12/31/2023 9.60 0.0 Y Description: 22NF NONSEALED LEADACID Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2360 RR DME RTL MAXFEE 01/01/2024 12.76 0.0 Y Description: 22NF NONSEALED LEADACID Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2361 NU DME PUR MAXFEE 01/01/2014 12/31/2023 139.47 0.0 Y Description: 22NF SEALED LEADACID BATTERY Category: Durable Medical CMS Add: 01/01/2004 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,683 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E2361 NU DME PUR MAXFEE 01/01/2024 137.15 0.0 Y Description: 22NF SEALED LEADACID BATTERY Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2361 RR DME RTL MAXFEE 01/01/2014 12/31/2023 13.95 0.0 Y Description: 22NF SEALED LEADACID BATTERY Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2361 RR DME RTL MAXFEE 01/01/2024 13.90 0.0 Y Description: 22NF SEALED LEADACID BATTERY Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2362 NU DME PUR MAXFEE 01/01/2014 12/31/2023 91.98 0.0 Y Description: GR24 NONSEALED LEADACID Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2362 NU DME PUR MAXFEE 01/01/2024 122.33 0.0 Y Description: GR24 NONSEALED LEADACID Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2362 RR DME RTL MAXFEE 01/01/2014 12/31/2023 9.20 0.0 Y Description: GR24 NONSEALED LEADACID Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2362 RR DME RTL MAXFEE 01/01/2024 12.23 0.0 Y Description: GR24 NONSEALED LEADACID Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2363 NU DME PUR MAXFEE 01/01/2014 12/31/2023 186.00 0.0 Y Description: GR24 SEALED LEADACID BATTERY Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2363 NU DME PUR MAXFEE 01/01/2024 182.72 0.0 Y Description: GR24 SEALED LEADACID BATTERY Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2363 RR DME RTL MAXFEE 01/01/2014 12/31/2023 18.61 0.0 Y Description: GR24 SEALED LEADACID BATTERY Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2363 RR DME RTL MAXFEE 01/01/2024 18.27 0.0 Y Description: GR24 SEALED LEADACID BATTERY Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2364 NU DME PUR MAXFEE 01/01/2014 12/31/2023 95.49 0.0 Y Description: U1NONSEALED LEADACID BATTERY Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2364 NU DME PUR MAXFEE 01/01/2024 127.00 0.0 Y Description: U1NONSEALED LEADACID BATTERY Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2364 RR DME RTL MAXFEE 01/01/2014 12/31/2023 9.60 0.0 Y Description: U1NONSEALED LEADACID BATTERY Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2364 RR DME RTL MAXFEE 01/01/2024 12.76 0.0 Y Description: U1NONSEALED LEADACID BATTERY Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2365 NU DME PUR MAXFEE 01/01/2014 12/31/2023 112.17 0.0 Y Description: U1 SEALED LEADACID BATTERY Category: Durable Medical CMS Add: 01/01/2004 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,684 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E2365 NU DME PUR MAXFEE 01/01/2024 89.07 0.0 Y Description: U1 SEALED LEADACID BATTERY Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2365 RR DME RTL MAXFEE 01/01/2014 12/31/2023 11.22 0.0 Y Description: U1 SEALED LEADACID BATTERY Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2365 RR DME RTL MAXFEE 01/01/2024 9.82 0.0 Y Description: U1 SEALED LEADACID BATTERY Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2366 NU DME PUR MAXFEE 01/01/2014 12/31/2023 224.08 0.0 Y Description: BATTERY CHARGER, SINGLE MODE Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2366 NU DME PUR MAXFEE 01/01/2024 183.19 0.0 Y Description: BATTERY CHARGER, SINGLE MODE Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2366 RR DME RTL MAXFEE 01/01/2014 12/31/2023 22.47 0.0 Y Description: BATTERY CHARGER, SINGLE MODE Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2366 RR DME RTL MAXFEE 01/01/2024 20.19 0.0 Y Description: BATTERY CHARGER, SINGLE MODE Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2367 NU DME PUR MAXFEE 11/01/2023 443.15 0.0 Y Description: BATTERY CHARGER, DUAL MODE Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2367 NU KE DME PUR MAXFEE 11/01/2023 460.56 0.0 Y Description: BATTERY CHARGER, DUAL MODE Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2367 NU KU DME PUR MAXFEE 11/01/2023 480.35 0.0 Y Description: BATTERY CHARGER, DUAL MODE Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2367 RR DME RTL MAXFEE 11/01/2023 44.31 0.0 Y Description: BATTERY CHARGER, DUAL MODE Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2367 RR KE DME RTL MAXFEE 11/01/2023 46.06 0.0 Y Description: BATTERY CHARGER, DUAL MODE Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2367 RR KU DME RTL MAXFEE 11/01/2023 48.01 0.0 Y Description: BATTERY CHARGER, DUAL MODE Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2368 NU DME PUR MAXFEE 01/01/2014 12/31/2023 439.08 0.0 Y Description: PWR WC DRIVEWHEEL MOTOR REPL Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E2368 NU DME PUR MAXFEE 01/01/2024 441.50 0.0 Y Description: PWR WC DRIVEWHEEL MOTOR REPL Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E2369 NU DME PUR MAXFEE 01/01/2014 12/31/2023 382.45 0.0 Y Description: PWR WC DRIVEWHEEL GEAR REPL Category: Durable Medical CMS Add: 01/01/2005 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,685 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E2369 NU DME PUR MAXFEE 01/01/2024 457.10 0.0 Y Description: PWR WC DRIVEWHEEL GEAR REPL Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E2370 NU DME PUR MAXFEE 01/01/2014 12/31/2023 682.41 0.0 Y Description: PWR WC DR WH MOTOR/GEAR COMB Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E2370 NU DME PUR MAXFEE 01/01/2024 588.40 0.0 Y Description: PWR WC DR WH MOTOR/GEAR COMB Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E2371 NU DME PUR MAXFEE 01/01/2014 12/31/2023 150.74 0.0 Y Description: GR27 SEALED LEADACID BATTERY Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2371 NU DME PUR MAXFEE 01/01/2024 165.58 0.0 Y Description: GR27 SEALED LEADACID BATTERY Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2371 RR DME RTL MAXFEE 01/01/2014 12/31/2023 15.08 0.0 Y Description: GR27 SEALED LEADACID BATTERY Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2371 RR DME RTL MAXFEE 01/01/2024 16.56 0.0 Y Description: GR27 SEALED LEADACID BATTERY Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2372 NU DME PUR MAXFEE 01/01/2014 12/31/2023 91.98 0.0 Y Description: GR27 NON-SEALED LEADACID Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2372 NU DME PUR MAXFEE 01/01/2024 119.57 0.0 Y Description: GR27 NON-SEALED LEADACID Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2372 RR DME RTL MAXFEE 01/01/2014 12/31/2023 9.20 0.0 Y Description: GR27 NON-SEALED LEADACID Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2372 RR DME RTL MAXFEE 01/01/2024 11.96 0.0 Y Description: GR27 NON-SEALED LEADACID Category: Durable Medical CMS Add: 01/01/2006 CMS Term: E2373 NU DME PUR MAXFEE 01/01/2014 12/31/2023 1069.60 0.0 Y Description: HAND/CHIN CTRL SPEC JOYSTICK Category: Durable Medical CMS Add: 01/01/2007 CMS Term: E2373 NU DME PUR MAXFEE 01/01/2024 914.20 0.0 Y Description: HAND/CHIN CTRL SPEC JOYSTICK Category: Durable Medical CMS Add: 01/01/2007 CMS Term: E2374 NU DME PUR MAXFEE 01/01/2014 12/31/2023 534.02 0.0 Y Description: HAND/CHIN CTRL STD JOYSTICK Category: Durable Medical CMS Add: 01/01/2007 CMS Term: E2374 NU DME PUR MAXFEE 01/01/2024 583.50 0.0 Y Description: HAND/CHIN CTRL STD JOYSTICK Category: Durable Medical CMS Add: 01/01/2007 CMS Term: E2375 NU DME PUR MAXFEE 01/01/2014 12/31/2023 728.08 0.0 Y Description: NON-EXPANDABLE CONTROLLER Category: Durable Medical CMS Add: 01/01/2007 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,686 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E2375 NU DME PUR MAXFEE 01/01/2024 701.60 0.0 Y Description: NON-EXPANDABLE CONTROLLER Category: Durable Medical CMS Add: 01/01/2007 CMS Term: E2376 NU DME PUR MAXFEE 01/01/2014 12/31/2023 1140.93 0.0 Y Description: EXPANDABLE CONTROLLER, REPL Category: Durable Medical CMS Add: 01/01/2007 CMS Term: E2376 NU DME PUR MAXFEE 01/01/2024 1454.00 0.0 Y Description: EXPANDABLE CONTROLLER, REPL Category: Durable Medical CMS Add: 01/01/2007 CMS Term: E2376 RR DME RTL MAXFEE 01/01/2014 12/31/2023 114.10 0.0 Y Description: EXPANDABLE CONTROLLER, REPL Category: Durable Medical CMS Add: 01/01/2007 CMS Term: E2376 RR DME RTL MAXFEE 01/01/2024 145.40 0.0 Y Description: EXPANDABLE CONTROLLER, REPL Category: Durable Medical CMS Add: 01/01/2007 CMS Term: E2377 NU DME PUR MAXFEE 01/01/2014 12/31/2023 412.85 0.0 Y Description: EXPANDABLE CONTROLLER, INITL Category: Durable Medical CMS Add: 01/01/2007 CMS Term: E2377 NU DME PUR MAXFEE 01/01/2024 535.30 0.0 Y Description: EXPANDABLE CONTROLLER, INITL Category: Durable Medical CMS Add: 01/01/2007 CMS Term: E2378 NU DME PUR MAXFEE 01/01/2024 643.40 0.0 Y Description: PW ACTUATOR REPLACEMENT Category: Durable Medical CMS Add: 01/01/2013 CMS Term: E2378 NU DME PUR MAXFEE 07/01/2014 12/31/2023 553.99 0.0 Y Description: PW ACTUATOR REPLACEMENT Category: Durable Medical CMS Add: 01/01/2013 CMS Term: E2378 RR DME RTL MAXFEE 01/01/2024 64.34 0.0 Y Description: PW ACTUATOR REPLACEMENT Category: Durable Medical CMS Add: 01/01/2013 CMS Term: E2378 RR DME RTL MAXFEE 07/01/2014 12/31/2023 55.41 0.0 Y Description: PW ACTUATOR REPLACEMENT Category: Durable Medical CMS Add: 01/01/2013 CMS Term: E2381 NU DME PUR MAXFEE 01/01/2014 12/31/2023 76.18 0.0 Y Description: PNEUM DRIVE WHEEL TIRE Category: Durable Medical CMS Add: 01/01/2007 CMS Term: E2381 NU DME PUR MAXFEE 01/01/2024 70.01 0.0 Y Description: PNEUM DRIVE WHEEL TIRE Category: Durable Medical CMS Add: 01/01/2007 CMS Term: E2382 NU DME PUR MAXFEE 01/01/2014 12/31/2023 20.77 0.0 Y Description: TUBE, PNEUM WHEEL DRIVE TIRE Category: Durable Medical CMS Add: 01/01/2007 CMS Term: E2382 NU DME PUR MAXFEE 01/01/2024 21.64 0.0 Y Description: TUBE, PNEUM WHEEL DRIVE TIRE Category: Durable Medical CMS Add: 01/01/2007 CMS Term: E2383 NU DME PUR MAXFEE 01/01/2014 12/31/2023 151.88 0.0 Y Description: INSERT, PNEUM WHEEL DRIVE Category: Durable Medical CMS Add: 01/01/2007 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,687 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E2383 NU DME PUR MAXFEE 01/01/2024 142.85 0.0 Y Description: INSERT, PNEUM WHEEL DRIVE Category: Durable Medical CMS Add: 01/01/2007 CMS Term: E2384 NU DME PUR MAXFEE 01/01/2014 12/31/2023 80.91 0.0 Y Description: PNEUMATIC CASTER TIRE Category: Durable Medical CMS Add: 01/01/2007 CMS Term: E2384 NU DME PUR MAXFEE 01/01/2024 69.72 0.0 Y Description: PNEUMATIC CASTER TIRE Category: Durable Medical CMS Add: 01/01/2007 CMS Term: E2385 NU DME PUR MAXFEE 01/01/2014 12/31/2023 49.50 0.0 Y Description: TUBE, PNEUMATIC CASTER TIRE Category: Durable Medical CMS Add: 01/01/2007 CMS Term: E2385 NU DME PUR MAXFEE 01/01/2024 51.84 0.0 Y Description: TUBE, PNEUMATIC CASTER TIRE Category: Durable Medical CMS Add: 01/01/2007 CMS Term: E2386 NU DME PUR MAXFEE 01/01/2014 12/31/2023 150.51 0.0 Y Description: FOAM FILLED DRIVE WHEEL TIRE Category: Durable Medical CMS Add: 01/01/2007 CMS Term: E2386 NU DME PUR MAXFEE 01/01/2024 118.89 0.0 Y Description: FOAM FILLED DRIVE WHEEL TIRE Category: Durable Medical CMS Add: 01/01/2007 CMS Term: E2387 NU DME PUR MAXFEE 01/01/2014 12/31/2023 67.49 0.0 Y Description: FOAM FILLED CASTER TIRE Category: Durable Medical CMS Add: 01/01/2007 CMS Term: E2387 NU DME PUR MAXFEE 01/01/2024 57.21 0.0 Y Description: FOAM FILLED CASTER TIRE Category: Durable Medical CMS Add: 01/01/2007 CMS Term: E2388 NU DME PUR MAXFEE 01/01/2014 12/31/2023 42.83 0.0 Y Description: FOAM DRIVE WHEEL TIRE Category: Durable Medical CMS Add: 01/01/2007 CMS Term: E2388 NU DME PUR MAXFEE 01/01/2024 55.40 0.0 Y Description: FOAM DRIVE WHEEL TIRE Category: Durable Medical CMS Add: 01/01/2007 CMS Term: E2389 NU DME PUR MAXFEE 01/01/2014 12/31/2023 23.26 0.0 Y Description: FOAM CASTER TIRE Category: Durable Medical CMS Add: 01/01/2007 CMS Term: E2389 NU DME PUR MAXFEE 01/01/2024 30.74 0.0 Y Description: FOAM CASTER TIRE Category: Durable Medical CMS Add: 01/01/2007 CMS Term: E2390 NU DME PUR MAXFEE 01/01/2014 12/31/2023 36.37 0.0 Y Description: SOLID DRIVE WHEEL TIRE Category: Durable Medical CMS Add: 01/01/2007 CMS Term: E2390 NU DME PUR MAXFEE 01/01/2024 47.72 0.0 Y Description: SOLID DRIVE WHEEL TIRE Category: Durable Medical CMS Add: 01/01/2007 CMS Term: E2391 NU DME PUR MAXFEE 01/01/2014 12/31/2023 17.43 0.0 Y Description: SOLID CASTER TIRE Category: Durable Medical CMS Add: 01/01/2007 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,688 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E2391 NU DME PUR MAXFEE 01/01/2024 20.81 0.0 Y Description: SOLID CASTER TIRE Category: Durable Medical CMS Add: 01/01/2007 CMS Term: E2392 NU DME PUR MAXFEE 01/01/2014 12/31/2023 45.80 0.0 Y Description: SOLID CASTER TIRE, INTEGRATE Category: Durable Medical CMS Add: 01/01/2007 CMS Term: E2392 NU DME PUR MAXFEE 01/01/2024 51.76 0.0 Y Description: SOLID CASTER TIRE, INTEGRATE Category: Durable Medical CMS Add: 01/01/2007 CMS Term: E2394 NU DME PUR MAXFEE 01/01/2014 12/31/2023 65.24 0.0 Y Description: DRIVE WHEEL EXCLUDES TIRE Category: Durable Medical CMS Add: 01/01/2007 CMS Term: E2394 NU DME PUR MAXFEE 01/01/2024 62.75 0.0 Y Description: DRIVE WHEEL EXCLUDES TIRE Category: Durable Medical CMS Add: 01/01/2007 CMS Term: E2395 NU DME PUR MAXFEE 01/01/2014 12/31/2023 46.37 0.0 Y Description: CASTER WHEEL EXCLUDES TIRE Category: Durable Medical CMS Add: 01/01/2007 CMS Term: E2395 NU DME PUR MAXFEE 01/01/2024 55.12 0.0 Y Description: CASTER WHEEL EXCLUDES TIRE Category: Durable Medical CMS Add: 01/01/2007 CMS Term: E2396 NU DME PUR MAXFEE 01/01/2014 12/31/2023 66.51 0.0 Y Description: CASTER FORK Category: Durable Medical CMS Add: 01/01/2007 CMS Term: E2396 NU DME PUR MAXFEE 01/01/2024 52.50 0.0 Y Description: CASTER FORK Category: Durable Medical CMS Add: 01/01/2007 CMS Term: E2397 NU DME PUR MAXFEE 01/01/2014 12/31/2023 414.13 0.0 Y Description: PWC ACC, LITH-BASED BATTERY Category: Durable Medical CMS Add: 01/01/2008 CMS Term: E2397 NU DME PUR MAXFEE 01/01/2024 488.38 0.0 Y Description: PWC ACC, LITH-BASED BATTERY Category: Durable Medical CMS Add: 01/01/2008 CMS Term: E2397 RR DME RTL MAXFEE 01/01/2014 12/31/2023 41.41 0.0 Y Description: PWC ACC, LITH-BASED BATTERY Category: Durable Medical CMS Add: 01/01/2008 CMS Term: E2397 RR DME RTL MAXFEE 01/01/2024 52.48 0.0 Y Description: PWC ACC, LITH-BASED BATTERY Category: Durable Medical CMS Add: 01/01/2008 CMS Term: E2398 DME DEF SYSMAN Y Y Description: WC DYNAMIC POS BACK HARDWARE Category: Durable Medical CMS Add: 01/01/2020 CMS Term: E2402 NU DME PUR MAXFEE 01/01/2023 12/31/2023 10577.70 0.0 Y Description: NEG PRESS WOUND THERAPY PUMP Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2402 NU DME PUR MAXFEE 01/01/2024 7771.80 0.0 Y Description: NEG PRESS WOUND THERAPY PUMP Category: Durable Medical CMS Add: 01/01/2004 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,689 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E2402 RR DME RTL MAXFEE 01/01/2023 12/31/2023 1057.77 0.0 Y Description: NEG PRESS WOUND THERAPY PUMP Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2402 RR DME RTL MAXFEE 01/01/2024 777.18 0.0 Y Description: NEG PRESS WOUND THERAPY PUMP Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2500 NU DME PUR MAXFEE 02/01/2021 455.20 0.0 Y Description: SGD DIGITIZED PRE-REC <=8MIN Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2500 RR DME RTL MAXFEE 02/01/2021 45.53 0.0 Y Description: SGD DIGITIZED PRE-REC <=8MIN Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2502 NU DME PUR MAXFEE 01/01/2023 1590.24 0.0 Y Description: SGD PREREC MSG >8MIN <=20MIN Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2502 RR DME RTL MAXFEE 01/01/2023 159.04 0.0 Y Description: SGD PREREC MSG >8MIN <=20MIN Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2504 NU DME PUR MAXFEE 01/01/2014 12/31/2023 1577.42 0.0 Y Description: SGD PREREC MSG>20MIN <=40MIN Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2504 NU DME PUR MAXFEE 01/01/2024 2097.77 0.0 Y Description: SGD PREREC MSG>20MIN <=40MIN Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2504 RR DME RTL MAXFEE 01/01/2014 12/31/2023 157.76 0.0 Y Description: SGD PREREC MSG>20MIN <=40MIN Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2504 RR DME RTL MAXFEE 01/01/2024 209.80 0.0 Y Description: SGD PREREC MSG>20MIN <=40MIN Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2506 NU DME PUR MAXFEE 01/01/2023 3075.93 0.0 Y Description: SGD PREREC MSG > 40 MIN Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2506 RR DME RTL MAXFEE 01/01/2023 307.58 0.0 Y Description: SGD PREREC MSG > 40 MIN Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2508 NU DME PUR MAXFEE 01/01/2023 12/31/2023 4756.42 0.0 Y Description: SGD SPELLING PHYS CONTACT Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2508 NU DME PUR MAXFEE 01/01/2024 4880.09 0.0 Y Description: SGD SPELLING PHYS CONTACT Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2508 RR DME RTL MAXFEE 01/01/2023 12/31/2023 475.64 0.0 Y Description: SGD SPELLING PHYS CONTACT Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2508 RR DME RTL MAXFEE 01/01/2024 488.01 0.0 Y Description: SGD SPELLING PHYS CONTACT Category: Durable Medical CMS Add: 01/01/2004 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,690 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E2510 NU DME PUR MAXFEE 01/01/2023 12/31/2023 9000.90 0.0 Y Description: SGD W MULTI METHODS MSG/ACCS Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2510 NU DME PUR MAXFEE 01/01/2024 9234.92 0.0 Y Description: SGD W MULTI METHODS MSG/ACCS Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2510 RR DME RTL MAXFEE 01/01/2023 12/31/2023 900.09 0.0 Y Description: SGD W MULTI METHODS MSG/ACCS Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2510 RR DME RTL MAXFEE 01/01/2024 923.49 0.0 Y Description: SGD W MULTI METHODS MSG/ACCS Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2511 DME DEF SYSMAN Y Y Description: SGD SFTWRE PRGRM FOR PC/PDA Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2512 DME DEF SYSMAN Y Y Description: SGD ACCESSORY, MOUNTING SYS Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2599 DME DEF SYSMAN Y Y Description: SGD ACCESSORY NOC Category: Durable Medical CMS Add: 01/01/2004 CMS Term: E2601 NU DME PUR MAXFEE 01/01/2014 12/31/2023 75.35 0.0 Description: GEN W/C CUSHION WDTH < 22 IN Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E2601 NU DME PUR MAXFEE 01/01/2024 44.15 0.0 Description: GEN W/C CUSHION WDTH < 22 IN Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E2602 NU DME PUR MAXFEE 01/01/2014 12/31/2023 137.60 0.0 Y Description: GEN W/C CUSHION WDTH >=22 IN Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E2602 NU DME PUR MAXFEE 01/01/2024 94.37 0.0 Y Description: GEN W/C CUSHION WDTH >=22 IN Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E2603 NU DME PUR MAXFEE 01/01/2014 12/31/2023 189.58 0.0 Y Description: SKIN PROTECT WC CUS WD <22IN Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E2603 NU DME PUR MAXFEE 01/01/2024 117.97 0.0 Y Description: SKIN PROTECT WC CUS WD <22IN Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E2604 NU DME PUR MAXFEE 01/01/2014 12/31/2023 268.40 0.0 Y Description: SKIN PROTECT WC CUS WD>=22IN Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E2604 NU DME PUR MAXFEE 01/01/2024 148.84 0.0 Y Description: SKIN PROTECT WC CUS WD>=22IN Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E2605 NU DME PUR MAXFEE 01/01/2014 12/31/2023 321.69 0.0 Y Description: POSITION WC CUSH WDTH <22 IN Category: Durable Medical CMS Add: 01/01/2005 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,691 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E2605 NU DME PUR MAXFEE 01/01/2024 231.55 0.0 Y Description: POSITION WC CUSH WDTH <22 IN Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E2606 NU DME PUR MAXFEE 01/01/2014 12/31/2023 370.66 0.0 Y Description: POSITION WC CUSH WDTH>=22 IN Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E2606 NU DME PUR MAXFEE 01/01/2024 374.95 0.0 Y Description: POSITION WC CUSH WDTH>=22 IN Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E2607 NU DME PUR MAXFEE 01/01/2014 12/31/2023 251.26 0.0 Y Description: SKIN PRO/POS WC CUS WD <22IN Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E2607 NU DME PUR MAXFEE 01/01/2024 228.97 0.0 Y Description: SKIN PRO/POS WC CUS WD <22IN Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E2608 NU DME PUR MAXFEE 01/01/2014 12/31/2023 300.90 0.0 Y Description: SKIN PRO/POS WC CUS WD>=22IN Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E2608 NU DME PUR MAXFEE 01/01/2024 274.98 0.0 Y Description: SKIN PRO/POS WC CUS WD>=22IN Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E2609 DME DEF SYSMAN Y Y Description: CUSTOM FABRICATE W/C CUSHION Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E2610 NOCOV DEF SYSMAN Description: POWERED W/C CUSHION Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: E2611 NU DME PUR MAXFEE 01/01/2014 12/31/2023 265.50 0.0 Description: GEN USE BACK CUSH WDTH <22IN Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E2611 NU DME PUR MAXFEE 01/01/2024 138.11 0.0 Description: GEN USE BACK CUSH WDTH <22IN Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E2612 NU DME PUR MAXFEE 01/01/2014 12/31/2023 359.16 0.0 Y Description: GEN USE BACK CUSH WDTH>=22IN Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E2612 NU DME PUR MAXFEE 01/01/2024 333.80 0.0 Y Description: GEN USE BACK CUSH WDTH>=22IN Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E2613 NU DME PUR MAXFEE 01/01/2014 12/31/2023 334.08 0.0 Y Description: POSITION BACK CUSH WD <22IN Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E2613 NU DME PUR MAXFEE 01/01/2024 358.36 0.0 Y Description: POSITION BACK CUSH WD <22IN Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E2614 NU DME PUR MAXFEE 01/01/2014 12/31/2023 462.34 0.0 Y Description: POSITION BACK CUSH WD>=22IN Category: Durable Medical CMS Add: 01/01/2005 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,692 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E2614 NU DME PUR MAXFEE 01/01/2024 506.37 0.0 Y Description: POSITION BACK CUSH WD>=22IN Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E2615 NU DME PUR MAXFEE 01/01/2014 12/31/2023 384.47 0.0 Y Description: POS BACK POST/LAT WDTH <22IN Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E2615 NU DME PUR MAXFEE 01/01/2024 398.71 0.0 Y Description: POS BACK POST/LAT WDTH <22IN Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E2616 NU DME PUR MAXFEE 01/01/2014 12/31/2023 517.29 0.0 Y Description: POS BACK POST/LAT WDTH>=22IN Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E2616 NU DME PUR MAXFEE 01/01/2024 562.57 0.0 Y Description: POS BACK POST/LAT WDTH>=22IN Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E2617 DME DEF SYSMAN Y Y Description: CUSTOM FAB W/C BACK CUSHION Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E2619 NU DME PUR MAXFEE 01/01/2014 12/31/2023 43.62 0.0 Y Description: REPLACE COVER W/C SEAT CUSH Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E2619 NU DME PUR MAXFEE 01/01/2024 56.89 0.0 Y Description: REPLACE COVER W/C SEAT CUSH Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E2620 NU DME PUR MAXFEE 01/01/2014 12/31/2023 488.55 0.0 Y Description: WC PLANAR BACK CUSH WD <22IN Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E2620 NU DME PUR MAXFEE 01/01/2024 432.65 0.0 Y Description: WC PLANAR BACK CUSH WD <22IN Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E2621 NU DME PUR MAXFEE 01/01/2014 12/31/2023 465.55 0.0 Y Description: WC PLANAR BACK CUSH WD>=22IN Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E2621 NU DME PUR MAXFEE 01/01/2024 538.45 0.0 Y Description: WC PLANAR BACK CUSH WD>=22IN Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E2622 NU DME PUR MAXFEE 01/01/2014 12/31/2023 299.68 0.0 Y 0-1 Description: ADJ SKIN PRO W/C CUS WD<22IN Category: Durable Medical CMS Add: 01/01/2011 CMS Term: E2622 NU DME PUR MAXFEE 01/01/2024 362.58 0.0 Y 0-1 Description: ADJ SKIN PRO W/C CUS WD<22IN Category: Durable Medical CMS Add: 01/01/2011 CMS Term: E2622 RR DME RTL MAXFEE 01/01/2014 12/31/2023 29.97 0.0 Y 0-1 Description: ADJ SKIN PRO W/C CUS WD<22IN Category: Durable Medical CMS Add: 01/01/2011 CMS Term: E2622 RR DME RTL MAXFEE 01/01/2024 36.26 0.0 Y 0-1 Description: ADJ SKIN PRO W/C CUS WD<22IN Category: Durable Medical CMS Add: 01/01/2011 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,693 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E2623 NU DME PUR MAXFEE 01/01/2014 12/31/2023 381.33 0.0 Y 0-1 Description: ADJ SKIN PRO WC CUS WD>=22IN Category: Durable Medical CMS Add: 01/01/2011 CMS Term: E2623 NU DME PUR MAXFEE 01/01/2024 459.26 0.0 Y 0-1 Description: ADJ SKIN PRO WC CUS WD>=22IN Category: Durable Medical CMS Add: 01/01/2011 CMS Term: E2623 RR DME RTL MAXFEE 01/01/2014 12/31/2023 38.14 0.0 Y 0-1 Description: ADJ SKIN PRO WC CUS WD>=22IN Category: Durable Medical CMS Add: 01/01/2011 CMS Term: E2623 RR DME RTL MAXFEE 01/01/2024 45.93 0.0 Y 0-1 Description: ADJ SKIN PRO WC CUS WD>=22IN Category: Durable Medical CMS Add: 01/01/2011 CMS Term: E2624 NU DME PUR MAXFEE 01/01/2014 12/31/2023 302.14 0.0 Y 0-1 Description: ADJ SKIN PRO/POS CUS<22IN Category: Durable Medical CMS Add: 01/01/2011 CMS Term: E2624 NU DME PUR MAXFEE 01/01/2024 367.69 0.0 Y 0-1 Description: ADJ SKIN PRO/POS CUS<22IN Category: Durable Medical CMS Add: 01/01/2011 CMS Term: E2624 RR DME RTL MAXFEE 01/01/2014 12/31/2023 30.22 0.0 Y 0-1 Description: ADJ SKIN PRO/POS CUS<22IN Category: Durable Medical CMS Add: 01/01/2011 CMS Term: E2624 RR DME RTL MAXFEE 01/01/2024 36.77 0.0 Y 0-1 Description: ADJ SKIN PRO/POS CUS<22IN Category: Durable Medical CMS Add: 01/01/2011 CMS Term: E2625 NU DME PUR MAXFEE 01/01/2014 12/31/2023 382.49 0.0 Y Description: ADJ SKIN PRO/POS WC CUS>=22 Category: Durable Medical CMS Add: 01/01/2011 CMS Term: E2625 NU DME PUR MAXFEE 01/01/2024 457.76 0.0 Y Description: ADJ SKIN PRO/POS WC CUS>=22 Category: Durable Medical CMS Add: 01/01/2011 CMS Term: E2625 RR DME RTL MAXFEE 01/01/2014 12/31/2023 38.24 0.0 Y Description: ADJ SKIN PRO/POS WC CUS>=22 Category: Durable Medical CMS Add: 01/01/2011 CMS Term: E2625 RR DME RTL MAXFEE 01/01/2024 45.77 0.0 Y Description: ADJ SKIN PRO/POS WC CUS>=22 Category: Durable Medical CMS Add: 01/01/2011 CMS Term: E2626 NU DME PUR MAXFEE 01/01/2012 12/31/2023 567.09 0.0 Description: SEO MOBILE ARM SUP ATT TO WC Category: Durable Medical CMS Add: 01/01/2012 CMS Term: E2626 NU DME PUR MAXFEE 01/01/2024 656.72 0.0 Description: SEO MOBILE ARM SUP ATT TO WC Category: Durable Medical CMS Add: 01/01/2012 CMS Term: E2626 RR DME RTL MAXFEE 01/01/2012 12/31/2023 56.70 0.0 Description: SEO MOBILE ARM SUP ATT TO WC Category: Durable Medical CMS Add: 01/01/2012 CMS Term: E2626 RR DME RTL MAXFEE 01/01/2024 70.19 0.0 Description: SEO MOBILE ARM SUP ATT TO WC Category: Durable Medical CMS Add: 01/01/2012 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,694 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E2627 NU DME PUR MAXFEE 01/01/2012 12/31/2023 904.89 0.0 Description: ARM SUPP ATT TO WC RANCHO TY Category: Durable Medical CMS Add: 01/01/2012 CMS Term: E2627 NU DME PUR MAXFEE 01/01/2024 1061.69 0.0 Description: ARM SUPP ATT TO WC RANCHO TY Category: Durable Medical CMS Add: 01/01/2012 CMS Term: E2627 RR DME RTL MAXFEE 01/01/2012 12/31/2023 90.52 0.0 Description: ARM SUPP ATT TO WC RANCHO TY Category: Durable Medical CMS Add: 01/01/2012 CMS Term: E2627 RR DME RTL MAXFEE 01/01/2024 107.91 0.0 Description: ARM SUPP ATT TO WC RANCHO TY Category: Durable Medical CMS Add: 01/01/2012 CMS Term: E2628 NU DME PUR MAXFEE 01/01/2012 12/31/2023 681.69 0.0 Description: MOBILE ARM SUPPORTS RECLININ Category: Durable Medical CMS Add: 01/01/2012 CMS Term: E2628 NU DME PUR MAXFEE 01/01/2024 810.15 0.0 Description: MOBILE ARM SUPPORTS RECLININ Category: Durable Medical CMS Add: 01/01/2012 CMS Term: E2628 RR DME RTL MAXFEE 01/01/2012 12/31/2023 68.17 0.0 Description: MOBILE ARM SUPPORTS RECLININ Category: Durable Medical CMS Add: 01/01/2012 CMS Term: E2628 RR DME RTL MAXFEE 01/01/2024 84.40 0.0 Description: MOBILE ARM SUPPORTS RECLININ Category: Durable Medical CMS Add: 01/01/2012 CMS Term: E2629 NU DME PUR MAXFEE 01/01/2012 12/31/2023 979.38 0.0 Description: FRICTION DAMPENING ARM SUPP Category: Durable Medical CMS Add: 01/01/2012 CMS Term: E2629 NU DME PUR MAXFEE 01/01/2024 1121.51 0.0 Description: FRICTION DAMPENING ARM SUPP Category: Durable Medical CMS Add: 01/01/2012 CMS Term: E2629 RR DME RTL MAXFEE 01/01/2012 12/31/2023 97.93 0.0 Description: FRICTION DAMPENING ARM SUPP Category: Durable Medical CMS Add: 01/01/2012 CMS Term: E2629 RR DME RTL MAXFEE 01/01/2024 114.52 0.0 Description: FRICTION DAMPENING ARM SUPP Category: Durable Medical CMS Add: 01/01/2012 CMS Term: E2630 NU DME PUR MAXFEE 01/01/2012 12/31/2023 709.72 0.0 Description: MONOSUSPENSION ARM/HAND SUPP Category: Durable Medical CMS Add: 01/01/2012 CMS Term: E2630 NU DME PUR MAXFEE 01/01/2024 728.02 0.0 Description: MONOSUSPENSION ARM/HAND SUPP Category: Durable Medical CMS Add: 01/01/2012 CMS Term: E2630 RR DME RTL MAXFEE 01/01/2012 12/31/2023 70.97 0.0 Description: MONOSUSPENSION ARM/HAND SUPP Category: Durable Medical CMS Add: 01/01/2012 CMS Term: E2630 RR DME RTL MAXFEE 01/01/2024 77.53 0.0 Description: MONOSUSPENSION ARM/HAND SUPP Category: Durable Medical CMS Add: 01/01/2012 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,695 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- E2631 NU DME PUR MAXFEE 01/01/2012 12/31/2023 283.90 0.0 Description: ELEVAT PROXIMAL ARM SUPPORT Category: Durable Medical CMS Add: 01/01/2012 CMS Term: E2631 NU DME PUR MAXFEE 01/01/2024 311.43 0.0 Description: ELEVAT PROXIMAL ARM SUPPORT Category: Durable Medical CMS Add: 01/01/2012 CMS Term: E2631 RR DME RTL MAXFEE 01/01/2012 12/31/2023 28.39 0.0 Description: ELEVAT PROXIMAL ARM SUPPORT Category: Durable Medical CMS Add: 01/01/2012 CMS Term: E2631 RR DME RTL MAXFEE 01/01/2024 31.86 0.0 Description: ELEVAT PROXIMAL ARM SUPPORT Category: Durable Medical CMS Add: 01/01/2012 CMS Term: E2632 NU DME PUR MAXFEE 01/01/2012 12/31/2023 180.52 0.0 Description: OFFSET/LAT ROCKER ARM W/ELA Category: Durable Medical CMS Add: 01/01/2012 CMS Term: E2632 NU DME PUR MAXFEE 01/01/2024 198.18 0.0 Description: OFFSET/LAT ROCKER ARM W/ELA Category: Durable Medical CMS Add: 01/01/2012 CMS Term: E2632 RR DME RTL MAXFEE 01/01/2012 12/31/2023 18.05 0.0 Description: OFFSET/LAT ROCKER ARM W/ELA Category: Durable Medical CMS Add: 01/01/2012 CMS Term: E2632 RR DME RTL MAXFEE 01/01/2024 20.08 0.0 Description: OFFSET/LAT ROCKER ARM W/ELA Category: Durable Medical CMS Add: 01/01/2012 CMS Term: E2633 NU DME PUR MAXFEE 01/01/2012 12/31/2023 153.12 0.0 Description: MOBILE ARM SUPPORT SUPINATOR Category: Durable Medical CMS Add: 01/01/2012 CMS Term: E2633 NU DME PUR MAXFEE 01/01/2024 157.07 0.0 Description: MOBILE ARM SUPPORT SUPINATOR Category: Durable Medical CMS Add: 01/01/2012 CMS Term: E2633 RR DME RTL MAXFEE 01/01/2012 12/31/2023 15.33 0.0 Description: MOBILE ARM SUPPORT SUPINATOR Category: Durable Medical CMS Add: 01/01/2012 CMS Term: E2633 RR DME RTL MAXFEE 01/01/2024 16.58 0.0 Description: MOBILE ARM SUPPORT SUPINATOR Category: Durable Medical CMS Add: 01/01/2012 CMS Term: E3000 NOCOV DEF SYSMAN Description: SPEECH VOLUME MODULATION SYS Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: E8000 DME DEF SYSMAN Y Y Description: POSTERIOR GAIT TRAINER Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E8001 DME DEF SYSMAN Y Y Description: UPRIGHT GAIT TRAINER Category: Durable Medical CMS Add: 01/01/2005 CMS Term: E8002 DME DEF SYSMAN Y Y Description: ANTERIOR GAIT TRAINER Category: Durable Medical CMS Add: 01/01/2005 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,696 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G0008 NOCOV DEF SYSMAN Description: ADMIN INFLUENZA VIRUS VAC Category: Non Covered Services CMS Add: 01/01/1994 CMS Term: G0009 NOCOV DEF SYSMAN Description: ADMIN PNEUMOCOCCAL VACCINE Category: Non Covered Services CMS Add: 01/01/1994 CMS Term: G0010 NOCOV DEF SYSMAN Description: ADMIN HEPATITIS B VACCINE Category: Non Covered Services CMS Add: 01/01/1994 CMS Term: G0012 NOCOV DEF SYSMAN Description: INJECTION OF HIV PREP DRUG Category: Non Covered Services CMS Add: 01/02/2024 CMS Term: G0017 MENTL DEF RBRVS 01/01/2024 208.61 0-1 Description: CRISIS PSYCHOTHERAPY 60M Category: Mental Health CMS Add: 01/01/2024 CMS Term: G0018 MENTL DEF RBRVS 01/01/2024 102.57 Description: CRISIS PSYCHOTHERAPY ADD 30M Category: Mental Health CMS Add: 01/01/2024 CMS Term: G0019 NOCOV DEF SYSMAN Description: COMM HLTH INTG SVS SDOH 60MN Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: G0022 NOCOV DEF SYSMAN Description: COMM HLTH INTG SVS ADD 30 M Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: G0023 NOCOV DEF SYSMAN Description: PIN SERVICE 60M PER MONTH Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: G0024 NOCOV DEF SYSMAN Description: PIN SRV ADD 30 MIN PR M Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: G0027 NOCOV DEF SYSMAN Description: SEMEN ANALYSIS Category: Non Covered Services CMS Add: 01/01/1995 CMS Term: G0029 NOCOV DEF SYSMAN Description: NO TOB SCR/CESS INT Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G0030 NOCOV DEF SYSMAN Description: PT SCR TOB & CESS INT Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G0031 NOCOV DEF SYSMAN Description: PALL SERV DURING MEAS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G0032 NOCOV DEF SYSMAN Description: 2+ ANTIPSY SCHIZ Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G0033 NOCOV DEF SYSMAN Description: 2+ BENZO SEIZ Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,697 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G0034 NOCOV DEF SYSMAN Description: PALL SERV DURING MEAS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G0035 NOCOV DEF SYSMAN Description: PT ED POS 23 Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G0036 NOCOV DEF SYSMAN Description: PT/PTN DECLN ASSESS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G0037 NOCOV DEF SYSMAN Description: PT NOT ABLE TO PARTICIPATE Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G0038 NOCOV DEF SYSMAN Description: CLIN PT NO REF Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G0039 NOCOV DEF SYSMAN Description: PT NO REF, RN SPEC Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G0040 NOCOV DEF SYSMAN Description: PT PHYS/OCC THERAPY Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G0041 NOCOV DEF SYSMAN Description: PT/PTN DECLN REFERRAL Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G0042 NOCOV DEF SYSMAN Description: REF TO THERAPY Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G0043 NOCOV DEF SYSMAN Description: PT MECH PROS HT VALV Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G0044 NOCOV DEF SYSMAN Description: PT MITRAL STENOSIS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G0045 NOCOV DEF SYSMAN Description: MRS 90 DAYS POST STK Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G0046 NOCOV DEF SYSMAN Description: NO MRS 90 DAYS POST STK Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G0047 NOCOV DEF SYSMAN Description: PED BLUNT HD TRAUM Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G0048 NOCOV DEF SYSMAN Description: PALL SERV DURING MEAS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G0049 NOCOV DEF SYSMAN Description: MAIN HEMO IN-CNTR Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,698 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G0050 NOCOV DEF SYSMAN Description: PT W/ LMTED LIFE EXPEC Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G0051 NOCOV DEF SYSMAN Description: PT HOSPICE MNTH Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G0052 NOCOV DEF SYSMAN Description: PT PERI DIALYSIS DUR MO Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G0053 NOCOV DEF SYSMAN Description: ADV RHEUM PT CARE MVP Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G0054 NOCOV DEF SYSMAN Description: STRK CR PREV POS OUTCME MVP Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G0055 NOCOV DEF SYSMAN Description: ADV CARE HEART DX MVP Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G0057 NOCOV DEF SYSMAN Description: BEST PCT PT SAFETY EM MVP Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G0058 NOCOV DEF SYSMAN Description: IMPRV CARE LE JNT REPR MVP Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G0059 NOCOV DEF SYSMAN Description: PT SFTY POS EXP W ANETH MVP Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G0060 NOCOV DEF SYSMAN Description: ALLERGY/IMMUNOLOGY SS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G0061 NOCOV DEF SYSMAN Description: ANESTHESIOLOGY SS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G0062 NOCOV DEF SYSMAN Description: AUDIOLOGY SS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G0063 NOCOV DEF SYSMAN Description: CARDIOLOGY SS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G0064 NOCOV DEF SYSMAN Description: CERT NURSE MIDWIFE SS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G0065 NOCOV DEF SYSMAN Description: CHIROPRACTIC SS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G0066 NOCOV DEF SYSMAN Description: CLINICAL SOCIAL WORK SS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,699 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G0067 NOCOV DEF SYSMAN Description: DENTISTRY SS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G0068 NOCOV DEF SYSMAN Description: ADM IV INFUSION DRUG IN HOME Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: G0069 NOCOV DEF SYSMAN Description: ADM SQ INFUSION DRUG IN HOME Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: G0070 NOCOV DEF SYSMAN Description: ADM OF CHEMO DRUG IN HOME Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: G0071* NOCOV DEF SYSMAN Description: COMM SVCS BY RHC/FQHC 5 MIN Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: G0076 NOCOV DEF SYSMAN Description: CARE MANAG H VST NEW PT 20 M Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: G0077 NOCOV DEF SYSMAN Description: CARE MANAG H VST NEW PT 30 M Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: G0078 NOCOV DEF SYSMAN Description: CARE MANAG H VST NEW PT 45 M Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: G0079 NOCOV DEF SYSMAN Description: CARE MANAG H VST NEW PT 60 M Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: G0080 NOCOV DEF SYSMAN Description: CARE MANAG H VST NEW PT 75 M Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: G0081 NOCOV DEF SYSMAN Description: CARE MAN H V EXT PT 20 MI Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: G0082 NOCOV DEF SYSMAN Description: CARE MAN H V EXT PT 30 M Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: G0083 NOCOV DEF SYSMAN Description: CARE MAN H V EXT PT 45 M Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: G0084 NOCOV DEF SYSMAN Description: CARE MAN H V EXT PT 60 M Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: G0085 NOCOV DEF SYSMAN Description: CARE MAN H V EXT PT 75 M Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: G0086 NOCOV DEF SYSMAN Description: CARE MAN HOME CARE PLAN 30 M Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,700 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G0087 NOCOV DEF SYSMAN Description: CARE MAN HOME CARE PLAN 60 M Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: G0088 NOCOV DEF SYSMAN Description: ADM IV DRUG 1ST HOME VISIT Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: G0089 NOCOV DEF SYSMAN Description: ADM SUBQ DRUG 1ST HOME VISIT Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: G0090 NOCOV DEF SYSMAN Description: ADM IV CHEMO 1ST HOME VISIT Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: G0101 NOCOV DEF SYSMAN Description: CA SCREEN;PELVIC/BREAST EXAM Category: Non Covered Services CMS Add: 01/01/1998 CMS Term: G0102 NOCOV DEF SYSMAN Description: PROSTATE CA SCREENING; DRE Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: G0103 LAB L60 MAXFEE 01/01/2020 19.31 0.0 0-1 Description: PSA SCREENING Category: Laboratory CMS Add: 01/01/2000 CMS Term: G0104 NOCOV DEF SYSMAN Description: CA SCREEN;FLEXI SIGMOIDSCOPE Category: Non Covered Services CMS Add: 01/01/1998 CMS Term: G0105 NOCOV DEF SYSMAN Description: COLORECTAL SCRN; HI RISK IND Category: Non Covered Services CMS Add: 01/01/1998 CMS Term: G0106 NOCOV DEF SYSMAN Description: COLON CA SCREEN;BARIUM ENEMA Category: Non Covered Services CMS Add: 01/01/1998 CMS Term: G0108 U6 DIABE DEF MAXFEE 01/01/2024 26.07 0.0 Description: DIAB MANAGE TRN PER INDIV Category: Diabetes SMT CMS Add: 07/01/1998 CMS Term: G0108 U6 DIABE DEF MAXFEE 02/01/2014 12/31/2023 22.50 0.0 Description: DIAB MANAGE TRN PER INDIV Category: Diabetes SMT CMS Add: 07/01/1998 CMS Term: G0109 U6 DIABE DEF MAXFEE 01/01/2024 7.41 0.0 Description: DIAB MANAGE TRN IND/GROUP Category: Diabetes SMT CMS Add: 07/01/1998 CMS Term: G0109 U6 DIABE DEF MAXFEE 02/01/2014 12/31/2023 22.50 0.0 Description: DIAB MANAGE TRN IND/GROUP Category: Diabetes SMT CMS Add: 07/01/1998 CMS Term: G0117 NOCOV DEF SYSMAN Description: GLAUCOMA SCRN HGH RISK DIREC Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: G0118 NOCOV DEF SYSMAN Description: GLAUCOMA SCRN HGH RISK DIREC Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,701 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G0120 NOCOV DEF SYSMAN Description: COLON CA SCRN; BARIUM ENEMA Category: Non Covered Services CMS Add: 01/01/1998 CMS Term: G0121 NOCOV DEF SYSMAN Description: COLON CA SCRN NOT HI RSK IND Category: Non Covered Services CMS Add: 01/01/1998 CMS Term: G0122 NOCOV DEF SYSMAN Description: COLON CA SCRN; BARIUM ENEMA Category: Non Covered Services CMS Add: 01/01/1998 CMS Term: G0123 LAB L60 MAXFEE 01/01/2024 20.26 0.0 Description: SCREEN CERV/VAG THIN LAYER Category: Laboratory CMS Add: 04/01/1998 CMS Term: G0123 LAB L60 MAXFEE 09/01/2001 12/31/2023 14.60 0.0 Description: SCREEN CERV/VAG THIN LAYER Category: Laboratory CMS Add: 04/01/1998 CMS Term: G0124 26 LAB DEF RBRVS 02/01/2015 19.35 Description: SCREEN C/V THIN LAYER BY MD Category: Laboratory CMS Add: 04/01/1998 CMS Term: G0124 26 LAB L60 MAXFEE 01/01/2024 20.15 0.0 Description: SCREEN C/V THIN LAYER BY MD Category: Laboratory CMS Add: 04/01/1998 CMS Term: G0124 LAB DEF RBRVS 01/01/2024 21.63 Description: SCREEN C/V THIN LAYER BY MD Category: Laboratory CMS Add: 04/01/1998 CMS Term: G0124 LAB DEF RBRVS 02/01/2015 12/31/2023 22.68 Description: SCREEN C/V THIN LAYER BY MD Category: Laboratory CMS Add: 04/01/1998 CMS Term: G0127 MEDSV DEF RBRVS 01/01/2024 21.97 Description: TRIM NAIL(S) Category: Medical Services CMS Add: 01/01/1998 CMS Term: G0127 MEDSV DEF RBRVS 09/01/2019 12/31/2023 19.11 Description: TRIM NAIL(S) Category: Medical Services CMS Add: 01/01/1998 CMS Term: G0128 MEDSV DEF RBRVS 01/01/2024 8.19 Description: CORF SKILLED NURSING SERVICE Category: Medical Services CMS Add: 04/01/1998 CMS Term: G0128 MEDSV DEF RBRVS 02/01/2015 12/31/2023 6.77 Description: CORF SKILLED NURSING SERVICE Category: Medical Services CMS Add: 04/01/1998 CMS Term: G0129 NOCOV DEF SYSMAN Description: PHP/IOP OT SERVICE Category: Non Covered Services CMS Add: 04/01/2000 CMS Term: G0130 26 RADIO DEF RBRVS 01/01/2024 10.39 Description: SINGLE ENERGY X-RAY STUDY Category: Radiology CMS Add: 07/01/1998 CMS Term: G0130 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 8.31 Description: SINGLE ENERGY X-RAY STUDY Category: Radiology CMS Add: 07/01/1998 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,702 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G0130 RADIO DEF RBRVS 01/01/2024 33.40 Description: SINGLE ENERGY X-RAY STUDY Category: Radiology CMS Add: 07/01/1998 CMS Term: G0130 RADIO DEF RBRVS 02/01/2015 12/31/2023 24.08 Description: SINGLE ENERGY X-RAY STUDY Category: Radiology CMS Add: 07/01/1998 CMS Term: G0130 TC RADIO DEF RBRVS 01/01/2024 23.01 Description: SINGLE ENERGY X-RAY STUDY Category: Radiology CMS Add: 07/01/1998 CMS Term: G0130 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 15.77 Description: SINGLE ENERGY X-RAY STUDY Category: Radiology CMS Add: 07/01/1998 CMS Term: G0136 MEDSV DEF RBRVS 01/01/2024 17.99 Description: ADM OF SOC DTR ASSESS 5-15 M Category: Medical Services CMS Add: 01/01/2024 CMS Term: G0140 NOCOV DEF SYSMAN Description: NAV SRV PEER SUP 60 MIN PR M Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: G0141 LAB DEF RBRVS 01/01/2024 21.63 Description: SCR C/V CYTO,AUTOSYS AND MD Category: Laboratory CMS Add: 01/01/1999 CMS Term: G0141 LAB DEF RBRVS 02/01/2015 12/31/2023 15.50 Description: SCR C/V CYTO,AUTOSYS AND MD Category: Laboratory CMS Add: 01/01/1999 CMS Term: G0143 LAB L60 MAXFEE 01/01/2024 27.05 0.0 Description: SCR C/V CYTO,THINLAYER,RESCR Category: Laboratory CMS Add: 01/01/1999 CMS Term: G0143 LAB L60 MAXFEE 09/01/2001 12/31/2023 14.60 0.0 Description: SCR C/V CYTO,THINLAYER,RESCR Category: Laboratory CMS Add: 01/01/1999 CMS Term: G0144 NOCOV DEF SYSMAN Description: SCR C/V CYTO,THINLAYER,RESCR Category: Non Covered Services CMS Add: 01/01/1999 CMS Term: G0145 NOCOV DEF SYSMAN Description: SCR C/V CYTO,THINLAYER,RESCR Category: Non Covered Services CMS Add: 01/01/1999 CMS Term: G0146 NOCOV DEF SYSMAN Description: NAV SRV PEER SUP ADD 30 PR M Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: G0147 LAB L60 MAXFEE 01/01/2017 12/31/2023 14.49 0.0 Description: SCR C/V CYTO, AUTOMATED SYS Category: Laboratory CMS Add: 01/01/1999 CMS Term: G0147 LAB L60 MAXFEE 01/01/2024 17.31 0.0 Description: SCR C/V CYTO, AUTOMATED SYS Category: Laboratory CMS Add: 01/01/1999 CMS Term: G0148 LAB L60 MAXFEE 01/01/2017 12/31/2023 14.49 0.0 Description: SCR C/V CYTO, AUTOSYS, RESCR Category: Laboratory CMS Add: 01/01/1999 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,703 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G0148 LAB L60 MAXFEE 01/01/2024 31.94 0.0 Description: SCR C/V CYTO, AUTOSYS, RESCR Category: Laboratory CMS Add: 01/01/1999 CMS Term: G0151 THEPY PRF MAXFEE 01/01/2024 24.14 0.0 Y Description: HHCP-SERV OF PT,EA 15 MIN Category: Therapy Services CMS Add: 07/01/1999 CMS Term: G0151 U5 U7 UA DDWA WDD MAXFEE 01/01/2008 18.12 0.0 Y Description: HHCP-SERV OF PT,EA 15 MIN Category: CIH Waiver CMS Add: 07/01/1999 CMS Term: G0151 U5 U7 UA MFPCI W3M MAXFEE 01/01/2014 18.12 0.0 Y Description: HHCP-SERV OF PT,EA 15 MIN Category: MFP CIH Waiver CMS Add: 07/01/1999 CMS Term: G0151 U5 U7 UA MFPTS W5M MAXFEE 10/01/2009 18.12 0.0 Y Description: HHCP-SERV OF PT,EA 15 MIN Category: MFP SOF Waiver CMS Add: 07/01/1999 CMS Term: G0151 U5 U7 UA SSFS WSS MAXFEE 01/01/2008 18.12 0.0 Y Description: HHCP-SERV OF PT,EA 15 MIN Category: Family Support Waivr CMS Add: 07/01/1999 CMS Term: G0152 THEPY PRF MAXFEE 01/01/2024 22.30 0.0 Y Description: HHCP-SERV OF OT,EA 15 MIN Category: Therapy Services CMS Add: 07/01/1999 CMS Term: G0152 U5 U7 UA DDWA WDD MAXFEE 01/01/2008 17.99 0.0 Y Description: HHCP-SERV OF OT,EA 15 MIN Category: CIH Waiver CMS Add: 07/01/1999 CMS Term: G0152 U5 U7 UA MFPCI W3M MAXFEE 01/01/2014 17.99 0.0 Y Description: HHCP-SERV OF OT,EA 15 MIN Category: MFP CIH Waiver CMS Add: 07/01/1999 CMS Term: G0152 U5 U7 UA MFPTS W5M MAXFEE 10/01/2009 17.99 0.0 Y Description: HHCP-SERV OF OT,EA 15 MIN Category: MFP SOF Waiver CMS Add: 07/01/1999 CMS Term: G0152 U5 U7 UA SSFS WSS MAXFEE 01/01/2008 17.99 0.0 Y Description: HHCP-SERV OF OT,EA 15 MIN Category: Family Support Waivr CMS Add: 07/01/1999 CMS Term: G0153 THEPY PRF MAXFEE 01/01/2024 24.34 0.0 Y Description: HHCP-SVS OF S/L PATH,EA 15MN Category: Therapy Services CMS Add: 07/01/1999 CMS Term: G0155 NOCOV DEF SYSMAN Description: HHCP-SVS OF CSW,EA 15 MIN Category: Non Covered Services CMS Add: 07/01/1999 CMS Term: G0156 NOCOV DEF SYSMAN Description: HHCP-SVS OF AIDE,EA 15 MIN Category: Non Covered Services CMS Add: 07/01/1999 CMS Term: G0157 NOCOV DEF SYSMAN Description: HHC PT ASSISTANT EA 15 Category: Non Covered Services CMS Add: 01/01/2011 CMS Term: G0158 NOCOV DEF SYSMAN Description: HHC OT ASSISTANT EA 15 Category: Non Covered Services CMS Add: 01/01/2011 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,704 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G0159 NOCOV DEF SYSMAN Description: HHC PT MAINT EA 15 MIN Category: Non Covered Services CMS Add: 01/01/2011 CMS Term: G0160 NOCOV DEF SYSMAN Description: HHC OCCUP THERAPY EA 15 Category: Non Covered Services CMS Add: 01/01/2011 CMS Term: G0161 NOCOV DEF SYSMAN Description: HHC SLP EA 15 MIN Category: Non Covered Services CMS Add: 01/01/2011 CMS Term: G0162 NOCOV DEF SYSMAN Description: HHC RN E&M PLAN SVS, 15 MIN Category: Non Covered Services CMS Add: 01/01/2011 CMS Term: G0166 MEDSV DEF RBRVS 01/01/2024 95.73 Description: EXTRNL COUNTERPULSE, PER TX Category: Medical Services CMS Add: 01/01/2000 CMS Term: G0166 MEDSV DEF RBRVS 09/01/2019 12/31/2023 86.27 Description: EXTRNL COUNTERPULSE, PER TX Category: Medical Services CMS Add: 01/01/2000 CMS Term: G0168 MEDSV DEF RBRVS 01/01/2024 114.89 Description: WOUND CLOSURE BY ADHESIVE Category: Medical Services CMS Add: 01/01/2000 CMS Term: G0168 MEDSV DEF RBRVS 02/01/2015 12/31/2023 40.16 Description: WOUND CLOSURE BY ADHESIVE Category: Medical Services CMS Add: 01/01/2000 CMS Term: G0175 NOCOV DEF SYSMAN Description: OPPS SERVICE,SCHED TEAM CONF Category: Non Covered Services CMS Add: 07/01/2000 CMS Term: G0176 NOCOV DEF SYSMAN Description: OPPS/PHP/IOP; ACTIVITY THRPY Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: G0177 NOCOV DEF SYSMAN Description: OPPS/PHP/IOP; TRAIN & EDUC Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: G0179 NOCOV DEF SYSMAN Description: MD RECERTIFICATION HHA PT Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: G0180 NOCOV DEF SYSMAN Description: MD CERTIFICATION HHA PATIENT Category: Non Covered Services CMS Add: 10/01/2000 CMS Term: G0181 NOCOV DEF SYSMAN Description: HOME HEALTH CARE SUPERVISION Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: G0182 NOCOV DEF SYSMAN Description: HOSPICE CARE SUPERVISION Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: G0183 NOCOV DEF SYSMAN Description: OCULAR PHOTODYNAMIC THERA Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: 06/30/2015 *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,705 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G0186 MEDSV DEF BILL90 Description: DSTRY EYE LESN,FDR VSSL TECH Category: Medical Services CMS Add: 01/01/2001 CMS Term: G0219 NOCOV DEF SYSMAN Description: PET IMG WHOLBOD MELANO NONCO Category: Non Covered Services CMS Add: 07/01/2001 CMS Term: G0235 NOCOV DEF SYSMAN Description: PET NOT OTHERWISE SPECIFIED Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G0237 THEPY DEF RBRVS 01/01/2024 9.73 Y Description: THERAPEUTIC PROCD STRG ENDUR Category: Therapy Services CMS Add: 01/01/2002 CMS Term: G0237 THEPY DEF RBRVS 02/01/2015 12/31/2023 11.48 Y Description: THERAPEUTIC PROCD STRG ENDUR Category: Therapy Services CMS Add: 01/01/2002 CMS Term: G0238 THEPY DEF RBRVS 01/01/2024 9.42 Y Description: OTH RESP PROC, INDIV Category: Therapy Services CMS Add: 01/01/2002 CMS Term: G0238 THEPY DEF RBRVS 09/01/2019 12/31/2023 12.47 Y Description: OTH RESP PROC, INDIV Category: Therapy Services CMS Add: 01/01/2002 CMS Term: G0239 THEPY DEF RBRVS 01/01/2024 11.58 Y Description: OTH RESP PROC, GROUP Category: Therapy Services CMS Add: 01/01/2002 CMS Term: G0239 THEPY DEF RBRVS 02/01/2015 12/31/2023 7.51 Y Description: OTH RESP PROC, GROUP Category: Therapy Services CMS Add: 01/01/2002 CMS Term: G0245 NOCOV DEF SYSMAN Description: INITIAL FOOT EXAM PT LOPS Category: Non Covered Services CMS Add: 07/01/2002 CMS Term: G0246 NOCOV DEF SYSMAN Description: FOLLOWUP EVAL OF FOOT PT LOP Category: Non Covered Services CMS Add: 07/01/2002 CMS Term: G0247 NOCOV DEF SYSMAN Description: ROUTINE FOOTCARE PT W LOPS Category: Non Covered Services CMS Add: 07/01/2002 CMS Term: G0248* NOCOV DEF SYSMAN Description: DEMONSTRATE USE HOME INR MON Category: Non Covered Services CMS Add: 07/01/2002 CMS Term: G0249* NOCOV DEF SYSMAN Description: PROVIDE INR TEST MATER/EQUIP Category: Non Covered Services CMS Add: 07/01/2002 CMS Term: G0250 NOCOV DEF SYSMAN Description: MD INR TEST REVIE INTER MGMT Category: Non Covered Services CMS Add: 07/01/2002 CMS Term: G0252 NOCOV DEF SYSMAN Description: PET IMAGING INITIAL DX Category: Non Covered Services CMS Add: 10/01/2002 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,706 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G0255 NOCOV DEF SYSMAN Description: CURRENT PERCEP THRESHOLD TST Category: Non Covered Services CMS Add: 10/01/2002 CMS Term: G0257 NOCOV DEF SYSMAN Description: UNSCHED DIALYSIS ESRD PT HOS Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: G0259 NOCOV DEF SYSMAN Description: INJECT FOR SACROILIAC JOINT Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: G0260 NOCOV DEF SYSMAN Description: INJ FOR SACROILIAC JT ANESTH Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: G0268 NOCOV DEF SYSMAN Description: REMOVAL OF IMPACTED WAX MD Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: G0269 NOCOV DEF SYSMAN Description: OCCLUSIVE DEVICE IN VEIN ART Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: G0270 NOCOV DEF SYSMAN Description: MNT SUBS TX FOR CHANGE DX Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: G0271 NOCOV DEF SYSMAN Description: GROUP MNT 2 OR MORE 30 MINS Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: G0276 NOCOV DEF SYSMAN Description: PILD/PLACEBO CONTROL CLIN TR Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: G0277 MEDSV DEF RBRVS 01/01/2024 156.53 Description: HBOT, FULL BODY CHAMBER, 30M Category: Medical Services CMS Add: 01/01/2015 CMS Term: G0277 MEDSV DEF RBRVS 02/01/2015 12/31/2023 32.53 Description: HBOT, FULL BODY CHAMBER, 30M Category: Medical Services CMS Add: 01/01/2015 CMS Term: G0278 NOCOV DEF SYSMAN Description: ILIAC ART ANGIO,CARDIAC CATH Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: G0279 26 RADIO DEF RBRVS 01/01/2024 27.77 Description: TOMOSYNTHESIS, MAMMO Category: Radiology CMS Add: 01/01/2015 CMS Term: G0279 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 22.23 Description: TOMOSYNTHESIS, MAMMO Category: Radiology CMS Add: 01/01/2015 CMS Term: G0279 RADIO DEF RBRVS 01/01/2024 50.00 Description: TOMOSYNTHESIS, MAMMO Category: Radiology CMS Add: 01/01/2015 CMS Term: G0279 RADIO DEF RBRVS 02/01/2015 12/31/2023 39.98 Description: TOMOSYNTHESIS, MAMMO Category: Radiology CMS Add: 01/01/2015 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,707 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G0279 TC RADIO DEF RBRVS 01/01/2024 22.23 Description: TOMOSYNTHESIS, MAMMO Category: Radiology CMS Add: 01/01/2015 CMS Term: G0279 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 17.75 Description: TOMOSYNTHESIS, MAMMO Category: Radiology CMS Add: 01/01/2015 CMS Term: G0281 MEDSV DEF RBRVS 01/01/2024 11.51 Y Description: ELEC STIM UNATTEND FOR PRESS Category: Medical Services CMS Add: 04/01/2003 CMS Term: G0281 MEDSV DEF RBRVS 09/01/2019 12/31/2023 6.74 Y Description: ELEC STIM UNATTEND FOR PRESS Category: Medical Services CMS Add: 04/01/2003 CMS Term: G0282 MEDSV DEF BILL90 Y Description: ELECT STIM WOUND CARE NOT PD Category: Medical Services CMS Add: 04/01/2003 CMS Term: G0283 MEDSV DEF RBRVS 01/01/2024 11.51 Y Description: ELEC STIM OTHER THAN WOUND Category: Medical Services CMS Add: 01/01/2003 CMS Term: G0283 MEDSV DEF RBRVS 09/01/2019 12/31/2023 6.74 Y Description: ELEC STIM OTHER THAN WOUND Category: Medical Services CMS Add: 01/01/2003 CMS Term: G0288 MEDSV DEF RBRVS 01/01/2024 35.57 Description: RECON, CTA FOR SURG PLAN Category: Medical Services CMS Add: 01/01/2003 CMS Term: G0288 MEDSV DEF RBRVS 02/01/2015 12/31/2023 264.31 Description: RECON, CTA FOR SURG PLAN Category: Medical Services CMS Add: 01/01/2003 CMS Term: G0289 MEDSV DEF RBRVS 01/01/2024 78.28 Description: ARTHRO, LOOSE BODY + CHONDRO Category: Medical Services CMS Add: 01/01/2003 CMS Term: G0289 MEDSV DEF RBRVS 09/01/2019 12/31/2023 66.35 Description: ARTHRO, LOOSE BODY + CHONDRO Category: Medical Services CMS Add: 01/01/2003 CMS Term: G0293 MEDSV DEF BILL90 Description: NON-COV SURG PROC,CLIN TRIAL Category: Medical Services CMS Add: 01/01/2003 CMS Term: G0294 MEDSV DEF BILL90 Description: NON-COV PROC, CLINICAL TRIAL Category: Medical Services CMS Add: 01/01/2003 CMS Term: G0295 NOCOV DEF SYSMAN Description: ELECTROMAGNETIC THERAPY ONC Category: Non Covered Services CMS Add: 04/01/2003 CMS Term: G0296 NOCOV DEF SYSMAN Description: VISIT TO DETERM LDCT ELIG Category: Non Covered Services CMS Add: 02/05/2015 CMS Term: G0299 NOCOV DEF SYSMAN Description: HHS/HOSPICE OF RN EA 15 MIN Category: Non Covered Services CMS Add: 11/02/2015 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,708 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G0300 NOCOV DEF SYSMAN Description: HHS/HOSPICE OF LPN EA 15 MIN Category: Non Covered Services CMS Add: 11/02/2015 CMS Term: G0302 NOCOV DEF SYSMAN Description: PRE-OP SERVICE LVRS COMPLETE Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: G0303 NOCOV DEF SYSMAN Description: PRE-OP SERVICE LVRS 10-15DOS Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: G0304 NOCOV DEF SYSMAN Description: PRE-OP SERVICE LVRS 1-9 DOS Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: G0305 NOCOV DEF SYSMAN Description: POST OP SERVICE LVRS MIN 6 Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: G0306 LAB L60 MAXFEE 01/01/2020 7.77 0.0 Description: CBC/DIFFWBC W/O PLATELET Category: Laboratory CMS Add: 01/01/2004 CMS Term: G0307 LAB L60 MAXFEE 01/01/2020 6.47 0.0 Description: CBC WITHOUT PLATELET Category: Laboratory CMS Add: 01/01/2004 CMS Term: G0310 MEDSV DEF MAXFEE 01/01/2024 37.48 0.0 15-999years Description: IMMUNIZE COUNSEL 5-15 MIN Category: Medical Services CMS Add: 05/11/2022 CMS Term: G0310 MEDSV DEF MAXFEE 10/01/2022 12/31/2023 28.92 0.0 15-999years Description: IMMUNIZE COUNSEL 5-15 MIN Category: Medical Services CMS Add: 05/11/2022 CMS Term: G0311 MEDSV DEF MAXFEE 01/01/2024 57.88 0.0 15-999years Description: IMMUNIZE COUNSEL 16-30 MINS Category: Medical Services CMS Add: 05/11/2022 CMS Term: G0311 MEDSV DEF MAXFEE 10/01/2022 12/31/2023 44.66 0.0 15-999years Description: IMMUNIZE COUNSEL 16-30 MINS Category: Medical Services CMS Add: 05/11/2022 CMS Term: G0312 MEDSV E01 MAXFEE 01/01/2024 37.48 0.0 0-20years Description: IMMUNIZE COUNS < 21YR 5-15 M Category: Medical Services CMS Add: 05/11/2022 CMS Term: G0312 MEDSV E01 MAXFEE 09/01/2022 12/31/2023 28.92 0.0 0-20years Description: IMMUNIZE COUNS < 21YR 5-15 M Category: Medical Services CMS Add: 05/11/2022 CMS Term: G0313 MEDSV E01 MAXFEE 01/01/2024 57.88 0.0 0-20years Description: IMMUNIZE COUNS < 21YR 6-30 M Category: Medical Services CMS Add: 05/11/2022 CMS Term: G0313 MEDSV E01 MAXFEE 09/01/2022 12/31/2023 44.66 0.0 0-20years Description: IMMUNIZE COUNS < 21YR 6-30 M Category: Medical Services CMS Add: 05/11/2022 CMS Term: G0314 MEDSV E01 MAXFEE 01/01/2024 57.88 0.0 0-20years Description: COUNSEL IMMUNE <21 16-30 M Category: Medical Services CMS Add: 05/11/2022 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,709 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G0314 MEDSV E01 MAXFEE 12/02/2021 12/31/2023 44.66 0.0 0-20years Description: COUNSEL IMMUNE <21 16-30 M Category: Medical Services CMS Add: 05/11/2022 CMS Term: G0315 MEDSV E01 MAXFEE 01/01/2024 37.48 0.0 0-20years Description: COUNSEL IMMUNE <21 5-15 M Category: Medical Services CMS Add: 05/11/2022 CMS Term: G0315 MEDSV E01 MAXFEE 12/02/2021 12/31/2023 28.92 0.0 0-20years Description: COUNSEL IMMUNE <21 5-15 M Category: Medical Services CMS Add: 05/11/2022 CMS Term: G0316 NOCOV DEF SYSMAN Description: PROLONG INPT EVAL ADD15 M Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: G0317 NOCOV DEF SYSMAN Description: PROLONG NURSIN FAC EVAL 15M Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: G0318 NOCOV DEF SYSMAN Description: PROLONG HOME EVAL ADD 15M Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: G0320 NOCOV DEF SYSMAN Description: TWO-WAY AUDIO AND VIDEO HHS Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: G0321 NOCOV DEF SYSMAN Description: AUDIO-ONLY HHS Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: G0322 NOCOV DEF SYSMAN Description: HOME H PHYSIO DATA COLLEC TR Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: G0323 NOCOV DEF SYSMAN Description: CARE MANAGE BEH SVS 20MINS Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: G0327 MEDSV DEF BILL90 50-75years Description: COLON CA SCRN;BLD-BSD BIOMRK Category: Medical Services CMS Add: 07/01/2021 CMS Term: G0328 NOCOV DEF SYSMAN Description: FECAL BLOOD SCRN IMMUNOASSAY Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: G0329 NOCOV DEF SYSMAN Description: ELECTROMAGNTIC TX FOR ULCERS Category: Non Covered Services CMS Add: 07/01/2004 CMS Term: G0330 MEDSV DEF BILL90 Description: FACILITY SVS DENTAL REHAB Category: Medical Services CMS Add: 01/01/2023 CMS Term: G0333 NOCOV DEF SYSMAN Description: DISPENSE FEE INITIAL 30 DAY Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G0337 NOCOV DEF SYSMAN Description: HOSPICE EVALUATION PREELECTI Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,710 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G0339 MEDSV PRF MAXFEE 01/01/2024 11000.00 0.0 Description: ROBOT LIN-RADSURG COM, FIRST Category: Medical Services CMS Add: 01/01/2004 CMS Term: G0340 MEDSV PRF MAXFEE 01/01/2024 9900.00 0.0 Description: ROBT LIN-RADSURG FRACTX 2-5 Category: Medical Services CMS Add: 01/01/2004 CMS Term: G0341 NOCOV DEF SYSMAN Description: PERCUTANEOUS ISLET CELLTRANS Category: Non Covered Services CMS Add: 10/01/2004 CMS Term: G0342 NOCOV DEF SYSMAN Description: LAPAROSCOPY ISLET CELL TRANS Category: Non Covered Services CMS Add: 10/01/2004 CMS Term: G0343 NOCOV DEF SYSMAN Description: LAPAROTOMY ISLET CELL TRANSP Category: Non Covered Services CMS Add: 10/01/2004 CMS Term: G0372 MEDSV DEF RBRVS 01/01/2024 8.39 Description: MD SERVICE REQUIRED FOR PMD Category: Medical Services CMS Add: 10/25/2005 CMS Term: G0372 MEDSV DEF RBRVS 02/01/2015 12/31/2023 6.22 Description: MD SERVICE REQUIRED FOR PMD Category: Medical Services CMS Add: 10/25/2005 CMS Term: G0378 NOCOV DEF SYSMAN Description: HOSPITAL OBSERVATION PER HR Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G0379 NOCOV DEF SYSMAN Description: DIRECT REFER HOSPITAL OBSERV Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G0380 NOCOV DEF SYSMAN Description: LEV 1 HOSP TYPE B ED VISIT Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: G0381 NOCOV DEF SYSMAN Description: LEV 2 HOSP TYPE B ED VISIT Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: G0382 NOCOV DEF SYSMAN Description: LEV 3 HOSP TYPE B ED VISIT Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: G0383 NOCOV DEF SYSMAN Description: LEV 4 HOSP TYPE B ED VISIT Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: G0384 NOCOV DEF SYSMAN Description: LEV 5 HOSP TYPE B ED VISIT Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: G0390 NOCOV DEF SYSMAN Description: TRAUMA RESPONS W/HOSP CRITI Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: G0396 NOCOV DEF SYSMAN Description: ALCOHOL/SUBS INTERV 15-30MN Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,711 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G0397 NOCOV DEF SYSMAN Description: ALCOHOL/SUBS INTERV >30 MIN Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: G0398 NOCOV DEF SYSMAN Description: HOME SLEEP TEST/TYPE 2 PORTA Category: Non Covered Services CMS Add: 03/13/2008 CMS Term: G0399 NOCOV DEF SYSMAN Description: HOME SLEEP TEST/TYPE 3 PORTA Category: Non Covered Services CMS Add: 03/13/2008 CMS Term: G0400 NOCOV DEF SYSMAN Description: HOME SLEEP TEST/TYPE 4 PORTA Category: Non Covered Services CMS Add: 03/13/2008 CMS Term: G0402 NOCOV DEF SYSMAN Description: INITIAL PREVENTIVE EXAM Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: G0403 NOCOV DEF SYSMAN Description: EKG FOR INITIAL PREVENT EXAM Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: G0404 NOCOV DEF SYSMAN Description: EKG TRACING FOR INITIAL PREV Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: G0405 NOCOV DEF SYSMAN Description: EKG INTERPRET & REPORT PREVE Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: G0406 NOCOV DEF SYSMAN Description: INPT/TELE FOLLOW UP 15 Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: G0407 NOCOV DEF SYSMAN Description: INPT/TELE FOLLOW UP 25 Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: G0408 NOCOV DEF SYSMAN Description: INPT/TELE FOLLOW UP 35 Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: G0409 NOCOV DEF SYSMAN Description: CORF RELATED SERV 15 MINS EA Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: G0410 NOCOV DEF SYSMAN Description: GRP PSYCH PHP/IOP 45-50 Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: G0411 NOCOV DEF SYSMAN Description: INTERACTIVE GRP PSYC PHP/IOP Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: G0412 MEDSV DEF RBRVS 01/01/2024 671.78 Description: OPEN TX ILIAC SPINE UNI/BIL Category: Medical Services CMS Add: 01/01/2009 CMS Term: G0412 MEDSV DEF RBRVS 02/01/2015 12/31/2023 476.23 Description: OPEN TX ILIAC SPINE UNI/BIL Category: Medical Services CMS Add: 01/01/2009 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,712 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G0413 MEDSV DEF RBRVS 01/01/2024 985.08 Description: PELVIC RING FRACTURE UNI/BIL Category: Medical Services CMS Add: 01/01/2009 CMS Term: G0413 MEDSV DEF RBRVS 02/01/2015 12/31/2023 701.07 Description: PELVIC RING FRACTURE UNI/BIL Category: Medical Services CMS Add: 01/01/2009 CMS Term: G0414 MEDSV DEF RBRVS 01/01/2024 929.19 Description: PELVIC RING FX TREAT INT FIX Category: Medical Services CMS Add: 01/01/2009 CMS Term: G0414 MEDSV DEF RBRVS 09/01/2019 12/31/2023 656.53 Description: PELVIC RING FX TREAT INT FIX Category: Medical Services CMS Add: 01/01/2009 CMS Term: G0415 MEDSV DEF RBRVS 01/01/2024 1265.33 Description: OPEN TX POST PELVIC FXCTURE Category: Medical Services CMS Add: 01/01/2009 CMS Term: G0415 MEDSV DEF RBRVS 02/01/2015 12/31/2023 910.56 Description: OPEN TX POST PELVIC FXCTURE Category: Medical Services CMS Add: 01/01/2009 CMS Term: G0416 26 LAB DEF RBRVS 01/01/2024 169.27 Description: PROSTATE BIOPSY, ANY MTHD Category: Laboratory CMS Add: 01/01/2009 CMS Term: G0416 26 LAB DEF RBRVS 02/01/2015 12/31/2023 133.14 Description: PROSTATE BIOPSY, ANY MTHD Category: Laboratory CMS Add: 01/01/2009 CMS Term: G0416 LAB DEF RBRVS 01/01/2024 340.32 Description: PROSTATE BIOPSY, ANY MTHD Category: Laboratory CMS Add: 01/01/2009 CMS Term: G0416 LAB DEF RBRVS 02/01/2015 12/31/2023 455.83 Description: PROSTATE BIOPSY, ANY MTHD Category: Laboratory CMS Add: 01/01/2009 CMS Term: G0416 TC LAB DEF RBRVS 01/01/2024 171.05 Description: PROSTATE BIOPSY, ANY MTHD Category: Laboratory CMS Add: 01/01/2009 CMS Term: G0416 TC LAB DEF RBRVS 02/01/2015 12/31/2023 322.69 Description: PROSTATE BIOPSY, ANY MTHD Category: Laboratory CMS Add: 01/01/2009 CMS Term: G0420 NOCOV DEF SYSMAN Description: ED SVC CKD IND PER SESSION Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: G0421 NOCOV DEF SYSMAN Description: ED SVC CKD GRP PER SESSION Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: G0422 NOCOV DEF SYSMAN Description: INTENS CARDIAC REHAB W/EXERC Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: G0423 NOCOV DEF SYSMAN Description: INTENS CARDIAC REHAB NO EXER Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,713 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G0425 NOCOV DEF SYSMAN Description: INPT/ED TELECONSULT30 Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: G0426 NOCOV DEF SYSMAN Description: INPT/ED TELECONSULT50 Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: G0427 NOCOV DEF SYSMAN Description: INPT/ED TELECONSULT70 Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: G0428 NOCOV DEF SYSMAN Description: COLLAGEN MENISCUS IMPLANT Category: Non Covered Services CMS Add: 05/25/2010 CMS Term: G0429 NOCOV DEF SYSMAN Description: DERMAL FILLER INJECTION(S) Category: Non Covered Services CMS Add: 03/23/2010 CMS Term: G0432 NOCOV DEF SYSMAN Description: EIA HIV-1/HIV-2 SCREEN Category: Non Covered Services CMS Add: 12/08/2009 CMS Term: G0433 LAB L60 MAXFEE 01/01/2018 18.29 0.0 Description: ELISA HIV-1/HIV-2 SCREEN Category: Laboratory CMS Add: 12/08/2009 CMS Term: G0435 NOCOV DEF SYSMAN Description: ORAL HIV-1/HIV-2 SCREEN Category: Non Covered Services CMS Add: 12/08/2009 CMS Term: G0438 NOCOV DEF SYSMAN Description: PPPS, INITIAL VISIT Category: Non Covered Services CMS Add: 01/01/2011 CMS Term: G0439 NOCOV DEF SYSMAN Description: PPPS, SUBSEQ VISIT Category: Non Covered Services CMS Add: 01/01/2011 CMS Term: G0442 NOCOV DEF SYSMAN Description: ANNUAL ALCOHOL SCREEN 15 MIN Category: Non Covered Services CMS Add: 10/14/2011 CMS Term: G0443 NOCOV DEF SYSMAN Description: BRIEF ALCOHOL MISUSE COUNSEL Category: Non Covered Services CMS Add: 10/14/2011 CMS Term: G0444 MEDSV DEF RBRVS 01/01/2012 12/31/2023 12.93 Description: DEPRESSION SCREEN ANNUAL Category: Medical Services CMS Add: 10/14/2011 CMS Term: G0444 MEDSV DEF RBRVS 01/01/2024 17.37 Description: DEPRESSION SCREEN ANNUAL Category: Medical Services CMS Add: 10/14/2011 CMS Term: G0445 NOCOV DEF SYSMAN Description: HIGH INTEN BEH COUNS STD 30M Category: Non Covered Services CMS Add: 11/08/2011 CMS Term: G0446 NOCOV DEF SYSMAN Description: INTENS BEHAVE THER CARDIO DX Category: Non Covered Services CMS Add: 11/08/2011 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,714 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G0447 NOCOV DEF SYSMAN Description: BEHAVIOR COUNSEL OBESITY 15M Category: Non Covered Services CMS Add: 11/29/2011 CMS Term: G0448 NOCOV DEF SYSMAN Description: PLACE PERM PACING CARDIOVERT Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G0451 NOCOV DEF SYSMAN Description: DEVLOPMENT TEST INTERPT&REP Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G0452 26 LAB DEF RBRVS 01/01/2024 45.11 Y Description: MOLECULAR PATHOLOGY INTERPR Category: Laboratory CMS Add: 01/01/2013 CMS Term: G0452 26 LAB DEF RBRVS 10/01/2020 12/31/2023 13.74 Y Description: MOLECULAR PATHOLOGY INTERPR Category: Laboratory CMS Add: 01/01/2013 CMS Term: G0452 LAB DEF RBRVS 01/01/2021 12/31/2023 36.71 Y Description: MOLECULAR PATHOLOGY INTERPR Category: Laboratory CMS Add: 01/01/2013 CMS Term: G0452 LAB DEF RBRVS 01/01/2024 47.74 Y Description: MOLECULAR PATHOLOGY INTERPR Category: Laboratory CMS Add: 01/01/2013 CMS Term: G0452 TC LAB DEF RBRVS 01/01/2021 2.63 Y Description: MOLECULAR PATHOLOGY INTERPR Category: Laboratory CMS Add: 01/01/2013 CMS Term: G0453 NOCOV DEF SYSMAN Description: CONT INTRAOP NEURO MONITOR Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: G0454 NOCOV DEF SYSMAN Description: MD DOCUMENT VISIT BY NPP Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: G0455 NOCOV DEF SYSMAN Description: FECAL MICROBIOTA PREP INSTIL Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: G0458 NOCOV DEF SYSMAN Description: LDR PROSTATE BRACHY COMP RAT Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: G0459 NOCOV DEF SYSMAN Description: TELEHEALTH INPT PHARM MGMT Category: Non Covered Services CMS Add: 08/02/2012 CMS Term: G0460 NOCOV DEF SYSMAN Description: AUTOLOG PRP NOT DIAB ULCER Category: Non Covered Services CMS Add: 08/02/2012 CMS Term: G0463 MEDSV DEF MAXFEE 08/19/2016 0.00 0.0 Description: HOSPITAL OUTPT CLINIC VISIT Category: Medical Services CMS Add: 01/01/2014 CMS Term: G0464 NOCOV DEF SYSMAN Description: COLOREC CA SCR, STO BAS DNA Category: Non Covered Services CMS Add: 10/09/2014 CMS Term: 12/31/2015 *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,715 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G0465 NOCOV DEF SYSMAN Description: AUTOLOG PRP DIAB WOUND ULCER Category: Non Covered Services CMS Add: 04/13/2021 CMS Term: G0466 MEDSV DEF MAXFEE 01/01/2024 230.41 0.0 Description: FQHC VISIT NEW PATIENT Category: Medical Services CMS Add: 10/01/2014 CMS Term: G0466 MEDSV DEF MAXFEE 10/01/2014 12/31/2023 41.05 0.0 Description: FQHC VISIT NEW PATIENT Category: Medical Services CMS Add: 10/01/2014 CMS Term: G0467 MEDSV DEF MAXFEE 01/01/2024 171.74 0.0 Description: FQHC VISIT, ESTAB PT Category: Medical Services CMS Add: 10/01/2014 CMS Term: G0467 MEDSV DEF MAXFEE 10/01/2014 12/31/2023 30.60 0.0 Description: FQHC VISIT, ESTAB PT Category: Medical Services CMS Add: 10/01/2014 CMS Term: G0468 MEDSV DEF MAXFEE 01/01/2024 230.41 0.0 Description: FQHC VISIT, IPPE OR AWV Category: Medical Services CMS Add: 10/01/2014 CMS Term: G0468 MEDSV DEF MAXFEE 10/01/2014 12/31/2023 41.05 0.0 Description: FQHC VISIT, IPPE OR AWV Category: Medical Services CMS Add: 10/01/2014 CMS Term: G0469 MEDSV DEF MAXFEE 01/01/2024 230.41 0.0 Description: FQHC VISIT, MH NEW PT Category: Medical Services CMS Add: 10/01/2014 CMS Term: G0469 MEDSV DEF MAXFEE 10/01/2014 12/31/2023 41.05 0.0 Description: FQHC VISIT, MH NEW PT Category: Medical Services CMS Add: 10/01/2014 CMS Term: G0470 MEDSV DEF MAXFEE 01/01/2024 171.74 0.0 Description: FQHC VISIT, MH ESTAB PT Category: Medical Services CMS Add: 10/01/2014 CMS Term: G0470 MEDSV DEF MAXFEE 10/01/2014 12/31/2023 30.60 0.0 Description: FQHC VISIT, MH ESTAB PT Category: Medical Services CMS Add: 10/01/2014 CMS Term: G0471 LAB DEF MAXFEE 01/01/2024 10.57 0.0 Description: VEN BLOOD COLL SNF/HHA Category: Laboratory CMS Add: 04/01/2014 CMS Term: G0471 LAB DEF MAXFEE 04/01/2014 12/31/2023 3.00 0.0 Description: VEN BLOOD COLL SNF/HHA Category: Laboratory CMS Add: 04/01/2014 CMS Term: G0472 LAB L60 MAXFEE 01/01/2024 46.35 0.0 Description: HEP C SCREEN HIGH RISK/OTHER Category: Laboratory CMS Add: 06/02/2014 CMS Term: G0472 LAB L60 MAXFEE 03/16/2016 12/31/2023 19.44 0.0 Description: HEP C SCREEN HIGH RISK/OTHER Category: Laboratory CMS Add: 06/02/2014 CMS Term: G0473 NOCOV DEF SYSMAN Description: GROUP BEHAVE COUNS 2-10 Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,716 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G0475 NOCOV DEF SYSMAN Description: HIV COMBINATION ASSAY Category: Non Covered Services CMS Add: 04/13/2015 CMS Term: G0476 NOCOV DEF SYSMAN Description: HPV COMBO ASSAY CA SCREEN Category: Non Covered Services CMS Add: 07/09/2015 CMS Term: G0480 LAB L60 MAXFEE 01/01/2016 12/31/2023 77.12 0.0 Description: DRUG TEST DEF 1-7 CLASSES Category: Laboratory CMS Add: 01/01/2016 CMS Term: G0480 LAB L60 MAXFEE 01/01/2024 114.43 0.0 Description: DRUG TEST DEF 1-7 CLASSES Category: Laboratory CMS Add: 01/01/2016 CMS Term: G0481 LAB L60 MAXFEE 01/01/2016 12/31/2023 118.65 0.0 Description: DRUG TEST DEF 8-14 CLASSES Category: Laboratory CMS Add: 01/01/2016 CMS Term: G0481 LAB L60 MAXFEE 01/01/2024 156.59 0.0 Description: DRUG TEST DEF 8-14 CLASSES Category: Laboratory CMS Add: 01/01/2016 CMS Term: G0482 LAB L60 MAXFEE 01/01/2016 12/31/2023 160.18 0.0 Y Description: DRUG TEST DEF 15-21 CLASSES Category: Laboratory CMS Add: 01/01/2016 CMS Term: G0482 LAB L60 MAXFEE 01/01/2024 198.74 0.0 Y Description: DRUG TEST DEF 15-21 CLASSES Category: Laboratory CMS Add: 01/01/2016 CMS Term: G0483 LAB L60 MAXFEE 01/01/2016 12/31/2023 207.64 0.0 Y Description: DRUG TEST DEF 22+ CLASSES Category: Laboratory CMS Add: 01/01/2016 CMS Term: G0483 LAB L60 MAXFEE 01/01/2024 246.92 0.0 Y Description: DRUG TEST DEF 22+ CLASSES Category: Laboratory CMS Add: 01/01/2016 CMS Term: G0490 NOCOV DEF SYSMAN Description: HOME VISIT RN, LPN BY RHC/FQ Category: Non Covered Services CMS Add: 04/01/2016 CMS Term: G0491 NOCOV DEF SYSMAN Description: DIALYSIS ACU KIDNEY NO ESRD Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G0492 NOCOV DEF SYSMAN Description: MD/OTH EVAL ACUT KID NO ESRD Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G0493 NOCOV DEF SYSMAN Description: RN CARE EA 15 MIN HH/HOSPICE Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G0494 NOCOV DEF SYSMAN Description: LPN CARE EA 15MIN HH/HOSPICE Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G0495 NOCOV DEF SYSMAN Description: RN CARE TRAIN/EDU IN HH Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,717 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G0496 NOCOV DEF SYSMAN Description: LPN CARE TRAIN/EDU IN HH Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G0498 MEDSV PRF MAXFEE 01/01/2024 148.52 0.0 Description: CHEMO EXTEND IV INFUS W/PUMP Category: Medical Services CMS Add: 01/01/2016 CMS Term: G0499 LAB L60 MAXFEE 01/01/2020 28.27 0.0 Description: HEPB SCREEN HIGH RISK INDIV Category: Laboratory CMS Add: 09/28/2016 CMS Term: G0500 NOCOV DEF SYSMAN Description: MOD SEDAT ENDO SERVICE >5YRS Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G0501 NOCOV DEF SYSMAN Description: RESOURCE-INTEN SVC DURING OV Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G0506 NOCOV DEF SYSMAN Description: COMP ASSES CARE PLAN CCM SVC Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G0508 NOCOV DEF SYSMAN Description: CRIT CARE TELEHEA CONSULT 60 Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G0509 NOCOV DEF SYSMAN Description: CRIT CARE TELEHEA CONSULT 50 Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G0511 NOCOV DEF SYSMAN Description: CCM/BHI BY RHC/FQHC 20MIN MO Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G0512 NOCOV DEF SYSMAN Description: COCM BY RHC/FQHC 60 MIN MO Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G0513 MEDSV DEF RBRVS 01/01/2018 12/31/2023 47.29 Description: PROLONG PREV SVCS, FIRST 30M Category: Medical Services CMS Add: 01/01/2018 CMS Term: G0513 MEDSV DEF RBRVS 01/01/2024 60.38 Description: PROLONG PREV SVCS, FIRST 30M Category: Medical Services CMS Add: 01/01/2018 CMS Term: G0514 MEDSV DEF RBRVS 01/01/2018 12/31/2023 47.29 Description: PROLONG PREV SVCS, ADDL 30M Category: Medical Services CMS Add: 01/01/2018 CMS Term: G0514 MEDSV DEF RBRVS 01/01/2024 60.38 Description: PROLONG PREV SVCS, ADDL 30M Category: Medical Services CMS Add: 01/01/2018 CMS Term: G0516 MEDSV DEF RBRVS 01/01/2018 12/31/2023 166.48 Description: INSERT DRUG DEL IMPLANT, >=4 Category: Medical Services CMS Add: 01/01/2018 CMS Term: G0516 MEDSV DEF RBRVS 01/01/2024 187.24 Description: INSERT DRUG DEL IMPLANT, >=4 Category: Medical Services CMS Add: 01/01/2018 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,718 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G0517 MEDSV DEF RBRVS 01/01/2018 12/31/2023 183.34 Description: REMOVE DRUG IMPLANT Category: Medical Services CMS Add: 01/01/2018 CMS Term: G0517 MEDSV DEF RBRVS 01/01/2024 207.69 Description: REMOVE DRUG IMPLANT Category: Medical Services CMS Add: 01/01/2018 CMS Term: G0518 MEDSV DEF RBRVS 01/01/2018 12/31/2023 316.18 Description: REMOVE W INSERT DRUG IMPLANT Category: Medical Services CMS Add: 01/01/2018 CMS Term: G0518 MEDSV DEF RBRVS 01/01/2024 363.70 Description: REMOVE W INSERT DRUG IMPLANT Category: Medical Services CMS Add: 01/01/2018 CMS Term: G0659 LAB L60 MAXFEE 01/01/2020 62.14 0.0 Description: DRUG TEST DEF SIMPLE ALL CL Category: Laboratory CMS Add: 01/01/2017 CMS Term: G0913 NOCOV DEF SYSMAN Description: IMPROVE VISUAL FUNCT Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G0914 NOCOV DEF SYSMAN Description: SURVEY NOT COMPLETE Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G0915 NOCOV DEF SYSMAN Description: NO IMPROVE VISUAL FUNCT Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G0916 NOCOV DEF SYSMAN Description: SATISFY WITH CARE Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G0917 NOCOV DEF SYSMAN Description: CARE SURVEY NOT COMPLETE Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G0918 NOCOV DEF SYSMAN Description: NO SATISFY WITH CARE Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G1001 NOCOV DEF SYSMAN Description: CDSM EVICORE Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: G1002 NOCOV DEF SYSMAN Description: CDSM MEDCURRENT Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: G1003 NOCOV DEF SYSMAN Description: CDSM MEDICALIS Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: G1004 NOCOV DEF SYSMAN Description: CDSM NDSC Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: G1007 NOCOV DEF SYSMAN Description: CDSM AIM Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,719 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G1008 NOCOV DEF SYSMAN Description: CDSM CRANBERRY PK Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: G1010 NOCOV DEF SYSMAN Description: CDSM STANSON Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: G1011 NOCOV DEF SYSMAN Description: CDSM QUALIFIED NOS Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: G1012 NOCOV DEF SYSMAN Description: CDSM AGILEMD Category: Non Covered Services CMS Add: 04/01/2020 CMS Term: G1013 NOCOV DEF SYSMAN Description: CDSM EVIDENCECARE Category: Non Covered Services CMS Add: 04/01/2020 CMS Term: G1014 NOCOV DEF SYSMAN Description: CDSM INVENIQA Category: Non Covered Services CMS Add: 04/01/2020 CMS Term: G1015 NOCOV DEF SYSMAN Description: CDSM RELIANT Category: Non Covered Services CMS Add: 04/01/2020 CMS Term: G1016 NOCOV DEF SYSMAN Description: CDSM SPEED OF CARE Category: Non Covered Services CMS Add: 04/01/2020 CMS Term: G1017 NOCOV DEF SYSMAN Description: CDSM HEALTHHELP Category: Non Covered Services CMS Add: 04/01/2020 CMS Term: G1018 NOCOV DEF SYSMAN Description: CDSM INFINX Category: Non Covered Services CMS Add: 04/01/2020 CMS Term: G1019 NOCOV DEF SYSMAN Description: CDSM LOGICNETS Category: Non Covered Services CMS Add: 04/01/2020 CMS Term: G1020 NOCOV DEF SYSMAN Description: CDSM CURBSIDE Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: G1021 NOCOV DEF SYSMAN Description: CDSM EHEALTHLINE Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: G1022 NOCOV DEF SYSMAN Description: CDSM INTERMOUNTAIN Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: G1023 NOCOV DEF SYSMAN Description: CDSM PERSIVIA Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: G1024 NOCOV DEF SYSMAN Description: CDSM RADRITE Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,720 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G1025 NOCOV DEF SYSMAN Description: PT MNTH 1 MCP PROV Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G1026 NOCOV DEF SYSMAN Description: PT HEMO > 3MO Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G1027 NOCOV DEF SYSMAN Description: PT HEMO < 3MO Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G1028 NOCOV DEF SYSMAN Description: TAKE HOME SUPPLY 8MG PER 0.1 Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G2000 NOCOV DEF SYSMAN Description: BLINDED CONV. TX MDD CLIN TR Category: Non Covered Services CMS Add: 08/01/2018 CMS Term: G2001 NOCOV DEF SYSMAN Description: POST D/C H VST NEW PT 20 M Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: G2002 NOCOV DEF SYSMAN Description: POST-D/C H VST NEW PT 30 M Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: G2003 NOCOV DEF SYSMAN Description: POST-D/C H VST NEW PT 45 M Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: G2004 NOCOV DEF SYSMAN Description: POST-D/C H VST NEW PT 60 M Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: G2005 NOCOV DEF SYSMAN Description: POST-D/C H VST NEW PT 75 M Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: G2006 NOCOV DEF SYSMAN Description: POST-D/C H VST EXT PT 20 M Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: G2007 NOCOV DEF SYSMAN Description: POST-D/C H VST EXT PT 30 M Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: G2008 NOCOV DEF SYSMAN Description: POST-D/C H VST EXT PT 45 M Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: G2009 NOCOV DEF SYSMAN Description: POST-D/C H VST EXT PT 60 M Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: G2010* NOCOV DEF SYSMAN Description: REMOT IMAGE SUBMIT BY PT Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: G2011 NOCOV DEF SYSMAN Description: ALCOHOL/SUB MISUSE ASSESS Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,721 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G2012* NOCOV DEF SYSMAN Description: BRIEF CHECK IN BY MD/QHP Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: G2013 NOCOV DEF SYSMAN Description: POST-D/C H VST EXT PT 75 M Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: G2014 NOCOV DEF SYSMAN Description: POST-D/C CARE PLAN OVERS 30M Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: G2015 NOCOV DEF SYSMAN Description: POST-D/C CARE PLAN OVERS 60M Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: G2020 NOCOV DEF SYSMAN Description: HI INTEN SERV FOR SIP MODEL Category: Non Covered Services CMS Add: 04/01/2021 CMS Term: G2021 NOCOV DEF SYSMAN Description: HEA CARE PRACT TX IN PLACE Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: G2022 NOCOV DEF SYSMAN Description: BENEF REFUSES SERVICE, MOD Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: G2025* NOCOV DEF SYSMAN Description: DIS SITE TELE SVCS RHC/FQHC Category: Non Covered Services CMS Add: 01/27/2020 CMS Term: G2066 MEDSV DEF MAXFEE 01/01/2024 38.03 0.0 Description: INTER DEVC REMOTE 30D Category: Medical Services CMS Add: 01/01/2020 CMS Term: 12/31/2023 G2067 DRUG DEF MAXFEE 07/01/2023 235.76 0.0 Description: MED ASSIST TX METH WK Category: Drugs CMS Add: 01/01/2020 CMS Term: G2068 DRUG DEF MAXFEE 07/01/2023 277.00 0.0 Description: MED ASSIST TX BUPRE ORAL Category: Drugs CMS Add: 01/01/2020 CMS Term: G2069 DRUG DEF MAXFEE 07/01/2023 1940.86 0.0 Description: MED ASSIST TX INJECT Category: Drugs CMS Add: 01/01/2020 CMS Term: G2070 DRUG DEF MAXFEE 07/01/2023 5384.00 0.0 Description: MED ASSIST TX IMPLANT Category: Drugs CMS Add: 01/01/2020 CMS Term: G2071 DRUG DEF MAXFEE 07/01/2023 453.63 0.0 Description: MED TX REMOVE IMPLANT Category: Drugs CMS Add: 01/01/2020 CMS Term: G2072 DRUG DEF MAXFEE 07/01/2023 5604.87 0.0 Description: MED TX INSERT/REMOVE IMP Category: Drugs CMS Add: 01/01/2020 CMS Term: G2073 DRUG DEF MAXFEE 07/01/2023 1543.60 0.0 Description: MED TX NALTREXONE Category: Drugs CMS Add: 01/01/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,722 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G2074 DRUG DEF MAXFEE 07/01/2023 185.88 0.0 Description: MED ASSIST TX NO DRUG Category: Drugs CMS Add: 01/01/2020 CMS Term: G2075 NOCOV DEF SYSMAN Description: MED TX MEDS NOS Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: G2076 DRUG DEF MAXFEE 07/01/2023 180.89 0.0 Description: INTAKE ACT W/MED EXAM Category: Drugs CMS Add: 01/01/2020 CMS Term: G2077 DRUG DEF MAXFEE 07/01/2023 111.16 0.0 Description: PERIODIC ASSESSMENT Category: Drugs CMS Add: 01/01/2020 CMS Term: G2078 DRUG DEF MAXFEE 07/01/2023 39.29 0.0 Description: TAKE-HOME METH Category: Drugs CMS Add: 01/01/2020 CMS Term: G2079 DRUG DEF MAXFEE 07/01/2023 80.53 0.0 Description: TAKE-HOM BUPRENORPHINE Category: Drugs CMS Add: 01/01/2020 CMS Term: G2080 DRUG DEF MAXFEE 07/01/2023 31.19 0.0 Description: ADD 30 MINS COUNSEL Category: Drugs CMS Add: 01/01/2020 CMS Term: G2081 NOCOV DEF SYSMAN Description: PT 66+ SNP OR LTC POS > 90D Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: G2082 DRUG DEF RBRVS 01/01/2020 06/15/2023 522.03 Description: VISIT ESKETAMINE 56M OR LESS Category: Drugs CMS Add: 01/01/2020 CMS Term: G2082 DRUG DEF RBRVS 06/16/2023 758.66 Description: VISIT ESKETAMINE 56M OR LESS Category: Drugs CMS Add: 01/01/2020 CMS Term: G2083 DRUG DEF RBRVS 01/01/2020 06/15/2023 762.56 Description: VISIT ESKETAMINE, > 56M Category: Drugs CMS Add: 01/01/2020 CMS Term: G2083 DRUG DEF RBRVS 06/16/2023 1076.94 Description: VISIT ESKETAMINE, > 56M Category: Drugs CMS Add: 01/01/2020 CMS Term: G2086 NOCOV DEF SYSMAN Description: OFF BASE OPIOID TX 70MIN Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: G2087 NOCOV DEF SYSMAN Description: OFF BASE OPIOID TX, 60 M Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: G2088 NOCOV DEF SYSMAN Description: OFF BASE OPIOID TX, ADD30 Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: G2090 NOCOV DEF SYSMAN Description: PT 66+ FRAILTY AND MED DEM Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,723 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G2091 NOCOV DEF SYSMAN Description: PT 66+ FRAILTY AND ADV ILL Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: G2092 NOCOV DEF SYSMAN Description: ACE ARB ARNI Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: G2093 NOCOV DEF SYSMAN Description: MED DOC RSN NO ACE ARN ARNI Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: G2094 NOCOV DEF SYSMAN Description: PT RSN NO ACE ARN ARNI Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: G2096 NOCOV DEF SYSMAN Description: NO RSN ACE ARB ARNI Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: G2097 NOCOV DEF SYSMAN Description: DX URI 3D AFTER OTHER DX Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: G2098 NOCOV DEF SYSMAN Description: PT 66+ FRAILTY AND MED DEM Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: G2099 NOCOV DEF SYSMAN Description: PT 66+ FRAILTY AND ADV ILL Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: G2100 NOCOV DEF SYSMAN Description: PT 66+ FRAILTY AND MED DEM Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: G2101 NOCOV DEF SYSMAN Description: PT 66+ FRAILTY AND ADV ILL Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: G2105 NOCOV DEF SYSMAN Description: PT 66+ SNP OR LTC POS > 90D Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: G2106 NOCOV DEF SYSMAN Description: PT 66+ FRAILTY AND MED DEM Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: G2107 NOCOV DEF SYSMAN Description: PT 66+ FRAILTY AND ADV ILL Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: G2112 NOCOV DEF SYSMAN Description: PRED<=5 MG RA GLU <6M Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: G2113 NOCOV DEF SYSMAN Description: PRED>5 MG >6M, NO CHG DA Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: G2115 NOCOV DEF SYSMAN Description: PT 66-80 FRAILTY AND MED DEM Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,724 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G2116 NOCOV DEF SYSMAN Description: PT 66-80 FRAILTY AND ADV ILL Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: G2118 NOCOV DEF SYSMAN Description: PT 81+ FRAILTY Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: G2121 NOCOV DEF SYSMAN Description: PSY DEP ANX AP AND ICD ASSE Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: G2122 NOCOV DEF SYSMAN Description: PSY/DEP/ANX/APANDICD NOASSE Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: G2125 NOCOV DEF SYSMAN Description: PT 81+ FRAILTY Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: G2126 NOCOV DEF SYSMAN Description: PT 66-80 FRAILTY AND ADV ILL Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: G2127 NOCOV DEF SYSMAN Description: PT 66-80 FRAILTY AND MED DEM Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: G2128 NOCOV DEF SYSMAN Description: NO ASPIRIN MED RSN Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: G2129 NOCOV DEF SYSMAN Description: NO BP OUTPT Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: G2136 NOCOV DEF SYSMAN Description: BK PAIN VAS 6-20WK <= 3 Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: G2137 NOCOV DEF SYSMAN Description: BK PAIN VAS 6-20WK > 3 Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: G2138 NOCOV DEF SYSMAN Description: BK PAIN VAS 9-15MO <= 3 Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: G2139 NOCOV DEF SYSMAN Description: BK PAIN VAS 9-15MO > 3 Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: G2140 NOCOV DEF SYSMAN Description: LEG PAIN VAS 6-20WK <= 3 Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: G2141 NOCOV DEF SYSMAN Description: LEG PAIN VAS 6-20WK > 3 Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: G2142 NOCOV DEF SYSMAN Description: FS ODI 9-15MO POSTOP<= 22 Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,725 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G2143 NOCOV DEF SYSMAN Description: FS ODI 9-15MO > 22 Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: G2144 NOCOV DEF SYSMAN Description: FS ODI 6-20WK POSTOP <= 22 Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: G2145 NOCOV DEF SYSMAN Description: FSODI 6-20WK >22 OR CHG 30PT Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: G2146 NOCOV DEF SYSMAN Description: LEG PAIN VAS 9-15MO <= 3 Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: G2147 NOCOV DEF SYSMAN Description: LEG PAIN VAS 9-15MO > 3 Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: G2148 NOCOV DEF SYSMAN Description: MPM USED Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: G2149 NOCOV DEF SYSMAN Description: NO MPM MED RSN Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: G2150 NOCOV DEF SYSMAN Description: NO MPM Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: G2151 NOCOV DEF SYSMAN Description: DX DEGEN NEURO Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: G2152 NOCOV DEF SYSMAN Description: RES CHANGE SC >=0 Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: G2167 NOCOV DEF SYSMAN Description: RES CHANGE SC < 0 Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: G2168 NOCOV DEF SYSMAN Description: SVS BY PT IN HOME HEALTH Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: G2169 NOCOV DEF SYSMAN Description: SVS BY OT IN HOME HEALTH Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: G2172 NOCOV DEF SYSMAN Description: TX FOR OPIOID USE DEMO PROJ Category: Non Covered Services CMS Add: 04/01/2021 CMS Term: G2173 NOCOV DEF SYSMAN Description: URI W COMORB 12M OTH DX Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: G2174 NOCOV DEF SYSMAN Description: URI NEW RX ANTIBIOTIC 30D Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,726 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G2175 NOCOV DEF SYSMAN Description: PT COMORB DX 12M OF EPI Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: G2176 NOCOV DEF SYSMAN Description: OUTPT ED OBS W INPT ADMIT Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: G2177 NOCOV DEF SYSMAN Description: BRONCH W RX ANTIBX 30D Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: G2178 NOCOV DEF SYSMAN Description: PT NOT ELIG LOW NEURO EX Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: G2179 NOCOV DEF SYSMAN Description: MED DOC RSN NO LOW EX Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: G2180 NOCOV DEF SYSMAN Description: INELIG FOOTWR EVAL Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: G2181 NOCOV DEF SYSMAN Description: BMI NOT DOC MEDRSN PTREF Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: G2182 NOCOV DEF SYSMAN Description: PT 1ST BIOLOG ANTIRHEUM Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: G2183 NOCOV DEF SYSMAN Description: DOC PT UNABLE COMM Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: G2184 NOCOV DEF SYSMAN Description: NO CAREGIVER Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: G2185 NOCOV DEF SYSMAN Description: CAREGIVER DEM TRAINED Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: G2186 NOCOV DEF SYSMAN Description: PT REF APP RSRCS Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: G2187 NOCOV DEF SYSMAN Description: CLIN IND IMG HD TRAUMA Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: G2188 NOCOV DEF SYSMAN Description: PT 50 YRS W/CLIN IND HD Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: G2189 NOCOV DEF SYSMAN Description: IMG HD ABNML NEURO EXAM Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: G2190 NOCOV DEF SYSMAN Description: IND IMG HD RAD NECK Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,727 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G2191 NOCOV DEF SYSMAN Description: IND IMG HD POS HD ACHE Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: G2192 NOCOV DEF SYSMAN Description: >55 YRS TEMP HD ACHE Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: G2193 NOCOV DEF SYSMAN Description: <6YR NEW ONSET HD ACHE Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: G2194 NOCOV DEF SYSMAN Description: NEW HDACHE PED PT DIS Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: G2195 NOCOV DEF SYSMAN Description: OCCIP HDACHE CHILD Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: G2196 NOCOV DEF SYSMAN Description: SCREEN UNHLTHY ETOH USE Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: G2197 NOCOV DEF SYSMAN Description: SCREEN HLTHY ETOH USE Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: G2199 NOCOV DEF SYSMAN Description: NOT SCRN ETOH NO RSN Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: G2200 NOCOV DEF SYSMAN Description: UNHLTHY ETOH RCVD COUNS Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: G2202 NOCOV DEF SYSMAN Description: NO RSN NO BRIEF COUNS Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: G2204 NOCOV DEF SYSMAN Description: PT 45-85 W/ SCOPE Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: G2205 NOCOV DEF SYSMAN Description: PREG DRNG ADJV TRTMT Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: G2206 NOCOV DEF SYSMAN Description: ADJV TRTMT CHEMO HER2 Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: G2207 NOCOV DEF SYSMAN Description: RSN NO TRTMT CHEM HER2 Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: G2208 NOCOV DEF SYSMAN Description: NO TRTMT CHEMO AND HER2 Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: G2209 NOCOV DEF SYSMAN Description: REFUSED TO PARTICIPATE Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,728 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G2210 NOCOV DEF SYSMAN Description: NO NECK FS PROM NO RSN Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: G2211 NOCOV DEF SYSMAN Description: COMPLEX E/M VISIT ADD ON Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: G2212 MEDSV DEF RBRVS 01/01/2021 12/31/2023 24.89 Description: PROLONG OUTPT/OFFICE VIS Category: Medical Services CMS Add: 01/01/2021 CMS Term: G2212 MEDSV DEF RBRVS 01/01/2024 30.58 Description: PROLONG OUTPT/OFFICE VIS Category: Medical Services CMS Add: 01/01/2021 CMS Term: G2213 MEDSV DEF RBRVS 01/01/2024 62.24 Description: INITIAT MED ASSIST TX IN ER Category: Medical Services CMS Add: 01/01/2021 CMS Term: G2213 MEDSV DEF RBRVS 07/07/2022 12/31/2023 51.36 Description: INITIAT MED ASSIST TX IN ER Category: Medical Services CMS Add: 01/01/2021 CMS Term: G2214 NOCOV DEF SYSMAN Description: INIT/SUB PSYCH CARE M 1ST 30 Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: G2215 NOCOV DEF SYSMAN Description: HOME SUPPLY NASAL NALOXONE Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: G2216 NOCOV DEF SYSMAN Description: HOME SUPPLY INJECT NALOXON Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: G2250 NOCOV DEF SYSMAN Description: REMOT IMG SUB BY PT, NON E/M Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: G2251 NOCOV DEF SYSMAN Description: BRIEF CHKIN, 5-10, NON-E/M Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: G2252 NOCOV DEF SYSMAN Description: BRIEF CHKIN BY MD/QHP, 11-20 Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: G3002 NOCOV DEF SYSMAN Description: CHRONIC PAIN MGMT 30 MINS Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: G3003 NOCOV DEF SYSMAN Description: CHRONIC PAIN MGMT ADDL 15M Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: G4000 NOCOV DEF SYSMAN Description: DERMATOLOGY SS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G4001 NOCOV DEF SYSMAN Description: DIAGNOSTIC RAD SS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,729 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G4002 NOCOV DEF SYSMAN Description: EP CARDIO SS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G4003 NOCOV DEF SYSMAN Description: EMERGENCY MED SS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G4004 NOCOV DEF SYSMAN Description: ENDOCRINOLOGY SS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G4005 NOCOV DEF SYSMAN Description: FAMILY MEDICINE SS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G4006 NOCOV DEF SYSMAN Description: GASTROENTEROLOGY SS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G4007 NOCOV DEF SYSMAN Description: GENERAL SURGERY SS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G4008 NOCOV DEF SYSMAN Description: GERIATRICS SS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G4009 NOCOV DEF SYSMAN Description: HOSPITALISTS SS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G4010 NOCOV DEF SYSMAN Description: INFECTIOUS DISEASE SS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G4011 NOCOV DEF SYSMAN Description: INTERNAL MEDICINE SS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G4012 NOCOV DEF SYSMAN Description: INTERVENTIONAL RAD SS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G4013 NOCOV DEF SYSMAN Description: MNTAL/BEHAV/PSYCH HLTH SS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G4014 NOCOV DEF SYSMAN Description: NEPHROLOGY SS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G4015 NOCOV DEF SYSMAN Description: NEUROLOGY SS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G4016 NOCOV DEF SYSMAN Description: NEUROSURGICAL SS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G4017 NOCOV DEF SYSMAN Description: NUTRITION/DIETICIAN SS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,730 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G4018 NOCOV DEF SYSMAN Description: OB/GYN SS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G4019 NOCOV DEF SYSMAN Description: ONCOLOGY/HEMA SS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G4020 NOCOV DEF SYSMAN Description: OPHTHALMOLOGY/OPTOMETRY SS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G4021 NOCOV DEF SYSMAN Description: ORTHOPEDIC SURGERY SS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G4022 NOCOV DEF SYSMAN Description: OTOLARYNGOLOGY SS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G4023 NOCOV DEF SYSMAN Description: PATHOLOGY SS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G4024 NOCOV DEF SYSMAN Description: PEDIATRICS SS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G4025 NOCOV DEF SYSMAN Description: PHYSICAL MEDICINE SS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G4026 NOCOV DEF SYSMAN Description: PHYS/OCC THERAPY SS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G4027 NOCOV DEF SYSMAN Description: PLASTIC SURGERY SS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G4028 NOCOV DEF SYSMAN Description: PODIATRY SS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G4029 NOCOV DEF SYSMAN Description: PREVENTIVE MEDICINE SS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G4030 NOCOV DEF SYSMAN Description: PULMONOLOGY SS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G4031 NOCOV DEF SYSMAN Description: RADIATION ONCOLOGY SS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G4032 NOCOV DEF SYSMAN Description: RHEUMATOLOGY SS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G4033 NOCOV DEF SYSMAN Description: SKILLED NURSING FACILITY SS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,731 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G4034 NOCOV DEF SYSMAN Description: SPEECH LANGUAGE PATH SS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G4035 NOCOV DEF SYSMAN Description: THORACIC SURGERY SS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G4036 NOCOV DEF SYSMAN Description: URGENT CARE SS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G4037 NOCOV DEF SYSMAN Description: UROLOGY SS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G4038 NOCOV DEF SYSMAN Description: VASCULAR SURGERY SS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G6001 26 RADIO DEF RBRVS 01/01/2024 30.47 Description: ECHO GUIDANCE RADIOTHERAPY Category: Radiology CMS Add: 01/01/2015 CMS Term: G6001 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 21.61 Description: ECHO GUIDANCE RADIOTHERAPY Category: Radiology CMS Add: 01/01/2015 CMS Term: G6001 RADIO DEF RBRVS 01/01/2024 167.70 Description: ECHO GUIDANCE RADIOTHERAPY Category: Radiology CMS Add: 01/01/2015 CMS Term: G6001 RADIO DEF RBRVS 02/01/2015 12/31/2023 36.64 Description: ECHO GUIDANCE RADIOTHERAPY Category: Radiology CMS Add: 01/01/2015 CMS Term: G6001 TC RADIO DEF RBRVS 01/01/2024 137.23 Description: ECHO GUIDANCE RADIOTHERAPY Category: Radiology CMS Add: 01/01/2015 CMS Term: G6001 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 15.03 Description: ECHO GUIDANCE RADIOTHERAPY Category: Radiology CMS Add: 01/01/2015 CMS Term: G6002 26 RADIO DEF RBRVS 01/01/2024 19.71 Description: STEREOSCOPIC X-RAY GUIDANCE Category: Radiology CMS Add: 01/01/2015 CMS Term: G6002 26 RADIO DEF RBRVS 02/01/2015 12/31/2023 14.77 Description: STEREOSCOPIC X-RAY GUIDANCE Category: Radiology CMS Add: 01/01/2015 CMS Term: G6002 RADIO DEF RBRVS 01/01/2024 69.58 Description: STEREOSCOPIC X-RAY GUIDANCE Category: Radiology CMS Add: 01/01/2015 CMS Term: G6002 RADIO DEF RBRVS 02/01/2015 12/31/2023 52.59 Description: STEREOSCOPIC X-RAY GUIDANCE Category: Radiology CMS Add: 01/01/2015 CMS Term: G6002 TC RADIO DEF RBRVS 01/01/2024 49.86 Description: STEREOSCOPIC X-RAY GUIDANCE Category: Radiology CMS Add: 01/01/2015 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,732 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G6002 TC RADIO DEF RBRVS 02/01/2015 12/31/2023 37.82 Description: STEREOSCOPIC X-RAY GUIDANCE Category: Radiology CMS Add: 01/01/2015 CMS Term: G6003 RADIO DEF RBRVS 01/01/2024 140.93 Description: RADIATION TREATMENT DELIVERY Category: Radiology CMS Add: 01/01/2015 CMS Term: G6003 RADIO DEF RBRVS 02/01/2015 12/31/2023 111.88 Description: RADIATION TREATMENT DELIVERY Category: Radiology CMS Add: 01/01/2015 CMS Term: G6004 RADIO DEF RBRVS 01/01/2024 119.02 Description: RADIATION TREATMENT DELIVERY Category: Radiology CMS Add: 01/01/2015 CMS Term: G6004 RADIO DEF RBRVS 02/01/2015 12/31/2023 86.62 Description: RADIATION TREATMENT DELIVERY Category: Radiology CMS Add: 01/01/2015 CMS Term: G6005 RADIO DEF RBRVS 01/01/2024 119.32 Description: RADIATION TREATMENT DELIVERY Category: Radiology CMS Add: 01/01/2015 CMS Term: G6005 RADIO DEF RBRVS 02/01/2015 12/31/2023 96.77 Description: RADIATION TREATMENT DELIVERY Category: Radiology CMS Add: 01/01/2015 CMS Term: G6006 RADIO DEF RBRVS 01/01/2024 118.71 Description: RADIATION TREATMENT DELIVERY Category: Radiology CMS Add: 01/01/2015 CMS Term: G6006 RADIO DEF RBRVS 02/01/2015 12/31/2023 96.28 Description: RADIATION TREATMENT DELIVERY Category: Radiology CMS Add: 01/01/2015 CMS Term: G6007 RADIO DEF RBRVS 01/01/2024 219.66 Description: RADIATION TREATMENT DELIVERY Category: Radiology CMS Add: 01/01/2015 CMS Term: G6007 RADIO DEF RBRVS 02/01/2015 12/31/2023 178.02 Description: RADIATION TREATMENT DELIVERY Category: Radiology CMS Add: 01/01/2015 CMS Term: G6008 RADIO DEF RBRVS 01/01/2024 164.25 Description: RADIATION TREATMENT DELIVERY Category: Radiology CMS Add: 01/01/2015 CMS Term: G6008 RADIO DEF RBRVS 02/01/2015 12/31/2023 119.81 Description: RADIATION TREATMENT DELIVERY Category: Radiology CMS Add: 01/01/2015 CMS Term: G6009 RADIO DEF RBRVS 01/01/2024 163.63 Description: RADIATION TREATMENT DELIVERY Category: Radiology CMS Add: 01/01/2015 CMS Term: G6009 RADIO DEF RBRVS 02/01/2015 12/31/2023 132.69 Description: RADIATION TREATMENT DELIVERY Category: Radiology CMS Add: 01/01/2015 CMS Term: G6010 RADIO DEF RBRVS 01/01/2024 162.70 Description: RADIATION TREATMENT DELIVERY Category: Radiology CMS Add: 01/01/2015 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,733 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G6010 RADIO DEF RBRVS 02/01/2015 12/31/2023 132.69 Description: RADIATION TREATMENT DELIVERY Category: Radiology CMS Add: 01/01/2015 CMS Term: G6011 RADIO DEF RBRVS 01/01/2024 219.20 Description: RADIATION TREATMENT DELIVERY Category: Radiology CMS Add: 01/01/2015 CMS Term: G6011 RADIO DEF RBRVS 02/01/2015 12/31/2023 190.41 Description: RADIATION TREATMENT DELIVERY Category: Radiology CMS Add: 01/01/2015 CMS Term: G6012 RADIO DEF RBRVS 01/01/2024 216.73 Description: RADIATION TREATMENT DELIVERY Category: Radiology CMS Add: 01/01/2015 CMS Term: G6012 RADIO DEF RBRVS 02/01/2015 12/31/2023 157.71 Description: RADIATION TREATMENT DELIVERY Category: Radiology CMS Add: 01/01/2015 CMS Term: G6013 RADIO DEF RBRVS 01/01/2024 217.35 Description: RADIATION TREATMENT DELIVERY Category: Radiology CMS Add: 01/01/2015 CMS Term: G6013 RADIO DEF RBRVS 02/01/2015 12/31/2023 177.53 Description: RADIATION TREATMENT DELIVERY Category: Radiology CMS Add: 01/01/2015 CMS Term: G6014 RADIO DEF RBRVS 01/01/2024 216.11 Description: RADIATION TREATMENT DELIVERY Category: Radiology CMS Add: 01/01/2015 CMS Term: G6014 RADIO DEF RBRVS 02/01/2015 12/31/2023 177.53 Description: RADIATION TREATMENT DELIVERY Category: Radiology CMS Add: 01/01/2015 CMS Term: G6015 RADIO DEF RBRVS 01/01/2024 331.89 Description: RADIATION TX DELIVERY IMRT Category: Radiology CMS Add: 01/01/2015 CMS Term: G6015 RADIO DEF RBRVS 02/01/2015 12/31/2023 276.86 Description: RADIATION TX DELIVERY IMRT Category: Radiology CMS Add: 01/01/2015 CMS Term: G6016 RADIO DEF RBRVS 01/01/2024 331.41 Description: DELIVERY COMP IMRT Category: Radiology CMS Add: 01/01/2015 CMS Term: G6016 RADIO DEF RBRVS 02/01/2015 12/31/2023 276.37 Description: DELIVERY COMP IMRT Category: Radiology CMS Add: 01/01/2015 CMS Term: G6017 NOCOV DEF SYSMAN Description: INTRAFRACTION TRACK MOTION Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: G8395 NOCOV DEF SYSMAN Description: LVEF>=40% DOC NORMAL OR MILD Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: G8396 NOCOV DEF SYSMAN Description: LVEF NOT PERFORMED Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,734 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G8397 NOCOV DEF SYSMAN Description: DIL MACULA/FUNDUS EXAM/W DOC Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: G8399 NOCOV DEF SYSMAN Description: PT W/DXA RESULTS DOCUMENT Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: G8400 NOCOV DEF SYSMAN Description: PT W/DXA NO RESULTS DOC Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: G8404 NOCOV DEF SYSMAN Description: LOW EXTEMITY NEUR EXAM DOCUM Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: G8405 NOCOV DEF SYSMAN Description: LOW EXTEMITY NEUR NOT PERFOR Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: G8410 NOCOV DEF SYSMAN Description: EVAL ON FOOT DOCUMENTED Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: G8415 NOCOV DEF SYSMAN Description: EVAL ON FOOT NOT PERFORMED Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: G8416 NOCOV DEF SYSMAN Description: PT INELIG FOOTWEAR EVALUATIO Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: G8417 NOCOV DEF SYSMAN Description: CALC BMI ABV UP PARAM F/U Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: G8418 NOCOV DEF SYSMAN Description: CALC BMI BLW LOW PARAM F/U Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: G8419 NOCOV DEF SYSMAN Description: CALC BMI OUT NRM PARAM NOF/U Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: G8420 NOCOV DEF SYSMAN Description: CALC BMI NORM PARAMETERS Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: G8421 NOCOV DEF SYSMAN Description: BMI NOT CALCULATED Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: G8427 NOCOV DEF SYSMAN Description: DOCREV CUR MEDS BY ELIG CLIN Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: G8428 NOCOV DEF SYSMAN Description: CUR MEDS NOT DOCUMENT Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: G8430 NOCOV DEF SYSMAN Description: DOC MED RSN NO MEDREC Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,735 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G8431 NOCOV DEF SYSMAN Description: POS CLIN DEPRES SCRN F/U DOC Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: G8432 NOCOV DEF SYSMAN Description: DEP SCR NOT DOC, RNG Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: G8433 NOCOV DEF SYSMAN Description: SCR FOR DEP NOT CPT DOC RSN Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: G8450 NOCOV DEF SYSMAN Description: BETA-BLOC RX PT W/ABN LVEF Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: G8451 NOCOV DEF SYSMAN Description: PT W/ABN LVEF INELIG B-BLOC Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: G8452 NOCOV DEF SYSMAN Description: PT W/ABN LVEF B-BLOC NO RX Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: G8459 NOCOV DEF SYSMAN Description: DOC PT REC ANTIVIR TREAT Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 12/31/2013 G8462 NOCOV DEF SYSMAN Description: PT INELIG COUNS NO ANTVIR TX Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 12/31/2013 G8463 NOCOV DEF SYSMAN Description: PT REC ANTIVIRAL TREAT DOC Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 12/31/2013 G8465 NOCOV DEF SYSMAN Description: HIGH RISK RECURRENCE PRO CA Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: G8473 NOCOV DEF SYSMAN Description: ACE/ARB THXPY RX'D Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: G8474 NOCOV DEF SYSMAN Description: ACE/ARB NOT RX'D; DOC REAS Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: G8475 NOCOV DEF SYSMAN Description: ACE/ARB THXPY NOT RX'D Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: G8476 NOCOV DEF SYSMAN Description: BP SYS <140 AND DIAS <90 Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: G8477 NOCOV DEF SYSMAN Description: BP SYS>=140 AND/OR DIAS >=90 Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: G8478 NOCOV DEF SYSMAN Description: BP NOT PERFORMED/DOC Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,736 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G8482 NOCOV DEF SYSMAN Description: FLU IMMUNIZE ORDER/ADMIN Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: G8483 NOCOV DEF SYSMAN Description: FLU IMM NO ADMIN DOC REA Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: G8484 NOCOV DEF SYSMAN Description: FLU IMMUNIZE NO ADMIN Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: G8510 NOCOV DEF SYSMAN Description: SCR DEP NEG, NO PLAN REQD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: G8511 NOCOV DEF SYSMAN Description: SCR DEP POS, NO PLAN DOC RNG Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: G8535 NOCOV DEF SYSMAN Description: ELD MALTREATMENT NOT DOC Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: G8536 NOCOV DEF SYSMAN Description: NO DOC ELDER MAL SCRN Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: G8539 NOCOV DEF SYSMAN Description: DOC FUNCT AND CARE PLAN Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: G8540 NOCOV DEF SYSMAN Description: FOA NOT DOC AS BEING PERF Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: G8541 NOCOV DEF SYSMAN Description: NO DOC CUR FUNCT ASSESS Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: G8542 NOCOV DEF SYSMAN Description: DOC FUNCT NO DEFICIENCIES Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: G8543 NOCOV DEF SYSMAN Description: CUR FUNCT ASSES; NO CARE PLN Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: G8553 NOCOV DEF SYSMAN Description: PRESCRIP TRANSMIT VIA ERX SY Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 12/31/2013 G8556 NOCOV DEF SYSMAN Description: REF TO DOC OTOLOG EVAL Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 12/31/2013 G8557 NOCOV DEF SYSMAN Description: PT INELIG REF OTOLOG EVAL Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 12/31/2013 G8558 NOCOV DEF SYSMAN Description: NO REF TO DOC OTOLOG EVAL Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 12/31/2013 *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,737 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G8559 NOCOV DEF SYSMAN Description: PT REF DOC OTO EVAL Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: G8560 NOCOV DEF SYSMAN Description: PT HX ACT DRAIN PREV 90 DAYS Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: G8561 NOCOV DEF SYSMAN Description: PT INELIG FOR REF OTO EVAL Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: G8562 NOCOV DEF SYSMAN Description: PT NO HX ACT DRAIN 90 D Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: G8563 NOCOV DEF SYSMAN Description: PT NO REF OTO REAS NO SPEC Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: G8564 NOCOV DEF SYSMAN Description: PT REF OTO EVAL Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: G8565 NOCOV DEF SYSMAN Description: VER DOC HEAR LOSS Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: G8566 NOCOV DEF SYSMAN Description: PT INELIG REF OTO EVAL Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: G8567 NOCOV DEF SYSMAN Description: PT NO DOC HEAR LOSS Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: G8568 NOCOV DEF SYSMAN Description: PT NO REF OTOLO NO SPEC Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: G8569 NOCOV DEF SYSMAN Description: PROL INTUBATION REQ Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: G8570 NOCOV DEF SYSMAN Description: NO PROL INTUB REQ Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: G8575 NOCOV DEF SYSMAN Description: POSTOP REN FAIL Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: G8576 NOCOV DEF SYSMAN Description: NO POSTOP REN FAIL Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: G8577 NOCOV DEF SYSMAN Description: REOP REQ BLD GRFT OTH Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: G8578 NOCOV DEF SYSMAN Description: NO REOP REQ BLD GRFT OTH Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,738 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G8588 NOCOV DEF SYSMAN Description: SYS BP <140 Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 12/31/2013 G8589 NOCOV DEF SYSMAN Description: SYS BP >= 140 Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 12/31/2013 G8590 NOCOV DEF SYSMAN Description: DIA BP < 90 Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 12/31/2013 G8591 NOCOV DEF SYSMAN Description: DIA BP >= 90 Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 12/31/2013 G8592 NOCOV DEF SYSMAN Description: NO BP MEASURE Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 12/31/2013 G8596 NOCOV DEF SYSMAN Description: NO LDL PERF Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 12/31/2013 G8598 NOCOV DEF SYSMAN Description: ASA/ANTIPLAT THER USED Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: G8599 NOCOV DEF SYSMAN Description: NO ASA/ANTIPLAT THER USE RNG Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: G8600 NOCOV DEF SYSMAN Description: TPA INITI W/IN 4.5 HR Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: G8601 NOCOV DEF SYSMAN Description: NO ELIG TPA INIT W/IN 4.5 HR Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: G8602 NOCOV DEF SYSMAN Description: NO TPA INIT W/IN 4.5 HR Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: G8603 NOCOV DEF SYSMAN Description: SPOK LANG COMP SCORE Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 12/31/2013 G8604 NOCOV DEF SYSMAN Description: NO HIGH SCORE SPOK LANG Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 12/31/2013 G8605 NOCOV DEF SYSMAN Description: NO SPOK LANG COMP SCORE Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 12/31/2013 G8606 NOCOV DEF SYSMAN Description: ATTENTION SCORE Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 12/31/2013 G8607 NOCOV DEF SYSMAN Description: NO HIGH SCORE ATTENTION Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 12/31/2013 *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,739 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G8608 NOCOV DEF SYSMAN Description: NO ATTENTION SCORE Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 12/31/2013 G8609 NOCOV DEF SYSMAN Description: MEMORY SCORE Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 12/31/2013 G8610 NOCOV DEF SYSMAN Description: NO HIGH SCORE MEMORY Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 12/31/2013 G8611 NOCOV DEF SYSMAN Description: NO MEMORY SCORE Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 12/31/2013 G8612 NOCOV DEF SYSMAN Description: MOTO SPEECH SCORE Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 12/31/2013 G8613 NOCOV DEF SYSMAN Description: NO HIGH SCORE MOTO SPEECH Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 12/31/2013 G8614 NOCOV DEF SYSMAN Description: NO MOTO SPEECH SCORE Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 12/31/2013 G8615 NOCOV DEF SYSMAN Description: READING SCORE Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 12/31/2013 G8616 NOCOV DEF SYSMAN Description: NO HIGH SCORE READING Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 12/31/2013 G8617 NOCOV DEF SYSMAN Description: NO READING SCORE Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 12/31/2013 G8618 NOCOV DEF SYSMAN Description: SPOK LANG EXP SCORE Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 12/31/2013 G8619 NOCOV DEF SYSMAN Description: NO HIGH SCORE SPOK LANG EXP Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 12/31/2013 G8620 NOCOV DEF SYSMAN Description: NO SPOK LANG EXP SCORE Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 12/31/2013 G8621 NOCOV DEF SYSMAN Description: WRITING SCORE Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 12/31/2013 G8622 NOCOV DEF SYSMAN Description: NO HIGH SCORE WRITING Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 12/31/2013 G8623 NOCOV DEF SYSMAN Description: NO WRITING SCORE Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 12/31/2013 *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,740 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G8624 NOCOV DEF SYSMAN Description: SWALLOWING SCORE Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 12/31/2013 G8625 NOCOV DEF SYSMAN Description: NO HIGH SCORE SWALLOWING Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 12/31/2013 G8626 NOCOV DEF SYSMAN Description: NO SWALLOWING SCORE Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 12/31/2013 G8633 NOCOV DEF SYSMAN Description: PHARM THER OSTEO RX Category: Non Covered Services CMS Add: 01/01/2011 CMS Term: G8635 NOCOV DEF SYSMAN Description: NO PHARM THER OSTEO RX Category: Non Covered Services CMS Add: 01/01/2011 CMS Term: G8642 NOCOV DEF SYSMAN Description: HRDSHP RURAL W/O INTERNET Category: Non Covered Services CMS Add: 01/01/2011 CMS Term: 12/31/2013 G8643 NOCOV DEF SYSMAN Description: HRDSHP W/O SUFF PHARM W/ERX Category: Non Covered Services CMS Add: 01/01/2011 CMS Term: 12/31/2013 G8644 NOCOV DEF SYSMAN Description: EP NO PRESCRIBE PRIV Category: Non Covered Services CMS Add: 01/01/2011 CMS Term: 12/31/2013 G8647 NOCOV DEF SYSMAN Description: RAFSCRS KI SCOR >= 0 Category: Non Covered Services CMS Add: 01/01/2011 CMS Term: G8648 NOCOV DEF SYSMAN Description: RAFSCRS KI SCOR < 0 Category: Non Covered Services CMS Add: 01/01/2011 CMS Term: G8650 NOCOV DEF SYSMAN Description: RAFS CRS KI NO SCOR NO RSN Category: Non Covered Services CMS Add: 01/01/2011 CMS Term: G8651 NOCOV DEF SYSMAN Description: RAFSCRS HI SCOR >=0 Category: Non Covered Services CMS Add: 01/01/2011 CMS Term: G8652 NOCOV DEF SYSMAN Description: RAFSCRS HI SCOR < 0 Category: Non Covered Services CMS Add: 01/01/2011 CMS Term: G8654 NOCOV DEF SYSMAN Description: RAFS CRS HI NO SCOR NO SURV Category: Non Covered Services CMS Add: 01/01/2011 CMS Term: G8655 NOCOV DEF SYSMAN Description: RAFSCRS LLFAI SCOR >= 0 Category: Non Covered Services CMS Add: 01/01/2011 CMS Term: G8656 NOCOV DEF SYSMAN Description: RAFSCRS LLFAI SCOR < 0 Category: Non Covered Services CMS Add: 01/01/2011 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,741 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G8658 NOCOV DEF SYSMAN Description: RAFSCRS LLFAI NO SCOR + SURV Category: Non Covered Services CMS Add: 01/01/2011 CMS Term: G8659 NOCOV DEF SYSMAN Description: RAFSCRS LBI SCOR >= 0 Category: Non Covered Services CMS Add: 01/01/2011 CMS Term: G8660 NOCOV DEF SYSMAN Description: RAFSCRS LBI SCOR < 0 Category: Non Covered Services CMS Add: 01/01/2011 CMS Term: G8661 NOCOV DEF SYSMAN Description: RAFSCRS LBI NO SCOR Category: Non Covered Services CMS Add: 01/01/2011 CMS Term: G8662 NOCOV DEF SYSMAN Description: RAFS CRS LBI NO SCOR NO SURV Category: Non Covered Services CMS Add: 01/01/2011 CMS Term: G8663 NOCOV DEF SYSMAN Description: RAFSCRS SI SCOR >= 0 Category: Non Covered Services CMS Add: 01/01/2011 CMS Term: G8664 NOCOV DEF SYSMAN Description: RAFSCRS SI SCOR < 0 Category: Non Covered Services CMS Add: 01/01/2011 CMS Term: G8666 NOCOV DEF SYSMAN Description: RAFS CRS SI NO SCOR NO SURV Category: Non Covered Services CMS Add: 01/01/2011 CMS Term: G8667 NOCOV DEF SYSMAN Description: RAFSCRS EWH SCOR >= 0 Category: Non Covered Services CMS Add: 01/01/2011 CMS Term: G8668 NOCOV DEF SYSMAN Description: RAFSCRS EWH SCOR < 0 Category: Non Covered Services CMS Add: 01/01/2011 CMS Term: G8670 NOCOV DEF SYSMAN Description: RAFS CRS EWH NO SCOR NO SURV Category: Non Covered Services CMS Add: 01/01/2011 CMS Term: G8694 NOCOV DEF SYSMAN Description: LVEF <=40% Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G8708 NOCOV DEF SYSMAN Description: ANTIBIOTIC NOT PRES Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G8709 NOCOV DEF SYSMAN Description: URI EP COMPETE DIAG Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G8710 NOCOV DEF SYSMAN Description: PT PRES ANTIBIOTIC Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G8711 NOCOV DEF SYSMAN Description: PRES ANTIBX ON/WITHIN 3 DAY Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,742 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G8712 NOCOV DEF SYSMAN Description: NOT PRES ANTIBIOTIC Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G8721 NOCOV DEF SYSMAN Description: PT, PN, HIST GRADE DOC Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G8722 NOCOV DEF SYSMAN Description: MED REAS PT, PN, NOT DOC Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G8723 NOCOV DEF SYSMAN Description: SPEC SIT NOT PRIM TUMOR Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G8724 NOCOV DEF SYSMAN Description: PT, PN, HIST GRADE NOT DOC Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G8733 NOCOV DEF SYSMAN Description: DOC POS ELDER MAL SCRN PLAN Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G8734 NOCOV DEF SYSMAN Description: DOC NEG ELD REQ Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G8735 NOCOV DEF SYSMAN Description: ELD MAL SCRN POS NO PLAN Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G8741 NOCOV DEF SYSMAN Description: NOT TX SPOKEN LANG Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 12/31/2013 G8742 NOCOV DEF SYSMAN Description: NOT TX ATTENTION Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 12/31/2013 G8743 NOCOV DEF SYSMAN Description: NOT TX MEMORY Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 12/31/2013 G8744 NOCOV DEF SYSMAN Description: NOT TX MOTOR SPEECH Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 12/31/2013 G8745 NOCOV DEF SYSMAN Description: NOT TX READING Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 12/31/2013 G8746 NOCOV DEF SYSMAN Description: NOT TX SPOKEN LANG EXPRESS Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 12/31/2013 G8747 NOCOV DEF SYSMAN Description: NOT TX WRITING Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 12/31/2013 G8748 NOCOV DEF SYSMAN Description: NOT TX SWALLOWING Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 12/31/2013 *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,743 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G8749 NOCOV DEF SYSMAN Description: NO SIGNS MELANOMA Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G8752 NOCOV DEF SYSMAN Description: SYS BP LESS 140 Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G8753 NOCOV DEF SYSMAN Description: SYS BP > OR = 140 Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G8754 NOCOV DEF SYSMAN Description: DIAS BP LESS 90 Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G8755 NOCOV DEF SYSMAN Description: DIAS BP > OR = 90 Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G8756 NOCOV DEF SYSMAN Description: NO BP MEASURE DOC Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G8783 NOCOV DEF SYSMAN Description: BP SCRN PERF REC INTERVAL Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G8785 NOCOV DEF SYSMAN Description: BP SCRN NO PERF AT INTERVAL Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G8790 NOCOV DEF SYSMAN Description: SYSTOLIC <130MMHG Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 12/31/2013 G8791 NOCOV DEF SYSMAN Description: SYSTOLIC 130-139MMHG Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 12/31/2013 G8792 NOCOV DEF SYSMAN Description: SYSTOLIC >=140MMHG Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 12/31/2013 G8793 NOCOV DEF SYSMAN Description: DIASTOLIC <80MMHG Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 12/31/2013 G8794 NOCOV DEF SYSMAN Description: DIASTOLIC 80-89MMHG Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 12/31/2013 G8795 NOCOV DEF SYSMAN Description: DIASTOLIC >=90MMHG Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 12/31/2013 G8796 NOCOV DEF SYSMAN Description: BP NOT DOC Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 12/31/2013 G8797 NOCOV DEF SYSMAN Description: SPECIMEN SITE NOT ESOPHAGUS Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,744 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G8798 NOCOV DEF SYSMAN Description: SPECIMEN SITE NOT PROSTATE Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G8799 NOCOV DEF SYSMAN Description: ANTICOAG ORDERED Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 12/31/2013 G8800 NOCOV DEF SYSMAN Description: DOC REAS ANTICOAG NOT ORDER Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 12/31/2013 G8801 NOCOV DEF SYSMAN Description: ANTICOAG NOT ORDERED Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 12/31/2013 G8806 NOCOV DEF SYSMAN Description: PERF ULTRSND TO LCT PREG DOC Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G8807 NOCOV DEF SYSMAN Description: NO TA TV ULTRASND Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G8808 NOCOV DEF SYSMAN Description: ULTRASOUND NOT PERF, RNG Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G8812 NOCOV DEF SYSMAN Description: PT NOT ELIG CTA, DUPLEX, MRA Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 12/31/2013 G8813 NOCOV DEF SYSMAN Description: CTA, DUPLEX, MRA PERFORMED Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 12/31/2013 G8814 NOCOV DEF SYSMAN Description: NO CTA, DUPLEX, MRA Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 12/31/2013 G8815 NOCOV DEF SYSMAN Description: DOC REAS NO STATIN THERAPY Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G8816 NOCOV DEF SYSMAN Description: STATIN MED PRES AT DISCH Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G8817 NOCOV DEF SYSMAN Description: DOC REAS NO STATIN MED DISCH Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G8826 NOCOV DEF SYSMAN Description: PT DISCH HOME DAY #2 EVAR Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G8827 NOCOV DEF SYSMAN Description: ANEURYSM <= 5.5CM FOR WOMEN Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 12/31/2013 G8833 NOCOV DEF SYSMAN Description: PT NOT DISCH HOME DAY#2 EVAR Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,745 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G8834 NOCOV DEF SYSMAN Description: PT DISCH HOME DAY #2 CEA Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G8835 NOCOV DEF SYSMAN Description: ASYMPTOM NO TRANS Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 12/31/2013 G8838 NOCOV DEF SYSMAN Description: NOT DISCH HOME BY DAY #2 Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G8839 NOCOV DEF SYSMAN Description: SLEEP APNEA ASSESS Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G8840 NOCOV DEF SYSMAN Description: DOC REAS NO SLEEP APNEA Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G8841 NOCOV DEF SYSMAN Description: NO SLEEP APNEA ASSESS Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G8842 NOCOV DEF SYSMAN Description: AHI OR RDI INITIAL DX Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G8843 NOCOV DEF SYSMAN Description: DOC REAS NO AHI OR RDI Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G8844 NOCOV DEF SYSMAN Description: NO AHI OR RDI INITIAL DX Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G8845 NOCOV DEF SYSMAN Description: POS AIRWAY PRESS PRESCRIBED Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G8846 NOCOV DEF SYSMAN Description: MOD OR SEVERE OSA Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G8849 NOCOV DEF SYSMAN Description: DOC REAS NO POS AIR PRESS Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G8850 NOCOV DEF SYSMAN Description: NO PAP PRESCRIBED Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G8851 NOCOV DEF SYSMAN Description: ADHERE TX ASSESS AT LST ANN Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G8854 NOCOV DEF SYSMAN Description: REAS NO ADHERE THERAPY Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G8855 NOCOV DEF SYSMAN Description: THER NOT ASSESSED ANNUALLY Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,746 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G8856 NOCOV DEF SYSMAN Description: REF FOR OTO EVAL Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G8857 NOCOV DEF SYSMAN Description: NO ELIG REF FOR OTO EVAL Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G8858 NOCOV DEF SYSMAN Description: NOT REF FOR OTO EVAL Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G8863 NOCOV DEF SYSMAN Description: NO ASSESS BONE LOSS Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G8864 NOCOV DEF SYSMAN Description: PNEUMOCOCCAL VACCINE ADMIN Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G8865 NOCOV DEF SYSMAN Description: DOC MED REAS NO PNEUMOCOCCAL Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G8866 NOCOV DEF SYSMAN Description: DOC PT REAS NO PNEUMOCOCCAL Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G8867 NOCOV DEF SYSMAN Description: NO PNEUMOCOCCAL ADMIN Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G8869 NOCOV DEF SYSMAN Description: DOC IMMUNE HEP B ANTITNF Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G8875 NOCOV DEF SYSMAN Description: BREAST CANCER DX MIN INVSIVE Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G8876 NOCOV DEF SYSMAN Description: DOC REAS NO MIN INV DX Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G8877 NOCOV DEF SYSMAN Description: NO BRST CNCR DX MIN INVASIVE Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G8878 NOCOV DEF SYSMAN Description: SENT LYMPH NODE BIOPSY Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G8880 NOCOV DEF SYSMAN Description: SEN LYM P NODE BIOP NOT PERF Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G8881 NOCOV DEF SYSMAN Description: BRST CNCR STAGE > T1N0M0 Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G8882 NOCOV DEF SYSMAN Description: NO SENT LYMPH NODE BIOPSY Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,747 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G8907 NOCOV DEF SYSMAN Description: PT DOC NO EVENTS ON DISCHARG Category: Non Covered Services CMS Add: 04/01/2012 CMS Term: G8908 NOCOV DEF SYSMAN Description: PT DOC W BURN PRIOR TO D/C Category: Non Covered Services CMS Add: 04/01/2012 CMS Term: G8909 NOCOV DEF SYSMAN Description: PT DOC NO BURN PRIOR TO D/C Category: Non Covered Services CMS Add: 04/01/2012 CMS Term: G8910 NOCOV DEF SYSMAN Description: PT DOC TO HAVE FALL IN ASC Category: Non Covered Services CMS Add: 04/01/2012 CMS Term: G8911 NOCOV DEF SYSMAN Description: PT DOC NO FALL IN ASC Category: Non Covered Services CMS Add: 04/01/2012 CMS Term: G8912 NOCOV DEF SYSMAN Description: PT DOC WITH WRONG EVENT Category: Non Covered Services CMS Add: 04/01/2012 CMS Term: G8913 NOCOV DEF SYSMAN Description: PT DOC NO WRONG EVENT Category: Non Covered Services CMS Add: 04/01/2012 CMS Term: G8914 NOCOV DEF SYSMAN Description: PT TRANS TO HOSP POST D/C Category: Non Covered Services CMS Add: 04/01/2012 CMS Term: G8915 NOCOV DEF SYSMAN Description: PT NOT TRANS TO HOSP AT D/C Category: Non Covered Services CMS Add: 04/01/2012 CMS Term: G8916 NOCOV DEF SYSMAN Description: PT W IV AB GIVEN ON TIME Category: Non Covered Services CMS Add: 04/01/2012 CMS Term: G8917 NOCOV DEF SYSMAN Description: PT W IV AB NOT GIVEN ON TIME Category: Non Covered Services CMS Add: 04/01/2012 CMS Term: G8918 NOCOV DEF SYSMAN Description: PT W/O PREOP ORDER IV AB PRO Category: Non Covered Services CMS Add: 04/01/2012 CMS Term: G8919 NOCOV DEF SYSMAN Description: MST RCNT SYS BP <140MMG Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 12/31/2013 G8920 NOCOV DEF SYSMAN Description: MST RCNT SYS BP >=140MMHG Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 12/31/2013 G8921 NOCOV DEF SYSMAN Description: MST RCNT DIA BP <90MMHG Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 12/31/2013 G8922 NOCOV DEF SYSMAN Description: MST RCNT DIA BP >=90MMHG Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 12/31/2013 *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,748 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G8923 NOCOV DEF SYSMAN Description: LVEF <= 40% OR LVSD Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: G8924 NOCOV DEF SYSMAN Description: SPIR RES DOC FEV1/FVC<70% Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: G8934 NOCOV DEF SYSMAN Description: LVEF <=40% OR DEP LV SYS FCN Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: G8935 NOCOV DEF SYSMAN Description: RX ACE OR ARB THERAPY Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: G8936 NOCOV DEF SYSMAN Description: PT NOT ELIGIBLE ACE/ARB Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: G8937 NOCOV DEF SYSMAN Description: NO RX ACE/ARB THERAPY Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: G8942 NOCOV DEF SYSMAN Description: DOC FCN/CARE PLAN W/30 DAYS Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: G8944 NOCOV DEF SYSMAN Description: AJCC MEL CNR STG 0 - IIC Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: G8945 NOCOV DEF SYSMAN Description: ANEURYSM <=6 CM FOR MEN Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 12/31/2013 G8946 NOCOV DEF SYSMAN Description: MIBM BUT NO DX OF BREAST CA Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: G8950 NOCOV DEF SYSMAN Description: PRE-HTN OR HTN DOC, F/U INDC Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: G8952 NOCOV DEF SYSMAN Description: PRE-HTN/HTN, NO F/U, NOT GVN Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: G8954 NOCOV DEF SYSMAN Description: PT DATA RPT QUAL CLIN DB REG Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 12/31/2013 G8955 NOCOV DEF SYSMAN Description: MOST RECENT ASSESS VOL MGMT Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: G8956 NOCOV DEF SYSMAN Description: PT RCV HEDIA OUTPT DYLS FAC Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: G8958 NOCOV DEF SYSMAN Description: ASSESS VOL MGMT NOT DOC Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,749 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G8961 NOCOV DEF SYSMAN Description: CSIT LOWRISK SURG PTS PREOP Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: G8962 NOCOV DEF SYSMAN Description: CSIT ON PT ANY REAS 30 DAYS Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: G8965 NOCOV DEF SYSMAN Description: CSIT PERF ON LOW CHD RSK Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: G8966 NOCOV DEF SYSMAN Description: CSIT PERF SX OR HIGH CHD RSK Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: G8967 NOCOV DEF SYSMAN Description: WARF OR OTHER FDA DRUG PRESC Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: G8968 NOCOV DEF SYSMAN Description: DOC MED NOT PRESB Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: G8969 NOCOV DEF SYSMAN Description: DOC PT RSN NO PRESC WARF/FDA Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: G8970 NOCOV DEF SYSMAN Description: NO RSK FAC OR 1 MOD RISK TE Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: G9001 NOCOV DEF SYSMAN Description: MCCD, INITIAL RATE Category: Non Covered Services CMS Add: 10/01/2000 CMS Term: G9002 NOCOV DEF SYSMAN Description: MCCD,MAINTENANCE RATE Category: Non Covered Services CMS Add: 10/01/2000 CMS Term: G9003 NOCOV DEF SYSMAN Description: MCCD, RISK ADJ HI, INITIAL Category: Non Covered Services CMS Add: 10/01/2000 CMS Term: G9004 NOCOV DEF SYSMAN Description: MCCD, RISK ADJ LO, INITIAL Category: Non Covered Services CMS Add: 10/01/2000 CMS Term: G9005 NOCOV DEF SYSMAN Description: MCCD, RISK ADJ, MAINTENANCE Category: Non Covered Services CMS Add: 10/01/2000 CMS Term: G9006 NOCOV DEF SYSMAN Description: MCCD, HOME MONITORING Category: Non Covered Services CMS Add: 10/01/2000 CMS Term: G9007 NOCOV DEF SYSMAN Description: MCCD, SCH TEAM CONF Category: Non Covered Services CMS Add: 10/01/2000 CMS Term: G9008 NOCOV DEF SYSMAN Description: MCCD,PHYS COOR-CARE OVRSGHT Category: Non Covered Services CMS Add: 10/01/2000 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,750 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G9009 NOCOV DEF SYSMAN Description: MCCD, RISK ADJ, LEVEL 3 Category: Non Covered Services CMS Add: 10/01/2001 CMS Term: G9010 NOCOV DEF SYSMAN Description: MCCD, RISK ADJ, LEVEL 4 Category: Non Covered Services CMS Add: 10/01/2001 CMS Term: G9011 NOCOV DEF SYSMAN Description: MCCD, RISK ADJ, LEVEL 5 Category: Non Covered Services CMS Add: 10/01/2001 CMS Term: G9012 NOCOV DEF SYSMAN Description: OTHER SPECIFIED CASE MGMT Category: Non Covered Services CMS Add: 10/01/2001 CMS Term: G9013 NOCOV DEF SYSMAN Description: ESRD DEMO BUNDLE LEVEL I Category: Non Covered Services CMS Add: 07/01/2004 CMS Term: G9014 NOCOV DEF SYSMAN Description: ESRD DEMO BUNDLE-LEVEL II Category: Non Covered Services CMS Add: 07/01/2004 CMS Term: G9016 NOCOV DEF SYSMAN Description: DEMO-SMOKING CESSATION COUN Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: G9037 NOCOV DEF SYSMAN Description: SERVICES PROVIDED BY REHA Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: 06/30/2015 G9050 NOCOV DEF SYSMAN Description: ONCOLOGY WORK-UP EVALUATION Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9051 NOCOV DEF SYSMAN Description: ONCOLOGY TX DECISION-MGMT Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9052 NOCOV DEF SYSMAN Description: ONC SURVEILLANCE FOR DISEASE Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9053 NOCOV DEF SYSMAN Description: ONC EXPECTANT MANAGEMENT PT Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9054 NOCOV DEF SYSMAN Description: ONC SUPERVISION PALLIATIVE Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9055 NOCOV DEF SYSMAN Description: ONC VISIT UNSPECIFIED NOS Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9056 NOCOV DEF SYSMAN Description: ONC PRAC MGMT ADHERES GUIDE Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9057 NOCOV DEF SYSMAN Description: ONC PRACT MGMT DIFFERS TRIAL Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,751 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G9058 NOCOV DEF SYSMAN Description: ONC PRAC MGMT DISAGREE W/GUI Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9059 NOCOV DEF SYSMAN Description: ONC PRAC MGMT PT OPT ALTERNA Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9060 NOCOV DEF SYSMAN Description: ONC PRAC MGMT DIF PT COMORB Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9061 NOCOV DEF SYSMAN Description: ONC PRAC COND NOADD BY GUIDE Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9062 NOCOV DEF SYSMAN Description: ONC PRAC GUIDE DIFFERS NOS Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9063 NOCOV DEF SYSMAN Description: ONC DX NSCLC STGI NO PROGRES Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9064 NOCOV DEF SYSMAN Description: ONC DX NSCLC STG2 NO PROGRES Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9065 NOCOV DEF SYSMAN Description: ONC DX NSCLC STG3A NO PROGRE Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9066 NOCOV DEF SYSMAN Description: ONC DX NSCLC STG3B-4 METASTA Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9067 NOCOV DEF SYSMAN Description: ONC DX NSCLC DX UNKNOWN NOS Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9068 NOCOV DEF SYSMAN Description: ONC DX SCLC/NSCLC LIMITED Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9069 NOCOV DEF SYSMAN Description: ONC DX SCLC/NSCLC EXT AT DX Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9070 NOCOV DEF SYSMAN Description: ONC DX SCLC/NSCLC EXT UNKNWN Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9071 NOCOV DEF SYSMAN Description: ONC DX BRST STG1-2B HR,NOPRO Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9072 NOCOV DEF SYSMAN Description: ONC DX BRST STG1-2 NOPROGRES Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9073 NOCOV DEF SYSMAN Description: ONC DX BRST STG3-HR, NO PRO Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,752 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G9074 NOCOV DEF SYSMAN Description: ONC DX BRST STG3-NOPROGRESS Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9075 NOCOV DEF SYSMAN Description: ONC DX BRST METASTIC/ RECUR Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9077 NOCOV DEF SYSMAN Description: ONC DX PROSTATE T1NO PROGRES Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9078 NOCOV DEF SYSMAN Description: ONC DX PROSTATE T2NO PROGRES Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9079 NOCOV DEF SYSMAN Description: ONC DX PROSTATE T3B-T4NOPROG Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9080 NOCOV DEF SYSMAN Description: ONC DX PROSTATE W/RISE PSA Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9083 NOCOV DEF SYSMAN Description: ONC DX PROSTATE UNKNWN NOS Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9084 NOCOV DEF SYSMAN Description: ONC DX COLON T1-3,N1-2,NO PR Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9085 NOCOV DEF SYSMAN Description: ONC DX COLON T4, N0 W/O PROG Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9086 NOCOV DEF SYSMAN Description: ONC DX COLON T1-4 NO DX PROG Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9087 NOCOV DEF SYSMAN Description: ONC DX COLON METAS EVID DX Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9088 NOCOV DEF SYSMAN Description: ONC DX COLON METAS NOEVID DX Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9089 NOCOV DEF SYSMAN Description: ONC DX COLON EXTENT UNKNOWN Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9090 NOCOV DEF SYSMAN Description: ONC DX RECTAL T1-2 NO PROGR Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9091 NOCOV DEF SYSMAN Description: ONC DX RECTAL T3 N0 NO PROG Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9092 NOCOV DEF SYSMAN Description: ONC DX RECTAL T1-3,N1-2NOPRG Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,753 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G9093 NOCOV DEF SYSMAN Description: ONC DX RECTAL T4,N,M0 NO PRG Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9094 NOCOV DEF SYSMAN Description: ONC DX RECTAL M1 W/METS PROG Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9095 NOCOV DEF SYSMAN Description: ONC DX RECTAL EXTENT UNKNWN Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9096 NOCOV DEF SYSMAN Description: ONC DX ESOPHAG T1-T3 NOPROG Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9097 NOCOV DEF SYSMAN Description: ONC DX ESOPHAGEAL T4 NO PROG Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9098 NOCOV DEF SYSMAN Description: ONC DX ESOPHAGEAL METS RECUR Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9099 NOCOV DEF SYSMAN Description: ONC DX ESOPHAGEAL UNKNOWN Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9100 NOCOV DEF SYSMAN Description: ONC DX GASTRIC NO RECURRENCE Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9101 NOCOV DEF SYSMAN Description: ONC DX GASTRIC P R1-R2NOPROG Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9102 NOCOV DEF SYSMAN Description: ONC DX GASTRIC UNRESECTABLE Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9103 NOCOV DEF SYSMAN Description: ONC DX GASTRIC RECURRENT Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9104 NOCOV DEF SYSMAN Description: ONC DX GASTRIC UNKNOWN NOS Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9105 NOCOV DEF SYSMAN Description: ONC DX PANCREATC P R0 RES NO Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9106 NOCOV DEF SYSMAN Description: ONC DX PANCREATC P R1/R2 NO Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9107 NOCOV DEF SYSMAN Description: ONC DX PANCREATIC UNRESECTAB Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9108 NOCOV DEF SYSMAN Description: ONC DX PANCREATIC UNKNWN NOS Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,754 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G9109 NOCOV DEF SYSMAN Description: ONC DX HEAD/NECK T1-T2NO PRG Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9110 NOCOV DEF SYSMAN Description: ONC DX HEAD/NECK T3-4 NOPROG Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9111 NOCOV DEF SYSMAN Description: ONC DX HEAD/NECK M1 METS REC Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9112 NOCOV DEF SYSMAN Description: ONC DX HEAD/NECK EXT UNKNOWN Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9113 NOCOV DEF SYSMAN Description: ONC DX OVARIAN STG1A-B NO PR Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9114 NOCOV DEF SYSMAN Description: ONC DX OVARIAN STG1A-B OR 2 Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9115 NOCOV DEF SYSMAN Description: ONC DX OVARIAN STG3/4 NOPROG Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9116 NOCOV DEF SYSMAN Description: ONC DX OVARIAN RECURRENCE Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9117 NOCOV DEF SYSMAN Description: ONC DX OVARIAN UNKNOWN NOS Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9123 NOCOV DEF SYSMAN Description: ONC DX CML CHRONIC PHASE Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9124 NOCOV DEF SYSMAN Description: ONC DX CML ACCELER PHASE Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9125 NOCOV DEF SYSMAN Description: ONC DX CML BLAST PHASE Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9126 NOCOV DEF SYSMAN Description: ONC DX CML REMISSION Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9128 NOCOV DEF SYSMAN Description: ONC DX MULTI MYELOMA STAGE I Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9129 NOCOV DEF SYSMAN Description: ONC DX MULT MYELOMA STG2 HIG Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: G9130 NOCOV DEF SYSMAN Description: ONC DX MULTI MYELOMA UNKNOWN Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,755 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G9131 NOCOV DEF SYSMAN Description: ONC DX BRST UNKNOWN NOS Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: G9132 NOCOV DEF SYSMAN Description: ONC DX PROSTATE METS NO CAST Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: G9133 NOCOV DEF SYSMAN Description: ONC DX PROSTATE CLINICAL MET Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: G9134 NOCOV DEF SYSMAN Description: ONC NHLSTG 1-2 NO RELAP NO Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: G9135 NOCOV DEF SYSMAN Description: ONC DX NHL STG 3-4 NOT RELAP Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: G9136 NOCOV DEF SYSMAN Description: ONC DX NHL TRANS TO LG BCELL Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: G9137 NOCOV DEF SYSMAN Description: ONC DX NHL RELAPSE/REFRACTOR Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: G9138 NOCOV DEF SYSMAN Description: ONC DX NHL STG UNKNOWN Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: G9139 NOCOV DEF SYSMAN Description: ONC DX CML DX STATUS UNKNOWN Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: G9140 NOCOV DEF SYSMAN Description: FRONTIER EXTENDED STAY DEMO Category: Non Covered Services CMS Add: 10/01/2007 CMS Term: G9143 NOCOV DEF SYSMAN Description: WARFARIN RESPON GENETIC TEST Category: Non Covered Services CMS Add: 08/03/2009 CMS Term: G9147 NOCOV DEF SYSMAN Description: OUTPT IV INSULIN TX ANY MEA Category: Non Covered Services CMS Add: 12/23/2009 CMS Term: G9148 NOCOV DEF SYSMAN Description: MEDICAL HOME LEVEL 1 Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: G9149 NOCOV DEF SYSMAN Description: MEDICAL HOME LEVEL II Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: G9150 NOCOV DEF SYSMAN Description: MEDICAL HOME LEVEL III Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: G9151 NOCOV DEF SYSMAN Description: MAPCP DEMO STATE Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,756 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G9152 NOCOV DEF SYSMAN Description: MAPCP DEMO COMMUNITY Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: G9153 NOCOV DEF SYSMAN Description: MAPCP DEMO PHYSICIAN Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: G9156 NOCOV DEF SYSMAN Description: EVALUATION FOR WHEELCHAIR Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: G9157 MEDSV DEF RBRVS 01/01/2024 89.80 Description: TRANSESOPH DOPPL CARDIAC MON Category: Medical Services CMS Add: 01/01/2013 CMS Term: G9157 MEDSV DEF RBRVS 02/12/2016 12/31/2023 71.33 Description: TRANSESOPH DOPPL CARDIAC MON Category: Medical Services CMS Add: 01/01/2013 CMS Term: G9187 NOCOV DEF SYSMAN Description: BPCI HOME VISIT Category: Non Covered Services CMS Add: 10/01/2013 CMS Term: G9188 NOCOV DEF SYSMAN Description: BETA NOT GIVEN NO REASON Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9189 NOCOV DEF SYSMAN Description: BETA PRES OR ALREADY TAKING Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9190 NOCOV DEF SYSMAN Description: MEDICAL REASON FOR NO BETA Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9191 NOCOV DEF SYSMAN Description: PT REASON FOR NO BETA Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9212 NOCOV DEF SYSMAN Description: DOC OF DSM-IV INIT EVAL Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9213 NOCOV DEF SYSMAN Description: NO DOC OF DSM-IV Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9223 NOCOV DEF SYSMAN Description: PJP PROPH ORDERED CD4 LOW Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9225 NOCOV DEF SYSMAN Description: NORSN NO FOOT EXAM Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9226 NOCOV DEF SYSMAN Description: 3 COMP FOOT EXAM COMPLETED Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9227 NOCOV DEF SYSMAN Description: FOA DOC, CARE PLAN NOT DOC Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,757 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G9228 NOCOV DEF SYSMAN Description: GC CHL SYP DOCUMENTED Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9230 NOCOV DEF SYSMAN Description: NORSN FOR GC CHL SYP TEST Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9231 NOCOV DEF SYSMAN Description: DOC ESRD DIA TRANS PREG Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9242 NOCOV DEF SYSMAN Description: DOC VIRAL LOAD >=200 Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9243 NOCOV DEF SYSMAN Description: DOC VIRAL LOAD <200 Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9246 NOCOV DEF SYSMAN Description: NO MED VISIT IN 24MO Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9247 NOCOV DEF SYSMAN Description: 1 MED VISIT IN 24MO Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9254 NOCOV DEF SYSMAN Description: DOC PT DISCHG >2D Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9255 NOCOV DEF SYSMAN Description: DOC PT DISCHG <=2D Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9273 NOCOV DEF SYSMAN Description: SYS<140 AND DIA<90 Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9274 NOCOV DEF SYSMAN Description: BP OUT OF NRML LIMITS Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9275 NOCOV DEF SYSMAN Description: DOC OF NON TOBACCO USER Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9276 NOCOV DEF SYSMAN Description: DOC OF TOBACCO USER Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9277 NOCOV DEF SYSMAN Description: DOC DAILY ASPIRIN OR CONTRA Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9278 NOCOV DEF SYSMAN Description: DOC NO DAILY ASPIRIN Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9279 NOCOV DEF SYSMAN Description: PNE SCRN DONE DOC VAC DONE Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,758 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G9280 NOCOV DEF SYSMAN Description: PNE NOT GIVEN NORSN Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9281 NOCOV DEF SYSMAN Description: PNE SCRN DONE DOC NOT IND Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9282 NOCOV DEF SYSMAN Description: DOC MEDRSN NO HISTO TYPE Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9283 NOCOV DEF SYSMAN Description: HIST TYPE DOC ON REPORT Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9284 NOCOV DEF SYSMAN Description: NO HIST TYPE DOC ON REPORT Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9285 NOCOV DEF SYSMAN Description: SITE NOT SMALL CELL LUNG CA Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9286 NOCOV DEF SYSMAN Description: ANTIBIO RX W IN 10D OF SYMPT Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9287 NOCOV DEF SYSMAN Description: NO ANTIBIO W IN 10D OF SYMPT Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9288 NOCOV DEF SYSMAN Description: DOC MEDRSN NO HIST TYPE RPT Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9289 NOCOV DEF SYSMAN Description: DOC TYPE NSM LUNG CA Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9290 NOCOV DEF SYSMAN Description: NO DOC TYPE NSM LUNG CA Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9291 NOCOV DEF SYSMAN Description: NOT NSM LUNG CA Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9292 NOCOV DEF SYSMAN Description: MEDRSN NO PT CATEGORY Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9293 NOCOV DEF SYSMAN Description: NO PT CATEGORY ON REPORT Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9294 NOCOV DEF SYSMAN Description: PT CAT AND THCK ON REPORT Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9295 NOCOV DEF SYSMAN Description: NON CUTANEOUS LOC Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,759 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G9296 NOCOV DEF SYSMAN Description: DOC SHARE DEC PRIOR PROC Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9297 NOCOV DEF SYSMAN Description: NO DOC SHARE DEC PRIOR PROC Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9298 NOCOV DEF SYSMAN Description: EVAL RISK VTE CARD 30D PRIOR Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9299 NOCOV DEF SYSMAN Description: NO EVAL RISK VTE CARD PRIOR Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9305 NOCOV DEF SYSMAN Description: NO INTERV REQ FOR LEAK Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9306 NOCOV DEF SYSMAN Description: INTERV REQ FOR LEAK Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9307 NOCOV DEF SYSMAN Description: NO RET FOR SURG W IN 30D Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9308 NOCOV DEF SYSMAN Description: UNPL RET OR W/COMPL W/IN 30D Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9309 NOCOV DEF SYSMAN Description: NO UNPLND HOSP READM IN 30D Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9310 NOCOV DEF SYSMAN Description: UNPLND HOSP READM IN 30D Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9311 NOCOV DEF SYSMAN Description: NO SURG SITE INFECTION Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9312 NOCOV DEF SYSMAN Description: SURGICAL SITE INFECTION Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9313 NOCOV DEF SYSMAN Description: AMOXIC NOT PRESC AS 1ST LINE Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9314 NOCOV DEF SYSMAN Description: NORSN NOT FIRST LINE AMOX Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9315 NOCOV DEF SYSMAN Description: AMOX W/WO CLAV RX Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9316 NOCOV DEF SYSMAN Description: DOC COMM RISK CALC Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,760 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G9317 NOCOV DEF SYSMAN Description: NO DOC COMM RISK CALC Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9318 NOCOV DEF SYSMAN Description: IMAGE STD NOMENCLATURE Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9319 NOCOV DEF SYSMAN Description: IMAGE NOT STD NOMENCLATURE Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9321 NOCOV DEF SYSMAN Description: DOC COUNT OF CT IN 12MO Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9322 NOCOV DEF SYSMAN Description: NO DOC COUNT OF CT IN 12MO Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9341 NOCOV DEF SYSMAN Description: SRCH FOR CT W IN 12 MOS Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9342 NOCOV DEF SYSMAN Description: NO SRCH FOR CT IN 12MO NORSN Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9344 NOCOV DEF SYSMAN Description: SYSRSN NO DICOM SRCH Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9345 NOCOV DEF SYSMAN Description: FOLLOW UP PULM NOD Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9347 NOCOV DEF SYSMAN Description: NO FOLLOW UP PULM NOD NORSN Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9351 NOCOV DEF SYSMAN Description: DOC >1 SINUS CT W 90D DX Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9352 NOCOV DEF SYSMAN Description: NOT >1 SINUS CT W 90D DX Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9353 NOCOV DEF SYSMAN Description: MEDRSN >1 SINUS CT W 90D DX Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9354 NOCOV DEF SYSMAN Description: 1 OR NO CT SINUS W/IN 90D DX Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9355 NOCOV DEF SYSMAN Description: NO EARLY IND/DELIVERY Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9356 NOCOV DEF SYSMAN Description: EARLY IND/DELIVERY Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,761 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G9357 NOCOV DEF SYSMAN Description: PP EVAL/EDU PERF Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9358 NOCOV DEF SYSMAN Description: PP EVAL/EDU NOT PERF Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9361 NOCOV DEF SYSMAN Description: DOC RSN ELECT C-SEC/INDUCT Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: G9364 NOCOV DEF SYSMAN Description: SINUS CAUS BAC INX Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: G9367 NOCOV DEF SYSMAN Description: >= 2 SAME HI-RSK MED ORD Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: G9368 NOCOV DEF SYSMAN Description: >= 2 SAME HI-RSK MED NOT ORD Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: G9380 NOCOV DEF SYSMAN Description: OFF ASSIS EOL ISS Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: G9382 NOCOV DEF SYSMAN Description: NO OFF ASSIS EOL Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: G9383 NOCOV DEF SYSMAN Description: RECD SCRN HCV INFEC Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: G9384 NOCOV DEF SYSMAN Description: DOC MED RSN NO HCV SCRN Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: G9385 NOCOV DEF SYSMAN Description: DOC PT REAS NOT REC HCV SRN Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: G9386 NOCOV DEF SYSMAN Description: SCRN HCV INFEC NOT RECD Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: G9393 NOCOV DEF SYSMAN Description: INI PHQ9 >9 REMISS <5 Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: G9394 NOCOV DEF SYSMAN Description: DX BIPOL, DEATH, NHRES, HOSP Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: G9395 NOCOV DEF SYSMAN Description: INI PHQ9 >9 NO REMISS >=5 Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: G9396 NOCOV DEF SYSMAN Description: INI PHQ9 >9 NOT ASSESS Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,762 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G9402 NOCOV DEF SYSMAN Description: RECD F/U W/IN 30D DISCH Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: G9403 NOCOV DEF SYSMAN Description: DOC REAS NO 30 DAY F/U Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: G9404 NOCOV DEF SYSMAN Description: NO 30 DAY F/U Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: G9405 NOCOV DEF SYSMAN Description: RECD F/U W/IN 7D DC Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: G9406 NOCOV DEF SYSMAN Description: DOC REAS NO 7D F/U Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: G9407 NOCOV DEF SYSMAN Description: NO 7D F/U Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: G9408 NOCOV DEF SYSMAN Description: CARD TAMP W/IN 30D Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: G9409 NOCOV DEF SYSMAN Description: NO CARD TAMP E/IN 30D Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: G9410 NOCOV DEF SYSMAN Description: ADMIT W/IN 180D REQ REMOV Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: G9411 NOCOV DEF SYSMAN Description: NO ADMIT W/IN 180D REQ REMOV Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: G9412 NOCOV DEF SYSMAN Description: ADMIT W/IN 180D REQ SURG REV Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: G9413 NOCOV DEF SYSMAN Description: NO ADMIT REQ SURG REV Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: G9414 NOCOV DEF SYSMAN Description: 1DOSE MENIG VAC BTWN 11 & 13 Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: G9415 NOCOV DEF SYSMAN Description: NO 1DOSE MENI VAC BTWN 11&13 Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: G9416 NOCOV DEF SYSMAN Description: PT 1 TDAP BETW 10-13 YRS Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: G9417 NOCOV DEF SYSMAN Description: PT NOT 1 TDAP BETW 10-13 YRS Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,763 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G9418 NOCOV DEF SYSMAN Description: LUNGCX BX RPT DOCS CLASS Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: G9419 NOCOV DEF SYSMAN Description: MED REAS NOT INCL HISTO TYPE Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: G9420 NOCOV DEF SYSMAN Description: SPEC SITE NO LUNG Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: G9421 NOCOV DEF SYSMAN Description: LUNG CX BX RPT NO DOC CLASS Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: G9422 NOCOV DEF SYSMAN Description: RPT DOC CLASS HISTO TYPE Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: G9423 NOCOV DEF SYSMAN Description: MED REAS RPT NO HISTO TYPE Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: G9424 NOCOV DEF SYSMAN Description: SITE NO LUNG OR LUNG CX Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: G9425 NOCOV DEF SYSMAN Description: SPEC RPT NO DOC CLASS HISTO Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: G9426 NOCOV DEF SYSMAN Description: IMPR MED TIME EDARR PAIN MED Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: G9427 NOCOV DEF SYSMAN Description: NO IMPRO MED TIME PAIN MED Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: G9428 NOCOV DEF SYSMAN Description: PATHO RPT INCL PT CTG Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: G9429 NOCOV DEF SYSMAN Description: DOC MED RSN NO PT CAT Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: G9430 NOCOV DEF SYSMAN Description: SPEC SITE NO CUTANEOUS Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: G9431 NOCOV DEF SYSMAN Description: PATHO RPT NO PT CTG Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: G9432 NOCOV DEF SYSMAN Description: ASTH CONTROLLED Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: G9434 NOCOV DEF SYSMAN Description: ASTH NOT CONTROLLED Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,764 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G9452 NOCOV DEF SYSMAN Description: DOC MED REAS NO HCV TEST Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: G9455 NOCOV DEF SYSMAN Description: ABD IMAG W/US, CT OR MRI Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: G9456 NOCOV DEF SYSMAN Description: DOC MED PT REAS NO HCC SCRN Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: G9457 NOCOV DEF SYSMAN Description: PT NO ABD IMG NO DOC RSN Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: G9458 NOCOV DEF SYSMAN Description: TOB USER RECD CESS INTERV Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: G9459 NOCOV DEF SYSMAN Description: TOB NON-USER Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: G9460 NOCOV DEF SYSMAN Description: NO TOB ASSESS OR CESS INTER Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: G9468 NOCOV DEF SYSMAN Description: NO RECD CORTICO>=10MG/D >60D Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: G9470 NOCOV DEF SYSMAN Description: NO REC CORTICO>60D 1RX 600MG Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: G9471 NOCOV DEF SYSMAN Description: W/IN 2YR DXA NOT ORDER Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: G9473 NOCOV DEF SYSMAN Description: CHAP SERVICES AT HOSPICE Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9474 NOCOV DEF SYSMAN Description: DIET COUNSEL AT HOSPICE Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9475 NOCOV DEF SYSMAN Description: OTHER COUNSELOR AT HOSPICE Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9476 NOCOV DEF SYSMAN Description: VOLUN SERVICE AT HOSPICE Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9477 NOCOV DEF SYSMAN Description: CARE COORD AT HOSPICE Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9478 NOCOV DEF SYSMAN Description: OTHE THERAPIST AT HOSPICE Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,765 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G9479 NOCOV DEF SYSMAN Description: PHARMACIST AT HOSPICE Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9480 NOCOV DEF SYSMAN Description: ADMISSION TO MCCM Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9481 NOCOV DEF SYSMAN Description: REMOTE E/M NEW PT 10MINS Category: Non Covered Services CMS Add: 04/01/2016 CMS Term: G9482 NOCOV DEF SYSMAN Description: REMOTE E/M NEW PT 20MINS Category: Non Covered Services CMS Add: 04/01/2016 CMS Term: G9483 NOCOV DEF SYSMAN Description: REMOTE E/M NEW PT 30MINS Category: Non Covered Services CMS Add: 04/01/2016 CMS Term: G9484 NOCOV DEF SYSMAN Description: REMOTE E/M NEW PT 45MINS Category: Non Covered Services CMS Add: 04/01/2016 CMS Term: G9485 NOCOV DEF SYSMAN Description: REMOTE E/M NEW PT 60MINS Category: Non Covered Services CMS Add: 04/01/2016 CMS Term: G9486 NOCOV DEF SYSMAN Description: REMOTE E/M EST. PT 10MINS Category: Non Covered Services CMS Add: 04/01/2016 CMS Term: G9487 NOCOV DEF SYSMAN Description: REMOTE E/M EST. PT 15MINS Category: Non Covered Services CMS Add: 04/01/2016 CMS Term: G9488 NOCOV DEF SYSMAN Description: REMOTE E/M EST. PT 25MINS Category: Non Covered Services CMS Add: 04/01/2016 CMS Term: G9489 NOCOV DEF SYSMAN Description: REMOTE E/M EST. PT 40MINS Category: Non Covered Services CMS Add: 04/01/2016 CMS Term: G9490 NOCOV DEF SYSMAN Description: CMMI MOD HOME VISIT Category: Non Covered Services CMS Add: 04/01/2016 CMS Term: G9497 NOCOV DEF SYSMAN Description: REC INST NO SMOKE DAY SURG Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9498 NOCOV DEF SYSMAN Description: ABX REG PRESCRIBED Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9500 NOCOV DEF SYSMAN Description: RAD EXPOS IND/EXP TM DOC Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9501 NOCOV DEF SYSMAN Description: RAD EXPOS IND/EXP TM NO DOC Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,766 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G9502 NOCOV DEF SYSMAN Description: MED REAS NO PERF FOOT EXAM Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9504 NOCOV DEF SYSMAN Description: DOC RSN HEP B STAT NOT ASSES Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9505 NOCOV DEF SYSMAN Description: ABX PRES W/IN 10 DYS OF SYMP Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9507 NOCOV DEF SYSMAN Description: DOC REAS ON STATIN OR CONTRA Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9508 NOCOV DEF SYSMAN Description: DOC PT NOT ON STATIN Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9509 NOCOV DEF SYSMAN Description: ADIT MDD DYS REM 12 MNTHS Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9510 NOCOV DEF SYSMAN Description: REMIS12M NOT PHQ-9 SCORE <5 Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9511 NOCOV DEF SYSMAN Description: IDX EVT DTE PHQ>9 DOC 12 MO Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9512 NOCOV DEF SYSMAN Description: INDIV PDC > 0.8 Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9513 NOCOV DEF SYSMAN Description: INDIV PDC NOT > 0.8 Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9514 NOCOV DEF SYSMAN Description: REQ RET OR W/IN 90D OF SURG Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9515 NOCOV DEF SYSMAN Description: NO REAS, NO RET OR W/IN 90D Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9516 NOCOV DEF SYSMAN Description: IMPR VIS ACUIT W/IN 90D Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9517 NOCOV DEF SYSMAN Description: NO IMPR VIS ACUIT W/IN 90D Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9518 NOCOV DEF SYSMAN Description: DOC ACTIVE INJ DRUG USE Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9519 NOCOV DEF SYSMAN Description: FINAL REF +/- 1.0 W/IN 90D Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,767 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G9520 NOCOV DEF SYSMAN Description: REFRACT NOT +/- 1.0 W/IN 90D Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9521 NOCOV DEF SYSMAN Description: ER AND IP HOSP <2 IN 12 MOS Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9522 NOCOV DEF SYSMAN Description: ER/IP HOSP =/>2 IN 12 MOS Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9529 NOCOV DEF SYSMAN Description: MINOR BLUNT TRAUMA W/HEAD CT Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9530 NOCOV DEF SYSMAN Description: PT MBHT HD CT ORD EC PROV Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9531 NOCOV DEF SYSMAN Description: PT DOC Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9533 NOCOV DEF SYSMAN Description: INDIC FOR HEAD CT NOT VALID Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9537 NOCOV DEF SYSMAN Description: IMG HD CLIN TRIAL Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9539 NOCOV DEF SYSMAN Description: INTENT POT REMV TIME PLACEMT Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9540 NOCOV DEF SYSMAN Description: PT ALIVE 3 MOS POST PROC Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9541 NOCOV DEF SYSMAN Description: FILTER REM 3 MON PLMT Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9542 NOCOV DEF SYSMAN Description: DOC REASS APPR REMO FILT 3MS Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9543 NOCOV DEF SYSMAN Description: DOC 2X RE-ASSESS FILT REMOV Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9544 NOCOV DEF SYSMAN Description: NO FILT REMOV W/IN 3MOS PLCM Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9547 NOCOV DEF SYSMAN Description: CYS REN LES OR ADREN Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9548 NOCOV DEF SYSMAN Description: NO F/U REC IMAGE STUDY Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,768 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G9549 NOCOV DEF SYSMAN Description: DOC MED RSN FOR F/U IMAG Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9550 NOCOV DEF SYSMAN Description: IMAG REC Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9551 NOCOV DEF SYSMAN Description: IMAG NO LES Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9552 NOCOV DEF SYSMAN Description: INC THYR NODE <1.0 IN RPT Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9553 NOCOV DEF SYSMAN Description: PRIOR THYROID DISE DX Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9554 NOCOV DEF SYSMAN Description: CT/CTA/MRI/A CHST FOLL REC Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9555 NOCOV DEF SYSMAN Description: DOC MED RSN FOR FOLLUP IMAGE Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9556 NOCOV DEF SYSMAN Description: CT/CTA/MRI/A NO FOLLUP IMAG Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9557 NOCOV DEF SYSMAN Description: CT/CTA/MRI/A NO THYR <1.0CM Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9580 NOCOV DEF SYSMAN Description: DOOR TO PUNC TIME <2HRS Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9582 NOCOV DEF SYSMAN Description: DOOR TO PUNC TIME >2HR, NRG Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9593 NOCOV DEF SYSMAN Description: LOW PECARN PED HEAD TRAUMA Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9594 NOCOV DEF SYSMAN Description: PT MBHT HD CT ORD EC PROV Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9595 NOCOV DEF SYSMAN Description: DOC SHNT/TUM/COAG Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9597 NOCOV DEF SYSMAN Description: NO LOW PECARN PED HEAD TRAUM Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9598 NOCOV DEF SYSMAN Description: AOR ANE 5.5-5.9 CM MAX DIAM Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,769 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G9599 NOCOV DEF SYSMAN Description: AOR ANE >=6.0 CM MAX DIAM Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9603 NOCOV DEF SYSMAN Description: PT SURV IMPROV BSLINE TX Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9604 NOCOV DEF SYSMAN Description: PT SURV RESULTS NOT AVAIL Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9605 NOCOV DEF SYSMAN Description: SURV SCORE NO IMPROV W/TX Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9606 NOCOV DEF SYSMAN Description: INTRAOP CYST EVAL TRAC INJ Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9607 NOCOV DEF SYSMAN Description: DOC MED RSN NOT PERF CYSTOSC Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9608 NOCOV DEF SYSMAN Description: INTRAOP CYST EVAL NOT DONE Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9609 NOCOV DEF SYSMAN Description: DOC ORDER ANTI-PLAT Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9610 NOCOV DEF SYSMAN Description: DOC MD RSN NO ANTIPLA Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9611 NOCOV DEF SYSMAN Description: NO DOC ORDER ANTI-PLAT RNG Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9621 NOCOV DEF SYSMAN Description: SCR UNHEAL ETOH W/COUNSEL Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9622 NOCOV DEF SYSMAN Description: NO UNHEAL ETOH USER Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9624 NOCOV DEF SYSMAN Description: PT NOT SCRN OR NO COUNSELING Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9625 NOCOV DEF SYSMAN Description: PT BL SRG 30 DAY PST SRG Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9626 NOCOV DEF SYSMAN Description: MED RSN NO RPT BLADDER INJ Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9627 NOCOV DEF SYSMAN Description: PT NO BL SRG 30 DAY PST SRG Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,770 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G9628 NOCOV DEF SYSMAN Description: PT BWLI SRG 30 DAY PST SRG Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9629 NOCOV DEF SYSMAN Description: MED RSN NO RPT BOWEL INJ Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9630 NOCOV DEF SYSMAN Description: PT NO BWLI SRG 30 DAY SRG Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9637 NOCOV DEF SYSMAN Description: DOC >1 DOSE REDUC TECH Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9638 NOCOV DEF SYSMAN Description: NO DOC >1 DOSE REDUC TECH Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9642 NOCOV DEF SYSMAN Description: CURRENT SMOKER Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9643 NOCOV DEF SYSMAN Description: ELECTIVE SURGERY Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9644 NOCOV DEF SYSMAN Description: NO SMOK B/4 ANES DAY OF SURG Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9645 NOCOV DEF SYSMAN Description: HAD SMOKE B/4 ANES DAY SURG Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9646 NOCOV DEF SYSMAN Description: PT W/90D MRS 0-2 Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9648 NOCOV DEF SYSMAN Description: PT W/90D MRS >2 Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9649 NOCOV DEF SYSMAN Description: PSOR AS DOC SPC BM Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9651 NOCOV DEF SYSMAN Description: PSOR AS DOC NO SPC BM Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9654 NOCOV DEF SYSMAN Description: MON ANESTH CARE Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9655 NOCOV DEF SYSMAN Description: TOC TOOL INCL KEY ELEM Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9656 NOCOV DEF SYSMAN Description: PT TRANS FROM ANEST TO PACU Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,771 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G9658 NOCOV DEF SYSMAN Description: TOC TOOL INCL ELEM NOT USED Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9659 NOCOV DEF SYSMAN Description: >=86Y NO HX COLO CA/RSN SCOP Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9660 NOCOV DEF SYSMAN Description: DOC MED RSN SCOPE PT >= 86Y Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9661 NOCOV DEF SYSMAN Description: PT >= 86 W/ HI RISK Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9662 NOCOV DEF SYSMAN Description: PRIOR DX/ACTIVE CLIN ASCVD Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9663 NOCOV DEF SYSMAN Description: FAST/DIR LDL >= 190 MG/DL Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9664 NOCOV DEF SYSMAN Description: TAKING STATIN OR REC'D ORDER Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9665 NOCOV DEF SYSMAN Description: NO STATIN/NO ORDER STATIN Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9674 NOCOV DEF SYSMAN Description: PT W/CLIN ASCVD DX Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9675 NOCOV DEF SYSMAN Description: PT W/FAST/DIR LAB LDL-C >190 Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9676 NOCOV DEF SYSMAN Description: 40-75Y W/TYPE 1/2 W/LDL-C RS Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: G9679 NOCOV DEF SYSMAN Description: ACUTE CARE PNEUMONIA Category: Non Covered Services CMS Add: 10/01/2016 CMS Term: G9680 NOCOV DEF SYSMAN Description: ACUTE CARE CONGESTIVE HEART Category: Non Covered Services CMS Add: 10/01/2016 CMS Term: G9681 NOCOV DEF SYSMAN Description: ACUTE CARE CHRONIC OBSTRUCT Category: Non Covered Services CMS Add: 10/01/2016 CMS Term: G9682 NOCOV DEF SYSMAN Description: ACUTE CARE SKIN INFECTION Category: Non Covered Services CMS Add: 10/01/2016 CMS Term: G9683 NOCOV DEF SYSMAN Description: ACUTE FLUID/ELECTRO DISORDER Category: Non Covered Services CMS Add: 10/01/2016 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,772 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G9684 NOCOV DEF SYSMAN Description: ACUTE CARE URINARY TRACT INF Category: Non Covered Services CMS Add: 10/01/2016 CMS Term: G9685 NOCOV DEF SYSMAN Description: ACUTE NURSING FACILITY CARE Category: Non Covered Services CMS Add: 10/01/2016 CMS Term: G9687 NOCOV DEF SYSMAN Description: HOSPICE ANYTIME MSMT PER Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9688 NOCOV DEF SYSMAN Description: PT W/HOSP ANYTIME MSMT PER Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9689 NOCOV DEF SYSMAN Description: INPT ELECT CAROTID INTERVENT Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9690 NOCOV DEF SYSMAN Description: PT IN HOS Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9691 NOCOV DEF SYSMAN Description: PT HOSP DUR MSMT PERIOD Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9692 NOCOV DEF SYSMAN Description: HOSP RECD BY PT DUR MSMT PER Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9693 NOCOV DEF SYSMAN Description: PT USE HOSP DURING MSMT PER Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9694 NOCOV DEF SYSMAN Description: HOSP SRV USED PT IN MSMT PER Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9695 NOCOV DEF SYSMAN Description: LONG ACT INHAL BRONCHDIL PRE Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9696 NOCOV DEF SYSMAN Description: MED RSN NO PRESC BRONCHDIL Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9698 NOCOV DEF SYSMAN Description: SYS RSN NO PRESC BRONCHDIL Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9699 NOCOV DEF SYSMAN Description: LONG INHAL BRONCHDIL NO PRES Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9700 NOCOV DEF SYSMAN Description: PT IS W/HOSP DURING MSMT PER Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9702 NOCOV DEF SYSMAN Description: PT USE HOSP DURING MSMT PER Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,773 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G9703 NOCOV DEF SYSMAN Description: ANBX 30 PRIOR TO EPISODE Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9704 NOCOV DEF SYSMAN Description: AJCC BR CA STG I: T1 MIC/T1A Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9705 NOCOV DEF SYSMAN Description: AJCC BR CA STG IB Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9706 NOCOV DEF SYSMAN Description: LOW RECUR PROST CA Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9707 NOCOV DEF SYSMAN Description: PT HAD HOSP DUR MSMT PER Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9708 NOCOV DEF SYSMAN Description: BILAT MAST/HX BI /UNILAT MAS Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9709 NOCOV DEF SYSMAN Description: HOSP SRV USED PT IN MSMT PER Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9710 NOCOV DEF SYSMAN Description: PT PROV HOSP SRV MSMT PER Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9711 NOCOV DEF SYSMAN Description: PT HX TOT COL OR COLON CA Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9712 NOCOV DEF SYSMAN Description: DOC MED RSN PRESC ANBX Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9713 NOCOV DEF SYSMAN Description: PT USE HOSP DURING MSMT PER Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9714 NOCOV DEF SYSMAN Description: PT IS W/HOSP DURING MSMT PER Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9716 NOCOV DEF SYSMAN Description: BMI DOC ONL FUP NOT CMPLTD Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9717 NOCOV DEF SYSMAN Description: DOC PT DX BIPOL Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9719 NOCOV DEF SYSMAN Description: PT NOT AMBUL/IMMOB/WC Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9720 NOCOV DEF SYSMAN Description: HOSPICE ANYTIME MSMT PER Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,774 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G9721 NOCOV DEF SYSMAN Description: PT NOT AMBUL/IMMOB/WC Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9722 NOCOV DEF SYSMAN Description: DOC HX RENAL FAIL OR CR+ >=4 Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9723 NOCOV DEF SYSMAN Description: HOSP RECD BY PT DUR MSMT PER Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9724 NOCOV DEF SYSMAN Description: PT W/DOC USE ANTICOAG MST YR Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9726 NOCOV DEF SYSMAN Description: REFUSED TO PARTICIPATE Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9727 NOCOV DEF SYSMAN Description: PT UNABLE CMPLT LEPF PROM Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9728 NOCOV DEF SYSMAN Description: REFUSED TO PARTICIPATE Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9729 NOCOV DEF SYSMAN Description: PT UNBL CMPLT LEPF PROM Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9730 NOCOV DEF SYSMAN Description: REFUSED TO PARTICIPATE Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9731 NOCOV DEF SYSMAN Description: PT UNBL CMPLT LEPF PROM Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9732 NOCOV DEF SYSMAN Description: REFUSED TO PARTICIPATE Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9733 NOCOV DEF SYSMAN Description: PT UNBL CMPLT LB FS PROM Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9734 NOCOV DEF SYSMAN Description: REFUSED TO PARTICIPATE Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9735 NOCOV DEF SYSMAN Description: PT UNBL CMPLT SHLD FS PROM Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9736 NOCOV DEF SYSMAN Description: REFUSED TO PARTICIPATE Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9737 NOCOV DEF SYSMAN Description: PT UNBL CMPLT EWH FS PROM Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,775 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G9740 NOCOV DEF SYSMAN Description: HOSP SRV TO PT DUR MSMT PER Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9741 NOCOV DEF SYSMAN Description: PT W/HOSP ANYTIME MSMT PER Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9744 NOCOV DEF SYSMAN Description: PT NOT ELI D/T ACT DIG HTN Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9745 NOCOV DEF SYSMAN Description: DOC RSN NO HBP SCRN OR F/U Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9746 NOCOV DEF SYSMAN Description: MIT STEN, VALVE OR TRANS AF Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9751 NOCOV DEF SYSMAN Description: PT DIED W/IN 24 MOS RPT TIME Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9752 NOCOV DEF SYSMAN Description: URGENT SURGERY Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9753 NOCOV DEF SYSMAN Description: DOC NO DICOM, CT OTHER FAC Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9754 NOCOV DEF SYSMAN Description: INCID PULM NODULE Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9755 NOCOV DEF SYSMAN Description: DOC MED RSN NO FLLW UP Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9756 NOCOV DEF SYSMAN Description: SURG PROC W/SILICONE OIL Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9757 NOCOV DEF SYSMAN Description: SURG PROC W/SILICONE OIL Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9758 NOCOV DEF SYSMAN Description: PT IN HOS Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9760 NOCOV DEF SYSMAN Description: PT W/HOSP ANYTIME MSMT PER Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9761 NOCOV DEF SYSMAN Description: PT W/HOSP ANYTIME MSMT PER Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9762 NOCOV DEF SYSMAN Description: PT HAD >= 2-3 HPV VACCINES Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,776 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G9763 NOCOV DEF SYSMAN Description: PT NOT HAVE 2-3 HPV VACCINES Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9764 NOCOV DEF SYSMAN Description: PT TREATD W/ORAL SYST OR BIO Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9765 NOCOV DEF SYSMAN Description: DOC PAT DECLINED THERAPY Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9766 NOCOV DEF SYSMAN Description: CVA STROKE DX TX TRANSF FAC Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9767 NOCOV DEF SYSMAN Description: HOSP NEW DX CVA CONSID EVST Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9768 NOCOV DEF SYSMAN Description: PT W/HOSP ANYTIME MSMT PER Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9769 NOCOV DEF SYSMAN Description: BN DEN 2YR/GOT OST MED/THER Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9770 NOCOV DEF SYSMAN Description: PERIP NERVE BLOCK Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9771 NOCOV DEF SYSMAN Description: ANES END, 1 TEMP >35.5(95.9) Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9772 NOCOV DEF SYSMAN Description: DOC MED RSN NO TEMP >= 35.5 Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9773 NOCOV DEF SYSMAN Description: 1 BOD TEMP >=35.5 Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9775 NOCOV DEF SYSMAN Description: RECD 2 ANTI-EMET PRE/INTRAOP Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9776 NOCOV DEF SYSMAN Description: DOC MED RSN NO PROPH ANTIEM Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9777 NOCOV DEF SYSMAN Description: PT NO ANTIEMET PRE/INTRAOP Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9779 NOCOV DEF SYSMAN Description: PTS BREASTFEEDING Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9780 NOCOV DEF SYSMAN Description: PTS DX W/RHABDOMYOLYSIS Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,777 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G9781 NOCOV DEF SYSMAN Description: DOC RSN NO STATIN Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9782 NOCOV DEF SYSMAN Description: HX DX FAM/PURE HYPERCHOLES Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9784 NOCOV DEF SYSMAN Description: PATH/DERM PROV 2ND BIOP OPIN Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9785 NOCOV DEF SYSMAN Description: PATH REPORT SENT Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9786 NOCOV DEF SYSMAN Description: PATH REPORT NOT SENT Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9787 NOCOV DEF SYSMAN Description: PT ALIVE Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9788 NOCOV DEF SYSMAN Description: MOST RCT BP /= 140/90 Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9791 NOCOV DEF SYSMAN Description: MOST RCT TOB STAT FREE Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9792 NOCOV DEF SYSMAN Description: MOST RCT TOB STAT NOT FREE Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9793 NOCOV DEF SYSMAN Description: PT ON DAILY ASA/ANTIPLAT Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9794 NOCOV DEF SYSMAN Description: DOC MED RSN NO DAILY ASPIRIN Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9795 NOCOV DEF SYSMAN Description: PT NO DAILY ASA/ANTIPLAT Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9796 NOCOV DEF SYSMAN Description: PT NOT CURRENTLY ON STATIN Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9797 NOCOV DEF SYSMAN Description: PT CURRENTLY ON STATIN Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,778 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G9805 NOCOV DEF SYSMAN Description: PT W/HOSP ANYTIME MSMT PER Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9806 NOCOV DEF SYSMAN Description: PT RECD CERV CYTO/HPV Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9807 NOCOV DEF SYSMAN Description: PT NO RECD CERV CYTO/HPV Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9812 NOCOV DEF SYSMAN Description: PT DIED DURING INPT/30D AFT Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9813 NOCOV DEF SYSMAN Description: PT NOT DIED W/IN 30D OF PROC Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9818 NOCOV DEF SYSMAN Description: DOC SEX ACTIVITY Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9819 NOCOV DEF SYSMAN Description: PT W/HOSP ANYTIME MSMT PER Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9820 NOCOV DEF SYSMAN Description: DOC CHLAM SCR TEST W/FOLLOW Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9821 NOCOV DEF SYSMAN Description: NO DOC CHLAM SCR TS W/FOLLOW Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9822 NOCOV DEF SYSMAN Description: ENDO ABL PROC YR PREV IND DT Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9823 NOCOV DEF SYSMAN Description: ENDO SMPL/HYST BX RES DOC Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9824 NOCOV DEF SYSMAN Description: ENDO SMPL/HYST BX RES NO DOC Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9830 NOCOV DEF SYSMAN Description: HER-2 POS Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9831 NOCOV DEF SYSMAN Description: AJCC STG BRT CA DX II OR III Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9832 NOCOV DEF SYSMAN Description: BRT CA DX I, NO T1/T1A/T1B Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9838 NOCOV DEF SYSMAN Description: PT MET DIS AT DX Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,779 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G9839 NOCOV DEF SYSMAN Description: ANTI-EGFR MON ANTI THER Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9840 NOCOV DEF SYSMAN Description: GENE TESTING PERFORMED Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9841 NOCOV DEF SYSMAN Description: GENE TESTING NOT PERFORMED Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9842 NOCOV DEF SYSMAN Description: PT MET DIS AT DX Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9843 NOCOV DEF SYSMAN Description: KRAS OR NRAS GENE MUTATION Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9844 NOCOV DEF SYSMAN Description: PT NO RECD ANTI-EGFR THER Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9845 NOCOV DEF SYSMAN Description: PT RECD ANTI-EGFR THER Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9846 NOCOV DEF SYSMAN Description: PT DIED FROM CANCER Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9847 NOCOV DEF SYSMAN Description: PT RECD CHEMO LAST 14D LIFE Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9848 NOCOV DEF SYSMAN Description: PT NO CHEMO LAST 14D LIFE Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9858 NOCOV DEF SYSMAN Description: PT ENROLL HOSPICE Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9859 NOCOV DEF SYSMAN Description: PT DIED FROM CANCER Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9860 NOCOV DEF SYSMAN Description: PT LESS 3D HOSPICE Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9861 NOCOV DEF SYSMAN Description: PT MORE THAN 3D HOSPICE Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9862 NOCOV DEF SYSMAN Description: DOC RSN NO 10 YR FOLLOW Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: G9868 NOCOV DEF SYSMAN Description: CMMI ASYNTELEHEALTH <10MIN Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,780 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G9869 NOCOV DEF SYSMAN Description: CMMI ASYNTELEHEALTH 10-20MIN Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9870 NOCOV DEF SYSMAN Description: CMMI ASYNTELEHEALTH >20MIN Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9873 NOCOV DEF SYSMAN Description: 1 EM CORE SESSION Category: Non Covered Services CMS Add: 04/01/2018 CMS Term: G9874 NOCOV DEF SYSMAN Description: 4 EM CORE SESSIONS Category: Non Covered Services CMS Add: 04/01/2018 CMS Term: G9875 NOCOV DEF SYSMAN Description: 9 EM CORE SESSIONS Category: Non Covered Services CMS Add: 04/01/2018 CMS Term: G9876 NOCOV DEF SYSMAN Description: 2 EM CORE MS MO 7-9 NO WL Category: Non Covered Services CMS Add: 04/01/2018 CMS Term: G9877 NOCOV DEF SYSMAN Description: 2 EM CORE MS MO 10-12 NO WL Category: Non Covered Services CMS Add: 04/01/2018 CMS Term: G9878 NOCOV DEF SYSMAN Description: 2 EM CORE MS MO 7-9 WL Category: Non Covered Services CMS Add: 04/01/2018 CMS Term: G9879 NOCOV DEF SYSMAN Description: 2 EM CORE MS MO 10-12 WL Category: Non Covered Services CMS Add: 04/01/2018 CMS Term: G9880 NOCOV DEF SYSMAN Description: EM 5 PERCENT WL Category: Non Covered Services CMS Add: 04/01/2018 CMS Term: G9881 NOCOV DEF SYSMAN Description: EM 9 PERCENT WL Category: Non Covered Services CMS Add: 04/01/2018 CMS Term: G9882 NOCOV DEF SYSMAN Description: 2 EM ONGOING MS MO 13-15 WL Category: Non Covered Services CMS Add: 04/01/2018 CMS Term: G9883 NOCOV DEF SYSMAN Description: 2 EM ONGOING MS MO 16-18 WL Category: Non Covered Services CMS Add: 04/01/2018 CMS Term: G9884 NOCOV DEF SYSMAN Description: 2 EM ONGOING MS MO 19-21 WL Category: Non Covered Services CMS Add: 04/01/2018 CMS Term: G9885 NOCOV DEF SYSMAN Description: 2 EM ONGOING MS MO 22-24 WL Category: Non Covered Services CMS Add: 04/01/2018 CMS Term: G9886 NOCOV DEF SYSMAN Description: IN-PERSON ATTENDANCE G CODE Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,781 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G9887 NOCOV DEF SYSMAN Description: DISTANCE LEARNING ATTENDANCE Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: G9888 NOCOV DEF SYSMAN Description: 5% WL MAINTND FROM BSLINE WT Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: G9890 NOCOV DEF SYSMAN Description: EM BRIDGE PAYMENT Category: Non Covered Services CMS Add: 04/01/2018 CMS Term: G9891 NOCOV DEF SYSMAN Description: EM SESSION REPORTING Category: Non Covered Services CMS Add: 04/01/2018 CMS Term: G9892 NOCOV DEF SYSMAN Description: DOC PT RSN NO DIL MAC EXAM Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9893 NOCOV DEF SYSMAN Description: NO MAC EXAM Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9894 NOCOV DEF SYSMAN Description: ADR DEP THRPY PRESCRIBED Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9895 NOCOV DEF SYSMAN Description: DOC MED RSN NO ADR DEP THRPY Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9896 NOCOV DEF SYSMAN Description: DOC PT RSN NO ADR DEP THRPY Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9897 NOCOV DEF SYSMAN Description: PT NT PRSC ADR DEP THRPY RNG Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9898 NOCOV DEF SYSMAN Description: PT 66+ SNP OR LTC POS > 90D Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9899 NOCOV DEF SYSMAN Description: SCRN MAM PERF RSLTS DOC Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9900 NOCOV DEF SYSMAN Description: SCRN MAM PERF RSLTS NOT DOC Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9901 NOCOV DEF SYSMAN Description: PT 66+ SNP OR LTC POS > 90D Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9902 NOCOV DEF SYSMAN Description: PT SCRN TBCO AND ID AS USER Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9903 NOCOV DEF SYSMAN Description: PT SCRN TBCO ID AS NON USER Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,782 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G9905 NOCOV DEF SYSMAN Description: NO PT TBCO SCRN RNG Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9906 NOCOV DEF SYSMAN Description: PT RECV TBCO CESS INTERV Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9908 NOCOV DEF SYSMAN Description: NO PT TBCO CESS INTERV RNG Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9910 NOCOV DEF SYSMAN Description: PT 66+ SNP OR LTC POS > 90D Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9911 NOCOV DEF SYSMAN Description: NODE NEG PRE/POST SYST THER Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9912 NOCOV DEF SYSMAN Description: HBV STATUS ASSESED AND INT Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9913 NOCOV DEF SYSMAN Description: NO HBV STATUS ASSESD AND INT Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9914 NOCOV DEF SYSMAN Description: PT INITIATED ANTI-TNF AGENT Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9915 NOCOV DEF SYSMAN Description: NO DOCUMNTD HBV RESULTS RCD Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9916 NOCOV DEF SYSMAN Description: FUNCT STATUS PAST 12 MONTHS Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9917 NOCOV DEF SYSMAN Description: ADV DEM CRGVR LIMITED Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9918 NOCOV DEF SYSMAN Description: NO FUNCT STAT PERF, RSN NOS Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9919 NOCOV DEF SYSMAN Description: SCRN ND POS ND PROV OF REC Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9920 NOCOV DEF SYSMAN Description: SCRNING PERF AND NEGATIVE Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9921 NOCOV DEF SYSMAN Description: NO OR PART SCRN ND RNG OR OS Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9922 NOCOV DEF SYSMAN Description: SFTY CNCRNS SCRN ND MIT RECS Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,783 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G9923 NOCOV DEF SYSMAN Description: SAFTY CNCRNS SCRN AND NEG Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9925 NOCOV DEF SYSMAN Description: NO SCRN PROV RSN NOS Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9926 NOCOV DEF SYSMAN Description: SFTY CNCRNS SCRN BUT NO RECS Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9928 NOCOV DEF SYSMAN Description: NO WARF OR FDA DRUG PRESC Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9929 NOCOV DEF SYSMAN Description: TRS/REV AF Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9930 NOCOV DEF SYSMAN Description: COM CARE Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9931 NOCOV DEF SYSMAN Description: NO CHAD OR CHAD SCR 0 OR 1 Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9938 NOCOV DEF SYSMAN Description: PT 66+ SNP OR LTC POS > 90D Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9939 NOCOV DEF SYSMAN Description: SAME PATH/DERM PERF BIOPSY Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9940 NOCOV DEF SYSMAN Description: DOC REAS NO STATIN THERAPY Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9943 NOCOV DEF SYSMAN Description: BK PN NT MSR VAS SCL PRE/PST Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9945 NOCOV DEF SYSMAN Description: PT W/CANCER SCOLIOSIS Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9946 NOCOV DEF SYSMAN Description: BK PAIN NO VAS Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9949 NOCOV DEF SYSMAN Description: LEG PAIN NO VAS Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9954 NOCOV DEF SYSMAN Description: PT >2 RSK FAC POST-OP VOMIT Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9955 NOCOV DEF SYSMAN Description: INHLNT ANESTH ONLY FOR INDUC Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,784 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G9956 NOCOV DEF SYSMAN Description: COMBO THRPY OF >= 2 PROPHLY Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9957 NOCOV DEF SYSMAN Description: DOC MED RSN NO COMBO THRPY Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9958 NOCOV DEF SYSMAN Description: NO COMBO PROHPYL THRP FOR PT Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9959 NOCOV DEF SYSMAN Description: SYSTEMIC ANTIMICRO NOT PRESC Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9960 NOCOV DEF SYSMAN Description: MED RSN SYS ANTIMI NT RX Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9961 NOCOV DEF SYSMAN Description: SYSTEMIC ANTIMICRO PRESC Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9962 NOCOV DEF SYSMAN Description: EMBOLIZATION DOC SEPARATLY Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9963 NOCOV DEF SYSMAN Description: EMBOLIZATION NOT DOC SEPARAT Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9964 NOCOV DEF SYSMAN Description: PT RECV >=1 WELL-CHLD VISIT Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9965 NOCOV DEF SYSMAN Description: NO WELL-CHLD VIST RECV BY PT Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9968 NOCOV DEF SYSMAN Description: PT REFRD 2 PVDR/SPCLST IN PP Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9969 NOCOV DEF SYSMAN Description: PVDR RFRD PT RPRT RCVD Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9970 NOCOV DEF SYSMAN Description: PVDR RFRD PT NO RPRT RCVD Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9974 NOCOV DEF SYSMAN Description: MAC EXAM PERF Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9975 NOCOV DEF SYSMAN Description: DOC MED RSN NO DIL MAC EXAM Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: G9976 NOCOV DEF SYSMAN Description: DOC PAT RSN NO MAC EXM PERF Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 01/01/2018 *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,785 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G9977 NOCOV DEF SYSMAN Description: DIL MAC EXAM NO PERF RSN NOS Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 01/01/2018 G9978 NOCOV DEF SYSMAN Description: REMOTE E/M NEW PT 10MINS Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: G9979 NOCOV DEF SYSMAN Description: REMOTE E/M NEW PT 20MINS Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: G9980 NOCOV DEF SYSMAN Description: REMOTE E/M NEW PT 30 MINS Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: G9981 NOCOV DEF SYSMAN Description: REMOTE E/M NEW PT 45MINS Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: G9982 NOCOV DEF SYSMAN Description: REMOTE E/M NEW PT 60MINS Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: G9983 NOCOV DEF SYSMAN Description: REMOTE E/M EST. PT 10MINS Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: G9984 NOCOV DEF SYSMAN Description: REMOTE E/M EST. PT 15MINS Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: G9985 NOCOV DEF SYSMAN Description: REMOTE E/M EST. PT 25MINS Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: G9986 NOCOV DEF SYSMAN Description: REMOTE E/M EST. PT 40MINS Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: G9987 NOCOV DEF SYSMAN Description: BPCI ADVANCED IN HOME VISIT Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: G9988 NOCOV DEF SYSMAN Description: PALL SERV DURING MEAS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G9990 NOCOV DEF SYSMAN Description: NO PNEUM VAX ADMIN 19+ Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G9991 NOCOV DEF SYSMAN Description: PNEUM VAX ADMIN 19+ Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G9992 NOCOV DEF SYSMAN Description: PALL SERV DURING MEAS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G9993 NOCOV DEF SYSMAN Description: PALL SERV DURING MEAS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,786 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- G9994 NOCOV DEF SYSMAN Description: PALL SERV DURING MEAS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G9996 NOCOV DEF SYSMAN Description: DOC PT PAL OR HOSPICE Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G9997* TH MEDSV DEF MAXFEE 01/01/2023 60.00 0.0 Description: DOC PT PREG DUR MSRMT PD Category: Medical Services CMS Add: 01/01/2022 CMS Term: G9998 NOCOV DEF SYSMAN Description: DOC MED RSN <3 COLON Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: G9999 NOCOV DEF SYSMAN Description: DOC SYS RSN <3 COLON Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: H0001 NOCOV DEF SYSMAN Description: ALCOHOL AND/OR DRUG ASSESS Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: H0002 NOCOV DEF SYSMAN Description: ALCOHOL AND/OR DRUG SCREENIN Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: H0003 NOCOV DEF SYSMAN Description: ALCOHOL AND/OR DRUG SCREENIN Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: H0004 HR HW MRO DEF MAXFEE 07/01/2010 28.65 0.0 Y Description: ALCOHOL AND/OR DRUG SERVICES Category: MA Rehab Option CMS Add: 01/01/2001 CMS Term: H0004 HR HW U1 MRO DEF MAXFEE 07/01/2010 7.16 0.0 Y Description: ALCOHOL AND/OR DRUG SERVICES Category: MA Rehab Option CMS Add: 01/01/2001 CMS Term: H0004 HR U1 UB AMHH WUB MAXFEE 10/01/2013 7.16 0.0 Y 19-999years Description: ALCOHOL AND/OR DRUG SERVICES Category: Adult MNTL HLTH CMS Add: 01/01/2001 CMS Term: H0004 HR UB AMHH WUB MAXFEE 10/01/2013 28.65 0.0 Y 19-999years Description: ALCOHOL AND/OR DRUG SERVICES Category: Adult MNTL HLTH CMS Add: 01/01/2001 CMS Term: H0004 HS HW MRO DEF MAXFEE 07/01/2010 28.65 0.0 Y Description: ALCOHOL AND/OR DRUG SERVICES Category: MA Rehab Option CMS Add: 01/01/2001 CMS Term: H0004 HS HW U1 MRO DEF MAXFEE 07/01/2010 7.16 0.0 Y Description: ALCOHOL AND/OR DRUG SERVICES Category: MA Rehab Option CMS Add: 01/01/2001 CMS Term: H0004 HS U1 UB AMHH WUB MAXFEE 10/01/2013 7.16 0.0 Y 19-999years Description: ALCOHOL AND/OR DRUG SERVICES Category: Adult MNTL HLTH CMS Add: 01/01/2001 CMS Term: H0004 HS UB AMHH WUB MAXFEE 10/01/2013 28.65 0.0 Y 19-999years Description: ALCOHOL AND/OR DRUG SERVICES Category: Adult MNTL HLTH CMS Add: 01/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,787 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- H0004 HW MRO DEF MAXFEE 07/01/2010 28.65 0.0 Y Description: ALCOHOL AND/OR DRUG SERVICES Category: MA Rehab Option CMS Add: 01/01/2001 CMS Term: H0004 HW U1 MRO DEF MAXFEE 07/01/2010 7.16 0.0 Y Description: ALCOHOL AND/OR DRUG SERVICES Category: MA Rehab Option CMS Add: 01/01/2001 CMS Term: H0004 U1 U5 U7 DDWA WDD MAXFEE 01/01/2008 06/30/2023 18.20 0.0 Y Description: ALCOHOL AND/OR DRUG SERVICES Category: CIH Waiver CMS Add: 01/01/2001 CMS Term: H0004 U1 U5 U7 DDWA WDD MAXFEE 07/01/2023 18.56 0.0 Y Description: ALCOHOL AND/OR DRUG SERVICES Category: CIH Waiver CMS Add: 01/01/2001 CMS Term: H0004 U1 U5 U7 MFPCI W3M MAXFEE 01/01/2014 06/30/2023 18.20 0.0 Y Description: ALCOHOL AND/OR DRUG SERVICES Category: MFP CIH Waiver CMS Add: 01/01/2001 CMS Term: H0004 U1 U5 U7 MFPCI W3M MAXFEE 07/01/2023 18.56 0.0 Y Description: ALCOHOL AND/OR DRUG SERVICES Category: MFP CIH Waiver CMS Add: 01/01/2001 CMS Term: H0004 U1 U5 U7 MFPTS W5M MAXFEE 07/01/2023 18.56 0.0 Y Description: ALCOHOL AND/OR DRUG SERVICES Category: MFP SOF Waiver CMS Add: 01/01/2001 CMS Term: H0004 U1 U5 U7 SSFS WSS MAXFEE 01/01/2008 06/30/2023 18.20 0.0 Y Description: ALCOHOL AND/OR DRUG SERVICES Category: Family Support Waivr CMS Add: 01/01/2001 CMS Term: H0004 U1 U5 U7 SSFS WSS MAXFEE 07/01/2023 18.56 0.0 Y Description: ALCOHOL AND/OR DRUG SERVICES Category: Family Support Waivr CMS Add: 01/01/2001 CMS Term: H0004 U1 U7 MFPTB W2M MAXFEE 02/01/2020 06/30/2023 18.20 0.0 Y Description: ALCOHOL AND/OR DRUG SERVICES Category: MFP TBI CMS Add: 01/01/2001 CMS Term: H0004 U1 U7 MFPTB W2M MAXFEE 07/01/2023 18.56 0.0 Y Description: ALCOHOL AND/OR DRUG SERVICES Category: MFP TBI CMS Add: 01/01/2001 CMS Term: H0004 U1 U7 TBIWA WTB MAXFEE 02/01/2020 06/30/2023 18.20 0.0 Y Description: ALCOHOL AND/OR DRUG SERVICES Category: TBI Waiver CMS Add: 01/01/2001 CMS Term: H0004 U1 U7 TBIWA WTB MAXFEE 07/01/2023 18.56 0.0 Y Description: ALCOHOL AND/OR DRUG SERVICES Category: TBI Waiver CMS Add: 01/01/2001 CMS Term: H0004 U1 UB AMHH WUB MAXFEE 10/01/2013 7.16 0.0 Y 19-999years Description: ALCOHOL AND/OR DRUG SERVICES Category: Adult MNTL HLTH CMS Add: 01/01/2001 CMS Term: H0004 U2 U5 U7 DDWA WDD MAXFEE 01/01/2008 06/30/2023 18.20 0.0 Y Description: ALCOHOL AND/OR DRUG SERVICES Category: CIH Waiver CMS Add: 01/01/2001 CMS Term: H0004 U2 U5 U7 DDWA WDD MAXFEE 07/01/2023 18.56 0.0 Y Description: ALCOHOL AND/OR DRUG SERVICES Category: CIH Waiver CMS Add: 01/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,788 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- H0004 U2 U5 U7 MFPCI W3M MAXFEE 01/01/2014 06/30/2023 18.20 0.0 Y Description: ALCOHOL AND/OR DRUG SERVICES Category: MFP CIH Waiver CMS Add: 01/01/2001 CMS Term: H0004 U2 U5 U7 MFPCI W3M MAXFEE 07/01/2023 18.56 0.0 Y Description: ALCOHOL AND/OR DRUG SERVICES Category: MFP CIH Waiver CMS Add: 01/01/2001 CMS Term: H0004 U2 U5 U7 MFPTS W5M MAXFEE 07/01/2023 18.56 0.0 Y Description: ALCOHOL AND/OR DRUG SERVICES Category: MFP SOF Waiver CMS Add: 01/01/2001 CMS Term: H0004 U2 U5 U7 SSFS WSS MAXFEE 01/01/2008 06/30/2023 18.20 0.0 Y Description: ALCOHOL AND/OR DRUG SERVICES Category: Family Support Waivr CMS Add: 01/01/2001 CMS Term: H0004 U2 U5 U7 SSFS WSS MAXFEE 07/01/2023 18.56 0.0 Y Description: ALCOHOL AND/OR DRUG SERVICES Category: Family Support Waivr CMS Add: 01/01/2001 CMS Term: H0004 U2 U7 MFPTB W2M MAXFEE 02/01/2020 06/30/2023 18.20 0.0 Y Description: ALCOHOL AND/OR DRUG SERVICES Category: MFP TBI CMS Add: 01/01/2001 CMS Term: H0004 U2 U7 MFPTB W2M MAXFEE 07/01/2023 18.56 0.0 Y Description: ALCOHOL AND/OR DRUG SERVICES Category: MFP TBI CMS Add: 01/01/2001 CMS Term: H0004 U2 U7 TBIWA WTB MAXFEE 02/01/2020 06/30/2023 18.20 0.0 Y Description: ALCOHOL AND/OR DRUG SERVICES Category: TBI Waiver CMS Add: 01/01/2001 CMS Term: H0004 U2 U7 TBIWA WTB MAXFEE 07/01/2023 18.56 0.0 Y Description: ALCOHOL AND/OR DRUG SERVICES Category: TBI Waiver CMS Add: 01/01/2001 CMS Term: H0004 U3 U5 U7 DDWA WDD MAXFEE 01/01/2013 15.45 0.0 Y Description: ALCOHOL AND/OR DRUG SERVICES Category: CIH Waiver CMS Add: 01/01/2001 CMS Term: H0004 U3 U5 U7 MFPCI W3M MAXFEE 01/01/2013 15.45 0.0 Y Description: ALCOHOL AND/OR DRUG SERVICES Category: MFP CIH Waiver CMS Add: 01/01/2001 CMS Term: H0004 U3 U5 U7 MFPTS W5M MAXFEE 01/01/2013 15.45 0.0 Y Description: ALCOHOL AND/OR DRUG SERVICES Category: MFP SOF Waiver CMS Add: 01/01/2001 CMS Term: H0004 U3 U5 U7 SSFS WSS MAXFEE 01/01/2013 15.45 0.0 Y Description: ALCOHOL AND/OR DRUG SERVICES Category: Family Support Waivr CMS Add: 01/01/2001 CMS Term: H0004 U4 U7 ADWA WAD MAXFEE 01/01/2023 06/30/2023 10.00 0.0 Y Description: ALCOHOL AND/OR DRUG SERVICES Category: A&D Waiver CMS Add: 01/01/2001 CMS Term: H0004 U4 U7 ADWA WAD MAXFEE 07/01/2023 15.75 0.0 Y Description: ALCOHOL AND/OR DRUG SERVICES Category: A&D Waiver CMS Add: 01/01/2001 CMS Term: H0004 U4 U7 MFPAD W1M MAXFEE 01/01/2023 06/30/2023 10.00 0.0 Y Description: ALCOHOL AND/OR DRUG SERVICES Category: MFP Demo Grant CMS Add: 01/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,789 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- H0004 U4 U7 MFPAD W1M MAXFEE 07/01/2023 15.75 0.0 Y Description: ALCOHOL AND/OR DRUG SERVICES Category: MFP Demo Grant CMS Add: 01/01/2001 CMS Term: H0004 UB AMHH WUB MAXFEE 10/01/2013 28.65 0.0 Y 19-999years Description: ALCOHOL AND/OR DRUG SERVICES Category: Adult MNTL HLTH CMS Add: 01/01/2001 CMS Term: H0005 HR HW MRO DEF MAXFEE 07/01/2010 14.58 0.0 Y Description: ALCOHOL AND/OR DRUG SERVICES Category: MA Rehab Option CMS Add: 01/01/2001 CMS Term: H0005 HS HW MRO DEF MAXFEE 07/01/2010 14.58 0.0 Y Description: ALCOHOL AND/OR DRUG SERVICES Category: MA Rehab Option CMS Add: 01/01/2001 CMS Term: H0005 HW MRO DEF MAXFEE 07/01/2010 14.58 0.0 Y Description: ALCOHOL AND/OR DRUG SERVICES Category: MA Rehab Option CMS Add: 01/01/2001 CMS Term: H0006 NOCOV DEF SYSMAN Description: ALCOHOL AND/OR DRUG SERVICES Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: H0007 NOCOV DEF SYSMAN Description: ALCOHOL AND/OR DRUG SERVICES Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: H0008 NOCOV DEF SYSMAN Description: ALCOHOL AND/OR DRUG SERVICES Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: H0009 NOCOV DEF SYSMAN Description: ALCOHOL AND/OR DRUG SERVICES Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: H0010 U1 MENTL DEF MAXFEE 01/01/2024 516.07 0.0 Y 19-999;0-18years 0-1 Description: ALCOHOL AND/OR DRUG SERVICES Category: Mental Health CMS Add: 01/01/2001 CMS Term: H0010 U1 MENTL DEF MAXFEE 03/01/2018 12/31/2023 361.65 0.0 Y 19-999;0-18years 0-1 Description: ALCOHOL AND/OR DRUG SERVICES Category: Mental Health CMS Add: 01/01/2001 CMS Term: H0010 U2 MENTL DEF MAXFEE 01/01/2024 627.25 0.0 Y 19-999;0-18years 0-1 Description: ALCOHOL AND/OR DRUG SERVICES Category: Mental Health CMS Add: 01/01/2001 CMS Term: H0010 U2 MENTL DEF MAXFEE 03/01/2018 12/31/2023 439.56 0.0 Y 19-999;0-18years 0-1 Description: ALCOHOL AND/OR DRUG SERVICES Category: Mental Health CMS Add: 01/01/2001 CMS Term: H0011 NOCOV DEF SYSMAN Description: ALCOHOL AND/OR DRUG SERVICES Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: H0012 NOCOV DEF SYSMAN Description: ALCOHOL AND/OR DRUG SERVICES Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: H0013 NOCOV DEF SYSMAN Description: ALCOHOL AND/OR DRUG SERVICES Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,790 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- H0014 NOCOV DEF SYSMAN Description: ALCOHOL AND/OR DRUG SERVICES Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: H0015 MENTL ICA MAXFEE 01/01/2024 186.35 0.0 Y Description: ALCOHOL AND/OR DRUG SERVICES Category: Mental Health CMS Add: 01/01/2001 CMS Term: H0015 MENTL ICA MAXFEE 07/01/2019 12/31/2023 130.59 0.0 Y Description: ALCOHOL AND/OR DRUG SERVICES Category: Mental Health CMS Add: 01/01/2001 CMS Term: H0015 MENTL ICC MAXFEE 01/01/2024 426.99 0.0 Y Description: ALCOHOL AND/OR DRUG SERVICES Category: Mental Health CMS Add: 01/01/2001 CMS Term: H0015 MENTL ICC MAXFEE 07/01/2019 12/31/2023 299.22 0.0 Y Description: ALCOHOL AND/OR DRUG SERVICES Category: Mental Health CMS Add: 01/01/2001 CMS Term: H0016 NOCOV DEF SYSMAN Description: ALCOHOL AND/OR DRUG SERVICES Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: H0017 NOCOV DEF SYSMAN Description: ALCOHOL AND/OR DRUG SERVICES Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: H0018 NOCOV DEF SYSMAN Description: ALCOHOL AND/OR DRUG SERVICES Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: H0019 MENTL DEF MAXFEE 01/01/2004 12/31/2023 90.00 0.0 Y Description: ALCOHOL AND/OR DRUG SERVICES Category: Mental Health CMS Add: 01/01/2001 CMS Term: H0019 MENTL DEF MAXFEE 01/01/2024 128.43 0.0 Y Description: ALCOHOL AND/OR DRUG SERVICES Category: Mental Health CMS Add: 01/01/2001 CMS Term: H0020 NOCOV DEF SYSMAN Description: ALCOHOL AND/OR DRUG SERVICES Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: H0021 NOCOV DEF SYSMAN Description: ALCOHOL AND/OR DRUG TRAINING Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: H0022 NOCOV DEF SYSMAN Description: ALCOHOL AND/OR DRUG INTERVEN Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: H0024 NOCOV DEF SYSMAN Description: ALCOHOL AND/OR DRUG PREVENTI Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: H0025 NOCOV DEF SYSMAN Description: ALCOHOL AND/OR DRUG PREVENTI Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: H0026 NOCOV DEF SYSMAN Description: ALCOHOL AND/OR DRUG PREVENTI Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,791 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- H0027 NOCOV DEF SYSMAN Description: ALCOHOL AND/OR DRUG PREVENTI Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: H0028 NOCOV DEF SYSMAN Description: ALCOHOL AND/OR DRUG PREVENTI Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: H0029 NOCOV DEF SYSMAN Description: ALCOHOL AND/OR DRUG PREVENTI Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: H0030 NOCOV DEF SYSMAN Description: ALCOHOL AND/OR DRUG HOTLINE Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: H0031 HW MENTL DEF MAXFEE 01/01/2024 110.91 0.0 Description: MH HEALTH ASSESS BY NON-MD Category: Mental Health CMS Add: 01/01/2003 CMS Term: H0031 HW MENTL DEF MAXFEE 07/01/2010 12/31/2023 77.72 0.0 Description: MH HEALTH ASSESS BY NON-MD Category: Mental Health CMS Add: 01/01/2003 CMS Term: H0031 HW MRO DEF MAXFEE 01/01/2024 110.91 0.0 Y Description: MH HEALTH ASSESS BY NON-MD Category: MA Rehab Option CMS Add: 01/01/2003 CMS Term: H0031 HW MRO DEF MAXFEE 07/01/2010 12/31/2023 77.72 0.0 Y Description: MH HEALTH ASSESS BY NON-MD Category: MA Rehab Option CMS Add: 01/01/2003 CMS Term: H0031 MENTL DEF MAXFEE 01/01/2004 12/31/2023 203.07 0.0 Description: MH HEALTH ASSESS BY NON-MD Category: Mental Health CMS Add: 01/01/2003 CMS Term: H0031 MENTL DEF MAXFEE 01/01/2024 289.78 0.0 Description: MH HEALTH ASSESS BY NON-MD Category: Mental Health CMS Add: 01/01/2003 CMS Term: H0031 MRO DEF MAXFEE 01/01/2004 12/31/2023 203.07 0.0 Y Description: MH HEALTH ASSESS BY NON-MD Category: MA Rehab Option CMS Add: 01/01/2003 CMS Term: H0031 MRO DEF MAXFEE 01/01/2024 289.78 0.0 Y Description: MH HEALTH ASSESS BY NON-MD Category: MA Rehab Option CMS Add: 01/01/2003 CMS Term: H0032 NOCOV DEF SYSMAN Description: MH SVC PLAN DEV BY NON-MD Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: H0034 HR HW MENTL DEF MAXFEE 07/01/2010 18.62 0.0 Description: MED TRNG & SUPPORT PER 15MIN Category: Mental Health CMS Add: 01/01/2003 CMS Term: H0034 HR HW MRO DEF MAXFEE 07/01/2010 18.62 0.0 Y Description: MED TRNG & SUPPORT PER 15MIN Category: MA Rehab Option CMS Add: 01/01/2003 CMS Term: H0034 HR HW U1 MENTL DEF MAXFEE 07/01/2010 3.35 0.0 Description: MED TRNG & SUPPORT PER 15MIN Category: Mental Health CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,792 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- H0034 HR HW U1 MRO DEF MAXFEE 07/01/2010 3.35 0.0 Y Description: MED TRNG & SUPPORT PER 15MIN Category: MA Rehab Option CMS Add: 01/01/2003 CMS Term: H0034 HR U1 UB AMHH WUB MAXFEE 10/01/2013 3.35 0.0 Y 19-999years Description: MED TRNG & SUPPORT PER 15MIN Category: Adult MNTL HLTH CMS Add: 01/01/2003 CMS Term: H0034 HR UB AMHH WUB MAXFEE 10/01/2013 18.62 0.0 Y 19-999years Description: MED TRNG & SUPPORT PER 15MIN Category: Adult MNTL HLTH CMS Add: 01/01/2003 CMS Term: H0034 HS HW MENTL DEF MAXFEE 07/01/2010 18.62 0.0 Description: MED TRNG & SUPPORT PER 15MIN Category: Mental Health CMS Add: 01/01/2003 CMS Term: H0034 HS HW MRO DEF MAXFEE 07/01/2010 18.62 0.0 Y Description: MED TRNG & SUPPORT PER 15MIN Category: MA Rehab Option CMS Add: 01/01/2003 CMS Term: H0034 HS HW U1 MENTL DEF MAXFEE 07/01/2010 3.35 0.0 Description: MED TRNG & SUPPORT PER 15MIN Category: Mental Health CMS Add: 01/01/2003 CMS Term: H0034 HS HW U1 MRO DEF MAXFEE 07/01/2010 3.35 0.0 Y Description: MED TRNG & SUPPORT PER 15MIN Category: MA Rehab Option CMS Add: 01/01/2003 CMS Term: H0034 HS U1 UB AMHH WUB MAXFEE 10/01/2013 3.35 0.0 Y 19-999years Description: MED TRNG & SUPPORT PER 15MIN Category: Adult MNTL HLTH CMS Add: 01/01/2003 CMS Term: H0034 HS UB AMHH WUB MAXFEE 10/01/2013 18.62 0.0 Y 19-999years Description: MED TRNG & SUPPORT PER 15MIN Category: Adult MNTL HLTH CMS Add: 01/01/2003 CMS Term: H0034 HW MENTL DEF MAXFEE 07/01/2010 18.62 0.0 Description: MED TRNG & SUPPORT PER 15MIN Category: Mental Health CMS Add: 01/01/2003 CMS Term: H0034 HW MRO DEF MAXFEE 07/01/2010 18.62 0.0 Y Description: MED TRNG & SUPPORT PER 15MIN Category: MA Rehab Option CMS Add: 01/01/2003 CMS Term: H0034 HW U1 MENTL DEF MAXFEE 07/01/2010 3.35 0.0 Description: MED TRNG & SUPPORT PER 15MIN Category: Mental Health CMS Add: 01/01/2003 CMS Term: H0034 HW U1 MRO DEF MAXFEE 07/01/2010 3.35 0.0 Y Description: MED TRNG & SUPPORT PER 15MIN Category: MA Rehab Option CMS Add: 01/01/2003 CMS Term: H0034 U1 UB AMHH WUB MAXFEE 10/01/2013 3.35 0.0 Y 19-999years Description: MED TRNG & SUPPORT PER 15MIN Category: Adult MNTL HLTH CMS Add: 01/01/2003 CMS Term: H0034 U9 MENTL DEF MAXFEE 07/01/2023 18.62 0.0 Description: MED TRNG & SUPPORT PER 15MIN Category: Mental Health CMS Add: 01/01/2003 CMS Term: H0034 U9 MRO DEF MAXFEE 07/01/2023 18.62 0.0 Y Description: MED TRNG & SUPPORT PER 15MIN Category: MA Rehab Option CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,793 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- H0034 UB AMHH WUB MAXFEE 10/01/2013 18.62 0.0 Y 19-999years Description: MED TRNG & SUPPORT PER 15MIN Category: Adult MNTL HLTH CMS Add: 01/01/2003 CMS Term: H0035 MENTL DEF MAXFEE 01/01/2024 313.74 0.0 Y 0-1 Description: MH PARTIAL HOSP TX UNDER 24H Category: Mental Health CMS Add: 01/01/2003 CMS Term: H0035 MENTL DEF MAXFEE 09/01/2013 12/31/2023 219.86 0.0 Y 0-1 Description: MH PARTIAL HOSP TX UNDER 24H Category: Mental Health CMS Add: 01/01/2003 CMS Term: H0036 NOCOV DEF SYSMAN Description: COMM PSY FACE-FACE PER 15MIN Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: H0037 NOCOV DEF SYSMAN Description: COMM PSY SUP TX PGM PER DIEM Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: H0038 MENTL PRF MAXFEE 01/01/2024 12.20 0.0 Description: SELF-HELP/PEER SVC PER 15MIN Category: Mental Health CMS Add: 01/01/2003 CMS Term: H0039 NOCOV DEF SYSMAN Description: ASSER COM TX FACE-FACE/15MIN Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: H0040 NOCOV DEF SYSMAN Description: ASSERT COMM TX PGM PER DIEM Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: H0041 NOCOV DEF SYSMAN Description: FOS C CHLD NON-THER PER DIEM Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: H0042 NOCOV DEF SYSMAN Description: FOS C CHLD NON-THER PER MON Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: H0043 NOCOV DEF SYSMAN Description: SUPPORTED HOUSING, PER DIEM Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: H0044 NOCOV DEF SYSMAN Description: SUPPORTED HOUSING, PER MONTH Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: H0047 NOCOV DEF SYSMAN Description: ALCOHOL/DRUG ABUSE SVC NOS Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: H0048 NOCOV DEF SYSMAN Description: SPEC COLL NON-BLOOD:A/D TEST Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: H0049 NOCOV DEF SYSMAN Description: ALCOHOL/DRUG SCREENING Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: H0050 NOCOV DEF SYSMAN Description: ALCOHOL/DRUG SERVICE 15 MIN Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,794 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- H1000 NOCOV DEF SYSMAN Description: PRENATAL CARE ATRISK ASSESSM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: H1001 NOCOV DEF SYSMAN Description: ANTEPARTUM MANAGEMENT Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: H1002 NOCOV DEF SYSMAN Description: CARECOORDINATION PRENATAL Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: H1003 NOCOV DEF SYSMAN Description: PRENATAL AT RISK EDUCATION Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: H1004 NOCOV DEF SYSMAN Description: FOLLOW UP HOME VISIT/PRENTAL Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: H1005 NOCOV DEF SYSMAN Description: PRENATALCARE ENHANCED SRV PK Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: H1010 NOCOV DEF SYSMAN Description: NONMED FAMILY PLANNING ED Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: H1011 NOCOV DEF SYSMAN Description: FAMILY ASSESSMENT Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: H2000 MENTL DEF MAXFEE 01/01/2004 12/31/2023 369.70 0.0 Description: COMP MULTIDISIPLN EVALUATION Category: Mental Health CMS Add: 01/01/2003 CMS Term: H2000 MENTL DEF MAXFEE 01/01/2024 527.56 0.0 Description: COMP MULTIDISIPLN EVALUATION Category: Mental Health CMS Add: 01/01/2003 CMS Term: H2001 NOCOV DEF SYSMAN Description: REHABILITATION PROGRAM 1/2 D Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: H2010 NOCOV DEF SYSMAN Description: COMPREHENSIVE MED SVC 15 MIN Category: Non Covered Services CMS Add: 04/01/2003 CMS Term: H2011 MENTL DEF MAXFEE 01/01/2004 33.72 0.0 Description: CRISIS INTERVEN SVC, 15 MIN Category: Mental Health CMS Add: 04/01/2003 CMS Term: H2011 MENTL PRF MAXFEE 01/01/2024 48.12 0.0 Description: CRISIS INTERVEN SVC, 15 MIN Category: Mental Health CMS Add: 04/01/2003 CMS Term: H2011 UA MENTL DEF MAXFEE 07/01/2023 33.72 0.0 Description: CRISIS INTERVEN SVC, 15 MIN Category: Mental Health CMS Add: 04/01/2003 CMS Term: H2012 HA HW U1 MRO DEF MAXFEE 07/01/2010 14.62 0.0 Y Description: BEHAV HLTH DAY TREAT, PER HR Category: MA Rehab Option CMS Add: 04/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,795 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- H2012 HB HW U1 MRO DEF MAXFEE 07/01/2010 14.62 0.0 Y Description: BEHAV HLTH DAY TREAT, PER HR Category: MA Rehab Option CMS Add: 04/01/2003 CMS Term: H2013 TBI DEF SYSMAN Description: PSYCH HLTH FAC SVC, PER DIEM Category: Trauma Brain Injury CMS Add: 04/01/2003 CMS Term: H2014 HA CMHW WHA MAXFEE 07/01/2013 12/06/2023 19.26 0.0 Y 6-19years Description: SKILLS TRAIN AND DEV, 15 MIN Category: Child Mentl Hlth Wai CMS Add: 04/01/2003 CMS Term: H2014 HA CMHW WHA MAXFEE 12/07/2023 19.54 0.0 Y 6-19years Description: SKILLS TRAIN AND DEV, 15 MIN Category: Child Mentl Hlth Wai CMS Add: 04/01/2003 CMS Term: H2014 HR HW MRO DEF MAXFEE 07/01/2010 26.14 0.0 Y Description: SKILLS TRAIN AND DEV, 15 MIN Category: MA Rehab Option CMS Add: 04/01/2003 CMS Term: H2014 HR HW U1 MRO DEF MAXFEE 07/01/2010 4.71 0.0 Y Description: SKILLS TRAIN AND DEV, 15 MIN Category: MA Rehab Option CMS Add: 04/01/2003 CMS Term: H2014 HR U1 UB AMHH WUB MAXFEE 10/01/2013 4.71 0.0 Y 19-999years Description: SKILLS TRAIN AND DEV, 15 MIN Category: Adult MNTL HLTH CMS Add: 04/01/2003 CMS Term: H2014 HR UB AMHH WUB MAXFEE 10/01/2013 26.14 0.0 Y 19-999years Description: SKILLS TRAIN AND DEV, 15 MIN Category: Adult MNTL HLTH CMS Add: 04/01/2003 CMS Term: H2014 HS HW MRO DEF MAXFEE 07/01/2010 26.14 0.0 Y Description: SKILLS TRAIN AND DEV, 15 MIN Category: MA Rehab Option CMS Add: 04/01/2003 CMS Term: H2014 HS HW U1 MRO DEF MAXFEE 07/01/2010 4.71 0.0 Y Description: SKILLS TRAIN AND DEV, 15 MIN Category: MA Rehab Option CMS Add: 04/01/2003 CMS Term: H2014 HS U1 UB AMHH WUB MAXFEE 10/01/2013 4.71 0.0 Y 19-999years Description: SKILLS TRAIN AND DEV, 15 MIN Category: Adult MNTL HLTH CMS Add: 04/01/2003 CMS Term: H2014 HS UB AMHH WUB MAXFEE 10/01/2013 26.14 0.0 Y 19-999years Description: SKILLS TRAIN AND DEV, 15 MIN Category: Adult MNTL HLTH CMS Add: 04/01/2003 CMS Term: H2014 HW MRO DEF MAXFEE 07/01/2010 26.14 0.0 Y Description: SKILLS TRAIN AND DEV, 15 MIN Category: MA Rehab Option CMS Add: 04/01/2003 CMS Term: H2014 HW U1 MRO DEF MAXFEE 07/01/2010 4.71 0.0 Y Description: SKILLS TRAIN AND DEV, 15 MIN Category: MA Rehab Option CMS Add: 04/01/2003 CMS Term: H2014 U1 UB AMHH WUB MAXFEE 10/01/2013 4.71 0.0 Y 19-999years Description: SKILLS TRAIN AND DEV, 15 MIN Category: Adult MNTL HLTH CMS Add: 04/01/2003 CMS Term: H2014 U7 MFPTR W4M MAXFEE 10/01/2012 19.26 0.0 Y Description: SKILLS TRAIN AND DEV, 15 MIN Category: MFP PRTF Waiver CMS Add: 04/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,796 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- H2014 U7 PRTFW WPT MAXFEE 10/01/2012 19.26 0.0 Y Description: SKILLS TRAIN AND DEV, 15 MIN Category: PRTF Trans Waiver CMS Add: 04/01/2003 CMS Term: H2014 UB AMHH WUB MAXFEE 10/01/2013 26.14 0.0 Y 19-999years Description: SKILLS TRAIN AND DEV, 15 MIN Category: Adult MNTL HLTH CMS Add: 04/01/2003 CMS Term: H2015 HA CMHW WHA MAXFEE 07/01/2013 12/06/2023 15.00 0.0 Y 6-18years Description: COMP COMM SUPP SVC, 15 MIN Category: Child Mentl Hlth Wai CMS Add: 04/01/2003 CMS Term: H2015 HA CMHW WHA MAXFEE 12/07/2023 19.54 0.0 Y 6-18years Description: COMP COMM SUPP SVC, 15 MIN Category: Child Mentl Hlth Wai CMS Add: 04/01/2003 CMS Term: H2015 U1 U7 MFPTR W4M MAXFEE 10/01/2012 15.00 0.0 Y Description: COMP COMM SUPP SVC, 15 MIN Category: MFP PRTF Waiver CMS Add: 04/01/2003 CMS Term: H2015 U1 U7 PRTFW WPT MAXFEE 10/01/2012 15.00 0.0 Y Description: COMP COMM SUPP SVC, 15 MIN Category: PRTF Trans Waiver CMS Add: 04/01/2003 CMS Term: H2016 NOCOV DEF SYSMAN Description: COMP COMM SUPP SVC, PER DIEM Category: Non Covered Services CMS Add: 04/01/2003 CMS Term: H2017 HW MRO DEF MAXFEE 04/01/2016 7.92 0.0 Y 0-32 Description: PSYSOC REHAB SVC, PER 15 MIN Category: MA Rehab Option CMS Add: 04/01/2003 CMS Term: H2018 NOCOV DEF SYSMAN Description: PSYSOC REHAB SVC, PER DIEM Category: Non Covered Services CMS Add: 04/01/2003 CMS Term: H2019 HW MRO DEF MAXFEE 07/01/2010 30.62 0.0 Y Description: THER BEHAV SVC, PER 15 MIN Category: MA Rehab Option CMS Add: 04/01/2003 CMS Term: H2019 HW UA MRO DEF MAXFEE 07/01/2010 18.37 0.0 Y Description: THER BEHAV SVC, PER 15 MIN Category: MA Rehab Option CMS Add: 04/01/2003 CMS Term: H2019 U3 U7 MFPTR W4M MAXFEE 10/01/2012 22.50 0.0 Y Description: THER BEHAV SVC, PER 15 MIN Category: MFP PRTF Waiver CMS Add: 04/01/2003 CMS Term: H2019 U3 U7 PRTFW WPT MAXFEE 10/01/2012 22.50 0.0 Y Description: THER BEHAV SVC, PER 15 MIN Category: PRTF Trans Waiver CMS Add: 04/01/2003 CMS Term: H2019 U4 U7 MFPTR W4M MAXFEE 10/01/2012 17.50 0.0 Y Description: THER BEHAV SVC, PER 15 MIN Category: MFP PRTF Waiver CMS Add: 04/01/2003 CMS Term: H2019 U4 U7 PRTFW WPT MAXFEE 10/01/2012 17.50 0.0 Y Description: THER BEHAV SVC, PER 15 MIN Category: PRTF Trans Waiver CMS Add: 04/01/2003 CMS Term: H2020 U1 U5 U7 DDWA WDD MAXFEE 10/01/2009 104.60 0.0 Y Description: THER BEHAV SVC, PER DIEM Category: CIH Waiver CMS Add: 04/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,797 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- H2020 U1 U5 U7 MFPCI W3M MAXFEE 01/01/2014 104.60 0.0 Y Description: THER BEHAV SVC, PER DIEM Category: MFP CIH Waiver CMS Add: 04/01/2003 CMS Term: H2020 U1 U5 U7 MFPTS W5M MAXFEE 04/01/2010 104.60 0.0 Y Description: THER BEHAV SVC, PER DIEM Category: MFP SOF Waiver CMS Add: 04/01/2003 CMS Term: H2020 U1 U5 U7 SSFS WSS MAXFEE 04/01/2010 104.60 0.0 Y Description: THER BEHAV SVC, PER DIEM Category: Family Support Waivr CMS Add: 04/01/2003 CMS Term: H2020 U2 U5 U7 DDWA WDD MAXFEE 07/01/2023 39.53 0.0 Y Description: THER BEHAV SVC, PER DIEM Category: CIH Waiver CMS Add: 04/01/2003 CMS Term: H2020 U2 U5 U7 DDWA WDD MAXFEE 10/01/2009 06/30/2023 25.00 0.0 Y Description: THER BEHAV SVC, PER DIEM Category: CIH Waiver CMS Add: 04/01/2003 CMS Term: H2020 U2 U5 U7 MFPCI W3M MAXFEE 01/01/2014 06/30/2023 25.00 0.0 Y Description: THER BEHAV SVC, PER DIEM Category: MFP CIH Waiver CMS Add: 04/01/2003 CMS Term: H2020 U2 U5 U7 MFPCI W3M MAXFEE 07/01/2023 39.53 0.0 Y Description: THER BEHAV SVC, PER DIEM Category: MFP CIH Waiver CMS Add: 04/01/2003 CMS Term: H2020 U2 U5 U7 MFPTS W5M MAXFEE 07/01/2023 39.53 0.0 Y Description: THER BEHAV SVC, PER DIEM Category: MFP SOF Waiver CMS Add: 04/01/2003 CMS Term: H2020 U2 U5 U7 SSFS WSS MAXFEE 07/01/2023 39.53 0.0 Y Description: THER BEHAV SVC, PER DIEM Category: Family Support Waivr CMS Add: 04/01/2003 CMS Term: H2021 U1 U7 MFPTR W4M MAXFEE 10/01/2012 28.75 0.0 Y Description: COM WRAP-AROUND SV, 15 MIN Category: MFP PRTF Waiver CMS Add: 04/01/2003 CMS Term: H2021 U1 U7 PRTFW WPT MAXFEE 10/01/2012 28.75 0.0 Y Description: COM WRAP-AROUND SV, 15 MIN Category: PRTF Trans Waiver CMS Add: 04/01/2003 CMS Term: H2021 U2 U7 MFPTR W4M MAXFEE 10/01/2012 23.53 0.0 Y Description: COM WRAP-AROUND SV, 15 MIN Category: MFP PRTF Waiver CMS Add: 04/01/2003 CMS Term: H2021 U2 U7 PRTFW WPT MAXFEE 10/01/2012 23.53 0.0 Y Description: COM WRAP-AROUND SV, 15 MIN Category: PRTF Trans Waiver CMS Add: 04/01/2003 CMS Term: H2022 NOCOV DEF SYSMAN Description: COM WRAP-AROUND SV, PER DIEM Category: Non Covered Services CMS Add: 04/01/2003 CMS Term: H2023 U7 MFPTB W2M MAXFEE 06/02/2008 06/30/2023 9.17 0.0 Y Description: SUPPORTED EMPLOY, PER 15 MIN Category: MFP TBI CMS Add: 04/01/2003 CMS Term: H2023 U7 MFPTB W2M MAXFEE 07/01/2023 11.91 0.0 Y Description: SUPPORTED EMPLOY, PER 15 MIN Category: MFP TBI CMS Add: 04/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,798 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- H2023 U7 TBIWA WTB MAXFEE 01/01/2004 06/30/2023 9.17 0.0 Y Description: SUPPORTED EMPLOY, PER 15 MIN Category: TBI Waiver CMS Add: 04/01/2003 CMS Term: H2023 U7 TBIWA WTB MAXFEE 07/01/2023 11.91 0.0 Y Description: SUPPORTED EMPLOY, PER 15 MIN Category: TBI Waiver CMS Add: 04/01/2003 CMS Term: H2024 NOCOV DEF SYSMAN Description: SUPPORTED EMPLOY, PER DIEM Category: Non Covered Services CMS Add: 04/01/2003 CMS Term: H2025 NOCOV DEF SYSMAN Description: SUPP MAINT EMPLOY, 15 MIN Category: Non Covered Services CMS Add: 04/01/2003 CMS Term: H2026 NOCOV DEF SYSMAN Description: SUPP MAINT EMPLOY, PER DIEM Category: Non Covered Services CMS Add: 04/01/2003 CMS Term: H2027 NOCOV DEF SYSMAN Description: PSYCHOED SVC, PER 15 MIN Category: Non Covered Services CMS Add: 04/01/2003 CMS Term: H2028 NOCOV DEF SYSMAN Description: SEX OFFEND TX SVC, 15 MIN Category: Non Covered Services CMS Add: 04/01/2003 CMS Term: H2029 NOCOV DEF SYSMAN Description: SEX OFFEND TX SVC, PER DIEM Category: Non Covered Services CMS Add: 04/01/2003 CMS Term: H2030 NOCOV DEF SYSMAN Description: MH CLUBHOUSE SVC, PER 15 MIN Category: Non Covered Services CMS Add: 04/01/2003 CMS Term: H2031 NOCOV DEF SYSMAN Description: MH CLUBHOUSE SVC, PER DIEM Category: Non Covered Services CMS Add: 04/01/2003 CMS Term: H2032 U1 U5 U7 DDWA WDD MAXFEE 01/01/2008 06/30/2023 10.78 0.0 Y Description: ACTIVITY THERAPY, PER 15 MIN Category: CIH Waiver CMS Add: 04/01/2003 CMS Term: H2032 U1 U5 U7 DDWA WDD MAXFEE 07/01/2023 16.81 0.0 Y Description: ACTIVITY THERAPY, PER 15 MIN Category: CIH Waiver CMS Add: 04/01/2003 CMS Term: H2032 U1 U5 U7 MFPCI W3M MAXFEE 01/01/2014 06/30/2023 10.78 0.0 Y Description: ACTIVITY THERAPY, PER 15 MIN Category: MFP CIH Waiver CMS Add: 04/01/2003 CMS Term: H2032 U1 U5 U7 MFPCI W3M MAXFEE 07/01/2023 16.81 0.0 Y Description: ACTIVITY THERAPY, PER 15 MIN Category: MFP CIH Waiver CMS Add: 04/01/2003 CMS Term: H2032 U1 U5 U7 MFPTS W5M MAXFEE 07/01/2023 16.81 0.0 Y Description: ACTIVITY THERAPY, PER 15 MIN Category: MFP SOF Waiver CMS Add: 04/01/2003 CMS Term: H2032 U1 U5 U7 SSFS WSS MAXFEE 01/01/2008 06/30/2023 10.78 0.0 Y Description: ACTIVITY THERAPY, PER 15 MIN Category: Family Support Waivr CMS Add: 04/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,799 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- H2032 U1 U5 U7 SSFS WSS MAXFEE 07/01/2023 16.81 0.0 Y Description: ACTIVITY THERAPY, PER 15 MIN Category: Family Support Waivr CMS Add: 04/01/2003 CMS Term: H2032 U2 U5 U7 DDWA WDD MAXFEE 01/01/2008 06/30/2023 10.78 0.0 Y Description: ACTIVITY THERAPY, PER 15 MIN Category: CIH Waiver CMS Add: 04/01/2003 CMS Term: H2032 U2 U5 U7 DDWA WDD MAXFEE 07/01/2023 16.81 0.0 Y Description: ACTIVITY THERAPY, PER 15 MIN Category: CIH Waiver CMS Add: 04/01/2003 CMS Term: H2032 U2 U5 U7 MFPCI W3M MAXFEE 01/01/2014 06/30/2023 10.78 0.0 Y Description: ACTIVITY THERAPY, PER 15 MIN Category: MFP CIH Waiver CMS Add: 04/01/2003 CMS Term: H2032 U2 U5 U7 MFPCI W3M MAXFEE 07/01/2023 16.81 0.0 Y Description: ACTIVITY THERAPY, PER 15 MIN Category: MFP CIH Waiver CMS Add: 04/01/2003 CMS Term: H2032 U2 U5 U7 MFPTS W5M MAXFEE 07/01/2023 16.81 0.0 Y Description: ACTIVITY THERAPY, PER 15 MIN Category: MFP SOF Waiver CMS Add: 04/01/2003 CMS Term: H2032 U2 U5 U7 SSFS WSS MAXFEE 01/01/2008 06/30/2023 10.78 0.0 Y Description: ACTIVITY THERAPY, PER 15 MIN Category: Family Support Waivr CMS Add: 04/01/2003 CMS Term: H2032 U2 U5 U7 SSFS WSS MAXFEE 07/01/2023 16.81 0.0 Y Description: ACTIVITY THERAPY, PER 15 MIN Category: Family Support Waivr CMS Add: 04/01/2003 CMS Term: H2033 NOCOV DEF SYSMAN Description: MULTISYS THER/JUVENILE 15MIN Category: Non Covered Services CMS Add: 04/01/2003 CMS Term: H2034 U1 MENTL DEF MAXFEE 01/01/2024 180.46 0.0 Y 19-999;0-18years 0-1 Description: A/D HALFWAY HOUSE, PER DIEM Category: Mental Health CMS Add: 04/01/2003 CMS Term: H2034 U1 MENTL DEF MAXFEE 03/01/2018 12/31/2023 126.46 0.0 Y 19-999;0-18years 0-1 Description: A/D HALFWAY HOUSE, PER DIEM Category: Mental Health CMS Add: 04/01/2003 CMS Term: H2034 U2 MENTL DEF MAXFEE 01/01/2024 186.04 0.0 Y 19-999;0-18years 0-1 Description: A/D HALFWAY HOUSE, PER DIEM Category: Mental Health CMS Add: 04/01/2003 CMS Term: H2034 U2 MENTL DEF MAXFEE 03/01/2018 12/31/2023 130.37 0.0 Y 19-999;0-18years 0-1 Description: A/D HALFWAY HOUSE, PER DIEM Category: Mental Health CMS Add: 04/01/2003 CMS Term: H2035 HR HW MRO DEF MAXFEE 07/01/2010 58.32 0.0 Y Description: A/D TX PROGRAM, PER HOUR Category: MA Rehab Option CMS Add: 04/01/2003 CMS Term: H2035 HR U1 UB AMHH WUB MAXFEE 10/01/2013 14.58 0.0 Y 19-999years Description: A/D TX PROGRAM, PER HOUR Category: Adult MNTL HLTH CMS Add: 04/01/2003 CMS Term: H2035 HR UB AMHH WUB MAXFEE 10/01/2013 58.32 0.0 Y 19-999years Description: A/D TX PROGRAM, PER HOUR Category: Adult MNTL HLTH CMS Add: 04/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,800 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- H2035 HS HW MRO DEF MAXFEE 07/01/2010 58.32 0.0 Y Description: A/D TX PROGRAM, PER HOUR Category: MA Rehab Option CMS Add: 04/01/2003 CMS Term: H2035 HS U1 UB AMHH WUB MAXFEE 10/01/2013 14.58 0.0 Y 19-999years Description: A/D TX PROGRAM, PER HOUR Category: Adult MNTL HLTH CMS Add: 04/01/2003 CMS Term: H2035 HS UB AMHH WUB MAXFEE 10/01/2013 58.32 0.0 Y 19-999years Description: A/D TX PROGRAM, PER HOUR Category: Adult MNTL HLTH CMS Add: 04/01/2003 CMS Term: H2035 HW MRO DEF MAXFEE 07/01/2010 58.32 0.0 Y Description: A/D TX PROGRAM, PER HOUR Category: MA Rehab Option CMS Add: 04/01/2003 CMS Term: H2035 U1 UB AMHH WUB MAXFEE 10/01/2013 14.58 0.0 Y 19-999years Description: A/D TX PROGRAM, PER HOUR Category: Adult MNTL HLTH CMS Add: 04/01/2003 CMS Term: H2035 UB AMHH WUB MAXFEE 10/01/2013 58.32 0.0 Y 19-999years Description: A/D TX PROGRAM, PER HOUR Category: Adult MNTL HLTH CMS Add: 04/01/2003 CMS Term: H2036 NOCOV DEF SYSMAN Description: A/D TX PROGRAM, PER DIEM Category: Non Covered Services CMS Add: 04/01/2003 CMS Term: H2037 NOCOV DEF SYSMAN Description: DEV DELAY PREV DP CH, 15 MIN Category: Non Covered Services CMS Add: 04/01/2003 CMS Term: H2038 NOCOV DEF SYSMAN Description: SKILL TRAIN AND DEV/DIEM Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: H2040 NOCOV DEF SYSMAN Description: COORD SPECIALTY CARE, MONTH Category: Non Covered Services CMS Add: 10/01/2023 CMS Term: H2041 NOCOV DEF SYSMAN Description: COORD SPECIAL CARE ENCOUNTER Category: Non Covered Services CMS Add: 10/01/2023 CMS Term: H5000 NOCOV DEF SYSMAN Description: RESIDENTIAL CARE IN PUBLI Category: Non Covered Services CMS Add: 01/01/1900 CMS Term: 06/30/2015 J0120 DRUG DEF SYSMAN Description: TETRACYCLIN INJECTION Category: Drugs CMS Add: 01/01/1986 CMS Term: J0121 DRUG DEF MAXFEE 04/01/2023 09/30/2023 4.33 0.0 Description: INJ., OMADACYCLINE, 1 MG Category: Drugs CMS Add: 10/01/2019 CMS Term: J0121 DRUG DEF MAXFEE 04/01/2024 4.59 0.0 Description: INJ., OMADACYCLINE, 1 MG Category: Drugs CMS Add: 10/01/2019 CMS Term: J0121 DRUG DEF MAXFEE 10/01/2023 03/31/2024 4.46 0.0 Description: INJ., OMADACYCLINE, 1 MG Category: Drugs CMS Add: 10/01/2019 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,801 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J0122 DRUG DEF MAXFEE 10/01/2019 1.03 0.0 Description: INJ., ERAVACYCLINE, 1 MG Category: Drugs CMS Add: 10/01/2019 CMS Term: J0129 DRUG DEF MAXFEE 04/01/2023 09/30/2023 56.60 0.0 Description: ABATACEPT INJECTION Category: Drugs CMS Add: 01/01/2007 CMS Term: J0129 DRUG DEF MAXFEE 04/01/2024 59.98 0.0 Description: ABATACEPT INJECTION Category: Drugs CMS Add: 01/01/2007 CMS Term: J0129 DRUG DEF MAXFEE 10/01/2023 03/31/2024 57.96 0.0 Description: ABATACEPT INJECTION Category: Drugs CMS Add: 01/01/2007 CMS Term: J0130 DRUG DEF SYSMAN Description: ABCIXIMAB INJECTION Category: Drugs CMS Add: 01/01/1999 CMS Term: J0131 NOCOV DEF SYSMAN Description: INJ, ACETAMINOPHEN (NOS) Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: J0132 DRUG DEF MAXFEE 01/01/2023 0.65 0.0 Description: ACETYLCYSTEINE INJECTION Category: Drugs CMS Add: 01/01/2006 CMS Term: J0133 DRUG DEF MAXFEE 04/01/2014 0.05 0.0 Description: ACYCLOVIR INJECTION Category: Drugs CMS Add: 01/01/2006 CMS Term: J0134 DRUG DEF MAXFEE 04/01/2023 0.13 0.0 Description: INJ ACETAMINOPHEN -FRESENIUS Category: Drugs CMS Add: 01/01/2023 CMS Term: J0135 DRUG DEF MAXFEE 04/01/2023 1817.19 0.0 Description: ADALIMUMAB INJECTION Category: Drugs CMS Add: 01/01/2005 CMS Term: J0136 DRUG DEF MAXFEE 04/01/2023 06/30/2023 0.07 0.0 Description: INJ, ACETAMINOPHEN (B BRAUN) Category: Drugs CMS Add: 01/01/2023 CMS Term: J0136 DRUG DEF MAXFEE 07/01/2023 0.09 0.0 Description: INJ, ACETAMINOPHEN (B BRAUN) Category: Drugs CMS Add: 01/01/2023 CMS Term: J0137 DRUG DEF MAXFEE 07/01/2023 0.13 0.0 Description: INJ, ACETAMINOPHEN (HIKMA) Category: Drugs CMS Add: 07/01/2023 CMS Term: J0153 DRUG DEF MAXFEE 10/01/2022 0.88 0.0 Description: ADENOSINE INJ 1MG Category: Drugs CMS Add: 01/01/2015 CMS Term: J0171 DRUG DEF MAXFEE 04/01/2020 03/31/2024 0.10 0.0 Description: ADRENALIN EPINEPHRINE INJECT Category: Drugs CMS Add: 01/01/2011 CMS Term: J0171 DRUG DEF MAXFEE 04/01/2024 0.79 0.0 Description: ADRENALIN EPINEPHRINE INJECT Category: Drugs CMS Add: 01/01/2011 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,802 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J0172 DRUG DEF MAXFEE 03/08/2022 5.92 0.0 Y 50-85years Description: INJ, ADUCANUMAB-AVWA, 2 MG Category: Drugs CMS Add: 01/01/2022 CMS Term: J0173 NOCOV DEF SYSMAN Description: INJ, EPINEPHRINE (BELCHER) Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: J0174 DRUG DEF MAXFEE 07/06/2023 1.34 0.0 Y 50-90years Description: INJ, LECANEMAB-IRMB, 1 MG Category: Drugs CMS Add: 07/06/2023 CMS Term: J0178 DRUG DEF MAXFEE 01/01/2013 971.25 0.0 Description: AFLIBERCEPT INJECTION Category: Drugs CMS Add: 01/01/2013 CMS Term: J0179 DRUG DEF MAXFEE 04/01/2023 09/30/2023 330.23 0.0 Description: INJ, BROLUCIZUMAB-DBLL, 1 MG Category: Drugs CMS Add: 01/01/2020 CMS Term: J0179 DRUG DEF MAXFEE 04/01/2024 343.57 0.0 Description: INJ, BROLUCIZUMAB-DBLL, 1 MG Category: Drugs CMS Add: 01/01/2020 CMS Term: J0179 DRUG DEF MAXFEE 10/01/2023 03/31/2024 336.83 0.0 Description: INJ, BROLUCIZUMAB-DBLL, 1 MG Category: Drugs CMS Add: 01/01/2020 CMS Term: J0180 DRUG DEF MAXFEE 04/01/2023 03/31/2024 217.09 0.0 Description: AGALSIDASE BETA INJECTION Category: Drugs CMS Add: 01/01/2005 CMS Term: J0180 DRUG DEF MAXFEE 04/01/2024 223.60 0.0 Description: AGALSIDASE BETA INJECTION Category: Drugs CMS Add: 01/01/2005 CMS Term: J0184 DRUG DEF MAXFEE 01/01/2024 9.45 0.0 Description: INJ, AMISULPRIDE, 1 MG Category: Drugs CMS Add: 01/01/2024 CMS Term: J0185 DRUG DEF MAXFEE 01/01/2022 03/31/2024 3.39 0.0 Description: INJ., APREPITANT, 1 MG Category: Drugs CMS Add: 01/01/2019 CMS Term: J0185 DRUG DEF MAXFEE 04/01/2024 3.46 0.0 Description: INJ., APREPITANT, 1 MG Category: Drugs CMS Add: 01/01/2019 CMS Term: J0190 DRUG DEF SYSMAN Description: INJ BIPERIDEN LACTATE/5 MG Category: Drugs CMS Add: 01/01/1982 CMS Term: J0200 DRUG DEF SYSMAN Description: ALATROFLOXACIN MESYLATE Category: Drugs CMS Add: 01/01/2000 CMS Term: J0202 DRUG DEF MAXFEE 04/01/2023 09/30/2023 2428.03 0.0 Description: INJECTION, ALEMTUZUMAB Category: Drugs CMS Add: 01/01/2016 CMS Term: J0202 DRUG DEF MAXFEE 04/01/2024 2519.84 0.0 Description: INJECTION, ALEMTUZUMAB Category: Drugs CMS Add: 01/01/2016 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,803 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J0202 DRUG DEF MAXFEE 10/01/2023 03/31/2024 2488.73 0.0 Description: INJECTION, ALEMTUZUMAB Category: Drugs CMS Add: 01/01/2016 CMS Term: J0205 DRUG DEF SYSMAN Description: ALGLUCERASE INJECTION Category: Drugs CMS Add: 01/01/1993 CMS Term: J0206 DRUG DEF MAXFEE 07/01/2023 6.09 0.0 Description: INJ ALLOPURINOL SODIUM 1 MG Category: Drugs CMS Add: 07/01/2023 CMS Term: J0207 DRUG DEF MAXFEE 10/01/2012 474.53 0.0 Description: AMIFOSTINE Category: Drugs CMS Add: 01/01/1998 CMS Term: J0208 DRUG DEF MAXFEE 04/01/2023 95.90 0.0 Description: INJ, PEDMARK, 100 MG Category: Drugs CMS Add: 04/01/2023 CMS Term: J0210 DRUG DEF MAXFEE 07/01/2011 42.00 0.0 Description: METHYLDOPATE HCL INJECTION Category: Drugs CMS Add: 01/01/1984 CMS Term: J0215 DRUG DEF SYSMAN Description: ALEFACEPT Category: Drugs CMS Add: 01/01/2004 CMS Term: J0216 DRUG DEF MAXFEE 07/01/2023 2.54 0.0 Description: INJ, ALFENTANIL HCL, 500MCG Category: Drugs CMS Add: 07/01/2023 CMS Term: J0217 DRUG DEF MAXFEE 01/01/2024 03/31/2024 420.00 0.0 Description: INJ VELMANASE ALFA-TYCV 1 MG Category: Drugs CMS Add: 01/01/2024 CMS Term: J0217 DRUG DEF MAXFEE 04/01/2024 441.00 0.0 Description: INJ VELMANASE ALFA-TYCV 1 MG Category: Drugs CMS Add: 01/01/2024 CMS Term: J0218 DRUG DEF MAXFEE 04/01/2023 03/31/2024 374.96 0.0 Description: INJ OLIPUDASE ALFA-RPCP 1MG Category: Drugs CMS Add: 04/01/2023 CMS Term: J0218 DRUG DEF MAXFEE 04/01/2024 382.45 0.0 Description: INJ OLIPUDASE ALFA-RPCP 1MG Category: Drugs CMS Add: 04/01/2023 CMS Term: J0219 DRUG DEF MAXFEE 04/01/2023 03/31/2024 75.63 0.0 Description: INJ AVAL ALFA-NQPT 4MG Category: Drugs CMS Add: 04/01/2022 CMS Term: J0219 DRUG DEF MAXFEE 04/01/2024 77.90 0.0 Description: INJ AVAL ALFA-NQPT 4MG Category: Drugs CMS Add: 04/01/2022 CMS Term: J0220 DRUG DEF SYSMAN Description: ALGLUCOSIDASE ALFA INJECTION Category: Drugs CMS Add: 01/01/2008 CMS Term: J0221 DRUG DEF MAXFEE 04/01/2021 09/30/2023 176.53 0.0 Description: LUMIZYME INJECTION Category: Drugs CMS Add: 01/01/2012 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,804 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J0221 DRUG DEF MAXFEE 04/01/2024 202.53 0.0 Description: LUMIZYME INJECTION Category: Drugs CMS Add: 01/01/2012 CMS Term: J0221 DRUG DEF MAXFEE 10/01/2023 03/31/2024 196.63 0.0 Description: LUMIZYME INJECTION Category: Drugs CMS Add: 01/01/2012 CMS Term: J0222 DRUG DEF MAXFEE 07/01/2022 102.74 0.0 Y Description: INJ., PATISIRAN, 0.1 MG Category: Drugs CMS Add: 10/01/2019 CMS Term: J0223 DRUG DEF MAXFEE 04/01/2023 114.93 0.0 Description: INJ GIVOSIRAN 0.5 MG Category: Drugs CMS Add: 07/01/2020 CMS Term: J0224 NOCOV DEF SYSMAN Description: INJ. LUMASIRAN, 0.5 MG Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: J0225 DRUG DEF MAXFEE 04/01/2023 5012.74 0.0 Description: INJ, VUTRISIRAN, 1 MG Category: Drugs CMS Add: 01/01/2023 CMS Term: J0248 DRUG DEF MAXFEE 12/23/2021 5.46 0.0 Description: INJ, REMDESIVIR, 1 MG Category: Drugs CMS Add: 12/23/2021 CMS Term: J0256 DRUG DEF MAXFEE 01/01/2021 5.46 0.0 Description: ALPHA 1 PROTEINASE INHIBITOR Category: Drugs CMS Add: 01/01/1989 CMS Term: J0257 DRUG DEF MAXFEE 04/01/2023 03/31/2024 6.51 0.0 Description: GLASSIA INJECTION Category: Drugs CMS Add: 01/01/2012 CMS Term: J0257 DRUG DEF MAXFEE 04/01/2024 6.72 0.0 Description: GLASSIA INJECTION Category: Drugs CMS Add: 01/01/2012 CMS Term: J0270 DRUG DEF MAXFEE 01/01/2018 0.14 0.0 Description: ALPROSTADIL FOR INJECTION Category: Drugs CMS Add: 01/01/1997 CMS Term: J0275 DRUG DEF MAXFEE 04/01/2022 59.66 0.0 Description: ALPROSTADIL URETHRAL SUPPOS Category: Drugs CMS Add: 01/01/1999 CMS Term: J0278 DRUG DEF MAXFEE 04/01/2012 0.77 0.0 Description: AMIKACIN SULFATE INJECTION Category: Drugs CMS Add: 01/01/2006 CMS Term: J0280 DRUG DEF MAXFEE 04/01/2023 09/30/2023 4.74 0.0 Description: AMINOPHYLLIN 250 MG INJ Category: Drugs CMS Add: 01/01/1984 CMS Term: J0280 DRUG DEF MAXFEE 04/01/2024 5.32 0.0 Description: AMINOPHYLLIN 250 MG INJ Category: Drugs CMS Add: 01/01/1984 CMS Term: J0280 DRUG DEF MAXFEE 10/01/2023 03/31/2024 4.83 0.0 Description: AMINOPHYLLIN 250 MG INJ Category: Drugs CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,805 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J0282 DRUG DEF MAXFEE 04/01/2023 0.32 0.0 Description: AMIODARONE HCL Category: Drugs CMS Add: 01/01/2001 CMS Term: J0283 DRUG DEF MAXFEE 01/01/2023 4.04 0.0 Description: INJ, AMIODARONE (NEXTERONE) Category: Drugs CMS Add: 01/01/2023 CMS Term: J0285 DRUG DEF MAXFEE 01/01/2021 03/31/2024 45.89 0.0 Description: AMPHOTERICIN B Category: Drugs CMS Add: 01/01/1999 CMS Term: J0285 DRUG DEF MAXFEE 04/01/2024 50.40 0.0 Description: AMPHOTERICIN B Category: Drugs CMS Add: 01/01/1999 CMS Term: J0287 DRUG DEF MAXFEE 04/01/2022 11.03 0.0 Description: AMPHOTERICIN B LIPID COMPLEX Category: Drugs CMS Add: 01/01/2003 CMS Term: J0288 DRUG DEF SYSMAN Description: AMPHO B CHOLESTERYL SULFATE Category: Drugs CMS Add: 01/01/2003 CMS Term: J0289 DRUG DEF MAXFEE 04/01/2022 53.50 0.0 Description: AMPHOTERICIN B LIPOSOME INJ Category: Drugs CMS Add: 01/01/2003 CMS Term: J0290 DRUG DEF MAXFEE 04/01/2021 0.61 0.0 Description: AMPICILLIN 500 MG INJ Category: Drugs CMS Add: 01/01/1984 CMS Term: J0291 DRUG DEF MAXFEE 01/01/2024 3.63 0.0 Description: INJ., PLAZOMICIN, 5 MG Category: Drugs CMS Add: 10/01/2019 CMS Term: J0291 DRUG DEF MAXFEE 07/01/2023 12/31/2023 3.65 0.0 Description: INJ., PLAZOMICIN, 5 MG Category: Drugs CMS Add: 10/01/2019 CMS Term: J0291 DRUG DEF MAXFEE 10/01/2019 06/30/2023 3.31 0.0 Description: INJ., PLAZOMICIN, 5 MG Category: Drugs CMS Add: 10/01/2019 CMS Term: J0295 DRUG DEF MAXFEE 07/01/2022 1.68 0.0 Description: AMPICILLIN SULBACTAM 1.5 GM Category: Drugs CMS Add: 01/01/1995 CMS Term: J0300 DRUG DEF MAXFEE 04/01/2014 192.43 0.0 Description: AMOBARBITAL 125 MG INJ Category: Drugs CMS Add: 01/01/1982 CMS Term: J0330 DRUG DEF MAXFEE 07/01/2022 09/30/2023 0.53 0.0 Description: SUCCINYCHOLINE CHLORIDE INJ Category: Drugs CMS Add: 01/01/1986 CMS Term: J0330 DRUG DEF MAXFEE 10/01/2023 0.34 0.0 Description: SUCCINYCHOLINE CHLORIDE INJ Category: Drugs CMS Add: 01/01/1986 CMS Term: J0348 DRUG DEF MAXFEE 04/01/2022 2.00 0.0 Description: ANIDULAFUNGIN INJECTION Category: Drugs CMS Add: 01/01/2007 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,806 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J0349 DRUG DEF MAXFEE 10/01/2023 10.24 0.0 Description: INJ, REZAFUNGIN, 1 MG Category: Drugs CMS Add: 10/01/2023 CMS Term: J0350 DRUG DEF SYSMAN Description: INJECTION ANISTREPLASE 30 U Category: Drugs CMS Add: 01/01/1986 CMS Term: J0360 DRUG DEF MAXFEE 07/01/2019 3.68 0.0 Description: HYDRALAZINE HCL INJECTION Category: Drugs CMS Add: 01/01/1986 CMS Term: J0364 DRUG DEF MAXFEE 07/01/2022 36.45 0.0 Description: APOMORPHINE HYDROCHLORIDE Category: Drugs CMS Add: 01/01/2007 CMS Term: J0365 DRUG DEF SYSMAN Description: APROTONIN, 10,000 KIU Category: Drugs CMS Add: 01/01/2006 CMS Term: J0380 DRUG DEF SYSMAN Description: INJ METARAMINOL BITARTRATE Category: Drugs CMS Add: 01/01/1982 CMS Term: J0390 DRUG DEF SYSMAN Description: CHLOROQUINE INJECTION Category: Drugs CMS Add: 01/01/1986 CMS Term: J0391 NOCOV DEF SYSMAN Description: INJ, ARTESUNATE, 1MG Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: J0395 DRUG DEF SYSMAN Description: ARBUTAMINE HCL INJECTION Category: Drugs CMS Add: 01/01/1999 CMS Term: J0400 DRUG DEF SYSMAN Description: ARIPIPRAZOLE INJECTION Category: Drugs CMS Add: 01/01/2008 CMS Term: J0401 DRUG DEF MAXFEE 04/01/2023 03/31/2024 7.14 0.0 Description: INJ ARIPIPRAZOLE EXT REL 1MG Category: Drugs CMS Add: 01/01/2014 CMS Term: J0401 DRUG DEF MAXFEE 04/01/2024 7.40 0.0 Description: INJ ARIPIPRAZOLE EXT REL 1MG Category: Drugs CMS Add: 01/01/2014 CMS Term: J0402 DRUG DEF MAXFEE 01/01/2024 03/31/2024 5.95 0.0 Description: INJ, ABILIFY ASIMTUFII, 1 MG Category: Drugs CMS Add: 01/01/2024 CMS Term: J0402 DRUG DEF MAXFEE 04/01/2024 6.17 0.0 Description: INJ, ABILIFY ASIMTUFII, 1 MG Category: Drugs CMS Add: 01/01/2024 CMS Term: J0456 DRUG DEF MAXFEE 07/01/2021 3.65 0.0 Description: AZITHROMYCIN Category: Drugs CMS Add: 01/01/2000 CMS Term: J0457 DRUG DEF MAXFEE 07/01/2023 2.87 0.0 Description: INJECTION, AZTREONAM, 100 MG Category: Drugs CMS Add: 07/01/2023 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,807 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J0461 DRUG DEF MAXFEE 07/01/2021 0.05 0.0 Description: ATROPINE SULFATE INJECTION Category: Drugs CMS Add: 01/01/2010 CMS Term: J0470 DRUG DEF MAXFEE 07/01/2018 59.24 0.0 Description: DIMECAPROL INJECTION Category: Drugs CMS Add: 01/01/1982 CMS Term: J0475 DRUG DEF SYSMAN Description: BACLOFEN 10 MG INJECTION Category: Drugs CMS Add: 01/01/1994 CMS Term: J0476 DRUG DEF MAXFEE 07/01/2018 34.62 0.0 Description: BACLOFEN INTRATHECAL TRIAL Category: Drugs CMS Add: 01/01/1999 CMS Term: J0480 DRUG DEF MAXFEE 04/01/2023 09/30/2023 4422.57 0.0 Description: BASILIXIMAB Category: Drugs CMS Add: 01/01/2006 CMS Term: J0480 DRUG DEF MAXFEE 04/01/2024 4601.24 0.0 Description: BASILIXIMAB Category: Drugs CMS Add: 01/01/2006 CMS Term: J0480 DRUG DEF MAXFEE 10/01/2023 03/31/2024 4511.02 0.0 Description: BASILIXIMAB Category: Drugs CMS Add: 01/01/2006 CMS Term: J0485 DRUG DEF MAXFEE 04/01/2017 09/30/2023 3.97 0.0 Description: BELATACEPT INJECTION Category: Drugs CMS Add: 01/01/2013 CMS Term: J0485 DRUG DEF MAXFEE 10/01/2023 4.07 0.0 Description: BELATACEPT INJECTION Category: Drugs CMS Add: 01/01/2013 CMS Term: J0490 DRUG DEF MAXFEE 01/01/2024 53.64 0.0 Description: BELIMUMAB INJECTION Category: Drugs CMS Add: 01/01/2012 CMS Term: J0490 DRUG DEF MAXFEE 04/01/2023 12/31/2023 51.58 0.0 Description: BELIMUMAB INJECTION Category: Drugs CMS Add: 01/01/2012 CMS Term: J0491 DRUG DEF MAXFEE 04/01/2023 09/30/2023 16.83 0.0 Description: INJ ANIFROLUMAB-FNIA 1MG Category: Drugs CMS Add: 04/01/2022 CMS Term: J0491 DRUG DEF MAXFEE 04/01/2024 17.77 0.0 Description: INJ ANIFROLUMAB-FNIA 1MG Category: Drugs CMS Add: 04/01/2022 CMS Term: J0491 DRUG DEF MAXFEE 10/01/2023 03/31/2024 17.51 0.0 Description: INJ ANIFROLUMAB-FNIA 1MG Category: Drugs CMS Add: 04/01/2022 CMS Term: J0500 DRUG DEF MAXFEE 01/01/2022 25.83 0.0 Description: DICYCLOMINE INJECTION Category: Drugs CMS Add: 01/01/1986 CMS Term: J0515 DRUG DEF MAXFEE 07/01/2022 23.63 0.0 Description: INJ BENZTROPINE MESYLATE Category: Drugs CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,808 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J0517 DRUG DEF MAXFEE 04/01/2023 03/31/2024 192.90 0.0 Description: INJ., BENRALIZUMAB, 1 MG Category: Drugs CMS Add: 01/01/2019 CMS Term: J0517 DRUG DEF MAXFEE 04/01/2024 198.69 0.0 Description: INJ., BENRALIZUMAB, 1 MG Category: Drugs CMS Add: 01/01/2019 CMS Term: J0520 DRUG DEF SYSMAN Description: BETHANECHOL CHLORIDE INJECT Category: Drugs CMS Add: 01/01/1984 CMS Term: J0558 DRUG DEF MAXFEE 01/01/2016 2.84 0.0 Description: PENG BENZATHINE/PROCAINE INJ Category: Drugs CMS Add: 01/01/2011 CMS Term: J0561 DRUG DEF MAXFEE 04/01/2023 09/30/2023 20.05 0.0 Description: PENICILLIN G BENZATHINE INJ Category: Drugs CMS Add: 01/01/2011 CMS Term: J0561 DRUG DEF MAXFEE 04/01/2024 24.26 0.0 Description: PENICILLIN G BENZATHINE INJ Category: Drugs CMS Add: 01/01/2011 CMS Term: J0561 DRUG DEF MAXFEE 10/01/2023 03/31/2024 22.05 0.0 Description: PENICILLIN G BENZATHINE INJ Category: Drugs CMS Add: 01/01/2011 CMS Term: J0565 DRUG DEF MAXFEE 01/01/2018 39.90 0.0 Description: INJ, BEZLOTOXUMAB, 10 MG Category: Drugs CMS Add: 01/01/2018 CMS Term: J0567 DRUG DEF MAXFEE 04/01/2023 03/31/2024 108.88 0.0 Description: INJ., CERLIPONASE ALFA 1 MG Category: Drugs CMS Add: 01/01/2019 CMS Term: J0567 DRUG DEF MAXFEE 04/01/2024 111.93 0.0 Description: INJ., CERLIPONASE ALFA 1 MG Category: Drugs CMS Add: 01/01/2019 CMS Term: J0570 DRUG DEF SYSMAN Description: BUPRENORPHINE IMPLANT 74.2MG Category: Drugs CMS Add: 01/01/2017 CMS Term: J0571 DRUG DEF MAXFEE 07/01/2021 0.08 0.0 0-1 Description: BUPRENORPHINE ORAL 1MG Category: Drugs CMS Add: 01/01/2015 CMS Term: J0572 DRUG DEF MAXFEE 04/01/2022 0.68 0.0 0-1 Description: BUPREN/NAL UP TO 3MG BUPRENO Category: Drugs CMS Add: 01/01/2015 CMS Term: J0573 DRUG DEF MAXFEE 07/01/2022 4.19 0.0 0-1 Description: BUPREN/NAL 3.1 TO 6MG BUPREN Category: Drugs CMS Add: 01/01/2015 CMS Term: J0574 DRUG DEF MAXFEE 04/01/2022 0.98 0.0 0-1 Description: BUPREN/NAL 6.1 TO 10MG BUPRE Category: Drugs CMS Add: 01/01/2015 CMS Term: J0575 DRUG DEF MAXFEE 01/01/2024 6.46 0.0 0-1 Description: BUPREN/NAL OVER 10MG BUPRENO Category: Drugs CMS Add: 01/01/2015 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,809 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J0575 DRUG DEF MAXFEE 07/01/2022 12/31/2023 8.37 0.0 0-1 Description: BUPREN/NAL OVER 10MG BUPRENO Category: Drugs CMS Add: 01/01/2015 CMS Term: J0576 DRUG DEF MAXFEE 01/01/2024 03/31/2024 13.08 0.0 Y Description: INJ BUPRENORPH (BRIXADI) 1MG Category: Drugs CMS Add: 01/01/2024 CMS Term: 03/31/2024 J0576 DRUG DEF MAXFEE 04/01/2024 14.01 0.0 Y Description: INJ BUPRENORPH (BRIXADI) 1MG Category: Drugs CMS Add: 01/01/2024 CMS Term: 03/31/2024 J0583 DRUG DEF MAXFEE 01/01/2024 0.25 0.0 Description: BIVALIRUDIN Category: Drugs CMS Add: 01/01/2004 CMS Term: J0583 DRUG DEF MAXFEE 10/01/2022 12/31/2023 0.30 0.0 Description: BIVALIRUDIN Category: Drugs CMS Add: 01/01/2004 CMS Term: J0584 DRUG DEF MAXFEE 04/01/2023 09/30/2023 432.18 0.0 Description: INJECTION, BUROSUMAB-TWZA 1M Category: Drugs CMS Add: 01/01/2019 CMS Term: J0584 DRUG DEF MAXFEE 04/01/2024 467.40 0.0 Description: INJECTION, BUROSUMAB-TWZA 1M Category: Drugs CMS Add: 01/01/2019 CMS Term: J0584 DRUG DEF MAXFEE 10/01/2023 03/31/2024 445.15 0.0 Description: INJECTION, BUROSUMAB-TWZA 1M Category: Drugs CMS Add: 01/01/2019 CMS Term: J0585 DRUG DEF MAXFEE 10/01/2022 6.66 0.0 Description: INJECTION,ONABOTULINUMTOXINA Category: Drugs CMS Add: 01/01/1991 CMS Term: J0586 DRUG DEF MAXFEE 01/01/2021 9.02 0.0 Description: ABOBOTULINUMTOXINA Category: Drugs CMS Add: 01/01/2010 CMS Term: J0587 DRUG DEF MAXFEE 01/01/2023 06/30/2023 12.76 0.0 Description: INJ, RIMABOTULINUMTOXINB Category: Drugs CMS Add: 01/01/2002 CMS Term: J0587 DRUG DEF MAXFEE 07/01/2023 13.08 0.0 Description: INJ, RIMABOTULINUMTOXINB Category: Drugs CMS Add: 01/01/2002 CMS Term: J0588 DRUG DEF MAXFEE 10/01/2022 5.21 0.0 Description: INCOBOTULINUMTOXIN A Category: Drugs CMS Add: 01/01/2012 CMS Term: J0591 NOCOV DEF SYSMAN Description: INJ DEOXYCHOLIC ACID, 1 MG Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: J0592 DRUG DEF MAXFEE 04/01/2022 4.31 0.0 Description: BUPRENORPHINE HYDROCHLORIDE Category: Drugs CMS Add: 01/01/2003 CMS Term: J0593 DRUG DEF MAXFEE 04/01/2023 03/31/2024 86.94 0.0 Description: INJ., LANADELUMAB-FLYO, 1 MG Category: Drugs CMS Add: 10/01/2019 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,810 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J0593 DRUG DEF MAXFEE 04/01/2024 89.55 0.0 Description: INJ., LANADELUMAB-FLYO, 1 MG Category: Drugs CMS Add: 10/01/2019 CMS Term: J0594 DRUG DEF MAXFEE 10/01/2020 1.70 0.0 Description: BUSULFAN INJECTION Category: Drugs CMS Add: 01/01/2007 CMS Term: J0595 DRUG DEF MAXFEE 04/01/2023 09/30/2023 2.52 0.0 Description: BUTORPHANOL TARTRATE 1 MG Category: Drugs CMS Add: 01/01/2004 CMS Term: J0595 DRUG DEF MAXFEE 04/01/2024 3.05 0.0 Description: BUTORPHANOL TARTRATE 1 MG Category: Drugs CMS Add: 01/01/2004 CMS Term: J0595 DRUG DEF MAXFEE 10/01/2023 03/31/2024 2.77 0.0 Description: BUTORPHANOL TARTRATE 1 MG Category: Drugs CMS Add: 01/01/2004 CMS Term: J0596 DRUG DEF MAXFEE 04/01/2023 03/31/2024 36.35 0.0 Description: INJECTION, RUCONEST Category: Drugs CMS Add: 01/01/2016 CMS Term: J0596 DRUG DEF MAXFEE 04/01/2024 38.13 0.0 Description: INJECTION, RUCONEST Category: Drugs CMS Add: 01/01/2016 CMS Term: J0597 DRUG DEF MAXFEE 04/01/2023 03/31/2024 76.03 0.0 Description: C-1 ESTERASE, BERINERT Category: Drugs CMS Add: 01/01/2011 CMS Term: J0597 DRUG DEF MAXFEE 04/01/2024 80.60 0.0 Description: C-1 ESTERASE, BERINERT Category: Drugs CMS Add: 01/01/2011 CMS Term: J0598 DRUG DEF MAXFEE 04/01/2024 65.21 0.0 Description: C-1 ESTERASE, CINRYZE Category: Drugs CMS Add: 01/01/2010 CMS Term: J0598 DRUG DEF MAXFEE 07/01/2022 09/30/2023 61.46 0.0 Description: C-1 ESTERASE, CINRYZE Category: Drugs CMS Add: 01/01/2010 CMS Term: J0598 DRUG DEF MAXFEE 10/01/2023 03/31/2024 63.31 0.0 Description: C-1 ESTERASE, CINRYZE Category: Drugs CMS Add: 01/01/2010 CMS Term: J0599 DRUG DEF MAXFEE 04/01/2023 03/31/2024 11.11 0.0 Description: INJ., HAEGARDA 10 UNITS Category: Drugs CMS Add: 01/01/2019 CMS Term: J0599 DRUG DEF MAXFEE 04/01/2024 11.55 0.0 Description: INJ., HAEGARDA 10 UNITS Category: Drugs CMS Add: 01/01/2019 CMS Term: J0600 DRUG DEF MAXFEE 01/01/2015 5654.74 0.0 Description: EDETATE CALCIUM DISODIUM INJ Category: Drugs CMS Add: 01/01/1982 CMS Term: J0604 NOCOV DEF SYSMAN Description: CINACALCET, ESRD ON DIALYSIS Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,811 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J0606 DRUG DEF MAXFEE 04/01/2023 03/31/2024 3.93 0.0 Description: INJ, ETELCALCETIDE, 0.1 MG Category: Drugs CMS Add: 01/01/2018 CMS Term: J0606 DRUG DEF MAXFEE 04/01/2024 4.13 0.0 Description: INJ, ETELCALCETIDE, 0.1 MG Category: Drugs CMS Add: 01/01/2018 CMS Term: J0612 DRUG DEF MAXFEE 04/01/2023 06/30/2023 0.01 0.0 Description: INJ, CALCIUM GLUCONATE, NOS Category: Drugs CMS Add: 04/01/2023 CMS Term: J0612 DRUG DEF MAXFEE 07/01/2023 0.06 0.0 Description: INJ, CALCIUM GLUCONATE, NOS Category: Drugs CMS Add: 04/01/2023 CMS Term: J0613 DRUG DEF MAXFEE 04/01/2023 0.13 0.0 Description: CALCIUM GLUCON (WG CRITICAL) Category: Drugs CMS Add: 04/01/2023 CMS Term: J0620 DRUG DEF SYSMAN Description: CALCIUM GLYCER & LACT/10 ML Category: Drugs CMS Add: 01/01/1982 CMS Term: J0630 DRUG DEF MAXFEE 07/01/2021 3287.55 0.0 Description: CALCITONIN SALMON INJECTION Category: Drugs CMS Add: 01/01/1982 CMS Term: J0636 DRUG DEF MAXFEE 07/01/2018 0.63 0.0 Description: INJ CALCITRIOL PER 0.1 MCG Category: Drugs CMS Add: 01/01/2003 CMS Term: J0637 DRUG DEF MAXFEE 01/01/2024 5.93 0.0 Description: CASPOFUNGIN ACETATE Category: Drugs CMS Add: 01/01/2003 CMS Term: J0637 DRUG DEF MAXFEE 10/01/2018 12/31/2023 7.43 0.0 Description: CASPOFUNGIN ACETATE Category: Drugs CMS Add: 01/01/2003 CMS Term: J0638 DRUG DEF MAXFEE 04/01/2023 09/30/2023 122.26 0.0 Description: CANAKINUMAB INJECTION Category: Drugs CMS Add: 01/01/2011 CMS Term: J0638 DRUG DEF MAXFEE 04/01/2024 127.20 0.0 Description: CANAKINUMAB INJECTION Category: Drugs CMS Add: 01/01/2011 CMS Term: J0638 DRUG DEF MAXFEE 10/01/2023 03/31/2024 124.71 0.0 Description: CANAKINUMAB INJECTION Category: Drugs CMS Add: 01/01/2011 CMS Term: J0640 DRUG DEF MAXFEE 10/01/2014 2.64 0.0 Description: LEUCOVORIN CALCIUM INJECTION Category: Drugs CMS Add: 01/01/1982 CMS Term: J0641 DRUG DEF MAXFEE 01/01/2021 0.33 0.0 Description: INJ LEVOLEUCOVORIN NOS 0.5MG Category: Drugs CMS Add: 01/01/2009 CMS Term: J0642 DRUG DEF MAXFEE 01/01/2024 03/31/2024 2.20 0.0 Description: INJECTION, KHAPZORY, 0.5 MG Category: Drugs CMS Add: 10/01/2019 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,812 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J0642 DRUG DEF MAXFEE 04/01/2020 09/30/2023 2.12 0.0 Description: INJECTION, KHAPZORY, 0.5 MG Category: Drugs CMS Add: 10/01/2019 CMS Term: J0642 DRUG DEF MAXFEE 04/01/2024 2.33 0.0 Description: INJECTION, KHAPZORY, 0.5 MG Category: Drugs CMS Add: 10/01/2019 CMS Term: J0642 DRUG DEF MAXFEE 10/01/2023 12/31/2023 2.16 0.0 Description: INJECTION, KHAPZORY, 0.5 MG Category: Drugs CMS Add: 10/01/2019 CMS Term: J0665 DRUG DEF MAXFEE 07/01/2023 0.01 0.0 Description: INJ, BUPIVACAINE, NOS, 0.5MG Category: Drugs CMS Add: 07/01/2023 CMS Term: J0670 DRUG DEF MAXFEE 04/01/2022 1.47 0.0 Description: INJ MEPIVACAINE HCL/10 ML Category: Drugs CMS Add: 01/01/1986 CMS Term: J0688 DRUG DEF MAXFEE 01/01/2024 1.54 0.0 Description: INJ CEFAZOLIN SODIUM, HIKMA Category: Drugs CMS Add: 01/01/2024 CMS Term: J0689 DRUG DEF MAXFEE 01/01/2023 2.43 0.0 Description: INJ CEFAZOLIN SODIUM, BAXTER Category: Drugs CMS Add: 01/01/2023 CMS Term: J0690 DRUG DEF MAXFEE 01/01/2023 0.27 0.0 Description: CEFAZOLIN SODIUM INJECTION Category: Drugs CMS Add: 01/01/1982 CMS Term: J0691 DRUG DEF MAXFEE 07/01/2020 0.72 0.0 Description: INJ LEFAMULIN 1 MG Category: Drugs CMS Add: 07/01/2020 CMS Term: J0692 DRUG DEF MAXFEE 07/01/2022 1.26 0.0 Description: CEFEPIME HCL FOR INJECTION Category: Drugs CMS Add: 01/01/2002 CMS Term: J0694 DRUG DEF MAXFEE 04/01/2018 03/31/2024 3.15 0.0 Description: CEFOXITIN SODIUM INJECTION Category: Drugs CMS Add: 01/01/1992 CMS Term: J0694 DRUG DEF MAXFEE 04/01/2024 3.37 0.0 Description: CEFOXITIN SODIUM INJECTION Category: Drugs CMS Add: 01/01/1992 CMS Term: J0695 DRUG DEF MAXFEE 04/01/2023 03/31/2024 7.58 0.0 Description: INJ CEFTOLOZANE TAZOBACTAM Category: Drugs CMS Add: 01/01/2016 CMS Term: J0695 DRUG DEF MAXFEE 04/01/2024 8.33 0.0 Description: INJ CEFTOLOZANE TAZOBACTAM Category: Drugs CMS Add: 01/01/2016 CMS Term: J0696 DRUG DEF MAXFEE 04/01/2022 06/30/2023 0.29 0.0 Description: CEFTRIAXONE SODIUM INJECTION Category: Drugs CMS Add: 01/01/1990 CMS Term: J0696 DRUG DEF MAXFEE 07/01/2023 0.25 0.0 Description: CEFTRIAXONE SODIUM INJECTION Category: Drugs CMS Add: 01/01/1990 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,813 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J0697 DRUG DEF MAXFEE 01/01/2011 2.31 0.0 Description: STERILE CEFUROXIME INJECTION Category: Drugs CMS Add: 01/01/1990 CMS Term: J0698 DRUG DEF MAXFEE 04/01/2020 5.28 0.0 Description: CEFOTAXIME SODIUM INJECTION Category: Drugs CMS Add: 01/01/1991 CMS Term: J0699 DRUG DEF MAXFEE 04/01/2023 03/31/2024 2.20 0.0 Description: INJ, CEFIDEROCOL, 10 MG Category: Drugs CMS Add: 10/01/2021 CMS Term: J0699 DRUG DEF MAXFEE 04/01/2024 2.31 0.0 Description: INJ, CEFIDEROCOL, 10 MG Category: Drugs CMS Add: 10/01/2021 CMS Term: J0701 DRUG DEF MAXFEE 01/01/2023 11.18 0.0 Description: INJ. CEFEPIME HCL (BAXTER) Category: Drugs CMS Add: 01/01/2023 CMS Term: J0702 DRUG DEF MAXFEE 04/01/2023 8.40 0.0 Description: BETAMETHASONE ACET&SOD PHOSP Category: Drugs CMS Add: 01/01/1995 CMS Term: J0703 DRUG DEF MAXFEE 04/01/2023 06/30/2023 7.46 0.0 Description: INJ, CEFEPIME HCL (B BRAUN) Category: Drugs CMS Add: 01/01/2023 CMS Term: J0703 DRUG DEF MAXFEE 07/01/2023 7.84 0.0 Description: INJ, CEFEPIME HCL (B BRAUN) Category: Drugs CMS Add: 01/01/2023 CMS Term: J0706 DRUG DEF MAXFEE 01/01/2015 0.71 0.0 Description: CAFFEINE CITRATE INJECTION Category: Drugs CMS Add: 01/01/2002 CMS Term: J0710 DRUG DEF SYSMAN Description: CEPHAPIRIN SODIUM INJECTION Category: Drugs CMS Add: 01/01/1982 CMS Term: J0712 DRUG DEF MAXFEE 04/01/2023 4.09 0.0 Description: CEFTAROLINE FOSAMIL INJ Category: Drugs CMS Add: 01/01/2012 CMS Term: J0713 DRUG DEF MAXFEE 01/01/2021 1.58 0.0 Description: INJ CEFTAZIDIME PER 500 MG Category: Drugs CMS Add: 01/01/1996 CMS Term: J0714 DRUG DEF MAXFEE 04/01/2023 98.90 0.0 Description: CEFTAZIDIME AND AVIBACTAM Category: Drugs CMS Add: 01/01/2016 CMS Term: J0715 DRUG DEF SYSMAN Description: CEFTIZOXIME SODIUM / 500 MG Category: Drugs CMS Add: 01/01/1995 CMS Term: J0716 DRUG DEF SYSMAN Description: CENTRUROIDES IMMUNE F(AB) Category: Drugs CMS Add: 01/01/2013 CMS Term: J0717 DRUG DEF MAXFEE 04/01/2023 03/31/2024 14.18 0.0 Description: CERTOLIZUMAB PEGOL INJ 1MG Category: Drugs CMS Add: 01/01/2014 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,814 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J0717 DRUG DEF MAXFEE 04/01/2024 15.01 0.0 Description: CERTOLIZUMAB PEGOL INJ 1MG Category: Drugs CMS Add: 01/01/2014 CMS Term: J0720 DRUG DEF MAXFEE 04/01/2023 51.08 0.0 Description: CHLORAMPHENICOL SODIUM INJEC Category: Drugs CMS Add: 01/01/1982 CMS Term: J0725 DRUG DEF MAXFEE 04/01/2023 12.21 0.0 Description: CHORIONIC GONADOTROPIN/1000U Category: Drugs CMS Add: 01/01/1986 CMS Term: J0735 DRUG DEF MAXFEE 10/01/2011 21.00 0.0 Description: CLONIDINE HYDROCHLORIDE Category: Drugs CMS Add: 01/01/1998 CMS Term: J0736 DRUG DEF MAXFEE 07/01/2023 0.80 0.0 Description: INJ, CLINDAMYCIN PHOSP 300MG Category: Drugs CMS Add: 07/01/2023 CMS Term: J0737 DRUG DEF MAXFEE 07/01/2023 4.57 0.0 Description: INJ, CLINDAMYCIN (BAXTER) Category: Drugs CMS Add: 07/01/2023 CMS Term: J0739 DRUG DEF MAXFEE 04/01/2023 09/30/2023 6.57 0.0 Description: HIV PREP, INJ, CABOTEGRAVIR Category: Drugs CMS Add: 07/01/2022 CMS Term: J0739 DRUG DEF MAXFEE 04/01/2024 6.77 0.0 Description: HIV PREP, INJ, CABOTEGRAVIR Category: Drugs CMS Add: 07/01/2022 CMS Term: J0739 DRUG DEF MAXFEE 10/01/2023 03/31/2024 6.67 0.0 Description: HIV PREP, INJ, CABOTEGRAVIR Category: Drugs CMS Add: 07/01/2022 CMS Term: J0740 DRUG DEF MAXFEE 07/01/2014 777.00 0.0 Description: CIDOFOVIR INJECTION Category: Drugs CMS Add: 01/01/1998 CMS Term: J0741 DRUG DEF MAXFEE 04/01/2023 09/30/2023 22.17 0.0 Description: INJ, CABOTE RILPIVIR 2MG 3MG Category: Drugs CMS Add: 10/01/2021 CMS Term: J0741 DRUG DEF MAXFEE 04/01/2024 22.84 0.0 Description: INJ, CABOTE RILPIVIR 2MG 3MG Category: Drugs CMS Add: 10/01/2021 CMS Term: J0741 DRUG DEF MAXFEE 10/01/2023 03/31/2024 22.50 0.0 Description: INJ, CABOTE RILPIVIR 2MG 3MG Category: Drugs CMS Add: 10/01/2021 CMS Term: J0742 DRUG DEF MAXFEE 04/01/2023 03/31/2024 2.50 0.0 Description: INJ IMIP 4 CILAS 4 RELEB 2MG Category: Drugs CMS Add: 07/01/2020 CMS Term: J0742 DRUG DEF MAXFEE 04/01/2024 2.58 0.0 Description: INJ IMIP 4 CILAS 4 RELEB 2MG Category: Drugs CMS Add: 07/01/2020 CMS Term: J0743 DRUG DEF MAXFEE 07/01/2023 6.56 0.0 Description: CILASTATIN SODIUM INJECTION Category: Drugs CMS Add: 01/01/1993 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,815 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J0743 DRUG DEF MAXFEE 10/01/2017 06/30/2023 5.10 0.0 Description: CILASTATIN SODIUM INJECTION Category: Drugs CMS Add: 01/01/1993 CMS Term: J0744 DRUG DEF MAXFEE 10/01/2021 1.21 0.0 Description: CIPROFLOXACIN IV Category: Drugs CMS Add: 01/01/2002 CMS Term: J0745 DRUG DEF SYSMAN Description: INJ CODEINE PHOSPHATE /30 MG Category: Drugs CMS Add: 01/01/1986 CMS Term: J0750 NOCOV DEF SYSMAN Description: HIV PREP, FTC/TDF 200/300MG Category: Non Covered Services CMS Add: 01/02/2024 CMS Term: J0751 NOCOV DEF SYSMAN Description: HIV PREP, FTC/TAF 200/25MG Category: Non Covered Services CMS Add: 01/02/2024 CMS Term: J0770 DRUG DEF MAXFEE 04/01/2022 10.87 0.0 Description: COLISTIMETHATE SODIUM INJ Category: Drugs CMS Add: 01/01/1982 CMS Term: J0775 DRUG DEF MAXFEE 01/01/2023 06/30/2023 68.49 0.0 16-999years Description: COLLAGENASE, CLOST HIST INJ Category: Drugs CMS Add: 01/01/2011 CMS Term: J0775 DRUG DEF MAXFEE 01/01/2024 73.93 0.0 16-999years Description: COLLAGENASE, CLOST HIST INJ Category: Drugs CMS Add: 01/01/2011 CMS Term: J0775 DRUG DEF MAXFEE 07/01/2023 12/31/2023 71.16 0.0 16-999years Description: COLLAGENASE, CLOST HIST INJ Category: Drugs CMS Add: 01/01/2011 CMS Term: J0780 DRUG DEF MAXFEE 04/01/2024 4.82 0.0 Description: PROCHLORPERAZINE INJECTION Category: Drugs CMS Add: 01/01/1984 CMS Term: J0780 DRUG DEF MAXFEE 10/01/2022 03/31/2024 4.86 0.0 Description: PROCHLORPERAZINE INJECTION Category: Drugs CMS Add: 01/01/1984 CMS Term: J0791 DRUG DEF MAXFEE 04/01/2023 128.78 0.0 Y Description: INJ CRIZANLIZUMAB-TMCA 5MG Category: Drugs CMS Add: 07/01/2020 CMS Term: J0795 DRUG DEF SYSMAN Description: CORTICORELIN OVINE TRIFLUTAL Category: Drugs CMS Add: 01/01/2006 CMS Term: J0799 NOCOV DEF SYSMAN Description: HIV PREP, FDA APPROVED, NOC Category: Non Covered Services CMS Add: 01/02/2024 CMS Term: J0801 DRUG DEF MAXFEE 04/01/2024 4618.32 0.0 Description: INJ. ACTHAR GEL TO 40 UNITS Category: Drugs CMS Add: 10/01/2023 CMS Term: J0801 DRUG DEF MAXFEE 10/01/2023 03/31/2024 4483.82 0.0 Description: INJ. ACTHAR GEL TO 40 UNITS Category: Drugs CMS Add: 10/01/2023 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,816 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J0802 DRUG DEF MAXFEE 04/01/2024 3548.06 0.0 Description: INJ. (ANI), UP TO 40 UNITS Category: Drugs CMS Add: 10/01/2023 CMS Term: J0802 DRUG DEF MAXFEE 10/01/2023 03/31/2024 3444.74 0.0 Description: INJ. (ANI), UP TO 40 UNITS Category: Drugs CMS Add: 10/01/2023 CMS Term: J0834 DRUG DEF MAXFEE 10/01/2022 84.21 0.0 Description: INJ., COSYNTROPIN, 0.25 MG Category: Drugs CMS Add: 01/01/2010 CMS Term: J0840 DRUG DEF SYSMAN Description: CROTALIDAE POLY IMMUNE FAB Category: Drugs CMS Add: 01/01/2012 CMS Term: J0841 DRUG DEF SYSMAN Description: INJ CROTALIDAE IM F(AB')2 EQ Category: Drugs CMS Add: 01/01/2019 CMS Term: J0850 DRUG DEF MAXFEE 10/01/2022 1844.69 0.0 Description: CYTOMEGALOVIRUS IMM IV /VIAL Category: Drugs CMS Add: 01/01/1982 CMS Term: J0873 DRUG DEF MAXFEE 01/01/2024 0.12 0.0 Description: INJ, DAPTOMYCIN (XELLIA) Category: Drugs CMS Add: 01/01/2024 CMS Term: J0874 DRUG DEF MAXFEE 10/01/2023 0.07 0.0 Description: INJ, DAPTOMYCIN (BAXTER) Category: Drugs CMS Add: 10/01/2023 CMS Term: J0875 DRUG DEF MAXFEE 04/01/2022 06/30/2023 17.61 0.0 Description: INJECTION, DALBAVANCIN Category: Drugs CMS Add: 01/01/2016 CMS Term: J0875 DRUG DEF MAXFEE 04/01/2024 18.68 0.0 Description: INJECTION, DALBAVANCIN Category: Drugs CMS Add: 01/01/2016 CMS Term: J0875 DRUG DEF MAXFEE 07/01/2023 03/31/2024 18.14 0.0 Description: INJECTION, DALBAVANCIN Category: Drugs CMS Add: 01/01/2016 CMS Term: J0877 DRUG DEF MAXFEE 01/01/2023 0.15 0.0 Description: INJ, DAPTOMYCIN (HOSPIRA) Category: Drugs CMS Add: 01/01/2023 CMS Term: J0878 DRUG DEF MAXFEE 07/01/2021 0.04 0.0 Description: DAPTOMYCIN INJECTION Category: Drugs CMS Add: 01/01/2005 CMS Term: J0879 NOCOV DEF SYSMAN Description: DIFELIKEFALIN, ESRD ON DIALY Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: J0881 DRUG DEF MAXFEE 04/01/2017 8.13 0.0 Description: DARBEPOETIN ALFA, NON-ESRD Category: Drugs CMS Add: 01/01/2006 CMS Term: J0882 DRUG DEF MAXFEE 04/01/2017 8.13 0.0 Description: DARBEPOETIN ALFA, ESRD USE Category: Drugs CMS Add: 01/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,817 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J0883 DRUG DEF MAXFEE 04/01/2018 1.00 0.0 Description: ARGATROBAN NONESRD USE 1MG Category: Drugs CMS Add: 01/01/2017 CMS Term: J0884 DRUG DEF MAXFEE 04/01/2018 1.00 0.0 Description: ARGATROBAN ESRD DIALYSIS 1MG Category: Drugs CMS Add: 01/01/2017 CMS Term: J0885 DRUG DEF MAXFEE 04/01/2017 17.41 0.0 Description: EPOETIN ALFA, NON-ESRD Category: Drugs CMS Add: 01/01/2006 CMS Term: J0887 DRUG DEF MAXFEE 07/01/2019 3.03 0.0 Description: EPOETIN BETA ESRD USE Category: Drugs CMS Add: 01/01/2015 CMS Term: J0888 DRUG DEF MAXFEE 07/01/2019 3.03 0.0 Description: EPOETIN BETA NON ESRD Category: Drugs CMS Add: 01/01/2015 CMS Term: J0889 NOCOV DEF SYSMAN Description: DAPRODUSTAT ORAL 1MG ESRD Category: Non Covered Services CMS Add: 10/01/2023 CMS Term: J0890 DRUG DEF SYSMAN Description: PEGINESATIDE INJECTION Category: Drugs CMS Add: 01/01/2013 CMS Term: J0891 DRUG DEF MAXFEE 01/01/2023 4.16 0.0 Description: ARGATROBAN NONESRD (ACCORD) Category: Drugs CMS Add: 01/01/2023 CMS Term: J0892 DRUG DEF MAXFEE 01/01/2023 4.16 0.0 Description: ARGATROBAN DIALYSIS (ACCORD) Category: Drugs CMS Add: 01/01/2023 CMS Term: J0893 DRUG DEF MAXFEE 01/01/2023 06/30/2023 5.25 0.0 Description: INJ, DECITABINE (SUN PHARMA) Category: Drugs CMS Add: 01/01/2023 CMS Term: J0893 DRUG DEF MAXFEE 07/01/2023 2.10 0.0 Description: INJ, DECITABINE (SUN PHARMA) Category: Drugs CMS Add: 01/01/2023 CMS Term: J0894 DRUG DEF MAXFEE 10/01/2022 2.10 0.0 Description: DECITABINE INJECTION Category: Drugs CMS Add: 01/01/2007 CMS Term: J0895 DRUG DEF MAXFEE 04/01/2022 03/31/2024 8.41 0.0 Description: DEFEROXAMINE MESYLATE INJ Category: Drugs CMS Add: 01/01/1992 CMS Term: J0895 DRUG DEF MAXFEE 04/01/2024 9.26 0.0 Description: DEFEROXAMINE MESYLATE INJ Category: Drugs CMS Add: 01/01/1992 CMS Term: J0896 DRUG DEF MAXFEE 04/01/2023 09/30/2023 39.12 0.0 Description: INJ LUSPATERCEPT-AAMT 0.25MG Category: Drugs CMS Add: 07/01/2020 CMS Term: J0896 DRUG DEF MAXFEE 04/01/2024 40.70 0.0 Description: INJ LUSPATERCEPT-AAMT 0.25MG Category: Drugs CMS Add: 07/01/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,818 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J0896 DRUG DEF MAXFEE 10/01/2023 03/31/2024 39.90 0.0 Description: INJ LUSPATERCEPT-AAMT 0.25MG Category: Drugs CMS Add: 07/01/2020 CMS Term: J0897 DRUG DEF MAXFEE 04/01/2023 09/30/2023 25.18 0.0 Description: DENOSUMAB INJECTION Category: Drugs CMS Add: 01/01/2012 CMS Term: J0897 DRUG DEF MAXFEE 04/01/2024 27.95 0.0 Description: DENOSUMAB INJECTION Category: Drugs CMS Add: 01/01/2012 CMS Term: J0897 DRUG DEF MAXFEE 10/01/2023 03/31/2024 26.15 0.0 Description: DENOSUMAB INJECTION Category: Drugs CMS Add: 01/01/2012 CMS Term: J0898 DRUG DEF MAXFEE 01/01/2023 4.10 0.0 Description: ARGATROBAN NONESRD (AUROMED) Category: Drugs CMS Add: 01/01/2023 CMS Term: J0899 DRUG DEF MAXFEE 01/01/2023 4.10 0.0 Description: ARGATROBAN DIALYSIS, AUROMED Category: Drugs CMS Add: 01/01/2023 CMS Term: J0945 DRUG DEF SYSMAN Description: BROMPHENIRAMINE MALEATE INJ Category: Drugs CMS Add: 01/01/1982 CMS Term: J1000 DRUG DEF MAXFEE 04/01/2023 09/30/2023 32.36 0.0 Description: DEPO-ESTRADIOL CYPIONATE INJ Category: Drugs CMS Add: 01/01/1982 CMS Term: J1000 DRUG DEF MAXFEE 04/01/2024 38.96 0.0 Description: DEPO-ESTRADIOL CYPIONATE INJ Category: Drugs CMS Add: 01/01/1982 CMS Term: J1000 DRUG DEF MAXFEE 10/01/2023 03/31/2024 35.42 0.0 Description: DEPO-ESTRADIOL CYPIONATE INJ Category: Drugs CMS Add: 01/01/1982 CMS Term: J1020 DRUG DEF MAXFEE 01/01/2022 3.75 0.0 Description: METHYLPREDNISOLONE 20 MG INJ Category: Drugs CMS Add: 01/01/1982 CMS Term: 03/31/2024 J1030 DRUG DEF MAXFEE 01/01/2022 7.51 0.0 Description: METHYLPREDNISOLONE 40 MG INJ Category: Drugs CMS Add: 01/01/1982 CMS Term: 03/31/2024 J1040 DRUG DEF MAXFEE 01/01/2022 15.02 0.0 Description: METHYLPREDNISOLONE 80 MG INJ Category: Drugs CMS Add: 01/01/1982 CMS Term: 03/31/2024 J1050 DRUG DEF MAXFEE 10/01/2021 0.24 0.0 Description: MEDROXYPROGESTERONE ACETATE Category: Drugs CMS Add: 01/01/2013 CMS Term: J1071 DRUG DEF MAXFEE 04/01/2023 0.01 0.0 Y 0-400 Description: INJ TESTOSTERONE CYPIONATE Category: Drugs CMS Add: 01/01/2015 CMS Term: J1094 DRUG DEF SYSMAN Description: INJ DEXAMETHASONE ACETATE Category: Drugs CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,819 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J1095 DRUG DEF MAXFEE 01/01/2021 1.21 0.0 Description: INJECTION, DEXAMETHASONE 9% Category: Drugs CMS Add: 01/01/2019 CMS Term: J1096 DRUG DEF MAXFEE 10/01/2021 145.69 0.0 Description: DEXAMETHA OPTH INSERT 0.1 MG Category: Drugs CMS Add: 10/01/2019 CMS Term: J1097 DRUG DEF MAXFEE 04/01/2023 123.90 0.0 Description: PHENYLEP KETOROLAC OPTH SOLN Category: Drugs CMS Add: 10/01/2019 CMS Term: J1100 DRUG DEF MAXFEE 01/01/2016 0.05 0.0 Description: DEXAMETHASONE SODIUM PHOS Category: Drugs CMS Add: 01/01/1982 CMS Term: J1105 DRUG DEF MAXFEE 01/01/2024 0.61 0.0 Description: DEXMEDETOMIDINE FILM, 1 MCG Category: Drugs CMS Add: 01/01/2024 CMS Term: J1110 DRUG DEF MAXFEE 10/01/2022 69.62 0.0 Description: INJ DIHYDROERGOTAMINE MESYLT Category: Drugs CMS Add: 01/01/1982 CMS Term: J1120 DRUG DEF MAXFEE 10/01/2019 33.08 0.0 Description: ACETAZOLAMID SODIUM INJECTIO Category: Drugs CMS Add: 01/01/1982 CMS Term: J1130 DRUG DEF SYSMAN Description: INJ DICLOFENAC SODIUM 0.5MG Category: Drugs CMS Add: 01/01/2017 CMS Term: J1160 DRUG DEF MAXFEE 10/01/2016 5.78 0.0 Description: DIGOXIN INJECTION Category: Drugs CMS Add: 01/01/1982 CMS Term: J1162 DRUG DEF SYSMAN Description: DIGOXIN IMMUNE FAB (OVINE) Category: Drugs CMS Add: 01/01/2006 CMS Term: J1165 DRUG DEF MAXFEE 10/01/2019 0.34 0.0 Description: PHENYTOIN SODIUM INJECTION Category: Drugs CMS Add: 01/01/1982 CMS Term: J1170 DRUG DEF MAXFEE 07/01/2016 09/30/2023 0.58 0.0 Description: HYDROMORPHONE INJECTION Category: Drugs CMS Add: 01/01/1982 CMS Term: J1170 DRUG DEF MAXFEE 10/01/2023 0.79 0.0 Description: HYDROMORPHONE INJECTION Category: Drugs CMS Add: 01/01/1982 CMS Term: J1180 DRUG DEF SYSMAN Description: DYPHYLLINE INJECTION Category: Drugs CMS Add: 01/01/1982 CMS Term: J1190 DRUG DEF MAXFEE 10/01/2022 76.13 0.0 Description: DEXRAZOXANE HCL INJECTION Category: Drugs CMS Add: 01/01/1997 CMS Term: J1200 DRUG DEF MAXFEE 04/01/2019 0.86 0.0 Description: DIPHENHYDRAMINE HCL INJECTIO Category: Drugs CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,820 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J1201 DRUG DEF SYSMAN Description: INJ. CETIRIZINE HCL 0.5MG Category: Drugs CMS Add: 07/01/2020 CMS Term: J1205 DRUG DEF MAXFEE 07/01/2020 33.26 0.0 Description: CHLOROTHIAZIDE SODIUM INJ Category: Drugs CMS Add: 01/01/1982 CMS Term: J1212 DRUG DEF MAXFEE 04/01/2023 03/31/2024 694.98 0.0 Description: DIMETHYL SULFOXIDE 50% 50 ML Category: Drugs CMS Add: 01/01/1986 CMS Term: J1212 DRUG DEF MAXFEE 04/01/2024 729.73 0.0 Description: DIMETHYL SULFOXIDE 50% 50 ML Category: Drugs CMS Add: 01/01/1986 CMS Term: J1230 DRUG DEF MAXFEE 01/01/2018 09/30/2023 18.90 0.0 Description: METHADONE INJECTION Category: Drugs CMS Add: 01/01/1982 CMS Term: J1230 DRUG DEF MAXFEE 10/01/2023 22.44 0.0 Description: METHADONE INJECTION Category: Drugs CMS Add: 01/01/1982 CMS Term: J1240 DRUG DEF MAXFEE 04/01/2023 12.11 0.0 Description: DIMENHYDRINATE INJECTION Category: Drugs CMS Add: 01/01/1984 CMS Term: J1245 DRUG DEF MAXFEE 10/01/2018 4.16 0.0 Description: DIPYRIDAMOLE INJECTION Category: Drugs CMS Add: 01/01/1993 CMS Term: J1250 DRUG DEF MAXFEE 04/01/2023 4.84 0.0 Description: INJ DOBUTAMINE HCL/250 MG Category: Drugs CMS Add: 01/01/1996 CMS Term: J1260 DRUG DEF SYSMAN Description: DOLASETRON MESYLATE Category: Drugs CMS Add: 01/01/1999 CMS Term: J1265 DRUG DEF MAXFEE 04/01/2023 09/30/2023 0.29 0.0 Description: DOPAMINE INJECTION Category: Drugs CMS Add: 01/01/2006 CMS Term: J1265 DRUG DEF MAXFEE 04/01/2024 0.32 0.0 Description: DOPAMINE INJECTION Category: Drugs CMS Add: 01/01/2006 CMS Term: J1265 DRUG DEF MAXFEE 10/01/2023 03/31/2024 0.30 0.0 Description: DOPAMINE INJECTION Category: Drugs CMS Add: 01/01/2006 CMS Term: J1267 DRUG DEF SYSMAN Description: DORIPENEM INJECTION Category: Drugs CMS Add: 01/01/2009 CMS Term: J1270 DRUG DEF MAXFEE 07/01/2022 0.47 0.0 Description: INJECTION, DOXERCALCIFEROL Category: Drugs CMS Add: 01/01/2002 CMS Term: J1290 DRUG DEF MAXFEE 04/01/2023 03/31/2024 564.79 0.0 16-999years Description: ECALLANTIDE INJECTION Category: Drugs CMS Add: 01/01/2011 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,821 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J1290 DRUG DEF MAXFEE 04/01/2024 581.74 0.0 16-999years Description: ECALLANTIDE INJECTION Category: Drugs CMS Add: 01/01/2011 CMS Term: J1300 DRUG DEF MAXFEE 10/01/2017 228.30 0.0 Description: ECULIZUMAB INJECTION Category: Drugs CMS Add: 01/01/2008 CMS Term: J1301 DRUG DEF MAXFEE 07/01/2022 09/30/2023 21.40 0.0 Description: INJECTION, EDARAVONE, 1 MG Category: Drugs CMS Add: 01/01/2019 CMS Term: J1301 DRUG DEF MAXFEE 10/01/2023 21.83 0.0 Description: INJECTION, EDARAVONE, 1 MG Category: Drugs CMS Add: 01/01/2019 CMS Term: J1302 DRUG DEF MAXFEE 04/01/2023 03/31/2024 17.95 0.0 Description: INJ, SUTIMLIMAB-JOME, 10 MG Category: Drugs CMS Add: 10/01/2022 CMS Term: J1302 DRUG DEF MAXFEE 04/01/2024 18.30 0.0 Description: INJ, SUTIMLIMAB-JOME, 10 MG Category: Drugs CMS Add: 10/01/2022 CMS Term: J1303 DRUG DEF MAXFEE 10/01/2019 224.14 0.0 Description: INJ., RAVULIZUMAB-CWVZ 10 MG Category: Drugs CMS Add: 10/01/2019 CMS Term: J1304 DRUG DEF MAXFEE 01/01/2024 149.41 0.0 Description: INJ TOFERSEN INTRATHEC 1 MG Category: Drugs CMS Add: 01/01/2024 CMS Term: J1305 DRUG DEF MAXFEE 04/01/2023 03/31/2024 177.45 0.0 Y Description: INJ, EVINACUMAB-DGNB, 5MG Category: Drugs CMS Add: 10/01/2021 CMS Term: J1305 DRUG DEF MAXFEE 04/01/2024 184.55 0.0 Y Description: INJ, EVINACUMAB-DGNB, 5MG Category: Drugs CMS Add: 10/01/2021 CMS Term: J1306 DRUG DEF MAXFEE 04/01/2023 09/30/2023 12.17 0.0 Y 18-999years Description: INJECTION, INCLISIRAN, 1 MG Category: Drugs CMS Add: 07/01/2022 CMS Term: J1306 DRUG DEF MAXFEE 04/01/2024 12.47 0.0 Y 18-999years Description: INJECTION, INCLISIRAN, 1 MG Category: Drugs CMS Add: 07/01/2022 CMS Term: J1306 DRUG DEF MAXFEE 10/01/2023 03/31/2024 12.32 0.0 Y 18-999years Description: INJECTION, INCLISIRAN, 1 MG Category: Drugs CMS Add: 07/01/2022 CMS Term: J1320 DRUG DEF SYSMAN Description: AMITRIPTYLINE INJECTION Category: Drugs CMS Add: 01/01/1982 CMS Term: J1322 DRUG DEF MAXFEE 04/01/2023 03/31/2024 284.97 0.0 Description: ELOSULFASE ALFA, INJECTION Category: Drugs CMS Add: 01/01/2015 CMS Term: J1322 DRUG DEF MAXFEE 04/01/2024 292.74 0.0 Description: ELOSULFASE ALFA, INJECTION Category: Drugs CMS Add: 01/01/2015 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,822 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J1324 DRUG DEF MAXFEE 04/01/2017 0.70 0.0 Description: ENFUVIRTIDE INJECTION Category: Drugs CMS Add: 01/01/2007 CMS Term: J1325 DRUG DEF MAXFEE 01/01/2016 13.69 0.0 Description: EPOPROSTENOL INJECTION Category: Drugs CMS Add: 01/01/1998 CMS Term: J1327 DRUG DEF MAXFEE 04/01/2021 7.00 0.0 Description: EPTIFIBATIDE INJECTION Category: Drugs CMS Add: 01/01/2000 CMS Term: J1330 DRUG DEF SYSMAN Description: ERGONOVINE MALEATE INJECTION Category: Drugs CMS Add: 01/01/1986 CMS Term: J1335 DRUG DEF MAXFEE 10/01/2022 21.00 0.0 Description: ERTAPENEM INJECTION Category: Drugs CMS Add: 01/01/2004 CMS Term: J1364 DRUG DEF MAXFEE 04/01/2023 88.76 0.0 Description: ERYTHRO LACTOBIONATE /500 MG Category: Drugs CMS Add: 01/01/1995 CMS Term: J1380 DRUG DEF MAXFEE 07/01/2023 11.40 0.0 Description: ESTRADIOL VALERATE 10 MG INJ Category: Drugs CMS Add: 01/01/1982 CMS Term: J1380 DRUG DEF MAXFEE 10/01/2022 06/30/2023 12.11 0.0 Description: ESTRADIOL VALERATE 10 MG INJ Category: Drugs CMS Add: 01/01/1982 CMS Term: J1410 DRUG DEF MAXFEE 04/01/2023 03/31/2024 375.20 0.0 Description: INJ ESTROGEN CONJUGATE 25 MG Category: Drugs CMS Add: 01/01/1982 CMS Term: J1410 DRUG DEF MAXFEE 04/01/2024 386.45 0.0 Description: INJ ESTROGEN CONJUGATE 25 MG Category: Drugs CMS Add: 01/01/1982 CMS Term: J1411 NOCOV DEF SYSMAN Description: INJ, HEMGENIX, PER TX DOSE Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: J1412 DRUG DEF MAXFEE 01/01/2024 95156.25 0.0 Y Description: INJ ROCTAVIAN ML 2X10^13VC G Category: Drugs CMS Add: 01/01/2024 CMS Term: J1413 DRUG DEF MAXFEE 01/01/2024 3360000.00 0.0 Y Description: INJ DELANDISTROGENE MOX ROKL Category: Drugs CMS Add: 01/01/2024 CMS Term: J1426 DRUG DEF MAXFEE 10/01/2021 168.00 0.0 Y Description: INJECTION, CASIMERSEN, 10 MG Category: Drugs CMS Add: 10/01/2021 CMS Term: J1427 DRUG DEF MAXFEE 04/01/2021 59.22 0.0 Description: INJ. VILTOLARSEN Category: Drugs CMS Add: 04/01/2021 CMS Term: J1428 DRUG DEF MAXFEE 01/01/2018 168.00 0.0 Y Description: INJ, ETEPLIRSEN, 10 MG Category: Drugs CMS Add: 01/01/2018 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,823 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J1429 DRUG DEF MAXFEE 07/01/2020 168.00 0.0 Y Description: INJ GOLODIRSEN 10 MG Category: Drugs CMS Add: 07/01/2020 CMS Term: J1430 DRUG DEF SYSMAN Description: ETHANOLAMINE OLEATE 100 MG Category: Drugs CMS Add: 01/01/2006 CMS Term: J1435 DRUG DEF SYSMAN Description: INJECTION ESTRONE PER 1 MG Category: Drugs CMS Add: 01/01/1982 CMS Term: J1436 DRUG DEF SYSMAN Description: ETIDRONATE DISODIUM INJ Category: Drugs CMS Add: 01/01/1990 CMS Term: J1437 DRUG DEF MAXFEE 04/01/2022 26.65 0.0 Description: INJ. FE DERISOMALTOSE 10 MG Category: Drugs CMS Add: 10/01/2020 CMS Term: J1438 DRUG DEF MAXFEE 04/01/2023 03/31/2024 925.23 0.0 Description: ETANERCEPT INJECTION Category: Drugs CMS Add: 01/01/2000 CMS Term: J1438 DRUG DEF MAXFEE 04/01/2024 971.49 0.0 Description: ETANERCEPT INJECTION Category: Drugs CMS Add: 01/01/2000 CMS Term: J1439 DRUG DEF MAXFEE 01/01/2023 06/30/2023 1.80 0.0 Description: INJ FERRIC CARBOXYMALTOS 1MG Category: Drugs CMS Add: 01/01/2015 CMS Term: J1439 DRUG DEF MAXFEE 04/01/2024 1.94 0.0 Description: INJ FERRIC CARBOXYMALTOS 1MG Category: Drugs CMS Add: 01/01/2015 CMS Term: J1439 DRUG DEF MAXFEE 07/01/2023 09/30/2023 1.85 0.0 Description: INJ FERRIC CARBOXYMALTOS 1MG Category: Drugs CMS Add: 01/01/2015 CMS Term: J1439 DRUG DEF MAXFEE 10/01/2023 03/31/2024 1.89 0.0 Description: INJ FERRIC CARBOXYMALTOS 1MG Category: Drugs CMS Add: 01/01/2015 CMS Term: J1440 DRUG DEF MAXFEE 07/01/2023 63.00 0.0 Description: FECAL MICROBIOTA JSLM 1 ML Category: Drugs CMS Add: 07/01/2023 CMS Term: J1442 DRUG DEF MAXFEE 01/01/2018 1.10 0.0 Description: INJ FILGRASTIM EXCL BIOSIMIL Category: Drugs CMS Add: 01/01/2014 CMS Term: J1443 DRUG DEF MAXFEE 01/01/2020 0.04 0.0 Description: INJ FERRIC PYROPHOSPHATE CIT Category: Drugs CMS Add: 01/01/2016 CMS Term: J1444 DRUG DEF MAXFEE 07/01/2019 0.03 0.0 Description: FE PYRO CIT POW 0.1 MG IRON Category: Drugs CMS Add: 07/01/2019 CMS Term: J1445 NOCOV DEF SYSMAN Description: INJ TRIFERIC AVNU 0.1MG IRON Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,824 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J1447 DRUG DEF MAXFEE 01/01/2016 0.87 0.0 Description: INJ TBO FILGRASTIM 1 MICROG Category: Drugs CMS Add: 01/01/2016 CMS Term: J1448 DRUG DEF MAXFEE 01/01/2023 06/30/2023 5.13 0.0 Description: INJECTION, TRILACICLIB, 1MG Category: Drugs CMS Add: 10/01/2021 CMS Term: J1448 DRUG DEF MAXFEE 01/01/2024 5.33 0.0 Description: INJECTION, TRILACICLIB, 1MG Category: Drugs CMS Add: 10/01/2021 CMS Term: J1448 DRUG DEF MAXFEE 07/01/2023 12/31/2023 5.24 0.0 Description: INJECTION, TRILACICLIB, 1MG Category: Drugs CMS Add: 10/01/2021 CMS Term: J1449 DRUG DEF MAXFEE 04/01/2023 35.80 0.0 Description: INJ EFLAPEGRASTIM-XNST 0.1MG Category: Drugs CMS Add: 04/01/2023 CMS Term: J1450 DRUG DEF MAXFEE 07/01/2020 2.31 0.0 Description: FLUCONAZOLE Category: Drugs CMS Add: 01/01/2000 CMS Term: J1451 DRUG DEF MAXFEE 04/01/2024 10.34 0.0 Description: FOMEPIZOLE, 15 MG Category: Drugs CMS Add: 01/01/2006 CMS Term: J1451 DRUG DEF MAXFEE 07/01/2019 03/31/2024 10.35 0.0 Description: FOMEPIZOLE, 15 MG Category: Drugs CMS Add: 01/01/2006 CMS Term: J1452 DRUG DEF SYSMAN Description: INTRAOCULAR FOMIVIRSEN NA Category: Drugs CMS Add: 01/01/2001 CMS Term: J1453 DRUG DEF MAXFEE 01/01/2022 0.18 0.0 Description: FOSAPREPITANT INJECTION Category: Drugs CMS Add: 01/01/2009 CMS Term: J1454 DRUG DEF MAXFEE 10/01/2021 717.34 0.0 Description: INJ FOSNETUPITANT, PALONOSET Category: Drugs CMS Add: 01/01/2019 CMS Term: J1455 DRUG DEF MAXFEE 04/01/2021 03/31/2024 82.73 0.0 Description: FOSCARNET SODIUM INJECTION Category: Drugs CMS Add: 01/01/1993 CMS Term: J1455 DRUG DEF MAXFEE 04/01/2024 63.00 0.0 Description: FOSCARNET SODIUM INJECTION Category: Drugs CMS Add: 01/01/1993 CMS Term: J1456 DRUG DEF MAXFEE 01/01/2023 2.02 0.0 Description: INJ, FOSAPREPITANT (TEVA) Category: Drugs CMS Add: 01/01/2023 CMS Term: J1457 DRUG DEF SYSMAN Description: GALLIUM NITRATE INJECTION Category: Drugs CMS Add: 01/01/2005 CMS Term: J1458 DRUG DEF MAXFEE 04/01/2023 03/31/2024 469.98 0.0 Description: GALSULFASE INJECTION Category: Drugs CMS Add: 01/01/2007 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,825 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J1458 DRUG DEF MAXFEE 04/01/2024 483.00 0.0 Description: GALSULFASE INJECTION Category: Drugs CMS Add: 01/01/2007 CMS Term: J1459 DRUG DEF MAXFEE 04/01/2023 09/30/2023 87.92 0.0 Description: INJ IVIG PRIVIGEN 500 MG Category: Drugs CMS Add: 01/01/2009 CMS Term: J1459 DRUG DEF MAXFEE 04/01/2024 92.37 0.0 Description: INJ IVIG PRIVIGEN 500 MG Category: Drugs CMS Add: 01/01/2009 CMS Term: J1459 DRUG DEF MAXFEE 10/01/2023 03/31/2024 89.68 0.0 Description: INJ IVIG PRIVIGEN 500 MG Category: Drugs CMS Add: 01/01/2009 CMS Term: J1460 DRUG DEF MAXFEE 07/01/2023 49.92 0.0 Description: GAMMA GLOBULIN 1 CC INJ Category: Drugs CMS Add: 01/01/1984 CMS Term: J1460 DRUG DEF MAXFEE 10/01/2022 06/30/2023 48.46 0.0 Description: GAMMA GLOBULIN 1 CC INJ Category: Drugs CMS Add: 01/01/1984 CMS Term: J1551 DRUG DEF MAXFEE 07/01/2022 20.41 0.0 Description: INJ CUTAQUIG 100 MG Category: Drugs CMS Add: 07/01/2022 CMS Term: J1554 DRUG DEF MAXFEE 04/01/2021 477.23 0.0 Description: INJ. ASCENIV Category: Drugs CMS Add: 04/01/2021 CMS Term: J1555 DRUG DEF MAXFEE 04/01/2023 03/31/2024 22.23 0.0 Description: INJ CUVITRU, 100 MG Category: Drugs CMS Add: 01/01/2018 CMS Term: J1555 DRUG DEF MAXFEE 04/01/2024 23.57 0.0 Description: INJ CUVITRU, 100 MG Category: Drugs CMS Add: 01/01/2018 CMS Term: J1556 DRUG DEF MAXFEE 01/01/2020 69.83 0.0 Description: INJ, IMM GLOB BIVIGAM, 500MG Category: Drugs CMS Add: 01/01/2014 CMS Term: J1557 DRUG DEF MAXFEE 04/01/2023 107.85 0.0 Description: GAMMAPLEX INJECTION Category: Drugs CMS Add: 01/01/2012 CMS Term: J1558 DRUG DEF MAXFEE 04/01/2024 18.87 0.0 Description: INJ. XEMBIFY, 100 MG Category: Drugs CMS Add: 07/01/2020 CMS Term: J1558 DRUG DEF MAXFEE 10/01/2022 03/31/2024 18.50 0.0 Description: INJ. XEMBIFY, 100 MG Category: Drugs CMS Add: 07/01/2020 CMS Term: J1559 DRUG DEF MAXFEE 04/01/2023 09/30/2023 22.09 0.0 Description: HIZENTRA INJECTION Category: Drugs CMS Add: 01/01/2011 CMS Term: J1559 DRUG DEF MAXFEE 04/01/2024 23.09 0.0 Description: HIZENTRA INJECTION Category: Drugs CMS Add: 01/01/2011 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,826 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J1559 DRUG DEF MAXFEE 10/01/2023 03/31/2024 22.53 0.0 Description: HIZENTRA INJECTION Category: Drugs CMS Add: 01/01/2011 CMS Term: J1560 DRUG DEF MAXFEE 07/01/2023 499.16 0.0 Description: GAMMA GLOBULIN > 10 CC INJ Category: Drugs CMS Add: 01/01/1984 CMS Term: J1560 DRUG DEF MAXFEE 10/01/2022 06/30/2023 484.62 0.0 Description: GAMMA GLOBULIN > 10 CC INJ Category: Drugs CMS Add: 01/01/1984 CMS Term: J1561 DRUG DEF MAXFEE 04/01/2023 03/31/2024 71.88 0.0 Description: GAMUNEX-C/GAMMAKED Category: Drugs CMS Add: 01/01/2008 CMS Term: J1561 DRUG DEF MAXFEE 04/01/2024 73.32 0.0 Description: GAMUNEX-C/GAMMAKED Category: Drugs CMS Add: 01/01/2008 CMS Term: J1562 NOCOV DEF SYSMAN Description: VIVAGLOBIN, INJ Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: J1566 DRUG DEF MAXFEE 04/01/2023 03/31/2024 113.21 0.0 Description: IMMUNE GLOBULIN, POWDER Category: Drugs CMS Add: 01/01/2006 CMS Term: J1566 DRUG DEF MAXFEE 04/01/2024 117.74 0.0 Description: IMMUNE GLOBULIN, POWDER Category: Drugs CMS Add: 01/01/2006 CMS Term: J1568 DRUG DEF MAXFEE 04/01/2020 77.84 0.0 Description: OCTAGAM INJECTION Category: Drugs CMS Add: 01/01/2008 CMS Term: J1569 DRUG DEF MAXFEE 04/01/2023 03/31/2024 84.76 0.0 Description: GAMMAGARD LIQUID INJECTION Category: Drugs CMS Add: 01/01/2008 CMS Term: J1569 DRUG DEF MAXFEE 04/01/2024 89.00 0.0 Description: GAMMAGARD LIQUID INJECTION Category: Drugs CMS Add: 01/01/2008 CMS Term: J1570 DRUG DEF MAXFEE 01/01/2021 63.00 0.0 Description: GANCICLOVIR SODIUM INJECTION Category: Drugs CMS Add: 01/01/1994 CMS Term: J1571 DRUG DEF MAXFEE 01/01/2023 93.44 0.0 Description: HEPAGAM B IM INJECTION Category: Drugs CMS Add: 01/01/2008 CMS Term: J1572 DRUG DEF MAXFEE 04/01/2022 55.59 0.0 Description: FLEBOGAMMA INJECTION Category: Drugs CMS Add: 01/01/2008 CMS Term: J1573 DRUG DEF MAXFEE 01/01/2023 93.44 0.0 Description: HEPAGAM B INTRAVENOUS, INJ Category: Drugs CMS Add: 01/01/2008 CMS Term: J1574 DRUG DEF MAXFEE 01/01/2023 52.50 0.0 Description: INJ, GANCICLOVIR (EXELA) Category: Drugs CMS Add: 01/01/2023 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,827 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J1575 DRUG DEF MAXFEE 04/01/2023 03/31/2024 23.32 0.0 Description: HYQVIA 100MG IMMUNEGLOBULIN Category: Drugs CMS Add: 01/01/2016 CMS Term: J1575 DRUG DEF MAXFEE 04/01/2024 23.90 0.0 Description: HYQVIA 100MG IMMUNEGLOBULIN Category: Drugs CMS Add: 01/01/2016 CMS Term: J1576 DRUG DEF MAXFEE 07/01/2023 104.39 0.0 Description: INJ, PANZYGA, 500 MG Category: Drugs CMS Add: 07/01/2023 CMS Term: J1580 DRUG DEF MAXFEE 10/01/2022 0.94 0.0 Description: GARAMYCIN GENTAMICIN INJ Category: Drugs CMS Add: 01/01/1984 CMS Term: J1595 DRUG DEF MAXFEE 01/01/2020 52.50 0.0 Description: INJECTION GLATIRAMER ACETATE Category: Drugs CMS Add: 01/01/2004 CMS Term: J1596 DRUG DEF MAXFEE 01/01/2024 03/31/2024 0.33 0.0 Description: INJ, GLYCOPYRROLATE, 0.1 MG Category: Drugs CMS Add: 01/01/2024 CMS Term: J1596 DRUG DEF MAXFEE 04/01/2024 0.29 0.0 Description: INJ, GLYCOPYRROLATE, 0.1 MG Category: Drugs CMS Add: 01/01/2024 CMS Term: J1599 DRUG DEF SYSMAN Description: IVIG NON-LYOPHILIZED, NOS Category: Drugs CMS Add: 01/01/2011 CMS Term: J1600 DRUG DEF SYSMAN Description: GOLD SODIUM THIOMALEATE INJ Category: Drugs CMS Add: 01/01/1982 CMS Term: J1602 DRUG DEF MAXFEE 04/01/2021 41.98 0.0 Description: GOLIMUMAB FOR IV USE 1MG Category: Drugs CMS Add: 01/01/2014 CMS Term: J1610 DRUG DEF MAXFEE 04/01/2015 03/31/2024 180.18 0.0 Description: GLUCAGON HYDROCHLORIDE/1 MG Category: Drugs CMS Add: 01/01/1986 CMS Term: J1610 DRUG DEF MAXFEE 04/01/2024 294.00 0.0 Description: GLUCAGON HYDROCHLORIDE/1 MG Category: Drugs CMS Add: 01/01/1986 CMS Term: J1611 DRUG DEF MAXFEE 01/01/2023 170.10 0.0 Description: INJ GLUCAGON HCL, FRESENIUS Category: Drugs CMS Add: 01/01/2023 CMS Term: J1620 NOCOV DEF SYSMAN Description: GONADORELIN HYDROCH/ 100 MCG Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: J1626 DRUG DEF MAXFEE 07/01/2018 0.66 0.0 Description: GRANISETRON HCL INJECTION Category: Drugs CMS Add: 01/01/1998 CMS Term: J1627 DRUG DEF MAXFEE 04/01/2023 09/30/2023 7.52 0.0 Description: INJ, GRANISETRON, XR, 0.1 MG Category: Drugs CMS Add: 01/01/2018 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,828 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J1627 DRUG DEF MAXFEE 04/01/2024 7.90 0.0 Description: INJ, GRANISETRON, XR, 0.1 MG Category: Drugs CMS Add: 01/01/2018 CMS Term: J1627 DRUG DEF MAXFEE 10/01/2023 03/31/2024 7.71 0.0 Description: INJ, GRANISETRON, XR, 0.1 MG Category: Drugs CMS Add: 01/01/2018 CMS Term: J1628 DRUG DEF MAXFEE 04/01/2023 03/31/2024 138.73 0.0 Description: INJ., GUSELKUMAB, 1 MG Category: Drugs CMS Add: 01/01/2019 CMS Term: J1628 DRUG DEF MAXFEE 04/01/2024 145.66 0.0 Description: INJ., GUSELKUMAB, 1 MG Category: Drugs CMS Add: 01/01/2019 CMS Term: J1630 DRUG DEF MAXFEE 10/01/2022 0.92 0.0 Description: HALOPERIDOL INJECTION Category: Drugs CMS Add: 01/01/1986 CMS Term: J1631 DRUG DEF MAXFEE 04/01/2022 14.18 0.0 Description: HALOPERIDOL DECANOATE INJ Category: Drugs CMS Add: 01/01/1989 CMS Term: J1632 DRUG DEF MAXFEE 10/01/2020 78.23 0.0 Y Description: INJ., BREXANOLONE, 1 MG Category: Drugs CMS Add: 10/01/2020 CMS Term: J1640 DRUG DEF MAXFEE 04/01/2023 03/31/2024 30.42 0.0 Description: HEMIN, 1 MG Category: Drugs CMS Add: 01/01/2006 CMS Term: J1640 DRUG DEF MAXFEE 04/01/2024 31.24 0.0 Description: HEMIN, 1 MG Category: Drugs CMS Add: 01/01/2006 CMS Term: J1642 DRUG DEF MAXFEE 04/01/2016 0.01 0.0 Description: INJ HEPARIN SODIUM PER 10 U Category: Drugs CMS Add: 01/01/1995 CMS Term: J1643 DRUG DEF MAXFEE 01/01/2023 0.24 0.0 Description: INJ HEPARIN, PFIZER, 1000U Category: Drugs CMS Add: 01/01/2023 CMS Term: J1644 DRUG DEF MAXFEE 07/01/2022 0.18 0.0 Description: INJ HEPARIN SODIUM PER 1000U Category: Drugs CMS Add: 01/01/1995 CMS Term: J1645 DRUG DEF MAXFEE 04/01/2023 09/30/2023 26.08 0.0 Description: DALTEPARIN SODIUM Category: Drugs CMS Add: 01/01/1997 CMS Term: J1645 DRUG DEF MAXFEE 10/01/2023 7.34 0.0 Description: DALTEPARIN SODIUM Category: Drugs CMS Add: 01/01/1997 CMS Term: J1650 DRUG DEF MAXFEE 07/01/2023 0.71 0.0 Description: INJ ENOXAPARIN SODIUM Category: Drugs CMS Add: 01/01/1996 CMS Term: J1650 DRUG DEF MAXFEE 10/01/2015 06/30/2023 1.05 0.0 Description: INJ ENOXAPARIN SODIUM Category: Drugs CMS Add: 01/01/1996 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,829 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J1652 DRUG DEF MAXFEE 07/01/2021 1.84 0.0 Description: FONDAPARINUX SODIUM Category: Drugs CMS Add: 01/01/2003 CMS Term: J1655 DRUG DEF SYSMAN Description: TINZAPARIN SODIUM INJECTION Category: Drugs CMS Add: 01/01/2002 CMS Term: J1670 DRUG DEF MAXFEE 04/01/2024 681.63 0.0 Description: TETANUS IMMUNE GLOBULIN INJ Category: Drugs CMS Add: 01/01/1986 CMS Term: J1670 DRUG DEF MAXFEE 07/01/2023 03/31/2024 661.77 0.0 Description: TETANUS IMMUNE GLOBULIN INJ Category: Drugs CMS Add: 01/01/1986 CMS Term: J1670 DRUG DEF MAXFEE 10/01/2022 06/30/2023 642.50 0.0 Description: TETANUS IMMUNE GLOBULIN INJ Category: Drugs CMS Add: 01/01/1986 CMS Term: J1675 DRUG DEF SYSMAN Description: HISTRELIN ACETATE Category: Drugs CMS Add: 01/01/2006 CMS Term: J1700 DRUG DEF SYSMAN Description: HYDROCORTISONE ACETATE INJ Category: Drugs CMS Add: 01/01/1982 CMS Term: J1710 DRUG DEF SYSMAN Description: HYDROCORTISONE SODIUM PH INJ Category: Drugs CMS Add: 01/01/1982 CMS Term: J1720 DRUG DEF MAXFEE 04/01/2013 03/31/2024 2.10 0.0 Description: HYDROCORTISONE SODIUM SUCC I Category: Drugs CMS Add: 01/01/1982 CMS Term: J1720 DRUG DEF MAXFEE 04/01/2024 15.85 0.0 Description: HYDROCORTISONE SODIUM SUCC I Category: Drugs CMS Add: 01/01/1982 CMS Term: J1726 DRUG DEF MAXFEE 04/01/2018 30.66 0.0 Description: MAKENA, 10 MG Category: Drugs CMS Add: 01/01/2018 CMS Term: J1729 NOCOV DEF SYSMAN Description: INJ HYDROXYPROGST CAPOAT NOS Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: J1730 DRUG DEF SYSMAN Description: DIAZOXIDE INJECTION Category: Drugs CMS Add: 01/01/1982 CMS Term: J1738 DRUG DEF MAXFEE 10/01/2020 3.29 0.0 Description: INJ. MELOXICAM 1 MG Category: Drugs CMS Add: 10/01/2020 CMS Term: J1740 DRUG DEF MAXFEE 04/01/2023 84.00 0.0 Description: IBANDRONATE SODIUM INJECTION Category: Drugs CMS Add: 01/01/2007 CMS Term: J1741 NOCOV DEF SYSMAN Description: IBUPROFEN INJECTION Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,830 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J1742 DRUG DEF MAXFEE 07/01/2014 313.22 0.0 Description: IBUTILIDE FUMARATE INJECTION Category: Drugs CMS Add: 01/01/1998 CMS Term: J1743 DRUG DEF MAXFEE 04/01/2017 548.77 0.0 Description: IDURSULFASE INJECTION Category: Drugs CMS Add: 01/01/2008 CMS Term: J1744 DRUG DEF MAXFEE 07/01/2022 49.00 0.0 Description: ICATIBANT INJECTION Category: Drugs CMS Add: 01/01/2013 CMS Term: J1745 DRUG DEF MAXFEE 01/01/2022 49.88 0.0 Description: INFLIXIMAB NOT BIOSIMIL 10MG Category: Drugs CMS Add: 01/01/2000 CMS Term: J1746 DRUG DEF MAXFEE 04/01/2023 03/31/2024 75.15 0.0 Description: INJ., IBALIZUMAB-UIYK, 10 MG Category: Drugs CMS Add: 01/01/2019 CMS Term: J1746 DRUG DEF MAXFEE 04/01/2024 77.70 0.0 Description: INJ., IBALIZUMAB-UIYK, 10 MG Category: Drugs CMS Add: 01/01/2019 CMS Term: J1747 DRUG DEF MAXFEE 04/01/2023 03/31/2024 59.66 0.0 Description: INJ, SPESOLIMAB-SBZO, 1 MG Category: Drugs CMS Add: 04/01/2023 CMS Term: J1747 DRUG DEF MAXFEE 04/01/2024 60.85 0.0 Description: INJ, SPESOLIMAB-SBZO, 1 MG Category: Drugs CMS Add: 04/01/2023 CMS Term: J1750 DRUG DEF MAXFEE 04/01/2023 03/31/2024 17.75 0.0 Description: INJ IRON DEXTRAN Category: Drugs CMS Add: 12/31/2005 CMS Term: J1750 DRUG DEF MAXFEE 04/01/2024 17.76 0.0 Description: INJ IRON DEXTRAN Category: Drugs CMS Add: 12/31/2005 CMS Term: J1756 DRUG DEF MAXFEE 01/01/2012 0.38 0.0 Description: IRON SUCROSE INJECTION Category: Drugs CMS Add: 01/01/2003 CMS Term: J1786 DRUG DEF MAXFEE 04/01/2022 45.07 0.0 Description: IMUGLUCERASE INJECTION Category: Drugs CMS Add: 01/01/2011 CMS Term: J1790 DRUG DEF MAXFEE 04/01/2016 06/30/2023 2.54 0.0 Description: DROPERIDOL INJECTION Category: Drugs CMS Add: 01/01/1982 CMS Term: J1790 DRUG DEF MAXFEE 04/01/2024 9.78 0.0 Description: DROPERIDOL INJECTION Category: Drugs CMS Add: 01/01/1982 CMS Term: J1790 DRUG DEF MAXFEE 07/01/2023 03/31/2024 9.40 0.0 Description: DROPERIDOL INJECTION Category: Drugs CMS Add: 01/01/1982 CMS Term: J1800 DRUG DEF MAXFEE 10/01/2022 8.40 0.0 Description: PROPRANOLOL INJECTION Category: Drugs CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,831 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J1805 DRUG DEF MAXFEE 07/01/2023 0.39 0.0 Description: INJ, ESMOLOL HCL, 10MG Category: Drugs CMS Add: 07/01/2023 CMS Term: J1806 DRUG DEF MAXFEE 07/01/2023 0.50 0.0 Description: INJ ESMOLOL HCL WG CRIT CARE Category: Drugs CMS Add: 07/01/2023 CMS Term: J1810 DRUG DEF SYSMAN Description: DROPERIDOL/FENTANYL INJ Category: Drugs CMS Add: 01/01/1982 CMS Term: J1811 DRUG DEF MAXFEE 07/01/2023 15.19 0.0 Y Description: FIASP FOR INSULIN PUMP USE Category: Drugs CMS Add: 07/01/2023 CMS Term: J1812 DRUG DEF MAXFEE 07/01/2023 1.52 0.0 Y Description: INJ. INSULIN (FIASP) Category: Drugs CMS Add: 07/01/2023 CMS Term: J1813 DRUG DEF MAXFEE 07/01/2023 14.42 0.0 Y Description: LYUMJEV FOR INSULIN PUMP USE Category: Drugs CMS Add: 07/01/2023 CMS Term: J1814 DRUG DEF MAXFEE 07/01/2023 1.44 0.0 Y Description: INJ. INSULIN (LYUMJEV) Category: Drugs CMS Add: 07/01/2023 CMS Term: J1815 DRUG DEF MAXFEE 04/01/2024 0.13 0.0 Description: INSULIN INJECTION Category: Drugs CMS Add: 01/01/2003 CMS Term: J1815 DRUG DEF MAXFEE 10/01/2016 03/31/2024 0.72 0.0 Description: INSULIN INJECTION Category: Drugs CMS Add: 01/01/2003 CMS Term: J1817 DRUG DEF MAXFEE 04/01/2024 1.31 0.0 Description: INSULIN FOR INSULIN PUMP USE Category: Drugs CMS Add: 01/01/2003 CMS Term: J1817 DRUG DEF MAXFEE 10/01/2016 03/31/2024 7.23 0.0 Description: INSULIN FOR INSULIN PUMP USE Category: Drugs CMS Add: 01/01/2003 CMS Term: J1823 DRUG DEF MAXFEE 04/01/2023 03/31/2024 469.05 0.0 Description: INJ. INEBILIZUMAB-CDON, 1 MG Category: Drugs CMS Add: 01/01/2021 CMS Term: J1823 DRUG DEF MAXFEE 04/01/2024 479.83 0.0 Description: INJ. INEBILIZUMAB-CDON, 1 MG Category: Drugs CMS Add: 01/01/2021 CMS Term: J1826 DRUG DEF MAXFEE 04/01/2023 06/30/2023 2055.50 0.0 Description: INTERFERON BETA-1A INJ Category: Drugs CMS Add: 01/01/2011 CMS Term: J1826 DRUG DEF MAXFEE 04/01/2024 2169.78 0.0 Description: INTERFERON BETA-1A INJ Category: Drugs CMS Add: 01/01/2011 CMS Term: J1826 DRUG DEF MAXFEE 07/01/2023 03/31/2024 2086.33 0.0 Description: INTERFERON BETA-1A INJ Category: Drugs CMS Add: 01/01/2011 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,832 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J1830 DRUG DEF MAXFEE 04/01/2023 03/31/2024 449.82 0.0 Description: INTERFERON BETA-1B / .25 MG Category: Drugs CMS Add: 01/01/1982 CMS Term: J1830 DRUG DEF MAXFEE 04/01/2024 463.31 0.0 Description: INTERFERON BETA-1B / .25 MG Category: Drugs CMS Add: 01/01/1982 CMS Term: J1833 DRUG DEF MAXFEE 04/01/2023 03/31/2024 1.03 0.0 Description: INJECTION, ISAVUCONAZONIUM Category: Drugs CMS Add: 01/01/2016 CMS Term: J1833 DRUG DEF MAXFEE 04/01/2024 1.08 0.0 Description: INJECTION, ISAVUCONAZONIUM Category: Drugs CMS Add: 01/01/2016 CMS Term: J1835 DRUG DEF SYSMAN Description: ITRACONAZOLE INJECTION Category: Drugs CMS Add: 01/01/2002 CMS Term: J1836 DRUG DEF MAXFEE 07/01/2023 0.02 0.0 Description: INJ, METRONIDAZOLE, 10 MG Category: Drugs CMS Add: 07/01/2023 CMS Term: J1840 DRUG DEF SYSMAN Description: KANAMYCIN SULFATE 500 MG INJ Category: Drugs CMS Add: 01/01/1982 CMS Term: 03/31/2024 J1850 DRUG DEF SYSMAN Description: KANAMYCIN SULFATE 75 MG INJ Category: Drugs CMS Add: 01/01/1982 CMS Term: 03/31/2024 J1885 DRUG DEF MAXFEE 07/01/2016 0.27 0.0 Description: KETOROLAC TROMETHAMINE INJ Category: Drugs CMS Add: 01/01/1993 CMS Term: J1890 DRUG DEF SYSMAN Description: CEPHALOTHIN SODIUM INJECTION Category: Drugs CMS Add: 01/01/1982 CMS Term: J1920 DRUG DEF MAXFEE 07/01/2023 0.11 0.0 Description: INJ, LABETALOL HCL, 5MG Category: Drugs CMS Add: 07/01/2023 CMS Term: J1921 DRUG DEF MAXFEE 07/01/2023 0.74 0.0 Description: INJ LABETALOL HCL HIKMA, 5MG Category: Drugs CMS Add: 07/01/2023 CMS Term: J1930 DRUG DEF MAXFEE 10/01/2022 35.33 0.0 Description: LANREOTIDE INJECTION Category: Drugs CMS Add: 01/01/2009 CMS Term: J1931 DRUG DEF MAXFEE 04/01/2023 03/31/2024 37.27 0.0 Description: LARONIDASE INJECTION Category: Drugs CMS Add: 01/01/2005 CMS Term: J1931 DRUG DEF MAXFEE 04/01/2024 38.76 0.0 Description: LARONIDASE INJECTION Category: Drugs CMS Add: 01/01/2005 CMS Term: J1932 DRUG DEF MAXFEE 10/01/2022 77.81 0.0 Description: INJ, LANREOTIDE, (CIPLA) 1MG Category: Drugs CMS Add: 10/01/2022 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,833 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J1939 DRUG DEF MAXFEE 01/01/2024 03/31/2024 0.52 0.0 Description: INJ, BUMETANIDE, 0.5 MG Category: Drugs CMS Add: 01/01/2024 CMS Term: J1939 DRUG DEF MAXFEE 04/01/2024 0.58 0.0 Description: INJ, BUMETANIDE, 0.5 MG Category: Drugs CMS Add: 01/01/2024 CMS Term: J1940 DRUG DEF MAXFEE 04/01/2022 0.32 0.0 Description: FUROSEMIDE INJECTION Category: Drugs CMS Add: 01/01/1982 CMS Term: J1941 DRUG DEF MAXFEE 04/01/2024 235.74 0.0 Description: INJ, FUROSCIX, 20 MG Category: Drugs CMS Add: 07/01/2023 CMS Term: J1941 DRUG DEF MAXFEE 07/01/2023 03/31/2024 215.78 0.0 Description: INJ, FUROSCIX, 20 MG Category: Drugs CMS Add: 07/01/2023 CMS Term: J1943 DRUG DEF MAXFEE 04/01/2023 03/31/2024 3.57 0.0 Description: INJ., ARISTADA INITIO, 1 MG Category: Drugs CMS Add: 10/01/2019 CMS Term: J1943 DRUG DEF MAXFEE 04/01/2024 3.68 0.0 Description: INJ., ARISTADA INITIO, 1 MG Category: Drugs CMS Add: 10/01/2019 CMS Term: J1944 DRUG DEF MAXFEE 04/01/2023 03/31/2024 3.57 0.0 Description: ARIPIPRAZOLE LAUROXIL 1 MG Category: Drugs CMS Add: 10/01/2019 CMS Term: J1944 DRUG DEF MAXFEE 04/01/2024 3.68 0.0 Description: ARIPIPRAZOLE LAUROXIL 1 MG Category: Drugs CMS Add: 10/01/2019 CMS Term: J1945 DRUG DEF SYSMAN Description: LEPIRUDIN Category: Drugs CMS Add: 01/01/2006 CMS Term: J1950 DRUG DEF MAXFEE 04/01/2023 03/31/2024 1022.05 0.0 Description: LEUPROLIDE ACETATE /3.75 MG Category: Drugs CMS Add: 01/01/1986 CMS Term: J1950 DRUG DEF MAXFEE 04/01/2024 1073.15 0.0 Description: LEUPROLIDE ACETATE /3.75 MG Category: Drugs CMS Add: 01/01/1986 CMS Term: J1951 DRUG DEF MAXFEE 04/01/2023 03/31/2024 145.20 0.0 Description: INJ FENSOLVI 0.25 MG Category: Drugs CMS Add: 07/01/2021 CMS Term: J1951 DRUG DEF MAXFEE 04/01/2024 152.46 0.0 Description: INJ FENSOLVI 0.25 MG Category: Drugs CMS Add: 07/01/2021 CMS Term: J1952 DRUG DEF MAXFEE 06/23/2023 103.64 0.0 Description: LEUPROLIDE INJ, CAMCEVI, 1MG Category: Drugs CMS Add: 01/01/2022 CMS Term: J1953 DRUG DEF MAXFEE 07/01/2020 0.03 0.0 Description: LEVETIRACETAM INJECTION Category: Drugs CMS Add: 01/01/2009 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,834 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J1954 NOCOV DEF SYSMAN Description: LEUPROLIDE DEPOT CIPLA 7.5MG Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: J1955 DRUG DEF MAXFEE 01/01/2023 09/30/2023 38.61 0.0 Description: INJ LEVOCARNITINE PER 1 GM Category: Drugs CMS Add: 01/01/1996 CMS Term: J1955 DRUG DEF MAXFEE 10/01/2023 37.45 0.0 Description: INJ LEVOCARNITINE PER 1 GM Category: Drugs CMS Add: 01/01/1996 CMS Term: J1956 DRUG DEF MAXFEE 04/01/2019 0.77 0.0 Description: LEVOFLOXACIN INJECTION Category: Drugs CMS Add: 01/01/1999 CMS Term: J1960 DRUG DEF SYSMAN Description: LEVORPHANOL TARTRATE INJ Category: Drugs CMS Add: 01/01/1982 CMS Term: J1961 DRUG DEF MAXFEE 07/01/2023 22.09 0.0 Description: INJ, LENACAPAVIR, 1 MG Category: Drugs CMS Add: 07/01/2023 CMS Term: J1980 DRUG DEF MAXFEE 04/01/2023 35.13 0.0 Description: HYOSCYAMINE SULFATE INJ Category: Drugs CMS Add: 01/01/1982 CMS Term: J1990 DRUG DEF SYSMAN Description: CHLORDIAZEPOXIDE INJECTION Category: Drugs CMS Add: 01/01/1982 CMS Term: J2001 DRUG DEF MAXFEE 07/01/2022 0.04 0.0 Description: LIDOCAINE INJECTION Category: Drugs CMS Add: 01/01/2004 CMS Term: J2010 DRUG DEF MAXFEE 04/01/2016 06/30/2023 9.98 0.0 Description: LINCOMYCIN INJECTION Category: Drugs CMS Add: 01/01/1982 CMS Term: J2010 DRUG DEF MAXFEE 07/01/2023 8.40 0.0 Description: LINCOMYCIN INJECTION Category: Drugs CMS Add: 01/01/1982 CMS Term: J2020 DRUG DEF MAXFEE 10/01/2022 4.20 0.0 Description: LINEZOLID INJECTION Category: Drugs CMS Add: 01/01/2002 CMS Term: J2021 DRUG DEF MAXFEE 01/01/2023 03/31/2024 22.20 0.0 Description: INJ, LINEZOLID (HOSPIRA) Category: Drugs CMS Add: 01/01/2023 CMS Term: J2021 DRUG DEF MAXFEE 04/01/2024 24.42 0.0 Description: INJ, LINEZOLID (HOSPIRA) Category: Drugs CMS Add: 01/01/2023 CMS Term: J2060 DRUG DEF MAXFEE 10/01/2022 0.48 0.0 Description: LORAZEPAM INJECTION Category: Drugs CMS Add: 01/01/1982 CMS Term: J2062 DRUG DEF SYSMAN Description: LOXAPINE FOR INHALATION 1 MG Category: Drugs CMS Add: 01/01/2019 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,835 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J2150 DRUG DEF MAXFEE 04/01/2023 09/30/2023 2.80 0.0 Description: MANNITOL INJECTION Category: Drugs CMS Add: 01/01/1986 CMS Term: J2150 DRUG DEF MAXFEE 04/01/2024 3.09 0.0 Description: MANNITOL INJECTION Category: Drugs CMS Add: 01/01/1986 CMS Term: J2150 DRUG DEF MAXFEE 10/01/2023 03/31/2024 2.94 0.0 Description: MANNITOL INJECTION Category: Drugs CMS Add: 01/01/1986 CMS Term: J2170 DRUG DEF MAXFEE 04/01/2023 154.40 0.0 0-65years Description: MECASERMIN INJECTION Category: Drugs CMS Add: 01/01/2007 CMS Term: J2175 DRUG DEF MAXFEE 07/01/2020 3.04 0.0 Description: MEPERIDINE HYDROCHL /100 MG Category: Drugs CMS Add: 01/01/1986 CMS Term: J2180 DRUG DEF SYSMAN Description: MEPERIDINE/PROMETHAZINE INJ Category: Drugs CMS Add: 01/01/1982 CMS Term: J2182 DRUG DEF MAXFEE 04/01/2023 09/30/2023 34.77 0.0 Description: INJECTION, MEPOLIZUMAB, 1MG Category: Drugs CMS Add: 01/01/2017 CMS Term: J2182 DRUG DEF MAXFEE 04/01/2024 35.82 0.0 Description: INJECTION, MEPOLIZUMAB, 1MG Category: Drugs CMS Add: 01/01/2017 CMS Term: J2182 DRUG DEF MAXFEE 10/01/2023 03/31/2024 35.29 0.0 Description: INJECTION, MEPOLIZUMAB, 1MG Category: Drugs CMS Add: 01/01/2017 CMS Term: J2184 DRUG DEF MAXFEE 04/01/2023 06/30/2023 3.06 0.0 Description: INJ, MEROPENEM (B. BRAUN) Category: Drugs CMS Add: 01/01/2023 CMS Term: J2184 DRUG DEF MAXFEE 07/01/2023 3.14 0.0 Description: INJ, MEROPENEM (B. BRAUN) Category: Drugs CMS Add: 01/01/2023 CMS Term: J2185 DRUG DEF MAXFEE 07/01/2022 0.46 0.0 Description: MEROPENEM Category: Drugs CMS Add: 01/01/2004 CMS Term: J2186 DRUG DEF MAXFEE 04/01/2023 2.27 0.0 Description: INJ., MEROPENEM, VABORBACTAM Category: Drugs CMS Add: 01/01/2019 CMS Term: J2210 DRUG DEF MAXFEE 07/01/2018 7.14 0.0 Description: METHYLERGONOVIN MALEATE INJ Category: Drugs CMS Add: 01/01/1982 CMS Term: J2212 DRUG DEF MAXFEE 04/01/2023 03/31/2024 1.35 0.0 Description: METHYLNALTREXONE INJECTION Category: Drugs CMS Add: 01/01/2013 CMS Term: J2212 DRUG DEF MAXFEE 04/01/2024 1.40 0.0 Description: METHYLNALTREXONE INJECTION Category: Drugs CMS Add: 01/01/2013 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,836 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J2247 DRUG DEF MAXFEE 01/01/2023 1.57 0.0 Description: INJ, MICAFUNGIN (PAR PHARM) Category: Drugs CMS Add: 01/01/2023 CMS Term: J2248 DRUG DEF MAXFEE 10/01/2021 0.50 0.0 Description: MICAFUNGIN SODIUM INJECTION Category: Drugs CMS Add: 01/01/2007 CMS Term: J2249 DRUG DEF MAXFEE 07/01/2023 2.17 0.0 Description: INJ, REMIMAZOLAM, 1 MG Category: Drugs CMS Add: 07/01/2023 CMS Term: J2250 DRUG DEF MAXFEE 04/01/2018 0.04 0.0 Description: INJ MIDAZOLAM HYDROCHLORIDE Category: Drugs CMS Add: 01/01/1996 CMS Term: J2251 DRUG DEF MAXFEE 01/01/2023 0.31 0.0 Description: INJ MIDAZOLAM (WG CRIT CARE) Category: Drugs CMS Add: 01/01/2023 CMS Term: J2260 DRUG DEF MAXFEE 04/01/2019 1.44 0.0 Description: INJ MILRINONE LACTATE / 5 MG Category: Drugs CMS Add: 01/01/1986 CMS Term: J2265 NOCOV DEF SYSMAN Description: MINOCYCLINE HYDROCHLORIDE Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: J2270 DRUG DEF MAXFEE 04/01/2023 09/30/2023 0.13 0.0 Description: MORPHINE SULFATE INJECTION Category: Drugs CMS Add: 01/01/1982 CMS Term: J2270 DRUG DEF MAXFEE 10/01/2023 0.14 0.0 Description: MORPHINE SULFATE INJECTION Category: Drugs CMS Add: 01/01/1982 CMS Term: J2272 DRUG DEF MAXFEE 01/01/2023 3.20 0.0 Description: INJ, MORPHINE (FRESENIUS) Category: Drugs CMS Add: 01/01/2023 CMS Term: J2274 DRUG DEF MAXFEE 04/01/2020 09/30/2023 0.32 0.0 Description: INJ MORPHINE PF EPID ITHC Category: Drugs CMS Add: 01/01/2015 CMS Term: J2274 DRUG DEF MAXFEE 10/01/2023 7.43 0.0 Description: INJ MORPHINE PF EPID ITHC Category: Drugs CMS Add: 01/01/2015 CMS Term: J2278 DRUG DEF SYSMAN Description: ZICONOTIDE INJECTION Category: Drugs CMS Add: 01/01/2006 CMS Term: J2280 DRUG DEF MAXFEE 01/01/2018 11.57 0.0 Description: INJ, MOXIFLOXACIN 100 MG Category: Drugs CMS Add: 01/01/2004 CMS Term: J2281 DRUG DEF MAXFEE 01/01/2023 12.08 0.0 Description: INJ MOXIFLOXACIN (FRES KABI) Category: Drugs CMS Add: 01/01/2023 CMS Term: J2300 DRUG DEF MAXFEE 04/01/2022 03/31/2024 2.78 0.0 Description: INJ NALBUPHINE HYDROCHLORIDE Category: Drugs CMS Add: 01/01/1996 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,837 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J2300 DRUG DEF MAXFEE 04/01/2024 3.06 0.0 Description: INJ NALBUPHINE HYDROCHLORIDE Category: Drugs CMS Add: 01/01/1996 CMS Term: J2305 DRUG DEF MAXFEE 01/01/2024 1.63 0.0 Description: INJ, NITROGLYCERIN, 5 MG Category: Drugs CMS Add: 07/01/2023 CMS Term: J2305 DRUG DEF MAXFEE 07/01/2023 12/31/2023 1.50 0.0 Description: INJ, NITROGLYCERIN, 5 MG Category: Drugs CMS Add: 07/01/2023 CMS Term: J2310 DRUG DEF MAXFEE 07/01/2020 16.46 0.0 Description: INJ NALOXONE HYDROCHLORIDE Category: Drugs CMS Add: 01/01/1996 CMS Term: J2310 TRANS DEF MAXFEE 07/01/2020 16.46 0.0 Description: INJ NALOXONE HYDROCHLORIDE Category: Transportation CMS Add: 01/01/1996 CMS Term: J2311 DRUG DEF MAXFEE 01/01/2023 13.13 0.0 Description: INJ, NALOXONE HCL (ZIMHI) Category: Drugs CMS Add: 01/01/2023 CMS Term: J2315 DRUG DEF MAXFEE 04/01/2023 03/31/2024 4.39 0.0 Description: NALTREXONE, DEPOT FORM Category: Drugs CMS Add: 01/01/2007 CMS Term: J2315 DRUG DEF MAXFEE 04/01/2024 4.53 0.0 Description: NALTREXONE, DEPOT FORM Category: Drugs CMS Add: 01/01/2007 CMS Term: J2320 DRUG DEF SYSMAN Description: NANDROLONE DECANOATE 50 MG Category: Drugs CMS Add: 01/01/1986 CMS Term: J2323 DRUG DEF MAXFEE 04/01/2023 28.73 0.0 Description: NATALIZUMAB INJECTION Category: Drugs CMS Add: 01/01/2008 CMS Term: J2325 DRUG DEF SYSMAN Description: NESIRITIDE INJECTION Category: Drugs CMS Add: 01/01/2006 CMS Term: J2326 DRUG DEF MAXFEE 01/01/2023 12/31/2023 1165.83 0.0 Y Description: INJ, NUSINERSEN, 0.1MG Category: Drugs CMS Add: 01/01/2018 CMS Term: J2326 DRUG DEF MAXFEE 01/01/2024 1206.63 0.0 Y Description: INJ, NUSINERSEN, 0.1MG Category: Drugs CMS Add: 01/01/2018 CMS Term: J2327 DRUG DEF MAXFEE 01/01/2023 09/30/2023 15.99 0.0 Description: INJ RISANKIZUMAB-RZAA 1 MG Category: Drugs CMS Add: 01/01/2023 CMS Term: J2327 DRUG DEF MAXFEE 04/01/2024 17.16 0.0 Description: INJ RISANKIZUMAB-RZAA 1 MG Category: Drugs CMS Add: 01/01/2023 CMS Term: J2327 DRUG DEF MAXFEE 10/01/2023 03/31/2024 16.63 0.0 Description: INJ RISANKIZUMAB-RZAA 1 MG Category: Drugs CMS Add: 01/01/2023 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,838 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J2329 DRUG DEF MAXFEE 04/01/2024 73.31 0.0 Y Description: INJ UBLITUXIMAB-XIIY, 1 MG Category: Drugs CMS Add: 07/01/2023 CMS Term: J2329 DRUG DEF MAXFEE 07/01/2023 03/31/2024 68.83 0.0 Y Description: INJ UBLITUXIMAB-XIIY, 1 MG Category: Drugs CMS Add: 07/01/2023 CMS Term: J2329 TRANS DEF MAXFEE 04/01/2024 73.31 0.0 Y Description: INJ UBLITUXIMAB-XIIY, 1 MG Category: Transportation CMS Add: 07/01/2023 CMS Term: J2329 TRANS DEF MAXFEE 07/01/2023 03/31/2024 68.83 0.0 Y Description: INJ UBLITUXIMAB-XIIY, 1 MG Category: Transportation CMS Add: 07/01/2023 CMS Term: J2350 DRUG DEF MAXFEE 04/01/2023 03/31/2024 65.71 0.0 Description: INJECTION, OCRELIZUMAB, 1 MG Category: Drugs CMS Add: 01/01/2018 CMS Term: J2350 DRUG DEF MAXFEE 04/01/2024 69.00 0.0 Description: INJECTION, OCRELIZUMAB, 1 MG Category: Drugs CMS Add: 01/01/2018 CMS Term: J2353 DRUG DEF MAXFEE 04/01/2023 09/30/2023 227.99 0.0 Description: OCTREOTIDE INJECTION, DEPOT Category: Drugs CMS Add: 01/01/2004 CMS Term: J2353 DRUG DEF MAXFEE 04/01/2024 237.20 0.0 Description: OCTREOTIDE INJECTION, DEPOT Category: Drugs CMS Add: 01/01/2004 CMS Term: J2353 DRUG DEF MAXFEE 10/01/2023 03/31/2024 232.54 0.0 Description: OCTREOTIDE INJECTION, DEPOT Category: Drugs CMS Add: 01/01/2004 CMS Term: J2354 DRUG DEF MAXFEE 07/01/2019 0.13 0.0 Description: OCTREOTIDE INJ, NON-DEPOT Category: Drugs CMS Add: 01/01/2004 CMS Term: J2355 DRUG DEF SYSMAN Description: OPRELVEKIN INJECTION Category: Drugs CMS Add: 01/01/1999 CMS Term: J2356 DRUG DEF MAXFEE 04/01/2023 03/31/2024 19.23 0.0 Y 12-999years Description: INJ TEZEPELUMAB-EKKO, 1MG Category: Drugs CMS Add: 07/01/2022 CMS Term: J2356 DRUG DEF MAXFEE 04/01/2024 20.19 0.0 Y 12-999years Description: INJ TEZEPELUMAB-EKKO, 1MG Category: Drugs CMS Add: 07/01/2022 CMS Term: J2357 DRUG DEF MAXFEE 04/01/2023 09/30/2023 44.88 0.0 12-999years Description: OMALIZUMAB INJECTION Category: Drugs CMS Add: 01/01/2005 CMS Term: J2357 DRUG DEF MAXFEE 04/01/2024 48.47 0.0 12-999years Description: OMALIZUMAB INJECTION Category: Drugs CMS Add: 01/01/2005 CMS Term: J2357 DRUG DEF MAXFEE 10/01/2023 03/31/2024 45.73 0.0 12-999years Description: OMALIZUMAB INJECTION Category: Drugs CMS Add: 01/01/2005 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,839 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J2358 DRUG DEF MAXFEE 01/01/2015 2.95 0.0 Description: OLANZAPINE LONG-ACTING INJ Category: Drugs CMS Add: 01/01/2011 CMS Term: J2359 DRUG DEF MAXFEE 01/01/2024 1.05 0.0 Description: INJ. OLANZAPINE, 0.5MG Category: Drugs CMS Add: 10/01/2023 CMS Term: J2359 DRUG DEF MAXFEE 10/01/2023 12/31/2023 1.34 0.0 Description: INJ. OLANZAPINE, 0.5MG Category: Drugs CMS Add: 10/01/2023 CMS Term: J2360 DRUG DEF MAXFEE 04/01/2017 12.60 0.0 Description: ORPHENADRINE INJECTION Category: Drugs CMS Add: 01/01/1982 CMS Term: J2371 DRUG DEF MAXFEE 07/01/2023 0.01 0.0 Description: INJ PHENYLEPHRINE HCL 20 MCG Category: Drugs CMS Add: 07/01/2023 CMS Term: J2371 TRANS DEF MAXFEE 07/01/2023 0.01 0.0 Description: INJ PHENYLEPHRINE HCL 20 MCG Category: Transportation CMS Add: 07/01/2023 CMS Term: J2372 DRUG DEF MAXFEE 07/01/2023 0.21 0.0 Description: INJ, BIORPHEN, 20 MICROGRAMS Category: Drugs CMS Add: 07/01/2023 CMS Term: J2372 TRANS DEF MAXFEE 07/01/2023 0.21 0.0 Description: INJ, BIORPHEN, 20 MICROGRAMS Category: Transportation CMS Add: 07/01/2023 CMS Term: J2401 DRUG DEF MAXFEE 01/01/2023 0.03 0.0 Description: CHLOROPROCAINE HCL INJECTION Category: Drugs CMS Add: 01/01/2023 CMS Term: J2402 DRUG DEF MAXFEE 01/01/2023 0.32 0.0 Description: CHLOROPROCAINE (CLOROTEKAL) Category: Drugs CMS Add: 01/01/2023 CMS Term: J2403 NOCOV DEF SYSMAN Description: CHLOROPROCAINE OPHT GEL, 1MG Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: J2404 DRUG DEF MAXFEE 01/01/2024 0.08 0.0 Description: INJ, NICARDIPINE 0.1 MG Category: Drugs CMS Add: 01/01/2024 CMS Term: J2405 DRUG DEF MAXFEE 04/01/2023 0.12 0.0 Description: ONDANSETRON HCL INJECTION Category: Drugs CMS Add: 01/01/1993 CMS Term: J2406 DRUG DEF MAXFEE 01/01/2023 03/31/2024 44.02 0.0 Description: INJECTION, ORITAVANCIN 10 MG Category: Drugs CMS Add: 10/01/2021 CMS Term: J2406 DRUG DEF MAXFEE 04/01/2024 45.34 0.0 Description: INJECTION, ORITAVANCIN 10 MG Category: Drugs CMS Add: 10/01/2021 CMS Term: J2407 DRUG DEF MAXFEE 04/01/2023 29.58 0.0 Description: INJECTION, ORITAVANCIN Category: Drugs CMS Add: 01/01/2016 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,840 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J2410 DRUG DEF SYSMAN Description: OXYMORPHONE HCL INJECTION Category: Drugs CMS Add: 01/01/1982 CMS Term: J2425 DRUG DEF MAXFEE 04/01/2023 26.26 0.0 Description: PALIFERMIN INJECTION Category: Drugs CMS Add: 01/01/2006 CMS Term: J2426 DRUG DEF MAXFEE 04/01/2023 03/31/2024 15.02 0.0 Description: INJ, INVEGA SUSTENNA, 1 MG Category: Drugs CMS Add: 01/01/2011 CMS Term: J2426 DRUG DEF MAXFEE 04/01/2024 15.61 0.0 Description: INJ, INVEGA SUSTENNA, 1 MG Category: Drugs CMS Add: 01/01/2011 CMS Term: J2427 DRUG DEF MAXFEE 04/01/2024 13.38 0.0 Description: INJ, INVEGA HAFYERA/TRINZA Category: Drugs CMS Add: 07/01/2023 CMS Term: J2427 DRUG DEF MAXFEE 07/01/2023 03/31/2024 12.77 0.0 Description: INJ, INVEGA HAFYERA/TRINZA Category: Drugs CMS Add: 07/01/2023 CMS Term: J2430 DRUG DEF MAXFEE 04/01/2022 12.74 0.0 Description: PAMIDRONATE DISODIUM /30 MG Category: Drugs CMS Add: 01/01/1982 CMS Term: J2440 DRUG DEF MAXFEE 10/01/2021 39.38 0.0 Description: PAPAVERIN HCL INJECTION Category: Drugs CMS Add: 01/01/1986 CMS Term: J2460 DRUG DEF SYSMAN Description: OXYTETRACYCLINE INJECTION Category: Drugs CMS Add: 01/01/1982 CMS Term: J2469 DRUG DEF MAXFEE 04/01/2022 0.63 0.0 Description: PALONOSETRON HCL Category: Drugs CMS Add: 01/01/2005 CMS Term: J2501 DRUG DEF MAXFEE 10/01/2019 2.00 0.0 Description: PARICALCITOL Category: Drugs CMS Add: 01/01/2003 CMS Term: J2502 DRUG DEF MAXFEE 04/01/2023 09/30/2023 279.05 0.0 Description: INJ, PASIREOTIDE LONG ACTING Category: Drugs CMS Add: 01/01/2016 CMS Term: J2502 DRUG DEF MAXFEE 04/01/2024 304.73 0.0 Description: INJ, PASIREOTIDE LONG ACTING Category: Drugs CMS Add: 01/01/2016 CMS Term: J2502 DRUG DEF MAXFEE 10/01/2023 03/31/2024 291.61 0.0 Description: INJ, PASIREOTIDE LONG ACTING Category: Drugs CMS Add: 01/01/2016 CMS Term: J2503 DRUG DEF SYSMAN Description: PEGAPTANIB SODIUM INJECTION Category: Drugs CMS Add: 01/01/2006 CMS Term: J2504 DRUG DEF MAXFEE 04/01/2018 364.49 0.0 Description: PEGADEMASE BOVINE, 25 IU Category: Drugs CMS Add: 01/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,841 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J2506 DRUG DEF MAXFEE 01/01/2022 561.57 0.0 Description: INJ PEGFILGRAST EX BIO 0.5MG Category: Drugs CMS Add: 01/01/2022 CMS Term: J2507 DRUG DEF MAXFEE 04/01/2023 09/30/2023 3583.81 0.0 Y Description: PEGLOTICASE INJECTION Category: Drugs CMS Add: 01/01/2012 CMS Term: J2507 DRUG DEF MAXFEE 04/01/2024 3757.90 0.0 Y Description: PEGLOTICASE INJECTION Category: Drugs CMS Add: 01/01/2012 CMS Term: J2507 DRUG DEF MAXFEE 10/01/2023 03/31/2024 3669.82 0.0 Y Description: PEGLOTICASE INJECTION Category: Drugs CMS Add: 01/01/2012 CMS Term: J2508 DRUG DEF MAXFEE 01/01/2024 03/31/2024 217.09 0.0 Description: PEGUNIGALSIDASE ALFA-IWXJ Category: Drugs CMS Add: 01/01/2024 CMS Term: J2508 DRUG DEF MAXFEE 04/01/2024 227.95 0.0 Description: PEGUNIGALSIDASE ALFA-IWXJ Category: Drugs CMS Add: 01/01/2024 CMS Term: J2510 DRUG DEF MAXFEE 04/01/2023 40.56 0.0 Description: PENICILLIN G PROCAINE INJ Category: Drugs CMS Add: 01/01/1982 CMS Term: J2513 DRUG DEF SYSMAN Description: PENTASTARCH 10% SOLUTION Category: Drugs CMS Add: 01/01/2006 CMS Term: J2515 DRUG DEF MAXFEE 04/01/2022 47.25 0.0 Description: PENTOBARBITAL SODIUM INJ Category: Drugs CMS Add: 01/01/1982 CMS Term: J2540 DRUG DEF MAXFEE 01/01/2011 0.44 0.0 Description: PENICILLIN G POTASSIUM INJ Category: Drugs CMS Add: 01/01/1982 CMS Term: J2543 DRUG DEF MAXFEE 04/01/2021 1.05 0.0 Description: PIPERACILLIN/TAZOBACTAM Category: Drugs CMS Add: 01/01/2000 CMS Term: J2545 DRUG DEF MAXFEE 01/01/2020 09/30/2023 151.73 0.0 Description: PENTAMIDINE NON-COMP UNIT Category: Drugs CMS Add: 01/01/1992 CMS Term: J2545 DRUG DEF MAXFEE 10/01/2023 94.50 0.0 Description: PENTAMIDINE NON-COMP UNIT Category: Drugs CMS Add: 01/01/1992 CMS Term: J2547 DRUG DEF MAXFEE 01/01/2016 1.66 0.0 Description: INJECTION, PERAMIVIR Category: Drugs CMS Add: 01/01/2016 CMS Term: J2550 DRUG DEF MAXFEE 07/01/2022 1.81 0.0 Description: PROMETHAZINE HCL INJECTION Category: Drugs CMS Add: 01/01/1982 CMS Term: J2560 DRUG DEF MAXFEE 04/01/2018 03/31/2024 40.32 0.0 Description: PHENOBARBITAL SODIUM INJ Category: Drugs CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,842 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J2560 DRUG DEF MAXFEE 04/01/2024 33.92 0.0 Description: PHENOBARBITAL SODIUM INJ Category: Drugs CMS Add: 01/01/1982 CMS Term: J2561 DRUG DEF MAXFEE 07/01/2023 1.40 0.0 Description: INJ, SEZABY, 1 MG Category: Drugs CMS Add: 07/01/2023 CMS Term: J2562 DRUG DEF MAXFEE 01/01/2024 21.87 0.0 Description: PLERIXAFOR INJECTION Category: Drugs CMS Add: 01/01/2010 CMS Term: J2562 DRUG DEF MAXFEE 04/01/2023 09/30/2023 436.10 0.0 Description: PLERIXAFOR INJECTION Category: Drugs CMS Add: 01/01/2010 CMS Term: J2562 DRUG DEF MAXFEE 10/01/2023 12/31/2023 47.97 0.0 Description: PLERIXAFOR INJECTION Category: Drugs CMS Add: 01/01/2010 CMS Term: J2590 DRUG DEF MAXFEE 04/01/2023 0.94 0.0 Description: OXYTOCIN INJECTION Category: Drugs CMS Add: 01/01/1986 CMS Term: J2597 DRUG DEF MAXFEE 01/01/2024 3.94 0.0 Description: INJ DESMOPRESSIN ACETATE Category: Drugs CMS Add: 01/01/1996 CMS Term: J2597 DRUG DEF MAXFEE 07/01/2023 12/31/2023 5.07 0.0 Description: INJ DESMOPRESSIN ACETATE Category: Drugs CMS Add: 01/01/1996 CMS Term: J2597 DRUG DEF MAXFEE 10/01/2019 06/30/2023 2.70 0.0 Description: INJ DESMOPRESSIN ACETATE Category: Drugs CMS Add: 01/01/1996 CMS Term: J2598 DRUG DEF MAXFEE 07/01/2023 09/30/2023 2.63 0.0 Description: INJ, VASOPRESSIN, 1 UNIT Category: Drugs CMS Add: 07/01/2023 CMS Term: J2598 DRUG DEF MAXFEE 10/01/2023 1.21 0.0 Description: INJ, VASOPRESSIN, 1 UNIT Category: Drugs CMS Add: 07/01/2023 CMS Term: J2599 DRUG DEF MAXFEE 07/01/2023 2.63 0.0 Description: INJ VASOPRESSIN (AM REG) 1 U Category: Drugs CMS Add: 07/01/2023 CMS Term: J2650 DRUG DEF SYSMAN Description: PREDNISOLONE ACETATE INJ Category: Drugs CMS Add: 01/01/1982 CMS Term: J2670 DRUG DEF SYSMAN Description: TOTAZOLINE HCL INJECTION Category: Drugs CMS Add: 01/01/1986 CMS Term: J2675 DRUG DEF MAXFEE 01/01/2024 2.10 0.0 Description: INJ PROGESTERONE PER 50 MG Category: Drugs CMS Add: 01/01/1986 CMS Term: J2675 DRUG DEF MAXFEE 07/01/2018 12/31/2023 3.14 0.0 Description: INJ PROGESTERONE PER 50 MG Category: Drugs CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,843 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J2679 DRUG DEF MAXFEE 01/01/2024 10.08 0.0 Description: INJ FLUPHENAZINE HCL 1.25 MG Category: Drugs CMS Add: 01/01/2024 CMS Term: J2680 DRUG DEF MAXFEE 10/01/2018 16.38 0.0 Description: FLUPHENAZINE DECANOATE 25 MG Category: Drugs CMS Add: 01/01/1982 CMS Term: J2690 DRUG DEF MAXFEE 04/01/2022 76.40 0.0 Description: PROCAINAMIDE HCL INJECTION Category: Drugs CMS Add: 01/01/1982 CMS Term: J2700 DRUG DEF MAXFEE 10/01/2021 1.35 0.0 Description: OXACILLIN SODIUM INJECITON Category: Drugs CMS Add: 01/01/1982 CMS Term: J2704 DRUG DEF MAXFEE 10/01/2022 0.12 0.0 Description: INJ, PROPOFOL, 10 MG Category: Drugs CMS Add: 01/01/2015 CMS Term: J2710 DRUG DEF MAXFEE 01/01/2021 0.32 0.0 Description: NEOSTIGMINE METHYLSLFTE INJ Category: Drugs CMS Add: 01/01/1982 CMS Term: J2720 DRUG DEF MAXFEE 10/01/2020 09/30/2023 1.23 0.0 Description: INJ PROTAMINE SULFATE/10 MG Category: Drugs CMS Add: 01/01/1982 CMS Term: J2720 DRUG DEF MAXFEE 10/01/2023 1.39 0.0 Description: INJ PROTAMINE SULFATE/10 MG Category: Drugs CMS Add: 01/01/1982 CMS Term: J2724 DRUG DEF MAXFEE 04/01/2015 15.75 0.0 Description: PROTEIN C CONCENTRATE Category: Drugs CMS Add: 01/01/2008 CMS Term: J2725 DRUG DEF SYSMAN Description: INJ PROTIRELIN PER 250 MCG Category: Drugs CMS Add: 01/01/1995 CMS Term: J2730 DRUG DEF MAXFEE 05/01/2010 91.04 0.0 Description: PRALIDOXIME CHLORIDE INJ Category: Drugs CMS Add: 01/01/1986 CMS Term: J2760 DRUG DEF MAXFEE 04/01/2018 438.90 0.0 Description: PHENTOLAINE MESYLATE INJ Category: Drugs CMS Add: 01/01/1982 CMS Term: J2765 DRUG DEF MAXFEE 10/01/2022 1.24 0.0 Description: METOCLOPRAMIDE HCL INJECTION Category: Drugs CMS Add: 01/01/1982 CMS Term: J2770 DRUG DEF MAXFEE 10/01/2016 143.36 0.0 Description: QUINUPRISTIN/DALFOPRISTIN Category: Drugs CMS Add: 01/01/2001 CMS Term: J2777 DRUG DEF MAXFEE 10/01/2022 38.33 0.0 Description: INJ, FARICIMAB-SVOA, 0.1MG Category: Drugs CMS Add: 10/01/2022 CMS Term: J2778 DRUG DEF MAXFEE 05/01/2010 409.50 0.0 Description: RANIBIZUMAB INJECTION Category: Drugs CMS Add: 01/01/2008 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,844 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J2779 DRUG DEF MAXFEE 07/01/2022 84.00 0.0 Description: INJ, SUSVIMO 0.1 MG Category: Drugs CMS Add: 07/01/2022 CMS Term: J2780 DRUG DEF MAXFEE 10/01/2022 8.66 0.0 Description: RANITIDINE HYDROCHLORIDE INJ Category: Drugs CMS Add: 01/01/2000 CMS Term: J2781 DRUG DEF MAXFEE 10/01/2023 153.30 0.0 Description: INJ, PEGCETACOPLAN, 1MG Category: Drugs CMS Add: 10/01/2023 CMS Term: J2783 DRUG DEF MAXFEE 04/01/2023 09/30/2023 365.06 0.0 Description: RASBURICASE Category: Drugs CMS Add: 01/01/2004 CMS Term: J2783 DRUG DEF MAXFEE 04/01/2024 376.08 0.0 Description: RASBURICASE Category: Drugs CMS Add: 01/01/2004 CMS Term: J2783 DRUG DEF MAXFEE 10/01/2023 03/31/2024 372.36 0.0 Description: RASBURICASE Category: Drugs CMS Add: 01/01/2004 CMS Term: J2785 DRUG DEF MAXFEE 01/01/2024 5.25 0.0 Description: REGADENOSON INJECTION Category: Drugs CMS Add: 01/01/2009 CMS Term: J2785 DRUG DEF MAXFEE 04/01/2023 06/30/2023 45.94 0.0 Description: REGADENOSON INJECTION Category: Drugs CMS Add: 01/01/2009 CMS Term: J2785 DRUG DEF MAXFEE 07/01/2023 12/31/2023 7.88 0.0 Description: REGADENOSON INJECTION Category: Drugs CMS Add: 01/01/2009 CMS Term: J2786 DRUG DEF MAXFEE 01/01/2023 10.80 0.0 Description: INJECTION, RESLIZUMAB, 1MG Category: Drugs CMS Add: 01/01/2017 CMS Term: J2787 NOCOV DEF SYSMAN Description: RIBOFLAVIN 5'PHOS OPTH<=3ML Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: J2788 DRUG DEF MAXFEE 07/01/2018 30.40 0.0 Description: RHO D IMMUNE GLOBULIN 50 MCG Category: Drugs CMS Add: 01/01/2003 CMS Term: J2790 DRUG DEF MAXFEE 04/01/2024 86.97 0.0 Description: RHO D IMMUNE GLOBULIN INJ Category: Drugs CMS Add: 01/01/1986 CMS Term: J2790 DRUG DEF MAXFEE 07/01/2022 03/31/2024 80.40 0.0 Description: RHO D IMMUNE GLOBULIN INJ Category: Drugs CMS Add: 01/01/1986 CMS Term: J2791 DRUG DEF MAXFEE 07/01/2011 10.21 0.0 Description: RHOPHYLAC INJECTION Category: Drugs CMS Add: 01/01/2008 CMS Term: J2792 DRUG DEF MAXFEE 01/01/2023 38.02 0.0 Description: RHO(D) IMMUNE GLOBULIN H, SD Category: Drugs CMS Add: 01/01/1999 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,845 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J2793 NOCOV DEF SYSMAN Description: RILONACEPT INJECTION Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: J2794 DRUG DEF MAXFEE 04/01/2023 03/31/2024 12.31 0.0 Description: INJ RISPERDAL CONSTA, 0.5 MG Category: Drugs CMS Add: 01/01/2005 CMS Term: J2794 DRUG DEF MAXFEE 04/01/2024 11.15 0.0 Description: INJ RISPERDAL CONSTA, 0.5 MG Category: Drugs CMS Add: 01/01/2005 CMS Term: J2795 DRUG DEF MAXFEE 01/01/2016 0.04 0.0 Description: ROPIVACAINE HCL INJECTION Category: Drugs CMS Add: 01/01/2001 CMS Term: J2796 DRUG DEF MAXFEE 04/01/2023 03/31/2024 100.17 0.0 Description: ROMIPLOSTIM INJECTION Category: Drugs CMS Add: 01/01/2010 CMS Term: J2796 DRUG DEF MAXFEE 04/01/2024 105.18 0.0 Description: ROMIPLOSTIM INJECTION Category: Drugs CMS Add: 01/01/2010 CMS Term: J2797 DRUG DEF SYSMAN Description: INJ., ROLAPITANT, 0.5 MG Category: Drugs CMS Add: 01/01/2019 CMS Term: J2798 DRUG DEF MAXFEE 04/01/2023 03/31/2024 12.08 0.0 Description: INJ., PERSERIS, 0.5 MG Category: Drugs CMS Add: 10/01/2019 CMS Term: J2798 DRUG DEF MAXFEE 04/01/2024 12.68 0.0 Description: INJ., PERSERIS, 0.5 MG Category: Drugs CMS Add: 10/01/2019 CMS Term: J2799 DRUG DEF MAXFEE 01/01/2024 03/31/2024 25.87 0.0 Description: INJ, UZEDY, 1 MG Category: Drugs CMS Add: 01/01/2024 CMS Term: J2799 DRUG DEF MAXFEE 04/01/2024 26.91 0.0 Description: INJ, UZEDY, 1 MG Category: Drugs CMS Add: 01/01/2024 CMS Term: J2800 DRUG DEF MAXFEE 01/01/2021 6.26 0.0 Description: METHOCARBAMOL INJECTION Category: Drugs CMS Add: 01/01/1982 CMS Term: J2805 DRUG DEF SYSMAN Description: SINCALIDE INJECTION Category: Drugs CMS Add: 01/01/2006 CMS Term: J2806 NOCOV DEF SYSMAN Description: INJ SINCALIDE, MAIA, 5 MCG Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: J2810 DRUG DEF SYSMAN Description: INJ THEOPHYLLINE PER 40 MG Category: Drugs CMS Add: 01/01/1982 CMS Term: J2820 DRUG DEF MAXFEE 01/01/2020 12/31/2023 55.10 0.0 Description: SARGRAMOSTIM INJECTION Category: Drugs CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,846 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J2820 DRUG DEF MAXFEE 01/01/2024 64.78 0.0 Description: SARGRAMOSTIM INJECTION Category: Drugs CMS Add: 01/01/1982 CMS Term: J2840 DRUG DEF MAXFEE 04/01/2018 536.03 0.0 Description: INJ SEBELIPASE ALFA 1 MG Category: Drugs CMS Add: 01/01/2017 CMS Term: J2850 DRUG DEF SYSMAN Description: INJ SECRETIN SYNTHETIC HUMAN Category: Drugs CMS Add: 01/01/2006 CMS Term: J2860 DRUG DEF MAXFEE 01/01/2023 12/31/2023 139.28 0.0 Description: INJECTION, SILTUXIMAB Category: Drugs CMS Add: 01/01/2016 CMS Term: J2860 DRUG DEF MAXFEE 01/01/2024 153.50 0.0 Description: INJECTION, SILTUXIMAB Category: Drugs CMS Add: 01/01/2016 CMS Term: J2910 DRUG DEF SYSMAN Description: AUROTHIOGLUCOSE INJECITON Category: Drugs CMS Add: 01/01/1982 CMS Term: J2916 DRUG DEF MAXFEE 04/01/2018 1.72 0.0 Description: NA FERRIC GLUCONATE COMPLEX Category: Drugs CMS Add: 01/01/2003 CMS Term: J2920 DRUG DEF MAXFEE 07/01/2017 06/30/2023 1.26 0.0 Description: METHYLPREDNISOLONE INJECTION Category: Drugs CMS Add: 01/01/1982 CMS Term: 03/31/2024 J2920 DRUG DEF MAXFEE 07/01/2023 1.37 0.0 Description: METHYLPREDNISOLONE INJECTION Category: Drugs CMS Add: 01/01/1982 CMS Term: 03/31/2024 J2930 DRUG DEF MAXFEE 07/01/2017 06/30/2023 3.94 0.0 Description: METHYLPREDNISOLONE INJECTION Category: Drugs CMS Add: 01/01/1984 CMS Term: 03/31/2024 J2930 DRUG DEF MAXFEE 07/01/2023 4.27 0.0 Description: METHYLPREDNISOLONE INJECTION Category: Drugs CMS Add: 01/01/1984 CMS Term: 03/31/2024 J2940 DRUG DEF SYSMAN Description: SOMATREM INJECTION Category: Drugs CMS Add: 01/01/2002 CMS Term: J2941 DRUG DEF MAXFEE 07/01/2018 09/30/2023 57.03 0.0 Description: SOMATROPIN INJECTION Category: Drugs CMS Add: 01/01/2002 CMS Term: J2941 DRUG DEF MAXFEE 10/01/2023 59.89 0.0 Description: SOMATROPIN INJECTION Category: Drugs CMS Add: 01/01/2002 CMS Term: J2950 DRUG DEF SYSMAN Description: PROMAZINE HCL INJECTION Category: Drugs CMS Add: 01/01/1982 CMS Term: J2993 DRUG DEF MAXFEE 01/01/2023 12/31/2023 3021.03 0.0 Description: RETEPLASE INJECTION Category: Drugs CMS Add: 01/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,847 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J2993 DRUG DEF MAXFEE 01/01/2024 3172.09 0.0 Description: RETEPLASE INJECTION Category: Drugs CMS Add: 01/01/2001 CMS Term: J2995 DRUG DEF SYSMAN Description: INJ STREPTOKINASE /250000 IU Category: Drugs CMS Add: 01/01/1986 CMS Term: J2997 DRUG DEF MAXFEE 04/01/2023 03/31/2024 88.17 0.0 Description: ALTEPLASE RECOMBINANT Category: Drugs CMS Add: 01/01/2001 CMS Term: J2997 DRUG DEF MAXFEE 04/01/2024 92.40 0.0 Description: ALTEPLASE RECOMBINANT Category: Drugs CMS Add: 01/01/2001 CMS Term: J2998 DRUG DEF MAXFEE 04/01/2024 34.64 0.0 Description: INJ PLASMINOGEN TVMH 1MG Category: Drugs CMS Add: 07/01/2022 CMS Term: J2998 DRUG DEF MAXFEE 07/01/2022 03/31/2024 31.50 0.0 Description: INJ PLASMINOGEN TVMH 1MG Category: Drugs CMS Add: 07/01/2022 CMS Term: J3000 DRUG DEF MAXFEE 04/01/2018 78.75 0.0 Description: STREPTOMYCIN INJECTION Category: Drugs CMS Add: 01/01/1982 CMS Term: J3010 DRUG DEF MAXFEE 04/01/2023 09/30/2023 0.71 0.0 Description: FENTANYL CITRATE INJECTION Category: Drugs CMS Add: 01/01/1982 CMS Term: J3010 DRUG DEF MAXFEE 10/01/2023 0.78 0.0 Description: FENTANYL CITRATE INJECTION Category: Drugs CMS Add: 01/01/1982 CMS Term: J3030 DRUG DEF MAXFEE 01/01/2022 06/30/2023 12.60 0.0 Description: SUMATRIPTAN SUCCINATE / 6 MG Category: Drugs CMS Add: 01/01/1986 CMS Term: J3030 DRUG DEF MAXFEE 07/01/2023 11.55 0.0 Description: SUMATRIPTAN SUCCINATE / 6 MG Category: Drugs CMS Add: 01/01/1986 CMS Term: J3031 DRUG DEF MAXFEE 04/01/2023 03/31/2024 3.26 0.0 Description: INJ., FREMANEZUMAB-VFRM 1 MG Category: Drugs CMS Add: 10/01/2019 CMS Term: J3031 DRUG DEF MAXFEE 04/01/2024 3.42 0.0 Description: INJ., FREMANEZUMAB-VFRM 1 MG Category: Drugs CMS Add: 10/01/2019 CMS Term: J3032 DRUG DEF MAXFEE 04/01/2023 09/30/2023 17.33 0.0 Y Description: INJ. EPTINEZUMAB-JJMR 1 MG Category: Drugs CMS Add: 10/01/2020 CMS Term: J3032 DRUG DEF MAXFEE 04/01/2024 18.56 0.0 Y Description: INJ. EPTINEZUMAB-JJMR 1 MG Category: Drugs CMS Add: 10/01/2020 CMS Term: J3032 DRUG DEF MAXFEE 10/01/2023 03/31/2024 17.93 0.0 Y Description: INJ. EPTINEZUMAB-JJMR 1 MG Category: Drugs CMS Add: 10/01/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,848 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J3060 DRUG DEF MAXFEE 04/01/2023 45.82 0.0 Description: INJ, TALIGLUCERASE ALFA 10 U Category: Drugs CMS Add: 01/01/2014 CMS Term: J3070 DRUG DEF SYSMAN Description: PENTAZOCINE INJECTION Category: Drugs CMS Add: 01/01/1982 CMS Term: J3090 DRUG DEF MAXFEE 01/01/2023 12/31/2023 1.76 0.0 Description: INJ TEDIZOLID PHOSPHATE Category: Drugs CMS Add: 01/01/2016 CMS Term: J3090 DRUG DEF MAXFEE 01/01/2024 1.83 0.0 Description: INJ TEDIZOLID PHOSPHATE Category: Drugs CMS Add: 01/01/2016 CMS Term: J3095 DRUG DEF MAXFEE 04/01/2023 8.09 0.0 Description: TELAVANCIN INJECTION Category: Drugs CMS Add: 01/01/2011 CMS Term: J3101 DRUG DEF MAXFEE 04/01/2023 03/31/2024 154.94 0.0 Description: TENECTEPLASE INJECTION Category: Drugs CMS Add: 01/01/2009 CMS Term: J3101 DRUG DEF MAXFEE 04/01/2024 159.59 0.0 Description: TENECTEPLASE INJECTION Category: Drugs CMS Add: 01/01/2009 CMS Term: J3105 DRUG DEF MAXFEE 01/01/2021 1.37 0.0 Description: TERBUTALINE SULFATE INJ Category: Drugs CMS Add: 01/01/1987 CMS Term: J3110 DRUG DEF MAXFEE 10/01/2021 44.01 0.0 Y Description: TERIPARATIDE INJECTION Category: Drugs CMS Add: 01/01/2005 CMS Term: J3111 DRUG DEF MAXFEE 04/01/2023 09/30/2023 11.16 0.0 Y Description: INJ. ROMOSOZUMAB-AQQG 1 MG Category: Drugs CMS Add: 10/01/2019 CMS Term: J3111 DRUG DEF MAXFEE 04/01/2024 12.17 0.0 Y Description: INJ. ROMOSOZUMAB-AQQG 1 MG Category: Drugs CMS Add: 10/01/2019 CMS Term: J3111 DRUG DEF MAXFEE 10/01/2023 03/31/2024 11.59 0.0 Y Description: INJ. ROMOSOZUMAB-AQQG 1 MG Category: Drugs CMS Add: 10/01/2019 CMS Term: J3121 DRUG DEF MAXFEE 10/01/2018 0.07 0.0 Y 1-400 Description: INJ TESTOSTERO ENANTHATE 1MG Category: Drugs CMS Add: 01/01/2015 CMS Term: J3145 DRUG DEF MAXFEE 01/01/2023 06/30/2023 2.29 0.0 Y 1-750 Description: TESTOSTERONE UNDECANOATE 1MG Category: Drugs CMS Add: 01/01/2015 CMS Term: J3145 DRUG DEF MAXFEE 01/01/2024 2.52 0.0 Y 1-750 Description: TESTOSTERONE UNDECANOATE 1MG Category: Drugs CMS Add: 01/01/2015 CMS Term: J3145 DRUG DEF MAXFEE 07/01/2023 12/31/2023 2.40 0.0 Y 1-750 Description: TESTOSTERONE UNDECANOATE 1MG Category: Drugs CMS Add: 01/01/2015 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,849 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J3230 DRUG DEF MAXFEE 01/01/2021 34.76 0.0 Description: CHLORPROMAZINE HCL INJECTION Category: Drugs CMS Add: 01/01/1982 CMS Term: J3240 DRUG DEF MAXFEE 04/01/2023 03/31/2024 2025.47 0.0 Description: THYROTROPIN INJECTION Category: Drugs CMS Add: 01/01/1986 CMS Term: J3240 DRUG DEF MAXFEE 04/01/2024 2076.10 0.0 Description: THYROTROPIN INJECTION Category: Drugs CMS Add: 01/01/1986 CMS Term: J3241 DRUG DEF MAXFEE 01/01/2023 12/31/2023 324.90 0.0 Description: INJ. TEPROTUMUMAB-TRBW 10 MG Category: Drugs CMS Add: 10/01/2020 CMS Term: J3241 DRUG DEF MAXFEE 01/01/2024 334.33 0.0 Description: INJ. TEPROTUMUMAB-TRBW 10 MG Category: Drugs CMS Add: 10/01/2020 CMS Term: J3243 DRUG DEF MAXFEE 07/01/2023 1.26 0.0 Description: TIGECYCLINE INJECTION Category: Drugs CMS Add: 01/01/2007 CMS Term: J3243 DRUG DEF MAXFEE 10/01/2019 06/30/2023 2.18 0.0 Description: TIGECYCLINE INJECTION Category: Drugs CMS Add: 01/01/2007 CMS Term: J3244 DRUG DEF MAXFEE 01/01/2023 2.63 0.0 Description: INJ. TIGECYCLINE (ACCORD) Category: Drugs CMS Add: 01/01/2023 CMS Term: J3245 DRUG DEF MAXFEE 04/01/2023 03/31/2024 172.37 0.0 Description: INJ., TILDRAKIZUMAB, 1 MG Category: Drugs CMS Add: 01/01/2019 CMS Term: J3245 DRUG DEF MAXFEE 04/01/2024 180.99 0.0 Description: INJ., TILDRAKIZUMAB, 1 MG Category: Drugs CMS Add: 01/01/2019 CMS Term: J3246 DRUG DEF MAXFEE 07/01/2020 06/30/2023 3.92 0.0 Description: TIROFIBAN HCL Category: Drugs CMS Add: 01/01/2005 CMS Term: J3246 DRUG DEF MAXFEE 07/01/2023 4.10 0.0 Description: TIROFIBAN HCL Category: Drugs CMS Add: 01/01/2005 CMS Term: J3250 DRUG DEF MAXFEE 10/01/2020 38.13 0.0 Description: TRIMETHOBENZAMIDE HCL INJ Category: Drugs CMS Add: 01/01/1982 CMS Term: J3260 DRUG DEF MAXFEE 10/01/2018 1.50 0.0 Description: TOBRAMYCIN SULFATE INJECTION Category: Drugs CMS Add: 01/01/1982 CMS Term: J3262 DRUG DEF MAXFEE 04/01/2023 06/30/2023 6.64 0.0 2-999years Description: TOCILIZUMAB INJECTION Category: Drugs CMS Add: 01/01/2011 CMS Term: J3262 DRUG DEF MAXFEE 07/01/2023 6.97 0.0 2-999years Description: TOCILIZUMAB INJECTION Category: Drugs CMS Add: 01/01/2011 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,850 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J3265 DRUG DEF SYSMAN Description: INJECTION TORSEMIDE 10 MG/ML Category: Drugs CMS Add: 01/01/1996 CMS Term: J3280 DRUG DEF SYSMAN Description: THIETHYLPERAZINE MALEATE INJ Category: Drugs CMS Add: 01/01/1982 CMS Term: J3285 DRUG DEF MAXFEE 01/01/2021 60.16 0.0 Description: TREPROSTINIL INJECTION Category: Drugs CMS Add: 01/01/2006 CMS Term: J3299 DRUG DEF MAXFEE 07/01/2022 48.12 0.0 Description: INJ XIPERE 1 MG Category: Drugs CMS Add: 07/01/2022 CMS Term: J3300 DRUG DEF MAXFEE 01/01/2009 3.55 0.0 0-40 Description: TRIAMCINOLONE A INJ PRS-FREE Category: Drugs CMS Add: 01/01/2009 CMS Term: J3301 DRUG DEF MAXFEE 01/01/2020 09/30/2023 1.61 0.0 Description: TRIAMCINOLONE ACET INJ NOS Category: Drugs CMS Add: 01/01/1991 CMS Term: J3301 DRUG DEF MAXFEE 10/01/2023 1.38 0.0 Description: TRIAMCINOLONE ACET INJ NOS Category: Drugs CMS Add: 01/01/1991 CMS Term: J3302 DRUG DEF SYSMAN Description: TRIAMCINOLONE DIACETATE INJ Category: Drugs CMS Add: 01/01/1991 CMS Term: J3303 DRUG DEF SYSMAN Description: TRIAMCINOLONE HEXACETONL INJ Category: Drugs CMS Add: 01/01/1991 CMS Term: J3304 DRUG DEF MAXFEE 01/01/2024 03/31/2024 20.84 0.0 Description: INJ TRIAMCINOLONE ACE XR 1MG Category: Drugs CMS Add: 01/01/2019 CMS Term: J3304 DRUG DEF MAXFEE 04/01/2023 12/31/2023 20.43 0.0 Description: INJ TRIAMCINOLONE ACE XR 1MG Category: Drugs CMS Add: 01/01/2019 CMS Term: J3304 DRUG DEF MAXFEE 04/01/2024 21.26 0.0 Description: INJ TRIAMCINOLONE ACE XR 1MG Category: Drugs CMS Add: 01/01/2019 CMS Term: J3305 DRUG DEF SYSMAN Description: INJ TRIMETREXATE GLUCORONATE Category: Drugs CMS Add: 01/01/1996 CMS Term: J3310 DRUG DEF SYSMAN Description: PERPHENAZINE INJECITON Category: Drugs CMS Add: 01/01/1982 CMS Term: J3315 DRUG DEF MAXFEE 04/01/2011 03/31/2024 853.90 0.0 Description: TRIPTORELIN PAMOATE Category: Drugs CMS Add: 01/01/2003 CMS Term: J3315 DRUG DEF MAXFEE 04/01/2024 905.13 0.0 Description: TRIPTORELIN PAMOATE Category: Drugs CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,851 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J3316 DRUG DEF MAXFEE 04/01/2024 3475.63 0.0 Description: INJ., TRIPTORELIN XR 3.75 MG Category: Drugs CMS Add: 01/01/2019 CMS Term: J3316 DRUG DEF MAXFEE 07/01/2022 06/30/2023 3183.40 0.0 Description: INJ., TRIPTORELIN XR 3.75 MG Category: Drugs CMS Add: 01/01/2019 CMS Term: J3316 DRUG DEF MAXFEE 07/01/2023 03/31/2024 3278.90 0.0 Description: INJ., TRIPTORELIN XR 3.75 MG Category: Drugs CMS Add: 01/01/2019 CMS Term: J3320 DRUG DEF SYSMAN Description: SPECTINOMYCN DI-HCL INJ Category: Drugs CMS Add: 01/01/1982 CMS Term: J3350 DRUG DEF SYSMAN Description: UREA INJECTION Category: Drugs CMS Add: 01/01/1986 CMS Term: J3355 NOCOV DEF SYSMAN Description: UROFOLLITROPIN, 75 IU Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: J3357 DRUG DEF MAXFEE 04/01/2023 03/31/2024 309.37 0.0 18-999years Description: USTEKINUMAB SUB CU INJ, 1 MG Category: Drugs CMS Add: 01/01/2011 CMS Term: J3357 DRUG DEF MAXFEE 04/01/2024 324.83 0.0 18-999years Description: USTEKINUMAB SUB CU INJ, 1 MG Category: Drugs CMS Add: 01/01/2011 CMS Term: J3358 DRUG DEF MAXFEE 04/01/2023 03/31/2024 15.57 0.0 Description: USTEKINUMAB, IV INJECT, 1 MG Category: Drugs CMS Add: 01/01/2018 CMS Term: J3358 DRUG DEF MAXFEE 04/01/2024 16.35 0.0 Description: USTEKINUMAB, IV INJECT, 1 MG Category: Drugs CMS Add: 01/01/2018 CMS Term: J3360 DRUG DEF MAXFEE 04/01/2020 4.19 0.0 Description: DIAZEPAM INJECTION Category: Drugs CMS Add: 01/01/1982 CMS Term: J3364 DRUG DEF SYSMAN Description: UROKINASE 5000 IU INJECTION Category: Drugs CMS Add: 01/01/1993 CMS Term: J3365 DRUG DEF SYSMAN Description: UROKINASE 250,000 IU INJ Category: Drugs CMS Add: 01/01/1992 CMS Term: J3370 DRUG DEF MAXFEE 01/01/2020 1.71 0.0 Description: VANCOMYCIN HCL INJECTION Category: Drugs CMS Add: 01/01/1986 CMS Term: J3371 DRUG DEF MAXFEE 01/01/2023 6.78 0.0 Description: INJ, VANCOMYCIN HCL (MYLAN) Category: Drugs CMS Add: 01/01/2023 CMS Term: J3372 DRUG DEF MAXFEE 04/01/2023 3.15 0.0 Description: INJ, VANCOMYCIN HCL (XELLIA) Category: Drugs CMS Add: 01/01/2023 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,852 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J3380 DRUG DEF MAXFEE 04/01/2023 03/31/2024 28.62 0.0 Description: INJ VEDOLIZUMAB IV 1 MG Category: Drugs CMS Add: 01/01/2016 CMS Term: J3380 DRUG DEF MAXFEE 04/01/2024 30.33 0.0 Description: INJ VEDOLIZUMAB IV 1 MG Category: Drugs CMS Add: 01/01/2016 CMS Term: J3385 DRUG DEF MAXFEE 04/01/2023 383.48 0.0 Description: VELAGLUCERASE ALFA Category: Drugs CMS Add: 01/01/2011 CMS Term: J3396 DRUG DEF MAXFEE 04/01/2020 11.97 0.0 Description: VERTEPORFIN INJECTION Category: Drugs CMS Add: 01/01/2005 CMS Term: J3397 DRUG DEF MAXFEE 04/01/2023 03/31/2024 268.80 0.0 Description: INJ., VESTRONIDASE ALFA-VJBK Category: Drugs CMS Add: 01/01/2019 CMS Term: J3397 DRUG DEF MAXFEE 04/01/2024 276.89 0.0 Description: INJ., VESTRONIDASE ALFA-VJBK Category: Drugs CMS Add: 01/01/2019 CMS Term: J3398 DRUG DEF MAXFEE 01/01/2019 1785.00 0.0 Y Description: INJ LUXTURNA 1 BILLION VEC G Category: Drugs CMS Add: 01/01/2019 CMS Term: J3399 DRUG DEF MAXFEE 07/01/2020 2231250.00 0.0 Y Description: INJ ONASE ABEPAR-XIOI TREAT Category: Drugs CMS Add: 07/01/2020 CMS Term: J3400 DRUG DEF SYSMAN Description: TRIFLUPROMAZINE HCL INJ Category: Drugs CMS Add: 01/01/1982 CMS Term: J3401 DRUG DEF MAXFEE 01/01/2024 1018.50 0.0 Y Description: VYJUVEK 5X10^9PFU/ML, 0.1 ML Category: Drugs CMS Add: 01/01/2024 CMS Term: J3410 DRUG DEF MAXFEE 04/01/2018 20.33 0.0 Description: HYDROXYZINE HCL INJECTION Category: Drugs CMS Add: 01/01/1982 CMS Term: J3411 DRUG DEF MAXFEE 01/01/2023 06/30/2023 3.45 0.0 Description: THIAMINE HCL 100 MG Category: Drugs CMS Add: 01/01/2004 CMS Term: J3411 DRUG DEF MAXFEE 07/01/2023 3.26 0.0 Description: THIAMINE HCL 100 MG Category: Drugs CMS Add: 01/01/2004 CMS Term: J3415 DRUG DEF MAXFEE 04/01/2023 20.01 0.0 Description: PYRIDOXINE HCL 100 MG Category: Drugs CMS Add: 01/01/2004 CMS Term: J3420 DRUG DEF MAXFEE 01/01/2023 0.62 0.0 Description: VITAMIN B12 INJECTION Category: Drugs CMS Add: 01/01/1986 CMS Term: J3425 DRUG DEF MAXFEE 01/01/2024 0.01 0.0 Description: HYDROXOCOBALAMIN IM 10MCG Category: Drugs CMS Add: 01/01/2024 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,853 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J3430 DRUG DEF MAXFEE 04/01/2022 4.49 0.0 Description: VITAMIN K PHYTONADIONE INJ Category: Drugs CMS Add: 01/01/1982 CMS Term: J3465 DRUG DEF MAXFEE 01/01/2023 06/30/2023 1.84 0.0 Description: INJECTION, VORICONAZOLE Category: Drugs CMS Add: 01/01/2004 CMS Term: J3465 DRUG DEF MAXFEE 07/01/2023 1.20 0.0 Description: INJECTION, VORICONAZOLE Category: Drugs CMS Add: 01/01/2004 CMS Term: J3470 NOCOV DEF SYSMAN Description: HYALURONIDASE INJECTION Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: J3471 DRUG DEF MAXFEE 04/01/2023 0.53 0.0 Description: OVINE, UP TO 999 USP UNITS Category: Drugs CMS Add: 01/01/2006 CMS Term: J3472 DRUG DEF MAXFEE 04/01/2023 528.61 0.0 Description: OVINE, 1000 USP UNITS Category: Drugs CMS Add: 01/01/2006 CMS Term: J3473 DRUG DEF MAXFEE 07/01/2014 0.39 0.0 Description: HYALURONIDASE RECOMBINANT Category: Drugs CMS Add: 01/01/2007 CMS Term: J3475 DRUG DEF MAXFEE 10/01/2018 0.11 0.0 Description: INJ MAGNESIUM SULFATE Category: Drugs CMS Add: 01/01/1996 CMS Term: J3480 DRUG DEF MAXFEE 01/01/2023 0.10 0.0 Description: INJ POTASSIUM CHLORIDE Category: Drugs CMS Add: 01/01/1996 CMS Term: J3485 DRUG DEF MAXFEE 04/01/2013 1.53 0.0 Description: ZIDOVUDINE Category: Drugs CMS Add: 01/01/2001 CMS Term: J3486 DRUG DEF MAXFEE 01/01/2021 10.45 0.0 Description: ZIPRASIDONE MESYLATE Category: Drugs CMS Add: 01/01/2004 CMS Term: J3489 DRUG DEF MAXFEE 10/01/2017 11.55 0.0 3-999 Description: ZOLEDRONIC ACID 1MG Category: Drugs CMS Add: 01/01/2014 CMS Term: J3490 DRUG DEF SYSMAN Description: DRUGS UNCLASSIFIED INJECTION Category: Drugs CMS Add: 01/01/1986 CMS Term: J3490 TRANS DEF SYSMAN Description: DRUGS UNCLASSIFIED INJECTION Category: Transportation CMS Add: 01/01/1986 CMS Term: J3520 DRUG DEF SYSMAN Description: EDETATE DISODIUM PER 150 MG Category: Drugs CMS Add: 01/01/1986 CMS Term: J3530 NOCOV DEF SYSMAN Description: NASAL VACCINE INHALATION Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,854 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J3535 NOCOV DEF SYSMAN Description: METERED DOSE INHALER DRUG Category: Non Covered Services CMS Add: 01/01/1994 CMS Term: J3570 NOCOV DEF SYSMAN Description: LAETRILE AMYGDALIN VIT B17 Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: J3590 DRUG DEF SYSMAN 3-999 Description: UNCLASSIFIED BIOLOGICS Category: Drugs CMS Add: 01/01/2003 CMS Term: J3591 DRUG DEF SYSMAN Description: ESRD ON DIALYSI DRUG/BIO NOC Category: Drugs CMS Add: 01/01/2019 CMS Term: J7030 DRUG DEF MAXFEE 04/01/2023 06/30/2023 2.49 0.0 Description: NORMAL SALINE SOLUTION INFUS Category: Drugs CMS Add: 01/01/1982 CMS Term: J7030 DRUG DEF MAXFEE 07/01/2023 2.87 0.0 Description: NORMAL SALINE SOLUTION INFUS Category: Drugs CMS Add: 01/01/1982 CMS Term: J7040 DRUG DEF MAXFEE 04/01/2023 06/30/2023 1.24 0.0 Description: NORMAL SALINE SOLUTION INFUS Category: Drugs CMS Add: 01/01/1984 CMS Term: J7040 DRUG DEF MAXFEE 07/01/2023 1.43 0.0 Description: NORMAL SALINE SOLUTION INFUS Category: Drugs CMS Add: 01/01/1984 CMS Term: J7042 DRUG DEF MAXFEE 04/01/2023 06/30/2023 1.48 0.0 Description: 5% DEXTROSE/NORMAL SALINE Category: Drugs CMS Add: 01/01/1984 CMS Term: J7042 DRUG DEF MAXFEE 07/01/2023 1.61 0.0 Description: 5% DEXTROSE/NORMAL SALINE Category: Drugs CMS Add: 01/01/1984 CMS Term: J7050 DRUG DEF MAXFEE 04/01/2023 06/30/2023 0.62 0.0 Description: NORMAL SALINE SOLUTION INFUS Category: Drugs CMS Add: 01/01/1982 CMS Term: J7050 DRUG DEF MAXFEE 07/01/2023 0.72 0.0 Description: NORMAL SALINE SOLUTION INFUS Category: Drugs CMS Add: 01/01/1982 CMS Term: J7060 DRUG DEF MAXFEE 07/01/2023 2.05 0.0 Description: 5% DEXTROSE/WATER Category: Drugs CMS Add: 01/01/1985 CMS Term: J7060 DRUG DEF MAXFEE 10/01/2020 06/30/2023 1.94 0.0 Description: 5% DEXTROSE/WATER Category: Drugs CMS Add: 01/01/1985 CMS Term: J7070 DRUG DEF MAXFEE 07/01/2023 4.10 0.0 Description: D5W INFUSION Category: Drugs CMS Add: 01/01/1982 CMS Term: J7070 DRUG DEF MAXFEE 10/01/2020 06/30/2023 3.87 0.0 Description: D5W INFUSION Category: Drugs CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,855 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J7100 DRUG DEF MAXFEE 04/01/2023 09/30/2023 33.87 0.0 Description: DEXTRAN 40 INFUSION Category: Drugs CMS Add: 01/01/1982 CMS Term: J7100 DRUG DEF MAXFEE 04/01/2024 40.99 0.0 Description: DEXTRAN 40 INFUSION Category: Drugs CMS Add: 01/01/1982 CMS Term: J7100 DRUG DEF MAXFEE 10/01/2023 03/31/2024 37.26 0.0 Description: DEXTRAN 40 INFUSION Category: Drugs CMS Add: 01/01/1982 CMS Term: J7110 DRUG DEF SYSMAN Description: DEXTRAN 75 INFUSION Category: Drugs CMS Add: 01/01/1982 CMS Term: J7120 DRUG DEF MAXFEE 04/01/2023 06/30/2023 2.67 0.0 Description: RINGERS LACTATE INFUSION Category: Drugs CMS Add: 01/01/1982 CMS Term: J7120 DRUG DEF MAXFEE 07/01/2023 3.19 0.0 Description: RINGERS LACTATE INFUSION Category: Drugs CMS Add: 01/01/1982 CMS Term: J7121 NOCOV DEF SYSMAN Description: 5% DEXTROSE IN LAC RINGERS Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: J7131 DRUG DEF MAXFEE 01/01/2012 0.01 0.0 Description: HYPERTONIC SALINE SOL Category: Drugs CMS Add: 01/01/2012 CMS Term: J7168 DRUG DEF SYSMAN Description: PROTHROMBIN COMPLEX KCENTRA Category: Drugs CMS Add: 07/01/2021 CMS Term: J7169 DRUG DEF MAXFEE 07/01/2022 131.25 0.0 Description: INJ ANDEXXA, 10 MG Category: Drugs CMS Add: 07/01/2020 CMS Term: J7170 DRUG DEF SYSMAN Description: INJ., EMICIZUMAB-KXWH 0.5 MG Category: Drugs CMS Add: 01/01/2019 CMS Term: J7175 DRUG DEF SYSMAN Description: INJ, FACTOR X, (HUMAN), 1IU Category: Drugs CMS Add: 01/01/2017 CMS Term: J7177 DRUG DEF SYSMAN Description: INJ., FIBRYGA, 1 MG Category: Drugs CMS Add: 01/01/2019 CMS Term: J7178 DRUG DEF SYSMAN Description: INJ HUMAN FIBRINOGEN CON NOS Category: Drugs CMS Add: 01/01/2013 CMS Term: J7179 DRUG DEF SYSMAN Description: VONVENDI INJ 1 IU VWF:RCO Category: Drugs CMS Add: 01/01/2017 CMS Term: J7180 DRUG DEF SYSMAN Description: FACTOR XIII ANTI-HEM FACTOR Category: Drugs CMS Add: 01/01/2012 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,856 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J7181 DRUG DEF SYSMAN Description: FACTOR XIII RECOMB A-SUBUNIT Category: Drugs CMS Add: 01/01/2015 CMS Term: J7182 DRUG DEF SYSMAN Description: FACTOR VIII RECOMB NOVOEIGHT Category: Drugs CMS Add: 01/01/2015 CMS Term: J7183 DRUG DEF SYSMAN Description: WILATE INJECTION Category: Drugs CMS Add: 01/01/2012 CMS Term: J7185 DRUG DEF SYSMAN Description: XYNTHA INJ Category: Drugs CMS Add: 01/01/2010 CMS Term: J7186 DRUG DEF SYSMAN Description: ANTIHEMOPHILIC VIII/VWF COMP Category: Drugs CMS Add: 01/01/2009 CMS Term: J7187 DRUG DEF SYSMAN Description: HUMATE-P, INJ Category: Drugs CMS Add: 01/01/2007 CMS Term: J7188 DRUG DEF SYSMAN Description: FACTOR VIII RECOMB OBIZUR Category: Drugs CMS Add: 01/01/2016 CMS Term: J7189 DRUG DEF SYSMAN Description: FACTOR VIIA RECOMB NOVOSEVEN Category: Drugs CMS Add: 01/01/2006 CMS Term: J7190 DRUG DEF SYSMAN Description: FACTOR VIII Category: Drugs CMS Add: 01/01/1986 CMS Term: J7191 DRUG DEF SYSMAN Description: FACTOR VIII (PORCINE) Category: Drugs CMS Add: 01/01/1996 CMS Term: J7192 DRUG DEF SYSMAN Description: FACTOR VIII RECOMBINANT NOS Category: Drugs CMS Add: 01/01/1994 CMS Term: J7193 DRUG DEF SYSMAN Description: FACTOR IX NON-RECOMBINANT Category: Drugs CMS Add: 01/01/2002 CMS Term: J7194 DRUG DEF SYSMAN Description: FACTOR IX COMPLEX Category: Drugs CMS Add: 01/01/1986 CMS Term: J7195 DRUG DEF SYSMAN Description: FACTOR IX RECOMBINANT NOS Category: Drugs CMS Add: 01/01/2002 CMS Term: J7196 DRUG DEF MAXFEE 01/01/2011 102.37 0.0 Description: ANTITHROMBIN RECOMBINANT Category: Drugs CMS Add: 01/01/2011 CMS Term: J7197 DRUG DEF MAXFEE 04/01/2024 4.55 0.0 Description: ANTITHROMBIN III INJECTION Category: Drugs CMS Add: 01/01/1992 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,857 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J7197 DRUG DEF MAXFEE 07/01/2015 03/31/2024 4.07 0.0 Description: ANTITHROMBIN III INJECTION Category: Drugs CMS Add: 01/01/1992 CMS Term: J7198 DRUG DEF SYSMAN Description: ANTI-INHIBITOR Category: Drugs CMS Add: 01/01/2000 CMS Term: J7199 DRUG DEF SYSMAN Description: HEMOPHILIA CLOT FACTOR NOC Category: Drugs CMS Add: 01/01/2000 CMS Term: J7200 DRUG DEF SYSMAN Description: FACTOR IX RECOMBINAN RIXUBIS Category: Drugs CMS Add: 01/01/2015 CMS Term: J7201 DRUG DEF SYSMAN Description: FACTOR IX ALPROLIX RECOMB Category: Drugs CMS Add: 01/01/2015 CMS Term: J7202 DRUG DEF SYSMAN Description: FACTOR IX IDELVION INJ Category: Drugs CMS Add: 01/01/2017 CMS Term: J7203 DRUG DEF SYSMAN Description: FACTOR IX RECOMB GLY REBINYN Category: Drugs CMS Add: 01/01/2019 CMS Term: J7204 DRUG DEF SYSMAN Description: INJ RECOMBIN ESPEROCT PER IU Category: Drugs CMS Add: 07/01/2020 CMS Term: J7205 DRUG DEF SYSMAN Description: FACTOR VIII FC FUSION RECOMB Category: Drugs CMS Add: 01/01/2016 CMS Term: J7207 DRUG DEF SYSMAN Description: FACTOR VIII PEGYLATED RECOMB Category: Drugs CMS Add: 01/01/2017 CMS Term: J7208 DRUG DEF SYSMAN Description: INJ. JIVI 1 IU Category: Drugs CMS Add: 07/01/2019 CMS Term: J7209 DRUG DEF SYSMAN Description: FACTOR VIII NUWIQ RECOMB 1IU Category: Drugs CMS Add: 01/01/2017 CMS Term: J7210 DRUG DEF SYSMAN Description: INJ, AFSTYLA, 1 I.U. Category: Drugs CMS Add: 01/01/2018 CMS Term: J7211 DRUG DEF SYSMAN Description: INJ, KOVALTRY, 1 I.U. Category: Drugs CMS Add: 01/01/2018 CMS Term: J7212 DRUG DEF SYSMAN Description: FACTOR VIIA RECOMB SEVENFACT Category: Drugs CMS Add: 01/01/2021 CMS Term: J7213 DRUG DEF SYSMAN Description: INJ, IXINITY, 1 I.U. Category: Drugs CMS Add: 07/01/2023 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,858 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J7214 DRUG DEF SYSMAN Description: ALTUVIIIO PER FACTOR VIII IU Category: Drugs CMS Add: 10/01/2023 CMS Term: J7294 DRUG DEF MAXFEE 04/01/2023 2420.54 0.0 Description: SEG ACET AND ETH ESTR YEARLY Category: Drugs CMS Add: 10/01/2021 CMS Term: J7295 DRUG DEF MAXFEE 01/01/2024 85.38 0.0 Description: ETH ESTR AND ETON MONTHLY Category: Drugs CMS Add: 10/01/2021 CMS Term: J7295 DRUG DEF MAXFEE 07/01/2023 12/31/2023 109.01 0.0 Description: ETH ESTR AND ETON MONTHLY Category: Drugs CMS Add: 10/01/2021 CMS Term: J7295 DRUG DEF MAXFEE 10/01/2021 06/30/2023 145.15 0.0 Description: ETH ESTR AND ETON MONTHLY Category: Drugs CMS Add: 10/01/2021 CMS Term: J7296 DRUG DEF MAXFEE 04/01/2023 03/31/2024 1156.79 0.0 Description: KYLEENA, 19.5 MG Category: Drugs CMS Add: 01/01/2018 CMS Term: J7296 DRUG DEF MAXFEE 04/01/2024 1214.63 0.0 Description: KYLEENA, 19.5 MG Category: Drugs CMS Add: 01/01/2018 CMS Term: J7297 DRUG DEF MAXFEE 04/01/2021 03/31/2024 887.36 0.0 0-1 Description: LILETTA, 52 MG Category: Drugs CMS Add: 01/01/2016 CMS Term: J7297 DRUG DEF MAXFEE 04/01/2024 931.73 0.0 0-1 Description: LILETTA, 52 MG Category: Drugs CMS Add: 01/01/2016 CMS Term: J7298 DRUG DEF MAXFEE 04/01/2023 03/31/2024 1156.79 0.0 0-1 Description: MIRENA, 52 MG Category: Drugs CMS Add: 01/01/2016 CMS Term: J7298 DRUG DEF MAXFEE 04/01/2024 1214.63 0.0 0-1 Description: MIRENA, 52 MG Category: Drugs CMS Add: 01/01/2016 CMS Term: J7300 DRUG DEF MAXFEE 04/01/2023 03/31/2024 1076.25 0.0 Description: INTRAUT COPPER CONTRACEPTIVE Category: Drugs CMS Add: 01/01/1986 CMS Term: J7300 DRUG DEF MAXFEE 04/01/2024 1139.25 0.0 Description: INTRAUT COPPER CONTRACEPTIVE Category: Drugs CMS Add: 01/01/1986 CMS Term: J7301 DRUG DEF MAXFEE 04/01/2023 03/31/2024 963.22 0.0 Description: SKYLA, 13.5 MG Category: Drugs CMS Add: 01/01/2014 CMS Term: J7301 DRUG DEF MAXFEE 04/01/2024 1011.38 0.0 Description: SKYLA, 13.5 MG Category: Drugs CMS Add: 01/01/2014 CMS Term: J7304 DRUG DEF MAXFEE 07/01/2018 42.75 0.0 Description: CONTRACEPTIVE HORMONE PATCH Category: Drugs CMS Add: 01/01/2005 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,859 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J7306 DRUG DEF SYSMAN Description: LEVONORGESTREL IMPLANT SYS Category: Drugs CMS Add: 01/01/2006 CMS Term: J7307 DRUG DEF MAXFEE 04/01/2024 1214.09 0.0 Description: ETONOGESTREL IMPLANT SYSTEM Category: Drugs CMS Add: 01/01/2008 CMS Term: J7307 DRUG DEF MAXFEE 10/01/2022 03/31/2024 1147.10 0.0 Description: ETONOGESTREL IMPLANT SYSTEM Category: Drugs CMS Add: 01/01/2008 CMS Term: J7308 DRUG DEF MAXFEE 04/01/2023 412.88 0.0 Description: AMINOLEVULINIC ACID HCL TOP Category: Drugs CMS Add: 01/01/2002 CMS Term: J7309 DRUG DEF SYSMAN Description: METHYL AMINOLEVULINATE, TOP Category: Drugs CMS Add: 01/01/2011 CMS Term: J7310 DRUG DEF SYSMAN Description: GANCICLOVIR LONG ACT IMPLANT Category: Drugs CMS Add: 01/01/1997 CMS Term: J7311 DRUG DEF MAXFEE 10/01/2019 338.58 0.0 Y 0-1 Description: INJ., RETISERT, 0.01 MG Category: Drugs CMS Add: 01/01/2007 CMS Term: J7312 DRUG DEF MAXFEE 04/01/2023 205.95 0.0 Description: DEXAMETHASONE INTRA IMPLANT Category: Drugs CMS Add: 01/01/2011 CMS Term: J7313 DRUG DEF MAXFEE 01/01/2016 486.32 0.0 Description: INJ., ILUVIEN, 0.01 MG Category: Drugs CMS Add: 01/01/2016 CMS Term: J7314 DRUG DEF MAXFEE 04/01/2023 524.77 0.0 Y Description: INJ., YUTIQ, 0.01 MG Category: Drugs CMS Add: 10/01/2019 CMS Term: J7315 NOCOV DEF SYSMAN Description: OPHTHALMIC MITOMYCIN Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: J7316 DRUG DEF SYSMAN Description: INJ, OCRIPLASMIN, 0.125 MG Category: Drugs CMS Add: 01/01/2014 CMS Term: J7318 DRUG DEF MAXFEE 01/01/2024 18.81 0.0 Description: INJ, DUROLANE 1 MG Category: Drugs CMS Add: 01/01/2019 CMS Term: J7318 DRUG DEF MAXFEE 04/01/2023 12/31/2023 18.38 0.0 Description: INJ, DUROLANE 1 MG Category: Drugs CMS Add: 01/01/2019 CMS Term: J7320 DRUG DEF MAXFEE 07/01/2019 16.76 0.0 Description: GENVISC 850, INJ, 1MG Category: Drugs CMS Add: 01/01/2017 CMS Term: J7321 DRUG DEF MAXFEE 10/01/2018 199.50 0.0 Description: HYALGAN SUPARTZ VISCO-3 DOSE Category: Drugs CMS Add: 01/01/2008 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,860 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J7322 DRUG DEF MAXFEE 10/01/2019 31.37 0.0 Description: HYMOVIS INJECTION 1 MG Category: Drugs CMS Add: 01/01/2017 CMS Term: J7323 DRUG DEF MAXFEE 04/01/2022 03/31/2024 367.63 0.0 Description: EUFLEXXA INJ PER DOSE Category: Drugs CMS Add: 01/01/2008 CMS Term: J7323 DRUG DEF MAXFEE 04/01/2024 378.66 0.0 Description: EUFLEXXA INJ PER DOSE Category: Drugs CMS Add: 01/01/2008 CMS Term: J7324 DRUG DEF MAXFEE 01/01/2019 501.90 0.0 Description: ORTHOVISC INJ PER DOSE Category: Drugs CMS Add: 01/01/2008 CMS Term: J7325 DRUG DEF MAXFEE 04/01/2020 29.96 0.0 Description: SYNVISC OR SYNVISC-ONE Category: Drugs CMS Add: 01/01/2010 CMS Term: J7326 DRUG DEF MAXFEE 10/01/2020 1207.50 0.0 Description: GEL-ONE Category: Drugs CMS Add: 01/01/2012 CMS Term: J7327 DRUG DEF MAXFEE 01/01/2021 1575.00 0.0 Description: MONOVISC INJ PER DOSE Category: Drugs CMS Add: 01/01/2015 CMS Term: J7328 DRUG DEF MAXFEE 01/01/2024 2.34 0.0 Description: GELSYN-3 INJECTION 0.1 MG Category: Drugs CMS Add: 01/01/2016 CMS Term: J7328 DRUG DEF MAXFEE 04/01/2023 12/31/2023 2.28 0.0 Description: GELSYN-3 INJECTION 0.1 MG Category: Drugs CMS Add: 01/01/2016 CMS Term: J7329 DRUG DEF MAXFEE 01/01/2021 18.94 0.0 Description: INJ, TRIVISC 1 MG Category: Drugs CMS Add: 01/01/2019 CMS Term: J7330 DRUG DEF SYSMAN Description: CULTURED CHONDROCYTES IMPLNT Category: Drugs CMS Add: 01/01/2001 CMS Term: J7331 NOCOV DEF SYSMAN Description: SYNOJOYNT, INJ., 1 MG Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: J7332 DRUG DEF MAXFEE 12/05/2019 25.67 0.0 Description: INJ., TRILURON, 1 MG Category: Drugs CMS Add: 10/01/2019 CMS Term: J7336 NOCOV DEF SYSMAN Description: CAPSAICIN 8% PATCH Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: J7340 DRUG DEF MAXFEE 04/01/2023 03/31/2024 229.22 0.0 Y Description: CARBIDOPA LEVODOPA ENT 100ML Category: Drugs CMS Add: 01/01/2016 CMS Term: J7340 DRUG DEF MAXFEE 04/01/2024 237.24 0.0 Y Description: CARBIDOPA LEVODOPA ENT 100ML Category: Drugs CMS Add: 01/01/2016 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,861 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J7342 DRUG DEF SYSMAN Description: CIPROFLOXACIN OTIC SUSP 6 MG Category: Drugs CMS Add: 01/01/2017 CMS Term: J7345 NOCOV DEF SYSMAN Description: AMINOLEVULINIC ACID, 10% GEL Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: J7351 DRUG DEF MAXFEE 04/01/2024 208.64 0.0 Description: INJ BIMATOPROST ITC IMP1MCG Category: Drugs CMS Add: 10/01/2020 CMS Term: J7351 DRUG DEF MAXFEE 10/01/2020 03/31/2024 204.75 0.0 Description: INJ BIMATOPROST ITC IMP1MCG Category: Drugs CMS Add: 10/01/2020 CMS Term: J7352 NOCOV DEF SYSMAN Description: AFAMELANOTIDE IMPLANT, 1 MG Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: J7353 NOCOV DEF SYSMAN Description: ANACAULASE-BCDB 8.8% GEL 1 G Category: Non Covered Services CMS Add: 10/01/2023 CMS Term: J7402 DRUG DEF MAXFEE 10/01/2022 11.47 0.0 Description: MOMETASONE SINUS SINUVA Category: Drugs CMS Add: 04/01/2021 CMS Term: J7500 DRUG DEF MAXFEE 10/01/2020 0.20 0.0 Description: AZATHIOPRINE ORAL 50MG Category: Drugs CMS Add: 01/01/1988 CMS Term: J7501 DRUG DEF MAXFEE 07/01/2016 262.50 0.0 Description: AZATHIOPRINE PARENTERAL Category: Drugs CMS Add: 01/01/1988 CMS Term: J7502 DRUG DEF MAXFEE 07/01/2020 3.23 0.0 Description: CYCLOSPORINE ORAL 100 MG Category: Drugs CMS Add: 01/01/2000 CMS Term: J7503 DRUG DEF MAXFEE 04/01/2023 09/30/2023 1.67 0.0 Description: TACROL ENVARSUS EX REL ORAL Category: Drugs CMS Add: 01/01/2016 CMS Term: J7503 DRUG DEF MAXFEE 04/01/2024 1.76 0.0 Description: TACROL ENVARSUS EX REL ORAL Category: Drugs CMS Add: 01/01/2016 CMS Term: J7503 DRUG DEF MAXFEE 10/01/2023 03/31/2024 1.72 0.0 Description: TACROL ENVARSUS EX REL ORAL Category: Drugs CMS Add: 01/01/2016 CMS Term: J7504 DRUG DEF MAXFEE 04/01/2023 09/30/2023 3306.64 0.0 Description: LYMPHOCYTE IMMUNE GLOBULIN Category: Drugs CMS Add: 01/01/1988 CMS Term: J7504 DRUG DEF MAXFEE 04/01/2024 4001.04 0.0 Description: LYMPHOCYTE IMMUNE GLOBULIN Category: Drugs CMS Add: 01/01/1988 CMS Term: J7504 DRUG DEF MAXFEE 10/01/2023 03/31/2024 3637.31 0.0 Description: LYMPHOCYTE IMMUNE GLOBULIN Category: Drugs CMS Add: 01/01/1988 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,862 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J7505 DRUG DEF SYSMAN Description: MONOCLONAL ANTIBODIES Category: Drugs CMS Add: 01/01/1988 CMS Term: J7507 DRUG DEF MAXFEE 04/01/2022 03/31/2024 0.44 0.0 Description: TACROLIMUS IMME REL ORAL 1MG Category: Drugs CMS Add: 01/01/1995 CMS Term: J7507 DRUG DEF MAXFEE 04/01/2024 0.21 0.0 Description: TACROLIMUS IMME REL ORAL 1MG Category: Drugs CMS Add: 01/01/1995 CMS Term: J7508 DRUG DEF MAXFEE 04/01/2023 03/31/2024 0.57 0.0 Description: TACROL ASTAGRAF EX REL ORAL Category: Drugs CMS Add: 01/01/2014 CMS Term: J7508 DRUG DEF MAXFEE 04/01/2024 0.59 0.0 Description: TACROL ASTAGRAF EX REL ORAL Category: Drugs CMS Add: 01/01/2014 CMS Term: J7509 DRUG DEF MAXFEE 07/01/2020 0.23 0.0 Description: METHYLPREDNISOLONE ORAL Category: Drugs CMS Add: 01/01/1996 CMS Term: J7510 DRUG DEF MAXFEE 07/01/2021 0.22 0.0 Description: PREDNISOLONE ORAL PER 5 MG Category: Drugs CMS Add: 01/01/1996 CMS Term: J7511 DRUG DEF MAXFEE 04/01/2023 03/31/2024 1071.78 0.0 Description: ANTITHYMOCYTE GLOBULN RABBIT Category: Drugs CMS Add: 01/01/2002 CMS Term: J7511 DRUG DEF MAXFEE 04/01/2024 1119.47 0.0 Description: ANTITHYMOCYTE GLOBULN RABBIT Category: Drugs CMS Add: 01/01/2002 CMS Term: J7512 DRUG DEF MAXFEE 01/01/2016 0.01 0.0 Y Description: PREDNISONE IR OR DR ORAL 1MG Category: Drugs CMS Add: 01/01/2016 CMS Term: J7513 DRUG DEF SYSMAN Description: DACLIZUMAB, PARENTERAL Category: Drugs CMS Add: 01/01/1999 CMS Term: J7515 DRUG DEF MAXFEE 07/01/2020 0.81 0.0 Description: CYCLOSPORINE ORAL 25 MG Category: Drugs CMS Add: 01/01/2000 CMS Term: J7516 DRUG DEF MAXFEE 10/01/2017 41.06 0.0 Description: INJ, CYCLOSPORINE 250MG Category: Drugs CMS Add: 01/01/2000 CMS Term: J7517 DRUG DEF MAXFEE 01/01/2023 06/30/2023 0.21 0.0 Description: MYCOPHENOLATE MOFETIL ORAL Category: Drugs CMS Add: 01/01/2000 CMS Term: J7517 DRUG DEF MAXFEE 07/01/2023 0.20 0.0 Description: MYCOPHENOLATE MOFETIL ORAL Category: Drugs CMS Add: 01/01/2000 CMS Term: J7518 DRUG DEF MAXFEE 01/01/2022 0.19 0.0 Description: MYCOPHENOLIC ACID Category: Drugs CMS Add: 01/01/2005 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,863 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J7519 DRUG DEF MAXFEE 10/01/2023 0.87 0.0 Description: INJ. MYCOPHENOLATE MOFETIL Category: Drugs CMS Add: 10/01/2023 CMS Term: J7520 DRUG DEF MAXFEE 07/01/2021 5.24 0.0 Description: SIROLIMUS, ORAL Category: Drugs CMS Add: 01/01/2001 CMS Term: J7525 DRUG DEF MAXFEE 04/01/2023 03/31/2024 252.41 0.0 Description: TACROLIMUS INJECTION Category: Drugs CMS Add: 01/01/2001 CMS Term: J7525 DRUG DEF MAXFEE 04/01/2024 259.98 0.0 Description: TACROLIMUS INJECTION Category: Drugs CMS Add: 01/01/2001 CMS Term: J7527 NOCOV DEF SYSMAN Description: ORAL EVEROLIMUS Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: J7599 DRUG DEF SYSMAN Description: IMMUNOSUPPRESSIVE DRUG NOC Category: Drugs CMS Add: 01/01/1996 CMS Term: J7604 DRUG DEF SYSMAN Description: ACETYLCYSTEINE COMP UNIT Category: Drugs CMS Add: 01/01/2008 CMS Term: J7605 DRUG DEF MAXFEE 04/01/2023 2.45 0.0 Description: ARFORMOTEROL NON-COMP UNIT Category: Drugs CMS Add: 01/01/2008 CMS Term: J7606 DRUG DEF MAXFEE 07/01/2023 5.69 0.0 Description: FORMOTEROL FUMARATE, INH Category: Drugs CMS Add: 01/01/2009 CMS Term: J7606 DRUG DEF MAXFEE 10/01/2021 06/30/2023 16.84 0.0 Description: FORMOTEROL FUMARATE, INH Category: Drugs CMS Add: 01/01/2009 CMS Term: J7607 NOCOV DEF SYSMAN Description: LEVALBUTEROL COMP CON Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: J7608 NOCOV DEF SYSMAN Description: ACETYLCYSTEINE NON-COMP UNIT Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: J7609 NOCOV DEF SYSMAN Description: ALBUTEROL COMP UNIT Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: J7610 NOCOV DEF SYSMAN Description: ALBUTEROL COMP CON Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: J7611 DRUG DEF MAXFEE 10/01/2017 09/30/2023 0.08 0.0 Description: ALBUTEROL NON-COMP CON Category: Drugs CMS Add: 01/01/2005 CMS Term: J7611 DRUG DEF MAXFEE 10/01/2023 0.11 0.0 Description: ALBUTEROL NON-COMP CON Category: Drugs CMS Add: 01/01/2005 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,864 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J7612 DRUG DEF MAXFEE 10/01/2012 2.25 0.0 Description: LEVALBUTEROL NON-COMP CON Category: Drugs CMS Add: 01/01/2005 CMS Term: J7613 DRUG DEF MAXFEE 04/01/2012 0.07 0.0 Description: ALBUTEROL NON-COMP UNIT Category: Drugs CMS Add: 01/01/2005 CMS Term: J7614 DRUG DEF MAXFEE 10/01/2017 0.50 0.0 Description: LEVALBUTEROL NON-COMP UNIT Category: Drugs CMS Add: 01/01/2005 CMS Term: J7615 NOCOV DEF SYSMAN Description: LEVALBUTEROL COMP UNIT Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: J7620 DRUG DEF MAXFEE 01/01/2018 0.32 0.0 Description: ALBUTEROL IPRATROP NON-COMP Category: Drugs CMS Add: 01/01/2006 CMS Term: J7622 NOCOV DEF SYSMAN Description: BECLOMETHASONE COMP UNIT Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: J7624 NOCOV DEF SYSMAN Description: BETAMETHASONE COMP UNIT Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: J7626 DRUG DEF MAXFEE 05/01/2010 6.11 0.0 Description: BUDESONIDE NON-COMP UNIT Category: Drugs CMS Add: 01/01/2002 CMS Term: J7627 DRUG DEF SYSMAN Description: BUDESONIDE COMP UNIT Category: Drugs CMS Add: 01/01/2006 CMS Term: J7628 NOCOV DEF SYSMAN Description: BITOLTEROL MESYLATE COMP CON Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: J7629 NOCOV DEF SYSMAN Description: BITOLTEROL MESYLATE COMP UNT Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: J7631 NOCOV DEF SYSMAN Description: CROMOLYN SODIUM NONCOMP UNIT Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: J7632 DRUG DEF SYSMAN Description: CROMOLYN SODIUM COMP UNIT Category: Drugs CMS Add: 01/01/2008 CMS Term: J7633 DRUG DEF MAXFEE 07/01/2007 5.66 0.0 Description: BUDESONIDE NON-COMP CON Category: Drugs CMS Add: 01/01/2003 CMS Term: J7634 NOCOV DEF SYSMAN Description: BUDESONIDE COMP CON Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: J7635 NOCOV DEF SYSMAN Description: ATROPINE COMP CON Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,865 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J7636 NOCOV DEF SYSMAN Description: ATROPINE COMP UNIT Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: J7637 NOCOV DEF SYSMAN Description: DEXAMETHASONE COMP CON Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: J7638 NOCOV DEF SYSMAN Description: DEXAMETHASONE COMP UNIT Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: J7639 NOCOV DEF SYSMAN Description: DORNASE ALFA NON-COMP UNIT Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: J7640 NOCOV DEF SYSMAN Description: FORMOTEROL COMP UNIT Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: J7641 NOCOV DEF SYSMAN Description: FLUNISOLIDE COMP UNIT Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: J7642 NOCOV DEF SYSMAN Description: GLYCOPYRROLATE COMP CON Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: J7643 NOCOV DEF SYSMAN Description: GLYCOPYRROLATE COMP UNIT Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: J7644 DRUG DEF MAXFEE 04/01/2012 0.32 0.0 Description: IPRATROPIUM BROMIDE NON-COMP Category: Drugs CMS Add: 01/01/2000 CMS Term: J7645 NOCOV DEF SYSMAN Description: IPRATROPIUM BROMIDE COMP Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: J7647 NOCOV DEF SYSMAN Description: ISOETHARINE COMP CON Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: J7648 NOCOV DEF SYSMAN Description: ISOETHARINE NON-COMP CON Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: J7649 NOCOV DEF SYSMAN Description: ISOETHARINE NON-COMP UNIT Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: J7650 NOCOV DEF SYSMAN Description: ISOETHARINE COMP UNIT Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: J7657 NOCOV DEF SYSMAN Description: ISOPROTERENOL COMP CON Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: J7658 NOCOV DEF SYSMAN Description: ISOPROTERENOL NON-COMP CON Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,866 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J7659 NOCOV DEF SYSMAN Description: ISOPROTERENOL NON-COMP UNIT Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: J7660 NOCOV DEF SYSMAN Description: ISOPROTERENOL COMP UNIT Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: J7665 DRUG DEF SYSMAN Description: MANNITOL FOR INHALER Category: Drugs CMS Add: 01/01/2012 CMS Term: J7667 NOCOV DEF SYSMAN Description: METAPROTERENOL COMP CON Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: J7668 NOCOV DEF SYSMAN Description: METAPROTERENOL NON-COMP CON Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: J7669 NOCOV DEF SYSMAN Description: METAPROTERENOL NON-COMP UNIT Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: J7670 NOCOV DEF SYSMAN Description: METAPROTERENOL COMP UNIT Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: J7674 DRUG DEF SYSMAN Description: METHACHOLINE CHLORIDE, NEB Category: Drugs CMS Add: 01/01/2005 CMS Term: J7676 DRUG DEF SYSMAN Description: PENTAMIDINE COMP UNIT DOSE Category: Drugs CMS Add: 01/01/2008 CMS Term: J7677 DRUG DEF MAXFEE 04/01/2023 03/31/2024 0.26 0.0 Description: REVEFENACIN INH NON-COM 1MCG Category: Drugs CMS Add: 07/01/2019 CMS Term: J7677 DRUG DEF MAXFEE 04/01/2024 0.27 0.0 Description: REVEFENACIN INH NON-COM 1MCG Category: Drugs CMS Add: 07/01/2019 CMS Term: J7680 NOCOV DEF SYSMAN Description: TERBUTALINE SULF COMP CON Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: J7681 NOCOV DEF SYSMAN Description: TERBUTALINE SULF COMP UNIT Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: J7682 NOCOV DEF SYSMAN Description: TOBRAMYCIN NON-COMP UNIT Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: J7683 NOCOV DEF SYSMAN Description: TRIAMCINOLONE COMP CON Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: J7684 NOCOV DEF SYSMAN Description: TRIAMCINOLONE COMP UNIT Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,867 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J7685 NOCOV DEF SYSMAN Description: TOBRAMYCIN COMP UNIT Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: J7686 DRUG DEF MAXFEE 01/01/2023 03/31/2024 747.36 0.0 Description: TREPROSTINIL, NON-COMP UNIT Category: Drugs CMS Add: 01/01/2011 CMS Term: J7686 DRUG DEF MAXFEE 04/01/2024 783.98 0.0 Description: TREPROSTINIL, NON-COMP UNIT Category: Drugs CMS Add: 01/01/2011 CMS Term: J7699 DRUG DEF SYSMAN Description: INHALATION SOLUTION FOR DME Category: Drugs CMS Add: 01/01/1993 CMS Term: J7799 DRUG DEF SYSMAN Description: NON-INHALATION DRUG FOR DME Category: Drugs CMS Add: 01/01/1993 CMS Term: J7999 NOCOV DEF SYSMAN Description: COMPOUNDED DRUG, NOC Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: J8498 NOCOV DEF SYSMAN Description: ANTIEMETIC RECTAL/SUPP NOS Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: J8499 DRUG DEF SYSMAN Description: ORAL PRESCRIP DRUG NON CHEMO Category: Drugs CMS Add: 01/01/1995 CMS Term: J8501 NOCOV DEF SYSMAN Description: ORAL APREPITANT Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: J8510 DRUG DEF MAXFEE 01/01/2023 131.25 0.0 Description: ORAL BUSULFAN Category: Drugs CMS Add: 01/01/2000 CMS Term: J8515 NOCOV DEF SYSMAN Description: CABERGOLINE, ORAL 0.25MG Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: J8520 DRUG DEF MAXFEE 01/01/2020 0.53 0.0 Description: CAPECITABINE, ORAL, 150 MG Category: Drugs CMS Add: 01/01/2000 CMS Term: J8521 DRUG DEF MAXFEE 07/01/2020 0.53 0.0 Description: CAPECITABINE, ORAL, 500 MG Category: Drugs CMS Add: 01/01/2000 CMS Term: J8530 DRUG DEF MAXFEE 01/01/2022 2.21 0.0 Description: CYCLOPHOSPHAMIDE ORAL 25 MG Category: Drugs CMS Add: 01/01/1995 CMS Term: J8540 NOCOV DEF SYSMAN Description: ORAL DEXAMETHASONE Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: J8560 DRUG DEF MAXFEE 07/01/2016 79.10 0.0 Description: ETOPOSIDE ORAL 50 MG Category: Drugs CMS Add: 01/01/1995 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,868 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J8562 NOCOV DEF SYSMAN Description: ORAL FLUDARABINE PHOSPHATE Category: Non Covered Services CMS Add: 01/01/2011 CMS Term: J8565 DRUG DEF MAXFEE 07/01/2019 06/30/2023 272.61 0.0 Description: GEFITINIB ORAL Category: Drugs CMS Add: 01/01/2005 CMS Term: J8565 DRUG DEF MAXFEE 07/01/2023 139.82 0.0 Description: GEFITINIB ORAL Category: Drugs CMS Add: 01/01/2005 CMS Term: J8597 NOCOV DEF SYSMAN Description: ANTIEMETIC DRUG ORAL NOS Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: J8600 DRUG DEF MAXFEE 10/01/2017 9.62 0.0 Description: MELPHALAN ORAL 2 MG Category: Drugs CMS Add: 01/01/1995 CMS Term: J8610 DRUG DEF MAXFEE 01/01/2021 0.33 0.0 Description: METHOTREXATE ORAL 2.5 MG Category: Drugs CMS Add: 01/01/1995 CMS Term: J8650 DRUG DEF SYSMAN Description: NABILONE ORAL Category: Drugs CMS Add: 01/01/2007 CMS Term: J8655 DRUG DEF MAXFEE 01/01/2022 724.61 0.0 Description: ORAL NETUPITANT, PALONOSETRO Category: Drugs CMS Add: 01/01/2016 CMS Term: J8670 DRUG DEF SYSMAN Description: ROLAPITANT, ORAL, 1MG Category: Drugs CMS Add: 01/01/2017 CMS Term: J8700 DRUG DEF MAXFEE 04/01/2022 1.07 0.0 Description: TEMOZOLOMIDE Category: Drugs CMS Add: 01/01/2001 CMS Term: J8705 NOCOV DEF SYSMAN Description: TOPOTECAN ORAL Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: J8999 DRUG DEF SYSMAN Description: ORAL PRESCRIPTION DRUG CHEMO Category: Drugs CMS Add: 01/01/1995 CMS Term: J9000 DRUG DEF MAXFEE 04/01/2020 1.58 0.0 Description: DOXORUBICIN HCL INJECTION Category: Drugs CMS Add: 01/01/1984 CMS Term: J9015 DRUG DEF SYSMAN Description: ALDESLEUKIN INJECTION Category: Drugs CMS Add: 01/01/1996 CMS Term: J9017 DRUG DEF MAXFEE 04/01/2021 15.33 0.0 Description: ARSENIC TRIOXIDE INJECTION Category: Drugs CMS Add: 01/01/2002 CMS Term: J9019 DRUG DEF MAXFEE 04/01/2020 423.24 0.0 Description: ERWINAZE INJECTION Category: Drugs CMS Add: 01/01/2013 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,869 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J9020 DRUG DEF SYSMAN Description: ASPARAGINASE, NOS Category: Drugs CMS Add: 01/01/1984 CMS Term: J9021 DRUG DEF MAXFEE 04/01/2023 09/30/2023 49.25 0.0 Description: INJ, ASPARA, RYLAZE, 0.1 MG Category: Drugs CMS Add: 01/01/2022 CMS Term: J9021 DRUG DEF MAXFEE 04/01/2024 52.29 0.0 Description: INJ, ASPARA, RYLAZE, 0.1 MG Category: Drugs CMS Add: 01/01/2022 CMS Term: J9021 DRUG DEF MAXFEE 10/01/2023 03/31/2024 50.72 0.0 Description: INJ, ASPARA, RYLAZE, 0.1 MG Category: Drugs CMS Add: 01/01/2022 CMS Term: J9022 DRUG DEF MAXFEE 04/01/2023 09/30/2023 88.33 0.0 Description: INJ, ATEZOLIZUMAB,10 MG Category: Drugs CMS Add: 01/01/2018 CMS Term: J9022 DRUG DEF MAXFEE 04/01/2024 92.80 0.0 Description: INJ, ATEZOLIZUMAB,10 MG Category: Drugs CMS Add: 01/01/2018 CMS Term: J9022 DRUG DEF MAXFEE 10/01/2023 03/31/2024 90.54 0.0 Description: INJ, ATEZOLIZUMAB,10 MG Category: Drugs CMS Add: 01/01/2018 CMS Term: J9023 DRUG DEF MAXFEE 04/01/2023 09/30/2023 93.93 0.0 Y Description: INJECTION, AVELUMAB, 10 MG Category: Drugs CMS Add: 01/01/2018 CMS Term: J9023 DRUG DEF MAXFEE 04/01/2024 98.68 0.0 Y Description: INJECTION, AVELUMAB, 10 MG Category: Drugs CMS Add: 01/01/2018 CMS Term: J9023 DRUG DEF MAXFEE 10/01/2023 03/31/2024 95.81 0.0 Y Description: INJECTION, AVELUMAB, 10 MG Category: Drugs CMS Add: 01/01/2018 CMS Term: J9025 DRUG DEF MAXFEE 10/01/2021 0.41 0.0 Description: AZACITIDINE INJECTION Category: Drugs CMS Add: 01/01/2006 CMS Term: J9027 DRUG DEF MAXFEE 04/01/2021 42.00 0.0 Description: CLOFARABINE INJECTION Category: Drugs CMS Add: 01/01/2006 CMS Term: J9029 NOCOV DEF SYSMAN Description: INSTILL ADSTILADRIN, TX DOSE Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: J9030 DRUG DEF MAXFEE 07/01/2019 3.30 0.0 Description: BCG LIVE INTRAVESICAL 1MG Category: Drugs CMS Add: 07/01/2019 CMS Term: J9032 DRUG DEF MAXFEE 04/01/2023 06/30/2023 48.05 0.0 Description: INJECTION, BELINOSTAT, 10MG Category: Drugs CMS Add: 01/01/2016 CMS Term: J9032 DRUG DEF MAXFEE 04/01/2024 50.44 0.0 Description: INJECTION, BELINOSTAT, 10MG Category: Drugs CMS Add: 01/01/2016 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,870 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J9032 DRUG DEF MAXFEE 07/01/2023 09/30/2023 48.77 0.0 Description: INJECTION, BELINOSTAT, 10MG Category: Drugs CMS Add: 01/01/2016 CMS Term: J9032 DRUG DEF MAXFEE 10/01/2023 03/31/2024 49.50 0.0 Description: INJECTION, BELINOSTAT, 10MG Category: Drugs CMS Add: 01/01/2016 CMS Term: J9033 DRUG DEF SYSMAN Description: INJ., TREANDA 1 MG Category: Drugs CMS Add: 01/01/2009 CMS Term: J9034 DRUG DEF MAXFEE 07/01/2018 25.97 0.0 Description: INJ., BENDEKA 1 MG Category: Drugs CMS Add: 01/01/2017 CMS Term: J9035 DRUG DEF MAXFEE 10/01/2018 83.68 0.0 Description: BEVACIZUMAB INJECTION Category: Drugs CMS Add: 01/01/2005 CMS Term: J9036 DRUG DEF MAXFEE 04/01/2023 24.57 0.0 Description: INJ. BELRAPZO/BENDAMUSTINE Category: Drugs CMS Add: 07/01/2019 CMS Term: J9037 DRUG DEF MAXFEE 10/01/2022 46.34 0.0 Description: INJ BELANTAMAB MAFODOT BLMF Category: Drugs CMS Add: 04/01/2021 CMS Term: J9039 DRUG DEF MAXFEE 04/01/2023 03/31/2024 147.00 0.0 Description: INJECTION, BLINATUMOMAB Category: Drugs CMS Add: 01/01/2016 CMS Term: J9039 DRUG DEF MAXFEE 04/01/2024 154.35 0.0 Description: INJECTION, BLINATUMOMAB Category: Drugs CMS Add: 01/01/2016 CMS Term: J9040 DRUG DEF MAXFEE 01/01/2021 32.21 0.0 Description: BLEOMYCIN SULFATE INJECTION Category: Drugs CMS Add: 01/01/1984 CMS Term: J9041 DRUG DEF MAXFEE 04/01/2024 1.05 0.0 Description: INJECTION, BORTEZOMIB, 0.1MG Category: Drugs CMS Add: 01/01/2005 CMS Term: J9041 DRUG DEF MAXFEE 10/01/2022 03/31/2024 2.25 0.0 Description: INJECTION, BORTEZOMIB, 0.1MG Category: Drugs CMS Add: 01/01/2005 CMS Term: J9042 DRUG DEF MAXFEE 04/01/2023 09/30/2023 219.87 0.0 Description: BRENTUXIMAB VEDOTIN INJ Category: Drugs CMS Add: 01/01/2013 CMS Term: J9042 DRUG DEF MAXFEE 04/01/2024 237.34 0.0 Description: BRENTUXIMAB VEDOTIN INJ Category: Drugs CMS Add: 01/01/2013 CMS Term: J9042 DRUG DEF MAXFEE 10/01/2023 03/31/2024 228.44 0.0 Description: BRENTUXIMAB VEDOTIN INJ Category: Drugs CMS Add: 01/01/2013 CMS Term: J9043 DRUG DEF MAXFEE 04/01/2023 09/30/2023 231.02 0.0 Description: CABAZITAXEL INJECTION Category: Drugs CMS Add: 01/01/2012 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,871 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J9043 DRUG DEF MAXFEE 04/01/2024 242.71 0.0 Description: CABAZITAXEL INJECTION Category: Drugs CMS Add: 01/01/2012 CMS Term: J9043 DRUG DEF MAXFEE 10/01/2023 03/31/2024 235.64 0.0 Description: CABAZITAXEL INJECTION Category: Drugs CMS Add: 01/01/2012 CMS Term: J9045 DRUG DEF MAXFEE 07/01/2018 3.85 0.0 Description: CARBOPLATIN INJECTION Category: Drugs CMS Add: 01/01/1990 CMS Term: J9046 DRUG DEF MAXFEE 01/01/2023 7.50 0.0 Description: INJ, BORTEZOMIB, DR. REDDY'S Category: Drugs CMS Add: 01/01/2023 CMS Term: J9047 DRUG DEF MAXFEE 04/01/2023 03/31/2024 52.14 0.0 Description: INJECTION, CARFILZOMIB, 1 MG Category: Drugs CMS Add: 01/01/2014 CMS Term: J9047 DRUG DEF MAXFEE 04/01/2024 54.74 0.0 Description: INJECTION, CARFILZOMIB, 1 MG Category: Drugs CMS Add: 01/01/2014 CMS Term: J9048 DRUG DEF MAXFEE 04/01/2023 03/31/2024 48.09 0.0 Description: INJ, BORTEZOMIB FRESENIUSKAB Category: Drugs CMS Add: 01/01/2023 CMS Term: J9048 DRUG DEF MAXFEE 04/01/2024 9.00 0.0 Description: INJ, BORTEZOMIB FRESENIUSKAB Category: Drugs CMS Add: 01/01/2023 CMS Term: J9049 DRUG DEF MAXFEE 01/01/2023 12/31/2023 7.50 0.0 Description: INJ, BORTEZOMIB, HOSPIRA Category: Drugs CMS Add: 01/01/2023 CMS Term: J9049 DRUG DEF MAXFEE 01/01/2024 8.06 0.0 Description: INJ, BORTEZOMIB, HOSPIRA Category: Drugs CMS Add: 01/01/2023 CMS Term: J9050 DRUG DEF MAXFEE 10/01/2022 577.50 0.0 Description: CARMUSTINE INJECTION Category: Drugs CMS Add: 01/01/1984 CMS Term: J9051 NOCOV DEF SYSMAN Description: INJ, BORTEZOMIB (MAIA) Category: Non Covered Services CMS Add: 10/01/2023 CMS Term: J9052 DRUG DEF MAXFEE 01/01/2024 257.25 0.0 Description: INJ, CARMUSTINE (ACCORD) Category: Drugs CMS Add: 01/01/2024 CMS Term: J9055 DRUG DEF MAXFEE 04/01/2023 09/30/2023 78.79 0.0 Description: CETUXIMAB INJECTION Category: Drugs CMS Add: 01/01/2005 CMS Term: J9055 DRUG DEF MAXFEE 04/01/2024 82.77 0.0 Description: CETUXIMAB INJECTION Category: Drugs CMS Add: 01/01/2005 CMS Term: J9055 DRUG DEF MAXFEE 10/01/2023 03/31/2024 80.36 0.0 Description: CETUXIMAB INJECTION Category: Drugs CMS Add: 01/01/2005 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,872 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J9056 DRUG DEF MAXFEE 07/01/2023 09/30/2023 33.70 0.0 Description: INJ, BENDAMUSTINE, 1 MG Category: Drugs CMS Add: 07/01/2023 CMS Term: J9056 DRUG DEF MAXFEE 10/01/2023 34.37 0.0 Description: INJ, BENDAMUSTINE, 1 MG Category: Drugs CMS Add: 07/01/2023 CMS Term: J9057 DRUG DEF MAXFEE 04/01/2023 09/30/2023 88.37 0.0 Y Description: INJ., COPANLISIB, 1 MG Category: Drugs CMS Add: 01/01/2019 CMS Term: J9057 DRUG DEF MAXFEE 04/01/2024 91.94 0.0 Y Description: INJ., COPANLISIB, 1 MG Category: Drugs CMS Add: 01/01/2019 CMS Term: J9057 DRUG DEF MAXFEE 10/01/2023 03/31/2024 90.13 0.0 Y Description: INJ., COPANLISIB, 1 MG Category: Drugs CMS Add: 01/01/2019 CMS Term: J9058 NOCOV DEF SYSMAN Description: INJ APOTEX/BENDAMUSTINE 1 MG Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: J9059 DRUG DEF MAXFEE 07/01/2023 24.57 0.0 Description: INJ BENDAMUSTINE, BAXTER 1MG Category: Drugs CMS Add: 07/01/2023 CMS Term: J9060 DRUG DEF MAXFEE 04/01/2022 1.90 0.0 Description: CISPLATIN 10 MG INJECTION Category: Drugs CMS Add: 01/01/1984 CMS Term: J9061 DRUG DEF MAXFEE 01/01/2023 06/30/2023 19.70 0.0 Description: INJ, AMIVANTAMAB-VMJW Category: Drugs CMS Add: 01/01/2022 CMS Term: J9061 DRUG DEF MAXFEE 04/01/2024 20.90 0.0 Description: INJ, AMIVANTAMAB-VMJW Category: Drugs CMS Add: 01/01/2022 CMS Term: J9061 DRUG DEF MAXFEE 07/01/2023 03/31/2024 20.09 0.0 Description: INJ, AMIVANTAMAB-VMJW Category: Drugs CMS Add: 01/01/2022 CMS Term: J9063 DRUG DEF MAXFEE 04/01/2024 66.62 0.0 Description: INJ, ELAHERE, 1 MG Category: Drugs CMS Add: 07/01/2023 CMS Term: J9063 DRUG DEF MAXFEE 07/01/2023 03/31/2024 65.31 0.0 Description: INJ, ELAHERE, 1 MG Category: Drugs CMS Add: 07/01/2023 CMS Term: J9064 NOCOV DEF SYSMAN Description: INJ, CABAZITAXEL (SANDOZ) Category: Non Covered Services CMS Add: 10/01/2023 CMS Term: J9065 DRUG DEF MAXFEE 10/01/2013 36.75 0.0 Description: INJ CLADRIBINE PER 1 MG Category: Drugs CMS Add: 01/01/1995 CMS Term: J9070 DRUG DEF MAXFEE 04/01/2023 03/31/2024 26.40 0.0 Description: CYCLOPHOSPHAMIDE 100 MG INJ Category: Drugs CMS Add: 01/01/1984 CMS Term: 03/31/2024 *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,873 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J9070 DRUG DEF MAXFEE 04/01/2024 21.00 0.0 Description: CYCLOPHOSPHAMIDE 100 MG INJ Category: Drugs CMS Add: 01/01/1984 CMS Term: 03/31/2024 J9071 DRUG DEF MAXFEE 04/01/2022 3.83 0.0 Description: INJ CYCLOPHOSPHAMD AUROMEDIC Category: Drugs CMS Add: 04/01/2022 CMS Term: J9072 NOCOV DEF SYSMAN Description: INJ CYCLOPHOS DR.REDDY'S 5MG Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: J9098 DRUG DEF SYSMAN Description: CYTARABINE LIPOSOME INJ Category: Drugs CMS Add: 01/01/2004 CMS Term: J9100 DRUG DEF MAXFEE 04/01/2013 0.96 0.0 Description: CYTARABINE HCL 100 MG INJ Category: Drugs CMS Add: 01/01/1986 CMS Term: J9118 DRUG DEF MAXFEE 04/01/2023 03/31/2024 72.20 0.0 Description: INJ. CALASPARGASE PEGOL-MKNL Category: Drugs CMS Add: 10/01/2019 CMS Term: J9118 DRUG DEF MAXFEE 04/01/2024 75.81 0.0 Description: INJ. CALASPARGASE PEGOL-MKNL Category: Drugs CMS Add: 10/01/2019 CMS Term: J9119 DRUG DEF MAXFEE 01/01/2024 29.99 0.0 Y Description: INJ., CEMIPLIMAB-RWLC, 1 MG Category: Drugs CMS Add: 10/01/2019 CMS Term: J9119 DRUG DEF MAXFEE 07/01/2022 09/30/2023 28.83 0.0 Y Description: INJ., CEMIPLIMAB-RWLC, 1 MG Category: Drugs CMS Add: 10/01/2019 CMS Term: J9119 DRUG DEF MAXFEE 10/01/2023 12/31/2023 29.41 0.0 Y Description: INJ., CEMIPLIMAB-RWLC, 1 MG Category: Drugs CMS Add: 10/01/2019 CMS Term: J9120 DRUG DEF MAXFEE 04/01/2023 03/31/2024 774.38 0.0 Description: DACTINOMYCIN INJECTION Category: Drugs CMS Add: 01/01/1984 CMS Term: J9120 DRUG DEF MAXFEE 04/01/2024 525.00 0.0 Description: DACTINOMYCIN INJECTION Category: Drugs CMS Add: 01/01/1984 CMS Term: J9130 DRUG DEF MAXFEE 04/01/2023 6.30 0.0 Description: DACARBAZINE 100 MG INJ Category: Drugs CMS Add: 01/01/1986 CMS Term: J9144 DRUG DEF MAXFEE 04/01/2023 03/31/2024 53.19 0.0 Description: DARATUMUMAB, HYALURONIDASE Category: Drugs CMS Add: 01/01/2021 CMS Term: J9144 DRUG DEF MAXFEE 04/01/2024 56.54 0.0 Description: DARATUMUMAB, HYALURONIDASE Category: Drugs CMS Add: 01/01/2021 CMS Term: J9145 DRUG DEF MAXFEE 04/01/2023 03/31/2024 70.24 0.0 Description: INJECTION, DARATUMUMAB 10 MG Category: Drugs CMS Add: 01/01/2017 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,874 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J9145 DRUG DEF MAXFEE 04/01/2024 74.67 0.0 Description: INJECTION, DARATUMUMAB 10 MG Category: Drugs CMS Add: 01/01/2017 CMS Term: J9150 DRUG DEF MAXFEE 01/01/2016 41.42 0.0 Description: DAUNORUBICIN INJECTION Category: Drugs CMS Add: 01/01/1986 CMS Term: J9151 NOCOV DEF SYSMAN Description: DAUNORUBICIN CITRATE INJ Category: Non Covered Services CMS Add: 01/01/1999 CMS Term: J9153 DRUG DEF MAXFEE 04/01/2023 09/30/2023 229.57 0.0 Description: INJ DAUNORUBICIN, CYTARABINE Category: Drugs CMS Add: 01/01/2019 CMS Term: J9153 DRUG DEF MAXFEE 04/01/2024 243.41 0.0 Description: INJ DAUNORUBICIN, CYTARABINE Category: Drugs CMS Add: 01/01/2019 CMS Term: J9153 DRUG DEF MAXFEE 10/01/2023 03/31/2024 234.10 0.0 Description: INJ DAUNORUBICIN, CYTARABINE Category: Drugs CMS Add: 01/01/2019 CMS Term: J9155 DRUG DEF MAXFEE 10/01/2016 6.41 0.0 Description: DEGARELIX INJECTION Category: Drugs CMS Add: 01/01/2010 CMS Term: J9165 DRUG DEF SYSMAN Description: DIETHYLSTILBESTROL INJECTION Category: Drugs CMS Add: 01/01/1988 CMS Term: J9171 DRUG DEF MAXFEE 04/01/2020 1.02 0.0 Description: DOCETAXEL INJECTION Category: Drugs CMS Add: 01/01/2010 CMS Term: J9172 DRUG DEF MAXFEE 01/01/2024 2.10 0.0 Description: DOCETAXEL (INGENUS), 1 MG Category: Drugs CMS Add: 01/01/2024 CMS Term: J9173 DRUG DEF MAXFEE 04/01/2023 09/30/2023 81.69 0.0 Y Description: INJ., DURVALUMAB, 10 MG Category: Drugs CMS Add: 01/01/2019 CMS Term: J9173 DRUG DEF MAXFEE 04/01/2024 84.57 0.0 Y Description: INJ., DURVALUMAB, 10 MG Category: Drugs CMS Add: 01/01/2019 CMS Term: J9173 DRUG DEF MAXFEE 10/01/2023 03/31/2024 82.91 0.0 Y Description: INJ., DURVALUMAB, 10 MG Category: Drugs CMS Add: 01/01/2019 CMS Term: J9175 NOCOV DEF SYSMAN Description: ELLIOTTS B SOLUTION PER ML Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: J9176 DRUG DEF MAXFEE 04/01/2023 09/30/2023 7.36 0.0 Description: INJECTION, ELOTUZUMAB, 1MG Category: Drugs CMS Add: 01/01/2017 CMS Term: J9176 DRUG DEF MAXFEE 04/01/2024 7.66 0.0 Description: INJECTION, ELOTUZUMAB, 1MG Category: Drugs CMS Add: 01/01/2017 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,875 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J9176 DRUG DEF MAXFEE 10/01/2023 03/31/2024 7.51 0.0 Description: INJECTION, ELOTUZUMAB, 1MG Category: Drugs CMS Add: 01/01/2017 CMS Term: J9177 DRUG DEF MAXFEE 01/01/2023 06/30/2023 33.50 0.0 Description: INJ ENFORT VEDO-EJFV 0.25MG Category: Drugs CMS Add: 07/01/2020 CMS Term: J9177 DRUG DEF MAXFEE 01/01/2024 36.15 0.0 Description: INJ ENFORT VEDO-EJFV 0.25MG Category: Drugs CMS Add: 07/01/2020 CMS Term: J9177 DRUG DEF MAXFEE 07/01/2023 12/31/2023 34.79 0.0 Description: INJ ENFORT VEDO-EJFV 0.25MG Category: Drugs CMS Add: 07/01/2020 CMS Term: J9178 DRUG DEF MAXFEE 07/01/2022 1.96 0.0 Description: INJ, EPIRUBICIN HCL, 2 MG Category: Drugs CMS Add: 01/01/2004 CMS Term: J9179 DRUG DEF MAXFEE 04/01/2023 09/30/2023 140.07 0.0 Description: ERIBULIN MESYLATE INJECTION Category: Drugs CMS Add: 01/01/2012 CMS Term: J9179 DRUG DEF MAXFEE 04/01/2024 148.05 0.0 Description: ERIBULIN MESYLATE INJECTION Category: Drugs CMS Add: 01/01/2012 CMS Term: J9179 DRUG DEF MAXFEE 10/01/2023 03/31/2024 143.64 0.0 Description: ERIBULIN MESYLATE INJECTION Category: Drugs CMS Add: 01/01/2012 CMS Term: J9181 DRUG DEF MAXFEE 07/01/2020 0.53 0.0 Description: ETOPOSIDE INJECTION Category: Drugs CMS Add: 01/01/1987 CMS Term: J9185 DRUG DEF MAXFEE 10/01/2014 99.23 0.0 Description: FLUDARABINE PHOSPHATE INJ Category: Drugs CMS Add: 01/01/1994 CMS Term: J9190 DRUG DEF MAXFEE 10/01/2014 2.50 0.0 Description: FLUOROURACIL INJECTION Category: Drugs CMS Add: 01/01/1984 CMS Term: J9196 DRUG DEF MAXFEE 04/01/2023 9.70 0.0 Description: INJ GEMCITABINE HCL (ACCORD) Category: Drugs CMS Add: 04/01/2023 CMS Term: J9198 DRUG DEF MAXFEE 07/01/2020 39.90 0.0 Description: INJ. INFUGEM, 100 MG Category: Drugs CMS Add: 07/01/2020 CMS Term: J9200 DRUG DEF MAXFEE 10/01/2011 124.95 0.0 Description: FLOXURIDINE INJECTION Category: Drugs CMS Add: 01/01/1984 CMS Term: J9201 DRUG DEF MAXFEE 07/01/2016 8.13 0.0 Description: IN GEMCITABINE HCL NOS 200MG Category: Drugs CMS Add: 01/01/1998 CMS Term: J9202 DRUG DEF SYSMAN Description: GOSERELIN ACETATE IMPLANT Category: Drugs CMS Add: 01/01/1991 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,876 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J9203 DRUG DEF SYSMAN Description: GEMTUZUMAB OZOGAMICIN 0.1 MG Category: Drugs CMS Add: 01/01/2018 CMS Term: J9204 DRUG DEF MAXFEE 04/01/2023 09/30/2023 225.20 0.0 Description: INJ MOGAMULIZUMAB-KPKC, 1 MG Category: Drugs CMS Add: 10/01/2019 CMS Term: J9204 DRUG DEF MAXFEE 04/01/2024 236.59 0.0 Description: INJ MOGAMULIZUMAB-KPKC, 1 MG Category: Drugs CMS Add: 10/01/2019 CMS Term: J9204 DRUG DEF MAXFEE 10/01/2023 03/31/2024 231.96 0.0 Description: INJ MOGAMULIZUMAB-KPKC, 1 MG Category: Drugs CMS Add: 10/01/2019 CMS Term: J9205 DRUG DEF MAXFEE 01/01/2024 67.54 0.0 Description: INJ IRINOTECAN LIPOSOME 1 MG Category: Drugs CMS Add: 01/01/2017 CMS Term: J9205 DRUG DEF MAXFEE 04/01/2023 12/31/2023 65.91 0.0 Description: INJ IRINOTECAN LIPOSOME 1 MG Category: Drugs CMS Add: 01/01/2017 CMS Term: J9206 DRUG DEF MAXFEE 01/01/2020 09/30/2023 3.78 0.0 Description: IRINOTECAN INJECTION Category: Drugs CMS Add: 01/01/1998 CMS Term: J9206 DRUG DEF MAXFEE 10/01/2023 1.47 0.0 Description: IRINOTECAN INJECTION Category: Drugs CMS Add: 01/01/1998 CMS Term: J9207 DRUG DEF MAXFEE 01/01/2023 06/30/2023 123.65 0.0 Description: IXABEPILONE INJECTION Category: Drugs CMS Add: 01/01/2009 CMS Term: J9207 DRUG DEF MAXFEE 04/01/2024 135.54 0.0 Description: IXABEPILONE INJECTION Category: Drugs CMS Add: 01/01/2009 CMS Term: J9207 DRUG DEF MAXFEE 07/01/2023 03/31/2024 129.21 0.0 Description: IXABEPILONE INJECTION Category: Drugs CMS Add: 01/01/2009 CMS Term: J9208 DRUG DEF MAXFEE 04/01/2013 36.99 0.0 Description: IFOSFAMIDE INJECTION Category: Drugs CMS Add: 01/01/1990 CMS Term: J9209 DRUG DEF MAXFEE 07/01/2018 2.31 0.0 Description: MESNA INJECTION Category: Drugs CMS Add: 01/01/1990 CMS Term: J9210 DRUG DEF MAXFEE 04/01/2020 354.59 0.0 Description: INJ., EMAPALUMAB-LZSG, 1 MG Category: Drugs CMS Add: 10/01/2019 CMS Term: J9211 DRUG DEF MAXFEE 07/01/2018 31.50 0.0 Description: IDARUBICIN HCL INJECTION Category: Drugs CMS Add: 01/01/1993 CMS Term: J9212 DRUG DEF SYSMAN Description: INTERFERON ALFACON-1 INJ Category: Drugs CMS Add: 01/01/1999 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,877 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J9213 DRUG DEF SYSMAN Description: INTERFERON ALFA-2A INJ Category: Drugs CMS Add: 01/01/1993 CMS Term: J9214 DRUG DEF MAXFEE 04/01/2018 32.27 0.0 Description: INTERFERON ALFA-2B INJ Category: Drugs CMS Add: 01/01/1993 CMS Term: J9215 DRUG DEF SYSMAN Description: INTERFERON ALFA-N3 INJ Category: Drugs CMS Add: 01/01/1993 CMS Term: J9216 DRUG DEF MAXFEE 04/01/2023 03/31/2024 8228.30 0.0 Description: INTERFERON GAMMA 1-B INJ Category: Drugs CMS Add: 01/01/1993 CMS Term: J9216 DRUG DEF MAXFEE 04/01/2024 8549.21 0.0 Description: INTERFERON GAMMA 1-B INJ Category: Drugs CMS Add: 01/01/1993 CMS Term: J9217 DRUG DEF MAXFEE 04/01/2015 474.27 0.0 Description: LEUPROLIDE ACETATE SUSPNSION Category: Drugs CMS Add: 01/01/1991 CMS Term: J9218 DRUG DEF MAXFEE 10/01/2022 50.55 0.0 Description: LEUPROLIDE ACETATE INJECITON Category: Drugs CMS Add: 01/01/1990 CMS Term: J9219 DRUG DEF SYSMAN Description: LEUPROLIDE ACETATE IMPLANT Category: Drugs CMS Add: 01/01/2001 CMS Term: J9223 DRUG DEF MAXFEE 04/01/2023 09/30/2023 200.55 0.0 Description: INJ. LURBINECTEDIN, 0.1 MG Category: Drugs CMS Add: 01/01/2021 CMS Term: J9223 DRUG DEF MAXFEE 04/01/2024 208.69 0.0 Description: INJ. LURBINECTEDIN, 0.1 MG Category: Drugs CMS Add: 01/01/2021 CMS Term: J9223 DRUG DEF MAXFEE 10/01/2023 03/31/2024 205.54 0.0 Description: INJ. LURBINECTEDIN, 0.1 MG Category: Drugs CMS Add: 01/01/2021 CMS Term: J9225 DRUG DEF MAXFEE 01/01/2021 5117.55 0.0 Y Description: VANTAS IMPLANT Category: Drugs CMS Add: 01/01/2006 CMS Term: J9226 DRUG DEF MAXFEE 07/01/2022 06/30/2023 47438.15 0.0 Description: SUPPRELIN LA IMPLANT Category: Drugs CMS Add: 01/01/2008 CMS Term: J9226 DRUG DEF MAXFEE 07/01/2023 49762.62 0.0 Description: SUPPRELIN LA IMPLANT Category: Drugs CMS Add: 01/01/2008 CMS Term: J9227 DRUG DEF MAXFEE 04/01/2023 09/30/2023 77.17 0.0 Description: INJ. ISATUXIMAB-IRFC 10 MG Category: Drugs CMS Add: 10/01/2020 CMS Term: J9227 DRUG DEF MAXFEE 04/01/2024 81.08 0.0 Description: INJ. ISATUXIMAB-IRFC 10 MG Category: Drugs CMS Add: 10/01/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,878 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J9227 DRUG DEF MAXFEE 10/01/2023 03/31/2024 79.10 0.0 Description: INJ. ISATUXIMAB-IRFC 10 MG Category: Drugs CMS Add: 10/01/2020 CMS Term: J9228 DRUG DEF MAXFEE 04/01/2023 09/30/2023 172.22 0.0 Description: IPILIMUMAB INJECTION Category: Drugs CMS Add: 01/01/2012 CMS Term: J9228 DRUG DEF MAXFEE 04/01/2024 179.18 0.0 Description: IPILIMUMAB INJECTION Category: Drugs CMS Add: 01/01/2012 CMS Term: J9228 DRUG DEF MAXFEE 10/01/2023 03/31/2024 175.67 0.0 Description: IPILIMUMAB INJECTION Category: Drugs CMS Add: 01/01/2012 CMS Term: J9229 DRUG DEF MAXFEE 04/01/2023 09/30/2023 2505.69 0.0 Description: INJ INOTUZUMAB OZOGAM 0.1 MG Category: Drugs CMS Add: 01/01/2019 CMS Term: J9229 DRUG DEF MAXFEE 04/01/2024 2594.14 0.0 Description: INJ INOTUZUMAB OZOGAM 0.1 MG Category: Drugs CMS Add: 01/01/2019 CMS Term: J9229 DRUG DEF MAXFEE 10/01/2023 03/31/2024 2555.80 0.0 Description: INJ INOTUZUMAB OZOGAM 0.1 MG Category: Drugs CMS Add: 01/01/2019 CMS Term: J9230 DRUG DEF SYSMAN Description: MECHLORETHAMINE HCL INJ Category: Drugs CMS Add: 01/01/1986 CMS Term: J9245 DRUG DEF MAXFEE 07/01/2022 210.00 0.0 Description: INJ MELPHA HYDROCH NOS 50 MG Category: Drugs CMS Add: 01/01/1995 CMS Term: J9246 DRUG DEF MAXFEE 10/01/2022 33.58 0.0 Description: INJ., EVOMELA, 1 MG Category: Drugs CMS Add: 07/01/2020 CMS Term: J9247 DRUG DEF SYSMAN Description: INJ, MELPHALAN FLUFENAMI 1MG Category: Drugs CMS Add: 10/01/2021 CMS Term: J9250 DRUG DEF MAXFEE 04/01/2015 0.47 0.0 Description: METHOTREXATE SODIUM INJ Category: Drugs CMS Add: 01/01/1994 CMS Term: 03/31/2024 J9255 DRUG DEF MAXFEE 01/01/2024 1.94 0.0 Description: INJ, METHOTREXATE (ACCORD) Category: Drugs CMS Add: 01/01/2024 CMS Term: J9258 NOCOV DEF SYSMAN Description: PACLITAXEL (TEVA) Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: J9259 NOCOV DEF SYSMAN Description: PACLITAXEL (AMERICAN REGENT) Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: J9260 DRUG DEF MAXFEE 04/01/2015 4.73 0.0 Description: INJ METHOTREXATE SODIUM 50MG Category: Drugs CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,879 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J9261 DRUG DEF MAXFEE 01/01/2022 06/30/2023 138.81 0.0 Description: NELARABINE INJECTION Category: Drugs CMS Add: 01/01/2007 CMS Term: J9261 DRUG DEF MAXFEE 07/01/2023 138.60 0.0 Description: NELARABINE INJECTION Category: Drugs CMS Add: 01/01/2007 CMS Term: J9262 DRUG DEF MAXFEE 04/01/2023 3.99 0.0 Description: INJ, OMACETAXINE MEP, 0.01MG Category: Drugs CMS Add: 01/01/2014 CMS Term: J9263 DRUG DEF MAXFEE 10/01/2021 0.06 0.0 Description: OXALIPLATIN Category: Drugs CMS Add: 01/01/2004 CMS Term: J9264 DRUG DEF MAXFEE 07/01/2022 14.93 0.0 Description: PACLITAXEL PROTEIN BOUND Category: Drugs CMS Add: 01/01/2006 CMS Term: J9266 DRUG DEF MAXFEE 04/01/2023 03/31/2024 25538.24 0.0 Description: PEGASPARGASE INJECTION Category: Drugs CMS Add: 01/01/1996 CMS Term: J9266 DRUG DEF MAXFEE 04/01/2024 26815.15 0.0 Description: PEGASPARGASE INJECTION Category: Drugs CMS Add: 01/01/1996 CMS Term: J9267 DRUG DEF MAXFEE 07/01/2022 0.13 0.0 Description: PACLITAXEL INJECTION Category: Drugs CMS Add: 01/01/2015 CMS Term: J9268 DRUG DEF MAXFEE 04/01/2022 03/31/2024 2561.02 0.0 Description: PENTOSTATIN INJECTION Category: Drugs CMS Add: 01/01/1994 CMS Term: J9268 DRUG DEF MAXFEE 04/01/2024 2817.13 0.0 Description: PENTOSTATIN INJECTION Category: Drugs CMS Add: 01/01/1994 CMS Term: J9269 DRUG DEF MAXFEE 10/01/2022 324.58 0.0 Description: INJ. TAGRAXOFUSP-ERZS 10 MCG Category: Drugs CMS Add: 10/01/2019 CMS Term: J9270 DRUG DEF SYSMAN Description: PLICAMYCIN (MITHRAMYCIN) INJ Category: Drugs CMS Add: 01/01/1984 CMS Term: J9271 DRUG DEF MAXFEE 01/01/2023 06/30/2023 56.09 0.0 Description: INJ PEMBROLIZUMAB Category: Drugs CMS Add: 01/01/2016 CMS Term: J9271 DRUG DEF MAXFEE 01/01/2024 58.35 0.0 Description: INJ PEMBROLIZUMAB Category: Drugs CMS Add: 01/01/2016 CMS Term: J9271 DRUG DEF MAXFEE 07/01/2023 12/31/2023 57.21 0.0 Description: INJ PEMBROLIZUMAB Category: Drugs CMS Add: 01/01/2016 CMS Term: J9272 DRUG DEF MAXFEE 04/01/2023 09/30/2023 229.95 0.0 Description: INJ, DOSTARLIMAB-GXLY, 10 MG Category: Drugs CMS Add: 01/01/2022 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,880 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J9272 DRUG DEF MAXFEE 04/01/2024 238.06 0.0 Description: INJ, DOSTARLIMAB-GXLY, 10 MG Category: Drugs CMS Add: 01/01/2022 CMS Term: J9272 DRUG DEF MAXFEE 10/01/2023 03/31/2024 233.40 0.0 Description: INJ, DOSTARLIMAB-GXLY, 10 MG Category: Drugs CMS Add: 01/01/2022 CMS Term: J9273 DRUG DEF MAXFEE 01/01/2023 06/30/2023 160.49 0.0 Description: INJ TISOTU VEDOTIN-TFTV, 1MG Category: Drugs CMS Add: 04/01/2022 CMS Term: J9273 DRUG DEF MAXFEE 01/01/2024 173.22 0.0 Description: INJ TISOTU VEDOTIN-TFTV, 1MG Category: Drugs CMS Add: 04/01/2022 CMS Term: J9273 DRUG DEF MAXFEE 07/01/2023 12/31/2023 166.74 0.0 Description: INJ TISOTU VEDOTIN-TFTV, 1MG Category: Drugs CMS Add: 04/01/2022 CMS Term: J9274 DRUG DEF MAXFEE 04/01/2023 09/30/2023 201.90 0.0 Description: INJ, TEBENTAFUSP-TEBN, 1 MCG Category: Drugs CMS Add: 10/01/2022 CMS Term: J9274 DRUG DEF MAXFEE 04/01/2024 212.73 0.0 Description: INJ, TEBENTAFUSP-TEBN, 1 MCG Category: Drugs CMS Add: 10/01/2022 CMS Term: J9274 DRUG DEF MAXFEE 10/01/2023 03/31/2024 206.96 0.0 Description: INJ, TEBENTAFUSP-TEBN, 1 MCG Category: Drugs CMS Add: 10/01/2022 CMS Term: J9280 DRUG DEF MAXFEE 04/01/2023 28.88 0.0 Description: MITOMYCIN INJECTION Category: Drugs CMS Add: 01/01/1986 CMS Term: J9281 DRUG DEF MAXFEE 04/01/2023 09/30/2023 297.41 0.0 Description: MITOMYCIN INSTILLATION Category: Drugs CMS Add: 01/01/2021 CMS Term: J9281 DRUG DEF MAXFEE 04/01/2024 310.67 0.0 Description: MITOMYCIN INSTILLATION Category: Drugs CMS Add: 01/01/2021 CMS Term: J9281 DRUG DEF MAXFEE 10/01/2023 03/31/2024 304.85 0.0 Description: MITOMYCIN INSTILLATION Category: Drugs CMS Add: 01/01/2021 CMS Term: J9285 DRUG DEF SYSMAN Description: INJ, OLARATUMAB, 10 MG Category: Drugs CMS Add: 01/01/2018 CMS Term: J9286 DRUG DEF MAXFEE 01/01/2024 2682.48 0.0 Description: INJ GLOFITAMAB GXBM, 2.5 MG Category: Drugs CMS Add: 01/01/2024 CMS Term: J9293 DRUG DEF MAXFEE 04/01/2018 44.63 0.0 Description: MITOXANTRONE HYDROCHL / 5 MG Category: Drugs CMS Add: 01/01/1990 CMS Term: J9294 DRUG DEF MAXFEE 04/01/2023 9.45 0.0 Description: INJ PEMETREXED, HOSPIRA 10MG Category: Drugs CMS Add: 04/01/2023 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,881 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J9295 DRUG DEF MAXFEE 04/01/2019 5.68 0.0 Description: INJECTION, NECITUMUMAB, 1 MG Category: Drugs CMS Add: 01/01/2017 CMS Term: J9296 DRUG DEF MAXFEE 04/01/2023 9.56 0.0 Description: INJ PEMETREXED (ACCORD) 10MG Category: Drugs CMS Add: 04/01/2023 CMS Term: J9297 DRUG DEF MAXFEE 04/01/2023 06/30/2023 70.75 0.0 Description: INJ PEMETREXED (SANDOZ) 10MG Category: Drugs CMS Add: 04/01/2023 CMS Term: J9297 DRUG DEF MAXFEE 07/01/2023 9.56 0.0 Description: INJ PEMETREXED (SANDOZ) 10MG Category: Drugs CMS Add: 04/01/2023 CMS Term: J9298 DRUG DEF MAXFEE 04/01/2023 09/30/2023 183.33 0.0 Description: INJ NIVOL RELATLIMAB 3MG/1MG Category: Drugs CMS Add: 10/01/2022 CMS Term: J9298 DRUG DEF MAXFEE 04/01/2024 190.74 0.0 Description: INJ NIVOL RELATLIMAB 3MG/1MG Category: Drugs CMS Add: 10/01/2022 CMS Term: J9298 DRUG DEF MAXFEE 10/01/2023 03/31/2024 187.00 0.0 Description: INJ NIVOL RELATLIMAB 3MG/1MG Category: Drugs CMS Add: 10/01/2022 CMS Term: J9299 DRUG DEF MAXFEE 04/01/2023 09/30/2023 31.48 0.0 Description: INJECTION, NIVOLUMAB Category: Drugs CMS Add: 01/01/2016 CMS Term: J9299 DRUG DEF MAXFEE 04/01/2024 32.75 0.0 Description: INJECTION, NIVOLUMAB Category: Drugs CMS Add: 01/01/2016 CMS Term: J9299 DRUG DEF MAXFEE 10/01/2023 03/31/2024 32.10 0.0 Description: INJECTION, NIVOLUMAB Category: Drugs CMS Add: 01/01/2016 CMS Term: J9301 DRUG DEF MAXFEE 04/01/2023 03/31/2024 81.64 0.0 Description: OBINUTUZUMAB INJ Category: Drugs CMS Add: 01/01/2015 CMS Term: J9301 DRUG DEF MAXFEE 04/01/2024 86.54 0.0 Description: OBINUTUZUMAB INJ Category: Drugs CMS Add: 01/01/2015 CMS Term: J9302 DRUG DEF MAXFEE 04/01/2020 63.35 0.0 Description: OFATUMUMAB INJECTION Category: Drugs CMS Add: 01/01/2011 CMS Term: J9303 DRUG DEF MAXFEE 04/01/2023 03/31/2024 164.79 0.0 Description: PANITUMUMAB INJECTION Category: Drugs CMS Add: 01/01/2008 CMS Term: J9303 DRUG DEF MAXFEE 04/01/2024 173.03 0.0 Description: PANITUMUMAB INJECTION Category: Drugs CMS Add: 01/01/2008 CMS Term: J9304 NOCOV DEF SYSMAN Description: INJ. PEMETREXED, 10 MG Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,882 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J9305 DRUG DEF MAXFEE 01/01/2023 09/30/2023 3.15 0.0 Description: INJ. PEMETREXED NOS 10MG Category: Drugs CMS Add: 01/01/2005 CMS Term: J9305 DRUG DEF MAXFEE 10/01/2023 1.05 0.0 Description: INJ. PEMETREXED NOS 10MG Category: Drugs CMS Add: 01/01/2005 CMS Term: J9306 DRUG DEF MAXFEE 04/01/2023 03/31/2024 15.84 0.0 Description: INJECTION, PERTUZUMAB, 1 MG Category: Drugs CMS Add: 01/01/2014 CMS Term: J9306 DRUG DEF MAXFEE 04/01/2024 16.32 0.0 Description: INJECTION, PERTUZUMAB, 1 MG Category: Drugs CMS Add: 01/01/2014 CMS Term: J9307 DRUG DEF MAXFEE 01/01/2023 261.55 0.0 Description: PRALATREXATE INJECTION Category: Drugs CMS Add: 01/01/2011 CMS Term: J9308 DRUG DEF MAXFEE 04/01/2023 09/30/2023 71.37 0.0 Description: INJECTION, RAMUCIRUMAB Category: Drugs CMS Add: 01/01/2016 CMS Term: J9308 DRUG DEF MAXFEE 04/01/2024 74.98 0.0 Description: INJECTION, RAMUCIRUMAB Category: Drugs CMS Add: 01/01/2016 CMS Term: J9308 DRUG DEF MAXFEE 10/01/2023 03/31/2024 72.80 0.0 Description: INJECTION, RAMUCIRUMAB Category: Drugs CMS Add: 01/01/2016 CMS Term: J9309 DRUG DEF MAXFEE 04/01/2023 09/30/2023 120.51 0.0 Description: INJ, POLATUZUMAB VEDOTIN 1MG Category: Drugs CMS Add: 01/01/2020 CMS Term: J9309 DRUG DEF MAXFEE 04/01/2024 131.57 0.0 Description: INJ, POLATUZUMAB VEDOTIN 1MG Category: Drugs CMS Add: 01/01/2020 CMS Term: J9309 DRUG DEF MAXFEE 10/01/2023 03/31/2024 124.13 0.0 Description: INJ, POLATUZUMAB VEDOTIN 1MG Category: Drugs CMS Add: 01/01/2020 CMS Term: J9311 DRUG DEF MAXFEE 01/01/2019 49.32 0.0 Description: INJ RITUXIMAB, HYALURONIDASE Category: Drugs CMS Add: 01/01/2019 CMS Term: J9312 DRUG DEF MAXFEE 01/01/2019 98.65 0.0 Description: INJ., RITUXIMAB, 10 MG Category: Drugs CMS Add: 01/01/2019 CMS Term: J9313 DRUG DEF MAXFEE 01/01/2023 22.20 0.0 Description: INJ., LUMOXITI, 0.01 MG Category: Drugs CMS Add: 10/01/2019 CMS Term: J9314 DRUG DEF MAXFEE 01/01/2023 19.77 0.0 Description: INJ PEMETREXED (TEVA) 10MG Category: Drugs CMS Add: 01/01/2023 CMS Term: J9316 DRUG DEF MAXFEE 01/01/2021 03/31/2024 111.19 0.0 Description: PERTUZU, TRASTUZU, 10 MG Category: Drugs CMS Add: 01/01/2021 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,883 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J9316 DRUG DEF MAXFEE 04/01/2024 76.34 0.0 Description: PERTUZU, TRASTUZU, 10 MG Category: Drugs CMS Add: 01/01/2021 CMS Term: J9317 DRUG DEF MAXFEE 04/01/2023 09/30/2023 33.37 0.0 Description: SACITUZUMAB GOVITECAN-HZIY Category: Drugs CMS Add: 01/01/2021 CMS Term: J9317 DRUG DEF MAXFEE 04/01/2024 35.06 0.0 Description: SACITUZUMAB GOVITECAN-HZIY Category: Drugs CMS Add: 01/01/2021 CMS Term: J9317 DRUG DEF MAXFEE 10/01/2023 03/31/2024 34.20 0.0 Description: SACITUZUMAB GOVITECAN-HZIY Category: Drugs CMS Add: 01/01/2021 CMS Term: J9318 DRUG DEF MAXFEE 10/01/2021 33.59 0.0 Description: INJ ROMIDEPSIN NON-LYO 0.1MG Category: Drugs CMS Add: 10/01/2021 CMS Term: J9319 DRUG DEF MAXFEE 04/01/2022 33.27 0.0 Description: INJ ROMIDEPSIN LYOPHIL 0.1MG Category: Drugs CMS Add: 10/01/2021 CMS Term: J9320 DRUG DEF MAXFEE 01/01/2014 366.69 0.0 Description: STREPTOZOCIN INJECTION Category: Drugs CMS Add: 01/01/1986 CMS Term: J9321 DRUG DEF MAXFEE 01/01/2024 03/31/2024 53.29 0.0 Description: INJ EPCORITAMAB-BYSP 0.16 MG Category: Drugs CMS Add: 01/01/2024 CMS Term: J9321 DRUG DEF MAXFEE 04/01/2024 54.09 0.0 Description: INJ EPCORITAMAB-BYSP 0.16 MG Category: Drugs CMS Add: 01/01/2024 CMS Term: J9321 DRUG DEF MAXFEE 07/01/2023 12/31/2023 9.56 0.0 Description: INJ EPCORITAMAB-BYSP 0.16 MG Category: Drugs CMS Add: 01/01/2024 CMS Term: J9322 DRUG DEF MAXFEE 07/01/2023 9.56 0.0 Description: INJ PEMETREXED (BLUEPOINT) Category: Drugs CMS Add: 07/01/2023 CMS Term: J9323 DRUG DEF MAXFEE 07/01/2023 10.45 0.0 Description: INJ PEMETREXED DITROMETHAMIN Category: Drugs CMS Add: 07/01/2023 CMS Term: J9324 NOCOV DEF SYSMAN Description: INJ, PEMRYDI RTU, 10 MG Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: J9325 DRUG DEF MAXFEE 04/01/2023 03/31/2024 66.53 0.0 Description: INJ TALIMOGENE LAHERPAREPVEC Category: Drugs CMS Add: 01/01/2017 CMS Term: J9325 DRUG DEF MAXFEE 04/01/2024 69.86 0.0 Description: INJ TALIMOGENE LAHERPAREPVEC Category: Drugs CMS Add: 01/01/2017 CMS Term: J9328 DRUG DEF MAXFEE 04/01/2018 10.53 0.0 Description: TEMOZOLOMIDE INJECTION Category: Drugs CMS Add: 01/01/2010 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,884 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J9330 DRUG DEF MAXFEE 07/01/2021 49.56 0.0 Description: TEMSIROLIMUS INJECTION Category: Drugs CMS Add: 01/01/2009 CMS Term: J9331 DRUG DEF MAXFEE 04/01/2023 09/30/2023 73.38 0.0 Description: INJ SIROLIMUS PROT PART 1 MG Category: Drugs CMS Add: 07/01/2022 CMS Term: J9331 DRUG DEF MAXFEE 04/01/2024 77.83 0.0 Description: INJ SIROLIMUS PROT PART 1 MG Category: Drugs CMS Add: 07/01/2022 CMS Term: J9331 DRUG DEF MAXFEE 10/01/2023 03/31/2024 74.48 0.0 Description: INJ SIROLIMUS PROT PART 1 MG Category: Drugs CMS Add: 07/01/2022 CMS Term: J9332 DRUG DEF MAXFEE 04/01/2023 31.86 0.0 Description: INJ EFGARTIGIMOD 2MG Category: Drugs CMS Add: 07/01/2022 CMS Term: J9333 DRUG DEF MAXFEE 01/01/2024 22.69 0.0 Description: INJ RONZANOLIXIZUM-NOLI 1 MG Category: Drugs CMS Add: 01/01/2024 CMS Term: J9334 DRUG DEF MAXFEE 01/01/2024 32.86 0.0 Description: INJ EFGART-ALFA 2MG HYA-QVFC Category: Drugs CMS Add: 01/01/2024 CMS Term: J9340 DRUG DEF MAXFEE 04/01/2024 210.00 0.0 Description: THIOTEPA INJECTION Category: Drugs CMS Add: 01/01/1984 CMS Term: J9340 DRUG DEF MAXFEE 07/01/2020 03/31/2024 420.00 0.0 Description: THIOTEPA INJECTION Category: Drugs CMS Add: 01/01/1984 CMS Term: J9345 DRUG DEF MAXFEE 10/01/2023 29.90 0.0 Description: INJ, RETIFANLIMAB-DLWR, 1 MG Category: Drugs CMS Add: 10/01/2023 CMS Term: J9347 DRUG DEF MAXFEE 07/01/2023 136.50 0.0 Description: INJ, TREMELIMUMAB-ACTL, 1 MG Category: Drugs CMS Add: 07/01/2023 CMS Term: J9348 DRUG DEF MAXFEE 01/01/2023 09/30/2023 575.90 0.0 Description: INJ. NAXITAMAB-GQGK, 1 MG Category: Drugs CMS Add: 07/01/2021 CMS Term: J9348 DRUG DEF MAXFEE 10/01/2023 606.13 0.0 Description: INJ. NAXITAMAB-GQGK, 1 MG Category: Drugs CMS Add: 07/01/2021 CMS Term: J9349 DRUG DEF MAXFEE 04/01/2023 09/30/2023 13.37 0.0 Description: INJ., TAFASITAMAB-CXIX Category: Drugs CMS Add: 04/01/2021 CMS Term: J9349 DRUG DEF MAXFEE 04/01/2024 13.95 0.0 Description: INJ., TAFASITAMAB-CXIX Category: Drugs CMS Add: 04/01/2021 CMS Term: J9349 DRUG DEF MAXFEE 10/01/2023 03/31/2024 13.74 0.0 Description: INJ., TAFASITAMAB-CXIX Category: Drugs CMS Add: 04/01/2021 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,885 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J9350 DRUG DEF MAXFEE 04/01/2024 633.12 0.0 Description: INJ MOSUNETUZUMAB-AXGB, 1 MG Category: Drugs CMS Add: 07/01/2023 CMS Term: J9350 DRUG DEF MAXFEE 07/01/2023 03/31/2024 623.76 0.0 Description: INJ MOSUNETUZUMAB-AXGB, 1 MG Category: Drugs CMS Add: 07/01/2023 CMS Term: J9351 DRUG DEF MAXFEE 10/01/2022 1.82 0.0 Description: TOPOTECAN INJECTION Category: Drugs CMS Add: 01/01/2011 CMS Term: J9352 DRUG DEF MAXFEE 04/01/2023 03/31/2024 338.35 0.0 Description: INJECTION TRABECTEDIN 0.1MG Category: Drugs CMS Add: 01/01/2017 CMS Term: J9352 DRUG DEF MAXFEE 04/01/2024 362.04 0.0 Description: INJECTION TRABECTEDIN 0.1MG Category: Drugs CMS Add: 01/01/2017 CMS Term: J9353 DRUG DEF MAXFEE 04/01/2023 09/30/2023 46.06 0.0 Description: INJ. MARGETUXIMAB-CMKB, 5 MG Category: Drugs CMS Add: 07/01/2021 CMS Term: J9353 DRUG DEF MAXFEE 04/01/2024 48.39 0.0 Description: INJ. MARGETUXIMAB-CMKB, 5 MG Category: Drugs CMS Add: 07/01/2021 CMS Term: J9353 DRUG DEF MAXFEE 10/01/2023 03/31/2024 47.21 0.0 Description: INJ. MARGETUXIMAB-CMKB, 5 MG Category: Drugs CMS Add: 07/01/2021 CMS Term: J9354 DRUG DEF MAXFEE 04/01/2023 03/31/2024 39.29 0.0 Description: INJ, ADO-TRASTUZUMAB EMT 1MG Category: Drugs CMS Add: 01/01/2014 CMS Term: J9354 DRUG DEF MAXFEE 04/01/2024 40.86 0.0 Description: INJ, ADO-TRASTUZUMAB EMT 1MG Category: Drugs CMS Add: 01/01/2014 CMS Term: J9355 DRUG DEF MAXFEE 10/01/2018 109.09 0.0 Description: INJ TRASTUZUMAB EXCL BIOSIMI Category: Drugs CMS Add: 01/01/2000 CMS Term: J9356 DRUG DEF MAXFEE 07/01/2019 81.82 0.0 Description: INJ. HERCEPTIN HYLECTA, 10MG Category: Drugs CMS Add: 07/01/2019 CMS Term: J9357 DRUG DEF MAXFEE 07/01/2019 1476.29 0.0 Description: VALRUBICIN INJECTION Category: Drugs CMS Add: 01/01/2000 CMS Term: J9358 DRUG DEF MAXFEE 04/01/2023 09/30/2023 26.62 0.0 Description: INJ FAM-TRASTU DERU-NXKI 1MG Category: Drugs CMS Add: 07/01/2020 CMS Term: J9358 DRUG DEF MAXFEE 04/01/2024 28.37 0.0 Description: INJ FAM-TRASTU DERU-NXKI 1MG Category: Drugs CMS Add: 07/01/2020 CMS Term: J9358 DRUG DEF MAXFEE 10/01/2023 03/31/2024 27.81 0.0 Description: INJ FAM-TRASTU DERU-NXKI 1MG Category: Drugs CMS Add: 07/01/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,886 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J9359 DRUG DEF MAXFEE 04/01/2023 09/30/2023 195.70 0.0 Description: INJ LON TESIRIN-LPYL 0.075MG Category: Drugs CMS Add: 04/01/2022 CMS Term: J9359 DRUG DEF MAXFEE 04/01/2024 207.11 0.0 Description: INJ LON TESIRIN-LPYL 0.075MG Category: Drugs CMS Add: 04/01/2022 CMS Term: J9359 DRUG DEF MAXFEE 10/01/2023 03/31/2024 201.08 0.0 Description: INJ LON TESIRIN-LPYL 0.075MG Category: Drugs CMS Add: 04/01/2022 CMS Term: J9360 DRUG DEF MAXFEE 01/01/2024 5.64 0.0 Description: VINBLASTINE SULFATE INJ Category: Drugs CMS Add: 01/01/1986 CMS Term: J9360 DRUG DEF MAXFEE 04/01/2021 12/31/2023 4.95 0.0 Description: VINBLASTINE SULFATE INJ Category: Drugs CMS Add: 01/01/1986 CMS Term: J9370 DRUG DEF MAXFEE 04/01/2023 03/31/2024 7.34 0.0 Description: VINCRISTINE SULFATE 1 MG INJ Category: Drugs CMS Add: 01/01/1986 CMS Term: J9370 DRUG DEF MAXFEE 04/01/2024 8.09 0.0 Description: VINCRISTINE SULFATE 1 MG INJ Category: Drugs CMS Add: 01/01/1986 CMS Term: J9371 DRUG DEF MAXFEE 04/01/2022 3611.30 0.0 Description: INJ, VINCRISTINE SUL LIP 1MG Category: Drugs CMS Add: 01/01/2014 CMS Term: J9380 DRUG DEF MAXFEE 04/01/2024 32.52 0.0 Description: INJ TECLISTAMAB CQYV 0.5 MG Category: Drugs CMS Add: 07/01/2023 CMS Term: J9380 DRUG DEF MAXFEE 07/01/2023 03/31/2024 30.98 0.0 Description: INJ TECLISTAMAB CQYV 0.5 MG Category: Drugs CMS Add: 07/01/2023 CMS Term: J9381 DRUG DEF MAXFEE 04/01/2024 37.08 0.0 Description: INJ TEPLIZUMAB MZWV 5 MCG Category: Drugs CMS Add: 07/01/2023 CMS Term: J9381 DRUG DEF MAXFEE 07/01/2023 03/31/2024 36.36 0.0 Description: INJ TEPLIZUMAB MZWV 5 MCG Category: Drugs CMS Add: 07/01/2023 CMS Term: J9390 DRUG DEF MAXFEE 01/01/2022 18.90 0.0 Description: VINORELBINE TARTRATE INJ Category: Drugs CMS Add: 01/01/1996 CMS Term: J9393 DRUG DEF MAXFEE 01/01/2023 21.00 0.0 Description: INJ, FULVESTRANT (TEVA) Category: Drugs CMS Add: 01/01/2023 CMS Term: J9394 DRUG DEF MAXFEE 01/01/2023 52.50 0.0 Description: INJ, FULVESTRANT (FRESENIUS) Category: Drugs CMS Add: 01/01/2023 CMS Term: J9395 DRUG DEF MAXFEE 01/01/2023 12/31/2023 10.50 0.0 Description: INJECTION, FULVESTRANT Category: Drugs CMS Add: 01/01/2004 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,887 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- J9395 DRUG DEF MAXFEE 01/01/2024 9.71 0.0 Description: INJECTION, FULVESTRANT Category: Drugs CMS Add: 01/01/2004 CMS Term: J9400 DRUG DEF MAXFEE 01/01/2014 16.80 0.0 Description: INJ, ZIV-AFLIBERCEPT, 1MG Category: Drugs CMS Add: 01/01/2014 CMS Term: J9600 DRUG DEF SYSMAN Description: PORFIMER SODIUM INJECTION Category: Drugs CMS Add: 01/01/1998 CMS Term: J9999 DRUG DEF SYSMAN Description: CHEMOTHERAPY DRUG Category: Drugs CMS Add: 01/01/1986 CMS Term: K0001 NU DME PUR MAXFEE 01/01/2024 279.70 0.0 Y Description: STANDARD WHEELCHAIR Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0001 NU DME PUR MAXFEE 11/01/2023 12/31/2023 380.80 0.0 Y Description: STANDARD WHEELCHAIR Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0001 RR DME RTL MAXFEE 01/01/2024 27.97 0.0 Y Description: STANDARD WHEELCHAIR Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0001 RR DME RTL MAXFEE 11/01/2023 12/31/2023 38.08 0.0 Y Description: STANDARD WHEELCHAIR Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0002 NU DME PUR MAXFEE 01/01/2024 472.60 0.0 Y Description: STND HEMI (LOW SEAT) WHLCHR Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0002 NU DME PUR MAXFEE 11/01/2023 12/31/2023 616.20 0.0 Y Description: STND HEMI (LOW SEAT) WHLCHR Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0002 RR DME RTL MAXFEE 01/01/2024 47.26 0.0 Y Description: STND HEMI (LOW SEAT) WHLCHR Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0002 RR DME RTL MAXFEE 11/01/2023 12/31/2023 61.62 0.0 Y Description: STND HEMI (LOW SEAT) WHLCHR Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0003 NU DME PUR MAXFEE 01/01/2024 410.90 0.0 Y Description: LIGHTWEIGHT WHEELCHAIR Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0003 NU DME PUR MAXFEE 11/01/2023 12/31/2023 590.10 0.0 Y Description: LIGHTWEIGHT WHEELCHAIR Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0003 RR DME RTL MAXFEE 01/01/2024 41.09 0.0 Y Description: LIGHTWEIGHT WHEELCHAIR Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0003 RR DME RTL MAXFEE 11/01/2023 12/31/2023 59.01 0.0 Y Description: LIGHTWEIGHT WHEELCHAIR Category: Durable Medical CMS Add: 01/01/1994 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,888 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- K0004 NU DME PUR MAXFEE 01/01/2024 493.70 0.0 Y Description: HIGH STRENGTH LTWT WHLCHR Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0004 NU DME PUR MAXFEE 11/01/2023 12/31/2023 803.80 0.0 Y Description: HIGH STRENGTH LTWT WHLCHR Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0004 RR DME RTL MAXFEE 01/01/2024 49.37 0.0 Y Description: HIGH STRENGTH LTWT WHLCHR Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0004 RR DME RTL MAXFEE 11/01/2023 12/31/2023 80.38 0.0 Y Description: HIGH STRENGTH LTWT WHLCHR Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0005 NU DME PUR MAXFEE 01/01/2024 2522.56 0.0 Y Description: ULTRALIGHTWEIGHT WHEELCHAIR Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0005 NU DME PUR MAXFEE 11/01/2023 12/31/2023 2458.64 0.0 Y Description: ULTRALIGHTWEIGHT WHEELCHAIR Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0005 RR DME RTL MAXFEE 01/01/2024 252.23 0.0 Y Description: ULTRALIGHTWEIGHT WHEELCHAIR Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0005 RR DME RTL MAXFEE 11/01/2023 12/31/2023 245.84 0.0 Y Description: ULTRALIGHTWEIGHT WHEELCHAIR Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0006 NU DME PUR MAXFEE 01/01/2024 727.20 0.0 Y Description: HEAVY DUTY WHEELCHAIR Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0006 NU DME PUR MAXFEE 11/01/2023 12/31/2023 883.90 0.0 Y Description: HEAVY DUTY WHEELCHAIR Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0006 RR DME RTL MAXFEE 01/01/2024 72.72 0.0 Y Description: HEAVY DUTY WHEELCHAIR Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0006 RR DME RTL MAXFEE 11/01/2023 12/31/2023 88.39 0.0 Y Description: HEAVY DUTY WHEELCHAIR Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0007 NU DME PUR MAXFEE 01/01/2024 1034.60 0.0 Y Description: EXTRA HEAVY DUTY WHEELCHAIR Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0007 NU DME PUR MAXFEE 11/01/2023 12/31/2023 1346.80 0.0 Y Description: EXTRA HEAVY DUTY WHEELCHAIR Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0007 RR DME RTL MAXFEE 01/01/2024 103.46 0.0 Y Description: EXTRA HEAVY DUTY WHEELCHAIR Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0007 RR DME RTL MAXFEE 11/01/2023 12/31/2023 134.68 0.0 Y Description: EXTRA HEAVY DUTY WHEELCHAIR Category: Durable Medical CMS Add: 01/01/1994 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,889 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- K0008 NOCOV DEF SYSMAN Description: CSTM MANUAL WHEELCHAIR/BASE Category: Non Covered Services CMS Add: 07/01/2013 CMS Term: K0009 NU DME PUR MAXFEE 11/01/2023 988.70 0.0 Y Description: OTHER MANUAL WHEELCHAIR/BASE Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0009 RR DME RTL MAXFEE 11/01/2023 98.87 0.0 Y Description: OTHER MANUAL WHEELCHAIR/BASE Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0010 NU DME PUR MAXFEE 11/01/2023 3776.73 0.0 Y Description: STND WT FRAME POWER WHLCHR Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0010 RR DME RTL MAXFEE 11/01/2023 566.51 0.0 Y Description: STND WT FRAME POWER WHLCHR Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0011 NU DME PUR MAXFEE 07/18/2003 10/31/2023 5270.30 0.0 Y Description: STND WT PWR WHLCHR W CONTROL Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0011 NU DME PUR MAXFEE 11/01/2023 4541.73 0.0 Y Description: STND WT PWR WHLCHR W CONTROL Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0011 RR DME RTL MAXFEE 07/18/2003 10/31/2023 351.35 0.0 Y Description: STND WT PWR WHLCHR W CONTROL Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0011 RR DME RTL MAXFEE 11/01/2023 681.26 0.0 Y Description: STND WT PWR WHLCHR W CONTROL Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0011 RR KF DME RTL MAXFEE 11/01/2023 756.35 0.0 Y Description: STND WT PWR WHLCHR W CONTROL Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0012 NU DME PUR MAXFEE 01/01/2014 10/31/2023 3233.10 0.0 Y Description: LTWT PORTBL POWER WHLCHR Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0012 NU DME PUR MAXFEE 11/01/2023 2880.67 0.0 Y Description: LTWT PORTBL POWER WHLCHR Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0012 RR DME RTL MAXFEE 01/01/2014 10/31/2023 215.54 0.0 Y Description: LTWT PORTBL POWER WHLCHR Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0012 RR DME RTL MAXFEE 11/01/2023 432.10 0.0 Y Description: LTWT PORTBL POWER WHLCHR Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0013 NOCOV DEF SYSMAN Description: CUSTOM POWER WHLCHR BASE Category: Non Covered Services CMS Add: 07/01/2013 CMS Term: K0014 NOCOV DEF SYSMAN Description: OTHER POWER WHLCHR BASE Category: Non Covered Services CMS Add: 01/01/1994 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,890 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- K0015 NU DME PUR MAXFEE 11/01/2023 180.20 0.0 Y Description: DETACH NON-ADJ HT ARMRST REP Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0015 RR DME RTL MAXFEE 11/01/2023 18.02 0.0 Y Description: DETACH NON-ADJ HT ARMRST REP Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0015 RR KE DME RTL MAXFEE 11/01/2023 18.77 0.0 Y Description: DETACH NON-ADJ HT ARMRST REP Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0015 RR KU DME RTL MAXFEE 11/01/2023 20.83 0.0 Y Description: DETACH NON-ADJ HT ARMRST REP Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0017 NU DME PUR MAXFEE 11/01/2023 55.25 0.0 Y Description: DETACH ADJUST ARMREST BASE Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0017 NU KE DME PUR MAXFEE 11/01/2023 57.38 0.0 Y Description: DETACH ADJUST ARMREST BASE Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0017 NU KU DME PUR MAXFEE 11/01/2023 58.57 0.0 Y Description: DETACH ADJUST ARMREST BASE Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0017 RR DME RTL MAXFEE 11/01/2023 5.53 0.0 Y Description: DETACH ADJUST ARMREST BASE Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0017 RR KE DME RTL MAXFEE 11/01/2023 5.74 0.0 Y Description: DETACH ADJUST ARMREST BASE Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0017 RR KU DME RTL MAXFEE 11/01/2023 5.85 0.0 Y Description: DETACH ADJUST ARMREST BASE Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0018 NU DME PUR MAXFEE 11/01/2023 31.14 0.0 Y Description: DETACH ADJUST ARMRST UPPER Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0018 NU KE DME PUR MAXFEE 11/01/2023 32.32 0.0 Y Description: DETACH ADJUST ARMRST UPPER Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0018 NU KU DME PUR MAXFEE 11/01/2023 32.72 0.0 Y Description: DETACH ADJUST ARMRST UPPER Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0018 RR DME RTL MAXFEE 11/01/2023 3.11 0.0 Y Description: DETACH ADJUST ARMRST UPPER Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0018 RR KE DME RTL MAXFEE 11/01/2023 3.23 0.0 Y Description: DETACH ADJUST ARMRST UPPER Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0018 RR KU DME RTL MAXFEE 11/01/2023 3.27 0.0 Y Description: DETACH ADJUST ARMRST UPPER Category: Durable Medical CMS Add: 01/01/1994 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,891 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- K0019 NU DME PUR MAXFEE 11/01/2023 16.61 0.0 Y Description: ARM PAD REPL, EACH Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0019 NU KE DME PUR MAXFEE 11/01/2023 17.32 0.0 Y Description: ARM PAD REPL, EACH Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0019 NU KU DME PUR MAXFEE 11/01/2023 19.67 0.0 Y Description: ARM PAD REPL, EACH Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0019 RR DME RTL MAXFEE 11/01/2023 1.66 0.0 Y Description: ARM PAD REPL, EACH Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0019 RR KE DME RTL MAXFEE 11/01/2023 1.73 0.0 Y Description: ARM PAD REPL, EACH Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0019 RR KU DME RTL MAXFEE 11/01/2023 1.97 0.0 Y Description: ARM PAD REPL, EACH Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0020 NU DME PUR MAXFEE 11/01/2023 53.10 0.0 Y Description: FIXED ADJUST ARMREST PAIR Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0020 NU KE DME PUR MAXFEE 11/01/2023 55.03 0.0 Y Description: FIXED ADJUST ARMREST PAIR Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0020 NU KU DME PUR MAXFEE 11/01/2023 53.25 0.0 Y Description: FIXED ADJUST ARMREST PAIR Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0020 RR DME RTL MAXFEE 11/01/2023 5.31 0.0 Y Description: FIXED ADJUST ARMREST PAIR Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0020 RR KE DME RTL MAXFEE 11/01/2023 5.50 0.0 Y Description: FIXED ADJUST ARMREST PAIR Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0020 RR KU DME RTL MAXFEE 11/01/2023 5.33 0.0 Y Description: FIXED ADJUST ARMREST PAIR Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0037 NU DME PUR MAXFEE 11/01/2023 52.01 0.0 Y Description: HI MOUNT FLIP-UP FOOTREST EA Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0037 NU KE DME PUR MAXFEE 11/01/2023 54.01 0.0 Y Description: HI MOUNT FLIP-UP FOOTREST EA Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0037 NU KU DME PUR MAXFEE 11/01/2023 55.20 0.0 Y Description: HI MOUNT FLIP-UP FOOTREST EA Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0037 RR DME RTL MAXFEE 11/01/2023 4.92 0.0 Y Description: HI MOUNT FLIP-UP FOOTREST EA Category: Durable Medical CMS Add: 01/01/1994 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,892 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- K0037 RR KE DME RTL MAXFEE 11/01/2023 5.10 0.0 Y Description: HI MOUNT FLIP-UP FOOTREST EA Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0037 RR KU DME RTL MAXFEE 11/01/2023 4.93 0.0 Y Description: HI MOUNT FLIP-UP FOOTREST EA Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0038 NU DME PUR MAXFEE 11/01/2023 27.25 0.0 Y Description: LEG STRAP EACH Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0038 NU KE DME PUR MAXFEE 11/01/2023 28.26 0.0 Y Description: LEG STRAP EACH Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0038 NU KU DME PUR MAXFEE 11/01/2023 27.83 0.0 Y Description: LEG STRAP EACH Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0038 RR DME RTL MAXFEE 11/01/2023 2.73 0.0 Y Description: LEG STRAP EACH Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0038 RR KE DME RTL MAXFEE 11/01/2023 2.83 0.0 Y Description: LEG STRAP EACH Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0038 RR KU DME RTL MAXFEE 11/01/2023 2.77 0.0 Y Description: LEG STRAP EACH Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0039 NU DME PUR MAXFEE 11/01/2023 59.02 0.0 Y Description: LEG STRAP H STYLE EACH Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0039 NU KE DME PUR MAXFEE 11/01/2023 61.26 0.0 Y Description: LEG STRAP H STYLE EACH Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0039 NU KU DME PUR MAXFEE 11/01/2023 61.75 0.0 Y Description: LEG STRAP H STYLE EACH Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0039 RR DME RTL MAXFEE 11/01/2023 5.91 0.0 Y Description: LEG STRAP H STYLE EACH Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0039 RR KE DME RTL MAXFEE 11/01/2023 6.14 0.0 Y Description: LEG STRAP H STYLE EACH Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0039 RR KU DME RTL MAXFEE 11/01/2023 6.22 0.0 Y Description: LEG STRAP H STYLE EACH Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0040 NU DME PUR MAXFEE 01/01/2014 12/31/2023 74.67 0.0 Description: ADJUSTABLE ANGLE FOOTPLATE Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0040 NU DME PUR MAXFEE 01/01/2024 62.06 0.0 Description: ADJUSTABLE ANGLE FOOTPLATE Category: Durable Medical CMS Add: 01/01/1994 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,893 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- K0040 RR DME RTL MAXFEE 01/01/2014 12/31/2023 7.45 0.0 Description: ADJUSTABLE ANGLE FOOTPLATE Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0040 RR DME RTL MAXFEE 01/01/2024 6.63 0.0 Description: ADJUSTABLE ANGLE FOOTPLATE Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0041 NU DME PUR MAXFEE 11/01/2023 56.81 0.0 Y Description: LARGE SIZE FOOTPLATE EACH Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0041 NU KE DME PUR MAXFEE 11/01/2023 59.01 0.0 Y Description: LARGE SIZE FOOTPLATE EACH Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0041 NU KU DME PUR MAXFEE 11/01/2023 60.65 0.0 Y Description: LARGE SIZE FOOTPLATE EACH Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0041 RR DME RTL MAXFEE 11/01/2023 5.69 0.0 Y Description: LARGE SIZE FOOTPLATE EACH Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0041 RR KE DME RTL MAXFEE 11/01/2023 5.92 0.0 Y Description: LARGE SIZE FOOTPLATE EACH Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0041 RR KU DME RTL MAXFEE 11/01/2023 6.12 0.0 Y Description: LARGE SIZE FOOTPLATE EACH Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0042 NU DME PUR MAXFEE 11/01/2023 37.19 0.0 Y Description: STANDARD SIZE FTPLATE REP EA Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0042 NU KE DME PUR MAXFEE 11/01/2023 38.70 0.0 Y Description: STANDARD SIZE FTPLATE REP EA Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0042 NU KU DME PUR MAXFEE 11/01/2023 41.75 0.0 Y Description: STANDARD SIZE FTPLATE REP EA Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0042 RR DME RTL MAXFEE 11/01/2023 3.72 0.0 Y Description: STANDARD SIZE FTPLATE REP EA Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0042 RR KE DME RTL MAXFEE 11/01/2023 3.87 0.0 Y Description: STANDARD SIZE FTPLATE REP EA Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0042 RR KU DME RTL MAXFEE 11/01/2023 4.17 0.0 Y Description: STANDARD SIZE FTPLATE REP EA Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0043 NU DME PUR MAXFEE 01/01/2014 12/31/2023 19.53 0.0 Description: FTRST LOWR EXTEN TUBE REP EA Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0043 NU DME PUR MAXFEE 01/01/2024 22.10 0.0 Description: FTRST LOWR EXTEN TUBE REP EA Category: Durable Medical CMS Add: 01/01/1994 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,894 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- K0044 NU DME PUR MAXFEE 01/01/2014 12/31/2023 16.64 0.0 Description: FTRST UPR HANGER BRAC REP EA Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0044 NU DME PUR MAXFEE 01/01/2024 19.07 0.0 Description: FTRST UPR HANGER BRAC REP EA Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0044 RR DME RTL MAXFEE 01/01/2014 12/31/2023 1.67 0.0 Description: FTRST UPR HANGER BRAC REP EA Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0044 RR DME RTL MAXFEE 01/01/2024 1.92 0.0 Description: FTRST UPR HANGER BRAC REP EA Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0045 NU DME PUR MAXFEE 01/01/2014 12/31/2023 56.62 0.0 Description: FTRST COMPL ASSEMBLY REPL EA Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0045 NU DME PUR MAXFEE 01/01/2024 63.49 0.0 Description: FTRST COMPL ASSEMBLY REPL EA Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0046 NU DME PUR MAXFEE 11/01/2023 22.22 0.0 Y Description: ELEV LGRST LWR EXTEN REPL EA Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0046 NU KE DME PUR MAXFEE 11/01/2023 23.03 0.0 Y Description: ELEV LGRST LWR EXTEN REPL EA Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0046 NU KU DME PUR MAXFEE 11/01/2023 22.38 0.0 Y Description: ELEV LGRST LWR EXTEN REPL EA Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0046 RR DME RTL MAXFEE 11/01/2023 2.22 0.0 Y Description: ELEV LGRST LWR EXTEN REPL EA Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0046 RR KE DME RTL MAXFEE 11/01/2023 2.30 0.0 Y Description: ELEV LGRST LWR EXTEN REPL EA Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0046 RR KU DME RTL MAXFEE 11/01/2023 2.22 0.0 Y Description: ELEV LGRST LWR EXTEN REPL EA Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0047 NU DME PUR MAXFEE 11/01/2023 80.65 0.0 Y Description: ELEV LEGRST UPR HANGR REP EA Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0047 NU KE DME PUR MAXFEE 11/01/2023 83.83 0.0 Y Description: ELEV LEGRST UPR HANGR REP EA Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0047 NU KU DME PUR MAXFEE 11/01/2023 87.66 0.0 Y Description: ELEV LEGRST UPR HANGR REP EA Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0047 RR DME RTL MAXFEE 11/01/2023 8.07 0.0 Y Description: ELEV LEGRST UPR HANGR REP EA Category: Durable Medical CMS Add: 01/01/1994 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,895 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- K0047 RR KE DME RTL MAXFEE 11/01/2023 8.39 0.0 Y Description: ELEV LEGRST UPR HANGR REP EA Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0047 RR KU DME RTL MAXFEE 11/01/2023 8.79 0.0 Y Description: ELEV LEGRST UPR HANGR REP EA Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0050 NU DME PUR MAXFEE 11/01/2023 36.56 0.0 Y Description: RATCHET ASSEMBLY REPLACEMENT Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0050 NU KE DME PUR MAXFEE 11/01/2023 37.91 0.0 Y Description: RATCHET ASSEMBLY REPLACEMENT Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0050 NU KU DME PUR MAXFEE 11/01/2023 37.26 0.0 Y Description: RATCHET ASSEMBLY REPLACEMENT Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0050 RR DME RTL MAXFEE 11/01/2023 3.65 0.0 Y Description: RATCHET ASSEMBLY REPLACEMENT Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0050 RR KE DME RTL MAXFEE 11/01/2023 3.79 0.0 Y Description: RATCHET ASSEMBLY REPLACEMENT Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0050 RR KU DME RTL MAXFEE 11/01/2023 3.72 0.0 Y Description: RATCHET ASSEMBLY REPLACEMENT Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0051 NU DME PUR MAXFEE 11/01/2023 58.18 0.0 Y Description: CAM REL ASM FT/LEGRST REP EA Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0051 NU KE DME PUR MAXFEE 11/01/2023 60.37 0.0 Y Description: CAM REL ASM FT/LEGRST REP EA Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0051 NU KU DME PUR MAXFEE 11/01/2023 60.30 0.0 Y Description: CAM REL ASM FT/LEGRST REP EA Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0051 RR DME RTL MAXFEE 11/01/2023 5.83 0.0 Y Description: CAM REL ASM FT/LEGRST REP EA Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0051 RR KE DME RTL MAXFEE 11/01/2023 6.05 0.0 Y Description: CAM REL ASM FT/LEGRST REP EA Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0051 RR KU DME RTL MAXFEE 11/01/2023 6.08 0.0 Y Description: CAM REL ASM FT/LEGRST REP EA Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0052 NU DME PUR MAXFEE 11/01/2023 91.01 0.0 Y Description: SWINGAWAY DETACH FTREST REPL Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0052 NU KE DME PUR MAXFEE 11/01/2023 94.85 0.0 Y Description: SWINGAWAY DETACH FTREST REPL Category: Durable Medical CMS Add: 01/01/1994 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,896 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- K0052 NU KU DME PUR MAXFEE 11/01/2023 105.98 0.0 Y Description: SWINGAWAY DETACH FTREST REPL Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0052 RR DME RTL MAXFEE 11/01/2023 9.10 0.0 Y Description: SWINGAWAY DETACH FTREST REPL Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0052 RR KE DME RTL MAXFEE 11/01/2023 9.48 0.0 Y Description: SWINGAWAY DETACH FTREST REPL Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0052 RR KU DME RTL MAXFEE 11/01/2023 10.59 0.0 Y Description: SWINGAWAY DETACH FTREST REPL Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0053 NU DME PUR MAXFEE 11/01/2023 101.80 0.0 Y Description: ELEVATE FOOTREST ARTICULATE Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0053 NU KE DME PUR MAXFEE 11/01/2023 106.03 0.0 Y Description: ELEVATE FOOTREST ARTICULATE Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0053 NU KU DME PUR MAXFEE 11/01/2023 116.93 0.0 Y Description: ELEVATE FOOTREST ARTICULATE Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0053 RR DME RTL MAXFEE 11/01/2023 10.18 0.0 Y Description: ELEVATE FOOTREST ARTICULATE Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0053 RR KE DME RTL MAXFEE 11/01/2023 10.60 0.0 Y Description: ELEVATE FOOTREST ARTICULATE Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0053 RR KU DME RTL MAXFEE 11/01/2023 11.69 0.0 Y Description: ELEVATE FOOTREST ARTICULATE Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0056 NU DME PUR MAXFEE 11/01/2023 113.14 0.0 Y Description: SEAT HT <17 OR >=21 LTWT WC Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0056 NU KU DME PUR MAXFEE 11/01/2023 126.48 0.0 Y Description: SEAT HT <17 OR >=21 LTWT WC Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0056 RR DME RTL MAXFEE 11/01/2023 11.32 0.0 Y Description: SEAT HT <17 OR >=21 LTWT WC Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0056 RR KU DME RTL MAXFEE 11/01/2023 12.66 0.0 Y Description: SEAT HT <17 OR >=21 LTWT WC Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0065 NU DME PUR MAXFEE 11/01/2023 55.85 0.0 Y Description: SPOKE PROTECTORS Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0065 NU KU DME PUR MAXFEE 11/01/2023 59.10 0.0 Y Description: SPOKE PROTECTORS Category: Durable Medical CMS Add: 01/01/1994 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,897 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- K0065 RR DME RTL MAXFEE 11/01/2023 5.59 0.0 Y Description: SPOKE PROTECTORS Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0065 RR KU DME RTL MAXFEE 11/01/2023 5.91 0.0 Y Description: SPOKE PROTECTORS Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0069 NU DME PUR MAXFEE 11/01/2023 116.36 0.0 Y Description: RR WHL COMPL SOL TIRE REP EA Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0069 NU KU DME PUR MAXFEE 11/01/2023 132.90 0.0 Y Description: RR WHL COMPL SOL TIRE REP EA Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0069 RR DME RTL MAXFEE 11/01/2023 11.77 0.0 Y Description: RR WHL COMPL SOL TIRE REP EA Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0069 RR KU DME RTL MAXFEE 11/01/2023 13.84 0.0 Y Description: RR WHL COMPL SOL TIRE REP EA Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0070 NU DME PUR MAXFEE 11/01/2023 198.40 0.0 Y Description: RR WHL COMPL PNE TIRE REP EA Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0070 RR DME RTL MAXFEE 11/01/2023 19.84 0.0 Y Description: RR WHL COMPL PNE TIRE REP EA Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0070 RR KU DME RTL MAXFEE 11/01/2023 24.37 0.0 Y Description: RR WHL COMPL PNE TIRE REP EA Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0071 NU DME PUR MAXFEE 11/01/2023 132.18 0.0 Y Description: FR CSTR COMP PNE TIRE REP EA Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0071 NU KU DME PUR MAXFEE 11/01/2023 145.29 0.0 Y Description: FR CSTR COMP PNE TIRE REP EA Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0071 RR DME RTL MAXFEE 11/01/2023 13.22 0.0 Y Description: FR CSTR COMP PNE TIRE REP EA Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0071 RR KU DME RTL MAXFEE 11/01/2023 14.53 0.0 Y Description: FR CSTR COMP PNE TIRE REP EA Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0072 NU DME PUR MAXFEE 11/01/2023 80.85 0.0 Y Description: FR CSTR SEMI-PNE TIRE REP EA Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0072 NU KU DME PUR MAXFEE 11/01/2023 87.46 0.0 Y Description: FR CSTR SEMI-PNE TIRE REP EA Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0072 RR DME RTL MAXFEE 11/01/2023 8.09 0.0 Y Description: FR CSTR SEMI-PNE TIRE REP EA Category: Durable Medical CMS Add: 01/01/1994 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,898 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- K0072 RR KU DME RTL MAXFEE 11/01/2023 8.75 0.0 Y Description: FR CSTR SEMI-PNE TIRE REP EA Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0073 NU DME PUR MAXFEE 11/01/2023 42.72 0.0 Y Description: CASTER PIN LOCK EACH Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0073 NU KU DME PUR MAXFEE 11/01/2023 46.30 0.0 Y Description: CASTER PIN LOCK EACH Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0073 RR DME RTL MAXFEE 11/01/2023 4.27 0.0 Y Description: CASTER PIN LOCK EACH Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0073 RR KU DME RTL MAXFEE 11/01/2023 4.64 0.0 Y Description: CASTER PIN LOCK EACH Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0077 NU DME PUR MAXFEE 11/01/2023 66.07 0.0 Y Description: FR CSTR ASMB SOL TIRE REP EA Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0077 NU KU DME PUR MAXFEE 11/01/2023 78.27 0.0 Y Description: FR CSTR ASMB SOL TIRE REP EA Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0077 RR DME RTL MAXFEE 11/01/2023 6.66 0.0 Y Description: FR CSTR ASMB SOL TIRE REP EA Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0077 RR KU DME RTL MAXFEE 11/01/2023 7.80 0.0 Y Description: FR CSTR ASMB SOL TIRE REP EA Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0098 NU DME PUR MAXFEE 01/01/2014 10/31/2023 27.21 0.0 Y Description: DRIVE BELT FOR PWC, REPL Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0098 NU DME PUR MAXFEE 11/01/2023 29.01 0.0 Y Description: DRIVE BELT FOR PWC, REPL Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0098 NU KE DME PUR MAXFEE 11/01/2023 30.14 0.0 Y Description: DRIVE BELT FOR PWC, REPL Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0098 NU KU DME PUR MAXFEE 11/01/2023 31.19 0.0 Y Description: DRIVE BELT FOR PWC, REPL Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0098 RR DME RTL MAXFEE 01/01/2014 10/31/2023 2.72 0.0 Y Description: DRIVE BELT FOR PWC, REPL Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0098 RR DME RTL MAXFEE 11/01/2023 2.90 0.0 Y Description: DRIVE BELT FOR PWC, REPL Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0098 RR KE DME RTL MAXFEE 11/01/2023 3.02 0.0 Y Description: DRIVE BELT FOR PWC, REPL Category: Durable Medical CMS Add: 01/01/1994 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,899 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- K0098 RR KU DME RTL MAXFEE 11/01/2023 3.13 0.0 Y Description: DRIVE BELT FOR PWC, REPL Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0105 NU DME PUR MAXFEE 11/01/2023 120.74 0.0 Y Description: IV HANGER Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0105 NU KU DME PUR MAXFEE 11/01/2023 132.22 0.0 Y Description: IV HANGER Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0105 RR DME RTL MAXFEE 11/01/2023 12.07 0.0 Y Description: IV HANGER Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0105 RR KU DME RTL MAXFEE 11/01/2023 13.22 0.0 Y Description: IV HANGER Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0108 NU DME PUR MAXFEE 01/01/2014 12/31/2023 1950.00 0.0 Y Description: W/C COMPONENT-ACCESSORY NOS Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0108 NU DME PUR MAXFEE 01/01/2024 2535.00 0.0 Y Description: W/C COMPONENT-ACCESSORY NOS Category: Durable Medical CMS Add: 01/01/1994 CMS Term: K0117 NOCOV DEF SYSMAN Description: UNLISTED ITEM, ORTHOTIC Category: Non Covered Services CMS Add: 01/01/1990 CMS Term: 06/30/2015 K0118 NOCOV DEF SYSMAN Description: TENS SUPPLIES- Category: Non Covered Services CMS Add: 01/01/1990 CMS Term: 06/30/2015 K0131 NOCOV DEF SYSMAN Description: SPRING-POWERED Category: Non Covered Services CMS Add: 01/01/1990 CMS Term: 06/30/2015 K0132 NOCOV DEF SYSMAN Description: MALE EXTERNAL CATHETER Category: Non Covered Services CMS Add: 01/01/1990 CMS Term: 06/30/2015 K0133 NOCOV DEF SYSMAN Description: INTERMITTENT URINARY Category: Non Covered Services CMS Add: 01/01/1990 CMS Term: 06/30/2015 K0134 NOCOV DEF SYSMAN Description: INTERMITTENT URINARY Category: Non Covered Services CMS Add: 01/01/1990 CMS Term: 06/30/2015 K0135 NOCOV DEF SYSMAN Description: INTERMITTENT URINARY Category: Non Covered Services CMS Add: 01/01/1990 CMS Term: 06/30/2015 K0136 NOCOV DEF SYSMAN Description: INTERMITTENT URINARY Category: Non Covered Services CMS Add: 01/01/1990 CMS Term: 06/30/2015 K0147 NOCOV DEF SYSMAN Description: GASTROSTOMY TUBE Category: Non Covered Services CMS Add: 01/01/1990 CMS Term: 06/30/2015 *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,900 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- K0162 NOCOV DEF SYSMAN Description: PROGRESSIVE LENS, Category: Non Covered Services CMS Add: 01/01/1990 CMS Term: 06/30/2015 K0164 NOCOV DEF SYSMAN Description: OROPHARYNGEAL Category: Non Covered Services CMS Add: 01/01/1990 CMS Term: 06/30/2015 K0165 NOCOV DEF SYSMAN Description: TRACHEOSTOMY CARE Category: Non Covered Services CMS Add: 01/01/1990 CMS Term: 06/30/2015 K0166 NOCOV DEF SYSMAN Description: METHYLPREDNISOLONE, Category: Non Covered Services CMS Add: 01/01/1990 CMS Term: 06/30/2015 K0167 NOCOV DEF SYSMAN Description: PREDNISOLONE, Category: Non Covered Services CMS Add: 01/01/1990 CMS Term: 06/30/2015 K0195 NU DME PUR MAXFEE 11/01/2023 151.30 0.0 Y Description: ELEVATING WHLCHAIR LEG RESTS Category: Durable Medical CMS Add: 01/01/1993 CMS Term: K0195 RR DME RTL MAXFEE 11/01/2023 15.13 0.0 Y Description: ELEVATING WHLCHAIR LEG RESTS Category: Durable Medical CMS Add: 01/01/1993 CMS Term: K0195 RR KE DME RTL MAXFEE 11/01/2023 16.01 0.0 Y Description: ELEVATING WHLCHAIR LEG RESTS Category: Durable Medical CMS Add: 01/01/1993 CMS Term: K0195 RR KU DME RTL MAXFEE 11/01/2023 24.16 0.0 Y Description: ELEVATING WHLCHAIR LEG RESTS Category: Durable Medical CMS Add: 01/01/1993 CMS Term: K0247 NOCOV DEF SYSMAN Description: HYDROGEL DRG > 48 SQ IN W/B Category: Non Covered Services CMS Add: 01/01/1994 CMS Term: 12/31/1996 K0267 NOCOV DEF SYSMAN Description: ANY TYPE Category: Non Covered Services CMS Add: 01/01/1900 CMS Term: 06/30/2015 K0455 NOCOV DEF SYSMAN Description: PUMP UNINTERRUPTED INFUSION Category: Non Covered Services CMS Add: 01/01/1998 CMS Term: K0462 NOCOV DEF SYSMAN Description: TEMPORARY REPLACEMENT EQPMNT Category: Non Covered Services CMS Add: 07/01/1998 CMS Term: K0552 DME DEF MAXFEE 01/01/2014 12/31/2023 2.65 0.0 Description: SUP/EXT NON-INS INF PUMP SYR Category: Durable Medical CMS Add: 07/01/2003 CMS Term: K0552 DME DEF MAXFEE 01/01/2024 3.28 0.0 Description: SUP/EXT NON-INS INF PUMP SYR Category: Durable Medical CMS Add: 07/01/2003 CMS Term: K0554 NOCOV DEF SYSMAN Description: THER CGM RECEIVER/MONITOR Category: Non Covered Services CMS Add: 07/01/2017 CMS Term: 12/31/2022 *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,901 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- K0601 DME DEF MAXFEE 01/01/2014 12/31/2023 1.10 0.0 Description: REPL BATT SILVER OXIDE 1.5 V Category: Durable Medical CMS Add: 04/01/2003 CMS Term: K0601 DME DEF MAXFEE 01/01/2024 1.46 0.0 Description: REPL BATT SILVER OXIDE 1.5 V Category: Durable Medical CMS Add: 04/01/2003 CMS Term: K0602 DME DEF MAXFEE 01/01/2014 12/31/2023 6.36 0.0 Description: REPL BATT SILVER OXIDE 3 V Category: Durable Medical CMS Add: 04/01/2003 CMS Term: K0602 DME DEF MAXFEE 01/01/2024 8.24 0.0 Description: REPL BATT SILVER OXIDE 3 V Category: Durable Medical CMS Add: 04/01/2003 CMS Term: K0603 DME DEF MAXFEE 01/01/2014 12/31/2023 0.57 0.0 Description: REPL BATT ALKALINE 1.5 V Category: Durable Medical CMS Add: 04/01/2003 CMS Term: K0603 DME DEF MAXFEE 01/01/2024 0.74 0.0 Description: REPL BATT ALKALINE 1.5 V Category: Durable Medical CMS Add: 04/01/2003 CMS Term: K0604 DME DEF MAXFEE 01/01/2014 12/31/2023 6.09 0.0 Description: REPL BATT LITHIUM 3.6 V Category: Durable Medical CMS Add: 04/01/2003 CMS Term: K0604 DME DEF MAXFEE 01/01/2024 7.94 0.0 Description: REPL BATT LITHIUM 3.6 V Category: Durable Medical CMS Add: 04/01/2003 CMS Term: K0605 NOCOV DEF SYSMAN Description: REPL BATT LITHIUM 4.5 V Category: Non Covered Services CMS Add: 04/01/2003 CMS Term: K0606 NU DME PUR MAXFEE 01/01/2014 12/31/2023 28000.00 0.0 Y Description: AED GARMENT W ELEC ANALYSIS Category: Durable Medical CMS Add: 07/01/2003 CMS Term: K0606 NU DME PUR MAXFEE 01/01/2024 33489.90 0.0 Y Description: AED GARMENT W ELEC ANALYSIS Category: Durable Medical CMS Add: 07/01/2003 CMS Term: K0606 RR DME RTL MAXFEE 01/01/2014 12/31/2023 1866.67 0.0 Y Description: AED GARMENT W ELEC ANALYSIS Category: Durable Medical CMS Add: 07/01/2003 CMS Term: K0606 RR DME RTL MAXFEE 01/01/2024 3348.99 0.0 Y Description: AED GARMENT W ELEC ANALYSIS Category: Durable Medical CMS Add: 07/01/2003 CMS Term: K0607 NU DME PUR MAXFEE 01/01/2014 12/31/2023 198.31 0.0 Y Description: REPL BATT FOR AED Category: Durable Medical CMS Add: 07/01/2003 CMS Term: K0607 NU DME PUR MAXFEE 01/01/2024 258.40 0.0 Y Description: REPL BATT FOR AED Category: Durable Medical CMS Add: 07/01/2003 CMS Term: K0607 RR DME RTL MAXFEE 01/01/2014 12/31/2023 19.84 0.0 Y Description: REPL BATT FOR AED Category: Durable Medical CMS Add: 07/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,902 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- K0607 RR DME RTL MAXFEE 01/01/2024 25.84 0.0 Y Description: REPL BATT FOR AED Category: Durable Medical CMS Add: 07/01/2003 CMS Term: K0608 NU DME PUR MAXFEE 01/01/2014 12/31/2023 123.76 0.0 Y Description: REPL GARMENT FOR AED Category: Durable Medical CMS Add: 07/01/2003 CMS Term: K0608 NU DME PUR MAXFEE 01/01/2024 161.19 0.0 Y Description: REPL GARMENT FOR AED Category: Durable Medical CMS Add: 07/01/2003 CMS Term: K0608 RR DME RTL MAXFEE 01/01/2014 12/31/2023 12.39 0.0 Y Description: REPL GARMENT FOR AED Category: Durable Medical CMS Add: 07/01/2003 CMS Term: K0608 RR DME RTL MAXFEE 01/01/2024 16.15 0.0 Y Description: REPL GARMENT FOR AED Category: Durable Medical CMS Add: 07/01/2003 CMS Term: K0609 NU DME PUR MAXFEE 01/01/2014 12/31/2023 823.02 0.0 Y Description: REPL ELECTRODE FOR AED Category: Durable Medical CMS Add: 07/01/2003 CMS Term: K0609 NU DME PUR MAXFEE 01/01/2024 1071.98 0.0 Y Description: REPL ELECTRODE FOR AED Category: Durable Medical CMS Add: 07/01/2003 CMS Term: K0669 NOCOV DEF SYSMAN Description: SEAT/BACK CUS NO DMEPDAC VER Category: Non Covered Services CMS Add: 07/01/2004 CMS Term: K0672 DME DEF MAXFEE 01/01/2014 12/31/2023 76.79 0.0 Description: REMOVABLE SOFT INTERFACE LE Category: Durable Medical CMS Add: 04/01/2008 CMS Term: K0672 DME DEF MAXFEE 01/01/2024 97.26 0.0 Description: REMOVABLE SOFT INTERFACE LE Category: Durable Medical CMS Add: 04/01/2008 CMS Term: K0730 NU DME PUR MAXFEE 01/01/2023 12/31/2023 2292.60 0.0 Y Description: CTRL DOSE INH DRUG DELIV SYS Category: Durable Medical CMS Add: 07/01/2005 CMS Term: K0730 NU DME PUR MAXFEE 01/01/2024 2352.20 0.0 Y Description: CTRL DOSE INH DRUG DELIV SYS Category: Durable Medical CMS Add: 07/01/2005 CMS Term: K0730 RR DME RTL MAXFEE 01/01/2023 12/31/2023 229.26 0.0 Y Description: CTRL DOSE INH DRUG DELIV SYS Category: Durable Medical CMS Add: 07/01/2005 CMS Term: K0730 RR DME RTL MAXFEE 01/01/2024 235.22 0.0 Y Description: CTRL DOSE INH DRUG DELIV SYS Category: Durable Medical CMS Add: 07/01/2005 CMS Term: K0733 NU DME PUR MAXFEE 01/01/2014 12/31/2023 30.21 0.0 Y Description: 12-24HR SEALED LEAD ACID Category: Durable Medical CMS Add: 07/01/2006 CMS Term: K0733 NU DME PUR MAXFEE 01/01/2024 32.97 0.0 Y Description: 12-24HR SEALED LEAD ACID Category: Durable Medical CMS Add: 07/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,903 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- K0733 RR DME RTL MAXFEE 01/01/2014 12/31/2023 3.04 0.0 Y Description: 12-24HR SEALED LEAD ACID Category: Durable Medical CMS Add: 07/01/2006 CMS Term: K0733 RR DME RTL MAXFEE 01/01/2024 3.32 0.0 Y Description: 12-24HR SEALED LEAD ACID Category: Durable Medical CMS Add: 07/01/2006 CMS Term: K0738 RR DME RTL MAXFEE 01/01/2023 12/31/2023 44.76 0.0 Y Description: PORTABLE GAS OXYGEN SYSTEM Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0738 RR DME RTL MAXFEE 01/01/2024 43.75 0.0 Y Description: PORTABLE GAS OXYGEN SYSTEM Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0738 RR QB DME RTL MAXFEE 01/01/2023 12/31/2023 62.81 0.0 Y Description: PORTABLE GAS OXYGEN SYSTEM Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0738 RR QB DME RTL MAXFEE 01/01/2024 46.95 0.0 Y Description: PORTABLE GAS OXYGEN SYSTEM Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0738 RR QF DME RTL MAXFEE 01/01/2023 12/31/2023 62.81 0.0 Y Description: PORTABLE GAS OXYGEN SYSTEM Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0738 RR QF DME RTL MAXFEE 01/01/2024 46.95 0.0 Y Description: PORTABLE GAS OXYGEN SYSTEM Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0739 DME DEF MAXFEE 01/01/2010 12/31/2023 9.75 0.0 Description: REPAIR/SVC DME NON-OXYGEN EQ Category: Durable Medical CMS Add: 04/01/2009 CMS Term: K0739 DME DEF MAXFEE 01/01/2024 12.68 0.0 Description: REPAIR/SVC DME NON-OXYGEN EQ Category: Durable Medical CMS Add: 04/01/2009 CMS Term: K0740 NOCOV DEF SYSMAN Description: REPAIR/SVC OXYGEN EQUIPMENT Category: Non Covered Services CMS Add: 04/01/2009 CMS Term: K0743 NOCOV DEF SYSMAN Description: PORTABLE HOME SUCTION PUMP Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: K0744 NOCOV DEF SYSMAN Description: ABSORP DRG <= 16 SUC PUMP Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: K0745 NOCOV DEF SYSMAN Description: ABSORP DRG >16<=48 SUC PUMP Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: K0746 NOCOV DEF SYSMAN Description: ABSORP DRG >48 SUC PUMP Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: K0800 NU DME PUR MAXFEE 01/01/2023 12/31/2023 1073.48 0.0 Y 0-1 Description: POV GROUP 1 STD UP TO 300LBS Category: Durable Medical CMS Add: 10/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,904 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- K0800 NU DME PUR MAXFEE 01/01/2024 965.50 0.0 Y 0-1 Description: POV GROUP 1 STD UP TO 300LBS Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0800 RR DME RTL MAXFEE 01/01/2023 12/31/2023 107.35 0.0 Y 0-1 Description: POV GROUP 1 STD UP TO 300LBS Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0800 RR DME RTL MAXFEE 01/01/2024 96.55 0.0 Y 0-1 Description: POV GROUP 1 STD UP TO 300LBS Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0801 NU DME PUR MAXFEE 01/01/2023 12/31/2023 1873.47 0.0 Y 0-1 Description: POV GROUP 1 HD 301-450 LBS Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0801 NU DME PUR MAXFEE 01/01/2024 1752.70 0.0 Y 0-1 Description: POV GROUP 1 HD 301-450 LBS Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0801 RR DME RTL MAXFEE 01/01/2023 12/31/2023 187.34 0.0 Y 0-1 Description: POV GROUP 1 HD 301-450 LBS Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0801 RR DME RTL MAXFEE 01/01/2024 175.27 0.0 Y 0-1 Description: POV GROUP 1 HD 301-450 LBS Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0802 NU DME PUR MAXFEE 01/01/2023 12/31/2023 2428.57 0.0 0-1 Description: POV GROUP 1 VHD 451-600 LBS Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0802 NU DME PUR MAXFEE 01/01/2024 2407.02 0.0 0-1 Description: POV GROUP 1 VHD 451-600 LBS Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0802 RR DME RTL MAXFEE 01/01/2023 12/31/2023 242.86 0.0 0-1 Description: POV GROUP 1 VHD 451-600 LBS Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0802 RR DME RTL MAXFEE 01/01/2024 240.70 0.0 0-1 Description: POV GROUP 1 VHD 451-600 LBS Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0806 NU DME PUR MAXFEE 09/01/2008 10/31/2023 1563.91 0.0 Y Description: POV GROUP 2 STD UP TO 300LBS Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0806 NU DME PUR MAXFEE 11/01/2023 1651.97 0.0 Y Description: POV GROUP 2 STD UP TO 300LBS Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0806 RR DME RTL MAXFEE 09/01/2008 10/31/2023 156.39 0.0 Y Description: POV GROUP 2 STD UP TO 300LBS Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0806 RR DME RTL MAXFEE 11/01/2023 165.20 0.0 Y Description: POV GROUP 2 STD UP TO 300LBS Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0807 NU DME PUR MAXFEE 11/01/2023 2545.65 0.0 Y Description: POV GROUP 2 HD 301-450 LBS Category: Durable Medical CMS Add: 10/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,905 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- K0807 RR DME RTL MAXFEE 11/01/2023 254.57 0.0 Y Description: POV GROUP 2 HD 301-450 LBS Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0808 NU DME PUR MAXFEE 01/01/2024 3960.65 0.0 Y Description: POV GROUP 2 VHD 451-600 LBS Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0808 NU DME PUR MAXFEE 11/01/2023 12/31/2023 3936.08 0.0 Y Description: POV GROUP 2 VHD 451-600 LBS Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0808 RR DME RTL MAXFEE 01/01/2024 396.07 0.0 Y Description: POV GROUP 2 VHD 451-600 LBS Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0808 RR DME RTL MAXFEE 11/01/2023 12/31/2023 393.61 0.0 Y Description: POV GROUP 2 VHD 451-600 LBS Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0812 DME DEF SYSMAN Y Y 0-1 Description: POWER OPERATED VEHICLE NOC Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0813 NU DME PUR MAXFEE 01/01/2023 12/31/2023 2193.93 0.0 Y 0-1 Description: PWC GP 1 STD PORT SEAT/BACK Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0813 NU DME PUR MAXFEE 01/01/2024 2063.60 0.0 Y 0-1 Description: PWC GP 1 STD PORT SEAT/BACK Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0813 RR DME RTL MAXFEE 01/01/2023 12/31/2023 329.09 0.0 Y 0-1 Description: PWC GP 1 STD PORT SEAT/BACK Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0813 RR DME RTL MAXFEE 01/01/2024 309.54 0.0 Y 0-1 Description: PWC GP 1 STD PORT SEAT/BACK Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0814 NU DME PUR MAXFEE 01/01/2023 12/31/2023 2376.67 0.0 Y 0-1 Description: PWC GP 1 STD PORT CAP CHAIR Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0814 NU DME PUR MAXFEE 01/01/2024 2048.73 0.0 Y 0-1 Description: PWC GP 1 STD PORT CAP CHAIR Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0814 RR DME RTL MAXFEE 01/01/2023 12/31/2023 356.50 0.0 Y 0-1 Description: PWC GP 1 STD PORT CAP CHAIR Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0814 RR DME RTL MAXFEE 01/01/2024 307.31 0.0 Y 0-1 Description: PWC GP 1 STD PORT CAP CHAIR Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0815 NU DME PUR MAXFEE 01/01/2023 12/31/2023 2656.00 0.0 Y 0-1 Description: PWC GP 1 STD SEAT/BACK Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0815 NU DME PUR MAXFEE 01/01/2024 2263.87 0.0 Y 0-1 Description: PWC GP 1 STD SEAT/BACK Category: Durable Medical CMS Add: 10/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,906 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- K0815 RR DME RTL MAXFEE 01/01/2023 12/31/2023 398.40 0.0 Y 0-1 Description: PWC GP 1 STD SEAT/BACK Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0815 RR DME RTL MAXFEE 01/01/2024 339.58 0.0 Y 0-1 Description: PWC GP 1 STD SEAT/BACK Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0816 NU DME PUR MAXFEE 01/01/2023 12/31/2023 2525.27 0.0 Y 0-1 Description: PWC GP 1 STD CAP CHAIR Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0816 NU DME PUR MAXFEE 01/01/2024 2142.87 0.0 Y 0-1 Description: PWC GP 1 STD CAP CHAIR Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0816 RR DME RTL MAXFEE 01/01/2023 12/31/2023 378.79 0.0 Y 0-1 Description: PWC GP 1 STD CAP CHAIR Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0816 RR DME RTL MAXFEE 01/01/2024 321.43 0.0 Y 0-1 Description: PWC GP 1 STD CAP CHAIR Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0820 NU DME PUR MAXFEE 01/01/2023 12/31/2023 2259.67 0.0 Y 0-1 Description: PWC GP 2 STD PORT SEAT/BACK Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0820 NU DME PUR MAXFEE 01/01/2024 2089.27 0.0 Y 0-1 Description: PWC GP 2 STD PORT SEAT/BACK Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0820 RR DME RTL MAXFEE 01/01/2023 12/31/2023 338.95 0.0 Y 0-1 Description: PWC GP 2 STD PORT SEAT/BACK Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0820 RR DME RTL MAXFEE 01/01/2024 313.39 0.0 Y 0-1 Description: PWC GP 2 STD PORT SEAT/BACK Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0821 NU DME PUR MAXFEE 01/01/2023 12/31/2023 2523.73 0.0 Y 0-1 Description: PWC GP 2 STD PORT CAP CHAIR Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0821 NU DME PUR MAXFEE 01/01/2024 2164.20 0.0 Y 0-1 Description: PWC GP 2 STD PORT CAP CHAIR Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0821 RR DME RTL MAXFEE 01/01/2023 12/31/2023 378.56 0.0 Y 0-1 Description: PWC GP 2 STD PORT CAP CHAIR Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0821 RR DME RTL MAXFEE 01/01/2024 324.63 0.0 Y 0-1 Description: PWC GP 2 STD PORT CAP CHAIR Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0822 NU DME PUR MAXFEE 01/01/2023 12/31/2023 2809.73 0.0 Y 0-1 Description: PWC GP 2 STD SEAT/BACK Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0822 NU DME PUR MAXFEE 01/01/2024 2285.53 0.0 Y 0-1 Description: PWC GP 2 STD SEAT/BACK Category: Durable Medical CMS Add: 10/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,907 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- K0822 RR DME RTL MAXFEE 01/01/2023 12/31/2023 421.46 0.0 Y 0-1 Description: PWC GP 2 STD SEAT/BACK Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0822 RR DME RTL MAXFEE 01/01/2024 342.83 0.0 Y 0-1 Description: PWC GP 2 STD SEAT/BACK Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0823 NU DME PUR MAXFEE 01/01/2023 12/31/2023 2730.73 0.0 Y 0-1 Description: PWC GP 2 STD CAP CHAIR Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0823 NU DME PUR MAXFEE 01/01/2024 2166.67 0.0 Y 0-1 Description: PWC GP 2 STD CAP CHAIR Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0823 RR DME RTL MAXFEE 01/01/2023 12/31/2023 409.61 0.0 Y 0-1 Description: PWC GP 2 STD CAP CHAIR Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0823 RR DME RTL MAXFEE 01/01/2024 325.00 0.0 Y 0-1 Description: PWC GP 2 STD CAP CHAIR Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0824 NU DME PUR MAXFEE 01/01/2023 12/31/2023 3764.27 0.0 Y 0-1 Description: PWC GP 2 HD SEAT/BACK Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0824 NU DME PUR MAXFEE 01/01/2024 3263.87 0.0 Y 0-1 Description: PWC GP 2 HD SEAT/BACK Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0824 RR DME RTL MAXFEE 01/01/2023 12/31/2023 564.64 0.0 Y 0-1 Description: PWC GP 2 HD SEAT/BACK Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0824 RR DME RTL MAXFEE 01/01/2024 489.58 0.0 Y 0-1 Description: PWC GP 2 HD SEAT/BACK Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0825 NU DME PUR MAXFEE 01/01/2023 12/31/2023 3439.47 0.0 Y 0-1 Description: PWC GP 2 HD CAP CHAIR Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0825 NU DME PUR MAXFEE 01/01/2024 2978.80 0.0 Y 0-1 Description: PWC GP 2 HD CAP CHAIR Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0825 RR DME RTL MAXFEE 01/01/2023 12/31/2023 515.92 0.0 Y 0-1 Description: PWC GP 2 HD CAP CHAIR Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0825 RR DME RTL MAXFEE 01/01/2024 446.82 0.0 Y 0-1 Description: PWC GP 2 HD CAP CHAIR Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0826 NU DME PUR MAXFEE 01/01/2023 12/31/2023 6194.93 0.0 Y 0-1 Description: PWC GP 2 VHD SEAT/BACK Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0826 NU DME PUR MAXFEE 01/01/2024 6040.40 0.0 Y 0-1 Description: PWC GP 2 VHD SEAT/BACK Category: Durable Medical CMS Add: 10/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,908 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- K0826 RR DME RTL MAXFEE 01/01/2023 12/31/2023 929.24 0.0 Y 0-1 Description: PWC GP 2 VHD SEAT/BACK Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0826 RR DME RTL MAXFEE 01/01/2024 906.06 0.0 Y 0-1 Description: PWC GP 2 VHD SEAT/BACK Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0827 NU DME PUR MAXFEE 01/01/2023 12/31/2023 5318.93 0.0 Y 0-1 Description: PWC GP VHD CAP CHAIR Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0827 NU DME PUR MAXFEE 01/01/2024 5206.80 0.0 Y 0-1 Description: PWC GP VHD CAP CHAIR Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0827 RR DME RTL MAXFEE 01/01/2023 12/31/2023 797.84 0.0 Y 0-1 Description: PWC GP VHD CAP CHAIR Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0827 RR DME RTL MAXFEE 01/01/2024 781.02 0.0 Y 0-1 Description: PWC GP VHD CAP CHAIR Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0828 NU DME PUR MAXFEE 01/01/2023 7363.27 0.0 Y 0-1 Description: PWC GP 2 XTRA HD SEAT/BACK Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0828 RR DME RTL MAXFEE 01/01/2023 1104.49 0.0 Y 0-1 Description: PWC GP 2 XTRA HD SEAT/BACK Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0829 NU DME PUR MAXFEE 01/01/2023 12/31/2023 6905.40 0.0 Y 0-1 Description: PWC GP 2 XTRA HD CAP CHAIR Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0829 NU DME PUR MAXFEE 01/01/2024 6986.87 0.0 Y 0-1 Description: PWC GP 2 XTRA HD CAP CHAIR Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0829 RR DME RTL MAXFEE 01/01/2023 12/31/2023 1035.81 0.0 Y 0-1 Description: PWC GP 2 XTRA HD CAP CHAIR Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0829 RR DME RTL MAXFEE 01/01/2024 1048.03 0.0 Y 0-1 Description: PWC GP 2 XTRA HD CAP CHAIR Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0830 NOCOV DEF SYSMAN 0-1 Description: PWC GP2 STD SEAT ELEVATE S/B Category: Non Covered Services CMS Add: 10/01/2006 CMS Term: K0831 NOCOV DEF SYSMAN 0-1 Description: PWC GP2 STD SEAT ELEVATE CAP Category: Non Covered Services CMS Add: 10/01/2006 CMS Term: K0835 NU DME PUR MAXFEE 01/01/2023 12/31/2023 3224.73 0.0 Y 0-1 Description: PWC GP2 STD SING POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0835 NU DME PUR MAXFEE 01/01/2024 2831.93 0.0 Y 0-1 Description: PWC GP2 STD SING POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,909 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- K0835 RR DME RTL MAXFEE 01/01/2023 12/31/2023 483.71 0.0 Y 0-1 Description: PWC GP2 STD SING POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0835 RR DME RTL MAXFEE 01/01/2024 424.79 0.0 Y 0-1 Description: PWC GP2 STD SING POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0836 NU DME PUR MAXFEE 01/01/2023 12/31/2023 3344.53 0.0 Y 0-1 Description: PWC GP2 STD SING POW OPT CAP Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0836 NU DME PUR MAXFEE 01/01/2024 2937.33 0.0 Y 0-1 Description: PWC GP2 STD SING POW OPT CAP Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0836 RR DME RTL MAXFEE 01/01/2023 12/31/2023 501.68 0.0 Y 0-1 Description: PWC GP2 STD SING POW OPT CAP Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0836 RR DME RTL MAXFEE 01/01/2024 440.60 0.0 Y 0-1 Description: PWC GP2 STD SING POW OPT CAP Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0837 NU DME PUR MAXFEE 01/01/2023 12/31/2023 4032.53 0.0 Y 0-1 Description: PWC GP 2 HD SING POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0837 NU DME PUR MAXFEE 01/01/2024 3632.33 0.0 Y 0-1 Description: PWC GP 2 HD SING POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0837 RR DME RTL MAXFEE 01/01/2023 12/31/2023 604.88 0.0 Y 0-1 Description: PWC GP 2 HD SING POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0837 RR DME RTL MAXFEE 01/01/2024 544.85 0.0 Y 0-1 Description: PWC GP 2 HD SING POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0838 NU DME PUR MAXFEE 01/01/2023 12/31/2023 3585.67 0.0 Y 0-1 Description: PWC GP 2 HD SING POW OPT CAP Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0838 NU DME PUR MAXFEE 01/01/2024 3219.47 0.0 Y 0-1 Description: PWC GP 2 HD SING POW OPT CAP Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0838 RR DME RTL MAXFEE 01/01/2023 12/31/2023 537.85 0.0 Y 0-1 Description: PWC GP 2 HD SING POW OPT CAP Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0838 RR DME RTL MAXFEE 01/01/2024 482.92 0.0 Y 0-1 Description: PWC GP 2 HD SING POW OPT CAP Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0839 NU DME PUR MAXFEE 01/01/2023 12/31/2023 5309.87 0.0 Y 0-1 Description: PWC GP2 VHD SING POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0839 NU DME PUR MAXFEE 01/01/2024 4824.93 0.0 Y 0-1 Description: PWC GP2 VHD SING POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,910 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- K0839 RR DME RTL MAXFEE 01/01/2023 12/31/2023 796.48 0.0 Y 0-1 Description: PWC GP2 VHD SING POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0839 RR DME RTL MAXFEE 01/01/2024 723.74 0.0 Y 0-1 Description: PWC GP2 VHD SING POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0840 NU DME PUR MAXFEE 01/01/2023 12/31/2023 8115.73 0.0 Y 0-1 Description: PWC GP2 XHD SING POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0840 NU DME PUR MAXFEE 01/01/2024 7407.80 0.0 Y 0-1 Description: PWC GP2 XHD SING POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0840 RR DME RTL MAXFEE 01/01/2023 12/31/2023 1217.36 0.0 Y 0-1 Description: PWC GP2 XHD SING POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0840 RR DME RTL MAXFEE 01/01/2024 1111.17 0.0 Y 0-1 Description: PWC GP2 XHD SING POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0841 NU DME PUR MAXFEE 01/01/2023 12/31/2023 3561.33 0.0 Y 0-1 Description: PWC GP2 STD MULT POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0841 NU DME PUR MAXFEE 01/01/2024 3191.33 0.0 Y 0-1 Description: PWC GP2 STD MULT POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0841 RR DME RTL MAXFEE 01/01/2023 12/31/2023 534.20 0.0 Y 0-1 Description: PWC GP2 STD MULT POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0841 RR DME RTL MAXFEE 01/01/2024 478.70 0.0 Y 0-1 Description: PWC GP2 STD MULT POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0842 NU DME PUR MAXFEE 01/01/2023 12/31/2023 3558.00 0.0 Y 0-1 Description: PWC GP2 STD MULT POW OPT CAP Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0842 NU DME PUR MAXFEE 01/01/2024 3186.73 0.0 Y 0-1 Description: PWC GP2 STD MULT POW OPT CAP Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0842 RR DME RTL MAXFEE 01/01/2023 12/31/2023 533.70 0.0 Y 0-1 Description: PWC GP2 STD MULT POW OPT CAP Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0842 RR DME RTL MAXFEE 01/01/2024 478.01 0.0 Y 0-1 Description: PWC GP2 STD MULT POW OPT CAP Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0843 NU DME PUR MAXFEE 01/01/2023 12/31/2023 4244.60 0.0 Y 0-1 Description: PWC GP2 HD MULT POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0843 NU DME PUR MAXFEE 01/01/2024 3783.07 0.0 Y 0-1 Description: PWC GP2 HD MULT POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,911 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- K0843 RR DME RTL MAXFEE 01/01/2023 12/31/2023 636.69 0.0 Y 0-1 Description: PWC GP2 HD MULT POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0843 RR DME RTL MAXFEE 01/01/2024 567.46 0.0 Y 0-1 Description: PWC GP2 HD MULT POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0848 NU DME PUR MAXFEE 01/01/2023 12/31/2023 6057.20 0.0 Y 0-1 Description: PWC GP 3 STD SEAT/BACK Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0848 NU DME PUR MAXFEE 01/01/2024 6214.67 0.0 Y 0-1 Description: PWC GP 3 STD SEAT/BACK Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0848 RR DME RTL MAXFEE 01/01/2023 12/31/2023 908.58 0.0 Y 0-1 Description: PWC GP 3 STD SEAT/BACK Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0848 RR DME RTL MAXFEE 01/01/2024 932.20 0.0 Y 0-1 Description: PWC GP 3 STD SEAT/BACK Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0849 NU DME PUR MAXFEE 01/01/2023 12/31/2023 5823.53 0.0 Y 0-1 Description: PWC GP 3 STD CAP CHAIR Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0849 NU DME PUR MAXFEE 01/01/2024 5974.93 0.0 Y 0-1 Description: PWC GP 3 STD CAP CHAIR Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0849 RR DME RTL MAXFEE 01/01/2023 12/31/2023 873.53 0.0 Y 0-1 Description: PWC GP 3 STD CAP CHAIR Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0849 RR DME RTL MAXFEE 01/01/2024 896.24 0.0 Y 0-1 Description: PWC GP 3 STD CAP CHAIR Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0850 NU DME PUR MAXFEE 01/01/2023 12/31/2023 7025.93 0.0 Y 0-1 Description: PWC GP 3 HD SEAT/BACK Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0850 NU DME PUR MAXFEE 01/01/2024 7208.60 0.0 Y 0-1 Description: PWC GP 3 HD SEAT/BACK Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0850 RR DME RTL MAXFEE 01/01/2023 12/31/2023 1053.89 0.0 Y 0-1 Description: PWC GP 3 HD SEAT/BACK Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0850 RR DME RTL MAXFEE 01/01/2024 1081.29 0.0 Y 0-1 Description: PWC GP 3 HD SEAT/BACK Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0851 NU DME PUR MAXFEE 01/01/2023 12/31/2023 6755.53 0.0 Y 0-1 Description: PWC GP 3 HD CAP CHAIR Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0851 NU DME PUR MAXFEE 01/01/2024 6931.20 0.0 Y 0-1 Description: PWC GP 3 HD CAP CHAIR Category: Durable Medical CMS Add: 10/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,912 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- K0851 RR DME RTL MAXFEE 01/01/2023 12/31/2023 1013.33 0.0 Y 0-1 Description: PWC GP 3 HD CAP CHAIR Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0851 RR DME RTL MAXFEE 01/01/2024 1039.68 0.0 Y 0-1 Description: PWC GP 3 HD CAP CHAIR Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0852 NU DME PUR MAXFEE 01/01/2014 6971.00 0.0 Y 0-1 Description: PWC GP 3 VHD SEAT/BACK Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0852 RR DME RTL MAXFEE 01/01/2014 697.10 0.0 Y 0-1 Description: PWC GP 3 VHD SEAT/BACK Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0853 NU DME PUR MAXFEE 01/01/2023 12/31/2023 8339.40 0.0 Y 0-1 Description: PWC GP 3 VHD CAP CHAIR Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0853 NU DME PUR MAXFEE 01/01/2024 8556.20 0.0 Y 0-1 Description: PWC GP 3 VHD CAP CHAIR Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0853 RR DME RTL MAXFEE 01/01/2023 12/31/2023 1250.91 0.0 Y 0-1 Description: PWC GP 3 VHD CAP CHAIR Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0853 RR DME RTL MAXFEE 01/01/2024 1283.43 0.0 Y 0-1 Description: PWC GP 3 VHD CAP CHAIR Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0854 NU DME PUR MAXFEE 01/01/2014 12/31/2023 9115.60 0.0 Y 0-1 Description: PWC GP 3 XHD SEAT/BACK Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0854 NU DME PUR MAXFEE 01/01/2024 11047.80 0.0 Y 0-1 Description: PWC GP 3 XHD SEAT/BACK Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0854 RR DME RTL MAXFEE 01/01/2014 12/31/2023 911.56 0.0 Y 0-1 Description: PWC GP 3 XHD SEAT/BACK Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0854 RR DME RTL MAXFEE 01/01/2024 1657.17 0.0 Y 0-1 Description: PWC GP 3 XHD SEAT/BACK Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0855 NU DME PUR MAXFEE 01/01/2024 10707.60 0.0 Y 0-1 Description: PWC GP 3 XHD CAP CHAIR Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0855 NU DME PUR MAXFEE 02/01/2021 12/31/2023 9135.13 0.0 Y 0-1 Description: PWC GP 3 XHD CAP CHAIR Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0855 RR DME RTL MAXFEE 01/01/2024 1606.14 0.0 Y 0-1 Description: PWC GP 3 XHD CAP CHAIR Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0855 RR DME RTL MAXFEE 02/01/2021 12/31/2023 1370.27 0.0 Y 0-1 Description: PWC GP 3 XHD CAP CHAIR Category: Durable Medical CMS Add: 10/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,913 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- K0856 NU DME PUR MAXFEE 01/01/2023 12/31/2023 6501.53 0.0 Y 0-1 Description: PWC GP3 STD SING POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0856 NU DME PUR MAXFEE 01/01/2024 6670.60 0.0 Y 0-1 Description: PWC GP3 STD SING POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0856 RR DME RTL MAXFEE 01/01/2023 12/31/2023 975.23 0.0 Y 0-1 Description: PWC GP3 STD SING POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0856 RR DME RTL MAXFEE 01/01/2024 1000.59 0.0 Y 0-1 Description: PWC GP3 STD SING POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0857 NU DME PUR MAXFEE 01/01/2023 12/31/2023 6631.93 0.0 Y 0-1 Description: PWC GP3 STD SING POW OPT CAP Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0857 NU DME PUR MAXFEE 01/01/2024 6804.33 0.0 Y 0-1 Description: PWC GP3 STD SING POW OPT CAP Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0857 RR DME RTL MAXFEE 01/01/2023 12/31/2023 994.79 0.0 Y 0-1 Description: PWC GP3 STD SING POW OPT CAP Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0857 RR DME RTL MAXFEE 01/01/2024 1020.65 0.0 Y 0-1 Description: PWC GP3 STD SING POW OPT CAP Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0858 NU DME PUR MAXFEE 01/01/2023 12/31/2023 8066.60 0.0 Y 0-1 Description: PWC GP3 HD SING POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0858 NU DME PUR MAXFEE 01/01/2024 8276.33 0.0 Y 0-1 Description: PWC GP3 HD SING POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0858 RR DME RTL MAXFEE 01/01/2023 12/31/2023 1209.99 0.0 Y 0-1 Description: PWC GP3 HD SING POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0858 RR DME RTL MAXFEE 01/01/2024 1241.45 0.0 Y 0-1 Description: PWC GP3 HD SING POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0859 NU DME PUR MAXFEE 01/01/2023 12/31/2023 7693.07 0.0 Y 0-1 Description: PWC GP3 HD SING POW OPT CAP Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0859 NU DME PUR MAXFEE 01/01/2024 7893.07 0.0 Y 0-1 Description: PWC GP3 HD SING POW OPT CAP Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0859 RR DME RTL MAXFEE 01/01/2023 12/31/2023 1153.96 0.0 Y 0-1 Description: PWC GP3 HD SING POW OPT CAP Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0859 RR DME RTL MAXFEE 01/01/2024 1183.96 0.0 Y 0-1 Description: PWC GP3 HD SING POW OPT CAP Category: Durable Medical CMS Add: 10/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,914 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- K0860 NU DME PUR MAXFEE 01/01/2023 12/31/2023 11524.20 0.0 Y 0-1 Description: PWC GP3 VHD SING POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0860 NU DME PUR MAXFEE 01/01/2024 11823.80 0.0 Y 0-1 Description: PWC GP3 VHD SING POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0860 RR DME RTL MAXFEE 01/01/2023 12/31/2023 1728.63 0.0 Y 0-1 Description: PWC GP3 VHD SING POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0860 RR DME RTL MAXFEE 01/01/2024 1773.57 0.0 Y 0-1 Description: PWC GP3 VHD SING POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0861 NU DME PUR MAXFEE 01/01/2023 12/31/2023 6512.00 0.0 Y 0-1 Description: PWC GP3 STD MULT POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0861 NU DME PUR MAXFEE 01/01/2024 6681.33 0.0 Y 0-1 Description: PWC GP3 STD MULT POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0861 RR DME RTL MAXFEE 01/01/2023 12/31/2023 976.80 0.0 Y 0-1 Description: PWC GP3 STD MULT POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0861 RR DME RTL MAXFEE 01/01/2024 1002.20 0.0 Y 0-1 Description: PWC GP3 STD MULT POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0862 NU DME PUR MAXFEE 01/01/2023 12/31/2023 8066.60 0.0 Y 0-1 Description: PWC GP3 HD MULT POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0862 NU DME PUR MAXFEE 01/01/2024 8276.33 0.0 Y 0-1 Description: PWC GP3 HD MULT POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0862 RR DME RTL MAXFEE 01/01/2023 12/31/2023 1209.99 0.0 Y 0-1 Description: PWC GP3 HD MULT POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0862 RR DME RTL MAXFEE 01/01/2024 1241.45 0.0 Y 0-1 Description: PWC GP3 HD MULT POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0863 NU DME PUR MAXFEE 01/01/2023 12/31/2023 11524.20 0.0 Y 0-1 Description: PWC GP3 VHD MULT POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0863 NU DME PUR MAXFEE 01/01/2024 11823.80 0.0 Y 0-1 Description: PWC GP3 VHD MULT POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0863 RR DME RTL MAXFEE 01/01/2023 12/31/2023 1728.63 0.0 Y 0-1 Description: PWC GP3 VHD MULT POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0863 RR DME RTL MAXFEE 01/01/2024 1773.57 0.0 Y 0-1 Description: PWC GP3 VHD MULT POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,915 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- K0864 NU DME PUR MAXFEE 01/01/2024 14070.33 0.0 Y 0-1 Description: PWC GP3 XHD MULT POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0864 NU DME PUR MAXFEE 02/01/2021 12/31/2023 12004.00 0.0 Y 0-1 Description: PWC GP3 XHD MULT POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0864 RR DME RTL MAXFEE 01/01/2024 2110.55 0.0 Y 0-1 Description: PWC GP3 XHD MULT POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0864 RR DME RTL MAXFEE 02/01/2021 12/31/2023 1800.60 0.0 Y 0-1 Description: PWC GP3 XHD MULT POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0868 NU DME PUR MAXFEE 01/01/2014 12/31/2023 5173.10 0.0 Y 0-1 Description: PWC GP 4 STD SEAT/BACK Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0868 NU DME PUR MAXFEE 01/01/2024 6725.03 0.0 Y 0-1 Description: PWC GP 4 STD SEAT/BACK Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0868 RR DME RTL MAXFEE 01/01/2014 12/31/2023 517.31 0.0 Y 0-1 Description: PWC GP 4 STD SEAT/BACK Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0868 RR DME RTL MAXFEE 01/01/2024 672.50 0.0 Y 0-1 Description: PWC GP 4 STD SEAT/BACK Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0869 NU DME PUR MAXFEE 01/01/2014 12/31/2023 4972.10 0.0 Y 0-1 Description: PWC GP 4 STD CAP CHAIR Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0869 NU DME PUR MAXFEE 01/01/2024 6463.73 0.0 Y 0-1 Description: PWC GP 4 STD CAP CHAIR Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0869 RR DME RTL MAXFEE 01/01/2014 12/31/2023 497.21 0.0 Y 0-1 Description: PWC GP 4 STD CAP CHAIR Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0869 RR DME RTL MAXFEE 01/01/2024 646.37 0.0 Y 0-1 Description: PWC GP 4 STD CAP CHAIR Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0870 NU DME PUR MAXFEE 01/01/2014 12/31/2023 5742.10 0.0 Y 0-1 Description: PWC GP 4 HD SEAT/BACK Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0870 NU DME PUR MAXFEE 01/01/2024 7464.73 0.0 Y 0-1 Description: PWC GP 4 HD SEAT/BACK Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0870 RR DME RTL MAXFEE 01/01/2014 12/31/2023 574.21 0.0 Y 0-1 Description: PWC GP 4 HD SEAT/BACK Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0870 RR DME RTL MAXFEE 01/01/2024 746.47 0.0 Y 0-1 Description: PWC GP 4 HD SEAT/BACK Category: Durable Medical CMS Add: 10/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,916 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- K0871 NU DME PUR MAXFEE 01/01/2014 12/31/2023 6971.00 0.0 Y 0-1 Description: PWC GP 4 VHD SEAT/BACK Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0871 NU DME PUR MAXFEE 01/01/2024 9062.30 0.0 Y 0-1 Description: PWC GP 4 VHD SEAT/BACK Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0871 RR DME RTL MAXFEE 01/01/2014 12/31/2023 697.10 0.0 Y 0-1 Description: PWC GP 4 VHD SEAT/BACK Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0871 RR DME RTL MAXFEE 01/01/2024 906.23 0.0 Y 0-1 Description: PWC GP 4 VHD SEAT/BACK Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0877 NU DME PUR MAXFEE 01/01/2014 12/31/2023 5561.30 0.0 Y 0-1 Description: PWC GP4 STD SING POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0877 NU DME PUR MAXFEE 01/01/2024 7229.69 0.0 Y 0-1 Description: PWC GP4 STD SING POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0877 RR DME RTL MAXFEE 01/01/2014 12/31/2023 556.13 0.0 Y 0-1 Description: PWC GP4 STD SING POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0877 RR DME RTL MAXFEE 01/01/2024 722.97 0.0 Y 0-1 Description: PWC GP4 STD SING POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0878 NU DME PUR MAXFEE 01/01/2014 12/31/2023 5672.50 0.0 Y 0-1 Description: PWC GP4 STD SING POW OPT CAP Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0878 NU DME PUR MAXFEE 01/01/2024 7374.25 0.0 Y 0-1 Description: PWC GP4 STD SING POW OPT CAP Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0878 RR DME RTL MAXFEE 01/01/2014 12/31/2023 567.25 0.0 Y 0-1 Description: PWC GP4 STD SING POW OPT CAP Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0878 RR DME RTL MAXFEE 01/01/2024 737.43 0.0 Y 0-1 Description: PWC GP4 STD SING POW OPT CAP Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0879 NU DME PUR MAXFEE 01/01/2014 12/31/2023 6926.20 0.0 Y 0-1 Description: PWC GP4 HD SING POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0879 NU DME PUR MAXFEE 01/01/2024 9004.06 0.0 Y 0-1 Description: PWC GP4 HD SING POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0879 RR DME RTL MAXFEE 01/01/2014 12/31/2023 692.62 0.0 Y 0-1 Description: PWC GP4 HD SING POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0879 RR DME RTL MAXFEE 01/01/2024 900.41 0.0 Y 0-1 Description: PWC GP4 HD SING POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,917 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- K0880 NU DME PUR MAXFEE 01/01/2014 12/31/2023 9734.10 0.0 Y 0-1 Description: PWC GP4 VHD SING POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0880 NU DME PUR MAXFEE 01/01/2024 12654.33 0.0 Y 0-1 Description: PWC GP4 VHD SING POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0880 RR DME RTL MAXFEE 01/01/2014 12/31/2023 973.41 0.0 Y 0-1 Description: PWC GP4 VHD SING POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0880 RR DME RTL MAXFEE 01/01/2024 1265.43 0.0 Y 0-1 Description: PWC GP4 VHD SING POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0884 NU DME PUR MAXFEE 01/01/2014 12/31/2023 5570.10 0.0 Y 0-1 Description: PWC GP4 STD MULT POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0884 NU DME PUR MAXFEE 01/01/2024 7241.13 0.0 Y 0-1 Description: PWC GP4 STD MULT POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0884 RR DME RTL MAXFEE 01/01/2014 12/31/2023 557.01 0.0 Y 0-1 Description: PWC GP4 STD MULT POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0884 RR DME RTL MAXFEE 01/01/2024 724.11 0.0 Y 0-1 Description: PWC GP4 STD MULT POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0885 NU DME PUR MAXFEE 01/01/2014 12/31/2023 5570.10 0.0 Y 0-1 Description: PWC GP4 STD MULT POW OPT CAP Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0885 NU DME PUR MAXFEE 01/01/2024 7241.13 0.0 Y 0-1 Description: PWC GP4 STD MULT POW OPT CAP Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0885 RR DME RTL MAXFEE 01/01/2014 12/31/2023 557.01 0.0 Y 0-1 Description: PWC GP4 STD MULT POW OPT CAP Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0885 RR DME RTL MAXFEE 01/01/2024 724.11 0.0 Y 0-1 Description: PWC GP4 STD MULT POW OPT CAP Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0886 NU DME PUR MAXFEE 01/01/2014 12/31/2023 6926.20 0.0 Y 0-1 Description: PWC GP4 HD MULT POW S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0886 NU DME PUR MAXFEE 01/01/2024 9004.06 0.0 Y 0-1 Description: PWC GP4 HD MULT POW S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0886 RR DME RTL MAXFEE 01/01/2014 12/31/2023 692.62 0.0 Y 0-1 Description: PWC GP4 HD MULT POW S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0886 RR DME RTL MAXFEE 01/01/2024 900.41 0.0 Y 0-1 Description: PWC GP4 HD MULT POW S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,918 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- K0890 DME DEF SYSMAN Y Y 0-1 Description: PWC GP5 PED SING POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0891 DME DEF SYSMAN Y Y 0-1 Description: PWC GP5 PED MULT POW OPT S/B Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0898 DME DEF SYSMAN Y Y 0-1 Description: POWER WHEELCHAIR NOC Category: Durable Medical CMS Add: 10/01/2006 CMS Term: K0899 NOCOV DEF SYSMAN Description: POW MOBIL DEV NO DMEPDAC Category: Non Covered Services CMS Add: 10/01/2006 CMS Term: K0900 NOCOV DEF SYSMAN Description: CSTM DME OTHER THAN WHEELCHR Category: Non Covered Services CMS Add: 07/01/2013 CMS Term: K1004 NOCOV DEF SYSMAN Description: LO FREQ US DIATHERMY DEVICE Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: K1007 NOCOV DEF SYSMAN Description: BIL HKAF PC S/D MICRO SENSOR Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: K1027 DME DEF SYSMAN Y Description: ORAL DEV WITHOUT FIX MECH Category: Durable Medical CMS Add: 10/01/2021 CMS Term: K1030 NOCOV DEF SYSMAN Description: EXT RECHARGE BAT REPLACEMENT Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: K1034 NOCOV DEF SYSMAN Description: COVID TEST SELF-ADMN/COLLECT Category: Non Covered Services CMS Add: 04/04/2022 CMS Term: K1035 NOCOV DEF SYSMAN Description: MOL DIAG READER SELF-ADMN Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: K1036 NOCOV DEF SYSMAN Description: SUPPLIES FOR ULTRA DIATHERM Category: Non Covered Services CMS Add: 10/01/2023 CMS Term: L0112 DME DEF MAXFEE 01/01/2014 12/31/2023 1128.77 0.0 Description: CRANIAL CERVICAL ORTHOSIS Category: Durable Medical CMS Add: 01/01/2004 CMS Term: L0112 DME DEF MAXFEE 01/01/2024 1605.08 0.0 Description: CRANIAL CERVICAL ORTHOSIS Category: Durable Medical CMS Add: 01/01/2004 CMS Term: L0113 DME DEF MAXFEE 01/01/2014 12/31/2023 258.23 0.0 Description: CRANIAL CERVICAL TORTICOLLIS Category: Durable Medical CMS Add: 01/01/2009 CMS Term: L0113 DME DEF MAXFEE 01/01/2024 327.05 0.0 Description: CRANIAL CERVICAL TORTICOLLIS Category: Durable Medical CMS Add: 01/01/2009 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,919 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L0120 DME DEF MAXFEE 01/01/2014 12/31/2023 17.76 0.0 Description: CERV FLEX N/ADJ FOAM PRE OTS Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L0120 DME DEF MAXFEE 01/01/2024 30.33 0.0 Description: CERV FLEX N/ADJ FOAM PRE OTS Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L0130 DME DEF MAXFEE 01/01/2014 12/31/2023 109.90 0.0 Description: FLEX THERMOPLASTIC COLLAR MO Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L0130 DME DEF MAXFEE 01/01/2024 175.05 0.0 Description: FLEX THERMOPLASTIC COLLAR MO Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L0140 DME DEF MAXFEE 01/01/2014 12/31/2023 42.31 0.0 Description: CERVICAL SEMI-RIGID ADJUSTAB Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L0140 DME DEF MAXFEE 01/01/2024 68.65 0.0 Description: CERVICAL SEMI-RIGID ADJUSTAB Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L0150 DME DEF MAXFEE 01/01/2014 12/31/2023 73.99 0.0 Description: CERV SEMI-RIG ADJ MOLDED CHN Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L0150 DME DEF MAXFEE 01/01/2024 122.75 0.0 Description: CERV SEMI-RIG ADJ MOLDED CHN Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L0160 DME DEF MAXFEE 01/01/2014 12/31/2023 105.31 0.0 Description: CERV SR WIRE OCC/MAN PRE OTS Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L0160 DME DEF MAXFEE 01/01/2024 179.24 0.0 Description: CERV SR WIRE OCC/MAN PRE OTS Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L0170 DME DEF MAXFEE 01/01/2014 12/31/2023 495.93 0.0 Description: CERVICAL COLLAR MOLDED TO PT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L0170 DME DEF MAXFEE 01/01/2024 922.06 0.0 Description: CERVICAL COLLAR MOLDED TO PT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L0172 DME DEF MAXFEE 01/01/2014 12/31/2023 101.49 0.0 Description: CERV COL SR FOAM 2PC PRE OTS Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L0172 DME DEF MAXFEE 01/01/2024 162.42 0.0 Description: CERV COL SR FOAM 2PC PRE OTS Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L0174 DME DEF MAXFEE 01/01/2014 12/31/2023 183.98 0.0 Description: CERV SR 2PC THOR EXT PRE OTS Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L0174 DME DEF MAXFEE 01/01/2024 319.37 0.0 Description: CERV SR 2PC THOR EXT PRE OTS Category: Durable Medical CMS Add: 01/01/1988 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,920 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L0180 DME DEF MAXFEE 01/01/2014 12/31/2023 281.87 0.0 Description: CER POST COL OCC/MAN SUP ADJ Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L0180 DME DEF MAXFEE 01/01/2024 517.39 0.0 Description: CER POST COL OCC/MAN SUP ADJ Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L0190 DME DEF MAXFEE 01/01/2014 12/31/2023 377.52 0.0 Description: CERV COLLAR SUPP ADJ CERV BA Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L0190 DME DEF MAXFEE 01/01/2024 610.20 0.0 Description: CERV COLLAR SUPP ADJ CERV BA Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L0200 DME DEF MAXFEE 01/01/2014 12/31/2023 452.21 0.0 Description: CERV COL SUPP ADJ BAR & THOR Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L0200 DME DEF MAXFEE 01/01/2024 707.79 0.0 Description: CERV COL SUPP ADJ BAR & THOR Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L0220 DME DEF MAXFEE 01/01/2014 12/31/2023 86.75 0.0 Description: THOR RIB BELT CUSTOM FABRICA Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L0220 DME DEF MAXFEE 01/01/2024 148.15 0.0 Description: THOR RIB BELT CUSTOM FABRICA Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L0430 NOCOV DEF SYSMAN Description: DEWALL POSTURE PROTECTOR Category: Non Covered Services CMS Add: 01/01/1988 CMS Term: 12/31/2013 L0450 DME DEF MAXFEE 01/01/2014 12/31/2023 130.83 0.0 Description: TLSO FLEX TRUNK/THOR PRE OTS Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L0450 DME DEF MAXFEE 01/01/2024 133.92 0.0 Description: TLSO FLEX TRUNK/THOR PRE OTS Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L0452 DME DEF MAXFEE 01/01/2014 12/31/2023 248.14 0.0 Description: TLSO FLEX CUSTOM FAB THORACI Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L0452 DME DEF MAXFEE 01/01/2024 322.58 0.0 Description: TLSO FLEX CUSTOM FAB THORACI Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L0454 DME DEF MAXFEE 01/01/2014 12/31/2023 275.12 0.0 Description: TLSO TRNK SJ-T9 PRE CST Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L0454 DME DEF MAXFEE 01/01/2024 397.73 0.0 Description: TLSO TRNK SJ-T9 PRE CST Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L0455 DME DEF MAXFEE 01/01/2014 12/31/2023 275.12 0.0 Description: TLSO FLEX TRNK SJ-T9 PRE OTS Category: Durable Medical CMS Add: 01/01/2014 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,921 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L0455 DME DEF MAXFEE 01/01/2024 261.56 0.0 Description: TLSO FLEX TRNK SJ-T9 PRE OTS Category: Durable Medical CMS Add: 01/01/2014 CMS Term: L0456 DME DEF MAXFEE 01/01/2014 12/31/2023 275.12 0.0 Description: TLSO FLEX TRNK SJ-SS PRE CST Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L0456 DME DEF MAXFEE 01/01/2024 1140.59 0.0 Description: TLSO FLEX TRNK SJ-SS PRE CST Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L0457 DME DEF MAXFEE 01/01/2014 12/31/2023 275.12 0.0 Description: TLSO FLEX TRNK SJ-SS PRE OTS Category: Durable Medical CMS Add: 01/01/2014 CMS Term: L0457 DME DEF MAXFEE 01/01/2024 750.07 0.0 Description: TLSO FLEX TRNK SJ-SS PRE OTS Category: Durable Medical CMS Add: 01/01/2014 CMS Term: L0458 DME DEF MAXFEE 01/01/2014 12/31/2023 547.13 0.0 Description: TLSO 2MOD SYMPHIS-XIPHO PRE Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L0458 DME DEF MAXFEE 01/01/2024 1022.79 0.0 Description: TLSO 2MOD SYMPHIS-XIPHO PRE Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L0460 DME DEF MAXFEE 01/01/2014 12/31/2023 547.13 0.0 Description: TLSO 2 SHL SYMPHYS-STERN CST Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L0460 DME DEF MAXFEE 01/01/2024 1151.21 0.0 Description: TLSO 2 SHL SYMPHYS-STERN CST Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L0462 DME DEF MAXFEE 01/01/2014 12/31/2023 547.13 0.0 Description: TLSO 3MOD SACRO-SCAP PRE Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L0462 DME DEF MAXFEE 01/01/2024 1431.89 0.0 Description: TLSO 3MOD SACRO-SCAP PRE Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L0464 DME DEF MAXFEE 01/01/2014 12/31/2023 547.13 0.0 Description: TLSO 4MOD SACRO-SCAP PRE Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L0464 DME DEF MAXFEE 01/01/2024 1704.67 0.0 Description: TLSO 4MOD SACRO-SCAP PRE Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L0466 DME DEF MAXFEE 01/01/2014 12/31/2023 345.05 0.0 Description: TLSO R FRAM SOFT ANT PRE CST Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L0466 DME DEF MAXFEE 01/01/2024 435.10 0.0 Description: TLSO R FRAM SOFT ANT PRE CST Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L0467 DME DEF MAXFEE 01/01/2014 12/31/2023 345.05 0.0 Description: TLSO R FRAM SOFT PRE OTS Category: Durable Medical CMS Add: 01/01/2014 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,922 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L0467 DME DEF MAXFEE 01/01/2024 290.60 0.0 Description: TLSO R FRAM SOFT PRE OTS Category: Durable Medical CMS Add: 01/01/2014 CMS Term: L0468 DME DEF MAXFEE 01/01/2014 12/31/2023 345.05 0.0 Description: TLSO RIG FRAM PELVIC PRE CST Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L0468 DME DEF MAXFEE 01/01/2024 545.27 0.0 Description: TLSO RIG FRAM PELVIC PRE CST Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L0469 DME DEF MAXFEE 01/01/2014 12/31/2023 345.05 0.0 Description: TLSO RIG FRAM PELVIC PRE OTS Category: Durable Medical CMS Add: 01/01/2014 CMS Term: L0469 DME DEF MAXFEE 01/01/2024 368.00 0.0 Description: TLSO RIG FRAM PELVIC PRE OTS Category: Durable Medical CMS Add: 01/01/2014 CMS Term: L0470 DME DEF MAXFEE 01/01/2014 12/31/2023 479.92 0.0 Description: TLSO RIGID FRAME PRE SUBCLAV Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L0470 DME DEF MAXFEE 01/01/2024 754.54 0.0 Description: TLSO RIGID FRAME PRE SUBCLAV Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L0472 DME DEF MAXFEE 01/01/2014 12/31/2023 304.37 0.0 Description: TLSO RIGID FRAME HYPEREX PRE Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L0472 DME DEF MAXFEE 01/01/2024 464.30 0.0 Description: TLSO RIGID FRAME HYPEREX PRE Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L0480 DME DEF MAXFEE 01/01/2014 12/31/2023 1071.88 0.0 Description: TLSO RIGID PLASTIC CUSTOM FA Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L0480 DME DEF MAXFEE 01/01/2024 1732.20 0.0 Description: TLSO RIGID PLASTIC CUSTOM FA Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L0482 DME DEF MAXFEE 01/01/2014 12/31/2023 1167.31 0.0 Description: TLSO RIGID LINED CUSTOM FAB Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L0482 DME DEF MAXFEE 01/01/2024 1934.88 0.0 Description: TLSO RIGID LINED CUSTOM FAB Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L0484 DME DEF MAXFEE 01/01/2014 12/31/2023 1337.75 0.0 Description: TLSO RIGID PLASTIC CUST FAB Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L0484 DME DEF MAXFEE 01/01/2024 2089.58 0.0 Description: TLSO RIGID PLASTIC CUST FAB Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L0486 DME DEF MAXFEE 01/01/2014 12/31/2023 1419.28 0.0 Description: TLSO RIGIDLINED CUST FAB TWO Category: Durable Medical CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,923 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L0486 DME DEF MAXFEE 01/01/2024 2346.69 0.0 Description: TLSO RIGIDLINED CUST FAB TWO Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L0488 DME DEF MAXFEE 01/01/2014 12/31/2023 1008.64 0.0 Description: TLSO RIGID LINED PRE ONE PIE Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L0488 DME DEF MAXFEE 01/01/2024 1151.21 0.0 Description: TLSO RIGID LINED PRE ONE PIE Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L0490 DME DEF MAXFEE 01/01/2014 12/31/2023 843.32 0.0 Description: TLSO RIGID PLASTIC PRE ONE Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L0490 DME DEF MAXFEE 01/01/2024 324.40 0.0 Description: TLSO RIGID PLASTIC PRE ONE Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L0491 DME DEF MAXFEE 01/01/2014 12/31/2023 618.29 0.0 Description: TLSO 2 PIECE RIGID SHELL Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L0491 DME DEF MAXFEE 01/01/2024 880.74 0.0 Description: TLSO 2 PIECE RIGID SHELL Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L0492 DME DEF MAXFEE 01/01/2014 12/31/2023 402.60 0.0 Description: TLSO 3 PIECE RIGID SHELL Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L0492 DME DEF MAXFEE 01/01/2024 573.51 0.0 Description: TLSO 3 PIECE RIGID SHELL Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L0621 DME DEF MAXFEE 01/01/2014 12/31/2023 69.41 0.0 0-1 Description: SIO FLEX PELVIC/SACR PRE OTS Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L0621 DME DEF MAXFEE 01/01/2024 70.76 0.0 0-1 Description: SIO FLEX PELVIC/SACR PRE OTS Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L0622 DME DEF MAXFEE 01/01/2014 12/31/2023 215.18 0.0 Description: SIO FLEX PELVISACRAL CUSTOM Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L0622 DME DEF MAXFEE 01/01/2024 306.52 0.0 Description: SIO FLEX PELVISACRAL CUSTOM Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L0623 DME DEF MAXFEE 01/01/2014 12/31/2023 58.63 0.0 Description: SIO RIG PNL PELV/SAC PRE OTS Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L0623 DME DEF MAXFEE 01/01/2024 133.27 0.0 Description: SIO RIG PNL PELV/SAC PRE OTS Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L0624 DME DEF SYSMAN Y 0-1 Description: SIO PANEL CUSTOM Category: Durable Medical CMS Add: 01/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,924 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L0625 DME DEF MAXFEE 01/01/2014 12/31/2023 44.34 0.0 Description: LO FLEX L1-BELOW L5 PRE OTS Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L0625 DME DEF MAXFEE 01/01/2024 41.55 0.0 Description: LO FLEX L1-BELOW L5 PRE OTS Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L0626 DME DEF MAXFEE 01/01/2014 12/31/2023 62.75 0.0 Description: LO SAG RIG PNL STAYS PRE CST Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L0626 DME DEF MAXFEE 01/01/2024 89.39 0.0 Description: LO SAG RIG PNL STAYS PRE CST Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L0627 DME DEF MAXFEE 01/01/2014 12/31/2023 330.89 0.0 Description: LO SAG RI AN/POS PNL PRE CST Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L0627 DME DEF MAXFEE 01/01/2024 471.36 0.0 Description: LO SAG RI AN/POS PNL PRE CST Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L0628 DME DEF MAXFEE 01/01/2014 12/31/2023 67.53 0.0 Description: LSO FLEX NO RI STAYS PRE OTS Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L0628 DME DEF MAXFEE 01/01/2024 63.27 0.0 Description: LSO FLEX NO RI STAYS PRE OTS Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L0629 DME DEF SYSMAN Y Description: LSO FLEX W/RIGID STAYS CUST Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L0630 DME DEF MAXFEE 01/01/2014 12/31/2023 130.40 0.0 Description: LSO R POST PNL SJ-T9 PRE CST Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L0630 DME DEF MAXFEE 01/01/2024 185.75 0.0 Description: LSO R POST PNL SJ-T9 PRE CST Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L0631 DME DEF MAXFEE 01/01/2014 12/31/2023 826.44 0.0 Description: LSO SAG R AN/POS PNL PRE CST Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L0631 DME DEF MAXFEE 01/01/2024 1177.26 0.0 Description: LSO SAG R AN/POS PNL PRE CST Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L0632 DME DEF SYSMAN Y 0-1 Description: LSO SAG RIGID FRAME CUST Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L0633 DME DEF MAXFEE 01/01/2014 12/31/2023 230.86 0.0 Description: LSO SC R POS/LAT PNL PRE CST Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L0633 DME DEF MAXFEE 01/01/2024 328.85 0.0 Description: LSO SC R POS/LAT PNL PRE CST Category: Durable Medical CMS Add: 01/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,925 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L0634 DME DEF SYSMAN Y Description: LSO FLEXION CONTROL CUSTOM Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L0635 DME DEF MAXFEE 01/01/2014 12/31/2023 804.45 0.0 Description: LSO SAGIT RIGID PANEL PREFAB Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L0635 DME DEF MAXFEE 01/01/2024 1145.93 0.0 Description: LSO SAGIT RIGID PANEL PREFAB Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L0636 DME DEF MAXFEE 01/01/2014 12/31/2023 1091.47 0.0 Description: LSO SAGITTAL RIGID PANEL CUS Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L0636 DME DEF MAXFEE 01/01/2024 1554.83 0.0 Description: LSO SAGITTAL RIGID PANEL CUS Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L0637 DME DEF MAXFEE 01/01/2014 12/31/2023 856.21 0.0 Description: LSO SC R ANT/POS PNL PRE CST Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L0637 DME DEF MAXFEE 01/01/2024 1485.70 0.0 Description: LSO SC R ANT/POS PNL PRE CST Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L0638 DME DEF MAXFEE 01/01/2014 12/31/2023 1061.81 0.0 Description: LSO SAG-CORONAL PANEL CUSTOM Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L0638 DME DEF MAXFEE 01/01/2024 1512.55 0.0 Description: LSO SAG-CORONAL PANEL CUSTOM Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L0639 DME DEF MAXFEE 01/01/2014 12/31/2023 1042.94 0.0 Description: LSO S/C SHELL/PANEL PREFAB Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L0639 DME DEF MAXFEE 01/01/2024 1485.70 0.0 Description: LSO S/C SHELL/PANEL PREFAB Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L0640 DME DEF MAXFEE 01/01/2014 12/31/2023 842.41 0.0 Description: LSO S/C SHELL/PANEL CUSTOM Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L0640 DME DEF MAXFEE 01/01/2024 1200.00 0.0 Description: LSO S/C SHELL/PANEL CUSTOM Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L0641 DME DEF MAXFEE 01/01/2014 12/31/2023 62.75 0.0 Description: LO RIG POS PNL L1-L5 PRE OTS Category: Durable Medical CMS Add: 01/01/2014 CMS Term: L0641 DME DEF MAXFEE 01/01/2024 58.79 0.0 Description: LO RIG POS PNL L1-L5 PRE OTS Category: Durable Medical CMS Add: 01/01/2014 CMS Term: L0642 DME DEF MAXFEE 01/01/2014 12/31/2023 330.89 0.0 Description: LO SAG RI AN/POS PNL PRE OTS Category: Durable Medical CMS Add: 01/01/2014 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,926 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L0642 DME DEF MAXFEE 01/01/2024 310.04 0.0 Description: LO SAG RI AN/POS PNL PRE OTS Category: Durable Medical CMS Add: 01/01/2014 CMS Term: L0643 DME DEF MAXFEE 01/01/2014 12/31/2023 130.40 0.0 Description: LSO SAG CTR RIGI POS PRE OTS Category: Durable Medical CMS Add: 01/01/2014 CMS Term: L0643 DME DEF MAXFEE 01/01/2024 122.16 0.0 Description: LSO SAG CTR RIGI POS PRE OTS Category: Durable Medical CMS Add: 01/01/2014 CMS Term: L0648 DME DEF MAXFEE 01/01/2014 12/31/2023 826.44 0.0 Description: LSO SAG R AN/POS PNL PRE OTS Category: Durable Medical CMS Add: 01/01/2014 CMS Term: L0648 DME DEF MAXFEE 01/01/2024 774.31 0.0 Description: LSO SAG R AN/POS PNL PRE OTS Category: Durable Medical CMS Add: 01/01/2014 CMS Term: L0649 DME DEF MAXFEE 01/01/2014 12/31/2023 230.86 0.0 Description: LSO SC R POS/LAT PNL PRE OTS Category: Durable Medical CMS Add: 01/01/2014 CMS Term: L0649 DME DEF MAXFEE 01/01/2024 216.29 0.0 Description: LSO SC R POS/LAT PNL PRE OTS Category: Durable Medical CMS Add: 01/01/2014 CMS Term: L0650 DME DEF MAXFEE 01/01/2014 12/31/2023 813.40 0.0 Description: LSO SC R ANT/POS PNL PRE OTS Category: Durable Medical CMS Add: 01/01/2014 CMS Term: L0650 DME DEF MAXFEE 01/01/2024 926.80 0.0 Description: LSO SC R ANT/POS PNL PRE OTS Category: Durable Medical CMS Add: 01/01/2014 CMS Term: L0651 DME DEF MAXFEE 01/01/2014 12/31/2023 1042.94 0.0 Description: LSO SAG-CO SHELL PNL PRE OTS Category: Durable Medical CMS Add: 01/01/2014 CMS Term: L0651 DME DEF MAXFEE 01/01/2024 926.80 0.0 Description: LSO SAG-CO SHELL PNL PRE OTS Category: Durable Medical CMS Add: 01/01/2014 CMS Term: L0700 DME DEF MAXFEE 01/01/2014 12/31/2023 1434.90 0.0 Description: CTLSO A-P-L CONTROL MOLDED Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L0700 DME DEF MAXFEE 01/01/2024 2283.02 0.0 Description: CTLSO A-P-L CONTROL MOLDED Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L0710 DME DEF MAXFEE 01/01/2014 12/31/2023 1545.11 0.0 Description: CTLSO A-P-L CONTROL W/ INTER Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L0710 DME DEF MAXFEE 01/01/2024 2509.64 0.0 Description: CTLSO A-P-L CONTROL W/ INTER Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L0810 DME DEF MAXFEE 01/01/2014 12/31/2023 1809.63 0.0 Description: HALO CERVICAL INTO JCKT VEST Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,927 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L0810 DME DEF MAXFEE 01/01/2024 3065.32 0.0 Description: HALO CERVICAL INTO JCKT VEST Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L0820 DME DEF MAXFEE 01/01/2014 12/31/2023 1448.99 0.0 Description: HALO CERVICAL INTO BODY JACK Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L0820 DME DEF MAXFEE 01/01/2024 2411.28 0.0 Description: HALO CERVICAL INTO BODY JACK Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L0830 DME DEF MAXFEE 01/01/2014 12/31/2023 2324.57 0.0 Description: HALO CERV INTO MILWAUKEE TYP Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L0830 DME DEF MAXFEE 01/01/2024 3689.61 0.0 Description: HALO CERV INTO MILWAUKEE TYP Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L0859 DME DEF MAXFEE 01/01/2014 12/31/2023 917.03 0.0 Description: MRI COMPATIBLE SYSTEM Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L0859 DME DEF MAXFEE 01/01/2024 1306.31 0.0 Description: MRI COMPATIBLE SYSTEM Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L0861 DME DEF MAXFEE 01/01/2014 12/31/2023 173.53 0.0 Description: HALO REPL LINER/INTERFACE Category: Durable Medical CMS Add: 01/01/2004 CMS Term: L0861 DME DEF MAXFEE 01/01/2024 247.18 0.0 Description: HALO REPL LINER/INTERFACE Category: Durable Medical CMS Add: 01/01/2004 CMS Term: L0970 DME DEF MAXFEE 01/01/2014 12/31/2023 96.90 0.0 Description: TLSO CORSET FRONT Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L0970 DME DEF MAXFEE 01/01/2024 122.56 0.0 Description: TLSO CORSET FRONT Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L0972 DME DEF MAXFEE 01/01/2014 12/31/2023 89.92 0.0 Description: LSO CORSET FRONT Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L0972 DME DEF MAXFEE 01/01/2024 111.55 0.0 Description: LSO CORSET FRONT Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L0974 DME DEF MAXFEE 01/01/2014 12/31/2023 135.01 0.0 Description: TLSO FULL CORSET Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L0974 DME DEF MAXFEE 01/01/2024 200.41 0.0 Description: TLSO FULL CORSET Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L0976 DME DEF MAXFEE 01/01/2014 12/31/2023 103.88 0.0 Description: LSO FULL CORSET Category: Durable Medical CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,928 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L0976 DME DEF MAXFEE 01/01/2024 171.46 0.0 Description: LSO FULL CORSET Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L0978 DME DEF MAXFEE 01/01/2014 12/31/2023 147.00 0.0 Description: AXILLARY CRUTCH EXTENSION Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L0978 DME DEF MAXFEE 01/01/2024 215.80 0.0 Description: AXILLARY CRUTCH EXTENSION Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L0980 DME DEF MAXFEE 01/01/2014 12/31/2023 12.09 0.0 Description: PERONEAL STRAPS PAIR PRE OTS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L0980 DME DEF MAXFEE 01/01/2024 19.59 0.0 Description: PERONEAL STRAPS PAIR PRE OTS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L0982 DME DEF MAXFEE 01/01/2014 12/31/2023 12.79 0.0 Description: STOCKING SUP GRIPS 4 PRE OTS Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L0982 DME DEF MAXFEE 01/01/2024 17.94 0.0 Description: STOCKING SUP GRIPS 4 PRE OTS Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L0984 DME DEF MAXFEE 01/01/2014 12/31/2023 47.18 0.0 Description: PROTECT BODY SOCK EA PRE OTS Category: Durable Medical CMS Add: 01/01/1994 CMS Term: L0984 DME DEF MAXFEE 01/01/2024 77.60 0.0 Description: PROTECT BODY SOCK EA PRE OTS Category: Durable Medical CMS Add: 01/01/1994 CMS Term: L0999 DME DEF SYSMAN Y Description: ADD TO SPINAL ORTHOSIS NOS Category: Durable Medical CMS Add: 01/01/1998 CMS Term: L1000 DME DEF MAXFEE 01/01/2014 12/31/2023 1405.17 0.0 Description: CTLSO MILWAUKE INITIAL MODEL Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L1000 DME DEF MAXFEE 01/01/2024 2325.46 0.0 Description: CTLSO MILWAUKE INITIAL MODEL Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L1001 DME DEF MAXFEE 01/01/2014 12/31/2023 800.00 0.0 Y Description: CTLSO INFANT IMMOBILIZER Category: Durable Medical CMS Add: 01/01/2007 CMS Term: L1001 DME DEF MAXFEE 01/01/2024 1040.00 0.0 Y Description: CTLSO INFANT IMMOBILIZER Category: Durable Medical CMS Add: 01/01/2007 CMS Term: L1005 DME DEF MAXFEE 01/01/2014 12/31/2023 2276.79 0.0 Description: TENSION BASED SCOLIOSIS ORTH Category: Durable Medical CMS Add: 01/01/2002 CMS Term: L1005 DME DEF MAXFEE 01/01/2024 3670.52 0.0 Description: TENSION BASED SCOLIOSIS ORTH Category: Durable Medical CMS Add: 01/01/2002 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,929 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L1010 DME DEF MAXFEE 01/01/2014 12/31/2023 54.75 0.0 Description: CTLSO AXILLA SLING Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L1010 DME DEF MAXFEE 01/01/2024 95.95 0.0 Description: CTLSO AXILLA SLING Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L1020 DME DEF MAXFEE 01/01/2014 12/31/2023 75.38 0.0 Description: KYPHOSIS PAD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L1020 DME DEF MAXFEE 01/01/2024 123.58 0.0 Description: KYPHOSIS PAD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L1025 DME DEF MAXFEE 01/01/2014 12/31/2023 101.12 0.0 Description: KYPHOSIS PAD FLOATING Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L1025 DME DEF MAXFEE 01/01/2024 178.29 0.0 Description: KYPHOSIS PAD FLOATING Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L1030 DME DEF MAXFEE 01/01/2014 12/31/2023 54.43 0.0 Description: LUMBAR BOLSTER PAD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L1030 DME DEF MAXFEE 01/01/2024 89.80 0.0 Description: LUMBAR BOLSTER PAD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L1040 DME DEF MAXFEE 01/01/2014 12/31/2023 60.90 0.0 Description: LUMBAR OR LUMBAR RIB PAD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L1040 DME DEF MAXFEE 01/01/2024 101.68 0.0 Description: LUMBAR OR LUMBAR RIB PAD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L1050 DME DEF MAXFEE 01/01/2014 12/31/2023 74.15 0.0 Description: STERNAL PAD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L1050 DME DEF MAXFEE 01/01/2024 115.07 0.0 Description: STERNAL PAD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L1060 DME DEF MAXFEE 01/01/2014 12/31/2023 70.67 0.0 Description: THORACIC PAD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L1060 DME DEF MAXFEE 01/01/2024 124.20 0.0 Description: THORACIC PAD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L1070 DME DEF MAXFEE 01/01/2014 12/31/2023 76.40 0.0 Description: TRAPEZIUS SLING Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L1070 DME DEF MAXFEE 01/01/2024 128.66 0.0 Description: TRAPEZIUS SLING Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,930 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L1080 DME DEF MAXFEE 01/01/2014 12/31/2023 35.42 0.0 Description: OUTRIGGER Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L1080 DME DEF MAXFEE 01/01/2024 60.00 0.0 Description: OUTRIGGER Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L1085 DME DEF MAXFEE 01/01/2014 12/31/2023 121.42 0.0 Description: OUTRIGGER BIL W/ VERT EXTENS Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L1085 DME DEF MAXFEE 01/01/2024 200.88 0.0 Description: OUTRIGGER BIL W/ VERT EXTENS Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L1090 DME DEF MAXFEE 01/01/2014 12/31/2023 66.92 0.0 Description: LUMBAR SLING Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L1090 DME DEF MAXFEE 01/01/2024 115.40 0.0 Description: LUMBAR SLING Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L1100 DME DEF MAXFEE 01/01/2014 12/31/2023 137.90 0.0 Description: RING FLANGE PLASTIC/LEATHER Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L1100 DME DEF MAXFEE 01/01/2024 217.79 0.0 Description: RING FLANGE PLASTIC/LEATHER Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L1110 DME DEF MAXFEE 01/01/2014 12/31/2023 214.07 0.0 Description: RING FLANGE PLAS/LEATHER MOL Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L1110 DME DEF MAXFEE 01/01/2024 365.15 0.0 Description: RING FLANGE PLAS/LEATHER MOL Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L1120 DME DEF MAXFEE 01/01/2014 12/31/2023 26.05 0.0 Description: COVERS FOR UPRIGHT EACH Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L1120 DME DEF MAXFEE 01/01/2024 43.62 0.0 Description: COVERS FOR UPRIGHT EACH Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L1200 DME DEF MAXFEE 01/01/2014 12/31/2023 1310.61 0.0 Description: FURNSH INITIAL ORTHOSIS ONLY Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L1200 DME DEF MAXFEE 01/01/2024 2052.23 0.0 Description: FURNSH INITIAL ORTHOSIS ONLY Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L1210 DME DEF MAXFEE 01/01/2014 12/31/2023 180.44 0.0 Description: LATERAL THORACIC EXTENSION Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L1210 DME DEF MAXFEE 01/01/2024 280.58 0.0 Description: LATERAL THORACIC EXTENSION Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,931 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L1220 DME DEF MAXFEE 01/01/2014 12/31/2023 165.32 0.0 Description: ANTERIOR THORACIC EXTENSION Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L1220 DME DEF MAXFEE 01/01/2024 273.10 0.0 Description: ANTERIOR THORACIC EXTENSION Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L1230 DME DEF MAXFEE 01/01/2014 12/31/2023 416.91 0.0 Description: MILWAUKEE TYPE SUPERSTRUCTUR Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L1230 DME DEF MAXFEE 01/01/2024 765.05 0.0 Description: MILWAUKEE TYPE SUPERSTRUCTUR Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L1240 DME DEF MAXFEE 01/01/2014 12/31/2023 61.89 0.0 Description: LUMBAR DEROTATION PAD Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L1240 DME DEF MAXFEE 01/01/2024 104.30 0.0 Description: LUMBAR DEROTATION PAD Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L1250 DME DEF MAXFEE 01/01/2014 12/31/2023 57.74 0.0 Description: ANTERIOR ASIS PAD Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L1250 DME DEF MAXFEE 01/01/2024 90.70 0.0 Description: ANTERIOR ASIS PAD Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L1260 DME DEF MAXFEE 01/01/2014 12/31/2023 65.02 0.0 Description: ANTERIOR THORACIC DEROTATION Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L1260 DME DEF MAXFEE 01/01/2024 108.16 0.0 Description: ANTERIOR THORACIC DEROTATION Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L1270 DME DEF MAXFEE 01/01/2014 12/31/2023 59.09 0.0 Description: ABDOMINAL PAD Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L1270 DME DEF MAXFEE 01/01/2024 95.05 0.0 Description: ABDOMINAL PAD Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L1280 DME DEF MAXFEE 01/01/2014 12/31/2023 55.57 0.0 Description: RIB GUSSET (ELASTIC) EACH Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L1280 DME DEF MAXFEE 01/01/2024 100.20 0.0 Description: RIB GUSSET (ELASTIC) EACH Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L1290 DME DEF MAXFEE 01/01/2014 12/31/2023 57.28 0.0 Description: LATERAL TROCHANTERIC PAD Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L1290 DME DEF MAXFEE 01/01/2024 89.11 0.0 Description: LATERAL TROCHANTERIC PAD Category: Durable Medical CMS Add: 01/01/1988 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,932 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L1300 DME DEF MAXFEE 01/01/2014 12/31/2023 1166.48 0.0 Description: BODY JACKET MOLD TO PATIENT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L1300 DME DEF MAXFEE 01/01/2024 1976.48 0.0 Description: BODY JACKET MOLD TO PATIENT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L1310 DME DEF MAXFEE 01/01/2014 12/31/2023 1180.48 0.0 Description: POST-OPERATIVE BODY JACKET Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L1310 DME DEF MAXFEE 01/01/2024 2058.67 0.0 Description: POST-OPERATIVE BODY JACKET Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L1499 DME DEF SYSMAN Y Description: SPINAL ORTHOSIS NOS Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L1600 DME DEF MAXFEE 01/01/2014 12/31/2023 90.65 0.0 Description: HO FLEX FREJKA W/COV PRE CST Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L1600 DME DEF MAXFEE 01/01/2024 147.78 0.0 Description: HO FLEX FREJKA W/COV PRE CST Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L1610 DME DEF MAXFEE 01/01/2014 12/31/2023 35.15 0.0 Description: HO FREJKA COV ONLY PRE CST Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L1610 DME DEF MAXFEE 01/01/2024 62.77 0.0 Description: HO FREJKA COV ONLY PRE CST Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L1620 DME DEF MAXFEE 01/01/2014 12/31/2023 105.80 0.0 Description: HO FLEX PAVLIK HARNS PRE CST Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L1620 DME DEF MAXFEE 01/01/2024 180.19 0.0 Description: HO FLEX PAVLIK HARNS PRE CST Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L1630 DME DEF MAXFEE 01/01/2014 12/31/2023 148.43 0.0 Description: ABDUCT CONTROL HIP SEMI-FLEX Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L1630 DME DEF MAXFEE 01/01/2024 242.27 0.0 Description: ABDUCT CONTROL HIP SEMI-FLEX Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L1640 DME DEF MAXFEE 01/01/2014 12/31/2023 319.55 0.0 Description: PELV BAND/SPREAD BAR THIGH C Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L1640 DME DEF MAXFEE 01/01/2024 542.89 0.0 Description: PELV BAND/SPREAD BAR THIGH C Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L1650 DME DEF MAXFEE 01/01/2014 12/31/2023 173.02 0.0 Description: HO ABDUCTION HIP ADJUSTABLE Category: Durable Medical CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,933 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L1650 DME DEF MAXFEE 01/01/2024 282.82 0.0 Description: HO ABDUCTION HIP ADJUSTABLE Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L1652 DME DEF MAXFEE 01/01/2014 12/31/2023 256.37 0.0 Description: HO BI THIGHCUFFS W SPRDR BAR Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L1652 DME DEF MAXFEE 01/01/2024 408.80 0.0 Description: HO BI THIGHCUFFS W SPRDR BAR Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L1660 DME DEF MAXFEE 01/01/2014 12/31/2023 145.42 0.0 Description: HO ABDUCTION STATIC PLASTIC Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L1660 DME DEF MAXFEE 01/01/2024 207.24 0.0 Description: HO ABDUCTION STATIC PLASTIC Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L1680 DME DEF MAXFEE 01/01/2014 12/31/2023 846.10 0.0 Description: PELVIC & HIP CONTROL THIGH C Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L1680 DME DEF MAXFEE 01/01/2024 1306.52 0.0 Description: PELVIC & HIP CONTROL THIGH C Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L1681 DME DEF MAXFEE 10/01/2023 2149.16 0.0 Y Description: HO BILATERAL HIP ABDUCTION Category: Durable Medical CMS Add: 10/01/2023 CMS Term: L1685 DME DEF MAXFEE 01/01/2014 12/31/2023 789.80 0.0 Description: POST-OP HIP ABDUCT CUSTOM FA Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L1685 DME DEF MAXFEE 01/01/2024 1275.49 0.0 Description: POST-OP HIP ABDUCT CUSTOM FA Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L1686 DME DEF MAXFEE 01/01/2014 12/31/2023 624.98 0.0 Description: HO POST-OP HIP ABDUCTION Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L1686 DME DEF MAXFEE 01/01/2024 1074.58 0.0 Description: HO POST-OP HIP ABDUCTION Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L1690 DME DEF MAXFEE 01/01/2014 12/31/2023 1375.57 0.0 Description: COMBINATION BILATERAL HO Category: Durable Medical CMS Add: 01/01/1999 CMS Term: L1690 DME DEF MAXFEE 01/01/2024 2217.64 0.0 Description: COMBINATION BILATERAL HO Category: Durable Medical CMS Add: 01/01/1999 CMS Term: L1700 DME DEF MAXFEE 01/01/2014 12/31/2023 1091.96 0.0 Description: LEG PERTHES ORTH TORONTO TYP Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L1700 DME DEF MAXFEE 01/01/2024 1784.23 0.0 Description: LEG PERTHES ORTH TORONTO TYP Category: Durable Medical CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,934 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L1710 DME DEF MAXFEE 01/01/2014 12/31/2023 1265.79 0.0 Description: LEGG PERTHES ORTH NEWINGTON Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L1710 DME DEF MAXFEE 01/01/2024 2272.03 0.0 Description: LEGG PERTHES ORTH NEWINGTON Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L1720 DME DEF MAXFEE 01/01/2014 12/31/2023 1014.10 0.0 Description: LEGG PERTHES ORTHOSIS TRILAT Category: Durable Medical CMS Add: 01/01/1985 CMS Term: L1720 DME DEF MAXFEE 01/01/2024 1691.74 0.0 Description: LEGG PERTHES ORTHOSIS TRILAT Category: Durable Medical CMS Add: 01/01/1985 CMS Term: L1730 DME DEF MAXFEE 01/01/2014 12/31/2023 896.87 0.0 Description: LEGG PERTHES ORTH SCOTTISH R Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L1730 DME DEF MAXFEE 01/01/2024 1428.21 0.0 Description: LEGG PERTHES ORTH SCOTTISH R Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L1755 DME DEF MAXFEE 01/01/2014 12/31/2023 1115.19 0.0 Description: LEGG PERTHES PATTEN BOTTOM T Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L1755 DME DEF MAXFEE 01/01/2024 2053.35 0.0 Description: LEGG PERTHES PATTEN BOTTOM T Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L1810 DME DEF MAXFEE 01/01/2014 12/31/2023 68.68 0.0 Description: KO ELASTIC WITH JOINTS Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L1810 DME DEF MAXFEE 01/01/2024 118.06 0.0 Description: KO ELASTIC WITH JOINTS Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L1812 DME DEF MAXFEE 01/01/2014 12/31/2023 68.68 0.0 Description: KO ELASTIC W/JOINTS PRE OTS Category: Durable Medical CMS Add: 01/01/2014 CMS Term: L1812 DME DEF MAXFEE 01/01/2024 85.18 0.0 Description: KO ELASTIC W/JOINTS PRE OTS Category: Durable Medical CMS Add: 01/01/2014 CMS Term: L1820 DME DEF MAXFEE 01/01/2014 12/31/2023 98.44 0.0 Description: KO ELAS W/ CONDYLE PADS & JO Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L1820 DME DEF MAXFEE 01/01/2024 162.98 0.0 Description: KO ELAS W/ CONDYLE PADS & JO Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L1830 DME DEF MAXFEE 01/01/2014 12/31/2023 57.96 0.0 Description: KO IMMOB CANVAS LONG PRE OTS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L1830 DME DEF MAXFEE 01/01/2024 74.01 0.0 Description: KO IMMOB CANVAS LONG PRE OTS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,935 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L1831 DME DEF MAXFEE 01/01/2014 12/31/2023 236.95 0.0 Description: KNEE ORTH POS LOCKING JOINT Category: Durable Medical CMS Add: 01/01/2004 CMS Term: L1831 DME DEF MAXFEE 01/01/2024 337.52 0.0 Description: KNEE ORTH POS LOCKING JOINT Category: Durable Medical CMS Add: 01/01/2004 CMS Term: L1832 DME DEF MAXFEE 01/01/2014 12/31/2023 408.36 0.0 Description: KO ADJ JNT POS R SUP PRE CST Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L1832 DME DEF MAXFEE 01/01/2024 789.92 0.0 Description: KO ADJ JNT POS R SUP PRE CST Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L1833 DME DEF MAXFEE 01/01/2014 12/31/2023 408.36 0.0 Description: KO ADJ JNT POS R SUP PRE OTS Category: Durable Medical CMS Add: 01/01/2014 CMS Term: L1833 DME DEF MAXFEE 01/01/2024 558.82 0.0 Description: KO ADJ JNT POS R SUP PRE OTS Category: Durable Medical CMS Add: 01/01/2014 CMS Term: L1834 DME DEF MAXFEE 01/01/2014 12/31/2023 501.42 0.0 Description: KO W/0 JOINT RIGID MOLDED TO Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L1834 DME DEF MAXFEE 01/01/2024 832.39 0.0 Description: KO W/0 JOINT RIGID MOLDED TO Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L1836 DME DEF MAXFEE 01/01/2014 12/31/2023 95.96 0.0 Description: KO RIGID W/O JOINTS PRE OTS Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L1836 DME DEF MAXFEE 01/01/2024 109.18 0.0 Description: KO RIGID W/O JOINTS PRE OTS Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L1840 DME DEF MAXFEE 01/01/2014 12/31/2023 605.99 0.0 Description: KO DEROT ANT CRUCIATE CUSTOM Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L1840 DME DEF MAXFEE 01/01/2024 1078.46 0.0 Description: KO DEROT ANT CRUCIATE CUSTOM Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L1843 DME DEF MAXFEE 01/01/2014 12/31/2023 402.46 0.0 Description: KO SINGLE UPRIGHT PRE CST Category: Durable Medical CMS Add: 01/01/1998 CMS Term: L1843 DME DEF MAXFEE 01/01/2024 1029.00 0.0 Description: KO SINGLE UPRIGHT PRE CST Category: Durable Medical CMS Add: 01/01/1998 CMS Term: L1844 DME DEF MAXFEE 01/01/2014 12/31/2023 1134.98 0.0 Description: KO W/ADJ JT ROT CNTRL MOLDED Category: Durable Medical CMS Add: 01/01/1993 CMS Term: L1844 DME DEF MAXFEE 01/01/2024 1746.40 0.0 Description: KO W/ADJ JT ROT CNTRL MOLDED Category: Durable Medical CMS Add: 01/01/1993 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,936 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L1845 DME DEF MAXFEE 01/01/2014 12/31/2023 692.04 0.0 Description: KO DOUBLE UPRIGHT PRE CST Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L1845 DME DEF MAXFEE 01/01/2024 960.65 0.0 Description: KO DOUBLE UPRIGHT PRE CST Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L1846 DME DEF MAXFEE 01/01/2014 12/31/2023 760.16 0.0 Description: KO W ADJ FLEX/EXT ROTAT MOLD Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L1846 DME DEF MAXFEE 01/01/2024 1341.80 0.0 Description: KO W ADJ FLEX/EXT ROTAT MOLD Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L1847 DME DEF MAXFEE 01/01/2014 12/31/2023 409.15 0.0 Description: KO DBL UPRIGHT W/AIR PRE CST Category: Durable Medical CMS Add: 01/01/1999 CMS Term: L1847 DME DEF MAXFEE 01/01/2024 659.61 0.0 Description: KO DBL UPRIGHT W/AIR PRE CST Category: Durable Medical CMS Add: 01/01/1999 CMS Term: L1848 DME DEF MAXFEE 01/01/2014 12/31/2023 409.15 0.0 Description: KO DBL UPRIGHT W/AIR PRE OTS Category: Durable Medical CMS Add: 01/01/2014 CMS Term: L1848 DME DEF MAXFEE 01/01/2024 659.61 0.0 Description: KO DBL UPRIGHT W/AIR PRE OTS Category: Durable Medical CMS Add: 01/01/2014 CMS Term: L1850 DME DEF MAXFEE 01/01/2014 12/31/2023 199.36 0.0 Description: KO SWEDISH TYPE PRE OTS Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L1850 DME DEF MAXFEE 01/01/2024 245.04 0.0 Description: KO SWEDISH TYPE PRE OTS Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L1851 DME DEF MAXFEE 01/01/2017 12/31/2023 861.37 0.0 Description: KO SINGLE UPRIGHT PREFAB OTS Category: Durable Medical CMS Add: 01/01/2017 CMS Term: L1851 DME DEF MAXFEE 01/01/2024 734.18 0.0 Description: KO SINGLE UPRIGHT PREFAB OTS Category: Durable Medical CMS Add: 01/01/2017 CMS Term: L1852 DME DEF MAXFEE 01/01/2017 12/31/2023 804.16 0.0 Description: KO DOUBLE UPRIGHT PREFAB OTS Category: Durable Medical CMS Add: 01/01/2017 CMS Term: L1852 DME DEF MAXFEE 01/01/2024 695.15 0.0 Description: KO DOUBLE UPRIGHT PREFAB OTS Category: Durable Medical CMS Add: 01/01/2017 CMS Term: L1860 DME DEF MAXFEE 01/01/2014 12/31/2023 838.14 0.0 Description: KO SUPRACONDYLAR SOCKET MOLD Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L1860 DME DEF MAXFEE 01/01/2024 1430.05 0.0 Description: KO SUPRACONDYLAR SOCKET MOLD Category: Durable Medical CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,937 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L1900 DME DEF MAXFEE 01/01/2014 12/31/2023 173.37 0.0 Description: AFO SPRNG WIR DRSFLX CALF BD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L1900 DME DEF MAXFEE 01/01/2024 327.19 0.0 Description: AFO SPRNG WIR DRSFLX CALF BD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L1902 DME DEF MAXFEE 01/01/2014 12/31/2023 53.96 0.0 Description: AFO ANKLE GAUNTLET PRE OTS Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L1902 DME DEF MAXFEE 01/01/2024 85.60 0.0 Description: AFO ANKLE GAUNTLET PRE OTS Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L1904 DME DEF MAXFEE 01/01/2014 12/31/2023 301.13 0.0 Description: AFO MOLDED ANKLE GAUNTLET Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L1904 DME DEF MAXFEE 01/01/2024 517.63 0.0 Description: AFO MOLDED ANKLE GAUNTLET Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L1906 DME DEF MAXFEE 01/01/2014 12/31/2023 77.00 0.0 Description: AFO MULTILIG ANK SUP PRE OTS Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L1906 DME DEF MAXFEE 01/01/2024 128.96 0.0 Description: AFO MULTILIG ANK SUP PRE OTS Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L1907 DME DEF MAXFEE 01/01/2014 12/31/2023 453.00 0.0 Description: AFO SUPRAMALLEOLAR CUSTOM Category: Durable Medical CMS Add: 01/01/2004 CMS Term: L1907 DME DEF MAXFEE 01/01/2024 645.32 0.0 Description: AFO SUPRAMALLEOLAR CUSTOM Category: Durable Medical CMS Add: 01/01/2004 CMS Term: L1910 DME DEF MAXFEE 01/01/2014 12/31/2023 208.04 0.0 Description: AFO SING BAR CLASP ATTACH SH Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L1910 DME DEF MAXFEE 01/01/2024 321.61 0.0 Description: AFO SING BAR CLASP ATTACH SH Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L1920 DME DEF MAXFEE 01/01/2014 12/31/2023 296.84 0.0 Description: AFO SING UPRIGHT W/ ADJUST S Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L1920 DME DEF MAXFEE 01/01/2024 471.11 0.0 Description: AFO SING UPRIGHT W/ ADJUST S Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L1930 DME DEF MAXFEE 01/01/2014 12/31/2023 179.18 0.0 Description: AFO PLASTIC Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L1930 DME DEF MAXFEE 01/01/2024 288.91 0.0 Description: AFO PLASTIC Category: Durable Medical CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,938 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L1932 DME DEF MAXFEE 01/01/2014 12/31/2023 641.76 0.0 Description: AFO RIG ANT TIB PREFAB TCF/= Category: Durable Medical CMS Add: 01/01/2005 CMS Term: L1932 DME DEF MAXFEE 01/01/2024 1023.33 0.0 Description: AFO RIG ANT TIB PREFAB TCF/= Category: Durable Medical CMS Add: 01/01/2005 CMS Term: L1940 DME DEF MAXFEE 01/01/2014 12/31/2023 321.82 0.0 Description: AFO MOLDED TO PATIENT PLASTI Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L1940 DME DEF MAXFEE 01/01/2024 558.47 0.0 Description: AFO MOLDED TO PATIENT PLASTI Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L1945 DME DEF MAXFEE 01/01/2014 12/31/2023 727.79 0.0 Description: AFO MOLDED PLAS RIG ANT TIB Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L1945 DME DEF MAXFEE 01/01/2024 1287.27 0.0 Description: AFO MOLDED PLAS RIG ANT TIB Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L1950 DME DEF MAXFEE 01/01/2014 12/31/2023 528.71 0.0 Description: AFO SPIRAL MOLDED TO PT PLAS Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L1950 DME DEF MAXFEE 01/01/2024 881.96 0.0 Description: AFO SPIRAL MOLDED TO PT PLAS Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L1951 DME DEF MAXFEE 01/01/2014 12/31/2023 676.11 0.0 Description: AFO SPIRAL PREFABRICATED Category: Durable Medical CMS Add: 01/01/2004 CMS Term: L1951 DME DEF MAXFEE 01/01/2024 963.09 0.0 Description: AFO SPIRAL PREFABRICATED Category: Durable Medical CMS Add: 01/01/2004 CMS Term: L1960 DME DEF MAXFEE 01/01/2014 12/31/2023 388.58 0.0 Description: AFO POS SOLID ANK PLASTIC MO Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L1960 DME DEF MAXFEE 01/01/2024 710.88 0.0 Description: AFO POS SOLID ANK PLASTIC MO Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L1970 DME DEF MAXFEE 01/01/2014 12/31/2023 464.06 0.0 Description: AFO PLASTIC MOLDED W/ANKLE J Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L1970 DME DEF MAXFEE 01/01/2024 793.74 0.0 Description: AFO PLASTIC MOLDED W/ANKLE J Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L1971 DME DEF MAXFEE 01/01/2014 12/31/2023 377.36 0.0 Description: AFO W/ANKLE JOINT, PREFAB Category: Durable Medical CMS Add: 01/01/2004 CMS Term: L1971 DME DEF MAXFEE 01/01/2024 537.58 0.0 Description: AFO W/ANKLE JOINT, PREFAB Category: Durable Medical CMS Add: 01/01/2004 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,939 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L1980 DME DEF MAXFEE 01/01/2014 12/31/2023 292.75 0.0 Description: AFO SING SOLID STIRRUP CALF Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L1980 DME DEF MAXFEE 01/01/2024 463.04 0.0 Description: AFO SING SOLID STIRRUP CALF Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L1990 DME DEF MAXFEE 01/01/2014 12/31/2023 291.31 0.0 Description: AFO DOUB SOLID STIRRUP CALF Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L1990 DME DEF MAXFEE 01/01/2024 535.91 0.0 Description: AFO DOUB SOLID STIRRUP CALF Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L2000 DME DEF MAXFEE 01/01/2014 12/31/2023 834.44 0.0 Description: KAFO SING FRE STIRR THI/CALF Category: Durable Medical CMS Add: 01/01/1985 CMS Term: L2000 DME DEF MAXFEE 01/01/2024 1282.90 0.0 Description: KAFO SING FRE STIRR THI/CALF Category: Durable Medical CMS Add: 01/01/1985 CMS Term: L2005 DME DEF MAXFEE 01/01/2014 12/31/2023 2588.80 0.0 Description: KAFO SNG/DBL MECHANICAL ACT Category: Durable Medical CMS Add: 01/01/2005 CMS Term: L2005 DME DEF MAXFEE 01/01/2024 4699.29 0.0 Description: KAFO SNG/DBL MECHANICAL ACT Category: Durable Medical CMS Add: 01/01/2005 CMS Term: L2006 DME DEF MAXFEE 01/01/2024 36894.87 0.0 Y Y Description: KAF SNG/DBL SWG/STN MCPR CUS Category: Durable Medical CMS Add: 01/01/2020 CMS Term: L2010 DME DEF MAXFEE 01/01/2014 12/31/2023 655.72 0.0 Description: KAFO SNG SOLID STIRRUP W/O J Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2010 DME DEF MAXFEE 01/01/2024 1000.65 0.0 Description: KAFO SNG SOLID STIRRUP W/O J Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2020 DME DEF MAXFEE 01/01/2014 12/31/2023 754.91 0.0 Description: KAFO DBL SOLID STIRRUP BAND/ Category: Durable Medical CMS Add: 01/01/1985 CMS Term: L2020 DME DEF MAXFEE 01/01/2024 1263.79 0.0 Description: KAFO DBL SOLID STIRRUP BAND/ Category: Durable Medical CMS Add: 01/01/1985 CMS Term: L2030 DME DEF MAXFEE 01/01/2014 12/31/2023 835.23 0.0 Description: KAFO DBL SOLID STIRRUP W/O J Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2030 DME DEF MAXFEE 01/01/2024 1242.20 0.0 Description: KAFO DBL SOLID STIRRUP W/O J Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2034 DME DEF MAXFEE 01/01/2014 12/31/2023 1635.45 0.0 Description: KAFO PLA SIN UP W/WO K/A CUS Category: Durable Medical CMS Add: 01/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,940 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L2034 DME DEF MAXFEE 01/01/2024 2329.70 0.0 Description: KAFO PLA SIN UP W/WO K/A CUS Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L2035 DME DEF MAXFEE 01/01/2014 12/31/2023 129.11 0.0 Description: KAFO PLASTIC PEDIATRIC SIZE Category: Durable Medical CMS Add: 01/01/1998 CMS Term: L2035 DME DEF MAXFEE 01/01/2024 198.68 0.0 Description: KAFO PLASTIC PEDIATRIC SIZE Category: Durable Medical CMS Add: 01/01/1998 CMS Term: L2036 DME DEF MAXFEE 01/01/2014 12/31/2023 1189.17 0.0 Description: KAFO PLAS DOUB FREE KNEE MOL Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2036 DME DEF MAXFEE 01/01/2024 2126.12 0.0 Description: KAFO PLAS DOUB FREE KNEE MOL Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2037 DME DEF MAXFEE 01/01/2014 12/31/2023 1080.10 0.0 Description: KAFO PLAS SING FREE KNEE MOL Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L2037 DME DEF MAXFEE 01/01/2024 1901.78 0.0 Description: KAFO PLAS SING FREE KNEE MOL Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L2038 DME DEF MAXFEE 01/01/2014 12/31/2023 939.78 0.0 Description: KAFO W/O JOINT MULTI-AXIS AN Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L2038 DME DEF MAXFEE 01/01/2024 1533.11 0.0 Description: KAFO W/O JOINT MULTI-AXIS AN Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L2040 DME DEF MAXFEE 01/01/2014 12/31/2023 152.41 0.0 Description: HKAFO TORSION BIL ROT STRAPS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2040 DME DEF MAXFEE 01/01/2024 232.01 0.0 Description: HKAFO TORSION BIL ROT STRAPS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2050 DME DEF MAXFEE 01/01/2014 12/31/2023 366.50 0.0 Description: HKAFO TORSION CABLE HIP PELV Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L2050 DME DEF MAXFEE 01/01/2024 558.85 0.0 Description: HKAFO TORSION CABLE HIP PELV Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L2060 DME DEF MAXFEE 01/01/2014 12/31/2023 462.69 0.0 Description: HKAFO TORSION BALL BEARING J Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L2060 DME DEF MAXFEE 01/01/2024 699.01 0.0 Description: HKAFO TORSION BALL BEARING J Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L2070 DME DEF MAXFEE 01/01/2014 12/31/2023 116.51 0.0 Description: HKAFO TORSION UNILAT ROT STR Category: Durable Medical CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,941 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L2070 DME DEF MAXFEE 01/01/2024 178.00 0.0 Description: HKAFO TORSION UNILAT ROT STR Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L2080 DME DEF MAXFEE 01/01/2014 12/31/2023 277.70 0.0 Description: HKAFO UNILAT TORSION CABLE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2080 DME DEF MAXFEE 01/01/2024 427.97 0.0 Description: HKAFO UNILAT TORSION CABLE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2090 DME DEF MAXFEE 01/01/2014 12/31/2023 351.67 0.0 Description: HKAFO UNILAT TORSION BALL BR Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L2090 DME DEF MAXFEE 01/01/2024 570.22 0.0 Description: HKAFO UNILAT TORSION BALL BR Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L2106 DME DEF MAXFEE 01/01/2014 12/31/2023 458.55 0.0 Description: AFO TIB FX CAST PLASTER MOLD Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2106 DME DEF MAXFEE 01/01/2024 903.93 0.0 Description: AFO TIB FX CAST PLASTER MOLD Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2108 DME DEF MAXFEE 01/01/2014 12/31/2023 771.67 0.0 Description: AFO TIB FX CAST MOLDED TO PT Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2108 DME DEF MAXFEE 01/01/2024 1318.41 0.0 Description: AFO TIB FX CAST MOLDED TO PT Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2112 DME DEF MAXFEE 01/01/2014 12/31/2023 348.71 0.0 Description: AFO TIBIAL FRACTURE SOFT Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2112 DME DEF MAXFEE 01/01/2024 578.57 0.0 Description: AFO TIBIAL FRACTURE SOFT Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2114 DME DEF MAXFEE 01/01/2014 12/31/2023 404.07 0.0 Description: AFO TIB FX SEMI-RIGID Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2114 DME DEF MAXFEE 01/01/2024 724.68 0.0 Description: AFO TIB FX SEMI-RIGID Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2116 DME DEF MAXFEE 01/01/2014 12/31/2023 454.73 0.0 Description: AFO TIBIAL FRACTURE RIGID Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2116 DME DEF MAXFEE 01/01/2024 883.89 0.0 Description: AFO TIBIAL FRACTURE RIGID Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2126 DME DEF MAXFEE 01/01/2014 12/31/2023 834.67 0.0 Description: KAFO FEM FX CAST THERMOPLAS Category: Durable Medical CMS Add: 01/01/1988 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,942 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L2126 DME DEF MAXFEE 01/01/2024 1464.34 0.0 Description: KAFO FEM FX CAST THERMOPLAS Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2128 DME DEF MAXFEE 01/01/2014 12/31/2023 1092.59 0.0 Description: KAFO FEM FX CAST MOLDED TO P Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2128 DME DEF MAXFEE 01/01/2024 1838.72 0.0 Description: KAFO FEM FX CAST MOLDED TO P Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2132 DME DEF MAXFEE 01/01/2014 12/31/2023 698.20 0.0 Description: KAFO FEMORAL FX CAST SOFT Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2132 DME DEF MAXFEE 01/01/2024 1116.07 0.0 Description: KAFO FEMORAL FX CAST SOFT Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2134 DME DEF MAXFEE 01/01/2014 12/31/2023 829.24 0.0 Description: KAFO FEM FX CAST SEMI-RIGID Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2134 DME DEF MAXFEE 01/01/2024 1321.57 0.0 Description: KAFO FEM FX CAST SEMI-RIGID Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2136 DME DEF MAXFEE 01/01/2014 12/31/2023 875.82 0.0 Description: KAFO FEMORAL FX CAST RIGID Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2136 DME DEF MAXFEE 01/01/2024 1446.26 0.0 Description: KAFO FEMORAL FX CAST RIGID Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2180 DME DEF MAXFEE 01/01/2014 12/31/2023 104.06 0.0 Description: PLAS SHOE INSERT W ANK JOINT Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2180 DME DEF MAXFEE 01/01/2024 152.04 0.0 Description: PLAS SHOE INSERT W ANK JOINT Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2182 DME DEF MAXFEE 01/01/2014 12/31/2023 73.18 0.0 Description: DROP LOCK KNEE Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2182 DME DEF MAXFEE 01/01/2024 131.05 0.0 Description: DROP LOCK KNEE Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2184 DME DEF MAXFEE 01/01/2014 12/31/2023 81.86 0.0 Description: LIMITED MOTION KNEE JOINT Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2184 DME DEF MAXFEE 01/01/2024 132.83 0.0 Description: LIMITED MOTION KNEE JOINT Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2186 DME DEF MAXFEE 01/01/2014 12/31/2023 99.54 0.0 Description: ADJ MOTION KNEE JNT LERMAN T Category: Durable Medical CMS Add: 01/01/1988 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,943 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L2186 DME DEF MAXFEE 01/01/2024 176.66 0.0 Description: ADJ MOTION KNEE JNT LERMAN T Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2188 DME DEF MAXFEE 01/01/2014 12/31/2023 191.42 0.0 Description: QUADRILATERAL BRIM Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2188 DME DEF MAXFEE 01/01/2024 321.14 0.0 Description: QUADRILATERAL BRIM Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2190 DME DEF MAXFEE 01/01/2014 12/31/2023 56.30 0.0 Description: WAIST BELT Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2190 DME DEF MAXFEE 01/01/2024 97.82 0.0 Description: WAIST BELT Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2192 DME DEF MAXFEE 01/01/2014 12/31/2023 230.55 0.0 Description: PELVIC BAND & BELT THIGH FLA Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2192 DME DEF MAXFEE 01/01/2024 382.34 0.0 Description: PELVIC BAND & BELT THIGH FLA Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2200 DME DEF MAXFEE 01/01/2014 12/31/2023 31.67 0.0 Description: LIMITED ANKLE MOTION EA JNT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2200 DME DEF MAXFEE 01/01/2024 57.62 0.0 Description: LIMITED ANKLE MOTION EA JNT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2210 DME DEF MAXFEE 01/01/2014 12/31/2023 42.77 0.0 Description: DORSIFLEXION ASSIST EACH JOI Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2210 DME DEF MAXFEE 01/01/2024 72.08 0.0 Description: DORSIFLEXION ASSIST EACH JOI Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2220 DME DEF MAXFEE 01/01/2014 12/31/2023 52.42 0.0 Description: DORSI & PLANTAR FLEX ASS/RES Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2220 DME DEF MAXFEE 01/01/2024 92.79 0.0 Description: DORSI & PLANTAR FLEX ASS/RES Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2230 DME DEF MAXFEE 01/01/2014 12/31/2023 59.65 0.0 Description: SPLIT FLAT CALIPER STIRR & P Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2230 DME DEF MAXFEE 01/01/2024 109.70 0.0 Description: SPLIT FLAT CALIPER STIRR & P Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2232 DME DEF MAXFEE 01/01/2014 12/31/2023 78.20 0.0 Description: ROCKER BOTTOM, CONTACT AFO Category: Durable Medical CMS Add: 01/01/2005 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,944 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L2232 DME DEF MAXFEE 01/01/2024 111.40 0.0 Description: ROCKER BOTTOM, CONTACT AFO Category: Durable Medical CMS Add: 01/01/2005 CMS Term: L2240 DME DEF MAXFEE 01/01/2014 12/31/2023 67.57 0.0 Description: ROUND CALIPER AND PLATE ATTA Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2240 DME DEF MAXFEE 01/01/2024 109.19 0.0 Description: ROUND CALIPER AND PLATE ATTA Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2250 DME DEF MAXFEE 01/01/2014 12/31/2023 273.21 0.0 Description: FOOT PLATE MOLDED STIRRUP AT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2250 DME DEF MAXFEE 01/01/2024 383.06 0.0 Description: FOOT PLATE MOLDED STIRRUP AT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2260 DME DEF MAXFEE 01/01/2014 12/31/2023 127.38 0.0 Description: REINFORCED SOLID STIRRUP Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2260 DME DEF MAXFEE 01/01/2024 214.95 0.0 Description: REINFORCED SOLID STIRRUP Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2265 DME DEF MAXFEE 01/01/2014 12/31/2023 78.57 0.0 Description: LONG TONGUE STIRRUP Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L2265 DME DEF MAXFEE 01/01/2024 154.16 0.0 Description: LONG TONGUE STIRRUP Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L2270 DME DEF MAXFEE 01/01/2014 12/31/2023 42.62 0.0 Description: VARUS/VALGUS STRAP PADDED/LI Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2270 DME DEF MAXFEE 01/01/2024 70.69 0.0 Description: VARUS/VALGUS STRAP PADDED/LI Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2275 DME DEF MAXFEE 01/01/2014 12/31/2023 90.84 0.0 Description: PLASTIC MOD LOW EXT PAD/LINE Category: Durable Medical CMS Add: 01/01/1994 CMS Term: L2275 DME DEF MAXFEE 01/01/2024 149.48 0.0 Description: PLASTIC MOD LOW EXT PAD/LINE Category: Durable Medical CMS Add: 01/01/1994 CMS Term: L2280 DME DEF MAXFEE 01/01/2014 12/31/2023 387.26 0.0 Description: MOLDED INNER BOOT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2280 DME DEF MAXFEE 01/01/2024 647.40 0.0 Description: MOLDED INNER BOOT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2300 DME DEF MAXFEE 01/01/2014 12/31/2023 172.07 0.0 Description: ABDUCTION BAR JOINTED ADJUST Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,945 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L2300 DME DEF MAXFEE 01/01/2024 288.71 0.0 Description: ABDUCTION BAR JOINTED ADJUST Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2310 DME DEF MAXFEE 01/01/2014 12/31/2023 77.71 0.0 Description: ABDUCTION BAR-STRAIGHT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2310 DME DEF MAXFEE 01/01/2024 131.92 0.0 Description: ABDUCTION BAR-STRAIGHT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2320 DME DEF MAXFEE 01/01/2014 12/31/2023 136.31 0.0 Description: NON-MOLDED LACER Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2320 DME DEF MAXFEE 01/01/2024 221.23 0.0 Description: NON-MOLDED LACER Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2330 DME DEF MAXFEE 01/01/2014 12/31/2023 282.49 0.0 Description: LACER MOLDED TO PATIENT MODE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2330 DME DEF MAXFEE 01/01/2024 421.05 0.0 Description: LACER MOLDED TO PATIENT MODE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2335 DME DEF MAXFEE 01/01/2014 12/31/2023 178.91 0.0 Description: ANTERIOR SWING BAND Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2335 DME DEF MAXFEE 01/01/2024 322.37 0.0 Description: ANTERIOR SWING BAND Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2340 DME DEF MAXFEE 01/01/2014 12/31/2023 288.88 0.0 Description: PRE-TIBIAL SHELL MOLDED TO P Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2340 DME DEF MAXFEE 01/01/2024 479.25 0.0 Description: PRE-TIBIAL SHELL MOLDED TO P Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2350 DME DEF MAXFEE 01/01/2014 12/31/2023 581.67 0.0 Description: PROSTHETIC TYPE SOCKET MOLDE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2350 DME DEF MAXFEE 01/01/2024 955.48 0.0 Description: PROSTHETIC TYPE SOCKET MOLDE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2360 DME DEF MAXFEE 01/01/2014 12/31/2023 41.76 0.0 Description: EXTENDED STEEL SHANK Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2360 DME DEF MAXFEE 01/01/2024 59.13 0.0 Description: EXTENDED STEEL SHANK Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2370 DME DEF MAXFEE 01/01/2014 12/31/2023 201.33 0.0 Description: PATTEN BOTTOM Category: Durable Medical CMS Add: 01/01/1988 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,946 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L2370 DME DEF MAXFEE 01/01/2024 367.02 0.0 Description: PATTEN BOTTOM Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2375 DME DEF MAXFEE 01/01/2014 12/31/2023 78.55 0.0 Description: TORSION ANK & HALF SOLID STI Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2375 DME DEF MAXFEE 01/01/2024 141.11 0.0 Description: TORSION ANK & HALF SOLID STI Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2380 DME DEF MAXFEE 01/01/2014 12/31/2023 78.51 0.0 Description: TORSION STRAIGHT KNEE JOINT Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2380 DME DEF MAXFEE 01/01/2024 148.00 0.0 Description: TORSION STRAIGHT KNEE JOINT Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2385 DME DEF MAXFEE 01/01/2014 12/31/2023 92.92 0.0 Description: STRAIGHT KNEE JOINT HEAVY DU Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2385 DME DEF MAXFEE 01/01/2024 168.51 0.0 Description: STRAIGHT KNEE JOINT HEAVY DU Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2387 DME DEF MAXFEE 01/01/2014 12/31/2023 153.69 0.0 Description: ADD LE POLY KNEE CUSTOM KAFO Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L2387 DME DEF MAXFEE 01/01/2024 218.92 0.0 Description: ADD LE POLY KNEE CUSTOM KAFO Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L2390 DME DEF MAXFEE 01/01/2014 12/31/2023 70.93 0.0 Description: OFFSET KNEE JOINT EACH Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2390 DME DEF MAXFEE 01/01/2024 117.38 0.0 Description: OFFSET KNEE JOINT EACH Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2395 DME DEF MAXFEE 01/01/2014 12/31/2023 102.20 0.0 Description: OFFSET KNEE JOINT HEAVY DUTY Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2395 DME DEF MAXFEE 01/01/2024 167.78 0.0 Description: OFFSET KNEE JOINT HEAVY DUTY Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2397 DME DEF MAXFEE 01/01/2014 12/31/2023 83.68 0.0 Description: SUSPENSION SLEEVE LOWER EXT Category: Durable Medical CMS Add: 01/01/1994 CMS Term: L2397 DME DEF MAXFEE 01/01/2024 139.97 0.0 Description: SUSPENSION SLEEVE LOWER EXT Category: Durable Medical CMS Add: 01/01/1994 CMS Term: L2405 DME DEF MAXFEE 01/01/2014 12/31/2023 40.56 0.0 Description: KNEE JOINT DROP LOCK EA JNT Category: Durable Medical CMS Add: 01/01/1988 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,947 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L2405 DME DEF MAXFEE 01/01/2024 99.98 0.0 Description: KNEE JOINT DROP LOCK EA JNT Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2415 DME DEF MAXFEE 01/01/2014 12/31/2023 119.17 0.0 Description: KNEE JOINT CAM LOCK EACH JOI Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2415 DME DEF MAXFEE 01/01/2024 139.32 0.0 Description: KNEE JOINT CAM LOCK EACH JOI Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2425 DME DEF MAXFEE 01/01/2014 12/31/2023 130.77 0.0 Description: KNEE DISC/DIAL LOCK/ADJ FLEX Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2425 DME DEF MAXFEE 01/01/2024 164.40 0.0 Description: KNEE DISC/DIAL LOCK/ADJ FLEX Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2430 DME DEF MAXFEE 01/01/2014 12/31/2023 72.55 0.0 Description: KNEE JNT RATCHET LOCK EA JNT Category: Durable Medical CMS Add: 01/01/1997 CMS Term: L2430 DME DEF MAXFEE 01/01/2024 164.40 0.0 Description: KNEE JNT RATCHET LOCK EA JNT Category: Durable Medical CMS Add: 01/01/1997 CMS Term: L2492 DME DEF MAXFEE 01/01/2014 12/31/2023 65.89 0.0 Description: KNEE LIFT LOOP DROP LOCK RIN Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2492 DME DEF MAXFEE 01/01/2024 134.51 0.0 Description: KNEE LIFT LOOP DROP LOCK RIN Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2500 DME DEF MAXFEE 01/01/2014 12/31/2023 203.68 0.0 Description: THI/GLUT/ISCHIA WGT BEARING Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2500 DME DEF MAXFEE 01/01/2024 358.87 0.0 Description: THI/GLUT/ISCHIA WGT BEARING Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2510 DME DEF MAXFEE 01/01/2014 12/31/2023 476.91 0.0 Description: TH/WGHT BEAR QUAD-LAT BRIM M Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2510 DME DEF MAXFEE 01/01/2024 924.92 0.0 Description: TH/WGHT BEAR QUAD-LAT BRIM M Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2520 DME DEF MAXFEE 01/01/2014 12/31/2023 330.00 0.0 Description: TH/WGHT BEAR QUAD-LAT BRIM C Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2520 DME DEF MAXFEE 01/01/2024 616.42 0.0 Description: TH/WGHT BEAR QUAD-LAT BRIM C Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2525 DME DEF MAXFEE 01/01/2014 12/31/2023 812.15 0.0 Description: TH/WGHT BEAR NAR M-L BRIM MO Category: Durable Medical CMS Add: 01/01/1989 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,948 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L2525 DME DEF MAXFEE 01/01/2024 1307.13 0.0 Description: TH/WGHT BEAR NAR M-L BRIM MO Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L2526 DME DEF MAXFEE 01/01/2014 12/31/2023 456.73 0.0 Description: TH/WGHT BEAR NAR M-L BRIM CU Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L2526 DME DEF MAXFEE 01/01/2024 734.47 0.0 Description: TH/WGHT BEAR NAR M-L BRIM CU Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L2530 DME DEF MAXFEE 01/01/2014 12/31/2023 155.87 0.0 Description: THIGH/WGHT BEAR LACER NON-MO Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2530 DME DEF MAXFEE 01/01/2024 275.03 0.0 Description: THIGH/WGHT BEAR LACER NON-MO Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2540 DME DEF MAXFEE 01/01/2014 12/31/2023 284.56 0.0 Description: THIGH/WGHT BEAR LACER MOLDED Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2540 DME DEF MAXFEE 01/01/2024 520.42 0.0 Description: THIGH/WGHT BEAR LACER MOLDED Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2550 DME DEF MAXFEE 01/01/2014 12/31/2023 233.10 0.0 Description: THIGH/WGHT BEAR HIGH ROLL CU Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2550 DME DEF MAXFEE 01/01/2024 390.20 0.0 Description: THIGH/WGHT BEAR HIGH ROLL CU Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2570 DME DEF MAXFEE 01/01/2014 12/31/2023 307.55 0.0 Description: HIP CLEVIS TYPE 2 POSIT JNT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2570 DME DEF MAXFEE 01/01/2024 510.75 0.0 Description: HIP CLEVIS TYPE 2 POSIT JNT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2580 DME DEF MAXFEE 01/01/2014 12/31/2023 305.67 0.0 Description: PELVIC CONTROL PELVIC SLING Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2580 DME DEF MAXFEE 01/01/2024 497.67 0.0 Description: PELVIC CONTROL PELVIC SLING Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2600 DME DEF MAXFEE 01/01/2014 12/31/2023 160.68 0.0 Description: HIP CLEVIS/THRUST BEARING FR Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2600 DME DEF MAXFEE 01/01/2024 244.60 0.0 Description: HIP CLEVIS/THRUST BEARING FR Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2610 DME DEF MAXFEE 01/01/2014 12/31/2023 179.83 0.0 Description: HIP CLEVIS/THRUST BEARING LO Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,949 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L2610 DME DEF MAXFEE 01/01/2024 270.28 0.0 Description: HIP CLEVIS/THRUST BEARING LO Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2620 DME DEF MAXFEE 01/01/2014 12/31/2023 173.44 0.0 Description: PELVIC CONTROL HIP HEAVY DUT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2620 DME DEF MAXFEE 01/01/2024 286.71 0.0 Description: PELVIC CONTROL HIP HEAVY DUT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2622 DME DEF MAXFEE 01/01/2014 12/31/2023 223.40 0.0 Description: HIP JOINT ADJUSTABLE FLEXION Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2622 DME DEF MAXFEE 01/01/2024 364.92 0.0 Description: HIP JOINT ADJUSTABLE FLEXION Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2624 DME DEF MAXFEE 01/01/2014 12/31/2023 283.49 0.0 Description: HIP ADJ FLEX EXT ABDUCT CONT Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2624 DME DEF MAXFEE 01/01/2024 447.47 0.0 Description: HIP ADJ FLEX EXT ABDUCT CONT Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2627 DME DEF MAXFEE 01/01/2014 12/31/2023 1386.48 0.0 Description: PLASTIC MOLD RECIPRO HIP & C Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L2627 DME DEF MAXFEE 01/01/2024 2451.00 0.0 Description: PLASTIC MOLD RECIPRO HIP & C Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L2628 DME DEF MAXFEE 01/01/2014 12/31/2023 1086.28 0.0 Description: METAL FRAME RECIPRO HIP & CA Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L2628 DME DEF MAXFEE 01/01/2024 1796.53 0.0 Description: METAL FRAME RECIPRO HIP & CA Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L2630 DME DEF MAXFEE 01/01/2014 12/31/2023 163.42 0.0 Description: PELVIC CONTROL BAND & BELT U Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2630 DME DEF MAXFEE 01/01/2024 265.53 0.0 Description: PELVIC CONTROL BAND & BELT U Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2640 DME DEF MAXFEE 01/01/2014 12/31/2023 218.64 0.0 Description: PELVIC CONTROL BAND & BELT B Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2640 DME DEF MAXFEE 01/01/2024 360.35 0.0 Description: PELVIC CONTROL BAND & BELT B Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2650 DME DEF MAXFEE 01/01/2014 12/31/2023 101.29 0.0 Description: PELV & THOR CONTROL GLUTEAL Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,950 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L2650 DME DEF MAXFEE 01/01/2024 158.69 0.0 Description: PELV & THOR CONTROL GLUTEAL Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2660 DME DEF MAXFEE 01/01/2014 12/31/2023 131.88 0.0 Description: THORACIC CONTROL THORACIC BA Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2660 DME DEF MAXFEE 01/01/2024 205.48 0.0 Description: THORACIC CONTROL THORACIC BA Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2670 DME DEF MAXFEE 01/01/2014 12/31/2023 109.66 0.0 Description: THORAC CONT PARASPINAL UPRIG Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2670 DME DEF MAXFEE 01/01/2024 182.91 0.0 Description: THORAC CONT PARASPINAL UPRIG Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2680 DME DEF MAXFEE 01/01/2014 12/31/2023 104.45 0.0 Description: THORAC CONT LAT SUPPORT UPRI Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2680 DME DEF MAXFEE 01/01/2024 167.80 0.0 Description: THORAC CONT LAT SUPPORT UPRI Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2750 DME DEF MAXFEE 01/01/2014 12/31/2023 56.57 0.0 Description: PLATING CHROME/NICKEL PR BAR Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2750 DME DEF MAXFEE 01/01/2024 89.62 0.0 Description: PLATING CHROME/NICKEL PR BAR Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2755 DME DEF MAXFEE 01/01/2014 12/31/2023 96.43 0.0 Description: CARBON GRAPHITE LAMINATION Category: Durable Medical CMS Add: 01/01/1997 CMS Term: L2755 DME DEF MAXFEE 01/01/2024 149.84 0.0 Description: CARBON GRAPHITE LAMINATION Category: Durable Medical CMS Add: 01/01/1997 CMS Term: L2760 DME DEF MAXFEE 01/01/2014 12/31/2023 45.13 0.0 Description: EXTENSION PER EXTENSION PER Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2760 DME DEF MAXFEE 01/01/2024 65.15 0.0 Description: EXTENSION PER EXTENSION PER Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2768 DME DEF MAXFEE 01/01/2014 12/31/2023 92.69 0.0 Description: ORTHO SIDEBAR DISCONNECT Category: Durable Medical CMS Add: 01/01/2002 CMS Term: L2768 DME DEF MAXFEE 01/01/2024 149.41 0.0 Description: ORTHO SIDEBAR DISCONNECT Category: Durable Medical CMS Add: 01/01/2002 CMS Term: L2780 DME DEF MAXFEE 01/01/2014 12/31/2023 43.50 0.0 Description: NON-CORROSIVE FINISH Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,951 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L2780 DME DEF MAXFEE 01/01/2024 72.57 0.0 Description: NON-CORROSIVE FINISH Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L2785 DME DEF MAXFEE 01/01/2014 12/31/2023 20.62 0.0 Description: DROP LOCK RETAINER EACH Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2785 DME DEF MAXFEE 01/01/2024 33.98 0.0 Description: DROP LOCK RETAINER EACH Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2795 DME DEF MAXFEE 01/01/2014 12/31/2023 55.74 0.0 Description: KNEE CONTROL FULL KNEECAP Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2795 DME DEF MAXFEE 01/01/2024 94.05 0.0 Description: KNEE CONTROL FULL KNEECAP Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2800 DME DEF MAXFEE 01/01/2014 12/31/2023 69.88 0.0 Description: KNEE CAP MEDIAL OR LATERAL P Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2800 DME DEF MAXFEE 01/01/2024 115.49 0.0 Description: KNEE CAP MEDIAL OR LATERAL P Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2810 DME DEF MAXFEE 01/01/2014 12/31/2023 54.81 0.0 Description: KNEE CONTROL CONDYLAR PAD Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2810 DME DEF MAXFEE 01/01/2024 93.66 0.0 Description: KNEE CONTROL CONDYLAR PAD Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2820 DME DEF MAXFEE 01/01/2014 12/31/2023 56.32 0.0 Description: SOFT INTERFACE BELOW KNEE SE Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2820 DME DEF MAXFEE 01/01/2024 93.12 0.0 Description: SOFT INTERFACE BELOW KNEE SE Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2830 DME DEF MAXFEE 01/01/2014 12/31/2023 61.70 0.0 Description: SOFT INTERFACE ABOVE KNEE SE Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2830 DME DEF MAXFEE 01/01/2024 100.74 0.0 Description: SOFT INTERFACE ABOVE KNEE SE Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L2840 DME DEF MAXFEE 01/01/2014 12/31/2023 30.13 0.0 Description: TIBIAL LENGTH SOCK FX OR EQU Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L2840 DME DEF MAXFEE 01/01/2024 49.47 0.0 Description: TIBIAL LENGTH SOCK FX OR EQU Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L2850 DME DEF MAXFEE 01/01/2014 12/31/2023 45.78 0.0 Description: FEMORAL LGTH SOCK FX OR EQUA Category: Durable Medical CMS Add: 01/01/1989 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,952 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L2850 DME DEF MAXFEE 01/01/2024 69.37 0.0 Description: FEMORAL LGTH SOCK FX OR EQUA Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L2861 DME DEF MAXFEE 01/01/2010 12/31/2023 262.34 0.0 Description: TORSION MECHANISM KNEE/ANKLE Category: Durable Medical CMS Add: 01/01/2010 CMS Term: L2861 DME DEF MAXFEE 01/01/2024 341.04 0.0 Description: TORSION MECHANISM KNEE/ANKLE Category: Durable Medical CMS Add: 01/01/2010 CMS Term: L2999 DME DEF SYSMAN Y Description: LOWER EXTREMITY ORTHOSIS NOS Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L3000 DME DEF MAXFEE 01/01/2014 12/31/2023 80.00 0.0 Description: FT INSERT UCB BERKELEY SHELL Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L3000 DME DEF MAXFEE 01/01/2024 360.25 0.0 Description: FT INSERT UCB BERKELEY SHELL Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L3001 DME DEF MAXFEE 01/01/2014 12/31/2023 106.49 0.0 Description: FOOT INSERT REMOV MOLDED SPE Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3001 DME DEF MAXFEE 01/01/2024 151.69 0.0 Description: FOOT INSERT REMOV MOLDED SPE Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3002 DME DEF MAXFEE 01/01/2014 12/31/2023 130.03 0.0 Description: FOOT INSERT PLASTAZOTE OR EQ Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3002 DME DEF MAXFEE 01/01/2024 185.21 0.0 Description: FOOT INSERT PLASTAZOTE OR EQ Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3003 DME DEF MAXFEE 01/01/2014 12/31/2023 140.27 0.0 Description: FOOT INSERT SILICONE GEL EAC Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3003 DME DEF MAXFEE 01/01/2024 199.80 0.0 Description: FOOT INSERT SILICONE GEL EAC Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3010 DME DEF MAXFEE 01/01/2014 12/31/2023 80.00 0.0 Description: FOOT LONGITUDINAL ARCH SUPPO Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L3010 DME DEF MAXFEE 01/01/2024 199.80 0.0 Description: FOOT LONGITUDINAL ARCH SUPPO Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L3020 DME DEF MAXFEE 01/01/2014 12/31/2023 80.00 0.0 Description: FOOT LONGITUD/METATARSAL SUP Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3020 DME DEF MAXFEE 01/01/2024 227.53 0.0 Description: FOOT LONGITUD/METATARSAL SUP Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,953 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L3030 DME DEF MAXFEE 01/01/2014 12/31/2023 35.00 0.0 Description: FOOT ARCH SUPPORT REMOV PREM Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3030 DME DEF MAXFEE 01/01/2024 87.50 0.0 Description: FOOT ARCH SUPPORT REMOV PREM Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3031 DME DEF MAXFEE 01/01/2024 140.45 0.0 Description: FOOT LAMIN/PREPREG COMPOSITE Category: Durable Medical CMS Add: 01/01/2004 CMS Term: L3031 DME DEF MAXFEE 07/01/2014 12/31/2023 115.50 0.0 Description: FOOT LAMIN/PREPREG COMPOSITE Category: Durable Medical CMS Add: 01/01/2004 CMS Term: L3040 DME DEF MAXFEE 01/01/2014 12/31/2023 22.00 0.0 Description: FT ARCH SUPRT PREMOLD LONGIT Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L3040 DME DEF MAXFEE 01/01/2024 53.98 0.0 Description: FT ARCH SUPRT PREMOLD LONGIT Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L3050 DME DEF MAXFEE 01/01/2014 12/31/2023 25.00 0.0 Description: FOOT ARCH SUPP PREMOLD METAT Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L3050 DME DEF MAXFEE 01/01/2024 53.98 0.0 Description: FOOT ARCH SUPP PREMOLD METAT Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L3060 DME DEF MAXFEE 01/01/2014 12/31/2023 22.00 0.0 Description: FOOT ARCH SUPP LONGITUD/META Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L3060 DME DEF MAXFEE 01/01/2024 84.59 0.0 Description: FOOT ARCH SUPP LONGITUD/META Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L3070 DME DEF MAXFEE 01/01/2014 12/31/2023 6.50 0.0 Description: ARCH SUPRT ATT TO SHO LONGIT Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3070 DME DEF MAXFEE 01/01/2024 36.46 0.0 Description: ARCH SUPRT ATT TO SHO LONGIT Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3080 DME DEF MAXFEE 01/01/2014 12/31/2023 6.50 0.0 Description: ARCH SUPP ATT TO SHOE METATA Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3080 DME DEF MAXFEE 01/01/2024 36.46 0.0 Description: ARCH SUPP ATT TO SHOE METATA Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3090 DME DEF MAXFEE 01/01/2014 12/31/2023 9.50 0.0 Description: ARCH SUPP ATT TO SHOE LONG/M Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3090 DME DEF MAXFEE 01/01/2024 46.68 0.0 Description: ARCH SUPP ATT TO SHOE LONG/M Category: Durable Medical CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,954 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L3100 DME DEF MAXFEE 01/01/2014 12/31/2023 30.00 0.0 Description: HALLUS-VALGUS NT DYN PRE OTS Category: Durable Medical CMS Add: 01/01/1985 CMS Term: L3100 DME DEF MAXFEE 01/01/2024 49.61 0.0 Description: HALLUS-VALGUS NT DYN PRE OTS Category: Durable Medical CMS Add: 01/01/1985 CMS Term: L3140 DME DEF MAXFEE 01/01/2014 12/31/2023 75.00 0.0 Description: ABDUCTION ROTATION BAR SHOE Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L3140 DME DEF MAXFEE 01/01/2024 102.10 0.0 Description: ABDUCTION ROTATION BAR SHOE Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L3150 DME DEF MAXFEE 01/01/2014 12/31/2023 75.00 0.0 Description: ABDUCT ROTATION BAR W/O SHOE Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3150 DME DEF MAXFEE 01/01/2024 93.36 0.0 Description: ABDUCT ROTATION BAR W/O SHOE Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3160 DME DEF SYSMAN Y Description: SHOE STYLED POSITIONING DEV Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3161 DME DEF SYSMAN Y Y Description: FOOT, ADDUCTUS POSITION, ADJ Category: Durable Medical CMS Add: 01/01/2024 CMS Term: L3170 DME DEF MAXFEE 01/01/2014 12/31/2023 75.00 0.0 Description: FOOT PLAS HEEL STABI PRE OTS Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3170 DME DEF MAXFEE 01/01/2024 58.33 0.0 Description: FOOT PLAS HEEL STABI PRE OTS Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3201 DME DEF MAXFEE 01/01/2024 45.67 0.0 Description: OXFORD W SUPINAT/PRONAT INF Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3201 DME DEF MAXFEE 12/15/2012 12/31/2023 35.13 0.0 Description: OXFORD W SUPINAT/PRONAT INF Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3202 DME DEF SYSMAN Y Description: OXFORD W/ SUPINAT/PRONATOR C Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3203 DME DEF SYSMAN Y Description: OXFORD W/ SUPINATOR/PRONATOR Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3204 DME DEF SYSMAN Y Description: HIGHTOP W/ SUPP/PRONATOR INF Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3206 DME DEF SYSMAN Y Description: HIGHTOP W/ SUPP/PRONATOR CHI Category: Durable Medical CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,955 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L3207 DME DEF SYSMAN Y Description: HIGHTOP W/ SUPP/PRONATOR JUN Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3208 DME DEF SYSMAN Y Description: SURGICAL BOOT EACH INFANT Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3209 DME DEF SYSMAN Y Description: SURGICAL BOOT EACH CHILD Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3211 DME DEF SYSMAN Y Description: SURGICAL BOOT EACH JUNIOR Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3212 DME DEF SYSMAN Y Description: BENESCH BOOT PAIR INFANT Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3213 DME DEF SYSMAN Y Description: BENESCH BOOT PAIR CHILD Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3214 DME DEF SYSMAN Y Description: BENESCH BOOT PAIR JUNIOR Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3215 DME DEF MAXFEE 01/01/2014 12/31/2023 87.00 0.0 Y Description: ORTHOPEDIC FTWEAR LADIES OXF Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3215 DME DEF MAXFEE 01/01/2024 113.10 0.0 Y Description: ORTHOPEDIC FTWEAR LADIES OXF Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3216 DME DEF MAXFEE 01/01/2024 49.17 0.0 Y Description: ORTHOPED LADIES SHOES DPTH I Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3216 DME DEF MAXFEE 07/01/2014 12/31/2023 37.82 0.0 Y Description: ORTHOPED LADIES SHOES DPTH I Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3217 DME DEF SYSMAN Y Y Description: LADIES SHOES HIGHTOP DEPTH I Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3219 DME DEF MAXFEE 01/01/2014 12/31/2023 92.56 0.0 Y Description: ORTHOPEDIC MENS SHOES OXFORD Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3219 DME DEF MAXFEE 01/01/2024 120.33 0.0 Y Description: ORTHOPEDIC MENS SHOES OXFORD Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3221 DME DEF MAXFEE 01/01/2024 65.27 0.0 Y Description: ORTHOPEDIC MENS SHOES DPTH I Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3221 DME DEF MAXFEE 07/01/2014 12/31/2023 50.21 0.0 Y Description: ORTHOPEDIC MENS SHOES DPTH I Category: Durable Medical CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,956 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L3222 DME DEF MAXFEE 01/01/2024 92.48 0.0 Y Description: MENS SHOES HIGHTOP DEPTH INL Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3222 DME DEF MAXFEE 07/01/2014 12/31/2023 71.14 0.0 Y Description: MENS SHOES HIGHTOP DEPTH INL Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3224 DME DEF MAXFEE 01/01/2014 12/31/2023 47.10 0.0 Description: WOMAN'S SHOE OXFORD BRACE Category: Durable Medical CMS Add: 01/01/1995 CMS Term: L3224 DME DEF MAXFEE 01/01/2024 77.49 0.0 Description: WOMAN'S SHOE OXFORD BRACE Category: Durable Medical CMS Add: 01/01/1995 CMS Term: L3225 DME DEF MAXFEE 01/01/2014 12/31/2023 51.44 0.0 Description: MAN'S SHOE OXFORD BRACE Category: Durable Medical CMS Add: 01/01/1995 CMS Term: L3225 DME DEF MAXFEE 01/01/2024 84.64 0.0 Description: MAN'S SHOE OXFORD BRACE Category: Durable Medical CMS Add: 01/01/1995 CMS Term: L3230 DME DEF MAXFEE 01/01/2014 12/31/2023 130.00 0.0 Description: CUSTOM SHOES DEPTH INLAY Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3230 DME DEF MAXFEE 01/01/2024 169.00 0.0 Description: CUSTOM SHOES DEPTH INLAY Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3250 DME DEF MAXFEE 01/01/2014 12/31/2023 335.00 0.0 Y Description: CUSTOM MOLD SHOE REMOV PROST Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3250 DME DEF MAXFEE 01/01/2024 435.50 0.0 Y Description: CUSTOM MOLD SHOE REMOV PROST Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3251 DME DEF SYSMAN Y Y Description: SHOE MOLDED TO PT SILICONE S Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3252 DME DEF SYSMAN Y Y Description: SHOE MOLDED PLASTAZOTE CUST Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3253 DME DEF SYSMAN Y Description: SHOE MOLDED PLASTAZOTE CUST Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3254 DME DEF SYSMAN Y Description: ORTH FOOT NON-STNDARD SIZE/W Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3255 DME DEF SYSMAN Y Description: ORTH FOOT NON-STANDARD SIZE/ Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3257 DME DEF SYSMAN Y Description: ORTH FOOT ADD CHARGE SPLIT S Category: Durable Medical CMS Add: 01/01/1988 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,957 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L3260 DME DEF SYSMAN Y Description: AMBULATORY SURGICAL BOOT EAC Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3265 DME DEF SYSMAN Y Description: PLASTAZOTE SANDAL EACH Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3300 DME DEF MAXFEE 01/01/2014 12/31/2023 17.00 0.0 Description: SHO LIFT TAPER TO METATARSAL Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3300 DME DEF MAXFEE 01/01/2024 59.81 0.0 Description: SHO LIFT TAPER TO METATARSAL Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3310 DME DEF MAXFEE 01/01/2014 12/31/2023 28.00 0.0 Description: SHOE LIFT ELEV HEEL/SOLE NEO Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3310 DME DEF MAXFEE 01/01/2024 93.36 0.0 Description: SHOE LIFT ELEV HEEL/SOLE NEO Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3320 DME DEF MAXFEE 01/01/2014 12/31/2023 50.00 0.0 Description: SHOE LIFT ELEV HEEL/SOLE COR Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3320 DME DEF MAXFEE 01/01/2024 65.00 0.0 Description: SHOE LIFT ELEV HEEL/SOLE COR Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3330 DME DEF MAXFEE 01/01/2014 12/31/2023 20.00 0.0 Description: LIFTS ELEVATION METAL EXTENS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3330 DME DEF MAXFEE 01/01/2024 649.02 0.0 Description: LIFTS ELEVATION METAL EXTENS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3332 DME DEF MAXFEE 01/01/2014 12/31/2023 6.00 0.0 Description: SHOE LIFTS TAPERED TO ONE-HA Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3332 DME DEF MAXFEE 01/01/2024 84.59 0.0 Description: SHOE LIFTS TAPERED TO ONE-HA Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3334 DME DEF MAXFEE 01/01/2014 12/31/2023 10.00 0.0 Description: SHOE LIFTS ELEVATION HEEL /I Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3334 DME DEF MAXFEE 01/01/2024 43.73 0.0 Description: SHOE LIFTS ELEVATION HEEL /I Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3340 DME DEF MAXFEE 01/01/2014 12/31/2023 12.00 0.0 Description: SHOE WEDGE SACH Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L3340 DME DEF MAXFEE 01/01/2024 97.74 0.0 Description: SHOE WEDGE SACH Category: Durable Medical CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,958 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L3350 DME DEF MAXFEE 01/01/2014 12/31/2023 7.00 0.0 Description: SHOE HEEL WEDGE Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L3350 DME DEF MAXFEE 01/01/2024 26.23 0.0 Description: SHOE HEEL WEDGE Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L3360 DME DEF MAXFEE 01/01/2014 12/31/2023 7.00 0.0 Description: SHOE SOLE WEDGE OUTSIDE SOLE Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3360 DME DEF MAXFEE 01/01/2024 40.83 0.0 Description: SHOE SOLE WEDGE OUTSIDE SOLE Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3370 DME DEF MAXFEE 01/01/2014 12/31/2023 8.00 0.0 Description: SHOE SOLE WEDGE BETWEEN SOLE Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3370 DME DEF MAXFEE 01/01/2024 56.88 0.0 Description: SHOE SOLE WEDGE BETWEEN SOLE Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3380 DME DEF MAXFEE 01/01/2014 12/31/2023 10.00 0.0 Description: SHOE CLUBFOOT WEDGE Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L3380 DME DEF MAXFEE 01/01/2024 56.88 0.0 Description: SHOE CLUBFOOT WEDGE Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L3390 DME DEF MAXFEE 01/01/2014 12/31/2023 8.00 0.0 Description: SHOE OUTFLARE WEDGE Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L3390 DME DEF MAXFEE 01/01/2024 56.88 0.0 Description: SHOE OUTFLARE WEDGE Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L3400 DME DEF MAXFEE 01/01/2014 12/31/2023 15.00 0.0 Description: SHOE METATARSAL BAR WEDGE RO Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3400 DME DEF MAXFEE 01/01/2024 46.68 0.0 Description: SHOE METATARSAL BAR WEDGE RO Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3410 DME DEF MAXFEE 01/01/2014 12/31/2023 20.00 0.0 Description: SHOE METATARSAL BAR BETWEEN Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3410 DME DEF MAXFEE 01/01/2024 106.46 0.0 Description: SHOE METATARSAL BAR BETWEEN Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3420 DME DEF MAXFEE 01/01/2014 12/31/2023 11.00 0.0 Description: FULL SOLE/HEEL WEDGE BTWEEN Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3420 DME DEF MAXFEE 01/01/2024 62.72 0.0 Description: FULL SOLE/HEEL WEDGE BTWEEN Category: Durable Medical CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,959 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L3430 DME DEF MAXFEE 01/01/2014 12/31/2023 17.00 0.0 Description: SHO HEEL COUNT PLAST REINFOR Category: Durable Medical CMS Add: 01/01/1985 CMS Term: L3430 DME DEF MAXFEE 01/01/2024 183.77 0.0 Description: SHO HEEL COUNT PLAST REINFOR Category: Durable Medical CMS Add: 01/01/1985 CMS Term: L3440 DME DEF MAXFEE 01/01/2014 12/31/2023 17.00 0.0 Description: HEEL LEATHER REINFORCED Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3440 DME DEF MAXFEE 01/01/2024 87.50 0.0 Description: HEEL LEATHER REINFORCED Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3450 DME DEF MAXFEE 01/01/2014 12/31/2023 20.00 0.0 Description: SHOE HEEL SACH CUSHION TYPE Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3450 DME DEF MAXFEE 01/01/2024 121.02 0.0 Description: SHOE HEEL SACH CUSHION TYPE Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3455 DME DEF MAXFEE 01/01/2014 12/31/2023 8.00 0.0 Description: SHOE HEEL NEW LEATHER STANDA Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3455 DME DEF MAXFEE 01/01/2024 46.68 0.0 Description: SHOE HEEL NEW LEATHER STANDA Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3460 DME DEF MAXFEE 01/01/2014 12/31/2023 7.00 0.0 Description: SHOE HEEL NEW RUBBER STANDAR Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3460 DME DEF MAXFEE 01/01/2024 39.40 0.0 Description: SHOE HEEL NEW RUBBER STANDAR Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3465 DME DEF MAXFEE 01/01/2014 12/31/2023 10.00 0.0 Description: SHOE HEEL THOMAS WITH WEDGE Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3465 DME DEF MAXFEE 01/01/2024 67.13 0.0 Description: SHOE HEEL THOMAS WITH WEDGE Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3470 DME DEF MAXFEE 01/01/2014 12/31/2023 15.00 0.0 Description: SHOE HEEL THOMAS EXTEND TO B Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3470 DME DEF MAXFEE 01/01/2024 71.45 0.0 Description: SHOE HEEL THOMAS EXTEND TO B Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3480 DME DEF MAXFEE 01/01/2014 12/31/2023 15.00 0.0 Description: SHOE HEEL PAD & DEPRESS FOR Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3480 DME DEF MAXFEE 01/01/2024 71.45 0.0 Description: SHOE HEEL PAD & DEPRESS FOR Category: Durable Medical CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,960 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L3485 DME DEF SYSMAN Y Description: SHOE HEEL PAD REMOVABLE FOR Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3500 DME DEF MAXFEE 01/01/2014 12/31/2023 24.00 0.0 Description: ORTHO SHOE ADD LEATHER INSOL Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3500 DME DEF MAXFEE 01/01/2024 33.53 0.0 Description: ORTHO SHOE ADD LEATHER INSOL Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3510 DME DEF MAXFEE 01/01/2014 12/31/2023 24.00 0.0 Y Description: ORTHOPEDIC SHOE ADD RUB INSL Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3510 DME DEF MAXFEE 01/01/2024 33.53 0.0 Y Description: ORTHOPEDIC SHOE ADD RUB INSL Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3520 DME DEF MAXFEE 01/01/2014 12/31/2023 24.00 0.0 Description: O SHOE ADD FELT W LEATH INSL Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3520 DME DEF MAXFEE 01/01/2024 36.46 0.0 Description: O SHOE ADD FELT W LEATH INSL Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3530 DME DEF MAXFEE 01/01/2014 12/31/2023 12.00 0.0 Description: ORTHO SHOE ADD HALF SOLE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3530 DME DEF MAXFEE 01/01/2024 36.46 0.0 Description: ORTHO SHOE ADD HALF SOLE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3540 DME DEF MAXFEE 01/01/2014 12/31/2023 15.00 0.0 Description: ORTHO SHOE ADD FULL SOLE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3540 DME DEF MAXFEE 01/01/2024 58.33 0.0 Description: ORTHO SHOE ADD FULL SOLE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3550 DME DEF MAXFEE 01/01/2014 12/31/2023 10.50 0.0 Description: O SHOE ADD STANDARD TOE TAP Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3550 DME DEF MAXFEE 01/01/2024 10.25 0.0 Description: O SHOE ADD STANDARD TOE TAP Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3560 DME DEF MAXFEE 01/01/2014 12/31/2023 10.50 0.0 Description: O SHOE ADD HORSESHOE TOE TAP Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3560 DME DEF MAXFEE 01/01/2024 26.23 0.0 Description: O SHOE ADD HORSESHOE TOE TAP Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3570 DME DEF MAXFEE 01/01/2014 12/31/2023 10.00 0.0 Description: O SHOE ADD INSTEP EXTENSION Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,961 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L3570 DME DEF MAXFEE 01/01/2024 97.74 0.0 Description: O SHOE ADD INSTEP EXTENSION Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3580 DME DEF MAXFEE 01/01/2014 12/31/2023 15.00 0.0 Description: O SHOE ADD INSTEP VELCRO CLO Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3580 DME DEF MAXFEE 01/01/2024 74.38 0.0 Description: O SHOE ADD INSTEP VELCRO CLO Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3590 DME DEF MAXFEE 01/01/2014 12/31/2023 8.00 0.0 Description: O SHOE CONVERT TO SOF COUNTE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3590 DME DEF MAXFEE 01/01/2024 61.27 0.0 Description: O SHOE CONVERT TO SOF COUNTE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3595 DME DEF MAXFEE 01/01/2014 12/31/2023 10.00 0.0 Description: ORTHO SHOE ADD MARCH BAR Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3595 DME DEF MAXFEE 01/01/2024 48.10 0.0 Description: ORTHO SHOE ADD MARCH BAR Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3600 DME DEF MAXFEE 01/01/2014 12/31/2023 20.00 0.0 Description: TRANS SHOE CALIP PLATE EXIST Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3600 DME DEF MAXFEE 01/01/2024 87.50 0.0 Description: TRANS SHOE CALIP PLATE EXIST Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3610 DME DEF MAXFEE 01/01/2014 12/31/2023 43.00 0.0 Description: TRANS SHOE CALIPER PLATE NEW Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3610 DME DEF MAXFEE 01/01/2024 115.22 0.0 Description: TRANS SHOE CALIPER PLATE NEW Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3620 DME DEF MAXFEE 01/01/2014 12/31/2023 20.00 0.0 Description: TRANS SHOE SOLID STIRRUP EXI Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3620 DME DEF MAXFEE 01/01/2024 87.50 0.0 Description: TRANS SHOE SOLID STIRRUP EXI Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3630 DME DEF MAXFEE 01/01/2014 12/31/2023 32.00 0.0 Description: TRANS SHOE SOLID STIRRUP NEW Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3630 DME DEF MAXFEE 01/01/2024 115.22 0.0 Description: TRANS SHOE SOLID STIRRUP NEW Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3640 DME DEF MAXFEE 01/01/2014 12/31/2023 15.00 0.0 Description: SHOE DENNIS BROWNE SPLINT BO Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,962 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L3640 DME DEF MAXFEE 01/01/2024 49.61 0.0 Description: SHOE DENNIS BROWNE SPLINT BO Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3649 DME DEF SYSMAN Y Y Description: ORTHOPEDIC SHOE MODIFICA NOS Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L3650 DME DEF MAXFEE 01/01/2014 12/31/2023 45.19 0.0 Description: SO 8 ABD RESTRAINT PRE OTS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3650 DME DEF MAXFEE 01/01/2024 75.21 0.0 Description: SO 8 ABD RESTRAINT PRE OTS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3660 DME DEF MAXFEE 01/01/2014 12/31/2023 68.68 0.0 Description: SO 8 AB RSTR CAN/WEB PRE OTS Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L3660 DME DEF MAXFEE 01/01/2024 107.85 0.0 Description: SO 8 AB RSTR CAN/WEB PRE OTS Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L3670 DME DEF MAXFEE 01/01/2014 12/31/2023 75.99 0.0 Description: SO ACRO/CLAV CAN WEB PRE OTS Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L3670 DME DEF MAXFEE 01/01/2024 118.65 0.0 Description: SO ACRO/CLAV CAN WEB PRE OTS Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L3671 DME DEF MAXFEE 01/01/2014 12/31/2023 660.16 0.0 Description: SO CAP DESIGN W/O JNTS CF Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L3671 DME DEF MAXFEE 01/01/2024 940.42 0.0 Description: SO CAP DESIGN W/O JNTS CF Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L3674 DME DEF MAXFEE 01/01/2014 12/31/2023 973.09 0.0 Description: SO AIRPLANE W/WO JOINT CF Category: Durable Medical CMS Add: 01/01/2011 CMS Term: L3674 DME DEF MAXFEE 01/01/2024 1233.68 0.0 Description: SO AIRPLANE W/WO JOINT CF Category: Durable Medical CMS Add: 01/01/2011 CMS Term: L3675 DME DEF MAXFEE 01/01/2014 12/31/2023 113.61 0.0 Description: SO VEST CANVAS/WEB PRE OTS Category: Durable Medical CMS Add: 01/01/1999 CMS Term: L3675 DME DEF MAXFEE 01/01/2024 183.19 0.0 Description: SO VEST CANVAS/WEB PRE OTS Category: Durable Medical CMS Add: 01/01/1999 CMS Term: L3677 DME DEF SYSMAN Y Description: SO HARD PLAS STABILI PRE CST Category: Durable Medical CMS Add: 01/01/2002 CMS Term: L3678 DME DEF SYSMAN Y Description: SO HARD PLAS STABILI PRE OTS Category: Durable Medical CMS Add: 01/01/2014 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,963 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L3702 DME DEF MAXFEE 01/01/2014 12/31/2023 211.56 0.0 Description: EO W/O JOINTS CF Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L3702 DME DEF MAXFEE 01/01/2024 301.38 0.0 Description: EO W/O JOINTS CF Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L3710 DME DEF MAXFEE 01/01/2014 12/31/2023 78.89 0.0 Description: EO ELAS W/METAL JNTS PRE OTS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3710 DME DEF MAXFEE 01/01/2024 149.03 0.0 Description: EO ELAS W/METAL JNTS PRE OTS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3720 DME DEF MAXFEE 01/01/2014 12/31/2023 459.11 0.0 Description: FOREARM/ARM CUFFS FREE MOTIO Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3720 DME DEF MAXFEE 01/01/2024 713.14 0.0 Description: FOREARM/ARM CUFFS FREE MOTIO Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3730 DME DEF MAXFEE 01/01/2014 12/31/2023 574.61 0.0 Description: FOREARM/ARM CUFFS EXT/FLEX A Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L3730 DME DEF MAXFEE 01/01/2024 945.89 0.0 Description: FOREARM/ARM CUFFS EXT/FLEX A Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L3740 DME DEF MAXFEE 01/01/2014 12/31/2023 676.38 0.0 Description: CUFFS ADJ LOCK W/ ACTIVE CON Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L3740 DME DEF MAXFEE 01/01/2024 1121.44 0.0 Description: CUFFS ADJ LOCK W/ ACTIVE CON Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L3760 DME DEF MAXFEE 01/01/2014 12/31/2023 326.64 0.0 Description: EO ADJ JT PREFAB CUSTOM FIT Category: Durable Medical CMS Add: 01/01/2001 CMS Term: L3760 DME DEF MAXFEE 01/01/2024 521.97 0.0 Description: EO ADJ JT PREFAB CUSTOM FIT Category: Durable Medical CMS Add: 01/01/2001 CMS Term: L3761 DME DEF MAXFEE 01/01/2018 12/31/2023 441.75 0.0 Description: EO, ADJ LOCK JOINT PREFAB OT Category: Durable Medical CMS Add: 01/01/2018 CMS Term: L3761 DME DEF MAXFEE 01/01/2024 521.97 0.0 Description: EO, ADJ LOCK JOINT PREFAB OT Category: Durable Medical CMS Add: 01/01/2018 CMS Term: L3762 DME DEF MAXFEE 01/01/2014 12/31/2023 70.38 0.0 Description: EO RIGID W/O JOINTS PRE OTS Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L3762 DME DEF MAXFEE 01/01/2024 112.21 0.0 Description: EO RIGID W/O JOINTS PRE OTS Category: Durable Medical CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,964 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L3763 DME DEF MAXFEE 01/01/2014 12/31/2023 939.46 0.0 Description: EWHO RIGID W/O JNTS CF Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L3763 DME DEF MAXFEE 01/01/2024 781.04 0.0 Description: EWHO RIGID W/O JNTS CF Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L3764 DME DEF MAXFEE 01/01/2014 12/31/2023 994.82 0.0 Description: EWHO W/JOINT(S) CF Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L3764 DME DEF MAXFEE 01/01/2024 817.38 0.0 Description: EWHO W/JOINT(S) CF Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L3765 DME DEF MAXFEE 01/01/2014 12/31/2023 939.46 0.0 Description: EWHFO RIGID W/O JNTS CF Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L3765 DME DEF MAXFEE 01/01/2024 1338.28 0.0 Description: EWHFO RIGID W/O JNTS CF Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L3766 DME DEF MAXFEE 01/01/2014 12/31/2023 994.82 0.0 Description: EWHFO W/JOINT(S) CF Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L3766 DME DEF MAXFEE 01/01/2024 1417.15 0.0 Description: EWHFO W/JOINT(S) CF Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L3806 DME DEF MAXFEE 01/01/2014 12/31/2023 310.09 0.0 Description: WHFO W/JOINT(S) CUSTOM FAB Category: Durable Medical CMS Add: 01/01/2007 CMS Term: L3806 DME DEF MAXFEE 01/01/2024 474.07 0.0 Description: WHFO W/JOINT(S) CUSTOM FAB Category: Durable Medical CMS Add: 01/01/2007 CMS Term: L3807 DME DEF MAXFEE 01/01/2014 12/31/2023 161.88 0.0 Description: WHFO W/O JOINTS PRE CST Category: Durable Medical CMS Add: 01/01/2000 CMS Term: L3807 DME DEF MAXFEE 01/01/2024 260.97 0.0 Description: WHFO W/O JOINTS PRE CST Category: Durable Medical CMS Add: 01/01/2000 CMS Term: L3808 DME DEF MAXFEE 01/01/2014 12/31/2023 192.66 0.0 Description: WHFO, RIGID W/O JOINTS Category: Durable Medical CMS Add: 01/01/2007 CMS Term: L3808 DME DEF MAXFEE 01/01/2024 371.79 0.0 Description: WHFO, RIGID W/O JOINTS Category: Durable Medical CMS Add: 01/01/2007 CMS Term: L3809 DME DEF MAXFEE 01/01/2014 12/31/2023 161.88 0.0 Description: WHFO W/O JOINTS PRE OTS Category: Durable Medical CMS Add: 01/01/2014 CMS Term: L3809 DME DEF MAXFEE 01/01/2024 260.97 0.0 Description: WHFO W/O JOINTS PRE OTS Category: Durable Medical CMS Add: 01/01/2014 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,965 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L3891 DME DEF MAXFEE 01/01/2010 12/31/2023 255.99 0.0 Description: TORSION MECHANISM WRIST/ELBO Category: Durable Medical CMS Add: 01/01/2010 CMS Term: L3891 DME DEF MAXFEE 01/01/2024 332.79 0.0 Description: TORSION MECHANISM WRIST/ELBO Category: Durable Medical CMS Add: 01/01/2010 CMS Term: L3900 DME DEF MAXFEE 01/01/2014 12/31/2023 943.70 0.0 Description: HINGE EXTENSION/FLEX WRIST/F Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3900 DME DEF MAXFEE 01/01/2024 1690.73 0.0 Description: HINGE EXTENSION/FLEX WRIST/F Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3901 DME DEF MAXFEE 01/01/2014 12/31/2023 1185.59 0.0 Description: HINGE EXT/FLEX WRIST FINGER Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3901 DME DEF MAXFEE 01/01/2024 2215.80 0.0 Description: HINGE EXT/FLEX WRIST FINGER Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3904 DME DEF MAXFEE 01/01/2014 12/31/2023 2279.85 0.0 Description: WHFO ELECTRIC CUSTOM FITTED Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L3904 DME DEF MAXFEE 01/01/2024 3522.87 0.0 Description: WHFO ELECTRIC CUSTOM FITTED Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L3905 DME DEF MAXFEE 01/01/2014 12/31/2023 726.59 0.0 Description: WHO W/NONTORSION JNT(S) CF Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L3905 DME DEF MAXFEE 01/01/2024 1035.01 0.0 Description: WHO W/NONTORSION JNT(S) CF Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L3906 DME DEF MAXFEE 01/01/2014 12/31/2023 289.29 0.0 Description: WHO W/O JOINTS CF Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3906 DME DEF MAXFEE 01/01/2024 528.91 0.0 Description: WHO W/O JOINTS CF Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3908 DME DEF MAXFEE 01/01/2014 12/31/2023 47.04 0.0 Description: WHO COCK-UP NONMOLDE PRE OTS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3908 DME DEF MAXFEE 01/01/2024 76.52 0.0 Description: WHO COCK-UP NONMOLDE PRE OTS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3912 DME DEF MAXFEE 01/01/2014 12/31/2023 70.75 0.0 Description: HFO FLEXION GLOVE PRE OTS Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L3912 DME DEF MAXFEE 01/01/2024 109.96 0.0 Description: HFO FLEXION GLOVE PRE OTS Category: Durable Medical CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,966 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L3913 DME DEF MAXFEE 01/01/2014 12/31/2023 198.42 0.0 Description: HFO W/O JOINTS CF Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L3913 DME DEF MAXFEE 01/01/2024 282.65 0.0 Description: HFO W/O JOINTS CF Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L3915 DME DEF MAXFEE 01/01/2014 12/31/2023 362.88 0.0 Description: WHO NONTORSION JNTS PRE CST Category: Durable Medical CMS Add: 01/01/2007 CMS Term: L3915 DME DEF MAXFEE 01/01/2024 554.80 0.0 Description: WHO NONTORSION JNTS PRE CST Category: Durable Medical CMS Add: 01/01/2007 CMS Term: L3916 DME DEF MAXFEE 01/01/2014 12/31/2023 362.88 0.0 Description: WHO NONTORSION JNTS PRE OTS Category: Durable Medical CMS Add: 01/01/2014 CMS Term: L3916 DME DEF MAXFEE 01/01/2024 554.80 0.0 Description: WHO NONTORSION JNTS PRE OTS Category: Durable Medical CMS Add: 01/01/2014 CMS Term: L3917 DME DEF MAXFEE 01/01/2014 12/31/2023 77.37 0.0 Description: METACARP FX ORTHOSIS PRE CST Category: Durable Medical CMS Add: 01/01/2004 CMS Term: L3917 DME DEF MAXFEE 01/01/2024 110.21 0.0 Description: METACARP FX ORTHOSIS PRE CST Category: Durable Medical CMS Add: 01/01/2004 CMS Term: L3918 DME DEF MAXFEE 01/01/2014 12/31/2023 77.37 0.0 Description: METACARP FX ORTHOSIS PRE OTS Category: Durable Medical CMS Add: 01/01/2014 CMS Term: L3918 DME DEF MAXFEE 01/01/2024 110.21 0.0 Description: METACARP FX ORTHOSIS PRE OTS Category: Durable Medical CMS Add: 01/01/2014 CMS Term: L3919 DME DEF MAXFEE 01/01/2014 12/31/2023 198.42 0.0 Description: HO W/O JOINTS CF Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L3919 DME DEF MAXFEE 01/01/2024 282.65 0.0 Description: HO W/O JOINTS CF Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L3921 DME DEF MAXFEE 01/01/2014 12/31/2023 235.33 0.0 Description: HFO W/JOINT(S) CF Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L3921 DME DEF MAXFEE 01/01/2024 335.26 0.0 Description: HFO W/JOINT(S) CF Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L3923 DME DEF MAXFEE 01/01/2014 12/31/2023 27.19 0.0 Description: HFO WITHOUT JOINTS PRE CST Category: Durable Medical CMS Add: 01/01/2001 CMS Term: L3923 DME DEF MAXFEE 01/01/2024 100.82 0.0 Description: HFO WITHOUT JOINTS PRE CST Category: Durable Medical CMS Add: 01/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,967 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L3924 DME DEF MAXFEE 01/01/2014 12/31/2023 27.19 0.0 Description: HFO WITHOUT JOINTS PRE OTS Category: Durable Medical CMS Add: 01/01/2014 CMS Term: L3924 DME DEF MAXFEE 01/01/2024 100.82 0.0 Description: HFO WITHOUT JOINTS PRE OTS Category: Durable Medical CMS Add: 01/01/2014 CMS Term: L3925 DME DEF MAXFEE 01/01/2014 12/31/2023 51.55 0.0 Description: FO PIP DIP JNT/SPRNG PRE OTS Category: Durable Medical CMS Add: 01/01/2008 CMS Term: L3925 DME DEF MAXFEE 01/01/2024 68.56 0.0 Description: FO PIP DIP JNT/SPRNG PRE OTS Category: Durable Medical CMS Add: 01/01/2008 CMS Term: L3927 DME DEF MAXFEE 01/01/2014 12/31/2023 27.48 0.0 Description: FO PIP DIP NO JT SPR PRE OTS Category: Durable Medical CMS Add: 01/01/2008 CMS Term: L3927 DME DEF MAXFEE 01/01/2024 36.53 0.0 Description: FO PIP DIP NO JT SPR PRE OTS Category: Durable Medical CMS Add: 01/01/2008 CMS Term: L3929 DME DEF MAXFEE 01/01/2014 12/31/2023 71.68 0.0 Description: HFO NONTORSION JNTS PRE CST Category: Durable Medical CMS Add: 01/01/2008 CMS Term: L3929 DME DEF MAXFEE 01/01/2024 95.33 0.0 Description: HFO NONTORSION JNTS PRE CST Category: Durable Medical CMS Add: 01/01/2008 CMS Term: L3930 DME DEF MAXFEE 01/01/2014 12/31/2023 71.68 0.0 Description: HFO NONTORSION JNTS PRE OTS Category: Durable Medical CMS Add: 01/01/2014 CMS Term: L3930 DME DEF MAXFEE 01/01/2024 95.33 0.0 Description: HFO NONTORSION JNTS PRE OTS Category: Durable Medical CMS Add: 01/01/2014 CMS Term: L3931 DME DEF MAXFEE 01/01/2014 12/31/2023 163.63 0.0 Description: WHFO NONTORSION JOINT PREFAB Category: Durable Medical CMS Add: 01/01/2008 CMS Term: L3931 DME DEF MAXFEE 01/01/2024 217.61 0.0 Description: WHFO NONTORSION JOINT PREFAB Category: Durable Medical CMS Add: 01/01/2008 CMS Term: L3933 DME DEF MAXFEE 01/01/2014 12/31/2023 156.33 0.0 Description: FO W/O JOINTS CF Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L3933 DME DEF MAXFEE 01/01/2024 222.69 0.0 Description: FO W/O JOINTS CF Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L3935 DME DEF MAXFEE 01/01/2014 12/31/2023 161.86 0.0 Description: FO NONTORSION JOINT CF Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L3935 DME DEF MAXFEE 01/01/2024 230.56 0.0 Description: FO NONTORSION JOINT CF Category: Durable Medical CMS Add: 01/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,968 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L3956 DME DEF SYSMAN Y Description: ADD JOINT UPPER EXT ORTHOSIS Category: Durable Medical CMS Add: 01/01/1997 CMS Term: L3960 DME DEF MAXFEE 01/01/2014 12/31/2023 464.25 0.0 Description: SEWHO AIRPLAN DESIG ABDU POS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3960 DME DEF MAXFEE 01/01/2024 832.42 0.0 Description: SEWHO AIRPLAN DESIG ABDU POS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L3961 DME DEF MAXFEE 01/01/2014 12/31/2023 1230.98 0.0 Description: SEWHO CAP DESIGN W/O JNTS CF Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L3961 DME DEF MAXFEE 01/01/2024 1753.55 0.0 Description: SEWHO CAP DESIGN W/O JNTS CF Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L3962 DME DEF MAXFEE 01/01/2014 12/31/2023 450.96 0.0 Description: SEWHO ERBS PALSEY DESIGN ABD Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L3962 DME DEF MAXFEE 01/01/2024 752.87 0.0 Description: SEWHO ERBS PALSEY DESIGN ABD Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L3967 DME DEF MAXFEE 01/01/2014 12/31/2023 1453.35 0.0 Description: SEWHO AIRPLANE W/O JNTS CF Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L3967 DME DEF MAXFEE 01/01/2024 2070.32 0.0 Description: SEWHO AIRPLANE W/O JNTS CF Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L3971 DME DEF MAXFEE 01/01/2014 12/31/2023 1379.58 0.0 Description: SEWHO CAP DESIGN W/JNT(S) CF Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L3971 DME DEF MAXFEE 01/01/2024 1965.22 0.0 Description: SEWHO CAP DESIGN W/JNT(S) CF Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L3973 DME DEF MAXFEE 01/01/2014 12/31/2023 1453.35 0.0 Description: SEWHO AIRPLANE W/JNT(S) CF Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L3973 DME DEF MAXFEE 01/01/2024 2070.32 0.0 Description: SEWHO AIRPLANE W/JNT(S) CF Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L3975 DME DEF MAXFEE 01/01/2014 12/31/2023 1230.98 0.0 Description: SEWHFO CAP DESIGN W/O JNT CF Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L3975 DME DEF MAXFEE 01/01/2024 1753.55 0.0 Description: SEWHFO CAP DESIGN W/O JNT CF Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L3976 DME DEF MAXFEE 01/01/2014 12/31/2023 1230.98 0.0 Description: SEWHFO AIRPLANE W/O JNTS CF Category: Durable Medical CMS Add: 01/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,969 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L3976 DME DEF MAXFEE 01/01/2024 1753.55 0.0 Description: SEWHFO AIRPLANE W/O JNTS CF Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L3977 DME DEF MAXFEE 01/01/2014 12/31/2023 1379.58 0.0 Description: SEWHFO CAP DESGN W/JNT(S) CF Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L3977 DME DEF MAXFEE 01/01/2024 1965.22 0.0 Description: SEWHFO CAP DESGN W/JNT(S) CF Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L3978 DME DEF MAXFEE 01/01/2014 12/31/2023 1453.35 0.0 Description: SEWHFO AIRPLANE W/JNT(S) CF Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L3978 DME DEF MAXFEE 01/01/2024 2070.32 0.0 Description: SEWHFO AIRPLANE W/JNT(S) CF Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L3980 DME DEF MAXFEE 01/01/2014 12/31/2023 254.98 0.0 Description: UP EXT FX ORTHOS HUMERAL NOS Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L3980 DME DEF MAXFEE 01/01/2024 403.77 0.0 Description: UP EXT FX ORTHOS HUMERAL NOS Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L3981 DME DEF MAXFEE 01/01/2015 12/31/2023 876.82 0.0 Description: UE FX ORTH SHOUL CAP FOREARM Category: Durable Medical CMS Add: 01/01/2015 CMS Term: L3981 DME DEF MAXFEE 01/01/2024 1050.55 0.0 Description: UE FX ORTH SHOUL CAP FOREARM Category: Durable Medical CMS Add: 01/01/2015 CMS Term: L3982 DME DEF MAXFEE 01/01/2014 12/31/2023 248.08 0.0 Description: UPPER EXT FX ORTHOSIS RAD/UL Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3982 DME DEF MAXFEE 01/01/2024 409.98 0.0 Description: UPPER EXT FX ORTHOSIS RAD/UL Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L3984 DME DEF MAXFEE 01/01/2014 12/31/2023 225.33 0.0 Description: UPPER EXT FX ORTHOSIS WRIST Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L3984 DME DEF MAXFEE 01/01/2024 361.16 0.0 Description: UPPER EXT FX ORTHOSIS WRIST Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L3995 DME DEF MAXFEE 01/01/2014 12/31/2023 27.12 0.0 Description: SOCK FRACTURE OR EQUAL EACH Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L3995 DME DEF MAXFEE 01/01/2024 42.85 0.0 Description: SOCK FRACTURE OR EQUAL EACH Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L3999 DME DEF SYSMAN Y Description: UPPER LIMB ORTHOSIS NOS Category: Durable Medical CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,970 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L4000 DME DEF MAXFEE 01/01/2014 12/31/2023 899.59 0.0 Description: REPL GIRDLE MILWAUKEE ORTH Category: Durable Medical CMS Add: 01/01/1985 CMS Term: L4000 DME DEF MAXFEE 01/01/2024 1515.41 0.0 Description: REPL GIRDLE MILWAUKEE ORTH Category: Durable Medical CMS Add: 01/01/1985 CMS Term: L4002 DME DEF SYSMAN Y Description: REPLACE STRAP, ANY ORTHOSIS Category: Durable Medical CMS Add: 01/01/2005 CMS Term: L4010 DME DEF MAXFEE 01/01/2014 12/31/2023 525.61 0.0 Description: REPLACE TRILATERAL SOCKET BR Category: Durable Medical CMS Add: 01/01/1985 CMS Term: L4010 DME DEF MAXFEE 01/01/2024 921.09 0.0 Description: REPLACE TRILATERAL SOCKET BR Category: Durable Medical CMS Add: 01/01/1985 CMS Term: L4020 DME DEF MAXFEE 01/01/2014 12/31/2023 582.66 0.0 Description: REPLACE QUADLAT SOCKET BRIM Category: Durable Medical CMS Add: 01/01/1985 CMS Term: L4020 DME DEF MAXFEE 01/01/2024 1106.47 0.0 Description: REPLACE QUADLAT SOCKET BRIM Category: Durable Medical CMS Add: 01/01/1985 CMS Term: L4030 DME DEF MAXFEE 01/01/2014 12/31/2023 368.63 0.0 Description: REPLACE SOCKET BRIM CUST FIT Category: Durable Medical CMS Add: 01/01/1985 CMS Term: L4030 DME DEF MAXFEE 01/01/2024 703.14 0.0 Description: REPLACE SOCKET BRIM CUST FIT Category: Durable Medical CMS Add: 01/01/1985 CMS Term: L4040 DME DEF MAXFEE 01/01/2014 12/31/2023 271.40 0.0 Description: REPLACE MOLDED THIGH LACER Category: Durable Medical CMS Add: 01/01/1985 CMS Term: L4040 DME DEF MAXFEE 01/01/2024 476.17 0.0 Description: REPLACE MOLDED THIGH LACER Category: Durable Medical CMS Add: 01/01/1985 CMS Term: L4045 DME DEF MAXFEE 01/01/2014 12/31/2023 213.20 0.0 Description: REPLACE NON-MOLDED THIGH LAC Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L4045 DME DEF MAXFEE 01/01/2024 351.75 0.0 Description: REPLACE NON-MOLDED THIGH LAC Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L4050 DME DEF MAXFEE 01/01/2014 12/31/2023 274.39 0.0 Description: REPLACE MOLDED CALF LACER Category: Durable Medical CMS Add: 01/01/1985 CMS Term: L4050 DME DEF MAXFEE 01/01/2024 471.59 0.0 Description: REPLACE MOLDED CALF LACER Category: Durable Medical CMS Add: 01/01/1985 CMS Term: L4055 DME DEF MAXFEE 01/01/2014 12/31/2023 171.49 0.0 Description: REPLACE NON-MOLDED CALF LACE Category: Durable Medical CMS Add: 01/01/1988 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,971 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L4055 DME DEF MAXFEE 01/01/2024 286.66 0.0 Description: REPLACE NON-MOLDED CALF LACE Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L4060 DME DEF MAXFEE 01/01/2014 12/31/2023 212.04 0.0 Description: REPLACE HIGH ROLL CUFF Category: Durable Medical CMS Add: 01/01/1985 CMS Term: L4060 DME DEF MAXFEE 01/01/2024 372.62 0.0 Description: REPLACE HIGH ROLL CUFF Category: Durable Medical CMS Add: 01/01/1985 CMS Term: L4070 DME DEF MAXFEE 01/01/2014 12/31/2023 179.60 0.0 Description: REPLACE PROX & DIST UPRIGHT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L4070 DME DEF MAXFEE 01/01/2024 301.77 0.0 Description: REPLACE PROX & DIST UPRIGHT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L4080 DME DEF MAXFEE 01/01/2014 12/31/2023 67.30 0.0 Description: REPL MET BAND KAFO-AFO PROX Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L4080 DME DEF MAXFEE 01/01/2024 113.93 0.0 Description: REPL MET BAND KAFO-AFO PROX Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L4090 DME DEF MAXFEE 01/01/2014 12/31/2023 60.18 0.0 Description: REPL MET BAND KAFO-AFO CALF/ Category: Durable Medical CMS Add: 01/01/1985 CMS Term: L4090 DME DEF MAXFEE 01/01/2024 96.93 0.0 Description: REPL MET BAND KAFO-AFO CALF/ Category: Durable Medical CMS Add: 01/01/1985 CMS Term: L4100 DME DEF MAXFEE 01/01/2014 12/31/2023 69.46 0.0 Description: REPL LEATH CUFF KAFO PROX TH Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L4100 DME DEF MAXFEE 01/01/2024 116.46 0.0 Description: REPL LEATH CUFF KAFO PROX TH Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L4110 DME DEF MAXFEE 01/01/2014 12/31/2023 55.73 0.0 Description: REPL LEATH CUFF KAFO-AFO CAL Category: Durable Medical CMS Add: 01/01/1985 CMS Term: L4110 DME DEF MAXFEE 01/01/2024 90.93 0.0 Description: REPL LEATH CUFF KAFO-AFO CAL Category: Durable Medical CMS Add: 01/01/1985 CMS Term: L4130 DME DEF MAXFEE 01/01/2014 12/31/2023 331.45 0.0 Description: REPLACE PRETIBIAL SHELL Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L4130 DME DEF MAXFEE 01/01/2024 549.67 0.0 Description: REPLACE PRETIBIAL SHELL Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L4205 DME DEF MAXFEE 01/01/2024 28.16 0.0 Description: ORTHO DVC REPAIR PER 15 MIN Category: Durable Medical CMS Add: 01/01/1997 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,972 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L4205 DME DEF MAXFEE 07/01/2014 12/31/2023 21.66 0.0 Description: ORTHO DVC REPAIR PER 15 MIN Category: Durable Medical CMS Add: 01/01/1997 CMS Term: L4210 DME DEF SYSMAN Y Description: ORTH DEV REPAIR/REPL MINOR P Category: Durable Medical CMS Add: 01/01/1985 CMS Term: L4350 DME DEF MAXFEE 01/01/2014 12/31/2023 62.71 0.0 Description: ANKLE CONTROL ORTHO PRE OTS Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L4350 DME DEF MAXFEE 01/01/2024 110.96 0.0 Description: ANKLE CONTROL ORTHO PRE OTS Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L4360 DME DEF MAXFEE 01/01/2014 12/31/2023 179.63 0.0 Description: PNEUMAT WALKING BOOT PRE CST Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L4360 DME DEF MAXFEE 01/01/2024 296.91 0.0 Description: PNEUMAT WALKING BOOT PRE CST Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L4361 DME DEF MAXFEE 01/01/2014 12/31/2023 179.63 0.0 Description: PNEUMA/VAC WALK BOOT PRE OTS Category: Durable Medical CMS Add: 01/01/2014 CMS Term: L4361 DME DEF MAXFEE 01/01/2024 296.91 0.0 Description: PNEUMA/VAC WALK BOOT PRE OTS Category: Durable Medical CMS Add: 01/01/2014 CMS Term: L4370 DME DEF MAXFEE 01/01/2014 12/31/2023 150.39 0.0 Description: PNEUM FULL LEG SPLNT PRE OTS Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L4370 DME DEF MAXFEE 01/01/2024 269.92 0.0 Description: PNEUM FULL LEG SPLNT PRE OTS Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L4386 DME DEF MAXFEE 01/01/2014 12/31/2023 114.03 0.0 Description: NON-PNEUM WALK BOOT PRE CST Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L4386 DME DEF MAXFEE 01/01/2024 181.83 0.0 Description: NON-PNEUM WALK BOOT PRE CST Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L4387 DME DEF MAXFEE 01/01/2014 12/31/2023 114.03 0.0 Description: NON-PNEUM WALK BOOT PRE OTS Category: Durable Medical CMS Add: 01/01/2014 CMS Term: L4387 DME DEF MAXFEE 01/01/2024 181.83 0.0 Description: NON-PNEUM WALK BOOT PRE OTS Category: Durable Medical CMS Add: 01/01/2014 CMS Term: L4392 DME DEF MAXFEE 01/01/2014 12/31/2023 17.36 0.0 Description: REPLACE AFO SOFT INTERFACE Category: Durable Medical CMS Add: 01/01/1997 CMS Term: L4392 DME DEF MAXFEE 01/01/2024 26.98 0.0 Description: REPLACE AFO SOFT INTERFACE Category: Durable Medical CMS Add: 01/01/1997 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,973 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L4394 DME DEF MAXFEE 01/01/2014 12/31/2023 12.68 0.0 Description: REPLACE FOOT DROP SPINT Category: Durable Medical CMS Add: 01/01/1997 CMS Term: L4394 DME DEF MAXFEE 01/01/2024 19.69 0.0 Description: REPLACE FOOT DROP SPINT Category: Durable Medical CMS Add: 01/01/1997 CMS Term: L4396 DME DEF MAXFEE 01/01/2014 12/31/2023 123.84 0.0 Description: STATIC OR DYNAMI AFO PRE CST Category: Durable Medical CMS Add: 01/01/1997 CMS Term: L4396 DME DEF MAXFEE 01/01/2024 192.45 0.0 Description: STATIC OR DYNAMI AFO PRE CST Category: Durable Medical CMS Add: 01/01/1997 CMS Term: L4397 DME DEF MAXFEE 01/01/2014 12/31/2023 123.84 0.0 Description: STATIC OR DYNAMI AFO PRE OTS Category: Durable Medical CMS Add: 01/01/2014 CMS Term: L4397 DME DEF MAXFEE 01/01/2024 192.45 0.0 Description: STATIC OR DYNAMI AFO PRE OTS Category: Durable Medical CMS Add: 01/01/2014 CMS Term: L4398 DME DEF MAXFEE 01/01/2014 12/31/2023 57.01 0.0 Description: FOOT DROP SPLINT PRE OTS Category: Durable Medical CMS Add: 01/01/1997 CMS Term: L4398 DME DEF MAXFEE 01/01/2024 88.58 0.0 Description: FOOT DROP SPLINT PRE OTS Category: Durable Medical CMS Add: 01/01/1997 CMS Term: L4631 DME DEF MAXFEE 01/01/2014 12/31/2023 1333.46 0.0 Description: AFO, WALK BOOT TYPE, CUS FAB Category: Durable Medical CMS Add: 01/01/2011 CMS Term: L4631 DME DEF MAXFEE 01/01/2024 1690.57 0.0 Description: AFO, WALK BOOT TYPE, CUS FAB Category: Durable Medical CMS Add: 01/01/2011 CMS Term: L5000 DME DEF MAXFEE 01/01/2014 12/31/2023 339.65 0.0 Description: SHO INSERT W ARCH TOE FILLER Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L5000 DME DEF MAXFEE 01/01/2024 658.53 0.0 Description: SHO INSERT W ARCH TOE FILLER Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L5010 DME DEF MAXFEE 01/01/2014 12/31/2023 1130.28 0.0 Description: MOLD SOCKET ANK HGT W/ TOE F Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L5010 DME DEF MAXFEE 01/01/2024 1840.01 0.0 Description: MOLD SOCKET ANK HGT W/ TOE F Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L5020 DME DEF MAXFEE 01/01/2014 12/31/2023 1807.31 0.0 Description: TIBIAL TUBERCLE HGT W/ TOE F Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L5020 DME DEF MAXFEE 01/01/2024 2882.70 0.0 Description: TIBIAL TUBERCLE HGT W/ TOE F Category: Durable Medical CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,974 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L5050 DME DEF MAXFEE 01/01/2014 12/31/2023 1829.69 0.0 Description: ANK SYMES MOLD SCKT SACH FT Category: Durable Medical CMS Add: 01/01/1985 CMS Term: L5050 DME DEF MAXFEE 01/01/2024 3148.45 0.0 Description: ANK SYMES MOLD SCKT SACH FT Category: Durable Medical CMS Add: 01/01/1985 CMS Term: L5060 DME DEF MAXFEE 01/01/2014 12/31/2023 2400.59 0.0 Description: SYMES MET FR LEATH SOCKET AR Category: Durable Medical CMS Add: 01/01/1985 CMS Term: L5060 DME DEF MAXFEE 01/01/2024 3881.13 0.0 Description: SYMES MET FR LEATH SOCKET AR Category: Durable Medical CMS Add: 01/01/1985 CMS Term: L5100 DME DEF MAXFEE 01/01/2014 12/31/2023 1778.29 0.0 Description: MOLDED SOCKET SHIN SACH FOOT Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L5100 DME DEF MAXFEE 01/01/2024 3134.98 0.0 Description: MOLDED SOCKET SHIN SACH FOOT Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L5105 DME DEF MAXFEE 01/01/2014 12/31/2023 2695.21 0.0 Description: PLAST SOCKET JTS/THGH LACER Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L5105 DME DEF MAXFEE 01/01/2024 4424.14 0.0 Description: PLAST SOCKET JTS/THGH LACER Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L5150 DME DEF MAXFEE 01/01/2014 12/31/2023 3015.53 0.0 Description: MOLD SCKT EXT KNEE SHIN SACH Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L5150 DME DEF MAXFEE 01/01/2024 4918.59 0.0 Description: MOLD SCKT EXT KNEE SHIN SACH Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L5160 DME DEF MAXFEE 01/01/2014 12/31/2023 2994.73 0.0 Description: MOLD SOCKET BENT KNEE SHIN S Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L5160 DME DEF MAXFEE 01/01/2024 5400.38 0.0 Description: MOLD SOCKET BENT KNEE SHIN S Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L5200 DME DEF MAXFEE 01/01/2014 12/31/2023 1975.67 0.0 Description: KNE SING AXIS FRIC SHIN SACH Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L5200 DME DEF MAXFEE 01/01/2024 4176.80 0.0 Description: KNE SING AXIS FRIC SHIN SACH Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L5210 DME DEF MAXFEE 01/01/2014 12/31/2023 1815.01 0.0 Description: NO KNEE/ANKLE JOINTS W/ FT B Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L5210 DME DEF MAXFEE 01/01/2024 3316.37 0.0 Description: NO KNEE/ANKLE JOINTS W/ FT B Category: Durable Medical CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,975 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L5220 DME DEF MAXFEE 01/01/2014 12/31/2023 2014.68 0.0 Description: NO KNEE JOINT WITH ARTIC ALI Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L5220 DME DEF MAXFEE 01/01/2024 3653.21 0.0 Description: NO KNEE JOINT WITH ARTIC ALI Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L5230 DME DEF MAXFEE 01/01/2014 12/31/2023 2919.13 0.0 Description: FEM FOCAL DEFIC CONSTANT FRI Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L5230 DME DEF MAXFEE 01/01/2024 5479.25 0.0 Description: FEM FOCAL DEFIC CONSTANT FRI Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L5250 DME DEF MAXFEE 01/01/2014 12/31/2023 3951.72 0.0 Description: HIP CANAD SING AXI CONS FRIC Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L5250 DME DEF MAXFEE 01/01/2024 6424.57 0.0 Description: HIP CANAD SING AXI CONS FRIC Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L5270 DME DEF MAXFEE 01/01/2014 12/31/2023 4191.40 0.0 Description: TILT TABLE LOCKING HIP SING Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L5270 DME DEF MAXFEE 01/01/2024 7158.23 0.0 Description: TILT TABLE LOCKING HIP SING Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L5280 DME DEF MAXFEE 01/01/2014 12/31/2023 2888.20 0.0 Description: HEMIPELVECT CANAD SING AXIS Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L5280 DME DEF MAXFEE 01/01/2024 6958.07 0.0 Description: HEMIPELVECT CANAD SING AXIS Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L5301 DME DEF MAXFEE 01/01/2014 12/31/2023 1821.31 0.0 Description: BK MOLD SOCKET SACH FT ENDO Category: Durable Medical CMS Add: 01/01/2002 CMS Term: L5301 DME DEF MAXFEE 01/01/2024 3078.48 0.0 Description: BK MOLD SOCKET SACH FT ENDO Category: Durable Medical CMS Add: 01/01/2002 CMS Term: L5312 DME DEF MAXFEE 01/01/2012 12/31/2023 3917.60 0.0 Description: KNEE DISART, SACH FT, ENDO Category: Durable Medical CMS Add: 01/01/2012 CMS Term: L5312 DME DEF MAXFEE 01/01/2024 4850.36 0.0 Description: KNEE DISART, SACH FT, ENDO Category: Durable Medical CMS Add: 01/01/2012 CMS Term: L5321 DME DEF MAXFEE 01/01/2014 12/31/2023 2607.16 0.0 Description: AK OPEN END SACH Category: Durable Medical CMS Add: 01/01/2002 CMS Term: L5321 DME DEF MAXFEE 01/01/2024 4105.06 0.0 Description: AK OPEN END SACH Category: Durable Medical CMS Add: 01/01/2002 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,976 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L5331 DME DEF MAXFEE 01/01/2014 12/31/2023 3689.22 0.0 Description: HIP DISART CANADIAN SACH FT Category: Durable Medical CMS Add: 01/01/2002 CMS Term: L5331 DME DEF MAXFEE 01/01/2024 6012.41 0.0 Description: HIP DISART CANADIAN SACH FT Category: Durable Medical CMS Add: 01/01/2002 CMS Term: L5341 DME DEF MAXFEE 01/01/2014 12/31/2023 4009.01 0.0 Description: HEMIPELVECTOMY CANADIAN SACH Category: Durable Medical CMS Add: 01/01/2002 CMS Term: L5341 DME DEF MAXFEE 01/01/2024 6391.11 0.0 Description: HEMIPELVECTOMY CANADIAN SACH Category: Durable Medical CMS Add: 01/01/2002 CMS Term: L5400 DME DEF MAXFEE 01/01/2014 12/31/2023 1081.75 0.0 Description: POSTOP DRESS & 1 CAST CHG BK Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L5400 DME DEF MAXFEE 01/01/2024 1833.24 0.0 Description: POSTOP DRESS & 1 CAST CHG BK Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L5410 DME DEF MAXFEE 01/01/2014 12/31/2023 350.53 0.0 Description: POSTOP DSG BK EA ADD CAST CH Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5410 DME DEF MAXFEE 01/01/2024 506.47 0.0 Description: POSTOP DSG BK EA ADD CAST CH Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5420 DME DEF MAXFEE 01/01/2014 12/31/2023 1445.50 0.0 Description: POSTOP DSG & 1 CAST CHG AK/D Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L5420 DME DEF MAXFEE 01/01/2024 2315.31 0.0 Description: POSTOP DSG & 1 CAST CHG AK/D Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L5430 DME DEF MAXFEE 01/01/2014 12/31/2023 1080.00 0.0 Description: POSTOP DSG AK EA ADD CAST CH Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5430 DME DEF MAXFEE 01/01/2024 628.48 0.0 Description: POSTOP DSG AK EA ADD CAST CH Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5450 DME DEF MAXFEE 01/01/2014 12/31/2023 321.71 0.0 Description: POSTOP APP NON-WGT BEAR DSG Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L5450 DME DEF MAXFEE 01/01/2024 543.42 0.0 Description: POSTOP APP NON-WGT BEAR DSG Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L5460 DME DEF MAXFEE 01/01/2014 12/31/2023 425.78 0.0 Description: POSTOP APP NON-WGT BEAR DSG Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L5460 DME DEF MAXFEE 01/01/2024 712.76 0.0 Description: POSTOP APP NON-WGT BEAR DSG Category: Durable Medical CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,977 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L5500 DME DEF MAXFEE 01/01/2014 12/31/2023 1215.32 0.0 Description: INIT BK PTB PLASTER DIRECT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5500 DME DEF MAXFEE 01/01/2024 1694.45 0.0 Description: INIT BK PTB PLASTER DIRECT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5505 DME DEF MAXFEE 01/01/2014 12/31/2023 1705.00 0.0 Description: INIT AK ISCHAL PLSTR DIRECT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5505 DME DEF MAXFEE 01/01/2024 2383.63 0.0 Description: INIT AK ISCHAL PLSTR DIRECT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5510 DME DEF MAXFEE 01/01/2014 12/31/2023 1273.96 0.0 Description: PREP BK PTB PLASTER MOLDED Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5510 DME DEF MAXFEE 01/01/2024 2023.46 0.0 Description: PREP BK PTB PLASTER MOLDED Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5520 DME DEF MAXFEE 01/01/2014 12/31/2023 1499.40 0.0 Description: PERP BK PTB THERMOPLS DIRECT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5520 DME DEF MAXFEE 01/01/2024 1813.79 0.0 Description: PERP BK PTB THERMOPLS DIRECT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5530 DME DEF MAXFEE 01/01/2014 12/31/2023 1623.13 0.0 Description: PREP BK PTB THERMOPLS MOLDED Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5530 DME DEF MAXFEE 01/01/2024 2384.35 0.0 Description: PREP BK PTB THERMOPLS MOLDED Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5535 DME DEF MAXFEE 01/01/2014 12/31/2023 1460.30 0.0 Description: PREP BK PTB OPEN END SOCKET Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L5535 DME DEF MAXFEE 01/01/2024 2222.72 0.0 Description: PREP BK PTB OPEN END SOCKET Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L5540 DME DEF MAXFEE 01/01/2014 12/31/2023 1369.19 0.0 Description: PREP BK PTB LAMINATED SOCKET Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5540 DME DEF MAXFEE 01/01/2024 2354.17 0.0 Description: PREP BK PTB LAMINATED SOCKET Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5560 DME DEF MAXFEE 01/01/2014 12/31/2023 1750.95 0.0 Description: PREP AK ISCHIAL PLAST MOLDED Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5560 DME DEF MAXFEE 01/01/2024 2682.46 0.0 Description: PREP AK ISCHIAL PLAST MOLDED Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,978 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L5570 DME DEF MAXFEE 01/01/2014 12/31/2023 1641.85 0.0 Description: PREP AK ISCHIAL DIRECT FORM Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5570 DME DEF MAXFEE 01/01/2024 2603.42 0.0 Description: PREP AK ISCHIAL DIRECT FORM Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5580 DME DEF MAXFEE 01/01/2014 12/31/2023 1847.70 0.0 Description: PREP AK ISCHIAL THERMO MOLD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5580 DME DEF MAXFEE 01/01/2024 3231.23 0.0 Description: PREP AK ISCHIAL THERMO MOLD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5585 DME DEF MAXFEE 01/01/2014 12/31/2023 2155.64 0.0 Description: PREP AK ISCHIAL OPEN END Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L5585 DME DEF MAXFEE 01/01/2024 3784.02 0.0 Description: PREP AK ISCHIAL OPEN END Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L5590 DME DEF MAXFEE 01/01/2014 12/31/2023 2067.11 0.0 Description: PREP AK ISCHIAL LAMINATED Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5590 DME DEF MAXFEE 01/01/2024 3368.87 0.0 Description: PREP AK ISCHIAL LAMINATED Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5595 DME DEF MAXFEE 01/01/2014 12/31/2023 3058.11 0.0 Description: HIP DISARTIC SACH THERMOPLS Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L5595 DME DEF MAXFEE 01/01/2024 5264.68 0.0 Description: HIP DISARTIC SACH THERMOPLS Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L5600 DME DEF MAXFEE 01/01/2014 12/31/2023 3382.99 0.0 Description: HIP DISART SACH LAMINAT MOLD Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L5600 DME DEF MAXFEE 01/01/2024 5991.98 0.0 Description: HIP DISART SACH LAMINAT MOLD Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L5610 DME DEF MAXFEE 01/01/2014 12/31/2023 1939.07 0.0 Description: ABOVE KNEE HYDRACADENCE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5610 DME DEF MAXFEE 01/01/2024 2889.90 0.0 Description: ABOVE KNEE HYDRACADENCE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5611 DME DEF MAXFEE 01/01/2014 12/31/2023 1122.48 0.0 Description: AK 4 BAR LINK W/FRIC SWING Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L5611 DME DEF MAXFEE 01/01/2024 1840.62 0.0 Description: AK 4 BAR LINK W/FRIC SWING Category: Durable Medical CMS Add: 01/01/1989 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,979 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L5613 DME DEF MAXFEE 01/01/2014 12/31/2023 1711.60 0.0 Description: AK 4 BAR LING W/HYDRAUL SWIG Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L5613 DME DEF MAXFEE 01/01/2024 2799.70 0.0 Description: AK 4 BAR LING W/HYDRAUL SWIG Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L5614 DME DEF MAXFEE 01/01/2014 12/31/2023 1260.12 0.0 Description: 4-BAR LINK ABOVE KNEE W/SWNG Category: Durable Medical CMS Add: 01/01/1994 CMS Term: L5614 DME DEF MAXFEE 01/01/2024 1938.98 0.0 Description: 4-BAR LINK ABOVE KNEE W/SWNG Category: Durable Medical CMS Add: 01/01/1994 CMS Term: L5615 DME DEF MAXFEE 01/01/2024 6632.94 0.0 Y Description: AK 4 BAR LINK HYDL SWG/STANC Category: Durable Medical CMS Add: 01/01/2024 CMS Term: L5616 DME DEF MAXFEE 01/01/2014 12/31/2023 1034.40 0.0 Description: AK UNIV MULTIPLEX SYS FRICT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5616 DME DEF MAXFEE 01/01/2024 1688.13 0.0 Description: AK UNIV MULTIPLEX SYS FRICT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5617 DME DEF MAXFEE 01/01/2014 12/31/2023 402.42 0.0 Description: AK/BK SELF-ALIGNING UNIT EA Category: Durable Medical CMS Add: 01/01/1996 CMS Term: L5617 DME DEF MAXFEE 01/01/2024 642.90 0.0 Description: AK/BK SELF-ALIGNING UNIT EA Category: Durable Medical CMS Add: 01/01/1996 CMS Term: L5618 DME DEF MAXFEE 01/01/2014 12/31/2023 220.03 0.0 Description: TEST SOCKET SYMES Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5618 DME DEF MAXFEE 01/01/2024 383.93 0.0 Description: TEST SOCKET SYMES Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5620 DME DEF MAXFEE 01/01/2014 12/31/2023 205.98 0.0 Description: TEST SOCKET BELOW KNEE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5620 DME DEF MAXFEE 01/01/2024 340.63 0.0 Description: TEST SOCKET BELOW KNEE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5622 DME DEF MAXFEE 01/01/2014 12/31/2023 258.55 0.0 Description: TEST SOCKET KNEE DISARTICULA Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5622 DME DEF MAXFEE 01/01/2024 458.92 0.0 Description: TEST SOCKET KNEE DISARTICULA Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5624 DME DEF MAXFEE 01/01/2014 12/31/2023 273.82 0.0 Description: TEST SOCKET ABOVE KNEE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,980 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L5624 DME DEF MAXFEE 01/01/2024 458.74 0.0 Description: TEST SOCKET ABOVE KNEE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5626 DME DEF MAXFEE 01/01/2014 12/31/2023 439.86 0.0 Description: TEST SOCKET HIP DISARTICULAT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5626 DME DEF MAXFEE 01/01/2024 726.24 0.0 Description: TEST SOCKET HIP DISARTICULAT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5628 DME DEF MAXFEE 01/01/2014 12/31/2023 444.59 0.0 Description: TEST SOCKET HEMIPELVECTOMY Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5628 DME DEF MAXFEE 01/01/2024 735.42 0.0 Description: TEST SOCKET HEMIPELVECTOMY Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5629 DME DEF MAXFEE 01/01/2014 12/31/2023 216.80 0.0 Description: BELOW KNEE ACRYLIC SOCKET Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L5629 DME DEF MAXFEE 01/01/2024 363.05 0.0 Description: BELOW KNEE ACRYLIC SOCKET Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L5630 DME DEF MAXFEE 01/01/2014 12/31/2023 366.23 0.0 Description: SYME TYP EXPANDABL WALL SCKT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5630 DME DEF MAXFEE 01/01/2024 630.82 0.0 Description: SYME TYP EXPANDABL WALL SCKT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5631 DME DEF MAXFEE 01/01/2014 12/31/2023 299.97 0.0 Description: AK/KNEE DISARTIC ACRYLIC SOC Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L5631 DME DEF MAXFEE 01/01/2024 501.95 0.0 Description: AK/KNEE DISARTIC ACRYLIC SOC Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L5632 DME DEF MAXFEE 01/01/2014 12/31/2023 196.10 0.0 Description: SYMES TYPE PTB BRIM DESIGN S Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5632 DME DEF MAXFEE 01/01/2024 309.38 0.0 Description: SYMES TYPE PTB BRIM DESIGN S Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5634 DME DEF MAXFEE 01/01/2014 12/31/2023 209.18 0.0 Description: SYMES TYPE POSTER OPENING SO Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5634 DME DEF MAXFEE 01/01/2024 386.90 0.0 Description: SYMES TYPE POSTER OPENING SO Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5636 DME DEF MAXFEE 01/01/2014 12/31/2023 174.92 0.0 Description: SYMES TYPE MEDIAL OPENING SO Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,981 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L5636 DME DEF MAXFEE 01/01/2024 295.73 0.0 Description: SYMES TYPE MEDIAL OPENING SO Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5637 DME DEF MAXFEE 01/01/2014 12/31/2023 268.34 0.0 Description: BELOW KNEE TOTAL CONTACT Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L5637 DME DEF MAXFEE 01/01/2024 440.04 0.0 Description: BELOW KNEE TOTAL CONTACT Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L5638 DME DEF MAXFEE 01/01/2014 12/31/2023 429.15 0.0 Description: BELOW KNEE LEATHER SOCKET Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5638 DME DEF MAXFEE 01/01/2024 741.28 0.0 Description: BELOW KNEE LEATHER SOCKET Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5639 DME DEF MAXFEE 01/01/2014 12/31/2023 829.57 0.0 Description: BELOW KNEE WOOD SOCKET Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L5639 DME DEF MAXFEE 01/01/2024 1280.84 0.0 Description: BELOW KNEE WOOD SOCKET Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L5640 DME DEF MAXFEE 01/01/2014 12/31/2023 477.25 0.0 Description: KNEE DISARTICULAT LEATHER SO Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5640 DME DEF MAXFEE 01/01/2024 841.90 0.0 Description: KNEE DISARTICULAT LEATHER SO Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5642 DME DEF MAXFEE 01/01/2014 12/31/2023 438.40 0.0 Description: ABOVE KNEE LEATHER SOCKET Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5642 DME DEF MAXFEE 01/01/2024 780.41 0.0 Description: ABOVE KNEE LEATHER SOCKET Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5643 DME DEF MAXFEE 01/01/2014 12/31/2023 1249.70 0.0 Description: HIP FLEX INNER SOCKET EXT FR Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L5643 DME DEF MAXFEE 01/01/2024 2301.83 0.0 Description: HIP FLEX INNER SOCKET EXT FR Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L5644 DME DEF MAXFEE 01/01/2014 12/31/2023 411.48 0.0 Description: ABOVE KNEE WOOD SOCKET Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5644 DME DEF MAXFEE 01/01/2024 674.75 0.0 Description: ABOVE KNEE WOOD SOCKET Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5645 DME DEF MAXFEE 01/01/2014 12/31/2023 596.46 0.0 Description: BK FLEX INNER SOCKET EXT FRA Category: Durable Medical CMS Add: 01/01/1988 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,982 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L5645 DME DEF MAXFEE 01/01/2024 1119.38 0.0 Description: BK FLEX INNER SOCKET EXT FRA Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L5646 DME DEF MAXFEE 01/01/2014 12/31/2023 412.80 0.0 Description: BELOW KNEE CUSHION SOCKET Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5646 DME DEF MAXFEE 01/01/2024 709.38 0.0 Description: BELOW KNEE CUSHION SOCKET Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5647 DME DEF MAXFEE 01/01/2014 12/31/2023 543.79 0.0 Description: BELOW KNEE SUCTION SOCKET Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L5647 DME DEF MAXFEE 01/01/2024 908.74 0.0 Description: BELOW KNEE SUCTION SOCKET Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L5648 DME DEF MAXFEE 01/01/2014 12/31/2023 464.09 0.0 Description: ABOVE KNEE CUSHION SOCKET Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5648 DME DEF MAXFEE 01/01/2024 838.19 0.0 Description: ABOVE KNEE CUSHION SOCKET Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5649 DME DEF MAXFEE 01/01/2014 12/31/2023 1764.20 0.0 Description: ISCH CONTAINMT/NARROW M-L SO Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L5649 DME DEF MAXFEE 01/01/2024 2816.38 0.0 Description: ISCH CONTAINMT/NARROW M-L SO Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L5650 DME DEF MAXFEE 01/01/2014 12/31/2023 348.83 0.0 Description: TOT CONTACT AK/KNEE DISART S Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5650 DME DEF MAXFEE 01/01/2024 557.71 0.0 Description: TOT CONTACT AK/KNEE DISART S Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5651 DME DEF MAXFEE 01/01/2014 12/31/2023 1012.48 0.0 Description: AK FLEX INNER SOCKET EXT FRA Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L5651 DME DEF MAXFEE 01/01/2024 1634.01 0.0 Description: AK FLEX INNER SOCKET EXT FRA Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L5652 DME DEF MAXFEE 01/01/2014 12/31/2023 310.53 0.0 Description: SUCTION SUSP AK/KNEE DISART Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5652 DME DEF MAXFEE 01/01/2024 498.07 0.0 Description: SUCTION SUSP AK/KNEE DISART Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5653 DME DEF MAXFEE 01/01/2014 12/31/2023 439.05 0.0 Description: KNEE DISART EXPAND WALL SOCK Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,983 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L5653 DME DEF MAXFEE 01/01/2024 777.13 0.0 Description: KNEE DISART EXPAND WALL SOCK Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5654 DME DEF MAXFEE 01/01/2014 12/31/2023 302.97 0.0 Description: SOCKET INSERT SYMES Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5654 DME DEF MAXFEE 01/01/2024 450.50 0.0 Description: SOCKET INSERT SYMES Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5655 DME DEF MAXFEE 01/01/2014 12/31/2023 192.65 0.0 Description: SOCKET INSERT BELOW KNEE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5655 DME DEF MAXFEE 01/01/2024 325.26 0.0 Description: SOCKET INSERT BELOW KNEE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5656 DME DEF MAXFEE 01/01/2014 12/31/2023 344.77 0.0 Description: SOCKET INSERT KNEE ARTICULAT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5656 DME DEF MAXFEE 01/01/2024 494.14 0.0 Description: SOCKET INSERT KNEE ARTICULAT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5658 DME DEF MAXFEE 01/01/2014 12/31/2023 338.81 0.0 Description: SOCKET INSERT ABOVE KNEE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5658 DME DEF MAXFEE 01/01/2024 521.58 0.0 Description: SOCKET INSERT ABOVE KNEE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5661 DME DEF MAXFEE 01/01/2014 12/31/2023 451.06 0.0 Description: MULTI-DUROMETER SYMES Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L5661 DME DEF MAXFEE 01/01/2024 748.35 0.0 Description: MULTI-DUROMETER SYMES Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L5665 DME DEF MAXFEE 01/01/2014 12/31/2023 414.87 0.0 Description: MULTI-DUROMETER BELOW KNEE Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L5665 DME DEF MAXFEE 01/01/2024 665.31 0.0 Description: MULTI-DUROMETER BELOW KNEE Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L5666 DME DEF MAXFEE 01/01/2014 12/31/2023 48.22 0.0 Description: BELOW KNEE CUFF SUSPENSION Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5666 DME DEF MAXFEE 01/01/2024 88.09 0.0 Description: BELOW KNEE CUFF SUSPENSION Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5668 DME DEF MAXFEE 01/01/2014 12/31/2023 68.66 0.0 Description: BK MOLDED DISTAL CUSHION Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,984 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L5668 DME DEF MAXFEE 01/01/2024 131.22 0.0 Description: BK MOLDED DISTAL CUSHION Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5670 DME DEF MAXFEE 01/01/2014 12/31/2023 187.44 0.0 Description: BK MOLDED SUPRACONDYLAR SUSP Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5670 DME DEF MAXFEE 01/01/2024 309.99 0.0 Description: BK MOLDED SUPRACONDYLAR SUSP Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5671 DME DEF MAXFEE 01/01/2014 12/31/2023 394.56 0.0 Description: BK/AK LOCKING MECHANISM Category: Durable Medical CMS Add: 01/01/2002 CMS Term: L5671 DME DEF MAXFEE 01/01/2024 568.25 0.0 Description: BK/AK LOCKING MECHANISM Category: Durable Medical CMS Add: 01/01/2002 CMS Term: L5672 DME DEF MAXFEE 01/01/2014 12/31/2023 285.16 0.0 Description: BK REMOVABLE MEDIAL BRIM SUS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5672 DME DEF MAXFEE 01/01/2024 410.21 0.0 Description: BK REMOVABLE MEDIAL BRIM SUS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5673 DME DEF MAXFEE 01/01/2014 12/31/2023 633.97 0.0 Description: SOCKET INSERT W LOCK MECH Category: Durable Medical CMS Add: 01/01/2004 CMS Term: L5673 DME DEF MAXFEE 01/01/2024 903.12 0.0 Description: SOCKET INSERT W LOCK MECH Category: Durable Medical CMS Add: 01/01/2004 CMS Term: L5676 DME DEF MAXFEE 01/01/2014 12/31/2023 245.61 0.0 Description: BK KNEE JOINTS SINGLE AXIS P Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5676 DME DEF MAXFEE 01/01/2024 413.98 0.0 Description: BK KNEE JOINTS SINGLE AXIS P Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5677 DME DEF MAXFEE 01/01/2014 12/31/2023 344.72 0.0 Description: BK KNEE JOINTS POLYCENTRIC P Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L5677 DME DEF MAXFEE 01/01/2024 634.01 0.0 Description: BK KNEE JOINTS POLYCENTRIC P Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L5678 DME DEF MAXFEE 01/01/2014 12/31/2023 26.82 0.0 Description: BK JOINT COVERS PAIR Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L5678 DME DEF MAXFEE 01/01/2024 45.36 0.0 Description: BK JOINT COVERS PAIR Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L5679 DME DEF MAXFEE 01/01/2014 12/31/2023 528.30 0.0 Description: SOCKET INSERT W/O LOCK MECH Category: Durable Medical CMS Add: 01/01/2004 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,985 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L5679 DME DEF MAXFEE 01/01/2024 752.58 0.0 Description: SOCKET INSERT W/O LOCK MECH Category: Durable Medical CMS Add: 01/01/2004 CMS Term: L5680 DME DEF MAXFEE 01/01/2014 12/31/2023 210.63 0.0 Description: BK THIGH LACER NON-MOLDED Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5680 DME DEF MAXFEE 01/01/2024 347.72 0.0 Description: BK THIGH LACER NON-MOLDED Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5681 DME DEF MAXFEE 01/01/2014 12/31/2023 1061.04 0.0 Description: INTL CUSTM CONG/LATYP INSERT Category: Durable Medical CMS Add: 01/01/2004 CMS Term: L5681 DME DEF MAXFEE 01/01/2024 1511.46 0.0 Description: INTL CUSTM CONG/LATYP INSERT Category: Durable Medical CMS Add: 01/01/2004 CMS Term: L5682 DME DEF MAXFEE 01/01/2014 12/31/2023 428.18 0.0 Description: BK THIGH LACER GLUT/ISCHIA M Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5682 DME DEF MAXFEE 01/01/2024 714.45 0.0 Description: BK THIGH LACER GLUT/ISCHIA M Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5683 DME DEF MAXFEE 01/01/2014 12/31/2023 1061.04 0.0 Description: INITIAL CUSTOM SOCKET INSERT Category: Durable Medical CMS Add: 01/01/2004 CMS Term: L5683 DME DEF MAXFEE 01/01/2024 1511.46 0.0 Description: INITIAL CUSTOM SOCKET INSERT Category: Durable Medical CMS Add: 01/01/2004 CMS Term: L5684 DME DEF MAXFEE 01/01/2014 12/31/2023 33.67 0.0 Description: BK FORK STRAP Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5684 DME DEF MAXFEE 01/01/2024 54.99 0.0 Description: BK FORK STRAP Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5685 DME DEF MAXFEE 01/01/2014 12/31/2023 103.32 0.0 Description: BELOW KNEE SUS/SEAL SLEEVE Category: Durable Medical CMS Add: 01/01/2005 CMS Term: L5685 DME DEF MAXFEE 01/01/2024 147.20 0.0 Description: BELOW KNEE SUS/SEAL SLEEVE Category: Durable Medical CMS Add: 01/01/2005 CMS Term: L5686 DME DEF MAXFEE 01/01/2014 12/31/2023 41.31 0.0 Description: BK BACK CHECK Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5686 DME DEF MAXFEE 01/01/2024 66.13 0.0 Description: BK BACK CHECK Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5688 DME DEF MAXFEE 01/01/2014 12/31/2023 42.15 0.0 Description: BK WAIST BELT WEBBING Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,986 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L5688 DME DEF MAXFEE 01/01/2024 70.24 0.0 Description: BK WAIST BELT WEBBING Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5690 DME DEF MAXFEE 01/01/2014 12/31/2023 72.57 0.0 Description: BK WAIST BELT PADDED AND LIN Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5690 DME DEF MAXFEE 01/01/2024 143.38 0.0 Description: BK WAIST BELT PADDED AND LIN Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5692 DME DEF MAXFEE 01/01/2014 12/31/2023 91.78 0.0 Description: AK PELVIC CONTROL BELT LIGHT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5692 DME DEF MAXFEE 01/01/2024 151.80 0.0 Description: AK PELVIC CONTROL BELT LIGHT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5694 DME DEF MAXFEE 01/01/2014 12/31/2023 125.53 0.0 Description: AK PELVIC CONTROL BELT PAD/L Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5694 DME DEF MAXFEE 01/01/2024 207.25 0.0 Description: AK PELVIC CONTROL BELT PAD/L Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5695 DME DEF MAXFEE 01/01/2014 12/31/2023 112.62 0.0 Description: AK SLEEVE SUSP NEOPRENE/EQUA Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L5695 DME DEF MAXFEE 01/01/2024 186.30 0.0 Description: AK SLEEVE SUSP NEOPRENE/EQUA Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L5696 DME DEF MAXFEE 01/01/2014 12/31/2023 126.98 0.0 Description: AK/KNEE DISARTIC PELVIC JOIN Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5696 DME DEF MAXFEE 01/01/2024 225.05 0.0 Description: AK/KNEE DISARTIC PELVIC JOIN Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5697 DME DEF MAXFEE 01/01/2014 12/31/2023 55.46 0.0 Description: AK/KNEE DISARTIC PELVIC BAND Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5697 DME DEF MAXFEE 01/01/2024 106.87 0.0 Description: AK/KNEE DISARTIC PELVIC BAND Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5698 DME DEF MAXFEE 01/01/2014 12/31/2023 81.73 0.0 Description: AK/KNEE DISARTIC SILESIAN BA Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5698 DME DEF MAXFEE 01/01/2024 137.10 0.0 Description: AK/KNEE DISARTIC SILESIAN BA Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5699 DME DEF MAXFEE 01/01/2014 12/31/2023 127.73 0.0 Description: SHOULDER HARNESS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,987 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L5699 DME DEF MAXFEE 01/01/2024 234.32 0.0 Description: SHOULDER HARNESS Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5700 DME DEF MAXFEE 01/01/2014 12/31/2023 2172.33 0.0 Description: REPLACE SOCKET BELOW KNEE Category: Durable Medical CMS Add: 01/01/1994 CMS Term: L5700 DME DEF MAXFEE 01/01/2024 3524.50 0.0 Description: REPLACE SOCKET BELOW KNEE Category: Durable Medical CMS Add: 01/01/1994 CMS Term: L5701 DME DEF MAXFEE 01/01/2014 12/31/2023 2697.12 0.0 Description: REPLACE SOCKET ABOVE KNEE Category: Durable Medical CMS Add: 01/01/1994 CMS Term: L5701 DME DEF MAXFEE 01/01/2024 4372.47 0.0 Description: REPLACE SOCKET ABOVE KNEE Category: Durable Medical CMS Add: 01/01/1994 CMS Term: L5702 DME DEF MAXFEE 01/01/2014 12/31/2023 3446.36 0.0 Description: REPLACE SOCKET HIP Category: Durable Medical CMS Add: 01/01/1994 CMS Term: L5702 DME DEF MAXFEE 01/01/2024 5510.83 0.0 Description: REPLACE SOCKET HIP Category: Durable Medical CMS Add: 01/01/1994 CMS Term: L5703 DME DEF MAXFEE 01/01/2014 12/31/2023 2034.99 0.0 Description: SYMES ANKLE W/O (SACH) FOOT Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L5703 DME DEF MAXFEE 01/01/2024 2898.86 0.0 Description: SYMES ANKLE W/O (SACH) FOOT Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L5704 DME DEF MAXFEE 01/01/2014 12/31/2023 417.68 0.0 Description: CUSTOM SHAPE COVER BK Category: Durable Medical CMS Add: 01/01/1994 CMS Term: L5704 DME DEF MAXFEE 01/01/2024 718.63 0.0 Description: CUSTOM SHAPE COVER BK Category: Durable Medical CMS Add: 01/01/1994 CMS Term: L5705 DME DEF MAXFEE 01/01/2014 12/31/2023 736.86 0.0 Description: CUSTOM SHAPE COVER AK Category: Durable Medical CMS Add: 01/01/1994 CMS Term: L5705 DME DEF MAXFEE 01/01/2024 1317.52 0.0 Description: CUSTOM SHAPE COVER AK Category: Durable Medical CMS Add: 01/01/1994 CMS Term: L5706 DME DEF MAXFEE 01/01/2014 12/31/2023 722.92 0.0 Description: CUSTOM SHAPE CVR KNEE DISART Category: Durable Medical CMS Add: 01/01/1994 CMS Term: L5706 DME DEF MAXFEE 01/01/2024 1285.07 0.0 Description: CUSTOM SHAPE CVR KNEE DISART Category: Durable Medical CMS Add: 01/01/1994 CMS Term: L5707 DME DEF MAXFEE 01/01/2014 12/31/2023 981.28 0.0 Description: CUSTOM SHAPE CVR HIP DISART Category: Durable Medical CMS Add: 01/01/1994 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,988 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L5707 DME DEF MAXFEE 01/01/2024 1726.53 0.0 Description: CUSTOM SHAPE CVR HIP DISART Category: Durable Medical CMS Add: 01/01/1994 CMS Term: L5710 DME DEF MAXFEE 01/01/2014 12/31/2023 248.86 0.0 Description: KNE-SHIN EXO SNG AXI MNL LOC Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5710 DME DEF MAXFEE 01/01/2024 410.88 0.0 Description: KNE-SHIN EXO SNG AXI MNL LOC Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5711 DME DEF MAXFEE 01/01/2014 12/31/2023 422.23 0.0 Description: KNEE-SHIN EXO MNL LOCK ULTRA Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L5711 DME DEF MAXFEE 01/01/2024 689.57 0.0 Description: KNEE-SHIN EXO MNL LOCK ULTRA Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L5712 DME DEF MAXFEE 01/01/2014 12/31/2023 298.42 0.0 Description: KNEE-SHIN EXO FRICT SWG & ST Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5712 DME DEF MAXFEE 01/01/2024 492.26 0.0 Description: KNEE-SHIN EXO FRICT SWG & ST Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5714 DME DEF MAXFEE 01/01/2014 12/31/2023 348.71 0.0 Description: KNEE-SHIN EXO VARIABLE FRICT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5714 DME DEF MAXFEE 01/01/2024 500.88 0.0 Description: KNEE-SHIN EXO VARIABLE FRICT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5716 DME DEF MAXFEE 01/01/2014 12/31/2023 556.18 0.0 Description: KNEE-SHIN EXO MECH STANCE PH Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5716 DME DEF MAXFEE 01/01/2024 990.41 0.0 Description: KNEE-SHIN EXO MECH STANCE PH Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5718 DME DEF MAXFEE 01/01/2014 12/31/2023 656.91 0.0 Description: KNEE-SHIN EXO FRCT SWG & STA Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5718 DME DEF MAXFEE 01/01/2024 1059.05 0.0 Description: KNEE-SHIN EXO FRCT SWG & STA Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5722 DME DEF MAXFEE 01/01/2014 12/31/2023 735.77 0.0 Description: KNEE-SHIN PNEUM SWG FRCT EXO Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5722 DME DEF MAXFEE 01/01/2024 1287.89 0.0 Description: KNEE-SHIN PNEUM SWG FRCT EXO Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5724 DME DEF MAXFEE 01/01/2014 12/31/2023 1185.29 0.0 Description: KNEE-SHIN EXO FLUID SWING PH Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,989 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L5724 DME DEF MAXFEE 01/01/2024 1985.07 0.0 Description: KNEE-SHIN EXO FLUID SWING PH Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5726 DME DEF MAXFEE 01/01/2014 12/31/2023 1287.58 0.0 Description: KNEE-SHIN EXT JNTS FLD SWG E Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5726 DME DEF MAXFEE 01/01/2024 2363.30 0.0 Description: KNEE-SHIN EXT JNTS FLD SWG E Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5728 DME DEF MAXFEE 01/01/2014 12/31/2023 1837.79 0.0 Description: KNEE-SHIN FLUID SWG & STANCE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5728 DME DEF MAXFEE 01/01/2024 2769.53 0.0 Description: KNEE-SHIN FLUID SWG & STANCE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5780 DME DEF MAXFEE 01/01/2014 12/31/2023 911.23 0.0 Description: KNEE-SHIN PNEUM/HYDRA PNEUM Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5780 DME DEF MAXFEE 01/01/2024 1524.83 0.0 Description: KNEE-SHIN PNEUM/HYDRA PNEUM Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L5781 DME DEF MAXFEE 01/01/2014 12/31/2023 2883.17 0.0 Description: LOWER LIMB PROS VACUUM PUMP Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L5781 DME DEF MAXFEE 01/01/2024 4597.54 0.0 Description: LOWER LIMB PROS VACUUM PUMP Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L5782 DME DEF MAXFEE 01/01/2014 12/31/2023 3402.47 0.0 Description: HD LOW LIMB PROS VACUUM PUMP Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L5782 DME DEF MAXFEE 01/01/2024 4846.85 0.0 Description: HD LOW LIMB PROS VACUUM PUMP Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L5785 DME DEF MAXFEE 01/01/2014 12/31/2023 357.65 0.0 Description: EXOSKELETAL BK ULTRALT MATER Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L5785 DME DEF MAXFEE 01/01/2024 593.54 0.0 Description: EXOSKELETAL BK ULTRALT MATER Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L5790 DME DEF MAXFEE 01/01/2014 12/31/2023 498.66 0.0 Description: EXOSKELETAL AK ULTRA-LIGHT M Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L5790 DME DEF MAXFEE 01/01/2024 856.63 0.0 Description: EXOSKELETAL AK ULTRA-LIGHT M Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L5795 DME DEF MAXFEE 01/01/2014 12/31/2023 721.12 0.0 Description: EXOSKEL HIP ULTRA-LIGHT MATE Category: Durable Medical CMS Add: 01/01/1988 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,990 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L5795 DME DEF MAXFEE 01/01/2024 1226.59 0.0 Description: EXOSKEL HIP ULTRA-LIGHT MATE Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L5810 DME DEF MAXFEE 01/01/2014 12/31/2023 335.91 0.0 Description: ENDOSKEL KNEE-SHIN MNL LOCK Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L5810 DME DEF MAXFEE 01/01/2024 653.52 0.0 Description: ENDOSKEL KNEE-SHIN MNL LOCK Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L5811 DME DEF MAXFEE 01/01/2014 12/31/2023 503.64 0.0 Description: ENDO KNEE-SHIN MNL LCK ULTRA Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L5811 DME DEF MAXFEE 01/01/2024 901.86 0.0 Description: ENDO KNEE-SHIN MNL LCK ULTRA Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L5812 DME DEF MAXFEE 01/01/2014 12/31/2023 388.66 0.0 Description: ENDO KNEE-SHIN FRCT SWG & ST Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L5812 DME DEF MAXFEE 01/01/2024 678.69 0.0 Description: ENDO KNEE-SHIN FRCT SWG & ST Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L5814 DME DEF MAXFEE 01/01/2014 12/31/2023 2745.91 0.0 Description: ENDO KNEE-SHIN HYDRAL SWG PH Category: Durable Medical CMS Add: 01/01/1997 CMS Term: L5814 DME DEF MAXFEE 01/01/2024 4267.42 0.0 Description: ENDO KNEE-SHIN HYDRAL SWG PH Category: Durable Medical CMS Add: 01/01/1997 CMS Term: L5816 DME DEF MAXFEE 01/01/2014 12/31/2023 579.40 0.0 Description: ENDO KNEE-SHIN POLYC MCH STA Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L5816 DME DEF MAXFEE 01/01/2024 971.56 0.0 Description: ENDO KNEE-SHIN POLYC MCH STA Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L5818 DME DEF MAXFEE 01/01/2014 12/31/2023 669.34 0.0 Description: ENDO KNEE-SHIN FRCT SWG & ST Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L5818 DME DEF MAXFEE 01/01/2024 1097.08 0.0 Description: ENDO KNEE-SHIN FRCT SWG & ST Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L5822 DME DEF MAXFEE 01/01/2014 12/31/2023 1154.45 0.0 Description: ENDO KNEE-SHIN PNEUM SWG FRC Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L5822 DME DEF MAXFEE 01/01/2024 2012.57 0.0 Description: ENDO KNEE-SHIN PNEUM SWG FRC Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L5824 DME DEF MAXFEE 01/01/2014 12/31/2023 1166.77 0.0 Description: ENDO KNEE-SHIN FLUID SWING P Category: Durable Medical CMS Add: 01/01/1988 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,991 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L5824 DME DEF MAXFEE 01/01/2024 1902.47 0.0 Description: ENDO KNEE-SHIN FLUID SWING P Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L5826 DME DEF MAXFEE 01/01/2014 12/31/2023 2332.05 0.0 Description: MINIATURE KNEE JOINT Category: Durable Medical CMS Add: 01/01/1998 CMS Term: L5826 DME DEF MAXFEE 01/01/2024 3588.36 0.0 Description: MINIATURE KNEE JOINT Category: Durable Medical CMS Add: 01/01/1998 CMS Term: L5828 DME DEF MAXFEE 01/01/2014 12/31/2023 2062.13 0.0 Description: ENDO KNEE-SHIN FLUID SWG/STA Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L5828 DME DEF MAXFEE 01/01/2024 3385.93 0.0 Description: ENDO KNEE-SHIN FLUID SWG/STA Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L5830 DME DEF MAXFEE 01/01/2014 12/31/2023 1411.38 0.0 Description: ENDO KNEE-SHIN PNEUM/SWG PHA Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L5830 DME DEF MAXFEE 01/01/2024 2283.02 0.0 Description: ENDO KNEE-SHIN PNEUM/SWG PHA Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L5840 DME DEF MAXFEE 01/01/2014 12/31/2023 2688.62 0.0 Description: MULTI-AXIAL KNEE/SHIN SYSTEM Category: Durable Medical CMS Add: 01/01/1994 CMS Term: L5840 DME DEF MAXFEE 01/01/2024 4480.96 0.0 Description: MULTI-AXIAL KNEE/SHIN SYSTEM Category: Durable Medical CMS Add: 01/01/1994 CMS Term: L5845 DME DEF MAXFEE 01/01/2014 12/31/2023 2701.11 0.0 Description: KNEE-SHIN SYS STANCE FLEXION Category: Durable Medical CMS Add: 01/01/1996 CMS Term: L5845 DME DEF MAXFEE 01/01/2024 2059.51 0.0 Description: KNEE-SHIN SYS STANCE FLEXION Category: Durable Medical CMS Add: 01/01/1996 CMS Term: L5848 DME DEF MAXFEE 01/01/2014 12/31/2023 774.85 0.0 Description: KNEE-SHIN SYS HYDRAUL STANCE Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L5848 DME DEF MAXFEE 01/01/2024 1235.60 0.0 Description: KNEE-SHIN SYS HYDRAUL STANCE Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L5850 DME DEF MAXFEE 01/01/2014 12/31/2023 85.95 0.0 Description: ENDO AK/HIP KNEE EXTENS ASSI Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L5850 DME DEF MAXFEE 01/01/2024 146.14 0.0 Description: ENDO AK/HIP KNEE EXTENS ASSI Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L5855 DME DEF MAXFEE 01/01/2014 12/31/2023 244.98 0.0 Description: MECH HIP EXTENSION ASSIST Category: Durable Medical CMS Add: 01/01/1994 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,992 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L5855 DME DEF MAXFEE 01/01/2024 352.81 0.0 Description: MECH HIP EXTENSION ASSIST Category: Durable Medical CMS Add: 01/01/1994 CMS Term: L5856 DME DEF MAXFEE 01/01/2014 12/31/2023 17323.21 0.0 Description: ELEC KNEE-SHIN SWING/STANCE Category: Durable Medical CMS Add: 01/01/2005 CMS Term: L5856 DME DEF MAXFEE 01/01/2024 27583.78 0.0 Description: ELEC KNEE-SHIN SWING/STANCE Category: Durable Medical CMS Add: 01/01/2005 CMS Term: L5857 DME DEF MAXFEE 01/01/2014 12/31/2023 6163.08 0.0 Description: ELEC KNEE-SHIN SWING ONLY Category: Durable Medical CMS Add: 01/01/2005 CMS Term: L5857 DME DEF MAXFEE 01/01/2024 9787.76 0.0 Description: ELEC KNEE-SHIN SWING ONLY Category: Durable Medical CMS Add: 01/01/2005 CMS Term: L5858 DME DEF MAXFEE 01/01/2014 12/31/2023 14991.32 0.0 Description: STANCE PHASE ONLY Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L5858 DME DEF MAXFEE 01/01/2024 21355.23 0.0 Description: STANCE PHASE ONLY Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L5859 DME DEF MAXFEE 01/01/2024 16671.82 0.0 Description: KNEE-SHIN PRO FLEX/EXT CONT Category: Durable Medical CMS Add: 01/01/2013 CMS Term: L5859 DME DEF MAXFEE 07/01/2014 12/31/2023 13537.41 0.0 Description: KNEE-SHIN PRO FLEX/EXT CONT Category: Durable Medical CMS Add: 01/01/2013 CMS Term: L5910 DME DEF MAXFEE 01/01/2014 12/31/2023 246.31 0.0 Description: ENDO BELOW KNEE ALIGNABLE SY Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L5910 DME DEF MAXFEE 01/01/2024 413.75 0.0 Description: ENDO BELOW KNEE ALIGNABLE SY Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L5920 DME DEF MAXFEE 01/01/2014 12/31/2023 362.06 0.0 Description: ENDO AK/HIP ALIGNABLE SYSTEM Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L5920 DME DEF MAXFEE 01/01/2024 606.16 0.0 Description: ENDO AK/HIP ALIGNABLE SYSTEM Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L5925 DME DEF MAXFEE 01/01/2014 12/31/2023 266.53 0.0 Description: ABOVE KNEE MANUAL LOCK Category: Durable Medical CMS Add: 01/01/1994 CMS Term: L5925 DME DEF MAXFEE 01/01/2024 383.86 0.0 Description: ABOVE KNEE MANUAL LOCK Category: Durable Medical CMS Add: 01/01/1994 CMS Term: L5926 DME DEF MAXFEE 01/01/2024 758.03 0.0 Y Description: ENDOSKEL POSIT ROTAT UNIT Category: Durable Medical CMS Add: 01/01/2024 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,993 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L5930 DME DEF MAXFEE 01/01/2014 12/31/2023 2420.00 0.0 Description: HIGH ACTIVITY KNEE FRAME Category: Durable Medical CMS Add: 01/01/1996 CMS Term: L5930 DME DEF MAXFEE 01/01/2024 3867.59 0.0 Description: HIGH ACTIVITY KNEE FRAME Category: Durable Medical CMS Add: 01/01/1996 CMS Term: L5940 DME DEF MAXFEE 01/01/2014 12/31/2023 353.39 0.0 Description: ENDO BK ULTRA-LIGHT MATERIAL Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L5940 DME DEF MAXFEE 01/01/2024 573.04 0.0 Description: ENDO BK ULTRA-LIGHT MATERIAL Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L5950 DME DEF MAXFEE 01/01/2014 12/31/2023 535.38 0.0 Description: ENDO AK ULTRA-LIGHT MATERIAL Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L5950 DME DEF MAXFEE 01/01/2024 888.80 0.0 Description: ENDO AK ULTRA-LIGHT MATERIAL Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L5960 DME DEF MAXFEE 01/01/2014 12/31/2023 741.39 0.0 Description: ENDO HIP ULTRA-LIGHT MATERIA Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L5960 DME DEF MAXFEE 01/01/2024 1328.99 0.0 Description: ENDO HIP ULTRA-LIGHT MATERIA Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L5961 DME DEF MAXFEE 01/01/2024 5484.70 0.0 Description: ENDO POLY HIP, PNEU/HYD/ROT Category: Durable Medical CMS Add: 01/01/2011 CMS Term: L5961 DME DEF MAXFEE 12/15/2012 12/31/2023 4429.95 0.0 Description: ENDO POLY HIP, PNEU/HYD/ROT Category: Durable Medical CMS Add: 01/01/2011 CMS Term: L5962 DME DEF MAXFEE 01/01/2014 12/31/2023 466.26 0.0 Description: BELOW KNEE FLEX COVER SYSTEM Category: Durable Medical CMS Add: 01/01/1994 CMS Term: L5962 DME DEF MAXFEE 01/01/2024 671.50 0.0 Description: BELOW KNEE FLEX COVER SYSTEM Category: Durable Medical CMS Add: 01/01/1994 CMS Term: L5964 DME DEF MAXFEE 01/01/2014 12/31/2023 742.89 0.0 Description: ABOVE KNEE FLEX COVER SYSTEM Category: Durable Medical CMS Add: 01/01/1994 CMS Term: L5964 DME DEF MAXFEE 01/01/2024 1288.06 0.0 Description: ABOVE KNEE FLEX COVER SYSTEM Category: Durable Medical CMS Add: 01/01/1994 CMS Term: L5966 DME DEF MAXFEE 01/01/2014 12/31/2023 946.62 0.0 Description: HIP FLEXIBLE COVER SYSTEM Category: Durable Medical CMS Add: 01/01/1994 CMS Term: L5966 DME DEF MAXFEE 01/01/2024 1659.25 0.0 Description: HIP FLEXIBLE COVER SYSTEM Category: Durable Medical CMS Add: 01/01/1994 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,994 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L5968 DME DEF MAXFEE 01/01/2014 12/31/2023 2590.04 0.0 Description: MULTIAXIAL ANKLE W DORSIFLEX Category: Durable Medical CMS Add: 01/01/1999 CMS Term: L5968 DME DEF MAXFEE 01/01/2024 4175.50 0.0 Description: MULTIAXIAL ANKLE W DORSIFLEX Category: Durable Medical CMS Add: 01/01/1999 CMS Term: L5969 DME DEF MAXFEE 01/01/2014 12/31/2023 13709.14 0.0 Description: AK/FT POWER ASST INCL MOTORS Category: Durable Medical CMS Add: 01/01/2014 CMS Term: L5969 DME DEF MAXFEE 01/01/2024 17821.88 0.0 Description: AK/FT POWER ASST INCL MOTORS Category: Durable Medical CMS Add: 01/01/2014 CMS Term: L5970 DME DEF MAXFEE 01/01/2014 12/31/2023 140.45 0.0 Description: FOOT EXTERNAL KEEL SACH FOOT Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L5970 DME DEF MAXFEE 01/01/2024 249.59 0.0 Description: FOOT EXTERNAL KEEL SACH FOOT Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L5971 DME DEF MAXFEE 01/01/2014 12/31/2023 175.23 0.0 Description: SACH FOOT, REPLACEMENT Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L5971 DME DEF MAXFEE 01/01/2024 249.59 0.0 Description: SACH FOOT, REPLACEMENT Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L5972 DME DEF MAXFEE 01/01/2014 12/31/2023 303.92 0.0 Description: FLEXIBLE KEEL FOOT Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L5972 DME DEF MAXFEE 01/01/2024 454.66 0.0 Description: FLEXIBLE KEEL FOOT Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L5973 NOCOV DEF SYSMAN Description: ANK-FOOT SYS DORS-PLANT FLEX Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: L5974 DME DEF MAXFEE 01/01/2014 12/31/2023 197.51 0.0 Description: FOOT SINGLE AXIS ANKLE/FOOT Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L5974 DME DEF MAXFEE 01/01/2024 266.22 0.0 Description: FOOT SINGLE AXIS ANKLE/FOOT Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L5975 DME DEF MAXFEE 01/01/2014 12/31/2023 330.42 0.0 Description: COMBO ANKLE/FOOT PROSTHESIS Category: Durable Medical CMS Add: 01/01/1999 CMS Term: L5975 DME DEF MAXFEE 01/01/2024 532.70 0.0 Description: COMBO ANKLE/FOOT PROSTHESIS Category: Durable Medical CMS Add: 01/01/1999 CMS Term: L5976 DME DEF MAXFEE 01/01/2014 12/31/2023 439.57 0.0 Description: ENERGY STORING FOOT Category: Durable Medical CMS Add: 01/01/1989 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,995 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L5976 DME DEF MAXFEE 01/01/2024 675.26 0.0 Description: ENERGY STORING FOOT Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L5978 DME DEF MAXFEE 01/01/2014 12/31/2023 204.28 0.0 Description: FT PROSTH MULTIAXIAL ANKL/FT Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L5978 DME DEF MAXFEE 01/01/2024 357.81 0.0 Description: FT PROSTH MULTIAXIAL ANKL/FT Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L5979 DME DEF MAXFEE 01/01/2014 12/31/2023 1809.99 0.0 Description: MULTI-AXIAL ANKLE/FT PROSTH Category: Durable Medical CMS Add: 01/01/1994 CMS Term: L5979 DME DEF MAXFEE 01/01/2024 2864.88 0.0 Description: MULTI-AXIAL ANKLE/FT PROSTH Category: Durable Medical CMS Add: 01/01/1994 CMS Term: L5980 DME DEF MAXFEE 01/01/2014 12/31/2023 2802.27 0.0 Description: FLEX FOOT SYSTEM Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L5980 DME DEF MAXFEE 01/01/2024 4364.90 0.0 Description: FLEX FOOT SYSTEM Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L5981 DME DEF MAXFEE 01/01/2014 12/31/2023 2284.67 0.0 Description: FLEX-WALK SYS LOW EXT PROSTH Category: Durable Medical CMS Add: 01/01/1994 CMS Term: L5981 DME DEF MAXFEE 01/01/2024 3920.74 0.0 Description: FLEX-WALK SYS LOW EXT PROSTH Category: Durable Medical CMS Add: 01/01/1994 CMS Term: L5982 DME DEF MAXFEE 01/01/2014 12/31/2023 415.91 0.0 Description: EXOSKELETAL AXIAL ROTATION U Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L5982 DME DEF MAXFEE 01/01/2024 736.54 0.0 Description: EXOSKELETAL AXIAL ROTATION U Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L5984 DME DEF MAXFEE 01/01/2014 12/31/2023 459.16 0.0 Description: ENDOSKELETAL AXIAL ROTATION Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L5984 DME DEF MAXFEE 01/01/2024 738.82 0.0 Description: ENDOSKELETAL AXIAL ROTATION Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L5985 DME DEF MAXFEE 01/01/2014 12/31/2023 203.10 0.0 Description: LWR EXT DYNAMIC PROSTH PYLON Category: Durable Medical CMS Add: 01/01/1996 CMS Term: L5985 DME DEF MAXFEE 01/01/2024 324.48 0.0 Description: LWR EXT DYNAMIC PROSTH PYLON Category: Durable Medical CMS Add: 01/01/1996 CMS Term: L5986 DME DEF MAXFEE 01/01/2014 12/31/2023 537.02 0.0 Description: MULTI-AXIAL ROTATION UNIT Category: Durable Medical CMS Add: 01/01/1989 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,996 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L5986 DME DEF MAXFEE 01/01/2024 891.23 0.0 Description: MULTI-AXIAL ROTATION UNIT Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L5987 DME DEF MAXFEE 01/01/2014 12/31/2023 5318.79 0.0 Description: SHANK FT W VERT LOAD PYLON Category: Durable Medical CMS Add: 01/01/1997 CMS Term: L5987 DME DEF MAXFEE 01/01/2024 8265.96 0.0 Description: SHANK FT W VERT LOAD PYLON Category: Durable Medical CMS Add: 01/01/1997 CMS Term: L5988 DME DEF MAXFEE 01/01/2014 12/31/2023 1423.84 0.0 Description: VERTICAL SHOCK REDUCING PYLO Category: Durable Medical CMS Add: 01/01/1999 CMS Term: L5988 DME DEF MAXFEE 01/01/2024 2295.44 0.0 Description: VERTICAL SHOCK REDUCING PYLO Category: Durable Medical CMS Add: 01/01/1999 CMS Term: L5990 DME DEF MAXFEE 01/01/2014 12/31/2023 1293.06 0.0 Description: USER ADJUSTABLE HEEL HEIGHT Category: Durable Medical CMS Add: 01/01/2002 CMS Term: L5990 DME DEF MAXFEE 01/01/2024 2084.54 0.0 Description: USER ADJUSTABLE HEEL HEIGHT Category: Durable Medical CMS Add: 01/01/2002 CMS Term: L5991 DME DEF MAXFEE 10/01/2023 10969.24 0.0 Y 22-65years Description: LOW PROS EXT OSSEO CONNECTOR Category: Durable Medical CMS Add: 10/01/2023 CMS Term: L5999 DME DEF SYSMAN Y Description: LOWR EXTREMITY PROSTHES NOS Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L6000 DME DEF MAXFEE 01/01/2014 12/31/2023 1232.42 0.0 Description: PART HAND THUMB REM Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L6000 DME DEF MAXFEE 01/01/2024 2023.88 0.0 Description: PART HAND THUMB REM Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L6010 DME DEF MAXFEE 01/01/2014 12/31/2023 1372.61 0.0 Description: PART HAND LITTLE/RING Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L6010 DME DEF MAXFEE 01/01/2024 2252.25 0.0 Description: PART HAND LITTLE/RING Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L6020 DME DEF MAXFEE 01/01/2014 12/31/2023 1271.02 0.0 Description: PART HAND NO FINGERS Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L6020 DME DEF MAXFEE 01/01/2024 2099.86 0.0 Description: PART HAND NO FINGERS Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L6026 DME DEF MAXFEE 01/01/2015 12/31/2023 4171.65 0.0 Description: PART HAND MYO EXCLU TERM DEV Category: Durable Medical CMS Add: 01/01/2015 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,997 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L6026 DME DEF MAXFEE 01/01/2024 4998.20 0.0 Description: PART HAND MYO EXCLU TERM DEV Category: Durable Medical CMS Add: 01/01/2015 CMS Term: L6050 DME DEF MAXFEE 01/01/2014 12/31/2023 1658.10 0.0 Description: WRST MLD SCK FLX HNG TRI PAD Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L6050 DME DEF MAXFEE 01/01/2024 2856.23 0.0 Description: WRST MLD SCK FLX HNG TRI PAD Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L6055 DME DEF MAXFEE 01/01/2014 12/31/2023 1897.24 0.0 Description: WRST MOLD SOCK W/EXP INTERFA Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6055 DME DEF MAXFEE 01/01/2024 3643.28 0.0 Description: WRST MOLD SOCK W/EXP INTERFA Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6100 DME DEF MAXFEE 01/01/2014 12/31/2023 1668.13 0.0 Description: ELB MOLD SOCK FLEX HINGE PAD Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L6100 DME DEF MAXFEE 01/01/2024 2890.41 0.0 Description: ELB MOLD SOCK FLEX HINGE PAD Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L6110 DME DEF MAXFEE 01/01/2014 12/31/2023 1753.94 0.0 Description: ELBOW MOLD SOCK SUSPENSION T Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L6110 DME DEF MAXFEE 01/01/2024 3057.86 0.0 Description: ELBOW MOLD SOCK SUSPENSION T Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L6120 DME DEF MAXFEE 01/01/2014 12/31/2023 1960.21 0.0 Description: ELBOW MOLD DOUB SPLT SOC STE Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L6120 DME DEF MAXFEE 01/01/2024 3458.45 0.0 Description: ELBOW MOLD DOUB SPLT SOC STE Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L6130 DME DEF MAXFEE 01/01/2014 12/31/2023 2124.52 0.0 Description: ELBOW STUMP ACTIVATED LOCK H Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L6130 DME DEF MAXFEE 01/01/2024 3648.73 0.0 Description: ELBOW STUMP ACTIVATED LOCK H Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L6200 DME DEF MAXFEE 01/01/2014 12/31/2023 2287.63 0.0 Description: ELBOW MOLD OUTSID LOCK HINGE Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L6200 DME DEF MAXFEE 01/01/2024 3758.63 0.0 Description: ELBOW MOLD OUTSID LOCK HINGE Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L6205 DME DEF MAXFEE 01/01/2014 12/31/2023 3074.80 0.0 Description: ELBOW MOLDED W/ EXPAND INTER Category: Durable Medical CMS Add: 01/01/1988 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,998 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L6205 DME DEF MAXFEE 01/01/2024 5184.95 0.0 Description: ELBOW MOLDED W/ EXPAND INTER Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6250 DME DEF MAXFEE 01/01/2014 12/31/2023 2270.62 0.0 Description: ELBOW INTER LOC ELBOW FORARM Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L6250 DME DEF MAXFEE 01/01/2024 3697.83 0.0 Description: ELBOW INTER LOC ELBOW FORARM Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L6300 DME DEF MAXFEE 01/01/2014 12/31/2023 3070.39 0.0 Description: SHLDER DISART INT LOCK ELBOW Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L6300 DME DEF MAXFEE 01/01/2024 5100.33 0.0 Description: SHLDER DISART INT LOCK ELBOW Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L6310 DME DEF MAXFEE 01/01/2014 12/31/2023 2707.65 0.0 Description: SHOULDER PASSIVE RESTOR COMP Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L6310 DME DEF MAXFEE 01/01/2024 4622.35 0.0 Description: SHOULDER PASSIVE RESTOR COMP Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L6320 DME DEF MAXFEE 01/01/2014 12/31/2023 1428.18 0.0 Description: SHOULDER PASSIVE RESTOR CAP Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L6320 DME DEF MAXFEE 01/01/2024 2409.02 0.0 Description: SHOULDER PASSIVE RESTOR CAP Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L6350 DME DEF MAXFEE 01/01/2014 12/31/2023 3319.87 0.0 Description: THORACIC INTERN LOCK ELBOW Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L6350 DME DEF MAXFEE 01/01/2024 5588.38 0.0 Description: THORACIC INTERN LOCK ELBOW Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L6360 DME DEF MAXFEE 01/01/2014 12/31/2023 2912.79 0.0 Description: THORACIC PASSIVE RESTOR COMP Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L6360 DME DEF MAXFEE 01/01/2024 4851.70 0.0 Description: THORACIC PASSIVE RESTOR COMP Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L6370 DME DEF MAXFEE 01/01/2014 12/31/2023 1647.55 0.0 Description: THORACIC PASSIVE RESTOR CAP Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L6370 DME DEF MAXFEE 01/01/2024 2813.66 0.0 Description: THORACIC PASSIVE RESTOR CAP Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L6380 DME DEF MAXFEE 01/01/2014 12/31/2023 903.41 0.0 Description: POSTOP DSG CAST CHG WRST/ELB Category: Durable Medical CMS Add: 01/01/1988 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1,999 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L6380 DME DEF MAXFEE 01/01/2024 1627.34 0.0 Description: POSTOP DSG CAST CHG WRST/ELB Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6382 DME DEF MAXFEE 01/01/2014 12/31/2023 1046.98 0.0 Description: POSTOP DSG CAST CHG ELB DIS/ Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6382 DME DEF MAXFEE 01/01/2024 1937.27 0.0 Description: POSTOP DSG CAST CHG ELB DIS/ Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6384 DME DEF MAXFEE 01/01/2014 12/31/2023 1311.58 0.0 Description: POSTOP DSG CAST CHG SHLDER/T Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6384 DME DEF MAXFEE 01/01/2024 2450.76 0.0 Description: POSTOP DSG CAST CHG SHLDER/T Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6386 DME DEF MAXFEE 01/01/2014 12/31/2023 292.22 0.0 Description: POSTOP EA CAST CHG & REALIGN Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6386 DME DEF MAXFEE 01/01/2024 537.22 0.0 Description: POSTOP EA CAST CHG & REALIGN Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6388 DME DEF MAXFEE 01/01/2014 12/31/2023 333.46 0.0 Description: POSTOP APPLICAT RIGID DSG ON Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6388 DME DEF MAXFEE 01/01/2024 591.61 0.0 Description: POSTOP APPLICAT RIGID DSG ON Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6400 DME DEF MAXFEE 01/01/2014 12/31/2023 1919.97 0.0 Description: BELOW ELBOW PROSTH TISS SHAP Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L6400 DME DEF MAXFEE 01/01/2024 3126.69 0.0 Description: BELOW ELBOW PROSTH TISS SHAP Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L6450 DME DEF MAXFEE 01/01/2014 12/31/2023 2535.17 0.0 Description: ELB DISART PROSTH TISS SHAP Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L6450 DME DEF MAXFEE 01/01/2024 4086.42 0.0 Description: ELB DISART PROSTH TISS SHAP Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L6500 DME DEF MAXFEE 01/01/2014 12/31/2023 2491.66 0.0 Description: ABOVE ELBOW PROSTH TISS SHAP Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L6500 DME DEF MAXFEE 01/01/2024 4012.79 0.0 Description: ABOVE ELBOW PROSTH TISS SHAP Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L6550 DME DEF MAXFEE 01/01/2014 12/31/2023 3118.08 0.0 Description: SHLDR DISAR PROSTH TISS SHAP Category: Durable Medical CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,000 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L6550 DME DEF MAXFEE 01/01/2024 5197.39 0.0 Description: SHLDR DISAR PROSTH TISS SHAP Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L6570 DME DEF MAXFEE 01/01/2014 12/31/2023 3455.55 0.0 Description: SCAP THORAC PROSTH TISS SHAP Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L6570 DME DEF MAXFEE 01/01/2024 5802.20 0.0 Description: SCAP THORAC PROSTH TISS SHAP Category: Durable Medical CMS Add: 01/01/1984 CMS Term: L6580 DME DEF MAXFEE 01/01/2014 12/31/2023 1234.57 0.0 Description: WRIST/ELBOW BOWDEN CABLE MOL Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6580 DME DEF MAXFEE 01/01/2024 2319.85 0.0 Description: WRIST/ELBOW BOWDEN CABLE MOL Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6582 DME DEF MAXFEE 01/01/2014 12/31/2023 1050.35 0.0 Description: WRIST/ELBOW BOWDEN CBL DIR F Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6582 DME DEF MAXFEE 01/01/2024 1948.36 0.0 Description: WRIST/ELBOW BOWDEN CBL DIR F Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6584 DME DEF MAXFEE 01/01/2014 12/31/2023 1538.03 0.0 Description: ELBOW FAIR LEAD CABLE MOLDED Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6584 DME DEF MAXFEE 01/01/2024 2885.00 0.0 Description: ELBOW FAIR LEAD CABLE MOLDED Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6586 DME DEF MAXFEE 01/01/2014 12/31/2023 1368.45 0.0 Description: ELBOW FAIR LEAD CABLE DIR FO Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6586 DME DEF MAXFEE 01/01/2024 2570.71 0.0 Description: ELBOW FAIR LEAD CABLE DIR FO Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6588 DME DEF MAXFEE 01/01/2014 12/31/2023 2264.99 0.0 Description: SHDR FAIR LEAD CABLE MOLDED Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6588 DME DEF MAXFEE 01/01/2024 4094.19 0.0 Description: SHDR FAIR LEAD CABLE MOLDED Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6590 DME DEF MAXFEE 01/01/2014 12/31/2023 2003.63 0.0 Description: SHDR FAIR LEAD CABLE DIRECT Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6590 DME DEF MAXFEE 01/01/2024 3568.24 0.0 Description: SHDR FAIR LEAD CABLE DIRECT Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6600 DME DEF MAXFEE 01/01/2014 12/31/2023 134.37 0.0 Description: POLYCENTRIC HINGE PAIR Category: Durable Medical CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,001 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L6600 DME DEF MAXFEE 01/01/2024 260.62 0.0 Description: POLYCENTRIC HINGE PAIR Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L6605 DME DEF MAXFEE 01/01/2014 12/31/2023 138.60 0.0 Description: SINGLE PIVOT HINGE PAIR Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L6605 DME DEF MAXFEE 01/01/2024 268.26 0.0 Description: SINGLE PIVOT HINGE PAIR Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L6610 DME DEF MAXFEE 01/01/2014 12/31/2023 151.49 0.0 Description: FLEXIBLE METAL HINGE PAIR Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L6610 DME DEF MAXFEE 01/01/2024 253.60 0.0 Description: FLEXIBLE METAL HINGE PAIR Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L6611 DME DEF MAXFEE 01/01/2014 12/31/2023 309.44 0.0 Description: ADDITIONAL SWITCH, EXT POWER Category: Durable Medical CMS Add: 01/01/2007 CMS Term: L6611 DME DEF MAXFEE 01/01/2024 473.08 0.0 Description: ADDITIONAL SWITCH, EXT POWER Category: Durable Medical CMS Add: 01/01/2007 CMS Term: L6615 DME DEF MAXFEE 01/01/2014 12/31/2023 144.79 0.0 Description: DISCONNECT LOCKING WRIST UNI Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L6615 DME DEF MAXFEE 01/01/2024 246.17 0.0 Description: DISCONNECT LOCKING WRIST UNI Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L6616 DME DEF MAXFEE 01/01/2014 12/31/2023 44.92 0.0 Description: DISCONNECT INSERT LOCKING WR Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L6616 DME DEF MAXFEE 01/01/2024 74.10 0.0 Description: DISCONNECT INSERT LOCKING WR Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L6620 DME DEF MAXFEE 01/01/2014 12/31/2023 282.08 0.0 Description: FLEXION/EXTENSION WRIST UNIT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L6620 DME DEF MAXFEE 01/01/2024 430.34 0.0 Description: FLEXION/EXTENSION WRIST UNIT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L6621 DME DEF MAXFEE 01/01/2014 12/31/2023 1845.00 0.0 Description: FLEX/EXT WRIST W/WO FRICTION Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L6621 DME DEF MAXFEE 01/01/2024 2628.22 0.0 Description: FLEX/EXT WRIST W/WO FRICTION Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L6623 DME DEF MAXFEE 01/01/2014 12/31/2023 493.36 0.0 Description: SPRING-ASS ROT WRST W/ LATCH Category: Durable Medical CMS Add: 01/01/1988 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,002 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L6623 DME DEF MAXFEE 01/01/2024 819.80 0.0 Description: SPRING-ASS ROT WRST W/ LATCH Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6624 DME DEF MAXFEE 01/01/2014 12/31/2023 2830.47 0.0 Description: FLEX/EXT/ROTATION WRIST UNIT Category: Durable Medical CMS Add: 01/01/2007 CMS Term: L6624 DME DEF MAXFEE 01/01/2024 4327.39 0.0 Description: FLEX/EXT/ROTATION WRIST UNIT Category: Durable Medical CMS Add: 01/01/2007 CMS Term: L6625 DME DEF MAXFEE 01/01/2014 12/31/2023 356.33 0.0 Description: ROTATION WRST W/ CABLE LOCK Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L6625 DME DEF MAXFEE 01/01/2024 607.59 0.0 Description: ROTATION WRST W/ CABLE LOCK Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L6628 DME DEF MAXFEE 01/01/2014 12/31/2023 390.84 0.0 Description: QUICK DISCONN HOOK ADAPTER O Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6628 DME DEF MAXFEE 01/01/2024 654.02 0.0 Description: QUICK DISCONN HOOK ADAPTER O Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6629 DME DEF MAXFEE 01/01/2014 12/31/2023 138.13 0.0 Description: LAMINATION COLLAR W/ COUPLIN Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6629 DME DEF MAXFEE 01/01/2024 222.85 0.0 Description: LAMINATION COLLAR W/ COUPLIN Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6630 DME DEF MAXFEE 01/01/2014 12/31/2023 187.37 0.0 Description: STAINLESS STEEL ANY WRIST Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L6630 DME DEF MAXFEE 01/01/2024 328.28 0.0 Description: STAINLESS STEEL ANY WRIST Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L6632 DME DEF MAXFEE 01/01/2014 12/31/2023 45.62 0.0 Description: LATEX SUSPENSION SLEEVE EACH Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6632 DME DEF MAXFEE 01/01/2024 74.22 0.0 Description: LATEX SUSPENSION SLEEVE EACH Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6635 DME DEF MAXFEE 01/01/2014 12/31/2023 157.91 0.0 Description: LIFT ASSIST FOR ELBOW Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L6635 DME DEF MAXFEE 01/01/2024 237.26 0.0 Description: LIFT ASSIST FOR ELBOW Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L6637 DME DEF MAXFEE 01/01/2014 12/31/2023 251.68 0.0 Description: NUDGE CONTROL ELBOW LOCK Category: Durable Medical CMS Add: 01/01/1988 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,003 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L6637 DME DEF MAXFEE 01/01/2024 464.52 0.0 Description: NUDGE CONTROL ELBOW LOCK Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6638 DME DEF MAXFEE 01/01/2014 12/31/2023 1801.98 0.0 Description: ELEC LOCK ON MANUAL PW ELBOW Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L6638 DME DEF MAXFEE 01/01/2024 2873.46 0.0 Description: ELEC LOCK ON MANUAL PW ELBOW Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L6640 DME DEF MAXFEE 01/01/2014 12/31/2023 215.81 0.0 Description: SHOULDER ABDUCTION JOINT PAI Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L6640 DME DEF MAXFEE 01/01/2024 386.86 0.0 Description: SHOULDER ABDUCTION JOINT PAI Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L6641 DME DEF MAXFEE 01/01/2014 12/31/2023 113.73 0.0 Description: EXCURSION AMPLIFIER PULLEY T Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6641 DME DEF MAXFEE 01/01/2024 225.27 0.0 Description: EXCURSION AMPLIFIER PULLEY T Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6642 DME DEF MAXFEE 01/01/2014 12/31/2023 195.06 0.0 Description: EXCURSION AMPLIFIER LEVER TY Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6642 DME DEF MAXFEE 01/01/2024 331.22 0.0 Description: EXCURSION AMPLIFIER LEVER TY Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6645 DME DEF MAXFEE 01/01/2014 12/31/2023 245.41 0.0 Description: SHOULDER FLEXION-ABDUCTION J Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L6645 DME DEF MAXFEE 01/01/2024 418.38 0.0 Description: SHOULDER FLEXION-ABDUCTION J Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L6646 DME DEF MAXFEE 01/01/2014 12/31/2023 2272.70 0.0 Description: MULTIPO LOCKING SHOULDER JNT Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L6646 DME DEF MAXFEE 01/01/2024 3624.08 0.0 Description: MULTIPO LOCKING SHOULDER JNT Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L6647 DME DEF MAXFEE 01/01/2014 12/31/2023 374.16 0.0 Description: SHOULDER LOCK ACTUATOR Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L6647 DME DEF MAXFEE 01/01/2024 596.65 0.0 Description: SHOULDER LOCK ACTUATOR Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L6648 DME DEF MAXFEE 01/01/2014 12/31/2023 2343.98 0.0 Description: EXT PWRD SHLDER LOCK/UNLOCK Category: Durable Medical CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,004 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L6648 DME DEF MAXFEE 01/01/2024 3737.73 0.0 Description: EXT PWRD SHLDER LOCK/UNLOCK Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L6650 DME DEF MAXFEE 01/01/2014 12/31/2023 249.86 0.0 Description: SHOULDER UNIVERSAL JOINT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L6650 DME DEF MAXFEE 01/01/2024 453.78 0.0 Description: SHOULDER UNIVERSAL JOINT Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L6655 DME DEF MAXFEE 01/01/2014 12/31/2023 54.01 0.0 Description: STANDARD CONTROL CABLE EXTRA Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L6655 DME DEF MAXFEE 01/01/2024 88.03 0.0 Description: STANDARD CONTROL CABLE EXTRA Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L6660 DME DEF MAXFEE 01/01/2014 12/31/2023 65.99 0.0 Description: HEAVY DUTY CONTROL CABLE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L6660 DME DEF MAXFEE 01/01/2024 117.80 0.0 Description: HEAVY DUTY CONTROL CABLE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L6665 DME DEF MAXFEE 01/01/2014 12/31/2023 31.14 0.0 Description: TEFLON OR EQUAL CABLE LINING Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L6665 DME DEF MAXFEE 01/01/2024 52.61 0.0 Description: TEFLON OR EQUAL CABLE LINING Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L6670 DME DEF MAXFEE 01/01/2014 12/31/2023 32.56 0.0 Description: HOOK TO HAND CABLE ADAPTER Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L6670 DME DEF MAXFEE 01/01/2024 54.79 0.0 Description: HOOK TO HAND CABLE ADAPTER Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L6672 DME DEF MAXFEE 01/01/2014 12/31/2023 148.13 0.0 Description: HARNESS CHEST/SHLDER SADDLE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L6672 DME DEF MAXFEE 01/01/2024 251.42 0.0 Description: HARNESS CHEST/SHLDER SADDLE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L6675 DME DEF MAXFEE 01/01/2014 12/31/2023 80.42 0.0 Description: HARNESS FIGURE OF 8 SING CON Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L6675 DME DEF MAXFEE 01/01/2024 137.20 0.0 Description: HARNESS FIGURE OF 8 SING CON Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L6676 DME DEF MAXFEE 01/01/2014 12/31/2023 84.62 0.0 Description: HARNESS FIGURE OF 8 DUAL CON Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,005 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L6676 DME DEF MAXFEE 01/01/2024 143.54 0.0 Description: HARNESS FIGURE OF 8 DUAL CON Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L6677 DME DEF MAXFEE 01/01/2014 12/31/2023 239.27 0.0 Description: UE TRIPLE CONTROL HARNESS Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L6677 DME DEF MAXFEE 01/01/2024 340.85 0.0 Description: UE TRIPLE CONTROL HARNESS Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L6680 DME DEF MAXFEE 01/01/2014 12/31/2023 169.32 0.0 Description: TEST SOCK WRIST DISART/BEL E Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L6680 DME DEF MAXFEE 01/01/2024 353.39 0.0 Description: TEST SOCK WRIST DISART/BEL E Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L6682 DME DEF MAXFEE 01/01/2014 12/31/2023 217.66 0.0 Description: TEST SOCK ELBW DISART/ABOVE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L6682 DME DEF MAXFEE 01/01/2024 390.73 0.0 Description: TEST SOCK ELBW DISART/ABOVE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L6684 DME DEF MAXFEE 01/01/2014 12/31/2023 287.51 0.0 Description: TEST SOCKET SHLDR DISART/THO Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L6684 DME DEF MAXFEE 01/01/2024 530.95 0.0 Description: TEST SOCKET SHLDR DISART/THO Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L6686 DME DEF MAXFEE 01/01/2014 12/31/2023 424.65 0.0 Description: SUCTION SOCKET Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6686 DME DEF MAXFEE 01/01/2024 787.86 0.0 Description: SUCTION SOCKET Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6687 DME DEF MAXFEE 01/01/2014 12/31/2023 396.05 0.0 Description: FRAME TYP SOCKET BEL ELBOW/W Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6687 DME DEF MAXFEE 01/01/2024 658.95 0.0 Description: FRAME TYP SOCKET BEL ELBOW/W Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6688 DME DEF MAXFEE 01/01/2014 12/31/2023 372.98 0.0 Description: FRAME TYP SOCK ABOVE ELB/DIS Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6688 DME DEF MAXFEE 01/01/2024 729.29 0.0 Description: FRAME TYP SOCK ABOVE ELB/DIS Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6689 DME DEF MAXFEE 01/01/2014 12/31/2023 470.87 0.0 Description: FRAME TYP SOCKET SHOULDER DI Category: Durable Medical CMS Add: 01/01/1988 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,006 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L6689 DME DEF MAXFEE 01/01/2024 869.18 0.0 Description: FRAME TYP SOCKET SHOULDER DI Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6690 DME DEF MAXFEE 01/01/2014 12/31/2023 496.19 0.0 Description: FRAME TYP SOCK INTERSCAP-THO Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6690 DME DEF MAXFEE 01/01/2024 1023.32 0.0 Description: FRAME TYP SOCK INTERSCAP-THO Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6691 DME DEF MAXFEE 01/01/2014 12/31/2023 234.49 0.0 Description: REMOVABLE INSERT EACH Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6691 DME DEF MAXFEE 01/01/2024 403.94 0.0 Description: REMOVABLE INSERT EACH Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6692 DME DEF MAXFEE 01/01/2014 12/31/2023 410.83 0.0 Description: SILICONE GEL INSERT OR EQUAL Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L6692 DME DEF MAXFEE 01/01/2024 734.88 0.0 Description: SILICONE GEL INSERT OR EQUAL Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L6693 DME DEF MAXFEE 01/01/2014 12/31/2023 2023.47 0.0 Description: LOCKINGELBOW FOREARM CNTRBAL Category: Durable Medical CMS Add: 01/01/1999 CMS Term: L6693 DME DEF MAXFEE 01/01/2024 3262.15 0.0 Description: LOCKINGELBOW FOREARM CNTRBAL Category: Durable Medical CMS Add: 01/01/1999 CMS Term: L6694 DME DEF MAXFEE 01/01/2014 12/31/2023 633.97 0.0 Description: ELBOW SOCKET INS USE W/LOCK Category: Durable Medical CMS Add: 01/01/2005 CMS Term: L6694 DME DEF MAXFEE 01/01/2024 903.12 0.0 Description: ELBOW SOCKET INS USE W/LOCK Category: Durable Medical CMS Add: 01/01/2005 CMS Term: L6695 DME DEF MAXFEE 01/01/2014 12/31/2023 528.30 0.0 Description: ELBOW SOCKET INS USE W/O LCK Category: Durable Medical CMS Add: 01/01/2005 CMS Term: L6695 DME DEF MAXFEE 01/01/2024 752.58 0.0 Description: ELBOW SOCKET INS USE W/O LCK Category: Durable Medical CMS Add: 01/01/2005 CMS Term: L6696 DME DEF MAXFEE 01/01/2014 12/31/2023 1061.04 0.0 Description: CUS ELBO SKT IN FOR CON/ATYP Category: Durable Medical CMS Add: 01/01/2005 CMS Term: L6696 DME DEF MAXFEE 01/01/2024 1511.46 0.0 Description: CUS ELBO SKT IN FOR CON/ATYP Category: Durable Medical CMS Add: 01/01/2005 CMS Term: L6697 DME DEF MAXFEE 01/01/2014 12/31/2023 1061.04 0.0 Description: CUS ELBO SKT IN NOT CON/ATYP Category: Durable Medical CMS Add: 01/01/2005 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,007 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L6697 DME DEF MAXFEE 01/01/2024 1511.46 0.0 Description: CUS ELBO SKT IN NOT CON/ATYP Category: Durable Medical CMS Add: 01/01/2005 CMS Term: L6698 DME DEF MAXFEE 01/01/2014 12/31/2023 398.91 0.0 Description: BELOW/ABOVE ELBOW LOCK MECH Category: Durable Medical CMS Add: 01/01/2005 CMS Term: L6698 DME DEF MAXFEE 01/01/2024 568.25 0.0 Description: BELOW/ABOVE ELBOW LOCK MECH Category: Durable Medical CMS Add: 01/01/2005 CMS Term: L6703 DME DEF MAXFEE 01/01/2014 12/31/2023 294.26 0.0 Description: TERM DEV, PASSIVE HAND MITT Category: Durable Medical CMS Add: 01/01/2007 CMS Term: L6703 DME DEF MAXFEE 01/01/2024 401.90 0.0 Description: TERM DEV, PASSIVE HAND MITT Category: Durable Medical CMS Add: 01/01/2007 CMS Term: L6704 DME DEF MAXFEE 01/01/2014 12/31/2023 568.01 0.0 Description: TERM DEV, SPORT/REC/WORK ATT Category: Durable Medical CMS Add: 01/01/2007 CMS Term: L6704 DME DEF MAXFEE 01/01/2024 775.78 0.0 Description: TERM DEV, SPORT/REC/WORK ATT Category: Durable Medical CMS Add: 01/01/2007 CMS Term: L6706 DME DEF MAXFEE 01/01/2014 12/31/2023 352.50 0.0 Description: TERM DEV MECH HOOK VOL OPEN Category: Durable Medical CMS Add: 01/01/2007 CMS Term: L6706 DME DEF MAXFEE 01/01/2024 481.42 0.0 Description: TERM DEV MECH HOOK VOL OPEN Category: Durable Medical CMS Add: 01/01/2007 CMS Term: L6707 DME DEF MAXFEE 01/01/2014 12/31/2023 1246.92 0.0 Description: TERM DEV MECH HOOK VOL CLOSE Category: Durable Medical CMS Add: 01/01/2007 CMS Term: L6707 DME DEF MAXFEE 01/01/2024 1703.04 0.0 Description: TERM DEV MECH HOOK VOL CLOSE Category: Durable Medical CMS Add: 01/01/2007 CMS Term: L6708 DME DEF MAXFEE 01/01/2014 12/31/2023 824.26 0.0 Description: TERM DEV MECH HAND VOL OPEN Category: Durable Medical CMS Add: 01/01/2007 CMS Term: L6708 DME DEF MAXFEE 01/01/2024 1125.77 0.0 Description: TERM DEV MECH HAND VOL OPEN Category: Durable Medical CMS Add: 01/01/2007 CMS Term: L6709 DME DEF MAXFEE 01/01/2014 12/31/2023 1169.84 0.0 Description: TERM DEV MECH HAND VOL CLOSE Category: Durable Medical CMS Add: 01/01/2007 CMS Term: L6709 DME DEF MAXFEE 01/01/2024 1597.76 0.0 Description: TERM DEV MECH HAND VOL CLOSE Category: Durable Medical CMS Add: 01/01/2007 CMS Term: L6711 DME DEF MAXFEE 01/01/2014 12/31/2023 609.93 0.0 Description: PED TERM DEV, HOOK, VOL OPEN Category: Durable Medical CMS Add: 01/01/2009 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,008 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L6711 DME DEF MAXFEE 01/01/2024 772.51 0.0 Description: PED TERM DEV, HOOK, VOL OPEN Category: Durable Medical CMS Add: 01/01/2009 CMS Term: L6712 DME DEF MAXFEE 01/01/2014 12/31/2023 1123.04 0.0 Description: PED TERM DEV, HOOK, VOL CLOS Category: Durable Medical CMS Add: 01/01/2009 CMS Term: L6712 DME DEF MAXFEE 01/01/2024 1422.39 0.0 Description: PED TERM DEV, HOOK, VOL CLOS Category: Durable Medical CMS Add: 01/01/2009 CMS Term: L6713 DME DEF MAXFEE 01/01/2014 12/31/2023 1417.35 0.0 Description: PED TERM DEV, HAND, VOL OPEN Category: Durable Medical CMS Add: 01/01/2009 CMS Term: L6713 DME DEF MAXFEE 01/01/2024 1795.15 0.0 Description: PED TERM DEV, HAND, VOL OPEN Category: Durable Medical CMS Add: 01/01/2009 CMS Term: L6714 DME DEF MAXFEE 01/01/2014 12/31/2023 1200.50 0.0 Description: PED TERM DEV, HAND, VOL CLOS Category: Durable Medical CMS Add: 01/01/2009 CMS Term: L6714 DME DEF MAXFEE 01/01/2024 1520.48 0.0 Description: PED TERM DEV, HAND, VOL CLOS Category: Durable Medical CMS Add: 01/01/2009 CMS Term: L6715 DME DEF MAXFEE 01/01/2024 3627.72 0.0 Description: TERM DEVICE, MULTI ART DIGIT Category: Durable Medical CMS Add: 01/01/2012 CMS Term: L6715 DME DEF MAXFEE 07/01/2014 12/31/2023 2983.05 0.0 Description: TERM DEVICE, MULTI ART DIGIT Category: Durable Medical CMS Add: 01/01/2012 CMS Term: L6721 DME DEF MAXFEE 01/01/2014 12/31/2023 2133.78 0.0 Description: HOOK/HAND, HVY DTY, VOL OPEN Category: Durable Medical CMS Add: 01/01/2009 CMS Term: L6721 DME DEF MAXFEE 01/01/2024 2702.54 0.0 Description: HOOK/HAND, HVY DTY, VOL OPEN Category: Durable Medical CMS Add: 01/01/2009 CMS Term: L6722 DME DEF MAXFEE 01/01/2014 12/31/2023 1839.46 0.0 Description: HOOK/HAND, HVY DTY, VOL CLOS Category: Durable Medical CMS Add: 01/01/2009 CMS Term: L6722 DME DEF MAXFEE 01/01/2024 2329.75 0.0 Description: HOOK/HAND, HVY DTY, VOL CLOS Category: Durable Medical CMS Add: 01/01/2009 CMS Term: L6805 DME DEF MAXFEE 01/01/2014 12/31/2023 281.30 0.0 Description: TERM DEV MODIFIER WRIST UNIT Category: Durable Medical CMS Add: 01/01/1985 CMS Term: L6805 DME DEF MAXFEE 01/01/2024 440.69 0.0 Description: TERM DEV MODIFIER WRIST UNIT Category: Durable Medical CMS Add: 01/01/1985 CMS Term: L6810 DME DEF MAXFEE 01/01/2014 12/31/2023 135.68 0.0 Description: TERM DEV PRECISION PINCH DEV Category: Durable Medical CMS Add: 01/01/1988 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,009 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L6810 DME DEF MAXFEE 01/01/2024 234.28 0.0 Description: TERM DEV PRECISION PINCH DEV Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6880 DME DEF MAXFEE 01/01/2024 27453.53 0.0 Description: ELEC HAND IND ART DIGITS Category: Durable Medical CMS Add: 01/01/2012 CMS Term: L6880 DME DEF MAXFEE 07/01/2014 12/31/2023 22574.88 0.0 Description: ELEC HAND IND ART DIGITS Category: Durable Medical CMS Add: 01/01/2012 CMS Term: L6881 DME DEF MAXFEE 01/01/2014 12/31/2023 2913.86 0.0 Description: TERM DEV AUTO GRASP FEATURE Category: Durable Medical CMS Add: 01/01/2002 CMS Term: L6881 DME DEF MAXFEE 01/01/2024 4697.60 0.0 Description: TERM DEV AUTO GRASP FEATURE Category: Durable Medical CMS Add: 01/01/2002 CMS Term: L6882 DME DEF MAXFEE 01/01/2014 12/31/2023 2210.31 0.0 Description: MICROPROCESSOR CONTROL UPLMB Category: Durable Medical CMS Add: 01/01/2002 CMS Term: L6882 DME DEF MAXFEE 01/01/2024 3563.35 0.0 Description: MICROPROCESSOR CONTROL UPLMB Category: Durable Medical CMS Add: 01/01/2002 CMS Term: L6883 DME DEF MAXFEE 01/01/2014 12/31/2023 1602.34 0.0 Description: REPLC SOCKT BELOW E/W DISA Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L6883 DME DEF MAXFEE 01/01/2024 2282.55 0.0 Description: REPLC SOCKT BELOW E/W DISA Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L6884 DME DEF MAXFEE 01/01/2014 12/31/2023 2192.38 0.0 Description: REPLC SOCKT ABOVE ELBOW DISA Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L6884 DME DEF MAXFEE 01/01/2024 3123.05 0.0 Description: REPLC SOCKT ABOVE ELBOW DISA Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L6885 DME DEF MAXFEE 01/01/2014 12/31/2023 3405.88 0.0 Description: REPLC SOCKT SHLDR DIS/INTERC Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L6885 DME DEF MAXFEE 01/01/2024 4851.70 0.0 Description: REPLC SOCKT SHLDR DIS/INTERC Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L6890 DME DEF MAXFEE 01/01/2014 12/31/2023 142.37 0.0 Description: PREFAB GLOVE FOR TERM DEVICE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L6890 DME DEF MAXFEE 01/01/2024 229.49 0.0 Description: PREFAB GLOVE FOR TERM DEVICE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L6895 DME DEF MAXFEE 01/01/2014 12/31/2023 470.64 0.0 Description: CUSTOM GLOVE FOR TERM DEVICE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,010 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L6895 DME DEF MAXFEE 01/01/2024 767.36 0.0 Description: CUSTOM GLOVE FOR TERM DEVICE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L6900 DME DEF MAXFEE 01/01/2014 12/31/2023 1347.57 0.0 Description: HAND RESTORAT THUMB/1 FINGER Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L6900 DME DEF MAXFEE 01/01/2024 2228.35 0.0 Description: HAND RESTORAT THUMB/1 FINGER Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L6905 DME DEF MAXFEE 01/01/2014 12/31/2023 1340.61 0.0 Description: HAND RESTORATION MULTIPLE FI Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L6905 DME DEF MAXFEE 01/01/2024 2205.44 0.0 Description: HAND RESTORATION MULTIPLE FI Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L6910 DME DEF MAXFEE 01/01/2014 12/31/2023 1310.66 0.0 Description: HAND RESTORATION NO FINGERS Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L6910 DME DEF MAXFEE 01/01/2024 2168.10 0.0 Description: HAND RESTORATION NO FINGERS Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L6915 DME DEF MAXFEE 01/01/2014 12/31/2023 491.65 0.0 Description: HAND RESTORATION REPLACMNT G Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L6915 DME DEF MAXFEE 01/01/2024 931.55 0.0 Description: HAND RESTORATION REPLACMNT G Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L6920 DME DEF MAXFEE 01/01/2014 12/31/2023 5812.21 0.0 Description: WRIST DISARTICUL SWITCH CTRL Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6920 DME DEF MAXFEE 01/01/2024 9625.47 0.0 Description: WRIST DISARTICUL SWITCH CTRL Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6925 DME DEF MAXFEE 01/01/2014 12/31/2023 5649.51 0.0 Description: WRIST DISART MYOELECTRONIC C Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6925 DME DEF MAXFEE 01/01/2024 10283.22 0.0 Description: WRIST DISART MYOELECTRONIC C Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6930 DME DEF MAXFEE 01/01/2014 12/31/2023 5770.83 0.0 Description: BELOW ELBOW SWITCH CONTROL Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6930 DME DEF MAXFEE 01/01/2024 9270.68 0.0 Description: BELOW ELBOW SWITCH CONTROL Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6935 DME DEF MAXFEE 01/01/2014 12/31/2023 6191.70 0.0 Description: BELOW ELBOW MYOELECTRONIC CT Category: Durable Medical CMS Add: 01/01/1988 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,011 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L6935 DME DEF MAXFEE 01/01/2024 10234.89 0.0 Description: BELOW ELBOW MYOELECTRONIC CT Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6940 DME DEF MAXFEE 01/01/2014 12/31/2023 6924.39 0.0 Description: ELBOW DISARTICULATION SWITCH Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6940 DME DEF MAXFEE 01/01/2024 11971.48 0.0 Description: ELBOW DISARTICULATION SWITCH Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6945 DME DEF MAXFEE 01/01/2014 12/31/2023 7777.52 0.0 Description: ELBOW DISART MYOELECTRONIC C Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6945 DME DEF MAXFEE 01/01/2024 13355.74 0.0 Description: ELBOW DISART MYOELECTRONIC C Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6950 DME DEF MAXFEE 01/01/2014 12/31/2023 7201.48 0.0 Description: ABOVE ELBOW SWITCH CONTROL Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6950 DME DEF MAXFEE 01/01/2024 11949.28 0.0 Description: ABOVE ELBOW SWITCH CONTROL Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6955 DME DEF MAXFEE 01/01/2014 12/31/2023 8563.61 0.0 Description: ABOVE ELBOW MYOELECTRONIC CT Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6955 DME DEF MAXFEE 01/01/2024 13857.41 0.0 Description: ABOVE ELBOW MYOELECTRONIC CT Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6960 DME DEF MAXFEE 01/01/2014 12/31/2023 8420.30 0.0 Description: SHLDR DISARTIC SWITCH CONTRO Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6960 DME DEF MAXFEE 01/01/2024 14577.46 0.0 Description: SHLDR DISARTIC SWITCH CONTRO Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6965 DME DEF MAXFEE 01/01/2014 12/31/2023 9918.12 0.0 Description: SHLDR DISARTIC MYOELECTRONIC Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6965 DME DEF MAXFEE 01/01/2024 17269.26 0.0 Description: SHLDR DISARTIC MYOELECTRONIC Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6970 DME DEF MAXFEE 01/01/2014 12/31/2023 7093.58 0.0 Description: INTERSCAPULAR-THOR SWITCH CT Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6970 DME DEF MAXFEE 01/01/2024 18484.83 0.0 Description: INTERSCAPULAR-THOR SWITCH CT Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L6975 DME DEF MAXFEE 01/01/2014 12/31/2023 7322.40 0.0 Description: INTERSCAP-THOR MYOELECTRONIC Category: Durable Medical CMS Add: 01/01/1988 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,012 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L6975 DME DEF MAXFEE 01/01/2024 20374.64 0.0 Description: INTERSCAP-THOR MYOELECTRONIC Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L7007 DME DEF MAXFEE 01/01/2014 12/31/2023 3072.89 0.0 15-999years Description: ADULT ELECTRIC HAND Category: Durable Medical CMS Add: 01/01/2007 CMS Term: L7007 DME DEF MAXFEE 01/01/2024 4196.90 0.0 15-999years Description: ADULT ELECTRIC HAND Category: Durable Medical CMS Add: 01/01/2007 CMS Term: L7008 DME DEF MAXFEE 01/01/2014 12/31/2023 4765.16 0.0 0-19years Description: PEDIATRIC ELECTRIC HAND Category: Durable Medical CMS Add: 01/01/2007 CMS Term: L7008 DME DEF MAXFEE 01/01/2024 6508.13 0.0 0-19years Description: PEDIATRIC ELECTRIC HAND Category: Durable Medical CMS Add: 01/01/2007 CMS Term: L7009 DME DEF MAXFEE 01/01/2014 12/31/2023 3143.94 0.0 15-999years Description: ADULT ELECTRIC HOOK Category: Durable Medical CMS Add: 01/01/2007 CMS Term: L7009 DME DEF MAXFEE 01/01/2024 4293.93 0.0 15-999years Description: ADULT ELECTRIC HOOK Category: Durable Medical CMS Add: 01/01/2007 CMS Term: L7040 DME DEF MAXFEE 01/01/2014 12/31/2023 2049.99 0.0 Description: PREHENSILE ACTUATOR Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L7040 DME DEF MAXFEE 01/01/2024 3494.98 0.0 Description: PREHENSILE ACTUATOR Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L7045 DME DEF MAXFEE 01/01/2014 12/31/2023 1067.51 0.0 Description: PEDIATRIC ELECTRIC HOOK Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L7045 DME DEF MAXFEE 01/01/2024 1846.51 0.0 Description: PEDIATRIC ELECTRIC HOOK Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L7170 DME DEF MAXFEE 01/01/2014 12/31/2023 4180.48 0.0 Description: ELECTRONIC ELBOW HOSMER SWIT Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L7170 DME DEF MAXFEE 01/01/2024 6911.74 0.0 Description: ELECTRONIC ELBOW HOSMER SWIT Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L7180 DME DEF MAXFEE 01/01/2014 12/31/2023 25912.94 0.0 Description: ELECTRONIC ELBOW SEQUENTIAL Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L7180 DME DEF MAXFEE 01/01/2024 44716.65 0.0 Description: ELECTRONIC ELBOW SEQUENTIAL Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L7181 DME DEF MAXFEE 01/01/2024 46040.03 0.0 Description: ELECTRONIC ELBO SIMULTANEOUS Category: Durable Medical CMS Add: 01/01/2005 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,013 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L7181 DME DEF MAXFEE 07/01/2014 12/31/2023 37858.44 0.0 Description: ELECTRONIC ELBO SIMULTANEOUS Category: Durable Medical CMS Add: 01/01/2005 CMS Term: L7185 DME DEF MAXFEE 01/01/2014 12/31/2023 4403.54 0.0 Description: ELECTRON ELBOW ADOLESCENT SW Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L7185 DME DEF MAXFEE 01/01/2024 7266.49 0.0 Description: ELECTRON ELBOW ADOLESCENT SW Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L7186 DME DEF MAXFEE 01/01/2014 12/31/2023 7543.91 0.0 Description: ELECTRON ELBOW CHILD SWITCH Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L7186 DME DEF MAXFEE 01/01/2024 12215.99 0.0 Description: ELECTRON ELBOW CHILD SWITCH Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L7190 DME DEF MAXFEE 01/01/2014 12/31/2023 5674.24 0.0 Description: ELBOW ADOLESCENT MYOELECTRON Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L7190 DME DEF MAXFEE 01/01/2024 9641.94 0.0 Description: ELBOW ADOLESCENT MYOELECTRON Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L7191 DME DEF MAXFEE 01/01/2014 12/31/2023 8006.19 0.0 Description: ELBOW CHILD MYOELECTRONIC CT Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L7191 DME DEF MAXFEE 01/01/2024 12849.29 0.0 Description: ELBOW CHILD MYOELECTRONIC CT Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L7259 DME DEF MAXFEE 01/01/2015 12/31/2023 3930.32 0.0 Description: ELECTRONIC WRIST ROTATOR ANY Category: Durable Medical CMS Add: 01/01/2015 CMS Term: L7259 DME DEF MAXFEE 01/01/2024 4709.06 0.0 Description: ELECTRONIC WRIST ROTATOR ANY Category: Durable Medical CMS Add: 01/01/2015 CMS Term: L7360 DME DEF MAXFEE 01/01/2014 12/31/2023 160.97 0.0 Description: SIX VOLT BAT OTTO BOCK/EQ EA Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L7360 DME DEF MAXFEE 01/01/2024 303.98 0.0 Description: SIX VOLT BAT OTTO BOCK/EQ EA Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L7362 DME DEF MAXFEE 01/01/2014 12/31/2023 194.22 0.0 Description: BATTERY CHRGR SIX VOLT OTTO Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L7362 DME DEF MAXFEE 01/01/2024 332.08 0.0 Description: BATTERY CHRGR SIX VOLT OTTO Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L7364 DME DEF MAXFEE 01/01/2014 12/31/2023 346.66 0.0 Description: TWELVE VOLT BATTERY UTAH/EQU Category: Durable Medical CMS Add: 01/01/1988 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,014 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L7364 DME DEF MAXFEE 01/01/2024 587.59 0.0 Description: TWELVE VOLT BATTERY UTAH/EQU Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L7366 DME DEF MAXFEE 01/01/2014 12/31/2023 478.81 0.0 Description: BATTERY CHRGR 12 VOLT UTAH/E Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L7366 DME DEF MAXFEE 01/01/2024 808.09 0.0 Description: BATTERY CHRGR 12 VOLT UTAH/E Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L7367 DME DEF MAXFEE 01/01/2014 12/31/2023 280.54 0.0 Description: REPLACEMNT LITHIUM IONBATTER Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L7367 DME DEF MAXFEE 01/01/2024 447.37 0.0 Description: REPLACEMNT LITHIUM IONBATTER Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L7368 DME DEF MAXFEE 01/01/2014 12/31/2023 363.67 0.0 Description: LITHIUM ION BATTERY CHARGER Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L7368 DME DEF MAXFEE 01/01/2024 579.91 0.0 Description: LITHIUM ION BATTERY CHARGER Category: Durable Medical CMS Add: 01/01/2003 CMS Term: L7400 DME DEF MAXFEE 01/01/2014 12/31/2023 247.22 0.0 Description: ADD UE PROST BE/WD, ULTLITE Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L7400 DME DEF MAXFEE 01/01/2024 352.16 0.0 Description: ADD UE PROST BE/WD, ULTLITE Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L7401 DME DEF MAXFEE 01/01/2014 12/31/2023 276.75 0.0 Description: ADD UE PROST A/E ULTLITE MAT Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L7401 DME DEF MAXFEE 01/01/2024 394.21 0.0 Description: ADD UE PROST A/E ULTLITE MAT Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L7402 DME DEF MAXFEE 01/01/2014 12/31/2023 298.88 0.0 Description: ADD UE PROST S/D ULTLITE MAT Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L7402 DME DEF MAXFEE 01/01/2024 425.77 0.0 Description: ADD UE PROST S/D ULTLITE MAT Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L7403 DME DEF MAXFEE 01/01/2014 12/31/2023 297.05 0.0 Description: ADD UE PROST B/E ACRYLIC Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L7403 DME DEF MAXFEE 01/01/2024 423.17 0.0 Description: ADD UE PROST B/E ACRYLIC Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L7404 DME DEF MAXFEE 01/01/2014 12/31/2023 448.34 0.0 Description: ADD UE PROST A/E ACRYLIC Category: Durable Medical CMS Add: 01/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,015 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L7404 DME DEF MAXFEE 01/01/2024 638.69 0.0 Description: ADD UE PROST A/E ACRYLIC Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L7405 DME DEF MAXFEE 01/01/2014 12/31/2023 586.34 0.0 Description: ADD UE PROST S/D ACRYLIC Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L7405 DME DEF MAXFEE 01/01/2024 835.24 0.0 Description: ADD UE PROST S/D ACRYLIC Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L7499 DME DEF SYSMAN Y Description: UPPER EXTREMITY PROSTHES NOS Category: Durable Medical CMS Add: 01/01/1985 CMS Term: L7510 DME DEF SYSMAN Y Description: PROSTHETIC DEVICE REPAIR REP Category: Durable Medical CMS Add: 01/01/1985 CMS Term: L7520 DME DEF MAXFEE 01/01/2024 38.26 0.0 Description: REPAIR PROSTHESIS PER 15 MIN Category: Durable Medical CMS Add: 01/01/1997 CMS Term: L7520 DME DEF MAXFEE 07/01/2014 12/31/2023 29.43 0.0 Description: REPAIR PROSTHESIS PER 15 MIN Category: Durable Medical CMS Add: 01/01/1997 CMS Term: L7600 DME DEF SYSMAN Y Description: PROSTHETIC DONNING SLEEVE Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L7700 DME DEF MAXFEE 01/01/2018 12/31/2023 145.49 0.0 Description: PROS SOC INSERT GASKET/SEAL Category: Durable Medical CMS Add: 01/01/2018 CMS Term: L7700 DME DEF MAXFEE 01/01/2024 171.91 0.0 Description: PROS SOC INSERT GASKET/SEAL Category: Durable Medical CMS Add: 01/01/2018 CMS Term: L7900 NOCOV DEF SYSMAN Description: MALE VACUUM ERECTION SYSTEM Category: Non Covered Services CMS Add: 01/01/1997 CMS Term: L7902 NOCOV DEF SYSMAN Description: TENSION RING, VAC ERECT DEV Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: L8000 DME DEF MAXFEE 01/01/2014 12/31/2023 33.56 0.0 Description: MASTECTOMY BRA Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L8000 DME DEF MAXFEE 01/01/2024 48.65 0.0 Description: MASTECTOMY BRA Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L8001 DME DEF MAXFEE 01/01/2014 12/31/2023 89.40 0.0 Description: BREAST PROSTHESIS BRA & FORM Category: Durable Medical CMS Add: 01/01/2002 CMS Term: L8001 DME DEF MAXFEE 01/01/2024 144.16 0.0 Description: BREAST PROSTHESIS BRA & FORM Category: Durable Medical CMS Add: 01/01/2002 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,016 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L8002 DME DEF MAXFEE 01/01/2014 12/31/2023 117.59 0.0 Description: BRST PRSTH BRA & BILAT FORM Category: Durable Medical CMS Add: 01/01/2002 CMS Term: L8002 DME DEF MAXFEE 01/01/2024 189.57 0.0 Description: BRST PRSTH BRA & BILAT FORM Category: Durable Medical CMS Add: 01/01/2002 CMS Term: L8010 DME DEF MAXFEE 01/01/2014 12/31/2023 40.56 0.0 Description: MASTECTOMY SLEEVE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L8010 DME DEF MAXFEE 01/01/2024 52.73 0.0 Description: MASTECTOMY SLEEVE Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L8015 DME DEF MAXFEE 01/01/2014 12/31/2023 42.82 0.0 Description: EXT BREASTPROSTHESIS GARMENT Category: Durable Medical CMS Add: 01/01/1999 CMS Term: L8015 DME DEF MAXFEE 01/01/2024 68.87 0.0 Description: EXT BREASTPROSTHESIS GARMENT Category: Durable Medical CMS Add: 01/01/1999 CMS Term: L8020 DME DEF MAXFEE 01/01/2014 12/31/2023 176.58 0.0 Description: MASTECTOMY FORM Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L8020 DME DEF MAXFEE 01/01/2024 259.79 0.0 Description: MASTECTOMY FORM Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L8030 DME DEF MAXFEE 01/01/2014 12/31/2023 262.92 0.0 Description: BREAST PROSTHES W/O ADHESIVE Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L8030 DME DEF MAXFEE 01/01/2024 401.62 0.0 Description: BREAST PROSTHES W/O ADHESIVE Category: Durable Medical CMS Add: 01/01/1989 CMS Term: L8031 DME DEF MAXFEE 01/01/2014 12/31/2023 317.10 0.0 Description: BREAST PROSTHESIS W ADHESIVE Category: Durable Medical CMS Add: 01/01/2010 CMS Term: L8031 DME DEF MAXFEE 01/01/2024 401.62 0.0 Description: BREAST PROSTHESIS W ADHESIVE Category: Durable Medical CMS Add: 01/01/2010 CMS Term: L8032 NOCOV DEF SYSMAN Description: REUSABLE NIPPLE PROSTHESIS Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: L8033 NOCOV DEF SYSMAN Description: NIPPLE PROSTHESIS CUSTOM, EA Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: L8035 DME DEF MAXFEE 01/01/2014 12/31/2023 2611.22 0.0 Description: CUSTOM BREAST PROSTHESIS Category: Durable Medical CMS Add: 01/01/1999 CMS Term: L8035 DME DEF MAXFEE 01/01/2024 4209.64 0.0 Description: CUSTOM BREAST PROSTHESIS Category: Durable Medical CMS Add: 01/01/1999 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,017 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L8039 DME DEF SYSMAN Y Description: BREAST PROSTHESIS NOS Category: Durable Medical CMS Add: 01/01/1998 CMS Term: L8040 DME DEF MAXFEE 01/01/2014 12/31/2023 1290.00 0.0 Description: NASAL PROSTHESIS Category: Durable Medical CMS Add: 01/01/2001 CMS Term: L8040 DME DEF MAXFEE 01/01/2024 2848.67 0.0 Description: NASAL PROSTHESIS Category: Durable Medical CMS Add: 01/01/2001 CMS Term: L8040 KM DME DEF MAXFEE 01/01/2014 12/31/2023 1225.49 0.0 Description: NASAL PROSTHESIS Category: Durable Medical CMS Add: 01/01/2001 CMS Term: L8040 KM DME DEF MAXFEE 01/01/2024 2706.24 0.0 Description: NASAL PROSTHESIS Category: Durable Medical CMS Add: 01/01/2001 CMS Term: L8040 KN DME DEF MAXFEE 01/01/2014 12/31/2023 516.00 0.0 Description: NASAL PROSTHESIS Category: Durable Medical CMS Add: 01/01/2001 CMS Term: L8040 KN DME DEF MAXFEE 01/01/2024 1139.46 0.0 Description: NASAL PROSTHESIS Category: Durable Medical CMS Add: 01/01/2001 CMS Term: L8041 DME DEF MAXFEE 01/01/2014 12/31/2023 1554.73 0.0 Description: MIDFACIAL PROSTHESIS Category: Durable Medical CMS Add: 01/01/2001 CMS Term: L8041 DME DEF MAXFEE 01/01/2024 3433.26 0.0 Description: MIDFACIAL PROSTHESIS Category: Durable Medical CMS Add: 01/01/2001 CMS Term: L8041 KM DME DEF MAXFEE 01/01/2014 12/31/2023 1476.99 0.0 Description: MIDFACIAL PROSTHESIS Category: Durable Medical CMS Add: 01/01/2001 CMS Term: L8041 KM DME DEF MAXFEE 01/01/2024 3261.55 0.0 Description: MIDFACIAL PROSTHESIS Category: Durable Medical CMS Add: 01/01/2001 CMS Term: L8041 KN DME DEF MAXFEE 01/01/2014 12/31/2023 621.90 0.0 Description: MIDFACIAL PROSTHESIS Category: Durable Medical CMS Add: 01/01/2001 CMS Term: L8041 KN DME DEF MAXFEE 01/01/2024 1373.32 0.0 Description: MIDFACIAL PROSTHESIS Category: Durable Medical CMS Add: 01/01/2001 CMS Term: L8042 DME DEF MAXFEE 01/01/2014 12/31/2023 1746.89 0.0 Description: ORBITAL PROSTHESIS Category: Durable Medical CMS Add: 01/01/2001 CMS Term: L8042 DME DEF MAXFEE 01/01/2024 3857.58 0.0 Description: ORBITAL PROSTHESIS Category: Durable Medical CMS Add: 01/01/2001 CMS Term: L8042 KM DME DEF MAXFEE 01/01/2014 12/31/2023 1659.55 0.0 Description: ORBITAL PROSTHESIS Category: Durable Medical CMS Add: 01/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,018 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L8042 KM DME DEF MAXFEE 01/01/2024 3664.72 0.0 Description: ORBITAL PROSTHESIS Category: Durable Medical CMS Add: 01/01/2001 CMS Term: L8042 KN DME DEF MAXFEE 01/01/2014 12/31/2023 698.76 0.0 Description: ORBITAL PROSTHESIS Category: Durable Medical CMS Add: 01/01/2001 CMS Term: L8042 KN DME DEF MAXFEE 01/01/2024 1543.05 0.0 Description: ORBITAL PROSTHESIS Category: Durable Medical CMS Add: 01/01/2001 CMS Term: L8043 DME DEF MAXFEE 01/01/2014 12/31/2023 1956.51 0.0 Description: UPPER FACIAL PROSTHESIS Category: Durable Medical CMS Add: 01/01/2001 CMS Term: L8043 DME DEF MAXFEE 01/01/2024 4320.51 0.0 Description: UPPER FACIAL PROSTHESIS Category: Durable Medical CMS Add: 01/01/2001 CMS Term: L8043 KM DME DEF MAXFEE 01/01/2014 12/31/2023 1858.69 0.0 Description: UPPER FACIAL PROSTHESIS Category: Durable Medical CMS Add: 01/01/2001 CMS Term: L8043 KM DME DEF MAXFEE 01/01/2024 4104.50 0.0 Description: UPPER FACIAL PROSTHESIS Category: Durable Medical CMS Add: 01/01/2001 CMS Term: L8043 KN DME DEF MAXFEE 01/01/2014 12/31/2023 782.61 0.0 Description: UPPER FACIAL PROSTHESIS Category: Durable Medical CMS Add: 01/01/2001 CMS Term: L8043 KN DME DEF MAXFEE 01/01/2024 1728.22 0.0 Description: UPPER FACIAL PROSTHESIS Category: Durable Medical CMS Add: 01/01/2001 CMS Term: L8044 DME DEF MAXFEE 01/01/2014 12/31/2023 2166.14 0.0 Description: HEMI-FACIAL PROSTHESIS Category: Durable Medical CMS Add: 01/01/2001 CMS Term: L8044 DME DEF MAXFEE 01/01/2024 4783.41 0.0 Description: HEMI-FACIAL PROSTHESIS Category: Durable Medical CMS Add: 01/01/2001 CMS Term: L8044 KM DME DEF MAXFEE 01/01/2014 12/31/2023 2057.83 0.0 Description: HEMI-FACIAL PROSTHESIS Category: Durable Medical CMS Add: 01/01/2001 CMS Term: L8044 KM DME DEF MAXFEE 01/01/2024 4544.21 0.0 Description: HEMI-FACIAL PROSTHESIS Category: Durable Medical CMS Add: 01/01/2001 CMS Term: L8044 KN DME DEF MAXFEE 01/01/2014 12/31/2023 866.46 0.0 Description: HEMI-FACIAL PROSTHESIS Category: Durable Medical CMS Add: 01/01/2001 CMS Term: L8044 KN DME DEF MAXFEE 01/01/2024 1913.35 0.0 Description: HEMI-FACIAL PROSTHESIS Category: Durable Medical CMS Add: 01/01/2001 CMS Term: L8045 DME DEF MAXFEE 01/01/2014 12/31/2023 1679.35 0.0 Description: AURICULAR PROSTHESIS Category: Durable Medical CMS Add: 01/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,019 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L8045 DME DEF MAXFEE 01/01/2024 3745.73 0.0 Description: AURICULAR PROSTHESIS Category: Durable Medical CMS Add: 01/01/2001 CMS Term: L8045 KM DME DEF MAXFEE 01/01/2014 12/31/2023 1595.39 0.0 Description: AURICULAR PROSTHESIS Category: Durable Medical CMS Add: 01/01/2001 CMS Term: L8045 KM DME DEF MAXFEE 01/01/2024 3558.44 0.0 Description: AURICULAR PROSTHESIS Category: Durable Medical CMS Add: 01/01/2001 CMS Term: L8045 KN DME DEF MAXFEE 01/01/2014 12/31/2023 671.74 0.0 Description: AURICULAR PROSTHESIS Category: Durable Medical CMS Add: 01/01/2001 CMS Term: L8045 KN DME DEF MAXFEE 01/01/2024 1498.29 0.0 Description: AURICULAR PROSTHESIS Category: Durable Medical CMS Add: 01/01/2001 CMS Term: L8046 DME DEF MAXFEE 01/01/2014 12/31/2023 1397.51 0.0 Description: PARTIAL FACIAL PROSTHESIS Category: Durable Medical CMS Add: 01/01/2001 CMS Term: L8046 DME DEF MAXFEE 01/01/2024 3086.10 0.0 Description: PARTIAL FACIAL PROSTHESIS Category: Durable Medical CMS Add: 01/01/2001 CMS Term: L8046 KM DME DEF MAXFEE 01/01/2014 12/31/2023 1327.63 0.0 Description: PARTIAL FACIAL PROSTHESIS Category: Durable Medical CMS Add: 01/01/2001 CMS Term: L8046 KM DME DEF MAXFEE 01/01/2024 2931.78 0.0 Description: PARTIAL FACIAL PROSTHESIS Category: Durable Medical CMS Add: 01/01/2001 CMS Term: L8046 KN DME DEF MAXFEE 01/01/2014 12/31/2023 559.00 0.0 Description: PARTIAL FACIAL PROSTHESIS Category: Durable Medical CMS Add: 01/01/2001 CMS Term: L8046 KN DME DEF MAXFEE 01/01/2024 1234.45 0.0 Description: PARTIAL FACIAL PROSTHESIS Category: Durable Medical CMS Add: 01/01/2001 CMS Term: L8047 DME DEF MAXFEE 01/01/2014 12/31/2023 716.22 0.0 Description: NASAL SEPTAL PROSTHESIS Category: Durable Medical CMS Add: 01/01/2001 CMS Term: L8047 DME DEF MAXFEE 01/01/2024 1581.62 0.0 Description: NASAL SEPTAL PROSTHESIS Category: Durable Medical CMS Add: 01/01/2001 CMS Term: L8047 KM DME DEF MAXFEE 01/01/2014 12/31/2023 680.42 0.0 Description: NASAL SEPTAL PROSTHESIS Category: Durable Medical CMS Add: 01/01/2001 CMS Term: L8047 KM DME DEF MAXFEE 01/01/2024 1502.54 0.0 Description: NASAL SEPTAL PROSTHESIS Category: Durable Medical CMS Add: 01/01/2001 CMS Term: L8047 KN DME DEF MAXFEE 01/01/2014 12/31/2023 286.49 0.0 Description: NASAL SEPTAL PROSTHESIS Category: Durable Medical CMS Add: 01/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,020 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L8047 KN DME DEF MAXFEE 01/01/2024 632.68 0.0 Description: NASAL SEPTAL PROSTHESIS Category: Durable Medical CMS Add: 01/01/2001 CMS Term: L8048 DME DEF SYSMAN Y Description: UNSPEC MAXILLOFACIAL PROSTH Category: Durable Medical CMS Add: 01/01/2001 CMS Term: L8049 DME DEF MAXFEE 01/01/2001 12/31/2023 15.69 0.0 Description: REPAIR MAXILLOFACIAL PROSTH Category: Durable Medical CMS Add: 01/01/2001 CMS Term: L8049 DME DEF MAXFEE 01/01/2024 20.40 0.0 Description: REPAIR MAXILLOFACIAL PROSTH Category: Durable Medical CMS Add: 01/01/2001 CMS Term: L8300 DME DEF MAXFEE 01/01/2014 12/31/2023 58.30 0.0 Description: TRUSS SINGLE W/ STANDARD PAD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L8300 DME DEF MAXFEE 01/01/2024 96.37 0.0 Description: TRUSS SINGLE W/ STANDARD PAD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L8310 DME DEF MAXFEE 01/01/2014 12/31/2023 116.38 0.0 Description: TRUSS DOUBLE W/ STANDARD PAD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L8310 DME DEF MAXFEE 01/01/2024 170.72 0.0 Description: TRUSS DOUBLE W/ STANDARD PAD Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L8320 DME DEF MAXFEE 01/01/2014 12/31/2023 40.74 0.0 Description: TRUSS ADDITION TO STD PAD WA Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L8320 DME DEF MAXFEE 01/01/2024 70.83 0.0 Description: TRUSS ADDITION TO STD PAD WA Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L8330 DME DEF MAXFEE 01/01/2014 12/31/2023 33.65 0.0 Description: TRUSS ADD TO STD PAD SCROTAL Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L8330 DME DEF MAXFEE 01/01/2024 56.40 0.0 Description: TRUSS ADD TO STD PAD SCROTAL Category: Durable Medical CMS Add: 01/01/1986 CMS Term: L8400 DME DEF MAXFEE 01/01/2014 12/31/2023 11.08 0.0 Description: SHEATH BELOW KNEE Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L8400 DME DEF MAXFEE 01/01/2024 17.98 0.0 Description: SHEATH BELOW KNEE Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L8410 DME DEF MAXFEE 01/01/2014 12/31/2023 14.27 0.0 Description: SHEATH ABOVE KNEE Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L8410 DME DEF MAXFEE 01/01/2024 23.67 0.0 Description: SHEATH ABOVE KNEE Category: Durable Medical CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,021 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L8415 DME DEF MAXFEE 01/01/2014 12/31/2023 17.69 0.0 Description: SHEATH UPPER LIMB Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L8415 DME DEF MAXFEE 01/01/2024 24.49 0.0 Description: SHEATH UPPER LIMB Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L8417 DME DEF MAXFEE 01/01/2014 12/31/2023 55.60 0.0 Description: PROS SHEATH/SOCK W GEL CUSHN Category: Durable Medical CMS Add: 01/01/1997 CMS Term: L8417 DME DEF MAXFEE 01/01/2024 86.42 0.0 Description: PROS SHEATH/SOCK W GEL CUSHN Category: Durable Medical CMS Add: 01/01/1997 CMS Term: L8420 DME DEF MAXFEE 01/01/2014 12/31/2023 14.67 0.0 Description: PROSTHETIC SOCK MULTI PLY BK Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L8420 DME DEF MAXFEE 01/01/2024 23.97 0.0 Description: PROSTHETIC SOCK MULTI PLY BK Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L8430 DME DEF MAXFEE 01/01/2014 12/31/2023 15.85 0.0 Description: PROSTHETIC SOCK MULTI PLY AK Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L8430 DME DEF MAXFEE 01/01/2024 27.14 0.0 Description: PROSTHETIC SOCK MULTI PLY AK Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L8435 DME DEF MAXFEE 01/01/2014 12/31/2023 15.52 0.0 Description: PROS SOCK MULTI PLY UPPER LM Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L8435 DME DEF MAXFEE 01/01/2024 25.79 0.0 Description: PROS SOCK MULTI PLY UPPER LM Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L8440 DME DEF MAXFEE 01/01/2014 12/31/2023 28.86 0.0 Description: SHRINKER BELOW KNEE Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L8440 DME DEF MAXFEE 01/01/2024 53.56 0.0 Description: SHRINKER BELOW KNEE Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L8460 DME DEF MAXFEE 01/01/2014 12/31/2023 45.65 0.0 Description: SHRINKER ABOVE KNEE Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L8460 DME DEF MAXFEE 01/01/2024 76.14 0.0 Description: SHRINKER ABOVE KNEE Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L8465 DME DEF MAXFEE 01/01/2014 12/31/2023 36.14 0.0 Description: SHRINKER UPPER LIMB Category: Durable Medical CMS Add: 01/01/1988 CMS Term: L8465 DME DEF MAXFEE 01/01/2024 70.37 0.0 Description: SHRINKER UPPER LIMB Category: Durable Medical CMS Add: 01/01/1988 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,022 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L8470 DME DEF MAXFEE 01/01/2014 12/31/2023 4.74 0.0 Description: PROS SOCK SINGLE PLY BK Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L8470 DME DEF MAXFEE 01/01/2024 7.62 0.0 Description: PROS SOCK SINGLE PLY BK Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L8480 DME DEF MAXFEE 01/01/2014 12/31/2023 6.38 0.0 Description: PROS SOCK SINGLE PLY AK Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L8480 DME DEF MAXFEE 01/01/2024 10.52 0.0 Description: PROS SOCK SINGLE PLY AK Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L8485 DME DEF MAXFEE 01/01/2014 12/31/2023 8.82 0.0 Description: PROS SOCK SINGLE PLY UPPER L Category: Durable Medical CMS Add: 01/01/1994 CMS Term: L8485 DME DEF MAXFEE 01/01/2024 14.15 0.0 Description: PROS SOCK SINGLE PLY UPPER L Category: Durable Medical CMS Add: 01/01/1994 CMS Term: L8499 DME DEF SYSMAN Y Description: UNLISTED MISC PROSTHETIC SER Category: Durable Medical CMS Add: 01/01/1982 CMS Term: L8500 DME DEF MAXFEE 01/01/2014 12/31/2023 464.77 0.0 Description: ARTIFICIAL LARYNX Category: Durable Medical CMS Add: 01/01/1990 CMS Term: L8500 DME DEF MAXFEE 01/01/2024 756.15 0.0 Description: ARTIFICIAL LARYNX Category: Durable Medical CMS Add: 01/01/1990 CMS Term: L8501 DME DEF MAXFEE 01/01/2014 12/31/2023 81.61 0.0 Description: TRACHEOSTOMY SPEAKING VALVE Category: Durable Medical CMS Add: 01/01/1990 CMS Term: L8501 DME DEF MAXFEE 01/01/2024 138.00 0.0 Description: TRACHEOSTOMY SPEAKING VALVE Category: Durable Medical CMS Add: 01/01/1990 CMS Term: L8505 DME DEF SYSMAN Y Description: ARTIFICIAL LARYNX, ACCESSORY Category: Durable Medical CMS Add: 01/01/2002 CMS Term: L8507 DME DEF MAXFEE 01/01/2014 12/31/2023 29.85 0.0 Y Description: TRACH-ESOPH VOICE PROS PT IN Category: Durable Medical CMS Add: 01/01/2002 CMS Term: L8507 DME DEF MAXFEE 01/01/2024 48.11 0.0 Y Description: TRACH-ESOPH VOICE PROS PT IN Category: Durable Medical CMS Add: 01/01/2002 CMS Term: L8509 DME DEF MAXFEE 01/01/2014 12/31/2023 77.84 0.0 Description: TRACH-ESOPH VOICE PROS MD IN Category: Durable Medical CMS Add: 01/01/2002 CMS Term: L8509 DME DEF MAXFEE 01/01/2024 125.49 0.0 Description: TRACH-ESOPH VOICE PROS MD IN Category: Durable Medical CMS Add: 01/01/2002 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,023 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L8510 DME DEF MAXFEE 01/01/2014 12/31/2023 180.11 0.0 Description: VOICE AMPLIFIER Category: Durable Medical CMS Add: 01/01/2002 CMS Term: L8510 DME DEF MAXFEE 01/01/2024 290.37 0.0 Description: VOICE AMPLIFIER Category: Durable Medical CMS Add: 01/01/2002 CMS Term: L8511 DME DEF MAXFEE 01/01/2014 12/31/2023 58.66 0.0 Description: INDWELLING TRACH INSERT Category: Durable Medical CMS Add: 01/01/2004 CMS Term: L8511 DME DEF MAXFEE 01/01/2024 83.56 0.0 Description: INDWELLING TRACH INSERT Category: Durable Medical CMS Add: 01/01/2004 CMS Term: L8512 DME DEF MAXFEE 01/01/2014 12/31/2023 1.76 0.0 Description: GEL CAP FOR TRACH VOICE PROS Category: Durable Medical CMS Add: 01/01/2004 CMS Term: L8512 DME DEF MAXFEE 01/01/2024 2.50 0.0 Description: GEL CAP FOR TRACH VOICE PROS Category: Durable Medical CMS Add: 01/01/2004 CMS Term: L8513 DME DEF MAXFEE 01/01/2014 12/31/2023 4.19 0.0 Description: TRACH PROS CLEANING DEVICE Category: Durable Medical CMS Add: 01/01/2004 CMS Term: L8513 DME DEF MAXFEE 01/01/2024 5.97 0.0 Description: TRACH PROS CLEANING DEVICE Category: Durable Medical CMS Add: 01/01/2004 CMS Term: L8514 DME DEF MAXFEE 01/01/2014 12/31/2023 76.08 0.0 Description: REPL TRACH PUNCTURE DILATOR Category: Durable Medical CMS Add: 01/01/2004 CMS Term: L8514 DME DEF MAXFEE 01/01/2024 108.36 0.0 Description: REPL TRACH PUNCTURE DILATOR Category: Durable Medical CMS Add: 01/01/2004 CMS Term: L8515 DME DEF MAXFEE 01/01/2014 12/31/2023 45.46 0.0 Description: GEL CAP APP DEVICE FOR TRACH Category: Durable Medical CMS Add: 01/01/2005 CMS Term: L8515 DME DEF MAXFEE 01/01/2024 72.54 0.0 Description: GEL CAP APP DEVICE FOR TRACH Category: Durable Medical CMS Add: 01/01/2005 CMS Term: L8600 NOCOV DEF SYSMAN Description: IMPLANT BREAST SILICONE/EQ Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: L8603 MEDSV DEF MAXFEE 01/01/2014 12/31/2023 325.11 0.0 Description: COLLAGEN IMP URINARY 2.5 ML Category: Medical Services CMS Add: 01/01/1995 CMS Term: L8603 MEDSV DEF MAXFEE 01/01/2024 500.25 0.0 Description: COLLAGEN IMP URINARY 2.5 ML Category: Medical Services CMS Add: 01/01/1995 CMS Term: L8604 DRUG DEF SYSMAN Y Description: DEXTRANOMER/HYALURONIC ACID Category: Drugs CMS Add: 01/01/2009 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,024 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L8605 NOCOV DEF SYSMAN Description: INJ BULKING AGENT ANAL CANAL Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: L8606 DRUG DEF MAXFEE 01/01/2014 158.02 0.0 Description: SYNTHETIC IMPLNT URINARY 1ML Category: Drugs CMS Add: 01/01/2001 CMS Term: L8607 NOCOV DEF SYSMAN Description: INJ VOCAL CORD BULKING AGENT Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: L8608 NOCOV DEF SYSMAN Description: ARG II EXT COM/SUP/ACC MISC Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: L8609 NOCOV DEF SYSMAN Description: ARTIFICIAL CORNEA Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: L8610 MEDSV DEF MAXFEE 01/01/2014 12/31/2023 464.29 0.0 Description: OCULAR IMPLANT Category: Medical Services CMS Add: 01/01/1992 CMS Term: L8610 MEDSV DEF MAXFEE 01/01/2024 781.07 0.0 Description: OCULAR IMPLANT Category: Medical Services CMS Add: 01/01/1992 CMS Term: L8612 MEDSV DEF MAXFEE 01/01/2014 12/31/2023 482.32 0.0 Description: AQUEOUS SHUNT PROSTHESIS Category: Medical Services CMS Add: 01/01/1992 CMS Term: L8612 MEDSV DEF MAXFEE 01/01/2024 909.43 0.0 Description: AQUEOUS SHUNT PROSTHESIS Category: Medical Services CMS Add: 01/01/1992 CMS Term: L8613 MEDSV DEF MAXFEE 01/01/2014 12/31/2023 203.97 0.0 Description: OSSICULAR IMPLANT Category: Medical Services CMS Add: 01/01/1992 CMS Term: L8613 MEDSV DEF MAXFEE 01/01/2024 390.48 0.0 Description: OSSICULAR IMPLANT Category: Medical Services CMS Add: 01/01/1992 CMS Term: L8614 AUDIO DEF MAXFEE 01/01/2014 12/31/2023 14082.29 0.0 Description: COCHLEAR DEVICE Category: Audiology CMS Add: 01/01/1992 CMS Term: L8614 AUDIO DEF MAXFEE 01/01/2024 22498.13 0.0 Description: COCHLEAR DEVICE Category: Audiology CMS Add: 01/01/1992 CMS Term: L8615 AUDIO DEF MAXFEE 01/01/2014 12/31/2023 325.07 0.0 Y Description: COCH IMPLANT HEADSET REPLACE Category: Audiology CMS Add: 01/01/2005 CMS Term: L8615 AUDIO DEF MAXFEE 01/01/2024 518.23 0.0 Y Description: COCH IMPLANT HEADSET REPLACE Category: Audiology CMS Add: 01/01/2005 CMS Term: L8616 DME DEF MAXFEE 01/01/2014 12/31/2023 75.71 0.0 Y Description: COCH IMPLANT MICROPHONE REPL Category: Durable Medical CMS Add: 01/01/2005 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,025 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L8616 DME DEF MAXFEE 01/01/2024 120.69 0.0 Y Description: COCH IMPLANT MICROPHONE REPL Category: Durable Medical CMS Add: 01/01/2005 CMS Term: L8617 DME DEF MAXFEE 01/01/2014 12/31/2023 66.13 0.0 Y Description: COCH IMPLANT TRANS COIL REPL Category: Durable Medical CMS Add: 01/01/2005 CMS Term: L8617 DME DEF MAXFEE 01/01/2024 105.42 0.0 Y Description: COCH IMPLANT TRANS COIL REPL Category: Durable Medical CMS Add: 01/01/2005 CMS Term: L8618 DME DEF MAXFEE 01/01/2014 12/31/2023 18.89 0.0 Y Description: COCH IMPLANT TRAN CABLE REPL Category: Durable Medical CMS Add: 01/01/2005 CMS Term: L8618 DME DEF MAXFEE 01/01/2024 30.14 0.0 Y Description: COCH IMPLANT TRAN CABLE REPL Category: Durable Medical CMS Add: 01/01/2005 CMS Term: L8619 AUDIO DEF MAXFEE 01/01/2014 12/31/2023 6045.36 0.0 Y Description: COCH IMP EXT PROC/CONTR RPLC Category: Audiology CMS Add: 01/01/1996 CMS Term: L8619 AUDIO DEF MAXFEE 01/01/2024 9658.19 0.0 Y Description: COCH IMP EXT PROC/CONTR RPLC Category: Audiology CMS Add: 01/01/1996 CMS Term: L8621 DME DEF MAXFEE 01/01/2014 12/31/2023 0.45 0.0 Description: REPL ZINC AIR BATTERY Category: Durable Medical CMS Add: 01/01/2005 CMS Term: L8621 DME DEF MAXFEE 01/01/2024 0.71 0.0 Description: REPL ZINC AIR BATTERY Category: Durable Medical CMS Add: 01/01/2005 CMS Term: L8622 DME DEF MAXFEE 01/01/2014 12/31/2023 0.24 0.0 Description: REPL ALKALINE BATTERY Category: Durable Medical CMS Add: 01/01/2005 CMS Term: L8622 DME DEF MAXFEE 01/01/2024 0.37 0.0 Description: REPL ALKALINE BATTERY Category: Durable Medical CMS Add: 01/01/2005 CMS Term: L8623 DME DEF MAXFEE 01/01/2014 12/31/2023 52.18 0.0 Description: LITH ION BATT CID,NON-EARLVL Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L8623 DME DEF MAXFEE 01/01/2024 74.33 0.0 Description: LITH ION BATT CID,NON-EARLVL Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L8624 DME DEF MAXFEE 01/01/2014 12/31/2023 130.08 0.0 Description: LITH ION BATT CID, EAR LEVEL Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L8624 DME DEF MAXFEE 01/01/2024 185.30 0.0 Description: LITH ION BATT CID, EAR LEVEL Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L8625 DME DEF MAXFEE 01/01/2018 12/31/2023 183.68 0.0 Description: CHARGER COCH IMPL/AOI BATTRY Category: Durable Medical CMS Add: 01/01/2018 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,026 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L8625 DME DEF MAXFEE 01/01/2024 217.03 0.0 Description: CHARGER COCH IMPL/AOI BATTRY Category: Durable Medical CMS Add: 01/01/2018 CMS Term: L8627 DME DEF MAXFEE 01/01/2014 12/31/2023 6472.47 0.0 Y Description: CID EXT SPEECH PROCESS REPL Category: Durable Medical CMS Add: 01/01/2010 CMS Term: L8627 DME DEF MAXFEE 01/01/2024 8197.66 0.0 Y Description: CID EXT SPEECH PROCESS REPL Category: Durable Medical CMS Add: 01/01/2010 CMS Term: L8628 DME DEF MAXFEE 01/01/2014 12/31/2023 1153.15 0.0 Y Description: CID EXT CONTROLLER REPL Category: Durable Medical CMS Add: 01/01/2010 CMS Term: L8628 DME DEF MAXFEE 01/01/2024 1460.51 0.0 Y Description: CID EXT CONTROLLER REPL Category: Durable Medical CMS Add: 01/01/2010 CMS Term: L8629 DME DEF MAXFEE 01/01/2014 12/31/2023 162.45 0.0 Y Description: CID TRANSMIT COIL AND CABLE Category: Durable Medical CMS Add: 01/01/2010 CMS Term: L8629 DME DEF MAXFEE 01/01/2024 205.74 0.0 Y Description: CID TRANSMIT COIL AND CABLE Category: Durable Medical CMS Add: 01/01/2010 CMS Term: L8630 MEDSV DEF MAXFEE 01/01/2014 12/31/2023 267.25 0.0 Description: METACARPOPHALANGEAL IMPLANT Category: Medical Services CMS Add: 01/01/1992 CMS Term: L8630 MEDSV DEF MAXFEE 01/01/2024 513.18 0.0 Description: METACARPOPHALANGEAL IMPLANT Category: Medical Services CMS Add: 01/01/1992 CMS Term: L8631 DME DEF MAXFEE 01/01/2014 12/31/2023 1774.41 0.0 Description: MCP JOINT REPL 2 PC OR MORE Category: Durable Medical CMS Add: 01/01/2004 CMS Term: L8631 DME DEF MAXFEE 01/01/2024 2527.67 0.0 Description: MCP JOINT REPL 2 PC OR MORE Category: Durable Medical CMS Add: 01/01/2004 CMS Term: L8641 MEDSV DEF MAXFEE 01/01/2014 12/31/2023 277.67 0.0 Description: METATARSAL JOINT IMPLANT Category: Medical Services CMS Add: 01/01/1992 CMS Term: L8641 MEDSV DEF MAXFEE 01/01/2024 399.90 0.0 Description: METATARSAL JOINT IMPLANT Category: Medical Services CMS Add: 01/01/1992 CMS Term: L8642 MEDSV DEF MAXFEE 01/01/2014 12/31/2023 225.22 0.0 Description: HALLUX IMPLANT Category: Medical Services CMS Add: 01/01/1992 CMS Term: L8642 MEDSV DEF MAXFEE 01/01/2024 357.57 0.0 Description: HALLUX IMPLANT Category: Medical Services CMS Add: 01/01/1992 CMS Term: L8658 MEDSV DEF MAXFEE 01/01/2014 12/31/2023 242.10 0.0 Description: INTERPHALANGEAL JOINT SPACER Category: Medical Services CMS Add: 01/01/1992 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,027 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L8658 MEDSV DEF MAXFEE 01/01/2024 348.67 0.0 Description: INTERPHALANGEAL JOINT SPACER Category: Medical Services CMS Add: 01/01/1992 CMS Term: L8659 DME DEF MAXFEE 01/01/2014 12/31/2023 1556.54 0.0 Description: INTERPHALANGEAL JOINT REPL Category: Durable Medical CMS Add: 01/01/2004 CMS Term: L8659 DME DEF MAXFEE 01/01/2024 2217.30 0.0 Description: INTERPHALANGEAL JOINT REPL Category: Durable Medical CMS Add: 01/01/2004 CMS Term: L8670 MEDSV DEF MAXFEE 01/01/2014 12/31/2023 397.40 0.0 Description: VASCULAR GRAFT, SYNTHETIC Category: Medical Services CMS Add: 01/01/1992 CMS Term: L8670 MEDSV DEF MAXFEE 01/01/2024 635.94 0.0 Description: VASCULAR GRAFT, SYNTHETIC Category: Medical Services CMS Add: 01/01/1992 CMS Term: L8678 MDSPY DEF MAXFEE 04/01/2023 9.70 0.0 Description: EXT SPLY IMPLT NEUROSTIM Category: Medical Supplies CMS Add: 04/01/2023 CMS Term: L8679 DME DEF MAXFEE 01/01/2014 12/31/2023 8096.09 0.0 Y Description: IMP NEUROSTI PLS GN ANY TYPE Category: Durable Medical CMS Add: 01/01/2014 CMS Term: L8679 DME DEF MAXFEE 01/01/2024 9845.73 0.0 Y Description: IMP NEUROSTI PLS GN ANY TYPE Category: Durable Medical CMS Add: 01/01/2014 CMS Term: L8680* DME DEF MAXFEE 01/01/2014 12/31/2023 380.50 0.0 Y 0-1 Description: IMPLT NEUROSTIM ELCTR EACH Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L8680* DME DEF MAXFEE 01/01/2024 494.65 0.0 Y 0-1 Description: IMPLT NEUROSTIM ELCTR EACH Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L8680* DME DEF SYSMAN Y 0-1 Description: IMPLT NEUROSTIM ELCTR EACH Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L8681 DME DEF MAXFEE 01/01/2014 12/31/2023 919.96 0.0 Y Description: PT PRGRM FOR IMPLT NEUROSTIM Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L8681 DME DEF MAXFEE 01/01/2024 1310.50 0.0 Y Description: PT PRGRM FOR IMPLT NEUROSTIM Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L8682 DME DEF MAXFEE 01/01/2014 12/31/2023 4938.25 0.0 Y Description: IMPLT NEUROSTIM RADIOFQ REC Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L8682 DME DEF MAXFEE 01/01/2024 7034.56 0.0 Y Description: IMPLT NEUROSTIM RADIOFQ REC Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L8683 DME DEF MAXFEE 01/01/2014 12/31/2023 4346.79 0.0 Y Description: RADIOFQ TRSMTR FOR IMPLT NEU Category: Durable Medical CMS Add: 01/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,028 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L8683 DME DEF MAXFEE 01/01/2024 6192.04 0.0 Y Description: RADIOFQ TRSMTR FOR IMPLT NEU Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L8684 DME DEF MAXFEE 01/01/2014 12/31/2023 682.08 0.0 Y Description: RADIOF TRSMTR IMPLT SCRL NEU Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L8684 DME DEF MAXFEE 01/01/2024 971.61 0.0 Y Description: RADIOF TRSMTR IMPLT SCRL NEU Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L8685 DME DEF MAXFEE 01/01/2014 12/31/2023 10831.98 0.0 Y Description: IMPLT NROSTM PLS GEN SNG REC Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L8685 DME DEF MAXFEE 01/01/2024 14081.57 0.0 Y Description: IMPLT NROSTM PLS GEN SNG REC Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L8686* DME DEF MAXFEE 01/01/2014 12/31/2023 6911.68 0.0 Y 0-1 Description: IMPLT NROSTM PLS GEN SNG NON Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L8686* DME DEF MAXFEE 01/01/2024 8985.18 0.0 Y 0-1 Description: IMPLT NROSTM PLS GEN SNG NON Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L8686* DME DEF SYSMAN Y 0-1 Description: IMPLT NROSTM PLS GEN SNG NON Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L8687 DME DEF MAXFEE 01/01/2014 12/31/2023 14096.73 0.0 Y Description: IMPLT NROSTM PLS GEN DUA REC Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L8687 DME DEF MAXFEE 01/01/2024 18325.75 0.0 Y Description: IMPLT NROSTM PLS GEN DUA REC Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L8688 DME DEF MAXFEE 01/01/2014 12/31/2023 8994.87 0.0 Y Description: IMPLT NROSTM PLS GEN DUA NON Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L8688 DME DEF MAXFEE 01/01/2024 11693.33 0.0 Y Description: IMPLT NROSTM PLS GEN DUA NON Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L8689 DME DEF MAXFEE 01/01/2014 12/31/2023 1391.39 0.0 Y Description: EXTERNAL RECHARG SYS INTERN Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L8689 DME DEF MAXFEE 01/01/2024 1982.04 0.0 Y Description: EXTERNAL RECHARG SYS INTERN Category: Durable Medical CMS Add: 01/01/2006 CMS Term: L8690 DME DEF MAXFEE 01/01/2014 12/31/2023 3431.40 0.0 Y Description: AUD OSSEO DEV, INT/EXT COMP Category: Durable Medical CMS Add: 01/01/2007 CMS Term: L8690 DME DEF MAXFEE 01/01/2024 5466.16 0.0 Y Description: AUD OSSEO DEV, INT/EXT COMP Category: Durable Medical CMS Add: 01/01/2007 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,029 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- L8691 DME DEF MAXFEE 01/01/2014 12/31/2023 1923.42 0.0 Y Description: AOI SND PROC REPL EXCL ACTUA Category: Durable Medical CMS Add: 01/01/2007 CMS Term: L8691 DME DEF MAXFEE 01/01/2024 1978.82 0.0 Y Description: AOI SND PROC REPL EXCL ACTUA Category: Durable Medical CMS Add: 01/01/2007 CMS Term: L8692 DME DEF SYSMAN Y Y Description: NON-OSSEOINTEGRATED SND PROC Category: Durable Medical CMS Add: 01/01/2010 CMS Term: L8693 DME DEF MAXFEE 01/01/2014 12/31/2023 1374.28 0.0 Y Description: AUD OSSEO DEV, ABUTMENT Category: Durable Medical CMS Add: 01/01/2011 CMS Term: L8693 DME DEF MAXFEE 01/01/2024 1742.32 0.0 Y Description: AUD OSSEO DEV, ABUTMENT Category: Durable Medical CMS Add: 01/01/2011 CMS Term: L8694 DME DEF MAXFEE 01/01/2018 12/31/2023 918.37 0.0 Y Description: AOI TRANSDUCER/ACTUATOR REPL Category: Durable Medical CMS Add: 01/01/2018 CMS Term: L8694 DME DEF MAXFEE 01/01/2024 1085.14 0.0 Y Description: AOI TRANSDUCER/ACTUATOR REPL Category: Durable Medical CMS Add: 01/01/2018 CMS Term: L8695 DME DEF MAXFEE 01/01/2014 12/31/2023 14.10 0.0 Description: EXTERNAL RECHARG SYS EXTERN Category: Durable Medical CMS Add: 01/01/2007 CMS Term: L8695 DME DEF MAXFEE 01/01/2024 19.16 0.0 Description: EXTERNAL RECHARG SYS EXTERN Category: Durable Medical CMS Add: 01/01/2007 CMS Term: L8696 DME DEF MAXFEE 01/01/2015 12/31/2023 207.84 0.0 Description: EXT ANTENNA PHREN NERVE STIM Category: Durable Medical CMS Add: 01/01/2015 CMS Term: L8696 DME DEF MAXFEE 01/01/2024 249.03 0.0 Description: EXT ANTENNA PHREN NERVE STIM Category: Durable Medical CMS Add: 01/01/2015 CMS Term: L8698 DME DEF SYSMAN Y Y Description: MISC USED WITH TOT ART HEART Category: Durable Medical CMS Add: 01/01/2019 CMS Term: L8699 MEDSV DEF SYSMAN Y Y Description: PROSTHETIC IMPLANT NOS Category: Medical Services CMS Add: 01/01/1998 CMS Term: L8701 DME DEF SYSMAN Y Y Description: EWH S/D UPRT MICRO SENSOR Category: Durable Medical CMS Add: 01/01/2019 CMS Term: L8702 DME DEF SYSMAN Y Y Description: EWHF S/D UPRT MICRO SENSOR Category: Durable Medical CMS Add: 01/01/2019 CMS Term: L9900 DME DEF SYSMAN Y Description: O&P SUPPLY/ACCESSORY/SERVICE Category: Durable Medical CMS Add: 01/01/2000 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,030 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- M0001 NOCOV DEF SYSMAN Description: ADVANCING CANCER CARE MVP Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M0002 NOCOV DEF SYSMAN Description: OPT CARE KIDNEY HLTH MVP Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M0003 NOCOV DEF SYSMAN Description: OPT CARE EPISOD NEURO MVP Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M0004 NOCOV DEF SYSMAN Description: SUPPORT CARE NEUR COND MVP Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M0005 NOCOV DEF SYSMAN Description: VALUE IN PRIMARY CARE MVP Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M0010 NOCOV DEF SYSMAN Description: EOM MEOS PAYMENT Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: M0050 NOCOV DEF SYSMAN Description: AMBULATORY SURGICAL CENTE Category: Non Covered Services CMS Add: 01/01/1900 CMS Term: 06/30/2015 M0051 NOCOV DEF SYSMAN Description: AMBULATORY SURGICAL CENTE Category: Non Covered Services CMS Add: 01/01/1900 CMS Term: 06/30/2015 M0052 NOCOV DEF SYSMAN Description: AMBULATORY SURGICAL CENTE Category: Non Covered Services CMS Add: 01/01/1900 CMS Term: 06/30/2015 M0053 NOCOV DEF SYSMAN Description: AMBULATORY SURGICAL CENTE Category: Non Covered Services CMS Add: 01/01/1900 CMS Term: 06/30/2015 M0054 NOCOV DEF SYSMAN Description: AMBULATORY SURGICAL CENTE Category: Non Covered Services CMS Add: 01/01/1900 CMS Term: 06/30/2015 M0075 NOCOV DEF SYSMAN Description: CELLULAR THERAPY Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: M0076 NOCOV DEF SYSMAN Description: PROLOTHERAPY Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: M0100 NOCOV DEF SYSMAN Description: INTRAGASTRIC HYPOTHERMIA Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: M0201 DDWA DEF MAXFEE 01/01/2023 34.57 0.0 Description: PNE FLU HEPB COV HOME ADMIN Category: CIH Waiver CMS Add: 06/08/2021 CMS Term: M0201 MEDSV DEF MAXFEE 01/01/2023 34.57 0.0 Description: PNE FLU HEPB COV HOME ADMIN Category: Medical Services CMS Add: 06/08/2021 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,031 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- M0201 SSFS DEF MAXFEE 01/01/2023 34.57 0.0 Description: PNE FLU HEPB COV HOME ADMIN Category: Family Support Waivr CMS Add: 06/08/2021 CMS Term: M0201 TRANS DEF MAXFEE 01/01/2023 34.57 0.0 Description: PNE FLU HEPB COV HOME ADMIN Category: Transportation CMS Add: 06/08/2021 CMS Term: M0240 MEDSV DEF MAXFEE 01/01/2024 422.10 0.0 12-999years Description: CASIRI AND IMDEV REPEAT Category: Medical Services CMS Add: 07/30/2021 CMS Term: M0240 MEDSV DEF MAXFEE 07/30/2021 12/31/2023 403.66 0.0 12-999years Description: CASIRI AND IMDEV REPEAT Category: Medical Services CMS Add: 07/30/2021 CMS Term: M0241 MEDSV DEF MAXFEE 01/01/2024 703.50 0.0 12-999years Description: CASIRI AND IMDEV REPEAT HM Category: Medical Services CMS Add: 07/30/2021 CMS Term: M0241 MEDSV DEF MAXFEE 07/30/2021 12/31/2023 673.15 0.0 12-999years Description: CASIRI AND IMDEV REPEAT HM Category: Medical Services CMS Add: 07/30/2021 CMS Term: M0243 MEDSV DEF MAXFEE 01/01/2024 422.10 0.0 12-999years Description: CASIRIVI AND IMDEVI INJ Category: Medical Services CMS Add: 11/21/2020 CMS Term: M0243 MEDSV DEF MAXFEE 05/06/2021 12/31/2023 403.66 0.0 12-999years Description: CASIRIVI AND IMDEVI INJ Category: Medical Services CMS Add: 11/21/2020 CMS Term: M0244 MEDSV DEF MAXFEE 01/01/2024 703.50 0.0 12-999years Description: CASIRIVI AND IMDEVI INJ HM Category: Medical Services CMS Add: 05/06/2021 CMS Term: M0244 MEDSV DEF MAXFEE 05/06/2021 12/31/2023 673.15 0.0 12-999years Description: CASIRIVI AND IMDEVI INJ HM Category: Medical Services CMS Add: 05/06/2021 CMS Term: M0245 DRUG DEF MAXFEE 05/06/2021 403.66 0.0 12-999years Description: BAMLAN AND ETESEV INFUSION Category: Drugs CMS Add: 02/09/2021 CMS Term: M0246 MEDSV DEF MAXFEE 01/01/2024 703.50 0.0 12-999years Description: BAMLAN AND ETESEV INFUS HOME Category: Medical Services CMS Add: 05/06/2021 CMS Term: M0246 MEDSV DEF MAXFEE 05/06/2021 12/31/2023 673.15 0.0 12-999years Description: BAMLAN AND ETESEV INFUS HOME Category: Medical Services CMS Add: 05/06/2021 CMS Term: M0247 NOCOV DEF SYSMAN Description: SOTROVIMAB INFUSION Category: Non Covered Services CMS Add: 05/26/2021 CMS Term: M0248 NOCOV DEF SYSMAN Description: SOTROVIMAB INF, HOME ADMIN Category: Non Covered Services CMS Add: 05/26/2021 CMS Term: M0249 DRUG DEF MAXFEE 06/24/2021 403.66 0.0 2-999years Description: ADM TOCILIZU COVID-19 1ST Category: Drugs CMS Add: 06/24/2021 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,032 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- M0250 DRUG DEF MAXFEE 06/24/2021 403.66 0.0 2-999years Description: ADM TOCILIZU COVID-19 2ND Category: Drugs CMS Add: 06/24/2021 CMS Term: M0300 NOCOV DEF SYSMAN Description: IV CHELATIONTHERAPY Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: M0301 NOCOV DEF SYSMAN Description: FABRIC WRAPPING OF ANEURYSM Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: M0900 NOCOV DEF SYSMAN Description: EXCISION REVISION OR REMO Category: Non Covered Services CMS Add: 01/01/1900 CMS Term: 06/30/2015 M1003 NOCOV DEF SYSMAN Description: TB SCR 12 MO PRI FST BIO DZ Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: M1004 NOCOV DEF SYSMAN Description: DOC MED RSN NO SRN TB Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: M1005 NOCOV DEF SYSMAN Description: TB SCR NO PERF Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: M1006 NOCOV DEF SYSMAN Description: DZ NOT ASES, NO RSN Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: M1007 NOCOV DEF SYSMAN Description: >=50% TOTAL PT OUTPT RA ENCT Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: M1008 NOCOV DEF SYSMAN Description: <50% TOTAL PT OUTPT RA ENCTS Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: M1009 NOCOV DEF SYSMAN Description: DC EOC DOC MED REC Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: M1010 NOCOV DEF SYSMAN Description: DC EOC DOC MED REC Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: M1011 NOCOV DEF SYSMAN Description: DC EOC DOC MED REC Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: M1012 NOCOV DEF SYSMAN Description: DC EOC DOC MED REC Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: M1013 NOCOV DEF SYSMAN Description: DC EOC DOC MED REC Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: M1014 NOCOV DEF SYSMAN Description: DC EPI CARE DOC MEDREC Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,033 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- M1016 NOCOV DEF SYSMAN Description: PT DX MEOP OR SUR STERI Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: M1018 NOCOV DEF SYSMAN Description: PT DX HST CR PT SK LG CR SCR Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: M1019 NOCOV DEF SYSMAN Description: ADL PT MJ DEP DS RS 12 PHQ<5 Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: M1020 NOCOV DEF SYSMAN Description: ADL PT MJ DEP DS NO RS 12 MO Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: M1021 NOCOV DEF SYSMAN Description: PT UC IN PP Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: M1027 NOCOV DEF SYSMAN Description: IMG HEAD (CT OR MRI) OBTND Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: M1028 NOCOV DEF SYSMAN Description: DOC OF PT PRM HDA DX AND OTR Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: M1029 NOCOV DEF SYSMAN Description: DOC SYSM RSN IMG HD Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: M1032 NOCOV DEF SYSMAN Description: ADT TKNG PHARMTHRY FOR OUD Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: M1034 NOCOV DEF SYSMAN Description: ADT 180 DYS PHARMTHRY OUD Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: M1035 NOCOV DEF SYSMAN Description: ADT PD OUT MAT PR 180 DYS TX Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: M1036 NOCOV DEF SYSMAN Description: ADT NO 180 DYS PHARMTHRY OUD Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: M1037 NOCOV DEF SYSMAN Description: PT DX LUM SP REG CACR Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: M1038 NOCOV DEF SYSMAN Description: PT DX LUM SP REG FRACT Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: M1039 NOCOV DEF SYSMAN Description: PT DX LUM SP REG INF Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: M1040 NOCOV DEF SYSMAN Description: PT DX LUM IDI OR CONG SCOL Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,034 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- M1041 NOCOV DEF SYSMAN Description: PT CR FT INF LM OR PT ID SL Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: M1043 NOCOV DEF SYSMAN Description: FS NO ODI 9-15MO Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: M1045 NOCOV DEF SYSMAN Description: FS OKS 9-15MO >= 37 >= 71 Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: M1046 NOCOV DEF SYSMAN Description: FS OKS 9-15MO < 37 < 71 Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: M1049 NOCOV DEF SYSMAN Description: FS WTH SCR NO ODI PRE AND P Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: M1051 NOCOV DEF SYSMAN Description: PT W/CANCER SCOLIOSIS Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: M1052 NOCOV DEF SYSMAN Description: LG PN NOT MEAS W/ VAS 1YR PO Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: M1054 NOCOV DEF SYSMAN Description: PT UC IN PP Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: M1055 NOCOV DEF SYSMAN Description: ASPIRIN USED Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: M1056 NOCOV DEF SYSMAN Description: PRESC ANTICO MED IN PP Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: M1057 NOCOV DEF SYSMAN Description: ASPIRIN NOT USED, NO RSN Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: M1058 NOCOV DEF SYSMAN Description: PT PRM NURS HM RES IN PP Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: M1059 NOCOV DEF SYSMAN Description: PT NO PRM NURS HM RES IN PP Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: M1060 NOCOV DEF SYSMAN Description: PT DIED IN PP Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: M1067 NOCOV DEF SYSMAN Description: HSPC PT PRV TIME MEAM PER Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: M1068 NOCOV DEF SYSMAN Description: PT NOT AMBULATORY Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,035 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- M1069 NOCOV DEF SYSMAN Description: PT SCR FT FALL RSK Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: M1070 NOCOV DEF SYSMAN Description: PT NOT SCRN FUT FALL NO RSN Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: M1072 NOCOV DEF SYSMAN Description: ROM RAD THERAPY ANAL, PC Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 01/01/2022 M1073 NOCOV DEF SYSMAN Description: ROM RAD THERAPY ANAL, TC Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 01/01/2022 M1074 NOCOV DEF SYSMAN Description: ROM RAD THERAPY BLADDER, PC Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 01/01/2022 M1075 NOCOV DEF SYSMAN Description: ROM RAD THERAPY BLADDER, TC Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 01/01/2022 M1076 NOCOV DEF SYSMAN Description: ROM RAD THER BONE METS, PC Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 01/01/2022 M1077 NOCOV DEF SYSMAN Description: ROM RAD THER BONE METS, TC Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 01/01/2022 M1078 NOCOV DEF SYSMAN Description: ROM RAD THER BRAIN METS, PC Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 01/01/2022 M1079 NOCOV DEF SYSMAN Description: ROM RAD THER BRAIN METS, TC Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 01/01/2022 M1080 NOCOV DEF SYSMAN Description: ROM RAD THERAPY BREAST, PC Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 01/01/2022 M1081 NOCOV DEF SYSMAN Description: ROM RAD THERAPY BREAST, TC Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 01/01/2022 M1082 NOCOV DEF SYSMAN Description: ROM RAD THERAPY CERVICAL, PC Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 01/01/2022 M1083 NOCOV DEF SYSMAN Description: ROM RAD THERAPY CERVICAL, TC Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 01/01/2022 M1084 NOCOV DEF SYSMAN Description: ROM RAD THERAPY CNS, PC Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 01/01/2022 M1085 NOCOV DEF SYSMAN Description: ROM RAD THERAPY CNS, TC Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 01/01/2022 *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,036 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- M1086 NOCOV DEF SYSMAN Description: ROM RAD THER COLORECTAL, PC Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 01/01/2022 M1087 NOCOV DEF SYSMAN Description: ROM RAD THER COLORECTAL, TC Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 01/01/2022 M1088 NOCOV DEF SYSMAN Description: ROM RAD THER HEAD/NECK, PC Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 01/01/2022 M1089 NOCOV DEF SYSMAN Description: ROM RAD THER HEAD/NECK, TC Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 01/01/2022 M1094 NOCOV DEF SYSMAN Description: ROM RAD THERAPY LUNG, PC Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 01/01/2022 M1095 NOCOV DEF SYSMAN Description: ROM RAD THERAPY LUNG, TC Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 01/01/2022 M1096 NOCOV DEF SYSMAN Description: ROM RAD THERAPY LYMPHOMA, PC Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 01/01/2022 M1097 NOCOV DEF SYSMAN Description: ROM RAD THERAPY LYMPHOMA, TC Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 01/01/2022 M1098 NOCOV DEF SYSMAN Description: ROM RAD THERAPY PANCREAS, PC Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 01/01/2022 M1099 NOCOV DEF SYSMAN Description: ROM RAD THERAPY PANCREAS, PC Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 01/01/2022 M1100 NOCOV DEF SYSMAN Description: ROM RAD THERAPY PROSTATE, PC Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 01/01/2022 M1101 NOCOV DEF SYSMAN Description: ROM RAD THERAPY PROSTATE, TC Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 01/01/2022 M1102 NOCOV DEF SYSMAN Description: ROM RAD THERAPY GI, PC Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 01/01/2022 M1103 NOCOV DEF SYSMAN Description: ROM RAD THERAPY GI, TC Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 01/01/2022 M1104 NOCOV DEF SYSMAN Description: ROM RAD THERAPY UTERUS, PC Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 01/01/2022 M1105 NOCOV DEF SYSMAN Description: ROM RAD THERAPY UTERUS, TC Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 01/01/2022 *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,037 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- M1106 NOCOV DEF SYSMAN Description: START EOC DOC MED REC Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: M1107 NOCOV DEF SYSMAN Description: DOCU DX DEGEN NEURO Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: M1108 NOCOV DEF SYSMAN Description: OC NI PT HOME PROG Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: M1109 NOCOV DEF SYSMAN Description: OC NI PT DC Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: M1110 NOCOV DEF SYSMAN Description: OC NOT P PT SELFDC Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: M1111 NOCOV DEF SYSMAN Description: START EOC DOC MED REC Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: M1112 NOCOV DEF SYSMAN Description: DOCU DX DEGEN NEURO Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: M1113 NOCOV DEF SYSMAN Description: OC NI PT HOME PROG Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: M1114 NOCOV DEF SYSMAN Description: OC NI PT DC Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: M1115 NOCOV DEF SYSMAN Description: OC NI PT SELFDC Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: M1116 NOCOV DEF SYSMAN Description: START EOC DOC MED REC Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: M1117 NOCOV DEF SYSMAN Description: DOCU DX DEGEN NEURO Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: M1118 NOCOV DEF SYSMAN Description: OC NI PT HOME PROG Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: M1119 NOCOV DEF SYSMAN Description: OC NI PT DC Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: M1120 NOCOV DEF SYSMAN Description: OC NI PT SELFDC Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: M1121 NOCOV DEF SYSMAN Description: START EOC DOC MED REC Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,038 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- M1122 NOCOV DEF SYSMAN Description: DOCU DX DEGEN NEURO Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: M1123 NOCOV DEF SYSMAN Description: OC NI PT HOME PROG Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: M1124 NOCOV DEF SYSMAN Description: OC NI PT DC 1-2 VIS Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: M1125 NOCOV DEF SYSMAN Description: OC NI PT SELFDC 1-2 VIS Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: M1126 NOCOV DEF SYSMAN Description: START EOC DOC MED REC Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: M1127 NOCOV DEF SYSMAN Description: DOCU DX DEGEN NEURO Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: M1128 NOCOV DEF SYSMAN Description: OC NI PT HOME PROG Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: M1129 NOCOV DEF SYSMAN Description: OC NI PT DC Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: M1130 NOCOV DEF SYSMAN Description: OC NI PT SELFDC Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: M1131 NOCOV DEF SYSMAN Description: DOCU DX DEGEN NEURO Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: M1132 NOCOV DEF SYSMAN Description: OC NI PT HOME PROG Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: M1133 NOCOV DEF SYSMAN Description: OC NI PT DC Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: M1134 NOCOV DEF SYSMAN Description: OC NI PT SELFDC Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: M1135 NOCOV DEF SYSMAN Description: START EOC DOC MED REC Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: M1141 NOCOV DEF SYSMAN Description: FS NO OKS Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: M1142 NOCOV DEF SYSMAN Description: EMERGE CASES Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,039 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- M1143 NOCOV DEF SYSMAN Description: NI REHAB MED CHIRO Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: M1146 NOCOV DEF SYSMAN Description: ONGOING CARE NOT IND Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: M1147 NOCOV DEF SYSMAN Description: CARE NOT POSS MED RSN Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: M1148 NOCOV DEF SYSMAN Description: PT SELF DSCHG Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: M1149 NOCOV DEF SYSMAN Description: NO NECK FS PROM INCAP Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: M1150 NOCOV DEF SYSMAN Description: LVEF <=40% OR MOD/SEV L VSF Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M1151 NOCOV DEF SYSMAN Description: PT W/ HX TRNSPLT OR LVAD Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M1152 NOCOV DEF SYSMAN Description: PT W/ HX TRNSPLT OR LVAD Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M1153 NOCOV DEF SYSMAN Description: PT W/ DX OSTEO DOE Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M1154 NOCOV DEF SYSMAN Description: HOSPC SERV DUR MEAS PD Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M1155 NOCOV DEF SYSMAN Description: PT ANPHX DUE TO PNEUM Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M1159 NOCOV DEF SYSMAN Description: HOSPC SERV DUR MEAS PD Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M1160 NOCOV DEF SYSMAN Description: PT ANPHX DUE TO MENGB BEF 13 Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M1161 NOCOV DEF SYSMAN Description: PT ANPHX DUE TO DTP BEF 13 Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M1162 NOCOV DEF SYSMAN Description: PT ENCEPH DUE TO DTP BEF 13 Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M1163 NOCOV DEF SYSMAN Description: PT ANPHX DUE TO HPV BEF 13 Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,040 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- M1164 NOCOV DEF SYSMAN Description: PT W/ DEMENTIA ANY TIME Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M1165 NOCOV DEF SYSMAN Description: PT USE HSPC DUR MEAS PD Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M1166 NOCOV DEF SYSMAN Description: PATH RPT TIS SPEC WLE/REEXC Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M1167 NOCOV DEF SYSMAN Description: HSPC DUR MEAS PD Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M1168 NOCOV DEF SYSMAN Description: PT RECD FLU VAX 7/1-6/30 Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M1169 NOCOV DEF SYSMAN Description: DOC MED RSN NO FLU VAX Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M1170 NOCOV DEF SYSMAN Description: PT W/O FLU VAX 7/1-6/30 Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M1171 NOCOV DEF SYSMAN Description: PT RECD 1 TD/TDAP 9YRS PRIOR Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M1172 NOCOV DEF SYSMAN Description: DOC MED RSN NO TD/TDAP Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M1173 NOCOV DEF SYSMAN Description: PT NO REC TD/TDAP 9YRS PRIOR Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M1174 NOCOV DEF SYSMAN Description: PT W 2 HZV ON/AFT 50 Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M1175 NOCOV DEF SYSMAN Description: DOC MED RSN NO HZV Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M1176 NOCOV DEF SYSMAN Description: PT W/O HZV ON/AFT AGE 50 Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M1177 NOCOV DEF SYSMAN Description: PT RECD PCV ON/AFT 60 Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M1178 NOCOV DEF SYSMAN Description: DOC MED RSN NO PCV Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M1179 NOCOV DEF SYSMAN Description: NO PCV RECD Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,041 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- M1180 NOCOV DEF SYSMAN Description: PT IMM CKPT INHIB THERAPY Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M1181 NOCOV DEF SYSMAN Description: GR 2 OR> DIA OR GR2 OR> COL Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M1182 NOCOV DEF SYSMAN Description: NOT ELG PRE EX IBD/UC/CROHN Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M1183 NOCOV DEF SYSMAN Description: DOC IMM CKPT INHIB HLD Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M1184 NOCOV DEF SYSMAN Description: DOC MED RSN NO CST/IST RX Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M1185 NOCOV DEF SYSMAN Description: IMM CKPT INHIB NOT HLD NO RX Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M1186 NOCOV DEF SYSMAN Description: PT W/ RX FOR HSPC/PLLTV CARE Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M1187 NOCOV DEF SYSMAN Description: PT W/ ESRD Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M1188 NOCOV DEF SYSMAN Description: PT W/ CKD STG 5 Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M1189 NOCOV DEF SYSMAN Description: DOC KHE PEF W/EFGR/UACR Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M1190 NOCOV DEF SYSMAN Description: DOC KHE NOT PEF W/EFGR/UACR Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M1191 NOCOV DEF SYSMAN Description: HSPC SVC ANY TIME IN MEAS PD Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M1192 NOCOV DEF SYSMAN Description: PT W/ DX SQ CELL CA OF ESOPH Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M1193 NOCOV DEF SYSMAN Description: RPTS W/ IMP/CON MMR/MSI Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M1194 NOCOV DEF SYSMAN Description: MED RSN NO IMP/CON MMR/MSI Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M1195 NOCOV DEF SYSMAN Description: RPT WO IMP/CON MMR/MSI Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,042 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- M1196 NOCOV DEF SYSMAN Description: IXV NRS VRS IQA >=4 Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M1197 NOCOV DEF SYSMAN Description: ISA REDUCED >=3 FR IXV Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M1198 NOCOV DEF SYSMAN Description: ISA NOT RED 3PTS /NO ASSESS Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M1199 NOCOV DEF SYSMAN Description: PT REC'G RRT Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M1200 NOCOV DEF SYSMAN Description: ACE-I/ARB RX Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M1201 NOCOV DEF SYSMAN Description: MED RSN NO ACE-I/ARB RX Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M1202 NOCOV DEF SYSMAN Description: PT RSN NO ACE-I/ARB RX Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M1203 NOCOV DEF SYSMAN Description: NO RSN ACE-I/ARB RX Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M1204 NOCOV DEF SYSMAN Description: IXV NRS VRS IQA >=4 Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M1205 NOCOV DEF SYSMAN Description: ISA REDUCED >=3 Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M1206 NOCOV DEF SYSMAN Description: ISA NOT RED 3PTS/NO ASSESS Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M1207 NOCOV DEF SYSMAN Description: PT SCRN SDOH Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M1208 NOCOV DEF SYSMAN Description: PT NO SCRN SDOH Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M1209 NOCOV DEF SYSMAN Description: >=2 SAME HI-RSK MED W/O DIAG Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M1210 NOCOV DEF SYSMAN Description: >=2 SAME MEDS TBL4 NOT ORD Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: M1211 NOCOV DEF SYSMAN Description: HEMOGLOBIN A1C LEVEL >9.0% Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,043 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- M1212 NOCOV DEF SYSMAN Description: MISSING HB A1C LEVEL Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1213 NOCOV DEF SYSMAN Description: NO HX SPIRO PRS SPIRO>=70% Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1214 NOCOV DEF SYSMAN Description: SPIRO RESULTS WTH OBS DOC Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1215 NOCOV DEF SYSMAN Description: MED RSN FOR NO DOC SPIRO Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1216 NOCOV DEF SYSMAN Description: NO SPIRO DOC NO RES DOC Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1217 NOCOV DEF SYSMAN Description: SYS RSN NO DOC SPIRO Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1218 NOCOV DEF SYSMAN Description: PT COPD SYMPTOMS Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1219 NOCOV DEF SYSMAN Description: ANPHX DUE TO VAX Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1220 NOCOV DEF SYSMAN Description: DRE WTH INTERP RTNOPTHY Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1221 NOCOV DEF SYSMAN Description: DRE W/O RTNOPTHY Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1222 NOCOV DEF SYSMAN Description: GLAUCOMA PLN OF CARE NOT DOC Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1223 NOCOV DEF SYSMAN Description: GLAUCOMA PLAN OF CARE DOC Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1224 NOCOV DEF SYSMAN Description: IOP DEC <20% FROM BASE Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1225 NOCOV DEF SYSMAN Description: IOP DEC>=20% FROM BASE Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1226 NOCOV DEF SYSMAN Description: IOP NOT DOC Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1227 NOCOV DEF SYSMAN Description: EB THERAPY PRESCRIBED Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,044 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- M1228 NOCOV DEF SYSMAN Description: PT + HCV ABY +VIR W/ RX 3 MO Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1229 NOCOV DEF SYSMAN Description: PT W/ +HCV +VIR REF WIN 1 MO Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1230 NOCOV DEF SYSMAN Description: PT HCV RCTV ABY NO F/U TST Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1231 NOCOV DEF SYSMAN Description: PT HCV TST NO REACTIVE RES Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1232 NOCOV DEF SYSMAN Description: PT HCV TST REACTIVE RESULT Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1233 NOCOV DEF SYSMAN Description: PT NO HCV ABY OR RESULT Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1234 NOCOV DEF SYSMAN Description: PT HCV RCTV ABY F/U NEG Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1235 NOCOV DEF SYSMAN Description: DOC PT HCV ABY RNA TST Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1236 NOCOV DEF SYSMAN Description: BASELINE MRS > 2 Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1237 NOCOV DEF SYSMAN Description: PT RSN NO SCRN Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1238 NOCOV DEF SYSMAN Description: DOC 2ND RECOM HZV 2-6 MO INT Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1239 NOCOV DEF SYSMAN Description: PT NO RESP HEARD Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1240 NOCOV DEF SYSMAN Description: PT NO RESP BEST INT Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1241 NOCOV DEF SYSMAN Description: PT NO RESP SEEN AS PERSON Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1242 NOCOV DEF SYSMAN Description: PT NO RESP IMPRT TO ME Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1243 NOCOV DEF SYSMAN Description: PT OTHR THN TRUE HEARD Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,045 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- M1244 NOCOV DEF SYSMAN Description: PT OTHR THN TRUE BEST INT Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1245 NOCOV DEF SYSMAN Description: PT OTHR THN TRUE PERSON Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1246 NOCOV DEF SYSMAN Description: PT OTHR THN TRUE IMPRT TO ME Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1247 NOCOV DEF SYSMAN Description: PT RESP TRUE BEST INT Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1248 NOCOV DEF SYSMAN Description: PT RESP TRUE SEEN AS PERSON Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1249 NOCOV DEF SYSMAN Description: PT RESP TRUE IMPRT TO ME Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1250 NOCOV DEF SYSMAN Description: PT RESP TRUE HEARD Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1251 NOCOV DEF SYSMAN Description: PTS PROXY CMPLT HU SURV Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1252 NOCOV DEF SYSMAN Description: PTS NO CMPLT HU SURVEY Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1253 NOCOV DEF SYSMAN Description: PTS HU SURV NO AMB PLLTV Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1254 NOCOV DEF SYSMAN Description: PTS DECEASED PRIOR HU SURV Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1255 NOCOV DEF SYSMAN Description: PTS W/ OTHR RSN VST,+PRG TST Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1256 NOCOV DEF SYSMAN Description: PRIOR HISTORY OF KNOWN CVD Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1257 NOCOV DEF SYSMAN Description: CVD RISK ASSESS NOT PERF Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1258 NOCOV DEF SYSMAN Description: CVD RISK ASSESS PERF Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1259 NOCOV DEF SYSMAN Description: PT KID TRANSPLT WTLST LV DON Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,046 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- M1260 NOCOV DEF SYSMAN Description: PT NO KD TRNSPLT WTLST LV DO Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1261 NOCOV DEF SYSMAN Description: PTS ON WTLIST BEF DIALYSIS Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1262 NOCOV DEF SYSMAN Description: PTS TRANSPLT BEF DIALYSIS Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1263 NOCOV DEF SYSMAN Description: PTS HOSP DIALYSIS DT Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1264 NOCOV DEF SYSMAN Description: PTS 75+ DIALYSIS DT Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1265 NOCOV DEF SYSMAN Description: CMS 2728 COMPLETED Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1266 NOCOV DEF SYSMAN Description: PTS ADMIT SNF Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1267 NOCOV DEF SYSMAN Description: PT NO ACT KID TRANSPLT WTLST Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1268 NOCOV DEF SYSMAN Description: PT AC STAT KID TRNSPLT WTLST Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1269 NOCOV DEF SYSMAN Description: REC'D ESRD MCP LST DAY OF MO Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1270 NOCOV DEF SYSMAN Description: PTS NO KID TRANSPLT WTLST Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1271 NOCOV DEF SYSMAN Description: PTS DEM ANY TIME/DUR MO Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1272 NOCOV DEF SYSMAN Description: PTS KID TRANSPLT WTLST Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1273 NOCOV DEF SYSMAN Description: PTS SNF 1 YR DIALYSIS Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1274 NOCOV DEF SYSMAN Description: PTS SNF EXL MO Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1275 NOCOV DEF SYSMAN Description: PTS HOSP EXL Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,047 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- M1276 NOCOV DEF SYSMAN Description: CALC BMI OUT NRM PARAM NOF/U Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1277 NOCOV DEF SYSMAN Description: COLORECTAL CA SCREEN DOC REV Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1278 NOCOV DEF SYSMAN Description: PRE-HTN OR HTN DOC, F/U INDC Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1279 NOCOV DEF SYSMAN Description: PRE-HTN/HTN, NO F/U, NOT GVN Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1280 NOCOV DEF SYSMAN Description: BILAT MAST/HX BI /UNILAT MAS Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1281 NOCOV DEF SYSMAN Description: BP SCRN NO PERF AT INTERVAL Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1282 NOCOV DEF SYSMAN Description: PT SCRN TBCO ID AS NON USER Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1283 NOCOV DEF SYSMAN Description: PT SCRN TBCO AND ID AS USER Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1284 NOCOV DEF SYSMAN Description: PT 66+ SNP OR LTC POS > 90D Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1285 NOCOV DEF SYSMAN Description: SCRN MAM PERF RSLTS NOT DOC Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1286 NOCOV DEF SYSMAN Description: BMI DOC ONL FUP NOT CMPLTD Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1287 NOCOV DEF SYSMAN Description: CALC BMI BLW LOW PARAM F/U Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1288 NOCOV DEF SYSMAN Description: DOC RSN NO HBP SCRN OR F/U Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1289 NOCOV DEF SYSMAN Description: NO PT TBCO CESS INTERV RNG Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1290 NOCOV DEF SYSMAN Description: PT NOT ELI D/T ACT DIG HTN Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1291 NOCOV DEF SYSMAN Description: PT 66+ FRAILTY AND MED DEM Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,048 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- M1292 NOCOV DEF SYSMAN Description: PT 66+ FRAIL INPT ADV ILL Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1293 NOCOV DEF SYSMAN Description: CALC BMI ABV UP PARAM F/U Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1294 NOCOV DEF SYSMAN Description: BP SCRN PERF REC INTERVAL Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1295 NOCOV DEF SYSMAN Description: PT HX TOT COL OR COLON CA Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1296 NOCOV DEF SYSMAN Description: CALC BMI NORM PARAMETERS Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1297 NOCOV DEF SYSMAN Description: BMI NOT DOC MEDRSN PTREF Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1298 NOCOV DEF SYSMAN Description: DOC PT PREG DUR MSRMT PD Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1299 NOCOV DEF SYSMAN Description: FLU IMMUNIZE ORDER/ADMIN Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1300 NOCOV DEF SYSMAN Description: FLU IMM NO ADMIN DOC REA Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1301 NOCOV DEF SYSMAN Description: PT RECV TBCO CESS INTERV Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1302 NOCOV DEF SYSMAN Description: SCRN MAM PERF RSLTS DOC Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1303 NOCOV DEF SYSMAN Description: HOSPC SERV DUR MEAS PD Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1304 NOCOV DEF SYSMAN Description: NO PNEUM VAX ADMIN 19+ Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1305 NOCOV DEF SYSMAN Description: PNEUM VAX ADMIN 19+ Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1306 NOCOV DEF SYSMAN Description: PT ANPHX DUE TO PNEUM Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1307 NOCOV DEF SYSMAN Description: DOC PT PAL OR HOSPICE Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,049 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- M1308 NOCOV DEF SYSMAN Description: FLU IMMUNIZE NO ADMIN Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1309 NOCOV DEF SYSMAN Description: PALL SERV DURING MEAS Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1310 NOCOV DEF SYSMAN Description: PT SCR TOB & CESS INT Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1311 NOCOV DEF SYSMAN Description: APHLX TO VAX BEF ENC Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1312 NOCOV DEF SYSMAN Description: NO PT TBCO SCRN RNG Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1313 NOCOV DEF SYSMAN Description: NO TOB SCR/CESS INT Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1314 NOCOV DEF SYSMAN Description: BMI NOT CALCULATED Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1315 NOCOV DEF SYSMAN Description: CRC NO DOC NO RSN Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1316 NOCOV DEF SYSMAN Description: TOBACCO NON-USER Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1317 NOCOV DEF SYSMAN Description: PTS COUNSL CPT OPT OUT Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1318 NOCOV DEF SYSMAN Description: PTS NO CSP DOC CONTACT Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1319 NOCOV DEF SYSMAN Description: PTS CSP DOC CONTACT Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1320 NOCOV DEF SYSMAN Description: PTS SCRN + HRSN Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1321 NOCOV DEF SYSMAN Description: PTS NO 7WK INJ,NO IOP,IOP>25 Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1322 NOCOV DEF SYSMAN Description: PTS 7WK INJ, SCRN IOP =<25 Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1323 NOCOV DEF SYSMAN Description: PTS 7WK INJ, SCRN IOP >25 Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,050 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- M1324 NOCOV DEF SYSMAN Description: PTS INTRAVITREAL/PCI Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1325 NOCOV DEF SYSMAN Description: DOC MED RSN NOT SEEN Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1326 NOCOV DEF SYSMAN Description: PTS DX HYPOTONY Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1327 NOCOV DEF SYSMAN Description: PTS NO EVAL INI XM NO 8 WKS Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1328 NOCOV DEF SYSMAN Description: PTS DX ACUTE VITREOUS HEM Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1329 NOCOV DEF SYSMAN Description: PTS ACT PVD 2 WKS 8 WKS Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1330 NOCOV DEF SYSMAN Description: DOC PTS RSN NO F/U XM Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1331 NOCOV DEF SYSMAN Description: PTS EVAL INI XM 8 WKS Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1332 NOCOV DEF SYSMAN Description: PTS NO EVAL INI XM NO 2 WKS Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1333 NOCOV DEF SYSMAN Description: ACUTE VITREOUS HEMORRHAGE Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1334 NOCOV DEF SYSMAN Description: PTS ACT PVD 2 WKS 2 WKS Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1335 NOCOV DEF SYSMAN Description: DOC PTS RSN NO F/U XM Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1336 NOCOV DEF SYSMAN Description: PTS EVAL INI XM 2 WKS Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1337 NOCOV DEF SYSMAN Description: ACUTE PVD Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1338 NOCOV DEF SYSMAN Description: PT F/U 30-180 DYS NO + IMPRV Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1339 NOCOV DEF SYSMAN Description: PTS F/U 30-180 DYS + IMPROV Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,051 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- M1340 NOCOV DEF SYSMAN Description: INDX WHODAS 2.0 OR SDS Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1341 NOCOV DEF SYSMAN Description: PT NO F/U 30-180 DYS Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1342 NOCOV DEF SYSMAN Description: PTS DIED PERF PER Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1343 NOCOV DEF SYSMAN Description: PT PAM LVL 4 BASE OR SRT LIN Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1344 NOCOV DEF SYSMAN Description: PTS NO BSLN OR 2ND PAM SCORE Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1345 NOCOV DEF SYSMAN Description: PT BSLN PAM, 2ND SCR 6-12 MO Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1346 NOCOV DEF SYSMAN Description: PTS NO PAM 6 PTS 6-12 MO Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1347 NOCOV DEF SYSMAN Description: PT PAM INCR 3 PT 6-12 MO Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1348 NOCOV DEF SYSMAN Description: PT PAM INCR 6 PT 6-12 MO Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1349 NOCOV DEF SYSMAN Description: PT NO PAM 3 PTS 6-12 MO Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1350 NOCOV DEF SYSMAN Description: PT W/ SUIC SAF PLN INIT REV Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1351 NOCOV DEF SYSMAN Description: PT CMPLT SUICD SAF PLN 120DY Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1352 NOCOV DEF SYSMAN Description: SUICD C-SSRS ASSESSMENT, EQU Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1353 NOCOV DEF SYSMAN Description: PTS NO CMPLT SUICD SAF PLN Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1354 NOCOV DEF SYSMAN Description: PT NO SUICD SAF PLN 120DY Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1355 NOCOV DEF SYSMAN Description: SUICD BASED CLN EVAL Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,052 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- M1356 NOCOV DEF SYSMAN Description: PT DIED DUR MEAS PD Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1357 NOCOV DEF SYSMAN Description: PT W/RED SUIC IDEA 120 DAYS Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1358 NOCOV DEF SYSMAN Description: PTS NO =20PCT Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1365 NOCOV DEF SYSMAN Description: HOSP+PALL CARE SPEC CODE 17 Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1366 NOCOV DEF SYSMAN Description: FOCUS ON WOMEN'S HEALTH MVP Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1367 NOCOV DEF SYSMAN Description: QUAL CARE ENT DISORDER MVP Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1368 NOCOV DEF SYSMAN Description: PREV TRT INF D/O HIV/HEP MVP Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1369 NOCOV DEF SYSMAN Description: QUALCARE MENTAL HLTH/SUD MVP Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: M1370 NOCOV DEF SYSMAN Description: REHAB SUPPORT MSK CARE MVP Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: P0001 LAB DEF MAXFEE 01/01/2024 15.60 0.0 Description: AUTOMATED, MULTICHANNEL T Category: Laboratory CMS Add: 01/01/1900 CMS Term: 06/30/2015 *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,053 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- P0001 LAB DEF MAXFEE 07/20/1981 12/31/2023 12.00 0.0 Description: AUTOMATED, MULTICHANNEL T Category: Laboratory CMS Add: 01/01/1900 CMS Term: 06/30/2015 P2028 NOCOV DEF SYSMAN Description: CEPHALIN FLOCULATION TEST Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: P2029 NOCOV DEF SYSMAN Description: CONGO RED BLOOD TEST Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: P2031 NOCOV DEF SYSMAN Description: HAIR ANALYSIS Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: P2033 NOCOV DEF SYSMAN Description: BLOOD THYMOL TURBIDITY Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: P2038 NOCOV DEF SYSMAN Description: BLOOD MUCOPROTEIN Category: Non Covered Services CMS Add: 01/01/1986 CMS Term: P3000 NOCOV DEF SYSMAN Description: SCREEN PAP BY TECH W MD SUPV Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: P3001 NOCOV DEF SYSMAN Description: SCREENING PAP SMEAR BY PHYS Category: Non Covered Services CMS Add: 01/01/1992 CMS Term: P7001 LAB L60 MAXFEE 01/01/1994 12/31/2023 17.36 0.0 Description: CULTURE BACTERIAL URINE Category: Laboratory CMS Add: 01/01/1986 CMS Term: P7001 LAB L60 MAXFEE 01/01/2024 22.57 0.0 Description: CULTURE BACTERIAL URINE Category: Laboratory CMS Add: 01/01/1986 CMS Term: P9010 LAB DEF MAXFEE 01/01/2024 288.11 0.0 Description: WHOLE BLOOD FOR TRANSFUSION Category: Laboratory CMS Add: 01/01/1987 CMS Term: P9010 LAB DEF MAXFEE 06/17/2016 12/31/2023 221.62 0.0 Description: WHOLE BLOOD FOR TRANSFUSION Category: Laboratory CMS Add: 01/01/1987 CMS Term: P9011 LAB DEF MAXFEE 01/01/2024 133.25 0.0 Description: BLOOD SPLIT UNIT Category: Laboratory CMS Add: 01/01/1987 CMS Term: P9011 LAB DEF MAXFEE 06/17/2016 12/31/2023 102.50 0.0 Description: BLOOD SPLIT UNIT Category: Laboratory CMS Add: 01/01/1987 CMS Term: P9012 LAB DEF MAXFEE 01/01/2024 77.53 0.0 Description: CRYOPRECIPITATE EACH UNIT Category: Laboratory CMS Add: 01/01/1987 CMS Term: P9012 LAB DEF MAXFEE 06/17/2016 12/31/2023 59.64 0.0 Description: CRYOPRECIPITATE EACH UNIT Category: Laboratory CMS Add: 01/01/1987 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,054 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- P9016 LAB DEF MAXFEE 01/01/2024 239.64 0.0 Description: RBC LEUKOCYTES REDUCED Category: Laboratory CMS Add: 01/01/1987 CMS Term: P9016 LAB DEF MAXFEE 06/17/2016 12/31/2023 184.34 0.0 Description: RBC LEUKOCYTES REDUCED Category: Laboratory CMS Add: 01/01/1987 CMS Term: P9017 LAB DEF MAXFEE 01/01/2024 94.33 0.0 Description: PLASMA 1 DONOR FRZ W/IN 8 HR Category: Laboratory CMS Add: 01/01/1987 CMS Term: P9017 LAB DEF MAXFEE 06/17/2016 12/31/2023 72.56 0.0 Description: PLASMA 1 DONOR FRZ W/IN 8 HR Category: Laboratory CMS Add: 01/01/1987 CMS Term: P9019 LAB DEF MAXFEE 01/01/2024 153.44 0.0 Description: PLATELETS, EACH UNIT Category: Laboratory CMS Add: 01/01/1987 CMS Term: P9019 LAB DEF MAXFEE 06/17/2016 12/31/2023 118.03 0.0 Description: PLATELETS, EACH UNIT Category: Laboratory CMS Add: 01/01/1987 CMS Term: P9020 LAB DEF MAXFEE 01/01/2024 156.21 0.0 Description: PLAELET RICH PLASMA UNIT Category: Laboratory CMS Add: 01/01/1987 CMS Term: P9020 LAB DEF MAXFEE 06/17/2016 12/31/2023 120.16 0.0 Description: PLAELET RICH PLASMA UNIT Category: Laboratory CMS Add: 01/01/1987 CMS Term: P9021 LAB DEF MAXFEE 01/01/2024 189.53 0.0 Description: RED BLOOD CELLS UNIT Category: Laboratory CMS Add: 01/01/1987 CMS Term: P9021 LAB DEF MAXFEE 06/17/2016 12/31/2023 145.79 0.0 Description: RED BLOOD CELLS UNIT Category: Laboratory CMS Add: 01/01/1987 CMS Term: P9022 LAB DEF MAXFEE 01/01/2024 399.70 0.0 Description: WASHED RED BLOOD CELLS UNIT Category: Laboratory CMS Add: 01/01/1987 CMS Term: P9022 LAB DEF MAXFEE 06/17/2016 12/31/2023 307.46 0.0 Description: WASHED RED BLOOD CELLS UNIT Category: Laboratory CMS Add: 01/01/1987 CMS Term: P9023 LAB DEF MAXFEE 01/01/2024 98.67 0.0 Description: FROZEN PLASMA, POOLED, SD Category: Laboratory CMS Add: 01/01/2000 CMS Term: P9023 LAB DEF MAXFEE 06/17/2016 12/31/2023 75.90 0.0 Description: FROZEN PLASMA, POOLED, SD Category: Laboratory CMS Add: 01/01/2000 CMS Term: P9025 LAB DEF MAXFEE 01/01/2024 85.41 0.0 Description: PLASMA CRYO REDU PATH EACH Category: Laboratory CMS Add: 10/01/2021 CMS Term: P9025 LAB DEF MAXFEE 10/01/2021 12/31/2023 65.70 0.0 Description: PLASMA CRYO REDU PATH EACH Category: Laboratory CMS Add: 10/01/2021 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,055 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- P9026 LAB DEF MAXFEE 01/01/2024 103.81 0.0 Description: CRYO FIB COMP PATH REDU EACH Category: Laboratory CMS Add: 10/01/2021 CMS Term: P9026 LAB DEF MAXFEE 10/01/2021 12/31/2023 79.85 0.0 Description: CRYO FIB COMP PATH REDU EACH Category: Laboratory CMS Add: 10/01/2021 CMS Term: P9031 LAB DEF MAXFEE 01/01/2024 151.22 0.0 Description: PLATELETS LEUKOCYTES REDUCED Category: Laboratory CMS Add: 01/01/2001 CMS Term: P9031 LAB DEF MAXFEE 06/17/2016 12/31/2023 116.32 0.0 Description: PLATELETS LEUKOCYTES REDUCED Category: Laboratory CMS Add: 01/01/2001 CMS Term: P9032 LAB DEF MAXFEE 01/01/2024 206.82 0.0 Description: PLATELETS, IRRADIATED Category: Laboratory CMS Add: 01/01/2001 CMS Term: P9032 LAB DEF MAXFEE 06/17/2016 12/31/2023 159.09 0.0 Description: PLATELETS, IRRADIATED Category: Laboratory CMS Add: 01/01/2001 CMS Term: P9033 LAB DEF MAXFEE 01/01/2024 210.70 0.0 Description: PLATELETS LEUKOREDUCED IRRAD Category: Laboratory CMS Add: 01/01/2001 CMS Term: P9033 LAB DEF MAXFEE 06/17/2016 12/31/2023 162.08 0.0 Description: PLATELETS LEUKOREDUCED IRRAD Category: Laboratory CMS Add: 01/01/2001 CMS Term: P9034 LAB DEF MAXFEE 01/01/2024 552.70 0.0 Description: PLATELETS, PHERESIS Category: Laboratory CMS Add: 01/01/2001 CMS Term: P9034 LAB DEF MAXFEE 06/17/2016 12/31/2023 425.15 0.0 Description: PLATELETS, PHERESIS Category: Laboratory CMS Add: 01/01/2001 CMS Term: P9035 LAB DEF MAXFEE 01/01/2024 634.78 0.0 Description: PLATELET PHERES LEUKOREDUCED Category: Laboratory CMS Add: 01/01/2001 CMS Term: P9035 LAB DEF MAXFEE 06/17/2016 12/31/2023 488.29 0.0 Description: PLATELET PHERES LEUKOREDUCED Category: Laboratory CMS Add: 01/01/2001 CMS Term: P9036 LAB DEF MAXFEE 01/01/2024 686.54 0.0 Description: PLATELET PHERESIS IRRADIATED Category: Laboratory CMS Add: 01/01/2001 CMS Term: P9036 LAB DEF MAXFEE 06/17/2016 12/31/2023 528.11 0.0 Description: PLATELET PHERESIS IRRADIATED Category: Laboratory CMS Add: 01/01/2001 CMS Term: P9037 LAB DEF MAXFEE 01/01/2024 834.41 0.0 Description: PLATE PHERES LEUKOREDU IRRAD Category: Laboratory CMS Add: 01/01/2001 CMS Term: P9037 LAB DEF MAXFEE 06/17/2016 12/31/2023 641.85 0.0 Description: PLATE PHERES LEUKOREDU IRRAD Category: Laboratory CMS Add: 01/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,056 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- P9038 LAB DEF MAXFEE 01/01/2024 267.57 0.0 Description: RBC IRRADIATED Category: Laboratory CMS Add: 01/01/2001 CMS Term: P9038 LAB DEF MAXFEE 06/17/2016 12/31/2023 205.82 0.0 Description: RBC IRRADIATED Category: Laboratory CMS Add: 01/01/2001 CMS Term: P9039 LAB DEF MAXFEE 01/01/2024 494.42 0.0 Description: RBC DEGLYCEROLIZED Category: Laboratory CMS Add: 01/01/2001 CMS Term: P9039 LAB DEF MAXFEE 06/17/2016 12/31/2023 380.32 0.0 Description: RBC DEGLYCEROLIZED Category: Laboratory CMS Add: 01/01/2001 CMS Term: P9040 LAB DEF MAXFEE 01/01/2024 347.92 0.0 Description: RBC LEUKOREDUCED IRRADIATED Category: Laboratory CMS Add: 01/01/2001 CMS Term: P9040 LAB DEF MAXFEE 06/17/2016 12/31/2023 267.63 0.0 Description: RBC LEUKOREDUCED IRRADIATED Category: Laboratory CMS Add: 01/01/2001 CMS Term: P9041 LAB DEF MAXFEE 01/01/2024 12.71 0.0 Description: ALBUMIN (HUMAN),5%, 50ML Category: Laboratory CMS Add: 01/01/2001 CMS Term: P9041 LAB DEF MAXFEE 04/01/2023 12/31/2023 9.78 0.0 Description: ALBUMIN (HUMAN),5%, 50ML Category: Laboratory CMS Add: 01/01/2001 CMS Term: P9043 LAB DEF MAXFEE 01/01/2024 14.44 0.0 Description: PLASMA PROTEIN FRACT,5%,50ML Category: Laboratory CMS Add: 01/01/2001 CMS Term: P9043 LAB DEF MAXFEE 07/01/2016 12/31/2023 11.11 0.0 Description: PLASMA PROTEIN FRACT,5%,50ML Category: Laboratory CMS Add: 01/01/2001 CMS Term: P9044 LAB DEF MAXFEE 01/01/2024 66.46 0.0 Description: CRYOPRECIPITATEREDUCEDPLASMA Category: Laboratory CMS Add: 01/01/2001 CMS Term: P9044 LAB DEF MAXFEE 06/17/2016 12/31/2023 51.12 0.0 Description: CRYOPRECIPITATEREDUCEDPLASMA Category: Laboratory CMS Add: 01/01/2001 CMS Term: P9045 LAB DEF MAXFEE 01/01/2024 63.56 0.0 Description: ALBUMIN (HUMAN), 5%, 250 ML Category: Laboratory CMS Add: 01/01/2002 CMS Term: P9045 LAB DEF MAXFEE 04/01/2023 12/31/2023 48.89 0.0 Description: ALBUMIN (HUMAN), 5%, 250 ML Category: Laboratory CMS Add: 01/01/2002 CMS Term: P9046 LAB DEF MAXFEE 01/01/2024 25.12 0.0 Description: ALBUMIN (HUMAN), 25%, 20 ML Category: Laboratory CMS Add: 01/01/2002 CMS Term: P9046 LAB DEF MAXFEE 10/01/2021 12/31/2023 19.32 0.0 Description: ALBUMIN (HUMAN), 25%, 20 ML Category: Laboratory CMS Add: 01/01/2002 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,057 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- P9047 LAB DEF MAXFEE 01/01/2024 62.80 0.0 Description: ALBUMIN (HUMAN), 25%, 50ML Category: Laboratory CMS Add: 01/01/2002 CMS Term: P9047 LAB DEF MAXFEE 10/01/2021 12/31/2023 48.31 0.0 Description: ALBUMIN (HUMAN), 25%, 50ML Category: Laboratory CMS Add: 01/01/2002 CMS Term: P9048 LAB DEF MAXFEE 01/01/2024 72.19 0.0 Description: PLASMAPROTEIN FRACT,5%,250ML Category: Laboratory CMS Add: 01/01/2002 CMS Term: P9048 LAB DEF MAXFEE 07/01/2016 12/31/2023 55.53 0.0 Description: PLASMAPROTEIN FRACT,5%,250ML Category: Laboratory CMS Add: 01/01/2002 CMS Term: P9050 LAB DEF MAXFEE 01/01/2024 1974.02 0.0 Description: GRANULOCYTES, PHERESIS UNIT Category: Laboratory CMS Add: 01/01/2002 CMS Term: P9050 LAB DEF MAXFEE 06/17/2016 12/31/2023 1518.48 0.0 Description: GRANULOCYTES, PHERESIS UNIT Category: Laboratory CMS Add: 01/01/2002 CMS Term: P9051 LAB DEF MAXFEE 01/01/2024 260.60 0.0 Description: BLOOD, L/R, CMV-NEG Category: Laboratory CMS Add: 01/01/2004 CMS Term: P9051 LAB DEF MAXFEE 06/17/2016 12/31/2023 200.46 0.0 Description: BLOOD, L/R, CMV-NEG Category: Laboratory CMS Add: 01/01/2004 CMS Term: P9052 LAB DEF MAXFEE 01/01/2024 916.47 0.0 Description: PLATELETS, HLA-M, L/R, UNIT Category: Laboratory CMS Add: 01/01/2004 CMS Term: P9052 LAB DEF MAXFEE 06/17/2016 12/31/2023 704.98 0.0 Description: PLATELETS, HLA-M, L/R, UNIT Category: Laboratory CMS Add: 01/01/2004 CMS Term: P9053 LAB DEF MAXFEE 01/01/2024 768.26 0.0 Description: PLT, PHER, L/R CMV-NEG, IRR Category: Laboratory CMS Add: 01/01/2004 CMS Term: P9053 LAB DEF MAXFEE 06/17/2016 12/31/2023 590.97 0.0 Description: PLT, PHER, L/R CMV-NEG, IRR Category: Laboratory CMS Add: 01/01/2004 CMS Term: P9054 LAB DEF MAXFEE 01/01/2024 417.66 0.0 Description: BLOOD, L/R, FROZ/DEGLY/WASH Category: Laboratory CMS Add: 01/01/2004 CMS Term: P9054 LAB DEF MAXFEE 06/17/2016 12/31/2023 321.28 0.0 Description: BLOOD, L/R, FROZ/DEGLY/WASH Category: Laboratory CMS Add: 01/01/2004 CMS Term: P9055 LAB DEF MAXFEE 01/01/2024 601.22 0.0 Description: PLT, APH/PHER, L/R, CMV-NEG Category: Laboratory CMS Add: 01/01/2004 CMS Term: P9055 LAB DEF MAXFEE 06/17/2016 12/31/2023 462.48 0.0 Description: PLT, APH/PHER, L/R, CMV-NEG Category: Laboratory CMS Add: 01/01/2004 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,058 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- P9056 LAB DEF MAXFEE 01/01/2024 165.63 0.0 Description: BLOOD, L/R, IRRADIATED Category: Laboratory CMS Add: 01/01/2004 CMS Term: P9056 LAB DEF MAXFEE 06/17/2016 12/31/2023 127.41 0.0 Description: BLOOD, L/R, IRRADIATED Category: Laboratory CMS Add: 01/01/2004 CMS Term: P9057 LAB DEF MAXFEE 01/01/2024 264.36 0.0 Description: RBC, FRZ/DEG/WSH, L/R, IRRAD Category: Laboratory CMS Add: 01/01/2004 CMS Term: P9057 LAB DEF MAXFEE 06/17/2016 12/31/2023 203.35 0.0 Description: RBC, FRZ/DEG/WSH, L/R, IRRAD Category: Laboratory CMS Add: 01/01/2004 CMS Term: P9058 LAB DEF MAXFEE 01/01/2024 324.00 0.0 Description: RBC, L/R, CMV-NEG, IRRAD Category: Laboratory CMS Add: 01/01/2004 CMS Term: P9058 LAB DEF MAXFEE 06/17/2016 12/31/2023 249.23 0.0 Description: RBC, L/R, CMV-NEG, IRRAD Category: Laboratory CMS Add: 01/01/2004 CMS Term: P9059 LAB DEF MAXFEE 01/01/2024 95.00 0.0 Description: PLASMA, FRZ BETWEEN 8-24HOUR Category: Laboratory CMS Add: 01/01/2004 CMS Term: P9059 LAB DEF MAXFEE 06/17/2016 12/31/2023 73.08 0.0 Description: PLASMA, FRZ BETWEEN 8-24HOUR Category: Laboratory CMS Add: 01/01/2004 CMS Term: P9060 LAB DEF MAXFEE 01/01/2024 66.85 0.0 Description: FR FRZ PLASMA DONOR RETESTED Category: Laboratory CMS Add: 01/01/2004 CMS Term: P9060 LAB DEF MAXFEE 06/17/2016 12/31/2023 51.42 0.0 Description: FR FRZ PLASMA DONOR RETESTED Category: Laboratory CMS Add: 01/01/2004 CMS Term: P9070 LAB DEF MAXFEE 01/01/2024 95.00 0.0 Description: PATHOGEN REDUCED PLASMA POOL Category: Laboratory CMS Add: 01/01/2016 CMS Term: P9070 LAB DEF MAXFEE 06/17/2016 12/31/2023 73.08 0.0 Description: PATHOGEN REDUCED PLASMA POOL Category: Laboratory CMS Add: 01/01/2016 CMS Term: P9071 LAB DEF MAXFEE 01/01/2024 94.33 0.0 Description: PATHOGEN REDUCED PLASMA SING Category: Laboratory CMS Add: 01/01/2016 CMS Term: P9071 LAB DEF MAXFEE 06/17/2016 12/31/2023 72.56 0.0 Description: PATHOGEN REDUCED PLASMA SING Category: Laboratory CMS Add: 01/01/2016 CMS Term: P9073 LAB DEF MAXFEE 01/01/2018 12/31/2023 624.66 0.0 Description: PLATELETS PHERESIS PATH REDU Category: Laboratory CMS Add: 01/01/2018 CMS Term: P9073 LAB DEF MAXFEE 01/01/2024 812.06 0.0 Description: PLATELETS PHERESIS PATH REDU Category: Laboratory CMS Add: 01/01/2018 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,059 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- P9099 LAB DEF BILL90 Description: BLOOD COMPONENT/PRODUCT NOC Category: Laboratory CMS Add: 01/01/2020 CMS Term: P9100 LAB L60 MAXFEE 01/01/2018 12/31/2023 25.50 0.0 Description: PATHOGEN TEST FOR PLATELETS Category: Laboratory CMS Add: 01/01/2018 CMS Term: P9100 LAB L60 MAXFEE 01/01/2024 33.15 0.0 Description: PATHOGEN TEST FOR PLATELETS Category: Laboratory CMS Add: 01/01/2018 CMS Term: P9603 LAB DEF MAXFEE 01/01/2024 1.31 0.0 Description: ONE-WAY ALLOW PRORATED MILES Category: Laboratory CMS Add: 01/01/1987 CMS Term: P9603 LAB DEF MAXFEE 05/20/2021 12/31/2023 1.01 0.0 Description: ONE-WAY ALLOW PRORATED MILES Category: Laboratory CMS Add: 01/01/1987 CMS Term: P9604 LAB DEF MAXFEE 01/01/1987 12/31/2023 1.62 0.0 Description: ONE-WAY ALLOW PRORATED TRIP Category: Laboratory CMS Add: 01/01/1987 CMS Term: P9604 LAB DEF MAXFEE 01/01/2024 2.11 0.0 Description: ONE-WAY ALLOW PRORATED TRIP Category: Laboratory CMS Add: 01/01/1987 CMS Term: P9612 LAB L60 MAXFEE 01/01/1999 12/31/2023 3.00 0.0 Description: CATHETERIZE FOR URINE SPEC Category: Laboratory CMS Add: 01/01/1999 CMS Term: P9612 LAB L60 MAXFEE 01/01/2024 8.57 0.0 Description: CATHETERIZE FOR URINE SPEC Category: Laboratory CMS Add: 01/01/1999 CMS Term: P9615 LAB L60 MAXFEE 01/01/2024 8.57 0.0 Description: URINE SPECIMEN COLLECT MULT Category: Laboratory CMS Add: 01/01/1985 CMS Term: P9615 LAB L60 MAXFEE 07/01/1985 12/31/2023 3.00 0.0 Description: URINE SPECIMEN COLLECT MULT Category: Laboratory CMS Add: 01/01/1985 CMS Term: Q0035 NOCOV DEF SYSMAN Description: CARDIOKYMOGRAPHY Category: Non Covered Services CMS Add: 01/01/1989 CMS Term: Q0081 DRUG DEF BILL90 Description: INFUSION THER OTHER THAN CHE Category: Drugs CMS Add: 01/01/1992 CMS Term: Q0083 DRUG DEF BILL90 Description: CHEMO BY OTHER THAN INFUSION Category: Drugs CMS Add: 01/01/1992 CMS Term: Q0084 DRUG DEF BILL90 Description: CHEMOTHERAPY BY INFUSION Category: Drugs CMS Add: 01/01/1992 CMS Term: Q0085 DRUG DEF BILL90 Description: CHEMO BY BOTH INFUSION AND O Category: Drugs CMS Add: 01/01/1992 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,060 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- Q0091 LAB DEF RBRVS 01/01/2024 40.64 Description: OBTAINING SCREEN PAP SMEAR Category: Laboratory CMS Add: 01/01/1992 CMS Term: Q0091 LAB DEF RBRVS 02/01/2015 12/31/2023 17.37 Description: OBTAINING SCREEN PAP SMEAR Category: Laboratory CMS Add: 01/01/1992 CMS Term: Q0092 NOCOV DEF SYSMAN Description: SET UP PORT XRAY EQUIPMENT Category: Non Covered Services CMS Add: 01/01/1993 CMS Term: Q0111 LAB L60 MAXFEE 01/01/2015 12/31/2023 5.81 0.0 Description: WET MOUNTS/ W PREPARATIONS Category: Laboratory CMS Add: 01/01/1994 CMS Term: Q0111 LAB L60 MAXFEE 01/01/2024 17.31 0.0 Description: WET MOUNTS/ W PREPARATIONS Category: Laboratory CMS Add: 01/01/1994 CMS Term: Q0112 LAB L60 MAXFEE 01/01/2015 12/31/2023 5.81 0.0 Description: POTASSIUM HYDROXIDE PREPS Category: Laboratory CMS Add: 01/01/1994 CMS Term: Q0112 LAB L60 MAXFEE 01/01/2024 5.83 0.0 Description: POTASSIUM HYDROXIDE PREPS Category: Laboratory CMS Add: 01/01/1994 CMS Term: Q0113 LAB L60 MAXFEE 01/01/2020 4.27 0.0 Description: PINWORM EXAMINATIONS Category: Laboratory CMS Add: 01/01/1994 CMS Term: Q0114 LAB L60 MAXFEE 01/01/2015 9.74 0.0 Description: FERN TEST Category: Laboratory CMS Add: 01/01/1994 CMS Term: Q0115 LAB L60 MAXFEE 01/01/2015 12/31/2023 13.46 0.0 Description: POST-COITAL MUCOUS EXAM Category: Laboratory CMS Add: 01/01/1994 CMS Term: Q0115 LAB L60 MAXFEE 01/01/2024 25.00 0.0 Description: POST-COITAL MUCOUS EXAM Category: Laboratory CMS Add: 01/01/1994 CMS Term: Q0138 DRUG DEF MAXFEE 10/01/2021 1.79 0.0 Description: FERUMOXYTOL, NON-ESRD Category: Drugs CMS Add: 01/01/2010 CMS Term: Q0139 DRUG DEF MAXFEE 10/01/2021 1.79 0.0 Description: FERUMOXYTOL, ESRD USE Category: Drugs CMS Add: 01/01/2010 CMS Term: Q0144 DRUG DEF MAXFEE 04/01/2024 2.45 0.0 Description: AZITHROMYCIN DIHYDRATE, ORAL Category: Drugs CMS Add: 07/01/1996 CMS Term: Q0144 DRUG DEF MAXFEE 10/01/2019 03/31/2024 2.68 0.0 Description: AZITHROMYCIN DIHYDRATE, ORAL Category: Drugs CMS Add: 07/01/1996 CMS Term: Q0161 DRUG DEF MAXFEE 01/01/2024 0.02 0.0 Description: CHLORPROMAZINE HCL 5MG ORAL Category: Drugs CMS Add: 01/01/2014 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,061 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- Q0161 DRUG DEF MAXFEE 04/01/2022 12/31/2023 0.09 0.0 Description: CHLORPROMAZINE HCL 5MG ORAL Category: Drugs CMS Add: 01/01/2014 CMS Term: Q0162 DRUG DEF MAXFEE 04/01/2021 0.02 0.0 Description: ONDANSETRON ORAL Category: Drugs CMS Add: 01/01/2012 CMS Term: Q0163 NOCOV DEF SYSMAN Description: DIPHENHYDRAMINE HCL 50MG Category: Non Covered Services CMS Add: 04/01/1998 CMS Term: Q0164 DRUG DEF MAXFEE 01/01/2024 0.18 0.0 Description: PROCHLORPERAZINE MALEATE 5MG Category: Drugs CMS Add: 04/01/1998 CMS Term: Q0164 DRUG DEF MAXFEE 10/01/2019 12/31/2023 0.25 0.0 Description: PROCHLORPERAZINE MALEATE 5MG Category: Drugs CMS Add: 04/01/1998 CMS Term: Q0166 DRUG DEF MAXFEE 07/01/2023 1.10 0.0 Description: GRANISETRON HCL 1 MG ORAL Category: Drugs CMS Add: 04/01/1998 CMS Term: Q0166 DRUG DEF MAXFEE 10/01/2022 06/30/2023 3.15 0.0 Description: GRANISETRON HCL 1 MG ORAL Category: Drugs CMS Add: 04/01/1998 CMS Term: Q0167 DRUG DEF MAXFEE 04/01/2023 1.09 0.0 Description: DRONABINOL 2.5MG ORAL Category: Drugs CMS Add: 04/01/1998 CMS Term: Q0169 DRUG DEF MAXFEE 10/01/2015 0.05 0.0 Description: PROMETHAZINE HCL 12.5MG ORAL Category: Drugs CMS Add: 04/01/1998 CMS Term: Q0173 DRUG DEF MAXFEE 01/01/2023 1.15 0.0 Description: TRIMETHOBENZAMIDE HCL 250MG Category: Drugs CMS Add: 04/01/1998 CMS Term: Q0174 DRUG DEF SYSMAN Description: THIETHYLPERAZINE MALEATE10MG Category: Drugs CMS Add: 04/01/1998 CMS Term: Q0175 DRUG DEF MAXFEE 04/01/2023 0.13 0.0 Description: PERPHENAZINE 4MG ORAL Category: Drugs CMS Add: 04/01/1998 CMS Term: Q0177 DRUG DEF MAXFEE 07/01/2011 0.08 0.0 Description: HYDROXYZINE PAMOATE 25MG Category: Drugs CMS Add: 04/01/1998 CMS Term: Q0180 DRUG DEF SYSMAN Description: DOLASETRON MESYLATE ORAL Category: Drugs CMS Add: 04/01/1998 CMS Term: Q0181 DRUG DEF BILL90 Description: UNSPECIFIED ORAL ANTI-EMETIC Category: Drugs CMS Add: 04/01/1998 CMS Term: Q0220 DRUG DEF MAXFEE 12/08/2021 0.00 0.0 12-999years Description: TIXAGEV AND CILGAV, 300MG Category: Drugs CMS Add: 12/08/2021 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,062 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- Q0221 DRUG DEF MAXFEE 02/24/2022 0.00 0.0 12-999years Description: TIXAGEV AND CILGAV, 600MG Category: Drugs CMS Add: 02/24/2022 CMS Term: Q0240 DRUG DEF MAXFEE 07/30/2021 0.00 0.0 Description: CASIRIVI AND IMDEVI 600 MG Category: Drugs CMS Add: 07/30/2021 CMS Term: Q0243 DRUG DEF MAXFEE 11/21/2020 0.00 0.0 Description: CASIRIVIMAB AND IMDEVIMAB Category: Drugs CMS Add: 11/21/2020 CMS Term: Q0244 DRUG DEF MAXFEE 06/03/2021 0.00 0.0 Description: CASIRIVI AND IMDEVI 1200 MG Category: Drugs CMS Add: 06/03/2021 CMS Term: Q0245 DRUG DEF MAXFEE 02/09/2021 0.00 0.0 Description: BAMLANIVIMAB AND ETESEVIMA Category: Drugs CMS Add: 02/09/2021 CMS Term: Q0247 NOCOV DEF SYSMAN Description: SOTROVIMAB Category: Non Covered Services CMS Add: 05/26/2021 CMS Term: Q0249 DRUG DEF MAXFEE 04/01/2023 06/30/2023 6.64 0.0 2-999years Description: TOCILIZUMAB FOR COVID-19 Category: Drugs CMS Add: 06/24/2021 CMS Term: Q0249 DRUG DEF MAXFEE 07/01/2023 6.97 0.0 2-999years Description: TOCILIZUMAB FOR COVID-19 Category: Drugs CMS Add: 06/24/2021 CMS Term: Q0477 MDSPY DEF MAXFEE 01/01/2018 12/31/2023 81.40 0.0 Description: PWR MODULE PT CABLE LVAD RPL Category: Medical Supplies CMS Add: 01/01/2018 CMS Term: Q0477 MDSPY DEF MAXFEE 01/01/2024 891.49 0.0 Description: PWR MODULE PT CABLE LVAD RPL Category: Medical Supplies CMS Add: 01/01/2018 CMS Term: Q0478 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 166.54 0.0 Y 0-1 Description: POWER ADAPTER, COMBO VAD Category: Medical Supplies CMS Add: 01/01/2011 CMS Term: Q0478 MDSPY DEF MAXFEE 01/01/2024 211.15 0.0 Y 0-1 Description: POWER ADAPTER, COMBO VAD Category: Medical Supplies CMS Add: 01/01/2011 CMS Term: Q0479 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 10946.27 0.0 Y 0-1 Description: POWER MODULE COMBO VAD, REP Category: Medical Supplies CMS Add: 01/01/2011 CMS Term: Q0479 MDSPY DEF MAXFEE 01/01/2024 13792.83 0.0 Y 0-1 Description: POWER MODULE COMBO VAD, REP Category: Medical Supplies CMS Add: 01/01/2011 CMS Term: Q0480 MDSPY DEF MAXFEE 01/01/2024 99999.95 0.0 Y 0-1 Description: DRIVER PNEUMATIC VAD, REP Category: Medical Supplies CMS Add: 10/01/2005 CMS Term: Q0480 MDSPY DEF MAXFEE 07/01/2016 12/31/2023 72648.53 0.0 Y 0-1 Description: DRIVER PNEUMATIC VAD, REP Category: Medical Supplies CMS Add: 10/01/2005 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,063 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- Q0481 MDSPY DEF MAXFEE 01/01/2024 16696.66 0.0 Y 0-1 Description: MICROPRCSR CU ELEC VAD, REP Category: Medical Supplies CMS Add: 10/01/2005 CMS Term: Q0481 MDSPY DEF MAXFEE 07/01/2016 12/31/2023 11721.01 0.0 Y 0-1 Description: MICROPRCSR CU ELEC VAD, REP Category: Medical Supplies CMS Add: 10/01/2005 CMS Term: Q0482 MDSPY DEF MAXFEE 01/01/2024 5229.70 0.0 Y 0-1 Description: MICROPRCSR CU COMBO VAD, REP Category: Medical Supplies CMS Add: 10/01/2005 CMS Term: Q0482 MDSPY DEF MAXFEE 07/01/2016 12/31/2023 3671.23 0.0 Y 0-1 Description: MICROPRCSR CU COMBO VAD, REP Category: Medical Supplies CMS Add: 10/01/2005 CMS Term: Q0483 MDSPY DEF MAXFEE 01/01/2024 21543.99 0.0 Y 0-1 Description: MONITOR ELEC VAD, REP Category: Medical Supplies CMS Add: 10/01/2005 CMS Term: Q0483 MDSPY DEF MAXFEE 07/01/2016 12/31/2023 15123.84 0.0 Y 0-1 Description: MONITOR ELEC VAD, REP Category: Medical Supplies CMS Add: 10/01/2005 CMS Term: Q0484 MDSPY DEF MAXFEE 01/01/2024 4183.77 0.0 Y 0-1 Description: MONITOR ELEC OR COMB VAD REP Category: Medical Supplies CMS Add: 10/01/2005 CMS Term: Q0484 MDSPY DEF MAXFEE 07/01/2016 12/31/2023 2937.00 0.0 Y 0-1 Description: MONITOR ELEC OR COMB VAD REP Category: Medical Supplies CMS Add: 10/01/2005 CMS Term: Q0485 MDSPY DEF MAXFEE 01/01/2024 403.96 0.0 Y 0-1 Description: MONITOR CABLE ELEC VAD, REP Category: Medical Supplies CMS Add: 10/01/2005 CMS Term: Q0485 MDSPY DEF MAXFEE 07/01/2016 12/31/2023 283.58 0.0 Y 0-1 Description: MONITOR CABLE ELEC VAD, REP Category: Medical Supplies CMS Add: 10/01/2005 CMS Term: Q0486 MDSPY DEF MAXFEE 01/01/2024 336.20 0.0 Y 0-1 Description: MON CABLE ELEC/PNEUM VAD REP Category: Medical Supplies CMS Add: 10/01/2005 CMS Term: Q0486 MDSPY DEF MAXFEE 07/01/2016 12/31/2023 236.00 0.0 Y 0-1 Description: MON CABLE ELEC/PNEUM VAD REP Category: Medical Supplies CMS Add: 10/01/2005 CMS Term: Q0487 MDSPY DEF MAXFEE 01/01/2024 392.21 0.0 Y 0-1 Description: LEADS ANY TYPE VAD, REP ONLY Category: Medical Supplies CMS Add: 10/01/2005 CMS Term: Q0487 MDSPY DEF MAXFEE 07/01/2016 12/31/2023 275.34 0.0 Y 0-1 Description: LEADS ANY TYPE VAD, REP ONLY Category: Medical Supplies CMS Add: 10/01/2005 CMS Term: Q0488 MDSPY DEF SYSMAN Y Y Description: PWR PACK BASE ELEC VAD, REP Category: Medical Supplies CMS Add: 10/01/2005 CMS Term: Q0489 MDSPY DEF MAXFEE 01/01/2024 18677.48 0.0 Y 0-1 Description: PWR PCK BASE COMBO VAD, REP Category: Medical Supplies CMS Add: 10/01/2005 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,064 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- Q0489 MDSPY DEF MAXFEE 07/01/2016 12/31/2023 13111.55 0.0 Y 0-1 Description: PWR PCK BASE COMBO VAD, REP Category: Medical Supplies CMS Add: 10/01/2005 CMS Term: Q0490 MDSPY DEF MAXFEE 01/01/2024 807.90 0.0 Y 0-1 Description: EMR PWR SOURCE ELEC VAD, REP Category: Medical Supplies CMS Add: 10/01/2005 CMS Term: Q0490 MDSPY DEF MAXFEE 07/01/2016 12/31/2023 567.14 0.0 Y 0-1 Description: EMR PWR SOURCE ELEC VAD, REP Category: Medical Supplies CMS Add: 10/01/2005 CMS Term: Q0491 MDSPY DEF MAXFEE 01/01/2024 1270.11 0.0 Y 0-1 Description: EMR PWR SOURCE COMBO VAD REP Category: Medical Supplies CMS Add: 10/01/2005 CMS Term: Q0491 MDSPY DEF MAXFEE 07/01/2016 12/31/2023 891.60 0.0 Y 0-1 Description: EMR PWR SOURCE COMBO VAD REP Category: Medical Supplies CMS Add: 10/01/2005 CMS Term: Q0492 MDSPY DEF MAXFEE 01/01/2024 102.34 0.0 Y 0-1 Description: EMR PWR CBL ELEC VAD, REP Category: Medical Supplies CMS Add: 10/01/2005 CMS Term: Q0492 MDSPY DEF MAXFEE 07/01/2016 12/31/2023 71.84 0.0 Y 0-1 Description: EMR PWR CBL ELEC VAD, REP Category: Medical Supplies CMS Add: 10/01/2005 CMS Term: Q0493 MDSPY DEF MAXFEE 01/01/2024 291.35 0.0 Y 0-1 Description: EMR PWR CBL COMBO VAD, REP Category: Medical Supplies CMS Add: 10/01/2005 CMS Term: Q0493 MDSPY DEF MAXFEE 07/01/2016 12/31/2023 204.53 0.0 Y 0-1 Description: EMR PWR CBL COMBO VAD, REP Category: Medical Supplies CMS Add: 10/01/2005 CMS Term: Q0494 MDSPY DEF MAXFEE 01/01/2024 246.53 0.0 Y 0-1 Description: EMR HD PMP ELEC/COMBO, REP Category: Medical Supplies CMS Add: 10/01/2005 CMS Term: Q0494 MDSPY DEF MAXFEE 07/01/2016 12/31/2023 173.06 0.0 Y 0-1 Description: EMR HD PMP ELEC/COMBO, REP Category: Medical Supplies CMS Add: 10/01/2005 CMS Term: Q0495 MDSPY DEF MAXFEE 01/01/2024 4799.64 0.0 Y 0-1 Description: CHARGER ELEC/COMBO VAD, REP Category: Medical Supplies CMS Add: 10/01/2005 CMS Term: Q0495 MDSPY DEF MAXFEE 07/01/2016 12/31/2023 3369.33 0.0 Y 0-1 Description: CHARGER ELEC/COMBO VAD, REP Category: Medical Supplies CMS Add: 10/01/2005 CMS Term: Q0496 MDSPY DEF MAXFEE 01/01/2024 1722.68 0.0 Y 0-1 Description: BATTERY ELEC/COMBO VAD, REP Category: Medical Supplies CMS Add: 10/01/2005 CMS Term: Q0496 MDSPY DEF MAXFEE 07/01/2016 12/31/2023 1209.32 0.0 Y 0-1 Description: BATTERY ELEC/COMBO VAD, REP Category: Medical Supplies CMS Add: 10/01/2005 CMS Term: Q0497 MDSPY DEF MAXFEE 01/01/2024 537.90 0.0 Y 0-1 Description: BAT CLPS ELEC/COMB VAD, REP Category: Medical Supplies CMS Add: 10/01/2005 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,065 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- Q0497 MDSPY DEF MAXFEE 07/01/2016 12/31/2023 377.62 0.0 Y 0-1 Description: BAT CLPS ELEC/COMB VAD, REP Category: Medical Supplies CMS Add: 10/01/2005 CMS Term: Q0498 MDSPY DEF MAXFEE 01/01/2024 590.20 0.0 Y 0-1 Description: HOLSTER ELEC/COMBO VAD, REP Category: Medical Supplies CMS Add: 10/01/2005 CMS Term: Q0498 MDSPY DEF MAXFEE 07/01/2016 12/31/2023 414.32 0.0 Y 0-1 Description: HOLSTER ELEC/COMBO VAD, REP Category: Medical Supplies CMS Add: 10/01/2005 CMS Term: Q0499 MDSPY DEF MAXFEE 01/01/2024 191.77 0.0 Y 0-1 Description: BELT/VEST ELEC/COMBO VAD REP Category: Medical Supplies CMS Add: 10/01/2005 CMS Term: Q0499 MDSPY DEF MAXFEE 07/01/2016 12/31/2023 134.61 0.0 Y 0-1 Description: BELT/VEST ELEC/COMBO VAD REP Category: Medical Supplies CMS Add: 10/01/2005 CMS Term: Q0500 MDSPY DEF MAXFEE 01/01/2024 35.07 0.0 Y 0-1 Description: FILTERS ELEC/COMBO VAD, REP Category: Medical Supplies CMS Add: 10/01/2005 CMS Term: Q0500 MDSPY DEF MAXFEE 07/01/2016 12/31/2023 24.63 0.0 Y 0-1 Description: FILTERS ELEC/COMBO VAD, REP Category: Medical Supplies CMS Add: 10/01/2005 CMS Term: Q0501 MDSPY DEF MAXFEE 01/01/2024 586.80 0.0 Y 0-1 Description: SHWR COV ELEC/COMBO VAD, REP Category: Medical Supplies CMS Add: 10/01/2005 CMS Term: Q0501 MDSPY DEF MAXFEE 07/01/2016 12/31/2023 411.93 0.0 Y 0-1 Description: SHWR COV ELEC/COMBO VAD, REP Category: Medical Supplies CMS Add: 10/01/2005 CMS Term: Q0502 MDSPY DEF MAXFEE 01/01/2024 747.12 0.0 Y 0-1 Description: MOBILITY CART PNEUM VAD, REP Category: Medical Supplies CMS Add: 10/01/2005 CMS Term: Q0502 MDSPY DEF MAXFEE 07/01/2016 12/31/2023 524.47 0.0 Y 0-1 Description: MOBILITY CART PNEUM VAD, REP Category: Medical Supplies CMS Add: 10/01/2005 CMS Term: Q0503 MDSPY DEF MAXFEE 01/01/2024 1494.16 0.0 Y 0-1 Description: BATTERY PNEUM VAD REPLACEMNT Category: Medical Supplies CMS Add: 10/01/2005 CMS Term: Q0503 MDSPY DEF MAXFEE 07/01/2016 12/31/2023 937.27 0.0 Y 0-1 Description: BATTERY PNEUM VAD REPLACEMNT Category: Medical Supplies CMS Add: 10/01/2005 CMS Term: Q0504 MDSPY DEF MAXFEE 01/01/2024 788.47 0.0 Y 0-1 Description: PWR ADPT PNEUM VAD, REP VEH Category: Medical Supplies CMS Add: 10/01/2005 CMS Term: Q0504 MDSPY DEF MAXFEE 07/01/2016 12/31/2023 553.49 0.0 Y 0-1 Description: PWR ADPT PNEUM VAD, REP VEH Category: Medical Supplies CMS Add: 10/01/2005 CMS Term: Q0506 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 774.86 0.0 Y 0-1 Description: LITH-ION BATT ELEC/PNEUM VAD Category: Medical Supplies CMS Add: 01/01/2010 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,066 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- Q0506 MDSPY DEF MAXFEE 01/01/2024 981.40 0.0 Y 0-1 Description: LITH-ION BATT ELEC/PNEUM VAD Category: Medical Supplies CMS Add: 01/01/2010 CMS Term: Q0507 MDSPY DEF SYSMAN Y Y 0-1 Description: MISC SUP/ACC EXT VAD Category: Medical Supplies CMS Add: 04/01/2013 CMS Term: Q0508 MDSPY DEF SYSMAN Y Y 0-1 Description: MIS SUP/ACC IMP VAD Category: Medical Supplies CMS Add: 04/01/2013 CMS Term: Q0509 MDSPY DEF SYSMAN Y 0-1 Description: MIS SUP/AC IMP VAD NOPAY MED Category: Medical Supplies CMS Add: 04/01/2013 CMS Term: Q0510 NOCOV DEF SYSMAN Description: DISPENS FEE IMMUNOSUPRESSIVE Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: Q0511 NOCOV DEF SYSMAN Description: SUP FEE ANTIEM,ANTICA,IMMUNO Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: Q0512 NOCOV DEF SYSMAN Description: PX SUP FEE ANTI-CAN SUB PRES Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: Q0513 NOCOV DEF SYSMAN Description: DISP FEE INHAL DRUGS/30 DAYS Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: Q0514 NOCOV DEF SYSMAN Description: DISP FEE INHAL DRUGS/90 DAYS Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: Q0515 DRUG DEF SYSMAN Y Description: SERMORELIN ACETATE INJECTION Category: Drugs CMS Add: 01/01/2006 CMS Term: Q0516 NOCOV DEF SYSMAN Description: SUPPLY FEE HIV PREP 30-DAYS Category: Non Covered Services CMS Add: 01/02/2024 CMS Term: Q0517 NOCOV DEF SYSMAN Description: SUPPLY FEE HIV PREP 60-DAYS Category: Non Covered Services CMS Add: 01/02/2024 CMS Term: Q0518 NOCOV DEF SYSMAN Description: SUPPLY FEE HIV PREP 90-DAYS Category: Non Covered Services CMS Add: 01/02/2024 CMS Term: Q1004 NOCOV DEF SYSMAN Description: NTIOL CATEGORY 4 Category: Non Covered Services CMS Add: 07/01/1999 CMS Term: Q1005 NOCOV DEF SYSMAN Description: NTIOL CATEGORY 5 Category: Non Covered Services CMS Add: 07/01/1999 CMS Term: Q2004 MEDSV DEF SYSMAN Description: BLADDER CALCULI IRRIG SOL Category: Medical Services CMS Add: 07/01/2000 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,067 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- Q2009 DRUG DEF MAXFEE 01/01/2024 0.52 0.0 Description: FOSPHENYTOIN INJ PE Category: Drugs CMS Add: 07/01/2000 CMS Term: Q2009 DRUG DEF MAXFEE 04/01/2013 12/31/2023 0.58 0.0 Description: FOSPHENYTOIN INJ PE Category: Drugs CMS Add: 07/01/2000 CMS Term: Q2017 DRUG DEF MAXFEE 01/01/2017 2620.75 0.0 Description: TENIPOSIDE, 50 MG Category: Drugs CMS Add: 07/01/2000 CMS Term: Q2026 NOCOV DEF SYSMAN Description: RADIESSE INJECTION Category: Non Covered Services CMS Add: 07/01/2010 CMS Term: Q2027 NOCOV DEF SYSMAN Description: SCULPTRA INJECTION Category: Non Covered Services CMS Add: 07/01/2010 CMS Term: 12/31/2013 Q2028 NOCOV DEF SYSMAN Description: INJ, SCULPTRA, 0.5MG Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: Q2034 NOCOV DEF SYSMAN Description: AGRIFLU VACCINE Category: Non Covered Services CMS Add: 07/01/2012 CMS Term: Q2035 NOCOV DEF SYSMAN Description: AFLURIA VACC, 3 YRS & >, IM Category: Non Covered Services CMS Add: 01/01/2011 CMS Term: Q2036 NOCOV DEF SYSMAN Description: FLULAVAL VACC, 3 YRS & >, IM Category: Non Covered Services CMS Add: 01/01/2011 CMS Term: Q2037 NOCOV DEF SYSMAN Description: FLUVIRIN VACC, 3 YRS & >, IM Category: Non Covered Services CMS Add: 01/01/2011 CMS Term: Q2038 NOCOV DEF SYSMAN Description: FLUZONE VACC, 3 YRS & >, IM Category: Non Covered Services CMS Add: 01/01/2011 CMS Term: Q2039 NOCOV DEF SYSMAN Description: INFLUENZA VIRUS VACCINE, NOS Category: Non Covered Services CMS Add: 01/01/2011 CMS Term: Q2041 DRUG DEF MAXFEE 01/01/2024 485100.00 0.0 Y Description: AXICABTAGENE CILOLEUCEL CAR+ Category: Drugs CMS Add: 04/01/2018 CMS Term: Q2041 DRUG DEF MAXFEE 10/01/2022 12/31/2023 445200.00 0.0 Y Description: AXICABTAGENE CILOLEUCEL CAR+ Category: Drugs CMS Add: 04/01/2018 CMS Term: Q2042 DRUG DEF SYSMAN Y Description: TISAGENLECLEUCEL CAR-POS T Category: Drugs CMS Add: 01/01/2019 CMS Term: Q2043 DRUG DEF MAXFEE 07/01/2020 65732.65 0.0 Y Description: SIPULEUCEL-T AUTO CD54+ Category: Drugs CMS Add: 07/01/2011 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,068 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- Q2049 DRUG DEF MAXFEE 07/01/2012 503.63 0.0 Description: IMPORTED LIPODOX INJ Category: Drugs CMS Add: 07/01/2012 CMS Term: Q2050 DRUG DEF MAXFEE 01/01/2022 06/30/2023 313.27 0.0 Description: DOXORUBICIN INJ 10MG Category: Drugs CMS Add: 07/01/2013 CMS Term: Q2050 DRUG DEF MAXFEE 07/01/2023 236.25 0.0 Description: DOXORUBICIN INJ 10MG Category: Drugs CMS Add: 07/01/2013 CMS Term: Q2052 NOCOV DEF SYSMAN Description: HOME IVIG, SERVICES/SUPPLIES Category: Non Covered Services CMS Add: 04/01/2014 CMS Term: Q2053 DRUG DEF MAXFEE 10/01/2022 445200.00 0.0 Y Description: BREXUCABTAGENE CAR POS T Category: Drugs CMS Add: 04/01/2021 CMS Term: Q2054 DRUG DEF MAXFEE 01/01/2024 511851.30 0.0 Y Description: LISOCABTAGENE MARA CAR POS T Category: Drugs CMS Add: 10/01/2021 CMS Term: Q2054 DRUG DEF MAXFEE 04/01/2023 12/31/2023 469588.35 0.0 Y Description: LISOCABTAGENE MARA CAR POS T Category: Drugs CMS Add: 10/01/2021 CMS Term: Q2055 DRUG DEF MAXFEE 01/01/2024 523328.35 0.0 Y Description: IDECABTAGENE VICLEUCEL CAR Category: Drugs CMS Add: 01/01/2022 CMS Term: Q2055 DRUG DEF MAXFEE 04/01/2023 12/31/2023 480117.75 0.0 Y Description: IDECABTAGENE VICLEUCEL CAR Category: Drugs CMS Add: 01/01/2022 CMS Term: Q2056 DRUG DEF MAXFEE 07/01/2023 502897.50 0.0 Y 18-999years Description: CILTACABTAGENE CAR-POS T Category: Drugs CMS Add: 10/01/2022 CMS Term: Q2056 DRUG DEF MAXFEE 10/01/2022 06/30/2023 488250.00 0.0 Y 18-999years Description: CILTACABTAGENE CAR-POS T Category: Drugs CMS Add: 10/01/2022 CMS Term: Q3001 MEDSV DEF BILL90 Description: BRACHYTHERAPY RADIOELEMENTS Category: Medical Services CMS Add: 07/01/2000 CMS Term: Q3014 MEDSV DEF MAXFEE 05/01/2006 21.86 0.0 Description: TELEHEALTH FACILITY FEE Category: Medical Services CMS Add: 10/01/2001 CMS Term: Q3027 DRUG DEF MAXFEE 04/01/2023 06/30/2023 68.52 0.0 Description: INJ BETA INTERFERON IM 1 MCG Category: Drugs CMS Add: 01/01/2014 CMS Term: Q3027 DRUG DEF MAXFEE 04/01/2024 72.33 0.0 Description: INJ BETA INTERFERON IM 1 MCG Category: Drugs CMS Add: 01/01/2014 CMS Term: Q3027 DRUG DEF MAXFEE 07/01/2023 03/31/2024 69.54 0.0 Description: INJ BETA INTERFERON IM 1 MCG Category: Drugs CMS Add: 01/01/2014 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,069 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- Q3028 DRUG DEF MAXFEE 04/01/2023 03/31/2024 19.73 0.0 Description: INJ BETA INTERFERON SQ 1 MCG Category: Drugs CMS Add: 01/01/2014 CMS Term: Q3028 DRUG DEF MAXFEE 04/01/2024 21.01 0.0 Description: INJ BETA INTERFERON SQ 1 MCG Category: Drugs CMS Add: 01/01/2014 CMS Term: Q3031 NOCOV DEF SYSMAN Description: COLLAGEN SKIN TEST Category: Non Covered Services CMS Add: 04/01/2003 CMS Term: Q4001 MDSPY DEF MAXFEE 01/01/2024 58.20 0.0 15-999years Description: CAST SUP BODY CAST PLASTER Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4001 MDSPY DEF MAXFEE 07/01/2001 12/31/2023 34.78 0.0 15-999years Description: CAST SUP BODY CAST PLASTER Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4002 MDSPY DEF MAXFEE 01/01/2024 219.89 0.0 15-999years Description: CAST SUP BODY CAST FIBERGLAS Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4002 MDSPY DEF MAXFEE 07/01/2001 12/31/2023 131.44 0.0 15-999years Description: CAST SUP BODY CAST FIBERGLAS Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4003 MDSPY DEF MAXFEE 01/01/2024 41.78 0.0 11-999years Description: CAST SUP SHOULDER CAST PLSTR Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4003 MDSPY DEF MAXFEE 07/01/2001 12/31/2023 131.44 0.0 11-999years Description: CAST SUP SHOULDER CAST PLSTR Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4004 MDSPY DEF MAXFEE 01/01/2024 144.67 0.0 11-999years Description: CAST SUP SHOULDER CAST FBRGL Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4004 MDSPY DEF MAXFEE 07/01/2001 12/31/2023 86.48 0.0 11-999years Description: CAST SUP SHOULDER CAST FBRGL Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4005 MDSPY DEF MAXFEE 01/01/2024 15.41 0.0 11-999years Description: CAST SUP LONG ARM ADULT PLST Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4005 MDSPY DEF MAXFEE 07/01/2001 12/31/2023 9.21 0.0 11-999years Description: CAST SUP LONG ARM ADULT PLST Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4006 MDSPY DEF MAXFEE 01/01/2024 34.72 0.0 11-999years Description: CAST SUP LONG ARM ADULT FBRG Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4006 MDSPY DEF MAXFEE 07/01/2001 12/31/2023 20.76 0.0 11-999years Description: CAST SUP LONG ARM ADULT FBRG Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4007 MDSPY DEF MAXFEE 01/01/2024 7.70 0.0 0-10years Description: CAST SUP LONG ARM PED PLSTER Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,070 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- Q4007 MDSPY DEF MAXFEE 07/01/2001 12/31/2023 4.61 0.0 0-10years Description: CAST SUP LONG ARM PED PLSTER Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4008 MDSPY DEF MAXFEE 01/01/2024 17.35 0.0 0-10years Description: CAST SUP LONG ARM PED FBRGLS Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4008 MDSPY DEF MAXFEE 07/01/2001 12/31/2023 10.38 0.0 0-10years Description: CAST SUP LONG ARM PED FBRGLS Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4009 MDSPY DEF MAXFEE 01/01/2024 10.29 0.0 11-999years Description: CAST SUP SHT ARM ADULT PLSTR Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4009 MDSPY DEF MAXFEE 07/01/2001 12/31/2023 6.14 0.0 11-999years Description: CAST SUP SHT ARM ADULT PLSTR Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4010 MDSPY DEF MAXFEE 01/01/2024 23.14 0.0 11-999years Description: CAST SUP SHT ARM ADULT FBRGL Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4010 MDSPY DEF MAXFEE 07/01/2001 12/31/2023 13.84 0.0 11-999years Description: CAST SUP SHT ARM ADULT FBRGL Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4011 MDSPY DEF MAXFEE 01/01/2024 5.13 0.0 0-10years Description: CAST SUP SHT ARM PED PLASTER Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4011 MDSPY DEF MAXFEE 07/01/2001 12/31/2023 3.07 0.0 0-10years Description: CAST SUP SHT ARM PED PLASTER Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4012 MDSPY DEF MAXFEE 01/01/2024 11.60 0.0 0-10years Description: CAST SUP SHT ARM PED FBRGLAS Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4012 MDSPY DEF MAXFEE 07/01/2001 12/31/2023 6.92 0.0 0-10years Description: CAST SUP SHT ARM PED FBRGLAS Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4013 MDSPY DEF MAXFEE 01/01/2024 18.73 0.0 11-999years Description: CAST SUP GAUNTLET PLASTER Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4013 MDSPY DEF MAXFEE 07/01/2001 12/31/2023 11.18 0.0 11-999years Description: CAST SUP GAUNTLET PLASTER Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4014 MDSPY DEF MAXFEE 01/01/2024 31.58 0.0 11-999years Description: CAST SUP GAUNTLET FIBERGLASS Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4014 MDSPY DEF MAXFEE 07/01/2001 12/31/2023 18.88 0.0 11-999years Description: CAST SUP GAUNTLET FIBERGLASS Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4015 MDSPY DEF MAXFEE 01/01/2024 9.38 0.0 0-10years Description: CAST SUP GAUNTLET PED PLSTER Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,071 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- Q4015 MDSPY DEF MAXFEE 07/01/2001 12/31/2023 5.59 0.0 0-10years Description: CAST SUP GAUNTLET PED PLSTER Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4016 MDSPY DEF MAXFEE 01/01/2024 15.78 0.0 0-10years Description: CAST SUP GAUNTLET PED FBRGLS Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4016 MDSPY DEF MAXFEE 07/01/2001 12/31/2023 9.44 0.0 0-10years Description: CAST SUP GAUNTLET PED FBRGLS Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4017 MDSPY DEF MAXFEE 01/01/2024 10.82 0.0 11-999years Description: CAST SUP LNG ARM SPLINT PLST Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4017 MDSPY DEF MAXFEE 07/01/2001 12/31/2023 6.47 0.0 11-999years Description: CAST SUP LNG ARM SPLINT PLST Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4018 MDSPY DEF MAXFEE 01/01/2024 17.25 0.0 11-999years Description: CAST SUP LNG ARM SPLINT FBRG Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4018 MDSPY DEF MAXFEE 07/01/2001 12/31/2023 10.32 0.0 11-999years Description: CAST SUP LNG ARM SPLINT FBRG Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4019 MDSPY DEF MAXFEE 01/01/2024 5.42 0.0 0-10years Description: CAST SUP LNG ARM SPLNT PED P Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4019 MDSPY DEF MAXFEE 07/01/2001 12/31/2023 3.24 0.0 0-10years Description: CAST SUP LNG ARM SPLNT PED P Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4020 MDSPY DEF MAXFEE 01/01/2024 8.66 0.0 0-10years Description: CAST SUP LNG ARM SPLNT PED F Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4020 MDSPY DEF MAXFEE 07/01/2001 12/31/2023 5.16 0.0 0-10years Description: CAST SUP LNG ARM SPLNT PED F Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4021 MDSPY DEF MAXFEE 01/01/2024 8.01 0.0 11-999years Description: CAST SUP SHT ARM SPLINT PLST Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4021 MDSPY DEF MAXFEE 07/01/2001 12/31/2023 4.79 0.0 11-999years Description: CAST SUP SHT ARM SPLINT PLST Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4022 MDSPY DEF MAXFEE 01/01/2024 14.46 0.0 11-999years Description: CAST SUP SHT ARM SPLINT FBRG Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4022 MDSPY DEF MAXFEE 07/01/2001 12/31/2023 8.64 0.0 11-999years Description: CAST SUP SHT ARM SPLINT FBRG Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4023 MDSPY DEF MAXFEE 01/01/2024 4.03 0.0 0-10years Description: CAST SUP SHT ARM SPLNT PED P Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,072 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- Q4023 MDSPY DEF MAXFEE 07/01/2001 12/31/2023 2.40 0.0 0-10years Description: CAST SUP SHT ARM SPLNT PED P Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4024 MDSPY DEF MAXFEE 01/01/2024 7.24 0.0 0-10years Description: CAST SUP SHT ARM SPLNT PED F Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4024 MDSPY DEF MAXFEE 07/01/2001 12/31/2023 4.32 0.0 0-10years Description: CAST SUP SHT ARM SPLNT PED F Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4025 MDSPY DEF MAXFEE 01/01/2024 44.90 0.0 11-999years Description: CAST SUP HIP SPICA PLASTER Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4025 MDSPY DEF MAXFEE 07/01/2001 12/31/2023 26.86 0.0 11-999years Description: CAST SUP HIP SPICA PLASTER Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4026 MDSPY DEF MAXFEE 01/01/2024 140.27 0.0 11-999years Description: CAST SUP HIP SPICA FIBERGLAS Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4026 MDSPY DEF MAXFEE 07/01/2001 12/31/2023 83.85 0.0 11-999years Description: CAST SUP HIP SPICA FIBERGLAS Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4027 MDSPY DEF MAXFEE 01/01/2024 22.48 0.0 0-10years Description: CAST SUP HIP SPICA PED PLSTR Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4027 MDSPY DEF MAXFEE 07/01/2001 12/31/2023 13.43 0.0 0-10years Description: CAST SUP HIP SPICA PED PLSTR Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4028 MDSPY DEF MAXFEE 01/01/2024 70.18 0.0 0-10years Description: CAST SUP HIP SPICA PED FBRGL Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4028 MDSPY DEF MAXFEE 07/01/2001 12/31/2023 41.93 0.0 0-10years Description: CAST SUP HIP SPICA PED FBRGL Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4029 MDSPY DEF MAXFEE 01/01/2024 34.36 0.0 11-999years Description: CAST SUP LONG LEG PLASTER Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4029 MDSPY DEF MAXFEE 07/01/2001 12/31/2023 20.53 0.0 11-999years Description: CAST SUP LONG LEG PLASTER Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4030 MDSPY DEF MAXFEE 01/01/2024 90.44 0.0 11-999years Description: CAST SUP LONG LEG FIBERGLASS Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4030 MDSPY DEF MAXFEE 07/01/2001 12/31/2023 54.05 0.0 11-999years Description: CAST SUP LONG LEG FIBERGLASS Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4031 MDSPY DEF MAXFEE 01/01/2024 17.16 0.0 0-10years Description: CAST SUP LNG LEG PED PLASTER Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,073 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- Q4031 MDSPY DEF MAXFEE 07/01/2001 12/31/2023 10.27 0.0 0-10years Description: CAST SUP LNG LEG PED PLASTER Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4032 MDSPY DEF MAXFEE 01/01/2024 45.22 0.0 0-10years Description: CAST SUP LNG LEG PED FBRGLS Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4032 MDSPY DEF MAXFEE 07/01/2001 12/31/2023 27.03 0.0 0-10years Description: CAST SUP LNG LEG PED FBRGLS Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4033 MDSPY DEF MAXFEE 01/01/2024 32.06 0.0 11-999years Description: CAST SUP LNG LEG CYLINDER PL Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4033 MDSPY DEF MAXFEE 07/01/2001 12/31/2023 19.15 0.0 11-999years Description: CAST SUP LNG LEG CYLINDER PL Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4034 MDSPY DEF MAXFEE 01/01/2024 79.69 0.0 11-999years Description: CAST SUP LNG LEG CYLINDER FB Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4034 MDSPY DEF MAXFEE 07/01/2001 12/31/2023 47.65 0.0 11-999years Description: CAST SUP LNG LEG CYLINDER FB Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4035 MDSPY DEF MAXFEE 01/01/2024 16.02 0.0 0-10years Description: CAST SUP LNGLEG CYLNDR PED P Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4035 MDSPY DEF MAXFEE 07/01/2001 12/31/2023 9.58 0.0 0-10years Description: CAST SUP LNGLEG CYLNDR PED P Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4036 MDSPY DEF MAXFEE 01/01/2024 39.87 0.0 0-10years Description: CAST SUP LNGLEG CYLNDR PED F Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4036 MDSPY DEF MAXFEE 07/01/2001 12/31/2023 23.83 0.0 0-10years Description: CAST SUP LNGLEG CYLNDR PED F Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4037 MDSPY DEF MAXFEE 01/01/2024 19.52 0.0 11-999years Description: CAST SUP SHRT LEG PLASTER Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4037 MDSPY DEF MAXFEE 07/01/2001 12/31/2023 11.69 0.0 11-999years Description: CAST SUP SHRT LEG PLASTER Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4038 MDSPY DEF MAXFEE 01/01/2024 48.97 0.0 11-999years Description: CAST SUP SHRT LEG FIBERGLASS Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4038 MDSPY DEF MAXFEE 07/01/2001 12/31/2023 29.27 0.0 11-999years Description: CAST SUP SHRT LEG FIBERGLASS Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4039 MDSPY DEF MAXFEE 01/01/2024 9.80 0.0 0-10years Description: CAST SUP SHRT LEG PED PLSTER Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,074 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- Q4039 MDSPY DEF MAXFEE 07/01/2001 12/31/2023 5.85 0.0 0-10years Description: CAST SUP SHRT LEG PED PLSTER Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4040 MDSPY DEF MAXFEE 01/01/2024 24.48 0.0 0-10years Description: CAST SUP SHRT LEG PED FBRGLS Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4040 MDSPY DEF MAXFEE 07/01/2001 12/31/2023 14.64 0.0 0-10years Description: CAST SUP SHRT LEG PED FBRGLS Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4041 MDSPY DEF MAXFEE 01/01/2024 23.77 0.0 11-999years Description: CAST SUP LNG LEG SPLNT PLSTR Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4041 MDSPY DEF MAXFEE 07/01/2001 12/31/2023 14.21 0.0 11-999years Description: CAST SUP LNG LEG SPLNT PLSTR Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4042 MDSPY DEF MAXFEE 01/01/2024 40.58 0.0 11-999years Description: CAST SUP LNG LEG SPLNT FBRGL Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4042 MDSPY DEF MAXFEE 07/01/2001 12/31/2023 24.25 0.0 11-999years Description: CAST SUP LNG LEG SPLNT FBRGL Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4043 MDSPY DEF MAXFEE 01/01/2024 11.89 0.0 0-10years Description: CAST SUP LNG LEG SPLNT PED P Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4043 MDSPY DEF MAXFEE 07/01/2001 12/31/2023 7.10 0.0 0-10years Description: CAST SUP LNG LEG SPLNT PED P Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4044 MDSPY DEF MAXFEE 01/01/2024 20.32 0.0 0-10years Description: CAST SUP LNG LEG SPLNT PED F Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4044 MDSPY DEF MAXFEE 07/01/2001 12/31/2023 12.13 0.0 0-10years Description: CAST SUP LNG LEG SPLNT PED F Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4045 MDSPY DEF MAXFEE 01/01/2024 13.80 0.0 11-999years Description: CAST SUP SHT LEG SPLNT PLSTR Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4045 MDSPY DEF MAXFEE 07/01/2001 12/31/2023 8.25 0.0 11-999years Description: CAST SUP SHT LEG SPLNT PLSTR Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4046 MDSPY DEF MAXFEE 01/01/2024 22.19 0.0 11-999years Description: CAST SUP SHT LEG SPLNT FBRGL Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4046 MDSPY DEF MAXFEE 07/01/2001 12/31/2023 13.27 0.0 11-999years Description: CAST SUP SHT LEG SPLNT FBRGL Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4047 MDSPY DEF MAXFEE 01/01/2024 6.87 0.0 0-10years Description: CAST SUP SHT LEG SPLNT PED P Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,075 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- Q4047 MDSPY DEF MAXFEE 07/01/2001 12/31/2023 4.12 0.0 0-10years Description: CAST SUP SHT LEG SPLNT PED P Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4048 MDSPY DEF MAXFEE 01/01/2024 11.11 0.0 0-10years Description: CAST SUP SHT LEG SPLNT PED F Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4048 MDSPY DEF MAXFEE 07/01/2001 12/31/2023 6.64 0.0 0-10years Description: CAST SUP SHT LEG SPLNT PED F Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4049 MDSPY DEF MAXFEE 01/01/2024 2.50 0.0 Description: FINGER SPLINT, STATIC Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4049 MDSPY DEF MAXFEE 07/01/2001 12/31/2023 1.50 0.0 Description: FINGER SPLINT, STATIC Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4050 MDSPY DEF SYSMAN Y Description: CAST SUPPLIES UNLISTED Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4051 MDSPY DEF SYSMAN Y Description: SPLINT SUPPLIES MISC Category: Medical Supplies CMS Add: 07/01/2001 CMS Term: Q4074 NOCOV DEF SYSMAN Description: ILOPROST NON-COMP UNIT DOSE Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: Q4081 DRUG DEF MAXFEE 04/01/2017 1.74 0.0 Description: EPOETIN ALFA, 100 UNITS ESRD Category: Drugs CMS Add: 01/01/2007 CMS Term: Q4082 NOCOV DEF SYSMAN Description: DRUG/BIO NOC PART B DRUG CAP Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: Q4100 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: SKIN SUBSTITUTE, NOS Category: Medical Services CMS Add: 01/01/2009 CMS Term: Q4100 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: SKIN SUBSTITUTE, NOS Category: Medical Services CMS Add: 01/01/2009 CMS Term: Q4101 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: APLIGRAF Category: Medical Services CMS Add: 01/01/2009 CMS Term: Q4101 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: APLIGRAF Category: Medical Services CMS Add: 01/01/2009 CMS Term: Q4102 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: OASIS WOUND MATRIX Category: Medical Services CMS Add: 01/01/2009 CMS Term: Q4102 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: OASIS WOUND MATRIX Category: Medical Services CMS Add: 01/01/2009 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,076 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- Q4103 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: OASIS BURN MATRIX Category: Medical Services CMS Add: 01/01/2009 CMS Term: Q4103 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: OASIS BURN MATRIX Category: Medical Services CMS Add: 01/01/2009 CMS Term: Q4104 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: INTEGRA BMWD Category: Medical Services CMS Add: 01/01/2009 CMS Term: Q4104 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: INTEGRA BMWD Category: Medical Services CMS Add: 01/01/2009 CMS Term: Q4105 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: INTEGRA DRT OR OMNIGRAFT Category: Medical Services CMS Add: 01/01/2009 CMS Term: Q4105 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: INTEGRA DRT OR OMNIGRAFT Category: Medical Services CMS Add: 01/01/2009 CMS Term: Q4106 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: DERMAGRAFT Category: Medical Services CMS Add: 01/01/2009 CMS Term: Q4106 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: DERMAGRAFT Category: Medical Services CMS Add: 01/01/2009 CMS Term: Q4107 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: GRAFTJACKET Category: Medical Services CMS Add: 01/01/2009 CMS Term: Q4107 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: GRAFTJACKET Category: Medical Services CMS Add: 01/01/2009 CMS Term: Q4108 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: INTEGRA MATRIX Category: Medical Services CMS Add: 01/01/2009 CMS Term: Q4108 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: INTEGRA MATRIX Category: Medical Services CMS Add: 01/01/2009 CMS Term: Q4110 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: PRIMATRIX Category: Medical Services CMS Add: 01/01/2009 CMS Term: Q4110 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: PRIMATRIX Category: Medical Services CMS Add: 01/01/2009 CMS Term: Q4111 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: GAMMAGRAFT Category: Medical Services CMS Add: 01/01/2009 CMS Term: Q4111 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: GAMMAGRAFT Category: Medical Services CMS Add: 01/01/2009 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,077 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- Q4112 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: CYMETRA INJECTABLE Category: Medical Services CMS Add: 01/01/2009 CMS Term: Q4112 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: CYMETRA INJECTABLE Category: Medical Services CMS Add: 01/01/2009 CMS Term: Q4113 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: GRAFTJACKET XPRESS Category: Medical Services CMS Add: 01/01/2009 CMS Term: Q4113 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: GRAFTJACKET XPRESS Category: Medical Services CMS Add: 01/01/2009 CMS Term: Q4114 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: INTEGRA FLOWABLE WOUND MATRI Category: Medical Services CMS Add: 01/01/2009 CMS Term: Q4114 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: INTEGRA FLOWABLE WOUND MATRI Category: Medical Services CMS Add: 01/01/2009 CMS Term: Q4115 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: ALLOSKIN Category: Medical Services CMS Add: 07/01/2009 CMS Term: Q4115 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: ALLOSKIN Category: Medical Services CMS Add: 07/01/2009 CMS Term: Q4116 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: ALLODERM Category: Medical Services CMS Add: 07/01/2009 CMS Term: Q4116 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: ALLODERM Category: Medical Services CMS Add: 07/01/2009 CMS Term: Q4117 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: HYALOMATRIX Category: Medical Services CMS Add: 01/01/2011 CMS Term: Q4117 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: HYALOMATRIX Category: Medical Services CMS Add: 01/01/2011 CMS Term: Q4118 DRUG DEF MAXFEE 05/11/2017 37.56 0.0 Description: MATRISTEM MICROMATRIX Category: Drugs CMS Add: 01/01/2011 CMS Term: Q4121 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: THERASKIN Category: Medical Services CMS Add: 01/01/2011 CMS Term: Q4121 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: THERASKIN Category: Medical Services CMS Add: 01/01/2011 CMS Term: Q4122 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: DERMACELL, AWM, POROUS SQ CM Category: Medical Services CMS Add: 01/01/2012 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,078 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- Q4122 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: DERMACELL, AWM, POROUS SQ CM Category: Medical Services CMS Add: 01/01/2012 CMS Term: Q4123 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: ALLOSKIN Category: Medical Services CMS Add: 01/01/2012 CMS Term: Q4123 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: ALLOSKIN Category: Medical Services CMS Add: 01/01/2012 CMS Term: Q4124 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: OASIS TRI-LAYER WOUND MATRIX Category: Medical Services CMS Add: 01/01/2012 CMS Term: Q4124 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: OASIS TRI-LAYER WOUND MATRIX Category: Medical Services CMS Add: 01/01/2012 CMS Term: Q4125 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: ARTHROFLEX Category: Medical Services CMS Add: 01/01/2012 CMS Term: Q4125 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: ARTHROFLEX Category: Medical Services CMS Add: 01/01/2012 CMS Term: Q4126 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: MEMODERM/DERMA/TRANZ/INTEGUP Category: Medical Services CMS Add: 01/01/2012 CMS Term: Q4126 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: MEMODERM/DERMA/TRANZ/INTEGUP Category: Medical Services CMS Add: 01/01/2012 CMS Term: Q4127 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: TALYMED Category: Medical Services CMS Add: 01/01/2012 CMS Term: Q4127 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: TALYMED Category: Medical Services CMS Add: 01/01/2012 CMS Term: Q4128 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: FLEXHD/ALLOPATCHHD/SQ CM Category: Medical Services CMS Add: 01/01/2012 CMS Term: Q4128 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: FLEXHD/ALLOPATCHHD/SQ CM Category: Medical Services CMS Add: 01/01/2012 CMS Term: Q4130 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: STRATTICE TM Category: Medical Services CMS Add: 01/01/2012 CMS Term: Q4130 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: STRATTICE TM Category: Medical Services CMS Add: 01/01/2012 CMS Term: Q4132 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: GRAFIX CORE, GRAFIXPL CORE Category: Medical Services CMS Add: 01/01/2013 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,079 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- Q4132 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: GRAFIX CORE, GRAFIXPL CORE Category: Medical Services CMS Add: 01/01/2013 CMS Term: Q4133 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: GRAFIX STRAVIX PRIME PL SQCM Category: Medical Services CMS Add: 01/01/2013 CMS Term: Q4133 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: GRAFIX STRAVIX PRIME PL SQCM Category: Medical Services CMS Add: 01/01/2013 CMS Term: Q4134 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: HMATRIX Category: Medical Services CMS Add: 01/01/2013 CMS Term: Q4134 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: HMATRIX Category: Medical Services CMS Add: 01/01/2013 CMS Term: Q4135 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: MEDISKIN Category: Medical Services CMS Add: 01/01/2013 CMS Term: Q4135 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: MEDISKIN Category: Medical Services CMS Add: 01/01/2013 CMS Term: Q4136 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: EZDERM Category: Medical Services CMS Add: 01/01/2013 CMS Term: Q4136 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: EZDERM Category: Medical Services CMS Add: 01/01/2013 CMS Term: Q4137 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: AMNIOEXCEL BIODEXCEL 1SQ CM Category: Medical Services CMS Add: 01/01/2014 CMS Term: Q4137 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: AMNIOEXCEL BIODEXCEL 1SQ CM Category: Medical Services CMS Add: 01/01/2014 CMS Term: Q4138 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: BIODFENCE DRYFLEX, 1CM Category: Medical Services CMS Add: 01/01/2014 CMS Term: Q4138 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: BIODFENCE DRYFLEX, 1CM Category: Medical Services CMS Add: 01/01/2014 CMS Term: Q4139 DRUG DEF MAXFEE 05/11/2017 37.56 0.0 Description: AMNIO OR BIODMATRIX, INJ 1CC Category: Drugs CMS Add: 01/01/2014 CMS Term: Q4140 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: BIODFENCE 1CM Category: Medical Services CMS Add: 01/01/2014 CMS Term: Q4140 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: BIODFENCE 1CM Category: Medical Services CMS Add: 01/01/2014 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,080 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- Q4141 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: ALLOSKIN AC, 1 CM Category: Medical Services CMS Add: 01/01/2014 CMS Term: Q4141 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: ALLOSKIN AC, 1 CM Category: Medical Services CMS Add: 01/01/2014 CMS Term: Q4142 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: XCM BIOLOGIC TISS MATRIX 1CM Category: Medical Services CMS Add: 01/01/2014 CMS Term: Q4142 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: XCM BIOLOGIC TISS MATRIX 1CM Category: Medical Services CMS Add: 01/01/2014 CMS Term: Q4143 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: REPRIZA, 1CM Category: Medical Services CMS Add: 01/01/2014 CMS Term: Q4143 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: REPRIZA, 1CM Category: Medical Services CMS Add: 01/01/2014 CMS Term: Q4145 DRUG DEF MAXFEE 05/11/2017 37.56 0.0 Description: EPIFIX, INJ, 1MG Category: Drugs CMS Add: 01/01/2014 CMS Term: Q4146 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: TENSIX, 1CM Category: Medical Services CMS Add: 01/01/2014 CMS Term: Q4146 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: TENSIX, 1CM Category: Medical Services CMS Add: 01/01/2014 CMS Term: Q4147 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: ARCHITECT ECM PX FX 1 SQ CM Category: Medical Services CMS Add: 01/01/2014 CMS Term: Q4147 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: ARCHITECT ECM PX FX 1 SQ CM Category: Medical Services CMS Add: 01/01/2014 CMS Term: Q4148 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: NEOX NEOX RT OR CLARIX CORD Category: Medical Services CMS Add: 01/01/2014 CMS Term: Q4148 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: NEOX NEOX RT OR CLARIX CORD Category: Medical Services CMS Add: 01/01/2014 CMS Term: Q4149 DRUG DEF MAXFEE 05/11/2017 37.56 0.0 Description: EXCELLAGEN, 0.1 CC Category: Drugs CMS Add: 01/01/2014 CMS Term: Q4150 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: ALLOWRAP DS OR DRY 1 SQ CM Category: Medical Services CMS Add: 01/01/2015 CMS Term: Q4150 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: ALLOWRAP DS OR DRY 1 SQ CM Category: Medical Services CMS Add: 01/01/2015 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,081 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- Q4151 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: AMNIOBAND, GUARDIAN 1 SQ CM Category: Medical Services CMS Add: 01/01/2015 CMS Term: Q4151 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: AMNIOBAND, GUARDIAN 1 SQ CM Category: Medical Services CMS Add: 01/01/2015 CMS Term: Q4152 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: DERMAPURE 1 SQUARE CM Category: Medical Services CMS Add: 01/01/2015 CMS Term: Q4152 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: DERMAPURE 1 SQUARE CM Category: Medical Services CMS Add: 01/01/2015 CMS Term: Q4153 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: DERMAVEST, PLURIVEST SQ CM Category: Medical Services CMS Add: 01/01/2015 CMS Term: Q4153 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: DERMAVEST, PLURIVEST SQ CM Category: Medical Services CMS Add: 01/01/2015 CMS Term: Q4154 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: BIOVANCE 1 SQUARE CM Category: Medical Services CMS Add: 01/01/2015 CMS Term: Q4154 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: BIOVANCE 1 SQUARE CM Category: Medical Services CMS Add: 01/01/2015 CMS Term: Q4155 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: NEOXFLO OR CLARIXFLO 1 MG Category: Medical Services CMS Add: 01/01/2015 CMS Term: Q4155 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: NEOXFLO OR CLARIXFLO 1 MG Category: Medical Services CMS Add: 01/01/2015 CMS Term: Q4156 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: NEOX 100 OR CLARIX 100 Category: Medical Services CMS Add: 01/01/2015 CMS Term: Q4156 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: NEOX 100 OR CLARIX 100 Category: Medical Services CMS Add: 01/01/2015 CMS Term: Q4157 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: REVITALON 1 SQUARE CM Category: Medical Services CMS Add: 01/01/2015 CMS Term: Q4157 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: REVITALON 1 SQUARE CM Category: Medical Services CMS Add: 01/01/2015 CMS Term: Q4158 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: KERECIS OMEGA3, PER SQ CM Category: Medical Services CMS Add: 01/01/2015 CMS Term: Q4158 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: KERECIS OMEGA3, PER SQ CM Category: Medical Services CMS Add: 01/01/2015 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,082 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- Q4159 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: AFFINITY1 SQUARE CM Category: Medical Services CMS Add: 01/01/2015 CMS Term: Q4159 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: AFFINITY1 SQUARE CM Category: Medical Services CMS Add: 01/01/2015 CMS Term: Q4160 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: NUSHIELD 1 SQUARE CM Category: Medical Services CMS Add: 01/01/2015 CMS Term: Q4160 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: NUSHIELD 1 SQUARE CM Category: Medical Services CMS Add: 01/01/2015 CMS Term: Q4161 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: BIO-CONNEKT PER SQUARE CM Category: Medical Services CMS Add: 01/01/2016 CMS Term: Q4161 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: BIO-CONNEKT PER SQUARE CM Category: Medical Services CMS Add: 01/01/2016 CMS Term: Q4162 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: WNDEX FLW, BIOSKN FLW, 0.5CC Category: Medical Services CMS Add: 01/01/2016 CMS Term: Q4162 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: WNDEX FLW, BIOSKN FLW, 0.5CC Category: Medical Services CMS Add: 01/01/2016 CMS Term: Q4163 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: WOUNDEX, BIOSKIN, PER SQ CM Category: Medical Services CMS Add: 01/01/2016 CMS Term: Q4163 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: WOUNDEX, BIOSKIN, PER SQ CM Category: Medical Services CMS Add: 01/01/2016 CMS Term: Q4164 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: HELICOLL, PER SQUARE CM Category: Medical Services CMS Add: 01/01/2016 CMS Term: Q4164 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: HELICOLL, PER SQUARE CM Category: Medical Services CMS Add: 01/01/2016 CMS Term: Q4165 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: KERAMATRIX, KERASORB SQ CM Category: Medical Services CMS Add: 01/01/2016 CMS Term: Q4165 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: KERAMATRIX, KERASORB SQ CM Category: Medical Services CMS Add: 01/01/2016 CMS Term: Q4166 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: CYTAL, PER SQUARE CENTIMETER Category: Medical Services CMS Add: 01/01/2017 CMS Term: Q4166 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: CYTAL, PER SQUARE CENTIMETER Category: Medical Services CMS Add: 01/01/2017 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,083 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- Q4167 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: TRUSKIN, PER SQ CENTIMETER Category: Medical Services CMS Add: 01/01/2017 CMS Term: Q4167 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: TRUSKIN, PER SQ CENTIMETER Category: Medical Services CMS Add: 01/01/2017 CMS Term: Q4168 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: AMNIOBAND, 1 MG Category: Medical Services CMS Add: 01/01/2017 CMS Term: Q4168 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: AMNIOBAND, 1 MG Category: Medical Services CMS Add: 01/01/2017 CMS Term: Q4169 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: ARTACENT WOUND, PER SQ CM Category: Medical Services CMS Add: 01/01/2017 CMS Term: Q4169 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: ARTACENT WOUND, PER SQ CM Category: Medical Services CMS Add: 01/01/2017 CMS Term: Q4170 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: CYGNUS, PER SQ CM Category: Medical Services CMS Add: 01/01/2017 CMS Term: Q4170 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: CYGNUS, PER SQ CM Category: Medical Services CMS Add: 01/01/2017 CMS Term: Q4171 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: INTERFYL, 1 MG Category: Medical Services CMS Add: 01/01/2017 CMS Term: Q4171 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: INTERFYL, 1 MG Category: Medical Services CMS Add: 01/01/2017 CMS Term: Q4173 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: PALINGEN OR PALINGEN XPLUS Category: Medical Services CMS Add: 01/01/2017 CMS Term: Q4173 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: PALINGEN OR PALINGEN XPLUS Category: Medical Services CMS Add: 01/01/2017 CMS Term: Q4174 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: PALINGEN OR PROMATRX Category: Medical Services CMS Add: 01/01/2017 CMS Term: Q4174 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: PALINGEN OR PROMATRX Category: Medical Services CMS Add: 01/01/2017 CMS Term: Q4175 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: MIRODERM Category: Medical Services CMS Add: 01/01/2017 CMS Term: Q4175 MEDSV DEF MAXFEE 05/11/2017 12/31/2023 37.56 0.0 Description: MIRODERM Category: Medical Services CMS Add: 01/01/2017 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,084 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- Q4176 MDSPY DEF MAXFEE 01/01/2018 12/31/2023 37.56 0.0 Description: NEOPATCH OR THERION, 1 SQ CM Category: Medical Supplies CMS Add: 01/01/2018 CMS Term: Q4176 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: NEOPATCH OR THERION, 1 SQ CM Category: Medical Supplies CMS Add: 01/01/2018 CMS Term: Q4177 MDSPY DEF MAXFEE 01/01/2018 12/31/2023 37.56 0.0 Description: FLOWERAMNIOFLO, 0.1 CC Category: Medical Supplies CMS Add: 01/01/2018 CMS Term: Q4177 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: FLOWERAMNIOFLO, 0.1 CC Category: Medical Supplies CMS Add: 01/01/2018 CMS Term: Q4178 MDSPY DEF MAXFEE 01/01/2018 12/31/2023 37.56 0.0 Description: FLOWERAMNIOPATCH, PER SQ CM Category: Medical Supplies CMS Add: 01/01/2018 CMS Term: Q4178 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: FLOWERAMNIOPATCH, PER SQ CM Category: Medical Supplies CMS Add: 01/01/2018 CMS Term: Q4179 MDSPY DEF MAXFEE 01/01/2018 12/31/2023 37.56 0.0 Description: FLOWERDERM, PER SQ CM Category: Medical Supplies CMS Add: 01/01/2018 CMS Term: Q4179 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: FLOWERDERM, PER SQ CM Category: Medical Supplies CMS Add: 01/01/2018 CMS Term: Q4180 MDSPY DEF MAXFEE 01/01/2018 12/31/2023 37.56 0.0 Description: REVITA, PER SQ CM Category: Medical Supplies CMS Add: 01/01/2018 CMS Term: Q4180 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: REVITA, PER SQ CM Category: Medical Supplies CMS Add: 01/01/2018 CMS Term: Q4181 MDSPY DEF MAXFEE 01/01/2018 12/31/2023 37.56 0.0 Description: AMNIO WOUND, PER SQUARE CM Category: Medical Supplies CMS Add: 01/01/2018 CMS Term: Q4181 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: AMNIO WOUND, PER SQUARE CM Category: Medical Supplies CMS Add: 01/01/2018 CMS Term: Q4182 MDSPY DEF MAXFEE 01/01/2018 12/31/2023 37.56 0.0 Description: TRANSCYTE, PER SQ CENTIMETER Category: Medical Supplies CMS Add: 01/01/2018 CMS Term: Q4182 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: TRANSCYTE, PER SQ CENTIMETER Category: Medical Supplies CMS Add: 01/01/2018 CMS Term: Q4183 MDSPY DEF MAXFEE 01/01/2019 12/31/2023 37.56 0.0 Description: SURGIGRAFT, 1 SQ CM Category: Medical Supplies CMS Add: 01/01/2019 CMS Term: Q4183 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: SURGIGRAFT, 1 SQ CM Category: Medical Supplies CMS Add: 01/01/2019 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,085 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- Q4184 MDSPY DEF MAXFEE 01/01/2019 12/31/2023 37.56 0.0 Description: CELLESTA OR DUO PER SQ CM Category: Medical Supplies CMS Add: 01/01/2019 CMS Term: Q4184 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: CELLESTA OR DUO PER SQ CM Category: Medical Supplies CMS Add: 01/01/2019 CMS Term: Q4185 MDSPY DEF MAXFEE 01/01/2019 12/31/2023 37.56 0.0 Description: CELLESTA FLOWAB AMNION 0.5CC Category: Medical Supplies CMS Add: 01/01/2019 CMS Term: Q4185 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: CELLESTA FLOWAB AMNION 0.5CC Category: Medical Supplies CMS Add: 01/01/2019 CMS Term: Q4186 MDSPY DEF MAXFEE 01/01/2019 12/31/2023 37.56 0.0 Description: EPIFIX 1 SQ CM Category: Medical Supplies CMS Add: 01/01/2019 CMS Term: Q4186 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: EPIFIX 1 SQ CM Category: Medical Supplies CMS Add: 01/01/2019 CMS Term: Q4187 MDSPY DEF MAXFEE 01/01/2019 12/31/2023 37.56 0.0 Description: EPICORD 1 SQ CM Category: Medical Supplies CMS Add: 01/01/2019 CMS Term: Q4187 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: EPICORD 1 SQ CM Category: Medical Supplies CMS Add: 01/01/2019 CMS Term: Q4188 MDSPY DEF MAXFEE 01/01/2019 12/31/2023 37.56 0.0 Description: AMNIOARMOR 1 SQ CM Category: Medical Supplies CMS Add: 01/01/2019 CMS Term: Q4188 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: AMNIOARMOR 1 SQ CM Category: Medical Supplies CMS Add: 01/01/2019 CMS Term: Q4189 MDSPY DEF MAXFEE 01/01/2019 12/31/2023 37.56 0.0 Description: ARTACENT AC, 1 MG Category: Medical Supplies CMS Add: 01/01/2019 CMS Term: Q4189 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: ARTACENT AC, 1 MG Category: Medical Supplies CMS Add: 01/01/2019 CMS Term: Q4190 MDSPY DEF MAXFEE 01/01/2019 12/31/2023 37.56 0.0 Description: ARTACENT AC 1 SQ CM Category: Medical Supplies CMS Add: 01/01/2019 CMS Term: Q4190 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: ARTACENT AC 1 SQ CM Category: Medical Supplies CMS Add: 01/01/2019 CMS Term: Q4191 MDSPY DEF MAXFEE 01/01/2019 12/31/2023 37.56 0.0 Description: RESTORIGIN 1 SQ CM Category: Medical Supplies CMS Add: 01/01/2019 CMS Term: Q4191 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: RESTORIGIN 1 SQ CM Category: Medical Supplies CMS Add: 01/01/2019 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,086 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- Q4192 MDSPY DEF MAXFEE 01/01/2019 12/31/2023 37.56 0.0 Description: RESTORIGIN, 1 CC Category: Medical Supplies CMS Add: 01/01/2019 CMS Term: Q4192 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: RESTORIGIN, 1 CC Category: Medical Supplies CMS Add: 01/01/2019 CMS Term: Q4193 MDSPY DEF MAXFEE 01/01/2019 12/31/2023 37.56 0.0 Description: COLL-E-DERM 1 SQ CM Category: Medical Supplies CMS Add: 01/01/2019 CMS Term: Q4193 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: COLL-E-DERM 1 SQ CM Category: Medical Supplies CMS Add: 01/01/2019 CMS Term: Q4194 MDSPY DEF MAXFEE 01/01/2019 12/31/2023 37.56 0.0 Description: NOVACHOR 1 SQ CM Category: Medical Supplies CMS Add: 01/01/2019 CMS Term: Q4194 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: NOVACHOR 1 SQ CM Category: Medical Supplies CMS Add: 01/01/2019 CMS Term: Q4195 MDSPY DEF MAXFEE 01/01/2019 12/31/2023 37.56 0.0 Description: PURAPLY 1 SQ CM Category: Medical Supplies CMS Add: 01/01/2019 CMS Term: Q4195 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: PURAPLY 1 SQ CM Category: Medical Supplies CMS Add: 01/01/2019 CMS Term: Q4196 MDSPY DEF MAXFEE 01/01/2019 12/31/2023 37.56 0.0 Description: PURAPLY AM 1 SQ CM Category: Medical Supplies CMS Add: 01/01/2019 CMS Term: Q4196 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: PURAPLY AM 1 SQ CM Category: Medical Supplies CMS Add: 01/01/2019 CMS Term: Q4197 MDSPY DEF MAXFEE 01/01/2019 12/31/2023 37.56 0.0 Description: PURAPLY XT 1 SQ CM Category: Medical Supplies CMS Add: 01/01/2019 CMS Term: Q4197 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: PURAPLY XT 1 SQ CM Category: Medical Supplies CMS Add: 01/01/2019 CMS Term: Q4198 MDSPY DEF MAXFEE 01/01/2019 12/31/2023 37.56 0.0 Description: GENESIS AMNIO MEMBRANE 1SQCM Category: Medical Supplies CMS Add: 01/01/2019 CMS Term: Q4198 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: GENESIS AMNIO MEMBRANE 1SQCM Category: Medical Supplies CMS Add: 01/01/2019 CMS Term: Q4199 MDSPY DEF MAXFEE 01/01/2022 12/31/2023 37.56 0.0 Description: CYGNUS MATRIX, PER SQ CM Category: Medical Supplies CMS Add: 01/01/2022 CMS Term: Q4199 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: CYGNUS MATRIX, PER SQ CM Category: Medical Supplies CMS Add: 01/01/2022 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,087 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- Q4200 MDSPY DEF MAXFEE 01/01/2019 12/31/2023 37.56 0.0 Description: SKIN TE 1 SQ CM Category: Medical Supplies CMS Add: 01/01/2019 CMS Term: Q4200 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: SKIN TE 1 SQ CM Category: Medical Supplies CMS Add: 01/01/2019 CMS Term: Q4201 MDSPY DEF MAXFEE 01/01/2019 12/31/2023 37.56 0.0 Description: MATRION 1 SQ CM Category: Medical Supplies CMS Add: 01/01/2019 CMS Term: Q4201 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: MATRION 1 SQ CM Category: Medical Supplies CMS Add: 01/01/2019 CMS Term: Q4202 MDSPY DEF MAXFEE 01/01/2019 12/31/2023 37.56 0.0 Description: KEROXX (2.5G/CC), 1CC Category: Medical Supplies CMS Add: 01/01/2019 CMS Term: Q4202 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: KEROXX (2.5G/CC), 1CC Category: Medical Supplies CMS Add: 01/01/2019 CMS Term: Q4203 MDSPY DEF MAXFEE 01/01/2019 12/31/2023 37.56 0.0 Description: DERMA-GIDE, 1 SQ CM Category: Medical Supplies CMS Add: 01/01/2019 CMS Term: Q4203 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: DERMA-GIDE, 1 SQ CM Category: Medical Supplies CMS Add: 01/01/2019 CMS Term: Q4204 MDSPY DEF MAXFEE 01/01/2019 12/31/2023 37.56 0.0 Description: XWRAP 1 SQ CM Category: Medical Supplies CMS Add: 01/01/2019 CMS Term: Q4204 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: XWRAP 1 SQ CM Category: Medical Supplies CMS Add: 01/01/2019 CMS Term: Q4205 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: MEMBRANE GRAFT OR WRAP SQ CM Category: Medical Supplies CMS Add: 10/01/2019 CMS Term: Q4205 MDSPY DEF MAXFEE 10/01/2019 12/31/2023 37.56 0.0 Description: MEMBRANE GRAFT OR WRAP SQ CM Category: Medical Supplies CMS Add: 10/01/2019 CMS Term: Q4206 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: FLUID FLOW OR FLUID GF 1 CC Category: Medical Supplies CMS Add: 10/01/2019 CMS Term: Q4206 MDSPY DEF MAXFEE 10/01/2019 12/31/2023 37.56 0.0 Description: FLUID FLOW OR FLUID GF 1 CC Category: Medical Supplies CMS Add: 10/01/2019 CMS Term: Q4208 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: NOVAFIX PER SQ CM Category: Medical Supplies CMS Add: 10/01/2019 CMS Term: Q4208 MDSPY DEF MAXFEE 10/01/2019 12/31/2023 37.56 0.0 Description: NOVAFIX PER SQ CM Category: Medical Supplies CMS Add: 10/01/2019 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,088 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- Q4209 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: SURGRAFT PER SQ CM Category: Medical Supplies CMS Add: 10/01/2019 CMS Term: Q4209 MDSPY DEF MAXFEE 10/01/2019 12/31/2023 37.56 0.0 Description: SURGRAFT PER SQ CM Category: Medical Supplies CMS Add: 10/01/2019 CMS Term: Q4210 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: AXOLOTL GRAF DUALGRAF SQ CM Category: Medical Supplies CMS Add: 10/01/2019 CMS Term: Q4210 MDSPY DEF MAXFEE 10/01/2019 12/31/2023 37.56 0.0 Description: AXOLOTL GRAF DUALGRAF SQ CM Category: Medical Supplies CMS Add: 10/01/2019 CMS Term: Q4211 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: AMNION BIO OR AXOBIO SQ CM Category: Medical Supplies CMS Add: 10/01/2019 CMS Term: Q4211 MDSPY DEF MAXFEE 10/01/2019 12/31/2023 37.56 0.0 Description: AMNION BIO OR AXOBIO SQ CM Category: Medical Supplies CMS Add: 10/01/2019 CMS Term: Q4212 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: ALLOGEN, PER CC Category: Medical Supplies CMS Add: 10/01/2019 CMS Term: Q4212 MDSPY DEF MAXFEE 10/01/2019 12/31/2023 37.56 0.0 Description: ALLOGEN, PER CC Category: Medical Supplies CMS Add: 10/01/2019 CMS Term: Q4213 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: ASCENT, 0.5 MG Category: Medical Supplies CMS Add: 10/01/2019 CMS Term: Q4213 MDSPY DEF MAXFEE 10/01/2019 12/31/2023 37.56 0.0 Description: ASCENT, 0.5 MG Category: Medical Supplies CMS Add: 10/01/2019 CMS Term: Q4214 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: CELLESTA CORD PER SQ CM Category: Medical Supplies CMS Add: 10/01/2019 CMS Term: Q4214 MDSPY DEF MAXFEE 10/01/2019 12/31/2023 37.56 0.0 Description: CELLESTA CORD PER SQ CM Category: Medical Supplies CMS Add: 10/01/2019 CMS Term: Q4215 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: AXOLOTL AMBIENT, CRYO 0.1 MG Category: Medical Supplies CMS Add: 10/01/2019 CMS Term: Q4215 MDSPY DEF MAXFEE 10/01/2019 12/31/2023 37.56 0.0 Description: AXOLOTL AMBIENT, CRYO 0.1 MG Category: Medical Supplies CMS Add: 10/01/2019 CMS Term: Q4216 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: ARTACENT CORD PER SQ CM Category: Medical Supplies CMS Add: 10/01/2019 CMS Term: Q4216 MDSPY DEF MAXFEE 10/01/2019 12/31/2023 37.56 0.0 Description: ARTACENT CORD PER SQ CM Category: Medical Supplies CMS Add: 10/01/2019 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,089 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- Q4217 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: WOUNDFIX BIOWOUND PLUS XPLUS Category: Medical Supplies CMS Add: 10/01/2019 CMS Term: Q4217 MDSPY DEF MAXFEE 10/01/2019 12/31/2023 37.56 0.0 Description: WOUNDFIX BIOWOUND PLUS XPLUS Category: Medical Supplies CMS Add: 10/01/2019 CMS Term: Q4218 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: SURGICORD PER SQ CM Category: Medical Supplies CMS Add: 10/01/2019 CMS Term: Q4218 MDSPY DEF MAXFEE 10/01/2019 12/31/2023 37.56 0.0 Description: SURGICORD PER SQ CM Category: Medical Supplies CMS Add: 10/01/2019 CMS Term: Q4219 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: SURGIGRAFT DUAL PER SQ CM Category: Medical Supplies CMS Add: 10/01/2019 CMS Term: Q4219 MDSPY DEF MAXFEE 10/01/2019 12/31/2023 37.56 0.0 Description: SURGIGRAFT DUAL PER SQ CM Category: Medical Supplies CMS Add: 10/01/2019 CMS Term: Q4220 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: BELLACELL HD, SUREDERM SQ CM Category: Medical Supplies CMS Add: 10/01/2019 CMS Term: Q4220 MDSPY DEF MAXFEE 10/01/2019 12/31/2023 37.56 0.0 Description: BELLACELL HD, SUREDERM SQ CM Category: Medical Supplies CMS Add: 10/01/2019 CMS Term: Q4221 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: AMNIOWRAP2 PER SQ CM Category: Medical Supplies CMS Add: 10/01/2019 CMS Term: Q4221 MDSPY DEF MAXFEE 10/01/2019 12/31/2023 37.56 0.0 Description: AMNIOWRAP2 PER SQ CM Category: Medical Supplies CMS Add: 10/01/2019 CMS Term: Q4222 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: PROGENAMATRIX, PER SQ CM Category: Medical Supplies CMS Add: 10/01/2019 CMS Term: Q4222 MDSPY DEF MAXFEE 10/01/2019 12/31/2023 37.56 0.0 Description: PROGENAMATRIX, PER SQ CM Category: Medical Supplies CMS Add: 10/01/2019 CMS Term: Q4224 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: HHF10-P PER SQ CM Category: Medical Supplies CMS Add: 04/01/2022 CMS Term: Q4224 MDSPY DEF MAXFEE 04/01/2022 12/31/2023 37.56 0.0 Description: HHF10-P PER SQ CM Category: Medical Supplies CMS Add: 04/01/2022 CMS Term: Q4225 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: AMNIO OR DERMA TL, PER SQ CM Category: Medical Supplies CMS Add: 04/01/2022 CMS Term: Q4225 MDSPY DEF MAXFEE 04/01/2022 12/31/2023 37.56 0.0 Description: AMNIO OR DERMA TL, PER SQ CM Category: Medical Supplies CMS Add: 04/01/2022 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,090 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- Q4226 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: MYOWN HARV PREP PROC SQ CM Category: Medical Supplies CMS Add: 10/01/2019 CMS Term: Q4226 MDSPY DEF MAXFEE 10/01/2019 12/31/2023 37.56 0.0 Description: MYOWN HARV PREP PROC SQ CM Category: Medical Supplies CMS Add: 10/01/2019 CMS Term: Q4227 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: AMNIOCORE PER SQ CM Category: Medical Supplies CMS Add: 07/01/2020 CMS Term: Q4227 MDSPY DEF MAXFEE 07/01/2020 12/31/2023 37.56 0.0 Description: AMNIOCORE PER SQ CM Category: Medical Supplies CMS Add: 07/01/2020 CMS Term: Q4229 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: COGENEX AMNIO MEMB PER SQ CM Category: Medical Supplies CMS Add: 07/01/2020 CMS Term: Q4229 MDSPY DEF MAXFEE 07/01/2020 12/31/2023 37.56 0.0 Description: COGENEX AMNIO MEMB PER SQ CM Category: Medical Supplies CMS Add: 07/01/2020 CMS Term: Q4230 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: COGENEX FLOW AMNION 0.5 CC Category: Medical Supplies CMS Add: 07/01/2020 CMS Term: Q4230 MDSPY DEF MAXFEE 07/01/2020 12/31/2023 37.56 0.0 Description: COGENEX FLOW AMNION 0.5 CC Category: Medical Supplies CMS Add: 07/01/2020 CMS Term: Q4231 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: CORPLEX P, PER CC Category: Medical Supplies CMS Add: 07/01/2020 CMS Term: Q4231 MDSPY DEF MAXFEE 07/01/2020 12/31/2023 37.56 0.0 Description: CORPLEX P, PER CC Category: Medical Supplies CMS Add: 07/01/2020 CMS Term: Q4232 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: CORPLEX, PER SQ CM Category: Medical Supplies CMS Add: 07/01/2020 CMS Term: Q4232 MDSPY DEF MAXFEE 07/01/2020 12/31/2023 37.56 0.0 Description: CORPLEX, PER SQ CM Category: Medical Supplies CMS Add: 07/01/2020 CMS Term: Q4233 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: SURFACTOR /NUDYN PER 0.5 CC Category: Medical Supplies CMS Add: 07/01/2020 CMS Term: Q4233 MDSPY DEF MAXFEE 07/01/2020 12/31/2023 37.56 0.0 Description: SURFACTOR /NUDYN PER 0.5 CC Category: Medical Supplies CMS Add: 07/01/2020 CMS Term: Q4234 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: XCELLERATE, PER SQ CM Category: Medical Supplies CMS Add: 07/01/2020 CMS Term: Q4234 MDSPY DEF MAXFEE 07/01/2020 12/31/2023 37.56 0.0 Description: XCELLERATE, PER SQ CM Category: Medical Supplies CMS Add: 07/01/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,091 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- Q4235 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: AMNIOREPAIR OR ALTIPLY SQ CM Category: Medical Supplies CMS Add: 07/01/2020 CMS Term: Q4235 MDSPY DEF MAXFEE 07/01/2020 12/31/2023 37.56 0.0 Description: AMNIOREPAIR OR ALTIPLY SQ CM Category: Medical Supplies CMS Add: 07/01/2020 CMS Term: Q4237 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: CRYO-CORD, PER SQ CM Category: Medical Supplies CMS Add: 07/01/2020 CMS Term: Q4237 MDSPY DEF MAXFEE 07/01/2020 12/31/2023 37.56 0.0 Description: CRYO-CORD, PER SQ CM Category: Medical Supplies CMS Add: 07/01/2020 CMS Term: Q4238 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: DERM-MAXX, PER SQ CM Category: Medical Supplies CMS Add: 07/01/2020 CMS Term: Q4238 MDSPY DEF MAXFEE 07/01/2020 12/31/2023 37.56 0.0 Description: DERM-MAXX, PER SQ CM Category: Medical Supplies CMS Add: 07/01/2020 CMS Term: Q4239 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: AMNIO-MAXX OR LITE PER SQ CM Category: Medical Supplies CMS Add: 07/01/2020 CMS Term: Q4239 MDSPY DEF MAXFEE 07/01/2020 12/31/2023 37.56 0.0 Description: AMNIO-MAXX OR LITE PER SQ CM Category: Medical Supplies CMS Add: 07/01/2020 CMS Term: Q4240 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: CORECYTE TOPICAL ONLY 0.5 CC Category: Medical Supplies CMS Add: 07/01/2020 CMS Term: Q4240 MDSPY DEF MAXFEE 07/01/2020 12/31/2023 37.56 0.0 Description: CORECYTE TOPICAL ONLY 0.5 CC Category: Medical Supplies CMS Add: 07/01/2020 CMS Term: Q4241 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: POLYCYTE, TOPICAL ONLY 0.5CC Category: Medical Supplies CMS Add: 07/01/2020 CMS Term: Q4241 MDSPY DEF MAXFEE 07/01/2020 12/31/2023 37.56 0.0 Description: POLYCYTE, TOPICAL ONLY 0.5CC Category: Medical Supplies CMS Add: 07/01/2020 CMS Term: Q4242 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: AMNIOCYTE PLUS, PER 0.5 CC Category: Medical Supplies CMS Add: 07/01/2020 CMS Term: Q4242 MDSPY DEF MAXFEE 07/01/2020 12/31/2023 37.56 0.0 Description: AMNIOCYTE PLUS, PER 0.5 CC Category: Medical Supplies CMS Add: 07/01/2020 CMS Term: Q4244 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: PROCENTA, PER 200 MG Category: Medical Supplies CMS Add: 07/01/2020 CMS Term: 03/31/2024 Q4244 MDSPY DEF MAXFEE 07/01/2020 12/31/2023 37.56 0.0 Description: PROCENTA, PER 200 MG Category: Medical Supplies CMS Add: 07/01/2020 CMS Term: 03/31/2024 *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,092 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- Q4245 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: AMNIOTEXT, PER CC Category: Medical Supplies CMS Add: 07/01/2020 CMS Term: Q4245 MDSPY DEF MAXFEE 07/01/2020 12/31/2023 37.56 0.0 Description: AMNIOTEXT, PER CC Category: Medical Supplies CMS Add: 07/01/2020 CMS Term: Q4246 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: CORETEXT OR PROTEXT, PER CC Category: Medical Supplies CMS Add: 07/01/2020 CMS Term: Q4246 MDSPY DEF MAXFEE 07/01/2020 12/31/2023 37.56 0.0 Description: CORETEXT OR PROTEXT, PER CC Category: Medical Supplies CMS Add: 07/01/2020 CMS Term: Q4247 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: AMNIOTEXT PATCH, PER SQ CM Category: Medical Supplies CMS Add: 07/01/2020 CMS Term: Q4247 MDSPY DEF MAXFEE 07/01/2020 12/31/2023 37.56 0.0 Description: AMNIOTEXT PATCH, PER SQ CM Category: Medical Supplies CMS Add: 07/01/2020 CMS Term: Q4248 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: DERMACYTE AMN MEM ALLO SQ CM Category: Medical Supplies CMS Add: 07/01/2020 CMS Term: Q4248 MDSPY DEF MAXFEE 07/01/2020 12/31/2023 37.56 0.0 Description: DERMACYTE AMN MEM ALLO SQ CM Category: Medical Supplies CMS Add: 07/01/2020 CMS Term: Q4249 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: AMNIPLY, PER SQ CM Category: Medical Services CMS Add: 10/01/2020 CMS Term: Q4249 MEDSV DEF MAXFEE 10/01/2020 12/31/2023 37.56 0.0 Description: AMNIPLY, PER SQ CM Category: Medical Services CMS Add: 10/01/2020 CMS Term: Q4250 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: AMNIOAMP-MP PER SQ CM Category: Medical Services CMS Add: 10/01/2020 CMS Term: Q4250 MEDSV DEF MAXFEE 10/01/2020 12/31/2023 37.56 0.0 Description: AMNIOAMP-MP PER SQ CM Category: Medical Services CMS Add: 10/01/2020 CMS Term: Q4251 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: VIM, PER SQUARE CENTIMETER Category: Medical Services CMS Add: 10/01/2021 CMS Term: Q4251 MEDSV DEF MAXFEE 10/01/2021 12/31/2023 37.56 0.0 Description: VIM, PER SQUARE CENTIMETER Category: Medical Services CMS Add: 10/01/2021 CMS Term: Q4252 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: VENDAJE, PER SQUARE CENTIMET Category: Medical Services CMS Add: 10/01/2021 CMS Term: Q4252 MEDSV DEF MAXFEE 10/01/2021 12/31/2023 37.56 0.0 Description: VENDAJE, PER SQUARE CENTIMET Category: Medical Services CMS Add: 10/01/2021 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,093 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- Q4253 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: ZENITH AMNIOTIC MEMBRANE PSC Category: Medical Services CMS Add: 10/01/2021 CMS Term: Q4253 MEDSV DEF MAXFEE 10/01/2021 12/31/2023 37.56 0.0 Description: ZENITH AMNIOTIC MEMBRANE PSC Category: Medical Services CMS Add: 10/01/2021 CMS Term: Q4254 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: NOVAFIX DL PER SQ CM Category: Medical Services CMS Add: 10/01/2020 CMS Term: Q4254 MEDSV DEF MAXFEE 10/01/2020 12/31/2023 37.56 0.0 Description: NOVAFIX DL PER SQ CM Category: Medical Services CMS Add: 10/01/2020 CMS Term: Q4255 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: REGUARD, TOPICAL USE PER SQ Category: Medical Services CMS Add: 10/01/2020 CMS Term: Q4256 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: MLG COMPLET, PER SQ CM Category: Medical Supplies CMS Add: 04/01/2022 CMS Term: Q4256 MDSPY DEF MAXFEE 04/01/2022 12/31/2023 37.56 0.0 Description: MLG COMPLET, PER SQ CM Category: Medical Supplies CMS Add: 04/01/2022 CMS Term: Q4257 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: RELESE, PER SQ CM Category: Medical Supplies CMS Add: 04/01/2022 CMS Term: Q4257 MDSPY DEF MAXFEE 04/01/2022 12/31/2023 37.56 0.0 Description: RELESE, PER SQ CM Category: Medical Supplies CMS Add: 04/01/2022 CMS Term: Q4258 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: ENVERSE, PER SQ CM Category: Medical Supplies CMS Add: 04/01/2022 CMS Term: Q4258 MDSPY DEF MAXFEE 04/01/2022 12/31/2023 37.56 0.0 Description: ENVERSE, PER SQ CM Category: Medical Supplies CMS Add: 04/01/2022 CMS Term: Q4259 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: CELERA PER SQ CM Category: Medical Supplies CMS Add: 07/01/2022 CMS Term: Q4259 MDSPY DEF MAXFEE 07/01/2022 12/31/2023 37.56 0.0 Description: CELERA PER SQ CM Category: Medical Supplies CMS Add: 07/01/2022 CMS Term: Q4260 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: SIGNATURE APATCH, PER SQ CM Category: Medical Supplies CMS Add: 07/01/2022 CMS Term: Q4260 MDSPY DEF MAXFEE 07/01/2022 12/31/2023 37.56 0.0 Description: SIGNATURE APATCH, PER SQ CM Category: Medical Supplies CMS Add: 07/01/2022 CMS Term: Q4261 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: TAG, PER SQUARE CENTIMETER Category: Medical Supplies CMS Add: 07/01/2022 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,094 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- Q4261 MDSPY DEF MAXFEE 07/01/2022 12/31/2023 37.56 0.0 Description: TAG, PER SQUARE CENTIMETER Category: Medical Supplies CMS Add: 07/01/2022 CMS Term: Q4262 MDSPY DEF MAXFEE 01/01/2023 12/31/2023 37.56 0.0 Description: DUAL LAYER IMPAX, PER SQ CM Category: Medical Supplies CMS Add: 01/01/2023 CMS Term: Q4262 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: DUAL LAYER IMPAX, PER SQ CM Category: Medical Supplies CMS Add: 01/01/2023 CMS Term: Q4263 MDSPY DEF MAXFEE 01/01/2023 12/31/2023 37.56 0.0 Description: SURGRAFT TL, PER SQ CM Category: Medical Supplies CMS Add: 01/01/2023 CMS Term: Q4263 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: SURGRAFT TL, PER SQ CM Category: Medical Supplies CMS Add: 01/01/2023 CMS Term: Q4264 MDSPY DEF MAXFEE 01/01/2023 12/31/2023 37.56 0.0 Description: COCOON MEMBRANE, PER SQ CM Category: Medical Supplies CMS Add: 01/01/2023 CMS Term: Q4264 MDSPY DEF MAXFEE 01/01/2024 48.83 0.0 Description: COCOON MEMBRANE, PER SQ CM Category: Medical Supplies CMS Add: 01/01/2023 CMS Term: Q4265 MDSPY DEF MAXFEE 01/01/2024 48.68 0.0 Description: NEOSTIM TL PER SQ CM Category: Medical Supplies CMS Add: 04/01/2023 CMS Term: Q4265 MDSPY DEF MAXFEE 04/01/2023 12/31/2023 37.56 0.0 Description: NEOSTIM TL PER SQ CM Category: Medical Supplies CMS Add: 04/01/2023 CMS Term: Q4266 MDSPY DEF MAXFEE 01/01/2024 48.68 0.0 Description: NEOSTIM PER SQ CM Category: Medical Supplies CMS Add: 04/01/2023 CMS Term: Q4266 MDSPY DEF MAXFEE 04/01/2023 12/31/2023 37.56 0.0 Description: NEOSTIM PER SQ CM Category: Medical Supplies CMS Add: 04/01/2023 CMS Term: Q4267 MDSPY DEF MAXFEE 01/01/2024 48.68 0.0 Description: NEOSTIM DL PER SQ CM Category: Medical Supplies CMS Add: 04/01/2023 CMS Term: Q4267 MDSPY DEF MAXFEE 04/01/2023 12/31/2023 37.56 0.0 Description: NEOSTIM DL PER SQ CM Category: Medical Supplies CMS Add: 04/01/2023 CMS Term: Q4268 MDSPY DEF MAXFEE 01/01/2024 48.68 0.0 Description: SURGRAFT FT PER SQ CM Category: Medical Supplies CMS Add: 04/01/2023 CMS Term: Q4268 MDSPY DEF MAXFEE 04/01/2023 12/31/2023 37.56 0.0 Description: SURGRAFT FT PER SQ CM Category: Medical Supplies CMS Add: 04/01/2023 CMS Term: Q4269 MDSPY DEF MAXFEE 01/01/2024 48.68 0.0 Description: SURGRAFT XT PER SQ CM Category: Medical Supplies CMS Add: 04/01/2023 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,095 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- Q4269 MDSPY DEF MAXFEE 04/01/2023 12/31/2023 37.56 0.0 Description: SURGRAFT XT PER SQ CM Category: Medical Supplies CMS Add: 04/01/2023 CMS Term: Q4270 MDSPY DEF MAXFEE 01/01/2024 48.68 0.0 Description: COMPLETE SL PER SQ CM Category: Medical Supplies CMS Add: 04/01/2023 CMS Term: Q4270 MDSPY DEF MAXFEE 04/01/2023 12/31/2023 37.56 0.0 Description: COMPLETE SL PER SQ CM Category: Medical Supplies CMS Add: 04/01/2023 CMS Term: Q4271 MDSPY DEF MAXFEE 01/01/2024 48.68 0.0 Description: COMPLETE FT PER SQ CM Category: Medical Supplies CMS Add: 04/01/2023 CMS Term: Q4271 MDSPY DEF MAXFEE 04/01/2023 12/31/2023 37.56 0.0 Description: COMPLETE FT PER SQ CM Category: Medical Supplies CMS Add: 04/01/2023 CMS Term: Q4272 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Y Description: ESANO A, PER SQ CM Category: Medical Services CMS Add: 07/01/2023 CMS Term: Q4272 MEDSV DEF MAXFEE 07/01/2023 12/31/2023 37.56 0.0 Y Description: ESANO A, PER SQ CM Category: Medical Services CMS Add: 07/01/2023 CMS Term: Q4273 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: ESANO AAA, PER SQ CM Category: Medical Services CMS Add: 07/01/2023 CMS Term: Q4273 MEDSV DEF MAXFEE 07/01/2023 12/31/2023 37.56 0.0 Description: ESANO AAA, PER SQ CM Category: Medical Services CMS Add: 07/01/2023 CMS Term: Q4274 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: ESANO AC, PER SQ CM Category: Medical Services CMS Add: 07/01/2023 CMS Term: Q4274 MEDSV DEF MAXFEE 07/01/2023 12/31/2023 37.56 0.0 Description: ESANO AC, PER SQ CM Category: Medical Services CMS Add: 07/01/2023 CMS Term: Q4275 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: ESANO ACA, PER SQ CM Category: Medical Services CMS Add: 07/01/2023 CMS Term: Q4275 MEDSV DEF MAXFEE 07/01/2023 12/31/2023 37.56 0.0 Description: ESANO ACA, PER SQ CM Category: Medical Services CMS Add: 07/01/2023 CMS Term: Q4276 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: ORION, PER SQ CM Category: Medical Services CMS Add: 07/01/2023 CMS Term: Q4276 MEDSV DEF MAXFEE 07/01/2023 12/31/2023 37.56 0.0 Description: ORION, PER SQ CM Category: Medical Services CMS Add: 07/01/2023 CMS Term: Q4277 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: WOUNDPLUS E-GRAT, PER SQ CM Category: Medical Services CMS Add: 07/01/2023 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,096 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- Q4277 MEDSV DEF MAXFEE 07/01/2023 12/31/2023 37.56 0.0 Description: WOUNDPLUS E-GRAT, PER SQ CM Category: Medical Services CMS Add: 07/01/2023 CMS Term: Q4278 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: EPIEFFECT, PER SQ CM Category: Medical Services CMS Add: 07/01/2023 CMS Term: Q4278 MEDSV DEF MAXFEE 07/01/2023 12/31/2023 37.56 0.0 Description: EPIEFFECT, PER SQ CM Category: Medical Services CMS Add: 07/01/2023 CMS Term: Q4279 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: VENDAJE AC, PER SQ CM Category: Medical Services CMS Add: 01/01/2024 CMS Term: Q4280 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: XCELL AMNIO MATRIX PER SQ CM Category: Medical Services CMS Add: 07/01/2023 CMS Term: Q4280 MEDSV DEF MAXFEE 07/01/2023 12/31/2023 37.56 0.0 Description: XCELL AMNIO MATRIX PER SQ CM Category: Medical Services CMS Add: 07/01/2023 CMS Term: Q4281 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: BARRERA SLOR DL PER SQ CM Category: Medical Services CMS Add: 07/01/2023 CMS Term: Q4281 MEDSV DEF MAXFEE 07/01/2023 12/31/2023 37.56 0.0 Description: BARRERA SLOR DL PER SQ CM Category: Medical Services CMS Add: 07/01/2023 CMS Term: Q4282 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: CYGNUS DUAL PER SQ CM Category: Medical Services CMS Add: 07/01/2023 CMS Term: Q4282 MEDSV DEF MAXFEE 07/01/2023 12/31/2023 37.56 0.0 Description: CYGNUS DUAL PER SQ CM Category: Medical Services CMS Add: 07/01/2023 CMS Term: Q4283 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: BIOVANCE TRI OR 3L, SQ CM Category: Medical Services CMS Add: 07/01/2023 CMS Term: Q4283 MEDSV DEF MAXFEE 07/01/2023 12/31/2023 37.56 0.0 Description: BIOVANCE TRI OR 3L, SQ CM Category: Medical Services CMS Add: 07/01/2023 CMS Term: Q4284 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: DERMABIND SL, PER SQ CM Category: Medical Services CMS Add: 07/01/2023 CMS Term: Q4284 MEDSV DEF MAXFEE 07/01/2023 12/31/2023 37.56 0.0 Description: DERMABIND SL, PER SQ CM Category: Medical Services CMS Add: 07/01/2023 CMS Term: Q4285 MDSPY DEF MAXFEE 01/01/2024 48.68 0.0 Description: NUDYN DL OR DL MESH PR SQ CM Category: Medical Supplies CMS Add: 10/01/2023 CMS Term: Q4285 MDSPY DEF MAXFEE 10/01/2023 12/31/2023 37.56 0.0 Description: NUDYN DL OR DL MESH PR SQ CM Category: Medical Supplies CMS Add: 10/01/2023 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,097 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- Q4286 MDSPY DEF MAXFEE 01/01/2024 48.68 0.0 Description: NUDYN SL OR SLW, PER SQ CM Category: Medical Supplies CMS Add: 10/01/2023 CMS Term: Q4286 MDSPY DEF MAXFEE 10/01/2023 12/31/2023 37.56 0.0 Description: NUDYN SL OR SLW, PER SQ CM Category: Medical Supplies CMS Add: 10/01/2023 CMS Term: Q4287 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: DERMABIND DL, PER SQ CM Category: Medical Services CMS Add: 01/01/2024 CMS Term: Q4288 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: DERMABIND CH, PER SQ CM Category: Medical Services CMS Add: 01/01/2024 CMS Term: Q4289 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: REVOSHIELD+ AMNIO, PER SQ CM Category: Medical Services CMS Add: 01/01/2024 CMS Term: Q4290 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: MEMBRANE WRAP HYDR PER SQ CM Category: Medical Services CMS Add: 01/01/2024 CMS Term: Q4291 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: LAMELLAS XT, PER SQ CM Category: Medical Services CMS Add: 01/01/2024 CMS Term: Q4292 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: LAMELLAS, PER SQ CM Category: Medical Services CMS Add: 01/01/2024 CMS Term: Q4293 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: ACESSO DL, PER SQ CM Category: Medical Services CMS Add: 01/01/2024 CMS Term: Q4294 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: AMNIO QUAD-CORE, PER SQ CM Category: Medical Services CMS Add: 01/01/2024 CMS Term: Q4295 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: AMNIO TRI-CORE, PER SQ CM Category: Medical Services CMS Add: 01/01/2024 CMS Term: Q4296 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: REBOUND MATRIX, PER SQ CM Category: Medical Services CMS Add: 01/01/2024 CMS Term: Q4297 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: EMERGE MATRIX, PER SQ CM Category: Medical Services CMS Add: 01/01/2024 CMS Term: Q4298 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: AMNICORE PRO, PER SQ CM Category: Medical Services CMS Add: 01/01/2024 CMS Term: Q4299 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: AMNICORE PRO+, PER SQ CM Category: Medical Services CMS Add: 01/01/2024 CMS Term: Q4300 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: ACESSO TL, PER SQ CM Category: Medical Services CMS Add: 01/01/2024 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,098 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- Q4301 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: ACTIVATE MATRIX, PER SQ CM Category: Medical Services CMS Add: 01/01/2024 CMS Term: Q4302 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: COMPLETE ACA, PER SQ CM Category: Medical Services CMS Add: 01/01/2024 CMS Term: Q4303 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: COMPLETE AA, PER SQ CM Category: Medical Services CMS Add: 01/01/2024 CMS Term: Q4304 MEDSV DEF MAXFEE 01/01/2024 48.68 0.0 Description: GRAFIX PLUS, PER SQ CM Category: Medical Services CMS Add: 01/01/2024 CMS Term: Q5001 NOCOV DEF SYSMAN Description: HOSPICE OR HOME HLTH IN HOME Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: Q5002 NOCOV DEF SYSMAN Description: HOSPICE/HOME HLTH IN ASST LV Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: Q5003 NOCOV DEF SYSMAN Description: HOSPICE IN LT/NON-SKILLED NF Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: Q5004 NOCOV DEF SYSMAN Description: HOSPICE IN SNF Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: Q5005 NOCOV DEF SYSMAN Description: HOSPICE, INPATIENT HOSPITAL Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: Q5006 NOCOV DEF SYSMAN Description: HOSPICE IN HOSPICE FACILITY Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: Q5007 NOCOV DEF SYSMAN Description: HOSPICE IN LTCH Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: Q5008 NOCOV DEF SYSMAN Description: HOSPICE IN INPATIENT PSYCH Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: Q5009 NOCOV DEF SYSMAN Description: HOSPICE/HOME HLTH, PLACE NOS Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: Q5010 NOCOV DEF SYSMAN Description: HOSPICE HOME CARE IN HOSPICE Category: Non Covered Services CMS Add: 10/01/2010 CMS Term: Q5101 DRUG DEF MAXFEE 10/01/2018 0.96 0.0 Description: INJECTION, ZARXIO Category: Drugs CMS Add: 07/01/2015 CMS Term: Q5103 DRUG DEF MAXFEE 04/01/2018 99.36 0.0 Description: INJECTION, INFLECTRA Category: Drugs CMS Add: 04/01/2018 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,099 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- Q5104 DRUG DEF MAXFEE 04/01/2018 79.11 0.0 Description: INJECTION, RENFLEXIS Category: Drugs CMS Add: 04/01/2018 CMS Term: Q5105 DRUG DEF MAXFEE 07/01/2018 1.16 0.0 Description: INJ RETACRIT ESRD ON DIALYSI Category: Drugs CMS Add: 07/01/2018 CMS Term: Q5106 DRUG DEF MAXFEE 07/01/2018 11.58 0.0 Description: INJ RETACRIT NON-ESRD USE Category: Drugs CMS Add: 07/01/2018 CMS Term: Q5107 DRUG DEF MAXFEE 10/01/2021 73.26 0.0 Description: INJ MVASI 10 MG Category: Drugs CMS Add: 01/01/2019 CMS Term: Q5108 DRUG DEF MAXFEE 01/01/2024 182.66 0.0 Description: INJECTION, FULPHILA Category: Drugs CMS Add: 10/01/2018 CMS Term: Q5108 DRUG DEF MAXFEE 10/01/2018 12/31/2023 365.31 0.0 Description: INJECTION, FULPHILA Category: Drugs CMS Add: 10/01/2018 CMS Term: Q5109 NOCOV DEF SYSMAN Description: INJECTION, IXIFI, 10 MG Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: Q5110 DRUG DEF MAXFEE 10/01/2018 0.77 0.0 Description: NIVESTYM Category: Drugs CMS Add: 10/01/2018 CMS Term: Q5111 DRUG DEF MAXFEE 08/16/2019 365.31 0.0 Description: INJECTION, UDENYCA 0.5 MG Category: Drugs CMS Add: 01/01/2019 CMS Term: Q5112 DRUG DEF MAXFEE 07/16/2020 92.73 0.0 Description: INJ ONTRUZANT 10 MG Category: Drugs CMS Add: 07/01/2019 CMS Term: Q5113 DRUG DEF MAXFEE 07/16/2020 98.18 0.0 Description: INJ HERZUMA 10 MG Category: Drugs CMS Add: 07/01/2019 CMS Term: Q5114 DRUG DEF MAXFEE 01/01/2024 65.63 0.0 Description: INJ OGIVRI 10 MG Category: Drugs CMS Add: 07/01/2019 CMS Term: Q5114 DRUG DEF MAXFEE 02/21/2020 12/31/2023 92.43 0.0 Description: INJ OGIVRI 10 MG Category: Drugs CMS Add: 07/01/2019 CMS Term: Q5115 DRUG DEF MAXFEE 02/21/2020 88.78 0.0 Description: INJ TRUXIMA 10 MG Category: Drugs CMS Add: 07/01/2019 CMS Term: Q5116 DRUG DEF MAXFEE 05/01/2020 84.78 0.0 Description: INJ., TRAZIMERA, 10 MG Category: Drugs CMS Add: 10/01/2019 CMS Term: Q5117 DRUG DEF MAXFEE 10/01/2021 95.20 0.0 Y Description: INJ., KANJINTI, 10 MG Category: Drugs CMS Add: 10/01/2019 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,100 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- Q5118 DRUG DEF MAXFEE 04/24/2020 64.41 0.0 Description: INJ., ZIRABEV, 10 MG Category: Drugs CMS Add: 10/01/2019 CMS Term: Q5119 DRUG DEF MAXFEE 07/01/2020 75.26 0.0 Description: INJ RUXIENCE, 10 MG Category: Drugs CMS Add: 07/01/2020 CMS Term: Q5120 DRUG DEF MAXFEE 07/01/2020 343.48 0.0 Description: INJ PEGFILGRASTIM-BMEZ 0.5MG Category: Drugs CMS Add: 07/01/2020 CMS Term: Q5121 DRUG DEF MAXFEE 10/08/2020 52.50 0.0 Description: INJ. AVSOLA, 10 MG Category: Drugs CMS Add: 07/01/2020 CMS Term: Q5122 DRUG DEF MAXFEE 01/01/2021 343.44 0.0 Description: INJ, NYVEPRIA Category: Drugs CMS Add: 01/01/2021 CMS Term: Q5123 DRUG DEF MAXFEE 07/01/2021 75.26 0.0 Description: INJ. RIABNI, 10 MG Category: Drugs CMS Add: 07/01/2021 CMS Term: Q5124 DRUG DEF MAXFEE 03/02/2023 237.30 0.0 Description: INJ. BYOOVIZ, 0.1 MG Category: Drugs CMS Add: 04/01/2022 CMS Term: Q5125 NOCOV DEF SYSMAN Description: INJ, RELEUKO 1 MCG Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: Q5126 DRUG DEF MAXFEE 01/01/2023 75.45 0.0 Description: INJ ALYMSYS 10 MG Category: Drugs CMS Add: 01/01/2023 CMS Term: Q5127 DRUG DEF MAXFEE 04/01/2024 376.27 0.0 Description: INJ, STIMUFEND, 0.5 MG Category: Drugs CMS Add: 04/01/2023 CMS Term: Q5127 DRUG DEF MAXFEE 04/15/2023 03/31/2024 365.31 0.0 Description: INJ, STIMUFEND, 0.5 MG Category: Drugs CMS Add: 04/01/2023 CMS Term: Q5128 DRUG DEF MAXFEE 04/01/2023 385.60 0.0 Description: INJ, CIMERLI, 0.1 MG Category: Drugs CMS Add: 04/01/2023 CMS Term: Q5129 DRUG DEF MAXFEE 04/15/2023 71.13 0.0 Description: INJ, VEGZELMA, 10 MG Category: Drugs CMS Add: 04/01/2023 CMS Term: Q5130 DRUG DEF MAXFEE 05/24/2023 218.75 0.0 Description: INJ, FYLNETRA, 0.5 MG Category: Drugs CMS Add: 04/01/2023 CMS Term: Q5131 NOCOV DEF SYSMAN Description: INJ, IDACIO, 20 MG Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: Q5132 NOCOV DEF SYSMAN Description: INJ, ABRILADA, 10 MG Category: Non Covered Services CMS Add: 01/01/2024 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,101 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- Q9001 NOCOV DEF SYSMAN Description: CHAPLAIN ASSESSMENT Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: Q9002 NOCOV DEF SYSMAN Description: CHAPLAIN COUNSEL INDIVIDU Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: Q9003 NOCOV DEF SYSMAN Description: CHAPLAIN COUNSEL GROUP Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: Q9004 NOCOV DEF SYSMAN Description: VA WHOLE HEALTH PARTNER SERV Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: Q9950 NOCOV DEF SYSMAN Description: INJ SULF HEXA LIPID MICROSPH Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: Q9951 NOCOV DEF SYSMAN Description: LOCM >= 400 MG/ML IODINE,1ML Category: Non Covered Services CMS Add: 04/01/2005 CMS Term: Q9953 NOCOV DEF SYSMAN Description: INJ FE-BASED MR CONTRAST,1ML Category: Non Covered Services CMS Add: 04/01/2005 CMS Term: Q9954 DRUG DEF SYSMAN Description: ORAL MR CONTRAST, 100 ML Category: Drugs CMS Add: 04/01/2005 CMS Term: Q9955 NOCOV DEF SYSMAN Description: INJ PERFLEXANE LIP MICROS,ML Category: Non Covered Services CMS Add: 04/01/2005 CMS Term: Q9956 DRUG DEF MAXFEE 07/01/2011 49.14 0.0 Description: INJ OCTAFLUOROPROPANE MIC,ML Category: Drugs CMS Add: 04/01/2005 CMS Term: Q9957 DRUG DEF MAXFEE 04/01/2023 06/30/2023 159.20 0.0 Description: INJ PERFLUTREN LIP MICROS,ML Category: Drugs CMS Add: 04/01/2005 CMS Term: Q9957 DRUG DEF MAXFEE 04/01/2024 168.75 0.0 Description: INJ PERFLUTREN LIP MICROS,ML Category: Drugs CMS Add: 04/01/2005 CMS Term: Q9957 DRUG DEF MAXFEE 07/01/2023 03/31/2024 166.09 0.0 Description: INJ PERFLUTREN LIP MICROS,ML Category: Drugs CMS Add: 04/01/2005 CMS Term: Q9958 NOCOV DEF SYSMAN Description: HOCM <=149 MG/ML IODINE, 1ML Category: Non Covered Services CMS Add: 07/01/2005 CMS Term: Q9959 NOCOV DEF SYSMAN Description: HOCM 150-199MG/ML IODINE,1ML Category: Non Covered Services CMS Add: 07/01/2005 CMS Term: Q9960 NOCOV DEF SYSMAN Description: HOCM 200-249MG/ML IODINE,1ML Category: Non Covered Services CMS Add: 07/01/2005 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,102 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- Q9961 NOCOV DEF SYSMAN Description: HOCM 250-299MG/ML IODINE,1ML Category: Non Covered Services CMS Add: 07/01/2005 CMS Term: Q9962 NOCOV DEF SYSMAN Description: HOCM 300-349MG/ML IODINE,1ML Category: Non Covered Services CMS Add: 07/01/2005 CMS Term: Q9963 NOCOV DEF SYSMAN Description: HOCM 350-399MG/ML IODINE,1ML Category: Non Covered Services CMS Add: 07/01/2005 CMS Term: Q9964 NOCOV DEF SYSMAN Description: HOCM>= 400MG/ML IODINE, 1ML Category: Non Covered Services CMS Add: 07/01/2005 CMS Term: Q9965 MEDSV PRF MAXFEE 01/01/2024 0.91 0.0 Description: LOCM 100-199MG/ML IODINE,1ML Category: Medical Services CMS Add: 01/01/2008 CMS Term: Q9966 MEDSV PRF MAXFEE 01/01/2024 03/31/2024 0.52 0.0 Description: LOCM 200-299MG/ML IODINE,1ML Category: Medical Services CMS Add: 01/01/2008 CMS Term: Q9966 MEDSV PRF MAXFEE 04/01/2024 0.72 0.0 Description: LOCM 200-299MG/ML IODINE,1ML Category: Medical Services CMS Add: 01/01/2008 CMS Term: Q9967 MEDSV PRF MAXFEE 01/01/2024 0.53 0.0 Description: LOCM 300-399MG/ML IODINE,1ML Category: Medical Services CMS Add: 01/01/2008 CMS Term: Q9968 NOCOV DEF SYSMAN Description: VISUALIZATION ADJUNCT Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: Q9969 NOCOV DEF SYSMAN Description: NON-HEU TC-99M ADD-ON/DOSE Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: Q9982 NOCOV DEF SYSMAN Description: FLUTEMETAMOL F18 DIAGNOSTIC Category: Non Covered Services CMS Add: 07/01/2016 CMS Term: Q9983 NOCOV DEF SYSMAN Description: FLORBETABEN F18 DIAGNOSTIC Category: Non Covered Services CMS Add: 07/01/2016 CMS Term: Q9991 DRUG DEF MAXFEE 04/01/2023 03/31/2024 2016.53 0.0 Y Description: BUPRENORPH XR 100 MG OR LESS Category: Drugs CMS Add: 07/01/2018 CMS Term: Q9991 DRUG DEF MAXFEE 04/01/2024 2117.35 0.0 Y Description: BUPRENORPH XR 100 MG OR LESS Category: Drugs CMS Add: 07/01/2018 CMS Term: Q9992 DRUG DEF MAXFEE 04/01/2023 03/31/2024 2016.52 0.0 Y Description: BUPRENORPHINE XR OVER 100 MG Category: Drugs CMS Add: 07/01/2018 CMS Term: Q9992 DRUG DEF MAXFEE 04/01/2024 2117.35 0.0 Y Description: BUPRENORPHINE XR OVER 100 MG Category: Drugs CMS Add: 07/01/2018 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,103 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- R0070 RADIO PRF MAXFEE 01/01/2024 194.54 0.0 Description: TRANSPORT PORTABLE X-RAY Category: Radiology CMS Add: 01/01/1982 CMS Term: R0075 UN RADIO DEF MAXFEE 01/01/2024 38.18 0.0 Description: TRANSPORT PORT X-RAY MULTIPL Category: Radiology CMS Add: 01/01/1986 CMS Term: R0075 UN RADIO DEF MAXFEE 02/13/2017 12/31/2023 35.92 0.0 Description: TRANSPORT PORT X-RAY MULTIPL Category: Radiology CMS Add: 01/01/1986 CMS Term: R0075 UP RADIO DEF MAXFEE 01/01/2024 25.19 0.0 Description: TRANSPORT PORT X-RAY MULTIPL Category: Radiology CMS Add: 01/01/1986 CMS Term: R0075 UP RADIO DEF MAXFEE 02/13/2017 12/31/2023 23.70 0.0 Description: TRANSPORT PORT X-RAY MULTIPL Category: Radiology CMS Add: 01/01/1986 CMS Term: R0075 UQ RADIO DEF MAXFEE 01/01/2024 19.09 0.0 Description: TRANSPORT PORT X-RAY MULTIPL Category: Radiology CMS Add: 01/01/1986 CMS Term: R0075 UQ RADIO DEF MAXFEE 02/13/2017 12/31/2023 17.96 0.0 Description: TRANSPORT PORT X-RAY MULTIPL Category: Radiology CMS Add: 01/01/1986 CMS Term: R0075 UR RADIO DEF MAXFEE 01/01/2024 15.28 0.0 Description: TRANSPORT PORT X-RAY MULTIPL Category: Radiology CMS Add: 01/01/1986 CMS Term: R0075 UR RADIO DEF MAXFEE 02/13/2017 12/31/2023 14.37 0.0 Description: TRANSPORT PORT X-RAY MULTIPL Category: Radiology CMS Add: 01/01/1986 CMS Term: R0075 US RADIO DEF MAXFEE 01/01/2024 12.21 0.0 Description: TRANSPORT PORT X-RAY MULTIPL Category: Radiology CMS Add: 01/01/1986 CMS Term: R0075 US RADIO DEF MAXFEE 02/13/2017 12/31/2023 11.49 0.0 Description: TRANSPORT PORT X-RAY MULTIPL Category: Radiology CMS Add: 01/01/1986 CMS Term: R0076 NOCOV DEF SYSMAN Description: TRANSPORT PORTABLE EKG Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: S0012 NOCOV DEF SYSMAN Description: BUTORPHANOL TARTRATE, NASAL Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S0013 DRUG DEF MAXFEE 04/01/2023 03/31/2024 13.79 0.0 Y Description: ESKETAMINE, NASAL SPRAY Category: Drugs CMS Add: 01/01/2021 CMS Term: S0013 DRUG DEF MAXFEE 04/01/2024 14.48 0.0 Y Description: ESKETAMINE, NASAL SPRAY Category: Drugs CMS Add: 01/01/2021 CMS Term: S0014 NOCOV DEF SYSMAN Description: TACRINE HYDROCHLORIDE, 10 MG Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,104 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- S0017 NOCOV DEF SYSMAN Description: INJECTION, AMINOCAPROIC ACID Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S0021 NOCOV DEF SYSMAN Description: INJECTION, CEFOPERAZONE SOD Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S0023 NOCOV DEF SYSMAN Description: INJECTION, CIMETIDINE HYDROC Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S0028 NOCOV DEF SYSMAN Description: INJECTION, FAMOTIDINE, 20 MG Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S0032 NOCOV DEF SYSMAN Description: INJECTION, NAFCILLIN SODIUM Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S0034 NOCOV DEF SYSMAN Description: INJECTION, OFLOXACIN, 400 MG Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S0039 NOCOV DEF SYSMAN Description: INJECTION, SULFAMETHOXAZOLE Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S0040 NOCOV DEF SYSMAN Description: INJECTION, TICARCILLIN DISOD Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S0074 NOCOV DEF SYSMAN Description: INJECTION, CEFOTETAN DISODIU Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S0078 NOCOV DEF SYSMAN Description: INJECTION, FOSPHENYTOIN SODI Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S0080 NOCOV DEF SYSMAN Description: INJECTION, PENTAMIDINE ISETH Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S0081 NOCOV DEF SYSMAN Description: INJECTION, PIPERACILLIN SODI Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S0088 NOCOV DEF SYSMAN Description: IMATINIB 100 MG Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S0090 NOCOV DEF SYSMAN Description: SILDENAFIL CITRATE, 25 MG Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S0091 NOCOV DEF SYSMAN Description: GRANISETRON 1MG Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S0092 NOCOV DEF SYSMAN Description: HYDROMORPHONE 250 MG Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,105 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- S0093 NOCOV DEF SYSMAN Description: MORPHINE 500 MG Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S0104 NOCOV DEF SYSMAN Description: ZIDOVUDINE, ORAL, 100 MG Category: Non Covered Services CMS Add: 10/01/2002 CMS Term: S0106 NOCOV DEF SYSMAN Description: BUPROPION HCL SR 60 TABLETS Category: Non Covered Services CMS Add: 04/01/2002 CMS Term: S0108 NOCOV DEF SYSMAN Description: MERCAPTOPURINE 50 MG Category: Non Covered Services CMS Add: 04/01/2002 CMS Term: S0109 NOCOV DEF SYSMAN Description: METHADONE ORAL 5MG Category: Non Covered Services CMS Add: 10/01/2004 CMS Term: S0117 NOCOV DEF SYSMAN Description: TRETINOIN TOPICAL 5 G Category: Non Covered Services CMS Add: 07/01/2004 CMS Term: S0119 NOCOV DEF SYSMAN Description: ONDANSETRON 4 MG Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: S0122 NOCOV DEF SYSMAN Description: INJ MENOTROPINS 75 IU Category: Non Covered Services CMS Add: 04/01/2002 CMS Term: S0126 NOCOV DEF SYSMAN Description: INJ FOLLITROPIN ALFA 75 IU Category: Non Covered Services CMS Add: 04/01/2002 CMS Term: S0128 NOCOV DEF SYSMAN Description: INJ FOLLITROPIN BETA 75 IU Category: Non Covered Services CMS Add: 04/01/2002 CMS Term: S0132 NOCOV DEF SYSMAN Description: INJ GANIRELIX ACETAT 250 MCG Category: Non Covered Services CMS Add: 04/01/2002 CMS Term: S0136 NOCOV DEF SYSMAN Description: CLOZAPINE, 25 MG Category: Non Covered Services CMS Add: 04/01/2003 CMS Term: S0137 NOCOV DEF SYSMAN Description: DIDANOSINE, 25 MG Category: Non Covered Services CMS Add: 04/01/2003 CMS Term: S0138 NOCOV DEF SYSMAN Description: FINASTERIDE, 5 MG Category: Non Covered Services CMS Add: 04/01/2003 CMS Term: S0139 NOCOV DEF SYSMAN Description: MINOXIDIL, 10 MG Category: Non Covered Services CMS Add: 04/01/2003 CMS Term: S0140 NOCOV DEF SYSMAN Description: SAQUINAVIR, 200 MG Category: Non Covered Services CMS Add: 04/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,106 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- S0142 NOCOV DEF SYSMAN Description: COLISTIMETHATE INH SOL MG Category: Non Covered Services CMS Add: 04/01/2005 CMS Term: S0145 DRUG DEF MAXFEE 12/10/2021 1072.56 0.0 Description: PEG INTERFERON ALFA-2A/180 Category: Drugs CMS Add: 07/01/2005 CMS Term: S0148 DRUG DEF SYSMAN Description: PEG INTERFERON ALFA-2B/10 Category: Drugs CMS Add: 10/01/2010 CMS Term: S0155 NOCOV DEF SYSMAN Description: EPOPROSTENOL DILUTANT Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S0156 NOCOV DEF SYSMAN Description: EXEMESTANE, 25 MG Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: S0157 NOCOV DEF SYSMAN Description: BECAPLERMIN GEL 1%, 0.5 GM Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: S0160 NOCOV DEF SYSMAN Description: DEXTROAMPHETAMINE Category: Non Covered Services CMS Add: 04/01/2004 CMS Term: S0164 DRUG DEF MAXFEE 01/01/2021 2.94 0.0 Description: INJECTION PANTROPRAZOLE Category: Drugs CMS Add: 04/01/2004 CMS Term: S0169 NOCOV DEF SYSMAN Description: CALCITROL Category: Non Covered Services CMS Add: 10/01/2010 CMS Term: S0170 NOCOV DEF SYSMAN Description: ANASTROZOLE 1 MG Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S0172 NOCOV DEF SYSMAN Description: CHLORAMBUCIL 2 MG Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S0174 NOCOV DEF SYSMAN Description: DOLASETRON 50 MG Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S0175 NOCOV DEF SYSMAN Description: FLUTAMIDE 125 MG Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S0176 NOCOV DEF SYSMAN Description: HYDROXYUREA 500 MG Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S0177 NOCOV DEF SYSMAN Description: LEVAMISOLE 50 MG Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S0178 NOCOV DEF SYSMAN Description: LOMUSTINE 10 MG Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,107 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- S0179 NOCOV DEF SYSMAN Description: MEGESTROL 20 MG Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S0182 NOCOV DEF SYSMAN Description: PROCARBAZINE, ORAL Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S0183 NOCOV DEF SYSMAN Description: PROCHLORPERAZINE 5 MG Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S0187 NOCOV DEF SYSMAN Description: TAMOXIFEN 10 MG Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S0189 NOCOV DEF SYSMAN Description: TESTOSTERONE PELLET 75 MG Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S0190 DRUG DEF MAXFEE 12/10/2021 70.35 0.0 0-3 Description: MIFEPRISTONE, ORAL, 200 MG Category: Drugs CMS Add: 01/01/2001 CMS Term: S0191 DRUG DEF MAXFEE 12/10/2021 0.88 0.0 Description: MISOPROSTOL, ORAL, 200 MCG Category: Drugs CMS Add: 01/01/2001 CMS Term: S0194 NOCOV DEF SYSMAN Description: VITAMIN SUPPL 100 CAPS Category: Non Covered Services CMS Add: 04/01/2004 CMS Term: S0197 NOCOV DEF SYSMAN Description: PRENATAL VITAMINS 30 DAY Category: Non Covered Services CMS Add: 04/01/2005 CMS Term: S0199 NOCOV DEF SYSMAN Description: MED ABORTION INC ALL EX DRUG Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: S0201 NOCOV DEF SYSMAN Description: PARTIAL HOSPITALIZATION SERV Category: Non Covered Services CMS Add: 10/01/2002 CMS Term: S0207 NOCOV DEF SYSMAN Description: PARAMEDICINTERCEP NONHOSPALS Category: Non Covered Services CMS Add: 10/01/2002 CMS Term: S0208 NOCOV DEF SYSMAN Description: PARAMED INTRCEPT NONVOL Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S0209 NOCOV DEF SYSMAN Description: WC VAN MILEAGE PER MI Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S0215 NOCOV DEF SYSMAN Description: NONEMERG TRANSP MILEAGE Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S0220 NOCOV DEF SYSMAN Description: MEDICAL CONFERENCE BY PHYSIC Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,108 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- S0221 NOCOV DEF SYSMAN Description: MEDICAL CONFERENCE, 60 MIN Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: S0250 NOCOV DEF SYSMAN Description: COMP GERIATR ASSMT TEAM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S0255 NOCOV DEF SYSMAN Description: HOSPICE REFER VISIT NONMD Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S0257 NOCOV DEF SYSMAN Description: END OF LIFE COUNSELING Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: S0260 NOCOV DEF SYSMAN Description: H&P FOR SURGERY Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S0265 NOCOV DEF SYSMAN Description: GENETIC COUNSEL 15 MINS Category: Non Covered Services CMS Add: 07/01/2005 CMS Term: S0270 NOCOV DEF SYSMAN Description: HOME STD CASE RATE 30 DAYS Category: Non Covered Services CMS Add: 04/01/2007 CMS Term: S0271 NOCOV DEF SYSMAN Description: HOME HOSPICE CASE 30 DAYS Category: Non Covered Services CMS Add: 04/01/2007 CMS Term: S0272 NOCOV DEF SYSMAN Description: HOME EPISODIC CASE 30 DAYS Category: Non Covered Services CMS Add: 04/01/2007 CMS Term: S0273 NOCOV DEF SYSMAN Description: MD HOME VISIT OUTSIDE CAP Category: Non Covered Services CMS Add: 04/01/2007 CMS Term: S0274 NOCOV DEF SYSMAN Description: NURSE PRACTR VISIT OUTS CAP Category: Non Covered Services CMS Add: 04/01/2007 CMS Term: S0280 NOCOV DEF SYSMAN Description: MEDICAL HOME, INITIAL PLAN Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: S0281 NOCOV DEF SYSMAN Description: MEDICAL HOME, MAINTENANCE Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: S0285 NOCOV DEF SYSMAN Description: CNSLT BEFORE SCREEN COLONOSC Category: Non Covered Services CMS Add: 07/01/2016 CMS Term: S0302 NOCOV DEF SYSMAN Description: COMPLETED EPSDT Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S0310 NOCOV DEF SYSMAN Description: HOSPITALIST VISIT Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,109 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- S0311 NOCOV DEF SYSMAN Description: COMP MGMT CARE COORD ADV ILL Category: Non Covered Services CMS Add: 07/01/2016 CMS Term: S0315 NOCOV DEF SYSMAN Description: DISEASE MANAGEMENT PROGRAM Category: Non Covered Services CMS Add: 10/01/2002 CMS Term: S0316 NOCOV DEF SYSMAN Description: FOLLOW-UP/REASSESSMENT Category: Non Covered Services CMS Add: 10/01/2002 CMS Term: S0317 NOCOV DEF SYSMAN Description: DISEASE MGMT PER DIEM Category: Non Covered Services CMS Add: 07/01/2003 CMS Term: S0320 NOCOV DEF SYSMAN Description: RN TELEPHONE CALLS TO DMP Category: Non Covered Services CMS Add: 10/01/2002 CMS Term: S0340 NOCOV DEF SYSMAN Description: LIFESTYLE MOD 1ST STAGE Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S0341 NOCOV DEF SYSMAN Description: LIFESTYLE MOD 2 OR 3 STAGE Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S0342 NOCOV DEF SYSMAN Description: LIFESTYLE MOD 4TH STAGE Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S0353 NOCOV DEF SYSMAN Description: CANCER TREATMENTPLAN INITIAL Category: Non Covered Services CMS Add: 04/01/2012 CMS Term: S0354 NOCOV DEF SYSMAN Description: CANCER TREATMENT PLAN CHANGE Category: Non Covered Services CMS Add: 04/01/2012 CMS Term: S0390 NOCOV DEF SYSMAN Description: ROUT FOOT CARE PER VISIT Category: Non Covered Services CMS Add: 04/01/2002 CMS Term: S0395 NOCOV DEF SYSMAN Description: IMPRESSION CASTING FT Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S0400 NOCOV DEF SYSMAN Description: GLOBAL ESWL KIDNEY Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S0500 NOCOV DEF SYSMAN Description: DISPOS CONT LENS Category: Non Covered Services CMS Add: 07/01/2001 CMS Term: S0504 NOCOV DEF SYSMAN Description: SINGL PRSCRP LENS Category: Non Covered Services CMS Add: 07/01/2001 CMS Term: S0506 NOCOV DEF SYSMAN Description: BIFOC PRSCP LENS Category: Non Covered Services CMS Add: 07/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,110 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- S0508 NOCOV DEF SYSMAN Description: TRIFOC PRSCRP LENS Category: Non Covered Services CMS Add: 07/01/2001 CMS Term: S0510 NOCOV DEF SYSMAN Description: NON-PRSCRP LENS Category: Non Covered Services CMS Add: 07/01/2001 CMS Term: S0512 NOCOV DEF SYSMAN Description: DAILY CONT LENS Category: Non Covered Services CMS Add: 07/01/2001 CMS Term: S0514 NOCOV DEF SYSMAN Description: COLOR CONT LENS Category: Non Covered Services CMS Add: 07/01/2001 CMS Term: S0515 NOCOV DEF SYSMAN Description: SCLERAL LENS LIQUID BANDAGE Category: Non Covered Services CMS Add: 10/01/2004 CMS Term: S0516 NOCOV DEF SYSMAN Description: SAFETY FRAMES Category: Non Covered Services CMS Add: 07/01/2001 CMS Term: S0518 NOCOV DEF SYSMAN Description: SUNGLASS FRAMES Category: Non Covered Services CMS Add: 07/01/2001 CMS Term: S0580 NOCOV DEF SYSMAN Description: POLYCARB LENS Category: Non Covered Services CMS Add: 07/01/2001 CMS Term: S0581 NOCOV DEF SYSMAN Description: NONSTND LENS Category: Non Covered Services CMS Add: 07/01/2001 CMS Term: S0590 NOCOV DEF SYSMAN Description: MISC INTEGRAL LENS SERV Category: Non Covered Services CMS Add: 07/01/2001 CMS Term: S0592 NOCOV DEF SYSMAN Description: COMP CONT LENS EVAL Category: Non Covered Services CMS Add: 07/01/2001 CMS Term: S0595 NOCOV DEF SYSMAN Description: NEW LENSES IN PTS OLD FRAME Category: Non Covered Services CMS Add: 04/01/2005 CMS Term: S0596 NOCOV DEF SYSMAN Description: PHAKIC IOL REFRACTIVE ERROR Category: Non Covered Services CMS Add: 04/01/2012 CMS Term: S0601 NOCOV DEF SYSMAN Description: SCREENING PROCTOSCOPY Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S0610 NOCOV DEF SYSMAN Description: ANNUAL GYNECOLOGICAL EXAMINA Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S0612 NOCOV DEF SYSMAN Description: ANNUAL GYNECOLOGICAL EXAMINA Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,111 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- S0613 MEDSV DEF MAXFEE 01/01/2024 32.34 0.0 Description: ANN BREAST EXAM Category: Medical Services CMS Add: 07/01/2005 CMS Term: S0618 AUDIO DEF BILL90 Description: AUDIOMETRY FOR HEARING AID Category: Audiology CMS Add: 04/01/2004 CMS Term: S0620 NOCOV DEF SYSMAN Description: ROUTINE OPHTHALMOLOGICAL EXA Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S0621 NOCOV DEF SYSMAN Description: ROUTINE OPHTHALMOLOGICAL EXA Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S0622 NOCOV DEF SYSMAN Description: PHYS EXAM FOR COLLEGE Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S0630 NOCOV DEF SYSMAN Description: REMOVAL OF SUTURES Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: S0800 NOCOV DEF SYSMAN Description: LASER IN SITU KERATOMILEUSIS Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S0810 NOCOV DEF SYSMAN Description: PHOTOREFRACTIVE KERATECTOMY Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S0812 NOCOV DEF SYSMAN Description: PHOTOTHERAP KERATECT Category: Non Covered Services CMS Add: 07/01/2001 CMS Term: S1001 NOCOV DEF SYSMAN Description: DELUXE ITEM Category: Non Covered Services CMS Add: 07/01/2001 CMS Term: S1002 NOCOV DEF SYSMAN Description: CUSTOM ITEM Category: Non Covered Services CMS Add: 07/01/2001 CMS Term: S1015 NOCOV DEF SYSMAN Description: IV TUBING EXTENSION SET Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: S1016 NOCOV DEF SYSMAN Description: NON-PVC INTRAVENOUS ADMINIST Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: S1030 MDSPY DEF SYSMAN Y Description: GLUC MONITOR PURCHASE Category: Medical Supplies CMS Add: 01/01/2002 CMS Term: S1031 NOCOV DEF SYSMAN Description: GLUC MONITOR RENTAL Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S1034 NOCOV DEF SYSMAN Description: ART PANCREAS SYSTEM Category: Non Covered Services CMS Add: 07/01/2014 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,112 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- S1035 NOCOV DEF SYSMAN Description: ART PANCREAS INV DISP SENSOR Category: Non Covered Services CMS Add: 07/01/2014 CMS Term: S1036 NOCOV DEF SYSMAN Description: ART PANCREAS EXT TRANSMITTER Category: Non Covered Services CMS Add: 07/01/2014 CMS Term: S1037 NOCOV DEF SYSMAN Description: ART PANCREAS EXT RECEIVER Category: Non Covered Services CMS Add: 07/01/2014 CMS Term: S1040 MEDSV DEF MAXFEE 01/01/2014 12/31/2023 1480.11 0.0 Y Description: CRANIAL REMOLDING ORTHOSIS Category: Medical Services CMS Add: 10/01/2002 CMS Term: S1040 MEDSV DEF MAXFEE 01/01/2024 1918.22 0.0 Y Description: CRANIAL REMOLDING ORTHOSIS Category: Medical Services CMS Add: 10/01/2002 CMS Term: S1091 NOCOV DEF SYSMAN Description: STENT NON-CORONARY PROPEL Category: Non Covered Services CMS Add: 04/01/2021 CMS Term: S2053 NOCOV DEF SYSMAN Description: TRANSPLANTATION OF SMALL INT Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S2054 NOCOV DEF SYSMAN Description: TRANSPLANTATION OF MULTIVISC Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S2055 NOCOV DEF SYSMAN Description: HARVESTING OF DONOR MULTIVIS Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S2060 NOCOV DEF SYSMAN Description: LOBAR LUNG TRANSPLANTATION Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: S2061 NOCOV DEF SYSMAN Description: DONOR LOBECTOMY (LUNG) Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: S2065 NOCOV DEF SYSMAN Description: SIMULT PANC KIDN TRANS Category: Non Covered Services CMS Add: 07/01/2001 CMS Term: S2066 MEDSV DEF BILL90 Y Y Description: BREAST GAP FLAP RECONST Category: Medical Services CMS Add: 07/01/2007 CMS Term: S2067 MEDSV DEF BILL90 Y Y Description: BREAST "STACKED" DIEP/GAP Category: Medical Services CMS Add: 07/01/2007 CMS Term: S2068 MEDSV DEF BILL90 Y Y Description: BREAST DIEP OR SIEA FLAP Category: Medical Services CMS Add: 01/01/2006 CMS Term: S2070 MEDSV DEF BILL90 Description: CYSTO LASER TX URETERAL CALC Category: Medical Services CMS Add: 10/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,113 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- S2079 MEDSV DEF MAXFEE 01/01/2024 348.13 0.0 Description: LAP ESOPHAGOMYOTOMY Category: Medical Services CMS Add: 01/01/2006 CMS Term: S2080 NOCOV DEF SYSMAN Description: LAUP Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S2083 MEDSV DEF BILL90 Description: ADJUSTMENT GASTRIC BAND Category: Medical Services CMS Add: 04/01/2004 CMS Term: S2095 MEDSV DEF BILL90 Description: TRANSCATH EMBOLIZ MICROSPHER Category: Medical Services CMS Add: 01/01/2004 CMS Term: S2102 NOCOV DEF SYSMAN Description: ISLET CELL TISSUE TRANSPLANT Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: S2103 NOCOV DEF SYSMAN Description: ADRENAL TISSUE TRANSPLANT Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: S2107 NOCOV DEF SYSMAN Description: ADOPTIVE IMMUNOTHERAPY Category: Non Covered Services CMS Add: 04/01/2002 CMS Term: S2112 NOCOV DEF SYSMAN Description: KNEE ARTHROSCP HARV Category: Non Covered Services CMS Add: 07/01/2001 CMS Term: S2115 NOCOV DEF SYSMAN Description: PERIACETABULAR OSTEOTOMY Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S2117 MEDSV DEF BILL90 Description: ARTHROEREISIS, SUBTALAR Category: Medical Services CMS Add: 10/01/2005 CMS Term: S2118 MEDSV DEF BILL90 Y Description: TOTAL HIP RESURFACING Category: Medical Services CMS Add: 10/01/2008 CMS Term: S2120 NOCOV DEF SYSMAN Description: LOW DENSITY LIPOPROTEIN(LDL) Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: S2140 NOCOV DEF SYSMAN Description: CORD BLOOD HARVESTING Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: S2142 NOCOV DEF SYSMAN Description: CORD BLOOD-DERIVED STEM-CELL Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: S2150 NOCOV DEF SYSMAN Description: BMT HARV/TRANSPL 28D PKG Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S2152 NOCOV DEF SYSMAN Description: SOLID ORGAN TRANSPL PKG Category: Non Covered Services CMS Add: 04/01/2004 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,114 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- S2202 NOCOV DEF SYSMAN Description: ECHOSCLEROTHERAPY Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: S2205 NOCOV DEF SYSMAN Description: MINIMALLY INVASIVE DIRECT CO Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S2206 NOCOV DEF SYSMAN Description: MINIMALLY INVASIVE DIRECT CO Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S2207 NOCOV DEF SYSMAN Description: MINIMALLY INVASIVE DIRECT CO Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S2208 NOCOV DEF SYSMAN Description: MINIMALLY INVASIVE DIRECT CO Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S2209 NOCOV DEF SYSMAN Description: MINIMALLY INVASIVE DIRECT CO Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S2225 MEDSV DEF BILL90 Y Description: MYRINGOTOMY LASER-ASSIST Category: Medical Services CMS Add: 01/01/2004 CMS Term: S2230 NOCOV DEF SYSMAN Description: IMPLANT SEMI-IMP HEAR Category: Non Covered Services CMS Add: 10/01/2003 CMS Term: S2235 MEDSV DEF BILL90 Y 12-999years Description: IMPLANT AUDITORY BRAIN IMP Category: Medical Services CMS Add: 10/01/2003 CMS Term: S2260 NOCOV DEF SYSMAN Description: INDUCED ABORTION 17-24 WEEKS Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S2265 NOCOV DEF SYSMAN Description: INDUCED ABORTION 25-28 WKS Category: Non Covered Services CMS Add: 10/01/2002 CMS Term: S2266 NOCOV DEF SYSMAN Description: INDUCED ABORTION 29-31 WKS Category: Non Covered Services CMS Add: 10/01/2002 CMS Term: S2267 NOCOV DEF SYSMAN Description: INDUCED ABORTION 32 OR MORE Category: Non Covered Services CMS Add: 10/01/2002 CMS Term: S2300 NOCOV DEF SYSMAN Description: ARTHROSCOPY, SHOULDER, SURGI Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S2325 MEDSV DEF MAXFEE 01/01/2024 1114.73 0.0 Description: HIP CORE DECOMPRESSION Category: Medical Services CMS Add: 10/01/2006 CMS Term: S2340 NOCOV DEF SYSMAN Description: CHEMODENERVATION OF ABDUCTOR Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,115 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- S2341 NOCOV DEF SYSMAN Description: CHEMODENERV ADDUCT VOCAL Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S2342 NOCOV DEF SYSMAN Description: NASAL ENDOSCOP PO DEBRID Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S2348 MEDSV DEF BILL90 Y Description: DECOMPRESS DISC RF LUMBAR Category: Medical Services CMS Add: 01/01/2005 CMS Term: S2350 NOCOV DEF SYSMAN Description: DISKECTOMY, ANTERIOR, WITH D Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S2351 NOCOV DEF SYSMAN Description: DISKECTOMY, ANTERIOR, WITH D Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S2400 MEDSV DEF BILL90 Y Description: FETAL SURG CONGEN HERNIA Category: Medical Services CMS Add: 01/01/2002 CMS Term: S2401 NOCOV DEF SYSMAN Description: FETAL SURG URIN TRAC OBSTR Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S2402 NOCOV DEF SYSMAN Description: FETAL SURG CONG CYST MALF Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S2403 NOCOV DEF SYSMAN Description: FETAL SURG PULMON SEQUEST Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S2404 NOCOV DEF SYSMAN Description: FETAL SURG MYELOMENINGO Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S2405 NOCOV DEF SYSMAN Description: FETAL SURG SACROCOC TERATOMA Category: Non Covered Services CMS Add: 04/01/2002 CMS Term: S2409 NOCOV DEF SYSMAN Description: FETAL SURG NOC Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S2411 NOCOV DEF SYSMAN Description: FETOSCOP LASER THER TTTS Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S2900 NOCOV DEF SYSMAN Description: ROBOTIC SURGICAL SYSTEM Category: Non Covered Services CMS Add: 07/01/2005 CMS Term: S3000 NOCOV DEF SYSMAN Description: BILAT DIL RETINAL EXAM Category: Non Covered Services CMS Add: 04/01/2003 CMS Term: S3005 NOCOV DEF SYSMAN Description: EVAL SELF-ASSESS DEPRESSION Category: Non Covered Services CMS Add: 04/01/2005 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,116 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- S3600 NOCOV DEF SYSMAN Description: STAT LAB Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S3601 NOCOV DEF SYSMAN Description: STAT LAB HOME/NF Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S3620 NOCOV DEF SYSMAN Description: NEWBORN METABOLIC SCREENING Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: S3625 NOCOV DEF SYSMAN Description: MATERNAL TRIPLE SCREEN TEST Category: Non Covered Services CMS Add: 07/01/2003 CMS Term: 12/31/2013 S3630 NOCOV DEF SYSMAN Description: EOSINOPHIL BLOOD COUNT Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S3645 NOCOV DEF SYSMAN Description: HIV-1 ANTIBODY TESTING OF OR Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S3650 NOCOV DEF SYSMAN Description: SALIVA TEST, HORMONE LEVEL; Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S3652 NOCOV DEF SYSMAN Description: SALIVA TEST, HORMONE LEVEL; Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S3655 NOCOV DEF SYSMAN Description: ANTISPERM ANTIBODIES TEST Category: Non Covered Services CMS Add: 10/01/2002 CMS Term: S3708 NOCOV DEF SYSMAN Description: GASTROINTESTINAL FAT ABSORPT Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: S3722 NOCOV DEF SYSMAN Description: DOSE OPTIMIZATION AUC - 5FU Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: S3800 NOCOV DEF SYSMAN Description: GENETIC TESTING ALS Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: S3833 NOCOV DEF SYSMAN Description: COMP APC SEQUENCE Category: Non Covered Services CMS Add: 04/01/2003 CMS Term: 12/31/2013 S3834 NOCOV DEF SYSMAN Description: SING MUTATION APC Category: Non Covered Services CMS Add: 04/01/2003 CMS Term: 12/31/2013 S3840 NOCOV DEF SYSMAN Description: DNA ANALYSIS RET-ONCOGENE Category: Non Covered Services CMS Add: 07/01/2003 CMS Term: S3841 NOCOV DEF SYSMAN Description: GENE TEST RETINOBLASTOMA Category: Non Covered Services CMS Add: 07/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,117 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- S3842 LAB DEF BILL90 Y Description: GENE TEST HIPPEL-LINDAU Category: Laboratory CMS Add: 07/01/2003 CMS Term: S3844 LAB DEF BILL90 Y Description: DNA ANALYSIS DEAFNESS Category: Laboratory CMS Add: 07/01/2003 CMS Term: S3845 NOCOV DEF SYSMAN Description: GENE TEST ALPHA-THALASSEMIA Category: Non Covered Services CMS Add: 07/01/2003 CMS Term: S3846 LAB DEF BILL90 Y Description: GENE TEST BETA-THALASSEMIA Category: Laboratory CMS Add: 07/01/2003 CMS Term: S3849 NOCOV DEF SYSMAN Description: GENE TEST NIEMANN-PICK Category: Non Covered Services CMS Add: 07/01/2003 CMS Term: S3850 LAB DEF BILL90 Y Description: GENE TEST SICKLE CELL Category: Laboratory CMS Add: 07/01/2003 CMS Term: S3852 NOCOV DEF SYSMAN Description: DNA ANALYSIS APOE ALZHEIMER Category: Non Covered Services CMS Add: 07/01/2003 CMS Term: S3853 LAB DEF BILL90 Y Description: GENE TEST MYO MUSCLR DYST Category: Laboratory CMS Add: 01/01/2004 CMS Term: S3854 NOCOV DEF SYSMAN Description: GENE PROFILE PANEL BREAST Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: S3861 LAB DEF BILL90 Y Description: GENETIC TEST BRUGADA Category: Laboratory CMS Add: 10/01/2008 CMS Term: S3865 LAB DEF BILL90 Y Description: COMP GENET TEST HYP CARDIOMY Category: Laboratory CMS Add: 04/01/2009 CMS Term: S3866 LAB DEF BILL90 Y Description: SPEC GENE TEST HYP CARDIOMY Category: Laboratory CMS Add: 04/01/2009 CMS Term: S3870 NOCOV DEF SYSMAN Description: CGH TEST DEVELOPMENTAL DELAY Category: Non Covered Services CMS Add: 04/01/2009 CMS Term: S3900 NOCOV DEF SYSMAN Description: SURFACE EMG Category: Non Covered Services CMS Add: 07/01/2001 CMS Term: S3902 NOCOV DEF SYSMAN Description: BALLISTOCARDIOGRAM Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: S3904 NOCOV DEF SYSMAN Description: MASTERS TWO STEP Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,118 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- S4005 MEDSV DEF MAXFEE 01/01/2024 354.65 0.0 Description: INTERIM LABOR FACILITY GLOBA Category: Medical Services CMS Add: 04/01/2002 CMS Term: S4005 MEDSV DEF MAXFEE 02/01/2012 12/31/2023 273.65 0.0 Description: INTERIM LABOR FACILITY GLOBA Category: Medical Services CMS Add: 04/01/2002 CMS Term: S4011 NOCOV DEF SYSMAN Description: IVF PACKAGE Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S4013 NOCOV DEF SYSMAN Description: COMPL GIFT CASE RATE Category: Non Covered Services CMS Add: 04/01/2002 CMS Term: S4014 NOCOV DEF SYSMAN Description: COMPL ZIFT CASE RATE Category: Non Covered Services CMS Add: 04/01/2002 CMS Term: S4015 NOCOV DEF SYSMAN Description: COMPLETE IVF NOS CASE RATE Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S4016 NOCOV DEF SYSMAN Description: FROZEN IVF CASE RATE Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S4017 NOCOV DEF SYSMAN Description: IVF CANC A STIM CASE RATE Category: Non Covered Services CMS Add: 04/01/2002 CMS Term: S4018 NOCOV DEF SYSMAN Description: F EMB TRNS CANC CASE RATE Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S4020 NOCOV DEF SYSMAN Description: IVF CANC A ASPIR CASE RATE Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S4021 NOCOV DEF SYSMAN Description: IVF CANC P ASPIR CASE RATE Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S4022 NOCOV DEF SYSMAN Description: ASST OOCYTE FERT CASE RATE Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S4023 NOCOV DEF SYSMAN Description: INCOMPL DONOR EGG CASE RATE Category: Non Covered Services CMS Add: 04/01/2002 CMS Term: S4025 NOCOV DEF SYSMAN Description: DONOR SERV IVF CASE RATE Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S4026 NOCOV DEF SYSMAN Description: PROCURE DONOR SPERM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S4027 NOCOV DEF SYSMAN Description: STORE PREV FROZ EMBRYOS Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,119 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- S4028 NOCOV DEF SYSMAN Description: MICROSURG EPI SPERM ASP Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S4030 NOCOV DEF SYSMAN Description: SPERM PROCURE INIT VISIT Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S4031 NOCOV DEF SYSMAN Description: SPERM PROCURE SUBS VISIT Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S4035 NOCOV DEF SYSMAN Description: STIMULATED IUI CASE RATE Category: Non Covered Services CMS Add: 04/01/2002 CMS Term: S4037 NOCOV DEF SYSMAN Description: CRYO EMBRYO TRANSF CASE RATE Category: Non Covered Services CMS Add: 04/01/2002 CMS Term: S4040 NOCOV DEF SYSMAN Description: MONIT STORE CRYO EMBRYO 30 D Category: Non Covered Services CMS Add: 04/01/2002 CMS Term: S4042 NOCOV DEF SYSMAN Description: OVULATION MGMT PER CYCLE Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: S4981 NOCOV DEF SYSMAN Description: INSERT LEVONORGESTREL IUS Category: Non Covered Services CMS Add: 07/01/2001 CMS Term: S4989 NOCOV DEF SYSMAN Description: CONTRACEPT IUD Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S4990 NOCOV DEF SYSMAN Description: NICOTINE PATCH LEGEND Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S4991 NOCOV DEF SYSMAN Description: NICOTINE PATCH NONLEGEND Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S4993 MEDSV DEF SYSMAN Description: CONTRACEPTIVE PILLS FOR BC Category: Medical Services CMS Add: 04/01/2002 CMS Term: S4995 NOCOV DEF SYSMAN Description: SMOKING CESSATION GUM Category: Non Covered Services CMS Add: 04/01/2002 CMS Term: S5000 NOCOV DEF SYSMAN Description: PRESCRIPTION DRUG, GENERIC Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: S5001 NOCOV DEF SYSMAN Description: PRESCRIPTION DRUG,BRAND NAME Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: S5010 NOCOV DEF SYSMAN Description: 5% DEXTROSE AND 0.45% SALINE Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,120 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- S5012 NOCOV DEF SYSMAN Description: 5% DEXTROSE WITH POTASSIUM Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: S5013 NOCOV DEF SYSMAN Description: 5%DEXTROSE/0.45%SALINE1000ML Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: S5014 NOCOV DEF SYSMAN Description: D5W/0.45NS W KCL AND MGS04 Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: S5035 NOCOV DEF SYSMAN Description: HIT ROUTINE DEVICE MAINT Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S5036 NOCOV DEF SYSMAN Description: HIT DEVICE REPAIR Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S5100 U1 U5 U7 DDWA WDD MAXFEE 07/01/2021 06/30/2023 1.65 0.0 Y 18-999years Description: ADULT DAYCARE SERVICES 15MIN Category: CIH Waiver CMS Add: 01/01/2003 CMS Term: S5100 U1 U5 U7 DDWA WDD MAXFEE 07/01/2023 2.93 0.0 Y 18-999years Description: ADULT DAYCARE SERVICES 15MIN Category: CIH Waiver CMS Add: 01/01/2003 CMS Term: S5100 U1 U5 U7 MFPCI W3M MAXFEE 07/01/2021 06/30/2023 1.65 0.0 Y 18-999years Description: ADULT DAYCARE SERVICES 15MIN Category: MFP CIH Waiver CMS Add: 01/01/2003 CMS Term: S5100 U1 U5 U7 MFPCI W3M MAXFEE 07/01/2023 2.93 0.0 Y 18-999years Description: ADULT DAYCARE SERVICES 15MIN Category: MFP CIH Waiver CMS Add: 01/01/2003 CMS Term: S5100 U1 U5 U7 MFPTS W5M MAXFEE 07/01/2021 06/30/2023 1.65 0.0 Y Description: ADULT DAYCARE SERVICES 15MIN Category: MFP SOF Waiver CMS Add: 01/01/2003 CMS Term: S5100 U1 U5 U7 MFPTS W5M MAXFEE 07/01/2023 2.93 0.0 Y Description: ADULT DAYCARE SERVICES 15MIN Category: MFP SOF Waiver CMS Add: 01/01/2003 CMS Term: S5100 U1 U5 U7 SSFS WSS MAXFEE 07/01/2021 06/30/2023 1.65 0.0 Y 18-999years Description: ADULT DAYCARE SERVICES 15MIN Category: Family Support Waivr CMS Add: 01/01/2003 CMS Term: S5100 U1 U5 U7 SSFS WSS MAXFEE 07/01/2023 2.93 0.0 Y 18-999years Description: ADULT DAYCARE SERVICES 15MIN Category: Family Support Waivr CMS Add: 01/01/2003 CMS Term: S5100 U1 U7 ADWA WAD MAXFEE 02/01/2020 06/30/2023 2.64 0.0 Y Description: ADULT DAYCARE SERVICES 15MIN Category: A&D Waiver CMS Add: 01/01/2003 CMS Term: S5100 U1 U7 ADWA WAD MAXFEE 07/01/2023 2.93 0.0 Y Description: ADULT DAYCARE SERVICES 15MIN Category: A&D Waiver CMS Add: 01/01/2003 CMS Term: S5100 U1 U7 MFPAD W1M MAXFEE 02/01/2020 06/30/2023 2.64 0.0 Y Description: ADULT DAYCARE SERVICES 15MIN Category: MFP Demo Grant CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,121 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- S5100 U1 U7 MFPAD W1M MAXFEE 07/01/2023 2.93 0.0 Y Description: ADULT DAYCARE SERVICES 15MIN Category: MFP Demo Grant CMS Add: 01/01/2003 CMS Term: S5100 U1 U7 MFPTB W2M MAXFEE 02/01/2020 06/30/2023 2.64 0.0 Y Description: ADULT DAYCARE SERVICES 15MIN Category: MFP TBI CMS Add: 01/01/2003 CMS Term: S5100 U1 U7 MFPTB W2M MAXFEE 07/01/2023 2.93 0.0 Y Description: ADULT DAYCARE SERVICES 15MIN Category: MFP TBI CMS Add: 01/01/2003 CMS Term: S5100 U1 U7 TBIWA WTB MAXFEE 02/01/2020 06/30/2023 2.64 0.0 Y Description: ADULT DAYCARE SERVICES 15MIN Category: TBI Waiver CMS Add: 01/01/2003 CMS Term: S5100 U1 U7 TBIWA WTB MAXFEE 07/01/2023 2.93 0.0 Y Description: ADULT DAYCARE SERVICES 15MIN Category: TBI Waiver CMS Add: 01/01/2003 CMS Term: S5100 U1 U7 UC ADWA WAD MAXFEE 02/01/2020 06/30/2023 2.82 0.0 Y Description: ADULT DAYCARE SERVICES 15MIN Category: A&D Waiver CMS Add: 01/01/2003 CMS Term: S5100 U1 U7 UC ADWA WAD MAXFEE 07/01/2023 3.32 0.0 Y Description: ADULT DAYCARE SERVICES 15MIN Category: A&D Waiver CMS Add: 01/01/2003 CMS Term: S5100 U1 U7 UC MFPAD W1M MAXFEE 02/01/2020 06/30/2023 2.82 0.0 Y Description: ADULT DAYCARE SERVICES 15MIN Category: MFP Demo Grant CMS Add: 01/01/2003 CMS Term: S5100 U1 U7 UC MFPAD W1M MAXFEE 07/01/2023 3.32 0.0 Y Description: ADULT DAYCARE SERVICES 15MIN Category: MFP Demo Grant CMS Add: 01/01/2003 CMS Term: S5100 U1 U7 UC MFPTB W2M MAXFEE 02/01/2020 06/30/2023 2.82 0.0 Y Description: ADULT DAYCARE SERVICES 15MIN Category: MFP TBI CMS Add: 01/01/2003 CMS Term: S5100 U1 U7 UC MFPTB W2M MAXFEE 07/01/2023 3.32 0.0 Y Description: ADULT DAYCARE SERVICES 15MIN Category: MFP TBI CMS Add: 01/01/2003 CMS Term: S5100 U1 U7 UC TBIWA WTB MAXFEE 02/01/2020 06/30/2023 2.82 0.0 Y Description: ADULT DAYCARE SERVICES 15MIN Category: TBI Waiver CMS Add: 01/01/2003 CMS Term: S5100 U1 U7 UC TBIWA WTB MAXFEE 07/01/2023 3.32 0.0 Y Description: ADULT DAYCARE SERVICES 15MIN Category: TBI Waiver CMS Add: 01/01/2003 CMS Term: S5100 U2 U5 U7 DDWA WDD MAXFEE 07/01/2021 06/30/2023 2.15 0.0 Y 18-999years Description: ADULT DAYCARE SERVICES 15MIN Category: CIH Waiver CMS Add: 01/01/2003 CMS Term: S5100 U2 U5 U7 DDWA WDD MAXFEE 07/01/2023 3.30 0.0 Y 18-999years Description: ADULT DAYCARE SERVICES 15MIN Category: CIH Waiver CMS Add: 01/01/2003 CMS Term: S5100 U2 U5 U7 MFPCI W3M MAXFEE 07/01/2021 06/30/2023 2.15 0.0 Y 18-999years Description: ADULT DAYCARE SERVICES 15MIN Category: MFP CIH Waiver CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,122 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- S5100 U2 U5 U7 MFPCI W3M MAXFEE 07/01/2023 3.30 0.0 Y 18-999years Description: ADULT DAYCARE SERVICES 15MIN Category: MFP CIH Waiver CMS Add: 01/01/2003 CMS Term: S5100 U2 U5 U7 MFPTS W5M MAXFEE 07/01/2021 06/30/2023 2.15 0.0 Y Description: ADULT DAYCARE SERVICES 15MIN Category: MFP SOF Waiver CMS Add: 01/01/2003 CMS Term: S5100 U2 U5 U7 MFPTS W5M MAXFEE 07/01/2023 3.30 0.0 Y Description: ADULT DAYCARE SERVICES 15MIN Category: MFP SOF Waiver CMS Add: 01/01/2003 CMS Term: S5100 U2 U5 U7 SSFS WSS MAXFEE 07/01/2021 06/30/2023 2.15 0.0 Y 18-999years Description: ADULT DAYCARE SERVICES 15MIN Category: Family Support Waivr CMS Add: 01/01/2003 CMS Term: S5100 U2 U5 U7 SSFS WSS MAXFEE 07/01/2023 3.30 0.0 Y 18-999years Description: ADULT DAYCARE SERVICES 15MIN Category: Family Support Waivr CMS Add: 01/01/2003 CMS Term: S5100 U2 U7 ADWA WAD MAXFEE 02/01/2020 06/30/2023 3.18 0.0 Y Description: ADULT DAYCARE SERVICES 15MIN Category: A&D Waiver CMS Add: 01/01/2003 CMS Term: S5100 U2 U7 ADWA WAD MAXFEE 07/01/2023 3.30 0.0 Y Description: ADULT DAYCARE SERVICES 15MIN Category: A&D Waiver CMS Add: 01/01/2003 CMS Term: S5100 U2 U7 MFPAD W1M MAXFEE 02/01/2020 06/30/2023 3.18 0.0 Y Description: ADULT DAYCARE SERVICES 15MIN Category: MFP Demo Grant CMS Add: 01/01/2003 CMS Term: S5100 U2 U7 MFPAD W1M MAXFEE 07/01/2023 3.30 0.0 Y Description: ADULT DAYCARE SERVICES 15MIN Category: MFP Demo Grant CMS Add: 01/01/2003 CMS Term: S5100 U2 U7 MFPTB W2M MAXFEE 02/01/2020 06/30/2023 3.18 0.0 Y Description: ADULT DAYCARE SERVICES 15MIN Category: MFP TBI CMS Add: 01/01/2003 CMS Term: S5100 U2 U7 MFPTB W2M MAXFEE 07/01/2023 3.30 0.0 Y Description: ADULT DAYCARE SERVICES 15MIN Category: MFP TBI CMS Add: 01/01/2003 CMS Term: S5100 U2 U7 TBIWA WTB MAXFEE 02/01/2020 06/30/2023 3.18 0.0 Y Description: ADULT DAYCARE SERVICES 15MIN Category: TBI Waiver CMS Add: 01/01/2003 CMS Term: S5100 U2 U7 TBIWA WTB MAXFEE 07/01/2023 3.30 0.0 Y Description: ADULT DAYCARE SERVICES 15MIN Category: TBI Waiver CMS Add: 01/01/2003 CMS Term: S5100 U2 U7 UC ADWA WAD MAXFEE 02/01/2020 06/30/2023 3.40 0.0 Y Description: ADULT DAYCARE SERVICES 15MIN Category: A&D Waiver CMS Add: 01/01/2003 CMS Term: S5100 U2 U7 UC ADWA WAD MAXFEE 07/01/2023 3.74 0.0 Y Description: ADULT DAYCARE SERVICES 15MIN Category: A&D Waiver CMS Add: 01/01/2003 CMS Term: S5100 U2 U7 UC MFPAD W1M MAXFEE 02/01/2020 06/30/2023 3.40 0.0 Y Description: ADULT DAYCARE SERVICES 15MIN Category: MFP Demo Grant CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,123 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- S5100 U2 U7 UC MFPAD W1M MAXFEE 07/01/2023 3.74 0.0 Y Description: ADULT DAYCARE SERVICES 15MIN Category: MFP Demo Grant CMS Add: 01/01/2003 CMS Term: S5100 U2 U7 UC MFPTB W2M MAXFEE 02/01/2020 06/30/2023 3.40 0.0 Y Description: ADULT DAYCARE SERVICES 15MIN Category: MFP TBI CMS Add: 01/01/2003 CMS Term: S5100 U2 U7 UC MFPTB W2M MAXFEE 07/01/2023 3.74 0.0 Y Description: ADULT DAYCARE SERVICES 15MIN Category: MFP TBI CMS Add: 01/01/2003 CMS Term: S5100 U2 U7 UC TBIWA WTB MAXFEE 02/01/2020 06/30/2023 3.40 0.0 Y Description: ADULT DAYCARE SERVICES 15MIN Category: TBI Waiver CMS Add: 01/01/2003 CMS Term: S5100 U2 U7 UC TBIWA WTB MAXFEE 07/01/2023 3.74 0.0 Y Description: ADULT DAYCARE SERVICES 15MIN Category: TBI Waiver CMS Add: 01/01/2003 CMS Term: S5100 U3 U5 U7 DDWA WDD MAXFEE 07/01/2021 06/30/2023 2.57 0.0 Y 18-999years Description: ADULT DAYCARE SERVICES 15MIN Category: CIH Waiver CMS Add: 01/01/2003 CMS Term: S5100 U3 U5 U7 DDWA WDD MAXFEE 07/01/2023 4.20 0.0 Y 18-999years Description: ADULT DAYCARE SERVICES 15MIN Category: CIH Waiver CMS Add: 01/01/2003 CMS Term: S5100 U3 U5 U7 MFPCI W3M MAXFEE 07/01/2021 06/30/2023 2.57 0.0 Y 18-999years Description: ADULT DAYCARE SERVICES 15MIN Category: MFP CIH Waiver CMS Add: 01/01/2003 CMS Term: S5100 U3 U5 U7 MFPCI W3M MAXFEE 07/01/2023 4.20 0.0 Y 18-999years Description: ADULT DAYCARE SERVICES 15MIN Category: MFP CIH Waiver CMS Add: 01/01/2003 CMS Term: S5100 U3 U5 U7 MFPTS W5M MAXFEE 07/01/2021 06/30/2023 2.57 0.0 Y Description: ADULT DAYCARE SERVICES 15MIN Category: MFP SOF Waiver CMS Add: 01/01/2003 CMS Term: S5100 U3 U5 U7 MFPTS W5M MAXFEE 07/01/2023 4.20 0.0 Y Description: ADULT DAYCARE SERVICES 15MIN Category: MFP SOF Waiver CMS Add: 01/01/2003 CMS Term: S5100 U3 U5 U7 SSFS WSS MAXFEE 07/01/2021 06/30/2023 2.57 0.0 Y 18-999years Description: ADULT DAYCARE SERVICES 15MIN Category: Family Support Waivr CMS Add: 01/01/2003 CMS Term: S5100 U3 U5 U7 SSFS WSS MAXFEE 07/01/2023 4.20 0.0 Y 18-999years Description: ADULT DAYCARE SERVICES 15MIN Category: Family Support Waivr CMS Add: 01/01/2003 CMS Term: S5100 U3 U7 ADWA WAD MAXFEE 02/01/2020 06/30/2023 3.66 0.0 Y Description: ADULT DAYCARE SERVICES 15MIN Category: A&D Waiver CMS Add: 01/01/2003 CMS Term: S5100 U3 U7 ADWA WAD MAXFEE 07/01/2023 4.20 0.0 Y Description: ADULT DAYCARE SERVICES 15MIN Category: A&D Waiver CMS Add: 01/01/2003 CMS Term: S5100 U3 U7 MFPAD W1M MAXFEE 02/01/2020 06/30/2023 3.66 0.0 Y Description: ADULT DAYCARE SERVICES 15MIN Category: MFP Demo Grant CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,124 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- S5100 U3 U7 MFPAD W1M MAXFEE 07/01/2023 4.20 0.0 Y Description: ADULT DAYCARE SERVICES 15MIN Category: MFP Demo Grant CMS Add: 01/01/2003 CMS Term: S5100 U3 U7 MFPTB W2M MAXFEE 02/01/2020 06/30/2023 3.66 0.0 Y Description: ADULT DAYCARE SERVICES 15MIN Category: MFP TBI CMS Add: 01/01/2003 CMS Term: S5100 U3 U7 MFPTB W2M MAXFEE 07/01/2023 4.20 0.0 Y Description: ADULT DAYCARE SERVICES 15MIN Category: MFP TBI CMS Add: 01/01/2003 CMS Term: S5100 U3 U7 TBIWA WTB MAXFEE 02/01/2020 06/30/2023 3.66 0.0 Y Description: ADULT DAYCARE SERVICES 15MIN Category: TBI Waiver CMS Add: 01/01/2003 CMS Term: S5100 U3 U7 TBIWA WTB MAXFEE 07/01/2023 4.20 0.0 Y Description: ADULT DAYCARE SERVICES 15MIN Category: TBI Waiver CMS Add: 01/01/2003 CMS Term: S5100 U3 U7 UC ADWA WAD MAXFEE 02/01/2020 06/30/2023 3.91 0.0 Y Description: ADULT DAYCARE SERVICES 15MIN Category: A&D Waiver CMS Add: 01/01/2003 CMS Term: S5100 U3 U7 UC ADWA WAD MAXFEE 07/01/2023 4.76 0.0 Y Description: ADULT DAYCARE SERVICES 15MIN Category: A&D Waiver CMS Add: 01/01/2003 CMS Term: S5100 U3 U7 UC MFPAD W1M MAXFEE 02/01/2020 06/30/2023 3.91 0.0 Y Description: ADULT DAYCARE SERVICES 15MIN Category: MFP Demo Grant CMS Add: 01/01/2003 CMS Term: S5100 U3 U7 UC MFPAD W1M MAXFEE 07/01/2023 4.76 0.0 Y Description: ADULT DAYCARE SERVICES 15MIN Category: MFP Demo Grant CMS Add: 01/01/2003 CMS Term: S5100 U3 U7 UC MFPTB W2M MAXFEE 02/01/2020 06/30/2023 3.91 0.0 Y Description: ADULT DAYCARE SERVICES 15MIN Category: MFP TBI CMS Add: 01/01/2003 CMS Term: S5100 U3 U7 UC MFPTB W2M MAXFEE 07/01/2023 4.76 0.0 Y Description: ADULT DAYCARE SERVICES 15MIN Category: MFP TBI CMS Add: 01/01/2003 CMS Term: S5100 U3 U7 UC TBIWA WTB MAXFEE 02/01/2020 06/30/2023 3.91 0.0 Y Description: ADULT DAYCARE SERVICES 15MIN Category: TBI Waiver CMS Add: 01/01/2003 CMS Term: S5100 U3 U7 UC TBIWA WTB MAXFEE 07/01/2023 4.76 0.0 Y Description: ADULT DAYCARE SERVICES 15MIN Category: TBI Waiver CMS Add: 01/01/2003 CMS Term: S5101 U1 U5 U7 DDWA WDD MAXFEE 07/01/2021 06/30/2023 26.28 0.0 Y 18-999years 0-2 Description: ADULT DAY CARE PER HALF DAY Category: CIH Waiver CMS Add: 01/01/2003 CMS Term: S5101 U1 U5 U7 DDWA WDD MAXFEE 07/01/2023 37.18 0.0 Y 18-999years 0-2 Description: ADULT DAY CARE PER HALF DAY Category: CIH Waiver CMS Add: 01/01/2003 CMS Term: S5101 U1 U5 U7 MFPCI W3M MAXFEE 07/01/2021 06/30/2023 26.28 0.0 Y 18-999years 0-2 Description: ADULT DAY CARE PER HALF DAY Category: MFP CIH Waiver CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,125 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- S5101 U1 U5 U7 MFPCI W3M MAXFEE 07/01/2023 37.18 0.0 Y 18-999years 0-2 Description: ADULT DAY CARE PER HALF DAY Category: MFP CIH Waiver CMS Add: 01/01/2003 CMS Term: S5101 U1 U5 U7 MFPTS W5M MAXFEE 07/01/2021 06/30/2023 26.28 0.0 Y Description: ADULT DAY CARE PER HALF DAY Category: MFP SOF Waiver CMS Add: 01/01/2003 CMS Term: S5101 U1 U5 U7 MFPTS W5M MAXFEE 07/01/2023 37.18 0.0 Y Description: ADULT DAY CARE PER HALF DAY Category: MFP SOF Waiver CMS Add: 01/01/2003 CMS Term: S5101 U1 U5 U7 SSFS WSS MAXFEE 07/01/2021 06/30/2023 26.28 0.0 Y 18-999years 0-2 Description: ADULT DAY CARE PER HALF DAY Category: Family Support Waivr CMS Add: 01/01/2003 CMS Term: S5101 U1 U5 U7 SSFS WSS MAXFEE 07/01/2023 37.18 0.0 Y 18-999years 0-2 Description: ADULT DAY CARE PER HALF DAY Category: Family Support Waivr CMS Add: 01/01/2003 CMS Term: S5101 U2 U5 U7 DDWA WDD MAXFEE 07/01/2021 06/30/2023 34.47 0.0 Y 18-999years 0-2 Description: ADULT DAY CARE PER HALF DAY Category: CIH Waiver CMS Add: 01/01/2003 CMS Term: S5101 U2 U5 U7 DDWA WDD MAXFEE 07/01/2023 43.75 0.0 Y 18-999years 0-2 Description: ADULT DAY CARE PER HALF DAY Category: CIH Waiver CMS Add: 01/01/2003 CMS Term: S5101 U2 U5 U7 MFPCI W3M MAXFEE 07/01/2021 06/30/2023 34.47 0.0 Y 18-999years 0-2 Description: ADULT DAY CARE PER HALF DAY Category: MFP CIH Waiver CMS Add: 01/01/2003 CMS Term: S5101 U2 U5 U7 MFPCI W3M MAXFEE 07/01/2023 43.75 0.0 Y 18-999years 0-2 Description: ADULT DAY CARE PER HALF DAY Category: MFP CIH Waiver CMS Add: 01/01/2003 CMS Term: S5101 U2 U5 U7 MFPTS W5M MAXFEE 07/01/2021 06/30/2023 34.47 0.0 Y Description: ADULT DAY CARE PER HALF DAY Category: MFP SOF Waiver CMS Add: 01/01/2003 CMS Term: S5101 U2 U5 U7 MFPTS W5M MAXFEE 07/01/2023 43.75 0.0 Y Description: ADULT DAY CARE PER HALF DAY Category: MFP SOF Waiver CMS Add: 01/01/2003 CMS Term: S5101 U2 U5 U7 SSFS WSS MAXFEE 07/01/2021 06/30/2023 34.47 0.0 Y 18-999years 0-2 Description: ADULT DAY CARE PER HALF DAY Category: Family Support Waivr CMS Add: 01/01/2003 CMS Term: S5101 U2 U5 U7 SSFS WSS MAXFEE 07/01/2023 43.75 0.0 Y 18-999years 0-2 Description: ADULT DAY CARE PER HALF DAY Category: Family Support Waivr CMS Add: 01/01/2003 CMS Term: S5101 U3 U5 U7 DDWA WDD MAXFEE 07/01/2021 06/30/2023 41.04 0.0 Y 18-999years 0-2 Description: ADULT DAY CARE PER HALF DAY Category: CIH Waiver CMS Add: 01/01/2003 CMS Term: S5101 U3 U5 U7 DDWA WDD MAXFEE 07/01/2023 54.74 0.0 Y 18-999years 0-2 Description: ADULT DAY CARE PER HALF DAY Category: CIH Waiver CMS Add: 01/01/2003 CMS Term: S5101 U3 U5 U7 MFPCI W3M MAXFEE 07/01/2021 06/30/2023 41.04 0.0 Y 18-999years 0-2 Description: ADULT DAY CARE PER HALF DAY Category: MFP CIH Waiver CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,126 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- S5101 U3 U5 U7 MFPCI W3M MAXFEE 07/01/2023 54.74 0.0 Y 18-999years 0-2 Description: ADULT DAY CARE PER HALF DAY Category: MFP CIH Waiver CMS Add: 01/01/2003 CMS Term: S5101 U3 U5 U7 MFPTS W5M MAXFEE 07/01/2021 06/30/2023 41.04 0.0 Y Description: ADULT DAY CARE PER HALF DAY Category: MFP SOF Waiver CMS Add: 01/01/2003 CMS Term: S5101 U3 U5 U7 MFPTS W5M MAXFEE 07/01/2023 54.74 0.0 Y Description: ADULT DAY CARE PER HALF DAY Category: MFP SOF Waiver CMS Add: 01/01/2003 CMS Term: S5101 U3 U5 U7 SSFS WSS MAXFEE 07/01/2021 06/30/2023 41.04 0.0 Y 18-999years 0-2 Description: ADULT DAY CARE PER HALF DAY Category: Family Support Waivr CMS Add: 01/01/2003 CMS Term: S5101 U3 U5 U7 SSFS WSS MAXFEE 07/01/2023 54.74 0.0 Y 18-999years 0-2 Description: ADULT DAY CARE PER HALF DAY Category: Family Support Waivr CMS Add: 01/01/2003 CMS Term: S5101 UB AMHH WUB MAXFEE 10/01/2013 28.80 0.0 Y 19-999years Description: ADULT DAY CARE PER HALF DAY Category: Adult MNTL HLTH CMS Add: 01/01/2003 CMS Term: S5102 NOCOV DEF SYSMAN Description: ADULT DAY CARE PER DIEM Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: S5105 NOCOV DEF SYSMAN Description: CENTERBASED DAY CARE PERDIEM Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: S5108 NOCOV DEF SYSMAN Description: HOMECARE TRAIN PT 15 MIN Category: Non Covered Services CMS Add: 04/01/2003 CMS Term: S5109 NOCOV DEF SYSMAN Description: HOMECARE TRAIN PT SESSION Category: Non Covered Services CMS Add: 04/01/2003 CMS Term: S5110 NOCOV DEF SYSMAN Description: FAMILY HOMECARE TRAINING 15M Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: S5111 HA CMHW WHA MAXFEE 07/01/2013 500.00 0.0 Y 6-18years Description: FAMILY HOMECARE TRAIN/SESSIO Category: Child Mentl Hlth Wai CMS Add: 01/01/2003 CMS Term: S5111 U5 U7 DDWA WDD MAXFEE 07/16/2020 5000.00 0.0 Y Description: FAMILY HOMECARE TRAIN/SESSIO Category: CIH Waiver CMS Add: 01/01/2003 CMS Term: S5111 U5 U7 MFPCI W3M MAXFEE 07/16/2020 5000.00 0.0 Y Description: FAMILY HOMECARE TRAIN/SESSIO Category: MFP CIH Waiver CMS Add: 01/01/2003 CMS Term: S5111 U5 U7 MFPTS W5M MAXFEE 07/16/2020 5000.00 0.0 Y Description: FAMILY HOMECARE TRAIN/SESSIO Category: MFP SOF Waiver CMS Add: 01/01/2003 CMS Term: S5111 U5 U7 SSFS WSS MAXFEE 07/16/2020 5000.00 0.0 Y Description: FAMILY HOMECARE TRAIN/SESSIO Category: Family Support Waivr CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,127 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- S5111 U7 MFPTR W4M MAXFEE 10/01/2012 2000.00 0.0 Y Description: FAMILY HOMECARE TRAIN/SESSIO Category: MFP PRTF Waiver CMS Add: 01/01/2003 CMS Term: S5111 U7 PRTFW WPT MAXFEE 10/01/2012 2000.00 0.0 Y Description: FAMILY HOMECARE TRAIN/SESSIO Category: PRTF Trans Waiver CMS Add: 01/01/2003 CMS Term: S5115 NOCOV DEF SYSMAN Description: NONFAMILY HOMECARE TRAIN/15M Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: S5116 HA CMHW WHA MAXFEE 07/01/2013 500.00 0.0 Y 6-18years Description: NONFAMILY HC TRAIN/SESSION Category: Child Mentl Hlth Wai CMS Add: 01/01/2003 CMS Term: S5116 U5 U7 DDWA WDD MAXFEE 07/16/2020 5000.00 0.0 Y Description: NONFAMILY HC TRAIN/SESSION Category: CIH Waiver CMS Add: 01/01/2003 CMS Term: S5116 U5 U7 MFPCI W3M MAXFEE 07/16/2020 5000.00 0.0 Y Description: NONFAMILY HC TRAIN/SESSION Category: MFP CIH Waiver CMS Add: 01/01/2003 CMS Term: S5116 U5 U7 MFPTS W5M MAXFEE 07/16/2020 5000.00 0.0 Y Description: NONFAMILY HC TRAIN/SESSION Category: MFP SOF Waiver CMS Add: 01/01/2003 CMS Term: S5116 U5 U7 SSFS WSS MAXFEE 07/16/2020 5000.00 0.0 Y Description: NONFAMILY HC TRAIN/SESSION Category: Family Support Waivr CMS Add: 01/01/2003 CMS Term: S5116 U7 MFPTR W4M MAXFEE 10/01/2012 2000.00 0.0 Y Description: NONFAMILY HC TRAIN/SESSION Category: MFP PRTF Waiver CMS Add: 01/01/2003 CMS Term: S5116 U7 PRTFW WPT MAXFEE 10/01/2012 2000.00 0.0 Y Description: NONFAMILY HC TRAIN/SESSION Category: PRTF Trans Waiver CMS Add: 01/01/2003 CMS Term: S5120 NOCOV DEF SYSMAN Description: CHORE SERVICES PER 15 MIN Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: S5121 NOCOV DEF SYSMAN Description: CHORE SERVICES PER DIEM Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: S5125 ADWA DEF SYSMAN Y Description: ATTENDANT CARE SERVICE /15M Category: A&D Waiver CMS Add: 01/01/2003 CMS Term: S5125 MFPAD DEF SYSMAN Y Description: ATTENDANT CARE SERVICE /15M Category: MFP Demo Grant CMS Add: 01/01/2003 CMS Term: S5125 TU U1 U7 ADWA WAD MAXFEE 02/01/2020 1.81 0.0 Y Description: ATTENDANT CARE SERVICE /15M Category: A&D Waiver CMS Add: 01/01/2003 CMS Term: S5125 TU U1 U7 MFPAD W1M MAXFEE 02/01/2020 1.81 0.0 Y Description: ATTENDANT CARE SERVICE /15M Category: MFP Demo Grant CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,128 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- S5125 U1 U7 ADWA WAD MAXFEE 02/01/2020 06/30/2023 3.61 0.0 Y Description: ATTENDANT CARE SERVICE /15M Category: A&D Waiver CMS Add: 01/01/2003 CMS Term: S5125 U1 U7 ADWA WAD MAXFEE 07/01/2023 8.21 0.0 Y Description: ATTENDANT CARE SERVICE /15M Category: A&D Waiver CMS Add: 01/01/2003 CMS Term: S5125 U1 U7 MFPAD W1M MAXFEE 02/01/2020 06/30/2023 3.61 0.0 Y Description: ATTENDANT CARE SERVICE /15M Category: MFP Demo Grant CMS Add: 01/01/2003 CMS Term: S5125 U1 U7 MFPAD W1M MAXFEE 07/01/2023 8.21 0.0 Y Description: ATTENDANT CARE SERVICE /15M Category: MFP Demo Grant CMS Add: 01/01/2003 CMS Term: S5125 U7 ADWA WAD MAXFEE 02/01/2020 06/30/2023 4.05 0.0 Y Description: ATTENDANT CARE SERVICE /15M Category: A&D Waiver CMS Add: 01/01/2003 CMS Term: S5125 U7 ADWA WAD MAXFEE 07/01/2023 8.21 0.0 Y Description: ATTENDANT CARE SERVICE /15M Category: A&D Waiver CMS Add: 01/01/2003 CMS Term: S5125 U7 MFPAD W1M MAXFEE 02/01/2020 06/30/2023 4.05 0.0 Y Description: ATTENDANT CARE SERVICE /15M Category: MFP Demo Grant CMS Add: 01/01/2003 CMS Term: S5125 U7 MFPAD W1M MAXFEE 07/01/2023 8.21 0.0 Y Description: ATTENDANT CARE SERVICE /15M Category: MFP Demo Grant CMS Add: 01/01/2003 CMS Term: S5125 U7 MFPTB W2M MAXFEE 02/01/2020 06/30/2023 4.05 0.0 Y Description: ATTENDANT CARE SERVICE /15M Category: MFP TBI CMS Add: 01/01/2003 CMS Term: S5125 U7 MFPTB W2M MAXFEE 07/01/2023 8.21 0.0 Y Description: ATTENDANT CARE SERVICE /15M Category: MFP TBI CMS Add: 01/01/2003 CMS Term: S5125 U7 TBIWA WTB MAXFEE 02/01/2020 06/30/2023 4.05 0.0 Y Description: ATTENDANT CARE SERVICE /15M Category: TBI Waiver CMS Add: 01/01/2003 CMS Term: S5125 U7 TBIWA WTB MAXFEE 07/01/2023 8.21 0.0 Y Description: ATTENDANT CARE SERVICE /15M Category: TBI Waiver CMS Add: 01/01/2003 CMS Term: S5125 U7 UA ADWA WAD MAXFEE 02/01/2020 06/30/2023 5.82 0.0 Y Description: ATTENDANT CARE SERVICE /15M Category: A&D Waiver CMS Add: 01/01/2003 CMS Term: S5125 U7 UA ADWA WAD MAXFEE 07/01/2023 8.59 0.0 Y Description: ATTENDANT CARE SERVICE /15M Category: A&D Waiver CMS Add: 01/01/2003 CMS Term: S5125 U7 UA MFPAD W1M MAXFEE 02/01/2020 06/30/2023 5.82 0.0 Y Description: ATTENDANT CARE SERVICE /15M Category: MFP Demo Grant CMS Add: 01/01/2003 CMS Term: S5125 U7 UA MFPAD W1M MAXFEE 07/01/2023 8.59 0.0 Y Description: ATTENDANT CARE SERVICE /15M Category: MFP Demo Grant CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,129 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- S5125 U7 UA MFPTB W2M MAXFEE 02/01/2020 06/30/2023 5.82 0.0 Y Description: ATTENDANT CARE SERVICE /15M Category: MFP TBI CMS Add: 01/01/2003 CMS Term: S5125 U7 UA MFPTB W2M MAXFEE 07/01/2023 8.59 0.0 Y Description: ATTENDANT CARE SERVICE /15M Category: MFP TBI CMS Add: 01/01/2003 CMS Term: S5125 U7 UA TBIWA WTB MAXFEE 02/01/2020 06/30/2023 5.82 0.0 Y Description: ATTENDANT CARE SERVICE /15M Category: TBI Waiver CMS Add: 01/01/2003 CMS Term: S5125 U7 UA TBIWA WTB MAXFEE 07/01/2023 8.59 0.0 Y Description: ATTENDANT CARE SERVICE /15M Category: TBI Waiver CMS Add: 01/01/2003 CMS Term: S5125 U7 UA UC ADWA WAD MAXFEE 04/01/2021 06/30/2023 5.82 0.0 Y Description: ATTENDANT CARE SERVICE /15M Category: A&D Waiver CMS Add: 01/01/2003 CMS Term: S5125 U7 UA UC ADWA WAD MAXFEE 07/01/2023 8.59 0.0 Y Description: ATTENDANT CARE SERVICE /15M Category: A&D Waiver CMS Add: 01/01/2003 CMS Term: S5125 U7 UA UC MFPAD W1M MAXFEE 04/01/2021 06/30/2023 5.82 0.0 Y Description: ATTENDANT CARE SERVICE /15M Category: MFP Demo Grant CMS Add: 01/01/2003 CMS Term: S5125 U7 UA UC MFPAD W1M MAXFEE 07/01/2023 8.59 0.0 Y Description: ATTENDANT CARE SERVICE /15M Category: MFP Demo Grant CMS Add: 01/01/2003 CMS Term: S5125 U7 UA UC MFPTB W2M MAXFEE 04/01/2021 06/30/2023 5.82 0.0 Y Description: ATTENDANT CARE SERVICE /15M Category: MFP TBI CMS Add: 01/01/2003 CMS Term: S5125 U7 UA UC MFPTB W2M MAXFEE 07/01/2023 8.59 0.0 Y Description: ATTENDANT CARE SERVICE /15M Category: MFP TBI CMS Add: 01/01/2003 CMS Term: S5125 U7 UA UC TBIWA WTB MAXFEE 04/01/2021 06/30/2023 5.82 0.0 Y Description: ATTENDANT CARE SERVICE /15M Category: TBI Waiver CMS Add: 01/01/2003 CMS Term: S5125 U7 UA UC TBIWA WTB MAXFEE 07/01/2023 8.59 0.0 Y Description: ATTENDANT CARE SERVICE /15M Category: TBI Waiver CMS Add: 01/01/2003 CMS Term: S5126 NOCOV DEF SYSMAN Description: ATTENDANT CARE SERVICE /DIEM Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: S5130 U7 ADWA WAD MAXFEE 02/01/2020 06/30/2023 4.59 0.0 Y Description: HOMAKER SERVICE NOS PER 15M Category: A&D Waiver CMS Add: 01/01/2003 CMS Term: S5130 U7 ADWA WAD MAXFEE 07/01/2023 7.68 0.0 Y Description: HOMAKER SERVICE NOS PER 15M Category: A&D Waiver CMS Add: 01/01/2003 CMS Term: S5130 U7 MFPAD W1M MAXFEE 02/01/2020 06/30/2023 4.59 0.0 Y Description: HOMAKER SERVICE NOS PER 15M Category: MFP Demo Grant CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,130 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- S5130 U7 MFPAD W1M MAXFEE 07/01/2023 7.68 0.0 Y Description: HOMAKER SERVICE NOS PER 15M Category: MFP Demo Grant CMS Add: 01/01/2003 CMS Term: S5130 U7 MFPTB W2M MAXFEE 02/01/2020 06/30/2023 4.59 0.0 Y Description: HOMAKER SERVICE NOS PER 15M Category: MFP TBI CMS Add: 01/01/2003 CMS Term: S5130 U7 MFPTB W2M MAXFEE 07/01/2023 7.68 0.0 Y Description: HOMAKER SERVICE NOS PER 15M Category: MFP TBI CMS Add: 01/01/2003 CMS Term: S5130 U7 TBIWA WTB MAXFEE 02/01/2020 06/30/2023 4.59 0.0 Y Description: HOMAKER SERVICE NOS PER 15M Category: TBI Waiver CMS Add: 01/01/2003 CMS Term: S5130 U7 TBIWA WTB MAXFEE 07/01/2023 7.68 0.0 Y Description: HOMAKER SERVICE NOS PER 15M Category: TBI Waiver CMS Add: 01/01/2003 CMS Term: S5130 U7 UA ADWA WAD MAXFEE 02/01/2020 06/30/2023 4.99 0.0 Y Description: HOMAKER SERVICE NOS PER 15M Category: A&D Waiver CMS Add: 01/01/2003 CMS Term: S5130 U7 UA ADWA WAD MAXFEE 07/01/2023 7.93 0.0 Y Description: HOMAKER SERVICE NOS PER 15M Category: A&D Waiver CMS Add: 01/01/2003 CMS Term: S5130 U7 UA MFPAD W1M MAXFEE 02/01/2020 06/30/2023 4.99 0.0 Y Description: HOMAKER SERVICE NOS PER 15M Category: MFP Demo Grant CMS Add: 01/01/2003 CMS Term: S5130 U7 UA MFPAD W1M MAXFEE 07/01/2023 7.93 0.0 Y Description: HOMAKER SERVICE NOS PER 15M Category: MFP Demo Grant CMS Add: 01/01/2003 CMS Term: S5130 U7 UA MFPTB W2M MAXFEE 02/01/2020 06/30/2023 4.99 0.0 Y Description: HOMAKER SERVICE NOS PER 15M Category: MFP TBI CMS Add: 01/01/2003 CMS Term: S5130 U7 UA MFPTB W2M MAXFEE 07/01/2023 7.93 0.0 Y Description: HOMAKER SERVICE NOS PER 15M Category: MFP TBI CMS Add: 01/01/2003 CMS Term: S5130 U7 UA TBIWA WTB MAXFEE 02/01/2020 06/30/2023 4.99 0.0 Y Description: HOMAKER SERVICE NOS PER 15M Category: TBI Waiver CMS Add: 01/01/2003 CMS Term: S5130 U7 UA TBIWA WTB MAXFEE 07/01/2023 7.93 0.0 Y Description: HOMAKER SERVICE NOS PER 15M Category: TBI Waiver CMS Add: 01/01/2003 CMS Term: S5131 NOCOV DEF SYSMAN Description: HOMEMAKER SERVICE NOS /DIEM Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: S5135 NOCOV DEF SYSMAN Description: ADULT COMPANIONCARE PER 15M Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: S5136 NOCOV DEF SYSMAN Description: ADULT COMPANIONCARE PER DIEM Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,131 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- S5140 U1 U7 ADWA WAD MAXFEE 02/01/2020 06/30/2023 60.50 0.0 Y Description: ADULT FOSTER CARE PER DIEM Category: A&D Waiver CMS Add: 01/01/2003 CMS Term: S5140 U1 U7 ADWA WAD MAXFEE 07/01/2023 77.54 0.0 Y Description: ADULT FOSTER CARE PER DIEM Category: A&D Waiver CMS Add: 01/01/2003 CMS Term: S5140 U1 U7 MFPAD W1M MAXFEE 02/01/2020 06/30/2023 60.50 0.0 Y 18-999years Description: ADULT FOSTER CARE PER DIEM Category: MFP Demo Grant CMS Add: 01/01/2003 CMS Term: S5140 U1 U7 MFPAD W1M MAXFEE 07/01/2023 77.54 0.0 Y 18-999years Description: ADULT FOSTER CARE PER DIEM Category: MFP Demo Grant CMS Add: 01/01/2003 CMS Term: S5140 U2 U7 ADWA WAD MAXFEE 02/01/2020 06/30/2023 71.04 0.0 Y Description: ADULT FOSTER CARE PER DIEM Category: A&D Waiver CMS Add: 01/01/2003 CMS Term: S5140 U2 U7 ADWA WAD MAXFEE 07/01/2023 99.71 0.0 Y Description: ADULT FOSTER CARE PER DIEM Category: A&D Waiver CMS Add: 01/01/2003 CMS Term: S5140 U2 U7 MFPAD W1M MAXFEE 02/01/2020 06/30/2023 71.04 0.0 Y 18-999years Description: ADULT FOSTER CARE PER DIEM Category: MFP Demo Grant CMS Add: 01/01/2003 CMS Term: S5140 U2 U7 MFPAD W1M MAXFEE 07/01/2023 99.71 0.0 Y 18-999years Description: ADULT FOSTER CARE PER DIEM Category: MFP Demo Grant CMS Add: 01/01/2003 CMS Term: S5140 U3 U7 ADWA WAD MAXFEE 02/01/2020 06/30/2023 81.58 0.0 Y Description: ADULT FOSTER CARE PER DIEM Category: A&D Waiver CMS Add: 01/01/2003 CMS Term: S5140 U3 U7 ADWA WAD MAXFEE 07/01/2023 133.44 0.0 Y Description: ADULT FOSTER CARE PER DIEM Category: A&D Waiver CMS Add: 01/01/2003 CMS Term: S5140 U3 U7 MFPAD W1M MAXFEE 02/01/2020 06/30/2023 81.58 0.0 Y 18-999years Description: ADULT FOSTER CARE PER DIEM Category: MFP Demo Grant CMS Add: 01/01/2003 CMS Term: S5140 U3 U7 MFPAD W1M MAXFEE 07/01/2023 133.44 0.0 Y 18-999years Description: ADULT FOSTER CARE PER DIEM Category: MFP Demo Grant CMS Add: 01/01/2003 CMS Term: S5141 U1 U7 ADWA WAD MAXFEE 02/01/2020 06/30/2023 60.23 0.0 Y Description: ADULT FOSTER CARE PER MONTH Category: A&D Waiver CMS Add: 01/01/2003 CMS Term: S5141 U1 U7 ADWA WAD MAXFEE 07/01/2023 67.93 0.0 Y Description: ADULT FOSTER CARE PER MONTH Category: A&D Waiver CMS Add: 01/01/2003 CMS Term: S5141 U1 U7 MFPAD W1M MAXFEE 02/01/2020 06/30/2023 60.23 0.0 Y Description: ADULT FOSTER CARE PER MONTH Category: MFP Demo Grant CMS Add: 01/01/2003 CMS Term: S5141 U1 U7 MFPAD W1M MAXFEE 07/01/2023 67.93 0.0 Y Description: ADULT FOSTER CARE PER MONTH Category: MFP Demo Grant CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,132 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- S5141 U1 U7 MFPTB W2M MAXFEE 02/01/2020 06/30/2023 60.23 0.0 Y Description: ADULT FOSTER CARE PER MONTH Category: MFP TBI CMS Add: 01/01/2003 CMS Term: S5141 U1 U7 MFPTB W2M MAXFEE 07/01/2023 67.93 0.0 Y Description: ADULT FOSTER CARE PER MONTH Category: MFP TBI CMS Add: 01/01/2003 CMS Term: S5141 U1 U7 TBIWA WTB MAXFEE 02/01/2020 06/30/2023 60.23 0.0 Y Description: ADULT FOSTER CARE PER MONTH Category: TBI Waiver CMS Add: 01/01/2003 CMS Term: S5141 U1 U7 TBIWA WTB MAXFEE 07/01/2023 67.93 0.0 Y Description: ADULT FOSTER CARE PER MONTH Category: TBI Waiver CMS Add: 01/01/2003 CMS Term: S5141 U2 U7 ADWA WAD MAXFEE 02/01/2020 06/30/2023 69.50 0.0 Y Description: ADULT FOSTER CARE PER MONTH Category: A&D Waiver CMS Add: 01/01/2003 CMS Term: S5141 U2 U7 ADWA WAD MAXFEE 07/01/2023 72.34 0.0 Y Description: ADULT FOSTER CARE PER MONTH Category: A&D Waiver CMS Add: 01/01/2003 CMS Term: S5141 U2 U7 MFPAD W1M MAXFEE 02/01/2020 06/30/2023 69.50 0.0 Y Description: ADULT FOSTER CARE PER MONTH Category: MFP Demo Grant CMS Add: 01/01/2003 CMS Term: S5141 U2 U7 MFPAD W1M MAXFEE 07/01/2023 72.34 0.0 Y Description: ADULT FOSTER CARE PER MONTH Category: MFP Demo Grant CMS Add: 01/01/2003 CMS Term: S5141 U2 U7 MFPTB W2M MAXFEE 02/01/2020 06/30/2023 69.50 0.0 Y Description: ADULT FOSTER CARE PER MONTH Category: MFP TBI CMS Add: 01/01/2003 CMS Term: S5141 U2 U7 MFPTB W2M MAXFEE 07/01/2023 72.34 0.0 Y Description: ADULT FOSTER CARE PER MONTH Category: MFP TBI CMS Add: 01/01/2003 CMS Term: S5141 U2 U7 TBIWA WTB MAXFEE 02/01/2020 06/30/2023 69.50 0.0 Y Description: ADULT FOSTER CARE PER MONTH Category: TBI Waiver CMS Add: 01/01/2003 CMS Term: S5141 U2 U7 TBIWA WTB MAXFEE 07/01/2023 72.34 0.0 Y Description: ADULT FOSTER CARE PER MONTH Category: TBI Waiver CMS Add: 01/01/2003 CMS Term: S5141 U3 U7 ADWA WAD MAXFEE 02/01/2020 06/30/2023 82.14 0.0 Y Description: ADULT FOSTER CARE PER MONTH Category: A&D Waiver CMS Add: 01/01/2003 CMS Term: S5141 U3 U7 ADWA WAD MAXFEE 07/01/2023 90.64 0.0 Y Description: ADULT FOSTER CARE PER MONTH Category: A&D Waiver CMS Add: 01/01/2003 CMS Term: S5141 U3 U7 MFPAD W1M MAXFEE 02/01/2020 06/30/2023 82.14 0.0 Y Description: ADULT FOSTER CARE PER MONTH Category: MFP Demo Grant CMS Add: 01/01/2003 CMS Term: S5141 U3 U7 MFPAD W1M MAXFEE 07/01/2023 90.64 0.0 Y Description: ADULT FOSTER CARE PER MONTH Category: MFP Demo Grant CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,133 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- S5141 U3 U7 MFPTB W2M MAXFEE 02/01/2020 06/30/2023 82.14 0.0 Y Description: ADULT FOSTER CARE PER MONTH Category: MFP TBI CMS Add: 01/01/2003 CMS Term: S5141 U3 U7 MFPTB W2M MAXFEE 07/01/2023 90.64 0.0 Y Description: ADULT FOSTER CARE PER MONTH Category: MFP TBI CMS Add: 01/01/2003 CMS Term: S5141 U3 U7 TBIWA WTB MAXFEE 02/01/2020 06/30/2023 82.14 0.0 Y Description: ADULT FOSTER CARE PER MONTH Category: TBI Waiver CMS Add: 01/01/2003 CMS Term: S5141 U3 U7 TBIWA WTB MAXFEE 07/01/2023 90.64 0.0 Y Description: ADULT FOSTER CARE PER MONTH Category: TBI Waiver CMS Add: 01/01/2003 CMS Term: S5145 NOCOV DEF SYSMAN Description: CHILD FOSTERCARE TH PER DIEM Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: S5146 NOCOV DEF SYSMAN Description: THER FOSTERCARE CHILD /MONTH Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: S5150 U7 U9 UA ADWA WAD MAXFEE 02/01/2020 06/30/2023 5.59 0.0 Y Description: UNSKILLED RESPITE CARE /15M Category: A&D Waiver CMS Add: 01/01/2003 CMS Term: S5150 U7 U9 UA ADWA WAD MAXFEE 07/01/2023 9.23 0.0 Y Description: UNSKILLED RESPITE CARE /15M Category: A&D Waiver CMS Add: 01/01/2003 CMS Term: S5150 U7 U9 UA MFPAD W1M MAXFEE 02/01/2020 06/30/2023 5.59 0.0 Y Description: UNSKILLED RESPITE CARE /15M Category: MFP Demo Grant CMS Add: 01/01/2003 CMS Term: S5150 U7 U9 UA MFPAD W1M MAXFEE 07/01/2023 9.23 0.0 Y Description: UNSKILLED RESPITE CARE /15M Category: MFP Demo Grant CMS Add: 01/01/2003 CMS Term: S5150 U7 U9 UA MFPTB W2M MAXFEE 02/01/2020 06/30/2023 5.59 0.0 Y Description: UNSKILLED RESPITE CARE /15M Category: MFP TBI CMS Add: 01/01/2003 CMS Term: S5150 U7 U9 UA MFPTB W2M MAXFEE 07/01/2023 9.23 0.0 Y Description: UNSKILLED RESPITE CARE /15M Category: MFP TBI CMS Add: 01/01/2003 CMS Term: S5150 U7 U9 UA TBIWA WTB MAXFEE 02/01/2020 06/30/2023 5.59 0.0 Y Description: UNSKILLED RESPITE CARE /15M Category: TBI Waiver CMS Add: 01/01/2003 CMS Term: S5150 U7 U9 UA TBIWA WTB MAXFEE 07/01/2023 9.23 0.0 Y Description: UNSKILLED RESPITE CARE /15M Category: TBI Waiver CMS Add: 01/01/2003 CMS Term: S5150 UB AMHH WUB MAXFEE 10/01/2013 3.50 0.0 Y 19-999years Description: UNSKILLED RESPITE CARE /15M Category: Adult MNTL HLTH CMS Add: 01/01/2003 CMS Term: S5151 HA CMHW WHA MAXFEE 07/01/2018 12/06/2023 243.77 0.0 Y 6-18years Description: UNSKILLED RESPITECARE /DIEM Category: Child Mentl Hlth Wai CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,134 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- S5151 HA CMHW WHA MAXFEE 12/07/2023 402.97 0.0 Y 6-18years Description: UNSKILLED RESPITECARE /DIEM Category: Child Mentl Hlth Wai CMS Add: 01/01/2003 CMS Term: S5151 HA U1 CMHW WHA MAXFEE 07/01/2018 12/06/2023 292.53 0.0 Y 6-18years Description: UNSKILLED RESPITECARE /DIEM Category: Child Mentl Hlth Wai CMS Add: 01/01/2003 CMS Term: S5151 HA U1 CMHW WHA MAXFEE 12/07/2023 463.42 0.0 Y 6-18years Description: UNSKILLED RESPITECARE /DIEM Category: Child Mentl Hlth Wai CMS Add: 01/01/2003 CMS Term: S5151 HA U2 CMHW WHA MAXFEE 07/01/2013 12/06/2023 321.52 0.0 Y 6-18years Description: UNSKILLED RESPITECARE /DIEM Category: Child Mentl Hlth Wai CMS Add: 01/01/2003 CMS Term: S5151 HA U2 CMHW WHA MAXFEE 12/07/2023 408.77 0.0 Y 6-18years Description: UNSKILLED RESPITECARE /DIEM Category: Child Mentl Hlth Wai CMS Add: 01/01/2003 CMS Term: S5151 U2 U7 MFPTR W4M MAXFEE 10/01/2012 120.00 0.0 Y Description: UNSKILLED RESPITECARE /DIEM Category: MFP PRTF Waiver CMS Add: 01/01/2003 CMS Term: S5151 U2 U7 PRTFW WPT MAXFEE 10/01/2012 120.00 0.0 Y Description: UNSKILLED RESPITECARE /DIEM Category: PRTF Trans Waiver CMS Add: 01/01/2003 CMS Term: S5151 U3 U7 MFPTR W4M MAXFEE 10/01/2012 321.52 0.0 Y Description: UNSKILLED RESPITECARE /DIEM Category: MFP PRTF Waiver CMS Add: 01/01/2003 CMS Term: S5151 U3 U7 PRTFW WPT MAXFEE 10/01/2012 321.52 0.0 Y Description: UNSKILLED RESPITECARE /DIEM Category: PRTF Trans Waiver CMS Add: 01/01/2003 CMS Term: S5151 U5 U7 DDWA WDD MAXFEE 07/01/2021 06/30/2023 29.81 0.0 Y Description: UNSKILLED RESPITECARE /DIEM Category: CIH Waiver CMS Add: 01/01/2003 CMS Term: S5151 U5 U7 DDWA WDD MAXFEE 07/01/2023 43.38 0.0 Y Description: UNSKILLED RESPITECARE /DIEM Category: CIH Waiver CMS Add: 01/01/2003 CMS Term: S5151 U5 U7 MFPCI W3M MAXFEE 07/01/2021 06/30/2023 29.81 0.0 Y Description: UNSKILLED RESPITECARE /DIEM Category: MFP CIH Waiver CMS Add: 01/01/2003 CMS Term: S5151 U5 U7 MFPCI W3M MAXFEE 07/01/2023 43.38 0.0 Y Description: UNSKILLED RESPITECARE /DIEM Category: MFP CIH Waiver CMS Add: 01/01/2003 CMS Term: S5151 U5 U7 MFPTS W5M MAXFEE 07/01/2021 06/30/2023 29.81 0.0 Y Description: UNSKILLED RESPITECARE /DIEM Category: MFP SOF Waiver CMS Add: 01/01/2003 CMS Term: S5151 U5 U7 MFPTS W5M MAXFEE 07/01/2023 43.38 0.0 Y Description: UNSKILLED RESPITECARE /DIEM Category: MFP SOF Waiver CMS Add: 01/01/2003 CMS Term: S5151 U5 U7 SSFS WSS MAXFEE 07/01/2021 06/30/2023 29.81 0.0 Y Description: UNSKILLED RESPITECARE /DIEM Category: Family Support Waivr CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,135 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- S5151 U5 U7 SSFS WSS MAXFEE 07/01/2023 43.38 0.0 Y Description: UNSKILLED RESPITECARE /DIEM Category: Family Support Waivr CMS Add: 01/01/2003 CMS Term: S5151 U7 MFPTR W4M MAXFEE 10/01/2012 100.00 0.0 Y Description: UNSKILLED RESPITECARE /DIEM Category: MFP PRTF Waiver CMS Add: 01/01/2003 CMS Term: S5151 U7 PRTFW WPT MAXFEE 10/01/2012 100.00 0.0 Y Description: UNSKILLED RESPITECARE /DIEM Category: PRTF Trans Waiver CMS Add: 01/01/2003 CMS Term: S5151 UB AMHH WUB MAXFEE 10/01/2013 100.00 0.0 Y 19-999years 0-2 Description: UNSKILLED RESPITECARE /DIEM Category: Adult MNTL HLTH CMS Add: 01/01/2003 CMS Term: S5160 U5 U7 DDWA WDD MAXFEE 01/01/2008 06/30/2023 52.07 0.0 Y Description: EMER RESPONSE SYS INSTAL&TST Category: CIH Waiver CMS Add: 01/01/2003 CMS Term: S5160 U5 U7 DDWA WDD MAXFEE 07/01/2023 54.41 0.0 Y Description: EMER RESPONSE SYS INSTAL&TST Category: CIH Waiver CMS Add: 01/01/2003 CMS Term: S5160 U5 U7 MFPCI W3M MAXFEE 01/01/2014 06/30/2023 52.07 0.0 Y Description: EMER RESPONSE SYS INSTAL&TST Category: MFP CIH Waiver CMS Add: 01/01/2003 CMS Term: S5160 U5 U7 MFPCI W3M MAXFEE 07/01/2023 54.41 0.0 Y Description: EMER RESPONSE SYS INSTAL&TST Category: MFP CIH Waiver CMS Add: 01/01/2003 CMS Term: S5160 U5 U7 MFPTS W5M MAXFEE 07/01/2023 54.41 0.0 Y Description: EMER RESPONSE SYS INSTAL&TST Category: MFP SOF Waiver CMS Add: 01/01/2003 CMS Term: S5160 U5 U7 SSFS WSS MAXFEE 01/01/2008 06/30/2023 52.07 0.0 Y Description: EMER RESPONSE SYS INSTAL&TST Category: Family Support Waivr CMS Add: 01/01/2003 CMS Term: S5160 U5 U7 SSFS WSS MAXFEE 07/01/2023 54.41 0.0 Y Description: EMER RESPONSE SYS INSTAL&TST Category: Family Support Waivr CMS Add: 01/01/2003 CMS Term: S5160 U7 ADWA WAD MAXFEE 07/01/2008 54.41 0.0 Y Description: EMER RESPONSE SYS INSTAL&TST Category: A&D Waiver CMS Add: 01/01/2003 CMS Term: S5160 U7 MFPAD W1M MAXFEE 06/02/2008 54.41 0.0 Y Description: EMER RESPONSE SYS INSTAL&TST Category: MFP Demo Grant CMS Add: 01/01/2003 CMS Term: S5160 U7 MFPTB W2M MAXFEE 02/01/2020 54.41 0.0 Y Description: EMER RESPONSE SYS INSTAL&TST Category: MFP TBI CMS Add: 01/01/2003 CMS Term: S5160 U7 TBIWA WTB MAXFEE 02/01/2020 54.41 0.0 Y Description: EMER RESPONSE SYS INSTAL&TST Category: TBI Waiver CMS Add: 01/01/2003 CMS Term: S5161 U5 U7 DDWA WDD MAXFEE 01/01/2008 06/30/2023 52.07 0.0 Y Description: EMER RSPNS SYS SERV PERMONTH Category: CIH Waiver CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,136 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- S5161 U5 U7 DDWA WDD MAXFEE 07/01/2023 54.41 0.0 Y Description: EMER RSPNS SYS SERV PERMONTH Category: CIH Waiver CMS Add: 01/01/2003 CMS Term: S5161 U5 U7 MFPCI W3M MAXFEE 01/01/2014 06/30/2023 52.07 0.0 Y Description: EMER RSPNS SYS SERV PERMONTH Category: MFP CIH Waiver CMS Add: 01/01/2003 CMS Term: S5161 U5 U7 MFPCI W3M MAXFEE 07/01/2023 54.41 0.0 Y Description: EMER RSPNS SYS SERV PERMONTH Category: MFP CIH Waiver CMS Add: 01/01/2003 CMS Term: S5161 U5 U7 MFPTS W5M MAXFEE 07/01/2023 54.41 0.0 Y Description: EMER RSPNS SYS SERV PERMONTH Category: MFP SOF Waiver CMS Add: 01/01/2003 CMS Term: S5161 U5 U7 SSFS WSS MAXFEE 01/01/2008 06/30/2023 52.07 0.0 Y Description: EMER RSPNS SYS SERV PERMONTH Category: Family Support Waivr CMS Add: 01/01/2003 CMS Term: S5161 U5 U7 SSFS WSS MAXFEE 07/01/2023 54.41 0.0 Y Description: EMER RSPNS SYS SERV PERMONTH Category: Family Support Waivr CMS Add: 01/01/2003 CMS Term: S5161 U7 ADWA WAD MAXFEE 07/01/2008 54.41 0.0 Y Description: EMER RSPNS SYS SERV PERMONTH Category: A&D Waiver CMS Add: 01/01/2003 CMS Term: S5161 U7 MFPAD W1M MAXFEE 06/02/2008 54.41 0.0 Y Description: EMER RSPNS SYS SERV PERMONTH Category: MFP Demo Grant CMS Add: 01/01/2003 CMS Term: S5161 U7 MFPTB W2M MAXFEE 02/01/2020 54.41 0.0 Y Description: EMER RSPNS SYS SERV PERMONTH Category: MFP TBI CMS Add: 01/01/2003 CMS Term: S5161 U7 TBIWA WTB MAXFEE 02/01/2020 54.41 0.0 Y Description: EMER RSPNS SYS SERV PERMONTH Category: TBI Waiver CMS Add: 01/01/2003 CMS Term: S5162 NOCOV DEF SYSMAN Description: EMER RSPNS SYSTEM PURCHASE Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: S5165 ADWA DEF SYSMAN Y Description: HOME MODIFICATIONS PER SERV Category: A&D Waiver CMS Add: 01/01/2003 CMS Term: S5165 DDWA DEF SYSMAN Y Description: HOME MODIFICATIONS PER SERV Category: CIH Waiver CMS Add: 01/01/2003 CMS Term: S5165 MFPAD DEF SYSMAN Y Description: HOME MODIFICATIONS PER SERV Category: MFP Demo Grant CMS Add: 01/01/2003 CMS Term: S5165 MFPCI DEF SYSMAN Y Description: HOME MODIFICATIONS PER SERV Category: MFP CIH Waiver CMS Add: 01/01/2003 CMS Term: S5165 MFPTB DEF SYSMAN Y Description: HOME MODIFICATIONS PER SERV Category: MFP TBI CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,137 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- S5165 MFPTS DEF SYSMAN Y Description: HOME MODIFICATIONS PER SERV Category: MFP SOF Waiver CMS Add: 01/01/2003 CMS Term: S5165 SSFS DEF SYSMAN Y Description: HOME MODIFICATIONS PER SERV Category: Family Support Waivr CMS Add: 01/01/2003 CMS Term: S5165 TBIWA DEF SYSMAN Y Description: HOME MODIFICATIONS PER SERV Category: TBI Waiver CMS Add: 01/01/2003 CMS Term: S5170 NOCOV DEF SYSMAN Description: HOMEDELIVERED PREPARED MEAL Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: S5170 U7 ADWA WAD MAXFEE 02/01/2020 06/30/2023 6.00 0.0 Y Description: HOMEDELIVERED PREPARED MEAL Category: A&D Waiver CMS Add: 01/01/2003 CMS Term: S5170 U7 ADWA WAD MAXFEE 07/01/2023 7.76 0.0 Y Description: HOMEDELIVERED PREPARED MEAL Category: A&D Waiver CMS Add: 01/01/2003 CMS Term: S5170 U7 MFPAD W1M MAXFEE 02/01/2020 06/30/2023 6.00 0.0 Y Description: HOMEDELIVERED PREPARED MEAL Category: MFP Demo Grant CMS Add: 01/01/2003 CMS Term: S5170 U7 MFPAD W1M MAXFEE 07/01/2023 7.76 0.0 Y Description: HOMEDELIVERED PREPARED MEAL Category: MFP Demo Grant CMS Add: 01/01/2003 CMS Term: S5170 U7 MFPTB W2M MAXFEE 02/01/2020 06/30/2023 6.00 0.0 Y Description: HOMEDELIVERED PREPARED MEAL Category: MFP TBI CMS Add: 01/01/2003 CMS Term: S5170 U7 MFPTB W2M MAXFEE 07/01/2023 7.76 0.0 Y Description: HOMEDELIVERED PREPARED MEAL Category: MFP TBI CMS Add: 01/01/2003 CMS Term: S5170 U7 TBIWA WTB MAXFEE 02/01/2020 06/30/2023 6.00 0.0 Y Description: HOMEDELIVERED PREPARED MEAL Category: TBI Waiver CMS Add: 01/01/2003 CMS Term: S5170 U7 TBIWA WTB MAXFEE 07/01/2023 7.76 0.0 Y Description: HOMEDELIVERED PREPARED MEAL Category: TBI Waiver CMS Add: 01/01/2003 CMS Term: S5175 NOCOV DEF SYSMAN Description: LAUNDRY SERV,EXT,PROF,/ORDER Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: S5180 NOCOV DEF SYSMAN Description: HH RESPIRATORY THRPY IN EVAL Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: S5181 NOCOV DEF SYSMAN Description: HH RESPIRATORY THRPY NOS/DAY Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: S5185 NOCOV DEF SYSMAN Description: MED REMINDER SERV PER MONTH Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,138 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- S5190 NOCOV DEF SYSMAN Description: WELLNESS ASSESSMENT BY NONPH Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: S5199 NOCOV DEF SYSMAN Description: PERSONAL CARE ITEM NOS EACH Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: S5497 NOCOV DEF SYSMAN Description: HIT CATH CARE NOC Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S5498 NOCOV DEF SYSMAN Description: HIT SIMPLE CATH CARE Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S5501 NOCOV DEF SYSMAN Description: HIT COMPLEX CATH CARE Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S5502 NOCOV DEF SYSMAN Description: HIT INTERIM CATH CARE Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S5517 NOCOV DEF SYSMAN Description: HIT DECLOTTING KIT Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S5518 NOCOV DEF SYSMAN Description: HIT CATH REPAIR KIT Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S5520 NOCOV DEF SYSMAN Description: HIT PICC INSERT KIT Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S5521 NOCOV DEF SYSMAN Description: HIT MIDLINE CATH INSERT KIT Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S5522 NOCOV DEF SYSMAN Description: HIT PICC INSERT NO SUPP Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S5523 NOCOV DEF SYSMAN Description: HIP MIDLINE CATH INSERT KIT Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S5550 NOCOV DEF SYSMAN Description: INSULIN RAPID 5 U Category: Non Covered Services CMS Add: 10/01/2003 CMS Term: S5551 NOCOV DEF SYSMAN Description: INSULIN MOST RAPID 5 U Category: Non Covered Services CMS Add: 10/01/2003 CMS Term: S5552 NOCOV DEF SYSMAN Description: INSULIN INTERMED 5 U Category: Non Covered Services CMS Add: 10/01/2003 CMS Term: S5553 NOCOV DEF SYSMAN Description: INSULIN LONG ACTING 5 U Category: Non Covered Services CMS Add: 10/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,139 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- S5560 NOCOV DEF SYSMAN Description: INSULIN REUSE PEN 1.5 ML Category: Non Covered Services CMS Add: 10/01/2003 CMS Term: S5561 NOCOV DEF SYSMAN Description: INSULIN REUSE PEN 3 ML Category: Non Covered Services CMS Add: 10/01/2003 CMS Term: S5565 NOCOV DEF SYSMAN Description: INSULIN CARTRIDGE 150 U Category: Non Covered Services CMS Add: 10/01/2003 CMS Term: S5566 NOCOV DEF SYSMAN Description: INSULIN CARTRIDGE 300 U Category: Non Covered Services CMS Add: 10/01/2003 CMS Term: S5570 NOCOV DEF SYSMAN Description: INSULIN DISPOS PEN 1.5 ML Category: Non Covered Services CMS Add: 10/01/2003 CMS Term: S5571 NOCOV DEF SYSMAN Description: INSULIN DISPOS PEN 3 ML Category: Non Covered Services CMS Add: 10/01/2003 CMS Term: S8030 NOCOV DEF SYSMAN Description: TANTALUM RING APPLICATION Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S8035 NOCOV DEF SYSMAN Description: MAGNETIC SOURCE IMAGING Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S8037 NOCOV DEF SYSMAN Description: MRCP Category: Non Covered Services CMS Add: 07/01/2001 CMS Term: S8040 NOCOV DEF SYSMAN Description: TOPOGRAPHIC BRAIN MAPPING Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S8042 NOCOV DEF SYSMAN Description: MRI LOW FIELD Category: Non Covered Services CMS Add: 04/01/2002 CMS Term: S8055 NOCOV DEF SYSMAN Description: US GUIDANCE FETAL REDUCT Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S8080 NOCOV DEF SYSMAN Description: SCINTIMAMMOGRAPHY Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: S8085 NOCOV DEF SYSMAN Description: FLUORINE-18 FLUORODEOXYGLUCO Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: S8092 NOCOV DEF SYSMAN Description: ELECTRON BEAM COMPUTED TOMOG Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S8096 NOCOV DEF SYSMAN Description: PORTABLE PEAK FLOW METER Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,140 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- S8097 NOCOV DEF SYSMAN Description: ASTHMA KIT Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S8100 MDSPY DEF SYSMAN Y Description: SPACER WITHOUT MASK Category: Medical Supplies CMS Add: 01/01/2002 CMS Term: S8101 MDSPY DEF SYSMAN Y Description: SPACER WITH MASK Category: Medical Supplies CMS Add: 01/01/2002 CMS Term: S8110 NOCOV DEF SYSMAN Description: PEAK EXPIRATORY FLOW RATE (P Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S8120 MDSPY DEF SYSMAN Y Description: O2 CONTENTS GAS CUBIC FT Category: Medical Supplies CMS Add: 10/01/2003 CMS Term: S8121 MDSPY DEF SYSMAN Y Description: O2 CONTENTS LIQUID LB Category: Medical Supplies CMS Add: 10/01/2003 CMS Term: S8130 NOCOV DEF SYSMAN Description: INTERFERENTIAL STIM 2 CHAN Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: S8131 NOCOV DEF SYSMAN Description: INTERFERENTIAL STIM 4 CHAN Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: S8185 MDSPY DEF SYSMAN Y Description: FLUTTER DEVICE Category: Medical Supplies CMS Add: 01/01/2002 CMS Term: S8186 MDSPY DEF SYSMAN Y Description: SWIVEL ADAPTOR Category: Medical Supplies CMS Add: 01/01/2002 CMS Term: S8189 MDSPY DEF SYSMAN Y Y Description: TRACH SUPPLY NOC Category: Medical Supplies CMS Add: 01/01/2002 CMS Term: S8210 NOCOV DEF SYSMAN Description: MUCUS TRAP Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: S8265 NOCOV DEF SYSMAN Description: HABERMAN FEEDER Category: Non Covered Services CMS Add: 04/01/2002 CMS Term: S8270 NOCOV DEF SYSMAN Description: ENURESIS ALARM Category: Non Covered Services CMS Add: 07/01/2005 CMS Term: S8301 NOCOV DEF SYSMAN Description: INFECT CONTROL SUPPLIES NOS Category: Non Covered Services CMS Add: 07/01/2004 CMS Term: S8415 NOCOV DEF SYSMAN Description: SUPPLIES FOR HOME DELIVERY Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,141 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- S8420 MDSPY DEF SYSMAN Y Description: CUSTOM GRADIENT SLEEV/GLOV Category: Medical Supplies CMS Add: 01/01/2002 CMS Term: S8421 MDSPY DEF SYSMAN Y Description: READY GRADIENT SLEEV/GLOV Category: Medical Supplies CMS Add: 01/01/2002 CMS Term: S8422 MDSPY DEF SYSMAN Y Description: CUSTOM GRAD SLEEVE MED Category: Medical Supplies CMS Add: 01/01/2002 CMS Term: S8423 MDSPY DEF SYSMAN Y Description: CUSTOM GRAD SLEEVE HEAVY Category: Medical Supplies CMS Add: 01/01/2002 CMS Term: S8424 MDSPY DEF SYSMAN Y Description: READY GRADIENT SLEEVE Category: Medical Supplies CMS Add: 01/01/2002 CMS Term: S8425 MDSPY DEF SYSMAN Y Description: CUSTOM GRAD GLOVE MED Category: Medical Supplies CMS Add: 01/01/2002 CMS Term: S8426 MDSPY DEF SYSMAN Y Description: CUSTOM GRAD GLOVE HEAVY Category: Medical Supplies CMS Add: 01/01/2002 CMS Term: S8427 MDSPY DEF SYSMAN Y Description: READY GRADIENT GLOVE Category: Medical Supplies CMS Add: 01/01/2002 CMS Term: S8428 MDSPY DEF SYSMAN Y Description: READY GRADIENT GAUNTLET Category: Medical Supplies CMS Add: 01/01/2002 CMS Term: S8429 NOCOV DEF SYSMAN Description: GRADIENT PRESSURE WRAP Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S8430 NOCOV DEF SYSMAN Description: PADDING FOR COMPRSSN BDG Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S8431 NOCOV DEF SYSMAN Description: COMPRESSION BANDAGE Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S8450 NOCOV DEF SYSMAN Description: SPLINT DIGIT Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S8451 NOCOV DEF SYSMAN Description: SPLINT WRIST OR ANKLE Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S8452 NOCOV DEF SYSMAN Description: SPLINT ELBOW Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S8460 NOCOV DEF SYSMAN Description: CAMISOLE POST-MAST Category: Non Covered Services CMS Add: 04/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,142 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- S8490 NOCOV DEF SYSMAN Description: 100 INSULIN SYRINGES Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S8930 NOCOV DEF SYSMAN Description: AURICULAR ELECTROSTIMULATION Category: Non Covered Services CMS Add: 04/01/2012 CMS Term: S8940 NOCOV DEF SYSMAN Description: HIPPOTHERAPY PER SESSION Category: Non Covered Services CMS Add: 04/01/2005 CMS Term: S8948 NOCOV DEF SYSMAN Description: LOW-LEVEL LASER TRMT 15 MIN Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: S8950 NOCOV DEF SYSMAN Description: COMPLEX LYMPHEDEMA THERAPY, Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S8990 NOCOV DEF SYSMAN Description: PT OR MANIP FOR MAINT Category: Non Covered Services CMS Add: 04/01/2003 CMS Term: S8999 NOCOV DEF SYSMAN Description: RESUSCITATION BAG Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: S9001 NOCOV DEF SYSMAN Description: HOME UTERINE MONITOR WITH OR Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S9007 NOCOV DEF SYSMAN Description: ULTRAFILTRATION MONITOR Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: S9024 NOCOV DEF SYSMAN Description: PARANASAL SINUS ULTRASOUND Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S9025 NOCOV DEF SYSMAN Description: OMNICARDIOGRAM/CARDIOINTEGRA Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: S9034 NOCOV DEF SYSMAN Description: ESWL FOR GALLSTONES Category: Non Covered Services CMS Add: 04/01/2002 CMS Term: S9055 NOCOV DEF SYSMAN Description: PROCUREN OR OTHER GROWTH FAC Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S9056 NOCOV DEF SYSMAN Description: COMA STIMULATION PER DIEM Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S9061 NOCOV DEF SYSMAN Description: MEDICAL SUPPLIES AND EQUIPME Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: S9083 NOCOV DEF SYSMAN Description: URGENT CARE CENTER GLOBAL Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,143 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- S9088 NOCOV DEF SYSMAN Description: SERVICES PROVIDED IN URGENT Category: Non Covered Services CMS Add: 01/01/2001 CMS Term: S9090 NOCOV DEF SYSMAN Description: VERTEBRAL AXIAL DECOMPRESSIO Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S9097 NOCOV DEF SYSMAN Description: HOME VISIT WOUND CARE Category: Non Covered Services CMS Add: 10/01/2004 CMS Term: S9098 NOCOV DEF SYSMAN Description: HOME PHOTOTHERAPY VISIT Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9110 NOCOV DEF SYSMAN Description: TELEMONITORING/HOME PER MNTH Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: S9117 NOCOV DEF SYSMAN Description: BACK SCHOOL VISIT Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9122 NOCOV DEF SYSMAN Description: HOME HEALTH AIDE OR CERTIFIE Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S9123 NOCOV DEF SYSMAN Description: NURSING CARE IN HOME RN Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S9124 NOCOV DEF SYSMAN Description: NURSING CARE, IN THE HOME; B Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S9125 NOCOV DEF SYSMAN Description: RESPITE CARE, IN THE HOME, P Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S9126 NOCOV DEF SYSMAN Description: HOSPICE CARE, IN THE HOME, P Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S9127 NOCOV DEF SYSMAN Description: SOCIAL WORK VISIT, IN THE HO Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S9128 NOCOV DEF SYSMAN Description: SPEECH THERAPY, IN THE HOME, Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S9129 NOCOV DEF SYSMAN Description: OCCUPATIONAL THERAPY, IN THE Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S9131 NOCOV DEF SYSMAN Description: PT IN THE HOME PER DIEM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9140 NOCOV DEF SYSMAN Description: DIABETIC MANAGEMENT PROGRAM, Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,144 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- S9141 NOCOV DEF SYSMAN Description: DIABETIC MANAGEMENT PROGRAM, Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S9145 NOCOV DEF SYSMAN Description: INSULIN PUMP INITIATION Category: Non Covered Services CMS Add: 04/01/2002 CMS Term: S9150 NOCOV DEF SYSMAN Description: EVALUATION BY OCULARIST Category: Non Covered Services CMS Add: 04/01/2002 CMS Term: S9152 NOCOV DEF SYSMAN Description: SPEECH THERAPY, RE-EVAL Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: S9208 NOCOV DEF SYSMAN Description: HOME MGMT PRETERM LABOR Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9209 NOCOV DEF SYSMAN Description: HOME MGMT PPROM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9211 NOCOV DEF SYSMAN Description: HOME MGMT GEST HYPERTENSION Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9212 NOCOV DEF SYSMAN Description: HM POSTPAR HYPER PER DIEM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9213 NOCOV DEF SYSMAN Description: HM PREECLAMP PER DIEM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9214 NOCOV DEF SYSMAN Description: HM GEST DM PER DIEM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9325 NOCOV DEF SYSMAN Description: HIT PAIN MGMT PER DIEM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9326 NOCOV DEF SYSMAN Description: HIT CONT PAIN PER DIEM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9327 NOCOV DEF SYSMAN Description: HIT INT PAIN PER DIEM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9328 NOCOV DEF SYSMAN Description: HIT PAIN IMP PUMP DIEM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9329 NOCOV DEF SYSMAN Description: HIT CHEMO PER DIEM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9330 NOCOV DEF SYSMAN Description: HIT CONT CHEM DIEM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,145 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- S9331 NOCOV DEF SYSMAN Description: HIT INTERMIT CHEMO DIEM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9335 NOCOV DEF SYSMAN Description: HT HEMODIALYSIS DIEM Category: Non Covered Services CMS Add: 07/01/2003 CMS Term: S9336 NOCOV DEF SYSMAN Description: HIT CONT ANTICOAG DIEM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9338 NOCOV DEF SYSMAN Description: HIT IMMUNOTHERAPY DIEM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9339 NOCOV DEF SYSMAN Description: HIT PERITON DIALYSIS DIEM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9340 NOCOV DEF SYSMAN Description: HIT ENTERAL PER DIEM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9341 NOCOV DEF SYSMAN Description: HIT ENTERAL GRAV DIEM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9342 NOCOV DEF SYSMAN Description: HIT ENTERAL PUMP DIEM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9343 NOCOV DEF SYSMAN Description: HIT ENTERAL BOLUS NURS Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9345 NOCOV DEF SYSMAN Description: HIT ANTI-HEMOPHIL DIEM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9346 NOCOV DEF SYSMAN Description: HIT ALPHA-1-PROTEINAS DIEM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9347 NOCOV DEF SYSMAN Description: HIT LONGTERM INFUSION DIEM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9348 NOCOV DEF SYSMAN Description: HIT SYMPATHOMIM DIEM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9349 NOCOV DEF SYSMAN Description: HIT TOCOLYSIS DIEM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9351 NOCOV DEF SYSMAN Description: HIT CONT ANTIEMETIC DIEM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9353 NOCOV DEF SYSMAN Description: HIT CONT INSULIN DIEM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,146 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- S9355 NOCOV DEF SYSMAN Description: HIT CHELATION DIEM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9357 NOCOV DEF SYSMAN Description: HIT ENZYME REPLACE DIEM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9359 NOCOV DEF SYSMAN Description: HIT ANTI-TNF PER DIEM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9361 NOCOV DEF SYSMAN Description: HIT DIURETIC INFUS DIEM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9363 NOCOV DEF SYSMAN Description: HIT ANTI-SPASMOTIC DIEM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9364 NOCOV DEF SYSMAN Description: HIT TPN TOTAL DIEM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9365 NOCOV DEF SYSMAN Description: HIT TPN 1 LITER DIEM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9366 NOCOV DEF SYSMAN Description: HIT TPN 2 LITER DIEM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9367 NOCOV DEF SYSMAN Description: HIT TPN 3 LITER DIEM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9368 NOCOV DEF SYSMAN Description: HIT TPN OVER 3L DIEM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9370 NOCOV DEF SYSMAN Description: HT INJ ANTIEMETIC DIEM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9372 NOCOV DEF SYSMAN Description: HT INJ ANTICOAG DIEM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9373 NOCOV DEF SYSMAN Description: HIT HYDRA TOTAL DIEM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9374 NOCOV DEF SYSMAN Description: HIT HYDRA 1 LITER DIEM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9375 NOCOV DEF SYSMAN Description: HIT HYDRA 2 LITER DIEM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9376 NOCOV DEF SYSMAN Description: HIT HYDRA 3 LITER DIEM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,147 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- S9377 NOCOV DEF SYSMAN Description: HIT HYDRA OVER 3L DIEM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9379 NOCOV DEF SYSMAN Description: HIT NOC PER DIEM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9381 NOCOV DEF SYSMAN Description: HIT HIGH RISK/ESCORT Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9401 NOCOV DEF SYSMAN Description: ANTICOAG CLINIC PER SESSION Category: Non Covered Services CMS Add: 04/01/2002 CMS Term: S9430 NOCOV DEF SYSMAN Description: PHARMACY COMP/DISP SERV Category: Non Covered Services CMS Add: 04/01/2002 CMS Term: S9432 MDSPY DEF SYSMAN Y Description: MED FOOD NON INBORN ERR META Category: Medical Supplies CMS Add: 10/01/2021 CMS Term: S9433 NOCOV DEF SYSMAN Description: MEDICAL FOOD ORAL 100% NUTR Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: S9434 NOCOV DEF SYSMAN Description: MOD SOLID FOOD SUPPL Category: Non Covered Services CMS Add: 04/01/2003 CMS Term: S9435 MDSPY DEF MAXFEE 01/01/2014 12/31/2023 5.33 0.0 Y Description: MEDICAL FOODS FOR INBORN ERR Category: Medical Supplies CMS Add: 01/01/2001 CMS Term: S9435 MDSPY DEF MAXFEE 01/01/2024 6.93 0.0 Y Description: MEDICAL FOODS FOR INBORN ERR Category: Medical Supplies CMS Add: 01/01/2001 CMS Term: S9436 NOCOV DEF SYSMAN Description: LAMAZE CLASS Category: Non Covered Services CMS Add: 04/01/2002 CMS Term: S9437 NOCOV DEF SYSMAN Description: CHILDBIRTH REFRESHER CLASS Category: Non Covered Services CMS Add: 04/01/2002 CMS Term: S9438 NOCOV DEF SYSMAN Description: CESAREAN BIRTH CLASS Category: Non Covered Services CMS Add: 04/01/2002 CMS Term: S9439 NOCOV DEF SYSMAN Description: VBAC CLASS Category: Non Covered Services CMS Add: 04/01/2002 CMS Term: S9441 NOCOV DEF SYSMAN Description: ASTHMA EDUCATION Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9442 NOCOV DEF SYSMAN Description: BIRTHING CLASS Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,148 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- S9443 NOCOV DEF SYSMAN Description: LACTATION CLASS Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9444 NOCOV DEF SYSMAN Description: PARENTING CLASS Category: Non Covered Services CMS Add: 04/01/2002 CMS Term: S9445 NOCOV DEF SYSMAN Description: PT EDUCATION NOC INDIVID Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9446 NOCOV DEF SYSMAN Description: PT EDUCATION NOC GROUP Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9447 NOCOV DEF SYSMAN Description: INFANT SAFETY CLASS Category: Non Covered Services CMS Add: 04/01/2002 CMS Term: S9449 NOCOV DEF SYSMAN Description: WEIGHT MGMT CLASS Category: Non Covered Services CMS Add: 04/01/2002 CMS Term: S9451 NOCOV DEF SYSMAN Description: EXERCISE CLASS Category: Non Covered Services CMS Add: 04/01/2002 CMS Term: S9452 NOCOV DEF SYSMAN Description: NUTRITION CLASS Category: Non Covered Services CMS Add: 04/01/2002 CMS Term: S9453 NOCOV DEF SYSMAN Description: SMOKING CESSATION CLASS Category: Non Covered Services CMS Add: 04/01/2002 CMS Term: S9454 NOCOV DEF SYSMAN Description: STRESS MGMT CLASS Category: Non Covered Services CMS Add: 04/01/2002 CMS Term: S9455 NOCOV DEF SYSMAN Description: DIABETIC MANAGEMENT PROGRAM, Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S9460 NOCOV DEF SYSMAN Description: DIABETIC MANAGEMENT PROGRAM, Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S9465 NOCOV DEF SYSMAN Description: DIABETIC MANAGEMENT PROGRAM, Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S9470 NOCOV DEF SYSMAN Description: NUTRITIONAL COUNSELING, DIET Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S9472 NOCOV DEF SYSMAN Description: CARDIAC REHABILITATION PROGR Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S9473 NOCOV DEF SYSMAN Description: PULMONARY REHABILITATION PRO Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,149 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- S9474 NOCOV DEF SYSMAN Description: ENTEROSTOMAL THERAPY BY A RE Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S9475 NOCOV DEF SYSMAN Description: AMBULATORY SETTING SUBSTANCE Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S9476 NOCOV DEF SYSMAN Description: VESTIBULAR REHAB PER DIEM Category: Non Covered Services CMS Add: 10/01/2003 CMS Term: S9480 MENTL IPA MAXFEE 01/01/2024 186.35 0.0 Y Description: INTENSIVE OUTPATIENT PSYCHIA Category: Mental Health CMS Add: 01/01/2000 CMS Term: S9480 MENTL IPA MAXFEE 07/01/2019 12/31/2023 130.59 0.0 Y Description: INTENSIVE OUTPATIENT PSYCHIA Category: Mental Health CMS Add: 01/01/2000 CMS Term: S9480 MENTL IPC MAXFEE 01/01/2024 426.99 0.0 Y Description: INTENSIVE OUTPATIENT PSYCHIA Category: Mental Health CMS Add: 01/01/2000 CMS Term: S9480 MENTL IPC MAXFEE 07/01/2019 12/31/2023 299.22 0.0 Y Description: INTENSIVE OUTPATIENT PSYCHIA Category: Mental Health CMS Add: 01/01/2000 CMS Term: S9482 NOCOV DEF SYSMAN Description: FAMILY STABILIZATION 15 MIN Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: S9484 MENTL DEF MAXFEE 07/01/2023 184.92 0.0 Description: CRISIS INTERVENTION PER HOUR Category: Mental Health CMS Add: 07/01/2002 CMS Term: S9484 UB MENTL DEF MAXFEE 07/01/2023 194.92 0.0 Description: CRISIS INTERVENTION PER HOUR Category: Mental Health CMS Add: 07/01/2002 CMS Term: S9485 MENTL DEF MAXFEE 07/01/2023 345.72 0.0 Description: CRISIS INTERVENTION MENTAL H Category: Mental Health CMS Add: 01/01/2000 CMS Term: S9485 UB MENTL DEF MAXFEE 07/01/2023 355.72 0.0 Description: CRISIS INTERVENTION MENTAL H Category: Mental Health CMS Add: 01/01/2000 CMS Term: S9490 NOCOV DEF SYSMAN Description: HIT CORTICOSTEROID/DIEM Category: Non Covered Services CMS Add: 07/01/2002 CMS Term: S9494 NOCOV DEF SYSMAN Description: HIT ANTIBIOTIC TOTAL DIEM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9497 NOCOV DEF SYSMAN Description: HIT ANTIBIOTIC Q3H DIEM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9500 NOCOV DEF SYSMAN Description: HIT ANTIBIOTIC Q24H DIEM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,150 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- S9501 NOCOV DEF SYSMAN Description: HIT ANTIBIOTIC Q12H DIEM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9502 NOCOV DEF SYSMAN Description: HIT ANTIBIOTIC Q8H DIEM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9503 NOCOV DEF SYSMAN Description: HIT ANTIBIOTIC Q6H DIEM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9504 NOCOV DEF SYSMAN Description: HIT ANTIBIOTIC Q4H DIEM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9529 NOCOV DEF SYSMAN Description: VENIPUNCTURE HOME/SNF Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9537 NOCOV DEF SYSMAN Description: HT HEM HORM INJ DIEM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9538 NOCOV DEF SYSMAN Description: HIT BLOOD PRODUCTS DIEM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9542 NOCOV DEF SYSMAN Description: HT INJ NOC PER DIEM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9558 NOCOV DEF SYSMAN Description: HT INJ GROWTH HORM DIEM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9559 NOCOV DEF SYSMAN Description: HIT INJ INTERFERON DIEM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9560 NOCOV DEF SYSMAN Description: HT INJ HORMONE DIEM Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9562 NOCOV DEF SYSMAN Description: HT INJ PALIVIZUMAB/AB DIEM Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: S9563 NOCOV DEF SYSMAN Description: HT INJ IMMUNO DIEM Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: S9590 NOCOV DEF SYSMAN Description: HT IRRIGATION DIEM Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: S9810 NOCOV DEF SYSMAN Description: HT PHARM PER HOUR Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9900 NOCOV DEF SYSMAN Description: CHRISTIAN SCI PRACT VISIT Category: Non Covered Services CMS Add: 07/01/2002 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,151 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- S9901 NOCOV DEF SYSMAN Description: CHRISTIAN SCI NURSE VISIT Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: S9960 NOCOV DEF SYSMAN Description: AIR AMBULANC NONEMERG FIXED Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: S9961 NOCOV DEF SYSMAN Description: AIR AMBULAN NONEMERG ROTARY Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: S9970 NOCOV DEF SYSMAN Description: HEALTH CLUB MEMBERSHIP YR Category: Non Covered Services CMS Add: 04/01/2002 CMS Term: S9975 NOCOV DEF SYSMAN Description: TRANSPLANT RELATED PER DIEM Category: Non Covered Services CMS Add: 04/01/2002 CMS Term: S9976 NOCOV DEF SYSMAN Description: LODGING PER DIEM Category: Non Covered Services CMS Add: 04/01/2004 CMS Term: S9977 NOCOV DEF SYSMAN Description: MEALS PER DIEM Category: Non Covered Services CMS Add: 04/01/2004 CMS Term: S9981 MRT DEF MAXFEE 07/01/2002 10.00 0.0 Description: MED RECORD COPY ADMIN Category: Medical Review Team CMS Add: 01/01/2002 CMS Term: S9982 NOCOV DEF SYSMAN Description: MED RECORD COPY PER PAGE Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9986 NOCOV DEF SYSMAN Description: NOT MEDICALLY NECESSARY SVC Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9988 NOCOV DEF SYSMAN Description: SERV PART OF PHASE I TRIAL Category: Non Covered Services CMS Add: 04/01/2004 CMS Term: S9989 NOCOV DEF SYSMAN Description: SERVICES OUTSIDE US Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: S9990 NOCOV DEF SYSMAN Description: SERVICES PROVIDED AS PART OF Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S9991 NOCOV DEF SYSMAN Description: SERVICES PROVIDED AS PART OF Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S9992 NOCOV DEF SYSMAN Description: TRANSPORTATION COSTS TO AND Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S9994 NOCOV DEF SYSMAN Description: LODGING COSTS (E.G. HOTEL CH Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,152 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- S9996 NOCOV DEF SYSMAN Description: MEALS FOR CLINICAL TRIAL PAR Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: S9999 NOCOV DEF SYSMAN Description: SALES TAX Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: T1000 NOCOV DEF SYSMAN Description: PRIVATE DUTY/INDEPENDENT NSG Category: Non Covered Services CMS Add: 07/01/2001 CMS Term: T1001 NOCOV DEF SYSMAN Description: NURSING ASSESSMENT/EVALUATN Category: Non Covered Services CMS Add: 07/01/2001 CMS Term: T1002 NOCOV DEF SYSMAN Description: RN SERVICES UP TO 15 MINUTES Category: Non Covered Services CMS Add: 07/01/2001 CMS Term: T1003 NOCOV DEF SYSMAN Description: LPN/LVN SERVICES UP TO 15MIN Category: Non Covered Services CMS Add: 07/01/2001 CMS Term: T1004 NOCOV DEF SYSMAN Description: NSG AIDE SERVICE UP TO 15MIN Category: Non Covered Services CMS Add: 07/01/2001 CMS Term: T1005 HA CMHW WHA MAXFEE 07/01/2018 12/06/2023 6.09 0.0 Y 6-18years Description: RESPITE CARE SERVICE 15 MIN Category: Child Mentl Hlth Wai CMS Add: 07/01/2001 CMS Term: T1005 HA CMHW WHA MAXFEE 12/07/2023 14.53 0.0 Y 6-18years Description: RESPITE CARE SERVICE 15 MIN Category: Child Mentl Hlth Wai CMS Add: 07/01/2001 CMS Term: T1005 TD U5 U7 DDWA WDD MAXFEE 07/01/2021 06/30/2023 8.88 0.0 Y Description: RESPITE CARE SERVICE 15 MIN Category: CIH Waiver CMS Add: 07/01/2001 CMS Term: T1005 TD U5 U7 DDWA WDD MAXFEE 07/01/2023 17.10 0.0 Y Description: RESPITE CARE SERVICE 15 MIN Category: CIH Waiver CMS Add: 07/01/2001 CMS Term: T1005 TD U5 U7 MFPCI W3M MAXFEE 07/01/2021 06/30/2023 8.88 0.0 Y Description: RESPITE CARE SERVICE 15 MIN Category: MFP CIH Waiver CMS Add: 07/01/2001 CMS Term: T1005 TD U5 U7 MFPCI W3M MAXFEE 07/01/2023 17.10 0.0 Y Description: RESPITE CARE SERVICE 15 MIN Category: MFP CIH Waiver CMS Add: 07/01/2001 CMS Term: T1005 TD U5 U7 MFPTS W5M MAXFEE 07/01/2021 06/30/2023 8.88 0.0 Y Description: RESPITE CARE SERVICE 15 MIN Category: MFP SOF Waiver CMS Add: 07/01/2001 CMS Term: T1005 TD U5 U7 MFPTS W5M MAXFEE 07/01/2023 17.10 0.0 Y Description: RESPITE CARE SERVICE 15 MIN Category: MFP SOF Waiver CMS Add: 07/01/2001 CMS Term: T1005 TD U5 U7 SSFS WSS MAXFEE 07/01/2021 06/30/2023 8.88 0.0 Y Description: RESPITE CARE SERVICE 15 MIN Category: Family Support Waivr CMS Add: 07/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,153 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- T1005 TD U5 U7 SSFS WSS MAXFEE 07/01/2023 17.10 0.0 Y Description: RESPITE CARE SERVICE 15 MIN Category: Family Support Waivr CMS Add: 07/01/2001 CMS Term: T1005 TD U7 UA ADWA WAD MAXFEE 02/01/2020 06/30/2023 14.33 0.0 Y Description: RESPITE CARE SERVICE 15 MIN Category: A&D Waiver CMS Add: 07/01/2001 CMS Term: T1005 TD U7 UA ADWA WAD MAXFEE 07/01/2023 17.10 0.0 Y Description: RESPITE CARE SERVICE 15 MIN Category: A&D Waiver CMS Add: 07/01/2001 CMS Term: T1005 TD U7 UA MFPAD W1M MAXFEE 02/01/2020 06/30/2023 14.33 0.0 Y Description: RESPITE CARE SERVICE 15 MIN Category: MFP Demo Grant CMS Add: 07/01/2001 CMS Term: T1005 TD U7 UA MFPAD W1M MAXFEE 07/01/2023 17.10 0.0 Y Description: RESPITE CARE SERVICE 15 MIN Category: MFP Demo Grant CMS Add: 07/01/2001 CMS Term: T1005 TD U7 UA MFPTB W2M MAXFEE 02/01/2020 06/30/2023 14.33 0.0 Y Description: RESPITE CARE SERVICE 15 MIN Category: MFP TBI CMS Add: 07/01/2001 CMS Term: T1005 TD U7 UA MFPTB W2M MAXFEE 07/01/2023 17.10 0.0 Y Description: RESPITE CARE SERVICE 15 MIN Category: MFP TBI CMS Add: 07/01/2001 CMS Term: T1005 TD U7 UA TBIWA WTB MAXFEE 02/01/2020 06/30/2023 14.33 0.0 Y Description: RESPITE CARE SERVICE 15 MIN Category: TBI Waiver CMS Add: 07/01/2001 CMS Term: T1005 TD U7 UA TBIWA WTB MAXFEE 07/01/2023 17.10 0.0 Y Description: RESPITE CARE SERVICE 15 MIN Category: TBI Waiver CMS Add: 07/01/2001 CMS Term: T1005 TE U5 U7 DDWA WDD MAXFEE 07/01/2021 06/30/2023 6.74 0.0 Y Description: RESPITE CARE SERVICE 15 MIN Category: CIH Waiver CMS Add: 07/01/2001 CMS Term: T1005 TE U5 U7 DDWA WDD MAXFEE 07/01/2023 13.69 0.0 Y Description: RESPITE CARE SERVICE 15 MIN Category: CIH Waiver CMS Add: 07/01/2001 CMS Term: T1005 TE U5 U7 MFPCI W3M MAXFEE 07/01/2021 06/30/2023 6.74 0.0 Y Description: RESPITE CARE SERVICE 15 MIN Category: MFP CIH Waiver CMS Add: 07/01/2001 CMS Term: T1005 TE U5 U7 MFPCI W3M MAXFEE 07/01/2023 13.69 0.0 Y Description: RESPITE CARE SERVICE 15 MIN Category: MFP CIH Waiver CMS Add: 07/01/2001 CMS Term: T1005 TE U5 U7 MFPTS W5M MAXFEE 07/01/2021 06/30/2023 6.74 0.0 Y Description: RESPITE CARE SERVICE 15 MIN Category: MFP SOF Waiver CMS Add: 07/01/2001 CMS Term: T1005 TE U5 U7 MFPTS W5M MAXFEE 07/01/2023 13.69 0.0 Y Description: RESPITE CARE SERVICE 15 MIN Category: MFP SOF Waiver CMS Add: 07/01/2001 CMS Term: T1005 TE U5 U7 SSFS WSS MAXFEE 07/01/2021 06/30/2023 6.74 0.0 Y Description: RESPITE CARE SERVICE 15 MIN Category: Family Support Waivr CMS Add: 07/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,154 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- T1005 TE U5 U7 SSFS WSS MAXFEE 07/01/2023 13.69 0.0 Y Description: RESPITE CARE SERVICE 15 MIN Category: Family Support Waivr CMS Add: 07/01/2001 CMS Term: T1005 TE U7 UA ADWA WAD MAXFEE 02/01/2020 06/30/2023 10.57 0.0 Y Description: RESPITE CARE SERVICE 15 MIN Category: A&D Waiver CMS Add: 07/01/2001 CMS Term: T1005 TE U7 UA ADWA WAD MAXFEE 07/01/2023 13.69 0.0 Y Description: RESPITE CARE SERVICE 15 MIN Category: A&D Waiver CMS Add: 07/01/2001 CMS Term: T1005 TE U7 UA MFPAD W1M MAXFEE 02/01/2020 06/30/2023 10.57 0.0 Y Description: RESPITE CARE SERVICE 15 MIN Category: MFP Demo Grant CMS Add: 07/01/2001 CMS Term: T1005 TE U7 UA MFPAD W1M MAXFEE 07/01/2023 13.69 0.0 Y Description: RESPITE CARE SERVICE 15 MIN Category: MFP Demo Grant CMS Add: 07/01/2001 CMS Term: T1005 TE U7 UA MFPTB W2M MAXFEE 02/01/2020 06/30/2023 10.57 0.0 Y Description: RESPITE CARE SERVICE 15 MIN Category: MFP TBI CMS Add: 07/01/2001 CMS Term: T1005 TE U7 UA MFPTB W2M MAXFEE 07/01/2023 13.69 0.0 Y Description: RESPITE CARE SERVICE 15 MIN Category: MFP TBI CMS Add: 07/01/2001 CMS Term: T1005 TE U7 UA TBIWA WTB MAXFEE 02/01/2020 06/30/2023 10.57 0.0 Y Description: RESPITE CARE SERVICE 15 MIN Category: TBI Waiver CMS Add: 07/01/2001 CMS Term: T1005 TE U7 UA TBIWA WTB MAXFEE 07/01/2023 13.69 0.0 Y Description: RESPITE CARE SERVICE 15 MIN Category: TBI Waiver CMS Add: 07/01/2001 CMS Term: T1005 U7 MFPTR W4M MAXFEE 10/01/2012 4.00 0.0 Y Description: RESPITE CARE SERVICE 15 MIN Category: MFP PRTF Waiver CMS Add: 07/01/2001 CMS Term: T1005 U7 PRTFW WPT MAXFEE 10/01/2012 4.00 0.0 Y Description: RESPITE CARE SERVICE 15 MIN Category: PRTF Trans Waiver CMS Add: 07/01/2001 CMS Term: T1006 NOCOV DEF SYSMAN Description: FAMILY/COUPLE COUNSELING Category: Non Covered Services CMS Add: 07/01/2001 CMS Term: T1007 NOCOV DEF SYSMAN Description: TREATMENT PLAN DEVELOPMENT Category: Non Covered Services CMS Add: 07/01/2001 CMS Term: T1009 NOCOV DEF SYSMAN Description: CHILD SITTING SERVICES Category: Non Covered Services CMS Add: 07/01/2001 CMS Term: T1010 NOCOV DEF SYSMAN Description: MEALS WHEN RECEIVE SERVICES Category: Non Covered Services CMS Add: 07/01/2001 CMS Term: T1012 NOCOV DEF SYSMAN Description: ALCOHOL/SUBSTANCE ABUSE SKIL Category: Non Covered Services CMS Add: 07/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,155 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- T1013 NOCOV DEF SYSMAN Description: SIGN LANG/ORAL INTERPRETER Category: Non Covered Services CMS Add: 07/01/2001 CMS Term: T1014 NOCOV DEF SYSMAN Description: TELEHEALTH TRANSMIT, PER MIN Category: Non Covered Services CMS Add: 07/01/2001 CMS Term: T1016 EP MEDSV DEF MAXFEE 01/01/2024 11.46 0.0 0-20years Description: CASE MANAGEMENT Category: Medical Services CMS Add: 07/01/2002 CMS Term: T1016 EP MEDSV DEF MAXFEE 07/01/2019 12/31/2023 8.84 0.0 0-20years Description: CASE MANAGEMENT Category: Medical Services CMS Add: 07/01/2002 CMS Term: T1016 EP MRO DEF MAXFEE 01/01/2024 11.46 0.0 Y Description: CASE MANAGEMENT Category: MA Rehab Option CMS Add: 07/01/2002 CMS Term: T1016 EP MRO DEF MAXFEE 07/01/2019 12/31/2023 8.84 0.0 Y Description: CASE MANAGEMENT Category: MA Rehab Option CMS Add: 07/01/2002 CMS Term: T1016 HH MEDSV DEF MAXFEE 01/01/2024 18.83 0.0 0-20years Description: CASE MANAGEMENT Category: Medical Services CMS Add: 07/01/2002 CMS Term: T1016 HH MEDSV DEF MAXFEE 07/07/2019 12/31/2023 14.53 0.0 0-20years Description: CASE MANAGEMENT Category: Medical Services CMS Add: 07/01/2002 CMS Term: T1016 HH MRO DEF MAXFEE 01/01/2024 18.83 0.0 Y Description: CASE MANAGEMENT Category: MA Rehab Option CMS Add: 07/01/2002 CMS Term: T1016 HH MRO DEF MAXFEE 07/07/2019 12/31/2023 14.53 0.0 Y Description: CASE MANAGEMENT Category: MA Rehab Option CMS Add: 07/01/2002 CMS Term: T1016 HW MEDSV DEF MAXFEE 07/01/2010 14.53 0.0 0-20years Description: CASE MANAGEMENT Category: Medical Services CMS Add: 07/01/2002 CMS Term: T1016 HW MRO DEF MAXFEE 07/01/2010 14.53 0.0 Y Description: CASE MANAGEMENT Category: MA Rehab Option CMS Add: 07/01/2002 CMS Term: T1016 U3 UC BPHC WUC MAXFEE 06/01/2014 8.55 0.0 Y 19-999years 0-48 Description: CASE MANAGEMENT Category: Behavioral & Primary CMS Add: 07/01/2002 CMS Term: T1016 U3 UC MEDSV DEF MAXFEE 06/01/2014 12/31/2023 8.55 0.0 0-20years Description: CASE MANAGEMENT Category: Medical Services CMS Add: 07/01/2002 CMS Term: T1016 U3 UC MRO DEF MAXFEE 06/01/2014 12/31/2023 8.55 0.0 Y Description: CASE MANAGEMENT Category: MA Rehab Option CMS Add: 07/01/2002 CMS Term: T1016 UB AMHH WUB MAXFEE 10/01/2013 14.53 0.0 Y 19-999years Description: CASE MANAGEMENT Category: Adult MNTL HLTH CMS Add: 07/01/2002 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,156 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- T1016 UB MEDSV DEF MAXFEE 10/01/2013 12/31/2023 14.53 0.0 0-20years Description: CASE MANAGEMENT Category: Medical Services CMS Add: 07/01/2002 CMS Term: T1016 UB MRO DEF MAXFEE 10/01/2013 12/31/2023 14.53 0.0 Y Description: CASE MANAGEMENT Category: MA Rehab Option CMS Add: 07/01/2002 CMS Term: T1016 UC BPHC WUC MAXFEE 06/01/2014 14.53 0.0 Y 19-999years 0-48 Description: CASE MANAGEMENT Category: Behavioral & Primary CMS Add: 07/01/2002 CMS Term: T1016 UC MEDSV DEF MAXFEE 06/01/2014 12/31/2023 14.53 0.0 0-20years Description: CASE MANAGEMENT Category: Medical Services CMS Add: 07/01/2002 CMS Term: T1016 UC MRO DEF MAXFEE 06/01/2014 12/31/2023 14.53 0.0 Y Description: CASE MANAGEMENT Category: MA Rehab Option CMS Add: 07/01/2002 CMS Term: T1017 NOCOV DEF SYSMAN Description: TARGETED CASE MANAGEMENT Category: Non Covered Services CMS Add: 07/01/2002 CMS Term: T1018 NOCOV DEF SYSMAN Description: SCHOOL-BASED IEP SER BUNDLED Category: Non Covered Services CMS Add: 07/01/2002 CMS Term: T1019 NOCOV DEF SYSMAN Description: PERSONAL CARE SER PER 15 MIN Category: Non Covered Services CMS Add: 07/01/2002 CMS Term: T1020 U5 U7 DDWA WDD MAXFEE 07/01/2021 06/30/2023 31.57 0.0 Y Description: PERSONAL CARE SER PER DIEM Category: CIH Waiver CMS Add: 07/01/2002 CMS Term: T1020 U5 U7 DDWA WDD MAXFEE 07/01/2023 38.36 0.0 Y Description: PERSONAL CARE SER PER DIEM Category: CIH Waiver CMS Add: 07/01/2002 CMS Term: T1020 U5 U7 MFPCI W3M MAXFEE 07/01/2021 06/30/2023 31.57 0.0 Y Description: PERSONAL CARE SER PER DIEM Category: MFP CIH Waiver CMS Add: 07/01/2002 CMS Term: T1020 U5 U7 MFPCI W3M MAXFEE 07/01/2023 38.36 0.0 Y Description: PERSONAL CARE SER PER DIEM Category: MFP CIH Waiver CMS Add: 07/01/2002 CMS Term: T1020 U5 U7 MFPTS W5M MAXFEE 07/01/2021 06/30/2023 31.57 0.0 Y Description: PERSONAL CARE SER PER DIEM Category: MFP SOF Waiver CMS Add: 07/01/2002 CMS Term: T1020 U5 U7 MFPTS W5M MAXFEE 07/01/2023 38.36 0.0 Y Description: PERSONAL CARE SER PER DIEM Category: MFP SOF Waiver CMS Add: 07/01/2002 CMS Term: T1020 U5 U7 SSFS WSS MAXFEE 07/01/2021 06/30/2023 31.57 0.0 Y Description: PERSONAL CARE SER PER DIEM Category: Family Support Waivr CMS Add: 07/01/2002 CMS Term: T1020 U5 U7 SSFS WSS MAXFEE 07/01/2023 38.36 0.0 Y Description: PERSONAL CARE SER PER DIEM Category: Family Support Waivr CMS Add: 07/01/2002 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,157 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- T1020 U5 U7 UA DDWA WDD MAXFEE 07/01/2021 06/30/2023 2.21 0.0 Y Description: PERSONAL CARE SER PER DIEM Category: CIH Waiver CMS Add: 07/01/2002 CMS Term: T1020 U5 U7 UA DDWA WDD MAXFEE 07/01/2023 2.51 0.0 Y Description: PERSONAL CARE SER PER DIEM Category: CIH Waiver CMS Add: 07/01/2002 CMS Term: T1020 U5 U7 UA MFPCI W3M MAXFEE 07/01/2021 06/30/2023 2.21 0.0 Y Description: PERSONAL CARE SER PER DIEM Category: MFP CIH Waiver CMS Add: 07/01/2002 CMS Term: T1020 U5 U7 UA MFPCI W3M MAXFEE 07/01/2023 2.51 0.0 Y Description: PERSONAL CARE SER PER DIEM Category: MFP CIH Waiver CMS Add: 07/01/2002 CMS Term: T1020 U5 U7 UA MFPTS W5M MAXFEE 07/01/2021 06/30/2023 2.21 0.0 Y Description: PERSONAL CARE SER PER DIEM Category: MFP SOF Waiver CMS Add: 07/01/2002 CMS Term: T1020 U5 U7 UA MFPTS W5M MAXFEE 07/01/2023 2.51 0.0 Y Description: PERSONAL CARE SER PER DIEM Category: MFP SOF Waiver CMS Add: 07/01/2002 CMS Term: T1020 U5 U7 UA SSFS WSS MAXFEE 07/01/2021 06/30/2023 2.21 0.0 Y Description: PERSONAL CARE SER PER DIEM Category: Family Support Waivr CMS Add: 07/01/2002 CMS Term: T1020 U5 U7 UA SSFS WSS MAXFEE 07/01/2023 2.51 0.0 Y Description: PERSONAL CARE SER PER DIEM Category: Family Support Waivr CMS Add: 07/01/2002 CMS Term: T1021 NOCOV DEF SYSMAN Description: HH AIDE OR CN AIDE PER VISIT Category: Non Covered Services CMS Add: 07/01/2002 CMS Term: T1022 NOCOV DEF SYSMAN Description: CONTRACTED SERVICES PER DAY Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: T1023 NOCOV DEF SYSMAN Description: PROGRAM INTAKE ASSESSMENT Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: T1024 NOCOV DEF SYSMAN Description: TEAM EVALUATION & MANAGEMENT Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: T1025 NOCOV DEF SYSMAN Description: PED COMPR CARE PKG, PER DIEM Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: T1026 NOCOV DEF SYSMAN Description: PED COMPR CARE PKG, PER HOUR Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: T1027 MEDSV DEF BILL90 0-3years Description: FAMILY TRAINING & COUNSELING Category: Medical Services CMS Add: 01/01/2003 CMS Term: T1028 U5 U7 DDWA WDD MAXFEE 01/01/2008 06/30/2023 17.99 0.0 Y Description: HOME ENVIRONMENT ASSESSMENT Category: CIH Waiver CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,158 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- T1028 U5 U7 DDWA WDD MAXFEE 07/01/2023 18.53 0.0 Y Description: HOME ENVIRONMENT ASSESSMENT Category: CIH Waiver CMS Add: 01/01/2003 CMS Term: T1028 U5 U7 MFPCI W3M MAXFEE 01/01/2014 06/30/2023 17.99 0.0 Y Description: HOME ENVIRONMENT ASSESSMENT Category: MFP CIH Waiver CMS Add: 01/01/2003 CMS Term: T1028 U5 U7 MFPCI W3M MAXFEE 07/01/2023 18.53 0.0 Y Description: HOME ENVIRONMENT ASSESSMENT Category: MFP CIH Waiver CMS Add: 01/01/2003 CMS Term: T1028 U5 U7 MFPTS W5M MAXFEE 07/01/2023 18.53 0.0 Y Description: HOME ENVIRONMENT ASSESSMENT Category: MFP SOF Waiver CMS Add: 01/01/2003 CMS Term: T1028 U5 U7 MFPTS W5M MAXFEE 07/16/2020 06/30/2023 17.99 0.0 Y Description: HOME ENVIRONMENT ASSESSMENT Category: MFP SOF Waiver CMS Add: 01/01/2003 CMS Term: T1028 U5 U7 SSFS WSS MAXFEE 01/01/2008 06/30/2023 17.99 0.0 Y Description: HOME ENVIRONMENT ASSESSMENT Category: Family Support Waivr CMS Add: 01/01/2003 CMS Term: T1028 U5 U7 SSFS WSS MAXFEE 07/01/2023 18.53 0.0 Y Description: HOME ENVIRONMENT ASSESSMENT Category: Family Support Waivr CMS Add: 01/01/2003 CMS Term: T1028 U7 ADWA WAD MAXFEE 02/01/2020 06/30/2023 574.38 0.0 Y Description: HOME ENVIRONMENT ASSESSMENT Category: A&D Waiver CMS Add: 01/01/2003 CMS Term: T1028 U7 ADWA WAD MAXFEE 07/01/2023 628.00 0.0 Y Description: HOME ENVIRONMENT ASSESSMENT Category: A&D Waiver CMS Add: 01/01/2003 CMS Term: T1028 U7 MFPAD W1M MAXFEE 02/02/2020 06/30/2023 574.38 0.0 Y Description: HOME ENVIRONMENT ASSESSMENT Category: MFP Demo Grant CMS Add: 01/01/2003 CMS Term: T1028 U7 MFPAD W1M MAXFEE 07/01/2023 628.00 0.0 Y Description: HOME ENVIRONMENT ASSESSMENT Category: MFP Demo Grant CMS Add: 01/01/2003 CMS Term: T1029 MEDSV DEF MAXFEE 01/01/2024 366.57 0.0 Description: DWELLING LEAD INVESTIGATION Category: Medical Services CMS Add: 01/01/2003 CMS Term: T1029 MEDSV DEF MAXFEE 08/01/2005 12/31/2023 282.85 0.0 Description: DWELLING LEAD INVESTIGATION Category: Medical Services CMS Add: 01/01/2003 CMS Term: T1029 TS MEDSV DEF MAXFEE 01/01/2024 131.31 0.0 Description: DWELLING LEAD INVESTIGATION Category: Medical Services CMS Add: 01/01/2003 CMS Term: T1029 TS MEDSV DEF MAXFEE 08/01/2005 12/31/2023 101.32 0.0 Description: DWELLING LEAD INVESTIGATION Category: Medical Services CMS Add: 01/01/2003 CMS Term: T1030 NOCOV DEF SYSMAN Description: RN HOME CARE PER DIEM Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,159 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- T1031 NOCOV DEF SYSMAN Description: LPN HOME CARE PER DIEM Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: T1032 NOCOV DEF SYSMAN Description: SV DOULA BRTH WRK PER 15 MIN Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: T1033 NOCOV DEF SYSMAN Description: SV DOULA BRTH WRK PER DIEM Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: T1040 NOCOV DEF SYSMAN Description: COMM BH CLINIC SVC PER DIEM Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: T1041 NOCOV DEF SYSMAN Description: COMM BH CLINIC SVC PER MONTH Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: T1502 NOCOV DEF SYSMAN Description: MEDICATION ADMIN VISIT Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: T1503 NOCOV DEF SYSMAN Description: MED ADMIN, NOT ORAL/INJECT Category: Non Covered Services CMS Add: 04/01/2007 CMS Term: T1505 NOCOV DEF SYSMAN Description: ELEC MED COMP DEV, NOC Category: Non Covered Services CMS Add: 01/01/2011 CMS Term: T1999 NOCOV DEF SYSMAN Description: NOC RETAIL ITEMS ANDSUPPLIES Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: T2001 TRANS DEF MAXFEE 01/01/2014 12/31/2023 5.00 0.0 Description: N-ET; PATIENT ATTEND/ESCORT Category: Transportation CMS Add: 04/01/2002 CMS Term: T2001 TRANS DEF MAXFEE 01/01/2024 6.00 0.0 Description: N-ET; PATIENT ATTEND/ESCORT Category: Transportation CMS Add: 04/01/2002 CMS Term: T2002 U2 U5 U7 DDWA WDD MAXFEE 07/01/2021 06/30/2023 23.94 0.0 Y Description: N-ET; PER DIEM Category: CIH Waiver CMS Add: 04/01/2002 CMS Term: T2002 U2 U5 U7 DDWA WDD MAXFEE 07/01/2023 26.52 0.0 Y Description: N-ET; PER DIEM Category: CIH Waiver CMS Add: 04/01/2002 CMS Term: T2002 U2 U5 U7 MFPCI W3M MAXFEE 07/01/2021 06/30/2023 23.94 0.0 Y Description: N-ET; PER DIEM Category: MFP CIH Waiver CMS Add: 04/01/2002 CMS Term: T2002 U2 U5 U7 MFPCI W3M MAXFEE 07/01/2023 26.52 0.0 Y Description: N-ET; PER DIEM Category: MFP CIH Waiver CMS Add: 04/01/2002 CMS Term: T2002 U2 U5 U7 MFPTS W5M MAXFEE 07/01/2021 06/30/2023 23.94 0.0 Y Description: N-ET; PER DIEM Category: MFP SOF Waiver CMS Add: 04/01/2002 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,160 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- T2002 U2 U5 U7 MFPTS W5M MAXFEE 07/01/2023 26.52 0.0 Y Description: N-ET; PER DIEM Category: MFP SOF Waiver CMS Add: 04/01/2002 CMS Term: T2002 U2 U5 U7 SSFS WSS MAXFEE 07/01/2021 06/30/2023 23.94 0.0 Y Description: N-ET; PER DIEM Category: Family Support Waivr CMS Add: 04/01/2002 CMS Term: T2002 U2 U5 U7 SSFS WSS MAXFEE 07/01/2023 26.52 0.0 Y Description: N-ET; PER DIEM Category: Family Support Waivr CMS Add: 04/01/2002 CMS Term: T2002 U3 U5 U7 DDWA WDD MAXFEE 07/01/2021 47.88 0.0 Y Description: N-ET; PER DIEM Category: CIH Waiver CMS Add: 04/01/2002 CMS Term: T2002 U3 U5 U7 MFPCI W3M MAXFEE 07/01/2021 47.88 0.0 Y Description: N-ET; PER DIEM Category: MFP CIH Waiver CMS Add: 04/01/2002 CMS Term: T2002 U3 U5 U7 MFPTS W5M MAXFEE 07/01/2021 47.88 0.0 Y Description: N-ET; PER DIEM Category: MFP SOF Waiver CMS Add: 04/01/2002 CMS Term: T2002 U3 U5 U7 SSFS WSS MAXFEE 07/01/2021 47.88 0.0 Y Description: N-ET; PER DIEM Category: Family Support Waivr CMS Add: 04/01/2002 CMS Term: T2002 U5 U7 DDWA WDD MAXFEE 07/01/2021 06/30/2023 5.99 0.0 Y Description: N-ET; PER DIEM Category: CIH Waiver CMS Add: 04/01/2002 CMS Term: T2002 U5 U7 DDWA WDD MAXFEE 07/01/2023 15.05 0.0 Y Description: N-ET; PER DIEM Category: CIH Waiver CMS Add: 04/01/2002 CMS Term: T2002 U5 U7 MFPCI W3M MAXFEE 07/01/2021 06/30/2023 5.99 0.0 Y Description: N-ET; PER DIEM Category: MFP CIH Waiver CMS Add: 04/01/2002 CMS Term: T2002 U5 U7 MFPCI W3M MAXFEE 07/01/2023 15.05 0.0 Y Description: N-ET; PER DIEM Category: MFP CIH Waiver CMS Add: 04/01/2002 CMS Term: T2002 U5 U7 MFPTS W5M MAXFEE 07/01/2021 06/30/2023 5.99 0.0 Y Description: N-ET; PER DIEM Category: MFP SOF Waiver CMS Add: 04/01/2002 CMS Term: T2002 U5 U7 MFPTS W5M MAXFEE 07/01/2023 15.05 0.0 Y Description: N-ET; PER DIEM Category: MFP SOF Waiver CMS Add: 04/01/2002 CMS Term: T2002 U5 U7 SSFS WSS MAXFEE 07/01/2021 06/30/2023 5.99 0.0 Y Description: N-ET; PER DIEM Category: Family Support Waivr CMS Add: 04/01/2002 CMS Term: T2002 U5 U7 SSFS WSS MAXFEE 07/01/2023 15.05 0.0 Y Description: N-ET; PER DIEM Category: Family Support Waivr CMS Add: 04/01/2002 CMS Term: T2003 HA U1 CMHW WHA MAXFEE 07/01/2023 1.36 0.0 Y 6-18years Description: N-ET; ENCOUNTER/TRIP Category: Child Mentl Hlth Wai CMS Add: 04/01/2002 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,161 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- T2003 HA U1 UB CMHW WHA MAXFEE 07/01/2023 30.02 0.0 Y 6-18years Description: N-ET; ENCOUNTER/TRIP Category: Child Mentl Hlth Wai CMS Add: 04/01/2002 CMS Term: T2003 MRT DEF MAXFEE 01/01/2014 12/31/2023 10.00 0.0 Description: N-ET; ENCOUNTER/TRIP Category: Medical Review Team CMS Add: 04/01/2002 CMS Term: T2003 MRT DEF MAXFEE 01/01/2024 12.00 0.0 Description: N-ET; ENCOUNTER/TRIP Category: Medical Review Team CMS Add: 04/01/2002 CMS Term: T2003 SE MRT DEF MAXFEE 01/01/2024 12.00 0.0 Description: N-ET; ENCOUNTER/TRIP Category: Medical Review Team CMS Add: 04/01/2002 CMS Term: T2003 SE MRT DEF MAXFEE 07/01/2002 12/31/2023 10.00 0.0 Description: N-ET; ENCOUNTER/TRIP Category: Medical Review Team CMS Add: 04/01/2002 CMS Term: T2003 SE TRANS DEF MAXFEE 01/01/2024 12.00 0.0 Description: N-ET; ENCOUNTER/TRIP Category: Transportation CMS Add: 04/01/2002 CMS Term: T2003 SE TRANS DEF MAXFEE 07/01/2002 12/31/2023 10.00 0.0 Description: N-ET; ENCOUNTER/TRIP Category: Transportation CMS Add: 04/01/2002 CMS Term: T2003 TRANS DEF MAXFEE 01/01/2014 12/31/2023 10.00 0.0 Description: N-ET; ENCOUNTER/TRIP Category: Transportation CMS Add: 04/01/2002 CMS Term: T2003 TRANS DEF MAXFEE 01/01/2024 12.00 0.0 Description: N-ET; ENCOUNTER/TRIP Category: Transportation CMS Add: 04/01/2002 CMS Term: T2003 U1 U7 ADWA WAD MAXFEE 02/01/2020 1.06 0.0 Y Description: N-ET; ENCOUNTER/TRIP Category: A&D Waiver CMS Add: 04/01/2002 CMS Term: T2003 U1 U7 MFPAD W1M MAXFEE 02/01/2020 1.06 0.0 Y Description: N-ET; ENCOUNTER/TRIP Category: MFP Demo Grant CMS Add: 04/01/2002 CMS Term: T2003 U1 U7 MFPTB W2M MAXFEE 02/01/2020 1.06 0.0 Y Description: N-ET; ENCOUNTER/TRIP Category: MFP TBI CMS Add: 04/01/2002 CMS Term: T2003 U1 U7 MFPTR W4M MAXFEE 10/01/2012 20.00 0.0 Y Description: N-ET; ENCOUNTER/TRIP Category: MFP PRTF Waiver CMS Add: 04/01/2002 CMS Term: T2003 U1 U7 PRTFW WPT MAXFEE 10/01/2012 20.00 0.0 Y Description: N-ET; ENCOUNTER/TRIP Category: PRTF Trans Waiver CMS Add: 04/01/2002 CMS Term: T2003 U1 U7 TBIWA WTB MAXFEE 02/01/2020 1.06 0.0 Y Description: N-ET; ENCOUNTER/TRIP Category: TBI Waiver CMS Add: 04/01/2002 CMS Term: T2003 U1 U7 UB ADWA WAD MAXFEE 02/01/2020 06/30/2023 8.02 0.0 Y Description: N-ET; ENCOUNTER/TRIP Category: A&D Waiver CMS Add: 04/01/2002 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,162 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- T2003 U1 U7 UB ADWA WAD MAXFEE 07/01/2023 12.12 0.0 Y Description: N-ET; ENCOUNTER/TRIP Category: A&D Waiver CMS Add: 04/01/2002 CMS Term: T2003 U1 U7 UB MFPAD W1M MAXFEE 02/01/2020 06/30/2023 8.02 0.0 Y Description: N-ET; ENCOUNTER/TRIP Category: MFP Demo Grant CMS Add: 04/01/2002 CMS Term: T2003 U1 U7 UB MFPAD W1M MAXFEE 07/01/2023 12.12 0.0 Y Description: N-ET; ENCOUNTER/TRIP Category: MFP Demo Grant CMS Add: 04/01/2002 CMS Term: T2003 U1 U7 UB MFPTB W2M MAXFEE 02/01/2020 06/30/2023 8.02 0.0 Y Description: N-ET; ENCOUNTER/TRIP Category: MFP TBI CMS Add: 04/01/2002 CMS Term: T2003 U1 U7 UB MFPTB W2M MAXFEE 07/01/2023 12.12 0.0 Y Description: N-ET; ENCOUNTER/TRIP Category: MFP TBI CMS Add: 04/01/2002 CMS Term: T2003 U1 U7 UB TBIWA WTB MAXFEE 02/01/2020 06/30/2023 8.02 0.0 Y Description: N-ET; ENCOUNTER/TRIP Category: TBI Waiver CMS Add: 04/01/2002 CMS Term: T2003 U1 U7 UB TBIWA WTB MAXFEE 07/01/2023 12.12 0.0 Y Description: N-ET; ENCOUNTER/TRIP Category: TBI Waiver CMS Add: 04/01/2002 CMS Term: T2003 U2 U7 ADWA WAD MAXFEE 02/01/2020 1.54 0.0 Y Description: N-ET; ENCOUNTER/TRIP Category: A&D Waiver CMS Add: 04/01/2002 CMS Term: T2003 U2 U7 MFPAD W1M MAXFEE 02/01/2020 1.54 0.0 Y Description: N-ET; ENCOUNTER/TRIP Category: MFP Demo Grant CMS Add: 04/01/2002 CMS Term: T2003 U2 U7 MFPTB W2M MAXFEE 02/01/2020 1.54 0.0 Y Description: N-ET; ENCOUNTER/TRIP Category: MFP TBI CMS Add: 04/01/2002 CMS Term: T2003 U2 U7 TBIWA WTB MAXFEE 02/01/2020 1.54 0.0 Y Description: N-ET; ENCOUNTER/TRIP Category: TBI Waiver CMS Add: 04/01/2002 CMS Term: T2003 U2 U7 UB ADWA WAD MAXFEE 02/01/2020 06/30/2023 12.03 0.0 Y Description: N-ET; ENCOUNTER/TRIP Category: A&D Waiver CMS Add: 04/01/2002 CMS Term: T2003 U2 U7 UB ADWA WAD MAXFEE 07/01/2023 20.19 0.0 Y Description: N-ET; ENCOUNTER/TRIP Category: A&D Waiver CMS Add: 04/01/2002 CMS Term: T2003 U2 U7 UB MFPAD W1M MAXFEE 02/01/2020 06/30/2023 12.03 0.0 Y Description: N-ET; ENCOUNTER/TRIP Category: MFP Demo Grant CMS Add: 04/01/2002 CMS Term: T2003 U2 U7 UB MFPAD W1M MAXFEE 07/01/2023 20.19 0.0 Y Description: N-ET; ENCOUNTER/TRIP Category: MFP Demo Grant CMS Add: 04/01/2002 CMS Term: T2003 U2 U7 UB MFPTB W2M MAXFEE 02/01/2020 06/30/2023 12.03 0.0 Y Description: N-ET; ENCOUNTER/TRIP Category: MFP TBI CMS Add: 04/01/2002 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,163 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- T2003 U2 U7 UB MFPTB W2M MAXFEE 07/01/2023 20.19 0.0 Y Description: N-ET; ENCOUNTER/TRIP Category: MFP TBI CMS Add: 04/01/2002 CMS Term: T2003 U2 U7 UB TBIWA WTB MAXFEE 02/01/2020 06/30/2023 12.03 0.0 Y Description: N-ET; ENCOUNTER/TRIP Category: TBI Waiver CMS Add: 04/01/2002 CMS Term: T2003 U2 U7 UB TBIWA WTB MAXFEE 07/01/2023 20.19 0.0 Y Description: N-ET; ENCOUNTER/TRIP Category: TBI Waiver CMS Add: 04/01/2002 CMS Term: T2004 TRANS DEF MAXFEE 01/01/2014 12/31/2023 5.00 0.0 Description: N-ET; COMMERC CARRIER PASS Category: Transportation CMS Add: 04/01/2002 CMS Term: T2004 TRANS DEF MAXFEE 01/01/2024 6.00 0.0 Description: N-ET; COMMERC CARRIER PASS Category: Transportation CMS Add: 04/01/2002 CMS Term: T2005 NOCOV DEF SYSMAN Description: N-ET; STRETCHER VAN Category: Non Covered Services CMS Add: 04/01/2002 CMS Term: T2007 SE MRT DEF MAXFEE 07/01/2002 06/30/2023 4.50 0.0 Description: NON-EMER TRANSPORT WAIT TIME Category: Medical Review Team CMS Add: 01/01/2003 CMS Term: T2007 SE MRT DEF MAXFEE 07/01/2023 7.43 0.0 Description: NON-EMER TRANSPORT WAIT TIME Category: Medical Review Team CMS Add: 01/01/2003 CMS Term: T2007 SE TRANS DEF MAXFEE 07/01/2002 06/30/2023 4.50 0.0 Description: NON-EMER TRANSPORT WAIT TIME Category: Transportation CMS Add: 01/01/2003 CMS Term: T2007 SE TRANS DEF MAXFEE 07/01/2023 7.43 0.0 Description: NON-EMER TRANSPORT WAIT TIME Category: Transportation CMS Add: 01/01/2003 CMS Term: T2007 U3 MRT DEF MAXFEE 01/01/2014 06/30/2023 4.25 0.0 Description: NON-EMER TRANSPORT WAIT TIME Category: Medical Review Team CMS Add: 01/01/2003 CMS Term: T2007 U3 MRT DEF MAXFEE 07/01/2023 7.01 0.0 Description: NON-EMER TRANSPORT WAIT TIME Category: Medical Review Team CMS Add: 01/01/2003 CMS Term: T2007 U3 TRANS DEF MAXFEE 01/01/2014 06/30/2023 4.25 0.0 Description: NON-EMER TRANSPORT WAIT TIME Category: Transportation CMS Add: 01/01/2003 CMS Term: T2007 U3 TRANS DEF MAXFEE 07/01/2023 7.01 0.0 Description: NON-EMER TRANSPORT WAIT TIME Category: Transportation CMS Add: 01/01/2003 CMS Term: T2007 U5 MRT DEF MAXFEE 01/01/2014 06/30/2023 4.25 0.0 Description: NON-EMER TRANSPORT WAIT TIME Category: Medical Review Team CMS Add: 01/01/2003 CMS Term: T2007 U5 MRT DEF MAXFEE 07/01/2023 7.01 0.0 Description: NON-EMER TRANSPORT WAIT TIME Category: Medical Review Team CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,164 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- T2007 U5 TRANS DEF MAXFEE 01/01/2014 06/30/2023 4.25 0.0 Description: NON-EMER TRANSPORT WAIT TIME Category: Transportation CMS Add: 01/01/2003 CMS Term: T2007 U5 TRANS DEF MAXFEE 07/01/2023 7.01 0.0 Description: NON-EMER TRANSPORT WAIT TIME Category: Transportation CMS Add: 01/01/2003 CMS Term: T2010 NOCOV DEF SYSMAN Description: PASRR LEVEL I Category: Non Covered Services CMS Add: 04/01/2003 CMS Term: T2011 HI U1 UA PASRR DEF MAXFEE 01/01/2024 214.05 0.0 0-1 Description: PASRR LEVEL II Category: PASRR CMS Add: 04/01/2003 CMS Term: T2011 HI U1 UA PASRR DEF MAXFEE 07/01/2002 12/31/2023 150.00 0.0 0-1 Description: PASRR LEVEL II Category: PASRR CMS Add: 04/01/2003 CMS Term: T2011 TS U1 UB PASRR DEF MAXFEE 01/01/2024 204.77 0.0 0-1 Description: PASRR LEVEL II Category: PASRR CMS Add: 04/01/2003 CMS Term: T2011 TS U1 UB PASRR DEF MAXFEE 07/01/2002 12/31/2023 143.50 0.0 0-1 Description: PASRR LEVEL II Category: PASRR CMS Add: 04/01/2003 CMS Term: T2011 U1 UA PASRR DEF MAXFEE 01/01/2024 506.59 0.0 0-1 Description: PASRR LEVEL II Category: PASRR CMS Add: 04/01/2003 CMS Term: T2011 U1 UA PASRR DEF MAXFEE 07/01/2002 12/31/2023 355.00 0.0 0-1 Description: PASRR LEVEL II Category: PASRR CMS Add: 04/01/2003 CMS Term: T2011 U1 UB PASRR DEF MAXFEE 01/01/2024 459.49 0.0 0-1 Description: PASRR LEVEL II Category: PASRR CMS Add: 04/01/2003 CMS Term: T2011 U1 UB PASRR DEF MAXFEE 07/01/2002 12/31/2023 322.00 0.0 0-1 Description: PASRR LEVEL II Category: PASRR CMS Add: 04/01/2003 CMS Term: T2011 U2 UA PASRR DEF MAXFEE 01/01/2024 506.59 0.0 0-1 Description: PASRR LEVEL II Category: PASRR CMS Add: 04/01/2003 CMS Term: T2011 U2 UA PASRR DEF MAXFEE 07/01/2002 12/31/2023 355.00 0.0 0-1 Description: PASRR LEVEL II Category: PASRR CMS Add: 04/01/2003 CMS Term: T2011 U2 UB PASRR DEF MAXFEE 01/01/2024 459.49 0.0 0-1 Description: PASRR LEVEL II Category: PASRR CMS Add: 04/01/2003 CMS Term: T2011 U2 UB PASRR DEF MAXFEE 07/01/2002 12/31/2023 322.00 0.0 0-1 Description: PASRR LEVEL II Category: PASRR CMS Add: 04/01/2003 CMS Term: T2012 NOCOV DEF SYSMAN Description: HABIL ED WAIVER, PER DIEM Category: Non Covered Services CMS Add: 10/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,165 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- T2013 NOCOV DEF SYSMAN Description: HABIL ED WAIVER PER HOUR Category: Non Covered Services CMS Add: 10/01/2003 CMS Term: T2014 NOCOV DEF SYSMAN Description: HABIL PREVOC WAIVER, PER D Category: Non Covered Services CMS Add: 10/01/2003 CMS Term: T2015 U2 U5 U7 DDWA WDD MAXFEE 07/01/2021 06/30/2023 10.15 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U2 U5 U7 MFPCI W3M MAXFEE 07/01/2021 06/30/2023 10.15 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U2 U5 U7 MFPTS W5M MAXFEE 07/01/2021 06/30/2023 10.15 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP SOF Waiver CMS Add: 10/01/2003 CMS Term: T2015 U2 U5 U7 SSFS WSS MAXFEE 07/01/2021 06/30/2023 10.15 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2015 U2 U5 U7 UF DDWA WDD MAXFEE 05/01/2023 06/30/2023 10.15 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U2 U5 U7 UF DDWA WDD MAXFEE 07/01/2023 10.81 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U2 U5 U7 UF MFPCI W3M MAXFEE 05/01/2023 06/30/2023 10.15 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U2 U5 U7 UF MFPCI W3M MAXFEE 07/01/2023 10.81 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U2 U5 U7 UF MFPTS W5M MAXFEE 07/01/2023 10.81 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP SOF Waiver CMS Add: 10/01/2003 CMS Term: T2015 U2 U5 U7 UF SSFS WSS MAXFEE 05/01/2023 06/30/2023 10.15 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2015 U2 U5 U7 UF SSFS WSS MAXFEE 07/01/2023 10.81 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2015 U2 U5 U7 UG DDWA WDD MAXFEE 05/01/2023 06/30/2023 10.15 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U2 U5 U7 UG DDWA WDD MAXFEE 07/01/2023 10.81 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U2 U5 U7 UG MFPCI W3M MAXFEE 05/01/2023 06/30/2023 10.15 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,166 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- T2015 U2 U5 U7 UG MFPCI W3M MAXFEE 07/01/2023 10.81 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U2 U5 U7 UG MFPTS W5M MAXFEE 07/01/2023 10.81 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP SOF Waiver CMS Add: 10/01/2003 CMS Term: T2015 U2 U5 U7 UG SSFS WSS MAXFEE 05/01/2023 06/30/2023 10.15 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2015 U2 U5 U7 UG SSFS WSS MAXFEE 07/01/2023 10.81 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2015 U4 U5 U7 DDWA WDD MAXFEE 07/01/2021 06/30/2023 10.15 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U4 U5 U7 MFPCI W3M MAXFEE 07/01/2021 06/30/2023 10.15 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U4 U5 U7 MFPTS W5M MAXFEE 07/01/2021 06/30/2023 10.15 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP SOF Waiver CMS Add: 10/01/2003 CMS Term: T2015 U4 U5 U7 SSFS WSS MAXFEE 07/01/2021 06/30/2023 10.15 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2015 U4 U5 U7 UF DDWA WDD MAXFEE 05/01/2023 06/30/2023 10.15 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U4 U5 U7 UF DDWA WDD MAXFEE 07/01/2023 10.81 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U4 U5 U7 UF MFPCI W3M MAXFEE 05/01/2023 06/30/2023 10.15 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U4 U5 U7 UF MFPCI W3M MAXFEE 07/01/2023 10.81 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U4 U5 U7 UF MFPTS W5M MAXFEE 07/01/2023 10.81 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP SOF Waiver CMS Add: 10/01/2003 CMS Term: T2015 U4 U5 U7 UF SSFS WSS MAXFEE 05/01/2023 06/30/2023 10.15 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2015 U4 U5 U7 UF SSFS WSS MAXFEE 07/01/2023 10.81 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2015 U4 U5 U7 UG DDWA WDD MAXFEE 05/01/2023 06/30/2023 10.15 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,167 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- T2015 U4 U5 U7 UG DDWA WDD MAXFEE 07/01/2023 10.81 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U4 U5 U7 UG MFPCI W3M MAXFEE 05/01/2023 06/30/2023 10.15 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U4 U5 U7 UG MFPCI W3M MAXFEE 07/01/2023 10.81 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U4 U5 U7 UG MFPTS W5M MAXFEE 07/01/2023 10.81 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP SOF Waiver CMS Add: 10/01/2003 CMS Term: T2015 U4 U5 U7 UG SSFS WSS MAXFEE 05/01/2023 06/30/2023 10.15 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2015 U4 U5 U7 UG SSFS WSS MAXFEE 07/01/2023 10.81 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2015 U5 U6 U7 DDWA WDD MAXFEE 07/01/2021 06/30/2023 5.65 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U6 U7 MFPCI W3M MAXFEE 07/01/2021 06/30/2023 5.65 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U6 U7 MFPTS W5M MAXFEE 07/01/2021 06/30/2023 5.65 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP SOF Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U6 U7 SSFS WSS MAXFEE 07/01/2021 06/30/2023 5.65 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2015 U5 U6 U7 UF DDWA WDD MAXFEE 05/01/2023 06/30/2023 5.65 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U6 U7 UF DDWA WDD MAXFEE 07/01/2023 5.66 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U6 U7 UF MFPCI W3M MAXFEE 05/01/2023 06/30/2023 5.65 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U6 U7 UF MFPCI W3M MAXFEE 07/01/2023 5.66 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U6 U7 UF MFPTS W5M MAXFEE 07/01/2023 5.66 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP SOF Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U6 U7 UF SSFS WSS MAXFEE 05/01/2023 06/30/2023 5.65 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,168 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- T2015 U5 U6 U7 UF SSFS WSS MAXFEE 07/01/2023 5.66 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2015 U5 U6 U7 UG DDWA WDD MAXFEE 05/01/2023 06/30/2023 5.65 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U6 U7 UG DDWA WDD MAXFEE 07/01/2023 5.66 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U6 U7 UG MFPCI W3M MAXFEE 05/01/2023 06/30/2023 5.65 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U6 U7 UG MFPCI W3M MAXFEE 07/01/2023 5.66 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U6 U7 UG MFPTS W5M MAXFEE 07/01/2023 5.66 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP SOF Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U6 U7 UG SSFS WSS MAXFEE 05/01/2023 06/30/2023 5.65 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2015 U5 U6 U7 UG SSFS WSS MAXFEE 07/01/2023 5.66 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 U9 DDWA WDD MAXFEE 07/01/2021 06/30/2023 3.59 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 U9 MFPCI W3M MAXFEE 07/01/2021 06/30/2023 3.59 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 U9 MFPTS W5M MAXFEE 07/01/2021 06/30/2023 3.59 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP SOF Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 U9 SSFS WSS MAXFEE 07/01/2021 06/30/2023 3.59 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 U9 UF DDWA WDD MAXFEE 05/01/2023 06/30/2023 3.59 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 U9 UF DDWA WDD MAXFEE 07/01/2023 3.73 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 U9 UF MFPCI W3M MAXFEE 05/01/2023 06/30/2023 3.59 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 U9 UF MFPCI W3M MAXFEE 07/01/2023 3.73 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,169 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- T2015 U5 U7 U9 UF MFPTS W5M MAXFEE 07/01/2023 3.73 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP SOF Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 U9 UF SSFS WSS MAXFEE 05/01/2023 06/30/2023 3.59 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 U9 UF SSFS WSS MAXFEE 07/01/2023 3.73 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 U9 UG DDWA WDD MAXFEE 05/01/2023 06/30/2023 3.59 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 U9 UG DDWA WDD MAXFEE 07/01/2023 3.73 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 U9 UG MFPCI W3M MAXFEE 05/01/2023 06/30/2023 3.59 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 U9 UG MFPCI W3M MAXFEE 07/01/2023 3.73 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 U9 UG MFPTS W5M MAXFEE 07/01/2023 3.73 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP SOF Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 U9 UG SSFS WSS MAXFEE 05/01/2023 06/30/2023 3.59 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 U9 UG SSFS WSS MAXFEE 07/01/2023 3.73 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UA DDWA WDD MAXFEE 07/01/2021 06/30/2023 5.65 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UA MFPCI W3M MAXFEE 07/01/2021 06/30/2023 5.65 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UA MFPTS W5M MAXFEE 07/01/2021 06/30/2023 5.65 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP SOF Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UA SSFS WSS MAXFEE 07/01/2021 06/30/2023 5.65 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UA UF DDWA WDD MAXFEE 05/01/2023 06/30/2023 5.65 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UA UF DDWA WDD MAXFEE 07/01/2023 5.66 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,170 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- T2015 U5 U7 UA UF MFPCI W3M MAXFEE 05/01/2023 06/30/2023 5.65 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UA UF MFPCI W3M MAXFEE 07/01/2023 5.66 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UA UF MFPTS W5M MAXFEE 07/01/2023 5.66 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP SOF Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UA UF SSFS WSS MAXFEE 05/01/2023 06/30/2023 5.65 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UA UF SSFS WSS MAXFEE 07/01/2023 5.66 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UA UG DDWA WDD MAXFEE 05/01/2023 06/30/2023 5.65 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UA UG DDWA WDD MAXFEE 07/01/2023 5.66 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UA UG MFPCI W3M MAXFEE 05/01/2023 06/30/2023 5.65 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UA UG MFPCI W3M MAXFEE 07/01/2023 5.66 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UA UG MFPTS W5M MAXFEE 07/01/2023 5.66 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP SOF Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UA UG SSFS WSS MAXFEE 05/01/2023 06/30/2023 5.65 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UA UG SSFS WSS MAXFEE 07/01/2023 5.66 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UB DDWA WDD MAXFEE 07/01/2021 06/30/2023 5.65 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UB MFPCI W3M MAXFEE 07/01/2021 06/30/2023 5.65 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UB MFPTS W5M MAXFEE 07/01/2021 06/30/2023 5.65 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP SOF Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UB SSFS WSS MAXFEE 07/01/2021 06/30/2023 5.65 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,171 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- T2015 U5 U7 UB UF DDWA WDD MAXFEE 05/01/2023 06/30/2023 5.65 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UB UF DDWA WDD MAXFEE 07/01/2023 5.66 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UB UF MFPCI W3M MAXFEE 05/01/2023 06/30/2023 5.65 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UB UF MFPCI W3M MAXFEE 07/01/2023 5.66 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UB UF MFPTS W5M MAXFEE 07/01/2023 5.66 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP SOF Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UB UF SSFS WSS MAXFEE 05/01/2023 06/30/2023 5.65 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UB UF SSFS WSS MAXFEE 07/01/2023 5.66 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UB UG DDWA WDD MAXFEE 05/01/2023 06/30/2023 5.65 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UB UG DDWA WDD MAXFEE 07/01/2023 5.66 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UB UG MFPCI W3M MAXFEE 05/01/2023 06/30/2023 5.65 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UB UG MFPCI W3M MAXFEE 07/01/2023 5.66 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UB UG MFPTS W5M MAXFEE 07/01/2023 5.66 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP SOF Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UB UG SSFS WSS MAXFEE 05/01/2023 06/30/2023 5.65 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UB UG SSFS WSS MAXFEE 07/01/2023 5.66 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UC DDWA WDD MAXFEE 07/01/2021 06/30/2023 3.59 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UC MFPCI W3M MAXFEE 07/01/2021 06/30/2023 3.59 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,172 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- T2015 U5 U7 UC MFPTS W5M MAXFEE 07/01/2021 06/30/2023 3.59 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP SOF Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UC SSFS WSS MAXFEE 07/01/2021 06/30/2023 3.59 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UC UF DDWA WDD MAXFEE 05/01/2023 06/30/2023 3.59 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UC UF DDWA WDD MAXFEE 07/01/2023 3.73 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UC UF MFPCI W3M MAXFEE 05/01/2023 06/30/2023 3.59 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UC UF MFPCI W3M MAXFEE 07/01/2023 3.73 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UC UF MFPTS W5M MAXFEE 07/01/2023 3.73 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP SOF Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UC UF SSFS WSS MAXFEE 05/01/2023 06/30/2023 3.59 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UC UF SSFS WSS MAXFEE 07/01/2023 3.73 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UC UG DDWA WDD MAXFEE 05/01/2023 06/30/2023 3.59 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UC UG DDWA WDD MAXFEE 07/01/2023 3.73 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UC UG MFPCI W3M MAXFEE 05/01/2023 06/30/2023 3.59 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UC UG MFPCI W3M MAXFEE 07/01/2023 3.73 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UC UG MFPTS W5M MAXFEE 07/01/2023 3.73 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP SOF Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UC UG SSFS WSS MAXFEE 05/01/2023 06/30/2023 3.59 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UC UG SSFS WSS MAXFEE 07/01/2023 3.73 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,173 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- T2015 U5 U7 UD DDWA WDD MAXFEE 07/01/2021 06/30/2023 3.59 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UD MFPCI W3M MAXFEE 07/01/2021 06/30/2023 3.59 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UD MFPTS W5M MAXFEE 07/01/2021 06/30/2023 3.59 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP SOF Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UD SSFS WSS MAXFEE 07/01/2021 06/30/2023 3.59 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UD UF DDWA WDD MAXFEE 05/01/2023 06/30/2023 3.59 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UD UF DDWA WDD MAXFEE 07/01/2023 3.73 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UD UF MFPCI W3M MAXFEE 05/01/2023 06/30/2023 3.59 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UD UF MFPCI W3M MAXFEE 07/01/2023 3.73 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UD UF MFPTS W5M MAXFEE 07/01/2023 3.73 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP SOF Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UD UF SSFS WSS MAXFEE 05/01/2023 06/30/2023 3.59 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UD UF SSFS WSS MAXFEE 07/01/2023 3.73 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UD UG DDWA WDD MAXFEE 05/01/2023 06/30/2023 3.59 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UD UG DDWA WDD MAXFEE 07/01/2023 3.73 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UD UG MFPCI W3M MAXFEE 05/01/2023 06/30/2023 3.59 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UD UG MFPCI W3M MAXFEE 07/01/2023 3.73 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UD UG MFPTS W5M MAXFEE 07/01/2023 3.73 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: MFP SOF Waiver CMS Add: 10/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,174 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- T2015 U5 U7 UD UG SSFS WSS MAXFEE 05/01/2023 06/30/2023 3.59 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2015 U5 U7 UD UG SSFS WSS MAXFEE 07/01/2023 3.73 0.0 Y Description: HABIL PREVOC WAIVER PER HR Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2016 TG U5 U7 DDWA WDD MAXFEE 04/01/2015 1500.00 0.0 Y Description: HABIL RES WAIVER PER DIEM Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2016 TG U5 U7 MFPCI W3M MAXFEE 04/01/2015 1500.00 0.0 Y Description: HABIL RES WAIVER PER DIEM Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2016 TG U5 U7 MFPTS W5M MAXFEE 04/01/2015 1500.00 0.0 Y Description: HABIL RES WAIVER PER DIEM Category: MFP SOF Waiver CMS Add: 10/01/2003 CMS Term: T2016 TG U5 U7 SSFS WSS MAXFEE 04/01/2015 1500.00 0.0 Y Description: HABIL RES WAIVER PER DIEM Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2016 U5 U7 DDWA WDD MAXFEE 07/01/2021 06/30/2023 25.05 0.0 Y Description: HABIL RES WAIVER PER DIEM Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2016 U5 U7 DDWA WDD MAXFEE 07/01/2023 30.36 0.0 Y Description: HABIL RES WAIVER PER DIEM Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2016 U5 U7 MFPCI W3M MAXFEE 07/01/2021 06/30/2023 25.05 0.0 Y Description: HABIL RES WAIVER PER DIEM Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2016 U5 U7 MFPCI W3M MAXFEE 07/01/2023 30.36 0.0 Y Description: HABIL RES WAIVER PER DIEM Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2016 U5 U7 UA DDWA WDD MAXFEE 07/01/2021 06/30/2023 29.81 0.0 Y Description: HABIL RES WAIVER PER DIEM Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2016 U5 U7 UA DDWA WDD MAXFEE 07/01/2023 35.02 0.0 Y Description: HABIL RES WAIVER PER DIEM Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2016 U5 U7 UA MFPCI W3M MAXFEE 07/01/2021 06/30/2023 29.81 0.0 Y Description: HABIL RES WAIVER PER DIEM Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2016 U5 U7 UA MFPCI W3M MAXFEE 07/01/2023 35.02 0.0 Y Description: HABIL RES WAIVER PER DIEM Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2016 U5 U7 UA UN DDWA WDD MAXFEE 07/01/2021 06/30/2023 195.32 0.0 Y Description: HABIL RES WAIVER PER DIEM Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2016 U5 U7 UA UN DDWA WDD MAXFEE 07/01/2023 237.77 0.0 Y Description: HABIL RES WAIVER PER DIEM Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,175 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- T2016 U5 U7 UA UN MFPCI W3M MAXFEE 07/01/2021 06/30/2023 195.32 0.0 Y Description: HABIL RES WAIVER PER DIEM Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2016 U5 U7 UA UN MFPCI W3M MAXFEE 07/01/2023 237.77 0.0 Y Description: HABIL RES WAIVER PER DIEM Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2016 U5 U7 UA UP DDWA WDD MAXFEE 07/01/2021 06/30/2023 195.32 0.0 Y Description: HABIL RES WAIVER PER DIEM Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2016 U5 U7 UA UP DDWA WDD MAXFEE 07/01/2023 233.90 0.0 Y Description: HABIL RES WAIVER PER DIEM Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2016 U5 U7 UA UP MFPCI W3M MAXFEE 07/01/2021 06/30/2023 195.32 0.0 Y Description: HABIL RES WAIVER PER DIEM Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2016 U5 U7 UA UP MFPCI W3M MAXFEE 07/01/2023 233.90 0.0 Y Description: HABIL RES WAIVER PER DIEM Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2016 U5 U7 UA UQ DDWA WDD MAXFEE 07/01/2021 06/30/2023 182.80 0.0 Y Description: HABIL RES WAIVER PER DIEM Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2016 U5 U7 UA UQ DDWA WDD MAXFEE 07/01/2023 220.86 0.0 Y Description: HABIL RES WAIVER PER DIEM Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2016 U5 U7 UA UQ MFPCI W3M MAXFEE 07/01/2021 06/30/2023 182.80 0.0 Y Description: HABIL RES WAIVER PER DIEM Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2016 U5 U7 UA UQ MFPCI W3M MAXFEE 07/01/2023 220.86 0.0 Y Description: HABIL RES WAIVER PER DIEM Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2016 U5 U7 UB UN DDWA WDD MAXFEE 07/01/2021 06/30/2023 275.46 0.0 Y Description: HABIL RES WAIVER PER DIEM Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2016 U5 U7 UB UN DDWA WDD MAXFEE 07/01/2023 331.74 0.0 Y Description: HABIL RES WAIVER PER DIEM Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2016 U5 U7 UB UN MFPCI W3M MAXFEE 07/01/2021 06/30/2023 275.46 0.0 Y Description: HABIL RES WAIVER PER DIEM Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2016 U5 U7 UB UN MFPCI W3M MAXFEE 07/01/2023 331.74 0.0 Y Description: HABIL RES WAIVER PER DIEM Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2016 U5 U7 UB UP DDWA WDD MAXFEE 07/01/2021 06/30/2023 252.91 0.0 Y Description: HABIL RES WAIVER PER DIEM Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2016 U5 U7 UB UP DDWA WDD MAXFEE 07/01/2023 303.31 0.0 Y Description: HABIL RES WAIVER PER DIEM Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,176 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- T2016 U5 U7 UB UP MFPCI W3M MAXFEE 07/01/2021 06/30/2023 252.91 0.0 Y Description: HABIL RES WAIVER PER DIEM Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2016 U5 U7 UB UP MFPCI W3M MAXFEE 07/01/2023 303.31 0.0 Y Description: HABIL RES WAIVER PER DIEM Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2016 U5 U7 UB UQ DDWA WDD MAXFEE 07/01/2021 06/30/2023 235.38 0.0 Y Description: HABIL RES WAIVER PER DIEM Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2016 U5 U7 UB UQ DDWA WDD MAXFEE 07/01/2023 280.27 0.0 Y Description: HABIL RES WAIVER PER DIEM Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2016 U5 U7 UB UQ MFPCI W3M MAXFEE 07/01/2021 06/30/2023 235.38 0.0 Y Description: HABIL RES WAIVER PER DIEM Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2016 U5 U7 UB UQ MFPCI W3M MAXFEE 07/01/2023 280.27 0.0 Y Description: HABIL RES WAIVER PER DIEM Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2016 U5 U7 UC UN DDWA WDD MAXFEE 07/01/2021 06/30/2023 300.49 0.0 Y Description: HABIL RES WAIVER PER DIEM Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2016 U5 U7 UC UN DDWA WDD MAXFEE 07/01/2023 357.86 0.0 Y Description: HABIL RES WAIVER PER DIEM Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2016 U5 U7 UC UN MFPCI W3M MAXFEE 07/01/2021 06/30/2023 300.49 0.0 Y Description: HABIL RES WAIVER PER DIEM Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2016 U5 U7 UC UN MFPCI W3M MAXFEE 07/01/2023 357.86 0.0 Y Description: HABIL RES WAIVER PER DIEM Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2016 U5 U7 UC UP DDWA WDD MAXFEE 07/01/2021 06/30/2023 275.46 0.0 Y Description: HABIL RES WAIVER PER DIEM Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2016 U5 U7 UC UP DDWA WDD MAXFEE 07/01/2023 332.84 0.0 Y Description: HABIL RES WAIVER PER DIEM Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2016 U5 U7 UC UP MFPCI W3M MAXFEE 07/01/2021 06/30/2023 275.46 0.0 Y Description: HABIL RES WAIVER PER DIEM Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2016 U5 U7 UC UP MFPCI W3M MAXFEE 07/01/2023 332.84 0.0 Y Description: HABIL RES WAIVER PER DIEM Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2016 U5 U7 UC UQ DDWA WDD MAXFEE 07/01/2021 06/30/2023 250.41 0.0 Y Description: HABIL RES WAIVER PER DIEM Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2016 U5 U7 UC UQ DDWA WDD MAXFEE 07/01/2023 298.60 0.0 Y Description: HABIL RES WAIVER PER DIEM Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,177 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- T2016 U5 U7 UC UQ MFPCI W3M MAXFEE 07/01/2021 06/30/2023 250.41 0.0 Y Description: HABIL RES WAIVER PER DIEM Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2016 U5 U7 UC UQ MFPCI W3M MAXFEE 07/01/2023 298.60 0.0 Y Description: HABIL RES WAIVER PER DIEM Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2017 NOCOV DEF SYSMAN Description: HABIL RES WAIVER 15 MIN Category: Non Covered Services CMS Add: 10/01/2003 CMS Term: T2019 NOCOV DEF SYSMAN Description: HABIL SUP EMPL WAIVER 15MIN Category: Non Covered Services CMS Add: 10/01/2003 CMS Term: T2020 U2 U5 U7 DDWA WDD MAXFEE 07/01/2021 06/30/2023 10.15 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2020 U2 U5 U7 MFPCI W3M MAXFEE 07/01/2021 06/30/2023 10.15 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2020 U2 U5 U7 MFPTS W5M MAXFEE 07/01/2021 06/30/2023 10.15 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: MFP SOF Waiver CMS Add: 10/01/2003 CMS Term: T2020 U2 U5 U7 SSFS WSS MAXFEE 07/01/2021 06/30/2023 10.15 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2020 U2 U5 U7 UF DDWA WDD MAXFEE 05/01/2023 06/30/2023 10.15 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2020 U2 U5 U7 UF DDWA WDD MAXFEE 07/01/2023 13.28 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2020 U2 U5 U7 UF MFPCI W3M MAXFEE 05/01/2023 06/30/2023 10.15 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2020 U2 U5 U7 UF MFPCI W3M MAXFEE 07/01/2023 13.28 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2020 U2 U5 U7 UF MFPTS W5M MAXFEE 07/01/2023 13.28 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: MFP SOF Waiver CMS Add: 10/01/2003 CMS Term: T2020 U2 U5 U7 UF SSFS WSS MAXFEE 05/01/2023 06/30/2023 10.15 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2020 U2 U5 U7 UF SSFS WSS MAXFEE 07/01/2023 13.28 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2020 U2 U5 U7 UG DDWA WDD MAXFEE 05/01/2023 06/30/2023 10.15 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,178 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- T2020 U2 U5 U7 UG DDWA WDD MAXFEE 07/01/2023 13.28 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2020 U2 U5 U7 UG MFPCI W3M MAXFEE 05/01/2023 06/30/2023 10.15 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2020 U2 U5 U7 UG MFPCI W3M MAXFEE 07/01/2023 13.28 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2020 U2 U5 U7 UG MFPTS W5M MAXFEE 07/01/2023 13.28 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: MFP SOF Waiver CMS Add: 10/01/2003 CMS Term: T2020 U2 U5 U7 UG SSFS WSS MAXFEE 05/01/2023 06/30/2023 10.15 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2020 U2 U5 U7 UG SSFS WSS MAXFEE 07/01/2023 13.28 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2020 U5 U7 DDWA WDD MAXFEE 07/01/2021 06/30/2023 28.33 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2020 U5 U7 MFPCI W3M MAXFEE 07/01/2021 06/30/2023 28.33 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2020 U5 U7 MFPTS W5M MAXFEE 07/01/2021 06/30/2023 28.33 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: MFP SOF Waiver CMS Add: 10/01/2003 CMS Term: T2020 U5 U7 SSFS WSS MAXFEE 07/01/2021 06/30/2023 28.33 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2020 U5 U7 UA DDWA WDD MAXFEE 07/01/2021 06/30/2023 5.65 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2020 U5 U7 UA MFPCI W3M MAXFEE 07/01/2021 06/30/2023 5.65 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2020 U5 U7 UA MFPTS W5M MAXFEE 07/01/2021 06/30/2023 5.65 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: MFP SOF Waiver CMS Add: 10/01/2003 CMS Term: T2020 U5 U7 UA SSFS WSS MAXFEE 07/01/2021 06/30/2023 5.65 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2020 U5 U7 UA UF DDWA WDD MAXFEE 05/01/2023 06/30/2023 5.65 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2020 U5 U7 UA UF DDWA WDD MAXFEE 07/01/2023 6.54 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,179 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- T2020 U5 U7 UA UF MFPCI W3M MAXFEE 05/01/2023 06/30/2023 5.65 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2020 U5 U7 UA UF MFPCI W3M MAXFEE 07/01/2023 6.54 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2020 U5 U7 UA UF MFPTS W5M MAXFEE 07/01/2023 6.54 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: MFP SOF Waiver CMS Add: 10/01/2003 CMS Term: T2020 U5 U7 UA UF SSFS WSS MAXFEE 05/01/2023 06/30/2023 5.65 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2020 U5 U7 UA UF SSFS WSS MAXFEE 07/01/2023 6.54 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2020 U5 U7 UA UG DDWA WDD MAXFEE 05/01/2023 06/30/2023 5.65 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2020 U5 U7 UA UG DDWA WDD MAXFEE 07/01/2023 6.54 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2020 U5 U7 UA UG MFPCI W3M MAXFEE 05/01/2023 06/30/2023 5.65 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2020 U5 U7 UA UG MFPCI W3M MAXFEE 07/01/2023 6.54 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2020 U5 U7 UA UG MFPTS W5M MAXFEE 07/01/2023 6.54 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: MFP SOF Waiver CMS Add: 10/01/2003 CMS Term: T2020 U5 U7 UA UG SSFS WSS MAXFEE 05/01/2023 06/30/2023 5.65 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2020 U5 U7 UA UG SSFS WSS MAXFEE 07/01/2023 6.54 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2020 U5 U7 UB DDWA WDD MAXFEE 07/01/2021 06/30/2023 3.59 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2020 U5 U7 UB MFPCI W3M MAXFEE 07/01/2021 06/30/2023 3.59 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2020 U5 U7 UB MFPTS W5M MAXFEE 07/01/2021 06/30/2023 3.59 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: MFP SOF Waiver CMS Add: 10/01/2003 CMS Term: T2020 U5 U7 UB SSFS WSS MAXFEE 07/01/2021 06/30/2023 3.59 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,180 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- T2020 U5 U7 UB UF DDWA WDD MAXFEE 05/01/2023 06/30/2023 3.59 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2020 U5 U7 UB UF DDWA WDD MAXFEE 07/01/2023 4.20 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2020 U5 U7 UB UF MFPCI W3M MAXFEE 05/01/2023 06/30/2023 3.59 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2020 U5 U7 UB UF MFPCI W3M MAXFEE 07/01/2023 4.20 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2020 U5 U7 UB UF MFPTS W5M MAXFEE 07/01/2023 4.20 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: MFP SOF Waiver CMS Add: 10/01/2003 CMS Term: T2020 U5 U7 UB UF SSFS WSS MAXFEE 05/01/2023 06/30/2023 3.59 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2020 U5 U7 UB UF SSFS WSS MAXFEE 07/01/2023 4.20 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2020 U5 U7 UB UG DDWA WDD MAXFEE 05/01/2023 06/30/2023 3.59 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2020 U5 U7 UB UG DDWA WDD MAXFEE 07/01/2023 4.20 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2020 U5 U7 UB UG MFPCI W3M MAXFEE 05/01/2023 06/30/2023 3.59 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2020 U5 U7 UB UG MFPCI W3M MAXFEE 07/01/2023 4.20 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2020 U5 U7 UB UG MFPTS W5M MAXFEE 07/01/2023 4.20 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: MFP SOF Waiver CMS Add: 10/01/2003 CMS Term: T2020 U5 U7 UB UG SSFS WSS MAXFEE 05/01/2023 06/30/2023 3.59 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2020 U5 U7 UB UG SSFS WSS MAXFEE 07/01/2023 4.20 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2020 U5 U7 UF DDWA WDD MAXFEE 05/01/2023 06/30/2023 28.33 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2020 U5 U7 UF DDWA WDD MAXFEE 07/01/2023 36.88 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,181 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- T2020 U5 U7 UF MFPCI W3M MAXFEE 05/01/2023 06/30/2023 28.33 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2020 U5 U7 UF MFPCI W3M MAXFEE 07/01/2023 36.88 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2020 U5 U7 UF MFPTS W5M MAXFEE 07/01/2023 36.88 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: MFP SOF Waiver CMS Add: 10/01/2003 CMS Term: T2020 U5 U7 UF SSFS WSS MAXFEE 05/01/2023 06/30/2023 28.33 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2020 U5 U7 UF SSFS WSS MAXFEE 07/01/2023 36.88 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2020 U5 U7 UG DDWA WDD MAXFEE 05/01/2023 06/30/2023 28.33 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2020 U5 U7 UG DDWA WDD MAXFEE 07/01/2023 36.88 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2020 U5 U7 UG MFPCI W3M MAXFEE 05/01/2023 06/30/2023 28.33 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2020 U5 U7 UG MFPCI W3M MAXFEE 07/01/2023 36.88 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2020 U5 U7 UG MFPTS W5M MAXFEE 07/01/2023 36.88 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: MFP SOF Waiver CMS Add: 10/01/2003 CMS Term: T2020 U5 U7 UG SSFS WSS MAXFEE 05/01/2023 06/30/2023 28.33 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2020 U5 U7 UG SSFS WSS MAXFEE 07/01/2023 36.88 0.0 Y Description: DAY HABIL WAIVER PER DIEM Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2021 HQ U7 MFPTB W2M MAXFEE 06/02/2008 06/30/2023 1.67 0.0 Y Description: DAY HABIL WAIVER PER 15 MIN Category: MFP TBI CMS Add: 10/01/2003 CMS Term: T2021 HQ U7 MFPTB W2M MAXFEE 07/01/2023 2.35 0.0 Y Description: DAY HABIL WAIVER PER 15 MIN Category: MFP TBI CMS Add: 10/01/2003 CMS Term: T2021 HQ U7 TBIWA WTB MAXFEE 01/01/2004 06/30/2023 1.67 0.0 Y Description: DAY HABIL WAIVER PER 15 MIN Category: TBI Waiver CMS Add: 10/01/2003 CMS Term: T2021 HQ U7 TBIWA WTB MAXFEE 07/01/2023 2.35 0.0 Y Description: DAY HABIL WAIVER PER 15 MIN Category: TBI Waiver CMS Add: 10/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,182 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- T2021 U7 MFPTB W2M MAXFEE 06/02/2008 06/30/2023 8.38 0.0 Y Description: DAY HABIL WAIVER PER 15 MIN Category: MFP TBI CMS Add: 10/01/2003 CMS Term: T2021 U7 MFPTB W2M MAXFEE 07/01/2023 10.05 0.0 Y Description: DAY HABIL WAIVER PER 15 MIN Category: MFP TBI CMS Add: 10/01/2003 CMS Term: T2021 U7 TBIWA WTB MAXFEE 01/01/2004 06/30/2023 8.38 0.0 Y Description: DAY HABIL WAIVER PER 15 MIN Category: TBI Waiver CMS Add: 10/01/2003 CMS Term: T2021 U7 TBIWA WTB MAXFEE 07/01/2023 10.05 0.0 Y Description: DAY HABIL WAIVER PER 15 MIN Category: TBI Waiver CMS Add: 10/01/2003 CMS Term: T2022 HA CMHW WHA MAXFEE 07/01/2018 12/06/2023 965.49 0.0 Y 6-18years Description: CASE MANAGEMENT, PER MONTH Category: Child Mentl Hlth Wai CMS Add: 10/01/2003 CMS Term: T2022 HA CMHW WHA MAXFEE 12/07/2023 1074.69 0.0 Y 6-18years Description: CASE MANAGEMENT, PER MONTH Category: Child Mentl Hlth Wai CMS Add: 10/01/2003 CMS Term: T2022 U1 U5 U7 DDWA WDD MAXFEE 01/01/2014 06/30/2023 52.77 0.0 Y Description: CASE MANAGEMENT, PER MONTH Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2022 U1 U5 U7 DDWA WDD MAXFEE 07/01/2023 118.66 0.0 Y Description: CASE MANAGEMENT, PER MONTH Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2022 U1 U5 U7 MFPCI W3M MAXFEE 01/01/2014 06/30/2023 52.77 0.0 Y Description: CASE MANAGEMENT, PER MONTH Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2022 U1 U5 U7 MFPCI W3M MAXFEE 07/01/2023 118.66 0.0 Y Description: CASE MANAGEMENT, PER MONTH Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2022 U1 U7 ADWA WAD MAXFEE 02/01/2020 06/30/2023 10.30 0.0 Y Description: CASE MANAGEMENT, PER MONTH Category: A&D Waiver CMS Add: 10/01/2003 CMS Term: T2022 U1 U7 ADWA WAD MAXFEE 07/01/2023 14.21 0.0 Y Description: CASE MANAGEMENT, PER MONTH Category: A&D Waiver CMS Add: 10/01/2003 CMS Term: T2022 U1 U7 MFPAD W1M MAXFEE 02/01/2020 06/30/2023 10.30 0.0 Y Description: CASE MANAGEMENT, PER MONTH Category: MFP Demo Grant CMS Add: 10/01/2003 CMS Term: T2022 U1 U7 MFPAD W1M MAXFEE 07/01/2023 14.21 0.0 Y Description: CASE MANAGEMENT, PER MONTH Category: MFP Demo Grant CMS Add: 10/01/2003 CMS Term: T2022 U1 U7 MFPTB W2M MAXFEE 07/01/2023 14.21 0.0 Y Description: CASE MANAGEMENT, PER MONTH Category: MFP TBI CMS Add: 10/01/2003 CMS Term: T2022 U1 U7 TBIWA WTB MAXFEE 07/01/2023 14.21 0.0 Y Description: CASE MANAGEMENT, PER MONTH Category: TBI Waiver CMS Add: 10/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,183 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- T2022 U2 U5 U7 DDWA WDD MAXFEE 01/01/2014 06/30/2023 111.96 0.0 Y Description: CASE MANAGEMENT, PER MONTH Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2022 U2 U5 U7 DDWA WDD MAXFEE 07/01/2023 163.02 0.0 Y Description: CASE MANAGEMENT, PER MONTH Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2022 U2 U5 U7 MFPCI W3M MAXFEE 01/01/2014 06/30/2023 111.96 0.0 Y Description: CASE MANAGEMENT, PER MONTH Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2022 U2 U5 U7 MFPCI W3M MAXFEE 07/01/2023 163.02 0.0 Y Description: CASE MANAGEMENT, PER MONTH Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2022 U3 U5 U7 DDWA WDD MAXFEE 01/01/2014 06/30/2023 223.92 0.0 Y Description: CASE MANAGEMENT, PER MONTH Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2022 U3 U5 U7 DDWA WDD MAXFEE 07/01/2023 251.74 0.0 Y Description: CASE MANAGEMENT, PER MONTH Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2022 U3 U5 U7 MFPCI W3M MAXFEE 01/01/2014 06/30/2023 223.92 0.0 Y Description: CASE MANAGEMENT, PER MONTH Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2022 U3 U5 U7 MFPCI W3M MAXFEE 07/01/2023 251.74 0.0 Y Description: CASE MANAGEMENT, PER MONTH Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2022 U5 U7 DDWA WDD MAXFEE 07/01/2023 189.56 0.0 Y Description: CASE MANAGEMENT, PER MONTH Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2022 U5 U7 DDWA WDD MAXFEE 07/16/2020 06/30/2023 143.75 0.0 Y Description: CASE MANAGEMENT, PER MONTH Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2022 U5 U7 MFPCI W3M MAXFEE 07/01/2023 189.56 0.0 Y Description: CASE MANAGEMENT, PER MONTH Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2022 U5 U7 MFPCI W3M MAXFEE 07/16/2020 06/30/2023 143.75 0.0 Y Description: CASE MANAGEMENT, PER MONTH Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2022 U5 U7 MFPTS W5M MAXFEE 07/01/2023 189.56 0.0 Y Description: CASE MANAGEMENT, PER MONTH Category: MFP SOF Waiver CMS Add: 10/01/2003 CMS Term: T2022 U5 U7 MFPTS W5M MAXFEE 07/16/2020 06/30/2023 143.75 0.0 Y Description: CASE MANAGEMENT, PER MONTH Category: MFP SOF Waiver CMS Add: 10/01/2003 CMS Term: T2022 U5 U7 SSFS WSS MAXFEE 07/01/2023 189.56 0.0 Y Description: CASE MANAGEMENT, PER MONTH Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2022 U5 U7 SSFS WSS MAXFEE 07/16/2020 06/30/2023 143.75 0.0 Y Description: CASE MANAGEMENT, PER MONTH Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,184 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- T2022 U7 ADWA WAD MAXFEE 02/01/2020 06/30/2023 134.33 0.0 Y Description: CASE MANAGEMENT, PER MONTH Category: A&D Waiver CMS Add: 10/01/2003 CMS Term: T2022 U7 ADWA WAD MAXFEE 07/01/2023 189.56 0.0 Y Description: CASE MANAGEMENT, PER MONTH Category: A&D Waiver CMS Add: 10/01/2003 CMS Term: T2022 U7 MFPAD W1M MAXFEE 02/01/2020 06/30/2023 134.33 0.0 Y Description: CASE MANAGEMENT, PER MONTH Category: MFP Demo Grant CMS Add: 10/01/2003 CMS Term: T2022 U7 MFPAD W1M MAXFEE 07/01/2023 189.56 0.0 Y Description: CASE MANAGEMENT, PER MONTH Category: MFP Demo Grant CMS Add: 10/01/2003 CMS Term: T2022 U7 MFPTB W2M MAXFEE 02/01/2020 06/30/2023 134.33 0.0 Y Description: CASE MANAGEMENT, PER MONTH Category: MFP TBI CMS Add: 10/01/2003 CMS Term: T2022 U7 MFPTB W2M MAXFEE 07/01/2023 189.56 0.0 Y Description: CASE MANAGEMENT, PER MONTH Category: MFP TBI CMS Add: 10/01/2003 CMS Term: T2022 U7 TBIWA WTB MAXFEE 02/01/2020 06/30/2023 134.33 0.0 Y Description: CASE MANAGEMENT, PER MONTH Category: TBI Waiver CMS Add: 10/01/2003 CMS Term: T2022 U7 TBIWA WTB MAXFEE 07/01/2023 189.56 0.0 Y Description: CASE MANAGEMENT, PER MONTH Category: TBI Waiver CMS Add: 10/01/2003 CMS Term: T2023 NOCOV DEF SYSMAN Description: TARGETED CASE MGMT PER MONTH Category: Non Covered Services CMS Add: 10/01/2003 CMS Term: T2025 U1 U7 ADWA WAD MAXFEE 07/01/2018 4000.00 0.0 Y Description: WAIVER SERVICE, NOS Category: A&D Waiver CMS Add: 10/01/2003 CMS Term: T2025 U1 U7 MFPAD W1M MAXFEE 07/01/2018 4000.00 0.0 Y Description: WAIVER SERVICE, NOS Category: MFP Demo Grant CMS Add: 10/01/2003 CMS Term: T2025 U1 U7 MFPTB W2M MAXFEE 02/01/2020 4000.00 0.0 Y Description: WAIVER SERVICE, NOS Category: MFP TBI CMS Add: 10/01/2003 CMS Term: T2025 U1 U7 TBIWA WTB MAXFEE 02/01/2020 4000.00 0.0 Y Description: WAIVER SERVICE, NOS Category: TBI Waiver CMS Add: 10/01/2003 CMS Term: T2025 U2 U7 MFPTR W4M MAXFEE 10/01/2012 2000.00 0.0 Y Description: WAIVER SERVICE, NOS Category: MFP PRTF Waiver CMS Add: 10/01/2003 CMS Term: T2025 U2 U7 PRTFW WPT MAXFEE 10/01/2012 2000.00 0.0 Y Description: WAIVER SERVICE, NOS Category: PRTF Trans Waiver CMS Add: 10/01/2003 CMS Term: T2025 U5 U7 DDWA WDD MAXFEE 01/01/2008 545.00 0.0 Y Description: WAIVER SERVICE, NOS Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,185 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- T2025 U5 U7 MFPCI W3M MAXFEE 01/01/2014 545.00 0.0 Y Description: WAIVER SERVICE, NOS Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2025 U5 U7 UA DDWA WDD MAXFEE 07/01/2021 06/30/2023 42.13 0.0 Y Description: WAIVER SERVICE, NOS Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2025 U5 U7 UA DDWA WDD MAXFEE 07/01/2023 52.85 0.0 Y Description: WAIVER SERVICE, NOS Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2025 U5 U7 UA MFPCI W3M MAXFEE 07/01/2021 06/30/2023 42.13 0.0 Y Description: WAIVER SERVICE, NOS Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2025 U5 U7 UA MFPCI W3M MAXFEE 07/01/2023 52.85 0.0 Y Description: WAIVER SERVICE, NOS Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2025 U5 U7 UA MFPTS W5M MAXFEE 07/01/2021 06/30/2023 42.13 0.0 Y Description: WAIVER SERVICE, NOS Category: MFP SOF Waiver CMS Add: 10/01/2003 CMS Term: T2025 U5 U7 UA MFPTS W5M MAXFEE 07/01/2023 52.85 0.0 Y Description: WAIVER SERVICE, NOS Category: MFP SOF Waiver CMS Add: 10/01/2003 CMS Term: T2025 U5 U7 UA SSFS WSS MAXFEE 07/01/2021 06/30/2023 42.13 0.0 Y Description: WAIVER SERVICE, NOS Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2025 U5 U7 UA SSFS WSS MAXFEE 07/01/2023 52.85 0.0 Y Description: WAIVER SERVICE, NOS Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2026 NOCOV DEF SYSMAN Description: SPECIAL CHILDCARE WAIVER/D Category: Non Covered Services CMS Add: 10/01/2003 CMS Term: T2027 NOCOV DEF SYSMAN Description: SPEC CHILDCARE WAIVER 15 MIN Category: Non Covered Services CMS Add: 10/01/2003 CMS Term: T2028 NOCOV DEF SYSMAN Description: SPECIAL SUPPLY, NOS WAIVER Category: Non Covered Services CMS Add: 10/01/2003 CMS Term: T2029 NU U5 U7 DDWA WDD MAXFEE 07/16/2020 15000.00 0.0 Y Description: SPECIAL MED EQUIP, NOSWAIVER Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2029 NU U5 U7 MFPCI W3M MAXFEE 07/16/2020 15000.00 0.0 Y Description: SPECIAL MED EQUIP, NOSWAIVER Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2029 NU U5 U7 MFPTS W5M MAXFEE 01/01/2008 15000.00 0.0 Y Description: SPECIAL MED EQUIP, NOSWAIVER Category: MFP SOF Waiver CMS Add: 10/01/2003 CMS Term: T2029 NU U5 U7 SSFS WSS MAXFEE 07/16/2020 15000.00 0.0 Y Description: SPECIAL MED EQUIP, NOSWAIVER Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,186 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- T2029 NU U7 ADWA WAD MAXFEE 07/01/2008 06/30/2023 50000.00 0.0 Y Description: SPECIAL MED EQUIP, NOSWAIVER Category: A&D Waiver CMS Add: 10/01/2003 CMS Term: T2029 NU U7 ADWA WAD MAXFEE 07/01/2023 15000.00 0.0 Y Description: SPECIAL MED EQUIP, NOSWAIVER Category: A&D Waiver CMS Add: 10/01/2003 CMS Term: T2029 NU U7 MFPAD W1M MAXFEE 06/02/2008 06/30/2023 50000.00 0.0 Y Description: SPECIAL MED EQUIP, NOSWAIVER Category: MFP Demo Grant CMS Add: 10/01/2003 CMS Term: T2029 NU U7 MFPAD W1M MAXFEE 07/01/2023 15000.00 0.0 Y Description: SPECIAL MED EQUIP, NOSWAIVER Category: MFP Demo Grant CMS Add: 10/01/2003 CMS Term: T2029 NU U7 MFPTB W2M MAXFEE 06/02/2008 06/30/2023 50000.00 0.0 Y Description: SPECIAL MED EQUIP, NOSWAIVER Category: MFP TBI CMS Add: 10/01/2003 CMS Term: T2029 NU U7 MFPTB W2M MAXFEE 07/01/2023 15000.00 0.0 Y Description: SPECIAL MED EQUIP, NOSWAIVER Category: MFP TBI CMS Add: 10/01/2003 CMS Term: T2029 NU U7 TBIWA WTB MAXFEE 01/01/2004 06/30/2023 50000.00 0.0 Y Description: SPECIAL MED EQUIP, NOSWAIVER Category: TBI Waiver CMS Add: 10/01/2003 CMS Term: T2029 NU U7 TBIWA WTB MAXFEE 07/01/2023 15000.00 0.0 Y Description: SPECIAL MED EQUIP, NOSWAIVER Category: TBI Waiver CMS Add: 10/01/2003 CMS Term: T2029 U5 U7 U8 DDWA WDD MAXFEE 01/01/2009 06/30/2023 500.00 0.0 Y Description: SPECIAL MED EQUIP, NOSWAIVER Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2029 U5 U7 U8 DDWA WDD MAXFEE 07/01/2023 1000.00 0.0 Y Description: SPECIAL MED EQUIP, NOSWAIVER Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2029 U5 U7 U8 MFPCI W3M MAXFEE 01/01/2014 06/30/2023 500.00 0.0 Y Description: SPECIAL MED EQUIP, NOSWAIVER Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2029 U5 U7 U8 MFPCI W3M MAXFEE 07/01/2023 1000.00 0.0 Y Description: SPECIAL MED EQUIP, NOSWAIVER Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2029 U5 U7 U8 MFPTS W5M MAXFEE 07/01/2023 1000.00 0.0 Y Description: SPECIAL MED EQUIP, NOSWAIVER Category: MFP SOF Waiver CMS Add: 10/01/2003 CMS Term: T2029 U5 U7 U8 SSFS WSS MAXFEE 01/01/2009 06/30/2023 500.00 0.0 Y Description: SPECIAL MED EQUIP, NOSWAIVER Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2029 U5 U7 U8 SSFS WSS MAXFEE 07/01/2023 1000.00 0.0 Y Description: SPECIAL MED EQUIP, NOSWAIVER Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2029 U7 U8 ADWA WAD MAXFEE 02/01/2020 1000.00 0.0 Y Description: SPECIAL MED EQUIP, NOSWAIVER Category: A&D Waiver CMS Add: 10/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,187 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- T2029 U7 U8 MFPAD W1M MAXFEE 02/01/2020 1000.00 0.0 Y Description: SPECIAL MED EQUIP, NOSWAIVER Category: MFP Demo Grant CMS Add: 10/01/2003 CMS Term: T2029 U7 U8 MFPTB W2M MAXFEE 02/01/2020 1000.00 0.0 Y Description: SPECIAL MED EQUIP, NOSWAIVER Category: MFP TBI CMS Add: 10/01/2003 CMS Term: T2029 U7 U8 TBIWA WTB MAXFEE 02/01/2020 1000.00 0.0 Y Description: SPECIAL MED EQUIP, NOSWAIVER Category: TBI Waiver CMS Add: 10/01/2003 CMS Term: T2030 NOCOV DEF SYSMAN Description: ASSIST LIVING WAIVER/MONTH Category: Non Covered Services CMS Add: 10/01/2003 CMS Term: T2031 U1 U7 ADWA WAD MAXFEE 07/01/2022 06/30/2023 75.35 0.0 Y 18-999years Description: ASSIST LIVING WAIVER/DIEM Category: A&D Waiver CMS Add: 10/01/2003 CMS Term: T2031 U1 U7 ADWA WAD MAXFEE 07/01/2023 101.98 0.0 Y 18-999years Description: ASSIST LIVING WAIVER/DIEM Category: A&D Waiver CMS Add: 10/01/2003 CMS Term: T2031 U1 U7 MFPAD W1M MAXFEE 07/01/2022 06/30/2023 75.35 0.0 Y 18-999years Description: ASSIST LIVING WAIVER/DIEM Category: MFP Demo Grant CMS Add: 10/01/2003 CMS Term: T2031 U1 U7 MFPAD W1M MAXFEE 07/01/2023 101.98 0.0 Y 18-999years Description: ASSIST LIVING WAIVER/DIEM Category: MFP Demo Grant CMS Add: 10/01/2003 CMS Term: T2031 U1 U7 MFPTB W2M MAXFEE 07/01/2022 06/30/2023 75.35 0.0 Y 18-999years Description: ASSIST LIVING WAIVER/DIEM Category: MFP TBI CMS Add: 10/01/2003 CMS Term: T2031 U1 U7 MFPTB W2M MAXFEE 07/01/2023 101.98 0.0 Y 18-999years Description: ASSIST LIVING WAIVER/DIEM Category: MFP TBI CMS Add: 10/01/2003 CMS Term: T2031 U1 U7 TBIWA WTB MAXFEE 07/01/2022 06/30/2023 75.35 0.0 Y 18-999years Description: ASSIST LIVING WAIVER/DIEM Category: TBI Waiver CMS Add: 10/01/2003 CMS Term: T2031 U1 U7 TBIWA WTB MAXFEE 07/01/2023 101.98 0.0 Y 18-999years Description: ASSIST LIVING WAIVER/DIEM Category: TBI Waiver CMS Add: 10/01/2003 CMS Term: T2031 U1 U7 UA ADWA WAD MAXFEE 07/01/2022 06/30/2023 2237.90 0.0 Y 18-999years Description: ASSIST LIVING WAIVER/DIEM Category: A&D Waiver CMS Add: 10/01/2003 CMS Term: T2031 U1 U7 UA ADWA WAD MAXFEE 07/01/2023 3028.81 0.0 Y 18-999years Description: ASSIST LIVING WAIVER/DIEM Category: A&D Waiver CMS Add: 10/01/2003 CMS Term: T2031 U1 U7 UA MFPAD W1M MAXFEE 07/01/2022 06/30/2023 2237.90 0.0 Y 18-999years Description: ASSIST LIVING WAIVER/DIEM Category: MFP Demo Grant CMS Add: 10/01/2003 CMS Term: T2031 U1 U7 UA MFPAD W1M MAXFEE 07/01/2023 3028.81 0.0 Y 18-999years Description: ASSIST LIVING WAIVER/DIEM Category: MFP Demo Grant CMS Add: 10/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,188 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- T2031 U1 U7 UA MFPTB W2M MAXFEE 07/01/2022 06/30/2023 2237.90 0.0 Y 18-999years Description: ASSIST LIVING WAIVER/DIEM Category: MFP TBI CMS Add: 10/01/2003 CMS Term: T2031 U1 U7 UA MFPTB W2M MAXFEE 07/01/2023 3028.81 0.0 Y 18-999years Description: ASSIST LIVING WAIVER/DIEM Category: MFP TBI CMS Add: 10/01/2003 CMS Term: T2031 U1 U7 UA TBIWA WTB MAXFEE 07/01/2022 06/30/2023 2237.90 0.0 Y 18-999years Description: ASSIST LIVING WAIVER/DIEM Category: TBI Waiver CMS Add: 10/01/2003 CMS Term: T2031 U1 U7 UA TBIWA WTB MAXFEE 07/01/2023 3028.81 0.0 Y 18-999years Description: ASSIST LIVING WAIVER/DIEM Category: TBI Waiver CMS Add: 10/01/2003 CMS Term: T2031 U2 U7 ADWA WAD MAXFEE 07/01/2022 06/30/2023 83.68 0.0 Y 18-999years Description: ASSIST LIVING WAIVER/DIEM Category: A&D Waiver CMS Add: 10/01/2003 CMS Term: T2031 U2 U7 ADWA WAD MAXFEE 07/01/2023 112.13 0.0 Y 18-999years Description: ASSIST LIVING WAIVER/DIEM Category: A&D Waiver CMS Add: 10/01/2003 CMS Term: T2031 U2 U7 MFPAD W1M MAXFEE 07/01/2022 06/30/2023 83.68 0.0 Y 18-999years Description: ASSIST LIVING WAIVER/DIEM Category: MFP Demo Grant CMS Add: 10/01/2003 CMS Term: T2031 U2 U7 MFPAD W1M MAXFEE 07/01/2023 112.13 0.0 Y 18-999years Description: ASSIST LIVING WAIVER/DIEM Category: MFP Demo Grant CMS Add: 10/01/2003 CMS Term: T2031 U2 U7 MFPTB W2M MAXFEE 07/01/2022 06/30/2023 83.68 0.0 Y 18-999years Description: ASSIST LIVING WAIVER/DIEM Category: MFP TBI CMS Add: 10/01/2003 CMS Term: T2031 U2 U7 MFPTB W2M MAXFEE 07/01/2023 112.13 0.0 Y 18-999years Description: ASSIST LIVING WAIVER/DIEM Category: MFP TBI CMS Add: 10/01/2003 CMS Term: T2031 U2 U7 TBIWA WTB MAXFEE 07/01/2022 06/30/2023 83.68 0.0 Y 18-999years Description: ASSIST LIVING WAIVER/DIEM Category: TBI Waiver CMS Add: 10/01/2003 CMS Term: T2031 U2 U7 TBIWA WTB MAXFEE 07/01/2023 112.13 0.0 Y 18-999years Description: ASSIST LIVING WAIVER/DIEM Category: TBI Waiver CMS Add: 10/01/2003 CMS Term: T2031 U2 U7 UA ADWA WAD MAXFEE 07/01/2022 06/30/2023 2485.30 0.0 Y 18-999years Description: ASSIST LIVING WAIVER/DIEM Category: A&D Waiver CMS Add: 10/01/2003 CMS Term: T2031 U2 U7 UA ADWA WAD MAXFEE 07/01/2023 3330.26 0.0 Y 18-999years Description: ASSIST LIVING WAIVER/DIEM Category: A&D Waiver CMS Add: 10/01/2003 CMS Term: T2031 U2 U7 UA MFPAD W1M MAXFEE 07/01/2022 06/30/2023 2485.30 0.0 Y 18-999years Description: ASSIST LIVING WAIVER/DIEM Category: MFP Demo Grant CMS Add: 10/01/2003 CMS Term: T2031 U2 U7 UA MFPAD W1M MAXFEE 07/01/2023 3330.26 0.0 Y 18-999years Description: ASSIST LIVING WAIVER/DIEM Category: MFP Demo Grant CMS Add: 10/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,189 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- T2031 U2 U7 UA MFPTB W2M MAXFEE 07/01/2022 06/30/2023 2485.30 0.0 Y 18-999years Description: ASSIST LIVING WAIVER/DIEM Category: MFP TBI CMS Add: 10/01/2003 CMS Term: T2031 U2 U7 UA MFPTB W2M MAXFEE 07/01/2023 3330.26 0.0 Y 18-999years Description: ASSIST LIVING WAIVER/DIEM Category: MFP TBI CMS Add: 10/01/2003 CMS Term: T2031 U2 U7 UA TBIWA WTB MAXFEE 07/01/2022 06/30/2023 2485.30 0.0 Y 18-999years Description: ASSIST LIVING WAIVER/DIEM Category: TBI Waiver CMS Add: 10/01/2003 CMS Term: T2031 U2 U7 UA TBIWA WTB MAXFEE 07/01/2023 3330.26 0.0 Y 18-999years Description: ASSIST LIVING WAIVER/DIEM Category: TBI Waiver CMS Add: 10/01/2003 CMS Term: T2031 U3 U7 ADWA WAD MAXFEE 07/01/2022 06/30/2023 96.85 0.0 Y 18-999years Description: ASSIST LIVING WAIVER/DIEM Category: A&D Waiver CMS Add: 10/01/2003 CMS Term: T2031 U3 U7 ADWA WAD MAXFEE 07/01/2023 132.06 0.0 Y 18-999years Description: ASSIST LIVING WAIVER/DIEM Category: A&D Waiver CMS Add: 10/01/2003 CMS Term: T2031 U3 U7 MFPAD W1M MAXFEE 07/01/2022 06/30/2023 96.85 0.0 Y 18-999years Description: ASSIST LIVING WAIVER/DIEM Category: MFP Demo Grant CMS Add: 10/01/2003 CMS Term: T2031 U3 U7 MFPAD W1M MAXFEE 07/01/2023 132.06 0.0 Y 18-999years Description: ASSIST LIVING WAIVER/DIEM Category: MFP Demo Grant CMS Add: 10/01/2003 CMS Term: T2031 U3 U7 MFPTB W2M MAXFEE 07/01/2022 06/30/2023 96.85 0.0 Y 18-999years Description: ASSIST LIVING WAIVER/DIEM Category: MFP TBI CMS Add: 10/01/2003 CMS Term: T2031 U3 U7 MFPTB W2M MAXFEE 07/01/2023 132.06 0.0 Y 18-999years Description: ASSIST LIVING WAIVER/DIEM Category: MFP TBI CMS Add: 10/01/2003 CMS Term: T2031 U3 U7 TBIWA WTB MAXFEE 07/01/2022 06/30/2023 96.85 0.0 Y 18-999years Description: ASSIST LIVING WAIVER/DIEM Category: TBI Waiver CMS Add: 10/01/2003 CMS Term: T2031 U3 U7 TBIWA WTB MAXFEE 07/01/2023 132.06 0.0 Y 18-999years Description: ASSIST LIVING WAIVER/DIEM Category: TBI Waiver CMS Add: 10/01/2003 CMS Term: T2031 U3 U7 UA ADWA WAD MAXFEE 07/01/2022 06/30/2023 2876.45 0.0 Y 18-999years Description: ASSIST LIVING WAIVER/DIEM Category: A&D Waiver CMS Add: 10/01/2003 CMS Term: T2031 U3 U7 UA ADWA WAD MAXFEE 07/01/2023 3922.18 0.0 Y 18-999years Description: ASSIST LIVING WAIVER/DIEM Category: A&D Waiver CMS Add: 10/01/2003 CMS Term: T2031 U3 U7 UA MFPAD W1M MAXFEE 07/01/2022 06/30/2023 2876.45 0.0 Y 18-999years Description: ASSIST LIVING WAIVER/DIEM Category: MFP Demo Grant CMS Add: 10/01/2003 CMS Term: T2031 U3 U7 UA MFPAD W1M MAXFEE 07/01/2023 3922.18 0.0 Y 18-999years Description: ASSIST LIVING WAIVER/DIEM Category: MFP Demo Grant CMS Add: 10/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,190 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- T2031 U3 U7 UA MFPTB W2M MAXFEE 07/01/2022 06/30/2023 2876.45 0.0 Y 18-999years Description: ASSIST LIVING WAIVER/DIEM Category: MFP TBI CMS Add: 10/01/2003 CMS Term: T2031 U3 U7 UA MFPTB W2M MAXFEE 07/01/2023 3922.18 0.0 Y 18-999years Description: ASSIST LIVING WAIVER/DIEM Category: MFP TBI CMS Add: 10/01/2003 CMS Term: T2031 U3 U7 UA TBIWA WTB MAXFEE 07/01/2022 06/30/2023 2876.45 0.0 Y 18-999years Description: ASSIST LIVING WAIVER/DIEM Category: TBI Waiver CMS Add: 10/01/2003 CMS Term: T2031 U3 U7 UA TBIWA WTB MAXFEE 07/01/2023 3922.18 0.0 Y 18-999years Description: ASSIST LIVING WAIVER/DIEM Category: TBI Waiver CMS Add: 10/01/2003 CMS Term: T2032 NOCOV DEF SYSMAN Description: RES CARE, NOS WAIVER/MONTH Category: Non Covered Services CMS Add: 10/01/2003 CMS Term: T2033 U1 U5 U7 DDWA WDD MAXFEE 07/01/2023 77.54 0.0 Y Description: RES, NOS WAIVER PER DIEM Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2033 U1 U5 U7 DDWA WDD MAXFEE 10/01/2014 06/30/2023 51.87 0.0 Y Description: RES, NOS WAIVER PER DIEM Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2033 U1 U5 U7 MFPCI W3M MAXFEE 07/01/2023 77.54 0.0 Y Description: RES, NOS WAIVER PER DIEM Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2033 U1 U5 U7 MFPCI W3M MAXFEE 10/01/2014 06/30/2023 51.87 0.0 Y Description: RES, NOS WAIVER PER DIEM Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2033 U2 U5 U7 DDWA WDD MAXFEE 07/01/2023 99.71 0.0 Y Description: RES, NOS WAIVER PER DIEM Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2033 U2 U5 U7 DDWA WDD MAXFEE 10/01/2014 06/30/2023 75.67 0.0 Y Description: RES, NOS WAIVER PER DIEM Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2033 U2 U5 U7 MFPCI W3M MAXFEE 07/01/2023 99.71 0.0 Y Description: RES, NOS WAIVER PER DIEM Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2033 U2 U5 U7 MFPCI W3M MAXFEE 10/01/2014 06/30/2023 75.67 0.0 Y Description: RES, NOS WAIVER PER DIEM Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2033 U3 U5 U7 DDWA WDD MAXFEE 07/01/2023 133.44 0.0 Y Description: RES, NOS WAIVER PER DIEM Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2033 U3 U5 U7 DDWA WDD MAXFEE 10/01/2014 06/30/2023 102.87 0.0 Y Description: RES, NOS WAIVER PER DIEM Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2033 U3 U5 U7 MFPCI W3M MAXFEE 07/01/2023 133.44 0.0 Y Description: RES, NOS WAIVER PER DIEM Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,191 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- T2033 U3 U5 U7 MFPCI W3M MAXFEE 10/01/2014 06/30/2023 102.87 0.0 Y Description: RES, NOS WAIVER PER DIEM Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2033 U5 U7 MFPTS W5M MAXFEE 07/01/2021 06/30/2023 27.82 0.0 Y Description: RES, NOS WAIVER PER DIEM Category: MFP SOF Waiver CMS Add: 10/01/2003 CMS Term: T2033 U5 U7 MFPTS W5M MAXFEE 07/01/2023 34.39 0.0 Y Description: RES, NOS WAIVER PER DIEM Category: MFP SOF Waiver CMS Add: 10/01/2003 CMS Term: T2033 U5 U7 SSFS WSS MAXFEE 07/01/2021 06/30/2023 27.82 0.0 Y Description: RES, NOS WAIVER PER DIEM Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2033 U5 U7 SSFS WSS MAXFEE 07/01/2023 34.39 0.0 Y Description: RES, NOS WAIVER PER DIEM Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2034 NOCOV DEF SYSMAN Description: CRISIS INTERVEN WAIVER/DIEM Category: Non Covered Services CMS Add: 10/01/2003 CMS Term: T2035 NOCOV DEF SYSMAN Description: UTILITY SERVICES WAIVER Category: Non Covered Services CMS Add: 10/01/2003 CMS Term: T2036 NOCOV DEF SYSMAN Description: CAMP OVERNITE WAIVER/SESSION Category: Non Covered Services CMS Add: 10/01/2003 CMS Term: T2037 NOCOV DEF SYSMAN Description: CAMP DAY WAIVER/SESSION Category: Non Covered Services CMS Add: 10/01/2003 CMS Term: T2038 U5 U7 DDWA WDD MAXFEE 07/16/2020 2500.00 0.0 Y Description: COMM TRANS WAIVER/SERVICE Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2038 U5 U7 MFPCI W3M MAXFEE 07/16/2020 2500.00 0.0 Y Description: COMM TRANS WAIVER/SERVICE Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2038 U5 U7 UA DDWA WDD MAXFEE 07/01/2023 180.55 0.0 Y Description: COMM TRANS WAIVER/SERVICE Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2038 U5 U7 UA DDWA WDD MAXFEE 08/01/2018 06/30/2023 131.25 0.0 Y Description: COMM TRANS WAIVER/SERVICE Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2038 U5 U7 UA MFPCI W3M MAXFEE 07/01/2023 180.55 0.0 Y Description: COMM TRANS WAIVER/SERVICE Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2038 U7 ADWA WAD MAXFEE 07/01/2008 06/30/2023 1500.00 0.0 Y Description: COMM TRANS WAIVER/SERVICE Category: A&D Waiver CMS Add: 10/01/2003 CMS Term: T2038 U7 ADWA WAD MAXFEE 07/01/2023 2500.00 0.0 Y Description: COMM TRANS WAIVER/SERVICE Category: A&D Waiver CMS Add: 10/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,192 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- T2038 U7 MFPAD W1M MAXFEE 06/02/2008 06/30/2023 1500.00 0.0 Y Description: COMM TRANS WAIVER/SERVICE Category: MFP Demo Grant CMS Add: 10/01/2003 CMS Term: T2038 U7 MFPAD W1M MAXFEE 07/01/2023 2500.00 0.0 Y Description: COMM TRANS WAIVER/SERVICE Category: MFP Demo Grant CMS Add: 10/01/2003 CMS Term: T2038 U7 MFPTB W2M MAXFEE 01/01/2010 06/30/2023 1500.00 0.0 Y Description: COMM TRANS WAIVER/SERVICE Category: MFP TBI CMS Add: 10/01/2003 CMS Term: T2038 U7 MFPTB W2M MAXFEE 07/01/2023 2500.00 0.0 Y Description: COMM TRANS WAIVER/SERVICE Category: MFP TBI CMS Add: 10/01/2003 CMS Term: T2038 U7 TBIWA WTB MAXFEE 01/01/2010 06/30/2023 1500.00 0.0 Y Description: COMM TRANS WAIVER/SERVICE Category: TBI Waiver CMS Add: 10/01/2003 CMS Term: T2038 U7 TBIWA WTB MAXFEE 07/01/2023 2500.00 0.0 Y Description: COMM TRANS WAIVER/SERVICE Category: TBI Waiver CMS Add: 10/01/2003 CMS Term: T2039 ADWA DEF SYSMAN Y Description: VEHICLE MOD WAIVER/SERVICE Category: A&D Waiver CMS Add: 10/01/2003 CMS Term: T2039 DDWA DEF SYSMAN Y Description: VEHICLE MOD WAIVER/SERVICE Category: CIH Waiver CMS Add: 10/01/2003 CMS Term: T2039 MFPAD DEF SYSMAN Y Description: VEHICLE MOD WAIVER/SERVICE Category: MFP Demo Grant CMS Add: 10/01/2003 CMS Term: T2039 MFPCI DEF SYSMAN Y Description: VEHICLE MOD WAIVER/SERVICE Category: MFP CIH Waiver CMS Add: 10/01/2003 CMS Term: T2039 MFPTB DEF SYSMAN Y Description: VEHICLE MOD WAIVER/SERVICE Category: MFP TBI CMS Add: 10/01/2003 CMS Term: T2039 MFPTS DEF SYSMAN Y Description: VEHICLE MOD WAIVER/SERVICE Category: MFP SOF Waiver CMS Add: 10/01/2003 CMS Term: T2039 SSFS DEF SYSMAN Y Description: VEHICLE MOD WAIVER/SERVICE Category: Family Support Waivr CMS Add: 10/01/2003 CMS Term: T2039 TBIWA DEF SYSMAN Y Description: VEHICLE MOD WAIVER/SERVICE Category: TBI Waiver CMS Add: 10/01/2003 CMS Term: T2040 NOCOV DEF SYSMAN Description: FINANCIAL MGT WAIVER/15MIN Category: Non Covered Services CMS Add: 10/01/2003 CMS Term: T2041 NOCOV DEF SYSMAN Description: SUPPORT BROKER WAIVER/15 MIN Category: Non Covered Services CMS Add: 10/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,193 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- T2042 NOCOV DEF SYSMAN Description: HOSPICE ROUTINE HOME CARE Category: Non Covered Services CMS Add: 10/01/2003 CMS Term: T2043 NOCOV DEF SYSMAN Description: HOSPICE CONTINUOUS HOME CARE Category: Non Covered Services CMS Add: 10/01/2003 CMS Term: T2044 NOCOV DEF SYSMAN Description: HOSPICE RESPITE CARE Category: Non Covered Services CMS Add: 10/01/2003 CMS Term: T2045 NOCOV DEF SYSMAN Description: HOSPICE GENERAL CARE Category: Non Covered Services CMS Add: 10/01/2003 CMS Term: T2046 NOCOV DEF SYSMAN Description: HOSPICE LONG TERM CARE, R&B Category: Non Covered Services CMS Add: 10/01/2003 CMS Term: T2047 NOCOV DEF SYSMAN Description: HAB PREVO WAIVER PER 15 Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: T2049 NOCOV DEF SYSMAN Description: N-ET; STRETCHER VAN, MILEAGE Category: Non Covered Services CMS Add: 07/01/2004 CMS Term: T2050 NOCOV DEF SYSMAN Description: FINANCIAL MGT WAIVER/DIEM Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: T2051 NOCOV DEF SYSMAN Description: SUPPORT BROKER WAIVER/DIEM Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: T2101 DME DEF MAXFEE 01/01/2024 7.12 0.0 Y Description: BREAST MILK PROC/STORE/DIST Category: Durable Medical CMS Add: 01/01/2004 CMS Term: T2101 DME DEF MAXFEE 11/01/2022 12/31/2023 5.48 0.0 Y Description: BREAST MILK PROC/STORE/DIST Category: Durable Medical CMS Add: 01/01/2004 CMS Term: T4521 INCON DEF MAXFEE 01/01/2014 1.05 0.0 Y 3-999years Description: ADULT SIZE BRIEF/DIAPER SM Category: Incontinence CMS Add: 01/01/2005 CMS Term: T4521 INCON DEF SYSMAN Y 3-999years Description: ADULT SIZE BRIEF/DIAPER SM Category: Incontinence CMS Add: 01/01/2005 CMS Term: T4522 INCON DEF MAXFEE 01/01/2014 1.05 0.0 Y 3-999years Description: ADULT SIZE BRIEF/DIAPER MED Category: Incontinence CMS Add: 01/01/2005 CMS Term: T4522 INCON DEF SYSMAN Y 3-999years Description: ADULT SIZE BRIEF/DIAPER MED Category: Incontinence CMS Add: 01/01/2005 CMS Term: T4523 INCON DEF MAXFEE 01/01/2014 1.05 0.0 Y 3-999years Description: ADULT SIZE BRIEF/DIAPER LG Category: Incontinence CMS Add: 01/01/2005 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,194 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- T4523 INCON DEF SYSMAN Y 3-999years Description: ADULT SIZE BRIEF/DIAPER LG Category: Incontinence CMS Add: 01/01/2005 CMS Term: T4524 INCON DEF MAXFEE 01/01/2014 1.05 0.0 Y 3-999years Description: ADULT SIZE BRIEF/DIAPER XL Category: Incontinence CMS Add: 01/01/2005 CMS Term: T4524 INCON DEF SYSMAN Y 3-999years Description: ADULT SIZE BRIEF/DIAPER XL Category: Incontinence CMS Add: 01/01/2005 CMS Term: T4525 INCON DEF MAXFEE 01/01/2014 1.47 0.0 Y 3-999years Description: ADULT SIZE PULL-ON SM Category: Incontinence CMS Add: 01/01/2005 CMS Term: T4525 INCON DEF SYSMAN Y 3-999years Description: ADULT SIZE PULL-ON SM Category: Incontinence CMS Add: 01/01/2005 CMS Term: T4526 INCON DEF MAXFEE 01/01/2014 1.47 0.0 Y 3-999years Description: ADULT SIZE PULL-ON MED Category: Incontinence CMS Add: 01/01/2005 CMS Term: T4526 INCON DEF SYSMAN Y 3-999years Description: ADULT SIZE PULL-ON MED Category: Incontinence CMS Add: 01/01/2005 CMS Term: T4527 INCON DEF MAXFEE 01/01/2014 1.47 0.0 Y 3-999years Description: ADULT SIZE PULL-ON LG Category: Incontinence CMS Add: 01/01/2005 CMS Term: T4527 INCON DEF SYSMAN Y 3-999years Description: ADULT SIZE PULL-ON LG Category: Incontinence CMS Add: 01/01/2005 CMS Term: T4528 INCON DEF MAXFEE 01/01/2014 1.47 0.0 Y 3-999years Description: ADULT SIZE PULL-ON XL Category: Incontinence CMS Add: 01/01/2005 CMS Term: T4528 INCON DEF SYSMAN Y 3-999years Description: ADULT SIZE PULL-ON XL Category: Incontinence CMS Add: 01/01/2005 CMS Term: T4529 INCON DEF MAXFEE 01/01/2014 1.05 0.0 Y 3-999years Description: PED SIZE BRIEF/DIAPER SM/MED Category: Incontinence CMS Add: 01/01/2005 CMS Term: T4529 INCON DEF SYSMAN Y 3-999years Description: PED SIZE BRIEF/DIAPER SM/MED Category: Incontinence CMS Add: 01/01/2005 CMS Term: T4530 INCON DEF MAXFEE 01/01/2014 1.05 0.0 Y 3-999years Description: PED SIZE BRIEF/DIAPER LG Category: Incontinence CMS Add: 01/01/2005 CMS Term: T4530 INCON DEF SYSMAN Y 3-999years Description: PED SIZE BRIEF/DIAPER LG Category: Incontinence CMS Add: 01/01/2005 CMS Term: T4531 INCON DEF MAXFEE 01/01/2014 1.47 0.0 Y 3-999years Description: PED SIZE PULL-ON SM/MED Category: Incontinence CMS Add: 01/01/2005 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,195 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- T4531 INCON DEF SYSMAN Y 3-999years Description: PED SIZE PULL-ON SM/MED Category: Incontinence CMS Add: 01/01/2005 CMS Term: T4532 INCON DEF MAXFEE 01/01/2014 1.47 0.0 Y 3-999years Description: PED SIZE PULL-ON LG Category: Incontinence CMS Add: 01/01/2005 CMS Term: T4532 INCON DEF SYSMAN Y 3-999years Description: PED SIZE PULL-ON LG Category: Incontinence CMS Add: 01/01/2005 CMS Term: T4533 INCON DEF MAXFEE 01/01/2014 1.05 0.0 Y 3-999years Description: YOUTH SIZE BRIEF/DIAPER Category: Incontinence CMS Add: 01/01/2005 CMS Term: T4533 INCON DEF SYSMAN Y 3-999years Description: YOUTH SIZE BRIEF/DIAPER Category: Incontinence CMS Add: 01/01/2005 CMS Term: T4534 INCON DEF MAXFEE 01/01/2014 1.47 0.0 Y 3-999years Description: YOUTH SIZE PULL-ON Category: Incontinence CMS Add: 01/01/2005 CMS Term: T4534 INCON DEF SYSMAN Y 3-999years Description: YOUTH SIZE PULL-ON Category: Incontinence CMS Add: 01/01/2005 CMS Term: T4535 INCON DEF MAXFEE 01/01/2014 0.33 0.0 Y 3-999years Description: DISPOSABLE LINER/SHIELD/PAD Category: Incontinence CMS Add: 01/01/2005 CMS Term: T4536 INCON DEF MAXFEE 01/01/2014 12.95 0.0 Y 3-999years Description: REUSABLE PULL-ON ANY SIZE Category: Incontinence CMS Add: 01/01/2005 CMS Term: T4536 INCON DEF SYSMAN Y 3-999years Description: REUSABLE PULL-ON ANY SIZE Category: Incontinence CMS Add: 01/01/2005 CMS Term: T4537 INCON DEF MAXFEE 01/01/2014 22.00 0.0 3-999years Description: REUSABLE UNDERPAD BED SIZE Category: Incontinence CMS Add: 01/01/2005 CMS Term: T4538 NOCOV DEF SYSMAN Description: DIAPER SERV REUSABLE DIAPER Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: T4539 INCON DEF SYSMAN Y 3-999years Description: REUSE DIAPER/BRIEF ANY SIZE Category: Incontinence CMS Add: 01/01/2005 CMS Term: T4540 INCON DEF MAXFEE 01/01/2014 22.00 0.0 3-999years Description: REUSABLE UNDERPAD CHAIR SIZE Category: Incontinence CMS Add: 01/01/2005 CMS Term: T4541 INCON DEF MAXFEE 01/01/2014 0.47 0.0 3-999years Description: LARGE DISPOSABLE UNDERPAD Category: Incontinence CMS Add: 01/01/2005 CMS Term: T4542 INCON DEF MAXFEE 01/01/2014 0.47 0.0 3-999years Description: SMALL DISPOSABLE UNDERPAD Category: Incontinence CMS Add: 01/01/2005 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,196 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- T4543 INCON DEF MAXFEE 01/01/2014 1.75 0.0 Y Description: ADULT DISP BRIEF/DIAP ABV XL Category: Incontinence CMS Add: 01/01/2007 CMS Term: T4544 INCON DEF SYSMAN 3-999years Description: ADLT DISP UND/PULL ON ABV XL Category: Incontinence CMS Add: 01/01/2014 CMS Term: T4545 NOCOV DEF SYSMAN Description: INCON DISPOSABLE PENILE WRAP Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: T5001 NOCOV DEF SYSMAN Description: POSITION SEAT SPEC ORTH NEED Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: T5999 NOCOV DEF SYSMAN Description: SUPPLY, NOS Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: U0001 LAB DEF MAXFEE 02/04/2020 35.92 0.0 Description: 2019-NCOV DIAGNOSTIC P Category: Laboratory CMS Add: 02/04/2020 CMS Term: U0002 LAB DEF MAXFEE 02/04/2020 51.31 0.0 Description: COVID-19 LAB TEST NON-CDC Category: Laboratory CMS Add: 02/04/2020 CMS Term: V2020 VISIO DEF MAXFEE 01/01/2024 85.94 0.0 Description: VISION SVCS FRAMES PURCHASES Category: Vision CMS Add: 01/01/1985 CMS Term: V2020 VISIO DEF MAXFEE 10/05/1994 12/31/2023 20.00 0.0 Description: VISION SVCS FRAMES PURCHASES Category: Vision CMS Add: 01/01/1985 CMS Term: V2025 VISIO DEF SYSMAN Y Description: EYEGLASSES DELUX FRAMES Category: Vision CMS Add: 01/01/1992 CMS Term: V2100 VISIO DEF MAXFEE 01/01/1994 12/31/2023 24.42 0.0 Description: LENS SPHER SINGLE PLANO 4.00 Category: Vision CMS Add: 01/01/1985 CMS Term: V2100 VISIO DEF MAXFEE 01/01/2024 53.11 0.0 Description: LENS SPHER SINGLE PLANO 4.00 Category: Vision CMS Add: 01/01/1985 CMS Term: V2101 VISIO DEF MAXFEE 01/01/1994 12/31/2023 31.56 0.0 Description: SINGLE VISN SPHERE 4.12-7.00 Category: Vision CMS Add: 01/01/1985 CMS Term: V2101 VISIO DEF MAXFEE 01/01/2024 51.03 0.0 Description: SINGLE VISN SPHERE 4.12-7.00 Category: Vision CMS Add: 01/01/1985 CMS Term: V2102 VISIO DEF MAXFEE 01/01/1994 12/31/2023 48.91 0.0 Description: SINGL VISN SPHERE 7.12-20.00 Category: Vision CMS Add: 01/01/1985 CMS Term: V2102 VISIO DEF MAXFEE 01/01/2024 88.24 0.0 Description: SINGL VISN SPHERE 7.12-20.00 Category: Vision CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,197 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- V2103 VISIO DEF MAXFEE 01/01/1994 12/31/2023 26.04 0.0 Description: SPHEROCYLINDR 4.00D/12-2.00D Category: Vision CMS Add: 01/01/1985 CMS Term: V2103 VISIO DEF MAXFEE 01/01/2024 44.71 0.0 Description: SPHEROCYLINDR 4.00D/12-2.00D Category: Vision CMS Add: 01/01/1985 CMS Term: V2104 VISIO DEF MAXFEE 01/01/1994 12/31/2023 27.99 0.0 Description: SPHEROCYLINDR 4.00D/2.12-4D Category: Vision CMS Add: 01/01/1985 CMS Term: V2104 VISIO DEF MAXFEE 01/01/2024 46.09 0.0 Description: SPHEROCYLINDR 4.00D/2.12-4D Category: Vision CMS Add: 01/01/1985 CMS Term: V2105 VISIO DEF MAXFEE 01/01/1994 12/31/2023 35.13 0.0 Description: SPHEROCYLINDER 4.00D/4.25-6D Category: Vision CMS Add: 01/01/1985 CMS Term: V2105 VISIO DEF MAXFEE 01/01/2024 54.82 0.0 Description: SPHEROCYLINDER 4.00D/4.25-6D Category: Vision CMS Add: 01/01/1985 CMS Term: V2106 VISIO DEF MAXFEE 01/01/1994 12/31/2023 37.68 0.0 Description: SPHEROCYLINDER 4.00D/>6.00D Category: Vision CMS Add: 01/01/1985 CMS Term: V2106 VISIO DEF MAXFEE 01/01/2024 60.72 0.0 Description: SPHEROCYLINDER 4.00D/>6.00D Category: Vision CMS Add: 01/01/1985 CMS Term: V2107 VISIO DEF MAXFEE 01/01/1994 12/31/2023 33.47 0.0 Description: SPHEROCYLINDER 4.25D/12-2D Category: Vision CMS Add: 01/01/1985 CMS Term: V2107 VISIO DEF MAXFEE 01/01/2024 54.07 0.0 Description: SPHEROCYLINDER 4.25D/12-2D Category: Vision CMS Add: 01/01/1985 CMS Term: V2108 VISIO DEF MAXFEE 01/01/1994 12/31/2023 34.62 0.0 Description: SPHEROCYLINDER 4.25D/2.12-4D Category: Vision CMS Add: 01/01/1985 CMS Term: V2108 VISIO DEF MAXFEE 01/01/2024 54.22 0.0 Description: SPHEROCYLINDER 4.25D/2.12-4D Category: Vision CMS Add: 01/01/1985 CMS Term: V2109 VISIO DEF MAXFEE 01/01/1994 12/31/2023 42.35 0.0 Description: SPHEROCYLINDER 4.25D/4.25-6D Category: Vision CMS Add: 01/01/1985 CMS Term: V2109 VISIO DEF MAXFEE 01/01/2024 75.52 0.0 Description: SPHEROCYLINDER 4.25D/4.25-6D Category: Vision CMS Add: 01/01/1985 CMS Term: V2110 VISIO DEF MAXFEE 01/01/1994 12/31/2023 38.16 0.0 Description: SPHEROCYLINDER 4.25D/OVER 6D Category: Vision CMS Add: 01/01/1985 CMS Term: V2110 VISIO DEF MAXFEE 01/01/2024 60.99 0.0 Description: SPHEROCYLINDER 4.25D/OVER 6D Category: Vision CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,198 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- V2111 VISIO DEF MAXFEE 01/01/1994 12/31/2023 43.96 0.0 Description: SPHEROCYLINDR 7.25D/.25-2.25 Category: Vision CMS Add: 01/01/1985 CMS Term: V2111 VISIO DEF MAXFEE 01/01/2024 73.92 0.0 Description: SPHEROCYLINDR 7.25D/.25-2.25 Category: Vision CMS Add: 01/01/1985 CMS Term: V2112 VISIO DEF MAXFEE 01/01/1994 12/31/2023 48.01 0.0 Description: SPHEROCYLINDR 7.25D/2.25-4D Category: Vision CMS Add: 01/01/1985 CMS Term: V2112 VISIO DEF MAXFEE 01/01/2024 83.50 0.0 Description: SPHEROCYLINDR 7.25D/2.25-4D Category: Vision CMS Add: 01/01/1985 CMS Term: V2113 VISIO DEF MAXFEE 01/01/1994 12/31/2023 48.08 0.0 Description: SPHEROCYLINDR 7.25D/4.25-6D Category: Vision CMS Add: 01/01/1985 CMS Term: V2113 VISIO DEF MAXFEE 01/01/2024 84.44 0.0 Description: SPHEROCYLINDR 7.25D/4.25-6D Category: Vision CMS Add: 01/01/1985 CMS Term: V2114 VISIO DEF MAXFEE 01/01/1994 12/31/2023 58.98 0.0 Description: SPHEROCYLINDER OVER 12.00D Category: Vision CMS Add: 01/01/1985 CMS Term: V2114 VISIO DEF MAXFEE 01/01/2024 100.05 0.0 Description: SPHEROCYLINDER OVER 12.00D Category: Vision CMS Add: 01/01/1985 CMS Term: V2115 VISIO DEF MAXFEE 01/01/1994 12/31/2023 58.68 0.0 Description: LENS LENTICULAR BIFOCAL Category: Vision CMS Add: 01/01/1985 CMS Term: V2115 VISIO DEF MAXFEE 01/01/2024 100.84 0.0 Description: LENS LENTICULAR BIFOCAL Category: Vision CMS Add: 01/01/1985 CMS Term: V2118 VISIO DEF MAXFEE 01/01/1994 12/31/2023 63.54 0.0 Description: LENS ANISEIKONIC SINGLE Category: Vision CMS Add: 01/01/1985 CMS Term: V2118 VISIO DEF MAXFEE 01/01/2024 109.73 0.0 Description: LENS ANISEIKONIC SINGLE Category: Vision CMS Add: 01/01/1985 CMS Term: V2121 VISIO DEF MAXFEE 01/01/2004 12/31/2023 69.45 0.0 Description: LENTICULAR LENS, SINGLE Category: Vision CMS Add: 01/01/2004 CMS Term: V2121 VISIO DEF MAXFEE 01/01/2024 98.95 0.0 Description: LENTICULAR LENS, SINGLE Category: Vision CMS Add: 01/01/2004 CMS Term: V2199 VISIO DEF SYSMAN Y Description: LENS SINGLE VISION NOT OTH C Category: Vision CMS Add: 01/01/1985 CMS Term: V2200 VISIO DEF MAXFEE 01/01/1994 12/31/2023 32.49 0.0 Description: LENS SPHER BIFOC PLANO 4.00D Category: Vision CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,199 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- V2200 VISIO DEF MAXFEE 01/01/2024 59.81 0.0 Description: LENS SPHER BIFOC PLANO 4.00D Category: Vision CMS Add: 01/01/1985 CMS Term: V2201 VISIO DEF MAXFEE 01/01/1994 12/31/2023 35.27 0.0 Description: LENS SPHERE BIFOCAL 4.12-7.0 Category: Vision CMS Add: 01/01/1985 CMS Term: V2201 VISIO DEF MAXFEE 01/01/2024 64.08 0.0 Description: LENS SPHERE BIFOCAL 4.12-7.0 Category: Vision CMS Add: 01/01/1985 CMS Term: V2202 VISIO DEF MAXFEE 01/01/1994 12/31/2023 41.82 0.0 Description: LENS SPHERE BIFOCAL 7.12-20. Category: Vision CMS Add: 01/01/1985 CMS Term: V2202 VISIO DEF MAXFEE 01/01/2024 79.44 0.0 Description: LENS SPHERE BIFOCAL 7.12-20. Category: Vision CMS Add: 01/01/1985 CMS Term: V2203 VISIO DEF MAXFEE 01/01/1994 12/31/2023 32.72 0.0 Description: LENS SPHCYL BIFOCAL 4.00D/.1 Category: Vision CMS Add: 01/01/1985 CMS Term: V2203 VISIO DEF MAXFEE 01/01/2024 61.60 0.0 Description: LENS SPHCYL BIFOCAL 4.00D/.1 Category: Vision CMS Add: 01/01/1985 CMS Term: V2204 VISIO DEF MAXFEE 01/01/1994 12/31/2023 34.35 0.0 Description: LENS SPHCY BIFOCAL 4.00D/2.1 Category: Vision CMS Add: 01/01/1985 CMS Term: V2204 VISIO DEF MAXFEE 01/01/2024 63.38 0.0 Description: LENS SPHCY BIFOCAL 4.00D/2.1 Category: Vision CMS Add: 01/01/1985 CMS Term: V2205 VISIO DEF MAXFEE 01/01/1994 12/31/2023 37.36 0.0 Description: LENS SPHCY BIFOCAL 4.00D/4.2 Category: Vision CMS Add: 01/01/1985 CMS Term: V2205 VISIO DEF MAXFEE 01/01/2024 70.27 0.0 Description: LENS SPHCY BIFOCAL 4.00D/4.2 Category: Vision CMS Add: 01/01/1985 CMS Term: V2206 VISIO DEF MAXFEE 01/01/1994 12/31/2023 42.54 0.0 Description: LENS SPHCY BIFOCAL 4.00D/OVE Category: Vision CMS Add: 01/01/1985 CMS Term: V2206 VISIO DEF MAXFEE 01/01/2024 82.49 0.0 Description: LENS SPHCY BIFOCAL 4.00D/OVE Category: Vision CMS Add: 01/01/1985 CMS Term: V2207 VISIO DEF MAXFEE 01/01/1994 12/31/2023 36.16 0.0 Description: LENS SPHCY BIFOCAL 4.25-7D/. Category: Vision CMS Add: 01/01/1985 CMS Term: V2207 VISIO DEF MAXFEE 01/01/2024 69.72 0.0 Description: LENS SPHCY BIFOCAL 4.25-7D/. Category: Vision CMS Add: 01/01/1985 CMS Term: V2208 VISIO DEF MAXFEE 01/01/1994 12/31/2023 38.35 0.0 Description: LENS SPHCY BIFOCAL 4.25-7/2. Category: Vision CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,200 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- V2208 VISIO DEF MAXFEE 01/01/2024 68.51 0.0 Description: LENS SPHCY BIFOCAL 4.25-7/2. Category: Vision CMS Add: 01/01/1985 CMS Term: V2209 VISIO DEF MAXFEE 01/01/1994 12/31/2023 50.13 0.0 Description: LENS SPHCY BIFOCAL 4.25-7/4. Category: Vision CMS Add: 01/01/1985 CMS Term: V2209 VISIO DEF MAXFEE 01/01/2024 80.43 0.0 Description: LENS SPHCY BIFOCAL 4.25-7/4. Category: Vision CMS Add: 01/01/1985 CMS Term: V2210 VISIO DEF MAXFEE 01/01/1994 12/31/2023 53.42 0.0 Description: LENS SPHCY BIFOCAL 4.25-7/OV Category: Vision CMS Add: 01/01/1985 CMS Term: V2210 VISIO DEF MAXFEE 01/01/2024 86.67 0.0 Description: LENS SPHCY BIFOCAL 4.25-7/OV Category: Vision CMS Add: 01/01/1985 CMS Term: V2211 VISIO DEF MAXFEE 01/01/1994 12/31/2023 47.01 0.0 Description: LENS SPHCY BIFO 7.25-12/.25- Category: Vision CMS Add: 01/01/1985 CMS Term: V2211 VISIO DEF MAXFEE 01/01/2024 84.37 0.0 Description: LENS SPHCY BIFO 7.25-12/.25- Category: Vision CMS Add: 01/01/1985 CMS Term: V2212 VISIO DEF MAXFEE 01/01/1994 12/31/2023 49.02 0.0 Description: LENS SPHCYL BIFO 7.25-12/2.2 Category: Vision CMS Add: 01/01/1985 CMS Term: V2212 VISIO DEF MAXFEE 01/01/2024 88.31 0.0 Description: LENS SPHCYL BIFO 7.25-12/2.2 Category: Vision CMS Add: 01/01/1985 CMS Term: V2213 VISIO DEF MAXFEE 01/01/1994 12/31/2023 49.99 0.0 Description: LENS SPHCYL BIFO 7.25-12/4.2 Category: Vision CMS Add: 01/01/1985 CMS Term: V2213 VISIO DEF MAXFEE 01/01/2024 92.86 0.0 Description: LENS SPHCYL BIFO 7.25-12/4.2 Category: Vision CMS Add: 01/01/1985 CMS Term: V2214 VISIO DEF MAXFEE 01/01/1994 12/31/2023 55.00 0.0 Description: LENS SPHCYL BIFOCAL OVER 12. Category: Vision CMS Add: 01/01/1985 CMS Term: V2214 VISIO DEF MAXFEE 01/01/2024 97.05 0.0 Description: LENS SPHCYL BIFOCAL OVER 12. Category: Vision CMS Add: 01/01/1985 CMS Term: V2215 VISIO DEF MAXFEE 01/01/1994 12/31/2023 71.85 0.0 Description: LENS LENTICULAR BIFOCAL Category: Vision CMS Add: 01/01/1985 CMS Term: V2215 VISIO DEF MAXFEE 01/01/2024 121.17 0.0 Description: LENS LENTICULAR BIFOCAL Category: Vision CMS Add: 01/01/1985 CMS Term: V2218 VISIO DEF MAXFEE 01/01/1994 12/31/2023 76.38 0.0 Description: LENS ANISEIKONIC BIFOCAL Category: Vision CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,201 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- V2218 VISIO DEF MAXFEE 01/01/2024 123.48 0.0 Description: LENS ANISEIKONIC BIFOCAL Category: Vision CMS Add: 01/01/1985 CMS Term: V2219 VISIO DEF MAXFEE 01/01/1994 12/31/2023 33.43 0.0 Description: LENS BIFOCAL SEG WIDTH OVER Category: Vision CMS Add: 01/01/1985 CMS Term: V2219 VISIO DEF MAXFEE 01/01/2024 56.96 0.0 Description: LENS BIFOCAL SEG WIDTH OVER Category: Vision CMS Add: 01/01/1985 CMS Term: V2220 VISIO DEF MAXFEE 01/01/1994 12/31/2023 26.23 0.0 Description: LENS BIFOCAL ADD OVER 3.25D Category: Vision CMS Add: 01/01/1985 CMS Term: V2220 VISIO DEF MAXFEE 01/01/2024 50.59 0.0 Description: LENS BIFOCAL ADD OVER 3.25D Category: Vision CMS Add: 01/01/1985 CMS Term: V2221 VISIO DEF MAXFEE 01/01/2004 12/31/2023 70.84 0.0 Description: LENTICULAR LENS, BIFOCAL Category: Vision CMS Add: 01/01/2004 CMS Term: V2221 VISIO DEF MAXFEE 01/01/2024 100.91 0.0 Description: LENTICULAR LENS, BIFOCAL Category: Vision CMS Add: 01/01/2004 CMS Term: V2299 VISIO DEF SYSMAN Y Description: LENS BIFOCAL SPECIALITY Category: Vision CMS Add: 01/01/1985 CMS Term: V2300 VISIO DEF MAXFEE 01/01/1994 12/31/2023 41.83 0.0 Description: LENS SPHERE TRIFOCAL 4.00D Category: Vision CMS Add: 01/01/1985 CMS Term: V2300 VISIO DEF MAXFEE 01/01/2024 81.76 0.0 Description: LENS SPHERE TRIFOCAL 4.00D Category: Vision CMS Add: 01/01/1985 CMS Term: V2301 VISIO DEF MAXFEE 01/01/1994 12/31/2023 62.10 0.0 Description: LENS SPHERE TRIFOCAL 4.12-7. Category: Vision CMS Add: 01/01/1985 CMS Term: V2301 VISIO DEF MAXFEE 01/01/2024 100.28 0.0 Description: LENS SPHERE TRIFOCAL 4.12-7. Category: Vision CMS Add: 01/01/1985 CMS Term: V2302 VISIO DEF MAXFEE 01/01/1994 12/31/2023 60.98 0.0 Description: LENS SPHERE TRIFOCAL 7.12-20 Category: Vision CMS Add: 01/01/1985 CMS Term: V2302 VISIO DEF MAXFEE 01/01/2024 93.68 0.0 Description: LENS SPHERE TRIFOCAL 7.12-20 Category: Vision CMS Add: 01/01/1985 CMS Term: V2303 VISIO DEF MAXFEE 01/01/1994 12/31/2023 41.93 0.0 Description: LENS SPHCY TRIFOCAL 4.0/.12- Category: Vision CMS Add: 01/01/1985 CMS Term: V2303 VISIO DEF MAXFEE 01/01/2024 78.70 0.0 Description: LENS SPHCY TRIFOCAL 4.0/.12- Category: Vision CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,202 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- V2304 VISIO DEF MAXFEE 01/01/1994 12/31/2023 43.21 0.0 Description: LENS SPHCY TRIFOCAL 4.0/2.25 Category: Vision CMS Add: 01/01/1985 CMS Term: V2304 VISIO DEF MAXFEE 01/01/2024 79.62 0.0 Description: LENS SPHCY TRIFOCAL 4.0/2.25 Category: Vision CMS Add: 01/01/1985 CMS Term: V2305 VISIO DEF MAXFEE 01/01/1994 12/31/2023 50.34 0.0 Description: LENS SPHCY TRIFOCAL 4.0/4.25 Category: Vision CMS Add: 01/01/1985 CMS Term: V2305 VISIO DEF MAXFEE 01/01/2024 88.95 0.0 Description: LENS SPHCY TRIFOCAL 4.0/4.25 Category: Vision CMS Add: 01/01/1985 CMS Term: V2306 VISIO DEF MAXFEE 01/01/1994 12/31/2023 57.91 0.0 Description: LENS SPHCYL TRIFOCAL 4.00/>6 Category: Vision CMS Add: 01/01/1985 CMS Term: V2306 VISIO DEF MAXFEE 01/01/2024 91.59 0.0 Description: LENS SPHCYL TRIFOCAL 4.00/>6 Category: Vision CMS Add: 01/01/1985 CMS Term: V2307 VISIO DEF MAXFEE 01/01/1994 12/31/2023 48.36 0.0 Description: LENS SPHCY TRIFOCAL 4.25-7/. Category: Vision CMS Add: 01/01/1985 CMS Term: V2307 VISIO DEF MAXFEE 01/01/2024 87.20 0.0 Description: LENS SPHCY TRIFOCAL 4.25-7/. Category: Vision CMS Add: 01/01/1985 CMS Term: V2308 VISIO DEF MAXFEE 01/01/1994 12/31/2023 59.66 0.0 Description: LENS SPHC TRIFOCAL 4.25-7/2. Category: Vision CMS Add: 01/01/1985 CMS Term: V2308 VISIO DEF MAXFEE 01/01/2024 95.12 0.0 Description: LENS SPHC TRIFOCAL 4.25-7/2. Category: Vision CMS Add: 01/01/1985 CMS Term: V2309 VISIO DEF MAXFEE 01/01/1994 12/31/2023 61.13 0.0 Description: LENS SPHC TRIFOCAL 4.25-7/4. Category: Vision CMS Add: 01/01/1985 CMS Term: V2309 VISIO DEF MAXFEE 01/01/2024 99.54 0.0 Description: LENS SPHC TRIFOCAL 4.25-7/4. Category: Vision CMS Add: 01/01/1985 CMS Term: V2310 VISIO DEF MAXFEE 01/01/1994 12/31/2023 64.25 0.0 Description: LENS SPHC TRIFOCAL 4.25-7/>6 Category: Vision CMS Add: 01/01/1985 CMS Term: V2310 VISIO DEF MAXFEE 01/01/2024 103.97 0.0 Description: LENS SPHC TRIFOCAL 4.25-7/>6 Category: Vision CMS Add: 01/01/1985 CMS Term: V2311 VISIO DEF MAXFEE 01/01/1994 12/31/2023 72.56 0.0 Description: LENS SPHC TRIFO 7.25-12/.25- Category: Vision CMS Add: 01/01/1985 CMS Term: V2311 VISIO DEF MAXFEE 01/01/2024 120.05 0.0 Description: LENS SPHC TRIFO 7.25-12/.25- Category: Vision CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,203 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- V2312 VISIO DEF MAXFEE 01/01/1994 12/31/2023 66.13 0.0 Description: LENS SPHC TRIFO 7.25-12/2.25 Category: Vision CMS Add: 01/01/1985 CMS Term: V2312 VISIO DEF MAXFEE 01/01/2024 110.04 0.0 Description: LENS SPHC TRIFO 7.25-12/2.25 Category: Vision CMS Add: 01/01/1985 CMS Term: V2313 VISIO DEF MAXFEE 01/01/1994 12/31/2023 69.79 0.0 Description: LENS SPHC TRIFO 7.25-12/4.25 Category: Vision CMS Add: 01/01/1985 CMS Term: V2313 VISIO DEF MAXFEE 01/01/2024 120.12 0.0 Description: LENS SPHC TRIFO 7.25-12/4.25 Category: Vision CMS Add: 01/01/1985 CMS Term: V2314 VISIO DEF MAXFEE 01/01/1994 12/31/2023 73.00 0.0 Description: LENS SPHCYL TRIFOCAL OVER 12 Category: Vision CMS Add: 01/01/1985 CMS Term: V2314 VISIO DEF MAXFEE 01/01/2024 122.78 0.0 Description: LENS SPHCYL TRIFOCAL OVER 12 Category: Vision CMS Add: 01/01/1985 CMS Term: V2315 VISIO DEF MAXFEE 01/01/1994 12/31/2023 80.97 0.0 Description: LENS LENTICULAR TRIFOCAL Category: Vision CMS Add: 01/01/1985 CMS Term: V2315 VISIO DEF MAXFEE 01/01/2024 136.31 0.0 Description: LENS LENTICULAR TRIFOCAL Category: Vision CMS Add: 01/01/1985 CMS Term: V2318 VISIO DEF MAXFEE 01/01/1994 12/31/2023 95.32 0.0 Description: LENS ANISEIKONIC TRIFOCAL Category: Vision CMS Add: 01/01/1985 CMS Term: V2318 VISIO DEF MAXFEE 01/01/2024 167.58 0.0 Description: LENS ANISEIKONIC TRIFOCAL Category: Vision CMS Add: 01/01/1985 CMS Term: V2319 VISIO DEF MAXFEE 01/01/1994 12/31/2023 35.99 0.0 Description: LENS TRIFOCAL SEG WIDTH > 28 Category: Vision CMS Add: 01/01/1985 CMS Term: V2319 VISIO DEF MAXFEE 01/01/2024 75.65 0.0 Description: LENS TRIFOCAL SEG WIDTH > 28 Category: Vision CMS Add: 01/01/1985 CMS Term: V2320 VISIO DEF MAXFEE 01/01/1994 12/31/2023 43.67 0.0 Description: LENS TRIFOCAL ADD OVER 3.25D Category: Vision CMS Add: 01/01/1985 CMS Term: V2320 VISIO DEF MAXFEE 01/01/2024 79.80 0.0 Description: LENS TRIFOCAL ADD OVER 3.25D Category: Vision CMS Add: 01/01/1985 CMS Term: V2321 VISIO DEF MAXFEE 01/01/2004 12/31/2023 94.32 0.0 Description: LENTICULAR LENS, TRIFOCAL Category: Vision CMS Add: 01/01/2004 CMS Term: V2321 VISIO DEF MAXFEE 01/01/2024 134.36 0.0 Description: LENTICULAR LENS, TRIFOCAL Category: Vision CMS Add: 01/01/2004 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,204 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- V2399 VISIO DEF MAXFEE 01/01/2024 63.39 0.0 Description: LENS TRIFOCAL SPECIALITY Category: Vision CMS Add: 01/01/1985 CMS Term: V2399 VISIO DEF MAXFEE 12/23/1991 12/31/2023 51.75 0.0 Description: LENS TRIFOCAL SPECIALITY Category: Vision CMS Add: 01/01/1985 CMS Term: V2410 VISIO DEF MAXFEE 01/01/1994 12/31/2023 61.55 0.0 Description: LENS VARIAB ASPHERICITY SING Category: Vision CMS Add: 01/01/1984 CMS Term: V2410 VISIO DEF MAXFEE 01/01/2024 117.47 0.0 Description: LENS VARIAB ASPHERICITY SING Category: Vision CMS Add: 01/01/1984 CMS Term: V2430 VISIO DEF MAXFEE 01/01/1994 12/31/2023 70.96 0.0 Description: LENS VARIABLE ASPHERICITY BI Category: Vision CMS Add: 01/01/1984 CMS Term: V2430 VISIO DEF MAXFEE 01/01/2024 124.34 0.0 Description: LENS VARIABLE ASPHERICITY BI Category: Vision CMS Add: 01/01/1984 CMS Term: V2499 VISIO DEF SYSMAN Y Description: VARIABLE ASPHERICITY LENS Category: Vision CMS Add: 01/01/1984 CMS Term: V2500 VISIO DEF MAXFEE 01/01/1994 12/31/2023 63.28 0.0 Description: CONTACT LENS PMMA SPHERICAL Category: Vision CMS Add: 01/01/1985 CMS Term: V2500 VISIO DEF MAXFEE 01/01/2024 105.11 0.0 Description: CONTACT LENS PMMA SPHERICAL Category: Vision CMS Add: 01/01/1985 CMS Term: V2501 VISIO DEF MAXFEE 01/01/1994 12/31/2023 92.05 0.0 Description: CNTCT LENS PMMA-TORIC/PRISM Category: Vision CMS Add: 01/01/1985 CMS Term: V2501 VISIO DEF MAXFEE 01/01/2024 149.16 0.0 Description: CNTCT LENS PMMA-TORIC/PRISM Category: Vision CMS Add: 01/01/1985 CMS Term: V2502 VISIO DEF MAXFEE 01/01/1994 12/31/2023 119.80 0.0 Description: CONTACT LENS PMMA BIFOCAL Category: Vision CMS Add: 01/01/1985 CMS Term: V2502 VISIO DEF MAXFEE 01/01/2024 202.11 0.0 Description: CONTACT LENS PMMA BIFOCAL Category: Vision CMS Add: 01/01/1985 CMS Term: V2503 VISIO DEF MAXFEE 01/01/1994 12/31/2023 115.83 0.0 Description: CNTCT LENS PMMA COLOR VISION Category: Vision CMS Add: 01/01/1985 CMS Term: V2503 VISIO DEF MAXFEE 01/01/2024 195.20 0.0 Description: CNTCT LENS PMMA COLOR VISION Category: Vision CMS Add: 01/01/1985 CMS Term: V2510 VISIO DEF MAXFEE 01/01/1994 12/31/2023 85.99 0.0 Description: CNTCT GAS PERMEABLE SPHERICL Category: Vision CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,205 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- V2510 VISIO DEF MAXFEE 01/01/2024 140.16 0.0 Description: CNTCT GAS PERMEABLE SPHERICL Category: Vision CMS Add: 01/01/1985 CMS Term: V2511 VISIO DEF MAXFEE 01/01/1994 12/31/2023 126.38 0.0 Description: CNTCT TORIC PRISM BALLAST Category: Vision CMS Add: 01/01/1985 CMS Term: V2511 VISIO DEF MAXFEE 01/01/2024 207.74 0.0 Description: CNTCT TORIC PRISM BALLAST Category: Vision CMS Add: 01/01/1985 CMS Term: V2512 VISIO DEF MAXFEE 01/01/1994 12/31/2023 147.40 0.0 Description: CNTCT LENS GAS PERMBL BIFOCL Category: Vision CMS Add: 01/01/1985 CMS Term: V2512 VISIO DEF MAXFEE 01/01/2024 239.12 0.0 Description: CNTCT LENS GAS PERMBL BIFOCL Category: Vision CMS Add: 01/01/1985 CMS Term: V2513 VISIO DEF MAXFEE 01/01/1994 12/31/2023 135.15 0.0 Description: CONTACT LENS EXTENDED WEAR Category: Vision CMS Add: 01/01/1985 CMS Term: V2513 VISIO DEF MAXFEE 01/01/2024 240.90 0.0 Description: CONTACT LENS EXTENDED WEAR Category: Vision CMS Add: 01/01/1985 CMS Term: V2520 VISIO DEF MAXFEE 01/01/1994 12/31/2023 70.60 0.0 Description: CONTACT LENS HYDROPHILIC Category: Vision CMS Add: 01/01/1984 CMS Term: V2520 VISIO DEF MAXFEE 01/01/2024 139.66 0.0 Description: CONTACT LENS HYDROPHILIC Category: Vision CMS Add: 01/01/1984 CMS Term: V2521 VISIO DEF MAXFEE 01/01/1994 12/31/2023 156.74 0.0 Description: CNTCT LENS HYDROPHILIC TORIC Category: Vision CMS Add: 01/01/1985 CMS Term: V2521 VISIO DEF MAXFEE 01/01/2024 276.57 0.0 Description: CNTCT LENS HYDROPHILIC TORIC Category: Vision CMS Add: 01/01/1985 CMS Term: V2522 VISIO DEF MAXFEE 01/01/1994 12/31/2023 126.90 0.0 Description: CNTCT LENS HYDROPHIL BIFOCL Category: Vision CMS Add: 01/01/1985 CMS Term: V2522 VISIO DEF MAXFEE 01/01/2024 202.40 0.0 Description: CNTCT LENS HYDROPHIL BIFOCL Category: Vision CMS Add: 01/01/1985 CMS Term: V2523 VISIO DEF MAXFEE 01/01/1994 12/31/2023 105.28 0.0 Description: CNTCT LENS HYDROPHIL EXTEND Category: Vision CMS Add: 01/01/1985 CMS Term: V2523 VISIO DEF MAXFEE 01/01/2024 212.50 0.0 Description: CNTCT LENS HYDROPHIL EXTEND Category: Vision CMS Add: 01/01/1985 CMS Term: V2524 NOCOV DEF SYSMAN Description: CNTCT LENS HYDROPHIL PHOTOCH Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,206 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- V2525 VISIO DEF BILL90 Description: CL, HYDROPHILIC, DUAL FOCUS Category: Vision CMS Add: 04/01/2022 CMS Term: V2526 NOCOV DEF SYSMAN Description: CNTCT LENS BLUE VIOLET Category: Non Covered Services CMS Add: 10/01/2023 CMS Term: V2530 VISIO DEF MAXFEE 01/01/1994 12/31/2023 172.50 0.0 Description: CONTACT LENS GAS IMPERMEABLE Category: Vision CMS Add: 01/01/1985 CMS Term: V2530 VISIO DEF MAXFEE 01/01/2024 339.73 0.0 Description: CONTACT LENS GAS IMPERMEABLE Category: Vision CMS Add: 01/01/1985 CMS Term: V2531 VISIO DEF MAXFEE 01/01/2014 12/31/2023 506.52 0.0 Description: CONTACT LENS GAS PERMEABLE Category: Vision CMS Add: 01/01/1996 CMS Term: V2531 VISIO DEF MAXFEE 01/01/2024 622.14 0.0 Description: CONTACT LENS GAS PERMEABLE Category: Vision CMS Add: 01/01/1996 CMS Term: V2599 VISIO DEF SYSMAN Y Description: CONTACT LENS/ES OTHER TYPE Category: Vision CMS Add: 01/01/1985 CMS Term: V2600 VISIO DEF SYSMAN Y Description: HAND HELD LOW VISION AIDS Category: Vision CMS Add: 01/01/1985 CMS Term: V2610 VISIO DEF SYSMAN Y Description: SINGLE LENS SPECTACLE MOUNT Category: Vision CMS Add: 01/01/1985 CMS Term: V2615 VISIO DEF SYSMAN Y Description: TELESCOP/OTHR COMPOUND LENS Category: Vision CMS Add: 01/01/1985 CMS Term: V2623 DME DEF MAXFEE 01/01/1994 12/31/2023 696.09 0.0 Description: PLASTIC EYE PROSTH CUSTOM Category: Durable Medical CMS Add: 01/01/1985 CMS Term: V2623 DME DEF MAXFEE 01/01/2024 1077.25 0.0 Description: PLASTIC EYE PROSTH CUSTOM Category: Durable Medical CMS Add: 01/01/1985 CMS Term: V2624 DME DEF MAXFEE 01/01/2006 12/31/2023 45.20 0.0 Description: POLISHING ARTIFICAL EYE Category: Durable Medical CMS Add: 01/01/1993 CMS Term: V2624 DME DEF MAXFEE 01/01/2024 69.55 0.0 Description: POLISHING ARTIFICAL EYE Category: Durable Medical CMS Add: 01/01/1993 CMS Term: V2625 DME DEF MAXFEE 01/01/2006 12/31/2023 357.94 0.0 Description: ENLARGEMNT OF EYE PROSTHESIS Category: Durable Medical CMS Add: 01/01/1993 CMS Term: V2625 DME DEF MAXFEE 01/01/2024 550.79 0.0 Description: ENLARGEMNT OF EYE PROSTHESIS Category: Durable Medical CMS Add: 01/01/1993 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,207 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- V2626 DME DEF MAXFEE 01/01/2006 12/31/2023 148.13 0.0 Description: REDUCTION OF EYE PROSTHESIS Category: Durable Medical CMS Add: 01/01/1993 CMS Term: V2626 DME DEF MAXFEE 01/01/2024 227.92 0.0 Description: REDUCTION OF EYE PROSTHESIS Category: Durable Medical CMS Add: 01/01/1993 CMS Term: V2627 DME DEF MAXFEE 01/01/2006 12/31/2023 920.75 0.0 Description: SCLERAL COVER SHELL Category: Durable Medical CMS Add: 01/01/1993 CMS Term: V2627 DME DEF MAXFEE 01/01/2024 1634.00 0.0 Description: SCLERAL COVER SHELL Category: Durable Medical CMS Add: 01/01/1993 CMS Term: V2628 DME DEF MAXFEE 01/01/2006 12/31/2023 225.89 0.0 Description: FABRICATION & FITTING Category: Durable Medical CMS Add: 01/01/1993 CMS Term: V2628 DME DEF MAXFEE 01/01/2024 347.58 0.0 Description: FABRICATION & FITTING Category: Durable Medical CMS Add: 01/01/1993 CMS Term: V2629 DME DEF SYSMAN Y Description: PROSTHETIC EYE OTHER TYPE Category: Durable Medical CMS Add: 01/01/1985 CMS Term: V2630 VISIO DEF MAXFEE 01/01/1987 12/31/2023 385.00 0.0 Description: ANTER CHAMBER INTRAOCUL LENS Category: Vision CMS Add: 01/01/1985 CMS Term: V2630 VISIO DEF MAXFEE 01/01/2024 135.98 0.0 Description: ANTER CHAMBER INTRAOCUL LENS Category: Vision CMS Add: 01/01/1985 CMS Term: V2631 VISIO DEF MAXFEE 01/01/1987 12/31/2023 350.00 0.0 Description: IRIS SUPPORT INTRAOCLR LENS Category: Vision CMS Add: 01/01/1985 CMS Term: V2631 VISIO DEF MAXFEE 01/01/2024 135.98 0.0 Description: IRIS SUPPORT INTRAOCLR LENS Category: Vision CMS Add: 01/01/1985 CMS Term: V2632 VISIO DEF MAXFEE 01/01/1987 12/31/2023 360.00 0.0 Description: POST CHMBR INTRAOCULAR LENS Category: Vision CMS Add: 01/01/1985 CMS Term: V2632 VISIO DEF MAXFEE 01/01/2024 135.98 0.0 Description: POST CHMBR INTRAOCULAR LENS Category: Vision CMS Add: 01/01/1985 CMS Term: V2700 VISIO DEF MAXFEE 01/01/1994 12/31/2023 31.64 0.0 Description: BALANCE LENS Category: Vision CMS Add: 01/01/1985 CMS Term: V2700 VISIO DEF MAXFEE 01/01/2024 51.23 0.0 Description: BALANCE LENS Category: Vision CMS Add: 01/01/1985 CMS Term: V2702 NOCOV DEF SYSMAN Description: DELUXE LENS FEATURE Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,208 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- V2710 VISIO DEF MAXFEE 01/01/1994 12/31/2023 43.28 0.0 Description: GLASS/PLASTIC SLAB OFF PRISM Category: Vision CMS Add: 01/01/1985 CMS Term: V2710 VISIO DEF MAXFEE 01/01/2024 83.98 0.0 Description: GLASS/PLASTIC SLAB OFF PRISM Category: Vision CMS Add: 01/01/1985 CMS Term: V2715 VISIO DEF MAXFEE 01/01/1994 12/31/2023 9.15 0.0 Description: PRISM LENS/ES Category: Vision CMS Add: 01/01/1985 CMS Term: V2715 VISIO DEF MAXFEE 01/01/2024 16.46 0.0 Description: PRISM LENS/ES Category: Vision CMS Add: 01/01/1985 CMS Term: V2718 VISIO DEF MAXFEE 01/01/1994 12/31/2023 21.33 0.0 Description: FRESNELL PRISM PRESS-ON LENS Category: Vision CMS Add: 01/01/1985 CMS Term: V2718 VISIO DEF MAXFEE 01/01/2024 35.56 0.0 Description: FRESNELL PRISM PRESS-ON LENS Category: Vision CMS Add: 01/01/1985 CMS Term: V2730 VISIO DEF MAXFEE 01/01/1994 12/31/2023 17.29 0.0 Description: SPECIAL BASE CURVE Category: Vision CMS Add: 01/01/1985 CMS Term: V2730 VISIO DEF MAXFEE 01/01/2024 29.77 0.0 Description: SPECIAL BASE CURVE Category: Vision CMS Add: 01/01/1985 CMS Term: V2744 NOCOV DEF SYSMAN Description: TINT PHOTOCHROMATIC LENS/ES Category: Non Covered Services CMS Add: 01/01/1985 CMS Term: V2745 U1 VISIO DEF MAXFEE 01/01/2024 8.80 0.0 Description: TINT, ANY COLOR/SOLID/GRAD Category: Vision CMS Add: 01/01/2004 CMS Term: V2745 U1 VISIO DEF MAXFEE 04/01/2004 12/31/2023 7.18 0.0 Description: TINT, ANY COLOR/SOLID/GRAD Category: Vision CMS Add: 01/01/2004 CMS Term: V2745 U2 VISIO DEF MAXFEE 01/01/2024 8.45 0.0 Description: TINT, ANY COLOR/SOLID/GRAD Category: Vision CMS Add: 01/01/2004 CMS Term: V2745 U2 VISIO DEF MAXFEE 04/01/2004 12/31/2023 6.90 0.0 Description: TINT, ANY COLOR/SOLID/GRAD Category: Vision CMS Add: 01/01/2004 CMS Term: V2750 NOCOV DEF SYSMAN Description: ANTI-REFLECTIVE COATING Category: Non Covered Services CMS Add: 01/01/1985 CMS Term: V2755 VISIO DEF MAXFEE 01/01/1994 12/31/2023 11.13 0.0 Description: UV LENS/ES Category: Vision CMS Add: 01/01/1985 CMS Term: V2755 VISIO DEF MAXFEE 01/01/2024 19.14 0.0 Description: UV LENS/ES Category: Vision CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,209 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- V2756 NOCOV DEF SYSMAN Description: EYE GLASS CASE Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: V2760 NOCOV DEF SYSMAN Description: SCRATCH RESISTANT COATING Category: Non Covered Services CMS Add: 01/01/1985 CMS Term: V2761 NOCOV DEF SYSMAN Description: MIRROR COATING Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: V2762 NOCOV DEF SYSMAN Description: POLARIZATION, ANY LENS Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: V2770 VISIO DEF MAXFEE 01/01/1994 12/31/2023 12.93 0.0 Description: OCCLUDER LENS/ES Category: Vision CMS Add: 01/01/1985 CMS Term: V2770 VISIO DEF MAXFEE 01/01/2024 22.30 0.0 Description: OCCLUDER LENS/ES Category: Vision CMS Add: 01/01/1985 CMS Term: V2780 VISIO DEF MAXFEE 01/01/1994 12/31/2023 8.23 0.0 Description: OVERSIZE LENS/ES Category: Vision CMS Add: 01/01/1985 CMS Term: V2780 VISIO DEF MAXFEE 01/01/2024 14.31 0.0 Description: OVERSIZE LENS/ES Category: Vision CMS Add: 01/01/1985 CMS Term: V2781 NOCOV DEF SYSMAN Description: PROGRESSIVE LENS PER LENS Category: Non Covered Services CMS Add: 01/01/1996 CMS Term: V2782 NOCOV DEF SYSMAN Description: LENS, 1.54-1.65 P/1.60-1.79G Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: V2783 NOCOV DEF SYSMAN Description: LENS, >= 1.66 P/>=1.80 G Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: V2784 VISIO DEF MAXFEE 01/01/2004 12/31/2023 38.07 0.0 Description: LENS POLYCARB OR EQUAL Category: Vision CMS Add: 01/01/2004 CMS Term: V2784 VISIO DEF MAXFEE 01/01/2024 54.24 0.0 Description: LENS POLYCARB OR EQUAL Category: Vision CMS Add: 01/01/2004 CMS Term: V2785 VISIO DEF SYSMAN Y Description: CORNEAL TISSUE PROCESSING Category: Vision CMS Add: 01/01/1990 CMS Term: V2786 NOCOV DEF SYSMAN Description: OCCUPATIONAL MULTIFOCAL LENS Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: V2787 NOCOV DEF SYSMAN Description: ASTIGMATISM-CORRECT FUNCTION Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,210 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- V2788 NOCOV DEF SYSMAN Description: PRESBYOPIA-CORRECT FUNCTION Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: V2790 VISIO DEF BILL90 Description: AMNIOTIC MEMBRANE Category: Vision CMS Add: 01/01/2001 CMS Term: V2797 NOCOV DEF SYSMAN Description: VIS ITEM/SVC IN OTHER CODE Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: V2799 VISIO DEF SYSMAN Y Description: MISC VISION ITEM OR SERVICE Category: Vision CMS Add: 01/01/1985 CMS Term: V5008 NOCOV DEF SYSMAN Description: HEARING SCREENING Category: Non Covered Services CMS Add: 01/01/1990 CMS Term: V5010 AUDIO DEF BILL90 Description: ASSESSMENT FOR HEARING AID Category: Audiology CMS Add: 01/01/1984 CMS Term: V5011 NOCOV DEF SYSMAN Description: HEARING AID FITTING/CHECKING Category: Non Covered Services CMS Add: 01/01/1990 CMS Term: V5014 AUDIO DEF SYSMAN Y Description: HEARING AID REPAIR/MODIFYING Category: Audiology CMS Add: 01/01/1990 CMS Term: V5020 AUDIO DEF MAXFEE 01/01/2024 65.00 0.0 Description: CONFORMITY EVALUATION Category: Audiology CMS Add: 01/01/1984 CMS Term: V5020 AUDIO DEF MAXFEE 07/09/1979 12/31/2023 50.00 0.0 Description: CONFORMITY EVALUATION Category: Audiology CMS Add: 01/01/1984 CMS Term: V5030 AUDIO DEF MAXFEE 01/01/2014 12/31/2023 645.00 0.0 Y Description: BODY-WORN HEARING AID AIR Category: Audiology CMS Add: 01/01/1986 CMS Term: V5030 AUDIO DEF MAXFEE 01/01/2024 838.50 0.0 Y Description: BODY-WORN HEARING AID AIR Category: Audiology CMS Add: 01/01/1986 CMS Term: V5040 AUDIO DEF MAXFEE 01/01/2014 12/31/2023 645.00 0.0 Y Description: BODY-WORN HEARING AID BONE Category: Audiology CMS Add: 01/01/1986 CMS Term: V5040 AUDIO DEF MAXFEE 01/01/2024 838.50 0.0 Y Description: BODY-WORN HEARING AID BONE Category: Audiology CMS Add: 01/01/1986 CMS Term: V5050 AUDIO DEF MAXFEE 01/01/2024 733.90 0.0 Y Description: HEARING AID MONAURAL IN EAR Category: Audiology CMS Add: 01/01/1982 CMS Term: V5050 AUDIO DEF MAXFEE 07/01/2011 12/31/2023 564.54 0.0 Y Description: HEARING AID MONAURAL IN EAR Category: Audiology CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,211 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- V5060 AUDIO DEF MAXFEE 01/01/2024 577.29 0.0 Y Description: BEHIND EAR HEARING AID Category: Audiology CMS Add: 01/01/1982 CMS Term: V5060 AUDIO DEF MAXFEE 07/01/2011 12/31/2023 444.07 0.0 Y Description: BEHIND EAR HEARING AID Category: Audiology CMS Add: 01/01/1982 CMS Term: V5070 NOCOV DEF SYSMAN Description: GLASSES AIR CONDUCTION Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: V5080 AUDIO DEF SYSMAN Y Y Description: GLASSES BONE CONDUCTION Category: Audiology CMS Add: 01/01/1982 CMS Term: V5090 NOCOV DEF SYSMAN Description: HEARING AID DISPENSING FEE Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: V5095 AUDIO DEF SYSMAN Y Y Description: IMPLANT MID EAR HEARING PROS Category: Audiology CMS Add: 01/01/2003 CMS Term: V5100 AUDIO DEF SYSMAN Y Y Description: BODY-WORN BILAT HEARING AID Category: Audiology CMS Add: 01/01/1982 CMS Term: V5110 NOCOV DEF SYSMAN Description: HEARING AID DISPENSING FEE Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: V5120 AUDIO DEF SYSMAN Y Y Description: BODY-WORN BINAUR HEARING AID Category: Audiology CMS Add: 01/01/1982 CMS Term: V5130 AUDIO DEF MAXFEE 01/01/2024 1467.80 0.0 Y Description: IN EAR BINAURAL HEARING AID Category: Audiology CMS Add: 01/01/1982 CMS Term: V5130 AUDIO DEF MAXFEE 07/01/2011 12/31/2023 1129.08 0.0 Y Description: IN EAR BINAURAL HEARING AID Category: Audiology CMS Add: 01/01/1982 CMS Term: V5140 AUDIO DEF MAXFEE 01/01/2024 1154.58 0.0 Y Description: BEHIND EAR BINAUR HEARING AI Category: Audiology CMS Add: 01/01/1982 CMS Term: V5140 AUDIO DEF MAXFEE 07/01/2011 12/31/2023 888.14 0.0 Y Description: BEHIND EAR BINAUR HEARING AI Category: Audiology CMS Add: 01/01/1982 CMS Term: V5150 NOCOV DEF SYSMAN Description: GLASSES BINAURAL HEARING AID Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: V5160 AUDIO DEF MAXFEE 01/01/2024 455.00 0.0 Description: DISPENSING FEE BINAURAL Category: Audiology CMS Add: 01/01/1982 CMS Term: V5160 AUDIO DEF MAXFEE 07/01/2011 12/31/2023 350.00 0.0 Description: DISPENSING FEE BINAURAL Category: Audiology CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,212 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- V5171 AUDIO DEF SYSMAN Y Y Description: HEARING AID MONAURAL ITE Category: Audiology CMS Add: 01/01/2019 CMS Term: V5172 NOCOV DEF SYSMAN Description: HEARING AID MONAURAL ITC Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: V5181 AUDIO DEF SYSMAN Y Y Description: HEARING AID MONAURAL BTE Category: Audiology CMS Add: 01/01/2019 CMS Term: V5190 NOCOV DEF SYSMAN Description: HEARING AID MONAURAL GLASSES Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: V5200 NOCOV DEF SYSMAN Description: DISP FEE CONTRALATERAL MONAU Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: V5211 AUDIO DEF SYSMAN Y Y Description: HEARING AID BINAURAL ITE/ITE Category: Audiology CMS Add: 01/01/2019 CMS Term: V5212 NOCOV DEF SYSMAN Description: HEARING AID BINAURAL ITE/ITC Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: V5213 AUDIO DEF SYSMAN Y Y Description: HEARING AID BINAURAL ITE/BTE Category: Audiology CMS Add: 01/01/2019 CMS Term: V5214 NOCOV DEF SYSMAN Description: HEARING AID BINAURAL ITC/ITC Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: V5215 NOCOV DEF SYSMAN Description: HEARING AID BINAURAL ITC/BTE Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: V5221 AUDIO DEF SYSMAN Y Y Description: HEARING AID BINAURAL BTE/BTE Category: Audiology CMS Add: 01/01/2019 CMS Term: V5230 NOCOV DEF SYSMAN Description: HEARING AID BINAURAL GLASSES Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: V5240 NOCOV DEF SYSMAN Description: DISP FEE CONTRALATERAL BINAU Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: V5241 AUDIO DEF MAXFEE 01/01/2024 260.00 0.0 Description: DISPENSING FEE, MONAURAL Category: Audiology CMS Add: 01/01/2002 CMS Term: V5241 AUDIO DEF MAXFEE 07/01/2011 12/31/2023 200.00 0.0 Description: DISPENSING FEE, MONAURAL Category: Audiology CMS Add: 01/01/2002 CMS Term: V5242 NOCOV DEF SYSMAN Description: HEARING AID, MONAURAL, CIC Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,213 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- V5243 NOCOV DEF SYSMAN Description: HEARING AID, MONAURAL, ITC Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: V5244 NOCOV DEF SYSMAN Description: HEARING AID, PROG, MON, CIC Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: V5245 NOCOV DEF SYSMAN Description: HEARING AID, PROG, MON, ITC Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: V5246 AUDIO DEF SYSMAN Y Y Description: HEARING AID, PROG, MON, ITE Category: Audiology CMS Add: 01/01/2002 CMS Term: V5247 AUDIO DEF SYSMAN Y Y Description: HEARING AID, PROG, MON, BTE Category: Audiology CMS Add: 01/01/2002 CMS Term: V5248 NOCOV DEF SYSMAN Description: HEARING AID, BINAURAL, CIC Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: V5249 NOCOV DEF SYSMAN Description: HEARING AID, BINAURAL, ITC Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: V5250 NOCOV DEF SYSMAN Description: HEARING AID, PROG, BIN, CIC Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: V5251 NOCOV DEF SYSMAN Description: HEARING AID, PROG, BIN, ITC Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: V5252 AUDIO DEF SYSMAN Y Y Description: HEARING AID, PROG, BIN, ITE Category: Audiology CMS Add: 01/01/2002 CMS Term: V5253 AUDIO DEF SYSMAN Y Y Description: HEARING AID, PROG, BIN, BTE Category: Audiology CMS Add: 01/01/2002 CMS Term: V5254 NOCOV DEF SYSMAN Description: HEARING ID, DIGIT, MON, CIC Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: V5255 NOCOV DEF SYSMAN Description: HEARING AID, DIGIT, MON, ITC Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: V5256 AUDIO DEF MAXFEE 01/01/2024 767.96 0.0 Y Description: HEARING AID, DIGIT, MON, ITE Category: Audiology CMS Add: 01/01/2002 CMS Term: V5256 AUDIO DEF MAXFEE 07/01/2011 12/31/2023 590.74 0.0 Y Description: HEARING AID, DIGIT, MON, ITE Category: Audiology CMS Add: 01/01/2002 CMS Term: V5257 AUDIO DEF MAXFEE 01/01/2024 604.08 0.0 Y Description: HEARING AID, DIGIT, MON, BTE Category: Audiology CMS Add: 01/01/2002 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,214 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- V5257 AUDIO DEF MAXFEE 07/01/2011 12/31/2023 464.68 0.0 Y Description: HEARING AID, DIGIT, MON, BTE Category: Audiology CMS Add: 01/01/2002 CMS Term: V5258 NOCOV DEF SYSMAN Description: HEARING AID, DIGIT, BIN, CIC Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: V5259 NOCOV DEF SYSMAN Description: HEARING AID, DIGIT, BIN, ITC Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: V5260 AUDIO DEF MAXFEE 01/01/2024 1535.92 0.0 Y Description: HEARING AID, DIGIT, BIN, ITE Category: Audiology CMS Add: 01/01/2002 CMS Term: V5260 AUDIO DEF MAXFEE 07/01/2011 12/31/2023 1181.48 0.0 Y Description: HEARING AID, DIGIT, BIN, ITE Category: Audiology CMS Add: 01/01/2002 CMS Term: V5261 AUDIO DEF MAXFEE 01/01/2024 1208.17 0.0 Y Description: HEARING AID, DIGIT, BIN, BTE Category: Audiology CMS Add: 01/01/2002 CMS Term: V5261 AUDIO DEF MAXFEE 07/01/2011 12/31/2023 929.36 0.0 Y Description: HEARING AID, DIGIT, BIN, BTE Category: Audiology CMS Add: 01/01/2002 CMS Term: V5262 NOCOV DEF SYSMAN Description: HEARING AID, DISP, MONAURAL Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: V5263 NOCOV DEF SYSMAN Description: HEARING AID, DISP, BINAURAL Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: V5264 AUDIO DEF MAXFEE 01/01/2014 12/31/2023 35.00 0.0 Description: EAR MOLD/INSERT Category: Audiology CMS Add: 01/01/2002 CMS Term: V5264 AUDIO DEF MAXFEE 01/01/2024 45.50 0.0 Description: EAR MOLD/INSERT Category: Audiology CMS Add: 01/01/2002 CMS Term: V5265 NOCOV DEF SYSMAN Description: EAR MOLD/INSERT, DISP Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: V5266 AUDIO DEF MAXFEE 01/01/2014 12/31/2023 5.00 0.0 Description: BATTERY FOR HEARING DEVICE Category: Audiology CMS Add: 01/01/2002 CMS Term: V5266 AUDIO DEF MAXFEE 01/01/2024 6.50 0.0 Description: BATTERY FOR HEARING DEVICE Category: Audiology CMS Add: 01/01/2002 CMS Term: V5267 AUDIO DEF MAXFEE 01/01/2014 12/31/2023 15.00 0.0 Description: HEARING AID SUP/ACCESS/DEV Category: Audiology CMS Add: 01/01/2002 CMS Term: V5267 AUDIO DEF MAXFEE 01/01/2024 19.50 0.0 Description: HEARING AID SUP/ACCESS/DEV Category: Audiology CMS Add: 01/01/2002 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,215 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- V5268 NOCOV DEF SYSMAN Description: ALD TELEPHONE AMPLIFIER Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: V5269 NOCOV DEF SYSMAN Description: ALERTING DEVICE, ANY TYPE Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: V5270 NOCOV DEF SYSMAN Description: ALD, TV AMPLIFIER, ANY TYPE Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: V5271 NOCOV DEF SYSMAN Description: ALD, TV CAPTION DECODER Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: V5272 NOCOV DEF SYSMAN Description: TDD Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: V5273 NOCOV DEF SYSMAN Description: ALD FOR COCHLEAR IMPLANT Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: V5274 NOCOV DEF SYSMAN Description: ALD UNSPECIFIED Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: V5275 NOCOV DEF SYSMAN Description: EAR IMPRESSION Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: V5281 NOCOV DEF SYSMAN Description: ALD FM/DM SYSTEM, MONAURAL Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: V5282 NOCOV DEF SYSMAN Description: ALD FM/DM SYSTEM BINAURAL Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: V5283 NOCOV DEF SYSMAN Description: ALD NECK, LOOP IND RECEIVER Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: V5284 NOCOV DEF SYSMAN Description: ALD FM/DM EAR LEVEL RECEIVER Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: V5285 NOCOV DEF SYSMAN Description: ALD FM/DM AUD INPUT RECEIVER Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: V5286 NOCOV DEF SYSMAN Description: ALD BLU TOOTH FM/DM RECEIVER Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: V5287 NOCOV DEF SYSMAN Description: ALD FM/DM RECEIVER, NOS Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: V5288 NOCOV DEF SYSMAN Description: ALD FM/DM TRANSMITTER ALD Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 04/13/2024 Process : REFJW013 Run Time: 12:25:25 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2,216 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- V5289 NOCOV DEF SYSMAN Description: ALD FM/DM ADAPT/BOOT COUPLIN Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: V5290 NOCOV DEF SYSMAN Description: ALD TRANSMITTER MICROPHONE Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: V5298 NOCOV DEF SYSMAN Description: HEARING AID NOC Category: Non Covered Services CMS Add: 01/01/2003 CMS Term: V5299 AUDIO DEF SYSMAN Y Y Description: HEARING SERVICE Category: Audiology CMS Add: 01/01/1982 CMS Term: V5336 NOCOV DEF SYSMAN Description: REPAIR COMMUNICATION DEVICE Category: Non Covered Services CMS Add: 01/01/1990 CMS Term: V5362 NOCOV DEF SYSMAN Description: SPEECH SCREENING Category: Non Covered Services CMS Add: 01/01/1990 CMS Term: V5363 NOCOV DEF SYSMAN Description: LANGUAGE SCREENING Category: Non Covered Services CMS Add: 01/01/1990 CMS Term: V5364 NOCOV DEF SYSMAN Description: DYSPHAGIA SCREENING Category: Non Covered Services CMS Add: 01/01/1990 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. ** END OF REPORT **